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Colunga-Pedraza PR, Barbosa-Castillo LM, Coronado-Alejandro EU, Vaquera-Alfaro HA, López-Reyna IG, Colunga-Pedraza JE, Gómez-Almaguer D. Low-dose rituximab in steroid-refractory chronic graft-versus-host disease. Transpl Immunol 2023; 81:101959. [PMID: 37972876 DOI: 10.1016/j.trim.2023.101959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 11/10/2023] [Accepted: 11/12/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Chronic graft-versus-host disease (cGvHD) is a major complication that puts patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) at risk of death or infection. Currently, there is no gold standard for the first-line treatment of patients who do not respond to steroids, and there are several therapeutic options being evaluated in clinical trials for this disease to be used even in the first-line treatment for GvHD. There is evidence of the benefit of rituximab, an anti-CD20 antibody, at a standard dose of 375 mg/m2 weekly in the treatment of steroid-refractory chronic graft-versus disease (SR-cGvHD). OBJECTIVE To demonstrate the safety and efficacy of low-dose rituximab in a middle-income center in northeastern Mexico STUDY DESIGN: We report the experience of 26 patients with chronic graft-versus-graft disease who received low-dose rituximab (100 mg weekly for 4 weeks). We utilized the advances in the National Institutes of Health (NIH) criteria for diagnosis, scoring, trial design, and assessment of treatment response. RESULTS We obtained a 5-year overall survival of 23.6%, including four patients with complete response. The 1-year event-free survival was 70% for patients with rituximab. During the treatment, there were 3 hospitalizations, and the causes were: immune thrombocytopenia, a parapneumonic effusion, and a cerebral vascular event. The median length of hospital stay was twelve days. CONCLUSION A low dose of rituximab is an available and cost-effective option for patients with steroid-refractory cGvHD.
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Affiliation(s)
- Perla R Colunga-Pedraza
- Hematology service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero, Monterrey, Nuevo León 64460, Mexico.
| | - Luz María Barbosa-Castillo
- Hematology service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero, Monterrey, Nuevo León 64460, Mexico
| | - Edgar Ulises Coronado-Alejandro
- Hematology service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero, Monterrey, Nuevo León 64460, Mexico
| | - Héctor Alejandro Vaquera-Alfaro
- Hematology service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero, Monterrey, Nuevo León 64460, Mexico
| | - Ingrid Gabriela López-Reyna
- Hematology service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero, Monterrey, Nuevo León 64460, Mexico
| | - Julia E Colunga-Pedraza
- Hematology service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero, Monterrey, Nuevo León 64460, Mexico
| | - David Gómez-Almaguer
- Hematology service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero, Monterrey, Nuevo León 64460, Mexico
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Mature naive B cells regulate the outcome of murine acute graft-versus-host disease in an IL-10 independent manner. Transplant Cell Ther 2022; 28:181.e1-181.e9. [PMID: 35032717 DOI: 10.1016/j.jtct.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 12/30/2022]
Abstract
Graft-versus-host disease (GVHD) is the main complication of bone marrow transplantation (BMT). T CD4+ lymphocytes are the main effector cells for disease development but other cell types can determine disease outcome through cytokine production and antigen presentation. B cells are abundant in BMT products and are involved in chronic GVHD immunopathogenesis. However, their role in acute GVHD is still unclear. Here, we studied the role of donor resting B cells in a model of acute GVHD. Animals receiving transplants depleted of B cells presented a more severe disease, indicating a protective role for B cells. Mice transplanted with IL-10 KO B cells developed GVHD as severe as those receiving WT B cells. Besides that, mice transplanted with MHC II deficient B cells and as so, unable to present antigen to CD4+ T cells, developed as severe GVHD as animals transplanted without B cells. This result suggests that protection provided by mature naive B cells depends on antigen presentation and not IL-10 production by B cells. In the absence of donor B cells, transplanted mice exhibited disorganized lymphoid splenic tissue. Additionally, donor B cell depletion diminished the follicular T (Tfh)/T effector (Teff) ratio suggesting that protection was correlated with a shift to Tfh differentiation, reducing the number of effector T cells. Importantly, the Tfh/Teff shift impacts disease outcome since observed proinflammatory cytokine levels and tissue damage in target organs were consistent with disease protection. The role of transplanted B cells in the outcome of BMT and the development of acute GVHD should be carefully studied, since these cells are abundant in BMT products and are potent modulator and effector cells in allogeneic response. Extended Abstract Background: B cells are widely known for their ability to produce antibodies. In addition, B cells can act efficiently as antigen-presenting cells, implying the mutual regulation of both T and B lymphocyte subsets. T cell help for B cells has been known for more than 50 years; however, B cell help for T cells, especially regarding the modulation of follicular and regulatory phenotypes, had only lately been explored. Here, we studied the role of resting B cells in a model of systemic inflammatory disease mediated by T cells, graft-versus-host disease (GVHD), which is the main complication of allogeneic bone marrow transplantation. Objetive: The objective of this paper is to investigate the role of donor B cells in acute Graft-versus-Host Disease. STUDY DESIGN To investigate the role of donor B cells in aGVHD, we used a full MHC-mismatched bone marrow transplantation model. We infused C57BL/6 BM cells along with splenocytes depleted or not of B220+ cells into lethally irradiated BALB/c mice. We also used B cells from IL-10 KO mice to investigate the role of IL-10 produced by donor B cells and B cells from mice which cannot express MHC-II (CIITA KO) to investigate the role of cognate interaction between donor B and T cells. RESULTS Animals receiving transplants depleted of B cells presented a more severe disease, showing the existence of B cell-dependent protection. This protection was dependent on the T cell-B cell cognate interaction but not on IL-10 or Treg induction. In the absence of donor B cells, transplanted mice exhibited fewer GCs and a lower follicular T (Tfh)/T effector (Teff) ratio than mice transplanted in the presence of B cells. Protection was correlated with a shift to Tfh differentiation, reducing the number of effector cells. Importantly, the Tfh/Teff shift impacts disease outcome with less T cell-mediated disease due to more B cell-dependent Tfh generation with fewer effector T cells and lower proinflammatory cytokine levels detected in target organs. CONCLUSION We show that B-cell depleted bone marrow transplantation leads to a more severe disease, with earlier mortality related to increased organ damage. Such differences depend on cognate interactions between T cells and B cells, are IL-10 independent and are related to a shift in the differentiation of lymphocytes from the follicular helper phenotype to the effector phenotype. Therefore, Teffs, which are circulating cells, become relatively more numerous and can reach and damage the target tissues. These results point to caution in the early posttransplantation elimination of donor B cells. It is not a matter of eliminating only antibody-forming cells or cells that mediate Tfh generation but of B cells, which interact and modulate T cell activity, impacting a disease that is not antibody mediated.
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Tomaszewska A, Jagasia M, Beohou E, van der Werf S, Blaise D, Kanfer E, Milpied N, Reményi P, Ciceri F, Bourhis JH, Chevallier P, Solano C, Socié G, Bruno B, Rambaldi A, Castagna L, Kröger N, Corradini P, Afanasyev B, Ladetto M, Niederwieser D, Scheid C, Sengeloev H, Kroschinsky F, Yakoub-Agha I, Schoemans H, Koenecke C, Penack O, Perić Z, Greinix H, Duarte RF, Basak GW. Addition of Rituximab in Reduced Intensity Conditioning Regimens for B-Cell Malignancies Does Not Influence Transplant Outcomes: EBMT Registry Analyses Following Allogeneic Stem Cell Transplantation for B-Cell Malignancies. Front Immunol 2021; 11:613954. [PMID: 33603743 PMCID: PMC7884746 DOI: 10.3389/fimmu.2020.613954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 12/16/2020] [Indexed: 11/13/2022] Open
Abstract
Rituximab (R) is increasingly incorporated in reduced intensity conditioning (RIC) regimens for allogeneic hematopoietic cell transplantation (alloHCT) in patients with B-cell malignancies, not only to improve disease control, but also to prevent graft-versus-host disease (GVHD). There are no randomized prospective data to validate this practice, although single center data and the CIBMTR analysis have shown promising results. We aimed at validation of these findings in a large registry study. We conducted a retrospective analysis using the EBMT registry of 3,803 adult patients with B-cell malignancies undergoing alloHCT (2001-2013) with either rituximab (R-RIC-9%) or non-rituximab (RIC-91%) reduced intensity regimens respectively. Median age and median follow up were 55 years (range 19.1-77.3) and 43.2 months (range 0.3-179.8), respectively. There was no difference in transplant outcomes (R-RIC vs RIC), including 1-year overall survival (69.9% vs 70.7%), 1-year disease-free survival (64.4% vs 62.2%), 1-year non-relapse mortality (21% vs 22%), and day-100 incidence of acute GVHD 2-4° (12% vs 12%). In summary, we found that addition of rituximab in RIC regimens for B-cell malignancies had no significant impact on major transplant outcome variables. Of note, data on chronic GVHD was not available, limiting the conclusions that can be drawn from the present study.
