1
|
Akahoshi Y, Spyrou N, Hoepting M, Aguayo-Hiraldo P, Ayuk F, Chanswangphuwana C, Choe HK, Eder M, Etra AM, Grupp SA, Hexner EO, Hogan WJ, Kitko CL, Kraus S, Al Malki MM, Merli P, Qayed M, Reshef R, Schechter T, Ullrich E, Vasova I, Wölfl M, Zeiser R, Baez J, Beheshti R, Eng G, Gleich S, Kasikis S, Katsivelos N, Kowalyk S, Morales G, Young R, DeFilipp Z, Ferrara JLM, Levine JE, Nakamura R. Flares of acute graft-versus-host disease: a Mount Sinai Acute GVHD International Consortium analysis. Blood Adv 2024; 8:2047-2057. [PMID: 38324721 DOI: 10.1182/bloodadvances.2023012091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/19/2024] [Accepted: 01/19/2024] [Indexed: 02/09/2024] Open
Abstract
ABSTRACT The absence of a standardized definition for graft-versus-host disease (GVHD) flares and data on its clinical course are significant concerns. We retrospectively evaluated 968 patients across 23 Mount Sinai Acute GVHD International Consortium (MAGIC) transplant centers who achieved complete response (CR) or very good partial response (VGPR) within 4 weeks of treatment. The cumulative incidence of flares within 6 months was 22%, and flares were associated with a higher risk of nonrelapse mortality (NRM; adjusted hazard ratio [aHR], 4.84; 95% confidence interval [CI], 3.19-7.36; P < .001). Flares were more severe (grades 3/4, 41% vs 16%; P < .001) and had more frequent lower gastrointestinal (LGI) involvement (55% vs 32%; P < .001) than the initial GVHD. At CR/VGPR, elevated MAGIC biomarkers predicted the future occurrence of a flare, along with its severity and LGI involvement. In multivariate analyses, higher Ann Arbor (AA) biomarker scores at CR/VGPR were significant risk factors for flares (AA2 vs AA1: aHR, 1.81 [95% CI, 1.32-2.48; P = .001]; AA3 vs AA1: aHR, 3.14 [95% CI, 1.98-4.98; P < .001]), as were early response to initial treatment (aHR, 1.84; 95% CI, 1.21-2.80; P = .004) and HLA-mismatched unrelated donor (aHR, 1.74; 95% CI, 1.00-3.02; P = .049). MAGIC biomarkers also stratified the risk of NRM both at CR/VGPR and at the time of flare. We conclude that GVHD flares are common and carry a significant mortality risk. The occurrence of future flares can be predicted by serum biomarkers that may serve to guide adjustment and discontinuation of immunosuppression.
Collapse
Affiliation(s)
- Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Matthias Hoepting
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Paibel Aguayo-Hiraldo
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Chantiya Chanswangphuwana
- Division of Hematology and Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Hannah K Choe
- Blood and Marrow Transplantation Program, The Ohio State University, Columbus, OH
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Aaron M Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stephan A Grupp
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth O Hexner
- Department of Medicine and Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Carrie L Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Monzr M Al Malki
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Pietro Merli
- Department of Pediatric Hematology/Oncology and of Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Muna Qayed
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, GA
| | - Ran Reshef
- Blood and Marrow Transplantation Program and Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
| | - Tal Schechter
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Evelyn Ullrich
- Department of Pediatrics, Experimental Immunology and Cell Therapy, Goethe University Frankfurt, Frankfurt, Germany
| | - Ingrid Vasova
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children's Hospital, University Hospital of Würzburg, Würzburg, Germany
| | - Robert Zeiser
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rahnuma Beheshti
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gilbert Eng
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Stelios Kasikis
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nikolaos Katsivelos
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - James L M Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John E Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryotaro Nakamura
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| |
Collapse
|
2
|
Etra AM, El Jurdi N, Katsivelos N, Kwon D, Gergoudis SC, Morales G, Spyrou N, Kowalyk S, Aguayo-Hiraldo P, Akahoshi Y, Ayuk FA, Baez J, Betts BC, Chanswangphuwana C, Chen YB, Choe HK, DeFilipp Z, Gleich S, Hexner EO, Hogan WJ, Holler E, Kitko CL, Kraus S, Al Malki MM, MacMillan ML, Pawarode A, Quagliarella F, Qayed M, Reshef R, Schechter-Finkelstein T, Vasova I, Weisdorf DJ, Wölfl M, Young R, Nakamura R, Ferrara JLM, Levine JE, Holtan SG. Amphiregulin, ST2,and REG3α Biomarker Risk Algorithms as Predictors of Non-Relapse Mortality in Patients with Acute GVHD. Blood Adv 2024:bloodadvances.2023011049. [PMID: 38640195 DOI: 10.1182/bloodadvances.2023011049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 03/29/2024] [Accepted: 03/29/2024] [Indexed: 04/21/2024] Open
Abstract
Graft-vs-host disease (GVHD) is a major cause of non-relapse mortality (NRM) following allogeneic hematopoietic cell transplant (HCT). Algorithms containing either the GI GVHD biomarker amphiregulin (AREG) or a combination of two GI GVHD biomarkers, (ST2+REG3α) when measured at GVHD diagnosis are validated predictors of NRM risk, but have never been assessed in the same patients using identical statistical methods. We measured serum concentrations of ST2, REG3, and AREG by ELISA at the time of GVHD diagnosis in 715 patients divided by date of transplant into training (2004-2015) and validation (2015-2017) cohorts. The training cohort (n=341) was used to develop algorithms for predicting probability of 12 month NRM that contained all possible combinations of 1-3 biomarkers and a threshold corresponding to the concordance probability was used to stratify patients for risk of NRM. Algorithms were compared to each other based on several metrics including the area under the receiver operating characteristics curve (AUC), proportion of patients correctly classified, sensitivity, and specificity using only the validation cohort (n=374). All algorithms were strong discriminators of 12 month NRM, whether or not patients were systemically treated (n=321). An algorithm containing only ST2+REG3α had the highest AUC (0.757), correctly classified the most patients (75%), and more accurately risk stratified those who developed Minnesota standard risk GVHD and for patients who received post-transplant cyclophosphamide-based prophylaxis. An algorithm containing only AREG more accurately risk stratified patients with Minnesota high risk GVHD. Combining ST2, REG3α, and AREG into a single algorithm did not improve performance.
