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Haroun E, Agrawal K, Leibovitch J, Kassab J, Zoghbi M, Dutta D, Lim SH. Chronic graft-versus-host disease in pediatric patients: Differences and challenges. Blood Rev 2023; 60:101054. [PMID: 36805299 DOI: 10.1016/j.blre.2023.101054] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 02/10/2023]
Abstract
Despite the use of high-resolution molecular techniques for tissue typing, chronic graft-versus-host disease (cGVHD) remains a major complication following allogeneic hematopoietic stem cell transplant. cGVHD adversely affects the life-expectancy and quality of life. The latter is particularly important and functionally relevant in pediatric patients who have a longer life-expectancy than adults. Current laboratory evidence suggests that there is not any difference in the pathophysiology of cGVHD between adults and pediatric patients. However, there are some clinical features and complications of the disease that are different in pediatric patients. There are also challenges in the development of new therapeutics for this group of patients. In this review, we will discuss the epidemiology, pathophysiology, clinical features and consequences of the disease, and highlight the differences between pediatric and adult patients. We will examine the current treatment options for pediatric patients with moderate to severe cGVHD and discuss the challenges facing therapeutic development for cGVHD in the pediatric population.
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Affiliation(s)
- Elio Haroun
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, NY, United States of America
| | - Kavita Agrawal
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, NY, United States of America
| | - Jennifer Leibovitch
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, NY, United States of America
| | - Joseph Kassab
- Department of Medicine, Saint-Joseph University of Beirut, Beirut, Lebanon
| | - Marianne Zoghbi
- Department of Medicine, Saint-Joseph University of Beirut, Beirut, Lebanon
| | - Dibyendu Dutta
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, NY, United States of America
| | - Seah H Lim
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, NY, United States of America,; Sanofi Oncology, Cambridge, MA, United States of America.
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2
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Short course of voriconazole therapy as a risk factor for relapse of invasive pulmonary aspergillosis. Sci Rep 2020; 10:16078. [PMID: 32999399 PMCID: PMC7527978 DOI: 10.1038/s41598-020-73098-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/04/2020] [Indexed: 11/17/2022] Open
Abstract
To investigate associations of the duration of voriconazole treatment and radiological response with relapse of invasive pulmonary aspergillosis (IPA) in immunocompromised patients, we explored the risk factors for IPA relapse after successful initial treatment. All patients with proven or probable IPA who had finished voriconazole treatment between 2005 and 2019 in a tertiary-care hospital were reviewed. IPA relapse was defined as re-diagnosis of proven or probable IPA at the same site within 1 year after treatment termination. Short course of voriconazole treatment was defined as a treatment less than 9 weeks, which is a median of the recommended minimum duration of therapy from the Infectious Disease Society of America. The radiological response was defined as a reduction in IPA burden by more than 50% on chest computed tomography. Of 87 patients who had completed voriconazole treatment, 14 (16.1%) experienced IPA relapse. Multivariable Cox regression identified that short voriconazole treatment duration (adjusted hazard ratio [aHR], 3.7; 95% confidence interval [CI], 1.1–12.3; P = 0.033) and radiological non-response (aHR, 4.6; 95% CI, 1.2–17.5; P = 0.026) were independently associated with relapse of IPA after adjusting for several clinical risk factors. Longer duration of therapy should be considered for those at higher risk of relapse.
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3
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Huang A, Zhao X, Li M, Tang G, Fei Y, Wang R, Gao L, Ni X, Zhang W, Yang J, Hu X, Wang J. Suppression of Hematopoietic Primitive Cells in Patients with Secondary Failure of Platelet Recovery after Acute Graft-versus-Host Disease. Biol Blood Marrow Transplant 2020; 26:1840-1854. [PMID: 32534102 DOI: 10.1016/j.bbmt.2020.06.003] [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: 02/08/2020] [Revised: 05/31/2020] [Accepted: 06/01/2020] [Indexed: 10/24/2022]
Abstract
Secondary failure of platelet recovery (SFPR) can occur after allogeneic hematopoietic stem cell transplantation (alloHSCT), and 20% of cases are related to acute graft-versus-host disease (aGVHD). The underlying mechanisms of this association are unclear, however. The aim of the present study was to investigate the potential mechanisms of SFPR secondary to aGVHD, which may provide a new therapeutic strategy for these patients. A total of 468 patients with malignant hematologic disease who underwent alloHSCT were included. Sixty-six patients developed SFPR after alloHSCT, and in 45 of these 66 patients (68.2%), SFPR was secondary to grade II-IV aGVHD (SFPR/aGVHD). Compared with patients with good graft function (GGF), patients with SFPR had poor overall survival (20.72% versus 88.01%; P < .0001). Grade II-IV aGVHD was identified as an independent risk factor for SFPR in multivariate analysis (hazard ratio, 9.512; P < .0001). We observed reduced erythroid and megakaryocyte colony formation in bone marrow (BM) samples isolated from SFPR/aGVHD patients, consistent with the lower frequency of megakaryocyte and erythrocyte progenitors in BM. Levels of the inflammatory cytokines IL-2R and TNF-R1 were significantly higher in the SFPR/aGVHD group compared with the GGF group (P = .002 and .001, respectively), as were the frequencies of proinflammatory T helper subsets. Furthermore, the pathways that regulate hematopoiesis and immune responses were universally underexpressed in CD34+ cells isolated from SFPR/aGVHD patients. Differentially expressed genes were significantly enriched in the hematopoietic cell lineage pathway and other pathways involved in both immune responses and megakaryopoiesis. In summary, we found that both the immune microenvironment and compromised proliferation of hematopoietic primitive cells contribute to the development of SFPR secondary to aGVHD, and our data provide new insight into the mechanisms of SFPR in the context of aGVHD.
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Affiliation(s)
- Aijie Huang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Xiaoming Zhao
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Meizhang Li
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Gusheng Tang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Yang Fei
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Roujia Wang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Lei Gao
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Xiong Ni
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Weiping Zhang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Jianmin Yang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Xiaoxia Hu
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China.
| | - Jianmin Wang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China.
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4
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Pusic I, Pavletic SZ. Challenges in Conducting Studies in Chronic Graft- versus-Host Disease. Clin Hematol Int 2019; 1:36-44. [PMID: 34595409 PMCID: PMC8432377 DOI: 10.2991/chi.d.190314.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/10/2019] [Indexed: 12/03/2022] Open
Abstract
The lack of standardized criteria for measuring therapeutic response has been a major obstacle to the development of therapeutic trials in chronic graft-versus-host disease (cGvHD). Nevertheless, recent advances have been made in understanding of the biology and pathophysiology of cGvHD, as well as establishing more precise criteria for the diagnosis and classification of disease manifestations. The momentum has shifted, and currently there is a long list of new potential treatment targets being identified for cGvHD. Consequently, new drugs are being implemented for its prophylaxis and treatment. It is crucial to continue that trend and develop better systems to test new drugs in clinical practice that would eventually translate toward seeking regulatory review and approval. We provide a historical perspective and current challenges in conducting cGvHD clinical trials.
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Affiliation(s)
- Iskra Pusic
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Steven Z Pavletic
- National Institutes of Health, National Cancer Institute, Center for Cancer Research, Bethesda, Maryland
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5
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EBMT-NIH-CIBMTR Task Force position statement on standardized terminology & guidance for graft-versus-host disease assessment. Bone Marrow Transplant 2018; 53:1401-1415. [PMID: 29872128 PMCID: PMC6786777 DOI: 10.1038/s41409-018-0204-7] [Citation(s) in RCA: 237] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 03/05/2018] [Accepted: 04/03/2018] [Indexed: 11/21/2022]
Abstract
Several international recommendations address the assessment of graft-versus-host disease (GvHD) after hematopoietic cell transplantation (HCT). This position statement by GvHD experts from the European Society for Blood and Marrow Transplantation (EBMT), the National Institutes of Health (NIH) and the Center for International Blood and Marrow Transplant Research (CIBMTR) reviews the existing guidelines for both acute and chronic GvHD, addresses potential confusions that arise in daily practice and proposes consensus definitions for many key terms. We provide a historical perspective on the currently available guidelines and recommend the Mount Sinai Acute GvHD International Consortium (MAGIC) criteria for acute GvHD and the NIH 2014 criteria for chronic GvHD as the most comprehensive and detailed criteria available. This statement also offers practical guidance for the implementation of these recommendations and a set of consensus definitions for commonly used GvHD terms in order to facilitate future clinical and translational research. To assist the dissemination of these recommendations, a web-application based on this position statement is available (https://www.uzleuven.be/egvhd). We believe that adherence to a common set of GvHD assessment criteria is vitally important to improve the quality of data, compare results of retrospective studies and prospective clinical trials, and make therapeutic recommendations based on quality evidence.
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Fox TA, Chakraverty R, Burns S, Carpenter B, Thomson K, Lowe D, Fielding A, Peggs K, Kottaridis P, Uttenthal B, Bigley V, Buckland M, Grandage V, Denovan S, Grace S, Dahlstrom J, Workman S, Symes A, Mackinnon S, Hough R, Morris E. Successful outcome following allogeneic hematopoietic stem cell transplantation in adults with primary immunodeficiency. Blood 2018; 131:917-931. [PMID: 29279357 PMCID: PMC6225386 DOI: 10.1182/blood-2017-09-807487] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 12/14/2017] [Indexed: 12/14/2022] Open
Abstract
The primary immunodeficiencies (PIDs), rare inherited diseases characterized by severe dysfunction of immunity, have been successfully treated by allogeneic hematopoietic stem cell transplantation (Allo-HSCT) in childhood. Controversy exists regarding optimal timing and use of Allo-HSCT in adults, due to lack of experience and previous poor outcomes. Twenty-nine consecutive adult patients, with a mean age at transplant of 24 years (range, 17-50 years), underwent Allo-HSCT. Reduced-intensity conditioning (RIC) included fludarabine (Flu)/melphalan/alemtuzumab (n = 20), Flu/busulfan (Bu)/alemtuzumab (n = 8), and Flu/Bu/antithymocyte globulin (n = 1). Stem cell donors were matched unrelated donors or mismatched unrelated donors (n = 18) and matched related donors (n = 11). Overall survival (OS), event-free survival, transplant-related mortality (TRM), acute and chronic graft-versus-host disease incidence and severity, time to engraftment, lineage-specific chimerism, immune reconstitution, and discontinuation of immunoglobulin replacement therapy were recorded. OS at 3 years for the whole cohort was 85.2%. The rarer PID patients without chronic granulomatous disease (CGD) achieved an OS at 3 years of 88.9% (n = 18), compared with 81.8% for CGD patients (n = 11). TRM was low with only 4 deaths observed at a median follow-up of 3.5 years. There were no cases of early or late rejection. In all surviving patients, either stable mixed chimerism or full donor chimerism were observed. At last follow-up, 87% of the surviving patients had no evidence of persistent or recurrent infections. Allo-HSCT is safe and effective in young adult patients with severe PID and should be considered the treatment of choice where an appropriate donor is available.
