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Pan M, Wu Y, Yang L, Zhu P, Shi J, Lai X, Liu L, Zhao Y, Yu J, Huang H, Luo Y. Reduced intensity conditioning regimen of fludarabine, busulfan, ATG based haploidentical stem cell transplantation for older or unfit patients. Ann Hematol 2024:10.1007/s00277-024-05819-4. [PMID: 38829409 DOI: 10.1007/s00277-024-05819-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/26/2024] [Indexed: 06/05/2024]
Abstract
Reduced-intensity conditioning (RIC) regimens allogeneic hematopoietic stem cell transplantation (HSCT) was developed for older patients or those with poor functional status. Haploidentical donor was appropriate alternative donor for patients without matched donors or patients with emergency disease state. However, there was few studies report the outcomes of RIC regimen of anti-thymocyte globulin (ATG) based haploidentical HSCT. The selection of the appropriate RIC regimen based on age and comorbidities in ATG-based haploidentical HSCT remains poorly described. To investigate the safety and efficacy of RIC regimen ATG-based haploidentical HSCT in older or unfit patients. Additionally, to explore the potential factors that impact the prognosis of RIC regimen of ATG-based haploidentical HSCT. We included a retrospective cohort of 63 patients with hematologic malignant diseases who underwent their first RIC haploidentical HSCT from November 2016 to June 2022 at our institutions. The conditioning regimen involved fludarabine (Flu) 30 mg/m²/kg 6 days combined with busulfan 3.2 mg/kg 2 days (Bu2) or 3 days (Bu3). ATG-Fresenius (ATG-F) was administered 10 mg/kg in total, ATG-thymoglobulin (ATG-T) was administered 6 mg/kg in total. The median age of patients in the entire cohort was 60 (32-67) years with a median follow-up of 496 (83-2182) days. There were 29 patients with AML, 20 patients with MDS, and 14 patients with ALL. A total of 32 patients underwent Bu2 RIC haplo-HSCT and 31 patients were treated with Bu3 RIC haplo-HSCT. The 2-year overall survival (OS) and 2-year disease-free survival (DFS) in whole cohort were 67.7% (95% confidence interval [CI], 53.8 - 85.1%) and 61.4% (95% CI, 48.8 - 77.3%) respectively. The cumulative incidence rates of grades II to IV and grades III to IV acute graft-versus-host disease (aGVHD) in whole cohort were 15.8% (95% CI, 4.8 - 19.6%) and 9.7% (95% CI, 0.0 - 11.8%) respectively. The 2-year cumulative incidence of chronic GVHD was 34.0% (95% CI, 18.9 - 46.3%). The 2-year cumulative incidence rates of relapse (IR) and non-relapse mortality (NRM) rates in whole cohort were 27.5% (95% CI, 14.5 - 33.7%) and 11.6% (95% CI, 2.2 - 21.9%) respectively. The probability of 2-year OS were 60.2% (95% CI:42.5-85.3%) in Bu2 and 85.5%(95% CI:73.0-100%) in Bu3 group respectively(P = 0.150). The probability of 2-year DFS were 49.7% (95% CI:33.0-74.8%) in Bu2 and 72.6% (95% CI:55.5-95.5%) in Bu3 group respectively (P = 0.045). The 2-year IR of Bu2 group was significantly higher than Bu3 group (P = 0.045). However, the 2-year NRM were not significantly different between Bu2 and Bu3 group(P > 0.05). In multivariable analysis, RIC regimen of Bu3 had superior OS and DFS than Bu2 group respectively [HR 0.42, 95% CI 0.18-0.98; P = 0.044; HR 0.34, 95% CI 0.14-0.86; P = 0.022]. Besides, RIC regimen of Bu3 had lower IR than Bu2 group [HR 0.34, 95% CI 0.13-0.89; P = 0.029]. The RIC regimen of ATG-based haploidentical HSCT is a safe and effective treatment option for patients who are older or have poor functional status. In particular, a relatively high-intensity pre-treatment regimen consisting of Bu achieves significant improvements in OS and DFS, thus providing more favorable post-transplantation clinical outcomes.
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Affiliation(s)
- Mingyue Pan
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Yibo Wu
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Luxin Yang
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Panpan Zhu
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Jimin Shi
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Xiaoyu Lai
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Lizhen Liu
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Yanmin Zhao
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Jian Yu
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China
| | - He Huang
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China.
- Institute of Hematology, Zhejiang University, Hangzhou, China.
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China.
| | - Yi Luo
- Bone Marrow Transplantation Center of The First Affiliated Hospital & Liangzhu Laboratory, Zhejiang University School of Medicine, 1369 West Wenyi Road, Hangzhou, 311121, China.
- Institute of Hematology, Zhejiang University, Hangzhou, China.
- Zhejiang Province Engineering Research Center for Stem Cell and Immunity Therapy, Hangzhou, China.
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Abstract
Myelodysplastic syndromes (MDS) are a family of myeloid cancers with diverse genotypes and phenotypes characterized by ineffective haematopoiesis and risk of transformation to acute myeloid leukaemia (AML). Some epidemiological data indicate that MDS incidence is increasing in resource-rich regions but this is controversial. Most MDS cases are caused by randomly acquired somatic mutations. In some patients, the phenotype and/or genotype of MDS overlaps with that of bone marrow failure disorders such as aplastic anaemia, paroxysmal nocturnal haemoglobinuria (PNH) and AML. Prognostic systems, such as the revised International Prognostic Scoring System (IPSS-R), provide reasonably accurate predictions of survival at the population level. Therapeutic goals in individuals with lower-risk MDS include improving quality of life and minimizing erythrocyte and platelet transfusions. Therapeutic goals in people with higher-risk MDS include decreasing the risk of AML transformation and prolonging survival. Haematopoietic cell transplantation (HCT) can cure MDS, yet fewer than 10% of affected individuals receive this treatment. However, how, when and in which patients with HCT for MDS should be performed remains controversial, with some studies suggesting HCT is preferred in some individuals with higher-risk MDS. Advances in the understanding of MDS biology offer the prospect of new therapeutic approaches.
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Sieker K, Fleischmann M, Trommel M, Ramm U, Licher J, Bug G, Martin H, Serve H, Rödel C, Balermpas P. Twenty years of experience of a tertiary cancer center in total body irradiation with focus on oncological outcome and secondary malignancies. Strahlenther Onkol 2022; 198:547-557. [PMID: 35318487 PMCID: PMC9165288 DOI: 10.1007/s00066-022-01914-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/20/2022] [Indexed: 12/17/2022]
Abstract
Purpose Total body irradiation (TBI) is a common part of the myelo- and immuno-ablative conditioning regimen prior to an allogeneic hematopoietic stem cell transplantation (allo-HSCT). Due to concerns regarding acute and long-term complications, there is currently a decline in otherwise successfully established TBI-based conditioning regimens. Here we present an analysis of patient and treatment data with focus on survival and long-term toxicity. Methods Patients with hematologic diseases who received TBI as part of their conditioning regimen prior to allo-HSCT at Frankfurt University Hospital between 1997 and 2015 were identified and retrospectively analyzed. Results In all, 285 patients with a median age of 45 years were identified. Median radiotherapy dose applied was 10.5 Gy. Overall survival at 1, 2, 5, and 10 years was 72.6, 64.6, 54.4, and 51.6%, respectively. Median follow-up of patients alive was 102 months. The cumulative incidence of secondary malignancies was 12.3% (n = 35), with hematologic malignancies and skin cancer predominating. A TBI dose ≥ 8 Gy resulted in significantly improved event-free (p = 0.030) and overall survival (p = 0.025), whereas a total dose ≤ 8 Gy and acute myeloid leukemia (AML) diagnosis were associated with significantly increased rates of secondary malignancies (p = 0.003, p = 0.048) in univariate analysis. No significant correlation was observed between impaired renal or pulmonary function and TBI dose. Conclusion TBI remains an effective and well-established treatment, associated with distinct late-toxicity. However, in the present study we cannot confirm a dose–response relationship in intermediate dose ranges. Survival, occurrence of secondary malignancies, and late toxicities appear to be subject to substantial confounding in this context. Supplementary Information The online version of this article (10.1007/s00066-022-01914-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katharina Sieker
- Department of Radiation Oncology, University Hospital-Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Maximilian Fleischmann
- Department of Radiation Oncology, University Hospital-Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Martin Trommel
- Department of Radiation Oncology, University Hospital-Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Ulla Ramm
- Department of Radiation Oncology, University Hospital-Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Jörg Licher
- Department of Radiation Oncology, University Hospital-Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Gesine Bug
- Department of Medicine 2, Hematology/Oncology, Goethe University, Frankfurt, Germany
| | - Hans Martin
- Department of Medicine 2, Hematology/Oncology, Goethe University, Frankfurt, Germany
| | - Hubert Serve
- Department of Medicine 2, Hematology/Oncology, Goethe University, Frankfurt, Germany.,Frankfurt Cancer Institute, Goethe University, Frankfurt/Main, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK) partner site: Frankfurt am Main, Frankfurt am Main, Germany
| | - Claus Rödel
- Department of Radiation Oncology, University Hospital-Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.,Frankfurt Cancer Institute, Goethe University, Frankfurt/Main, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK) partner site: Frankfurt am Main, Frankfurt am Main, Germany
| | - Panagiotis Balermpas
- Department of Radiation Oncology, University Hospital-Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.,Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
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Jain AG, Elmariah H. BMT for Myelodysplastic Syndrome: When and Where and How. Front Oncol 2022; 11:771614. [PMID: 35070975 PMCID: PMC8770277 DOI: 10.3389/fonc.2021.771614] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are a diverse group of hematological malignancies distinguished by a combination of dysplasia in the bone marrow, cytopenias and the risk of leukemic transformation. The hallmark of MDS is bone marrow failure which occurs due to selective growth of somatically mutated clonal hematopoietic stem cells. Multiple prognostic models have been developed to help predict survival and leukemic transformation, including the international prognostic scoring system (IPSS), revised international prognostic scoring system (IPSS-R), WHO prognostic scoring system (WPSS) and MD Anderson prognostic scoring system (MDAPSS). This risk stratification informs management as low risk (LR)-MDS treatment focuses on improving quality of life and cytopenias, while the treatment of high risk (HR)-MDS focuses on delaying disease progression and improving survival. While therapies such as erythropoiesis stimulating agents (ESAs), erythroid maturation agents (EMAs), immunomodulatory imide drugs (IMIDs), and hypomethylating agents (HMAs) may provide benefit, allogeneic blood or marrow transplant (alloBMT) is the only treatment that can offer cure for MDS. However, this therapy is marred, historically, by high rates of toxicity and transplant related mortality (TRM). Because of this, alloBMT is considered in a minority of MDS patients. With modern techniques, alloBMT has become a suitable option even for patients of advanced age or with significant comorbidities, many of whom who would not have been considered for transplant in prior years. Hence, a formal transplant evaluation to weigh the complex balance of patient and disease related factors and determine the potential benefit of transplant should be considered early in the disease course for most MDS patients. Once alloBMT is recommended, timing is a crucial consideration since delaying transplant can lead to disease progression and development of other comorbidities that may preclude transplant. Despite the success of alloBMT, relapse remains a major barrier to success and novel approaches are necessary to mitigate this risk and improve long term cure rates. This review describes various factors that should be considered when choosing patients with MDS who should pursue transplant, approaches and timing of transplant, and future directions of the field.
