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Muffly L, Liang EC, Dolan JG, Pulsipher MA. How I use next-generation sequencing-MRD to plan approach and prevent relapse after HCT for children and adults with ALL. Blood 2024; 144:253-261. [PMID: 38728375 DOI: 10.1182/blood.2023023699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/11/2024] [Accepted: 04/24/2024] [Indexed: 05/12/2024] Open
Abstract
ABSTRACT Measurable residual disease (MRD) evaluation by multiparameter flow cytometry (MFC) or quantitative polymerase chain reaction methods is an established standard of care for assessing risk of relapse before or after hematopoietic cell transplantation (HCT) for acute lymphoblastic leukemia (ALL). Next-generation sequencing (NGS)-MRD has emerged as a highly effective approach that allows for the detection of lymphoblasts at a level of <1 in 106 nucleated cells, increasing sensitivity of ALL detection by 2 to 3 logs. Early studies have shown superior results compared with MFC and suggest that NGS-MRD may allow for the determination of patients in whom reduced toxicity transplant preparative approaches could be deployed without sacrificing outcomes. Many centers/study groups have implemented immune modulation approaches based on MRD measurements that have resulted in improved outcomes. Challenges remain with NGS-MRD, because it is not commercially available in many countries, and interpretation of results can be complex. Through patient case review, discussion of relevant studies, and detailed expert opinion, we share our approach to NGS-MRD testing before and after HCT in pediatric and adult ALL. Improved pre-HCT risk classification and post-HCT monitoring for relapse in bone marrow and less invasive peripheral blood monitoring by NGS-MRD may lead to alternative approaches to prevent relapse in patients undergoing this challenging procedure.
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Affiliation(s)
- Lori Muffly
- Division of Blood and Marrow Transplantation, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Emily C Liang
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA
| | - J Gregory Dolan
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Intermountain Primary Children's Hospital, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
| | - Michael A Pulsipher
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Intermountain Primary Children's Hospital, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
- Division of Pediatric Hematology and Oncology, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
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2
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Wang Y, Fu G, Xu L, Wang Y, Cheng Y, Zhang Y, Zhang X, Liu Y, Liu K, Huang X, Chang Y. Risk factors for positive post-transplantation measurable residual disease in patients with acute lymphoblastic leukemia. Chin Med J (Engl) 2024:00029330-990000000-01141. [PMID: 38979637 DOI: 10.1097/cm9.0000000000003150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND The level of measurable residual disease (MRD) before and after transplantation is related to inferior transplant outcomes, and post-hematopoietic stem cell transplantation measurable residual disease (post-HSCT MRD) has higher prognostic value in determining risk than pre-hematopoietic stem cell transplantation measurable residual disease (pre-HSCT MRD). However, only a few work has been devoted to the risk factors for positive post-HSCT MRD in patients with acute lymphoblastic leukemia (ALL). This study evaluated the risk factors for post-HSCT MRD positivity in patients with ALL who underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT). METHODS A total of 1683 ALL patients from Peking University People's Hospital between January 2009 and December 2019 were enrolled to evaluate the cumulative incidence of post-HSCT MRD. Cox proportional hazard regression models were built for time-to-event outcomes. Multivariate analysis was performed to determine independent influencing factors from the univariate analysis. RESULTS Both in total patients and in T-cell ALL or B-cell ALL, pediatric or adult, human leukocyte antigen-matched sibling donor transplantation or haploidentical SCT subgroups, positive pre-HSCT MRD was a risk factor for post-HSCT MRD positivity (P <0.001 for all). Disease status (complete remission 1 [CR1] vs. ≥CR2) was also a risk factor for post-HSCT MRD positivity in all patients and in the B cell-ALL, pediatric, or haploidentical SCT subgroups (P = 0.027; P = 0.003; P = 0.035; P = 0.003, respectively). A risk score for post-HSCT MRD positivity was developed using the variables pre-HSCT MRD and disease status. The cumulative incidence of post-HSCT MRD positivity was 12.3%, 25.1%, and 38.8% for subjects with scores of 0, 1, and 2-3, respectively (P <0.001). Multivariate analysis confirmed the association of the risk score with the cumulative incidence of post-HSCT MRD positivity and relapse as well as leukemia-free survival and overall survival. CONCLUSION Our results indicated that positive pre-MRD and disease status were two independent risk factors for post-HSCT MRD positivity in patients with ALL who underwent allo-HSCT.
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Affiliation(s)
- Yuewen Wang
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| | - Guomei Fu
- Department of Hematology, Peking University People's Hospital and National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Lanping Xu
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| | - Yu Wang
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| | - Yifei Cheng
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| | - Yuanyuan Zhang
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| | - Xiaohui Zhang
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| | - Yanrong Liu
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| | - Kaiyan Liu
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| | - Xiaojun Huang
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
- Department of Hematology, Peking University People's Hospital and National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
- Beijing Key Laboratory of Haematopoietic Stem Cell Transplantation, Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yingjun Chang
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
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3
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Kernan NA, Klein E, Mauguen A, Torok-Castanza J, Prockop SE, Scaradavou A, Curran K, Spitzer B, Cancio M, Ruggiero J, Allen J, Harris A, Oved J, O'Reilly RJ, Boelens JJ. Persistent or New Cytopenias Predict Relapse Better than Routine Bone Marrow Aspirate Evaluations After Hematopoietic Cell Transplantation for Acute Leukemia or Myelodysplastic Syndrome in Children and Young Adult Patients. Transplant Cell Ther 2024; 30:692.e1-692.e12. [PMID: 38643958 DOI: 10.1016/j.jtct.2024.04.012] [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: 02/15/2024] [Revised: 04/02/2024] [Accepted: 04/17/2024] [Indexed: 04/23/2024]
Abstract
The clinical value of serial routine bone marrow aspirates (rBMAs) in the first year after allogeneic hematopoietic cell transplantation (alloHCT) to detect or predict relapse of acute leukemia (AL) and myelodysplastic syndrome (MDS) in pediatric and young adult patients is unclear. The purpose of this analysis was to determine if assessment of minimal residual disease (MRD) by multiparameter flow cytometry (MFC, MFC-MRD) or donor chimerism (DC) in rBMAs or serial complete blood counts (CBCs) done in the year after alloHCT predicted relapse of AL or MDS in pediatric and young adult patients. We completed a retrospective analysis of patients with AL or MDS who had rBMAs performed after alloHCT between January 2012 and June 2018. Bone marrow (BM) was evaluated at approximately 3, 6, and 12 months for disease recurrence by morphology, MFC-MRD, and percent DC by short tandem repeat molecular testing. CBCs were performed at every clinic visit. The main outcome of interest was an assessment of whether MFC-MRD or DC in rBMAs or serial CBCs done in the year after alloHCT predicted relapse in AL or MDS pediatric and young adult patients. A total of 121 recipients with a median age of 13 years (range 1 to 32) were included: 108 with AL and, 13 with MDS. A total of 423 rBMAs (median 3; 0 to 13) were performed. Relapse at 2 years was 23% (95% CI: 16% to 31%) and at 5 years 25% (95% CI: 18% to 33%). One hundred fifty-four of 157 (98%) rBMAs evaluated for MRD by MFC were negative and did not preclude subsequent relapse. Additionally, low DC (<95%) did not predict relapse and high DC (≥95%) did not preclude relapse. For patients alive without relapse at 1 year, BM DC (P = .74) and peripheral T-cell DC (P = .93) did not predict relapse. Six patients with low-level T-cell and/or BM DC had a total of 8 to 20 BM evaluations, none of these patients relapsed. However, CBC results were informative for relapse; 28 of 31 (90%) relapse patients presented with an abnormal CBC with peripheral blood (PB) blasts (16 patients), cytopenias (9 patients), or extramedullary disease (EMD, 3 patients). Two patients with BM blasts >5% on rBMA had circulating blasts within 5 weeks of rBMA. Neutropenia (ANC <1.5 K/mcl) at 1 year was predictive of relapse (P = .01). Neutropenia and thrombocytopenia (<160 K/mcl) were predictive of disease-free survival (DFS) with inferior DFS for ANC <1.5 K/mcl, P = .001, or platelet count <160 K/mcl (P = .04). These results demonstrate rBMAs after alloHCT assessed for MRD by MFC and/or for level of DC are poor predictors for relapse in pediatric and young adult patients with AL or MDS. Relapse in these patients presents with PB blasts, cytopenias, or EMD. ANC and platelet count at 1-year were highly predictive for DFS.
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Affiliation(s)
- Nancy A Kernan
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Service. New York, New York.
| | - Elizabeth Klein
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Service. New York, New York
| | - Audrey Mauguen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Susan E Prockop
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Service. New York, New York; Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA Harvard Medical School, Boston, Massachusetts
| | - Andromachi Scaradavou
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Service. New York, New York; Department of Pediatrics, Weill Cornell Medicine, New York, New York
| | - Kevin Curran
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Service. New York, New York; Department of Pediatrics, Weill Cornell Medicine, New York, New York
| | - Barbara Spitzer
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Service. New York, New York; Hackensack University Medical Center, Hackensack, New Jersey
| | - Maria Cancio
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Service. New York, New York; Department of Pediatrics, Weill Cornell Medicine, New York, New York
| | - Julianne Ruggiero
- Division of Nursing, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jennifer Allen
- Division of Nursing, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Harris
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Service. New York, New York; Department of Pediatrics, Weill Cornell Medicine, New York, New York
| | - Joseph Oved
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Service. New York, New York; Department of Pediatrics, Weill Cornell Medicine, New York, New York
| | - Richard J O'Reilly
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Service. New York, New York; Department of Pediatrics, Weill Cornell Medicine, New York, New York
| | - Jaap Jan Boelens
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Service. New York, New York; Department of Pediatrics, Weill Cornell Medicine, New York, New York
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Naik S, Li Y, Talleur AC, Selukar S, Ashcraft E, Cheng C, Madden RM, Mamcarz E, Qudeimat A, Sharma A, Srinivasan A, Suliman AY, Epperly R, Obeng EA, Velasquez MP, Langfitt D, Schell S, Métais JY, Arnold PY, Hijano DR, Maron G, Merchant TE, Akel S, Leung W, Gottschalk S, Triplett BM. Memory T-cell enriched haploidentical transplantation with NK cell addback results in promising long-term outcomes: a phase II trial. J Hematol Oncol 2024; 17:50. [PMID: 38937803 PMCID: PMC11212178 DOI: 10.1186/s13045-024-01567-0] [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: 05/06/2024] [Accepted: 06/13/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Relapse remains a challenge after transplantation in pediatric patients with hematological malignancies. Myeloablative regimens used for disease control are associated with acute and long-term adverse effects. We used a CD45RA-depleted haploidentical graft for adoptive transfer of memory T cells combined with NK-cell addback and hypothesized that maximizing the graft-versus-leukemia (GVL) effect might allow for reduction in intensity of conditioning regimen. METHODS In this phase II clinical trial (NCT01807611), 72 patients with hematological malignancies (complete remission (CR)1: 25, ≥ CR2: 28, refractory disease: 19) received haploidentical CD34 + enriched and CD45RA-depleted hematopoietic progenitor cell grafts followed by NK-cell infusion. Conditioning included fludarabine, thiotepa, melphalan, cyclophosphamide, total lymphoid irradiation, and graft-versus-host disease (GVHD) prophylaxis consisted of a short-course sirolimus or mycophenolate mofetil without serotherapy. RESULTS The 3-year overall survival (OS) and event-free-survival (EFS) for patients in CR1 were 92% (95% CI:72-98) and 88% (95% CI: 67-96); ≥ CR2 were 81% (95% CI: 61-92) and 68% (95% CI: 47-82) and refractory disease were 32% (95% CI: 11-54) and 20% (95% CI: 6-40). The 3-year EFS for all patients in morphological CR was 77% (95% CI: 64-87) with no difference amongst recipients with or without minimal residual disease (P = 0.2992). Immune reconstitution was rapid, with mean CD3 and CD4 T-cell counts of 410/μL and 140/μL at day + 30. Cumulative incidence of acute GVHD and chronic GVHD was 36% and 26% but most patients with acute GVHD recovered rapidly with therapy. Lower rates of grade III-IV acute GVHD were observed with NK-cell alloreactive donors (P = 0.004), and higher rates of moderate/severe chronic GVHD occurred with maternal donors (P = 0.035). CONCLUSION The combination of a CD45RA-depleted graft and NK-cell addback led to robust immune reconstitution maximizing the GVL effect and allowed for use of a submyeloablative, TBI-free conditioning regimen that was associated with excellent EFS resulting in promising long-term outcomes in this high-risk population. The trial is registered at ClinicalTrials.gov (NCT01807611).
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Affiliation(s)
- Swati Naik
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA.
| | - Ying Li
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Aimee C Talleur
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Subodh Selukar
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Emily Ashcraft
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Cheng Cheng
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Renee M Madden
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Ewelina Mamcarz
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Amr Qudeimat
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Akshay Sharma
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Ashok Srinivasan
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Ali Y Suliman
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Rebecca Epperly
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Esther A Obeng
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - M Paulina Velasquez
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Deanna Langfitt
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Sarah Schell
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Jean-Yves Métais
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Paula Y Arnold
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Diego R Hijano
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Gabriela Maron
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Thomas E Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Salem Akel
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Wing Leung
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Stephen Gottschalk
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Brandon M Triplett
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA.
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5
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Akahoshi Y, Spyrou N, Hoepting M, Aguayo-Hiraldo P, Ayuk F, Chanswangphuwana C, Choe HK, Eder M, Etra AM, Grupp SA, Hexner EO, Hogan WJ, Kitko CL, Kraus S, Al Malki MM, Merli P, Qayed M, Reshef R, Schechter T, Ullrich E, Vasova I, Wölfl M, Zeiser R, Baez J, Beheshti R, Eng G, Gleich S, Kasikis S, Katsivelos N, Kowalyk S, Morales G, Young R, DeFilipp Z, Ferrara JLM, Levine JE, Nakamura R. Flares of acute graft-versus-host disease: a Mount Sinai Acute GVHD International Consortium analysis. Blood Adv 2024; 8:2047-2057. [PMID: 38324721 PMCID: PMC11103178 DOI: 10.1182/bloodadvances.2023012091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/19/2024] [Accepted: 01/19/2024] [Indexed: 02/09/2024] Open
Abstract
ABSTRACT The absence of a standardized definition for graft-versus-host disease (GVHD) flares and data on its clinical course are significant concerns. We retrospectively evaluated 968 patients across 23 Mount Sinai Acute GVHD International Consortium (MAGIC) transplant centers who achieved complete response (CR) or very good partial response (VGPR) within 4 weeks of treatment. The cumulative incidence of flares within 6 months was 22%, and flares were associated with a higher risk of nonrelapse mortality (NRM; adjusted hazard ratio [aHR], 4.84; 95% confidence interval [CI], 3.19-7.36; P < .001). Flares were more severe (grades 3/4, 41% vs 16%; P < .001) and had more frequent lower gastrointestinal (LGI) involvement (55% vs 32%; P < .001) than the initial GVHD. At CR/VGPR, elevated MAGIC biomarkers predicted the future occurrence of a flare, along with its severity and LGI involvement. In multivariate analyses, higher Ann Arbor (AA) biomarker scores at CR/VGPR were significant risk factors for flares (AA2 vs AA1: aHR, 1.81 [95% CI, 1.32-2.48; P = .001]; AA3 vs AA1: aHR, 3.14 [95% CI, 1.98-4.98; P < .001]), as were early response to initial treatment (aHR, 1.84; 95% CI, 1.21-2.80; P = .004) and HLA-mismatched unrelated donor (aHR, 1.74; 95% CI, 1.00-3.02; P = .049). MAGIC biomarkers also stratified the risk of NRM both at CR/VGPR and at the time of flare. We conclude that GVHD flares are common and carry a significant mortality risk. The occurrence of future flares can be predicted by serum biomarkers that may serve to guide adjustment and discontinuation of immunosuppression.
