NCCN Guidelines® Insights: Hematopoietic Cell Transplantation, Version 3.2022

N-acetyl-L-cysteine promoted hematopoietic recovery in patients with acute myeloid leukemia after complete remission--A pilot study

Chemotherapy is a cornerstone treatment for acute leukemia (AL), but it often results in bone marrow (BM) failure, leading to infections, anemia, and bleeding, which significantly impact patient survival. Endothelial progenitor cells (EPCs) are critical elements of the BM microenvironment and are essential for hematopoiesis. Our previous research using in vitro and AML mouse models indicated that BM EPC dysfunction, characterized by impaired angiogenesis and elevated reactive oxygen species (ROS) levels in AML patients, could be partially reversed after complete remission (CR) and further improved with N-acetyl-L-cysteine (NAC) treatment. This pilot cohort study (NCT06024031, www.clinicaltrials.gov) evaluated the effects of NAC on hematopoietic recovery in 30 newly diagnosed AML patients after induction chemotherapy, compared to a propensity-matched control group of 60 patients. Patients received oral NAC (400 mg, three times daily) for 28 days post-chemotherapy alongside standard supportive care. NAC treatment did not affect CR rates (90% vs. 80%, P=0.23), but significantly shortened platelet recovery time (19 vs. 22 days, P=0.0001) among CR patients. NAC improved EPC percentages, reduced ROS, and enhanced EPC hematopoiesis-supporting functions in patients who achieved CR. NAC was safe and effective in promoting normal hematopoiesis recovery in AML patients in CR following chemotherapy.

Impact of haematopoietic stem cell transplantation for benign and malignant haematologic and non-haematologic disorders on fertility: a systematic review and meta-analysis

Haematopoietic stem cell transplantation (HSCT) exposes patients to long-term complications like gonadal dysfunction and infertility. The European Society for Blood and Marrow Transplantation advised in 2015 that fertility preservation should be considered for children and adolescents requiring HSCT. This systematic review and meta-analysis is part of the FertiTOX project, which aims to close the data gap regarding the gonadotoxicity of anticancer therapies to provide more accurate advice regarding fertility preservation. This review were conducted in November 2023, covering articles since 2000. In total, 56 studies were included in the meta-analysis, comprising 1853 female malignant, 241 female benign, 1871 male malignant, and 226 male benign cases. The analysis, using a random-effects model, estimated the prevalence and its 95% confidence interval, revealing that overall infertility exceeded 30% in all groups. Female malignant cases had a prevalence of 65% (95% CI: 0.58-0.71), while in females with benign disease, it was 61% (CI: 0.48-0.73). Males with malignant disease had a prevalence of 41% (CI: 0.32-0.51), and those with benign disease had 31% (CI: 0.19-0.46). The > 30% overall prevalence indicates a clinical need for fertility preservation counseling in both genders undergoing HSCT. Further prospective studies are necessary to address HSCT's individual impact on gonadal function. This systematic review is registered with the International Prospective Register of Systematic Reviews (PROSPERO) under CRD42023486928.

Serum of interleukin-6 and procalcitonin as early diagnostic markers for the identification of poor hematopoietic reconstitution following allogeneic hematopoietic stem cell transplantation

BACKGROUND

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains a potential curative option for the treatment of various hematologic diseases. Poor hematopoietic reconstitution (PHR) is a common and serious complicating disease after allo-HSCT. The authors conducted a case-control study to determine the potential value of serum interleukin (IL)-6 and procalcitonin (PCT) levels during the peritransplantation period in predicting PHR after allo-HSCT.

METHODS

The concentrations of IL-6 and PCT were compared, and a receiver operating characteristic (ROC) curve was constructed to determine the optimal cutoff values. Sensitivity and specificity were subsequently calculated.

RESULTS

In our study, the levels of IL-6 and PCT were significantly elevated in patients with PHR compared to those in good hematopoietic restitution (GHR). The logistic regression analysis revealed that IL-6 and PCT posttransplantation were significant predictors of PHR after allo-HSCT. The calculation of the area under the curve (AUC) of IL-6 and PCT in predicting PHR was 0.805 and 0.724, respectively. The optimal cutoff values for PHR were 41.8 pg/mL and 0.404 ng/mL, with a sensitivity of 73.7% and 52.6% and a specificity of 81% and 85.7%, respectively. The AUC-ROC of IL-6 combined with PCT for predicting the PHR was 0.801, with a sensitivity of 75.4% and a specificity of 77.8%.

CONCLUSION

IL-6 and PCT can serve as potential biomarkers to predict PHR after allo-HSCT.

Higher risk of GVHD but better long-term survival: impact of p-ALG versus r-ATG in high-risk hematological malignancy patients following MSDT

PURPOSE

Disease relapse and graft-versus-host disease (GVHD) represent significant clinical challenges for high-risk hematological malignancies (HM) patients undergoing HLA-matched sibling donor transplantation (MSDT). How to balance the effect of GVHD and Graft versus leukemia (GVL) remains unclear for high-risk HM patients receiving MSDT. Here, we conducted a retrospective study to compare the efficacy in preventing disease relapse of 2 lymphocyte-depleting antibodies (r-ATG vs p-ALG) as the GVHD prevention strategy.

