1
|
Penack O, Marchetti M, Aljurf M, Arat M, Bonifazi F, Duarte RF, Giebel S, Greinix H, Hazenberg MD, Kröger N, Mielke S, Mohty M, Nagler A, Passweg J, Patriarca F, Ruutu T, Schoemans H, Solano C, Vrhovac R, Wolff D, Zeiser R, Sureda A, Peric Z. Prophylaxis and management of graft-versus-host disease after stem-cell transplantation for haematological malignancies: updated consensus recommendations of the European Society for Blood and Marrow Transplantation. Lancet Haematol 2024; 11:e147-e159. [PMID: 38184001 DOI: 10.1016/s2352-3026(23)00342-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/16/2023] [Accepted: 11/08/2023] [Indexed: 01/08/2024]
Abstract
Graft-versus-host disease (GVHD) is a major factor contributing to mortality and morbidity after allogeneic haematopoietic stem-cell transplantation (HSCT). In the last 3 years, there has been regulatory approval of new drugs and considerable change in clinical approaches to prophylaxis and management of GVHD. To standardise treatment approaches, the European Society for Blood and Marrow Transplantation (EBMT) has updated its clinical practice recommendations. We formed a panel of one methodologist and 22 experts in the field of GVHD management. The selection was made on the basis of their role in GVHD management in Europe and their contributions to the field, such as publications, presentations at conferences, and other research. We applied the GRADE process to ten PICO (patient, intervention, comparator, and outcome) questions: evidence was searched for by the panel and graded for each crucial outcome. In two consensus meetings, we discussed the evidence and voted on the wording and strengths of recommendations. Key updates to the recommendations include: (1) primary use of ruxolitinib in steroid-refractory acute GVHD and steroid-refractory chronic GVHD as the new standard of care, (2) use of rabbit anti-T-cell (thymocyte) globulin or post-transplantation cyclophosphamide as standard GVHD prophylaxis in peripheral blood stem-cell transplantations from unrelated donors, and (3) the addition of belumosudil to the available treatment options for steroid-refractory chronic GVHD. The EBMT proposes to use these recommendations as the basis for routine management of GVHD during allogenic HSCT. The current recommendations favour European practice and do not necessarily represent global preferences.
Collapse
Affiliation(s)
- Olaf Penack
- Department of Hematology, Oncology and Tumorimmunology, Charité - Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.
| | - Monia Marchetti
- Hematology Service, Oncology Unit, Hospital Cardinal Massaia, Asti, Italy
| | - Mahmoud Aljurf
- Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mutlu Arat
- Istanbul Florence Nightingale Hospital, Stem Cell Transplantation Unit, Istanbul, Türkiye
| | | | - Rafael F Duarte
- Hematopoietic Transplantation and Hemato-Oncology Section, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Sebastian Giebel
- Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Hildegard Greinix
- Division of Hematology, Medical University Graz, Auenbruggerplatz, Graz, Austria
| | - Mette D Hazenberg
- Department of Hematology, Amsterdam University Medical Centers, University of Amsterdam, Netherlands
| | | | - Stephan Mielke
- Karolinska Instituet and University Hospital, Department of Laboratory Medicine, Cell Therapy and Allogenic Stem Cell Transplantation (CAST), Stockholm, Sweden
| | - Mohamad Mohty
- Department of Haematology, Hôpital Saint-Antoine, Sorbonne University, Institut National de la Santé et de la Recherche Médicale (INSERM) Paris, France
| | - Arnon Nagler
- Hematology and Bone Marrow Transplant, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Jakob Passweg
- Hematology Division, University Hospital, Basel, Switzerland
| | - Francesca Patriarca
- Haematological Clinic and Transplant Centre, University Hospital of Central Friuli, Dipartimento Area Medica, University of Udine, Udine, Italy
| | - Tapani Ruutu
- Helsinki University Hospital Comprehensive Cancer Center and Clinical Research Institute, Helsinki University Hospital, Helsinki, Finland
| | - Hélène Schoemans
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium; Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery (AccentVV), KU Leuven, Leuven, Belgium
| | - Carlos Solano
- Hematology Department, Hospital Clínico Universitario - INCLIVA, University of Valencia, Valencia, Spain
| | - Radovan Vrhovac
- Department of Haematology, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Daniel Wolff
- Medical Clinic 3, Haematology and Oncology, Klinikum der Universität Regensburg, Regensburg, Germany
| | - Robert Zeiser
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, Freiburg University Medical Center, Freiburg, Germany
| | - Anna Sureda
- Clinical Hematology Department, Institut Català d'Oncologia-Hospitalet, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), University of Barcelona, Barcelona, Spain
| | - Zinaida Peric
- Department of Haematology, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| |
Collapse
|
2
|
Cohen JB, Brown NJ, Brown SA, Dent S, van Dorst DCH, Herrmann SM, Lang NN, Oudit GY, Touyz RM. Cancer Therapy-Related Hypertension: A Scientific Statement From the American Heart Association. Hypertension 2023; 80:e46-e57. [PMID: 36621810 PMCID: PMC10602651 DOI: 10.1161/hyp.0000000000000224] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Contemporary anticancer drugs have significantly improved cancer survival at the expense of cardiovascular toxicities, including heart disease, thromboembolic disease, and hypertension. One of the most common side effects of these drugs is hypertension, especially in patients treated with vascular endothelial growth factor inhibitors, as well as tyrosine kinase inhibitors and proteasome inhibitors. Adjunctive therapy, including corticosteroids, calcineurin inhibitors, and nonsteroidal anti-inflammatories, as well as anti-androgen hormone therapy for prostate cancer, may further increase blood pressure in these patients. Cancer therapy-induced hypertension is often dose limiting, increases cardiovascular mortality in cancer survivors, and is usually reversible after interruption or discontinuation of treatment. The exact molecular mechanisms underlying hypertension are unclear, but recent discoveries indicate an important role for reduced nitric oxide generation, oxidative stress, endothelin-1, prostaglandins, endothelial dysfunction, increased sympathetic outflow, and microvascular rarefaction. In addition, genetic polymorphisms in vascular endothelial growth factor receptors are implicated in vascular endothelial growth factor inhibitor-induced hypertension. Diagnosis, management, and follow-up of cancer therapy-induced hypertension follow national hypertension guidelines because evidence-based clinical trials specifically addressing patients who develop hypertension as a result of cancer therapy are currently lacking. Rigorous baseline assessment of patients before therapy is started requires particular emphasis on assessing and treating cardiovascular risk factors. Hypertension management follows guidelines for the general population, although special attention should be given to rebound hypotension after termination of cancer therapy. Management of these complex patients requires collaborative care involving oncologists, cardiologists, hypertension specialists, primary care professionals, and pharmacists to ensure the optimal therapeutic effect from cancer treatment while minimizing competing cardiovascular toxicities.
