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White J, Elemary M, Linn SM, Novitzky-Basso I, Culos S, Tan SK, Kelly K, Deotare U, Xenocostas A, Hamad N, Law A, Kumar R, Kim DDH. A Multicenter, Retrospective Study Evaluating Clinical Outcomes of Ruxolitinib Therapy In Heavily Pretreated Chronic GVHD Patients With Steroid Failure. Transplant Cell Ther 2023; 29:120.e1-120.e9. [PMID: 36460202 DOI: 10.1016/j.jtct.2022.11.025] [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: 08/09/2022] [Revised: 10/25/2022] [Accepted: 11/22/2022] [Indexed: 12/02/2022]
Abstract
Although ruxolitinib is emerging as the treatment of choice for steroid-refractory or -dependent chronic graft versus host disease (cGVHD) based on randomized control trial data, there is relatively little real-world data published on ruxolitinib for this indication. We wanted to evaluate the real-world efficacy and safety of ruxolitinib in cGVHD patients who have failed any previous systemic therapy for cGVHD. We retrospectively evaluated the efficacy of ruxolitinib in 115 heavily pretreated patients with steroid-refractory or -dependent chronic GVHD across 5 transplantation centers. The majority of the study population had severe cGVHD (60%) and received ruxolitinib at the fourth treatment line or beyond (82%, n = 96). The median duration of follow-up in this study population was 13 months. The overall response rate (ORR) was 48.6%, 54.9%, and 48.5% at 3, 6, and 12 months, respectively. Clinical benefit (an outcome metric combining ORR with steroid reduction) was observed in 58.7%, 64.8%, and 60.6% of patients at 3, 6, and 12 months, respectively. Approximately one third of patients (37.9%) were able to discontinue prednisone at 12 months, and 63.8% were able to taper prednisone to a daily dose <0.1 mg/kg at 12 months. Failure-free survival at 12 months was 64.6% (54.1%-73.2%). Multivariate analysis identified that patients with severe cGVHD were at a higher risk of failure because of a therapy switch, whereas a pretransplantation hematopoietic stem cell transplantation-comorbidity index score ≥ 3 was associated with a high risk of failure because of increasing risk of non-relapse mortality. Overall, this study demonstrates the therapeutic efficacy of ruxolitinib for cGVHD in a heavily pretreated real-world population.
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Affiliation(s)
- Jennifer White
- Vancouver General Hospital, British Columbia Cancer Agency, Vancouver, Canada; University of British Columbia, Vancouver, Canada
| | - Mohamed Elemary
- Saskatchewan Cancer Agency, Saskatoon, Canada; University of Saskatchewan, Saskatoon, Canada
| | - Swe Mar Linn
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | | | - Samantha Culos
- Vancouver General Hospital, British Columbia Cancer Agency, Vancouver, Canada
| | | | - Kate Kelly
- London Health Science Centre, London, Canada
| | - Uday Deotare
- London Health Science Centre, London, Canada; University of Western Ontario, London, Canada
| | - Anargyros Xenocostas
- London Health Science Centre, London, Canada; University of Western Ontario, London, Canada
| | - Nada Hamad
- St Vincent's Hospital Sydney, Sydney, Australia; University of New South Wales, Sydney, Australia
| | - Arjun Law
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada
| | - Rajat Kumar
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada
| | - Dennis Dong Hwan Kim
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; University of Toronto, Toronto, Canada.
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Nakamura N, Wada F, Kondo T, Aoki K, Arai Y, Mizumoto C, Kanda J, Kitawaki T, Yamashita K, Takaori-Kondo A. Significance of Omitting Day 11 Mini-Dose Methotrexate for GVHD Prophylaxis After Unrelated Bone Marrow Transplantation. Transplant Cell Ther 2023; 29:119.e1-119.e7. [PMID: 36372357 DOI: 10.1016/j.jtct.2022.11.006] [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: 08/20/2022] [Revised: 10/12/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022]
Abstract
The combination of calcineurin inhibitors and short-term methotrexate has been used as a standard graft-versus-host-disease (GVHD) prophylaxis in allogeneic hematopoietic stem cell transplantation. Mini-dose methotrexate (mini-MTX), consisting of 5 mg/m2/d on days 1, 3, 6, and 11, is occasionally selected as an alternative considering toxicity. The significance of day 11 administration remains unclear. We performed a retrospective study of 135 cases of unrelated bone marrow transplantation at our institute between 2006 and 2019 and compared the outcomes between day 11 MTX dose omitted (n = 72) and full-doses of mini-MTX (n = 63). In total cohort, the 4-year overall survival (OS) was 58.7 %, and the omitted group showed poor GVHD/relapse-free-survival (P = .01) with comparable OS (P = .11) and relapse-free survival (P = .11). Human leukocyte antigen (HLA) mismatch is a major risk factor for severe GVHD. We analyzed the impact of omitting day 11 MTX in 2 cohorts from HLA matched or mismatched donors. In both cohorts, the omitted group had a higher risk of severe acute and chronic GVHD. In conclusion, the omission of day 11 MTX was associated with a higher risk of severe GVHD. Therefore the omission of the day 11 dose is not recommended.
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Affiliation(s)
- Naokazu Nakamura
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Fumiya Wada
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan.
| | - Kazunari Aoki
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Stem Cell Genetics, Institute for Life and Medical Sciences, Kyoto University, Kyoto, Japan
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Clinical Laboratory Medicine, Faculty of Medicine, Kyoto University, Kyoto, Japan
| | - Chisaki Mizumoto
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshio Kitawaki
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kouhei Yamashita
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Srour M, Alsuliman T, Labreuche J, Bulabois CE, Chevallier P, Daguindau E, Forcade E, François S, Guillerm G, Coiteux V, Turlure P, Beguin Y, Yakoub-Agha I, Magro L. Nilotinib efficacy and safety as salvage treatment following imatinib intolerance and/or inefficacy in steroid refractory chronic graft-versus-host-disease (SR-cGVHD): a prospective, multicenter, phase II study on behalf of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC). Bone Marrow Transplant 2023; 58:401-406. [PMID: 36624161 DOI: 10.1038/s41409-022-01898-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 11/23/2022] [Accepted: 12/07/2022] [Indexed: 01/11/2023]
Abstract
Imatinib is used for patients with SR-cGVHD. However, in 50% of cases imatinib is discontinued due to intolerance or inefficacy. In order to investigate nilotinib's role as salvage therapy in those patients, we conducted a prospective, multicenter, phase II study. (NCT02891395). Patients with SR-cGVHD were included to receive imatinib. Patients who stopped imatinib due to intolerance or inefficacy switched to Nilotinib. The primary endpoint was defined as the week-12 response rate to Nilotinib. The response was considered successful if superior to the 30% endpoint. Sixty-two patients started the IM-phase. Fourteen patients (22%) discontinued imatinib before week 12 due to: cGVHD progression (10%) or TKI-class-specific intolerance (12%). At week 12, we observed complete remission in 13 patients (21%) and partial response in 8 patients (13%). Twenty-nine patients switched to Nilotinib. Nilotinib response at week-12 was observed in 6 patients (21%) while 23 patients (79%) discontinued Nilotinib due to intolerance/cGVHD progression. The primary endpoint was not reached. This prospective study confirmed the efficacy of imatinib in patients with steroid refractory cGVHD. It failed to demonstrate the efficacy of nilotinib as a salvage therapy in patients who were intolerant/unresponsive to imatinib.
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Affiliation(s)
- Micha Srour
- Service maladie du sang, centre hospitalier universitaire de Lille, 59000, Lille, France
| | - Tamim Alsuliman
- Sorbonne University, Paris, France.,Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Paris, France.,INSERM, UMRs 938, Paris, France
| | | | - Claude-Eric Bulabois
- CHU Grenoble Alpes - Université Grenoble Alpes, Service d'Hématologie, Grenoble, France
| | | | | | | | - Sylvie François
- Department of Clinical Hematology, Angers University Hospital, Angers, France
| | - Gaelle Guillerm
- Hematology Department, Brest University Hospital, Brest, France
| | - Valerie Coiteux
- Service maladie du sang, centre hospitalier universitaire de Lille, 59000, Lille, France
| | - Pascal Turlure
- Département d'Hématologie Clinique, CHU Limoges, Limoges, France
| | - Yves Beguin
- Department of Hematology, CHU of Liege and University of Liege, 4000, Liege, Belgium
| | - Ibrahim Yakoub-Agha
- Service maladie du sang, centre hospitalier universitaire de Lille, 59000, Lille, France. .,CHU de Lille, Univ Lille, INSERM U1286, Infinite, 59000, Lille, France.
| | - Leonardo Magro
- Service maladie du sang, centre hospitalier universitaire de Lille, 59000, Lille, France
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Scheid C, Kudernatsch R, Eckart M, Feig C, Straub V, Libutzki B, Mahlich J. Treatment Pathways and Health Outcomes of German Patients with Chronic Graft-Versus-Host Disease After Allogeneic Hematopoietic Cell Transplantation: A Retrospective Health Claims Data Analysis. Drugs Real World Outcomes 2022; 9:577-588. [PMID: 35779205 DOI: 10.1007/s40801-022-00320-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Although chronic graft-versus-host-disease (cGvHD) is an important long-term complication after allogenic hematopoietic cell transplantation (allo-HCT) and is associated with increased healthcare resource utilization, real-world evidence is scarce. OBJECTIVES The aim of the study was to evaluate survival of patients with cGvHD in Germany and to analyze hospitalization and treatment patterns. PATIENTS AND METHODS Based on a German claims database with 4.9 million enrollees, a retrospective longitudinal analysis covering a 6-year period between 2013 and 2018 was conducted. Patients with allo-HCT in 2014 or 2015 (index date) and no record of transplantation or documentation of GvHD 365 days prior to index were included. Patients who subsequently developed a cGVHD were compared with those who did not develop a cGVHD within 3 years after index date. cGVHD cases were identified based on documented International Classification of Diseases, Tenth Revision (ICD-10) diagnosis and treatment algorithms. Since the onset of cGvHD is defined at 100 days after allo-HCT, only those alive beyond day 100 were considered in the survival analysis. Patients who did not survive the first 100 days after allo-HCT were censored to prevent a selection bias due to early mortality within patients without GvHD. Survival rates were plotted using the Kaplan-Meier estimator. The number of hospitalizations and average lengths of stay as well as treatment patterns were descriptively examined. RESULTS Overall, 165 cGvHD patients were identified and compared with 43 patients without cGVHD. Short-term survival rates were better for patients with cGvHD; the 6-month survival probability was 95.8% for patients with cGVHD and 83.7% for patients without cGVHD. However, long-term survival was better in patients without GvHD; The 30-month survival probability was 65.5% for patients with cGVHD and 76.7% for patients without cGVHD. While overall 90% of cGvHD patients were hospitalized at least once, the share was only half for patients without GvHD (44%). 78.2% of patients with cGVHD received corticosteroids in combination with other predefined immunosuppressants. CONCLUSION Findings from this study reveal a high disease burden associated with cGvHD. This underlines the high medical need for new interventional strategies to improve survival and morbidity after allo-HCT.
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Affiliation(s)
- Christof Scheid
- Universitätsklinikum Köln (AöR), Kerpener Str. 62, 50937, Cologne, Germany
| | | | - Marie Eckart
- Janssen-Cilag GmbH, Johnson & Johnson Platz 1, 41470, Neuss, Germany
| | - Chiara Feig
- HGC Healthcare Consultants GmbH, Graf-Adolf-Platz 15, 40213, Dusseldorf, Germany
| | - Vincent Straub
- HGC Healthcare Consultants GmbH, Graf-Adolf-Platz 15, 40213, Dusseldorf, Germany
| | - Berit Libutzki
- HGC Healthcare Consultants GmbH, Graf-Adolf-Platz 15, 40213, Dusseldorf, Germany
- Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion regulation (ICPE), University of Groningen, University Medical Center Groningen, Groningen, Groningen, The Netherlands
| | - Jörg Mahlich
- DICE, Heinrich-Heine-University Düsseldorf, Universitätsstraße 1, 40225, Dusseldorf, Germany.
