1
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Sisinni L, Monserrate GXA, Hurtado JMP, Panesso M, Molina B, Fuentes C, Fuster JL, Verdu-Amoros J, Regueiro A, Palomo P, Beléndez C, Pascual A, Badell I, Mozo Y, Bueno D, Pérez-Martínez A, Fernández JM, Vicent MG, de Heredia CD. Haploidentical versus Cord Blood Transplantation in Pediatric AML. A Retrospective Outcome Analysis on Behalf of the Pediatric Subcommittee of GETH (Grupo Español de Trasplante Hematopoyético). Transplant Cell Ther 2024; 30:1015.e1-1015.e13. [PMID: 39067788 DOI: 10.1016/j.jtct.2024.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 07/18/2024] [Accepted: 07/18/2024] [Indexed: 07/30/2024]
Abstract
Haploidentical stem cell transplantation (Haplo-SCT) and cord blood transplantation (CBT) are both effective alternative treatments in patients suffering from acute myeloid leukemia (AML) and lacking a matched HLA donor. In the last years, many centers have abandoned CBT procedures mostly due to concern about poorer immune recovery compared with Haplo-SCT. We conducted a retrospective multicenter study comparing the outcomes using both alternative approaches in AML. A total of 122 transplants (86 Haplo-SCTs and 36 CBTs) from 12 Spanish centers were collected from 2007 to 2021. Median age at hematopoietic stem cell transplantation (HSCT) was 7 years (0.4-20). Thirty-nine patients (31.9%) showed positive minimal residual disease (MRD) at HSCT and a previous HSCT was performed in 37 patients (30.3%). The median infused cellularity was 14.4 × 106/kg CD34+ cells (6.0-22.07) for Haplo-SCT and 4.74 × 105/kg CD34+ cells (0.8-9.4) for CBT. Median time to neutrophil engraftment was 14 days (7-44) for Haplo-SCT and 17 days (8-29) for CBT (P = .03). The median time to platelet engraftment was 14 days (6-70) for Haplo-SCT and 43 days (10-151) for CBT (P < .001). Graft rejection was observed in 13 Haplo-SCTs (15%) and in 6 CBTs (16%). The cumulative incidence of acute graft versus host disease (GvHD) grades II-IV was 54% and 51% for Haplo-SCT and CBT, respectively (P = .50). The cumulative incidence of severe acute GvHD (grades III-IV) was 22% for Haplo-SCT and 25% for CBT (P = .90). There was a tendency to a higher risk of chronic GvHD in the Haplo-SCT group being the cumulative incidence of 30% for Haplo-SCT and 12% for CBT (P = .09). The cumulative incidence of relapse was 28% and 20% for Haplo-SCT and CBT, respectively (P = .60). We did not observe statistically significant differences in outcome measures between Haplo-SCT and CBT procedures: 5-year overall survival (OS) was 64% versus 57% (P = .50), 5-year disease-free survival (DFS) 58% versus 57% (P = .80), GvHD-free and relapse-free survival (GFRFS) 41% versus 54% (P = .30), and cumulative incidence of transplant-related mortality (TRM) 14% versus 15% (P = .80), respectively. In the multivariate analysis, MRD positivity and a disease status >CR1 at the time of HSCT were significantly associated with poorer outcomes (P < .05). In conclusion, our study supports that both haploidentical and cord blood transplantation show comparable outcomes in pediatric AML patients. We obtained comparable survival rates, although CBT showed a trend to lower rates of chronic GvHD and higher GFRFS, demonstrating that it should still be considered a valuable option, particularly for pediatric patients.
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Affiliation(s)
- Luisa Sisinni
- Hematología y Oncología Pediátrica, Hospital Universitario La Paz, Madrid.
