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Ueda Oshima M, Storer BE, Qiu H, Chauncey T, Asch J, Boyer MW, Giaccone L, Flowers M, Mielcarek M, Storb R, Maloney DG, Sandmaier BM. Long-term Outcomes with Nonmyeloablative HLA-Identical Related Hematopoietic Cell Transplantation Using Tacrolimus and Mycophenolate Mofetil for Graft-versus-Host Disease Prophylaxis. Transplant Cell Ther 2020; 27:163.e1-163.e7. [PMID: 33830025 DOI: 10.1016/j.jtct.2020.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/29/2020] [Accepted: 10/12/2020] [Indexed: 11/17/2022]
Abstract
Nonmyeloablative allogeneic hematopoietic cell transplantation (HCT) from HLA-identical related donors using cyclosporine (CSP) and mycophenolate mofetil (MMF) for postgrafting immunosuppression is effective therapy for hematologic cancers. However, graft-versus-host-disease (GVHD) remains a major cause of morbidity and mortality. Pilot data suggested lower acute GVHD incidence with tacrolimus/MMF compared to historical experience using CSP/MMF after nonmyeloablative HCT. In a phase II multicenter trial, we evaluated the effect of tacrolimus/MMF for GVHD prophylaxis after HLA-identical related donor peripheral blood HCT in patients with hematologic malignancies (n = 150) using conditioning with 2 Gy total body irradiation (TBI) for patients with a preceding (within 6 months) planned autologous HCT (n = 50) or combined with 90 mg/m2 fludarabine for those without recent autologous HCT (n = 100). Oral tacrolimus was given from days -3 to 56 (tapered by day +180 if no GVHD). Oral MMF was given from days 0 to 27. Patient median age was 57 (range, 20 to 74) years. The cumulative incidences (CI) of day 100 grade II to IV and III to IV acute GVHD were 27% and 4%, respectively. With median follow-up of 10.3 (range, 3.1 to 14.5) years, the 5-year CI of chronic extensive GVHD was 48%. One-year and 5-year estimates of nonrelapse mortality, relapse/progression, survival, and progression-free survival were 9% and 13%, 35% and 50%, 73% and 53%, and 56% and 37%, respectively. GVHD prophylaxis with tacrolimus/MMF resulted in a low risk of acute GVHD and compared favorably with results from a concurrent trial using CSP/MMF. A randomized phase III trial to investigate tacrolimus/MMF versus CSP/MMF in nonmyeloablative HCT is warranted.
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Affiliation(s)
- Masumi Ueda Oshima
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington.
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Huiying Qiu
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Thomas Chauncey
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington; VA Puget Sound Health Care System, Seattle, Washington
| | - Julie Asch
- Intermountain Healthcare, Salt Lake City, Utah
| | | | | | - Mary Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
| | - Marco Mielcarek
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
| | - Rainer Storb
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
| | - David G Maloney
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, Washington
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Venetoclax and Decitabine for T/Myeloid Mixed-Phenotype Acute Leukemia Not Otherwise Specified (MPAL NOS). Case Rep Hematol 2020; 2020:8811673. [PMID: 33101740 PMCID: PMC7569429 DOI: 10.1155/2020/8811673] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 09/24/2020] [Accepted: 09/28/2020] [Indexed: 11/20/2022] Open
Abstract
T/myeloid mixed-phenotype acute leukemia not otherwise specified (MPAL NOS) is an uncommon and aggressive leukemia without well-established treatment guidelines, particularly when relapsed. Venetoclax plus a hypomethylating agent offers a promising option in this situation since studies support its use in both acute myeloid and, albeit with fewer data to date, acute T-cell-lymphoblastic leukemias. We report the successful eradication of T/myeloid MPAL NOS relapsed after allogeneic stem cell transplant with venetoclax plus decitabine. A consolidative allogeneic stem cell transplant from a second donor was subsequently performed, and the patient remained without evidence of disease more than one year later. Further investigation is indicated to evaluate venetoclax combined with hypomethylating agents and/or other therapies for the management of T/myeloid MPAL NOS.
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3
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Blood and marrow transplantation during the emerging COVID-19 pandemic: the Seattle approach. Bone Marrow Transplant 2020; 56:305-313. [PMID: 32980860 PMCID: PMC7519858 DOI: 10.1038/s41409-020-01068-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/09/2020] [Accepted: 09/16/2020] [Indexed: 01/30/2023]
Abstract
On January 20, 2020, the first patient with coronavirus disease 2019 (COVID-19) in the United States of America was diagnosed in Washington state, which subsequently experienced rapidly increasing numbers of COVID-19 cases, hospitalizations, and deaths. This placed the Seattle Blood and Marrow Transplant Program at Fred Hutchinson Cancer Research Center (Fred Hutch) in the national epicenter of this pandemic. Here, we summarize the experience gained during our rapid response to the COVID-19 pandemic. Our efforts were aimed at safely performing urgent and potentially life-saving stem cell transplants in the setting of pandemic-related stresses on healthcare resources and shelter-in-place public health measures. We describe the unique circumstances and challenges encountered, the current state of the program amidst evolving COVID-19 cases in our community, and the guiding principles for recovery. We also estimate the collateral impact of directing clinical resources toward COVID-19-related care on cancer patients in need of stem cell transplantation. Although our experience was influenced by specific regional and institutional factors, it may help inform how transplant programs respond to COVID-19 and future pandemics.
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Chhabra S, Liu Y, Hemmer MT, Costa L, Pidala JA, Couriel DR, Alousi AM, Majhail NS, Stuart RK, Kim D, Ringden O, Urbano-Ispizua A, Saad A, Savani BN, Cooper B, Marks DI, Socie G, Schouten HC, Schoemans H, Abdel-Azim H, Yared J, Cahn JY, Wagner J, Antin JH, Verdonck LF, Lehmann L, Aljurf MD, MacMillan ML, Litzow MR, Solh MM, Qayed M, Hematti P, Kamble RT, Vij R, Hayashi RJ, Gale RP, Martino R, Seo S, Hashmi SK, Nishihori T, Teshima T, Gergis U, Inamoto Y, Spellman SR, Arora M, Hamilton BK. Comparative Analysis of Calcineurin Inhibitor-Based Methotrexate and Mycophenolate Mofetil-Containing Regimens for Prevention of Graft-versus-Host Disease after Reduced-Intensity Conditioning Allogeneic Transplantation. Biol Blood Marrow Transplant 2018; 25:73-85. [PMID: 30153491 DOI: 10.1016/j.bbmt.2018.08.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 08/09/2018] [Indexed: 01/11/2023]
Abstract
The combination of a calcineurin inhibitor (CNI) such as tacrolimus (TAC) or cyclosporine (CYSP) with methotrexate (MTX) or with mycophenolate mofetil (MMF) has been commonly used for graft-versus-host disease (GVHD) prophylaxis after reduced-intensity conditioning (RIC) allogeneic hematopoietic cell transplantation (alloHCT), but there are limited data comparing efficacy of the 2 regimens. We evaluated 1564 adult patients who underwent RIC alloHCT for acute myelogenous leukemia (AML) and acute lymphoblastic leukemia (ALL), chronic myelogenous leukemia (CML), and myelodysplastic syndrome (MDS) from 2000 to 2013 using HLA-identical sibling (matched related donor [MRD]) or unrelated donor (URD) peripheral blood graft and received CYSP or TAC with MTX or MMF for GVHD prophylaxis. Primary outcomes of the study were acute and chronic GVHD and overall survival (OS). The study divided the patient population into 4 cohorts based on regimen: MMF-TAC, MMF-CYSP, MTX-TAC, and MTX-CYSP. In the URD group, MMF-CYSP was associated with increased risk of grade II to IV acute GVHD (relative risk [RR], 1.78; P < .001) and grade III to IV acute GVHD (RR, 1.93; P = .006) compared with MTX-TAC. In the URD group, use of MMF-TAC (versus MTX-TAC) lead to higher nonrelapse mortality. (hazard ratio, 1.48; P = .008). In either group, no there was no difference in chronic GVHD, disease-free survival, and OS among the GVHD prophylaxis regimens. For RIC alloHCT using MRD, there are no differences in outcomes based on GVHD prophylaxis. However, with URD RIC alloHCT, MMF-CYSP was inferior to MTX-based regimens for acute GVHD prevention, but all the regimens were equivalent in terms of chronic GVHD and OS. Prospective studies, targeting URD recipients are needed to confirm these results.
