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Ben Abdeljelil N, Ben Yaiche I, Ouerghi R, Torjemane L, Belloumi D, Turki I, Mekni S, Kanoun RY, Ben Othman T, Ladeb S. Cyclophosphamide and horse anti-thymocyte globulin versus fludarabine, reduced cyclophosphamide and rabbit anti-thymocyte globulin conditioning regimen for allogeneic hematopoietic stem cell transplantation from matched sibling donors in patients with acquired aplastic anemia. Expert Rev Hematol 2024; 17:527-538. [PMID: 39011776 DOI: 10.1080/17474086.2024.2381572] [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: 01/18/2024] [Accepted: 07/15/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a potentially curative treatment for acquired aplastic anemia (acquired AA) in young patients. The objective of the study was to compare patient outcomes after Cyclophosphamide and horse antithymocyte globulin (Cy-hATG) versus Fludarabine-cyclophosphamide and rabbit ATG (Flu-Cy-rATG) as part of conditioning regimen in allo-HSCT for acquired AA. RESEARCH DESIGN AND METHODS Descriptive retrospective study conducted on patients with acquired AA who received allo-HSCT from HLA-matched sibling donors between January 2008 and August 2022 after conditioning regimen with Cy-hATG or Flu-Cy-rATG. RESULTS A total of 121 patients were enrolled. Cumulative incidence of graft failure was 11.2% in Cy-hATG and 5.3% Flu-Cy-rATG group. There were no significant differences between the two groups in terms of acute GVHD, chronic GVHD, and transplant related mortality. Flu-Cy-rATG group was associated with significantly higher CMV and EBV reactivation(s) compared to Cy-hATG group (p = 0.008 and 0.035, respectively). After a median follow-up of 58 months, estimated overall survival, event-free survival, and graft rejection-free survival were not statistically different between the two groups. CONCLUSIONS In high-risk population, Flu-Cy-rATG is associated with comparable outcomes to Cy-hATG in allo-HSCT from MSD. However, it seems to be associated with significant risk of viral infections.
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Affiliation(s)
- Nour Ben Abdeljelil
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Insaf Ben Yaiche
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Rihab Ouerghi
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Lamia Torjemane
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Dorra Belloumi
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Ines Turki
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Sabrine Mekni
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Rimel Yousr Kanoun
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Tarek Ben Othman
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
| | - Saloua Ladeb
- Centre National de Greffe de Moelle Osseuse, Université de Tunis El Manar Tunis, Tunis, Tunisia
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2
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Bacigalupo A. How to Run a Successful Transplant Program in Older Patients with Myeloid Malignancies. Transplant Cell Ther 2024; 30:734-736. [PMID: 39089767 DOI: 10.1016/j.jtct.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Affiliation(s)
- Andrea Bacigalupo
- Hematology Department, Fondazione Policlinico Universitario A.Gemelli-Roma
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3
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Herzog S, Shanley R, Holtan SG, MacMillan ML, Weisdorf DJ, El Jurdi N. Treatment-Responsive Acute Graft-versus-Host Disease after Post-Transplantation Cyclophosphamide-Based Prophylaxis: Incidence and Clinical Outcomes. Transplant Cell Ther 2024; 30:688.e1-688.e9. [PMID: 38734182 PMCID: PMC11223983 DOI: 10.1016/j.jtct.2024.05.007] [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: 03/12/2024] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Abstract
Post-transplantation cyclophosphamide (PTCy) following hematopoietic cell transplantation (HCT) has emerged as standard of care for graft-versus-host disease (GVHD) prevention in adult patients without increasing malignant relapse. We previously defined acute GVHD (aGVHD) treatment response categories as corticosteroid-sensitive (SS), -dependent (SD), or -resistant (SR) based on response to first-line corticosteroids and reported their clinical outcomes following non-PTCy-based prophylaxis. More than one-third of patients developed aGVHD necessitating systemic therapy. Cases were predominantly SR, with a 14% overall incidence of SR aGVHD. The incidence and clinical outcomes of these 3 distinct aGVHD treatment response groups following PTCy-based prophylaxis have not been well described. The objective of this retrospective single-institution cohort study was to assess the incidence and clinical outcomes of SS, SD, and SR aGVHD following HCT with PTCy-based prophylaxis using a prophylactic regimen of PTCy, tacrolimus, and mycophenolate mofetil (MMF). We included 196 consecutive adult and pediatric patients undergoing allogeneic HCT for malignant and non-malignant disorders at the University of Minnesota between 2017 and 2021. Patients received PTCy on days +3 and +4 plus tacrolimus and MMF prophylaxis. Bone marrow and peripheral blood stem cell graft sources and related and unrelated donors were included. Recipients received myeloablative or reduced-intensity conditioning regimens. Of the 196 allografts, 54 (28%) developed aGVHD before day +180, with a median time to onset of 50 days (interquartile range, 34 to 71 days). Of those, 32 patients (16% overall) developed maximum grade II-III aGVHD necessitating systemic corticosteroids, with the following response: 13 SS (41%), 10 SD (31%), and 9 SR (28%). The overall incidence of SR aGVHD was 4.6%. Only 12 patients (6%) developed maximum grade III aGVHD, and none had grade IV aGVHD. The 2-year overall survival analyzed from 80 days after initiation of systemic treatment was similar in the SS and SD groups (77 and 75%, respectively), comparable to those without aGVHD (81%), and was lowest in the SR group (20%), with GVHD the primary cause of death. Nonrelapse mortality was highest in the SR group. MN high-risk and higher GVHD grade at onset were risk factors for developing SR aGVHD. Overall, we report a low incidence (16%) of aGVHD requiring systemic corticosteroids with PTCy-based prophylaxis. aGVHD cases were predominantly SS aGVHD, with lower incidences of SD and SR aGVHD. Our findings suggest that PTCy-based prophylaxis reduces the rate of treatment-resistant aGVHD. Patients with SR aGVHD had the worst clinical outcomes and poorest survival. Those with SS and SD aGVHD had similar clinical outcomes, both better than seen with SR aGVHD.
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Affiliation(s)
- Shannon Herzog
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Ryan Shanley
- Biostatistics Core, University of Minnesota Masonic Cancer Center, Minneapolis, Minnesota
| | - Shernan G Holtan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Najla El Jurdi
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
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4
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Lisak M, Nicklasson M, Palmason R, Wichert S, Isaksson C, Andersson PO, Johansson JE, Lenhoff S, Brune M, Hansson M. Higher cyclosporine-A concentration increases the risk of relapse in AML following allogeneic stem cell transplantation from unrelated donors using anti-thymocyte globulin. Sci Rep 2023; 13:22777. [PMID: 38123675 PMCID: PMC10733303 DOI: 10.1038/s41598-023-50105-4] [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: 05/22/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023] Open
Abstract
Cyclosporine-A (CsA) is used to prevent acute graft-versus-host disease (aGvHD). European Society for Blood and Marrow transplantation (EBMT) recommends a CsA target serum concentration of 200-300 µg/L during the first month after allogeneic hematopoietic stem cell transplantation (HSCT). With this study, we investigated whether a median CsA concentration > 200 µg/L (CsAhigh) the first month after HSCT, compared to ≤ 200 µg/L (CsAlow), increased the relapse risk of acute myloid leukemia (AML), using unrelated donors (URD) and antithymocyte globulin (ATG). Data was collected from 157 patients with AML, transplanted 2010-2016. The cumulative incidence of relapse (CIR) at 60 months was 50% in the CsAhigh versus 32% in the CsAlow group (p = 0.016). In univariate analysis, CsAhigh versus CsAlow (p = 0.028), 10-unit increase of CsA as a continuous variable (p = 0.017) and high risk disease (p = 0.003) were associated with higher CIR. The results remained after adjusting for disease risk. Death following relapse occurred more frequently in the CsAhigh group (p = 0.0076). There were no significant differences in rates of aGvHD, chronic GvHD (cGvHD), EBV/CMV-infections or overall survival (OS) between the two groups. In conclusion, we found that a median CsA concentration > 200 µg/L, the first month after HSCT, results in higher CIR of AML when combined with ATG.
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Affiliation(s)
- Mikael Lisak
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden.
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
| | - Malin Nicklasson
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden
| | - Robert Palmason
- Department of Hematology, Skane University Hospital, Lund, Sweden
| | - Stina Wichert
- Department of Hematology, Skane University Hospital, Lund, Sweden
| | - Cecila Isaksson
- Department of Hematology, Norrland University Hospital, Umeå, Sweden
| | - Per-Ola Andersson
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Jan-Erik Johansson
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Stig Lenhoff
- Department of Hematology, Skane University Hospital, Lund, Sweden
| | - Mats Brune
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Markus Hansson
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Bruna stråket 5, plan 5, 413 45, Gothenburg, Sweden
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Hematology, Skane University Hospital, Lund, Sweden
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5
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Jones RJ, Bacigalupo A. The next horizon now that everyone has a donor: Precision allogeneic transplantation. Blood Rev 2023; 62:100990. [PMID: 35908981 DOI: 10.1016/j.blre.2022.100990] [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: 05/19/2022] [Revised: 06/28/2022] [Accepted: 07/07/2022] [Indexed: 11/23/2022]
Abstract
Post-transplant cyclophosphamide (PTCy) allows safe and effective partially matched donor allogeneic blood or marrow transplantation (alloBMT), so that almost everyone in need of the procedure now has a donor. Moreover, PTCy and other recent advances have lowered alloBMT mortality rates to less than half of that seen before the turn of the century, at costs that are substantially less than most newly approved anticancer agents. These advances also make tailoring BMT based on patients' unique diseases and characteristics now feasible for further improving outcomes. Personalizing every aspect of alloBMT, including conditioning, donor, graft type, and post-transplant maintenance is now possible. For example, alloBMT's antitumor activity historically was restricted to the allogeneic graft-versus-tumor effect directed against histocompatibility antigens. However, replacing exhausted immune systems with healthy non-exhausted, non-tolerant ones likely can enhance the activity of novel targeted therapies. The impressive results seen with tyrosine kinase inhibitors after alloBMT for patients with both Ph+ acute lymphoblastic leukemia and FLT/ITD+ acute myeloid leukemia herald the potential of precision BMT.
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Affiliation(s)
- Richard J Jones
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, John Hopkins University, Baltimore, MD, United States of America.
| | - Andrea Bacigalupo
- Hematology and Bone Marrow Transplant Unit, Fondazione Universitario Policlinico Gemelli IRCCS, Rome, Italy
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6
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Jurdi NE, Hoover A, O'Leary D, Cao Q, Gupta A, Ebens C, Maakaron JE, Betts BC, Rashidi A, Juckett MB, Lund T, Bachanova V, MacMillan ML, Miller JS, Orchard PJ, Wagner JE, Vercellotti G, Weisdorf DJ, Dusenbery K, Terezakis S, Holtan SG. Phase II Study of Myeloablative 7-8/8-Matched Allotransplantation with Post-Transplantation Cyclophosphamide, Tacrolimus, and Mycophenolate Mofetil. Transplant Cell Ther 2023; 29:576.e1-576.e5. [PMID: 37311510 PMCID: PMC10530433 DOI: 10.1016/j.jtct.2023.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 06/15/2023]
Abstract
Graft-versus-host disease (GVHD) is the major toxicity of allogeneic hematopoietic cell transplantation (HCT). We hypothesized that a GVHD prophylaxis regimen of post-transplantation cyclophosphamide (PTCy), tacrolimus (Tac), and mycophenolate mofetil (MMF) would be associated with incidences of acute and chronic GVHD in patients receiving a matched or single antigen mismatched HCT. This Phase II study was conducted at the University of Minnesota using a myeloablative regimen of either total body irradiation (TBI) at a total dose of 1320 cGy, administered in 165-cGy fractions, twice daily from day -4 to day -1, or busulfan (Bu) 3.2 mg/kg daily (cumulative area under the curve, 19,000 to 21,000 μmol/min/L) plus fludarabine (Flu) 40 mg/m2 once daily on days -5 to -2, followed by a GVHD prophylaxis regimen of PTCy 50 mg/kg on days +3 and +4, Tac, and MMF beginning on day +5. The primary endpoint was the cumulative incidence of chronic GVHD necessitating systemic immunosuppression (IST) at 1 year post-transplantation. Between March 2018 and May 2022, we enrolled 125 pediatric and adult patients, with a median follow-up of 813 days. The incidence of chronic GVHD necessitating systemic IST at 1 year was 5.5%. The rate of grade II-IV acute GVHD was 17.1%, and that of grade III-IV acute GVHD was 5.5%. Two-year overall survival was 73.7%, and 2-year graft-versus-host disease-free, relapse-free survival was 52.2%. The 2-year cumulative incidence of nonrelapse mortality was 10.2%, and the rate of relapse was 39.1%. There was no statistically significant difference in survival outcomes between recipients of matched donor transplants versus recipients of 7/8 matched donor transplants. Our data show that myeloablative HCT with PTCy/Tac/MMF results in an extremely low incidence of severe acute and chronic GVHD in well-matched allogeneic HCT.
