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Akahoshi Y, Spyrou N, Hoepting M, Aguayo-Hiraldo P, Ayuk F, Chanswangphuwana C, Choe HK, Eder M, Etra AM, Grupp SA, Hexner EO, Hogan WJ, Kitko CL, Kraus S, Al Malki MM, Merli P, Qayed M, Reshef R, Schechter T, Ullrich E, Vasova I, Wölfl M, Zeiser R, Baez J, Beheshti R, Eng G, Gleich S, Kasikis S, Katsivelos N, Kowalyk S, Morales G, Young R, DeFilipp Z, Ferrara JLM, Levine JE, Nakamura R. Flares of acute graft-versus-host disease: a Mount Sinai Acute GVHD International Consortium analysis. Blood Adv 2024; 8:2047-2057. [PMID: 38324721 DOI: 10.1182/bloodadvances.2023012091] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/19/2024] [Accepted: 01/19/2024] [Indexed: 02/09/2024] Open
Abstract
ABSTRACT The absence of a standardized definition for graft-versus-host disease (GVHD) flares and data on its clinical course are significant concerns. We retrospectively evaluated 968 patients across 23 Mount Sinai Acute GVHD International Consortium (MAGIC) transplant centers who achieved complete response (CR) or very good partial response (VGPR) within 4 weeks of treatment. The cumulative incidence of flares within 6 months was 22%, and flares were associated with a higher risk of nonrelapse mortality (NRM; adjusted hazard ratio [aHR], 4.84; 95% confidence interval [CI], 3.19-7.36; P < .001). Flares were more severe (grades 3/4, 41% vs 16%; P < .001) and had more frequent lower gastrointestinal (LGI) involvement (55% vs 32%; P < .001) than the initial GVHD. At CR/VGPR, elevated MAGIC biomarkers predicted the future occurrence of a flare, along with its severity and LGI involvement. In multivariate analyses, higher Ann Arbor (AA) biomarker scores at CR/VGPR were significant risk factors for flares (AA2 vs AA1: aHR, 1.81 [95% CI, 1.32-2.48; P = .001]; AA3 vs AA1: aHR, 3.14 [95% CI, 1.98-4.98; P < .001]), as were early response to initial treatment (aHR, 1.84; 95% CI, 1.21-2.80; P = .004) and HLA-mismatched unrelated donor (aHR, 1.74; 95% CI, 1.00-3.02; P = .049). MAGIC biomarkers also stratified the risk of NRM both at CR/VGPR and at the time of flare. We conclude that GVHD flares are common and carry a significant mortality risk. The occurrence of future flares can be predicted by serum biomarkers that may serve to guide adjustment and discontinuation of immunosuppression.
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Affiliation(s)
- Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Matthias Hoepting
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Paibel Aguayo-Hiraldo
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Chantiya Chanswangphuwana
- Division of Hematology and Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Hannah K Choe
- Blood and Marrow Transplantation Program, The Ohio State University, Columbus, OH
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Aaron M Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stephan A Grupp
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth O Hexner
- Department of Medicine and Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Carrie L Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Monzr M Al Malki
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Pietro Merli
- Department of Pediatric Hematology/Oncology and of Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Muna Qayed
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, GA
| | - Ran Reshef
- Blood and Marrow Transplantation Program and Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
| | - Tal Schechter
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Evelyn Ullrich
- Department of Pediatrics, Experimental Immunology and Cell Therapy, Goethe University Frankfurt, Frankfurt, Germany
| | - Ingrid Vasova
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children's Hospital, University Hospital of Würzburg, Würzburg, Germany
| | - Robert Zeiser
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rahnuma Beheshti
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gilbert Eng
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Stelios Kasikis
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nikolaos Katsivelos
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - James L M Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John E Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryotaro Nakamura
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
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2
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Etra AM, El Jurdi N, Katsivelos N, Kwon D, Gergoudis SC, Morales G, Spyrou N, Kowalyk S, Aguayo-Hiraldo P, Akahoshi Y, Ayuk FA, Baez J, Betts BC, Chanswangphuwana C, Chen YB, Choe HK, DeFilipp Z, Gleich S, Hexner EO, Hogan WJ, Holler E, Kitko CL, Kraus S, Al Malki MM, MacMillan ML, Pawarode A, Quagliarella F, Qayed M, Reshef R, Schechter-Finkelstein T, Vasova I, Weisdorf DJ, Wölfl M, Young R, Nakamura R, Ferrara JLM, Levine JE, Holtan SG. Amphiregulin, ST2,and REG3α Biomarker Risk Algorithms as Predictors of Non-Relapse Mortality in Patients with Acute GVHD. Blood Adv 2024:bloodadvances.2023011049. [PMID: 38640195 DOI: 10.1182/bloodadvances.2023011049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 03/29/2024] [Accepted: 03/29/2024] [Indexed: 04/21/2024] Open
Abstract
Graft-vs-host disease (GVHD) is a major cause of non-relapse mortality (NRM) following allogeneic hematopoietic cell transplant (HCT). Algorithms containing either the GI GVHD biomarker amphiregulin (AREG) or a combination of two GI GVHD biomarkers, (ST2+REG3α) when measured at GVHD diagnosis are validated predictors of NRM risk, but have never been assessed in the same patients using identical statistical methods. We measured serum concentrations of ST2, REG3, and AREG by ELISA at the time of GVHD diagnosis in 715 patients divided by date of transplant into training (2004-2015) and validation (2015-2017) cohorts. The training cohort (n=341) was used to develop algorithms for predicting probability of 12 month NRM that contained all possible combinations of 1-3 biomarkers and a threshold corresponding to the concordance probability was used to stratify patients for risk of NRM. Algorithms were compared to each other based on several metrics including the area under the receiver operating characteristics curve (AUC), proportion of patients correctly classified, sensitivity, and specificity using only the validation cohort (n=374). All algorithms were strong discriminators of 12 month NRM, whether or not patients were systemically treated (n=321). An algorithm containing only ST2+REG3α had the highest AUC (0.757), correctly classified the most patients (75%), and more accurately risk stratified those who developed Minnesota standard risk GVHD and for patients who received post-transplant cyclophosphamide-based prophylaxis. An algorithm containing only AREG more accurately risk stratified patients with Minnesota high risk GVHD. Combining ST2, REG3α, and AREG into a single algorithm did not improve performance.
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Affiliation(s)
- Aaron M Etra
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Najla El Jurdi
- University of Minnesota, Minneapolis, Minnesota, United States
| | | | - Deukwoo Kwon
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | | | - George Morales
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Nikolaos Spyrou
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Steven Kowalyk
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Paibel Aguayo-Hiraldo
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, United States
| | - Yu Akahoshi
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | | | - Janna Baez
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Brian C Betts
- University of Minnesota, Buffalo, New York, United States
| | - Chantiya Chanswangphuwana
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Yi-Bin Chen
- Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Hannah K Choe
- The Ohio State University, Columbus, Ohio, United States
| | | | | | - Elizabeth O Hexner
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States
| | | | - Ernst Holler
- University Hospital Regensburg, Regensburg, Germany
| | - Carrie L Kitko
- Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | | | - Monzr M Al Malki
- City of Hope National Medical Center, Duarte, California, United States
| | | | | | | | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, Georgia, United States
| | - Ran Reshef
- Columbia University Medical Center, New York, New York, United States
| | | | - Ingrid Vasova
- University Hospital Erlangen, Erlangen, Germany, Erlangen, Germany
| | | | | | - Rachel Young
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Ryotaro Nakamura
- City of Hope National Medical Center, Duarte, California, United States
| | - James L M Ferrara
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - John E Levine
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
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3
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DeFilipp Z, Kim HT, Spyrou N, Katsivelos N, Kowalyk S, Eng GW, Kasikis S, Beheshti R, Baez J, Akahoshi Y, Ayuk FA, Choe HK, Etra AM, Grupp SA, Hexner EO, Hogan WJ, Kitko CL, Qayed M, Reshef R, Vasova I, Zeiser R, Young R, Holler E, Ferrara JLM, Nakamura R, Levine JE, Chen YB. The MAGIC algorithm probability predicts treatment response and long-term outcomes to second-line therapy for acute GVHD. Blood Adv 2024:bloodadvances.2024012561. [PMID: 38640197 DOI: 10.1182/bloodadvances.2024012561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/21/2024] Open
Abstract
The significance of biomarkers at second-line treatment for acute graft-versus-host disease (GVHD) is not well characterized. We analyzed clinical data and serum samples at initiation of second-line systemic treatment of acute GVHD from 167 patients from 17 centers of the Mount Sinai Acute GVHD International Consortium (MAGIC) between 2016 and 2021. Sixty-two patients received ruxolitinib-based therapy while 102 received other systemic agents. In agreement with prospective trials, ruxolitinib resulted in higher day 28 (D28) ORR compared to non-ruxolitinib therapies (55% vs 31%, P=0.003) and patients who received ruxolitinib had significantly lower non-relapse mortality (NRM) than those who received non-ruxolitinib therapies (point estimates at 2-year: 35% vs 61%, p=0.002). Biomarker analyses demonstrated that the benefit from ruxolitinib was observed only in patients with low MAGIC algorithm probabilities (MAPs) at the start of second-line treatment. Among patients with a low MAP, those who received ruxolitinib experienced significantly lower NRM than those who received non-ruxolitinib therapies (point estimates at 2-year: 12% vs 41%, p=0.016). However, patients with a high MAP experienced high NRM regardless of treatment with ruxolitinib or non-ruxolitinib therapies (point estimates at 2-year: 67% vs 80%, p=0.65). A landmark analysis demonstrated that the relationship between D28 response and NRM largely depends on the MAP level at initiation of second-line therapy. In conclusion, the MAP measured at second-line systemic treatment for acute GVHD predicts treatment response and NRM. Outcomes of patients with high MAP are poor, regardless of treatment choice, and ruxolitinib appears to primarily benefit patients with low MAP.
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Affiliation(s)
| | - Haesook T Kim
- Dana-Farber Cancer Inst., Boston, Massachusetts, United States
| | - Nikolaos Spyrou
- Icahn School of Medicine at Mount Sinai, NEW YORK, New York, Japan
| | | | - Steven Kowalyk
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Gilbert W Eng
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Stelios Kasikis
- Icahn School of Medicine at Mount Sinai, New York City, New York, United States
| | - Rahnuma Beheshti
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Janna Baez
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Yu Akahoshi
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | | | - Hannah K Choe
- The Ohio State University, Columbus, Ohio, United States
| | - Aaron M Etra
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Stephan A Grupp
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Elizabeth O Hexner
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States
| | | | - Carrie L Kitko
- Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, Georgia, United States
| | - Ran Reshef
- Columbia University Medical Center, New York, New York, United States
| | - Ingrid Vasova
- University Hospital Erlangen, Erlangen, Germany, Erlangen, Germany
| | - Robert Zeiser
- University Medical Center Freiburg, Freiburg, Germany
| | - Rachel Young
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Ernst Holler
- University Hospital Regensburg, Regensburg, Germany
| | - James L M Ferrara
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Ryotaro Nakamura
- City of Hope National Medical Center, Duarte, California, United States
| | - John E Levine
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Yi-Bin Chen
- Massachusetts General Hospital, Boston, Massachusetts, United States
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4
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Takahashi T, Watkins B, Bratrude B, Neuberg D, Hebert K, Betz K, Yu A, Choi SW, Davis J, Duncan C, Giller R, Grimley M, Harris AC, Jacobsohn D, Lalefar N, Farhadfar N, Pulsipher MA, Shenoy S, Petrovic A, Schultz KR, Yanik GA, Blazar BR, Horan JT, Langston A, Kean LS, Qayed M. The Adverse Event Landscape of Stem Cell Transplant: Evidence for aGVHD Driving Early Transplant Associated Toxicities. Transplant Cell Ther 2024:S2666-6367(24)00317-8. [PMID: 38583802 DOI: 10.1016/j.jtct.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 03/07/2024] [Revised: 03/26/2024] [Accepted: 03/30/2024] [Indexed: 04/09/2024]
Abstract
Although unrelated-donor (URD) hematopoietic cell transplantation (HCT) is associated with many toxicities, a detailed analysis of adverse events, as defined by the Common Terminology Criteria for Adverse Events (CTCAE), has not previously been curated. This represents a major unmet need, especially as it relates to assessing the safety of novel agents. We analyzed a detailed AE database from the "ABA2" randomized, double-blind, placebo-controlled clinical trial of abatacept for acute graft-versus-host disease (aGVHD) prevention, for which the FDA mandated a detailed AE assessment through Day +180, and weekly neutrophil and platelet counts through Day +100. These were analyzed for their relationship to key transplant outcomes, with a major focus on the impact of aGVHD on the development/severity of AEs. A total of 2102 AEs and 1816 neutrophil/platelet counts were analyzed from 142 8/8-HLA-matched URD HCT recipients on ABA2 (placebo cohort, n = 69, abatacept cohort, n = 73). This analysis resulted in 2 major observations. (1) Among graft source, conditioning intensity, age, and Grade 2 to 4 aGVHD, only aGVHD impacted Grade 3 to 5 AE acquisition after the first month post-transplant. (2) The development of Grade 3 to 4 aGVHD was associated with thrombocytopenia. We have created a detailed resource for the transplant community by which to contextualize clinical toxicities after transplant. It has identified aGVHD as a major driver of post-HCT Grade 3 to 5 AEs, and underscored a link between aGVHD and thrombocytopenia. This establishes a critical safety framework upon which the impact of novel post-transplant aGVHD therapeutics should be evaluated. This trial was registered at www.clinicaltrials.gov (#NCT01743131).
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Affiliation(s)
- Takuto Takahashi
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, Georgia
| | - Brandi Bratrude
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Donna Neuberg
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kyle Hebert
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kayla Betz
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Alison Yu
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Jeffrey Davis
- BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christine Duncan
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Roger Giller
- Center for Cancer and Blood Disorders, Children Hospital of Colorado, University of Colorado, Aurora, Colorado
| | - Michael Grimley
- University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Andrew C Harris
- Memorial Sloan Kettering Cancer Center, New York City, New York
| | - David Jacobsohn
- Children's National Health System, Washington, District of Columbia
| | - Nahal Lalefar
- University of California San Francisco, UCSF Benioff Children's Hospital Oakland, Oakland, California
| | | | - Michael A Pulsipher
- Spencer Fox Eccles School of Medicine at the University of Utah, Intermountain Primary Children's Hospital, Salt Lake City, Utah
| | - Shalini Shenoy
- Washington University School of Medicine, St Louis, Missouri
| | - Aleksandra Petrovic
- Seattle Children's Hospital and Fred Hutch Cancer Center, Seattle, Washington
| | - Kirk R Schultz
- BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Bruce R Blazar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - John T Horan
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amelia Langston
- Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Leslie S Kean
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, Georgia
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5
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Spyrou N, Akahoshi Y, Kowalyk S, Morales G, Beheshti R, Aguayo-Hiraldo P, Al Malki MM, Ayuk F, Bader P, Baez J, Capellini A, Choe H, DeFilipp Z, Eder M, Eng G, Etra A, Gleich S, Grupp SA, Hexner E, Hoepting M, Hogan WJ, Kasikis S, Katsivelos N, Khan A, Kitko CL, Kraus S, Kwon D, Merli P, Portelli J, Qayed M, Reshef R, Schechter T, Vasova I, Wölfl M, Wudhikarn K, Young R, Holler E, Chen YB, Nakamura R, Levine JE, Ferrara JLM. A Day 14 Endpoint for Acute GVHD Clinical Trials. Transplant Cell Ther 2024; 30:421-432. [PMID: 38320730 PMCID: PMC11009039 DOI: 10.1016/j.jtct.2024.01.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/15/2024] [Accepted: 01/25/2024] [Indexed: 02/19/2024]
Abstract
The overall response rate (ORR) 28 days after treatment has been adopted as the primary endpoint for clinical trials of acute graft versus host disease (GVHD). However, physicians often need to modify immunosuppression earlier than day (D) 28, and non-relapse mortality (NRM) does not always correlate with ORR at D28. We studied 1144 patients that received systemic treatment for GVHD in the Mount Sinai Acute GVHD International Consortium (MAGIC) and divided them into a training set (n=764) and a validation set (n=380). We used a recursive partitioning algorithm to create a Mount Sinai model that classifies patients into favorable or unfavorable groups that predicted 12 month NRM according to overall GVHD grade at both onset and D14. In the Mount Sinai model grade II GVHD at D14 was unfavorable for grade III/IV GVHD at onset and predicted NRM as well as the D28 standard response model. The MAGIC algorithm probability (MAP) is a validated score that combines the serum concentrations of suppression of tumorigenicity 2 (ST2) and regenerating islet-derived 3-alpha (REG3α) to predict NRM. Inclusion of the D14 MAP biomarker score with the D14 Mount Sinai model created three distinct groups (good, intermediate, poor) with strikingly different NRM (8%, 35%, 76% respectively). This D14 MAGIC model displayed better AUC, sensitivity, positive and negative predictive value, and net benefit in decision curve analysis compared to the D28 standard response model. We conclude that this D14 MAGIC model could be useful in therapeutic decisions and may offer an improved endpoint for clinical trials of acute GVHD treatment.
