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Mohty R, Al Kadhimi Z, Kharfan-Dabaja M. Post-transplant cyclophosphamide or cell selection in haploidentical allogeneic hematopoietic cell transplantation? Hematology 2024; 29:2326384. [PMID: 38597828 DOI: 10.1080/16078454.2024.2326384] [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: 12/19/2023] [Accepted: 02/28/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND One major limitation for broader applicability of allogeneic hematopoietic cell transplantation (allo-HCT) in the past was the lack of HLA-matched histocompatible donors. Preclinical mouse studies using T-cell depleted haploidentical grafts led to an increased interest in the use of ex vivo T-cell depleted (TCD) haploidentical allo-HCT. TCD grafts through negative (T-cell depletion) or positive (CD34+ cell selection) techniques have been investigated to reduce the risk of graft-versus-host disease (GVHD) given the known implications of alloreactive T cells. A more practical approach to deplete alloreactive T cells in vivo using high doses of cyclophosphamide after allografting has proved to be feasible in overcoming the HLA barrier. Such approach has extended allo-HCT feasibility to patients for whom donors could not be found in the past. Nowadays, haploidentical donors represent a common donor source for patients in need of an allo-HCT. The broad application of haploidentical donors became possible by understanding the importance of depleting alloreactive donor T cells to facilitate engraftment and reduce incidence and severity of GVHD. These techniques involve ex vivo graft manipulation or in vivo utilization of pharmacologic agents, notably post-transplant cyclophosphamide (PTCy). DISCUSSION While acknowledging that no randomized controlled prospective studies have been yet conducted comparing TCD versus PTCy in haploidentical allo-HCT recipients, there are two advantages that would favor the PTCy, namely ease of application and lower cost. However, emerging data on adverse events associated with PTCy including, but not limited to cardiac associated toxicities or increased incidence of post-allograft infections, and others, are important to recognize.
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Affiliation(s)
- Razan Mohty
- Division of Hematology Oncology, Department of Medicine, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Zaid Al Kadhimi
- Division of Hematology Oncology, Department of Medicine, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Mohamed Kharfan-Dabaja
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
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2
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Mehta RS, Petersdorf EW, Wang T, Lee SJ. Haploidentical Versus Mismatched Unrelated Donor Hematopoietic Cell Transplantation: HLA Factors and Donor Age Considerations. Transplant Cell Ther 2024; 30:909.e1-909.e11. [PMID: 38992469 DOI: 10.1016/j.jtct.2024.07.005] [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: 05/25/2024] [Revised: 06/30/2024] [Accepted: 07/03/2024] [Indexed: 07/13/2024]
Abstract
HLA-mismatched unrelated donors and haploidentical related donors are suitable stem cell sources for hematopoietic cell transplantation (HCT) when patients lack HLA-matched donors. Clinical outcome after mismatched HCT is influenced by HLA factors including the similarity of peptide-binding motifs (PBMs) between the patient and unrelated donor, and of the HLA-B leader in unrelated and haploidentical donors. Whether these factors can aid in the selection between mismatched unrelated and haploidentical donors is not known. To address this question, we investigated outcomes between the two donor types defined by matching for the PBM and leader peptide. We compared PBM-matched (n = 614) and mismatched (n = 958) MMUDs with calcineurin-inhibitor-based prophylaxis to four haploidentical groups that received post-transplant cyclophosphamide (PTCy)-based prophylaxis. The haploidentical groups were B-leader matched/DRB1-mismatched (n = 722), B-leader matched/DRB1-matched (n = 154), B-leader mismatched/DRB1-mismatched (n = 493), and B-leader mismatched/DRB1-matched (n = 63). Multivariate analysis showed that the B-leader matched/DRB1-mismatched haploidentical group had the best overall survival (OS) compared to the PBM-matched MMUD, while other haploidentical groups had comparable OS. The PBM-mismatched MMUD showed the poorest outcomes, similar to the B-leader mismatched/DRB1-matched haploidentical group. Among non-HLA factors, donor age was the most significant predictor of OS. These results suggest that a B-leader matched/DRB1 mismatched haploidentical donor might be the preferred choice among donors of similar age. If such a donor is not available, the youngest donor from either PBM-matched unrelated or other haploidentical groups could be a beneficial choice. These findings need validation with both donor groups receiving PTCy-based graft-versus-host disease prophylaxis.
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Affiliation(s)
- Rohtesh S Mehta
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington.
| | - Effie W Petersdorf
- Division of Translational Science and Therapeutics, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Tao Wang
- CIBMTR (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, Minnesota
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington; CIBMTR (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, Minnesota
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Akahoshi Y, Spyrou N, Weber D, Aguayo-Hiraldo P, Ayuk F, Chanswangphuwana C, Choe HK, Eder M, Etra AM, Grupp SA, Hexner EO, Hogan WJ, Kitko CL, Kraus S, Al Malki MM, Merli P, Qayed M, Reshef R, Schechter T, Ullrich E, Vasova I, Wölfl M, Zeiser R, Baez J, Beheshti R, Eng G, Gleich S, Katsivelos N, Kowalyk S, Morales G, Young R, Chen YB, Nakamura R, Levine JE, Ferrara JLM. Novel MAGIC composite scores using both clinical symptoms and biomarkers best predict treatment outcomes of acute GVHD. Blood 2024; 144:1010-1021. [PMID: 38968143 DOI: 10.1182/blood.2024025106] [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: 04/26/2024] [Revised: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/07/2024] Open
Abstract
ABSTRACT Acute graft-versus-host disease (GVHD) grading systems that use only clinical symptoms at treatment initiation such as the Minnesota risk identify standard and high-risk categories but lack a low-risk category suitable to minimize immunosuppressive strategies. We developed a new grading system that includes a low-risk stratum based on clinical symptoms alone and determined whether the incorporation of biomarkers would improve the model's prognostic accuracy. We randomly divided 1863 patients in the Mount Sinai Acute GVHD International Consortium (MAGIC) who were treated for GVHD into training and validation cohorts. Patients in the training cohort were divided into 14 groups based on similarity of clinical symptoms and similar nonrelapse mortality (NRM); we used a classification and regression tree (CART) algorithm to create three Manhattan risk groups that produced a significantly higher area under the receiver operating characteristic curve (AUC) for 6-month NRM than the Minnesota risk classification (0.69 vs 0.64, P = .009) in the validation cohort. We integrated serum GVHD biomarker scores with Manhattan risk using patients with available serum samples and again used a CART algorithm to establish 3 MAGIC composite scores that significantly improved prediction of NRM compared to Manhattan risk (AUC, 0.76 vs 0.70, P = .010). Each increase in MAGIC composite score also corresponded to a significant decrease in day 28 treatment response (80% vs 63% vs 30%, P < .001). We conclude that the MAGIC composite score more accurately predicts response to therapy and long-term outcomes than systems based on clinical symptoms alone and may help guide clinical decisions and trial design.
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Affiliation(s)
- Yu Akahoshi
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nikolaos Spyrou
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Daniela Weber
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Paibel Aguayo-Hiraldo
- Division of Bone Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Chantiya Chanswangphuwana
- Division of Hematology and Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Hannah K Choe
- Division of Hematology, Blood and Marrow Transplant Program, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Aaron M Etra
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stephan A Grupp
- Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth O Hexner
- Department of Medicine and Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Carrie L Kitko
- Pediatric Hematology/Oncology Division, Vanderbilt University Medical Center, Nashville, TN
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | | | - Pietro Merli
- Department of Pediatric Hematology and Oncology, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Muna Qayed
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Ran Reshef
- Division of Hematology/Oncology and Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
| | - Tal Schechter
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Evelyn Ullrich
- Department of Pediatrics, Experimental Immunology and Cell Therapy, Goethe University Frankfurt, Frankfurt, Germany
| | - Ingrid Vasova
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
| | - Matthias Wölfl
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Robert Zeiser
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Janna Baez
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rahnuma Beheshti
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gilbert Eng
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Nikolaos Katsivelos
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rachel Young
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | | | - John E Levine
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - James L M Ferrara
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Najaf Khosravi H, Razi S, Rezaei N. The role of interleukin-2 in graft-versus-host disease pathogenesis, prevention and therapy. Cytokine 2024; 183:156723. [PMID: 39173281 DOI: 10.1016/j.cyto.2024.156723] [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: 05/31/2024] [Revised: 07/22/2024] [Accepted: 08/01/2024] [Indexed: 08/24/2024]
Abstract
Graft-versus-host disease (GVHD) is a significant complication following allogeneic hematopoietic cell transplantation (allo-HCT), posing substantial risks to patient survival. In the late follow-up phase of transplanted patients, GVHD is also a major cause of morbidity and disability, mostly due to low response to first-line steroids and the lack of effective standard therapies in the second line. This review provides a description of GVHD pathogenesis, with a focus on the central role of Interleukin-2 (IL-2). IL-2 is one of the critical mediators in the complex pathogenesis of GVHD, contributing to the intricate balance between regulatory T cells (Tregs) and effector T cells (Teffs). Due to this pivotal role, several studies investigate the potential of IL-2 as a therapeutic option for GVHD management. We discuss the outcomes of low-dose IL-2 therapies and their impact on Treg proliferation and steroid dependency reduction. Additionally, the effects of combining IL-2 with other treatments, such as extracorporeal photopheresis (ECP) and Treg-enriched lymphocyte infusions, are highlighted. Novel approaches, including modified IL-2 complexes and IL-2 receptor blockade, are explored for their potential in selectively enhancing Treg function and limiting Teff activation. The evolving understanding of IL-2's pivotal role in immune regulation presents promising prospects for applying treatment and prevention strategies for GVHD.
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Affiliation(s)
- Hila Najaf Khosravi
- Royan Institute for Stem Cell Biology and Technology, Tehran, Iran; Cancer Immunology Project (CIP), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Sepideh Razi
- Cancer Immunology Project (CIP), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; Cancer Immunology Project (CIP), Universal Scientific Education and Research Network (USERN), Stockholm, Sweden.
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5
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Chakraverty R. How Important Is Unrelated Donor Human Leukocyte Antigen Disparity in the Post-Transplant Cyclophosphamide Era? J Clin Oncol 2024:JCO2401303. [PMID: 39167734 DOI: 10.1200/jco-24-01303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Revised: 07/02/2024] [Accepted: 07/02/2024] [Indexed: 08/23/2024] Open
Affiliation(s)
- Ronjon Chakraverty
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
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6
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Sugita J, Morita K, Konuma T, Yanada M. Allogeneic hematopoietic cell transplantation from alternative donors in acute myeloid leukemia. Ann Hematol 2024:10.1007/s00277-024-05944-0. [PMID: 39153145 DOI: 10.1007/s00277-024-05944-0] [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: 01/09/2024] [Accepted: 08/12/2024] [Indexed: 08/19/2024]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) potentially provides a cure for patients with acute myeloid leukemia (AML) who are unlikely to be cured with chemotherapy alone. Previously, human leukocyte antigen (HLA)-matched related donors were used exclusively, which made the procedure available for a limited proportion of patients. The introduction of high-resolution HLA-typing technology, innovations in immunosuppressive therapy, and improved supportive care measures have significantly changed the situation. Now, patients without a matched related donor have an ample opportunity to receive allogeneic HCT with the use of matched or mismatched unrelated donors, umbilical cord blood grafts, or haploidentical related donors. The outcomes of alternative donor transplantations have improved over the past decades, and the growth of unrelated donor registries as well as the donor diversification have enhanced the chance of finding a suitable donor. With multiple alternative donor choices available for most patients, the donor selection is becoming increasingly important. To discuss the optimal donor choice in case of unavailability of an HLA-matched related donor, this article reviews the existing literature of retrospective and prospective comparisons of different alternative donor transplantations in AML and discusses the current state-of-art modalities in allogeneic HCT using alternative donors.
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Affiliation(s)
- Junichi Sugita
- Department of Hematology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Kaoru Morita
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Takaaki Konuma
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Masamitsu Yanada
- Department of Hematology and Oncology, Nagoya City University East Medical Center, 1-2-23 Wakamizu, Chikusa-ku, Nagoya, 464-8547, Japan.