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Affiliation(s)
- Najla El Jurdi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Alex Hoover
- Division of Pediatric Hematology/Oncology, University of Minnesota, Minneapolis, Minnesota
| | - Daniel O'Leary
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Qing Cao
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Ashish Gupta
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Christen Ebens
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Joseph E Maakaron
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Brian C Betts
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Armin Rashidi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Mark B Juckett
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Troy Lund
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Veronika Bachanova
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Jeffrey S Miller
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Paul J Orchard
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - John E Wagner
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Gregory Vercellotti
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Kathryn Dusenbery
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota
| | - Stephanie Terezakis
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota
| | - Shernan G Holtan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota.
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7
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El Jurdi N, Hoover A, O'Leary D, Cao Q, Gupta A, Ebens C, Maakaron J, Betts BC, Rashidi A, Juckett M, Lund T, Bachanova V, MacMillan M, Miller J, Orchard P, Wagner J, Vercellotti G, Weisdorf D, Dusenbery K, Terezakis S, Holtan S. Phase II Study of Myeloablative 8/8- or 7/8-Matched Allotransplantation with Post-Transplant Cyclophosphamide, Tacrolimus, and Mycophenolate Mofetil: Marked Reduction in GVHD Risk Without Increased Relapse Risk Compared to Historical Cyclosporine/Methotrexate. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.24.23287521. [PMID: 37034603 PMCID: PMC10081397 DOI: 10.1101/2023.03.24.23287521] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Introduction Graft-versus host disease (GVHD) is a major limitation to the success of allogeneic hematopoietic cell transplant (HCT). We hypothesized that the GVHD prophylaxis regimen of post-transplant cyclophosphamide (PTCy), tacrolimus (Tac) and mycophenolate mofetil (MMF) would reduce the incidence of GVHD in patients receiving a matched or single antigen mismatched HCT without an increase in risk of malignant relapse. Methods This is a phase II study conducted at the University of Minnesota using a myeloablative regimen of either: (A) total body irradiation (TBI, total dose 1320 cGy, administered in 165 cGy fractions, twice a day from days -4 to -1) or (B) Busulfan 3.2mg/kg daily (cumulative AUC 19,000 - 21,000 μmol/min/L) plus fludarabine 160mg/m2 days -5 to -2, followed by a GVHD prophylaxis regimen of PTCy (50mg/kg days +3 and +4), Tac and MMF (beginning day +5). The primary endpoint is cumulative incidence of chronic GVHD requiring systemic immunosuppression at 1-year post-transplant. We compared results to our previous myeloablative protocol for matched donors utilizing cyclosporine/methotrexate (CSA/MTX) GVHD prophylaxis. Results From March 2018 - June 2022, we enrolled and treated 125 pediatric and adult patients with a median follow up of 472 days. Grade II-IV acute GVHD occurred in 16% (95% confidence interval (CI): 9-23%); Grade III-IV acute GVHD was 4% (CI: 0-8%). No patients experienced grade IV GVHD, and there were no deaths due to GVHD before day 100. Only 3 developed chronic GVHD requiring immune suppression, (4%, CI: 0-8%). Two-year overall survival (OS) was 80% (CI: 69-87%), and (graft-versus-host disease-free, relapse-free survival) GRFS 57% (CI: 45-67%), both higher than historical CSA/MTX. The incidence of grade II-IV aGVHD, cGVHD, and NRM were all lower with PTCy/Tac/MMF compared to historical CSA/MTX. One-quarter (25%) experienced relapse (CI: 15-36%) similar to historical CSA/MTX. There was no statistically significant difference in survival outcomes between recipients of matched versus 7/8 donors. Conclusion Myeloablative HCT with PTCy/Tac/MMF results in extremely low incidence of severe acute or chronic GVHD, the primary endpoint of this clinical trial. Relapse risk is not increased compared to our historical CSA/MTX cohort.
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Affiliation(s)
- Najla El Jurdi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Alex Hoover
- Division of Pediatric Hematology/Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Daniel O'Leary
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Qing Cao
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Ashish Gupta
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Christen Ebens
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Joseph Maakaron
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Brian C Betts
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Armin Rashidi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Mark Juckett
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Troy Lund
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Veronika Bachanova
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Margaret MacMillan
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Jeffrey Miller
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Paul Orchard
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - John Wagner
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Gregory Vercellotti
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Daniel Weisdorf
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Kathryn Dusenbery
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN
| | | | - Shernan Holtan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
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8
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Arcuri LJ, Lerner D, Tavares RDCBDS. Lower levels of cyclosporine between days 0 and +21 may reduce later relapses without increasing graft-versus-host disease in children and adolescents with acute lymphoblastic leukemia who undergo myeloablative TBI-based allogeneic hematopoietic cell transplantation. Eur J Haematol Suppl 2022; 109:182-185. [PMID: 35532300 DOI: 10.1111/ejh.13787] [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: 03/05/2022] [Revised: 05/01/2022] [Accepted: 05/03/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The degree of immunosuppression required for adequate graft-versus-host disease (GVHD) prevention, while keeping an adequate graft-versus-leukemia effect, in children with acute leukemia has not been established. We report the results of a retrospective comparison of cyclosporine levels and relapse rate in children and adolescents with acute lymphoblastic leukemia (ALL). METHODS Patients <21 y/o with ALL in remission who underwent TBI-based hematopoietic cell transplantation from related or unrelated donors between 2008 and 2021 were included. Cyclosporine levels were measured twice a week and we calculated the area under the curve (AUC) from D0 to D + 7, D + 14, and D + 21. RESULTS We included 76 patients. There was a trend towards a lower incidence of relapse in patients with a mean AUC < 200 ng/ml at D + 21 (HR = 0.41; p = .08). The 5-year relapse rate was 26.9% for patients with a mean AUC < 200 ng/ml at D + 21 and 43.9% for patients with a mean AUC≥200 ng/ml at D + 21. Relapse protection was restricted to relapses happening after D + 120 (HR = 0.21; p = .04). CONCLUSIONS Our results show evidence that pediatric patients with ALL might benefit from lower cyclosporine levels between D0 and D + 21 without a detectable increase in GVHD. Large prospective studies comparing different cyclosporine levels are awaited.
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Affiliation(s)
- Leonardo Javier Arcuri
- Department of Bone Marrow Transplantation, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | - Decio Lerner
- Department of Bone Marrow Transplantation, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
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9
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Huang Y, Zou Y, Jiao Y, Shi P, Nie X, Huang W, Xiong C, Choi M, Huang C, Macintyre AN, Nichols A, Li F, Li CY, MacIver NJ, Cardona D, Brennan TV, Li Z, Chao NJ, Rathmell J, Chen BJ. Targeting Glycolysis in Alloreactive T Cells to Prevent Acute Graft- Versus-Host Disease While Preserving Graft-Versus-Leukemia Effect. Front Immunol 2022; 13:751296. [PMID: 35296079 PMCID: PMC8920494 DOI: 10.3389/fimmu.2022.751296] [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: 07/31/2021] [Accepted: 02/03/2022] [Indexed: 02/02/2023] Open
Abstract
Alloreactive donor T cells undergo extensive metabolic reprogramming to become activated and induce graft-versus-host disease (GVHD) upon alloantigen encounter. It is generally thought that glycolysis, which promotes T cell growth and clonal expansion, is employed in this process. However, conflicting data have been reported regarding the requirement of glycolysis to induce T cell-mediated GVHD due to the lack of T cell-specific treatments using glycolysis inhibitors. Importantly, previous studies have not evaluated whether graft-versus-leukemia (GVL) activity is preserved in donor T cells deficient for glycolysis. As a critical component affecting the clinical outcome, it is necessary to assess the anti-tumor activity following treatment with metabolic modulators in preclinical models. In the present study, we utilized T cells selectively deficient for glucose transporter 1 (Glut1T-KO), to examine the role of glycolysis exclusively in alloreactive T cells without off-targeting effects from antigen presenting cells and other cell types that are dependent on glycolysis. We demonstrated that transfer of Glut1T-KO T cells significantly improved acute GVHD outcomes through increased apoptotic rates, impaired expansion, and decreased proinflammatory cytokine production. In addition to impaired GVHD development, donor Glut1T-KO T cells mediated sufficient GVL activity to protect recipients from tumor development. A clinically relevant approach using donor T cells treated with a small molecule inhibitor of glycolysis, 2-Deoxy-D-glucose ex vivo, further demonstrated protection from tumor development. These findings indicate that treatment with glycolysis inhibitors prior to transplantation selectively eliminates alloreactive T cells, but spares non-alloreactive T cells including those that protect against tumor growth. The present study has established a definitive role for glycolysis in acute GVHD and demonstrated that acute GVHD can be selectively prevented through targeting glycolysis.
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Affiliation(s)
- Ying Huang
- Division of Hematologic Malignancies and Cellular Therapy/Bone Marrow Transplantation (BMT), Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Yujing Zou
- Division of Hematologic Malignancies and Cellular Therapy/Bone Marrow Transplantation (BMT), Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Yiqun Jiao
- Division of Hematologic Malignancies and Cellular Therapy/Bone Marrow Transplantation (BMT), Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Peijie Shi
- Division of Hematologic Malignancies and Cellular Therapy/Bone Marrow Transplantation (BMT), Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Xiaoli Nie
- Division of Hematologic Malignancies and Cellular Therapy/Bone Marrow Transplantation (BMT), Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Wei Huang
- Division of Hematologic Malignancies and Cellular Therapy/Bone Marrow Transplantation (BMT), Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Chuanfeng Xiong
- Division of Hematologic Malignancies and Cellular Therapy/Bone Marrow Transplantation (BMT), Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Michael Choi
- Division of Hematologic Malignancies and Cellular Therapy/Bone Marrow Transplantation (BMT), Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Charles Huang
- Division of Hematologic Malignancies and Cellular Therapy/Bone Marrow Transplantation (BMT), Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Andrew N. Macintyre
- Departments of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC, United States
| | - Amanda Nichols
- Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | - Fang Li
- Department of Dermatology, Duke University Medical Center, Durham, NC, United States
| | - Chuan-Yuan Li
- Departments of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC, United States,Department of Dermatology, Duke University Medical Center, Durham, NC, United States,Duke Cancer Institute, Duke University Medical Center, Durham, NC, United States
| | - Nancie J. MacIver
- Departments of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC, United States,Department of Pediatrics, Duke University Medical Center, Durham, NC, United States,Department of Immunology, Duke University Medical Center, Durham, NC, United States
| | - Diana M. Cardona
- Department of Pathology, Duke University Medical Center, Durham, NC, United States
| | - Todd V. Brennan
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Zhiguo Li
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, United States
| | - Nelson J. Chao
- Division of Hematologic Malignancies and Cellular Therapy/Bone Marrow Transplantation (BMT), Department of Medicine, Duke University Medical Center, Durham, NC, United States,Duke Cancer Institute, Duke University Medical Center, Durham, NC, United States,Department of Immunology, Duke University Medical Center, Durham, NC, United States,Department of Pathology, Duke University Medical Center, Durham, NC, United States
| | - Jeffrey C. Rathmell
- Vanderbilt Center for Immunobiology, Departments of Pathology, Microbiology, and Immunology, Cancer Biology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Benny J. Chen
- Division of Hematologic Malignancies and Cellular Therapy/Bone Marrow Transplantation (BMT), Department of Medicine, Duke University Medical Center, Durham, NC, United States,Duke Cancer Institute, Duke University Medical Center, Durham, NC, United States,*Correspondence: Benny J. Chen,
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10
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Kállay KM, Algeri M, Buechner J, Krauss AC. Bispecific Antibodies and Other Non-CAR Targeted Therapies and HSCT: Decreased Toxicity for Better Transplant Outcome in Paediatric ALL? Front Pediatr 2022; 9:795833. [PMID: 35252074 PMCID: PMC8889254 DOI: 10.3389/fped.2021.795833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/15/2021] [Indexed: 11/16/2022] Open
Abstract
This review will address the place of innovative, non-chemotherapy, non-CAR-T targeted therapies in the treatment of Acute Lymphoblastic Leukaemia (ALL), focusing on their use in the hematopoietic stem cell transplant (HSCT) context. The focus will be on the agent with the most experience to date, namely the bispecific T-cell engater (BiTE) blinatumomab, but references to antibody-drug conjugates (ADCs) such as inotuzumab ozogamicin and monoclonal antibodies such as daratumamab will be made as well. Specific issues to be addressed include: (1) The use of these agents to reduce measurable residual disease (MRD) prior to HSCT and their potential for improved transplant outcomes due to reduced toxicity compared to traditional chemotherapy salvage, as well as potentially increased toxicity with HSCT with particular agents; (2) the appropriate sequencing of innovative therapies, i.e., when to use BiTEs or antibodies versus CARs pre- and/or post-HSCT; this will include also the potential for impact on response of one group of agents on response to the other; (3) the role of these agents particularly in the post-HSCT relapse setting, or as maintenance to prevent relapse in this setting; (4) special populations in which these agents may substitute for traditional chemotherapy during induction or consolidation in patients with predisposing factors for toxicity with traditional therapy (e.g., Trisomy 21, infants), or those who develop infectious complications precluding delivery of full standard-of-care (SOC) chemotherapy during induction/consolidation (e.g., fungal infections); (5) the evidence we have to date regarding the potential for substitution of blinatumomab for some of the standard chemotherapy agents used pre-HSCT in patients without the above risk factors for toxicity, but with high risk disease going into transplant, in an attempt to decrease current rates of transplant-related mortality as well as morbidity; (6) the unique toxicity profile of these agents and concerns regarding particular side effects in the HSCT context. The manuscript will include both the data we have to date regarding the above issues, ongoing studies that are trying to explore them, and suggestions for future studies to further refine our knowledge base.
