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Salhotra A, Yuan S, Ali H. Fifty years of BMT: risk stratification, donor matching, and stem cell collection for transplantation. Front Oncol 2023; 13:1196564. [PMID: 37700828 PMCID: PMC10493308 DOI: 10.3389/fonc.2023.1196564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/07/2023] [Indexed: 09/14/2023] Open
Abstract
In this review, we discuss recipient risk assessment for allo-HCT regarding comorbidities present at baseline to predict non relapse mortality. We further reviewed the incorporation of remission status and cytogenetic risk prior to allograft transplantation to predict relapse rates for hematologic malignancies. HCT-CI and DRI are tools available to physicians to assess the risk-benefit of allo-HCT in patients referred for transplantation. Next, we discuss our algorithm for donor selection and criteria for donor selection in case matched donors are not available. Finally, we discuss our approach for stem cell mobilization, especially in donors failing G-CSF, and our approach for the use of plerixafor and data supporting its use.
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Affiliation(s)
- Amandeep Salhotra
- Department of Hematology and Hematopoietic Cell Transplantation (HCT), City of Hope National Medical Center, Duarte, CA, United States
| | - Shan Yuan
- Division of Transfusion Medicine, Department of Pathology and Laboratory Medicine, City of Hope National Medical Center, Duarte, CA, United States
| | - Haris Ali
- Department of Hematology and Hematopoietic Cell Transplantation (HCT), City of Hope National Medical Center, Duarte, CA, United States
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2
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Wm Te Loo DM, Harbers V, Vermeltfoort L, Coenen MJ. Influence of genetic variants on the pharmacokinetics and pharmacodynamics of sirolimus: a systematic review. Pharmacogenomics 2023; 24:629-639. [PMID: 37551646 DOI: 10.2217/pgs-2022-0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023] Open
Abstract
Sirolimus is an antiproliferative and immunosuppressive compound inhibiting the mTOR pathway, which is often activated in congenital low-flow vascular malformations. Studies have demonstrated the efficacy of sirolimus for this disease. Studies in kidney transplant patients suggest that genetic variants can influence these pharmacokinetic parameters. Therefore, a systematic literature search was performed to gain insight into pharmacogenetic studies with sirolimus. Most studies investigated CYP3A4 and CYP3A5, with inconsistent results. No pharmacogenetic studies focusing on sirolimus have been performed for low-flow vascular malformations. We analyzed two common variants of CYP3A4 and CYP3A5 (CYP3A4*22 and CYP3A5*3, respectively) in patients (n = 59) with congenital low-flow vascular malformations treated with sirolimus. No association with treatment outcome was identified in this small cohort of patients.
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Affiliation(s)
- D Maroeska Wm Te Loo
- Department of Pediatric Hematology, Amalia Children's Hospital, Radboud university medical center, Geert Grooteplein Zuid 32, Nijmegen, 6525 GA, The Netherlands
- Radboudumc Center of Expertise Hemangiomas & Congenital Vascular Malformations Nijmegen, Amalia Children's Hospital, Radboud university medical center, Rene Descartes Dreef 1, Nijmegen, 6525 GL, The Netherlands
| | - Veroniek Harbers
- Department of Medical Imaging, Radboud university medical center, Geert Grooteplein Zuid 22, Nijmegen, 6525 GA, The Netherlands
| | - Lars Vermeltfoort
- Department of Pediatric Hematology, Amalia Children's Hospital, Radboud university medical center, Geert Grooteplein Zuid 32, Nijmegen, 6525 GA, The Netherlands
| | - Marieke Jh Coenen
- Department of Clinical Chemistry, Erasmus University Medical Center, Dr Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
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3
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Saad A, Loren A, Bolaños-Meade J, Chen G, Couriel D, Di Stasi A, El-Jawahri A, Elmariah H, Farag S, Gundabolu K, Gutman J, Ho V, Hoeg R, Horwitz M, Hsu J, Kassim A, Kharfan Dabaja M, Magenau J, Martin T, Mielcarek M, Moreira J, Nakamura R, Nieto Y, Ninos C, Oliai C, Patel S, Randolph B, Schroeder M, Tzachanis D, Varshavsky-Yanovsky AN, Vusirikala M, Algieri F, Pluchino LA. NCCN Guidelines® Insights: Hematopoietic Cell Transplantation, Version 3.2022. J Natl Compr Canc Netw 2023; 21:108-115. [PMID: 36791762 DOI: 10.6004/jnccn.2023.0007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
The NCCN Guidelines for Hematopoietic Cell Transplantation (HCT) provide an evidence- and consensus-based approach for the use of autologous and allogeneic HCT in the management of malignant diseases in adult patients. HCT is a potentially curative treatment option for patients with certain types of malignancies; however, recurrent malignancy and transplant-related complications often limit the long-term survival of HCT recipients. The purpose of these guidelines is to provide guidance regarding aspects of HCT, including pretransplant recipient evaluation, hematopoietic cell mobilization, and treatment of graft-versus-host disease-a major complication of allogeneic HCT-to enable the patient and clinician to assess management options in the context of an individual patient's condition. These NCCN Guidelines Insights provide a summary of the important recent updates to the NCCN Guidelines for HCT, including the incorporation of a newly developed section on the Principles of Conditioning for HCT.
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Affiliation(s)
- Ayman Saad
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Alison Loren
- Abramson Cancer Center at the University of Pennsylvania
| | | | | | | | | | | | | | - Sherif Farag
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center
| | | | | | - Vincent Ho
- Dana-Farber/Brigham and Women's Cancer Center
| | | | | | | | | | | | | | - Thomas Martin
- UCSF Helen Diller Family Comprehensive Cancer Center
| | | | - Jonathan Moreira
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Yago Nieto
- The University of Texas MD Anderson Cancer Center
| | | | | | - Seema Patel
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Brion Randolph
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - Mark Schroeder
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
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4
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Farshbafnadi M, Razi S, Rezaei N. Transplantation. Clin Immunol 2023. [DOI: 10.1016/b978-0-12-818006-8.00008-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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5
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Campe J, Ullrich E. T Helper Cell Lineage-Defining Transcription Factors: Potent Targets for Specific GVHD Therapy? Front Immunol 2022; 12:806529. [PMID: 35069590 PMCID: PMC8766661 DOI: 10.3389/fimmu.2021.806529] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/14/2021] [Indexed: 12/12/2022] Open
Abstract
Allogenic hematopoietic stem cell transplantation (allo-HSCT) represents a potent and potentially curative treatment for many hematopoietic malignancies and hematologic disorders in adults and children. The donor-derived immunity, elicited by the stem cell transplant, can prevent disease relapse but is also responsible for the induction of graft-versus-host disease (GVHD). The pathophysiology of acute GVHD is not completely understood yet. In general, acute GVHD is driven by the inflammatory and cytotoxic effect of alloreactive donor T cells. Since several experimental approaches indicate that CD4 T cells play an important role in initiation and progression of acute GVHD, the contribution of the different CD4 T helper (Th) cell subtypes in the pathomechanism and regulation of the disease is a central point of current research. Th lineages derive from naïve CD4 T cell progenitors and lineage commitment is initiated by the surrounding cytokine milieu and subsequent changes in the transcription factor (TF) profile. Each T cell subtype has its own effector characteristics, immunologic function, and lineage specific cytokine profile, leading to the association with different immune responses and diseases. Acute GVHD is thought to be mainly driven by the Th1/Th17 axis, whereas Treg cells are attributed to attenuate GVHD effects. As the differentiation of each Th subset highly depends on the specific composition of activating and repressing TFs, these present a potent target to alter the Th cell landscape towards a GVHD-ameliorating direction, e.g. by inhibiting Th1 and Th17 differentiation. The finding, that targeting of Th1 and Th17 differentiation appears more effective for GVHD-prevention than a strategy to inhibit Th1 and Th17 cytokines supports this concept. In this review, we shed light on the current advances of potent TF inhibitors to alter Th cell differentiation and consecutively attenuate GVHD. We will focus especially on preclinical studies and outcomes of TF inhibition in murine GVHD models. Finally, we will point out the possible impact of a Th cell subset-specific immune modulation in context of GVHD.
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Affiliation(s)
- Julia Campe
- Experimental Immunology, Children's University Hospital, Goethe University Frankfurt, Frankfurt am Main, Germany.,Children's University Hospital, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Evelyn Ullrich
- Experimental Immunology, Children's University Hospital, Goethe University Frankfurt, Frankfurt am Main, Germany.,Children's University Hospital, Goethe University Frankfurt, Frankfurt am Main, Germany.,Frankfurt Cancer Institute, Goethe University Frankfurt, Frankfurt am Main, Germany.,German Cancer Consortium (Deutsches Konsortium für Translationale Krebsforschung (DKTK)), Partner Site Frankfurt/Mainz, Frankfurt am Main, Germany
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6
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Mirza AS, Tandon A, Jenneman D, Cao S, Brimer T, Kumar A, Kidd M, Khimani F, Faramand R, Mishra A, Liu H, Nishihori T, Perez L, Lazaryan A, Bejanyan N, Nieder M, Pidala J, Elmariah H. Outcomes Following Intolerance to Tacrolimus/Sirolimus Graft-Versus-Host Disease Prophylaxis for Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2022; 28:185.e1-185.e7. [PMID: 35017119 DOI: 10.1016/j.jtct.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/07/2021] [Accepted: 01/04/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although tacrolimus and sirolimus (TAC/SIR) is an accepted graft-versus-host disease (GVHD) prophylaxis following allogeneic hematopoietic cell transplant (HCT), toxicity from this regimen can lead to premature discontinuation of immunosuppression. There are limited studies reporting outcomes and subsequent treatment of patients with TAC/SIR intolerance. OBJECTIVES To assess outcomes of patients with TAC/SIR intolerance and guide subsequent management after intolerance. STUDY DESIGN We retrospectively analyzed transplant outcomes of consecutive adult patients at Moffitt Cancer Center who received allogeneic HCT with TAC/SIR as GVHD prophylaxis from 2009 to 2018. TAC/SIR intolerance was defined as discontinuation due to toxicity of either TAC or SIR before post-transplant day 100. RESULTS 777 patients met the inclusion criteria. Median follow-up was 22 (0.2-125) months. Intolerance occurred in 13% (n = 104) of patients at a median of 30 (range 5-90) days. The most common causes of intolerance were acute kidney injury (n = 53 [51%]), thrombotic microangiopathy (n = 31 [28%]), and veno-occlusive disease (n = 23 [22%]). The cumulative incidence of grade 2 to 4 acute GVHD at 100 days in TAC/SIR-intolerant patients was 50% (95% CI, 39%-64%) and 25% (95% CI, 22%-29%) in patients tolerant to this regimen (P < .0001). In multivariate analyses, grade 2 to 4 acute GVHD was significantly higher in TAC/SIR-intolerant patients (HR 2.40; 95% CI, 1.59-3.61; P < .0001). Similarly, in multivariate analyses, TAC/SIR-intolerant patients had more chronic GVHD (HR 1.48, 95% CI, 1.03-2.12; P = .03). The non-relapse mortality (NRM) at 1 year in TAC/SIR-intolerant patients was 47% (95% CI, 38%-59%) and 12% (95% CI, 10%-15%) in those tolerant to the regimen (P < .0001). The 2-year relapse free survival of TAC/SIR-intolerant patients was 35% (95% CI, 25%-44%) and 60% (95% CI, 57%-65%) among TAC/SIR-tolerant patients, (HR 2.30; 95% CI, 1.61-3.28; P < .0001). Intolerance stratified by early (≤30 days) versus late (31-100 days) significantly affected the cumulative incidence of acute GVHD at 75% (early [95% CI, 59%-94%]) versus 33% ([late] 95% CI, 21%-50%) (P = .001) as well as the cumulative incidence of NRM at 61% ([early] 95% CI, 48%-77%) versus 35% ([late] 95% CI, 24%-51%) (P = .006). After developing TAC/SIR intolerance, most patients were switched to an alternative 2-drug regimen (71/104 [68%]), with the most common being mycophenolate mofetil in addition to continuing TAC or SIR (68/71 [96%]). CONCLUSIONS Overall, TAC/SIR intolerance was associated with poorer outcomes. Early intolerance contributed to higher risk of acute GVHD, increased NRM, and inferior survival. Patients with early intolerance were often switched to an alternative agent, and patients with late intolerance tended to be continued on single-drug therapy without substitution. Single-drug versus 2-drug regimens after intolerance did not appear to affect outcomes. Management strategies to mitigate the risks of intolerance are warranted.
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Affiliation(s)
- Abu-Sayeef Mirza
- University of South Florida, Dept of Internal Medicine, Tampa, FL
| | - Ankita Tandon
- University of South Florida, Dept of Internal Medicine, Tampa, FL
| | - Dakota Jenneman
- University of South Florida, Dept of Internal Medicine, Tampa, FL
| | - Shu Cao
- University of South Florida, Dept of Internal Medicine, Tampa, FL
| | - Thomas Brimer
- University of South Florida, Dept of Internal Medicine, Tampa, FL
| | - Ambuj Kumar
- Morsani College of Medicine, Dept of Evidence Based Medicine, Tampa FL
| | - Michelle Kidd
- Moffitt Cancer Center, Dept. of Blood & Marrow Transplant and Cellular Immunotherapy, Tampa, FL
| | - Farhad Khimani
- Moffitt Cancer Center, Dept. of Blood & Marrow Transplant and Cellular Immunotherapy, Tampa, FL
| | - Rawan Faramand
- Moffitt Cancer Center, Dept. of Blood & Marrow Transplant and Cellular Immunotherapy, Tampa, FL
| | - Asmita Mishra
- Moffitt Cancer Center, Dept. of Blood & Marrow Transplant and Cellular Immunotherapy, Tampa, FL
| | - Hien Liu
- Moffitt Cancer Center, Dept. of Blood & Marrow Transplant and Cellular Immunotherapy, Tampa, FL
| | - Taiga Nishihori
- Moffitt Cancer Center, Dept. of Blood & Marrow Transplant and Cellular Immunotherapy, Tampa, FL
| | - Lia Perez
- Moffitt Cancer Center, Dept. of Blood & Marrow Transplant and Cellular Immunotherapy, Tampa, FL
| | - Aleksandr Lazaryan
- Moffitt Cancer Center, Dept. of Blood & Marrow Transplant and Cellular Immunotherapy, Tampa, FL
| | - Nelli Bejanyan
- Moffitt Cancer Center, Dept. of Blood & Marrow Transplant and Cellular Immunotherapy, Tampa, FL
| | - Michael Nieder
- Moffitt Cancer Center, Dept. of Blood & Marrow Transplant and Cellular Immunotherapy, Tampa, FL
| | - Joseph Pidala
- Moffitt Cancer Center, Dept. of Blood & Marrow Transplant and Cellular Immunotherapy, Tampa, FL
| | - Hany Elmariah
- Moffitt Cancer Center, Dept. of Blood & Marrow Transplant and Cellular Immunotherapy, Tampa, FL.
