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Garcia-Pouton N, Ortiz-Maldonado V, Peyrony O, Chumbita M, Aiello TF, Monzo-Gallo P, Lopera C, Puerta-Alcalde P, Magnano L, Martinez-Cibrian N, Pitart C, Juan M, Delgado J, Fernandez De Larrea C, Soriano Á, Urbano-Ispizua Á, Garcia-Vidal C. Infection epidemiology in relation to different therapy phases in patients with haematological malignancies receiving CAR T-cell therapy. Eur J Haematol 2024; 112:371-378. [PMID: 37879842 DOI: 10.1111/ejh.14122] [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: 07/22/2023] [Revised: 10/05/2023] [Accepted: 10/09/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND We described the real-life epidemiology and causes of infections on the different therapy phases in patients undergoing chimeric antigen receptor (CAR) T-cells directed towards CD19+ or BCMA+ cells. METHODS All consecutive patients receiving CAR T-cell therapy at our institution were prospectively followed-up. We performed various comparative analyses of all patients and subgroups with and without infections. RESULTS Ninety-one adults mainly received CAR T-cell therapy for acute leukaemia (53%) and lymphoma (33%). We documented a total of 77 infections in 47 (52%) patients, 37 (48%) during the initial neutropenic phase and 40 (52%) during the non-neutropenic phase. Infections during the neutropenic phase were mainly due to bacterial (29, 78%): catheter infections (11 [38%] cases), endogenous source (5 [17%]), and Clostridioides difficile (5 [17%]). Patients receiving corticosteroids after CAR T-cell therapy had a higher risk of endogenous infection (100% vs. 16%; p = .006). During the non-neutropenic phase, bacterial infections remained very frequent (24, 60%), mainly with catheter source (8, 33%). Respiratory tract infections were common (17, 43%). CONCLUSIONS Infections after CAR T-cell therapy were frequent. During the neutropenic phase, it is essential to prevent nosocomial infections and balance the use of antibiotics to lower endogenous bacteraemia and Clostridial infection rates.
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Affiliation(s)
- Nicol Garcia-Pouton
- Infectious Diseases Department, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Oliver Peyrony
- Infectious Diseases Department, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Mariana Chumbita
- Infectious Diseases Department, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Tommaso Francesco Aiello
- Infectious Diseases Department, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Patricia Monzo-Gallo
- Infectious Diseases Department, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Carlos Lopera
- Infectious Diseases Department, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Pedro Puerta-Alcalde
- Infectious Diseases Department, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Laura Magnano
- Haematology Department, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Nuria Martinez-Cibrian
- Haematology Department, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Cristina Pitart
- Microbiology Department, Hospital Clinic, University of Barcelona, ISGLOBAL, Barcelona, Spain
| | - Manel Juan
- Immunology Department, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Julio Delgado
- Haematology Department, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Álex Soriano
- Infectious Diseases Department, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
- CIBERINF, CIBER in Infectious Diseases, Barcelona, Spain
| | - Álvaro Urbano-Ispizua
- Haematology Department, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Carolina Garcia-Vidal
- Infectious Diseases Department, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
- CIBERINF, CIBER in Infectious Diseases, Barcelona, Spain
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2
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Aiello TF, Puerta-Alcalde P, Chumbita M, Lopera C, Monzó P, Cortes A, Fernández-Avilés F, Suárez-Lledó M, Correa J, Ortiz-Maldonado V, Cuesta G, Martinez-Cibrian N, Esteve J, Marcos MÁ, Mensa J, Soriano A, Garcia-Vidal C. Current outcomes of SARS-CoV-2 Omicron variant infection in high-risk haematological patients treated early with antivirals. J Antimicrob Chemother 2023; 78:1454-1459. [PMID: 37051877 DOI: 10.1093/jac/dkad105] [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: 10/26/2022] [Accepted: 03/17/2023] [Indexed: 04/14/2023] Open
Abstract
