Evaluation of factors associated with survival in allogeneic stem cell-transplanted patients admitted to the intensive care unit (ICU)

INTRODUCTION

There are conflicting results concerning the outcome of patients after an allogeneic hematopoietic stem cell transplantation (allo-HSCT) who required treatment in the intensive care unit (ICU). The aim of this study was to evaluate the outcome and prognostic parameters in terms of patient survival after allo-HSCT and admission to the ICU within the first 30 days after transplantation.

METHODS

Patients after allo-HSCT, who were ≥18 years and admitted to the ICU after the initiation of conditioning therapy and within the first 30 days after allo-HSCT at the University Hospital of Bonn between January 2017 and April 2021, were analysed retrospectively. Baseline data, laboratory parameters, established scoring systems, vital parameters, and outcome were collected.

RESULTS

44 patients (median age of 63 years) were analysed. The 90-day survival rate was 50% (N = 22) and the 1-year survival rate was 27% (N = 12). The 90-day and 1-year survival rates of patients who required MV were 38% (N = 13) and 18% (N = 6). There was a significant correlation between increased mortality and an APACHE-Score ≥20 (p = 0.03), a SAPS-II-Score ≥60 (p = 0.04) and a SOFA-Score ≥9 (p = 0.03). Invasive mechanical ventilation (p = 0.05) and vasopressor support (p = 0.03) showed a negative correlation with the outcome.

CONCLUSION

This study found several parameters (APACHE-II-Score, SAPS-II-Score, SOFA-Score, MV and vasopressor support) associated with increased mortality after allo-HSCT and admission to the ICU. The outcome of allo-HSCT patients admitted to the ICU is not as poor as previously reported. Even older patients under long-term ventilation may benefit from intensive care therapy.

Optimized Conformal Total Body Irradiation with VMAT Using a Linear-Accelerator-Based Radiosurgery Treatment System in Comparison to the Golden Standard Helical TomoTherapy

Modern irradiation techniques for optimized conformal TBI can be realized by Helical Tomotherapy (HT) or Volumetric Modulated Arc Therapy (VMAT), depending on the availability of suitable specialized equipment. In this dosimetric planning study, we compared both modalities and addressed the question of whether VMAT with small field sizes is also suitable as a backup in case of HT equipment malfunctions. For this purpose, we retrospectively used planning computed tomography (CT) data from 10 patients treated with HT with a total dose of 8 Gy (n = 5) or 12 Gy (n = 5) for treatment planning for VMAT with a small field size (36 × 22 cm). The target volume coverage, dose homogeneity at target volume, and dose reduction in organs at risk (OAR) (lungs, kidneys, lenses) were analyzed and compared. One patient was irradiated with both modalities due to a device failure of the HT equipment during the study, which facilitated a comparison in a real clinical setting. The findings indicate that in addition to a higher mean dose to the lenses in the 12 Gy group for VMAT and a better dose homogeneity in the target volume for HT, comparably good and adequate target dose coverage and dose reduction in the other OAR could be achieved for both modalities, with significantly longer treatment times for VMAT. In conclusion, after appropriate optimization of the treatment times, VMAT using linear accelerator radiosurgery technology can be used both as a backup in addition to HT and in clinical routines to perform optimized conformal TBI.

Whole body irradiation with intensity-modulated helical tomotherapy prior to haematopoietic stem cell transplantation: analysis of organs at risk by dose and its effect on blood kinetics

BACKGROUND

Intensity-modulated helical tomotherapy (HT) is a promising technique in preparation for bone marrow transplantation. Nevertheless, radiation-sensitive organs can be substantially compromised due to suboptimal delivery techniques of total body irradiation (TBI). To reduce the potential burden of radiation toxicity to organs at risk (OAR), high-quality coverage and homogeneity are essential. We investigated dosimetric data from kidney, lung and thorax, liver, and spleen in relation to peripheral blood kinetics. To further advance intensity-modulated total body irradiation (TBI), the potential for dose reduction to lung and kidney was considered in the analysis.