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7
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Kharfan-Dabaja MA, Reljic T, Kumar A, Yassine F, Keller K, Fernandez A, Murthy H, Ayala E, Aljurf M, Iqbal M. Omission of day +11 methotrexate dose and allogeneic hematopoietic cell transplantation outcomes: results of a systematic review/meta-analysis. Bone Marrow Transplant 2022; 57:65-71. [PMID: 34642451 DOI: 10.1038/s41409-021-01496-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/23/2021] [Accepted: 09/30/2021] [Indexed: 02/08/2023]
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) is potentially curative for patients with malignant and benign hematologic conditions. Graft-versus-host disease (GVHD) is a known complication of allo-HCT that results in significant morbidity and mortality. A common GVHD prophylaxis strategy combines a calcineurin inhibitor with methotrexate. When mucositis and organ toxicity develop, the day +11 dose is frequently omitted to limit further organ damage. The potential impact of this practice on allo-HCT outcomes is unclear as published data show conflicting results. Thus, we performed a systematic review/meta-analysis of the available literature to assess the impact of omitting day +11 methotrexate on allo-HCT recipients. Data were extracted in relation to benefits (overall survival [OS], progression-free survival [PFS]) and harms (acute and chronic GVHD, non-relapse mortality [NRM], and relapse). Pooled OS rate favored those who received day +11 methotrexate vs. those who did not (HR = 1.21; 95% CI = 1.02-1.43; p = 0.03). There was no significant difference in pooled rates of PFS (HR = 0.96; 95% CI = 0.60-1.52; p = 0.85), acute GVHD (HR = 1.03; 95% CI = 0.35-2.98; p = 0.96), chronic GVHD (HR = 0.83; 95% CI = 0.44-1.57; p = 0.57), NRM (HR = 0.86; 95% CI = 0.67-1.11; p = 0.25), and relapse (HR = 0.97; 95% CI = 0.75-1.26; p = 0.83) between the two groups. Large prospective multicenter studies are needed to better define the significance of day +11 methotrexate omission.
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Affiliation(s)
- Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Programs, Mayo Clinic, Jacksonville, FL, USA.
| | - Tea Reljic
- Research Methodology and Biostatistics Core, Office of Research, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Arni Kumar
- Largo High School, IB Program, Largo, FL, USA
| | - Farah Yassine
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Programs, Mayo Clinic, Jacksonville, FL, USA
| | - Katelyn Keller
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Programs, Mayo Clinic, Jacksonville, FL, USA
| | - Andre Fernandez
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Programs, Mayo Clinic, Jacksonville, FL, USA
| | - Hemant Murthy
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Programs, Mayo Clinic, Jacksonville, FL, USA
| | - Ernesto Ayala
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Programs, Mayo Clinic, Jacksonville, FL, USA
| | - Mahmoud Aljurf
- Department of Adult Hematology and Stem Cell Transplantation, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Madiha Iqbal
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapy Programs, Mayo Clinic, Jacksonville, FL, USA
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8
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Braun LM, Zeiser R. Kinase Inhibition as Treatment for Acute and Chronic Graft- Versus-Host Disease. Front Immunol 2021; 12:760199. [PMID: 34868001 PMCID: PMC8635802 DOI: 10.3389/fimmu.2021.760199] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/28/2021] [Indexed: 01/25/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HCT) is a potentially curative therapy for patients suffering from hematological malignancies via the donor immune system driven graft-versus-leukemia effect. However, the therapy is mainly limited by severe acute and chronic graft-versus-host disease (GvHD), both being life-threatening complications after allo-HCT. GvHD develops when donor T cells do not only recognize remaining tumor cells as foreign, but also the recipient’s tissue, leading to a severe inflammatory disease. Typical GvHD target organs include the skin, liver and intestinal tract. Currently all approved strategies for GvHD treatment are immunosuppressive therapies, with the first-line therapy being glucocorticoids. However, therapeutic options for glucocorticoid-refractory patients are still limited. Novel therapeutic approaches, which reduce GvHD severity while preserving GvL activity, are urgently needed. Targeting kinase activity with small molecule inhibitors has shown promising results in preclinical animal models and clinical trials. Well-studied kinase targets in GvHD include Rho-associated coiled-coil-containing kinase 2 (ROCK2), spleen tyrosine kinase (SYK), Bruton’s tyrosine kinase (BTK) and interleukin-2-inducible T-cell kinase (ITK) to control B- and T-cell activation in acute and chronic GvHD. Janus Kinase 1 (JAK1) and 2 (JAK2) are among the most intensively studied kinases in GvHD due to their importance in cytokine production and inflammatory cell activation and migration. Here, we discuss the role of kinase inhibition as novel treatment strategies for acute and chronic GvHD after allo-HCT.
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Affiliation(s)
- Lukas M Braun
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Faculty of Biology, University of Freiburg, Freiburg, Germany
| | - Robert Zeiser
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), University of Freiburg, Freiburg, Germany.,Centre for Biological Signalling Studies (BIOSS) and Centre for Integrative Biological Signalling Studies (CIBSS), University of Freiburg, Freiburg, Germany
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9
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Khimani F, Ranspach P, Elmariah H, Kim J, Whiting J, Nishihori T, Locke FL, Perez Perez A, Dean E, Mishra A, Perez L, Lazaryan A, Jain MD, Nieder M, Liu H, Faramand R, Hansen D, Alsina M, Ochoa L, Davila M, Anasetti C, Pidala J, Bejanyan N. Increased Infections and Delayed CD4 + T Cell but Faster B Cell Immune Reconstitution after Post-Transplantation Cyclophosphamide Compared to Conventional GVHD Prophylaxis in Allogeneic Transplantation. Transplant Cell Ther 2021; 27:940-948. [PMID: 34329754 DOI: 10.1016/j.jtct.2021.07.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/28/2021] [Accepted: 07/21/2021] [Indexed: 11/24/2022]
Abstract
Post-transplantation cyclophosphamide (PTCy) is being increasingly used for graft-versus-host disease (GVHD) prophylaxis after allogeneic hematopoietic cell transplantation (allo-HCT) across various donor types. However, immune reconstitution and infection incidence after PTCy-based versus conventional GVHD prophylaxis has not been well studied. We evaluated the infection density and immune reconstitution (ie, absolute CD4+ T cell, CD8+ T cell, natural killer cell, and B cell counts) at 3 months, 6 months, and 1 year post-HCT in 583 consecutive adult patients undergoing allo-HCT with myeloablative (n = 223) or reduced-intensity (n = 360) conditioning between 2012 and 2018. Haploidentical (haplo; n = 75) and 8/8 HLA-matched unrelated (MUD; n = 08) donor types were included. GVHD prophylaxis was PTCy-based in all haplo (n = 75) and in 38 MUD allo-HCT recipients, whereas tacrolimus/methotrexate (Tac/MTX) was used in 89 and Tac/Sirolimus (Tac/Sir) was used in 381 MUD allo-HCT recipients. Clinical outcomes, including infections, nonrelapse mortality (NRM), relapse, and overall survival (OS), were compared across the 4 treatment groups. The recovery of absolute total CD4+ T-cell count was significantly lower in the haplo-PTCy and MUD-PTCy groups compared with the Tac/MTX and Tac/Sir groups throughout 1 year post-allo-HCT (P = .025). In contrast, CD19+ B-cell counts at 6 months and thereafter were higher in the haplo-PTCy and MUD-PTCy groups compared with the Tac/MTX and Tac/Sir groups (P < .001). Total CD8+ T cell and NK cell recovery was not significantly different among the groups. Infection density analysis showed a significantly higher frequency of total infections in the haplo-PTCy and MUD-PTCy groups compared with the Tac/MTX and Tac/Sir groups (5.0 and 5.0 vs 1.8 and 2.6 per 1000-person days; P < .01) within 1 year of allo-HCT. The cumulative incidence of cytomegalovirus reactivation/infection at 1 year post-allo-HCT was higher in the haplo-PTCy group (51%) compared with the MUD-PTCy (26%), Tac/MTX (26%), or Tac/Sir (13%) groups (P < .001). The incidence of BK, human herpesvirus 6, and other viruses were also higher in the PTCy-based groups. Overall, the treatment groups had similar 2 year NRM (P = .27) and OS (P = .78) outcomes. Our data show that PTCy-based GVHD prophylaxis is associated with delayed CD4+ T cell but faster B cell immune reconstitution and a higher frequency of infections compared with conventional GVHD prophylaxis but has no impact on nonrelapse mortality or overall survival.
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Affiliation(s)
- Farhad Khimani
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.
| | - Peter Ranspach
- Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Hany Elmariah
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jongphil Kim
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Junmin Whiting
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Taiga Nishihori
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Frederick L Locke
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Ariel Perez Perez
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Erin Dean
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Asmita Mishra
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Lia Perez
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Aleksandr Lazaryan
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Michael D Jain
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Michael Nieder
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Hein Liu
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Rawan Faramand
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Doris Hansen
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Melissa Alsina
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Leonel Ochoa
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Marco Davila
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Claudio Anasetti
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Joseph Pidala
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Nelli Bejanyan
- Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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10
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A phase 2 trial of the histone deacetylase inhibitor panobinostat for graft-versus-host disease prevention. Blood Adv 2021; 5:2740-2750. [PMID: 34242388 DOI: 10.1182/bloodadvances.2021004225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/06/2021] [Indexed: 01/09/2023] Open
Abstract
Immunomodulatory properties of histone deacetylase inhibitors represent a reasonable approach for acute graft-versus-host disease (aGVHD) prevention. We report a phase 2 trial evaluating panobinostat (PANO) administered over 26 weeks, starting on day -5 (5 mg orally 3 times a week) with tacrolimus initiated on day -3 plus sirolimus on day -1, with a median patient age of 58 years (range, 19-72 years) (n = 38). Donor source consisted of HLA 8/8-matched donors, related (n = 13) or unrelated (n = 25), using granulocyte colony-stimulating factor-stimulated peripheral blood stem cells. Myeloablative (n = 18) or reduced-intensity (n = 20) conditioning regimens were used for patients with acute myeloid leukemia (n = 17), myelodysplastic syndrome (n = 13), or other malignancies (n = 8). The cumulative incidence of aGVHD II-IV by day 100 was 18.4% (90% confidence interval [CI], 9.4% to 29.9%). Cumulative incidence of chronic GVHD at 1 year was 31.6% (90% CI, 19.5% to 44.3%). Adverse events related to PANO were thrombocytopenia (n = 5), leukopenia (n = 6), gastrointestinal toxicity (n = 3), rash (n = 4), renal failure/peripheral edema (n = 1), and periorbital edema (n = 1). At 1 year, overall survival was 89.5% (90% CI, 81.6% to 98.0%), relapse-free survival was 78.9% (90% CI, 68.8% to 90.6%), nonrelapse mortality was 2.6% (90% CI, 0.3% to 9.9%), and GVHD relapse-free survival was 60.5% (90% CI, 48.8% to 75.1%). PANO hits histone 3 as early as day 15 in CD8, CD4 and T regs. In conclusion, PANO combination met the primary study end point for aGVHD prevention and warrants further testing. This trial was registered at www.clinicaltrials.gov as #NCT02588339.
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11
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Posttransplant cyclophosphamide as GVHD prophylaxis for peripheral blood stem cell HLA-mismatched unrelated donor transplant. Blood Adv 2021; 5:2650-2659. [PMID: 34156440 DOI: 10.1182/bloodadvances.2021004192] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/26/2021] [Indexed: 12/15/2022] Open
Abstract
Efficacy of PTCy after mismatched unrelated donor (MMUD) HCT is unknown. In this pilot clinical trial, we enrolled 38 patients with hematologic malignancies scheduled to undergo MMUD-HCT (≥6/8 HLA-matched donors) onto 1 of 2 conditioning strata: myeloablative using fludarabine and fractionated total body irradiation (n = 19) or reduced intensity with fludarabine/melphalan (n = 19). Graft source was peripheral blood stem cells (PBSCs), and GVHD prophylaxis was PTCy, tacrolimus, and mycophenolate mofetil. Patients' median age was 53 years (range, 21-72 years). Median number of HLA mismatches was 2 (range, 1-4) of 12 loci. Twenty-three patients (61%) were considered racial (n = 12) or ethnic (n = 11) minorities. Median time to neutrophil engraftment was 16 days (range, 13-35 days). With a median follow-up of 18.3 months (range, 4.3-25.0 months) for surviving patients, 1-year overall survival (OS) and GVHD-free/relapse-free survival (GRFS) were 87% (95% confidence interval [CI]: 71-94) and 68% (95% CI: 51-81), respectively. Cumulative incidence of nonrelapse mortality at 100 days and 1 year were 0% and 11% (95% CI: 4-27), respectively, whereas relapse/progression was 11% (95% CI: 4-27). Cumulative incidence of 100-day acute GVHD grades 2-4 and 3-4 and 1-year chronic GVHD were 50% (95% CI: 36-69), 18% (95% CI: 9-36), and 48% (95% CI: 34-68), respectively. The rate of moderate/severe chronic GVHD was 3% in the entire cohort. We showed highly promising OS/GRFS rates with an acceptable risk profile after PBSC-MMUD-HCT with PTCy. This trial was registered at www.clinicaltrials.gov as #NCT03128359.
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12
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A phase 2 trial of GVHD prophylaxis with PTCy, sirolimus, and MMF after peripheral blood haploidentical transplantation. Blood Adv 2021; 5:1154-1163. [PMID: 33635333 DOI: 10.1182/bloodadvances.2020003779] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/13/2021] [Indexed: 12/14/2022] Open
Abstract
The introduction of posttransplant cyclophosphamide (PTCy) made performing allogeneic hematopoietic cell transplantation (HCT) from HLA haplotype-incompatible donors possible. In a setting of PTCy and tacrolimus/mycophenolate mofetil (MMF) as a graft-versus-host disease (GVHD) prophylaxis, a peripheral blood (PB) graft source as compared with bone marrow reduces the relapse rate but increases acute GVHD (aGVHD) and chronic GVHD (cGVHD). This phase 2 trial assessed sirolimus and MMF efficacy following PTCy as a GVHD prophylaxis after PB haploidentical HCT (haplo-HCT). With 32 evaluable patients (≥18 years) enrolled, this study had 90% power to demonstrate a reduction in 100-day grade II-IV aGVHD to 20% from the historical benchmark of 40% after haplo-HCT using PTCy/tacrolimus/MMF. At a median follow-up of 16.1 months, the primary end point of the trial was met with a day-100 grade II-IV aGVHD cumulative incidence of 18.8% (95% confidence interval [CI], 7.5% to 34.0%). There were no graft-failure events and the 1-year probability of National Institutes of Health (NIH) moderate/severe cGVHD was 18.8% (95% CI, 7.4% to 34.0%), nonrelapse mortality was 18.8% (95% CI, 7.4% to 34.0%), relapse was 22.2% (95% CI, 9.6% to 38.2%), disease-free survival was 59.0% (95% CI, 44.1% to 79.0%), GVHD-free relapse-free survival was 49.6% (95% CI, 34.9% to 70.5%), and overall survival was 71.7% (95% CI, 57.7% to 89.2%) for the entire cohort. These data demonstrate that GVHD prophylaxis with sirolimus/MMF following PTCy effectively prevents grade II-IV aGVHD after PB haplo-HCT, warranting prospective comparison of sirolimus vs tacrolimus in combination with MMF following PTCy as GVHD prophylaxis after PB HCT. This trial was registered at www.clinicaltrials.gov as #NCT03018223.
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13
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Loke J, Buka R, Craddock C. Allogeneic Stem Cell Transplantation for Acute Myeloid Leukemia: Who, When, and How? Front Immunol 2021; 12:659595. [PMID: 34012445 PMCID: PMC8126705 DOI: 10.3389/fimmu.2021.659595] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/23/2021] [Indexed: 12/28/2022] Open
Abstract
Although the majority of patients with acute myeloid leukemia (AML) treated with intensive chemotherapy achieve a complete remission (CR), many are destined to relapse if treated with intensive chemotherapy alone. Allogeneic stem cell transplant (allo-SCT) represents a pivotally important treatment strategy in fit adults with AML because of its augmented anti-leukemic activity consequent upon dose intensification and the genesis of a potent graft-versus-leukemia effect. Increased donor availability coupled with the advent of reduced intensity conditioning (RIC) regimens has dramatically increased transplant access and consequently allo-SCT is now a key component of the treatment algorithm in both patients with AML in first CR (CR1) and advanced disease. Although transplant related mortality has fallen steadily over recent decades there has been no real progress in reducing the risk of disease relapse which remains the major cause of transplant failure and represents a major area of unmet need. A number of therapeutic approaches with the potential to reduce disease relapse, including advances in induction chemotherapy, the development of novel conditioning regimens and the emergence of the concept of post-transplant maintenance, are currently under development. Furthermore, the use of genetics and measurable residual disease technology in disease assessment has improved the identification of patients who are likely to benefit from an allo-SCT which now represents an increasingly personalized therapy. Future progress in optimizing transplant outcome will be dependent on the successful delivery by the international transplant community of randomized prospective clinical trials which permit examination of current and future transplant therapies with the same degree of rigor as is routinely adopted for non-transplant therapies.
