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Dovern E, Aydin M, Hazenberg MD, Tang MW, Suijk EM, Hoogendoorn GM, Van Tuijn CFJ, Kerkhoffs JL, Rutten CE, Zeerleder SS, de la Fuente J, Biemond BJ, Nur E. Azathioprine/hydroxyurea preconditioning prior to nonmyeloablative matched sibling donor hematopoietic stem cell transplantation in adults with sickle cell disease: A prospective observational cohort study. Am J Hematol 2024; 99:1523-1531. [PMID: 38733340 DOI: 10.1002/ajh.27360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/22/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024]
Abstract
Nonmyeloablative, matched sibling donor hematopoietic stem cell transplantation with alemtuzumab/total body irradiation (TBI) conditioning is a curative therapy with low toxicity for adults with sickle cell disease (SCD). However, relatively low donor chimerism levels and graft rejection remain important challenges. We hypothesized that adding azathioprine/hydroxyurea preconditioning will improve donor chimerism levels and reduce graft failure rate. In this prospective cohort study, we enrolled consecutive adult patients with SCD undergoing matched sibling donor transplantation at the Amsterdam UMC. Patients received azathioprine 150 mg/day and hydroxyurea 25 mg/kg/day for 3 months prior to alemtuzumab 1 mg/kg and 300 cGy TBI conditioning. Twenty patients with SCD (median age 26 years [range 19-49], 13 females) were transplanted. Median follow-up was 46.0 months (IQR 21.8-57.9). One-year overall survival and event-free survival (graft failure or death) were both 95% (95% confidence interval 86-100). Mean donor myeloid and T-cell chimerism 1-year post-transplant were 95.2% (SD ±10.6) and 67.3% (±15.3), respectively. One patient (5%) experienced graft failure without autologous regeneration, resulting in infections and death. All other patients had a corrected SCD phenotype and were able to discontinue sirolimus. Three patients were successfully treated with alemtuzumab (1 mg/kg) after the transplant because of declining donor chimerism and cytopenias to revert impending graft rejection. Toxicity was mostly related to sirolimus and alemtuzumab. One patient developed steroid-responsive grade II intestinal acute graft-versus-host disease. Collectively, preconditioning with azathioprine/hydroxyurea prior to nonmyeloablative matched sibling donor transplantation resulted in excellent event-free survival and robust donor T-cell chimerism, enabling the successful withdrawal of sirolimus. ClinicalTrials.gov: NCT05249452.
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Affiliation(s)
- Elisabeth Dovern
- Department of Hematology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Mesire Aydin
- Department of Hematology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Mette D Hazenberg
- Department of Hematology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Man Wai Tang
- Department of Hematology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Elisabeth M Suijk
- Department of Hematology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Gerianne M Hoogendoorn
- Department of Hematology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Charlotte F J Van Tuijn
- Department of Hematology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | | | - Caroline E Rutten
- Department of Hematology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Sacha S Zeerleder
- Department of Hematology, Division of Internal Medicine, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Josu de la Fuente
- Department of Paediatrics, St. Mary's Hospital, Imperial Healthcare NHS Trust, London, UK
- Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Bart J Biemond
- Department of Hematology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Erfan Nur
- Department of Hematology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands
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2
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Mukherjee D, Lawal RA, Fitzhugh CD, Hourigan CS, Dillon LW. TP53 mutation screening for patients at risk of myeloid malignancy. Leukemia 2024; 38:1604-1608. [PMID: 38796530 DOI: 10.1038/s41375-024-02283-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/28/2024]
Affiliation(s)
- Devdeep Mukherjee
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rialnat A Lawal
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Courtney D Fitzhugh
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Christopher S Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
- Virginia Tech FBRI Cancer Research Center, Washington, DC, USA.