OBJECTIVES We aimed to describe the clinical outcomes and duration of viral shedding in high-risk patients with haematological malignancies hospitalized with COVID-19 during Omicron variant predominance who received early treatment with antivirals. METHODS We conducted a prospective observational study on high-risk haematological patients admitted in our hospital between December 2021 and March 2022. We performed detection techniques on viral subgenomic mRNAs until negative results were obtained to document active, prolonged viral replication. RESULTS This analysis included 60 consecutive adults with high-risk haematological malignancies and COVID-19. All of these patients underwent early treatment with remdesivir. Thirty-two (53%) patients received combined antiviral strategies, with sotrovimab or hyperimmune plasma being added to remdesivir. The median length of viral replication-as measured by real-time RT-PCR and/or subgenomic RNA detection-was 20 (IQR 14-28) days. Prolonged viral replication (6 weeks after diagnosis) was documented in six (10%) patients. Only two patients had prolonged infection for more than 2 months. Overall mortality was 5%, whereas COVID-19-related mortality was 0%. CONCLUSIONS Current outcomes of high-risk patients with haematological malignancies hospitalized with COVID-19 during Omicron variant predminance are good with the use of early antiviral strategies. Persistent viral shedding is uncommon.
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Affiliation(s)
- Tommaso-Francesco Aiello
- Department of Infectious Diseases, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Pedro Puerta-Alcalde
- Department of Infectious Diseases, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Mariana Chumbita
- Department of Infectious Diseases, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Carlos Lopera
- Department of Infectious Diseases, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Patricia Monzó
- Department of Infectious Diseases, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Albert Cortes
- Department of Haematology, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Francesc Fernández-Avilés
- Department of Haematology, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - María Suárez-Lledó
- Department of Haematology, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Juan Correa
- Department of Haematology, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Valentín Ortiz-Maldonado
- Department of Haematology, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Genoveva Cuesta
- Department of Microbiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Nuria Martinez-Cibrian
- Department of Haematology, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jordi Esteve
- Department of Haematology, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Maria Ángeles Marcos
- Department of Microbiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Josep Mensa
- Department of Infectious Diseases, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Carolina Garcia-Vidal
- Department of Infectious Diseases, Hospital Clinic of Barcelona-IDIBAPS, University of Barcelona, Barcelona, Spain
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3
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Martinez-Cibrian N, Español-Rego M, Pascal M, Delgado J, Ortiz-Maldonado V. Practical aspects of chimeric antigen receptor T-cell administration: From commercial to point-of-care manufacturing. Front Immunol 2022; 13:1005457. [PMID: 36238283 PMCID: PMC9550897 DOI: 10.3389/fimmu.2022.1005457] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/07/2022] [Indexed: 11/30/2022] Open
Abstract
Chimeric antigen receptor T-cells targeting the CD19 antigen have achieved impressive results in patients with relapsed/refractory (R/R) B-cell malignancies, leading to their approval in the European Union and other jurisdictions. In Spain, the 100% academic anti-CD19 CART-cell product varnimcabtagene autoleucel (var-cel, ARI-0001 cells) has been extraordinarily approved under the Hospital Exemption clause for the treatment of patients older than 25 years of age with R/R acute lymphoblastic leukaemia. Var-cel has also been granted PRIority MEdicines designation by the European Medicines Agency for the same indication. In this review we reveal some practical aspects related to the preparation and administration of academic point-of-care CART-cell products, using var-cel as an example, and put them into the context of commercial products.