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Affiliation(s)
- Justin Loke
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Richard Buka
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Charles Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
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14
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Schäfer H, Blümel-Lehmann J, Ihorst G, Bertz H, Wäsch R, Zeiser R, Finke J, Marks R. A prospective single-center study on CNI-free GVHD prophylaxis with everolimus plus mycophenolate mofetil in allogeneic HCT. Ann Hematol 2021; 100:2095-2103. [PMID: 33755792 PMCID: PMC8285343 DOI: 10.1007/s00277-021-04487-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 03/02/2021] [Indexed: 12/02/2022]
Abstract
We report a single-center phase I/II trial exploring the combination of everolimus (EVE) and mycophenolate mofetil (MMF) as calcineurin inhibitor (CNI)-free GVHD prophylaxis for 24 patients with hematologic malignancies and indication for allogeneic HCT after a high dose or reduced-intensity ablative conditioning. The study was registered as EudraCT-2007-001892-12 and Clinicaltrials.gov as NCT00856505. All patients received PBSC grafts and no graft failure occurred. 7/24 patients (29%) developed acute grades III and IV GVHD (aGVHD), 16/19 evaluable patients (84%) developed chronic GVHD (cGVHD) of all grades, and 6/19 (31.6%) of higher grades. No severe toxicities related to study medication were observed. The median follow-up of all surviving patients is 2177 days. The 3-year OS was 45.2% (95% CI: 27.4–61.4%), and the 3-year PFS was 38.7% (95% CI: 22.0–55.1%). The cumulative incidence of relapse at 1 year and 3 year was 25% (95% CI: 12.5–50.0%), and 33.3% (95% CI: 18.9–58.7%), the cumulative incidence of NRM at 1 year and 3 years was 20.8% (95%CI: 9.6–45.5%), and 29.2% (95%CI: 15.6–54.4%), respectively. The utilization of CNI-free GVHD prophylaxis with EVE+MMF resulted in high rates of acute and chronic GVHD. Therefore, we do not recommend a CNI-free combination of mTOR inhibitor EVE with MMF as the sole GVHD prophylaxis. In subsequent studies, this combination should be modified, e.g., with further components like post-transplant cyclophosphamide (PTCy) or anti-thymocyte globulin (ATG).
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Affiliation(s)
- Henning Schäfer
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany. .,Department Hematology, Oncology & Stem Cell Transplantation, Faculty of Medicine and Medical Centre, University of Freiburg, Freiburg, Germany.
| | - Jacqueline Blümel-Lehmann
- Department Hematology, Oncology & Stem Cell Transplantation, Faculty of Medicine and Medical Centre, University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Faculty of Medicine and Medical Centre, University of Freiburg, Freiburg, Germany
| | - Hartmut Bertz
- Department Hematology, Oncology & Stem Cell Transplantation, Faculty of Medicine and Medical Centre, University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department Hematology, Oncology & Stem Cell Transplantation, Faculty of Medicine and Medical Centre, University of Freiburg, Freiburg, Germany
| | - Robert Zeiser
- Department Hematology, Oncology & Stem Cell Transplantation, Faculty of Medicine and Medical Centre, University of Freiburg, Freiburg, Germany
| | - Jürgen Finke
- Department Hematology, Oncology & Stem Cell Transplantation, Faculty of Medicine and Medical Centre, University of Freiburg, Freiburg, Germany
| | - Reinhard Marks
- Department Hematology, Oncology & Stem Cell Transplantation, Faculty of Medicine and Medical Centre, University of Freiburg, Freiburg, Germany
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15
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Pidala J, Walton K, Elmariah H, Kim J, Mishra A, Bejanyan N, Nishihori T, Khimani F, Perez L, Faramand RG, Davila ML, Nieder ML, Sagatys EM, Holtan SG, Lawrence NJ, Lawrence HR, Blazar BR, Anasetti C, Sebti SM, Betts BC. Pacritinib Combined with Sirolimus and Low-Dose Tacrolimus for GVHD Prevention after Allogeneic Hematopoietic Cell Transplantation: Preclinical and Phase I Trial Results. Clin Cancer Res 2021; 27:2712-2722. [PMID: 33753457 DOI: 10.1158/1078-0432.ccr-20-4725] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/22/2021] [Accepted: 03/10/2021] [Indexed: 01/17/2023]
Abstract
PURPOSE In this first-in-human, phase I, GVHD prevention trial (NCT02891603), we combine pacritinib (PAC), a JAK2 inhibitor, with sirolimus to concurrently reduce T-cell costimulation via mTOR and IL6 activity. We evaluate the safety of pacritinib when administered with sirolimus plus low-dose tacrolimus (PAC/SIR/TAC) after allogeneic hematopoietic cell transplantation. PATIENTS AND METHODS The preclinical efficacy and immune modulation of PAC/SIR were investigated in xenogeneic GVHD. Our phase I trial followed a 3+3 dose-escalation design, including dose level 1 (pacritinib 100 mg daily), level 2 (pacritinib 100 mg twice daily), and level 3 (pacritinib 200 mg twice daily). The primary endpoint was to identify the lowest biologically active and safe dose of pacritinib with SIR/TAC (n = 12). Acute GVHD was scored through day +100. Allografts included 8/8 HLA-matched related or unrelated donor peripheral blood stem cells. RESULTS In mice, we show that dual JAK2/mTOR inhibition significantly reduces xenogeneic GVHD and increases peripheral regulatory T cell (Treg) potency as well as Treg induction from conventional CD4+ T cells. Pacritinib 100 mg twice a day was identified as the minimum biologically active and safe dose for further study. JAK2/mTOR inhibition suppresses pathogenic Th1 and Th17 cells, spares Tregs and antileukemia effector cells, and exhibits preliminary activity in preventing GVHD. PAC/SIR/TAC preserves donor cytomegalovirus (CMV) immunity and permits timely engraftment without cytopenias. CONCLUSIONS We demonstrate that PAC/SIR/TAC is safe and preliminarily limits acute GVHD, preserves donor CMV immunity, and permits timely engraftment. The efficacy of PAC/SIR/TAC will be tested in our ongoing phase II GVHD prevention trial.
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Affiliation(s)
- Joseph Pidala
- Department of Blood and Marrow Transplantation - Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida.,Department of Immunology, Moffitt Cancer Center, Tampa, Florida.,Department of Oncologic Sciences, University of South Florida, Tampa, Florida
| | - Kelly Walton
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Hany Elmariah
- Department of Blood and Marrow Transplantation - Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida.,Department of Oncologic Sciences, University of South Florida, Tampa, Florida
| | - Jongphil Kim
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida
| | - Asmita Mishra
- Department of Blood and Marrow Transplantation - Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida.,Department of Oncologic Sciences, University of South Florida, Tampa, Florida
| | - Nelli Bejanyan
- Department of Blood and Marrow Transplantation - Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida.,Department of Oncologic Sciences, University of South Florida, Tampa, Florida
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation - Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida.,Department of Oncologic Sciences, University of South Florida, Tampa, Florida
| | - Farhad Khimani
- Department of Blood and Marrow Transplantation - Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida.,Department of Oncologic Sciences, University of South Florida, Tampa, Florida
| | - Lia Perez
- Department of Blood and Marrow Transplantation - Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida.,Department of Oncologic Sciences, University of South Florida, Tampa, Florida
| | - Rawan G Faramand
- Department of Blood and Marrow Transplantation - Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida.,Department of Oncologic Sciences, University of South Florida, Tampa, Florida
| | - Marco L Davila
- Department of Blood and Marrow Transplantation - Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida.,Department of Immunology, Moffitt Cancer Center, Tampa, Florida.,Department of Oncologic Sciences, University of South Florida, Tampa, Florida
| | - Michael L Nieder
- Department of Blood and Marrow Transplantation - Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida.,Department of Oncologic Sciences, University of South Florida, Tampa, Florida
| | - Elizabeth M Sagatys
- Department of Hematopathology and Laboratory Medicine, Moffitt Cancer Center, Tampa, Florida
| | - Shernan G Holtan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | | | | | - Bruce R Blazar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Claudio Anasetti
- Department of Blood and Marrow Transplantation - Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida.,Department of Immunology, Moffitt Cancer Center, Tampa, Florida.,Department of Oncologic Sciences, University of South Florida, Tampa, Florida
| | - Said M Sebti
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia
| | - Brian C Betts
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota.
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16
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Martinez-Cibrian N, Zeiser R, Perez-Simon JA. Graft-versus-host disease prophylaxis: Pathophysiology-based review on current approaches and future directions. Blood Rev 2020; 48:100792. [PMID: 33386151 DOI: 10.1016/j.blre.2020.100792] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/11/2020] [Accepted: 12/10/2020] [Indexed: 12/13/2022]
Abstract
Graft-versus-host disease (GvHD) was first described in 1959, since then major efforts have been made in order to understand its physiopathology and animal models have played a key role. Three steps, involving different pathways, have been recognised in either acute and chronic GvHD, identifying them as two distinct entities. In order to reduce GvHD incidence and severity, prophylactic measures were added to transplant protocols. The combination of a calcineurin inhibitor (CNI) plus an antimetabolite remains the standard of care. Better knowledge of GvHD pathophysiology has moved this field forward and nowadays different drugs are being used on a daily basis. Improving GvHD prophylaxis is a major goal as it would translate into less non-relapse mortality and better overall survival. As compared to CNI plus methotrexate the combination of CNI plus mycophenolate mophetil (MMF) allows us to obtain similar results in terms of GvHD incidence but a lower toxicity rate in terms of neutropenia or mucositis. The use of ATG has been related to a lower risk of acute and chronic GvHD in prospective randomized trials as well as the use of posttransplant Cyclophosphamide, with no or marginal impact on overall survival but with an improvement in GvHD-relapse free survival (GRFS). The use of sirolimus has been related to a lower risk of acute GvHD and significantly influenced overall survival in one prospective randomized trial. Other prospective trials have evaluated the use of receptors such as CCR5 or α4β7 to avoid T-cells trafficking into GvHD target organs, cytokine blockers or immune check point agonists. Also, epigenetic modifiers have shown promising results in phase II trials. Attention should be paid to graft-versus-leukemia, infections and immune recovery before bringing new prophylactic strategies to clinical practice. Although the list of novel agents for GvHD prophylaxis is growing, randomized trials are still lacking for many of them.
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Affiliation(s)
- Nuria Martinez-Cibrian
- Department of Hematology, University Hospital Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS/CSIC/CIBERONC), Universidad de Sevilla, Spain
| | - Robert Zeiser
- Department of Hematology, Oncology, and Stem Cell Transplantation, Faculty of Medicine, Freiburg University Medical Center, Freiburg, Germany
| | - Jose A Perez-Simon
- Department of Hematology, University Hospital Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS/CSIC/CIBERONC), Universidad de Sevilla, Spain.
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17
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Shrestha B, Walton K, Reff J, Sagatys EM, Tu N, Boucher J, Li G, Ghafoor T, Felices M, Miller JS, Pidala J, Blazar BR, Anasetti C, Betts BC, Davila ML. Human CD83-targeted chimeric antigen receptor T cells prevent and treat graft-versus-host disease. J Clin Invest 2020; 130:4652-4662. [PMID: 32437331 PMCID: PMC7456225 DOI: 10.1172/jci135754] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 05/15/2020] [Indexed: 12/17/2022] Open
Abstract
Graft-versus-host disease (GVHD) remains an important cause of morbidity and mortality after allogeneic hematopoietic cell transplantation (allo-HCT). For decades, GVHD prophylaxis has included calcineurin inhibitors, despite their incomplete efficacy and impairment of graft-versus-leukemia (GVL). Distinct from pharmacologic immune suppression, we have developed what we believe is a novel, human CD83-targeted chimeric antigen receptor (CAR) T cell for GVHD prevention. CD83 is expressed on allo-activated conventional CD4+ T cells (Tconvs) and proinflammatory dendritic cells (DCs), which are both implicated in GVHD pathogenesis. Human CD83 CAR T cells eradicate pathogenic CD83+ target cells, substantially increase the ratio of regulatory T cells (Tregs) to allo-activated Tconvs, and provide durable prevention of xenogeneic GVHD. CD83 CAR T cells are also capable of treating xenogeneic GVHD. We show that human acute myeloid leukemia (AML) expresses CD83 and that myeloid leukemia cell lines are readily killed by CD83 CAR T cells. Human CD83 CAR T cells are a promising cell-based approach to preventing 2 critical complications of allo-HCT - GVHD and relapse. Thus, the use of human CD83 CAR T cells for GVHD prevention and treatment, as well as for targeting CD83+ AML, warrants clinical investigation.
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Affiliation(s)
- Bishwas Shrestha
- Department of Immunology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Kelly Walton
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jordan Reff
- Department of Immunology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Elizabeth M. Sagatys
- Department of Hematopathology and Laboratory Medicine, Moffitt Cancer Center, Tampa, Florida, USA
- Department of Oncologic Sciences, University of South Florida, Tampa, Florida, USA
| | - Nhan Tu
- Department of Oncologic Sciences, University of South Florida, Tampa, Florida, USA
| | - Justin Boucher
- Department of Oncologic Sciences, University of South Florida, Tampa, Florida, USA
| | - Gongbo Li
- Department of Oncologic Sciences, University of South Florida, Tampa, Florida, USA
| | - Tayyebb Ghafoor
- Department of Oncologic Sciences, University of South Florida, Tampa, Florida, USA
| | - Martin Felices
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jeffrey S. Miller
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Joseph Pidala
- Department of Oncologic Sciences, University of South Florida, Tampa, Florida, USA
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA
| | - Bruce R. Blazar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Claudio Anasetti
- Department of Oncologic Sciences, University of South Florida, Tampa, Florida, USA
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA
| | - Brian C. Betts
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Marco L. Davila
- Department of Immunology, Moffitt Cancer Center, Tampa, Florida, USA
- Department of Oncologic Sciences, University of South Florida, Tampa, Florida, USA
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA
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18
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Walton K, Fernandez MR, Sagatys EM, Reff J, Kim J, Lee MC, Kiluk JV, Hui JYC, McKenna D, Hupp M, Forster C, Linden MA, Lawrence NJ, Lawrence HR, Pidala J, Pavletic SZ, Blazar BR, Sebti SM, Cleveland JL, Anasetti C, Betts BC. Metabolic reprogramming augments potency of human pSTAT3-inhibited iTregs to suppress alloreactivity. JCI Insight 2020; 5:136437. [PMID: 32255769 DOI: 10.1172/jci.insight.136437] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/01/2020] [Indexed: 12/18/2022] Open
Abstract
Immunosuppressive donor Tregs can prevent graft-versus-host disease (GVHD) or solid-organ allograft rejection. We previously demonstrated that inhibiting STAT3 phosphorylation (pSTAT3) augments FOXP3 expression, stabilizing induced Tregs (iTregs). Here we report that human pSTAT3-inhibited iTregs prevent human skin graft rejection and xenogeneic GVHD yet spare donor antileukemia immunity. pSTAT3-inhibited iTregs express increased levels of skin-homing cutaneous lymphocyte-associated antigen, immunosuppressive GARP and PD-1, and IL-9 that supports tolerizing mast cells. Further, pSTAT3-inhibited iTregs significantly reduced alloreactive conventional T cells, Th1, and Th17 cells implicated in GVHD and tissue rejection and impaired infiltration by pathogenic Th2 cells. Mechanistically, pSTAT3 inhibition of iTregs provoked a shift in metabolism from oxidative phosphorylation (OxPhos) to glycolysis and reduced electron transport chain activity. Strikingly, cotreatment with coenzyme Q10 restored OxPhos in pSTAT3-inhibited iTregs and augmented their suppressive potency. These findings support the rationale for clinically testing the safety and efficacy of metabolically tuned, human pSTAT3-inhibited iTregs to control alloreactive T cells.