| | - Laura W Dillon
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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3
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Kassim AA, de la Fuente J, Nur E, Wilkerson KL, Alahmari AD, Seber A, Bonfim C, Simões BP, Alzahrani M, Eckrich MJ, Horn B, Hanna R, Dhedin N, Rangarajan HG, Gouveia RV, Almohareb F, Aljurf M, Essa M, Alahmari B, Gatwood K, Connelly JA, Dovern E, Rodeghier M, DeBaun MR. An international learning collaborative phase 2 trial for haploidentical bone marrow transplant in sickle cell disease. Blood 2024; 143:2654-2665. [PMID: 38493482 DOI: 10.1182/blood.2023023301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/17/2024] [Accepted: 02/08/2024] [Indexed: 03/19/2024] Open
Abstract
ABSTRACT In the setting of a learning collaborative, we conducted an international multicenter phase 2 clinical trial testing the hypothesis that nonmyeloablative-related haploidentical bone marrow transplant (BMT) with thiotepa and posttransplant cyclophosphamide (PTCy) will result in 2-year event-free survival (no graft failure or death) of at least 80%. A total of 70 participants were evaluable based on the conditioning protocol. Graft failure occurred in 8 of 70 (11.4%) and only in participants aged <18 years; all had autologous reconstitution. After a median follow-up of 2.4 years, the 2-year Kaplan-Meier-based probability of event-free survival was 82.6%. The 2-year overall survival was 94.1%, with no difference between children and adult participants. After excluding participants with graft failure (n = 8), participants with engraftment had median whole blood donor chimerism values at days +180 and +365 after transplant of 100% (n = 58), respectively, and 96.6% (57/59) were off immunosuppression 1 year after transplant. The 1-year grade 3 to 4 acute graft-versus-host disease (GVHD) rate was 10%, and the 2-year moderate-severe chronic GVHD rate was 10%. Five participants (7.1%) died from infectious complications. We demonstrate that nonmyeloablative haploidentical BMT with thiotepa and PTCy is a readily available curative therapy for most adults, even those with organ damage, compared to the more expensive myeloablative gene therapy and gene editing. Additional strategies are required for children to decrease graft failure rates. The trial was registered at www.clinicaltrials.gov as #NCT01850108.
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Affiliation(s)
- Adetola A Kassim
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
- Vanderbilt-Meharry Sickle Cell Disease Center of Excellence, Vanderbilt University School of Medicine, Nashville, TN
| | - Josu de la Fuente
- Department of Paediatrics, St. Mary's Hospital, Imperial College, London, United Kingdom
| | - Erfan Nur
- Department of Hematology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Karina L Wilkerson
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
- Vanderbilt-Meharry Sickle Cell Disease Center of Excellence, Vanderbilt University School of Medicine, Nashville, TN
| | - Ali D Alahmari
- Adult Hematology and Stem Cell Therapy and Cellular Therapy Program, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
| | - Adriana Seber
- Pediatric Hematopoietic Stem Cell Transplantation Program, Pediatric Hematopoietic Cell Transplantation, Hospital Samaritano Higienopolis-Americas, São Paulo, Brazil
- Pediatric Hematopoietic Stem Cell Transplantation Program, Pediatric Hematopoietic Cell Transplantation, Instituto de Oncologia Pediatrica-Graacc/Unifesp, São Paulo, Brazil
| | - Carmem Bonfim
- Pediatric Bone Marrow Transplantation Program, Hospital Pequeno Príncipe/Instituto de Pesquisa Pele Pequeno Principe, Curitiba, Brazil
| | - Belinda Pinto Simões
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Department of Hematology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
- Department of Clinical Oncology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Mohsen Alzahrani
- Department of Pediatric Hematology/Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Michael J Eckrich
- Department of Pediatrics, Pediatric Transplant and Cellular Therapy, Wake Forest University School of Medicine, Atrium Health Levine Children's Hospital, Charlotte, NC