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Affiliation(s)
- Krisztián Miklós Kállay
- Pediatric Hematology and Stem Cell Transplantation Department, National Institute of Hematology and Infectious Diseases, Central Hospital of Southern Pest, Budapest, Hungary
| | - Mattia Algeri
- Department of Pediatric Hematology and Oncology, Scientific Institute for Research and Healthcare (IRCCS), Bambino Gesù Childrens' Hospital, Rome, Italy
| | - Jochen Buechner
- Department of Pediatric Hematology and Oncology, Oslo University Hospital, Oslo, Norway
| | - Aviva C. Krauss
- Division of Hematopoietic Stem Cell Transplantation, Department of Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel
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11
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The Role of Allogeneic Hematopoietic Stem Cell Transplantation in Pediatric Leukemia. J Clin Med 2021; 10:jcm10173790. [PMID: 34501237 PMCID: PMC8432223 DOI: 10.3390/jcm10173790] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/08/2021] [Accepted: 08/19/2021] [Indexed: 02/07/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) offers potentially curative treatment for many children with high-risk or relapsed acute leukemia (AL), thanks to the combination of intense preparative radio/chemotherapy and the graft-versus-leukemia (GvL) effect. Over the years, progress in high-resolution donor typing, choice of conditioning regimen, graft-versus-host disease (GvHD) prophylaxis and supportive care measures have continuously improved overall transplant outcome, and recent successes using alternative donors have extended the potential application of allotransplantation to most patients. In addition, the importance of minimal residual disease (MRD) before and after transplantation is being increasingly clarified and MRD-directed interventions may be employed to further ameliorate leukemia-free survival after allogeneic HSCT. These advances have occurred in parallel with continuous refinements in chemotherapy protocols and the development of targeted therapies, which may redefine the indications for HSCT in the coming years. This review discusses the role of HSCT in childhood AL by analysing transplant indications in both acute lymphoblastic and acute myeloid leukemia, together with current and most promising strategies to further improve transplant outcome, including optimization of conditioning regimen and MRD-directed interventions.
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12
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Leclerc V, Ducher M, Ceraulo A, Bertrand Y, Bleyzac N. A Clinical Decision Support Tool to Find the Best Initial Intravenous Cyclosporine Regimen in Pediatric Hematopoietic Stem Cell Transplantation. J Clin Pharmacol 2021; 61:1485-1492. [PMID: 34105165 DOI: 10.1002/jcph.1924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/04/2021] [Indexed: 12/20/2022]
Abstract
To optimize cyclosporine A (CsA) dosing regimen in pediatric patients undergoing hematopoietic stem cell transplantation (HSCT), we aimed to provide clinicians with a validated decision support tool for determining the most suitable first dose of intravenous CsA. We used a 10-year monocentric data set of pediatric patients undergoing HSCT. Discretization of all variables was performed according to literature or thanks to algorithms using Shannon entropy (from information theory) or equal width intervals. The first 8 years were used to build the Bayesian network model. This model underwent a 10-fold cross-validation, and then a prospective validation with data of the last 2 years. There were 3.3% and 4.1% of missing values in the training and the validation data set, respectively. After prospective validation, the Tree-Augmented Naïve Bayesian network shows interesting prediction performances with an average area under the receiver operating characteristic curve of 0.804, 32.8% of misclassified patients, a true-positive rate of 0.672, and a false-positive rate of 0.285. This validated model allows good predictions to propose an optimized and personalized initial CsA dose for pediatric patients undergoing HSCT. The clinical impact of its use should be further evaluated.
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Affiliation(s)
- Vincent Leclerc
- Targeted Therapies in Oncology, Faculté de Médecine et de Maïeutique Lyon-Sud Charles Mérieux, Université Claude Bernard Lyon 1, Oullins, France.,Pharmacy Department, Hôpital Pierre Garraud, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France
| | - Michel Ducher
- Targeted Therapies in Oncology, Faculté de Médecine et de Maïeutique Lyon-Sud Charles Mérieux, Université Claude Bernard Lyon 1, Oullins, France.,Pharmacy Department, Hôpital Pierre Garraud, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France
| | - Antony Ceraulo
- Institute of Pediatric Hematology and Oncology (IHOPe), Hematology Unit, Hospices Civils de Lyon and Claude Bernard University, Lyon, France
| | - Yves Bertrand
- Institute of Pediatric Hematology and Oncology (IHOPe), Hematology Unit, Hospices Civils de Lyon and Claude Bernard University, Lyon, France
| | - Nathalie Bleyzac
- Targeted Therapies in Oncology, Faculté de Médecine et de Maïeutique Lyon-Sud Charles Mérieux, Université Claude Bernard Lyon 1, Oullins, France
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13
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Effect of Early Post-Transplantation Tacrolimus Concentration on the Risk of Acute Graft-Versus-Host Disease in Allogenic Stem Cell Transplantation. Cancers (Basel) 2021; 13:cancers13040613. [PMID: 33557088 PMCID: PMC7913846 DOI: 10.3390/cancers13040613] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/21/2021] [Accepted: 02/01/2021] [Indexed: 12/01/2022] Open
Abstract
Simple Summary Allogeneic hematopoietic stem cell transplantation is a potentially curative treatment for many hematological malignancies and disorders but is often complicated by a relapse of the underlying disease, graft-vs-host disease and infectious complications. However, despite the introduction of calcineurin inhibitors such as tacrolimus, graft-versus-host disease remains one of the major life-threatening complications of allogeneic hematopoietic stem cell transplantation. Due to a variety of factors, there is variability in tacrolimus concentrations during the early weeks post-transplantation. Since the immunologic events leading to acute GVHD also occur in the first few days post-transplantation, it is important that optimal levels be attained early after transplantation. The findings from this study will help inform the management of optimal tacrolimus levels to be attained early post-transplantation. Abstract Acute graft versus host disease (aGVHD) remains a leading cause of morbidity and mortality in allogeneic hematopoietic stem cell transplant (allo-HSCT). Tacrolimus (TAC), a calcineurin inhibitor that prevents T-cell activation, is commonly used as a GVHD prophylaxis. However, there is variability in the serum concentrations of TAC, and little is known on the impact of early TAC levels on aGVHD. We retrospectively analyzed 673 consecutive patients undergoing allo-HSCT at the Ohio State University between 2002 and 2016. Week 1 TAC was associated with a lower risk of aGVHD II–IV at TAC level ≥10.15 ng/mL (p = 0.03) compared to the lowest quartile. The cumulative incidence of relapse at 1, 3 and 5 years was 33%, 38% and 41%, respectively. TAC levels at week 2, ≥11.55 ng/mL, were associated with an increased risk of relapse (p = 0.01) compared to the lowest quartile. Subset analysis with acute myeloid leukemia and myelodysplastic syndrome patients showed significantly reduced aGVHD with TAC level ≥10.15 ng/mL at week 1 and a higher risk of relapse associated with week 2 TAC level ≥11.55 ng/mL (p = 0.02). Hence, achieving ≥10 ng/mL during the first week of HCT may mitigate the risk of aGVHD. However, levels (>11 ng/mL) beyond the first week may be associated with suppressed graft versus tumor effect and higher relapse.
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14
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Holtan SG, Versluis J, Weisdorf DJ, Cornelissen JJ. Optimizing Donor Choice and GVHD Prophylaxis in Allogeneic Hematopoietic Cell Transplantation. J Clin Oncol 2021; 39:373-385. [PMID: 33434075 DOI: 10.1200/jco.20.01771] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Shernan G Holtan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Jurjen Versluis
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Daniel J Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Jan J Cornelissen
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
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15
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Engle JA, Wasko JA, Rogosheske J, Defor TE, Rashidi A. Comparison of continuous versus intermittent infusion cyclosporine and impact on transplant related outcomes in allogeneic transplant recipients. J Oncol Pharm Pract 2020; 27:1835-1841. [PMID: 33138698 DOI: 10.1177/1078155220970608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Continuous infusion (CIVI) cyclosporine (CsA) is an alternative for allograft recipients intolerant of twice daily infusions (TDI). The importance of achieving therapeutic levels of CsA early after allogeneic HCT has been demonstrated in previous studies. Our study evaluated the incidence of acute graft versus host disease (GVHD) and survival among patients receiving CIVI vs. TDI CsA during their first allogeneic HCT. METHODS A retrospective study of adult patients undergoing first allogeneic HCT at the University of Minnesota Medical Center between 2011 and 2017. Patients were grouped according to the administration method. The primary outcome was the occurrence of acute grade II-IV GVHD by day +180. Secondary outcomes included the 1-year incidence of chronic GVHD, relapse, and overall survival. RESULTS 42 patients intolerant of TDI CsA received CsA via CIVI for >48 hours for a median of 9 days (range, 3-32 days). CsA concentrations were similar between groups. We found no difference between the rates of grade II-IV acute (45% vs 53%, p = 0.59) or chronic (17% vs 30%, p = 0.20) GVHD or overall survival (57% vs 67%, p = 0.10). Subgroup analysis of patients that received myeloablative conditioning or umbilical cord blood did not reveal significant differences in GVHD or overall survival. Cumulative incidence of relapse was higher among the continuous infusion group (39% vs. 23%, p < 0.01). CONCLUSION Due to the finding of increased risk of relapse, cyclosporine should be administered as traditional twice daily infusion unless necessary. A prospective clinical trial is needed to confirm these results.
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Affiliation(s)
- Jeff A Engle
- Fairview Pharmacy Services, M Health Fairview University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Justin A Wasko
- Department of Pharmacy, M Health Fairview University of Minnesota Medical Center, Minneapolis, MN, USA
| | - John Rogosheske
- Department of Pharmacy, M Health Fairview University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Todd E Defor
- Department of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Armin Rashidi
- Hematology, Oncology, and Transplant, University of Minnesota, Minneapolis, MN, USA
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16
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Antirelapse effect of pretransplant exposure to rabbit antithymocyte globulin. Blood Adv 2020; 3:1394-1405. [PMID: 31043372 DOI: 10.1182/bloodadvances.2018030247] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 03/24/2019] [Indexed: 01/15/2023] Open
Abstract
It remains unknown why rabbit antithymocyte globulin (ATG; Thymoglobulin) has not affected relapse after hematopoietic cell transplantation (HCT) in randomized studies. We hypothesized that high pre-HCT ATG area under the curve (AUC) would be associated with a low incidence of relapse, whereas high post-HCT AUC would be associated with a high incidence of relapse. We measured serum levels of ATG capable of binding to mononuclear cells (MNCs), lymphocytes, T cells, CD4 T cells, or CD33 cells. We estimated pre- and post-HCT AUCs in 152 adult recipients of myeloablative conditioning and blood stem cells. High pre-HCT AUCs of MNC- and CD33 cell-binding ATG were associated with a low incidence of relapse and high relapse-free survival (RFS). There was a trend toward an association of high post-HCT AUC of lymphocyte-binding ATG with a high incidence of relapse and low RFS. High pre-HCT AUCs were also associated with faster engraftment and had no impact on graft-versus-host disease (GVHD) or fatal infections. High post-HCT AUCs were associated with a low risk of GVHD, seemed associated with an increased risk of fatal infections, and had no impact on engraftment. In conclusion, pre-HCT AUC seems to have a positive, whereas post-HCT AUC seems to have a negative, impact on relapse.
