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Kulasekararaj A, Cavenagh J, Dokal I, Foukaneli T, Gandhi S, Garg M, Griffin M, Hillmen P, Ireland R, Killick S, Mansour S, Mufti G, Potter V, Snowden J, Stanworth S, Zuha R, Marsh J. Guidelines for the diagnosis and management of adult aplastic anaemia: A British Society for Haematology Guideline. Br J Haematol 2024; 204:784-804. [PMID: 38247114 DOI: 10.1111/bjh.19236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/26/2023] [Accepted: 11/20/2023] [Indexed: 01/23/2024]
Abstract
Pancytopenia with hypocellular bone marrow is the hallmark of aplastic anaemia (AA) and the diagnosis is confirmed after careful evaluation, following exclusion of alternate diagnosis including hypoplastic myelodysplastic syndromes. Emerging use of molecular cyto-genomics is helpful in delineating immune mediated AA from inherited bone marrow failures (IBMF). Camitta criteria is used to assess disease severity, which along with age and availability of human leucocyte antigen compatible donor are determinants for therapeutic decisions. Supportive care with blood and platelet transfusion support, along with anti-microbial prophylaxis and prompt management of opportunistic infections remain key throughout the disease course. The standard first-line treatment for newly diagnosed acquired severe/very severe AA patients is horse anti-thymocyte globulin and ciclosporin-based immunosuppressive therapy (IST) with eltrombopag or allogeneic haemopoietic stem cell transplant (HSCT) from a matched sibling donor. Unrelated donor HSCT in adults should be considered after lack of response to IST, and up front for young adults with severe infections and a readily available matched unrelated donor. Management of IBMF, AA in pregnancy and in elderly require special attention. In view of the rarity of AA and complexity of management, appropriate discussion in multidisciplinary meetings and involvement of expert centres is strongly recommended to improve patient outcomes.
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Affiliation(s)
- Austin Kulasekararaj
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Jamie Cavenagh
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Inderjeet Dokal
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London and Barts Health NHS Trust, London, UK
| | - Theodora Foukaneli
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- NHS Blood and Transplant, Bristol, UK
| | - Shreyans Gandhi
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Mamta Garg
- Leicester Royal Infirmary, Leicester, UK
- British Society Haematology Task Force Representative, London, UK
| | | | | | - Robin Ireland
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Sally Killick
- University Hospitals Dorset NHS Foundation Trust, The Royal Bournemouth Hospital, Bournemouth, UK
| | - Sahar Mansour
- St George's Hospital/St George's University of London, London, UK
| | - Ghulam Mufti
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Victoria Potter
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - John Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Roslin Zuha
- James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, Norfolk, England
| | - Judith Marsh
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
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2
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Fang M, Song H, Zhang J, Li S, Shen D, Tang Y. Efficacy and safety of immunosuppressive therapy with or without eltrombopag in pediatric patients with acquired aplastic anemia: A Chinese retrospective study. Pediatr Hematol Oncol 2021; 38:633-646. [PMID: 33724146 DOI: 10.1080/08880018.2021.1895924] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
To determine the efficacy and safety of eltrombopag (E-PAG) combined with intensive immunosuppressive therapy (IST) for the treatment of pediatric patients with severe aplastic anemia (SAA). A total of 57 pediatric patients with newly diagnosed severe aplastic anemia were enrolled in this study. Thirty nine patients were treated with IST alone, consisting of porcine anti-human thymocyte globulin (30 mg/kg/day × 5 days) and cyclosporine A (CsA) (treated for 2 years, with a trough concentration maintained at 200-250 ng/mL), and 18 patients were treated with IST + E-PAG (12.5-50 mg/day, maintained for 6 months). We found no statistical difference between the response rates at 3 months for the two groups (CR: 12.8% vs. 22.2% p > 0.05, ORR: 56.4% vs. 77.7% p > 0.05). However, we found a statistical difference between the response rates at 6 months for the two groups (CR: 17.9% vs. 50% p < 0.05, ORR: 69.2% vs. 94.4% p < 0.05). The main side-effect during treatment with E-PAG was having a slightly to moderately elevated bilirubin level, which was temporary and controllable, accounting for approximately 66.6% (12/18) of patients in the IST + E-PAG group vs. 20.5% (8/39) of those in the IST group (p < 0.05). IST + E-PAG therapy appears to be more effective than IST alone for the treatment of pediatric SAA, with good tolerability and compliance. This approach deserves further exploration.
