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Heneghan C, Smilow E, Tanhehco Y, Jin Z, Cofnas P, Schwartz S, Patel N, Carberry D, Silverman J, Huynh P, Hagan B, Tobin K, Bhatia M, George D, Garvin J, Satwani P. Safety of hematopoietic cell infusion in children with malignant and non-malignant diseases. Pediatr Transplant 2017; 21. [PMID: 28845921 DOI: 10.1111/petr.13038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2017] [Indexed: 12/25/2022]
Abstract
HPC infusions have been associated with a variety of adverse events related to either patient or HPC product-related factors. Studies documenting infusion-related AEs in children are limited. We reviewed HPC infusion records in 354 children. Infusion-related adverse events were classified as follows: grade 0-absent, grade I-mild, grade II-moderate, grade III-severe, grade IV-life-threatening, and grade V-death. The percentage of patients with grade 0, I, and II-IV AEs was as follows: 0 = 67%, I = 23.4%, and II-V = 9.6% (one patient had fatal anaphylactic reaction to dimethyl sulfoxide). The incidence of grade II-IV hypertension was 7.1%. There was a higher incidence of AEs with infusion of allogeneic bone marrow versus allogeneic PBSCs (47.4% vs 25.3%, P = .001). Cryopreserved products had a lower incidence of infusion-associated AEs compared with fresh HPC products (24% vs 39.4%, P = .003). Allogeneic HPC infusion volume (>100 mL) was a significant risk factor for infusion-associated AEs (P < .001). Patients >10 years who received autologous HPC infusions had higher risk of AEs when compared to patients <10 years (P = .01). Our study demonstrated that despite a high incidence of infusion-associated hypertension, HPC infusion is relatively safe in children. Investigating strategies to optimize management of hypertension in the setting of HPC infusion is warranted.
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Affiliation(s)
- Chelsea Heneghan
- Department of Nursing, Morgan Stanly Children's Hospital of New York Presbyterian, New York, NY, USA
| | - Elana Smilow
- Department of Nursing, Morgan Stanly Children's Hospital of New York Presbyterian, New York, NY, USA
| | - Yvette Tanhehco
- Department of Pathology, Columbia University, New York, NY, USA
| | - Zhezhen Jin
- Department of Biostatistics, Columbia University, New York, NY, USA
| | - Paige Cofnas
- Department of Nursing, Morgan Stanly Children's Hospital of New York Presbyterian, New York, NY, USA
| | - Sharon Schwartz
- Department of Nursing, Morgan Stanly Children's Hospital of New York Presbyterian, New York, NY, USA
| | - Nita Patel
- Department of Pathology, Columbia University, New York, NY, USA
| | | | - Justin Silverman
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - Paul Huynh
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - Brittany Hagan
- Department of Nursing, Morgan Stanly Children's Hospital of New York Presbyterian, New York, NY, USA
| | - Kim Tobin
- Department of Nursing, Morgan Stanly Children's Hospital of New York Presbyterian, New York, NY, USA
| | - Monica Bhatia
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - Diane George
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - James Garvin
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - Prakash Satwani
- Department of Pediatrics, Columbia University, New York, NY, USA
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Minimal residual disease- and graft-vs.-host disease-guided multiple consolidation chemotherapy and donor lymphocyte infusion prevent second acute leukemia relapse after allotransplant. J Hematol Oncol 2016; 9:87. [PMID: 27629395 PMCID: PMC5024494 DOI: 10.1186/s13045-016-0319-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 09/06/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Persons with acute leukemia relapsing after allotransplant and who respond to anti-leukemia interventions are at high risk of a second relapse. We studied the impact of minimal residual disease (MRD)- and graft-vs.