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Affiliation(s)
- Agnieszka Tomaszewska
- Department of Hematology, Transplantology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Madan Jagasia
- Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, United States
| | | | | | | | - Edward Kanfer
- Hammersmith Hospital, Imperial College Healthcare, London, United Kingdom
| | | | | | | | - Jean H Bourhis
- Gustave Roussy Institute de Cancérologie, Val de Marne, France
| | | | | | | | - Benedetto Bruno
- A.O.U. Citta della Salute e della Scienza di Torino, Universita di Torino, Turin, Italy
| | | | | | | | - Paolo Corradini
- Fondazione IRCCS Istituto Nazionale dei Tumori, University of Milano, Milan, Italy
| | - Boris Afanasyev
- First State Pavlov Medical University of St. Petersburg, St. Petersburg, Russia
| | | | | | | | | | | | | | | | | | - Olaf Penack
- Department of Hematology, Oncology, and Tumor Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Hildegard Greinix
- Department of Hematology and Oncology, Medical University of Graz, Graz, Austria
| | - Rafael F Duarte
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Grzegorz W Basak
- Department of Hematology, Transplantology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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Klobuch S, Weber D, Holler B, Edinger M, Herr W, Holler E, Wolff D. Long-term follow-up of rituximab in treatment of chronic graft-versus-host disease-single center experience. Ann Hematol 2019; 98:2399-2405. [PMID: 31375860 DOI: 10.1007/s00277-019-03768-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 07/25/2019] [Indexed: 12/19/2022]
Abstract
Rituximab was recently described also as first-line therapy of chronic graft-versus-host disease (cGvHD). We retrospectively analyzed the efficacy and safety of all patients receiving rituximab for treatment of cGvHD between 2005 and 2016 at the Regensburg University transplant center with a median follow-up after rituximab therapy of 2.8 years. Responses of 29 allogeneic stem cell-transplanted patients (median age 49) with previous failure of response to steroids including one patient after donor lymphocyte infusion were assessed. Three months after rituximab application, the overall response rate was 31% (7% complete (n = 2) and 24% partial remission (n = 7)). At 12 months, overall survival was 72% (n = 21) and failure-free survival was 24% (n = 7). We further analyzed associations of rituximab response with clinical characteristics showing a higher response rate in steroid-dependent cGvHD patients (89% of 9 responding compared to steroid refractory patients (11% responding)). However, this difference was not statistically significant. Seven patients (24%) (including four lethal infectious complications) developed serious infections requiring hospitalization within 1-9 months after rituximab therapy exclusively in patients failing to respond to rituximab. In conclusion, rituximab appears to be an effective treatment of cGvHD especially in steroid dependent patients, but identification of biomarker predicting response will be crucial to avoid long-term infectious morbidity and mortality in non-responders.
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Affiliation(s)
- Sebastian Klobuch
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.
| | - Daniela Weber
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University Hospital Regensburg, Regensburg, Germany
| | - Barbara Holler
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Edinger
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University Hospital Regensburg, Regensburg, Germany
| | - Wolfgang Herr
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University Hospital Regensburg, Regensburg, Germany
| | - Ernst Holler
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University Hospital Regensburg, Regensburg, Germany
| | - Daniel Wolff
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University Hospital Regensburg, Regensburg, Germany
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Modifying Graft-versus-Host Disease in a Humanized Mouse Model by Targeting Macrophages or B-Cells. J Immunol Res 2019; 2019:3538963. [PMID: 31205954 PMCID: PMC6530157 DOI: 10.1155/2019/3538963] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 03/19/2019] [Accepted: 04/02/2019] [Indexed: 01/03/2023] Open
Abstract
Humanized mouse models can well be modified to study specific aspects of Graft-versus-Host Disease (GvHD). This paper shows the results of both macrophage depletion and (early) B-cell depletion in a humanized mouse model using RAG2-/- γc-/- mice injected with HuPBMCs. Macrophage depletion showed a significant decrease in survival and also lead to a change in the histomorphology of the xenogeneic reaction. Higher levels of infiltrating B-cells were observed in various organs of mice depleted for macrophages. With (early) B-cell depletion using Rituximab, a clear improvement on clinical symptoms was observed, even when probably only inactivated B-cells were deleted. However, the histological examinations only showed a significant morphological effect on liver fibrosis. This may be related to a difference in the mRNA levels of TGF-β. Also, lower mRNA levels of Tregs in some organs were observed after Rituximab treatment, which contradicts that a higher number of Tregs would always be related to less severe GvHD. Our data show that both macrophage depletion and (early) B-cell depletion in a xenogeneic mouse model can influence the clinical, histological, and cytokine production of a GvHD response.
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6
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Prospective evaluation of sequential treatment of sclerotic chronic graft versus host disease with rituximab and nilotinib. Bone Marrow Transplant 2018; 53:1255-1262. [PMID: 29549292 DOI: 10.1038/s41409-018-0158-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 02/08/2018] [Accepted: 02/12/2018] [Indexed: 11/08/2022]
Abstract
Sclerotic chronic graft vs. host disease (cGVHD) still has a large impact on morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). We performed the first prospective study to test whether sequential therapy of the anti-CD20 antibody rituximab followed by 6 months treatment with tyrosine kinase inhibitor nilotinib is a favorable treatment strategy for patients with sclerotic cGVHD. Twenty-nine patients were included, 24 were available for analysis. We observed objective responses in 71% of patients (two patients CR, 15 patients PR). Moreover, two out of five patients suffering from severe ulcerations showed complete resolution of ulcers. Observed responses lasted until the end of study follow-up. The majority of responding patients could reduce daily corticosteroid dose with more than 50%. Furthermore, CD5+ B-cells are significantly lower (p = 0.007) in responding patients at baseline, proposing a new biomarker predictive for response. In conclusion, sequential treatment of rituximab followed by nilotinib associates with a very high response rate in this difficult to treat patient population. CD5+ B-cells could assist in guiding treatment choices and might be a first step toward more personalized cGVHD treatment. This trial was registered at the Dutch clinical trial registry as NTR1222.
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7
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The Role of B Cell Targeting in Chronic Graft-Versus-Host Disease. Biomedicines 2017; 5:biomedicines5040061. [PMID: 29039818 PMCID: PMC5744085 DOI: 10.3390/biomedicines5040061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 09/20/2017] [Accepted: 10/09/2017] [Indexed: 11/17/2022] Open
Abstract
Chronic graft-versus-host disease (cGVHD) is a leading cause of late morbidity and mortality following allogeneic stem cell transplantation. Current therapies, including corticosteroids and calcineurin inhibitors, are only effective in roughly 50% of cases; therefore, new treatment strategies are under investigation. What was previously felt to be a T cell disease has more recently been shown to involve activation of both T and B cells, as well as a number of cytokines. With a better understanding of its pathophysiology have come more expansive preclinical and clinical trials, many focused on B cell signaling. This report briefly reviews our current understanding of cGVHD pathophysiology and reviews clinical and preclinical trials with B cell-targeted agents.
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Rituximab-based first-line treatment of cGVHD after allogeneic SCT: results of a phase 2 study. Blood 2017; 130:2186-2195. [PMID: 28864814 DOI: 10.1182/blood-2017-05-786137] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 08/21/2017] [Indexed: 01/14/2023] Open
Abstract
Chronic graft-versus-host disease (cGVHD) is the main cause of late nonrelapse mortality and morbidity after allogeneic stem cell transplantation (allo-SCT). To improve such patients' outcomes, we conducted a phase 2, prospective, multicenter trial to test the efficacy of the addition of rituximab to corticosteroids (CSs) and cyclosporine A (CsA) as first-line therapy for newly diagnosed cGVHD after allo-SCT. Twenty-four patients (median age, 47 years) with mild (n = 2), moderate (n = 7), or severe (n = 15) cGVHD were included. All patients received rituximab 375 mg/m2 weekly for 4 weeks, followed by a second course 1 month later for patients with partial response. Twenty of 24 patients (83%) were in response at 1 year. Furthermore, among 19 evaluable patients, 14 (74%) were off CSs. The estimated 1-year overall survival was 83%, and the 1-year cumulative incidence of nonrelapse mortality was 14%. One patient died of progressive multifocal leukoencephalopathy. Although PD-L1hi naive B cells were significantly decreased at diagnosis of cGVHD, they increased after anti-CD20 B-cell depletion. In contrast, activated ICOShi PD-1hi circulating T follicular helper (Tfh) cells decreased after rituximab treatment. Overall, the addition of rituximab to corticosteroid and CsA appeared to be safe and effective for first-line treatment of cGVHD. Furthermore, our data suggest that this efficacy may be in part related to an effect on PD-L1hi B cells and Tfh cells. This study was registered at www.clinicaltrials.gov as identifier NCT01135641.
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9
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Presland RB. Biology of chronic graft- vs-host disease: Immune mechanisms and progress in biomarker discovery. World J Transplant 2016; 6:608-619. [PMID: 28058210 PMCID: PMC5175218 DOI: 10.5500/wjt.v6.i4.608] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 07/02/2016] [Accepted: 09/18/2016] [Indexed: 02/05/2023] Open
Abstract
Chronic graft-vs-host disease (cGVHD) is the leading cause of long-term morbidity and mortality following allogeneic hematopoietic stem cell transplantation. It presents as a chronic inflammatory and sclerotic autoimmune-like condition that most frequently affects the skin, oral mucosa, liver, eyes and gastrointestinal tract. Both clinical and animal studies have shown that multiple T cell subsets including Th1, Th2, Th17, T follicular helper cells and regulatory T-cells play some role in cGVHD development and progression; B cells also play an important role in the disease including the production of antibodies to HY and nuclear antigens that can cause serious tissue damage. An array of cytokines and chemokines produced by different types of immune cells also mediate tissue inflammation and damage of cGVHD target tissues such as the skin and oral cavity. Many of these same immune regulators have been studied as candidate cGVHD biomarkers. Recent studies suggest that some of these biomarkers may be useful for determining disease prognosis and planning long-term clinical follow-up of cGVHD patients.
