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Notarantonio AB, Robin M, D'Aveni M. Current challenges in conditioning regimens for MDS transplantation. Blood Rev 2024; 67:101223. [PMID: 39089962 DOI: 10.1016/j.blre.2024.101223] [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: 06/03/2024] [Revised: 07/07/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024]
Abstract
Myelodysplastic syndrome (MDS) is a very heterogeneous clonal disorder. Patients with "higher-risk" MDS, defined by specific recurrent genetic abnormalities, have a poor prognosis because of a high risk of progression to secondary acute myeloid leukemia with low chemosensitivity. Allogeneic hematopoietic stem cell transplantation remains the only treatment that offers durable disease control because the donor immune system allows graft-versus-MDS effects. In terms of preparation steps before transplantation, targeting the malignant clone by increasing the conditioning regimen intensity is still a matter of intense debate. MDS is mainly diagnosed in older patients, and high toxicity related to common myeloablative conditioning regimens has been reported. Efforts to include new drugs in the conditioning regimen to achieve the best malignant clone control without increasing toxicity have been made over the past 20 years. We summarized these retrospective and prospective studies and evaluated the limitations of the available evidence to delineate the ideal conditioning regimen.
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Affiliation(s)
- A B Notarantonio
- Hematology Department, University Hospital of Nancy, France; CNRS 7365, IMoPA, University of Lorraine, F-54000, France
| | - M Robin
- Hematology Department, Saint-Louis Hospital, APHP, Paris, France
| | - M D'Aveni
- Hematology Department, University Hospital of Nancy, France; CNRS 7365, IMoPA, University of Lorraine, F-54000, France.
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2
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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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3
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Chaekal OK, Gomez-Arteaga A, Chen Z, Soave R, Shore T, Mayer S, Phillips A, Hsu JM, Drelick A, Kodiyanplakkal RPL, Plate M, Satlin MJ, van Besien K. Predictors of Covid-19 Vaccination Response After In-Vivo T-Cell-Depleted Stem Cell Transplantation. Transplant Cell Ther 2022; 28:618.e1-618.e10. [PMID: 35724850 PMCID: PMC9213029 DOI: 10.1016/j.jtct.2022.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 05/26/2022] [Accepted: 06/13/2022] [Indexed: 01/06/2023]
Abstract
Covid-19 vaccination is recommended in allogeneic transplant recipients, but many questions remain regarding its efficacy. Here we studied serologic responses in 145 patients who had undergone allogeneic transplantation using in vivo T-cell depletion. Median age was 57 (range 21-79) at transplantation and 61 (range 24-80) at vaccination. Sixty-nine percent were Caucasian. One third each received transplants from HLA-identical related (MRD), adult unrelated (MUD), or haploidentical-cord blood donors. Graft-versus-host disease (GVHD) prophylaxis involved in-vivo T-cell depletion using alemtuzumab for MRD or MUD transplants and anti-thymocyte globulin for haplo-cord transplants. Patients were vaccinated between January 2021 and January 2022, an average of 31 months (range 3-111 months) after transplantation. Sixty-one percent received the BNT162b2 (bioNtech/Pfizer) vaccine, 34% received mRNA-1273 (Moderna), and 5% received JNJ-78436735 (Johnson & Johnson). After the initial vaccinations (2 doses for BNT162b2 and mRNA-1273, 1 dose for JNJ-7843673), 124 of the 145 (85%) patients had a detectable SARS-CoV-2 spike protein (S) antibody, and 21 (15%) did not respond. Ninety-nine (68%) had high-level responses (≥100 binding antibody units [BAU]/mL)m and 25 (17%) had a low-level response (<100 BAU/mL). In multivariable analysis, lymphocyte count less than 1 × 109/ mL, having chronic GVHD, and being vaccinated in the first year after transplantation emerged as independent predictors for poor response. Neither donor source nor prior exposure to rituximab was predictive of antibody response. SARS-CoV-2 vaccination induced generally high response rates in recipients of allogeneic transplants including recipients of umbilical cord blood transplants and after in-vivo T cell depletion. Responses are less robust in those vaccinated in the first year after transplantation, those with low lymphocyte counts, and those with chronic GVHD.
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Affiliation(s)
- Ok-Kyong Chaekal
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York; Department of Medicine, Division of Hematology/Oncology, Cell Therapy Program, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - Alexandra Gomez-Arteaga
- Department of Medicine, Division of Hematology/Oncology, Cell Therapy Program, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - Zhengming Chen
- Division of Biostatistics, Department of Population Sciences, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - Rosemary Soave
- Division of Infectious Diseases, Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - Tsiporah Shore
- Department of Medicine, Division of Hematology/Oncology, Cell Therapy Program, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - Sebastian Mayer
- Department of Medicine, Division of Hematology/Oncology, Cell Therapy Program, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - Adrienne Phillips
- Department of Medicine, Division of Hematology/Oncology, Cell Therapy Program, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - Jing Mei Hsu
- Department of Medicine, Division of Hematology/Oncology, Cell Therapy Program, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - Alexander Drelick
- Division of Infectious Diseases, Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - Rosy Priya L Kodiyanplakkal
- Division of Infectious Diseases, Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - Markus Plate
- Division of Infectious Diseases, Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - Michael J Satlin
- Division of Infectious Diseases, Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - Koen van Besien
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York; Department of Medicine, Division of Hematology/Oncology, Cell Therapy Program, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York.
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A phase 1 trial utilizing TMI with fludarabine-melphalan in patients with hematologic malignancies undergoing second allo-SCT. Blood Adv 2022; 7:285-292. [PMID: 35851593 PMCID: PMC9898602 DOI: 10.1182/bloodadvances.2022007530] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 02/01/2023] Open
Abstract
Relapse after allogeneic stem cell transplantation (allo-SCT) remains the primary cause of treatment failure. A second SCT can result in long-term survival in a subset of patients, but the relapse rate remains high. We conducted a single-center, phase 1, modified 3 + 3 dose-escalation study of the feasibility of combining intensity-modulated total marrow irradiation (IM-TMI) with fludarabine and melphalan for conditioning. Between December 2015 and May 2020, 21 patients with relapsed hematologic disease undergoing second or greater allo-SCT were treated with IM-TMI doses of 6 Gy, 9 Gy, or 12 Gy. Dose-limiting toxicity was defined as a grade 3 or higher treatment-related adverse event; mucositis was the primary dose-limiting toxicity. The median times to neutrophil and platelet engraftment were 10 and 18 days, respectively. The 1-year cumulative incidence of graft-versus-host disease was 65% (95% confidence interval CI, 38-83). The nonrelapse mortality at 2 years was 17% (95% CI, 4-39). Cumulative incidence of relapse at 2 years was 35% (95% CI, 13-58). Two-year progression-free survival and overall survival were 48% and 50%. We conclude that combining IM-TMI with fludarabine-melphalan is feasible. We recommend 12 Gy of IM-TMI with fludarabine-melphalan for second SCT, although 9 Gy may be used for older or underweight patients.
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Curative potential of fludarabine, melphalan, and non-myeloablative dosage of busulfan in elderly patients with myeloid malignancy. Int J Hematol 2019; 111:247-255. [DOI: 10.1007/s12185-019-02763-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 10/15/2019] [Accepted: 10/16/2019] [Indexed: 01/24/2023]
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Full donor chimerism without graft-versus-host disease: the key factor for maximum benefit of pre-emptive donor lymphocyte infusions (pDLI). Bone Marrow Transplant 2019; 55:562-569. [PMID: 31558789 DOI: 10.1038/s41409-019-0695-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/15/2019] [Accepted: 08/05/2019] [Indexed: 11/08/2022]
Abstract
Compared to standard-conditioned regimens, reduced-intensity conditioning and T-cell depletion deliver lower transplant-related mortality and decreased graft-vs-host disease after allogeneic hematopoietic stem-cell transplantation. These advantages may however be mitigated by increased relapse rates and delays in achievement of full donor chimerism (FDC). Pre-emptive donor lymphocyte infusions (pDLI) facilitate the conversion of mixed (MDC) to FDC. However, there is a lack of published data on the risk/benefit analysis of this intervention. We performed a retrospective analysis of 119 patients who received 276 pDLI doses for falling CD3 chimerism, CD3 < 50% or mixed XX/XY karyotype. 71/119(60%) Patients achieved FDC, with only one reverting to MDC. Cumulative incidence (CI) of relapse at 5 years was significantly lower in the FDC group (16.0 vs 41.4%, p < 0.001). Those patients who achieved FDC had improved EFS (p < 0.001) and OS (p < 0.001). Interestingly, patients with FDC who developed DLI-induced graft-vs-host disease (GvHD) showed a similar outcome to those with MDC. The majority of patients who receive pDLI convert to FDC and retain that status. Achievement of FDC after pDLI impacts on survival, and those patients who achieve FDC without GvHD, experience maximum clinical benefit. Strategies to minimise DLI-induced GvHD should be considered to maximise the therapeutic potential of this intervention.
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Robin M, Raj K, Chevret S, Gauthier J, de Lavallade H, Michonneau D, McLornan D, Peffault de Latour R, Potter V, Kulasekararaj A, Sicre de Fontbrune F, Pagliuca A, Yakoub-Agha I, Socié G, Mufti GJ. Alemtuzumab vs anti-thymocyte globulin in patients transplanted from an unrelated donor after a reduced intensity conditioning. Eur J Haematol 2018; 101:466-474. [PMID: 29714032 DOI: 10.1111/ejh.13085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Relapse and graft-vs-host disease (GVHD) are still the main complications after allogeneic hematopoietic stem cell transplantation, especially in the setting of reduced intensity regimen (RIC) and unrelated donor. We compared here anti-thymocyte globulin (ATG) or alemtuzumab as GVHD prophylaxis in patients with myeloid disease transplanted after RIC and from an unrelated donor. METHOD ATG and alemtuzumab patients have been matched by age, gender, HLA matching, comorbidities and cytogenetics risk (119 patients in each group). RESULTS After matching, we found that ATG decreased the risk of relapse (HR: 0.55, P = .0049) and improved relapse-free survival (RFS, HR: 0.70, P = .042). The improved RFS with ATG was more pronounced in CMV-positive patients but was not influenced by disease risk. Regarding overall survival, GVHD-free relapse-free survival and transplant-related mortality, the risk was similar using ATG or alemtuzumab. CONCLUSION Even if GVHD risk is lowered by alemtuzumab use, it does not translate in better outcome due to higher risk of relapse.
