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Piekarska A, Pawelec K, Szmigielska-Kapłon A, Ussowicz M. The state of the art in the treatment of severe aplastic anemia: immunotherapy and hematopoietic cell transplantation in children and adults. Front Immunol 2024; 15:1378432. [PMID: 38646536 PMCID: PMC11026616 DOI: 10.3389/fimmu.2024.1378432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/22/2024] [Indexed: 04/23/2024] Open
Abstract
Acquired aplastic anemia (AA) is an immune-mediated bone marrow (BM) failure where marrow disruption is driven by a cytotoxic T-cell-mediated autoimmune attack against hematopoietic stem cells. The key diagnostic challenge in children, but also in adults, is to exclude the possible underlying congenital condition and myelodysplasia. The choice of treatment options, either allogeneic hematopoietic cell transplantation (alloHCT) or immunosuppressive therapy (IST), depends on the patient's age, comorbidities, and access to a suitable donor and effective therapeutic agents. Since 2022, horse antithymocyte globulin (hATG) has been available again in Europe and is recommended for IST as a more effective option than rabbit ATG. Therefore, an update on immunosuppressive strategies is warranted. Despite an improved response to the new immunosuppression protocols with hATG and eltrombopag, some patients are not cured or remain at risk of aplasia relapse or clonal evolution and require postponed alloHCT. The transplantation field has evolved, becoming safer and more accessible. Upfront alloHCT from unrelated donors is becoming a tempting option. With the use of posttransplant cyclophosphamide, haploidentical HCT offers promising outcomes also in AA. In this paper, we present the state of the art in the management of severe AA for pediatric and adult patients based on the available guidelines and recently published studies.
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Affiliation(s)
- Agnieszka Piekarska
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Katarzyna Pawelec
- Department of Oncology, Pediatric Hematology, Clinical Transplantology and Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | | | - Marek Ussowicz
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland
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2
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Storb R. Allogeneic bone marrow transplantation for aplastic anemia. Int J Hematol 2024; 119:220-230. [PMID: 36576660 PMCID: PMC10300230 DOI: 10.1007/s12185-022-03506-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/29/2022]
Abstract
After more than 60 years of intense research in allogeneic hematopoietic cell transplantation (HCT), this therapy has progressed from one that was fraught with seemingly insurmountable complications to a standard treatment of patients with aplastic anemia. During the 1970s and 1980s, HCT donors were almost exclusively HLA-identical siblings. Subsequent advances in the understanding of the complexity of the HLA region along with the development of molecular HLA typing and the establishment of unrelated volunteer donor registries have resulted in an ever-increasing use of such donors. Most recent breakthroughs have enabled HLA-haploidentical HCT and, thereby, finding donors for nearly every patient. The outstanding outcomes reported with any of the donor options have made allogeneic HCT the preferred treatment over immunosuppressive therapy.
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Affiliation(s)
- Rainer Storb
- Fred Hutchinson Cancer Center and the University of Washington School of Medicine, 1100 Fairview Avenue N, D1-100, Seattle, WA, 98109, USA.
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3
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Kotb A, Alzahrani H, Alahmari A, Syed Osman Ahmed, Alhayli S, Shaheen M, Chaudhri N, Alsharif F, Hanbali A, Alfraih F, Alshaibani A, Albabtain AA, Alfayez M, Alotaibi AS, Elhassan T, Rasheed W, Almohareb F, Aljurf M, El Fakih R. Incidence and risk factors for secondary graft failure in uniformly treated patients with severe aplastic anemia receiving fludarabine and cyclophosphamide for conditioning and matched sibling bone marrow graft as stem cell source. Cytotherapy 2023; 25:1331-1337. [PMID: 37737766 DOI: 10.1016/j.jcyt.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND AIMS Graft failure after allogeneic transplant for aplastic anemia is problematic. The risk of graft failure depends on multiple variables, including the preparative regimen, donor type, stem cell dose and source among other variables. METHODS We performed a retrospective analysis of patients with aplastic anemia who underwent matched-sibling allogeneic transplant at a single center. RESULTS We identified 82 patients who fit the inclusion criteria. One had primary graft failure and was excluded from this analysis. The recipient median age was 22 years. The donor median age was 23 years. The median time from diagnosis to transplant was 1.6 months. The median number of red cell transfusions before transplant was nine. The median number of platelet transfusions before transplant was 18. Thirteen patients developed secondary graft failure, with a cumulative incidence at 5 years of 16% and median time to develop secondary graft failure of 129 days. All patients engrafted with a median time for neutrophil engraftment of 19 days and a median time for platelet engraftment of 22 days. The survival of patients with or without secondary graft failure was not different. Major or bidirectional ABO incompatibility and older recipient age were statistically significantly associated with greater risk of secondary graft failure. CONCLUSIONS Secondary graft failure is a significant complication after allogeneic transplant for SAA. Identification of recipients at risk and mitigating the potential risks of this complication is warranted.
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Affiliation(s)
- Ahmed Kotb
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Hematology Unit, Department of Medicine, Zagazig University, Zagazig, Egypt
| | - Hazzaa Alzahrani
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ali Alahmari
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Syed Osman Ahmed
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saud Alhayli
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Marwan Shaheen
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Naeem Chaudhri
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Fahad Alsharif
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Amr Hanbali
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Feras Alfraih
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Alfadel Alshaibani
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Mansour Alfayez
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ahmad S Alotaibi
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Tusneem Elhassan
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Walid Rasheed
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Fahad Almohareb
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Riad El Fakih
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; School of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
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Wang H, Wang N, Wang L, Du J, Li F, Shao Y, Peng B, Luan S, Wang L, Jin X, Gao C, Dou L, Liu D. Targeted dosing of anti-thymocyte globulin in adult unmanipulated haploidentical peripheral blood stem cell transplantation: A single-arm, phase 2 trial. Am J Hematol 2023; 98:1732-1741. [PMID: 37706580 DOI: 10.1002/ajh.27068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/14/2023] [Accepted: 08/09/2023] [Indexed: 09/15/2023]
Abstract
Anti-thymocyte globulin (ATG) is widely used in allogeneic hematopoietic stem cell transplantation to prevent severe graft-versus-host disease (GVHD) and graft failure. However, overexposure to ATG may increase cytomegalovirus (CMV), Epstein-Barr virus (EBV) reactivation, non-relapse mortality, and disease recurrence. To investigate the optimal dosing of ATG, we established a targeted dosing strategy based on ATG concentration monitoring for haploidentical peripheral blood stem cell transplantation (haplo-PBSCT). The aim of this phase 2 trial is to evaluate the safety and efficacy of the ATG-targeted dosing strategy in adult unmanipulated haplo-PBSCT. ATG was administered for 4 days (-5 days to -2 days) during conditioning. The ATG doses on -3 days and -2 days were adjusted by our dosing strategy to achieve the optimal ATG exposure. The primary endpoint was CMV reactivation on +180 days. Between December 2020 and January 2022, 66 haplo-PBSCT patients were enrolled and 63 of them were evaluable with a median follow-up of 632 days. The cumulative incidence of CMV reactivation was 36.7% and that of EBV was 58.7%. The 1-year disease-free survival was 82.5%, overall survival was 92.1%, and CD4+ T-cell reconstruction on +100 days was 76.8%. The most common severe regimen-associated toxicities (> grade 3) were infections (51.5%) and gastrointestinal toxicity (25.5%). A total of 102 haplo-PBSCT patients who received the conventional fixed ATG dose (cumulative 10 mg/kg) comprised historical control. The outcomes in historical control were inferior to those of phase 2 trial cohort (CMV reactivation: 70.8%, p < .001; EBV reactivation: 76.0%, p = .024; CD4 + T-cell reconstruction: 54.1%, p = .040). In conclusion, ATG-targeted dosing strategy reduced CMV/EBV reactivation and improved survival without increasing GVHD after haplo-PBSCT. These advantages may be associated with accelerated immune reconstitution.
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Affiliation(s)
- Haitao Wang
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Nan Wang
- Medical School of Chinese PLA, Beijing, China
| | - Lili Wang
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jishan Du
- Medical School of Chinese PLA, Beijing, China
| | - Fei Li
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | | | - Bo Peng
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Songhua Luan
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Lu Wang
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiangshu Jin
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Chunji Gao
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Liping Dou
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Daihong Liu
- Senior Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
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Chakupurakal G, Freudenberger P, Skoetz N, Ahr H, Theurich S. Polyclonal anti-thymocyte globulins for the prophylaxis of graft-versus-host disease after allogeneic stem cell or bone marrow transplantation in adults. Cochrane Database Syst Rev 2023; 6:CD009159. [PMID: 37341189 PMCID: PMC10284458 DOI: 10.1002/14651858.cd009159.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
BACKGROUND Allogeneic haematopoietic stem cell transplantation (SCT) is an established treatment for many malignant and non-malignant haematological disorders. Graft-versus-host disease (GVHD), a condition frequently occurring after an allogeneic SCT, is the result of host tissues being attacked by donor immune cells. It affects more than half of the patients after transplant either as acute and or chronic GVHD. One strategy for the prevention of GVHD is the administration of anti-thymocyte globulins (ATGs), a set of polyclonal antibodies directed against a variety of immune cell epitopes, leading to immunosuppression and immunomodulation. OBJECTIVES To assess the effect of ATG used for the prevention of GVHD in patients undergoing allogeneic SCT with regard to overall survival, incidence and severity of acute and chronic GVHD, incidence of relapse, non-relapse mortality, graft failure and adverse events. SEARCH METHODS For this update we searched the CENTRAL, MEDLINE, Embase, trial registers and conference proceedings on the 18th November 2022 along with reference checking and contacting study authors to identify additional studies. We did not apply language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) investigating the impact of ATG on GVHD prophylaxis in adults suffering from haematological diseases and undergoing allogeneic SCT. The selection criteria were modified from the previous version of this review. Paediatric studies and studies where patients aged < 18 years constituted more than 20 % of the total number were excluded. Treatment arms had to differ only in the addition of ATG to the standard GVHD prophylaxis regimen. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by the Cochrane Collaboration for data collection, extraction and analyses. MAIN RESULTS For this update we included seven new RCTs, leading to a total of ten studies investigating 1413 participants. All patients had a haematological condition which warranted an allogeneic SCT. The risk of bias was estimated as low for seven and unclear for three studies. ATG probably has little or no influence on overall survival (HR (hazard ratio) 0.93 (95 % confidence interval (CI) 0.77 to 1.13, nine studies, n = 1249, moderate-certainty evidence)). Estimated absolute effect: 430 surviving people per 1000 people not receiving ATG compared to 456 people surviving per 1000 people receiving the intervention (95 % CI 385 to 522 per 1000 people). ATG results in a reduction in acute GVHD II to IV with relative risk (RR) 0.68 (95 % CI 0.60 to 0.79, 10 studies, n = 1413, high-certainty evidence). Estimated absolute effect: 418 acute GVHD II to IV per 1000 people not receiving ATG compared to 285 per 1000 people receiving the intervention (95 % CI 251 to 331 per 1000 people). Addition of ATG results in a reduction of overall chronic GvHD with a RR of 0.53 (95 % CI 0.45 to 0.61, eight studies, n = 1273, high-certainty evidence). Estimated absolute effect: 506 chronic GVHD per 1000 people not receiving ATG compared to 268 per 1000 people receiving the intervention (95 % CI 228 to 369 per 1000 people). Further data on severe acute GVHD and extensive chronic GVHD are available in the manuscript. ATG probably slightly increases the incidence of relapse with a RR of 1.21 (95 % CI 0.99 to 1.49, eight studies, n =1315, moderate-certainty evidence). Non relapse mortality is probably slightly or not affected by ATG with an HR of 0.86 (95 % CI 0.67 to 1.11, nine studies, n=1370, moderate-certainty evidence). ATG prophylaxis may result in no increase in graft failure with a RR of 1.55 (95 % CI 0.54 to 4.44, eight studies, n = 1240, low-certainty evidence). Adverse events could not be analysed due to the serious heterogeneity in the reporting between the studies, which limited comparability (moderate-certainty evidence) and are reported in a descriptive manner. Subgroup analyses on ATG types, doses and donor type are available in the manuscript. AUTHORS' CONCLUSIONS This systematic review suggests that the addition of ATG during allogeneic SCT probably has little or no influence on overall survival. ATG results in a reduction in the incidence and severity of acute and chronic GvHD. ATG intervention probably slightly increases the incidence of relapse and probably does not affect the non relapse mortality. Graft failure may not be affected by ATG prophylaxis. Analysis of data on adverse events was reported in a narrative manner. A limitation for the analysis was the imprecision in reporting between the studies thereby reducing the confidence in the certainty of evidence.
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Affiliation(s)
- Geothy Chakupurakal
- Praxis for Haematology and Oncology, Koblenz, Germany
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine at the University of Cologne, Cologne, Germany
| | | | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Hans Ahr
- Rheinland Klinikum, Dormagen, Germany
| | - Sebastian Theurich
- Department of Medicine III, University Hospital LMU, Ludwig-Maximilians-Universität München, Munich, Germany
- Cancer and Immunometabolism Research Group, Gene Center LMU, Munich, Germany
- German Cancer Consortium (DKTK), Munich Site , German Cancer Research Center, Heidelberg, Germany
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6
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Pınar IE, Özkalemkaş F, Ersal T, Gürsoy V, Gülderen E, Özkocaman V. Severe aplastic anemia and a healthy pregnancy immediately following syngeneic transplantation: An extremely rare case report. Transplant Proc 2023; 55:715-717. [PMID: 36931953 DOI: 10.1016/j.transproceed.2023.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 02/19/2023] [Indexed: 03/17/2023]
Abstract
Aplastic anemia is potentially fatal, particularly if the disease does not respond to immunotherapy and progresses to severe pancytopenia. Allogeneic hematopoietic stem cell transplant from an HLA-matched sibling donor, the first-line treatment in patients younger than 40 years, is used as a curative treatment option in severe aplastic anemia. The availability of an identical twin donor is infrequent, and there is limited experience in this context. Additionally, the choices for a conditioning regimen for a syngeneic transplant to prevent engraftment failure and the necessity of graft-vs-host disease prophylaxis are controversial. Although long-term survival gradually increases after an allogeneic hematopoietic stem cell transplant, hypogonadism and infertility are the main problems that significantly affect patients' quality of life. We present a patient diagnosed with severe aplastic anemia who has had a healthy pregnancy immediately after a syngeneic transplant.
