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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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McLornan DP, Hernandez-Boluda JC, Czerw T, Cross N, Joachim Deeg H, Ditschkowski M, Moonim MT, Polverelli N, Robin M, Aljurf M, Conneally E, Hayden P, Yakoub-Agha I. Allogeneic haematopoietic cell transplantation for myelofibrosis: proposed definitions and management strategies for graft failure, poor graft function and relapse: best practice recommendations of the EBMT Chronic Malignancies Working Party. Leukemia 2021; 35:2445-2459. [PMID: 34040148 DOI: 10.1038/s41375-021-01294-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/04/2021] [Accepted: 05/07/2021] [Indexed: 01/31/2023]
Abstract
Allogeneic haematopoietic cell transplantation (allo-HCT) remains the only curative approach in myelofibrosis (MF). Despite advances over recent decades, relapse and non-relapse mortality rates remain significant. Relapse rates vary between 15 and 25% across retrospective studies and management strategies vary widely, ranging from palliation to adoptive immunotherapy and, in some cases, a second allo-HCT. Moreover, in allo-HCT, there is a higher incidence of poor graft function and graft failure due to splenomegaly and a hostile "pro-inflammatory" marrow niche. The Practice Harmonisation and Guidelines subcommittee of the Chronic Malignancies Working Party (CMWP) of EBMT convened an international panel consisting of transplant haematologists, histopathologists and molecular biologists to propose practical, clinically relevant definitions of graft failure, poor graft function and relapse as well as management strategies following allo-HCT. A systematic approach to molecular monitoring, histopathological assessment and chimerism testing is proposed. These proposed recommendations aim to increase the accuracy and uniformity of reporting and to thereby facilitate the development of more consistent approaches to these challenging issues. In addition, we propose management strategies for these complications.
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Affiliation(s)
- Donal P McLornan
- Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust and University College Hospitals, London, UK.
| | | | - Tomasz Czerw
- Maria Sklodowska-Curie Institute, Gliwice, Poland
| | - Nicholas Cross
- National Genetics Reference Laboratory (Wessex), Salisbury District Hospital, Salisbury, UK
| | - H Joachim Deeg
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - Marcus Ditschkowski
- Department for Bone Marrow Transplantation, University of Essen, Essen, Germany
| | - Mufaddal T Moonim
- Department of Histopathology, Imperial College Healthcare NHS Trust, London, UK
| | - Nicola Polverelli
- Unit of Blood Diseases and Stem Cell Transplantation, Department of Clinical and Experimental Sciences-University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Marie Robin
- Hopital Saint-Louis, APHP, Université de Paris, Paris, France
| | - Mahmoud Aljurf
- Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Patrick Hayden
- Haematology Department, St. James Hospital, Dublin, Ireland
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Fan Y, Artz AS, van Besien K, Stock W, Larson RA, Odenike O, Godley LA, Kline J, Cunningham JM, LaBelle JL, Bishop MR, Liu H. Outcomes following second allogeneic stem cell transplant for disease relapse after T cell depleted transplant correlate with remission status and remission duration after the first transplant. Exp Hematol Oncol 2019; 8:1. [PMID: 30622841 PMCID: PMC6317199 DOI: 10.1186/s40164-018-0125-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 12/24/2018] [Indexed: 12/25/2022] Open
Abstract
