1
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Shindiapina P, Pietrzak M, Seweryn M, McLaughlin E, Zhang X, Makowski M, Ahmed EH, Schlotter S, Pearson R, Kitzler R, Mozhenkova A, Le-Rademacher J, Little RF, Akpek G, Ayala E, Devine SM, Kaplan LD, Noy A, Popat UR, Hsu JW, Morris LE, Mendizabal AM, Krishnan A, Wachsman W, Williams N, Sharma N, Hofmeister CC, Forman SJ, Navarro WH, Alvarnas JC, Ambinder RF, Lozanski G, Baiocchi RA. Immune Recovery Following Autologous Hematopoietic Stem Cell Transplantation in HIV-Related Lymphoma Patients on the BMT CTN 0803/AMC 071 Trial. Front Immunol 2021; 12:700045. [PMID: 34539628 PMCID: PMC8446430 DOI: 10.3389/fimmu.2021.700045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/13/2021] [Indexed: 12/13/2022] Open
Abstract
We report a first in-depth comparison of immune reconstitution in patients with HIV-related lymphoma following autologous hematopoietic cell transplant (AHCT) recipients (n=37, lymphoma, BEAM conditioning), HIV(-) AHCT recipients (n=30, myeloma, melphalan conditioning) at 56, 180, and 365 days post-AHCT, and 71 healthy control subjects. Principal component analysis showed that immune cell composition in HIV(+) and HIV(-) AHCT recipients clustered away from healthy controls and from each other at each time point, but approached healthy controls over time. Unsupervised feature importance score analysis identified activated T cells, cytotoxic memory and effector T cells [higher in HIV(+)], and naïve and memory T helper cells [lower HIV(+)] as a having a significant impact on differences between HIV(+) AHCT recipient and healthy control lymphocyte composition (p<0.0033). HIV(+) AHCT recipients also demonstrated lower median absolute numbers of activated B cells and lower NK cell sub-populations, compared to healthy controls (p<0.0033) and HIV(-) AHCT recipients (p<0.006). HIV(+) patient T cells showed robust IFNγ production in response to HIV and EBV recall antigens. Overall, HIV(+) AHCT recipients, but not HIV(-) AHCT recipients, exhibited reconstitution of pro-inflammatory immune profiling that was consistent with that seen in patients with chronic HIV infection treated with antiretroviral regimens. Our results further support the use of AHCT in HIV(+) individuals with relapsed/refractory lymphoma.
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Affiliation(s)
- Polina Shindiapina
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States.,Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Maciej Pietrzak
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, United States
| | - Michal Seweryn
- Biobank Lab, Department of Molecular Biophysics, Faculty of Biology and Environmental Protection, University of Łódź, Łódź, Poland
| | - Eric McLaughlin
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, United States
| | - Xiaoli Zhang
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, United States
| | | | - Elshafa Hassan Ahmed
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States.,Department of Veterenary Biosciences, College of Veterenary Medicine, The Ohio State University, Columbus, OH, United States
| | - Sarah Schlotter
- College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Rebecca Pearson
- Department of Pathology, The Ohio State University, Columbus, OH, United States
| | - Rhonda Kitzler
- Department of Pathology, The Ohio State University, Columbus, OH, United States
| | - Anna Mozhenkova
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Jennifer Le-Rademacher
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, United States
| | - Richard F Little
- National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Gorgun Akpek
- Pacific Central Coast Health Centers, San Luis Obispo, CA, United States
| | - Ernesto Ayala
- Department of Internal Medicine, Hematology & Oncology, Mayo Clinic, Jacksonville, FL, United States
| | - Steven M Devine
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, MN, United States
| | - Lawrence D Kaplan
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Ariela Noy
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY, United States
| | - Uday R Popat
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas, MD Anderson Cancer Center, Houston, TX, United States
| | - Jack W Hsu
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL, United States
| | - Lawrence E Morris
- Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, United States
| | | | - Amrita Krishnan
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - William Wachsman
- Moores University of California San Diego Cancer Center, La Jolla, CA, United States.,Veterans Affairs San Diego Healthcare System, San Diego, CA, United States
| | - Nita Williams
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Nidhi Sharma
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | | | - Stephen J Forman
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - Willis H Navarro
- Division of Hematology/Oncology/Transplantation, University of Minnesota, Minneapolis, MN, United States.,Global Research and Development, Atara Biotherapeutics, Inc., San Francisco, CA, United States
| | - Joseph C Alvarnas
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - Richard F Ambinder
- Division of Hematologic Malignancies, Sidney Kimmel Comprehensive Cancer Center (SKCCC), Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Gerard Lozanski
- Department of Pathology, The Ohio State University, Columbus, OH, United States
| | - Robert A Baiocchi
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States.,Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
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Hu B, Lin X, Lee HC, Huang X, Tidwell RSS, Ahn KW, Hu ZH, Jabbour E, Verstovsek S, Ravandi F, Garcia-Manero G, Kharfan-Dabaja MA, Hossain NM, Marks DI, Kamble RT, Inamoto Y, Kindwall-Keller T, Saad A, Litzow MR, Savani BN, Hale GA, Bacher U, Gerds AT, Liesveld JL, Ustun C, Olsson RF, Daly A, Grunwald MR, Solh M, DeFilipp Z, Aljurf M, Wirk B, Akpek G, Nishihori T, Cerny J, Seo S, Hsu JW, Champlin R, de Lima M, Alyea E, Popat U, Sobecks R, Scott BL, Kantarjian H, Cortes J, Saber W. Timing of allogeneic hematopoietic cell transplantation (alloHCT) for chronic myeloid leukemia (CML) patients. Leuk Lymphoma 2020; 61:2811-2820. [PMID: 32662346 DOI: 10.1080/10428194.2020.1783444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
While TKI are the preferred first-line treatment for chronic phase (CP) CML, alloHCT remains an important consideration. The aim is to estimate residual life expectancy (RLE) for patients initially diagnosed with CP CML based on timing of alloHCT or continuation of TKI in various settings: CP1 CML, CP2 + [after transformation to accelerated phase (AP) or blast phase (BP)], AP, or BP. Non-transplant cohort included single-institution patients initiating TKI and switched TKI due to failure. CIBMTR transplant cohort included CML patients who underwent HLA sibling matched (MRD) or unrelated donor (MUD) alloHCT. AlloHCT appeared to shorten survival in CP1 CML with overall mortality hazard ratio (HR) for alloHCT of 2.4 (95% CI 1.2-4.9; p = .02). In BP CML, there was a trend toward higher survival with alloHCT; HR = 0.7 (0.5-1.1; p = .099). AlloHCT in CP2 + [HR = 2.0 (0.8-4.9), p = .13] and AP [HR = 1.1 (0.6-2.1); p = .80] is less clear and should be determined on a case-by-case basis.
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Affiliation(s)
- Bei Hu
- Department of Lymphoma/Myeloma, UT MD Anderson Cancer Center, Houston, TX, USA.,Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Xiao Lin
- Department of Lymphoma/Myeloma, UT MD Anderson Cancer Center, Houston, TX, USA.,Research Center of Biostatistics and Computational Pharmacy, China Pharmaceutical University, Juangsu Sheng, China
| | - Hans C Lee
- Department of Lymphoma/Myeloma, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Xuelin Huang
- Department of Biostatistics, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Kwang Woo Ahn
- Department of Medicine, Medical College of Wisconsin, CIBMTR (Center for International Blood and Marrow Transplant Research), Milwaukee, WI, USA.,Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Zhen-Huan Hu
- Department of Medicine, Medical College of Wisconsin, CIBMTR (Center for International Blood and Marrow Transplant Research), Milwaukee, WI, USA
| | - Elias Jabbour
- Department of Lymphoma/Myeloma, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Lymphoma/Myeloma, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Lymphoma/Myeloma, UT MD Anderson Cancer Center, Houston, TX, USA
| | | | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Nasheed M Hossain
- Loyola University Chicago-Stritch School of Medicine, Maywood, IL, USA
| | - David I Marks
- Adult Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, UK
| | - Rammuriti T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Yoshihiro Inamoto
- Divsion of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Tamila Kindwall-Keller
- Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, VA, USA
| | - Ayman Saad
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Mark R Litzow
- Division of Hematology and Transplant Center, Mayo Clinic Rochester, Rochester, MN, USA
| | - Bipin N Savani
- Divsion of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gregory A Hale
- Department of Hematology/Oncology, Johns Hopkins All Children's Hospital, Petersburg, FL, USA
| | - Ulrike Bacher
- Department of Hematology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Aaron T Gerds
- Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jane L Liesveld
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Celalettin Ustun
- Division of Hematology/Oncology/Cell Therapy, Rush University, Chicago, IL, USA
| | - Richard F Olsson
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Andrew Daly
- Tom Baker Cancer Center, Calgary, Alberta, Canada
| | - Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Melhem Solh
- The Blood and Marrow Transplant Group of Georgia, Northside Hospital, Atlanta, GA, USA
| | - Zachariah DeFilipp
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, MA, USA
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Baldeep Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Gorgun Akpek
- Stem Cell Transplantation and Cell Therapy, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer and Research Institute, Tampa, FL, USA
| | - Jan Cerny
- Division of Hematology/Oncology, Department of Medicine, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Sachiko Seo
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | - Jack W Hsu
- Division of Hematology & Oncology, Department of Medicine, Shands HealthCare and University of Florida, Gainesville, FL, USA
| | - Richard Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marcos de Lima
- Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Edwin Alyea
- Center of Hematologic Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Uday Popat
- Department of Lymphoma/Myeloma, UT MD Anderson Cancer Center, Houston, TX, USA
| | - Ronald Sobecks
- Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bart L Scott
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Hagop Kantarjian
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jorge Cortes
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Division of Hematology/Oncology, Department of Medicine, Georgia Cancer Center at Augusta University, Augusta, GA, USA
| | - Wael Saber
- Department of Medicine, Medical College of Wisconsin, CIBMTR (Center for International Blood and Marrow Transplant Research), Milwaukee, WI, USA
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3
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Paulson K, Brazauskas R, Khera N, He N, Majhail N, Akpek G, Aljurf M, Buchbinder D, Burns L, Beattie S, Freytes C, Garcia A, Gajewski J, Hahn T, Knight J, LeMaistre C, Lazarus H, Szwajcer D, Seftel M, Wirk B, Wood W, Saber W. Inferior Access to Allogeneic Transplant in Disadvantaged Populations: A Center for International Blood and Marrow Transplant Research Analysis. Biol Blood Marrow Transplant 2019; 25:2086-2090. [PMID: 31228584 DOI: 10.1016/j.bbmt.2019.06.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [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: 04/12/2019] [Revised: 06/06/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Abstract
Allogeneic hematopoietic cell transplantation (alloHCT) is offered in a limited number of medical centers and is associated with significant direct and indirect costs. The degree to which social and geographic barriers reduce access to alloHCT is unknown. Data from the Surveillance, Epidemiology and End Results Program (SEER) and the Center for International Blood and Marrow Transplant Research (CIBMTR) were integrated to determine the rate of unrelated donor (URD) alloHCT for acute myelogenous leukemia (AML), acute lymphoblastic leukemia (ALL), and myelodysplastic syndrome (MDS) performed between 2000 and 2010 in the 612 counties covered by SEER. The total incidence of AML, ALL, and MDS was determined using SEER, and the number of alloHCTs performed in the same time period and geographic area were determined using the CIBMTR database. We then determined which sociodemographic attributes influenced the rate of alloHCT (rural/urban status, median family size, percentage of residents below the poverty line, and percentage of minority race). In the entire cohort, higher levels of poverty were associated with lower rates of alloHCT (estimated rate ratio [ERR], .86 for a 10% increase in the percentage of the population below the poverty line; P < .01), whereas rural location was not (ERR, .87; P = .11). Thus, patients from areas with higher poverty rates diagnosed with ALL, AML, and MDS are less likely patients from wealthier counties to undergo URD alloHCT. There is need to better understand the reasons for this disparity and to encourage policy and advocacy efforts to improve access to medical care for all.
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Affiliation(s)
- Kristjan Paulson
- CancerCare Manitoba/University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Ruta Brazauskas
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nandita Khera
- Department of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona
| | - Naya He
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Navneet Majhail
- Blood & Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Gorgun Akpek
- Stem Cell Transplantation and Cell Therapy, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - David Buchbinder
- Division of Pediatrics Hematology, Children's Hospital of Orange County, Orange, California
| | - Linda Burns
- Be The Match/National Marrow Donor Program, Minneapolis, Minnesota
| | - Sara Beattie
- Department of Psychosocial Oncology and Rehabilitation, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | | | - Anne Garcia
- MedStar Georgetown University Hospital, Washington, DC
| | | | - Theresa Hahn
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Jennifer Knight
- Department of Psychiatry, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Charles LeMaistre
- Hematology and Bone Marrow Transplant, Sarah Cannon, Nashville, Tennessee
| | - Hillard Lazarus
- Seidman Cancer Center, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - David Szwajcer
- CancerCare Manitoba/University of Manitoba, Winnipeg, Manitoba, Canada
| | - Matthew Seftel
- CancerCare Manitoba/University of Manitoba, Winnipeg, Manitoba, Canada
| | - Baldeep Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, Washington
| | - William Wood
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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4
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Scott EC, Hari P, Kumar S, Fraser R, Davila O, Shah N, Gale RP, Diaz MA, Agrawal V, Cornell RF, Ganguly S, Akpek G, Freytes C, Hashmi S, Malek E, Kamble RT, Lazarus H, Solh M, Usmani SZ, Kanate AS, Saad A, Chhabra S, Gergis U, Cerny J, Kyle RA, Lee C, Kindwall-Keller T, Assal A, Hildebrandt GC, Holmberg L, Maziarz RT, Nishihori T, Seo S, Kumar S, Mark T, D'Souza A. Staging Systems for Newly Diagnosed Myeloma Patients Undergoing Autologous Hematopoietic Cell Transplantation: The Revised International Staging System Shows the Most Differentiation between Groups. Biol Blood Marrow Transplant 2018; 24:2443-2449. [PMID: 30142419 PMCID: PMC6293469 DOI: 10.1016/j.bbmt.2018.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 08/03/2018] [Accepted: 08/04/2018] [Indexed: 12/30/2022]
Abstract
The Revised International Staging System (R-ISS) and the International Myeloma Working Group 2014 (IMWG 2014) are newer staging systems used to prognosticate multiple myeloma (MM) outcomes. We hypothesized that these would provide better prognostic differentiation for newly diagnosed multiple myeloma (MM) compared with ISS. We analyzed the Center for International Blood and Marrow Transplant Research database from 2008 to 2014 to compare the 3 systems (N = 628) among newly diagnosed MM patients undergoing upfront autologous hematopoietic cell transplantation (AHCT). The median follow-up of survivors was 48 (range, 3 to 99) months. The R-ISS provided the greatest differentiation between survival curves for each stage (for overall survival [OS], the differentiation was 1.74 using the R-ISS, 1.58 using ISS, and 1.60 using the IMWG 2014) . Univariate analyses at 3 years for OS showed R-ISS I at 88% (95% confidence interval [CI], 83% to 93%), II at 75% (95% CI, 70% to 80%), and III at 56% (95% CI, 3% to 69%; P < .001). An integrated Brier score function demonstrated the R-ISS had the best prediction for PFS, though all systems had similar prediction for OS. Among available systems, the R-ISS is the most optimal among available prognostic tools for newly diagnosed MM undergoing AHCT. We recommend that serum lactate dehydrogenase and cytogenetic data be performed on every MM patient at diagnosis to allow accurate prognostication.
