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Mamo T, Sumstad D, DeFor TE, Cao Q, MacMillan ML, Brunstein C, Juckett M, McKenna DH. Harvest Quality, Nucleated Cell Dose and Clinical Outcomes in Bone Marrow Transplantation: A Retrospective Study. Transplant Cell Ther 2023; 29:638.e1-638.e8. [PMID: 37419326 PMCID: PMC10592389 DOI: 10.1016/j.jtct.2023.07.003] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/29/2023] [Accepted: 07/02/2023] [Indexed: 07/09/2023]
Abstract
Higher doses of infused nucleated cells (NCs) are associated with improved clinical outcomes in bone marrow transplantation (BMT) recipients. Most clinicians recommend infusing at least 2.0 × 108 NCs/kg. BMT clinicians request a target NC dose, but the harvested NC dose may be below the requested NC dose even before cell processing. We conducted this retrospective study to investigate the quality of bone marrow (BM) harvest and factors that influence infused NC doses at our institution. We also correlated infused NC doses with clinical outcomes. The study population included 347 BMT recipients (median age, 11 years; range, <1 to 75 years) at the University of Minnesota between 2009 and 2019. Underlying diagnoses mainly included 39% malignant and 61% nonmalignant diagnoses. Requested, harvested, and infused NC doses, as well as cell processing data, were obtained from the Cell Therapy Laboratory; clinical outcomes data were obtained from the University of Minnesota BMT Database. BM harvests were facilitated either by our institution (61%) or by the National Marrow Donor Program (39%). Associations of infused doses with baseline characteristics were assessed using the general Wilcoxon test/Pearson's correlation coefficient. The association of infused dose with neutrophil engraftment (absolute neutrophil count >500) by day 42, platelet engraftment (>20,000) by 6 months, acute graft-versus-host disease grade II-IV, and overall survival (OS) at 5 years were evaluated using regression and Kaplan-Meier curves. The median requested NC dose was 3.0 × 108/kg (range, 2 to 8 × 108/kg), and the median harvested and infused NC doses were 4.0 × 108/kg and 3.6 × 108/kg, respectively. Only 7% of donors had a harvested dose below the minimum requested dose. Moreover, the correlation between requested doses and harvested doses was adequate, with a harvested/requested dose ratio <.5 observed in only 5% of harvests. Additionally, the harvest volume and cell processing method were significantly correlated with the infused dose. Harvest volume exceeding the median of 948 mL was related to a significantly lower infused dose (P < .01). Moreover, hydroxyethyl starch (HES)/buffy coat processing (used to reduce RBCs with major ABO incompatibility) led to a significantly lower infused dose (P < .01). Donor age (median, 19 years; range, <1 to-70 years) and sex did not significantly influence the infused dose. Finally, the infused dose was significantly correlated with neutrophil and platelet engraftment (P < .05) but not with 5-year OS (P = .87) or aGVHD (P = .33). In our program's experience, BM harvesting is efficient and meets the requested minimum dose for 93% of recipients. Harvest volume and cell process play significant roles in determining the final infused dose. Minimizing harvest volume and cell processing could lead to increased infused dose and thus improved outcomes. Moreover, a higher infused dose leads to a better rate of neutrophil and platelet engraftment but not to improved OS, which may be linked to the sample size of our study.
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Affiliation(s)
- Theodros Mamo
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota.