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Affiliation(s)
- Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Matthias Hoepting
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Paibel Aguayo-Hiraldo
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Chantiya Chanswangphuwana
- Division of Hematology and Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Hannah K. Choe
- Blood and Marrow Transplantation Program, The Ohio State University, Columbus, OH
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Aaron M. Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stephan A. Grupp
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth O. Hexner
- Department of Medicine and Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Carrie L. Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Monzr M. Al Malki
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Pietro Merli
- Department of Pediatric Hematology/Oncology and of Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Muna Qayed
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, GA
| | - Ran Reshef
- Blood and Marrow Transplantation Program and Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
| | - Tal Schechter
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Evelyn Ullrich
- Department of Pediatrics, Experimental Immunology and Cell Therapy, Goethe University Frankfurt, Frankfurt, Germany
| | - Ingrid Vasova
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children's Hospital, University Hospital of Würzburg, Würzburg, Germany
| | - Robert Zeiser
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rahnuma Beheshti
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gilbert Eng
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Stelios Kasikis
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nikolaos Katsivelos
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - James L. M. Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John E. Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryotaro Nakamura
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
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6
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Lin M, Zhao X, Chang Y, Zhao X. Current assessment and management of measurable residual disease in patients with acute lymphoblastic leukemia in the setting of CAR-T-cell therapy. Chin Med J (Engl) 2024; 137:140-151. [PMID: 38148315 PMCID: PMC10798764 DOI: 10.1097/cm9.0000000000002945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Indexed: 12/28/2023] Open
Abstract
ABSTRACT Chimeric antigen receptor (CAR)-modified T-cell therapy has achieved remarkable success in the treatment of acute lymphoblastic leukemia (ALL). Measurable/minimal residual disease (MRD) monitoring plays a significant role in the prognostication and management of patients undergoing CAR-T-cell therapy. Common MRD detection methods include flow cytometry (FCM), polymerase chain reaction (PCR), and next-generation sequencing (NGS), and each method has advantages and limitations. It has been well documented that MRD positivity predicts a poor prognosis and even disease relapse. Thus, how to perform prognostic evaluations, stratify risk based on MRD status, and apply MRD monitoring to guide individual therapeutic decisions have important implications in clinical practice. This review assesses the common and novel MRD assessment methods. In addition, we emphasize the critical role of MRD as a prognostic biomarker and summarize the latest studies regarding MRD-directed combination therapy with CAR-T-cell therapy and allogeneic hematopoietic stem cell transplantation (allo-HSCT), as well as other therapeutic strategies to improve treatment effect. Furthermore, this review discusses current challenges and strategies for MRD detection in the setting of disease relapse after targeted therapy.
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Affiliation(s)
- Minghao Lin
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Xiaosu Zhao
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Yingjun Chang
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Xiangyu Zhao
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
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7
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Lamble AJ, Moskop A, Pulsipher MA, Maude SL, Summers C, Annesley C, Baruchel A, Gore L, Amrolia P, Shah N. INSPIRED Symposium Part 2: Prevention and Management of Relapse Following Chimeric Antigen Receptor T Cell Therapy for B Cell Acute Lymphoblastic Leukemia. Transplant Cell Ther 2023; 29:674-684. [PMID: 37689393 DOI: 10.1016/j.jtct.2023.08.030] [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: 08/02/2023] [Accepted: 08/30/2023] [Indexed: 09/11/2023]
Abstract
Although CD19-directed chimeric antigen receptor (CAR) T cell therapy (CAR-T) for relapsed/refractory B cell acute lymphoblastic leukemia (B-ALL) has been transformative in inducing and sustaining remission, relapse rates remain unacceptably high, with approximately 50% of children and young adults experiencing relapse within the first year postinfusion. Emerging strategies to extend the durability of remission involve the use of prognostic biomarkers to identify those at high risk of relapse or incorporate strategies aimed to enhancing functional CAR T cell persistence. Nonetheless, with antigen loss/down-regulation or evolution to lineage switch as major mechanisms of relapse, optimizing single antigen targeting alone is insufficient. Here, with a focus on relapse prevention strategies, including postinfusion surveillance and treatment approaches being explored to optimize post-CAR-T management (eg, combinatorial antigen targeting strategies, preemptive hematopoietic cell transplantation), we review the current state of the art in the prevention and management of post CAR-T relapse. We highlight the advancements in the field and identify gaps in the literature to guide future research in optimizing the prevention and management of post-CAR-T relapse in children and young adults with B-ALL.
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Affiliation(s)
- Adam J Lamble
- Division of Hematology/Oncology, University of Washington, Seattle Children's Hospital, Seattle, Washington.
| | - Amy Moskop
- Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, Wisconsin
| | - Michael A Pulsipher
- Division of Hematology and Oncology, Intermountain Primary Children's Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah
| | - Shannon L Maude
- Division of Oncology, Cell Therapy and Transplant Section, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Corinne Summers
- Division of Hematology/Oncology, University of Washington, Seattle Children's Hospital, Seattle, Washington; Fred Hutchinson Cancer Center, Seattle, Washington
| | - Colleen Annesley
- Division of Hematology/Oncology, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - André Baruchel
- Pediatric Hematology Department, Robert Debré University Hospital, AP-HP and Université Paris Cité, Paris, France
| | - Lia Gore
- Pediatric Hematology/Oncology/BMT-CT, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| | - Persis Amrolia
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - Nirali Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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8
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Rahman ZA, Kebriaei P. SOHO State of the Art Updates and Next Questions | Philadelphia Chromosome Positive Acute Lymphoblastic Leukemia in Adults: Therapeutic Options and Challenges in 2023. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:779-785. [PMID: 37438208 DOI: 10.1016/j.clml.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 07/14/2023]
Abstract
The therapeutic landscape of Philadelphia chromosome positive acute lymphoblastic leukemia (ALL) for adults has dramatically changed over the past 2 decades; the emergence of newer generations of tyrosine kinase inhibitors and incorporation of targeted immunotherapies into front-line therapy have significantly improved outcomes to the point where an argument can be made that this entity may no longer be considered a high-risk ALL subgroup. In this review article, we discuss different front-line regimens (both intensive and deintensified regimens including chemotherapy-free regimens). We also review disease monitoring strategies, discuss the role of allogeneic hematopoietic stem cell transplantation, and discuss the rapidly changing therapeutic landscape for patients with relapsed disease.
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Affiliation(s)
- Zaid Abdel Rahman
- Department of Stem Cell Transplantation and Cellular Therapy, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Kantarjian HM, Logan AC, Zaman F, Gökbuget N, Bargou RC, Zeng Y, Zugmaier G, Locatelli F. Survival outcomes in patients with relapsed/refractory or MRD-positive B-cell acute lymphoblastic leukemia treated with blinatumomab. Ther Adv Hematol 2023; 14:20406207231201454. [PMID: 37822571 PMCID: PMC10563488 DOI: 10.1177/20406207231201454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/30/2023] [Indexed: 10/13/2023] Open
Abstract
Blinatumomab has demonstrated significant efficacy in adult and pediatric patients with relapsed/refractory B-cell acute lymphoblastic leukemia (R/R B-cell ALL) and patients with measurable residual disease (MRD). This review aimed to compare median relapse-free survival (RFS) and median overall survival (OS) in adult and pediatric patients with R/R or MRD-positive B-cell ALL from pivotal studies [MT-103-211 and TOWER for adults with Philadelphia chromosome (Ph)-negative R/R B-cell ALL, ALCANTARA for adults with Ph-positive R/R B-cell ALL, MT-103-203 for adults with MRD-positive B-cell ALL, and MT-103-205 for pediatric patients with R/R B-cell ALL], with the median RFS and OS from retrospective analyses, country or ethnicity-specific studies, and studies based on real-world evidence (RWE) identified from a literature search. Adults with Ph-negative R/R B-cell ALL who received blinatumomab as first salvage demonstrated a numerically longer median OS compared with that in patients from pivotal studies (MT-103-211 and TOWER) without additional safety concerns. In pediatric patients with R/R B-cell ALL treated with blinatumomab, the median RFS and OS from retrospective analyses and country/ethnicity-specific studies were comparable with the median RFS and OS from the pivotal study MT-103-205. The median RFS and OS from RWE studies in adults with R/R B-cell ALL were numerically longer than the median RFS and OS from pivotal studies (MT-103-211, TOWER, and ALCANTARA); however, this trend was not observed in pediatric patients with R/R B-cell ALL. In conclusion, this analysis identified first salvage adults with Ph-negative R/R B-cell ALL as particularly well-suited for treatment with blinatumomab since survival outcomes from retrospective analyses reported in this patient subgroup were numerically better compared with those from pivotal studies without additional safety signals.
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Affiliation(s)
- Hagop M. Kantarjian
- Department of Leukemia, MD Anderson Cancer Center, The University of Texas, 1515 Holcombe Blvd., Unit 428, Houston, TX 77030, USA
| | - Aaron C. Logan
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Ralf C. Bargou
- Comprehensive Cancer Center Mainfranken, Uniklinikum Würzburg, Würzburg, Germany
| | - Yi Zeng
- Amgen Inc., Thousand Oaks, CA, USA
| | | | - Franco Locatelli
- Department of Pediatric Hematology/Oncology and Cell and Gene Therapy, IRCCS Bambino Gesù Children’s Hospital, Catholic University of the Sacred Heart, Rome, Italy
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Yano M, Ishida H, Hara J, Kawaguchi H, Ito E, Moriya-Saito A, Hashii Y, Deguchi T, Miyamura T, Sato A, Hori H, Horibe K, Imamura T. Outcome of hematopoietic stem cell transplantation in pediatric patients with acute lymphoblastic leukemia not in remission enrolled in JACLS ALL-02. Int J Hematol 2023; 118:364-373. [PMID: 37358749 DOI: 10.1007/s12185-023-03626-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 06/27/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) is only indicated for acute lymphoblastic leukemia (ALL) patients for whom other treatments are unlikely to be curative. However, outcomes of patients not in complete remission (CR) at HSCT remain very poor. To improve the outcomes of patients receiving HSCT, it is important to obtain detailed clinical information about patients with ALL receiving HSCT in CR and not in CR. Patients enrolled in the Japan Association of Childhood Leukemia Study ALL-02 who underwent HSCT and were not in CR (non-CR patients, n = 55) were examined. The 1-year overall survival (OS) rate of non-CR patients was 27.3%. Compared with CR patients, non-CR patients experienced very early and early relapse significantly more frequently and had poorer prognostic factors. Most interestingly, high hyperdiploid (HHD) patients showed an excellent 1-year OS of 80%. In addition, long-term survival among surviving HHD patients was longer than 5 years. All eight patients who survived after undergoing HSCT while not in CR were younger than 10 years at initial diagnosis and were negative for central nervous system involvement. While limited, these results suggest that a subset of patients may benefit from HSCT while not in CR.
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Affiliation(s)
- Mio Yano
- Department of Pediatrics, Kyoto City Hospital, Kyoto, Japan
| | - Hisashi Ishida
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Junichi Hara
- Department of Pediatric Hematology and Oncology, Osaka City General Hospital, Osaka, Japan
| | - Hiroshi Kawaguchi
- Department of Pediatrics, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Etsuro Ito
- Department of Pediatrics, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Akiko Moriya-Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Yoshiko Hashii
- Department of Pediatrics, Osaka International Cancer Institute, Osaka, Japan
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takao Deguchi
- Division of Cancer Immunodiagnostics, Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
- Department of Pediatrics, Mie University, Tsu, Japan
| | - Takako Miyamura
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Atsushi Sato
- Department of Hematology and Oncology, Miyagi Children's Hospital, Sendai, Japan
| | - Hiroki Hori
- Department of Pediatrics, Mie University, Tsu, Japan
| | - Keizo Horibe
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Toshihiko Imamura
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kajii-cho Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.
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11
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Prockop S, Wachter F. The current landscape: Allogeneic hematopoietic stem cell transplant for acute lymphoblastic leukemia. Best Pract Res Clin Haematol 2023; 36:101485. [PMID: 37611999 DOI: 10.1016/j.beha.2023.101485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 05/31/2023] [Indexed: 08/25/2023]
Abstract
One of the consistent features in development of hematopoietic stem cell transplant (HCT) for Acute Lymphoblastic Leukemia (ALL) is the rapidity with which discoveries in the laboratory are translated into innovations in clinical care. Just a few years after murine studies demonstrated that rescue from radiation induced marrow failure is mediated by cellular not humoral factors, E. Donnall Thomas reported on the transfer of bone marrow cells into irradiated leukemia patients. This was followed quickly by the first descriptions of Graft versus Leukemia (GvL) effect and Graft versus Host Disease (GvHD). Despite the pivotal nature of these findings, early human transplants were uniformly unsuccessful and identified the challenges that continue to thwart transplanters today - leukemic relapse, regimen related toxicity, and GvHD. While originally only an option for young, fit patients with a matched family donor, expansion of the donor pool to include unrelated donors, umbilical cord blood units, and more recently the growing use of haploidentical donors have all made transplant a more accessible therapy for patients with ALL. Novel agents for conditioning, prevention and treatment of GvHD have improved outcomes and investigators continue to develop novel treatment strategies that balance regimen related toxicity with disease control. Our evolving understanding of how to prevent and treat GvHD and how to prevent relapse are incorporated into novel clinical trials that are expected to further improve outcomes. Here we review current considerations and future directions for both adult and pediatric patients undergoing HCT for ALL, including indication for transplant, donor selection, cytoreductive regimens, and outcomes.
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Affiliation(s)
- Susan Prockop
- Pediatric Stem Cell Transplant Program, DFCI/BCH Center for Cancer and Blood Disorders, Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States.
| | - Franziska Wachter
- Pediatric Stem Cell Transplant Program, DFCI/BCH Center for Cancer and Blood Disorders, Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States.
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12
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Maese LD, Pulsipher MA. Blinatumomab Conundrum in Low-Risk Relapsed B-Cell ALL. J Clin Oncol 2023; 41:4087-4092. [PMID: 37311171 DOI: 10.1200/jco.23.00594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/03/2023] [Accepted: 04/28/2023] [Indexed: 06/15/2023] Open
Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. BACKGROUND The Children's Oncology Group (COG) AALL1331 trial demonstrated improved survival and less toxicity in children with high-/intermediate-risk relapsed ALL receiving blinatumomab compared with intensive chemotherapy before hematopoietic stem-cell transplant (HSCT). The low-risk arm of AALL1331 compared addition of three cycles of blinatumomab to chemotherapy alone, but a survival improvement was not noted. Secondary analyses showed improvement in disease-free survival (DFS) and overall survival (OS) of low-risk patients with bone marrow disease ± extramedullary (EM) involvement (4-year DFS 72.7% ± 5.8% v 53.7% ± 6.7%; 4-year OS 97.1% ± 2.1% v 84.8% ± 4.8%), but failed to show an advantage with blinatumomab for patients with isolated EM relapse. Of note, DFS of isolated CNS (iCNS) relapse was worse than previous studies at 24% on both arms, likely because of decreases in CNS-intensive therapy compared with previous approaches and inadequacy of blinatumomab for controlling CNS disease. CASE Our case of late isolated CNS B-cell ALL relapse outlines challenges for clinicians attempting to decrease toxicity and avoid HSCT: (1) defining of low risk appropriately, (2) attempting to reduce the treatment burden of past protocols, and (3) understanding approach and timing of cranial irradiation. APPROACH Although AALL1331 therapy without blinatumomab leads to excellent survival in patients with isolated testicular relapse, we recommend a modified AALL02P2 backbone of chemotherapy with 1,800 cGy cranial radiotherapy for patients with late iCNS relapse. Future studies integrating chimeric antigen receptor T cells, which have better CNS penetration, may help decrease the intensive treatment burden for patients with late iCNS recurrence.
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Affiliation(s)
- Luke D Maese
- Intermountain Primary Children's Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
| | - Michael A Pulsipher
- Intermountain Primary Children's Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
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13
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Kitko CL, Bollard CM, Cairo MS, Chewning J, Fry TJ, Pulsipher MA, Shenoy S, Wall DA, Levine JE. Children's Oncology Group's 2023 blueprint for research: Cellular therapy and stem cell transplantation. Pediatr Blood Cancer 2023; 70 Suppl 6:e30577. [PMID: 37480158 PMCID: PMC10527977 DOI: 10.1002/pbc.30577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/23/2023]
Abstract
Since the publication of the last Cellular Therapy and Stem Cell Transplant blueprint in 2013, Children's Oncology Group cellular therapy-based trials advanced the field and created new standards of care across a wide spectrum of pediatric cancer diagnoses. Key findings include that tandem autologous transplant improved survival for patients with neuroblastoma and atypical teratoid/rhabdoid brain tumors, one umbilical cord blood (UCB) donor was safer than two UCB donors, killer immunoglobulin receptor (KIR) mismatched donors did not improve survival for pediatric acute myeloid leukemia when in vivo T-cell depletion is used, and the depth of remission as measured by next-generation sequencing-based minimal residual disease assessment pretransplant was the best predictor of relapse for acute lymphoblastic leukemia. Plans for the next decade include optimizing donor selection for transplants for acute leukemia/myelodysplastic syndrome, using novel engineered cellular therapies to target a wide array of malignancies, and developing better treatments for cellular therapy toxicities such as viral infections and graft-vs-host disease.
