1
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von dem Borne PA, Kemps-Mols BM, de Wreede LC, van Beek AA, Snijders TJF, van Lammeren D, Tijmensen J, Sijs-Szabó A, Oudshoorn MA, Halkes CJM, van Balen P, Marijt WAE, Tjon JML, Vermaat JSP, Veelken H. The degree of HLA matching determines the incidence of cytokine release syndrome and associated nonrelapse mortality in matched related and unrelated allogeneic stem cell transplantation with post-transplant cyclophosphamide. Leuk Lymphoma 2024:1-11. [PMID: 38710017 DOI: 10.1080/10428194.2024.2344060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 04/12/2024] [Indexed: 05/08/2024]
Abstract
Cytokine release syndrome (CRS) occurs frequently after haplo-identical allogeneic stem cell transplantation (alloSCT) with post-transplant cyclophosphamide (PTCy), increasing nonrelapse mortality (NRM) and decreasing survival. Data on CRS in HLA-matched alloSCT are limited and effects of specific HLA-mismatches on CRS development unknown. We hypothesized that in HLA-matched alloSCT increasing degrees of HLA-mismatching influence CRS incidence, NRM and survival. Retrospective analysis of 126 HLA-matched PTCy-alloSCT patients showed that higher degrees of HLA-mismatching significantly increased CRS incidence (26%, 75% and 90% CRS with 12/12, 10/10 and 9/10 matched donors, respectively). Maximum temperature during CRS increased with higher HLA-mismatch. Specific associations between HLA-mismatches and CRS could be determined. Grade 2 CRS and CRS-induced grade 3 fever were associated with significantly increased NRM (p < 0.001 and p = 0.003, respectively) and inferior survival (p < 0.001 and p = 0.005, respectively). NRM was mainly caused by disease conditions that may be considered CRS-induced inflammatory responses (encephalopathy, cryptogenic organizing pneumonia and multi-organ failure).
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Affiliation(s)
| | - Berit M Kemps-Mols
- Department of Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Liesbeth C de Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Adriaan A van Beek
- Department of Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Tjeerd J F Snijders
- Department of Hematology, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | - Janneke Tijmensen
- Department of Hematology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Aniko Sijs-Szabó
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mirjam A Oudshoorn
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Peter van Balen
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - W A Erik Marijt
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jennifer M L Tjon
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Joost S P Vermaat
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hendrik Veelken
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
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2
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Little JS, Duléry R, Shapiro RM, Aleissa MM, Prockop SE, Koreth J, Ritz J, Antin JH, Cutler C, Nikiforow S, Romee R, Issa NC, Ho VT, Baden LR, Soiffer RJ, Gooptu M. Opportunistic Infections in Patients Receiving Post-Transplantation Cyclophosphamide: Impact of Haploidentical versus Unrelated Donor Allograft. Transplant Cell Ther 2024; 30:233.e1-233.e14. [PMID: 37984797 DOI: 10.1016/j.jtct.2023.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023]
Abstract
Post-transplantation cyclophosphamide (PTCy) is an effective strategy for graft-versus-host disease (GVHD) prophylaxis and is the standard of care for haploidentical hematopoietic cell transplantation (HCT). It is increasingly used for matched and mismatched unrelated donor (MUD/MMUD) HCT, but infections remain a concern. The objective of this study was to evaluate the characteristics and risk factors for infections in haploidentical and unrelated donor HCT recipients treated with PTCy-based GVHD prophylaxis. This single-center retrospective study examined 354 consecutive adults undergoing HCT with PTCy-based GVHD prophylaxis (161 MUD/MMUD; 193 haploidentical) between 2015 and 2022. Opportunistic infections (OIs), including cytomegalovirus (CMV), adenovirus (AdV), Epstein-Barr virus (EBV), and invasive fungal disease (IFD), were assessed from day 0 through day +365. The 1-year cumulative incidence functions of OIs and nonrelapse mortality (NRM) were calculated using dates of relapse and repeat HCT as competing risks. Secondary analysis evaluated risk factors for OIs and NRM using univariate and multivariable Cox regression models. Haploidentical HCT recipients had an increased risk of OIs compared to unrelated donor allograft recipients (39% for haploidentical versus 25% for MUD/MMUD; hazard ratio [HR], 1.70; 95% confidence interval [CI], 1.16 to 2.49; P = .006). On multivariable analysis, haploidentical donor (HR, 1.50; 95% CI, 1.01 to 2.23; P = .046), prior HCT (HR, 1.99; 95% CI, 1.29 to 3.09; P = .002), and diagnosis of aGVHD (HR, 1.47; 95% CI, 1.02 to 2.14; P = .041) were associated with increased risk of OIs. NRM within the first year was not significantly different between the 2 cohorts (HR, 1.11; 95% CI, .64 to 1.93; P = .70). Overall, haploidentical donor was a significant risk factor for OIs in patients receiving PTCy, although 1-year NRM was not different between haploidentical HCT and MUD/MMUD HCT recipients. CMV and AdV infections were significantly increased among haploidentical HCT recipients, whereas the incidences of EBV infection and IFD were similar in the 2 cohorts. Our findings may have implications for infection monitoring and prophylaxis in the setting of PTCy, particularly in haploidentical HCT recipients.