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Affiliation(s)
- Emma C Scott
- Center for Hematologic Malignancies, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Parameswaran Hari
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sathish Kumar
- Hematology/Oncology, Singapore General Hospital, Singapore
| | - Raphael Fraser
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Omar Davila
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nina Shah
- Department of Stem Cell Transplantation, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Miguel Angel Diaz
- Department of Hematology/Oncology, Hospital Infantil Universitario Niño Jesus, Madrid, Spain
| | - Vaibhav Agrawal
- Division of Hematology/Oncology, Indiana University Simon Cancer Center, Indianapolis, Indiana
| | - Robert F Cornell
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Siddhartha Ganguly
- Blood and Marrow Transplantation, Division of Hematology and Oncology, University of Kansas Medical Center, Kansas City, Kansas
| | - Gorgun Akpek
- Stem Cell Transplantation and Cell Therapy, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Cesar Freytes
- School of Medicine, Texas Transplant Institute, San Antonio, Texas
| | - Shahrukh Hashmi
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota; Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ehsan Malek
- Seidman Cancer Center, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Rammurti T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Hillard Lazarus
- Seidman Cancer Center, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Melhem Solh
- Blood and Marrow Transplant Group of Georgia, Northside Hospital, Atlanta, Georgia
| | - Saad Z Usmani
- Department of Hematologic Oncology & Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, North Carolina
| | - Abraham S Kanate
- Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, Morgantown, West Virginia
| | - Ayman Saad
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Saurabh Chhabra
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Usama Gergis
- Hematolgic Malignancies & Bone Marrow Transplant, Department of Medical Oncology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Jan Cerny
- Division of Hematology/Oncology, UMass Memorial Medical Center, Worcester, Massachusetts
| | - Robert A Kyle
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Cindy Lee
- Department of Haematology, Royal Adelaide Hospital, Adelaide, Australia
| | - Tamila Kindwall-Keller
- Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, Virginia
| | - Amer Assal
- Division of Hematology/Oncology, Columbia University Medical Center, New York, New York
| | - Gerhard C Hildebrandt
- Markey Cancer Center, University of Kentucky Chandler Medical Center, Lexington, Kentucky
| | - Leona Holmberg
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Richard T Maziarz
- Adult Blood and Marrow Stem Cell Transplant Program, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Sachiko Seo
- Department of Hematology & Oncology, National Cancer Research Center East, Chiba, Japan
| | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Tomer Mark
- University of Colorado Hospital, Aurora, Colorado
| | - Anita D'Souza
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
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5
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Gerds AT, Woo Ahn K, Hu ZH, Abdel-Azim H, Akpek G, Aljurf M, Ballen KK, Beitinjaneh A, Bacher U, Cahn JY, Chhabra S, Cutler C, Daly A, DeFilipp Z, Gale RP, Gergis U, Grunwald MR, Hale GA, Hamilton BK, Jagasia M, Kamble RT, Kindwall-Keller T, Nishihori T, Olsson RF, Ramanathan M, Saad AA, Solh M, Ustun C, Valcárcel D, Warlick E, Wirk BM, Kalaycio M, Alyea E, Popat U, Sobecks R, Saber W. Outcomes after Umbilical Cord Blood Transplantation for Myelodysplastic Syndromes. Biol Blood Marrow Transplant 2017; 23:971-979. [PMID: 28288952 DOI: 10.1016/j.bbmt.2017.03.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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: 12/12/2016] [Accepted: 03/08/2017] [Indexed: 11/19/2022]
Abstract
For patients with hematologic malignancies undergoing allogeneic hematopoietic cell transplantation, umbilical cord blood transplantation (UCBT) has become an acceptable alternative donor source in the absence of a matched sibling or unrelated donor. To date, however, there have been few published series dedicated solely to describing the outcomes of adult patients with myelodysplastic syndrome (MDS) who have undergone UCBT. Between 2004 and 2013, 176 adults with MDS underwent UCBT as reported to the Center for International Blood and Marrow Transplant Research. Median age at the time of transplantation was 56 years (range, 18-73 years). The study group included 10% with very low, 23% with low, 19% with intermediate, 19% with high, and 13% with very high-risk Revised International Prognostic Scoring System (IPSS-R) scores. The 100-day probability of grade II-IV acute graft-versus-host disease (GVHD) was 38%, and the 3-year probability of chronic GVHD was 28%. The probabilities of relapse and transplantation-related mortality (TRM) at 3 years were 32% and 40%, respectively, leading to a 3-year disease-free survival (DFS) of 28% and an overall survival (OS) of 31%. In multivariate analysis, increasing IPSS-R score at the time of HCT was associated with inferior TRM (P = .0056), DFS (P = .018), and OS (P = .0082), but not with GVHD or relapse. The presence of pretransplantation comorbidities was associated with TRM (P = .001), DFS (P = .02), and OS (P = .001). Reduced-intensity conditioning was associated with increased risk of relapse (relative risk, 3.95; 95% confidence interval, 1.78-8.75; P < .001), and although a higher proportion of myeloablative UCBTs were performed in patients with high-risk disease, the effect of conditioning regimen intensity was the same regardless of IPSS-R score. For some individuals who lack a matched sibling or unrelated donor, UCBT can result in long-term DFS; however, the success of UCBT in this population is hampered by a high rate of TRM.
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Affiliation(s)
- Aaron T Gerds
- Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Kwang Woo Ahn
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Zhen-Huan Hu
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hisham Abdel-Azim
- Division of Hematology, Oncology and Blood & Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Gorgun Akpek
- Stem Cell Transplantation and Cell Therapy, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Karen K Ballen
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Amer Beitinjaneh
- Division of Hematology and Oncology, University of Miami, Miami, Florida
| | - Ulrike Bacher
- Department of Hematology, Inselspital Bern, Bern, Switzerland; Interdisciplinary Clinic for Stem Cell Transplantation, University Cancer Center Hamburg, Hamburg, Germany
| | - Jean-Yves Cahn
- Department of Hematology, University Hospital, Grenoble, France
| | - Saurabh Chhabra
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Corey Cutler
- Center for Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Andrew Daly
- Tom Baker Cancer Center, Calgary, Alberta, Canada
| | - Zachariah DeFilipp
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Usama Gergis
- Hematolgic Malignancies & Bone Marrow Transplant, Department of Medical Oncology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | | | - Gregory A Hale
- Department of Hematology/Oncology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Betty Ky Hamilton
- Blood & Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Madan Jagasia
- Division of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rammurti T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Tamila Kindwall-Keller
- Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, Virginia
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Richard F Olsson
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Muthalagu Ramanathan
- Division of Hematology and Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, Massachusetts
| | - Ayman A Saad
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Melhem Solh
- The Blood and Marrow Transplant Group of Georgia, Northside Hospital, Atlanta, Georgia
| | - Celalettin Ustun
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - David Valcárcel
- Department of Hematology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Erica Warlick
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Baldeep M Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, Washington
| | - Matt Kalaycio
- Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edwin Alyea
- Center for Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Uday Popat
- M.D. Anderson Cancer Center, Houston, Texas
| | - Ronald Sobecks
- Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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6
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Cornell RF, D'Souza A, Kassim AA, Costa LJ, Innis-Shelton RD, Zhang MJ, Huang J, Abidi M, Aiello J, Akpek G, Bashey A, Bashir Q, Cerny J, Comenzo R, Diaz MA, Freytes C, Gale RP, Ganguly S, Hamadani M, Hashmi S, Holmberg L, Hossain N, Kamble RT, Kharfan-Dabaja M, Kindwall-Keller T, Kyle R, Kumar S, Lazarus H, Lee C, Maiolino A, Marks DI, Meehan K, Mikhael J, Nath R, Nishihori T, Olsson RF, Ramanathan M, Saad A, Seo S, Usmani S, Vesole D, Vij R, Vogl D, Wirk BM, Yared J, Krishnan A, Mark T, Nieto Y, Hari P. Maintenance versus Induction Therapy Choice on Outcomes after Autologous Transplantation for Multiple Myeloma. Biol Blood Marrow Transplant 2017; 23:269-277. [PMID: 27864161 PMCID: PMC5346183 DOI: 10.1016/j.bbmt.2016.11.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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: 10/13/2016] [Accepted: 11/11/2016] [Indexed: 02/07/2023]
Abstract
Bortezomib (V), lenalidomide (R), cyclophosphamide (C), and dexamethasone (D) are components of the most commonly used modern doublet (RD, VD) or triplet (VRD, CVD) initial induction regimens before autologous hematopoietic cell transplantation (AHCT) for multiple myeloma (MM) in the United States. In this study we evaluated 693 patients receiving "upfront" AHCT after initial induction therapy with modern doublet or triplet regimens using data reported to the Center for International Blood and Marrow Transplant Research from 2008 to 2013. Analysis was limited to those receiving a single AHCT after 1 line of induction therapy within 12 months from treatment initiation for MM. In multivariate analysis, progression-free survival (PFS) and overall survival were similar irrespective of induction regimen. However, high-risk cytogenetics and nonreceipt of post-transplant maintenance/consolidation therapy were associated with higher risk of relapse. Patients receiving post-transplant therapy had significantly improved 3-year PFS versus no post-transplant therapy (55% versus 39%, P = .0001). This benefit was most evident in patients not achieving at least a complete response post-AHCT (P = .005). In patients receiving upfront AHCT, the choice of induction regimen (doublet or triplet therapies) appears to be of lower impact than use of post-transplant therapy.
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Affiliation(s)
- Robert F Cornell
- Division of Hematology/Oncology Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anita D'Souza
- Center for International Blood and Marrow Transplant Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Adetola A Kassim
- Division of Hematology/Oncology Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Luciano J Costa
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Racquel D Innis-Shelton
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mei-Jie Zhang
- Center for International Blood and Marrow Transplant Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jiaxing Huang
- Center for International Blood and Marrow Transplant Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Muneer Abidi
- Division of BMT, Department of Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | | | - Gorgun Akpek
- Stem Cell Transplantation and Cell Therapy, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Asad Bashey
- Blood and Marrow Transplant Program at Northside Hospital, Atlanta, Georgia
| | - Qaiser Bashir
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jan Cerny
- Division of Hematology and Oncology, Department of Medicine, UMass Memorial Medical Center, Worchester, Massachusetts
| | | | - Miguel Angel Diaz
- Department of Hematology/Oncology, Hospital Infantil Universitario Nino Jesus, Madrid, Spain
| | - César Freytes
- South Texas Veterans Health Care System and University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - 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, Kansas
| | - Mehdi Hamadani
- Center for International Blood and Marrow Transplant Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Leona Holmberg
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Rammurti T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Mohamed Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Tamila Kindwall-Keller
- Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, Virginia
| | | | | | - Hillard Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Cindy Lee
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Angelo Maiolino
- Hospital Universitbrio Clementinio Fraga Filho, Universidade Federal do Rio de Janerio, Rio de Janerio, Brazil
| | - David I Marks
- Adult Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Kenneth Meehan
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Joe Mikhael
- Mayo Clinic Arizona and Phoenix Children's Hospital, Phoenix, Arizona
| | - Rajneesh Nath
- Division of Hematology and Oncology, Department of Medicine, UMass Memorial Medical Center, Worchester, Massachusetts
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Richard F Olsson
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinksa Institutet, Stockholm, Sweden; Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Muthalagu Ramanathan
- Division of Hematology and Oncology, Department of Medicine, UMass Memorial Medical Center, Worchester, Massachusetts
| | - Ayman Saad
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sachiko Seo
- National Cancer Research Center, East Hospital, Chiba, Japan
| | - Saad Usmani
- Department of Hematology v Medical Oncology, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - David Vesole
- John Theurer Cancer Center at Hackensack UMC, Hackensack, New Jersey
| | - Ravi Vij
- Divison of Hematology and Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Dan Vogl
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Baldeep M Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, Washington
| | - Jean Yared
- Blood & Marrow Transplantation Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland
| | | | - Tomer Mark
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Yago Nieto
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Parameswaran Hari
- Center for International Blood and Marrow Transplant Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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7
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Liu HD, Ahn KW, Hu ZH, Hamadani M, Nishihori T, Wirk B, Beitinjaneh A, Rizzieri D, Grunwald MR, Sabloff M, Olsson RF, Bajel A, Bredeson C, Daly A, Inamoto Y, Majhail N, Saad A, Gupta V, Gerds A, Malone A, Tallman M, Reshef R, Marks DI, Copelan E, Gergis U, Savoie ML, Ustun C, Litzow MR, Cahn JY, Kindwall-Keller T, Akpek G, Savani BN, Aljurf M, Rowe JM, Wiernik PH, Hsu JW, Cortes J, Kalaycio M, Maziarz R, Sobecks R, Popat U, Alyea E, Saber W. Allogeneic Hematopoietic Cell Transplantation for Adult Chronic Myelomonocytic Leukemia. Biol Blood Marrow Transplant 2017; 23:767-775. [PMID: 28115276 DOI: 10.1016/j.bbmt.2017.01.078] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [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: 06/16/2016] [Accepted: 01/12/2017] [Indexed: 10/20/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is potentially curative for patients with chronic myelomonocytic leukemia (CMML); however, few data exist regarding prognostic factors and transplantation outcomes. We performed this retrospective study to identify prognostic factors for post-transplantation outcomes. The CMML-specific prognostic scoring system (CPSS) has been validated in subjects receiving nontransplantation therapy and was included in our study. From 2001 to 2012, 209 adult subjects who received HCT for CMML were reported to the Center for International Blood and Marrow Transplant Research. The median age at transplantation was 57 years (range, 23 to 74). Median follow-up was 51 months (range, 3 to 122). On multivariate analyses, CPSS scores, Karnofsky performance status (KPS), and graft source were significant predictors of survival (P = .004, P = .01, P = .01, respectively). Higher CPSS scores were not associated with disease-free survival, relapse, or transplantation-related mortality. In a restricted analysis of subjects with relapse after HCT, those with intermediate-2/high risk had a nearly 2-fold increased risk of death after relapse compared to those with low/intermediate-1 CPSS scores. Respective 1-year, 3-year, and 5-year survival rates for low/intermediate-1 risk subjects were 61% (95% confidence interval [CI], 52% to 72%), 48% (95% CI, 37% to 59%), and 44% (95% CI, 33% to 55%), and for intermediate-2/high risk subjects were 38% (95% CI, 28% to 49%), 32% (95% CI, 21% to 42%), and 19% (95% CI, 8% to 29%). We conclude that higher CPSS score at time of transplantation, lower KPS, and a bone marrow graft are associated with inferior survival after HCT. Further investigation of CMML disease-related biology may provide insights into other risk factors predictive of post-transplantation outcomes.
