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Cooper JP, Storer BE, Granot N, Gyurkocza B, Sorror ML, Chauncey TR, Shizuru J, Franke GN, Maris MB, Boyer M, Bruno B, Sahebi F, Langston AA, Hari P, Agura ED, Lykke Petersen S, Maziarz RT, Bethge W, Asch J, Gutman JA, Olesen G, Yeager AM, Hübel K, Hogan WJ, Maloney DG, Mielcarek M, Martin PJ, Flowers MED, Georges GE, Woolfrey AE, Deeg JH, Scott BL, McDonald GB, Storb R, Sandmaier BM. Allogeneic hematopoietic cell transplantation with non-myeloablative conditioning for patients with hematologic malignancies: Improved outcomes over two decades. Haematologica 2021; 106:1599-1607. [PMID: 32499241 PMCID: PMC8168504 DOI: 10.3324/haematol.2020.248187] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Indexed: 12/18/2022] Open
Abstract
We have used a non-myeloablative conditioning regimen for allogeneic hematopoietic cell transplantation for the past 20 years. During that period, changes in clinical practice have been aimed at reducing morbidity and mortality from infections, organ toxicity, and graft-versus-host disease. We hypothesized that improvements in clinical practice led to better transplantation outcomes over time. From 1997–2017, 1,720 patients with hematologic malignancies received low-dose total body irradiation ± fludarabine or clofarabine before transplantation from HLAmatched sibling or unrelated donors, followed by mycophenolate mofetil and a calcineurin inhibitor ± sirolimus. We compared outcomes in three cohorts by year of transplantation: 1997–2003 (n=562), 2004–2009 (n =594), and 2010–2017 (n=564). The proportion of patients ≥60 years old increased from 27% in 1997–2003 to 56% in 2010–2017, and with scores from the Hematopoietic Cell Transplantation Comorbidity Index of ≥3 increased from 25% in 1997–2003 to 45% in 2010–2017. Use of unrelated donors increased from 34% in 1997–2003 to 65% in 2010–2017. When outcomes from 2004–2009 and 2010–2017 were compared to 1997–2003, improvements were noted in overall survival (P=0.0001 for 2004–2009 and P≤0.0001 for 2010–2017), progression-free survival (P=0.002 for 2004–2009 and P<0.0001 for 2010–2017), non-relapse mortality (P<0.0001 for 2004– 2009 and P<0.0001 for 2010–2017), and in rates of grades 2–4 acute and chronic graft-versus-host disease. For patients with hematologic malignancies who underwent transplantation with non-myeloablative conditioning, outcomes have improved during the past two decades. Trials reported are registered under clinicaltrials gov. Identifiers: NCT00003145, NCT00003196, 005803, NCT00006251, NCT00014235, NCT00027820, NCT00031655, NCT00036738, NCT00045435, NCT00052546, NCT00060424, NCT00075478, NCT00078858, NCT00089011, NCT00104858, NCT00105001, NCT00110058, NCT00397813, NCT00793572, NCT01231412, NCT01252667, NCT01527045.
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Affiliation(s)
- Jason P Cooper
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - Barry E Storer
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - Noa Granot
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Boglark Gyurkocza
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - Mohamed L Sorror
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - Thomas R Chauncey
- Fred Hucthinson Cancer Research Center, Univ of Washington, VA Puget Sound Health Care, Seattle, USA
| | | | | | - Michael B Maris
- Colorado Blood Cancer Institute at HealthONE Presbyterian/St. Luke Medical Center, Denver, USA
| | | | - Benedetto Bruno
- Azienda Ospedaliera S Giovanni Battista, University of Turin, Turin, Italy
| | - Firoozeh Sahebi
- City of Hope/Kaiser Permanente Medical Group, Duarte, CA, USA
| | | | | | | | | | | | | | | | | | | | | | - Kai Hübel
- University Hospital of Cologne, Cologne, Germany
| | | | - David G Maloney
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - Marco Mielcarek
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - Paul J Martin
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - Mary E D Flowers
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - George E Georges
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - Ann E Woolfrey
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - Joachim H Deeg
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - Bart L Scott
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - George B McDonald
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - Rainer Storb
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - Brenda M Sandmaier
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
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Mallhi KK, Srikanthan MA, Baker KK, Frangoul HA, Torgerson TR, Petrovic A, Geddis AE, Carpenter PA, Baker KS, Sandmaier BM, Thakar MS, Skoda-Smith S, Kiem HP, Storb R, Woolfrey AE, Burroughs LM. HLA-Haploidentical Hematopoietic Cell Transplantation for Treatment of Nonmalignant Diseases Using Nonmyeloablative Conditioning and Post-Transplant Cyclophosphamide. Biol Blood Marrow Transplant 2020; 26:1332-1341. [PMID: 32234377 DOI: 10.1016/j.bbmt.2020.03.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 01/25/2023]
Abstract
Allogeneic hematopoietic cell transplant (HCT) is often the only curative therapy for patients with nonmalignant diseases; however, many patients do not have an HLA-matched donor. Historically, poor survival has been seen after HLA-haploidentical HCT because of poor immune reconstitution, increased infections, graft-versus-host disease (GVHD), and graft failure. Encouraging results have been reported using a nonmyeloablative T cell-replete HLA-haploidentical transplant approach in patients with hematologic malignancies. Here we report the outcomes of 23 patients with various nonmalignant diseases using a similar approach. Patients received HLA-haploidentical bone marrow (n = 17) or granulocyte colony-stimulating factor-mobilized peripheral blood stem cell (n = 6) grafts after conditioning with cyclophosphamide 50 mg/kg, fludarabine 150 mg/m2, and 2 or 4 Gy total body irradiation. Postgrafting immunosuppression consisted of cyclophosphamide, mycophenolate mofetil, tacrolimus, ± sirolimus. Median patient age at HCT was 10.8 years. Day 100 transplant-related mortality (TRM) was 0%. Two patients died at later time points, 1 from intracranial hemorrhage/disseminated fungal infection in the setting of graft failure and 1 from infection/GVHD. The estimated probabilities of grades II to IV and III to IV acute GVHD at day 100 and 2-year National Institutes of Health consensus chronic GVHD were 78%, 26%, and 42%, respectively. With a median follow-up of 2.5 years, the 2-year overall and event-free rates of survival were 91% and 78%, respectively. These results are encouraging and demonstrate favorable disease-specific lineage engraftment with low TRM in patients with nonmalignant diseases using nonmyeloablative conditioning followed by T cell-replete HLA-haploidentical grafts. However, additional strategies are needed for GVHD prevention to make this a viable treatment approach for patients with nonmalignant diseases.
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Affiliation(s)
- Kanwaldeep K Mallhi
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Division of Hematology and Oncology, Seattle Children's Hospital, Seattle, Washington
| | - Meera A Srikanthan
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Division of Hematology and Oncology, Seattle Children's Hospital, Seattle, Washington
| | - Kelsey K Baker
- Clinical Biostatistics, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Haydar A Frangoul
- Children's Hospital at TriStar Centennial and Sarah Cannon Research Institute, Nashville, Tennessee
| | - Troy R Torgerson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Division of Immunology, Seattle Children's Hospital, Seattle, Washington
| | - Aleksandra Petrovic
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Division of Immunology, Seattle Children's Hospital, Seattle, Washington
| | - Amy E Geddis
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Division of Hematology and Oncology, Seattle Children's Hospital, Seattle, Washington
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Division of Hematology and Oncology, Seattle Children's Hospital, Seattle, Washington
| | - K Scott Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Division of Hematology and Oncology, Seattle Children's Hospital, Seattle, Washington
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, Division of Medical Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Monica S Thakar
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Division of Hematology and Oncology, Seattle Children's Hospital, Seattle, Washington
| | - Suzanne Skoda-Smith
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Division of Immunology, Seattle Children's Hospital, Seattle, Washington
| | - Hans-Peter Kiem
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, Division of Medical Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Rainer Storb
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, Division of Medical Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Ann E Woolfrey
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Division of Hematology and Oncology, Seattle Children's Hospital, Seattle, Washington
| | - Lauri M Burroughs
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Division of Hematology and Oncology, Seattle Children's Hospital, Seattle, Washington.
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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 Haematol 2019; 6:e409-e418. [PMID: 31248843 DOI: 10.1016/s2352-3026(19)30088-2] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Elsawy M, Storer BE, Milano F, Sandmaier BM, Delaney C, Salit RB, Rashad AH, Woolfrey AE, Appelbaum FR, Storb R, Sorror ML. Prognostic Performance of the Augmented Hematopoietic Cell Transplantation-Specific Comorbidity/Age Index in Recipients of Allogeneic Hematopoietic Stem Cell Transplantation from Alternative Graft Sources. Biol Blood Marrow Transplant 2018; 25:1045-1052. [PMID: 30500442 DOI: 10.1016/j.bbmt.2018.11.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 11/25/2018] [Indexed: 01/11/2023]
Abstract
The Hematopoietic Cell Transplantation-Specific Comorbidity Index (HCT-CI) was developed and validated to weigh the burden of pretransplantation comorbidities and estimate their impact on post-transplantation risks of nonrelapse mortality (NRM). Recently, the HCT-CI was augmented by the addition of both age and the values of 3 markers: ferritin, albumin, and platelet count. So far, research involving The HCT-CI has been limited almost exclusively to recipients of allogeneic hematopoietic cell transplantation (HCT) from HLA-matched grafts. To this end, we sought to investigate the discriminative capacity of an augmented comorbidity/age index among 724 recipients of allogeneic HCT from HLA-mismatched (n = 345), haploidentical (n = 117), and umbilical cord blood (UCB; n = 262) grafts between 2000 and 2013. In the overall cohort, the augmented comorbidity/age index had a higher c-statistic estimate for prediction of NRM compared with the original HCT-CI (.63 versus .59). Findings were similar for recipients of HLA-mismatched (.62 versus .59), haploidentical (.60 versus .54), or UCB grafts (.65 versus .61). Compared with patients with an HCT-CI score ≥4, those with a score <4 had a higher survival rate among recipients of HLA-mismatched (55% versus 39%; P < .0008), HLA-haploidentical (58% versus 38%; P = .01), or UCB (67% versus 48%; P = .004) grafts. Our results demonstrate the utility of the augmented comorbidity/age index as a valid prognostic tool among recipients of allogeneic HCT from alternative graft sources.
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Affiliation(s)
- Mahmoud Elsawy
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle, Washington; Division of Hematology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle, Washington; Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington
| | - Filippo Milano
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine; Seattle, Washington
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine; Seattle, Washington
| | - Colleen Delaney
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine; Seattle, Washington
| | - Rachel B Salit
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine; Seattle, Washington
| | | | - Ann E Woolfrey
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine; Seattle, Washington
| | - Frederick R Appelbaum
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine; Seattle, Washington
| | - Rainer Storb
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine; Seattle, Washington
| | - Mohamed L Sorror
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine; Seattle, Washington.
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Adair JE, Chandrasekaran D, Sghia-Hughes G, Haworth KG, Woolfrey AE, Burroughs LM, Choi GY, Becker PS, Kiem HP. Novel lineage depletion preserves autologous blood stem cells for gene therapy of Fanconi anemia complementation group A. Haematologica 2018; 103:1806-1814. [PMID: 29976742 PMCID: PMC6278989 DOI: 10.3324/haematol.2018.194571] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 07/04/2018] [Indexed: 01/20/2023] Open
Abstract
A hallmark of Fanconi anemia is accelerated decline in hematopoietic stem and progenitor cells (CD34 +) leading to bone marrow failure. Long-term treatment requires hematopoietic cell transplantation from an unaffected donor but is associated with potentially severe side-effects. Gene therapy to correct the genetic defect in the patient's own CD34+ cells has been limited by low CD34+ cell numbers and viability. Here we demonstrate an altered ratio of CD34Hi to CD34Lo cells in Fanconi patients relative to healthy donors, with exclusive in vitro repopulating ability in only CD34Hi cells, underscoring a need for novel strategies to preserve limited CD34+ cells. To address this need, we developed a clinical protocol to deplete lineage+(CD3+, CD14+, CD16+ and CD19+) cells from blood and marrow products. This process depletes >90% of lineage+cells while retaining ≥60% of the initial CD34+cell fraction, reduces total nucleated cells by 1-2 logs, and maintains transduction efficiency and cell viability following gene transfer. Importantly, transduced lineage- cell products engrafted equivalently to that of purified CD34+ cells from the same donor when xenotransplanted at matched CD34+ cell doses. This novel selection strategy has been approved by the regulatory agencies in a gene therapy study for Fanconi anemia patients (NCI Clinical Trial Reporting Program Registry ID NCI-2011-00202; clinicaltrials.gov identifier: 01331018).