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Affiliation(s)
- Ibrahim Ethem Pınar
- Department of Internal Medicine, Division of Hematology, Bursa Uludag University, Faculty of Medicine, Bursa, Turkey.
| | - Fahir Özkalemkaş
- Department of Internal Medicine, Division of Hematology, Bursa Uludag University, Faculty of Medicine, Bursa, Turkey
| | - Tuba Ersal
- Department of Internal Medicine, Division of Hematology, Bursa Uludag University, Faculty of Medicine, Bursa, Turkey
| | - Vildan Gürsoy
- Department of Internal Medicine, Division of Hematology, Bursa City Hospital, Bursa, Turkey
| | - Esra Gülderen
- Department of Internal Medicine, Bursa Uludag University Faculty of Medicine, Bursa, Turkey
| | - Vildan Özkocaman
- Department of Internal Medicine, Division of Hematology, Bursa Uludag University, Faculty of Medicine, Bursa, Turkey
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7
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Nakamura Y, Mori T, Kako S, Yamazaki H, Kanda Y, Uchida N, Tanaka M, Nawa Y, Fukuda T, Ichinohe T, Atsuta Y, Onishi Y. Outcome of peripheral blood stem cell transplantation from HLA-identical sibling donors for adult patients with aplastic anemia. Int J Hematol 2023; 117:356-365. [PMID: 36378405 DOI: 10.1007/s12185-022-03487-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022]
Abstract
Although bone marrow transplantation is the recommended form of allogeneic hematopoietic stem cell transplantation for aplastic anemia, some patients undergo peripheral blood stem cell transplantation (PBSCT). Therefore, there is critical demand to identify factors affecting transplantation outcomes. Using the Japanese registry database, we retrospectively analyzed outcomes of 94 adult patients with aplastic anemia who underwent PBSCT from HLA-identical sibling donors. The cumulative incidence of neutrophil engraftment was 94% (95% confidence interval [CI] 86-97%), and was significantly higher in patients who received anti-thymocyte globulin (ATG) in conditioning. The cumulative incidence rate was 26% (95% CI 17-35%) in grades II-IV acute graft-versus-host disease (GVHD) and 20% (95% CI 13-29%) in extensive chronic GVHD, and tended to be lower in patients with chronic GVHD who received ATG-based conditioning. The 5-year overall survival (OS) rate was 70% (95% CI 59-78%). In multivariate analysis, patient age < 40 years, shorter period from diagnosis to transplantation, better performance status, and ATG-based conditioning were significantly correlated with favorable OS. In conclusion, PBSCT from HLA-identical sibling donors for aplastic anemia would result in acceptable outcomes. Several risk factors identified in our study should be considered when selecting a stem cell source.
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Affiliation(s)
- Yukinori Nakamura
- Third Department of Internal Medicine, Yamaguchi University Hospital, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan.
| | - Takehiko Mori
- Department of Hematology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shinichi Kako
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hirohito Yamazaki
- Division of Transfusion Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Naoyuki Uchida
- Department of Hematology, Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital, Tokyo, Japan
| | - Masatsugu Tanaka
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Yuichiro Nawa
- Division of Hematology, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Takahiro Fukuda
- Hematopoietic Stem Cell Transplantation Division, National Cancer Center Hospital, Tokyo, Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagakute, Japan.,Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Yasushi Onishi
- Department of Hematology, Tohoku University Hospital, Sendai, Japan
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Watkins B, Williams KM. Controversies and expectations for the prevention of GVHD: A biological and clinical perspective. Front Immunol 2022; 13:1057694. [PMID: 36505500 PMCID: PMC9726707 DOI: 10.3389/fimmu.2022.1057694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/03/2022] [Indexed: 11/24/2022] Open
Abstract
Severe acute and chronic graft versus host disease (GVHD) remains a major cause of morbidity and mortality after allogeneic hematopoietic cell transplantation. Historically, cord blood and matched sibling transplantation has been associated with the lowest rates of GVHD. Newer methods have modified the lymphocyte components to minimize alloimmunity, including: anti-thymocyte globulin, post-transplant cyclophosphamide, alpha/beta T cell depletion, and abatacept. These agents have shown promise in reducing severe GVHD, however, can be associated with increased risks of relapse, graft failure, infections, and delayed immune reconstitution. Nonetheless, these GVHD prophylaxis strategies have permitted expansion of donor sources, especially critical for those of non-Caucasian decent who previously lacked transplant options. This review will focus on the biologic mechanisms driving GVHD, the method by which each agent impacts these activated pathways, and the clinical consequences of these modern prophylaxis approaches. In addition, emerging novel targeted strategies will be described. These GVHD prophylaxis approaches have revolutionized our ability to increase access to transplant and have provided important insights into the biology of GVHD and immune reconstitution.
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9
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Fludarabine/Cyclophosphamide Conditioning Regimen in Aplastic Anemia Patients Receiving Matched-Sibling Donor Transplant Is Non-inferior to ATG/Cyclophosphamide: A Single-Center Experience from Pakistan. Stem Cells Int 2022; 2022:1442613. [PMID: 36117722 PMCID: PMC9481407 DOI: 10.1155/2022/1442613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022] Open
Abstract
The successful outcome of allogeneic hematopoietic stem cell transplant (HSCT) in aplastic anemia patients is driven by suitable donor selection, appropriate conditioning regimen, early intervention, and optimal supportive care after transplant. Pakistan, being a developing country, faces grave economic challenges due to meager health care budget; therefore, cost constraints remain the foremost impediment in optimizing transplant facilities for socioeconomically deprived patients. We conducted a single-center retrospective analysis of aplastic anemia patients (N = 130), who received matched sibling donor transplants from 2011 to 2019, treated with either fludarabine/cyclophosphamide (Flu/Cy) or antithymocyte globulin/cyclophosphamide (ATG/CY) conditioning regimen. Median age was 16 years (IQR, 11-20), and it ranged from 3 to 48 years. The median time from diagnosis to transplant was 3 months (IQR, 2 to 4), and it ranged from 1 to 8 months. The estimated overall survival (OS), relapse-free survival (RFS), and GvHD-free survival (GFS) were found to be 69.0%, 66.7%, and 64.3% in the ATG/Cy group while 76.1%, 72.7%, and 62.5% in the Flu/Cy group, respectively, after a median follow-up of 30 months (IQR, 8 to 55), and it ranged from 0 to 98 months for the study groups. The Flu/Cy regimen was well tolerated and was not associated with increased risk of GvHD. Hence, it may be an appropriate alternative conditioning regimen for developing countries with limited health care resources.
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Ebrahimi A, Ahmadi H, Ghasrodashti ZP, Tanideh N, Shahriarirad R, Erfani A, Ranjbar K, Ashkani-Esfahani S. Therapeutic effects of stem cells in different body systems, a novel method that is yet to gain trust: A comprehensive review. Bosn J Basic Med Sci 2021; 21:672-701. [PMID: 34255619 PMCID: PMC8554700 DOI: 10.17305/bjbms.2021.5508] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 04/25/2021] [Indexed: 11/30/2022] Open
Abstract
Stem cell therapy has been used to treat several types of diseases, and it is expected that its therapeutic uses shall increase as novel lines of evidence begin to appear. Furthermore, stem cells have the potential to make new tissues and organs. Thus, some scientists propose that organ transplantation will significantly rely on stem cell technology and organogenesis in the future. Stem cells and its robust potential to differentiate into specific types of cells and regenerate tissues and body organs, have been investigated by numerous clinician scientists and researchers for their therapeutic effects. Degenerative diseases in different organs have been the main target of stem cell therapy. Neurodegenerative diseases such as Alzheimer's, musculoskeletal diseases such as osteoarthritis, congenital cardiovascular diseases, and blood cell diseases such as leukemia are among the health conditions that have benefited from stem cell therapy advancements. One of the most challenging parts of the process of incorporating stem cells into clinical practice is controlling their division and differentiation potentials. Sometimes, their potential for uncontrolled growth will make these cells tumorigenic. Another caveat in this process is the ability to control the differentiation process. While stem cells can easily differentiate into a wide variety of cells, a paracrine effect controlled activity, being in an appropriate medium will cause abnormal differentiation leading to treatment failure. In this review, we aim to provide an overview of the therapeutic effects of stem cells in diseases of various organ systems. In order to advance this new treatment to its full potential, researchers should focus on establishing methods to control the differentiation process, while policymakers should take an active role in providing adequate facilities and equipment for these projects. Large population clinical trials are a necessary tool that will help build trust in this method. Moreover, improving social awareness about the advantages and adverse effects of stem cell therapy is required to develop a rational demand in the society, and consequently, healthcare systems should consider established stem cell-based therapeutic methods in their treatment algorithms.
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Affiliation(s)
- Alireza Ebrahimi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hanie Ahmadi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Pourfraidon Ghasrodashti
- Molecular Pathology and Cytogenetics Laboratory, Department of Pathology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nader Tanideh
- Stem Cells Technology Research Center, Department of Pharmacology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Shahriarirad
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amirhossein Erfani
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Keivan Ranjbar
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Soheil Ashkani-Esfahani
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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11
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Salamonowicz-Bodzioch M, Rosa M, Frączkiewicz J, Gorczyńska E, Gul K, Janeczko-Czarnecka M, Jarmoliński T, Kałwak K, Mielcarek-Siedziuk M, Olejnik I, Owoc-Lempach J, Panasiuk A, Gajek K, Rybka B, Ryczan-Krawczyk R, Ussowicz M. Fludarabine-Cyclophosphamide-Based Conditioning with Antithymocyte Globulin Serotherapy Is Associated with Durable Engraftment and Manageable Infections in Children with Severe Aplastic Anemia. J Clin Med 2021; 10:jcm10194416. [PMID: 34640434 PMCID: PMC8509585 DOI: 10.3390/jcm10194416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/21/2021] [Accepted: 09/23/2021] [Indexed: 01/18/2023] Open
Abstract
Severe aplastic anemia (SAA) is a bone marrow failure syndrome that can be treated with hematopoietic cell transplantation (HCT) or immunosuppressive (IS) therapy. A retrospective cohort of 56 children with SAA undergoing transplantation with fludarabine-cyclophosphamide-ATG-based conditioning (FluCyATG) was analyzed. The endpoints were overall survival (OS), event-free survival (EFS), cumulative incidence (CI) of graft versus host disease (GVHD) and CI of viral replication. Engraftment was achieved in 53/56 patients, and four patients died (two due to fungal infection, and two of neuroinfection). The median time to neutrophil engraftment was 14 days and to platelet engraftment was 16 days, and median donor chimerism was above 98%. The overall incidence of acute GVHD was 41.5%, and that of grade III-IV acute GVHD was 14.3%. Chronic GVHD was diagnosed in 14.2% of children. The probability of 2-year GVHD-free survival was 76.1%. In the univariate analysis, a higher dose of cyclophosphamide and previous IS therapy were significant risk factors for worse overall survival. Episodes of viral replication occurred in 33/56 (58.9%) patients, but did not influence OS. The main advantages of FluCyATG include early engraftment with a very high level of donor chimerism, high overall survival and a low risk of viral replication after HCT.
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Affiliation(s)
- Małgorzata Salamonowicz-Bodzioch
- Department of Pediatric Oncology, Haematology and Bone Marrow Transplantation, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (M.R.); (J.F.); (E.G.); (K.G.); (M.J.-C.); (T.J.); (K.K.); (M.M.-S.); (I.O.); (J.O.-L.); (K.G.); (B.R.); (R.R.-K.); (M.U.)