| | - Darin Sumstad
- M Health, Fairview Cell Therapy Laboratory and Molecular & Cellular Therapeutics, University of Minnesota, St Paul, Minnesota
| | - Todd E DeFor
- Masonic Cancer Center Biostatistics Core, University of Minnesota, Minneapolis, Minnesota
| | - Qing Cao
- Masonic Cancer Center Biostatistics Core, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Blood and Marrow Transplantation & Cellular Therapy Program, University of Minnesota, Minneapolis, Minnesota; Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Claudio Brunstein
- Blood and Marrow Transplantation & Cellular Therapy Program, University of Minnesota, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Mark Juckett
- Blood and Marrow Transplantation & Cellular Therapy Program, University of Minnesota, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - David H McKenna
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota; M Health, Fairview Cell Therapy Laboratory and Molecular & Cellular Therapeutics, University of Minnesota, St Paul, Minnesota
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Rashidi A, Huselton EJ, Stefanski HE, DeFor TE, Shanley R, Choi J, DiPersio JF, Juckett M, Miller JS, Weisdorf DJ, Schroeder MA. A Multicenter Phase 2 Clinical Trial of 10-Day Decitabine, Dose-Escalated Donor Lymphocyte Infusion, and Ruxolitinib for Relapsed Acute Myeloid Leukemia and Myelodysplastic Syndromes after Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2023; 29:328.e1-328.e6. [PMID: 36804933 PMCID: PMC10149582 DOI: 10.1016/j.jtct.2023.02.010] [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: 09/27/2022] [Revised: 12/22/2022] [Accepted: 02/10/2023] [Indexed: 02/22/2023]
Abstract
Post-transplantation relapse of acute myeloid leukemia and myelodysplastic syndromes has a poor prognosis. Donor lymphocyte infusion (DLI) is one treatment approach. However, efficacy is limited, and toxicity, mostly in the form of acute graft-versus-host disease (GVHD), is frequent. We tested a novel approach using 10-day decitabine, dose-escalated DLI, and ruxolitinib in a multicenter phase 2 trial aimed at increasing the efficacy of DLI and reducing its toxicity. Up to four 28-day cycles were administered. The primary endpoint was 6-month overall survival (OS). Of the 14 patients who started cycle 1, 13 received 1 DLI, 6 received 2 DLIs, and 1 received 3 4 DLIs. A preplanned interim analysis after enrolling 14 patients suggested futility, and the trial was closed to accrual. The final analysis showed a 6-month OS of 36% (95% confidence interval [CI], 18 to 72), a 1-year progression-free survival of 7% (95% CI, 1% to 47%), a 6-month cumulative incidence of grade II-IV acute GVHD of 57% (95% CI, 26% to 80%), and a 1-year nonrelapse mortality of 14% (95% CI, 2% to 38%). The combined modality treatment studied in this trial was ineffective and did not reduce DLI toxicity.
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Affiliation(s)
- Armin Rashidi
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota; Clinical Research Division, Fred Hutchinson Cancer Center and Division of Oncology, University of Washington, Seattle, Washington.
| | - Eric J Huselton
- Division of Hematology and Oncology, University of Rochester, Rochester, New York
| | - Heather E Stefanski
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Todd E DeFor
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Ryan Shanley
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Jaebok Choi
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - John F DiPersio
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Mark Juckett
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Jeffrey S Miller
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Mark A Schroeder
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
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El Jurdi N, Okoev G, DeFor TE, Holtan SG, Betts BC, Blazar BR, Brunstein CG, MacMillan ML, Weisdorf DJ, Arora M. Predictors and outcomes of flares in chronic graft-versus-host disease. Bone Marrow Transplant 2022; 57:790-794. [DOI: 10.1038/s41409-022-01628-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 02/11/2022] [Accepted: 02/17/2022] [Indexed: 11/10/2022]
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El Jurdi N, Shabaneh A, Betts BC, Rashidi A, MacMillan ML, Arora M, DeFor TE, Miller DD, Schultz B, Mortari A, Weisdorf D, Wang J, Holtan S. Distinctive Transcriptional and Microbial Signature in Cutaneous Acute Graft-Vs-Host-Disease. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00192-0] [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: 11/29/2022]
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Krieger E, Hinderlie P, Wagner JE, Miller JS, DeFor TE, Felices M, MacMillan ML. Early Engraftment and Lymphocyte Reconstitution Outcomes after Alpha/Beta T Cell Receptor Depletion in Patients Transplanted for Fanconi Anemia. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00710-2] [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]
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El Jurdi N, O’Leary D, He F, DeFor TE, Rashidi A, Warlick E, Gupta A, Maakaron JE, Arora M, Janakiram M, Slungaard A, Smith AR, Bachanova V, Brunstein CG, MacMillan ML, Miller JS, Betts BC, Ebens CL, Stefanski HE, Lund TC, Orchard PJ, Vercellotti GM, Weisdorf D, Holtan S. Low Incidence of Chronic Graft-Versus-Host Disease in Myeloablative Allogeneic Hematopoietic Cell Transplantation with Post-Transplant Cyclophosphamide Using Matched Related or Unrelated Donors: Phase II Study Interim Analysis. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00530-9] [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: 10/18/2022]