METHOD

A retrospective analysis was conducted on 48 patients with high-risk HM patients who underwent MSDT at our center from January 2019 to January 2024. Among them, 22 patients were in the p-ALG group (45mg/kg), and 26 patients were in the r-ATG group (3.5-4.5mg/kg). The primary end point of this study was disease relapse.

RESULTS

We found that the p-ALG group had a higher 3-year cumulative incidence of chronic GVHD than the r-ATG group (64.4% ± 13.6% vs. 28.8% ± 9.7%, P = 0.016). There was no significant difference in total acute GVHD (aGVHD) (54.5% ± 11% vs.26.9% ± 8.9%, P = 0.81) and 3-year extensive cGVHD (20.3% ± 11.3% vs. 7.9% ± 5.5%, P = 0.27) between the 2 groups. In terms of patient prognosis, the p-ALG group showed a higher 3-year overall survival rate compared to the r-ATG group (100% vs. 75.5% ± 8.8%, P = 0.039). The 3-year disease-free survival (DFS) rate was significantly higher in the p-ALG group compared to the r-ATG group (95.5% ± 4.4% versus 61% ± 10.6%, P = 0.046). Furthermore, the p-ALG group exhibited a longer duration of disease remission after transplantation, as evidenced by a lower 3-year cumulative incidence of post-transplantation Minimal Residual Disease positivity (post-MRD+) compared to the r-ATG group (4.5% ± 4.4% versus 40.5% ± 11%, P = 0.022).

CONCLUSION

In comparison to r-ATG, the administration of low-dose p-ALG (45mg/kg) in high-risk HM patients receiving MSDT is associated with an increased incidence of GVHD but results in a more favorable survival prognosis.

Role of Cardio-Oncology Rehabilitation in Hematopoietic Stem Cell Transplantation and Chimeric Antigen Receptor T-Cell (CAR-T) Therapy

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) and chimeric antigen receptor T-cell (CAR-T) therapy often lead to severe sarcopenia and cachexia during treatment, making it difficult to maintain exercise tolerance. Consequently, "cancer rehabilitation" programs have been implemented to sustain and improve physical activity and motor function. Hematologic malignancies often involve the use of cardiotoxic drugs. Moreover, graft-vs.-host disease associated with allo-HSCT and the cytokine release syndrome in CAR-T therapy elevate the risk of cardiovascular complications. Thus, establishing "cardio-oncology rehabilitation" (CORE) is essential to support cancer patients and survivors. CORE is expected to enhance quality of life, improve cardiopulmonary function, reduce cancer and cardiac events recurrence, and prolong survival. Our institution conducts cardiopulmonary exercise testing before HSCT and CAR-T therapy, with exercise prescriptions based on heart rate at the anaerobic threshold and guidance on resistance exercises. This report discusses current trends in CORE for patients undergoing HSCT and CAR-T therapy, along with future challenges.

Paediatric Acute Lymphoblastic Leukaemia: A Narrative Review of Current Knowledge and Advancements

PURPOSE OF REVIEW

This review aims to provide an update on current knowledge regarding paediatric acute lymphoblastic leukaemia (ALL), focusing on recent advancements in diagnosis and treatment, as well as future directions in the field.

RECENT FINDINGS

ALL is the most frequently diagnosed paediatric malignancy, with advances leading to a 90% survival rate. The heterogeneity of childhood ALL requires a precise diagnostic algorithm incorporating morphological, immunophenotypic, and cytogenetic analyses. Research is exploring next-generation sequencing and artificial intelligence-aided techniques for future diagnostic approaches. Despite these advancements, global disparities in healthcare access hinder prompt diagnosis and management. The pathophysiology of ALL involves chromosomal and genetic alterations which disrupt cell-cycle regulation and result in uncontrolled lymphoblast proliferation. Environmental factors also contribute to leukaemogenesis. Risk-stratification based on genetic subtypes has significant implications for risk-based therapy. Chemotherapy is administered in three phases: induction, consolidation, and maintenance, with prophylactic intrathecal chemotherapy considered essential. For high-risk, refractory, or relapsed ALL, haematopoietic stem cell transplantation and novel therapies such as tyrosine kinase inhibitors, chimeric antigen receptor T-cell therapy, and blinatumomab immunotherapy, have improved outcomes. Ongoing clinical trials aim to further improve treatment efficacy, reduce toxicity, and increase survival. Although prevention strategies for ALL exist at three levels, the supporting evidence remains limited, highlighting a need for further research. Continued research and clinical trials are essential to addressing the gaps treatment efficacy and prevention strategies. Efforts to improve global healthcare access and integrate novel diagnostic and therapeutic approaches are crucial for advancing outcomes for paediatric patients with ALL.

