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Barbarito G, Hiroshima L, Oppizzi L, Saini G, Kristovich K, Klein O, Hosszu K, Boehlke K, Gupta A, Mcavoy D, Shyr D, Boelens JJ, Bertaina A. Model-Based Antithymocyte Globulin in αβhaplo-Hematopoietic Stem Cell Transplantation Facilitates Engraftment, Expedites T Cell Recovery, and Mitigates the Risk of Acute Graft-versus-Host Disease. Transplant Cell Ther 2024:S2666-6367(24)00412-3. [PMID: 38768907 DOI: 10.1016/j.jtct.2024.05.015] [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: 02/08/2024] [Revised: 05/06/2024] [Accepted: 05/13/2024] [Indexed: 05/22/2024]
Abstract
In αβ T-cell/CD19 B-cell depleted hematopoietic stem cell transplantation (αβhaplo-HSCT) recipients, antithymocyte globulin (ATG; Thymoglobulin) is used for preventing graft rejection and graft-versus-host disease (GVHD). The optimal dosing remains to be established, however. Here we present the first comparative analysis of 3 different ATG dosing strategies and their impact on immune reconstitution and GVHD. Our study aimed to evaluate the effects of 3 distinct dosing strategies of ATG on engraftment success, αβ+ and γδ+ T cell immune reconstitution, and the incidence and severity of acute GVHD in recipients of αβhaplo-HSCT. This comparative analysis included 3 cohorts of pediatric patients with malignant (n = 36) or nonmalignant (n = 8) disease. Cohorts 1 and 2 were given fixed ATG doses, whereas cohort 3 received doses via a new nomogram, based on absolute lymphocyte count (ALC) and body weight (BW). Cohort 3 showed a 0% incidence of day 100 grade II-IV acute GVHD, compared to 48% in cohort 1 and 27% in cohort 2. Furthermore, cohort 3 (the ALC/BW-based cohort) had a significant increase in CD4+ and CD8+ naïve T cells by day 90 (P = .04 and .03, respectively). Additionally, we found that the reconstitution and maturation of γδ+ T cells post-HSCT was not impacted across all 3 cohorts. Cumulative ATG exposure in all cohorts was lower than previously reported in T cell-replete settings, with a lower pre-HSCT exposure (<40 AU*day/mL) correlating with engraftment failure (P = .007). Conversely, a post-HSCT ATG exposure of 10 to 15 AU*day/mL was optimal for improving day 100 CD4+ (P = .058) and CD8+ (P = .03) immune reconstitution without increasing the risk of relapse or nonrelapse mortality. This study represents the first comparative analysis of ATG exposure in αβhaplo-HSCT recipients. Our findings indicate that (1) a 1- to 2-fold ATG to ATLG bioequivalence is more effective than previously established standards, and (2) ATG exposure post-HSCT does not adversely affect γδ+ T cell immune reconstitution. Furthermore, a model-based ATG dosing strategy effectively reduces graft rejection and day 100 acute GVHD while also promoting early CD4+/CD8+ immune reconstitution. These insights suggest that further optimization, including more distal administration of higher ATG doses within an ALC/BW-based strategy, will yield even greater improvements in outcomes.
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Affiliation(s)
- Giulia Barbarito
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Lyndsie Hiroshima
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Linda Oppizzi
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Gopin Saini
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Karen Kristovich
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Orly Klein
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Kinga Hosszu
- MSK Kids, Transplantation and Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York; Immune Discovery and Monitoring Service, Department of Pediatrics and Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kylan Boehlke
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Aditi Gupta
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Devin Mcavoy
- MSK Kids, Transplantation and Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York; Immune Discovery and Monitoring Service, Department of Pediatrics and Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David Shyr
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Jaap Jan Boelens
- MSK Kids, Transplantation and Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York; Immune Discovery and Monitoring Service, Department of Pediatrics and Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alice Bertaina
- Division of Hematology, Oncology, Stem Cell Transplantation, and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.