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Koyama D, Ito M, Yokohata E, Watakabe K, Onodera K, Goto T, Seto A, Watanabe K, Doisaki M, Ozawa Y, Yamaguchi T, Miyamura K. Autoimmune-like hepatitis after allogeneic hematopoietic stem cell transplantation: humoral hepatic GvHD. Bone Marrow Transplant 2016; 52:151-153. [DOI: 10.1038/bmt.2016.202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Kennedy VE, Savani BN, Greer JP, Kassim AA, Engelhardt BG, Goodman SA, Sengsayadeth S, Chinratanalab W, Jagasia M. Reduced-Intensity Conditioning with Fludarabine, Cyclophosphamide, and Rituximab Is Associated with Improved Outcomes Compared with Fludarabine and Busulfan after Allogeneic Stem Cell Transplantation for B Cell Malignancies. Biol Blood Marrow Transplant 2016; 22:1801-1807. [PMID: 27377900 DOI: 10.1016/j.bbmt.2016.06.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 06/29/2016] [Indexed: 12/17/2022]
Abstract
Reduced-intensity conditioning (RIC) has been used increasingly for allogeneic hematopoietic cell transplantation to minimize transplant-related mortality while maintaining the graft-versus-tumor effect. In B cell lymphoid malignancies, reduced-intensity regimens containing rituximab, an antiCD20 antibody, have been associated with favorable survival; however, the long-term outcomes of rituximab-containing versus nonrituximab-containing regimens for allogeneic hematopoietic cell transplantation in B cell lymphoid malignancies remain to be determined. We retrospectively analyzed 94 patients who received an allogeneic transplant for a B cell lymphoid malignancy. Of these, 33 received RIC with fludarabine, cyclophosphamide, and rituximab (FCR) and graft-versus-host disease (GVHD) prophylaxis with a calcineurin inhibitor and mini-methotrexate, and 61 received RIC with fludarabine and busulfan (FluBu) and GVHD prophylaxis with a calcineurin inhibitor and mycophenolate mofetil. The 2-year overall survival was superior in patients who received FCR versus FluBu (72.7% versus 54.1%, P = .031), and in multivariable analysis adjusted for Disease Risk Index and donor type, only the conditioning regimen (FluBu versus FCR: HR, 2.06; 95% CI, 1.04 to 4.08; P = .037) and Disease Risk Index (low versus intermediate/high: HR, .38; 95% CI, .17 to .86; P = .02) were independent predictors of overall survival. The 2-year cumulative incidence of chronic GVHD was lower in patients who received FCR versus FluBu (24.2% versus 51.7%, P = .01). There was no difference in rate of relapse/progression or acute GVHD. Our results demonstrate that the use of RIC with FCR and GVHD prophylaxis with a calcineurin inhibitor and mini-methotrexate is associated with decreased chronic GVHD and improved overall survival.
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Affiliation(s)
- Vanessa E Kennedy
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Bipin N Savani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Hematology/Oncology, Stem Cell Transplant, Department of Medicine, Veterans Affairs Medical Center, Nashville, Tennessee; Division of Hematology/Oncology, Stem Cell Transplantation, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - John P Greer
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Hematology/Oncology, Stem Cell Transplantation, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Adetola A Kassim
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Hematology/Oncology, Stem Cell Transplantation, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Brian G Engelhardt
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Hematology/Oncology, Stem Cell Transplantation, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Stacey A Goodman
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Hematology/Oncology, Stem Cell Transplant, Department of Medicine, Veterans Affairs Medical Center, Nashville, Tennessee; Division of Hematology/Oncology, Stem Cell Transplantation, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Salyka Sengsayadeth
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Hematology/Oncology, Stem Cell Transplantation, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Wichai Chinratanalab
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Hematology/Oncology, Stem Cell Transplant, Department of Medicine, Veterans Affairs Medical Center, Nashville, Tennessee; Division of Hematology/Oncology, Stem Cell Transplantation, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Madan Jagasia
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Hematology/Oncology, Stem Cell Transplantation, Department of Medicine, Vanderbilt University, Nashville, Tennessee
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12
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Kanakry JA, Gocke CD, Bolaños-Meade J, Gladstone DE, Swinnen LJ, Blackford AL, Fuchs EJ, Huff CA, Borrello I, Matsui WH, Brodsky RA, Rosner GL, Shanbhag S, Luznik L, Jones RJ, Ambinder RF, Kasamon YL. Phase II Study of Nonmyeloablative Allogeneic Bone Marrow Transplantation for B Cell Lymphoma with Post-Transplantation Rituximab and Donor Selection Based First on Non-HLA Factors. Biol Blood Marrow Transplant 2015; 21:2115-2122. [PMID: 26183076 DOI: 10.1016/j.bbmt.2015.07.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 07/07/2015] [Indexed: 11/12/2022]
Abstract
Outcomes of nonmyeloablative (NMA), HLA-haploidentical (haplo), related-donor allogeneic blood or marrow transplantation (allo-BMT) with high-dose post-transplantation cyclophosphamide (PTCy) appear to be similar to those using HLA-matched donors. Thus, it may be possible to prioritize donor factors other than HLA matching that could enhance antitumor activity. The Fc receptor polymorphism FCGR3A-158VV may confer greater sensitivity to rituximab than FCGR3A-158FF. In a prospective phase II study of NMA, related-donor allo-BMT with PTCy and post-transplantation rituximab for patients with B cell lymphomas, we hypothesized that donor selection that prioritized FCGR3A-158 polymorphism over HLA matching would be feasible, safe, and improve outcomes. The primary endpoint was 1-year progression-free survival (PFS). Of 83 patients transplanted (median age, 59 years), 69 (83%) received haplo grafts. Fifty-four (65%) received a graft that maintained or improved their Fc receptor polymorphism status. With 2.6-year median follow-up, the 1-year PFS and overall survival (OS) probabilities were 71% and 86%, respectively, with 1-year relapse and nonrelapse mortality (NRM) probabilities of 20% and 8%. At 1 year, the probability of acute grades II to IV graft-versus-host disease (GVHD) was 41%, with acute grades III to IV GVHD probability of 5% and chronic GVHD probability of 11%. Among haplo transplants, the 1-year probabilities of PFS, OS, relapse, and NRM were 70%, 83%, 20%, and 10%, respectively. No differences in outcomes were observed based on donor FCGR3A-158 polymorphism. Excess infection risk was not apparent with post-transplantation rituximab. Although donor selection based on FCGR3A-158 polymorphism was not shown to influence PFS, this study suggests that donor selection based on criteria other than best HLA match is feasible and safe. This study opens the way for the future investigation of donor prioritization based on promising non-HLA factors that may improve antitumor activity and decrease relapse after allo-BMT. This study was registered at www.clinicaltrials.gov as NCT00946023.
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Affiliation(s)
- Jennifer A Kanakry
- Department of Oncology, Division of Hematologic Malignancies, Johns Hopkins University, Baltimore, Maryland
| | | | - Javier Bolaños-Meade
- Department of Oncology, Division of Hematologic Malignancies, Johns Hopkins University, Baltimore, Maryland
| | - Douglas E Gladstone
- Department of Oncology, Division of Hematologic Malignancies, Johns Hopkins University, Baltimore, Maryland
| | - Lode J Swinnen
- Department of Oncology, Division of Hematologic Malignancies, Johns Hopkins University, Baltimore, Maryland
| | - Amanda L Blackford
- Department of Oncology Biostatistics, Johns Hopkins University, Baltimore, Maryland
| | - Ephraim J Fuchs
- Department of Oncology, Division of Hematologic Malignancies, Johns Hopkins University, Baltimore, Maryland
| | - Carol Ann Huff
- Department of Oncology, Division of Hematologic Malignancies, Johns Hopkins University, Baltimore, Maryland
| | - Ivan Borrello
- Department of Oncology, Division of Hematologic Malignancies, Johns Hopkins University, Baltimore, Maryland
| | - William H Matsui
- Department of Oncology, Division of Hematologic Malignancies, Johns Hopkins University, Baltimore, Maryland
| | - Robert A Brodsky
- Department of Oncology, Division of Hematologic Malignancies, Johns Hopkins University, Baltimore, Maryland
| | - Gary L Rosner
- Department of Oncology Biostatistics, Johns Hopkins University, Baltimore, Maryland
| | - Satish Shanbhag
- Department of Oncology, Division of Hematologic Malignancies, Johns Hopkins University, Baltimore, Maryland
| | - Leo Luznik
- Department of Oncology, Division of Hematologic Malignancies, Johns Hopkins University, Baltimore, Maryland
| | - Richard J Jones
- Department of Oncology, Division of Hematologic Malignancies, Johns Hopkins University, Baltimore, Maryland
| | - Richard F Ambinder
- Department of Oncology, Division of Hematologic Malignancies, Johns Hopkins University, Baltimore, Maryland.