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Affiliation(s)
- Meixin Fang
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
| | - Hua Song
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
| | - Jingying Zhang
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
| | - Sisi Li
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
| | - Diying Shen
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
| | - Yongmin Tang
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
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3
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Lévesque JP, Summers KM, Millard SM, Bisht K, Winkler IG, Pettit AR. Role of macrophages and phagocytes in orchestrating normal and pathologic hematopoietic niches. Exp Hematol 2021; 100:12-31.e1. [PMID: 34298116 DOI: 10.1016/j.exphem.2021.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/02/2021] [Accepted: 07/06/2021] [Indexed: 12/13/2022]
Abstract
The bone marrow (BM) contains a mosaic of niches specialized in supporting different maturity stages of hematopoietic stem and progenitor cells such as hematopoietic stem cells and myeloid, lymphoid, and erythroid progenitors. Recent advances in BM imaging and conditional gene knockout mice have revealed that niches are a complex network of cells of mesenchymal, endothelial, neuronal, and hematopoietic origins, together with local physicochemical parameters. Within these complex structures, phagocytes, such as neutrophils, macrophages, and dendritic cells, all of which are of hematopoietic origin, have been found to be important in regulating several niches in the BM, including hematopoietic stem cell niches, erythropoietic niches, and niches involved in endosteal bone formation. There is also increasing evidence that these macrophages have an important role in adapting hematopoiesis, erythropoiesis, and bone formation in response to inflammatory stressors and play a key part in maintaining the integrity and function of these. Likewise, there is also accumulating evidence that subsets of monocytes, macrophages, and other phagocytes contribute to the progression and response to treatment of several lymphoid malignancies such as multiple myeloma, Hodgkin lymphoma, and non-Hodgkin lymphoma, as well as lymphoblastic leukemia, and may also play a role in myelodysplastic syndrome and myeloproliferative neoplasms associated with Noonan syndrome and aplastic anemia. In this review, the potential functions of macrophages and other phagocytes in normal and pathologic niches are discussed, as are the challenges in studying BM and other tissue-resident macrophages at the molecular level.
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Affiliation(s)
- Jean-Pierre Lévesque
- Mater Research Institute, University of Queensland, Woolloongabba, QLD, Australia.
| | - Kim M Summers
- Mater Research Institute, University of Queensland, Woolloongabba, QLD, Australia
| | - Susan M Millard
- Mater Research Institute, University of Queensland, Woolloongabba, QLD, Australia
| | - Kavita Bisht
- Mater Research Institute, University of Queensland, Woolloongabba, QLD, Australia
| | - Ingrid G Winkler
- Mater Research Institute, University of Queensland, Woolloongabba, QLD, Australia
| | - Allison R Pettit
- Mater Research Institute, University of Queensland, Woolloongabba, QLD, Australia
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Kasinathan G, Lee BS, Sathar J. Very severe aplastic anemia in an 80-year-old man. Clin Case Rep 2021; 9:1330-1333. [PMID: 33768838 PMCID: PMC7981752 DOI: 10.1002/ccr3.3757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/18/2020] [Accepted: 10/20/2020] [Indexed: 12/04/2022] Open
Abstract
Although the patient with very severe aplastic anemia might be a fit elderly receiving standard therapy, there are factors which contribute to an adverse outcome such as severity of pancytopenia, absence of minor paroxysmal nocturnal hemoglobinuria clone and infective complications of therapy.