- Correspondence: ; Tel.: +48-71-7332700; Fax: +48-71-7332709
| | - Monika Rosa
- Department of Pediatric Oncology, Haematology and Bone Marrow Transplantation, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (M.R.); (J.F.); (E.G.); (K.G.); (M.J.-C.); (T.J.); (K.K.); (M.M.-S.); (I.O.); (J.O.-L.); (K.G.); (B.R.); (R.R.-K.); (M.U.)
| | - Jowita Frączkiewicz
- Department of Pediatric Oncology, Haematology and Bone Marrow Transplantation, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (M.R.); (J.F.); (E.G.); (K.G.); (M.J.-C.); (T.J.); (K.K.); (M.M.-S.); (I.O.); (J.O.-L.); (K.G.); (B.R.); (R.R.-K.); (M.U.)
| | - Ewa Gorczyńska
- Department of Pediatric Oncology, Haematology and Bone Marrow Transplantation, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (M.R.); (J.F.); (E.G.); (K.G.); (M.J.-C.); (T.J.); (K.K.); (M.M.-S.); (I.O.); (J.O.-L.); (K.G.); (B.R.); (R.R.-K.); (M.U.)
| | - Katarzyna Gul
- Department of Pediatric Oncology, Haematology and Bone Marrow Transplantation, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (M.R.); (J.F.); (E.G.); (K.G.); (M.J.-C.); (T.J.); (K.K.); (M.M.-S.); (I.O.); (J.O.-L.); (K.G.); (B.R.); (R.R.-K.); (M.U.)
| | - Małgorzata Janeczko-Czarnecka
- Department of Pediatric Oncology, Haematology and Bone Marrow Transplantation, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (M.R.); (J.F.); (E.G.); (K.G.); (M.J.-C.); (T.J.); (K.K.); (M.M.-S.); (I.O.); (J.O.-L.); (K.G.); (B.R.); (R.R.-K.); (M.U.)
| | - Tomasz Jarmoliński
- Department of Pediatric Oncology, Haematology and Bone Marrow Transplantation, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (M.R.); (J.F.); (E.G.); (K.G.); (M.J.-C.); (T.J.); (K.K.); (M.M.-S.); (I.O.); (J.O.-L.); (K.G.); (B.R.); (R.R.-K.); (M.U.)
| | - Krzysztof Kałwak
- Department of Pediatric Oncology, Haematology and Bone Marrow Transplantation, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (M.R.); (J.F.); (E.G.); (K.G.); (M.J.-C.); (T.J.); (K.K.); (M.M.-S.); (I.O.); (J.O.-L.); (K.G.); (B.R.); (R.R.-K.); (M.U.)
| | - Monika Mielcarek-Siedziuk
- Department of Pediatric Oncology, Haematology and Bone Marrow Transplantation, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (M.R.); (J.F.); (E.G.); (K.G.); (M.J.-C.); (T.J.); (K.K.); (M.M.-S.); (I.O.); (J.O.-L.); (K.G.); (B.R.); (R.R.-K.); (M.U.)
| | - Igor Olejnik
- Department of Pediatric Oncology, Haematology and Bone Marrow Transplantation, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (M.R.); (J.F.); (E.G.); (K.G.); (M.J.-C.); (T.J.); (K.K.); (M.M.-S.); (I.O.); (J.O.-L.); (K.G.); (B.R.); (R.R.-K.); (M.U.)
| | - Joanna Owoc-Lempach
- Department of Pediatric Oncology, Haematology and Bone Marrow Transplantation, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (M.R.); (J.F.); (E.G.); (K.G.); (M.J.-C.); (T.J.); (K.K.); (M.M.-S.); (I.O.); (J.O.-L.); (K.G.); (B.R.); (R.R.-K.); (M.U.)
| | - Anna Panasiuk
- Department of Oncology, Hematolgy and Transplantology, University Hospital USK in Wroclaw, 50-556 Wroclaw, Poland;
| | - Kornelia Gajek
- Department of Pediatric Oncology, Haematology and Bone Marrow Transplantation, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (M.R.); (J.F.); (E.G.); (K.G.); (M.J.-C.); (T.J.); (K.K.); (M.M.-S.); (I.O.); (J.O.-L.); (K.G.); (B.R.); (R.R.-K.); (M.U.)
| | - Blanka Rybka
- Department of Pediatric Oncology, Haematology and Bone Marrow Transplantation, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (M.R.); (J.F.); (E.G.); (K.G.); (M.J.-C.); (T.J.); (K.K.); (M.M.-S.); (I.O.); (J.O.-L.); (K.G.); (B.R.); (R.R.-K.); (M.U.)
| | - Renata Ryczan-Krawczyk
- Department of Pediatric Oncology, Haematology and Bone Marrow Transplantation, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (M.R.); (J.F.); (E.G.); (K.G.); (M.J.-C.); (T.J.); (K.K.); (M.M.-S.); (I.O.); (J.O.-L.); (K.G.); (B.R.); (R.R.-K.); (M.U.)
| | - Marek Ussowicz
- Department of Pediatric Oncology, Haematology and Bone Marrow Transplantation, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; (M.R.); (J.F.); (E.G.); (K.G.); (M.J.-C.); (T.J.); (K.K.); (M.M.-S.); (I.O.); (J.O.-L.); (K.G.); (B.R.); (R.R.-K.); (M.U.)
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12
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Full Dose Cyclophosphamide with the Addition of Fludarabine for Matched Sibling Transplants in Severe Aplastic Anemia. Transplant Cell Ther 2021; 27:851.e1-851.e6. [PMID: 34126277 DOI: 10.1016/j.jtct.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 05/21/2021] [Accepted: 06/03/2021] [Indexed: 11/21/2022]
Abstract
The recommended therapy for severe aplastic anemia (SAA) in younger patients with a matched sibling donor (MSD) is allogeneic hematopoietic cell transplantation (allo-HCT). A number of conditioning regimens and protocols have been used for these patients. Here we report a homogeneous cohort of SAA patients receiving a uniform transplantation protocol. This study is a retrospective analysis of 82 consecutive patients with SAA who underwent MSD allo-HCT at a single center. The median duration of follow-up for survivors was 100 months, the 10-year overall survival (OS) was 87.5%, and the 10-year event-free survival was 75.3%. The OS was 97.4% for "mobilized" bone marrow (BM) graft recipients and 78.9% for "nonmobilized" BM graft recipients (P = .01. The cumulative incidence of acute graft-versus-host disease (GVHD) was 25.6%, that of chronic GVHD was 27.16%, and that of graft failure was 16.2%. Recipient age ≥30 years and transplantation at >6 months after SAA diagnosis were associated with a increased risk of events. In the presence of a fully matched sibling donor, allo-HCT with a mobilized BM graft and fludarabine-cyclophosphamide conditioning is an efficacious and safe approach. Early transplantation is associated with a better outcome, emphasizing the importance of not delaying transplantation in these patients. Prospective trials are needed to determine the optimal regimen.
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13
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Xu ZL, Huang XJ. Optimizing outcomes for haploidentical hematopoietic stem cell transplantation in severe aplastic anemia with intensive GVHD prophylaxis: a review of current findings. Expert Rev Hematol 2021; 14:449-455. [PMID: 33945370 DOI: 10.1080/17474086.2021.1923475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Allogeneic hematopoietic stem cell transplantation (allo-HSCT) has resulted in increased levels of disease-free survival in severe aplastic anemia (SAA). Haploidentical transplantation (haplo-SCT) was previously not recommended due to unacceptable incidences of graft-versus-host disease (GvHD) and graft failures. With the advent of intensive GvHD prophylaxis strategies, the outcomes obtained with haplo-SCT for SAA have gradually improved.Areas covered: A comprehensive search considered PubMed reported articles before 1 February 2021, presented abstracts, and clinical trials pertaining to haplo-HSCT for SAA. This manuscript covers modern approaches with intensive GvHD prophylaxis in haplo-SCT for SAA. The representative methods consist of granulocyte colony stimulating factor (G-CSF) plus ATG-based and posttransplantation cyclophosphamide (PT-Cy)-based protocols.Expert opinion: Currently, haplo-SCT has become a feasible option for treating SAA. The G-CSF/ATG-based protocol included the largest sample size and reported comparable survival rates with identical siblings. The PT-Cy protocol resulted in a relatively lower incidence of GvHD and seemingly poorer but continuously improved engraftment with augmented conditioning. The optimized outcomes are constantly updated with the modification of the conditioning regimen, donor selection, graft source and GvHD prophylaxis. In the future, we should pay more attention to quality of life in addition to survival, and personalized haplo-SCT may improve outcomes.
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Affiliation(s)
- Zheng-Li Xu
- National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiao-Jun Huang
- National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
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14
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George B, Lionel S, Selvarajan S, Abubacker FN, Korula A, Devasia AJ, Kulkarni U, Lakshmi KM, Sindhuvi E, Abraham A, Mathews V. An Antithymocyte Globulin-Free Conditioning Regimen Using Fludarabine and Cyclophosphamide Is Associated with Good Outcomes in Patients Undergoing Matched Related Family Donor Transplantation for Aplastic Anemia. Transplant Cell Ther 2021; 27:409.e1-409.e6. [PMID: 33965181 DOI: 10.1016/j.jtct.2021.01.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 01/26/2021] [Accepted: 01/31/2021] [Indexed: 02/02/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) using fludarabine (Flu)-based conditioning regimens are being increasingly being used in patients with aplastic anemia (AA). We describe an antithymocyte globulin (ATG)-free conditioning regimen consisting of Flu and cyclophosphamide (Cy) in patients undergoing matched related donor (MRD) HSCT for AA. Between 2004 and 2019, 212 patients underwent MRD HSCT using Flu (30 mg/m2/day for 6 days) and Cy (60 mg/kg/day for 2 days) for conditioning. The graft source was peripheral blood stem cells in all patients. Graft-versus-host disease (GVHD) prophylaxis consisted mainly of cyclosporine and methotrexate, although 41 patients received post-transplantation Cy as part of a study. Engraftment occurred in 91% of patients at a median of 16 days, whereas 4 patients (1.8%) experienced primary graft failure and 15 (7.1%) died before achieving engraftment. Toxicity was minimal. The incidence of grade II-IV acute GVHD (aGVHD) was 27.9%, and that of grade III-IV aGVHD was 11.3%. Chronic GVHD occurred in 41.6%. 80% were free of immunosuppression at 60 months and long-term complications were seen in 8.4%. At a median of 46 months, 158 patients were alive and well, with a 5-year overall survival (OS) of 75.3 ± 3.0%. The 5-year OS was 80.6 ± 4.1% for patients age <20 years (n = 93), 74.5 ± 4.6% for those age 20 to 40 years (n = 91), and 59.7 ± 9.5% for those age >40 years (n = 28) (P = .11). Patients classified as low risk had better OS compared with those at high risk (93.2 ± 2.9% versus 65.7 ± 4.1%; P = .000). Factors affecting OS on multivariate analysis included aGVHD (P = .02) and graft failure (P = .000). This large series using Flu/Cy for conditioning before MRD HSCT confirms good outcomes in patients with AA, with excellent outcomes in low-risk patients. Suitable modifications are needed to improve outcomes in high-risk patients.
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Affiliation(s)
- Biju George
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India.
| | - Sharon Lionel
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Sushil Selvarajan
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Fouzia N Abubacker
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Anu Korula
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Anup J Devasia
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Uday Kulkarni
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Kavitha M Lakshmi
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Eunice Sindhuvi
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Aby Abraham
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
| | - Vikram Mathews
- Department of Haematology, Christian Medical College, Ida Scudder Road, Vellore - 632004, Tamil Nadu, India
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15
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Granot N, Storb R. History of hematopoietic cell transplantation: challenges and progress. Haematologica 2020; 105:2716-2729. [PMID: 33054108 PMCID: PMC7716373 DOI: 10.3324/haematol.2019.245688] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/25/2020] [Indexed: 11/10/2022] Open
Abstract
After more than 60 years of research in allogeneic hematopoietic cell transplantation (HCT), this therapy has advanced from one that was declared dead in the 1960s to a standard treatment of otherwise fatal malignant and non-malignant blood diseases. To date, close to 1.5 million hematopoietic cell transplants have been performed in more than 1,500 transplantation centers worldwide. This review will highlight the enormous efforts by numerous investigators throughout the world who have brought the experimental field of HCT to clinical reality, examine ongoing challenges, and provide insights for the future.
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Affiliation(s)
- Noa Granot
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA.
| | - Rainer Storb
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA.
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16
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Iftikhar R, Chaudhry QUN, Anwer F, Neupane K, Rafae A, Mahmood SK, Ghafoor T, Shahbaz N, Khan MA, Khattak TA, Shamshad GU, Rehman J, Farhan M, Khan M, Ansar I, Ashraf R, Marsh J, Satti TM, Ahmed P. Allogeneic hematopoietic stem cell transplantation in aplastic anemia: current indications and transplant strategies. Blood Rev 2020; 47:100772. [PMID: 33187812 DOI: 10.1016/j.blre.2020.100772] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/12/2020] [Accepted: 10/15/2020] [Indexed: 12/18/2022]
Abstract
Treatment options for newly diagnosed aplastic anemia (AA) patient includes upfront allogeneic hematopoietic stem cell transplant (HSCT) or immunosuppressive therapy (IST). With recent advances in supportive care, conditioning regimens and post-transplant immunosuppression the overall survival for HSCT approaches 70-90%. Transplant eligibility needs to be assessed considering age, comorbidities, donor availability and probability of response to immunosuppressive therapy (IST). Upfront HSCT should be offered to children and young adults with matched related donor (MRD). Upfront HSCT may also be offered to children and young adults with rapidly available matched unrelated donor (MUD) who require urgent HSCT. Bone marrow (BM) graft source and cyclosporine (CsA) plus methotrexate (MTX) as graft versus host disease (GVHD) prophylaxis are preferable when using anti-thymocyte globulin (ATG) based conditioning regimens. Alemtuzumab is an acceptable alternative to ATG and is used with CsA alone and with either BM or peripheral blood stem cells (PBSC). Cyclophosphamide (CY) plus ATG conditioning is preferable for patients receiving MRD transplant, while Fludarabine (Flu) based conditioning is reserved for older adults, those with risk factors of graft failure and those receiving MUD HSCT. For haploidentical transplant, use of low dose radiotherapy and post-transplant cyclophosphamide has resulted in a marked reduction in graft failure and GVHD.
