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Graham C, Litzow M. The use of haploidentical stem cell transplant as an alternative donor source in patients with decreased access to matched unrelated donors. Hematology 2024; 29:2338300. [PMID: 38753458 DOI: 10.1080/16078454.2024.2338300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/28/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION The likelihood of finding HLA-matched unrelated donors for rare HLA types and non-white European ancestry continues to be a challenge with less than a 70% chance of finding a full match. Mismatched transplants continue to have high rates of transplant-related mortality. With the near-universal ability to find a haploidentical donor in families, haploidentical transplants have become of more critical importance in ethnic minority groups and patients with rare HLA types. METHODS Data was collected through clinical trials, review articles, and case reports published in the National Library of Medicine. RESULTS The use of improved lymphodepleting conditioning regimens, graft versus host disease (GVHD) prophylaxis using regimens such as post-transplant cyclophosphamide, mycophenolate, and tacrolimus have improved engraftment to nearly 100 percent and reduced transplant-related mortality to less than 20 percent. Attention to donor-specific antibodies (DSAs) with interventions using bortezomib, rituximab, and plasmapheresis has decreased graft failure rates. CONCLUSION With improved prevention of GVHD with interventions such as post-transplant cyclophosphamide and management of DSAs, haploidentical transplants continue to improve transplant-related mortality (TRM) compared to patients who received matched-related donor transplants. While TRM continues to improve, ongoing research with haploidentical transplants will focus on improving graft and donor immunosuppression and identifying the best regimens to improve TRM without compromising relapse-free survival.
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Affiliation(s)
| | - Mark Litzow
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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2
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Esquirol A, Pascual MJ, Montoro J, Piñana JL, Ferrà C, Herruzo B, Garcia-Cadenas I, Balaguer A, Perez A, Huguet M, Redondo S, Villalba M, Hernandez-Boluda JC, Chorao P, Hernani R, Sanz J, Solano C, Sierra J, Martino R. COMPARISON OF THREE STRATEGIES OF GVHD PROPHYLAXIS AFTER T-CELL REPLETE HAPLOIDENTICAL HEMATOPOIETIC TRANSPLANTATION: TACROLIMUS vs. CALCINEURIN INHIBITORS-MMF vs. SIROLIMUS-MMF. Transplant Cell Ther 2024:S2666-6367(24)00557-8. [PMID: 39116938 DOI: 10.1016/j.jtct.2024.07.027] [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: 05/10/2024] [Revised: 07/12/2024] [Accepted: 07/29/2024] [Indexed: 08/10/2024]
Abstract
Since the introduction of post-transplant cyclophosphamide (PTCy), haploidentical HSCT (HaploSCT) has become a real alternative for patients who lack other eligible donors. The standard GvHD prophylaxis after PTCy has been a calcineurin inhibitor plus MMF (up to day+35), but promising results with sirolimus (+/- MMF) and single-agent tacrolimus have been recently published. The current multicenter retrospective study compared the outcomes of 372 adult HaploSCT recipients who received TBF conditioning; PTCY and additional GVHD prophylaxis with one of three strategies, cohort-A: single-agent tacrolimus (N 222), cohort-B: CNI-MMF (N 49) and cohort-C: sirolimus-MMF (N 101). No differences in terms of grade II-IV (20%, 25%, and 30%) and III-IV (9%, 6%, and 15%) aGvHD at 100 days were found. However, cohort A had the lowest incidence of overall cGvHD [24%, 47%, and 52%, respectively (p 0.001)] and moderate-severe cGvHD [13%, 35%, and 33%, respectively (p 0.001)]. There were no differences in the 3-year overall survival, progression-free survival, NRM nor relapse among the cohorts. In conclusion, our study suggests that single-agent tacrolimus, CNI+MMF and sirolimus+MMF GvHD prophylaxis lead to similar outcomes following HaploSCT with TBF and PTCy, with low incidence of grade III-IV aGvHD, albeit possible differences in cGVHD require further investigation.
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Affiliation(s)
- A Esquirol
- Hematology Department, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes. Universitat Autonoma of Barcelona Spain.
| | - M J Pascual
- Hematology Department, Hospital Regional Universitario, Malaga. Spain
| | - J Montoro
- Department of Haematology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - J L Piñana
- Hematology Department, Hospital Clinico Universitario, Valencia
| | - C Ferrà
- Hematology Department, Hospital Germans Trias i Pujol, Badalona, Spain
| | - B Herruzo
- Hematology Department, Hospital Regional Universitario, Malaga. Spain
| | - I Garcia-Cadenas
- Hematology Department, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes. Universitat Autonoma of Barcelona Spain
| | - A Balaguer
- Department of Haematology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - A Perez
- Hematology Department, Hospital Clinico Universitario, Valencia
| | - M Huguet
- Hematology Department, Hospital Germans Trias i Pujol, Badalona, Spain
| | - S Redondo
- Hematology Department, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes. Universitat Autonoma of Barcelona Spain
| | - M Villalba
- Department of Haematology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - P Chorao
- Department of Haematology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - R Hernani
- Hematology Department, Hospital Clinico Universitario, Valencia
| | - J Sanz
- Department of Haematology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - C Solano
- Hematology Department, Hospital Clinico Universitario, Valencia
| | - J Sierra
- Hematology Department, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes. Universitat Autonoma of Barcelona Spain
| | - R Martino
- Hematology Department, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau and Jose Carreras Leukemia Research Institutes. Universitat Autonoma of Barcelona Spain
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Richardson T, Scheid C, Herling M, Frenzel LP, Herling C, Aguilar MRC, Theurich S, Hallek M, Holtick U. Post-transplant-cyclophosphamide and short-term Everolimus as graft-versus-host-prophylaxis in patients with relapsed/refractory lymphoma and myeloma-Final results of the phase II OCTET-EVER trial. Eur J Haematol 2024; 113:163-171. [PMID: 38616351 DOI: 10.1111/ejh.14210] [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: 12/31/2023] [Revised: 03/16/2024] [Accepted: 03/25/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Conditioning regimens and the choice of immunosuppression have substantial impact on immune reconstitution after allogeneic hematopoietic stem cell transplantation (aHSCT). The pivotal mechanism to maintain remission is the induction of the graft-versus-tumor effect. Relapse as well as graft versus host disease remain common. Classic immunosuppressive strategies implementing calcineurin inhibitors (CNI) have significant toxicities, hamper the immune recovery, and reduce the anti-cancer immune response. METHODS We designed a phase II clinical trial for patients with relapsed and refractory lymphoid malignancies undergoing aHSCT using a CNI-free approach consisting of post-transplant cyclophosphamide (PTCy) and short-term Everolimus after reduced-intensity conditioning and matched peripheral blood stem cell transplantation. The results of the 19 planned patients are presented. Primary endpoint is the cumulative incidence and severity of acute GvHD. RESULTS Overall incidence of acute GvHD was 53% with no grade III or IV. Cumulative incidence of NRM at 1, 2, and 4 years was 11%, 11%, and 16%, respectively, with a median follow-up of 43 months. Cumulative incidence of relapse was 32%, 32%, and 42% at 1, 2, and 4 years after transplant, respectively. Four out of six early relapses were multiple myeloma patients. Overall survival was 79%, 74%, and 62% at 1, 2, and 4 years. GvHD-relapse-free-survival was 47% after 3 years. CONCLUSIONS Using PTCy and short-term Everolimus is safe with low rates of aGvHD and no severe aGvHD or cGvHD translating into a low rate of non-relapse mortality. Our results in this difficult to treat patient population are encouraging and warrant further studies.