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Affiliation(s)
| | - Bee Sun Lee
- Department of HematologyAmpang HospitalAmpangMalaysia
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5
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Chen FF, Guo ZW, Zhang LN, Yang C, Chen M, Ye F, Han B. [The change of quality of life in 52 patients with non-severe aplastic anemia after cyclosporine A therapy]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 41:806-810. [PMID: 33190436 PMCID: PMC7656084 DOI: 10.3760/cma.j.issn.0253-2727.2020.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
目的 研究非重型再生障碍性贫血(NSAA)患者接受环孢素A(CsA)治疗前后生活质量的变化,并分析生活质量改善的影响因素。 方法 收集2014年1月至2016年1月在北京协和医院门诊初次治疗、仅使用CsA的NSAA患者,在治疗前和治疗2年后分别填写SF-36量表,与正常中国人模型(常模)比较;并调查评估患者的年龄、性别、文化程度、家庭年收入、付费方式、依从性、治疗前一般健康状况及治疗2年后的疗效,分析其与生活质量改善的关系。 结果 共52例患者符合入组条件,其中男性27例(51.9%),女性25例(48.1%),中位年龄48(21~85)岁。CsA治疗2年,完全治疗反应(CR)15例(28.8%),部分治疗反应(PR)25例(48.1%),无治疗反应(NR)12例(23.1%),治疗总有效率(CR+PR)76.9%。患者治疗前SF-36量表躯体和心理健康得分差于常模(P值均<0.05)。治疗后,躯体方面及总体生活质量虽仍然低于常模(P值均<0.05),但心理健康与常模比较差异无统计学意义(P值均>0.05),精力(VT)、精神健康(MH)得分高于常模[VT:(58.8±20.1)分对(52.3±20.9)分,P=0.023;MH:(65.9±17.6)分对(59.7±22.9)分,P=0.014]。不同社会背景与生活质量改善均无显著相关性。起病时体能状况评分(ECOG评分)较低者生活质量改善更大。CsA治疗有效者生活质量均得到显著改善。 结论 NSAA患者生活质量低于常人,CsA治疗可以改善患者的生活质量,尤其是心理健康情况。不同社会背景的患者均可从治疗中获益,而起病较重者获益更大。
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Affiliation(s)
- F F Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academe of Medical Science, Beijing 100730, China
| | - Z W Guo
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academe of Medical Science, Beijing 100730, China
| | - L N Zhang
- Department of Hematology, Chuiyangliu Hospital affiliated to Tsinghua University, Beijing 100022, China
| | - C Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academe of Medical Science, Beijing 100730, China
| | - M Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academe of Medical Science, Beijing 100730, China
| | - F Ye
- Department of Hematology, Chuiyangliu Hospital affiliated to Tsinghua University, Beijing 100022, China
| | - B Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academe of Medical Science, Beijing 100730, China
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6
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Jia JS. [Prediction and treatment prospect of immunosuppressive therapy in patients with severe aplastic anemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:874-877. [PMID: 33190453 PMCID: PMC7656085 DOI: 10.3760/cma.j.issn.0253-2727.2020.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Indexed: 11/23/2022]
Affiliation(s)
- J S Jia
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
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Similar outcomes of alemtuzumab-based hematopoietic cell transplantation for SAA patients older or younger than 50 years. Blood Adv 2020; 3:3070-3079. [PMID: 31648330 DOI: 10.1182/bloodadvances.2019000480] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/27/2019] [Indexed: 12/11/2022] Open
Abstract
Survival after allogeneic hematopoietic cell transplantation (HSCT) for severe aplastic anemia (SAA) among older patients remains poor and associated with increased risk for graft-versus-host disease (GVHD). In this retrospective study of 65 consecutive patients with acquired SAA who were transplanted using fludarabine, low-dose cyclophosphamide, and alemtuzumab (FCC), outcomes of 27 patients aged at least 50 years were compared with those of 38 patients younger than 50 years. The median age of the older cohort was 61 years (range, 51-71 years); 21 (78%) patients were transplanted from unrelated donors (3 of 21 from HLA 9/10 mismatch donors) and 6 from matched sibling donors. One-year GVHD-free, relapse-free survival (GRFS) was comparable to that of patients younger than 50 years (84% vs 94%, respectively; P = .23). Both groups showed low rates of acute (5% vs 4%) and chronic (18% vs 14%) GVHD, with no cases of severe GVHD among matched donor transplants, and similar 1-year transplant-related mortality (14% vs 5.4%, older vs younger; P = .23). HSCT comorbidity index (HTC-CI) scores were similar between the groups, but overall survival with an HCT-CI of at least 3 was lower compared with a score less than 3 (76% vs 98%; P = .005). Median donor T-cell chimerism among older patients was 64% and 60% at 1 and 3 years, respectively, and was similar to that of younger patients. Increased B regulatory cells potentially contributed to low alloreactivity and mutual donor-recipient tolerance in older patients. Effect of comorbidities rather than age alone may be a more important determinant of suitability for FCC HSCT in older patients.