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17
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ATIR101 administered after T-cell-depleted haploidentical HSCT reduces NRM and improves overall survival in acute leukemia. Leukemia 2020; 34:1907-1923. [PMID: 32047237 PMCID: PMC7326707 DOI: 10.1038/s41375-020-0733-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 01/09/2020] [Accepted: 01/29/2020] [Indexed: 12/19/2022]
Abstract
Overcoming graft-versus-host disease (GvHD) without increasing relapse and severe infections is a major challenge after allogeneic hematopoietic stem-cell transplantation (HSCT). ATIR101 is a haploidentical, naïve cell-enriched T-cell product, depleted of recipient-alloreactive T cells to minimize the risk of GvHD and provide graft-versus-infection and -leukemia activity. Safety and efficacy of ATIR101 administered after T-cell-depleted haploidentical HSCT (TCD-haplo + ATIR101) without posttransplant immunosuppressors were evaluated in a Phase 2, multicenter study of 23 patients with acute leukemia and compared with an observational cohort undergoing TCD-haplo alone (n = 35), matched unrelated donor (MUD; n = 64), mismatched unrelated donor (MMUD; n = 37), and umbilical cord blood (UCB; n = 22) HSCT. The primary endpoint, 6-month non-relapse mortality (NRM), was 13% with TCD-haplo + ATIR101. One year post HSCT, TCD-haplo + ATIR101 resulted in lower NRM versus TCD-haplo alone (P = 0.008). GvHD-free, relapse-free survival (GRFS) was higher with TCD-haplo + ATIR101 versus MMUD and UCB (both P < 0.03; 1-year rates: 56.5%, 27.0%, and 22.7%, respectively) and was not statistically different from MUD (1 year: 40.6%). ATIR101 grafts with high third-party reactivity were associated with fewer clinically relevant viral infections. Results suggest that haploidentical, selective donor-cell depletion may eliminate requirements for posttransplant immunosuppressors without increasing GvHD risk, with similar GRFS to MUD. Following these results, a randomized Phase 3 trial versus posttransplant cyclophosphamide had been initiated.
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18
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Severity of mucositis during allogeneic transplantation impacts post-transplant cyclosporin absorption. Bone Marrow Transplant 2020; 55:1857-1859. [DOI: 10.1038/s41409-020-0795-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/02/2019] [Accepted: 01/13/2020] [Indexed: 11/08/2022]
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19
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Balduzzi A, Dalle JH, Wachowiak J, Yaniv I, Yesilipek A, Sedlacek P, Bierings M, Ifversen M, Sufliarska S, Kalwak K, Lankester A, Toporski J, Di Maio L, Glogova E, Poetschger U, Peters C. Transplantation in Children and Adolescents with Acute Lymphoblastic Leukemia from a Matched Donor versus an HLA-Identical Sibling: Is the Outcome Comparable? Results from the International BFM ALL SCT 2007 Study. Biol Blood Marrow Transplant 2019; 25:2197-2210. [PMID: 31319153 DOI: 10.1016/j.bbmt.2019.07.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 07/07/2019] [Accepted: 07/08/2019] [Indexed: 12/19/2022]
Abstract
Eligibility criteria for hematopoietic stem cell transplantation (HSCT) in acute lymphoblastic leukemia (ALL) vary according to disease characteristics, response to treatment, and type of available donor. As the risk profile of the patient worsens, a wider degree of HLA mismatching is considered acceptable. A total of 138 children and adolescents who underwent HSCT from HLA-identical sibling donors (MSDs) and 210 who underwent HSCT from matched donors (MDs) (median age, 9 years; 68% male) in 10 countries were enrolled in the International-BFM ALL SCT 2007 prospective study to assess the impact of donor type in HSCT for pediatric ALL. The 4-year event-free survival (65 ± 5% vs 61 ± 4%; P = .287), overall survival (72 ± 4% versus 68 ± 4%; P = .235), cumulative incidence of relapse (24 ± 4% versus 25 ± 3%; P = .658) and nonrelapse mortality (10 ± 3% versus 14 ± 3%; P = .212) were not significantly different between MSD and MD graft recipients. The risk of extensive chronic (cGVHD) was lower in MD graft recipients than in MSD graft recipients (hazard ratio [HR], .38; P = .002), and the risks of severe acute GVHD (aGVHD) and cGVHD were higher in peripheral blood stem cell graft recipients than in bone marrow graft recipients (HR, 2.06; P = .026). Compared with the absence of aGVHD, grade I-II aGVHD was associated with a lower risk of graft failure (HR, .63; P = .042) and grade III-IV aGVHD was associated with a higher risk of graft failure (HR, 1.85; P = .020) and nonleukemic death (HR, 8.76; P < .0001), despite a lower risk of relapse (HR, .32; P = .021). Compared with the absence of cGVHD, extensive cGVHD was associated with a higher risk of nonleukemic death (HR, 8.12; P < .0001). Because the outcomes of transplantation from a matched donor were not inferior to those of transplantation from an HLA-identical sibling, eligibility criteria for transplantation might be reviewed in pediatric ALL and possibly in other malignancies as well. Bone marrow should be the preferred stem cell source, and the addition of MTX should be considered in MSD graft recipients.
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Affiliation(s)
- Adriana Balduzzi
- Clinica Pediatrica, Università degli Studi di Milano Bicocca, Fondazione Monza e Brianza per il Bambino e la sua Mamma, Ospedale San Gerardo, Monza, Italy.
| | - Jean-Hugues Dalle
- Hemato-Immunology Department, Robert-Debre Hospital, APHP and Paris-Diderot University, Paris, France
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, University of Medical Sciences, Poznan, Poland
| | - Isaac Yaniv
- Pediatric Hematology Oncology, Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Akif Yesilipek
- Antalya Medicalpark Hospital, Pediatric Stem Cell Transplantation Unit, Antalya, Turkey
| | - Petr Sedlacek
- Department of Pediatric Hematology and Oncology, University Hospital Motol, Prague, Czech Republic
| | - Marc Bierings
- Princess Maxima Centre for Pediatric Oncology and Utrecht University Children's Hospital, Utrecht, The Netherlands
| | - Marianne Ifversen
- Department of Pediatric and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sabina Sufliarska
- Bone Marrow Transplantation Unit, Comenius University Children's Hospital, Bratislava, Slovakia, Bratislava, Slovakia
| | - Krzysztof Kalwak
- Department of Pediatric Hematology/Oncology and BMT, Wroclaw Medical University, Wroclaw, Poland
| | - Arjan Lankester
- Department of Pediatrics, University Medical Centre, Willem-Alexander Children's Hospital, Leiden, The Netherlands
| | - Jacek Toporski
- Children's Hospital, Skåne University Hospital, Lund, Sweden
| | - Lucia Di Maio
- Clinica Pediatrica, Università degli Studi di Milano Bicocca, Fondazione Monza e Brianza per il Bambino e la sua Mamma, Ospedale San Gerardo, Monza, Italy
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20
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Medication adherence after pediatric allogeneic stem cell transplantation: Barriers and facilitators. Eur J Oncol Nurs 2019; 38:1-7. [DOI: 10.1016/j.ejon.2018.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 11/13/2018] [Accepted: 11/21/2018] [Indexed: 11/21/2022]
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21
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Bacigalupo A, Van Lint MT, Sica S, Laurenti L, Rosales MB, Dominietto A, di Grazia C, Angelucci E. High vs low dose cyclosporine-a, after allogeneic marrow transplantation in leukemia: Long term follow up of a randomized study. Am J Hematol 2018; 93. [PMID: 29726028 DOI: 10.1002/ajh.25131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 04/27/2018] [Accepted: 05/01/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Andrea Bacigalupo
- Istituto di Ematologia, Fondazione Policlinico Universitario A Gemelli, Universita' Cattolica, Roma, Italy
| | | | - Simona Sica
- Istituto di Ematologia, Fondazione Policlinico Universitario A Gemelli, Universita' Cattolica, Roma, Italy
| | - Luca Laurenti
- Istituto di Ematologia, Fondazione Policlinico Universitario A Gemelli, Universita' Cattolica, Roma, Italy
| | - Maria Belen Rosales
- Istituto di Ematologia, Fondazione Policlinico Universitario A Gemelli, Universita' Cattolica, Roma, Italy
| | - Alida Dominietto
- Divisione di Ematologia, IRCCS AOU San Martino IST, Genova, Italy
| | - Carmen di Grazia
- Divisione di Ematologia, IRCCS AOU San Martino IST, Genova, Italy
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22
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Hematopoietic Stem Cell Transplantation for Adult Philadelphia-Negative Acute Lymphoblastic Leukemia in the First Complete Remission in the Era of Minimal Residual Disease. Curr Oncol Rep 2018; 20:36. [PMID: 29577208 DOI: 10.1007/s11912-018-0679-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the potential role of allogeneic hematopoietic stem cell transplantation (allo-HSCT) for Philadelphia-negative (Ph-) adult acute lymphoblastic leukemia (ALL) in first complete remission (CR1) in the era of minimal residual disease (MRD). RECENT FINDINGS Allo-HSCT continues to have a role in the therapy of a selected group of high-risk adult patients with ALL in CR1. Although the clinical significance of MRD has been studied less extensively in adults with ALL than in children, recent studies support its role as the strongest prognostic factor that can identify patients that are unlikely to be cured by standard chemotherapy and benefit from undergoing allo-HSCT. In addition, MRD status both pre- and post-HSCT has been found to correlate directly with the risk of relapse. Currently, the clinical challenge consists on applying MRD and molecular failure to integrate novel agents and immunotherapy to lower MRD before allo-HSCT and to modulate the graft versus leukemia (GVL) effect after transplant.
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Yaniv I, Krauss AC, Beohou E, Dalissier A, Corbacioglu S, Zecca M, Afanasyev BV, Berger M, Diaz MA, Kalwak K, Sedlacek P, Varotto S, Peters C, Bader P. Second Hematopoietic Stem Cell Transplantation for Post-Transplantation Relapsed Acute Leukemia in Children: A Retrospective EBMT-PDWP Study. Biol Blood Marrow Transplant 2018; 24:1629-1642. [PMID: 29548831 DOI: 10.1016/j.bbmt.2018.03.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 03/06/2018] [Indexed: 02/05/2023]
Abstract
Outcome data were collected from the European Society for Blood and Marrow Transplantation registry on 373 children from 120 centers with relapsed leukemia (214 with acute lymphoblastic leukemia [ALL] and 159 with acute myelogenous leukemia [AML]) who underwent second allogeneic hematopoietic stem cell transplantation (HSCT) between 2004 and 2013. Overall survival (OS) was 38% at 2 years and 29% at 5 years, and leukemia-free survival (LFS) was 30% at 2 years and 25% at 5 years. Median follow-up after second HSCT was 36.4 months in the ALL group and 50.2 months in the AML group. In the ALL group, OS was 43% at 2 years and 33% at 5 years, and LFS was 34% at 2 years and 31% at 5 years. In the AML group, OS was 32% at 2 years and 24% at 5 years, and LFS was 24% at 2 years and 17% at 5 years. The 2-year nonrelapse mortality (NRM) rate was 22% in the ALL group and 18% in the AML group. Favorable prognostic factors (P < .05) for OS and LFS included >12 months between transplantations and chronic graft-versus-host disease after the first HSCT (in both groups), complete response before the second HSCT (ALL group only), and age >12 years (AML group only). Findings were more consistent over time in the ALL group, with no significant differences between 2-year and 5-year rates of relapse, NRM, and LFS. Children with relapsed acute leukemias have a substantial likelihood of long-term survival following second HSCT. Given the many novel targeted and immunomodulation therapies currently under development, it is important to identify specific patient subpopulations that may benefit from a second HSCT compared with those better suited to new approaches.