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Affiliation(s)
- Akriti G Jain
- Fellow, Hematology Oncology, H. Lee Moffitt Cancer and Research Institute, Tampa, FL, United States
| | - Hany Elmariah
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer and Research Institute, Tampa, FL, United States
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Liu L, Jia M, Sun L, Tian W, Tang P, Jiang Z. Meta-analysis of the benefit of hypomethylating agents before allogeneic hematopoietic stem cell transplantation in myelodysplastic syndromes. Clin Exp Med 2021; 21:537-543. [PMID: 33866494 PMCID: PMC8505317 DOI: 10.1007/s10238-021-00712-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 04/07/2021] [Indexed: 12/15/2022]
Abstract
Hypomethylating agents (HMAs) are effective therapies in myelodysplastic syndromes (MDS), but allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the only way to cure MDS. According to the current literature, it is difficult to confirm whether HMAs bridging therapy is beneficial for MDS patients receiving allo-HSCT. Therefore, we tried to evaluate the effect of HMAs on long-term survival of the MDS patients. Databases, including PubMed, Embase Ovid, and the Cochrane Library, were searched for studies published up to January 10, 2021. Patients who accepted HMAs bridging to allo-HSCT were defined as experimental group, while patients who received the best supportive care (BSC) before allo-HSCT were control group. Overall survival (OS) was the primary end point. Seven studies were included in the final analysis. The final results showed no OS differences between patients accepted HMAs before allo-HSCT and those received BSC (HR = 0.86, 95% CI: 0.64-1.15, p = 0.32), indicating that MDS patients' long-term survival did not benefit from HMAs bridging therapy before allo-HSCT. This conclusion needs to be further verified by a large number of prospective randomized controlled trials, which have guiding significance for the treatment of MDS patients.
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Affiliation(s)
- Liu Liu
- Department of Hematology, First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, 450052, China.
| | - Menglu Jia
- Department of Hematology, First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, 450052, China
| | - Ling Sun
- Department of Hematology, First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, 450052, China
| | - Wenliang Tian
- Department of Hematology, First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, 450052, China
| | - Ping Tang
- Department of Hematology, First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, 450052, China
| | - Zhongxing Jiang
- Department of Hematology, First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, 450052, China
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6
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Campidelli A, Robin M, Remen T, Luc A, Labussière-Wallet H, Dulery R, Srour M, Ceballos P, Forcade E, Nguyen-Quoc S, Furst S, Turlure P, Bay JO, Simand C, Marçais A, Daguindau E, Rubio MT, D'Aveni M. On Behalf of the SFGM-TC: Retrospective Comparison of Reduced and Higher Intensity Conditioning for High-Risk Myelodysplastic Syndrome Treated With Allogeneic Stem-Cell Transplantation. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:34-43. [PMID: 34456160 DOI: 10.1016/j.clml.2021.07.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Allogeneic hematopoietic stem-cell transplantation (allo-HSCT) remains the best curative option for high-risk myelodysplastic syndrome . We retrospectively compared patient outcomes after allo-HSCT according to the intensity of the conditioning regimen. PATIENTS AND METHODS Three conditioning regimens were compared in 427 patients allografted for high-risk myelodysplastic syndrome: reduced-intensity conditioning (RIC), fludarabine (150-160 mg/m2) and busulfan (6.4 mg/kg); sequential FLAMSA-RIC, fludarabine, amsacrine, and aracytine followed by RIC; and myeloablative with reduced toxicity (RTC), fludarabine and busulfan (9.6 mg/kg or 12.8 mg/kg). RESULTS The patients in the 3 conditioning groups were different in regards to the number of treatment lines (P< .001), percentage of blasts in bone marrow (P< .001), and disease status at transplantation (P< .001). No significant differences in outcomes (overall survival, progression-free survival, nonrelapse mortality, relapse incidence, and graft versus host disease relapse-free survival) were observed between the 3 groups. Using propensity score analysis to overcome baseline imbalances, we compared 70 patients receiving FLAMSA-RIC to 260 patients receiving RIC, and compared 83 patients receiving RTC to 252 patients receiving RIC. The only factor influencing overall and progression-free survival was cytogenetic risk at transplantation. After the covariate adjustment using propensity score to reduce baseline imbalances, the only factor influencing overall and progression-free survival was still cytogenetic risk at transplantation. CONCLUSION Overall survival appears to be similar with the 3 conditioning regimens. The only factor influencing survival is cytogenetic risk at transplantation, suggesting that new promising drugs in the conditioning and/or early interventions after transplantation are needed to improve outcomes in these patients.
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Affiliation(s)
| | - Marie Robin
- Hematology department, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Thomas Remen
- Unit of Methodology, Data-management, and Statistics (UMDS), University hospital of Nancy, France
| | - Amandine Luc
- Unit of Methodology, Data-management, and Statistics (UMDS), University hospital of Nancy, France
| | | | - Rémi Dulery
- Hematology department, Hôpital Saint-Antoine, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Micha Srour
- Hematology department, Hôpital Claude Huriez, Lille, France
| | | | - Edouard Forcade
- Hematology department, Hôpital Haut-Levêque, Bordeaux, France
| | | | - Sabine Furst
- Hematology department, Institut Paoli Calmette, Marseille, France
| | - Pascal Turlure
- Hematology department, Hôpital Dupuytren, Limoges, France
| | - Jacques-Olivier Bay
- Service de Thérapie Cellulaire et d'Hématologie Clinique Adulte, Université d'Auvergne, CHU Clermont-Ferrand Hôpital Estaing, Clermont-Ferrand, France
| | - Célestine Simand
- Hematology Department, Institut de Cancerologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Ambroise Marçais
- Hematology department, Hôpital Necker, Assistance Publique des Hôpitaux de Paris, Paris, France
| | | | | | - Maud D'Aveni
- Hematology department, CHRU Nancy, F-54000, Nancy, France.
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7
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Yu J, Du Y, Ahmad S, Patel RD, Varela JC, Chang CC, Mori S. Comparison of Myeloablative versus Reduced-Intensity Conditioning Regimens in Allogeneic Stem Cell Transplantation Recipients with Acute Myelogenous Leukemia with Measurable Residual Disease-Negative Disease at the Time of Transplantation: A Retrospective Cohort Study. Transplant Cell Ther 2021; 27:663.e1-663.e6. [PMID: 33951497 DOI: 10.1016/j.jtct.2021.04.017] [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: 03/08/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
The ideal conditioning intensity in allogeneic hematopoietic stem cell transplantation (HSCT) is evolving. Previous prospective studies comparing myeloablative conditioning (MAC) versus reduced-intensity conditioning (RIC) regimens in adults with acute myelogenous leukemia (AML) have shown mixed results. In many of these studies, patients were not stratified based on measurable residual disease (MRD). We evaluated the effect of conditioning intensity on the outcomes of AML patients in complete remission (CR) with flow cytometry evidence of MRD negativity. A total of 135 patients age 20 to 75 years with AML in CR1 or CR2 and flow cytometry evidence of MRD negativity who underwent allogeneic HSCT at our center between 2011 and 2019 were evaluated. We compared overall survival (OS), relapse-free survival (RFS), nonrelapse mortality (NRM), relapse, and acute and chronic graft-versus-host disease (GVHD) in recipients of MAC (n = 89) and RIC (n = 46). Although the patients receiving RIC were older (62 versus 51 years; P < .0001), there were no statistically significant differences between the groups in terms of Eastern Cooperative Oncology Group and European Leukemia Network risk criteria and disease status (CR1 or CR2) at the time of transplantation. At a median follow-up of 24.6 months, no statistically significant differences in OS (hazard ratio [HR], 0.78; 95% confidence interval [CI] 0.42 to 1.42, P = .411) or RFS (HR, 1.004; 95% CI, 0.48 to 2.09, P = .99) were identified. The cumulative incidence of NRM (HR, 0.595; 95% CI, 0.24 to 1.48; P = .2644) and relapse (HR, 1.007; 95% CI, 0.45 to 2.23; P = .9872) was not different between the 2 groups. Grade II-IV and grade III-IV acute GVHD were more frequent in the MAC group (39.3% verses 19.9% [P = .018] and 19.3% versus 2.3% [P < .001], respectively), as was moderate/severe chronic GVHD (23.6% versus 15.8%; P = .038). Our data indicate that conditioning intensity did not appear to affect OS, RFS, NRM, and relapse risk in patients with MRD-negative AML as measured by flow cytometry. RIC resulted in less severe acute and chronic GVHD.
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Affiliation(s)
- James Yu
- Department of Internal Medicine, AdventHealth Orlando Hospital, Orlando, Florida
| | - Yuan Du
- Research Institute, AdventHealth Orlando Hospital, Orlando, Florida
| | - Sarfraz Ahmad
- Gynecologic Oncology Program, AdventHealth Orlando Hospital, Orlando, Florida
| | - Rushang D Patel
- Blood and Marrow Transplant Center, AdventHealth Orlando Hospital, Orlando, Florida
| | - Juan Carlos Varela
- Blood and Marrow Transplant Center, AdventHealth Orlando Hospital, Orlando, Florida
| | - Chung-Che Chang
- Department of Pathology and Laboratory Medicine, AdventHealth Orlando Hospital, Orlando, Florida
| | - Shahram Mori
- Blood and Marrow Transplant Center, AdventHealth Orlando Hospital, Orlando, Florida.
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Scott BL, Pasquini MC, Fei M, Fraser R, Wu J, Devine SM, Porter DL, Maziarz RT, Warlick E, Fernandez HF, Soiffer RJ, Alyea E, Hamadani M, Bashey A, Giralt S, Geller NL, Leifer E, Hourigan CS, Gui G, Mendizabal A, Horowitz MM, Deeg HJ, Horwitz ME. Myeloablative versus Reduced-Intensity Conditioning for Hematopoietic Cell Transplantation in Acute Myelogenous Leukemia and Myelodysplastic Syndromes-Long-Term Follow-Up of the BMT CTN 0901 Clinical Trial. Transplant Cell Ther 2021; 27:483.e1-483.e6. [PMID: 33775615 DOI: 10.1016/j.jtct.2021.02.031] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 01/02/2023]
Abstract
Several prospective randomized trials comparing conditioning intensity before allogeneic hematopoietic cell transplantation (HCT) have been performed, with conflicting results. Although reduced-intensity conditioning (RIC) leads to lower treatment-related mortality (TRM), this is offset by higher rates of relapse. Long-term follow-up of randomized comparative trials are limited. Here we present long-term follow-up of a randomized comparison of myeloablative conditioning (MAC) compared with RIC before HCT for acute myelogenous leukemia (AML) or myelodysplasia (MDS). Long-term comparative analyses of overall survival, relapse, and relapse-free survival were performed. Patients age 18 to 65 years with <5% marrow myeloblasts were randomized to receive MAC (n = 135) or RIC (n = 137), followed by HCT from an HLA-matched donor. The primary endpoint of the trial was an 18-month pointwise comparison of overall survival. The analyses were performed using a proportional hazards model. The median follow-up of the entire cohort was 51 months. At 4 years, the transplant-related mortality (TRM) was 25.1% for MAC, compared with 9.9% for RIC (P < .001). Patients who received RIC had a significantly higher risk of relapse compared to those who received MAC (hazard ratio [HR], 4.06; 95% CI, 2.59 to 6.35; P < 0.001). Among the patients who relapsed after HCT, postrelapse survival was similar at 3 years (24% for MAC and 26% for RIC). Overall survival was superior for patients who received MAC compared to those who received RIC (HR, 1.54; 95% CI, 1.07 to 2.2; P = .03). Our data show that patients who received MAC were at higher risk of late TRM compared with those who received RIC; however, because of the exceedingly high rates of relapse in the RIC arm, overall survival remained significantly better for patients who received MAC. Among patients with MDS or AML eligible for either MAC or RIC regimens, long-term follow up demonstrates a survival advantage for patients who received MAC.