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Affiliation(s)
- Kelly Walton
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | | | | | | | - Jongphil Kim
- Department of Biostatistics and Bioinformatics, and
| | | | - John V Kiluk
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | | | - David McKenna
- Department of Laboratory Medicine and Pathology, and
| | - Meghan Hupp
- Department of Laboratory Medicine and Pathology, and
| | - Colleen Forster
- Bionet Histology Research Laboratory, University of Minnesota, Minneapolis, Minnesota, USA
| | | | | | | | - Joseph Pidala
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA
| | - Steven Z Pavletic
- Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Bruce R Blazar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Said M Sebti
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia USA
| | | | - Claudio Anasetti
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida, USA
| | - Brian C Betts
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
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19
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Al Malki MM, Gendzekhadze K, Yang D, Mokhtari S, Parker P, Karanes C, Palmer J, Snyder D, Forman SJ, Nademanee A, Nakamura R. Long-term Outcome of Allogeneic Hematopoietic Stem Cell Transplantation From Unrelated Donor Using Tacrolimus/Sirolimus-based GvHD Prophylaxis: Impact of HLA Mismatch. Transplantation 2020; 104:1070-1080. [PMID: 31449184 PMCID: PMC9071270 DOI: 10.1097/tp.0000000000002932] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While tacrolimus and sirolimus (T/S)-based graft-versus-host disease (GvHD) prophylaxis has been effective in preventing acute GvHD post hematopoietic cell transplantation (HCT), its efficacy and long-term outcome in matched (MUD) and mismatched unrelated donor (mMUD) setting is not well defined. METHODS Herein, we evaluated a consecutive case-series of 482 patients who underwent unrelated donor HCT (2005-2013) with T/S-based GvHD prophylaxis. RESULTS With a median follow-up of 6.2 years (range = 2.4-11.3), the 5-year overall survival (OS) and relapse/progression-free survival were 47.5% (95% confidence interval [CI]: 43.0-52.0) and 43.6% (95% CI: 39.1-48.1), respectively; and the 5-year cumulative incidence of nonrelapse mortality (NRM) and relapse were 24.9%, and 31.5%, respectively. In this cohort, mMUD was associated with worse OS (39.0% versus 50.7% at 5 y; P = 0.034), primarily due to greater risk of NRM (33.5% versus 21.7%; P = 0.038). While rates of relapse, acute (II-IV or III-IV) or chronic GvHD (limited or extensive) were not different, death caused by chronic GvHD (20.8% versus 12.8%; P = 0.022) and infection (33.0% versus 18.1%; P < 0.01) were significantly greater in mMUD. In multivariable analysis, high-risk disease (hazard ratio [HR] = 2.21, 95% CI: 1.16-4.23; P < 0.01) and mMUD (HR = 1.55, 95% CI: 1.15-2.08; P = 0.004) were independent predictive factors for OS. CONCLUSIONS T/S-based GvHD prophylaxis is an effective and acceptable GvHD prophylactic regimen. However, survival after mMUD remained poor, possibly related to the severity of chronic GvHD.
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Affiliation(s)
- Monzr M Al Malki
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, CA
| | | | - Dongyun Yang
- Department of Information Sciences, Division of Biostatistics, City of Hope, Duarte, CA
| | - Sally Mokhtari
- Department of Clinical Translational Program Development, City of Hope, Duarte, CA
| | - Pablo Parker
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, CA
| | - Chatchada Karanes
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, CA
| | - Joycelynne Palmer
- Department of Information Sciences, Division of Biostatistics, City of Hope, Duarte, CA
| | - David Snyder
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, CA
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, CA
| | - Auayporn Nademanee
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, CA
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope, Duarte, CA
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20
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Laham-Karam N, Pinto GP, Poso A, Kokkonen P. Transcription and Translation Inhibitors in Cancer Treatment. Front Chem 2020; 8:276. [PMID: 32373584 PMCID: PMC7186406 DOI: 10.3389/fchem.2020.00276] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/20/2020] [Indexed: 12/12/2022] Open
Abstract
Transcription and translation are fundamental cellular processes that govern the protein production of cells. These processes are generally up regulated in cancer cells, to maintain the enhanced metabolism and proliferative state of these cells. As such cancerous cells can be susceptible to transcription and translation inhibitors. There are numerous druggable proteins involved in transcription and translation which make lucrative targets for cancer drug development. In addition to proteins, recent years have shown that the "undruggable" transcription factors and RNA molecules can also be targeted to hamper the transcription or translation in cancer. In this review, we summarize the properties and function of the transcription and translation inhibitors that have been tested and developed, focusing on the advances of the last 5 years. To complement this, we also discuss some of the recent advances in targeting oncogenes tightly controlling transcription including transcription factors and KRAS. In addition to natural and synthetic compounds, we review DNA and RNA based approaches to develop cancer drugs. Finally, we conclude with the outlook to the future of the development of transcription and translation inhibitors.
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Affiliation(s)
- Nihay Laham-Karam
- A. I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Gaspar P. Pinto
- International Clinical Research Center, St. Anne University Hospital, Brno, Czechia
- Loschmidt Laboratories, Department of Experimental Biology and RECETOX, Faculty of Science, Masaryk University, Brno, Czechia
| | - Antti Poso
- School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- University Hospital Tübingen, Department of Internal Medicine VIII, University of Tübingen, Tübingen, Germany
| | - Piia Kokkonen
- School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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21
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DiMaggio E, Zhou JM, Caddell R, Tombleson R, Perkins J, Anasetti C, Khimani F, Pidala J, Nishihori T, Perez L, Betts B, Fernandez HF, Mishra A. Reduced-intensity fludarabine/melphalan confers similar survival to busulfan/fludarabine myeloablative regimens for patients with acute myeloid leukemia and myelodysplasia. Leuk Lymphoma 2020; 61:1678-1687. [PMID: 32133897 DOI: 10.1080/10428194.2020.1731498] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Optimal conditioning chemotherapy for patients with acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) remains uncertain. Myeloablative regimens such as fludarabine/busulfan are favored over reduced-intensity fludarabine/melphalan (Flu/Mel); however, it is not known if Flu/Mel is inferior. We analyzed hematopoietic cell transplantation recipients with AML and MDS who received fludarabine with once-daily intravenous busulfan targeted to either area under the curve (AUC) 5300 µM*L/min (Flu/Bu 5300) (n = 246) or AUC 3500 µM*L/min (Flu/Bu 3500) (n = 81), or Flu/Mel (n = 69). Flu/Bu regimens were compared separately to Flu/Mel. After 2-year follow-up, no differences in overall or relapse-free survival were found between Flu/Bu 5300 or 3500 versus Flu/Mel though relapse rates were significantly higher; 33.1% (p = 0.024), 44.6% (p = 0.002), versus 19.4%, respectively. Flu/Bu 5300 (p = 0.008) and Flu/Bu 3500 (p < 0.001) groups were prognostic for relapse compared to Flu/Mel. Flu/Mel yields lower relapse rates and similar survival benefit when compared to Flu/Bu 3500 or 5300 µM*L/min.
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Affiliation(s)
| | - Jun-Min Zhou
- Biostatistics Core, Moffitt Cancer Center, Tampa, FL, USA
| | - Ryan Caddell
- Department of Pharmacy, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Janelle Perkins
- College of Pharmacy, University of South Florida, Tampa, FL, USA
| | - Claudio Anasetti
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Farhad Khimani
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Joseph Pidala
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Lia Perez
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Brian Betts
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Hugo F Fernandez
- Moffitt Malignant Hematology and Cellular Therapy at Memorial Healthcare System, Pembroke Pines, FL, USA
| | - Asmita Mishra
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
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22
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Abstract
Introduction: Graft-versus-host disease (GVHD) is the most common complication of hematopoietic stem cell transplantation (HSCT); therefore, the prevention of GVHD is important for a successful treatment. Tacrolimus (Tac), a calcineurin inhibitor, has been widely used for the prophylaxis of GVHD in HSCT recipients. Areas covered: This review introduces phase II/III of clinical trials related with Tac's roles in the prevention of GVHD in HSCT. Furthermore, we discuss the normal ranges of Tac concentrations, pharmacogenetics, and drug interactions of Tac, as well as its side effects in adult HSCT recipients. Expert opinion: A series of studies has established the efficacy and safety of Tac alone or in combination with other agents in HSCT. However, successful administration of Tac is complicated by its narrow therapeutic window, inter-patient pharmacokinetic variability, and a spectrum of undesirable side effects. It is necessary to maintain concentrations of Tac within the desired ranges for GVHD prophylaxis. Moreover, various factors contribute to significant variability in Tac pharmacokinetics, including drug interactions and genomic variation.
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Affiliation(s)
- Yuan Gao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Soochow University , Suzhou , China
| | - Jingjing Ma
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Soochow University , Suzhou , China
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23
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Flippe L, Bézie S, Anegon I, Guillonneau C. Future prospects for CD8 + regulatory T cells in immune tolerance. Immunol Rev 2019; 292:209-224. [PMID: 31593314 PMCID: PMC7027528 DOI: 10.1111/imr.12812] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
CD8+ Tregs have been long described and significant progresses have been made about their phenotype, their functional mechanisms, and their suppressive ability compared to conventional CD4+ Tregs. They are now at the dawn of their clinical use. In this review, we will summarize their phenotypic characteristics, their mechanisms of action, the similarities, differences and synergies between CD8+ and CD4+ Tregs, and we will discuss the biology, development and induction of CD8+ Tregs, their manufacturing for clinical use, considering open questions/uncertainties and future technically accessible improvements notably through genetic modifications.
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Affiliation(s)
- Léa Flippe
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes, France.,Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France.,LabEx IGO "Immunotherapy, Graft, Oncology", Nantes, France
| | - Séverine Bézie
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes, France.,Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France.,LabEx IGO "Immunotherapy, Graft, Oncology", Nantes, France
| | - Ignacio Anegon
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes, France.,Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France.,LabEx IGO "Immunotherapy, Graft, Oncology", Nantes, France
| | - Carole Guillonneau
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes, France.,Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France.,LabEx IGO "Immunotherapy, Graft, Oncology", Nantes, France
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24
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Effect of Sirolimus on Immune Reconstitution Following Myeloablative Allogeneic Stem Cell Transplantation: An Ancillary Analysis of a Randomized Controlled Trial Comparing Tacrolimus/Sirolimus and Tacrolimus/Methotrexate (Blood and Marrow Transplant Clinical Trials Network/BMT CTN 0402). Biol Blood Marrow Transplant 2019; 25:2143-2151. [PMID: 31271885 DOI: 10.1016/j.bbmt.2019.06.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 06/26/2019] [Accepted: 06/26/2019] [Indexed: 11/21/2022]
Abstract
Although allogeneic hematopoietic cell transplantation (HCT) is a potentially curative therapy for hematologic neoplasms, one of its limiting toxicities continues to be graft-versus-host disease, both acute (aGVHD) and chronic (cGVHD). Sirolimus is a mammalian target of rapamycin inhibitor that has proven effective in GVHD prophylaxis in combination with a calcineurin inhibitor, such as tacrolimus. The impact of sirolimus on immune reconstitution has not been comprehensively investigated in vivo thus far, however. Here we present an ancillary analysis of the randomized study BMT-CTN 0402 that examined the effect of sirolimus on immune subsets post-transplantation. We further examine the association between different lymphocyte subsets and outcomes post-transplantation in each arm. BMT-CTN 0402 was a randomized trial (n = 304) comparing 2 GVHD prophylaxis regimens, tacrolimus/sirolimus (Tac/Sir) and tacrolimus/methotrexate (Tac/MTX), in patients with acute myelogenous leukemia, acute lymphoblastic leukemia, or myelodysplastic syndrome undergoing myeloablative HLA-matched HCT. There were no differences in 114-day GVHD-free survival (primary endpoint), aGVHD, cGVHD, relapse, or overall survival (OS) between the 2 arms. Of the 304 patients, 264 had available samples for the current immune reconstitution analysis. Blood samples were collected at 1, 3, 6, 12, and 24 months post-HCT. Multiparameter flow cytometry was performed at the project laboratory (Esoterix Clinical Trials Services) in a blinded fashion, and results for the 2 arms were compared. Multivariable Cox regression models, treating each phenotypic parameter as a time-dependent variable, were constructed to study the impact of reconstitution on clinical outcomes. There were no significant differences in patient and transplantation characteristics between the Tac/Sir and Tac/MTX arms in this analysis. Absolute lymphocyte count and CD3+ cell, CD4+ cell, and conventional T cell (Tcon) counts were significantly decreased in the Tac/Sir arm for up to 3 months post-HCT, whereas CD8+ cells recovered even more slowly (up to 6 months) in this arm. Interestingly, there was no clear difference in the absolute number of regulatory T cells (Tregs, defined as CD4+CD25+ cells) between the 2 arms at any point post-HCT; however, the Treg:Tcon ratio was significantly greater in the Tac/Sir arm in the first 3 months after HCT. B lymphocyte recovery was significantly compromised in the Tac/Sir arm from 1 month to 6 months after HCT, whereas natural killer cell reconstitution was not affected in the Tac/Sir arm. In the outcomes analysis, higher numbers of CD3+ cells, CD4+ cells, CD8+ cells, and Tregs were associated with better OS. Neither Treg numbers nor the Treg:Tcon ratio was correlated with GVHD. Our findings indicate that Tac/Sir has a more profound T cell suppressive effect than the combination of Tac/MTX in the early post-transplantation period, and particularly compromises the recovery of CD8+ T cells, which have been implicated in aGVHD. Sirolimus used in vivo with tacrolimus does not appear to result in increased absolute numbers of Tregs, but might have a beneficial effect on the Treg:Tcon balance in the first 3 months after transplantation. Nonetheless, no differences in aGVHD or cGVHD between the 2 arms were observed in the parent randomized trial. Calcineurin-inhibitor free, sirolimus-containing GVHD prophylaxis strategies, incorporating other novel agents, should be investigated further to maximize the potential favorable effect of sirolimus on Treg:Tcon balance in the post-transplantation immune repertoire. Sirolimus significantly compromises B cell recovery in the first 6 months post-HCT, with potential complex effects on cGVHD that merit further study.
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25
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Ruggeri A. Sirolimus-based graft-versus-host disease prophylaxis. LANCET HAEMATOLOGY 2019; 6:e387-e388. [PMID: 31248842 DOI: 10.1016/s2352-3026(19)30108-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 05/14/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Annalisa Ruggeri
- Department of Pediatric Hematology and Oncology, IRCCS Ospedale Pediatrico Bambino Gesù, 00165 Rome, Italy; Eurocord, Hôpital Saint Louis, Paris, France.