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Affiliation(s)
- Carrie L. Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Catherine M Bollard
- Center for Cancer and Immunology Research, Children’s National Hospital, Washington, DC
- GW Cancer Center, George Washington University, Washington, DC
- Division of Blood and Marrow Transplantation, Children’s National Hospital, Washington, DC
| | - Mitchell S. Cairo
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Maria Fareri Children's Hospital, Westchester Medical Center, New York Medical College, Valhalla, New York, NY
| | - Joseph Chewning
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Terry J. Fry
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, CO
| | - Michael A. Pulsipher
- Division of Hematology and Oncology, Intermountain Primary Children’s Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine, Salt Lake City, UT
| | - Shalini Shenoy
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Washington University, St Louis, MO
| | - Donna A. Wall
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Canada
| | - John E. Levine
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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14
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Yilmaz B, Koc A, Dogru O, Tufan Tas B, Senay RE. The results of the modified St Jude Total Therapy XV Protocol in the treatment of low- and middle-income children with acute lymphoblastic leukemia. Leuk Lymphoma 2023; 64:1304-1314. [PMID: 37165575 DOI: 10.1080/10428194.2023.2205976] [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: 01/30/2023] [Revised: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 05/12/2023]
Abstract
The St Jude Total Therapy Study XV was the first clinical trial to prospectively use minimal residual disease levels during and after remission induction therapy to guide risk-directed treatment. We used the Total Therapy XV protocol with minimal modification in treating 115 newly diagnosed pediatric acute lymphoblastic leukemia patients from low- and middle-income groups from January 2011 to December 2017. The mean age at diagnosis was 5.97 ± 3.96 years. The median follow-up period was 88 months. Three (2.6%) patients had bone marrow relapse, and one (0.87%) had an isolated central nervous system relapse. Nineteen of the patients (16.52%) died due to infection-related complications, three (2.61%) died due to progressive disease, and one (0.87%) died due to hematopoietic stem cell transplant complications. Five-year overall survival was 80%, and event-free survival was 78.3%. Our results showed that the Total XV treatment protocol could be used successfully in patients with ALL from low- and middle-income populations. However, infection-related deaths remain a significant problem.
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Affiliation(s)
- Baris Yilmaz
- Pediatric Hematology and Oncology, SB Marmara University Medical School Education and Research Hospital, Istanbul, Türkiye
| | - Ahmet Koc
- Pediatric Hematology and Oncology, SB Marmara University Medical School Education and Research Hospital, Istanbul, Türkiye
| | - Omer Dogru
- Pediatric Hematology and Oncology, SB Marmara University Medical School Education and Research Hospital, Istanbul, Türkiye
| | - Burcu Tufan Tas
- Pediatric Hematology and Oncology, SB Marmara University Medical School Education and Research Hospital, Istanbul, Türkiye
| | - Rabia Emel Senay
- Pediatric Hematology and Oncology, SB Marmara University Medical School Education and Research Hospital, Istanbul, Türkiye
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15
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Ma L, Xu LP, Wang Y, Zhang XH, Chen H, Chen YH, Wang FR, Han W, Sun YQ, Yan CH, Lv M, Tang FF, Mo XD, Wang ZD, Jiang Q, Lu J, Jiang H, Liu YR, Liu KY, Chang YJ, Huang XJ. Effects of isolated central nervous system involvement evaluated by multiparameter flow cytometry prior to allografting on outcomes of patients with acute lymphoblastic leukemia. Front Oncol 2023; 13:1166990. [PMID: 37251948 PMCID: PMC10209422 DOI: 10.3389/fonc.2023.1166990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/24/2023] [Indexed: 05/31/2023] Open
Abstract
Introduction Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains a major strategy to cure patients with acute lymphoblastic leukemia (ALL). The aim of this study was to evaluate whether isolated flow cytometry (FCM)-positive central nervous system (CNS) involvement before allo-HSCT is clinically significant. Methods The effects of isolated FCM-positive CNS involvement prior to transplantation on the outcomes of 1406 ALL patients with complete remission (CR) were retrospectively investigated. Results Patients were classified into isolated FCM-positive CNS involvement (n=31), cytology-positive CNS involvement (n = 43), and negative CNS involvement (n = 1332) groups. Among the three groups, the 5-year cumulative incidence of relapse (CIR) values were 42.3%, 48.8%, and 23.4%, respectively (P<0.001). The 5-year leukemia-free survival (LFS) values were 44.7%, 34.9%, and 60.8%, respectively (P<0.001). Compared with the negative CNS group (n=1332), the 5-year CIR of the pre-HSCT CNS involvement group (n=74) was higher (46.3% vs. 23.4%, P<0.001], and the 5-year LFS was inferior (39.1% vs. 60.8%, P<0.001). Multivariate analysis indicated that four variables, T-cell ALL, in second complete remission or beyond (CR2+) at HSCT, pre-HSCT measurable residual disease positivity, and pre-HSCT CNS involvement, were independently associated with a higher CIR and inferior LFS. A new scoring system was developed using the following four variables: low-risk, intermediate-risk, high-risk, and extremely high-risk groups. The 5-year CIR values were 16.9%, 27.8%, 50.9%, and 66.7%, respectively (P<0.001), while the 5-year LFS values were 67.6%, 56.9%, 31.0%, and 13.3%, respectively (P<0.001). Conclusion Our results suggest that ALL patients with isolated FCM-positive CNS involvement are at a higher risk of recurrence after transplantation. Patients with pre-HSCT CNS involvement had higher CIR and inferior survival outcomes.
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Rascon J, Vaisnore R, Pasauliene R, Kovalova Z, Jakaitiene A, Vaitkeviciene G. Pediatric Hematopoietic Stem Cell Transplantation: Challenges in Small European Countries. Transplant Cell Ther 2023; 29:269.e1-269.e10. [PMID: 36641033 DOI: 10.1016/j.jtct.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/01/2023] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Affiliation(s)
- Jelena Rascon
- Center for Pediatric Oncology and Hematology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Vilnius University, Institute of Clinical Medicine, Clinic of Children's Diseases, Vilnius, Lithuania.
| | - Ramune Vaisnore
- Institute of Data Science and Digital Technologies, Vilnius University, Vilnius, Lithuania
| | - Ramune Pasauliene
- Center for Pediatric Oncology and Hematology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Zanna Kovalova
- Department of Hematology and Oncology, Children's Clinical University Hospital, Riga, Latvia; Riga Stradins University, Riga, Latvia
| | - Audrone Jakaitiene
- Institute of Data Science and Digital Technologies, Vilnius University, Vilnius, Lithuania; Department of Human and Medical Genetics, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania
| | - Goda Vaitkeviciene
- Center for Pediatric Oncology and Hematology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Vilnius University, Institute of Clinical Medicine, Clinic of Children's Diseases, Vilnius, Lithuania
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17
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Myers RM, Shah NN, Pulsipher MA. How I use risk factors for success or failure of CD19 CAR T cells to guide management of children and AYA with B-cell ALL. Blood 2023; 141:1251-1264. [PMID: 36416729 PMCID: PMC10082355 DOI: 10.1182/blood.2022016937] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 11/24/2022] Open
Abstract
By overcoming chemotherapeutic resistance, chimeric antigen receptor (CAR) T cells facilitate deep, complete remissions and offer the potential for long-term cure in a substantial fraction of patients with chemotherapy refractory disease. However, that success is tempered with 10% to 30% of patients not achieving remission and over half of patients treated eventually experiencing relapse. With over a decade of experience using CAR T cells in children, adolescents, and young adults (AYA) to treat relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL) and 5 years since the first US Food and Drug Administration approval, data defining the nuances of patient-specific risk factors are emerging. With the commercial availability of 2 unique CD19 CAR T-cell constructs for B-ALL, in this article, we review the current literature, outline our approach to patients, and discuss how individual factors inform strategies to optimize outcomes in children and AYA receiving CD19 CAR T cells. We include data from both prospective and recent large retrospective studies that offer insight into understanding when the risks of CAR T-cell therapy failure are high and offer perspectives suggesting when consolidative hematopoietic cell transplantation or experimental CAR T-cell and/or alternative immunotherapy should be considered. We also propose areas where prospective trials addressing the optimal use of CAR T-cell therapy are needed.
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Affiliation(s)
- Regina M. Myers
- Division of Oncology, Cell Therapy and Transplant Section, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Nirali N. Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Michael A. Pulsipher
- Division of Hematology and Oncology, Intermountain Primary Children’s Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
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Wayne AS, Huynh V, Hijiya N, Rouce RH, Brown PA, Krueger J, Kitko CL, Ziga ED, Hermiston ML, Richards MK, Baruchel A, Schuberth PC, Rossi J, Zhou L, Goyal L, Jain R, Vezan R, Masouleh BK, Lee DW. Three-year results from phase I of ZUMA-4: KTE-X19 in pediatric relapsed/refractory acute lymphoblastic leukemia. Haematologica 2023; 108:747-760. [PMID: 36263840 PMCID: PMC9973494 DOI: 10.3324/haematol.2022.280678] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Indexed: 11/09/2022] Open
Abstract
Here we present the 3-year results of ZUMA-4, a phase I/II multicenter study evaluating the safety and efficacy of KTEX19, an autologous anti-CD19 chimeric antigen receptor (CAR) T-cell therapy, in pediatric/adolescent patients with relapsed/refractory B-cell acute lymphoblastic leukemia. Phase I explored two dose levels and formulations. The primary endpoint was the incidence of dose-limiting toxicities. Thirty-one patients were enrolled; KTE-X19 was administered to 24 patients (median age 13.5 years, range 3-20; median follow-up 36.1 months). No dose-limiting toxicities were observed. All treated patients had grade ≥3 adverse events, commonly hypotension (50%) and anemia (42%). Grade 3 cytokine release syndrome rates were 33% in all treated patients, 75% in patients given the dose of 2×106 CAR T cells/kg, 27% in patients given the dose of 1×106 cells/kg in the 68 mL formulation, and 22% in patients given the dose of 1×106 cells/kg in the 40 mL formulation; the percentages of patients experiencing grade ≥3 neurologic events were 21%, 25%, 27%, and 11% respectively. Overall complete remission rates (including complete remission with incomplete hematologic recovery) were 67% in all treated patients, 75% in patients given 2×106 CAR T cells/kg, 64% in patients given 1×106 cells/kg in the 68 mL formulation, and 67% in patients given 1×106 cells/kg in the 40 mL formulation. Overall minimal residual diseasenegativity rates were 100% among responders; 88% of responders underwent subsequent allogeneic stem-cell transplantation. In the 1×106 (40 mL) group (recommended phase II dose), the median duration of remission censored at allogeneic stem-cell transplantation and median overall survival were not reached. Pediatric/adolescent patients with relapsed/refractory B-cell acute lymphoblastic leukemia achieved high minimal residual disease-negative remission rates with a manageable safety profile after a single dose of KTE-X19. Phase II of the study is ongoing at the dose of 1×106 CAR T cells/kg in the 40 mL formulation. ClinicalTrials.gov: NCT02625480.
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Affiliation(s)
- Alan S Wayne
- Children's Hospital Los Angeles, USC Norris Comprehensive Cancer Center and Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Van Huynh
- CHOC Children's Hospital, Orange, CA
| | - Nobuko Hijiya
- Columbia University Irving Medical Center, New York City, NY
| | | | | | - Joerg Krueger
- The Hospital for Sick Children, University of Toronto, Ontario
| | | | | | - Michelle L Hermiston
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA
| | | | - Andre Baruchel
- Hôpital Universitaire Robert Debré (APHP) and Université de Paris, Paris
| | | | - John Rossi
- Kite, a Gilead Company, Santa Monica, CA
| | - Lang Zhou
- Kite, a Gilead Company, Santa Monica, CA
| | | | - Rajul Jain
- Kite, a Gilead Company, Santa Monica, CA
| | | | | | - Daniel W Lee
- University of Virginia Children's Hospital, UVA Cancer Center, UVA School of Medicine, Charlottesville, VA
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19
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Tecchio C, Russignan A, Krampera M. Immunophenotypic measurable residual disease monitoring in adult acute lymphoblastic leukemia patients undergoing allogeneic hematopoietic stem cell transplantation. Front Oncol 2023; 13:1047554. [PMID: 36910638 PMCID: PMC9992536 DOI: 10.3389/fonc.2023.1047554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 01/11/2023] [Indexed: 02/24/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) offers a survival benefit to adult patients affected by acute lymphoblastic leukemia (ALL). However, to avoid an overt disease relapse, patients with pre or post transplant persistence or occurrence of measurable residual disease (MRD) may require cellular or pharmacological interventions with eventual side effects. While the significance of multiparametric flow cytometry (MFC) in the guidance of ALL treatment in both adult and pediatric patients is undebated, fewer data are available regarding the impact of MRD monitoring, as assessed by MFC analysis, in the allo-HSCT settings. Aim of this article is to summarize and discuss currently available information on the role of MFC detection of MRD in adult ALL patients undergoing allo-HSCT. The significance of MFC-based MRD according to sensitivity level, timing, and in relation to molecular techniques of MRD and chimerism assessment will be also discussed.
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Affiliation(s)
- Cristina Tecchio
- Department of Medicine, Section of Hematology and Bone Marrow Transplant Unit, University of Verona, Verona, Italy
| | - Anna Russignan
- Department of Medicine, Section of Hematology and Bone Marrow Transplant Unit, University of Verona, Verona, Italy
| | - Mauro Krampera
- Department of Medicine, Section of Hematology and Bone Marrow Transplant Unit, University of Verona, Verona, Italy
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20
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Moreno C, Ramos-Elbal E, Velasco P, Aguilar Y, Gonzáález Martínez B, Fuentes C, Molinos Á, Guerra-García P, Palomo P, Verdu J, Adán Pedroso RM, Vagace JM, López-Duarte M, Regueiro A, Tasso M, Dapena JL, Salinas JA, Navarro S, Bautista F, Lassaletta Á, Lendínez F, Rives S, Pascual A, Rodríguez A, Pérez-Hurtado JM, Fernández JM, Pérez-Martínez A, González-Vicent M, Díaz de Heredia C, Fuster JL. Haploidentical vs. HLA-matched donor hematopoietic stem-cell transplantation for pediatric patients with acute lymphoblastic leukemia in second remission: A collaborative retrospective study of the Spanish Group for Bone Marrow Transplantation in Children (GETMON/GETH) and the Spanish Childhood Relapsed ALL Board (ReALLNet). Front Pediatr 2023; 11:1140637. [PMID: 37020654 PMCID: PMC10067875 DOI: 10.3389/fped.2023.1140637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/23/2023] [Indexed: 04/07/2023] Open
Abstract
Introduction Studies addressing the role of haploidentical as alternative to HLA-matched donors for stem cell transplantation (SCT) often include patients with diverse hematological malignancies in different remission statuses. Methods We compared outcomes of children with acute lymphoblastic leukemia (ALL) undergoing SCT in second complete remission (CR2) from haploidentical (n = 25) versus HLA-matched donor (n = 51). Results Patients were equally distributed across both groups according to age, immunophenotype, time to and site of relapse, relapse risk-group allocation, and minimal residual disease (MRD) before SCT. Incidence of graft failure, acute graft versus host disease (GVHD), and other early complications did not differ between both groups. We found no differences in overall survival (58.7% versus 59.5%; p = .8), leukemia free survival (LFS) (48% versus 36.4%; p = .5), event free survival (40% versus 34.4%; p = .69), cumulative incidence (CI) of subsequent relapse (28% versus 40.9%; p = .69), treatment related mortality (24% versus 23.6%; p = .83), CI of cGVHD (4.5% versus 18.7%; p = .2), and chronic GVHD-free and leukemia-free survival (44% versus 26.3%; p = .3) after haploidentical donor SCT. Chronic GVHD (HR = 0.09; p=.02) had protective impact, and MRD ≥ 0.01% before SCT (HR = 2.59; p=.01) had unfavorable impact on LFS. Discussion These results support the role of haploidentical donor SCT in children with ALL in CR2.