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7
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Ramgopal A, Braverman EL, Sun LK, Monlish D, Wittmann C, Kemp F, Qin M, Ramsey MJ, Cattley R, Hawse W, Byersdorfer CA. AMPK drives both glycolytic and oxidative metabolism in murine and human T cells during graft-versus-host disease. Blood Adv 2024; 8:4149-4162. [PMID: 38810258 PMCID: PMC11345362 DOI: 10.1182/bloodadvances.2023010740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 05/15/2024] [Accepted: 05/19/2024] [Indexed: 05/31/2024] Open
Abstract
ABSTRACT Allogeneic T cells reprogram their metabolism during acute graft-versus-host disease (GVHD) in a process involving the cellular energy sensor adenosine monophosphate (AMP)-activated protein kinase (AMPK). Deletion of AMPK in donor T cells limits GVHD but still preserves homeostatic reconstitution and graft-versus-leukemia effects. In the current studies, murine AMPK knock-out (KO) T cells decreased oxidative metabolism at early time points posttransplant and lacked a compensatory increase in glycolysis after inhibition of the electron transport chain. Immunoprecipitation using an antibody specific to phosphorylated targets of AMPK determined that AMPK modified interactions of several glycolytic enzymes including aldolase, enolase, pyruvate kinase M, and glyceraldehyde 3-phosphate dehydrogenase (GAPDH), with enzyme assays confirming impaired aldolase and GAPDH activity in AMPK KO T cells. Importantly, these changes in glycolysis correlated with both an impaired ability of AMPK KO T cells to produce significant amounts of interferon gamma upon antigenic restimulation and a decrease in the total number of donor CD4 T cells recovered at later times posttransplant. Human T cells lacking AMPK gave similar results, with glycolytic compensation impaired both in vitro and after expansion in vivo. Xenogeneic GVHD results also mirrored those of the murine model, with reduced CD4/CD8 ratios and a significant improvement in disease severity. Together these data highlight a significant role for AMPK in controlling oxidative and glycolytic metabolism in both murine and human T cells and endorse further study of AMPK inhibition as a potential clinical target for future GVHD therapies.
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Affiliation(s)
- Archana Ramgopal
- Division of Blood and Marrow Transplant and Cellular Therapies, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Erica L. Braverman
- Division of Blood and Marrow Transplant and Cellular Therapies, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Lee-Kai Sun
- Division of Blood and Marrow Transplant and Cellular Therapies, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Darlene Monlish
- Division of Blood and Marrow Transplant and Cellular Therapies, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Christopher Wittmann
- Division of Blood and Marrow Transplant and Cellular Therapies, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Felicia Kemp
- Division of Blood and Marrow Transplant and Cellular Therapies, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Mengtao Qin
- Division of Blood and Marrow Transplant and Cellular Therapies, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh PA
- School of Medicine, Tsinghua University, Beijing, China
| | - Manda J. Ramsey
- Division of Blood and Marrow Transplant and Cellular Therapies, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Richard Cattley
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA
| | - William Hawse
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA
| | - Craig A. Byersdorfer
- Division of Blood and Marrow Transplant and Cellular Therapies, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh PA
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Kim NH, Hamadani M, Abedin S. New investigational drugs for steroid-refractory acute graft-versus-host disease: a review of the literature. Expert Opin Investig Drugs 2024; 33:791-799. [PMID: 38973782 PMCID: PMC11305901 DOI: 10.1080/13543784.2024.2377322] [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: 04/21/2024] [Accepted: 07/03/2024] [Indexed: 07/09/2024]
Abstract
INTRODUCTION Steroid-refractory acute graft-versus-host disease (SR-aGVHD) remains a formidable obstacle in the field of allogeneic hematopoietic cell transplantation (allo-HCT), significantly contributing to patient morbidity and mortality. The current therapeutic landscape for SR-aGVHD is limited, often yielding suboptimal results, thereby emphasizing the urgent need for innovative and effective treatments. AREAS COVERED In light of the pivotal REACH2 trial, ruxolitinib phosphate, a Janus kinase inhibitor, has gained prominence as the standard treatment for SR-aGVHD. Nevertheless, a considerable number of patients either do not respond to or cannot tolerate this therapy. This review delves into emerging treatments for SR-aGVHD, including mesenchymal stromal cells (MSCs), fecal microbiota transplantation (FMT), CD3/CD7 blockade, neihulizumab, begelomab, tocilizumab, and vedolizumab. While some of these agents have shown encouraging results in early-phase trials, issues such as treatment-related toxicities and inconsistent responses in larger studies highlight the necessity for ongoing research. EXPERT OPINION Current trials exploring new agents and combination therapies offer hope for fulfilling the unmet clinical needs in SR-aGVHD, potentially leading to more effective and precise treatment strategies.
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Affiliation(s)
- Na Hyun Kim
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
| | - Mehdi Hamadani
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
| | - Sameem Abedin
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
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9
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Shaffer BC, Gooptu M, DeFor TE, Maiers M, Bolaños-Meade J, Abboud R, Briggs AD, Khimani F, Modi D, Newcomb R, Shpall EJ, Bupp C, Spellman SR, Stefanski HE, Shaw BE, Auletta JJ, Devine SM, Jimenez Jimenez AM, Al Malki MM. Post-Transplant Cyclophosphamide-Based Graft-Versus-Host Disease Prophylaxis Attenuates Disparity in Outcomes Between Use of Matched or Mismatched Unrelated Donors. J Clin Oncol 2024:JCO2400184. [PMID: 39018507 DOI: 10.1200/jco.24.00184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/02/2024] [Accepted: 05/07/2024] [Indexed: 07/19/2024] Open
Abstract
PURPOSE Access to allogeneic hematopoietic cell transplantation (HCT) remains limited among persons of non-European ancestry if human leukocyte antigen (HLA) matching is required. We evaluated whether post-transplant cyclophosphamide (PTCy)-based graft-versus-host disease (GVHD) prophylaxis improved HCT outcomes with HLA-matched unrelated donor (MUD) and mismatched unrelated donor (MMUD) HCT when compared with calcineurin inhibitor (CNI)-based prophylaxis. METHODS Three-year overall survival (OS) and GVHD-free, relapse-free survival (GRFS) were compared between adult recipients undergoing initial MUD or single HLA locus MMUD HCT with either PTCy- or CNI-based prophylaxis who were reported to the Center for International Blood and Marrow Transplant Research between 2017 and 2021. RESULTS Included were 10,025 HCT recipients (7,272 recipients of MUD with CNI, 1,681 MUD with PTCy, 613 MMUD with CNI, and 459 MMUD with PTCy) who underwent HCT for acute leukemia (70.9%) or myelodysplastic syndromes (29.2%). Median patient age was 60.7 years (range, 18.0-82.7) and median follow-up was 36.6 (range, 3.0-77.8) months. When compared with MUD HCT with PTCy, MMUD HCT with PTCy had similar OS (hazard ratio [HR], 0.96 [95% CI, 0.823 to 1.11]; P = .60) and GRFS (HR, 0.90 [0.79 to 1.02]; P = .1). When compared with MUD HCT with CNI, OS was improved after MUD HCT with PTCy (HR, 0.88 [0.80 to 0.96]; P = .004) and GRFS was improved with PTCy after either MUD (HR, 0.61 [0.57 to 0.66]; P < .0001) or MMUD (HR, 0.68 [0.60 to 0.76]; P < .0001) HCT. Benefit from PTCy was independent of patient ancestry. Global registry level analysis demonstrated that inclusion of MMUD increased donor availability regardless of recipient ancestry. CONCLUSION Use of PTCy results in comparable OS and GRFS using either MUD or MMUD HCT, expanding access to HCT for patients from all racial and ethnic ancestry groups.
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Affiliation(s)
- Brian C Shaffer
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mahasweta Gooptu
- Department of Hematology/Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Todd E DeFor
- CIBMTR (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, MN
| | - Martin Maiers
- CIBMTR (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, MN
| | | | - Ramzi Abboud
- Washington University School of Medicine, St Louis, MO
| | | | - Farhad Khimani
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Dipenkumar Modi
- Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, MI
| | | | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Caitrin Bupp
- CIBMTR (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, MN
| | - Stephen R Spellman
- CIBMTR (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, MN
| | - Heather E Stefanski
- CIBMTR (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, MN
| | - Bronwen E Shaw
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Jeffery J Auletta
- CIBMTR (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, MN
- Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children's Hospital, Columbus, OH
| | - Steven M Devine
- CIBMTR (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, MN
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10
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Little J, Rauseo AM, Zuniga-Moya JC, Spec A, Pappas P, Perfect J, McCarthy T, Schwartz IS. Clinical Mycology Today: Emerging Challenges and Opportunities. Open Forum Infect Dis 2024; 11:ofae363. [PMID: 39045011 PMCID: PMC11263878 DOI: 10.1093/ofid/ofae363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 06/25/2024] [Indexed: 07/25/2024] Open
Abstract
The Mycoses Study Group Education and Research Consortium is a collective of clinicians, researchers, and educators with the common goal to advance awareness, diagnosis, and management of invasive fungal diseases. Clinical Mycology Today, the Mycoses Study Group Education and Research Consortium's biennial meeting, is dedicated to discussing the most pressing contemporary issues facing the field of clinical mycology, promoting clinical, translational, and basic science collaborations, and mentoring the next generation of clinical mycologists. Here, we review the current opportunities and challenges facing the field of mycology that arose from discussions at the 2022 meeting, with emphasis on novel host risk factors, emerging resistant fungal pathogens, the evolving antifungal pipeline, and critical issues affecting the advancement of mycology research.
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Affiliation(s)
- Jessica Little
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Adriana M Rauseo
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Julio C Zuniga-Moya
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Peter Pappas
- Division of Infectious Diseases, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Todd McCarthy
- Division of Infectious Diseases, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ilan S Schwartz
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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11
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Finke J, Schmoor C, Ayuk F, Hasenkamp J, Verbeek M, Wagner EM, Biersack H, Schäfer-Eckart K, Wolf D, Stuhler G, Reibke R, Schmid C, Kaufmann M, Eder M, Bertz H, Grishina O. Long term results of a prospective multicenter observational study on the use of anti-human T-lymphocyte immunoglobulin (ATLG) in unrelated donor transplantation (ATOS study). Bone Marrow Transplant 2024; 59:936-941. [PMID: 38493275 PMCID: PMC11226393 DOI: 10.1038/s41409-024-02264-9] [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: 12/21/2023] [Revised: 02/27/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024]
Abstract
ATOS is a prospective observational study evaluating the outcome of patients receiving anti-human T-lymphocyte immunoglobulin (ATLG) in unrelated donor transplantation. Primary endpoint was severe GvHD and relapse-free survival (SGRFS). GvHD prophylaxis consisted of ATLG and CSA/ MTX or MMF. Outcome was compared to the ATLG arm of our prospective randomized phase III multicenter trial trial (RCT) [1, 2]. 165 patients, median age 54 (18; 77) years, with haematological malignancies with early (45.5%), intermediate (17.6%), and advanced (37.0%) disease were included. ATLG dose differed between centers according to local practise (median total ATLG dose of 46 (IQR 32-60, range 15-91) mg/kg). Median follow-up was 70 months. Estimated probabilities at 5 years follow up were for SGRFS 0.27, OS 0.52, DFS 0.43, NRM 0.23, relapse 0.34, acute GvhD °III/IV 0.13, severe chronic GvHD 0.27. OS rates differed dependent on disease status. An effect of the given ATLG dose could not be separated from potential center effects. Despite higher age and more advanced disease in ATOS, outcome was similar to the ATLG arm of our RCT. This long-term, multicenter, experience in routine clinical practice confirms the GvHD-protective effect of ATLG without compromising relapse and non-relapse mortality rates.Clinical Trial Registry: German clinical trials register DRKS00004581.
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Affiliation(s)
- Jürgen Finke
- University Medical Center and Medical Faculty, University of Freiburg, Breisgau, Germany.