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Affiliation(s)
- Tim Richardson
- Department I of Internal Medicine, Medical Faculty and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Christof Scheid
- Department I of Internal Medicine, Medical Faculty and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Marco Herling
- Department of Hematology, Cellular Therapy, and Hemostaseology, University Hospital Leipzig, Leipzig, Germany
| | - Lukas P Frenzel
- Department I of Internal Medicine, Medical Faculty and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Carmen Herling
- Department of Hematology, Cellular Therapy, and Hemostaseology, University Hospital Leipzig, Leipzig, Germany
| | - Marta Rebecca Cruz Aguilar
- Department I of Internal Medicine, Medical Faculty and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Sebastian Theurich
- Department of Medicine III, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany
| | - Michael Hallek
- Department I of Internal Medicine, Medical Faculty and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Udo Holtick
- Department I of Internal Medicine, Medical Faculty and University Hospital of Cologne, University of Cologne, Cologne, Germany
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Arcuri LJ, Ribeiro AAF, Hamerschlak N, Kerbauy MN. Posttransplant cyclophosphamide beyond haploidentical transplantation. Ann Hematol 2024; 103:1483-1491. [PMID: 37261557 DOI: 10.1007/s00277-023-05300-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 05/26/2023] [Indexed: 06/02/2023]
Abstract
Posttransplant cyclophosphamide (PTCy) has practically revolutionized haploidentical (Haplo) hematopoietic cell transplantation (HCT). Comparisons between Haplo with PTCy and unrelated donor (URD) with conventional graft-versus-host disease (GVHD) prophylaxis have shown comparable overall survival with lower incidences of GVHD with Haplo/PTCy and led to the following question: is it PTCy so good that can be successfully incorporated into matched related donor (MRD) and URD HCT? In this review, we discuss other ways of doing PTCy, PTCy in peripheral blood haploidentical transplants, PTCy in the context of matched related and matched unrelated donors, PTCy with mismatched unrelated donors, and PTCy following checkpoint inhibitor treatment. PTCy is emerging as a new standard GVHD prophylaxis in haploidentical, HLA-matched, and -mismatched HCT.
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Affiliation(s)
- Leonardo Javier Arcuri
- Academic Research Organization, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, São Paulo, SP, 05652-900, Brazil.
- Bone Marrow Transplantation Unit, Insituto Nacional de Cancer, Rio de Janeiro, Brazil.
| | | | - Nelson Hamerschlak
- Bone Marrow Transplantation Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
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5
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Alfaro Moya T, Salas MQ, Santos Carreira A, Atenafu EG, Law AD, Lam W, Pasic I, Kim DDH, Michelis FV, Novitzky Basso I, Gerbitz A, Lipton JH, Kumar R, Mattsson J, Viswabandya A. Dual T cell depletion for graft versus host disease prevention in peripheral blood haploidentical hematopoietic cell transplantation for adults with hematological malignancies. Bone Marrow Transplant 2024; 59:534-540. [PMID: 38317015 DOI: 10.1038/s41409-024-02216-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 02/07/2024]
Abstract
The ideal immunosuppressive agents to complement post-transplant cyclophosphamide (PTCy) in PBSC-based haploidentical hematopoietic cell transplantation (haplo-HCT) remain debated. This study looks at our experience with ATG-PTCy-Cyclosporine (CsA) prophylaxis in PB haplo-HCT since 2015. Between October 2015 and December 2021, 157 adults underwent haploidentical hematopoietic cell transplantation (haplo-HCT) using a GVHD prophylaxis regimen comprising rabbit-ATG, PTCy, and CsA. Among these patients, 76.4% received a total ATG dose of 4.5 mg/kg, and 23.5% received 2 mg/kg. T-cell replete peripheral blood stem cell (PBSC) grafts were infused on day 0. The study reported a median follow-up of 32 months (range 0.3-61.64) for survivors. The cumulative incidence of grade II-IV and grade III-IV acute GVHD at day +100 was 26.3% and 9.5%, respectively. Moderate/severe chronic GVHD at 1 year was 19.9%. The 2-year overall survival (OS) was 49.4%, with a relapse-free survival (RFS) of 44.6%. In multivariate analysis, older patients, and those with high/very-high disease risk indices (DRI) were at higher risk for worse OS and higher non-relapse mortality (NRM). The study confirms that using PTCy and ATG (4.5 mg/kg), alongside CsA is safe and effective in preventing GVHD when using peripheral blood as the stem cell source in haploidentical hematopoietic cell transplantation (haplo-HCT).
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Affiliation(s)
- Tommy Alfaro Moya
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Maria Queralt Salas
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Hematology, Bone Marrow Transplantation Unit, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Abel Santos Carreira
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princes Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Arjun Datt Law
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Wilson Lam
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Ivan Pasic
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Dennis Dong Hwan Kim
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Fotios V Michelis
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Igor Novitzky Basso
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Armin Gerbitz
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Jeffrey Howard Lipton
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Rajat Kumar
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Jonas Mattsson
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Auro Viswabandya
- University of Toronto, Department of Medicine, Section of Medical Oncology and Hematology, Toronto, ON, Canada.
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
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Robinson CR, Habib A, Klomjit N, Cao Q, Holtan SG. Nephrons and non-relapse mortality: simplified comorbidity index and acute kidney injury are associated with NRM in adults undergoing allogeneic hematopoietic cell transplant. FRONTIERS IN TRANSPLANTATION 2024; 3:1352413. [PMID: 38993762 PMCID: PMC11235361 DOI: 10.3389/frtra.2024.1352413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/06/2024] [Indexed: 07/13/2024]
Abstract
The Simplified Comorbidity Index (SCI) is a recently published 5-component, pre-transplant tool to predict non-relapse mortality (NRM) in allogeneic hematopoietic cell transplantation (alloHCT) patients. The SCI captures chronic kidney disease (CKD) using estimated glomerular filtration rate (eGFR) based on the CKD-EPI equation (KDIGO 2021 CKD-EPI), which may be more sensitive to predict risk of NRM than the creatinine cut-off in the 16-component, Hematopoietic Cell Transplant-Comorbidity Index (HCT-CI). We retrospectively assessed the ability of the SCI to risk-stratify patients and the impact of acute kidney injury (AKI) to NRM in adults who underwent alloHCT at the University of Minnesota. We included 373 patients who underwent their first alloHCT between 2015 and 2019. Through multivariate analysis, we found that patients with an SCI of greater than 4 had a higher risk of NRM. Additionally, we noted that AKIs stages 2-3 prior to day +100 was independently associated with a 3-fold greater NRM than patients who did not experience clinically significant AKI.
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Affiliation(s)
- Clark Raymond Robinson
- Division of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Alma Habib
- Department of Hematology, The Ohio State University, Columbus, OH, United States
| | - Nattawat Klomjit
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, MN, United States
| | - Qing Cao
- Biostatistics and Bioinformatics, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, United States
| | - Shernan Grace Holtan
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, United States
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De Togni E, Cole O, Abboud R. Janus kinase inhibition in the treatment and prevention of graft-versus-host disease. Front Immunol 2024; 15:1304065. [PMID: 38380328 PMCID: PMC10877010 DOI: 10.3389/fimmu.2024.1304065] [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: 09/28/2023] [Accepted: 01/18/2024] [Indexed: 02/22/2024] Open
Abstract
Graft-versus-host disease (GVHD) is a significant cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). For many years, corticosteroids have been the mainstay treatment for GVHD, but cases of steroid-refractory GVHD and the severe adverse effects of high-dose corticosteroids have increased the need for preventative and therapeutic strategies for GVHD. Due to the nature of alloreactive T cells, GVHD is inherently linked to the graft-versus-leukemia (GVL) effect, the therapeutic driving force behind stem cell transplantation. A considerable clinical challenge is to preserve GVL while suppressing GVHD. The field of GVHD research has greatly expanded over the past decades, including advancements in T cell modulation and depletion, antibody therapies, chemotherapeutics, cellular therapies, and Janus kinase inhibition. In this review, we discuss current approaches and advances in the prophylaxis and treatment of GVHD with a focus on new emerging advancements in Janus kinase inhibitor therapy.