Collapse
|
3
|
Lin A, Brown S, Maloy M, Ruiz JD, Devlin S, DeRespiris L, Proli A, Jakubowski AA, Papadopoulos EB, Sauter CS, Tamari R, Castro-Malaspina H, Shaffer B, Barker J, Perales MA, Giralt SA, Gyurkocza B. Impact of omitting post-transplant minidose-methotrexate doses in allogeneic hematopoietic cell transplantation. Leuk Lymphoma 2022; 63:1686-1693. [PMID: 35142567 PMCID: PMC9983694 DOI: 10.1080/10428194.2022.2032036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Given prophylactic methotrexate (MTX) is often held in the setting of toxicity we investigated the impact of omitting minidose-MTX dose(s). Outcomes were compared between patients who had 1-3 doses omitted and those who received all four planned doses of minidose-MTX. Of 370 consecutive patients, 50 had MTX dose(s) omitted. When MTX was omitted, initial management was mycophenolate mofetil (MMF; 36/50 patients) with or without corticosteroids (14/50 patients). Rates of grade 3-4 acute GVHD were similar between groups. Omission of minidose-MTX resulted in an increased risk of chronic GVHD (cGVHD; HR 2.27; p = .024) and decreased overall survival (HR 1.61; p = .024). However, other transplant-related outcomes were comparable. In summary, omission of minidose-MTX doses was not associated with an increased risk of acute GVHD when an alternative was added (e.g. MMF ± corticosteroids). This did not abrogate the increased risk of cGVHD or decreased overall survival.
Collapse
Affiliation(s)
- A Lin
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY
| | - S Brown
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - M Maloy
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - JD Ruiz
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - S Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - L DeRespiris
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Proli
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY
| | - AA Jakubowski
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - EB Papadopoulos
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - CS Sauter
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - R Tamari
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - H Castro-Malaspina
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - B Shaffer
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - J Barker
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - MA Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - SA Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Department of Medicine, Weill Cornell Medical College, New York, NY
| | - B Gyurkocza
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Department of Medicine, Weill Cornell Medical College, New York, NY
| |
Collapse
|
4
|
Bejanyan N, Rogosheske J, Cao Q, Lazaryan A, Holtan S, Ustun C, Jacobson P, MacMillan M, Weisdorf DJ, Wagner J, Arora M, Brunstein CG. Weight-based mycophenolate mofetil dosing predicts acute GVHD and relapse after allogeneic hematopoietic cell transplantation. Eur J Haematol 2020; 106:205-212. [PMID: 33084139 DOI: 10.1111/ejh.13537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/15/2020] [Accepted: 10/17/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Higher MMF dose can reduce acute GVHD risk after allogeneic hematopoietic cell transplantation (HCT). We examined the effect of MMF dose, relative to patient actual body weight (mg/kg/day), on outcomes of 680 adults after HCT. METHODS MMF was combined with cyclosporine (n = 599) or sirolimus (n = 81). We divided MMF dose/kg/day in quartiles. RESULTS The median time to grade II-IV acute GVHD was 32 days. The incidence of grade II-IV acute GVHD at day 30 was 30% in 1st (<29), 20% in 2nd (29-34), 16% in 3rd (35-41), and 19% in 4th (≥42) quartile (P < .01). Corresponding relapse incidence at 1 year was 16%, 25%, 27%, and 31%, respectively (P = .01). In multivariate analysis, as compared to 1st quartile, higher dose of weight-based MMF reduced grade II-IV acute GVHD (HR = 0.64 for 2nd, HR = 0.48 for 3rd, and HR = 0.55 for 4th quartile), but increased the risk of relapse (HR = 1.63 for 2nd, HR = 1.75 for 3rd, and HR = 2.31 for 4th quartile). CONCLUSIONS Weight-based MMF dose had no significant impact on engraftment, chronic GVHD, or survival. These data suggest that higher weight-based MMF dose reduces the risk of acute GVHD at the expense of increased relapse and supports conducting prospective studies to optimize MMF dosing after HCT.
Collapse
Affiliation(s)
- Nelli Bejanyan
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - John Rogosheske
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Qing Cao
- Biostatistics Core, Masonic Cancer Center. Adult and Pediatric Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - Aleksandr Lazaryan
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Shernan Holtan
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Celalettin Ustun
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Pamala Jacobson
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Margaret MacMillan
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - John Wagner
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Claudio G Brunstein
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
5
|
Battipaglia G, Labopin M, Hamladji RM, Blaise D, Chevallier P, Brissot E, Gerbitz A, Socié G, Afanasyev B, Ciceri F, Meijer E, Koc Y, Cornelissen JJ, Huynh A, Ozdogu H, Maertens J, Paul F, Labussière-Wallet H, Ruggeri A, Aljurf M, Bazarbachi A, Savani B, Nagler A, Mohty M. Post-transplantation cyclophosphamide versus antithymocyte globulin in patients with acute myeloid leukemia undergoing allogeneic stem cell transplantation from HLA-identical sibling donors: A retrospective analysis from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Cancer 2020; 127:209-218. [PMID: 33119152 DOI: 10.1002/cncr.33255] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/24/2020] [Accepted: 07/16/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Graft-versus-host disease (GVHD) is a major complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Addition of antithymocyte globulin (ATG) or post-transplantation cyclophosphamide (PTCY) to standard immunosuppressive agents reduces GVHD in different donor settings. METHODS We compared the outcomes of adults with acute myeloid leukemia undergoing allo-HSCT from HLA-identical sibling donors after the use of PTCY (n = 197) or ATG (n = 1913). RESULTS Patients in the PTCY group were younger than those in the ATG group (median age, 47 vs 54 years; P < .01). Peripheral blood was the most frequently used stem cell source, being significantly more frequent in the ATG group than in the PTCY group (95% vs 70% P < .01). The conditioning regimen was more frequently myeloablative in the PTCY group than in the ATG group (59% vs 48%; P < .01). Time to neutrophil engraftment was shorter in the ATG group than in the PTCY group (17 vs 20 days; P < .01). No differences were observed according to the other transplantation outcomes, except for chronic GVHD of all grades and extensive chronic GVHD at 2 years, which were significantly lower in the ATG group compared with the PTCY group (P < .02). CONCLUSION PTCY is feasible in an HLA-identical sibling setting, and despite similar outcomes, ATG may be associated with lower incidence of chronic GVHD.