| | - Claudia Schmoor
- Clinical Trials Unit, Medical Center and Faculty of Medicine, University of Freiburg, Breisgau, Germany
| | - Francis Ayuk
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Mareike Verbeek
- Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Clinic and Policlinic for Internal Medicine III. München, Munich, Germany
| | | | - Harald Biersack
- Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Germany
- Klinikum Kulmbach, Bavaria, Germany
| | | | - Dominik Wolf
- Medical Clinic 3, Universitätsklinikum Bonn, Bonn, Germany
- Dpt. Hematology and Oncology, Comprehensive Cancer Center Innsbruck (CCCI), Innsbruck, Austria
| | - Gernot Stuhler
- DKD Helios Klinik Wiesbaden, Wiesbaden, Germany
- Universätsklinikum Würzburg, Würzburg, Germany
| | - Roland Reibke
- University Medical Center LMU München, Munich, Germany
| | | | | | - Matthias Eder
- University Medical Center Hannover, Hannover, Germany
| | - Hartmut Bertz
- University Medical Center and Medical Faculty, University of Freiburg, Breisgau, Germany
| | - Olga Grishina
- Clinical Trials Unit, Medical Center and Faculty of Medicine, University of Freiburg, Breisgau, Germany
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12
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Naik S, Li Y, Talleur AC, Selukar S, Ashcraft E, Cheng C, Madden RM, Mamcarz E, Qudeimat A, Sharma A, Srinivasan A, Suliman AY, Epperly R, Obeng EA, Velasquez MP, Langfitt D, Schell S, Métais JY, Arnold PY, Hijano DR, Maron G, Merchant TE, Akel S, Leung W, Gottschalk S, Triplett BM. Memory T-cell enriched haploidentical transplantation with NK cell addback results in promising long-term outcomes: a phase II trial. J Hematol Oncol 2024; 17:50. [PMID: 38937803 PMCID: PMC11212178 DOI: 10.1186/s13045-024-01567-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 06/13/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Relapse remains a challenge after transplantation in pediatric patients with hematological malignancies. Myeloablative regimens used for disease control are associated with acute and long-term adverse effects. We used a CD45RA-depleted haploidentical graft for adoptive transfer of memory T cells combined with NK-cell addback and hypothesized that maximizing the graft-versus-leukemia (GVL) effect might allow for reduction in intensity of conditioning regimen. METHODS In this phase II clinical trial (NCT01807611), 72 patients with hematological malignancies (complete remission (CR)1: 25, ≥ CR2: 28, refractory disease: 19) received haploidentical CD34 + enriched and CD45RA-depleted hematopoietic progenitor cell grafts followed by NK-cell infusion. Conditioning included fludarabine, thiotepa, melphalan, cyclophosphamide, total lymphoid irradiation, and graft-versus-host disease (GVHD) prophylaxis consisted of a short-course sirolimus or mycophenolate mofetil without serotherapy. RESULTS The 3-year overall survival (OS) and event-free-survival (EFS) for patients in CR1 were 92% (95% CI:72-98) and 88% (95% CI: 67-96); ≥ CR2 were 81% (95% CI: 61-92) and 68% (95% CI: 47-82) and refractory disease were 32% (95% CI: 11-54) and 20% (95% CI: 6-40). The 3-year EFS for all patients in morphological CR was 77% (95% CI: 64-87) with no difference amongst recipients with or without minimal residual disease (P = 0.2992). Immune reconstitution was rapid, with mean CD3 and CD4 T-cell counts of 410/μL and 140/μL at day + 30. Cumulative incidence of acute GVHD and chronic GVHD was 36% and 26% but most patients with acute GVHD recovered rapidly with therapy. Lower rates of grade III-IV acute GVHD were observed with NK-cell alloreactive donors (P = 0.004), and higher rates of moderate/severe chronic GVHD occurred with maternal donors (P = 0.035). CONCLUSION The combination of a CD45RA-depleted graft and NK-cell addback led to robust immune reconstitution maximizing the GVL effect and allowed for use of a submyeloablative, TBI-free conditioning regimen that was associated with excellent EFS resulting in promising long-term outcomes in this high-risk population. The trial is registered at ClinicalTrials.gov (NCT01807611).
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Affiliation(s)
- Swati Naik
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA.
| | - Ying Li
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Aimee C Talleur
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Subodh Selukar
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Emily Ashcraft
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Cheng Cheng
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Renee M Madden
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Ewelina Mamcarz
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Amr Qudeimat
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Akshay Sharma
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Ashok Srinivasan
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Ali Y Suliman
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Rebecca Epperly
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Esther A Obeng
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - M Paulina Velasquez
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Deanna Langfitt
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Sarah Schell
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Jean-Yves Métais
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Paula Y Arnold
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Diego R Hijano
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Gabriela Maron
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Thomas E Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Salem Akel
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Wing Leung
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Stephen Gottschalk
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Brandon M Triplett
- Department of Bone Marrow Transplantation & Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN, USA.
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13
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Etra A, El Jurdi N, Katsivelos N, Kwon D, Gergoudis S, Morales G, Spyrou N, Kowalyk S, Aguayo-Hiraldo P, Akahoshi Y, Ayuk F, Baez J, Betts BC, Chanswangphuwana C, Chen YB, Choe H, DeFilipp Z, Gleich S, Hexner E, Hogan WJ, Holler E, Kitko CL, Kraus S, Al Malki M, MacMillan M, Pawarode A, Quagliarella F, Qayed M, Reshef R, Schechter T, Vasova I, Weisdorf D, Wölfl M, Young R, Nakamura R, Ferrara JLM, Levine JE, Holtan S. Amphiregulin, ST2, and REG3α biomarker risk algorithms as predictors of nonrelapse mortality in patients with acute GVHD. Blood Adv 2024; 8:3284-3292. [PMID: 38640195 PMCID: PMC11226972 DOI: 10.1182/bloodadvances.2023011049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 03/29/2024] [Accepted: 03/29/2024] [Indexed: 04/21/2024] Open
Abstract
ABSTRACT Graft-versus-host disease (GVHD) is a major cause of nonrelapse mortality (NRM) after allogeneic hematopoietic cell transplantation. Algorithms containing either the gastrointestinal (GI) GVHD biomarker amphiregulin (AREG) or a combination of 2 GI GVHD biomarkers (suppressor of tumorigenicity-2 [ST2] + regenerating family member 3 alpha [REG3α]) when measured at GVHD diagnosis are validated predictors of NRM risk but have never been assessed in the same patients using identical statistical methods. We measured the serum concentrations of ST2, REG3α, and AREG by enzyme-linked immunosorbent assay at the time of GVHD diagnosis in 715 patients divided by the date of transplantation into training (2004-2015) and validation (2015-2017) cohorts. The training cohort (n = 341) was used to develop algorithms for predicting the probability of 12-month NRM that contained all possible combinations of 1 to 3 biomarkers and a threshold corresponding to the concordance probability was used to stratify patients for the risk of NRM. Algorithms were compared with each other based on several metrics, including the area under the receiver operating characteristics curve, proportion of patients correctly classified, sensitivity, and specificity using only the validation cohort (n = 374). All algorithms were strong discriminators of 12-month NRM, whether or not patients were systemically treated (n = 321). An algorithm containing only ST2 + REG3α had the highest area under the receiver operating characteristics curve (0.757), correctly classified the most patients (75%), and more accurately risk-stratified those who developed Minnesota standard-risk GVHD and for patients who received posttransplant cyclophosphamide-based prophylaxis. An algorithm containing only AREG more accurately risk-stratified patients with Minnesota high-risk GVHD. Combining ST2, REG3α, and AREG into a single algorithm did not improve performance.
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Affiliation(s)
- Aaron Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Najla El Jurdi
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
| | - Nikolaos Katsivelos
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Deukwoo Kwon
- Department of Population Health Science and Policy, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stephanie Gergoudis
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Paibel Aguayo-Hiraldo
- Division of Hematology, Oncology, and Blood and Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, CA
| | - Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Brian C. Betts
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
| | | | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Hannah Choe
- Division of Hematology, James Cancer Center, The Ohio State University, Columbus, OH
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Elizabeth Hexner
- Blood and Marrow Transplantation Program, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Carrie L. Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Monzr Al Malki
- Hematology/Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, CA
| | - Margaret MacMillan
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
| | - Attaphol Pawarode
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI
| | | | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, GA
| | - Ran Reshef
- Blood and Marrow Transplantation Program, Columbia University Medical Center, New York, NY
| | - Tal Schechter
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Ingrid Vasova
- Med. Klinik III/Poliklinik, Universitatsklinik Erlangen, Erlangen, Germany
| | - Daniel Weisdorf
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children’s Hospital, University of Würzburg, Würzburg, Germany
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryotaro Nakamura
- Hematology/Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, CA
| | - James L. M. Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John E. Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shernan Holtan
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
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14
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Jaiswal SR, Agarwal M, Bhagawati G, Das BC, Baligar P, Garg M, Biswas S, Chakrabarti S. Long-Term Follow-Up of Abatacept, Post-Transplantation Cyclophosphamide, and Sirolimus-Based Haploidentical Transplantation in Younger Patients with Nonmalignant Diseases. Transplant Cell Ther 2024; 30:605.e1-605.e13. [PMID: 38490295 DOI: 10.1016/j.jtct.2024.03.010] [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: 02/02/2024] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 03/17/2024]
Abstract
Haploidentical (haplo) hematopoietic cell transplantation (HCT) for nonmalignant disease (NMD) carries inherent challenges of both alloreactivity and graft failure. Building on promising results from pilot studies in which abatacept was combined with post-transplantation cyclophosphamide (PTCy) and sirolimus (AbaCyS) in younger NMD patients undergoing haplo-HCT, we present the long-term outcomes of this protocol. On the back of uniform disease-specific conditioning regimens containing antithymocyte globulin 4.5 mg/kg from day -9 to day -7, GVHD prophylaxis with AbaCyS consisted of abatacept administered on days 0, +5, +20, +35, and monthly until 180 days with PTCy and sirolimus. The patients were followed up with longitudinal assessment of immune reconstitution, growth, and reproductive development and quality of life (QoL) analyses. Among 40 patients (aplastic anemia, n = 24; hemoglobinopathies, n = 14; and primary immunodeficiencies, n = 2) with a median age of 10 years (range, 2 to 25 years), 95% achieved sustained engraftment. Post-transplantation hemophagocytic syndrome was detected in 3 patients, leading to graft failure in 2 cases. The incidence of acute graft-versus-host disease (GVHD) was 2.6%, and that of chronic GVHD (cGVHD) was 14.3%. Cytomegalovirus, adenovirus, and Epstein-Barr virus infections were observed in 45%, 5%, and 0% respectively. Rates of nonrelapse mortality, overall survival, event-free survival, and GVHD-free, event-free survival were 5%, 95%, 90%, and 82%, respectively, at a median follow-up of 4.6 years. Absence of cGVHD correlated with younger patient age and early sustained recovery of regulatory T cells and mature natural killer cells, which in turn was associated with improved QoL and lack of late infections. The AbaCyS protocol was associated with excellent long-term survival, with attenuation of both early and late alloreactivity in >80% of younger patients undergoing haplo-HCT for NMD. This study sheds light on predispositions to cGVHD and its impact on QoL, warranting further optimization of this approach.
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Affiliation(s)
- Sarita Rani Jaiswal
- Department of Blood and Marrow Transplantation, Dharamshila Narayana Superspeciality Hospital and Research Centre, New Delhi, India; Cellular Therapy and Immunology, Manashi Chakrabarti Foundation, Kolkata, India; Amity Institute of Molecular Medicine and Stem Cell Research, Amity University, Noida, Uttar Pradesh, India.
| | - Mahak Agarwal
- Department of Blood and Marrow Transplantation, Dharamshila Narayana Superspeciality Hospital and Research Centre, New Delhi, India; Cellular Therapy and Immunology, Manashi Chakrabarti Foundation, Kolkata, India
| | - Gitali Bhagawati
- Department of Microbiology, Dharamshila Narayana Superspeciality Hospital and Research Centre, New Delhi, India
| | - Bhudev Chandra Das
- Amity Institute of Molecular Medicine and Stem Cell Research, Amity University, Noida, Uttar Pradesh, India
| | - Prakash Baligar
- Amity Institute of Molecular Medicine and Stem Cell Research, Amity University, Noida, Uttar Pradesh, India
| | - Manoj Garg
- Amity Institute of Molecular Medicine and Stem Cell Research, Amity University, Noida, Uttar Pradesh, India
| | - Subhrajit Biswas
- Amity Institute of Molecular Medicine and Stem Cell Research, Amity University, Noida, Uttar Pradesh, India
| | - Suparno Chakrabarti
- Department of Blood and Marrow Transplantation, Dharamshila Narayana Superspeciality Hospital and Research Centre, New Delhi, India; Cellular Therapy and Immunology, Manashi Chakrabarti Foundation, Kolkata, India; Amity Institute of Molecular Medicine and Stem Cell Research, Amity University, Noida, Uttar Pradesh, India
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15
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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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16
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Trunk AD, Guo M, Budvytyte L, Islam NS, Khera N, Hamilton BK, Amonoo HL. Hematopoietic Stem-Cell Transplantation: Exploring the Latest Advances and Gaps in Disparities, Psychosocial and Symptom Management Interventions, and Chronic Graft-Versus-Host Disease Care. Am Soc Clin Oncol Educ Book 2024; 44:e432186. [PMID: 38754066 DOI: 10.1200/edbk_432186] [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: 05/18/2024]
Abstract
Although allogeneic hematopoietic cell transplantation (HCT) offers a potential for cure for many patients with advanced hematologic malignancies and bone marrow failure or immunodeficiency syndromes, it is an intensive treatment and accompanied by short- and long-term physical and psychological symptoms requiring specialized care. With substantial advances in therapeutic approaches for HCT and supportive care, HCT survivors experience less morbidity and mortality. However, disparities in both HCT access and outcomes persist, and HCT survivors and their caregivers often lack access to much-needed psychosocial care. Additionally, more medical and psychosocial resources are needed to holistically care for HCT survivors with chronic graft-versus-host disease (GVHD). Hence, this chapter focuses on three areas pertaining to advances and gaps in HCT care: disparities in access to and outcomes of HCT, psychosocial and physical symptom management with supportive care interventions, and GVHD prevention and management.
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Affiliation(s)
- Andrew D Trunk
- Blood and Marrow Transplant Program, Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Michelle Guo
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | | | | | - Betty K Hamilton
- Blood and Marrow Transplant Program, Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Hermioni L Amonoo
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
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17
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Devine SM. The Evolution of Hematopoietic Stem Cell Transplantation to Overcome Access Disparities: The Role of NMDP. Cells 2024; 13:933. [PMID: 38891065 PMCID: PMC11171651 DOI: 10.3390/cells13110933] [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: 04/05/2024] [Revised: 05/13/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
NMDP recognizes that despite advances in hematopoietic stem cell transplantation (HSCT) and other cell therapies, not all patients have equitable access to treatment, and disparities in outcomes remain. This paper explores the recent work of NMDP to accelerate progress and expand access to more patients through transformative clinical research, particularly in the use of mismatched unrelated donors for HSCT.