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Affiliation(s)
- Elisa De Togni
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Oladipo Cole
- Division of Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Ramzi Abboud
- Division of Oncology, Washington University School of Medicine, St. Louis, MO, United States
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Elmariah H, Otoukesh S, Kumar A, Ali H, Arslan S, Shouse G, Pourhassan H, Nishihori T, Faramand R, Mishra A, Khimani F, Fernandez H, Lazaryan A, Nieder M, Perez L, Liu H, Nakamura R, Pidala J, Marcucci G, Forman SJ, Anasetti C, Locke F, Bejanyan N, Al Malki MM. Sirolimus Is an Acceptable Alternative to Tacrolimus for Graft-versus-Host Disease Prophylaxis after Haploidentical Peripheral Blood Stem Cell Transplantation with Post-Transplantation Cyclophosphamide. Transplant Cell Ther 2024; 30:229.e1-229.e11. [PMID: 37952648 DOI: 10.1016/j.jtct.2023.11.010] [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: 05/14/2023] [Revised: 10/25/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023]
Abstract
Graft-versus-host disease (GVHD) prophylaxis with post-transplantation cyclophosphamide (PTCy), tacrolimus (Tac), and mycophenolate mofetil (MMF) for allogeneic haploidentical donor (haplo) hematopoietic cell transplantation (HCT) results in comparable outcomes to matched unrelated donor HCT. A phase II study from the Moffitt Cancer Center substituting sirolimus (Siro) for Tac in this prophylactic regimen reported comparable rates of grade II-IV acute GVHD (aGVHD). Many centers have substituted Siro for Tac in this setting based on a preferable side effect profile, although comparative data are limited. In this study, we retrospectively compared outcomes in haplo-HCT with PTCy/Siro/MMF versus haplo-HCT with PTCy/Tac/MMF. The study cohort included all consecutive patients receiving haploidentical donor T cell-replete peripheral blood stem cell (PBSC) HCT for hematologic malignancies at Moffitt Cancer Center or the City of Hope National Medical Center between 2014 and 2019. A total of 423 patients were included, of whom 84 (20%) received PTCy/Siro/MMF and 339 (80%) received PTCy/Tac/MMF. The median age for the entire cohort was 54 years (range, 18 to 78 years), and the median follow-up was 30 months. The Siro group had a higher proportion of patients age ≥60 years (58% versus 34%; P < .01), and the groups also differed in diagnosis type, conditioning regimen, and cytomegalovirus serostatus. There were no significant differences in the rates of grade II-IV aGVHD (45% versus 47%; P = .6) at day +100 or chronic GVHD (cGVHD) (47% versus 54%; P = .79) at 2 years post-HCT. In multivariate analysis, neutrophil engraftment at day +30 was significantly better in the Tac group (odds ratio, .30; 95% confidence interval, .1 to .83; P = .02), with a median time to engraftment of 17 days versus 18 days in the Siro group, but platelet engraftment was similar in the 2 groups. Otherwise, in multivariate analysis, GVHD prophylaxis type had no significant influence on aGVHD or cGVHD, nonrelapse mortality, relapse, GVHD-free relapse-free survival, disease-free survival, or overall survival after PBSC haplo-HCT. These findings suggest that Siro is a comparable alternative to Tac in combination with PTCy/MMF for GVHD prophylaxis, with overall similar clinical outcomes despite delayed engraftment after peripheral blood stem cell haplo-HCT. Although Tac remains the standard of care, Siro may be substituted based on the side effect profile of these medications, with consideration of patient medical comorbidities at HCT.
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Affiliation(s)
- Hany Elmariah
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Salman Otoukesh
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | | | - Haris Ali
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Shukaib Arslan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Geoffrey Shouse
- City of Hope Comprehensive Cancer Center, Duarte, California
| | - Hoda Pourhassan
- City of Hope Comprehensive Cancer Center, Duarte, California
| | - Taiga Nishihori
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Rawan Faramand
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Asmita Mishra
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Farhad Khimani
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Hugo Fernandez
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Aleksandr Lazaryan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Michael Nieder
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Lia Perez
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Hien Liu
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Joseph Pidala
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Guido Marcucci
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Claudio Anasetti
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Frederick Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Nelli Bejanyan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.
| | - Monzr M Al Malki
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
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Zeng Q, Zhang H, Kuang P, Li J, Chen X, Dong T, Wu Q, Zhang C, Chen C, Niu T, Liu T, Liu Z, Ji J. The MAGIC algorithm probability (MAP)-guided preemptive therapy of acute graft versus host disease with methylprednisolone: A randomized controlled trial. Am J Hematol 2023; 98:1550-1558. [PMID: 37497879 DOI: 10.1002/ajh.27020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/05/2023] [Accepted: 06/30/2023] [Indexed: 07/28/2023]
Abstract
Acute graft versus host disease (aGvHD) is a severe complication that arises in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) and remains the primary cause of nonrelapse mortality (NRM). The MAGIC algorithm probability (MAP) has been proposed to identify patients at intermediate and high risk of developing aGvHD. The levels of suppression of tumorigenicity 2 (ST2) and regenerating islet-derived 3α (Reg3α) were assessed, and MAP was calculated on days 7, 14, 21, and 28 after allo-HSCT. Based on the MAP results, patients were classified into low-, intermediate-, or high-risk groups for the development of aGvHD. Random assignment was performed to allocate intermediate- or high-risk patients to receive preemptive therapy with methylprednisolone or not. The 100-day cumulative incidences of grade 2 or higher (35.5% ± 8.6%) and grade 3 or higher (12.9% ± 6.0%) aGvHD in the methylprednisolone group were significantly lower than those in the control group (66.7% ± 7.9%, p = .01; 42.9% ± 8.4%, p = .01), and similar to those observed in the low-risk group (31.7% ± 7.3%, p = .75; 2.4% ± 2.4%, p = .08). The 6-month cumulative incidences of NRM were 14.1% ± 6.6%, 22.7% ± 7.1%, and 2.4% ± 2.4% in the methylprednisolone, control, and low-risk groups, respectively, with no significant difference between the methylprednisolone and control groups (p = .29). Methylprednisolone did not increase infections (p = .34). The 100-day cumulative incidences of cytomegalovirus (CMV) reactivation were 67.7% ± 8.4%, 65.6% ± 8.4%, and 46.3% ± 7.8% (p = .08), and those of grade 2 or higher hemorrhagic cystitis were 29.0% ± 8.2%, 45.2% ± 8.9% and 22.0% ± 6.5% (p = .11) in the methylprednisolone, control, and low-risk groups, respectively. MAP-guided preemptive therapy for aGvHD is promising. The long-term efficacy and safety remain to be investigated.
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Affiliation(s)
- Qiang Zeng
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Hang Zhang
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Pu Kuang
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Li
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Xinchuan Chen
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Tian Dong
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Qiuhui Wu
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
- Stem Cell Transplantation & Cellular Therapy Division, Clinic Trial Center, West China Hospital, Sichuan University, Chengdu, China
| | - Chuanli Zhang
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Chunping Chen
- Department of Hematology, Shangjin Nanfu Hospital, Chengdu, China
| | - Ting Niu
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Ting Liu
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhigang Liu
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
- Stem Cell Transplantation & Cellular Therapy Division, Clinic Trial Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Ji
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
- Stem Cell Transplantation & Cellular Therapy Division, Clinic Trial Center, West China Hospital, Sichuan University, Chengdu, China
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10
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Balaguer-Roselló A, Gil-Perotín S, Montoro J, Bataller L, Lamas B, Villalba M, Facal A, Guerreiro M, Chorão P, Bataller A, Granados P, Gómez I, Solves P, Louro A, de la Rubia J, Sanz MÁ, Sanz J. Reduced Incidence of Neurologic Complications after Allogeneic Hematopoietic Stem Cell Transplantation with Calcineurin-Free Graft-versus-Host Disease Prophylaxis. Transplant Cell Ther 2023; 29:610.e1-610.e12. [PMID: 37451486 DOI: 10.1016/j.jtct.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
Calcineurin inhibitors (CNIs), including cyclosporine and tacrolimus, are frequently associated with neurologic complications after allogeneic hematopoietic stem cell transplantation (HSCT). However, there is a lack of studies comparing the incidence and characteristics of neurologic complications in patients undergoing HSCT based on CNI-free or CNI-based GVHD prophylaxis. This retrospective single-center study analyzed the neurologic complications in 2 cohorts of patients undergoing HSCT with either CNI-based GVHD prophylaxis (n = 523) or CNI-free prophylaxis with post-transplantation cyclophosphamide, sirolimus, and mycophenolate mofetil (n = 371). The latter cohort included older patients and received more reduced-intensity conditioning and transplants from matched unrelated and haploidentical donors. The 2-year cumulative incidence of neurologic complications was significantly lower in the CNI-free cohort (6.9% versus 11.9%; P = .016), and GVHD prophylaxis was the sole statistically significant variable in multivariate analysis (hazard ratio, 2.2; 95% confidence interval [CI], .25 to 3.13; P = .0017). The distribution of neurologic types was similar in the 2 cohorts, with encephalopathy the most prevalent complication, except for headaches and myopathy, which decreased equally from 15% in the CNI-based cohort to 4% in the CNI-free cohort. Neurologic complications had negative impacts on mortality and survival rates, with a significantly higher 2-year cumulative incidence of nonrelapse mortality (NRM) (44% [95% CI, 34% to 54%] versus 16% [95% CI, 13% to 18%]; P < .0001) and inferior overall survival (66% [95% CI, 62% to 69%] versus 46% [95% CI, 37% to 58%]; P < .0001) in patients with neurologic complications. This study suggests that CNI-free GVHD prophylaxis with post-transplantation cyclophosphamide, sirolimus, and mycophenolate mofetil may reduce not only the incidence of GVHD incidence, but also the rates of neurologic complications and NRM, leading to improved survival outcomes in patients undergoing HSCT.