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Affiliation(s)
- Isaac Yaniv
- Rina Zaizov Hematology-Oncology Division, Schneider Children's Medical Center of Israel, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Aviva C Krauss
- Rina Zaizov Hematology-Oncology Division, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Eric Beohou
- EBMT Paris study office/CEREST-TC, Department of Haematology, Saint Antoine Hospital, INSERM UMR 938, Paris, France
| | - Arnaud Dalissier
- EBMT Paris study office/CEREST-TC, Department of Haematology, Saint Antoine Hospital, INSERM UMR 938, Paris, France
| | - Selim Corbacioglu
- Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Regensburg, Regensburg, Germany
| | - Marco Zecca
- Pediatric Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Boris V Afanasyev
- Hematology and Transplantation Department, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russian Federation
| | - Massimo Berger
- Pediatric Onco-Hematology, Regina Margherita Children Hospital, Torino, Italy
| | - Miguel Angel Diaz
- Division of Hematopoietic Stem Cell Transplantation, "Nino Jesus" Children Hospital, Madrid, Spain
| | - Krzysztof Kalwak
- Department of Pediatric Hematology/Oncology and Bone Marrow Transplantation, Cape of Hope Wroclaw Medical University, Wroclaw, Poland
| | - Petr Sedlacek
- Pediatric Hematology-Oncology, University Hospital Motol, Prague, Czech Republic
| | - Stefania Varotto
- Oncoematologia Pediatrica, Azienda Ospedaliera-Universita, Padova, Italy
| | - Christina Peters
- AustriaStem Cell Transplantation Unit, St. Anna Children's Hospital, Vienna, Austria
| | - Peter Bader
- Department for Children and Adolescents; Division for Stem Cell Transplantation and Immunology, University Hospital Frankfurt, Frankfurt, Germany
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Lovisa F, Zecca M, Rossi B, Campeggio M, Magrin E, Giarin E, Buldini B, Songia S, Cazzaniga G, Mina T, Acquafredda G, Quarello P, Locatelli F, Fagioli F, Basso G. Pre- and post-transplant minimal residual disease predicts relapse occurrence in children with acute lymphoblastic leukaemia. Br J Haematol 2018; 180:680-693. [DOI: 10.1111/bjh.15086] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 11/07/2017] [Indexed: 01/20/2023]
Affiliation(s)
- Federica Lovisa
- Clinic of Paediatric Haemato-Oncology, Department of Women's and Children's Health; University of Padua; Padua Italy
- Istituto di Ricerca Pediatrica Città della Speranza; Padua Italy
| | - Marco Zecca
- Paediatric Haematology/Oncology; Fondazione IRCCS Policlinico San Matteo; Pavia Italy
| | - Bartolomeo Rossi
- Clinic of Paediatric Haemato-Oncology, Department of Women's and Children's Health; University of Padua; Padua Italy
- Istituto di Ricerca Pediatrica Città della Speranza; Padua Italy
| | - Mimma Campeggio
- Clinic of Paediatric Haemato-Oncology, Department of Women's and Children's Health; University of Padua; Padua Italy
- Istituto di Ricerca Pediatrica Città della Speranza; Padua Italy
| | - Elisa Magrin
- Clinic of Paediatric Haemato-Oncology, Department of Women's and Children's Health; University of Padua; Padua Italy
- Istituto di Ricerca Pediatrica Città della Speranza; Padua Italy
- Departments of Biotherapy; Necker Children's Hospital; Assistance Publique-Hôpitaux de Paris; Paris France
| | - Emanuela Giarin
- Clinic of Paediatric Haemato-Oncology, Department of Women's and Children's Health; University of Padua; Padua Italy
- Istituto di Ricerca Pediatrica Città della Speranza; Padua Italy
| | - Barbara Buldini
- Clinic of Paediatric Haemato-Oncology, Department of Women's and Children's Health; University of Padua; Padua Italy
| | - Simona Songia
- Centro Ricerca Tettamanti; Paediatric Clinics; University of Milano-Bicocca; San Gerardo Hospital/Fondazione MBBM; Monza Italy
| | - Giovanni Cazzaniga
- Centro Ricerca Tettamanti; Paediatric Clinics; University of Milano-Bicocca; San Gerardo Hospital/Fondazione MBBM; Monza Italy
| | - Tommaso Mina
- Paediatric Haematology/Oncology; Fondazione IRCCS Policlinico San Matteo; Pavia Italy
| | - Gloria Acquafredda
- Paediatric Haematology/Oncology; Fondazione IRCCS Policlinico San Matteo; Pavia Italy
| | - Paola Quarello
- Paediatric Onco-Haematology; Stem Cell Transplantation and Cellular Therapy Division; Regina Margherita Children's Hospital; Turin Italy
| | - Franco Locatelli
- Paediatric Haematology/Oncology; IRCCS Ospedale “Bambino Gesù”; Roma Italy
- Department of Paediatric Sciences; University of Pavia; Pavia Italy
| | - Franca Fagioli
- Paediatric Onco-Haematology; Stem Cell Transplantation and Cellular Therapy Division; Regina Margherita Children's Hospital; Turin Italy
| | - Giuseppe Basso
- Clinic of Paediatric Haemato-Oncology, Department of Women's and Children's Health; University of Padua; Padua Italy
- Istituto di Ricerca Pediatrica Città della Speranza; Padua Italy
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Elgarten CW, Arnold DE, Bunin NJ, Seif AE. Outcomes of matched sibling donor bone marrow transplantation in children using single-agent calcineurin inhibitors as prophylaxis for graft versus host disease. Pediatr Blood Cancer 2018; 65:10.1002/pbc.26726. [PMID: 28748621 PMCID: PMC5699955 DOI: 10.1002/pbc.26726] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/20/2017] [Accepted: 06/22/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Optimal graft versus host disease (GVHD) prophylaxis prevents severe manifestations without excess immunosuppression. Standard prophylaxis includes a calcineurin inhibitor (CNI) with low-dose methotrexate. However, single-agent CNI may be sufficient prophylaxis for a defined group of patients. Single-agent CNI has been used for GVHD prophylaxis for human leukocyte antigen (HLA)-matched sibling donor (MSD) bone marrow transplants (BMTs) in young patients at the Children's Hospital of Philadelphia for over 20 years. Here, we describe outcomes using this prophylactic strategy in a recent cohort. PROCEDURE We performed a single-institution chart review and retrospective analysis of consecutive children undergoing MSD BMT who received single-agent CNI for GVHD prophylaxis between January 2002 and December 2014. RESULTS Fifty-two children with a median age of 6.1 years (interquartile range [IQR] 2.5-8.3) and donor age of 6 years (IQR 3-10), with malignant and nonmalignant diseases (n = 35 and 17, respectively) were evaluated. Forty-three (82.6%) received oral prophylaxis with single-agent tacrolimus after initial intravenous therapy. Rates of GVHD were consistent with reported rates on dual prophylaxis: the overall incidence of grades 2-4 acute GVHD was 25.5%, grades 3-4 GVHD 9.8%, and chronic GVHD 10.4%. The cumulative incidence of relapse among children with malignancy was 20% at a median of 237 days (IQR 194-318) post-transplant. Two-year overall survival was 82.7% (95% confidence interval [CI]: 69.4-90.6%) and event-free survival was 78.9% (95% CI: 65.1-87.7%). No patient experienced graft failure. CONCLUSIONS Single-agent CNI is a safe, effective approach to GVHD prophylaxis in young patients undergoing HLA-identical sibling BMT. Additionally, single-agent oral tacrolimus is a reasonable alternative to cyclosporine in this population.
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Affiliation(s)
- Caitlin W. Elgarten
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Danielle E. Arnold
- Division of Immunology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nancy J. Bunin
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alix E. Seif
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Qayed M, Wang T, Hemmer MT, Spellman S, Arora M, Couriel D, Alousi A, Pidala J, Abdel-Azim H, Aljurf M, Ayas M, Bitan M, Cairo M, Choi SW, Dandoy C, Delgado D, Gale RP, Hale G, Frangoul H, Kamble RT, Kharfan-Dabaja M, Lehman L, Levine J, MacMillan M, Marks DI, Nishihori T, Olsson RF, Hematti P, Ringden O, Saad A, Satwani P, Savani BN, Schultz KR, Seo S, Shenoy S, Waller EK, Yu L, Horowitz MM, Horan J. Influence of Age on Acute and Chronic GVHD in Children Undergoing HLA-Identical Sibling Bone Marrow Transplantation for Acute Leukemia: Implications for Prophylaxis. Biol Blood Marrow Transplant 2017; 24:521-528. [PMID: 29155316 DOI: 10.1016/j.bbmt.2017.11.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 11/02/2017] [Indexed: 10/18/2022]
Abstract
Relapse remains the major cause of mortality after hematopoietic cell transplantation (HCT) for pediatric acute leukemia. Previous research has suggested that reducing the intensity of calcineurin inhibitor-based graft-versus-host disease (GVHD) prophylaxis may be an effective strategy for abrogating the risk of relapse in pediatric patients undergoing matched sibling donor (MSD) HCT. We reasoned that the benefits of this strategy could be maximized by selectively applying it to those patients least likely to develop GVHD. We conducted a study of risk factors for GVHD, to risk-stratify patients based on age. Patients age <18 years with leukemia who received myeloablative, T cell-replete MSD bone marrow transplantation and calcineurin inhibitor-based GVHD prophylaxis between 2000 and 2013 and were entered into the Center for International Blood and Marrow Transplant Research registry were included. The cumulative incidence of grade II-IV acute GVHD (aGVHD) was 19%, that of grade II-IV aGVHD 7%, and that of chronic GVHD (cGVHD) was 16%. Compared with age 13 to 18 years, age 2 to 12 years was associated with a lower risk of grade II-IV aGVHD (hazard ratio [HR], .42; 95% confidence interval [CI], .26 to .70; P = .0008), grade II-IV aGVHD (HR, .24; 95% CI, .10 to .56; P = .001), and cGVHD (HR, .32; 95% CI, .19 to .54; P < .001). Compared with 2000-2004, the risk of grade II-IV aGVHD was lower in children undergoing transplantation in 2005-2008 (HR, .36; 95% CI, .20 to .65; P = .0007) and in 2009-2013 (HR, .24; 95% CI. .11 to .53; P = .0004). Similarly, the risk of grade III-IV aGVHD was lower in children undergoing transplantation in 2005-2008 (HR, .23; 95% CI, .08 to .65; P = .0056) and 2009-2013 (HR, .16; 95% CI, .04 to .67; P = .0126) compared with those doing so in 2000-2004. We conclude that aGVHD rates have decreased significantly over time, and that children age 2 to 12 years are at very low risk for aGVHD and cGVHD. These results should be validated in an independent analysis, because these patients with high-risk malignancies may be good candidates for trials of reduced GVHD prophylaxis.
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Affiliation(s)
- Muna Qayed
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Atlanta, Georgia.
| | - Tao Wang
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael T Hemmer
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Stephen Spellman
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be the Match, Minneapolis, Minnesota
| | - Mukta Arora
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Daniel Couriel
- Department of Internal Medicine, Division of Hematology and Hematologic Malignancies, Utah Blood and Marrow Transplant Program, Salt Lake City, Utah
| | - Amin Alousi
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Joseph Pidala
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Hisham Abdel-Azim
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mouhab Ayas
- Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital and Research Center, Ridayh, Saudi Arabia
| | - Menachem Bitan
- Department of Pediatric Hematology/Oncology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Mitchell Cairo
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, New York Medical College, Valhalla, New York
| | - Sung Won Choi
- Department of Pediatrics and Communicable Diseases, The University of Michigan, Ann Arbor, Michigan
| | - Christopher Dandoy
- , Department of Pediatrics, Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David Delgado
- Department of Pediatrics, Indiana University Hospital, Indianapolis, Indiana
| | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Gregory Hale
- Department of Hematology/Oncology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Haydar Frangoul
- Pediatric Hematology - Oncology, The Children's Hospital at TriStar Centennial and Sarah Cannon Research Institute, Nashville, Tennessee
| | - Rammurti T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Mohamed Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Leslie Lehman
- Department of Pediatrics - Hematology Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - John Levine
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Margaret MacMillan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - David I Marks
- Adult Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Richard F Olsson
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Peiman Hematti
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Medicine, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Olov Ringden
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ayman Saad
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Prakash Satwani
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kirk R Schultz
- Department of Pediatric Hematology, Oncology and Bone Marrow Transplant, British Columbia's Children's Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sachiko Seo
- National Cancer Research Center, East Hospital, Kashiwa, Chiba, Japan
| | - Shalini Shenoy
- Department of Pediatrics - Hematology Oncology, Washington University, St. Louis, Missouri
| | - Edmund K Waller
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Lolie Yu
- Division of Hematology/Oncology, Center for Cancer and Blood Disorders, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Mary M Horowitz
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John Horan
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Atlanta, Georgia
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Page KM, Labopin M, Ruggeri A, Michel G, Diaz de Heredia C, O'Brien T, Picardi A, Ayas M, Bittencourt H, Vora AJ, Troy J, Bonfim C, Volt F, Gluckman E, Bader P, Kurtzberg J, Rocha V. Factors Associated with Long-Term Risk of Relapse after Unrelated Cord Blood Transplantation in Children with Acute Lymphoblastic Leukemia in Remission. Biol Blood Marrow Transplant 2017; 23:1350-1358. [PMID: 28438676 PMCID: PMC5569913 DOI: 10.1016/j.bbmt.2017.04.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 04/16/2017] [Indexed: 12/20/2022]
Abstract
For pediatric patients with acute lymphoblastic leukemia (ALL), relapse is an important cause of treatment failure after unrelated cord blood transplant (UCBT). Compared with other donor sources, relapse is similar or even reduced after UCBT despite less graft-versus-host disease (GVHD). We performed a retrospective analysis to identify risk factors associated with the 5-year cumulative incidence of relapse after UCBT. In this retrospective, registry-based study, we examined the outcomes of 640 children (<18 years) with ALL in first complete remission (CR1; n = 257, 40%) or second complete remission (CR2; n = 383, 60%) who received myeloablative conditioning followed by a single-unit UCBT from 2000 to 2012. Most received antithymocyte globulin (88%) or total body irradiation (TBI; 69%), and cord blood grafts were primarily mismatched at 1 (50%) or 2+ (34%) HLA loci. Considering patients in CR1, the rates of 5-year overall survival (OS), leukemia-free survival (LFS), and relapse were 59%, 52%, and 23%, respectively. In multivariate analysis (MVA), acute GVHD (grades II to IV) and TBI protected against relapse. In patients in CR2, rates of 5-year OS, LFS, and the cumulative incidence of relapse were 46%, 44%, and 28%, respectively. In MVA, longer duration from diagnosis to UCBT (≥30 months) and TBI were associated with decreased relapse risk. Importantly, receiving a fully HLA matched graft was a strong risk factor for increased relapse in MVA. An exploratory analysis of all 640 patients supported the important association between the presence of acute GVHD and less relapse but also demonstrated an increased risk of nonrelapse mortality. In conclusion, the impact of GVHD as a graft-versus-leukemia marker is evident in pediatric ALL after UCBT. Strategies that promote graft-versus-leukemia while harnessing GVHD should be further investigated.