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Affiliation(s)
- Bart L Scott
- Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Marcelo C Pasquini
- BMT & Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mingwei Fei
- BMT & Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Raphael Fraser
- BMT & Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Juan Wu
- The Emmes Corporation, Rockville, Maryland
| | - Steve M Devine
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | | | | | | | | | | | | | - Mehdi Hamadani
- BMT & Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Asad Bashey
- Northside Hospital Cancer Institute, Atlanta, Georgia
| | - Sergio Giralt
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy L Geller
- National Heart Lung and Blood Institute, Bethesda, Maryland
| | - Eric Leifer
- National Heart Lung and Blood Institute, Bethesda, Maryland
| | | | - Gege Gui
- National Heart Lung and Blood Institute, Bethesda, Maryland
| | | | - Mary M Horowitz
- BMT & Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - H Joachim Deeg
- Fred Hutchinson Cancer Research Center, Seattle, Washington
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9
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Oran B, Saliba RM, Mehta RS, Alousi AM, Marin D, Valdez BC, Chen J, Bashir Q, Ciurea SO, Olson AL, Hosing C, Kebriaei P, Rezvani K, Shpall EJ, Champlin RE, Andersson BS, Popat UR. Fractionated busulfan myeloablative conditioning improves survival in older patients with acute myeloid leukemia and myelodysplastic syndrome. Cancer 2021; 127:1598-1605. [PMID: 33471943 DOI: 10.1002/cncr.33383] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/06/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND A myeloablative conditioning regimen can be safely given to older patients and those with comorbidities without increasing nonrelapse mortality (NRM) by fractionating the dose of intravenous busulfan. How this approach compares in efficacy with traditional, nonfractionated, lower dose regimens is unknown. METHODS Outcomes were compared in patients with acute myeloid leukemia (AML) or myelodysplastic syndrome who received either myeloablative, fractionated busulfan (f-Bu) dosed to achieve an area under the curve of 20,000 μmol per minute (f-Bu20K) over 2 weeks (n = 84) or a standard, nonfractionated, lower busulfan dose regimen of 16,000 μmol per minute (Bu16K) over 4 days (n = 78). Both groups also received fludarabine 40 mg/m2 intravenously for 4 days. Graft-versus-host disease prophylaxis was tacrolimus and methotrexate. Patients in the Bu16K group who had unrelated donors also received antithymocyte globulin. The primary endpoint was progression-free survival. RESULTS Roughly one-half of the patients were aged >65 years, approximately 40% had poor-risk cytogenetics, approximately 40% of those with AML were not in complete remission, and approximately 40% had a comorbidity index >3. At 2 years, progression-free survival was significantly improved in the f-Bu20K group compared with the Bu16K group (45% vs 24%, respectively; hazard ratio [HR], 0.6; 95% CI, 0.4-0.8; P = .004). This was because of a significant reduction in progression (34% vs 59%, respectively; HR, 0.5; 95% CI, 0.3-0.8; P = .003) without any increase in NRM (21% vs 15%, respectively; HR, 1.4; 95% CI, 0.7-3; P = .3), which resulted in improved overall survival (51% vs 31%, respectively; HR, 0.6; 95% CI, 0.3-0.9; P = .01). CONCLUSIONS A myeloablative, fractionated busulfan regimen reduces relapse and improves survival without increasing NRM in older patients with AML and myelodysplastic syndrome.
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Affiliation(s)
- Betül Oran
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rima M Saliba
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rohtesh S Mehta
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amin M Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David Marin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ben C Valdez
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Julianne Chen
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stefan O Ciurea
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amanda L Olson
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Katy Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Borje S Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Uday R Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
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10
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Ashizawa M, Kanda Y. Preservation of fertility in patients with hematological malignancies. Jpn J Clin Oncol 2020; 50:729-742. [PMID: 32419028 DOI: 10.1093/jjco/hyaa043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/06/2020] [Accepted: 03/19/2020] [Indexed: 11/13/2022] Open
Abstract
Oncofertility is the medical field that bridges oncology and reproduction that seeks to give healthcare providers and patients the opportunity to optimize residual fertility. The treatment for hematological malignancies carries gonadal toxicity, so that the preservation of fertility should be considered in all patients in childhood, adolescence and young adulthood. Most patients who receive only chemotherapy remain fertile, whereas those who receive regimens consisting of high-dose alkylating agents or total body irradiation can develop permanent infertility. In postpubertal patients, there are established methods for preserving fertility, such as the cryopreservation of sperm, oocytes and embryos. Although ideally performed before the initiation of gonadotoxic treatment, these procedures for fertility preservation can be performed any time prior to the loss of gonadal function. In contrast, a standard option is not available in prepubertal patients, and the preservation of fertility must be sought through experimental methods. Future advances in reproductive medicine may overcome this limitation. Gonadal tissue cryopreservation might be performed in the hope that sperm or mature oocytes could later be extracted from cryopreserved tissue. Healthcare providers, including hematologists, reproductive endocrinologists, nurses, clinical psychotherapists and embryologists, need to optimize the patient's fertility through shared decision-making while always remaining aware of the rapidly progressing developments in reproductive medicine.
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Affiliation(s)
- Masahiro Ashizawa
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan, and
| | - Yoshinobu Kanda
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan, and.,Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
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11
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Ma S, Shi W, Li Z, Tang L, Wang H, Xia L, Hu Y. Reduced-intensity versus Myeloablative Conditioning Regimens for Younger Adults with Acute Myeloid Leukemia and Myelodysplastic Syndrome: A systematic review and meta-analysis. J Cancer 2020; 11:5223-5235. [PMID: 32742468 PMCID: PMC7378925 DOI: 10.7150/jca.46081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 06/15/2020] [Indexed: 01/06/2023] Open
Abstract
Background: Historically, reduced-intensity conditioning (RIC) was recommended to be performed for older patients who were considered ineligible for myeloablative conditioning (MAC) before allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, the evidence regarding the optimal conditioning intensity in younger patients with AML or MDS is weak and contradictory. Methods: PubMed, Medline, Embase, and other online sources were searched from the initial period to February 25, 2020. Odds ratios and 95% confidence intervals were calculated to estimate pooling effects. Results: Four randomized controlled trials (RCTs) about conditioning intensity involving 633 patients were included. There were no significant differences of 1/2/4/5 years progression-free survival (PFS) and relapse incidence (RI) between two conditioning intensities. Overall survival (OS) was similar at 1/2/4 years, but patients receiving RIC had a higher OS at 5 years. Additionally, RIC were associated with lower non-relapse mortality, less grade II-IV and grade III-IV acute graft-versus-host disease (GVHD), and lower incidence of chronic GVHD compared with MAC regimens. Subgroup analysis showed similar OS and RI for AML patients, and there was a trend towards lower NRM and grade II-IV aGVHD in RIC group. Available data for MDS indicated that OS, PFS, and RI were comparable. For intermediate-risk patients, there was no evidence that RIC is inferior to MAC. However, for high-risk patients, MAC tends to perform better. Conclusions: Based on the above results, it might be concluded that RIC is a feasible treatment option for adults with AML or MDS younger than 66 years, particularly those with intermediate-risk disease. Future RCTs incorporating of risk stratifications are warranted to guide the optimal decision under certain conditions.
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Affiliation(s)
- Shengling Ma
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Shi
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA
| | - Ziying Li
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liang Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huafang Wang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Linghui Xia
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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12
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13
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Chien SH, Liu YC, Liu CJ, Ko PS, Wang HY, Hsiao LT, Lin JS, Chiou TJ, Liu CY, Gau JP. European Group for Blood and Marrow Transplantation score correlates with outcomes of older patients undergoing allogeneic hematopoietic stem cell transplantation. J Chin Med Assoc 2020; 83:238-244. [PMID: 31904659 DOI: 10.1097/jcma.0000000000000255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) are hematological diseases predominantly occurring in older patients. Although allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the curative therapy for refractory AML or high-risk MDS, old age is often a hurdle to the procedure. We conducted a retrospective study to analyze the prognostic factors predicting outcomes of older patients undergoing allo-HSCT for acute leukemia and MDS. METHODS We collected data from patients diagnosed with acute leukemia or MDS, who underwent allo-HSCT at >50 years of age and reviewed clinical characteristics, including age, sex, underlying disease, European Group for Blood and Bone Marrow Transplantation (EBMT) risk score, and presence of acute graft-versus-host disease (aGVHD) or chronic GVHD (cGVHD). The Cox proportional hazard model was adopted to explore the independent prognostic factors for overall survival (OS), progression-free survival (PFS), and non-relapse mortality (NRM). RESULTS A total of 85 older patients were included, with the median age at allo-HSCT being 55 years. The significant prognostic factors for worse OS or PFS were an EBMT risk score > 3 and grade III-IV aGVHD, while patients with moderate to severe cGVHD would have better OS or PFS. Interestingly, it is not cGVHD but grade III-IV aGVHD that significantly correlated with NRM. CONCLUSION This cohort study suggests that an EBMT risk score >3 and grade III-IV aGVHD predict poor outcomes, and careful management of GVHD may allow better survival for older patients undergoing allo-HSCT.
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Affiliation(s)
- Sheng-Hsuan Chien
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yao-Chung Liu
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chia-Jen Liu
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Po-Shen Ko
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Hao-Yuan Wang
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Liang-Tsai Hsiao
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Jeong-Shi Lin
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Tzeon-Jye Chiou
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Chun-Yu Liu
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Jyh-Pyng Gau
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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14
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Westervelt P. Role of Transplant Conditioning Regimen Intensity in High-Risk Acute Myelogenous Leukemia. Biol Blood Marrow Transplant 2019; 26:e51-e52. [PMID: 31881282 DOI: 10.1016/j.bbmt.2019.12.727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 12/19/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Peter Westervelt
- Bone Marrow Transplantation & Leukemia, Washington University in Saint Louis, St. Louis, Missouri.
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15
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Prem S, Atenafu EG, Lam W, Law A, Michelis FV, Kim D, Viswabandya A, Howard Lipton J, Mattsson J, Kumar R. Allogeneic stem cell transplant in myelodysplastic syndrome-factors impacting survival. Eur J Haematol 2019; 104:116-124. [PMID: 31737967 DOI: 10.1111/ejh.13353] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/03/2019] [Accepted: 11/06/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The primary aim of this study was to evaluate survival outcomes following allo-HCT in myelodysplastic syndrome (MDS), and the secondary aim was to study variables impacting survival. METHODS This analysis describes patient characteristics, treatment, and outcomes in 125 consecutive adult patients with MDS transplanted from 2005 to 2018. RESULTS The median age was 61 years, and median follow-up in patients alive at last follow-up was 29 months. The 2-year OS and RFS were 39% (95%CI 30%-48%) and 35.3% (95% CI: 27%-44%), respectively. Transfusion dependence, high-risk cytogenetics, and high serum ferritin were independent risk factors for death. The cumulative incidence of relapse (CIR) and non-relapse mortality (NRM) at 2 years were 23% and 41.6%, respectively. High serum ferritin was significantly associated with NRM. There was no association between the percentage of bone marrow blasts (either at diagnosis or at pretransplant evaluation), on relapse or survival. Induction chemotherapy did not offer any survival advantage in MDS RAEB-2 patients compared to cytoreduction with azacytidine alone. CONCLUSION Our results highlight the importance of karyotype on survival after allo-HCT and identify serum ferritin and transfusion dependence as important surrogate markers of outcome. In addition, our results demonstrate the efficacy of azacytidine for pretransplant cytoreduction.