| | | | | | - Melissa Panesso
- Servicio de Oncología y Hematología Pediátrica, Unidad HSCT. Hospital Universitari Vall d'Hebron, Barcelona
| | - Blanca Molina
- Hematología-Oncología Pediátrica, Hospital Niño Jesús, Madrid
| | | | - José Luís Fuster
- Sección de Oncohematología Pediátrica, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB), Murcia
| | - Jaime Verdu-Amoros
- Hematología Pediátrica, Hospital Clínico Universitario; INCLIVA-Biomedical Research Institute, Valencia
| | | | - Pilar Palomo
- Hematología Pediátrica, Hospital Universitario Central de Asturia, Oviedo
| | | | | | - Isabel Badell
- Hematología-Oncología Pediátrica, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Yasmina Mozo
- Hematología y Oncología Pediátrica, Hospital Universitario La Paz, Madrid
| | - David Bueno
- Hematología y Oncología Pediátrica, Hospital Universitario La Paz, Madrid
| | | | | | | | - Cristina Díaz de Heredia
- Servicio de Oncología y Hematología Pediátrica, Unidad HSCT. Hospital Universitari Vall d'Hebron, Barcelona
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2
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Mayani H. Umbilical Cord Blood Hematopoietic Cells: From Biology to Hematopoietic Transplants and Cellular Therapies. Arch Med Res 2024; 55:103042. [PMID: 39003965 DOI: 10.1016/j.arcmed.2024.103042] [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: 03/27/2024] [Revised: 06/13/2024] [Accepted: 07/03/2024] [Indexed: 07/16/2024]
Abstract
Umbilical cord blood (UCB) is a rich source of hematopoietic stem and progenitor cells that are biologically superior to their adult counterparts. UCB cells can be stored for several years without compromising their numbers or function. Today, public and private UCB banks have been established in several countries around the world. After 35 years since the first UCB transplant (UCBT), more than 50,000 UCBTs have been performed worldwide. In pediatric patients, UCBT is comparable to or superior to bone marrow transplantation. In adult patients, UCB can be an alternative source of hematopoietic cells when an HLA-matched unrelated adult donor is not available and when a transplant is urgently needed. Delayed engraftment (due to reduced absolute numbers of hematopoietic cells) and higher costs have led many medical institutions not to consider UCB as a first-line cell source for hematopoietic transplants. As a result, the use of UCB as a source of hematopoietic stem and progenitor cells for transplantation has declined over the past decade. Several approaches are being investigated to make UCBTs more efficient, including improving the homing capabilities of primitive UCB cells and increasing the number of hematopoietic cells to be infused. Several of these approaches have already been applied in the clinic with promising results. UCB also contains immune effector cells, including monocytes and various lymphocyte subsets, which, together with stem and progenitor cells, are excellent candidates for the development of cellular therapies for hematological and non-hematological diseases.
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Affiliation(s)
- Hector Mayani
- Oncology Research Unit, National Medical Center, Mexican Institute of Social Security, Mexico City, Mexico.
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3
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Takahashi T, Lake AJ, Wachter F, Calderon FA, Dandoy C, Keating AK. Effects of Total Body Irradiation on Hematopoietic Cell Transplantation Outcomes in Pediatric Acute Myeloid Leukemia with Prior Central Nervous System Involvement. Transplant Cell Ther 2024; 30:812.e1-812.e11. [PMID: 38763417 DOI: 10.1016/j.jtct.2024.05.014] [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: 03/28/2024] [Revised: 05/02/2024] [Accepted: 05/13/2024] [Indexed: 05/21/2024]
Abstract
The implications of previous central nervous system (CNS) involvement in children with acute myeloid leukemia (AML) undergoing hematopoietic cell transplantation (HCT) remain inadequately understood. Patients with CNS disease require more upfront CNS-directed intrathecal therapy, but little is known about whether transplant conditioning regimens should be intensified or if previous CNS involvement impacts post-HCT outcomes. While total body irradiation (TBI) remains standard for pediatric acute lymphoblastic leukemia myeloablative conditioning, it has been largely replaced with chemotherapy-only myeloablation in pediatric AML, primarily due to toxicity and late effects associated with TBI. In the setting of previous CNS involvement, it has been suggested that TBI-based myeloablation may have advantages due to superior CNS tissue penetration and thus decreased rates of AML relapse post-HCT. We analyzed a publicly available dataset derived from the Center for International Blood and Marrow Transplantation Research (CIBMTR) registry to characterize the impact of TBI in HCT preparative regimens in pediatric AML patients with a history of CNS involvement. The study dataset was obtained from the CIBMTR data repository. The study cohort included patients aged ≤21 years who underwent initial allogeneic HCT with myeloablative conditioning for de novo AML in the first or second complete remission (CR) between 2008 and 2016, who provided consent for research. Patients with mismatched related donor transplants and noncalcineurin inhibitor graft-versus-host disease (GVHD) prophylaxis were excluded. The dataset was further modified by excluding patients with missing disease site data or those with non-CNS extramedullary disease. Patients were categorized as CNS-positive or -negative AML (AML-CNS(+) and AML-CNS(-), respectively) based on the disease status at diagnosis. The Cox regression model and Fine-Grey methods were employed to delineate the effects of TBI and CNS disease on key HCT outcomes. The study cohort comprised 550 pediatric AML patients, of which 25% (n = 136) were AML-CNS(+). CNS involvement was more prevalent in patients aged 0 to 3 years, patients who were in the second CR, and those with a mismatched unrelated donor or umbilical cord blood. AML-CNS(+) patients demonstrated a lower relapse rate (hazard ratio: 0.50, 95% confidence interval: 0.33 to 0.76) compared to AML-CNS(-) patients, with comparable disease-free survival (DFS) and overall survival (OS) (P = .10 and 0.20, respectively) in the two cohorts. The entire TBI-treated cohort showed an association with increased risks of grade 2 to 4 acute GVHD, bloodstream infections, and endocrine dysfunction. TBI use within the AML-CNS(+) cohort was associated with a lower relapse rate but increased risks of nonrelapse mortality and a trend of higher grade 3 to 4 acute GVHD. In this population-based analysis of pediatric patients with de novo AML undergoing HCT, TBI-based conditioning regimens did not confer an advantage in DFS or OS compared to non-TBI regimens, irrespective of CNS disease status. However, TBI use was associated with increased risks of short- and long-term comorbidities. These findings underscore the need for careful consideration of TBI in pediatric AML.