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Singh S, DeFor TE, Weisdorf D, Carrier C, Nick ML, Schafer E, Brunstein CG, El Jurdi N, Holtan S, Maakaron JE, Rashidi A, Ramesh V, Te HS, Arora M, He F. Prevalence and Predictors of Pre-HCT Frailty in Autologous and Allogeneic Hematopoietic Cell Transplant Recipients. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00345-1] [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: 10/18/2022]
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Brunstein CG, DeFor TE, Fuchs EJ, Karanes C, McGuirk JP, Rezvani AR, Eapen M, O'Donnell PV, Weisdorf DJ. Engraftment of Double Cord Blood Transplantation after Nonmyeloablative Conditioning with Escalated Total Body Irradiation Dosing to Facilitate Engraftment in Immunocompetent Patients. Transplant Cell Ther 2021; 27:879.e1-879.e3. [PMID: 34273598 DOI: 10.1016/j.jtct.2021.07.006] [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: 06/08/2021] [Revised: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Abstract
To improve accrual to a randomized clinical trial of double unrelated cord blood (dUCB) versus HLA-haploidentical bone marrow (haplo-BM) transplantation, patients with less previous therapy and potentially greater immunocompetence were enrolled. To reduce the risk of graft rejection, patients randomized to receive dUCB received a higher dose of total body irradiation (TBI) (300 cGy versus 200 cGy). In this study, we investigated whether the inclusion of recipients of 300 cGy TBI influenced the trial outcomes. This was a secondary analysis of dUCB recipients, 161 who received TBI 200 cGy and 18 who received TBI 300 cGy. Fine and Gray regression was used to evaluate the effect of TBI dose on relapse and nonrelapse mortality (NRM). Cox regression was used for evaluation of neutrophil engraftment and overall survival. Patient characteristics were similar in the 2 TBI dose subgroups. The probability of neutrophil engraftment was 100% for patients who received TBI 300 cGy versus 91% (95% confidence interval, 86% to 95%) for those who received TBI 200 cGy (P = .64), which was similar after regression analysis adjusting for age, total infused nucleated cell dose, HLA matching to the patient, and comorbidity score. We also investigated whether the lower survival probability and higher cumulative incidence of NRM observed in the dUCB arm of BMT CTN 1101 could be influenced by the TBI 300 cGy patient subset. There was no significant difference in the 1-year incidences of NRM and relapse or in 1-year survival, even after adjustment in multivariate analysis. Patients in BMT CTN 1101 who received TBI 300 cGy and 200 cGy had similar engraftment and early mortality. We conclude that inclusion of a modified regimen for dUCB transplantation had no demonstrable influence on this large randomized trial.
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Affiliation(s)
- Claudio G Brunstein
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota.
| | - Todd E DeFor
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Ephraim J Fuchs
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
| | - Chatchada Karanes
- Department of Hematology/HCT, City of Hope National Medical Center, Duarte, California
| | - Joseph P McGuirk
- The University of Kansas Medical Center, Division of Hematologic Malignancies and Cellular Therapeutics, Blood and Marrow Transplant, Kansas City, Kansas
| | - Andrew R Rezvani
- Division of Blood and Marrow Transplantation, Department of Medicine, Stanford University Medical Center, Stanford, California
| | - Mary Eapen
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Paul V O'Donnell
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Daniel J Weisdorf
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
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Takahashi T, Arora M, Okoev G, DeFor TE, Weisdorf DJ, MacMillan ML. Late-Onset Acute and Chronic Graft-versus-Host Disease in Children: Clinical Features and Response to Therapy. Transplant Cell Ther 2021; 27:667.e1-667.e5. [PMID: 34077812 DOI: 10.1016/j.jtct.2021.05.022] [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: 04/18/2021] [Revised: 05/13/2021] [Accepted: 05/13/2021] [Indexed: 10/21/2022]
Abstract
Although acute graft-versus-host disease (aGVHD) and chronic GVHD (cGVHD) are known causes of morbidity and mortality after allogeneic hematopoietic cell transplantation (HCT), the syndrome of late aGVHD is less well understood, particularly in children. We aimed to characterize the clinical features and response to therapy of late aGVHD and cGVHD by retrospectively reviewing 573 consecutive patients age <18 years who underwent their first allogeneic HCT at the University of Minnesota. We included patients with de novo late aGVHD (ie, first occurrence of aGVHD after day +100 post-HCT) and cGVHD. We retrospectively scored cGVHD cases based on the 2014 National Institutes of Health guidelines. At 3 years, 9 patients (2%) had developed late aGVHD, 16 (3%) had overlap cGVHD, and 7 had (1%) classic cGVHD. No cases of joint or genital cGVHD were observed. The overall response to therapy at 6 months was 78% (95% confidence interval [CI], 40% to 97%) after late aGVHD and 43% (95% CI, 23% to 66%) after cGVHD. Higher nonrelapse mortality from day +100 was seen in patients with cGVHD but not in those with late aGVHD compared with patients without GVHD (hazard ratio, 3.6 [95% CI, 1.3 to 10.0] and 1.6 [95% CI, 0.2 to 11.7], respectively). We found variable organ involvement and treatment responses between patients with late aGVHD and those with cGVHD in a single-center pediatric cohort. Further research is needed to investigate the risks and clinical features of late aGVHD and cGVHD in larger cohorts to better understand how to tailor even more effective GVHD preventive and therapeutic approaches in children.