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Affiliation(s)
- Shruti Prem
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Wilson Lam
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Arjun Law
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Dennis Kim
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | | | | | - Rajat Kumar
- Princess Margaret Cancer Centre, Toronto, ON, Canada
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16
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Jentzsch M, Döhring C, Linke R, Hille A, Grimm J, Pönisch W, Vucinic V, Franke G, Behre G, Niederwieser D, Schwind S. Comparison of non-myeloablative and reduced-intensity allogeneic stem cell transplantation in older patients with myelodysplastic syndromes. Am J Hematol 2019; 94:1344-1352. [PMID: 31495933 DOI: 10.1002/ajh.25636] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/20/2019] [Accepted: 09/05/2019] [Indexed: 11/07/2022]
Abstract
Allogeneic stem cell transplantation (HSCT) remains the only curative treatment for myelodysplastic syndromes (MDS) or myelodysplastic/myeloproliferative neoplasms (MDS/MPN) patients. The introduction of reduced intensity (RIC) and non-myeloablative (NMA) conditioning enabled HSCT in older or comorbid individuals representing the majority of patients. Studies comparing RIC and NMA conditioning are limited. We retrospectively analyzed 151 MDS or MDS/MPN patients older than 50 years who received NMA- or RIC-HSCT. Patients younger or older than 65 years at HSCT were analyzed separately. Patients receiving RIC-HSCT or NMA-HSCT were balanced in factors reflecting disease aggressiveness and the HCT-CI comorbidity score. The NMA conditioned patients had a higher incidence of graft rejection and chronic graft-vs-host disease. Cumulative incidence of relapse (CIR), non-relapse mortality (NRM) and overall survival (OS), did not differ significantly with regard to the conditioning regime in the whole cohort. In patients <65 years at HSCT, NMA conditioning associated with higher NRM and shorter OS by trend, while CIR was similar in both groups. In multivariable analyzes, the conditioning regimen remained a prognostic factor for NRM and OS in patients <65 years at HSCT. In MDS patients NMA and RIC conditioning result in similar disease control, but especially patients <65 years may benefit from RIC-HSCT.
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Affiliation(s)
- Madlen Jentzsch
- Department of Hematology and Clinical Oncology University of Leipzig Leipzig Germany
| | - Christine Döhring
- Department of Hematology and Clinical Oncology University of Leipzig Leipzig Germany
| | - Richard Linke
- Department of Hematology and Clinical Oncology University of Leipzig Leipzig Germany
| | - Andrea Hille
- Department of Hematology and Clinical Oncology University of Leipzig Leipzig Germany
| | - Juliane Grimm
- Department of Hematology and Clinical Oncology University of Leipzig Leipzig Germany
| | - Wolfram Pönisch
- Department of Hematology and Clinical Oncology University of Leipzig Leipzig Germany
| | - Vladan Vucinic
- Department of Hematology and Clinical Oncology University of Leipzig Leipzig Germany
| | - Georg‐Nikolaus Franke
- Department of Hematology and Clinical Oncology University of Leipzig Leipzig Germany
| | - Gerhard Behre
- Department of Hematology and Clinical Oncology University of Leipzig Leipzig Germany
| | - Dietger Niederwieser
- Department of Hematology and Clinical Oncology University of Leipzig Leipzig Germany
| | - Sebastian Schwind
- Department of Hematology and Clinical Oncology University of Leipzig Leipzig Germany
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17
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Varadarajan I, Ballen KK. What have we learned from transplanting older patients? Best Pract Res Clin Haematol 2019; 32:101110. [PMID: 31779974 DOI: 10.1016/j.beha.2019.101110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Aggressive curative therapies have now been extended to patients older than 65 years, a fast-growing segment of the population. As the number of allogeneic transplants in patients older than age 65 is increasing, attention is now focused on improving outcomes in this group. This paper discusses important aspects of allogeneic transplant in the older patient, focusing on donor and patient selection, choice of conditioning regimen and graft source, and the importance of timely access to a transplant center.
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Affiliation(s)
- Indumathy Varadarajan
- University of Virginia Cancer Center, 1300 Jefferson Park Avenue, Charlottesville, VA, 22908, USA
| | - Karen K Ballen
- University of Virginia Cancer Center, 1300 Jefferson Park Avenue, Charlottesville, VA, 22908, USA.
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18
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Qin Y, Kuang P, Zeng Q, Wu Y, Liu T. Hypomethylating agents for patients with myelodysplastic syndromes prior to hematopoietic stem cell transplantation: a systematic review and meta-analysis. Ann Hematol 2019; 98:2523-2531. [DOI: 10.1007/s00277-019-03811-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 09/26/2019] [Indexed: 12/15/2022]
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19
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Myeloablative vs reduced-intensity conditioning allogeneic hematopoietic cell transplantation for chronic myeloid leukemia. Blood Adv 2019; 2:2922-2936. [PMID: 30396912 DOI: 10.1182/bloodadvances.2018024844] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/04/2018] [Indexed: 12/12/2022] Open
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) is a potentially curative treatment of chronic myeloid leukemia (CML). Optimal conditioning intensity for allo-HCT for CML in the era of tyrosine kinase inhibitors (TKIs) is unknown. Using the Center for International Blood and Marrow Transplant Research database, we sought to determine whether reduced-intensity/nonmyeloablative conditioning (RIC) allo-HCT and myeloablative conditioning (MAC) result in similar outcomes in CML patients. We evaluated 1395 CML allo-HCT recipients between the ages of 18 and 60 years. The disease status at transplant was divided into the following categories: chronic phase 1, chronic phase 2 or greater, and accelerated phase. Patients in blast phase at transplant and alternative donor transplants were excluded. The primary outcome was overall survival (OS) after allo-HCT. MAC (n = 1204) and RIC allo-HCT recipients (n = 191) from 2007 to 2014 were included. Patient, disease, and transplantation characteristics were similar, with a few exceptions. Multivariable analysis showed no significant difference in OS between MAC and RIC groups. In addition, leukemia-free survival and nonrelapse mortality did not differ significantly between the 2 groups. Compared with MAC, the RIC group had a higher risk of early relapse after allo-HCT (hazard ratio [HR], 1.85; P = .001). The cumulative incidence of chronic graft-versus-host disease (cGVHD) was lower with RIC than with MAC (HR, 0.77; P = .02). RIC provides similar survival and lower cGVHD compared with MAC and therefore may be a reasonable alternative to MAC for CML patients in the TKI era.
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Ashizawa M, Akahoshi Y, Nakano H, Kawamura S, Takeshita J, Yoshino N, Misaki Y, Yoshimura K, Gomyo A, Tamaki M, Kusuda M, Kameda K, Wada H, Kawamura K, Sato M, Terasako-Saito K, Tanihara A, Kimura SI, Nakasone H, Kako S, Akahane K, Wakatsuki M, Shirai K, Kanda Y. Updated Clinical Outcomes of Hematopoietic Stem Cell Transplantation Using Myeloablative Total Body Irradiation with Ovarian Shielding to Preserve Fertility. Biol Blood Marrow Transplant 2019; 25:2461-2467. [PMID: 31394267 DOI: 10.1016/j.bbmt.2019.07.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 11/30/2022]
Abstract
Myeloablative conditioning regimens are associated with severe gonadal toxicity. To preserve ovarian function, we have been investigating ovarian shielding during total body irradiation (TBI) with a myeloablative dose. In this report, we update the clinical outcomes. Female patients with standard-risk hematologic diseases, aged 40 years or younger, who desired to have children, were included (n = 19). The conditioning regimen consisted of TBI at 12 Gy with ovarian shielding and cyclophosphamide (120 mg/kg) or cytarabine (24 g/m2). Ovarian shielding reduced the actual irradiation dose applied to the ovaries from 12 Gy to 2 to 3 Gy. The median age at hematopoietic stem cell transplantation (HSCT) was 24 years (range, 19 to 33 years). With a median follow-up period of 1449 days (range, 64 to 3694) after HSCT, 5-year overall survival and 1- and 5-year relapse rates were 67%, 17%, and 31%, respectively. Only 2 of 14 patients with acute myeloid or lymphoid leukemia in remission have relapsed thus far. The 6-month and 1-year cumulative rates of menstrual recovery were 42% and 78%, respectively. In all patients with menstrual recovery, menstruation recovered within 1 year. The serum anti-Müllerian hormone (AMH) level tended to gradually increase after menstrual recovery. Three patients with extensive chronic graft-versus-host disease experienced delayed recovery of menstruation and serum AMH. Five pregnancies in 3 patients resulted in normal delivery in 1, selective cesarean operation in 1, current pregnancy in 1, and natural abortion in 2. These results suggest that a myeloablative TBI regimen with ovarian shielding could preserve fertility after HSCT without an apparent increase in relapse in standard-risk patients. Because serum AMH recovered gradually over time, the AMH level during the early phase after HSCT may have little value as a marker of ovarian reserve.
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Affiliation(s)
- Masahiro Ashizawa
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Yu Akahoshi
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hirofumi Nakano
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Shunto Kawamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Junko Takeshita
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Nozomu Yoshino
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yukiko Misaki
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Kazuki Yoshimura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Ayumi Gomyo
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masaharu Tamaki
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Machiko Kusuda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Kazuaki Kameda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hidenori Wada
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Koji Kawamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Miki Sato
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Kiriko Terasako-Saito
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Aki Tanihara
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Shun-Ichi Kimura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hideki Nakasone
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Shinichi Kako
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Keiko Akahane
- Division of Radiology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masaru Wakatsuki
- Department of Radiology, Jichi Medical University, Tochigi, Japan
| | - Katsuyuki Shirai
- Division of Radiology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan; Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan.
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21
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Conditioning intensity in secondary AML with prior myelodysplastic syndrome/myeloproliferative disorders: an EBMT ALWP study. Blood Adv 2019; 2:2127-2135. [PMID: 30143527 DOI: 10.1182/bloodadvances.2018019976] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 06/27/2018] [Indexed: 12/22/2022] Open
Abstract
Patients with secondary AML (sAML) with antecedent myelodysplastic syndrome (MDS) or myeloproliferative neoplasms (MPNs) tend to have high-risk disease based on the older age of patients, high-risk cytogenetics, and higher number of prior treatments. Allogeneic hematopoietic cell transplant (HCT) is the only potentially curative therapy available. Eight hundred and two adults with sAML and prior MDS/MPN who received a first HCT between 2000 and 2016 were included in the European Society for Blood and Marrow Transplant (EBMT) Acute Leukemia Working Party (ALWP) study. Median age of the cohort was 59.6 years (range, 18.6-78.6 years). Myeloablative conditioning (MAC) was given to 40% of patients, and 60% received reduced-intensity conditioning (RIC). Overall, the 2-year cumulative incidence of relapse (RI) was 37%, leukemia-free survival (LFS) was 40%, overall survival (OS) was 46%, nonrelapse mortality (NRM) was 23%, and chronic graft-versus-host disease (cGVHD) was 39%. In univariate analysis, a statistical difference between conditioning regimens 6 months after HCT in favor of the MAC group was noted with regard to RI (hazard ratio [HR], 1.47; P = .03), LFS (HR, 1.43; P = .01), and OS (HR, 1.55; P < .05). There was no difference in the cumulative incidence of NRM (HR, 1.38; P = .15). This effect was similarly seen in multivariate analysis (MVA): cumulative incidence of relapse (HR, 1.79; P < .05), LFS (HR, 1.43; P = .02), and OS (HR, 1.53; P = .005) with no difference in NRM (HR, 1; P = .98). This EBMT ALWP analysis suggests that long-term survival can be achieved in patients with sAML with antecedent MDS/MPN and that MAC is a suitable conditioning regimen in patients with sAML.