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Affiliation(s)
- Takuto Takahashi
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Alexander J Lake
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Franziska Wachter
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Francesca Alvarez Calderon
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Christopher Dandoy
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amy K Keating
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
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4
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Graff Z, Wachter F, Eapen M, Lehmann L, Cooper T. Navigating Treatment Options and Communication in Relapsed Pediatric AML. Am Soc Clin Oncol Educ Book 2024; 44:e438690. [PMID: 38862135 DOI: 10.1200/edbk_438690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
Despite improved outcomes in newly diagnosed pediatric AML, relapsed disease remains a therapeutic challenge. Factors contributing to slow progress in improving outcomes include inherent challenges in pediatric clinical trial accrual and the scarcity of novel targeted/immunotherapy agents available for pediatric development. This paradigm is changing, however, as international collaboration grows in parallel with the development of promising targeted agents. In this review, we discuss the therapeutic landscape of relapsed pediatric AML, including conventional chemotherapy, targeted therapies, and the challenges of drug approvals in this patient population. We highlight current efforts to improve communication among academia, industry, and regulatory authorities and discuss the importance of international collaboration to improve access to new therapies. Among the therapeutic options, we highlight the approach to second hematopoietic stem cell transplant (HSCT) and discuss which patients are most likely to benefit from this potentially curative intervention. Importantly, we acknowledge the challenges in providing these high-risk interventions to our patients and their families and the importance of shared communication and decision making when considering early-phase clinical trials and second HSCT.
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Affiliation(s)
- Zachary Graff
- Department of Pediatrics, Division of Hematology, Oncology, and BMT, Medical College of Wisconsin, Milwaukee, WI
| | - Franziska Wachter
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Mary Eapen
- Department of Medicine, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Leslie Lehmann
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Todd Cooper
- Department of Pediatrics, Division of Hematology and Oncology, Seattle Children's Hospital, Seattle, WA
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5
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Kinsella FAM, Maroto MAL, Loke J, Craddock C. Strategies to reduce relapse risk in patients undergoing allogeneic stem cell transplantation for acute myeloid leukaemia. Br J Haematol 2024; 204:2173-2183. [PMID: 38602216 DOI: 10.1111/bjh.19463] [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: 12/21/2023] [Revised: 03/11/2024] [Accepted: 04/02/2024] [Indexed: 04/12/2024]
Abstract
Allogeneic stem cell transplantation is a centrally important curative strategy in adults with acute myeloid leukaemia; however, relapse occurs in a significant proportion of patients and remains the leading cause of treatment failure. The prognosis for patients who relapse post-transplant remains poor, and the development of new strategies with the ability to reduce disease recurrence without increasing transplant toxicity remains a priority. In this review, within the context of our understanding of disease biology and the graft-versus-leukaemia (GVL) effect, we will discuss established, evolving and novel approaches for increasing remission rates, decreasing measurable residual disease pretransplant, future methods to augment the GVL effect and the opportunities for post-transplant maintenance. Future progress depends upon the development of innovative trials and networks, which will ensure the rapid assessment of emerging therapies in prospective clinical trials.