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Affiliation(s)
- Hien Duong Liu
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio.
| | - Kwang Woo Ahn
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Zhen-Huan Hu
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mehdi Hamadani
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Baldeep Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, Washington
| | - Amer Beitinjaneh
- Department of Hematology and Oncology, University of Miami Sylvester Cancer Center, Miami, Florida
| | - David Rizzieri
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina
| | - Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - Mitchell Sabloff
- Division of Hematology, Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Canada
| | - Richard F Olsson
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Ashish Bajel
- Department of Haematology and Bone Marrow Transplant, Royal Melbourne Hospital, Victoria, Australia
| | - Christopher Bredeson
- The Ottawa Hospital Blood and Marrow Transplant Program and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Andrew Daly
- Department of Medicine, Tom Baker Cancer Centre, Calgary, Canada; Department of Oncology, Tom Baker Cancer Centre, Calgary, Canada
| | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Navneet Majhail
- Blood and Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Ayman Saad
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Vikas Gupta
- Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Aaron Gerds
- Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Adriana Malone
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Martin Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan, New York, New York
| | - Ran Reshef
- Blood and Marrow Transplantation Program and Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York
| | - David I Marks
- Pediatric Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Edward Copelan
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - Usama Gergis
- Hematologic Malignancies & Bone Marrow Transplant, Department of Medical Oncology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Mary Lynn Savoie
- Division of Hematology and Hematologic Malignancies, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Celalettin Ustun
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Mark R Litzow
- Division of Hematology and Transplant Center, Mayo Clinic Rochester, Rochester, Minnesota
| | - Jean-Yves Cahn
- Department of Hematology, University Hospital, Grenoble, France
| | - Tamila Kindwall-Keller
- Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, Virginia
| | - Gorgun Akpek
- Stem Cell Transplantation and Cellular Therapy Program, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center and Research, Riyadh, Saudi Arabia
| | - Jacob M Rowe
- Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Jack W Hsu
- Division of Hematology and Oncology, Department of Medicine, Shands HealthCare & University of Florida, Gainesville, Florida
| | - Jorge Cortes
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matt Kalaycio
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Richard Maziarz
- Adult Blood and Marrow Stem Cell Transplant Program, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Ronald Sobecks
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Uday Popat
- Department of Stem Cell Transplantation, MD Anderson Cancer Center, Houston, Texas
| | - Edwin Alyea
- Center for Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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8
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Artz AS, Logan B, Zhu X, Akpek G, Bufarull RM, Gupta V, Lazarus HM, Litzow M, Loren A, Majhail NS, Maziarz RT, McCarthy P, Popat U, Saber W, Spellman S, Ringden O, Wickrema A, Pasquini MC, Cooke KR. The prognostic value of serum C-reactive protein, ferritin, and albumin prior to allogeneic transplantation for acute myeloid leukemia and myelodysplastic syndromes. Haematologica 2016; 101:1426-1433. [PMID: 27662010 DOI: 10.3324/haematol.2016.145847] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 07/26/2016] [Indexed: 01/02/2023] Open
Abstract
We sought to confirm the prognostic importance of simple clinically available biomarkers of C-reactive protein, serum albumin, and ferritin prior to allogeneic hematopoietic cell transplantation. The study population consisted of 784 adults with acute myeloid leukemia in remission or myelodysplastic syndromes undergoing unrelated donor transplant reported to the Center for International Blood and Marrow Transplant Research. C-reactive protein and ferritin were centrally quantified by ELISA from cryopreserved plasma whereas each center provided pre-transplant albumin. In multivariate analysis, transplant-related mortality was associated with the pre-specified thresholds of C-reactive protein more than 10 mg/L (P=0.008) and albumin less than 3.5 g/dL (P=0.01) but not ferritin more than 2500 ng/mL. Only low albumin independently influenced overall mortality. Optimal thresholds affecting transplant-related mortality were defined as: C-reactive protein more than 3.67 mg/L, log(ferritin), and albumin less than 3.4 g/dL. A 3-level biomarker risk group based on these values separated risks of transplant-related mortality: low risk (reference), intermediate (HR=1.66, P=0.015), and high risk (HR=2.7, P<0.001). One-year survival was 74%, 67% and 56% for low-, intermediate- and high-risk groups. Routinely available pre-transplant biomarkers independently risk-stratify for transplant-related mortality and survival.
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Affiliation(s)
- Andrew S Artz
- Section of Hematology/Oncology, University of Chicago School of Medicine, IL, USA
| | - Brent Logan
- CIBMTR, (Center for International Blood and Marrow Transplant Research), Department of Medicine, Milwaukee, WI, USA.,Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Xiaochun Zhu
- CIBMTR, (Center for International Blood and Marrow Transplant Research), Department of Medicine, Milwaukee, WI, USA
| | - Gorgun Akpek
- Stem Cell Transplantation and Cellular Therapy Program, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | | | - Vikas Gupta
- Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Hillard M Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Mark Litzow
- Division of Hematology and Transplant Center, Mayo Clinic Rochester, Minneapolis, MN, USA
| | - Alison Loren
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Navneet S Majhail
- Blood & Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, OH, USA
| | - Richard T Maziarz
- Adult Blood and Marrow Stem Cell Transplant Program, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Philip McCarthy
- Blood & Marrow Transplant Program, Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Uday Popat
- MD Anderson Cancer Center, Houston, TX, USA
| | - Wael Saber
- CIBMTR, (Center for International Blood and Marrow Transplant Research), Department of Medicine, Milwaukee, WI, USA
| | - Stephen Spellman
- CIBMTR (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, MN, USA
| | - Olle Ringden
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden.,Centre for Allogeneic Stem Cell Transplantation, Stockholm, Sweden
| | - Amittha Wickrema
- Section of Hematology/Oncology, University of Chicago School of Medicine, IL, USA
| | - Marcelo C Pasquini
- CIBMTR, (Center for International Blood and Marrow Transplant Research), Department of Medicine, Milwaukee, WI, USA
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9
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Martin PJ, Lee SJ, Przepiorka D, Horowitz MM, Koreth J, Vogelsang GB, Walker I, Carpenter PA, Griffith LM, Akpek G, Mohty M, Wolff D, Pavletic SZ, Cutler CS. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: VI. The 2014 Clinical Trial Design Working Group Report. Biol Blood Marrow Transplant 2015; 21:1343-59. [PMID: 25985921 DOI: 10.1016/j.bbmt.2015.05.004] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [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: 05/04/2015] [Accepted: 05/05/2015] [Indexed: 10/23/2022]
Abstract
Treatment of chronic graft-versus-host disease is intended to produce a sustainable benefit by reducing symptom burden, controlling objective manifestations of disease activity, preventing damage and impairment, and improving overall survival without causing disproportionate harms related to the treatment itself. Successful management can control the disease until systemic treatment is no longer needed. The complexity of the disease, the extended duration of follow-up needed to observe disease resolution and withdrawal of immunosuppressive treatment, and the lack of fully developed shorter term endpoints impede progress in the field. Identification and characterization of primary endpoints demonstrating clinical benefit without requiring years of follow-up is urgently needed, with the understanding that clinical benefit encompasses not only the self-evident benefit of the primary endpoint but also any other associated benefits. This report discusses regulatory considerations, eligibility criteria, the value of controlled trial designs, the merits of proposed primary endpoints, and key considerations elaborated from experience and progress during the past decade. The report concludes by mapping an overall approach that could support and lead to maximally informative clinical trials, especially those that seek to demonstrate clinical benefit along a pathway to regulatory review and approval.
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Affiliation(s)
- Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Donna Przepiorka
- Center for Drug Evaluation Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Mary M Horowitz
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John Koreth
- Division of Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Georgia B Vogelsang
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Irwin Walker
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Linda M Griffith
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Gorgun Akpek
- Stem Cell Transplant Program, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Mohamad Mohty
- Clinical Hematology and Cellular Therapy Department, Hôpital Saint-Antoine, University Pierre & Marie Curie, INSERM U938, Paris, France
| | - Daniel Wolff
- Department of Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Steven Z Pavletic
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Corey S Cutler
- Division of Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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10
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Inamoto Y, Shah NN, Savani BN, Shaw BE, Abraham AA, Ahmed IA, Akpek G, Atsuta Y, Baker KS, Basak GW, Bitan M, DeFilipp Z, Gregory TK, Greinix HT, Hamadani M, Hamilton BK, Hayashi RJ, Jacobsohn DA, Kamble RT, Kasow KA, Khera N, Lazarus HM, Malone AK, Lupo-Stanghellini MT, Margossian SP, Muffly LS, Norkin M, Ramanathan M, Salooja N, Schoemans H, Wingard JR, Wirk B, Wood WA, Yong A, Duncan CN, Flowers MED, Majhail NS. Secondary solid cancer screening following hematopoietic cell transplantation. Bone Marrow Transplant 2015; 50:1013-23. [PMID: 25822223 DOI: 10.1038/bmt.2015.63] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 12/30/2014] [Accepted: 12/31/2014] [Indexed: 11/10/2022]
Abstract
Hematopoietic stem cell transplant (HCT) recipients have a substantial risk of developing secondary solid cancers, particularly beyond 5 years after HCT and without reaching a plateau overtime. A working group was established through the Center for International Blood and Marrow Transplant Research and the European Group for Blood and Marrow Transplantation with the goal to facilitate implementation of cancer screening appropriate to HCT recipients. The working group reviewed guidelines and methods for cancer screening applicable to the general population and reviewed the incidence and risk factors for secondary cancers after HCT. A consensus approach was used to establish recommendations for individual secondary cancers. The most common sites include oral cavity, skin, breast and thyroid. Risks of cancers are increased after HCT compared with the general population in skin, thyroid, oral cavity, esophagus, liver, nervous system, bone and connective tissues. Myeloablative TBI, young age at HCT, chronic GVHD and prolonged immunosuppressive treatment beyond 24 months were well-documented risk factors for many types of secondary cancers. All HCT recipients should be advised of the risks of secondary cancers annually and encouraged to undergo recommended screening based on their predisposition. Here we propose guidelines to help clinicians in providing screening and preventive care for secondary cancers among HCT recipients.
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Affiliation(s)
- Y Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - N N Shah
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), National Institute of Health (NIH), Bethesda, MD, USA
| | - B N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - B E Shaw
- Center for International Blood and Marrow Transplant Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - A A Abraham
- Division of Blood and Marrow Transplantation, Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC, USA
| | - I A Ahmed
- Department of Hematology Oncology and Bone Marrow Transplantation, The Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - G Akpek
- Section of Hematology Oncology, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - Y Atsuta
- 1] Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan [2] Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - K S Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - G W Basak
- Department of Hematology, Oncology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - M Bitan
- Department of Pediatric Hematology/Oncology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Z DeFilipp
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - T K Gregory
- Colorado Blood Cancer Institute at Presbyterian/St Luke's Medical Center, Denver, CO, USA
| | - H T Greinix
- Bone Marrow Transplantation Unit, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - M Hamadani
- Center for International Blood and Marrow Transplant Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - B K Hamilton
- Blood and Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - R J Hayashi
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - D A Jacobsohn
- Division of Blood and Marrow Transplantation, Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC, USA
| | - R T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, USA
| | - K A Kasow
- Division of Hematology-Oncology, Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
| | - N Khera
- Department of Hematology/Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - H M Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - A K Malone
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - M T Lupo-Stanghellini
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - S P Margossian
- Department of Pediatric Oncology, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, MA, USA
| | - L S Muffly
- Division of Blood and Marrow Transplantation, Stanford University, Stanford, CA, USA
| | - M Norkin
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - M Ramanathan
- Division of Hematology and Oncology, Department of Medicine, UMass Memorial Medical Center, Worchester, MA, USA
| | | | - H Schoemans
- University Hospital of Leuven, Leuven, Belgium
| | - J R Wingard
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - B Wirk
- Department of Internal Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - W A Wood
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina, Chapel Hill, Chapel Hill, NC, USA
| | - A Yong
- Royal Adelaide Hospital/SA Pathology and School of Medicine, University of Adelaide, Adelaide, Australia
| | - C N Duncan
- Department of Pediatric Oncology, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, MA, USA
| | - M E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - N S Majhail
- Blood and Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
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11
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Olsson RF, Logan BR, Chaudhury S, Zhu X, Akpek G, Bolwell BJ, Bredeson CN, Dvorak CC, Gupta V, Ho VT, Lazarus HM, Marks DI, Ringdén OTH, Pasquini MC, Schriber JR, Cooke KR. Primary graft failure after myeloablative allogeneic hematopoietic cell transplantation for hematologic malignancies. Leukemia 2015; 29:1754-62. [PMID: 25772027 PMCID: PMC4527886 DOI: 10.1038/leu.2015.75] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [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: 10/20/2014] [Revised: 02/09/2015] [Accepted: 03/09/2015] [Indexed: 11/18/2022]
Abstract
Clinical outcomes after primary graft failure (PGF) remain poor. Here we present a large retrospective analysis (n=23,272) which investigates means to prevent PGF and early detection of patients at high risk. In patients with hematologic malignancies, who underwent their first myeloablative allogeneic hematopoietic cell transplantation, PGF was reported in 1,278 (5.5%), and there was a marked difference in PGFs using peripheral blood stem cell compared to bone marrow grafts (2.5 vs. 7.3%; P<0.001). A 4-fold increase of PGF was observed in myeloproliferative disorders compared to acute leukemia (P<0.001). Other risk factors for PGF included recipient age below 30, HLA-mismatch, male recipients of female donor grafts, ABO-incompatibility, busulfan/cyclophosphamide conditioning, and cryopreservation. In bone marrow transplants, total nucleated cell doses ≤2.4 × 108/kg were associated with PGF (OR 1.39; P<0.001). The use of tacrolimus-based immunosuppression and granulocyte colony-stimulating factor were associated with decreased PGF risk. These data, allow clinicians to do more informed choices with respect to graft source, donor selection, conditioning and immunosuppressive regimens to reduce the risk of PGF. Moreover, a novel risk score determined on day 21 post-transplant may provide the rationale for an early request for additional hematopoietic stem cells.