-host disease (GvHD)-guided multiple consolidation chemotherapy and donor lymphocyte infusions (DLIs) to prevent second relapse in patients with acute leukemia relapsing post-transplant and who achieved complete remission after induction chemotherapy and DLI. METHODS Forty-seven subjects with acute leukemia relapsing after an allotransplant and who achieved complete remission after post-relapse induction chemotherapy and DLI were eligible. The use of consolidation chemotherapy and DLI was guided by the results of MRD testing and whether or not DLI caused acute and/or chronic GvHD. Outcomes were compared with those of 34 similar historical controls who did not receive consolidation chemotherapy and DLIs after induction chemotherapy and DLI. RESULTS One-year cumulative incidence of relapse (CIR; 22 % 95 % confidence interval (10, 35 %) vs. 56 % (39, 73 %); P < 0.0001), leukemia-free survival (LFS; 71 % (57, 84 %) vs. 35 % (19, 51 %); P < 0.0001), and survival (78 % (66, 90 %) vs. 44 % (27, 61 %); P < 0.0001) was significantly better in subjects than controls. In multivariate analyses, no chronic GvHD after therapy (hazard ratio (HR) = 3.56 (1.09, 11.58); P = 0.035) and a positive MRD test after therapy (HR = 21.04 (4.44, 94.87); P < 0.0001) were associated with an increased CIR. CONCLUSION These data suggest MRD- and GvHD-guided multiple consolidation chemotherapy and DLIs reduce CIR and increase LFS and survival compared with controls in persons relapsing after allotransplant for acute leukemia. TRIAL REGISTRATION ChiCTR-ONC-12002912 . Donor lymphocyte infusion for the treatment of leukemia relapse following allogeneic hematopoeitic stem cell transplant.
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Yan CH, Wang JZ, Liu DH, Xu LP, Chen H, Liu KY, Huang XJ. Chemotherapy followed by modified donor lymphocyte infusion as a treatment for relapsed acute leukemia after haploidentical hematopoietic stem cell transplantation without in vitro T-cell depletion: superior outcomes compared with chemotherapy alone and an analysis of prognostic factors. Eur J Haematol 2013; 91:304-14. [PMID: 23837640 DOI: 10.1111/ejh.12168] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2013] [Indexed: 02/02/2023]
Abstract
We retrospectively compared the antileukemic effects of chemotherapy alone and chemotherapy followed by modified donor lymphocyte infusion (DLI) in 82 patients with relapsed acute leukemia after haploidentical hematopoietic stem cell transplantation (HSCT) without in vitro T-cell depletion. We also investigated prognostic factors in patients receiving chemotherapy followed by modified DLI. Thirty-two patients received chemotherapy alone, and the remaining 50 patients received chemotherapy followed by modified DLI. In patients receiving chemotherapy followed by modified DLI, complete remission rate was significantly higher (64.0% vs. 12.5%, P = 0.000), the incidence of relapse was significantly lower (50.0% vs. 100.0%, P = 0.000), and disease-free survival was significantly improved (36.0% vs. 0.0%, P = 0.000) compared with patients receiving chemotherapy alone. Multivariate analysis demonstrated that patients with chronic graft-versus-host disease (GVHD) after intervention (P = 0.000) and patients receiving chemotherapy followed by modified DLI (P = 0.037) were associated with a lower relapse rate. Furthermore, in patients receiving chemotherapy followed by modified DLI, multivariate analysis demonstrated that chronic GVHD after modified DLI (P = 0.039) and duration of minimal residual disease (MRD) (-) ≥4 months after modified DLI (P = 0.001) were associated with a lower relapse rate. Our study is the first to suggest that chemotherapy followed by modified DLI is associated with stronger antileukemic effects and better survival in relapsed acute leukemia after haploidentical HSCT without in vitro T-cell depletion. Furthermore, our study suggests that lack of chronic GVHD and duration of MRD (-) <4 months after modified DLI are associated with higher relapse rates in patients receiving chemotherapy followed by modified DLI.
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Affiliation(s)
- Chen-Hua Yan
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
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Bishop MR. Donor lymphocyte infusion: beauty is in the eye of the beholder. Biol Blood Marrow Transplant 2013; 19:849-50. [PMID: 23611978 DOI: 10.1016/j.bbmt.2013.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 04/10/2013] [Indexed: 11/16/2022]
Affiliation(s)
- Michael R Bishop
- Section of Hematology/Oncology, University of Chicago, Chicago, Illinois 60637, USA.