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Affiliation(s)
- Jessica S Little
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Rémy Duléry
- Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts; Sorbonne University, Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Inserm UMRs 938, Centre de recherche Saint-Antoine, Paris, France
| | - Roman M Shapiro
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Muneerah M Aleissa
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Susan E Prockop
- Harvard Medical School, Boston, Massachusetts; Hematopoietic Stem Cell Transplant Program, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - John Koreth
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jerome Ritz
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joseph H Antin
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Corey Cutler
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sarah Nikiforow
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Rizwan Romee
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nicolas C Issa
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Vincent T Ho
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lindsey R Baden
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Robert J Soiffer
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mahasweta Gooptu
- Harvard Medical School, Boston, Massachusetts; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, Massachusetts
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3
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Gates TJ, Wangmo D, Zhao X, Subramanian S. Allogeneic tumor cell-derived extracellular vesicles stimulate CD8 T cell response in colorectal cancer. Mol Ther Oncolytics 2023; 31:100727. [PMID: 37822487 PMCID: PMC10562189 DOI: 10.1016/j.omto.2023.100727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 09/14/2023] [Indexed: 10/13/2023] Open
Abstract
Most colorectal cancer (CRC) patients present with a microsatellite-stable phenotype, rendering them resistant to immune checkpoint inhibitors (ICIs). Among the contributors to ICI resistance, tumor-derived extracellular vesicles (TEVs) have emerged as critical players. Previously we demonstrated that autologous transfer of TEVs without miR-424 can induce tumor antigen-specific immune responses in CRC models. Therefore, we postulated that allogeneic TEVs, modified to lack miR-424 and derived from an MC38 cells, could induce CD8+ T cell responses while restraining CT26 cell-based tumor. Here, we show that prophylactic administration of MC38 TEVs, without miR-424, showed a significant augmentation in CD8+ T-cells within CT26 tumors. This allogenic TEV effect was evident in CT26 tumors but not B16-F10 melanoma. Furthermore, we demonstrated the capacity of dendritic cells (DCs) to internalize TEVs, a possible mechanism to elicit immune response. Our investigation of autologously administered DCs, which had been exposed to modified TEVs, underscores their potential to dampen tumor growth while elevating CD8+ T cell levels vis-a-vis MC38 wild-type TEVs exposed to DCs. Notably, the modified TEVs were well tolerated and did not increase peripheral blood cytokine levels. Our findings underscore the potential of modified allogeneic TEVs without immune-suppressive factors to elicit robust T cell responses and limit tumor growth.
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Affiliation(s)
- Travis J. Gates
- Department of Pharmacology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Dechen Wangmo
- Department of Pharmacology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Xianda Zhao
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Subbaya Subramanian
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Masonic Cancer Center, University of Minnesota Medical School, Minneapolis, MN, USA
- Center for Immunology, University of Minnesota Medical School, Minneapolis, MN, USA
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4
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Weber D, Hiergeist A, Weber M, Ghimire S, Salzberger B, Wolff D, Poeck H, Gessner A, Edinger M, Herr W, Meedt E, Holler E. Restrictive Versus Permissive Use of Broad-spectrum Antibiotics in Patients Receiving Allogeneic Stem Cell Transplantation and With Early Fever Due to Cytokine Release Syndrome: Evidence for Beneficial Microbiota Protection Without Increase in Infectious Complications. Clin Infect Dis 2023; 77:1432-1439. [PMID: 37386935 DOI: 10.1093/cid/ciad389] [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: 02/25/2023] [Revised: 06/15/2023] [Accepted: 06/21/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Intestinal microbiome contributes to the pathophysiology of acute gastrointestinal (GI) graft-versus-host disease (GvHD) and loss of microbiome diversity influences the outcome of patients after allogeneic stem cell transplantation (SCT). Systemic broad-spectrum antibiotics have been identified as a major cause of early intestinal dysbiosis. METHODS In 2017, our transplant unit at the university hospital in Regensburg changed the antibiotic strategy from a permissive way with initiation of antibiotics in all patients with neutropenic fever independent of the underlying cause and risk to a restrictive use in cases with high likelihood of cytokine release syndrome (eg, after anti-thymocyte globulin [ATG] therapy). We analyzed clinical data and microbiome parameters obtained 7 days after allogeneic SCT from 188 patients with ATG therapy transplanted in 2015/2016 (permissive cohort, n = 101) and 2918/2019 (restrictive cohort, n = 87). RESULTS Restrictive antibiotic treatment postponed the beginning of antibiotic administration from 1.4 ± 7.6 days prior to 1.7 ± 5.5 days after SCT (P = .01) and significantly reduced the duration of antibiotic administration by 5.8 days (P < .001) without increase in infectious complications. Furthermore, we observed beneficial effects of the restrictive strategy compared with the permissive way on microbiome diversity (urinary 3-indoxylsulfate, P = .01; Shannon and Simpson indices, P < .001) and species abundance 7 days post-transplant as well as a positive trend toward a reduced incidence of severe GI GvHD (P = .1). CONCLUSIONS Our data indicate that microbiota protection can be achieved by a more careful selection of neutropenic patients qualifying for antibiotic treatment during allogeneic SCT without increased risk of infectious complications.
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Affiliation(s)
- Daniela Weber
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Hiergeist
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Markus Weber
- Department of Trauma and Orthopedic Surgery, Barmherzige Brüder Hospital Regensburg, Regensburg, Germany
| | - Sakhila Ghimire
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Bernd Salzberger
- Department of Infection Prevention and Infectious Diseases, University Hospital Regensburg, Regensburg, Germany
| | - Daniel Wolff
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Hendrik Poeck
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - André Gessner
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Edinger
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Wolfgang Herr
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Elisabeth Meedt
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
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5
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Duléry R, Brissot E, Mohty M. Combining post-transplant cyclophosphamide with antithymocyte globulin for graft-versus-host disease prophylaxis in hematological malignancies. Blood Rev 2023; 62:101080. [PMID: 37085459 DOI: 10.1016/j.blre.2023.101080] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 04/10/2023] [Indexed: 04/23/2023]
Abstract
In search of an ideal partner or alternative to conventional immunosuppressive agents, rabbit anti-thymocyte globulin (ATG) and, more recently, post-transplant cyclophosphamide (PT-Cy) have both emerged as valid and efficient options for preventing graft-versus-host disease (GvHD). To further reduce the risk of GvHD, strategies combining ATG and PT-Cy have recently been investigated. In a haploidentical setting, retrospective studies suggest that combining PT-Cy and ATG may result in a lower incidence of chronic GvHD without increasing the risks of infection or relapse, when compared to PT-Cy without ATG. In haploidentical or unrelated donor settings, adding reduced doses of PT-Cy to ATG may reduce the risk of acute and chronic GvHD and improve survival, particularly GvHD-free, relapse-free survival (GRFS), when compared to ATG without PT-Cy. Overall, the combination of PT-Cy and ATG is a safe and promising approach for patients with hematological malignancies undergoing allogeneic hematopoietic stem cell transplantation (HSCT).