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Affiliation(s)
- Aitana Balaguer-Roselló
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain.
| | - Sara Gil-Perotín
- Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Juan Montoro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Luis Bataller
- Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Brais Lamas
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Marta Villalba
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Ana Facal
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Manuel Guerreiro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pedro Chorão
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Ana Bataller
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pablo Granados
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Inés Gómez
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Pilar Solves
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Alberto Louro
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Javier de la Rubia
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Miguel Ángel Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Jaime Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain
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11
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Moore J, Hamad N, Gottlieb D, Bajel A, Ritchie D, Yeung D, Greenwood M, Purtill D, Tran S, Solterbeck A, Aarons D, Kwan J. Early cessation of calcineurin inhibitors is feasible post-haploidentical blood stem cell transplant: the ANZHIT 1 study. Blood Adv 2023; 7:5554-5565. [PMID: 37467011 PMCID: PMC10514140 DOI: 10.1182/bloodadvances.2023009840] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 05/25/2023] [Accepted: 06/18/2023] [Indexed: 07/20/2023] Open
Abstract
Haploidentical hematopoietic stem cell transplant (haplo-HSCT) using posttransplant cyclophosphamide (PTCy) is appropriate for those who lack matched donors. Most studies using PTCy have been retrospective making conclusions difficult. ANZHIT-1 was a phase 2 study conducted at 6 Australian allogeneic HSCT centers. The primary end points were disease-free and overall survival at 2 years after HSCT. The reduced-intensity conditioning (RIC) included fludarabine, cyclophosphamide, and 200 cGy total body irradiation, and the myeloablative conditioning (MAC) was IV fludarabine and busulfan. PTCy, MMF and a calcineurin inhibitor (CNI) were used for graft-versus-host disease (GVHD) prophylaxis. CNIs were weaned and ceased by day +120 in eligible patients on day 60. Patients (n = 78) with hematological malignancies were included in the study, with a median follow-up of 732 days (range, 28-1728). HSCT was RIC in 46 patients and MAC in 32 patients. Disease-free survival probability at 2 years was 67.5% (95% [CI], 53.2-85.6) for MAC recipients and 68.3% (95% CI, 56.3-83.01) for RIC recipients. Transplant-related mortality (TRM) on day 100 and year 1 was 4.9% (95% CI, 1.6-15.3) and 17.9% (95% CI, 8.8-36.5), respectively, in the MAC group compared with 3.1% (95% CI, 0.8.1-12) and 11.6% (95% CI, 6-22.4), respectively, in the RIC group. The median time for elective cessation of CNI was day 142.5 days, with no excess chronic GVHD (cGVHD) or mortality. Of the evaluable patients, 71.6% discontinued immunosuppression 12 months after transplant. This prospective haplo-HSCT trial using PTCY demonstrated encouraging survival rates, indicating that early CNI withdrawal is feasible and safe.
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Affiliation(s)
- John Moore
- Haematology Department, St Vincent’s Hospital, Sydney, Australia
| | - Nada Hamad
- Haematology Department, St Vincent’s Hospital, Sydney, Australia
| | - David Gottlieb
- Haematology Department, Westmead Hospital, Sydney, Australia
| | - Ashish Bajel
- Haematology Department, Royal Melbourne Hospital, Melbourne, Australia
| | - David Ritchie
- Haematology Department, Royal Melbourne Hospital, Melbourne, Australia
| | - David Yeung
- Haematology Department, Royal Adelaide Hospital, Adelaide, Australia
| | - Matthew Greenwood
- Haematology Department, Royal North Shore Hospital Sydney, Sydney, Australia
| | - Duncan Purtill
- Haematology Department, Fiona Stanley Hospital, Perth, Australia
| | - Steven Tran
- Australasian Bone Marrow Transplant Recipients Registry, Sydney, Australia
| | | | - Donna Aarons
- Australasian Bone Marrow Transplant Recipients Registry, Sydney, Australia
| | - John Kwan
- Haematology Department, Westmead Hospital, Sydney, Australia
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12
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Patel DA, Crain M, Pusic I, Schroeder MA. Acute Graft-versus-Host Disease: An Update on New Treatment Options. Drugs 2023:10.1007/s40265-023-01889-2. [PMID: 37247105 DOI: 10.1007/s40265-023-01889-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 05/30/2023]
Abstract
Acute graft-versus-host disease (GVHD) occurs in approximately 50% of patients and remains a primary driver of non-relapse and transplant-related mortality. The best treatment remains prevention with either in vivo or ex vivo T-cell depletion, with multiple strategies used worldwide based on factors such as institution preference, ability to perform graft manipulation, and ongoing clinical trials. Predicting patients at high risk for developing severe acute GVHD based on clinical and biomarker-based criteria allows for escalation or potential de-escalation of therapy. Modern therapies for treatment of the disease include JAK/STAT pathway inhibitors, which are standard of care in the second-line setting and are being investigated for upfront management of non-severe risk based on biomarkers. Salvage therapies beyond the second-line remain suboptimal. In this review, we will focus on the most clinically used GVHD prevention and treatment strategies, including the accumulating data on JAK inhibitors in both settings.
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Affiliation(s)
- Dilan A Patel
- Section of BMT & Leukemia, Division of Oncology, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Mallory Crain
- Section of BMT & Leukemia, Division of Oncology, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Iskra Pusic
- Section of BMT & Leukemia, Division of Oncology, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Mark A Schroeder
- Section of BMT & Leukemia, Division of Oncology, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, MO, USA.
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13
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Hess NJ, Kink JA, Hematti P. Exosomes, MDSCs and Tregs: A new frontier for GVHD prevention and treatment. Front Immunol 2023; 14:1143381. [PMID: 37063900 PMCID: PMC10090348 DOI: 10.3389/fimmu.2023.1143381] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
The development of graft versus host disease (GVHD) represents a long-standing complication of allogeneic hematopoietic cell transplantation (allo-HCT). Different approaches have been used to control the development of GVHD with most relying on variations of chemotherapy drugs to eliminate allo-reactive T cells. While these approaches have proven effective, it is generally accepted that safer, and less toxic GVHD prophylaxis drugs are required to reduce the health burden placed on allo-HCT recipients. In this review, we will summarize the emerging concepts revolving around three biologic-based therapies for GVHD using T regulatory cells (Tregs), myeloid-derived-suppressor-cells (MDSCs) and mesenchymal stromal cell (MSC) exosomes. This review will highlight how each specific modality is unique in its mechanism of action, but also share a common theme in their ability to preferentially activate and expand Treg populations in vivo. As these three GVHD prevention/treatment modalities continue their path toward clinical application, it is imperative the field understand both the biological advantages and disadvantages of each approach.
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Affiliation(s)
- Nicholas J. Hess
- Division of Hematology, Oncology and Palliative Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
- University of Wisconsin Carbone Cancer Center, Madison, WI, United States
| | - John A. Kink
- Division of Hematology, Oncology and Palliative Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
- University of Wisconsin Carbone Cancer Center, Madison, WI, United States
| | - Peiman Hematti
- Division of Hematology, Oncology and Palliative Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
- University of Wisconsin Carbone Cancer Center, Madison, WI, United States
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14
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Zhang J, Wang X, Wang R, Chen G, Wang J, Feng J, Li Y, Yu Z, Xiao H. Rapamycin Treatment Alleviates Chronic GVHD-Induced Lupus Nephritis in Mice by Recovering IL-2 Production and Regulatory T Cells While Inhibiting Effector T Cells Activation. Biomedicines 2023; 11:biomedicines11030949. [PMID: 36979928 PMCID: PMC10045991 DOI: 10.3390/biomedicines11030949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/07/2023] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
In this study, we test the therapeutic effects of rapamycin in a murine model of SLE-like experimental lupus nephritis induced by chronic graft-versus-host disease (cGVHD). Our results suggest that rapamycin treatment reduced autoantibody production, inhibited T lymphocyte and subsequent B cell activation, and reduced inflammatory cytokine and chemokine production, thereby protecting renal function and alleviating histological lupus nephritis by reducing the occurrence of albuminuria. To explore the potential mechanism of rapamycin's reduction of kidney damage in mice with lupus nephritis, a series of functional assays were conducted. As expected, rapamycin remarkably inhibited the lymphocytes' proliferation within the morbid mice. Interestingly, significantly increased proportions of peripheral CD4+FOXP3+ and CD4+CD25high T cells were observed in rapamycin-treated group animals, suggesting an up-regulation of regulatory T cells (Tregs) in the periphery by rapamycin treatment. Furthermore, consistent with the results regarding changes in mRNA abundance in kidney by real-time PCR analysis, intracellular cytokine staining demonstrated that rapamycin treatment remarkably diminished the secretion of Th1 and Th2 cytokines, including IFN-γ, IL-4 and IL-10, in splenocytes of the morbid mice. However, the production of IL-2 from splenocytes in rapamycin-treated mice was significantly higher than in the cells from control group animals. These findings suggest that rapamycin treatment might alleviate systemic lupus erythematosus (SLE)-like experimental lupus nephritis through the recovery of IL-2 production, which promotes the expansion of regulatory T cells while inhibiting effector T cell activation. Our studies demonstrated that, unlike other commonly used immunosuppressants, rapamycin does not appear to interfere with tolerance induction but permits the expansion and suppressive function of Tregs in vivo.