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Affiliation(s)
- Marie Robin
- Service d'hématologie greffe, Hôpital Saint-Louis, APHP, Paris, France.,INSERM 1131 Université Paris 7, Paris, France
| | - Kavita Raj
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - Sylvie Chevret
- Service de biostatistique, Hôpital Saint-Louis, APHP, Université Paris 7, Paris, France
| | - Jordan Gauthier
- CHU de Lille, LIRIC INSERM U955, Université Lille2, Paris, France
| | - Hugues de Lavallade
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - David Michonneau
- Service d'hématologie greffe, Hôpital Saint-Louis, APHP, Paris, France.,INSERM 1160 Université Paris 7, Paris, France
| | - Donal McLornan
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | | | - Victoria Potter
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - Austin Kulasekararaj
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | | | - Antonio Pagliuca
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
| | - Ibrahim Yakoub-Agha
- Service de biostatistique, Hôpital Saint-Louis, APHP, Université Paris 7, Paris, France
| | - Gérard Socié
- Service d'hématologie greffe, Hôpital Saint-Louis, APHP, Paris, France.,INSERM 1160 Université Paris 7, Paris, France
| | - Ghulam J Mufti
- Department of Haematological Medicine, Kings College Hospital and Kings College London, London, UK
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D’Angelo CR, Novitsky B, Mee Lee S, Godley LA, Kline J, Larson RA, Liu H, Odenike O, Stock W, Bishop MR, Artz AS. Characterization of cancer comorbidity prior to allogeneic hematopoietic cell transplantation. Leuk Lymphoma 2018; 60:629-638. [DOI: 10.1080/10428194.2018.1493728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
| | - Brianna Novitsky
- Department of Public Health Studies, University of Chicago, Chicago, IL, USA
| | - Sang Mee Lee
- Comprehensive Cancer Center, University of Chicago, Chicago, IL, USA
| | - Lucy A. Godley
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Justin Kline
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Hongtao Liu
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Olatoyosi Odenike
- Department of Public Health Studies, University of Chicago, Chicago, IL, USA
| | - Wendy Stock
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Andrew S. Artz
- Department of Medicine, University of Chicago, Chicago, IL, USA
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Deeg HJ, Stevens EA, Salit RB, Ermoian RP, Fang M, Gyurkocza B, Sorror ML, Fatobene G, Baumgart J, Burroughs LM, Delaney C, Doney K, Egan DN, Flowers ME, Milano F, Radich JP, Scott BL, Sickle EJ, Wood BL, Yeung C, Storer BE. Transplant Conditioning with Treosulfan/Fludarabine with or without Total Body Irradiation: A Randomized Phase II Trial in Patients with Myelodysplastic Syndrome and Acute Myeloid Leukemia. Biol Blood Marrow Transplant 2018; 24:956-963. [DOI: 10.1016/j.bbmt.2017.12.785] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 12/14/2017] [Indexed: 01/28/2023]
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Yang T, Lin Q, Ren J, Chen P, Yuan X, Luo X, Liu T, Zheng J, Zheng Z, Zheng X, Chen X, Zhang L, Zheng H, Chen Z, Hua X, Le S, Li J, Chen Z, Hu J. A 5-day cytoreductive chemotherapy followed by haplo-identical hsct (FA5-BUCY) as a tumor-ablative regimen improved the survival of patients with advanced hematological malignancies. Oncotarget 2018; 7:78773-78786. [PMID: 27705929 PMCID: PMC5346676 DOI: 10.18632/oncotarget.12383] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 09/20/2016] [Indexed: 02/01/2023] Open
Abstract
Haplo-HSCT has been used when HLA-matched siblings are not available. Conditioning regimens aim to reduce tumor burden prior to HSCT and provide sufficient immunoablation. We report the outcome of haplo-HSCT in 63 consecutive patients from 2/2013 to 12/2015 (19 females/44 males) with high-risk or relapsed/refractory hematological malignancies (n=29-AML; 8-sAML; 19-ALL; 5-advanced-MDS; 2-CML-BC). Median age was 20 years (range: 1.1-49). Twenty-one patients achieved remission prior to transplant, while 42 did not. Patients received FA5-BUCY, i.e., 5-day salvage chemotherapy (Fludarabine/Ara-C) and conditioning (Busulfan/Cyclophosphamide). GvHD prophylaxis included ATG, CsA, MMF and short-term MTX. All patients received stem cells from bone marrow and peripheral blood, and achieved successful engraftment, except two who died before. With a median follow-up of 269 days (120-1081), 42/63 patients are still alive and disease-free. Two-year OS and RFS were similar in patients not in remission and in those in complete remission (61.3% vs 56.3%, p=0.88; 58.3% vs 56.3%, p=0.991). Non-relapse mortality and relapse incidence were 22.2% and 11.1%, respectively. Severe acute-GvHD occurred in 4/63 patients. Transplant-related mortality was low at day+100 (17.5%) and for the entire study period (20.6%). Unexpectedly, few patients experienced mild-to-moderate toxicity, and main causes of death were infection and GvHD. BM blast counts, age, and donor-recipient gender-pairs did not affect the outcome. Less chemotherapy cycles prior to HSCT might result in more favorable outcome. Thus, haplo-HSCT with FA5-BUCY appears promising for advanced disease, especially when TBI and amsacrine, used for FLAMSA, are not available and in pediatric patients for whom TBI is not recommended.
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Affiliation(s)
- Ting Yang
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Qiaoxian Lin
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Jinhua Ren
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Ping Chen
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Xiaohong Yuan
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Xiaofeng Luo
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Tingbo Liu
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Jing Zheng
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Zhihong Zheng
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Xiaoyun Zheng
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Xinji Chen
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Langhui Zhang
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Hao Zheng
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Zaisheng Chen
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Xueling Hua
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Shaohua Le
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Jian Li
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Zhizhe Chen
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
| | - Jianda Hu
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China
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Tsai SB, Rhodes J, Liu H, Shore T, Bishop M, Cushing MM, Gergis U, Godley L, Kline J, Larson RA, Mayer S, Odenike O, Stock W, Wickrema A, van Besien K, Artz AS. Reduced-Intensity Allogeneic Transplant for Acute Myeloid Leukemia and Myelodysplastic Syndrome Using Combined CD34-Selected Haploidentical Graft and a Single Umbilical Cord Unit Compared with Matched Unrelated Donor Stem Cells in Older Adults. Biol Blood Marrow Transplant 2017; 24:997-1004. [PMID: 29288821 DOI: 10.1016/j.bbmt.2017.12.794] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 12/20/2017] [Indexed: 11/12/2022]
Abstract
Haplo/cord transplantation combines an umbilical cord blood (UCB) graft with CD34-selected haploidentical cells and results in rapid hematopoietic recovery followed by durable UCB engraftment. We compared outcomes of transplants in older patients with acute myeloid leukemia (AML) or high-risk myelodysplastic syndromes (MDS) who received either HLA-matched unrelated donor (MUD) cells or haplo/cord grafts. Between 2007 and 2013, 109 adults ages 50 and older underwent similar reduced-intensity conditioning with fludarabine and melphalan and antibody-mediated T cell depletion for AML (n = 83) or high-risk MDS (n = 26) followed by either a MUD (n = 68) or haplo/cord (n = 41) graft. Patient characteristics were similar for each graft source except for more minority patients receiving a haplo/cord transplant (P = .01). One half of the AML patients were not in remission. Two-year progression-free survival (PFS), overall survival (OS), and graft-versus-host disease-free relapse-free survival were 38%, 48%, and 32.1% for MUD and 33%, 48%, and 33.8% for haplo/cord transplants (P = .62 for PFS; P = .97 for OS; P= .84), respectively. Acute grades II to IV and chronic graft-versus-host-disease rates did not differ at 19.5% and 4.9% in haplo/cord compared with 25% and 7.4% after MUD (P = .53 and P = .62, respectively). Multivariate analysis confirmed no significant differences in transplant outcomes by donor type. Haplo/cord reduced-intensity transplantation achieves similar outcomes relative to MUD in older AML and MDS patients, making this a promising option for those without matched donors.
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Affiliation(s)
- Stephanie B Tsai
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois; Section of Hematology-Oncology, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Joanna Rhodes
- Hematopoietic Stem Cell Transplant Program, Weill-Cornell Medical College, New York, New York
| | - Hongtao Liu
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Tsiporah Shore
- Hematopoietic Stem Cell Transplant Program, Weill-Cornell Medical College, New York, New York
| | - Michael Bishop
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Melissa M Cushing
- Department of Pathology, Weill-Cornell Medical College, New York, New York
| | - Usama Gergis
- Hematopoietic Stem Cell Transplant Program, Weill-Cornell Medical College, New York, New York
| | - Lucy Godley
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Justin Kline
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Richard A Larson
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Sebastian Mayer
- Hematopoietic Stem Cell Transplant Program, Weill-Cornell Medical College, New York, New York
| | - Olatoyosi Odenike
- Section of Hematology-Oncology, Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Wendy Stock
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Amittha Wickrema
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Koen van Besien
- Hematopoietic Stem Cell Transplant Program, Weill-Cornell Medical College, New York, New York
| | - Andrew S Artz
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois.
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12
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Ali R, Ramdial J, Algaze S, Beitinjaneh A. The Role of Anti-Thymocyte Globulin or Alemtuzumab-Based Serotherapy in the Prophylaxis and Management of Graft-Versus-Host Disease. Biomedicines 2017; 5:biomedicines5040067. [PMID: 29186076 PMCID: PMC5744091 DOI: 10.3390/biomedicines5040067] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/01/2017] [Accepted: 11/20/2017] [Indexed: 12/02/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplant is an established treatment modality for hematologic and non-hematologic diseases. However, it is associated with acute and long-term sequelae which can translate into mortality. Graft-versus-host disease (GVHD) remains a glaring obstacle, especially with the advent of reduced-intensity conditioning. Serotherapy capitalizes on antibodies which target T cells and other immune cells to mitigate this effect. This article focuses on the utility of two such agents: anti-thymocyte globulin (ATG) and alemtuzumab. ATG has demonstrated benefit in prophylaxis against GVHD, especially in the chronic presentation. However, there is limited impact of ATG on overall survival and it has little utility in the treatment context. There may be an initial improvement, particularly in skin manifestations, but no substantial benefit has been elicited. Alemtuzumab has shown benefit in both prophylaxis and treatment of GVHD, but at the consequence of a more profound immunosuppressive phase, mandating aggressive viral prophylaxis. There remains heterogeneity in the doses and regimens of the agents, with no standardized protocol in place. Furthermore, it seems that once steroid-refractory GVHD has been established, there is little that can be offered to offset the ultimately dismal outcome. Here we present a systematic overview of ATG- or alemtuzumab-based serotherapy in the prophylaxis and management of GVHD.