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Affiliation(s)
- Saurabh Chhabra
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Ying Liu
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Institute for Health and Society, Department of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael T Hemmer
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Luciano Costa
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joseph A Pidala
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Daniel R Couriel
- Division of Hematology and Hematologic Malignancies, Utah Blood and Marrow Transplant Program, Salt Lake City, Utah
| | - Amin M Alousi
- Department of Stem Cell Transplantation, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Navneet S Majhail
- Blood & Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Robert K Stuart
- Division of Hematology/Oncology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Dennis Kim
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Center, Toronto, Canada
| | - Olle Ringden
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Alvaro Urbano-Ispizua
- Department of Hematology, IDIBAPS, Institute of Research Josep Carreras, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Ayman Saad
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brenda Cooper
- Department of Medicine-Hematology and Oncology, University Hospitals Case Medical Center, Cleveland, Ohio
| | - David I Marks
- Adult Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Gerard Socie
- Department of Hematology, Hôpital Saint Louis, Paris, France
| | - Harry C Schouten
- Department of Hematology, Academische Ziekenhuis, Maastricht, the Netherlands
| | - Helene Schoemans
- Department of Hematology, 26-Department of Pediatrics, University Hospital of Leuven, Leuven, Belgium
| | - Hisham Abdel-Azim
- Division of Hematology, Oncology and Blood & Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Jean Yared
- Blood & Marrow Transplantation Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland
| | - Jean-Yves Cahn
- Department of Hematology, CHU Grenoble Alpes, Grenoble, France
| | - John Wagner
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joseph H Antin
- Division of Hematologic Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Leo F Verdonck
- Departmentt of Hematology/Oncology, Isala Clinic, Zwolle, the Netherlands
| | - Leslie Lehmann
- Division of Hematologic Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mahmoud D Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Margaret L MacMillan
- University of Minnesota Blood and Marrow Transplant Program, Minneapolis, Minnesota
| | - Mark R Litzow
- Division of Hematology and Transplant Center, Mayo Clinic Rochester, Rochester, Minnesota
| | - Melhem M Solh
- Blood and Marrow Transplant Group of Georgia, Northside Hospital, Atlanta, Georgia
| | - Muna Qayed
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Peiman Hematti
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Medicine, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Rammurti T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Ravi Vij
- Division of Hematology and Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Robert J Hayashi
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Robert P Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Rodrigo Martino
- Divison of Clinical Hematology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Sachiko Seo
- Department of Hematology & Oncology, National Cancer Research Center East, Chiba, Japan
| | - Shahrukh K Hashmi
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia; Division of Hematology and Transplant Center, Mayo Clinic Rochester, Rochester, Minnesota
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Takanori Teshima
- Department of Hematology Kyushu University Hospital, Sapporo, Japan
| | - Usama Gergis
- Hematolgic Malignancies & Bone Marrow Transplant, Department of Medical Oncology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Yoshihiro Inamoto
- Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota.
| | - Betty K Hamilton
- Blood & Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
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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.
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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.
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6
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Gao L, Liu J, Zhang Y, Chen X, Gao L, Zhang C, Liu Y, Kong P, Zhong J, Sun A, Du X, Su Y, Li H, Liu H, Peng X, Zhang X. Low incidence of acute graft-versus-host disease with short-term tacrolimus in haploidentical hematopoietic stem cell transplantation. Leuk Res 2017; 57:27-36. [PMID: 28273549 DOI: 10.1016/j.leukres.2017.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 01/22/2017] [Accepted: 02/22/2017] [Indexed: 01/29/2023]
Abstract
Although tacrolimus (Tac) has immunosuppressive properties and exhibits promising efficacy against graft-versus-host disease (GVHD), little is known about Tac in the prophylaxis of GVHD after HLA-haploidentical hematopoietic stem cell transplantation (haplo-HSCT). In a multicenter randomized controlled trial, 174 patients received haplo-HSCT with GVHD prophylaxis involving short-term Tac (from -8days to +30days) or cyclosporine (CsA). The 100day cumulative incidences of acute GVHD (aGVHD) and grade III-IV aGVHD with the short-term Tac regimen and CsA regimen were 29.1 (19.5-38.7)% vs. 50.0(39.6-60.4)% (p=0.005) and 3.6(0.0-7.5)% vs. 13.5(6.1-20.9)% (p=0.027), respectively. There were no significant differences in the incidences of chronic GVHD (cGVHD), relapse and cytomegalovirus infection. Lymphocyte subset analysis showed that T cells decreased to lower levels on the short-term Tac regimen within 3 months of transplantation. The disease-free survival and overall survival on the short-term Tac and CsA regimens were 59.3 (48.9-69.7)% vs. 55.7 (45.3-66.1)% (p=0.696) and 65.1 (55.1-75.1)% vs. 61.4 (51.2-71.6)% (p=0.075), respectively. Our findings indicate that the short-term Tac regimen for GVHD prophylaxis in patients undergoing haplo-HSCT is associated with a low incidence and slight severity of aGVHD and did not increase the incidence of relapse and cytomegalovirus infection.
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Affiliation(s)
- Lei Gao
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China.
| | - Jia Liu
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Yanqi Zhang
- Department of Health Statistics, College of Military Preventive Medicine, Third Military Medical University, Chongqing, China
| | - Xinghua Chen
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Li Gao
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Cheng Zhang
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Yao Liu
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Peiyan Kong
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Jiangfan Zhong
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Aihua Sun
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Xin Du
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Yi Su
- Department of Hematology, General Hospital of Chengdu Military Region of PLA, Chengdu, China
| | - Huimin Li
- Department of Hematology, Affiliated Hospital of Kunming Medical College, Kunming, China
| | - Hong Liu
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Xiangui Peng
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Xi Zhang
- Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China.