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Affiliation(s)
- Steven M. Devine
- NMDP, Minneapolis, MN 55401, USA;
- CIBMTR (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, MN 55401, USA
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18
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Mehta RS. SOHO State of the Art Updates and Next Questions | Current Status and Future Directions of Donor Selection. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024:S2152-2650(24)00183-6. [PMID: 38825445 DOI: 10.1016/j.clml.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 05/10/2024] [Indexed: 06/04/2024]
Abstract
The landscape of HLA matching in hematopoietic cell transplantation (HCT) is continuously advancing, introducing more nuanced criteria beyond traditional 10/10 HLA-A, -B, -C, and -DRB1 allele matching. For 10/10 matched donors, prioritizing a donor with a "core" permissive HLA-DPB1 mismatch is recommended over "noncore" permissive mismatches, with nonpermissive mismatches being the least prefered. In the one-antigen mismatched setting (7/8 HLA-matched), HLA-C matching, particularly avoiding high-expression mismatches at residues 116 or 77/80, is preferred over HLA-A or HLA-B mismatches. HLA B-leader matching is beneficial in both one-antigen mismatched and haploidentical HCT. Additionally, specific HLA mismatches in haploidentical HCT, such as DRB1 mismatches with DQB1 matches and DPB1 nonpermissive mismatches are linked to better outcomes. Among non-HLA factors, evidence consistently underscores the pivotal impact of donor age on overall survival. For HLA-mismatched transplants, including haploidentical HCT, avoidance of donors against whom the recipient has preformed donor-specific antibodies is paramount. Selecting a cytomegalovirus (CMV) seronegative donor is important particularly for CMV-negative recipients; however, more research is needed in the letermovir prophylaxis era. The impact of ABO-matching on transplant outcomes is debatable. Other unanswered questions include defining "younger" donors and establishing hierarchy in donor selection based on factors like CMV status, ABO compatibility, or sex-mismatch, to name a few. Future research addressing these issues will refine donor selection algorithms and improve transplant success. In conclusion, selecting a donor for HCT requires multifaceted considerations, integrating evolving HLA-matching criteria and non-HLA factors, to optimize HCT outcomes in this rapidly advancing field.
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Affiliation(s)
- Rohtesh S Mehta
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA.
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19
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Munshi PN, McCurdy SR. Age barriers in allogeneic hematopoietic cell transplantation: Raising the silver curtain. Am J Hematol 2024; 99:922-937. [PMID: 38414188 DOI: 10.1002/ajh.27228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 12/13/2023] [Accepted: 01/01/2024] [Indexed: 02/29/2024]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is no longer exclusively for the young. With an aging population, development of non-intensive remission-inducing strategies for hematologic malignancies, and novel graft-versus-host disease-prevention platforms, an older population of patients is pursuing HCT. The evolving population of HCT recipients requires an overhaul in the way we risk-stratify and optimize patients prior to HCT. Here, we review the history and current state of HCT for older adults and propose an assessment and intervention flow to bridge the gaps in today's clinical guidelines.
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Affiliation(s)
- Pashna N Munshi
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shannon R McCurdy
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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20
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Major-Monfried H, Hosszu K, McAvoy DP, Vallone A, Shukla N, Gillio A, Spitzer B, Kung AL, Cancio M, Curran K, Scaradavou A, Oved JH, O'Reilly RJ, Boelens JJ, Harris AC. Two novel assays demonstrate persistent daratumumab exposure in a pediatric patient with delayed engraftment following allogeneic hematopoietic stem cell transplantation. Cytotherapy 2024; 26:466-471. [PMID: 38430078 DOI: 10.1016/j.jcyt.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 11/08/2023] [Accepted: 01/25/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND AIMS Daratumumab, a human IgG monoclonal antibody targeting CD38, is a promising treatment for pediatric patients with relapsed or refractory T-cell acute lymphoblastic leukemia (T-ALL). We describe a case of delayed engraftment following a mismatched, unrelated donor hematopoietic stem cell transplant (HSCT) in a 14-year-old female with relapsed T-ALL, treated with daratumumab and chemotherapy. By Day 28 post-HSCT, the patient had no neutrophil engraftment but full donor myeloid chimerism. METHODS We developed two novel, semi-quantitative, antibody-based assays to measure the patient's bound and plasma daratumumab levels to determine if prolonged drug exposure may have contributed to her slow engraftment. RESULTS Daratumumab levels were significantly elevated more than 30 days after the patient's final infusion, and levels inversely correlated with her white blood cell counts. To clear daratumumab, the patient underwent several rounds of plasmapheresis and subsequently engrafted. CONCLUSIONS This is the first report of both delayed daratumumab clearance and delayed stem cell engraftment following daratumumab treatment in a pediatric patient. Further investigation is needed to elucidate the optimal dosing of daratumumab for treatment of acute leukemias in pediatric populations as well as daratumumab's potential effects on hematopoietic stem cells and stem cell engraftment following allogenic HSCT.
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Affiliation(s)
- Hannah Major-Monfried
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
| | - Kinga Hosszu
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Devin P McAvoy
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alexander Vallone
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Neerav Shukla
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alfred Gillio
- Pediatric Blood and Marrow Transplantation, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Barbara Spitzer
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Pediatric Blood and Marrow Transplantation, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Andrew L Kung
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Maria Cancio
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kevin Curran
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andromachi Scaradavou
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joseph H Oved
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Richard J O'Reilly
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jaap Jan Boelens
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrew C Harris
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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21
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Gorfinkel L, Raghunandan S, Watkins B, Hebert K, Neuberg DS, Bratrude B, Betz K, Yu A, Choi SW, Davis J, Duncan C, Giller R, Grimley M, Harris AC, Jacobsohn D, Lalefar N, Farhadfar N, Pulsipher MA, Shenoy S, Petrovic A, Schultz KR, Yanik GA, Blazar BR, Horan JT, Langston A, Kean LS, Qayed M. Overlap chronic GVHD is associated with adverse survival outcomes compared to classic chronic GVHD. Bone Marrow Transplant 2024; 59:680-687. [PMID: 38383714 PMCID: PMC11221458 DOI: 10.1038/s41409-024-02245-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/20/2023] [Accepted: 02/07/2024] [Indexed: 02/23/2024]
Abstract
Chronic graft-versus-host-disease (cGVHD) is divided into two subtypes: classic (absence of acute GVHD features) and overlap cGVHD ('ocGVHD'), in which both chronic and acute GVHD clinical features are present simultaneously. While worse outcomes with ocGVHD have been reported, there are few recent analyses. We performed a secondary analysis of data from the ABA2 trial (N = 185), in which detailed GVHD data were collected prospectively and systematically adjudicated. Analyses included cumulative incidence of classic versus ocGVHD, their specific organ manifestations, global disease severity scores, non-relapse mortality (NRM), disease-free survival (DFS) and overall survival (OS) in these two cGVHD subtypes. Of 92 patients who developed cGVHD, 35 were classified as ocGVHD. The 1-year cumulative incidence, organ involvement, and global severity of classic and ocGVHD were similar between ABA2 patients receiving CNI/MTX+placebo and CNI/MTX+abatacept; thus, cohorts were combined for ocGVHD evaluation. This analysis identified ocGVHD as having significantly higher severity at presentation and at maximum global severity compared to classic cGVHD. OS and DFS were significantly lower for ocGVHD versus classic cGVHD. OcGVHD is associated with increased cGVHD severity scores, and is associated with decreased OS and DFS compared to classic cGVHD, underscoring the high risks with this cGVHD subtype.
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Affiliation(s)
- Lev Gorfinkel
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sharmila Raghunandan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
| | - Kyle Hebert
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Donna S Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Brandi Bratrude
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kayla Betz
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Alison Yu
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Jeffrey Davis
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Christine Duncan
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Roger Giller
- Center for Cancer and Blood Disorders, Children Hospital of Colorado, University of Colorado, Aurora, CO, USA
| | - Michael Grimley
- University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | - Nahal Lalefar
- University of California San Francisco, UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | | | | | - Shalini Shenoy
- Washington University School of Medicine, St Louis, MO, USA
| | | | - Kirk R Schultz
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | | | - Bruce R Blazar
- University of Minnesota, Department of Pediatrics, Division of Blood and Marrow Transplantation, Minneapolis, MN, USA
| | - John T Horan
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Amelia Langston
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Leslie S Kean
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA.
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22
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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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23
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Bono R, Sapienza G, Tringali S, Rotolo C, Patti C, Mulè A, Calafiore V, Santoro A, Castagna L. Allogeneic Stem Cell Transplantation in Refractory Acute Myeloid Leukaemia. Cells 2024; 13:755. [PMID: 38727291 PMCID: PMC11083056 DOI: 10.3390/cells13090755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
Refractory acute myeloid leukaemia is very difficult to treat and represents an unmet clinical need. In recent years, new drugs and combinations of drugs have been tested in this category, with encouraging results. However, all treated patients relapsed and died from the disease. The only curative option is allogeneic transplantation through a graft from a healthy donor immune system. Using myeloablative conditioning regimens, the median overall survival regimens is 19%. Several so-called sequential induction chemotherapies followed by allogeneic transplantation conditioned by reduced intensity regimens have been developed, improving the overall survival to 25-57%. In the allogeneic transplantation field, continuous improvements in practices, particularly regarding graft versus host disease prevention, infection prevention, and treatment, have allowed us to observe improvements in survival rates. This is true mainly for patients in complete remission before transplantation and less so for refractory patients. However, full myeloablative regimens are toxic and carry a high risk of treatment-related mortality. In this review, we describe the results obtained with the different modalities used in more recent retrospective and prospective studies. Based on these findings, we speculate how allogeneic stem cell transplantation could be modified to maximise its therapeutic effect on refractory acute myeloid leukaemia.
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Affiliation(s)
- Roberto Bono
- BMT Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy; (R.B.); (G.S.); (S.T.); (C.R.)
| | - Giuseppe Sapienza
- BMT Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy; (R.B.); (G.S.); (S.T.); (C.R.)
| | - Stefania Tringali
- BMT Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy; (R.B.); (G.S.); (S.T.); (C.R.)
| | - Cristina Rotolo
- BMT Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy; (R.B.); (G.S.); (S.T.); (C.R.)
| | - Caterina Patti
- Onco-Hematology Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy; (C.P.); (A.M.); (V.C.)
| | - Antonino Mulè
- Onco-Hematology Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy; (C.P.); (A.M.); (V.C.)
| | - Valeria Calafiore
- Onco-Hematology Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy; (C.P.); (A.M.); (V.C.)
| | - Alessandra Santoro
- Onco-Hematology and Cell Manipulation Laboratory Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy;
| | - Luca Castagna
- BMT Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy; (R.B.); (G.S.); (S.T.); (C.R.)
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24
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Copsel SN, Garrido VT, Barreras H, Bader CS, Pfeiffer B, Mateo-Victoriano B, Wolf D, Gallardo M, Paczesny S, Komanduri KV, Benjamin CL, Villarino AV, Saluja AK, Levy RB. Minnelide suppresses GVHD and enhances survival while maintaining GVT responses. JCI Insight 2024; 9:e165936. [PMID: 38602775 PMCID: PMC11141936 DOI: 10.1172/jci.insight.165936] [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: 10/04/2022] [Accepted: 04/03/2024] [Indexed: 04/13/2024] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (aHSCT) can cure patients with otherwise fatal leukemias and lymphomas. However, the benefits of aHSCT are limited by graft-versus-host disease (GVHD). Minnelide, a water-soluble analog of triptolide, has demonstrated potent antiinflammatory and antitumor activity in several preclinical models and has proven both safe and efficacious in clinical trials for advanced gastrointestinal malignancies. Here, we tested the effectiveness of Minnelide in preventing acute GVHD as compared with posttransplant cyclophosphamide (PTCy). Strikingly, we found Minnelide improved survival, weight loss, and clinical scores in an MHC-mismatched model of aHSCT. These benefits were also apparent in minor MHC-matched aHSCT and xenogeneic HSCT models. Minnelide was comparable to PTCy in terms of survival, GVHD clinical score, and colonic length. Notably, in addition to decreased donor T cell infiltration early after aHSCT, several regulatory cell populations, including Tregs, ILC2s, and myeloid-derived stem cells in the colon were increased, which together may account for Minnelide's GVHD suppression after aHSCT. Importantly, Minnelide's GVHD prevention was accompanied by preservation of graft-versus-tumor activity. As Minnelide possesses anti-acute myeloid leukemia (anti-AML) activity and is being applied in clinical trials, together with the present findings, we conclude that this compound might provide a new approach for patients with AML undergoing aHSCT.