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Affiliation(s)
- Celia Moreno
- Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | | | - Pablo Velasco
- Hospital Universitario Vall d’Hebron, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | | | - Berta Gonzáález Martínez
- Hospital Universitario La Paz, IdiPAZ, Instituto de Investigación, Hospital Universitario La Paz, Madrid, Spain
| | | | | | - Pilar Guerra-García
- Hospital Universitario La Paz, IdiPAZ, Instituto de Investigación, Hospital Universitario La Paz, Madrid, Spain
- Hospital Universitario 12 de octubre, Madrid, Spain
| | - Pilar Palomo
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Jaime Verdu
- Hospital Universitario de Valencia, Valencia, Spain
| | | | | | - Mónica López-Duarte
- Hospital de Valdecilla, Instituto de Investigación Sanitaria Valdecilla, IDIVAL, Santander, Spain
| | - Alexandra Regueiro
- Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - María Tasso
- Hospital General Universitario Doctor Balmis, Alicante, Spain
| | - José Luis Dapena
- Pediatric Cancer Center, Hospital Sant Joan de Déu, Barcelona, Spain
- Institut de Recerca San Joan de Déu,Barcelona, Spain
| | | | - Samuel Navarro
- Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | | | | | | | - Susana Rives
- Pediatric Cancer Center, Hospital Sant Joan de Déu, Barcelona, Spain
- Institut de Recerca San Joan de Déu,Barcelona, Spain
| | | | | | | | | | - Antonio Pérez-Martínez
- Hospital Universitario La Paz, IdiPAZ, Instituto de Investigación, Hospital Universitario La Paz, Madrid, Spain
| | | | | | - José Luis Fuster
- Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria (IMIB), Murcia, Spain
- Correspondence: José Luis Fuster
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21
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Dekker SE, Leonard J, Muffly L. SOHO State of the Art Updates and Next Questions: Measurable Residual Disease in Acute Lymphoblastic Leukemia - Optimization and Innovation in 2022 and Beyond. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:878-882. [PMID: 36130863 DOI: 10.1016/j.clml.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 01/26/2023]
Abstract
Measurable residual disease (MRD) is an established component of acute lymphoblastic leukemia (ALL) management in both children and adults. Society guidelines and expert consensus documents include assessment of MRD as the standard of care following induction therapy, consolidation therapy, and at additional time points, depending on the treatment regimen administered. Further, the approval of blinatumomab for MRD+ B-ALL has advanced the concept of MRD response as a clinical endpoint in ALL. Although the utility of MRD in ALL has been well defined over the last decades, several questions remain. In this review we focus on areas of ongoing controversy and exploration in ALL MRD, including the following: (1) Does increasing the depth of MRD assessment add prognostic value? (2) Is there a role for ongoing MRD monitoring once patients achieve MRD response? (3) Can MRD assessment of the peripheral blood be substituted for bone marrow? (4) Should MRD assays be applied to the analysis of the central nervous system (CNS)? Ongoing studies should answer the majority of these questions in the coming years.
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Affiliation(s)
- Simone E Dekker
- Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Jessica Leonard
- Division of Hematology-Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR
| | - Lori Muffly
- Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford University, Stanford, CA.
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22
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Saygin C, Cannova J, Stock W, Muffly L. Measurable residual disease in acute lymphoblastic leukemia: methods and clinical context in adult patients. Haematologica 2022; 107:2783-2793. [PMID: 36453516 PMCID: PMC9713546 DOI: 10.3324/haematol.2022.280638] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Indexed: 12/04/2022] Open
Abstract
Measurable residual disease (MRD) is the most powerful independent predictor of risk of relapse and long-term survival in adults and children with acute lymphoblastic leukemia (ALL). For almost all patients with ALL there is a reliable method to evaluate MRD, which can be done using multi-color flow cytometry, quantitative polymerase chain reaction to detect specific fusion transcripts or immunoglobulin/T-cell receptor gene rearrangements, and high-throughput next-generation sequencing. While next-generation sequencing-based MRD detection has been increasingly utilized in clinical practice due to its high sensitivity, the clinical significance of very low MRD levels (<10-4) is not fully characterized. Several new immunotherapy approaches including blinatumomab, inotuzumab ozogamicin, and chimeric antigen receptor T-cell therapies have demonstrated efficacy in eradicating MRD in patients with B-ALL. However, new approaches to target MRD in patients with T-ALL remain an unmet need. As our MRD detection assays become more sensitive and expanding novel therapeutics enter clinical development, the future of ALL therapy will increasingly utilize MRD as a criterion to either intensify or modify therapy to prevent relapse or de-escalate therapy to reduce treatment-related morbidity and mortality.
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Affiliation(s)
- Caner Saygin
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL
| | - Joseph Cannova
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL
| | - Wendy Stock
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL
| | - Lori Muffly
- Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford University, Stanford, CA, USA,L. Muffly
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23
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Mezger K, Ebert S, Muhle HE, Stadt UZ, Borkhardt A, Dilloo D, Faber J, Feuchtinger T, Imschweiler T, Jorch N, Pekrun A, Schmid I, Schramm F, Zimmermann M, Horstmann MA, Escherich G. Amsacrine combined with etoposide and methylprednisolone is a feasible and safe component in first-line intensified treatment of pediatric patients with high-risk acute lymphoblastic leukemia in CoALL08-09 trial. Pediatr Blood Cancer 2022; 69:e29997. [PMID: 36129234 DOI: 10.1002/pbc.29997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/27/2022] [Accepted: 08/12/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND The prognosis of children with acute lymphoblastic leukemia (ALL) has improved considerably over the past five decades. However, to achieve cure in patients with refractory or relapsed disease, novel treatment options are necessary. METHODS In the multicenter trial Cooperative Study Group for Childhood Acute Lymphoblastic Leukemia (CoALL)08-09, one additional treatment element consisting of the rarely used chemotherapeutic agent amsacrine combined with etoposide and methylprednisolone (AEP) (amsacrine 2 × 100 mg/m2 , etoposide 2 × 500 mg/m2 , and methylprednisolone 4 × 1000 mg/m2 ) was incorporated into the first-line treatment of pediatric patients with poor treatment responses at the end of induction (EOI), measured by minimal residual disease (MRD). These patients were stratified into a high-risk intensified arm (HR-I), including an AEP element at the end of consolidation. Patients with induction failure (IF), that is, with lack of cytomorphological remission EOI, were eligible for hematopoietic stem cell transplantation (HSCT) after remission had been reached. These patients received AEP as a part of their MRD-guided bridging-to-transplant treatments. RESULTS A significant improvement in probability of overall survival (pOS) was noted for the CoALL08-09 HR-I patients compared to MRD-matched patients from the preceding CoALL07-03 trial in the absence of severe or persistent treatment-related toxicities. Relapse rate and probability of event-free survival (pEFS) did not differ significantly between trials. In patients with IF, stable or improved MRD responses after AEP were observed without severe or persistent treatment-related toxicities. CONCLUSION In conclusion, AEP is well tolerated as a component of the HR treatment and is useful in bridging-to-transplant settings.
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Affiliation(s)
- Kerstin Mezger
- Clinic of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Sabine Ebert
- Clinic of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Hannah Elisa Muhle
- Clinic of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Udo Zur Stadt
- Clinic of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Arndt Borkhardt
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty Duesseldorf, Duesseldorf, Germany
| | - Dagmar Dilloo
- Department of Pediatric Hematology/Oncology, University Hospital Bonn, Bonn, Germany
| | - Jörg Faber
- Department of Pediatric Hematology/Oncology, University Hospital Mainz, Mainz, Germany
| | - Tobias Feuchtinger
- Dr. von Hauner Children's Hospital, Ludwig Maximilian University, Munich, Germany
| | - Thomas Imschweiler
- Department of Pediatric Hematology and Oncology, Helios Hospital, Krefeld, Germany
| | - Norbert Jorch
- Department of Pediatric Hematology and Oncology, Hospital Bielefeld, Bielefeld, Germany
| | - Arnulf Pekrun
- Department of Pediatric Hematology and Oncology, Hospital Bremen-Mitte, Bremen, Germany
| | - Irene Schmid
- Dr. von Hauner Children's Hospital, Ludwig Maximilian University, Munich, Germany
| | - Franziska Schramm
- Clinic of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Zimmermann
- Department of Pediatric Haematology and Oncology, Medical School Hannover, Hannover, Germany
| | - Martin A Horstmann
- Clinic of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriele Escherich
- Clinic of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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24
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Dinikina YV, Mikhailov AV, Rusina MA, Smirnova AY, Vorob’ov NA, Kataev NA, Kubasov AV. First experience of total body irradiation in conditioning regimes for allogenic hematopoietic stem cells transplantation in children with acute lymphoblastic leukemia in Saint Petersburg. ONCOHEMATOLOGY 2022. [DOI: 10.17650/1818-8346-2022-17-4-126-137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Background. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an effective treatment method of refractory and recurrent forms of acute leukemia in children, while the question of choosing a conditioning regimen in order to achieve the best treatment results remains debatable. Conditioning based on total body irradiation (TbI) was confirmed to be most effective in some trials, but there are still issues of overcoming early and late toxicity, as well as difficulties in planning and routing patients.Aim. To share the experience of interdisciplinary patient management during the conditioning period with TbI inclusion in Saint petersburg, to evaluate the feasibility, toxicity and effectiveness of the method.Materials and methods. patients undergoing allo-HSCT for high risk acute lymphoblastic leukemia conditioned either with TbI (n = 12) or chemotherapy (n = 10) were included. Medical data were retrospectively analyzed with an assessment of the following transplant outcomes: HSCT-associated toxicity, the frequency and severity of infectious complications, graft versus host disease, as well as overall and event-free survival rates. we have evaluated radiotherapy plans in order to assess the compliance of radiation exposure with acceptable values for critical organs.Results. All patients with acute lymphoblastic leukemia in both groups received appropriate myeloablative conditioning. According to the study results, despite the lack of significance, we obtained differences in HSCT-associated mortality (8.3 and 30 %; p = 0.151), 2-years overall and event-free survival (66 ± 13.6 and 36 ± 16.1 %; p = 0.122) in group with TbI and HdCT respectively. It should be noted that there was a trend towards a decrease of toxic reactions frequency in case of TbI-containing regimens; however we didn’t reveal any significant differences in the number of infectious complications during post-transplant period. The median follow-up was 24.2 months and there were no signs of delayed toxicity.Conclusion. TbI-based conditioning was well tolerated with a low incidence of early and delayed toxicity, better overall and event-free survival. based on feasibility of TbI in Saint petersburg hospitals it is possible to recommend the method in routine practice, taking into account clinical indications.
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Affiliation(s)
- Yu. V. Dinikina
- V.A. Almazov National Medical Research Centre, Ministry of Health of Russia
| | - A. V. Mikhailov
- Diagnostic and Treatment Center, International Institute of Biological Systems named after Sergey Berezin; I.I. Mechnikov North-West State Medical University, Ministry of Health of Russia
| | - M. A. Rusina
- V.A. Almazov National Medical Research Centre, Ministry of Health of Russia
| | - A. Yu. Smirnova
- V.A. Almazov National Medical Research Centre, Ministry of Health of Russia
| | - N. A. Vorob’ov
- Diagnostic and Treatment Center, International Institute of Biological Systems named after Sergey Berezin; Saint Petersburg State University
| | - N. A. Kataev
- Diagnostic and Treatment Center, International Institute of Biological Systems named after Sergey Berezin
| | - A. V. Kubasov
- Diagnostic and Treatment Center, International Institute of Biological Systems named after Sergey Berezin
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25
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Stanojevic M, Grant M, Vesely SK, Knoblach S, Kanakry CG, Nazarian J, Panditharatna E, Panchapakesan K, Gress RE, Holter-Chakrabarty J, Williams KM. Peripheral blood marker of residual acute leukemia after hematopoietic cell transplantation using multi-plex digital droplet PCR. Front Immunol 2022; 13:999298. [PMID: 36248870 PMCID: PMC9556966 DOI: 10.3389/fimmu.2022.999298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/12/2022] [Indexed: 11/17/2022] Open
Abstract
Background Relapse remains the primary cause of death after hematopoietic cell transplantation (HCT) for acute leukemia. The ability to identify minimal/measurable residual disease (MRD) via the blood could identify patients earlier when immunologic interventions may be more successful. We evaluated a new test that could quantify blood tumor mRNA as leukemia MRD surveillance using droplet digital PCR (ddPCR). Methods The multiplex ddPCR assay was developed using tumor cell lines positive for the tumor associated antigens (TAA: WT1, PRAME, BIRC5), with homeostatic ABL1. On IRB-approved protocols, RNA was isolated from mononuclear cells from acute leukemia patients after HCT (n = 31 subjects; n = 91 specimens) and healthy donors (n = 20). ddPCR simultaneously quantitated mRNA expression of WT1, PRAME, BIRC5, and ABL1 and the TAA/ABL1 blood ratio was measured in patients with and without active leukemia after HCT. Results Tumor cell lines confirmed quantitation of TAAs. In patients with active acute leukemia after HCT (MRD+ or relapse; n=19), the blood levels of WT1/ABL1, PRAME/ABL1, and BIRC5/ABL1 exceeded healthy donors (p<0.0001, p=0.0286, and p=0.0064 respectively). Active disease status was associated with TAA positivity (1+ TAA vs 0 TAA) with an odds ratio=10.67, (p=0.0070, 95% confidence interval 1.91 - 59.62). The area under the curve is 0.7544. Changes in ddPCR correlated with disease response captured on standard of care tests, accurately denoting positive or negative disease burden in 15/16 (95%). Of patients with MRD+ or relapsed leukemia after HCT, 84% were positive for at least one TAA/ABL1 in the peripheral blood. In summary, we have developed a new method for blood MRD monitoring of leukemia after HCT and present preliminary data that the TAA/ABL1 ratio may may serve as a novel surrogate biomarker for relapse of acute leukemia after HCT.
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Affiliation(s)
- M. Stanojevic
- Department of Pediatrics, MedStar Georgetown University Hospital, Washington, DC, United States
| | - M. Grant
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - S. K. Vesely
- Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma, OK, United States
| | - S. Knoblach
- Children’s Research Institute, Research Center for Genetic Medicine, Children’s National Health System, Washington, DC, United States
| | - C. G. Kanakry
- Experimental Transplantation and Immunotherapy Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - J. Nazarian
- Children’s Research Institute, Research Center for Genetic Medicine, Children’s National Health System, Washington, DC, United States,Department of Oncology, Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - E. Panditharatna
- Department of Pediatric Oncology, Dana-Farber Boston Children’s Cancer and Blood Disorders Center, Boston, MA, United States
| | - K. Panchapakesan
- Children’s Research Institute, Research Center for Genetic Medicine, Children’s National Health System, Washington, DC, United States
| | - R. E. Gress
- Experimental Transplantation and Immunotherapy Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - J. Holter-Chakrabarty
- Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma, OK, United States
| | - Kirsten M. Williams
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, United States,*Correspondence: Kirsten M. Williams,
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26
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Ragoonanan D, Sheikh IN, Gupta S, Khazal SJ, Tewari P, Petropoulos D, Li S, Mahadeo KM. The Evolution of Chimeric Antigen Receptor T-Cell Therapy in Children, Adolescents and Young Adults with Acute Lymphoblastic Leukemia. Biomedicines 2022; 10:biomedicines10092286. [PMID: 36140387 PMCID: PMC9496125 DOI: 10.3390/biomedicines10092286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 08/05/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Chimeric antigen receptor T-cell (CAR T) therapy is a revolutionary treatment for pediatric, adolescent and young adult patients (AYA) with relapsed/refractory B-cell acute lymphoblastic leukemia. While the landscape of immunotherapy continues to rapidly evolve, widespread use of CAR T therapy is limited and many questions remain regarding the durability of CAR T therapy, methods to avoid CAR T therapy resistance and the role of consolidative stem cell transplant. Modified strategies to develop effective and persistent CAR T cells at lower costs and decreased toxicities are warranted. In this review we present current indications, limitations and future directions of CAR T therapy for ALL in the pediatric and AYA population.