| | - Biljana Horn
- Department of Pediatrics, Pediatric Bone Marrow Transplant and Cell Therapy Program, University of Florida, Gainesville, FL
| | - Rabi Hanna
- Department of Pediatric Hematology/Oncology, Pediatric Hematology Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH
| | - Nathalie Dhedin
- Department of Hematology, Hematology Adolescents and Young Adults, Saint-Louis Hospital, Paris, France
| | - Hemalatha G Rangarajan
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, OH
| | - Roseane Vasconcelos Gouveia
- Pediatric Hematopoietic Stem Cell Transplantation Program, Pediatric Hematopoietic Cell Transplantation, Hospital Samaritano Higienopolis-Americas, São Paulo, Brazil
- Pediatric Hematopoietic Stem Cell Transplantation Program, Pediatric Hematopoietic Cell Transplantation, Instituto de Oncologia Pediatrica-Graacc/Unifesp, São Paulo, Brazil
| | - Fahad Almohareb
- Adult Hematology and Stem Cell Therapy and Cellular Therapy Program, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
| | - Mahmoud Aljurf
- Adult Hematology and Stem Cell Therapy and Cellular Therapy Program, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
| | - Mohammed Essa
- Department of Pediatric Hematology/Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Bader Alahmari
- Department of Pediatric Hematology/Oncology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Katie Gatwood
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - James A Connelly
- Department of Pediatrics, Hematology/Oncology, Vanderbilt University School of Medicine, Nashville, TN
| | - Elisabeth Dovern
- Department of Hematology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Michael R DeBaun
- Vanderbilt-Meharry Sickle Cell Disease Center of Excellence, Vanderbilt University School of Medicine, Nashville, TN
- Department of Pediatrics, Hematology/Oncology, Vanderbilt University School of Medicine, Nashville, TN
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4
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Damlaj M, Alahmari B, Alaskar A, Alhejazi A, Alsadi H, Ahmed M, Alanazi T, Ahmed R, Alharbi A, Shehabeddine I, Alzaidi A, Alkhuraisat S, Mahassnah I, Alquraan H, Ballili M, Alzahrani M. Favorable outcome of non-myeloablative allogeneic transplantation in adult patients with severe sickle cell disease: A single center experience of 200 patients. Am J Hematol 2024; 99:1023-1030. [PMID: 38488686 DOI: 10.1002/ajh.27295] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 03/02/2024] [Accepted: 03/06/2024] [Indexed: 05/16/2024]
Abstract
Allogeneic hematopoietic stem cell transplant (HSCT) for adults with severe sickle cell disease (SCD) is potentially curative but not commonly utilized therapy due to complications such as graft failure (GF) and organ toxicity. Herein, we are reporting our long-term outcome data of non-myeloablative (NMA) HSCT in adults with severe SCD with emphasis on factors predicting event free survival (EFS). Adults with severe SCD undergoing NMA match-related donor allogeneic HSCT from 2015 to 2021 with at least 12 months of follow-up were included. A total of 200 patients were included with a median age of 26 years (14-43) and 56% were male. The median infused CD34 dose was 13.7 (5.07-25.8), respectively. Median absolute neutrophil count engraftment was 19 (13-39) days with 51% of patients receiving GCSF to expedite recovery. A total of 17 patients experienced GF; 3 as primary and 14 as secondary within a median time of 204 days (40-905). A 76% successfully discontinued sirolimus at the last follow-up. Median follow-up for the cohort is 29.2 (2.1-71.4) months. Estimated 3-year EFS and OS were 88.2% (81.9-92.5) and 94.6% (89.2-97.3). At multivariable analysis, minor ABC incompatibility hazard ratio (HR) 4 (1.3-12.1; 0.014) and allo-antibody against non-ABO donor antigens HR 4.3 (1.3-14.1; 0.016) were significant for EFS. No clonal evolution or myeloid malignancies were seen. This largest single-center report of NMA HSCT in adults with severe SCD further delineated its feasibility, potential toxicities, and fertility outcomes. GF remains a major impediment and appears dependent on ABO matching and non-ABO antibodies.