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Affiliation(s)
| | | | | | | | - Brent Pfeiffer
- Department of Pediatrics, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | | | | | | | - Sophie Paczesny
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Krishna V. Komanduri
- Department of Microbiology and Immunology
- Sylvester Comprehensive Cancer Center
- Department of Medicine, and
| | - Cara L. Benjamin
- Sylvester Comprehensive Cancer Center
- Department of Medicine, and
| | | | - Ashok K. Saluja
- Department of Surgery, and
- Sylvester Comprehensive Cancer Center
| | - Robert B. Levy
- Department of Microbiology and Immunology
- Sylvester Comprehensive Cancer Center
- Department of Ophthalmology, University of Miami, Miller School of Medicine, Miami, Florida, USA
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25
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Lieberman MM, Tong JH, Odukwe NU, Chavel CA, Purdon TJ, Burchett R, Gillard BM, Brackett CM, McGray AJR, Bramson JL, Brentjens RJ, Lee KP, Olejniczak SH. Endogenous CD28 drives CAR T cell responses in multiple myeloma. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.03.21.586084. [PMID: 38562904 PMCID: PMC10983979 DOI: 10.1101/2024.03.21.586084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Recent FDA approvals of chimeric antigen receptor (CAR) T cell therapy for multiple myeloma (MM) have reshaped the therapeutic landscape for this incurable cancer. In pivotal clinical trials B cell maturation antigen (BCMA) targeted, 4-1BB co-stimulated (BBζ) CAR T cells dramatically outperformed standard-of-care chemotherapy, yet most patients experienced MM relapse within two years of therapy, underscoring the need to improve CAR T cell efficacy in MM. We set out to determine if inhibition of MM bone marrow microenvironment (BME) survival signaling could increase sensitivity to CAR T cells. In contrast to expectations, blocking the CD28 MM survival signal with abatacept (CTLA4-Ig) accelerated disease relapse following CAR T therapy in preclinical models, potentially due to blocking CD28 signaling in CAR T cells. Knockout studies confirmed that endogenous CD28 expressed on BBζ CAR T cells drove in vivo anti-MM activity. Mechanistically, CD28 reprogrammed mitochondrial metabolism to maintain redox balance and CAR T cell proliferation in the MM BME. Transient CD28 inhibition with abatacept restrained rapid BBζ CAR T cell expansion and limited inflammatory cytokines in the MM BME without significantly affecting long-term survival of treated mice. Overall, data directly demonstrate a need for CD28 signaling for sustained in vivo function of CAR T cells and indicate that transient CD28 blockade could reduce cytokine release and associated toxicities.
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Affiliation(s)
- Mackenzie M. Lieberman
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Jason H. Tong
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Nkechi U. Odukwe
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Colin A. Chavel
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Terence J. Purdon
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Rebecca Burchett
- Department of Pathology and Molecular Medicine, McMaster Immunology Research Centre, McMaster University, Hamilton, ON, Canada
| | - Bryan M. Gillard
- Department of Pharmacology and Therapeutics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Craig M. Brackett
- Department of Cell Stress Biology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - A. J. Robert McGray
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Jonathan L. Bramson
- Department of Pathology and Molecular Medicine, McMaster Immunology Research Centre, McMaster University, Hamilton, ON, Canada
| | - Renier J. Brentjens
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Kelvin P. Lee
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN, 46202, USA
| | - Scott H. Olejniczak
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
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26
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Takahashi T, Watkins B, Bratrude B, Neuberg D, Hebert K, Betz K, Yu A, Choi SW, Davis J, Duncan C, Giller R, Grimley M, Harris AC, Jacobsohn D, Lalefar N, Farhadfar N, Pulsipher MA, Shenoy S, Petrovic A, Schultz KR, Yanik GA, Blazar BR, Horan JT, Langston A, Kean LS, Qayed M. The Adverse Event Landscape of Stem Cell Transplant: Evidence for aGVHD Driving Early Transplant Associated Toxicities. Transplant Cell Ther 2024:S2666-6367(24)00317-8. [PMID: 38583802 DOI: 10.1016/j.jtct.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 03/26/2024] [Accepted: 03/30/2024] [Indexed: 04/09/2024]
Abstract
Although unrelated-donor (URD) hematopoietic cell transplantation (HCT) is associated with many toxicities, a detailed analysis of adverse events, as defined by the Common Terminology Criteria for Adverse Events (CTCAE), has not previously been curated. This represents a major unmet need, especially as it relates to assessing the safety of novel agents. We analyzed a detailed AE database from the "ABA2" randomized, double-blind, placebo-controlled clinical trial of abatacept for acute graft-versus-host disease (aGVHD) prevention, for which the FDA mandated a detailed AE assessment through Day +180, and weekly neutrophil and platelet counts through Day +100. These were analyzed for their relationship to key transplant outcomes, with a major focus on the impact of aGVHD on the development/severity of AEs. A total of 2102 AEs and 1816 neutrophil/platelet counts were analyzed from 142 8/8-HLA-matched URD HCT recipients on ABA2 (placebo cohort, n = 69, abatacept cohort, n = 73). This analysis resulted in 2 major observations. (1) Among graft source, conditioning intensity, age, and Grade 2 to 4 aGVHD, only aGVHD impacted Grade 3 to 5 AE acquisition after the first month post-transplant. (2) The development of Grade 3 to 4 aGVHD was associated with thrombocytopenia. We have created a detailed resource for the transplant community by which to contextualize clinical toxicities after transplant. It has identified aGVHD as a major driver of post-HCT Grade 3 to 5 AEs, and underscored a link between aGVHD and thrombocytopenia. This establishes a critical safety framework upon which the impact of novel post-transplant aGVHD therapeutics should be evaluated. This trial was registered at www.clinicaltrials.gov (#NCT01743131).
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Affiliation(s)
- Takuto Takahashi
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, Georgia
| | - Brandi Bratrude
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Donna Neuberg
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kyle Hebert
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kayla Betz
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Alison Yu
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Jeffrey Davis
- BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christine Duncan
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Roger Giller
- Center for Cancer and Blood Disorders, Children Hospital of Colorado, University of Colorado, Aurora, Colorado
| | - Michael Grimley
- University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Andrew C Harris
- Memorial Sloan Kettering Cancer Center, New York City, New York
| | - David Jacobsohn
- Children's National Health System, Washington, District of Columbia
| | - Nahal Lalefar
- University of California San Francisco, UCSF Benioff Children's Hospital Oakland, Oakland, California
| | | | - Michael A Pulsipher
- Spencer Fox Eccles School of Medicine at the University of Utah, Intermountain Primary Children's Hospital, Salt Lake City, Utah
| | - Shalini Shenoy
- Washington University School of Medicine, St Louis, Missouri
| | - Aleksandra Petrovic
- Seattle Children's Hospital and Fred Hutch Cancer Center, Seattle, Washington
| | - Kirk R Schultz
- BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Bruce R Blazar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - John T Horan
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amelia Langston
- Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Leslie S Kean
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, Georgia
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27
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Neidemire-Colley L, Khanal S, Braunreiter KM, Gao Y, Kumar R, Snyder KJ, Weber MA, Surana S, Toirov O, Karunasiri M, Duszynski ME, Chi M, Malik P, Kalyan S, Chan WK, Naeimi Kararoudi M, Choe HK, Garzon R, Ranganathan P. CRISPR/Cas9 deletion of MIR155HG in human T cells reduces incidence and severity of acute GVHD in a xenogeneic model. Blood Adv 2024; 8:947-958. [PMID: 38181781 PMCID: PMC10877121 DOI: 10.1182/bloodadvances.2023010570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 12/19/2023] [Accepted: 12/19/2023] [Indexed: 01/07/2024] Open
Abstract
ABSTRACT Acute graft-versus-host disease (GVHD) is a major complication of allogeneic hematopoietic cell transplantation (allo-HCT). Using preclinical mouse models of disease, previous work in our laboratory has linked microRNA-155 (miR-155) to the development of acute GVHD. Transplantation of donor T cells from miR-155 host gene (MIR155HG) knockout mice prevented acute GVHD in multiple murine models of disease while maintaining critical graft-versus-leukemia (GVL) response, necessary for relapse prevention. In this study, we used clustered, regularly interspaced, short palindromic repeats (CRISPR)/Cas9 genome editing to delete miR-155 in primary T cells (MIR155HGΔexon3) from human donors, resulting in stable and sustained reduction in expression of miR-155. Using the xenogeneic model of acute GVHD, we show that NOD/SCID/IL2rγnull (NSG) mice receiving MIR155HGΔexon3 human T cells provide protection from lethal acute GVHD compared with mice that received human T cells with intact miR-155. MIR155HGΔexon3 human T cells persist in the recipients displaying decreased proliferation potential, reduced pathogenic T helper-1 cell population, and infiltration into GVHD target organs, such as the liver and skin. Importantly, MIR155HGΔexon3 human T cells retain GVL response significantly improving survival in an in vivo model of xeno-GVL. Altogether, we show that CRISPR/Cas9-mediated deletion of MIR155HG in primary human donor T cells is an innovative approach to generate allogeneic donor T cells that provide protection from lethal GVHD while maintaining robust antileukemic response.
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Affiliation(s)
- Lotus Neidemire-Colley
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
- Biological Sciences Graduate Program, The Ohio State University, Columbus, OH
| | - Shrijan Khanal
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
- Molecular, Cellular and Developmental Biology Graduate Program, The Ohio State University, Columbus, OH
| | - Kara M. Braunreiter
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
- Pelotonia Institute for Immuno-Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Yandi Gao
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
- Pelotonia Institute for Immuno-Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Rathan Kumar
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
- Biological Sciences Graduate Program, The Ohio State University, Columbus, OH
| | - Katiri J. Snyder
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
- Biological Sciences Graduate Program, The Ohio State University, Columbus, OH
| | - Margot A. Weber
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Simran Surana
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Olimjon Toirov
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Malith Karunasiri
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Molly E. Duszynski
- Division of Experimental Hematology and Cancer Biology, Cancer and Blood Disease Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Mengna Chi
- Division of Experimental Hematology and Cancer Biology, Cancer and Blood Disease Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Punam Malik
- Division of Experimental Hematology and Cancer Biology, Cancer and Blood Disease Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Sonu Kalyan
- Department of Pathology, New York University Langone Health, Long Island, NY
| | - Wing K. Chan
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Meisam Naeimi Kararoudi
- Center for Childhood Cancer and Blood Diseases, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Hannah K. Choe
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
- Pelotonia Institute for Immuno-Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Ramiro Garzon
- Division of Hematology and Hematological Malignancies, Huntsman Cancer Institute, The University of Utah, Salt Lake City, UT
| | - Parvathi Ranganathan
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
- Pelotonia Institute for Immuno-Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
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28
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Fingerson S, Maiers M, Bolon YT, Devine SM, Spellman SR. Expanding donor options: haploidentical transplant recipients are also highly likely to have a 7/8-matched unrelated donor. Blood Adv 2024; 8:758-765. [PMID: 38127270 PMCID: PMC10847856 DOI: 10.1182/bloodadvances.2023011814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
ABSTRACT The use of haploidentical related donor (HRD) hematopoietic cell transplants (HCTs) in the United States grew by more than fourfold in the last decade, driven mainly by use of posttransplant cyclophosphamide (PTCy)-based graft-versus-host-disease prophylaxis. However, not all patients have a suitable HRD available. In this study, we explored the existence of unrelated donors (URDs) on the National Marrow Donor Program (NMDP) registry at the 8/8- or 7/8-match level for patients receiving HRD HCT in the United States and reporting to the Center for International Blood and Marrow Transplant Research between 2013 and 2020. The data consist of 9696 HRD HCT recipients. The NMDP search prognosis score and a search simulation were used to estimate counts of URD matches on the registry. NMDP search prognosis varied by patient ancestry, with 27.5% non-Hispanic White having a good score compared with 4.6% of African American HRD HCT recipients. Overall, 34% of recipients had ≥1 8/8-matched URDs and 84% had ≥1 7/8 URDs. Recipients of older HRDs (≥35 years) had a likelihood of between 20%- 65% of having ≥5 existing 7/8-matched URDs who were aged ≤35 years. Donor-selection practices varied among the 10 highest-volume HRD centers: 6 had >20% chance of an existing 8/8-matched URD for their HRD recipients, whereas 4 centers had low likelihood of identifying an 8/8-matched URD. In conclusion, although most US patients undergoing HRD HCT do not have an existing 8/8 URD, the majority have an existing 7/8-matched URD. Studies comparing outcomes in patients receiving either HRD or 7/8-matched URD HCT and PTCy-based graft-versus-host disease prophylaxis may be warranted.