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Affiliation(s)
- Jennifer E Adair
- Fred Hutchinson Cancer Research Center
- University of Washington School of Medicine, Seattle, WA, USA
| | | | | | | | - Ann E Woolfrey
- Fred Hutchinson Cancer Research Center
- University of Washington School of Medicine, Seattle, WA, USA
| | - Lauri M Burroughs
- Fred Hutchinson Cancer Research Center
- University of Washington School of Medicine, Seattle, WA, USA
| | | | - Pamela S Becker
- Fred Hutchinson Cancer Research Center
- University of Washington School of Medicine, Seattle, WA, USA
| | - Hans-Peter Kiem
- Fred Hutchinson Cancer Research Center
- University of Washington School of Medicine, Seattle, WA, USA
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Brogile L, Thakar M, Logan BR, Artz A, Jacobsohn DA, Bunin NJ, Burroughs L, Martinez C, Nelson AS, Woolfrey AE, Pasquini MC, Sorror ML. Evaluation of the Hematopoietic Cell Comorbidity Index (HCT-CI) in Recipients of Allogeneic Transplantation for Non-Malignant. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Bajwa RPS, Mahadeo KM, Taragin BH, Dvorak CC, McArthur J, Jeyapalan A, Duncan CN, Tamburro R, Gehred A, Lehmann L, Richardson P, Auletta JJ, Woolfrey AE. Consensus Report by Pediatric Acute Lung Injury and Sepsis Investigators and Pediatric Blood and Marrow Transplantation Consortium Joint Working Committees: Supportive Care Guidelines for Management of Veno-Occlusive Disease in Children and Adolescents, Part 1: Focus on Investigations, Prophylaxis, and Specific Treatment. Biol Blood Marrow Transplant 2017; 23:1817-1825. [PMID: 28754544 DOI: 10.1016/j.bbmt.2017.07.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 07/20/2017] [Indexed: 12/13/2022]
Abstract
Veno-occlusive disease (VOD) is a common and potentially fatal complication in children undergoing hematopoietic cell transplantation (HCT). It occurs in about one-third of all patients undergoing transplantation and is fatal in 50% of patients with severe disease. Early intervention and specific treatment with defibrotide are associated with improved outcomes. However, there is a lack of supportive care guidelines for management of the multiorgan dysfunction seen in most cases. There is high variability in the management of VOD, which may contribute to the increased morbidity and mortality. Although there is ample research in the specific treatment of VOD, there is paucity of literature regarding the management of ascites, transfusions requirements, fluids and electrolyte dysfunction, delirium, and investigations in children with VOD. The joint working committees of the Pediatric Acute Lung Injury and Sepsis Investigators and the Pediatric Blood and Marrow Transplantation Consortium collaborated to develop a series of evidence-based supportive care guidelines for management of VOD. The quality of evidence was rated and recommendations were made using Grading of Recommendations, Assessment, Development and Evaluation criteria. This manuscript is part 1 of the series and focuses on the need to develop these guidelines; methodology used to establish the guidelines; and investigations needed for diagnosis, prophylaxis, and treatment of VOD in children.
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Affiliation(s)
- Rajinder P S Bajwa
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio.
| | - Kris M Mahadeo
- Division of Pediatric Blood and Marrow Transplantation, The University of Texas, MD Anderson Children's Cancer Hospital, Houston, Texas
| | - Benjamin H Taragin
- Department of Pediatric Radiology, Children's Hospital at Montefiore, Bronx, New York
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Jennifer McArthur
- Department of Pediatric Critical Care Medicine St Jude Children's Research Hospital, Memphis, Tennessee
| | - Asumthia Jeyapalan
- Division of Pediatric Critical Care Medicine, University of Miami- Miller School of Medicine, Miami, Florida
| | - Christine N Duncan
- Division of Pediatric Stem Cell Transplant, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Robert Tamburro
- Division of Pediatric Critical Care Medicine, Pennsylvania University, Penn State Hershey Children's Hospital, Hershey, PA
| | - Alison Gehred
- Medical Library division, Nationwide Children's Hospital, Columbus, Ohio
| | - Leslie Lehmann
- Division of Pediatric Stem Cell Transplant, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Paul Richardson
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jeffery J Auletta
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio; Division of Infectious Diseases, Nationwide Children's Hospital, Columbus
| | - Ann E Woolfrey
- Fred Hutchinson Cancer Research Center and University of Washington, Seattle, Washington
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8
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Burroughs LM, Shimamura A, Talano JA, Domm JA, Baker KK, Delaney C, Frangoul H, Margolis DA, Baker KS, Nemecek ER, Geddis AE, Sandmaier BM, Deeg HJ, Storb R, Woolfrey AE. Allogeneic Hematopoietic Cell Transplantation Using Treosulfan-Based Conditioning for Treatment of Marrow Failure Disorders. Biol Blood Marrow Transplant 2017; 23:1669-1677. [PMID: 28602958 DOI: 10.1016/j.bbmt.2017.06.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 06/05/2017] [Indexed: 12/20/2022]
Abstract
Hematopoietic cell transplantation (HCT) is effective in the treatment of inherited marrow failure disorders and other nonmalignant diseases. Conventional myeloablative conditioning regimens have been associated with high transplant-related mortality, particularly in patients with comorbid conditions. Here we report on 14 patients with marrow failure disorders (Shwachman-Diamond syndrome, n = 3; Diamond Blackfan anemia, n = 4; GATA2 deficiency, n = 2; paroxysmal nocturnal hemoglobinuria, n = 4; and an undefined marrow failure disorder, n = 1) who underwent HCT on a prospective, phase II, multicenter clinical trial. Patients were given HLA-matched related (n = 2) or unrelated (n = 12) grafts after conditioning with treosulfan (42 g/m2), fludarabine (150 mg/m2), ± thymoglobulin (n = 11; 6 mg/kg). All patients engrafted. At a median follow-up of 3 years, 13 patients are alive with complete correction of their underlying disease. These results indicate that the combination of treosulfan, fludarabine, and thymoglobulin is effective at establishing donor engraftment with a low toxicity profile and excellent disease-free survival in patients with marrow failure disorders.
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Affiliation(s)
- Lauri M Burroughs
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Hematology-Oncology, Seattle Children's Hospital, Seattle, Washington.
| | - Akiko Shimamura
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Hematology-Oncology, Seattle Children's Hospital, Seattle, Washington
| | - Julie-An Talano
- Division of Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Jennifer A Domm
- Pediatric Hematology Oncology, Vanderbilt University, Nashville, Tennessee
| | - Kelsey K Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Colleen Delaney
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Hematology-Oncology, Seattle Children's Hospital, Seattle, Washington
| | - Haydar Frangoul
- Pediatric Hematology Oncology, Vanderbilt University, Nashville, Tennessee
| | - David A Margolis
- Division of Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - K Scott Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Hematology-Oncology, Seattle Children's Hospital, Seattle, Washington
| | - Eneida R Nemecek
- Pediatric Blood and Marrow Transplant Program, Doernbecher Children's Hospital, Oregon Health and Sciences University, Portland, Oregon
| | - Amy E Geddis
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Hematology-Oncology, Seattle Children's Hospital, Seattle, Washington
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - H Joachim Deeg
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Rainer Storb
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Ann E Woolfrey
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Hematology-Oncology, Seattle Children's Hospital, Seattle, Washington
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9
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Bader P, Salzmann-Manrique E, Sr. AB, Dalle JH, Woolfrey AE, Bar M, Verneris MR, Borowitz MJ, Shah NN, Gossai N, Shaw PJ, Chen AR, Kreyenberg H, Di Maio L, Eckert C, van der Velden VH, Lankester A, Klingebiel TE, Peters C, Grupp SA, Pulsipher MA. Monitoring of MRD before and after Allogeneic Hematopoietic Cell Transplantation (HCT) of Childhood ALL by FC and RQ-PCR: A Retrospective Assessment on Behalf of the Pdwp of the Ebmt, the Cog, the Pbmtc, the I-Bfm and the Westhafen-Intercontinental-Group. Biol Blood Marrow Transplant 2017. [DOI: 10.1016/j.bbmt.2017.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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10
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Sabloff M, Wang T, Zhu X, Artz AS, Adekola K, Abraham A, Auletta JJ, Battiwalla M, Beitinjaneh A, Bredeson CN, Bufarull RM, Cahn JY, Cerny J, Chhabra S, Copelan EA, Daly A, Dias A, Diaz MA, Freytes CO, Gale RP, Ganguly S, Hale GA, Hamilton BK, Hashmi SK, Hematti P, Hildebrandt GC, Holmberg LA, Hong S, Kekre N, Lazarus HM, Lazaryan A, Luger SM, Muffly L, Nagler A, Nishihori T, Norkin M, Olsson R, Perales MA, Rashidi A, Romee R, Saad A, Seo S, Ulrickson ML, Ustun C, Wirk BM, Woolfrey AE, Yared J, Pasquini MC, Mineishi S. Impact of Higher-Dose Total Body Irradiation Conditioning on Outcome of an Allogeneic Hematopoietic Cell Transplant (HCT) in the Modern Era. Biol Blood Marrow Transplant 2017. [DOI: 10.1016/j.bbmt.2017.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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11
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Peterson CW, Benne C, Polacino P, Kaur J, McAllister CE, Filali-Mouhim A, Obenza W, Pecor TA, Huang ML, Baldessari A, Murnane RD, Woolfrey AE, Jerome KR, Hu SL, Klatt NR, DeRosa S, Sékaly RP, Kiem HP. Loss of immune homeostasis dictates SHIV rebound after stem-cell transplantation. JCI Insight 2017; 2:e91230. [PMID: 28239658 DOI: 10.1172/jci.insight.91230] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The conditioning regimen used as part of the Berlin patient's hematopoietic cell transplant likely contributed to his eradication of HIV infection. We studied the impact of conditioning in simian-human immunodeficiency virus-infected (SHIV-infected) macaques suppressed by combination antiretroviral therapy (cART). The conditioning regimen resulted in a dramatic, but incomplete depletion of CD4+ and CD8+ T cells and CD20+ B cells, increased T cell activation and exhaustion, and a significant loss of SHIV-specific Abs. The disrupted T cell homeostasis and markers of microbial translocation positively correlated with an increased viral rebound after cART interruption. Quantitative viral outgrowth and Tat/rev-induced limiting dilution assays showed that the size of the latent SHIV reservoir did not correlate with viral rebound. These findings identify perturbations of the immune system as a mechanism for the failure of autologous transplantation to eradicate HIV. Thus, transplantation strategies may be improved by incorporating immune modulators to prevent disrupted homeostasis, and gene therapy to protect transplanted cells.
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Affiliation(s)
- Christopher W Peterson
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Clarisse Benne
- Department of Pathology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Patricia Polacino
- Washington National Primate Research Center, Seattle, Washington, USA
| | - Jasbir Kaur
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Cristina E McAllister
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | | | - Willi Obenza
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Tiffany A Pecor
- Washington National Primate Research Center, Seattle, Washington, USA
| | - Meei-Li Huang
- Division of Vaccine and Infectious Diseases, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Audrey Baldessari
- Washington National Primate Research Center, Seattle, Washington, USA
| | - Robert D Murnane
- Washington National Primate Research Center, Seattle, Washington, USA
| | - Ann E Woolfrey
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Keith R Jerome
- Division of Vaccine and Infectious Diseases, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Laboratory Medicine
| | - Shiu-Lok Hu
- Washington National Primate Research Center, Seattle, Washington, USA.,Department of Pharmaceutics and
| | - Nichole R Klatt
- Washington National Primate Research Center, Seattle, Washington, USA.,Department of Pharmaceutics and
| | - Stephen DeRosa
- Division of Vaccine and Infectious Diseases, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Rafick P Sékaly
- Department of Pathology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Hans-Peter Kiem
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA.,Department of Pathology, University of Washington, Seattle, Washington, USA
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12
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Kim HT, Zhang MJ, Woolfrey AE, St Martin A, Chen J, Saber W, Perales MA, Armand P, Eapen M. Donor and recipient sex in allogeneic stem cell transplantation: what really matters. Haematologica 2016; 101:1260-1266. [PMID: 27354023 DOI: 10.3324/haematol.2016.147645] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 06/23/2016] [Indexed: 02/02/2023] Open
Abstract
We investigated whether and how recipient-donor sex affects transplantation outcomes of 11,797 patients transplanted between 2008 and 2010. Thirty-seven percent were male recipients with male donors, 21% male recipients with female donors, 25% female recipients with male donors, and 17% female recipients with female donors. In multivariable analyses, male recipients had inferior overall survival and progression-free survival compared to females regardless of donor sex, with an 11% relative increase in the hazard of death (P<0.0001) and a 10% relative increase in the hazard of death or relapse (P<0.0001). The detrimental effect of male recipients varied by donor sex. For male recipients with male donors, there was a 12% relative increase in the subdistribution hazard of relapse compared with female recipients with male donors (P=0.0036) and male recipients with female donors (P=0.0037). For male recipients with female donors, there was a 19% relative increase in the subdistribution hazard of non-relapse mortality compared with male recipients with male donors (P<0.0001) and a 22% relative increase compared with female recipients with male donors (P=0.0003). In addition, male recipients with female donors showed a 21% relative increase in the subdistribution hazard of chronic graft-versus-host disease (P<0.0001) compared with female recipients with male donors. Donor sex had no effect on outcomes for female recipients. Transplantation of grafts from male and female donors was associated with inferior overall survival and progression-free survival in male recipients with differing patterns of failure. Recipient sex is an important prognostic factor independent of donor sex.