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Affiliation(s)
- R F Olsson
- 1] Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden [2] Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
| | - B R Logan
- 1] CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA [2] Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA
| | - S Chaudhury
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - X Zhu
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - G Akpek
- Section of Hematology/Oncology, Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - B J Bolwell
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - C N Bredeson
- The Ottawa Hospital Blood and Marrow Transplant Program and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - C C Dvorak
- Department of Pediatrics, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - V Gupta
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - V T Ho
- Center for Hematologic Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - H M Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - D I Marks
- Pediatric Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, UK
| | - O T H Ringdén
- 1] Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden [2] Centre for Allogeneic Stem Cell Transplantation, Stockholm, Sweden
| | - M C Pasquini
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J R Schriber
- 1] Cancer Transplant Institute, Virginia G Piper Cancer Center, Scottsdale, AZ, USA [2] Arizona Oncology, Scottsdale, AZ, USA
| | - K R Cooke
- Pediatric Blood and Marrow Transplantation Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
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12
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Bachanova V, Burns LJ, Wang T, Carreras J, Gale RP, Wiernik PH, Ballen KK, Wirk B, Munker R, Rizzieri DA, Chen YB, Gibson J, Akpek G, Costa LJ, Kamble RT, Aljurf MD, Hsu JW, Cairo MS, Schouten HC, Bacher U, Savani BN, Wingard JR, Lazarus HM, Laport GG, Montoto S, Maloney DG, Smith SM, Brunstein C, Saber W. Alternative donors extend transplantation for patients with lymphoma who lack an HLA matched donor. Bone Marrow Transplant 2014; 50:197-203. [PMID: 25402415 PMCID: PMC4336786 DOI: 10.1038/bmt.2014.259] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [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: 07/15/2014] [Revised: 10/01/2014] [Accepted: 10/02/2014] [Indexed: 01/26/2023]
Abstract
Alternative donor transplantation is increasingly used for high risk lymphoma patients. We analyzed 1593 transplant recipients (2000 to 2010) and compared transplant outcomes in recipients of 8/8 allele human leukocyte antigen (HLA)-A, -B, -C, and DRB1 matched unrelated donors (MUD; n=1176), 7/8 allele HLA-matched unrelated donors (MMUD; n=275) and umbilical cord blood donors (1 or 2 units UCB; n=142). Adjusted 3-year non-relapse mortality of MMUD (44%) was higher as compared to MUD (35%; p=0.004), but similar to UCB recipients (37%; p=0.19), although UCB had lower rates of neutrophil and platelet recovery compared to unrelated donor groups. With a median follow-up of 55 months, 3-year adjusted cumulative incidence of relapse was lower after MMUD compared with MUD (25% vs 33%, p=0.003) but similar between UCB and MUD (30% vs 33%; p=0.48). In multivariate analysis UCB recipients had lower risks of acute and chronic graft versus host disease compared with adult donor groups (UCB vs MUD: HR=0.68, p=0.05; HR=0.35; p<0.001). Adjusted 3-year overall survival was comparable (43% MUD, 37% MMUD and 41% UCB). Data highlight that patients with lymphoma have acceptable survival after alternative donor transplantation. MMUD and UCB can expand the curative potential of allotransplant to patients who lack suitable HLA-matched sibling or MUD.
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Affiliation(s)
- V Bachanova
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - L J Burns
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - T Wang
- 1] Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA [2] Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Carreras
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - R P Gale
- Division of Experimental Medicine, Department of Medicine, Hematology Research Center, Imperial College London, London, UK
| | - P H Wiernik
- Our Lady of Mercy Medical Center, Bronx, NY, USA
| | - K K Ballen
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - B Wirk
- BMT Program, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - R Munker
- Department of Hematology/Oncology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - D A Rizzieri
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, NC, USA
| | - Y-B Chen
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - J Gibson
- Department of Hematology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - G Akpek
- Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - L J Costa
- Medical University of South Carolina, Charleston, SC, USA
| | - R T Kamble
- Department of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - M D Aljurf
- Department of Oncology, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
| | - J W Hsu
- Shands HealthCare & University of Florida, Gainesville, FL, USA
| | - M S Cairo
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - H C Schouten
- Academische Ziekenhuis Maastricht, Maastricht, Netherlands
| | - U Bacher
- 1] Department of Stem Cell Transplantation, University of Hamburg, Hamburg, Germany [2] MLL Munich Leukemia Laboratory, Munich, Germany
| | - B N Savani
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - J R Wingard
- 1] Shands HealthCare & University of Florida, Gainesville, FL, USA [2] LifeSouth Community Blood Centers, Gainesville, FL, USA
| | - H M Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - G G Laport
- Division of BMT, Stanford Hospitals & Clinics, Stanford, CA, USA
| | - S Montoto
- Department of Haemato-oncology, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - D G Maloney
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - S M Smith
- Section of Hematology/Oncology, The University of Chicago, Chicago, IL, USA
| | - C Brunstein
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - W Saber
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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13
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Hsu JW, Wingard JR, Logan BR, Chitphakdithai P, Akpek G, Anderlini P, Artz AS, Bredeson C, Goldstein S, Hale G, Hematti P, Joshi S, Kamble RT, Lazarus HM, O'Donnell PV, Pulsipher MA, Savani BN, Schears RM, Shaw BE, Confer DL. Race and ethnicity influences collection of granulocyte colony-stimulating factor-mobilized peripheral blood progenitor cells from unrelated donors, a Center for International Blood and Marrow Transplant Research analysis. Biol Blood Marrow Transplant 2014; 21:165-71. [PMID: 25316111 DOI: 10.1016/j.bbmt.2014.10.007] [Citation(s) in RCA: 22] [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] [Received: 08/27/2014] [Accepted: 10/07/2014] [Indexed: 11/27/2022]
Abstract
Little information exists on the effect of race and ethnicity on collection of peripheral blood stem cells (PBSC) for allogeneic transplantation. We studied 10,776 donors from the National Marrow Donor Program who underwent PBSC collection from 2006 to 2012. Self-reported donor race/ethnic information included Caucasian, Hispanic, Black/African American (AA), Asian/Pacific Islander (API), and Native American (NA). All donors were mobilized with subcutaneous filgrastim at an approximate dose of 10 μg/kg/day for 5 days. Overall, AA donors had the highest median yields of mononuclear cells per liter and CD34(+) cells per liter of blood processed (3.1 × 10(9) and 44 × 10(6), respectively), whereas Caucasians had the lowest median yields at 2.8 × 10(9) and 33.7 × 10(6), respectively. Multivariate analysis of CD34(+) per liter mobilization yields using Caucasians as the comparator and controlling for age, gender, body mass index, and year of apheresis revealed increased yields in overweight and obese AA and API donors. In Hispanic donors, only male obese donors had higher CD34(+) per liter mobilization yields compared with Caucasian donors. No differences in CD34(+) per liter yields were seen between Caucasian and NA donors. Characterization of these differences may allow optimization of mobilization regimens to allow enhancement of mobilization yields without compromising donor safety.
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Affiliation(s)
- Jack W Hsu
- University of Florida Shands Cancer Center, Gainesville, Florida.
| | - John R Wingard
- University of Florida Shands Cancer Center, Gainesville, Florida
| | - Brent R Logan
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pintip Chitphakdithai
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | - Gorgun Akpek
- Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Paolo Anderlini
- University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | | | - Chris Bredeson
- Ottawa Hospital Blood and Marrow Transplant Program, Ottawa, Ontario, Canada
| | | | - Gregory Hale
- All Children's Hospital, St. Petersburg, Florida
| | - Peiman Hematti
- University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | | | - Rammurti T Kamble
- Baylor College of Medicine Center for Cell and Gene Therapy, Houston, Texas
| | - Hillard M Lazarus
- University Hospitals Case Medical Center, Seidman Cancer Center, Cleveland, Ohio
| | | | - Michael A Pulsipher
- University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah
| | - Bipin N Savani
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Bronwen E Shaw
- Anthony Nolan Research Institute, London, United Kingdom
| | - Dennis L Confer
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota; National Marrow Donor Program, Minneapolis, Minnesota
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14
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Rapoport AP, Aqui NA, Stadtmauer EA, Vogl DT, Xu YY, Kalos M, Cai L, Fang HB, Weiss BM, Badros A, Yanovich S, Akpek G, Tsao P, Cross A, Mann D, Philip S, Kerr N, Brennan A, Zheng Z, Ruehle K, Milliron T, Strome SE, Salazar AM, Levine BL, June CH. Combination immunotherapy after ASCT for multiple myeloma using MAGE-A3/Poly-ICLC immunizations followed by adoptive transfer of vaccine-primed and costimulated autologous T cells. Clin Cancer Res 2014; 20:1355-65. [PMID: 24520093 DOI: 10.1158/1078-0432.ccr-13-2817] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE Myeloma-directed cellular immune responses after autologous stem cell transplantation (ASCT) may reduce relapse rates. We studied whether coinjecting the TLR-3 agonist and vaccine adjuvant Poly-ICLC with a MAGE-A3 peptide vaccine was safe and would elicit a high frequency of vaccine-directed immune responses when combined with vaccine-primed and costimulated autologous T cells. EXPERIMENTAL DESIGN In a phase II clinical trial (NCT01245673), we evaluated the safety and activity of ex vivo expanded autologous T cells primed in vivo using a MAGE-A3 multipeptide vaccine (compound GL-0817) combined with Poly-ICLC (Hiltonol), granulocyte macrophage colony-stimulating factor (GM-CSF) ± montanide. Twenty-seven patients with active and/or high-risk myeloma received autografts followed by anti-CD3/anti-CD28-costimulated autologous T cells, accompanied by MAGE-A3 peptide immunizations before T-cell collection and five times after ASCT. Immune responses to the vaccine were evaluated by cytokine production (all patients), dextramer binding to CD8(+) T cells, and ELISA performed serially after transplant. RESULTS T-cell infusions were well tolerated, whereas vaccine injection site reactions occurred in >90% of patients. Two of nine patients who received montanide developed sterile abscesses; however, this did not occur in the 18 patients who did not receive montanide. Dextramer staining demonstrated MAGE-A3-specific CD8 T cells in 7 of 8 evaluable HLA-A2(+) patients (88%), whereas vaccine-specific cytokine-producing T cells were generated in 19 of 25 patients (76%). Antibody responses developed in 7 of 9 patients (78%) who received montanide and only weakly in 2 of 18 patients (11%) who did not. The 2-year overall survival was 74% [95% confidence interval (CI), 54%-100%] and 2-year event-free survival was 56% (95% CI, 37%-85%). CONCLUSIONS A high frequency of vaccine-specific T-cell responses were generated after transplant by combining costimulated autologous T cells with a Poly-ICLC/GM-CSF-primed MAGE-A3 vaccine.
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Affiliation(s)
- Aaron P Rapoport
- Authors' Affiliations: University of Maryland Marlene and Stewart Greenebaum Cancer Center; Center for Vaccine Development and Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, Maryland; Oncovir Inc., Washington, District of Columbia; Department of Pathology, University of Pennsylvania; and Abramson Cancer Center of the University of Pennsylvania, Philadelphia, Pennsylvania
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15
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Warlick ED, Paulson K, Brazauskas R, Zhong X, Miller AM, Camitta BM, George B, Savani BN, Ustun C, Marks DI, Waller EK, Baron F, Freytes CO, Socie G, Akpek G, Schouten HC, Lazarus HM, Horwitz EM, Koreth J, Cahn JY, Bornhauser M, Seftel M, Cairo MS, Laughlin MJ, Sabloff M, Ringdén O, Gale RP, Kamble RT, Vij R, Gergis U, Mathews V, Saber W, Chen YB, Liesveld JL, Cutler CS, Ghobadi A, Uy GL, Eapen M, Weisdorf DJ, Litzow MR. Effect of postremission therapy before reduced-intensity conditioning allogeneic transplantation for acute myeloid leukemia in first complete remission. Biol Blood Marrow Transplant 2014; 20:202-8. [PMID: 24184335 PMCID: PMC3924751 DOI: 10.1016/j.bbmt.2013.10.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [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: 08/19/2013] [Accepted: 10/28/2013] [Indexed: 11/23/2022]
Abstract
The impact of pretransplant (hematopoietic cell transplantation [HCT]) cytarabine consolidation therapy on post-HCT outcomes has yet to be evaluated after reduced-intensity or nonmyeloablative conditioning. We analyzed 604 adults with acute myeloid leukemia in first complete remission (CR1) reported to the Center for International Blood and Marrow Transplant Research who received a reduced-intensity or nonmyeloablative conditioning HCT from an HLA-identical sibling, HLA-matched unrelated donor, or umbilical cord blood donor from 2000 to 2010. We compared transplant outcomes based on exposure to cytarabine postremission consolidation. Three-year survival rates were 36% (95% confidence interval [CI], 29% to 43%) in the no consolidation arm and 42% (95% CI, 37% to 47%) in the cytarabine consolidation arm (P = .16). Disease-free survival was 34% (95% CI, 27% to 41%) and 41% (95% CI, 35% to 46%; P = .15), respectively. Three-year cumulative incidences of relapse were 37% (95% CI, 30% to 44%) and 38% (95% CI, 33% to 43%), respectively (P = .80). Multivariate regression confirmed no effect of consolidation on relapse, disease-free survival, and survival. Before reduced-intensity or nonmyeloablative conditioning HCT, these data suggest pre-HCT consolidation cytarabine does not significantly alter outcomes and support prompt transition to transplant as soon as morphologic CR1 is attained. If HCT is delayed while identifying a donor, our data suggest that consolidation does not increase transplant treatment-related mortality and is reasonable if required.
