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Dillon LW, Gui G, Ravindra N, Andrew G, Mukherjee D, Wong ZC, Huang Y, Gerhold J, Holman M, D’Angelo J, Miller J, Higgins J, Salk JJ, Auletta JJ, El Chaer F, Devine SM, Jimenez-Jimenez AM, De Lima MJG, Litzow MR, Kebriaei P, Saber W, Spellman SR, Zeger SL, Page KM, Hourigan CS. Measurable Residual FLT3 Internal Tandem Duplication Before Allogeneic Transplant for Acute Myeloid Leukemia. JAMA Oncol 2024:2818452. [PMID: 38696205 PMCID: PMC11066770 DOI: 10.1001/jamaoncol.2024.0985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/07/2023] [Indexed: 05/05/2024]
Abstract
Importance Persistence of FLT3 internal tandem duplication (ITD) in adults with acute myeloid leukemia (AML) in first complete remission (CR) prior to allogeneic hematopoietic cell transplant (HCT) is associated with increased relapse and death after transplant, but the association between the level of measurable residual disease (MRD) detected and clinical outcome is unknown. Objective To examine the association between pre-allogeneic HCT MRD level with relapse and death posttransplant in adults with AML in first CR. Design, Setting, and Participants In this cohort study, DNA sequencing was performed on first CR blood from patients with FLT3-ITD AML transplanted from March 2013 to February 2019. Clinical follow-up was through May 2022. Data were analyzed from October 2022 to December 2023. Exposure Centralized DNA sequencing for FLT3-ITD in pre-allogeneic HCT first CR blood using a commercially available kit. Main Outcomes and Measures The primary outcomes were overall survival and cumulative incidence of relapse, with non-relapse-associated mortality as a competing risk post-allogeneic HCT. Kaplan-Meier estimations (log-rank tests), Cox proportional hazards models, and Fine-Gray models were used to estimate the end points. Results Of 537 included patients with FLT3-ITD AML from the Pre-MEASURE study, 296 (55.1%) were female, and the median (IQR) age was 55.6 (42.9-64.1) years. Using the variant allele fraction (VAF) threshold of 0.01% or greater for MRD positivity, the results closely aligned with those previously reported. With no VAF threshold applied (VAF greater than 0%), 263 FLT3-ITD variants (median [range] VAF, 0.005% [0.0002%-44%]), and 177 patients (33.0%) with positive findings were identified. Multivariable analyses showed that residual FLT3-ITD was the variable most associated with relapse and overall survival, with a dose-dependent correlation. Patients receiving reduced-intensity conditioning without melphalan or nonmyeloablative conditioning had increased risk of relapse and death at any given level of MRD compared with those receiving reduced-intensity conditioning with melphalan or myeloablative conditioning. Conclusions and Relevance This study provides generalizable and clinically applicable evidence that the detection of residual FLT3-ITD in the blood of adults in first CR from AML prior to allogeneic HCT is associated with an increased risk of relapse and death, particularly for those with a VAF of 0.01% or greater. While transplant conditioning intensification, an intervention not available to all, may help mitigate some of this risk, alternative approaches will be necessary for this high-risk population of patients who are underserved by the current standard of care.