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Affiliation(s)
- Haesook T Kim
- Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA
| | - Mei-Jie Zhang
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Ann E Woolfrey
- Department of Medicine, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Andrew St Martin
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Junfang Chen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | - Philippe Armand
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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13
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Deol A, Sengsayadeth S, Ahn KW, Wang HL, Aljurf M, Antin JH, Battiwalla M, Bornhauser M, Cahn JY, Camitta B, Chen YB, Cutler CS, Gale RP, Ganguly S, Hamadani M, Inamoto Y, Jagasia M, Kamble R, Koreth J, Lazarus HM, Liesveld J, Litzow MR, Marks DI, Nishihori T, Olsson RF, Reshef R, Rowe JM, Saad AA, Sabloff M, Schouten HC, Shea TC, Soiffer RJ, Uy GL, Waller EK, Wiernik PH, Wirk B, Woolfrey AE, Bunjes D, Devine S, de Lima M, Sandmaier BM, Weisdorf D, Khoury HJ, Saber W. Does FLT3 mutation impact survival after hematopoietic stem cell transplantation for acute myeloid leukemia? A Center for International Blood and Marrow Transplant Research (CIBMTR) analysis. Cancer 2016; 122:3005-3014. [PMID: 27315441 DOI: 10.1002/cncr.30140] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 04/18/2016] [Accepted: 05/03/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients with FMS like tyrosine kinase 3 (FLT3)-mutated acute myeloid leukemia (AML) have a poor prognosis and are referred for early allogeneic hematopoietic stem cell transplantation (HCT). METHODS Data from the Center for International Blood and Marrow Transplant Research (CIBMTR) were used to evaluate 511 adult patients with de novo AML who underwent HCT during 2008 through 2011 to determine whether FLT3 mutations had an impact on HCT outcomes. RESULTS In total, 158 patients (31%) had FLT3 mutations. Univariate and multivariate analyses revealed an increased risk of relapse at 3 years in the FLT3 mutated group compared with the wild-type (WT) group (38% [95% confidence interval (CI), 30%-45%] vs 28% [95% CI, 24%-33%]; P = .04; relative risk, 1.60 [95% CI, 1.15-2.22]; P = .0048). However, FLT3 mutation status was not significantly associated with nonrelapse mortality, leukemia-free survival, or overall survival. Although more patients in the FLT3 mutated group died from relapsed primary disease compared with those in the WT group (60% vs 46%), the 3-year overall survival rate was comparable for the 2 groups (mutated group: 49%; 95% CI, 40%-57%; WT group: 55%, 95% CI, 50%-60%; P = .20). CONCLUSIONS The current data indicate that FLT3 mutation status did not adversely impact overall survival after HCT, and about 50% of patients with this mutation who underwent HCT were long-term survivors. Cancer 2016;122:3005-3014. © 2016 American Cancer Society.
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Affiliation(s)
- Abhinav Deol
- Department of Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, MI
| | | | - Kwang Woo Ahn
- CIBMTR, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI.,Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI
| | - Hai-Lin Wang
- CIBMTR, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riydah, Saudi Arabia
| | - Joseph Harry Antin
- Center for Hematologic Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Minoo Battiwalla
- Hematology Branch, National Heart Lung and Blood Institute, Bethesda, MD
| | | | - Jean-Yves Cahn
- Department of Hematology, University Hospital, Grenoble, France
| | - Bruce Camitta
- Midwest Center for Cancer and Blood Disorders, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, WI
| | - Yi-Bin Chen
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Corey S Cutler
- Center for Hematologic Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Siddhartha Ganguly
- Blood and Marrow Transplantation, Division of Hematology and Oncology, University of Kansas Medical Center, Kansas City, KS
| | - Mehdi Hamadani
- CIBMTR, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | | | - Rammurti Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX
| | - John Koreth
- Center for Hematologic Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Hillard M Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH
| | - Jane Liesveld
- Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | - Mark R Litzow
- Division of Hematology and Transplant Center, Mayo Clinic Rochester
| | - David I Marks
- Pediatric Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Richard F Olsson
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Clinical Research, Sormland, Uppsala University, Uppsala, Sweden
| | - Ran Reshef
- Blood and Marrow Transplantation Program and Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY
| | - Jacob M Rowe
- Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Ayman A Saad
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Mitchell Sabloff
- Division of Hematology, Department of Medicine, University of Ottawa and Ottawa Hospital Research institute, Ottawa, Canada
| | - Harry C Schouten
- Department of Hematology, Academische Ziekenhuis, Maastricht, Netherlands
| | - Thomas C Shea
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina Health Care, Chapel Hill, NC
| | - Robert J Soiffer
- Center for Hematologic Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Geoffrey L Uy
- Divsion of Onocology, Washington University School of Medicine, St. Louis, MO
| | - Edmond K Waller
- Department of Hematology and Medical Oncology, Winship Cancer Insitute, Emory University, Atlanta, GA
| | | | - Baldeep Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, WA
| | | | - Donald Bunjes
- Department of Internal Medicine III, Universitatsklinkum Ulm, Ulm, Germany
| | - Steven Devine
- Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center- James, Columbus, OH
| | - Marcos de Lima
- Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH
| | - Brenda M Sandmaier
- Division of Medical Oncology, University of Washington and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Hanna Jean Khoury
- Department of Hematology and Medical Oncology, Winship Cancer Insitute, Emory University, Atlanta, GA
| | - Wael Saber
- CIBMTR, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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14
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Vusirikala M, Naik S, Maziarz RT, Baumeister S, Aquino V, Ma H, Moseley A, Woolfrey AE, Krishnamurti L, Chen GL, Sandmaier BM, Bertaina A, Perales MA, Williams DA, Kapoor N. BPX-501 Cells (Donor T Cells Transduced with iC9 Suicide Gene) Treatment Following TCR Alpha Beta Depleted Stem Cell Transplantation in Adults and Children with Hematological Disorders. Biol Blood Marrow Transplant 2016. [DOI: 10.1016/j.bbmt.2015.11.863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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15
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Seftel MD, Neuberg D, Zhang MJ, Wang HL, Ballen KK, Bergeron J, Couban S, Freytes CO, Hamadani M, Kharfan-Dabaja MA, Lazarus HM, Nishihori T, Paulson K, Saber W, Sallan SE, Soiffer R, Tallman MS, Woolfrey AE, DeAngelo DJ, Weisdorf DJ. Pediatric-inspired therapy compared to allografting for Philadelphia chromosome-negative adult ALL in first complete remission. Am J Hematol 2016; 91:322-9. [PMID: 26701142 DOI: 10.1002/ajh.24285] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 12/15/2015] [Accepted: 12/17/2015] [Indexed: 12/17/2022]
Abstract
For adults with Philadelphia chromosome-negative (Ph-) acute lymphoblastic leukemia (ALL) in first complete remission (CR1), allogeneic hematopoietic cell transplantation (HCT) is an established curative strategy. However, pediatric-inspired chemotherapy may also offer durable leukemia-free survival in the absence of HCT. We compared 422 HCT recipients aged 18-50 years with Ph-ALL in CR1 reported to the CIBMTR with an age-matched concurrent cohort of 108 Ph- ALL CR1 patients who received a Dana-Farber Consortium pediatric-inspired non-HCT regimen. At 4 years of follow-up, incidence of relapse after HCT was 24% (95% CI 19-28) versus 23% (95% CI 15-32) for the non-HCT (chemo) cohort (P=0.97). Treatment-related mortality (TRM) was higher in the HCT cohort [HCT 37% (95% CI 31-42) versus chemo 6% (95% CI 3-12), P<0.0001]. DFS in the HCT cohort was 40% (95% CI 35-45) versus 71% (95% CI 60-79) for chemo, P<0.0001. Similarly, OS favored chemo [HCT 45% (95% CI 40-50)] versus chemo 73% [(95% CI 63-81), P<0.0001]. In multivariable analysis, the sole factor predictive of shorter OS was the administration of HCT [hazard ratio 3.12 (1.99-4.90), P<0.0001]. For younger adults with Ph- ALL, pediatric-inspired chemotherapy had lower TRM, no increase in relapse, and superior overall survival compared to HCT. Am. J. Hematol. 91:322-329, 2016. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Matthew D. Seftel
- Department of Medical Oncology and Haematology; CancerCare Manitoba; Winnipeg Manitoba Canada
| | - Donna Neuberg
- Department of Biostatistics and Computational Biology; Dana-Farber Cancer Institute; Boston Massachutsetts
| | - Mei-Jie Zhang
- Center for International Blood and Marrow Transplant Research (CIBMTR ), Department of Medicine; Medical College of Wisconsin; Milwaukee Wisconsin
- Medical College of Wisconsin, Division of Biostatistics; Institute for Health and Society; Milwaukee Wisconsin
| | - Hai-Lin Wang
- Center for International Blood and Marrow Transplant Research (CIBMTR ), Department of Medicine; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Karen Kuhn Ballen
- Department of Hematology/Oncology; Massachusetts General Hospital; Boston Massachusetts
| | - Julie Bergeron
- Department of Hematology; Hôpital Maisonneuve-Rosemont; Montréal Quebec Canada
| | - Stephen Couban
- Division of Haematology; Queen Elizabeth II Health Sciences Centre, Dalhousie University; Halifax Nova Scotia Canada
| | - César O. Freytes
- South Texas Veterans Health Care System and University of Texas Health Science Center San Antonio; San Antonio Texas
| | - Mehdi Hamadani
- Center for International Blood and Marrow Transplant Research (CIBMTR ), Department of Medicine; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Mohamed A. Kharfan-Dabaja
- Department of Blood and Marrow Transplantation; H. Lee Moffitt Cancer Center and Research Institute; Tampa Florida
| | - Hillard M. Lazarus
- Department of Medicine; Seidman Cancer Center, University Hospitals Case Medical Center; Cleveland Ohio
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation; H. Lee Moffitt Cancer Center and Research Institute; Tampa Florida
| | - Kristjan Paulson
- Department of Medical Oncology and Haematology; CancerCare Manitoba; Winnipeg Manitoba Canada
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research (CIBMTR ), Department of Medicine; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Stephen E. Sallan
- Department of Pediatric Oncology; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Robert Soiffer
- Department of Medical Oncology/Hematologic Malignancies; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Martin S. Tallman
- Department of Medicine; Leukemia Service, Memorial Sloan Kettering Cancer Center; New York New York
| | - Ann E. Woolfrey
- Department of Pediatric Hematopoietic Cell Transplant; Fred Hutchinson Cancer Research Center; Seattle Washington
| | - Daniel J. DeAngelo
- Department of Medical Oncology/Hematologic Malignancies; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Daniel J. Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine; University of Minnesota Medical Center; Minneapolis Minnesota
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16
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Kollman C, Spellman SR, Zhang MJ, Hassebroek A, Anasetti C, Antin JH, Champlin RE, Confer DL, DiPersio JF, Fernandez-Viña M, Hartzman RJ, Horowitz MM, Hurley CK, Karanes C, Maiers M, Mueller CR, Perales MA, Setterholm M, Woolfrey AE, Yu N, Eapen M. The effect of donor characteristics on survival after unrelated donor transplantation for hematologic malignancy. Blood 2016; 127:260-7. [PMID: 26527675 PMCID: PMC4713163 DOI: 10.1182/blood-2015-08-663823] [Citation(s) in RCA: 204] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/19/2015] [Indexed: 01/22/2023] Open
Abstract
There are >24 million registered adult donors, and the numbers of unrelated donor transplantations are increasing. The optimal strategy for prioritizing among comparably HLA-matched potential donors has not been established. Therefore, the objective of the current analyses was to study the association between donor characteristics (age, sex, parity, cytomegalovirus serostatus, HLA match, and blood group ABO match) and survival after transplantation for hematologic malignancy. The association of donor characteristics with transplantation outcomes was examined using either logistic or Cox regression models, adjusting for patient disease and transplantation characteristics associated with outcomes in 2 independent datasets: 1988 to 2006 (N = 6349; training cohort) and 2007 to 2011 (N = 4690; validation cohort). All donor-recipient pairs had allele-level HLA typing at HLA-A, -B, -C, and -DRB1, which is the current standard for selecting donors. Adjusting for patient disease and transplantation characteristics, survival was better after transplantation of grafts from young donors (aged 18-32 years) who were HLA matched to recipients (P < .001). These findings were validated for transplantations that occurred between 2007 and 2011. For every 10-year increment in donor age, there is a 5.5% increase in the hazard ratio for overall mortality. Increasing HLA disparity was also associated with worsening survival. Donor age and donor-recipient HLA match are important when selecting adult unrelated donors. Other donor characteristics such as sex, parity, and cytomegalovirus serostatus were not associated with survival. The effect of ABO matching on survival is modest and must be studied further before definitive recommendations can be offered.