- Miltenyi Biomedicine, Friedrich-Ebert-Straße 68, 51429, Bergisch Gladbach, Germany.
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Ramalingam R, Kaur H, Scott JX, Sneha LM, Arunkumar G, Srinivasan A, Paul SFD. Evaluation of cytogenetic and molecular markers with MTX-mediated toxicity in pediatric acute lymphoblastic leukemia patients. Cancer Chemother Pharmacol 2022; 89:393-400. [PMID: 35157101 DOI: 10.1007/s00280-022-04405-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/31/2022] [Indexed: 01/29/2023]
Abstract
PURPOSE Pediatric acute lymphoblastic leukemia (pALL) patients have better overall survival and methotrexate (MTX) is an effective drug used in their treatment. However, the treatment-related adverse effects (TRAEs) have a bigger impact on the therapy. In this study, we have evaluated the association of polymorphisms in genes encoding proteins engaged in MTX metabolism, and the cytogenetic aberrations with TRAEs. METHODS A total of 115 patients between the age of 1 and 18 years (average: 6.6) under maintenance therapy were selected for the study. SLC19A1 (c.80G > A), MTHFR (c.677C > T; c.1298A > C), and TYMS (c.*450_*455del) genotypes were determined using PCR techniques and Sanger sequencing. Cytogenetic and SNP findings were analyzed for any association with the reported toxicities using odds ratio, chi-square test, multifactor dimensionality reduction (MDR) analysis for synergistic effect and, multinomial logistic regression analysis for the likelihood of adverse events. RESULTS Among the evaluated genetic variations, SLC19A1 (c.80G > A) was significantly associated with TRAEs (OR = 5.71, p = 0.002). Multinomial logistic regression analysis (chi-sq = 16.64, p < 0.001) and MDR analysis (chi-sq = 10.51 p < 0.001) confirmed the finding. On the other hand, no significant association was observed between adverse events and any specific cytogenetic aberration. CONCLUSION SLC19A1 facilitates the import of cyclic dinucleotides and reduced folates, evaluating genotypes in this gene can help in better management of patients on methotrexate treatment. Assessing a broader gene panel can help in finding more associated markers and delivering personalized medicine to the patients.
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Affiliation(s)
- Ravi Ramalingam
- Department of Human Genetics, Faculty of Biomedical Sciences and Technology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Harpreet Kaur
- Department of Human Genetics, Faculty of Biomedical Sciences and Technology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Julius Xavier Scott
- Department of Pediatric Oncology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Latha M Sneha
- Department of Pediatric Oncology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | | | - Arathi Srinivasan
- Department of Pediatric Oncology, Kanchi Kamakoti Child Trust Hospital, Chennai, Tamil Nadu, India
| | - Solomon F D Paul
- Department of Human Genetics, Faculty of Biomedical Sciences and Technology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India.
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Ramalingam R, Kaur H, Scott JX, Sneha LM, Arun Kumar GP, Srinivasan A, Paul SF. Pharmacogenetic evaluation of 6-mercaptopurine-mediated toxicity in pediatric acute lymphoblastic leukemia patients from a South Indian population. Pharmacogenomics 2021; 22:401-411. [PMID: 33876659 DOI: 10.2217/pgs-2020-0193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Aim: To evaluate the variants in the genes coding for the proteins involved in thiopurine and folate metabolism with treatment related adverse effects (TRAEs). Materials & methods: Eleven variants in seven candidate genes were genotyped in 127 pediatric acute lymphoblastic leukemia patients under 6-mercaptopurine (6-MP) treatment to infer the association of selected genotypes with TRAEs. Results: Among the genotypes inspected, NUDT15 (c.415C>T) and SLC19A1 (c.80G>A) showed a significant association with the TRAEs (odds ratio = 4.01, p = 0.002 and odds ratio = 7.78, p = 0.002). Conclusion: SLC19A1 and NUDT15 play an important role in the metabolism of 6-MP and it is necessary to spot other variants in associated pathways and investigate the factors that can impact 6-MP metabolism.
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Affiliation(s)
- Ravi Ramalingam
- Department of Human Genetics, Sri Ramachandra Institute of Higher Education & Research, Chennai, India
| | - Harpreet Kaur
- Department of Human Genetics, Sri Ramachandra Institute of Higher Education & Research, Chennai, India
| | - Julius Xavier Scott
- Department of Pediatric Oncology, Sri Ramachandra Institute of Higher Education & Research, Chennai, India
| | - Latha M Sneha
- Department of Pediatric Oncology, Sri Ramachandra Institute of Higher Education & Research, Chennai, India
| | | | - Arathi Srinivasan
- Department of Pediatric Oncology, Kanchi Kamakoti Child Trust Hospital, Chennai, Tamil Nadu, India
| | - Solomon Fd Paul
- Department of Human Genetics, Sri Ramachandra Institute of Higher Education & Research, Chennai, India
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Post-transplant ferritin level predicts outcomes after allogeneic hematopoietic stem cell transplant, independent from pre-transplant ferritin level. Ann Hematol 2021; 100:789-798. [PMID: 33415423 DOI: 10.1007/s00277-020-04363-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 11/30/2020] [Indexed: 12/20/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HCT) is associated with significant morbidity and mortality. Elevated pre-transplant ferritin level (ferritinPre-HCT) is reported to be associated with increased mortality following HCT. The present study attempted to determine whether post-transplant ferritin level (ferritinPost-HCT) is associated with outcomes post-HCT, especially in the subgroups which developed acute or chronic graft-versus-host disease (GVHD). Out of 229 patients with serum ferritin level measured post-HCT, median ferritinPost-HCT was 2178 ng/mL. Patients were stratified into low- or high-risk groups using recursive partitioning, based on ferritinPost-HCT (≤ 3169 vs > 3169 ng/mL) and ferritinPre-HCT (≤ 669 vs > 669 ng/mL). Compared to the low ferritinPost-HCT group, the high ferritinPost-HCT group had lower 3-year overall survival (OS) (40.0% vs 66.7%, p < 0.001) and higher non-relapse mortality (NRM) (48.6% vs 17.8%, p < 0.001), but no difference in relapse (10.5% vs 19.7%, p = 0.079). Multivariate analysis confirmed ferritinPost-HCT as an independent prognostic factor for OS (p = 0.001, HR = 2.323) and NRM (p < 0.001, HR = 3.905). However, ferritinPre-HCT did not stratify well for OS or NRM. FerritinPost-HCT was also found to be an independent prognostic marker for OS and NRM in the subgroups which developed GVHD. In our cohort, high ferritinPost-HCT levels were significantly associated with decreased OS and increased NRM independent of ferritinPre-HCT or GVHD. Additional studies including larger sample sizes and prospective investigation are warranted to clarify the prognostic significance and pathophysiology of pre- and post-transplant hyperferritinemia.
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Maas-Bauer K, Kiote-Schmidt C, Bertz H, Apostolova P, Wäsch R, Ihorst G, Finke J, Zeiser R. Ruxolitinib-ECP combination treatment for refractory severe chronic graft-versus-host disease. Bone Marrow Transplant 2020; 56:909-916. [PMID: 33203951 DOI: 10.1038/s41409-020-01122-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/25/2020] [Accepted: 10/29/2020] [Indexed: 02/06/2023]
Abstract
Glucocorticoid-refractory (SR) chronic (c) graft-versus-host disease (GVHD) is a multisystem immunological disease and the leading cause of non-relapse mortality (NRM) in patients surviving longer than 2 years after allogeneic hematopoietic cell transplantation. Both ruxolitinib (RUX) and extracorporeal photopheresis (ECP) have shown activity for SR-cGVHD which motivated us to treat refractory cGHVD patients with the RUX-ECP combination. In this retrospective survey, 23 patients received RUX-ECP as salvage therapy for SR-cGVHD. The best response (CR or PR) at any time point during treatment was 74% (17/23) including 9% (2/23) CR and 65% (15/23) PR. The 24-months-survival was 75% (CI 56.0-94.1). Newly diagnosed cytopenia occurred in 22% (5/23) and CMV reactivation was observed in 26% (6/23) of the patients. Serum levels of soluble interleukin-2 receptor (sIL-2R) correlated with response. Our retrospective analysis shows that the RUX-ECP combination is safe and has activity in a fraction of patients with SR-cGVHD, which needs validation in a prospective trial.
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Affiliation(s)
- Kristina Maas-Bauer
- Department of Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Chrissoula Kiote-Schmidt
- Department of Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Hartmut Bertz
- Department of Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Petya Apostolova
- Department of Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department of Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Jürgen Finke
- Department of Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Robert Zeiser
- Department of Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany.
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9
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Alba-Linero C, Rodriguez Calvo de Mora M, Lavado Valenzuela R, Pascual Cascón MJ, Martín Cerezo AR, Álvarez Pérez M, Recio LV, Jerez Aragonés JM, García Campos JM. Ocular surface characterization after allogeneic stem cell transplantation: A prospective study in a referral center. Indian J Ophthalmol 2020; 68:1556-1562. [PMID: 32709775 PMCID: PMC7640859 DOI: 10.4103/ijo.ijo_1865_19] [Citation(s) in RCA: 5] [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: 10/20/2019] [Revised: 02/03/2020] [Accepted: 02/20/2020] [Indexed: 02/04/2023] Open
Abstract
Purpose To characterize anatomical and functional changes in the ocular surface after hematopoietic stem cell transplantation. Methods Three groups of patients were included in the study. Group 1: patients who had undergone allogeneic hematopoietic stem cell transplantation (HSCT) (n = 26). Group 2: patients who developed chronic graft versus host disease (GvHD) after HSCT (n = 14). Group 3: healthy subjects (n = 20). A complete ophthalmological examination was undertaken in all subjects, including Schirmer's test, TBUT (break-up-time) test, Oxford scale, OSDI test, corneal tomography, and conjunctival CD8+ lymphocyte detection. Results In Branch 1 (comparative analysis before and after HSCT in Group 1), statistically significant differences were found in the following variables: best-corrected visual acuity (BCVA) OD (P = 0.08), OSDI test (P = 0.003), TBUT OU (OD P= 0, OS P= 0.0003), Oxford test OU (OD P= 0.01, OS P= 0.0049), and CD8+ lymphocytes OU (OD P= 0.003, OS P= 0.01). In Branch 2 (comparative analysis between Group 2 and 3), the variables with statistically significant differences (P < 0.001) in OU were: BCVA, OSDI test, Schirmer's test OU, TBUT test, Oxford test, and CD8+ lymphocytes. Finally, in Branch 3 (comparative analysis between Group 1 after HSCT and Group 2), statistically significant differences (P < 0.001) were found OU: in OSDI test, Schirmer's test, and Oxford test OU; and with P < 0.005 in TBUT test OU. Conclusion In our study, statistically significant changes were observed in the OSDI test, TBUT test, Oxford Scale, and the detection of CD8+ lymphocytes in patients who underwent HSCT. Differences were more significant in those patients who had developed GvHD after HSCT compared to those without GvHD.