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Affiliation(s)
- Raheel Iftikhar
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan.
| | - Qamar Un Nisa Chaudhry
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Faiz Anwer
- Department of Hematology, Medical Oncology, Tausig Cancer Center, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Karun Neupane
- Department of Internal Medicine, Manipal College of Medical Sciences, Pokhara 33700, Nepal
| | - Abdul Rafae
- Department of Internal Medicine, McLaren Flint Michigan State University, United States
| | - Syed Kamran Mahmood
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Tariq Ghafoor
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Nighat Shahbaz
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Mehreen Ali Khan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Tariq Azam Khattak
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Ghassan Umair Shamshad
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Jahanzeb Rehman
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Muhammad Farhan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Maryam Khan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Iqraa Ansar
- Shifa College of Medicine, Islamabad 44000, Pakistan
| | - Rabia Ashraf
- King Edward Medical University, Lahore 54000, Pakistan
| | - Judith Marsh
- Department of Hematological Medicine, King's College Hospital, Denmark Hill, London SE59RS, UK
| | | | - Parvez Ahmed
- Department of Hematology Oncology and Stem Cell Transplant, Quaid-e-Azam International Hospital, Islamabad 44000, Pakistan
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17
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Onishi Y, Mori T, Yamazaki H, Takenaka K, Yamaguchi H, Shingai N, Ozawa Y, Iida H, Ota S, Uchida N, Miyamoto T, Katayama Y, Kato J, Yoshioka S, Onizuka M, Ichinohe T, Atsuta Y. Cyclosporine/methotrexate versus tacrolimus/methotrexate with or without anti-thymocyte globulin as GVHD prophylaxis in adult patients with aplastic anemia. Ann Hematol 2020; 100:217-228. [PMID: 33033911 DOI: 10.1007/s00277-020-04290-1] [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: 07/21/2020] [Accepted: 09/28/2020] [Indexed: 11/29/2022]
Abstract
The impact of calcineurin inhibitor types and anti-thymocyte globulin (ATG) in conditioning on overall survival (OS) and GVHD-free, relapse-free survival (GRFS) has not yet been analyzed in detail for aplastic anemia. We herein examined 517 adult patients with aplastic anemia who underwent BMT from HLA-matched sibling donors (MSD, n = 255) and unrelated donors (UD, n = 262) and were treated with cyclosporine A (CSA) + methotrexate (MTX) (n = 258) and tacrolimus (TAC) + MTX (n = 259). In total, 330 patients received ATG in conditioning. CSA + MTX versus TAC + MTX did not have a significant impact on acute and chronic GVHD, OS, or GRFS in each donor type. The use of ATG in conditioning reduced the risk of grade II-IV acute GVHD in the MSD and UD cohorts (HR 0.42, P = 0.014, and HR 0.3, P < 0.001, respectively); however, a differential impact on GRFS was identified, namely, better GRFS in MSD recipients (HR 0.56, P = 0.016), but not in UD recipients (HR 1.1, P = 0.657). In conclusion, CSA + MTX and TAC + MTX were similar as GVHD prophylaxis regardless of the donor type, and ATG in conditioning increased GRFS in MSD transplants, but not in UD transplants.
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Affiliation(s)
- Yasushi Onishi
- Department of Hematology and Rheumatology, Tohoku University Hospital, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
| | - Takehiko Mori
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hirohito Yamazaki
- Division of Transfusion Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Katsuto Takenaka
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Matsuyama, Japan
| | | | - Naoki Shingai
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yukiyasu Ozawa
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Hiroatsu Iida
- Division of Cell Therapy, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Shuichi Ota
- Department of Hematology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Naoyuki Uchida
- Department of Hematology, Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital, Tokyo, Japan
| | - Toshihiro Miyamoto
- Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuta Katayama
- Department of Hematology, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Jun Kato
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Yoshioka
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Makoto Onizuka
- Department of Hematology/Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan
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18
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Choice of conditioning regimens for bone marrow transplantation in severe aplastic anemia. Blood Adv 2020; 3:3123-3131. [PMID: 31648332 DOI: 10.1182/bloodadvances.2019000722] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/22/2019] [Indexed: 11/20/2022] Open
Abstract
Allogeneic bone marrow transplantation (BMT) is curative therapy for the treatment of patients with severe aplastic anemia (SAA). However, several conditioning regimens can be used for BMT. We evaluated transplant conditioning regimens for BMT in SAA after HLA-matched sibling and unrelated donor BMT. For recipients of HLA-matched sibling donor transplantation (n = 955), fludarabine (Flu)/cyclophosphamide (Cy)/antithymocyte globulin (ATG) or Cy/ATG led to the best survival. The 5-year probabilities of survival with Flu/Cy/ATG, Cy/ATG, Cy ± Flu, and busulfan/Cy were 91%, 91%, 80%, and 84%, respectively (P = .001). For recipients of 8/8 and 7/8 HLA allele-matched unrelated donor transplantation (n = 409), there were no differences in survival between regimens. The 5-year probabilities of survival with Cy/ATG/total body irradiation 200 cGy, Flu/Cy/ATG/total body irradiation 200 cGy, Flu/Cy/ATG, and Cy/ATG were 77%, 80%, 75%, and 72%, respectively (P = .61). Rabbit-derived ATG compared with equine-derived ATG was associated with a lower risk of grade II to IV acute graft-versus-host disease (GVHD) (hazard ratio [HR], 0.39; P < .001) but not chronic GVHD. Independent of conditioning regimen, survival was lower in patients aged >30 years after HLA-matched sibling (HR, 2.74; P < .001) or unrelated donor (HR, 1.98; P = .001) transplantation. These data support Flu/Cy/ATG and Cy/ATG as optimal regimens for HLA-matched sibling BMT. Although survival after an unrelated donor BMT did not differ between regimens, use of rabbit-derived ATG may be preferred because of lower risks of acute GVHD.
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Iftikhar R, Chaudhry QUN, Mahmood SK, Ghafoor T, Satti HS, Shahbaz N, Khan MA, Khattak TA, Shamshad GU, Rehman J, Farhan M, Humayun S, Risalat A, Wahab A, Satti TM, Anwer F, Ahmed P. Single-Agent Cyclosporine for Graft-versus-Host Disease Prophylaxis in Patients with Acquired Aplastic Anemia Receiving Fludarabine-Based Conditioning. Biol Blood Marrow Transplant 2020; 26:2245-2251. [PMID: 32717437 DOI: 10.1016/j.bbmt.2020.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 07/16/2020] [Accepted: 07/20/2020] [Indexed: 11/20/2022]
Abstract
Cyclosporine (CsA) combined with short-course methotrexate is considered standard-of-care graft-versus-host disease (GVHD) prophylaxis for patients with severe aplastic anemia (AA) who undergo transplantation using cyclophosphamide (Cy) plus anti-thymocyte globulin (ATG) conditioning. However, there is no consensus on optimal post-transplant GVHD prophylaxis for patients undergoing matched related donor (MRD) transplantation using fludarabine (Flu)-based conditioning. We conducted a single-center retrospective analysis of patients with acquired AA (n = 106) undergoing MRD transplantation from July 2007 through January 2019. All patients received Flu-Cy-ATG conditioning and single-agent CsA as GVHD prophylaxis. Median age of the study cohort was 20 years (range, 3 to 52) and male to female ratio was 3.8:1. Median time from diagnosis to transplant was 11.5 months (range, 2.8 to 62). Graft source was bone marrow harvest in 71 (68%), combined bone marrow and peripheral blood stem cells in 34 (31%), and peripheral blood alone in 1 (1%) patient. Cumulative incidence of neutrophil engraftment at day 28 was 93.4% (95% confidence interval [CI], 87.3% to 97.1%) while that of platelet engraftment at day 100 was 90.5% (95% CI, 84% to 96%). Cumulative incidence of primary graft failure at day 28 was 6.6% (95% CI, 4% to 8%) while secondary graft failure occurred at a median of 190 days (range, 90 to 415) at a cumulative incidence of 3.7% (95% CI, 2% to 5%). Cumulative incidence of grade II to IV acute GVHD at day 100 was 3.8% (95% CI, 1.4% to 9.9%), while a 1-year probability of chronic GVHD was calculated as 7.5% (95% CI, 2.6% to 15%). Median follow-up post-transplant was 61 months (range, 6 to 144). Overall survival was 84.9%, disease-free survival was 80.2%, and GVHD-free relapse-free survival was 76.3%. This study indicates that single-agent cyclosporine is a feasible option for GVHD prophylaxis in MRD hematopoietic stem cell transplantation using Flu-Cy-ATG conditioning and is associated with very low rates of acute and chronic GVHD.
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Affiliation(s)
- Raheel Iftikhar
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan.
| | - Qamar Un Nisa Chaudhry
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Syed Kamran Mahmood
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Tariq Ghafoor
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Humayun Shafique Satti
- Department of Molecular Hematology, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Nighat Shahbaz
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Mehreen Ali Khan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Tariq Azam Khattak
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Ghassan Umair Shamshad
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Jahanzeb Rehman
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Muhammad Farhan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Saima Humayun
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Amina Risalat
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Ahsan Wahab
- Baptist Medical Center South, Montgomery, Alabama
| | | | - Faiz Anwer
- Department of Hematology, Medical Oncology, Tausig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Parvez Ahmed
- Department of Hematology Oncology and Stem Cell Transplant, Quaid-e-Azam International Hospital, Islamabad, Pakistan
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Salas MQ, Atenafu EG, Lam W, Law AD, Kim D(DH, Michelis FV, Al-Shaibani Z, Gerbitz A, Lipton JH, Viswabandya A, Mattsson J, Gupta V, Kumar R. High Overall and GVHD-Free Survival in Patients with Aplastic Anemia Receiving in vivo T-cell Depletion Transplants and Long-Term Complications. BLOOD CELL THERAPY 2020; 3:48-58. [PMID: 36714178 PMCID: PMC9847295 DOI: 10.31547/bct-2020-001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/24/2020] [Indexed: 02/01/2023]
Abstract
We report a single-center experience of allogeneic hematopoietic stem cell transplant for patients with severe aplastic anemia over 13 years of age. Fifty-eight patients were included, and in vivo T-cell depletion was used in all cases. Fifty-one (88%) received alemtuzumab and 7 (12%) were given rabbit anti-thymocyte globulin. The median follow-up period was 6 years (range: 0-13.5). Data was collected retrospectively and updated in April 2019. The median age was 31 years (range: 18-67). Forty (69%) recipients received grafts from related donors and 18 (31%) received them from unrelated donors. Peripheral blood grafts were infused in 12 (20.7%) patients. Five-year overall survival (OS) was 80.7%. Five-year graft-versus-host disease (GVHD)/rejection-free survival was 56%. Eight (13.8%) patients experienced graft failure. The cumulative incidence of grade II-IV acute GVHD at day 100 was 14% and that of chronic GVHD at 1 year was 7%. The selection of unrelated donors and the use of peripheral blood grafts were not significant risk factors for clinically relevant GVHD or for lower OS. Recipients older than 40 years showed significantly worse OS, as observed from the results of univariate analysis. T-cell depletion in severe aplastic anemia shows low rates of GVHD and high OS, but older patients remain a group with higher risk of mortality. Long-term complications were mainly autoimmune in character.
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Affiliation(s)
- Maria Queralt Salas
- University of Toronto, Dept of Medicine, Section of Medical Oncology and Hematology,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada,Hematology Department, Institut Català d'Oncologia-Hospitalet, IDIBELL, Barcelona, Spain
| | - Eshetu G. Atenafu
- Department of Biostatistics, Princes Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Wilson Lam
- University of Toronto, Dept of Medicine, Section of Medical Oncology and Hematology,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Arjun Datt Law
- University of Toronto, Dept of Medicine, Section of Medical Oncology and Hematology,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Dennis (Dong Hwan) Kim
- University of Toronto, Dept of Medicine, Section of Medical Oncology and Hematology,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Fotios V. Michelis
- University of Toronto, Dept of Medicine, Section of Medical Oncology and Hematology,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Zeyad Al-Shaibani
- University of Toronto, Dept of Medicine, Section of Medical Oncology and Hematology,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Armin Gerbitz
- University of Toronto, Dept of Medicine, Section of Medical Oncology and Hematology,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey Howard Lipton
- University of Toronto, Dept of Medicine, Section of Medical Oncology and Hematology,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Auro Viswabandya
- University of Toronto, Dept of Medicine, Section of Medical Oncology and Hematology,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jonas Mattsson
- University of Toronto, Dept of Medicine, Section of Medical Oncology and Hematology,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Vikas Gupta
- University of Toronto, Dept of Medicine, Section of Medical Oncology and Hematology
| | - Rajat Kumar
- University of Toronto, Dept of Medicine, Section of Medical Oncology and Hematology,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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21
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Kamranzadeh Fumani H, Jalili M, Rad S, Babakhani D, Maleki N, Asadollah Mousavi S, Ghavamzadeh A. Outcome of peripheral blood allogeneic hematopoietic stem cell transplantation as a treatment option in patients with severe aplastic anemia between 40 and 50 years. Hematol Oncol Stem Cell Ther 2020; 15:52-58. [PMID: 32652051 DOI: 10.1016/j.hemonc.2020.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 06/13/2020] [Indexed: 11/16/2022] Open
Abstract
The frontline treatment for patients younger than 40 years with severe aplastic anemia (AA) is allogeneic hematopoietic stem cell transplantation (HSCT) from a human leukocyte antigen-identical sibling donor. However, in patients with severe AA who are older than 40 years, allogeneic HSCT has been found to be associated with increased treatment-related mortality and toxicity, even when matched sibling donors are used. We report our institutional experience with allogeneic HSCT in patients with severe AA between 40 and 50 years. A total of 19 patients with severe AA were included in the study. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method. The mean age of patients at the time of transplant was 43.79 years, and 57.9% were male. The mortality rate was 36.8%, attributed to infection (10.5%), relapse (15.8%), and renal failure (5.3%) in all cases. Acute graft-versus-host disease (GVHD) occurred in five patients (26.3%), and chronic GVHD occurred in two patients (10.5%). The 5-year OS was 62% and the 5-year DFS was 52%. We found that the patient's age, platelet level prior to transplantation, and the number of CD3 cells infused for each transplant were independent prognostic factors for OS, and the age and sex of the patient, graft rejection, and platelet level prior to transplantation were significant prognostic factors associated with DFS. We recommend that immunosuppressive therapy be considered as a first-line treatment in patients with severe AA who are older than 40 years. Allogeneic HSCT can be considered a valid alternative option in patients whose suppression therapy fails.