Collapse
Affiliation(s)
- Aaron M Etra
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Najla El Jurdi
- University of Minnesota, Minneapolis, Minnesota, United States
| | | | - Deukwoo Kwon
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | | | - George Morales
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Nikolaos Spyrou
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Steven Kowalyk
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Paibel Aguayo-Hiraldo
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, United States
| | - Yu Akahoshi
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | | | - Janna Baez
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Brian C Betts
- University of Minnesota, Buffalo, New York, United States
| | - Chantiya Chanswangphuwana
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Yi-Bin Chen
- Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Hannah K Choe
- The Ohio State University, Columbus, Ohio, United States
| | | | | | - Elizabeth O Hexner
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States
| | | | - Ernst Holler
- University Hospital Regensburg, Regensburg, Germany
| | - Carrie L Kitko
- Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | | | - Monzr M Al Malki
- City of Hope National Medical Center, Duarte, California, United States
| | | | | | | | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, Georgia, United States
| | - Ran Reshef
- Columbia University Medical Center, New York, New York, United States
| | | | - Ingrid Vasova
- University Hospital Erlangen, Erlangen, Germany, Erlangen, Germany
| | | | | | - Rachel Young
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Ryotaro Nakamura
- City of Hope National Medical Center, Duarte, California, United States
| | - James L M Ferrara
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - John E Levine
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | | |
Collapse
|
3
|
DeFilipp Z, Kim HT, Spyrou N, Katsivelos N, Kowalyk S, Eng GW, Kasikis S, Beheshti R, Baez J, Akahoshi Y, Ayuk FA, Choe HK, Etra AM, Grupp SA, Hexner EO, Hogan WJ, Kitko CL, Qayed M, Reshef R, Vasova I, Zeiser R, Young R, Holler E, Ferrara JLM, Nakamura R, Levine JE, Chen YB. The MAGIC algorithm probability predicts treatment response and long-term outcomes to second-line therapy for acute GVHD. Blood Adv 2024:bloodadvances.2024012561. [PMID: 38640197 DOI: 10.1182/bloodadvances.2024012561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/21/2024] Open
Abstract
The significance of biomarkers at second-line treatment for acute graft-versus-host disease (GVHD) is not well characterized. We analyzed clinical data and serum samples at initiation of second-line systemic treatment of acute GVHD from 167 patients from 17 centers of the Mount Sinai Acute GVHD International Consortium (MAGIC) between 2016 and 2021. Sixty-two patients received ruxolitinib-based therapy while 102 received other systemic agents. In agreement with prospective trials, ruxolitinib resulted in higher day 28 (D28) ORR compared to non-ruxolitinib therapies (55% vs 31%, P=0.003) and patients who received ruxolitinib had significantly lower non-relapse mortality (NRM) than those who received non-ruxolitinib therapies (point estimates at 2-year: 35% vs 61%, p=0.002). Biomarker analyses demonstrated that the benefit from ruxolitinib was observed only in patients with low MAGIC algorithm probabilities (MAPs) at the start of second-line treatment. Among patients with a low MAP, those who received ruxolitinib experienced significantly lower NRM than those who received non-ruxolitinib therapies (point estimates at 2-year: 12% vs 41%, p=0.016). However, patients with a high MAP experienced high NRM regardless of treatment with ruxolitinib or non-ruxolitinib therapies (point estimates at 2-year: 67% vs 80%, p=0.65). A landmark analysis demonstrated that the relationship between D28 response and NRM largely depends on the MAP level at initiation of second-line therapy. In conclusion, the MAP measured at second-line systemic treatment for acute GVHD predicts treatment response and NRM. Outcomes of patients with high MAP are poor, regardless of treatment choice, and ruxolitinib appears to primarily benefit patients with low MAP.