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Affiliation(s)
- Rémy Duléry
- Sorbonne University, Department of Clinical Hematology and Cellular Therapy, Saint Antoine Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; INSERM, UMRs 938, Centre de recherche Saint Antoine (CRSA), Paris, France
| | - Eolia Brissot
- Sorbonne University, Department of Clinical Hematology and Cellular Therapy, Saint Antoine Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; INSERM, UMRs 938, Centre de recherche Saint Antoine (CRSA), Paris, France
| | - Mohamad Mohty
- Sorbonne University, Department of Clinical Hematology and Cellular Therapy, Saint Antoine Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; INSERM, UMRs 938, Centre de recherche Saint Antoine (CRSA), Paris, France.
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6
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Li A, Feng R. [CAR-T cell therapy-related long-term cytopenias]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:870-875. [PMID: 38049346 PMCID: PMC10694071 DOI: 10.3760/cma.j.issn.0253-2727.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Indexed: 12/06/2023]
Affiliation(s)
- A Li
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - R Feng
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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7
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Heo BY, Lee MW, Choi S, Jung Y, Pham TTD, Jang Y, Park JH, Kang S, Koh JS, Jo DY, Kwon J, Song IC. Autoimmune Limbic Encephalitis in Patients with Hematologic Malignancies after Haploidentical Hematopoietic Stem Cell Transplantation with Post-Transplant Cyclophosphamide. Cells 2023; 12:2049. [PMID: 37626859 PMCID: PMC10453524 DOI: 10.3390/cells12162049] [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: 07/13/2023] [Revised: 08/05/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Autoimmune limbic encephalitis (LE) is a rare, but devastating complication of allogeneic hematopoietic stem cell transplantation (HSCT). There is currently limited evidence describing the risk factors, laboratory features, and underlying mechanisms of this neurologic adverse event. We retrospectively reviewed available clinical, imaging, and laboratory data from adult patients with hematological malignancies who underwent haploidentical HSCT with post-transplant cyclophosphamide (PTCy) at Chungnam National University Hospital from June 2016 to May 2020. Patients who developed LE were compared to those who did not based on clinical assessment, serum inflammatory biomarkers, and reconstitution of various T cell populations. Of 35 patients, 4 developed LE. There were no differences in patient demographics, donor demographics, or treatment conditions between patients that did and did not develop LE. Overall, patients with LE had worse clinical outcomes and overall survival than those without. In addition, they tended to have higher markers of systemic inflammation in the early post-transplant period, including fever, C-reactive protein (CRP), and cytokines. Remarkably, baseline interleukin-6 levels before HSCT were found to be higher in patients who developed LE than those who did not. In addition, analysis of T cell subsets showed impaired expansion of CD25+FOXP3+ regulatory T (Treg) cells in LE compared to non-LE patients despite appropriate reconstitution of the total CD4+ T cell population. Patients that developed LE within the first 30 days of HSCT were likely to have high serum IL-6 among other inflammatory cytokines coupled with suppression of regulatory T cell differentiation. Further work is needed on the mechanisms underlying impaired Treg expansion following HSCT and potential therapies.
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Affiliation(s)
- Bu Yeon Heo
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Myung-Won Lee
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munwha-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Suyoung Choi
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Yunju Jung
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Thi Thuy Duong Pham
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Yunseon Jang
- Translational Immunology Institute, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Jung-Hyun Park
- Translational Immunology Institute, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Sora Kang
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munwha-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Jeong Suk Koh
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munwha-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Deog-Yeon Jo
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munwha-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Jaeyul Kwon
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Translational Immunology Institute, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Ik-Chan Song
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munwha-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Translational Immunology Institute, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
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8
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Pruitt A, Gao F, De Togni E, Cochran H, Godbole S, Slade M, Abboud R. Impact of donor age and relationship on outcomes of peripheral blood haploidentical hematopoietic cell transplantation. Bone Marrow Transplant 2023; 58:855-862. [PMID: 37117266 PMCID: PMC10400423 DOI: 10.1038/s41409-023-01984-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/23/2023] [Accepted: 04/03/2023] [Indexed: 04/30/2023]
Abstract
Here we describe a retrospective analysis of outcomes in 299 patients who underwent peripheral blood haplo-HCT with PTCy from July 2009 through May 2021 and their association with donor characteristics. Patients had mostly acute leukemias and high or very high DRI. Multivariate analyses were conducted examining OS, NRM, relapse, cytokine release syndrome, acute and chronic GVHD. Donor characteristics included age, sex, relationship, ABO status, CMV status, and HLA match grade. Our analysis revealed increasing donor age was associated with higher NRM (compared to age <30; age 30-44 HR, 1.65; P = 0.110, age >44 HR, 1.80; P = 0.056) but lower relapse risk (compared to age <30; age 30-44 HR, 0.61; P = 0.034, age > 44 HR, 0.71; P = 0.132). There were no differences in CRS, aGVHD or cGVHD. We found no difference in outcomes based on the donor-recipient relationship. No differences were found based on HLA match grade or DRB1 match status. Increasing donor age was associated with lower relapse risk but higher NRM, resulting in no difference in OS based on donor age. Other donor factors including relationship (parent/sibling/child/ maternal), CMV status, donor sex, HLA match grade, and DRB1 status were not associated with outcomes.
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Affiliation(s)
- Aaron Pruitt
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Feng Gao
- Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Elisa De Togni
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Hunter Cochran
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Sonia Godbole
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael Slade
- Division of Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ramzi Abboud
- Division of Oncology, Washington University School of Medicine, St. Louis, MO, USA.