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Affiliation(s)
- Dristhi Ragoonanan
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence: (D.R.); (I.N.S.)
| | - Irtiza N. Sheikh
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence: (D.R.); (I.N.S.)
| | - Sumit Gupta
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sajad J. Khazal
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Priti Tewari
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Demetrios Petropoulos
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Shulin Li
- Department of Pediatrics Research, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Kris M. Mahadeo
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Hoeben BAW, Pazos M, Seravalli E, Bosman ME, Losert C, Albert MH, Boterberg T, Ospovat I, Mico Milla S, Demiroz Abakay C, Engellau J, Jóhannesson V, Kos G, Supiot S, Llagostera C, Bierings M, Scarzello G, Seiersen K, Smith E, Ocanto A, Ferrer C, Bentzen SM, Kobyzeva DA, Loginova AA, Janssens GO. ESTRO ACROP and SIOPE recommendations for myeloablative Total Body Irradiation in children. Radiother Oncol 2022; 173:119-133. [PMID: 35661674 DOI: 10.1016/j.radonc.2022.05.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/26/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Myeloablative Total Body Irradiation (TBI) is an important modality in conditioning for allogeneic hematopoietic stem cell transplantation (HSCT), especially in children with high-risk acute lymphoblastic leukemia (ALL). TBI practices are heterogeneous and institution-specific. Since TBI is associated with multiple late adverse effects, recommendations may help to standardize practices and improve the outcome versus toxicity ratio for children. MATERIAL AND METHODS The European Society for Paediatric Oncology (SIOPE) Radiotherapy TBI Working Group together with ESTRO experts conducted a literature search and evaluation regarding myeloablative TBI techniques and toxicities in children. Findings were discussed in bimonthly virtual meetings and consensus recommendations were established. RESULTS Myeloablative TBI in HSCT conditioning is mostly performed for high-risk ALL patients or patients with recurring hematologic malignancies. TBI is discouraged in children <3-4 years old because of increased toxicity risk. Publications regarding TBI are mostly retrospective studies with level III-IV evidence. Preferential TBI dose in children is 12-14.4 Gy in 1.6-2 Gy fractions b.i.d. Dose reduction should be considered for the lungs to <8 Gy, for the kidneys to ≤10 Gy, and for the lenses to <12 Gy, for dose rates ≥6 cGy/min. Highly conformal techniques i.e. TomoTherapy and VMAT TBI or Total Marrow (and/or Lymphoid) Irradiation as implemented in several centers, improve dose homogeneity and organ sparing, and should be evaluated in studies. CONCLUSIONS These ESTRO ACROP SIOPE recommendations provide expert consensus for conventional and highly conformal myeloablative TBI in children, as well as a supporting literature overview of TBI techniques and toxicities.
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Affiliation(s)
- Bianca A W Hoeben
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
| | - Montserrat Pazos
- Dept. of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Enrica Seravalli
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Mirjam E Bosman
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Christoph Losert
- Dept. of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Michael H Albert
- Dept. of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Germany
| | - Tom Boterberg
- Dept. of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Inna Ospovat
- Dept. of Radiation Oncology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Soraya Mico Milla
- Dept. of Radiation Oncology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Candan Demiroz Abakay
- Dept. of Radiation Oncology, Uludag University Faculty of Medicine Hospital, Bursa, Turkey
| | - Jacob Engellau
- Dept. of Radiation Oncology, Skåne University Hospital, Lund, Sweden
| | | | - Gregor Kos
- Dept. of Radiation Oncology, Institute of Oncology Ljubljana, Slovenia
| | - Stéphane Supiot
- Dept. of Radiation Oncology, Institut de Cancérologie de l'Ouest, Nantes St. Herblain, France
| | - Camille Llagostera
- Dept. of Medical Physics, Institut de Cancérologie de l'Ouest, Nantes St. Herblain, France
| | - Marc Bierings
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Giovanni Scarzello
- Dept. of Radiation Oncology, Veneto Institute of Oncology-IRCCS, Padua, Italy
| | | | - Ed Smith
- Dept. of Radiation Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Abrahams Ocanto
- Dept. of Radiation Oncology, La Paz University Hospital, Madrid, Spain
| | - Carlos Ferrer
- Dept. of Medical Physics and Radiation Protection, La Paz University Hospital, Madrid, Spain
| | - Søren M Bentzen
- Dept. of Epidemiology and Public Health, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, United States
| | - Daria A Kobyzeva
- Dept. of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna A Loginova
- Dept. of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Geert O Janssens
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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Poyer F, Füreder A, Holter W, Peters C, Boztug H, Dworzak M, Engstler G, Friesenbichler W, Köhrer S, Lüftinger R, Ronceray L, Witt V, Pichler H, Attarbaschi A. Relapsed acute lymphoblastic leukaemia after allogeneic stem cell transplantation: a therapeutic dilemma challenging the armamentarium of immunotherapies currently available (case reports). Ther Adv Hematol 2022; 13:20406207221099468. [PMID: 35646299 PMCID: PMC9134426 DOI: 10.1177/20406207221099468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 04/19/2022] [Indexed: 12/05/2022] Open
Abstract
While survival rates in paediatric acute lymphoblastic leukaemia (ALL) nowadays
exceed 90%, systemic ALL relapse, especially after haemopoietic stem cell
transplantation (HSCT), is associated with a poor outcome. As there is currently
no standardized treatment for this situation, individualized treatment is often
pursued. Exemplified by two clinical scenarios, the aim of this article is to
highlight the challenge for treating physicians to find a customized treatment
strategy integrating the role of conventional chemotherapy, immunotherapeutic
approaches and second allogeneic HSCT. Case 1 describes a 2-year-old girl with
an early isolated bone marrow relapse of an infant
KMT2A-rearranged B-cell precursor ALL after allogeneic HSCT.
After bridging chemotherapy and lymphodepleting chemotherapy, chimeric antigen
receptor (CAR) T-cells (tisagenlecleucel) were administered for remission
induction, followed by a second HSCT from the 9/10 human leukocyte antigen
(HLA)-matched mother. Case 2 describes a 16-year-old girl with a late, isolated
bone marrow relapse of B-cell precursor ALL after allogeneic HSCT who
experienced severe treatment toxicities including stage IV renal insufficiency.
After dose-reduced bridging chemotherapy, CAR T-cells (tisagenlecleucel) were
administered for remission induction despite a CD19- clone without
prior lymphodepletion due to enhanced persisting toxicity. This was followed by
a second allogeneic HSCT from the haploidentical mother. While patient 2
relapsed around Day + 180 after the second HSCT, patient 1 is still in complete
remission >360 days after the second HSCT. Both cases demonstrate the
challenges associated with systemic ALL relapse after first allogeneic HSCT,
including chemotherapy-resistant disease and persisting organ damage inflicted
by previous therapy. Immunotherapeutic approaches, such as CAR T-cells, can
induce remission and enable a second allogeneic HSCT. However, optimal therapy
for systemic ALL relapse after first HSCT remains to be defined.
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Affiliation(s)
- Fiona Poyer
- Department of Pediatric Haematology and Oncology, St. Anna Children’s Hospital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Anna Füreder
- Department of Pediatric Haematology and Oncology, St. Anna Children’s Hospital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Holter
- Department of Pediatric Haematology and Oncology, St. Anna Children’s Hospital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Children’s Cancer Research Institute, St. Anna Kinderkrebsforschung, Vienna, Austria
| | - Christina Peters
- Department of Pediatric Haematology and Oncology, St. Anna Children’s Hospital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Children’s Cancer Research Institute, St. Anna Kinderkrebsforschung, Vienna, Austria
| | - Heidrun Boztug
- Department of Pediatric Haematology and Oncology, St. Anna Children’s Hospital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Dworzak
- Department of Pediatric Haematology and Oncology, St. Anna Children’s Hospital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Children’s Cancer Research Institute, St. Anna Kinderkrebsforschung, Vienna, Austria
| | - Gernot Engstler
- Department of Pediatric Haematology and Oncology, St. Anna Children’s Hospital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Waltraud Friesenbichler
- Department of Pediatric Haematology and Oncology, St. Anna Children’s Hospital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Stefan Köhrer
- Department of Pediatric Haematology and Oncology, St. Anna Children’s Hospital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Children’s Cancer Research Institute, St. Anna Kinderkrebsforschung, Vienna, Austria
| | - Roswitha Lüftinger
- Department of Pediatric Haematology and Oncology, St. Anna Children’s Hospital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Leila Ronceray
- Department of Pediatric Haematology and Oncology, St. Anna Children’s Hospital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Volker Witt
- Department of Pediatric Haematology and Oncology, St. Anna Children’s Hospital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Herbert Pichler
- Department of Pediatric Haematology and Oncology, St. Anna Children’s Hospital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Andishe Attarbaschi
- Department of Pediatric Haematology and Oncology, St. Anna Children’s Hospital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Vienna, Austria
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Wang L, Chen R, Li L, Zhu L, Huang X, Ye X. Prognostic implication of early minimal residual disease evaluation in patients with chronic myelomonocytic leukemia. Am J Cancer Res 2022; 12:2216-2225. [PMID: 35693086 PMCID: PMC9185623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 04/15/2022] [Indexed: 06/15/2023] Open
Abstract
To investigate the prognostic implication of minimal residual disease (MRD) evaluation in chronic myelomonocytic leukemia (CMML), we conducted a restropective study included a total of 174 CMML patients in our hospital from January 2010 to March 2021. In which 50/174 (29%) bone marrow samples were conducted by multiparameter flow cytometry (FCM) assessed MRD analysis after the first three cycles of treatment and were included in this study. MRD was detected by six- to eight-colour FCM. The achievement of early MRD negativity had better clinical outcomes in patients with CMML, which fared better prognosis in terms of not only PFS (P=0.006) but also OS (P=0.02) after the first cycle, and PFS (P=0.023 and P=0.041) after the second and third cycles, whereas no significantly influence in OS. In addition, MRD negative after initial treatment remained its independent prognostic value associated with PFS (adjusted hazard ratio [HR] 0.161, 95 CI 0.035-0.738; P=0.019) and OS (adjusted HR 0.136; 95 CI 0.017-1.077; P=0.059), indicating that patients with MRD-negative after the initial treatment alone could obtain the greatest clinical benefit. According to MRD level, the patients were divided into 4 different groups: very low risk (fewer than 10-4 cells) in 15 cases, low risk (10-4 to 10-3 cells) in 6; and 6 were at intermediate risk (fewer than 10-3 to 10-2 cells). The rest of 23 patients were were assigned to the high-risk grades (more than 10-2 residual cells), we find this risk stratification model is significantly associated with better PFS (P=0.002) but marginal significantly associated with OS (P=0.068). Notably, patients with DNMT3A mutation fared a shorter PFS in the MRD positive subgroup (P=0.068). MRD is highly predictive of prognosis, and its combination with molecular profile may help identify patients at increased risk for progression to further improve the management of patients with CMML. Large-scaled investigations are warranted to validate our conclusions and its potential in clinical practice.
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Affiliation(s)
- Lulu Wang
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang UniversityHangzhou, Zhejiang, China
- Program in Clinical Medicine, School of Medicine of Zhejiang UniversityHangzhou, Zhejiang, China
| | - Rongrong Chen
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang UniversityHangzhou, Zhejiang, China
- Program in Clinical Medicine, School of Medicine of Zhejiang UniversityHangzhou, Zhejiang, China
| | - Li Li
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang UniversityHangzhou, Zhejiang, China
| | - Lixia Zhu
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang UniversityHangzhou, Zhejiang, China
| | - Xianbo Huang
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang UniversityHangzhou, Zhejiang, China
| | - Xiujin Ye
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang UniversityHangzhou, Zhejiang, China
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30
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Liang EC, Craig J, Torelli S, Cunanan K, Iglesias M, Arai S, Frank MJ, Johnston L, Lowsky R, Meyer EH, Miklos DB, Negrin R, Rezvani A, Shiraz P, Shizuru J, Sidana S, Weng WK, Bharadwaj S, Muffly L. Allogeneic Hematopoietic Cell Transplantation for Adult Acute Lymphoblastic Leukemia in the Modern Era. Transplant Cell Ther 2022; 28:490-495. [PMID: 35584783 PMCID: PMC10153066 DOI: 10.1016/j.jtct.2022.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/19/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) remains an important treatment for adults with acute lymphoblastic leukemia (ALL). We hypothesized that advances in ALL and transplantation have resulted in improved HCT outcomes in recent years. In this study, we evaluated the characteristics and outcomes of adult ALL patients undergoing allogeneic HCT over the last decade. Patients with ALL aged 18 years and older who underwent allogeneic HCT at Stanford University between 2008 and 2019 were included in this study. Patients were divided into 2 eras based on year of HCT: 2008 to 2013 (earlier era) and 2014 to 2019 (later era). A total of 285 patients were included: 119 patients underwent HCT in the earlier era and 166 in the later era. Patients who underwent transplantation in the later era were more likely to be Hispanic (38% versus 21%) and to have an HCT-comorbidity index ≥3 (31% versus 18%). Donor source for HCT also differed with an increase in the use of HLA-mismatched donor sources (38% versus 24%), notably umbilical cord blood in the later era (16% versus 0%). Patients in the later era were less likely to undergo transplantation with active disease (4% versus 16%); pre-HCT rates of measurable residual disease were similar across the eras (38% versus 40%). In unadjusted analyses, overall survival (OS) improved across eras, with 2-year estimates for the later and earlier eras of 73% (95% confidence interval [CI], 66%-80%) versus 55% (95% CI, 46%-64%), respectively. Multivariable analysis confirmed the association between later era and OS (hazard ratio = 0.52, 95% CI, 0.34-0.78). Finally, among patients relapsing after HCT (25% in later era and 33% in earlier era), the use of novel immunotherapies increased in the later era (44% versus 3%), as did the median OS after post-HCT relapse (16 months versus 8 months, P< .001). OS after HCT for adult ALL has improved in recent years. This is due, in part, to a significant improvement in the ability to effectively salvage adults with ALL relapsing after HCT.
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Affiliation(s)
- Emily C Liang
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Juliana Craig
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Stefan Torelli
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Kristen Cunanan
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Maria Iglesias
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Sally Arai
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Matthew J Frank
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Laura Johnston
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Robert Lowsky
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Everett H Meyer
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - David B Miklos
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Robert Negrin
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Andrew Rezvani
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Parveen Shiraz
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Judith Shizuru
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Surbhi Sidana
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Wen-Kai Weng
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Sushma Bharadwaj
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Lori Muffly
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, California.
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31
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[A retrospective comparative study of haplotype hematopoietic stem cell transplantation and human leukocyte antigen-matched sibling donor hematopoietic stem cell transplantation in the treatment of acute B-lymphocyte leukemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:221-228. [PMID: 35405780 PMCID: PMC9072065 DOI: 10.3760/cma.j.issn.0253-2727.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To investigate whether haplotype hematopoietic stem cell transplantation (haplo-HSCT) is effective in the treatment of pre transplant minimal residual disease (Pre-MRD) positive acute B lymphoblastic leukemia (B-ALL) compared with HLA- matched sibling donor transplantation (MSDT) . Methods: A total of 998 patients with B-ALL in complete remission pre-HSCT who either received haplo-HSCT (n=788) or underwent MSDT (n=210) were retrospectively analyzed. The pre-transplantation leukemia burden was evaluated according to Pre-MRD determinedusing multiparameter flow cytometry (MFC) . Results: Of these patients, 997 (99.9% ) achieved sustained, full donor chimerism. The 100-day cumulative incidences of neutrophil engraftment, platelet engraftment, and grades Ⅱ-Ⅳ acute graft-versus-host disease (GVHD) were 99.9% (997/998) , 95.3% (951/998) , and 26.6% (95% CI 23.8% -29.4% ) , respectively. The 3-year cumulative incidence of total chronic GVHD was 49.1% (95% CI 45.7% -52.4% ) . The 3-year cumulative incidence of relapse (CIR) and non-relapse mortality (NRM) of the 998 cases were 17.3% (95% CI 15.0% -19.7% ) and 13.8% (95% CI 11.6% -16.0% ) , respectively. The 3-year probabilities of leukemia-free survival (LFS) and overall survival (OS) were 69.1% (95% CI 66.1% -72.1% ) and 73.0% (95% CI 70.2% -75.8% ) , respectively. In the total patient group, cases with positive Pre-MRD (n=282) experienced significantly higher CIR than that of subjects with negative Pre-MRD [n=716, 31.6% (95% CI 25.8% -37.5% ) vs 14.3% (95% CI 11.4% -17.2% ) , P<0.001]. For patients in the positive Pre-MRD subgroup, cases treated with haplo-HSCT (n=219) had a lower 3-year CIR than that of cases who underwent MSDT [n=63, 27.2% (95% CI 21.0% -33.4% ) vs 47.0% (95% CI 33.8% -60.2% ) , P=0.002]. The total 998 cases were classified as five subgroups, including cases with negative Pre-MRD group (n=716) , cases with Pre-MRD<0.01% group (n=46) , cases with Pre-MRD 0.01% -<0.1% group (n=117) , cases with Pre-MRD 0.1% -<1% group (n=87) , and cases with Pre-MRD≥1% group (n=32) . For subjects in the Pre-MRD<0.01% group, haplo-HSCT (n=40) had a lower CIR than that of MSDT [n=6, 10.0% (95% CI 0.4% -19.6% ) vs 32.3% (95% CI 0% -69.9% ) , P=0.017]. For patients in the Pre-MRD 0.01% -<0.1% group, haplo-HSCT (n=81) also had a lower 3-year CIR than that of MSDT [n=36, 20.4% (95% CI 10.4% -30.4% ) vs 47.0% (95% CI 29.2% -64.8% ) , P=0.004]. In the other three subgroups, the 3-year CIR was comparable between patients who underwent haplo-HSCT and those received MSDT. A subgroup analysis of patients with Pre-MRD<0.1% (n=163) was performed, the results showed that cases received haplo-HSCT (n=121) experienced lower 3-year CIR [16.0% (95% CI 9.4% -22.7% ) vs 40.5% (95% CI 25.2% -55.8% ) , P<0.001], better 3-year LFS [78.2% (95% CI 70.6% -85.8% ) vs 47.6% (95% CI 32.2% -63.0% ) , P<0.001] and OS [80.5% (95% CI 73.1% -87.9% ) vs 54.6% (95% CI 39.2% -70.0% ) , P<0.001] than those of MSDT (n=42) , but comparable in 3-year NRM [5.8% (95% CI 1.6% -10.0% ) vs 11.9% (95% CI 2.0% -21.8% ) , P=0.188]. Multivariate analysis showed that haplo-HSCT was associated with lower CIR (HR=0.248, 95% CI 0.131-0.472, P<0.001) , and superior LFS (HR=0.275, 95% CI 0.157-0.483, P<0.001) and OS (HR=0.286, 95% CI 0.159-0.513, P<0.001) . Conclusion: Haplo HSCT has a survival advantage over MSDT in the treatment of B-ALL patients with pre MRD<0.1% .