| | - Yvette L Kasamon
- Department of Oncology, Division of Hematologic Malignancies, Johns Hopkins University, Baltimore, Maryland
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13
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Kuzmina Z, Gounden V, Curtis L, Avila D, RNP TT, Baruffaldi J, Cowen EW, Naik HB, Hasni SA, Mays JW, Mitchell S, Baird K, Steinberg SM, Pavletic SZ. Clinical significance of autoantibodies in a large cohort of patients with chronic graft-versus-host disease defined by NIH criteria. Am J Hematol 2015; 90:114-9. [PMID: 25363867 DOI: 10.1002/ajh.23885] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 10/22/2014] [Accepted: 10/27/2014] [Indexed: 12/26/2022]
Abstract
There is an unmet need for identifying new clinical biomarkers in chronic Graft-versus-Host-disease (cGVHD) suitable for diagnosis and disease monitoring. Circulating autoantibodies represent an ongoing immune response and suggest a pathogenic role for B cells in cGVHD. Autoantibodies could be useful markers of cGVHD disease activity, severity, or organ specificity; however, their clinical utility is not established. The focus of this study was to determine the incidence and associations of a broad array of clinical autoantibodies with cGVHD manifestations in a large patient cohort characterized by NIH criteria. A panel of 21 circulating antibodies commonly used in clinical medicine was tested in 280 cGVHD patients (70% severe) enrolled in a cross-sectional prospective natural history study. Median cGVHD duration was two years. Patients with circulating autoantibodies (62%) had significantly higher levels of IgM (P < 0.0001), IgG (P < 0.0001), and IgA (P = 0.001), elevated uric acid (P = 0.008) and total protein (P = 0.0004), and higher numbers of CD3+ (P = 0.002), CD4+ (P = 0.001), CD8+ (P = 0.023) T cells, and CD19+ B cells (P < 0.0001). Multiple antibodies were detected in 35% of patients. Prior rituximab therapy (n = 66) was associated with reduced presence of autoantibodies (48 vs. 66% P = 0.01). Only oral cGVHD was significantly associated with presence of autoantibodies in this study (P = 0.028). No significant associations were found between cGVHD activity and severity, and presence of autoantibodies. Circulating autoantibodies are common in patients with advanced cGVHD. Their presence is associated with better quantitative immunologic reconstitution but does not have utility as a clinical biomarker of cGVHD.
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Affiliation(s)
- Zoya Kuzmina
- Graft-versus-Host and Autoimmunity Unit, Experimental Transplantation and Immunology Branch, National Cancer Institute NCI, National Institutes of Health; Bethesda Maryland
- Internal Medicine Department; Evangelical Hospital; Vienna Austria
| | - Verena Gounden
- Department of Laboratory Medicine; Clinical Center, National Cancer Institute NCI, National Institutes of Health
| | - Lauren Curtis
- Graft-versus-Host and Autoimmunity Unit, Experimental Transplantation and Immunology Branch, National Cancer Institute NCI, National Institutes of Health; Bethesda Maryland
| | - Daniele Avila
- Graft-versus-Host and Autoimmunity Unit, Experimental Transplantation and Immunology Branch, National Cancer Institute NCI, National Institutes of Health; Bethesda Maryland
| | - Tiffani Taylor RNP
- Graft-versus-Host and Autoimmunity Unit, Experimental Transplantation and Immunology Branch, National Cancer Institute NCI, National Institutes of Health; Bethesda Maryland
| | - Judy Baruffaldi
- Graft-versus-Host and Autoimmunity Unit, Experimental Transplantation and Immunology Branch, National Cancer Institute NCI, National Institutes of Health; Bethesda Maryland
| | - Edward W. Cowen
- Dermatology Branch, National Cancer Institute NCI, National Institutes of Health
| | - Haley B. Naik
- Dermatology Branch, National Cancer Institute NCI, National Institutes of Health
| | - Sarfaraz A. Hasni
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Cancer Institute NCI, National Institutes of Health
| | | | - Sandra Mitchell
- Outcomes Research Branch, Division of Cancer Control and Population Sciences NIH
| | - Kristin Baird
- Pediatric Oncology Branch, National Cancer Institute NCI, National Institutes of Health
| | - Seth M. Steinberg
- Biostatistics and Data Management Section NIH, Center for Cancer Research
| | - Steven Z. Pavletic
- Graft-versus-Host and Autoimmunity Unit, Experimental Transplantation and Immunology Branch, National Cancer Institute NCI, National Institutes of Health; Bethesda Maryland
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14
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Abstract
Although B cells have emerged as important contributors to chronic graft-versus-host-disease (cGVHD) pathogenesis, the mechanisms responsible for their sustained activation remain unknown. We previously showed that patients with cGVHD have significantly increased B cell-activating factor (BAFF) levels and that their B cells are activated and resistant to apoptosis. Exogenous BAFF confers a state of immediate responsiveness to antigen stimulation in normal murine B cells. To address this in cGVHD, we studied B-cell receptor (BCR) responsiveness in 48 patients who were >1 year out from allogeneic hematopoietic stem cell transplantation (HSCT). We found that B cells from cGVHD patients had significantly increased proliferative responses to BCR stimulation along with elevated basal levels of the proximal BCR signaling components B cell linker protein (BLNK) and Syk. After initiation of BCR signaling, cGVHD B cells exhibited increased BLNK and Syk phosphorylation compared with B cells from patients without cGVHD. Blocking Syk kinase activity prevented relative post-HSCT BCR hyper-responsiveness of cGVHD B cells. These data suggest that a lowered BCR signaling threshold in cGVHD associates with increased B-cell proliferation and activation in response to antigen. We reveal a mechanism underpinning aberrant B-cell activation in cGVHD and suggest that therapeutic inhibition of the involved kinases may benefit these patients.
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15
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Saillard C, Crocchiolo R, Furst S, El-Cheikh J, Castagna L, Signori A, Oudin C, Faucher C, Lemarie C, Chabannon C, Granata A, Blaise D. National Institutes of Health classification for chronic graft-versus-host disease predicts outcome of allo-hematopoietic stem cell transplant after fludarabine-busulfan-antithymocyte globulin conditioning regimen. Leuk Lymphoma 2014; 55:1106-12. [PMID: 23822538 DOI: 10.3109/10428194.2013.820285] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Abstract In 2005, the National Institutes of Health (NIH) proposed standard criteria for diagnosis, organ scoring and global assessment of chronic graft-versus-host disease (cGvHD) severity. We retrospectively reclassified cGvHD with NIH criteria in a monocentric cohort of 130 consecutive adult patients with hematological malignancies presenting cGvHD after receiving allo-hematopoietic stem cell transplant (HSCT) with a fludarabine-busulfan-antithymocyte globulin (ATG) conditioning regimen, among 313 consecutive HSCT recipients. We compared NIH and Seattle classifications to correlate severity and outcome. The follow up range was effectively 2-120 months. Forty-four percent developed Seattle-defined cGvHD (22% limited, 78% extensive forms). Using NIH criteria, there were 23%, 40% and 37% mild, moderate and severe forms, respectively, and 58%, 32% and 8% classic cGvHD, late acute GvHD and overlap syndrome. Five-year overall survival was 55% (49-61), and cumulative incidences of non-relapse mortality (NRM) and relapse/progression at 2 years were 19% (14-23) and 19% (14-24). NIH mild and moderate forms were associated with better survival compared to severe cGvHD (hazard ratio [HR] = 3.28, 95% confidence interval [CI]: 1.38-7.82, p = 0.007), due to higher NRM among patients with severe cGvHD (HR = 3.04, 95% CI: 1.05-8.78, p = 0.04) but comparable relapse risk (p = NS). In conclusion, the NIH classification appears to be more accurate in predicting outcome mostly by the reclassification of old-defined extensive forms into NIH-defined moderate or severe.
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Affiliation(s)
- Colombe Saillard
- Hematology Department, Institut Paoli-Calmettes , Marseille , France
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16
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Abstract
Anti-CD20 monoclonal antibodies (MoAbs), employed in treating CD20⁺ lymphomas and autoimmune diseases, appear to have broader functions than just eradicating malignant B-cells and decreasing autoantibody production. Rituximab-induced T-cell inactivation, reported both in-vitro and in-vivo, may contribute to the increased risk of T-cell-dependent infections, observed in patients receiving this therapy. T-cell polarization into a suppressive phenotype, often observed in patients receiving rituximab for autoimmune disorders, was reported to be associated with prolonged remissions. Elimination of B-cells serving as antigen-presenting cells, thereby causing impaired T-cell activation, could play a significant role in induction of these changes. Direct binding of rituximab to a CD20dim T-cell population, inducing its depletion, may contribute to the decreased T-cell activation following rituximab therapy. Further investigation of the complex network through which rituximab and new anti-CD20 MoAbs act, would advance the employment of these agents in different clinical settings.
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17
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Rituximab prophylaxis prevents corticosteroid-requiring chronic GVHD after allogeneic peripheral blood stem cell transplantation: results of a phase 2 trial. Blood 2013; 122:1510-7. [PMID: 23861248 DOI: 10.1182/blood-2013-04-495895] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
B cells are implicated in the pathophysiology of chronic graft-vs-host disease (GVHD), and phase 2 trials suggest that B cell depletion can treat established chronic GVHD. We hypothesized that posttransplantation B cell depletion could prevent the occurrence of chronic GVHD. We performed a 65-patient phase 2 trial of rituximab (375 mg/m(2) IV), administered at 3, 6, 9, and 12 months after transplantation. Rituximab administration was safe without severe infusional adverse events. The cumulative incidences of chronic GVHD and systemic corticosteroid-requiring chronic GVHD at 2 years from transplantation were 48% and 31%, respectively, both lower than the corresponding rates in a concurrent control cohort (60%, P = .1, and 48.5%, P = .015). There was no difference in relapse incidence, but treatment-related mortality at 4 years from transplantation was significantly lower in treated subjects when compared with controls (5% vs 19%, P = .02), and overall survival was superior at 4 years (71% vs 56%, P = .05). At 2 years from transplantation, the B-cell activating factor/B-cell ratio was significantly higher in subjects who developed chronic GVHD in comparison with those without chronic GVHD (P = .039). Rituximab can prevent systemic corticosteroid-requiring chronic GVHD after peripheral blood stem cell transplantation and should be tested in a prospective randomized trial.