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Affiliation(s)
- Nuria Martinez-Cibrian
- Department of Haematology, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Marta Español-Rego
- Department of Immunology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Mariona Pascal
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Department of Immunology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Julio Delgado
- Department of Haematology, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Department of Medicine, Universitat de Barcelona, Barcelona, Spain
- *Correspondence: Julio Delgado,
| | - Valentín Ortiz-Maldonado
- Department of Haematology, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
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4
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Kuhnl A, Roddie C, Kirkwood AA, Tholouli E, Menne T, Patel A, Besley C, Chaganti S, Sanderson R, O'Reilly M, Norman J, Osborne W, Bloor A, Lugthart S, Malladi R, Patten PEM, Neill L, Martinez-Cibrian N, Kennedy H, Phillips EH, Jones C, Sharplin K, El-Sharkawi D, Latif AL, Mathew A, Uttenthal B, Stewart O, Marzolini MAV, Townsend W, Cwynarski K, Ardeshna K, Ardavan A, Robinson K, Pagliuca A, Collins GP, Johnson R, McMillan A. A national service for delivering CD19 CAR-Tin large B-cell lymphoma - The UK real-world experience. Br J Haematol 2022; 198:492-502. [PMID: 35485402 DOI: 10.1111/bjh.18209] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [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: 01/25/2022] [Revised: 03/22/2022] [Accepted: 04/08/2022] [Indexed: 01/01/2023]
Abstract
CD19 CAR-T have emerged as a new standard treatment for relapsed/refractory (r/r) large B-cell lymphoma (LBCL). CAR-T real-world (RW) outcomes published to date suggest significant variability across countries. We provide results of a large national cohort of patients intended to be treated with CAR-T in the UK. Consecutive patients with r/r LBCL approved for CAR-T by the National CAR-T Clinical Panel between December 2018 and November 2020 across all UK CAR-T centres were included. 404/432 patients were approved [292 axicabtagene ciloleucel (axi-cel), 112 tisagenlecleucel (tisa-cel)], 300 (74%) received the cells. 110/300 (38.3%) patients achieved complete remission (CR) at 6 months (m). The overall response rate was 77% (52% CR) for axi-cel, 57% (44% CR) for tisa-cel. The 12-month progression-free survival was 41.8% (axi-cel) and 27.4% (tisa-cel). Median overall survival for the intention-to-treat population was 10.5 m, 16.2 m for infused patients. The incidence of grade ≥3 cytokine release syndrome and neurotoxicity were 7.6%/19.6% for axi-cel and 7.9%/3.9% for tisa-cel. This prospective RW population of CAR-T eligible patients offers important insights into the clinical benefit of CD19 CAR-T in LBCL in daily practice. Our results confirm long-term efficacy in patients receiving treatment similar to the pivotal trials, but highlight the significance of early CAR-T failure.
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Affiliation(s)
- Andrea Kuhnl
- Department of Haematology, King's College Hospital, London, UK
| | - Claire Roddie
- Department of Haematology, University College London Hospitals, London, UK.,UCL Cancer Institute, University College London, London, UK
| | - Amy A Kirkwood
- Cancer Research UK & UCL Cancer Trials Centre, UCL Cancer Institute, University College London, London, UK
| | - Eleni Tholouli
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Tobias Menne
- Department of Haematology, Freeman Hospital, Newcastle, UK
| | - Amit Patel
- Department of Haematology, The Christie Hospital, Manchester, UK
| | - Caroline Besley
- Department of Haematology, University Hospitals Bristol and Weston, Bristol, UK
| | - Sridhar Chaganti
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - Robin Sanderson
- Department of Haematology, King's College Hospital, London, UK
| | - Maeve O'Reilly
- Department of Haematology, University College London Hospitals, London, UK
| | - Jane Norman
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Wendy Osborne