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9
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Yao JM, Otoukesh S, Kim H, Yang D, Mokhtari S, Samara Y, Blackmon A, Arslan S, Agrawal V, Pourhassan H, Amanam I, Ball B, Koller P, Salhotra A, Becker P, Curtin P, Artz A, Aldoss I, Ali H, Stewart F, Smith E, Stein A, Marcucci G, Forman SJ, Nakamura R, Al Malki MM. Tocilizumab for Cytokine Release Syndrome Management After Haploidentical Hematopoietic Cell Transplantation With Post-Transplantation Cyclophosphamide-Based Graft-Versus-Host Disease Prophylaxis. Transplant Cell Ther 2023; 29:515.e1-515.e7. [PMID: 37182736 PMCID: PMC10527340 DOI: 10.1016/j.jtct.2023.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/26/2023] [Accepted: 05/08/2023] [Indexed: 05/16/2023]
Abstract
Cytokine release syndrome (CRS) is a common complication after haploidentical hematopoietic cell transplantation (HaploHCT). Severe CRS after haploHCT leads to higher risk of non-relapse mortality (NRM) and worse overall survival (OS). Tocilizumab (TOCI) is an interleukin-6 receptor inhibitor and is commonly used as first-line for CRS management after chimeric antigen receptor T cell therapy, but the impact of TOCI administration for CRS management on Haplo HCT outcomes is not known. In this single center retrospective analysis, we compared HCT outcomes in patients treated with or without TOCI for CRS management after HaploHCT with post-transplantation cyclophosphamide- (PTCy-) based graft-versus-host disease (GvHD) prophylaxis. Of the 115 patients eligible patients who underwent HaploHCT at City of Hope between 2019 to 2021 and developed CRS, we identified 11 patients who received tocilizumab for CRS management (TOCI). These patients were matched with 21 patients who developed CRS but did not receive tocilizumab (NO-TOCI) based on age at the time of HCT (≤64 years or >65 years or older), conditioning intensity (myeloablative versus reduced-intensity/nonmyeloablative), and CRS grading (1, 2, versus 3-4). Instead of 22 controls, we chose 21 patients because there was only 1 control matched with 1 TOCI treatment patient in 1 stratum. With only 11 patients in receiving tocilizumab for CRS treatment, matching with 21 patients who developed CRS but did not receive tocilizumab, we had 80% power to detect big differences (hazard ratio [HR] = 3.4 or higher) in transplantation outcomes using a 2-sided 0.05 test. The power would be reduced to about 20% to 30% if the difference was moderate (HR = 2.0) using the same test. No CRS-related deaths were recorded in either group. Median time to neutrophil engraftment was 21 days (range 16-43) in TOCI and 18 days (range 14-23) in NO-TOCI group (HR = 0.55; 95% confidence interval [CI] = 0.28-1.06, P = .08). Median time to platelet engraftment was 34 days (range 20-81) in TOCI and 28 days (range 12-94) in NO-TOCI group (HR = 0.56; 95% CI = 0.25-1.22, P = .19). Cumulative incidences of day 100 acute GvHD grades II-IV (P = .97) and grades III-IV (P = .47) were similar between the 2 groups. However, cumulative incidence of chronic GvHD at 1 year was significantly higher in patients receiving TOCI (64% versus 24%; P = .05). Rates of NRM (P = .66), relapse (P = .83), disease-free survival (P = .86), and overall survival (P = .73) were similar at 1 year after HCT between the 2 groups. Tocilizumab administration for CRS management after HaploHCT appears to be safe with no short-term adverse effect and no effect on relapse rate. However, the significantly higher cumulative incidence of chronic GvHD, negates the high efficacy of PTCy on GvHD prophylaxis in this patient population. Therefore using tocilizumab for CRS management in the HaploHCT population with PTCy maybe kept only for patients with severe CRS. The impact on such approach on long term outcome in HaploHCT with PTCy will need to be evaluated in a larger retrospective study or a prospective manner.
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Affiliation(s)
- Janny M Yao
- Department of Pharmacy, City of Hope National Medical Center, Duarte, California
| | - Salman Otoukesh
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Hanna Kim
- Department of Pharmacy, City of Hope National Medical Center, Duarte, California
| | - Dongyun Yang
- Department of Computational and Quantitative Medicine, Division of Biostatistics, City of Hope National Medical Center, Duarte, California
| | - Sally Mokhtari
- Department of Clinical and Translational Project Development, City of Hope National Medical Center, Duarte, California
| | - Yazeed Samara
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Amanda Blackmon
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Shukaib Arslan
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Vaibhav Agrawal
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Hoda Pourhassan
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Idoroenyi Amanam
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Brian Ball
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Paul Koller
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Amandeep Salhotra
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Pamela Becker
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Peter Curtin
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Andrew Artz
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Haris Ali
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Forrest Stewart
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Eileen Smith
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Anthony Stein
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Guido Marcucci
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California
| | - Monzr M Al Malki
- Department of Hematology and Hematopoietic cell transplantation, City of Hope National Medical Center, Duarte, California.
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10
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Gates TJ, Wangmo D, Zhao X, Subramanian S. Allogeneic Tumor Cell-Derived Extracellular Vesicles Stimulate CD8 T Cell Response in Colorectal Cancer. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.04.17.537250. [PMID: 37131597 PMCID: PMC10153182 DOI: 10.1101/2023.04.17.537250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Colorectal Cancer (CRC) is the second leading cause of cancer-related death in the United States. Most CRC patients present with a microsatellite stable (MSS) phenotype and are highly resistant to immunotherapies. Tumor extracellular vesicles (TEVs), secreted by tumor cells, can contribute to intrinsic resistance to immunotherapy in CRC. We previously showed that autologous TEVs without functional miR-424 induce anti-tumor immune responses. We hypothesized that allogeneic modified CRC-TEVs without miR-424 (mouse homolog miR-322) derived from an MC38 background would effectively stimulate CD8+ T cell response and limit CT26 tumor growth. Here we show that prophylactic administration of MC38 TEVs without functional miR-424 significantly increased CD8+ T cells in CT26 CRC tumors and limited tumor growth, not B16-F10 melanoma tumors. We further show that the depletion of CD4+ and CD8+ T cells abolished the protective effects of MC38 TEVs without functional miR-424. We further show that TEVs can be taken up by DCs in vitro, and subsequent prophylactic administration of autologous DCs exposed to MC38 TEVs without functional miR-424 suppressed tumor growth and increased CD8+ T cells compared to MC38 wild-type TEVs exposed to DCs, in Balb/c mice bearing CT26 tumors. Notably, the modified EVs were well tolerated and did not increase cytokine expression in peripheral blood. These findings suggest that allogeneic-modified CRC-EVs without immune suppressive miR-424 can induce antitumor CD8+ T cell responses and limit tumor growth in vivo.