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Affiliation(s)
| | | | - Rocío Lavado Valenzuela
- Instituto de Investigación Biomédica de Málaga, Malaga, Spain
- Laboratorio de Biologia Molecular del Cáncer, Malaga, Spain
| | | | | | - Martina Álvarez Pérez
- Instituto de Investigación Biomédica de Málaga, Malaga, Spain
- Laboratorio de Biologia Molecular del Cáncer, Malaga, Spain
- Department of Pathology, School of Medicine, University of Malaga, Malaga, Spain
| | - Luis Vicioso Recio
- Department of Pathology, School of Medicine, University of Malaga, Malaga, Spain
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10
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Pagliuca S, Prata PH, Xhaard A, Frieri C, Giannoni L, Sutra Del Galy A, Brignier A, Sicre de Fontbrune F, Michonneau D, Dhedin N, Peffault de Latour R, Socié G, Robin M. Long-term outcomes and risk factor analysis of steroid-refractory graft versus host disease after hematopoietic stem cell transplantation. Bone Marrow Transplant 2020; 56:38-49. [PMID: 32587336 DOI: 10.1038/s41409-020-0977-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/19/2020] [Accepted: 06/10/2020] [Indexed: 11/09/2022]
Abstract
Steroid-refractory graft versus host disease (GVHD) represents a fearsome complication after allogeneic hematopoietic stem cell transplantation (HSCT). We conducted a retrospective study on outcomes and risk factors associated with acute and chronic steroid-refractory GVHD in a large cohort of 1207 patients receiving HSCT in Saint Louis Hospital between 2007 and 2017. Among patients who developed an acute and/or a chronic GVHD, the cumulative incidences of acute and chronic steroid-refractory disease were 31% and 48%, respectively, at day +100 and 1-year post-HSCT. Through a multivariable analysis we selected several risk factors associated with the development of a steroid-refractory disease. For acute GVHD steroid refractoriness, we identified (1) a very high disease risk index, (2) an unrelated donor, (3) the absence of in vivo T-depletion as GVHD prophylaxis, and (4) a reduced intensity conditioning regimen. For chronic GVHD, (1) the use of peripheral blood stem cells, (2) unrelated donors, and (3) absence of in vivo T-depletion were more likely associated with a steroid-refractory disease. After the construction of a multistate dynamic model, we found that the probability of being alive without relapse after the resolution of all GVHD episodes was about 36% in the long term.
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Affiliation(s)
- Simona Pagliuca
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France. .,Université de Paris, Paris, France. .,Department of Translational Hematology and Oncology Research, Cleveland Clinic Foundation, Cleveland, Ohio, United States.
| | - Pedro Henrique Prata
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France
| | - Aliénor Xhaard
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France
| | - Camilla Frieri
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France.,Université de Paris, Paris, France.,Department of Hematology and Transplantation, Federico II University, Naples, Italy
| | - Livia Giannoni
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France
| | - Aurelien Sutra Del Galy
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France.,Université de Paris, Paris, France
| | - Anne Brignier
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Therapeutic Apheresis Unit, Paris, France
| | - Flore Sicre de Fontbrune
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France
| | - David Michonneau
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France.,Université de Paris, Paris, France.,INSERM UMR 976, Paris, France
| | - Nathalie Dhedin
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France
| | - Régis Peffault de Latour
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France.,Université de Paris, Paris, France
| | - Gérard Socié
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France.,Université de Paris, Paris, France.,INSERM UMR 976, Paris, France
| | - Marie Robin
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France
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11
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Afzal A, Tarbunova M, Despotis G, Grossman BJ. The CELLEX is comparable to the UVAR-XTS for the treatment of acute and chronic graft versus host disease (GVHD). Transfusion 2020; 60:351-357. [PMID: 31919871 DOI: 10.1111/trf.15653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Two extracorporeal photopheresis (ECP) instruments, the CELLEX and the UVARXTS are currently being used "off-label" in the US for treatment of graft versus host disease (GVHD). Our study compared the performance of the two instruments in the setting of acute and chronic GVHD. STUDY DESIGN AND METHODS We retrospectively analyzed the outcomes of patients with steroid refractory or steroid resistant GVHD undergoing ECP at Barnes Jewish Hospital. Multivariate logistic regression was used to evaluate the comparative efficacy of the two instruments with respect to steroid dose reduction (≥50% from baseline) and clinical improvement in GVHD. Chi-square/Fisher exact tests were used to compare the incidence of adverse events, while multivariate Cox regression was employed to assess a potential difference in mortality between the two instrument treatment cohorts. RESULTS After adjusting for potential confounders, there was no significant difference in the odds of steroid dose reduction (OR = 1.41, 95% confidence interval [CI]: 0.51-3.90, p = 0.50) or clinical improvement (OR 2.0, 95% CI: 0.63-6.41, p = 0.24) between the two instrument treatment cohorts. The frequency of adverse events (CELLEX 45.4%; UVAR XTS 40.5%, p = 0.55) was also comparable between the cohorts. There was no significant difference in mortality of either acute or chronic GVHD patients when treated by the CELLEX as compared to the UVAR-XTS (aHR 0.66, 95% CI: 0.35-1.25, p = 0.20). CONCLUSION The efficacy and safety of the two ECP instruments, the CELLEX and the UVAR-XTS, are comparable for the treatment of acute and chronic GVHD.
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Affiliation(s)
- Amber Afzal
- Division of Hematology and Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Maryna Tarbunova
- Department of Pathology, University of Minnesota, Minneapolis, Minnesota
| | - George Despotis
- Department of Anesthesiology, Washington University School of Medicine, St Louis, Missouri.,Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
| | - Brenda J Grossman
- Division of Hematology and Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri.,Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
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12
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Higher response rates in patients with severe chronic skin graft-versus-host disease treated with extracorporeal photopheresis. Cent Eur J Immunol 2019; 44:84-91. [PMID: 31114441 PMCID: PMC6526584 DOI: 10.5114/ceji.2018.75831] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 04/10/2018] [Indexed: 01/30/2023] Open
Abstract
Introduction Different forms of graft-versus-host disease (GVHD) remain a major cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). The prognosis for steroid-refractory chronic GVHD (cGVHD) remains poor. Our aim was to evaluate extracorporeal photopheresis (ECP) treatment in cGVHD patients with different organ involvement to detect subgroups of patients with the best response. Material and methods Thirty-four patients who underwent HSCT and developed moderate (n = 7) or severe (n = 27) steroid-refractory or steroid-dependent cGVHD treated with ECP were included in the analysis. A matched cGVHD control patient group untreated with ECP was collected for comparison. Results Compared to the control group and the stable/progressive disease (SD/PD) patients, individuals with complete/partial remission have higher overall survival and lower transplant-related mortality. Furthermore, patients with complete and partial remission (CR/PR) had significantly higher levels of albumin and platelets after ECP treatment compared to patients with stable or progressive cGVHD (SD/PD). Corticosteroid treatment and other immunosuppressive agents could successfully be tapered in the CR/PR group compared to the SD/PD patients. In this study patients with skin cGVHD are those with the highest rate of CR/PR after ECP treatment. Conclusions Our results suggest that ECP treatment is safe and effective for patients with predominantly skin, oral and liver cGVHD.
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13
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Clinical versus histological grading in the assessment of cutaneous graft versus host disease. Eur J Med Res 2019; 24:19. [PMID: 30971293 PMCID: PMC6457000 DOI: 10.1186/s40001-019-0377-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 04/03/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Skin biopsies are often used in daily practice for the diagnosis of acute (aGvHD) or chronic graft versus host disease (cGvHD). With the latest understanding in pathogenesis and new National Institute of Health (NIH) classifications for aGvHD and cGvHD, there is a need to evaluate the current prognostic value of histological grading cutaneous GvHD and its correlation to the clinical grade. METHODS In a retrospective study with 120 skin biopsies (all taken for suspected GvHD) from 110 patients (all classified according to the NIH), biopsies were revised and graded, blinded for clinical information, for either acute of chronic features. Morphological grades were compared for concordance with the clinical grade and survival analyses were done for clinical and histological grading. RESULTS Correlation for histologic vs. clinical grading was (very) poor for aGvHD and cGvHD (weighted κ - 0.038 and 0.0009, respectively). Patients with clinical aGvHD had worse prognosis compared to cGvHD. However, at time of biopsy neither clinical nor histological grading predicted the eventual survival for either aGvHD (p = 0.9739 and p = 0.0744, respectively) or cGvHD (p = 0.2149 and p = 0.4465, respectively). CONCLUSIONS Confirming the diagnosis of GvHD is still a valuable reason for taking a skin biopsy, but this study shows that histologic grading of GvHD in the skin biopsy has no additional value for clinicians in current practice.
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14
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Pusic I, Pavletic SZ. Challenges in Conducting Studies in Chronic Graft- versus-Host Disease. Clin Hematol Int 2019; 1:36-44. [PMID: 34595409 PMCID: PMC8432377 DOI: 10.2991/chi.d.190314.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/10/2019] [Indexed: 12/03/2022] Open
Abstract
The lack of standardized criteria for measuring therapeutic response has been a major obstacle to the development of therapeutic trials in chronic graft-versus-host disease (cGvHD). Nevertheless, recent advances have been made in understanding of the biology and pathophysiology of cGvHD, as well as establishing more precise criteria for the diagnosis and classification of disease manifestations. The momentum has shifted, and currently there is a long list of new potential treatment targets being identified for cGvHD. Consequently, new drugs are being implemented for its prophylaxis and treatment. It is crucial to continue that trend and develop better systems to test new drugs in clinical practice that would eventually translate toward seeking regulatory review and approval. We provide a historical perspective and current challenges in conducting cGvHD clinical trials.
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Affiliation(s)
- Iskra Pusic
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Steven Z Pavletic
- National Institutes of Health, National Cancer Institute, Center for Cancer Research, Bethesda, Maryland
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15
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Ooi KGJ, Khoo P, Vaclavik V, Watson SL. Statins in ophthalmology. Surv Ophthalmol 2019; 64:401-432. [PMID: 30703407 DOI: 10.1016/j.survophthal.2019.01.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 01/14/2019] [Accepted: 01/17/2019] [Indexed: 01/07/2023]
Abstract
Statins, 3-hydroxy-3-methyl-gutaryl coenzyme A reductase inhibitors, are a class of lipid-lowering drugs with anti-inflammatory, immunomodulatory, and vascular effects. Statins are increasingly being used in the treatment of a variety of medical conditions. We examine the actions of statins on the eye and its associated ophthalmic disorders. Statins can be synthetic or nonsynthetic, and their differentiating derivations may contribute to their varying cholesterol-lowering and pleiotropic effects. There is conflicting evidence on the ocular therapeutic and adverse effects of the statins. Statins may play a role in reducing the burden of dry eye, corneal ulcer scarring, thyroid-associated orbitopathy, glaucoma, uveitis and other associated ocular inflammatory states, cataract, proliferative vitreoretinopathy, diabetic retinopathy, macular degeneration, and choroidal melanoma. Topical preparations of statins can be formulated, thereby extending the range of ocular diseases that may be amenable to treatment. Statins have a relatively safe side effect profile, but rare and serious adverse reactions have been reported with their usage in ophthalmology, including myopathies and rhabdomyolysis with acute renal failure.