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Affiliation(s)
- Erica D Warlick
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
| | - Kristjan Paulson
- Department of Hematology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ruta Brazauskas
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Xiaobo Zhong
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Alan M Miller
- Department of Oncology, Baylor University Medical Center, Dallas, Texas
| | - Bruce M Camitta
- Department of Pediatrics, Midwest Center for Cancer and Blood Disorders, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Biju George
- Department of Hematology, Christian Medical College Hospital, Vellore, India
| | - Bipin N Savani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Celalettin Ustun
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - David I Marks
- Bristol Adult BMT Unit, Bristol Children's Hospital, Bristol, United Kingdom
| | - Edmund K Waller
- Bone Marrow and Stem Cell Transplant Center, Emory University Hospital, Atlanta, Georgia
| | - Frédéric Baron
- Universitaire de Liege, Centre Hospitalier Universitaire - Sart-Tilman, Liege, Belgium
| | - César O Freytes
- Department of Hematopoietic Stem Cell Transplant Program, South Texas Veterans Health Care System and University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Gérard Socie
- Service d'Hematologie, Hopital Saint Louis, Paris, France
| | - Gorgun Akpek
- SCTCT Program, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Harry C Schouten
- Division of Hematology, Academische Ziekenhuis Maastricht, Maastricht, Netherlands
| | - Hillard M Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Edwin M Horwitz
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John Koreth
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Jean-Yves Cahn
- Department of Hematology, University Hospital, Grenoble, France
| | - Martin Bornhauser
- Medizinische Klinik und Poliklinik I, Universitatsklinikum Carl Gustav Carus, Dresden, Germany
| | - Matthew Seftel
- Department of Hematology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mitchell S Cairo
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, Maria Fareri Children's Hospital, New York Medical College, Valhalla, New York
| | - Mary J Laughlin
- Hematopoietic Cell Transplantation Program, University of Virginia, Charlottesville, Virginia
| | - Mitchell Sabloff
- Division of Hematology, Department of Medicine, University of Ottawa and The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Olle Ringdén
- Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Robert Peter Gale
- Section of Hematology, Division of Experimental Medicine, Department of Medicine, Imperial College, London, United Kingdom
| | - Rammurti T Kamble
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Ravi Vij
- Washington University School of Medicine, St. Louis, Missouri
| | - Usama Gergis
- Weill Cornell Medical College, New York, New York
| | - Vikram Mathews
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Yi-Bin Chen
- Department of BMT, Massachusetts General Hospital, Boston, Massachusetts
| | - Jane L Liesveld
- Department of Hematology/Oncology, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Corey S Cutler
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Armin Ghobadi
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Geoffrey L Uy
- Section of Hematology, Division of Experimental Medicine, Department of Medicine, Imperial College, London, United Kingdom
| | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Daniel J Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Mark R Litzow
- Department of Hematology and Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
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Rapoport AP, Stadtmauer EA, Vogl DT, Weiss B, Binder-Scholl GK, Smethurst DP, Finklestein J, Kulikovskaya I, Gupta M, Brewer JE, Bennett AD, Gerry AB, Pumphrey NJ, Tayton-Martin HK, Ribeiro L, Badros AZ, Yanovich S, Akpek G, Kerr N, Philip S, Westphal S, Bruce LL, Jakobsen BK, June CH, Kalos M. Adoptive immunotherapy with engineered T cells expressing and HLA-A2 restricted affinity-enhanced TCR for LAGE-1 and NY-ESO-1 in patients with multiple myeloma following auto-SCT. J Immunother Cancer 2013. [PMCID: PMC3990335 DOI: 10.1186/2051-1426-1-s1-p30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Akpek G, Pasquini MC, Logan B, Agovi MA, Lazarus HM, Marks DI, Bornhaeüser M, Ringdén O, Maziarz RT, Gupta V, Popat U, Maharaj D, Bolwell BJ, Rizzo JD, Ballen KK, Cooke KR, McCarthy PL, Ho VT. Effects of spleen status on early outcomes after hematopoietic cell transplantation. Bone Marrow Transplant 2013; 48:825-31. [PMID: 23222382 PMCID: PMC3606905 DOI: 10.1038/bmt.2012.249] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 08/30/2012] [Accepted: 11/02/2012] [Indexed: 01/14/2023]
Abstract
To assess the impact of spleen status on engraftment, and early morbidity and mortality after allogeneic hematopoietic cell transplantation (HCT), we analyzed 9,683 myeloablative allograft recipients from 1990 to 2006; 472 had prior splenectomy (SP), 300 splenic irradiation (SI), 1,471 with splenomegaly (SM), and 7,440 with normal spleen (NS). Median times to neutrophil engraftment (NE) and platelet engraftment (PE) were 15 vs 18 days and 22 vs 24 days for the SP and NS groups, respectively (P<0.001). Hematopoietic recovery at day +100 was not different across all groups, however the odds ratio of days +14 and +21 NE and day +28 PE were 3.26, 2.25 and 1.28 for SP, and 0.56, 0.55, and 0.82 for SM groups compared to NS (P<0.001), respectively. Among patients with SM, use of peripheral blood grafts improved NE at day +21, and CD34+ cell dose >5.7 × 10(6)/kg improved PE at day+28. After adjusting variables by Cox regression, the incidence of GVHD and OS were not different among groups. SM is associated with delayed engraftment, whereas SP prior to HCT facilitates early engraftment without having an impact on survival.
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Affiliation(s)
- G Akpek
- Marlene and Stewart Greenbaum Cancer Center, University of Maryland, Baltimore, MD, USA.
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Rapoport AP, Stadtmauer EA, Vogl DT, Weiss B, Binder-Scholl GK, Smethurst DP, Finkelstein J, Kulikovskaya I, Gupta M, Suppa E, Mikheeva T, Brewer JE, Bennett AD, Gerry AB, Pumphrey NJ, Tayton-Martin HK, Ribeiro L, Veloso E, Zheng Z, Bados AZ, Yanovich S, Akpek G, Dengel K, Kerr N, Philip S, Betts KM, Westphal S, Levine BL, Jakobsen BK, June CH, Kalos M. Abstract 4575: Correlates of clinical response following autologous stem cell transplant and adoptive immunotherapy with engineered T cells expressing an affinity-enhanced T cell receptor in patients with mutliple myeloma. Cancer Res 2013. [DOI: 10.1158/1538-7445.am2013-4575] [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] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Adoptive immunotherapy for cancer has been limited by lack of antigen specificity, low levels of target expression, and failure to break self-tolerance. We are conducting an early phase clinical trial (NCT01352286) attempting to overcome these barriers using T cells engineered with an HLA-A0201 restricted, affinity-enhanced TCR that recognizes an epitope expressed by the NY-ESO-1 and LAGE-1 cancer testis antigens; these cells are infused in the setting of profound lymphodepletion that accompanies high-dose chemotherapy with autologous stem cell transplant (aSCT) for patients with high risk or relapsed multiple myeloma (MM).
Methods: Inclusion criteria include: 1) eligibility for aSCT, 2) PS of 0-2, 3) high risk MM or relapse after prior therapy, 4) HLA-A0201 positive, and 5) NY-ESO-1 and/or LAGE-1 positive tumor by PCR. CD25 depleted T cells are activated and expanded using anti-CD3/28 antibody conjugated microbeads, and genetically modified with a lentiviral vector. T cells are administered four days after high dose melphalan and two days following auto-SCT. Patients are evaluated for MM responses in accordance with the IMWG criteria at 6 weeks, and 3 and 6 months. At 3 months, patients with adequate marrow function start lenalidomide maintenance. Blood and marrow are monitored for persistence of engineered cells by qPCR and by surface expression of the NY-ESO-1 / LAGE-1 TCR using dextramerTM reagents. NY-ESO-1 and LAGE-1 antigen expression in marrow was assessed by qRT-PCR at baseline and post infusion.
Results: As of November 2012, 21 patients have been enrolled, 15 have been infused; 4 were taken off study prior to infusion due to disease progression. An average of 2.7 x 109 engineered T cells were administered per patient (range 8.3 x 108-4.2 x 109), and the average transduction efficiency was 33% (range 30%-45%). More than 50% (8/15) of patients have high risk chromosomal abnormalities, and 3 (20%) have received prior aSCT. At 3 months post aSCT, 73% of patients were in a very good partial response (VGPR) or better. Gastrointestinal toxicity resulting from autologous GVHD (aGVHD) occurred in a subset of patients at a higher rate than reported following aSCT alone or aSCT and T cell infusion, and was resolved in all cases. Infused T cells typically showed peak expansion in blood at day 14, followed by durable persistence in blood and marrow at 6-12 months in all but one patient. Disease progression is typically accompanied by very low levels or loss of engineered T cell persistence or loss of target antigen on tumor.
Conclusions:
We report for the first time that possible correlates of clinical response in this study include persistence of engineered T cells and loss of antigen, suggesting specific activity of the infused cells. Infusions are well tolerated with a possible risk of manageable aGVHD.
Citation Format: Aaron P. Rapoport, Edward A. Stadtmauer, Dan T. Vogl, Brendan Weiss, Gwendolyn K. Binder-Scholl, Dominic P. Smethurst, Jeffrey Finkelstein, Irina Kulikovskaya, Minnal Gupta, Erica Suppa, Tatiana Mikheeva, Joanna E. Brewer, Alan D. Bennett, Andrew B. Gerry, Nick J. Pumphrey, Helen K. Tayton-Martin, Lilliam Ribeiro, Elizabeth Veloso, Zhaohui Zheng, Ashraf Z. Bados, Saul Yanovich, Gorgun Akpek, Karen Dengel, Naseem Kerr, Sunita Philip, Kelly-Marie Betts, Sandra Westphal, Bruce L. Levine, Bent K. Jakobsen, Carl H. June, Michael Kalos. Correlates of clinical response following autologous stem cell transplant and adoptive immunotherapy with engineered T cells expressing an affinity-enhanced T cell receptor in patients with mutliple myeloma. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4575. doi:10.1158/1538-7445.AM2013-4575
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Affiliation(s)
- Aaron P. Rapoport
- 1The Greenebaum Cancer Center, University of Maryland, Baltimore, MD
| | - Edward A. Stadtmauer
- 2Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Dan T. Vogl
- 2Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Brendan Weiss
- 2Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Jeffrey Finkelstein
- 2Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Irina Kulikovskaya
- 2Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Minnal Gupta
- 2Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Erica Suppa
- 2Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tatiana Mikheeva
- 2Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | | | | | - Elizabeth Veloso
- 2Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Zhaohui Zheng
- 5Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ashraf Z. Bados
- 1The Greenebaum Cancer Center, University of Maryland, Baltimore, MD
| | - Saul Yanovich
- 1The Greenebaum Cancer Center, University of Maryland, Baltimore, MD
| | - Gorgun Akpek
- 1The Greenebaum Cancer Center, University of Maryland, Baltimore, MD
| | - Karen Dengel
- 2Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Naseem Kerr
- 2Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sunita Philip
- 1The Greenebaum Cancer Center, University of Maryland, Baltimore, MD
| | - Kelly-Marie Betts
- 1The Greenebaum Cancer Center, University of Maryland, Baltimore, MD
| | - Sandra Westphal
- 1The Greenebaum Cancer Center, University of Maryland, Baltimore, MD
| | - Bruce L. Levine
- 5Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Carl H. June
- 2Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael Kalos
- 2Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Levine B, Rapoport A, Stadtmauer E, Vogl D, Weiss B, Binder-Scholl G, Smethurst D, Brewer J, Bennett A, Gerry A, Pumphrey N, Tayton-Martin H, Ribiero L, Veloso E, Finklestein J, Kulikovskaya I, Gupta M, Suppa E, Mikheeva T, Zheng Z, Brennan A, Bersenev A, Tripic T, Cribioli E, Cotte J, Badros A, Yanovich S, Akpek G, McConville H, Kerr N, Philip S, Betts K, Westphal S, Kalos M, Jacobsen B, June C. Adoptive transfer of gene-modified T-cells engineered to express high-affinity tcr's for cancer-testis antigens NY-ESO-1 or lage-1, in multiple myeloma (MM) patients post autologous hematopoietic stem cell transplant (ASCT). Cytotherapy 2013. [DOI: 10.1016/j.jcyt.2013.01.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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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20
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Bhatnagar B, Goloubeva OG, Gilmore S, Hoffman A, Ruehle K, Akpek G, Rapoport A, Yanovich S, Badros AZ. Risk factors for oral mucositis (OM) in multiple myeloma (MM) patients receiving high-dose melphalan (Mel) prior to autologous stem cell transplantation (SCT). J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.e19565] [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] [Indexed: 11/20/2022] Open
Abstract
e19565 Background: OM is a common complication of high-dose melphalan in MM patients (pts). Proposed risk factors for OM in SCT include: low albumin and high serum creatinine (Cr) levels, both were evaluated in MM patients undergoing Mel/ASCT. (Grazziutti, ML, Bone Marrow Transplant 2006). Methods: This is a single center retrospective chart review of 214 sequentially treated MM pts who received Mel 200mg/m2 conditioning prior to SCT between January 2005-September 2011. Data collected included: demographics, Hgb, Cr, C-reactive protein and albumin on the day of SCT, length of hospital stay. OM assessment was graded as follows: Grade 1, no OM; Grade 2, mild OM; the pts maintained adequate oral intake; Grade 3, decreased oral intake and/or use of oral narcotics; Grade 4, severe OM needing intravenous narcotics. Results: The table below describes pt characteristics grouped by OM grade. Overall, 56 pts (27%) had grade 3/4 OM. Multivariate analysis of variance revealed no statistically significant correlation between OM grade and Hgb, Cr, albumin, CRP; the overall test’s p value = 0.55. There were no racial or gender differences with regard to grade of mucositis, the p-values range are 0.75 and 0.31, respectively (likelihood ratio chi-square test). Most interestingly, OM did not impact length of hospital stay. Conclusions: We did not establish any predictive risk factors for OM as previously described. Analysis of the impact of OM on MM response and event and overall survival will be presented. Studies of Mel pharmacogenetics may provide insight to patients' predisposition to OM. [Table: see text]
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Affiliation(s)
- Bhavana Bhatnagar
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD
| | - Olga G. Goloubeva
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD
| | - Steven Gilmore
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD
| | - Arnold Hoffman
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD
| | - Kathleen Ruehle
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD
| | - Gorgun Akpek
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD
| | - Aaron Rapoport
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD
| | - Saul Yanovich
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD
| | - Ashraf Z. Badros
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD
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Battiwalla M, Ellis K, Li P, Pavletic SZ, Akpek G, Hematti P, Klumpp TR, Maziarz RT, Savani BN, Aljurf MD, Cairo MS, Drobyski WR, George B, Hahn T, Khera N, Litzow MR, Loren AW, Saber W, Arora M, Urbano-Ispizua A, Cutler C, Flowers MED, Spellman SR. HLA DR15 antigen status does not impact graft-versus-host disease or survival in HLA-matched sibling transplantation for hematologic malignancies. Biol Blood Marrow Transplant 2012; 18:1302-8. [PMID: 22414493 DOI: 10.1016/j.bbmt.2012.02.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 02/23/2012] [Indexed: 11/27/2022]
Abstract
The HLA class II DRB1 antigen DR15 is an important prognostic marker in immune-mediated marrow failure states. DR15 has also been associated with favorable outcomes (reduced acute graft-versus-host disease [aGVHD] and relapse) after allogeneic hematopoietic cell transplant. To elucidate the impact of DR15 on transplantation outcomes, we conducted a retrospective study of 2891 recipients of first allogeneic stem cell transplant from HLA-matched sibling donors for the treatment of acute leukemia, chronic myeloid leukemia, or myelodysplastic syndrome (MDS) between 1990 and 2007. All patients received conventional myeloablative conditioning, T-replete grafts, and cyclosporine plus methotrexate-based GVHD prophylaxis. DNA-based HLA typing allowed categorization of 732 patients (25.3%) as positive and 2159 patients (74.7%) as negative for DRB1*15:01 or *15:02 (DR15). There were no significant differences in baseline characteristics between the HLA DR15 positive and negative groups. In univariate analysis, HLA-DR15 status had no impact on neutrophil engraftment, aGVHD, chronic GVHD (cGVHD), treatment-related mortality, relapse, disease-free survival, or overall survival (OS). In multivariate analysis, DR15 status showed no significant difference in aGVHD, cGVHD, OS, or relapse. In conclusion, DR15 status had no impact on major HLA-matched sibling donor hematopoietic cell transplant outcomes in this large and homogenous cohort of patients with leukemia and MDS.