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Affiliation(s)
- Jilu Zhang
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing 100850, China
- Department of Biomedicine, Institute of Frontier Medical Sciences, Jilin University, Changchun 130021, China
| | - Xun Wang
- Department of Experimental Hematology and Biochemistry, Beijing Key Laboratory for Radiobiology, Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Renxi Wang
- Laboratory of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Capital Medical University, Ministry of Science and Technology, Beijing 100054, China
| | - Guojiang Chen
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing 100850, China
| | - Jing Wang
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing 100850, China
| | - Jiannan Feng
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing 100850, China
| | - Yan Li
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing 100850, China
| | - Zuyin Yu
- Department of Experimental Hematology and Biochemistry, Beijing Key Laboratory for Radiobiology, Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - He Xiao
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing 100850, China
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15
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Donor HLA mismatch promotes full donor T-cell chimerism in the allogeneic stem cell transplant with reduced-intensity conditioning and post-transplant cyclophosphamide GVHD prophylaxis. Ann Hematol 2023; 102:613-620. [PMID: 36527460 DOI: 10.1007/s00277-022-05077-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022]
Abstract
Full donor T-cell chimerism (FDTCC) after allogeneic stem cell transplant (allo-SCT) has been associated with improved outcomes in hematologic malignancy. We studied if donor human leukocyte antigen (HLA) mismatch improves achievement of FDTCC because mismatched HLA promotes donor T-cell proliferation where recipient T-cells had been impaired by previous treatment. Patients (N = 138) received allo-SCT with reduced-intensity conditioning (RIC) from 39 HLA mismatched donors (16 unrelated; 23 haploidentical) with post-transplant cyclophosphamide (PTCy) or 99 matched donors (21 siblings; 78 unrelated) with PTCy (N = 18) or non-PTCy (N = 81). Achievement of FDTCC by day 100 was higher with HLA mismatched donors than matched donors (82.1% vs. 27.3%, p < 00,001), which was further improved with 200 cGy total body irradiation (87.9%) or lymphoid (versus myeloid) malignancy (93.8%). Since all mismatched transplants used PTCy, FDTCC was higher with PTCy than non-PTCy (68.4% vs. 25.7%, p < 0.00001), but not in the matched transplant with PTCy (38.9%), negating PTCy as the primary driver. Lymphocyte recovery was delayed with PTCy than without (median on day + 30: 100 vs. 630/µL, p < 0.0001). The benefit of FDTCC was not translated into survival outcomes, especially in myeloid malignancies, possibly due to the insufficient graft-versus-tumor effects from the delayed lymphocyte recovery. Further studies are necessary to improve lymphocyte count recovery in PTCy transplants.
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16
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Iqbal M, Nieto FAM, Brannick KM, Li Z, Murthy H, Foran J, Roy V, Kharfan-Dabaja MA, Ayala E. A Calcineurin Inhibitor Free Graft Versus Host Disease Prophylaxis for Patients Undergoing Matched Related and Matched Unrelated Donor Allogeneic Hematopoietic Cell Transplant. Transplant Cell Ther 2023; 29:327.e1-327.e9. [PMID: 36758832 DOI: 10.1016/j.jtct.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/01/2023] [Accepted: 02/01/2023] [Indexed: 02/10/2023]
Abstract
Post-transplantation cyclophosphamide (PTCy) and calcineurin inhibitor (CNI)-based graft versus host disease (GVHD) prophylaxis has been associated with lower rates of acute and chronic GVHD compared with the traditional prophylaxis of CNI and methotrexate (MTX) in matched related donor (MRD) and matched unrelated donor (MUD) allogeneic hematopoietic cell transplantation (allo-HCT). The combination of PTCy with sirolimus (PTCy-Siro) as CNI-free GVHD prophylaxis has shown promising results, with cumulative rates of grade II-IV acute and chronic GVHD in the range of 15% to 27% and 20% to 27%, respectively, in patients undergoing MRD, MUD, and haploidentical allo-HCT. We report a single-center, nonrandomized comparison of patients undergoing matched donor allo-HCT receiving PTCy-Siro with those receiving the standard GVHD prophylaxis of tacrolimus and methotrexate (Tac-MTX). One hundred and sixteen consecutive patients who had undergone an MRD or MUD allo-HCT between January 2018 and January 2021 and received either PTCy-Siro (n = 29) or Tac-MTX (n = 87) as GVHD prophylaxis regimens were eligible for inclusion. Patients receiving PTCy-Siro had a significantly shorter median time to immunosuppression withdrawal than patients receiving Tac-MTX (138 days [range, 37 to 312 days] versus 232 days [range, 66 to 1120 days]; P < .001). There was no significant difference between the 2 arms in the incidence of grade II-IV acute GVHD, grade III-IV acute GVHD, steroid-refractory acute GVHD, or clinical infections. At a median follow-up of 1.1 years (range, 0 to 1.8 years), patients receiving PTCy-Siro were significantly less likely to have chronic GVHD, with 2-year freedom from GVHD of 75% (95% confidence interval [CI], 58% to 98%) versus 20% (95% CI, 10% to 40%) for those receiving Tac-MTX (P = .005).
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Affiliation(s)
- Madiha Iqbal
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida.
| | | | | | - Zhuo Li
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida
| | - Hemant Murthy
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida
| | - James Foran
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida
| | - Vivek Roy
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida
| | | | - Ernesto Ayala
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, Florida
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17
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Souchet L, Masouridi S, Marçais A, Ibrahim A, Chauvel C, Turquet E, Derail M, Yakoub-Agha I, Crocchiolo R. [Diagnosis, prophylaxis and therapeutic management of acute GVH: Guidelines from the SFGM-TC]. Bull Cancer 2023; 110:S79-S87. [PMID: 36437127 DOI: 10.1016/j.bulcan.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 11/02/2022] [Accepted: 11/02/2022] [Indexed: 11/25/2022]
Abstract
Acute GVHD is a potentially severe complication of hematopoietic stem cell transplantation, responsible for morbidity and mortality that can affect the prognosis after transplantation. Within the framework of the 12th workshop of practice harmonization of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC), diagnostic modalities of acute GVHD are updated. The conventional prevention (depending on donor, conditioning, and stem cell source) and treatment schemes (depending on affected organ and intensity) of aGVHD are clarified, and new therapeutic options are discussed.