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Jamy O, Zeiser R, Chen YB. Novel developments in the prophylaxis and treatment of acute GVHD. Blood 2023; 142:1037-1046. [PMID: 37471585 DOI: 10.1182/blood.2023020073] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/27/2023] [Accepted: 07/13/2023] [Indexed: 07/22/2023] Open
Abstract
Acute graft-versus-host disease (aGVHD) is a major life-threatening complication after allogeneic hematopoietic cell transplant. Traditional standard prophylaxis for aGVHD has included a calcineurin inhibitor plus an antimetabolite, whereas treatment has relied mainly on corticosteroids, followed by multiple nonstandard second-line options. In the past decade, this basic framework has been reshaped by approval of antithymocyte globulin products, the emergence of posttransplant cyclophosphamide, and recent pivotal trials studying abatacept and vedolizumab for GVHD prophylaxis, whereas ruxolitinib was approved for corticosteroid-refractory aGVHD treatment. Because of this progress, routine acute GVHD prophylaxis and treatment practices are starting to shift, and results of ongoing trials are eagerly awaited. Here, we review recent developments in aGVHD prevention and therapy, along with ongoing and future planned clinical trials in this space, outlining what future goals should be and the limitations of current clinical trial designs and end points.
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Affiliation(s)
- Omer Jamy
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Robert Zeiser
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, Albert Ludwigs University, Freiburg, Germany
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cell Therapy Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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3
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Liu X, Huang C, Cao X, Yang X, Li S, Jiang S, Lin W, Liu L, Ding X, Tang X, Miao L. A fully validated flow cytometry method to quantitatively analyze active rATG in human serum and its application in pharmacokinetic study for therapeutic drug monitoring. J Pharm Biomed Anal 2023; 234:115483. [PMID: 37454500 DOI: 10.1016/j.jpba.2023.115483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 05/14/2023] [Accepted: 05/23/2023] [Indexed: 07/18/2023]
Abstract
Rabbit anti-thymocyte globulin (rATG) has been widely used to prevent graft-versus-host disease (GvHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). The therapeutic window of rATG is narrow, and it may increase the risk of relapse, viral reactivation, delayed immune reconstitution and GvHD when overexposed or underexposed. Therefore, a reliable method for detecting the rATG concentration in human serum by flow cytometry was established and fully validated for therapeutic drug monitoring. In this method, Jurkat T cells were used to capture active rATG in human serum, and PE-labeled donkey anti-rabbit IgG was used as a secondary antibody. The method showed good specificity, selectivity and excellent linearity at concentration of 0.00300-20.0 AU/mL. The intra- and interday precision values were all within 20% at four concentration levels for the analyte. The stock solutions of rATG showed no significant degradation after storage at ambient temperature for 8 h and at - 80 °C for 481 days. No significant degradation of rATG in serum was observed at ambient temperature for 6 h, during six freezethaw cycles and at - 80 °C for at least 373 days. This method was fully validated and successfully applied to monitor active rATG concentration in serum of patients with haploid-identical hematopoietic stem cell transplantation.
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Affiliation(s)
- Xiaoxue Liu
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chenrong Huang
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xuanqi Cao
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Jiangsu, China
| | - Xiao Yang
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Jiangsu, China
| | - Sijia Li
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | | | - Wang Lin
- Suzhou Vocational Health College, Suzhou, China
| | - Linsheng Liu
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoliang Ding
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaowen Tang
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Jiangsu, China.
| | - Liyan Miao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China; Institute for Interdisciplinary Drug Research and Translational Sciences, Soochow University, Suzhou, China; College of Pharmaceutical Sciences, Soochow University, Suzhou, China.