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Affiliation(s)
- Thomas A Fox
- Institute of Immunity and Transplantation, University College London (UCL), London, United Kingdom
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
| | - Ronjon Chakraverty
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
- Department of Haematology, Cancer Institute, UCL, London, United Kingdom
| | - Siobhan Burns
- Institute of Immunity and Transplantation, University College London (UCL), London, United Kingdom
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
| | - Benjamin Carpenter
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Kirsty Thomson
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Cancer Institute, UCL, London, United Kingdom
| | - David Lowe
- Institute of Immunity and Transplantation, University College London (UCL), London, United Kingdom
- Department of Immunology, Royal Free London NHS FT, London, United Kingdom
| | - Adele Fielding
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
- Department of Haematology, Cancer Institute, UCL, London, United Kingdom
| | - Karl Peggs
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Cancer Institute, UCL, London, United Kingdom
| | - Panagiotis Kottaridis
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
| | - Benjamin Uttenthal
- Department of Haematology, Addenbrookes' Hospital, Cambridge, United Kingdom; and
| | - Venetia Bigley
- Institute of Cellular Medicine, Newcastle University, Newcastle, United Kingdom
| | - Matthew Buckland
- Institute of Immunity and Transplantation, University College London (UCL), London, United Kingdom
- Department of Immunology, Royal Free London NHS FT, London, United Kingdom
| | - Victoria Grandage
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Shari Denovan
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Sarah Grace
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Julia Dahlstrom
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Sarita Workman
- Department of Immunology, Royal Free London NHS FT, London, United Kingdom
| | - Andrew Symes
- Department of Immunology, Royal Free London NHS FT, London, United Kingdom
| | - Stephen Mackinnon
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Haematology, Royal Free London NHS FT, London, United Kingdom
- Department of Haematology, Cancer Institute, UCL, London, United Kingdom
| | - Rachael Hough
- Teenage and Young Adult BMT Programme, UCL Hospital NHS FT, London, United Kingdom
| | - Emma Morris
- Institute of Immunity and Transplantation, University College London (UCL), London, United Kingdom
- Bone Marrow Transplant (BMT) Programme, UCL Hospital National Health Service Foundation Trust (NHS FT), London, United Kingdom
- Department of Immunology, Royal Free London NHS FT, London, United Kingdom
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7
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Metheny L, Eid S, Lingas K, Ofir R, Pinzur L, Meyerson H, Lazarus HM, Huang AY. Posttransplant Intramuscular Injection of PLX-R18 Mesenchymal-Like Adherent Stromal Cells Improves Human Hematopoietic Engraftment in A Murine Transplant Model. Front Med (Lausanne) 2018. [PMID: 29520362 PMCID: PMC5827167 DOI: 10.3389/fmed.2018.00037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Late-term complications of hematopoietic cell transplantation (HCT) are numerous and include incomplete engraftment. One possible mechanism of incomplete engraftment after HCT is cytokine-mediated suppression or dysfunction of the bone marrow microenvironment. Mesenchymal stromal cells (MSCs) elaborate cytokines that nurture or stimulate the marrow microenvironment by several mechanisms. We hypothesize that the administration of exogenous MSCs may modulate the bone marrow milieu and improve peripheral blood count recovery in the setting of incomplete engraftment. In the current study, we demonstrated that posttransplant intramuscular administration of human placental derived mesenchymal-like adherent stromal cells [PLacental eXpanded (PLX)-R18] harvested from a three-dimensional in vitro culture system improved posttransplant engraftment of human immune compartment in an immune-deficient murine transplantation model. As measured by the percentage of CD45+ cell recovery, we observed improvement in the peripheral blood counts at weeks 6 (8.4 vs. 24.1%, p < 0.001) and 8 (7.3 vs. 13.1%, p < 0.05) and in the bone marrow at week 8 (28 vs. 40.0%, p < 0.01) in the PLX-R18 cohort. As measured by percentage of CD19+ cell recovery, there was improvement at weeks 6 (12.6 vs. 3.8%) and 8 (10.1 vs. 4.1%). These results suggest that PLX-R18 may have a therapeutic role in improving incomplete engraftment after HCT.
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Affiliation(s)
- Leland Metheny
- Stem Cell Transplant Program, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, United States
| | - Saada Eid
- Divsion of Pediatric Hematology-Oncology, Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States.,Angie Fowler AYA Cancer Institute, UH Rainbow Babies & Children's Hospital, Cleveland, OH, United States
| | - Karen Lingas
- Divsion of Pediatric Hematology-Oncology, Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States.,Angie Fowler AYA Cancer Institute, UH Rainbow Babies & Children's Hospital, Cleveland, OH, United States
| | | | | | - Howard Meyerson
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, United States.,University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Hillard M Lazarus
- Stem Cell Transplant Program, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, United States
| | - Alex Y Huang
- Divsion of Pediatric Hematology-Oncology, Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States.,Angie Fowler AYA Cancer Institute, UH Rainbow Babies & Children's Hospital, Cleveland, OH, United States.,Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, United States.,University Hospitals Cleveland Medical Center, Cleveland, OH, United States
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8
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Saliba RM, Sarantopoulos S, Kitko CL, Pawarode A, Goldstein SC, Magenau J, Alousi AM, Churay T, Justman H, Paczesny S, Reddy P, Couriel DR. B-cell activating factor (BAFF) plasma level at the time of chronic GvHD diagnosis is a potential predictor of non-relapse mortality. Bone Marrow Transplant 2017; 52:1010-1015. [PMID: 28481353 DOI: 10.1038/bmt.2017.73] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 01/14/2017] [Accepted: 01/25/2017] [Indexed: 01/19/2023]
Abstract
Biological markers for risk stratification of chronic GvHD (cGvHD) could improve the care of patients undergoing allogeneic hematopoietic stem cell transplantation. Increased plasma levels of B-cell activating factor (BAFF), chemokine (C-X-C motif) ligand 9 (CXCL9) and elafin have been associated with the diagnosis, but not with outcome in patients with cGvHD. We evaluated the association between levels of these soluble proteins, measured by ELISA at the time of cGvHD diagnosis and before the initiation of therapy, with non-relapse-mortality (NRM). Based on the log-transformed values, factor levels were divided into tertiles defined respectively as low, intermediate, and high levels. On univariable analysis, BAFF levels were significantly associated with NRM, whereas CXCL9 and elafin levels were not. Both low (⩽2.3 ng/mL, hazard ratio (HR)=5.8, P=0.03) and high (>5.7 ng/mL, HR=5.4, P=0.03) BAFF levels were associated with a significantly higher NRM compared with intermediate BAFF level. The significant effect of high or low BAFF levels persisted in multivariable analysis. A subset of cGvHD patients had persistently low BAFF levels. In conclusion, our data show that BAFF levels at the time of cGvHD diagnosis are associated with NRM, and also are potentially useful for risk stratification. These results warrant confirmation in larger studies.
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Affiliation(s)
- R M Saliba
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S Sarantopoulos
- Division of Cell Therapy and Hematologic Malignancies, Duke Cancer Institute, Duke University Durham, NC, USA
| | - C L Kitko
- Department of Pediatrics, Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - A Pawarode
- Adult Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, MI, USA
| | - S C Goldstein
- Adult Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, MI, USA
| | - J Magenau
- Adult Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, MI, USA
| | - A M Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - T Churay
- Adult Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, MI, USA
| | - H Justman
- Adult Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, MI, USA
| | - S Paczesny
- Department of Pediatrics, Microbiology and Immunology, Indiana University School of Medicine, Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA
| | - P Reddy
- Adult Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, MI, USA
| | - D R Couriel
- Blood and Marrow Transplantation Program, Huntsman Cancer Institute, University of Utah Hospital, Salt Lake City, UT, USA
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9
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Lazaryan A, Arora M. Evolving concepts in prognostic scoring of chronic GvHD. Bone Marrow Transplant 2017; 52:1361-1366. [PMID: 28346419 DOI: 10.1038/bmt.2017.50] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 01/03/2017] [Accepted: 02/16/2017] [Indexed: 01/27/2023]
Abstract
Chronic GvHD (cGvHD) remains one of the most complex and challenging complications after allogeneic hematopoietic cell transplantation. Emerging knowledge about the clinical manifestations and associated organ involvement of cGvHD has led to the establishment of prognostic parameters for post-transplant survival among affected allograft recipients. Studies employing the pre-National Institutes of Health (NIH) consensus data on cGvHD incidence and its risks have led to development of the CIBMTR's cGvHD risk stratification, which serves as the most refined and validated prognostic tool for estimating survival of patients with cGvHD. However, cGvHD global severity scoring has recently evolved as a powerful prognostic tool for patient survival in the post-NIH consensus era. Current use of the substantially redefined NIH criteria of cGvHD diagnosis and measurements of its severity makes it challenging to interpret prognostic scoring systems generated in the pre-NIH era. Some of the pre-NIH prognostic parameters, however, appear to retain their significance in predicting survival independently from the NIH global severity score. Thus, future analyses of prospective cohorts of patients with cGvHD defined by NIH consensus criteria will be critical in reconciling and integrating various prognostic scoring systems of cGvHD.