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7
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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]
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8
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Eapen M, Logan BR, Horowitz MM, Zhong X, Perales MA, Lee SJ, Rocha V, Soiffer RJ, Champlin RE. Bone marrow or peripheral blood for reduced-intensity conditioning unrelated donor transplantation. J Clin Oncol 2014; 33:364-9. [PMID: 25534391 DOI: 10.1200/jco.2014.57.2446] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There have been no randomized trials that have compared peripheral blood (PB) with bone marrow (BM) grafts in the setting of reduced-intensity conditioning (RIC) transplantations for hematologic malignancy. Because immune modulation plays a significant role in sustaining clinical remission after RIC, we hypothesize that higher graft-versus-host disease (GVHD) associated with PB transplantation may offer a survival advantage. PATIENTS AND METHODS The primary outcome evaluated was overall survival. Cox regression models were built to study outcomes after transplantation of PB (n = 887) relative to BM (n = 219) for patients with acute myeloid leukemia, myelodysplastic syndrome, or non-Hodgkin lymphoma, the three most common indications for unrelated RIC transplantation. Transplantations were performed in the United States between 2000 and 2008. Conditioning regimens consisted of an alkylating agent and fludarabine, and GVHD prophylaxis involved a calcineurin inhibitor (CNI) with either methotrexate (MTX) or mycophenolate mofetil (MMF). RESULTS After adjusting for age, performance score, donor-recipient HLA-match, disease, and disease status at transplantation (factors associated with overall survival), there were no significant differences in 5-year rates of survival after transplantation of PB compared with BM: 34% versus 38% with CNI-MTX and 27% versus 20% with CNI-MMF GVHD prophylaxis. CONCLUSION Survival after transplantation of PB and BM are comparable in the setting of nonirradiation RIC regimens for hematologic malignancy. The effect of GVHD prophylaxis on survival merits further evaluation.
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Affiliation(s)
- Mary Eapen
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX.
| | - Brent R Logan
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Mary M Horowitz
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Xiaobo Zhong
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Miguel-Angel Perales
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Stephanie J Lee
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Vanderson Rocha
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Robert J Soiffer
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
| | - Richard E Champlin
- Mary Eapen, Brent R. Logan, Mary M. Horowitz, and Xiaobo Zhong, Medical College of Wisconsin, Milwaukee, WI; Miguel-Angel Perales, Memorial Sloan-Kettering Cancer Center, New York, NY; Stephanie J. Lee, Fred Hutchinson Cancer Research Center, Seattle, WA; Vanderson Rocha, Churchill Hospital, Oxford, United Kingdom; Robert J. Soiffer, Dana-Farber Cancer Institute, Boston, MA; and Richard E. Champlin, MD Anderson Cancer Center, Houston, TX
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Ratanatharathorn V, Deol A, Ayash L, Cronin S, Bhutani D, Lum LG, Abidi M, Ventimiglia M, Mellert K, Uberti JP. Low-dose antithymocyte globulin enhanced the efficacy of tacrolimus and mycophenolate for GVHD prophylaxis in recipients of unrelated SCT. Bone Marrow Transplant 2014; 50:106-12. [PMID: 25285804 DOI: 10.1038/bmt.2014.203] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 07/03/2014] [Accepted: 07/29/2014] [Indexed: 11/12/2022]
Abstract
We performed a retrospective analysis of the outcome of 197 consecutive unrelated donor transplant recipients who received GVHD prophylaxis either TM regimen (tacrolimus and mycophenolate) (121 patients) or TM/ATG-G regimen (TM with low-dose antithymocyte globulin (ATG) of 4.5 mg/kg, ATG-G, Genzyme) (76 patients). Cumulative incidences of grade II-IV acute GVHD for the TM and TM/ATG-G cohorts were 49% and 61% (P=0.11) and grade III-IV acute GVHD for the TM and TM/ATG-G cohorts were 27% and 14% (P=0.02), respectively. There was no difference in the incidence of relapse or disease progression between TM and TM/ATG-G-16% and 23% (P=0.64). TM/ATG-G cohort had lower incidence of non-relapse mortality (NRM; 37% vs 20%, P=0.01), chronic GVHD (56% vs 43%, P<0.001) and more favorable global chronic GVHD severity (P<0.001). Univariate analyses showed improved OS and PFS of patients who received TM/ATG-G. Multivariate analysis confirmed TM/ATG-G had a favorable influence on OS (P=0.05) but not on PFS (P=0.07). We concluded that low-dose ATG of 4.5 mg/kg given in conjunction with TM improved GVHD prophylaxis without increased risk of relapse. Lower NRM, lower incidence and severity of chronic GVHD could potentially improve survival.
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Affiliation(s)
- V Ratanatharathorn
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - A Deol
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - L Ayash
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - S Cronin
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - D Bhutani
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - L G Lum
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - M Abidi
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - M Ventimiglia
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - K Mellert
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - J P Uberti
- Blood and Marrow Stem Cell Transplantation Program, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
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Kharfan‐Dabaja M, Mhaskar R, Reljic T, Pidala J, Perkins JB, Djulbegovic B, Kumar A. Mycophenolate mofetil versus methotrexate for prevention of graft-versus-host disease in people receiving allogeneic hematopoietic stem cell transplantation. Cochrane Database Syst Rev 2014; 2014:CD010280. [PMID: 25061777 PMCID: PMC10945354 DOI: 10.1002/14651858.cd010280.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (allo-HCT) is associated with improved outcomes for people with various hematologic diseases; however, the morbidity and mortality resulting from acute and subsequently chronic graft-versus-host disease (GVHD) pose a serious challenge to wider applicability of allo-HCT. Intravenous methotrexate in combination with a calcineurin inhibitor, cyclosporine or tacrolimus, is a widely used regimen for the prophylaxis of acute GVHD, but the administration of methotrexate is associated with a number of adverse events. Mycophenolate mofetil, in combination with a calcineurin inhibitor, has been used extensively in people undergoing allo-HCT. Conflicting results regarding various clinical outcomes following allo-HCT have been observed when comparing mycophenolate mofetil-based regimens against methotrexate-based regimens for acute GVHD prophylaxis. OBJECTIVES PRIMARY OBJECTIVE to assess the effect of mycophenolate mofetil versus methotrexate for prevention of acute GVHD in people undergoing allo-HCT. SECONDARY OBJECTIVES to evaluate the effect of mycophenolate mofetil versus methotrexate for overall survival, prevention of chronic GVHD, incidence of relapse, treatment-related harms, nonrelapse mortality, and quality of life. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL) and MEDLINE from inception to March 2014. We handsearched conference abstracts from the last two meetings (2011 and 2012) of relevant societies in the field. We searched ClinicalTrials.gov, Novartis clinical trials database (www.novctrd.com), Roche clinical trial protocol registry (www.roche-trials.com), Australian New Zealand Clinical Trials Registry (ANZCTR), and the metaRegister of Controlled Trials for ongoing trials. SELECTION CRITERIA Two review authors independently reviewed all titles/abstracts and selected full-text articles for inclusion. We included all references that reported results of randomized controlled trials (RCTs) of mycophenolate mofetil versus methotrexate for the prophylaxis of GVHD among people undergoing allo-HCT in this review. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on outcomes from all studies and compared prior to data entry and analysis. We expressed results as risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes and hazard ratios (HR) and 95% CIs for time-to-event outcomes. We pooled the individual study effects using the random-effects model. Estimates lower than one indicate that mycophenolate mofetil was favored over methotrexate. MAIN RESULTS We included three trials enrolling 177 participants (174 participants analyzed). All participants in the trials by Keihl et al. and Bolwell et al. received cyclosporine while all participants enrolled in the trial by Perkins et al. received tacrolimus. However, the results did not differ by the type of calcineurin inhibitor employed (cyclosporine versus tacrolimus). There was no evidence for a difference between mycophenolate mofetil versus methotrexate for the outcomes of incidence of acute GVHD (RR 1.25; 95% CI 0.75 to 2.09; P value = 0.39, very low quality evidence), overall survival (HR 0.73; 95% CI 0.45 to 1.17; P value = 0.19, low-quality evidence), median days to neutrophil engraftment (HR 0.77; 95% CI 0.51 to 1.17; P value = 0.23, low-quality evidence), incidence of relapse (RR 0.84; 95% CI 0.52 to 1.38; P value = 0.50, low-quality evidence), non-relapse mortality (RR 1.21; 95% CI 0.62 to 2.36; P value = 0.57, low-quality evidence), and incidence of chronic GVHD (RR 0.92; 95% CI 0.65 to 1.30; P value = 0.62, low-quality evidence). There was low-quality evidence that mycophenolate mofetil compared with methotrexate improved platelet engraftment period (HR 0.87; 95% CI 0.81 to 0.93; P value < 0.0001, low-quality evidence). There was low-quality evidence that mycophenolate mofetil compared with methotrexate resulted in decreased incidence of severe mucositis (RR 0.48; 95% CI 0.32 to 0.73; P value = 0.0006, low-quality evidence), use of parenteral nutrition (RR 0.48; 95% CI 0.26 to 0.91; P value = 0.02, low-quality evidence), and medication for pain control (RR 0.76; 95% CI 0.63 to 0.91; P value = 0.002, low-quality evidence). Overall heterogeneity was not detected in the analysis except for the outcome of neutrophil engraftment. None of the included studies reported any outcomes related to quality of life. Overall quality of evidence was low. AUTHORS' CONCLUSIONS The use of mycophenolate mofetil compared with methotrexate for primary prevention of GVHD seems to be associated with a more favorable toxicity profile, without an apparent compromise on disease relapse, transplant-associated mortality, or overall survival. The effects on incidence of GVHD between people receiving mycophenolate mofetil compared with people receiving methotrexate were uncertain. There is a need for additional high-quality RCTs to determine the optimal GVHD prevention strategy. Future studies should take into account a comprehensive view of clinical benefit, including measures of morbidity, symptom burden, and healthcare resource utilization associated with interventions.
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Affiliation(s)
- Mohamed Kharfan‐Dabaja
- H. Lee Moffitt Cancer Center, Division of Oncologic Sciences, University of South FloridaDepartment of Blood and Marrow TransplantationTampaFloridaUSA
- American University of BeirutDivision of Hematology‐Oncology and Bone Marrow Transplantation ProgramBeirutLebanon
| | - Rahul Mhaskar
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
| | - Tea Reljic
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
| | - Joseph Pidala
- H. Lee Moffitt Cancer Center, Division of Oncologic Sciences, University of South FloridaDepartment of Blood and Marrow TransplantationTampaFloridaUSA
| | - Janelle B Perkins
- Division of Oncologic Sciences, University of South FloridaDepartment of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center12902 Magnolia Dr.TampaFloridaUSA33612
| | - Benjamin Djulbegovic
- H. Lee Moffitt Cancer Center, Division of Oncologic Sciences, University of South FloridaDepartment of Blood and Marrow TransplantationTampaFloridaUSA
- University of South FloridaUSF Clinical Translational Science Institute, Departments of Medicine, Hematology and Health Outcome Research12901 Bruce B. Downs Boulevard, CMS 3057TampaFloridaUSA33612
| | - Ambuj Kumar
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
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11
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Differential effects of mycophenolate mofetil and cyclosporine A on peripheral blood and cord blood natural killer cells activated with interleukin-2. Cytotherapy 2014; 16:1409-18. [PMID: 24969967 DOI: 10.1016/j.jcyt.2014.05.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 04/24/2014] [Accepted: 05/08/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND AIMS Graft-versus-host disease remains a major cause of death after hematopoietic stem cell transplantation. Cyclosporine (CsA) and mycophenolate mofetil (MMF) have been successfully used alone or in combination as prophylaxis for graft-versus-host disease. Although the effects of these drugs on T cells have been studied, little is known about the effects of both drugs on natural killer (NK) cells. We examined if the sensitivity of umbilical cord blood (CB) NK cells to MMF and/or CsA differs from their adult counterparts. METHODS An approach that was based on flow cytometry and real-time polymerase chain reaction was used to assess the effects of MMF, CsA and the combination of both drugs on the viability, activation, proliferation and cytotoxicity of peripheral blood (PB) and CB NK cells after culture with interleukin-2. RESULTS MMF alone or together with CsA induced cell death of CB NK cells but not of PB NK cells. MMF and CsA had differential effects on NK cell activation but significantly reduced proliferation of CB NK cells. MMF reduced perforin expression by PB NK cells, whereas CsA alone or together with MMF drastically decreased degranulation of CB and PB NK cells. However, neither affected cytokine secretion by PB and CB NK cells. CONCLUSIONS This study showed that CB NK cells were more sensitive to MMF and CsA than were PB NK cells. MMF and CsA had significant effects on NK cells that could jeopardize the beneficial effects of NK cells after hematopoietic stem cell transplantation.
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AlJohani NI, Thompson K, Hasegawa W, White D, Kew A, Couban S. Non-myeloablative allogeneic hematopoietic transplantation for patients with hematologic malignancies: 9-year single-centre experience. Curr Oncol 2014; 21:e434-40. [PMID: 24940103 DOI: 10.3747/co.21.1846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Matched related and unrelated allogeneic nonmyeloablative hematopoietic transplantation (nmt) is increasingly being used in patients with hematologic malignancies. Conditioning regimens and indications for nmt vary considerably from centre to centre. Our institution uses intravenous fludarabine and cyclophosphamide, plus graft-versus-host disease (gvhd) prophylaxis with tacrolimus and mycophenolate mofetil. We retrospectively analyzed 89 consecutive patients who underwent nmt (65 related, 24 unrelated) at our institution from October 2002 to September 2011. The most frequent indications for nmt were acute myelocytic leukemia (high-risk in first complete or subsequent remission: n = 20, 22.5%) and relapsed follicular lymphoma (n = 18, 20.2%). The cumulative incidence of acute gvhd (grades 2-4) was 28.1% (n = 25), and rates were similar for related (n = 18, 28%) and unrelated (n = 7, 29%) nmt. At a median follow-up of 22.6 months, the cumulative incidence of chronic gvhd (limited and extensive) was 68% (n = 61): 68.5% (n = 44) for related and 71% (n = 17) for unrelated nmt. The 100-day transplant-related mortality rate was 2.2%: 1.5% for related and 4.2% for unrelated nmt. Of the 89 patients, 30 (33.7%) have relapsed: 41.5% after related and 12.5% after unrelated nmt. Relapse rates were similar in patients with myeloid and lymphoid malignancies (36.4% vs. 33.3%). The 3-year overall and progression-free survival rates were 50.0% and 43.4% respectively, with multivariate analysis showing that neither rate was affected by age, disease group, status at transplantation, or related compared with unrelated nmt. Our findings indicate that, despite its limitations, including the incidence of chronic gvhd, nmt is an important treatment modality for a selected subgroup of patients with hematologic malignancies.