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Affiliation(s)
- Laura W. Dillon
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Gege Gui
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Niveditha Ravindra
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Georgia Andrew
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Devdeep Mukherjee
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Zoë C. Wong
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | | | | | | | | | | | - Jesse J. Salk
- TwinStrand Biosciences, Seattle, Washington
- University of Washington School of Medicine, Seattle
| | - Jeffery J. Auletta
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
- The Ohio State University College of Medicine, Columbus
| | | | - Steven M. Devine
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | | | | | | | | | - Wael Saber
- Medical College of Wisconsin, Milwaukee
- National Marrow Donor Program, Minneapolis, Minnesota
| | - Stephen R. Spellman
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
- National Marrow Donor Program, Minneapolis, Minnesota
| | - Scott L. Zeger
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kristin M. Page
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
- Medical College of Wisconsin, Milwaukee
| | - Christopher S. Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
- Virginia Tech Fralin Biomedical Research Institute Cancer Research Center, Washington, DC
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Shaw BE, Jimenez-Jimenez AM, Burns LJ, Logan BR, Khimani F, Shaffer BC, Shah NN, Mussetter A, Tang XY, McCarty JM, Alavi A, Farhadfar N, Jamieson K, Hardy NM, Choe H, Ambinder RF, Anasetti C, Perales MA, Spellman SR, Howard A, Komanduri KV, Luznik L, Norkin M, Pidala JA, Ratanatharathorn V, Confer DL, Devine SM, Horowitz MM, Bolaños-Meade J. Three-Year Outcomes in Recipients of Mismatched Unrelated Bone Marrow Donor Transplants Using Post-Transplantation Cyclophosphamide: Follow-Up from a National Marrow Donor Program-Sponsored Prospective Clinical Trial. Transplant Cell Ther 2023; 29:208.e1-208.e6. [PMID: 36584941 PMCID: PMC9992261 DOI: 10.1016/j.jtct.2022.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 11/28/2022] [Revised: 12/16/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022]
Abstract
The use of post-transplantation cyclophosphamide (PTCy) as graft-versus-host disease (GVHD) prophylaxis has resulted in reductions in GVHD and improved outcomes in allogeneic hematopoietic cell transplantation (HCT) using HLA-mismatched related donors. We report the 3-year outcomes of the first multicenter prospective clinical trial using PTCy in the setting of mismatched unrelated donor (MMUD) bone marrow HCT. The study enrolled 80 patients, treated with either myeloablative conditioning (MAC; n = 40) or reduced-intensity conditioning (RIC; n = 40), with the primary endpoint of 1-year overall survival (OS). The median follow-up for this study was 34 months (range, 12 to 46 months) in the RIC group and 36 months (range, 18 to 49 months) in the MAC group. Three-year OS and nonrelapse mortality were 70% and 15%, respectively, in the RIC group and 62% and 10% in the MAC group. No GVHD was reported after 1 year. The incidence of relapse was 29% in the RIC group and 51% in the MAC group. OS did not differ based on HLA match grade (63% in the 7/8 strata and 71% in the 4 to 6/8 strata). These encouraging outcomes, which were sustained for 3 years post-HCT, support the continued exploration of MMUD HCT using a PTCy platform. Important future areas to address include relapse reduction and furthering our understanding of optimal donor selection based on HLA and non-HLA factors.
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Affiliation(s)
- Bronwen E Shaw
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | | | - Linda J Burns
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Brent R Logan
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Farhad Khimani
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Brian C Shaffer
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nirav N Shah
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Alisha Mussetter
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Xiao-Ying Tang
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John M McCarty
- Cellular Immunotherapies and Transplant Program, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Asif Alavi
- Department of Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | - Nosha Farhadfar
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Katarzyna Jamieson
- University of North Carolina Hospitals-Chapel Hill, Chapel Hill, North Carolina
| | - Nancy M Hardy
- Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland
| | - Hannah Choe
- Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Richard F Ambinder
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
| | - Claudio Anasetti
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Alan Howard
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Krishna V Komanduri
- Division of Hematology and Oncology, UCSF Health and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, California
| | - Leo Luznik
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
| | - Maxim Norkin
- Baptist MD Anderson Cancer Center, Jacksonville, Florida
| | - Joseph A Pidala
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | | | - Dennis L Confer
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Steven M Devine
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Mary M Horowitz
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Javier Bolaños-Meade
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
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Diaz-Paez M, Mones K, Suzuki V, Jean P, Pereira D, Beitinjaneh PA, Lekakis LJ, Jimenez-Jimenez AM, Goodman M, Benjamin CL, Komanduri KV, Wang TP. Outcomes in Patients Undergoing Extracorporeal Photopheresis (ECP) for Management of Acute Graft-Versus-Host Disease (GvHD). Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00431-1] [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: 02/07/2023]
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Murthy HS, Ahn KW, Estrada-Merly N, Alkhateeb HB, Bal S, Kharfan-Dabaja MA, Dholaria B, Foss F, Gowda L, Jagadeesh D, Sauter C, Abid MB, Aljurf M, Awan FT, Bacher U, Badawy SM, Battiwalla M, Bredeson C, Cerny J, Chhabra S, Deol A, Diaz MA, Farhadfar N, Freytes C, Gajewski J, Gandhi MJ, Ganguly S, Grunwald MR, Halter J, Hashmi S, Hildebrandt GC, Inamoto Y, Jimenez-Jimenez AM, Kalaycio M, Kamble R, Krem MM, Lazarus HM, Lazaryan A, Maakaron J, Munshi PN, Munker R, Nazha A, Nishihori T, OIuwole OO, Ortí G, Pan DC, Patel SS, Pawarode A, Rizzieri D, Saba NS, Savani B, Seo S, Ustun C, van der Poel M, Verdonck LF, Wagner JL, Wirk B, Oran B, Nakamura R, Scott B, Saber W. Outcomes of Allogeneic Hematopoietic Cell Transplantation in T-cell Prolymphocytic Leukemia: A Contemporary Analysis from the Center for International Blood and Marrow Transplant Research. Transplant Cell Ther 2022; 28:187.e1-187.e10. [PMID: 35081472 PMCID: PMC8977261 DOI: 10.1016/j.jtct.2022.01.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/11/2022] [Accepted: 01/17/2022] [Indexed: 10/19/2022]
Abstract
T cell prolymphocytic leukemia (T-PLL) is a rare, aggressive malignancy with limited treatment options and poor long-term survival. Previous studies of allogeneic hematopoietic cell transplantation (alloHCT) for T-PLL are limited by small numbers, and descriptions of patient and transplantation characteristics and outcomes after alloHCT are sparse. In this study, we evaluated outcomes of alloHCT in patients with T-PLL and attempted to identify predictors of post-transplantation relapse and survival. We conducted an analysis of data using the Center for International Blood and Marrow Transplant Research database on 266 patients with T-PLL who underwent alloHCT between 2008 and 2018. The 4-year rates of overall survival (OS), disease-free survival (DFS), relapse, and treatment-related mortality (TRM) were 30.0% (95% confidence interval [CI], 23.8% to 36.5%), 25.7% (95% CI, 20% to 32%), 41.9% (95% CI, 35.5% to 48.4%), and 32.4% (95% CI, 26.4% to 38.6%), respectively. In multivariable analyses, 3 variables were associated with inferior OS: receipt of a myeloablative conditioning (MAC) regimen (hazard ratio [HR], 2.18; P < .0001), age >60 years (HR, 1.61; P = .0053), and suboptimal performance status, defined by Karnofsky Performance Status (KPS) <90 (HR, 1.53; P = .0073). Receipt of an MAC regimen also was associated with increased TRM (HR, 3.31; P < .0001), an elevated cumulative incidence of grade II-IV acute graft-versus-host disease (HR, 2.94; P = .0011), and inferior DFS (HR, 1.86; P = .0004). Conditioning intensity was not associated with relapse; however, stable disease/progression was correlated with increased risk of relapse (HR, 2.13; P = .0072). Both in vivo T cell depletion (TCD) as part of conditioning and KPS <90 were associated with worse TRM and inferior DFS. Receipt of total body irradiation had no significant effect on OS, DFS, or TRM. Our data show that reduced-intensity conditioning without in vivo TCD (ie, without antithymocyte globulin or alemtuzumab) before alloHCT was associated with long-term DFS in patients with T-PLL who were age ≤60 years or who had a KPS >90 or chemosensitive disease.