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Affiliation(s)
- A Lazaryan
- Department of Medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - M Arora
- Department of Medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, MN, USA
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10
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Lei M, Liu L, Wu D. [Progress of chronic graft-versus-host disease]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:79-82. [PMID: 26876262 PMCID: PMC7342310 DOI: 10.3760/cma.j.issn.0253-2727.2016.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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11
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Weitz M, Strahm B, Meerpohl JJ, Schmidt M, Bassler D. Extracorporeal photopheresis versus alternative treatment for chronic graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients. Cochrane Database Syst Rev 2015; 2015:CD009898. [PMID: 26666581 PMCID: PMC7093760 DOI: 10.1002/14651858.cd009898.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Chronic graft-versus-host disease (GvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation occurring in 6% to 65% of the recipients. Currently, the therapeutic mainstay for chronic GvHD are corticosteroids that are frequently combined with other immunosuppressive agents in people with steroid-refractory manifestations. There is no established standard treatment for steroid-refractory chronic GvHD. The therapeutic options for these patients include extracorporeal photopheresis (ECP), an immunomodulatory treatment that involves ex vivo collection of mononuclear cells from peripheral blood, exposure to the photoactive agent 8-methoxypsoralen, ultraviolet radiation and re-infusion of the processed cell product. The mechanisms of action of ECP are not completely understood. This is an updated version of a Cochrane review first published in 2014. OBJECTIVES To evaluate the effectiveness and safety of ECP for the management of chronic GvHD in children and adolescents after haematopoietic stem cell transplantation. SEARCH METHODS We searched the Cochrane Register of Controlled Trials (CENTRAL) (Issue 9, 2015), MEDLINE and EMBASE databases from their inception to 23 September 2015. We searched the reference lists of potentially relevant studies without any language restriction. We searched eight trial registers and five conference proceedings on 29 September 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing ECP with or without alternative treatment versus alternative treatment alone in paediatric patients with chronic GvHD after haematopoietic stem cell transplantation. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. We resolved disagreements in the selection of trials by consultation with a third review author. MAIN RESULTS No additional studies were identified in this 2015 review update, in total leading to no studies meeting the criteria for inclusion in this review. AUTHORS' CONCLUSIONS The efficacy of ECP in the treatment of chronic GvHD in paediatric patients after haematopoietic stem cell transplantation based on RCTs cannot be evaluated since the original version of this review and the first review update found no RCTs. Current recommendations are based on retrospective or observational studies only. Thus, ideally, ECP should be applied in the context of controlled trials only. However, performing RCTs in this patient population will be challenging due to the limited number of patients, the variable disease presentation and the lack of well-defined response criteria. International collaboration, multicentre trials and appropriate funding for such trials will be needed. If treatment decisions based on clinical data are made in favour of ECP, patients should be carefully monitored for beneficial and harmful effects. In addition, efforts should be made to share this information with other clinicians, for example by setting up registries for paediatric patients that are treated with ECP.
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Affiliation(s)
- Marcus Weitz
- University Children's HospitalPediatric NephrologySteinwiesstrasse 75ZurichSwitzerland8032
| | - Brigitte Strahm
- University Medical School FreiburgPediatric Hematology and Oncology Centre for Pediatrics and Adolescent MedicineMathildenstrasse 1FreiburgGermany79106
| | - Joerg J Meerpohl
- Medical Center ‐ University of FreiburgCochrane GermanyBerliner Allee 29FreiburgGermany79110
| | - Maria Schmidt
- University Children's HospitalPediatric NephrologySteinwiesstrasse 75ZurichSwitzerland8032
| | - Dirk Bassler
- University Hospital ZurichDepartment of NeonatologyFrauenklinikstrasse 10ZurichSwitzerland
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12
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Prognostic factors for survival of patients with newly diagnosed chronic GVHD according to NIH criteria. Ann Hematol 2015. [DOI: 10.1007/s00277-015-2452-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Vaughn JE, Gooley T, Maziarz RT, Pulsipher MA, Bhatia S, Maloney DG, Sandmaier BM, Flowers ME, Storb R, Sorror ML. Pre-transplant comorbidity burden and post-transplant chronic graft-versus-host disease. Br J Haematol 2015; 171:411-6. [PMID: 26194447 DOI: 10.1111/bjh.13591] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 06/17/2015] [Indexed: 11/30/2022]
Abstract
The Haematopoietic Cell Transplantation-Comorbidity Index (HCT-CI) was designed as a predictor of non-relapse mortality after HCT. Chronic graft-versus-host disease (GVHD) contributes to mortality after HCT. Here, we investigated whether the HCT-CI could predict development of chronic GVHD or post-chronic GVHD mortality. We retrospectively analysed data from 2909 patients treated with allogeneic HCT for malignant and non-malignant haematological conditions at four institutions. In Cox regression models adjusted for potential confounders, increasing HCT-CI was not statistically significantly associated with the development of chronic GVHD [hazard ratio (HR) = 1·02, P = 0·34]. Yet, the index was associated with an increased risk of non-relapse mortality (HR = 1·29, P < 0·0001) as well as overall mortality (HR = 1·25, P < 0·001) following the development of chronic GVHD. The association between HCT-CI and post-chronic GVHD mortality was similar regardless of donor type or stem cell source. HCT-CI scores could be incorporated in the design of clinical trials for treatment of chronic GVHD.
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Affiliation(s)
- Jennifer E Vaughn
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Ted Gooley
- Clinical Statistics Program, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Biostatistics, University of Washington School of Public Health, Seattle, WA, USA
| | - Richard T Maziarz
- Center for Hematologic Malignancies, OHSU Knight Cancer Institute, Portland, OR, USA.,Division of Hematology and Medical Oncology, Oregon Health & Science University School of Medicine, Portland, OR, USA
| | - Michael A Pulsipher
- Division of Hematology and Hematological Malignancies, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, UT, USA.,Pediatric Blood and Marrow Transplant Program, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Smita Bhatia
- City of Hope School of Medicine, Duarte, CA, USA
| | - David G Maloney
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Mary E Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Rainer Storb
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Mohamed L Sorror
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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14
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Carpenter PA, Kitko CL, Elad S, Flowers MED, Gea-Banacloche JC, Halter JP, Hoodin F, Johnston L, Lawitschka A, McDonald GB, Opipari AW, Savani BN, Schultz KR, Smith SR, Syrjala KL, Treister N, Vogelsang GB, Williams KM, Pavletic SZ, Martin PJ, Lee SJ, Couriel DR. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: V. The 2014 Ancillary Therapy and Supportive Care Working Group Report. Biol Blood Marrow Transplant 2015; 21:1167-87. [PMID: 25838185 DOI: 10.1016/j.bbmt.2015.03.024] [Citation(s) in RCA: 143] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 03/27/2015] [Indexed: 12/26/2022]
Abstract
The 2006 National Institutes of Health (NIH) Consensus paper presented recommendations by the Ancillary Therapy and Supportive Care Working Group to support clinical research trials in chronic graft-versus-host disease (GVHD). Topics covered in that inaugural effort included the prevention and management of infections and common complications of chronic GVHD, as well as recommendations for patient education and appropriate follow-up. Given the new literature that has emerged during the past 8 years, we made further organ-specific refinements to these guidelines. Minimum frequencies are suggested for monitoring key parameters relevant to chronic GVHD during systemic immunosuppressive therapy and, thereafter, referral to existing late effects consensus guidelines is advised. Using the framework of the prior consensus, the 2014 NIH recommendations are organized by organ or other relevant systems and graded according to the strength and quality of supporting evidence.
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Affiliation(s)
- Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Carrie L Kitko
- Blood and Marrow Transplantation Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan
| | - Sharon Elad
- Division of Oral Medicine, Eastman Institute for Oral Health and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Juan C Gea-Banacloche
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jörg P Halter
- Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Flora Hoodin
- Department of Psychology, Eastern Michigan University, Ypsilanti, Michigan
| | - Laura Johnston
- Department of Blood and Marrow Transplantation, Stanford University Medical Center, Stanford, California
| | - Anita Lawitschka
- St. Anna Children's Hospital, Medical University, Vienna, Austria
| | - George B McDonald
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Anthony W Opipari
- Department of Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, Michigan
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kirk R Schultz
- Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital and University of BC, Vancouver, British Columbia
| | - Sean R Smith
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan
| | - Karen L Syrjala
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Nathaniel Treister
- Division of Oral Medicine and Dentistry, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Georgia B Vogelsang
- Oncology Department, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kirsten M Williams
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Steven Z Pavletic
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Daniel R Couriel
- Blood and Marrow Transplantation Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan
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15
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Jagasia MH, Greinix HT, Arora M, Williams KM, Wolff D, Cowen EW, Palmer J, Weisdorf D, Treister NS, Cheng GS, Kerr H, Stratton P, Duarte RF, McDonald GB, Inamoto Y, Vigorito A, Arai S, Datiles MB, Jacobsohn D, Heller T, Kitko CL, Mitchell SA, Martin PJ, Shulman H, Wu RS, Cutler CS, Vogelsang GB, Lee SJ, Pavletic SZ, Flowers MED. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: I. The 2014 Diagnosis and Staging Working Group report. Biol Blood Marrow Transplant 2015; 21:389-401.e1. [PMID: 25529383 PMCID: PMC4329079 DOI: 10.1016/j.bbmt.2014.12.001] [Citation(s) in RCA: 1725] [Impact Index Per Article: 191.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 12/01/2014] [Indexed: 12/13/2022]
Abstract
The 2005 National Institutes of Health (NIH) Consensus Conference proposed new criteria for diagnosing and scoring the severity of chronic graft-versus-host disease (GVHD). The 2014 NIH consensus maintains the framework of the prior consensus with further refinement based on new evidence. Revisions have been made to address areas of controversy or confusion, such as the overlap chronic GVHD subcategory and the distinction between active disease and past tissue damage. Diagnostic criteria for involvement of mouth, eyes, genitalia, and lungs have been revised. Categories of chronic GVHD should be defined in ways that indicate prognosis, guide treatment, and define eligibility for clinical trials. Revisions have been made to focus attention on the causes of organ-specific abnormalities. Attribution of organ-specific abnormalities to chronic GVHD has been addressed. This paradigm shift provides greater specificity and more accurately measures the global burden of disease attributed to GVHD, and it will facilitate biomarker association studies.
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Affiliation(s)
- Madan H Jagasia
- Department of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hildegard T Greinix
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Mukta Arora
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Kirsten M Williams
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Department of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Daniel Wolff
- Department of Internal Medicine, University of Regensburg, Regensburg, Germany
| | - Edward W Cowen
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jeanne Palmer
- Department of Hematology Oncology/Blood and Marrow Transplant, Mayo Clinic Arizona, Phoenix, Arizona
| | - Daniel Weisdorf
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Nathaniel S Treister
- Department of Surgery, Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, Boston, Massachusetts
| | - Guang-Shing Cheng
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Holly Kerr
- Hematology Department, BC Cancer Agency, Vancouver, British Columbia, Canada
| | - Pamela Stratton
- Pediatric and Reproductive Endocrinology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Rafael F Duarte
- Department of Hematology, Institut Catala d'Oncologia, Barcelona, Spain
| | - George B McDonald
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Afonso Vigorito
- Hematology and Hemotherapy Center, Hemocentro Unicamp, Campinas, Sao Paulo, Brazil
| | - Sally Arai
- Department of Blood and Marrow Transplantation, Stanford University Medical Center, Stanford, California
| | - Manuel B Datiles
- The Eye Clinic, National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - David Jacobsohn
- Department of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, Maryland
| | - Carrie L Kitko
- Blood and Marrow Transplant Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan
| | - Sandra A Mitchell
- Department of Applied Research Cancer Control and Population Sciences, National Institutes of Health, Bethesda, Maryland
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Howard Shulman
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Roy S Wu
- Cancer Therapy Evaluation Program, National Institutes of Health, Bethesda, Maryland
| | - Corey S Cutler
- Division of Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Georgia B Vogelsang
- Oncology Department, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Steven Z Pavletic
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
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16
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Jagasia MH, Greinix HT, Arora M, Williams KM, Wolff D, Cowen EW, Palmer J, Weisdorf D, Treister NS, Cheng GS, Kerr H, Stratton P, Duarte RF, McDonald GB, Inamoto Y, Vigorito A, Arai S, Datiles MB, Jacobsohn D, Heller T, Kitko CL, Mitchell SA, Martin PJ, Shulman H, Wu RS, Cutler CS, Vogelsang GB, Lee SJ, Pavletic SZ, Flowers MED. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: I. The 2014 Diagnosis and Staging Working Group report. BIOLOGY OF BLOOD AND MARROW TRANSPLANTATION : JOURNAL OF THE AMERICAN SOCIETY FOR BLOOD AND MARROW TRANSPLANTATION 2014. [PMID: 25529383 DOI: 10.1016/j.bbmt.2014.12.001.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The 2005 National Institutes of Health (NIH) Consensus Conference proposed new criteria for diagnosing and scoring the severity of chronic graft-versus-host disease (GVHD). The 2014 NIH consensus maintains the framework of the prior consensus with further refinement based on new evidence. Revisions have been made to address areas of controversy or confusion, such as the overlap chronic GVHD subcategory and the distinction between active disease and past tissue damage. Diagnostic criteria for involvement of mouth, eyes, genitalia, and lungs have been revised. Categories of chronic GVHD should be defined in ways that indicate prognosis, guide treatment, and define eligibility for clinical trials. Revisions have been made to focus attention on the causes of organ-specific abnormalities. Attribution of organ-specific abnormalities to chronic GVHD has been addressed. This paradigm shift provides greater specificity and more accurately measures the global burden of disease attributed to GVHD, and it will facilitate biomarker association studies.