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Affiliation(s)
| | - Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, MN
| | - Mei-Jie Zhang
- Center for International Blood and Marrow Transplant Research and Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI
| | - Anna Hassebroek
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, MN
| | | | - Joseph H Antin
- Center for Hematologic Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Dennis L Confer
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, MN
| | | | | | - Robert J Hartzman
- C.W. Bill Young Marrow Donor Recruitment and Research Program, Department of Defense Marrow Donor Program, Bone Marrow Research Directorate, Naval Medical Research Center, Department of the Navy, Washington, DC
| | - Mary M Horowitz
- Center for International Blood and Marrow Transplant Research and
| | | | | | - Martin Maiers
- National Marrow Donor Program/Be The Match, Minneapolis, MN
| | | | | | | | | | - Neng Yu
- American Red Cross Blood Services East Division, Dedham, MA; and
| | - Mary Eapen
- Center for International Blood and Marrow Transplant Research and Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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17
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Burroughs LM, Nemecek ER, Torgerson TR, Storer BE, Talano JA, Domm J, Giller RH, Shimamura A, Delaney C, Skoda-Smith S, Thakar MS, Baker KS, Rawlings DJ, Englund JA, Flowers MED, Deeg HJ, Storb R, Woolfrey AE. Treosulfan-based conditioning and hematopoietic cell transplantation for nonmalignant diseases: a prospective multicenter trial. Biol Blood Marrow Transplant 2014; 20:1996-2003. [PMID: 25196857 DOI: 10.1016/j.bbmt.2014.08.020] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 08/25/2014] [Indexed: 01/09/2023]
Abstract
Hematopoietic cell transplantation is an effective treatment for patients with nonmalignant diseases and for many is the only known cure. Conventional myeloablative regimens have been associated with unacceptably high early transplant-related mortality (TRM), particularly in patients with comorbid conditions. This prospective multicenter trial was designed to determine the safety and engraftment efficacy of treosulfan-based conditioning in patients with nonmalignant diseases. Thirty-one patients received HLA-matched related (n = 4) or unrelated (n = 27) grafts after conditioning with treosulfan (total dose, 42 g/m(2)), fludarabine (total dose, 150 mg/m(2)), ± thymoglobulin (6 mg/kg; n = 22). Graft-versus-host disease (GVHD) prophylaxis consisted of tacrolimus and methotrexate. All patients engrafted. Day-100 TRM was 0%. With a median follow-up of 2 years, the 2-year survival was 90%. Three patients died of GVHD, recurrent hemophagocytic lymphohistiocytosis, and a surgical complication, respectively. The cumulative incidences of grades II to IV and III to IV acute GVHD at day 100 and chronic GVHD at 2 years were 62%, 10%, and 21%, respectively. Patients who received thymoglobulin had a significantly lower incidence of grades III to IV acute GVHD (0% versus 33%; P = .005). These results indicate that the combination of treosulfan, fludarabine, and thymoglobulin is effective at establishing donor engraftment with low toxicity and improved survival in patients with nonmalignant diseases and support the need for future disease-specific clinical trials.
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Affiliation(s)
- Lauri M Burroughs
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington.
| | | | - Troy R Torgerson
- University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Barry E Storer
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | | | | | | | - Akiko Shimamura
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Colleen Delaney
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Suzanne Skoda-Smith
- University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | | | - K Scott Baker
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - David J Rawlings
- University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Janet A Englund
- University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
| | - Mary E D Flowers
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - H Joachim Deeg
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Rainer Storb
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Ann E Woolfrey
- Fred Hutchinson Cancer Research Center, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington; Seattle Children's Hospital, Seattle, Washington
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18
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Kornblit B, Maloney DG, Storer BE, Maris MB, Vindeløv L, Hari P, Langston AA, Pulsipher MA, Bethge WA, Chauncey TR, Lange T, Petersen FB, Hübel K, Woolfrey AE, Flowers MED, Storb R, Sandmaier BM. A randomized phase II trial of tacrolimus, mycophenolate mofetil and sirolimus after non-myeloablative unrelated donor transplantation. Haematologica 2014; 99:1624-31. [PMID: 25085357 DOI: 10.3324/haematol.2014.108340] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The study is a randomized phase II trial investigating graft-versus-host disease prophylaxis after non-myeloablative (90 mg/m(2) fludarabine and 2 Gy total body irradiation) human leukocyte antigen matched unrelated donor transplantation. Patients were randomized as follows: arm 1 - tacrolimus 180 days and mycophenolate mofetil 95 days (n=69); arm 2 - tacrolimus 150 days and mycophenolate mofetil 180 days (n=71); arm 3 - tacrolimus 150 days, mycophenolate mofetil 180 days and sirolimus 80 days (n=68). All patients had sustained engraftment. Grade II-IV acute graft-versus-host disease rates in the 3 arms were 64%, 48% and 47% at Day 150, respectively (arm 3 vs. arm 1 (hazard ratio 0.62; P=0.04). Owing to the decreased incidence of acute graft-versus-host disease, systemic steroid use was lower at Day 150 in arm 3 (32% vs. 55% in arm 1 and 49% in arm 2; overall P=0.009 by hazard ratio analysis). The Day 150 incidence of cytomegalovirus reactivation was lower in arm 3 (arm 1, 54%; arm 2, 47%; arm 3, 22%; overall P=0.002 by hazard ratio analysis). Non-relapse mortality was comparable in the three arms at two years (arm 1, 26%; arm 2, 23%; arm 3, 18%). Toxicity rates and other outcome measures were similar between the three arms. The addition of sirolimus to tacrolimus and mycophenolate mofetil is safe and associated with lower incidence of acute graft-versus-host disease and cytomegalovirus reactivation. (clinicaltrials.gov identifier: 00105001).
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Affiliation(s)
- Brian Kornblit
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - David G Maloney
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | | | | | | | - Michael A Pulsipher
- Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | | | | | | | | | - Ann E Woolfrey
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Division of 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 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 Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Division of Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
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19
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Burns LJ, Gajewski JL, Majhail NS, Navarro W, Perales MA, Shereck E, Selby GB, Snyder EL, Woolfrey AE, Litzow MR. Challenges and Potential Solutions for Recruitment and Retention of Hematopoietic Cell Transplantation Physicians: The National Marrow Donor Program’s System Capacity Initiative Physician Workforce Group Report. Biol Blood Marrow Transplant 2014; 20:617-21. [DOI: 10.1016/j.bbmt.2014.01.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 01/28/2014] [Indexed: 10/25/2022]
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20
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Peterson CW, Younan P, Polacino PS, Maurice NJ, Miller HW, Prlic M, Jerome KR, Woolfrey AE, Hu SL, Kiem HP. Robust suppression of env-SHIV viremia in Macaca nemestrina by 3-drug ART is independent of timing of initiation during chronic infection. J Med Primatol 2014; 42:237-46. [PMID: 24025078 DOI: 10.1111/jmp.12060] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Nonhuman primates (NHPs) are an important model organism for studies of HIV pathogenesis and preclinical evaluation of anti-HIV therapies. The successful translation of NHP-derived data to clinically relevant anti-HIV studies will require better understanding of the viral strains and NHP species used and their responses to existing antiretroviral therapies (ART). METHODS Five pigtailed macaques (Macaca nemestrina) were productively infected with the SIV/HIV chimeric virus SHIV-1157 ipd3N4 following intravenous challenge. After 8 or 27 weeks, ART (PMPA, FTC, raltegravir) was initiated. Viral load, T-cell counts, and production of SHIV-specific antibodies were monitored throughout the course of infection and ART. RESULTS ART led to a rapid and sustained decrease in plasma viral load. Suppression of plasma viremia by ART was independent of the timing of initiation during chronic infection. CONCLUSIONS We present a new NHP model of HIV infection on antiretroviral therapy, which should prove applicable to multiple clinically relevant anti-HIV approaches.
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21
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Pidala J, Lee SJ, Spellman SR, Wang H, Ahn KW, Aljurf MD, Askar M, Dehn J, Fernandez Viña MA, Gratwohl A, Gupta V, Hanna R, Hurley CK, Inamoto Y, Kassim AA, Nishihori T, Oudshoorn M, Petersdorf EW, Prasad VK, Saber W, Schultz KR, Wood WA, Storek J, Woolfrey AE, Anasetti C. HLA-Mismatch Is Associated with Worse Outcomes after Myeloablative Conditioning and Unrelated Donor Hematopoietic Cell Transplantation: A Cibmtr Analysis. Biol Blood Marrow Transplant 2014. [DOI: 10.1016/j.bbmt.2013.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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22
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Gupta V, Malone AK, Hari PN, Ahn KW, Hu ZH, Gale RP, Ballen KK, Hamadani M, Olavarria E, Gerds AT, Waller EK, Costa LJ, Antin JH, Kamble RT, van Besien KM, Savani BN, Schouten HC, Szer J, Cahn JY, de Lima MJ, Wirk B, Aljurf MD, Popat U, Bejanyan N, Litzow MR, Norkin M, Lewis ID, Hale GA, Woolfrey AE, Miller AM, Ustun C, Jagasia MH, Lill M, Maziarz RT, Cortes J, Kalaycio ME, Saber W. Reduced-intensity hematopoietic cell transplantation for patients with primary myelofibrosis: a cohort analysis from the center for international blood and marrow transplant research. Biol Blood Marrow Transplant 2014; 20:89-97. [PMID: 24161923 PMCID: PMC3886623 DOI: 10.1016/j.bbmt.2013.10.018] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 10/18/2013] [Indexed: 11/30/2022]
Abstract
We evaluated outcomes and associated prognostic factors in 233 patients undergoing allogeneic hematopoietic cell transplantation (HCT) for primary myelofibrosis (MF) using reduced-intensity conditioning (RIC). The median age at RIC HCT was 55 yr. Donors were a matched sibling donor (MSD) in 34% of RIC HCTs, an HLA well-matched unrelated donor (URD) in 45%, and a partially matched/mismatched URD in 21%. Risk stratification according to the Dynamic International Prognostic Scoring System (DIPSS) was 12% low, 49% intermediate-1, 37% intermediate-2, and 1% high. The probability of survival at 5 yr was 47% (95% confidence interval [CI], 40% to 53%). In a multivariate analysis, donor type was the sole independent factor associated with survival. Adjusted probabilities of survival at 5-yr were 56% (95% CI, 44% to 67%) for MSD, 48% (95% CI, 37% to 58%) for well-matched URD, and 34% (95% CI, 21% to 47%) for partially matched/mismatched URD (P = .002). The relative risk (RR) for NRM was 3.92 (P = .006) for well-matched URD and 9.37 (P < .0001) for partially matched/mismatched URD. Trends toward increased NRM (RR, 1.7; P = .07) and inferior survival (RR, 1.37; P = .10) were observed in DIPSS intermediate-2/high-risk patients compared with DIPSS low/intermediate-1 risk patients. Our data indicate that RIC HCT is a potentially curative option for patients with MF, and that donor type is the most important factor influencing survival in these patients.
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Affiliation(s)
- Vikas Gupta
- Princess Margaret Cancer Center, University of Toronto, Toronto, Canada.
| | | | - Parameswaran N Hari
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kwang Woo Ahn
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Zhen-Huan Hu
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert Peter Gale
- Section of Hematology, Division of Experimental Medicine, Department of Medicine, Imperial College, London, UK
| | | | - Mehdi Hamadani
- West Virginia University Hospitals, Morgantown, West Virginia
| | - Eduardo Olavarria
- Hematology Department and BMT Unit, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Aaron T Gerds
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edmund K Waller
- Bone Marrow and Stem Cell Transplant Center, Emory University Hospital, Atlanta, Georgia
| | - Luciano J Costa
- Blood and Marrow Transplant Program, Medical University of South Carolina, Charleston, South Carolina
| | | | - Rammurti T Kamble
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Koen M van Besien
- Stem Cell Transplant Program, Weill Cornell Medical College, New York, New York
| | - Bipin N Savani
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Jeffrey Szer
- Clinical Haematology and BMT Service, Royal Melbourne Hospital, Victoria, Australia
| | - Jean-Yves Cahn
- Department of Hematology, University Hospital, Grenoble, France
| | - Marcos J de Lima
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Baldeep Wirk
- Department of Hematology/Oncology, Shands HealthCare and University of Florida, Gainesville, Florida
| | - Mahmoud D Aljurf
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Uday Popat
- Stem Cell Transplantation and Cellular Therapy, M.D. Anderson Cancer Center, Houston, Texas
| | - Nelli Bejanyan
- Division of Hematology, Oncology, and Transplantation, University of Minnesota Medical Center, Minneapolis, Minnesota
| | | | - Maxim Norkin
- Department of Hematology/Oncology, Shands HealthCare and University of Florida, Gainesville, Florida
| | - Ian D Lewis
- Haematology and Bone Marrow Transplant Unit, Royal Adelaide Hospital/SA Pathology, Adelaide, Australia
| | | | - Ann E Woolfrey
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Celalettin Ustun
- Division of Hematology, Oncology, and Transplantation, University of Minnesota Medical Center, Minneapolis, Minnesota
| | | | - Michael Lill
- Division of Hematology/Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Richard T Maziarz
- Center for Hematologic Malignancies, Oregon Health and Science University, Portland, Oregon
| | - Jorge Cortes
- Stem Cell Transplantation and Cellular Therapy, M.D. Anderson Cancer Center, Houston, Texas
| | | | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
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23
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Pidala J, Wang T, Haagenson M, Spellman SR, Askar M, Battiwalla M, Baxter-Lowe LA, Bitan M, Fernandez-Viña M, Gandhi M, Jakubowski AA, Maiers M, Marino SR, Marsh SGE, Oudshoorn M, Palmer J, Prasad VK, Reddy V, Ringden O, Saber W, Santarone S, Schultz KR, Setterholm M, Trachtenberg E, Turner EV, Woolfrey AE, Lee SJ, Anasetti C. Amino acid substitution at peptide-binding pockets of HLA class I molecules increases risk of severe acute GVHD and mortality. Blood 2013; 122:3651-8. [PMID: 23982174 PMCID: PMC3837514 DOI: 10.1182/blood-2013-05-501510] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 08/19/2013] [Indexed: 12/20/2022] Open
Abstract
HLA disparity has a negative impact on the outcomes of hematopoietic cell transplantation (HCT). We studied the independent impact of amino acid substitution (AAS) at peptide-binding positions 9, 99, 116, and 156, and killer immunoglobulin-like receptor binding position 77 of HLA-A, B, or C, on the risks for grade 3-4 acute graft-versus-host disease (GVHD), chronic GVHD, treatment-related mortality (TRM), relapse, and overall survival. In multivariate analysis, a mismatch at HLA-C position 116 was associated with increased risk for severe acute GVHD (hazard ratio [HR] = 1.45, 95% confidence interval [CI] = 1.15-1.82, P = .0016). Mismatch at HLA-C position 99 was associated with increased transplant-related mortality (HR = 1.37, 95% CI = 1.1-1.69, P = .0038). Mismatch at HLA-B position 9 was associated with increased chronic GVHD (HR = 2.28, 95% CI = 1.36-3.82, P = .0018). No AAS were significantly associated with outcome at HLA-A. Specific AAS pair combinations with a frequency >30 were tested for association with HCT outcomes. Cysteine to tyrosine substitution at position 99 of HLA-C was associated with increased TRM (HR = 1.78, 95% = CI 1.27-2.51, P = .0009). These results demonstrate that donor-recipient mismatch for certain peptide-binding residues of the HLA class I molecule is associated with increased risk for acute and chronic GVHD and death.