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4
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Khanolkar RA, Tripathi G, Dharmani-Khan P, Dabas R, Kinzel M, Kalra A, Puckrin R, Jimenez-Zepeda V, Jamani K, Duggan PR, Chaudhry A, Bryant A, Stewart DA, Khan FM, Storek J. Incomplete chimerism following myeloablative and anti-thymocyte globulin-conditioned hematopoietic cell transplantation is a risk factor for relapse and chronic graft-versus-host disease. Cytotherapy 2022; 24:1225-1231. [PMID: 36057497 DOI: 10.1016/j.jcyt.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/16/2022] [Accepted: 07/31/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND AIMS The value of routine chimerism determination after myeloablative hematopoietic cell transplantation (HCT) is unclear, particularly in the setting of anti-thymocyte globulin (ATG)-based graft-versus-host disease (GVHD) prophylaxis. METHODS Blood samples were collected at 3 months post-HCT from 558 patients who received myeloablative conditioning and ATG-based GVHD prophylaxis. Chimerism was assessed using multiplex polymerase chain reaction of short tandem repeats in sorted T cells (CD3+) and leukemia lineage cells (CD13+CD33+ for myeloid malignancies and CD19+ for B-lymphoid malignancies). ATG exposure was determined using a flow cytometry-based assay. The primary outcomes of interest were relapse and chronic GVHD (cGVHD). RESULTS Incomplete (<95%) T-cell chimerism and leukemia lineage chimerism were present in 17% and 4% of patients, respectively. Patients with incomplete T-cell chimerism had a significantly greater incidence of relapse (36% versus 22%, subhazard ratio [SHR] = 2.03, P = 0.001) and lower incidence of cGVHD (8% versus 25%, SHR = 0.29, P < 0.001) compared with patients with complete chimerism. In multivariate modeling, patients with high post-transplant ATG area under the curve and any cytomegalovirus (CMV) serostatus other than donor/recipient seropositivity (non-D+R+) had an increased likelihood of incomplete T-cell chimerism. Patients with incomplete leukemia lineage chimerism had a significantly greater incidence of relapse (50% versus 23%, SHR = 2.70, P = 0.011) and, surprisingly, a greater incidence of cGVHD (45% versus 20%, SHR = 2.64, P = 0.003). CONCLUSIONS High post-transplant ATG exposure and non-D+R+ CMV serostatus predispose patients to incomplete T-cell chimerism, which is associated with an increased risk of relapse. The increased risk of cGVHD with incomplete B-cell/myeloid chimerism is a novel finding that suggests an important role for recipient antigen-presenting cells in cGVHD pathogenesis.
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Affiliation(s)
- Rutvij A Khanolkar
- Department of Medicine, University of Calgary, Calgary, Canada, T2N 4N1.
| | - Gaurav Tripathi
- Department of Laboratory Medicine and Pathology, University of Calgary, Calgary, Canada, T2N 4N1; Alberta Precision Laboratories, Calgary, Canada, T2N 4N1
| | - Poonam Dharmani-Khan
- Department of Laboratory Medicine and Pathology, University of Calgary, Calgary, Canada, T2N 4N1; Alberta Precision Laboratories, Calgary, Canada, T2N 4N1
| | - Rosy Dabas
- Department of Medicine, University of Calgary, Calgary, Canada, T2N 4N1
| | - Megan Kinzel
- Department of Medicine, University of Calgary, Calgary, Canada, T2N 4N1
| | - Amit Kalra
- Department of Medicine, University of Calgary, Calgary, Canada, T2N 4N1
| | - Robert Puckrin
- Department of Medicine, University of Calgary, Calgary, Canada, T2N 4N1; Alberta Health Services, Calgary, Canada, T2N 4N1
| | - Victor Jimenez-Zepeda
- Department of Medicine, University of Calgary, Calgary, Canada, T2N 4N1; Alberta Health Services, Calgary, Canada, T2N 4N1
| | - Kareem Jamani
- Department of Medicine, University of Calgary, Calgary, Canada, T2N 4N1; Alberta Health Services, Calgary, Canada, T2N 4N1
| | - Peter R Duggan
- Department of Medicine, University of Calgary, Calgary, Canada, T2N 4N1; Alberta Health Services, Calgary, Canada, T2N 4N1
| | - Ahsan Chaudhry
- Department of Medicine, University of Calgary, Calgary, Canada, T2N 4N1; Alberta Health Services, Calgary, Canada, T2N 4N1
| | - Adam Bryant
- Department of Medicine, University of Calgary, Calgary, Canada, T2N 4N1; Alberta Health Services, Calgary, Canada, T2N 4N1
| | - Douglas A Stewart
- Department of Medicine, University of Calgary, Calgary, Canada, T2N 4N1; Alberta Health Services, Calgary, Canada, T2N 4N1
| | - Faisal M Khan
- Department of Laboratory Medicine and Pathology, University of Calgary, Calgary, Canada, T2N 4N1; Alberta Precision Laboratories, Calgary, Canada, T2N 4N1
| | - Jan Storek