Collapse
Affiliation(s)
| | - Haesook T Kim
- Dana-Farber Cancer Inst., Boston, Massachusetts, United States
| | - Nikolaos Spyrou
- Icahn School of Medicine at Mount Sinai, NEW YORK, New York, Japan
| | | | - Steven Kowalyk
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Gilbert W Eng
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Stelios Kasikis
- Icahn School of Medicine at Mount Sinai, New York City, New York, United States
| | - Rahnuma Beheshti
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Janna Baez
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Yu Akahoshi
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | | | - Hannah K Choe
- The Ohio State University, Columbus, Ohio, United States
| | - Aaron M Etra
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Stephan A Grupp
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Elizabeth O Hexner
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States
| | | | - Carrie L Kitko
- Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, and Emory University, Atlanta, Georgia, United States
| | - Ran Reshef
- Columbia University Medical Center, New York, New York, United States
| | - Ingrid Vasova
- University Hospital Erlangen, Erlangen, Germany, Erlangen, Germany
| | - Robert Zeiser
- University Medical Center Freiburg, Freiburg, Germany
| | - Rachel Young
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Ernst Holler
- University Hospital Regensburg, Regensburg, Germany
| | - James L M Ferrara
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Ryotaro Nakamura
- City of Hope National Medical Center, Duarte, California, United States
| | - John E Levine
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Yi-Bin Chen
- Massachusetts General Hospital, Boston, Massachusetts, United States
| |
Collapse
|
4
|
Spyrou N, Akahoshi Y, Kowalyk S, Morales G, Beheshti R, Aguayo-Hiraldo P, Al Malki MM, Ayuk F, Bader P, Baez J, Capellini A, Choe H, DeFilipp Z, Eder M, Eng G, Etra A, Gleich S, Grupp SA, Hexner E, Hoepting M, Hogan WJ, Kasikis S, Katsivelos N, Khan A, Kitko CL, Kraus S, Kwon D, Merli P, Portelli J, Qayed M, Reshef R, Schechter T, Vasova I, Wölfl M, Wudhikarn K, Young R, Holler E, Chen YB, Nakamura R, Levine JE, Ferrara JLM. A Day 14 Endpoint for Acute GVHD Clinical Trials. Transplant Cell Ther 2024; 30:421-432. [PMID: 38320730 PMCID: PMC11009039 DOI: 10.1016/j.jtct.2024.01.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/15/2024] [Accepted: 01/25/2024] [Indexed: 02/19/2024]
Abstract
The overall response rate (ORR) 28 days after treatment has been adopted as the primary endpoint for clinical trials of acute graft versus host disease (GVHD). However, physicians often need to modify immunosuppression earlier than day (D) 28, and non-relapse mortality (NRM) does not always correlate with ORR at D28. We studied 1144 patients that received systemic treatment for GVHD in the Mount Sinai Acute GVHD International Consortium (MAGIC) and divided them into a training set (n=764) and a validation set (n=380). We used a recursive partitioning algorithm to create a Mount Sinai model that classifies patients into favorable or unfavorable groups that predicted 12 month NRM according to overall GVHD grade at both onset and D14. In the Mount Sinai model grade II GVHD at D14 was unfavorable for grade III/IV GVHD at onset and predicted NRM as well as the D28 standard response model. The MAGIC algorithm probability (MAP) is a validated score that combines the serum concentrations of suppression of tumorigenicity 2 (ST2) and regenerating islet-derived 3-alpha (REG3α) to predict NRM. Inclusion of the D14 MAP biomarker score with the D14 Mount Sinai model created three distinct groups (good, intermediate, poor) with strikingly different NRM (8%, 35%, 76% respectively). This D14 MAGIC model displayed better AUC, sensitivity, positive and negative predictive value, and net benefit in decision curve analysis compared to the D28 standard response model. We conclude that this D14 MAGIC model could be useful in therapeutic decisions and may offer an improved endpoint for clinical trials of acute GVHD treatment.
Collapse
Affiliation(s)
- Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rahnuma Beheshti
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Paibel Aguayo-Hiraldo
- Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Monzr M Al Malki
- Hematology/Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, CA
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Bader
- Division for Stem Cell Transplantation and Immunology, Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt, Germany
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexandra Capellini
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hannah Choe
- Division of Hematology, The James Comprehensive Cancer Center, The Ohio State University, Columbus, OH
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Gilbert Eng
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Aaron Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Stephan A Grupp
- Division of Oncology, Children's Hospital of Philadelphia, and Perelman School of Medicine, Philadelphia, PA
| | - Elizabeth Hexner
- Blood and Marrow Transplantation Program, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthias Hoepting
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | | | - Stelios Kasikis
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nikolaos Katsivelos
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alina Khan
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Carrie L Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville TN
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Deukwoo Kwon
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Pietro Merli
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy
| | - Joseph Portelli
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Ran Reshef
- Blood and Marrow Transplantation Program, Columbia University Medical Center, New York, NY
| | - Tal Schechter
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Ingrid Vasova
- Dept. of Internal Medicine 5, Hematology/Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Kitsada Wudhikarn
- Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Ryotaro Nakamura
- Hematology/Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, CA
| | - John E Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - James L M Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
| |
Collapse
|
5
|
Qayed M, Kapoor U, Gillespie S, Westbrook A, Aguayo-Hiraldo P, Ayuk FA, Aziz M, Baez J, Choe H, DeFilipp Z, Etra A, Grupp SA, Hexner E, Holler E, Hogan WJ, Kowalyk S, Merli P, Morales G, Nakamura R, Pulsipher MA, Schechter T, Shah J, Spyrou N, Srinagesh HK, Wölfl M, Yanik G, Young R, Kitko CL, Ferrara JLM, Levine JE. A Validated Risk Stratification That Incorporates MAGIC Biomarkers Predicts Long-Term Outcomes in Pediatric Patients with Acute GVHD. Transplant Cell Ther 2024:S2666-6367(24)00294-X. [PMID: 38548227 DOI: 10.1016/j.jtct.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/11/2024] [Accepted: 03/20/2024] [Indexed: 04/10/2024]
Abstract
Acute graft versus host disease (GVHD) is a common and serious complication of allogeneic hematopoietic cell transplantation (HCT) in children but overall clinical grade at onset only modestly predicts response to treatment and survival outcomes. Two tools to assess risk at initiation of treatment were recently developed. The Minnesota risk system stratifies children for risk of nonrelapse mortality (NRM) according to the pattern of GVHD target organ severity. The Mount Sinai Acute GVHD International Consortium (MAGIC) algorithm of 2 serum biomarkers (ST2 and REG3α) predicts NRM in adult patients but has not been validated in a pediatric population. We aimed to develop and validate a system that stratifies children at the onset of GVHD for risk of 6-month NRM. We determined the MAGIC algorithm probabilities (MAPs) and Minnesota risk for a multicenter cohort of 315 pediatric patients who developed GVHD requiring treatment with systemic corticosteroids. MAPs created 3 risk groups with distinct outcomes at the start of treatment and were more accurate than Minnesota risk stratification for prediction of NRM (area under the receiver operating curve (AUC), .79 versus .62, P = .001). A novel model that combined Minnesota risk and biomarker scores created from a training cohort was more accurate than either biomarkers or clinical systems in a validation cohort (AUC .87) and stratified patients into 2 groups with highly different 6-month NRM (5% versus 38%, P < .001). In summary, we validated the MAP as a prognostic biomarker in pediatric patients with GVHD, and a novel risk stratification that combines Minnesota risk and biomarker risk performed best. Biomarker-based risk stratification can be used in clinical trials to develop more tailored approaches for children who require treatment for GVHD.