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24
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Storb R, Gyurkocza B, Storer BE, Sorror ML, Blume K, Niederwieser D, Chauncey TR, Pulsipher MA, Petersen FB, Sahebi F, Agura ED, Hari P, Bruno B, McSweeney PA, Maris MB, Maziarz RT, Langston AA, Bethge W, Vindeløv L, Franke GN, Laport GG, Yeager AM, Hübel K, Deeg HJ, Georges GE, Flowers MED, Martin PJ, Mielcarek M, Woolfrey AE, Maloney DG, Sandmaier BM. Graft-versus-host disease and graft-versus-tumor effects after allogeneic hematopoietic cell transplantation. J Clin Oncol 2013; 31:1530-8. [PMID: 23478054 PMCID: PMC3625710 DOI: 10.1200/jco.2012.45.0247] [Citation(s) in RCA: 166] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We designed a minimal-intensity conditioning regimen for allogeneic hematopoietic cell transplantation (HCT) in patients with advanced hematologic malignancies unable to tolerate high-intensity regimens because of age, serious comorbidities, or previous high-dose HCT. The regimen allows the purest assessment of graft-versus-tumor (GVT) effects apart from conditioning and graft-versus-host disease (GVHD) not augmented by regimen-related toxicities. PATIENTS AND METHODS Patients received low-dose total-body irradiation ± fludarabine before HCT from HLA-matched related (n = 611) or unrelated (n = 481) donors, followed by mycophenolate mofetil and a calcineurin inhibitor to aid engraftment and control GVHD. Median patient age was 56 years (range, 7 to 75 years). Forty-five percent of patients had comorbidity scores of ≥ 3. Median follow-up time was 5 years (range, 0.6 to 12.7 years). RESULTS Depending on disease risk, comorbidities, and GVHD, lasting remissions were seen in 45% to 75% of patients, and 5-year survival ranged from 25% to 60%. At 5 years, the nonrelapse mortality (NRM) rate was 24%, and the relapse mortality rate was 34.5%. Most NRM was a result of GVHD. The most significant factors associated with GVHD-associated NRM were serious comorbidities and grafts from unrelated donors. Most relapses occurred early while the immune system was compromised. GVT effects were comparable after unrelated and related grafts. Chronic GVHD, but not acute GVHD, further increased GVT effects. The potential benefit associated with chronic GVHD was outweighed by increased NRM. CONCLUSION Allogeneic HCT relying on GVT effects is feasible and results in cures of an appreciable number of malignancies. Improved results could come from methods that control progression of malignancy early after HCT and effectively prevent GVHD.
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25
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Ballen KK, Woolfrey AE, Zhu X, Ahn KW, Wirk B, Arora M, George B, Savani BN, Bolwell B, Porter DL, Copelan E, Hale G, Schouten HC, Lewis I, Cahn JY, Halter J, Cortes J, Kalaycio ME, Antin J, Aljurf MD, Carabasi MH, Hamadani M, McCarthy P, Pavletic S, Gupta V, Deeg HJ, Maziarz RT, Horowitz MM, Saber W. Allogeneic hematopoietic cell transplantation for advanced polycythemia vera and essential thrombocythemia. Biol Blood Marrow Transplant 2012; 18:1446-54. [PMID: 22449610 PMCID: PMC3499973 DOI: 10.1016/j.bbmt.2012.03.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 03/19/2012] [Indexed: 11/20/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is curative for selected patients with advanced essential thrombocythemia (ET) or polycythemia vera (PV). From 1990 to 2007, 75 patients with ET (median age 49 years) and 42 patients with PV (median age 53 years) underwent transplantations at the Fred Hutchinson Cancer Research Center (FHCRC; n = 43) or at other Center for International Blood and Marrow Transplant Research (CIBMTR) centers (n = 74). Thirty-eight percent of the patients had splenomegaly and 28% had a prior splenectomy. Most patients (69% for ET and 67% for PV) received a myeloablative (MA) conditioning regimen. Cumulative incidence of neutrophil engraftment at 28 days was 88% for ET patients and 90% for PV patients. Acute graft-versus-host disease (aGVHD) grades II to IV occurred in 57% and 50% of ET and PV patients, respectively. The 1-year treatment-related mortality (TRM) was 27% for ET and 22% for PV. The 5-year cumulative incidence of relapse was 13% for ET and 30% for PV. Five-year survival/progression-free survival (PFS) was 55%/47% and 71%/48% for ET and PV, respectively. Patients without splenomegaly had faster neutrophil and platelet engraftment, but there were no differences in TRM, survival, or PFS. Presence of myelofibrosis (MF) did not affect engraftment or TRM. Over 45% of the patients who undergo transplantations for ET and PV experience long-term PFS.
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Affiliation(s)
- Karen K Ballen
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts 02214, USA.
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26
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Thakar MS, Bonfim C, Sandmaier BM, O’Donnell P, Ribeiro L, Gooley T, Deeg HJ, Flowers ME, Pasquini R, Storb R, Woolfrey AE, Kiem HP. Cyclophosphamide-based in vivo T-cell depletion for HLA-haploidentical transplantation in Fanconi anemia. Pediatr Hematol Oncol 2012; 29:568-78. [PMID: 22839094 PMCID: PMC3622043 DOI: 10.3109/08880018.2012.708708] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is the only known cure for patients with Fanconi anemia (FA) who develop aplasia or leukemia. However, transplant regimens typically contain high-dose alkylators, which are poorly tolerated in FA patients. Furthermore, as many patients lack human leukocyte antigen (HLA)-matched family donors, alternative donors are used, which can increase the risk of both graft rejection and graft-versus-host disease (GVHD). To improve on these three concerns, we developed a multi-institutional clinical trial using a fludarabine (FLU)-based conditioning regimen with limited alkylators/low-dose radiation, HLA-haploidentical marrow, followed by reduced-dose cyclophosphamide (CY) to treat three FA patients with aplasia. All three patients engrafted with 100% donor CD3 chimerism at 1 month. One patient died early from disseminated toxoplasmosis infection. Of the two survivors, one had significant pretransplant co-morbidities and inadequate immunosuppression, and developed severe acute GVHD. The other patient had only mild acute and no chronic GVHD. With a follow-up of 2 and 3 years, respectively, both patients are doing well, are transfusion-independent, and maintain full donor chimerism. The patient with severe GVHD has resolving oral GVHD and good quality of life. We conclude that using low-intensity conditioning, HLA-haploidentical marrow, and reduced-dose CY for in vivo T-cell depletion can correct life-threatening aplasia in FA patients.
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Affiliation(s)
- MS Thakar
- Medical College of Wisconsin, Milwaukee, WI
| | - C Bonfim
- Hospital de Clinicas, Universidade do Parana, Curitiba Brazil
| | - BM Sandmaier
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - P O’Donnell
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - L Ribeiro
- Hospital de Clinicas, Universidade do Parana, Curitiba Brazil
| | - T Gooley
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - HJ Deeg
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - ME Flowers
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - R Pasquini
- Hospital de Clinicas, Universidade do Parana, Curitiba Brazil
| | - R Storb
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - AE Woolfrey
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - HP Kiem
- Fred Hutchinson Cancer Research Center, Seattle, WA
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27
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Aspesberro F, Guthrie KA, Woolfrey AE, Brogan TV, Roberts JS. Outcome of pediatric hematopoietic stem cell transplant recipients requiring mechanical ventilation. J Intensive Care Med 2012; 29:31-7. [PMID: 22904208 DOI: 10.1177/0885066612457343] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To assess the risk factors for intensive care unit admission among children receiving hematopoietic stem cell transplantation (HSCT) and to test the hypothesis that multiple organ failure (MOF) increases the odds of death among HSCT patients who receive mechanical ventilation (MV). METHODS The chart of all consecutive HSCTs at Seattle Children's Hospital and pediatric HSCT patients admitted to the pediatric critical care unit of a tertiary care pediatric hospital from January 2000 to September 2006 were reviewed retrospectively. RESULTS Charts of 266 HSCT patients were reviewed. Nonmalignant disease compared to hematologic malignancy, acute graft versus host disease grades III and IV, and second transplant increased the odds of pediatric intensive care unit admission. Among patients receiving MV for >24 hours, 9 (25%) survived for 6 months, while 8 patients (22%) were long-term survivors with a median follow-up time of 3.6 years, a significant improvement compared to a long-term survival of 7% (odds ratio 0.25, 95% confidence intervals: 0.09-0.72, P = .01) reported in a previously published cohort of pediatric HSCT patients at the same institution from 1983 to 1996. Cardiovascular failure, duration of MV for greater than 1 week, and prolonged receipt of continuous renal replacement therapy (CRRT) increased the risk of mortality. CONCLUSIONS Six-month survival of pediatric HSCT patients was 25% and the odds of death were increased by cardiovascular failure but not by MOF. Receipt of mechanical support (ventilation, CRRT) or cardiovascular support (inotropic agents) decreased the likelihood of long-term survival.
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28
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Spellman SR, Eapen M, Logan BR, Mueller C, Rubinstein P, Setterholm MI, Woolfrey AE, Horowitz MM, Confer DL, Hurley CK. A perspective on the selection of unrelated donors and cord blood units for transplantation. Blood 2012; 120:259-65. [PMID: 22596257 PMCID: PMC3398760 DOI: 10.1182/blood-2012-03-379032] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 05/04/2012] [Indexed: 12/20/2022] Open
Abstract
Selection of a suitable graft for allogeneic hematopoietic stem cell transplantation involves consideration of both donor and recipient characteristics. Of primary importance is sufficient donor-recipient HLA matching to ensure engraftment and acceptable rates of GVHD. In this Perspective, the National Marrow Donor Program and the Center for International Blood and Marrow Transplant Research provide guidelines, based on large studies correlating graft characteristics with clinical transplantation outcomes, on appropriate typing strategies and matching criteria for unrelated adult donor and cord blood graft selection.
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Affiliation(s)
- Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, 9200 West Wisconsin Ave., Milwaukee, WI 53226, USA
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29
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Burroughs LM, Woolfrey AE, Storer BE, Deeg HJ, Flowers MED, Martin PJ, Carpenter PA, Doney K, Appelbaum FR, Sanders JE, Storb R. Success of allogeneic marrow transplantation for children with severe aplastic anaemia. Br J Haematol 2012; 158:120-8. [PMID: 22533862 DOI: 10.1111/j.1365-2141.2012.09130.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 03/12/2012] [Indexed: 12/14/2022]
Abstract
Allogeneic marrow transplantation offers curative therapy for children with severe aplastic anaemia (SAA). We report the outcomes of 148 children with SAA who received human leucocyte antigen (HLA)-matched related marrow grafts between 1971 and 2010. Patients were divided into three groups, reflecting changes in conditioning and graft-versus-host disease (GVHD) prophylaxis regimens that occurred over time. Patients in Group 1 were conditioned with cyclophosphamide (CY; 200 mg/kg) followed by 'long' (102 d) methotrexate (MTX). Patients in Groups 2 and 3 received CY alone (Group 2) or combined with anti-thymocyte globulin (Group 3) followed by 'short' (days 1, 3, 6, and 11) MTX and ciclosporin (until day 180). With a median follow-up of 25 years, the 5-year survivals were 66%, 95%, and 100% for Groups 1, 2, and 3, respectively (overall P < 0·0001). The 3-year estimates of graft rejection were 22%, 32%, and 7%, respectively. The probabilities of grades III-IV acute and 2-year chronic GVHD were 15%, 0%, and 3%, and 21%, 21%, and 10%, respectively. Advances in preparative and GVHD prophylaxis regimens, and supportive care during the past 40 years have led to improved outcomes for children with SAA. These results confirm the use of allogeneic marrow transplantation for children with SAA who have HLA-matched related donors.
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30
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Rosenthal J, Woolfrey AE, Pawlowska A, Thomas SH, Appelbaum F, Forman S. Hematopoietic cell transplantation with autologous cord blood in patients with severe aplastic anemia: an opportunity to revisit the controversy regarding cord blood banking for private use. Pediatr Blood Cancer 2011; 56:1009-12. [PMID: 21370429 DOI: 10.1002/pbc.22970] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Accepted: 11/16/2010] [Indexed: 11/12/2022]
Abstract
The controversy surrounding private banking of umbilical cord blood units (CBU), as a safeguard against future malignancy or other life-threatening conditions, raises many questions in pediatric clinical practice. Recent favorable experiences with autologous transplantation for severe aplastic anemia using privately stored CBU, suggested a possible utility. While private banking is difficult to justify statistically or empirically, there may exist rare cases where autologous transplant of stored umbilical CBU could be beneficial. The reality of privately banked CBU and the possibility for future discovery of additional indications for autologous cord blood transplant, motivated us to re-examine our attitudes towards private cord blood banking.