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18
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Sellar RS, Peggs KS. Recent progress in managing graft-versus-host disease and viral infections following allogeneic stem cell transplantation. Future Oncol 2013; 8:1549-65. [PMID: 23231517 DOI: 10.2217/fon.12.153] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Despite recent reductions in transplant-related mortality, post-transplant complications such as graft-versus-host disease (GvHD) remain major obstacles to the successful application of allogeneic hematopoietic transplantation. Steroid-refractory GvHD has a poor outcome. Although there are a variety of new approaches to the treatment of refractory GvHD, many have limited evidence of efficacy. Other approaches appear to be unacceptably toxic. It would be preferable to improve GvHD prophylaxis. There is good evidence that rates of GvHD can be reduced without unacceptable reduction of the graft-versus-leukemia effect or compromising overall survival. However, prophylactic measures aimed at reducing T-cell numbers or functions are associated with high rates of reactivation of latent viruses. New technologies that allow rapid generation of virus-specific T-cells show promise to reduce the frequency and severity of such reactivations and have the potential to revolutionize the approach to post-transplant infectious complications.
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Affiliation(s)
- Rob S Sellar
- UCL Cancer Institute, Department of Haematology, London, WC1E 6BT, UK
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19
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The role of allogeneic haematopoietic progenitor cell transplantation in patients with diffuse large B-cell non-Hodgkin lymphomas (DLBCL). Bone Marrow Transplant 2013; 48:1271-8. [PMID: 23318539 DOI: 10.1038/bmt.2012.266] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 11/04/2012] [Accepted: 11/13/2012] [Indexed: 11/08/2022]
Abstract
Despite the undoubted improvement in the prognosis of patients with diffuse large B-cell lymphomas (DLBCLs) with the addition of rituximab in the front-line treatment, a significant proportion of patients still relapse. Salvage immune-chemotherapy followed by high-dose therapy with autologous haematopoietic cell transplantation (auto-HCT) remains the treatment of choice for such patients, especially in those who demonstrate chemosensitive disease. In recent years, allogeneic haematopoietic cell transplantation (allo-HCT) has increasingly been used for patients who are resistant to salvage treatment or relapse after an auto-HCT. Strategies using reduced intensity conditioning regimens have allowed application of this approach to a broader range of patients. PFS is up to 55% with a risk of relapse up to 80% depending on different studies. In multivariate analysis, several factors have been associated with favourable outcome including chemosensitivity of the disease, younger age and Karnofsky performance status at the time of the transplant being the strongest ones. DLIs have shown to induce durable responses in relapsed or progressed disease; however, its role remains controversial as the results are inferior to the responses seen in other haematological malignancies. More recently, the addition of MoAbs in the non-myeloablative conditioning regimens has shown encouraging results. In conclusion, allo-HCT is a feasible option in selective patients with chemosensitive DBCL, as it reduces the risk of relapse; however, this is achieved at the cost of significant non-relapse mortality.
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20
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Crocchiolo R, Saillard C, Signori A, Fürst S, El Cheikh J, Castagna L, Oudin C, Granata A, Faucher C, Devillier R, Crocchiolo D, Sormani MP, Chabannon C, Blaise D. Response to immunosuppressive treatment predicts outcome in patients with chronic graft-versus-host disease: a single-center analysis of longitudinal data. Biol Blood Marrow Transplant 2012; 19:576-83. [PMID: 23270984 DOI: 10.1016/j.bbmt.2012.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Accepted: 12/19/2012] [Indexed: 11/25/2022]
Abstract
It has been reported that chronic graft-versus-host disease (cGVHD) is associated with significant morbidity and mortality after allogeneic stem cell transplantation (allo-SCT). The risk of relapse is generally reduced when cGVHD is present, but prognosis may be affected by increased toxicity and/or risk of infection associated with immunosuppressive treatment (IST). We performed a longitudinal data analysis of cGVHD, including the evolution of cGVHD itself over time in response to IST, in a single-center cohort of 313 consecutive patients undergoing allo-SCT. We found that lack of sustained response without withdrawal of IST within 6 months of cGVHD development was associated with higher transplantation-related mortality (hazard ratio, 2.32; 95% confidence interval, 1.24-4.33) compared with cGVHD-free patients. Conversely, response conferred better overall survival (hazard ratio, 0.42; 95% confidence interval, 0.18-0.95). Our analytical approach allowed us to integrate the evolution of cGVHD in a predictive model of transplantation outcome; notably, remission associated with permanent discontinuation of IST within the first 6 months from the occurrence of cGVHD seemed to correlate most closely with final outcome. Further confirmation from larger studies is needed.
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21
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Devillier R, Castagna L, Gonzague L, El-Cheikh J, Fürst S, Faucher C, Michel R, Blaise D. TLI in refractory chronic GVHD. Bone Marrow Transplant 2012; 48:854-8. [PMID: 23222383 DOI: 10.1038/bmt.2012.240] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Refractory chronic GVHD (cGVHD) remains a major cause of morbidity after transplantation. Many drugs are used but there is no consensus on the standard of care. We investigated the efficacy of TLI in corticosteroid-refractory cGVHD. We analyzed retrospectively 31 patients receiving one or more TLI session for refractory cGVHD from 2000 to 2007. The main objective was to evaluate the response rate after TLI. Decreased corticosteroid doses and/or discontinued immunosuppressive agents were considered to be surrogate markers of response. All but one patient presented with severe cGVHD at the time of TLI. The median number of previous immunosuppressive treatment lines was 3 (range: 2-4). Fourteen patients (45%) achieved an objective response after TLI and 8 (25%) were cGVHD free at long-term follow-up. In all, 5 (29%) of the 17 nonresponsive patients did not show the features of progressive cGVHD and could decrease the amount of immunosuppressive drugs taken. Response after TLI significantly improved 5-year GVHD-related mortality (14% vs 42%, P=0.038) but not OS (58%vs 64% P=0.27). Regarding the promising response rate in this heavily pretreated population, we reasoned that TLI could be an alternative treatment for corticosteroid-refractory cGVHD.
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Affiliation(s)
- R Devillier
- Department of Hematology, Transplantation Program, Institut Paoli Calmettes, Marseille, France
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22
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B cells from patients with chronic GVHD are activated and primed for survival via BAFF-mediated pathways. Blood 2012; 120:2529-36. [PMID: 22896003 DOI: 10.1182/blood-2012-06-438911] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Recent data reveal an important role for B cells in the pathogenesis of chronic GVHD (cGVHD). Patients with cGVHD have delayed B-cell reconstitution and elevated BAFF to B-cell ratios compared to patients without cGVHD. The mechanisms promoting and sustaining B-cell activation in this disease, however, remain unknown. As BAFF increases murine B-cell metabolism and survival and maintains autoreactive B-cell clones, we performed ex vivo analyses of peripheral B cells from 51 patients who either had or did not have active cGVHD and were greater than 1 year from the time of allogeneic hematopoietic stem cell transplantation. We found that B cells from patients with active cGVHD were in a heightened metabolic state and were resistant to apoptosis. Exogenous BAFF treatment amplified cell size and survival in B cells from these patients. We found significantly increased signaling through ERK and AKT that associated with decreased levels of proapoptotic Bim, suggesting a mechanistic link between elevated BAFF levels and aberrant B-cell survival. Thus, we identify a role for BAFF in the pathogenesis of cGVHD and define B-cell activation and survival pathways suitable for novel therapeutic development in cGVHD.
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23
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Development of a Population-Based Cost-Effectiveness Model of Chronic Graft-Versus-Host Disease in Spain. Clin Ther 2012; 34:1774-87. [DOI: 10.1016/j.clinthera.2012.06.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 06/21/2012] [Accepted: 06/29/2012] [Indexed: 11/20/2022]
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24
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Hymes SR, Alousi AM, Cowen EW. Graft-versus-host disease: part II. Management of cutaneous graft-versus-host disease. J Am Acad Dermatol 2012; 66:535.e1-16; quiz 551-2. [PMID: 22421124 DOI: 10.1016/j.jaad.2011.11.961] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 11/18/2011] [Accepted: 11/19/2011] [Indexed: 10/28/2022]
Abstract
Dermatologists are ideally suited to manage the various cutaneous sequelae of graft-versus-host disease (GVHD) outlined in part I of this review. However, the complexity of the patient with GVHD, including comorbidities, potential drug interactions related to polypharmacy, and the lack of evidence-based treatment guidelines, are significant challenges to optimizing patient care. In this section, we will provide an outline for the role of the dermatologist in a multispecialty approach to caring for patients with GVHD.
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Affiliation(s)
- Sharon R Hymes
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas 77030-4009, USA.