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Affiliation(s)
- Kenneth G-J Ooi
- Save Sight Institute, University of Sydney, Sydney, New South Wales, Australia.
| | - Pauline Khoo
- Save Sight Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Veronika Vaclavik
- Jules Gonin Eye Hospital, University of Lausanne, Lausanne, Switzerland
| | - Stephanie L Watson
- Save Sight Institute, University of Sydney, Sydney, New South Wales, Australia
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16
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Gandelman JS, Song DJ, Chen H, Engelhardt BG, Chen YB, Clark WB, Giver CR, Waller EK, Jung DK, Jagasia M. A Prospective Trial of Extracorporeal Photopheresis for Chronic Graft-versus-Host Disease Reveals Significant Disease Response and No Association with Frequency of Regulatory T Cells. Biol Blood Marrow Transplant 2018; 24:2373-2380. [DOI: 10.1016/j.bbmt.2018.06.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 06/28/2018] [Indexed: 12/18/2022]
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17
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Mawardi H, Hashmi SK, Elad S, Aljurf M, Treister N. Chronic graft‐versus‐host disease: Current management paradigm and future perspectives. Oral Dis 2018; 25:931-948. [DOI: 10.1111/odi.12936] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/04/2018] [Accepted: 07/04/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Hani Mawardi
- Faculty of Dentistry King AbdulAziz University Jeddah Kingdom of Saudi Arabia
- AlFarabi Private College Jeddah Kingdom of Saudi Arabia
| | - Shahrukh K. Hashmi
- Department of Medicine Mayo Clinic Rochester Minnesota
- Oncology Center KFSHRC Riyadh Kingdom of Saudi Arabia
| | - Sharon Elad
- Department of Dentistry University of Rochester Rochester New York
| | | | - Nathaniel Treister
- Division of Oral Medicine and Dentistry, Brigham and Women's Hospital Boston Massachusetts
- Department of Oral Medicine, Infection and Immunity Harvard School of Dental Medicine Boston Massachusetts
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18
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Akahoshi Y, Kimura SI, Gomyo A, Hayakawa J, Tamaki M, Harada N, Kusuda M, Kameda K, Ugai T, Wada H, Ishihara Y, Kawamura K, Sakamoto K, Sato M, Terasako-Saito K, Kikuchi M, Nakasone H, Kako S, Kanda Y. Delayed platelet recovery after allogeneic hematopoietic stem cell transplantation: Association with chronic graft-versus-host disease and survival outcome. Hematol Oncol 2017; 36:276-284. [DOI: 10.1002/hon.2427] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/07/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Yu Akahoshi
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Shun-ichi Kimura
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Ayumi Gomyo
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Jin Hayakawa
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Masaharu Tamaki
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Naonori Harada
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Machiko Kusuda
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Kazuaki Kameda
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Tomotaka Ugai
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Hidenori Wada
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Yuko Ishihara
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Koji Kawamura
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Kana Sakamoto
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Miki Sato
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Kiriko Terasako-Saito
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Misato Kikuchi
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Hideki Nakasone
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Shinichi Kako
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Yoshinobu Kanda
- Division of Hematology, Saitama Medical Center; Jichi Medical University; Saitama Japan
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19
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Lazaryan A, Arora M. Evolving concepts in prognostic scoring of chronic GvHD. Bone Marrow Transplant 2017; 52:1361-1366. [PMID: 28346419 DOI: 10.1038/bmt.2017.50] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 01/03/2017] [Accepted: 02/16/2017] [Indexed: 01/27/2023]
Abstract
Chronic GvHD (cGvHD) remains one of the most complex and challenging complications after allogeneic hematopoietic cell transplantation. Emerging knowledge about the clinical manifestations and associated organ involvement of cGvHD has led to the establishment of prognostic parameters for post-transplant survival among affected allograft recipients. Studies employing the pre-National Institutes of Health (NIH) consensus data on cGvHD incidence and its risks have led to development of the CIBMTR's cGvHD risk stratification, which serves as the most refined and validated prognostic tool for estimating survival of patients with cGvHD. However, cGvHD global severity scoring has recently evolved as a powerful prognostic tool for patient survival in the post-NIH consensus era. Current use of the substantially redefined NIH criteria of cGvHD diagnosis and measurements of its severity makes it challenging to interpret prognostic scoring systems generated in the pre-NIH era. Some of the pre-NIH prognostic parameters, however, appear to retain their significance in predicting survival independently from the NIH global severity score. Thus, future analyses of prospective cohorts of patients with cGvHD defined by NIH consensus criteria will be critical in reconciling and integrating various prognostic scoring systems of cGvHD.
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Affiliation(s)
- A Lazaryan
- Department of Medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - M Arora
- Department of Medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, MN, USA
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20
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Pirsl F, Curtis LM, Steinberg SM, Tella SH, Katić M, Dobbin M, Hsu J, Hakim FT, Mays JW, Im AP, Pulanić D, Mitchell SA, Baruffaldi J, Masuch L, Halverson DC, Gress RE, Barsony J, Pavletic SZ. Characterization and Risk Factor Analysis of Osteoporosis in a Large Cohort of Patients with Chronic Graft-versus-Host Disease. Biol Blood Marrow Transplant 2016; 22:1517-1524. [PMID: 27118572 DOI: 10.1016/j.bbmt.2016.04.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 04/16/2016] [Indexed: 01/23/2023]
Abstract
The National Institutes of Health Chronic Graft-versus-Host Disease (cGVHD) Consensus Project Ancillary and Supportive Care Guidelines recommend annual assessment of bone mineral density (BMD) to monitor bone health. The study of osteoporosis in patients with cGVHD has been limited to small numbers of patients, and the guidelines are based on experience with other chronic diseases and expert opinion. We hypothesized that the prevalence of osteoporosis is high in a cohort of 258 patients with moderate to severe cGVHD because of prolonged exposure to risk factors for osteoporosis after allogeneic hematopoietic stem cell transplantation. We defined osteoporosis using BMD criteria (T-score ≤-2.5) at 3 anatomic sites-the femoral neck (FN), lumbar spine (LS), and total hip (TH)-and characterized risk factors through univariate and multivariate analyses. We found that low body weight (FN, P < .0001; LS, P = .0002; TH, P < .0001), malnutrition (FN, P = .0002; LS, P = .03; TH, P = .0076), higher platelet count (FN, P = .0065; TH, P = .0025), higher average National Institutes of Health organ score (FN, P = .038), higher prednisone dose (LS, P = .032), lower complement component 3 (LS, P = .0073), and physical inactivity (FN, P = .01) were associated with osteoporosis in at least 1 site. T-scores were significantly lower in the FN compared with the LS or TH (P < .0001 for both). The prevalence of osteoporosis and osteopenia was high (17% and 60%, respectively), supporting current recommendations for frequent monitoring of BMD. The association of higher platelet count in patients with cGVHD and osteoporosis has not been reported previously and represents a new area of interest in the study of osteoporosis after allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
- Filip Pirsl
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Lauren M Curtis
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
| | - Seth M Steinberg
- Biostatistics and Data Management Section, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Sri Harsha Tella
- National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Mašenjka Katić
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Marnie Dobbin
- Clinical Nutrition Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Jennifer Hsu
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Fran T Hakim
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jacqueline W Mays
- Oral and Pharyngeal Cancer Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Annie P Im
- Adult Hematopoietic Stem Cell Transplant Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Dražen Pulanić
- Division of Hematology, Department of Internal Medicine, University Hospital Center Zagreb and University of Zagreb School of Medicine, Zagreb, Croatia; Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek, Croatia
| | - Sandra A Mitchell
- Outcomes Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Judy Baruffaldi
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Licia Masuch
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - David C Halverson
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Ronald E Gress
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Julianna Barsony
- Division of Endocrinology and Metabolism, Department of Medicine, Georgetown University Medical Center, Washington, DC
| | - Steven Z Pavletic
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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21
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Itonaga H, Iwanaga M, Aoki K, Aoki J, Ishiyama K, Ishikawa T, Sakura T, Fukuda T, Najima Y, Yujiri T, Mori T, Kurokawa M, Nawa Y, Uchida N, Morishita Y, Hashimoto H, Eto T, Hirokawa M, Morishima Y, Nagamura-Inoue T, Atsuta Y, Miyazaki Y. Impacts of graft-versus-host disease on outcomes after allogeneic hematopoietic stem cell transplantation for chronic myelomonocytic leukemia: A nationwide retrospective study. Leuk Res 2016; 41:48-55. [DOI: 10.1016/j.leukres.2015.12.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 11/12/2015] [Accepted: 12/15/2015] [Indexed: 12/20/2022]
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22
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Prognostic factors for survival of patients with newly diagnosed chronic GVHD according to NIH criteria. Ann Hematol 2015. [DOI: 10.1007/s00277-015-2452-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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23
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Yeral M, Kasar M, Boga C, Kozanoglu I, Ozdogu H, Sariturk C. Clinical Relevance of Apheretic Graft Composition in Patients With Acute Myeloblastic Leukemia Who Received a Busulfan-Fludarabine-Antithymocyte Globulin Conditioning Regimen for Allogeneic Transplant. EXP CLIN TRANSPLANT 2015; 13:453-60. [PMID: 26103468 DOI: 10.6002/ect.2014.0223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Sparse data are available about the effects of apheretic graft composition on the clinical transplant outcome in allotransplanted patients who have hematologic malignant disease. Major obstacles in recent studies have included heterogeneity of patient populations and differences in the conditioning regimens used. MATERIALS AND METHODS This prospective study included 50 patients who had acute myeloblastic leukemia and received busulfan-fludarabine-antithymocyte globulin-based conditioning for peripheral allogeneic stem cell transplant. The concentration of CD34+ cells, T-cell subsets, B cells, and natural killer cells in the graft were analyzed by flow cytometry in the donors who were matched for human leukocyte antigen. RESULTS In univariate analysis, infusion with a higher dose of natural killer cells (> 1.55 × 106/kg) was associated with improved survival (P = .007 for disease-free survival; P = .024 for overall survival) in patients with acute myeloblastic leukemia. Cox regression models revealed that increased concentration of natural killer cells and CD34+ cells positively affected the clinical outcome of allotransplanted patients (P = .005 for both cell types). According to univariate analysis, these findings were dependent on minimal residual disease and acute graft-versus-host disease. Graft-versus-host disease (acute and chronic forms) was not affected by graft composition. CONCLUSIONS Our results suggest that increased concentration of natural killer cells and CD34+ cells in the apheretic product may predict better survival. In contrast, busulfan-fludarabine-antithymocyte globulin-based conditioning eliminates the disadvantages that resulted from the high content of T-cell subsets and B cells, and the course of the transplant and clinical parameters were not affected by the amount of T and B cells.
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Affiliation(s)
- Mahmut Yeral
- Baskent University Adana Adult Bone Marrow Transplantation Center, Adana, Turkey
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Kasar M, Asma S, Kozanoglu I, Maytalman E, Boga C, Ozdogu H, Yeral M. Effectiveness of fludarabine- and busulfan-based conditioning regimens in patients with acute myeloblastic leukemia: 8-year experience in a single center. Transplant Proc 2015; 47:1217-21. [PMID: 26036558 DOI: 10.1016/j.transproceed.2014.10.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 10/28/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a curative treatment for acute myeloblastic leukemia (AML). Because the conditioning regimen of busulfan plus cyclophosphamide carries significant risks of toxicity, we evaluated the factors affecting survival after fludarabine replacement instead of cyclophosphamide. METHODS The study included 55 patients who underwent allo-HSCT for AML and received busulfan, fludarabine, and antithymocyte globulin (ATG). RESULTS Forty-eight patients received a myeloablative regimen; 7 patients received a reduced-intensity conditioning regimen. The neutrophil and platelet engraftment times were 12 days (range 9 to 20) and 12 days (range 7 to 19), respectively. Graft-vs-host disease (GvHD) developed in 10% and 50% of the patients, respectively. Seven patients received donor lymphocyte infusion. Of them, 5 patients developed grade I or II GvHD, one grade IV GvHD. The median follow-up period was 20.6 months. The predicted progression-free survival (PFS) at 1 and 3 years after transplantation was 78% and 74%, respectively. The overall survival (OS) at 1, 3, and 5 years was 76%, 74%, and 62%, respectively. Treatment-related mortality (infection in 1 patient, GvHD in 2 patients) occurred in 3 patients (5.5%). Multivariate analysis revealed that OS and PFS were not influenced by age, dose of busulfan or ATG, or presence of cytomegalovirus antigenemia. Acute GvHD and pretransplantation minimal residual disease positivity negatively affected the transplant outcome. The presence of active disease at the time of transplantation was found as an independent risk factor for AML. CONCLUSIONS Busulfan- and fludarabine-based conditioning regimens are effective for AML, and have acceptable toxicity, morbidity, and mortality.