- Department of Medicine, University of Calgary, Calgary, Canada, T2N 4N1; Alberta Health Services, Calgary, Canada, T2N 4N1
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5
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Wang H, Zhao Y, Fang S, Wang L, Peng B, Yang J, Wang N, Du J, Li F, Jin X, Luan S, Wu X, Dou L, Liu D. Optimal Active Anti-Thymocyte Globulin Exposure Associated with Minimum Risk of Virus Reactivation and Comparable Acute Graft-Versus-Host Disease Under Adult Myeloablative Haploidentical Peripheral Blood Stem Cell Transplantation. Transplant Cell Ther 2022; 28:332.e1-332.e10. [PMID: 35314377 DOI: 10.1016/j.jtct.2022.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 03/13/2022] [Accepted: 03/15/2022] [Indexed: 11/15/2022]
Abstract
Anti-thymocyte globulin (ATG) is often included in the conditioning regimen to prevent graft-versus-host disease (GVHD) in allogeneic hematopoietic cell transplantation (allo-HCT). However, the risk of virus reactivation increases significantly. We conducted a single-center prospective study to identify the optimal ATG exposure that ensures engraftment, effectively prevents acute GVHD, and reduces the risk of virus reactivation without increasing relapse of malignant diseases in haploidentical peripheral blood stem cell transplantation (haplo-PBSCT). From September 2018 to June 2020, 106 patients (median age, 32 years) with malignant hematological diseases who received haplo-PBSCT for the first time were enrolled. All patients received 10 mg/kg rabbit ATG (thymoglobulin) divided for 4 days (days -5 to -2). Pre-transplant, post-transplant, and total areas under the concentration-time curve (AUCs) of active ATG were calculated. Total AUC of active ATG was shown to be the best predictor for virus reactivation and acute GVHD of grades II to IV or grades III and IV. The optimal total AUC range of active ATG was 100 to 148.5 UE/mL/day. The median time was 14 versus 13 days (P = .184) for myeloid engraftment and 13 versus 13 days (P = .263) for platelet engraftment in the optimal and non-optimal AUC groups, respectively. The optimal AUC group showed a lower cumulative incidence of cytomegalovirus (CMV) reactivation and persistent CMV viremia than the non-optimal AUC group: 60.6% (95% confidence interval [CI], 48.3%-73.1%) versus 77.1% (95% CI, 64.5%-87.7%; P = .016) and 31.5% (95% CI, 21.2%-45.3%) versus 56.3% (95% CI, 42.9%-70.4%; P = .007), respectively. The cumulative incidence of persistent Epstein-Barr virus (EBV) viremia in the optimal AUC group was significantly lower than the non-optimal total AUC group: 33.1% (95% CI, 22.5%-46.8%) versus 52.6% (95% CI, 39.3%-67.2%; P = .048). However, there was no difference in EBV reactivation (P = .752). Similar outcomes were observed for grade II to IV and grade III and IV acute GVHD between the two groups: 48.6% (95% CI, 36.8%-62.0%) versus 37.0% (95% CI, 24.8%-52.5%; P = .113) and 10.4% (95% CI, 4.8%-21.7%) versus 4.2% (95% CI, 1.0%-15.6%; P = .234, respectively. Relapse, non-relapse mortality, and disease-free survival demonstrated no significant differences between the two groups. But, overall survival at 2 years tended to increase in the optimal AUC group: 75.7% (95% CI, 62.4%-84.8%) versus 57.8% (95% CI, 42.4%-70.4%; P = .061). These data support an optimal active ATG exposure of 110 to 148.5 UE/mL/day in haplo-PBSCT. Individualized dosing of ATG in allo-HCT might reduce the risk of virus reactivation and effectively prevent acute GVHD simultaneously.
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Affiliation(s)
- HaiTao Wang
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China; Chinese PLA General Hospital, Beijing, China
| | | | - Shu Fang
- Chinese PLA General Hospital, Beijing, China; School of Medicine, Nankai University, Tianjin, China
| | - LiLi Wang
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Bo Peng
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | | | - Nan Wang
- Chinese PLA General Hospital, Beijing, China
| | - JiShan Du
- Chinese PLA General Hospital, Beijing, China
| | - Fei Li
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - XiangShu Jin
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - SongHua Luan
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - XiaoXiong Wu
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - LiPing Dou
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China; Chinese PLA General Hospital, Beijing, China; The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.
| | - DaiHong Liu
- Department of Hematology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China; Chinese PLA General Hospital, Beijing, China.