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26
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Sandmaier BM, Kornblit B, Storer BE, Olesen G, Maris MB, Langston AA, Gutman JA, Petersen SL, Chauncey TR, Bethge WA, Pulsipher MA, Woolfrey AE, Mielcarek M, Martin PJ, Appelbaum FR, Flowers MED, Maloney DG, Storb R. Addition of sirolimus to standard cyclosporine plus mycophenolate mofetil-based graft-versus-host disease prophylaxis for patients after unrelated non-myeloablative haemopoietic stem cell transplantation: a multicentre, randomised, phase 3 trial. LANCET HAEMATOLOGY 2019; 6:e409-e418. [PMID: 31248843 DOI: 10.1016/s2352-3026(19)30088-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/10/2019] [Accepted: 04/16/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Acute graft-versus-host-disease (GVHD) after non-myeloablative human leucocyte antigen (HLA)-matched, unrelated donor, allogeneic haemopoietic stem cell transplantation (HSCT) is associated with considerable morbidity and mortality. This trial aimed to evaluate the efficacy of adding sirolimus to the standard cyclosporine and mycophenolate mofetil prophylaxis therapy for preventing acute GVHD in this setting. METHODS This multicentre, randomised, phase 3 trial took place at nine HSCT centres based in the USA, Denmark, and Germany. Eligible patients were diagnosed with advanced haematological malignancies treatable by allogeneic HSCT, had a Karnofsky score greater than or equal to 60, were aged older than 50 years, or if they were aged 50 years or younger, were considered at high risk of regimen-related toxicity associated with a high-dose pre-transplantation conditioning regimen. Patients were randomly allocated by an adaptive randomisation scheme stratified by transplantation centre to receive either the standard GVHD prophylaxis regimen (cyclosporine and mycophenolate mofetil) or the triple-drug combination regimen (cyclosporine, mycophenolate mofetil, and sirolimus). Patients and physicians were not masked to treatment. All patients were prepared for HSCT with fludarabine (30 mg/m2 per day) 4, 3, and 2 days before receiving 2 or 3 Gy total body irradiation on the day of HSCT (day 0). In both study groups, 5·0 mg/kg of cyclosporine was administered orally twice daily starting 3 days before HSCT, and (in the absence of GVHD) tapered from day 96 through to day 150. In the standard GVHD prophylaxis group, 15 mg/kg of mycophenolate mofetil was given orally three times daily from day 0 until day 30, then twice daily until day 150, and (in the absence of GVHD) tapered off by day 180. In the triple-drug group, mycophenolate mofetil doses were the same as in the standard group, but the drug was discontinued on day 40. Sirolimus was started 3 days before HSCT, taken orally at 2 mg once daily and adjusted to maintain trough concentrations between 3-12 ng/mL through to day 150, and (in the absence of GVHD) tapered off by day 180. The primary endpoint was the cumulative incidence of grade 2-4 acute GVHD at day 100 post-transplantation. Secondary endpoints were non-relapse mortality, overall survival, progression-free survival, cumulative incidence of grade 3-4 acute GVHD, and cumulative incidence of chronic GVHD. Efficacy and safety analyses were per protocol, including all patients who received conditioning treatment and underwent transplantation. Toxic effects were measured according to the Common Terminology Criteria for Adverse Events (CTCAE). The current study was closed prematurely by recommendation of the Data and Safety Monitoring Board on July 27, 2016, after 168 patients received the allocated intervention, based on the results of a prespecified interim analysis for futility. This study is registered with ClinicalTrials.gov, number NCT01231412. FINDINGS Participants were recruited between Nov 1, 2010, and July 27, 2016. Of 180 patients enrolled in the study, 167 received the complete study intervention and were included in safety and efficacy analyses: 77 patients in the standard GVHD prophylaxis group and 90 in the triple-drug group. At the time of analysis, median follow-up was 48 months (IQR 31-60). The cumulative incidence of grade 2-4 acute GVHD at day 100 was lower in the triple-drug group compared with the standard GVHD prophylaxis group (26% [95% CI 17-35] in the triple-drug group vs 52% [41-63] in the standard group; HR 0·45 [95% CI 0·28-0·73]; p=0·0013). After 1 and 4 years, non-relapse mortality increased to 4% (95% CI 0-9) and 16% (8-24) in the triple-drug group and 16% (8-24) and 32% (21-43) in the standard group (HR 0·48 [0·26-0·90]; p=0·021). Overall survival at 1 year was 86% (95% CI 78-93) in the triple-drug group and 70% in the standard group (60-80) and at 4 years it was 64% in the triple-drug group (54-75) and 46% in the standard group (34-57%; HR 0·62 [0·40-0·97]; p=0·035). Progression-free survival at 1 year was 77% (95% CI 68-85) in the triple-drug group and 64% (53-74) in the standard drug group, and at 4 years it was 59% in the triple-drug group (49-70) and 41% in the standard group (30-53%; HR 0·64 [0·42-0·99]; p=0·045). We observed no difference in the cumulative incidence of grade 3-4 acute GVHD (2% [0-5] in the triple-drug group vs 8% [2-14] in the standard group; HR 0·55 [0·16-1·96]; p=0·36) and chronic GVHD (49% [39-59] in triple-drug group vs 50% [39-61] in the standard group; HR 0·94 [0·62-1·40]; p=0·74). In both groups the most common CTCAE grade 4 or higher toxic effects were pulmonary. INTERPRETATION Adding sirolimus to cyclosporine and mycophenolate mofetil resulted in a significantly lower proportion of patients developing acute GVHD compared with patients treated with cyclosporine and mycophenolate mofetil alone. Based on these results, the combination of cyclosporine, mycophenolate mofetil, and sirolimus has become the new standard GVHD prophylaxis regimen for patients treated with non-myeloablative conditioning and HLA-matched unrelated HSCT at the Fred Hutchinson Cancer Research Center. FUNDING National Institutes of Health.
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Affiliation(s)
- Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA.
| | - Brian Kornblit
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Haematology, Rigshospitalet, Copenhagen, Denmark
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Gitte Olesen
- Department of Hematology and Department of Clinical Medicine, Aarhus Hospital, Aarhus, Denmark
| | | | - Amelia A Langston
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Jonathan A Gutman
- Division of Hematology, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Thomas R Chauncey
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA; Marrow Transplant Unit, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Wolfgang A Bethge
- Department of Internal Medicine II - Hematology and Oncology, University Hospital of Eberhard Karls University, Tuebingen, Germany
| | - Michael A Pulsipher
- Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Hospital Los Angeles, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Ann E Woolfrey
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Marco Mielcarek
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Fred R Appelbaum
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - David G Maloney
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Rainer Storb
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
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27
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Copsel S, Wolf D, Komanduri KV, Levy RB. The promise of CD4 +FoxP3 + regulatory T-cell manipulation in vivo: applications for allogeneic hematopoietic stem cell transplantation. Haematologica 2019; 104:1309-1321. [PMID: 31221786 PMCID: PMC6601084 DOI: 10.3324/haematol.2018.198838] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/07/2019] [Indexed: 12/12/2022] Open
Abstract
CD4+FoxP3+ regulatory T cells (Tregs) are a non-redundant population critical for the maintenance of self-tolerance. Over the past decade, the use of these cells for therapeutic purposes in transplantation and autoimmune disease has emerged based on their capacity to inhibit immune activation. Basic science discoveries have led to identifying key receptors on Tregs that can regulate their proliferation and function. Notably, the understanding that IL-2 signaling is crucial for Treg homeostasis promoted the hypothesis that in vivo IL-2 treatment could provide a strategy to control the compartment. The use of low-dose IL-2 in vivo was shown to selectively expand Tregs versus other immune cells. Interestingly, a number of other Treg cell surface proteins, including CD28, CD45, IL-33R and TNFRSF members, have been identified which can also induce activation and proliferation of this population. Pre-clinical studies have exploited these observations to prevent and treat mice developing autoimmune diseases and graft-versus-host disease post-allogeneic hematopoietic stem cell transplantation. These findings support the development of translational strategies to expand Tregs in patients. Excitingly, the use of low-dose IL-2 for patients suffering from graft-versus-host disease and autoimmune disease has demonstrated increased Treg levels together with beneficial outcomes. To date, promising pre-clinical and clinical studies have directly targeted Tregs and clearly established the ability to increase their levels and augment their function in vivo. Here we review the evolving field of in vivo Treg manipulation and its application to allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
| | | | - Krishna V Komanduri
- Department of Microbiology and Immunology.,Sylvester Comprehensive Cancer Center.,Division of Transplantation and Cellular Therapy, Department of Medicine
| | - Robert B Levy
- Department of Microbiology and Immunology .,Division of Transplantation and Cellular Therapy, Department of Medicine.,Department of Ophthalmology, Miller School of Medicine, University of Miami, FL, USA
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28
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Salhotra A, Mei M, Stiller T, Mokhtari S, Herrera AF, Chen R, Popplewell L, Zain J, Ali H, Sandhu K, Budde E, Nademanee A, Forman SJ, Nakamura R. Outcomes of Patients with Recurrent and Refractory Lymphoma Undergoing Allogeneic Hematopoietic Cell Transplantation with BEAM Conditioning and Sirolimus- and Tacrolimus-Based GVHD Prophylaxis. Biol Blood Marrow Transplant 2018; 25:287-292. [PMID: 30227232 DOI: 10.1016/j.bbmt.2018.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 09/07/2018] [Indexed: 11/17/2022]
Abstract
The current standard of care for patients with Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) is high-dose conditioning followed by autologous stem cell transplantation (ASCT). For some patients (ie, those with highest-risk disease, insufficient stem cell numbers after mobilization, or bone marrow involvement) allogeneic hematopoietic cell transplantation (alloHCT) offers the potential for cure. However, the majority of patients undergoing alloHCT receive reduced-intensity conditioning as a preparative regimen, and studies assessing outcomes of patients after alloHCT with myeloablative conditioning are limited. In this retrospective study, we reviewed outcomes of 22 patients with recurrent and refractory NHL who underwent alloHCT with myeloablative BEAM conditioning and received tacrolimus/sirolimus as graft-versus-host disease (GVHD) prophylaxis at City of Hope between 2005 and 2018. With a median follow-up of 2.6 years (range, 1.0 to 11.2 years), the probabilities of 2-year overall survival and event-free survival were 58.3% (95% confidence interval [CI], 35.0% to 75.8%) and 45.5% (95% CI, 24.4% to 64.3%), respectively. The cumulative incidence of grade II to IV acute GVHD was 45.5% (95% CI, 23.8% to 64.9%), with only 1 patient developing grade IV acute GVHD. However, chronic GVHD was seen in 55% of the patients (n = 12). Of the 22 eligible patients, 2 had undergone previous ASCT and 2 had undergone previous alloHCT. Both patients with previous ASCT developed severe regimen-related toxicity. Patients who underwent alloHCT with chemorefractory disease had lower survival rates, with 1-year OS and EFS of 44.4% and 33.0%, respectively. In conclusion, alloHCT with a BEAM preparative regimen and tacrolimus/sirolimus-based GVHD should be considered as an alternative option for patients with highest-risk lymphoma whose outcomes are expectedly poor after ASCT.
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Affiliation(s)
- Amandeep Salhotra
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Division of Biostatistics, Department of Information Sciences, City of Hope, Duarte, California
| | - Matthew Mei
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Department of Hematology and Hematopoietic Cell Transplantation, Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - Tracey Stiller
- Division of Biostatistics, Department of Information Sciences, City of Hope, Duarte, California
| | - Sally Mokhtari
- Department of Clinical Translational Program Development, City of Hope, Duarte, California
| | - Alex F Herrera
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Robert Chen
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Leslie Popplewell
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Jasmine Zain
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Haris Ali
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Department of Hematology and Hematopoietic Cell Transplantation, Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - Karamjeet Sandhu
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Department of Hematology and Hematopoietic Cell Transplantation, Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - Elizabeth Budde
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Department of Hematology and Hematopoietic Cell Transplantation, Gehr Family Center for Leukemia Research, City of Hope, Duarte, California
| | - Auayporn Nademanee
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Department of Hematology and Hematopoietic Cell Transplantation, Gehr Family Center for Leukemia Research, City of Hope, Duarte, California.
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29
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Tkachev V, Furlan SN, Watkins B, Hunt DJ, Zheng HB, Panoskaltsis-Mortari A, Betz K, Brown M, Schell JB, Zeleski K, Yu A, Kirby I, Cooley S, Miller JS, Blazar BR, Casson D, Bland-Ward P, Kean LS. Combined OX40L and mTOR blockade controls effector T cell activation while preserving T reg reconstitution after transplant. Sci Transl Med 2018; 9:9/408/eaan3085. [PMID: 28931653 DOI: 10.1126/scitranslmed.aan3085] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 06/27/2017] [Indexed: 12/14/2022]
Abstract
A critical question facing the field of transplantation is how to control effector T cell (Teff) activation while preserving regulatory T cell (Treg) function. Standard calcineurin inhibitor-based strategies can partially control Teffs, but breakthrough activation still occurs, and these agents are antagonistic to Treg function. Conversely, mechanistic target of rapamycin (mTOR) inhibition with sirolimus is more Treg-compatible but is inadequate to fully control Teff activation. In contrast, blockade of OX40L signaling has the capacity to partially control Teff activation despite maintaining Treg function. We used the nonhuman primate graft-versus-host disease (GVHD) model to probe the efficacy of combinatorial immunomodulation with sirolimus and the OX40L-blocking antibody KY1005. Our results demonstrate significant biologic activity of KY1005 alone (prolonging median GVHD-free survival from 8 to 19.5 days), as well as marked, synergistic control of GVHD with KY1005 + sirolimus (median survival time, >100 days; P < 0.01 compared to all other regimens), which was associated with potent control of both TH/TC1 (T helper cell 1/cytotoxic T cell 1) and TH/TC17 activation. Combined administration also maintained Treg reconstitution [resulting in an enhanced Treg/Teff ratio (40% over baseline) in the KY1005/sirolimus cohort compared to a 2.9-fold decrease in the unprophylaxed GVHD cohort]. This unique immunologic signature resulted in transplant recipients that were able to control GVHD for the length of analysis and to down-regulate donor/recipient alloreactivity despite maintaining anti-third-party responses. These data indicate that combined OX40L blockade and sirolimus represents a promising strategy to induce immune balance after transplant and is an important candidate regimen for clinical translation.
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Affiliation(s)
- Victor Tkachev
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA.
| | - Scott N Furlan
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA.,Department of Pediatrics, University of Washington, Seattle, WA 98195, USA.,Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Benjamin Watkins
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA.,Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Daniel J Hunt
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Hengqi Betty Zheng
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Angela Panoskaltsis-Mortari
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | - Kayla Betz
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Melanie Brown
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - John B Schell
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Katie Zeleski
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Alison Yu
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | | | - Sarah Cooley
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | - Jeffrey S Miller
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | - Bruce R Blazar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55454, USA
| | | | | | - Leslie S Kean
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA 98101, USA. .,Department of Pediatrics, University of Washington, Seattle, WA 98195, USA.,Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
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30
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Pidala J, Beato F, Kim J, Betts B, Jim H, Sagatys E, Levine JE, Ferrara JL, Ozbek U, Ayala E, Davila M, Fernandez HF, Field T, Kharfan-Dabaja MA, Khaira D, Khimani F, Locke FL, Mishra A, Nieder M, Nishihori T, Perez L, Riches M, Anasetti C. In vivo IL-12/IL-23p40 neutralization blocks Th1/Th17 response after allogeneic hematopoietic cell transplantation. Haematologica 2018; 103:531-539. [PMID: 29242294 PMCID: PMC5830373 DOI: 10.3324/haematol.2017.171199] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 12/06/2017] [Indexed: 12/22/2022] Open
Abstract
T-helper 1 and T-helper 17 lymphocytes mediate acute graft-versus-host disease (GvHD). Interleukin 12 is critical for T-helper 1 differentiation and interleukin 23 for T-helper 17 maintenance. Interleukin 12 and 23 are heterodimeric cytokines that share the p40 subunit (IL-12/IL-23p40). In a randomized, blinded, placebo-controlled trial, we examined the biological impact and clinical outcomes following IL-12/IL-23p40 neutralization using ustekinumab. Thirty patients received peripheral blood mobilized hematopoietic cell transplantation (HCT) from HLA-matched sibling or unrelated donors, received sirolimus plus tacrolimus as GvHD prophylaxis, and were randomized to ustekinumab versus placebo with 1:1 allocation after stratification by donor type. The primary end point of the trial was the mean percentage (%) T-regulatory (Treg) cells on day 30 post HCT. Ustekinumab was delivered by subcutaneous injection on day -1 and day +20 after transplantation. On day 30 post transplant, no significant difference in % Treg was observed. Ustekinumab suppressed serum IL-12/IL-23p40 levels. Host-reactive donor alloresponse at days 30 and 90 after transplantation was polarized with significant reduction in IL-17 and IFN-α production and increase in IL-4. No toxicity attributed to ustekinumab was observed. Overall survival and National Institute of Health moderate/severe chronic GvHD-free, relapse-free survival were significantly improved among ustekinumab-treated patients. No significant improvements were observed in acute or chronic GvHD, relapse, or non-relapse mortality. These data provide first evidence that IL-12/IL-23p40 neutralization can polarize donor anti-host alloresponse in vivo and provide initial clinical efficacy evidence to be tested in subsequent trials. (Trial registered at clinicaltrials.gov identifier: 01713400).