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Affiliation(s)
- Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rahnuma Beheshti
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Paibel Aguayo-Hiraldo
- Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Monzr M Al Malki
- Hematology/Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, CA
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Bader
- Division for Stem Cell Transplantation and Immunology, Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt, Germany
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexandra Capellini
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hannah Choe
- Division of Hematology, The James Comprehensive Cancer Center, The Ohio State University, Columbus, OH
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Gilbert Eng
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Aaron Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Stephan A Grupp
- Division of Oncology, Children's Hospital of Philadelphia, and Perelman School of Medicine, Philadelphia, PA
| | - Elizabeth Hexner
- Blood and Marrow Transplantation Program, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthias Hoepting
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | | | - Stelios Kasikis
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nikolaos Katsivelos
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alina Khan
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Carrie L Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville TN
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Deukwoo Kwon
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Pietro Merli
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy
| | - Joseph Portelli
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Ran Reshef
- Blood and Marrow Transplantation Program, Columbia University Medical Center, New York, NY
| | - Tal Schechter
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Ingrid Vasova
- Dept. of Internal Medicine 5, Hematology/Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Kitsada Wudhikarn
- Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Ryotaro Nakamura
- Hematology/Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, CA
| | - John E Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - James L M Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
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6
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Keller MD, Schattgen SA, Chandrakasan S, Allen EK, Jensen-Wachspress MA, Lazarski CA, Qayed M, Lang H, Hanley PJ, Tanna J, Pai SY, Parikh S, Berger SI, Gottschalk S, Pulsipher MA, Thomas PG, Bollard CM. Secondary bone marrow graft loss after third-party virus-specific T cell infusion: Case report of a rare complication. Nat Commun 2024; 15:2749. [PMID: 38553461 PMCID: PMC10980733 DOI: 10.1038/s41467-024-47056-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/20/2023] [Indexed: 04/02/2024] Open
Abstract
Virus-specific T cells (VST) from partially-HLA matched donors have been effective for treatment of refractory viral infections in immunocompromised patients in prior studies with a good safety profile, but rare adverse events have been described. Here we describe a unique and severe adverse event of VST therapy in an infant with severe combined immunodeficiency, who receives, as part of a clinical trial (NCT03475212), third party VSTs for treating cytomegalovirus viremia following bone marrow transplantation. At one-month post-VST infusion, rejection of graft and reversal of chimerism is observed, as is an expansion of T cells exclusively from the VST donor. Single-cell gene expression and T cell receptor profiling demonstrate a narrow repertoire of predominantly activated CD4+ T cells in the recipient at the time of rejection, with the repertoire overlapping more with that of peripheral blood from VST donor than the infused VST product. This case thus demonstrates a rare but serious side effect of VST therapy.
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Affiliation(s)
- Michael D Keller
- Center for Cancer and Immunology Research, Children's National Hospital, Washington, DC, USA
- Division of Allergy and Immunology, Children's National Hospital, Washington, DC, USA
- GW Cancer Center, George Washington University, Washington, DC, USA
| | - Stefan A Schattgen
- Department of Immunology, St Jude Children's Research Hospital, Memphis, TN, USA
| | | | - E Kaitlynn Allen
- Department of Immunology, St Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Christopher A Lazarski
- Center for Cancer and Immunology Research, Children's National Hospital, Washington, DC, USA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Hospital of Atlanta, Atlanta, GA, USA
| | - Haili Lang
- Center for Cancer and Immunology Research, Children's National Hospital, Washington, DC, USA
| | - Patrick J Hanley
- Center for Cancer and Immunology Research, Children's National Hospital, Washington, DC, USA
- GW Cancer Center, George Washington University, Washington, DC, USA
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC, USA
| | - Jay Tanna
- Center for Cancer and Immunology Research, Children's National Hospital, Washington, DC, USA
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC, USA
| | - Sung-Yun Pai
- Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Suhag Parikh
- Aflac Cancer and Blood Disorders Center, Children's Hospital of Atlanta, Atlanta, GA, USA
| | - Seth I Berger
- Center for Genetic Medicine Research, Children's National Hospital, Washington, DC, USA
| | - Stephen Gottschalk
- Department of Immunology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Michael A Pulsipher
- Division of Pediatric Hematology/Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Paul G Thomas
- Department of Immunology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Catherine M Bollard
- Center for Cancer and Immunology Research, Children's National Hospital, Washington, DC, USA.
- GW Cancer Center, George Washington University, Washington, DC, USA.
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC, USA.
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7
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Qayed M, Kapoor U, Gillespie S, Westbrook A, Aguayo-Hiraldo P, Ayuk FA, Aziz M, Baez J, Choe H, DeFilipp Z, Etra A, Grupp SA, Hexner E, Holler E, Hogan WJ, Kowalyk S, Merli P, Morales G, Nakamura R, Pulsipher MA, Schechter T, Shah J, Spyrou N, Srinagesh HK, Wölfl M, Yanik G, Young R, Kitko CL, Ferrara JLM, Levine JE. A Validated Risk Stratification That Incorporates MAGIC Biomarkers Predicts Long-Term Outcomes in Pediatric Patients with Acute GVHD. Transplant Cell Ther 2024:S2666-6367(24)00294-X. [PMID: 38548227 DOI: 10.1016/j.jtct.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 01/29/2024] [Revised: 03/11/2024] [Accepted: 03/20/2024] [Indexed: 04/10/2024]
Abstract
Acute graft versus host disease (GVHD) is a common and serious complication of allogeneic hematopoietic cell transplantation (HCT) in children but overall clinical grade at onset only modestly predicts response to treatment and survival outcomes. Two tools to assess risk at initiation of treatment were recently developed. The Minnesota risk system stratifies children for risk of nonrelapse mortality (NRM) according to the pattern of GVHD target organ severity. The Mount Sinai Acute GVHD International Consortium (MAGIC) algorithm of 2 serum biomarkers (ST2 and REG3α) predicts NRM in adult patients but has not been validated in a pediatric population. We aimed to develop and validate a system that stratifies children at the onset of GVHD for risk of 6-month NRM. We determined the MAGIC algorithm probabilities (MAPs) and Minnesota risk for a multicenter cohort of 315 pediatric patients who developed GVHD requiring treatment with systemic corticosteroids. MAPs created 3 risk groups with distinct outcomes at the start of treatment and were more accurate than Minnesota risk stratification for prediction of NRM (area under the receiver operating curve (AUC), .79 versus .62, P = .001). A novel model that combined Minnesota risk and biomarker scores created from a training cohort was more accurate than either biomarkers or clinical systems in a validation cohort (AUC .87) and stratified patients into 2 groups with highly different 6-month NRM (5% versus 38%, P < .001). In summary, we validated the MAP as a prognostic biomarker in pediatric patients with GVHD, and a novel risk stratification that combines Minnesota risk and biomarker risk performed best. Biomarker-based risk stratification can be used in clinical trials to develop more tailored approaches for children who require treatment for GVHD.
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Affiliation(s)
- Muna Qayed
- Emory University School of Medicine, Atlanta, Georgia; Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia.
| | - Urvi Kapoor
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Scott Gillespie
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Adrianna Westbrook
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Paibel Aguayo-Hiraldo
- Division of Hematology, Oncology, and BMT, Children's Hospital Los Angeles, Los Angeles, California
| | - Francis A Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mina Aziz
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Janna Baez
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hannah Choe
- Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Aaron Etra
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephan A Grupp
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth Hexner
- Blood and Marrow Transplantation Program, Abramson Cancer Center and the Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | | | - Steven Kowalyk
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Pietro Merli
- Ospedale Pediatrico Bambino Gesú, IRCCS, Rome, Italy
| | - George Morales
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ryotaro Nakamura
- Hematology/Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, California
| | - Michael A Pulsipher
- Division of Hematology, Oncology, and BMT, Children's Hospital Los Angeles, Los Angeles, California; Division of Hematology and Oncology, Intermountain Primary Children's Hospital, Huntsman Cancer Institute at the Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah
| | - Tal Schechter
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jay Shah
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nikolaos Spyrou
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hrishikesh K Srinagesh
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Gregory Yanik
- Pediatric Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan
| | - Rachel Young
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carrie L Kitko
- Pediatric Blood and Marrow Transplant Program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James L M Ferrara
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John E Levine
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
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8
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Schoettler ML, Patel S, Bryson E, Deeb L, Watkins B, Qayed M, Chandrakasan S, Fitch T, Silvis K, Jones J, Chonat S, Williams KM. Compassionate Use Narsoplimab for Severe Refractory Transplantation-Associated Thrombotic Microangiopathy in Children. Transplant Cell Ther 2024; 30:336.e1-336.e8. [PMID: 38145741 DOI: 10.1016/j.jtct.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 12/27/2023]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a common and potentially severe complication of hematopoietic cell transplantation. TA-TMA-directed therapy with eculizumab, a complement C5 inhibitor, has resulted in a survival benefit in some studies. However, children with TA-TMA refractory to C5 inhibition with eculizumab (rTA-TMA) have mortality rates exceeding 80%, and there are no other known therapies. Narsoplimab, an inhibitor of the MASP-2 effector enzyme of the lectin pathway, has been studied in adults with TA-TMA as first-line therapy with a response rate of 61%. Although there are limited data on narsoplimab use as a second-line agent in children, we hypothesized, that complement pathways proximal to C5 are activated in rTA-TMA, and that narsoplimab may ameliorate rTA-TMA in children. In this single-center study, children were enrolled on single-patient, Institutional Review Board-approved compassionate use protocols for narsoplimab treatment. Clinical complement lab tests were obtained at the discretion of the treating physician, although all patients were also offered participation in a companion biomarker study. Research blood samples were obtained at the time of TA-TMA diagnosis, prior to eculizumab treatment, at the time of refractory TA-TMA diagnosis prior to the first narsoplimab dose, and 2 weeks after the first narsoplimab dose. Single ELISA kits were used to measure markers of complement activation according to the manufacture's instructions. Five children with rTA-TMA received narsoplimab; 3 were in multiorgan failure and 2 had worsening multiorgan dysfunction at the time of treatment. Additional comorbidities at the time of treatment included sinusoidal obstructive syndrome (SOS; n = 3), viral infection (n = 3), and steroid-refractory stage 4 lower gut grade IV acute graft-versus-host disease (aGVHD, n = 3). Two infants with concurrent SOS and no aGVHD had resolution of organ dysfunction; 1 also developed transfusion-independence (complete response), and the other's hematologic response was not assessable in the setting of leukemia and chemotherapy (partial response). One additional patient achieved transfusion independence but had no improvement in organ manifestations (partial response), and 2 patients treated late in the course of disease had no response. Narsoplimab was well tolerated without any attributed adverse effects. Three patients consented to provide additional research blood samples. One patient with resolution of organ failure demonstrated evidence of proximal pathway activation prior to narsoplimab treatment with subsequent declines in Ba, Bb, C3a, and C5a and increases in C3 in both clinical and research lab tests. Otherwise, there was no clear pattern of other complement markers, including MASP-2 levels, after therapy. In this cohort of ill children with rTA-TMA and multiple comorbidities, 3 patients benefited from narsoplimab. Notably, the 2 patients with resolution of organ involvement did not have steroid-refractory aGVHD, which is thought to be a critical driver of TA-TMA. Additional studies are needed to determine which patients are most likely to benefit from narsoplimab and which markers may be most helpful for monitoring lectin pathway activation and inhibition.
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Affiliation(s)
- Michelle L Schoettler
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia.
| | - Seema Patel
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Elyse Bryson
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Laura Deeb
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Shanmuganathan Chandrakasan
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Taylor Fitch
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Katherine Silvis
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Jayre Jones
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
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9
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Schoettler ML, French K, Harris A, Bryson E, Deeb L, Hudson Z, Obordo J, Chandrakasan S, Parikh S, Watkins B, Stenger E, Qayed M, Chonat S, Westbrook A, Switchenko J, Williams KM. D-dimer and sinusoidal obstructive syndrome-novel poor prognostic features of thrombotic microangiopathy in children after hematopoietic cellular therapy in a single institution prospective cohort study. Am J Hematol 2024; 99:370-379. [PMID: 38164997 DOI: 10.1002/ajh.27186] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/03/2023] [Indexed: 01/03/2024]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a common, severe complication of allogeneic hematopoietic cellular therapy (HCT). Even when treated in many studies, morbidity and mortality rates are high. This prospective single-institution cohort study serially enrolled all allogeneic HCT recipients from August 2019-August 2022. Patients were universally screened for TA-TMA and intermediate and high-risk patients were immediately treated with eculizumab. Sub-distribution cox-proportional hazards models were used to identify sub-distribution hazard ratios (sHR) for multi-organ dysfunction (MOD) and non-relapse-related mortality (NRM). Of 136 patients, 36 (26%) were diagnosed with TA-TMA and 21/36 (58%) developed MOD, significantly more than those without TA-TMA, (p < .0001). Of those with TA-TMA, 18 (50%) had high-risk TA-TMA (HR-TA-TMA), 11 (31%) had intermediate-risk TA-TMA (IR-TA-TMA), and 8 (22%) had standard risk (SR-TA-TMA). Twenty-six were treated with eculizumab (1/8 SR, 7/11 IR, and 18/18 HR). Elevated D-dimer predicted the development of MOD (sHR 7.6, 95% confidence interval [CI] 1.8-32.3). Children with concurrent sinusoidal obstructive syndrome (SOS) and TA-TMA had an excess risk of MOD of 34% and data supported a biologic interaction. The adjusted NRM risk was significantly higher in the TA-TMA patients (sHR 10.54, 95% CI 3.8-29.2, p < .0001), despite prompt treatment with eculizumab. Significant RF for NRM in TA-TMA patients included SOS (HR 2.89, 95% 1.07-7.80) and elevated D-dimer (HR 3.82, 95% CI 1.14-12.84). An unrelated donor source and random urine protein to creatine ratio ≥2 mg/mg were significantly associated with no response to eculizumab (odds ratio 15, 95% CI 2.0-113.6 and OR 6.5, 95% CI 1.1-38.6 respectively). TA-TMA was independently associated with NRM despite early diagnosis and treatment with eculizumab in this large pediatric transplant cohort. Prognostic implications of D-dimer in TA-TMA merit further investigation as this is a readily accessible biomarker. Concurrent SOS is an exclusion criterion of many ongoing clinical trials, but these data highlight these patients could benefit from novel therapeutic approaches. Multi-institutional clinical trials are needed to understand the impact of TA-TMA-targeted therapies.
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Affiliation(s)
- Michelle L Schoettler
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Kaley French
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Anora Harris
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Elyse Bryson
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Laura Deeb
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Zuri Hudson
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Jeremy Obordo
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Shanmuganathan Chandrakasan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Suhag Parikh
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Elizabeth Stenger
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | - Adrianna Westbrook
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
| | | | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Pediatric Hematopoietic Cellular Therapy, Atlanta, Georgia, USA
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10
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Gorfinkel L, Raghunandan S, Watkins B, Hebert K, Neuberg DS, Bratrude B, Betz K, Yu A, Choi SW, Davis J, Duncan C, Giller R, Grimley M, Harris AC, Jacobsohn D, Lalefar N, Farhadfar N, Pulsipher MA, Shenoy S, Petrovic A, Schultz KR, Yanik GA, Blazar BR, Horan JT, Langston A, Kean LS, Qayed M. Overlap chronic GVHD is associated with adverse survival outcomes compared to classic chronic GVHD. Bone Marrow Transplant 2024:10.1038/s41409-024-02245-y. [PMID: 38383714 DOI: 10.1038/s41409-024-02245-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/20/2023] [Accepted: 02/07/2024] [Indexed: 02/23/2024]
Abstract
Chronic graft-versus-host-disease (cGVHD) is divided into two subtypes: classic (absence of acute GVHD features) and overlap cGVHD ('ocGVHD'), in which both chronic and acute GVHD clinical features are present simultaneously. While worse outcomes with ocGVHD have been reported, there are few recent analyses. We performed a secondary analysis of data from the ABA2 trial (N = 185), in which detailed GVHD data were collected prospectively and systematically adjudicated. Analyses included cumulative incidence of classic versus ocGVHD, their specific organ manifestations, global disease severity scores, non-relapse mortality (NRM), disease-free survival (DFS) and overall survival (OS) in these two cGVHD subtypes. Of 92 patients who developed cGVHD, 35 were classified as ocGVHD. The 1-year cumulative incidence, organ involvement, and global severity of classic and ocGVHD were similar between ABA2 patients receiving CNI/MTX+placebo and CNI/MTX+abatacept; thus, cohorts were combined for ocGVHD evaluation. This analysis identified ocGVHD as having significantly higher severity at presentation and at maximum global severity compared to classic cGVHD. OS and DFS were significantly lower for ocGVHD versus classic cGVHD. OcGVHD is associated with increased cGVHD severity scores, and is associated with decreased OS and DFS compared to classic cGVHD, underscoring the high risks with this cGVHD subtype.