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25
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Prophylactic rituximab after allogeneic transplantation decreases B-cell alloimmunity with low chronic GVHD incidence. Blood 2012; 119:6145-54. [PMID: 22563089 DOI: 10.1182/blood-2011-12-395970] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
B cells are involved in the pathogenesis of chronic GVHD (cGVHD). We hypothesized that prophylactic anti-B-cell therapy delivered 2 months after transplantation would decrease allogeneic donor B-cell immunity and possibly the incidence of cGVHD. Therefore, in the present study, patients with high-risk chronic lymphocytic leukemia (n = 22) and mantle-cell lymphoma (n = 13) received a total lymphoid irradiation of 80 cGy for 10 days and antithymocyte globulin 1.5 mg/kg/d for 5 days. Rituximab (375 mg/m(2)) was infused weekly on days 56, 63, 70, and 77 after transplantation. The incidence of acute GVHD was 6%. The cumulative incidence of cGVHD was 20%. Nonrelapse mortality was 3%. Rituximab treatment after allogeneic transplantation significantly reduced B-cell allogeneic immunity, with complete prevention of alloreactive H-Y Ab development in male patients with female donors (P = .01). Overall survival and freedom from progression at 4 years for chronic lymphocytic leukemia patients were 73% and 47%, respectively; for mantle-cell lymphoma patients, they were 69% and 53%, respectively.
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26
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Dignan FL, Amrolia P, Clark A, Cornish J, Jackson G, Mahendra P, Scarisbrick JJ, Taylor PC, Shaw BE, Potter MN. Diagnosis and management of chronic graft-versus-host disease. Br J Haematol 2012; 158:46-61. [DOI: 10.1111/j.1365-2141.2012.09128.x] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
| | - Persis Amrolia
- Department of Bone Marrow Transplantation; Great Ormond Street Hospital; London; UK
| | - Andrew Clark
- Bone Marrow Transplant Unit; Beatson Oncology Centre; Gartnavel Hospital; Glasgow; UK
| | - Jacqueline Cornish
- Department of Haematology; Bristol Royal Hospital for Children; Bristol; UK
| | - Graham Jackson
- Department of Haematology; Freeman Road Hospital; Newcastle; UK
| | - Prem Mahendra
- Department of Haematology; University Hospital Birmingham; Birmingham; UK
| | | | - Peter C. Taylor
- Department of Haematology; Rotherham General Hospital; Rotherham; UK
| | | | - Michael N. Potter
- Section of Haemato-oncology; The Royal Marsden NHS Foundation Trust; London; UK
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27
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Gutiérrez-Aguirre CH, Cantú-Rodríguez OG, Borjas-Almaguer OD, González-Llano O, Jaime-Pérez JC, Solano-Genesta M, Gómez-Guijosa M, Mancias-Guerra C, Tarin L, Gómez-Almaguer D. Effectiveness of subcutaneous low-dose alemtuzumab and rituximab combination therapy for steroid-resistant chronic graft-versus-host disease. Haematologica 2011; 97:717-22. [PMID: 22133770 DOI: 10.3324/haematol.2011.054577] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Chronic graft-versus-host disease is a common late complication of allogeneic hematopoietic stem cell transplantation. Corticosteroids are the standard initial treatment. Second-line treatment has not been well defined. We evaluated the effectiveness and safety of low doses of alemtuzumab plus low doses of rituximab in the treatment of steroid-refractory chronic graft-versus-host disease. DESIGN AND METHODS Ten men and 5 women were prospectively included in the study. All patients received one cycle of subcutaneous alemtuzumab 10 mg/day/3 days and intravenous rituximab 100 mg on Days +4, +11, +18 and +25. The therapeutic response was measured on Days +30, +90 and +365 of the protocol. RESULTS Median age was 41 years. The main site involved was the oral mucosa (86.7%) followed by the eyes (66.7%), liver (60%), skin (53%), lungs (13.3%) and intestinal tract (6.7%). The overall response was 100% at Day +30 evaluation: 10 patients (67%) had partial remission, 5 (33%) had complete remission. At Day +90 evaluation, 7 (50%) patients had partial remission, 4 (28%) had complete remission; 3 (21%) had relapsed chronic graft-versus-host disease and one patient did not reach the evaluation time point. So far, 5 patients have reached the Day +365 follow-up evaluation; 2 (40%) had partial remission, 2 had complete remission and one experienced chronic graft-versus-host disease progression. Adverse effects were mainly infections in 67% of patients; these were all quickly solved, except for one patient who died from pneumonia. CONCLUSIONS This combination therapy appears to be an efficacious and safe treatment for steroid-refractory chronic graft-versus-host disease. Longer follow up to determine the durability of response and survival is required (ClinicalTrials.gov: NCT01042509).
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Affiliation(s)
- Cesar Homero Gutiérrez-Aguirre
- Service of Hematology, Hospital Universitario Dr José E González Universidad Autónoma de Nuevo León, Monterrey, NL, México
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Olivieri J, Coluzzi S, Attolico I, Olivieri A. Tirosin kinase inhibitors in chronic graft versus host disease: from bench to bedside. ScientificWorldJournal 2011; 11:1908-31. [PMID: 22125447 PMCID: PMC3217614 DOI: 10.1100/2011/924954] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 09/05/2011] [Indexed: 02/07/2023] Open
Abstract
Chronic Graft Versus Host Disease (cGVHD) is a major complication of allogeneic stem-cell transplantation (SCT). In many inflammatory fibrotic diseases, such as Systemic Scleroderma (SSc) and cGVHD with fibrotic features, an abnormal activation of transforming growth factor (TGFβ) and platelet-derived growth factor receptor (PDGF-R) pathways have been observed. Tyrosin Kinase Inhibitors (TKIs), which are currently used for treatment of patients with Chronic Myeloid Leukemia (CML), share potent antifibrotic and antiinflammatory properties, being powerful dual inhibitors of both PDGF-R and TGFβ pathways. Moreover accumulating in vitro data confirm that TKIs, interacting with the TCR and other signalling molecules, carry potent immunomodulatory effects, being involved in both T-cell and B-cell response. Translation to the clinical setting revealed that treatment with Imatinib can achieve encouraging responses in patients with autoimmune diseases and steroid-refractory cGVHD, showing a favourable toxicity profile. While the exact mechanisms leading to such efficacy are still under investigation, use of TKIs in the context of clinical trials should be promoted, aiming to evaluate the biological changes induced in vivo by TKIs and to assess the long term outcome of these patients. Second-generation TKIs, with more favourable toxicity profile are under evaluation in the same setting.
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Affiliation(s)
- Jacopo Olivieri
- Department of Internal Medicine, Università Politecnica delle Marche, 60121 Ancona, Italy.
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Kim SJ, Won JH. B cell homeostasis and the development of chronic graft-versus-host disease: implications for B cell-depleting therapy. Leuk Lymphoma 2011; 53:19-25. [PMID: 21740304 DOI: 10.3109/10428194.2011.603448] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chronic graft-versus-host disease (GVHD) is a serious complication that develops frequently in survivors of allogeneic stem cell transplant. Since elucidation of the role of B cells in the pathogenesis of chronic GVHD, B cell-depleting therapy with rituximab has been associated with beneficial effects in clinical and laboratory studies in patients with chronic GVHD. Although the mechanism underlying the contribution of B cells to the development of chronic GVHD is poorly understood, recent studies have proposed that B cell reconstitution after allogeneic stem cell transplant is involved in the development of chronic GVHD. Inadequate reconstitution of naive B cells and the persistence of high levels of B cell-activating factor have been found in patients with chronic GVHD, and these changes might be associated with the expansion of activated CD27-positive B cells that produce autoantibody in chronic GVHD. In the light of this altered B cell homeostasis in chronic GVHD, the role of rituximab in controlling the clinical manifestations of chronic GVHD has been studied. In this review, we address the role of B cells in the pathogenesis of chronic GVHD and the response to B cell-depleting therapy based on B cell homeostasis.
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Affiliation(s)
- Seok Jin Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Crocchiolo R, Castagna L, El-Cheikh J, Helvig A, Fürst S, Faucher C, Vazquez A, Granata A, Coso D, Bouabdallah R, Blaise D. Prior rituximab administration is associated with reduced rate of acute GVHD after in vivo T-cell depleted transplantation in lymphoma patients. Exp Hematol 2011; 39:892-6. [DOI: 10.1016/j.exphem.2011.06.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Revised: 05/25/2011] [Accepted: 06/11/2011] [Indexed: 11/26/2022]
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Le Gouill S, Mohty M, Guillaume T, Gastinne T, Moreau P. Allogeneic Stem Cell Transplantation in Mantle Cell Lymphoma: Where Are We Now and Which Way Should We Go? Semin Hematol 2011; 48:227-39. [DOI: 10.1053/j.seminhematol.2011.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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32
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Schroeder T, Haas R, Kobbe G. Treatment of graft-versus-host disease with monoclonal antibodies and related fusion proteins. Expert Rev Hematol 2011; 3:633-51. [PMID: 21083479 DOI: 10.1586/ehm.10.46] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation has evolved from an experimental treatment approach to a widely used, curative therapy to treat malignant and nonmalignant diseases of the hematopoietic system. Despite advances in donor selection, conditioning regimens and supportive care, acute and chronic graft-versus-host disease (GvHD) remain a major cause of morbidity and mortality. Steroids are the standard first-line treatment and are able to control GvHD in approximately 50% of patients. Those who fail on steroids have a poor long-term prognosis. Therefore, a large number of drugs and procedures have been evaluated as second-line therapy. Monoclonal antibodies have increasingly been used to treat malignancy and autoimmune disease during the last 20 years. Their unique ability to target specific antigens theoretically enables them to directly interfere with cellular mechanisms that are involved in GvHD pathology. For this reason, monoclonal antibodies have been studied extensively as a second-line treatment for acute and chronic GvHD. The purpose of this article is to collect published data on clinical trials from the current literature and to give an overview on efficacy and toxicity of monoclonal antibody treatment for GvHD.