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32
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Singh J, Gorniak M, Grigoriadis G, Westerman D, McBean M, Venn N, Law T, Sutton R, Morgan S, Fleming S. Correlation between a 10-color flow cytometric measurable residual disease (MRD) analysis and molecular MRD in adult B-acute lymphoblastic leukemia. CYTOMETRY. PART B, CLINICAL CYTOMETRY 2022; 102:115-122. [PMID: 34806309 DOI: 10.1002/cyto.b.22043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/21/2021] [Accepted: 11/10/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND Measurable residual disease (MRD) monitoring in acute lymphoblastic leukemia (ALL) is an important predictive factor for patient outcome and treatment intensification. Molecular monitoring, particularly with quantitative polymerase chain reaction (qPCR) to measure immunoglobin heavy or kappa chain (Ig) or T-cell receptor (TCR) gene rearrangements, offers high sensitivity but accessibility is limited by expertise, cost, and turnaround time. Flow cytometric assays are cheaper and more widely available, and sensitivity is improved with multi-parameter flow cytometry at eight or more colors. METHODS We developed a 10-color single tube flow cytometry assay. Samples were subject to bulk ammonium chloride lysis to maximize cell yields with a target of 1 × 106 events. Once normal maturation patterns were established, patient samples were analyzed in parallel to standard molecular monitoring. RESULTS Flow cytometry was performed on 114 samples. An informative immunophenotype was identifiable in all 22 patients who had a diagnostic sample. MRD analysis was performed on 87 samples. The median lower limits of detection and quantification were 0.004% (range 0.0005%-0.028%) and 0.01% (range 0.001%-0.07%) respectively. Sixty-five samples had concurrent molecular MRD testing, with good correlation (r = 0.83, p < 0.001). Results were concordant in 52 samples, and discordant in 13 samples, including one case where impending relapse was detected by flow cytometry but not Ig/TCR qPCR. CONCLUSIONS Our 10-color flow cytometric MRD assay provided adequate sensitivity and good correlation with molecular assays. This technique offers rapid and affordable testing in B-ALL patients, including cases where a suitable molecular assay cannot be developed or has reduced sensitivity.
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Affiliation(s)
- Jasmine Singh
- Laboratory Haematology, Alfred Pathology, Melbourne, Victoria, Australia
| | - Malgorzata Gorniak
- Laboratory Haematology, Alfred Pathology, Melbourne, Victoria, Australia
| | - George Grigoriadis
- Laboratory Haematology, Alfred Pathology, Melbourne, Victoria, Australia.,Clinical Haematology, Monash Health, Clayton, Victoria, Australia
| | - David Westerman
- Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Michelle McBean
- Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Nicola Venn
- Children's Cancer Institute and School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia
| | - Tamara Law
- Children's Cancer Institute and School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia
| | - Rosemary Sutton
- Children's Cancer Institute and School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia
| | - Sue Morgan
- Laboratory Haematology, Alfred Pathology, Melbourne, Victoria, Australia
| | - Shaun Fleming
- Laboratory Haematology, Alfred Pathology, Melbourne, Victoria, Australia.,Clinical Haematology, Monash Health, Clayton, Victoria, Australia
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33
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Vettenranta K, Dobsinska V, Kertész G, Svec P, Buechner J, Schultz KR. What Is the Role of HSCT in Philadelphia-Chromosome-Positive and Philadelphia-Chromosome-Like ALL in the Tyrosine Kinase Inhibitor Era? Front Pediatr 2022; 9:807002. [PMID: 35186828 PMCID: PMC8848997 DOI: 10.3389/fped.2021.807002] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/16/2021] [Indexed: 11/13/2022] Open
Abstract
Previously, the outcome of paediatric Philadelphia-chromosome-positive (Ph+) ALL treated with conventional chemotherapy alone was poor, necessitating the use of haematopoietic stem cell transplantation (HSCT) for the best outcomes. The recent addition of tyrosine kinase inhibitors (TKIs) alongside the chemotherapy regimens for Ph+ ALL has markedly improved outcomes, replacing the need for HSCT for lower risk patients. An additional poor prognosis group of Philadelphia-chromosome-like (Ph-like) ALL has also been identified. This group also can be targeted by TKIs in combination with chemotherapy, but the role of HSCT in this population is not clear. The impact of novel targeted immunotherapies (chimeric antigen receptor T cells and bispecific or drug-conjugated antibodies) has improved the outcome of patients, in combination with chemotherapy, and made the role of HSCT as the optimal curative therapy for Ph+ ALL and Ph-like ALL less clear. The prognosis of patients with Ph+ ALL and persistent minimal residual disease (MRD) at the end of consolidation despite TKI therapy or with additional genetic risk factors remains inferior when HSCT is not used. For such high-risk patients, HSCT using total-body-irradiation-containing conditioning is currently recommended. This review aims to provide an update on the current and future role of HSCT for Ph+ ALL and addresses key questions related to the management of these patients, including the role of HSCT in first complete remission, MRD evaluation and related actions post HSCT, TKI usage post HSCT, and the putative role of HSCT in Ph-like ALL.
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Affiliation(s)
- Kim Vettenranta
- University of Helsinki and Children's Hospital, University of Helsinki, Helsinki, Finland
| | - Veronika Dobsinska
- Department of Pediatric Hematology and Oncology, National Institute of Children's Diseases, Comenius University, Bratislava, Slovakia
| | - Gabriella Kertész
- Department of Pediatric Hematology and Stem Cell Transplantation, Central Hospital of Southern Pest – National Institute of Hematology and Infectious Diseases, Budapest, Hungary
| | - Peter Svec
- Department of Pediatric Hematology and Oncology, National Institute of Children's Diseases, Comenius University, Bratislava, Slovakia
| | - Jochen Buechner
- Department of Pediatric Hematology and Oncology, Oslo University Hospital, Oslo, Norway
| | - Kirk R. Schultz
- Michael Cuccione Childhood Cancer Research Program, British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
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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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Rozmus J, Bhatt ST, Buxbaum NP, Cuvelier GDE, Li AM, Kitko CL, Schultz KR. Is It Possible to Separate the Graft-Versus-Leukemia (GVL) Effect Against B Cell Acute Lymphoblastic Leukemia From Graft-Versus-Host Disease (GVHD) After Hematopoietic Cell Transplant? Front Pediatr 2022; 10:796994. [PMID: 35402356 PMCID: PMC8987503 DOI: 10.3389/fped.2022.796994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Hematopoietic cell transplant is a curative therapy for many pediatric patients with high risk acute lymphoblastic leukemia. Its therapeutic mechanism is primarily based on the generation of an alloreactive graft-versus-leukemia effect that can eliminate residual leukemia cells thus preventing relapse. However its efficacy is diminished by the concurrent emergence of harmful graft-versus-host disease disease which affects healthly tissue leading to significant morbidity and mortality. The purpose of this review is to describe the interventions that have been trialed in order to augment the beneficial graft-versus leukemia effect post-hematopoietic cell transplant while limiting the harmful consequences of graft-versus-host disease. This includes many emerging and promising strategies such as ex vivo and in vivo graft manipulation, targeted cell therapies, T-cell engagers and multiple pharmacologic interventions that stimulate specific donor effector cells.
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Affiliation(s)
- Jacob Rozmus
- Division of Hematology, Oncology and Bone Marrow Transplant, Department of Pediatrics, Faculty of Medicine, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Sima T Bhatt
- Washington University, Saint Louis, MO, United States
| | | | - Geoffrey D E Cuvelier
- Pediatric Blood and Marrow Transplantation, Cancer Care Manitoba, University of Manitoba, Winnipeg, MB, Canada
| | - Amanda M Li
- Division of Hematology, Oncology and Bone Marrow Transplant, Department of Pediatrics, Faculty of Medicine, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Carrie L Kitko
- Pediatric Hematology/Oncology Division, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Kirk R Schultz
- Division of Hematology, Oncology and Bone Marrow Transplant, Department of Pediatrics, Faculty of Medicine, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
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Sobkowiak-Sobierajska A, Lindemans C, Sykora T, Wachowiak J, Dalle JH, Bonig H, Gennery A, Lawitschka A. Management of Chronic Graft-vs.-Host Disease in Children and Adolescents With ALL: Present Status and Model for a Personalised Management Plan. Front Pediatr 2022; 10:808103. [PMID: 35252060 PMCID: PMC8894895 DOI: 10.3389/fped.2022.808103] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/24/2022] [Indexed: 12/18/2022] Open
Abstract
Herein we review current practice regarding the management of chronic graft-vs.-host disease (cGvHD) in paediatric patients after allogeneic haematopoietic stem cell transplantation (HSCT) for acute lymphoblastic leukaemia (ALL). Topics covered include: (i) the epidemiology of cGvHD; (ii) an overview of advances in our understanding cGvHD pathogenesis; (iii) current knowledge regarding risk factors for cGvHD and prevention strategies complemented by biomarkers; (iii) the paediatric aspects of the 2014 National Institutes for Health-defined diagnosis and grading of cGvHD; and (iv) current options for cGvHD treatment. We cover topical therapy and newly approved tyrosine kinase inhibitors, emphasising the use of immunomodulatory approaches in the context of the delicate counterbalance between immunosuppression and immune reconstitution as well as risks of relapse and infectious complications. We examine real-world approaches of response assessment and tapering schedules of treatment. Furthermore, we report on the optimal timepoints for therapeutic interventions and changes in relation to immune reconstitution and risk of relapse/infection. Additionally, we review the different options for anti-infectious prophylaxis. Finally, we put forth a theory of a holistic view of paediatric cGvHD and its associated manifestations and propose a checklist for individualised risk evaluation with aggregated considerations including site-specific cGvHD evaluation with attention to each individual's GvHD history, previous medical history, comorbidities, and personal tolerance and psychosocial circumstances. To complement this checklist, we present a treatment algorithm using representative patients to inform the personalised management plans for patients with cGvHD after HSCT for ALL who are at high risk of relapse.
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Affiliation(s)
| | - Caroline Lindemans
- Department of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.,Pediatric Blood and Bone Marrow Transplantation, Princess Máxima Center, Utrecht, Netherlands
| | - Tomas Sykora
- Department of Pediatric Hematology and Oncology - Haematopoietic Stem Cell Transplantation Unit, National Institute of Children's Diseases and Medical Faculty, Comenius University, Bratislava, Slovakia
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jean-Hugues Dalle
- Hematology and Immunology Department, Robert-Debré Hospital, Assistance Publique-Hôpitaux de Paris and University of Paris, Paris, France
| | - Halvard Bonig
- Goethe University Medical Center, Institute of Transfusion Medicine and Immunohematology, and German Red Cross Blood Center Frankfurt, Frankfurt, Germany
| | - Andrew Gennery
- Medical School, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Anita Lawitschka
- Stem Cell Transplantation Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria.,St. Anna Children's Cancer Research Institute, Vienna, Austria
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Pulsipher MA, Han X, Maude SL, Laetsch TW, Qayed M, Rives S, Boyer MW, Hiramatsu H, Yanik GA, Driscoll T, Myers GD, Bader P, Baruchel A, Buechner J, Stefanski HE, Kalfoglou C, Nguyen K, Waldron ER, Thudium Mueller K, Maier HJ, Kari G, Grupp SA. Next-Generation Sequencing of Minimal Residual Disease for Predicting Relapse after Tisagenlecleucel in Children and Young Adults with Acute Lymphoblastic Leukemia. Blood Cancer Discov 2022; 3:66-81. [PMID: 35019853 PMCID: PMC9924295 DOI: 10.1158/2643-3230.bcd-21-0095] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/29/2021] [Accepted: 11/01/2021] [Indexed: 11/16/2022] Open
Abstract
We assessed minimal residual disease (MRD) detection and B-cell aplasia after tisagenlecleucel therapy for acute lymphoblastic leukemia (ALL) to define biomarkers predictive of relapse (N = 143). Next-generation sequencing (NGS) MRD detection >0 in bone marrow (BM) was highly associated with relapse. B-cell recovery [signifying loss of functional chimeric antigen receptor (CAR) T cells] within the first year of treatment was associated with a hazard ratio (HR) for relapse of 4.5 [95% confidence interval (CI), 2.03-9.97; P < 0.001]. Multivariate analysis at day 28 showed independent associations of BMNGS-MRD >0 (HR = 4.87; 95% CI, 2.18-10.8; P < 0.001) and B-cell recovery (HR = 3.33; 95% CI, 1.44-7.69; P = 0.005) with relapse. By 3 months, the BMNGS-MRD HR increased to 12 (95% CI, 2.87-50; P < 0.001), whereas B-cell recovery was not independently predictive (HR = 1.27; 95% CI, 0.33-4.79; P = 0.7). Relapses occurring with persistence of B-cell aplasia were largely CD19- (23/25: 88%). Detectable BMNGS-MRD reliably predicts risk with sufficient time to consider approaches to relapse prevention such as hematopoietic cell transplantation (HCT) or second CAR-T cell infusion. SIGNIFICANCE: Detectable disease by BMNGS-MRD with or without B-cell aplasia is highly predictive of relapse after tisagenlecleucel therapy for ALL. Clonotypic rearrangements used to follow NGS-MRD did not change after loss of CD19 or lineage switch. High-risk patients identified by these biomarkers may benefit from HCT or investigational cell therapies.See related commentary by Ghorashian and Bartram, p. 2.This article is highlighted in the In This Issue feature, p. 1.