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Affiliation(s)
- Lev Gorfinkel
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sharmila Raghunandan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
| | - Kyle Hebert
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Donna S Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Brandi Bratrude
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kayla Betz
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Alison Yu
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Jeffrey Davis
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Christine Duncan
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Roger Giller
- Center for Cancer and Blood Disorders, Children Hospital of Colorado, University of Colorado, Aurora, CO, USA
| | - Michael Grimley
- University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | - Nahal Lalefar
- University of California San Francisco, UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | | | | | - Shalini Shenoy
- Washington University School of Medicine, St Louis, MO, USA
| | | | - Kirk R Schultz
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | | | - Bruce R Blazar
- University of Minnesota, Department of Pediatrics, Division of Blood and Marrow Transplantation, Minneapolis, MN, USA
| | - John T Horan
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Amelia Langston
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Leslie S Kean
- Boston Children's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA.
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11
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Watkins B, Qayed M. Novel approaches to acute graft-versus-host disease prevention. Hematology Am Soc Hematol Educ Program 2023; 2023:155-163. [PMID: 38066861 PMCID: PMC10727007 DOI: 10.1182/hematology.2023000426] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The field of graft-versus-host disease (GvHD) has experienced significant growth, with increased number of clinical trials and the approval of several agents by the US Food and Drug Administration for both acute and chronic GvHD treatment. In addition, the development of prognostic biomarker algorithms has enabled risk stratification in acute GvHD. However, prevention remains the cornerstone of GvHD management. Notable recent changes include the expansion of donor options with the increased use of haploidentical donor and unrelated donor transplantation, the development of ex vivo selective T-cell depletion strategies, recent approval by the Food and Drug Administration of abatacept for GvHD prevention, and the application of posttransplant cyclophosphamide in matched and mismatched donor settings. In this article, we review the results of recent clinical trials in GvHD prophylaxis and discuss the changes in clinical practice and promising emerging strategies driving the field forward.
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Affiliation(s)
- Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA
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12
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Patel PA, Teherani MF, Xiang Y, Bernardo V, Chandrakasan S, Goggin KP, Haight A, Horwitz E, Liang WH, Parikh SH, Schoettler ML, Spencer K, Stenger E, Watkins B, Williams KM, Leung K, Jaggi P, Qayed M. Short-Course Empiric Antibiotics in Children Undergoing Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2023; 29:778.e1-778.e6. [PMID: 37739225 DOI: 10.1016/j.jtct.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 09/24/2023]
Abstract
Fever is common in children undergoing hematopoietic cell transplantation (HCT). Empiric antibiotic (EA) therapy is initiated and often continued until neutrophil engraftment. Prolonged antibiotic exposure reduces microbiome diversity and causes overgrowth of pathogenic organisms, leading to such complications as infections from antibiotic-resistant organisms and Clostridium difficile colitis. Shorter courses of EA therapy have been studied in adults undergoing HCT without significant safety concerns, but data in children are lacking. We instituted a single-center preintervention/ postintervention quality improvement (QI) project to assess the feasibility of short-course EA therapy for first fever in patients undergoing HCT. We aimed to reduce the median duration of broad-spectrum antibiotic use in eligible patients from 20 days in 2020 to 10 days in 2021. Patients were eligible for the intervention, limiting EAs to 7 days for first fever, if they were admitted for their first allogeneic HCT, were afebrile for >24 hours, had no infection requiring systemic treatment, and were hemodynamically stable. Outcome measures included days of EA therapy for first fever and total broad-spectrum antibiotic use during the period of hospitalization, defined as the time from the start of conditioning to 30 days after HCT or hospital discharge, whichever occurred first. Balancing measures included bloodstream infection (BSI), fever, and intensive care (ICU) admission within 3 days of stopping EA therapy. Project criteria were applied retrospectively to patients who underwent HCT in 2020 to construct a preintervention short-course-eligible cohort. During the intervention period, 41 patients underwent allogeneic HCT, of whom 17 (41%) were eligible for short-course EA therapy. Among eligible patients, the median age was 5.3 years, 47% had an underlying malignancy, and 88% received myeloablative conditioning. There were no differences in demographic or HCT characteristics between patients eligible for short-course EA during the intervention and preintervention period (n = 24). The short-course EA schedule was adhered to by 14 of the 17 eligible patients (82%). The duration of EA for first fever and total broad-spectrum antibiotic use was significantly decreased in the short-course EA-eligible patients compared to the preintervention cohort, from a median of 17 days to 8 days and from 20 days to 10 days, respectively (P < .01). Of the 14 patients adhering to short-course EA, 2 experienced a balancing measure of recurrent fever requiring resumption of EA, but no infection was identified. There were no BSIs, ICU admissions, or deaths during the hospitalization period in patients who received short-course EA. In this single-center QI project, short-course EA for initial fever was successfully applied to children undergoing allogeneic HCT using strict criteria and led to a significant decrease in broad-spectrum antibiotic use during hospitalization. These results should be validated in a prospective clinical trial to include the impact of short-course EA on antibiotic-resistant organisms, the intestinal microbiome, and HCT outcomes.
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Affiliation(s)
- Pratik A Patel
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia; Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia.
| | - Mehgan F Teherani
- Division of Pediatric Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yijin Xiang
- Department of Pediatrics, Emory University, Atlanta, Georgia
| | | | - Shanmuganathan Chandrakasan
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kathryn P Goggin
- Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia
| | - Ann Haight
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Edwin Horwitz
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Wayne H Liang
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Suhag H Parikh
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Michelle L Schoettler
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | | | - Elizabeth Stenger
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Benjamin Watkins
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kirsten M Williams
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kathryn Leung
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Preeti Jaggi
- Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia
| | - Muna Qayed
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
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13
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Knight TE, Ahn KW, Hebert KM, Atshan R, Wall DA, Chiengthong K, Lund TC, Prestidge T, Rangarajan HG, Dvorak CC, Auletta JJ, Kent M, Hashem H, Talano JA, Rotz SJ, Fraint E, Myers KC, Leung W, Sharma A, Bhatt NS, Driscoll TA, Yu LC, Schultz KR, Qayed M, Broglie L, Eapen M, Yanik GA. No impact of CD34 + cell dose on outcome among children undergoing autologous hematopoietic stem cell transplant for high-risk neuroblastoma. Bone Marrow Transplant 2023; 58:1390-1393. [PMID: 37666957 DOI: 10.1038/s41409-023-02092-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 09/06/2023]
Affiliation(s)
- Tristan E Knight
- Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Kwang Woo Ahn
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kyle M Hebert
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rasha Atshan
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Donna A Wall
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Kanhatai Chiengthong
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Troy C Lund
- Division of Pediatric Blood and Marrow Transplantation & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Tim Prestidge
- Blood and Cancer Centre, Starship Children's Hospital, Auckland, New Zealand
| | - Hemalatha G Rangarajan
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Jeffery J Auletta
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, MN, USA
- Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children's Hospital, Columbus, OH, USA
| | - Michael Kent
- Atrium Health Levine Children's, Charlotte, NC, USA
| | - Hasan Hashem
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, King Hussein Cancer Center, Amman, Jordan
| | - Julie-An Talano
- Department of Pediatric Hematology Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, OH, USA
| | - Ellen Fraint
- Division of Pediatric Hematology, Oncology, and Cellular Therapy, The Children's Hospital at Montefiore, Bronx, NY, USA
| | - Kasiani C Myers
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Wing Leung
- Duke-NUS Medical School, Singapore, Singapore
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Neel S Bhatt
- Division of Hematology and Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Timothy A Driscoll
- Duke University Pediatric Transplantation and Cellular Therapy, Durham, NC, USA
| | - Lolie C Yu
- Division of Hematology/Oncology & HSCT, The Center for Cancer and Blood Disorders, Children's Hospital, Louisiana State University Medical Center, New Orleans, LA, USA
| | - Kirk R Schultz
- Department of Pediatric Hematology, Oncology and Bone Marrow Transplant, British Columbia's Children's Hospital, The University of British Columbia, Vancouver, BC, Canada
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Larisa Broglie
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
- Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Mary Eapen
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Gregory A Yanik
- Mott Children's Hospital, University of Michigan Medical Center, Ann Arbor, MI, USA
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14
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Zinter MS, Dvorak CC, Mayday MY, Reyes G, Simon MR, Pearce EM, Kim H, Shaw PJ, Rowan CM, Auletta JJ, Martin PL, Godder K, Duncan CN, Lalefar NR, Kreml EM, Hume JR, Abdel-Azim H, Hurley C, Cuvelier GDE, Keating AK, Qayed M, Killinger JS, Fitzgerald JC, Hanna R, Mahadeo KM, Quigg TC, Satwani P, Castillo P, Gertz SJ, Moore TB, Hanisch B, Abdel-Mageed A, Phelan R, Davis DB, Hudspeth MP, Yanik GA, Pulsipher MA, Sulaiman I, Segal LN, Versluys BA, Lindemans CA, Boelens JJ, DeRisi JL. Pulmonary microbiome and transcriptome signatures reveal distinct pathobiologic states associated with mortality in two cohorts of pediatric stem cell transplant patients. medRxiv 2023:2023.11.29.23299130. [PMID: 38077035 PMCID: PMC10705623 DOI: 10.1101/2023.11.29.23299130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
Lung injury is a major determinant of survival after pediatric hematopoietic cell transplantation (HCT). A deeper understanding of the relationship between pulmonary microbes, immunity, and the lung epithelium is needed to improve outcomes. In this multicenter study, we collected 278 bronchoalveolar lavage (BAL) samples from 229 patients treated at 32 children's hospitals between 2014-2022. Using paired metatranscriptomes and human gene expression data, we identified 4 patient clusters with varying BAL composition. Among those requiring respiratory support prior to sampling, in-hospital mortality varied from 22-60% depending on the cluster (p=0.007). The most common patient subtype, Cluster 1, showed a moderate quantity and high diversity of commensal microbes with robust metabolic activity, low rates of infection, gene expression indicating alveolar macrophage predominance, and low mortality. The second most common cluster showed a very high burden of airway microbes, gene expression enriched for neutrophil signaling, frequent bacterial infections, and moderate mortality. Cluster 3 showed significant depletion of commensal microbes, a loss of biodiversity, gene expression indicative of fibroproliferative pathways, increased viral and fungal pathogens, and high mortality. Finally, Cluster 4 showed profound microbiome depletion with enrichment of Staphylococci and viruses, gene expression driven by lymphocyte activation and cellular injury, and the highest mortality. BAL clusters were modeled with a random forest classifier and reproduced in a geographically distinct validation cohort of 57 patients from The Netherlands, recapitulating similar cluster-based mortality differences (p=0.022). Degree of antibiotic exposure was strongly associated with depletion of BAL microbes and enrichment of fungi. Potential pathogens were parsed from all detected microbes by analyzing each BAL microbe relative to the overall microbiome composition, which yielded increased sensitivity for numerous previously occult pathogens. These findings support personalized interpretation of the pulmonary microenvironment in pediatric HCT, which may facilitate biology-targeted interventions to improve outcomes.
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Affiliation(s)
- Matt S Zinter
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
- Division of Allergy, Immunology, and Bone Marrow Transplantation, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Christopher C Dvorak
- Division of Allergy, Immunology, and Bone Marrow Transplantation, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Madeline Y Mayday
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
- Departments of Laboratory Medicine and Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Gustavo Reyes
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Miriam R Simon
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Emma M Pearce
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Hanna Kim
- Division of Critical Care Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Peter J Shaw
- The Children`s Hospital at Westmead, Sydney, Australia
| | - Courtney M Rowan
- Indiana University, Department of Pediatrics, Division of Critical Care Medicine, Indianapolis, IN, USA
| | - Jeffrey J Auletta
- Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children's Hospital, Columbus, OH, USA
- CIBMTR (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, MN, USA
| | - Paul L Martin
- Division of Pediatric and Cellular Therapy, Duke University Medical Center, Durham, NC, USA
| | - Kamar Godder
- Cancer and Blood Disorders Center, Nicklaus Children's Hospital, Miami, FL, USA
| | - Christine N Duncan
- Harvard Medical School, Boston, Massachusetts; Division of Pediatric Oncology, Department of Pediatrics, Dana-Farber Cancer Institute and Boston Children's Hospital, Boston, MA, USA
| | - Nahal R Lalefar
- Division of Pediatric Hematology/Oncology, UCSF Benioff Children's Hospital Oakland, University of California San Francisco, Oakland, CA, USA
| | - Erin M Kreml
- Department of Child Health, Division of Critical Care Medicine, University of Arizona, Phoenix, AZ, USA
| | - Janet R Hume
- University of Minnesota, Department of Pediatrics, Division of Critical Care Medicine, Minneapolis, MN, USA
| | - Hisham Abdel-Azim
- Department of Pediatrics, Division of Hematology/Oncology and Transplant and Cell Therapy, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Loma Linda University School of Medicine, Cancer Center, Children Hospital and Medical Center, Loma Linda, CA, USA
| | - Caitlin Hurley
- Division of Critical Care, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Geoffrey D E Cuvelier
- CancerCare Manitoba, Manitoba Blood and Marrow Transplant Program, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amy K Keating
- Center for Cancer and Blood Disorders, Children's Hospital Colorado and University of Colorado, Aurora, CO, USA
- Harvard Medical School, Boston, Massachusetts; Division of Pediatric Oncology, Department of Pediatrics, Dana-Farber Cancer Institute and Boston Children's Hospital, Boston, MA, USA
| | - Muna Qayed
- Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA
| | - James S Killinger
- Division of Pediatric Critical Care, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Rabi Hanna
- Department of Pediatric Hematology, Oncology and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kris M Mahadeo
- Department of Pediatrics, Division of Hematology/Oncology, MD Anderson Cancer Center, Houston, TX, USA
- Division of Pediatric and Cellular Therapy, Duke University Medical Center, Durham, NC, USA
| | - Troy C Quigg
- Pediatric Blood and Marrow Transplantation Program, Texas Transplant Institute, Methodist Children's Hospital, San Antonio, TX, USA
- Section of Pediatric BMT and Cellular Therapy, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - Prakash Satwani
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, Columbia University, New York, NY, USA
| | - Paul Castillo
- University of Florida, Gainesville, UF Health Shands Children's Hospital, Gainesville, FL, USA
| | - Shira J Gertz
- Department of Pediatrics, Division of Critical Care Medicine, Joseph M Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack, NJ, USA
- Department of Pediatrics, St. Barnabas Medical Center, Livingston, NJ, USA
| | - Theodore B Moore
- Department of Pediatric Hematology-Oncology, Mattel Children's Hospital, University of California, Los Angeles, CA, USA
| | - Benjamin Hanisch
- Children's National Hospital, Washington, District of Columbia, USA
| | - Aly Abdel-Mageed
- Section of Pediatric BMT and Cellular Therapy, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - Rachel Phelan
- Division of Pediatric Hematology/Oncology/BMT, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Dereck B Davis
- Department of Pediatrics, Hematology/Oncology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Michelle P Hudspeth
- Adult and Pediatric Blood & Marrow Transplantation, Pediatric Hematology/Oncology, Medical University of South Carolina Children's Hospital/Hollings Cancer Center, Charleston, SC, USA
| | - Greg A Yanik
- Pediatric Blood and Bone Marrow Transplantation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael A Pulsipher
- Division of Hematology, Oncology, Transplantation, and Immunology, Primary Children's Hospital, Huntsman Cancer Institute, Spense Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT, USA
| | - Imran Sulaiman
- Departments of Respiratory Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Laura and Isaac Perlmutter Cancer Center, New York University Grossman School of Medicine, New York University (NYU) Langone Health, New York, NY, USA
| | - Leopoldo N Segal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Laura and Isaac Perlmutter Cancer Center, New York University Grossman School of Medicine, New York University (NYU) Langone Health, New York, NY, USA
| | - Birgitta A Versluys
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Division of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
| | - Caroline A Lindemans
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Laura and Isaac Perlmutter Cancer Center, New York University Grossman School of Medicine, New York University (NYU) Langone Health, New York, NY, USA
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Jaap J Boelens
- Department of Stem Cell Transplantation, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
- Division of Pediatrics, University Medical Center Utrecht, Utrecht, Netherlands
- Transplantation and Cellular Therapy, MSK Kids, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph L DeRisi
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
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15
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Raghunandan S, Gorfinkel L, Bratrude B, Suessmuth Y, Hebert K, Neuberg D, Williams KM, Schoettler ML, Langston AA, Kean LS, Qayed M, Horan J, Watkins BK. Abatacept for the prevention of graft versus host disease in pediatric patients receiving 7/8 HLA-mismatched unrelated transplant for hematologic malignancies: a real-world analysis. Bone Marrow Transplant 2023; 58:1260-1263. [PMID: 37580396 PMCID: PMC10622310 DOI: 10.1038/s41409-023-02034-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/15/2023] [Accepted: 07/03/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Sharmila Raghunandan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA.