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Affiliation(s)
- Madan H Jagasia
- Department of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hildegard T Greinix
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Mukta Arora
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Kirsten M Williams
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Department of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Daniel Wolff
- Department of Internal Medicine, University of Regensburg, Regensburg, Germany
| | - Edward W Cowen
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jeanne Palmer
- Department of Hematology Oncology/Blood and Marrow Transplant, Mayo Clinic Arizona, Phoenix, Arizona
| | - Daniel Weisdorf
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Nathaniel S Treister
- Department of Surgery, Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, Boston, Massachusetts
| | - Guang-Shing Cheng
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Holly Kerr
- Hematology Department, BC Cancer Agency, Vancouver, British Columbia, Canada
| | - Pamela Stratton
- Pediatric and Reproductive Endocrinology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Rafael F Duarte
- Department of Hematology, Institut Catala d'Oncologia, Barcelona, Spain
| | - George B McDonald
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Afonso Vigorito
- Hematology and Hemotherapy Center, Hemocentro Unicamp, Campinas, Sao Paulo, Brazil
| | - Sally Arai
- Department of Blood and Marrow Transplantation, Stanford University Medical Center, Stanford, California
| | - Manuel B Datiles
- The Eye Clinic, National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - David Jacobsohn
- Department of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, Maryland
| | - Carrie L Kitko
- Blood and Marrow Transplant Program, University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan
| | - Sandra A Mitchell
- Department of Applied Research Cancer Control and Population Sciences, National Institutes of Health, Bethesda, Maryland
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Howard Shulman
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Roy S Wu
- Cancer Therapy Evaluation Program, National Institutes of Health, Bethesda, Maryland
| | - Corey S Cutler
- Division of Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Georgia B Vogelsang
- Oncology Department, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Steven Z Pavletic
- Center for Cancer Research National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
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17
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Center for International Blood and Marrow Transplant Research chronic graft-versus-host disease risk score predicts mortality in an independent validation cohort. Biol Blood Marrow Transplant 2014; 21:640-5. [PMID: 25528390 DOI: 10.1016/j.bbmt.2014.10.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 10/24/2014] [Indexed: 11/22/2022]
Abstract
We previously reported a risk score that predicted mortality in patients with chronic graft-versus-host disease (CGVHD) after hematopoietic stem cell transplantation (HCT) between 1995 and 2004 and reported to the Center for International Blood and Marrow Transplant Research (CIBMTR). We sought to validate this risk score in an independent CIBMTR cohort of 1128 patients with CGVHD who underwent transplantation between 2005 and 2007 using the same inclusion criteria and risk score calculations. According to the sum of the overall risk score (range, 1 to 12), patients were assigned to 4 risk groups (RGs): RG1 (0 to 2), RG2 (3 to 6), RG3 (7 to 8), and RG4 (9 to 10). RG3 and RG4 were combined, as RG4 accounted for only 1% of the total cohort. Cumulative incidences of nonrelapse mortality (NRM) and probability of overall survival were significantly different between each RG (all P < .01). NRM and overall survival at 5 years after CGVHD for each RG were 17% and 72% in RG1, 26% and 53% in RG2, and 44% and 25% in RG3, respectively (all P < .01). Our study validates the prognostic value of the CIBMTR CGVHD RGs for overall survival and NRM in a contemporary transplantation population. The CIBMTR CGVHD RGs can be used to predict major outcomes, tailor treatment planning, and enroll patients in clinical trials.
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18
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Späth C, Busemann C, Krüger WH. Allogeneic stem cell transplantation in patients above 55: suggestion for a further stratification of the HCT-CI. J Cancer Res Clin Oncol 2014; 140:1981-8. [PMID: 24965745 DOI: 10.1007/s00432-014-1748-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 06/12/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Allogeneic stem cell transplantation (alloSCT) has become available for elderly patients or for patients with comorbidities by introduction of reduced-intense conditioning. Comorbidity-related prognosis after alloSCT can be estimated by the hematopoietic cell transplantation comorbidity index (HCT-CI). MATERIAL AND METHODS The charts from 85 patients who have undergone 90 alloSCTs between 1999 and 2011 were analysed. Most patients received a dose-reduced conditioning and a graft from an unrelated donor. Patients were stratified for age, HCT-CI, cGvHD versus no cGvHD, and a modified HCT-CI with a further split high-risk score. RESULTS Age over 60 years did not affect the outcome. Manifestation of cGvHD improved the prognosis significantly. An additional stratification of the high-risk group of the HCT-CI revealed that even a fraction of these patients can have considerable benefit from an alloSCT. Furthermore, this high-risk collective could be clearly discriminated into two groups with different outcomes. CONCLUSIONS The investigation confirms that age is no absolute risk factor for alloSCT and demonstrates the heterogeneity of the high-risk group of the HCT-CI. A comprehensive investigation of an additional stratification is suggested. Furthermore, the authors encourage early withdrawal of immunosuppression, even in elderly patients and patients with comorbidities to permit graft-versus-leukaemia/lymphoma, since cGvHD is associated with a significantly better prognosis.
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Affiliation(s)
- Christian Späth
- Department of Internal Medicine C - Haematology and Oncology, Marrow Transplantation, and Palliative Care, Ernst-Moritz-Arndt-University Greifswald, Ferdinand-Sauerbruch-Str., 17475, Greifswald, Germany
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19
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Abstract
Chronic graft-versus-host disease (GVHD) is a frequent and potentially life-threatening complication of allogeneic hematopoietic stem cell transplantation. Increased transplantation of older patients and the more frequent use of unrelated donors has led to increased numbers of patients with this painful complication. Recent advances have been made in understanding the pathophysiology of chronic GVHD and in establishing precise criteria for diagnosis and classification of disease manifestations. These advances will hopefully pave the way for improving both the prophylaxis and treatment of chronic GVHD.
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20
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Abstract
Chronic graft-versus-host disease (GVHD) is a frequent and potentially life-threatening complication of allogeneic hematopoietic stem cell transplantation. Increased transplantation of older patients and the more frequent use of unrelated donors has led to increased numbers of patients with this painful complication. Recent advances have been made in understanding the pathophysiology of chronic GVHD and in establishing precise criteria for diagnosis and classification of disease manifestations. These advances will hopefully pave the way for improving both the prophylaxis and treatment of chronic GVHD.
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21
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von Bonin M, Bornhäuser M. Concise Review: The Bone Marrow Niche as a Target of Graft Versus Host Disease. Stem Cells 2014; 32:1420-8. [DOI: 10.1002/stem.1691] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 02/09/2014] [Indexed: 12/12/2022]
Affiliation(s)
- Malte von Bonin
- Medizinische Klinik und Poliklinik 1; Universitätsklinikum Carl-Gustav Carus, Medizinische Fakultät der Technischen Universität Dresden; Dresden Germany
- German Cancer Consortium (DKTK); Im Neuenheimer Feld 280 Heidelberg Germany
- German Cancer Research Center (DKFZ); Im Neuenheimer Feld 280 Heidelberg Germany
| | - Martin Bornhäuser
- Medizinische Klinik und Poliklinik 1; Universitätsklinikum Carl-Gustav Carus, Medizinische Fakultät der Technischen Universität Dresden; Dresden Germany
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22
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Gazourian L, Rogers AJ, Ibanga R, Weinhouse GL, Pinto-Plata V, Ritz J, Soiffer RJ, Antin JH, Washko GR, Baron RM, Ho VT. Factors associated with bronchiolitis obliterans syndrome and chronic graft-versus-host disease after allogeneic hematopoietic cell transplantation. Am J Hematol 2014; 89:404-9. [PMID: 24375545 DOI: 10.1002/ajh.23656] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/08/2013] [Accepted: 12/19/2013] [Indexed: 01/12/2023]
Abstract
Bronchiolitis obliterans syndrome (BOS) is a form of chronic graft vs. host disease (cGVHD) and a highly morbid pulmonary complication after allogeneic hematopoietic stem cell transplantation (HSCT). We assessed the prevalence and risk factors for BOS and cGVHD in a cohort of HSCT recipients, including those who received reduced intensity conditioning (RIC) HSCT. Between January 1, 2000 and June 30, 2010, all patients who underwent allogeneic HSCT at our institution (n = 1854) were retrospectively screened for the development of BOS by PFT criteria. We matched the BOS cases with two groups of control patients: (1) patients who had concurrent cGVHD without BOS and (2) those who developed neither cGVHD nor BOS. Comparisons between BOS patients and controls were conducted using t-test or Fisher's exact tests. Multivariate regression analysis was performed to examine factors associated with BOS diagnosis. All statistical analyses were performed using SAS 9.2. We identified 89 patients (4.8%) meeting diagnostic criteria for BOS at a median time of 491 days (range: 48-2067) after HSCT. Eighty-six (97%) of our BOS cohort had extra-pulmonary cGVHD. In multivariate analysis compared to patients without cGVHD, patients who received busulfan-based conditioning, had unrelated donors, and had female donors were significantly more likely to develop BOS, while ATG administration was associated with a lower risk of BOS. Our novel results suggest that busulfan conditioning, even in RIC transplantation, could be an important risk factor for BOS and cGVHD.