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Affiliation(s)
- Laetitia Souchet
- Hôpital Pitié Salpêtrière, Service d'hématologie clinique, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - Stavroula Masouridi
- Hôpitaux universitaires de Genève, Service d'hématologie, 4, rue Gabrielle-Perret-Gentil, 1211 Genève, Suisse
| | - Ambroise Marçais
- Université Paris Cité, Assistance Publique-Hôpitaux de Paris, Service Hématologie Adultes, Hôpital Necker Enfants Malades, Paris, France
| | | | | | - Eric Turquet
- CHU Rennes, Service d'hématologie, Rennes, France
| | | | | | - Roberto Crocchiolo
- Service d'Aphérèse Thérapeutique, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italie
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18
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Huang Z, Yan H, Teng Y, Shi W, Xia L. Lower dose of ATG combined with basiliximab for haploidentical hematopoietic stem cell transplantation is associated with effective control of GVHD and less CMV viremia. Front Immunol 2022; 13:1017850. [PMID: 36458000 PMCID: PMC9705727 DOI: 10.3389/fimmu.2022.1017850] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/31/2022] [Indexed: 09/09/2023] Open
Abstract
Currently, the graft-versus-host disease (GVHD) prophylaxis consists of an immunosuppressive therapy mainly based on antithymocyte globulin (ATG) or post-transplant cyclophosphamide (PTCy). GVHD remains a major complication and limitation to successful allogeneic haploidentical hematopoietic stem cell transplantation (haplo-HSCT). We modified the ATG-based GVHD prophylaxis with the addition of basiliximab in the setting of haplo-HSCT and attempted to explore the appropriate dosages. We conducted a retrospective analysis of 239 patients with intermediate- or high-risk hematologic malignancies who received haplo-HSCT with unmanipulated peripheral blood stem cells combined or not with bone marrow. All patients received the same GVHD prophylaxis consisting of the combination of methotrexate, cyclosporine or tacrolimus, mycofenolate-mofetil, and basiliximab with different doses of ATG (5-9mg/kg). With a median time of 11 days (range, 7-40 days), the rate of neutrophil engraftment was 96.65%. The 100-day cumulative incidences (CIs) of grade II-IV and III-IV aGVHD were 15.8 ± 2.5% and 5.0 ± 1.5%, while the 2-year CIs of total cGVHD and extensive cGVHD were 9.8 ± 2.2% and 4.1 ± 1.5%, respectively. The 3-year CIs of treatment-related mortality (TRM), relapse, overall survival (OS), and disease-free survival (DFS) were 14.6 ± 2.6%, 28.1 ± 3.4%, 60.9 ± 3.4%, 57.3 ± 3.4%, respectively. Furthermore, the impact of the reduction of the ATG dose to 6 mg/kg or less in combination with basiliximab on GVHD prevention and transplant outcomes among patients was analyzed. Compared to higher dose of ATG(>6mg/kg), lower dose of ATG (≤6mg/kg) was associated with a significant reduced risk of CMV viremia (52.38% vs 79.35%, P<0.001), while the incidences of aGVHD and cGVHD were similar between the two dose levels. No significant effect was found with regard to the risk of relapse, TRM, and OS. ATG combined with basiliximab could prevent GVHD efficiently and safely. The optimal scheme of using this combined regimen of ATG and basiliximab is that administration of lower dose ATG (≤6mg/kg), which seems to be more appropriate for balancing infection control and GVHD prophylaxis.
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Affiliation(s)
| | | | | | - Wei Shi
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Linghui Xia
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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19
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Wong JY, Liu A, Han C, Dandapani S, Schultheiss T, Palmer J, Yang D, Somlo G, Salhotra A, Hui S, Al Malki MM, Rosenthal J, Stein A. Total marrow irradiation (TMI): Addressing an unmet need in hematopoietic cell transplantation - a single institution experience review. Front Oncol 2022; 12:1003908. [PMID: 36263219 PMCID: PMC9574324 DOI: 10.3389/fonc.2022.1003908] [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: 07/26/2022] [Accepted: 09/12/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose TMI utilizes IMRT to deliver organ sparing targeted radiotherapy in patients undergoing hematopoietic cell transplantation (HCT). TMI addresses an unmet need, specifically patients with refractory or relapsed (R/R) hematologic malignancies who have poor outcomes with standard HCT regimens and where attempts to improve outcomes by adding or dose escalating TBI are not possible due to increased toxicities. Over 500 patients have received TMI at this center. This review summarizes this experience including planning and delivery, clinical results, and future directions. Methods Patients were treated on prospective allogeneic HCT trials using helical tomographic or VMAT IMRT delivery. Target structures included the bone/marrow only (TMI), or the addition of lymph nodes, and spleen (total marrow and lymphoid irradiation, TMLI). Total dose ranged from 12 to 20 Gy at 1.5-2.0 Gy fractions twice daily. Results Trials demonstrate engraftment in all patients and a low incidence of radiation related toxicities and extramedullary relapses. In R/R acute leukemia TMLI 20 Gy, etoposide, and cyclophosphamide (Cy) results in a 1-year non-relapse mortality (NRM) rate of 6% and 2-year overall survival (OS) of 48%; TMLI 12 Gy added to fludarabine (flu) and melphalan (mel) in older patients (≥ 60 years old) results in a NRM rate of 33% comparable to flu/mel alone, and 5-year OS of 42%; and TMLI 20 Gy/flu/Cy and post-transplant Cy (PTCy) in haplo-identical HCT results in a 2-year NRM rate of 13% and 1-year OS of 83%. In AML in complete remission, TMLI 20 Gy and PTCy results in 2-year NRM, OS, and GVHD free/relapse-free survival (GRFS) rates of 0%, 86·7%, and 59.3%, respectively. Conclusion TMI/TMLI shows significant promise, low NRM rates, the ability to offer myeloablative radiation containing regimens to older patients, the ability to dose escalate, and response and survival rates that compare favorably to published results. Collaboration between radiation oncology and hematology is key to successful implementation. TMI/TMLI represents a paradigm shift from TBI towards novel strategies to integrate a safer and more effective target-specific radiation therapy into HCT conditioning beyond what is possible with TBI and will help expand and redefine the role of radiotherapy in HCT.
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Affiliation(s)
- Jeffrey Y.C. Wong
- Departments of Radiation Oncology, City of Hope, Duarte, CA, United States
| | - An Liu
- Departments of Radiation Oncology, City of Hope, Duarte, CA, United States
| | - Chunhui Han
- Departments of Radiation Oncology, City of Hope, Duarte, CA, United States
| | - Savita Dandapani
- Departments of Radiation Oncology, City of Hope, Duarte, CA, United States
| | | | - Joycelynne Palmer
- Department Computational and Quantitative Medicine, City of Hope, Duarte, CA, United States
| | - Dongyun Yang
- Department Computational and Quantitative Medicine, City of Hope, Duarte, CA, United States
| | - George Somlo
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, United States
| | - Amandeep Salhotra
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, United States
| | - Susanta Hui
- Departments of Radiation Oncology, City of Hope, Duarte, CA, United States
| | - Monzr M. Al Malki
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, United States
| | - Joseph Rosenthal
- Department of Pediatrics, City of Hope, Duarte, CA, United States
| | - Anthony Stein
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, United States
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20
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Brunstein CG, O’Donnell PV, Logan B, Dawson P, Costa L, Cutler C, Craig M, Hogan W, Horowitz MM, Horwitz ME, Karanes C, Magenau JM, Malone A, McCarty J, McGuirk JP, Morris LE, Rezvani AR, Salit R, Vasu S, Eapen M, Fuchs EJ. Impact of Center Experience with Donor Type on Outcomes: A Secondary Analysis, Blood and Marrow Transplant Clinical Trials Network 1101Open for Accrual June 2012Open for Accrual June 2012. Transplant Cell Ther 2022; 28:406.e1-406.e6. [PMID: 35390529 PMCID: PMC9253061 DOI: 10.1016/j.jtct.2022.03.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/14/2022] [Accepted: 03/28/2022] [Indexed: 11/26/2022]
Abstract
We previously reported the results of Blood and Marrow Transplant Clinical Trials Network (BMT CTN) 1101, a randomized comparison of hematopoietic cell transplantation (HCT) performed with double umbilical cord blood units (dUCB) or with haploidentical bone marrow (haplo-BMT) with post-transplantation cyclophosphamide (PTCy) in the nonmyeloablative setting. Those results showed similar progression-free survival in the 2 treatment groups but lower nonrelapse mortality and better overall survival in the haplo-BM arm. In this secondary analysis, we sought to investigate whether transplantation center's previous experience with haplo-BM and/or dUCB HCT had an impact on outcomes. All patients randomized in BMT CTN 1101 were included. Center experience was assigned based on the number of transplantations with each platform performed in the year before initiation of the study according to the Center for International Blood and Marrow Transplant Research. Centers were then classified as a dUCB center (>10 dUCB HCTs; n = 117 patients, 10 centers), a haplo-BM center (>10 haplo-BM HCTs and ≤10 dUCB HCTs; n = 110 patients, 2 centers), or other center (≤10 haplo and ≤10 dUCB HCTs; n = 140 patients, 21 centers). After adjusting for age, Karnofsky Performance Status, and Disease Risk Index, we found that haplo-BM centers had lower overall mortality with this donor type compared with dUCB centers (hazard ratio [HR], 2.56; 95% confidence interval [CI], 1.44 to 4.56). In contrast, there were no differences in overall mortality between haplo-BM and dUCB in centers that were experienced with dUCB HCT (HR, 1.02; 95% CI, .59 to 1.79) or had limited to no experience with either dUCB or haplo-BM HCT (HR, 1.36; 95% CI, .83 to 2.21). The higher risk of treatment failure and overall mortality in dUCB HCT in haplo BM-experienced centers was driven by a significantly higher risk of relapse (HR, 1.78; 95% CI, 1.07 to 2.97). With the exception of worse outcomes among dUCB HCT recipients in haplo-BM centers, transplantation center experience in the year before initiation of BMT CTN 1101 had a limited impact on the outcomes of this randomized clinical trial.