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Affiliation(s)
- N I AlJohani
- Division of Hematology, Department of Medicine, Dalhousie University, and Capital District Health Authority, Halifax, NS
| | - K Thompson
- Research Methods Unit, Department of Medicine, Centre for Clinical Research, Dalhousie University, and Capital District Health Authority, Halifax, NS
| | - W Hasegawa
- Division of Hematology, Department of Medicine, Dalhousie University, and Capital District Health Authority, Halifax, NS
| | - D White
- Division of Hematology, Department of Medicine, Dalhousie University, and Capital District Health Authority, Halifax, NS
| | - A Kew
- Division of Hematology, Department of Medicine, Dalhousie University, and Capital District Health Authority, Halifax, NS
| | - S Couban
- Division of Hematology, Department of Medicine, Dalhousie University, and Capital District Health Authority, Halifax, NS
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13
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Donato ML, Siegel DS, Vesole DH, McKiernan P, Nyirenda T, Pecora AL, Baker M, Goldberg SL, Mato A, Goy A, Rowley SD. The graft-versus-myeloma effect: chronic graft-versus-host disease but not acute graft-versus-host disease prolongs survival in patients with multiple myeloma receiving allogeneic transplantation. Biol Blood Marrow Transplant 2014; 20:1211-6. [PMID: 24792872 DOI: 10.1016/j.bbmt.2014.04.027] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 04/15/2014] [Indexed: 12/20/2022]
Abstract
We conducted a study of patients with multiple myeloma (MM) undergoing allogeneic transplantation to evaluate outcome parameters. Fifty-seven consecutive patients with MM received an allogeneic transplantation between 2004 and 2011 at our institution. Patients who had received at least 1 prior autologous transplantation were included. Twenty-six patients underwent allogeneic transplantation for consolidation after a response to their first autograft, and 30 patients received an allogeneic transplantation as salvage therapy. Donor source was evenly distributed between related and unrelated. The median follow-up was 52 months. Thirty-two (57.1%) patients achieved a complete response (CR). At 5 years, 49.2% of all patients were in CR. Sixteen patients received either donor lymphocyte infusions or immune suppression withdrawal for disease progression, with a 62.5% response rate. The 5-year overall survival (OS) for all patients was 59%. The 5-year OS for the 30 patients in the consolidation group was 82% compared with 38% for those in the salvage group. In multivariate analysis, 3 factors remained significantly associated with OS. These include being in the salvage group (hazard ratio [HR], 4.05; P = .0196), acute graft-versus-host disease (aGVHD) (HR, 2.99; P = .034), and chronic graft-versus-host disease (cGVHD), which was highly protective, with a 5-year OS of 78.8% for patients with cGVHD versus 42.6% for patients without cGVHD (HR .17, P = .008). Our data show that allogeneic transplantation for MM can lead to sustained remissions. aGVHD is significantly deleterious to OS and progression-free survival, whereas cGVHD is strongly favorable, supporting an important role for the graft-versus-myeloma effect.
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Affiliation(s)
- Michele L Donato
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey.
| | - David S Siegel
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey
| | - David H Vesole
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey
| | - Phyllis McKiernan
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey
| | - Themba Nyirenda
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey
| | - Andrew L Pecora
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey
| | - Melissa Baker
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey
| | - Stuart L Goldberg
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey
| | - Anthony Mato
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey
| | - Andre Goy
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey
| | - Scott D Rowley
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey
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15
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Al-Kadhimi Z, Gul Z, Chen W, Smith D, Abidi M, Deol A, Ayash L, Lum L, Waller EK, Ratanatharathorn V, Uberti J. High incidence of severe acute graft-versus-host disease with tacrolimus and mycophenolate mofetil in a large cohort of related and unrelated allogeneic transplantation patients. Biol Blood Marrow Transplant 2014; 20:979-85. [PMID: 24709007 DOI: 10.1016/j.bbmt.2014.03.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 03/16/2014] [Indexed: 01/01/2023]
Abstract
Both acute and chronic graft-versus-host disease (GVHD) are major causes of morbidity and mortality in patients undergoing allogeneic hematopoietic stem cell transplantation (AHSCT). The optimal pharmacological regimen for GVHD prophylaxis is unclear, but combinations of a calcineurin inhibitor (cyclosporin or tacrolimus [Tac]) and an antimetabolite (methotrexate or mycophenolate mofetil [MMF]) are typically used. We retrospectively evaluated the clinical outcomes of 414 consecutive patients who underwent AHSCT from sibling (SD) or unrelated donors (UD) with Tac/MMF combination, between January 2005 and August 2010. The median follow-up was 60 months. Less than one third of the patients received a reduced-intensity chemoregimen. The incidence of grades III and IV acute GVHD was 22.3% and 36.5% in SD and UD groups, respectively (P = .0007). The incidence of chronic GVHD was 47.1% and 52.7% in the SD and UD groups, respectively. Nonrelapse mortality (NRM) at 60 months was 33.3% and 46.5% in the SD and UD groups, respectively (P = .0016). The incidence of relapse was 22.4% for UD and 28.8% for SD. Five-year overall survival was 43% and 34% in the SD and UD groups, respectively (P = .0183). GVHD was the leading cause of death for the entire cohort. Multivariable analysis showed that 8/8 HLA match, patient's age < 60, and low-risk disease were associated with better survival. The use of Tac/MMF for GVHD prophylaxis was associated with a relatively high incidence of severe acute GVHD and NRM in AHSCT from sibling and unrelated donors.
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Affiliation(s)
- Zaid Al-Kadhimi
- Department of Hematology and Medical Oncology, Emory University and Winship Cancer Center, Atlanta, Georgia.