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Affiliation(s)
- Lee Gazourian
- Department of Medicine, Division of Pulmonary and Critical Care Medicine; Brigham and Women's Hospital; Boston Massachusetts
| | - Angela J. Rogers
- Department of Medicine, Division of Pulmonary and Critical Care Medicine; Stanford University Medical Center; Stanford California
| | - Ruby Ibanga
- Department of Medicine, Division of Pulmonary and Critical Care Medicine; Brigham and Women's Hospital; Boston Massachusetts
| | - Gerald L. Weinhouse
- Department of Medicine, Division of Pulmonary and Critical Care Medicine; Brigham and Women's Hospital; Boston Massachusetts
| | - Victor Pinto-Plata
- Department of Medicine, Division of Pulmonary and Critical Care Medicine; Brigham and Women's Hospital; Boston Massachusetts
| | - Jerome Ritz
- Department of Medical Oncology, Division of Hematologic Malignancies; Dana Farber Cancer Institute; Boston Massachusetts
| | - Robert J. Soiffer
- Department of Medical Oncology, Division of Hematologic Malignancies; Dana Farber Cancer Institute; Boston Massachusetts
| | - Joseph H. Antin
- Department of Medical Oncology, Division of Hematologic Malignancies; Dana Farber Cancer Institute; Boston Massachusetts
| | - George R. Washko
- Department of Medicine, Division of Pulmonary and Critical Care Medicine; Brigham and Women's Hospital; Boston Massachusetts
| | - Rebecca M. Baron
- Department of Medicine, Division of Pulmonary and Critical Care Medicine; Brigham and Women's Hospital; Boston Massachusetts
| | - Vincent T. Ho
- Department of Medical Oncology, Division of Hematologic Malignancies; Dana Farber Cancer Institute; Boston Massachusetts
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Weitz M, Strahm B, Meerpohl JJ, Bassler D. Extracorporeal photopheresis versus alternative treatment for chronic graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients. Cochrane Database Syst Rev 2014:CD009898. [PMID: 24569961 DOI: 10.1002/14651858.cd009898.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Chronic graft-versus-host disease (GvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation occurring in 6% to 65% of the recipients. Currently, the therapeutic mainstay for chronic GvHD are corticosteroids that are frequently combined with other immunosuppressive agents in people with steroid-refractory manifestations. There is no established standard treatment for steroid-refractory chronic GvHD. The therapeutic options in these people include extracorporeal photopheresis (ECP), an immunomodulatory treatment that involves ex vivo collection of mononuclear cells from peripheral blood, exposure to the photoactive agent 8-methoxypsoralen, ultraviolet radiation and re-infusion of the processed cell product. The mechanisms of action of ECP are not completely understood. OBJECTIVES To evaluate the effectiveness and safety of ECP for the management of chronic GvHD in children and adolescents after haematopoietic stem cell transplantation. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (Issue 9, 2012), MEDLINE and EMBASE databases from their inception to 12 September 2012. We searched the reference lists of potentially relevant studies without any language restriction. We searched eight trial registers and five conference proceedings. We also contacted experts in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing ECP with or without alternative treatment versus alternative treatment alone in paediatric patients with chronic GvHD after haematopoietic stem cell transplantation. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. We resolved disagreements in the selection of trials by consultation with a third review author. MAIN RESULTS We found no studies meeting the criteria for inclusion in this review. AUTHORS' CONCLUSIONS The efficacy of ECP in the treatment of chronic GvHD in paediatric patients after haematopoietic stem cell transplantation based on RCTs can currently not be evaluated since we have found no such studies. Current recommendations are based on retrospective or observational studies only. Thus, ideally, ECP should be applied in the context of controlled trials only. However, performing RCTs in this patient population will be challenging due to the limited number of patients, the variable disease presentation and the lack of well-defined response criteria. International collaboration, multicentre trials and appropriate funding for such trials will be needed. If treatment decisions based on clinical grounds in favour of ECP are made, people should be carefully monitored for beneficial and harmful effects and efforts should be made to share this information with other clinicians, for example by setting up registries for paediatric patients that are treated with ECP.
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Affiliation(s)
- Marcus Weitz
- Department of Pediatrics, University of Tuebingen, Hoppe-Seyler-Strasse 1, Tübingen, Germany, 72076
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24
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Gleicher N. Graft-versus-host disease and immunologic rejection: implications for diagnosis and treatments of pregnancy complications. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.3.1.37] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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25
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Mortensen KB, Gerds TA, Bjerrum OW, Lindmark A, Sengeløv H, Andersen CL. The prevalence and prognostic value of concomitant eosinophilia in chronic graft-versus-host disease after allogeneic stem cell transplantation. Leuk Res 2013; 38:334-9. [PMID: 24439053 DOI: 10.1016/j.leukres.2013.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 11/21/2013] [Accepted: 12/07/2013] [Indexed: 12/30/2022]
Abstract
The prognostic significance of eosinophilia after myeloablative allogeneic stem cell transplantation (ASCT) remains to be established. Patients, whom developed chronic graft-versus-host disease (cGVHD) after ASCT, were included (n = 142). Eosinophil count was analyzed at cGVHD onset. We observed no significant association between EO and the grade of cGVHD, thrombocytopenia, nor extensive skin involvement. Importantly, we observed no significant association between cGVHD with concomitant eosinophilia and long-term clinical outcomes, and subgroup analyses revealed a considerable confounding effect of ongoing steroid treatment. In conclusion, we advocate that prognostic conclusions regarding cGVHD with concomitant eosinophilia after ASCT should be interpreted with caution.
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Affiliation(s)
| | | | - Ole Weis Bjerrum
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Lindmark
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Sengeløv
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christen Lykkegaard Andersen
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark; Department of Hematology, Roskilde Hospital, Roskilde, Denmark
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26
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Bat T, Steinberg SM, Childs R, Calvo KR, Barrett AJ, Battiwalla M, Baird K, Zhang D, Pulanic D, Dunbar CE, Pavletic SZ. Active thrombopoiesis is associated with worse severity and activity of chronic GVHD. Bone Marrow Transplant 2013; 48:1569-73. [PMID: 23832091 DOI: 10.1038/bmt.2013.95] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 05/22/2013] [Accepted: 05/25/2013] [Indexed: 11/09/2022]
Abstract
Chronic GVHD (cGVHD) is a major complication of allogeneic hematopoietic SCT. Post transplant thrombocytopenia in patients with cGVHD has been associated with poor outcome and its etiology is unclear. We investigated whether thrombopoiesis, assessed via measurement of the absolute immature platelet number (AIPN) in the blood, is impaired in cGVHD, and whether the level of thrombopoiesis correlates with the severity and activity of cGVHD as assessed via the National Institutes of Health (NIH) organ scoring system. We used a cohort of 110 well-characterized cGVHD patients, including 83 (75%) with severe cGVHD per NIH global score. Higher AIPN was associated with active therapeutic intent (P=0.026), lower Karnofsky score (P=0.0013), worse joint/fascia cGVHD (P=0.0005) and worse skin cGVHD (P=0.0044). AIPN correlated with platelet counts and was not correlated with ANC, WBC, C-reactive protein (CRP), absolute lymphocyte count (ALC), albumin, total and average NIH scores, or number of prior systemic therapies. AIPN values for cGVHD patients substantially overlapped those of the normal population. Higher AIPN, as marker of active thrombopoiesisis, was associated with worse severity and activity of cGVHD, especially skin and joints/fascia manifestations. Among patients with stable moderate or severe cGVHD, there was no evidence of hypoproduction of platelets. Future studies should further investigate the role of thrombopoiesis in cGVHD.
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Affiliation(s)
- T Bat
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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27
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Kohrt HE, Tian L, Li L, Alizadeh AA, Hsieh S, Tibshirani RJ, Strober S, Sarwal M, Lowsky R. Identification of gene microarray expression profiles in patients with chronic graft-versus-host disease following allogeneic hematopoietic cell transplantation. Clin Immunol 2013; 148:124-35. [PMID: 23685278 DOI: 10.1016/j.clim.2013.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 04/19/2013] [Accepted: 04/23/2013] [Indexed: 01/24/2023]
Abstract
Chronic graft-versus-host disease (GVHD) results in significant morbidity and mortality, limiting the benefit of allogeneic hematopoietic cell transplantation (HCT). Peripheral blood gene expression profiling of the donor immune repertoire following HCT may provide associated genes and pathways thereby improving the pathophysiologic understanding of chronic GVHD. We profiled 70 patients and identified candidate genes that provided mechanistic insight in the biologic pathways that underlie chronic GVHD. Our data revealed that the dominant gene signature in patients with chronic GVHD represented compensatory responses that control inflammation and included the interleukin-1 decoy receptor, IL-1 receptor type II, and genes that were profibrotic and associated with the IL-4, IL-6 and IL-10 signaling pathways. In addition, we identified three genes that were important regulators of extracellular matrix. Validation of this discovery phase study will determine if the identified genes have diagnostic, prognostic or therapeutic implications.
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Affiliation(s)
- Holbrook E Kohrt
- Department of Medicine Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305 USA
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28
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Validation of NIH consensus criteria for diagnosis and severity-grading of chronic graft-versus-host disease. Int J Hematol 2013; 97:263-71. [PMID: 23371545 DOI: 10.1007/s12185-013-1268-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 12/28/2012] [Accepted: 01/15/2013] [Indexed: 10/27/2022]
Abstract
To validate the National Institutes of Health (NIH) consensus criteria for chronic GVHD, we retrospectively reviewed 143 patients who developed GVHD later than 100 days after allogeneic hematopoietic stem cell transplantation. Their GVHD was reclassified and the severity was graded according to the criteria. Only four patients (2.8 %) could not be reclassified into any type of GVHD. In the remaining 139 patients, reclassified subtypes were late acute GVHD in 52 patients (37.4 %), classic chronic GVHD in 33 (23.7 %), and overlap syndrome in 54 (38.8 %). Of 87 patients with classic chronic GVHD or overlap syndrome, the severity was graded as mild in 21 patients (24 %), moderate in 53 (61 %), and severe in 13 (15 %). The proportions of moderate (70 %) and severe (20 %) disease were significantly higher in patients with overlap syndrome than those with classic chronic GVHD (46 and 6 %, respectively; P < 0.001). Univariate and multivariate analyses of subtypes and severity did not identify any significant prognostic values in any of the transplant outcomes, such as transplant-related mortality, overall survival, GVHD-specific survival, or discontinuation of systemic immunosuppressants. These findings suggest that the NIH consensus criteria are useful for classification of chronic GVHD, but have limited significance in predicting clinical outcomes. The validity of these criteria remains inconclusive, and future prospective studies will be required to refine them.