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Affiliation(s)
- M Kasar
- Baskent University Adana Adult Bone Marrow Transplantation Center, Adana, Turkey
| | - S Asma
- Baskent University Adana Adult Bone Marrow Transplantation Center, Adana, Turkey
| | - I Kozanoglu
- Baskent University Adana Adult Bone Marrow Transplantation Center, Adana, Turkey
| | - E Maytalman
- Baskent University Adana Adult Bone Marrow Transplantation Center, Adana, Turkey
| | - C Boga
- Baskent University Adana Adult Bone Marrow Transplantation Center, Adana, Turkey
| | - H Ozdogu
- Baskent University Adana Adult Bone Marrow Transplantation Center, Adana, Turkey
| | - M Yeral
- Baskent University Adana Adult Bone Marrow Transplantation Center, Adana, Turkey.
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Lee SJ, Wolff D, Kitko C, Koreth J, Inamoto Y, Jagasia M, Pidala J, Olivieri A, Martin PJ, Przepiorka D, Pusic I, Dignan F, Mitchell SA, Lawitschka A, Jacobsohn D, Hall AM, Flowers MED, Schultz KR, Vogelsang G, Pavletic S. Measuring therapeutic response in chronic graft-versus-host disease. National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: IV. The 2014 Response Criteria Working Group report. Biol Blood Marrow Transplant 2015; 21:984-99. [PMID: 25796139 PMCID: PMC4744804 DOI: 10.1016/j.bbmt.2015.02.025] [Citation(s) in RCA: 258] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 02/26/2015] [Indexed: 12/17/2022]
Abstract
In 2005, the National Institutes of Health (NIH) Chronic Graft-versus-Host Disease (GVHD) Consensus Response Criteria Working Group recommended several measures to document serial evaluations of chronic GVHD organ involvement. Provisional definitions of complete response, partial response, and progression were proposed for each organ and for overall outcome. Based on publications over the last 9 years, the 2014 Working Group has updated its recommendations for measures and interpretation of organ and overall responses. Major changes include elimination of several clinical parameters from the determination of response, updates to or addition of new organ scales to assess response, and the recognition that progression excludes minimal, clinically insignificant worsening that does not usually warrant a change in therapy. The response definitions have been revised to reflect these changes and are expected to enhance reliability and practical utility of these measures in clinical trials. Clarification is provided about response assessment after the addition of topical or organ-targeted treatment. Ancillary measures are strongly encouraged in clinical trials. Areas suggested for additional research include criteria to identify irreversible organ damage and validation of the modified response criteria, including in the pediatric population.
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Affiliation(s)
- Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Daniel Wolff
- Department of Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Carrie Kitko
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - John Koreth
- Division of Hematologic Malignancies, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Madan Jagasia
- Division of Hematology-Oncology, Vanderbilt University, Nashville, Tennessee
| | - Joseph Pidala
- Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Attilio Olivieri
- Department of Clinical and Molecular Sciences, University of Ancona, Ancona, Italy
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Donna Przepiorka
- US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, Maryland
| | - Iskra Pusic
- Department of Medicine, Washington University, St. Louis, Missouri
| | - Fiona Dignan
- Department of Clinical Haematology, University of Manchester, Manchester, United Kingdom
| | - Sandra A Mitchell
- Outcomes Research Branch, National Cancer Institute, Bethesda, Maryland
| | - Anita Lawitschka
- Stem Cell Transplant Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - David Jacobsohn
- Division of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Anne M Hall
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Kirk R Schultz
- BC Children's Hospital, University of British Columbia, Vancouver, Canada
| | | | - Steven Pavletic
- Outcomes Research Branch, National Cancer Institute, Bethesda, Maryland.
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Santos PSDS, Coracin FL, Barros JCDA, Gallottini MHC. Histopathologic diagnosis of chronic graft-versus-host disease of the oral mucosa according to the National Institutes of Health Consensus. ACTA ACUST UNITED AC 2014; 12:204-10. [PMID: 25003927 PMCID: PMC4891164 DOI: 10.1590/s1679-45082014ao2974] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 04/15/2014] [Indexed: 01/26/2023]
Abstract
Objective To validate the minimal criteria of the histopathologic diagnosis of oral chronic graft-versus-host disease, based on the histopathologic classification of the National Institutes of Health and correlate them with clinical features. Methods Forty-one specimens containing both oral mucosa and salivary glands were analyzed in slides stained with hematoxylin-eosin. The histological specimens were blindly examined by two trained pathologists using criteria recommended for the histopathologic diagnosis of chronic graft-versus-host disease proposed by the National Institutes of Health Consensus. The clinical classification of chronic graft-versus-host disease was correlated with analysis of slides. Results Our data showed that the epithelium was involved in 39/41 specimens, presenting acanthosis (29/70.7%), exocytosis of lymphocytes (29/70.7%), thickening of basal lamina (29/70.7%), and apoptosis (15/36.6%). Connective tissue presented interstitial inflammatory infiltrate (38/92.7%). Minor salivary glands showed periductal fibrosis (38/92.7%), mixed periductal inflammatory infiltrate (32/78%), ductal ectasia (30/73.2%), lymphocytes around and into acinar units (30/73.2%), and interstitial fibrosis (29/70.7%). The most common clinical manifestations were lichenoid aspect (40/97.6%), complaints of sensitivity to oral feeding (38/92.7%), and dry mouth sensation (36/87.8%). Conclusion This study validated the National Institutes of Health Consensus of minimal histologic criteria for diagnosis of oral chronic graft-versus-host disease and has not found an association between the severity of clinical manifestation and the histopathological stage.
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Affiliation(s)
| | - Fábio Luiz Coracin
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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27
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Okamoto S, Fujiwara H, Nishimori H, Matsuoka KI, Fujii N, Kondo E, Tanaka T, Yoshimura A, Tanimoto M, Maeda Y. Anti-IL-12/23 p40 antibody attenuates experimental chronic graft-versus-host disease via suppression of IFN-γ/IL-17-producing cells. THE JOURNAL OF IMMUNOLOGY 2014; 194:1357-63. [PMID: 25527789 DOI: 10.4049/jimmunol.1400973] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Chronic graft-versus-host disease (GVHD) is a major cause of late death and morbidity after allogeneic hematopoietic cell transplantation. Recently, in addition to Th2 cells, Th1 and Th17 cells have been shown to contribute to chronic GVHD progression. IL-12 induces Th1 cells and IL-23 plays a role in stabilizing and/or amplifying Th17 cells, as well as in inducing IFN-γ/IL-17 double-producing cells. Because mAb targeting the p40 subunit common to both IL-12 and IL-23 can inhibit both IL-12R and IL-23R-mediated signaling, we investigated the effects of anti-p40 mAb on a well-defined chronic GVHD mice model. Treatment of anti-p40 mAb in allogeneic recipients significantly reduced the severity of clinical and pathological chronic GVHD. Intracellular staining revealed that IFN-γ single-positive (IL-17(-)) and IFN-γ/IL-17 double-positive cells were suppressed in anti-p40 mAb-treated allogeneic recipients compared with control recipients. The cytokine levels of IFN-γ and IL-17 were also decreased in serum from anti-p40 mAb-treated allogeneic recipients. T-bet expression of donor IL-17(+) CD4(+) T cells was reduced significantly in anti-p40 mAb-treated recipients, and this reduction in T-bet expression was associated with IL-22 production by donor T cells. These results suggested that anti-p40 mAb attenuated chronic GVHD via suppression of IFN-γ/IL-17-producing cells, and that targeting the IL-12/IL-23 pathway may represent a promising therapeutic strategy for preventing and treating chronic GVHD.
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Affiliation(s)
- Sachiyo Okamoto
- Department of Hematology, Oncology, and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Hideaki Fujiwara
- Department of Hematology, Oncology, and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Hisakazu Nishimori
- Department of Hematology, Oncology, and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Ken-ichi Matsuoka
- Department of Hematology, Oncology, and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Nobuharu Fujii
- Department of Hematology, Oncology, and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Eisei Kondo
- Department of Hematology, Oncology, and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Takehiro Tanaka
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan; and
| | - Akihiko Yoshimura
- Department of Microbiology and Immunology, Keio University School of Medicine, Tokyo 108-8345, Japan
| | - Mitsune Tanimoto
- Department of Hematology, Oncology, and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Yoshinobu Maeda
- Department of Hematology, Oncology, and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan;
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Center for International Blood and Marrow Transplant Research chronic graft-versus-host disease risk score predicts mortality in an independent validation cohort. Biol Blood Marrow Transplant 2014; 21:640-5. [PMID: 25528390 DOI: 10.1016/j.bbmt.2014.10.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 10/24/2014] [Indexed: 11/22/2022]
Abstract
We previously reported a risk score that predicted mortality in patients with chronic graft-versus-host disease (CGVHD) after hematopoietic stem cell transplantation (HCT) between 1995 and 2004 and reported to the Center for International Blood and Marrow Transplant Research (CIBMTR). We sought to validate this risk score in an independent CIBMTR cohort of 1128 patients with CGVHD who underwent transplantation between 2005 and 2007 using the same inclusion criteria and risk score calculations. According to the sum of the overall risk score (range, 1 to 12), patients were assigned to 4 risk groups (RGs): RG1 (0 to 2), RG2 (3 to 6), RG3 (7 to 8), and RG4 (9 to 10). RG3 and RG4 were combined, as RG4 accounted for only 1% of the total cohort. Cumulative incidences of nonrelapse mortality (NRM) and probability of overall survival were significantly different between each RG (all P < .01). NRM and overall survival at 5 years after CGVHD for each RG were 17% and 72% in RG1, 26% and 53% in RG2, and 44% and 25% in RG3, respectively (all P < .01). Our study validates the prognostic value of the CIBMTR CGVHD RGs for overall survival and NRM in a contemporary transplantation population. The CIBMTR CGVHD RGs can be used to predict major outcomes, tailor treatment planning, and enroll patients in clinical trials.
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29
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Nail dystrophy, edema, and eosinophilia: harbingers of severe chronic GVHD of the skin in children. Bone Marrow Transplant 2014; 49:1521-7. [PMID: 25243619 DOI: 10.1038/bmt.2014.194] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 07/03/2014] [Accepted: 07/17/2014] [Indexed: 11/08/2022]
Abstract
The prognostic value of adnexal findings in chronic GVHD (cGVHD) has not been investigated in children. Dermatologic examinations were performed in a severe cohort of 11 children with skin cGVHD seen over a 2-year period. Findings were compared with 25 additional patients with skin cGVHD and 97 control patients. In 36 patients with skin cGVHD, nail dystrophy was present in 45% of patients, and was significantly associated with sclerotic disease and lung cGVHD. Pterygium inversum unguis (PIU) was associated with severe lung disease, with significantly lower % predicted FVC and FEV1 in those with PIU than those without. Forty-four percent of GVHD patients had preceding peripheral edema and 56% had preceding peripheral eosinophilia. Peripheral edema and eosinophilia were significantly associated with sclerotic cGVHD and persisted until the diagnosis of cGVHD in all patients. Comparison of data with control patients showed that incidence of nail dystrophy, incidence of peripheral edema and mean peak peripheral eosinophil count of patients with skin cGVHD was significantly higher than those without cGVHD. This study suggests that nail dystrophy, persistent peripheral edema and persistent peripheral eosinophilia are harbingers of severe cGVHD of the skin in children. The presence of PIU may be a harbinger of severe lung involvement.