Collapse
Affiliation(s)
- Giorgia Battipaglia
- Hematology Department, Hôpital Saint Antoine, Service d'Hématologie et Thérapie Cellulaire, Paris, France.,Hematology Department, Federico II University, Naples, Italy
| | - Myriam Labopin
- Hematology Department, Hôpital Saint Antoine, Service d'Hématologie et Thérapie Cellulaire, Paris, France.,Acute Leukemia Working Party of EBMT, Paris, France.,Hospital Saint-Antoine, Sorbonne University, INSERM U938, Paris, France
| | - Rose-Marie Hamladji
- Centre Pierre et Marie Curie, Service Hématologie Greffe de Moëlle, Alger, Algeria
| | - Didier Blaise
- Programme de Transplantation & Therapie Cellulaire, Centre de Recherche en Cancérologie de Marseille, Institut Paoli Calmettes, Marseille, France
| | | | - Eolia Brissot
- Hematology Department, Hôpital Saint Antoine, Service d'Hématologie et Thérapie Cellulaire, Paris, France.,Hospital Saint-Antoine, Sorbonne University, INSERM U938, Paris, France
| | - Armin Gerbitz
- Charité Universitaetsmedizin Berlin, Campus Virchow Klinikum, Medizinische Klinik m. S. Hämatologie/Onkologie, Berlin, Germany
| | - Gerard Socié
- Department of Hematology-BMT, Hopital St. Louis, Paris, France
| | - Boris Afanasyev
- First State Pavlov Medical University of St. Petersburg, Raisa Gorbacheva Memorial Research Institute for Paediatric Oncology, Hematology, and Transplantation, St. Petersburg, Russia
| | - Fabio Ciceri
- Ospedale San Raffaele s.r.l., Haematology and BMT, Milano, Italy
| | - Ellen Meijer
- Department of Hematology (Br 250), VU University Medical Center, Amsterdam, Netherlands
| | - Yener Koc
- Medical Park Hospitals, Stem Cell Transplant Unit, Antalya, Turkey
| | - Jan J Cornelissen
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Anne Huynh
- CHU-Institut Universitaire du Cancer Toulouse, Oncopole, Toulouse, France
| | - Hakan Ozdogu
- Haematology Division, BMT Unit, Haematology Research Laboratory, Baskent University Hospital, Adana, Turkey
| | - Johan Maertens
- Department of Hematology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Franciane Paul
- Département d`Hématologie Clinique, CHU Lapeyronie, Montpellier, France
| | | | - Annalisa Ruggeri
- Ospedale San Raffaele s.r.l., Haematology and BMT, Milano, Italy
| | - Mahmoud Aljurf
- Oncology Center, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Bipin Savani
- Division of Hematology/Oncology, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Arnon Nagler
- Acute Leukemia Working Party of EBMT, Paris, France.,Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Mohamad Mohty
- Hematology Department, Hôpital Saint Antoine, Service d'Hématologie et Thérapie Cellulaire, Paris, France.,Acute Leukemia Working Party of EBMT, Paris, France.,Hospital Saint-Antoine, Sorbonne University, INSERM U938, Paris, France
| |
Collapse
|
6
|
Ramzi M, Haghighat S, Namdari N, Haghighinejad H. Combination of Low-Dose, Short-Course Mycophenolate Mofetil With Cyclosporine and Methotrexate for Graft-Versus-Host Disease Prophylaxis in Allogeneic Stem Cell Transplant. EXP CLIN TRANSPLANT 2020; 19:1328-1333. [PMID: 32778017 DOI: 10.6002/ect.2020.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES With the standard regimen for graft-versushost disease prophylaxis in allogeneic stem cell transplant with human leukocyte antigen-matched donor, grade II-IV acute graft-versus-host disease occurs in 30% to 50% of sibling and up to 80% of unrelated recipients. Studies with limited patient numbers have shown efficacy and safety of mycophenolate mofetil for graft-versus-host disease prophylaxis. We investigated the effect of low-dose mycophenolate mofetil added to a standardized prophylaxis regimen for graft-versus-host disease in related human leukocyte antigen-matched allogeneic stem cell transplant. MATERIALS AND METHODS In this prospective randomized clinical trial, we compared cyclosporine and methotrexate versus the combination of cyclosporine, methotrexate, and mycophenolate mofetil in all patients who underwent human leukocyte antigencompatible related donor allogeneic stem cell transplant for acute leukemia during 3 years at the Bone Marrow Transplant Unit at Namazi Hospital, Shiraz University of Medical Sciences (Shiraz, Iran). RESULTS All 134 patients in both groups underwent successful engraftment. Recovery times for neutrophils and platelets were not significantly different between groups (P < .05). Incidence of acute graft-versus-host disease in the cyclosporine, methotrexate, and mycophenolate mofetil group was less than in the cyclosporine and methotrexate group (21.6% vs 40.9%; P = .041). Incidence of grade II-IV acute graftversus-host disease in the mycophenolate mofetil group was 15.2% versus the control group at 33% (P = .045). CONCLUSIONS Our single-center study suggests the combination of mycophenolate mofetil, cyclosporine, and methotrexate is superior to the standard regimen of cyclosporine and methotrexate for graft-versushost disease prophylaxis after human leukocyte antigen-matched related donor allogeneic stem cell transplant.