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Affiliation(s)
- Kristin M Page
- Division of Pediatric Blood and Marrow Transplantation, Duke University Medical Center, Durham, North Carolina.
| | - Myriam Labopin
- EBMT, Acute Leukemia Working Party, Service d'hematologie et therapie cellulaire, Hôpital Saint Antoine, Paris, France
| | - Annalisa Ruggeri
- EBMT, Acute Leukemia Working Party, Service d'hematologie et therapie cellulaire, Hôpital Saint Antoine, Paris, France; Eurocord, Hospital Saint Louis APHP, University Paris-Diderot, Paris, France; Monacord, Centre Scientifique de Monaco, Monaco-Ville, Monaco
| | - Gerard Michel
- Timone Enfants Hospital and Aix-Marseille University, Department of Pediatric Hematology and Oncology, Marseille, France
| | | | - Tracey O'Brien
- Blood and Marrow Transplant Program, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | | | - Mouhab Ayas
- Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | | | - Ajay J Vora
- Department of Pediatric Haematology, The Children's Hospital, Sheffield, UK; Department of Haematology and Oncology, Great Ormond Street Hospital, London, UK
| | - Jesse Troy
- Division of Pediatric Blood and Marrow Transplantation, Duke University Medical Center, Durham, North Carolina
| | - Carmen Bonfim
- Hospital Das Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Fernanda Volt
- Eurocord, Hospital Saint Louis APHP, University Paris-Diderot, Paris, France; Monacord, Centre Scientifique de Monaco, Monaco-Ville, Monaco
| | - Eliane Gluckman
- Eurocord, Hospital Saint Louis APHP, University Paris-Diderot, Paris, France; Monacord, Centre Scientifique de Monaco, Monaco-Ville, Monaco
| | - Peter Bader
- Division for Stem Cell Transplantation and Immunology, Hospital for Children and Adolescents, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Joanne Kurtzberg
- Division of Pediatric Blood and Marrow Transplantation, Duke University Medical Center, Durham, North Carolina
| | - Vanderson Rocha
- Eurocord, Hospital Saint Louis APHP, University Paris-Diderot, Paris, France; Monacord, Centre Scientifique de Monaco, Monaco-Ville, Monaco; Hospital Das Clinicas, University of Sao Paulo, Sao Paulo, Brazil; Churchill Hospital, Oxford University, Oxford, UK
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28
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Yuan J, Pei R, Su W, Cao J, Lu Y. Meta-analysis of the actions of antithymocyte globulin in patients undergoing allogeneic hematopoietic cell transplantation. Oncotarget 2017; 8:10871-10882. [PMID: 28107198 PMCID: PMC5355230 DOI: 10.18632/oncotarget.14719] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 12/20/2016] [Indexed: 12/26/2022] Open
Abstract
Graft-versus-host disease (GVHD) is a serious complication associated with allogeneic hematopoietic cell transplantation (allo-HCT). Antithymocyte globulin (ATG) is widely used prior to allo-HCT for GVHD prevention, though evidence of its efficacy remains unclear. We therefore identified nine randomized controlled trials (RCTs), enrolling 1089 patients (554 in the ATG group and 535 in the non-ATG group) to conduct a meta-analysis of the actions of ATG in allo-HCT. A relative risk or risk ratio (RR) and 95% confidence interval (CI) were calculated for each outcome. Rabbit ATG reduced overall acute (a) GVHD (RR 0.77, 95% CI 0.67-0.89, P = 0.0004), grade III-IV aGVHD (RR 0.53, 95% CI 0.32-0.88, P = 0.01), overall chronic (c) GVHD (RR 0.52, 95% CI 0.42-0.64, P < 0.00001) and extensive cGVHD (RR 0.28, 95% CI 0.18-0.43, P < 0.00001), without increased risk of relapse (RR 1.17, 95% CI 0.91-1.49, P = 0.23). By contrast, horse ATG did not reduce overall aGVHD (RR 1.25, 95% CI 0.88-1.79, P = 0.22) or cGVHD (RR 1.67, 95% CI 0.96-2.91, P = 0.07). ATG marginally reduced 100-day transplant related mortality (RR 0.75, 95% CI 0.56-1.00, P = 0.05) without compromising overall survival or increased risk of infections. Further studies are required to evaluate the optimal dosage and formulation of ATG in different conditioning regimens of transplantation with varied sources of graft and donor.
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Affiliation(s)
- Jiaojiao Yuan
- Medical School of Ningbo University, Ningbo, Zhejiang, P.R. China
| | - Renzhi Pei
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, Ningbo, Zhejiang, P.R. China
| | - Wensi Su
- Medical School of Ningbo University, Ningbo, Zhejiang, P.R. China
| | - Junjie Cao
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, Ningbo, Zhejiang, P.R. China
| | - Ying Lu
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, Ningbo, Zhejiang, P.R. China
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29
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Lamble A, Phelan R, Burke M. When Less Is Good, Is None Better? The Prognostic and Therapeutic Significance of Peri-Transplant Minimal Residual Disease Assessment in Pediatric Acute Lymphoblastic Leukemia. J Clin Med 2017; 6:E66. [PMID: 28686179 PMCID: PMC5532574 DOI: 10.3390/jcm6070066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/26/2017] [Accepted: 07/03/2017] [Indexed: 02/06/2023] Open
Abstract
The measurement of minimal residual disease (MRD) in pediatric acute lymphoblastic leukemia (ALL) has become the most important prognostic tool of, and the backbone to, upfront risk stratification. While MRD assessment is the standard of care for assessing response and predicting outcomes for pediatric patients with ALL receiving chemotherapy, its use in allogeneic hematopoietic stem cell transplant (HSCT) has been less clearly defined. Herein, we discuss the importance of MRD assessment during the peri-HSCT period and its role in prognostication and management.
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Affiliation(s)
- Adam Lamble
- Pediatric Hematology/Oncology, Oregon Health & Science University, Portland, OR 97239, USA.
| | - Rachel Phelan
- Pediatric Hematology/Oncology/Blood and Marrow Transplant, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
| | - Michael Burke
- Pediatric Hematology/Oncology/Blood and Marrow Transplant, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Shimomura Y, Hara M, Hashimoto H, Ishikawa T. Elevated bone marrow eosinophil count is associated with high incidence of severe acute GvHD after allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2017. [DOI: 10.1038/bmt.2017.98] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Uygun V, Uygun DF, Daloğlu H, Öztürkmen SI, Karasu G, Hazar V, Yeşilipek A. Outcomes of high-grade gastrointestinal graft-versus-host disease posthematopoietic stem cell transplantation in children. Medicine (Baltimore) 2016; 95:e5242. [PMID: 27858879 PMCID: PMC5591127 DOI: 10.1097/md.0000000000005242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We explored the clinical course of acute high-grade gastrointestinal graft-versus-host disease in children in a single center. This was a retrospective analysis of 28 pediatric patients who presented with a clinical diagnosis of stage III and IV acute graft-versus-host disease (aGVHD) of the gastrointestinal system (GIS). Generally, skin involvement was the initial manifestation of aGVHD that began in the first 3 weeks of hematopoietic stem cell transplantation (HSCT); on the other hand, GIS involvement predominated after the second week of HSCT. Reported adult data show a survival rate of only 25%; however, our study showed more favorable outcomes in children with a survival rate of 55%. We monitored levels of albumin and immunoglobulin G and observed low levels overall during treatment of unresponsive patients, although only albumin levels were shown to be significantly different. We observed a significant increase in mortality with the use of antithymocyte globulin in GIS aGVHD, although antithymocyte globulin used for graft-versus-host disease prophylaxis had no demonstrable effect on GIS aGVHD mortality. Whether the significantly lower GIS aGVHD mortality among the children recruited in our study than among their historical adult counterparts is a primary result of the specific attributes of the pediatric GIS, or whether it originated from HSCT kinetics remains to be determined by future studies.
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Affiliation(s)
- Vedat Uygun
- Bahçeşehir University, Medical Park Antalya Hospital, Pediatric BMT Unit
- Correspondence: Vedat Uygun, Bahçeşehir University, Medical Park Antalya Hospital, Pediatric BMT Unit, Fener Mah. Tekelioğlu Cad. No. 7, Lara, Antalya, Turkey (e-mail: )
| | - Dilara F.K. Uygun
- Akdeniz University School of Medicine, Department of Pediatric Allergy and Immunology
| | | | | | - Gülsün Karasu
- Bahçeşehir University, Medical Park Göztepe Hospital, Pediatric BMT Unit
| | - Volkan Hazar
- Medipol University Faculty of Medicine, Pediatric Hematology & Oncology and BMT Unit, İstanbul, Turkey
| | - Akif Yeşilipek
- Bahçeşehir University, Medical Park Antalya Hospital, Pediatric BMT Unit
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Antithymocyte Globulin at Clinically Relevant Concentrations Kills Leukemic Blasts. Biol Blood Marrow Transplant 2016; 22:815-24. [DOI: 10.1016/j.bbmt.2016.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 01/04/2016] [Indexed: 01/03/2023]
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Affiliation(s)
- Gregory M T Guilcher
- Section of Pediatric Oncology/BMT, Alberta Children's Hospital; Departments of Oncology and Pediatrics, University of Calgary, Calgary, Alberta, Canada
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Inamoto Y, Flowers MED, Wang T, Urbano-Ispizua A, Hemmer MT, Cutler CS, Couriel DR, Alousi AM, Antin JH, Gale RP, Gupta V, Hamilton BK, Kharfan-Dabaja MA, Marks DI, Ringdén OTH, Socié G, Solh MM, Akpek G, Cairo MS, Chao NJ, Hayashi RJ, Nishihori T, Reshef R, Saad A, Shah A, Teshima T, Tallman MS, Wirk B, Spellman SR, Arora M, Martin PJ. Tacrolimus versus Cyclosporine after Hematopoietic Cell Transplantation for Acquired Aplastic Anemia. Biol Blood Marrow Transplant 2015; 21:1776-82. [PMID: 26033280 PMCID: PMC4568149 DOI: 10.1016/j.bbmt.2015.05.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 05/23/2015] [Indexed: 11/25/2022]
Abstract
Combinations of cyclosporine (CSP) with methotrexate (MTX) have been widely used for immunosuppression after allogeneic transplantation for acquired aplastic anemia. We compared outcomes with tacrolimus (TAC)+MTX versus CSP+MTX after transplantation from HLA-identical siblings (SIB) or unrelated donors (URD) in a retrospective cohort of 949 patients with severe aplastic anemia. Study endpoints included hematopoietic recovery, graft failure, acute graft-versus-host disease (GVHD), chronic GVHD, and mortality. TAC+MTX was used more frequently in older patients and, in recent years, in both SIB and URD groups. In multivariate analysis, TAC+MTX was associated with a lower risk of mortality in URD recipients and with slightly earlier absolute neutrophil count recovery in SIB recipients. Other outcomes did not differ statistically between the 2 regimens. No firm conclusions were reached regarding the relative merits of TAC+MTX versus CSP+MTX after hematopoietic cell transplantation for acquired aplastic anemia. Prospective studies would be needed to determine whether the use of TAC+MTX is associated with lower risk of mortality in URD recipients with acquired aplastic anemia.
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Affiliation(s)
- Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan.