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Affiliation(s)
- Stephanie Fingerson
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program, Minneapolis, MN
| | - Martin Maiers
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program, Minneapolis, MN
| | - Yung-Tsi Bolon
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program, Minneapolis, MN
| | - Steven M. Devine
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program, Minneapolis, MN
| | - Stephen R. Spellman
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program, Minneapolis, MN
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29
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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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30
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Pennington KM, Simonetto D, Taner T, Mangaonkar AA. Pulmonary, Hepatic, and Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Telomere Biology Disorders. Curr Hematol Malig Rep 2024:10.1007/s11899-024-00724-z. [PMID: 38315384 DOI: 10.1007/s11899-024-00724-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 02/07/2024]
Abstract
PURPOSE OF THE REVIEW This study aimed to summarize evidence and provide consensus-based guidelines for management of transplantation in patients with telomere biology disorders (TBD). Specifically, this review focuses on clinical management of lung, liver, and bone marrow transplantation in TBD patients. RECENT FINDINGS TBD patients have specific unique biological vulnerabilities such as T cell immunodeficiency, susceptibility to infections, hypersensitivity to chemotherapy and radiation, and cytopenias. Furthermore, multiple organ involvement at diagnosis makes clinical management especially challenging due to higher degree of organ damage, and stress-induced telomeric crisis. Sequential and combined organ transplants, development of novel radiation and alkylator-free conditioning regimen, and use of novel drugs for graft-versus-host disease prophylaxis are some of the recent updates in the field. Multidisciplinary management is essential to optimize transplant outcomes in patients with TBD. In this review, we provide consensus-based transplant management guidelines for clinical management of transplant in TBD.
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Affiliation(s)
| | - Douglas Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, USA.
| | - Timucin Taner
- Departments of Surgery and Immunology, Mayo Clinic, Rochester, USA.
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31
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Penack O, Marchetti M, Aljurf M, Arat M, Bonifazi F, Duarte RF, Giebel S, Greinix H, Hazenberg MD, Kröger N, Mielke S, Mohty M, Nagler A, Passweg J, Patriarca F, Ruutu T, Schoemans H, Solano C, Vrhovac R, Wolff D, Zeiser R, Sureda A, Peric Z. Prophylaxis and management of graft-versus-host disease after stem-cell transplantation for haematological malignancies: updated consensus recommendations of the European Society for Blood and Marrow Transplantation. Lancet Haematol 2024; 11:e147-e159. [PMID: 38184001 DOI: 10.1016/s2352-3026(23)00342-3] [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: 07/04/2023] [Revised: 10/16/2023] [Accepted: 11/08/2023] [Indexed: 01/08/2024]
Abstract
Graft-versus-host disease (GVHD) is a major factor contributing to mortality and morbidity after allogeneic haematopoietic stem-cell transplantation (HSCT). In the last 3 years, there has been regulatory approval of new drugs and considerable change in clinical approaches to prophylaxis and management of GVHD. To standardise treatment approaches, the European Society for Blood and Marrow Transplantation (EBMT) has updated its clinical practice recommendations. We formed a panel of one methodologist and 22 experts in the field of GVHD management. The selection was made on the basis of their role in GVHD management in Europe and their contributions to the field, such as publications, presentations at conferences, and other research. We applied the GRADE process to ten PICO (patient, intervention, comparator, and outcome) questions: evidence was searched for by the panel and graded for each crucial outcome. In two consensus meetings, we discussed the evidence and voted on the wording and strengths of recommendations. Key updates to the recommendations include: (1) primary use of ruxolitinib in steroid-refractory acute GVHD and steroid-refractory chronic GVHD as the new standard of care, (2) use of rabbit anti-T-cell (thymocyte) globulin or post-transplantation cyclophosphamide as standard GVHD prophylaxis in peripheral blood stem-cell transplantations from unrelated donors, and (3) the addition of belumosudil to the available treatment options for steroid-refractory chronic GVHD. The EBMT proposes to use these recommendations as the basis for routine management of GVHD during allogenic HSCT. The current recommendations favour European practice and do not necessarily represent global preferences.
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Affiliation(s)
- Olaf Penack
- Department of Hematology, Oncology and Tumorimmunology, Charité - Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.
| | - Monia Marchetti
- Hematology Service, Oncology Unit, Hospital Cardinal Massaia, Asti, Italy
| | - Mahmoud Aljurf
- Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mutlu Arat
- Istanbul Florence Nightingale Hospital, Stem Cell Transplantation Unit, Istanbul, Türkiye
| | | | - Rafael F Duarte
- Hematopoietic Transplantation and Hemato-Oncology Section, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Sebastian Giebel
- Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Hildegard Greinix
- Division of Hematology, Medical University Graz, Auenbruggerplatz, Graz, Austria
| | - Mette D Hazenberg
- Department of Hematology, Amsterdam University Medical Centers, University of Amsterdam, Netherlands
| | | | - Stephan Mielke
- Karolinska Instituet and University Hospital, Department of Laboratory Medicine, Cell Therapy and Allogenic Stem Cell Transplantation (CAST), Stockholm, Sweden
| | - Mohamad Mohty
- Department of Haematology, Hôpital Saint-Antoine, Sorbonne University, Institut National de la Santé et de la Recherche Médicale (INSERM) Paris, France
| | - Arnon Nagler
- Hematology and Bone Marrow Transplant, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Jakob Passweg
- Hematology Division, University Hospital, Basel, Switzerland
| | - Francesca Patriarca
- Haematological Clinic and Transplant Centre, University Hospital of Central Friuli, Dipartimento Area Medica, University of Udine, Udine, Italy
| | - Tapani Ruutu
- Helsinki University Hospital Comprehensive Cancer Center and Clinical Research Institute, Helsinki University Hospital, Helsinki, Finland
| | - Hélène Schoemans
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium; Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery (AccentVV), KU Leuven, Leuven, Belgium
| | - Carlos Solano
- Hematology Department, Hospital Clínico Universitario - INCLIVA, University of Valencia, Valencia, Spain
| | - Radovan Vrhovac
- Department of Haematology, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Daniel Wolff
- Medical Clinic 3, Haematology and Oncology, Klinikum der Universität Regensburg, Regensburg, Germany
| | - Robert Zeiser
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Freiburg University Medical Center, Freiburg, Germany
| | - Anna Sureda
- Clinical Hematology Department, Institut Català d'Oncologia-Hospitalet, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), University of Barcelona, Barcelona, Spain
| | - Zinaida Peric
- Department of Haematology, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
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32
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Gabelli M, Pérez-Martínez A, Bueno Sánchez D, Lucchini G, Grenier LP, Couture F, Limerick E, Bernaud V, Trabazo Del Castillo M, Ngwube A. Abatacept treatment for autoimmune hemolytic anemia occurring post hematopoietic stem cell transplantation. Bone Marrow Transplant 2024; 59:288-290. [PMID: 38097758 DOI: 10.1038/s41409-023-02173-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 11/29/2023] [Accepted: 12/01/2023] [Indexed: 02/09/2024]
Affiliation(s)
- Maria Gabelli
- Bone Marrow Transplantation, Great Ormond Street Hospital for Children, London, United Kingdom.
- Pediatric Hematology, Oncology and Stem Cell Transplantation, Università degli Studi di Padova, Padova, Italy.
| | - Antonio Pérez-Martínez
- Pediatric Hematology, Oncology and Stem Cell Transplantation, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación La Paz, Madrid, Spain
| | - David Bueno Sánchez
- Pediatric Hematology, Oncology and Stem Cell Transplantation, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación La Paz, Madrid, Spain
| | - Giovanna Lucchini
- Bone Marrow Transplantation, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Louis-Philippe Grenier
- Bone Marrow Transplantation, CHU de Québec-Université Laval, Hotel-Dieu de Québec, Québec, Canada
| | - Felix Couture
- Bone Marrow Transplantation, CHU de Québec-Université Laval, Hotel-Dieu de Québec, Québec, Canada
| | - Emily Limerick
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Victoria Bernaud
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Maria Trabazo Del Castillo
- Pediatric Hematology, Oncology and Stem Cell Transplantation, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Alexander Ngwube
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, USA
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33
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Magenau J, Jaglowski S, Uberti J, Farag SS, Riwes MM, Pawarode A, Anand S, Ghosh M, Maciejewski J, Braun T, Devenport M, Lu S, Banerjee B, DaSilva C, Devine S, Zhang MJ, Burns LJ, Liu Y, Zheng P, Reddy P. A phase 2 trial of CD24Fc for prevention of graft-versus-host disease. Blood 2024; 143:21-31. [PMID: 37647633 PMCID: PMC10934299 DOI: 10.1182/blood.2023020250] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/25/2023] [Accepted: 08/13/2023] [Indexed: 09/01/2023] Open
Abstract
ABSTRACT Patients who undergo human leukocyte antigen-matched unrelated donor (MUD) allogeneic hematopoietic stem cell transplantation (HSCT) with myeloablative conditioning for hematologic malignancies often develop acute graft-versus-host disease (GVHD) despite standard calcineurin inhibitor-based prophylaxis in combination with methotrexate. This trial evaluated a novel human CD24 fusion protein (CD24Fc/MK-7110) that selectively targets and mitigates inflammation due to damage-associated molecular patterns underlying acute GVHD while preserving protective immunity after myeloablative conditioning. This phase 2a, multicenter study evaluated the pharmacokinetics, safety, and efficacy of CD24Fc in combination with tacrolimus and methotrexate in preventing acute GVHD in adults undergoing MUD HSCT for hematologic malignancies. A double-blind, placebo-controlled, dose-escalation phase to identify a recommended dose was followed by an open-label expansion phase with matched controls to further evaluate the efficacy and safety of CD24Fc in preventing acute GVHD. A multidose regimen of CD24Fc produced sustained drug exposure with similar safety outcomes when compared with single-dose regimens. Grade 3 to 4 acute GVHD-free survival at day 180 was 96.2% (95% confidence interval [CI], 75.7-99.4) in the CD24Fc expansion cohort (CD24Fc multidose), compared with 73.6% (95% CI, 63.2-81.4) in matched controls (hazard ratio, 0.1 [95% CI, 0.0-0.6]; log-rank test, P = .03). No participants in the CD24Fc escalation or expansion phases experienced dose-limiting toxicities (DLTs). The multidose regimen of CD24Fc was well tolerated with no DLTs and was associated with high rates of severe acute GVHD-free survival after myeloablative MUD HSCT. This trial was registered at ClinicalTrials.gov as #NCT02663622.
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Affiliation(s)
- John Magenau
- Transplantation and Cellular Therapy Program, Rogel Cancer Center, University of Michigan, Ann Arbor, MI
| | - Samantha Jaglowski
- The James Cancer Hospital and Solove Research Institute, Ohio State University, Columbus, OH
| | - Joseph Uberti
- Karmanos Cancer Center, Hudson-Webber Cancer Research Center, Detroit, MI
| | - Sherif S. Farag
- Blood and Bone Marrow Stem Cell Transplant and Immune Cell Therapy Program, Indiana University, Indianapolis, IN
| | - Mary Mansour Riwes
- Transplantation and Cellular Therapy Program, Rogel Cancer Center, University of Michigan, Ann Arbor, MI
| | - Attaphol Pawarode
- Transplantation and Cellular Therapy Program, Rogel Cancer Center, University of Michigan, Ann Arbor, MI
| | - Sarah Anand
- Transplantation and Cellular Therapy Program, Rogel Cancer Center, University of Michigan, Ann Arbor, MI
| | - Monalisa Ghosh
- Transplantation and Cellular Therapy Program, Rogel Cancer Center, University of Michigan, Ann Arbor, MI
| | - John Maciejewski
- Transplantation and Cellular Therapy Program, Rogel Cancer Center, University of Michigan, Ann Arbor, MI
| | - Thomas Braun
- Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | | | | | | | | | | | - Mei-Jie Zhang
- Center for International Blood and Marrow Transplant Research, Milwaukee, WI
| | - Linda J. Burns
- Center for International Blood and Marrow Transplant Research, Milwaukee, WI
| | - Yang Liu
- OncoImmune, Inc, Rockville, MD
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | - Pan Zheng
- OncoImmune, Inc, Rockville, MD
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | - Pavan Reddy
- Transplantation and Cellular Therapy Program, Rogel Cancer Center, University of Michigan, Ann Arbor, MI
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34
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Dykes K, Tzachanis D, Koura D. A Difficult Case of Calcineurin Inhibitor Neurotoxicity Post-Haploidentical HCT With a Successful Novel Solution: Cytotoxic T-Lymphocyte-Associated Protein 4-Immunoglobulin Blockade for GVHD Prophylaxis. Cell Transplant 2024; 33:9636897241265249. [PMID: 39076086 PMCID: PMC11289812 DOI: 10.1177/09636897241265249] [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: 04/16/2024] [Revised: 06/12/2024] [Accepted: 06/12/2024] [Indexed: 07/31/2024] Open
Abstract
Post-allogeneic hematopoietic cell transplant (HCT) immunosuppression regimens are given as graft-versus-host disease (GVHD) prophylaxis. Most GVHD prophylaxis regimens are based on calcineurin inhibitors (CNIs). Unfortunately, CNIs are associated with significant associated morbidity, frequently cannot be tolerated, and often need to be discontinued. There is no consensus as to which alternative immunosuppression should be used in cases where CNIs have to be permanently discontinued. Cytotoxic T-lymphocyte-associated protein 4-immunoglobulin (CTLA4-Ig) blocking agents are well tolerated and have been used extensively in patients with autoimmune disease and as post-transplant immunosuppression. There are two CTLA4-Ig agents: belatacept and abatacept. Belatacept is routinely used in adult kidney transplantation to prevent rejection and abatacept has been approved by the Food and Drug Administration (FDA) for GVHD prophylaxis in patients undergoing a matched or one allele-mismatched unrelated allogenic HCT. Herein, we describe a case in which abatacept was given off-label to replace tacrolimus GVHD prophylaxis in a patient with neurotoxicity undergoing haploidentical HCT. This case suggests that CTLA4-Ig blockade may be a good alternative to a CNI in cases where the CNI needs to be discontinued and warrants further investigation.