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30
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Curtis LM, Grkovic L, Mitchell SA, Steinberg SM, Cowen EW, Datiles MB, Mays J, Bassim C, Joe G, Comis LE, Berger A, Avila D, Taylor T, Pulanic D, Cole K, Baruffaldi J, Fowler DH, Gress RE, Pavletic SZ. NIH response criteria measures are associated with important parameters of disease severity in patients with chronic GVHD. Bone Marrow Transplant 2014; 49:1513-20. [PMID: 25153693 DOI: 10.1038/bmt.2014.188] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 07/02/2014] [Accepted: 07/10/2014] [Indexed: 11/09/2022]
Abstract
Lack of standardized criteria measuring therapeutic response remains an obstacle to the development of better treatments for chronic GVHD (cGVHD). This cross-sectional prospective study examined the concurrent and predictive validity of 18 clinician-reported ('Form A') and 8 patient-reported ('Form B') response measures proposed by NIH criteria. Concurrent parameters of interest were NIH global score, cGVHD activity, Lee symptom score and SF36 PCS. Patient cohort included 193 adults with moderate-to-severe cGVHD. Measures associated with the highest number of outcomes were lung function score (LFS), 2-min walk, grip strength, 4-point health-care provider (HCP) and patient global scores, 11-point clinician- and patient-reported global symptom severity scores, and Karnofsky performance score (KPS). Measures associated with survival in univariate analyses led to a Cox model containing skin erythema, LFS, KPS, eosinophil count and interval from cGVHD diagnosis to enrollment as jointly associated with survival. In conclusion, 4-point HCP and patient global scores and 11-point clinician- and patient-reported global symptom severity scores are associated with the majority of concurrent outcomes. Skin erythema is a potentially reversible sign of cGVHD that is associated with survival. These results define a subset of measures that should be prioritized for evaluation in future studies.
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Affiliation(s)
- L M Curtis
- 1] Medical Oncology Service, National Institutes of Health, National Cancer Institute, Bethesda, MD, USA [2] Experimental Transplantation and Immunology Branch, National Institutes of Health, National Cancer Institute, Bethesda, MD, USA
| | - L Grkovic
- 1] Experimental Transplantation and Immunology Branch, National Institutes of Health, National Cancer Institute, Bethesda, MD, USA [2] Department of Hematology, Clinical Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
| | - S A Mitchell
- Outcomes Research Branch; Division of Cancer Control and Population Sciences, National Institutes of Health, National Cancer Institute, Bethesda, MD, USA
| | - S M Steinberg
- Biostatistics and Data Management Section, National Institutes of Health, National Cancer Institute, Rockville, MD, USA
| | - E W Cowen
- Dermatology Branch, National Institutes of Health, National Cancer Institute, Bethesda, MD, USA
| | - M B Datiles
- National Institutes of Health, National Eye Institute, Bethesda, MD, USA
| | - J Mays
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - C Bassim
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - G Joe
- Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - L E Comis
- Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - A Berger
- Pain and Palliative Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - D Avila
- Experimental Transplantation and Immunology Branch, National Institutes of Health, National Cancer Institute, Bethesda, MD, USA
| | - T Taylor
- Experimental Transplantation and Immunology Branch, National Institutes of Health, National Cancer Institute, Bethesda, MD, USA
| | - D Pulanic
- Department of Hematology, Clinical Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
| | - K Cole
- Experimental Transplantation and Immunology Branch, National Institutes of Health, National Cancer Institute, Bethesda, MD, USA
| | - J Baruffaldi
- Experimental Transplantation and Immunology Branch, National Institutes of Health, National Cancer Institute, Bethesda, MD, USA
| | - D H Fowler
- Experimental Transplantation and Immunology Branch, National Institutes of Health, National Cancer Institute, Bethesda, MD, USA
| | - R E Gress
- Experimental Transplantation and Immunology Branch, National Institutes of Health, National Cancer Institute, Bethesda, MD, USA
| | - S Z Pavletic
- Experimental Transplantation and Immunology Branch, National Institutes of Health, National Cancer Institute, Bethesda, MD, USA
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Salvage therapy with everolimus reduces the severity of treatment-refractory chronic GVHD without impairing disease control: a dual center retrospective analysis. Bone Marrow Transplant 2014; 49:1412-8. [PMID: 25089598 DOI: 10.1038/bmt.2014.170] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 06/13/2014] [Accepted: 06/17/2014] [Indexed: 11/08/2022]
Abstract
Chronic GVHD (cGVHD) remains the most important cause of late non-relapse mortality post allogeneic hematopoietic SCT (HSCT). Although first-line treatment of cGVHD with steroids is well established, evidence for second-line treatment remains limited. Here, we report a dual center retrospective analysis of the off-label salvage treatment of steroid-refractory cGVHD with everolimus. Out of 80 patients with a median age of 50 (17-70) years, 14 (17%) suffered from mild, 39 (49%) from moderate and 27 (34%) from severe cGVHD. At the final analysis, median follow-up after introduction of everolimus was 724 (14-2205) days. Thirty-four patients (43%) required the addition of further immunosuppression during everolimus-based therapy. Global NIH Severity Score improved in 34 patients (43%), remained stable in 37 patients (46%) and worsened in 9 patients (11%). The total sum of Global NIH Severity Scores in all patients assessable was significantly reduced after treatment with everolimus (P<0.0001). Most frequent grade 3/4 toxicities included infections (n=30) and thrombocytopenia (n=15). There was a single case of relapse. Everolimus-based salvage treatment of refractory cGVHD results in significant improvement of the NIH Severity Score without impairing control of the malignant disease. Finally, these preliminary results demand further verification in prospective trials.
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32
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von Bonin M, Bornhäuser M. Concise Review: The Bone Marrow Niche as a Target of Graft Versus Host Disease. Stem Cells 2014; 32:1420-8. [DOI: 10.1002/stem.1691] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 02/09/2014] [Indexed: 12/12/2022]
Affiliation(s)
- Malte von Bonin
- Medizinische Klinik und Poliklinik 1; Universitätsklinikum Carl-Gustav Carus, Medizinische Fakultät der Technischen Universität Dresden; Dresden Germany
- German Cancer Consortium (DKTK); Im Neuenheimer Feld 280 Heidelberg Germany
- German Cancer Research Center (DKFZ); Im Neuenheimer Feld 280 Heidelberg Germany
| | - Martin Bornhäuser
- Medizinische Klinik und Poliklinik 1; Universitätsklinikum Carl-Gustav Carus, Medizinische Fakultät der Technischen Universität Dresden; Dresden Germany
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33
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Nguyen C, Ranque B, Baubet T, Bérezné A, Mestre-Stanislas C, Rannou F, Papelard A, Morell-Dubois S, Revel M, Moro MR, Guillevin L, Poiraudeau S, Mouthon L. Clinical, functional and health-related quality of life correlates of clinically significant symptoms of anxiety and depression in patients with systemic sclerosis: a cross-sectional survey. PLoS One 2014; 9:e90484. [PMID: 24587375 PMCID: PMC3938731 DOI: 10.1371/journal.pone.0090484] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Accepted: 02/03/2014] [Indexed: 11/20/2022] Open
Abstract
Objectives To identify clinical, functional and health-related quality of life (HRQoL) correlates of clinically significant symptoms of anxiety and depression in patients with systemic sclerosis (SSc). Methods Three-hundred-and-eighty-one patients fulfilling the American College of Rheumatology and/or the Leroy and Medsger criteria for SSc were assessed for visceral involvement, disability and HRQoL (assessed by SF-36). Clinically significant symptoms of anxiety and depression were evaluated with the Hospital Anxiety Depression Scale (HAD) (defined cut-off≥8). Results 9.2% the patients had limited SSc, 50.5% limited cutaneous SSc (lcSSc), and 40.3% diffuse cutaneous SSc (dcSSc). Overall, 40.4% and 58.8% of the patients had clinically significant symptoms of depression and anxiety, respectively. Compared to patients without clinically significant symptoms of depression, patients with clinically significant symptoms of depression had poorer health status, HRQoL mental and physical component, and greater global disability, hand disability and aesthetic impairment. Compared to patients without clinically significant symptoms of anxiety, patients with clinically significant symptoms of anxiety had poorer SF-36 mental and physical component scores. On multivariable analysis, excluding mental component score of SF-36, variables independently associated with clinically significant symptoms of depression and anxiety were global disability and physical component of SF-36, plus female gender for clinically significant symptoms of anxiety only. Remarkably, patients with and without clinically significant psychiatric symptoms were comparable for all disease-related clinical features assessed. Conclusion High levels of clinically significant symptoms of anxiety and depression are observed among SSc patients. Clinically significant psychiatric symptoms are rather associated with increased disability and altered HRQoL, than with disease-specific organ manifestations.
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Affiliation(s)
- Christelle Nguyen
- Pôle de Médecine Interne, Centre de Référence pour les Vascularites Nécrosantes et la Sclérodermie Systémique, Hôpital Cochin, Faculté de Médecine Paris Descartes, Université Paris Descartes & Assistance Publique-Hôpitaux de Paris, Paris, France
- Service de Médecine Physique et Réadaptation, Hôpital Cochin, Faculté de Médecine Paris Descartes, Université Paris Descartes & Assistance Publique-Hôpitaux de Paris, INSERM, Institut Fédératif de Recherche sur le Handicap, Paris, France
| | - Brigitte Ranque
- Service de Médecine Interne, Hôpital Européen Georges Pompidou, Faculté de Médecine Paris Descartes, Université Paris Descartes & Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Thierry Baubet
- Service de Psychopathologie, Hôpital d’Avicenne, EA 3413, Université Paris XIII & Assistance Publique-Hôpitaux de Paris, Bobigny, France
| | - Alice Bérezné
- Pôle de Médecine Interne, Centre de Référence pour les Vascularites Nécrosantes et la Sclérodermie Systémique, Hôpital Cochin, Faculté de Médecine Paris Descartes, Université Paris Descartes & Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Caroline Mestre-Stanislas
- Pôle de Médecine Interne, Centre de Référence pour les Vascularites Nécrosantes et la Sclérodermie Systémique, Hôpital Cochin, Faculté de Médecine Paris Descartes, Université Paris Descartes & Assistance Publique-Hôpitaux de Paris, Paris, France
| | - François Rannou
- Service de Médecine Physique et Réadaptation, Hôpital Cochin, Faculté de Médecine Paris Descartes, Université Paris Descartes & Assistance Publique-Hôpitaux de Paris, INSERM, Institut Fédératif de Recherche sur le Handicap, Paris, France
| | - Agathe Papelard
- Service de Médecine Physique et Réadaptation, Hôpital Cochin, Faculté de Médecine Paris Descartes, Université Paris Descartes & Assistance Publique-Hôpitaux de Paris, INSERM, Institut Fédératif de Recherche sur le Handicap, Paris, France
| | - Sandrine Morell-Dubois
- Service de Médecine Interne, Centre de Référence pour la Sclérodermie Systémique, Hôpital Claude Huriez, Université Lille 2, Lille, France
| | - Michel Revel
- Service de Médecine Physique et Réadaptation, Hôpital Cochin, Faculté de Médecine Paris Descartes, Université Paris Descartes & Assistance Publique-Hôpitaux de Paris, INSERM, Institut Fédératif de Recherche sur le Handicap, Paris, France
| | - Marie-Rose Moro
- Service de Psychopathologie de l’Adolescent, Hôpital Cochin, Faculté de Médecine Paris Descartes, Université Paris Descartes & Assistance Publique-Hôpitaux de Paris, INSERM U669, Paris, France
| | - Loïc Guillevin
- Pôle de Médecine Interne, Centre de Référence pour les Vascularites Nécrosantes et la Sclérodermie Systémique, Hôpital Cochin, Faculté de Médecine Paris Descartes, Université Paris Descartes & Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Serge Poiraudeau
- Service de Médecine Physique et Réadaptation, Hôpital Cochin, Faculté de Médecine Paris Descartes, Université Paris Descartes & Assistance Publique-Hôpitaux de Paris, INSERM, Institut Fédératif de Recherche sur le Handicap, Paris, France
| | - Luc Mouthon
- Pôle de Médecine Interne, Centre de Référence pour les Vascularites Nécrosantes et la Sclérodermie Systémique, Hôpital Cochin, Faculté de Médecine Paris Descartes, Université Paris Descartes & Assistance Publique-Hôpitaux de Paris, Paris, France
- * E-mail:
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Abstract
It is well known that platelets interact with cells of the innate immune system to promote tissue repair. In contrast, it is less clear whether these links extend to cells of the adaptive immune system, such as T cells. In this issue of the JCI, Morrell and colleagues provide compelling evidence that platelets are required to limit CD4+ Th17 differentiation through the actions of the chemokine platelet factor 4 (PF4). Absence of PF4 in the host leads to exaggerated Th17 differentiation after transplantation and rapid graft rejection. The authors' findings argue that platelets are not bit part players, but rather fully fledged, critical members of the adaptive immune system.