| | - Zartash Gul
- Division of Hematology/BMT, Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Wei Chen
- Biostatistics Core, Department of Oncology, Wayne State University/Karmanos Cancer Center, Detroit, Michigan
| | - Daryn Smith
- Biostatistics Core, Department of Oncology, Wayne State University/Karmanos Cancer Center, Detroit, Michigan
| | - Muneer Abidi
- Blood and Marrow Program, Department of Oncology, Wayne State University/Karmanos Cancer Center, Detroit, Michigan
| | - Abhinav Deol
- Blood and Marrow Program, Department of Oncology, Wayne State University/Karmanos Cancer Center, Detroit, Michigan
| | - Lois Ayash
- Blood and Marrow Program, Department of Oncology, Wayne State University/Karmanos Cancer Center, Detroit, Michigan
| | - Lawrence Lum
- Blood and Marrow Program, Department of Oncology, Wayne State University/Karmanos Cancer Center, Detroit, Michigan
| | - Edmund K Waller
- Department of Hematology and Medical Oncology, Emory University and Winship Cancer Center, Atlanta, Georgia
| | - Voravit Ratanatharathorn
- Blood and Marrow Program, Department of Oncology, Wayne State University/Karmanos Cancer Center, Detroit, Michigan
| | - Joseph Uberti
- Blood and Marrow Program, Department of Oncology, Wayne State University/Karmanos Cancer Center, Detroit, Michigan
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Acute GVHD prophylaxis with standard-dose, micro-dose or no MTX after fludarabine/melphalan conditioning. Bone Marrow Transplant 2013; 49:248-53. [PMID: 24162612 DOI: 10.1038/bmt.2013.167] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 05/03/2013] [Accepted: 05/20/2013] [Indexed: 11/08/2022]
Abstract
MTX is a standard component of acute GVHD prophylaxis. However, its use can be limited by toxicity. On the basis of disease risk, we prospectively assigned 132 consecutive patients from January 2005 to February 2011 undergoing first allogeneic hematopoietic cell transplant after conditioning with fludarabine and melphalan to acute GVHD prophylaxis with tacrolimus/MTX (TAC/MTX, N=22), TAC/micro-dose MTX/mycophenolate mofetil (TAC/μMTX/MMF, N=78) or TAC/MMF (TAC/MMF, N=32), to optimize acute GVHD prevention and decrease mortality. The median (range) follow-up was 24 (0.8-60) months. The median patient ages (range) were 37 (23-63), 56 (20-68) and 54 (22-68) years (P<0.0001) for TAC/MTX, TAC/μMTX/MMF and TAC/MMF, respectively. The 100-day cumulative incidences of grade III-IV acute GVHD were 19, 23 and 49% (P=0.015), respectively. The cumulative incidences of severe chronic GVHD at 1 year were 38, 29 and 79% (P<0.001), respectively. Regimen-related toxicities were not significantly different among the three prophylaxis regimens. PFS and OS were equivalent between the TAC/MTX and TAC/μMTX/MMF arms despite significantly older patients in the latter arm, and both had superior PFS and OS than the TAC/MMF arm. Acute GVHD prophylaxis with TAC/μMTX/MMF is as effective as TAC/MTX and superior to TAC/MMF.
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17
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Promising role of reduced-toxicity hematopoietic stem cell transplantation (PART-I). Stem Cell Rev Rep 2013; 8:1254-64. [PMID: 22836809 DOI: 10.1007/s12015-012-9401-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) remains a potential curative option for many patients with hematological malignancies (HM). However, the high rate of transplantation-related mortality (TRM) restricted the use of standard myeloablative HSCT to a minority of young and fit patients. Over the past few years, it has become evident that the alloreactivity of the immunocompetent donor cells mediated anti-malignancy effects independent of the action of high dose chemoradiotherapy. The use of reduced intensity conditioning (RIC) regimens has allowed a graft-versus-malignancy (GvM) effect to be exploited in patients who were previously ineligible for HSCT on the grounds of age and comorbidity. Retrospective analysis showed that RIC has been associated with lower TRM but a higher relapse rate leading to similar intermediate term overall and progression-free survivals when compared to standard myeloablative HSCT. However, the long term antitumor effect of this approach is less well established. Prospective studies are ongoing to define which patients might most benefit from reduced toxicity stem cell transplant (RT-SCT) and which transplant protocols are suitable for the different types of HM. The advent of RT-SCT permits the delivery of a potentially curative GvM effect to the majority of patients with HM whose outcome with conventional chemotherapy would be dismal. Remaining challenges include development of effective strategies to reduce relapse rates by augmenting GvM effects without increasing toxicity.
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18
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Martino M, Montanari M, Bruno B, Console G, Irrera G, Messina G, Offidani M, Scortechini I, Moscato T, Fedele R, Milone G, Castagna L, Olivieri A. Autologous hematopoietic progenitor cell transplantation for multiple myeloma through an outpatient program. Expert Opin Biol Ther 2012; 12:1449-62. [DOI: 10.1517/14712598.2012.707185] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Wakahashi K, Yamamori M, Minagawa K, Ishii S, Nishikawa S, Shimoyama M, Kawano H, Kawano Y, Kawamori Y, Sada A, Matsui T, Katayama Y. Pharmacokinetics-based optimal dose prediction of donor source-dependent response to mycophenolate mofetil in unrelated hematopoietic cell transplantation. Int J Hematol 2011; 94:193-202. [DOI: 10.1007/s12185-011-0888-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2011] [Revised: 06/14/2011] [Accepted: 06/14/2011] [Indexed: 11/28/2022]
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20
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Heher EC, Spitzer TR. Hematopoietic Stem Cell Transplantation in Patients With Chronic Kidney Disease. Semin Nephrol 2010; 30:602-14. [DOI: 10.1016/j.semnephrol.2010.09.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Tacrolimus and mycofenolate mofetil as GvHD prophylaxis following nonmyeloablative conditioning and unrelated hematopoietic SCT for adult patients with advanced hematologic diseases. Bone Marrow Transplant 2010; 46:747-55. [DOI: 10.1038/bmt.2010.167] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Perkins J, Field T, Kim J, Kharfan-Dabaja MA, Fernandez H, Ayala E, Perez L, Xu M, Alsina M, Ochoa L, Sullivan D, Janssen W, Anasetti C. A Randomized Phase II Trial Comparing Tacrolimus and Mycophenolate Mofetil to Tacrolimus and Methotrexate for Acute Graft-versus-Host Disease Prophylaxis. Biol Blood Marrow Transplant 2010; 16:937-47. [DOI: 10.1016/j.bbmt.2010.01.010] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Accepted: 01/18/2010] [Indexed: 01/15/2023]
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Nishikawa S, Okamura A, Yamamori M, Minagawa K, Kawamori Y, Kawano Y, Kawano H, Ono K, Katayama Y, Shimoyama M, Matsui T. Extended Mycophenolate Mofetil Administration Beyond Day 30 in Allogeneic Hematopoietic Stem Cell Transplantation as Preemptive Therapy for Severe Graft-Versus-Host Disease. Transplant Proc 2009; 41:3873-6. [DOI: 10.1016/j.transproceed.2009.06.231] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 05/04/2009] [Accepted: 06/19/2009] [Indexed: 10/20/2022]
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Ho VT, Aldridge J, Kim HT, Cutler C, Koreth J, Armand P, Antin JH, Soiffer RJ, Alyea EP. Comparison of Tacrolimus and Sirolimus (Tac/Sir) versus Tacrolimus, Sirolimus, and mini-methotrexate (Tac/Sir/MTX) as acute graft-versus-host disease prophylaxis after reduced-intensity conditioning allogeneic peripheral blood stem cell transplantation. Biol Blood Marrow Transplant 2009; 15:844-50. [PMID: 19539216 DOI: 10.1016/j.bbmt.2009.03.017] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 03/17/2009] [Indexed: 11/12/2022]
Abstract
Previous studies have shown that adding sirolimus to a tacrolimus/mini-methotrexate regimen (Tac/Sir/MTX) as graft-versus-host disease (GVHD) prophylaxis produces low rates of acute GVHD (aGVHD) after reduced-intensity conditioning (RIC) allogeneic stem cell transplantation (SCT). To assess whether posttransplantation methotrexate MTX can be safely eliminated altogether, we conducted a prospective clinical trial testing the combination of T and Sir alone (tac/sir) as GVHD prophylaxis after RIC SCT from matched related donors. We compared the results with patients who received (Tac/Sir/MTX) as GVHD prophylaxis after RIC SCT from matched related donors in a previous prospective study. Patients in both groups received i.v. fludarabine (Flu) 30 mg/m(2)/day and i.v. busulfan (Bu) 0.8 mg/kg/day on days -5 to -2 as conditioning, followed by transplantation of unmanipulated filgrastim-mobilized peripheral blood stem cells (PBSCS). After transplantation, patients in both groups received Tac and Sir orally starting on day -3, with doses adjusted to achieve trough serum levels of 5 to 10 ng/mL and 3 to 12 ng/mL, respectively. The patients in the Tac/Sir/MTX group also received mini-MTX therapy (5 mg/m(2) i.v.) on days +1, +3, and +6. Filgrastim 5 microg/kg/day s.c. was started on day +1 and continued until neutrophil engraftment. Twenty-nine patients received the Tac/Sir regimen, and 46 patients received the Tac/Sir/MTX regimen. The 2 groups were balanced in terms of age, sex, and disease characteristics. Engraftment was brisk and donor chimerism after transplantation robust in both groups. The cumulative incidence of grade II-IV aGVHD was similar in the 2 groups (17% for Tac/Sir versus 11% for Tac/Sir/MTX; P = .46). There also were no differences between the 2 groups in cumulative incidence of extensive chronic GVHD (cGVHD), treatment-related mortality (TRM), disease relapse, or survival. The Tac/Sir combination for GVHD prophylaxis is well tolerated and associated with a low incidence of aGVHD in matched related donor RIC SCT. The omission of mini-MTX from the Tac/Sir GVHD prophylaxis regimen appears to have no adverse effect on the development of aGVHD.