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Affiliation(s)
- Hosein Kamranzadeh Fumani
- Hematology, Oncology and Stem Cell Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Jalili
- Hematology, Oncology and Stem Cell Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Soroush Rad
- Hematology, Oncology and Stem Cell Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Davood Babakhani
- Hematology, Oncology and Stem Cell Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasrollah Maleki
- Hematology, Oncology and Stem Cell Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Seyed Asadollah Mousavi
- Hematology, Oncology and Stem Cell Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ardeshir Ghavamzadeh
- Hematology, Oncology and Stem Cell Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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22
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Bonifazi F, Rubio MT, Bacigalupo A, Boelens JJ, Finke J, Greinix H, Mohty M, Nagler A, Passweg J, Rambaldi A, Socie G, Solano C, Walker I, Barosi G, Kröger N. Rabbit ATG/ATLG in preventing graft-versus-host disease after allogeneic stem cell transplantation: consensus-based recommendations by an international expert panel. Bone Marrow Transplant 2020; 55:1093-1102. [PMID: 31969678 PMCID: PMC7269907 DOI: 10.1038/s41409-020-0792-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/04/2019] [Accepted: 01/13/2020] [Indexed: 11/26/2022]
Abstract
This collaborative initiative aimed to provide recommendations on the use of polyclonal antithymocyte globulin (ATG) or anti-T lymphocyte globulin (ATLG) for the prevention of graft-versus-host disease (GvHD) after allogeneic hematopoietic stem cell transplantation (HSCT). A comprehensive review of articles released up to October, 2018 was performed as a source of scientific evidence. Fourteen clinically relevant key questions to the domains indication, administration, and post-transplant management were developed and recommendations were produced using the Delphi technique involving a Panel of 14 experts. ATG/ATLG was strongly recommended as part of myeloablative conditioning regimen prior to matched or mismatched unrelated bone marrow or peripheral blood allogeneic HSCT in malignant diseases to prevent severe acute and chronic GvHD. ATG/ATLG was also recommended prior to HLA-identical sibling peripheral HSCT with good but lesser bulk of evidence. In reduced intensity or nonmyeloablative conditioning regimens, ATG/ATLG was deemed appropriate to reduce the incidence of acute and chronic GvHD, but a higher risk of relapse should be taken into account. Recommendations regarding dose, application, and premedication were also provided as well as post-transplant infectious prophylaxis and vaccination. Overall, these recommendations can be used for a proper and safe application of polyclonal ATG/ATLG to prevent GvHD after allogeneic HSCT.
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Affiliation(s)
- Francesca Bonifazi
- Institute of Hematology "Seragnoli", University Hospital "S. Orsola Malpighi", Bologna, Italy.
| | - Marie-Thérèse Rubio
- Department of Hematology, Hôpital Brabois, CHRU Nancy and CNRS UMR 7365, Biopole del'Université del Lorraine, Vendoeuvre les Nancy, France
| | - Andrea Bacigalupo
- "Fondazione Policlinico Universitario A. Gemelli IRCCS", Rome, Italy
- Institute of Hematology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jaap Jan Boelens
- Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jürgen Finke
- Freiburg University Medical Faculty and Medical Center, Department for Medicine, Hematology, Oncology and Stem Cell Transplantation, Freiburg, Germany
| | - Hildegard Greinix
- Division of Hematology, Medical University of Graz, Auenbruggerplatz 38, 8036, Graz, Austria
| | - Mohamad Mohty
- Service d'Hématologie clinique et Thérapie cellulaire, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, INSERM UMRs 938, Paris, France
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Jakob Passweg
- Division of Hematology, Department of Medicine, University Hospital Basel, Basel, Switzerland
| | - Alessandro Rambaldi
- Department of Oncology, University of Milano and Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Gérard Socie
- Service d' Hématologie-greffe, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Inserm UMR 976, Paris, France
| | - Carlos Solano
- Hematology Service, Hospital Clínico Universitario-INCLIVA; Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - Irwin Walker
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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23
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Iftikhar R, Chaudhry QUN, Satti TM, Mahmood SK, Ghafoor T, Shamshad GU, Shahbaz N, Khan MA, Khattak TA, Rehman J, Farhan M, Humayun S, Haq H, Naqvi SAA, Anwer F, Satti HS, Ahmed P. Comparison of Conventional Cyclophosphamide versus Fludarabine-Based Conditioning in High-Risk Aplastic Anemia Patients Undergoing Matched-Related Donor Transplantation. Clin Hematol Int 2020; 2:82-91. [PMID: 34595447 PMCID: PMC8432348 DOI: 10.2991/chi.d.200426.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 04/24/2020] [Indexed: 11/30/2022] Open
Abstract
Allogeneic stem cell transplant for high-risk aplastic anemia (AA) yields inferior results using conventional cyclophosphamide (CY)-based conditioning. The use of fludarabine (Flu)-based regimens has resulted in improved outcomes in high-risk patients. Limited data are available comparing these two conditioning regimens in such patients. We retrospectively analyzed 192 high-risk patients undergoing matched-related donor transplantation from July 2001 to December 2018. The median age was 19.5 (2–52) years. Patients were divided into 2 groups, Cy200 anti-thymocyte globulin (ATG)20 (Gp1 n = 79) or Flu120–150 Cy120–160 ATG20 (Gp2 n = 113). The risk of graft failure was significantly higher in Gp1, and the majority occurred in patients with >2 risk factors (p = 0.02). The incidence of grade II-IV acute graft versus host disease (GVHD) and chronic GVHD was not significantly different between the two groups. The overall survival (OS) of the study cohort was 81.3 %, disease-free survival (DFS) 76.6 % and GVHD-free relapse-free survival (GRFS) was 64.1%. DFS and GRFS were significantly higher in Gp2 as compared to Gp1: DFS 84.1% versus 68.4 % (p = 0.02), GRFS 77.9% versus 54.4% (p = 0.01), respectively. We conclude that Flu-based conditioning is associated with superior OS, DFS and GRFS as compared to the conventional Cy-based regimen in high-risk AA.
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Affiliation(s)
- Raheel Iftikhar
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Qamar Un Nisa Chaudhry
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Tariq Mehmood Satti
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Syed Kamran Mahmood
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Tariq Ghafoor
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Ghassan Umair Shamshad
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Nighat Shahbaz
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Mehreen Ali Khan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Tariq Azam Khattak
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Jahanzeb Rehman
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Muhammad Farhan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Saima Humayun
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Humera Haq
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Syeda Ammaara Anwaar Naqvi
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi 46000, Pakistan
| | - Faiz Anwer
- Department of Hematology, Medical Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH 44195, USA
| | | | - Parvez Ahmed
- Department of Hematology-Oncology and Stem Cell Transplant, Quaid-e-Azam International Hospital, Islamabad 44000, Pakistan
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24
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Comparison of HLA-matched sibling and unrelated donor transplantation in adult patients with acquired severe aplastic anemia. Bone Marrow Transplant 2020; 55:1570-1579. [PMID: 32024992 DOI: 10.1038/s41409-020-0820-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 12/12/2022]
Abstract
The recent improvements in the outcomes of severe aplastic anemia (SAA) patients who received allogeneic stem cell transplantation (SCT) from unrelated donors (URD) suggest the possibility of its alternative first-line treatment. To address this issue, results of adult SAA patients receiving allogeneic SCT were compared between the following three donor-type groups: 8/8-matched sibling (MSD; n = 153), 8/8 well-matched unrelated (WM-URD; n = 72), and 6-7/8 partially matched unrelated (PM-URD; n = 33). Proportion of patients who experienced immunosuppressive treatment failures was significantly higher in the URD groups than in the MSD group (P< 0.01). The incidences of graft failure and transplant-related mortality, and graft-vs.-host disease-free, failure-free survival rates of the MSD, WM-URD, and PM-URD groups were 14.6, 0, and 0% (P< 0.01); 6.1, 10.3, and 21.7% (P= 0.03); and 76.7, 55.5, and 51.5% (P< 0.01), respectively. The overall survival (OS) rate of the MSD group (93.9%) was higher than that of the PM-URD (78.3%; P < 0.01) group, but not to that of the WM-URD (86.2%; P= 0.18) group. Our study showed comparable OS between the MSD group and WM-URD group, which suggest that the URD-SCT can be used as a first-line treatment for adult SAA patients with WM-URD.
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25
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Cilloni D, Andreani G, Dragani M, De Gobbi M, Saglio G. Synergistic effect of eltrombopag and deferasirox in aplastic anemia: a clinical case and review of the literature. Leuk Lymphoma 2020; 61:234-236. [DOI: 10.1080/10428194.2019.1660969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Daniela Cilloni
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Giacomo Andreani
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Matteo Dragani
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Marco De Gobbi
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Giuseppe Saglio
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
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26
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Yang X, Bai Y, Guo H, Shi M, Zhang W, Pei Y, Song J, Drokow EK, Huang G, Liu X, Xu J, Kai Sun. Evaluating and monitoring bone marrow hypoplasia in adults with aplastic anemia via high-resolution iliac magnetic resonance imaging in the current era. Medicine (Baltimore) 2019; 98:e18214. [PMID: 31804346 PMCID: PMC6919526 DOI: 10.1097/md.0000000000018214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The diagnosis and monitoring of aplastic anemia (AA) rely heavily on a complete blood count (CBC), and multiple-site bone marrow (BM) aspirations and biopsies. However, these approaches have certain limitations. We aimed to assess high-resolution magnetic resonance imaging (MRI) as a complementary approach for evaluating BM hypoplasia and monitoring treatment response in adults with AA in the current era.Twelve newly diagnosed AA patients and 12 sex- and age-matched healthy controls were enrolled in this study from January 2017 to August 2018. A bilateral iliac 3.0T MRI was used to collect data for each subject, and the signal intensity on the T1-weighted images (T1WIs) were expressed as a contrast-to-noise ratio (CNR). The MRI, CBC, and BM biopsy data were analyzed and compared.A qualitative analysis identified a significant difference in MRI signal characteristics between the AA group and the healthy control group. The clinical classifications of very severe aplastic anemia (VSAA) and severe aplastic anemia (SAA) corresponded to pattern I and pattern II on the MR images, respectively. However, this imaging classification did not correlate with the biopsy-based BM cellularity measure. A quantitative analysis showed a significantly higher signal intensity in AA patients than in controls. A within-group comparison revealed that more severe types of AA, based on the clinical classification, corresponded to stronger signals. Notably, MRI could detect treatment response earlier than CBC, regardless of whether there were improvements in hematopoiesis.MRI can be used to predict the therapeutic effects in patients with AA and is an important complementary tool for evaluating and monitoring BM hypoplasia.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Junling Xu
- Department of Nuclear Medicine, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Henan, PR China
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Combination of HLA-Matched Sibling Allogeneic Hematopoietic Stem Cell Transplantation With Unrelated Cord Blood Unit in Patients Aged 35 to 50 Years With Severe Aplastic Anemia: Preliminary Summary of a Single-Arm Trial. Transplant Proc 2019; 51:3431-3436. [PMID: 31733793 DOI: 10.1016/j.transproceed.2019.07.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/09/2019] [Indexed: 11/22/2022]
Abstract
This study reports a single-arm trial in the interim phase in 4 patients with median age of 40.5 years who have undergone combined HLA-matched sibling donor (MSD) stem cell graft and an unrelated cord blood (UCB) unit for the treatment of severe aplastic anemia (SAA). The median time was 10 days for neutrophil engraftment (9-18 days) and 17 days for platelets (12-24 days). Median follow-up of 22 months (ranging from 16 to 29 months) showed survival of the 4 patients with complete hematological response. Acute graft-vs-host disease (GVHD) (grade II) occurred only in 1 patient, yet chronic GVHD was free. One patient showed a pattern of transient MSD graft followed by dominant UCB chimerism, and another 1 achieved mixed chimerism in the first 6 months after allogeneic hematopoietic stem cell transplantation (allo-HSCT) then evolved to a stable MSD graft. The other 2 patients sustained a full MSD graft during the post-HSCT period. Nevertheless, none of the patients developed primary and secondary graft failure up to the final follow-up. Although this is a small cohort, the dual transplantation combining HLA-matched sibling allogeneic hematopoietic stem cell transplantation with unrelated cord blood unit may deserve further exploration for treatment of SAA patients aged 35 to 50 years old.
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Darrigo LG, Colturato V, de Souza MP, Loth G, Calixto R, Seber A, Zecchin VG, Esteves Daudt L, Tavares RB, Arcuri L, de Macedo AV, Vieira AK, Kuwahara C, Ribeiro L, Fernandes JF, Flowers ME, Pasquini R, Bonfim C. Allogeneic Bone Marrow Transplants for Pediatric Severe Aplastic Anemia: Real-world Data comparing Matched Related and Unrelated Donors in a Developing Country. Retrospective study on behalf of the Pediatric Hematopoietic Stem Cell Transplant Working Group of the Brazilian Bone Marrow Transplantation Society (SBTMO) and the Brazil-Seattle Consortium (Gedeco). Pediatr Transplant 2019; 23:e13552. [PMID: 31297928 DOI: 10.1111/petr.13552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/29/2019] [Accepted: 06/18/2019] [Indexed: 01/06/2023]
Abstract
In this study, we report on major MRD or URD BMT outcomes in pediatric patients with SAA in Brazil. This was a retrospective study, which included 106 patients ≤18 years old who received a first BMT for SAA. All patients received bone marrow as graft source from an MRD (n = 69) or a URD (n = 37). Conditioning regimen was non-myeloablative in 73.6% of cases, and GVHD prophylaxis comprised a calcineurin inhibitor plus methotrexate in 89.6% of patients. After a median follow-up of 4.5 years after BMT, 81 patients are alive, with a 4-year OS of 77% and no statistically significant difference between the MRD and URD groups (82% vs. 69%, respectively; P = .08). Grade III-IV aGVHD at 6 months and cGVHD at 2 years were observed in 8% and 14% of cases, respectively, and were not statistically different between the groups. Twenty-five (23%) patients died at a median of 2.9 months after BMT. Our study showed that 4-year OS after BMT was not statistically different between MRD and URD recipients. This study shows that the outcomes of pediatric patients transplanted for SAA with a URD in Brazil are approaching those of MRD transplants. In contrast, OS after MRD BMT was lower than we would expect based on previous reports. The wide range of preparatory regimens used by the study centers highlights the need for standardized protocols for these children. Our findings provide a benchmark for future studies focused on improving BMT outcomes in this setting in Brazil.