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29
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Abstract
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HCT) is an effective immunotherapy for human cancer. More than 20 000 allo-HCTs are performed each year worldwide, primarily for the treatment of hematologic malignancies. Several technical innovations implemented in allo-HCT over past 2 decades have reduced NRM by 50% and improved overall survival. The allo-HCT practice has changed with the introduction of peripheral blood, cord blood, and haploidentical transplantations and reduced-intensity conditioning, and the patient population is also different regarding age and diagnosis. However, both acute and chronic GVHD remain serious barriers to successful allo-HCT and it is not clear that a major improvement has occurred in our ability to prevent or treat GVHD. Nevertheless, there is an increasing knowledge of the biology and clinical manifestations and the field is getting better organized. These advances will almost certainly lead to major progress in the near future. As the long list of new potential targets and respective drugs are developed, systems need to be developed for rapid testing of them in clinical practice. The current reality is that no single agent has yet to be approved by the US Food and Drug Administration for GVHD prevention or therapy. Although a primary goal of these efforts is to develop better therapies for GVHD, the ultimate goal is to develop treatments that lead to effective prevention or preemption of life-threatening and disabling GVHD manifestations while harnessing the desirable graft-versus-tumor effects.
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30
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Fassil H, Bassim CW, Mays J, Edwards D, Baird K, Steinberg SM, Williams KM, Cowen EW, Mitchell SA, Hakim FT, Taylor T, Avila D, Zhang D, Grkovic L, Datiles M, Gress RE, Pavletic SZ. Oral chronic graft-vs.-host disease characterization using the NIH scale. J Dent Res 2012; 91:45S-51S. [PMID: 22699667 DOI: 10.1177/0022034512450881] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Chronic graft-vs.-host disease (cGVHD) is a complication of allogeneic hematopoietic stem cell transplantation (alloHSCT). Oral cGVHD is manifested by mucosal, salivary, and/or sclerotic changes that have been linked to pain and poor quality of life. Our aim was to describe the demographic, clinical, and laboratory markers of oral cGVHD in alloHSCT patients (N = 187) enrolled in a cGVHD cross-sectional study at the NIH (#NCT00331968). We propose a meaningful and reproducible measure of disease defined by a cut-off point reflecting clinical minimally detectable change (0-2 = no oral cGVHD, 3-15 = oral cGVHD) on the 15-point NIH cGVHD clinician assessment scale. Forty-four patients had oral cGVHD. Oral cGVHD was associated with a quiescent or de novo type of cGVHD onset (p = 0.05), higher cGVHD severity (p = 0.033), lower albumin (p = 0.0008), higher total complement (p = 0.012), greater bother from foods or oral ulcers and greater mouth pain, and sensitivity (p < 0.0001). Multivariable logistic regression modeling with albumin, mouth pain, and total complement was 74.3% predictive of oral cGVHD and 80.2% predictive of non-oral cGVHD. We propose the use of >2 points on the NIH scale as a reproducible definition of clinically significant oral cGVHD, which may be useful in clinical settings or as eligibility criterion or as an endpoint in clinical trials.
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Affiliation(s)
- H Fassil
- Experimental Transplantation and Immunology Branch, National Cancer Institute, NIH, 10 Center Drive, Bethesda, MD 20892, USA.
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31
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Chronic GVHD: Where are we? Where do we want to be? Will immunomodulatory drugs help? Bone Marrow Transplant 2012; 48:203-9. [DOI: 10.1038/bmt.2012.76] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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32
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Pidala J, Vogelsang G, Martin P, Chai X, Storer B, Pavletic S, Weisdorf DJ, Jagasia M, Cutler C, Palmer J, Jacobsohn D, Arai S, Lee SJ. Overlap subtype of chronic graft-versus-host disease is associated with an adverse prognosis, functional impairment, and inferior patient-reported outcomes: a Chronic Graft-versus-Host Disease Consortium study. Haematologica 2011; 97:451-8. [PMID: 22058206 DOI: 10.3324/haematol.2011.055186] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The National Institutes of Health Consensus Conference proposed the term "overlap" graft-versus-host disease to describe the situation when both acute and chronic graft-versus-host disease are present. DESIGN AND METHODS We examined whether the overlap subtype of graft-versus-host disease was associated with a different prognosis, functional limitations, or patient-reported outcomes compared to "classic" chronic graft-versus-host disease without any acute features. RESULTS Prospective data were collected from 427 patients from nine centers. Patients were classified as having overlap (n=352) or classic chronic (n=75) graft-versus-host disease based on reported organ involvement. Overlap cases had a significantly shorter median time from transplantation to cohort enrollment (P=0.01), were more likely to be incident cases (P<0.001), and had a lower platelet count at onset of the graft-versus-host disease (P<0.001). Patients with overlap graft-versus-host disease had significantly greater functional impairment measured by a 2-minute walk test, higher symptom burden and lower Human Activity Profile scores. Quality of life was similar, except patients with overlap graft-versus-host disease had worse social functioning, assessed by the Short Form-36. Multivariable analysis utilizing time-varying covariates demonstrated that the overlap subtype of graft-versus-host disease was associated with worse overall survival (HR 2.1, 95% CI 1.1-4.7; P=0.03) and higher non-relapse mortality (HR 2.8, 95% CI 1.2-8.3; P=0.02) than classic chronic graft-versus-host disease. CONCLUSIONS These findings suggest that the presence of acute features in patients with chronic graft-versus-host disease is a marker of adverse prognosis, greater functional impairment, and higher symptom burden.
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33
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Ahmad I, Labbé AC, Chagnon M, Busque L, Cohen S, Kiss T, Lachance S, Roy DC, Sauvageau G, Roy J. Incidence and Prognostic Value of Eosinophilia in Chronic Graft-versus-Host Disease after Nonmyeloablative Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2011; 17:1673-8. [DOI: 10.1016/j.bbmt.2011.04.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2010] [Accepted: 04/22/2011] [Indexed: 12/20/2022]
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34
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Pidala J. Graft-vs-Host Disease following Allogeneic Hematopoietic Cell Transplantation. Cancer Control 2011; 18:268-76. [DOI: 10.1177/107327481101800407] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Allogeneic hematopoietic cell transplantation (HCT) is a potentially curative therapy with proven efficacy in the management of hematologic malignancies. However, it is complicated by the syndromes of acute and chronic graft-vs-host disease (GVHD). Methods A narrative review is provided to summarize major biologic insights into the pathogenesis of these immune-mediated disorders, as well as advances in diagnosis, classification, prevention, management, and allied supportive care with the aim of providing essential understanding for clinicians with or without subspecialty experience in the field of blood and marrow transplantation. Results Major scientific advances have contributed to enhanced understanding of the pathogenesis of these disorders, and clinical investigation has provided more effective preventive and therapeutic strategies for GVHD. However, since acute GVHD and chronic GVHD remain leading sources of transplantation-related morbidity and mortality, ongoing investigation is needed to develop new approaches to addressing these syndromes. Conclusions The major challenge for future investigation will be to capitalize on biologic insights in order to develop novel strategies for the prevention and therapy of acute and chronic GVHD that will address the current shortcomings in existing therapeutic approaches.
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Affiliation(s)
- Joseph Pidala
- H. Lee Moffitt Cancer Center & Research Institute and the Department of Oncologic Sciences at the University of South Florida College of Medicine, Tampa, Florida
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35
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Significantly worse survival of patients with NIH-defined chronic graft-versus-host disease and thrombocytopenia or progressive onset type: results of a prospective study. Leukemia 2011; 26:746-56. [PMID: 21926960 DOI: 10.1038/leu.2011.257] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Chronic graft-versus-host disease (GVHD) remains a serious complication after allogeneic hematopoietic stem cell transplantation (HCT). In 2005 the National Institutes of Health (NIH) established new criteria for chronic GVHD based on retrospective data and expert recommendations. We prospectively evaluated the incidence of NIH-defined chronic GVHD and its prognostic impact in 178 consecutive patients. The cumulative incidence of chronic GVHD at 3 years was 64, 48 and 16% for chronic classic GVHD and overlap syndrome. Prior acute GVHD and myeloablative conditioning were significantly associated with increased risk of chronic GVHD. Three-year survival (overall survival (OS)) for late-acute GVHD, chronic classic and overlap chronic GVHD when assigned on day 100 were 69, 83 and 73%. OS was significantly worse for patients with platelet counts below 100 g/l at onset of chronic GVHD (35% versus 86%, P<0.0001) and progressive as compared with de novo and quiescent onset of chronic GVHD (54.5% versus 89.5% versus 84%, P = 0.022 and 0.001). Peak severity of chronic GVHD had no impact on non-relapse mortality (NRM) and OS. Recurrent acute GVHD, platelet counts below 100 g/l at diagnosis of chronic GVHD, progressive onset of chronic GVHD and advanced disease stage prior to HCT were significantly associated with increased NRM. This prospective analysis provides for the first-time data on the incidence rates of NIH-defined chronic GVHD categories and identified risk factors for the occurrence of chronic GVHD. A prognostic value of thrombocytopenia and progressive onset type of chronic GVHD for survival after HCT was observed in NIH-defined chronic GVHD.
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36
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Risk factors associated with increased nonrelapse mortality and with poor overall survival in children with chronic graft-versus-host disease. Blood 2011; 118:4472-9. [PMID: 21878671 DOI: 10.1182/blood-2011-04-349068] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
There is a paucity of information regarding the factors that affect nonrelapse mortality (NRM) and overall survival among children that develop chronic graft-versus-host disease (cGVHD). We performed multivariate analyses using data from the Center for International Blood and Marrow Transplant Research to identify risk factors for NRM and survival in 1117 pediatric subjects with leukemia or myelodysplastic syndrome, transplanted from related donors, unrelated donors (URD), or unrelated cord blood between 1995 and 2004. We identified 4 variables associated with higher NRM: HLA partially matched or mismatched URD, peripheral blood cell graft, Karnofsky/Lansky score < 80 at cGVHD diagnosis, and platelets < 100 × 10(9)/L at cGVHD diagnosis. Factors associated with significantly worse survival were: age > 10 years, transplantation from HLA partially matched or mismatched URD, advanced disease at transplantation, Karnofsky/Lansky < 80; and platelets < 100 × 10(9)/L. Cumulative incidence of discontinuation of systemic immune suppression at 1, 3, and 5 years after diagnosis of cGVHD were 22% (20%-25%), 34% (31%-37%), and 37% (34%-40%), respectively. This is the largest study elucidating variables affecting outcome after diagnosis of cGVHD in pediatric allograft recipients. These variables may be useful for risk stratification, development of future clinical trials, and family counseling in children with cGVHD.