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Affiliation(s)
- Minoo Battiwalla
- National Heart Lung and Blood Institute, National Institute of Health, 9000 Rockville Pike, Bethesda, MD 20892, USA.
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Singh SN, Cao Q, Gojo I, Rapoport AP, Akpek G. Durable complete remission after single agent decitabine in AML relapsing in extramedullary sites after allo-SCT. Bone Marrow Transplant 2011; 47:1008-9. [PMID: 22080965 DOI: 10.1038/bmt.2011.210] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Akpek G, Uslu A, Huebner T, Taner A, Rapoport A, Gojo I, Akpolat Y, Ioffe O, Kleinberg M, Baer M. Granulomatous amebic encephalitis: an under-recognized cause of infectious mortality after hematopoietic stem cell transplantation. Transpl Infect Dis 2011; 13:366-73. [DOI: 10.1111/j.1399-3062.2011.00612.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Akpek G, Gunay C, Shvartsbeyn M, Ranjit J, Aurelian L. Herpes Simplex Virus induced Stem Cell Differentiation and Association With Graft-Versus-Host Disease (GVHD) in Bone Marrow Transplant Recipients. Biol Blood Marrow Transplant 2011. [DOI: 10.1016/j.bbmt.2010.12.541] [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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Akpek G, Marangoz D, Ilyas C, Akbulut V, Bhatnagar B, Ruehle K, Badros A, Yanovich S, Rapoport A. Melphalan and Total-Body Irradiation (MEL-TBI) is an Effective Conditioning Regimen for Allogeneic Stem Cell Transplantation (Allo-SCT) in Patients With Very Poor-Risk Refractory Hematologic Malignancies. Biol Blood Marrow Transplant 2011. [DOI: 10.1016/j.bbmt.2010.12.493] [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: 11/26/2022]
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26
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Koç Y, Akpek G, Akpolat T, Güllü I, Kansu E, Kiraz S, Batman F, Duru S, Kansu T, Akkaya S, Telatar H, Zileli T. Topical sucralfate therapy for oral ulcers in Behçet's disease: a randomized double-blind study. J DERMATOL TREAT 2009. [DOI: 10.3109/09546639209088723] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Rapoport AP, Stadtmauer EA, Aqui N, Vogl D, Chew A, Fang HB, Janofsky S, Yager K, Veloso E, Zheng Z, Milliron T, Westphal S, Cotte J, Huynh H, Cannon A, Yanovich S, Akpek G, Tan M, Virts K, Ruehle K, Harris C, Philip S, Vonderheide RH, Levine BL, June CH. Rapid immune recovery and graft-versus-host disease-like engraftment syndrome following adoptive transfer of Costimulated autologous T cells. Clin Cancer Res 2009; 15:4499-507. [PMID: 19509133 DOI: 10.1158/1078-0432.ccr-09-0418] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Previously, we showed that adoptive transfer of in vivo vaccine-primed and ex vivo (anti-CD3/anti-CD28) costimulated autologous T cells (ex-T) at day +12 after transplant increased CD4 and CD8 T-cell counts at day +42 and augmented vaccine-specific immune responses in patients with myeloma. Here, we investigated the safety and kinetics of T-cell recovery after infusing ex-T at day +2 after transplant. EXPERIMENTAL DESIGN In this phase I/II two-arm clinical trial, 50 patients with myeloma received autografts after high-dose melphalan followed by infusions of ex-T at day +2 after transplant. Patients also received pretransplant and posttransplant immunizations using a pneumococcal conjugate vaccine only (arm B; n = 24) or the pneumococcal conjugate vaccine plus an HLA-A2-restricted microltipeptide vaccine for HLA-A2(+) patients (arm A; n = 26). RESULTS The mean number of T cells infused was 4.26 x 10(10) (range, 1.59-5.0). At day 14 after transplant, the median CD3, CD4, and CD8 counts were 4,198, 1,545, and 2,858 cells/microL, respectively. Interleukin (IL)-6 and IL-15 levels increased early after transplant and IL-15 levels correlated significantly to day 14 T-cell counts. Robust vaccine-specific B- and T-cell responses were generated. T-cell infusions were well tolerated with no effect on hematopoietic recovery. Eight patients (16%) developed a T-cell "engraftment syndrome" characterized by diarrhea and fever that was clinically and histopathologically indistinguishable from grade 1 to 3 acute graft-versus-host disease (GVHD) of the gastrointestinal tract (seven patients) and/or grade 1 to 2 cutaneous GVHD (four patients). CONCLUSIONS Adoptive T-cell transfers achieve robust T-cell recovery early after transplant and induce moderate-to-severe autologous GVHD in a subset of patients.
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Affiliation(s)
- Aaron P Rapoport
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, Maryland, USA.
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Ilyas C, Forrest GN, Akpek G. Potential clinical benefit of donor lymphocyte infusion in the treatment of refractory invasive fungal pneumonia. Bone Marrow Transplant 2007; 40:599-601. [PMID: 17618316 DOI: 10.1038/sj.bmt.1705773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Badros A, Goloubeva O, Fenton R, Rapoport AP, Akpek G, Harris C, Ruehle K, Westphal S, Meisenberg B. Phase I Trial of First-Line Bortezomib/Thalidomide plus Chemotherapy for Induction and Stem Cell Mobilization in Patients with Multiple Myeloma. ACTA ACUST UNITED AC 2006; 7:210-6. [PMID: 17229337 DOI: 10.3816/clm.2006.n.061] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [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]
Abstract
BACKGROUND In preclinical studies, bortezomib was shown to suppress tumor growth, sensitize malignant cells to apoptosis, and reverse chemotherapy resistance. PATIENTS AND METHODS We evaluated the addition of escalating doses of bortezomib 0.7, 1, and 1.3 mg/m2 intravenously on days 1, 4, and 8 to DT-PACE (cisplatin 10 mg/m2, doxorubicin 10 mg/m2, cyclophosphamide 400 mg/m2, and etoposide 40 mg/m2 per day by intravenous continuous infusion on days 1-4) plus oral dexamethasone 40 mg on days 1-4 and thalidomide 200 mg on days 1-8 in newly diagnosed patients with multiple myeloma. Peripheral blood stem cells were collected after cycle 1. Twelve patients completed the study, and all received autologous stem cell transplantation (SCT). RESULTS Hematologic toxicities were predictable, with 3 episodes of neutropenic fever. Grade >/= 2 nonhematologic toxicities included diarrhea (n = 1), deep vein thrombosis (n = 2), hypotension (n = 2), syncope (n = 1), and peripheral neuropathy (n = 3). The median number of CD34+ cells collected was 20.57 x 10 superset6 CD34+ cells/kg. After 2 cycles, 10 of 12 patients exhibited a partial response or better. Best response after autologous SCT, complete response/near complete response was exhibited in 9 patients, and partial response was exhibited in 3 patients. At a median of 20 months, 4 patients experienced relapse and 1 had died. Bortezomib/DT-PACE compared favorably with DT-PACE with regard to leukapheresis days, total CD34+ cell collection, and engraftment. CONCLUSION This novel strategy of simultaneous proteasome inhibition in combination with thalidomide and chemotherapy was effective and safe, allowing for adequate stem cell collection and early autologous SCT; its impact on overall survival, especially in patients with high-risk myeloma, awaits further investigation.
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Affiliation(s)
- Ashraf Badros
- University of Maryland Greenebaum Cancer Center, Baltimore, MD, USA.
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Abstract
The optimum graft-versus-host disease (GVHD) management in today's clinical practice remains controversial. There is an enormous heterogeneity among transplanters in their therapeutic decisions for each individual patient with GVHD. Existing guidelines do not always cover many unique clinical scenarios. Consequently, a significant number of allograft recipients fail either because of severe GVHD or relapse of underlying malignancy. Until more effective methods are available, tailoring the current GVHD management by modification of immunosuppressive therapy in each patient based on disease and transplant characteristics may decrease the mortality. The purpose of this review is to raise several questions among readers about GVHD management and generate new hypotheses, which may need to be tested in cooperative group studies.
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Affiliation(s)
- G Akpek
- Blood and Marrow Transplantation Program, Greenbaum Cancer Center, Baltimore, MD 21201, USA.
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Pavletic SZ, Martin P, Lee SJ, Mitchell S, Jacobsohn D, Cowen EW, Turner ML, Akpek G, Gilman A, McDonald G, Schubert M, Berger A, Bross P, Chien JW, Couriel D, Dunn JP, Fall-Dickson J, Farrell A, Flowers MED, Greinix H, Hirschfeld S, Gerber L, Kim S, Knobler R, Lachenbruch PA, Miller FW, Mittleman B, Papadopoulos E, Parsons SK, Przepiorka D, Robinson M, Ward M, Reeve B, Rider LG, Shulman H, Schultz KR, Weisdorf D, Vogelsang GB. Measuring therapeutic response in chronic graft-versus-host disease: National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: IV. Response Criteria Working Group report. Biol Blood Marrow Transplant 2006; 12:252-66. [PMID: 16503494 DOI: 10.1016/j.bbmt.2006.01.008] [Citation(s) in RCA: 321] [Impact Index Per Article: 17.8] [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] [Received: 01/17/2006] [Accepted: 01/18/2006] [Indexed: 02/08/2023]
Abstract
The lack of standardized criteria for quantitative measurement of therapeutic response in clinical trials poses a major obstacle for the development of new agents in chronic graft-versus-host disease (GVHD). This consensus document was developed to address several objectives for response criteria to be used in chronic GVHD-related clinical trials. The proposed measures should be practical for use both by transplantation and nontransplantation medical providers, adaptable for use in adults and in children, and focused on the most important chronic GVHD manifestations. The measures should also give preference to quantitative, rather than semiquantitative, measures; capture information regarding signs, symptoms, and function separately from each other; and use validated scales whenever possible to demonstrate improved patient outcomes and meet requirements for regulatory approval of novel agents. Based on these criteria, we propose a set of measures to be considered for use in clinical trials, and forms for data collection are provided (). Measures should be made at 3-month intervals and whenever major changes are made in treatment. Provisional definitions of complete response, partial response, and progression are proposed for each organ and for overall outcomes. The proposed response criteria are based on current expert consensus opinion and are intended to improve consistency in the conduct and reporting of chronic GVHD trials, but their use remains to be demonstrated in practice.
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Affiliation(s)
- Steven Z Pavletic
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892-1203, USA.
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Jain M, Titanji R, Rapoport AP, Wang W, Gocke C, Cross A, Akpek G. A fatal Clostridium infection in an allogeneic stem cell transplant recipient. Bone Marrow Transplant 2005; 36:455-7. [PMID: 15995716 DOI: 10.1038/sj.bmt.1705052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Rapoport AP, Guo C, Badros A, Hakimian R, Akpek G, Kiggundu E, Meisenberg B, Mannuel H, Takebe N, Fenton R, Bolaños-Meade J, Heyman M, Gojo I, Ruehle K, Natt S, Ratterree B, Withers T, Sarkodee-Adoo C, Phillips GL, Tricot G. Autologous stem cell transplantation followed by consolidation chemotherapy for relapsed or refractory Hodgkin's lymphoma. Bone Marrow Transplant 2004; 34:883-90. [PMID: 15517008 DOI: 10.1038/sj.bmt.1704661] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [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: 11/08/2022]
Abstract
Relapse remains a major cause of treatment failure after autotransplantation (auto-PBSCT) for Hodgkin's disease (HD). The administration of non-crossresistant therapies during the post-transplant period may delay or prevent relapse. We prospectively studied the role of consolidation chemotherapy (CC) after auto-PBSCT in 37 patients with relapsed or refractory HD. Patients received high-dose gemcitabine-BCNU-melphalan and auto-PBSCT followed by involved-field radiation and up to four cycles of the DCEP-G regimen, which consisted of dexamethasone, cyclophosphamide, etoposide, cisplatin, gemcitabine given at 3 and 9 months post transplant alternating with a second regimen (DPP) of dexamethasone, cisplatin, paclitaxel at 6 and 12 months post transplant. The probabilities of event-free survival (EFS) and overall survival (OS) at 2.5 years were 59% (95% CI=42-76%) and 86% (95% CI=71-99%), respectively. In all, 17 patients received 54 courses of CC and 15 were surviving event free (2.5 years, EFS=87%). There were no treatment-related deaths during or after the CC phase. Post-transplant CC is feasible and well tolerated. The impact of this approach on EFS should be evaluated in a larger, randomized study.