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8
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Qi WW, Fu R. [Progress in diagnosis and treatment in the elderly patients with aplastic anemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:80-83. [PMID: 32023761 PMCID: PMC7357911 DOI: 10.3760/cma.j.issn.0253-2727.2020.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- W W Qi
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
| | - R Fu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin 300052, China
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Bone Marrow Failure in Children: Approach to Diagnosis and Treatment. Indian J Pediatr 2020; 87:141-149. [PMID: 31628637 DOI: 10.1007/s12098-019-03066-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/20/2019] [Indexed: 10/25/2022]
Abstract
Bone marrow failure has many different etiologies, including genetic defects which manifest with specific syndromes, as well as acquired conditions as a result of insults to the bone marrow leading to aplasia. The clinical picture is varied and clues for the underlying cause may or may not be evident at the time of presentation, frequently leading to a complex workup with a battery of tests often done to rule out genetic defects. The treatment approach for bone marrow failure is very dependent on the underlying cause, which makes it all the more critical to have an accurate diagnosis. First line management essentially consists of either hematopoietic stem cell transplant or immunosuppressive therapy. In this review authors will provide a broad look at the causes of bone marrow failure, the stepwise diagnostic algorithm and the approach to decision making for treatment. Fine details of each cause, and of each treatment modality are beyond the scope of this review which aims to provide an overview.
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10
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Liu J, Lu XY, Cheng L, Yang Y, Lin SY, Yin H, Liu XQ, Wu XM, He GS. Clinical outcomes of immunosuppressive therapy for severe aplastic anemia patients with absolute neutrophil count of zero. Hematology 2019; 24:492-497. [PMID: 31221029 DOI: 10.1080/16078454.2019.1631424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Jia Liu
- Department of hematology, The First people’s Hospital of Changzhou, The Third Affiliated Hospital of Soochow University, Changzhou, People’s Republic of China
- Department of hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, People’s Republic of China
| | - Xing-Yu Lu
- Department of hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, People’s Republic of China
| | - Lang Cheng
- Department of hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, People’s Republic of China
| | - Yan Yang
- Department of Hematology, The Affiliated Hospital of Jilin University, Changchun, People’s Republic of China
| | - Sheng-Yun Lin
- Department of Hematology, Zhejiang Province Hospital of TCM, The First Affiliated Hospital of Zhejiang TCM University, Hangzhou, People's Republic of China
| | - Hua Yin
- Department of hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, People’s Republic of China
| | - Xiao-Qing Liu
- Department of hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, People’s Republic of China
| | - Xue-Mei Wu
- Department of hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, People’s Republic of China
| | - Guang-Sheng He
- Department of hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, People’s Republic of China
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Rice C, Eikema DJ, Marsh JCW, Knol C, Hebert K, Putter H, Peterson E, Deeg HJ, Halkes S, Pidala J, Anderlini P, Tischer J, Kroger N, McDonald A, Antin JH, Schaap NP, Hallek M, Einsele H, Mathews V, Kapoor N, Boelens JJ, Mufti GJ, Potter V, Pefault de la Tour R, Eapen M, Dufour C. Allogeneic Hematopoietic Cell Transplantation in Patients Aged 50Years or Older with Severe Aplastic Anemia. Biol Blood Marrow Transplant 2019; 25:488-495. [PMID: 30194027 PMCID: PMC6401340 DOI: 10.1016/j.bbmt.2018.08.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 08/26/2018] [Indexed: 01/30/2023]