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Affiliation(s)
- Moussab Damlaj
- Division of Hematology, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- Blood and Cancer Research Unit, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Division of Hematology, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
- College of Medicine, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, UAE
| | - Bader Alahmari
- Division of Hematology, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- Blood and Cancer Research Unit, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ahmed Alaskar
- Division of Hematology, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- Blood and Cancer Research Unit, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ayman Alhejazi
- Division of Hematology, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- Blood and Cancer Research Unit, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Husam Alsadi
- Division of Hematology, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mazin Ahmed
- Division of Hematology, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Tahani Alanazi
- Division of Hematology, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Rasha Ahmed
- Division of Hematology, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Amani Alharbi
- Division of Hematology, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Inaam Shehabeddine
- Division of Hematology, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Afnan Alzaidi
- Division of Hematology, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Suha Alkhuraisat
- Division of Hematology, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Isam Mahassnah
- Division of Hematology, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Hamza Alquraan
- Division of Hematology, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Maybelle Ballili
- Division of Hematology, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mohsen Alzahrani
- Division of Hematology, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- Blood and Cancer Research Unit, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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5
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Mukherjee D, Lawal RA, Fitzhugh CD, Hourigan CS, Dillon LW. TP53 mutation screening for patients at risk of myeloid malignancy. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.06.24302401. [PMID: 38410480 PMCID: PMC10896414 DOI: 10.1101/2024.02.06.24302401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
There is increasing recognition of the risk of developing therapy-related myeloid malignancy, including after cellular therapy. While retrospective studies have implicated pre-existing TP53 mutated hematopoietic clones as a common causative mechanism, no prospective screening to identify those patients at greatest risk is currently possible. We demonstrate that ultradeep DNA-sequencing prior to therapy may be used for discovery of TP53 mutations that are subsequently associated with malignancy.
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Affiliation(s)
- Devdeep Mukherjee
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Rialnat A. Lawal
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Courtney D. Fitzhugh
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Christopher S. Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Myeloid Malignancies Program, National Institutes of Health, Bethesda, MD
| | - Laura W. Dillon
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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6
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Leonard A, Tisdale JF. A new frontier: FDA approvals for gene therapy in sickle cell disease. Mol Ther 2024; 32:264-267. [PMID: 38246166 PMCID: PMC10862012 DOI: 10.1016/j.ymthe.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 01/23/2024] Open
Affiliation(s)
- Alexis Leonard
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - John F Tisdale
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute and National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA.
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7
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Limerick EM, Fitzhugh CD. The challenge of eliciting opinions of gene therapy for SCD. Blood Adv 2023; 7:7369-7370. [PMID: 38085553 PMCID: PMC10726235 DOI: 10.1182/bloodadvances.2023011606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Affiliation(s)
- Emily M Limerick
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Courtney D Fitzhugh
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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8
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Kassim AA. The range of haploidentical transplant protocols in sickle cell disease: all haplos are not created equally. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:532-541. [PMID: 38066894 PMCID: PMC10727056 DOI: 10.1182/hematology.2023000486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The ideal curative therapy for sickle cell disease (SCD) must be applicable across all ages and include individuals with strokes and preexisting heart, lung, and kidney disease. Myeloablative, matched sibling donor hematopoietic stem cell transplant (HCT) for children with SCD has shown excellent outcomes over the past 3 decades but has been restricted due to the limited availability of a human leukocyte antigen-matched sibling donor (10%-15%) and increased treatment-related death in adults with myeloablative conditioning. To overcome these 2 significant barriers to curative therapy in SCD, related haploidentical HCT has become an active area of research. The use of related haploidentical donors (first- and second-degree relatives) increases the donor pool to at least 90% of those eligible across the life span. Importantly, most adults, even with strokes or significant comorbidities, can tolerate the nonmyeloablative conditioning regimen without treatment-related death. Since 2013, at least 3 related haploidentical HCT strategies have emerged as potential curative therapies for SCD: (1) a nonmyeloablative, T-cell replete, bone marrow transplant with thiotepa and posttransplant cyclophosphamide with a goal of complete donor chimerism; (2) a nonmyeloablative, in vivo T-cell depletion, using peripheral blood stem cells (PBSCs) with a goal of stable mixed donor-recipient chimerism; and (3) a myeloablative, ex vivo T-cell depletion using PBSCs and advanced-technology graft manipulation, with a goal of complete donor chimerism. We review the similarities, differences, outcomes, and gaps in knowledge with these 3 haploidentical HCT approaches for SCD.