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Affiliation(s)
- Takuto Takahashi
- Blood and Marrow Transplantation and Cellular Therapy Program, Masonic Cancer Center, University of Minnesota Medical School, Minneapolis, Minnesota; Department of Pediatrics, Masonic Cancer Center, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Mukta Arora
- Blood and Marrow Transplantation and Cellular Therapy Program, Masonic Cancer Center, University of Minnesota Medical School, Minneapolis, Minnesota; Department of Medicine, Masonic Cancer Center, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Grigori Okoev
- Blood and Marrow Transplantation and Cellular Therapy Program, Masonic Cancer Center, University of Minnesota Medical School, Minneapolis, Minnesota; Department of Medicine, Masonic Cancer Center, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Todd E DeFor
- Blood and Marrow Transplantation and Cellular Therapy Program, Masonic Cancer Center, University of Minnesota Medical School, Minneapolis, Minnesota; Department of Biostatistics Core, Masonic Cancer Center, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Blood and Marrow Transplantation and Cellular Therapy Program, Masonic Cancer Center, University of Minnesota Medical School, Minneapolis, Minnesota; Department of Medicine, Masonic Cancer Center, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Blood and Marrow Transplantation and Cellular Therapy Program, Masonic Cancer Center, University of Minnesota Medical School, Minneapolis, Minnesota; Department of Pediatrics, Masonic Cancer Center, University of Minnesota Medical School, Minneapolis, Minnesota.
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Chinnabhandar V, DeFor TE, Tryon R, Wagner JE, MacMillan ML. Nonhematologic neoplasia in biallelic BRCA2 mutated Fanconi anemia. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.10041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10041 Background: Fanconi anemia (FA) is a cancer predisposition disorder. Affected individuals do not tolerate conventional doses of chemotherapy or radiation well. Biallelic BRCA2 mutations cause a rare (̃3%) form of FA. Most patients with this subtype have a family history of breast cancer and die in early childhood. Optimal management remains uncertain. Herein, we report the world’s largest single center cohort of biallelic BRCA2 patients, with a focus on non-hematologic malignancies. Methods: The University of Minnesota’s prospectively maintained FA database was analyzed for data on biallelic BRCA2 mutated FA patients. IRB-approved consent was obtained for all subjects. Results: Twenty patients with biallelic BRCA2 were identified. Median age of FA diagnosis was 1.5 years (range: 0-16.2 years). All patients had a significant history of cancer in the family with breast cancer being particularly frequent (65%). Eight (40%) patients developed non-hematologic neoplasia before 18 years of age. These included 10 malignant tumors and 4 benign neoplastic lesions; 3 patients had more than one solid tumor (see Table). Surgical resection was attempted in all malignant tumors, dose reduced adjuvant chemotherapy was utilized in 5 cases and radiation in one case. Thirteen (65%) patients developed hematologic malignancies (AML=6, ALL=3, MDS=4), all without preceding marrow failure. Fourteen patients underwent allogeneic HCT. Eleven patients have died, 3 from solid tumors and 5 from leukemias. Nine patients are currently alive, of whom 3 are post-HCT. Only 4 (age range: 6.5-16.3 years) patients in the cohort remain free of any oncologic diagnoses. Conclusions: Patients with FA due to biallelic BRCA2 mutations have a unique phenotype with an extraordinarily high risk of early-onset de-novo acute leukemia and solid tumors, often both diagnosed in the same patient. They require extensive, lifelong cancer surveillance from an early age to optimize outcomes. Therapy for malignant diagnoses should aim to minimise exposure to genotoxic / crosslinking agents and radiation. BRCA2 mutation testing in family members and appropriate genetic counselling is essential. Additionally, a family history of BRCA2 mutated cancers should prompt FA testing in offspring with any relevant FA-related clinical findings. Nonhematologic neoplasia and therapy.[Table: see text]
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El Jurdi N, Elhusseini H, Beckman J, DeFor TE, Okoev G, Rogosheske J, Lazaryan A, Weiler K, Bachanova V, Betts BC, Blazar BR, Brunstein CG, He F, Holtan SG, Janakiram M, Gangaraju R, Maakaron J, MacMillan ML, Rashidi A, Warlick ED, Bhatia S, Vercellotti G, Weisdorf DJ, Arora M. High incidence of thromboembolism in patients with chronic GVHD: association with severity of GVHD and donor-recipient ABO blood group. Blood Cancer J 2021; 11:96. [PMID: 34006823 PMCID: PMC8131386 DOI: 10.1038/s41408-021-00488-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/20/2021] [Accepted: 04/29/2021] [Indexed: 02/08/2023] Open