- Department of Haematology, Freeman Hospital, Newcastle, UK
| | - Adrian Bloor
- Department of Haematology, The Christie Hospital, Manchester, UK
| | - Sanne Lugthart
- Department of Haematology, University Hospitals Bristol and Weston, Bristol, UK
| | - Ram Malladi
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK.,Department of Haematology, Addenbrookes Hospital, Cambridge, UK
| | - Piers E M Patten
- Department of Haematology, King's College Hospital, London, UK.,Comprehensive Cancer Centre, King's College London, London, UK
| | - Lorna Neill
- Department of Haematology, University College London Hospitals, London, UK
| | | | - Hannah Kennedy
- Department of Haematology, Freeman Hospital, Newcastle, UK
| | - Elizabeth H Phillips
- Department of Medical Oncology, The Christie Hospital, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Ceri Jones
- Department of Haematology, University Hospital of Wales, Cardiff, UK
| | - Kirsty Sharplin
- Department of Haematology, University Hospitals Bristol and Weston, Bristol, UK
| | | | | | - Amrith Mathew
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Orla Stewart
- Department of Haematology, King's College Hospital, London, UK
| | | | - William Townsend
- Department of Haematology, University College London Hospitals, London, UK
| | - Kate Cwynarski
- Department of Haematology, University College London Hospitals, London, UK
| | - Kirit Ardeshna
- Department of Haematology, University College London Hospitals, London, UK
| | - Arzhang Ardavan
- NCRI Consumer Forum, London, UK.,Department of Physics, University of Oxford, UK
| | | | | | - Graham P Collins
- Department of Haematology, Oxford University Hospital, Oxford, UK
| | | | - Andrew McMillan
- Department of Haematology, Nottingham University Hospitals, Nottingham, UK
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5
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Iacoboni G, Villacampa G, Martinez-Cibrian N, Bailén R, Lopez Corral L, Sanchez JM, Guerreiro M, Caballero AC, Mussetti A, Sancho JM, Hernani R, Abrisqueta P, Solano C, Sureda A, Briones J, Martin Garcia-Sancho A, Kwon M, Reguera-Ortega JL, Barba P. Real-world evidence of tisagenlecleucel for the treatment of relapsed or refractory large B-cell lymphoma. Cancer Med 2021; 10:3214-3223. [PMID: 33932100 PMCID: PMC8124109 DOI: 10.1002/cam4.3881] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/09/2021] [Accepted: 03/17/2021] [Indexed: 12/20/2022] Open
Abstract
Tisagenlecleucel (tisa-cel) is a second-generation autologous CD19-targeted chimeric antigen receptor (CAR) T-cell therapy approved for relapsed/refractory (R/R) large B-cell lymphoma (LBCL). The approval was based on the results of phase II JULIET trial, with a best overall response rate (ORR) and complete response (CR) rate in infused patients of 52% and 40%, respectively. We report outcomes with tisa-cel in the standard-of-care (SOC) setting for R/R LBCL. Data from all patients with R/R LBCL who underwent leukapheresis from December 2018 until June 2020 with the intent to receive SOC tisa-cel were retrospectively collected at 10 Spanish institutions. Toxicities were graded according to ASTCT criteria and responses were assessed as per Lugano 2014 classification. Of 91 patients who underwent leukapheresis, 75 (82%) received tisa-cel therapy. Grade 3 or higher cytokine release syndrome and neurotoxicity occurred in 5% and 1%, respectively; non-relapse mortality was 4%. Among the infused patients, best ORR and CR were 60% and 32%, respectively, with a median duration of response of 8.9 months. With a median follow-up of 14.1 months from CAR T-cell infusion, median progression-free survival and overall survival were 3 months and 10.7 months, respectively. At 12 months, patients in CR at first disease evaluation had a PFS of 87% and OS of 93%. Patients with an elevated lactate dehydrogenase showed a shorter PFS and OS on multivariate analysis. Treatment with tisa-cel for patients with relapsed/refractory LBCL in a European SOC setting showed a manageable safety profile and durable complete responses.