Collapse
Affiliation(s)
- Mani Ramzi
- From the Hematology Research Center and Bone Marrow Transplantation Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | | | | |
Collapse
|
7
|
Imahashi N, Terakura S, Kondo E, Kako S, Uchida N, Kobayashi H, Inamoto Y, Sakai H, Tanaka M, Ishikawa J, Kozai Y, Matsuoka KI, Kimura T, Fukuda T, Atsuta Y, Kanda J. Comparison of reduced-intensity/toxicity conditioning regimens for umbilical cord blood transplantation for lymphoid malignancies. Bone Marrow Transplant 2020; 55:2098-2108. [PMID: 32440015 DOI: 10.1038/s41409-020-0905-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/01/2020] [Accepted: 04/06/2020] [Indexed: 11/09/2022]
Abstract
To investigate which reduced-intensity conditioning (RIC)/reduced-toxicity conditioning (RTC) is superior for umbilical cord blood transplantation (UCBT) for lymphoid malignancies, we retrospectively compared three widely used RIC/RTC regimens: fludarabine/melphalan/total body irradiation (FM-TBI, n = 524), fludarabine/cyclophosphamide/total body irradiation (FC-TBI, n = 96), and fludarabine/busulfan/total body irradiation or melphalan (FB-based, n = 159). Among patients with acute lymphoblastic leukemia (ALL) (n = 314), there were no differences in overall survival (OS) by conditioning regimen. Among patients with malignant lymphoma (ML) (n = 465), FM-TBI and FC-TBI regimens had similar OS, whereas FB-based regimen had lower OS (hazard ratio [HR], 1.73; P < 0.01) than did FM-TBI regimen due to higher non-relapse mortality (HR, 1.72; P = 0.02). In addition, mycophenolate mofetil-containing GVHD prophylaxis was associated with better OS than methotrexate-containing GVHD prophylaxis among patients who received FM-TBI (HR, 0.65; P = 0.03) and FC-TBI (HR, 0.25; P < 0.01) regimens due to a decreased relapse risk. In summary, our results suggest that all three RIC/RTC regimens have comparable clinical outcomes in ALL, while the FM-TBI or FC-TBI regimens combined with mycophenolate mofetil-containing GVHD prophylaxis is preferable in RIC/RTC-UCBT for ML. Large prospective studies are warranted to confirm these results.
Collapse
Affiliation(s)
- Nobuhiko Imahashi
- Department of Hematology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan.
| | - Seitaro Terakura
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eisei Kondo
- Department of Hematology, Kawasaki Medical School, Kurashiki, Japan
| | - Shinichi Kako
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Naoyuki Uchida
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | - Hikaru Kobayashi
- Department of Hematology, Nagano Red Cross Hospital, Nagano, Japan
| | - Yoshihiro Inamoto
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Hitoshi Sakai
- Division of Hematology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masatsugu Tanaka
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Jun Ishikawa
- Department of Hematology, Osaka International Cancer Institute, Osaka, Japan
| | - Yasuji Kozai
- Department of Transfusion Medicine, Tokyo Metropolitan Tama Medical Center, Fuchu, Japan
| | - Ken-Ichi Matsuoka
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Takafumi Kimura
- Preparation Department, Japanese Red Cross Kinki Block Blood Center, Osaka, Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan.,Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | |
Collapse
|
8
|
Prophylaxis and management of graft versus host disease after stem-cell transplantation for haematological malignancies: updated consensus recommendations of the European Society for Blood and Marrow Transplantation. LANCET HAEMATOLOGY 2020; 7:e157-e167. [PMID: 32004485 DOI: 10.1016/s2352-3026(19)30256-x] [Citation(s) in RCA: 283] [Impact Index Per Article: 70.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 01/02/2023]
Abstract
Graft-versus-host disease (GVHD) is a major factor contributing to mortality and morbidity after allogeneic stem-cell transplantation. Because of the small number of results from well designed, large-scale, clinical studies there is considerable variability in the prevention and treatment of GVHD worldwide. In 2014, to standardise treatment approaches the European Society of Blood and Marrow Transplantation published recommendations on the management of GVHD in the setting of HLA-identical sibling or unrelated donor transplantation in adult patients with haematological malignancies. Here we update these recommendations including the results of study published after 2014. Evidence was searched in three steps: first, a widespread scan of published trials, meta-analyses, and systematic reviews; second, expert opinion was added for specific issues following several rounds of debate; and third, a refined search to target debated or rapidly updating issues. On the basis of this evidence and the 2014 recommendations, five members of the EBMT Transplant Complications Working Party created 38 statements on GVHD prophylaxis, drug management, and treatment of acute and chronic GVHD. Subsequently, they created the EBMT GVHD management recommendation expert panel by recruiting 20 experts with expertise in GVHD management. An email-based, two-round Delphi panel approach was used to manage the consensus. Modified National Comprehensive Cancer Network categories for evidence and consensus were applied to the approved statements. We reached 100% consensus for 29 recommendations and 95% consensus for nine recommendations. Key updates to these recommendations include a broader use of rabbit anti-T-cell globulin; lower steroid doses for the management of grade 2 acute GVHD with isolated skin or upper gastrointestinal tract manifestations; fluticasone, azithromycin, and montelukast should be used for bronchiolitis obliterans syndrome; and the addition of newer treatment options for resteroid-refractory acute and chronic GVHD. In addition, we discuss specific aspects of GVHD prophylaxis and management in the setting of haploidentical transplantation and in paediatric patients, but no formal recommendations on those procedures have been provided in this Review. The European Society of Blood and Marrow Transplantation proposes to use these recommendations as a basis for the routine management of GVHD during stem-cell transplantation.
Collapse
|
9
|
Hashmi H, Bhandari S, Dhanoa J, Wu X, Rai S, Figg L, Baize T, Krem M, Hegazi M, Emmons R. Clinical Outcomes Using Mycophenolate and Tacrolimus for Graft-versus-Host Disease Prophylaxis in Patients Undergoing Allogeneic Stem Cell Transplant: A Single Institution Experience. Cureus 2020; 12:e6893. [PMID: 32190456 PMCID: PMC7058400 DOI: 10.7759/cureus.6893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
For recipients of allogeneic hematopoietic stem cell transplant (HSCT), mycophenolate mofetil (MMF) plus tacrolimus combination is mostly used in reduced-intensity (RIC), and nonmyeloablative conditioning (NMAC) whereas methotrexate and tacrolimus combination is preferred in myeloablative conditioning (MAC). We present single institution outcomes in patients undergoing allogeneic HSCT with both MAC and NMAC/RIC regimen using MMF and tacrolimus for graft-versus-host disease (GVHD) prophylaxis. Data from all adult patients who underwent allogeneic HSCT from 2007 to 2017 was collected from Data Back to Centers web-based application of Center for International Blood and Marrow Transplant Research (CIBMTR). A total of 150 patients were included with the mean age of 46.9 years. For the patients who received MAC (n=109), the cumulative incidence of grade II-IV acute GVHD at day 100 was 37%, grade II-IV acute GVHD at one year was 51%, and chronic GVHD at one year was 38%. For the patients who received NMAC/RIC (n=41), the cumulative incidence of grade II-IV acute GVHD at day 100 was 31%, grade II-IV acute GVHD at one year was 28%, and chronic GVHD at one year was 36%. This institutional analysis shows that the combination of MMF and tacrolimus yields acceptable outcomes for the prevention of acute and chronic GVHD.