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Affiliation(s)
- Robert Ali
- Hematology/Medical Oncology Fellow, University of Miami/Miller School of Medicine, Miami, FL 33136, USA.
| | - Jeremy Ramdial
- Hematology/Medical Oncology Fellow, University of Miami/Miller School of Medicine, Miami, FL 33136, USA.
| | - Sandra Algaze
- Internal Medicine Residency Program, University of Miami/Miller School of Medicine, Miami, FL 33136, USA.
| | - Amer Beitinjaneh
- Associate Professor of Medicine, Stem Cell Transplant and Cellular Therapy Program, Sylvester Comprehensive Cancer Center, University of Miami/Miller School of Medicine; Miami, FL 33136, USA.
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13
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Hilal T, Slone S, Peterson S, Bodine C, Gul Z. Cytomegalovirus reactivation is associated with a lower rate of early relapse in myeloid malignancies independent of in-vivo T cell depletion strategy. Leuk Res 2017; 57:37-44. [PMID: 28279876 DOI: 10.1016/j.leukres.2017.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 02/22/2017] [Accepted: 02/26/2017] [Indexed: 11/19/2022]
Abstract
The association between cytomegalovirus (CMV) reactivation and relapse risk has not been evaluated in relation to T cell depletion strategies. We evaluated 93 patients who underwent allogeneic hematopoietic stem cell transplantation (HSCT) and analyzed the association between T cell depletion strategies with the cumulative incidence of relapse and CMV reactivation. A total of 33% of patients who received ATG vs. 34% who received alemtuzumab developed CMV reactivation. The cumulative incidence of relapse was 3% at 1year and 20% at 3 years in patients with CMV reactivation vs. 30% at 1year and 38% at 3 years in patients without CMV reactivation (p=0.02). When analyzed separately, this effect persisted in the myeloid, but not the lymphoid group. There was a numerical trend towards increased non-relapse mortality (NRM) in patients with CMV reactivation, especially in the myeloid group. The choice of T cell depleting agent and the rate of CMV reactivation were not associated with different overall survival (OS) rates. These results suggest that the choice of T cell depletion strategy may have similar effects on rates of CMV reactivation, disease relapse, and survival. Further studies examining these variables in patients not exposed to in-vivo T cell depleting agents may be of interest.
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Affiliation(s)
- Talal Hilal
- Department of Internal Medicine, University of Kentucky, Lexington, KY, United States; Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, AZ, United States.
| | - Stacey Slone
- Biostatistics Shared Resource Facility, University of Kentucky Markey Cancer Center, Lexington, KY, United States
| | - Shawn Peterson
- Department of Internal Medicine, University of Kentucky, Lexington, KY, United States
| | - Charles Bodine
- Department of Internal Medicine, University of Kentucky, Lexington, KY, United States
| | - Zartash Gul
- Division of Hematology and Blood and Marrow Transplant, University of Kentucky Markey Cancer Center, Lexington, KY, United States; Division of Hematology, University of Cincinnati Cancer Center, Cincinnati, OH, United States
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14
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Ruggeri A, Battipaglia G, Labopin M, Ehninger G, Beelen D, Tischer J, Ganser A, Schwerdtfeger R, Glass B, Finke J, Michallet M, Stelljes M, Jindra P, Arnold R, Kröger N, Mohty M, Nagler A. Unrelated donor versus matched sibling donor in adults with acute myeloid leukemia in first relapse: an ALWP-EBMT study. J Hematol Oncol 2016; 9:89. [PMID: 27639553 PMCID: PMC5027089 DOI: 10.1186/s13045-016-0321-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 09/08/2016] [Indexed: 12/02/2022] Open
Abstract
Background Allogeneic stem cell transplantation is the only curative option for patients with acute myeloid leukemia (AML) experiencing relapse. Either matched sibling donor (MSD) or unrelated donor (UD) is indicated. Methods We analyzed 1554 adults with AML transplanted from MSD (n = 961) or UD (n = 593, HLA-matched 10/10, n = 481; 9/10, n = 112). Compared to MSD, UD recipients were older (49 vs 52 years, p = 0.001), transplanted more recently (2009 vs 2006, p = 0.001), and with a longer interval to transplant (10 vs 9 months, p = 0.001). Conditioning regimen was more frequently myeloablative for patients transplanted with a MSD (61 vs 46 %, p = 0.001). Median follow-up was 28 (range 3–157) months. Results Cumulative incidence (CI) of neutrophil engraftment (p = 0.07), grades II–IV acute GVHD (p = 0.11), chronic GVHD (p = 0.9), and non-relapse mortality (NRM, p = 0.24) was not different according to the type of donor. At 2 years, CI of relapse (relapse incidence (RI)) was 57 vs 49 % (p = 0.001). Leukemia-free survival (LFS) at 2 years was 21 vs 26 % (p = 0.001), and overall survival (OS) was 26 vs 33 % (p = 0.004) for MSD vs UD, respectively. Chronic GVHD as time-dependent variable was associated with lower RI (HR 0.78, p = 0.05), higher NRM (HR 1.71, p = 0.001), and higher OS (HR 0.69, p = 0.001). According to HLA match, RI was 57 vs 50 vs 45 %, (p = 0.001) NRM was 23 vs 23 vs 29 % (p = 0.26), and LFS at 2 years was 21 vs 27 vs 25 % (p = 0.003) for MSD, 10/10, and 9/10 UD, respectively. In multivariate analysis adjusted for differences between the two groups, UD was associated with lower RI (HR 0.76, p = 0.001) and higher LFS (HR 0.83, p = 0.001) compared to MSD. Interval between diagnosis and transplant was the other factor associated with better outcomes (RI (HR 0.62, p < 0.001) and LFS (HR 0.67, p < 0.001)). Conclusions Transplantation using UD was associated with better LFS and lower RI compared to MSD for high-risk patients with AML transplanted in first relapse.
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Affiliation(s)
- Annalisa Ruggeri
- Service d'Hématologie et Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, 184 Rue du Faubourg Saint Antoine, 75012, Paris, France.
| | - Giorgia Battipaglia
- Service d'Hématologie et Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, 184 Rue du Faubourg Saint Antoine, 75012, Paris, France.,Department of Hematology and Marrow Transplantation, University Federico II of Naples, Naples, Italy
| | - Myriam Labopin
- Service d'Hématologie et Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, 184 Rue du Faubourg Saint Antoine, 75012, Paris, France
| | - Gerhard Ehninger
- Medical Clinic and Polyclinic, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Dietrich Beelen
- Department of Bone Marrow Transplantation, University Hospital Essen, Essen, Germany
| | - Johanna Tischer
- Department of Internal Medicine III, UH of Munich (LMU), Munich, Germany
| | - Arnold Ganser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Rainer Schwerdtfeger
- Department of Haematology, Oncology Helios-Klinikum Berlin-Buch, Schwanebecker Chaussee 50, 13125, Berlin, Germany
| | - Bertram Glass
- Department of Hematology, Oncology and Stem Cell Transplantation, Asklepios Hospital St. Georg, Hamburg, Germany
| | - Jurgen Finke
- Department of Hematology/Oncology and Stem Cell Transplantation, University Medical Center, Freiburg, Germany
| | - Mauricette Michallet
- Department of Hematology, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre Bénite, France
| | | | - Pavel Jindra
- Departments of Hematology/Oncology, Charles University Hospital, Pilsen, Czech Republic
| | | | - Nicolaus Kröger
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mohamad Mohty
- Service d'Hématologie et Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, 184 Rue du Faubourg Saint Antoine, 75012, Paris, France.,Hôpital Saint-Antoine, Paris University UPMC, INSERM U938, Paris, France.,Université Pierre and Marie Curie, Paris, France
| | - Arnon Nagler
- Université Pierre and Marie Curie, Paris, France.,Hematology Division, Chaim Sheba Medical Center, Tel Hashomer, Israel.,ALWP Office, Hôpital Saint Antoine, AP-HP, Paris, France
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15
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Kayser S, Benner A, Thiede C, Martens U, Huber J, Stadtherr P, Janssen JWG, Röllig C, Uppenkamp MJ, Bochtler T, Hegenbart U, Ehninger G, Ho AD, Dreger P, Krämer A. Pretransplant NPM1 MRD levels predict outcome after allogeneic hematopoietic stem cell transplantation in patients with acute myeloid leukemia. Blood Cancer J 2016; 6:e449. [PMID: 27471865 PMCID: PMC5030374 DOI: 10.1038/bcj.2016.46] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 05/19/2016] [Indexed: 12/19/2022] Open
Abstract
The objective was to evaluate the prognostic impact of pre-transplant minimal residual disease (MRD) as determined by real-time quantitative polymerase chain reaction in 67 adult NPM1-mutated acute myeloid leukemia patients receiving allogeneic hematopoietic stem cell transplantation (HSCT). Twenty-eight of the 67 patients had a FLT3-ITD (42%). Median age at transplantation was 54.7 years, median follow-up for survival from time of allografting was 4.9 years. At transplantation, 31 patients were in first, 20 in second complete remission (CR) and 16 had refractory disease (RD). Pre-transplant NPM1 MRD levels were measured in 39 CR patients. Overall survival (OS) for patients transplanted in CR was significantly longer as compared to patients with RD (P=0.004), irrespective of whether the patients were transplanted in first or second CR (P=0.74). There was a highly significant difference in OS after allogeneic HSCT between pre-transplant MRD-positive and MRD-negative patients (estimated 5-year OS rates of 40 vs 89% P=0.007). Multivariable analyses on time to relapse and OS revealed pre-transplant NPM1 MRD levels >1% as an independent prognostic factor for poor survival after allogeneic HSCT, whereas FLT3-ITD had no impact. Notably, outcome of patients with pre-transplant NPM1 MRD positivity >1% was as poor as that of patients transplanted with RD.