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Affiliation(s)
- Joseph Pidala
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA .,Oncologic Sciences, College of the Medicine at University of South Florida, Tampa, FL, USA
| | - Francisca Beato
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - Jongphil Kim
- Biostatistics, Moffitt Cancer Center, Tampa, FL, USA
| | - Brian Betts
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA,Oncologic Sciences, College of the Medicine at University of South Florida, Tampa, FL, USA
| | - Heather Jim
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA,Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA
| | - Elizabeth Sagatys
- Hematopathology and Laboratory Medicine, Moffitt Cancer Center, Tampa, FL, USA
| | - John E. Levine
- Tisch Cancer Institute, the Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - James L.M. Ferrara
- Tisch Cancer Institute, the Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - Umut Ozbek
- Tisch Cancer Institute, the Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - Ernesto Ayala
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA,Oncologic Sciences, College of the Medicine at University of South Florida, Tampa, FL, USA
| | - Marco Davila
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA,Oncologic Sciences, College of the Medicine at University of South Florida, Tampa, FL, USA
| | - Hugo F. Fernandez
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA,Oncologic Sciences, College of the Medicine at University of South Florida, Tampa, FL, USA
| | - Teresa Field
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA,Oncologic Sciences, College of the Medicine at University of South Florida, Tampa, FL, USA
| | - Mohamed A. Kharfan-Dabaja
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA,Oncologic Sciences, College of the Medicine at University of South Florida, Tampa, FL, USA
| | - Divis Khaira
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA,Oncologic Sciences, College of the Medicine at University of South Florida, Tampa, FL, USA
| | - Farhad Khimani
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA,Oncologic Sciences, College of the Medicine at University of South Florida, Tampa, FL, USA
| | - Frederick L. Locke
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA,Oncologic Sciences, College of the Medicine at University of South Florida, Tampa, FL, USA
| | - Asmita Mishra
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA,Oncologic Sciences, College of the Medicine at University of South Florida, Tampa, FL, USA
| | - Michael Nieder
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA,Oncologic Sciences, College of the Medicine at University of South Florida, Tampa, FL, USA
| | - Taiga Nishihori
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA,Oncologic Sciences, College of the Medicine at University of South Florida, Tampa, FL, USA
| | - Lia Perez
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA,Oncologic Sciences, College of the Medicine at University of South Florida, Tampa, FL, USA
| | - Marcie Riches
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA,Oncologic Sciences, College of the Medicine at University of South Florida, Tampa, FL, USA
| | - Claudio Anasetti
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA,Oncologic Sciences, College of the Medicine at University of South Florida, Tampa, FL, USA
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31
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Betts BC, Veerapathran A, Pidala J, Yang H, Horna P, Walton K, Cubitt CL, Gunawan S, Lawrence HR, Lawrence NJ, Sebti SM, Anasetti C. Targeting Aurora kinase A and JAK2 prevents GVHD while maintaining Treg and antitumor CTL function. Sci Transl Med 2018; 9:9/372/eaai8269. [PMID: 28077684 DOI: 10.1126/scitranslmed.aai8269] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 08/17/2016] [Accepted: 10/10/2016] [Indexed: 12/12/2022]
Abstract
Graft-versus-host disease (GVHD) is a leading cause of nonrelapse mortality after allogeneic hematopoietic cell transplantation. T cell costimulation by CD28 contributes to GVHD, but prevention is incomplete when targeting CD28, downstream mammalian target of rapamycin (mTOR), or Aurora A. Likewise, interleukin-6 (IL-6)-mediated Janus kinase 2 (JAK2) signaling promotes alloreactivity, yet JAK2 inhibition does not eliminate GVHD. We provide evidence that blocking Aurora A and JAK2 in human T cells is synergistic in vitro, prevents xenogeneic GVHD, and maintains antitumor responses by cytotoxic T lymphocytes (CTLs). Aurora A/JAK2 inhibition is immunosuppressive but permits the differentiation of inducible regulatory T cells (iTregs) that are hyperfunctional and CD39 bright and efficiently scavenge adenosine triphosphate (ATP). Increased iTreg potency is primarily a function of Aurora A blockade, whereas JAK2 inhibition suppresses T helper 17 (TH17) differentiation. Inhibiting either Aurora A or JAK2 significantly suppresses TH1 T cells. However, CTL generated in vivo retains tumor-specific killing despite Aurora A/JAK2 blockade. Thus, inhibiting CD28 and IL-6 signal transduction pathways in donor T cells can increase the Treg/Tconv ratio, prevent GVHD, and preserve antitumor CTL.
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Affiliation(s)
- Brian C Betts
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL 33612, USA. .,Department of Immunology, Moffitt Cancer Center, Tampa, FL 33612, USA.,Department of Oncologic Sciences, University of South Florida, Tampa, FL 33612, USA
| | - Anandharaman Veerapathran
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL 33612, USA.,Department of Immunology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Joseph Pidala
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL 33612, USA.,Department of Immunology, Moffitt Cancer Center, Tampa, FL 33612, USA.,Department of Oncologic Sciences, University of South Florida, Tampa, FL 33612, USA
| | - Hua Yang
- Department of Oncologic Sciences, University of South Florida, Tampa, FL 33612, USA
| | - Pedro Horna
- Department of Oncologic Sciences, University of South Florida, Tampa, FL 33612, USA.,Department of Hematopathology and Laboratory Medicine, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Kelly Walton
- Department of Immunology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | | | - Steven Gunawan
- Department of Oncologic Sciences, University of South Florida, Tampa, FL 33612, USA
| | - Harshani R Lawrence
- Department of Oncologic Sciences, University of South Florida, Tampa, FL 33612, USA.,Department of Drug Discovery, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Nicholas J Lawrence
- Department of Oncologic Sciences, University of South Florida, Tampa, FL 33612, USA.,Department of Drug Discovery, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Said M Sebti
- Department of Oncologic Sciences, University of South Florida, Tampa, FL 33612, USA.,Department of Drug Discovery, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Claudio Anasetti
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL 33612, USA.,Department of Immunology, Moffitt Cancer Center, Tampa, FL 33612, USA.,Department of Oncologic Sciences, University of South Florida, Tampa, FL 33612, USA
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32
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Pan GH, Chen Z, Xu L, Zhu JH, Xiang P, Ma JJ, Peng YW, Li GH, Chen XY, Fang JL, Guo YH, Zhang L, Liu LS. Low-dose tacrolimus combined with donor-derived mesenchymal stem cells after renal transplantation: a prospective, non-randomized study. Oncotarget 2017; 7:12089-101. [PMID: 26933811 PMCID: PMC4914271 DOI: 10.18632/oncotarget.7725] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 01/29/2016] [Indexed: 12/22/2022] Open
Abstract
Calcineurin inhibitors, including tacrolimus, are largely responsible for advances in allotransplantation. However, the nephrotoxicity associated with these immunosuppressants impairs patients' long-term survival after renal allograft. Therefore, novel regimens that minimize or even eliminate calcineurin inhibitors could improve transplantation outcomes. In this pilot study, we investigated the use of low-dose tacrolimus in combination with mesenchymal stem cells (MSCs), which are immunosuppressive and prolong allograft survival in experimental organ transplant models. Donor-derived, bone marrow MSCs combined with a sparing dose of tacrolimus (0.04-0.05 mg/kg/day) were administered to 16 de novo living-related kidney transplant recipients; 16 other patients received a standard dose of tacrolimus (0.07-0.08 mg/kg/day). The safety of MSC infusion, acute rejection, graft function, graft survival, and patient survival were evaluated over ≥24 months following kidney transplantation. All patients survived and had stable renal function at the 24 month follow-up. The combination of low-dose tacrolimus and MSCs was as effective as standard dose tacrolimus in maintaining graft survival at least 2 years after transplantation. In addition, both groups had similar urea, urine protein, urinary RBC, urinary WBC, 24-h urine protein, and creatinine clearance rates from 7 days to 24 months after transplantation. Furthermore, no differences in the proportion of lymphocytes, CD19, CD3, CD34, CD38, and natural killer cells were detected between the control and experimental groups. None of the MSC recipients experienced immediate or long-term toxicity from the treatment. This preliminary data suggests that the addition of MSCs permits the use of lower dosages of nephrotoxic calcineurin inhibitors following renal transplantation.
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Affiliation(s)
- Guang-Hui Pan
- The Transplantation Centre, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Zheng Chen
- The Transplantation Centre, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Lu Xu
- The Transplantation Centre, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Jing-Hui Zhu
- The Transplantation Centre, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Peng Xiang
- Center for Stem Cell Biology and Tissue Engineering, SunYat-sen University, Guangzhou, Guangdong, China
| | - Jun-Jie Ma
- The Transplantation Centre, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Yan-Wen Peng
- Center for Stem Cell Biology and Tissue Engineering, SunYat-sen University, Guangzhou, Guangdong, China
| | - Guang-Hui Li
- The Transplantation Centre, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Xiao-Yong Chen
- Center for Stem Cell Biology and Tissue Engineering, SunYat-sen University, Guangzhou, Guangdong, China
| | - Jia-Li Fang
- The Transplantation Centre, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Yu-He Guo
- The Transplantation Centre, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Lei Zhang
- The Transplantation Centre, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Long-Shan Liu
- Laboratory of General Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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33
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Betts BC, Pidala J, Kim J, Mishra A, Nishihori T, Perez L, Ochoa-Bayona JL, Khimani F, Walton K, Bookout R, Nieder M, Khaira DK, Davila M, Alsina M, Field T, Ayala E, Locke FL, Riches M, Kharfan-Dabaja M, Fernandez H, Anasetti C. IL-2 promotes early Treg reconstitution after allogeneic hematopoietic cell transplantation. Haematologica 2017; 102:948-957. [PMID: 28104702 PMCID: PMC5477614 DOI: 10.3324/haematol.2016.153072] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 01/18/2017] [Indexed: 01/04/2023] Open
Abstract
Graft-versus-host disease (GvHD) remains a major cause of transplant-related mortality. Interleukin-2 (IL-2) plus sirolimus (SIR) synergistically reduces acute GvHD in rodents and promotes regulatory T cells. This phase II trial tested the hypothesis that IL-2 would facilitate STAT5 phosphorylation in donor T cells, expand regulatory T cells, and ameliorate GvHD. Between 16th April 2014 and 19th December 2015, 20 patients received IL-2 (200,000 IU/m2 thrice weekly, days 0 to +90) with SIR (5-14 ng/mL) and tacrolimus (TAC) (3-7 ng/mL) after HLA-matched related or unrelated allogeneic hematopoietic cell transplantation (HCT). The study was designed to capture an increase in regulatory T cells from 16.0% to more than 23.2% at day +30. IL-2/SIR/TAC significantly increased regulatory T cells at day +30 compared to our published data with SIR/TAC (23.8% vs. 16.0%, P=0.0016; 0.052 k/uL vs. 0.037 k/uL, P=0.0163), achieving the primary study end point. However, adding IL-2 to SIR/TAC led to a fall in regulatory T cells by day +90 and did not reduce acute or chronic GvHD. Patients who discontinued IL-2 before day +100 showed a suggested trend toward less grade II-IV acute GvHD (16.7% vs. 50%, P=0.1475). We surmise that the reported accumulation of IL-2 receptors in circulation over time may neutralize IL-2, lead to progressive loss of regulatory T cells, and offset its clinical efficacy. The amount of phospho-STAT3+ CD4+ T cells correlated with donor T-cell activation and acute GvHD incidence despite early T-cell STAT5 phosphorylation by IL-2. Optimizing IL-2 dosing and overcoming cytokine sequestration by soluble IL-2 receptor may sustain lasting regulatory T cells after transplantation. However, an approach to target STAT3 is needed to enhance GvHD prevention. (clinicaltrials.gov identifier: 01927120).
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Affiliation(s)
- Brian C Betts
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
- Department of Immunology, Moffitt Cancer Center, Tampa, FL, USA
| | - Joseph Pidala
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
- Department of Immunology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jongphil Kim
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA
| | - Asmita Mishra
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - Lia Perez
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Farhad Khimani
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - Kelly Walton
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - Ryan Bookout
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - Michael Nieder
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - Divis K Khaira
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - Marco Davila
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
- Department of Immunology, Moffitt Cancer Center, Tampa, FL, USA
| | - Melissa Alsina
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - Teresa Field
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - Ernesto Ayala
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - Frederick L Locke
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - Marcie Riches
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Hugo Fernandez
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - Claudio Anasetti
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
- Department of Immunology, Moffitt Cancer Center, Tampa, FL, USA
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Kanate AS, Hari PN, Pasquini MC, Visotcky A, Ahn KW, Boyd J, Guru Murthy GS, Rizzo JD, Saber W, Drobyski W, Michaelis L, Atallah E, Carlson KS, D'Souza A, Fenske TS, Cumpston A, Bunner P, Craig M, Horowitz MM, Hamadani M. Recipient Immune Modulation with Atorvastatin for Acute Graft-versus-Host Disease Prophylaxis after Allogeneic Transplantation. Biol Blood Marrow Transplant 2017; 23:1295-1302. [PMID: 28412518 DOI: 10.1016/j.bbmt.2017.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 04/09/2017] [Indexed: 11/16/2022]
Abstract
Atorvastatin administration to both the donors and recipients of matched related donor (MRD) allogeneic hematopoietic cell transplantation (allo-HCT) as acute graft-versus-host disease (GVHD) prophylaxis has been shown to be safe and effective. However, its efficacy as acute GVHD prophylaxis when given only to allo-HCT recipients is unknown. We conducted a phase II study to evaluate the safety and efficacy of atorvastatin-based acute GVHD prophylaxis given only to the recipients of MRD (n = 30) or matched unrelated donor (MUD) (n = 39) allo-HCT, enrolled in 2 separate cohorts. Atorvastatin (40 mg/day) was administered along with standard GVHD prophylaxis consisting of tacrolimus and methotrexate. All patients were evaluable for acute GVHD. The cumulative incidences of grade II to IV acute GVHD at day +100 in the MRD and MUD cohorts were 9.9% (95% confidence interval [CI], 0 to 20%) and 29.6% (95% CI,15.6% to 43.6%), respectively. The cumulative incidences of grade III and IV acute GVHD at day +100 in the MRD and MUD cohorts were 3.4% (95% CI, 0 to 9.7%) and 18.3% (95% CI, 6.3% to 30.4%), respectively. The corresponding rates of moderate/severe chronic GVHD at 1 year were 28.1% (95% CI, 11% to 45.2%) and 38.9% (95% CI, 20.9% to 57%), respectively. In the MRD cohort, the 1-year nonrelapse mortality, relapse rate, progression-free survival, and overall survival were 6.7% (95% CI, 0 to 15.4%), 43.3% (95% CI, 24.9% to 61.7%), 50% (95% CI, 32.1% to 67.9%), and 66.7% (95% CI, 49.8% to 83.6%), respectively. The respective figures for the MUD cohort were 10.3% (95% CI, 8% to 19.7%), 20.5% (95% CI, 7.9% to 33.1%), 69.2% (95% CI, 54.7% to 83.7%), and 79.5% (95% CI, 66.8% to 92.2%), respectively. No grade 4 toxicities attributable to atorvastatin were seen. In conclusion, the addition of atorvastatin to standard GVHD prophylaxis in only the recipients of MRD and MUD allo-HCT appears to be feasible and safe. The preliminary efficacy seen here warrants confirmation in randomized trials.