Collapse
Affiliation(s)
- Hamza Hashmi
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer and Research Center, Tampa, USA
| | - Shruti Bhandari
- Division of Medical Oncology and Hematology, University of Louisville, Louisville, USA
| | - Jugraj Dhanoa
- Internal Medicine, University of Louisville, School of Medicine, Louisville, USA
| | - Xiaoyong Wu
- Bioinformatics and Biostatistics, University of Louisville, School of Public Health and Information Science, Louisville, USA
| | - Shesh Rai
- Bioinformatics and Biostatistics, University of Louisville, School of Public Health and Information Science, Louisville, USA
| | - Lindsay Figg
- Division of Clinical Oncology Pharmacy, University of Louisville Hospital, Louisville, USA
| | - Timothy Baize
- Division of Clinical Oncology Pharmacy, University of Louisville Hospital, Louisville, USA
| | - Maxwell Krem
- Division of Hematology and Blood and Marrow Transplant, University of Kentucky, Lexington, USA
| | - Mohamed Hegazi
- Division of Blood and Marrow Transplant, University of Louisville, Louisville, USA
| | - Robert Emmons
- Division of Blood and Marrow Transplant, University of Louisville, Louisville, USA
| |
Collapse
|
10
|
Jensen RR, Healy RM, Ford CD, Child B, Majers J, Draper B, Hasan Y, Hoda D. Amlodipine and calcineurin inhibitor‐induced nephrotoxicity following allogeneic hematopoietic stem cell transplant. Clin Transplant 2019; 33:e13633. [DOI: 10.1111/ctr.13633] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/03/2019] [Accepted: 06/05/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Ryan R. Jensen
- Intermountain Healthcare Acute Leukemia, Blood and Marrow Transplant Program LDS Hospital Salt Lake City Utah
- Department of Pharmacy LDS Hospital Salt Lake City Utah
| | - Regan M. Healy
- Intermountain Healthcare Acute Leukemia, Blood and Marrow Transplant Program LDS Hospital Salt Lake City Utah
- Department of Pharmacy LDS Hospital Salt Lake City Utah
| | - Clyde D. Ford
- Intermountain Healthcare Acute Leukemia, Blood and Marrow Transplant Program LDS Hospital Salt Lake City Utah
| | - Berrie Child
- Intermountain Healthcare Acute Leukemia, Blood and Marrow Transplant Program LDS Hospital Salt Lake City Utah
- Department of Pharmacy LDS Hospital Salt Lake City Utah
| | - Jacob Majers
- Intermountain Healthcare Acute Leukemia, Blood and Marrow Transplant Program LDS Hospital Salt Lake City Utah
- Department of Pharmacy LDS Hospital Salt Lake City Utah
| | - Brent Draper
- Intermountain Healthcare Acute Leukemia, Blood and Marrow Transplant Program LDS Hospital Salt Lake City Utah
- Department of Pharmacy LDS Hospital Salt Lake City Utah
| | - Yousef Hasan
- Royal College of Surgeons in Ireland Dublin Ireland
| | - Daanish Hoda
- Intermountain Healthcare Acute Leukemia, Blood and Marrow Transplant Program LDS Hospital Salt Lake City Utah
| |
Collapse
|
11
|
Inferior Outcomes with Cyclosporine and Mycophenolate Mofetil after Myeloablative Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:1744-1755. [PMID: 31158502 DOI: 10.1016/j.bbmt.2019.05.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 01/06/2023]
Abstract
Combination therapy with a calcineurin inhibitor (CNI), such as cyclosporine (CSA) or tacrolimus (Tac), and methotrexate (MTX) or mycophenolate mofetil (MMF) is a widely used approach to graft-versus-host disease (GVHD) prevention. Data on the comparative effectiveness of MMF compared with MTX are limited and conflicting, however. We analyzed data from the Center for International Blood and Marrow Transplant Research for adult patients undergoing first myeloablative hematopoietic cell transplantation (HCT) from an HLA-identical matched related donor (MRD; n = 3979) or matched unrelated donor (URD; n = 4163) using CSA+MMF, CSA+MTX, Tac+MMF, or Tac+MTX for GVHD prevention between 2000 and 2013. Within the MRD cohort, 2252 patients received CSA+MTX, 1391 received Tac+MTX, 114 received CSA+MMF, and 222 received Tac+MMF. Recipients of CSA+MMF had a higher incidence of acute GVHD grade II-IV (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.24 to 2.20; P < .001) and grade III-IV (HR, 1.92; 95% CI, 1.31 to 2.83; P < .001) compared with Tac+MTX. The use of CSA+MMF was also associated with inferior overall survival (OS) (HR, 2.31; 95% CI, 1.73 to 3.09; P < .001) due to higher transplantation-related mortality (TRM) (HR, 4.03; 95% CI, 2.61 to 6.23; P < .001) compared with Tac+MTX. Within the URD cohort, 974 patients received CSA+MTX, 2697 received Tac+MTX, 68 received CSA+MMF, and 424 received Tac+MMF. CSA+MMF was again significantly associated with a higher incidence of grade III-IV acute GVHD (HR, 2.31; 95% CI, 1.57 to 3.42; P <0001), worse OS (HR, 2.36; 95% CI, 1.67 to 3.35; P < .001), and higher TRM (HR, 3.09; 95% CI, 2.00 to 4.77; P < .001), compared with Tac+MTX and other regimens. Thus, this large retrospective comparison of MMF versus MTX in combination with CSA or Tac demonstrates significantly worse GVHD and survival outcomes with CSA+MMF compared with Tac+MTX.
Collapse
|
12
|
Kumar S, Leigh ND, Cao X. The Role of Co-stimulatory/Co-inhibitory Signals in Graft-vs.-Host Disease. Front Immunol 2018; 9:3003. [PMID: 30627129 PMCID: PMC6309815 DOI: 10.3389/fimmu.2018.03003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 12/05/2018] [Indexed: 12/31/2022] Open
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) is an effective immunotherapeutic approach for various hematologic and immunologic ailments. Despite the beneficial impact of allo-HCT, its adverse effects cause severe health concerns. After transplantation, recognition of host cells as foreign entities by donor T cells induces graft-vs.-host disease (GVHD). Activation, proliferation and trafficking of donor T cells to target organs and tissues are critical steps in the pathogenesis of GVHD. T cell activation is a synergistic process of T cell receptor (TCR) recognition of major histocompatibility complex (MHC)-anchored antigen and co-stimulatory/co-inhibitory signaling in the presence of cytokines. Most of the currently used therapeutic regimens for GVHD are based on inhibiting the allogeneic T cell response or T-cell depletion (TCD). However, the immunosuppressive drugs and TCD hamper the therapeutic potential of allo-HCT, resulting in attenuated graft-vs.-leukemia (GVL) effect as well as increased vulnerability to infection. In view of the drawback of overbroad immunosuppression, co-stimulatory, and co-inhibitory molecules are plausible targets for selective modulation of T cell activation and function that can improve the effectiveness of allo-HCT. Therefore, this review collates existing knowledge of T cell co-stimulation and co-inhibition with current research that may have the potential to provide novel approaches to cure GVHD without sacrificing the beneficial effects of allo-HCT.