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Affiliation(s)
- S Kayser
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - A Benner
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - C Thiede
- Department of Medicine I, University Hospital Carl-Gustav-Carus, Dresden, Germany
| | - U Martens
- Cancer Center Heilbronn-Franken, Heilbronn, Germany
| | - J Huber
- Cancer Center Heilbronn-Franken, Heilbronn, Germany
| | - P Stadtherr
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - J W G Janssen
- Institute of Human Genetics, University of Heidelberg, Heidelberg, Germany
| | - C Röllig
- Department of Medicine I, University Hospital Carl-Gustav-Carus, Dresden, Germany
| | - M J Uppenkamp
- Department of Oncology, Hospital of Ludwigshafen, Ludwigshafen, Germany
| | - T Bochtler
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - U Hegenbart
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - G Ehninger
- Department of Medicine I, University Hospital Carl-Gustav-Carus, Dresden, Germany
| | - A D Ho
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - P Dreger
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - A Krämer
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
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16
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Thomas CM, Ippoliti C, Roboz GJ, Feldman E, Savva D, James S, van Besien K. Clofarabine as a bridge to hematopoietic stem cell transplant. Leuk Lymphoma 2016; 58:230-232. [PMID: 27240704 DOI: 10.1080/10428194.2016.1185784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Christan M Thomas
- a Department of Pharmacy , St John's University College of Pharmacy , NY , USA.,b NewYork-Presbyterian Hospital , Weill Cornell Medical College , NY , USA
| | - Cindy Ippoliti
- b NewYork-Presbyterian Hospital , Weill Cornell Medical College , NY , USA
| | - Gail J Roboz
- b NewYork-Presbyterian Hospital , Weill Cornell Medical College , NY , USA
| | | | - Dimitrios Savva
- a Department of Pharmacy , St John's University College of Pharmacy , NY , USA
| | - Sara James
- a Department of Pharmacy , St John's University College of Pharmacy , NY , USA
| | - Koen van Besien
- d Department of Hematology/Oncology , University of Chicago , 5841 South Maryland , Chicago , IL , USA
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17
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D’Angelo CR, Kocherginsky M, Pisano J, Bishop MR, Godley LA, Kline J, Larson RA, Liu H, Odenike O, Stock W, Artz AS. Incidence and predictors of respiratory viral infections by multiplex PCR in allogeneic hematopoietic cell transplant recipients 50 years and older including geriatric assessment. Leuk Lymphoma 2015; 57:1807-13. [DOI: 10.3109/10428194.2015.1113279] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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18
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Zhang Y, Huang Y, Wei J, Yan Z, He Y, Ma Q, Yang D, Feng S, Han M, Jiang E. [Control study of melphalan instead of cyclophosphamide as a myeloablative conditioning regimen for allogeneic hematopoietic stem cell transplantation for treatment of myeloid malignancies]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2015; 36:835-9. [PMID: 26477761 PMCID: PMC7364934 DOI: 10.3760/cma.j.issn.0253-2727.2015.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
目的 评价以马法兰(Mel)替代改良白消安(Bu)+环磷酰胺(Cy)(Bu/Cy)方案中Cy的预处理方案在异基因造血干细胞移植(allo-HSCT)治疗恶性髓系血液病中的有效性及安全性。 方法 分析94例进行allo-HSCT的恶性髓系血液病患者临床资料,其中48例采用Bu+Cy+氟达拉滨(Flu)+阿糖胞苷(Ara-C)(BCFA)方案预处理,46例采用Bu+Mel+Flu+ Ara-C (BMFA)方案预处理。移植后观察比较两组预处理方案相关不良反应、植入率、移植物抗宿主病(GVHD)、感染发生、非复发死亡(NRM)率以及总生存(OS)率。 结果 两组患者均获得中性粒细胞成功植入。BMFA组Ⅲ~Ⅳ度口腔溃疡以及腹泻发生率均高于BCFA组(P<0.05),BMFA组急性GVHD(aGVHD)发生率较高,但差异无统计学意义(36.5%对56.5%,P=0.100)。中位随访42个月,BCFA组和BMFA组NRM率分别为12.5%和19.6% (P=0.400)。BMFA组复发率显著低于BCFA组,分别为4.3%和25.0%(P=0.009)。两组OS率分别为(71.8±6.7)%和(76.1±6.3)%(P=0.852),无病生存(DFS)率分别为(67.8±8.9)%和(76.1±6.3)%(P=0.567),BCFA组均略低于BMFA组,但差异均无统计学意义。 结论 应用Mel替代Cy的预处理方案治疗恶性髓系血液病复发率较低,并获得较满意的DFS率,但应注意预处理相关毒性的预防及aGVHD的治疗和干预。
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Affiliation(s)
- Ying Zhang
- Institute of Hematology & Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Yong Huang
- Institute of Hematology & Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Jialin Wei
- Institute of Hematology & Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Zhangsong Yan
- Institute of Hematology & Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Yi He
- Institute of Hematology & Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Qiaoling Ma
- Institute of Hematology & Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Donglin Yang
- Institute of Hematology & Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Sizhou Feng
- Institute of Hematology & Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Mingzhe Han
- Institute of Hematology & Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Erlie Jiang
- Institute of Hematology & Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
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19
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Pingali SR, Champlin RE. Pushing the envelope-nonmyeloablative and reduced intensity preparative regimens for allogeneic hematopoietic transplantation. Bone Marrow Transplant 2015; 50:1157-67. [PMID: 25985053 PMCID: PMC4809137 DOI: 10.1038/bmt.2015.61] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 11/17/2014] [Indexed: 12/30/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) was originally developed to allow delivery of myeloablative doses of chemotherapy and radiotherapy. With better understanding of disease pathophysiology, the graft vs malignancy (GVM) effect of allogeneic hematopoietic transplantation and toxicities associated with myeloablative conditioning (MAC) regimens, the focus shifted to developing less toxic conditioning regimens to reduce treatment-related morbidity without compromising survival. Although HCT with MAC is preferred to reduced intensity conditioning (RIC) for most patients ⩽60 years with AML/myelodysplastic syndrome and ALL, RIC and nonmyeloablative (NMA) regimens allow HCT for many otherwise ineligible patients. Reduced intensity preparative regimens have produced high rates of PFS for diagnoses, which are highly sensitive to GVM. Relapse of the malignancy is the major cause of treatment failure with RIC/NMA HCT. Incorporation of novel agents like bortezomib or lenalidomide, addition of cellular immunotherapy and use of targeted radiation therapies could further improve outcome. In this review, we discuss commonly used RIC/NMA regimens and promising novel regimens.
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Affiliation(s)
- S R Pingali
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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20
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Kharfan-Dabaja MA, Labopin M, Bazarbachi A, Socie G, Kroeger N, Blaise D, Veelken H, Bermudez A, Or R, Lioure B, Beelen D, Fegueux N, Hamladji RM, Nagler A, Mohty M. Higher busulfan dose intensity appears to improve leukemia-free and overall survival in AML allografted in CR2: An analysis from the Acute Leukemia Working Party of the European Group for Blood and Marrow Transplantation. Leuk Res 2015; 39:933-7. [PMID: 26003666 DOI: 10.1016/j.leukres.2015.04.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 03/09/2015] [Accepted: 04/15/2015] [Indexed: 10/23/2022]
Abstract
Allogeneic hematopoietic cell transplantation is a potentially curative treatment in patients with acute myeloid leukemia. Recent advances in the field of hematopoietic cell allografting have resulted in a practice shift, favoring less intense preparative regimens. We present results of a retrospective comparative analysis of two preparative regimens, namely FB2 (IV fludarabine plus IV busulfan 6.4mg/kg±10%) and FB4 (IV fludarabine plus IV busulfan 12.8mg/kg ±10%), in patients with acute myeloid leukemia undergoing hematopoietic cell allografting in second complete remission at EBMT participating centers. Between 2003 and 2010, 128 AML patients in second complete remission were allografted following a preparative regimen of FB2 (n=88) or FB4 (n=40). The median time-to-neutrophil engraftment was similar whether patients received FB2 (16 (5-38) days) or FB4 (16 (9-29) days), p=0.45. A multivariate analysis showed that use of FB4 resulted in improved 2-year leukemia-free (HR=0.44 (95%CI=0.21, 0.94), p=0.03) and overall survival (HR=0.38 (95%CI=0.16, 0.86), p=0.02). Cumulative incidence of non-relapse mortality (2-year) for all patients was 21% (95%CI=14-28%). Our analysis suggests that FB4 improves 2-year leukemia-free and overall survival in AML allografted in second complete remission. A confirmatory randomized controlled trial that compares these two preparative regimens (FB2 vs. FB4) in AML in CR2 is definitely warranted.
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Affiliation(s)
- Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, FL, United States
| | | | - Ali Bazarbachi
- Division of Hematology-Oncology and BMT Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Gerard Socie
- Service d'Hématologie Greffe, Hôpital Saint Louis, Paris, France
| | - Nicolaus Kroeger
- Bone Marrow Transplantation Centre, Univ. Hospital Eppendorf, Hamburg, Germany
| | - Didier Blaise
- Unité de Transplantation et de Thérapie Cellulaire (U2T), Institut Paoli-Calmettes, Marseille, France
| | | | - Arancha Bermudez
- Dept of Hematology, Hospital Universitario Marqués de Valdecilla, Instituto de Formación e Investigación Marqués de Valdecilla, Santander, Spain
| | - Reuven Or
- Dept of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah University Hospital, Jerusalem, Israel
| | - Bruno Lioure
- CHU Hautepierre-Département d'Hématologie et Oncologie, Strasbourg, France
| | - Dietrich Beelen
- University Hospital, Department of Bone Marrow Transplantation, Essen, Germany
| | | | | | - Arnon Nagler
- Acute Leukemia Working Party of EBMT, Paris, France; Hematology Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Mohamad Mohty
- Acute Leukemia Working Party of EBMT, Paris, France; Département d'Hématologie, Hopital Saint Antoine, Paris, France.
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21
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Reduced-intensity conditioned allogeneic SCT in adults with AML. Bone Marrow Transplant 2015; 50:759-69. [PMID: 25730186 DOI: 10.1038/bmt.2015.7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 01/13/2015] [Accepted: 01/14/2015] [Indexed: 02/08/2023]
Abstract
AML is currently the most common indication for reduced-intensity conditioned (RIC) allo-SCT. Reduced-intensity regimens allow a potent GVL response to occur with minimized treatment-related toxicity in patients of older age or with comorbidities that preclude the use of myeloablative conditioning. Whether RIC SCT is appropriate for younger and more standard risk patients is not well defined and the field is changing rapidly; a prospective randomized trial of myeloablative vs RIC (BMT-CTN 0901) was recently closed when early results indicated better outcomes for myeloablative regimens. However, detailed results are not available, and all patients in that study were eligible for myeloablative conditioning. RIC transplants will likely remain the standard of care as many patients with AML are not eligible for myeloablative conditioning. Recent publication of mature results from retrospective and prospective cohorts provide contemporary efficacy and toxicity data for these attenuated regimens. In addition, recent studies explore the use of alternative donors, introduce regimens that attempt to reduce toxicity without reducing intensity, and identify predictive factors that pave the way to personalized approaches. These studies paint a picture of the future of RIC transplants. Here we review the current status of RIC allogeneic SCT in AML.