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Affiliation(s)
- Adetola A. Kassim
- Department of Hematology/Oncology, Vanderbilt University School of Medicine, Nashville, TN
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9
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Spencer Chapman M, Cull AH, Ciuculescu MF, Esrick EB, Mitchell E, Jung H, O'Neill L, Roberts K, Fabre MA, Williams N, Nangalia J, Quinton J, Fox JM, Pellin D, Makani J, Armant M, Williams DA, Campbell PJ, Kent DG. Clonal selection of hematopoietic stem cells after gene therapy for sickle cell disease. Nat Med 2023; 29:3175-3183. [PMID: 37973947 PMCID: PMC10719109 DOI: 10.1038/s41591-023-02636-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/10/2023] [Indexed: 11/19/2023]
Abstract
Gene therapy (GT) provides a potentially curative treatment option for patients with sickle cell disease (SCD); however, the occurrence of myeloid malignancies in GT clinical trials has prompted concern, with several postulated mechanisms. Here, we used whole-genome sequencing to track hematopoietic stem cells (HSCs) from six patients with SCD at pre- and post-GT time points to map the somatic mutation and clonal landscape of gene-modified and unmodified HSCs. Pre-GT, phylogenetic trees were highly polyclonal and mutation burdens per cell were elevated in some, but not all, patients. Post-GT, no clonal expansions were identified among gene-modified or unmodified cells; however, an increased frequency of potential driver mutations associated with myeloid neoplasms or clonal hematopoiesis (DNMT3A- and EZH2-mutated clones in particular) was observed in both genetically modified and unmodified cells, suggesting positive selection of mutant clones during GT. This work sheds light on HSC clonal dynamics and the mutational landscape after GT in SCD, highlighting the enhanced fitness of some HSCs harboring pre-existing driver mutations. Future studies should define the long-term fate of mutant clones, including any contribution to expansions associated with myeloid neoplasms.
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Affiliation(s)
- Michael Spencer Chapman
- Wellcome Sanger Institute, Hinxton, UK
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Alyssa H Cull
- York Biomedical Research Institute, University of York, York, UK
| | | | - Erica B Esrick
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Emily Mitchell
- Wellcome Sanger Institute, Hinxton, UK
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Wellcome-Medical Research Council Cambridge Stem Cell Institute, Cambridge, UK
| | | | | | | | - Margarete A Fabre
- Wellcome Sanger Institute, Hinxton, UK
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Wellcome-Medical Research Council Cambridge Stem Cell Institute, Cambridge, UK
- Centre for Genomics Research, Discovery Sciences, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | | | - Jyoti Nangalia
- Wellcome Sanger Institute, Hinxton, UK
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Wellcome-Medical Research Council Cambridge Stem Cell Institute, Cambridge, UK
| | - Joanne Quinton
- York Biomedical Research Institute, University of York, York, UK
| | - James M Fox
- York Biomedical Research Institute, University of York, York, UK
| | - Danilo Pellin
- Harvard Medical School, Boston, MA, USA
- Gene Therapy Program, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Julie Makani
- Muhimbili University of Health and Allied Sciences (MUHAS), Dar-es-Salaam, Tanzania
- SickleInAfrica Clinical Coordinating Center, MUHAS, Dar-es-Salaam, Tanzania
- Imperial College London, London, UK
| | - Myriam Armant
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA, USA
| | - David A Williams
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Gene Therapy Program, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA.