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Management of relapse after allo-SCT for AML and the role of second transplantation. Bone Marrow Transplant 2009; 44:769-77. [PMID: 19855439 DOI: 10.1038/bmt.2009.300] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Relapse after allo-SCT for AML carries very poor prognosis. Second allo-SCT, although curative, is not an appropriate treatment option for a large number of relapsing patients (only 2-20% patients receive a second allo-SCT), and efforts to increase the number of patients who may benefit from a second allo-SCT are ongoing. In addition, understanding the varied biological processes that are operative in disease relapse has encouraged the development of novel therapies, and could be beneficial to patients who are currently managed conservatively with supportive care for relapsed disease. Incorporating novel combinations of drugs with immunomodulation, although theoretically attractive, should be tested in the setting of clinical trials. In this review, we discuss the currently available approaches for relapsed AML after allo-SCT.
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Administration of short-term immunosuppressive agents after DLI reduces the incidence of DLI-associated acute GVHD without influencing the GVL effect. Bone Marrow Transplant 2009; 44:309-16. [DOI: 10.1038/bmt.2009.26] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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7
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Huang XJ, Liu DH, Liu KY, Xu LP, Chen YH, Wang Y, Han W, Chen H. Modified donor lymphocyte infusion after HLA-mismatched/haploidentical T cell-replete hematopoietic stem cell transplantation for prophylaxis of relapse of leukemia in patients with advanced leukemia. J Clin Immunol 2008; 28:276-83. [PMID: 18204965 DOI: 10.1007/s10875-007-9166-z] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2007] [Accepted: 12/27/2007] [Indexed: 11/27/2022]
Abstract
We evaluated the safety and efficacy of donor lymphocyte infusion (DLI) with granulocyte colony-stimulating factor priming and short-term immunosuppressive agents for prophylaxis of relapse in patients with advanced leukemia after human leukocyte antigen (HLA)-mismatched T cell-replete hematopoietic stem cell transplantation (HCT). Twenty-nine patients received prophylactic DLI at a median 75 (33-120) days after HCT. Acute graft-vs-host disease (GVHD) grades 3-4 occurred in six patients, and all cases were controlled. Eleven patients were alive and relapse-free with a probability of leukemia-free survival (LFS) of 37.3 +/- 9.6% at 3 years. Chronic GVHD was associated with a lower relapse rate and higher probability of LFS. Prophylactic-modified DLI is feasible in patients with advanced leukemia to prevent relapse after HLA-mismatched HCT.
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Affiliation(s)
- Xiao-Jun Huang
- Institute of Hematology, People's Hospital, Peking University, no. 11 Xizhimen South Street, 100044 Beijing, People's Republic of China.
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8
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Huang XJ, Wang Y, Liu DH, Xu LP, Chen H, Chen YH, Han W, Shi HX, Liu KY. Modified donor lymphocyte infusion (DLI) for the prophylaxis of leukemia relapse after hematopoietic stem cell transplantation in patients with advanced leukemia--feasibility and safety study. J Clin Immunol 2008; 28:390-7. [PMID: 18347959 DOI: 10.1007/s10875-008-9193-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Accepted: 02/26/2008] [Indexed: 10/22/2022]
Abstract
PURPOSE We retrospectively evaluated the feasibility and safety of a modified prophylactic donor lymphocytes infusion (DLI) approach in advanced leukemia. MATERIALS AND METHODS Thirty-three patients with advanced leukemia received modified prophylactic DLI; that is, granulocyte colony-stimulating factor-primed peripheral blood progenitor cells instead of steady-donor lymphocyte harvests were used, and a short-term immunosuppressive agent (cyclosporine A or methotrexate 10 mg once per week for 2 to 4 weeks) was used for prevention of DLI-associated graft versus host disease (GVHD) after human leukocyte antigen-identical sibling hematopoietic stem cell transplantation. RESULTS Thirty-nine infusions were performed in 33 patients. The mononuclear cells and median CD3+ cells infused for DLI were 1-2 x 10(8) and 0.93 x 10(6) per kilogram, respectively. Six patients experienced II-IV-grade acute GVHD. Twenty patients developed chronic GVHD. No GVHD-related death or transfusion-related pancytopenia was observed. With an 18-month median follow-up, 16 patients were in disease-free survival, and overall survival at 1 and 1.5 years was 69.0% and 50.2%, respectively. CONCLUSION The modified prophylactic DLI strategy might represent a step forward in the treatment of advanced leukemia.