Collapse
Affiliation(s)
- Muna Qayed
- Emory University School of Medicine, Atlanta, Georgia; Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia.
| | - Urvi Kapoor
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Scott Gillespie
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Adrianna Westbrook
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Paibel Aguayo-Hiraldo
- Division of Hematology, Oncology, and BMT, Children's Hospital Los Angeles, Los Angeles, California
| | - Francis A Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mina Aziz
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Janna Baez
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hannah Choe
- Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Aaron Etra
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephan A Grupp
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth Hexner
- Blood and Marrow Transplantation Program, Abramson Cancer Center and the Division of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | | | - Steven Kowalyk
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Pietro Merli
- Ospedale Pediatrico Bambino Gesú, IRCCS, Rome, Italy
| | - George Morales
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ryotaro Nakamura
- Hematology/Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, California
| | - Michael A Pulsipher
- Division of Hematology, Oncology, and BMT, Children's Hospital Los Angeles, Los Angeles, California; Division of Hematology and Oncology, Intermountain Primary Children's Hospital, Huntsman Cancer Institute at the Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah
| | - Tal Schechter
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jay Shah
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nikolaos Spyrou
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hrishikesh K Srinagesh
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Gregory Yanik
- Pediatric Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan
| | - Rachel Young
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carrie L Kitko
- Pediatric Blood and Marrow Transplant Program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James L M Ferrara
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John E Levine
- The Tisch Cancer Institute and Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| |
Collapse
|
6
|
Spyrou N, Akahoshi Y, Ayuk F, Holler E, Choe H, Etra A, Hogan WJ, Rösler W, Hexner E, DeFilipp Z, Reshef R, Chanswangphuwana C, Qayed M, Kraus S, Eder M, Javorniczky NR, Grupp SA, Kitko CL, Merli P, Aguayo-Hiraldo P, Wölfl M, Baez J, Beheshti R, Eng G, Gleich S, Katsivelos N, Khan A, Kowalyk S, Morales G, Young R, Nakamura R, Chen YB, Levine JE, Ferrara JLM. The utility of biomarkers in acute GVHD prognostication. Blood Adv 2023; 7:5152-5155. [PMID: 37142257 PMCID: PMC10480526 DOI: 10.1182/bloodadvances.2023009929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 05/06/2023] Open
Affiliation(s)
- Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Hannah Choe
- Division of Hematology, The James Comprehensive Cancer Center, The Ohio State University, Columbus, OH
| | - Aaron Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Wolf Rösler
- Department of Internal Medicine 5, Hematology/Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Elizabeth Hexner
- Blood and Marrow Transplantation Program, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Ran Reshef
- Blood and Marrow Transplantation Program, Columbia University Medical Center, New York, NY
| | - Chantiya Chanswangphuwana
- Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Nora Rebeka Javorniczky
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, Albert Ludwigs University, Freiburg, Germany
| | - Stephan A. Grupp
- Division of Oncology, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, PA
| | - Carrie L. Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Pietro Merli
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy
| | - Paibel Aguayo-Hiraldo
- Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rahnuma Beheshti
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gilbert Eng
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Nikolaos Katsivelos
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alina Khan
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryotaro Nakamura
- Hematology/Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, CA
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - John E. Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - James L. M. Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
7
|
Al Malki MM, London K, Baez J, Akahoshi Y, Hogan WJ, Etra A, Choe H, Hexner E, Langston A, Abhyankar S, Ponce DM, DeFilipp Z, Kitko CL, Adekola K, Reshef R, Ayuk F, Capellini A, Chanswangphuwana C, Eder M, Eng G, Gandhi I, Grupp S, Gleich S, Holler E, Javorniczky NR, Kasikis S, Kowalyk S, Morales G, Özbek U, Rösler W, Spyrou N, Yanik G, Young R, Chen YB, Nakamura R, Ferrara JLM, Levine JE. Phase 2 study of natalizumab plus standard corticosteroid treatment for high-risk acute graft-versus-host disease. Blood Adv 2023; 7:5189-5198. [PMID: 37235690 PMCID: PMC10505783 DOI: 10.1182/bloodadvances.2023009853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 05/28/2023] Open
Abstract
Graft-versus-host disease (GVHD) of the gastrointestinal (GI) tract is the main cause of nonrelapse mortality (NRM) after allogeneic hematopoietic cell transplantation. Ann Arbor (AA) scores derived from serum biomarkers at onset of GVHD quantify GI crypt damage; AA2/3 scores correlate with resistance to treatment and higher NRM. We conducted a multicenter, phase 2 study using natalizumab, a humanized monoclonal antibody that blocks T-cell trafficking to the GI tract through the α4 subunit of α4β7 integrin, combined with corticosteroids as primary treatment for patients with new onset AA2/3 GVHD. Seventy-five patients who were evaluable were enrolled and treated; 81% received natalizumab within 2 days of starting corticosteroids. Therapy was well tolerated with no treatment emergent adverse events in >10% of patients. Outcomes for patients treated with natalizumab plus corticosteroids were compared with 150 well-matched controls from the MAGIC database whose primary treatment was corticosteroids alone. There were no significant differences in overall or complete response between patients treated with natalizumab plus corticosteroids and those treated with corticosteroids alone (60% vs 58%; P = .67% and 48% vs 48%; P = 1.0, respectively) including relevant subgroups. There were also no significant differences in NRM or overall survival at 12 months in patients treated with natalizumab plus corticosteroids compared with controls treated with corticosteroids alone (38% vs 39%; P = .80% and 46% vs 54%; P = .48, respectively). In this multicenter biomarker-based phase 2 study, natalizumab combined with corticosteroids failed to improve outcome of patients with newly diagnosed high-risk GVHD. This trial was registered at www.clinicaltrials.gov as # NCT02133924.