PATIENTS AND METHODS

46 patients undergoing TBI were included in this analysis, partially divided into dose groups (2, 4, 8, and 12 Gy). HT was performed using a rotating gantry to ensuring optimal reduction of radiation to the lungs and kidneys and to provide optimal coverage of other OAR. Common dosimetric parameters, such as D05, D95, and D50, were calculated and analysed. Leukocytes, neutrophils, platelets, creatinine, GFR, haemoglobin, overall survival, and graft-versus-host disease were related to the dosimetric evaluation using statistical tests.

RESULTS

The mean D95 of the lung is 48.23%, less than half the prescribed and unreduced dose. The D95 of the chest is almost twice as high at 84.95%. Overall liver coverage values ranged from 96.79% for D95 to 107% for D05. The average dose sparing of all patients analysed resulted in an average D95 of 68.64% in the right kidney and 69.31% in the left kidney. Average D95 in the spleen was 94.28% and D05 was 107.05%. Homogeneity indexes ranged from 1.12 for liver to 2.28 for lung. The additional significance analyses conducted on these blood kinetics showed a significant difference between the 2 Gray group and the other three groups for leukocyte counts. Further statistical comparisons of the dose groups showed no significant differences. However, there were significant changes in the dose of OAR prescribed with dose sparing (e.g., lung vs. rib and kidney).

CONCLUSION

Using intensity-modulated helical tomotherapy to deliver TBI is a feasible method in preparation for haematopoietic stem cell transplantation. Significant dose sparing in radiosensitive organs such as the lungs and kidneys is achievable with good overall quality of coverage. Peripheral blood kinetics support the positive impact of HT and its advantages strongly encourage its implementation within clinical routine.

Total marrow irradiation versus total body irradiation using intensity-modulated helical tomotherapy

BACKGROUND

Total body irradiation (TBI) is often a component of the conditioning regimen prior to hematopoietic stem cell transplantation in patients with hematological malignancies. However, total marrow irradiation (TMI) could be an alternative method for reducing radiation therapy-associated toxicity, as it specifically targets the skeleton and thus could better protect organs at risk. Here, we compared dosimetric changes in irradiation received by the target volume and organs at risk between TBI and TMI plans.

MATERIALS AND METHODS

Theoretical TMI plans were calculated for 35 patients with various hematological malignancies who had already received TBI in our clinic. We then statistically compared irradiation doses between the new TMI plans and existing TBI plans. We examined whether TMI provides greater protection of organs at risk while maintaining the prescribed dose in the targeted skeletal area. We also compared beam-on times between TBI and TMI.

RESULTS

TMI planning achieved significant reductions in the mean, minimum, and maximum irradiation doses in the lungs, kidneys, liver, spleen, and body (i.e., remaining tissue except organs and skeleton). In particular, the mean dose was reduced by 49% in the liver and spleen and by 55-59% in the kidneys. Moreover, TMI planning reduced the corpus beam-on time by an average of 217 s.

CONCLUSION

TMI planning achieved significant dose reduction in organs at risk while still achieving the prescribed dose in the target volume. Additionally, TMI planning reduced the beam-on time for corpus plans despite a high modulation factor.

Prevalence, therapy and tumour response in patients with rheumatic immune-related adverse events following immune checkpoint inhibitor therapy: a single-centre analysis

Background:

Immune checkpoint inhibitors (ICIs) improved cancer therapy by inducing a higher immune system activity. This effect can cause rheumatic immune-related adverse events (rh-irAEs), which have not yet been extensively studied.

Methods:

We analysed 437 patients between 2014 and 2019, treated with ipilimumab (anti-CTLA-4) and/or nivolumab (anti-PD-1) or pembrolizumab (anti-PD-1) at the Clinic for Internal Medicine III, Oncology, Haematology and Rheumatology at the University Hospital Bonn, Germany.