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Affiliation(s)
- Xiao-Jun Huang
- Peking University Institute of Hematology, People's Hospital, Beijing, 100044, People's Republic of China,
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Loren AW, Porter DL. Donor leukocyte infusions for the treatment of relapsed acute leukemia after allogeneic stem cell transplantation. Bone Marrow Transplant 2007; 41:483-93. [PMID: 18026156 DOI: 10.1038/sj.bmt.1705898] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Allogeneic stem cell transplantation (SCT) offers the only hope for cure for many adults with acute leukemia. Unfortunately, many patients relapse and die of their disease even after transplantation. Although in some cases, allogeneic SCT is effective because the intensive conditioning therapy eradicates all malignant cells, it has long been recognized that the adoptive transfer of donor immunity plays a critically important role in the induction and maintenance of remission. Recognition of the graft-versus-leukemia (GVL) effect of allogeneic SCT has prompted attempts at remission re-induction by adoptive immunotherapy with donor lymphocyte infusions (DLIs) in patients with relapsed disease after allogeneic SCT. In some cases, DLI-induced remissions are sustained and patients cured when no other treatment modality was effective. This review discusses the rationale, biology, complications and future applications of DLI in acute leukemia patients after allogeneic SCT.
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Affiliation(s)
- A W Loren
- Bone Marrow and Stem Cell Transplant Program, University of Pennsylvania Abramson Cancer Center, Philadelphia, PA 19104, USA.
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Loren AW, Porter DL. Donor leukocyte infusions after unrelated donor hematopoietic stem cell transplantation. Curr Opin Oncol 2006; 18:107-14. [PMID: 16462177 DOI: 10.1097/01.cco.0000208781.61452.d3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Donor leukocyte infusions provide direct and potent graft-versus-tumor activity to treat relapse after allogeneic stem cell transplantation. Extensive data are available on the use of donor leukocyte infusion after matched-sibling stem cell transplantation, but reports are remarkably few on the use of donor leukocyte infusion after unrelated-donor stem cell transplantation. But the role for unrelated-donor leukocyte infusion is not well established. RECENT FINDINGS The dramatic success of donor leukocyte infusion to treat relapse after matched-sibling stem cell transplantation has led to the use of unrelated-donor leukocyte infusion in many patients. Several case studies suggest that unrelated-donor leukocyte infusion effectively induces direct graft-versus-tumor reactions with toxicity comparable to that of matched-sibling donor leukocyte infusion. Important issues include the relationship between dose and response/toxicity appropriate timing, dose, and schedule; and identification of the best tumor targets. In particular nonmyeloablative transplant strategies using unrelated donors are expanding rapidly, but relapse rates are high. There is a paucity of data on unrelated-donor leukocyte infusion in this setting. SUMMARY This review summarizes recent data on the use of unrelated-donor leukocyte infusion. We discuss anticipated outcomes and identify areas under active investigation in both ablative and nonmyeloablative unrelated-donor stem cell transplantation.