Collapse
Affiliation(s)
- Monzr M. Al Malki
- Hematology/Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Kaitlyn London
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Aaron Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hannah Choe
- Division of Hematology, James Cancer Center, The Ohio State University, Columbus, OH
| | - Elizabeth Hexner
- Blood and Marrow Transplantation Program, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Sunil Abhyankar
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS
| | - Doris M. Ponce
- Division of Hematology/Oncology, Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering, New York, NY
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Carrie L. Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Kehinde Adekola
- Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Ran Reshef
- Blood and Marrow Transplantation, Columbia University Medical Center, New York, NY
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandra Capellini
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Chantiya Chanswangphuwana
- Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Gilbert Eng
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Isha Gandhi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stephan Grupp
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Nora Rebeka Javorniczky
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, Albert Ludwigs University, Freiburg, Germany
| | - Stelios Kasikis
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Umut Özbek
- Department of Population Health Science and Policy, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Wolf Rösler
- Department of Internal Medicine 5, University Hospital Erlangen, Erlangen, Germany
| | - Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gregory Yanik
- Blood and Marrow Transplant Program, Michigan Medicine, Ann Arbor, MI
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Ryotaro Nakamura
- Hematology/Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - James L. M. Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John E. Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
8
|
Akahoshi Y, Spyrou N, Hogan WJ, Ayuk F, DeFilipp Z, Weber D, Choe HK, Hexner EO, Rösler W, Etra AM, Sandhu K, Yanik GA, Chanswangphuwana C, Kitko CL, Reshef R, Kraus S, Wölfl M, Eder M, Bertrand H, Qayed M, Merli P, Grupp SA, Aguayo-Hiraldo P, Schechter T, Ullrich E, Baez J, Beheshti R, Gleich S, Kowalyk S, Morales G, Young R, Kwon D, Nakamura R, Levine JE, Ferrara JLM, Chen YB. Incidence, clinical presentation, risk factors, outcomes, and biomarkers in de novo late acute GVHD. Blood Adv 2023; 7:4479-4491. [PMID: 37315175 PMCID: PMC10440469 DOI: 10.1182/bloodadvances.2023009885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/24/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023] Open
Abstract
Late acute graft-versus-host disease (GVHD) is defined as de novo acute GVHD presenting beyond 100 days after allogeneic hematopoietic cell transplantation (HCT) without manifestations of chronic GVHD. Data are limited regarding its characteristics, clinical course, and risk factors because of underrecognition and changes in classification. We evaluated 3542 consecutive adult recipients of first HCTs at 24 Mount Sinai Acute GVHD International Consortium (MAGIC) centers between January 2014 and August 2021 to better describe the clinical evolution and outcomes of late acute GVHD. The cumulative incidence of classic acute GVHD that required systemic treatment was 35.2%, and an additional 5.7% of patients required treatment for late acute GVHD. At the onset of symptoms, late acute GVHD was more severe than classic acute GVHD based on both clinical and MAGIC algorithm probability biomarker parameters and showed a lower overall response rate on day 28. Both clinical and biomarker grading at the time of treatment stratified the risk of nonrelapse mortality (NRM) in patients with classic and late acute GVHD, respectively, but long-term NRM and overall survival did not differ between patients with classic and late acute GVHD. Advanced age, female-to-male sex mismatch, and the use of reduced intensity conditioning were associated with the development of late acute GVHD, whereas the use of posttransplant cyclophosphamide-based GVHD prevention was protective mainly because of shifts in GVHD timing. Because overall outcomes were comparable, our findings, although not definitive, suggest that similar treatment strategies, including eligibility for clinical trials, based solely on clinical presentation at onset are appropriate.