Results:

Of the 437 patients 60% were males. Patients were mainly treated for melanoma, lung cancer, head and neck tumour and urothelial carcinoma. At least one immune-related adverse event (irAE) was observed in 163 patients (37.3%), including rh-irAE. Most common side effects were rash, colitis and hepatitis. We identified 19 patients (4.3%) with a minimum of one rh-irAE due to ICI therapy; three of those had a pre-existing rheumatic disease. Arthralgia developed most frequently in eight patients (42.1%). Other rh-irAEs were: arthritis (n = 7; distinguished in rheumatoid arthritis, psoriatic arthritis, juvenile idiopathic arthritis and undifferentiated arthritis), myalgia (n = 2) and myositis (n = 3). Most rh-irAEs were classified as moderately severe (Common Terminology Criteria of Adverse Events grade 2: 68.4%). Median time between starting ICI therapy and the occurrence of rh-irAE was 109 days (interquartile range 40–420 days). Fifteen patients (78.9%) were treated with glucocorticosteroids. In four cases additional therapy with methotrexate or tocilizumab was required. Even though patients benefited from ICI treatment, therapy had to be discontinued in six of the participants due to rh-irAE. Interestingly, patients with rh-irAE had a significantly higher tumour response compared with patients without rh-irAE (94.4% versus 43.5%; p < 0.0001).

Conclusion:

Rh-irAEs occur under ICI therapy, especially in patients with higher tumour response. However, they are not the most frequent irAE after ICI exposure: 9.3% of all irAEs were rheumatic (20 rh-irAE cases in 19 patients of a total of 215 irAE cases in 163 patients).

FRI0548 PREVALENCE AND THERAPY OF RHEUMATOLOGICAL ADVERSE EVENTS DUE TO IMMUNE CHECKPOINT INHIBITOR THERAPY

Background:

Immune checkpoint inhibitors (ICIs) have improved cancer therapy and especially clinical outcomes for patients with many malignancies [1]. ICIs lead to a higher immune system activity and subsequent attack of tumor cells. However, this effect can cause rheumatological immune related adverse events (rh-irAE), which have not yet been extensively studied.

Objectives:

To determine the prevalence and type of rh-irAE in patients treated with ICIs. Additionally, our study focused on duration, severity and therapy of rh-irAE as well as the correlation between tumor response rate and patients with or without rh-irAE.

Methods:

We analysed 437 patients between January 2014 and October 2019, treated with ipilimumab (anti-CTLA-4) and/ or nivolumab (anti-PD-1) or pembrolizumab (anti-PD-1) at the Department of Oncology, Hematology and Rheumatology at the University Hospital in Bonn, Germany.

Results:

Of the 437 patients, 260 (60%) were males, 177 (40%) were females with a mean age of 64 years (SD ± 14) at the beginning of the ICI-therapy. 152 patients (34.8%) displayed at least one irAE.

We identified 20 patients (4.6%) with a minimum of one rh-irAE due to ICI-therapy, seven of those had a pre-existing rheumatological disease. Those 20 patients were initially treated for melanoma, lung cancer, head and neck tumor and gastrointestinal carcinoma. Rh-irAE occurred in one patient (2.6%) with ipilimumab, in nine patients (4.8%) with nivolumab, in nine patients (5.7%) with pembrolizumab and in one patient (1.9%) with a combination of ipilimumab and nivolumab.

Arthralgia developed most frequently in nine of the 20 patients (45%). Arthritis and myositis occurred with equal frequencies, in three cases each (3 patients, 15%). Furthermore, three of the 20 patients (15%) developed a psoriatic arthritis and one patient (5%) osteoarthritis. The time to the first rh-irAE after exposure to ICIs was in median 100 days (IQR 45 – 406 days). Most rh-irAE were classified as moderate severe (CTCAE [Common Terminology Criteria of Adverse Events] grade 2: 55%).

15 patients (75%) were treated with systemic corticosteroids. In three cases (15%) additional therapy with methotrexate and in one patient (5%) with tocilizumab was required. Other therapies including non-steroidal anti-inflammatory drugs and opioids were also used in eight patients. Even though patients benefited from ICI treatment, therapy had to be discontinued in nine of them (45%).

Interestingly, patients with rh-irAE had a significantly higher tumor response rate compared to patients without any irAE (95% vs. 33%; p<0,0001).

Table 1.