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Affiliation(s)
- Francesca A M Kinsella
- Centre for Clinical Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Maria A L Maroto
- Centre for Clinical Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Justin Loke
- Centre for Clinical Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Charles Craddock
- Centre for Clinical Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Clinical Trials Unit, University of Warwick, Warwick, UK
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6
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Belbachir S, Abraham A, Sharma A, Prockop S, DeZern AE, Bonfim C, Bidgoli A, Li J, Ruggeri A, Bertaina A, Boelens JJ, Purtill D. Engineering the best transplant outcome for high-risk acute myeloid leukemia: the donor, the graft and beyond. Cytotherapy 2024; 26:546-555. [PMID: 38054912 DOI: 10.1016/j.jcyt.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 12/07/2023]
Abstract
Allogeneic hemopoietic cell transplantation remains the goal of therapy for high-risk acute myeloid leukemia (AML). However, treatment failure in the form of leukemia relapse or severe graft-versus-host disease remains a critical area of unmet need. Recently, significant progress has been made in the cell therapy-based interventions both before and after transplant. In this review, the Stem Cell Engineering Committee of the International Society for Cell and Gene Therapy summarizes the literature regarding the identification of high risk in AML, treatment approaches before transplant, optimal transplant platforms and measures that may be taken after transplant to ideally prevent, or, if need be, treat AML relapse. Although some strategies remain in the early phases of clinical investigation, they are built on progress in pre-clinical research and cellular engineering techniques that are already improving outcomes for children and adults with high-risk malignancies.
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Affiliation(s)
- Safia Belbachir
- Haematology Department, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Allistair Abraham
- Center for Cancer and Immunology Research, CETI, Children's National Hospital, Washington, District of Columbia, USA
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Susan Prockop
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts USA
| | - Amy E DeZern
- Bone Marrow Failure and MDS Program, John Hopkins Medicine, Baltimore, Maryland, USA
| | - Carmem Bonfim
- Pediatric Blood and Marrow Transplantation Division/Instituto de Pesquisa Pele Pequeno Principe Research/Faculdades Pequeno Príncipe, Curitiba, Brazil
| | - Alan Bidgoli
- Division of Blood and Marrow Transplantation, Children's Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, Georgia, USA
| | - Jinjing Li
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, New South Wales, Australia
| | | | - Alice Bertaina
- Division of Hematology, Oncology, Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Jaap Jan Boelens
- Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, and Department of Pediatrics, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Duncan Purtill
- Haematology Department, Fiona Stanley Hospital, Perth, Western Australia, Australia; PathWest Laboratory Medicine, Perth, Western Australia, Australia.
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7
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Hammami MB, Verceles JA, Goldfinger M, Shah N, Sica RA, Mantzaris I, Kornblum N, Konopleva M, Shastri A, Shapiro LC, Feldman EJ, Gritsman K, Verma A, Cooper DL. Improving Unrelated Donor Equity: Assessing Mismatched Donor Opportunities with Real-World Data in a Minority-Predominant Cohort. Transplant Cell Ther 2024; 30:544.e1-544.e8. [PMID: 38417677 DOI: 10.1016/j.jtct.2024.02.020] [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: 12/31/2023] [Revised: 02/15/2024] [Accepted: 02/21/2024] [Indexed: 03/01/2024]
Abstract
Recent advances in graft-versus-host disease (GVHD) prophylaxis including post-transplant cyclophosphamide (PTCy) and abatacept have significantly improved outcomes following HLA-mismatched allogenic hematopoietic stem cell transplantation (allo-HSCT) and have tremendous potential for reducing racial disparities in donor availability. A recent small study employing bone marrow as the source of stem cells showed similar outcomes after 5/8 versus 7/8 matches and is currently being tested in a larger study using peripheral blood stem cells. In this study, we examine real-world alternative donor HSCT options for a minority-predominant cohort in the Bronx, NY, focusing on the availability of lesser-matched (5/8 to 7/8) donors. Records of patients who underwent HLA typing at Montefiore Medical Center (2019 to 2022) were reviewed. The National Marrow Donor Program registry was queried to evaluate the availability of donors with at least 99% likelihood of HLA match at various levels (5/8, 6/8, 7/8, 8/8). Two hundred forty-one patients were included, 70% were non-White. Although the availability of ≥7/8 donors was less common in non-White patients, 100% of patients from each group had at least one or more 5/8 and 6/8 HLA-matched donors and more than 80% of these patients had >100 potential 5/8 and 6/8 HLA-matched donors. There was no statistical difference by race or ethnicity in the mean number of donors at 5/8 and 6/8 HLA-match levels. We demonstrate through real-world data that patients from diverse ethnic and racial backgrounds have access to 5/8 and 6/8 HLA-matched donors for allo-HSCT, potentially eliminating disparities in donor availability and allowing prioritization of other donor selection characteristics such as donor age, sex, ABO, and B leader matching. Further work is needed to study whether the use of mismatched donors offers a more potent graft-versus malignancy effect and optimal GVHD prophylaxis.