| | - Lev Gorfinkel
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | - Brandi Bratrude
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | - Yvonne Suessmuth
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
| | - Kyle Hebert
- Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
| | - Michelle L Schoettler
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
| | | | - Leslie S Kean
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
| | - John Horan
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | - Benjamin K Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, GA, USA
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16
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Barsan V, Li Y, Prabhu S, Baggott C, Nguyen K, Pacenta H, Phillips CL, Rossoff J, Stefanski H, Talano JA, Moskop A, Baumeister S, Verneris MR, Myers GD, Karras NA, Cooper S, Qayed M, Hermiston M, Satwani P, Krupski C, Keating A, Fabrizio V, Chinnabhandar V, Kunicki M, Curran KJ, Mackall CL, Laetsch TW, Schultz LM. Tisagenlecleucel utilisation and outcomes across refractory, first relapse and multiply relapsed B-cell acute lymphoblastic leukemia: a retrospective analysis of real-world patterns. EClinicalMedicine 2023; 65:102268. [PMID: 37954907 PMCID: PMC10632672 DOI: 10.1016/j.eclinm.2023.102268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 09/19/2023] [Accepted: 09/26/2023] [Indexed: 11/14/2023] Open
Abstract
Background Tisagenlecleucel was approved by the Food and Drug Administration (FDA) in 2017 for refractory B-cell acute lymphoblastic leukemia (B-ALL) and B-ALL in ≥2nd relapse. Outcomes of patients receiving commercial tisagenlecleucel upon 1st relapse have yet to be established. We aimed to report real-world tisagenlecleucel utilisation patterns and outcomes across indications, specifically including patients treated in 1st relapse, an indication omitted from formal FDA approval. Methods We conducted a retrospective analysis of real-world tisagenlecleucel utilisation patterns across 185 children and young adults treated between August 30, 2017 and March 6, 2020 from centres participating in the Pediatric Real-World CAR Consortium (PRWCC), within the United States. We described definitions of refractory B-ALL used in the real-world setting and categorised patients by reported Chimeric Antigen Receptor (CAR) T-cell indication, including refractory, 1st relapse and ≥2nd relapse B-ALL. We analysed baseline patient characteristics and post-tisagenlecleucel outcomes across defined cohorts. Findings Thirty-six percent (n = 67) of our cohort received tisagenlecleucel following 1st relapse. Of 66 evaluable patients, 56 (85%, 95% CI 74-92%) achieved morphologic complete response. Overall-survival (OS) and event-free survival (EFS) at 1-year were 69%, (95% CI 58-82%) and 49%, (95% CI 37-64%), respectively, with survival outcomes statistically comparable to remaining patients (OS; p = 0.14, EFS; p = 0.39). Notably, toxicity was increased in this cohort, warranting further study. Interestingly, of 30 patients treated for upfront refractory disease, 23 (77%, 95% CI 58-90%) had flow cytometry and/or next-generation sequencing (NGS) minimum residual disease (MRD)-only disease at the end of induction, not meeting the historic morphologic definition of refractory. Interpretation Our findings suggested that tisagenlecleucel response and survival rates overlap across patients treated with upfront refractory B-ALL, B-ALL ≥2nd relapse and B-ALL in 1st relapse. We additionally highlighted that definitions of refractory B-ALL are evolving beyond morphologic measures of residual disease. Funding St. Baldrick's/Stand Up 2 Cancer, Parker Institute for Cancer Immunotherapy, Virginia and D.K. Ludwig Fund for Cancer Research.
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Affiliation(s)
- Valentin Barsan
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Road, Suite 300, Palo Alto, CA 94304, USA
| | - Yimei Li
- Department of Pediatrics, Children's Hospital of Philadelphia/University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Snehit Prabhu
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Road, Suite 300, Palo Alto, CA 94304, USA
| | - Christina Baggott
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Road, Suite 300, Palo Alto, CA 94304, USA
| | - Khanh Nguyen
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Road, Suite 300, Palo Alto, CA 94304, USA
| | - Holly Pacenta
- Cook Children’s Hospital, 1500 Cooper St 5th Floor, Fort Worth, TX 76104, USA
- Department of Pediatrics, The University of Texas Southwestern Medical Center/Children’s Health, 5323 Harry Hines Blvd., Dallas, TX 75390-9063, USA
| | - Christine L. Phillips
- Department of Pediatrics, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
- Cincinnati Children’s Hospital Medical Center, Cancer and Blood Disease Institute, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
| | - Jenna Rossoff
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Chicago, IL 60611, USA
| | - Heather Stefanski
- Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical School, 2450 Riverside Ave S AO-102, Minneapolis, MN 55454, USA
| | - Julie-An Talano
- Department of Pediatric Hematology Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA
| | - Amy Moskop
- Department of Pediatric Hematology Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA
| | - Susanne Baumeister
- Dana Farber/Boston Children’s Hospital, 450 Brookline Avenue Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA 02115, USA
| | - Michael R. Verneris
- University of Colorado, Anschutz Medical Campus, Colorado Children’s Hospital, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | | | - Nicole A. Karras
- Department of Pediatrics, City of Hope National Medical Center, 1500 E Duarte Rd, Duarte, CA 91010, USA
| | - Stacy Cooper
- Department of Oncology, Sidney Kimmel Cancer Center at John Hopkins School of Medicine, Baltimore, MD, USA
| | - Muna Qayed
- Emory University and Children’s Healthcare of Atlanta, 2015 Uppergate Drive, Atlanta, GA 30322, USA
| | - Michelle Hermiston
- University of California San Francisco Benioff Children’s Hospital, 1975 4th St., San Francisco, CA 94158, USA
| | - Prakash Satwani
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant, Department of Pediatrics, Columbia University Medical Center, 630 West 168th Street, New York, NY 10032, USA
| | - Christa Krupski
- Department of Pediatrics, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
- Cincinnati Children’s Hospital Medical Center, Cancer and Blood Disease Institute, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
| | - Amy Keating
- University of Colorado, Anschutz Medical Campus, Colorado Children’s Hospital, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Vanessa Fabrizio
- University of Colorado, Anschutz Medical Campus, Colorado Children’s Hospital, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Vasant Chinnabhandar
- Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical School, 2450 Riverside Ave S AO-102, Minneapolis, MN 55454, USA
| | - Michael Kunicki
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Road, Suite 300, Palo Alto, CA 94304, USA
| | - Kevin J. Curran
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Crystal L. Mackall
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Road, Suite 300, Palo Alto, CA 94304, USA
- Center for Cancer Cell Therapy, Stanford University School of Medicine, Stanford Cancer Institute, 265 Campus Drive, Stanford, CA 94305, USA
- Division of Blood and Bone Marrow Transplantation, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Room H0101, Stanford, CA 94305-5623, USA
| | - Theodore W. Laetsch
- Department of Pediatrics, Children's Hospital of Philadelphia/University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Liora M. Schultz
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Road, Suite 300, Palo Alto, CA 94304, USA
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17
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Raghunandan S, Qayed M, Watkins BK, Graiser M, Gorfinkel L, Westbrook A, Gillespie S, Bratrude B, Petrovic A, Suessmuth Y, Horan J, Kean LS, Langston AA. Abatacept for graft versus host disease prophylaxis in patients 60 years and older receiving mismatched unrelated donor transplantation for hematologic malignancies. Bone Marrow Transplant 2023; 58:1264-1266. [PMID: 37580397 PMCID: PMC10622309 DOI: 10.1038/s41409-023-02043-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/02/2023] [Accepted: 07/11/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Sharmila Raghunandan
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA.
- Emory University, Atlanta, GA, USA.
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
- Emory University, Atlanta, GA, USA
| | - Ben K Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
- Emory University, Atlanta, GA, USA
| | - Michael Graiser
- Emory University, Atlanta, GA, USA
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Lev Gorfinkel
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | | | | | | | | | - Yvonne Suessmuth
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
- Emory University, Atlanta, GA, USA
| | - John Horan
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | - Leslie S Kean
- Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | - Amelia A Langston
- Emory University, Atlanta, GA, USA
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
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18
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Hughes C, Harris A, Watkins B, Qayed M, Parikh S, Horwitz E, Stenger E, Williams KM, Schoettler ML. Severe refractory hemorrhagic cystitis after hematopoietic cell transplantation responds to recombinant human keratinocyte growth factor-Case report and review of the literature. Pediatr Blood Cancer 2023; 70:e30606. [PMID: 37533091 DOI: 10.1002/pbc.30606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 07/10/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Catherine Hughes
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Anora Harris
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Suhag Parikh
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Edwin Horwitz
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Elizabeth Stenger
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Michelle L Schoettler
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Division of Pediatrics, Emory University, Atlanta, Georgia, USA
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19
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Spyrou N, Akahoshi Y, Ayuk F, Holler E, Choe H, Etra A, Hogan WJ, Rösler W, Hexner E, DeFilipp Z, Reshef R, Chanswangphuwana C, Qayed M, Kraus S, Eder M, Javorniczky NR, Grupp SA, Kitko CL, Merli P, Aguayo-Hiraldo P, Wölfl M, Baez J, Beheshti R, Eng G, Gleich S, Katsivelos N, Khan A, Kowalyk S, Morales G, Young R, Nakamura R, Chen YB, Levine JE, Ferrara JLM. The utility of biomarkers in acute GVHD prognostication. Blood Adv 2023; 7:5152-5155. [PMID: 37142257 PMCID: PMC10480526 DOI: 10.1182/bloodadvances.2023009929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 05/06/2023] Open
Affiliation(s)
- Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Hannah Choe
- Division of Hematology, The James Comprehensive Cancer Center, The Ohio State University, Columbus, OH
| | - Aaron Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Wolf Rösler
- Department of Internal Medicine 5, Hematology/Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Elizabeth Hexner
- Blood and Marrow Transplantation Program, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Ran Reshef
- Blood and Marrow Transplantation Program, Columbia University Medical Center, New York, NY
| | - Chantiya Chanswangphuwana
- Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Nora Rebeka Javorniczky
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, Albert Ludwigs University, Freiburg, Germany
| | - Stephan A. Grupp
- Division of Oncology, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, PA
| | - Carrie L. Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Pietro Merli
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy
| | - Paibel Aguayo-Hiraldo
- Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rahnuma Beheshti
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gilbert Eng
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Nikolaos Katsivelos
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alina Khan
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryotaro Nakamura
- Hematology/Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, CA
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - John E. Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - James L. M. Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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20
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Takahashi T, Al-Kofahi M, Jaber M, Bratrude B, Betz K, Suessmuth Y, Yu A, Neuberg DS, Choi SW, Davis J, Duncan C, Giller R, Grimley M, Harris AC, Jacobsohn D, Lalefar N, Farhadfar N, Pulsipher MA, Shenoy S, Petrovic A, Schultz KR, Yanik GA, Blazar BR, Horan JT, Watkins B, Langston A, Qayed M, Kean LS. Higher abatacept exposure after transplant decreases acute GVHD risk without increasing adverse events. Blood 2023; 142:700-710. [PMID: 37319437 PMCID: PMC10797507 DOI: 10.1182/blood.2023020035] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/04/2023] [Accepted: 05/04/2023] [Indexed: 06/17/2023] Open
Abstract
In the ABA2 study, the T-cell costimulation blockade agent, abatacept, was safe and effective in preventing acute graft-versus-host disease (aGVHD) after unrelated-donor hematopoietic cell transplant (HCT), leading to US Food and Drug Administration approval. Here, we performed a determination of abatacept pharmacokinetics (PK), which enabled an examination of how abatacept exposure-response relationships affected clinical outcomes. We performed a population PK analysis of IV abatacept using nonlinear mixed-effect modeling and assessed the association between abatacept exposure and key transplant outcomes. We tested the association between the trough after dose 1 (Ctrough_1) and grade (GR) 2 or 4 aGVHD (GR2-4 aGVHD) through day +100. An optimal Ctrough_1 threshold was identified via recursive partitioning and classification tree analysis. This demonstrated that abatacept PK was characterized by a 2-compartment model with first-order elimination. The ABA2 dosing regimen was based on previous work targeting a steady-state abatacept trough of 10 μg/mL. However, a higher Ctrough_1 (≥39 μg/mL, attained in ∼60% of patients on ABA2) was associated with a favorable GR2-4 aGVHD risk (hazard ratio, 0.35; 95% confidence interval, 0.19-0.65; P < .001), with a Ctrough_1 <39 μg/mL associated with GR2-4 aGVHD risk indistinguishable from placebo (P = .37). Importantly, no significant association was found between Ctrough_1 and key safety indicators, including relapse, and cytomegalovirus or Epstein-Barr virus viremia. These data demonstrate that a higher abatacept Ctrough_1 (≥39 μg/mL) was associated with a favorable GR2-4 aGVHD risk, without any observed exposure-toxicity relationships. This trial was registered at www.clinicaltrials.gov as #NCT01743131.