Collapse
Affiliation(s)
- Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Daniela Weber
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Hannah K. Choe
- Blood and Marrow Transplantation Program, The Ohio State University, Columbus, OH
| | - Elizabeth O. Hexner
- Department of Medicine, Division of Hematology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Wolf Rösler
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
| | - Aaron M. Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Karamjeet Sandhu
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Gregory A. Yanik
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI
| | - Chantiya Chanswangphuwana
- Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Carrie L. Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Ran Reshef
- Blood and Marrow Transplantation Program and Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children's Hospital, University Hospital of Würzburg, Würzburg, Germany
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Hannah Bertrand
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Muna Qayed
- Emory University School of Medicine, Atlanta, GA
| | - Pietro Merli
- Department of Haematology-Oncology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Stephan A. Grupp
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Paibel Aguayo-Hiraldo
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, CA
| | - Tal Schechter
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Evelyn Ullrich
- Frankfurt Cancer Institute, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rahnuma Beheshti
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Deukwoo Kwon
- Department of Population Health Science and Policy, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - John E. Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - James L. M. Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
9
|
Etra A, Capellini A, Alousi A, Al Malki MM, Choe H, DeFilipp Z, Hogan WJ, Kitko CL, Ayuk F, Baez J, Gandhi I, Kasikis S, Gleich S, Hexner E, Hoepting M, Kapoor U, Kowalyk S, Kwon D, Langston A, Mielcarek M, Morales G, Özbek U, Qayed M, Reshef R, Rösler W, Spyrou N, Young R, Chen YB, Ferrara JLM, Levine JE. Effective treatment of low-risk acute GVHD with itacitinib monotherapy. Blood 2023; 141:481-489. [PMID: 36095841 PMCID: PMC9936304 DOI: 10.1182/blood.2022017442] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/27/2022] [Accepted: 07/31/2022] [Indexed: 02/07/2023] Open
Abstract
The standard primary treatment for acute graft-versus-host disease (GVHD) requires prolonged, high-dose systemic corticosteroids (SCSs) that delay reconstitution of the immune system. We used validated clinical and biomarker staging criteria to identify a group of patients with low-risk (LR) GVHD that is very likely to respond to SCS. We hypothesized that itacitinib, a selective JAK1 inhibitor, would effectively treat LR GVHD without SCS. We treated 70 patients with LR GVHD in a multicenter, phase 2 trial (NCT03846479) with 28 days of itacitinib 200 mg/d (responders could receive a second 28-day cycle), and we compared their outcomes to those of 140 contemporaneous, matched control patients treated with SCSs. More patients responded to itacitinib within 7 days (81% vs 66%, P = .02), and response rates at day 28 were very high for both groups (89% vs 86%, P = .67), with few symptomatic flares (11% vs 12%, P = .88). Fewer itacitinib-treated patients developed a serious infection within 90 days (27% vs 42%, P = .04) due to fewer viral and fungal infections. Grade ≥3 cytopenias were similar between groups except for less severe leukopenia with itacitinib (16% vs 31%, P = .02). No other grade ≥3 adverse events occurred in >10% of itacitinib-treated patients. There were no significant differences between groups at 1 year for nonrelapse mortality (4% vs 11%, P = .21), relapse (18% vs 21%, P = .64), chronic GVHD (28% vs 33%, P = .33), or survival (88% vs 80%, P = .11). Itacitinib monotherapy seems to be a safe and effective alternative to SCS treatment for LR GVHD and deserves further investigation.
Collapse
Affiliation(s)
- Aaron Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexandra Capellini
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Amin Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Monzr M. Al Malki
- Hematology/Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, CA
| | - Hannah Choe
- Division of Hematology, James Cancer Center, The Ohio State University, Columbus, OH
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | | | - Carrie L. Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Isha Gandhi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stelios Kasikis
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Elizabeth Hexner
- Blood and Marrow Transplantation Program, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthias Hoepting
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Urvi Kapoor
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Deukwoo Kwon
- Department of Population Health Science and Policy, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Marco Mielcarek
- Adult Blood and Marrow Transplant Program, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Umut Özbek
- Department of Population Health Science and Policy, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Ran Reshef
- Blood and Marrow Transplantation Program, Columbia University Medical Center, New York, NY
| | - Wolf Rösler
- Med. Klinik III/Poliklinik, Universitatsklinik Erlangen, Erlangen, Germany
| | - Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - James L. M. Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John E. Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
10
|
Akahoshi Y, Spyrou N, Hogan WJ, Ayuk F, DeFilipp Z, Weber D, Choe H, Hexner E, Rösler W, Etra A, Sandhu KS, Yanik GA, Chanswangphuwana C, Kitko CL, Reshef R, Kraus S, Wölfl M, Eder M, Bertrand H, Qayed M, Merli P, Grupp SA, Aguayo-Hiraldo DP, Schechter T, Ullrich E, Baez J, Kowalyk S, Morales G, Young MR, Nakamura R, Levine JE, Ferrara J, Chen DYB. De Novo Late Acute Gvhd: Incidence, Outcomes, and Impact of Biomarkers Compared to Classic Acute Gvhd. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00101-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