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Affiliation(s)
- M Bakri Hammami
- Department of Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Jhannine Alyssa Verceles
- Department of Hematology-Oncology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Mendel Goldfinger
- Department of Hematology-Oncology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Nishi Shah
- Department of Hematology-Oncology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - R Alejandro Sica
- Department of Hematology-Oncology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Ioannis Mantzaris
- Department of Hematology-Oncology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Noah Kornblum
- Department of Hematology-Oncology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Marina Konopleva
- Department of Hematology-Oncology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Aditi Shastri
- Department of Hematology-Oncology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Lauren C Shapiro
- Department of Hematology-Oncology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Eric J Feldman
- Department of Hematology-Oncology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Kira Gritsman
- Department of Hematology-Oncology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Amit Verma
- Department of Hematology-Oncology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Dennis L Cooper
- Department of Hematology-Oncology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York.
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8
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Horgan C, Bitetti S, Newbould M, Sethuraman C, Fagbemi A, Kala A, Williams N, Wynn R. Non-Graft-versus-Host Disease Enterocolitis Following Cord Blood Transplantation is Real, with Poorly Understood Pathophysiology, and Requires Distinct Management, with Eventual Resolution without Immune Suppression. Transplant Cell Ther 2024; 30:440.e1-440.e9. [PMID: 38052367 DOI: 10.1016/j.jtct.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 11/14/2023] [Accepted: 11/28/2023] [Indexed: 12/07/2023]
Abstract
Enterocolitis is common after cord blood transplantation (CBT) and a specific, non-graft-versus-host disease (GVHD) entity with specific histopathologic features ("cord colitis") has been described in some cases in selected series. Immune suppression is not without risk, and we have used it only when biopsy features are consistent with classical GVHD. In the absence of biopsy features of classical GVHD, our management of intestinal failure has been supportive, and we have withdrawn immune suppression to allow immune reconstitution and better prevent relapse of malignant disease and reduce infectious complications. We evaluated our approach over an 11-year period in a retrospective study of all patients at our large pediatric CBT center who experienced intestinal failure necessitating endoscopy and biopsy in the post-CBT period. We conducted a blinded histopathologic review of gastrointestinal (GI) biopsy specimens from all patients who had undergone GI endoscopy for intestinal failure in the post-CBT period. Patient records were evaluated to determine clinical HSCT course and outcome data, including mortality, relapse, and infection, as well as the duration of immune suppression and parenteral nutrition. Out of 144 patients who underwent CBT during the study period, 25 (17%) experienced intestinal failure requiring endoscopy. Thirteen patients were diagnosed with acute GVHD after blinded review of biopsy specimens, and 12 patients had non-GVHD enterocolitis. Management in the absence of GVHD on GI biopsy is supportive, with withdrawal of immune suppression in patients with malignant disease and continuing in accordance with institutional practice in those with nonmalignant disease. Compared with the GVHD cohort, the non-GVHD enterocolitis cohort had superior overall survival (91% versus 41%; P = .04) and a shorter duration of immune suppression (mean, 112 days versus 180 days; P = .049), reflecting these different management approaches. These results demonstrate that different histopathologic findings in those with intestinal failure after CBT likely indicates a different etiology from GVHD and mandates a different clinical management strategy to achieve optimal clinical outcomes.
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Affiliation(s)
- Claire Horgan
- Department of Paediatric Bone Marrow Transplant and Cellular Therapy, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Stefania Bitetti
- Department of Paediatric Histopathology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Melanie Newbould
- Department of Paediatric Histopathology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Chitra Sethuraman
- Department of Paediatric Histopathology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Andrew Fagbemi
- Department of Paediatric Gastroenterology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Adnan Kala
- Department of Paediatric Gastroenterology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Nicola Williams
- Department of Paediatric Bone Marrow Transplant and Cellular Therapy, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Robert Wynn
- Department of Paediatric Bone Marrow Transplant and Cellular Therapy, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom.