Collapse
Affiliation(s)
- Sandeep Kumar
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Nicholas D Leigh
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Xuefang Cao
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States.,Department of Microbiology and Immunology, Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD, United States
| |
Collapse
|
13
|
Effect of bone marrow CD34+cells and T-cell subsets on clinical outcomes after myeloablative allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2018; 54:775-781. [DOI: 10.1038/s41409-018-0380-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 10/02/2018] [Accepted: 10/13/2018] [Indexed: 12/17/2022]
|
14
|
Nikiforow S, Wang T, Hemmer M, Spellman S, Akpek G, Antin JH, Choi SW, Inamoto Y, Khoury HJ, MacMillan M, Marks DI, Meehan K, Nakasone H, Nishihori T, Olsson R, Paczesny S, Przepiorka D, Reddy V, Reshef R, Schoemans H, Waller N, Weisdorf D, Wirk B, Horowitz M, Alousi A, Couriel D, Pidala J, Arora M, Cutler C. Upper gastrointestinal acute graft- versus-host disease adds minimal prognostic value in isolation or with other graft- versus-host disease symptoms as currently diagnosed and treated. Haematologica 2018; 103:1708-1719. [PMID: 30076185 PMCID: PMC6165812 DOI: 10.3324/haematol.2017.182550] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 07/31/2018] [Indexed: 11/16/2022] Open
Abstract
Upper gastrointestinal acute graft-versus-host disease is reported in approximately 30% of hematopoietic stem cell transplant recipients developing acute graft-versus-host disease. Currently classified as Grade II in consensus criteria, upper gastrointestinal acute graft-versus-host disease is often treated with systemic immunosuppression. We reviewed the Center for International Blood and Marrow Transplant Research database to assess the prognostic implications of upper gastrointestinal acute graft-versus-host disease in isolation or with other acute graft-versus-host disease manifestations. 8567 adult recipients of myeloablative allogeneic hematopoietic stem cell transplant receiving T-cell replete grafts for acute leukemia, chronic myeloid leukemia or myelodysplastic syndrome between 2000 and 2012 were analyzed. 51% of transplants were from unrelated donors. Reported upper gastrointestinal acute graft-versus-host disease incidence was 12.1%; 2.7% of recipients had isolated upper gastrointestinal acute graft-versus-host disease, of whom 95% received systemic steroids. Patients with isolated upper gastrointestinal involvement had similar survival, disease-free survival, transplant-related mortality, and relapse as patients with Grades 0, I, or II acute graft-versus-host disease. Unrelated donor recipients with isolated upper gastrointestinal acute graft-versus-host disease had less subsequent chronic graft-versus-host disease than those with Grades I or II disease (P=0.016 and P=0.0004, respectively). Upper gastrointestinal involvement added no significant prognostic information when present in addition to other manifestations of Grades I or II acute graft-versus-host disease. If upper gastrointestinal symptoms were reclassified as Grade 0 or I, 425 of 2083 patients (20.4%) with Grade II disease would be downgraded, potentially impacting the interpretation of clinical trial outcomes. Defining upper gastrointestinal acute graft-versus-host disease as a Grade II entity, as it is currently diagnosed and treated, is not strongly supported by this analysis. The general approach to diagnosis, treatment and grading of upper gastrointestinal symptoms and their impact on subsequent acute graft-versus-host disease therapy warrants reevaluation.
Collapse
Affiliation(s)
- Sarah Nikiforow
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA, USA .,Harvard Medical School, Boston, MA, USA
| | - Tao Wang
- Center for International Blood and Marrow Transplant Research (CIBMTR), Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael Hemmer
- Center for International Blood and Marrow Transplant Research (CIBMTR), Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Görgün Akpek
- Rush University Medical Center, Chicago, IL, USA
| | - Joseph H Antin
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Sung Won Choi
- University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
| | | | | | | | | | - Ken Meehan
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | | | | | | - Sophie Paczesny
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Donna Przepiorka
- US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, MD, USA
| | - Vijay Reddy
- University of Central Florida College of Medicine, Orlando, FL, USA
| | - Ran Reshef
- Columbia University Medical Center, New York, NY, USA
| | | | - Ned Waller
- Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Mary Horowitz
- Center for International Blood and Marrow Transplant Research (CIBMTR), Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amin Alousi
- MD Anderson Cancer Research Center, Houston, TX, USA
| | - Daniel Couriel
- University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA
| | | | - Mukta Arora
- CIBMTR, Minneapolis, MN, USA.,University of Minnesota, Minneapolis, MN, USA
| | - Corey Cutler
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | |
Collapse
|
15
|
Sun Z, Liu H, Luo C, Geng L, Zheng C, Tang B, Zhu X, Tong J, Wang X, Ding K, Wan X, Zhang L, Yao W, Song K, Zhang X, Wu Y, Yang H, Han Y, Liu X, Zhu W, Wu J, Wang Z. Better outcomes of modified myeloablative conditioning without antithymocyte globulin versus myeloablative conditioning in cord blood transplantation for hematological malignancies: A retrospective (development) and a prospective (validation) study. Int J Cancer 2018; 143:699-708. [PMID: 29473150 PMCID: PMC6033117 DOI: 10.1002/ijc.31339] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 01/30/2018] [Accepted: 02/02/2018] [Indexed: 01/22/2023]
Abstract
Cord blood transplantation (CBT) is an effective option for treating hematological malignancies, but graft failure (GF) remains the primary cause of therapy failure. Thus, based on myeloablative conditioning (MAC) of busulfan with cyclophosphamide (Bu/Cy) or total body irradiation with Cy (TBI/Cy), fludarabine (Flu) was added to Bu/Cy and cytarabine (CA) to TBI/Cy for a modified myeloablative conditioning (MMAC). To compare the prognosis of MMAC with MAC, we conducted a retrospective study including 58 patients who underwent CBT with MAC or MMAC from 2000 to 2011. Neutrophil and platelet engraftment rate, overall survival (OS) and disease free survival (DFS) were significantly higher in the MMAC group (adjusted hazard ratio [HR], 2.58, 2.43, 0.36 and 0.37; p < 0.01, p = 0.01, p = 0.02 and p = 0.02, separately). Nonrelapse mortality (NRM) was comparable (p = 0.183). To validate the outcomes noted in the MMAC group, we conducted a prospective single‐arm clinical trial including 188 patients who underwent CBT with MMAC from 2011 to 2015. Engraftment rate, survival and NRM of the MMAC group in the prospective trail (MMAC‐P) were similar to the MMAC group in the retrospective study (MMAC‐R). This study is the first to demonstrate the superiority of MMAC to MAC in CBT for hematological malignancies. What's new? Cord blood transplants can help patients with blood cancer, but too often, the transplant fails due to immune rejection or other problems. Typically, patients receive myeloablative conditioning (MAC) prior to CBT, but more intense regimen might improve transplant success. Here, the authors compared the success of modified myeloablative conditioning (MMAC) with conventional MAC by looking at 58 patients over an 11‐year period. They then followed up with a four‐year prospective study, including 188 patients who received cord blood transplant with MMAC. The modified conditioning regimen boosted graft success and improved survival of patients with hematological cancers.