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Affiliation(s)
- Gloria Iacoboni
- Department of Hematology, University Hospital Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain.,Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Guillermo Villacampa
- Oncology Data Science, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | | | - Rebeca Bailén
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Lucia Lopez Corral
- Hematology Department, Hospital Clínico Universitario de Salamanca, IBSAL, CIBERONC, Salamanca, Spain.,Centro de Investigación del Cáncer-IBMCC, Salamanca, Spain
| | - Jose M Sanchez
- Hematology Department, Hospital 12 de Octubre, Madrid, Spain
| | | | - Ana Carolina Caballero
- Hematology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Alberto Mussetti
- Hematology Department, Institut Catala d'Oncologia, Hospital Duran i Reynals, L'Hospitalet De Llobregat, Spain.,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet De Llobregat, Barcelona, Spain
| | - Juan-Manuel Sancho
- Hematology Department, ICO-IJC Hospital Germans Trias i Pujol, Barcelona, Spain
| | - Rafael Hernani
- Department of Hematology, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Pau Abrisqueta
- Department of Hematology, University Hospital Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain.,Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Carlos Solano
- Department of Hematology, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain.,Department of Medicine, University of Valencia, Valencia, Spain
| | - Anna Sureda
- Hematology Department, Institut Catala d'Oncologia, Hospital Duran i Reynals, L'Hospitalet De Llobregat, Spain.,Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet De Llobregat, Barcelona, Spain
| | - Javier Briones
- Hematology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Alejandro Martin Garcia-Sancho
- Hematology Department, Hospital Clínico Universitario de Salamanca, IBSAL, CIBERONC, Salamanca, Spain.,Centro de Investigación del Cáncer-IBMCC, Salamanca, Spain
| | - Mi Kwon
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | | | - Pere Barba
- Department of Hematology, University Hospital Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain.,Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
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6
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Martinez-Cibrian N, Zeiser R, Perez-Simon JA. Graft-versus-host disease prophylaxis: Pathophysiology-based review on current approaches and future directions. Blood Rev 2020; 48:100792. [PMID: 33386151 DOI: 10.1016/j.blre.2020.100792] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/11/2020] [Accepted: 12/10/2020] [Indexed: 12/13/2022]
Abstract
Graft-versus-host disease (GvHD) was first described in 1959, since then major efforts have been made in order to understand its physiopathology and animal models have played a key role. Three steps, involving different pathways, have been recognised in either acute and chronic GvHD, identifying them as two distinct entities. In order to reduce GvHD incidence and severity, prophylactic measures were added to transplant protocols. The combination of a calcineurin inhibitor (CNI) plus an antimetabolite remains the standard of care. Better knowledge of GvHD pathophysiology has moved this field forward and nowadays different drugs are being used on a daily basis. Improving GvHD prophylaxis is a major goal as it would translate into less non-relapse mortality and better overall survival. As compared to CNI plus methotrexate the combination of CNI plus mycophenolate mophetil (MMF) allows us to obtain similar results in terms of GvHD incidence but a lower toxicity rate in terms of neutropenia or mucositis. The use of ATG has been related to a lower risk of acute and chronic GvHD in prospective randomized trials as well as the use of posttransplant Cyclophosphamide, with no or marginal impact on overall survival but with an improvement in GvHD-relapse free survival (GRFS). The use of sirolimus has been related to a lower risk of acute GvHD and significantly influenced overall survival in one prospective randomized trial. Other prospective trials have evaluated the use of receptors such as CCR5 or α4β7 to avoid T-cells trafficking into GvHD target organs, cytokine blockers or immune check point agonists. Also, epigenetic modifiers have shown promising results in phase II trials. Attention should be paid to graft-versus-leukemia, infections and immune recovery before bringing new prophylactic strategies to clinical practice. Although the list of novel agents for GvHD prophylaxis is growing, randomized trials are still lacking for many of them.
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Affiliation(s)
- Nuria Martinez-Cibrian
- Department of Hematology, University Hospital Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS/CSIC/CIBERONC), Universidad de Sevilla, Spain
| | - Robert Zeiser
- Department of Hematology, Oncology, and Stem Cell Transplantation, Faculty of Medicine, Freiburg University Medical Center, Freiburg, Germany
| | - Jose A Perez-Simon
- Department of Hematology, University Hospital Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS/CSIC/CIBERONC), Universidad de Sevilla, Spain.
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