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9
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Cohen S, Bambace N, Ahmad I, Roy J, Tang X, Zhang MJ, Burns L, Barabé F, Bernard L, Delisle JS, Kiss T, Lachance S, Roy DC, Veilleux O, Sauvageau G. Improved outcomes of UM171-expanded cord blood transplantation compared with other graft sources: real-world evidence. Blood Adv 2023; 7:5717-5726. [PMID: 37467030 PMCID: PMC10539875 DOI: 10.1182/bloodadvances.2023010599] [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: 05/01/2023] [Revised: 06/14/2023] [Accepted: 06/22/2023] [Indexed: 07/20/2023] Open
Abstract
Cord blood (CB) transplantation is hampered by low cell dose and high nonrelapse mortality (NRM). A phase 1-2 trial of UM171-expanded CB transplants demonstrated safety and favorable preliminary efficacy. The aim of the current analysis was to retrospectively compare results of the phase 1-2 trial with those after unmanipulated CB and matched-unrelated donor (MUD) transplants. Data from recipients of CB and MUD transplants were obtained from the Center for International Blood and Marrow Transplant Research (CIBMTR) database. Patients were directly matched for the number of previous allogeneic hematopoietic stem cell transplants (alloHCT), disease and refined Disease Risk Index. Patients were further matched by propensity score for age, comorbidity index, and performance status. Primary end points included NRM, progression-free survival (PFS), overall survival (OS), and graft-versus-host disease (GVHD)-free relapse-free survival (GRFS) at 1 and 2 years after alloHCT. Overall, 137 patients from CIBMTR (67 CB, 70 MUD) and 22 with UM171-expanded CB were included. NRM at 1 and 2 years was lower, PFS and GRFS at 2 years and OS at 1 year were improved for UM171-expanded CBs compared with CB controls. Compared with MUD controls, UM171 recipients had lower 1- and 2-year NRM, higher 2-year PFS, and higher 1- and 2-year GRFS. Furthermore, UM171-expanded CB recipients experienced less grades 3-4 acute GVHD and chronic GVHD compared with MUD graft recipients. Compared with real-world evidence with CB and MUD alloHCT, this study suggests that UM171-expanded CB recipients may benefit from lower NRM and higher GRFS. This trial was registered at www.clinicaltrials.gov as #NCT02668315.
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Affiliation(s)
- Sandra Cohen
- Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, CIUSSS de l’Est de l’Île de Montréal, Montréal, QC, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Nadia Bambace
- Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, CIUSSS de l’Est de l’Île de Montréal, Montréal, QC, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Imran Ahmad
- Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, CIUSSS de l’Est de l’Île de Montréal, Montréal, QC, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Jean Roy
- Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, CIUSSS de l’Est de l’Île de Montréal, Montréal, QC, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Xiaoying Tang
- Center for International Blood and Marrow Transplant Research, Milwaukee, WI
| | - Mei-Jie Zhang
- Center for International Blood and Marrow Transplant Research, Milwaukee, WI
| | - Linda Burns
- Center for International Blood and Marrow Transplant Research, Milwaukee, WI
| | - Frédéric Barabé
- Centre Hospitalier Universitaire de Québec, Université Laval, Québec, QC, Canada
| | - Léa Bernard
- Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, CIUSSS de l’Est de l’Île de Montréal, Montréal, QC, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Jean-Sébastien Delisle
- Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, CIUSSS de l’Est de l’Île de Montréal, Montréal, QC, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Thomas Kiss
- Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, CIUSSS de l’Est de l’Île de Montréal, Montréal, QC, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Silvy Lachance
- Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, CIUSSS de l’Est de l’Île de Montréal, Montréal, QC, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Denis-Claude Roy
- Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, CIUSSS de l’Est de l’Île de Montréal, Montréal, QC, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Olivier Veilleux
- Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, CIUSSS de l’Est de l’Île de Montréal, Montréal, QC, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Guy Sauvageau
- Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, CIUSSS de l’Est de l’Île de Montréal, Montréal, QC, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Institut de Recherche en Immunologie et Cancérologie, Université de Montréal, Montréal, QC, Canada
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10
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Borrill R, Poulton K, Wynn R. Immunology of cord blood T-cells favors augmented disease response during clinical pediatric stem cell transplantation for acute leukemia. Front Pediatr 2023; 11:1232281. [PMID: 37780051 PMCID: PMC10534014 DOI: 10.3389/fped.2023.1232281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/22/2023] [Indexed: 10/03/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) has been an important and efficacious treatment for acute leukemia in children for over 60 years. It works primarily through the graft-vs.-leukemia (GVL) effect, in which donor T-cells and other immune cells act to eliminate residual leukemia. Cord blood is an alternative source of stem cells for transplantation, with distinct biological and immunological characteristics. Retrospective clinical studies report superior relapse rates with cord blood transplantation (CBT), when compared to other stem cell sources, particularly for patients with high-risk leukemia. Xenograft models also support the superiority of cord blood T-cells in eradicating malignancy, when compared to those derived from peripheral blood. Conversely, CBT has historically been associated with an increased risk of transplant-related mortality (TRM) and morbidity, particularly from infection. Here we discuss clinical aspects of CBT, the unique immunology of cord blood T-cells, their role in the GVL effect and future methods to maximize their utility in cellular therapies for leukemia, honing and harnessing their antitumor properties whilst managing the risks of TRM.