Abstract
We report on 499 patients with severe aplastic anemia aged ≥ 50years who underwent hematopoietic cell transplantation (HCT) from HLA-matched sibling (n = 275, 55%) or HLA-matched (8/8) unrelated donors (n = 187, 37%) between 2005 and 2016. The median age at HCT was 57.8 years; 16% of patients were 65 to 77years old. Multivariable analysis confirmed higher mortality risks for patients with performance score less than 90% (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.03 to 1.92; P = .03) and after unrelated donor transplantation (HR, 1.47; 95% CI, 1 to 2.16; P = .05). The 3-year probabilities of survival for patients with performance scores of 90 to 100 and less than 90 after HLA-matched sibling transplant were 66% (range, 57% to 75%) and 57% (range, 47% to 76%), respectively. The corresponding probabilities after HLA-matched unrelated donor transplantation were 57% (range, 48% to 67%) and 48% (range, 36% to 59%). Age at transplantation was not associated with survival, but grades II to IV acute graft-versus-host disease (GVHD) risks were higher for patients aged 65years or older (subdistribution HR [sHR], 1.7; 95% confidence interval, 1.07 to 2.72; P = .026). Chronic GVHD was lower with the GVHD prophylaxis regimens calcineurin inhibitor (CNI) + methotrexate (sHR, .52; 95% CI, .33 to .81; P = .004) and CNI alone or with other agents (sHR, .27; 95% CI, .14 to .53; P < .001) compared with CNI + mycophenolate. Although donor availability is modifiable only to a limited extent, choice of GVHD prophylaxis and selection of patients with good performance scores are key for improved outcomes.
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Affiliation(s)
- Carmel Rice
- Department of Haematology, King's College Hospital, London, United Kingdom
| | | | - Judith C W Marsh
- Department of Haematology, King's College Hospital, London, United Kingdom; Department of Haematology, King's College London, London, United Kingdom.
| | - Cora Knol
- EBMT Data Office, Leiden, Netherlands
| | - Kyle Hebert
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Stijn Halkes
- Leiden University Medical Centre, Leiden, Netherlands
| | | | | | | | | | - Andrew McDonald
- Albert Stem Cell Transplantation Centre, Pretoria Gauteng, South Africa
| | | | | | | | | | | | - Neena Kapoor
- Children's Hospital of Los Angeles, Los Angeles, California
| | | | - Ghulam J Mufti
- Department of Haematology, King's College Hospital, London, United Kingdom; Department of Haematology, King's College London, London, United Kingdom
| | - Victoria Potter
- Department of Haematology, King's College Hospital, London, United Kingdom
| | | | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Medinger M, Drexler B, Lengerke C, Passweg J. Pathogenesis of Acquired Aplastic Anemia and the Role of the Bone Marrow Microenvironment. Front Oncol 2018; 8:587. [PMID: 30568919 PMCID: PMC6290278 DOI: 10.3389/fonc.2018.00587] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/22/2018] [Indexed: 12/18/2022] Open
Abstract
Aplastic anemia (AA) is characterized by bone marrow (BM) hypocellularity, resulting in peripheral cytopenias. An antigen-driven and likely auto-immune dysregulated T-cell homeostasis results in hematopoietic stem cell injury, which ultimately leads to the pathogenesis of the acquired form of this disease. Auto-immune and inflammatory processes further influence the disease course as well as response rate to therapy, mainly consisting of intensive immunosuppressive therapy and allogeneic hematopoietic cell transplantation. Bone marrow hematopoietic stem and progenitor cells are strongly regulated by the crosstalk with the surrounding microenvironment and its components like mesenchymal stromal cells, also consistently altered in AA. Whether latter is a contributing cause or rather consequence of the disease remains an open question. Overall, niche disruption may contribute to disease progression, sustain pancytopenia and promote clonal evolution. Here we review the existing knowledge on BM microenvironmental changes in acquired AA and discuss their relevance for the pathogenesis and therapy.