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Gleicher N. Graft-versus-host disease and immunologic rejection: implications for diagnosis and treatments of pregnancy complications. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.3.1.37] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Mortensen KB, Gerds TA, Bjerrum OW, Lindmark A, Sengeløv H, Andersen CL. The prevalence and prognostic value of concomitant eosinophilia in chronic graft-versus-host disease after allogeneic stem cell transplantation. Leuk Res 2013; 38:334-9. [PMID: 24439053 DOI: 10.1016/j.leukres.2013.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 11/21/2013] [Accepted: 12/07/2013] [Indexed: 12/30/2022]
Abstract
The prognostic significance of eosinophilia after myeloablative allogeneic stem cell transplantation (ASCT) remains to be established. Patients, whom developed chronic graft-versus-host disease (cGVHD) after ASCT, were included (n = 142). Eosinophil count was analyzed at cGVHD onset. We observed no significant association between EO and the grade of cGVHD, thrombocytopenia, nor extensive skin involvement. Importantly, we observed no significant association between cGVHD with concomitant eosinophilia and long-term clinical outcomes, and subgroup analyses revealed a considerable confounding effect of ongoing steroid treatment. In conclusion, we advocate that prognostic conclusions regarding cGVHD with concomitant eosinophilia after ASCT should be interpreted with caution.
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Affiliation(s)
| | | | - Ole Weis Bjerrum
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Lindmark
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Sengeløv
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christen Lykkegaard Andersen
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark; Department of Hematology, Roskilde Hospital, Roskilde, Denmark
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37
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Kanda J, Nakasone H, Atsuta Y, Toubai T, Yokoyama H, Fukuda T, Taniguchi S, Ohashi K, Ogawa H, Eto T, Miyamura K, Morishima Y, Nagamura-Inoue T, Sakamaki H, Murata M. Risk factors and organ involvement of chronic GVHD in Japan. Bone Marrow Transplant 2013; 49:228-35. [DOI: 10.1038/bmt.2013.151] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 08/10/2013] [Accepted: 08/12/2013] [Indexed: 12/30/2022]
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Beier F, Arbter K, Kittan NA, Andreesen R, Krause SW, Holler E, Hildebrandt GC. Regression of eosinophil counts after diagnosis of chronic graft-versus-host disease as a potential marker for improved clinical outcome. Mol Clin Oncol 2013; 2:81-86. [PMID: 24649312 DOI: 10.3892/mco.2013.192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 04/16/2013] [Indexed: 11/06/2022] Open
Abstract
Eosinophilia after allogeneic hematopoietic stem cell transplantation (allo-HSCT) has been associated with the development of acute and chronic graft-versus-host disease (cGVHD). However, a limited number of studies have investigated the course of eosinophil counts in relation to the onset of cGVHD. In this study, the course of relative eosinophil counts (RECs) was retrospectively analyzed in 64 patients who developed cGVHD following allogeneic HSCT in relation to overall survival (OS), relapse rate and clinical course of cGVHD. At onset of cGVHD, eosinophilia was observed in 45% of the patients and developed one week prior to cGVHD diagnosis. Furthermore, a trend towards improved OS in patients with eosinophilia was observed. Beneficial effects were most evident in patients who exhibited decreasing eosinophil counts one week after diagnosis of cGVHD. By contrast, an increase in or stable eosinophil counts one week after diagnosis were associated with significantly impaired OS and a significantly higher rate of later aggravation of cGVHD. Findings of this study suggested that the course of eosinophil counts may provide a useful parameter in the assessment of cGVHD development and activity allowing the potential identification of patient subpopulations with a good outcome and reduced cGVHD-related mortality.
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Affiliation(s)
- Fabian Beier
- Department of Hematology and Oncology, University of Regensburg Medical Center, D-93053 Regensburg, Germany
| | - Klaus Arbter
- Department of Hematology and Oncology, University of Regensburg Medical Center, D-93053 Regensburg, Germany
| | - Nicolai A Kittan
- Department of Hematology and Oncology, University of Regensburg Medical Center, D-93053 Regensburg, Germany ; ; Feist-Weiller Cancer Center, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA 71130, USA
| | - Reinhard Andreesen
- Department of Hematology and Oncology, University of Regensburg Medical Center, D-93053 Regensburg, Germany
| | - Stefan W Krause
- Department of Hematology and Oncology, University of Regensburg Medical Center, D-93053 Regensburg, Germany ; ; Department of Hematology and Oncology, University of Erlangen Medical Center, D-91054 Erlangen, Germany
| | - Ernst Holler
- Department of Hematology and Oncology, University of Regensburg Medical Center, D-93053 Regensburg, Germany
| | - Gerhard C Hildebrandt
- Department of Hematology and Oncology, University of Regensburg Medical Center, D-93053 Regensburg, Germany ; ; Feist-Weiller Cancer Center, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA 71130, USA
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Park AR, La HO, Cho BS, Kim SJ, Lee BK, Rhie JY, Gwak HS. Comparison of budesonide and dexamethasone for local treatment of oral chronic graft-versus-host disease. Am J Health Syst Pharm 2013; 70:1383-91. [DOI: 10.2146/ajhp120567] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Ae Ryoung Park
- Department of Pharmacy, Seoul St. Mary’s Hospital, Catholic University of Korea, Seoul, South Korea
| | - Hyen Oh La
- Department of Pharmacology, College of Medicine, Catholic University of Korea, and Director, Department of Pharmacy, Seoul St. Mary’s Hospital
| | - Byung Sik Cho
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, College of Medicine, Catholic University of Korea
| | - Soon Joo Kim
- Department of Pharmacy, Seoul St. Mary’s Hospital
| | - Byung Koo Lee
- College of Pharmacy and Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul
| | - Jeong Yeon Rhie
- College of Pharmacy and Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul
| | - Hye Sun Gwak
- College of Pharmacy and Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul
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40
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Bat T, Steinberg SM, Childs R, Calvo KR, Barrett AJ, Battiwalla M, Baird K, Zhang D, Pulanic D, Dunbar CE, Pavletic SZ. Active thrombopoiesis is associated with worse severity and activity of chronic GVHD. Bone Marrow Transplant 2013; 48:1569-73. [PMID: 23832091 DOI: 10.1038/bmt.2013.95] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 05/22/2013] [Accepted: 05/25/2013] [Indexed: 11/09/2022]
Abstract
Chronic GVHD (cGVHD) is a major complication of allogeneic hematopoietic SCT. Post transplant thrombocytopenia in patients with cGVHD has been associated with poor outcome and its etiology is unclear. We investigated whether thrombopoiesis, assessed via measurement of the absolute immature platelet number (AIPN) in the blood, is impaired in cGVHD, and whether the level of thrombopoiesis correlates with the severity and activity of cGVHD as assessed via the National Institutes of Health (NIH) organ scoring system. We used a cohort of 110 well-characterized cGVHD patients, including 83 (75%) with severe cGVHD per NIH global score. Higher AIPN was associated with active therapeutic intent (P=0.026), lower Karnofsky score (P=0.0013), worse joint/fascia cGVHD (P=0.0005) and worse skin cGVHD (P=0.0044). AIPN correlated with platelet counts and was not correlated with ANC, WBC, C-reactive protein (CRP), absolute lymphocyte count (ALC), albumin, total and average NIH scores, or number of prior systemic therapies. AIPN values for cGVHD patients substantially overlapped those of the normal population. Higher AIPN, as marker of active thrombopoiesisis, was associated with worse severity and activity of cGVHD, especially skin and joints/fascia manifestations. Among patients with stable moderate or severe cGVHD, there was no evidence of hypoproduction of platelets. Future studies should further investigate the role of thrombopoiesis in cGVHD.
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Affiliation(s)
- T Bat
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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41
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Kohrt HE, Tian L, Li L, Alizadeh AA, Hsieh S, Tibshirani RJ, Strober S, Sarwal M, Lowsky R. Identification of gene microarray expression profiles in patients with chronic graft-versus-host disease following allogeneic hematopoietic cell transplantation. Clin Immunol 2013; 148:124-35. [PMID: 23685278 DOI: 10.1016/j.clim.2013.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 04/19/2013] [Accepted: 04/23/2013] [Indexed: 01/24/2023]
Abstract
Chronic graft-versus-host disease (GVHD) results in significant morbidity and mortality, limiting the benefit of allogeneic hematopoietic cell transplantation (HCT). Peripheral blood gene expression profiling of the donor immune repertoire following HCT may provide associated genes and pathways thereby improving the pathophysiologic understanding of chronic GVHD. We profiled 70 patients and identified candidate genes that provided mechanistic insight in the biologic pathways that underlie chronic GVHD. Our data revealed that the dominant gene signature in patients with chronic GVHD represented compensatory responses that control inflammation and included the interleukin-1 decoy receptor, IL-1 receptor type II, and genes that were profibrotic and associated with the IL-4, IL-6 and IL-10 signaling pathways. In addition, we identified three genes that were important regulators of extracellular matrix. Validation of this discovery phase study will determine if the identified genes have diagnostic, prognostic or therapeutic implications.
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Affiliation(s)
- Holbrook E Kohrt
- Department of Medicine Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305 USA
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42
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Validation of NIH consensus criteria for diagnosis and severity-grading of chronic graft-versus-host disease. Int J Hematol 2013; 97:263-71. [PMID: 23371545 DOI: 10.1007/s12185-013-1268-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 12/28/2012] [Accepted: 01/15/2013] [Indexed: 10/27/2022]
Abstract
To validate the National Institutes of Health (NIH) consensus criteria for chronic GVHD, we retrospectively reviewed 143 patients who developed GVHD later than 100 days after allogeneic hematopoietic stem cell transplantation. Their GVHD was reclassified and the severity was graded according to the criteria. Only four patients (2.8 %) could not be reclassified into any type of GVHD. In the remaining 139 patients, reclassified subtypes were late acute GVHD in 52 patients (37.4 %), classic chronic GVHD in 33 (23.7 %), and overlap syndrome in 54 (38.8 %). Of 87 patients with classic chronic GVHD or overlap syndrome, the severity was graded as mild in 21 patients (24 %), moderate in 53 (61 %), and severe in 13 (15 %). The proportions of moderate (70 %) and severe (20 %) disease were significantly higher in patients with overlap syndrome than those with classic chronic GVHD (46 and 6 %, respectively; P < 0.001). Univariate and multivariate analyses of subtypes and severity did not identify any significant prognostic values in any of the transplant outcomes, such as transplant-related mortality, overall survival, GVHD-specific survival, or discontinuation of systemic immunosuppressants. These findings suggest that the NIH consensus criteria are useful for classification of chronic GVHD, but have limited significance in predicting clinical outcomes. The validity of these criteria remains inconclusive, and future prospective studies will be required to refine them.