Background Second allogeneic hematopoietic stem cell transplant (HCT) remains as an option for disease relapse after initial HCT. Methods We analyzed retrospectively the outcomes of 65 consecutive patients who underwent a second HCT for disease relapse at the University of Chicago. Univariate and multivariate analysis were conducted, and a scoring system was generated to select the patients who would benefit second HCT. Results All except four patients received T cell depleted (TCD) first HCT. The majority of patients had AML (n = 47) and high risk MDS (n = 5). The median age at second HCT was 45 years (11–73). 13 patients (20%) achieved CR before second HCT. 98% (n = 64) and 72% (n = 47) patients achieved neutrophil and platelet engraftment at a median interval of 10 and 18 days, respectively, following the second HCT. With a median follow up of 23 (5.5–140) months for survivors after second HCT, the estimated 2 years PFS was 17.5% and the 2 years OS was 22.6%. The day 100 cumulative incidence of non-relapse mortality rate was 23.6%, and the cumulative incidence of aGVHD and cGVHD were 16.9% and 7.7% respectively at 1 year after second HCT. In univariate analysis, patients with remission duration after first HCT of > 12 months and those in CR before second HCT had significantly better PFS and OS. A scoring system using disease status before second HCT (CR = 0 vs. non-CR = 1), and remission duration after first HCT (< 6 = 2, 6–12 = 1 and > 12 months = 0) was generated as an approach to classify patients into different risk categories in the purpose to provide guidance to the transplant physician to inform the outcomes to potential patients undergoing 2nd HCT. A score of < 2 (n = 26) identified a group with PFS and OS of 31.6% and 36.2% at 2 years after second HCT. Conclusion In conclusion, second HCT is a viable option for disease relapse after TCD HCT for patients entering second HCT in remission and/or remission duration > 12 months after first HCT with acceptable rates of GVHD and donor engraftment.
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Affiliation(s)
- Yun Fan
- 1Department of Hematology, Beijing Hospital, Beijing, China
| | - Andrew S Artz
- 2Department of Medicine, Section of Hematology/Oncology, The University of Chicago Medical Center, 5841 S. Maryland, MC 2115, Chicago, IL 60637-1470 USA
| | - Koen van Besien
- 3Division of Hematology/Oncology, Weill Cornell Medical College, New York, NY USA
| | - Wendy Stock
- 2Department of Medicine, Section of Hematology/Oncology, The University of Chicago Medical Center, 5841 S. Maryland, MC 2115, Chicago, IL 60637-1470 USA
| | - Richard A Larson
- 2Department of Medicine, Section of Hematology/Oncology, The University of Chicago Medical Center, 5841 S. Maryland, MC 2115, Chicago, IL 60637-1470 USA
| | - Olatoyosi Odenike
- 2Department of Medicine, Section of Hematology/Oncology, The University of Chicago Medical Center, 5841 S. Maryland, MC 2115, Chicago, IL 60637-1470 USA
| | - Lucy A Godley
- 2Department of Medicine, Section of Hematology/Oncology, The University of Chicago Medical Center, 5841 S. Maryland, MC 2115, Chicago, IL 60637-1470 USA
| | - Justin Kline
- 2Department of Medicine, Section of Hematology/Oncology, The University of Chicago Medical Center, 5841 S. Maryland, MC 2115, Chicago, IL 60637-1470 USA
| | - John M Cunningham
- 4Department of Pediatrics, University of Chicago Comer Children's Hospital, Chicago, IL USA
| | - James L LaBelle
- 4Department of Pediatrics, University of Chicago Comer Children's Hospital, Chicago, IL USA
| | - Michael R Bishop
- 2Department of Medicine, Section of Hematology/Oncology, The University of Chicago Medical Center, 5841 S. Maryland, MC 2115, Chicago, IL 60637-1470 USA
| | - Hongtao Liu
- 2Department of Medicine, Section of Hematology/Oncology, The University of Chicago Medical Center, 5841 S. Maryland, MC 2115, Chicago, IL 60637-1470 USA
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Torrent A, Ferrá C, Ribera JM. Rescue treatment of patients with relapsed acute leukemia after first allogeneic hematopoietic stem cell transplantation. Med Clin (Barc) 2018; 151:376-377. [PMID: 29295789 DOI: 10.1016/j.medcli.2017.11.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 11/23/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Anna Torrent
- Servicio de Hematología Clínica, Institut Català d'Oncologia-Hospital Germans Trias i Pujol, Badalona, Barcelona, España; Institut de Recerca contra la Leucèmia Josep Carreras, Badalona, Barcelona, España; Universitat Autònoma de Barcelona, Barcelona, España.