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Affiliation(s)
- A P Rapoport
- University of Maryland Greenebaum Cancer Center, Baltimore, MD 21201, USA.
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Akpek G, Lee SJ, Flowers ME, Pavletic SZ, Arora M, Lee S, Piantadosi S, Guthrie KA, Lynch JC, Takatu A, Horowitz MM, Antin JH, Weisdorf DJ, Martin PJ, Vogelsang GB. Performance of a new clinical grading system for chronic graft-versus-host disease: a multicenter study. Blood 2003; 102:802-9. [PMID: 12714524 DOI: 10.1182/blood-2002-10-3141] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.5] [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: 11/20/2022] Open
Abstract
We recently reported 3 risk factors (RFs) at diagnosis of chronic graft-versus-host disease (cGVHD) that were significantly associated with increased nonrelapse mortality. These included extensive skin involvement (ESI), thrombocytopenia (TP), and progressive type of onset (PTO). The hazard ratio (HR) for mortality of the patients with prognostic score (PS) between 0 and 2 (intermediate-risk; 1 RF) compared to those with PS 0 (favorable-risk; 0 RF) was 3.7 (95% CI, 1.4, 9.3); the HR for patients with PS equal to or more than 2 (high-risk; > 1 RF) compared with intermediate-risk group was 6.9 (3.8, 12.4). A rare presentation of TP and PTO without ESI yielded a PS of 1.8 (intermediate-risk). This paper reports the performance of the prognostic model and the individual RFs using data from an additional 1105 patients from University of Nebraska (n = 60), International Bone Marrow Transplantation Registry (n = 708), Fred Hutchinson Cancer Research Center (n = 188), and University of Minnesota (n = 149). The extent of skin involvement was quantified in 3 cohorts using the available data collected in different formats before the analysis. Although the HR for mortality of the patients in the intermediate-risk group versus those in the favorable-risk group ranged from 2.3 to 8.9 across the centers, it was between 1.6 to 6.9 for patients in the high-risk group versus those in the intermediate-risk group. Although TP itself was uniformly associated with increased risk of mortality across all test samples, ESI and PTO showed statistically significant associations with mortality in 1 and 2 cohorts, respectively. In conclusion, the model was predictive of cGVHD-specific survival, but the mortality hazard associated with ESI was lower in each of these test samples compared with the learning sample. Although the new clinical grading based on the model is promising because of its utility across multiple independent data sets, prospective validation is needed.
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Affiliation(s)
- Gorgun Akpek
- Department of Oncology, Johns Hopkins University, Baltimore, MD, USA
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Lee SJ, Vogelsang G, Gilman A, Weisdorf DJ, Pavletic S, Antin JH, Horowitz MM, Akpek G, Flowers ME, Couriel D, Martin PJ. A survey of diagnosis, management, and grading of chronic GVHD. Biol Blood Marrow Transplant 2003; 8:32-9. [PMID: 11846354 DOI: 10.1053/bbmt.2002.v8.pm11846354] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [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: 11/11/2022]
Abstract
Chronic GVHD (cGVHD) is a potentially devastating late complication of allogeneic stem cell transplantation. To better understand current diagnostic and treatment practices regarding this complication, we mailed a self-administered survey to 188 adult and pediatric transplantation programs. The survey collected data on experience with therapies for cGVHD and presented 6 vignettes to assess agreement about the diagnosis, clinical management, grading, and prognosis of patients with symptoms of cGVHD. Response rate to the survey was 51%. Of the respondents, 28% felt they had "great success" in treating patients with systemic corticosteroids, and 13% had similar success with cyclosporine or mycophenolate mofetil; less success and experience were reported with other agents. Respondents estimated an average 3-year, nonrelapse mortality of 16% (95% CI, 14%-19%) for patients assessed to have limited disease and 39% (95% CI, 36%-43%) for extensive disease. Analysis of responses to the 6 vignettes showed that agreement was greatest for supportive care issues, willingness to enroll patients in clinical trials, and use of systemic immunosuppression for symptomatic cGVHD. Less agreement was seen for diagnosis and management when cGVHD manifestations were atypical or less severe, the decision of whether to taper immunosuppression in the face of stable symptoms, and for assignment of mild, moderate, or severe cGVHD grades. Most respondents were willing to use systemic immunosuppression to treat symptoms that they believed to be caused by cGVHD, but differences of opinion about cGVHD diagnosis and disease activity resulted in significant practice variation. Low estimates of treatment success were noted and reflected an overall pessimism about the success of therapy for cGVHD. We conclude that studies defining appropriate diagnostic pathways, criteria for disease activity, and prognosis could help standardize management of cGVHD. There is an urgent need to develop and test new approaches to treat cGVHD.
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Affiliation(s)
- Stephanie J Lee
- Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts 02115, USA.
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Akpek G, Knight RD, Wright DG. Use of oral mucosal neutrophil counts to detect the onset and resolution of profound neutropenia following high-dose myelosuppressive chemotherapy. Am J Hematol 2003; 72:13-9. [PMID: 12508262 DOI: 10.1002/ajh.10250] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [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: 11/06/2022]
Abstract
Severe neutropenia following cytotoxic, anti-cancer chemotherapy is well-known to be associated with an increased risk of infections that may be life-threatening, particularly if not treated immediately. Consequently, serial measurements of neutrophil counts in peripheral blood are done routinely following the administration of high-dose myelosuppressive chemotherapy in order to monitor the onset, severity, and duration of iatrogenic neutropenia. We have studied a non-invasive method of quantifying neutrophils recoverable from the oral mucosa, a normal tissue site of neutrophil turnover, as an alternative approach for monitoring severe, chemotherapy-induced neutropenia. This method is based on the quantification of fluorochrome-stained neutrophils present in timed mouthwash specimens. Blood neutrophil (ANC) and mucosal neutrophil counts (MNC) were measured repeatedly in 23 patients who had been treated with dose-intensive chemotherapy for a variety of indications. All 23 patients developed profound neutropenia (ANC < 100/mm3), and 19 developed neutropenic fever (>101 degrees F) during the 2 weeks following treatment. Nadirs of neutropenia defined by MNC were significantly less prolonged than those defined by the ANC. Furthermore, the onset and resolution of neutropenic fever coincided more precisely with nadirs of neutropenia defined by the MNC than with those defined by the ANC. Our findings indicate that oral mucosal neutrophil counts predict the timing of clinical events associated with neutropenia (e.g., the onset and resolution of fever) with significantly greater accuracy than blood neutrophil counts.
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Affiliation(s)
- Gorgun Akpek
- Castle Hematology Research Laboratory of the Section of Hematology and Oncology, Department of Medicine, Boston University Medical Center, Boston, Massachusetts 02118, USA
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Abstract
Corticosteroids remain essential for controlling active chronic graft-versus-host disease (cGVHD). However, the optimum dose and administration schedule is unknown. We have reviewed our results in 61 patients with severe refractory cGVHD who were treated with a high-dose pulse steroid regimen (PS) consisting of methylprednisolone at 10 mg/kg per day for 4 consecutive days, with subsequent tapering doses. After 4 days, all patients received a course of additional immunosuppressive therapy. The median age of the 56 patients who were evaluable for response was 32 years (range, 0.2-57 years). Patients had failed a median of 2 (range, 1-5) treatments prior to the PS. The median follow-up for 45 surviving patients after PS was 1.5 years. The probability of survival at 1 year and 2 years after PS was 88% (95% confidence interval [CI], 76%-95%) and 81% (95% CI, 65%-91%), respectively. Twenty-seven patients (48%) showed a major response to PS with substantial improvement of cGVHD manifestations, including softening of the skin, increased range of motion, and improved performance status; 15 patients (27%) showed a minor response, defined as improvement in some but not all symptoms of cGVHD. Of the 42 responders, 21 (50%) had progression of their cGVHD afterwards. The median time to progression was 1.9 years. The probability of progression at 1 and 2 years after PS was 36% (95% CI, 23%-53%) and 54% (95% CI, 38%-71%), respectively. The probability of progression at 1 year was 25% (95% CI, 12%-47%) and 55% (95% CI, 32%-81%) for patients who had major and minor response, respectively (hazard ratio, 2.13). Ten of the 42 responders (24%) were able to discontinue all systemic immunosuppressive treatments. The probability of discontinuation at 1 and 2 years after PS was 9% (95% CI, 3%-25%) and 27% (95% CI, 15%-48%), respectively. The treatment was well tolerated with no serious adverse events. Our results suggest that PS is a well-tolerated regimen for achieving rapid clinical response in the majority of patients with cGVHD who failed on multiple previous therapies. Further studies are warranted to maintain the efficacy of this regimen by combining with new active agents in cGVHD.
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Affiliation(s)
- G Akpek
- Division of Hematologic Malignancies/BMT, The Johns Hopkins Oncology Center, Baltimore 21231, USA.
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Akpek G, Lenz G, Lee SM, Sanchorawala V, Wright DG, Colarusso T, Waraska K, Lerner A, Vosburgh E, Skinner M, Comenzo RL. Immunologic recovery after autologous blood stem cell transplantation in patients with AL-amyloidosis. Bone Marrow Transplant 2001; 28:1105-9. [PMID: 11803350 DOI: 10.1038/sj.bmt.1703298] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2000] [Accepted: 09/24/2001] [Indexed: 11/09/2022]
Abstract
We prospectively studied absolute lymphocyte (ALC) and monocyte counts (AMC), lymphocyte subsets and proliferative in vitro responses to mitogen and antigen in 12 patients with AL-amyloidosis (AL) undergoing autologous blood stem cell transplantation (SCT) with high-dose i.v. melphalan. Myeloid and lymphoid recovery (>500 per microl) occurred in a median of 10 days post SCT. While there was a continuous decline in the number of CD4+ T cells at 3 months, ALC, AMC, B cells (CD19+), CD8+ T cells, and NK cells (CD16+/56+) returned to baseline. While T cell proliferative responses to phytohemagglutinin (PHA) remained depressed, B cell function measured by the proliferative response to staphylococcal antigen returned to baseline by 3 months. To supplement our findings, we retrospectively evaluated ALC, AMC and serum immunoglobulin levels in a separate group of patients treated with the same protocol at our institution. ALC and AMC recovery was similar to the pattern observed in the initial study group. Immunoglobulin levels remained within normal ranges at 3 and 12 months after SCT. Of 50 patients who were followed for a minimum of 1 year following SCT, seven (14%) developed shingles and one (2%) had PCP pneumonia. In conclusion, cellular immune function, reflected by absolute numbers of CD4+ T cells and PHA responsive T cell proliferation, is significantly suppressed at 3 months after SCT in patients with AL, and this post-transplant immunosuppression is associated with a low but clinically meaningful occurrence of opportunistic infections typical of T cell immunosuppression.
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Affiliation(s)
- G Akpek
- Section of Hematology and Oncology, Department of Medicine, Boston University Medical Center, Boston, MA, USA
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Akpek G, Ambinder RF, Piantadosi S, Abrams RA, Brodsky RA, Vogelsang GB, Zahurak ML, Fuller D, Miller CB, Noga SJ, Fuchs E, Flinn IW, O'Donnell P, Seifter EJ, Mann RB, Jones RJ. Long-term results of blood and marrow transplantation for Hodgkin's lymphoma. J Clin Oncol 2001; 19:4314-21. [PMID: 11731514 DOI: 10.1200/jco.2001.19.23.4314] [Citation(s) in RCA: 143] [Impact Index Per Article: 6.2] [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: 11/20/2022] Open
Abstract
PURPOSE To evaluate the long-term outcome after allogeneic (allo) and autologous (auto) blood or marrow transplantation (BMT) in patients with relapsed or refractory Hodgkin's lymphoma (HL). PATIENTS AND METHODS We analyzed the outcome of 157 consecutive patients with relapsed or refractory HL, who underwent BMT between March 1985 and April 1998. Patients <or= age 55 with HLA-matched siblings were prioritized toward allo BMT. The median age was 28 years (range, 13 to 52 years) for the 53 allo patients and 30.5 years (range, 11 to 62 years) for the 104 auto patients. RESULTS The median follow-up after BMT for surviving patients was 5.1 years (range, 1 to 13.8 years). For the entire group, the probabilities of event-free survival (EFS) and relapse at 10 years were 26% (95% confidence interval [CI], 18% to 33%) and 58% (95% CI, 48% to 69%), respectively. According to multivariate analysis, disease status before BMT (sensitive relapse if responding to conventional-dose therapy or resistant disease if not) (hazard ratio [HR] = 0.39, P < .0001) and date of BMT (HR = 0.93, P = .004) were independent predictors of EFS, whereas only disease status (HR = 0.35, P < .0001) influenced relapse. There was a trend for probability of relapse in sensitive patients to be less after allo BMT at 34% (range, 8% to 59%) versus 51% (range, 36% to 67%) for the auto patients (HR = 0.51, P = .17). There was a continuing risk of relapse or secondary acute myeloid leukemia (AML)/myelodysplastic syndrome (MDS) for 12 years after auto BMT, whereas there were no cases of secondary AML/MDS or relapses beyond 3 years after allo BMT. CONCLUSION There seems to be a clinical graft-versus-HL effect associated with allo BMT. Allo BMT for HL also seems to have a lower risk of secondary AML/MDS than auto BMT. Thus, allo BMT warrants continued study in HL.