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22
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Hematopoietic cell transplant for acute myeloid leukemia and myelodysplastic syndrome: conditioning regimen intensity. Blood Adv 2019; 2:2095-2103. [PMID: 30135184 DOI: 10.1182/bloodadvances.2018021980] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 07/24/2018] [Indexed: 11/20/2022] Open
Abstract
In this study, we sought to identify specific individual high-intensity or reduced-intensity conditioning regimens with the best relapse-free survival (RFS) rather than the global high- vs reduced-intensity regimen comparison. Patients (median age, 58 years) with acute myeloid leukemia (AML; n = 1258), who were in first or subsequent remission, or with MDS (n = 951) who had refractory anemia with unilineage or multilineage dysplasia, 5q- syndrome, or refractory anemia with excess blasts received nonirradiation-containing regimens and were transplanted between 2009 and 2014 in the United States. Three-year RFS with high-intensity busulfan/cyclophosphamide (Bu4/Cy; 44%) was comparable to conditioning with high-intensity fludarabine/busulfan (Flu/Bu4; 44%), reduced-intensity fludarabine/melphalan (Flu/Mel; 52%; P = .53), and Flu/Mel + anti-thymocyte globulin (ATG; 44%; P = .38). RFS was lower with reduced-intensity Flu/Bu2 + ATG (31%; P = .0006). RFS was also lower with high-intensity Flu/Bu4 + ATG (38%; P = .05) and reduced-intensity Flu/Bu2 (38%; P = .02), although the difference did not reach the level of significance set for these analysis. RFS with Flu/Mel was superior to RFS with Flu/Bu2 (P = .01) and Flu/Bu2 + ATG (P = .0006). The 3-year incidence of relapse was 22% with Flu/Mel compared with 46% with Flu/Bu2 and 56% with Flu/Bu2 + ATG. With only a modest reduction in nonrelapse mortality with the Flu/Bu2 regimens, the higher relapse incidence resulted in lower RFS. The data support optimal RFS with Bu4/Cy, Flu/Bu4, and Flu/Mel regimens for AML in remission or MDS. The low relapse rate with reduced-intensity Flu/Mel resulted in RFS comparable to that after the higher-intensity regimens.
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23
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Monaco F, Scott BL, Chauncey TR, Petersen FB, Storer BE, Baron F, Flowers ME, Deeg HJ, Maloney DG, Storb R, Sandmaier BM. Total body irradiation dose escalation decreases risk of progression and graft rejection after hematopoietic cell transplantation for myelodysplastic syndromes or myeloproliferative neoplasms. Haematologica 2019; 104:1221-1229. [PMID: 30630975 PMCID: PMC6545836 DOI: 10.3324/haematol.2018.199398] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 01/02/2019] [Indexed: 11/09/2022] Open
Abstract
A non-myeloablative regimen of fludarabine and 200 cGy total body irradiation combined with post-grafting immunosuppression with mycophenolate mofetil and a calcineurin inhibitor facilitates allogeneic hematopoietic cell transplantation from HLA-matched related or unrelated donors in older patients and/or those with comorbidities. However, outcomes of prior studies have been disappointing in patients with myelodysplastic syndromes or myeloproliferative neoplasms due to high incidences of progression or graft failure (together termed hematopoietic cell transplantation-failure). We hypothesized that escalating the total body irradiation dose may improve the outcomes and subsequently performed a phase II total body irradiation dose-escalation trial. Patients with median age 66 years were enrolled in two arms to receive non-myeloablative conditioning followed by hematopoietic cell transplantation with total body irradiation dose escalation for excessive hematopoietic cell transplantation-failure: Arm A: myeloproliferative neoplasm/myelodysplastic syndrome low risk (n=36); and Arm B: myelodysplastic syndrome high-risk/chronic myelomonocytic leukemia (n=41). Total body irradiation dose levels were: Level-1 (300 cGy), Level-2 (400 cGy), or Level-3 (450 cGy). Patients received intravenous fludarabine 30 mg/m2 for three days. Total body irradiation was administered on day 0 followed by infusion of peripheral blood stem cells from HLA-matched related (n=30) or unrelated (n=47) donors. Post-grafting immunosuppression with mycophenolate mofetil and cyclosporine was administered. The primary end point was day 200 hematopoietic cell transplant failure, with the objective of reducing the incidence to <20%. The primary end point was reached on Arm A at dose Level-1 (300 cGy total body irradiation) with a cumulative incidence of day 200 hematopoietic cell transplant failure of 11%, and on Arm B at dose Level-3 (450 cGy) with a cumulative incidence of day 200 hematopoietic cell transplant failure of 9%. Increasing the total body irradiation dose leads to a higher success rate with non-myeloablative conditioning by reducing relapse and rejection. Further studies are necessary to decrease non-relapse mortality, especially among patients with high-risk disease. Trial registered under clinicaltrials.gov identifier: NCT00397813.
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Affiliation(s)
| | - Bart L Scott
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,University of Washington, Seattle, WA, USA
| | - Thomas R Chauncey
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,University of Washington, Seattle, WA, USA.,VA Puget Sound Health Care System, Seattle, WA, USA
| | | | - Barry E Storer
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,University of Washington, Seattle, WA, USA
| | | | - Mary E Flowers
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,University of Washington, Seattle, WA, USA
| | - H Joachim Deeg
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,University of Washington, Seattle, WA, USA
| | - David G Maloney
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,University of Washington, Seattle, WA, USA
| | - Rainer Storb
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,University of Washington, Seattle, WA, USA
| | - Brenda M Sandmaier
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA .,University of Washington, Seattle, WA, USA
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24
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Ragon BK. The Art of Transplantation: Conditioning Intensity for Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2018; 25:e71-e72. [PMID: 30562588 DOI: 10.1016/j.bbmt.2018.12.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/12/2018] [Indexed: 10/27/2022]
Abstract
The search for the optimal conditioning regimen before allogeneic hematopoietic stem cell transplantation (HCT) for acute myelogenous leukemia (AML) and myelodysplastic syndromes (MDS) has been ongoing for decades. In this issue, Solh et al present an original analysis evaluating the impact of conditioning intensity on different disease risk index (DRI) groups of patients with AML and MDS. An impressive difference was observed in outcomes between reduced-intensity conditioning and myeloablative conditioning (MAC) regimens in the low/intermediate-risk disease groups, supporting the use of MAC in this population. Further prospective trials in this population are encouraged.
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Affiliation(s)
- Brittany Knick Ragon
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina.
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25
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Levin-Epstein R, Oliai C, Schiller G. Allogeneic Hematopoietic Stem Cell Transplantation for Older Patients With Acute Myeloid Leukemia. Curr Treat Options Oncol 2018; 19:63. [PMID: 30362051 DOI: 10.1007/s11864-018-0577-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OPINION STATEMENT Acute myelogenous leukemia (AML) in the elderly is complex and has a poor prognosis, often characterized by higher risk cytogenetic and molecular features compared to that in younger patients. Rates of transplant have been limited by concern related to non-relapse mortality, as older patients have historically been considered medically unfit for the transplantation process. Reduced-intensity conditioning (RIC) for hematopoietic stem cell transplantation (HSCT) has been shown to provide similar efficacy to myeloablative methods, with decreased non-relapse mortality in the elderly and improved efficacy over non-transplant approaches with cytotoxic chemotherapy alone. Targeted non-cytotoxic and modified cytotoxic agents have emerged to further improve transplant outcomes for older AML patients. Validated comorbidity indices are useful tools to assess an individual's fitness for undergoing HSCT rather than chronological age alone. We believe HSCT is the primary curative treatment approach for many older AML patients, taking into account risk and comorbidities, particularly given the tendency of leukemia in this population to harbor an unfavorable disease profile. We use RIC and advocate for the addition of targeted agents if applicable. With continuing data in support of transplant for older AML patients, we anticipate that transplant rates in this population will continue to rise.
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Affiliation(s)
- Rebecca Levin-Epstein
- UCLA Department of Radiation Oncology, 200 Medical Plaza, Suite B265, Los Angeles, CA, 90095, USA.
| | - Caspian Oliai
- UCLA Department of Hematology Oncology, 200 Medical Plaza, Suite 120, Los Angeles, CA, 90095, USA
| | - Gary Schiller
- UCLA Department of Hematology Oncology, 200 Medical Plaza, Suite 120, Los Angeles, CA, 90095, USA
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26
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Scott BL. It's Not All in the Conditioning or the Perils of Early Trial Cessation. Biol Blood Marrow Transplant 2018; 24:1957-1958. [PMID: 30125667 DOI: 10.1016/j.bbmt.2018.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 08/10/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Bart L Scott
- Fred Hutchinson Cancer Research Center, University of Washington School of Medicine, Seattle, Washington.
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27
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Yu ZP, Ding JH, Sun AN, Ge Z, Chen BA, Wu DP. A Randomized Study Comparing Stem Cell Transplantation Versus Conventional Therapy for Low- and Intermediate-Risk Myelodysplastic Syndromes Patients. Stem Cells Dev 2017; 26:1132-1139. [PMID: 28494646 DOI: 10.1089/scd.2017.0031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Zheng-Ping Yu
- Hematology Division, The First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Hematology (Key Department of Jiangsu Medicine), ZhongDa Hospital, Southeast University, Nanjing, China
| | - Jia-Hua Ding
- Department of Hematology (Key Department of Jiangsu Medicine), ZhongDa Hospital, Southeast University, Nanjing, China
| | - Ai-Ning Sun
- Hematology Division, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zheng Ge
- Department of Hematology (Key Department of Jiangsu Medicine), ZhongDa Hospital, Southeast University, Nanjing, China
| | - Bao-An Chen
- Department of Hematology (Key Department of Jiangsu Medicine), ZhongDa Hospital, Southeast University, Nanjing, China
| | - De-Pei Wu
- Hematology Division, The First Affiliated Hospital of Soochow University, Suzhou, China
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28
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Abstract
Allotransplantation cures patients by cytoreduction and the graft-versus-tumor (leukemia; graft-versus-leukemia [GVL]) alloresponse; both eliminate residual disease. The spectrum of conditioning intensity influences toxicities and non-relapse mortality. The spectrum of tumor sensitivity to the GVL response influences relapse. Balancing tolerable toxicities (influenced by patients' performance status and comorbidities) is also influenced by the graft. Intense immunosuppression (for engraftment and graft-versus-host disease prevention) may constrain the immunologic potency of the graft and limit the antineoplastic capacity of the transplant, thus requiring more intense or more effective conditioning regimens to limit the risks of relapse and permit satisfactory disease-free survival.
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Affiliation(s)
- Daniel J Weisdorf
- University of Minnesota, Department of Medicine, Division of Hematology, Oncology and Transplantation, 420 Delaware Street SE, MMC 480, Minneapolis, MN 55455, United Sates.