Independent risk factors of IFI in patients with SLEa

CandidiasisCryptococcosisAspergillosisHR (95% CI)PvalueHR (95% CI)PvalueHR (95% CI)PvalueAge>501.77 (1.27-2.47)<0.001Diabetes mellitus1.65 (1.16-2.35)0.006End-stage renal disease1.76 (1.29-2.41)<0.001Stroke1.77 (1.26-2.47)<0.0011.96 (1.09-3.53)0.024Mycophenolate mofetil2.72 (1.60-4.61)<0.0014.02 (1.32-12.26)0.015Cyclosporin4.94 (1.61-15.10)0.005Cyclophosphamide1.50 (1.07-2.10)0.019Intravenous steroid28.19 (21.17-37.52)<0.00163.51 (36.10-111.71)<0.00134.80 (15.09-80.24)<0.001

aAll factors withP<0.05 in univariate analysis were selected for Cox multivariate analysis.

CI, confidence interval; HR, hazard ratio.

Figure 1.

Incidence rate and incidence rata ratio of invasive fungal infection

Figure 2.

Kaplan-Meier curve of invasive fungal infection-free status in SLE versus non-SLE group.

Conclusion:

Our results show, that rh-irAE occur under ICI-therapy and in patients with higher tumor response. However, they are not the most frequent irAE after ICI exposure: 10.2% of all irAE were rheumatological (22 rh-irAE cases in 20 patients of a total of 216 irAE cases in 152 patients). As the use of ICIs is increasing for different malignancies the incidence of rh-irAE can be expected to increase.

References:

[1] Ribas A, Wolchok JD. Cancer immunotherapy using checkpoint blockade.Science. 2018;359(6382):1350-1355. doi:10.1126/science.aar4060

[2] Spain L, Diem S, Larkin J. Management of toxicities of immune checkpoint inhibitors.Cancer Treat Rev. 2016;44:51-60. doi:10.1016/j.ctrv.2016.02.001

Acknowledgments

Disclosure of Interests:

None declared

Higher number of multidisciplinary tumor board meetings per case leads to improved clinical outcome

BACKGROUND

This analysis aims at evaluating the impact of multidisciplinary tumor boards on clinical outcome of multiple tumor entities, the effect of the specific number of multidisciplinary tumor boards and potential differences between the tumor entities.

METHODS

By a matched-pair analysis we compared the response to treatment, overall survival, relapse or disease free survival and progression free survival of patients whose cases were discussed in a tumor board meeting with patients whose cases were not. It was performed with patients registered in the cancer registry of the University of Bonn and diagnosed between 2010 and 2016. After the matching process with a pool of 7262 patients a total of 454 patients with 66 different tumor types were included in this study.

RESULTS

First, patients with three or more multidisciplinary tumor board meetings in their history show a significantly better overall survival than patients with no tumor board meeting. Second, response to treatment, relapse free survival and time to progression were not found to be significantly different. Third, there was no significant difference for a specific tumor entity.

CONCLUSION

This study revealed a positive impact of a higher number of multidisciplinary tumor boards on the clinical outcome. Also, our analysis hints towards a positive effect of multidisciplinary tumor boards on overall survival.

Transfection of dendritic cells with in vitro-transcribed CMV RNA induces polyclonal CD8+- and CD4+-mediated CMV-specific T cell responses

Transfection of dendritic cells (DCs) with RNA was shown to be effective in the generation of antigen-specific T cells, probably due to the induction of a polyclonal T cell response directed against multiple antigens. To verify this assumption we used DCs, generated from cytomegalovirus (CMV)-negative or -positive donors, that were electroporated with in vitro-transcribed RNA (in vitro transcript, IVT) coding for the CMV pp65 antigen. We found that transfection of DCs with pp65 IVT induces an expansion of polyclonal CD8(+) T lymphocytes that recognize peptide antigens presented on different HLA molecules. These T lymphocytes are able to lyse DCs pulsed with pp65-derived peptides or transfected with the cognate IVT. Furthermore, this approach allowed the identification of immunodominant epitopes presented upon IVT transfection. Interestingly, transfection of DCs with pp65 IVT resulted in the induction of CD4(+)-specific T cells. Cotransfection of DCs with IVTs coding for the CMV antigens pp65 and IE1 elicited polyclonal T lymphocytes specific for peptides derived from both antigens. More importantly, cytotoxic T cells could be generated in two of three CMV-negative donors. Finally, functional CMV-specific autologous cytotoxic T lymphocytes were successfully generated from immunosuppressed patients after allogeneic hematopoietic stem cell transplantation.