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Affiliation(s)
- Kaitlyn Dykes
- Division of Hematology Oncology, Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
| | - Dimitrios Tzachanis
- Division of Blood & Bone Marrow Transplantation, Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
| | - Divya Koura
- Division of Blood & Bone Marrow Transplantation, Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
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35
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Watkins B, Qayed M. Novel approaches to acute graft-versus-host disease prevention. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:155-163. [PMID: 38066861 PMCID: PMC10727007 DOI: 10.1182/hematology.2023000426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The field of graft-versus-host disease (GvHD) has experienced significant growth, with increased number of clinical trials and the approval of several agents by the US Food and Drug Administration for both acute and chronic GvHD treatment. In addition, the development of prognostic biomarker algorithms has enabled risk stratification in acute GvHD. However, prevention remains the cornerstone of GvHD management. Notable recent changes include the expansion of donor options with the increased use of haploidentical donor and unrelated donor transplantation, the development of ex vivo selective T-cell depletion strategies, recent approval by the Food and Drug Administration of abatacept for GvHD prevention, and the application of posttransplant cyclophosphamide in matched and mismatched donor settings. In this article, we review the results of recent clinical trials in GvHD prophylaxis and discuss the changes in clinical practice and promising emerging strategies driving the field forward.
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Affiliation(s)
- Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA
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36
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Mishra A. Approaches to optimize outcomes in transplant recipients. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:723-730. [PMID: 38066935 PMCID: PMC10727018 DOI: 10.1182/hematology.2023000459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Curative therapy with an allogeneic hematopoietic cell transplant (HCT) can now be offered to a wider patient population due to improvements in donor selection, transplant conditioning regimens, and supportive care measures. However, risk of transplant-related morbidity and mortality remains, and thus appropriate transplant candidate workup pre-HCT for risk stratification and a management plan after HCT is crucial for success of the procedure. These include understanding and identifying risk of underlying malignant disease relapse, graft-versus-host disease, and infectious complications a patient may be predisposed toward, irrespective of allogeneic donor type. Progress in these domains with new therapeutic paradigms allows for development of a treatment plan prior to HCT to mitigate these potential risks tailored to the patient's case. Herein, we present case studies to focus on factors that influence decision-making in HCT and the approaches and strategies used to optimize post-HCT outcomes based on the individual HCT recipient's clinical scenario to improve on these high-risk scenarios.
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Affiliation(s)
- Asmita Mishra
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
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Weisdorf D, El Jurdi N, Holtan SG. The best GVHD prophylaxis: Or at least progress towards finding it. Best Pract Res Clin Haematol 2023; 36:101520. [PMID: 38092477 DOI: 10.1016/j.beha.2023.101520] [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] [Indexed: 12/18/2023]
Abstract
Options for GVHD prophylaxis after allogeneic hematopoietic cell transplantation can best be chosen by understanding the pathophysiology of GVHD. Interventions to limit T cell activation, expansion and subsequent tissue injury can each be utilized in designing successful GVHD prevention strategies Depleting, tolerizing or blunting T cells or host antigen presenting cells (APCs), blocking co-stimulation or more broadly suppressing inflammation have all been used. Interventions which spare regulatory T cells (Tregs) may prevent GVHD and facilitate controlled allo-responses and not compromise subsequent relapse risks. Graft manipulations and pharmacologic interventions each have potential to limit the morbidity of GVHD while permitting the immunocompetence to prevent infection or relapse.
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Affiliation(s)
- Daniel Weisdorf
- University of Minnesota, Hematology, Oncology and Transplantation, Department of Medicine, MMC 480, Minneapolis, MN, 55455, USA.
| | - Najla El Jurdi
- University of Minnesota, Hematology, Oncology and Transplantation, Department of Medicine, MMC 480, Minneapolis, MN, 55455, USA
| | - Shernan G Holtan
- University of Minnesota, Hematology, Oncology and Transplantation, Department of Medicine, MMC 480, Minneapolis, MN, 55455, USA
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38
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Kitchens WH, Larsen CP, Badell IR. Costimulatory Blockade and Solid Organ Transplantation: The Past, Present, and Future. Kidney Int Rep 2023; 8:2529-2545. [PMID: 38106575 PMCID: PMC10719580 DOI: 10.1016/j.ekir.2023.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/01/2023] [Accepted: 08/28/2023] [Indexed: 12/19/2023] Open
Abstract
Belatacept is the first costimulatory blockade agent clinically approved for transplant immunosuppression. Although more than 10 years of study have demonstrated that belatacept offers superior long-term renal allograft and patient survival compared to conventional calcineurin inhibitor (CNI)-based immunosuppression regimens, the clinical adoption of belatacept has continued to lag because of concerns of an early risk of acute cellular rejection (ACR) and various logistical barriers to its administration. In this review, the history of the clinical development of belatacept is examined, along with the findings of the seminal BENEFIT and BENEFIT-EXT trials culminating in the clinical approval of belatacept. Recent efforts to incorporate belatacept into novel CNI-free immunosuppression regimens are reviewed, as well as the experience of the Emory Transplant Center in using a tapered course of low-dose tacrolimus in belatacept-treated renal allograft patients to garner the long-term outcome benefits of belatacept without the short-term increased risks of ACR. Potential avenues to increase the clinical adoption of belatacept in the future are explored, including surmounting the logistical barriers of belatacept administration through subcutaneous administration or more infrequent belatacept dosing. In addition, belatacept conversion strategies and potential expanded clinical indications of belatacept are discussed for pediatric transplant recipients, extrarenal transplant recipients, treatment of antibody-mediated rejection (AMR), and in patients with failed renal allografts. Finally, we discuss the novel immunosuppressive drugs currently in the development pipeline that may aid in the expansion of costimulation blockade utilization.
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Affiliation(s)
- William H. Kitchens
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christian P. Larsen
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - I. Raul Badell
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Wu Y, Yu XZ. Tipping the GVH/GVL balance by targeting HIF1α. Cell Rep Med 2023; 4:101295. [PMID: 37992679 PMCID: PMC10694739 DOI: 10.1016/j.xcrm.2023.101295] [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: 10/19/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/24/2023]
Abstract
Promoting GVL activity while eliminating GVHD is the utmost goal to treat hematological malignancies with allo-HCT. Bailey et al. demonstrate that targeting HIF1α can favor GVL activity while limiting GVHD after allo-HCT even in combination with immune checkpoint inhibition.1.
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Affiliation(s)
- Yongxia Wu
- Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, WI, USA; Department of Cancer Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Xue-Zhong Yu
- Department of Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, WI, USA; Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; Department of Cancer Center, Medical College of Wisconsin, Milwaukee, WI, USA.
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Raghunandan S, Gorfinkel L, Bratrude B, Suessmuth Y, Hebert K, Neuberg D, Williams KM, Schoettler ML, Langston AA, Kean LS, Qayed M, Horan J, Watkins BK. Abatacept for the prevention of graft versus host disease in pediatric patients receiving 7/8 HLA-mismatched unrelated transplant for hematologic malignancies: a real-world analysis. Bone Marrow Transplant 2023; 58:1260-1263. [PMID: 37580396 PMCID: PMC10622310 DOI: 10.1038/s41409-023-02034-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/15/2023] [Accepted: 07/03/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Sharmila Raghunandan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA.
| | - Lev Gorfinkel
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | - Brandi Bratrude
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | - Yvonne Suessmuth
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
| | - Kyle Hebert
- Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
| | - Michelle L Schoettler
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
| | | | - Leslie S Kean
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
| | - John Horan
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | - Benjamin K Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
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Wobma H, Janssen E. Expanding IPEX: Inborn Errors of Regulatory T Cells. Rheum Dis Clin North Am 2023; 49:825-840. [PMID: 37821198 DOI: 10.1016/j.rdc.2023.06.009] [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] [Indexed: 10/13/2023]
Abstract
Regulatory T cells (Tregs) are critical for enforcing peripheral tolerance. Monogenic "Tregopathies" affecting Treg development, stability, and/or function commonly present with polyautoimmunity, atopic disease, and infection. While autoimmune manifestations may present in early childhood, as more disorders are characterized, conditions with later onset have been identified. Treg numbers in the blood may be decreased in Tregopathies, but this is not always the case, and genetic testing should be pursued when there is high clinical suspicion. Currently, hematopoietic cell transplantation is the only curative treatment, but gene therapies are in development, and small molecule inhibitors/biologics may also be used.
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Affiliation(s)
- Holly Wobma
- Division of Immunology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Erin Janssen
- Department of Pediatrics, Division of Pediatric Rheumatology, Michigan Medicine, C.S. Mott Children's Hospital, 1500 East Medical Center Drive, SPC 5718, Ann Arbor, MI 48109, USA.
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Mavers M. Inhibiting post-translational methylation to prevent GVHD. Mol Ther 2023; 31:3115-3116. [PMID: 37865095 PMCID: PMC10638046 DOI: 10.1016/j.ymthe.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/09/2023] [Accepted: 10/09/2023] [Indexed: 10/23/2023] Open
Affiliation(s)
- Melissa Mavers
- Division of Hematology and Oncology, Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO, USA.
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43
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Gooptu M, Bolaños-Meade J, Koreth J. Expanding post-transplant cyclophosphamide to matched unrelated donor transplants and beyond. Blood Rev 2023; 62:101053. [PMID: 36822991 DOI: 10.1016/j.blre.2023.101053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/23/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Affiliation(s)
- Mahasweta Gooptu
- Adult Stem-Cell Transplantation, Dana-Farber Cancer Institute, Harvard Medical School, 44 Binney Street, Boston 02215, USA
| | - Javier Bolaños-Meade
- Blood and Marrow Transplant Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, 401 N Broadway, Baltimore MD 21231, USA
| | - John Koreth
- Adult Stem-Cell Transplantation, Dana-Farber Cancer Institute, Harvard Medical School, 44 Binney Street, Boston 02215, USA.
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44
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Mohan S. Targeted Treatment of Diseases of Immune Dysregulation. Rheum Dis Clin North Am 2023; 49:913-929. [PMID: 37821203 DOI: 10.1016/j.rdc.2023.07.002] [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] [Indexed: 10/13/2023]
Abstract
Increasing molecular knowledge of autoinflammatory and autoimmune disorders has enabled more targeted treatment of these conditions. Treatment of inflammasomopathies is often aimed at interleukin-1 (IL-1) blockade, with potential use of other inhibitors targeting cytokines such as IL-18 and IL-6. Interferonopathies and some disorders with overlap features of autoimmunity and autoinflammation may improve with Janus kinase inhibition. Autoimmune conditions may also respond to inhibition of different cytokines, as well as to inhibition of T and B lymphocytes. Effective treatment is increasingly possible through targeted/precision medicine approaches.
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Affiliation(s)
- Smriti Mohan
- Division of Rheumatology, Department of Pediatrics, University of Michigan CS Mott Children's Hospital, 1500 East Medical Ctr Dr SPC 5718, Ann Arbor, MI 48109-5718, USA.
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45
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Raghunandan S, Qayed M, Watkins BK, Graiser M, Gorfinkel L, Westbrook A, Gillespie S, Bratrude B, Petrovic A, Suessmuth Y, Horan J, Kean LS, Langston AA. Abatacept for graft versus host disease prophylaxis in patients 60 years and older receiving mismatched unrelated donor transplantation for hematologic malignancies. Bone Marrow Transplant 2023; 58:1264-1266. [PMID: 37580397 PMCID: PMC10622309 DOI: 10.1038/s41409-023-02043-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/02/2023] [Accepted: 07/11/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Sharmila Raghunandan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA.
- Emory University, Atlanta, GA, USA.