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Affiliation(s)
- Abraham S Kanate
- Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, Morgantown, West Virginia
| | - Parameswaran N Hari
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Marcelo C Pasquini
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Alexis Visotcky
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kwang W Ahn
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jennifer Boyd
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - J Douglas Rizzo
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Wael Saber
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - William Drobyski
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laura Michaelis
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ehab Atallah
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Karen S Carlson
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anita D'Souza
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Timothy S Fenske
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aaron Cumpston
- Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, Morgantown, West Virginia
| | - Pamela Bunner
- Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, Morgantown, West Virginia
| | - Michael Craig
- Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, Morgantown, West Virginia
| | - Mary M Horowitz
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mehdi Hamadani
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Predictors of overall survival among patients treated with sirolimus/tacrolimus vs methotrexate/tacrolimus for GvHD prevention. Bone Marrow Transplant 2017; 52:1003-1009. [PMID: 28368376 DOI: 10.1038/bmt.2017.63] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 02/15/2017] [Accepted: 02/24/2017] [Indexed: 12/21/2022]
Abstract
Sirolimus (SIR)/tacrolimus (TAC) is an alternative to methotrexate (MTX)/TAC. However, rational selection among these GvHD prophylaxis approaches to optimize survival of individual patients is not possible based on current evidence. We compared SIR/TAC (n=293) to MTX/TAC (n=414). The primary objective was to identify unique predictors of overall survival (OS). Secondary objective was to compare acute and chronic GvHD, relapse, non-relapse mortality, thrombotic microangiopathy (TMA), hepatic veno-occlusive disease (VOD/SOS), and acute kidney injury. Day 100 grades II-IV acute GvHD was significantly reduced in SIR/TAC vs MTX/TAC group (63 vs 73%, P=0.02). An interaction between GvHD prophylaxis groups and comorbidity index (hematopoietic cell transplantation (HCT)-CI) significantly impacted OS. Patients with HCT-CI⩾4 had significantly worse OS with MTX/TAC (HR 1.86, 95% CI 1.14-3.04, P=0.01) while no such effect was seen for SIR/TAC (HR 0.78, 95% CI 0.48-1.26, P=0.31). Other end points did not significantly differ between groups except TMA and VOD/SOS were increased in the SIR/TAC group, but excess death from these complications was not observed. We conclude, GvHD prophylaxis approach of SIR/TAC is associated with reduced grades II-IV acute GvHD, comparable toxicity profile to MTX/TAC, and improved OS among patients with HCT-CI⩾4.
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Increased Foxp3 +Helios + Regulatory T Cells and Decreased Acute Graft-versus-Host Disease after Allogeneic Bone Marrow Transplantation in Patients Receiving Sirolimus and RGI-2001, an Activator of Invariant Natural Killer T Cells. Biol Blood Marrow Transplant 2017; 23:625-634. [PMID: 28104514 DOI: 10.1016/j.bbmt.2017.01.069] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 01/09/2017] [Indexed: 12/22/2022]
Abstract
Regulatory T (Treg) cells play a central role in immune tolerance and prevention of aberrant immune responses. Several studies have suggested that the risk of graft-versus-host disease (GVHD) after allogeneic hematopoietic cell transplantation (HCT) can be ameliorated by increasing Tregs. We have developed an approach of in vivo expansion of Tregs with RGI-2001, a novel liposomal formulation of a synthetic derivative of alpha-galactosylceramide, a naturally occurring ligand that binds to CD1 and activates and expands invariant natural killer cells. In preclinical studies, a single intravenous infusion of RGI-2001 expanded Treg and could ameliorate GVHD in a mouse model of allogeneic HCT. To explore the role of RGI-2001 in clinical HCT, we initiated a phase 2A clinical trial (n = 29), testing 2 different doses of RGI-2001 administered as a single infusion on day 0 of allogeneic HCT. RGI-2001 was well tolerated and without infusion reactions or cytokine release syndrome. A subset of patients (8 of 29, 28%) responded to RGI-2001 by inducing a markedly increased number of cells with a Treg phenotype. The Treg had a high Ki-67 index and were almost exclusively Helios+ and Foxp3+, indicating that their accumulation was due to expansion of natural Treg. Notably, the incidence of grade 2 to 4 GVHD in the 8 patients who responded to RGI-2001 was 12.5%, compared with 52.4% in the 21 patients who did not respond. No grade 3 or 4 GVHD was observed in the responder group, compared with a 9.5% incidence among nonresponders. Immunosuppression with sirolimus was also associated with a low incidence of GVHD, suggesting that RGI-2001 may have synergized with sirolimus to promote Treg expansion.
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Pharmacokinetics, Pharmacodynamics, and Pharmacogenomics of Immunosuppressants in Allogeneic Hematopoietic Cell Transplantation: Part II. Clin Pharmacokinet 2016; 55:551-93. [PMID: 26620047 DOI: 10.1007/s40262-015-0340-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Part I of this article included a pertinent review of allogeneic hematopoietic cell transplantation (alloHCT), the role of postgraft immunosuppression in alloHCT, and the pharmacokinetics, pharmacodynamics, and pharmacogenomics of the calcineurin inhibitors and methotrexate. In this article (Part II), we review the pharmacokinetics, pharmacodynamics, and pharmacogenomics of mycophenolic acid (MPA), sirolimus, and the antithymocyte globulins (ATG). We then discuss target concentration intervention (TCI) of these postgraft immunosuppressants in alloHCT patients, with a focus on current evidence for TCI and on how TCI may improve clinical management in these patients. Currently, TCI using trough concentrations is conducted for sirolimus in alloHCT patients. Several studies demonstrate that MPA plasma exposure is associated with clinical outcomes, with an increasing number of alloHCT patients needing TCI of MPA. Compared with MPA, there are fewer pharmacokinetic/dynamic studies of rabbit ATG and horse ATG in alloHCT patients. Future pharmacokinetic/dynamic research of postgraft immunosuppressants should include '-omics'-based tools: pharmacogenomics may be used to gain an improved understanding of the covariates influencing pharmacokinetics as well as proteomics and metabolomics as novel methods to elucidate pharmacodynamic responses.
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Locke FL, Pidala J, Storer B, Martin PJ, Pulsipher MA, Chauncey TR, Jacobsen N, Kröger N, Walker I, Light S, Shaw BE, Beato F, Laport GG, Nademanee A, Keating A, Socie G, Anasetti C. CD25 Blockade Delays Regulatory T Cell Reconstitution and Does Not Prevent Graft-versus-Host Disease After Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 23:405-411. [PMID: 28007665 DOI: 10.1016/j.bbmt.2016.12.624] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 12/14/2016] [Indexed: 11/26/2022]
Abstract
Daclizumab, a humanized monoclonal antibody, binds CD25 and blocks formation of the IL-2 receptor on T cells. A study of daclizumab as acute graft-versus-host disease (GVHD) prophylaxis after unrelated bone marrow transplantation was conducted before the importance of CD25+FOXP3+ regulatory T cells (Tregs) was recognized. Tregs can abrogate the onset of GVHD. The relation between Tregs and a graft-versus-malignancy effect is not fully understood. An international, multicenter, double-blind clinical trial randomized 210 adult or pediatric patients to receive 5 weekly doses of daclizumab at 0.3 mg/kg (n = 69) or 1.2 mg/kg (n = 76) or placebo (n = 65) after unrelated marrow transplantation for treatment of hematologic malignancies or severe aplastic anemia. The risk of acute GVHD did not differ among the groups (P = .68). Long-term follow-up of clinical outcomes and correlative analysis of peripheral blood T cell phenotype suggested that the patients treated with daclizumab had an increased risk of chronic GVHD (hazard ratio [HR], 1.49; 95% confidence interval [CI], 1.0 to 2.3; P = .08) and a decreased risk of relapse (HR, 0.57; 95% CI, 0.3 to 1.0; P = .05), but similar survival (HR, 0.89; 95% CI, 0.6 to 1.3; P = .53). T cells from a subset of patients (n = 107) were analyzed by flow cytometry. Compared with placebo, treatment with daclizumab decreased the proportion of Tregs among CD4 T cells at days 11-35 and increased the proportion of central memory cells among CD4 T cells at 1 year. Prophylactic administration of daclizumab does not prevent acute GVHD, but may increase the risk of chronic GVHD and decrease the risk of relapse. By delaying Treg reconstitution and promoting immunologic memory, anti-CD25 therapy may augment alloreactivity and antitumor immunity.
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Affiliation(s)
- Frederick L Locke
- Blood and Marrow Transplantation Program, Moffitt Cancer Center, Tampa, Florida
| | - Joseph Pidala
- Blood and Marrow Transplantation Program, Moffitt Cancer Center, Tampa, Florida
| | - Barry Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, Division of Oncology, University of Washington, Seattle, Washington
| | - Michael A Pulsipher
- Blood and Marrow Transplant Program, Huntsman Cancer Institute, University of Utah Medical Center, Salt Lake City, Utah
| | - Thomas R Chauncey
- Department of Medicine, Division of Oncology, University of Washington, Seattle, Washington; Cancer Care Division, VA Puget Sound Health Care System, Seattle, Washington
| | - Niels Jacobsen
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, Center of Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Irwin Walker
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Bronwen E Shaw
- Haemato-Oncology Unit, Royal Marsden Hospital, Sutton, United Kingdom
| | - Francisca Beato
- Blood and Marrow Transplantation Program, Moffitt Cancer Center, Tampa, Florida
| | - Ginna G Laport
- Division of Blood and Marrow Transplantation, Stanford University, Stanford, California
| | - Auayporn Nademanee
- Hematologic Malignancies and Stem Cell Transplantation Institute, City of Hope, Duarte, California
| | - Armand Keating
- Blood and Marrow Transplant Centre, Department of Hematology, Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Gerard Socie
- Department of Hematology/Transplantation, Hospital Saint Louis, Paris, France
| | - Claudio Anasetti
- Blood and Marrow Transplantation Program, Moffitt Cancer Center, Tampa, Florida.
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Clotrimazole troches induce supratherapeutic blood levels of sirolimus and tacrolimus in an allogeneic hematopoietic cell-transplant recipient resulting in acute kidney injury. Hematol Oncol Stem Cell Ther 2016; 9:157-161. [DOI: 10.1016/j.hemonc.2015.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/31/2015] [Accepted: 11/15/2015] [Indexed: 11/21/2022] Open
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Kharfan-Dabaja MA, Parody R, Perkins J, Lopez-Godino O, Lopez-Corral L, Vazquez L, Caballero D, Falantes J, Shapiro J, Ortí G, Barba P, Valcárcel D, Esquirol A, Martino R, Piñana JL, Solano C, Tsalatsanis A, Pidala J, Anasetti C, Perez-Simón JA. Tacrolimus plus sirolimus with or without ATG as GVHD prophylaxis in HLA-mismatched unrelated donor allogeneic stem cell transplantation. Bone Marrow Transplant 2016; 52:438-444. [PMID: 27819684 DOI: 10.1038/bmt.2016.269] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 08/23/2016] [Accepted: 08/24/2016] [Indexed: 12/28/2022]
Abstract
HLA-matched related or unrelated donors are not universally available. Consequently, patients can be offered hematopoietic stem cell transplantation (HSCT) from alternative donors, including mismatched unrelated donors (MMURD), known to cause a higher incidence of acute GVHD (aGVHD) and chronic GVHD. In vivo T-cell-depletion strategies, such as antithymocyte globulin (ATG) therapy, significantly decrease the risk of GVHD. We performed a multicenter, retrospective study comparing tacrolimus (TAC) and sirolimus (SIR) with or without ATG in 104 patients (TAC-SIR=45, TAC-SIR-ATG=59) who underwent MMURD HSCT. Use of ATG was associated with a lower incidence, albeit not statistically significant, of grades 2-4 aGVHD (46% vs 64%, P=0.09), no difference in grades 3-4 aGVHD (10% vs 15%, P=0.43), a trend for a lower incidence of moderate/severe chronic GVHD (16% vs 37%, P=0.09) and more frequent Epstein-Barr virus reactivation (54% vs 18%, P=0.0002). There were no statistically significant differences in 3-year overall survival (OS) (TAC-SIR-ATG=40% (95% confidence interval (CI)=24-56%) vs TAC-SIR=54% (95% CI=37-70%), P=0.43) or 3-year cumulative incidence of relapse/progression (TAC-SIR-ATG=40% (95% CI=28-58%) vs TAC-SIR=22% (95% CI=13-39%), P=0.92). An intermediate Center for International Blood & Marrow Transplant Research disease risk resulted in a significantly lower non-relapse mortality and better OS at 3 years. Our study suggests that addition of ATG to TAC-SIR in MMURD HSCT does not affect OS when compared with TAC-SIR alone.
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Affiliation(s)
- M A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - R Parody
- Department of Hematology, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS)/CSIC, Sevilla, Spain
| | - J Perkins
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,College of Pharmacy, University of South Florida, Tampa, FL, USA
| | | | | | - L Vazquez
- Hospital Universitario de Salamanca, Salamanca, Spain
| | - D Caballero
- Hospital Universitario de Salamanca, Salamanca, Spain
| | - J Falantes
- Department of Hematology, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS)/CSIC, Sevilla, Spain
| | - J Shapiro
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - G Ortí
- Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - P Barba
- Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - D Valcárcel
- Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - A Esquirol
- Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - R Martino
- Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - J L Piñana
- Hospital Clínico de Valenci, Valencia, Spain
| | - C Solano
- Hospital Clínico de Valenci, Valencia, Spain
| | - A Tsalatsanis
- Center for Evidence-Based Medicine, University of South Florida College of Medicine, Tampa, FL, USA
| | - J Pidala
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - C Anasetti
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - J A Perez-Simón
- Department of Hematology, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS)/CSIC, Sevilla, Spain
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Lutz M, Mielke S. New perspectives on the use of mTOR inhibitors in allogeneic haematopoietic stem cell transplantation and graft-versus-host disease. Br J Clin Pharmacol 2016; 82:1171-1179. [PMID: 27245261 PMCID: PMC5061796 DOI: 10.1111/bcp.13022] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/27/2016] [Accepted: 05/30/2016] [Indexed: 12/17/2022] Open
Abstract
Inhibition of the mechanistic target of rapamycin (mTOR) has been exploited largely both in solid tumour oncology and solid organ transplantation. More recently mTOR inhibitors such as sirolimus and everolimus have been introduced to the field of allogeneic haematopoietic stem cell transplantation where their unique combination of immunosuppressive purposes offering reduced nephrotoxicity and potential antimalignant effects reflect a unique drug profile that has led to their widespread use in both prophylaxis and therapy of graft-versus-host disease (GVHD). On the other hand haematological insufficiency, infectious complications as well as vasculopathies, have been frequently reported as limiting toxicities. Here, we review both the retrospective and prospective experience available to date and stress the need for prospective registration trials to reduce off label use and improve patient safety by optimizing dosing and enhancing pharmacovigilance. Furthermore, we speculate on the future role of mTOR inhibitors in allogeneic haematopoietic stem cell transplantation.
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Affiliation(s)
- Mathias Lutz
- Department of Medicine A, Münster University Medical Center, Münster, Germany
| | - Stephan Mielke
- Department of Internal Medicine II, Würzburg University Medical Center, Würzburg, Germany.