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Shaw BE, Jimenez-Jimenez AM, Burns LJ, Logan BR, Khimani F, Shaffer BC, Shah NN, Mussetter A, Tang XY, McCarty JM, Alavi A, Farhadfar N, Jamieson K, Hardy NM, Choe H, Ambinder RF, Anasetti C, Perales MA, Spellman SR, Howard A, Komanduri KV, Luznik L, Norkin M, Pidala JA, Ratanatharathorn V, Confer DL, Devine SM, Horowitz MM, Bolaños-Meade J. National Marrow Donor Program-Sponsored Multicenter, Phase II Trial of HLA-Mismatched Unrelated Donor Bone Marrow Transplantation Using Post-Transplant Cyclophosphamide. J Clin Oncol 2021; 39:1971-1982. [PMID: 33905264 PMCID: PMC8260905 DOI: 10.1200/jco.20.03502] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [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: 12/03/2020] [Revised: 02/01/2021] [Accepted: 03/16/2021] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Hematopoietic cell transplantation (HCT) is curative for hematologic disorders, but outcomes are historically inferior when using HLA-mismatched donors. Despite unrelated donor registries listing > 38 million volunteers, 25%-80% of US patients lack an HLA-matched unrelated donor, with significant disparity across ethnic groups. We hypothesized that HCT with a mismatched unrelated donor (MMUD) using post-transplant cyclophosphamide (PTCy), a novel strategy successful in overcoming genetic disparity using mismatched related donors, would be feasible and increase access to HCT. PATIENTS AND METHODS We performed a prospective phase II study of MMUD bone marrow HCT with PTCy for patients with hematologic malignancies. The primary end point was 1-year overall survival (OS), hypothesized to be 65% or better. 80 patients enrolled at 11 US transplant centers (December 2016-March 2019). Following myeloablative or reduced-intensity conditioning-based HCT, patients received PTCy on days +3, +4, with sirolimus and mycophenolate mofetil starting on day +5. We compared outcomes to Center for International Blood and Marrow Transplant Research contemporary controls receiving PTCy. RESULTS Notably, 48% of patients enrolled were ethnic minorities. 39% of pairs were matched for 4-6 out of 8 HLA alleles. The primary end point was met, with 1-year OS of 76% (90% CI, 67.3 to 83.3) in the entire cohort, and 72% and 79% in the myeloablative and reduced-intensity conditioning strata, respectively. Secondary end points related to engraftment and graft-versus-host-disease were reached. Multivariate analysis comparing the study group with other mismatched HCT controls found no significant differences in OS. CONCLUSION Our prospective study demonstrates the feasibility and effectiveness of HCT with an MMUD in the setting of PTCy. Remarkably, nearly half of the study participants belonged to an ethnic minority population, suggesting this approach may significantly expand access to HCT.
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Affiliation(s)
- Bronwen E. Shaw
- Center for International Blood and Marrow Transplant Research/Medical College of Wisconsin, Milwaukee, WI
| | | | - Linda J. Burns
- Center for International Blood and Marrow Transplant Research/Medical College of Wisconsin, Milwaukee, WI
| | - Brent R. Logan
- Center for International Blood and Marrow Transplant Research/Medical College of Wisconsin, Milwaukee, WI
| | - Farhad Khimani
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Brian C. Shaffer
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nirav N. Shah
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Alisha Mussetter
- Center for International Blood and Marrow Transplant Research/National Marrow Donor Program, Minneapolis, MN
| | - Xiao-Ying Tang
- Center for International Blood and Marrow Transplant Research/Medical College of Wisconsin, Milwaukee, WI
| | - John M. McCarty
- Massey Cancer Center Bone Marrow Transplant Program, Virginia Commonwealth University, Richmond, VA
| | - Asif Alavi
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University, Detroit, MI
| | - Nosha Farhadfar
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, FL
| | | | - Nancy M. Hardy
- Greenebaum Cancer Center, University of Maryland, Baltimore, MD
| | - Hannah Choe
- James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Richard F. Ambinder
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | | | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Stephen R. Spellman
- Center for International Blood and Marrow Transplant Research/National Marrow Donor Program, Minneapolis, MN
| | - Alan Howard
- Center for International Blood and Marrow Transplant Research/National Marrow Donor Program, Minneapolis, MN
| | | | - Leo Luznik
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Maxim Norkin
- LifeSouth Community Blood Centers, Baptist MD Anderson Cancer Center, Jacksonville, FL
| | | | - Voravit Ratanatharathorn
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University, Detroit, MI
| | - Dennis L. Confer
- Center for International Blood and Marrow Transplant Research/National Marrow Donor Program, Minneapolis, MN
| | - Steven M. Devine
- Center for International Blood and Marrow Transplant Research/National Marrow Donor Program, Minneapolis, MN
| | - Mary M. Horowitz
- Center for International Blood and Marrow Transplant Research/Medical College of Wisconsin, Milwaukee, WI
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