- Harvard Stem Cell Institute, Cambridge, MA, USA.
| | - Peter J Campbell
- Wellcome Sanger Institute, Hinxton, UK.
- Wellcome-Medical Research Council Cambridge Stem Cell Institute, Cambridge, UK.
| | - David G Kent
- York Biomedical Research Institute, University of York, York, UK.
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10
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Jacob SA, Talati R, Kanter J. The evolving treatment landscape for children with sickle cell disease. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:797-808. [PMID: 37858508 DOI: 10.1016/s2352-4642(23)00201-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 10/21/2023]
Abstract
Sickle cell disease is the most common inherited pathological haemoglobinopathy. Over the past 30 years, disease-related morbidity and mortality have improved in high-income countries due to advances in preventive care and treatments. Established disease-modifying therapies, such as hydroxyurea (hydrocarbamide), are continuing to have an important role in the treatment of sickle cell disease, and newer agents also show promise. In the past 5 years, the US Food and Drug Administration approved three additional sickle cell disease-modifying medications, and new gene therapies have been developed as an alternative curative treatment to haematopoietic stem-cell transplantation. In this Review, we discuss the current treatment landscape for paediatric sickle cell disease and emerging innovations in care. We also review the need for close, long-term management for children receiving newer therapies and the importance of ongoing investment in people with sickle cell disease in low-income and middle-income countries.
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Affiliation(s)
- Seethal A Jacob
- Division of Pediatric Hematology Oncology, Riley Hospital for Children, Indianapolis, IN, USA
| | - Ravi Talati
- Division of Pediatric Hematology, Oncology & Blood/Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Julie Kanter
- Lifespan Comprehensive Sickle Cell Center, University of Alabama, Birmingham, AL, USA.
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Vallée T, Schmid I, Gloning L, Bacova M, Ahrens J, Feuchtinger T, Klein C, Gaertner VD, Albert MH. Excellent outcome of stem cell transplantation for sickle cell disease. Ann Hematol 2023; 102:3217-3227. [PMID: 37726493 PMCID: PMC10567813 DOI: 10.1007/s00277-023-05447-4] [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: 06/15/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023]
Abstract
Many sickle cell disease (SCD) patients lack matched family donors (MFD) or matched unrelated donors (MUD), implying haploidentical donors (MMFD) as a logical donor choice. We used a reduced toxicity protocol for all donor types. We included 31 patients (2-22 years) with MFD (n = 15), MMFD (10), or MUD (6) HSCT and conditioning with alemtuzumab/ATG, thiotepa, fludarabine and treosulfan, and post-transplant cyclophosphamide for MMFD. After the initial six patients, treosulfan was replaced by targeted busulfan (AUC 65-75 ng*h/ml). After a median follow-up of 26 months (6-123), all patients are alive and off immunosuppression. Two MMFD patients experienced secondary graft failure with recurrence of SCD, both after treosulfan conditioning. Neither acute GVHD ≥ °III nor moderate/severe chronic GVHD was observed. The disease-free, severe GVHD-free survival was 100%, 100%, and 80% in the MFD, MUD, and MMFD groups, respectively (p = 0.106). There was a higher rate of virus reactivation in MMFD (100%) and MUD (83%) compared to MFD (40%; p = 0.005), but not of viral disease (20% vs 33% vs 13%; p = 0.576). Six patients had treosulfan-based conditioning, two of whom experienced graft failure (33%), compared to 0/25 (0%) after busulfan-based conditioning (p = 0.032). Donor chimerism was ≥ 80% in 28/31 patients (90%) at last follow-up. Reduced toxicity myeloablative conditioning resulted in excellent overall survival, negligible GVHD, and low toxicity among all donor groups in pediatric and young adult patients with SCD.
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Affiliation(s)
- Tanja Vallée
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Irene Schmid
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Lisa Gloning
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Martina Bacova
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Jutta Ahrens
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Tobias Feuchtinger
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Christoph Klein
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Vincent D Gaertner
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Michael H Albert
- Department of Pediatrics, Dr. Von Hauner Children's Hospital, University Hospital, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany.