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Affiliation(s)
- T Schroeder
- University of Duesseldorf, Medical Faculty, Department of Haematology, Oncology and Clinical Immunology, D-40225 Duesseldorf, Germany.
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Kharfan-Dabaja MA, Cutler CS. Rituximab for prevention and treatment of graft-versus-host disease. Int J Hematol 2011; 93:578-585. [PMID: 21547615 DOI: 10.1007/s12185-011-0855-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 03/20/2011] [Accepted: 04/06/2011] [Indexed: 11/26/2022]
Abstract
Growing understanding of the important role of B lymphocytes in alloreactivity has paved the way for evaluating anti-B cell therapy with rituximab in patients undergoing allogeneic hematopoietic cell transplantation. Data suggesting a beneficial reduction in incidence and severity of acute graft-versus-host disease (GVHD) are limited to non-randomized studies from single institutions using higher than conventional doses of rituximab. Additionally, rituximab is used as an effective treatment of corticosteroid-refractory chronic GVHD with good responses, particularly in cases of dermatologic and mucosal involvement. Post-transplant administration of rituximab appears to reduce the rate of chronic GVHD in preliminary studies.
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Affiliation(s)
- Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology and Bone Marrow Transplantation, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Corey S Cutler
- Division of Hematological Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA.
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Busca A. The use of monoclonal antibodies for the treatment of graft-versus-host disease following allogeneic stem cell transplantation. Expert Opin Biol Ther 2011; 11:687-97. [PMID: 21391897 DOI: 10.1517/14712598.2011.566852] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Graft-versus-host disease (GVHD) remains the leading cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). Steroids along with calcineurin inhibitors remain the standard initial therapy, however, less than half of the patients completely respond and there is no uniformly accepted therapy for patients with steroid-resistant GVHD. AREAS COVERED This paper reviews the current role and ongoing development of mAbs in the treatment of GVHD. Various mAbs to cell surface antigens on GVHD effector cells have been investigated for the treatment of acute GVHD: these include anti-TNF-α antibodies, IL-2 receptor antagonists, anti-CD3 and anti-CD52 mAbs, while anti-CD20 mAb has been extensively investigated in the setting of chronic GVHD. Overall, response rates have been reported to be greater than 60%, although it should be emphasized that the long-term survival still remains suboptimal, mainly due to the detrimental side effects of infectious complications, progressive GVHD and relapse of underlying malignancy. EXPERT OPINION Future challenges will include more appropriate definition of these agents in the therapeutic scenario of GVHD. Combinations of mAbs or mAb combined with newer immunosuppressive drugs might potentially achieve greater success, especially if used early in the disease process.
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Affiliation(s)
- Alessandro Busca
- Stem Cell Transplant Unit, AOU San Giovanni Battista, Corso Bramante 88, 10126 Turin, Italy.
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35
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Dierickx D, Delannoy A, Saja K, Verhoef G, Provan D. Anti-CD20 monoclonal antibodies and their use in adult autoimmune hematological disorders. Am J Hematol 2011; 86:278-91. [PMID: 21328427 DOI: 10.1002/ajh.21939] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Revised: 11/15/2010] [Accepted: 11/16/2010] [Indexed: 12/14/2022]
Abstract
Autoimmune hematological disorders encompass a broad group of hematological conditions characterized by the loss of self-tolerance to a variety of antigens. Despite good response to first-line therapy in the majority of patients, relapses are common, necessitating new and safe therapeutic options. The anti-CD20 monoclonal antibody rituximab has led to substantial improvement in the treatment of malignant and immune-mediated disorders involving B cells. Although experience with rituximab in immune-mediated hematological disorders is rarely supported by randomized trials, there is now substantial experience with rituximab suggesting that anti-CD20 therapy is an effective and well-tolerated alternative to immunosuppressive therapy in these disorders. However, caution is needed based on recent reports describing-sometimes severe-rituximab-related complications.
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Affiliation(s)
- Daan Dierickx
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium.
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36
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Abstract
Since its approval in 1997 by the US Food and Drug Administration, rituximab has been approved for use in certain B-cell lymphomas and treatment-resistant rheumatoid arthritis. Over the past 10 years, many published reports have suggested rituximab's efficacy in several inflammatory conditions in dermatology. This article includes a review of the mechanism of action, dosing, side-effect profile, and the current literature for various off-label uses of this CD20+ B-cell antagonist, rituximab.
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Affiliation(s)
- David R Carr
- Department of Dermatology, Wright State University, One Elizabeth Place, Suite 200, Dayton, OH 45408, USA
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37
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Kim SJ, Lee JW, Jung CW, Min CK, Cho B, Shin HJ, Chung JS, Kim H, Lee WS, Joo YD, Yang DH, Kook H, Kang HJ, Ahn HS, Yoon SS, Sohn SK, Min YH, Min WS, Park HS, Won JH. Weekly rituximab followed by monthly rituximab treatment for steroid-refractory chronic graft-versus-host disease: results from a prospective, multicenter, phase II study. Haematologica 2010; 95:1935-42. [PMID: 20663943 DOI: 10.3324/haematol.2010.026104] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Since it was suggested that B cells play a role in the pathogenesis of chronic graft-versus-host disease, rituximab, an anti-CD20 monoclonal antibody targeting B cells, has been shown to be effective in steroid-refractory, chronic graft-versus-host disease. However, most of the data were from small numbers of patients or retrospective analyses. We, therefore, conducted a multicenter phase II study to confirm the efficacy of this treatment strategy that targets B cells. DESIGN AND METHODS We diagnosed and evaluated chronic graft-versus-host disease according to the National Institute of Health criteria for clinical trials on this condition. The treatment consisted of weekly intravenous infusions of rituximab for 4 weeks followed by monthly rituximab for 4 months. We evaluated the patients' responses and monitored their disease activity until their final visit, which was on day 365. We also assessed the patients' subsequent quality of life and serum levels of B-cell-activating factor of the tumor necrosis factor family. RESULTS Among 37 patients enrolled (median age, 29 years; range 8-57 years), 32 patients responded to rituximab with 8 complete and 24 partial responses. Twenty-one patients maintained their response for 1 year, so their steroid treatment was discontinued or its dose reduced (21/37, or 56.8%), and their scores representing quality of life were improved although these changes were not statistically significant. The responses were better for clinical manifestations of the skin, oral cavity and musculoskeletal system (response rate, 71.4-100%) than for other organs. However, infectious complications and primary disease relapse accounted for the majority of treatment failure. The pre-treatment serum level of B cell-activating factor of the tumor necrosis factor family was not associated with better treatment outcome (P=0.147). CONCLUSIONS Rituximab could improve clinical responses and quality of life of patients with steroid-refractory chronic graft-versus-host disease, although such patients may need active prophylaxis against infection.
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Affiliation(s)
- Seok Jin Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Consensus Conference on Clinical Practice in Chronic GVHD: Second-Line Treatment of Chronic Graft-versus-Host Disease. Biol Blood Marrow Transplant 2010; 17:1-17. [PMID: 20685255 DOI: 10.1016/j.bbmt.2010.05.011] [Citation(s) in RCA: 237] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Accepted: 05/17/2010] [Indexed: 12/11/2022]
Abstract
Steroid refractory chronic graft-versus-host disease (cGVHD) is associated with a significant morbidity and mortality. Although first-line treatment of cGVHD is based on controlled trials, second-line treatment is almost solely based on phase II trials or retrospective analyses. The consensus conference on clinical practice in cGVHD held in Regensburg aimed to achieve a consensus on the current evidence of treatment options as well as to provide guidelines for daily clinical practice. Treatment modalities are the use of steroids and calcineurin inhibitors as well as immunomodulating modalities (photopheresis, mTOR-inhibitors, thalidomide, hydroxychloroquine, vitamin A analogs, clofazimine), and cytostatic agents (mycophenolate mofetil, methotrexate, cyclophosphamide, pentostatin). Recent reports showed some efficacy of rituximab, alemtuzumab, and etanercept in selected patients. Moreover, tyrosine kinase inihibitors such as imatinib came into the field because of their ability to interfere with the platelet-derived growth factor (PDGF-R) pathway involved in fibrosis. An other treatment option is low-dose thoracoabdominal irradiation. Although different treatment options are available, the "trial-and-error system" remains the only way to identify the drug effective in the individual patient, and valid biomarkers are eagerly needed to identify the likelihood of response to a drug in advance. Moreover, the sparse evidence for most treatment entities indicates the urgent need for systematic evaluation of second-line treatment options in cGVHD.
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39
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40
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Alousi AM, Uberti J, Ratanatharathorn V. The role of B cell depleting therapy in graft versus host disease after allogeneic hematopoietic cell transplant. Leuk Lymphoma 2010; 51:376-89. [DOI: 10.3109/10428190903586318] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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41
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Kato I, Umeda K, Awaya T, Yui Y, Niwa A, Fujino H, Matsubara H, Watanabe KI, Heike T, Adachi N, Endo F, Mizukami T, Nunoi H, Nakahata T, Adachi S. Successful treatment of refractory donor lymphocyte infusion-induced immune-mediated pancytopenia with rituximab. Pediatr Blood Cancer 2010; 54:329-31. [PMID: 19890900 DOI: 10.1002/pbc.22280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A 6-year-old male with chronic granulomatous disease, who was transplanted with bone marrow and exhibited increasing mixed chimerism, subsequently received two donor lymphocyte infusions (DLI). Two weeks after the second DLI, the patient developed acute graft-versus-host disease (GVHD) and progressive pancytopenia that was associated with autoantibody production. Conventional treatment did not improve the pancytopenia. However, administration of Rituximab (RTX) (375 mg/m(2)/week for four consecutive weeks) resulted in a rapid resolution of the pancytopenia. The patient achieved full donor chimerism without GVHD symptoms. RTX can be valuable for managing immune-mediated cytopenias that arise after DLI and are refractory to conventional therapies.