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Affiliation(s)
- Travis J Gates
- Department of Molecular Pharmacology and Therapeutics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Dechen Wangmo
- Department of Molecular Pharmacology and Therapeutics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Xianda Zhao
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Subbaya Subramanian
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota
- Masonic Cancer Center, University of Minnesota Medical School, Minneapolis, Minnesota
- Center for Immunology, University of Minnesota Medical School, Minneapolis, Minnesota
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11
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Cai B, Zou X, Ning X, Liu T, Li B, Lei Y, Qiao J, Hu K, Lei Y, Liu Z, Yao B, Ai H, Wang Y, Yu C, Guo M. Mismatched donor cell infusion-related syndrome following microtransplant in patients with acute myeloid leukemia. Chin Med J (Engl) 2023; 136:815-821. [PMID: 37027433 PMCID: PMC10150921 DOI: 10.1097/cm9.0000000000002611] [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: 01/06/2022] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Immunotherapies such as adoptive immune cell infusion and immune-modulating agents are widely used for cancer treatment, and the concomitant symptoms, including cytokine release syndrome (CRS) or immune-related adverse events (irAEs), are frequently reported. However, clinical manifestations induced by mismatched donor granulocyte colony-stimulating factor mobilized peripheral blood mononuclear cell (GPBMC) infusion in patients receiving microtransplant (MST) have not yet been well depicted. METHODS We analyzed 88 cycles of mismatched GPBMC infusion in patients with acute myeloid leukemia receiving MST and 54 cycles of chemotherapy without GPBMC infusion as a comparison. Clinical symptoms and their correlation with clinical features, laboratory findings, and clinical response were explored. RESULTS Fever (58.0% [51/88]) and chills (43.2% [38/88]) were the significant early-onset symptoms after GPBMC infusion. Patients possessing less human leukocyte antigen-matching loci with the donor or those with unrelated donors experienced more chills (3 [2-5] loci vs. 5 [3-5] loci, P = 0.043 and 66.7% [12/18] vs. 37.1% [26/70], P = 0.024). On the other hand, those with decreased CD4 + /CD8 + T-cell ratio developed more fever (0.8 [0.7-1.2] vs. 1.4 [1.1-2.2], P = 0.007). Multivariable analysis demonstrated that younger patients experienced more fever (odds ratio [OR] = 0.963, 95% confidence interval [CI]: 0.932-0.995, P = 0.022), while patients with younger donors experienced more chills (OR = 0.915, 95% CI: 0.859-0.975, P = 0.006). Elevated ultra-sensitive C-reactive protein levels in the absence of cytokine storm were observed following GPBMC infusion, which indicated mild and transient inflammatory response. Although no predictive value of infusion-related syndrome to leukemia burden change was found, the proportion of host pre-treatment activated T cells was positively correlated with leukemia control. CONCLUSIONS Mismatched GPBMC infusion in MST induced unique infusion-related symptoms and laboratory changes, which were associated with donor- or recipient-derived risk factors, with less safety and tolerance concerns than reported CRS or irAEs.
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Affiliation(s)
- Bo Cai
- Department of Hematology, The Fifth Medical Center, Chinese PLA General Hospital, Beijing 100071, China
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12
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Li N, Zhao C, Ma R, Lou R, Liu XJ, Zheng FM, Wang JZ, Wang Y, Huang XJ, Sun YQ. Cytokine profiling during conditioning in haploidentical stem cell transplantation and its prognostic impact on early transplant outcomes. Transpl Immunol 2023; 78:101830. [PMID: 36972853 DOI: 10.1016/j.trim.2023.101830] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 03/17/2023] [Accepted: 03/23/2023] [Indexed: 03/28/2023]
Abstract
Cytokine storm development is a major cause of many transplant-related complications, especially during the conditioning regimen. This study aimed to characterize the cytokine profile and determine its prognostic impact during conditioning in patients undergoing subsequent haploidentical stem cell transplantation. A total of 43 patients were enrolled in this study. Sixteen cytokines associated with cytokine release syndrome (CRS) during anti-thymocyte globulin (ATG) treatment were quantified in patients undergoing haploidentical stem cell transplantation. Thirty-six (83.7%) patients developed CRS during ATG treatment; most of those cases (33/36; 91.7%) were classified as grade 1 CRS, whereas only three (7.0%) developed grade 2 CRS. CRS was observed more frequently on the first (15/43; 34.9%) and second day (30/43; 69.8%) of ATG infusion. No factors were identified that could predict the development of CRS on the first day of ATG treatment. Five of the 16 cytokines (interleukins 6, 8, and 10 (IL-6, IL-8, and IL-10), C-reactive protein (CRP), and procalcitonin (PCT)) were significantly elevated during ATG treatment, although only the level of IL-6, IL-10, and PCT were associated with the severity of CRS. However, neither CRS nor the cytokine levels significantly impacted the development of acute graft-versus-host disease (GVHD) or cytomegalovirus (CMV) infection or affected overall survival.
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Affiliation(s)
- Na Li
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, PR China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation for the Treatment of Hematological Diseases, Beijing, PR China
| | - Chen Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, PR China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation for the Treatment of Hematological Diseases, Beijing, PR China
| | - Rui Ma
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, PR China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation for the Treatment of Hematological Diseases, Beijing, PR China
| | - Rui Lou
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, PR China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation for the Treatment of Hematological Diseases, Beijing, PR China
| | - Xiu-Juan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, PR China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation for the Treatment of Hematological Diseases, Beijing, PR China
| | - Feng-Mei Zheng
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, PR China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation for the Treatment of Hematological Diseases, Beijing, PR China
| | - Jing-Zhi Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, PR China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation for the Treatment of Hematological Diseases, Beijing, PR China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, PR China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation for the Treatment of Hematological Diseases, Beijing, PR China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, PR China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation for the Treatment of Hematological Diseases, Beijing, PR China; Peking-Tsinghua Center for Life Sciences, Beijing, PR China
| | - Yu-Qian Sun
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, PR China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation for the Treatment of Hematological Diseases, Beijing, PR China.