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Affiliation(s)
- Vincent T Ho
- Center for Hematologic Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA.
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Sabry W, Le Blanc R, Labbé AC, Sauvageau G, Couban S, Kiss T, Busque L, Cohen S, Lachance S, Roy DC, Roy J. Graft-versus-Host Disease Prophylaxis with Tacrolimus and Mycophenolate Mofetil in HLA-Matched Nonmyeloablative Transplant Recipients Is Associated with Very Low Incidence of GVHD and Nonrelapse Mortality. Biol Blood Marrow Transplant 2009; 15:919-29. [DOI: 10.1016/j.bbmt.2009.04.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Accepted: 04/07/2009] [Indexed: 10/20/2022]
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26
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Mizumoto C, Kanda J, Ichinohe T, Ishikawa T, Matsui M, Kadowaki N, Kondo T, Imada K, Hishizawa M, Kawabata H, Nishikori M, Yamashita K, Takaori-Kondo A, Hori T, Uchiyama T. Mycophenolate mofetil combined with tacrolimus and minidose methotrexate after unrelated donor bone marrow transplantation with reduced-intensity conditioning. Int J Hematol 2009; 89:538-545. [DOI: 10.1007/s12185-009-0306-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Revised: 03/10/2009] [Accepted: 03/17/2009] [Indexed: 11/29/2022]
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Affiliation(s)
- Francine Foss
- Medical Oncology and Bone Marrow Transplantation, Yale University School of Medicine, New Haven, CT 06520, USA.
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Alyea EP, Li S, Kim HT, Cutler C, Ho V, Soiffer RJ, Antin JH. Sirolimus, tacrolimus, and low-dose methotrexate as graft-versus-host disease prophylaxis in related and unrelated donor reduced-intensity conditioning allogeneic peripheral blood stem cell transplantation. Biol Blood Marrow Transplant 2008; 14:920-6. [PMID: 18640576 DOI: 10.1016/j.bbmt.2008.05.024] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2007] [Accepted: 05/30/2008] [Indexed: 11/12/2022]
Abstract
We assessed the combination of sirolimus, tacrolimus, and low-dose methotrexate as acute graft-versus-host disease (aGVHD) prophylaxis after reduced-intensity conditioning (RIC) allogeneic peripheral blood stem cell (PBSC) transplantation from matched related (MRD, n = 46) and unrelated (URD, n = 45) donors. All patients received fludarabine and intravenous busulfan conditioning followed by transplantation of mobilized PBSC. The median time to neutrophil engraftment was 13 days. The cumulative incidence of grade II-IV and III-IV aGVHD were 16% and 7%, respectively. There was no difference in the incidence of aGVHD between MRD and URD cohorts. Two-year cumulative incidence of extensive chronic GVHD (cGVHD) was 40%. Relapse-free survival (RFS) at 2 years was 34%: 21% in MRD and 45% in URD. Overall survival (OS) at 2 years was 59%: 47% in MRD and 67% in URD. High levels (>90%) of donor derived hematopoiesis were achieved in 59% of patients early after transplantation. The addition of sirolimus to tacrolimus and low-dose methotrexate as GVHD prophylaxis following RIC with fludarabine and low-dose intravenous busulfan is associated with rapid engraftment, low rates of aGVHD, and achievement of high levels of donor chimerism.
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Affiliation(s)
- Edwin P Alyea
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts 02115, USA.
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29
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Acute cellular rejection in a renal allograft immediately following leukocyte engraftment after auto-SCT. Bone Marrow Transplant 2008; 43:345-6. [DOI: 10.1038/bmt.2008.320] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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30
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Pharmacokinetics-based optimal dose-exploration of mycophenolate mofetil in allogeneic hematopoietic stem cell transplantation. Int J Hematol 2008; 88:104-110. [PMID: 18473127 DOI: 10.1007/s12185-008-0093-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Revised: 03/14/2008] [Accepted: 04/04/2008] [Indexed: 10/22/2022]
Abstract
For better clinical outcomes of mycophenolate mofetil (MMF) in allogeneic hematopoietic stem cell transplantation (alloSCT), higher mycophenolic acid (MPA) plasma levels are proposed to be desirable. Here, we investigate the optimal MMF dosing strategy based on pharmacokinetic studies in 20 Japanese alloSCT patients. The first 11 patients received MMF twice daily at an escalated dose from 15 mg/kg, according to real-time pharmacokinetic monitoring of the total MPA area under the curve (AUC). In the subsequent nine patients, MMF was given at a fixed dose of 1,000 mg three-times daily. The pharmacokinetic data revealed that the dose escalation in each individual did not always increase the AUC. In contrast, the increase of dosing frequency could statistically keep higher MPA plasma levels, as reflected in higher concentration at steady state (C (ss)) or trough value (C (trough)). There was no symptomatic adverse event in both groups. These results suggest that MMF administration of every 8 h after alloSCT would be better to maintain higher MPA plasma levels than that of every 12 h even in the same daily dose. Further studies are necessary to confirm the clinical benefit of MMF to prevent graft failure, as well as severe aGVHD.