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Affiliation(s)
- Roisin Borrill
- Blood and Marrow Transplant Unit, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, School of Biological Sciences, Lydia Becker Institute of Immunology and Inflammation, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Kay Poulton
- Transplantation Laboratory, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Robert Wynn
- Blood and Marrow Transplant Unit, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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11
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Prockop S, Wachter F. The current landscape: Allogeneic hematopoietic stem cell transplant for acute lymphoblastic leukemia. Best Pract Res Clin Haematol 2023; 36:101485. [PMID: 37611999 DOI: 10.1016/j.beha.2023.101485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 05/31/2023] [Indexed: 08/25/2023]
Abstract
One of the consistent features in development of hematopoietic stem cell transplant (HCT) for Acute Lymphoblastic Leukemia (ALL) is the rapidity with which discoveries in the laboratory are translated into innovations in clinical care. Just a few years after murine studies demonstrated that rescue from radiation induced marrow failure is mediated by cellular not humoral factors, E. Donnall Thomas reported on the transfer of bone marrow cells into irradiated leukemia patients. This was followed quickly by the first descriptions of Graft versus Leukemia (GvL) effect and Graft versus Host Disease (GvHD). Despite the pivotal nature of these findings, early human transplants were uniformly unsuccessful and identified the challenges that continue to thwart transplanters today - leukemic relapse, regimen related toxicity, and GvHD. While originally only an option for young, fit patients with a matched family donor, expansion of the donor pool to include unrelated donors, umbilical cord blood units, and more recently the growing use of haploidentical donors have all made transplant a more accessible therapy for patients with ALL. Novel agents for conditioning, prevention and treatment of GvHD have improved outcomes and investigators continue to develop novel treatment strategies that balance regimen related toxicity with disease control. Our evolving understanding of how to prevent and treat GvHD and how to prevent relapse are incorporated into novel clinical trials that are expected to further improve outcomes. Here we review current considerations and future directions for both adult and pediatric patients undergoing HCT for ALL, including indication for transplant, donor selection, cytoreductive regimens, and outcomes.
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Affiliation(s)
- Susan Prockop
- Pediatric Stem Cell Transplant Program, DFCI/BCH Center for Cancer and Blood Disorders, Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States.
| | - Franziska Wachter
- Pediatric Stem Cell Transplant Program, DFCI/BCH Center for Cancer and Blood Disorders, Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States.
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12
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Troullioud Lucas AG, Boelens JJ, Prockop SE, Curran KJ, Bresters D, Kollen W, Versluys B, Bierings MB, Archer A, Davis E, Klein E, Kernan NA, Lindemans CA, Scaradavou A. Excellent leukemia control after second hematopoietic cell transplants with unrelated cord blood grafts for post-transplant relapse in pediatric patients. Front Oncol 2023; 13:1221782. [PMID: 37649924 PMCID: PMC10465242 DOI: 10.3389/fonc.2023.1221782] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/24/2023] [Indexed: 09/01/2023] Open
Abstract
Background Patients with leukemia relapse after allogeneic hematopoietic cell transplant (HCT) have poor survival due to toxicity and disease progression. A second HCT often offers the only curative treatment. Methods We retrospectively reviewed our bi-institutional experience (MSKCC-USA; Utrecht-NL) with unrelated cord blood transplantation (CBT) for treatment of post-transplant relapse. Overall survival (OS) and event-free survival (EFS) were evaluated using the Kaplan-Meier method, treatment-related mortality (TRM) and relapse were evaluated using the competing risk method by Fine-Gray. Results Twenty-six patients age < 21 years received a second (n=24) or third (n=2) HCT with CB grafts during the period 2009-2021. Median age at first HCT (HCT1) was 11.5 (range: 0.9-17.7) years and all patients received myeloablative cytoreduction. Median time from HCT1 to relapse was 12.8 (range 5.5-189) months. At CBT, median patient age was 13.5 (range 1.4-19.1) years. Diagnoses were AML: 13; ALL: 4, MDS: 5, JMML: 2; CML: 1; mixed phenotype acute leukemia: 1. Sixteen patients (62%) were in advanced stage, either CR>2 or with active disease. Median time from HCT1 to CBT was 22.2 (range 7-63.2) months. All patients engrafted after CBT. Thirteen patients developed acute GvHD; 7 had grade III or IV. With a median survivor follow-up of 46.6 (range 17.4-155) months, 3-year OS was 69.2% (95% CI 53.6-89.5%) and 3-year EFS was 64.9% (95% CI 48.8-86.4%). Eight patients died, 3 of AML relapse and 5 due to toxicity (respiratory failure [n=4], GvHD [n=1]) at a median time of 7.7 (range 5.9-14.4) months after CBT. Cumulative incidence of TRM at 3 years was 19.2% (95% CI 4.1-34.4%). Notably, all TRM events occurred in patients transplanted up to 2015; no toxicity-related deaths were seen in the 16 patients who received CBT after 2015. Cumulative incidence of relapse was 15.9% (95% CI 1.6-30.2%) at 3 years, remarkably low for these very high-risk patients. Conclusions Survival was very encouraging following CB transplants in pediatric patients with recurrent leukemia after first HCT, and TRM has been low over the last decade. CBT needs to be strongly considered as a relatively safe salvage therapy option for post-transplant relapse.