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Affiliation(s)
- Takuto Takahashi
- Division Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN
| | - Mahmoud Al-Kofahi
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN
| | - Mutaz Jaber
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN
| | - Brandi Bratrude
- Division Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kayla Betz
- Division Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Yvonne Suessmuth
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
| | - Alison Yu
- Division Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Donna S. Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Sung W. Choi
- Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Jeffrey Davis
- BC Children’s Hospital, University of British Columbia, Vancouver, Canada
| | - Christine Duncan
- Division Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Roger Giller
- Center for Cancer and Blood Disorders, Children Hospital of Colorado, University of Colorado, Aurora, CO
| | - Michael Grimley
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Andrew C. Harris
- Pediatric Bone Marrow Transplant and Cellular Therapy Program, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David Jacobsohn
- Division of Blood and Marrow Transplantation, Center for Cancer and Blood Disorders, Children’s National Health System, Washington, DC
| | - Nahal Lalefar
- Division of Pediatric Hematology/Oncology, UCSF Benioff Children’s Hospital Oakland, University of California San Francisco, Oakland, CA
| | - Nosha Farhadfar
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, FL
| | - Michael A. Pulsipher
- Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine, Primary Children’s Hospital, University of Utah, Salt Lake City, UT
| | - Shalini Shenoy
- Division Hematology/Oncology, Washington University School of Medicine, St Louis, MO
| | - Aleksandra Petrovic
- Department of Pediatrics, Seattle Children’s Hospital and Fred Hutch Cancer Center, Seattle, WA
| | - Kirk R. Schultz
- BC Children’s Hospital, University of British Columbia, Vancouver, Canada
| | | | - Bruce R. Blazar
- Division of Blood and Marrow Transplant & Cellular Therapy, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - John T. Horan
- Division Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
| | | | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
| | - Leslie S. Kean
- Division Hematology/Oncology, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
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21
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Raghunandan S, Gorfinkel L, Graiser M, Bratrude B, Suessmuth Y, Gillespie S, Westbrook AL, Williams KM, Schoettler ML, Kean LS, Horan J, Langston AA, Qayed M, Watkins B. Abatacept for the prevention of GVHD in patients receiving mismatched unrelated transplants: a real-world analysis. Blood Adv 2023; 7:4395-4399. [PMID: 37285800 PMCID: PMC10432595 DOI: 10.1182/bloodadvances.2023010225] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/16/2023] [Accepted: 05/31/2023] [Indexed: 06/09/2023] Open
Affiliation(s)
- Sharmila Raghunandan
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
| | - Lev Gorfinkel
- Dana-Farber Cancer Institute, Boston Children’s Hospital, Boston, MA
| | | | - Brandi Bratrude
- Dana-Farber Cancer Institute, Boston Children’s Hospital, Boston, MA
| | - Yvonne Suessmuth
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
| | | | | | - Kirsten M. Williams
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
| | - Michelle L. Schoettler
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
| | - Leslie S. Kean
- Dana-Farber Cancer Institute, Boston Children’s Hospital, Boston, MA
| | - John Horan
- Dana-Farber Cancer Institute, Boston Children’s Hospital, Boston, MA
| | | | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
| | - Benjamin Watkins
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
- Department of Pediatrics, Emory University, Atlanta, GA
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22
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Akahoshi Y, Spyrou N, Hogan WJ, Ayuk F, DeFilipp Z, Weber D, Choe HK, Hexner EO, Rösler W, Etra AM, Sandhu K, Yanik GA, Chanswangphuwana C, Kitko CL, Reshef R, Kraus S, Wölfl M, Eder M, Bertrand H, Qayed M, Merli P, Grupp SA, Aguayo-Hiraldo P, Schechter T, Ullrich E, Baez J, Beheshti R, Gleich S, Kowalyk S, Morales G, Young R, Kwon D, Nakamura R, Levine JE, Ferrara JLM, Chen YB. Incidence, clinical presentation, risk factors, outcomes, and biomarkers in de novo late acute GVHD. Blood Adv 2023; 7:4479-4491. [PMID: 37315175 PMCID: PMC10440469 DOI: 10.1182/bloodadvances.2023009885] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/24/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023] Open
Abstract
Late acute graft-versus-host disease (GVHD) is defined as de novo acute GVHD presenting beyond 100 days after allogeneic hematopoietic cell transplantation (HCT) without manifestations of chronic GVHD. Data are limited regarding its characteristics, clinical course, and risk factors because of underrecognition and changes in classification. We evaluated 3542 consecutive adult recipients of first HCTs at 24 Mount Sinai Acute GVHD International Consortium (MAGIC) centers between January 2014 and August 2021 to better describe the clinical evolution and outcomes of late acute GVHD. The cumulative incidence of classic acute GVHD that required systemic treatment was 35.2%, and an additional 5.7% of patients required treatment for late acute GVHD. At the onset of symptoms, late acute GVHD was more severe than classic acute GVHD based on both clinical and MAGIC algorithm probability biomarker parameters and showed a lower overall response rate on day 28. Both clinical and biomarker grading at the time of treatment stratified the risk of nonrelapse mortality (NRM) in patients with classic and late acute GVHD, respectively, but long-term NRM and overall survival did not differ between patients with classic and late acute GVHD. Advanced age, female-to-male sex mismatch, and the use of reduced intensity conditioning were associated with the development of late acute GVHD, whereas the use of posttransplant cyclophosphamide-based GVHD prevention was protective mainly because of shifts in GVHD timing. Because overall outcomes were comparable, our findings, although not definitive, suggest that similar treatment strategies, including eligibility for clinical trials, based solely on clinical presentation at onset are appropriate.
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Affiliation(s)
- Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Daniela Weber
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Hannah K. Choe
- Blood and Marrow Transplantation Program, The Ohio State University, Columbus, OH
| | - Elizabeth O. Hexner
- Department of Medicine, Division of Hematology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Wolf Rösler
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
| | - Aaron M. Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Karamjeet Sandhu
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Gregory A. Yanik
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI
| | - Chantiya Chanswangphuwana
- Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Carrie L. Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Ran Reshef
- Blood and Marrow Transplantation Program and Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children's Hospital, University Hospital of Würzburg, Würzburg, Germany
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Hannah Bertrand
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Muna Qayed
- Emory University School of Medicine, Atlanta, GA
| | - Pietro Merli
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Stephan A. Grupp
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Paibel Aguayo-Hiraldo
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, CA
| | - Tal Schechter
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Evelyn Ullrich
- Frankfurt Cancer Institute, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rahnuma Beheshti
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Deukwoo Kwon
- Department of Population Health Science and Policy, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - John E. Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - James L. M. Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
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23
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Schoettler ML, Dandoy CE, Harris A, Chan M, Tarquinio KM, Jodele S, Qayed M, Watkins B, Kamat P, Petrillo T, Obordo J, Higham CS, Dvorak CC, Westbrook A, Zinter MS, Williams KM. Diffuse alveolar hemorrhage after hematopoietic cell transplantation- response to treatments and risk factors for mortality. Front Oncol 2023; 13:1232621. [PMID: 37546403 PMCID: PMC10399223 DOI: 10.3389/fonc.2023.1232621] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/26/2023] [Indexed: 08/08/2023] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of hematopoietic cellular therapy (HCT). This study aimed to evaluate the effect of DAH treatments on outcomes using data from consecutive HCT patients clinically diagnosed with DAH from 3 institutions between January 2018-August 2022. Endpoints included sustained complete response (sCR) defined as bleeding cessation without recurrent bleeding, and non-relapse mortality (NRM). Forty children developed DAH at a median of 56.5 days post-HCT (range 1-760). Thirty-five (88%) had at least one concurrent endothelial disorder, including transplant-associated thrombotic microangiopathy (n=30), sinusoidal obstructive syndrome (n=19), or acute graft versus host disease (n=10). Fifty percent had a concurrent pulmonary infection at the time of DAH. Common treatments included steroids (n=17, 25% sCR), inhaled tranexamic acid (INH TXA,n=26, 48% sCR), and inhaled recombinant activated factor VII (INH fVIIa, n=10, 73% sCR). NRM was 56% 100 days after first pulmonary bleed and 70% at 1 year. Steroid treatment was associated with increased risk of NRM (HR 2.25 95% CI 1.07-4.71, p=0.03), while treatment with INH TXA (HR 0.43, 95% CI 0.19- 0.96, p=0.04) and INH fVIIa (HR 0.22, 95% CI 0.07-0.62, p=0.005) were associated with decreased risk of NRM. Prospective studies are warranted to validate these findings.
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Affiliation(s)
- Michelle L. Schoettler
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
| | - Christopher E. Dandoy
- Cincinnati Children’s Medical Center, Division of Bone Marrow Transplantation and Immune Deficiency, University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Anora Harris
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
| | - Marilynn Chan
- Pediatric Pulmonary Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Keiko M. Tarquinio
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Sonata Jodele
- Cincinnati Children’s Medical Center, Division of Bone Marrow Transplantation and Immune Deficiency, University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Muna Qayed
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
| | - Benjamin Watkins
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
| | - Pradip Kamat
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Toni Petrillo
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Jeremy Obordo
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
| | - Christine S. Higham
- Pediatric Allergy, Immunology, and Bone Marrow Transplant Division, University of California, San Francisco, San Francisco, CA, United States
| | - Christopher C. Dvorak
- Pediatric Allergy, Immunology, and Bone Marrow Transplant Division, University of California, San Francisco, San Francisco, CA, United States
| | - Adrianna Westbrook
- Department of Pediatrics, Pediatric Biostatistics Core, Emory University, Atlanta, GA, United States
| | - Matt S. Zinter
- Pediatric Allergy, Immunology, and Bone Marrow Transplant Division, University of California, San Francisco, San Francisco, CA, United States
- Pediatric Critical Care, University of California, San Francisco, San Francisco, CA, United States
| | - Kirsten M. Williams
- Division of Blood and Marrow Transplantation, Children’s Healthcare of Atlanta, Aflac Blood and Cancer Disorders Center, Emory University, Atlanta, GA, United States
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24
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McNerney KO, Si Lim SJ, Ishikawa K, Dreyzin A, Vatsayan A, Chen JJ, Baggott C, Prabhu S, Pacenta HL, Philips C, Rossoff J, Stefanski HE, Talano JA, Moskop A, Verneris M, Myers D, Karras NA, Brown P, Bonifant CL, Qayed M, Hermiston M, Satwani P, Krupski C, Keating AK, Baumeister SHC, Fabrizio VA, Chinnabhandar V, Egeler E, Mavroukakis S, Curran KJ, Mackall CL, Laetsch TW, Schultz LM. HLH-like toxicities predict poor survival after the use of tisagenlecleucel in children and young adults with B-ALL. Blood Adv 2023; 7:2758-2771. [PMID: 36857419 PMCID: PMC10275701 DOI: 10.1182/bloodadvances.2022008893] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 02/17/2023] [Accepted: 02/19/2023] [Indexed: 03/03/2023] Open
Abstract
Chimeric antigen receptor-associated hemophagocytic lymphohistiocytosis (HLH)-like toxicities (LTs) involving hyperferritinemia, multiorgan dysfunction, coagulopathy, and/or hemophagocytosis are described as occurring in a subset of patients with cytokine release syndrome (CRS). Case series report poor outcomes for those with B-cell acute lymphoblastic leukemia (B-ALL) who develop HLH-LTs, although larger outcomes analyses of children and young adults (CAYAs) with B-ALL who develop these toxicities after the administration of commercially available tisagenlecleucel are not described. Using a multi-institutional database of 185 CAYAs with B-ALL, we conducted a retrospective cohort study including groups that developed HLH-LTs, high-grade (HG) CRS without HLH-LTs, or no to low-grade (NLG) CRS without HLH-LTs. Primary objectives included characterizing the incidence, outcomes, and preinfusion factors associated with HLH-LTs. Among 185 CAYAs infused with tisagenlecleucel, 26 (14.1%) met the criteria for HLH-LTs. One-year overall survival and relapse-free survival were 25.7% and 4.7%, respectively, in those with HLH-LTs compared with 80.1% and 57.6%, respectively, in those without. In multivariable analysis for death, meeting criteria for HLH-LTs carried a hazard ratio of 4.61 (95% confidence interval, 2.41-8.83), controlling for disease burden, age, and sex. Patients who developed HLH-LTs had higher pretisagenlecleucel disease burden, ferritin, and C-reactive protein levels and lower platelet and absolute neutrophil counts than patients with HG- or NLG-CRS without HLH-LTs. Overall, CAYAs with B-ALL who developed HLH-LTs after tisagenlecleucel experienced high rates of relapse and nonrelapse mortality, indicating the urgent need for further investigations into prevention and optimal management of patients who develop HLH-LTs after tisagenlecleucel.
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Affiliation(s)
- Kevin O. McNerney
- Cancer and Blood Disorders Institute, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephanie J. Si Lim
- Division of Oncology, Department of Pediatrics, John A. Burns School of Medicine, University of Hawai’i at Manoa, Honolulu, HI
| | - Kyle Ishikawa
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawai’i at Manoa, Honolulu, HI
| | - Alexandra Dreyzin
- Center for Cancer and Blood Disorders, Children’s National Hospital, Washington, DC
| | - Anant Vatsayan
- Center for Cancer and Blood Disorders, Children’s National Hospital, Washington, DC
| | - John J. Chen
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawai’i at Manoa, Honolulu, HI
| | - Christina Baggott
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, CA
| | - Snehit Prabhu
- Center for Cancer Cell Therapy, Stanford Cancer Institute, School of Medicine, Stanford University, Stanford, CA
| | - Holly L. Pacenta
- Department of Pediatrics, University of Texas Southwestern Medical Center/Children’s Health, Dallas, TX
- Division of Hematology and Oncology, Cook Children’s Medical Center, Fort Worth, TX
| | - Christine Philips
- Division of Pediatrics, University of Cincinnati, Cincinnati, OH
- Cincinnati Children’s Hospital Medical Center, Cancer and Blood Disease Institute, Cincinnati, OH
| | - Jenna Rossoff
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | | | - Julie-An Talano
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin and Children’s Wisconsin, Milwaukee, WI
| | - Amy Moskop
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin and Children’s Wisconsin, Milwaukee, WI
| | - Michael Verneris
- University of Colorado School of Medicine, Children’s Hospital of Colorado, Aurora, CO
| | - Doug Myers
- Department of Hematology, Oncology and Blood and Marrow Transplantation, Children’s Mercy Hospital, University of Missouri Kansas City, Kansas City, MO
| | - Nicole A. Karras
- Department of Pediatrics, City of Hope National Medical Center, Duarte, CA
| | - Patrick Brown
- Department of Oncology, Sidney Kimmel Cancer Center, John Hopkins University School of Medicine, Baltimore, MD
| | - Challice L. Bonifant
- Department of Oncology, Sidney Kimmel Cancer Center, John Hopkins University School of Medicine, Baltimore, MD
| | - Muna Qayed
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, Aflac Cancer and Blood Disorders Center, Emory University and Children’s Healthcare of Atlanta, Atlanta, GA
| | - Michelle Hermiston
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA
| | - Prakash Satwani
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant, Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Christa Krupski
- Division of Pediatrics, University of Cincinnati, Cincinnati, OH
- Cincinnati Children’s Hospital Medical Center, Cancer and Blood Disease Institute, Cincinnati, OH
| | - Amy K. Keating
- University of Colorado School of Medicine, Children’s Hospital of Colorado, Aurora, CO
| | - Susanne H. C. Baumeister
- Division of Pediatric Hematology-Oncology, Boston Children’s Hospital, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Vanessa A. Fabrizio
- University of Colorado School of Medicine, Children’s Hospital of Colorado, Aurora, CO
| | - Vasant Chinnabhandar
- Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Emily Egeler
- Center for Cancer Cell Therapy, Stanford Cancer Institute, School of Medicine, Stanford University, Stanford, CA
| | - Sharon Mavroukakis
- Center for Cancer Cell Therapy, Stanford Cancer Institute, School of Medicine, Stanford University, Stanford, CA
| | - Kevin J. Curran
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Pediatrics, Weill Cornell Medical College, Cornell University, New York, NY
| | - Crystal L. Mackall
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, CA
- Center for Cancer Cell Therapy, Stanford Cancer Institute, School of Medicine, Stanford University, Stanford, CA
- Department of Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Theodore W. Laetsch
- Department of Pediatrics and Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Division of Oncology, Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Liora M. Schultz
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, CA
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25
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Fraint E, Abdel-Azim H, Bhatt NS, Broglie L, Chattha A, Kohorst M, Ktena YP, Lee MA, Long S, Qayed M, Sharma A, Stefanski H, Vatsayan A, Wray L, Hamadani M, Carpenter PA. Evaluation of Children with Malignancies for Blood and Marrow Transplantation: A Report from the ASTCT Committee on Practice Guidelines. Transplant Cell Ther 2023; 29:293-301. [PMID: 36775202 DOI: 10.1016/j.jtct.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/03/2023] [Indexed: 02/12/2023]
Abstract
Evaluation of a candidate for hematopoietic cell transplantation (HCT) is a complex process with substantial intercenter variability. Although literature providing guidance for evaluating the eligibility of adults is well established, similar guidance for children is lacking. To address gaps between adult recommendations and the specific needs of children, we convened a panel of pediatric HCT experts from a wide geographic range of American Society of Transplantation and Cellular Therapy (ASTCT) member institutions to offer recommendations for pediatric-focused pre-HCT evaluation. In this report from the ASTCT Committee on Practice Guidelines, we present a practical framework for evaluating children with malignancies who are candidates for HCT. We also highlight key differences from adults and emphasize areas of unmet need that require additional research to delineate best practices.