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22
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Rabitsch W, Böhm A, Bojic M, Schellongowski P, Wöhrer S, Sliwa T, Keil F, Worel N, Greinix H, Hauswirth A, Kalhs P, Jaeger U, Valent P, Sperr WR. Clofarabine/cyclophosphamide for debulking before stem cell transplantation. Eur J Clin Invest 2014; 44:775-83. [PMID: 24942362 DOI: 10.1111/eci.12294] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 06/13/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Allogeneic haematopoietic stem cell transplantation (HSCT) is the only curative rescue therapy for patients (pts) with chemotherapy-refractory acute leukaemia. Disease control prior to HSCT is essential for long-term disease-free survival after HSCT. PATIENTS AND METHODS We have retrospectively analysed the outcome of 20 pts aged 21-64 years with refractory leukaemia (acute myeloid leukaemia, n = 16; acute lymphatic leukaemia, n = 4) who received debulking therapy with clofarabine (10 mg/m², days 1-4) and cyclophosphamide (200 mg/m², days 1-4; ClofCy) prior to HSCT. RESULTS Clofarabine/cyclophosphamide (1-4 cycles) was well tolerated and resulted in a substantial reduction of leukaemic cells in all pts. HSCT was performed in 15 of 20 pts. After HSCT (myeloablative, n = 9; dose-reduced, n = 6), all pts showed engraftment and full donor chimerism (related donors, n = 4 or unrelated donors, n = 11) and all pts achieved complete haematologic remission (CR). The median survival after HSCT is 531 days (range: 48-1462 days), and six pts are still alive after a median of 1245 days. Seven pts died after they had relapsed between days +152 and +1496. One patient died from acute graft-versus-host disease (day +48) and one from systemic fungal infection (day +87). CONCLUSION Clofarabine/cyclophosphamide is a novel effective treatment approach for pts with chemotherapy-refractory acute leukaemia prior to HSCT. Whether this novel debulking protocol leads to improved long-term outcome in pts with refractory leukaemias remains to be determined in forthcoming clinical studies.
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Affiliation(s)
- Werner Rabitsch
- Bone Marrow Transplantation Unit, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria; Intensive Care Unit, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
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23
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Oudin C, Chevallier P, Furst S, Guillaume T, El Cheikh J, Delaunay J, Castagna L, Faucher C, Granata A, Devillier R, Chabannon C, Esterni B, Vey N, Mohty M, Blaise D. Reduced-toxicity conditioning prior to allogeneic stem cell transplantation improves outcome in patients with myeloid malignancies. Haematologica 2014; 99:1762-8. [PMID: 25085356 DOI: 10.3324/haematol.2014.105981] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The introduction of reduced intensity/toxicity conditioning regimens has allowed allogeneic hematopoietic cell transplantation to be performed in patients who were previously considered too old or otherwise unfit. Although it led to a reduction in non-relapse mortality, disease control remains a major challenge. We studied the outcome of 165 patients with acute myeloid leukemia (n=124) or myelodysplastic syndrome (n=41) transplanted after conditioning with fludarabine (30 mg/m(2)/day for 5 days), intravenous busulfan (either 260 mg/m(2): reduced intensity conditioning, or 390-520 mg/m(2): reduced toxicity conditioning), and rabbit anti-thymoglobulin (2.5 mg/kg/day for 2 days). The median age of the patients at transplantation was 56.8 years. The 2-year relapse incidence was 29% (23% versus 39% for patients transplanted in first complete remission and those transplanted beyond first complete remission, respectively; P=0.008). The 2-year progression-free survival rate was 57% (95% CI: 49.9-65). It was higher in the groups with favorable or intermediate cytogenetics than in the group with unfavorable cytogenetics (72.7%, 60.5%, and 45.7%, respectively; P=0.03). The cumulative incidence of grades 2-4 and 3-4 acute graft-versus-host disease at day 100 was 19.3% and 7.9%, respectively. The cumulative incidence of chronic graft-versus-host disease at 1 year was 21.6% (severe forms: 7.8%). Non-relapse mortality at 1 year reached 11%. The 2-year overall survival rate was 61.8% (95% CI: 54.8-69.7). Unfavorable karyotype and disease status beyond first complete remission were associated with a poorer survival. This well-tolerated conditioning platform can lead to long-term disease control and offers possibilities of modulation according to disease stage or further development.
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Affiliation(s)
- Claire Oudin
- Département d'Hématologie, Institut Paoli Calmettes, Marseille, France Aix-Marseille University, Marseille, France
| | - Patrice Chevallier
- Centre Hospitalier Universitaire de Nantes, Service d'Hématologie Clinique, France
| | - Sabine Furst
- Département d'Hématologie, Institut Paoli Calmettes, Marseille, France
| | - Thierry Guillaume
- Centre Hospitalier Universitaire de Nantes, Service d'Hématologie Clinique, France
| | - Jean El Cheikh
- Département d'Hématologie, Institut Paoli Calmettes, Marseille, France
| | - Jacques Delaunay
- Centre Hospitalier Universitaire de Nantes, Service d'Hématologie Clinique, France
| | - Luca Castagna
- Département d'Hématologie, Institut Paoli Calmettes, Marseille, France Humanitas Cancer Center, Hematology Unit, Istituto Clinico Humanitas, Rozzano, Milano, Italy
| | - Catherine Faucher
- Département d'Hématologie, Institut Paoli Calmettes, Marseille, France
| | - Angela Granata
- Département d'Hématologie, Institut Paoli Calmettes, Marseille, France
| | - Raynier Devillier
- Département d'Hématologie, Institut Paoli Calmettes, Marseille, France Aix-Marseille University, Marseille, France Centre de Recherche en Cancérologie de Marseille (CRCM), Marseille, France
| | - Christian Chabannon
- Aix-Marseille University, Marseille, France Centre de Recherche en Cancérologie de Marseille (CRCM), Marseille, France Cell Therapy Unit, Institut Paoli Calmettes, Marseille, France
| | - Benjamin Esterni
- Unité de Biostatistiques, Institut Paoli Calmettes, Marseille, France
| | - Norbert Vey
- Département d'Hématologie, Institut Paoli Calmettes, Marseille, France Aix-Marseille University, Marseille, France Centre de Recherche en Cancérologie de Marseille (CRCM), Marseille, France
| | - Mohamad Mohty
- Centre Hospitalier Universitaire de Nantes, Service d'Hématologie Clinique, France Université de Nantes, Faculté de Médecine, France INSERM CRNCA UMR 892, Nantes, France Centre d'Investigation Clinique en Cancérologie (CI2C), Nantes, France Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, Paris, France Université Pierre et Marie Curie, Paris, France INSERM, UMRs 938, Paris, France
| | - Didier Blaise
- Département d'Hématologie, Institut Paoli Calmettes, Marseille, France Aix-Marseille University, Marseille, France Centre de Recherche en Cancérologie de Marseille (CRCM), Marseille, France
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Petri CR, O'Donnell PH, Cao H, Artz AS, Stock W, Wickrema A, Hard M, van Besien K. Clofarabine-associated acute kidney injury in patients undergoing hematopoietic stem cell transplant. Leuk Lymphoma 2014; 55:2866-73. [PMID: 24564572 DOI: 10.3109/10428194.2014.897701] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Abstract We examined clofarabine pharmacokinetics and association with renal toxicity in 62 patients participating in a phase I-II study of clofarabine-melphalan-alemtuzumab conditioning for hematopoietic stem cell transplant (HSCT). Pharmacokinetic parameters, including clofarabine area under the concentration-time curve (AUC), maximum concentration and clearance, were measured, and patients were monitored for renal injury. All patients had normal pretreatment creatinine values, but over half (55%) experienced acute kidney injury (AKI) after clofarabine administration. Age was the strongest predictor of AKI, with older patients at greater risk (p = 0.002). Clofarabine AUC was higher in patients who developed AKI, and patients with the highest dose-normalized AUCs experienced the most severe grades of AKI (p = 0.01). Lower baseline renal function, even when normal, was associated with lower clofarabine clearance (p = 0.008). These data suggest that renal-adjustment of clofarabine dosing should be considered for older and at-risk patients even when renal function is ostensibly normal.
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Affiliation(s)
- Camille R Petri
- University of Chicago Pritzker School of Medicine , Chicago, IL , USA
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25
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Gyurkocza B, Gutman J, Nemecek ER, Bar M, Milano F, Ramakrishnan A, Scott B, Fang M, Wood B, Pagel JM, Baumgart J, Delaney C, Maziarz RT, Sandmaier BM, Estey EH, Appelbaum FR, Storer BE, Deeg HJ. Treosulfan, fludarabine, and 2-Gy total body irradiation followed by allogeneic hematopoietic cell transplantation in patients with myelodysplastic syndrome and acute myeloid leukemia. Biol Blood Marrow Transplant 2014; 20:549-55. [PMID: 24440648 DOI: 10.1016/j.bbmt.2014.01.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 01/10/2014] [Indexed: 10/25/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) offers curative therapy for many patients with myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). However, post-HCT relapse remains a major problem, particularly in patients with high-risk cytogenetics. In this prospective phase II trial, we assessed the efficacy and toxicity of treosulfan, fludarabine, and 2 Gy total body irradiation (TBI) as conditioning for allogeneic HCT in patients with MDS or AML. Ninety-six patients with MDS (n = 36: 15 refractory cytopenia with multilineage dysplasia, 10 refractory anemia with excess blasts type 1, 10 refractory anemia with excess blasts type 2, 1 chronic myelomonocytic leukemia type 1) or AML (n = 60: 35 first complete remission [CR], 18 second CR, 3 advanced CR, 4 refractory relapse) were enrolled; median age was 51 (range, 1 to 60) years. Twelve patients had undergone a prior HCT with high-intensity conditioning. Patients received 14 g/m(2)/day treosulfan i.v. on days -6 to -4, 30 mg/m(2)/day fludarabine i.v. on days -6 to -2, and 2 Gy TBI on day 0, followed by infusion of hematopoietic cells from related (n = 27) or unrelated (n = 69) donors. Graft-versus-host disease prophylaxis consisted of tacrolimus and methotrexate. With a median follow-up of 30 months, the 2-year overall survival (OS), relapse incidence, and nonrelapse mortality were 73%, 27%, and 8%, respectively. The incidences of grades II to IV (III to IV) acute and chronic graft-versus-host disease were 59% (10%) and 47%, respectively. Two-year OS was not significantly different between MDS patients with poor-risk and good/intermediate-risk cytogenetics (69% and 85%, respectively) or between AML patients with unfavorable and favorable/intermediate-risk cytogenetics (64% and 76%, respectively). In AML patients, minimal residual disease (MRD; n = 10) at the time of HCT predicted higher relapse incidence (70% versus 18%) and lower OS (41% versus 79%) at 2 years, when compared with patients without MRD. In conclusion, treosulfan, fludarabine, and low-dose TBI provided effective conditioning for allogeneic HCT in patients with MDS or AML and resulted in low relapse incidence, regardless of cytogenetic risk. In patients with AML, MRD at the time of HCT remained a risk factor for post-HCT relapse.