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29
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Pulsipher MA. Reduced Intensity for Myelodysplastic Syndrome: Worth the Gamble? J Clin Oncol 2017; 35:2106-2108. [PMID: 28463632 DOI: 10.1200/jco.2017.72.8048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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30
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Scott BL, Pasquini MC, Logan BR, Wu J, Devine SM, Porter DL, Maziarz RT, Warlick ED, Fernandez HF, Alyea EP, Hamadani M, Bashey A, Giralt S, Geller NL, Leifer E, Le-Rademacher J, Mendizabal AM, Horowitz MM, Deeg HJ, Horwitz ME. Myeloablative Versus Reduced-Intensity Hematopoietic Cell Transplantation for Acute Myeloid Leukemia and Myelodysplastic Syndromes. J Clin Oncol 2017; 35:1154-1161. [PMID: 28380315 DOI: 10.1200/jco.2016.70.7091] [Citation(s) in RCA: 435] [Impact Index Per Article: 62.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The optimal regimen intensity before allogeneic hematopoietic cell transplantation (HCT) is unknown. We hypothesized that lower treatment-related mortality (TRM) with reduced-intensity conditioning (RIC) would result in improved overall survival (OS) compared with myeloablative conditioning (MAC). To test this hypothesis, we performed a phase III randomized trial comparing MAC with RIC in patients with acute myeloid leukemia or myelodysplastic syndromes. Patients and Methods Patients age 18 to 65 years with HCT comorbidity index ≤ 4 and < 5% marrow myeloblasts pre-HCT were randomly assigned to receive MAC (n = 135) or RIC (n = 137) followed by HCT from HLA-matched related or unrelated donors. The primary end point was OS 18 months post-random assignment based on an intent-to-treat analysis. Secondary end points included relapse-free survival (RFS) and TRM. Results Planned enrollment was 356 patients; accrual ceased at 272 because of high relapse incidence with RIC versus MAC (48.3%; 95% CI, 39.6% to 56.4% and 13.5%; 95% CI, 8.3% to 19.8%, respectively; P < .001). At 18 months, OS for patients in the RIC arm was 67.7% (95% CI, 59.1% to 74.9%) versus 77.5% (95% CI, 69.4% to 83.7%) for those in the MAC arm (difference, 9.8%; 95% CI, -0.8% to 20.3%; P = .07). TRM with RIC was 4.4% (95% CI, 1.8% to 8.9%) versus 15.8% (95% CI, 10.2% to 22.5%) with MAC ( P = .002). RFS with RIC was 47.3% (95% CI, 38.7% to 55.4%) versus 67.8% (95% CI, 59.1% to 75%) with MAC ( P < .01). Conclusion OS was higher with MAC, but this was not statistically significant. RIC resulted in lower TRM but higher relapse rates compared with MAC, with a statistically significant advantage in RFS with MAC. These data support the use of MAC as the standard of care for fit patients with acute myeloid leukemia or myelodysplastic syndromes.
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Affiliation(s)
- Bart L Scott
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Marcelo C Pasquini
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Brent R Logan
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Juan Wu
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Steven M Devine
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - David L Porter
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Richard T Maziarz
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Erica D Warlick
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Hugo F Fernandez
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Edwin P Alyea
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Mehdi Hamadani
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Asad Bashey
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Sergio Giralt
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Nancy L Geller
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Eric Leifer
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Jennifer Le-Rademacher
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Adam M Mendizabal
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Mary M Horowitz
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - H Joachim Deeg
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
| | - Mitchell E Horwitz
- Bart L. Scott and H. Joachim Deeg, Fred Hutchinson Cancer Research Center, Seattle, WA; Marcelo C. Pasquini, Brent R. Logan, Mehdi Hamadani, and Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; Juan Wu and Adam M. Mendizabal, Emmes Corporation, Rockville, MD; Steven M. Devine, Ohio State University Comprehensive Cancer Center, Columbus, OH; David L. Porter, University of Pennsylvania, Philadelphia, PA; Richard T. Maziarz, Oregon Health and Science University, Portland, OR; Erica D. Warlick, University of Minnesota, Minneapolis; Jennifer Le-Rademacher, Mayo Clinic, Rochester, MN; Hugo F. Fernandez, Moffitt Cancer Center, Tampa, FL; Edwin P. Alyea, Dana Farber Cancer Institute, Boston, MA; Asad Bashey, Northside Hospital Cancer Institute, Atlanta, GA; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Nancy L. Geller and Eric Leifer, National Heart, Lung, and Blood Institute, Bethesda, MD; and Mitchell E. Horwitz, Duke University, Durham, NC
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31
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Atilla E, Ataca Atilla P, Demirer T. A Review of Myeloablative vs Reduced Intensity/Non-Myeloablative Regimens in Allogeneic Hematopoietic Stem Cell Transplantations. Balkan Med J 2017; 34:1-9. [PMID: 28251017 PMCID: PMC5322516 DOI: 10.4274/balkanmedj.2017.0055] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/19/2017] [Indexed: 02/07/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (Allo-HSCT) is a curative treatment option for both malignant and some benign hematological diseases. During the last decade, many of the newer high-dose regimens in different intensity have been developed specifically for patients with hematologic malignancies and solid tumors. Today there are three main approaches used prior to allogeneic transplantation: Myeloablative (MA), Reduced Intensity Conditioning (RIC) and Non-MA (NMA) regimens. MA regimens cause irreversible cytopenia and there is a requirement for stem cell support. Patients who receive NMA regimen have minimal cytopenia and this type of regimen can be given without stem cell support. RIC regimens do not fit the criteria of MA and NMA: the cytopenia is reversible and the stem cell support is necessary. NMA/RIC for Allo-HSCT has opened a new era for treating elderly patients and those with comorbidities. The RIC conditioning was used for 40% of all Allo-HSCT and this trend continue to increase. In this paper, we will review these regimens in the setting of especially allogeneic HSCT and our aim is to describe the history, features and impact of these conditioning regimens on specific diseases.
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Affiliation(s)
- Erden Atilla
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Pınar Ataca Atilla
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Taner Demirer
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
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32
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Yeung CCS, Deeg HJ, Pritchard C, Wu D, Fang M. Jumping translocations in myelodysplastic syndromes. Cancer Genet 2016; 209:395-402. [PMID: 27751357 DOI: 10.1016/j.cancergen.2016.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 07/25/2016] [Accepted: 08/04/2016] [Indexed: 01/24/2023]
Abstract
Jumping translocations (JT) have been identified in numerous malignancies, including leukemia, but infrequently in patients with myelodysplastic syndromes (MDS). The responsible genetic region has been mapped to the JTB gene at 1q21, but breakpoints involving other chromosomal loci, such as 3q and 11q, have been described as well. We have characterized the pathological and mutational landscape, and the clinical course of 6 new MDS patients with jumping mutations using chromosome genomic array testing (CGAT) and target gene panel next generation sequencing. In addition, we have performed a literature review for other MDS cases with JTs as defined by ISCN 2013. Results support the concept that MDS in patients with jumping translocations has a poor prognosis with a high risk of progression to leukemia, and suggest that these patients warrant aggressive therapy, including HCT, early in the disease course.
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Affiliation(s)
- Cecilia C S Yeung
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview ave N, Seattle, WA 98109, USA; Department of Laboratory Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - H Joachim Deeg
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview ave N, Seattle, WA 98109, USA
| | - Colin Pritchard
- Department of Laboratory Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - David Wu
- Department of Laboratory Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Min Fang
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview ave N, Seattle, WA 98109, USA; Department of Pathology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA; Department of Laboratory Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
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33
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Goyal G, Gundabolu K, Vallabhajosyula S, Silberstein PT, Bhatt VR. Reduced-intensity conditioning allogeneic hematopoietic-cell transplantation for older patients with acute myeloid leukemia. Ther Adv Hematol 2016; 7:131-41. [PMID: 27247754 PMCID: PMC4872178 DOI: 10.1177/2040620716643493] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Elderly patients (>60 years) with acute myeloid leukemia have a poor prognosis with a chemotherapy-alone approach. Allogeneic hematopoietic-cell transplantation (HCT) can improve overall survival (OS). However, myeloablative regimens can have unacceptably high transplant-related mortality (TRM) in an unselected group of older patients. Reduced-intensity conditioning (RIC) or nonmyeloablative (NMA) conditioning regimens preserve the graft-versus-leukemia effects but reduce TRM. NMA regimens result in minimal cytopenia and may not require stem cell support for restoring hematopoiesis. RIC regimens, intermediate in intensity between NMA and myeloablative regimens, can cause prolonged myelosuppresion and usually require stem cell support. A few retrospective and prospective studies suggest a possibility of lower risk of relapse with myeloablative HCT in fit older patients with lower HCT comorbidity index; however, RIC and NMA HCTs have an important role in less-fit patients and those with significant comorbidities because of lower TRM. Whether early tapering of immunosuppression, monitoring of minimal residual disease, and post-transplant maintenance therapy can improve the outcomes of RIC and NMA HCT in elderly patients will require prospective trials.
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Affiliation(s)
- Gaurav Goyal
- Creighton University Medical Center, 601 North 30th Street, Ste 5850, Omaha, NE 68131, USA
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34
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Choi EJ, Lee JH, Lee JH, Kim DY, Park HS, Seol M, Lee YS, Kang YA, Jeon M, Lee KH. Non-myeloablative conditioning for lower-risk myelodysplastic syndrome with bone marrow blasts less than 5 %—a feasibility study. Ann Hematol 2016; 95:1151-61. [DOI: 10.1007/s00277-016-2679-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 04/16/2016] [Indexed: 01/02/2023]
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35
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Villa NY, Rahman MM, McFadden G, Cogle CR. Therapeutics for Graft-versus-Host Disease: From Conventional Therapies to Novel Virotherapeutic Strategies. Viruses 2016; 8:85. [PMID: 27011200 PMCID: PMC4810275 DOI: 10.3390/v8030085] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 03/09/2016] [Accepted: 03/09/2016] [Indexed: 02/06/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) has a curative potential for many hematologic malignancies and blood diseases. However, the success of allo-HSCT is limited by graft-versus-host disease (GVHD), an immunological syndrome that involves inflammation and tissue damage mediated by donor lymphocytes. Despite immune suppression, GVHD is highly incident even after allo-HSCT using human leukocyte antigen (HLA)-matched donors. Therefore, alternative and more effective therapies are needed to prevent or control GVHD while preserving the beneficial graft-versus-cancer (GVC) effects against residual disease. Among novel therapeutics for GVHD, oncolytic viruses such as myxoma virus (MYXV) are receiving increased attention due to their dual role in controlling GVHD while preserving or augmenting GVC. This review focuses on the molecular basis of GVHD, as well as state-of-the-art advances in developing novel therapies to prevent or control GVHD while minimizing impact on GVC. Recent literature regarding conventional and the emerging therapies are summarized, with special emphasis on virotherapy to prevent GVHD. Recent advances using preclinical models with oncolytic viruses such as MYXV to ameliorate the deleterious consequences of GVHD, while maintaining or improving the anti-cancer benefits of GVC will be reviewed.
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Affiliation(s)
- Nancy Y Villa
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL 32610, USA.
| | - Masmudur M Rahman
- Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL 32610, USA.
| | - Grant McFadden
- Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL 32610, USA.
| | - Christopher R Cogle
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL 32610, USA.
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36
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Robin M, Porcher R, Wolschke C, Sicre de Fontbrune F, Alchalby H, Christopeit M, Cassinat B, Zabelina T, Peffault de Latour R, Ayuk F, Socié G, Kröger N. Outcome after Transplantation According to Reduced-Intensity Conditioning Regimen in Patients Undergoing Transplantation for Myelofibrosis. Biol Blood Marrow Transplant 2016; 22:1206-1211. [PMID: 26970380 DOI: 10.1016/j.bbmt.2016.02.019] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 02/23/2016] [Indexed: 10/22/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation remains the sole curative option for myelofibrosis. Many transplantation recipients receive a reduced-intensity conditioning (RIC) regimen owing to age or comorbidities; however, there is little published evidence to guide the choice of RIC regimen. In this study, we compared outcomes in patients who received 1 of 2 frequently used RIC regimens for patients with myelofibrosis: fludarabine-busulfan (FB) and fludarabine-melphalan (FM). A total of 160 patients underwent a RIC allograft procedure (FB group, n = 105; FM group, n = 55). We have developed a complex statistical model involving weighting and adjustment to permit comparison between these 2 groups. After weighting, the incidence of acute graft-versus-host disease (GVHD) was 62% in the FM group and 31% in the FB group (P = .001), and the corresponding incidence of chronic GVHD was 49% and 53%, respectively. The 7-year progression-free survival was were 52% in the FM group versus 33% in the FB group, and the 7-year overall survival rate 52% in the FM group versus 59% in the FB group. Nonrelapse mortality (NRM) was 43% in the FM group and 31% in the FB group. Multivariable analyses revealed no significant differences in PFS between the 2 groups; however, the relapse rate was significantly lower in the FM group (hazard ratio, 9.21; P = .008), whereas a trend toward reduced NRM was seen in the FB group (hazard ratio, 0.51; P = .068). In conclusion, both regimens appear to be efficient in mediating disease control and can be used to successfully condition patients with myelofibrosis. The FM regimen appears to induce more NRM than the FB regimen, but with augmented control of disease, leading to comparable overall survival rates for both regimens.