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6
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Khanolkar RA, Faridi RM, Kinzel M, Jamani K, Savoie ML, Shafey M, Khan FM, Storek J. Impact of FLT3 internal tandem duplication and NPM1 mutations in acute myeloid leukemia treated with allogeneic hematopoietic cell transplantation. Cytotherapy 2021; 24:413-420. [PMID: 34863627 DOI: 10.1016/j.jcyt.2021.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/06/2021] [Accepted: 10/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND AIMS The internal tandem duplication of FLT3 (FLT3ITD) and NPM1 mutations (NPM1mut) are well-established prognostic factors in cytogenetically intermediate-risk acute myeloid leukemia (AML) when treated with chemotherapy alone. However, their prognostic value in the setting of allogeneic hematopoietic cell transplantation (HCT) is controversial. METHODS FLT3 and NPM1 mutational status was determined at diagnosis using single-gene polymerase chain reaction or next-generation sequencing in 247 adult patients with cytogenetically intermediate-risk AML who underwent myeloablative HCT. Multivariate Fine-Gray and Cox regression was used to analyze the cumulative incidence of relapse (CIR), relapse-free survival (RFS) and overall survival (OS). RESULTS FLT3ITD and NPM1mut were present in 74 of 247 (30%) and 79 of 247 (32%) patients, respectively. There was no significant difference between patients without a FLT3ITD or NPM1mut (FLT3NONITD/NPM1WT) and patients with a FLT3ITD mutation alone (FLT3ITD/NPM1WT) with regard to CIR (P = 0.60), RFS (P = 0.91) or OS (P = 0.66). Similarly, there was no significant difference between FLT3NONITD/NPM1WT and FLT3NONITD/NPM1mut patients with regard to CIR (P = 0.70), RFS (P = 0.75) or OS (P = 0.95). The presence of a concurrent mutation in NPM1 did not appear to modify the impact of having a FLT3ITD mutation. CONCLUSIONS In contrast to chemotherapy-only treatment, FLT3 and NPM1 mutational status does not appear to predict outcomes in patients with cytogenetically intermediate-risk AML following HCT. These results suggest that HCT may ameliorate the poor prognostic effect of FLT3ITD mutation and that HCT should be considered over chemotherapy-only treatment in FLT3ITD-mutated AML.
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Affiliation(s)
| | - Rehan M Faridi
- Cumming School of Medicine, University of Calgary, Calgary, Canada; Alberta Precision Laboratories, Calgary, Canada
| | - Megan Kinzel
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Kareem Jamani
- Cumming School of Medicine, University of Calgary, Calgary, Canada; Alberta Health Services, Calgary, Canada
| | - Mary L Savoie
- Cumming School of Medicine, University of Calgary, Calgary, Canada; Alberta Health Services, Calgary, Canada
| | - Mona Shafey
- Cumming School of Medicine, University of Calgary, Calgary, Canada; Alberta Health Services, Calgary, Canada
| | - Faisal M Khan
- Cumming School of Medicine, University of Calgary, Calgary, Canada; Alberta Precision Laboratories, Calgary, Canada
| | - Jan Storek
- Cumming School of Medicine, University of Calgary, Calgary, Canada; Alberta Health Services, Calgary, Canada
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7
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Kinzel M, Dowhan M, Kalra A, Williamson TS, Dabas R, Jamani K, Chaudhry A, Shafey M, Jimenez-Zepeda V, Duggan P, Daly A, Dharmani-Khan P, Khan F, Storek J. Risk Factors for the Incidence of and the Mortality due to Post-Transplant Lymphoproliferative Disorder after Hematopoietic Cell Transplantation. Transplant Cell Ther 2021; 28:53.e1-53.e10. [PMID: 34607072 DOI: 10.1016/j.jtct.2021.09.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/17/2021] [Accepted: 09/26/2021] [Indexed: 11/17/2022]
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a potentially serious complication that occurs following hematopoietic cell transplantation (HCT), in which B cells transformed by Epstein-Barr virus (EBV) proliferate uncontrollably. It is unknown whether risk factors for the incidence of PTLD are identical to those for mortality due to PTLD, a clinically more important outcome. We sought to determine the risk factors influencing the incidence of PTLD and those influencing mortality due to PTLD in a cohort of 1184 allogenic HCT recipients. All patients were predisposed to PTLD, because their graft-versus-host disease (GVHD) prophylaxis included antithymocyte globulin. The overall PTLD incidence was 9.0%, and mortality due to PTLD was 1.1%. In multivariate analysis, risk factors for PTLD incidence include donor+/recipient- (D+/R-) EBV serostatus (subhazard ratio [SHR], 3.3; P = .002), use of a donor other than an HLA-matched sibling donor (non-MSD) (SHR, 1.7; P = .029), receipt of total body irradiation (TBI; SHR, 3.3; P = .008), and the absence of GVHD (SHR, 3.3; P < .001). The sole risk factor for mortality due to PTLD among all patients was D+/R- serostatus (SHR, 5.8; P = .022). Risk factors for mortality due to PTLD among patients who developed PTLD were use of a bone marrow (BM) graft (compared with peripheral blood stem cells [PBSCs]; SHR, 22.8; P < .001) and extralymphatic involvement (SHR, 14.6; P < .001). Interestingly, whereas the absence of GVHD was a risk factor for PTLD incidence, there was a trend toward the presence of GVHD as a risk factor for PTLD mortality (SHR, 4.2; P = .093). Likewise, whereas use of a BM graft was a risk factor for PTLD mortality, there was a trend toward use of a PBSC graft as a risk factor for PTLD incidence (SHR, 0.44; P = .179). Some risk factors for the incidence of PTLD are identical to the risk factors for mortality due to PTLD (ie, D+/R- serostatus), whereas other risk factors are disparate. Specifically, TBI was identified as a risk factor for PTLD incidence but not for PTLD mortality; the absence of GVHD was a risk factor for PTLD incidence, whereas the presence of GVHD was possibly a risk factor for PTLD mortality; and receipt of a PBSC graft was possibly a risk factor for PTLD incidence, whereas receipt of a BM graft was a risk factor for PTLD mortality.
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Affiliation(s)
- Megan Kinzel
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | | | - Amit Kalra
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tyler S Williamson
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rosy Dabas
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kareem Jamani
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada
| | - Ahsan Chaudhry
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada
| | - Mona Shafey
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada
| | - Victor Jimenez-Zepeda
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada
| | - Peter Duggan
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada
| | - Andrew Daly
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada
| | - Poonam Dharmani-Khan
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada; Alberta Precision Laboratories, Calgary, Alberta, Canada
| | - Faisal Khan
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada; Alberta Precision Laboratories, Calgary, Alberta, Canada
| | - Jan Storek
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada
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Khanolkar RA, Kalra A, Kinzel M, Pratt LM, Dharmani-Khan P, Chaudhry A, Williamson TS, Daly A, Morris DG, Khan FM, Storek J. A biomarker-guided, prospective, phase 2 trial of pre-emptive graft-versus-host disease therapy using anti-thymocyte globulin. Cytotherapy 2021; 23:1007-1016. [PMID: 34373186 DOI: 10.1016/j.jcyt.2021.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/07/2021] [Accepted: 06/05/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND AIMS Intensified immunosuppressive prophylaxis for graft-versus-host disease (GVHD) may be toxic and therefore warranted only in patients at high risk of developing GVHD. In patients who underwent allogeneic hematopoietic cell transplant at the authors' center, high serum soluble IL-2 receptor alpha (sIL-2Rα) and low IL-15 levels on day 7 post-transplant were found to predict a high risk of developing clinically significant GVHD (sGVHD), defined as grade 2-4 acute GVHD or moderate to severe chronic GVHD. METHODS This was a prospective, phase 2 trial in which high-risk patients (serum sIL-2Rα >4500 ng/L or IL-15 <31 ng/L) received rabbit anti-thymocyte globulin (ATG) 3 mg/kg on day 8 post-transplant. Controls consisted of patients who had their sIL-2Rα/IL-15 levels measured but did not participate in the trial. A total of 68 trial patients and 143 controls were accrued to this study. The primary endpoint was incidence of sGVHD. RESULTS There was a reduction in sGVHD in high-risk trial patients (received day 8 ATG) compared with high-risk controls (did not receive day 8 ATG) (sub-hazard ratio [SHR] = 0.48, P < 0.05). There was no significant difference between the groups in overall survival or relapse; however, there was a greater incidence of non-GVHD-associated non-relapse mortality in high-risk trial patients (SHR = 3.73, P < 0.05), mostly related to infections. This may be due in part to the biomarkers ineffectively stratifying GVHD risk. CONCLUSIONS Pre-emptive ATG therapy is both feasible and effective at reducing sGVHD without increasing relapse. Further mitigation strategies are needed to reduce the risk of infection associated with intensified GVHD prophylaxis. This study was registered at ClinicalTrials.gov (NCT01994824).