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Affiliation(s)
- Boglarka Gyurkocza
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
| | - Jonathan Gutman
- Department of Medicine, University of Colorado, Denver, Colorado
| | - Eneida R Nemecek
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Merav Bar
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Filippo Milano
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Aravind Ramakrishnan
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Bart Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Min Fang
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | | | - John M Pagel
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Joachim Baumgart
- Department of Laboratory Medicine, University of Washing School of Medicine, Seattle, WA
| | - Colleen Delaney
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Richard T Maziarz
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Elihu H Estey
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Frederick R Appelbaum
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Hans Joachim Deeg
- Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
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26
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Abstract
Acute myeloid leukemia carries a dismal prognosis in patients over 60 years of age and, despite many clinical trials of both novel and conventional agents, there has been no significant improvement in overall survival during the last 30 years. Combinations of anthracyclines and cytarabine remain the cornerstone of therapy and produce complete remission in 45-55% of older patients, with a median survival of only 8-12 months. These statistics become even worse in patients over 70 years and those with unfavorable cytogenetics and/or poor performance status. Deciding which older acute myeloid leukemia patients would benefit from intensive chemotherapy is difficult and efforts are underway to improve existing risk-assessment tools. Many new agents are under development, including signal transduction inhibitors, farnesyl transferase inhibitors, antibodies and novel chemotherapeutics. To date, small-molecule inhibitors and targeted therapies have had limited single-agent efficacy and have required combination with chemotherapy. The role of hematopoietic stem cell transplantation in older patients is under investigation. All patients over 60 years of age with acute myeloid leukemia should be encouraged to participate in a clinical trial if possible.
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Affiliation(s)
- Gail J Roboz
- Weill Medical College of Cornell University and The New York Presbyterian Hospital, 520 East 70th Street, Starr 340A, New York, NY 10021, USA.
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27
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Diagnosis and treatment of primary myelodysplastic syndromes in adults: recommendations from the European LeukemiaNet. Blood 2013; 122:2943-64. [PMID: 23980065 DOI: 10.1182/blood-2013-03-492884] [Citation(s) in RCA: 486] [Impact Index Per Article: 44.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Within the myelodysplastic syndrome (MDS) work package of the European LeukemiaNet, an Expert Panel was selected according to the framework elements of the National Institutes of Health Consensus Development Program. A systematic review of the literature was performed that included indexed original papers, indexed reviews and educational papers, and abstracts of conference proceedings. Guidelines were developed on the basis of a list of patient- and therapy-oriented questions, and recommendations were formulated and ranked according to the supporting level of evidence. MDSs should be classified according to the 2008 World Health Organization criteria. An accurate risk assessment requires the evaluation of not only disease-related factors but also of those related to extrahematologic comorbidity. The assessment of individual risk enables the identification of fit patients with a poor prognosis who are candidates for up-front intensive treatments, primarily allogeneic stem cell transplantation. A high proportion of MDS patients are not eligible for potentially curative treatment because of advanced age and/or clinically relevant comorbidities and poor performance status. In these patients, the therapeutic intervention is aimed at preventing cytopenia-related morbidity and preserving quality of life. A number of new agents are being developed for which the available evidence is not sufficient to recommend routine use. The inclusion of patients into prospective clinical trials is strongly recommended.
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28
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Goker H, Ozdemir E, Uz B, Buyukasik Y, Turgut M, Serefhanoglu S, Aksu S, Sayinalp N, Haznedaroglu IC, Tekin F, Karacan Y, Unal S, Eliacik E, Isik A, Ozcebe OI. Comparative outcome of reduced intensity and myeloablative conditioning regimen in HLA identical sibling allogeneic hematopoietic stem cell transplantation for acute leukemia patients: a single center experience. Transfus Apher Sci 2013; 49:590-9. [PMID: 23981652 DOI: 10.1016/j.transci.2013.07.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 07/29/2013] [Indexed: 12/01/2022]
Abstract
Due to the high transplant related morbidity and mortality (TRM), relatively younger acute leukemia patients that have a good performance status and no comorbidity are eligible for myeloablative conditioning (MAC) followed by allogeneic hematopoietic stem cell transplantation (allo-HSCT). The outcomes of 84 consecutive adult patients with ALL (n=38) or AML (n=46) who underwent allo-HSCT from their HLA-identical siblings were evaluated retrospectively. The median age at transplantation was 34 (17-58 years) for the whole patient population. Of these, 24 patients received a MAC and 60 patients received a fludarabine-based reduced intensity conditioning regimen (RIC). After a median follow-up of 32 months (range, 1-119), for the entire group, the 3-year estimated overall survival (OS) was 57.5% and the disease-free survival (DFS) was 51.5%. The OS for ALL and AML patients were 53.9% vs 62.1%: and DFS were 50.5% and 53.4%, respectively. The 3-year estimated OS for RIC and MAC patients were 63.2% and 41.7%; and DFS were 57.1% and 34.7%, respectively. In ALL patients, conditioning regimens (RIC vs MAC) led to similar OS and DFS; however, in AML patients both OS (70.1% vs 21.4%) and DFS (59.3% vs 42.9%) were found to be higher in RIC patients compared to MAC recipients. Overall, the TRM at day 100 was 1.7% and has increased up to 5.1% at 1st year. In multivariate analysis, the diagnosis (p=0.03) and RIC regimen (p=0.027) were the prognostic variables for prolonged OS in all patients; and RIC regimen (p=0.031) was the only prognostic factor for prolonged OS in AML patients. The first complete remission (CR1) was correlated with a prolonged DFS as an independent variable for all patients (p=0.09). Eleven of the RIC patients (18.3%) and 6 of the MAC patients (25%) developed acute graft-versus-host disease (GvHD). Seventeen of the RIC patients (33.3%) and 4 of the MAC patients (16.7%) developed chronic GvHD. In conclusion, RIC conditioning regimens may provide a longer OS and DFS, especially in patients with AML who are in first CR, not eligible for MAC conditioning.
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Affiliation(s)
- Hakan Goker
- Division of Hematology, Department of Internal Medicine, Hacettepe University Medical School, Ankara, Turkey
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29
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Recent Advances in Transplantation for Primary Immune Deficiency Diseases: A Comprehensive Review. Clin Rev Allergy Immunol 2013; 46:131-44. [DOI: 10.1007/s12016-013-8379-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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30
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A novel clofarabine bridge strategy facilitates allogeneic transplantation in patients with relapsed/refractory leukemia and high-risk myelodysplastic syndromes. Bone Marrow Transplant 2013; 48:1437-43. [PMID: 23771005 DOI: 10.1038/bmt.2013.79] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 04/18/2013] [Accepted: 04/18/2013] [Indexed: 11/09/2022]
Abstract
Patients with relapsed/refractory leukemias or advanced myelodysplastic syndrome (MDS) fare poorly following allogeneic hematopoietic cell transplant (HCT). We report prospective phase II study results of 29 patients given clofarabine 30 mg/m(2)/day i.v. × 5 days followed immediately by HCT conditioning while at the cytopenic nadir. A total of 15/29 patients (52%) were cytoreduced according to pre-defined criteria (cellularity <20% and blasts <10%). Marrow cellularity (P<0.0001) and blast% (P=0.03) were reduced. Toxicities were acceptable, with transient hyperbilirubinemia (48%) and gr3-4 infections (10%). In all, 28/29 proceeded to transplant; 27 received ATG or alemtuzumab. Post HCT, 180 day non-relapse mortality (NRM) was 7% (95% confidence interval (CI): 1-21), relapse was 29% (95% CI: 13-46) and OS was 71% (95% CI: 51-85), comparing favorably to published data for high-risk patients. Two-year graft vs host disease incidence was 40% (95% CI: 21-58) and 2 year OS was 31% (95% CI: 14-48). Disease at the nadir correlated with inferior OS after HCT (HR=1.22 for each 10% marrow blasts, 95% CI: 1.02-1.46). For AML/MDS patients, there was a suggestion that successful cytoreduction increased PFS (330 vs 171 days, P=0.3) and OS (375 vs 195 days, P=0.31). Clofarabine used as a bridge to HCT reduces disease burden, is well tolerated, and permits high-risk patients to undergo HCT with acceptable NRM. Late relapses are common; thus, additional strategies should be pursued. NCT-00724009.
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31
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Promising role of reduced-toxicity hematopoietic stem cell transplantation (PART-I). Stem Cell Rev Rep 2013; 8:1254-64. [PMID: 22836809 DOI: 10.1007/s12015-012-9401-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) remains a potential curative option for many patients with hematological malignancies (HM). However, the high rate of transplantation-related mortality (TRM) restricted the use of standard myeloablative HSCT to a minority of young and fit patients. Over the past few years, it has become evident that the alloreactivity of the immunocompetent donor cells mediated anti-malignancy effects independent of the action of high dose chemoradiotherapy. The use of reduced intensity conditioning (RIC) regimens has allowed a graft-versus-malignancy (GvM) effect to be exploited in patients who were previously ineligible for HSCT on the grounds of age and comorbidity. Retrospective analysis showed that RIC has been associated with lower TRM but a higher relapse rate leading to similar intermediate term overall and progression-free survivals when compared to standard myeloablative HSCT. However, the long term antitumor effect of this approach is less well established. Prospective studies are ongoing to define which patients might most benefit from reduced toxicity stem cell transplant (RT-SCT) and which transplant protocols are suitable for the different types of HM. The advent of RT-SCT permits the delivery of a potentially curative GvM effect to the majority of patients with HM whose outcome with conventional chemotherapy would be dismal. Remaining challenges include development of effective strategies to reduce relapse rates by augmenting GvM effects without increasing toxicity.
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32
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Allogeneic Hematopoietic Cell Transplantation for Therapy-Related Myeloid Leukemia following Orthotopic Cardiac Transplantation. Case Rep Hematol 2013; 2013:140138. [PMID: 23607004 PMCID: PMC3625539 DOI: 10.1155/2013/140138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 03/14/2013] [Indexed: 11/18/2022] Open
Abstract
Therapy-related myeloid neoplasm (t-MN) is a subtype of acute myeloid leukemia with adverse cytogenetics and poor overall prognosis despite intensive induction chemotherapy and allogeneic hematopoietic cell transplantation (allo-HCT). It is increasingly recognized as a late complication of chronic immunosuppression in patients who have received solid organ transplantation. In this paper, we describe a case of t-MN following orthotopic cardiac transplantation and its treatment with allo-HCT. We discuss molecular and biological challenges and considerations in double solid organ and bone marrow transplantation and review similar cases at our institution. Our experience suggests general feasibility and safety of allo-HCT in patients who have received solid organ transplantation.