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Affiliation(s)
- Michael A. Pulsipher
- Section of Transplantation and Cellular Therapy, Children's Hospital Los Angeles Cancer and Blood Disease Institute, USC Keck School of Medicine, Los Angeles, California.,Corresponding Author: Michael A. Pulsipher, Huntsman Cancer Institute at the University of Utah, 2000 Circle of Hope Drive, Salt Lake City, UT 84112. Phone: 323-361-8840; Fax: 323-361-8068; E-mail:
| | - Xia Han
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Shannon L. Maude
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Theodore W. Laetsch
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Muna Qayed
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Aflac Cancer and Blood Disorders Center, Healthcare of Atlanta, Atlanta, Georgia
| | - Susana Rives
- Pediatric Hematology, Hospital Sant Joan de Déu de Barcelona, Fundació Sant Joan de Déu, Barcelona, Spain
| | - Michael W. Boyer
- Department of Pediatrics and Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Hidefumi Hiramatsu
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto City, Japan
| | - Gregory A. Yanik
- Michigan Medicine Bone Marrow Transplant and Leukemia, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Tim Driscoll
- Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - G. Doug Myers
- Pediatric Hematology and Oncology, Children's Mercy Hospital; University of Missouri—Kansas City School of Medicine, Kansas City, Missouri
| | - Peter Bader
- Division for Stem Cell Transplantation, Immunology and Intensive Care Medicine Hospital for Children and Adolescents University Hospital Frankfurt, Frankfurt, Germany
| | - Andre Baruchel
- Pediatric Hemato-Immunology Department, Hôpital Universitaire Robert Debré (APHP), Paris, France.,Université de Paris et Institut de Recherche Saint-Louis (EA3518), Paris, France
| | - Jochen Buechner
- Department of Pediatric Hematology and Oncology, Oslo University Hospital, Oslo, Norway
| | - Heather E. Stefanski
- Department of Pediatrics, The University of Minnesota Medical School, Minneapolis, Minnesota
| | | | - Kevin Nguyen
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | | | | | - Gabor Kari
- Novartis Pharmaceuticals Corporation, Basel, Switzerland
| | - Stephan A. Grupp
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Hoeben BAW, Wong JYC, Fog LS, Losert C, Filippi AR, Bentzen SM, Balduzzi A, Specht L. Total Body Irradiation in Haematopoietic Stem Cell Transplantation for Paediatric Acute Lymphoblastic Leukaemia: Review of the Literature and Future Directions. Front Pediatr 2021; 9:774348. [PMID: 34926349 PMCID: PMC8678472 DOI: 10.3389/fped.2021.774348] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 11/03/2021] [Indexed: 12/13/2022] Open
Abstract
Total body irradiation (TBI) has been a pivotal component of the conditioning regimen for allogeneic myeloablative haematopoietic stem cell transplantation (HSCT) in very-high-risk acute lymphoblastic leukaemia (ALL) for decades, especially in children and young adults. The myeloablative conditioning regimen has two aims: (1) to eradicate leukaemic cells, and (2) to prevent rejection of the graft through suppression of the recipient's immune system. Radiotherapy has the advantage of achieving an adequate dose effect in sanctuary sites and in areas with poor blood supply. However, radiotherapy is subject to radiobiological trade-offs between ALL cell destruction, immune and haematopoietic stem cell survival, and various adverse effects in normal tissue. To diminish toxicity, a shift from single-fraction to fractionated TBI has taken place. However, HSCT and TBI are still associated with multiple late sequelae, leaving room for improvement. This review discusses the past developments of TBI and considerations for dose, fractionation and dose-rate, as well as issues regarding TBI setup performance, limitations and possibilities for improvement. TBI is typically delivered using conventional irradiation techniques and centres have locally developed heterogeneous treatment methods and ways to achieve reduced doses in several organs. There are, however, limitations in options to shield organs at risk without compromising the anti-leukaemic and immunosuppressive effects of conventional TBI. Technological improvements in radiotherapy planning and delivery with highly conformal TBI or total marrow irradiation (TMI), and total marrow and lymphoid irradiation (TMLI) have opened the way to investigate the potential reduction of radiotherapy-related toxicities without jeopardising efficacy. The demonstration of the superiority of TBI compared with chemotherapy-only conditioning regimens for event-free and overall survival in the randomised For Omitting Radiation Under Majority age (FORUM) trial in children with high-risk ALL makes exploration of the optimal use of TBI delivery mandatory. Standardisation and comprehensive reporting of conventional TBI techniques as well as cooperation between radiotherapy centres may help to increase the ratio between treatment outcomes and toxicity, and future studies must determine potential added benefit of innovative conformal techniques to ultimately improve quality of life for paediatric ALL patients receiving TBI-conditioned HSCT.
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Affiliation(s)
- Bianca A. W. Hoeben
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Jeffrey Y. C. Wong
- Department of Radiation Oncology, City of Hope National Medical Center and Beckman Research Institute, Duarte, CA, United States
| | - Lotte S. Fog
- Alfred Health Radiation Oncology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Christoph Losert
- Department of Radiation Oncology, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Andrea R. Filippi
- Department of Radiation Oncology, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Søren M. Bentzen
- Division of Biostatistics and Bioinformatics, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Adriana Balduzzi
- Stem Cell Transplantation Unit, Clinica Paediatrica Università degli Studi di Milano Bicocca, Monza, Italy
| | - Lena Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Pincez T, Santiago R, Bittencourt H, Louis I, Bilodeau M, Rouette A, Jouan L, Landry JR, Couture F, Richer J, Teira P, Duval M, Cellot S. Intensive monitoring of minimal residual disease and chimerism after allogeneic hematopoietic stem cell transplantation for acute leukemia in children. Bone Marrow Transplant 2021; 56:2981-2989. [PMID: 34475524 DOI: 10.1038/s41409-021-01408-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/04/2021] [Accepted: 07/01/2021] [Indexed: 02/07/2023]
Abstract
Posttransplant leukemia detection before overt relapse is key to the success of immunotherapeutic interventions, as they are more efficient when leukemia burden is low. However, optimal schedule and monitoring methods are not well defined. We report the intensive bone marrow monitoring of minimal residual disease (MRD) using flow cytometry (FC) and nested reverse transcription polymerase chain reaction (RT-PCR) whenever a fusion transcript allowed it and chimerism by PCR at 11 timepoints in the first 2 years after transplant. Seventy-one transplants were performed in 59 consecutive children, for acute myeloid (n = 38), lymphoid (n = 31), or mixed-phenotype (n = 2) leukemia. MRD was monitored in 62 cases using FC (n = 58) and/or RT-PCR (n = 35). Sixty-seven percent of leukemia recurrences were detected before overt relapse, with a detection rate of 89% by RT-PCR and 40% by FC alone. Increased mixed chimerism was never the first evidence of recurrence. Two patients monitored by RT-PCR relapsed without previous MRD detection, one after missed scheduled evaluation and the other 4.7 years post transplant. Among the 22 cases with MRD detection without overt relapse, 19 received therapeutic interventions. Eight (42%) never relapsed. In conclusion, intensive marrow monitoring by RT-PCR effectively allows for early detection of posttransplant leukemia recurrence.
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Affiliation(s)
- Thomas Pincez
- Service d'Hématologie-Oncologie Pédiatrique, Centre de Cancérologie Charles-Bruneau, CHU Sainte-Justine, Montréal, QC, Canada
| | - Raoul Santiago
- Service d'Hématologie-Oncologie Pédiatrique, Centre de Cancérologie Charles-Bruneau, CHU Sainte-Justine, Montréal, QC, Canada
| | - Henrique Bittencourt
- Service d'Hématologie-Oncologie Pédiatrique, Centre de Cancérologie Charles-Bruneau, CHU Sainte-Justine, Montréal, QC, Canada.,Département de Pédiatrie, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
| | - Isabelle Louis
- Service d'Hématologie-Oncologie Pédiatrique, Centre de Cancérologie Charles-Bruneau, CHU Sainte-Justine, Montréal, QC, Canada
| | - Mélanie Bilodeau
- Service d'Hématologie-Oncologie Pédiatrique, Centre de Cancérologie Charles-Bruneau, CHU Sainte-Justine, Montréal, QC, Canada
| | - Alexandre Rouette
- Laboratoire de Diagnostic Moléculaire, CHU Sainte-Justine, Montréal, QC, Canada
| | - Loubna Jouan
- Centre Intégré de Génomique Clinique Pédiatrique, CHU Sainte-Justine, Montréal, QC, Canada
| | - Josette-Renée Landry
- Département de Pédiatrie, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
| | - Françoise Couture
- Laboratoire de Diagnostic Moléculaire, CHU Sainte-Justine, Montréal, QC, Canada
| | - Johanne Richer
- Service d'Hématologie-Oncologie Pédiatrique, Centre de Cancérologie Charles-Bruneau, CHU Sainte-Justine, Montréal, QC, Canada
| | - Pierre Teira
- Service d'Hématologie-Oncologie Pédiatrique, Centre de Cancérologie Charles-Bruneau, CHU Sainte-Justine, Montréal, QC, Canada.,Département de Pédiatrie, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
| | - Michel Duval
- Service d'Hématologie-Oncologie Pédiatrique, Centre de Cancérologie Charles-Bruneau, CHU Sainte-Justine, Montréal, QC, Canada. .,Département de Pédiatrie, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada.
| | - Sonia Cellot
- Service d'Hématologie-Oncologie Pédiatrique, Centre de Cancérologie Charles-Bruneau, CHU Sainte-Justine, Montréal, QC, Canada.,Département de Pédiatrie, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
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Clofarabine-fludarabine-busulfan in HCT for pediatric leukemia: an effective, low toxicity, TBI-free conditioning regimen. Blood Adv 2021; 6:1719-1730. [PMID: 34781362 PMCID: PMC8941455 DOI: 10.1182/bloodadvances.2021005224] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 10/10/2021] [Indexed: 11/20/2022] Open
Abstract
CloFluBu-conditioning results in encouraging EFS for ALL and AML, with low TRM, limited incidence of aGvHD and GF, and no cases of VOD. Minimal residual disease status prior to transplantation impacted outcome due to increased relapse risk in both AML and ALL patients.
We prospectively studied clofarabine-fludarabine-busulfan (CloFluBu)-conditioning in allogeneic hematopoietic cell therapy (HCT) for lymphoid and myeloid malignancies and hypothesized that CloFluBu provides a less toxic alternative to conventional conditioning regimens, with adequate antileukemic activity. All patients receiving their first HCT, from 2011-2019, were included and received CloFluBu. The primary endpoint was event-free survival (EFS). Secondary endpoints were overall survival (OS), graft-versus-host disease (GvHD)-relapse-free survival (GRFS), treatment-related mortality (TRM), cumulative incidence of relapse (CIR), acute and chronic GvHD (aGvHD and cGvHD), and veno-occlusive disease (VOD). Cox proportional hazard and Fine and Gray competing-risk models were used for data analysis. One hundred fifty-five children were included: 60 acute lymphoid leukemia (ALL), 69 acute myeloid leukemia (AML), and 26 other malignancies (mostly MDS-EB). The median age was 9.7 (0.5 to 18.6) years. Estimated 2-year EFS was 72.0% ± 6.0 in ALL patients, and 62.4% ± 6.0 in AML patients. TRM in the whole cohort was 11.0% ± 2.6, incidence of aGvHD 3 to 4 at 6 months was 12.3% ± 2.7, extensive cGvHD at 2 years was 6.4% ± 2.1. Minimal residual disease-positivity prior to HCT was associated with higher CIR, both in ALL and AML. CloFluBu showed limited toxicity and encouraging EFS. CloFluBu is a potentially less toxic alternative to conventional conditioning regimens. Randomized prospective studies are needed.
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Qayed M, Bleakley M, Shah NN. Role of chimeric antigen receptor T-cell therapy: bridge to transplantation or stand-alone therapy in pediatric acute lymphoblastic leukemia. Curr Opin Hematol 2021; 28:373-379. [PMID: 34508031 PMCID: PMC9079121 DOI: 10.1097/moh.0000000000000685] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To discuss the curative potential for chimeric antigen receptor T-cell (CAR-T) therapy, with or without consolidative hematopoietic stem cell transplantation (HCT) in the treatment of children and young adults with B lineage acute lymphoblastic leukemia (B-ALL). RECENT FINDINGS CAR-T targeting CD19 can induce durable remissions and prolong life in patients with relapsed/refractory B-ALL. Whether HCT is needed to consolidate remission and cure relapse/refractory B-ALL following a CD19 CAR-T induced remission remains controversial. Preliminary evidence suggests that consolidative HCT following CAR-T in HCT-naïve children improves leukemia-free survival. However, avoiding HCT-related late effects is a desirable goal, so identification of patients at high risk of relapse is needed to appropriately direct those patients to HCT when necessary, while avoiding HCT in others. High disease burden prior to CAR-T infusion, loss of B-cell aplasia and detection of measurable residual disease by flow cytometry or next-generation sequencing following CAR-T therapy associate with a higher relapse risk and may identify patients requiring consolidative HCT for relapse prevention. SUMMARY There is a pressing need to determine when CD19 CAR-T alone is likely to be curative and when a consolidative HCT will be required. We discuss the current state of knowledge and future directions.
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Affiliation(s)
- Muna Qayed
- Pediatric Hematology/Oncology and Bone Marrow Transplantation, Aflac Cancer and Blood Disorders Center, Emory University and Children’s Healthcare of Atlanta, Atlanta, GA
| | - Marie Bleakley
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle WA
| | - Nirali N. Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
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Spadea M, Saglio F, Tripodi SI, Menconi M, Zecca M, Fagioli F. Multivariate Analysis of Immune Reconstitution and Relapse Risk Scoring in Children Receiving Allogeneic Stem Cell Transplantation for Acute Leukemias. Transplant Direct 2021; 7:e774. [PMID: 34646937 PMCID: PMC8500617 DOI: 10.1097/txd.0000000000001226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/13/2021] [Indexed: 11/25/2022] Open
Abstract
A timely and effective immune reconstitution after hematopoietic stem cell transplantation (HSCT) is of crucial importance to enhance graft-versus-leukemia reaction in hematological malignancies. Several factors can influence the yield of this process, and new mathematical models are needed to describe this complex phenomenon.
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Affiliation(s)
- Manuela Spadea
- Pediatric Oncohematology, Stem Cell Transplantation and Cell Therapy Division, A.O.U. Città della Salute e della Scienza-Regina Margherita Children's Hospital, Turin, Italy
| | - Francesco Saglio
- Pediatric Oncohematology, Stem Cell Transplantation and Cell Therapy Division, A.O.U. Città della Salute e della Scienza-Regina Margherita Children's Hospital, Turin, Italy
| | - Serena I Tripodi
- Pediatric Hematology-Oncology, Fondazione Istituti di ricovero e cura a carattere scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Mariacristina Menconi
- Haematopoietic Stem Cell Transplantation Unit, Paediatric Clinic, University Hospital of Pisa, Pisa, Italy
| | - Marco Zecca
- Pediatric Hematology-Oncology, Fondazione Istituti di ricovero e cura a carattere scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Franca Fagioli
- Pediatric Oncohematology, Stem Cell Transplantation and Cell Therapy Division, A.O.U. Città della Salute e della Scienza-Regina Margherita Children's Hospital, Turin, Italy
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43
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Ceppi F, Rizzati F, Colombini A, Conter V, Cazzaniga G. Utilizing the prognostic impact of minimal residual disease in treatment decisions for pediatric acute lymphoblastic leukemia. Expert Rev Hematol 2021; 14:795-807. [PMID: 34374613 DOI: 10.1080/17474086.2021.1967137] [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] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Acute lymphoblastic leukemia (ALL) is the first pediatric cancer where the assessment of early response to therapy by minimal residual disease (MRD) monitoring has demonstrated its importance to improve risk-based treatment approaches. The most standardized tools to study MRD in ALL are multiparametric flow cytometry and realtime-quantitative polymerase chain reaction amplification-based methods. In recent years, MRD measurement has reached greater levels of sensitivity and standardization through international laboratory networks collaboration. AREAS COVERED We herewith describe how to assess and apply the prognostic impact of MRD in treatment decisions, with specific focus on pediatric ALL. We also highlight the role of MRD monitoring in the context of genetically homogeneous subgroups of pediatric ALL. However, some queries remain to be addressed and emerging technologies hold the promise of improving MRD detection in ALL patients. EXPERT OPINION Emerging technologies, like next generation flow cytometry, droplet digital PCR, and next generation sequencing appear to be important methods for assessing MRD in pediatric ALL. These more specific and/or sensitive MRD monitoring methods may help to predict relapse with greater accuracy, and are currently being used in clinical trials to improve pediatric ALL outcome by optimizing patient stratification and earlier MRD-based interventional therapy.
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Affiliation(s)
- Francesco Ceppi
- Pediatric Hematology-Oncology Unit, Division of Pediatrics, Woman-Mother-Child Department, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Frida Rizzati
- Pediatric Hematology-Oncology Unit, Division of Pediatrics, Woman-Mother-Child Department, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Antonella Colombini
- Pediatric Hematology-Oncology, University Milano Bicocca, Fondazione MBBM/Ospedale San Gerardo, Monza, Italy
| | - Valentino Conter
- Pediatric Hematology-Oncology, University Milano Bicocca, Fondazione MBBM/Ospedale San Gerardo, Monza, Italy
| | - Giovanni Cazzaniga
- Centro Ricerca Tettamanti, Pediatrics, School of Medicine, University of Milano Bicocca, Fondazione MBBM/Ospedale San Gerardo, Monza, Italy.,Medical Genetics, School of Medicine, University of Milano Bicocca, Monza, Italy
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Whole-genome sequencing facilitates patient-specific quantitative PCR-based minimal residual disease monitoring in acute lymphoblastic leukaemia, neuroblastoma and Ewing sarcoma. Br J Cancer 2021; 126:482-491. [PMID: 34471258 PMCID: PMC8810788 DOI: 10.1038/s41416-021-01538-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/07/2021] [Accepted: 08/23/2021] [Indexed: 12/12/2022] Open
Abstract
Background Minimal residual disease (MRD) measurement is a cornerstone of contemporary acute lymphoblastic leukaemia (ALL) treatment. The presence of immunoglobulin (Ig) and T cell receptor (TCR) gene recombinations in leukaemic clones allows widespread use of patient-specific, DNA-based MRD assays. In contrast, paediatric solid tumour MRD remains experimental and has focussed on generic assays targeting tumour-specific messenger RNA, methylated DNA or microRNA. Methods We examined the feasibility of using whole-genome sequencing (WGS) data to design tumour-specific polymerase chain reaction (PCR)-based MRD tests (WGS-MRD) in 18 children with high-risk relapsed cancer, including ALL, high-risk neuroblastoma (HR-NB) and Ewing sarcoma (EWS) (n = 6 each). Results Sensitive WGS-MRD assays were generated for each patient and allowed quantitation of 1 tumour cell per 10−4 (0.01%)–10–5 (0.001%) mononuclear cells. In ALL, WGS-MRD and Ig/TCR-MRD were highly concordant. WGS-MRD assays also showed good concordance between quantitative PCR and droplet digital PCR formats. In serial clinical samples, WGS-MRD correlated with disease course. In solid tumours, WGS-MRD assays were more sensitive than RNA-MRD assays. Conclusions WGS facilitated the development of patient-specific MRD tests in ALL, HR-NB and EWS with potential clinical utility in monitoring treatment response. WGS data could be used to design patient-specific MRD assays in a broad range of tumours.