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Affiliation(s)
- Joseph Rosenthal
- Department of Pediatrics, City of Hope, Duarte, California, USA.
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31
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Burroughs LM, Torgerson TR, Storb R, Carpenter PA, Rawlings DJ, Sanders J, Scharenberg AM, Skoda-Smith S, Englund J, Ochs HD, Woolfrey AE. Stable hematopoietic cell engraftment after low-intensity nonmyeloablative conditioning in patients with immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome. J Allergy Clin Immunol 2010; 126:1000-5. [PMID: 20643476 DOI: 10.1016/j.jaci.2010.05.021] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 05/18/2010] [Accepted: 05/20/2010] [Indexed: 01/16/2023]
Abstract
BACKGROUND Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is characterized by severe systemic autoimmunity caused by mutations in the forkhead box protein 3 (FOXP3) gene. Hematopoietic cell transplantation is currently the only viable option for long-term survival, but patients are frequently very ill and may not tolerate traditional myeloablative conditioning regimens. OBJECTIVE Here we present the outcome of hematopoietic cell transplantation using a low-intensity, nonmyeloablative conditioning regimen in 2 patients with IPEX syndrome and significant pretransplant risk factors. METHODS Two high-risk patients with IPEX syndrome received HLA-matched related bone marrow or unrelated peripheral blood stem cell grafts following conditioning with 90 mg/m(2) fludarabine and 4 Gy total body irradiation. Postgrafting immunosuppression consisted of mycophenolate mofetil and cyclosporine. Immune reconstitution and immune function was evaluated by measurement of donor chimerism, regulatory T-cell numbers, absolute lymphocyte subsets, and T-cell proliferation assays. RESULTS Both patients experienced minimal conditioning toxicity and successfully engrafted after hematopoietic cell transplantation. With a follow-up of 4 and 1 years, respectively, patients 1 and 2 have full immune function and normal FOXP3 protein expression. CONCLUSION A low-intensity, nonmyeloablative conditioning regimen can establish stable engraftment and correct the life-threatening immune deficiency and enteropathy of IPEX syndrome despite the presence of comorbidities that preclude conventional hematopoietic cell transplantation.
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Affiliation(s)
- Lauri M Burroughs
- Fred Hutchinson Cancer Research Center, Seattle, Wash 98109-1024, USA.
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32
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Brunstein CG, Gutman JA, Weisdorf DJ, Woolfrey AE, Defor TE, Gooley TA, Verneris MR, Appelbaum FR, Wagner JE, Delaney C. Allogeneic hematopoietic cell transplantation for hematologic malignancy: relative risks and benefits of double umbilical cord blood. Blood 2010; 116:4693-9. [PMID: 20686119 PMCID: PMC2996124 DOI: 10.1182/blood-2010-05-285304] [Citation(s) in RCA: 343] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Effectiveness of double umbilical cord blood (dUCB) grafts relative to conventional marrow and mobilized peripheral blood from related and unrelated donors has yet to be established. We studied 536 patients at the Fred Hutchinson Cancer Research Center and University of Minnesota with malignant disease who underwent transplantation with an human leukocyte antigen (HLA)-matched related donor (MRD, n = 204), HLA allele-matched unrelated donor (MUD, n = 152) or 1-antigen-mismatched unrelated adult donor (MMUD, n = 52) or 4-6/6 HLA matched dUCB (n = 128) graft after myeloablative conditioning. Leukemia-free survival at 5 years was similar for each donor type (dUCB 51% [95% confidence interval (CI), 41%-59%]; MRD 33% [95% CI, 26%-41%]; MUD 48% [40%-56%]; MMUD 38% [95% CI, 25%-51%]). The risk of relapse was lower in recipients of dUCB (15%, 95% CI, 9%-22%) compared with MRD (43%, 95% CI, 35%-52%), MUD (37%, 95% CI, 29%-46%) and MMUD (35%, 95% CI, 21%-48%), yet nonrelapse mortality was higher for dUCB (34%, 95% CI, 25%-42%), MRD (24% (95% CI, 17%-39%), and MUD (14%, 95% CI, 9%-20%). We conclude that leukemia-free survival after dUCB transplantation is comparable with that observed after MRD and MUD transplantation. For patients without an available HLA matched donor, the use of 2 partially HLA-matched UCB units is a suitable alternative.
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Nemecek ER, Guthrie KA, Sorror ML, Wood BL, Doney KC, Hilger RA, Scott BL, Kovacsovics TJ, Maziarz RT, Woolfrey AE, Bedalov A, Sanders JE, Pagel JM, Sickle EJ, Witherspoon R, Flowers ME, Appelbaum FR, Deeg HJ. Conditioning with treosulfan and fludarabine followed by allogeneic hematopoietic cell transplantation for high-risk hematologic malignancies. Biol Blood Marrow Transplant 2010; 17:341-50. [PMID: 20685259 DOI: 10.1016/j.bbmt.2010.05.007] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Accepted: 05/14/2010] [Indexed: 12/14/2022]
Abstract
In this prospective study 60 patients of median age 46 (range: 5-60 years), with acute myelogenous leukemia (AML; n = 44), acute lymphoblastic leukemia (ALL; n = 3), or myelodysplastic syndrome (MDS; n = 13) were conditioned for allogeneic hematopoietic cell transplantation with a treosulfan/fludarabine (Flu) combination. Most patients were considered at high risk for relapse or nonrelapse mortality (NRM). Patients received intravenous treosulfan, 12 g/m(2)/day (n = 5) or 14 g/m(2)/day (n = 55) on days -6 to -4, and Flu (30 mg/m(2)/day) on days -6 to -2, followed by infusion of marrow (n = 7) or peripheral blood stem cells (n = 53) from HLA-identical siblings (n = 30) or unrelated donors (n = 30). All patients engrafted. NRM was 5% at day 100, and 8% at 2 years. With a median follow-up of 22 months, the 2-year relapse-free survival (RFS) for all patients was 58% and 88% for patients without high-risk cytogenetics. The 2-year cumulative incidence of relapse was 33% (15% for patients with MDS, 34% for AML in first remission, 50% for AML or ALL beyond first remission and 63% for AML in refractory relapse). Thus, a treosulfan/Flu regimen was well tolerated and yielded encouraging survival and disease control with minimal NRM. Further trials are warranted to compare treosulfan/Flu to other widely used regimens, and to study the impact of using this regimen in more narrowly defined groups of patients.
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Affiliation(s)
- Eneida R Nemecek
- Oregon Health and Science University, Portland, Oregon 97239, USA.
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34
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Walter RB, Pagel JM, Gooley TA, Petersdorf EW, Sorror ML, Woolfrey AE, Hansen JA, Salter AI, Lansverk E, Stewart FM, O'Donnell PV, Appelbaum FR. Comparison of matched unrelated and matched related donor myeloablative hematopoietic cell transplantation for adults with acute myeloid leukemia in first remission. Leukemia 2010; 24:1276-82. [PMID: 20485378 PMCID: PMC3001162 DOI: 10.1038/leu.2010.102] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Hematopoietic cell transplantation (HCT) from a matched related donor (MRD) benefits many adults with acute myeloid leukemia (AML) in first complete remission (CR1). The majority of patients do not have such a donor, however, requiring use of an alternative donor if HCT is undertaken. We retrospectively analyzed 226 adult AML CR1 patients undergoing myeloablative unrelated donor (URD) (10/10 match, n=62; ≤9/10, n=29) or MRD (n=135) HCT from 1996–2007. Five-year estimates of overall survival (OS), relapse, and non-relapse mortality (NRM) were 57.9%, 29.7%, and 16.0%, respectively. Failure for each of these outcomes was slightly higher for 10/10 URD than MRD HCT, although statistical significance was not reached for any endpoint. The adjusted hazard ratios (HR) were 1.43 (0.89–2.30, p=0.14) for overall mortality, 1.17 (0.66–2.08, p=0.60) for relapse, and 1.79 (0.86–3.74, p=0.12) for NRM, respectively, and the adjusted odds ratio (OR) for grades 2–4 acute graft-versus-host disease was 1.50 (0.70–3.24, p=0.30). Overall mortality among 9/10 and 10/10 URD recipients was similar (adjusted HR=1.16 [0.52–2.61], p=0.71). These data indicate that URD HCT can provide long-term survival for CR1 AML; outcomes for 10/10 URD HCT, and possibly 9/10 URD HCT, suggest that this modality should be considered in the absence of a suitable MRD.
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Affiliation(s)
- R B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA.
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35
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Kalaycio ME, Kukreja M, Woolfrey AE, Szer J, Cortes J, Maziarz RT, Bolwell BJ, Buser A, Copelan E, Gale RP, Gupta V, Maharaj D, Marks DI, Pavletic SZ, Horowitz MM, Arora M. Allogeneic hematopoietic cell transplant for prolymphocytic leukemia. Biol Blood Marrow Transplant 2009; 16:543-7. [PMID: 19961946 DOI: 10.1016/j.bbmt.2009.11.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Accepted: 11/25/2009] [Indexed: 11/27/2022]
Abstract
The poor prognosis of patients with prolymphocytic leukemia (PLL) has led some clinicians to recommend allogeneic hematopoietic cell transplant (HCT). However, the data to support this approach is limited to case-reports and small case series. We reviewed the database of the Center for International Blood and Marrow Transplant Research (CIBMTR) to determine outcomes after allotransplant for patients with PLL. We identified 47 patients with a median age of 54 years (range: 30-75 years). With a median follow-up of 13 months, progression-free survival (PFS) was 33% (95% confidence interval [CI] 20%-47%) at 1 year. The most common cause of death was relapse or progression in 49%. The cumulative incidence of treatment-related mortality (TRM) at 1-year posttransplant was 28%. The small patient population prohibited prognostic factor analysis, but these data support consideration of allotransplant for PLL. Further study of a larger population of patients is needed to determine which patients are more likely to benefit.
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Affiliation(s)
- Matt E Kalaycio
- Taussig Cancer Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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36
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Burroughs LM, Storb R, Leisenring WM, Pulsipher MA, Loken MR, Torgerson TR, Ochs HD, Woolfrey AE. Intensive postgrafting immune suppression combined with nonmyeloablative conditioning for transplantation of HLA-identical hematopoietic cell grafts: results of a pilot study for treatment of primary immunodeficiency disorders. Bone Marrow Transplant 2007; 40:633-42. [PMID: 17660844 DOI: 10.1038/sj.bmt.1705778] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study was designed to determine the safety of a nonmyeloablative regimen in patients with primary immunodeficiency disorders (PID) who had infections, organ dysfunction or other risk factors that precluded conventional hematopoietic cell (HC) transplant. Fourteen patients received HLA-matched related (n=6) or unrelated (n=8) HC grafts from marrow (n=8), peripheral blood mononuclear cells (n=5) or umbilical cord blood (n=1), either without conditioning (n=1), or after 200 cGy total body irradiation alone (n=3) or with 90 mg/m2 fludarabine (n=10). All patients were given postgrafting immunosuppression with mycophenolate mofetil and cyclosporine. Mixed (n=5) or full (n=8) donor chimerism was established in 13 patients, and one patient rejected the graft. Eight patients developed acute grade III (n=1) and/or extensive chronic GVHD (n=8). With a median follow-up of 4.9 (range, 0.7-8.1) years, the 3-year overall survival, event-free survival and transplant-related mortality were 62, 62 and 23%, respectively. Correction of immune dysfunction was documented in 8 of 10 patients with stable donor engraftment. These preliminary results indicated that this approach was associated with stable donor engraftment and a low incidence of early mortality and, thus, can be considered for certain high-risk patients with PID. However, there was a risk of GVHD, which is an undesirable outcome for this group of patients.
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Affiliation(s)
- L M Burroughs
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA
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37
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Baron F, Sandmaier BM, Storer BE, Maris MB, Langston AA, Lange T, Petersdorf E, Bethge W, Maziarz RT, McSweeney PA, Pulsipher MA, Wade JC, Chauncey TR, Shizuru JA, Sorror ML, Woolfrey AE, Maloney DG, Storb R. Extended mycophenolate mofetil and shortened cyclosporine failed to reduce graft-versus-host disease after unrelated hematopoietic cell transplantation with nonmyeloablative conditioning. Biol Blood Marrow Transplant 2007; 13:1041-8. [PMID: 17697966 PMCID: PMC1986679 DOI: 10.1016/j.bbmt.2007.05.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Accepted: 05/15/2007] [Indexed: 01/21/2023]
Abstract
We previously reported data from 103 patients with hematologic malignancies (median age 54 years) who received peripheral blood stem cell (PBSC) grafts from HLA-matched unrelated donors after nonmyeloablative conditioning and were given postgrafting immunosuppression consisting of mycophenolate mofetil (MMF; administered from day 0 until day +40 with taper through day +96) and cyclosporine (CSP; given from day -3 to day +100, with taper through day 180) (historical patients). The incidences of grade II-IV acute and extensive chronic graft-versus-host disease (aGVHD, cGVHD) were 52% and 49%, respectively, and the 1-year probabilities of relapse, nonrelapse mortality (NRM), and progression-free survival (PFS) were 26%, 18%, and 56%, respectively. Here, we treated 71 patients with hematologic malignancies (median age 56 years) with unrelated PBSC grafts and investigated whether postgrafting immunosuppression with an extended course of MMF, given at full dosing until day +150 and then tapered through day +180, and a shortened course of CSP, through day +80, would promote tolerance induction and reduce the incidence of GVHD (current patients). We observed 77% grade II-IV aGVHD and 45% extensive cGVHD (P=.03, and P=.43, respectively, in current compared to historical patients). The 1-year probabilities of relapse, NRM, and PFS were 23%, 29%, and 47%, respectively (P=.89, P=.02, and P=.08 compared to the historical patients). We conclude that postgrafting immunosuppression with extended MMF and shortened CSP failed to decrease the incidence of GVHD among unrelated PBSC recipients given nonmyeloablative conditioning.