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13
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How I prevent GVHD in high-risk patients: posttransplant cyclophosphamide and beyond. Blood 2023; 141:49-59. [PMID: 35405017 DOI: 10.1182/blood.2021015129] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/09/2022] [Accepted: 03/21/2022] [Indexed: 01/10/2023] Open
Abstract
Advances in conditioning, graft-versus-host disease (GVHD) prophylaxis and antimicrobial prophylaxis have improved the safety of allogeneic hematopoietic cell transplantation (HCT), leading to a substantial increase in the number of patients transplanted each year. This influx of patients along with progress in remission-inducing and posttransplant maintenance strategies for hematologic malignancies has led to new GVHD risk factors and high-risk groups: HLA-mismatched related (haplo) and unrelated (MMUD) donors; older recipient age; posttransplant maintenance; prior checkpoint inhibitor and autologous HCT exposure; and patients with benign hematologic disorders. Along with the changing transplant population, the field of HCT has dramatically shifted in the past decade because of the widespread adoption of posttransplantation cyclophosphamide (PTCy), which has increased the use of HLA-mismatched related donors to levels comparable to HLA-matched related donors. Its success has led investigators to explore PTCy's utility for HLA-matched HCT, where we predict it will be embraced as well. Additionally, combinations of promising new agents for GVHD prophylaxis such as abatacept and JAK inhibitors with PTCy inspire hope for an even safer transplant platform. Using 3 illustrative cases, we review our current approach to transplantation of patients at high risk of GVHD using our modern armamentarium.
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14
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De Togni E, Wan F, Slade M, Plach K, Abboud R. The impact of tocilizumab treatment for cytokine release syndrome on the incidence of early blood stream infections after peripheral blood haploidentical hematopoietic cell transplantation. Leuk Lymphoma 2022; 63:2975-2981. [PMID: 35848998 DOI: 10.1080/10428194.2022.2100367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cytokine release syndrome (CRS) is a potentially fatal systemic inflammatory response that can occur in patients undergoing peripheral blood haploidentical hematopoietic cell transplantation (haplo-HCT). Severe CRS has previously been associated with increased infection risk. IL-6 inhibitors, such as tocilizumab, are useful in moderate to severe CRS, but their effect on infection risk has not been established in this setting. We examined the effect of tocilizumab on blood stream infections (BSIs) in the early post-transplant period in 235 patients who underwent haplo-HCT from 2013 to 2020. Mild CRS was associated with a lower incidence of BSI than severe CRS (OR 0.31, 95% CI 0.13-0.74). In the tocilizumab group, 31% of patients had positive blood cultures versus 14% in the non-tocilizumab group (OR 1.61, 95% CI 0.30-8.60, p = 0.58). However, when controlling for CRS grade, tocilizumab was not independently associated with increased rates of BSIs, suggesting it does not further increase infection risk.
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Affiliation(s)
- Elisa De Togni
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Fei Wan
- Department of Biostatistics Shared Resource Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael Slade
- Division of Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Kelly Plach
- Oncology Pharmacy Services, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Ramzi Abboud
- Division of Oncology, Washington University School of Medicine, St. Louis, MO, USA
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15
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Athale J, Busch LM, O'Grady NP. Cytokine Release Syndrome and Sepsis: Analogous Clinical Syndromes with Distinct Causes and Challenges in Management. Infect Dis Clin North Am 2022; 36:735-748. [PMID: 36328633 PMCID: PMC9641544 DOI: 10.1016/j.idc.2022.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Both cytokine release syndrome (CRS) and sepsis are clinical syndromes rather than distinct diseases and share considerable overlap. It can often be challenging to distinguish between the two, but it is important given the availability of targeted treatment options. In addition, several other clinical syndromes overlap with CRS and sepsis, further making it difficult to differentiate them. This has particularly been highlighted in the recent coronavirus disease-2019 pandemic. As we start to understand the differences in the inflammatory markers and presentations in these syndromes, hopefully we will be able to enhance treatment and improve outcomes.
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Affiliation(s)
- Janhavi Athale
- Department of Critical Care Medicine, Division of Hematology and Oncology, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Lindsay M Busch
- Department of Medicine, Emory University Hospital, 550 Peachtree Street Northeast, Atlanta, GA 30308, USA
| | - Naomi P O'Grady
- Internal Medicine Services, National Institutes of Health, Room 2-2734, Bethesda, MD 20892-1662, USA.
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16
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Si X, Gu T, Liu L, Huang Y, Han Y, Qian P, Huang H. Hematologic cytopenia post CAR T cell therapy: Etiology, potential mechanisms and perspective. Cancer Lett 2022; 550:215920. [PMID: 36122628 DOI: 10.1016/j.canlet.2022.215920] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/02/2022] [Accepted: 09/12/2022] [Indexed: 11/25/2022]
Abstract
Chimeric Antigen-Receptor (CAR) T-cell therapies have shown dramatic efficacy in treating relapsed and refractory cancers, especially B cell malignancies. However, these innovative therapies cause adverse toxicities that limit the broad application in clinical settings. Hematologic cytopenias, one frequently reported adverse event following CAR T cell treatment, are manifested as a disorder of hematopoiesis with decreased number of mature blood cells and subdivided into anemia, thrombocytopenia, leukopenia, and neutropenia, which increase the risk of infections, fatigue, bleeding, fever, and even fatality. Herein, we initially summarized the symptoms, etiology, risk factors and management of cytopenias. Further, we elaborated the cellular and molecular mechanisms underlying the initiation and progression of cytopenias following CAR T cell therapy based on previous studies about acquired cytopenias. Overall, this review will facilitate our understanding of the etiology of cytopenias and shed lights into developing new therapies against CAR T cell-induced cytopenias.
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Affiliation(s)
- Xiaohui Si
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Tianning Gu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Lianxuan Liu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Yue Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Yingli Han
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Pengxu Qian
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China; Institute of Hematology, Zhejiang University, Hangzhou, China; Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.