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Affiliation(s)
| | - Amit Kalra
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Megan Kinzel
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Laura M Pratt
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Poonam Dharmani-Khan
- Cumming School of Medicine, University of Calgary, Calgary, Canada; Alberta Health Services, Calgary, Canada; Alberta Precision Laboratories, Calgary, Canada
| | - Ahsan Chaudhry
- Cumming School of Medicine, University of Calgary, Calgary, Canada; Alberta Health Services, Calgary, Canada
| | | | - Andrew Daly
- Cumming School of Medicine, University of Calgary, Calgary, Canada; Alberta Health Services, Calgary, Canada
| | - Don G Morris
- Cumming School of Medicine, University of Calgary, Calgary, Canada; Alberta Health Services, Calgary, Canada
| | - Faisal M Khan
- Cumming School of Medicine, University of Calgary, Calgary, Canada; Alberta Health Services, Calgary, Canada; Alberta Precision Laboratories, Calgary, Canada
| | - Jan Storek
- Cumming School of Medicine, University of Calgary, Calgary, Canada; Alberta Health Services, Calgary, Canada
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Turki AT, Klisanin V, Bayraktar E, Kordelas L, Trenschel R, Ottinger H, Steckel NK, Tsachakis-Mück N, Leserer S, Ditschkowski M, Liebregts T, Koldehoff M, Fleischhauer K, Beelen DW. Optimizing anti-T-lymphocyte globulin dosing to improve long-term outcome after unrelated hematopoietic cell transplantation for hematologic malignancies. Am J Transplant 2020; 20:677-688. [PMID: 31597002 DOI: 10.1111/ajt.15642] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/06/2019] [Accepted: 09/25/2019] [Indexed: 01/25/2023]
Abstract
Prophylaxis of graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (HCT) remains challenging. Because prospective randomized trials of in-vivo T cell depletion using anti-T-lymphocyte globulin (ATLG) in addition to a calcineurin inhibitor and methotrexate (MTX) led to conflicting outcome results, we evaluated the impact of ATLG on clinical outcome, lymphocyte- and immune reconstitution survival models. In total, 1500 consecutive patients with hematologic malignancies received matched unrelated donor (MUD) HCT with cyclosporin and MTX (N = 723, 48%) or with additional ATLG (N = 777, 52%). In the ATLG cohort, grades III-IV acute (12% vs 23%) and extensive chronic GVHD (18% vs 34%) incidences were significantly reduced (P < .0001). Nonrelapse mortality (27% vs 45%) and relapse (30% vs 22%) differed also significantly. Event-free and overall survival estimates at 10 years were 44% and 51% with ATLG and 33% and 35% without ATLG (P < .002 and <.0001). A dose-dependent ATLG effect on lymphocyte- and neutrophil reconstitution was observed. At ATLG exposure, lymphocyte counts and survival associated through a logarithmically increasing function. In this survival model, the lymphocyte count optimum range at exposure was between 0.4 and 1.45/nL (P = .001). This study supports additional ATLG immune prophylaxis and is the first study to associate optimal lymphocyte counts with survival after MUD-HCT.
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Affiliation(s)
- Amin T Turki
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany.,Institute for Experimental Cellular Therapy, University Hospital Essen, Essen, Germany
| | - Vesna Klisanin
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Evren Bayraktar
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany.,Chair of Applied Mathematics and Numerics, TU Dortmund University, Dortmund, Germany
| | - Lambros Kordelas
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Rudolf Trenschel
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Hellmut Ottinger
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Nina K Steckel
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Nikolaos Tsachakis-Mück
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Saskia Leserer
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Markus Ditschkowski
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Tobias Liebregts
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | - Michael Koldehoff
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
| | | | - Dietrich W Beelen
- Department of Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
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Dabas R, Khan PD, Modi M, Khan FM, Storek J. More acute lymphoid leukemia than acute myeloid leukemia blasts are killed by rabbit antithymocyte globulin. Cytotherapy 2019; 21:1161-1165. [DOI: 10.1016/j.jcyt.2019.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/24/2019] [Accepted: 08/23/2019] [Indexed: 12/14/2022]
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11
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Jamani K, Kangarloo SB, Storek J. Reply to: Pharmacologic Considerations in Antithymocyte Globulin Exposure Calculation. Biol Blood Marrow Transplant 2019; 25:e216-e217. [DOI: 10.1016/j.bbmt.2019.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 04/01/2019] [Indexed: 11/29/2022]
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