11
|
Kasikis S, Baez J, Gandhi I, Grupp S, Kitko CL, Kowalyk S, Merli P, Morales G, Pulsipher MA, Qayed M, Wölfl M, Yanik G, See F, Hayes J, Grossman F, Burke E, Young R, Levine JE, Ferrara JLM. Mesenchymal stromal cell therapy induces high responses and survival in children with steroid refractory GVHD and poor risk biomarkers. Bone Marrow Transplant 2021; 56:2869-2870. [PMID: 34471240 PMCID: PMC9840529 DOI: 10.1038/s41409-021-01442-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/29/2021] [Accepted: 08/18/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Stelios Kasikis
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, NY, NY
| | - Janna Baez
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, NY, NY
| | - Isha Gandhi
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, NY, NY
| | - Stephan Grupp
- Children’s Hospital of Philadelphia and Perelman School of Medicine
| | | | - Steven Kowalyk
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, NY, NY
| | - Pietro Merli
- Istituto di Ricovero e Cura a Carattere Scientifico, Ospedale Pediatrico Bambino Gesuù, Rome, Italy
| | - George Morales
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, NY, NY
| | - Michael A. Pulsipher
- Section of Transplantation and Cellular Therapy, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Emory University and Children’s Healthcare of Atlanta, Atlanta, GA
| | - Matthias Wölfl
- Children’s Hospital, University of Würzburg, Würzburg Germany
| | | | | | | | | | | | - Rachel Young
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, NY, NY
| | - John E. Levine
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, NY, NY
| | | |
Collapse
|
12
|
Stolz L, Boyd J, Baez J, Minges P, Swarm M, Boutis K. 306EMF Defining the Learning Curve for First Trimester Ultrasound Image Interpretation Skills for Emergency Physicians. Ann Emerg Med 2021. [DOI: 10.1016/j.annemergmed.2021.09.320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
13
|
Hill J, LaFollette R, Hughes H, Mand S, Koehler J, Li J, Baez J, Lang S, McDonough E. 344 Qualitative Description of Synchronous Online Discussions During Weekly Academic Conference. Ann Emerg Med 2021. [DOI: 10.1016/j.annemergmed.2021.09.358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
14
|
Zewde MG, Morales G, Gandhi I, Özbek U, Aguayo-Hiraldo P, Ayuk F, Baez J, Chanswangphuwana C, Choe H, DeFilipp Z, Etra A, Grupp S, Hexner EO, Hogan W, Javorniczky NR, Kasikis S, Kitko CL, Kowalyk S, Meedt E, Merli P, Nakamura R, Qayed M, Reshef R, Rösler W, Schechter T, Weber D, Wölfl M, Yanik G, Young R, Levine JE, Ferrara JLM, Chen YB. Evaluation of Elafin as a Prognostic Biomarker in Acute Graft-versus-Host Disease. Transplant Cell Ther 2021; 27:988.e1-988.e7. [PMID: 34474163 DOI: 10.1016/j.jtct.2021.08.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 11/17/2022]
Abstract
Acute graft-versus-host disease (GVHD) is a major cause of mortality in patients undergoing hematopoietic cell transplantation (HCT) for hematologic malignancies. The skin is the most commonly involved organ in GVHD. Elafin, a protease inhibitor overexpressed in inflamed epidermis, was previously identified as a diagnostic biomarker of skin GVHD; however, this finding was restricted to a subset of patients with isolated skin GVHD. The main driver of nonrelapse mortality (NRM) in HCT recipients is gastrointestinal (GI) GVHD. Two biomarkers, Regenerating islet-derived 3a (REG3α) and Suppressor of tumorigenesis 2 (ST2), have been validated as biomarkers of GI GVHD that predict long-term outcomes in patients treated for GVHD. We undertook this study to determine the utility of elafin as a prognostic biomarker in the general population of acute GVHD patients in whom GVHD may develop in multiple organs. We analyzed serum elafin concentrations as a predictive biomarker of acute GVHD outcomes and compared it with ST2 and REG3α in a large group of patients treated at multiple centers. A total of 526 patients from the Mount Sinai Acute GVHD International Consortium (MAGIC) who had received corticosteroid treatment for skin GVHD and who had not been previously studied were analyzed. Serum concentrations of elafin, ST2, and REG3α were measured by ELISA in all patients. The patients were divided at random into equal training and validation sets, and a competing-risk regression model was developed to model 6-month NRM using elafin concentration in the training set. Additional models were developed using concentrations of ST2 and REG3α or the combination of all 3 biomarkers as predictors. Receiver operating characteristic (ROC) curves were constructed using the validation set to evaluate the predictive accuracy of each model and to stratify patients into high- and low-risk biomarker groups. The cumulative incidence of 6-month NRM, overall survival (OS), and 4-week treatment response were compared between the risk groups. Unexpectedly, patients in the low-risk elafin group demonstrated a higher incidence of 6-month NRM, although the difference was not statistically significant (17% versus 11%; P = .19). OS at 6 months (68% versus 68%; P > .99) and 4-week response (78% versus 78%; P = .98) were similar in the low-risk and high-risk elafin groups. The area under the ROC curve (AUC) was 0.55 for elafin and 0.75 for the combination of ST2 and REG3α. The addition of elafin to the other 2 biomarkers did not improve the AUC. Our data indicate that serum elafin concentrations measured at the initiation of systemic treatment for acute GVHD did not predict 6-month NRM, OS, or treatment response in a multicenter population of patients treated systemically for acute GVHD. As seen in previous studies, serum concentrations of the GI GVHD biomarkers ST2 and REG3α were significant predictors of NRM, and the addition of elafin levels did not improve their accuracy. These results underscore the importance of GI disease in driving NRM in patients who develop acute GVHD.