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17
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Acute kidney injury caused by haplostorm after allogenic hematopoietic stem cell transplant. Bone Marrow Transplant 2022; 57:1442-1444. [DOI: 10.1038/s41409-022-01720-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/09/2022] [Accepted: 05/16/2022] [Indexed: 11/08/2022]
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18
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Little JS, Shapiro RM, Aleissa MM, Kim A, Chang JBP, Kubiak DW, Zhou G, Antin JH, Koreth J, Nikiforow S, Cutler CS, Romee R, Issa NC, Ho VT, Gooptu M, Soiffer RJ, Baden LR. Invasive Yeast Infection After Haploidentical Donor Hematopoietic Cell Transplantation Associated with Cytokine Release Syndrome. Transplant Cell Ther 2022; 28:508.e1-508.e8. [PMID: 35526780 PMCID: PMC9357112 DOI: 10.1016/j.jtct.2022.04.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Use of haploidentical donor hematopoietic cell transplantation (haploHCT) has expanded but recent reports raise concern for increased rates of infectious complications. The incidence and risk factors for invasive fungal disease (IFD) after haploHCT have not been well elucidated. OBJECTIVE The objective of this study is to evaluate the incidence and risk factors for IFD after haploHCT. The identification of key risk factors will permit targeted prevention measures and may explain elevated risk for other infectious complications after haploHCT. STUDY DESIGN We performed a single-center retrospective study of all adults undergoing haploHCT between May 2011 and May 2021 (n=205). The 30-day and one-year cumulative incidence of proven or probable IFD and one-year non-relapse mortality (NRM) were assessed. Secondary analysis evaluated risk factors for invasive yeast infection (IYI) using univariate and multivariable Cox regression models. RESULTS Twenty-nine patients (14%) developed IFD following haploHCT. Nineteen (9.3%) developed IYI in the first year, 13 of which occurred early with a 30-day cumulative incidence of 6.3% (95% CI 2.9 - 9.6%) and increased NRM in patients with IYI (53.9% versus 10.9%). The majority of yeast isolates (17/20; 85%) were fluconazole susceptible. The incidence of IYI in the first 30 days after haploHCT was 10% among the 110 (54%) patients who developed cytokine release syndrome (CRS) and 21% among the 29 (14%) who received tocilizumab. On multivariable analysis, AML (HR 6.24; 1.66 - 23.37; p=0.007) and CRS (HR 4.65; 1.00 - 21.58; p=0.049) were associated with an increased risk of early IYI after haploHCT. CONCLUSION CRS after haploHCT is common and is associated with increased risk of early IYI. The identification of CRS as a risk factor for IYI raises questions about its potential association with other infections after haploHCT. Recognition of key risk factors for infection may permit individualized strategies for prevention and intervention and minimize potential side effects.
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Affiliation(s)
- Jessica S Little
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, USA; Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA.
| | - Roman M Shapiro
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA; Department of Pharmacy, Brigham and Women's Hospital, Boston, USA
| | - Muneerah M Aleissa
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Austin Kim
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, USA
| | - Jun Bai Park Chang
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, USA
| | - David W Kubiak
- Harvard Medical School, Boston, USA; Department of Pharmacy, Brigham and Women's Hospital, Boston, USA
| | - Guohai Zhou
- Harvard Medical School, Boston, USA; Center for Clinical Investigation, Brigham and Women's Hospital, Boston, USA
| | - Joseph H Antin
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - John Koreth
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Sarah Nikiforow
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Corey S Cutler
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Rizwan Romee
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Nicolas C Issa
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, USA; Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Vincent T Ho
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Mahasweta Gooptu
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Robert J Soiffer
- Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA
| | - Lindsey R Baden
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, USA; Harvard Medical School, Boston, USA; Stem Cell Transplant and Cellular Therapy, Dana-Farber Cancer Institute, Boston, USA; Center for Clinical Investigation, Brigham and Women's Hospital, Boston, USA.
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19
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Wang L, Dai B, Gao W, Wang J, Wan M, Wang R, Wang L, Jiang J, Blaise D, Hu J. Clinical Significance of Haplo-Fever and Cytokine Profiling After Graft Infusion in Allogeneic Stem Cell Transplantation From Haplo-Identical Donors. Front Med (Lausanne) 2022; 9:820591. [PMID: 35463028 PMCID: PMC9021571 DOI: 10.3389/fmed.2022.820591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
Abstract
Allogeneic stem cell transplantation from haplo-identical donors (haplo-HSCT) has become a well-established therapeutic option for hematological malignancies. The fever of unknown origin (haplo-fever) early after the infusion of T cell repleted graft, which returned to normal right after post-transplantation cyclophosphamide (PTCy), is a unique clinical feature in patients undergoing haplo-HSCT. In the current study, the characteristics of haplo-fever and cytokine profiles during haplo-fever were retrospectively analyzed in a cohort of 37 patients undergoing T cell repleted haplo-HSCT with PTCy as graft versus host disease (GvHD) prophylaxis. In total, 33 patients (89.2%) developed haplo-fever from day 0 to day +7. Patients with high peak temperatures tended to have a lower incidence of chronic GvHD (cGvHD) (p = 0.07), moderate to severe cGvHD (p = 0.08), and superior GvHD and relapse-free survival (GRFS, p = 0.04). During the haplo-fever, there were significant increases in multiple cytokines, such as interferon gamma, interleukin (IL) 6, IL2, IL2 receptor, IL8, IL10, IL17, and tumor necrosis factor (TNF). The increases in IL2 receptor (p = 0.037) and TNF (p < 0.001) on day +4 were correlated with the lower risk of cGvHD. Increased TNF > 1.8055-fold on day +4 was the best predictive threshold for cGvHD, and was correlated with a lower incidence of cGvHD (p < 0.001), moderate to severe cGvHD (p = 0.003), and superior GRFS (p < 0.001). These observations may reflect the early reactivation of donor T cells after haplo graft infusion, which would potentially be eliminated by PTCy. Further studies with larger independent cohorts of patients are warranted, to clarify the clinical significance of haplo-fever, and day +4 TNF as a potential biomarker to predict GvHD and GRFS.