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Devillier R, Castagna L, Gonzague L, El-Cheikh J, Fürst S, Faucher C, Michel R, Blaise D. TLI in refractory chronic GVHD. Bone Marrow Transplant 2012; 48:854-8. [PMID: 23222383 DOI: 10.1038/bmt.2012.240] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Refractory chronic GVHD (cGVHD) remains a major cause of morbidity after transplantation. Many drugs are used but there is no consensus on the standard of care. We investigated the efficacy of TLI in corticosteroid-refractory cGVHD. We analyzed retrospectively 31 patients receiving one or more TLI session for refractory cGVHD from 2000 to 2007. The main objective was to evaluate the response rate after TLI. Decreased corticosteroid doses and/or discontinued immunosuppressive agents were considered to be surrogate markers of response. All but one patient presented with severe cGVHD at the time of TLI. The median number of previous immunosuppressive treatment lines was 3 (range: 2-4). Fourteen patients (45%) achieved an objective response after TLI and 8 (25%) were cGVHD free at long-term follow-up. In all, 5 (29%) of the 17 nonresponsive patients did not show the features of progressive cGVHD and could decrease the amount of immunosuppressive drugs taken. Response after TLI significantly improved 5-year GVHD-related mortality (14% vs 42%, P=0.038) but not OS (58%vs 64% P=0.27). Regarding the promising response rate in this heavily pretreated population, we reasoned that TLI could be an alternative treatment for corticosteroid-refractory cGVHD.
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Affiliation(s)
- R Devillier
- Department of Hematology, Transplantation Program, Institut Paoli Calmettes, Marseille, France
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44
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Abstract
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HCT) is an effective immunotherapy for human cancer. More than 20 000 allo-HCTs are performed each year worldwide, primarily for the treatment of hematologic malignancies. Several technical innovations implemented in allo-HCT over past 2 decades have reduced NRM by 50% and improved overall survival. The allo-HCT practice has changed with the introduction of peripheral blood, cord blood, and haploidentical transplantations and reduced-intensity conditioning, and the patient population is also different regarding age and diagnosis. However, both acute and chronic GVHD remain serious barriers to successful allo-HCT and it is not clear that a major improvement has occurred in our ability to prevent or treat GVHD. Nevertheless, there is an increasing knowledge of the biology and clinical manifestations and the field is getting better organized. These advances will almost certainly lead to major progress in the near future. As the long list of new potential targets and respective drugs are developed, systems need to be developed for rapid testing of them in clinical practice. The current reality is that no single agent has yet to be approved by the US Food and Drug Administration for GVHD prevention or therapy. Although a primary goal of these efforts is to develop better therapies for GVHD, the ultimate goal is to develop treatments that lead to effective prevention or preemption of life-threatening and disabling GVHD manifestations while harnessing the desirable graft-versus-tumor effects.
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45
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Arora M, Pidala J, Cutler CS, Chai X, Kurland B, Jacobsohn DA, Pavletic SZ, Palmer J, Vogelsang G, Jagasia M, Schultz K, Lee SJ. Impact of prior acute GVHD on chronic GVHD outcomes: a chronic graft versus host disease consortium study. Leukemia 2012; 27:1196-201. [PMID: 23047477 DOI: 10.1038/leu.2012.292] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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46
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Ortiz E, Sakano E, Meirelles LR, Vigorito AC, Cintra ML, Paschoal IA, Chone CT. Histological features of the nasal mucosa in hematopoietic stem cell transplantation. Am J Rhinol Allergy 2012; 25:191-195. [PMID: 22186237 DOI: 10.2500/ajra.2011.25.3644] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Immunosuppression is the leading cause of recurrent sinus infections after hematopoietic stem cell transplant (HSCT), with increased incidence of sinusitis in patients with chronic graft versus host disease (GVHD). Histological descriptions of the oral mucosa, lung ciliary epithelium, and intestinal mucosa related to HSCT have been described. However, few have described the nasal mucosa. We, therefore, sought to elucidate the histological and ultrastructural features of the nasal mucosa in patients after HSCT to better understand the pathophysiology of the immune response. METHODS Uncinate processes from 24 HSCT patients and 12 immunocompetent patients were subjected to histological analyses via light and transmission electron microscopy (TEM). RESULTS TEM revealed aberrant cilia structure, altered mitochondria quantity, microvilli, and cytoplasm vacuolization. All HSCT patients with rhinosinusitis had significant loss or absence of cilia (p = 0.018). Apoptotic bodies were increased and Goblet cells decreased in nasal epithelium from patients with chronic GVHD (p = 0.04). CONCLUSION This tissue destruction likely enhances pathogen penetration resulting in recurrent infection.
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Affiliation(s)
- Erica Ortiz
- Department of Otolaryngology, UNICAMP Campinas, Sao Paulo, Brazil.
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47
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Hymes SR, Alousi AM, Cowen EW. Graft-versus-host disease: part II. Management of cutaneous graft-versus-host disease. J Am Acad Dermatol 2012; 66:535.e1-16; quiz 551-2. [PMID: 22421124 DOI: 10.1016/j.jaad.2011.11.961] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 11/18/2011] [Accepted: 11/19/2011] [Indexed: 10/28/2022]
Abstract
Dermatologists are ideally suited to manage the various cutaneous sequelae of graft-versus-host disease (GVHD) outlined in part I of this review. However, the complexity of the patient with GVHD, including comorbidities, potential drug interactions related to polypharmacy, and the lack of evidence-based treatment guidelines, are significant challenges to optimizing patient care. In this section, we will provide an outline for the role of the dermatologist in a multispecialty approach to caring for patients with GVHD.
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Affiliation(s)
- Sharon R Hymes
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas 77030-4009, USA.
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48
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Dignan FL, Amrolia P, Clark A, Cornish J, Jackson G, Mahendra P, Scarisbrick JJ, Taylor PC, Shaw BE, Potter MN. Diagnosis and management of chronic graft-versus-host disease. Br J Haematol 2012; 158:46-61. [DOI: 10.1111/j.1365-2141.2012.09128.x] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
| | - Persis Amrolia
- Department of Bone Marrow Transplantation; Great Ormond Street Hospital; London; UK
| | - Andrew Clark
- Bone Marrow Transplant Unit; Beatson Oncology Centre; Gartnavel Hospital; Glasgow; UK
| | - Jacqueline Cornish
- Department of Haematology; Bristol Royal Hospital for Children; Bristol; UK
| | - Graham Jackson
- Department of Haematology; Freeman Road Hospital; Newcastle; UK
| | - Prem Mahendra
- Department of Haematology; University Hospital Birmingham; Birmingham; UK
| | | | - Peter C. Taylor
- Department of Haematology; Rotherham General Hospital; Rotherham; UK
| | | | - Michael N. Potter
- Section of Haemato-oncology; The Royal Marsden NHS Foundation Trust; London; UK
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Pérez-Simón JA, Afram G, Martino R, Piñana JL, Caballero-Velazquez T, Ringden O, Valcarcel D, Caballero D, Remberger M, de Paz Y, Sierra J, Miguel JS, Hagglund H. Evaluation of prognostic factors among patients with chronic graft-versus-host disease. Haematologica 2012; 97:1187-95. [PMID: 22371184 DOI: 10.3324/haematol.2011.055244] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Chronic graft-versus-host disease (cGVHD) is a major complication after allogeneic stem cell transplantation with an adverse effect on both mortality and morbidity. In 2005, the National Institute of Health proposed new criteria for diagnosis and classification of chronic graft-versus-host disease for clinical trials. New sub-categories were recognized such as late onset acute graft-versus-host disease and overlap syndrome. DESIGN AND METHODS We evaluated the prognostic impact of the new sub-categories as well as the clinical scoring system proposed by the National Institute of Health in a retrospective, multicenter study of 820 patients undergoing allogeneic stem cell transplantation between 2000 and 2006 at 3 different institutions. Patients were retrospectively categorized according to the National Institute of Health criteria from patients' medical histories. RESULTS As far as the new sub-categories are concerned, in univariate analysis diagnosis of overlap syndrome adversely affected the outcome. Also, the number of organs involved for a cut-off value of 4 significantly influenced both cGVHD related mortality and survival. In multivariate analysis, in addition to NIH score, platelet count and performance score at the time of cGVHD diagnosis, plus gut involvement, significantly influenced outcome. These 3 variables allowed us to develop a simple score system which identifies 4 subgroups of patients with 84%, 64%, 43% and 0% overall survival at five years after cGVHD diagnosis (score 0: HR=15.96 (95% CI: 6.85-37.17), P<0.001; score 1: HR=5.47 (95% CI: 2.6-11.5), P<0.001; score 2: HR=2.8 (95% CI: 1.32-5.93), P=0.007). CONCLUSIONS In summary, we have identified a powerful and simple tool to discriminate different subgroups of patients in terms of chronic graft-versus-host disease related mortality and survival.
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Affiliation(s)
- Jose A Pérez-Simón
- Servicio de Hematología, Hospital Universitario de Salamanca, IBSAL, IBMCC (USAL-CSIC), Salamanca, Spain.
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50
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Wolff D, Bertz H, Greinix H, Lawitschka A, Halter J, Holler E. The treatment of chronic graft-versus-host disease: consensus recommendations of experts from Germany, Austria, and Switzerland. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:732-40. [PMID: 22114649 PMCID: PMC3221419 DOI: 10.3238/arztebl.2011.0732] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 03/08/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chronic graft-versus-host disease (cGVHD) is the commonest complication of allogeneic bone marrow and blood stem-cell transplantation, occurring in 50% of all cases and causing late mortality in as many as 25%. There are now about 10 000 patients with cGVHD in Germany, and their number is growing by about 500 each year. cGVHD is a chronic multisystem disease due to impaired tolerance mechanisms. It affects many organs in variable ways, impairing organ function and lowering quality of life. METHODS We present consensus recommendations on the treatment of cGVHD that were developed jointly by the German Working Group on Bone Marrow and Blood Stem-Cell Transplantation, the German and Austrian Societies of Hematology and Oncology, the Swiss Blood Stem-Cell Transplantation Group, and the German-Austrian Working Group on Pediatric Stem-Cell Transplantation. All of the recommendations are based on an evaluation of selected publications. RESULTS Recommendations are given regarding the diagnostic evaluation of cGVHD, first-line treatment (which has a response rate of 30% to 50%), second-line treatment, and topical immunosuppression. Patients with cGVHD should also receive supportive care including anti-infective prophylaxis, vaccinations, hormone replacement, prevention and treatment of osteoporosis, physiotherapy, rehabilitation, and psychosocial assistance. CONCLUSION Patients with cGVHD need multidisciplinary care under the guidance of the transplantation center. The aim of these recommendations is to standardize the treatment of cGVHD and thereby improve patient care.
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Affiliation(s)
- Daniel Wolff
- Abteilung für Hämatologie und Internistische Onkologie, Universität Regensburg, Franz-Josef Strauss Allee 11, 93053 Regensburg, Germany.
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