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Affiliation(s)
- Ellen Fraint
- Division of Pediatric Hematology, Oncology, and Cellular Therapy, Children's Hospital at Montefiore, Bronx, New York.
| | - Hisham Abdel-Azim
- Loma Linda University School of Medicine, Cancer Center, Children's Hospital and Medical Center, Loma Linda, California
| | - Neel S Bhatt
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Larisa Broglie
- Medical College of Wisconsin, Department of Pediatrics, Division of Pediatric Hematology/Oncology/Blood and Marrow Transplantation, Milwaukee, Wisconsin
| | - Asma Chattha
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mira Kohorst
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, Minnesota
| | - Yiouli P Ktena
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Michelle A Lee
- Division of Pediatric Hematology, Oncology, and Cellular Therapy, Children's Hospital at Montefiore, Bronx, New York
| | - Susie Long
- University of Minnesota Masonic Children's Hospital, MHealth Fairview Acute Care Pharmacy Services, Minneapolis, Minnesota
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Anant Vatsayan
- Children's National Medical Center, Washington, District of Columbia
| | - Lisa Wray
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mehdi Hamadani
- BMT & Cellular Therapy Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
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26
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Raghunandan S, Pauly M, Blum WG, Qayed M, Dhodapkar MV, Elkhalifa M, Watkins B, Schoettler M, Horwitz E, Parikh S, Chandrakasan S, Leung K, Bryson E, Deeb L, Kaufman JL, Worthington-White D, Alazraki A, Schecter JM, Madduri D, Jackson CC, Zudaire E, Taraseviciute-Morris A, Babich A, Nesheiwat T, Vogel M, Lendvai N, Pacaud L, Williams KM. BCMA CAR-T induces complete and durable remission in refractory plasmablastic lymphoma. J Immunother Cancer 2023; 11:jitc-2023-006684. [PMID: 37137553 PMCID: PMC10163502 DOI: 10.1136/jitc-2023-006684] [Citation(s) in RCA: 7] [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] [Accepted: 03/30/2023] [Indexed: 05/05/2023] Open
Abstract
Plasmablastic lymphoma (PBL) is a rare subtype of aggressive large B-cell lymphoma, with a dismal prognosis despite aggressive therapies. New approaches are needed for those with refractory disease. PBL expresses antigens similar to multiple myeloma (MM), including B-cell maturation antigen (BCMA). Chimeric antigen receptor T-cell (CAR-T) therapy directed against BCMA has shown efficacy for the treatment of heavily pretreated MM with low rates of grades 3 and 4 cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) in a phase Ib/II trial (A Study of JNJ-68284528, a CAR-T Directed Against BCMA in Participants With Relapsed or Refractory Multiple Myeloma (CARTITUDE-1), NCT03548207). However, data for the use of BCMA CAR-T for treating PBL are lacking.We report a challenging case of multiple refractory PBL that emerged from B-cell acute lymphoblastic leukemia in an adolescent who failed to respond to an allogeneic hematopoietic cell transplant. The patient developed rapidly advancing disease despite withdrawal of immunosuppression, treatment with etoposide, ibrutinib, and daratumumab, prompting consideration of BCMA CAR-T (under emergency investigational new drug (eIND)). The patient achieved a complete remission (CR), without recurrent acute graft versus host disease (GVHD), CRS or ICANS after BCMA CAR-T therapy. BCMA CAR-T expansion was detected in vivo, peaking on day 15. The patient remains in CR for more than a year post CAR-T therapy, supporting consideration of immunotherapy for future patients with refractory PBL, a disease with few treatment options.
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Affiliation(s)
- Sharmila Raghunandan
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Melinda Pauly
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - William G Blum
- Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Muna Qayed
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Madhav V Dhodapkar
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Mohamed Elkhalifa
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Benjamin Watkins
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Michelle Schoettler
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Edwin Horwitz
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Suhag Parikh
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Shanmuganathan Chandrakasan
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kathryn Leung
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Elyse Bryson
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Laura Deeb
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | - Diana Worthington-White
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Adina Alazraki
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | - Deepu Madduri
- Janssen Research and Development LLC, Raritan, New Jersey, USA
| | | | | | | | | | | | - Martin Vogel
- Janssen Global Services LLC, Raritan, New Jersey, USA
| | | | - Lida Pacaud
- Legend Biotech USA Inc, Piscataway, New Jersey, USA
| | - Kirsten M Williams
- Department of Pediatrics, Emory University School of Mecidine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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27
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Laetsch TW, Maude SL, Rives S, Hiramatsu H, Bittencourt H, Bader P, Baruchel A, Boyer M, De Moerloose B, Qayed M, Buechner J, Pulsipher MA, Myers GD, Stefanski HE, Martin PL, Nemecek E, Peters C, Yanik G, Khaw SL, Davis KL, Krueger J, Balduzzi A, Boissel N, Tiwari R, O'Donovan D, Grupp SA. Three-Year Update of Tisagenlecleucel in Pediatric and Young Adult Patients With Relapsed/Refractory Acute Lymphoblastic Leukemia in the ELIANA Trial. J Clin Oncol 2023; 41:1664-1669. [PMID: 36399695 PMCID: PMC10022844 DOI: 10.1200/jco.22.00642] [Citation(s) in RCA: 67] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 08/24/2022] [Accepted: 09/26/2022] [Indexed: 11/19/2022] Open
Abstract
Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.In the primary analysis of the global phase II ELIANA trial (ClinicalTrials.gov identifier: NCT02435849), tisagenlecleucel provided an overall remission rate of 81% in pediatric and young adult patients with relapsed or refractory B-cell acute lymphoblastic leukemia (R/R B-ALL), with 59% of responders remaining relapse-free at 12 months. Here, we report an update on efficacy, safety, and patient-reported quality of life in 79 pediatric and young adult patients with R/R B-ALL following a median follow-up of 38.8 months. The overall remission rate was 82%. The median event-free survival was 24 months, and the median overall survival was not reached. Event-free survival was 44% (95% CI, 31 to 57) and overall survival was 63% (95% CI, 51 to 73) at 3 years overall (most events occur within the first 2 years). The estimated 3-year relapse-free survival with and without censoring for subsequent therapy was 52% (95% CI, 37 to 66) and 48% (95% CI, 34 to 60), respectively. No new or unexpected long-term adverse events were reported. Grade 3/4 adverse events were reported in 29% of patients > 1 year after infusion; grade 3/4 infection rate did not increase > 1 year after infusion. Patients reported improvements in quality of life up to 36 months after infusion. These findings demonstrate favorable long-term safety and suggest tisagenlecleucel as a curative treatment option for heavily pretreated pediatric and young adult patients with R/R B-ALL.
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Affiliation(s)
- Theodore W. Laetsch
- Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Shannon L. Maude
- Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Susana Rives
- Department of Pediatric Hematology—Oncology and Institut de Recerca, Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Hidefumi Hiramatsu
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Henrique Bittencourt
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, Canada
- The Hematology Oncology Division and Charles-Bruneau Cancer Center, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada
| | - Peter Bader
- Division of Stem Cell Transplantation and Immunology, Hospital for Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
| | - André Baruchel
- University Hospital Robert Debré (APHP) and Université de Paris, Paris, France
| | - Michael Boyer
- Department of Pediatrics and Internal Medicine, University of Utah, Salt Lake City, UT
| | - Barbara De Moerloose
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, GA
| | - Jochen Buechner
- Department of Pediatric Hematology and Oncology, Oslo University Hospital, Oslo, Norway
| | - Michael A. Pulsipher
- Division of Hematology, Oncology, Blood and Marrow Transplant, Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, CA
- At the time of present work, now affiliated with Division of Pediatric Hematology and Oncology, Intermountain Primary Children's Hospital, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT
| | | | - Heather E. Stefanski
- National Bone Marrow Donor Program, Be the Match, Division of Pediatric Blood and Marrow Transplant, University of Minnesota, Minneapolis, MN
| | - Paul L. Martin
- Pediatric Transplant and Cellular Therapy, Duke University Medical Center, Durham, NC
| | | | - Christina Peters
- Stem Cell Transplantation Unit, St Anna Children's Hospital, Vienna, Austria
| | - Gregory Yanik
- Department of Pediatrics, University of Michigan Medical Center, Ann Arbor, MI
| | - Seong Lin Khaw
- Children's Cancer Centre, Royal Children's Hospital and Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Kara L. Davis
- Division of Hematology, Oncology, Stem Cell Transplant and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Joerg Krueger
- Division of Haematology/Oncology/Bone Marrow Transplantation, Hospital for Sick Children, Toronto, Canada
| | - Adriana Balduzzi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Monza, Italy
| | - Nicolas Boissel
- Saint-Louis Hospital (APHP) and Université de Paris Diderot, Paris, France
| | | | | | - Stephan A. Grupp
- Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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28
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Knight TE, Ahn KW, Hebert KM, Atshan R, Wall DA, Chiengthong K, Rotz SJ, Fraint E, Rangarajan HG, Auletta JJ, Sharma A, Kitko CL, Hashem H, Williams KM, Wirk B, Dvorak CC, Myers KC, Pulsipher MA, Warwick AB, Lalefar NR, Schultz KR, Qayed M, Broglie L, Eapen M, Yanik GA. Effect of Autograft CD34+ Dose on Outcome in Pediatric Patients Undergoing Autologous Hematopoietic Stem Cell Transplant for Central Nervous System Tumors. Transplant Cell Ther 2023:S2666-6367(23)01199-5. [PMID: 36990222 DOI: 10.1016/j.jtct.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/13/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Consolidation with autologous hematopoietic stem cell transplantation (HSCT) has improved survival for patients with central nervous system tumors (CNSTs). The impact of the autologous graft CD34+ dose on patient outcomes is unknown. OBJECTIVES To analyze the relationship between CD34+ dose, total nucleated cell (TNC) dose, and clinical outcomes, including overall survival (OS), progression free survival (PFS), relapse, non-relapse mortality (NRM), endothelial-injury complications (EIC), and time to neutrophil engraftment in children undergoing autologous HSCT for CNSTs. STUDY DESIGN A retrospective analysis of the CIBMTR database was performed. Children aged <10 years who underwent autologous HSCT between 2008-2018 for an indication of CNST were included. An optimal cut point was identified for patient age, CD34+ cell dose, and TNC, using the maximum likelihood method and PFS as an endpoint. Univariable analysis for PFS, OS, and relapse was described using the Kaplan-Meier estimator. Cox models were fitted for PFS and OS outcomes. Cause-specific hazards models were fitted for relapse and NRM. RESULTS One hundred fifteen patients met the inclusion criteria. A statistically significant association was identified between autograft CD34+ content and clinical outcomes. Children receiving >3.6×106/kg CD34+ cells experienced superior PFS (p=0.04) and OS (p=0.04) compared to children receiving ≤3.6×106/kg. Relapse rates were lower in patients receiving >3.6×106/kg CD34+ cells (p=0.05). Higher CD34+ doses were not associated with increased NRM (p=0.59). Stratification of CD34+ dose by quartile did not reveal any statistically significant differences between quartiles for 3-year PFS (p=0.66), OS (p=0.29), risk of relapse (p=0.57), or EIC (p=0.87). There were no significant differences in patient outcomes based on TNC, and those receiving a TNC >4.4×108/kg did not experience superior PFS (p=0.26), superior OS (p=0.14), reduced risk of relapse (p=0.37), or reduced NRM (p=0.25). Children with medulloblastoma had superior PFS (p<0.001), OS (p=0.01), and relapse rates (p=0.001) compared to those with other CNS tumor types. Median time to neutrophil engraftment was 10 days vs 12 days in the highest and lowest infused CD34+ quartiles, respectively. CONCLUSIONS For children undergoing autologous HSCT for CNSTs, increasing CD34+ cell dose was associated with significantly improved OS and PFS, and lower relapse rates, without increased NRM or EICs.
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Affiliation(s)
- Tristan E Knight
- Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, Washington; Division of Hematology and Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Kwang Woo Ahn
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin; CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kyle M Hebert
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rasha Atshan
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Donna A Wall
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kanhatai Chiengthong
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, Ohio
| | - Ellen Fraint
- Division of Pediatric Hematology, Oncology, and Cellular Therapy, The Children's Hospital at Montefiore, Bronx, New York
| | - Hemalatha G Rangarajan
- Department of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio
| | - Jeffery J Auletta
- CIBMTR (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, Minnesota; Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Carrie L Kitko
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hasan Hashem
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, King Hussein Cancer Center, Amman, Jordan
| | - Kirsten M Williams
- Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Baldeep Wirk
- Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Kasiani C Myers
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael A Pulsipher
- Intermountain Primary Children's Hospital Division of Hematology and Oncology, Huntsman Cancer Institute at the Spencer Eccles Fox School of Medicine at the University of Utah, Salt Lake City, Utah
| | - Anne B Warwick
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Nahal Rose Lalefar
- Division of Pediatric Hematology, UCSF Benioff Children's Hospital, Oakland, California
| | - Kirk R Schultz
- Department of Pediatric Hematology, Oncology and Bone Marrow Transplant, British Columbia's Children's Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Larisa Broglie
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Mary Eapen
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Gregory A Yanik
- Mott Children's Hospital, University of Michigan Medical Center, Ann Arbor, Michigan
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Etra A, Capellini A, Alousi A, Al Malki MM, Choe H, DeFilipp Z, Hogan WJ, Kitko CL, Ayuk F, Baez J, Gandhi I, Kasikis S, Gleich S, Hexner E, Hoepting M, Kapoor U, Kowalyk S, Kwon D, Langston A, Mielcarek M, Morales G, Özbek U, Qayed M, Reshef R, Rösler W, Spyrou N, Young R, Chen YB, Ferrara JLM, Levine JE. Effective treatment of low-risk acute GVHD with itacitinib monotherapy. Blood 2023; 141:481-489. [PMID: 36095841 PMCID: PMC9936304 DOI: 10.1182/blood.2022017442] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/27/2022] [Accepted: 07/31/2022] [Indexed: 02/07/2023] Open
Abstract
The standard primary treatment for acute graft-versus-host disease (GVHD) requires prolonged, high-dose systemic corticosteroids (SCSs) that delay reconstitution of the immune system. We used validated clinical and biomarker staging criteria to identify a group of patients with low-risk (LR) GVHD that is very likely to respond to SCS. We hypothesized that itacitinib, a selective JAK1 inhibitor, would effectively treat LR GVHD without SCS. We treated 70 patients with LR GVHD in a multicenter, phase 2 trial (NCT03846479) with 28 days of itacitinib 200 mg/d (responders could receive a second 28-day cycle), and we compared their outcomes to those of 140 contemporaneous, matched control patients treated with SCSs. More patients responded to itacitinib within 7 days (81% vs 66%, P = .02), and response rates at day 28 were very high for both groups (89% vs 86%, P = .67), with few symptomatic flares (11% vs 12%, P = .88). Fewer itacitinib-treated patients developed a serious infection within 90 days (27% vs 42%, P = .04) due to fewer viral and fungal infections. Grade ≥3 cytopenias were similar between groups except for less severe leukopenia with itacitinib (16% vs 31%, P = .02). No other grade ≥3 adverse events occurred in >10% of itacitinib-treated patients. There were no significant differences between groups at 1 year for nonrelapse mortality (4% vs 11%, P = .21), relapse (18% vs 21%, P = .64), chronic GVHD (28% vs 33%, P = .33), or survival (88% vs 80%, P = .11). Itacitinib monotherapy seems to be a safe and effective alternative to SCS treatment for LR GVHD and deserves further investigation.