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Affiliation(s)
| | | | | | - Gisele Loth
- Universidade Federal do Paraná, Curitiba, Brazil
| | - Rodolfo Calixto
- Real Hospital Português de Beneficência, Recife - PE, Brazil
| | | | | | | | | | | | | | | | | | | | | | - Mary E Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Tang XF, Jing YF, Lu W, Huang YZ, Wu NH, Luan Z. [A clinical study of haploidentical hematopoietic stem cell transplantation in the treatment of pediatric patients with acquired severe aplastic anemia: single center experience]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:301-305. [PMID: 31104441 PMCID: PMC7343012 DOI: 10.3760/cma.j.issn.0253-2727.2019.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
目的 探讨单倍型造血干细胞移植(haplo-HSCT)治疗儿童获得性重型再生障碍性贫血(SAA)的疗效。 方法 回顾性分析2011年12月1日至2017年12月1日接受haplo-HSCT的59例SAA患者。 结果 ①全部59例SAA患儿中男37例、女22例,中位年龄4.5(1.2~14.8)岁,中位体重43(12~80)kg;SAA-Ⅰ型47例,SAA-Ⅱ型12例,26例为极重型再生障碍性贫血(VSAA);首次移植56例,二次移植3例。②预处理选用白消安+环磷酰胺+抗胸腺细胞球蛋白(ATG)方案或白消安+氟达拉滨+环磷酰胺+ATG方案;采用环孢素A(CsA)+霉酚酸酯+甲氨蝶呤方案预防急性GVHD;回输单个核细胞中位数为15.60(7.74~21.04)×108/kg,CD34+细胞中位数为4.86(3.74~7.14)×106/kg。③全部59例患儿均获得中性粒细胞和血小板植入。中性粒细胞植入中位时间为13(10~19)d,血小板植入中位时间为19(9~62)d。④Ⅰ~Ⅱ、Ⅲ/Ⅳ度急性GVHD发生率分别为45.76%(27/59)、13.56%(8/59),慢性GVHD发生率为8.47%(5/59)。巨细胞病毒血症发生率为59.32%(35/59)、EB病毒血症发生率为28.81%(17/59)。⑤中位随访时间30(8~80)个月,57例无病存活,2例死亡(均死于GVHD),5年总生存率、无失败生存率均为(96.4±2.5)%。 结论 haplo-HSCT是儿童SAA疗效较好的治疗方法。
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Affiliation(s)
- X F Tang
- Department of Paediatrics, Sixth Medical Center of PLA General Hospital of the People Liberation Army. Beijing 100048, China
| | - Y F Jing
- Department of Paediatrics, Sixth Medical Center of PLA General Hospital of the People Liberation Army. Beijing 100048, China
| | - W Lu
- Department of Paediatrics, Sixth Medical Center of PLA General Hospital of the People Liberation Army. Beijing 100048, China
| | - Y Z Huang
- Hematology Department Laboratory, Sixth Medical Center of PLA General Hospital of the People Liberation Army, Beijing 100048, China
| | - N H Wu
- Department of Paediatrics, Sixth Medical Center of PLA General Hospital of the People Liberation Army. Beijing 100048, China
| | - Z Luan
- Department of Paediatrics, Sixth Medical Center of PLA General Hospital of the People Liberation Army. Beijing 100048, China
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Ochi T, Onishi Y, Nasu K, Onodera K, Kobayashi M, Ichikawa S, Fujiwara T, Fukuhara N, Yamada-Fujiwara M, Harigae H. Umbilical Cord Blood Transplantation Using Reduced-Intensity Conditioning without Antithymocyte Globulin in Adult Patients with Severe Aplastic Anemia. Biol Blood Marrow Transplant 2019; 25:e55-e59. [DOI: 10.1016/j.bbmt.2018.09.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/27/2018] [Indexed: 01/06/2023]
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Samarasinghe S, Clesham K, Iacobelli S, Sbianchi G, Knol C, Hamladji RM, Socié G, Aljurf M, Koh M, Sengeloev H, Dalle JH, Robinson S, Van Lint MT, Halkes CJM, Beelen D, Mufti GJ, Snowden J, Blaise D, de Latour RP, Marsh J, Dufour C, Risitano AM. Impact of T-cell depletion strategies on outcomes following hematopoietic stem cell transplantation for idiopathic aplastic anemia: A study on behalf of the European blood and marrow transplant severe aplastic anemia working party. Am J Hematol 2019; 94:80-86. [PMID: 30328134 DOI: 10.1002/ajh.25314] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/02/2018] [Accepted: 10/15/2018] [Indexed: 12/11/2022]
Abstract
We retrospectively analyzed the outcomes of 1837 adults and children with severe aplastic anemia (SAA) who underwent matched sibling donor (MSD) and matched unrelated donor (MUD) hemopoietic stem cell transplantation (HSCT) between 2000 and 2013. Patients were grouped by transplant conditioning containing either anti-thymocyte globulin (ATG) (n = 1283), alemtuzumab (n = 261), or no serotherapy (NS) (n = 293). The risks of chronic GvHD were significantly reduced when ATG or alemtuzumab were compared with NS (P = .021 and .003, respectively). Acute GVHD was significantly reduced in favor of alemtuzumab compared with ATG (P = .012) and NS (P < .001). By multivariate analysis, when compared with ATG, alemtuzumab was associated with a lower risk of developing acute (OR 0.262; 95% CI 0.14-0.47; P < .001) and chronic GVHD (HR 0.58; 95% CI 0.35-0.94; P = .027). OS was significantly better in ATG and alemtuzumab patients compared with NS (P = .010 and .025). Our data shows inclusion of serotherapy in MSD and MUD HSCT for patients with SAA reduces chronic GVHD and provides a survival advantage over patients not receiving serotherapy. Notably, alemtuzumab reduced the risk of acute and chronic GvHD compared with ATG and indicates that alemtuzumab might be the serotherapy of choice for MSD and MUD transplants for SAA.
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Affiliation(s)
| | - Katherine Clesham
- UCL Great Ormond Street Hospital for Children; London United Kingdom
| | - Simona Iacobelli
- Dipartimento di Biologia; Tor Vergata Università di Roma; Rome Italy
| | - Giulia Sbianchi
- Dipartimento di Biologia; Tor Vergata Università di Roma; Rome Italy
| | - Cora Knol
- EBMT Data Office; Leiden The Netherlands
| | | | | | - Mahmoud Aljurf
- King Faisal Hospital & Research Centre; Riyadh Saudi Arabia
| | - Mickey Koh
- St. George's Hospital; London United Kingdom
| | | | | | | | | | | | | | - Ghulam J. Mufti
- King's College Hospital/King's College London; London United Kingdom
| | - John Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust; Sheffield United Kingdom
| | | | | | - Judith Marsh
- King's College Hospital/King's College London; London United Kingdom
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Giebel S, Labopin M, Czerw T, Socié G, Blaise D, Ghavamzadeh A, Passweg J, Ljungman P, Poiré X, Chevallier P, Reményi P, Rambaldi A, Anafasyev B, Fegueux N, Rovira M, Itälä-Remes M, Bornhäuser M, Mohty M, Nagler A. Impact of anti-thymocyte globulin on results of allogeneic peripheral blood stem cell transplantation for patients with Philadelphia-positive acute lymphoblastic leukaemia: An analysis by the Acute Leukemia Working Party of the EBMT. Eur J Cancer 2018; 106:212-219. [PMID: 30528805 DOI: 10.1016/j.ejca.2018.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/20/2018] [Accepted: 11/05/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Anti-thymocyte globulin (ATG) is widely used to prevent graft-versus-host disease (GVHD) after allogeneic peripheral blood stem cell transplantation (alloPBSCT). The goal of this study was to retrospectively assess the effect of ATG on outcomes in the setting of Philadelphia chromosome-positive acute lymphoblastic leukaemia (Ph+ ALL). METHODS In the analysis, 1170 adult patients undergoing alloPBSCT from human leucocyte antigen-matched sibling or unrelated donors in the first complete remission between 2007 and 2016 were included. ATG was used in 429/575 (75%) and 121/595 (20%) patients transplanted from unrelated or sibling donors, respectively. RESULTS The incidence of chronic GVHD was 35% for patients treated with ATG compared with 52% in those not receiving ATG (p < 0.001), while the rate of extensive chronic GVHD was 16% and 36%, respectively (p < 0.001). The probability of survival free from GVHD and relapse (GRFS) was 42% and 32%, respectively (p = 0.002). In a multivariate model, the use of ATG was associated with reduced risk of overall chronic GVHD (hazard ratio [HR] = 0.52, p < 0.001) and extensive chronic GVHD (HR = 0.46, p < 0.001). It was also associated with better GRFS (HR = 0.77, p = 0.007), despite increased risk of relapse (HR = 1.41, p = 0.02). No significant effect was found with regard to the risk of non-relapse mortality and overall mortality. CONCLUSIONS The use of ATG for patients with Ph+ ALL undergoing alloPBSCT is associated with reduced risk of chronic GVHD without impact on survival and therefore, could be considered. However, increased risk of relapse suggests the need for strict monitoring of minimal residual diseases and appropriate interventions after transplantation.
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Affiliation(s)
- Sebastian Giebel
- Maria Sklodowska-Curie Institute - Cancer Center, Gliwice Branch, Gliwice, Poland.
| | - Myriam Labopin
- Hospital St. Antoine, Paris, France; Acute Leukemia Working Party of the EBMT, France
| | - Tomasz Czerw
- Maria Sklodowska-Curie Institute - Cancer Center, Gliwice Branch, Gliwice, Poland
| | | | | | | | | | - Per Ljungman
- Karolinska University Hospital and Karolinska Institutet Stockholm, Sweden
| | - Xavier Poiré
- Cliniques Universitaires St. Luc, Brussels, Belgium
| | | | - Péter Reményi
- Dél-pesti Centrumkórház -Országos Hematológiai és Infektológiai Intézet, Budapest, Hungary
| | | | - Boris Anafasyev
- First State Pavlov Medical University of St. Petersburg, Russia
| | | | - Montserrat Rovira
- Hospital Clinic, Institute of Hematology & Oncology, Barcelona, Spain
| | | | | | - Mohamad Mohty
- Hospital St. Antoine, Paris, France; Acute Leukemia Working Party of the EBMT, France
| | - Arnon Nagler
- Acute Leukemia Working Party of the EBMT, France; Chaim Sheba Medical Center, Tel-Hashomer, Israel
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Kumar A, Reljic T, Hamadani M, Mohty M, Kharfan-Dabaja MA. Antithymocyte globulin for graft-versus-host disease prophylaxis: an updated systematic review and meta-analysis. Bone Marrow Transplant 2018; 54:1094-1106. [PMID: 30446739 DOI: 10.1038/s41409-018-0393-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 10/08/2018] [Accepted: 10/12/2018] [Indexed: 12/11/2022]
Abstract
Graft-versus-host disease (GVHD) remains a limiting factor for successful allogeneic hematopoietic cell transplantation (allo-HCT). Conflicting data exist on the benefit of ATG on post-transplant survival. We performed a systematic review of randomized controlled trials (RCTs) to assess benefits and harms of thymoglobulin and Fresenius (re-branded as Grafalon) ATG formulations in patients undergoing allo-HCT for a variety of hematologic malignancies and bone marrow failure syndromes. A comprehensive search of MEDLINE, EMBASE, and Cochrane Library was performed. Data on methodological quality, benefits, and harms were extracted for each trial and pooled under a random-effects model. Eight RCTs (1134 patients) met the inclusion criteria. Methodological quality ranged from moderate to very low. Pooled results showed no difference in overall survival (OS) with the use of ATG (hazard ratio (HR) = 0.97; 95% confidence interval (CI) = 0.74-1.28; P = 0.83). ATG reduced grade II/III acute GVHD (risk ratio (RR) = 0.61; 95% CI = 0.48-0.77; P < 0.0001), grade III/IV acute GVHD (RR = 0.52; 95% CI = 0.34-0.81; P = 0.004), and chronic GVHD (RR = 0.52; 95% CI = 0.40-0.69; P < 0.00001) without an increase in non-relapse mortality (NRM) (RR = 0.91; 95% CI = 0.74-1.13; P = 0.40). Future studies with better methodological quality are needed to provide conclusive answers related to optimal dosing and timing of ATG for prevention of GVHD.