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Affiliation(s)
- Alison W Loren
- Stem Cell Transplant Program and Hematology-Oncology Division, Abramson Cancer Center, University of Pennsylvania, Philadelphia, 19104, USA
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11
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Affiliation(s)
- M Ortín
- Haematology S.D.U., Department of Cellular and Molecular Biology, St George's Hospital Medical School, London, UK
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12
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Humphreys BD, Soiffer RJ, Magee CC. Renal Failure Associated with Cancer and Its Treatment: An Update. J Am Soc Nephrol 2004; 16:151-61. [PMID: 15574506 DOI: 10.1681/asn.2004100843] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Benjamin D Humphreys
- Renal Division, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Nicolini FE, Wattel E, Michallet AS, Bourgeot JP, Tremisi JP, Hequet O, Michallet M. Long-term persistent lymphopenia in hematopoietic stem cell donors after donation for donor lymphocyte infusion. Exp Hematol 2004; 32:1033-9. [PMID: 15539080 DOI: 10.1016/j.exphem.2004.07.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2004] [Revised: 07/07/2004] [Accepted: 07/19/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To analyze the consequences of lymphocyte donations on lymphopoiesis in donors having previously undergone hematopoietic stem cell collection for allogeneic stem cell transplantation. METHODS Repeated analysis of leukocyte subsets in the peripheral blood of 76 hematopoietic stem cell donors undergoing lymphocyte donation(s) for DLI. RESULTS Grade I/II lymphopenia was present in 22 donors (29%) just before first apheresis for lymphocyte collection, demonstrating that former stem cell donation induced prolonged lymphopenia in a subset of donors. The monocytic lineage was not affected. Older age and history of PBSC harvest constituted 2 independent factors of lymphopenia, but had no influence on monocytopenia. The first apheresis induced lymphopenia in 36 donors (47%) and monocytopenia in 23 donors (39%). Lymphopenia before first apheresis and prior history of PBSC harvest were independent factors of apheresis-induced lymphopenia while those factors had no influence on monocytopenia. A time-dependent decrease in lymphocyte counts was observed in donors undergoing repeated aphereses, resulting in persistent and prolonged lymphopenia in 50% of donors. No persistent monocytopenia over time and aphereses was observed. Kaplan-Meier estimate of the risk to develop persistent lymphopenia after multiple aphereses was 21% +/- 6% at 2 months, 38% +/- 8% at 4 months, and 64% +/- 10% at 12 months. After Cox regression analysis, previous PBSC harvest remained the unique factor associated with the risk for persistent lymphopenia. CONCLUSIONS Monitoring the potential long-term effects of repeated aphereses in hematopoietic stem cell donors appears important. Selecting young bone marrow donors for subsequent DLI significantly reduces the risk for acute and prolonged lymphopenias.
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Alessandrino EP, Bernasconi P, Colombo AA, Caldera D, Malcovati L, Troletti D, Vanelli L, Varettoni M, Montanari F, Lazzarino M. Reduced-intensity conditioning regimen with thiotepa and fludarabine followed by allogeneic blood stem cell transplantation in haematological malignancies. Bone Marrow Transplant 2004; 34:1039-45. [PMID: 15516936 DOI: 10.1038/sj.bmt.1704717] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The aim of this study was to investigate thiotepa (TT) and fludarabine (Fluda) as a preparative regimen for allogeneic peripheral stem cell transplant in patients not eligible for a standard myeloablative regimen due to comorbidities and/or poor performance status. TT was given at a dose of 10 mg/kg over 2 days and Fluda at 125 mg/m(2) over 5 days. In all, 21 patients (14 male, seven female; 10 acute leukaemia, eight myelodysplastic syndrome, two non-Hodgkin's lymphoma, one Hodgkin's disease) were treated. The median age was 51 years (range 30-55 years). All patients achieved full donor-type chimaerism. Adverse events included mild nausea and vomiting in two patients and a slight increase of serum amylase in three. A total of 13 patients received RBC transfusions (median 6 U, range 1-23), and all received platelets (median 4 U, range 1-27). Four patients died of nonrelapse causes and five of relapse. The 1-year probabilities of transplant-related mortality and relapse were 19 and 29%, respectively. In total, 12 patients remain in complete remission (median follow-up: 786 days). The 3-year overall survival probability was 58%. We conclude that this regimen is feasible and well tolerated.
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Affiliation(s)
- E P Alessandrino
- Bone Marrow Transplantation Unit, Division of Haematology, IRCCS Policlinico San Matteo, Viale Golgi N. 19, Pavia 27100, Italy.