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33
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Matched unrelated or matched sibling donors result in comparable outcomes after non-myeloablative HSCT in patients with AML or MDS. Bone Marrow Transplant 2013; 48:1296-301. [DOI: 10.1038/bmt.2013.50] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Revised: 03/07/2013] [Accepted: 03/08/2013] [Indexed: 11/08/2022]
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34
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Pilot Study of Comprehensive Geriatric Assessment (CGA) in Allogeneic Transplant: CGA Captures a High Prevalence of Vulnerabilities in Older Transplant Recipients. Biol Blood Marrow Transplant 2013; 19:429-34. [DOI: 10.1016/j.bbmt.2012.11.006] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 11/11/2012] [Indexed: 12/21/2022]
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35
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Gill S, Porter DL. Reduced-intensity hematopoietic stem cell transplants for malignancies: harnessing the graft-versus-tumor effect. Annu Rev Med 2012; 64:101-17. [PMID: 23121181 DOI: 10.1146/annurev-med-121411-103452] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Allogeneic hematopoietic cell transplantation combines the power of cytotoxic chemo/radiotherapy with the ability of the new immune system to seek out and destroy tumor cells. However, administration of such myeloablative transplants is fraught with risks, some of which are related to the intensive conditioning regimens. Reductions in the intensity of the administered cytotoxic therapy have demonstrated that under some circumstances, the burden of fighting tumor and enhancing stem cell engraftment can be shouldered mostly by the transplanted immune system. Reduced intensity has allowed a potentially curative therapy for hematologic malignancies to be offered to an expanded patient population. Ongoing research seeks to enhance the safety and power of this form of allogeneic immunotherapy.
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Affiliation(s)
- Saar Gill
- Abramson Cancer Center, Department of Medicine, Perelman School of Medicine, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19104, USA.
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36
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Jamieson K, Odenike O. Late-phase investigational approaches for the treatment of relapsed/refractory acute myeloid leukemia. Expert Opin Pharmacother 2012; 13:2171-87. [DOI: 10.1517/14656566.2012.724061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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37
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Bayraktar UD, Bashir Q, Qazilbash M, Champlin RE, Ciurea SO. Fifty years of melphalan use in hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2012; 19:344-56. [PMID: 22922522 DOI: 10.1016/j.bbmt.2012.08.011] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 08/17/2012] [Indexed: 12/22/2022]
Abstract
Melphalan remains the most widely used agent in preparative regimens for hematopoietic stem cell transplantation (SCT). From its initial discovery more than 50 years ago, it has been gradually incorporated in the conditioning regimens for both autologous and allogeneic transplantations because of its myeloablative properties and broad antitumor effects as a DNA alkylating agent. Melphalan remains the mainstay conditioning for multiple myeloma and lymphomas, and it has been used successfully in preparative regimens of a variety of other hematological and nonhematological malignancies. The addition of newer agents to conditioning, such as bortezomib or lenalidomide for myeloma or clofarabine for myeloid malignancies, may improve antitumor effects for transplantation, whereas melphalan in combination with alemtuzumab may represent a backbone for future cellular therapy because of reliable engraftment and low toxicity profile. This review summarizes the development and the current use of this remarkable drug in hematopoietic SCT.
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Affiliation(s)
- Ulas D Bayraktar
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Steensma DP. Tuning the Rigging before Sailing off into the Stormy Sea of Stem Cell Transplants for Patients with Myelodysplastic Syndromes. Biol Blood Marrow Transplant 2012; 18:1145-7. [DOI: 10.1016/j.bbmt.2012.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 05/07/2012] [Indexed: 12/01/2022]
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Richa EM, Kunnavakkam R, Godley LA, Kline J, Odenike O, Larson RA, Nguyen V, Stock W, Wickrema A, Besien KV, Artz AS. Influence of related donor age on outcomes after peripheral blood stem cell transplantation. Cytotherapy 2012; 14:707-15. [DOI: 10.3109/14653249.2012.681041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Nakamura R, Palmer JM, O'Donnell MR, Stiller T, Thomas SH, Chao J, Alvarnas J, Parker PM, Pullarkat V, Maegawa R, Stein AS, Snyder DS, Bhatia R, Chang K, Wang S, Cai JL, Senitzer D, Forman SJ. Reduced intensity allogeneic hematopoietic stem cell transplantation for MDS using tacrolimus/sirolimus-based GVHD prophylaxis. Leuk Res 2012; 36:1152-6. [PMID: 22677229 DOI: 10.1016/j.leukres.2012.04.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 04/17/2012] [Accepted: 04/22/2012] [Indexed: 11/17/2022]
Abstract
We report a consecutive series of 59 patients with MDS who underwent reduced-intensity hematopoietic stem cell transplantation (RI-HSCT) with fludarabine/melphalan conditioning and tacrolimus/sirolimus-based GVHD prophylaxis. Two-year OS, EFS, and relapse incidences were 75.1%, 65.2%, and 20.9%, respectively. The cumulative incidence of non-relapse mortality at 100 days, 1 year, and 2 years was 3.4%, 8.5%, and 10.5%, respectively. The incidence of grade II-IV acute GVHD was 35.4%; grade III-IV was 18.6%. Forty of 55 evaluable patients developed chronic GVHD; of these 35 were extensive grade. This RI-HSCT protocol produces encouraging outcomes in MDS patients, and tacrolimus/sirolimus-based GVHD prophylaxis may contribute to that promising result.
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Affiliation(s)
- Ryotaro Nakamura
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, CA 91010, USA.
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Baron F, Labopin M, Niederwieser D, Vigouroux S, Cornelissen JJ, Malm C, Vindelov LL, Blaise D, Janssen JJWM, Petersen E, Socié G, Nagler A, Rocha V, Mohty M. Impact of graft-versus-host disease after reduced-intensity conditioning allogeneic stem cell transplantation for acute myeloid leukemia: a report from the Acute Leukemia Working Party of the European group for blood and marrow transplantation. Leukemia 2012; 26:2462-8. [PMID: 22699419 DOI: 10.1038/leu.2012.135] [Citation(s) in RCA: 139] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This report investigated the impact of graft-versus-host disease (GVHD) on transplantation outcomes in 1859 acute myeloid leukemia patients given allogeneic peripheral blood stem cells after reduced-intensity conditioning (RIC allo-SCT). Grade I acute GVHD was associated with a lower risk of relapse (hazards ratio (HR)=0.7, P=0.02) translating into a trend for better overall survival (OS; HR=1.3; P=0.07). Grade II acute GVHD had no net impact on OS, while grade III-IV acute GVHD was associated with a worse OS (HR=0.4, P<0.0.001) owing to high risk of nonrelapse mortality (NRM; HR=5.2, P<0.0001). In time-dependent multivariate Cox analyses, limited chronic GVHD tended to be associated with a lower risk of relapse (HR=0.72; P=0.07) translating into a better OS (HR=1.8; P<0.001), while extensive chronic GVHD was associated with a lower risk of relapse (HR=0.65; P=0.02) but also with higher NRM (HR=3.5; P<0.001) and thus had no net impact on OS. In-vivo T-cell depletion with antithymocyte globulin (ATG) or alemtuzumab was successful at preventing extensive chronic GVHD (P<0.001), but without improving OS for ATG and even with worsening OS for alemtuzumab (HR=0.65; P=0.001). These results highlight the role of the immune-mediated graft-versus-leukemia effect in the RIC allo-SCT setting, but also the need for improving the prevention and treatment of severe GVHD.
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Affiliation(s)
- F Baron
- Department of Hematology, University of Liège, Liège, Belgium.
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Sockel K, Ehninger G, Hofbauer LC, Platzbecker U. Optimizing management of myelodysplastic syndromes post-allogeneic transplantation. Expert Rev Hematol 2012; 4:669-80. [PMID: 22077530 DOI: 10.1586/ehm.11.58] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation is still the only potentially curative treatment for patients with myelodysplastic syndromes. Improvements in donor selection, supportive care and the introduction of reduced-intensity conditioning have led to a decrease in early transplant mortality. However, relapse rates have not changed significantly in recent years. Furthermore, treatment options for patients relapsing after hematopoietic stem cell transplantation are limited and often short-lived. Thus, optimizing the post-transplant outcome by maintenance approaches or minimal residual disease-directed preemptive therapy is an important goal of current clinical research. Further strategies aiming at an improved prevention of graft-versus-host disease are currently under investigation.
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Affiliation(s)
- Katja Sockel
- Medizinische Klinik und Poliklinik I, Universitätsklinikum 'Carl Gustav Carus' Dresden, 01307 Dresden, Germany
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Casper J, Holowiecki J, Trenschel R, Wandt H, Schaefer-Eckart K, Ruutu T, Volin L, Einsele H, Stuhler G, Uharek L, Blau I, Bornhaeuser M, Zander AR, Larsson K, Markiewicz M, Giebel S, Kruzel T, Mylius HA, Baumgart J, Pichlmeier U, Freund M, Beelen DW. Allogeneic hematopoietic SCT in patients with AML following treosulfan/fludarabine conditioning. Bone Marrow Transplant 2011; 47:1171-7. [PMID: 22158386 DOI: 10.1038/bmt.2011.242] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
An alternative reduced-toxicity conditioning regimen for allogeneic transplantation, based on treosulfan and fludarabine, has recently been identified. The safety and efficacy of this new conditioning regimen has been investigated prospectively in patients with AML. A total number of 75 patients with AML in CR were treated with 3 × 14 g/m(2) treosulfan and 5 × 30 mg/m(2) fludarabine, followed by matched sibling or unrelated SCT. Patients were evaluated for engraftment, adverse events, GVHD, and for non-relapse mortality, relapse incidence, overall and disease-free survival (DFS). All patients showed primary engraftment of neutrophils after a median of 20 days. Non-hematological adverse events grade III-IV in severity included mainly infections (59%) and gastrointestinal symptoms (7%). Acute GVHD grade II-IV occurred in 21% and extensive chronic GVHD occurred in 16% of the patients. After a median follow-up of 715 days, the 2-year overall and DFS estimates were 61% and 55%, respectively. The 2-year incidences of relapse and non-relapse mortality reached 34% and 11%, respectively. In summary, our data confirm promising safety and efficacy of the treosulfan-based conditioning therapy in AML patients, ClinicalTrials.gov Identifier: NCT01063660.
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Affiliation(s)
- J Casper
- Division of Hematology and Oncology, University of Rostock, Rostock, Germany.
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van Besien K, Stock W, Rich E, Odenike O, Godley LA, O'Donnell PH, Kline J, Nguyen V, Del Cerro P, Larson RA, Artz AS. Phase I-II study of clofarabine-melphalan-alemtuzumab conditioning for allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant 2011; 18:913-21. [PMID: 22079470 DOI: 10.1016/j.bbmt.2011.10.041] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 10/30/2011] [Indexed: 01/09/2023]
Abstract
We conducted a phase I-II study of transplantation conditioning with clofarabine-melphalan-alemtuzumab for patients with advanced hematologic malignancies. Ten patients were accrued to the phase I portion, which utilized an accelerated titration design. No dose-limiting toxicity was observed, and clofarabine 40 mg/m(2) × 5, melphalan 140 mg/m(2) × 1, and alemtuzumab 20 mg × 5 was adopted for the phase II study, which accrued 72 patients. Median age was 54 years. There were 44 patients with acute myelogenous leukemia or myelodysplastic syndromes, 27 with non-Hodgkin lymphoma, and nine patients with other hematologic malignancies. The largest subgroup of 35 patients had American Society for Blood and Marrow Transplantation high-risk, active disease. All evaluable patients engrafted with a median time to neutrophil and platelet recovery of 10 and 18 days, respectively. The cumulative incidence of treatment-related mortality was 26% at 1 year. Cumulative incidence of relapse was 29% at 1 year. Overall survival was 80% (95% confidence interval [CI], 71-89) at 100 days and 59% (95% CI, 47-71) at 1 year. Progression-free-survival was 45% (95% CI, 33-67) at 1 year. Rapid-onset renal failure was the main toxicity in the phase II study and more frequent in older patients and those with baseline decrease in glomerular filtration rate. Grade 3-5 renal toxicity was observed in 16 of 74 patients (21%) treated at the phase II doses. Clofarabine-melphalan-alemtuzumab conditioning yields promising response and duration of response, but renal toxicity poses a considerable risk particularly in older patients.