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Targeting mycophenolate mofetil for graft-versus-host disease prophylaxis after allogeneic blood stem cell transplantation. Bone Marrow Transplant 2008; 42:113-20. [PMID: 18362900 DOI: 10.1038/bmt.2008.85] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
As low trough levels of mycophenolic acid (MPA) have been measured in recipients of allo-SCTs, we performed a pilot study targeting mycophenolate mofetil (MMF) doses according to the MPA area under the concentration (AUC) levels. Twenty-nine patients were transplanted from matched sibling (n=7) and unrelated donors (n=22). Tacrolimus was given orally from day -1 to achieve trough blood levels of 5-10 ng/ml. MMF was started on day 0 at 1500 mg intravenously b.i.d. AUC measurements of MPA by HPLC were scheduled on days 3, 7 and 11 after transplantation. The MMF dose was modified to achieve an MPA AUC of 35-60 microg/ml/h. With the respective adjustments 66 and 75% surpassed the lower AUC target on days 7 and 11, respectively. The cumulative incidence of grade III-IV acute GVHD was 28% (8/29). Eight out of 24 evaluable patients (33%) suffer from limited (n=3) or extensive (n=5) chronic GVHD. Overall, the results of this study suggest that targeting of MPA exposure is feasible early after transplantation. A simplified MMF targeting strategy based on MPA C(max) or C(2h) levels seems to be warranted in future trials involving more patients at later time points in the outpatient setting.
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Kornblit B, Masmas T, Madsen HO, Ryder LP, Svejgaard A, Jakobsen B, Sengeløv H, Olesen G, Heilmann C, Dickmeiss E, Petersen SL, Vindeløv L. Haematopoietic cell transplantation with non-myeloablative conditioning in Denmark: disease-specific outcome, complications and hospitalization requirements of the first 100 transplants. Bone Marrow Transplant 2008; 41:851-9. [DOI: 10.1038/bmt.2008.10] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Impact of postgrafting immunosuppressive regimens on nonrelapse mortality and survival after nonmyeloablative allogeneic hematopoietic stem cell transplant using the fludarabine and low-dose total-body irradiation 200-cGy. Biol Blood Marrow Transplant 2007; 13:790-805. [PMID: 17580257 DOI: 10.1016/j.bbmt.2007.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2006] [Accepted: 03/01/2007] [Indexed: 10/23/2022]
Abstract
The development of nonmyeloablative (NM) hematopoietic cell transplantation (HCT) has extended the potential curative treatment option of allografting to patients in whom it was previously contraindicated because of advanced age or comorbidity. Acute and chronic graft versus host disease (GVHD) and its consequent nonrelapse mortality (NRM), remains the major limitation of NM HCT. In this report, we analyzed the outcome of 67 patients (median age, 45 years) with hematologic diseases receiving NM conditioning with fludarabine 90 mg/m(2) and total body irradiation (TBI) 200-cGy, followed by filgrastim-mobilized peripheral blood stem cell transplant from HLA identical (n = 61), 5/6 antigen-matched related (n = 1), 6/6 antigen-matched unrelated (n = 3), and 5/6 antigen-matched unrelated (n = 2) donors. The first cohort of 21 patients were given cyclosporine (CSP) and mycophenolate mofetil (MMF) as postgrafting immunosuppression, whereas the subsequent cohort was given additional methotrexate (MTX) and extended duration of CSP/MMF prophylaxis in an attempt to reduce graft-versus-host disease (GVHD). Sixty-four (95%) patients engrafted and 3 (5%) had secondary graft failure. Myelosuppression was moderate with neutrophil counts not declining below 500/microL in approximately 25% of patients, and with more than half of the patients not requiring any blood or platelet transfusion. The 2-year cumulative interval (CI) of grade II-IV, grade III-IV acute GVHD and chronic GVHD were 49%, 30%, and 34%, respectively. The 2-year probability of NRM, overall (OS), and progression-free (PFS) survival were 27%, 43%, and 28%, respectively. GVHD-related death accounted for 85% of NRM. Compared with patients receiving CSP/MMF, patients receiving extended duration of CSP/MMF with additional MTX in postgrafting immunosuppression had a significantly lower risk of grade III-IV acute GVHD (CI 20% versus 52%; P = .009) and NRM (CI at 2 years: 11% versus 62%; P < .001), without any significant adverse impact on the risk of relapse (CI at 2 years: 59% versus 33%; P = .174) Subgroup analysis of a cohort of patients given MTX/CSP/MMF showed that patients with "standard risk" diseases (n = 21) had a 3-year OS and PFS of 85% and 65%, respectively. This compares favorably to the 41% (P = .02) and 23% (P = .03) OS and PFS, respectively, in patients with "high-risk" diseases (n = 25). In conclusion, the addition of MTX onto the current postgrafting immunosuppression regimen with extended CSP/MMF prophylaxis duration provides more effective protection against severe GVHD, and is associated with more favorable outcome in patients receiving NM fludarabine/TBI conditioning than in patients receiving fludarabine/TBI conditioning with CSP and MMF without MTX.
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Abstract
PURPOSE OF REVIEW Chronic graft versus host disease is a debilitating and often fatal complication of allogeneic stem cell transplantation. The purpose of this review is to overview this disease and highlight recent findings in the literature over the past year. RECENT FINDINGS A new focus on chronic graft versus host disease as a long-term complication of transplantation has resulted in increased research activity in this disease. Here we review the recent in-vitro and clinical studies that focus on the pathophysiology of the disease, treatment and prevention. SUMMARY As more patients undergo and survive allogeneic stem cell transplantation more attention is being focused on the study of chronic graft versus host disease. Although the pathophysiology is still controversial, recent advances have been made in our understanding of this disease, including the balance of T helper type 1 and 2 cells, the role of B cells and autoantibodies, graft manipulation and prophylaxis, which may lead to advances in treatment and prevention. The series of recent publications put forward by the National Institutes of Health consensus project on criteria for clinical trials are expected to advance the standards and uniformity of chronic graft versus host disease clinical research.
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Affiliation(s)
- Kristin Baird
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892-1203, USA
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Barrett AJ, Savani BN. Stem cell transplantation with reduced-intensity conditioning regimens: a review of ten years experience with new transplant concepts and new therapeutic agents. Leukemia 2006; 20:1661-72. [PMID: 16871277 DOI: 10.1038/sj.leu.2404334] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The realization in the 1990s that allogeneic stem cell transplants (SCT) have a potentially curative graft-versus-leukemia (GVL) effect in addition to the antileukemic action of myeloablative conditioning regimens was a major stimulus for the development of reduced-intensity conditioning (RIC) regimens, aimed primarily at securing engraftment to provide the GVL effect, while minimizing regimen-related toxicity. It is now over 10 years since RIC regimens were heralded as a new direction in the field of SCT. Over the last decade much has been learned about the ways in which the conditioning regimen can be tailored to provide adequate immunosuppression, and modulated to deliver a chosen degree of antimalignant treatment. The huge literature of clinical data with RIC transplantation now permits us to more clearly define the success and limitations of the approach. This review examines the origins of RIC SCT, explores the degree to which the initial expectations and purpose of the approach have been realized, and outlines some ways forward for the field.
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Affiliation(s)
- A J Barrett
- Hematology Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda MD 20892-1202, USA.
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