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Affiliation(s)
- Aaron Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexandra Capellini
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Amin Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Monzr M. Al Malki
- Hematology/Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, CA
| | - Hannah Choe
- Division of Hematology, James Cancer Center, The Ohio State University, Columbus, OH
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | | | - Carrie L. Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Isha Gandhi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stelios Kasikis
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Elizabeth Hexner
- Blood and Marrow Transplantation Program, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthias Hoepting
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Urvi Kapoor
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Deukwoo Kwon
- Department of Population Health Science and Policy, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Marco Mielcarek
- Adult Blood and Marrow Transplant Program, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Umut Özbek
- Department of Population Health Science and Policy, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Ran Reshef
- Blood and Marrow Transplantation Program, Columbia University Medical Center, New York, NY
| | - Wolf Rösler
- Med. Klinik III/Poliklinik, Universitatsklinik Erlangen, Erlangen, Germany
| | - Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - James L. M. Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John E. Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Albanese A, Eran AS, Suessmuth Y, Betz K, Bratrude B, Keskula P, Cagnin LS, Langston AA, Qayed M, Horan J, Blazar BR, Watkins BK, Kean LS. Early Breakthrough T Cell Proliferation Despite CNI/MTX Prophylaxis Is a Harbinger of Acute Gvhd (AGVHD) and Is Controlled By Abatacept: Mechanism of Success of the ABA2 Agvhd Prevention Trial. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00403-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Akahoshi Y, Spyrou N, Hogan WJ, Ayuk F, DeFilipp Z, Weber D, Choe H, Hexner E, Rösler W, Etra A, Sandhu KS, Yanik GA, Chanswangphuwana C, Kitko CL, Reshef R, Kraus S, Wölfl M, Eder M, Bertrand H, Qayed M, Merli P, Grupp SA, Aguayo-Hiraldo DP, Schechter T, Ullrich E, Baez J, Kowalyk S, Morales G, Young MR, Nakamura R, Levine JE, Ferrara J, Chen DYB. De Novo Late Acute Gvhd: Incidence, Outcomes, and Impact of Biomarkers Compared to Classic Acute Gvhd. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00101-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Raghunandan S, Gorfinkel L, Bratrude B, Betz K, Suessmuth Y, Hebert K, Neuberg D, Williams KM, Schoettler ML, Langston AA, Kean LS, Qayed M, Horan J, Watkins BK. Abatacept for the Prevention of Graft Versus Host Disease in Pediatric Patients Receiving 7/8 HLA-Mismatched Unrelated Transplant for Hematologic Malignancies: A Real-World Analysis. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00405-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Takahashi T, Al-Kofahi M, Jaber M, Langston AA, Horan J, Bratrude B, Betz K, Suessmuth Y, Watkins BK, Qayed M, Kean LS. Mechanism of Success of Abatacept in Hematopoietic Stem Cell Transplantation: Pharmacokinetic-Pharmacodynamic (PK-PD) Analysis Demonstrates Greater Abatacept Exposure Decreases Acute Gvhd (AGVHD) Risk without Increasing Adverse Events. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00410-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Schoettler ML, French K, Harris A, Bryson E, Watkins B, Qayed M, Switchenko JM, Williams KM. Prospective Study of Allogeneic Pediatric Transplant Associated Thrombotic Microangiopathy-Novel Prognostic Markers, Biologic Interaction and Outcomes. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00089-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Duncan CN, Chen N, London WB, Kay-Green S, Anderson L, Ahmed I, Auletta JJ, Bambach B, Beebe KL, Chaudhury S, Lurie RH, Connelly JA, Dalal JD, Davila BJ, Dvorak CC, Goebel WS, Hanna R, Hudspeth M, Huo JS, Kapoor N, Kasow KA, Katsanis E, Lalefar N, Martin PL, Molinari L, Moore TB, Nemecek ER, Nuechterlein B, Oshrine B, Qayed M, Shenoy S, Vander Lugt MT, Shaw BE, Pulsipher MA, Baker KS. Skeletal Biology and Late Effects Following Allogeneic Transplantation for Pediatric Hematologic Malignancy: A Ptctc and CIBMTR Multicenter Study. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00119-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Al Malki MM, Shaffer BC, Devine SM, Shaw BE, Broglie L, Qayed M, Choi SW, Spellman S, Malmberg C, Ndifon E, Logan B, Auletta JJ, Stefanski HE, Olson J, Jimenez AJ. Access: A Multi-Center, Phase II Trial of HLA-Mismatched Unrelated Donor Hematopoietic Cell Transplantation with Post-Transplantation Cyclophosphamide for Patients with Hematologic Malignancies. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00377-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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McNerney KO, Lim SS, Miller A, Amankwah E, Dreyzin A, Vatsayan A, Hermiston M, Baggott C, Prabhu S, Pacenta HL, Phillips CL, Fabrizio VA, Rossoff J, Bonifant C, Stefanski HE, Talano J, Moskop A, Verneris MR, Myers D, Karras N, Qayed M, Satwani P, Krupski MC, Keating AK, Baumeister SH, Chinnabhandar V, Egeler E, Mavroukakis S, Curran KJ, Mackall C, Laetsch TW, Schultz LM. High Disease Burden and Severe Neutropenia Predict HLH Toxicity in Patients with B-Acute Lymphoblastic Leukemia (B-ALL) Treated with Tisagenlecleucel in the PRWCC. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00331-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Schultz LM, Eaton A, Baggott C, Rossoff J, Prabhu S, Keating AK, Krupski C, Pacenta H, Philips CL, Talano JA, Moskop A, Baumeister SH, Myers GD, Karras NA, Brown PA, Qayed M, Hermiston M, Satwani P, Wilcox R, Rabik CA, Fabrizio VA, Chinnabhandar V, Kunicki M, Mavroukakis S, Egeler E, Li Y, Mackall CL, Curran KJ, Verneris MR, Laetsch TW, Stefanski H. Outcomes After Nonresponse and Relapse Post-Tisagenlecleucel in Children, Adolescents, and Young Adults With B-Cell Acute Lymphoblastic Leukemia. J Clin Oncol 2023; 41:354-363. [PMID: 36108252 PMCID: PMC9839307 DOI: 10.1200/jco.22.01076] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/13/2022] [Accepted: 07/20/2022] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Nonresponse and relapse after CD19-chimeric antigen receptor (CAR) T-cell therapy continue to challenge survival outcomes. Phase II landmark data from the ELIANA trial demonstrated nonresponse and relapse rates of 14.5% and 28%, respectively, whereas use in the real-world setting showed nonresponse and relapse rates of 15% and 37%. Outcome analyses describing fate after post-CAR nonresponse and relapse remain limited. Here, we aim to establish survival outcomes after nonresponse and both CD19+ and CD19- relapses and explore treatment variables associated with inferior survival. METHODS We conducted a retrospective multi-institutional study of 80 children and young adults with B-cell acute lymphoblastic leukemia experiencing nonresponse (n = 23) or relapse (n = 57) after tisagenlecleucel. We analyze associations between baseline characteristics and these outcomes and establish survival rates and salvage approaches. RESULTS The overall survival (OS) at 12 months was 19% across nonresponders (n = 23; 95% CI, 7 to 50). Ninety-five percent of patients with nonresponse had high preinfusion disease burden. Among 156 morphologic responders, the cumulative incidence of relapse was 37% (95% CI, 30 to 47) at 12 months (CD19+; 21% [15 to 29], CD19-; 16% [11 to 24], median follow-up; 380 days). Across 57 patients experiencing relapse, the OS was 52% (95% CI, 38 to 71) at 12 months after time of relapse. Notably, CD19- relapse was associated with significantly decreased OS as compared with patients who relapsed with conserved CD19 expression (CD19- 12-month OS; 30% [14 to 66], CD19+ 12-month OS; 68% [49 to 92], P = .0068). Inotuzumab, CAR reinfusion, and chemotherapy were used as postrelapse salvage therapy with greatest frequency, yet high variability in treatment sequencing and responses limits efficacy analysis across salvage approaches. CONCLUSION We describe poor survival across patients experiencing nonresponse to tisagenlecleucel. In the post-tisagenlecleucel relapse setting, patients can be salvaged; however, CD19- relapse is distinctly associated with decreased survival outcomes.
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Affiliation(s)
- Liora M. Schultz
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Anne Eaton
- Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Christina Baggott
- Stanford University School of Medicine, Stanford Cancer Institute, Palo Alto, CA
| | - Jenna Rossoff
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Snehit Prabhu
- Stanford University School of Medicine, Stanford Cancer Institute, Palo Alto, CA
| | - Amy K. Keating
- University of Colorado School of Medicine, Children's Hospital of Colorado, Aurora, CO
| | - Christa Krupski
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Disease Institute, Cincinnati, OH
| | - Holly Pacenta
- Department of Pediatrics, The University of Texas Southwestern Medical Center/Children's Health, Dallas, TX
- Division of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX
| | - Christine L. Philips
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Disease Institute, Cincinnati, OH
| | - Julie-An Talano
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI
| | - Amy Moskop
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI
| | - Susanne H.C. Baumeister
- Pediatric Hematology-Oncology, Harvard Medical School, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA
| | - Gary Douglas Myers
- Children's Mercy Hospital, University of Missouri Kansas City, Kansas City, MO
| | - Nicole A. Karras
- Department of Pediatrics, City of Hope National Medical Center, Duarte, CA
| | - Patrick A. Brown
- Department of Oncology, Sidney Kimmel Cancer Center at John Hopkins School of Medicine, Baltimore, MD
| | - Muna Qayed
- Emory University and Children's Healthcare of Atlanta, Druid Hills, GA
| | - Michelle Hermiston
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA
| | - Prakash Satwani
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant, Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Rachel Wilcox
- Children's Mercy Hospital, University of Missouri Kansas City, Kansas City, MO
| | - Cara A. Rabik
- Division of Hematologic Malignancies I, Center for Drug Evaluation and Research (CDER), FDA
| | - Vanessa A. Fabrizio
- University of Colorado School of Medicine, Children's Hospital of Colorado, Aurora, CO
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center
- Department of Pediatrics, Weill Cornell Medical College
| | - Vasant Chinnabhandar
- Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Michael Kunicki
- Stanford University School of Medicine, Stanford Cancer Institute, Palo Alto, CA
| | - Sharon Mavroukakis
- Stanford University School of Medicine, Stanford Cancer Institute, Palo Alto, CA
| | - Emily Egeler
- Stanford University School of Medicine, Stanford Cancer Institute, Palo Alto, CA
| | - Yimei Li
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Pediatrics and Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Division of Oncology, Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Crystal L. Mackall
- Stanford University School of Medicine, Stanford Cancer Institute, Palo Alto, CA
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, Center for Cancer Cell Therapy, Stanford Cancer Institute, Palo Alto, CA
- Division of Blood and Bone Marrow Transplantation, Department of Medicine, Stanford University School of Medicine, Center for Cancer Cell Therapy, Stanford Cancer Institute, Palo Alto, CA
| | - Kevin J. Curran
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center
- Department of Pediatrics, Weill Cornell Medical College
| | - Michael R. Verneris
- University of Colorado School of Medicine, Children's Hospital of Colorado, Aurora, CO
| | - Theodore W. Laetsch
- Department of Pediatrics, The University of Texas Southwestern Medical Center/Children's Health, Dallas, TX
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Pediatrics and Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Division of Oncology, Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Heather Stefanski
- Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
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Stenger E, Giver CR, Langston A, Kota D, Das PK, Chinnadurai R, Galipeau J, Waller EK, Qayed M. Safety of autologous freshly expanded mesenchymal stromal cells for the treatment of graft-versus-host disease. Front Immunol 2022; 13:959658. [PMID: 36189324 PMCID: PMC9515357 DOI: 10.3389/fimmu.2022.959658] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/11/2022] [Indexed: 11/26/2022] Open
Abstract
Despite the curative potential of hematopoietic cell transplantation (HCT) for hematologic malignancies, graft-versus-host disease (GVHD) remains a substantial cause of morbidity and mortality, particularly if treatment is refractory. Treatment with additional immunosuppression including steroids often leads to opportunistic infections and organ dysfunction. Novel therapies are greatly needed, specifically ones that lead to responses in treatment-refractory patients and are better tolerated. Mesenchymal stromal cells (MSCs) are non-hematopoietic tolerogenic cells present in normal bone marrow (BM), which can be expanded ex vivo to therapeutic doses. Their safety and efficacy have been assessed in inflammatory disorders including GVHD, but heterogeneity in clinical responses has led some to examine MSC manufacturing and administration procedures, which may impact in vivo efficacy. We hypothesized that autologous, early-passage, and culture-recovered (after freeze and thaw) MSCs would be safe and may have superior efficacy. In this phase I single-center trial, we assessed MSC safety and early efficacy of an escalating number of doses (2 × 106/kg doses; dose level 1, single dose; dose level 2, two weekly doses; dose level 3, four weekly doses) in patients aged ≥12 years with treatment-refractory acute or chronic GVHD. Eleven enrolled patients received some or all planned MSC infusions, with a median age at enrollment of 37 years. The most common primary HCT indication was leukemia, and the median time from HCT to first MSC infusion was 2.6 years. MSC infusion was well tolerated, with all severe adverse events expected and determined to be unlikely or definitely not related to the study. Thus, no dose-limiting toxicities occurred in the three dose levels. Three of four patients with acute GVHD (or overlap with acute features) had responses seen at any timepoint, ranging from partial to complete. In those with a chronic GVHD indication (n = 7), an overall response at 3 months was partial in five, stable in one, and progressive in one. No appreciable differences were seen between dose levels in peripheral blood lymphocyte subsets. In conclusion, autologous and culture-recovered MSCs were safe in the setting of refractory GVHD following HCT for hematologic malignancy, and clinical responses were most notable in patients with acute GVHD.
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Affiliation(s)
- Elizabeth Stenger
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Cynthia R. Giver
- Bone Marrow and Stem Cell Transplant Center, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Amelia Langston
- Bone Marrow and Stem Cell Transplant Center, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Daniel Kota
- Bone Marrow and Stem Cell Transplant Center, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Pankoj Kumar Das
- Bone Marrow and Stem Cell Transplant Center, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Raghavan Chinnadurai
- Department of Biomedical Sciences, Mercer University School of Medicine, Savannah, GA, United States
| | - Jacques Galipeau
- Department of Medicine and Carbone Cancer Center, University of Wisconsin in Madison, Madison, WI, United States
| | - Edmund K. Waller
- Bone Marrow and Stem Cell Transplant Center, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, United States
- *Correspondence: Muna Qayed,
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Qayed M, McGuirk JP, Myers GD, Parameswaran V, Waller EK, Holman P, Rodrigues M, Clough LF, Willert J. Leukapheresis guidance and best practices for optimal chimeric antigen receptor T-cell manufacturing. Cytotherapy 2022; 24:869-878. [PMID: 35718701 DOI: 10.1016/j.jcyt.2022.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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: 12/13/2021] [Revised: 04/22/2022] [Accepted: 05/11/2022] [Indexed: 11/03/2022]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is an individualized immunotherapy that genetically reprograms a patient's T cells to target and eliminate cancer cells. Tisagenlecleucel is a US Food and Drug Administration-approved CD19-directed CAR T-cell therapy for patients with relapsed/refractory (r/r) B-cell acute lymphoblastic leukemia and r/r diffuse large B-cell lymphoma. Manufacturing CAR T cells is an intricate process that begins with leukapheresis to obtain T cells from the patient's peripheral blood. An optimal leukapheresis product is essential to the success of CAR T-cell therapy; therefore, understanding factors that may affect the quality or T-cell content is imperative. CAR T-cell therapy requires detailed organization throughout the entire multistep process, including appropriate training of a multidisciplinary team in leukapheresis collection, cell processing, timing and coordination with manufacturing and administration to achieve suitable patient care. Consideration of logistical parameters, including leukapheresis timing, location and patient availability, when clinically evaluating the patient and the trajectory of their disease progression must be reflected in the overall collection strategy. Challenges of obtaining optimal leukapheresis product for CAR T-cell manufacturing include vascular access for smaller patients, achieving sufficient T-cell yield, eliminating contaminating cell types in the leukapheresis product, determining appropriate washout periods for medication and managing adverse events at collection. In this review, the authors provide recommendations on navigating CAR T-cell therapy and leukapheresis based on experience and data from tisagenlecleucel manufacturing in clinical trials and the real-world setting.