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Affiliation(s)
- Itaru Kato
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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42
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Kharfan-Dabaja MA, Bazarbachi A. Emerging role of CD20 blockade in allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant 2010; 16:1347-54. [PMID: 20083213 DOI: 10.1016/j.bbmt.2010.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Accepted: 01/07/2010] [Indexed: 11/25/2022]
Abstract
There is growing evidence incriminating B lymphocytes in the pathogenesis of graft-versus-host disease (GVHD). Better understanding of the role of B lymphocytes has uncovered new therapeutic approaches, such as CD20 blockade, which appear to be improving outcomes in allogeneic hematopoietic cell transplant recipients. Administration of the chimeric murine/human anti-CD20 monoclonal antibody, rituximab, prior to hematopoietic cell allografting or as part of preparative regimens appears to reduce treatment-related mortality and to improve posttransplant outcomes mainly by decreasing the incidence and severity of acute GVHD. This beneficial effect of rituximab has not had an impact, to the same extent on the incidence of chronic GVHD, which remains a significant cause of morbidity and mortality following hematopoietic cell allografting. Alternatively, rituximab has been shown to be effective for treatment of cGVHD, but data is limited because of the lack of randomized controlled clinical trials and the small sample size in most of the published series. Incorporation of rituximab into the therapeutic armamentarium of Epstein-Barr virus-associated posttransplant lymphoproliferative disorder has clearly improved the overall prognosis of this dreadful disease. This review highlights the evolving role of CD20 blockade in allogeneic hematopoietic cell transplantation and the need to continue to refine B cell depletion strategies in this setting.
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Affiliation(s)
- Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, Florida 33612, USA.
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43
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Antibodies specifically target AML antigen NuSAP1 after allogeneic bone marrow transplantation. Blood 2010; 115:2077-87. [PMID: 20053754 DOI: 10.1182/blood-2009-03-211375] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Identifying the targets of immune response after allogeneic hematopoietic cell transplantation (HCT) promises to provide relevant immune therapy candidate proteins. We used protein microarrays to serologically identify nucleolar and spindle-associated protein 1 (NuSAP1) and chromatin assembly factor 1, subunit B (p60; CHAF1b) as targets of new antibody responses that developed after allogeneic HCT. Western blots and enzyme-linked immunosorbent assays (ELISA) validated their post-HCT recognition and enabled ELISA testing of 120 other patients with various malignancies who underwent allo-HCT. CHAF1b-specific antibodies were predominantly detected in patients with acute myeloid leukemia (AML), whereas NuSAP1-specific antibodies were exclusively detected in patients with AML 1 year after transplantation (P < .001). Complete genomic exon sequencing failed to identify a nonsynonymous single nucleotide polymorphism (SNP) for NuSAP1 and CHAF1b between the donor and recipient cells. Expression profiles and reverse transcriptase-polymerase chain reaction (RT-PCR) showed NuSAP1 was predominately expressed in the bone marrow CD34(+)CD90(+) hematopoietic stem cells, leukemic cell lines, and B lymphoblasts compared with other tissues or cells. Thus, NuSAP1 is recognized as an immunogenic antigen in 65% of patients with AML following allogeneic HCT and suggests a tumor antigen role.
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44
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Ratanatharathorn V, Pavletic S, Uberti JP. Clinical applications of rituximab in allogeneic stem cell transplantation: Anti-tumor and immunomodulatory effects. Cancer Treat Rev 2009; 35:653-61. [DOI: 10.1016/j.ctrv.2009.07.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Revised: 07/15/2009] [Accepted: 07/18/2009] [Indexed: 11/24/2022]
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45
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Abstract
Allogeneic hematopoietic stem cell transplantation is an established treatment modality for malignant and nonmalignant hematologic diseases. Acute and chronic graft-versus-host diseases (GVHDs) are a major cause of morbidity and mortality after allogeneic stem cell transplantation. T cells have been identified as key players in the graft-versus-host reaction and, therefore, most established drugs used against GVHD target T cells. Despite our knowledge on the pathogenesis of the GVH reaction, success of established therapies for prevention and treatment of GHVD is unsatisfactory. Recently, animal and human studies demonstrated that B cells are involved in the immunopathophysiology of acute and chronic GVHD. Early phase clinical trials of B-cell depletion with rituximab have shown beneficial effects on both acute and chronic GVHD. This review summarizes the current experimental and clinical evidence for the involvement of B cells in the pathogenesis of acute and chronic GVHD and discusses the clinical implications for the management of patients undergoing allogeneic stem cell transplantation.
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46
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Efficacy of Rituximab in the Setting of Steroid-Refractory Chronic Graft-versus-Host Disease: A Systematic Review and Meta-Analysis. Biol Blood Marrow Transplant 2009; 15:1005-13. [DOI: 10.1016/j.bbmt.2009.04.003] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Accepted: 04/06/2009] [Indexed: 11/19/2022]
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47
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Griffioen M, van Egmond EHM, Kester MGD, Willemze R, Falkenburg JHF, Heemskerk MHM. Retroviral transfer of human CD20 as a suicide gene for adoptive T-cell therapy. Haematologica 2009; 94:1316-20. [PMID: 19734426 PMCID: PMC2738728 DOI: 10.3324/haematol.2008.001677] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Revised: 03/10/2009] [Accepted: 04/16/2009] [Indexed: 12/11/2022] Open
Abstract
The aim of adoptive T-cell therapy of cancer is to selectively confer immunity against tumor cells. Autoimmune side effects, however, remain a risk, emphasizing the relevance of a suicide mechanism allowing in vivo elimination of infused T cells. We investigated the use of human CD20 as suicide gene in T-lymphocytes. Potential effects of forced CD20 expression on T-cell function were investigated by comparing CD20- and mock-transduced cytomegalovirus (CMV) specific T cells for cytolysis, cytokine release and proliferation. The use of CD20 as suicide gene was investigated in CMV specific T cells and in T cells genetically modified with an antigen specific T-cell receptor. No effect of CD20 on T-cell function was observed. CD20-transduced T cells with and without co-transferred T-cell receptor were efficiently eliminated by complement dependent cytotoxicity induced by therapeutic anti-CD20 antibody rituximab. The data support the broad value of CD20 as safety switch in adoptive T-cell therapy.
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Affiliation(s)
- Marieke Griffioen
- Department of Hematology, Laboratory of Experimental Hematology, Leiden University Medical Center, Albinusdreef 2, Leiden, The Netherlands.
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48
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Rituximab for the treatment of corticosteroid-refractory chronic graft-versus-host disease. Int J Hematol 2009; 90:253-260. [DOI: 10.1007/s12185-009-0370-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Revised: 05/23/2009] [Accepted: 06/03/2009] [Indexed: 10/20/2022]
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49
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Small TN, Robinson WH, Miklos DB. B cells and transplantation: an educational resource. Biol Blood Marrow Transplant 2009; 15:104-13. [PMID: 19147088 DOI: 10.1016/j.bbmt.2008.10.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Trudy N Small
- Department of Pediatrics and Clinical Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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50
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Bates JS, Engemann AM, Hammond JM. Clinical Utility of Rituximab in Chronic Graft-Versus-Host Disease. Ann Pharmacother 2009; 43:316-21. [DOI: 10.1345/aph.1l386] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To evaluate the use of rituximab in the clinical management of steroid-refractory chronic graft-versus-host disease (GVHD). Data Sources: Literature was accessed through MEDLINE and International Pharmaceutical Abstracts (1990–September 2008), both indexed and nonindexed citations, using the terms rituximab, graft-versus-host disease, monoclonal antibodies, and CD20. In addition, reference citations from the publications identified were reviewed. Study Selection and Data Extraction: All articles discussing rituximab as a therapeutic option in the treatment of GVHD that were published in English and enrolled human study participants were evaluated. Data Synthesis: Rituximab is a genetically engineered chimeric murine monoclonal antibody that binds to the CD20 differentiation antigen found on B-lymphocytes. GVHD is the leading cause of procedural-related morbidity and mortality following allogeneic hematopoietic stem cell transplantation (HSCT). Chronic GVHD (cGVHD) occurs in up to 70% of individuals undergoing HSCT, and approximately 40% of those patients are refractory to conventional T-lymphocyte–directed therapies. Limited treatments are available for individuals with steroid-refractory cGVHD. Rituximab therapy in individuals with extensive cGVHD has demonstrated clinical efficacy with manageable toxicities in retrospective and prospective studies. Conclusions: Available data suggest that rituximab is a treatment option for patients with extensive steroid-refractory cGVHD. Rituximab may be particularly effective for individuals with steroid-refractory cGVHD manifesting as thrombocytopenia or with sclerodermatous, cutaneous, and rheumatologic involvement.
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Affiliation(s)
- Jill S Bates
- Hematology/Oncology Specialty Resident, Department of Pharmacy, Duke University Medical Center, Durham, NC
| | | | - Julia M Hammond
- Oncology Clinical Coordinator, Department of Pharmacy, Duke University Medical Center
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