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Affiliation(s)
- Marie Robin
- Hematology Transplantation, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, 2 University Paris 7, INSERM UMR 1160, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, UMR-S 1153, France.
| | - Raphael Porcher
- INSERM U1153, Paris, France. Assistance Publique-Hôpitaux de Paris, Hôtel-Dieu, Centre d'Épidémiologie Clinique, Paris, France; Department of Stem Cell Transplantation, University Medical Center Hamburg, Hamburg, Germany
| | - Christine Wolschke
- Biologie Cellulaire, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Flore Sicre de Fontbrune
- Hematology Transplantation, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, 2 University Paris 7, INSERM UMR 1160, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, UMR-S 1153, France
| | - Haefaa Alchalby
- Biologie Cellulaire, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Maximilian Christopeit
- Biologie Cellulaire, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Bruno Cassinat
- Biologie Cellulaire, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Tatjana Zabelina
- Biologie Cellulaire, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Régis Peffault de Latour
- Hematology Transplantation, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, 2 University Paris 7, INSERM UMR 1160, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, UMR-S 1153, France
| | - Francis Ayuk
- Biologie Cellulaire, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Gérard Socié
- Hematology Transplantation, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, 2 University Paris 7, INSERM UMR 1160, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, UMR-S 1153, France
| | - Nicolaus Kröger
- Biologie Cellulaire, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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37
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Pingali SR, Champlin RE. Pushing the envelope-nonmyeloablative and reduced intensity preparative regimens for allogeneic hematopoietic transplantation. Bone Marrow Transplant 2015; 50:1157-67. [PMID: 25985053 PMCID: PMC4809137 DOI: 10.1038/bmt.2015.61] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 11/17/2014] [Indexed: 12/30/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) was originally developed to allow delivery of myeloablative doses of chemotherapy and radiotherapy. With better understanding of disease pathophysiology, the graft vs malignancy (GVM) effect of allogeneic hematopoietic transplantation and toxicities associated with myeloablative conditioning (MAC) regimens, the focus shifted to developing less toxic conditioning regimens to reduce treatment-related morbidity without compromising survival. Although HCT with MAC is preferred to reduced intensity conditioning (RIC) for most patients ⩽60 years with AML/myelodysplastic syndrome and ALL, RIC and nonmyeloablative (NMA) regimens allow HCT for many otherwise ineligible patients. Reduced intensity preparative regimens have produced high rates of PFS for diagnoses, which are highly sensitive to GVM. Relapse of the malignancy is the major cause of treatment failure with RIC/NMA HCT. Incorporation of novel agents like bortezomib or lenalidomide, addition of cellular immunotherapy and use of targeted radiation therapies could further improve outcome. In this review, we discuss commonly used RIC/NMA regimens and promising novel regimens.
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Affiliation(s)
- S R Pingali
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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38
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de Koning C, Plantinga M, Besseling P, Boelens JJ, Nierkens S. Immune Reconstitution after Allogeneic Hematopoietic Cell Transplantation in Children. Biol Blood Marrow Transplant 2015; 22:195-206. [PMID: 26341398 DOI: 10.1016/j.bbmt.2015.08.028] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 08/25/2015] [Indexed: 12/14/2022]
Abstract
Allogeneic (allo) hematopoietic cell transplantation (HCT) has evolved into a potent curative treatment option for a variety of malignant and nonmalignant diseases. The occurrence of complications and mortality after allo-HCT is, however, still high and is strongly associated with immune reconstitution (IR). Therefore, detailed information on IR through immunomonitoring is crucial to improve survival chances after HCT. To date, information about the reconstituting immune system after allo-HCT in pediatric patients is mostly derived from routine standard-of-care measurements. More profound knowledge on IR may provide tools to better predict and modulate adverse reactions and, subsequently, improve survival chances. Here, we provide an overview of IR (eg, immune cell subsets and circulating chemokines/cytokines) after allo-HCT in children, taking into account different cell sources and serotherapy, and discuss strategies to enhance immunomonitoring. We conclude that available IR data after allo-HCT contain limited information on immune cell families (mostly only generic T, B, and NK cells), which would improve with more detailed information on reconstituting cell subsets or effector cell functionality at earlier time points (<1 month). In addition, secretome data (eg, multiplex cytokine/chemokine profiles) could add to the understanding of IR mechanisms and cell functionality and may even provide (early) biomarkers for individual disease outcome, such as viral reactivity, graft-versus-host disease, or graft-versus-leukemia. The present data and suggestions for more detailed, standardized, and harmonized immunomonitoring in future (pediatric) allo-HCT studies will pave the path to "precision transplantation:" an individualized HCT approach (including conditioning), based on detailed information on IR and biomarkers, aiming to reduce transplantation related mortality and relapse, and subsequently improve survival chances.
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Affiliation(s)
- Coco de Koning
- Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Maud Plantinga
- Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Paul Besseling
- Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jaap Jan Boelens
- Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands; Pediatric Blood and Marrow Transplantation Program, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Stefan Nierkens
- Laboratory of Translational Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands.
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39
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Shea TC, Walko C, Chung Y, Ivanova A, Sheets J, Rao K, Gabriel D, Comeau T, Wood W, Coghill J, Armistead P, Sarantopoulos S, Serody J. Phase I/II Trial of Dose-Escalated Busulfan Delivered by Prolonged Continuous Infusion in Allogeneic Transplant Patients. Biol Blood Marrow Transplant 2015. [PMID: 26210442 DOI: 10.1016/j.bbmt.2015.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Intensive chemotherapy or chemotherapy plus irradiation and allogeneic stem cell transplantation can be curative for patients with hematologic diseases. Reduced-intensity transplants can also achieve cure and result in less treatment-related mortality but higher relapse rates. Thus, optimizing the conditioning regimens used in allogeneic transplantation remains an important goal. We conducted a phase I/II trial to determine the maximum tolerated dose (MTD) and dose-limiting toxicities (DLTs) of a continuous infusion of busulfan over 90 hours in conjunction with fludarabine followed by allogeneic related or unrelated donor transplant. Fifty-four patients with advanced hematologic malignancies were enrolled on this study. The MTD was identified as a 24-hour area under the curve (AUC) of approximately 7095 μM/min, which represents a 43% increase over the standard total daily AUC dose of 4800 μM/min given by intermittent schedules. DLTs at doses over 8000 μM/min were identified by a desquamative skin rash and mucositis. No dose-related increase in hepatic, pulmonary, or other organ toxicities were seen, whereas efficacy appeared to be improved at higher dose levels. Continuous-infusion busulfan with intermittent fludarabine provides an alternative treatment strategy that is generally well tolerated and permits an increase in total busulfan dose with encouraging efficacy. (NCI study no. NCT00448357.).
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Affiliation(s)
- Thomas C Shea
- Program in Bone Marrow and Stem Cell Transplantation, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.
| | - Christine Walko
- DeBartolo Family Personalized Medicine Institute, Division of Population Science, Moffitt Cancer Center, Tampa, Florida
| | - Yunro Chung
- Department of Biostatistics, University of North Carolina School of Public Health, Chapel Hill, North Carolina
| | - Anastasia Ivanova
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina; Department of Biostatistics, University of North Carolina School of Public Health, Chapel Hill, North Carolina
| | - Julia Sheets
- Program in Bone Marrow and Stem Cell Transplantation, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kamakshi Rao
- Program in Bone Marrow and Stem Cell Transplantation, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Don Gabriel
- Program in Bone Marrow and Stem Cell Transplantation, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Terry Comeau
- Stem Cell Transplant Program, St. John's Regional Hospital, New Brunswick, Canada
| | - William Wood
- Program in Bone Marrow and Stem Cell Transplantation, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - James Coghill
- Program in Bone Marrow and Stem Cell Transplantation, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Paul Armistead
- Program in Bone Marrow and Stem Cell Transplantation, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | | | - Jonathan Serody
- Program in Bone Marrow and Stem Cell Transplantation, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
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Magenau JM, Braun T, Reddy P, Parkin B, Pawarode A, Mineishi S, Choi S, Levine J, Li Y, Yanik G, Kitko C, Churay T, Frame D, Riwes MM, Harris A, Bixby D, Couriel DR, Goldstein SC. Allogeneic transplantation with myeloablative FluBu4 conditioning improves survival compared to reduced intensity FluBu2 conditioning for acute myeloid leukemia in remission. Ann Hematol 2015; 94:1033-41. [PMID: 25784222 DOI: 10.1007/s00277-015-2349-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/04/2015] [Indexed: 01/01/2023]
Abstract
The optimal intensity of conditioning for allogeneic hematopoietic stem cell transplantation (HCT) in acute myeloid leukemia (AML) remains undefined. Traditionally, myeloablative conditioning regimens improve disease control, but at the risk of greater nonrelapse mortality. Because fludarabine with myeloablative doses of intravenous busulfan using pharmacokinetic monitoring has excellent tolerability, we reasoned that this regimen would limit relapse without substantially elevating toxicity when compared to reduced intensity conditioning. We retrospectively analyzed 148 consecutive AML patients in remission receiving T cell replete HCT conditioned with fludarabine and intravenous busulfan at doses defined as reduced (6.4 mg/kg; FluBu2, n = 63) or myeloablative (12.8 mg/kg; FluBu4, n = 85). Early and late nonrelapse mortality (NRM) was similar among FluBu4 and FluBu2 recipients, respectively (day + 100: 4 vs 0 %; 5 years: 19 vs 22 %; p = 0.54). NRM did not differ between FluBu4 and FluBu2 in patients >50 years of age (24 vs 22 %, p = 0.75). Relapse was lower in recipients of FluBu4 (5 years: 30 vs 49 %; p = 0.04), especially in patients with poor risk cytogenetics (22 vs 59 %; p = 0.02) and those >50 years of age (28 vs 51 %; p = 0.02). Overall survival favored FluBu4 recipients at 5 years (53 vs 34 %, p = 0.02), a finding confirmed in multivariate analysis (HR: 0.57; 95 % CI: 0.34-0.95; p = 0.03). These data suggest that myeloablative FluBu4 may provide equivalent NRM, reduced relapse, and improved survival compared to FluBu2, emphasizing the importance of busulfan dose in conditioning for AML.