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Affiliation(s)
- Lining Wang
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Collaborative Innovation Center of Hematology, Department of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bo Dai
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Collaborative Innovation Center of Hematology, Department of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenhui Gao
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Collaborative Innovation Center of Hematology, Department of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Wang
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Collaborative Innovation Center of Hematology, Department of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ming Wan
- Shanghai Clinical Research Center, Fenglin International Centre, Shanghai, China
| | - Runshu Wang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, United States
| | - Ling Wang
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Collaborative Innovation Center of Hematology, Department of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jieling Jiang
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Collaborative Innovation Center of Hematology, Department of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Didier Blaise
- Transplantation and Cell Therapy Program, Leukemia Program, Centre de Recherche en Cancérologie de Marseille, Department of Hematology, Institut Paoli-Calmettes, Aix-Marseille University, Marseille, France
- Didier Blaise,
| | - Jiong Hu
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Collaborative Innovation Center of Hematology, Department of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Jiong Hu,
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20
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Baumeister SHC, Mohan GS, Elhaddad A, Lehmann L. Cytokine Release Syndrome and Associated Acute Toxicities in Pediatric Patients Undergoing Immune Effector Cell Therapy or Hematopoietic Cell Transplantation. Front Oncol 2022; 12:841117. [PMID: 35402259 PMCID: PMC8989409 DOI: 10.3389/fonc.2022.841117] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/08/2022] [Indexed: 02/05/2023] Open
Abstract
Immune effector cells (IEC) are a powerful and increasingly targeted tool, particularly for the control and eradication of malignant diseases. However, the infusion, expansion, and persistence of autologous or allogeneic IEC or engagement of endogenous immune cells can be associated with significant systemic multi-organ toxicities. Here we review the signs and symptoms, grading and pathophysiology of immune-related toxicities arising in the context of pediatric immunotherapies and haploidentical T cell replete Hematopoietic Cell Transplantation (HCT). Principles of management are discussed with particular focus on the intersection of these toxicities with the requirement for pediatric critical care level support.
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Affiliation(s)
- Susanne H. C. Baumeister
- Boston Children’s Hospital, Division of Pediatric Hematology-Oncology, Boston, MA, United States
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- *Correspondence: Susanne H. C. Baumeister,
| | - Gopi S. Mohan
- Boston Children’s Hospital, Division of Pediatric Hematology-Oncology, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Division of Pediatric Critical Care, Massachusetts General Hospital, Boston, MA, United States
| | - Alaa Elhaddad
- Children’s Cancer Hospital of Egypt, National Cancer Institute Cairo, Cairo, Egypt
| | - Leslie Lehmann
- Boston Children’s Hospital, Division of Pediatric Hematology-Oncology, Boston, MA, United States
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
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21
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Eastburg L, Russler-Germain DA, DiPersio JF, Fountaine T, Andolina JR, Abboud R, Huselton E. Increased early mortality after fludarabine and melphalan conditioning with peripheral blood grafts in haploidentical hematopoietic cell transplantation with post-transplant cyclophosphamide. Leuk Lymphoma 2021; 63:222-226. [PMID: 34794373 DOI: 10.1080/10428194.2021.1978087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Due to the evolving use of haploidentical donor grafts in hematopoietic cell transplantation, there is increased need to better understand the risks and benefits of using bone marrow versus peripheral blood grafts, as well as how specific pre-transplantation conditioning regimens impact patient safety and treatment outcomes. We performed a retrospective analysis of 38 patients at two centers who underwent haploidentical hematopoietic cell transplantation using fludarabine plus melphalan-based conditioning regimens with post-transplant cyclophosphamide and peripheral blood donor grafts. We observed an unexpectedly high rate of early non-relapse mortality and severe cytokine release syndrome. The poor outcomes with 1-year overall survival of 34%, disease-free survival of 29%, and non-relapse mortality of 34% motivate us to reconsider the appropriateness of the combination of fludarabine and melphalan conditioning with T-cell replete peripheral blood grafts in the setting of haploidentical hematopoietic cell transplant with post-transplant cyclophosphamide.
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Affiliation(s)
- Luke Eastburg
- University of Rochester Medical Center, Rochester, NY, USA
| | - David A Russler-Germain
- Division of Oncology, BMT Section, Washington University School of Medicine, St. Louis, MO, USA
| | - John F DiPersio
- Division of Oncology, BMT Section, Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Ramzi Abboud
- Division of Oncology, BMT Section, Washington University School of Medicine, St. Louis, MO, USA
| | - Eric Huselton
- University of Rochester Medical Center, Rochester, NY, USA
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22
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Tvedt THA, Vo AK, Bruserud Ø, Reikvam H. Cytokine Release Syndrome in the Immunotherapy of Hematological Malignancies: The Biology behind and Possible Clinical Consequences. J Clin Med 2021; 10:jcm10215190. [PMID: 34768710 PMCID: PMC8585070 DOI: 10.3390/jcm10215190] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/01/2021] [Accepted: 11/03/2021] [Indexed: 02/07/2023] Open
Abstract
Cytokine release syndrome (CRS) is an acute systemic inflammatory syndrome characterized by fever and multiple organ dysfunction associated with (i) chimeric antigen receptor (CAR)-T cell therapy, (ii) therapeutic antibodies, and (iii) haploidentical allogeneic stem cell transplantation (haplo-allo-HSCT). Severe CRS can be life-threatening in some cases and requires prompt management of those toxicities and is still a great challenge for physicians. The pathophysiology of CRS is still not fully understood, which also applies to the identifications of predictive biomarkers that can forecast these features in advance. However, a broad range of cytokines are involved in the dynamics of CRS. Treatment approaches include both broad spectrum of immunosuppressant, such as corticosteroids, as well as more specific inhibition of cytokine release. In the present manuscript we will try to review an update regarding pathophysiology, etiology, diagnostics, and therapeutic options for this serious complication.
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Affiliation(s)
| | - Anh Khoi Vo
- Department of Clinical Science, University of Bergen, 5020 Bergen, Norway; (A.K.V.); (Ø.B.)
| | - Øystein Bruserud
- Department of Clinical Science, University of Bergen, 5020 Bergen, Norway; (A.K.V.); (Ø.B.)
- Clinic for Medicine, Haukeland University Hospital, 5020 Bergen, Norway
| | - Håkon Reikvam
- Department of Clinical Science, University of Bergen, 5020 Bergen, Norway; (A.K.V.); (Ø.B.)
- Clinic for Medicine, Haukeland University Hospital, 5020 Bergen, Norway
- Correspondence:
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