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Affiliation(s)
- Ambuj Kumar
- Program for Comparative Effectiveness Research, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| | - Tea Reljic
- Program for Comparative Effectiveness Research, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Mehdi Hamadani
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mohamad Mohty
- Department of Haematology, Saint Antoine Hospital, University Pierre & Marie Curie and Inserm UMRs938, Paris, France
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
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Affiliation(s)
- Neal S Young
- From the Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
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DeZern AE, Brodsky RA. Haploidentical Donor Bone Marrow Transplantation for Severe Aplastic Anemia. Hematol Oncol Clin North Am 2018; 32:629-642. [PMID: 30047416 PMCID: PMC6063510 DOI: 10.1016/j.hoc.2018.04.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hematopoietic stem cell transplantation (bone marrow transplantation [BMT]) is the only curative treatment of severe aplastic anemia. BMT from an human leukocyte antigen (HLA)-matched sibling donor is the standard of care for young patients; immunosuppressive therapy is used for older patients or those lacking matched sibling donors. Patients with refractory or relapsed disease are increasingly treated with HLA haploidentical BMT. Historically, haploidentical BMT led to high rates of graft rejection and graft-versus-host disease. High-dose post transplant cyclophosphamide, which mitigates the risk of graft-versus-host disease, is a major advance. This article provides an overview of the haploidentical BMT approach in severe aplastic anemia.
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Affiliation(s)
- Amy E DeZern
- Division of Hematologic Malignancies, The Johns Hopkins University School of Medicine, 1650 Orleans Street, CRBI Room 3M87, Baltimore, MD 21287-0013, USA.
| | - Robert A Brodsky
- Division of Hematology, The Johns Hopkins University School of Medicine, 720 Rutland Avenue, Ross 1025, Baltimore, MD 21205, USA
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Abstract
PURPOSE OF REVIEW This review aimed to provide updated guidelines for the management of children with acquired aplastic anemia (AA), particularly focusing on hematopoietic stem cell transplantation (HSCT). RECENT FINDINGS Failure-free survival for children with aplastic anemia has been shown to be better after bone marrow transplantation (BMT) from matched or one-locus mismatched related donors (MRD/1MMRD) than after immunosuppressive therapy (IST). A combination of the absence of minor paroxysmal nocturnal hemoglobinuria clones and short telomere length was identified as a strong predictor of a poor response to IST. Upfront HSCT from matched unrelated donors (MUD) and MRD was recently demonstrated to have comparable outcomes. Moreover, unrelated cord blood transplantation (UCBT) and haploidentical HSCT have shown promising outcomes, and the fludarabine/melphalan-based regimen has resulted in excellent survival without poor graft function. BMT from MRD/1MMRD is the treatment of choice. When a MRD/1MMRD is not available, upfront BMT from a MUD should be considered for patients with only a slim chance of responding to IST. UCBT and haploidentical HSCT are promising options. This updated treatment algorithm should improve overall outcomes for children with AA.
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Successful outcomes of second hematopoietic stem cell transplantation with total nodal irradiation and ATG conditioning for graft failure in adult patients with severe aplastic anemia. Bone Marrow Transplant 2018; 53:1270-1277. [PMID: 29563590 DOI: 10.1038/s41409-018-0154-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 02/04/2018] [Accepted: 02/09/2018] [Indexed: 11/08/2022]
Abstract
Data regarding the optimal approach for second allogeneic hematopoietic stem cell transplantation (HSCT) after graft failure (GF) in acquired severe aplastic anemia (SAA) are still limited and heterogeneous. We examined 24 patients who underwent second HLA-matched sibling donor (MSD) peripheral blood HSCT for GF. The reconditioning regimen (TNI-750/ATG) consisted of a single dose of total nodal irradiation (TNI, 750 cGy) and antithymocyte globulin (ATG; Thymoglobulin®, 1.25 mg/kg/day for 3 days). All but one patient achieved successful engraftment of neutrophils (median 12 days, range 5-21) and platelets (median 15 days, range 9-316). Two patients with subsequent secondary GF achieved successful engraftment after a third HSCT from the same MSD. After a median follow-up of 57.4 months (range, 11.2-155.2), the 5-year overall survival and failure-free survival were 95.7% (95% confidence interval [CI] 87.7-100%) and 87.5% (95% CI 75.2-100%), respectively. One patient developed grade II acute graft-versus-host disease (GVHD), and the 2-year cumulative incidence of chronic GVHD was 23.5% (95% CI 8.1-43.5%). This study demonstrated successful outcomes following a second MSD HSCT in SAA after GF, and the results suggest TNI-750/ATG is a feasible reconditioning option. Future studies with larger cohorts will validate our results.
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Ali R, Ramdial J, Algaze S, Beitinjaneh A. The Role of Anti-Thymocyte Globulin or Alemtuzumab-Based Serotherapy in the Prophylaxis and Management of Graft-Versus-Host Disease. Biomedicines 2017; 5:biomedicines5040067. [PMID: 29186076 PMCID: PMC5744091 DOI: 10.3390/biomedicines5040067] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/01/2017] [Accepted: 11/20/2017] [Indexed: 12/02/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplant is an established treatment modality for hematologic and non-hematologic diseases. However, it is associated with acute and long-term sequelae which can translate into mortality. Graft-versus-host disease (GVHD) remains a glaring obstacle, especially with the advent of reduced-intensity conditioning. Serotherapy capitalizes on antibodies which target T cells and other immune cells to mitigate this effect. This article focuses on the utility of two such agents: anti-thymocyte globulin (ATG) and alemtuzumab. ATG has demonstrated benefit in prophylaxis against GVHD, especially in the chronic presentation. However, there is limited impact of ATG on overall survival and it has little utility in the treatment context. There may be an initial improvement, particularly in skin manifestations, but no substantial benefit has been elicited. Alemtuzumab has shown benefit in both prophylaxis and treatment of GVHD, but at the consequence of a more profound immunosuppressive phase, mandating aggressive viral prophylaxis. There remains heterogeneity in the doses and regimens of the agents, with no standardized protocol in place. Furthermore, it seems that once steroid-refractory GVHD has been established, there is little that can be offered to offset the ultimately dismal outcome. Here we present a systematic overview of ATG- or alemtuzumab-based serotherapy in the prophylaxis and management of GVHD.
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Affiliation(s)
- Robert Ali
- Hematology/Medical Oncology Fellow, University of Miami/Miller School of Medicine, Miami, FL 33136, USA.
| | - Jeremy Ramdial
- Hematology/Medical Oncology Fellow, University of Miami/Miller School of Medicine, Miami, FL 33136, USA.
| | - Sandra Algaze
- Internal Medicine Residency Program, University of Miami/Miller School of Medicine, Miami, FL 33136, USA.
| | - Amer Beitinjaneh
- Associate Professor of Medicine, Stem Cell Transplant and Cellular Therapy Program, Sylvester Comprehensive Cancer Center, University of Miami/Miller School of Medicine; Miami, FL 33136, USA.
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Chen X, Wei J, Huang Y, He Y, Yang D, Zhang R, Jiang E, Ma Q, Zhai W, Yao J, Zhang G, Feng S, Han M. Effect of Antithymocyte Globulin Source on Outcomes of HLA-Matched Sibling Allogeneic Hematopoietic Stem Cell Transplantation for Patients with Severe Aplastic Anemia. Biol Blood Marrow Transplant 2017; 24:86-90. [PMID: 29032265 DOI: 10.1016/j.bbmt.2017.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 10/03/2017] [Indexed: 11/30/2022]
Abstract
We wanted to evaluate efficacy of porcine antithymocyte globulin (ATG) in HLA-matched sibling donor allogeneic hematopoietic stem cell transplantation (MSD-HSCT) for patients with severe aplastic anemia (SAA). The clinical data of 113 SAA patients who received MSD-HSCT from January 2005 to November 2016 were analyzed retrospectively. Of these, 58 patients received rabbit ATG as a part of conditioning regimen (R-ATG group), whereas the other 55 patients received porcine ATG (P-ATG group). Patient baseline characteristics and donor conditions of the 2 groups were similar, except patients were older and more received peripheral blood stem cell transplantation in the P-ATG group. All patients engrafted in 2 groups. There were significant differences in the incidence of acute (20.7% ± 5.3% versus 43.4% ± 7.0%, P = .015) and chronic graft-versus- host disease (GVHD; 20.1% ± 5.8% versus 46.0% ± 7.9%, P = .003) between the R-ATG and P-ATG groups. However, there were no significant differences in terms of 3-year overall survival (93.1% ± 3.3% versus 84.4% ± 5.7%, P = .235), grades III to IV acute GVHD (3.4% ± 2.4% versus 12.3% ± 4.7%, P = .098), moderate to severe chronic GVHD (12.6% ± 4.9% versus 11.5% ± 4.9%, P = .905), or graft rejection (7.4% ± 3.6% versus 5.5% ± 3.1%, P = .852). There was also no significant difference with regard to the incidence of severe bacterial infection (P = .075), invasive fungal disease (P = .701), or cytomeglovirus viremia (P = .770). P-ATG showed satisfactory efficacy and safety compared with R-ATG in the setting of MSD-HSCT for SAA patients. P-ATG could be a potential alternative preparation for R-ATG, further offering the advantage of lower costs.
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Affiliation(s)
- Xin Chen
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Jialin Wei
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Yong Huang
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Yi He
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Donglin Yang
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Rongli Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Erlie Jiang
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Qiaoling Ma
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Weihua Zhai
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Jianfeng Yao
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Guixin Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China.
| | - Mingzhe Han
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
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Ghanem KM, Kharfan-Dabaja MA, El-Solh H, Harris N, Kreidieh N, Nehme R, Muwakkit SA, Saab R, Bazarbachi A, Abboud MR. Fludarabine-based reduced intensity regimen for matched related donor hematopoietic stem cell transplantation in acquired severe aplastic anemia. Curr Res Transl Med 2017; 65:115-119. [PMID: 28988743 DOI: 10.1016/j.retram.2017.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/05/2017] [Accepted: 09/06/2017] [Indexed: 10/18/2022]
Abstract
Different conditioning regimens have been evaluated in matched-related donor allogeneic hematopoietic stem cell transplantation (allo-HSCT) for acquired severe aplastic anemia (SAA) with varying results. In this manuscript, we report our experience with fludarabine (120mg/m2), very low dose cyclophosphamide (1200mg/m2) and antithymocyte globulin (7.5mg/kg). Low dose total body irradiation (2Gy) was added to the conditioning regimen for patients older than 15 years. Nineteen patients (median age 23years) underwent transplant between 2008 and 2015. The majority (89%) were younger than 40 years. Stem cell source was BM (n=11) or PBSC (n=8). GvHD prophylaxis consisted of cyclosporine and either a short course of methotrexate (n=9) or mycophenolate mofetil (n=10). Eighteen (94.7%) patients achieved sustained engraftment. The median times to neutrophil and platelet engraftments were 19 (range: 14-34) and 17.1 (range: 12-25) days, respectively. The day-30 cumulative incidence of neutrophil and platelet engraftment was 89.4% and 94.7%, respectively. No secondary graft rejection was observed. The 1-year cumulative incidence of aGvHD (grade II-IV) and cGvHD was 11.7% and 0%, respectively. The 2-year GvHD-free survival rate was 78.6% (95% CI: 52.5-91.4%). Fludarabine-based reduced intensity regimen for MRD allo-HSCT in SAA compares favorably to other available regimens. This regimen deserves further investigations with larger cohort of patients.
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Affiliation(s)
- K M Ghanem
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon; Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon
| | - M A Kharfan-Dabaja
- Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - H El-Solh
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon; Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon
| | - N Harris
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon; Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon
| | - N Kreidieh
- Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon; Department of Pathology and Laboratory Medicine, American University of Beirut, Beirut, Lebanon
| | - R Nehme
- Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - S A Muwakkit
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon; Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon
| | - R Saab
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon; Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon
| | - A Bazarbachi
- Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - M R Abboud
- Department of Pediatrics and Adolescent Medicine, American University of Beirut, Beirut, Lebanon; Bone Marrow Transplantation Program, American University of Beirut, Beirut, Lebanon.
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42
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Yuan J, Pei R, Su W, Cao J, Lu Y. Meta-analysis of the actions of antithymocyte globulin in patients undergoing allogeneic hematopoietic cell transplantation. Oncotarget 2017; 8:10871-10882. [PMID: 28107198 PMCID: PMC5355230 DOI: 10.18632/oncotarget.14719] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 12/20/2016] [Indexed: 12/26/2022] Open
Abstract
Graft-versus-host disease (GVHD) is a serious complication associated with allogeneic hematopoietic cell transplantation (allo-HCT). Antithymocyte globulin (ATG) is widely used prior to allo-HCT for GVHD prevention, though evidence of its efficacy remains unclear. We therefore identified nine randomized controlled trials (RCTs), enrolling 1089 patients (554 in the ATG group and 535 in the non-ATG group) to conduct a meta-analysis of the actions of ATG in allo-HCT. A relative risk or risk ratio (RR) and 95% confidence interval (CI) were calculated for each outcome. Rabbit ATG reduced overall acute (a) GVHD (RR 0.77, 95% CI 0.67-0.89, P = 0.0004), grade III-IV aGVHD (RR 0.53, 95% CI 0.32-0.88, P = 0.01), overall chronic (c) GVHD (RR 0.52, 95% CI 0.42-0.64, P < 0.00001) and extensive cGVHD (RR 0.28, 95% CI 0.18-0.43, P < 0.00001), without increased risk of relapse (RR 1.17, 95% CI 0.91-1.49, P = 0.23). By contrast, horse ATG did not reduce overall aGVHD (RR 1.25, 95% CI 0.88-1.79, P = 0.22) or cGVHD (RR 1.67, 95% CI 0.96-2.91, P = 0.07). ATG marginally reduced 100-day transplant related mortality (RR 0.75, 95% CI 0.56-1.00, P = 0.05) without compromising overall survival or increased risk of infections. Further studies are required to evaluate the optimal dosage and formulation of ATG in different conditioning regimens of transplantation with varied sources of graft and donor.