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Shah NC, Rangarajan HG, Ngwube A, Shenoy S. Mixed donor chimerism following stem cell transplantation for sickle cell disease. Curr Opin Hematol 2023; 30:187-193. [PMID: 37694765 DOI: 10.1097/moh.0000000000000786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Sickle cell disease is a debilitating hemoglobinopathy with high morbidity and mortality. Hematopoietic stem cell transplantation (HCT) is curative, but the presence of mixed donor/recipient chimerism post-HCT raises concerns about disease control long-term. Mixed donor/recipient chimerism is reported in significant numbers even after aggressive HCT conditioning regimens. Post-HCT, adequacy of donor erythropoiesis is crucial for disease control. This review explores the relationship between mixed donor/recipient chimerism and outcomes post-HCT. Serial chimerism analysis in lineage specific manner in erythroid or myeloid cells post-HCT predicts for disease control and HCT success. Adequate and stable donor-derived erythropoiesis is essential for reversing SCD manifestations. Myeloid lineage chimerism mirrors erythropoiesis is commercially available, and a reliable indicator of adequacy. Using this tool, the minimum threshold of donor chimerism is required to prevent SCD-related complications and maintain sickle hemoglobin less than 50% is approximately 20-25% even when a donor has Hb S trait. Curative interventions should, at a minimum, meet this goal long-term. Achieving a balance between successful engraftment while minimizing toxicity is important in patients vulnerable because of age or preexisting morbidity and is the objective of recent clinical trials. As HCT and gene therapies evolve, efficient long-term follow-up that includes durability assessment of mixed donor/recipient chimerism will be crucial.
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Affiliation(s)
- Niketa C Shah
- Section of Pediatric Hematology/Oncology and Stem cell Transplant, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Hemalatha G Rangarajan
- Division of Pediatric Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio
| | - Alexander Ngwube
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona
| | - Shalini Shenoy
- Division of Pediatric Hematology Oncology, Washington University, St. Louis, Missouri. USA
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Inam Z, Tisdale JF, Leonard A. Outcomes and long-term effects of hematopoietic stem cell transplant in sickle cell disease. Expert Rev Hematol 2023; 16:879-903. [PMID: 37800996 DOI: 10.1080/17474086.2023.2268271] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 10/04/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION Hematopoietic stem cell transplant (HSCT) is the only readily available curative option for sickle cell disease (SCD). Cure rates following human leukocyte antigen (HLA)-matched related donor HSCT with myeloablative or non-myeloablative conditioning are >90%. Alternative donor sources, including haploidentical donor and autologous with gene therapy, expand donor options but are limited by inferior outcomes, limited data, and/or shorter follow-up and therefore remain experimental. AREAS COVERED Outcomes are improving with time, with donor type and conditioning regimens having the greatest impact on long-term complications. Patients with stable donor engraftment do not experience SCD-related symptoms and have stabilization or improvement of end-organ pathology; however, the long-term effects of curative strategies remain to be fully established and have significant implications in a patient's decision to seek therapy. This review covers currently published literature on HSCT outcomes, including organ-specific outcomes implicated in SCD, as well as long-term effects. EXPERT OPINION HSCT, both allogeneic and autologous gene therapy, in the SCD population reverses the sickle phenotype, prevents further organ damage, can resolve prior organ dysfunction in both pediatric and adult patients. Data support greater success with HSCT at a younger age, thus, curative therapies should be discussed early in the patient's life.