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Affiliation(s)
- Koen van Besien
- Section of Hematology/Oncology, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA.
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Hamadani M, Mohty M, Kharfan-Dabaja MA. Reduced-Intensity Conditioning Allogeneic Hematopoietic Cell Transplantation in Adults with Acute Myeloid Leukemia. Cancer Control 2011; 18:237-45. [DOI: 10.1177/107327481101800404] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Acute myeloid leukemia (AML), whether de novo or arising from antecedent hematologic disorders in elderly patients, is less likely to be curable with standard chemotherapy regimens used for younger patients. Allogeneic hematopoietic cell transplantation (alloHCT) is currently the most efficient anti-leukemia treatment for AML and has shown a survival advantage in younger patients with intermediate- or poor-risk cytogenetics. Methods The authors review their experience as well as the published data regarding the role of reduced-intensity conditioning (RIC) alloHCT in adults with AML. MEDLINE/PubMed and EMBASE/Ovid were searched, as well as reference lists of relevant articles, conference proceedings, and ongoing trial databases. Results Elderly patients with AML have a poor survival for all cytogenetics subgroups (except for acute promyelocytic leukemia) and higher rates of transplant-related mortality with myeloablative alloHCT. RIC regimens have been shown to decrease procedure-related toxicity and have emerged as an attractive treatment modality in AML patients not suitable for myeloablative conditioning regimens. While prospective data comparing outcomes of AML patients undergoing RIC alloHCT vs conventional chemotherapy alone are not yet available, RIC alloHCT is a reasonable option for high-risk older patients and for younger AML patients with medical comorbidities who achieve a first or subsequent remission. The application of RIC for patients with refractory disease or untreated relapse as well as the use of alternative donors should be considered within the context of clinical trials. Conclusions RIC alloHCT is a safe and effective treatment modality in high-risk elderly AML patients and in younger AML patients with medical comorbidities.
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Affiliation(s)
- Mehdi Hamadani
- Osborn Hematopoietic Malignancy and Transplantation Program, Division of Hematology/Oncology at West Virginia University, Morgantown
| | - Mohamad Mohty
- Service d'Hématologie Clinique, CHU Hotel Dieu, Université de Nantes, Centre d'Investigation Clinique en Cancerologie [CI2C] and INSERM U892, Nantes, France
| | - Mohamed A. Kharfan-Dabaja
- Division of Hematology/Oncology and Bone Marrow Transplantation, Department of Internal Medicine and the Naef K. Basile Cancer Institute, American University of Beirut, Beirut, Lebanon
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Poiré X, van Besien K. Alemtuzumab in allogeneic hematopoetic stem cell transplantation. Expert Opin Biol Ther 2011; 11:1099-111. [PMID: 21702703 DOI: 10.1517/14712598.2011.592824] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION With the use of reduced-intensity conditioning (RIC), early toxicity of allogeneic stem cell transplantation (SCT) has been much reduced. Graft-versus-host disease (GvHD) causes morbidities and mortality. Alemtuzumab is a mAb directed against CD52. When administered prior to transplant, it leads to T-cell depletion. Incorporation of alemtuzumab in RIC results in low rates of GvHD and treatment-related mortality (TRM) in haematological diseases, even in the setting of mismatched-donor transplantation. AREAS COVERED The use of alemtuzumab for GvHD prophylaxis in SCT. The benefit of alemtuzumab-based conditioning is partially offset by increased disease relapse due to impaired graft-versus-tumor effect (GvT) and by slower immune reconstitution, necessitating special precautions. While GvHD is prevented with alemtuzumab, post-SCT interventions are often required. Most studies find that alemtuzumab-based conditioning results in decreased chronic GvHD and TRM, but also in decreased progression-free survival. Overall survival after 3 - 5 years is usually equivalent and quality of life may be improved because of a lower incidence of sequelae of chronic GvHD. Many aspects of alemtuzumab treatment are under investigation. EXPERT OPINION Alemtuzumab reduces GvHD and TRM after SCT. Use of alemtuzumab requires awareness and strict management of the risk of opportunistic infections and of an increased risk of disease recurrence.
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Affiliation(s)
- Xavier Poiré
- Section of Hematology, Department of Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 10 avenue Hippocrate, 1200 Brussels, Belgium
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Long-term outcome of reduced-intensity allogeneic hematopoietic SCT in patients with AML in CR. Bone Marrow Transplant 2011; 47:212-6. [PMID: 21423123 DOI: 10.1038/bmt.2011.61] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A total of 36 consecutive patients with AML in CR underwent reduced-intensity allogeneic hematopoietic SCT (RISCT) with fludarabine and melphalan conditioning. All patients were ineligible for myeloablative transplantation because of age or comorbidity. In total, 30 patients were in first CR and six patients were in second CR. Donors were siblings in 21 (58%) patients and were unrelated in 15 (42%) patients. Hematopoietic cell transplant specific comorbidity scores ≥3 were present in 26 (72%) patients. With a median follow-up of 52 months (range, 34-103 months), OS and PFS rates at 4 years were 71% (s.e., 8%) and 68% (s.e., 8%), respectively. At 4 years, the cumulative incidence of non-relapse mortality was 20% (s.e., 7%) and of relapse mortality was 8% (s.e., 5%). Neither OS nor PFS was affected by older age (>60 years), unrelated donor, melphalan dose, or comorbidity score. At last follow up, of the 24 surviving patients, 21 (88%) had performance status (ECOG) of 0 without any active chronic GVHD requiring steroids. Hence, RISCT with fludarabine and melphalan conditioning produces durable long-term remission in older patients with AML.
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Goldstein SC, Porter DL. Allogeneic immunotherapy to optimize the graft-versus-tumor effect: concepts and controversies. Expert Rev Hematol 2011; 3:301-14. [PMID: 21082981 DOI: 10.1586/ehm.10.29] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This article focuses on the recent evolution of novel conditioning regimens in combination with adoptive cellular therapy in the allogeneic transplant setting for hematologic malignancies. Building on data from animal models, the field of allogeneic transplantation is undergoing a paradigm shift toward immunosuppressive regimens with less toxicity that allow donor hematopoietic engraftment in order to provide a graft-versus-tumor effect as the primary goal of transplantation, rather than chemoablation. In addition, the strategies described in this article, including the use of T-cell subsets as adoptive therapy, will apply to a much broader pool of patients than traditional transplant approaches, thereby allowing more patients with life-limiting illnesses, previously deemed ineligible, to pursue therapy with curative intent.
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Affiliation(s)
- Steven C Goldstein
- Division of Hematology-Oncology/BMT, Abramson Cancer Center, University of Pennsylvania Medical Center, 2 Perelman, 3400 Civic Center Blvd, Philadelphia, PA, USA.
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Kenkre VP, Horowitz S, Artz AS, Liao C, Cohen KS, Godley LA, Kline JP, Smith SM, Stock W, van Besien K. T-cell-depleted allogeneic transplant without donor leukocyte infusions results in excellent long-term survival in patients with multiply relapsed Lymphoma. Predictors for survival after transplant relapse. Leuk Lymphoma 2011; 52:214-22. [PMID: 21142785 PMCID: PMC3617078 DOI: 10.3109/10428194.2010.538777] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We analyzed 67 patients with lymphoma who received alemtuzumab-based conditioning regimens for allogeneic stem cell transplant and no post-transplant DLI. The median age was 54 (24-70), 43% had unrelated donors, 34% had chemotherapy refractory disease, and 25% had an elevated LDH. With a median follow-up for survivors of 35 months, the estimated 3-year progression-free survival (PFS) and overall survival (OS) were 30% and 47%, respectively. Chemosensitivity by CT and pre-transplant LDH were independent prognostic factors for both overall survival and progression-free survival. Patient age, performance status, donor type, lymphoma subtype, disease sensitivity by PET, and conditioning regimen did not correlate with PFS and OS. Patients who relapsed greater than 6 months after allogeneic transplant were frequently able to re-enter a subsequent durable remission. Our experience confirms the curative potential of alemtuzumab-containing RIC regimens for allogeneic HCT in patients with relapsed lymphoma without prophylactic DLI. An elevated pre-transplant LDH and chemorefractory disease prior to transplant confer a worse prognosis, while PET scan findings do not have this same implication. Patients who relapse greater than 6 months after their transplant are likely to achieve a subsequent remission with any of a variety of interventions, suggesting that GVL effects can be operative even after recurrence. Our outcomes challenge the utility of the common practice of prophylactic DLI after T-depleted transplant for lymphoma.
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Affiliation(s)
- Vaishalee P Kenkre
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
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Porter DL. Allogeneic immunotherapy to optimize the graft-versus-tumor effect: concepts and controversies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2011; 2011:292-298. [PMID: 22160048 DOI: 10.1182/asheducation-2011.1.292] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Allogeneic stem cell transplantation (SCT) can be considered the most successful method of adoptive immunotherapy of cancer. It is successful in part because of the potent graft-versus-tumor (GVT) effects of the donor graft, which are independent of the conditioning regimen. This potent GVT reaction can be harnessed in some cases to treat patients who relapse after allogeneic SCT with the use of donor leukocyte infusions (DLIs). This has led to the rapid development of reduced-intensity conditioning (RIC) regimens for allogeneic SCT, an approach that relies primarily on GVT activity. However, the effects of GVT have clear disease specificity and remain associated with significant GVHD. Optimization of GVT induction will require a better understanding of the important target antigens and effector cells, as well as the development of methods that enhance GVT reactivity without excessive GVHD. The appropriate clinical setting and timing for GVT induction need to be defined more clearly, but ultimately, the immunologic control of cancer through allogeneic adoptive immunotherapy represents one of the most potent and promising therapeutic strategies for patients with hematologic malignancies.
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Affiliation(s)
- David L Porter
- Division of Hematology-Oncology, Blood and Marrow Transplant Program, University of Pennsylvania Medical Center, Philadelphia, PA, USA.
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