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Affiliation(s)
- Michael Medinger
- Division of Internal Medicine, Department of Medicine, University Hospital Basel, Basel, Switzerland.,Division of Hematology, Department of Medicine, University Hospital Basel, Basel, Switzerland
| | - Beatrice Drexler
- Division of Hematology, Department of Medicine, University Hospital Basel, Basel, Switzerland
| | - Claudia Lengerke
- Division of Hematology, Department of Medicine, University Hospital Basel, Basel, Switzerland
| | - Jakob Passweg
- Division of Hematology, Department of Medicine, University Hospital Basel, Basel, Switzerland
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Assi R, Garcia-Manero G, Ravandi F, Borthakur G, Daver NG, Jabbour E, Burger J, Estrov Z, Dinardo CD, Alvarado Y, Hendrickson S, Ferrajoli A, Wierda W, Cortes J, Kantarjian H, Kadia TM. Addition of eltrombopag to immunosuppressive therapy in patients with newly diagnosed aplastic anemia. Cancer 2018; 124:4192-4201. [PMID: 30307606 DOI: 10.1002/cncr.31658] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/09/2018] [Accepted: 05/10/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND The immune-mediated destruction of hematopoietic stem cells is implicated in the pathophysiology of aplastic anemia (AA). Immunosuppressive therapy (IST) using antithymocyte globulin and cyclosporine is successful in this setting. Eltrombopag is active in patients with refractory AA, presumably by increasing the bone marrow progenitors. METHODS This phase 2 trial initially was designed to evaluate standard IST in newly diagnosed patients with severe AA and later was amended to add eltrombopag to simultaneously address immune destruction and stem cell depletion. The primary outcome was the overall response rate (ORR) at 3 months and 6 months. RESULTS A total of 38 patients were enrolled: 17 (45%) received IST alone and 21 (55%) received additional eltrombopag. The ORR was 74%. Patients receiving IST plus eltrombopag had a similar ORR (76% vs 71%; P = .72), complete remission rate (38% vs 29%; P = .73), and median time to response (84 days vs 57 days; P = .30) compared with those receiving IST alone. The 2-year overall survival rate in the IST group was 91% compared with 82% for those patients treated with IST plus eltrombopag (P = .82). No cumulative toxicities were noted after the addition of eltrombopag. CONCLUSIONS The addition of eltrombopag to standard IST was well tolerated and resulted in similar responses.
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Affiliation(s)
- Rita Assi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jan Burger
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Courtney D Dinardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yesid Alvarado
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephany Hendrickson
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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14
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Contejean A, Resche-Rigon M, Tamburini J, Alcantara M, Jardin F, Lengliné E, Adès L, Bouscary D, Marçais A, Lebon D, Chabrot C, Terriou L, Barraco F, Banos A, Bussot L, Cahn JY, Hirsch P, Maillard N, Simon L, Fornecker LM, Socié G, de Latour RP, de Fontbrune FS. Aplastic anemia in the elderly: a nationwide survey on behalf of the French Reference Center for Aplastic Anemia. Haematologica 2018; 104:256-262. [PMID: 30262561 PMCID: PMC6355477 DOI: 10.3324/haematol.2018.198440] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 09/24/2018] [Indexed: 11/09/2022] Open
Abstract
Aplastic anemia is a rare but potentially life-threatening disease that may affect older patients. Data regarding the treatment of aplastic anemia in this ageing population remains scarce. We conducted a retrospective nationwide multicenter study in France to examine current treatments for aplastic anemia patients over 60 years old. Our aims were to evaluate efficacy and tolerance, and to analyze predictive factors for response and survival. Over the course of a decade, 88 patients (median age 68.5 years) were identified in 19 centers, with a median follow up of 2.7 years; 21% had very severe and 36% severe aplastic anemia. We analyzed 184 treatment lines, mostly involving the standard combination of anti-thymocyte globulin and cyclosporine-A (33%), which was also the most frequent first-line treatment (50%). After first-line therapy, 32% of patients achieved a complete response, and 15% a partial response. Responses were significantly better in first line and in patients with good performance status, as well as in those that had followed an anti-thymocyte globulin and cyclosporine-A regimen (overall response rate of 70% after first-line treatment). All treatments were well tolerated by patients, including over the age of 70. Three-year survival was 74.7% (median 7.36 years). Age, Charlson comorbidity index and very severe aplastic anemia were independently associated with mortality. Age, per se, is not a limiting factor to aplastic anemia treatment with anti-thymocyte globulin and cyclosporine-A; this regimen should be used as a first-line treatment in elderly patients if they have a good performance status and low comorbidity index score.