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Tao Wang
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Alvaro Urbano-Ispizua
- Department of Hematology, Hospital Clinic, University of Barcelona, IDIBAPS and Institute of Research Josep Carreras, Barcelona, Spain
| | - Michael T Hemmer
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Corey S Cutler
- Center for Hematologic Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Daniel R Couriel
- Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Amin M Alousi
- Division of Cancer Medicine, Department of Stem Cell Transplantation, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Joseph H Antin
- Center for Hematologic Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College of London, London, United Kingdom
| | - Vikas Gupta
- Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Betty K Hamilton
- Blood and Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - David I Marks
- Pediatric Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Olle T H Ringdén
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Allogeneic Stem Cell Transplantation, Stockholm, Sweden
| | - Gérard Socié
- Department of Hematology, Hospital Saint Louis, Paris, France
| | - Melhem M Solh
- Blood and Marrow Transplant Center, Florida Hospital Medical Group, Orlando, Florida
| | - Görgün Akpek
- Stem Cell Transplantation and Cellular Therapy Program, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Mitchell S Cairo
- Department of Pediatrics, New York Medical College, Valhalla, New York
| | - Nelson J Chao
- Division of Cell Therapy and Hematologica, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Robert J Hayashi
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Ran Reshef
- Department of Medicine, Abramson Cancer Center, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | - Ayman Saad
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ami Shah
- Division of Hematology/Oncology, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, California
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Martin S Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Baldeep Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, Washington
| | - Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minneapolis
| | - Mukta Arora
- Division of Hematology, Oncology, Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Pulsipher MA, Langholz B, Wall DA, Schultz KR, Bunin N, Carroll W, Raetz E, Gardner S, Goyal RK, Gastier-Foster J, Borowitz M, Teachey D, Grupp SA. Risk factors and timing of relapse after allogeneic transplantation in pediatric ALL: for whom and when should interventions be tested? Bone Marrow Transplant 2015; 50:1173-9. [PMID: 25961775 PMCID: PMC4573663 DOI: 10.1038/bmt.2015.103] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 02/17/2015] [Accepted: 03/11/2015] [Indexed: 11/09/2022]
Abstract
We previously showed that minimal residual disease (MRD) detection pre-hematopoietic cell transplant (HCT) and acute GvHD (aGvHD) independently predicted risk of relapse in pediatric ALL. In this study we further define risk by assessing timing of relapse and the effects of leukemia risk category and post-HCT MRD. By multivariate analysis, pre-HCT MRD <0.1% and aGvHD by day +55 were associated with decreased relapse and improved event-free survival (EFS). Intermediate leukemia risk status predicted decreased relapse, and improved EFS and overall survival (OS). Patients with pre-HCT MRD ⩾0.1% who did not develop aGvHD compared with those with MRD <0.1% who did develop aGvHD had much worse survival (2 years EFS 18% vs 71%; P=0.001, 2 years OS 46 vs 74%; P=0.04). Patients with pre-HCT MRD <0.1% who did not experience aGvHD had higher rates of relapse than those who did develop aGvHD (40% vs 13%; P= 0.008). Post-HCT MRD led to a substantial increase in relapse risk (HR=4.5, P<0.01). Patients at high risk of relapse can be defined after transplant using leukemia risk category, presence of MRD pre or post HCT, and occurrence of aGvHD. An optimal window to initiate intervention to prevent relapse occurs between day +55 and +200 after HCT.
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Affiliation(s)
- Michael A. Pulsipher
- Division of Hematology and Hematological Malignancies, Huntsman Cancer Institute/University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City, UT
| | - Bryan Langholz
- Department of Preventive Medicine, USC Keck School of Medicine, Los Angeles, CA
| | - Donna A. Wall
- Manitoba Blood and Marrow Transplant Program, Winnepeg, MB, Canada
| | - Kirk R. Schultz
- Department of Pediatrics University of BC, BC Children’s Hospital, Vancouver, BC, Canada
| | - Nancy Bunin
- Division of Oncology, Children’s Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William Carroll
- NYU Department of Pediatrics and Cancer Institute, NYU Langone Medical Center, New York, NY
| | - Elizabeth Raetz
- Division of Hematology and Hematological Malignancies, Huntsman Cancer Institute/University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City, UT
| | - Sharon Gardner
- NYU Department of Pediatrics and Cancer Institute, NYU Langone Medical Center, New York, NY
| | - Rakesh K. Goyal
- Division of Blood and Marrow Transplantation and Cellular Therapies, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Julie Gastier-Foster
- Department of Pathology and Laboratory Medicine, Nationwide Children’s Hospital, Columbus, OH and Departments of Pathology and Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Michael Borowitz
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - David Teachey
- Division of Oncology, Children’s Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stephan A. Grupp
- Division of Oncology, Children’s Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Pathology, Children’s Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Tafazoli A. Cyclosporine use in hematopoietic stem cell transplantation: pharmacokinetic approach. Immunotherapy 2015; 7:811-36. [DOI: 10.2217/imt.15.47] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Cyclosporine is one of the most vital agents in the process of successful allogeneic hematopoietic stem cell transplantation. Despite a long history and worldwide extent of cyclosporine use for prevention of graft versus host disease, currently there are lots of uncertainties about its optimal method of application to reach the best clinical outcome. A major portion of this problem stems from complicated cyclosporine pharmacokinetics. Study of cyclosporine pharmacokinetic behavior can significantly help recognition of its effectiveness and consequently, optimization of dosing, administration, monitoring and management of adverse effects. In this review, highly accredited but sparse scientific data are gathered in order to provide a better insight for preparation of practice guidelines and directing future studies for allogeneic hematopoietic cell recipients.
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Affiliation(s)
- Ali Tafazoli
- Clinical Pharmacy Department, School of Pharmacy, Shahid Beheshti University of Medical Sciences (SBMU), Vali-e-Asr Avenue, Niayesh Junction, PO Box: 14155/6153 Tehran, Iran
- Taleghani Bone Marrow Transplantation Center, Taleghani Hospital, Shahid Beheshti University of Medical Sciences (SBMU), Vali-e-Asr Avenue, Niayesh Junction, PO Box 14155/6153 Tehran, Iran
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Perez M, Décaudin B, Abou Chahla W, Nelken B, Barthélémy C, Lebuffe G, Odou P. In vitro analysis of overall particulate contamination exposure during multidrug IV therapy: impact of infusion sets. Pediatr Blood Cancer 2015; 62:1042-7. [PMID: 25755136 DOI: 10.1002/pbc.25442] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 01/02/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND Drug incompatibilities, recognizable through precipitate, may have clinical consequences for patients, especially during multidrug IV therapies, where vancomycin and piperacillin are present. Drug concentration and infusion set influence the overall particulate contamination of pediatric infusion protocols. The use of multi-lumen infusion sets could prevent such incompatibilities. Our goal was to define and assess a new way to infuse these drugs during leukemia treatment in children. PROCEDURES This in vitro study focused on a pediatric multidrug protocol for patients diagnosed with lymphoblastic leukemia and receiving allogeneic transplantation. Different vancomycin concentrations were tested to infuse incompatible drugs simultaneously without any particle formation (optimized multidrug protocol). A dynamic particle count test was used over 24 hr to evaluate the overall particulate contamination of our standard and optimized multidrug protocols, using both a standard and a multi-lumen infusion set. RESULTS No visible particles were detected on a decreased vancomycin concentration compared to the standard dose. For the optimized multidrug protocol, the use of a multi-lumen infusion set reduced overall particulate contamination by 68%, compared to the standard infusion set (P = 0.002). Large-sized particles were significantly reduced when using the multi-lumen infusion set approximately 60% (P = 0.027) and 90% (P = 0.009) for particle sizes ≥10 μm and 25 μm, respectively. CONCLUSIONS This study demonstrates that a large number of particles can be administered during parenteral multidrug infusion. The choice of drug concentration and/or the type of infusion set may reduce this. Further studies are required to evaluate adverse clinical effects.
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Affiliation(s)
- Maxime Perez
- EA GRITA, University Lille Nord de France, Lille, France; Institute of Pharmacy, Lille University Hospital, Lille, France
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Storek J, Mohty M, Boelens JJ. Rabbit Anti–T Cell Globulin in Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2015; 21:959-70. [DOI: 10.1016/j.bbmt.2014.11.676] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 11/14/2014] [Indexed: 12/27/2022]
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Peters C, Schrappe M, von Stackelberg A, Schrauder A, Bader P, Ebell W, Lang P, Sykora KW, Schrum J, Kremens B, Ehlert K, Albert MH, Meisel R, Matthes-Martin S, Gungor T, Holter W, Strahm B, Gruhn B, Schulz A, Woessmann W, Poetschger U, Zimmermann M, Klingebiel T. Stem-Cell Transplantation in Children With Acute Lymphoblastic Leukemia: A Prospective International Multicenter Trial Comparing Sibling Donors With Matched Unrelated Donors—The ALL-SCT-BFM-2003 Trial. J Clin Oncol 2015; 33:1265-74. [DOI: 10.1200/jco.2014.58.9747] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Purpose Although hematopoietic stem-cell transplantation is widely performed in children with high-risk acute lymphoblastic leukemia (ALL), the influence of donor types is poorly understood. Thus, transplantation outcomes were compared in the prospective multinational Berlin-Frankfurt-Muenster (BFM) study group trial: ALL-SCT-BFM 2003 (Allogeneic Stem Cell Transplantation in Children and Adolescents with Acute Lymphoblastic Leukemia). Patients and Methods After conditioning with total-body irradiation and etoposide, 411 children with high-risk ALL received highly standardized stem-cell transplantations during the first or later remissions. Depending on donor availability, grafts originated from HLA-genoidentical siblings or from HLA-matched unrelated donors who were identified and matched by high-resolution allelic typing and were compatible in at least 9 of 10 HLA loci. Results Four-year event-free survival (± standard deviation [SD]) did not differ between patients with transplantations from unrelated or sibling donors (0.67 ± 0.03 v 0.71 ± 0.05; P = .405), with cumulative incidences of nonrelapse mortality (± SD) of 0.10 ± 0.02 and 0.03 ± 0.02 (P = .017) and relapse rates (± SD) of 0.22 ± 0.02 and 0.24 ± 0.04 (P = .732), respectively. Among recipients of transplantations from unrelated donors, no significant differences in event-free survival, overall survival, or nonrelapse mortality were observed between 9/10 and 10/10 matched grafts or between peripheral blood stem cells and bone marrow. The absence of chronic graft-versus-host disease had no effect on event-free survival. Engraftment was faster after bone marrow transplantation from siblings and was associated with fewer severe infections and pulmonary complications. Conclusion Outcome among high-risk pediatric patients with ALL after hematopoietic stem-cell transplantation was not affected by donor type. Standardized myeloablative conditioning produced a low incidence of treatment-related mortality and effective control of leukemia.
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Affiliation(s)
- Christina Peters
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Martin Schrappe
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Arend von Stackelberg
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - André Schrauder
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Peter Bader
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Wolfram Ebell
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Peter Lang
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Karl-Walter Sykora
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Johanna Schrum
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Bernhard Kremens
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Karoline Ehlert
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Michael H. Albert
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Roland Meisel
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Susanne Matthes-Martin
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Tayfun Gungor
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Wolfgang Holter
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Brigitte Strahm
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Bernd Gruhn
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Ansgar Schulz
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Wilhelm Woessmann
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Ulrike Poetschger
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Martin Zimmermann
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
| | - Thomas Klingebiel
- Christina Peters, Susanne Matthes-Martin, and Ulrike Poetschger, St Anna Children's Hospital, Vienna, Austria; Martin Schrappe, University Medical Center Schleswig-Holstein and Christian-Albrechts-University Kiel; André Schrauder, Kinderarztpraxis am Aalborgring, Kiel; Arend von Stackelberg and Wolfram Ebell, Charité–Children's Hospital Berlin, Berlin; Peter Bader and Thomas Klingebiel, Johann Wolfgang Goethe University, Frankfurt; Peter Lang, University Hospital Tübingen, Tübingen; Karl-Walter Sykora
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40
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Superior outcome using cyclosporin A alone versus cyclosporin A plus methotrexate for post-transplant immunosuppression in children with acute leukemia undergoing sibling hematopoietic stem cell transplantation. J Cancer Res Clin Oncol 2014; 141:1089-94. [DOI: 10.1007/s00432-014-1885-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 11/23/2014] [Indexed: 12/14/2022]
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41
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Qin XY, Li GX, Qin YZ, Wang Y, Wang FR, Liu DH, Xu LP, Chen H, Han W, Wang JZ, Zhang XH, Li JL, Li LD, Liu KY, Huang XJ. Quantitative chimerism: an independent acute leukemia prognosis indicator following allogeneic hematopoietic SCT. Bone Marrow Transplant 2014; 49:1269-77. [DOI: 10.1038/bmt.2014.158] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 05/26/2014] [Accepted: 05/30/2014] [Indexed: 11/09/2022]
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42
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Pulsipher MA, Wayne AS, Schultz KR. New frontiers in pediatric Allo-SCT: novel approaches for children and adolescents with ALL. Bone Marrow Transplant 2014; 49:1259-65. [PMID: 24933210 DOI: 10.1038/bmt.2014.114] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 02/06/2014] [Accepted: 02/13/2014] [Indexed: 11/09/2022]
Abstract
Although most children with ALL can be cured by chemotherapy approaches, allogeneic hematopoietic cell transplant (HCT) therapy offers a better chance of cure to selected high-risk patients in first remission and most children who relapse. Although transplant-related mortality has decreased significantly in the past decade, relapse remains high after HCT for ALL; developing strategies to decrease relapse and improve survival are vital. Recent studies have shown that relapse risk can be accurately defined using measurements of minimal residual disease (MRD) both pre- and post-HCT and by knowing whether patients get GVHD in the first 2 months after transplant. With these risk definitions in hand, investigators are now applying novel agents and immunotherapeutic methods in attempt to lower MRD before transplant and modulate the GVL effect after transplant. With powerful new immunological approaches coming on line, the transplant process itself will likely expand to include pre and/or post-HCT interventions aimed at reducing relapse.