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Affiliation(s)
- Jiaojiao Yuan
- Medical School of Ningbo University, Ningbo, Zhejiang, P.R. China
| | - Renzhi Pei
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, Ningbo, Zhejiang, P.R. China
| | - Wensi Su
- Medical School of Ningbo University, Ningbo, Zhejiang, P.R. China
| | - Junjie Cao
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, Ningbo, Zhejiang, P.R. China
| | - Ying Lu
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, Ningbo, Zhejiang, P.R. China
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43
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de Koning C, Admiraal R, Nierkens S, Boelens JJ. Immune reconstitution and outcomes after conditioning with anti-thymocyte-globulin in unrelated cord blood transplantation; the good, the bad, and the ugly. Stem Cell Investig 2017; 4:38. [PMID: 28607912 DOI: 10.21037/sci.2017.05.02] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 04/17/2017] [Indexed: 01/07/2023]
Abstract
Unrelated umbilical cord blood transplantation (UCBT) exhibits a low risk of graft-versus-host-disease (GvHD) and has unique potent anti-virus and anti-leukemia effects. Anti-thymocyte globulin (ATG) in the conditioning regimen for UCBT is successful in reducing graft rejection and GvHD. Nevertheless, this beneficial effect of ATG coincides with its detrimental effect on immune reconstitution. The latter directly relates to a high incidence of viral infections and leukemia relapses. ATG has been used in transplant patients for over 30 years. In recent years, the knowledge on the mechanisms of action of ATG and its implementation in the UCBT setting has increased dramatically. Important data became available showing the highly variable pharmacokinetics (PK) of ATG and its consequence on outcome measures. Here, we review the effects of ATG on immune reconstitution and subsequent outcomes after UCBT, and describe the mechanisms causing these effects. We highlight the importance of optimizing ATG exposure before and after UCBT and discuss strategies to maintain the 'good' and overcome the 'bad and ugly' effects of ATG on UCBT outcome.
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Affiliation(s)
- Coco de Koning
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Rick Admiraal
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands.,Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Stefan Nierkens
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jaap Jan Boelens
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands.,Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht, the Netherlands
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44
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Boddu PC, Kadia TM. Updates on the pathophysiology and treatment of aplastic anemia: a comprehensive review. Expert Rev Hematol 2017; 10:433-448. [DOI: 10.1080/17474086.2017.1313700] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
| | - Tapan Mahendra Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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45
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Abstract
Acquired severe aplastic anemia (SAA) is a rare hematologic disease associated with significant morbidity and mortality. Immune destruction of hemopoietic stem cells plays an important role in pathogenesis, as shown by successful treatment with immunosuppressive agents, leading to transfusion independence or complete recovery of peripheral blood counts in a proportion of patients. Growth factors can be combined with immunosuppressive therapy (IST) and may improve response rates, as recently shown with thrombopoietin analogs. Anabolic steroids may still play a role in combination with IST. The problem with IST is failure to respond and the development of late clonal disorders. Bone marrow transplantation (BMT) is the other therapeutic option: a matched sibling donor remains the best choice. For patients lacking a matched family donor, unrelated donors can be readily found, although mostly for patients of Caucasian origin. Other BMT options include unrelated cord blood or mismatched family donors. Acute and chronic graft-versus-host disease remain important complications of BMT. Patient age is a strong predictor of outcome for both IST and BMT, and must be considered when designing therapeutic strategies. Early diagnosis and treatment, as well as long-term monitoring, remain crucial steps for successful treatment of SAA.
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46
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Arai Y, Jo T, Matsui H, Kondo T, Takaori-Kondo A. Efficacy of antithymocyte globulin for allogeneic hematopoietic cell transplantation: a systematic review and meta-analysis. Leuk Lymphoma 2016; 58:1840-1848. [PMID: 27951736 DOI: 10.1080/10428194.2016.1266624] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The efficacy of rabbit antithymocyte globulin (ATG) for the prevention of graft-versus-host disease (GVHD) has been evaluated in several randomized control trials, but the results show some discrepancies. Therefore, we performed a systematic review and meta-analysis covering the latest RCTs including six trials (total 845 patients). The incidence of acute and chronic GVHD was significantly lower in the ATG arms (risk ratio, 0.75 and 0.54, respectively). No significant differences were found regarding overall survival, the incidence of relapse, and non-relapse mortality; however, the incidence of cytomegalovirus and Epstein-Barr virus reactivation increased (risk ratio, 1.25 and 1.33), and neutrophil engraftment was significantly delayed (median, 2.66 days). In conclusion, rabbit ATG should be beneficial as a GVHD prophylaxis in addition to conventional regimens, with close monitoring of virus reactivation and enough attention to delayed engraftment. Studies comparing the timing and dosage of ATG are essential to determine the suitable prophylactic regimens.
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Affiliation(s)
- Yasuyuki Arai
- a Department of Hematology and Oncology, Graduate School of Medicine , Kyoto University , Kyoto , Japan.,b Laboratory of Host Defenses , National Institute of Allergy and Infectious Diseases, National Institutes of Health , Bethesda , MD , USA
| | - Tomoyasu Jo
- a Department of Hematology and Oncology, Graduate School of Medicine , Kyoto University , Kyoto , Japan
| | - Hiroyuki Matsui
- a Department of Hematology and Oncology, Graduate School of Medicine , Kyoto University , Kyoto , Japan
| | - Tadakazu Kondo
- a Department of Hematology and Oncology, Graduate School of Medicine , Kyoto University , Kyoto , Japan
| | - Akifumi Takaori-Kondo
- a Department of Hematology and Oncology, Graduate School of Medicine , Kyoto University , Kyoto , Japan
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47
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Baron F, Mohty M, Blaise D, Socié G, Labopin M, Esteve J, Ciceri F, Giebel S, Gorin NC, Savani BN, Schmid C, Nagler A. Anti-thymocyte globulin as graft-versus-host disease prevention in the setting of allogeneic peripheral blood stem cell transplantation: a review from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Haematologica 2016; 102:224-234. [PMID: 27927772 DOI: 10.3324/haematol.2016.148510] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 08/24/2016] [Indexed: 11/09/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation is increasingly used as treatment for patients with life-threatening blood diseases. Its curative potential is largely based on immune-mediated graft-versus-leukemia effects caused by donor T cells contained in the graft. Unfortunately, donor T cells are also the cause of graft-versus-host disease. The vast majority of human leukocyte antigen-matched allogeneic hematopoietic stem cell transplants are nowadays carried out with peripheral blood stem cells as the stem cell source. In comparison with bone marrows, peripheral blood stem cells contain more hematopoietic stem/progenitor cells but also one log more T cells. Consequently, the use of peripheral blood stem cells instead of bone marrow has been associated with faster hematologic recovery and a lower risk of relapse in patients with advanced disease, but also with a higher incidence of chronic graft-versus-host disease. These observations have been the basis for several studies aimed at assessing the impact of immunoregulation with anti-thymocyte globulin on transplantation outcomes in patients given human leukocyte antigen-matched peripheral blood stem cells from related or unrelated donors. After a brief introduction on anti-thymocyte globulin, this article reviews recent studies assessing the impact of anti-thymocyte globulin on transplantation outcomes in patients given peripheral blood stem cells from human leukocyte antigen-matched related or unrelated donors as well as in recipients of grafts from human leukocyte antigen haploidentical donors.
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Affiliation(s)
| | - Mohamad Mohty
- Hopital Saint-Antoine, AP-HP, Paris, France.,Université Pierre & Marie Curie, Paris, France.,INSERM UMRs U938, Paris, France
| | - Didier Blaise
- Aix Marseille Univ, CNRS, INSERM, CRCM, Institut Paoli-Calmettes, Marseille, France
| | - Gérard Socié
- AP-HP, Hematology Transplantation, Hospital Saint-Louis, Paris, France
| | - Myriam Labopin
- Hopital Saint-Antoine, AP-HP, Paris, France.,INSERM UMRs U938, Paris, France
| | - Jordi Esteve
- Department of Hematology, Hospital Clinic, Barcelona, Spain
| | - Fabio Ciceri
- Department of Hematology, Ospedale San Raffaele, Università degli Studi, Milano, Italy
| | - Sebastian Giebel
- Maria Sklodowska-Curie Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | | | - Bipin N Savani
- Long term Transplant Clinic, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christoph Schmid
- Klinikum Augsburg, Department of Hematology and Oncology, University of Munich, Augsburg, Germany
| | - Arnon Nagler
- Division of Hematology and Bone Marrow Transplantation, The Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel.,EBMT Paris Office, Hospital Saint Antoine, Paris, France
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48
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Abstract
Aplastic anemia (AA) is a potential life-threatening hematopoietic stem cell (HSC) disorder resulting in cytopenia. The mainstays of treatment for AA are definitive therapy to restore HSCs and supportive measures to ameliorate cytopenia-related complications. The standard definitive therapy is HSC transplantation for young and medically fit patients with suitable donors and immunosuppressive therapy (IST) with antithymocyte globulin and cyclosporine for the remaining patients. A significant proportion of patients are refractory to IST or relapse after IST. Various strategies have been explored in these patients, including second course of antithymocyte globulin, high-dose cyclophosphamide, and alemtuzumab. Eltrombopag, a thrombopoietin mimetic, has recently emerged as an encouraging and promising agent for patients with refractory AA. It has demonstrated efficacy in restoring trilineage hematopoiesis, and this positive effect continues after discontinuation of the drug. There are ongoing clinical trials exploring the role of eltrombopag as a first-line therapy in moderate to severe AA and a combination of eltrombopag with IST in severe AA.
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Affiliation(s)
- Su Han Lum
- Department of Blood and Marrow Transplant, Royal Manchester Children’s Hospital, Manchester, UK
| | - John D Grainger
- Department of Blood and Marrow Transplant, Royal Manchester Children’s Hospital, Manchester, UK
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49
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Törlén J, Ringdén O, Garming-Legert K, Ljungman P, Winiarski J, Remes K, Itälä-Remes M, Remberger M, Mattsson J. A prospective randomized trial comparing cyclosporine/methotrexate and tacrolimus/sirolimus as graft-versus-host disease prophylaxis after allogeneic hematopoietic stem cell transplantation. Haematologica 2016; 101:1417-1425. [PMID: 27662016 DOI: 10.3324/haematol.2016.149294] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 08/01/2016] [Indexed: 12/29/2022] Open
Abstract
Improvement of graft-versus-host disease prophylaxis remains an important goal in allogeneic hematopoietic stem cell transplantation. Based on reports of possibly preferential properties of sirolimus, we compared the standard regimen of cyclosporine and methotrexate (n=106) with a combination of tacrolimus and sirolimus (n=103) as graft-versus-host disease prophylaxis after allogeneic hematopoietic stem cell transplantation in a prospective, open, randomized trial. The hypothesis was that the tacrolimus/sirolimus regimen would lead to less acute graft-versus-host disease and reduced transplant-related mortality. There was no significant difference in the cumulative incidence of acute graft-versus-host disease of grades II-IV (41% vs. 51%; P=0.19) or grades III-IV (13% vs. 7%; P=0.09) between the groups. Time to neutrophil engraftment (18 days vs. 17 days; P=0.24) was similar, but time to platelet engraftment was longer in cyclosporine/methotrexate patients (14 vs. 12 days; P<0.01). No significant differences in incidence of oropharyngeal mucositis, time to full donor chimerism, or number of cytomegalovirus infections were seen between the two treatment arms, and transplant-related toxicities were equally distributed. Triglyceride (P=0.005) and cholesterol (P=0.009) levels were higher in tacrolimus/sirolimus patients. Transplant-related mortality (18% vs. 12%; P=0.40) and 5-year overall survival (72% vs. 71%; P=0.71) were similar. Five-year relapse-free survival in patients with malignant diagnoses was 65% in the cyclosporine/methotrexate group and 63% in the tacrolimus/sirolimus group (P=0.73). We conclude that tacrolimus/sirolimus remains a valid and safe alternative to cyclosporine/methotrexate as graft-versus-host disease prophylaxis after allogeneic hematopoietic stem cell transplantation, with comparable transplant-related outcomes. The trial was registered at clinicaltrials.gov identifier: 00993343.
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Affiliation(s)
- Johan Törlén
- Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden .,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Olle Ringdén
- Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Karin Garming-Legert
- Division of Oral and Maxillofacial Surgery, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden
| | - Per Ljungman
- Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden.,Department of Hematology, Karolinska University Hospital and Division of Hematology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jacek Winiarski
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Kari Remes
- Department of Internal Medicine, Turku University Hospital, Finland.,Turku University, Finland
| | | | - Mats Remberger
- Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Mattsson
- Center for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
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50
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Marrow grafts from HLA-identical siblings for severe aplastic anemia: does limiting the number of transplanted marrow cells reduce the risk of chronic GvHD? Bone Marrow Transplant 2016; 51:1573-1578. [PMID: 27479689 PMCID: PMC5143192 DOI: 10.1038/bmt.2016.198] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 06/02/2016] [Accepted: 06/18/2016] [Indexed: 11/24/2022]
Abstract
Twenty-one patients with severe aplastic anemia underwent marrow transplantation from HLA-identical siblings following a standard conditioning regimen with cyclophosphamide (50 mg/kg/day × 4 days) and horse antithymocyte globulin (30 mg/kg/day × 3 days). Post-grafting immunosuppression consisted of a short course of methotrexate combined with cyclosporine. The transplant protocol tested the hypothesis that the incidence of chronic graft-versus-disease (GVHD) could be reduced by limiting the marrow grafts to ≤2.5 × 108 nucleated marrow cells/kg. None of the patients rejected the graft, all had sustained engraftment and all are surviving a median of 4 (range 1–8) years after transplantation. Chronic GVHD developed in 16% of patients given ≤2.5 × 108 nucleated marrow cells/kg. Post-grafting immunosuppression has been discontinued in 20 of the 21 patients. In conclusion, limiting the number of transplanted marrow cells may have resulted in minimal improvement in the incidence and severity of chronic GVHD.
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