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Affiliation(s)
| | - Brenda M. Sandmaier
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | - Barry E. Storer
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | - Michael B. Maris
- Rocky Mountain Blood and Marrow Transplant Program, Denver, CO, USA
| | | | | | - Effie Petersdorf
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | | | | | | | | | | | - Thomas R. Chauncey
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
- VA Puget Sound Health Care System, Seattle, WA, USA
| | | | | | - Ann E. Woolfrey
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | - David G. Maloney
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | - Rainer Storb
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
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Carpenter PA, Hoffmeister P, Chesnut CH, Storer B, Charuhas PM, Woolfrey AE, Sanders JE. Bisphosphonate therapy for reduced bone mineral density in children with chronic graft-versus-host disease. Biol Blood Marrow Transplant 2007; 13:683-90. [PMID: 17531778 DOI: 10.1016/j.bbmt.2007.02.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2006] [Accepted: 02/05/2007] [Indexed: 11/20/2022]
Abstract
Reduced bone mineral density (BMD) occurs frequently in children after hematopoietic cell transplantation (HCT), but therapy for this complication is undefined. To determine the impact of bisphosphonate therapy on reduced BMD after HCT, we compared baseline and follow-up dual energy X-ray absorptiometry (DEXA) scans of 48 patients (controls) who received calcium and vitamin D to 18 patients who also received bisphosphonate therapy. Among the controls, median annualized increase in standardized BMD (sBMD) was 10% (range, -26% to +41%), but the deviation of sBMD from normal, as indicated by the Z-score, did not improve from baseline, -2.46 (range: -5.15 to -1.16) compared to follow-up, -2.79 (range: -5.76 to +0.07). For the bisphosphonate-treated patients, the median annualized increase in sBMD was 33% (range 3% to 147%, P = .0002) and the median Z-score improved from -3.57 (range: -5.13 to -0.86) at baseline, to -1.80 (-4.89 to +0.47) at follow-up (P = .06). The annualized median change in BMD Z-scores per year was +0.12 (-2.28 to +4.24) among the controls and +1.43 (-0.29 to +3.72) for the bisphosphonate group (P = .0002). The greatest improvement in BMD was observed in children who received therapy with bisphosphonates.
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Sreedharan A, Bowyer S, Wallace CA, Robertson MJ, Schmidt K, Woolfrey AE, Nelson RP. Macrophage activation syndrome and other systemic inflammatory conditions after BMT. Bone Marrow Transplant 2006; 37:629-34. [PMID: 16501594 DOI: 10.1038/sj.bmt.1705305] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Autologous hematopoietic cell transplantation (HCT) is being used to treat autoimmune diseases refractory to conventional therapy, including rheumatoid arthritis. Macrophage activation syndrome (MAS) is a descriptive term for a systemic inflammatory disorder that has been described in patients with juvenile rheumatoid arthritis (JRA). This case report describes a young adult with systemic JRA (sJRA) who developed MAS on day # 12 post-autologous transplantation. The patient developed high fever, laboratory evidence of disseminated intravascular coagulation (DIC), hepatocellular injury, pancytopenia and hyper-ferritinemia. All viral, bacterial and fungal studies were negative and the patient improved with high-dose glucocorticosteroid and cyclosporine therapy. Extreme elevation of serum ferritin was documented and helpful in monitoring response to therapy. A number of systemic inflammatory syndromes have been described in association with HCT. These include DIC, 'engraftment syndrome,' infection-associated hemophagocytic syndrome and familial hemophagocytic lymphohistiocytosis. Macrophage activation syndrome presents with features of DIC and is closely related or identical to infection-associated hemophagocytic syndrome. The diagnosis needs to be established in a timely fashion because early and appropriate treatment may improve outcome.
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Affiliation(s)
- A Sreedharan
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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40
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Sanders JE, Im HJ, Hoffmeister PA, Gooley TA, Woolfrey AE, Carpenter PA, Andrews RG, Bryant EM, Appelbaum FR. Allogeneic hematopoietic cell transplantation for infants with acute lymphoblastic leukemia. Blood 2005; 105:3749-56. [PMID: 15637143 PMCID: PMC1895011 DOI: 10.1182/blood-2004-08-3312] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2004] [Accepted: 12/23/2004] [Indexed: 11/20/2022] Open
Abstract
The role of transplantation in infants with acute lymphoblastic leukemia (ALL) is not defined. We analyzed results of 40 infants diagnosed before age 12 months who received a hematopoietic cell transplant (HCT) between July 1982 and February 2003 in first complete remission (CR1; n = 17), CR2/3 (n = 7), or relapse (n = 16). Patients were conditioned with cyclophosphamide with total body irradiation (n = 39) or busulfan (n = 1). Donors were matched related (n = 8), mismatched related (n = 16), or unrelated (n = 16). Graft-versus-host disease (GVHD) prophylaxis was methotrexate or cyclosporine (n = 7) or methotrexate plus cyclosporine (n = 33). Thirty-nine patients engrafted, 20 developed acute GVHD, and 7 developed chronic GVHD. Sixteen patients relapsed and 7 died of other causes. Patients in CR1 had disease-free survival (DFS) of 76% compared with 45% for CR2/CR3 and 8% for relapse (P < .001). Of 33 patients with cytogenetic data, 26 (79%) had MLL gene rearrangement. Fourteen of these 26 were in CR1 and 11 survive in remission. Outcome was associated with phase of disease, but having the MLL gene was not a factor predictive of outcome. Late effects included growth and other hormone deficiencies. These data demonstrate that infants with ALL and MLL gene have excellent DFS when they received transplants in CR1, and consideration for transplantation in CR1 is warranted.
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Affiliation(s)
- Jean E Sanders
- Fred Hutchinson Cancer Research Center, Clinical Research Division, 1100 Fairview Ave N, Seattle, WA 98109, USA.
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41
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Baron F, Maris MB, Sandmaier BM, Storer BE, Sorror M, Diaconescu R, Woolfrey AE, Chauncey TR, Flowers MED, Mielcarek M, Maloney DG, Storb R. Graft-versus-tumor effects after allogeneic hematopoietic cell transplantation with nonmyeloablative conditioning. J Clin Oncol 2005; 23:1993-2003. [PMID: 15774790 DOI: 10.1200/jco.2005.08.136] [Citation(s) in RCA: 282] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We have used a nonmyeloablative conditioning regimen consisting of total-body irradiation (2 Gy) with or without fludarabine (30 mg/m(2)/d for 3 days) for related and unrelated hematopoietic cell transplantation (HCT) in patients with hematologic malignancies who were not candidates for conventional HCT because of age, medical comorbidities, or preceding high-dose HCT. This approach relied on graft-versus-tumor (GVT) effects for control of malignancy. PATIENTS AND METHODS We analyzed GVT effects in 322 patients given grafts from HLA-matched related (n = 192) or unrelated donors (n = 130). RESULTS Of the 221 patients with measurable disease at HCT, 126 (57%) achieved complete (n = 98) or partial (n = 28) remissions. In multivariate analysis, there was a higher probability trend of achieving complete remissions in patients with chronic extensive graft-versus-host disease (GVHD; P = .07). One hundred eight patients (34%) relapsed or progressed. In multivariate analysis, achievement of full donor chimerism was associated with a decreased risk of relapse or progression (P = .002). Grade 2 to 4 acute GVHD had no significant impact on the risk of relapse or progression but was associated with increased risk of nonrelapse mortality and decreased probability of progression-free survival (PFS). Conversely, extensive chronic GVHD was associated with decreased risk of relapse or progression (P = .006) and increased probability of PFS (P = .003). CONCLUSION New approaches aimed at reducing the incidence of grade 2 to 4 acute GVHD might improve survival after allogeneic HCT after nonmyeloablative conditioning.
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Affiliation(s)
- Frédéric Baron
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, D1-100, PO Box 19024, Seattle, WA 98109-1024, USA
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42
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Nemecek ER, Gooley TA, Woolfrey AE, Carpenter PA, Matthews DC, Sanders JE. Outcome of allogeneic bone marrow transplantation for children with advanced acute myeloid leukemia. Bone Marrow Transplant 2005; 34:799-806. [PMID: 15361903 PMCID: PMC2926343 DOI: 10.1038/sj.bmt.1704689] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Allogeneic bone marrow transplantation (BMT) may offer the only chance of cure for children with acute myeloid leukemia (AML) in second complete remission (CR2) or with relapsed disease, but the outcome of these patients has not been clearly defined. We conducted a retrospective study of 58 children, median age 7.4 years (range 0.8-17.3), who received matched related or unrelated BMT at our institution for AML in CR2 (n = 12), in untreated first relapse (n = 11) or with refractory disease (n = 35), to identify risk factors associated with disease-free survival (DFS). Life threatening to fatal regimen-related toxicity was observed in 22% of patients. Estimates of DFS at 5 years (95% confidence interval) for patients in CR2, with untreated first relapse and refractory disease were 58% (27-80%), 36% (11-63%) and 9% (2-21%), respectively. Non-relapse mortality estimates were 0%, 27% (0-54%) and 17% (5-30%), and relapse estimates were 42% (14-70%), 36% (8-65%) and 74% (60-89%), respectively. Advanced disease phase and cytogenetic abnormalities at the time of transplantation were each associated with decreased DFS and increased relapse in multivariable regression models. Survival for children transplanted in CR2 or untreated first relapse is higher than that previously reported, but relapse remains the major cause of treatment failure regardless of disease stage.
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Affiliation(s)
- E R Nemecek
- Department of Pediatrics, Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA 98109, USA.
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43
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Sanders JE, Guthrie KA, Hoffmeister PA, Woolfrey AE, Carpenter PA, Appelbaum FR. Final adult height of patients who received hematopoietic cell transplantation in childhood. Blood 2005; 105:1348-54. [PMID: 15454481 DOI: 10.1182/blood-2004-07-2528] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractGrowth impairment and growth hormone (GH) deficiency are complications after total body irradiation (TBI) and hematopoietic cell transplantation (HCT). To determine the impact of GH therapy on growth, the final heights of 90 GH-deficient children who underwent fractionated TBI and HCT for malignancy were evaluated. Changes in height standard deviation (SD) from the diagnosis of GH deficiency to the achievement of final height were compared among 42 who did and 48 who did not receive GH therapy. At HCT, GH-treated patients were younger (P = .001), more likely to have undergone central nervous system irradiation (P = .007), and shorter (P = .005) than patients who did not receive GH therapy. After HCT, GH deficiency was diagnosed at 1.5 years (range, 0.8-9.5 years) for GH-treated and 1.2 years (range, 0.9-8.8 years) for nontreated patients. GH therapy was associated with significantly improved final height in children younger than 10 years at HCT (P = .0001), but GH therapy did not impact the growth of older children. Girls (P = .0001) and children diagnosed with acute myelogenous leukemia (AML), chronic myelogenous leukemia (CML), or myelodysplastic syndromes (MDS) (compared with acute lymphoblastic leukemia [ALL] or non-Hodgkin lymphoma [NHL]; P = .02) also showed more rapid growth than their counterparts. These data demonstrate that GH therapy improves the final height of young children after fractionated TBI.
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Affiliation(s)
- Jean E Sanders
- Clinical Research Division, Fred Hutchinson Cancer Research Center, D5-280, 1100 Fairview Ave N, Seattle, WA 98109, USA.
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44
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Yusuf U, Frangoul HA, Gooley TA, Woolfrey AE, Carpenter PA, Andrews RG, Deeg HJ, Appelbaum FR, Anasetti C, Storb R, Sanders JE. Allogeneic bone marrow transplantation in children with myelodysplastic syndrome or juvenile myelomonocytic leukemia: the Seattle experience. Bone Marrow Transplant 2004; 33:805-14. [PMID: 14755311 DOI: 10.1038/sj.bmt.1704438] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The purpose of this study was to evaluate the role of allogeneic bone marrow transplantation (BMT) in children with myelodysplastic syndrome (MDS). In total, 94 consecutive pediatric patients with MDS received an allogeneic BMT from 1976 to 2001 for refractory anemia (RA) (n=25), RA with ringed sideroblasts (RARS) (n=2), RA with excess blasts (RAEB) (n=20), RAEB in transformation (RAEB-T) (n=14), juvenile myelomonocytic leukemia (JMML) (n=32) or chronic myelomonocytic leukemia (CMML) (n=1). The estimated 3-year probabilities of survival, event-free survival (EFS), nonrelapse mortality and relapse were 50, 41, 28 and 29%, respectively. Patients with RA/RARS had an estimated 3-year survival of 74% compared to 68% in those with RAEB and 33% in patients with JMML/CMML. In multivariable analysis, patients with RAEB-T or JMML were 3.9 and 3.7 times more likely to die compared to those with RA/RARS and RAEB (P=0.005 and 0.004, respectively). Patients with RAEB-T were 5.5 times more likely to relapse (P=0.01). The median follow-up among the 43 surviving patients is 10 years (range 1-25). We conclude that allogeneic BMT for children with MDS is well tolerated and can be curative.