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Affiliation(s)
- Alexandre G. Troullioud Lucas
- Department of Pediatrics, Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States
| | - Jaap Jan Boelens
- Department of Pediatrics, Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States
| | - Susan E. Prockop
- Dana Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, United States
| | - Kevin J. Curran
- Department of Pediatrics, Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States
| | - Dorine Bresters
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Division of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Wouter Kollen
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Division of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Birgitta Versluys
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Division of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Marc B. Bierings
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Division of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Anne Archer
- Department of Pediatrics, Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Eric Davis
- Department of Pediatrics, Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Elizabeth Klein
- Department of Pediatrics, Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Nancy A. Kernan
- Department of Pediatrics, Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States
| | - Caroline A. Lindemans
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Division of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Andromachi Scaradavou
- Department of Pediatrics, Transplantation and Cellular Therapies Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States
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13
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Borrill R, Poulton K, Kusyk L, Routledge A, Bonney D, Hanasoge-Nataraj R, Powys M, Mustafa O, Campbell H, Senthil S, Dillon R, Jovanovic J, Morton S, James B, Rao K, Stanworth S, Konkel J, Wynn R. Granulocyte transfusion during cord blood transplant for relapsed, refractory AML is associated with massive CD8 + T-cell expansion, significant cytokine release syndrome and induction of disease remission. Br J Haematol 2023; 202:589-598. [PMID: 37211883 DOI: 10.1111/bjh.18863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/03/2023] [Accepted: 05/03/2023] [Indexed: 05/23/2023]
Abstract
In high-risk myeloid malignancy, relapse is reduced using cord blood transplant (CBT) but remains the principal cause of treatment failure. We previously described T-cell expansion in CBT recipients receiving granulocyte transfusions. We now report the safety and tolerability of such transfusions, T-cell expansion data, immunophenotype, cytokine profiles and clinical response in children with post-transplant relapsed acute leukaemia who received T-replete, HLA-mismatched CBT and pooled granulocytes within a phase I/II trial (ClinicalTrials.Gov NCT05425043). All patients received the transfusion schedule without significant clinical toxicity. Nine of ten patients treated had detectable measurable residual disease (MRD) pre-transplant. Nine patients achieved haematological remission, and eight became MRD negative. There were five deaths: transplant complications (n = 2), disease (n = 3), including two late relapses. Five patients are alive and in remission with 12.7 months median follow up. Significant T-cell expansion occurred in nine patients with a greater median lymphocyte count than a historical cohort between days 7-13 (median 1.73 × 109 /L vs. 0.1 × 109 /L; p < 0.0001). Expanded T-cells were predominantly CD8+ and effector memory or TEMRA phenotype. They exhibited markers of activation and cytotoxicity with interferon-gamma production. All patients developed grade 1-3 cytokine release syndrome (CRS) with elevated serum IL-6 and interferon-gamma.
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Affiliation(s)
- Roisin Borrill
- Blood and Marrow Transplant Unit, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Lydia Becker Institute of Immunology and Inflammation, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Kay Poulton
- Transplantation Laboratory, Manchester University NHS Foundation Trust, Manchester, UK
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Laura Kusyk
- Blood and Marrow Transplant Unit, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Amy Routledge
- Blood and Marrow Transplant Unit, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Denise Bonney
- Blood and Marrow Transplant Unit, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Ramya Hanasoge-Nataraj
- Blood and Marrow Transplant Unit, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Madeleine Powys
- Blood and Marrow Transplant Unit, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Omima Mustafa
- Blood and Marrow Transplant Unit, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Helen Campbell
- Blood and Marrow Transplant Unit, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Srividhya Senthil
- Blood and Marrow Transplant Unit, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Richard Dillon
- Department of Medical and Molecular Genetics, Kings College London, London, UK
| | - Jelena Jovanovic
- Department of Medical and Molecular Genetics, Kings College London, London, UK
| | | | - Beki James
- Leeds Children's Hospital, Leeds General Infirmary, Leeds, UK
| | - Kanchan Rao
- Department of Blood and Marrow Transplantation, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Joanne Konkel
- Lydia Becker Institute of Immunology and Inflammation, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Robert Wynn
- Blood and Marrow Transplant Unit, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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14
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Affiliation(s)
- James L LaBelle
- Department of Pediatrics, Section of Hematology and Oncology, University of Chicago, Chicago, IL
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