| | - Christelle Ferrá
- Servicio de Hematología Clínica, Institut Català d'Oncologia-Hospital Germans Trias i Pujol, Badalona, Barcelona, España; Institut de Recerca contra la Leucèmia Josep Carreras, Badalona, Barcelona, España; Universitat Autònoma de Barcelona, Barcelona, España
| | - Josep-Maria Ribera
- Servicio de Hematología Clínica, Institut Català d'Oncologia-Hospital Germans Trias i Pujol, Badalona, Barcelona, España; Institut de Recerca contra la Leucèmia Josep Carreras, Badalona, Barcelona, España; Universitat Autònoma de Barcelona, Barcelona, España
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de Lima M, Oran B, Champlin RE, Papadopoulos EB, Giralt SA, Scott BL, William BM, Hetzer J, Laille E, Hubbell B, Skikne BS, Craddock C. CC-486 Maintenance after Stem Cell Transplantation in Patients with Acute Myeloid Leukemia or Myelodysplastic Syndromes. Biol Blood Marrow Transplant 2018; 24:2017-2024. [PMID: 29933073 PMCID: PMC8059405 DOI: 10.1016/j.bbmt.2018.06.016] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 06/11/2018] [Indexed: 12/21/2022]
Abstract
Relapse is the main cause of treatment failure after allogeneic stem cell transplant (alloSCT) in acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS). Injectable azacitidine can improve post-transplant outcomes but presents challenges with exposure and compliance. Oral CC-486 allows extended dosing to prolong azacitidine activity. We investigated use of CC-486 maintenance therapy after alloSCT. Adults with MDS or AML in morphologic complete remission at CC-486 initiation (42 to 84 days after alloSCT) were included. Patients received 1 of 4 CC-486 dosing schedules per 28-day cycle for up to 12 cycles. Endpoints included safety, pharmacokinetics, graft-versus-host disease (GVHD) incidence, relapse/progression rate, and survival. Of 30 patients, 7 received CC-486 once daily for 7 days per cycle (200 mg, n = 3; 300 mg, n = 4) and 23 for 14 days per cycle (150 mg, n = 4; 200 mg, n = 19 [expansion cohort]). Grades 3 to 4 adverse events were infrequent and occurred with similar frequency across regimens. Standard concomitant medications did not alter CC-486 pharmacokinetic parameters. Three patients (10%) experienced grade III acute GVHD and 9 experienced chronic GVHD. Of 28 evaluable patients, 6 (21%) relapsed or had progressive disease: 3 of 7 patients (43%) who had received 7-day dosing and 3 of 23 (13%) who had received 14-day dosing. Transplant-related mortality was 3%. At 19 months of follow-up, median overall survival was not reached. Estimated 1-year survival rates were 86% and 81% in the 7-day and 14-day dosing cohorts, respectively. CC-486 maintenance was generally well tolerated, with low rates of relapse, disease progression, and GVHD. CC-486 maintenance may permit epigenetic manipulation of the alloreactive response postallograft. Findings require confirmation in randomized trials. (ClinicalTrials.govNCT01835587.)
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Affiliation(s)
- Marcos de Lima
- University Hospitals of Cleveland and Case Western Reserve University, Cleveland, Ohio.