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Affiliation(s)
- John M Magenau
- University of Michigan Comprehensive Cancer Center, Ann Arbor, MI, USA,
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41
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Robin M, Porcher R, Adès L, Raffoux E, Michallet M, François S, Cahn JY, Delmer A, Wattel E, Vigouroux S, Bay JO, Cornillon J, Huynh A, Nguyen S, Rubio MT, Vincent L, Maillard N, Charbonnier A, de Latour RP, Reman O, Dombret H, Fenaux P, Socié G. HLA-matched allogeneic stem cell transplantation improves outcome of higher risk myelodysplastic syndrome A prospective study on behalf of SFGM-TC and GFM. Leukemia 2015; 29:1496-501. [DOI: 10.1038/leu.2015.37] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 11/26/2014] [Accepted: 12/01/2014] [Indexed: 11/09/2022]
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Blau O, Blau IW. Some aspects of allogeneic stem cell transplantation in patients with myelodysplastic syndrome: advances and controversy. STEM CELLS AND CLONING-ADVANCES AND APPLICATIONS 2014; 7:101-8. [PMID: 25506229 PMCID: PMC4260682 DOI: 10.2147/sccaa.s50514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Myelodysplastic syndrome (MDS) is a heterogeneous group of myeloid disorders. MDS remains a disease of elderly patients; moreover, the incidence of high risk MDS is proportionally greater in elderly patients, with increased frequency of secondary acute myeloid leukemia, as well as adverse cytogenetic abnormalities. Allogeneic stem cell transplantation is a therapeutic approach with known curative potential for patients with MDS that allows the achievement of long-term disease control. Numerous controversies still exist regarding transplantation in MDS: timing of transplantation, disease status at transplantation and comorbidity, conditioning intensity, pretransplant therapy, and stem cell source. Various transplant modalities of different intensities and alternative donor sources are now in use. Current advances in transplant technology are allowing the consideration of older patients. This should result in a greater number of older patients benefiting from this potentially curative treatment modality. Despite advances in transplantation technology, there is still considerable morbidity and mortality associated with this approach. Nevertheless, with the introduction of reduced-intensity conditioning and thereby reduced early mortality, transplant numbers in MDS patients have significantly increased. Moreover, recent new developments with innovative drugs, including hypomethylating agents, have extended the therapeutic alternatives for MDS patients. Hypomethylating agents allow the delay of allogeneic stem cell transplantation by serving as an effective and well-tolerated means to reduce disease burden.
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Affiliation(s)
- Olga Blau
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Igor Wolfgang Blau
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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43
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Wetzko K, Platzbecker U. Transplants in Myelodysplastic Syndromes. Hematol Oncol Clin North Am 2014; 28:1011-22. [DOI: 10.1016/j.hoc.2014.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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44
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Díez Campelo M, Sánchez-Barba M, de Soria VGG, Martino R, Sanz G, Insunza A, Bernal T, Duarte R, Amigo M, Xicoy B, Tormo M, Iniesta F, Bailén A, Benlloch L, Córdoba I, López-Villar O, del Cañizo M. Results of allogeneic stem cell transplantation in the Spanish MDS registry: Prognostic factors for low risk patients. Leuk Res 2014; 38:1199-206. [DOI: 10.1016/j.leukres.2014.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 07/06/2014] [Accepted: 07/25/2014] [Indexed: 01/15/2023]
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45
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Park J, Choi EK, Kim JH, Lee SW, Song SY, Yoon SM, Kim YS, Kim SS, Park JH, Park J, Ahn SD. Effects of total body irradiation-based conditioning on allogeneic stem cell transplantation for pediatric acute leukemia: a single-institution study. Radiat Oncol J 2014; 32:198-207. [PMID: 25324992 PMCID: PMC4194303 DOI: 10.3857/roj.2014.32.3.198] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 06/30/2014] [Accepted: 09/01/2014] [Indexed: 11/13/2022] Open
Abstract
Purpose To evaluate the effects of total body irradiation (TBI), as a conditioning regimen prior to allogeneic stem cell transplantation (allo-SCT), in pediatric acute leukemia patients. Materials and Methods From January 2001 to December 2011, 28 patients, aged less than 18 years, were treated with TBI-based conditioning for allo-SCT in our institution. Of the 28 patients, 21 patients were diagnosed with acute lymphoblastic leukemia (ALL, 75%) and 7 were diagnosed with acute myeloid leukemia (AML, 25%). TBI was completed 4 days or 1 day before stem cell infusion. Patients underwent radiation therapy with bilateral parallel opposing fields and 6-MV X-rays. The Kaplan-Meier method was used to calculate survival outcomes. Results The 2-year event-free survival and overall survival rates were 66% and 56%, respectively (71.4% and 60.0% in AML patients vs. 64.3% and 52.4% in ALL patients, respectively). Treatment related mortality rate were 25%. Acute and chronic graft-versus-host disease was a major complication; other complications included endocrine dysfunction and pulmonary complications. Common complications from TBI were nausea (89%) and cataracts (7.1%). Conclusion The efficacy and toxicity data in this study of TBI-based conditioning to pediatric acute leukemia patients were comparable with previous studies. However, clinicians need to focus on the acute and chronic complications related to allo-SCT.
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Affiliation(s)
- Jongmoo Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Kyung Choi
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Wook Lee
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Si Yeol Song
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Min Yoon
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Seok Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Su Ssan Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Hong Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jaehyeon Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Do Ahn
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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46
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Abdul Wahid SF, Ismail NA, Mohd-Idris MR, Jamaluddin FW, Tumian N, Sze-Wei EY, Muhammad N, Nai ML. Comparison of reduced-intensity and myeloablative conditioning regimens for allogeneic hematopoietic stem cell transplantation in patients with acute myeloid leukemia and acute lymphoblastic leukemia: a meta-analysis. Stem Cells Dev 2014; 23:2535-52. [PMID: 25072307 DOI: 10.1089/scd.2014.0123] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Currently, the indications to perform reduced-intensity conditioning allogeneic hematopoietic stem cell transplant (RIC-HCT) are based on data derived mainly from large registry and single-centre retrospective studies. Thus, at the present time, there is limited direct evidence supporting the current practice in selecting patients with acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) for RIC versus myeloablative conditioning (MAC) transplants. To determine the relationship between dose intensity of conditioning regimen and survival outcomes after allografting in AML/ALL patients, we performed a meta-analysis of 23 clinical trials reported between 1990 and 2013 involving 15,258 adult patients that compare survival outcomes after RIC-HCT versus MAC-HCT. RIC-HCT resulted in comparable <2-year and 2-6 year overall survival (OS) rates post-transplantation even though the RIC-HCT recipients were older and had more active disease than MAC-HCT recipients. The 2-6 year progression-free survival (PFS), nonrelapse mortality, acute graft-versus-host disease (GvHD) and chronic GvHD rates were reduced after RIC-HCT, but relapse rate was increased. Similar outcomes were observed regardless of disease type and status at transplantation. Odds ratio for all outcomes remained comparable with or without performing separate analyses for the year of HCT and for retrospective versus prospective studies. Among RIC-HCT recipients, survival rates were superior if patients were in CR at transplantation. Significant inter-study heterogeneity for aGvHD data and publication bias for PFS data were observed. This meta-analysis showed no OS benefit of MAC-HCT over RIC-HCT across the entire cohort of patients suggesting that RIC-HCT could be an effective therapeutic option for AML/ALL patients who are ineligible for MAC-HCT and CR status is preferred before RIC-HCT.
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Affiliation(s)
- S Fadilah Abdul Wahid
- 1 Cell Therapy Center, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre , Kuala Lumpur, Malaysia
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Abstract
PURPOSE OF REVIEW The only current treatment capable of curing patients with myelodysplastic syndromes (MDS) is allogeneic haematopoietic stem cell transplantation (HCT). However, many MDS patients are older, often with substantial comorbid conditions, and the disease is heterogeneous. As a consequence, results of HCT vary considerably, and the practices of HCT for MDS are evolving. RECENT FINDINGS The newly published modified International Prognostic Scoring System (IPSS-R), developed for nontransplanted patients, also correlates with post-HCT outcome, with the patient's karyotype having the strongest impact. The presence of monosomal karyotype and various genetic and molecular markers have also been shown to have a prognostic value. The use of hypomethylating agents, before or after HCT, may reduce the post-HCT relapse risk or delay relapse. Low and reduced-intensity conditioning regimens have allowed to transplant growing numbers of older patients with MDS, and the development of novel regimens may lead to improved relapse-free survival even in patients with high-risk cytogenetics. The optimal stem cell source may differ for different patient populations and different disease risk categories. SUMMARY Transplant results for MDS have improved in recent years. Some patients even in the eighth decade of life have been transplanted successfully. Ongoing studies are aimed at further reducing transplant-related toxicity, graft-versus-host disease and post-HCT relapse.
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48
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Total lymphoid irradiation-antithymocyte globulin conditioning and allogeneic transplantation for patients with myelodysplastic syndromes and myeloproliferative neoplasms. Biol Blood Marrow Transplant 2014; 20:837-43. [PMID: 24607552 DOI: 10.1016/j.bbmt.2014.02.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 02/25/2014] [Indexed: 10/25/2022]
Abstract
Allogeneic hematopoietic cell transplantation (allo HCT) is the only curative therapy for the myelodysplastic syndromes (MDS) and myeloproliferative neoplasms (MPN), but treatment toxicity has been a barrier to its more widespread use. The nonmyeloablative regimen of total lymphoid irradiation (TLI) and antithymocyte globulin (ATG) permits the establishment of donor hematopoiesis necessary for the graft-versus-malignancy effect and is protective against acute graft-versus-host disease (aGVHD), but it has minimal direct cytotoxicity against myeloid diseases. We explored the use of TLI-ATG conditioning to treat 61 patients with allo HCT for MDS (n = 32), therapy-related myeloid neoplasms (n = 15), MPN (n = 9), and chronic myelomonocytic leukemia (n = 5). The median age of all patients was 63 years (range, 50 to 73). The cumulative incidence of aGVHD grades II to IV was 14% (95% confidence interval [CI], 4% to 23%) and for grades III to IV, 4% (95% CI, 0 to 9%), and it did not differ between patients who received allografts from related or unrelated donors. The cumulative incidence of nonrelapse mortality (NRM) at 100 days, 12 months, and 36 months was 0%, 7%, and 11%. Overall survival and progression-free survival were 41% (95% CI, 29% to 53%) and 35% (95% CI, 23% to 48%), respectively. The safety and tolerability of TLI-ATG, as exemplified by its low NRM, provides a foundation for further risk-adapted or prophylactic interventions to prevent disease progression.
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49
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Killick SB, Carter C, Culligan D, Dalley C, Das-Gupta E, Drummond M, Enright H, Jones GL, Kell J, Mills J, Mufti G, Parker J, Raj K, Sternberg A, Vyas P, Bowen D. Guidelines for the diagnosis and management of adult myelodysplastic syndromes. Br J Haematol 2014; 164:503-25. [PMID: 24372298 DOI: 10.1111/bjh.12694] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Sally B Killick
- The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
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Transplantation for children with acute myeloid leukemia: a comparison of outcomes with reduced intensity and myeloablative regimens. Blood 2014; 123:1615-20. [PMID: 24435046 DOI: 10.1182/blood-2013-10-535716] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The safety and efficacy of reduced-intensity conditioning (RIC) regimens for the treatment of pediatric acute myeloid leukemia is unknown. We compared the outcome of allogeneic hematopoietic cell transplantation in children with acute myeloid leukemia using RIC regimens with those receiving myeloablative-conditioning (MAC) regimens. A total of 180 patients were evaluated (39 with RIC and 141 with MAC regimens). Results of univariate and multivariate analysis showed no significant differences in the rates of acute and chronic graft-versus-host disease, leukemia-free, and overall survival between treatment groups. The 5-year probabilities of overall survival with RIC and MAC regimens were 45% and 48%, respectively (P = .99). Moreover, relapse rates were not higher with RIC compared with MAC regimens (39% vs 39%; P = .95), and recipients of MAC regimens were not at higher risk for transplant-related mortality compared with recipients of RIC regimens (16% vs 16%; P = .73). After carefully controlled analyses, we found that in this relatively modest study population, the data supported a role for RIC regimens for acute myeloid leukemia in children undergoing allogeneic hematopoietic cell transplantation. The data also provided justification for designing a carefully controlled randomized clinical trial that examines the efficacy of regimen intensity in this population.
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