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Choi SJ, Lee JH, Lee JH, Kim S, Seol M, Lee YS, Lee JS, Kim WK, Chi HS, Lee KH. Treatment of relapsed acute myeloid leukemia after allogeneic bone marrow transplantation with chemotherapy followed by G-CSF-primed donor leukocyte infusion: a high incidence of isolated extramedullary relapse. Leukemia 2004; 18:1789-97. [DOI: 10.1038/sj.leu.2403523] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kim JG, Sohn SK, Kim DH, Lee NY, Suh JS, Lee KS, Lee KB. A pilot study of cytoreductive chemotherapy combined with infusion of additional peripheral blood stem cells reserved at time of harvest for transplantation in case of relapsed hematologic malignancies after allogeneic peripheral blood stem cell transplant. Bone Marrow Transplant 2003; 33:231-6. [PMID: 14647258 DOI: 10.1038/sj.bmt.1704328] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Reharvesting leukocytes from donors for a donor leukocyte infusion (DLI) is inconvenient and occasionally impossible in case of unrelated donors. It is well known that the effect of a growth factor-primed DLI is comparable to that of a nonprimed DLI. In total, 42 patients with hematologic malignancies and a high risk of relapse were allocated, on an intent-to-treat basis, a peripheral blood stem cell transplantation (PBSCT) from HLA-matched sibling donors, and then at the time of harvest, additional peripheral blood stem cells (PBSCs) were also reserved for a therapeutic primed DLI in case of relapse. In all, 12 patients who relapsed after allogeneic PBSCT were treated with mainly cytarabine-based chemotherapy followed by a cryopreserved PBSC infusion. The median dose of CD3+ and CD34+ cells for the primed DLIs was 1.43 x 10(8)/kg and 4.75 x 10(6)/kg, respectively. Six of the 12 relapsed patients exhibited a complete response after the primed DLI, plus their 1-year survival rate was 33%. The new development or progression of graft-versus-host disease after a primed DLI was observed in 50% of the patients. Overall, the survival at 1 year was 16.7%. Accordingly, the induction of a graft-versus-leukemia effect through a primed DLI, using additional PBSCs reserved at the original time of harvest, would appear to be feasible for patients with relapsed hematologic malignancies. Furthermore, this approach is also more convenient for donors.
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Affiliation(s)
- J G Kim
- Department of Hematology/Oncology, Kyungpook National University Hospital, 50 Samduck 2-ka, Jung-ku, Korea
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Levine JE, Braun T, Penza SL, Beatty P, Cornetta K, Martino R, Drobyski WR, Barrett AJ, Porter DL, Giralt S, Leis J, Holmes HE, Johnson M, Horowitz M, Collins RH. Prospective trial of chemotherapy and donor leukocyte infusions for relapse of advanced myeloid malignancies after allogeneic stem-cell transplantation. J Clin Oncol 2002; 20:405-12. [PMID: 11786567 DOI: 10.1200/jco.2002.20.2.405] [Citation(s) in RCA: 153] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patients with advanced myeloid malignancies who experience relapse after allogeneic bone marrow transplantation (BMT) have a poor prognosis. Long-term survival after chemotherapy alone, second myeloablative transplant, or donor leukocyte infusions (DLIs) alone is unusual. DLIs may have minimal effectiveness in advanced disease because adequate cellular responses are not able to develop in the presence of bulky, fast-growing disease. A chemotherapy strategy was used to debulk disease before administration of granulocyte colony-stimulating factor (G-CSF)-primed DLIs. PATIENTS AND METHODS Sixty-five patients experiencing hematologic relapse of myeloid malignancy after HLA-matched sibling BMT were prospectively treated with cytarabine-based chemotherapy, then G-CSF-primed DLIs. No prophylactic immunosuppression was provided. RESULTS Twenty-seven of 57 assessable patients experienced a complete response. Graft-versus-host disease (GVHD) was observed in 56% of the patients. Treatment-related mortality was 23%. Overall survival at 2 years for the entire cohort was 19%. Patients with a complete response were more likely to survive, with 1- and 2-year survival rates of 51% and 41%, respectively, with a median follow-up of more than 2 years. The 1-year survival for nonresponders was 5%. A posttransplant remission lasting more than 6 months before relapse was associated with a higher likelihood of response. GVHD was not required for durable remission. CONCLUSION Salvage treatment with chemotherapy before DLI can help some patients with advanced myeloid relapse and is not dependent on GVHD. Patients with short remissions after BMT are unlikely to benefit from this approach, and the approach is associated with significant treatment-related mortality. Modifications of this approach or entirely different approaches will be required for most patients with this difficult clinical problem.