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Affiliation(s)
- Claudio G Brunstein
- Blood and Marrow Transplant Program, University of Minnesota, Mayo Mail Code 480, 420 Delaware Street SE, Minneapolis, MN 55455, United States.
| | | | - Brent Logan
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | | | - Corey Cutler
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | | | - Mary M Horowitz
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | | | | | | | | | | | | | | | - Rachel Salit
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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21
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Lazzari L, Balaguer-Roselló A, Montoro J, Greco R, Hernani R, Lupo-Stanghellini MT, Villalba M, Giglio F, Facal A, Lorentino F, Guerreiro M, Bruno A, Pérez A, Xue E, Clerici D, Piemontese S, Piñana JL, Sanz MÁ, Solano C, de la Rubia J, Ciceri F, Peccatori J, Sanz J. Post-transplant cyclophosphamide and sirolimus based graft-versus-host disease prophylaxis after allogeneic stem cell transplantation for acute myeloid leukemia. Bone Marrow Transplant 2022; 57:1389-1398. [PMID: 35680995 PMCID: PMC9439951 DOI: 10.1038/s41409-022-01725-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/16/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022]
Abstract
Post-transplant cyclophosphamide (PTCy) has emerged as a promising graft-versus-host disease (GvHD) prophylaxis in allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, no studies have reported the efficacy of a GvHD prophylaxis based on PTCy with sirolimus (Sir-PTCy) in patients with acute myeloid leukemia (AML). In this retrospective study, we analyze the use of sirolimus in combination with PTCy, with or without mycophenolate mofetil (MMF), on 242 consecutive adult patients with AML undergoing a myeloablative first allo-HSCT from different donor types, in three European centers between January 2017 and December 2020. Seventy-seven (32%) patients received allo-HSCT from HLA-matched sibling donor, 101 (42%) from HLA-matched and mismatched unrelated donor, and 64 (26%) from haploidentical donor. Except for neutrophil and platelet engraftment, which was slower in the haploidentical cohort, no significant differences were observed in major transplant outcomes according to donor type in univariate and multivariate analysis. GvHD prophylaxis with Sir-PTCy, with or without MMF, is safe and effective in patients with AML undergoing myeloablative allo-HSCT, resulting in low rates of transplant-related mortality, relapse/progression, and acute and chronic GvHD in all donor settings.
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Affiliation(s)
- Lorenzo Lazzari
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy.
| | | | - Juan Montoro
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Rafael Hernani
- Department of Hematology, Hospital Clínico Universitario, Valencia, Spain
| | | | - Marta Villalba
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Fabio Giglio
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ana Facal
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Francesca Lorentino
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Manuel Guerreiro
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Alessandro Bruno
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ariadna Pérez
- Department of Hematology, Hospital Clínico Universitario, Valencia, Spain
| | - Elisabetta Xue
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Daniela Clerici
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Simona Piemontese
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - José Luis Piñana
- Department of Hematology, Hospital Clínico Universitario, Valencia, Spain
| | - Miguel Ángel Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Carlos Solano
- Department of Hematology, Hospital Clínico Universitario, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - Javier de la Rubia
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Jacopo Peccatori
- Hematology and Bone Marrow Transplantation Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Jaime Sanz
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
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22
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Ngo D, Samuels D, Chen J, Koller PB, Al Malki MM. A Clinical Review of the Different Strategies to Minimize Hemorrhagic Cystitis Associated with the Use of Post-Transplant Cyclophosphamide in an Allogeneic Transplant. Transplant Cell Ther 2022; 28:349-354. [PMID: 35580733 DOI: 10.1016/j.jtct.2022.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 12/15/2022]
Abstract
Post-transplantation cyclophosphamide (PTCy) has improved hematopoietic stem cell transplantation outcomes for patients with major HLA disparities. Although PTCy in combination with calcineurin inhibitors is a successful graft-versus-host disease regimen, giving high doses of cyclophosphamide may cause hemorrhagic cystitis (HC). The strategies used to prevent HC are adapted from published data in the pre-transplantation conditioning setting. However, there is no consensus on what the optimal strategy is to prevent PTCy-associated HC. This review provides a summary of the different preventative strategies used in this setting. Based on the results published in current literature, hyperhydration is an effective preventative strategy, but it may cause fluid overload and other complications. Additionally, mesna at least 100% of the PTCy dose should be administered as a continuous infusion or frequent intermittent bolus infusion. More comparative studies between these strategies are needed to provide a definitive solution for preventing HC associated with PTCy.
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Affiliation(s)
- Dat Ngo
- Department of Pharmacy, City of Hope, City of Hope Medical Center, Duarte, California
| | - Diana Samuels
- Department of Pharmacy, City of Hope, City of Hope Medical Center, Duarte, California
| | - Jason Chen
- Department of Pharmacy, City of Hope, City of Hope Medical Center, Duarte, California.
| | - Paul B Koller
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope Medical Center, City of Hope, Duarte, California
| | - Monzr M Al Malki
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope Medical Center, City of Hope, Duarte, California
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23
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Triple post transplant cyclophosphamide (PTCY) based GVHD prophylaxis: HLA matched versus HLA haploidentical transplants. Bone Marrow Transplant 2022; 57:532-537. [DOI: 10.1038/s41409-022-01574-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 12/23/2021] [Accepted: 01/10/2022] [Indexed: 11/08/2022]
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24
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Otoukesh S, Elmariah H, Yang D, Clark MC, Siraj M, Ali H, Mogili K, Arslan S, Nishihori T, Nakamura R, Pidala J, Marcucci G, Forman SJ, Anasetti C, Al Malki MM, Bejanyan N. Cytokine Release Syndrome Following Peripheral Blood Stem Cell Haploidentical Hematopoietic Cell Transplantation with Post-Transplantation Cyclophosphamide. Transplant Cell Ther 2021; 28:111.e1-111.e8. [PMID: 34844022 DOI: 10.1016/j.jtct.2021.11.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/17/2021] [Accepted: 11/21/2021] [Indexed: 10/19/2022]
Abstract
Post-transplantation cyclophosphamide (PTCy) is a safe and efficacious graft-versus-host-disease (GVHD) prophylaxis following hematopoietic cell transplantation (HCT) from a haploidentical (haplo) donor. Cytokine release syndrome (CRS) is a common complication of this platform. Early fever post-haplo-HCT using bone marrow grafts is associated with higher CD3+ cell dose and CRS. However, the impact of CD3+ and CD34+ cell dose on CRS post-haplo-HCT using peripheral blood stem cell (PBSC) grafts is unknown. Our goals were to evaluate the incidence of CRS following PBSC transplantation (PBSCT) and to identify factors that can be modified to prevent the development of severe CRS in this setting. In 271 patients, we investigated factors associated with the development of CRS following haplo-PBSCT and examined the impact of CRS on clinical outcomes. Ninety-three percent of the patients developed CRS of any grade post-haplo-PBSCT. In multivariate analysis, severe CRS (grade 3-4 versus grade 0-1) was associated with higher nonrelapse mortality (hazard ratio [HR], 6.42; 95% confidence interval [CI], 2.68 to 15.39; P < .001), worse 1-year overall survival (HR, 3.40; 95% CI, 1.63 to 7.08; P = .005), and worse disease-free survival (HR, 4.02; 95% CI, 1.99 to 8.08; P < .001). Moderate to severe CRS (grade 2-4) did not impact 1-year relapse or acute GVHD (grade II-IV and III-IV) at 100 days (P = .71 and .19, respectively). Importantly, higher CD3+ cell dose, but not CD34+ cell dose, predicted a higher incidence of grade 2-4 CRS (HR, 1.20; 95% CI,1.07 to 1.36; P = .003) and grade 3-4 CRS (HR, 1.40; 95% CI, 1.05 to 1.86; P = .022). Both older age (HR, 8.57; 95% CI, 1.73 to 42.36; P < .001) and non-total body irradiation-based reduced-intensity conditioning with fludarabine/melphalan (HR, 15.38; 955 CI, 2.06 to 114.67; P < .001) were predictive of grade 3-4 CRS. Overall, we observed that severe CRS (grade 3-4) negatively affected transplantation outcome, and that higher CD3 cell dose was associated with the development of any grade CRS and severe CRS.