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Bejanyan N, Rogosheske J, DeFor TE, Lazaryan A, Arora M, Holtan SG, Jacobson PA, MacMillan ML, Verneris MR, Blazar BR, Weisdorf DJ, Wagner JE, Brunstein CG. Sirolimus and Mycophenolate Mofetil as Calcineurin Inhibitor-Free Graft-versus-Host Disease Prophylaxis for Reduced-Intensity Conditioning Umbilical Cord Blood Transplantation. Biol Blood Marrow Transplant 2016; 22:2025-2030. [PMID: 27519278 DOI: 10.1016/j.bbmt.2016.08.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 08/05/2016] [Indexed: 11/25/2022]
Abstract
The use of calcineurin inhibitors (CNIs) to reduce the risk of graft-versus-host disease (GVHD) after hematopoietic cell transplantation (HCT) requires intensive post-transplantation toxicity monitoring. Sirolimus-based GVHD prophylaxis is associated with a favorable toxicity profile and requires less intensive monitoring. However, the efficacy of sirolimus-based regimen compared with CNI-based regimen has not been evaluated in the setting of reduced-intensity conditioning (RIC) double umbilical cord blood (UCB) HCT. We compared outcomes of patients receiving sirolimus/mycophenolate mofetil (MMF) (n = 37) or cyclosporine (CSA)/MMF (n = 123) in an ongoing phase II study of RIC UCB transplantation. In multiple regression analysis, sirolimus/MMF did not influence the risk of grades II to IV or grades III and IV acute GVHD. In addition, there was no association between type of GVHD prophylaxis and hematopoietic engraftment. Infection density analysis found a significantly lower risk of infections with sirolimus/MMF between days +46 and +180 after HCT compared with CSA/MMF (3.4 versus 6.3 per 1000 patient-days, P = .03); however, no difference was observed before day +45. Sirolimus/MMF use resulted in no thrombotic microangiopathy, fewer instances of elevated serum creatinine >2 mg/dL (14% versus 45%; P <.01), and similar rates of sinusoidal obstruction syndrome (2.7% versus 4%; P = .68), compared with CSA/MMF. Disease-free survival at 1 year was 51% for sirolimus/MMF and 41% for CSA/MMF (P = .41), and sirolimus/MMF use did not influence the risk of nonrelapse mortality or survival. In conclusion, sirolimus/MMF GVHD prophylaxis was better tolerated and resulted in similar rates of GVHD and survival as compared to CSA/MMF after RIC double UCB transplantation.
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Affiliation(s)
- Nelli Bejanyan
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota.
| | - John Rogosheske
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Todd E DeFor
- Adult and Pediatric Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Aleksandr Lazaryan
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Mukta Arora
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Shernan G Holtan
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Pamala A Jacobson
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Michael R Verneris
- Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Bruce R Blazar
- Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - John E Wagner
- Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
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43
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Parody R, López-Corral L, Lopez-Godino O, Martinez C, Martino R, Solano C, Barba P, Caballero D, García-Cadenas I, Piñana JL, Marquez-Malaver FJ, Vazquez L, Esquirol A, Boluda JCH, Sanchez-Guijo F, Pérez-Simon JA. GvHD prophylaxis with tacrolimus plus sirolimus after reduced intensity conditioning allogeneic transplantation: results of a multicenter study. Bone Marrow Transplant 2016; 51:1524-1526. [DOI: 10.1038/bmt.2016.163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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44
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Nishihori T, Al-Kadhimi Z, Hamadani M, Kharfan-Dabaja MA. Antithymocyte globulin in allogeneic hematopoietic cell transplantation: benefits and limitations. Immunotherapy 2016; 8:435-47. [DOI: 10.2217/imt.15.128] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Significant advances have been made in allogeneic hematopoietic cell transplantation by reducing toxicities and optimizing its efficacy. Antithymocyte globulin (ATG) is an important in vivo T-cell depletion strategy, which reduces the risk of graft-versus-host disease in HLA-matched or -mismatched donor allografting. ATG effectively targets alloreactive T cells at the expense of potentially increasing the risk of post-hematopoietic cell transplantation infections and delayed immune reconstitution. We summarize the targets, mechanisms, various preparations of ATG, the growing role of ATG in prevention of graft-versus-host disease in various transplant modalities as well as emerging data on pharmacokinetic modeling for individualized ATG dosing. Further research is needed to optimize the ATG administration while minimizing the toxicities.
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Affiliation(s)
- Taiga Nishihori
- Department of Blood & Marrow Transplantation, H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, FOB-3, Tampa, FL 33612, USA
- Department of Oncologic Sciences, Morsani College of Medicine, Moffitt Cancer Center/University of South Florida, Tampa, FL, USA
| | | | | | - Mohamed A Kharfan-Dabaja
- Department of Blood & Marrow Transplantation, H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, FOB-3, Tampa, FL 33612, USA
- Department of Oncologic Sciences, Morsani College of Medicine, Moffitt Cancer Center/University of South Florida, Tampa, FL, USA
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45
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Armand P, Kim HT, Sainvil MM, Lange PB, Giardino AA, Bachanova V, Devine SM, Waller EK, Jagirdar N, Herrera AF, Cutler C, Ho VT, Koreth J, Alyea EP, McAfee SL, Soiffer RJ, Chen YB, Antin JH. The addition of sirolimus to the graft-versus-host disease prophylaxis regimen in reduced intensity allogeneic stem cell transplantation for lymphoma: a multicentre randomized trial. Br J Haematol 2016; 173:96-104. [PMID: 26729448 DOI: 10.1111/bjh.13931] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 11/18/2015] [Indexed: 11/28/2022]
Abstract
Inhibition of the mechanistic target of rapamycin (mTOR) pathway has clinical activity in lymphoma. The mTOR inhibitor sirolimus has been used in the prevention and treatment of graft-versus-host disease (GVHD) after allogeneic haematopoietic stem cell transplantation (HSCT). A retrospective study suggested that patients with lymphoma undergoing reduced intensity conditioning (RIC) HSCT who received sirolimus as part of their GVHD prophylaxis regimen had a lower rate of relapse. We therefore performed a multicentre randomized trial comparing tacrolimus, sirolimus and methotrexate to standard regimens in adult patients undergoing RIC HSCT for lymphoma in order to assess the possible benefit of sirolimus on HSCT outcome. 139 patients were randomized. There was no difference overall in 2-year overall survival, progression-free survival, relapse, non-relapse mortality or chronic GVHD. However, the sirolimus-containing arm had a significantly lower incidence of grade II-IV acute GVHD (9% vs. 25%, P = 0·015), which was more marked for unrelated donor grafts. In conclusion, the addition of sirolimus for GVHD prophylaxis in RIC HSCT is associated with no increased overall toxicity and a lower risk of acute GVHD, although it does not improve survival; this regimen is an acceptable option for GVHD prevention in RIC HSCT. This trial is registered at clinicaltrials.gov (NCT00928018).
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Affiliation(s)
- Philippe Armand
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Haesook T Kim
- Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Paulina B Lange
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Angela A Giardino
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Veronika Bachanova
- Department of Medical Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Steven M Devine
- Department of Medicine, The Ohio State University Comprehensive Cancer Center Ohio State University, Columbus, OH, USA
| | - Edmund K Waller
- Department of Hematology/Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Neera Jagirdar
- Department of Hematology/Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Corey Cutler
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Vincent T Ho
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - John Koreth
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Edwin P Alyea
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Steven L McAfee
- Bone Marrow Transplant Unit, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Robert J Soiffer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Yi-Bin Chen
- Bone Marrow Transplant Unit, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph H Antin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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46
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Hu Y, Cui Q, Ye Y, Luo Y, Tan Y, Shi J, Huang H. Reduction of Foxp3+ T cell subsets involved in incidence of chronic graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Hematol Oncol 2015; 35:118-124. [PMID: 26439896 DOI: 10.1002/hon.2255] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 08/07/2015] [Indexed: 02/05/2023]
Affiliation(s)
- Yongxian Hu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine; Zhejiang University; Hangzhou China
| | - Qu Cui
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine; Zhejiang University; Hangzhou China
- Department of Hematology, Beijing Tiantan Hospital; Capital Medical University; Dongcheng District Beijing China
| | - Yishan Ye
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine; Zhejiang University; Hangzhou China
| | - Yi Luo
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine; Zhejiang University; Hangzhou China
| | - Yamin Tan
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine; Zhejiang University; Hangzhou China
| | - Jimin Shi
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine; Zhejiang University; Hangzhou China
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine; Zhejiang University; Hangzhou China
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47
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Khaled SK, Palmer JM, Herzog J, Stiller T, Tsai NC, Senitzer D, Liu X, Thomas SH, Shayani S, Weitzel J, Forman SJ, Nakamura R. Influence of Absorption, Distribution, Metabolism, and Excretion Genomic Variants on Tacrolimus/Sirolimus Blood Levels and Graft-versus-Host Disease after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2015; 22:268-276. [PMID: 26325438 DOI: 10.1016/j.bbmt.2015.08.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/19/2015] [Indexed: 01/23/2023]
Abstract
Allelic variants of genes implicated in drug absorption, distribution, metabolism, and excretion (ADME) determine the pharmacokinetic variability of many medications and are increasingly recognized as important factors determining the success or failure of medical treatments. Both tacrolimus and sirolimus have narrow therapeutic ranges maintained by therapeutic drug monitoring (TDM). Using an ADME panel that covers >99% of the PharmaADME working group core list (188 single nucleotide polymorphism [SNP] and 12 copy number variant [CNV] assays in 36 pharmacogenetically relevant genes), we studied 177 patients who underwent allogeneic hematopoietic cell transplantation (HCT) using tacrolimus/sirolimus-based graft-versus-host disease (GVHD) prophylaxis. We tested for possible associations between ADME variants and tacrolimus/sirolimus drug levels, concentration/dose (C/D) ratio, and clinical endpoints, including acute GVHD. A total of 62 SNP and 6 CNV assays were evaluable after removing the variants, which were homozygous in (nearly) all samples. For sirolimus, rs2032582 (ABCB1) T-carriers versus non-T-carriers were associated with higher blood levels (P = .01), with similar results for C/D ratio. Generalized estimating equation analysis supported these findings. For tacrolimus, rs776746 CYP3A5*3/*3 and CYP3A5*3/*1 were associated with higher blood levels than CYP3A5*1/*1 (P = .002). By multivariable analysis, rs776746 CYP3A5*3/*3 and CYP3A5*3/*1 were independently associated with decreased acute GVHD compared with CYP3A5*1/*1, after adjustment for conditioning, donor type, race/ethnicity, and age. We demonstrated association of specific ADME genetic polymorphisms with blood levels of tacrolimus/sirolimus, and incidence of acute GVHD after HCT, in spite of TDM and dose adjustment. A larger ongoing study will determine whether these associations have clinical utility beyond TDM.
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Affiliation(s)
- Samer K Khaled
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research of the Hematologic Malignancies and Stem Cell Transplantation Institute of the City of Hope, Duarte, CA.
| | | | - Josef Herzog
- Division of Clinical Cancer Genetics, City of Hope, Duarte, California
| | - Tracey Stiller
- Division of Biostatistics, City of Hope, Duarte, California
| | - Ni-Chun Tsai
- Division of Biostatistics, City of Hope, Duarte, California
| | - David Senitzer
- Division of Histocompatibility (HLA Laboratory), City of Hope, Duarte, California
| | - Xueli Liu
- Division of Biostatistics, City of Hope, Duarte, California
| | - Sandra H Thomas
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | | | - Jeffrey Weitzel
- Division of Clinical Cancer Genetics, City of Hope, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
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48
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Nelson R, Shapiro JF, Perkins JB, Kim J, Nishihori T, Pidala J, Ayala E, Locke FL, Field T, Mishra A, Riches M, Betts B, Perez L, Yue B, Ochoa-Bayona JL, Alsina M, Fernandez H, Anasetti C, Kharfan-Dabaja MA. Sirolimus, tacrolimus and antithymocyte globulin as GVHD prophylaxis in HLA-mismatched unrelated donor hematopoietic cell transplantation: a single institution experience. Bone Marrow Transplant 2015; 50:1487-9. [PMID: 26301969 DOI: 10.1038/bmt.2015.192] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- R Nelson
- Department of Pharmacy, Moffitt Cancer Center, Tampa, FL, USA
| | - J F Shapiro
- Department of Pharmacy, Moffitt Cancer Center, Tampa, FL, USA
| | - J B Perkins
- Department of Pharmacotherapy and Clinical Research, College of Pharmacy, University of South Florida, Tampa, FL, USA
| | - J Kim
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA.,Department of Oncologic Sciences, College of Medicine, University of South Florida, Tampa, FL, USA
| | - T Nishihori
- Department of Oncologic Sciences, College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - J Pidala
- Department of Oncologic Sciences, College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - E Ayala
- Department of Oncologic Sciences, College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - F L Locke
- Department of Oncologic Sciences, College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - T Field
- Department of Oncologic Sciences, College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - A Mishra
- Department of Oncologic Sciences, College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - M Riches
- Department of Oncologic Sciences, College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - B Betts
- Department of Oncologic Sciences, College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - L Perez
- Department of Oncologic Sciences, College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - B Yue
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA
| | - J L Ochoa-Bayona
- Department of Oncologic Sciences, College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - M Alsina
- Department of Oncologic Sciences, College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - H Fernandez
- Department of Oncologic Sciences, College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - C Anasetti
- Department of Oncologic Sciences, College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
| | - M A Kharfan-Dabaja
- Department of Oncologic Sciences, College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
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49
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Gatza E, Choi SW. Approaches for the prevention of graft-versus-host disease following hematopoietic cell transplantation. Int J Hematol Oncol 2015; 4:113-126. [PMID: 27182433 DOI: 10.2217/ijh.15.13] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is an important therapeutic option for malignant and non-malignant diseases, but the more widespread application of the therapy remains limited by the occurrence of graft versus host disease (GVHD). GVHD results from immune-mediated injury by donor immune cells against tissues in the HCT recipient, and can be characterized as acute or chronic depending on the time of onset and site of organ involvement. The majority of efforts have focused on GVHD prevention. Calcineurin inhibitors are the most widely used agents and are included in almost all regimens. Despite current prophylaxis strategies, 40-70% of patients remain at risk for developing GVHD. Herein, we review standard and emerging therapies used in GVHD management.
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Affiliation(s)
- Erin Gatza
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, United States; Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, United States
| | - Sung Won Choi
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, United States; Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, United States
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50
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García-Martín P, Alarcón-Payer C, López-Fernández E, Moratalla L, Romero A, Sainz J, Ríos R, Jurado M. Transplantation-Associated Thrombotic Microangiopathy in Patients Treated With Sirolimus and Cyclosporine as Salvage Therapy for Graft-Versus-Host Disease. Ann Pharmacother 2015; 49:986-94. [DOI: 10.1177/1060028015593369] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Transplantation-associated thrombotic microangiopathy (TA-TMA) is a rare complication of hematopoietic stem cell transplantation. Because sirolimus (SIR) and calcineurin inhibitor—either cyclosporine (CsA) or tacrolimus—have become more common as graft-versus-host disease (GVHD) prophylaxis, we are witnessing a higher frequency of this complication. Objective: To analyze the incidence, timing, and management of TA-TMA in patients who received the combination of CsA and SIR as therapy for uncontrolled GVHD in one single center. Methods: This was a retrospective analysis from February 2002 to June 2014 of the combination of SIR and CsA as salvage therapy in 61 patients with treatment-refractory or relapsed acute GVHD (n = 24) or chronic GVHD (n = 37) in a tertiary hospital. Results: A total of 61 patients received CsA and SIR as salvage therapy for acute (n = 16), late acute (n = 8), overlap syndrome (n = 22), or classic chronic (n = 15) GVHD. We identified 13 patients with TA-TMA (21.3%), and the status of GVHD was active in 11 of 13 patients. Only 1 patient showed high CsA levels, and 6 of 13 patients had very high concentrations of SIR in blood. We used an enzyme inducer in 6 patients, which proved effective in 3. Overall survival for TA-TMA patients was inferior compared to that for non TA-TMA patients at 12 months (42.9% vs 51.9%) and 24 months (34.3% vs 49.1%), although this difference was not significant. Conclusion: Prompt identification and good management of TA-TMA, with better control of GVHD, may contribute to a decrease in patient mortality that would result from this complication.
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Affiliation(s)
- Paloma García-Martín
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | - Elisa López-Fernández
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Lucía Moratalla
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Antonio Romero
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Juan Sainz
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Genyo, Pfizer-University of Granada-Junta de Andalucía, Granada, Spain
| | - Rafael Ríos
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Genyo, Pfizer-University of Granada-Junta de Andalucía, Granada, Spain
| | - Manuel Jurado
- Department of Hematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Genyo, Pfizer-University of Granada-Junta de Andalucía, Granada, Spain
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