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Affiliation(s)
- G Akpek
- Johns Hopkins Oncology Center, Baltimore, MD 21231, USA
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Akpek G, Akpek EK, Li S, Green RW, O'Brien TP, Borowitz MJ. Unusual locations for lymphomas. Case 3. Successive occurrence of peripheral T-cell lymphoma with bilateral conjuctival involvement in a patient with low-grade B-cell lymphoma. J Clin Oncol 2001; 19:2964-6. [PMID: 11387371 DOI: 10.1200/jco.2001.19.11.2964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- G Akpek
- The John Hopkins University School of Medicine, Baltimore, MD, USA
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Akpek G, Lee SM, Gagnon DR, Cooley TP, Wright DG. Bone marrow aspiration, biopsy, and culture in the evaluation of HIV-infected patients for invasive mycobacteria and histoplasma infections. Am J Hematol 2001; 67:100-6. [PMID: 11343381 DOI: 10.1002/ajh.1086] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [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
Bone marrow (BM) aspiration and biopsy are used commonly in clinical practice to diagnose invasive tissue infections caused by Mycobacterium avium intracellulare (MAC), Mycobacterium tuberculosis (TB), and Histoplasma capsulatum (HC) in patients with human immunodeficiency virus-1 (HIV) infection. However, the value of these invasive procedures relative to other diagnostic approaches has not been clearly defined. To determine the value of BM culture and BM histology in the diagnosis of opportunistic MAC/TB and HC infections in immunosuppressed patients with HIV, we retrospectively reviewed the records of 56 adult patients with HIV who underwent a single BM aspiration, biopsy, and culture because of unexplained fever and/or other clinical features suggestive of MAC/TB or HC infection. Thirty-two patients (57%) were ultimately diagnosed with MAC/TB or HC infection by positive cultures of BM, blood, sputum, or bronchoalveolar lavage fluid or by the histologic detection of organisms in biopsies of BM or other tissues. The diagnostic sensitivity of BM cultures was equal to that of blood cultures (20/32, or 63%). Granuloma and/or histologically apparent organisms were seen in BM biopsy specimens in 11 of 32 individuals (34%) ultimately diagnosed with MAC/TB or HC infections. Among these 11 cases, both granuloma and acid-fast staining organisms were found in the BM biopsy specimens of 2 individuals for whom both BM and blood cultures were negative. Certain clinical symptoms and signs at the time of BM examination were found by logistic regression analysis to be significantly associated with a subsequent diagnosis of MAC/TB or HC infections; these included high fever, long duration of febrile days prior to BM examination, and elevated direct bilirubin. In conclusion, while the diagnostic sensitivity of BM cultures was found to be no greater than that of blood cultures in detecting MAC/TB or HC infections in immunosuppressed HIV+ patients, histopathologic examination of BM specimens resulted in the relatively rapid identification of nearly one third of infected patients who underwent BM examination, and also identified infections in some patients who were culture negative. These findings support the continued use of BM aspiration, biopsy, and culture for the diagnosis of opportunistic MAC/TB or HC infections in immunosuppressed HIV+ patients, particularly when selected clinical features are present.
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Affiliation(s)
- G Akpek
- Division of Hematologic Malignancies, Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Akpek G, McAneny D, Weintraub L. Risks and benefits of splenectomy in myelofibrosis with myeloid metaplasia: a retrospective analysis of 26 cases. J Surg Oncol 2001; 77:42-8. [PMID: 11344482 DOI: 10.1002/jso.1064] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [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: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVES To evaluate the outcomes of splenectomy in myelofibrosis and myeloid metaplasia (MMM). METHODS We retrospectively reviewed our records of 26 patients with MMM who underwent an open splenectomy at Boston University Medical Center between 1979 and 1995. Fourteen patients had agnogenic myeloid metaplasia (AMM) and 12 had myelofibrosis with antecedent myeloproliferative disorders (MF). The main indications for splenectomy were progressive transfusion-dependent anemia, painful splenomegaly, and hypercatabolic symptoms associated with cytopenia. RESULTS Median time to splenectomy after the diagnosis of MMM was 29 months ranging from 1 to 96 months. Three patients (11%) died within 1 month after the surgery because of sepsis. The most common peri- and postoperative complications were pneumonia and other bacterial infections (42%), cardiac events (19%), acute bleeding (15%), ileus (15%), and venous thrombosis (12%). Of the eight surviving patients who underwent splenectomy for transfusion dependent anemia, six (75%) had improvement in their hematocrit levels with abolishment of blood transfusions. A durable symptomatic palliation was achieved in all patients. Liver enlargement was noted in seven patients at 1-year evaluation. None of these patients developed hepatic failure. Leukemic transformation occurred in 8 of 18 patients (44%) postsplenectomy. The median overall survival for the entire group was 58.5 and 28 months from the diagnosis of MMM and the time of splenectomy, respectively. There was no difference in survival rates between patients with AMM and MF. CONCLUSIONS Splenectomy is an effective palliative procedure with an acceptable morbidity in selected patients with MMM. Progressive transfusion-dependent anemia should also be considered an indication for splenectomy in the absence of leukemic evolution.
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Affiliation(s)
- G Akpek
- Section of Hematology and Oncology in the Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA.
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Akpek G, Zahurak ML, Piantadosi S, Margolis J, Doherty J, Davidson R, Vogelsang GB. Development of a prognostic model for grading chronic graft-versus-host disease. Blood 2001; 97:1219-26. [PMID: 11222363 DOI: 10.1182/blood.v97.5.1219] [Citation(s) in RCA: 153] [Impact Index Per Article: 6.7] [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
The disease-specific survival (DSS) of 151 patients with chronic graft-versus-host disease (cGVHD) was studied in an attempt to stratify patients into risk groups and to form a basis for a new grading of cGVHD. The data included the outcome and 23 variables at the diagnosis of cGVHD and at the primary treatment failure (PTF). Eighty-nine patients (58%) failed primary therapy for cGVHD. Nonrelapse mortality was 44% after a median follow-up of 7.8 years. The probability of DSS at 10 years after diagnosis of cGVHD (DSS1) and after PTF (DSS2) was 51% (95% confidence interval [CI] = 39%, 60%) and 38% (95% CI = 28%, 49%), respectively. According to multivariate analysis, extensive skin involvement (ESI) more than 50% of body surface area; hazard ratio (HR) of 7.0 (95% CI = 3.6-13.4), thrombocytopenia (TP) (< 100 000/microL; HR, 3.6; 95% CI = 1.9-6.8), and progressive-type onset (PTO) (HR, 1.7; 95% CI = 0.9-3.0) significantly influenced DSS1. These 3 factors and Karnofsky Performance Score of less than 50% at PTF were significant predictors for DSS2. The DSS1 at 10 years for patients with prognostic factor score (PFS) at diagnosis of 0 (none), 1.9 and below [corrected] (ESI only or TP and/or PTO), above 1.9 and not above 3.5 [corrected] (ESI plus either TP or PTO), and more than 3.5 (all 3 factors) was 82%, 68%, 34%, and 3% (P =.05, <.001, <.001), respectively. The DSS2 at 5 years for patients with PFS at PTF of 0, 2 or less, 2 to 3.5, and more than 3.5 were 91%, 71%, 22%, and 4% (P =.2,.005, and <.001), respectively. It was concluded that these prognostic models might be useful in grouping the patients with similar outcome.
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Affiliation(s)
- G Akpek
- Johns Hopkins Oncology Center, Division of Hematologic Malignancies/BMT, and Oncology Biostatistics, Baltimore, MD 21231, USA.
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Abstract
Diarrhea is a difficult diagnostic problem in patients with chronic graft-versus-host disease (cGVHD) because there are many causes of it. Although intestinal involvement has been reported in early studies of untreated cGVHD, this is now a very rare presentation of the disease. In addition to other etiologies, pancreatic insufficiency should also be considered in patients with cGVHD who demonstrate malabsorption. The pathogenesis of pancreatic insufficiency in these patients is unknown. Pancreatic enzyme supplements can be very effective in treating this rare condition.
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Affiliation(s)
- G Akpek
- Hematologic Malignancies, Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Akpek G. Current controversies in bone marrow transplantation. J Natl Cancer Inst 2000; 92:1358-9. [PMID: 10944560 DOI: 10.1093/jnci/92.16.1358] [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: 11/14/2022] Open
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Akpek G, Koh HK, Bogen S, O'Hara C, Foss FM. Chemotherapy with etoposide, vincristine, doxorubicin, bolus cyclophosphamide, and oral prednisone in patients with refractory cutaneous T-cell lymphoma. Cancer 1999; 86:1368-76. [PMID: 10506727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
BACKGROUND This Phase II study was undertaken to assess the efficacy and toxicity of chemotherapy with etoposide, vincristine, doxorubicin, bolus cyclophosphamide, and oral prednisone (EPOCH regimen) in patients with advanced, refractory cutaneous T-cell lymphoma (CTCL). METHODS Fifteen patients were treated with a 96-hour continuous infusion of etoposide, vincristine, doxorubicin, bolus cyclophosphamide, and oral prednisone, followed by granulocyte-colony stimulating factor support and trimethoprim/sulfamethoxazole prophylaxis. The median age of the patients was 53 years (range, 17-82 years). Six patients had Sézary syndrome (SS), four patients had visceral involvement, and four patients had anaplastic large cell morphology, three with Ki-1 (CD30) positivity. All patients had disease that was refractory to prior chemotherapy or electron beam irradiation and eight of these patients had received cyclophosphamide, doxorubicin, vincristine, and prednisone. Seven patients had received prior interferon therapy and nine patients had received fludarabine and/or 2-CDA. RESULTS After a median of 5 cycles (range, 1-9 cycles), 4 patients achieved a complete response (27%) and 8 patients achieved a partial response (53%) for an overall response rate of 80% (95% confidence interval, 52-96%). Three patients with visceral involvement, two of three patients with anaplastic large cell morphology, and one patient with human T-cell lymphoma virus leukemia/lymphoma did not respond. All 12 responders had improvement in skin disease; 2 of 6 patients with SS had complete disappearance of circulating Sézary cells. The median progression free survival was 8.0 months (range, 3-22 months). After a median follow-up of 11.4 months (range, 2-56+ months), the median patient survival was 13.5 months. Grade 3 or 4 hematologic toxicity occurred in 8 patients (61%); 5 of these 8 patients had febrile neutropenia. Six patients developed staphylococcal bacteremia, two patients had disseminated herpes infection, and one patient had Pneumocystis carinii pneumonia. Grade 3 neurotoxicity occurred in one patient. Two patients had a significant decrease in left ventricular ejection fraction and one patient had supraventricular tachycardia. CONCLUSIONS EPOCH chemotherapy has a high response rate with acceptable toxicity in patients with advanced and refractory CTCL.
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Affiliation(s)
- G Akpek
- Section of Hematology and Oncology, Department of Medicine, Johns Hopkins Oncology Center, Baltimore, Maryland 21287-8985, USA
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Akpek G, Koh HK, Bogen S, O'Hara C, Foss FM. Chemotherapy with etoposide, vincristine, doxorubicin, bolus cyclophosphamide, and oral prednisone in patients with refractory cutaneous T-cell lymphoma. Cancer 1999. [DOI: 10.1002/(sici)1097-0142(19991001)86:7<1368::aid-cncr37>3.0.co;2-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Altindag ZZ, Sahin G, Işimer A, Akpek G, Kansu E. Dihydropteridine reductase activity and neopterin levels in leukemias and lymphomas: is there any correlation between these two parameters? Leuk Lymphoma 1999; 35:367-74. [PMID: 10706461 DOI: 10.3109/10428199909145741] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [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: 11/13/2022]
Abstract
Urinary neopterin levels, blood dihydropteridine reductase activity as well as other frequently used clinical parameters were evaluated in 110 patients suffering from various types of lymphomas and leukemias. Among them neopterin was detected as the most sensitive marker representing the severity of malignancy (p<0.00001). All patients with active diseases had significantly raised urinary neopterin levels compared to those in remission and healthy controls. Of 69 patients with active disease 66 (96%) were above the upper limit seen in healthy subjects. In addition, the highest neopterin excretion was found in patients with active chronic myeloid leukemia (1469+/-479 micromol/mol creatinine n=16). In contrast, only 1 of 41 patients in stable responsive disease and remission (2.4%) had increased urinary neopterin levels above the upper limit. Dihydropteridine reductase (DHPR) activities were also detected in all patients and control groups. In active disease slightly reduced (DHPR) activities were evident (3.42+/-0.37 for controls, 2.92+/-0.39 in active disease and 3.28+/-0.42 nmol red cytochrome C/min/5 mm diameter disc in remission patients). However in patients under medication this was strengthened. This data also suggest that DHPR activity can be effected by chemotherapy. The results of the present study support the fact that urinary neopterin levels may be an useful and reliable early prognostic marker for neoplasia when used together with other prognostic indicators. Our data also suggest that reductions in DHPR activities may also be an underlying cause for the neurological disorders that are commonly seen in patients with haematological malignancies.
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Affiliation(s)
- Z Z Altindag
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey
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Abstract
We reviewed our experience in 30 patients with direct Coombs-positive (DAT+) autoimmune hemolytic anemia (AHA) who underwent splenectomy. Twelve patients had idiopathic "warm" AHA (group I) and 18 had AHA associated with systemic diseases (group II). Complete response to splenectomy was defined as having normal hemoglobin and reticulocyte count lasting for at least 6 months without subsequent medical therapy. Subnormal but greater than 50% improvement in these parameters with or without medical therapy was considered to be a partial response. Median age was 64 (23-81) in group I and 68 (23-76) in group II. Median follow-up duration was 18 and 10.9 months, respectively. Nine of 11 (82%) evaluable patients with idiopathic AHA and 3 of 16 (19%) patients with associated disease achieved a complete response. Partial response was obtained in 2 (18%) and 6 (37%) patients in groups I and II, respectively. Both complete-response and overall-response rates were statistically different between two groups (P = 0.001 and 0.02). Postoperative courses of group I patients were uneventful except for one who developed a subphrenic abscess. Five patients in group II developed bacterial infections, which were mostly pneumonias. Our findings indicate that splenectomy is an effective treatment approach with low morbidity and mortality in patients with refractory idiopathic AHA. It should, however, be considered cautiously in AHA patients with underlying systemic diseases because of its decreased efficacy and increased surgical morbidity in this subgroup.
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Affiliation(s)
- G Akpek
- Section of Hematology/Oncology, Boston University School of Medicine, Massachusetts, USA
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