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Blood and Marrow Transplant Clinical Trials Network State of the Science Symposium 2021: Looking Forward as the Network Celebrates its 20th Year. Transplant Cell Ther 2021; 27:885-907. [PMID: 34461278 PMCID: PMC8556300 DOI: 10.1016/j.jtct.2021.08.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/15/2021] [Accepted: 08/15/2021] [Indexed: 11/22/2022]
Abstract
In 2021 the BMT CTN held the 4th State of the Science Symposium where the deliberations of 11 committees concerning major topics pertinent to a particular disease, modality, or complication of transplant, as well as two committees to consider clinical trial design and inclusion, diversity, and access as cross-cutting themes were reviewed. This article summarizes the individual committee reports and their recommendations on the highest priority questions in hematopoietic stem cell transplant and cell therapy to address in multicenter trials.
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46
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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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47
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Wang ZD, Wang YW, Xu LP, Zhang XH, Wang Y, Chen H, Chen YH, Wang FR, Han W, Sun YQ, Yan CH, Tang FF, Mo XD, Wang YZ, Liu YR, Liu KY, Huang XJ, Chang YJ. Predictive Value of Dynamic Peri-Transplantation MRD Assessed By MFC Either Alone or in Combination with Other Variables for Outcomes of Patients with T-Cell Acute Lymphoblastic Leukemia. Curr Med Sci 2021; 41:443-453. [PMID: 34185250 DOI: 10.1007/s11596-021-2390-6] [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: 03/31/2021] [Accepted: 06/18/2021] [Indexed: 10/21/2022]
Abstract
We performed a retrospective analysis to investigate dynamic peri-hematopoietic stem cell transplantation (HSCT) minimal/measurable residual disease (MRD) on outcomes in patients with T-cell acute lymphoblastic leukemia (T-ALL). A total of 271 patients were enrolled and classified into three groups: unchanged negative MRD pre- and post-HSCT group (group A), post-MRD non-increase group (group B), and post-MRD increase group (group C). The patients in group B and group C experienced a higher cumulative incidence of relapse (CIR) (42% vs. 71% vs. 16%, P<0.001) and lower leukemia-free survival (LFS) (46% vs. 21% vs. 70%, P<0.001) and overall survival (OS) (50% vs. 28% vs. 72%, P<0.001) than in group A, but there was no significant difference in non-relapse mortality (NRM) among three groups (14% vs. 12% vs. 8%, P=0.752). Multivariate analysis showed that dynamic peri-HSCT MRD was associated with CIR (HR=2.392, 95% CI, 1.816-3.151, P<0.001), LFS (HR=1.964, 95% CI, 1.546-2.496, P<0.001) and OS (HR=1.731, 95% CI, 1.348-2.222, P<0.001). We also established a risk scoring system based on dynamic peri-HSCT MRD combined with remission status pre-HSCT and onset of chronic graft-versus-host disease (GVHD). This risk scoring system could better distinguish CIR (c=0.730) than that for pre-HSCT MRD (c=0.562), post-HSCT MRD (c=0.616) and pre- and post-MRD dynamics (c=0.648). Our results confirm the outcome predictive value of dynamic peri-HSCT MRD either alone or in combination with other variables for patients with T-ALL.
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Affiliation(s)
- Zhi-Dong Wang
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Yue-Wen Wang
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Lan-Ping Xu
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Yu Wang
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Huan Chen
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Yu-Hong Chen
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Feng-Rong Wang
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Wei Han
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Yu-Qian Sun
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Chen-Hua Yan
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Fei-Fei Tang
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Xiao-Dong Mo
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China.,Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies, Chinese Academy of Medical Sciences, Beijing, 100005, China
| | - Ya-Zhe Wang
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Yan-Rong Liu
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Kai-Yan Liu
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China
| | - Xiao-Jun Huang
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China.,Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies, Chinese Academy of Medical Sciences, Beijing, 100005, China.,Peking-Tsinghua Center for Life Sciences, Beijing, 100871, China
| | - Ying-Jun Chang
- Peking University People's Hospital and Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China.
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Tardif M, Souza A, Krajinovic M, Bittencourt H, Tran TH. Molecular-based and antibody-based targeted pharmacological approaches in childhood acute lymphoblastic leukemia. Expert Opin Pharmacother 2021; 22:1871-1887. [PMID: 34011251 DOI: 10.1080/14656566.2021.1931683] [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] [Indexed: 02/06/2023]
Abstract
Introduction: Despite the significant survival improvement in childhood acutelymphoblastic leukemia (ALL), 15-20% of patients continue to relapse; outcomes following relapse remain suboptimal and have room for further improvement. Advances in genomics have shed new insights on the biology of ALL, led to the discovery of novel genomically defined ALL subtypes, refined prognostic significance and revealed new therapeutic vulnerabilities.Areas covered: In this review, the authors provide an overview of the genomic landscape of childhood ALL and highlight recent advances in molecular-based and antibody-based pharmacological approaches in the treatment of childhood ALL, from emerging preclinical evidence to published results of completed clinical trials.Expert opinion: Molecularly targeted therapies and immunotherapies have expanded the horizons of ALL therapy and represent promising therapeutic avenues for high-risk and relapsed/refractory ALL. These novel therapies are now moving into frontline ALL therapy and may define new treatment paradigms that aim to further improve survival and reduce chemotherapy-related toxicities in the management of pediatric ALL.
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Affiliation(s)
- Magalie Tardif
- Division of Pediatric Hematology-Oncology, Charles-Bruneau Cancer Centre, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Amalia Souza
- Division of Pediatric Hematology-Oncology, Charles-Bruneau Cancer Centre, CHU Sainte-Justine, Montréal, Québec, Canada
| | - Maja Krajinovic
- Division of Pediatric Hematology-Oncology, Charles-Bruneau Cancer Centre, CHU Sainte-Justine, Montréal, Québec, Canada.,Department of Medicine, Université De Montréal, Montréal, Québec, Canada
| | - Henrique Bittencourt
- Division of Pediatric Hematology-Oncology, Charles-Bruneau Cancer Centre, CHU Sainte-Justine, Montréal, Québec, Canada.,Department of Medicine, Université De Montréal, Montréal, Québec, Canada
| | - Thai Hoa Tran
- Division of Pediatric Hematology-Oncology, Charles-Bruneau Cancer Centre, CHU Sainte-Justine, Montréal, Québec, Canada.,Department of Medicine, Université De Montréal, Montréal, Québec, Canada
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Shen X, Pan J, Qi C, Feng Y, Wu H, Qian S, Lu H, Chen L, Li J, Miao K, Qiu H, Zhu H. Impact of pre-transplantation minimal residual disease (MRD) on the outcome of Allogeneic hematopoietic stem cell transplantation for acute leukemia. ACTA ACUST UNITED AC 2021; 26:295-300. [PMID: 33648437 DOI: 10.1080/16078454.2021.1889162] [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] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To investigate the impact of minimal residual disease (MRD) before allogeneic hematopoietic stem cell transplantation (allo-HSCT) on the outcome of acute leukemia. METHODS Data from 114 patients who were diagnosed with acute leukemia (AL) and underwent allo-HSCT between Jan 2013 and Dec 2019 were collected and analyzed. The patients were attributed into MRD positive (MRD+) group and MRD negative (MRD-) group. RESULTS Among the 114 acute leukemia patients, there were 32 MRD+ patients before transplantation, and 82 MRD- patients. No significant difference was found between the MRD+ group and the MRD- group in the incidence of acute graft-versus-host disease (aGvHD) (p = 0.09). Compared with the MRD+ group, the MRD- group had a higher incidence of chronic graft-versus-host disease (cGvHD) (p = 0.008). There is no significance in relapse between the two groups (p = 0.084), while the incidence of relapse was seemingly higher in the MRD+ group: 36.9% Vs 19.7% . We attributed to the lack of sample size and NRM in MRD+ group was remarkably higher. The MRD+ group had significantly worse one-year overall survival (OS) ( , p = 0.003) and one-year progression-free survival (PFS) (, p = 0.009). In the multivariate analysis, MRD+ was an independent prognostic factor for OS (HR = 1.898; 95%CI 1.042-3.457; p = 0.036). CONCLUSION Pre-transplantation MRD positive status is a risk factor for survival and prognosis after HSCT. Upon this, emphasis should be put on (1) screening more efficient chemo regimen with targeted agents, to help patients reach and keep MRD- status before transplantation; (2) designing better management with different GvHD prophylaxis treatment, timely disease monitoring and preemptive intervention on relapse.
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Affiliation(s)
- Xing Shen
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, People's Republic of China
| | - Jing Pan
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, People's Republic of China
| | - Chenchen Qi
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, People's Republic of China
| | - Yuan Feng
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, People's Republic of China
| | - Hanxin Wu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, People's Republic of China
| | - Sixuan Qian
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, People's Republic of China
| | - Hua Lu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, People's Republic of China
| | - Lijuan Chen
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, People's Republic of China
| | - Jianyong Li
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, People's Republic of China
| | - Kourong Miao
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, People's Republic of China
| | - Hairong Qiu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, People's Republic of China
| | - Han Zhu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China.,Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, Nanjing, People's Republic of China
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50
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Tosi M, Spinelli O, Leoncin M, Cavagna R, Pavoni C, Lussana F, Intermesoli T, Frison L, Perali G, Carobolante F, Viero P, Skert C, Rambaldi A, Bassan R. MRD-Based Therapeutic Decisions in Genetically Defined Subsets of Adolescents and Young Adult Philadelphia-Negative ALL. Cancers (Basel) 2021; 13:cancers13092108. [PMID: 33925541 PMCID: PMC8123823 DOI: 10.3390/cancers13092108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 12/05/2022] Open
Abstract
Simple Summary In acute lymphoblastic leukemia (ALL), once a complete remission is achieved following induction chemotherapy, the study of submicroscopic minimal residual disease (MRD) represents a highly sensitive tool to assess the efficacy of early chemotherapy courses and predict outcome. Because of the significant therapeutic progress occurred in adolescent and young adult (AYA) ALL, the importance of MRD in this peculiar age setting has grown considerably, to refine individual prognostic scores within different genetic subsets and support specific risk and MRD-oriented programs. The evidence coming from the most recent MRD-based studies and the new therapeutic directions for AYA ALL are critically reviewed according to ALL subset and risk category. Abstract In many clinical studies published over the past 20 years, adolescents and young adults (AYA) with Philadelphia chromosome negative acute lymphoblastic leukemia (Ph− ALL) were considered as a rather homogeneous clinico-prognostic group of patients suitable to receive intensive pediatric-like regimens with an improved outcome compared with the use of traditional adult ALL protocols. The AYA group was defined in most studies by an age range of 18–40 years, with some exceptions (up to 45 years). The experience collected in pediatric ALL with the study of post-induction minimal residual disease (MRD) was rapidly duplicated in AYA ALL, making MRD a widely accepted key factor for risk stratification and risk-oriented therapy with or without allogeneic stem cell transplantation and experimental new drugs for patients with MRD detectable after highly intensive chemotherapy. This combined strategy has resulted in long-term survival rates of AYA patients of 60–80%. The present review examines the evidence for MRD-guided therapies in AYA’s Ph− ALL, provides a critical appraisal of current treatment pitfalls and illustrates the ways of achieving further therapeutic improvement according to the massive knowledge recently generated in the field of ALL biology and MRD/risk/subset-specific therapy
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Affiliation(s)
- Manuela Tosi
- Hematology Unit, Azienda Socio Sanitaria Territoriale (ASST), Ospedale Papa Giovanni XXIII, 24127 Bergamo, Italy; (M.T.); (O.S.); (R.C.); (C.P.); (F.L.); (T.I.); (A.R.)
| | - Orietta Spinelli
- Hematology Unit, Azienda Socio Sanitaria Territoriale (ASST), Ospedale Papa Giovanni XXIII, 24127 Bergamo, Italy; (M.T.); (O.S.); (R.C.); (C.P.); (F.L.); (T.I.); (A.R.)
| | - Matteo Leoncin
- Hematology Unit, Azienda Ulss3 Serenissima, Ospedale dell’Angelo, 30174 Venezia-Mestre, Italy; (M.L.); (L.F.); (G.P.); (F.C.); (P.V.); (C.S.)
| | - Roberta Cavagna
- Hematology Unit, Azienda Socio Sanitaria Territoriale (ASST), Ospedale Papa Giovanni XXIII, 24127 Bergamo, Italy; (M.T.); (O.S.); (R.C.); (C.P.); (F.L.); (T.I.); (A.R.)
| | - Chiara Pavoni
- Hematology Unit, Azienda Socio Sanitaria Territoriale (ASST), Ospedale Papa Giovanni XXIII, 24127 Bergamo, Italy; (M.T.); (O.S.); (R.C.); (C.P.); (F.L.); (T.I.); (A.R.)
| | - Federico Lussana
- Hematology Unit, Azienda Socio Sanitaria Territoriale (ASST), Ospedale Papa Giovanni XXIII, 24127 Bergamo, Italy; (M.T.); (O.S.); (R.C.); (C.P.); (F.L.); (T.I.); (A.R.)
| | - Tamara Intermesoli
- Hematology Unit, Azienda Socio Sanitaria Territoriale (ASST), Ospedale Papa Giovanni XXIII, 24127 Bergamo, Italy; (M.T.); (O.S.); (R.C.); (C.P.); (F.L.); (T.I.); (A.R.)
| | - Luca Frison
- Hematology Unit, Azienda Ulss3 Serenissima, Ospedale dell’Angelo, 30174 Venezia-Mestre, Italy; (M.L.); (L.F.); (G.P.); (F.C.); (P.V.); (C.S.)
| | - Giulia Perali
- Hematology Unit, Azienda Ulss3 Serenissima, Ospedale dell’Angelo, 30174 Venezia-Mestre, Italy; (M.L.); (L.F.); (G.P.); (F.C.); (P.V.); (C.S.)
| | - Francesca Carobolante
- Hematology Unit, Azienda Ulss3 Serenissima, Ospedale dell’Angelo, 30174 Venezia-Mestre, Italy; (M.L.); (L.F.); (G.P.); (F.C.); (P.V.); (C.S.)
| | - Piera Viero
- Hematology Unit, Azienda Ulss3 Serenissima, Ospedale dell’Angelo, 30174 Venezia-Mestre, Italy; (M.L.); (L.F.); (G.P.); (F.C.); (P.V.); (C.S.)
| | - Cristina Skert
- Hematology Unit, Azienda Ulss3 Serenissima, Ospedale dell’Angelo, 30174 Venezia-Mestre, Italy; (M.L.); (L.F.); (G.P.); (F.C.); (P.V.); (C.S.)
| | - Alessandro Rambaldi
- Hematology Unit, Azienda Socio Sanitaria Territoriale (ASST), Ospedale Papa Giovanni XXIII, 24127 Bergamo, Italy; (M.T.); (O.S.); (R.C.); (C.P.); (F.L.); (T.I.); (A.R.)
- Department of Oncology-Hematology, University of Milan, 20122 Milan, Italy
| | - Renato Bassan
- Hematology Unit, Azienda Ulss3 Serenissima, Ospedale dell’Angelo, 30174 Venezia-Mestre, Italy; (M.L.); (L.F.); (G.P.); (F.C.); (P.V.); (C.S.)
- Correspondence: ; Tel.: +39-041-965-7362
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