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37
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Pidala J, Kim J, Anasetti C, Nishihori T, Betts B, Field T, Perkins J. The global severity of chronic graft-versus-host disease, determined by National Institutes of Health consensus criteria, is associated with overall survival and non-relapse mortality. Haematologica 2011; 96:1678-84. [PMID: 21791465 DOI: 10.3324/haematol.2011.049841] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The 2005 National Institutes of Health Consensus Development Conference on chronic graft-versus-host disease proposed major changes in the classification and grading of severity of chronic graft-versus-host disease. DESIGN AND METHODS We aimed to study the association of the proposed chronic graft-versus-host disease classification and global severity with transplantation outcomes among a consecutive series of patients who received pharmacokinetically-targeted doses of intravenous busulfan and fludarabine conditioning followed by transplantation of allogeneic peripheral blood stem cells. RESULTS From a total cohort (n = 242) of patients surviving more than 100 days after hematopoietic stem cell transplantation, 181 (75% of those at risk) had some manifestations of graft-versus-host disease after day 100. Of these, at onset 13 (7%) had late acute graft-versus-host disease, 62 (34%) had classic chronic graft-versus-host disease, and 106 (59%) had the overlap subtype of chronic graft-versus-host disease. The global severity of the chronic graft-versus-host disease was mild in 25% of cases, moderate in 46%, and severe in 29%. Multivariable modeling demonstrated the independent association of global severity of chronic graft-versus-host disease with overall survival (moderate/severe versus mild; HR 2.9, 95% CI 1.8-4.7, P < 0.0001) and non-relapse mortality (moderate versus mild; HR 3.86, 95% CI 1.17-12.73, P = 0.03, and severe versus mild (HR 10.06, 95% CI 3.07-32.97, P < 0.001). The type of onset of progressive chronic graft-versus-host disease and the platelet count at the time of diagnosis of the disease were significantly associated with overall survival. The occurrence and severity of chronic graft-versus-host disease was also significantly associated with primary disease relapse. CONCLUSIONS Patients with moderate to severe chronic graft-versus-host disease, as determined by National Institutes of Health Consensus criteria, have an inferior overall survival and worse non-relapse mortality. Clinical and research advances are needed to improve the outcomes of affected patients.
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Affiliation(s)
- Joseph Pidala
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, Fl 33612 USA.
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38
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Long-term outcome and lineage-specific chimerism in 194 patients with Wiskott-Aldrich syndrome treated by hematopoietic cell transplantation in the period 1980-2009: an international collaborative study. Blood 2011; 118:1675-84. [PMID: 21659547 DOI: 10.1182/blood-2010-11-319376] [Citation(s) in RCA: 210] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
In this retrospective collaborative study, we have analyzed long-term outcome and donor cell engraftment in 194 patients with Wiskott-Aldrich syndrome (WAS) who have been treated by hematopoietic cell transplantation (HCT) in the period 1980- 2009. Overall survival was 84.0% and was even higher (89.1% 5-year survival) for those who received HCT since the year 2000, reflecting recent improvement of outcome after transplantation from mismatched family donors and for patients who received HCT from an unrelated donor at older than 5 years. Patients who went to transplantation in better clinical conditions had a lower rate of post-HCT complications. Retrospective analysis of lineage-specific donor cell engraftment showed that stable full donor chimerism was attained by 72.3% of the patients who survived for at least 1 year after HCT. Mixed chimerism was associated with an increased risk of incomplete reconstitution of lymphocyte count and post-HCT autoimmunity, and myeloid donor cell chimerism < 50% was associated with persistent thrombocytopenia. These observations indicate continuous improvement of outcome after HCT for WAS and may have important implications for the development of novel protocols aiming to obtain full correction of the disease and reduce post-HCT complications.
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39
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Chronic GVHD risk score: a Center for International Blood and Marrow Transplant Research analysis. Blood 2011; 117:6714-20. [PMID: 21493797 DOI: 10.1182/blood-2010-12-323824] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Several risk factors are associated with increased mortality in patients with chronic graft-versus-host disease (cGVHD), but there is considerable variability in the reported factors. Therefore, we evaluated patient, transplantation, and cGVHD characteristics to develop a risk score in 5343 patients with cGVHD. Ten variables were identified as being significant in multivariate analysis of overall survival and nonrelapse mortality (NRM): age, prior acute GVHD, time from transplantation to cGVHD, donor type, disease status at transplantation, GVHD prophylaxis, gender mismatch, serum bilirubin, Karnofsky score, and platelet count. These 10 variables were used to build a cGVHD risk score, and 6 risk groups (RGs) were identified. The 5-year NRM was 5% (1%-9%) in RG1, 20% (19%-23%) in RG2, 33% (29%-37%) in RG3, 43% (40%-46%) in RG4, 63% (53%-74%) in RG5, and 72% (59%-85%) in RG6. The 5-year overall survival was highest at 91% (95% confidence interval [CI]:85%-97%) in RG1, followed by 67% (65%-69%) in RG2, 51% (46%-55%) in RG3, 40% (37%-43%) in RG4, 21% (12%-30%) in RG5, and 4% (0%-9%) in RG6 (all P < .01). This analysis demonstrates the usefulness of data from a large registry to develop risk-score categories for major transplantation outcomes. Validation of this cGVHD risk score is needed in a different population to ensure its broad applicability.
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40
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Greinix HT, Loddenkemper C, Pavletic SZ, Holler E, Socié G, Lawitschka A, Halter J, Wolff D. Diagnosis and staging of chronic graft-versus-host disease in the clinical practice. Biol Blood Marrow Transplant 2010; 17:167-75. [PMID: 20691801 DOI: 10.1016/j.bbmt.2010.07.017] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Accepted: 07/19/2010] [Indexed: 12/16/2022]
Abstract
Based on expert opinion and retrospective data the National Institutes of Health (NIH) Consensus Development Project proposed criteria for diagnosis and staging of both overall severity as well as organ severity of chronic graft-versus-host disease (cGVHD) for use in clinical trials. In 2008, representatives of German and Austrian allogeneic hematopoietic stem cell transplant (HSCT) centers established a study group on cGVHD during the annual meeting of the German Working Group on Bone Marrow and Blood Stem Cell Transplantation (DAG-KBT) to intensify a dialog among HSCT physicians, pathologists, and medical consultants focusing on the usefulness of the NIH consensus criteria for patient care in clinical practice and to promote collaborations between HSCT centers as well as different medical specialities involved in HSCT. We first conducted a survey of current practices of diagnosis, staging, and overall grading of cGVHD in daily clinical routine by sending an electronic questionnaire to the heads of the HSCT centers. During 3 meetings in 2009, more representatives of allogeneic HSCT centers were included into the discussion process, resulting in 81% participation representing 88% of all allogeneic HSCT activities in Germany, Austria, and Switzerland. During the third consensus meeting held in Regensburg, Germany, from November 6 to November 7, 2009, important agreements were achieved among participant having a strong impact on care of patients with cGVHD. Areas of disagreement such as distinction between classical NIH cGVHD and overlap syndrome or assignment of liver GVHD after day 100 to acute or chronic category will be further assessed in prospective observational studies among participants in the near future.
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Affiliation(s)
- Hildegard T Greinix
- Department of Internal Medicine I, Bone Marrow Transplantation, Medical University of Vienna, Vienna, Austria.
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41
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Abstract
Chronic graft-versus-host disease (GVHD) is a major complication after allogeneic haematopoietic stem cell transplantation (HSCT). Not only is it the major cause of late mortality in HSCT patients, but it also accounts for significant morbidity. Much of the literature on chronic GVHD has focused on adults. Chronic GVHD is of major importance in children, especially since they have years to live following the complications of chronic GVHD and its therapy. The goal is to review incidence, manifestations, and therapies, especially when applicable to the paediatric population.
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Li Q, Zhai Z, Xu X, Shen Y, Zhang A, Sun Z, Liu H, Geng L, Wang Y. Decrease of CD4(+)CD25(+) regulatory T cells and TGF-beta at early immune reconstitution is associated to the onset and severity of graft-versus-host disease following allogeneic haematogenesis stem cell transplantation. Leuk Res 2010; 34:1158-68. [PMID: 20409584 DOI: 10.1016/j.leukres.2010.03.017] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Revised: 03/06/2010] [Accepted: 03/09/2010] [Indexed: 11/25/2022]
Abstract
Graft-versus-host disease (GVHD) is a frequent and life threatening complication of allogeneic haematogenesis stem cell transplantation (aHSCT). The correlation of CD4(+)CD25(+) regulatory T cells (Tregs) in the patients after aHSCT to the occurrence and severity of acute and chronic GVHD (aGVHD and cGVHD) is not fully investigated. Here, we examined the levels of CD4(+)CD25(+) Tregs by assessment of CD4(+)CD25(high) and CD4(+)CD25(+)CD127(low) in peripheral blood, and the levels of serum TGF-beta and TNF-alpha in 56 patients at early immune reconstitution following aHSCT. Our data showed a significant reduction in the frequency of Tregs in patients with grades II-IV aGVHD and extensive cGVHD compared to healthy controls. Moreover, a decreased level of CD4(+)CD25(+) Tregs was correlated to increased severity of GVHD. The levels of CD4(+)CD25(+) Tregs in non-GVHD groups were however significantly higher than that in healthy controls. A significant decrease in the levels of TGF-beta and a significant increase the levels of TNF-alpha was also seen with increased severity of GVHD. This study suggested that measurement of CD4(+)CD25(+) Tregs along with serum TGF-beta and TNF-alpha at early immune reconstruction after aHSCT may indicate the onset and severity of both aGVHD and cGVHD.
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Affiliation(s)
- Qing Li
- The Central Laboratory of Medical Research Center in the Affiliated Anhui Provincial Hospital of Anhui Medical University, Hefei City, China
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43
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Viganò M, Vener C, Lampertico P, Annaloro C, Pichoud C, Zoulim F, Facchetti F, Poli F, Scalamogna M, Deliliers GL, Colombo M. Risk of hepatitis B surface antigen seroreversion after allogeneic hematopoietic SCT. Bone Marrow Transplant 2010; 46:125-31. [PMID: 20383209 DOI: 10.1038/bmt.2010.70] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Allogeneic hematopoietic SCT (HSCT) increases the risk of hepatitis B virus (HBV) reactivation in hepatitis B surface antigen (HBsAg) carriers but the incidence, risk factors and course of HBV reactivation after HSCT in HBsAg-negative/anti-hepatitis B core antigen (anti-HBc)-positive recipients are not well known. A total of 50 HBsAg-negative/anti-HBc-positive HSCT recipients with onco-hematological diseases, underwent sequential clinical and laboratory examinations, including serum HBsAg, during follow-up. Serum HBV DNA collected at HSCT was retrospectively amplified by a sensitive PCR assay. During 17 months of follow-up, six (12%) patients had seroreverted to HBsAg, 7-32 months after HSCT, with 1- and 5-year cumulative rates of 13 and 22%. HBsAg seroreversion was associated with serum HBeAg higher than 8 log₁₀ copies per ml HBV DNA and a 1.5 to 36 fold increase of serum alanine aminotransferase leading to HBeAg-positive chronic hepatitis B in all patients. Patients with chronic onco-hematological disease and long-lasting immunosuppression following HSCT had a higher risk of HBsAg seroreversion independently of serum HBV DNA levels at HSCT. HBsAg-negative/anti-HBc-positive HSCT recipients with chronic onco-hematological disease carry a significant risk of HBsAg seroreversion and HBeAg-positive chronic hepatitis B, independently of serum levels of HBV DNA at transplantation.