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Affiliation(s)
- Muna Qayed
- Blood and Marrow Transplant Program, Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, Georgia, USA.
| | - Joseph P McGuirk
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - G Doug Myers
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Vinod Parameswaran
- Avera Medical Group Hematology, Transplant & Cellular Therapy, Sioux Falls, South Dakota, USA
| | - Edmund K Waller
- Bone Marrow and Stem Cell Transplant Center, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Peter Holman
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | - Lee F Clough
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Jennifer Willert
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
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Vandris P, Chao K, Baggott C, Phillips CL, Qayed M, Rossoff J, Si Lim SJ, Winestone LE, Stefanski HE, Talano JAM, Margossian S, Verneris MR, Myers GD, Karras NA, Brown PA, Satwani P, Mackall C, Curran KJ, Laetsch TW, Schultz LM. Outcomes of Hispanic and non-Hispanic white pediatric and young adult patients with B-cell acute lymphoblastic leukemia after commercial tisagenlecleucel. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.10016] [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
10016 Background: Population-level data show significantly inferior outcomes for Hispanic children, adolescents, and young adults (CAYA) diagnosed with B-cell acute lymphoblastic leukemia (B-ALL) relative to non-Hispanic whites (NHW). Here, we compare outcomes between Hispanic and NHW CAYA patients with relapsed and/or refractory (RR) B-ALL receiving tisagenlecleucel, a CD19-specific chimeric antigen receptor (CAR) T cell therapy. Methods: We used data from the Pediatric Real World CAR Consortium retrospective cohort of 200 patients who underwent cell shipment for standard-of-care tisagenlecleucel between August 2017 and March 2020 (N=15 US institutions). Race/ethnicity was identified by medical record review. Patients reported as belonging to more than one racial/ethnic group were classified as multiracial and excluded from analysis. Baseline factors, outcomes, and safety post-infusion were characterized for Hispanic vs. NHW infused patients. Outcomes included complete response (CR) rate, overall survival (OS), duration of response (DOR), and duration of B-cell aplasia (DBA). A multivariate Cox model for OS was constructed, including all baseline factors. Results: Among 185 infused patients, 90 (48.6%) were NHW and 70 (37.8%) were Hispanic. Among 15 non-infused patients, 3 (20.0%) were NHW and 5 (33.3%) were Hispanic. Hispanic patients were significantly older at diagnosis (mean: 10.7 vs. 8.3 years, p=0.02) and had significantly shorter time from diagnosis to infusion (mean: 34.4 vs. 46.4 months, p=0.04). Hispanic and NHW patients did not significantly differ across sex, leukemia type, number of prior lines of therapy, receipt of prior CD19-directed therapy, level of disease burden pre-infusion, and number of relapses pre-infusion. Hispanic and NHW patients did not significantly differ across 1-month CR, 6-month OS, 1-year OS, 18-month OS, 6-month DOR, 1-year DOR, 6-month DBA, and 1-year DBA (Table). On multivariate analysis including the above covariates, OS did not significantly differ for Hispanic patients (HR=1.04, p=0.92). Hispanic and NHW patients did not significantly differ across grade ≥ 3 cytokine release syndrome, grade ≥ 3 neurotoxicity, grade 4 neutropenia, tumor lysis syndrome, or number of infections post-infusion. Conclusions: Outcomes were similar between Hispanic and NHW CAYA RR B-ALL patients receiving tisagenlecleucel in the real-world setting. Increasing access to CAR therapy among Hispanic CAYA B-ALL patients could help mitigate population-level disparities in outcomes observed after receipt of conventional therapies. [Table: see text]
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Affiliation(s)
| | - Karen Chao
- Medical College of Wisconsin, Milwaukee, WI
| | | | | | - Muna Qayed
- Emory University School of Medicine, Atlanta, GA
| | | | | | - Lena E. Winestone
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA
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Schultz LM, Baggott C, Prabhu S, Pacenta HL, Phillips CL, Rossoff J, Stefanski HE, Talano JA, Moskop A, Margossian SP, Verneris MR, Myers GD, Karras NA, Brown PA, Qayed M, Hermiston M, Satwani P, Krupski C, Keating AK, Wilcox R, Rabik CA, Fabrizio VA, Rouce RH, Chinnabhandar V, Kunicki M, Barsan VV, Goksenin AY, Li Y, Mavroukakis S, Egeler E, Curran KJ, Mackall CL, Laetsch TW. Disease Burden Affects Outcomes in Pediatric and Young Adult B-Cell Lymphoblastic Leukemia After Commercial Tisagenlecleucel: A Pediatric Real-World Chimeric Antigen Receptor Consortium Report. J Clin Oncol 2022; 40:945-955. [PMID: 34882493 PMCID: PMC9384925 DOI: 10.1200/jco.20.03585] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [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: 12/17/2022] Open
Abstract
PURPOSE Tisagenlecleucel is a CD19-specific chimeric antigen receptor T-cell therapy, US Food and Drug Administration-approved for children, adolescents, and young adults (CAYA) with relapsed and/or refractory (RR) B-cell acute lymphoblastic leukemia (B-ALL). The US Food and Drug Administration registration for tisagenlecleucel was based on a complete response (CR) rate of 81%, 12-month overall survival (OS) of 76%, and event-free survival (EFS) of 50%. We report clinical outcomes and analyze covariates of outcomes after commercial tisagenlecleucel. METHODS We conducted a retrospective, multi-institutional study of CAYA with RR B-ALL across 15 US institutions, who underwent leukapheresis shipment to Novartis for commercial tisagenlecleucel. A total of 200 patients were included in an intent-to-treat response analysis, and 185 infused patients were analyzed for survival and toxicity. RESULTS Intent-to-treat analysis demonstrates a 79% morphologic CR rate (95% CI, 72 to 84). The infused cohort had an 85% CR (95% CI, 79 to 89) and 12-month OS of 72% and EFS of 50%, with 335 days of median follow-up. Notably, 48% of patients had low-disease burden (< 5% bone marrow lymphoblasts, no CNS3, or other extramedullary disease), or undetectable disease, pretisagenlecleucel. Univariate and multivariate analyses associate high-disease burden (HB, ≥ 5% bone marrow lymphoblasts, CNS3, or non-CNS extramedullary) with inferior outcomes, with a 12-month OS of 58% and EFS of 31% compared with low-disease burden (OS; 85%, EFS; 70%) and undetectable disease (OS; 95%, EFS; 72%; P < .0001 for OS and EFS). Grade ≥ 3 cytokine release syndrome and neurotoxicity rates were 21% and 7% overall and 35% and 9% in patients with HB, respectively. CONCLUSION Commercial tisagenlecleucel in CAYA RR B-ALL demonstrates efficacy and tolerability. This first analysis of commercial tisagenlecleucel stratified by disease burden identifies HB preinfusion to associate with inferior OS and EFS and increased toxicity.
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Affiliation(s)
- Liora M. Schultz
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
- Liora M. Schultz, MD, Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Rd, Suite 300, Stanford, CA 94304; e-mail:
| | | | - Snehit Prabhu
- Stanford University School of Medicine, Stanford Cancer Institute, Stanford, CA
| | - Holly L. Pacenta
- Department of Pediatrics, The University of Texas Southwestern Medical Center/Children's Health, Dallas, TX
- Division of Hematology and Oncology, Cook Children's Medical Center, Fort Worth, TX
| | - Christine L. Phillips
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Disease Institute, Cincinnati, OH
| | - Jenna Rossoff
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Heather E. Stefanski
- Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Julie-An Talano
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Wauwatosa, WI
| | - Amy Moskop
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Wauwatosa, WI
| | - Steven P. Margossian
- Harvard Medical School, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Pediatric Hematology-Oncology, Boston, MA
| | - Michael R. Verneris
- University of Colorado School of Medicine, Children's Hospital of Colorado, Aurora, CO
| | - Gary Douglas Myers
- Children's Mercy Hospital, University of Missouri Kansas City, Kansas City, MO
| | - Nicole A. Karras
- Department of Pediatrics, City of Hope National Medical Center, Duarte, CA
| | - Patrick A. Brown
- Department of Oncology, Sidney Kimmel Cancer Center at John Hopkins School of Medicine, Baltimore, MD
| | - Muna Qayed
- Emory University and Children's Healthcare of Atlanta, Druid Hills, GA
| | - Michelle Hermiston
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA
| | - Prakash Satwani
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant, Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Christa Krupski
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Disease Institute, Cincinnati, OH
| | - Amy K. Keating
- University of Colorado School of Medicine, Children's Hospital of Colorado, Aurora, CO
| | - Rachel Wilcox
- Children's Mercy Hospital, University of Missouri Kansas City, Kansas City, MO
| | - Cara A. Rabik
- Division of Hematologic Malignancies I, Center for Drug Evaluation and Research (CDER), FDA, Silver Spring, MD
| | - Vanessa A. Fabrizio
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center
- Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | - Rayne H. Rouce
- Texas Children's Cancer Center, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX
| | - Vasant Chinnabhandar
- Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | | | - Valentin V. Barsan
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - A. Yasemin Goksenin
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA
| | - Yimei Li
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Emily Egeler
- Stanford University School of Medicine, Stanford, CA
| | - Kevin J. Curran
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center
- Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | - Crystal L. Mackall
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, CA
- Department of Medicine, Division of Blood and Bone Marrow Transplantation, Stanford University School of Medicine, Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, CA
| | - Theodore W. Laetsch
- Department of Pediatrics, The University of Texas Southwestern Medical Center/Children's Health, Dallas, TX
- Department of Pediatrics and Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Division of Oncology, Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
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Duncan CN, Baker S, London WB, Kao PC, Chen N, Auletta JJ, Ahmed I, Anderson L, Bambach B, Beebe KL, Chaudhury S, Connelly JA, Davila Saldana BJ, Dvorak CC, Eissa H, Giller RH, Goebel WS, Hanna R, Hudspeth M, Huo JS, Kapoor N, Kasow KA, Katsanis E, Lalefar N, Martin PL, Nemecek ER, Oshrine B, Qayed M, Shenoy S, Vander Lugt MT, Shaw BE, Pulsipher MA, Hingorani S. Chronic Kidney Disease Is Common in Survivors of Pediatric Allogeneic Hematopoietic Cell Transplantation: A Pediatric Transplantation and Cellular Therapy Consortium Study. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00672-8] [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: 12/01/2022]
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Knight TE, Chiengthong K, Wall DA, Herbert K, Ahn K, Broglie L, Schultz KR, Qayed M, Eapen M, Yanik GA. Impact of CD34+ Cell Dose on Outcome Among Children Undergoing Autologous Hematopoietic Stem Cell Transplant for High-Risk Neuroblastomas. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00483-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Schoettler ML, Spencer K, Lutterman D, Rumbika S, Haight AE, Stenger EO, Parikh S, Qayed M, Watkins BK, Krishnamurti L, Williams KM, Chonat S. Sickle Cell Disease Is a Risk Factor for Transplant Associated Thrombotic Microangiopathy in Children Undergoing Hematopoietic Cellular Therapy. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00182-8] [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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Raghunandan S, Bratrude B, Betz K, Suessmuth Y, Gillespie S, Westbrook AL, Williams KM, Schoettler ML, Langston AA, Horan J, Kean LS, Qayed M, Watkins BK. Abatacept for the Prevention of Gvhd in Pediatric Patients Receiving 7/8 HLA-Mismatched Unrelated Transplant for Hematologic Malignancies: A Single Center Experience. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00543-7] [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: 11/17/2022]
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Knight TE, Chiengthong K, Wall DA, Herbert K, Ahn K, Broglie L, Schultz KR, Qayed M, Eapen M, Yanik GA. Effect of Autograft CD34 + Dose on Outcome in Pediatric Patients Undergoing Autologous Hematopoietic Stem Cell Transplant for Central Nervous System Tumors. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00484-5] [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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Chandrakasan S, Gillespie S, Kumar D, Prince C, Park S, Qayed M. Impact of Hematogone Content in Bone Marrow Grafts on Immune Reconstitution in Pediatric Allogeneic Bone Marrow Transplantation Recipients. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00615-7] [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: 11/28/2022]
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McNerney KO, Lim SS, Dreyzin A, Vatsayan A, Baggott C, Prabhu S, Pacenta HL, Phillips CL, Rossoff J, Stefanski HE, Talano JA, Moskop A, Margossian S, Verneris MR, Myers D, Karras N, Brown PA, Qayed M, Hermiston M, Satwani P, Krupski MC, Keating AK, Wilcox R, Rabik CA, Baumeister S, Fabrizio VA, Chinnabhandar V, Goksenin Y, Curran KJ, Mackall C, Laetsch TW, Schultz LM. CAR-Associated Hemophagocytic Lymphohistiocytosis (HLH) with Use of Commercial Tisagenlecleucel in the Pediatric Real World CAR Consortium (PRWCC): Risk Factors and Outcomes. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00781-3] [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: 11/28/2022]
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Fabrizio VA, Phillips CL, Lane A, Baggott C, Prabhu S, Egeler E, Mavroukakis S, Pacenta H, Rossoff J, Stefanski HE, Talano JA, Moskop A, Margossian SP, Verneris MR, Myers GD, Karras NA, Brown PA, Qayed M, Hermiston M, Satwani P, Krupski C, Keating AK, Wilcox R, Rabik CA, Chinnabhandar V, Kunicki M, Goksenin AY, Curran KJ, Mackall CL, Laetsch TW, Schultz LM. Tisagenlecleucel outcomes in relapsed/refractory extramedullary ALL: a Pediatric Real World CAR Consortium Report. Blood Adv 2022; 6:600-610. [PMID: 34794180 PMCID: PMC8791593 DOI: 10.1182/bloodadvances.2021005564] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/27/2021] [Indexed: 11/20/2022] Open
Abstract
Chimeric antigen receptor (CAR) T cells have transformed the therapeutic options for relapsed/refractory (R/R) B-cell acute lymphoblastic leukemia. Data for CAR therapy in extramedullary (EM) involvement are limited. Retrospective data were abstracted from the Pediatric Real World CAR Consortium (PRWCC) of 184 infused patients from 15 US institutions. Response (complete response) rate, overall survival (OS), relapse-free survival (RFS), and duration of B-cell aplasia (BCA) in patients referred for tisagenlecleucel with EM disease (both central nervous system (CNS)3 and non-CNS EM) were compared with bone marrow (BM) only. Patients with CNS disease were further stratified for comparison. Outcomes are reported on 55 patients with EM disease before CAR therapy (CNS3, n = 40; non-CNS EM, n = 15). The median age at infusion in the CNS cohort was 10 years (range, <1-25 years), and in the non-CNS EM cohort it was 13 years (range, 2-26 years). In patients with CNS disease, 88% (35 of 40) achieved a complete response vs only 66% (10 of 15) with non-CNS EM disease. Patients with CNS disease (both with and without BM involvement) had 24-month OS outcomes comparable to those of non-CNS EM or BM only (P = .41). There was no difference in 12-month RFS between CNS, non-CNS EM, or BM-only patients (P = .92). No increased toxicity was seen with CNS or non-CNS EM disease (P = .3). Active CNS disease at time of infusion did not affect outcomes. Isolated CNS disease trended toward improved OS compared with combined CNS and BM (P = .12). R/R EM disease can be effectively treated with tisagenlecleucel; toxicity, relapse, and survival rates are comparable to those of patients with BM-only disease. Outcomes for isolated CNS relapse are encouraging.
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Affiliation(s)
- Vanessa A Fabrizio
- University of Colorado, Anschutz Medical Campus, Colorado Children's Hospital, Aurora, CO
| | - Christine L Phillips
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Diseases Institute, Cincinnati, OH
| | - Adam Lane
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Christina Baggott
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Snehit Prabhu
- Stanford University School of Medicine, Stanford Cancer Institute, Center for Cancer Cell Therapy, Stanford, CA
| | - Emily Egeler
- Stanford University School of Medicine, Stanford Cancer Institute, Center for Cancer Cell Therapy, Stanford, CA
| | - Sharon Mavroukakis
- Stanford University School of Medicine, Stanford Cancer Institute, Center for Cancer Cell Therapy, Stanford, CA
| | - Holly Pacenta
- Department of Pediatrics, The University of Texas Southwestern Medical Center/Children's Health, Dallas, TX
| | - Jenna Rossoff
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Heather E Stefanski
- Department of Pediatrics, Division of Pediatric Blood and Marrow Transplantation, University of Minnesota Medical School, Minneapolis, MN
| | - Julie-An Talano
- Department of Pediatric Hematology Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Amy Moskop
- Department of Pediatric Hematology Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Steven P Margossian
- Harvard Medical School, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Pediatric Hematology-Oncology, Boston, MA
| | - Michael R Verneris
- University of Colorado, Anschutz Medical Campus, Colorado Children's Hospital, Aurora, CO
| | | | - Nicole A Karras
- Department of Pediatrics, City of Hope National Medical Center, Duarte, CA
| | - Patrick A Brown
- Department of Oncology, Sidney Kimmel Cancer Center at John Hopkins School of Medicine, Baltimore, MD
| | - Muna Qayed
- Emory University and Children's Healthcare of Atlanta, Atlanta, GA
| | - Michelle Hermiston
- Benioff Children's Hospital, University of California San Francisco, San Francisco, CA
| | - Prakash Satwani
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant, Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Christa Krupski
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Diseases Institute, Cincinnati, OH
| | - Amy K Keating
- University of Colorado, Anschutz Medical Campus, Colorado Children's Hospital, Aurora, CO
| | | | - Cara A Rabik
- Department of Oncology, Sidney Kimmel Cancer Center at John Hopkins School of Medicine, Baltimore, MD
| | - Vasant Chinnabhandar
- Department of Pediatrics, Division of Pediatric Blood and Marrow Transplantation, University of Minnesota Medical School, Minneapolis, MN
| | - Michael Kunicki
- Division of Hematology and Oncology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - A Yasemin Goksenin
- Benioff Children's Hospital, University of California San Francisco, San Francisco, CA
| | - Kevin J Curran
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY
- Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | - Crystal L Mackall
- Division of Hematology and Oncology, Department of Pediatrics, Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, CA
- Division of Stem Cell Transplantation and Cell Therapy, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Theodore W Laetsch
- Department of Pediatrics, The University of Texas Southwestern Medical Center/Children's Health, Dallas, TX
- Department of Pediatrics and Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Division of Oncology, Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA; and
| | - Liora M Schultz
- Department of Pediatrics, Division of Hematology and Oncology, Stanford University School of Medicine, Stanford, CA
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