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Fujii S, Shimizu K, Fujimoto K, Kiyokawa T, Tsukamoto A, Sanada I, Kawano F. Treatment of post-transplanted, relapsed patients with hematological malignancies by infusion of HLA-matched, allogeneic-dendritic cells (DCs) pulsed with irradiated tumor cells and primed T cells. Leuk Lymphoma 2001; 42:357-69. [PMID: 11699400 DOI: 10.3109/10428190109064592] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Patients with hematological malignancies who relapse after bone marrow transplantation (BMT) are often treated with donor lymphocyte infusion. However, this procedure often results in graft-versus-host disease (GVHD). While, Dendritic cells (DCs), which present antigens to naive T cells, have been used in the immunotherapy of cancer, this approach has been logistically difficult due to limiting numbers of DCs. We have now developed a method for obtaining a large number of DCs by treating the granulocyte colony-stimulating factor (G-CSF) mobilized peripheral blood stem cells (PBSCs) from healthy donors with granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-4 (IL-4), and tumor necrosis factor-alpha (TNF-alpha). The resulting cells possess the morphologic, phenotypic, and functional characteristics of mature DCs. In in vitro studies, culture of these HLA-matched donor derived-DCs with irradiated each patient's tumor cells as an antigen source, followed by incubation with T cells from the patient, induced the production of highly cytotoxic T lymphocytes (CTLs) specific for the respective tumor cells in the semi-allogeneic setting. A transient, but objective clinical response was obtained in the absence of GVHD when we injected the DCs which had been pulsed with irradiated tumor cells as well as primed T cells from the same original donor of related- allogeneic stem cell transplantation into the relapsed patients. Our findings suggest that treatment of relapsed patients with such donor-derived DCs, and primed T cells may be effective as an adjunctive immunotherapy.
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Affiliation(s)
- S Fujii
- Centre for Bone Marrow Transplantation and Immunotherapy, Institute for Clinical Research, Kumamoto National Hospital, 1-5 Ninomaru, Kumamoto 860-0008, Japan.
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Min CK, Eom KS, Lee S, Kim DW, Lee JW, Min WS, Kim CC. Effect of induced GVHD in leukemia patients relapsing after allogeneic bone marrow transplantation: single-center experience of 33 adult patients. Bone Marrow Transplant 2001; 27:999-1005. [PMID: 11436112 DOI: 10.1038/sj.bmt.1703021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2000] [Accepted: 02/13/2001] [Indexed: 11/09/2022]
Abstract
In a retrospective single center study, we examined the outcome of induced GVHD in leukemia patients relapsing after allogeneic BMT. Thirty-three adult patients with leukemia (15 AML, 3 ALL, and 15 CML) persisting or relapsing 1-36 months (median, 6) after allogeneic BMT underwent various immune manipulations and consequently developed acute and/or chronic GVHD at our center. Immunotherapies to elicit GVHD comprised chemotherapy followed by PBSC (n = 18), non-myeloablative transplant (n = 2), PBL followed by IFN-alpha (n = 5), PBL alone (n = 3), abrupt cessation of CsA (n = 3), and CsA withdrawal combined with IFN-alpha (n = 2). Twenty-four (72.7%) patients obtained a remission including complete hematological or cytogenetic remission, respectively, for acute leukemias or CML. Overall survival of patients, estimated at 3 years using the Kaplan-Meier method, was 33.9% (95% CI, 20-52%). Twelve patients including two patients with ALL remain in complete hematological (n = 5) or cytogenetic remission (n = 7) 3-93 months (median 12) after achieving remission. Twelve (63.2%) of 19 dead patients died due to treatment-related toxicities; five patients from acute GVHD, three from GVHD followed by infections and four from infections. By multivariate Cox analysis, only chronic GVHD resulted in a higher probability of disease-free survival (P = 0.026). Eight patients who had both acute GVHD < or = grade I and chronic GVHD are all alive without leukemia. We conclude that acute GVHD is associated with considerable toxicity while chronic GVHD plays a role in retaining remission in leukemia relapsing after allogeneic BMT.