| | - Betul Oran
- Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard E Champlin
- Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Esperanza B Papadopoulos
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio A Giralt
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bart L Scott
- Transplantation Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Basem M William
- Division of Hematology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | | | | | | | | | - Charles Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom
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Haploidentical hematopoietic cell transplantation using in vitro T cell depleted grafts as salvage therapy in patients with disease relapse after prior allogeneic transplantation. Ann Hematol 2017; 96:817-827. [PMID: 28247058 DOI: 10.1007/s00277-017-2941-x] [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: 11/07/2016] [Accepted: 01/30/2017] [Indexed: 10/20/2022]
Abstract
Disease relapse after one or more allogeneic hematopoietic cell transplantations (HCT) represents a therapeutic challenge with all options bearing a significant morbidity and mortality. Haploidentical HCT may induce more pronounced anti-leukemic effects and was evaluated at our center in 25 consecutive patients with disease relapse after preceding HCT receiving haploidentical grafts after in vitro T cell depletion. Overall survival at 1 and 2 years was 32 and 14%, respectively. Of note, patients with complete remission (CR) before haploidentical HCT had a very favorable overall survival of 41.7% at 2 years. Cumulative incidence of non-relapse mortality was 36 and 40% at 1 and 2 years, respectively. With a cumulative incidence for relapse of 36 and 45.6% at 1 and 2 years, disease-free survival (DFS) was 28 and 14.4%, respectively. Here also, patients with CR before haploidentical HCT had a favorable DFS of 42% at 2 years. Only very limited acute (11 patients (44%) with a median grade 1) and chronic graft versus host disease (GvHD) (5 patients (11%), limited grade only) was observed. The main complications and causes of death comprised-besides relapse-infections and bleeding complications. Hence, haploidentical HCT can achieve long-term survival comparable to second transplantation with matched or mismatched donors for patients with otherwise deleterious prognosis and should be considered as a treatment option for patients experiencing disease relapse after previous allogeneic HCT.
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Rein LA, Sung AD, Rizzieri DA. New approaches to manipulate minimal residual disease after allogeneic stem cell transplantation. Int J Hematol Oncol 2013; 2. [PMID: 24303095 DOI: 10.2217/ijh.13.4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Minimal residual disease (MRD) is a complex topic that has been studied extensively in hematologic malignancies given its clinical implications related to prognosis. However, methods to monitor and treat MRD, especially after stem cell transplantation, are not well defined and vary in different disease processes. Alternative transplant strategies, such as reduced-intensity conditioning, have altered the way we assess and address MRD after transplantation. Development of new diagnostic tools have allowed for higher sensitivity and specificity of testing. Both targeted chemotherapeutic agents and immunotherapies have been developed to treat MRD in hopes of improving patient outcomes. This article aims to address ways to define and manipulate MRD specifically after stem cell transplantation.
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Affiliation(s)
- Lindsay Am Rein
- Division of Hematologic Malignancies & Cellular Therapy, Duke University Medical Center, Durham, NC 27710, USA
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Expanded indications for allogeneic stem cell transplantation in patients with myeloid malignancies. Curr Opin Hematol 2013; 20:115-22. [PMID: 23385613 DOI: 10.1097/moh.0b013e32835dd84a] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Hematopoietic stem cell transplantation (SCT) can be curative for myeloid malignancies such as acute myeloid leukemia (AML). Advancements in human leukocyte antigen (HLA) typing and supportive care have improved the risk-benefit ratio for SCT, expanding its indications. RECENT FINDINGS Allogeneic SCT is an established treatment for AML with intermediate-risk and high-risk cytogenetics in first complete remission (CR1), from matched related donors (MRDs). Similar survival benefits are seen for AML in CR1 with unfavorable cytogenetics using matched unrelated donors (URDs). Molecular characterization has delineated patients with AML at higher risk with normal cytogenetics [e.g., FLT3-internal tandem duplication (ITD)+]. The outcomes of allogeneic SCT are comparable in patients with therapy-related or de-novo AML when adjusted for disease status and cytogenetics. In patients lacking a MRD, the majority will have a suitable alternative using an URD, umbilical cord blood, or haploidentical-related donors; outcomes are either comparable or relatively acceptable compared to a matched sibling donor. Comorbidity indices aid in identifying elderly and debilitated patients who may benefit from SCT; the application of SCT has been further increased by reduced-intensity conditioning regimens. SUMMARY Allogeneic SCT may be extended to almost all patients with AML, and integration of toxicity and relapse risks will determine the best approach for allogeneic SCT in the future.
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