Cellular therapies in older adults with hematological malignancies: A case-based, state-of-the-art review

Cellular therapies, including autologous stem cell transplant (ASCT), allogeneic hematopoietic cell transplantation (alloHCT), and chimeric antigen receptor- (CAR-) T cell therapies are essential treatment modalities for many hematological malignancies. Although their use in older adults has substantially increased within the past decades, cellular therapies represent intensive treatment approaches that exclude a large percentage of older adults due to comorbidities and frailty. Under- and overtreatment in older adults with hematologic malignancy is a challenge and many treatment decisions are influenced by chronologic age. The advent of efficient and well-tolerated newer treatment approaches for multiple myeloma has challenged the role of ASCT. In the modern era, there are no randomized clinical trials of transplant versus non-transplant strategies for patients ≥65 years. Nonetheless, ASCT is feasible for selected older patients and does not result in long-term compromise in quality of life. AlloHCT is the only curative approach for acute myeloid leukemia of intermediate and unfavourable risk but carries a significant risk for non-relapse mortality depending on comorbidities, general fitness, and transplant-specific characteristics, such as intensity of conditioning and donor choice. However, alloHCT is feasible in appropriately-selected older adults. Early referral for evaluation is strongly encouraged as this is the most obvious barrier. CAR-T cell therapies have shown unprecedented clinical efficacy and durability in relapsed and refractory diffuse large B cell lymphoma. Its use is well tolerated in older adults, although evidence comes from limited case numbers. Whether patients who are deemed unfit for ASCT qualify for CAR-T cell therapy remains elusive, but the tolerability and efficacy of CAR-T cell therapy appears promising, especially for older patients. The evidence from randomized trials is strong in favor of using a comprehensive geriatric assessment (CGA) to reduce treatment-related toxicities and guide treatment intensity in the care for solid tumors; its use for evaluation of cellular therapies is less evidence-based. However, CGA can provide useful information on patients' fitness, resilient mechanisms, and reveal potential optimization strategies for compensating for vulnerabilities. In this narrative review, we will discuss key questions on cellular therapies in older adults based on illustrative patient cases.

Nutritional status and body mass index before hematopoietic stem cell transplantation (HSCT) and associated outcomes: a rapid review

PURPOSE

Hematopoietic stem cell transplantation (HSCT) recipients experience several post-HSCT complications affecting nutritional status, body mass index (BMI), and mortality that can potentially be mitigated by nutritional management. This rapid review examines the relationship between pre-HSCT nutritional status and BMI and post-HSCT survival.

METHODS

Articles were identified from PubMed, Scopus, and Embase. Two researchers independently completed the title, abstract, and full-text review. Inclusion criteria included the following: (1) randomized clinical trials or observational studies; (2) human subjects diagnosed with cancer and undergoing HSCT; (3) reported pre-HSCT nutritional status (e.g., diet recall, nutritional survey, dietitian session) or BMI; and (4) reported treatment related mortality and/or survival.

RESULTS

The initial search found 3036 articles, 28 were included in full-text review, and 18 met inclusion criteria. Articles had quasi-experimental (n = 2) and observational (n = 16) study designs. Of the studies, n = 5 reported nutritional intake decreased post-HSCT, and n = 2 reported nutrition intervention (i.e., controlled feeding) post-HSCT improved survival. Four studies reported having a BMI classified as underweight improved survival, while n = 5 reported having a BMI classified as overweight or obese improved survival.

CONCLUSION

Current research exploring the relationship between nutritional status and BMI with HSCT survival is mixed. Further research is needed to determine how nutritional status and BMI are associated withsurvival post-HSCT to inform future intervention work.

Machine learning applications and challenges in graft-versus-host disease: a scoping review

PURPOSE OF REVIEW

This review delves into the potential of artificial intelligence (AI), particularly machine learning (ML), in enhancing graft-versus-host disease (GVHD) risk assessment, diagnosis, and personalized treatment.

RECENT FINDINGS

Recent studies have demonstrated the superiority of ML algorithms over traditional multivariate statistical models in donor selection for allogeneic hematopoietic stem cell transplantation. ML has recently enabled dynamic risk assessment by modeling time-series data, an upgrade from the static, "snapshot" assessment of patients that conventional statistical models and older ML algorithms offer. Regarding diagnosis, a deep learning model, a subset of ML, can accurately identify skin segments affected with chronic GVHD with satisfactory results. ML methods such as Q-learning and deep reinforcement learning have been utilized to develop adaptive treatment strategies (ATS) for the personalized prevention and treatment of acute and chronic GVHD.

SUMMARY

To capitalize on these promising advancements, there is a need for large-scale, multicenter collaborations to develop generalizable ML models. Furthermore, addressing pertinent issues such as the implementation of stringent ethical guidelines is crucial before the widespread introduction of AI into GVHD care.