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Affiliation(s)
- Salman Otoukesh
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Hany Elmariah
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Dongyun Yang
- Department of Computational and Quantitative Medicine, Division of Biostatistics, City of Hope National Medical Center, Duarte, California
| | - Mary C Clark
- Department of Clinical and Translational Project Development, City of Hope National Medical Center, Duarte, California
| | | | - Haris Ali
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Krishnakar Mogili
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Shukaib Arslan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Taiga Nishihori
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Joseph Pidala
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Guido Marcucci
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Claudio Anasetti
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Monzr M Al Malki
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California.
| | - Nelli Bejanyan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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25
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Greco R, Lorentino F, Albanese S, Lupo Stanghellini MT, Giglio F, Piemontese S, Clerici D, Lazzari L, Marcatti M, Mastaglio S, Xue E, Farina F, Pavesi F, Assanelli A, Carrabba MG, Marktel S, Vago L, Bonini C, Corti C, Bernardi M, Ciceri F, Peccatori J. Posttransplantation Cyclophosphamide- and Sirolimus-Based Graft-Versus-Host-Disease Prophylaxis in Allogeneic Stem Cell Transplant. Transplant Cell Ther 2021; 27:776.e1-776.e13. [PMID: 34087452 DOI: 10.1016/j.jtct.2021.05.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 12/11/2022]
Abstract
Post-transplantation cyclophosphamide (PTCy) has emerged as a promising graft-versus-host-disease (GVHD) prophylaxis in the setting of allogeneic hematopoietic stem cell transplantation (HSCT) from haploidentical donors and more recently in matched donor transplants. Herein, we describe our real-life experience on 249 adult patients undergoing allogeneic HSCT, from HLA-matched related (MRD), HLA-matched unrelated (MUD), or mismatched related donors (MMRD). Patients received unmanipulated peripheral blood stem cells (PBSCs), using a GVHD prophylaxis with PTCy and sirolimus. Mycophenolate mofetil was added in MUD or MMRD. In the HLA-matched donor group (MRD, n = 48, MUD, n = 50), the cumulative incidence of grades II-IV and III-IV acute GvHD was 23% and 9% at 100 days, respectively. The cumulative incidence of chronic GvHD was 25% at 2 years, severe only for 5% of the patients. The cumulative incidences of relapse and transplant-related mortality (TRM) were 31% and 9% at 2 years, respectively. The 2-year overall survival (OS) was 72% and progression-free survival (PFS) 60%; the composite endpoint of GvHD/relapse-free survival (GRFS) was 52% at 2 years. In the haploidentical donor group (n = 151), we documented a cumulative incidence of grades II-IV and III-IV acute GVHD of 35% and 20% at 100 days, respectively, and a cumulative incidence of chronic GvHD of 39% at 2 years. We observed severe chronic GVHD in 15% of the patients. The cumulative incidence of relapse and TRM was 32% and 25% at 2 years, respectively. The 2-year OS was 48%, whereas PFS was 43%; GRFS was 28% at 2 years. However, more patients in the haploidentical group presented high/very high disease risk index (DRI) and higher HCT-comorbidity index. In patients classified in the low-intermediate DRI, 2-year GRFS was 53% in MRD, 65% in MUD, and 46% in haploidentical HSCT (P = .33). Sirolimus-PTCy platform deserves further investigation as an alternative to calcineurin-inhibitor-based GVHD prophylaxis for all donor sources. In patients presenting a low-intermediate DRI, this strategy translates in relevant survival independently from the transplant source.
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Affiliation(s)
- Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Lorentino
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; PhD Program in Public Health, Department of Medicine and Surgery, University of Milano-Bicocca, Italy
| | - Serena Albanese
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | | | - Fabio Giglio
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Simona Piemontese
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Daniela Clerici
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Lazzari
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Magda Marcatti
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Mastaglio
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elisabetta Xue
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Farina
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Pavesi
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Assanelli
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo G Carrabba
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sarah Marktel
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Vago
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Unit of Immunogenetics, Leukemia Genomics and Immunobiology, San Raffaele Scientific Institute, Milano, Italy
| | - Chiara Bonini
- University Vita-Salute San Raffaele, Milan, Italy; Experimental Hematology Unit, San Raffaele Scientific Institute, Milano, Italy
| | - Consuelo Corti
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Bernardi
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy.
| | - Jacopo Peccatori
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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26
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Hernani R, Piñana JL, Pérez A, Quintero A, Montoro J, Hernández‐Boluda JC, Carretero C, Balaguer‐Roselló A, Guerreiro M, Lorenzo I, Aguilar C, Giménez E, Navarro D, Sanz MA, Sanz J, Solano C. Sirolimus versus cyclosporine in haploidentical stem cell transplantation with posttransplant cyclophosphamide and mycophenolate mofetil as graft‐versus‐host disease prophylaxis. EJHAEM 2021; 2:236-248. [PMID: 35845283 PMCID: PMC9175741 DOI: 10.1002/jha2.183] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 11/12/2022]
Abstract
Sirolimus has emerged as an alternative to calcineurin inhibitors‐based (CNI) graft‐versus‐host disease (GVHD) prophylaxis. This retrospective study compares the outcome of 133 consecutive adult patients with haematological malignancies undergoing haploidentical stem cell transplantation with posttransplant cyclophosphamide (PTCy) and mycophenolate mofetil (MMF), combined with cyclosporine A (PTCy–CsA–MMF, n = 67) or sirolimus (PTCy–Sir–MMF, n = 66) as GVHD prophylaxis strategy. The median follow‐up was 48 (range 22–83) and 13 (range 3–33) months, respectively. PTCy–CsA–MMF was associated in multivariate analyses with a higher risk of acute kidney injury (HR 2.1, 95% CI, 1.21–3.57, p = .008) and thrombotic microangiopathy (HR 12.5, 95% CI, 1.66–93.5, p = .014), whereas PTCy–Sir–MMF was associated with a higher risk of hepatic sinusoidal obstruction syndrome (SOS) (HR 10.8, 95% CI, 1.52–77, p = .018), especially late‐onset forms, which totally resolved and none of the patients needed discontinuation of sirolimus. Two SOS‐related deaths were detected, both in the PTCy–CsA–MMF subgroup. Both GVHD prophylaxis strategies were otherwise comparable in terms of engraftment, GVHD incidence and survival.
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Affiliation(s)
- Rafael Hernani
- Department of Haematology Hospital Clínico Universitario Institute for Research INCLIVA Valencia Spain
| | - José Luis Piñana
- Department of Haematology Hospital Universitari i Politècnic La Fe Valencia Spain
- CIBERONC Instituto Carlos III Madrid Spain
| | - Ariadna Pérez
- Department of Haematology Hospital Clínico Universitario Institute for Research INCLIVA Valencia Spain
| | - Abdiel Quintero
- Department of Haematology Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Juan Montoro
- Department of Haematology Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Juan C. Hernández‐Boluda
- Department of Haematology Hospital Clínico Universitario Institute for Research INCLIVA Valencia Spain
- Department of Medicine University of Valencia Valencia Spain
| | - Carlos Carretero
- Department of Haematology Hospital Clínico Universitario Institute for Research INCLIVA Valencia Spain
| | | | - Manuel Guerreiro
- Department of Haematology Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Ignacio Lorenzo
- Department of Haematology Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Cristóbal Aguilar
- Department of Haematology Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Estela Giménez
- Microbiology Service Hospital Clínico Universitario Institute for Research INCLIVA Valencia Spain
| | - David Navarro
- Microbiology Service Hospital Clínico Universitario Institute for Research INCLIVA Valencia Spain
- Department of Microbiology University of Valencia Valencia Spain
| | - Miguel A. Sanz
- Department of Haematology Hospital Universitari i Politècnic La Fe Valencia Spain
- Department of Medicine University of Valencia Valencia Spain
- CIBERONC Instituto Carlos III Madrid Spain
| | - Jaime Sanz
- Department of Haematology Hospital Universitari i Politècnic La Fe Valencia Spain
- Department of Medicine University of Valencia Valencia Spain
- CIBERONC Instituto Carlos III Madrid Spain
| | - Carlos Solano
- Department of Haematology Hospital Clínico Universitario Institute for Research INCLIVA Valencia Spain
- Department of Medicine University of Valencia Valencia Spain
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