Collapse
Affiliation(s)
- Zimin Sun
- Department of Hematology, Anhui Provincial Hospital, Anhui Medical University, Hefei, China
| | - Huilan Liu
- Department of Hematology, Anhui Provincial Hospital, Anhui Medical University, Hefei, China
| | - Chenhui Luo
- Department of Hematology, Anhui Provincial Hospital, Anhui Medical University, Hefei, China
| | - Liangquan Geng
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Changcheng Zheng
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Baolin Tang
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Xiaoyu Zhu
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Juan Tong
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Xingbing Wang
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Kaiyang Ding
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Xiang Wan
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Lei Zhang
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Wen Yao
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Kaiding Song
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Xuhan Zhang
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Yue Wu
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Huizhi Yang
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Yongsheng Han
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Xin Liu
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Weibo Zhu
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Jingsheng Wu
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| | - Zuyi Wang
- The First Affiliated Hospital of University of Science and Technology of China, Anhui Sheng, China
| |
Collapse
|
16
|
Kurata K, Yakushijin K, Okamura A, Yamamori M, Ichikawa H, Sakai R, Mizutani Y, Kakiuchi S, Miyata Y, Kitao A, Kawamoto S, Matsuoka H, Murayama T, Minami H. Pharmacokinetics of intravenous mycophenolate mofetil in allogeneic hematopoietic stem cell-transplanted Japanese patients. Cancer Chemother Pharmacol 2018; 81:839-846. [PMID: 29511796 DOI: 10.1007/s00280-018-3550-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/23/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE Mycophenolate mofetil (MMF) is increasingly used among Japanese patients undergoing allogeneic hematopoietic stem cell transplantation (allo-SCT). Because pharmacokinetic data for MMF in the Asian population are limited, we conducted this investigation. METHODS Intravenous MMF (1000 mg/dose) was administered to 10 patients along with cyclosporine or tacrolimus for 10 days after allo-SCT; it was administered every 8 h in peripheral blood stem cell- and bone marrow-transplanted patients, and every 12 h in cord blood-transplanted patients. MMF was administered orally at the same dose from day 11. Plasma concentrations of mycophenolic acid (MPA) were measured by high-performance liquid chromatography. RESULTS The MPA AUC0 - tau was 31.9 ± 3.4, 26.2 ± 2.4, and 21.0 ± 2.2 µg*h/mL, the mean Ctrough was 0.25, 0.35, and 0.37 µg/mL, and the Cmax was 10.8, 9.2, and 5.5 µg/mL on days 2, 9, and 16, respectively. The AUC0 - tau and Cmax were significantly higher after intravenous MMF dosing than after oral MMF dosing. All patients exhibited successful neutrophil engraftments in a median time of 18 days. Grade II acute graft-versus-host disease (GvHD) of the skin was observed in two patients, and one patient developed limited chronic GvHD. Individual cases of transient and curable grade III oral mucositis and diarrhea were observed; however, MMF was not discontinued. No other severe complications or infections were observed. CONCLUSIONS Intravenously administered MMF was safe and possibly effective in achieving higher MPA plasma concentrations for GvHD prophylaxis after allo-SCT in Japanese patients.
Collapse
Affiliation(s)
- Keiji Kurata
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan.,Department of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Kimikazu Yakushijin
- Department of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Atsuo Okamura
- Department of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan.,Department of Hematology/Oncology, Kakogawa Central City Hospital, Kakogawa, Hyogo, Japan
| | - Motohiro Yamamori
- Department of Clinical Pharmacy, School of Pharmacy and Pharmaceutical Sciences, Mukogawa Women's University, Nishinomiya, Hyogo, Japan
| | - Hiroya Ichikawa
- Department of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Rina Sakai
- Department of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Yu Mizutani
- Department of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Seiji Kakiuchi
- Department of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Yoshiharu Miyata
- Department of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Akihito Kitao
- Department of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Shinichiro Kawamoto
- Department of Transfusion Medicine and Cell Therapy, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Hiroshi Matsuoka
- Department of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Tohru Murayama
- Department of Hematology, Hyogo Cancer Center, Akashi, Hyogo, Japan
| | - Hironobu Minami
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan. .,Department of Medical Oncology and Hematology, Kobe University Hospital, Kobe, Hyogo, Japan.