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Affiliation(s)
- M A Pulsipher
- Division of Hematology and Hematological Malignancies, Primary Children's Hospital, University of Utah School of Medicine/Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - A S Wayne
- Division of Hematology, Oncology, and Blood and Marrow Transplantation, Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, The Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - K R Schultz
- Department of Pediatrics, University of BC, BC Children's Hospital, Vancouver, British Columbia, Canada
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43
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Talano JM, Pulsipher MA, Symons HJ, Militano O, Shereck EB, Giller RH, Hancock L, Morris E, Cairo MS. New frontiers in pediatric Allo-SCT. Bone Marrow Transplant 2014; 49:1139-45. [PMID: 24820213 DOI: 10.1038/bmt.2014.89] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 03/13/2014] [Accepted: 03/15/2014] [Indexed: 01/02/2023]
Abstract
The inaugural meeting of 'New Frontiers in Pediatric Allogeneic Stem Cell Transplantation' organized by the Pediatric Blood and Transplant Consortium (PBMTC) was held at the American Society of Pediatric Hematology and Oncology Annual Meeting. This meeting provided an international platform for physicians and investigators active in the research and utilization of pediatric Allo-SCT in children and adolescents with malignant and non-malignant disease (NMD), to share information and develop future collaborative strategies. The primary objectives of the conference included: (1) to present advances in Allo-SCT in pediatric ALL and novel pre and post-transplant immunotherapy; (2) to highlight new strategies in alternative allogeneic stem cell donor sources for children and adolescents with non-malignant hematological disorders; (3) to discuss timing of immune reconstitution after Allo-SCT and methods of facilitating more rapid recovery of immunity; (4) to identify strategies of utilizing Allo-SCT in pediatric myeloproliferative disorders; (5) to develop diagnostic and therapeutic approaches to hematological complications post pediatric Allo-SCT; (6) to enhance the understanding of new novel cellular therapeutic approaches to pediatric malignant and non-malignant hematological disorders; and (7) to discuss optimizing drug therapy in pediatric recipients of Allo-SCT. This paper will provide a brief overview of the conference.
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Affiliation(s)
- J M Talano
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - M A Pulsipher
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - H J Symons
- Department of Oncology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - O Militano
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - E B Shereck
- Oregon Health and Science University, Portland, OR, USA
| | - R H Giller
- Children's Hospital Colorado, Aurora, CO, USA
| | - L Hancock
- Pediatric Blood and Marrow Transplant Consortium, Monrovia, CA, USA
| | - E Morris
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - M S Cairo
- 1] Department of Pediatrics, New York Medical College, Valhalla, NY, USA [2] Department of Medicine, New York Medical College, Valhalla, NY, USA [3] Department of Pathology, New York Medical College, Valhalla, NY, USA [4] Department of Microbiology and Immunology, New York Medical College, Valhalla, NY, USA [5] Department of Cell Biology and Anatomy, New York Medical College, Valhalla, NY, USA
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44
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Factors predictive of relapse of acute leukemia in children after allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant 2014; 20:1033-9. [PMID: 24691222 DOI: 10.1016/j.bbmt.2014.03.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 03/25/2014] [Indexed: 12/17/2022]
Abstract
The presence of minimal residual disease (MRD) before transplantation is the most important prognostic risk factor predictive of post-transplantation relapse in hematologic malignancies. However, MRD alone does not adequately predict relapse in all patients. To improve upon the ability to identify patients likely to relapse, we evaluated risk factors, in addition to MRD, that may be associated with development of post-transplantation relapse. In this single institution, retrospective cohort study of children with acute leukemia or myelodysplastic syndrome who had undergone a first allogeneic transplantation and had pretransplantation MRD evaluation, 40 of 93 patients (43%) experienced relapse. Univariate analysis demonstrated that African American race, high initial white blood cell count, central nervous system (CNS) disease at diagnosis, short first complete remission, nonmyeloablative (NMA) conditioning, lack of remission, and MRD before transplantation were associated with worse relapse-free survival (RFS). In a Cox multivariable analysis, CNS disease (P = .009), lack of remission (P = .01), and NMA conditioning (P = .04) were independently associated with inferior RFS. Among those in a morphologic complete remission who underwent a myeloablative transplantation, having both CNS disease at diagnosis (specifically in acute lymphoblastic leukemia) and MRD positivity was an independent risk factor predictive of relapse, which has not been previously reported. Results from our study support the existence of risk factors complimentary to pretransplantation MRD. Validation in a larger independent homogenous cohort is needed to develop a prognostic tool for clinical use to predict post-transplantation relapse.
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45
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Relapse assessment following allogeneic SCT in patients with MDS and AML. Ann Hematol 2014; 93:1097-110. [PMID: 24671364 DOI: 10.1007/s00277-014-2046-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 02/25/2014] [Indexed: 10/25/2022]
Abstract
Options to pre-emptively treat impending relapse of myelodysplastic syndromes (MDS) and acute myeloid leukaemia (AML) after allogeneic haematopoietic stem cell transplantation (allo-SCT) continuously increase. In recent years, the spectrum of diagnostic methods and parameters to perform post-transplant monitoring in patients with AML and MDS has grown. Cytomorphology, histomorphology, and chimaerism analysis are the mainstay in any panel of post-transplant monitoring. This may be individually combined with multiparameter flow cytometry (MFC) for the detection of residual cells with a leukaemia phenotype and quantitative real-time polymerase chain reaction (RQ-PCR) to assess gene expression, e.g., of WT1 or the residual mutation load (e.g., in case of an NPM1 mutation). Data evaluating the aforementioned methods alone or in combination are discussed in this review with particular emphasis on data pointing towards their suitability to steer pre-emptive post-transplant interventions such as immunotherapy, chemotherapy or therapy with demethylating agents.
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46
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Köchling J, Schmidt M, Rott Y, Sagner M, Ungefroren H, Wittig B, Henze G. Can anthocyanins improve maintenance therapy of Ph+acute lymphoblastic leukaemia? Eur J Haematol 2013; 90:291-300. [DOI: 10.1111/ejh.12071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2013] [Indexed: 12/31/2022]
Affiliation(s)
| | | | - Yvonne Rott
- Department of Paediatrics; UKSH; Campus Lübeck; Universität zu Lübeck; Germany
| | | | | | - Burghard Wittig
- Foundation Institute Molecular Biology and Bioinformatics; Freie Universität Berlin; Germany
| | - Günter Henze
- Department of Paediatric Oncology and Haematology; Charité - Universitätsmedizin Berlin; Germany
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47
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Faraci M, Caviglia I, Biral E, Morreale G, Giardino S, Garbarino L, Castagnola E, Dini G, Lanino E. Acute graft-versus-host disease in pediatric allogeneic hematopoietic stem cell transplantation. Single-center experience during 10 yr. Pediatr Transplant 2012; 16:887-93. [PMID: 23131057 DOI: 10.1111/petr.12009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
a-GvHD may complicate allogeneic HSCT. In this retrospective single-center study, we evaluated incidence and risk factors of a-GvHD in 197 consecutive allogeneic pediatric HSCTs applying Glucksberg and NIH a-GvHD classifications. Among 179 eligible transplants, the cumulative incidence of grade 0-I a-GvHD was 48% and grade II-IV was 52%. None of the considered variables significantly influenced the incidence of grade II-IV a-GvHD. Malignancy and myeloablation were associated with an increased risk of classic a-GvHD (p < 0.01). Seventy-two percentage of children are alive, with a significant difference in OS and TRM between grade 0 and I vs. grade II and IV a-GvHD; this observation was reproduced in the non-malignant setting, while only a disparity in TRM was evidenced in children with malignancy. In our experience, the incidence of a-GvHD was similar, regardless of donor type. Myeloablation and malignant disease represented the only risk factors for classic a-GvHD. Our results highlight the need for a better prevention of this complication in the non-malignant setting.
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Affiliation(s)
- Maura Faraci
- Hematopoietic Stem Cell Transplantation Unit, Haematology-Oncology Department, G. Gaslini Children's Research Institute, Genova, Italy.
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48
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Köchling J, Rott Y, Arndt S, Marschke C, Schmidt M, Wittig B, Kalies K, Westermann J, Henze G. Prevention and synergistic control of Ph+ ALL by a DNA vaccine and 6-mercaptopurine. Vaccine 2012; 30:5949-55. [DOI: 10.1016/j.vaccine.2012.07.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 07/03/2012] [Accepted: 07/18/2012] [Indexed: 02/05/2023]
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49
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Ruutu T, van Biezen A, Hertenstein B, Henseler A, Garderet L, Passweg J, Mohty M, Sureda A, Niederwieser D, Gratwohl A, de Witte T. Prophylaxis and treatment of GVHD after allogeneic haematopoietic SCT: a survey of centre strategies by the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant 2012; 47:1459-64. [PMID: 22410750 DOI: 10.1038/bmt.2012.45] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Recommendations on indications for allogeneic haematopoietic SCT have been presented, but transplantation techniques remain poorly standardized. Pre-transplant risk factors are well defined, and reported outcomes vary markedly among patients with similar risk characteristics. It would be of importance to know the impact of differences in treatment procedures. To study properly the different components of allogeneic transplantation, standardization of at least some central procedures would be needed. As the first step, the European Group for Blood and Marrow Transplantation (EBMT) performed a survey among all its 372 member centres performing allogeneic transplantations about their strategies in preventing and treating GVHD. Responses from 79 centres (21% return) from 25 countries (60% return) were received. Although some trends toward more uniform policies compared with a survey carried out 15 years earlier were observed, the present survey still showed marked variability in the GVHD prophylaxis and treatment strategies. On the basis of these findings, EBMT is developing a consensus process aiming at a standardized strategy.
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Affiliation(s)
- T Ruutu
- Department of Medicine, Division of Haematology, Helsinki University Central Hospital, Helsinki, Finland.
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50
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Preemptive immunotherapy in childhood acute myeloid leukemia for patients showing evidence of mixed chimerism after allogeneic stem cell transplantation. Blood 2011; 118:5681-8. [PMID: 21948300 DOI: 10.1182/blood-2011-04-348805] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Previous studies have shown that children with acute myeloid leukemia (AML) who developed mixed chimerism (MC) were at high risk for relapse after allogeneic stem-cell transplantation (allo-SCT). We investigated the feasibility of intensified preemptive immunotherapy in children receiving allo-SCT for AML. Eighty-four children were registered in our trial from May 2005 to April 2009; of these, 71 fulfilled the inclusion criteria and were treated according to the study protocol. Serial and semiquantitative analyses of posttransplantation chimerism were performed. Defined immunotherapy approaches were considered in MC patients. Continuous complete chimerism (CC) was observed in 51 of 71 patients. MC was detected in 20 patients and was followed by immunotherapy in 13. Six of 13 MC patients returned to CC without toxicity and remained in long-term remission. Overall, the probability of event-free survival (pEFS) was 66% (95% confidence interval [95% CI] = 53%-76%) for all patients and 46% (95% CI = 19%-70%) in MC patients with intervention; however, this number increased to 71% (95% CI = 26%-92%) in 7 of 13 MC patients on immunotherapy who were in remission at the time of transplantation. All MC patients without intervention relapsed. These results suggest that MC is a prognostic factor for impending relapse in childhood AML, and that preemptive immunotherapy may improve the outcome in defined high-risk patients after transplantation.
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