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MESH Headings
- Adolescent
- Anemia, Sideroblastic/therapy
- Bone Marrow Transplantation/adverse effects
- Child
- Child, Preschool
- Chromosomes, Human, Pair 7/genetics
- Female
- Graft vs Host Disease/etiology
- Humans
- Infant
- Leukemia, Myelomonocytic, Acute/genetics
- Leukemia, Myelomonocytic, Acute/therapy
- Leukemia, Myelomonocytic, Chronic/therapy
- Male
- Monosomy
- Myelodysplastic Syndromes/genetics
- Myelodysplastic Syndromes/therapy
- Survival Rate
- Transplantation, Homologous
- Washington
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Affiliation(s)
- U Yusuf
- Fred Hutchinson Cancer Research Center and University of Washington Department of Pediatrics, Seattle, WA 98109, USA
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45
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Meshinchi S, Leisenring WM, Carpenter PA, Woolfrey AE, Sievers EL, Radich JP, Sanders JE. Survival after second hematopoietic stem cell transplantation for recurrent pediatric acute myeloid leukemia. Biol Blood Marrow Transplant 2004; 9:706-13. [PMID: 14652854 DOI: 10.1016/j.bbmt.2003.08.003] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Recurrent acute myeloid leukemia (AML) after hematopoietic stem cell transplantation (HSCT) predicts a dismal prognosis. We sought to determine whether a second HSCT would result in long-term disease-free survival with acceptable toxicity. We evaluated the outcome of a second HSCT with a preparative regimen of cyclophosphamide and total body irradiation in pediatric patients with AML who relapsed after an initial HSCT with a busulfan and cyclophosphamide preparative regimen. Twenty-five patients aged 1.1 to 17.2 years (median, 4.1 years) with AML received a second HSCT for recurrent disease. All patients were conditioned with busulfan and cyclophosphamide for the first HSCT and with cyclophosphamide and total body irradiation for the second HSCT. Donor sources for the first HSCT were autologous (n = 11) or allogeneic (n = 14), whereas all donors for the second HSCT were allogeneic (12 matched related, 9 mismatched related, and 4 unrelated). Engraftment after the second HSCT occurred in all patients at median of 19.0 days (range, 11-32 days). The cumulative incidence of grade II to IV graft-versus-host disease was 76% after the second HSCT. Three patients died from regimen-related toxicity before day 100, 9 relapsed at a median of 5.4 months (range, 1.8-34.0 months), and 12 survived a median of 9.1 years (range, 7.0-14.4 years) after the second HSCT. The Kaplan-Meier estimates of survival at 100 days, 1 year, and 10 years were 88%, 56%, and 48%, respectively. The disease-free survival rate at 10 years was 44%. Multivariate Cox regression analysis suggested that patients who received a second HSCT in relapse had a relative risk of relapse of 7.8 (P =.02) compared with patients who underwent transplantation in remission. In addition, patients who received their second HSCT </=6 months after the first transplantation were at increased risk of relapse (P =.03). These data suggest that second HSCT after a failed initial transplantation results in long-term disease-free survival in one half of children with relapsed AML. Because a higher tumor burden at the time of second HSCT was associated with a higher risk of subsequent relapse, patients might benefit from reinduction therapy before the second HSCT.
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Affiliation(s)
- Soheil Meshinchi
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA.
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46
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Hogan WJ, Maris M, Storer B, Sandmaier BM, Maloney DG, Schoch HG, Woolfrey AE, Shulman HM, Storb R, McDonald GB. Hepatic injury after nonmyeloablative conditioning followed by allogeneic hematopoietic cell transplantation: a study of 193 patients. Blood 2004; 103:78-84. [PMID: 12969980 DOI: 10.1182/blood-2003-04-1311] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Liver injury is a frequent, serious complication of allogeneic hematopoietic cell transplantation (HCT) following myeloablative preparative regimens. We sought to determine the frequency and severity of hepatic injury after nonmyeloablative conditioning and its relationship to outcomes. One hundred ninety-three consecutive patients who received 2 Gy total body irradiation with or without fludarabine were evaluated for end points related to liver injury. Patients with diseases treatable by HCT who were ineligible for conventional myeloablative allogeneic HCT because of advanced age and/or comorbid conditions were included. Fifty-one patients (26%) developed hyperbilirubinemia of 68.4 microM (4 mg/dL) or greater, most commonly resulting from cholestasis due to graft-versus-host disease (GVHD) or sepsis. Pretransplantation factors associated with liver dysfunction were a diagnosis of aggressive malignancy (hazard ratio [HR] 1.9; P =.04) and the inclusion of fludarabine in the conditioning regimen (HR 1.8; P =.07). Overall survival at 1 year was superior for patients who had maximal serum bilirubin levels in the normal (78%) or minimally elevated (22.23-66.69 microM [1.3-3.9 mg/dL]) ranges (69%) compared with those in the 68.4 to 117.99 microM (4-6.9 mg/dL; 20%), 119.7 to 169.29 microM (7.0-9.9 mg/dL; 17%), and 171.0 microM (10 mg/dL; 19%) or greater groups. In summary, significant jaundice occurred in 26% of patients and was predominantly due to cholestasis resulting from GVHD and/or sepsis. Aggressive malignancies (mainly advanced disease) and later development of jaundice after transplantation predicted inferior survival.
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Affiliation(s)
- William J Hogan
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA
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47
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Bethge WA, Storer BE, Maris MB, Flowers MED, Maloney DG, Chauncey TR, Woolfrey AE, Storb R, Sandmaier BM. Relapse or progression after hematopoietic cell transplantation using nonmyeloablative conditioning: effect of interventions on outcome. Exp Hematol 2003; 31:974-80. [PMID: 14550814 DOI: 10.1016/s0301-472x(03)00225-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study analyzes the effect of interventions aimed at reinducing remissions in patients with relapse or progression of malignant disease following allogeneic hematopoietic cell transplantation (HCT) using nonmyeloablative conditioning. METHODS We performed a retrospective analysis of 81 instances of relapse or progression occurring among 224 patients given HCT as treatment of their hematologic malignancies. All patients received conditioning with 2 Gy total-body irradiation with or without fludarabine and with postgrafting immunosuppression with mycophenolate mofetil and cyclosporine. RESULTS Overall survival of patients after relapse or progression was 36%. Fifteen of the 81 patients were given no interventions. Three of these 15 (20%) patients are alive with disease while 12 died with disease progression. Sixty-six patients (81%) received interventions, including withdrawal of immunosuppression (n=32), donor lymphocyte infusions (n=13), or chemotherapy (n=21). Twenty of the 66 (30%) are alive, 5 in complete remission, 4 in partial remission, 1 with stable and 10 with progressive disease. The overall response rate to intervention was 27%. Forty-six (70%) of the patients given interventions died, mainly due to relapse/progression. Patients not receiving interventions had a 1-year survival estimate of 15% compared to 41% in patients given interventions. Factors associated with survival in patients given intervention were disease response (p=0.002), disease category (p=0.001), and time to relapse from transplantation (p=0.0005). CONCLUSIONS While the overall prognosis of patients relapsing or progressing after nonmyeloablative HCT is poor, interventions such as the combined use of immunotherapy and chemotherapy can improve patient survival.
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Affiliation(s)
- Wolfgang A Bethge
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, Washington 98109-1024, USA
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48
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Georges GE, Maris M, Sandmaier BM, Malone DG, Feinstein L, Niederweiser D, Shizuru JA, McSweeney PA, Chauncey TR, Agura E, Little MT, Sahebi F, Hegenbart U, Pulsipher MA, Bruno B, Forman S, Woolfrey AE, Radich JP, Blume KG, Storb R. Related and unrelated nonmyeloablative hematopoietic stem cell transplantation for malignant diseases. Int J Hematol 2002; 76 Suppl 1:184-9. [PMID: 12430851 DOI: 10.1007/bf03165242] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Patients with advanced hematological malignancies ineligible for conventional myeloablative allogeneic hematopoietic stem cell transplantation (HSCT) due to advanced age or medical contraindications were enrolled in multi-center study to investigate the safety and efficacy of nonmyeloablative HSCT using a 2 Gy total body irradi ation (TBI)-based regimen. A total of 192 patients (median age 55) were treated with HLA-matched sibling peripheral blood stem cell (PBSC) grafts, and 63 patients (median age 53) received a 10 of 10 HLA-antigen matched unrelated donor (URD) HSCT (PBSC graft, n = 48; marrow graft, n = 15). Diagnoses included multiple myeloma (n = 61), myelodysplastic syndrome (n = 55), chronic myeloid leukemia (n = 31), non-Hodgkin lymphoma (n = 31), acute myeloid leukemia (n = 28), chronic lymphocytic leukemia (n = 24), Hodgkin Disease (n = 14). The conditioning regimen was fludarabine 30 mg/m2/d x 3 days and 2 Gy TBI. Ninety-five related HSCT patients received 2 Gy TBI without fludarabine. Postgrafting immunosuppression was combined mycophenolate mofetil an cyclosporine. Transplants were well tolerated with a median of 0 days of hospitalization in the first 60 days for eligible patients. For related HSCT recipients, median follow-up was 289 (100-1,188) days. Nonfatal graft rejection occurred in 6.8%. Of those with sustained engraftment, graft-versus-host disease (GVHD) occurred in 49% (33% grade II, 11% grade III, 5% grade IV). Day-100 non-relapse mortality was 6%. Overall, 59% (114/192) of patients were alive. The relapse/disease progression mortality was 18%, and non-relapse mortality was 22%. The projecte 2-year survival and progression-free survival were 50% and 40%. For the URD HSCT recipients, median follow-up was 190 (100-468) days. Graft rejection occurred in 27% (17/63) of patients, mostly in recipients of marrow grafts (9/15). Acute GVHD occurred in 63% (50% grade II, 13% grade III) of 46 engrafted patients. Chronic GVHD requiring therapy occurred in 50% of patients. Of the 63 URD HSCT patients, 54% were alive, 37% in CR, 3% PR, and 14% with disease progression or relapse. Related and unrelated nonmyeloablative HSCT is feasible and potentially curative in patients with advanced hematological malignancies who have no other treatment options.
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Affiliation(s)
- George E Georges
- Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, USA
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49
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Abstract
Hematopoietic stem cell transplantation (HCT) may offer the only curative therapy for certain life-threatening immune deficiency disorders. Conventional HCT poses a risk to patients for severe morbidity, mortality, and late sequelae resulting from myeloablative preparative regimens. This review summarizes the development of nonmyeloablative regimens that have the potential to reduce both short- and long-term risks of HCT. Results of NM-HCT in a small number of patients indicate that this procedure may play an important role in treatment of life-threatening immune deficiencies.
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Affiliation(s)
- Ann E Woolfrey
- Fred Hutchinson Cancer Research Center and University of Washington, Seattle, USA
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50
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Woolfrey AE, Anasetti C, Storer B, Doney K, Milner LA, Sievers EL, Carpenter P, Martin P, Petersdorf E, Appelbaum FR, Hansen JA, Sanders JE. Factors associated with outcome after unrelated marrow transplantation for treatment of acute lymphoblastic leukemia in children. Blood 2002; 99:2002-8. [PMID: 11877272 DOI: 10.1182/blood.v99.6.2002] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Acute lymphoblastic leukemia (ALL) is the most common indication for transplantation of marrow from unrelated donors in children. We analyzed results of this procedure in children with ALL treated according to a standard protocol to determine risk factors for outcome. From January 1987 to 1999, 88 consecutively seen patients with ALL who were younger than 18 years received a marrow transplant from an HLA-matched (n = 56) or partly matched (n = 32) unrelated donor during first complete remission (CR1; n = 10), second remission (CR2; n = 34), third remission (CR3; n = 10), or relapse (n = 34). Patients received cyclophosphamide and fractionated total-body irradiation as conditioning treatment and were given methotrexate and cyclosporine for graft-versus-host disease (GVHD) prophylaxis. Three-year rates of leukemia-free survival (LFS) according to phase of disease were 70% for CR1, 46% for CR2, 20% for CR3, and 9% for relapse (P <.0001). Three-year cumulative relapse rates were 10%, 33%, 20%, and 50%, respectively, and 3-year cumulative rates of death not due to relapse were 20%, 22%, 60%, and 41%, respectively, for patients with CR1, CR2, CR3, and relapse. Grades III to IV acute GVHD occurred in 43% of patients given HLA-matched transplants and in 59% given partly matched transplants (P =.10); clinical extensive chronic GVHD occurred in 32% and 38%, respectively (P =.23). LFS rates were lower in patients with advanced disease (P <.0001), age 10 years or older (P =.002), or short duration of CR1 (P =.007). Thus, in addition to phase of disease, age and duration of CR1 were predictors of outcome after unrelated-donor transplantation for treatment of ALL in children. Outcome was particularly favorable in younger patients with early phases of the disease.
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Affiliation(s)
- Ann E Woolfrey
- Pediatric Transplantation, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109-1024, USA.
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