| |
Collapse
|
17
|
Elgarten CW, Arnold DE, Bunin NJ, Seif AE. Outcomes of matched sibling donor bone marrow transplantation in children using single-agent calcineurin inhibitors as prophylaxis for graft versus host disease. Pediatr Blood Cancer 2018; 65:10.1002/pbc.26726. [PMID: 28748621 PMCID: PMC5699955 DOI: 10.1002/pbc.26726] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/20/2017] [Accepted: 06/22/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Optimal graft versus host disease (GVHD) prophylaxis prevents severe manifestations without excess immunosuppression. Standard prophylaxis includes a calcineurin inhibitor (CNI) with low-dose methotrexate. However, single-agent CNI may be sufficient prophylaxis for a defined group of patients. Single-agent CNI has been used for GVHD prophylaxis for human leukocyte antigen (HLA)-matched sibling donor (MSD) bone marrow transplants (BMTs) in young patients at the Children's Hospital of Philadelphia for over 20 years. Here, we describe outcomes using this prophylactic strategy in a recent cohort. PROCEDURE We performed a single-institution chart review and retrospective analysis of consecutive children undergoing MSD BMT who received single-agent CNI for GVHD prophylaxis between January 2002 and December 2014. RESULTS Fifty-two children with a median age of 6.1 years (interquartile range [IQR] 2.5-8.3) and donor age of 6 years (IQR 3-10), with malignant and nonmalignant diseases (n = 35 and 17, respectively) were evaluated. Forty-three (82.6%) received oral prophylaxis with single-agent tacrolimus after initial intravenous therapy. Rates of GVHD were consistent with reported rates on dual prophylaxis: the overall incidence of grades 2-4 acute GVHD was 25.5%, grades 3-4 GVHD 9.8%, and chronic GVHD 10.4%. The cumulative incidence of relapse among children with malignancy was 20% at a median of 237 days (IQR 194-318) post-transplant. Two-year overall survival was 82.7% (95% confidence interval [CI]: 69.4-90.6%) and event-free survival was 78.9% (95% CI: 65.1-87.7%). No patient experienced graft failure. CONCLUSIONS Single-agent CNI is a safe, effective approach to GVHD prophylaxis in young patients undergoing HLA-identical sibling BMT. Additionally, single-agent oral tacrolimus is a reasonable alternative to cyclosporine in this population.
Collapse
Affiliation(s)
- Caitlin W. Elgarten
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Danielle E. Arnold
- Division of Immunology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nancy J. Bunin
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alix E. Seif
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
18
|
Yerushalmi R, Shem‐Tov N, Danylesko I, Shouval R, Nagler A, Shimoni A. The combination of cyclosporine and mycophenolate mofetil is less effective than cyclosporine and methotrexate in the prevention of acute graft-versus host disease after stem-cell transplantation from unrelated donors. Am J Hematol 2017; 92:259-268. [PMID: 28052467 DOI: 10.1002/ajh.24631] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/15/2016] [Accepted: 12/19/2016] [Indexed: 12/24/2022]
Abstract
Acute graft-versus-host disease (GVHD) is the major treatment-related complication after stem-cell transplantation (SCT) from unrelated-donors. Several GVHD prophylaxis regimens have been explored, but no regimen has shown superiority. We analyzed transplantation outcomes in 472 consecutive unrelated-donor SCT recipients, using cyclosporine/methotrexate (MTX, n = 314) or cyclosporine/mycophenolate-mofetil (MMF, n = 158) for GVHD prophylaxis. Neutrophil engraftment was faster after MMF, days 11 and 14, respectively (P = .001). Acute GVHD grade II-IV and III-IV occurred in 47% and 28% after MMF compared to 27% and 12% after MTX, respectively (P < .001). Nonrelapse mortality (NRM) was 44% and 24%, respectively (P < .001). Death associated with GVHD occurred in 25% and 8% (P < .0001), while other NRM causes occurred in 19% and 16%, respectively (P = .39). Relapse mortality was similar. Overall survival was better after MTX, 40% and 29%, respectively (P = .006). However, this difference had only borderline significance when adjusting for differences in patient characteristics (HR, 1.3, P = .08). To minimize potential selection bias we analyzed outcomes on the basis of an intention-to-treat like analysis. During the years 2008-2009, the leading GVHD prophylaxis regimen for unrelated-donor SCT included MMF (89% of transplants). During the other periods, MTX was used predominantly (82% of transplants). The two periods were otherwise well-matched. Acute GVHD occurred more often in 2008-2009. Death associated with GVHD occurred more often, while other NRM causes occurred less often resulting in similar NRM and overall survival. In conclusion, cyclosporine/MMF is associated with faster engraftment and possibly with less organ toxicity than cyclosporine/MTX. However, it is associated with increased rates of acute GVHD and GVHD-associated deaths.
Collapse
Affiliation(s)
- Ronit Yerushalmi
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
| | - Noga Shem‐Tov
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
| | - Ivetta Danylesko
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
| | - Roni Shouval
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
| | - Arnon Nagler
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
| | - Avichai Shimoni
- The Division of Hematology and Bone Marrow TransplantationTel‐Aviv UniversityChaim Sheba Medical Center, Tel‐Hashomer Israel
| |
Collapse
|
19
|
Nakane T, Nakamae H, Yamaguchi T, Kurosawa S, Okamura A, Hidaka M, Fuji S, Kohno A, Saito T, Aoyama Y, Hatanaka K, Katayama Y, Yakushijin K, Matsui T, Yamamori M, Takami A, Hino M, Fukuda T. Use of mycophenolate mofetil and a calcineurin inhibitor in allogeneic hematopoietic stem-cell transplantation from HLA-matched siblings or unrelated volunteer donors: Japanese multicenter phase II trials. Int J Hematol 2016; 105:485-496. [DOI: 10.1007/s12185-016-2154-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 11/16/2016] [Accepted: 11/16/2016] [Indexed: 12/16/2022]
|
20
|
Moiseev IS, Pirogova OV, Alyanski AL, Babenko EV, Gindina TL, Darskaya EI, Slesarchuk OA, Bondarenko SN, Afanasyev BV. Graft-versus-Host Disease Prophylaxis in Unrelated Peripheral Blood Stem Cell Transplantation with Post-Transplantation Cyclophosphamide, Tacrolimus, and Mycophenolate Mofetil. Biol Blood Marrow Transplant 2016; 22:1037-1042. [DOI: 10.1016/j.bbmt.2016.03.004] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 03/01/2016] [Indexed: 12/13/2022]
|
21
|
A Pilot Study of Continuous Infusion of Mycophenolate Mofetil for Prophylaxis of Graft-versus-Host-Disease in Pediatric Patients. Biol Blood Marrow Transplant 2016; 22:682-689. [DOI: 10.1016/j.bbmt.2015.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 12/15/2015] [Indexed: 12/30/2022]
|
22
|
Does day 11 omission of methotrexate due to toxicity influence the outcome in myeloablative hematopoietic cell transplant? Results from a single-center retrospective cohort study. Blood Cancer J 2015; 5:e344. [PMID: 26314986 PMCID: PMC4558594 DOI: 10.1038/bcj.2015.70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|