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Affiliation(s)
- C K Min
- The Catholic Hemopoietic Stem Cell Transplantation Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Lee JH, Lee KH, Kim S, Seol M, Kim SH, Kim WK, Lee JS. Combination chemotherapy of intermediate-dose cytarabine, idarubicin, plus etoposide and subsequent mobilized donor leukocyte infusion for relapsed acute leukemia after allogeneic bone marrow transplantation. Leuk Res 2001; 25:305-12. [PMID: 11248327 DOI: 10.1016/s0145-2126(00)00142-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The efficacy and side effects of intermediate-dose cytarabine, idarubicin plus etoposide and subsequent donor leukocyte infusion (DLI) were investigated in patients with acute leukemia who relapsed after allogeneic bone marrow transplantation (BMT). Patients were given cytarabine continuous i.v. (1 g/m2 per day x 5), idarubicin i.v. (12 mg/m2 per day x 3), and etoposide i.v. infusion (150 mg/m2 per day x 3). Two days later, G-CSF mobilized donor leukocytes were infused for 2 days. No graft-versus-host disease (GVHD) prophylaxis was given. Between August 1997 and February 2000, 13 patients enrolled (eight acute myeloid leukemia (AML) and five acute lymphoblastic leukemia (ALL)). All patients finished chemotherapy and DLI. Eleven patients (85%) achieved complete remission (CR) at median 27 days after DLI. After median follow up of 10.9 months (2.5-33.3), five of 11 patients who achieved CR relapsed. Overall, six of 13 patients were surviving (6/8 AML and 0/5 ALL, P=0.059). Marrow recovery after chemotherapy and DLI was rapid (12 days for absolute neutrophil count (ANC) >500/microl). Side effects included fever with neutropenia (100%), pneumonia (46%), grade II-IV mucositis (69%), grade III-IV acute GVHD (45%), and extensive chronic GVHD (64%). One patient died from chronic GVHD. Chemotherapy containing intermediate-dose cytarabine and DLI produced a high CR rate in acute leukemia in relapse after allogeneic BMT. A fraction of patients are surviving long term. Side effects were substantial but manageable.
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Affiliation(s)
- J H Lee
- Section of Oncology-Hematology, Department of Medicine, University of Ulsan, College of Medicine, Asan Medical Center, 388-1 Poongnap-dong, Songpa-ku, 138-736, Seoul, South Korea.
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Imoto S, Murayama T, Gomyo H, Mizuno I, Sugimoto T, Nakagawa T, Koizumi T. Long-term molecular remission induced by donor lymphocyte infusions for recurrent acute myeloblastic leukemia after allogeneic bone marrow transplantation. Bone Marrow Transplant 2000; 26:809-10. [PMID: 11042667 DOI: 10.1038/sj.bmt.1702602] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A case of acute myelogenous leukemia with a t(8;21) translocation relapsed 5 months after allogeneic bone marrow transplantation (allo-BMT). After chemotherapy-induced hematologic remission, the patient received donor lymphocyte infusions (DLI); 4.9 x 108/kg T cells were infused. After DLI, she achieved molecular CR for the first time after allo-BMT, which lasted for 40 months. However, she suffered from grade III acute GVHD of the skin and the liver. Hepatic GVHD was sustained and resulted in fatal outcome. The case demonstrates that DLI is a double-edged sword. Further study is necessary before DLI can be considered to be a beneficial therapy for acute leukemia. Bone Marrow Transplantation (2000) 26, 809-810.
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Affiliation(s)
- S Imoto
- Hematology/Oncology Division, Department of Internal Medicine, Hyogo Medical Center for Adults, Hyogo, Japan
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