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Affiliation(s)
- Zaina Inam
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
- Center for Cancer and Blood Disorders, Children's National Hospital, Washington, DC, USA
| | - John F Tisdale
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Alexis Leonard
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN, USA
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Meisel R. Secondary Malignancies After Allogeneic Hematopoietic Stem Cell Transplantation for Sickle Cell Disease Inform Gene Therapy Approaches. J Clin Oncol 2023; 41:3272-3273. [PMID: 37043702 DOI: 10.1200/jco.23.00403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 04/14/2023] Open
Affiliation(s)
- Roland Meisel
- Roland Meisel MD, Division of Pediatric Stem Cell Therapy, Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
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Eapen M, Brazauskas R, Williams DA, Walters MC, St Martin A, Jacobs BL, Antin JH, Bona K, Chaudhury S, Coleman-Cowger VH, DiFronzo NL, Esrick EB, Field JJ, Fitzhugh CD, Kanter J, Kapoor N, Kohn DB, Krishnamurti L, London WB, Pulsipher MA, Talib S, Thompson AA, Waller EK, Wun T, Horowitz MM. Secondary Neoplasms After Hematopoietic Cell Transplant for Sickle Cell Disease. J Clin Oncol 2023; 41:2227-2237. [PMID: 36623245 PMCID: PMC10448940 DOI: 10.1200/jco.22.01203] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 11/04/2022] [Accepted: 12/02/2022] [Indexed: 01/11/2023] Open
Abstract
PURPOSE To report the incidence and risk factors for secondary neoplasm after transplantation for sickle cell disease. METHODS Included are 1,096 transplants for sickle cell disease between 1991 and 2016. There were 22 secondary neoplasms. Types included leukemia/myelodysplastic syndrome (MDS; n = 15) and solid tumor (n = 7). Fine-Gray regression models examined for risk factors for leukemia/MDS and any secondary neoplasm. RESULTS The 10-year incidence of leukemia/MDS was 1.7% (95% CI, 0.90 to 2.9) and of any secondary neoplasm was 2.4% (95% CI, 1.4 to 3.8). After adjusting for other risk factors, risks for leukemia/MDS (hazard ratio, 22.69; 95% CI, 4.34 to 118.66; P = .0002) or any secondary neoplasm (hazard ratio, 7.78; 95% CI, 2.20 to 27.53; P = .0015) were higher with low-intensity (nonmyeloablative) regimens compared with more intense regimens. All low-intensity regimens included total-body irradiation (TBI 300 or 400 cGy with alemtuzumab, TBI 300 or 400 cGy with cyclophosphamide, TBI 200, 300, or 400 cGy with cyclophosphamide and fludarabine, or TBI 200 cGy with fludarabine). None of the patients receiving myeloablative and only 23% of those receiving reduced-intensity regimens received TBI. CONCLUSION Low-intensity regimens rely on tolerance induction and establishment of mixed-donor chimerism. Persistence of host cells exposed to low-dose radiation triggering myeloid malignancy is one plausible etiology. Pre-existing myeloid mutations and prior inflammation may also contribute but could not be studied using our data source. Choosing conditioning regimens likely to result in full-donor chimerism may in part mitigate the higher risk for leukemia/MDS.
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Affiliation(s)
- Mary Eapen
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Ruta Brazauskas
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - David A. Williams
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
| | - Mark C. Walters
- University of California San Francisco Benioff Children's Hospital, Oakland, CA
| | - Andrew St Martin
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Benjamin L. Jacobs
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Joseph H. Antin
- Dana-Farber Cancer Center, Harvard Medical School, Boston, MA
| | - Kira Bona
- Dana-Farber Cancer Center, Harvard Medical School, Boston, MA
| | | | | | | | - Erica B. Esrick
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
| | - Joshua J. Field
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Courtney D. Fitzhugh
- Cellular and Molecular Therapeutics Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Julie Kanter
- University of Alabama Birmingham, Birmingham, AL
| | - Neena Kapoor
- Children's Hospital of Los Angeles, Los Angeles, CA
| | - Donald B. Kohn
- David Geffen School of Medicine, University of California, Los Angeles, CA
| | | | - Wendy B. London
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
| | | | - Sohel Talib
- California Institute for Regenerative Medicine, San Francisco, CA
| | | | | | - Ted Wun
- University of California Davis School of Medicine, Davis, CA
| | - Mary M. Horowitz
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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