Collapse
Affiliation(s)
- Makda Getachew Zewde
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - George Morales
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Isha Gandhi
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Umut Özbek
- Biostatistics Shared Resource Facility, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Paibel Aguayo-Hiraldo
- Children's Center for Cancer and Blood Diseases, Blood and Marrow Transplantation Section, Children's Hospital Los Angeles, Los Angeles, California
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center, Hamburg-Eppendorf, Germany
| | - Janna Baez
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Hannah Choe
- Blood and Marrow Transplantation Program, Ohio State University, Columbus, Ohio
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Aaron Etra
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephan Grupp
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth O Hexner
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William Hogan
- Blood and Marrow Transplantation Program, Mayo Clinic, Rochester, Minnesota
| | - Nora Rebeka Javorniczky
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Stelios Kasikis
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carrie L Kitko
- Pediatric Blood and Marrow Transplantation Program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Steven Kowalyk
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elisabeth Meedt
- Blood and Marrow Transplantation Program, University of Regensburg, Regensburg, Germany
| | - Pietro Merli
- Department of Pediatric Hematology and Oncology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Ryotaro Nakamura
- Hematology and Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, California
| | - Muna Qayed
- Pediatric Blood and Marrow Transplantation Program, Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta
| | - Ran Reshef
- Blood and Marrow Transplantation Program, Columbia University, New York, New York
| | - Wolf Rösler
- Department of Internal Medicine 5, Hematology/Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Tal Schechter
- Division of Hematology/Oncology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Daniela Weber
- Blood and Marrow Transplantation Program, University of Regensburg, Regensburg, Germany
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Gregory Yanik
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan
| | - Rachel Young
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John E Levine
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - James L M Ferrara
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
15
|
Suárez C, Russo D, Baez J, Rossi A, Díaz F, Follett F, Rocca Rivarola M, Puigdevall JC. [Laparoscopic approach for treatement of gastroesophageal reflux in newborns and infants with severe respiratory disorders. When to indicate it?]. Cir Pediatr 2005; 18:83-7. [PMID: 16044645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Gastroesophageal reflux (GER) is a common finding in the newborn period, which is in general well tolerated, and tends to resolve spontaneously at about 18 months of age. However, a small number of children will present important respiratory manifestations (aspiration and apneic episodes), or increase in the manifestations of pre existing conditions (tracheomalacia, laryngomalacia), which can produce life threatning events. Ph monitoring does not completely discard the possibility of GER and the use of prokinetic drugs, in association with other drugs to protect the esophagus do not prevent serious consecuences produced by reflux to the airway. In this report six children with severe airway disease and marked GER, with no response to initial medical treatment required laparoscopic fundoplication. They have all resolved their airway disease, and are currently well. The laparocopic technique for fundoplication of small children seems to be a secure, well tolerated and definitive treatment in the hands of trained surgeons.
Collapse
Affiliation(s)
- C Suárez
- Servicio de Cirugía Infantil, Hospital Italiano de Córdoba, Provincia de Cordoba, Argentina
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Zimmerman Z, Baez J, Roskos M, Mammolenti M, Levy R. 113Analysis of CD4+CD25+ T regulatory cell survival and function following in vitro and in vivo irradiation. Biol Blood Marrow Transplant 2003. [DOI: 10.1016/s1083-8791(03)80114-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
17
|
Abstract
Although clinical studies have shown that posterior cut angle affects tibial component stability, biomechanical studies are lacking. Fifteen Sawbones tibiae were divided into 5 groups and prepared with 0 degrees , 3 degrees, 6 degrees, 9 degrees, and -5 degrees tibial surface cuts, and a tibial component was implanted with cement. Using a standard and then a highly congruent polyethylene insert, the knee was loaded at 0 degrees and 30 degrees of flexion. There were statistically significant increases in anterior micromotion of the standard polyethylene component for each increase in posterior slope cut angle, which increased for the highly congruent polyethylene component. The anterior slope cut (-5 degrees) led to significant posterior micromotion of the tibial polyethylene component. Increased posterior slope cut angle significantly decreased tibial anterior compressive strains and significantly increased tibial posterior compressive strains. The highly congruent insert significantly increased this posterior strain. The results indicate that cutting the articular surface of the tibia at a 0 degrees or 3 degrees posterior slope provides the greatest tibial component stability.
Collapse
Affiliation(s)
- B Bai
- Department of Orthpaedic Surgery, New York University Medical Center, Hospital for Joint diseases Orthopaedic Institute, New York 10003, USA
| | | | | | | |
Collapse
|
18
|
Abstract
A case of a 66-year-old woman with a giant fibrovascular polyp protruding from the mouth is presented. The polyp was successfully removed by a cervical esophagotomy.
Collapse
Affiliation(s)
- G Iriarte
- Department of Surgery, Hospital Guadalupano, Celaya, Gto, Mexico
| | | | | | | | | | | |
Collapse
|
19
|
Perez E, Cruz J, Henriquez L, Baez J. [Some considerations about hepatitus C virus]. Arch Domin Pediatr 1996; 32:57-62. [PMID: 12348030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
|
20
|
Abstract
A doublet of proteins (approximately 48,000 Mr) from the Paramecium cell body membrane fits several criteria for the external cAMP chemoreceptor. These criteria include: (i) selective elution from a cAMP affinity column, matching a specificity that could be predicted from the behavioral response and whole-cell binding; (ii) binding to wheat germ agglutinin indicating the presence of carbohydrate moieties indicating surface exposure; and (iii) selective inhibition of the intact cells' chemoresponse to cAMP by antibodies against the doublet. Additional evidence for the existence of a receptor, in general, comes from selective elimination of the cAMP chemoresponse by photoaffinity labeling of while cells with 8-N3-cAMP. The doublet proteins are not identical to the regulatory subunit of a cAMP-dependent protein kinase from Paramecium, the Dictyostelium cAMP chemoreceptor, or the 42-45 kDa range proteins related to the large surface glycoprotein in Paramecium. The doublet proteins are not readily separable and, as in Dictyostelium, may represent two different covalent modification states of the same protein. Amino acid analysis indicates that the proteins are similar, but does not distinguish between the possibilities of proteolysis and covalent modification. Once cloned, this doublet may prove to be only the fifth external, eukaryotic chemoreceptor to be identified.
Collapse
Affiliation(s)
- J L Van Houten
- Department of Zoology, University of Vermont, Burlington 05405
| | | | | | | | | |
Collapse
|