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Affiliation(s)
- M Viganò
- First Division of Gastroenterology, Department of Medicine, A M and A Migliavacca Center for Liver Disease, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Università di Milano, Milan, Italy.
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44
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Abstract
Five-year survival rates for childhood cancer now exceed 80% and with the significant progress made by the transplant community in developing less toxic conditioning regimens and in the treatment of posttransplant complications, allo-hematopoietic stem cell transplantation (HSCT) contributes significantly to that population of long-term survivors. In this context, the acute and long-term toxicities of chronic graft-versus-host disease (cGVHD) have an ever-increasing effect on organ function, quality of life, and survival; patients and families who initially felt great relief to be cured from the primary disease, now face the challenge of a chronic debilitating illness for which preventative and treatment strategies are suboptimal. Hence, the development of novel strategies that reduce and or control cGVHD, preserve graft-versus-tumor effects, facilitate engraftment and immune reconstitution, and enhance survival after allo-HSCT represents one of the most significant challenges facing physician-scientists and patients.
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Affiliation(s)
- Kristin Baird
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Building 10, Room 1-3750, 9000 Rockville Pike, MSC 1104, Bethesda, MD 20892-1104, USA.
| | - Kenneth Cooke
- Ohio Eminent Scholar and Leonard C Hanna Professor in Stem Cell and Regenerative Medicine, and Director, Pediatric Blood and Marrow Transplantation Program Director, Multidisciplinary Initiative in Graft-vs-Host Disease, Case Western Reserve University School of Medicine
| | - Kirk R. Schultz
- Director, Childhood Cancer Research Program of BC Children’s Hospital and the Child and Family Research Institute, and Professor of Pediatrics, BC Children’s Hospital
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45
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Evaluation of pentostatin in corticosteroid-refractory chronic graft-versus-host disease in children: a Pediatric Blood and Marrow Transplant Consortium study. Blood 2009; 114:4354-60. [DOI: 10.1182/blood-2009-05-224840] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
There is no standard therapy for steroid-refractory chronic graft-versus-host disease (GVHD). This problem is particularly daunting in children with chronic GVHD, whereby the effects of the disease and its treatment may impair normal growth and development. Children are also particularly vulnerable to failure and/or toxicity of therapy; for example, joint contractures or joint damage may result in life-long disability. The Pediatric Blood and Marrow Transplant Consortium performed a phase 2 trial of pentostatin for steroid-refractory chronic GVHD in 51 children (median age, 9.8 years) from 24 institutions. Overall response was 53% (95% confidence interval, 40%-64%), with a response of 59% (95% confidence interval, 42%-75%) in sclerosis. Thirteen subjects (25%) had toxicity requiring them to stop pentostatin. The drug had a significant steroid-sparing effect in those that responded. A trend was also observed toward increased survival at 3 years in responders versus nonresponders (69% vs 50%; P = .06). The intravenous administration of the drug ensures compliance in a patient group in which oral therapy is difficult to monitor. Pentostatin has activity in refractory chronic GVHD in children, and future studies, including treatment of children newly diagnosed with high-risk chronic GVHD, are warranted. The trial was registered at www.Clinicaltrials.gov as #NCT00144430.
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46
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Outcome of hematopoietic cell transplantation in children with sickle cell disease, a single center's experience. Bone Marrow Transplant 2009; 45:895-900. [PMID: 19784079 DOI: 10.1038/bmt.2009.244] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Multicenter trials have shown that hematopoietic cell transplantation (HCT) has an excellent outcome in children with sickle cell disease (SCD). As a single center, we performed a total of 11 transplants in 10 patients (6 males, 4 females) with SCD between 1997 and 2005. Eight patients had hemoglobin SS disease and two patients had HbSbeta(0) thalassemia. The median age of HCT was 10.1 (range 2.8-16.3) years. All donors were HLA-identical siblings; six patients received bone marrow (BM), two patients received mobilized peripheral blood, one patient received umbilical cord blood (UCB) and one patient received both UCB and BM from the same donor. Myeloablative conditioning regimen consisted of busulfan, horse antithymocyte globulin and cyclophosphamide. One patient had a gradual decrease in donor chimerism to 15% and subsequently received a second bone marrow transplant using a reduced intensity conditioning regimen consisting of alemtuzumab, fludarabine and melphalan leading to stable full engraftment. Currently, 9 out of 10 patients are alive with a median follow-up of 5.5 (range 2.9-11) years. As a single institution's experience with HCT in children with SCD, we report an excellent outcome, and a second HCT may be considered for patients with impending engraftment failure as a cure for SCD.
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47
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Pulanic D, Lozier JN, Pavletic SZ. Thrombocytopenia and hemostatic disorders in chronic graft versus host disease. Bone Marrow Transplant 2009; 44:393-403. [PMID: 19684626 DOI: 10.1038/bmt.2009.196] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Chronic graft versus host disease (cGVHD) is a major and frequent late complication in allogeneic stem cell transplantation recipients. Although thrombocytopenia in cGVHD patients is among the most consistent and strongest predictors of poor survival across many cGVHD studies, such correlation is still neither clearly explained nor well understood. Low platelet counts in the setting of cGVHD are associated with an increase in complications and treatment-related mortality, but usually not with higher relapse rate or engraftment failure rate. Bleeding might be occasionally increased along with, paradoxically, thrombosis. Hemostatic disorders in the context of cGVHD are significant complications with multifactorial etiology, including tissue injury with releasing microparticles, cytokine release, macrophage/monocyte clearance, CMV infection, production of transforming growth factor-beta, and low levels of thrombopoietin. Future clinical trials with agents that stimulate megakaryocytopoiesis or influence underlying impaired hemostasis mechanisms should investigate whether such interventions may improve outcomes in patients with cGVHD.
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Affiliation(s)
- D Pulanic
- Graft-versus-Host and Autoimmunity Unit, Experimental Transplantation and Immunology Branch, National Cancer Institute, Center for Cancer Research, National Institutes of Health, Bethesda, MD, USA
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48
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Rituximab for the treatment of corticosteroid-refractory chronic graft-versus-host disease. Int J Hematol 2009; 90:253-260. [DOI: 10.1007/s12185-009-0370-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Revised: 05/23/2009] [Accepted: 06/03/2009] [Indexed: 10/20/2022]
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49
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Peripheral blood eosinophilia has a favorable prognostic impact on transplant outcomes after allogeneic peripheral blood stem cell transplantation. Biol Blood Marrow Transplant 2009; 15:471-82. [PMID: 19285635 DOI: 10.1016/j.bbmt.2009.01.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2008] [Accepted: 01/06/2009] [Indexed: 11/23/2022]
Abstract
Peripheral eosinophilia after allogeneic stem cell transplant (ASCT) may reflect the activation of the Th2 cytokine pathway. A retrospective analysis was performed to evaluate the impact of early- (before day 100: EEo) or late-onset (beyond day 100: LEo) eosinophilia (> or =0.5 x 10(9)/L in peripheral blood) on transplant outcomes after peripheral blood SCT (PBSCT) in 237 patients. The incidence of EEo and LEo was 43% at day 100 and 62% at 2 years, respectively. Compared with patients without LEo, improved transplant outcomes were observed in patients with LEo: better overall survival (OS; 86% versus 41%, P = 5 x 10(-11)), lower nonrelapse mortality (NRM; 10% versus 37%, P = 3 x 10(-6)), lower relapse incidence (11% versus 31%, P = 3 x 10(-5)), and higher GVHD-specific survival (GSS; 90% versus 64%, P = 1 x 10(-6)) were observed. In addition, similar finding was observed when transplant outcomes were analyzed according to the occurrence of eosinophilia at the onset of cGVHD. The multivariate analyses confirmed a favorable implication of LEo on OS, NRM, and GSS. LEo was associated with: (1) less severe chronic GVHD (cGVHD), (2) higher prevalence of autoantibodies, and (3) rapid lymphocyte count recovery after ASCT. In summary, the development of eosinophila after allogeneic PBSCT seemed to be a prognostic marker for improving transplant outcome.
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50
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Bates JS, Engemann AM, Hammond JM. Clinical Utility of Rituximab in Chronic Graft-Versus-Host Disease. Ann Pharmacother 2009; 43:316-21. [DOI: 10.1345/aph.1l386] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To evaluate the use of rituximab in the clinical management of steroid-refractory chronic graft-versus-host disease (GVHD). Data Sources: Literature was accessed through MEDLINE and International Pharmaceutical Abstracts (1990–September 2008), both indexed and nonindexed citations, using the terms rituximab, graft-versus-host disease, monoclonal antibodies, and CD20. In addition, reference citations from the publications identified were reviewed. Study Selection and Data Extraction: All articles discussing rituximab as a therapeutic option in the treatment of GVHD that were published in English and enrolled human study participants were evaluated. Data Synthesis: Rituximab is a genetically engineered chimeric murine monoclonal antibody that binds to the CD20 differentiation antigen found on B-lymphocytes. GVHD is the leading cause of procedural-related morbidity and mortality following allogeneic hematopoietic stem cell transplantation (HSCT). Chronic GVHD (cGVHD) occurs in up to 70% of individuals undergoing HSCT, and approximately 40% of those patients are refractory to conventional T-lymphocyte–directed therapies. Limited treatments are available for individuals with steroid-refractory cGVHD. Rituximab therapy in individuals with extensive cGVHD has demonstrated clinical efficacy with manageable toxicities in retrospective and prospective studies. Conclusions: Available data suggest that rituximab is a treatment option for patients with extensive steroid-refractory cGVHD. Rituximab may be particularly effective for individuals with steroid-refractory cGVHD manifesting as thrombocytopenia or with sclerodermatous, cutaneous, and rheumatologic involvement.
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Affiliation(s)
- Jill S Bates
- Hematology/Oncology Specialty Resident, Department of Pharmacy, Duke University Medical Center, Durham, NC
| | | | - Julia M Hammond
- Oncology Clinical Coordinator, Department of Pharmacy, Duke University Medical Center
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