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Affiliation(s)
- Adrien Contejean
- French Reference Center for Aplastic Anemia, CHU Saint Louis, Paris.,Hematology department, CHU Cochin, Paris.,Paris Descartes University, Sorbonne Paris Cité
| | | | - Jérôme Tamburini
- Hematology department, CHU Cochin, Paris.,Paris Descartes University, Sorbonne Paris Cité
| | - Marion Alcantara
- Paris Descartes University, Sorbonne Paris Cité.,Department of biological hematology, CHU Necker, Paris.,Hematology department, Centre Henri Becquerel, Rouen
| | | | - Etienne Lengliné
- French Reference Center for Aplastic Anemia, CHU Saint Louis, Paris.,Hematology department, CHU Saint-Louis, Paris.,Paris Diderot University
| | - Lionel Adès
- Paris Diderot University.,Senior hematology department, CHU Saint-Louis, Paris
| | - Didier Bouscary
- Hematology department, CHU Cochin, Paris.,Paris Descartes University, Sorbonne Paris Cité
| | - Ambroise Marçais
- Paris Descartes University, Sorbonne Paris Cité.,Hematology department, CHU Necker, Paris
| | | | | | | | | | - Anne Banos
- Hematology department, CH Côte Basque, Bayonne
| | | | | | | | | | | | | | - Gerard Socié
- French Reference Center for Aplastic Anemia, CHU Saint Louis, Paris.,Paris Diderot University.,Bone-marrow transplantation department, CHU Saint-Louis, Paris.,Inserm UMR 1160, CHU Saint Louis, Paris, France
| | - Regis Peffault de Latour
- French Reference Center for Aplastic Anemia, CHU Saint Louis, Paris .,Paris Diderot University.,Bone-marrow transplantation department, CHU Saint-Louis, Paris
| | - Flore Sicre de Fontbrune
- French Reference Center for Aplastic Anemia, CHU Saint Louis, Paris.,Bone-marrow transplantation department, CHU Saint-Louis, Paris
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15
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Scheinberg P. Recent Advances and Long-Term Results of Medical Treatment of Acquired Aplastic Anemia: Are Patients Cured? Hematol Oncol Clin North Am 2018; 32:609-618. [PMID: 30047414 DOI: 10.1016/j.hoc.2018.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Horse antithymocyte globulin plus cyclosporine remains standard immunosuppressive therapy in severe aplastic anemia, with hematologic response rates of 60% to 70%. In those refractory to this regimen, a second course of therapy with rabbit antithymocyte globulin plus cyclosporine or alemtuzumab produces responses in 30% to 40%. Eltrombopag, a thrombopoietin receptor agonist, showed activity as a single agent in those refractory to initial immunosuppression with hematologic response rates of 40% to 50%. When combined with immunosuppression as frontline therapy, eltrombopag increased the rate of overall and complete response rates. Longer follow-up is needed to better define these outcomes.
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Affiliation(s)
- Phillip Scheinberg
- Division of Hematology, Hospital A Beneficência Portuguesa, Rua Martiniano de Carvalho, 951, São Paulo 01321-001, Brazil.
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