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
- Emory University, Atlanta, GA, USA
| | - Ben K Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
- Emory University, Atlanta, GA, USA
| | - Michael Graiser
- Emory University, Atlanta, GA, USA
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Lev Gorfinkel
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | | | | | | | | | - Yvonne Suessmuth
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
- Emory University, Atlanta, GA, USA
| | - John Horan
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | - Leslie S Kean
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | - Amelia A Langston
- Emory University, Atlanta, GA, USA
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
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46
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Chowdhury AS, Maiers M, Spellman SR, Deshpande T, Bolon YT, Devine SM. Existence of HLA-Mismatched Unrelated Donors Closes the Gap in Donor Availability Regardless of Recipient Ancestry. Transplant Cell Ther 2023; 29:686.e1-686.e8. [PMID: 37586457 PMCID: PMC10840626 DOI: 10.1016/j.jtct.2023.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 08/18/2023]
Abstract
In patients without a matched sibling donor (MSD) or well-matched unrelated donor (MUD), hematopoietic cell transplantation (HCT) can still be successful when using an HLA-mismatched unrelated donor (MMUD) in combination with post-transplantation cyclophosphamide (PTCy), abatacept, or other novel approaches. This may allow clinicians to choose a suitable donor from a wide range of donor options while optimizing other donor selection characteristics, including donor age. We hypothesized that allowing for a 5/8 HLA match level considering high-resolution matching at HLA-A, -B, -C and -DRB1, there is a potential to close the donor availability gap for all patients regardless of their race/ethnicity. In this work, we estimate the likelihood of matching for all racial/ethnic groups at different HLA match thresholds. Our study aimed to assess the potential for identifying an available MUD or MMUD in the National Marrow Donor Program (NMDP)/Be The Match (BTM) donor registry for 21 detailed and 5 broad racial/ethnic groups, using high-resolution HLA matching for HLA-A, -B, -C, and -DRB1 at various levels (8/8, 7/8, 6/8, and 5/8). We used donor registry population data from the NMDP/BTM in 2020 and redistributed the donor registry data according to existing population ratios, accounting for demonstrated donor availability. Finally, we used a genetic model at the population level to estimate the match likelihood for detailed and broad racial/ethnic groups. Likelihood of 8/8 HLA match ranging from 16% to 74% were obtained for various detailed racial/ethnic groups with available donors age ≤35 years. When considering more mismatches in the HLA loci, registry coverage became >99% with a 5/8 HLA match level for donors of all ages or those age ≤35 years, with HLA-DPB1 T cell epitope permissive matching, or when searching for donors outside of their racial/ethnic group. Our registry models demonstrate the potential for using MMUDs at various HLA match levels to study whether this will expand access to HCT across racial/ethnic groups. Expanded donor options may erase the donor availability gap for all patients while allowing for selection of MMUDs with favorable characteristics, such as younger age.
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Affiliation(s)
- Abu Sayed Chowdhury
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Martin Maiers
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Tushar Deshpande
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Yung-Tsi Bolon
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Steven M Devine
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota.
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Xu Z, Choi J, Cooper M, King J, Fiala MA, Liu J, Pusic I, Romee R, Cashen A, Jacoby MA, Stockerl-Goldstein K, Abboud C, Vij R, Uy G, Westervelt P, Walter MJ, DiPersio JF, Schroeder MA. Phase I-II Trial of Early Azacitidine after Matched Unrelated Donor Hematopoietic Cell Transplantation. Transplant Cell Ther 2023; 29:699.e1-699.e9. [PMID: 37597685 DOI: 10.1016/j.jtct.2023.08.017] [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: 06/08/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 08/21/2023]
Abstract
Graft-versus-host disease (GVHD) is a major complication after allogeneic hematopoietic cell transplantation (allo-HCT). The hypomethylating agent azacitidine (AZA) has been shown to be effective in preclinical and clinical studies for the prevention of acute GVHD (aGVHD). We sought to determine the maximum tolerated dose (MTD) of AZA when given on days 1 to 5 of a 28-day cycle for 4 cycles, starting on day +7 after allo-HCT, as well as its impact on aGVHD and chronic GVHD (cGVHD), relapse, and overall survival (OS) in patients undergoing matched unrelated donor allo-HCT. This study was a single-arm, single-center, open-label phase I-II study with a total of 15 and 38 patients enrolled in the phase I and II portions of the trial, respectively. A standard 3+3 study design was used in phase I, and all patients in phase II received AZA at the MTD determined in phase I. The MTD of AZA starting at day +7 post-transplantation was 45 mg/m2. Phase II of the study was halted after enrolling 38 of the planned 46 patients following an interim analysis that suggested futility. Overall, AZA at 45 mg/m2 exhibited a side effect profile consistent with prior reports and had a minimal impact on engraftment. The cumulative incidence of clinically significant aGVHD by day +180 was 39.9% (95% confidence interval [CI], 22% to 53.7%). The incidence of all-grade cGVHD was 61.4% (95% CI, 40.3% to 75%). At 1 year, OS was 73.7% (95% CI, 60.9% to 89.1%), and the disease relapse rate was 11.4% (95% CI, .2% to 21.3%). Our results suggest that early post-allo-HCT AZA has limited efficacy in preventing aGVHD and cGVHD but could have a beneficial effect in preventing disease relapse.
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Affiliation(s)
- Ziheng Xu
- Washington University School of Medicine, St. Louis, Missouri
| | - Jaebok Choi
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew Cooper
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey King
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Mark A Fiala
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Iskra Pusic
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Rizwan Romee
- Department of Medicine, Harvard Medical School, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amanda Cashen
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Meagan A Jacoby
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Keith Stockerl-Goldstein
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Camille Abboud
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Ravi Vij
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Geoffrey Uy
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Peter Westervelt
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew J Walter
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - John F DiPersio
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Mark A Schroeder
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.
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Puckrin R, Kwan ACF, Blosser N, Leyshon C, Duggan P, Daly A, Zepeda V, Stewart D, Chaudhry A, Storek J, Jamani K. Corticosteroids as graft-versus-host disease prophylaxis for allogeneic hematopoietic cell transplant recipients with calcineurin inhibitor intolerance. Cytotherapy 2023; 25:1101-1106. [PMID: 37306643 DOI: 10.1016/j.jcyt.2023.05.010] [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: 01/04/2023] [Revised: 05/01/2023] [Accepted: 05/26/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND AIMS Although calcineurin inhibitors (CNIs) have a well-established role in the prevention of graft-versus-host disease (GVHD) after allogeneic hematopoietic cell transplantation (HCT), their use can be limited by significant toxicities, which may result in premature treatment discontinuation. The optimal management of patients with CNI intolerance is unknown. The objective of this study was to determine the effectiveness of corticosteroids as GVHD prophylaxis for patients with CNI intolerance. METHODS This retrospective single-center study included consecutive adult patients with hematologic malignancies who underwent myeloablative peripheral blood allogeneic HCT with anti-thymocyte globulin, CNI, and methotrexate GVHD prophylaxis in Alberta, Canada. Multivariable competing-risks regression was used to compare cumulative incidences of GVHD, relapse, and non-relapse mortality between recipients of corticosteroid versus continuous CNI prophylaxis, and multivariable Cox proportional hazards regression was applied to compare overall survival, relapse-free survival (RFS) and moderate-to-severe chronic GVHD and RFS. RESULTS Among 509 allogeneic HCT recipients, 58 (11%) patients developed CNI intolerance and were switched to corticosteroid prophylaxis at median 28 days (range 1-53) after HCT. Compared with patients who received continuous CNI prophylaxis, recipients of corticosteroid prophylaxis had significantly greater cumulative incidences of grade 2-4 acute GVHD (subhazard ratio [SHR] 1.74, 95% confidence interval [CI] 1.08-2.80, P = 0.024), grade 3-4 acute GVHD (SHR 3.22, 95% CI 1.55-6.72, P = 0.002), and GVHD-related non-relapse mortality (SHR 3.07, 95% CI 1.54-6.12, P = 0.001). There were no significant differences in moderate-to-severe chronic GVHD (SHR 0.84, 95% CI 0.43-1.63, P = 0.60) or relapse (SHR 0.92, 95% CI 0.53-1.62, P = 0.78), but corticosteroid prophylaxis was associated with significantly inferior overall survival (hazard ratio [HR] 1.77, 95% CI 1.20-2.61, P = 0.004), RFS (HR 1.54, 95% CI 1.06-2.25, P = 0.024), and chronic GVHD and RFS (HR 1.46, 95% CI 1.04-2.05, P = 0.029). CONCLUSIONS Allogeneic HCT recipients with CNI intolerance are at increased risks of acute GVHD and poor outcomes despite institution of corticosteroid prophylaxis following premature CNI discontinuation. Alternative GVHD prophylaxis strategies are needed for this high-risk population.
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Affiliation(s)
- Robert Puckrin
- Tom Baker Cancer Centre and University of Calgary, Calgary, Alberta, Canada.
| | - Alex Chi Fung Kwan
- Cross Cancer Institute and University of Alberta, Edmonton, Alberta, Canada
| | - Nikki Blosser
- Tom Baker Cancer Centre and University of Calgary, Calgary, Alberta, Canada
| | - Catherine Leyshon
- Tom Baker Cancer Centre and University of Calgary, Calgary, Alberta, Canada
| | - Peter Duggan
- Tom Baker Cancer Centre and University of Calgary, Calgary, Alberta, Canada
| | - Andrew Daly
- Tom Baker Cancer Centre and University of Calgary, Calgary, Alberta, Canada
| | - Victor Zepeda
- Tom Baker Cancer Centre and University of Calgary, Calgary, Alberta, Canada
| | - Douglas Stewart
- Tom Baker Cancer Centre and University of Calgary, Calgary, Alberta, Canada
| | - Ahsan Chaudhry
- Tom Baker Cancer Centre and University of Calgary, Calgary, Alberta, Canada
| | - Jan Storek
- Tom Baker Cancer Centre and University of Calgary, Calgary, Alberta, Canada
| | - Kareem Jamani
- Tom Baker Cancer Centre and University of Calgary, Calgary, Alberta, Canada
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Jamy O, Zeiser R, Chen YB. Novel developments in the prophylaxis and treatment of acute GVHD. Blood 2023; 142:1037-1046. [PMID: 37471585 DOI: 10.1182/blood.2023020073] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/27/2023] [Accepted: 07/13/2023] [Indexed: 07/22/2023] Open
Abstract
Acute graft-versus-host disease (aGVHD) is a major life-threatening complication after allogeneic hematopoietic cell transplant. Traditional standard prophylaxis for aGVHD has included a calcineurin inhibitor plus an antimetabolite, whereas treatment has relied mainly on corticosteroids, followed by multiple nonstandard second-line options. In the past decade, this basic framework has been reshaped by approval of antithymocyte globulin products, the emergence of posttransplant cyclophosphamide, and recent pivotal trials studying abatacept and vedolizumab for GVHD prophylaxis, whereas ruxolitinib was approved for corticosteroid-refractory aGVHD treatment. Because of this progress, routine acute GVHD prophylaxis and treatment practices are starting to shift, and results of ongoing trials are eagerly awaited. Here, we review recent developments in aGVHD prevention and therapy, along with ongoing and future planned clinical trials in this space, outlining what future goals should be and the limitations of current clinical trial designs and end points.
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Affiliation(s)
- Omer Jamy
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Robert Zeiser
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, Albert Ludwigs University, Freiburg, Germany
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cell Therapy Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Gottardi F, Leardini D, Muratore E, Baccelli F, Cerasi S, Venturelli F, Zanaroli A, Belotti T, Prete A, Masetti R. Treatment of steroid-refractory graft versus host disease in children. FRONTIERS IN TRANSPLANTATION 2023; 2:1251112. [PMID: 38993897 PMCID: PMC11235274 DOI: 10.3389/frtra.2023.1251112] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/17/2023] [Indexed: 07/13/2024]
Abstract
Systemic steroids are still the first-line approach in acute graft-versus-host disease (aGvHD), and the backbone of chronic GvHD management. Refractoriness to steroid represent a major cause of morbidity and non-relapse mortality after hematopoietic stem cell transplantation (HSCT). In both backgrounds, several second-line immunosuppressive agents have been tested with variable results in terms of efficacy and toxicity. Solid evidence regarding these approaches is still lacking in the pediatric setting where results are mainly derived from adult experiences. Furthermore, the number of treated patients is limited and the incidence of acute and chronic GvHD is lower, resulting in a very heterogeneous approach to this complication by pediatric hematologists. Some conventional therapies and anti-cytokine monoclonal antibodies used in the adult setting have been evaluated in children. In recent years, the increasing understanding of the biological mechanisms underpinning the pathogenesis of GvHD justified the efforts toward the adoption of targeted therapies and non-pharmacologic approaches, with higher response rates and lower immunosuppressive effects. Moreover, many questions regarding the precise timing and setting in which to integrate these new approaches remain unanswered. This Review aims to critically explore the current evidence regarding novel approaches to treat SR-GvHD in pediatric HSCT recipients.
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Affiliation(s)
- Francesca Gottardi
- Pediatric Oncology and Hematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Davide Leardini
- Pediatric Oncology and Hematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Edoardo Muratore
- Pediatric Oncology and Hematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Baccelli
- Pediatric Oncology and Hematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sara Cerasi
- Pediatric Oncology and Hematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Venturelli
- Pediatric Oncology and Hematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Zanaroli
- Pediatric Oncology and Hematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Tamara Belotti
- Pediatric Oncology and Hematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Arcangelo Prete
- Pediatric Oncology and Hematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Riccardo Masetti
- Pediatric Oncology and Hematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
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