Abstract
Chronic graft-versus-host disease (cGVHD) after allogeneic hematopoietic cell transplantation (HCT) is associated with systemic inflammation and endothelial dysfunction, increasing risk for thromboembolic events (TEE). In 145 adult recipients who developed cGVHD after a matched sibling or umbilical cord blood donor HCT from 2010 to 2018, 32(22%) developed at least 1 TEE event, and 14(10%) developed 2 TEE events. The 5-year cumulative incidence of TEE was 22% (95% CI, 15–29%) with a median time from cGVHD to TEE of 234 days (range, 12–2050). Median time to the development of LE DVT or PE was 107 (range, 12–1925) compared to 450 days (range, 158–1300) for UE DVT. Cumulative incidence of TEE was 9% (95% CI, 0–20%), 17% (95% CI, 9–25%), and 38% (95% CI, 22–55%) in those with mild, moderate, and severe GVHD, respectively. Higher risk for TEE was associated with cGVHD severity (hazard ratio [HR] 4.9, [95% CI, 1.1–22.0]; p = 0.03), non-O-donor to recipient ABO match compared to O-donor to O-recipient match (HR 2.7, [95% CI, 1.0–7.5]; p = 0.053), and personal history of coronary artery disease (HR 2.4, [95% CI, 1.1–5.3]; p = 0.03). TEE was not associated with 2-year non-relapse mortality or 5-year overall survival. Patients with chronic GVHD after allogeneic hematopoietic cell transplantation are at high risk for thromboembolic events occurring years after diagnosis. More severe chronic GVHD, non-O donor-recipient ABO compared to O-O match and personal history of coronary artery disease are associated with higher risk of thromboembolic events.
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Affiliation(s)
- Najla El Jurdi
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - Heba Elhusseini
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Joan Beckman
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Todd E DeFor
- Biostatistics and Informatics, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Grigori Okoev
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - John Rogosheske
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Aleksandr Lazaryan
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Kristen Weiler
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Veronika Bachanova
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Brian C Betts
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Bruce R Blazar
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Claudio G Brunstein
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Fiona He
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Shernan G Holtan
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Murali Janakiram
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Radhika Gangaraju
- Department of Pediatrics, University of Alabama, Tuscaloosa, AL, USA
| | - Joseph Maakaron
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Margaret L MacMillan
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Armin Rashidi
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Erica D Warlick
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Smita Bhatia
- Department of Pediatrics, University of Alabama, Tuscaloosa, AL, USA
| | - Gregory Vercellotti
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Daniel J Weisdorf
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Mukta Arora
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Christakopoulos GE, DeFor TE, Hage S, Wagner JE, Linden MA, Brunstein C, Bejanyan N, Verneris MR, Smith AR. Phase I Dose-Finding, Safety, and Tolerability Trial of Romiplostim to Improve Platelet Recovery After UCB Transplantation. Transplant Cell Ther 2021; 27:497.e1-497.e6. [PMID: 33785364 DOI: 10.1016/j.jtct.2021.02.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 09/01/2020] [Revised: 12/22/2020] [Accepted: 02/26/2021] [Indexed: 11/18/2022]
Abstract
Platelet recovery is delayed after umbilical cord blood transplant (UCBT). Romiplostim is a thrombopoietin receptor agonist that has the potential to improve platelet engraftment after UCBT. The purpose of this study was to determine the safety profile and maximum tolerated dose (MTD) of romiplostim and to investigate whether romiplostim accelerates platelet recovery post-UCBT. It was a single-center, dose-finding, safety and tolerability phase I trial of weekly romiplostim in 20 adult patients who failed to achieve an un-transfused platelet count of 20 × 109/L by day +28 post-UCBT. Romiplostim was administered at the assigned dose as 6 weekly injections beginning by day +42 post-UCBT. Four dose levels (4, 6, 8, and 10 µg/kg per dose) were evaluated. The MTD of romiplostim was determined by the continual reassessment method, with a goal to identify a dose level with desired toxicity rate of ≤20%. Median age of the patients was 59.5 years, and 60% were female. Eleven patients received nonmyeloablative (NMA) double UCBT, seven patients received myeloablative single UCBT, and two patients received NMA single UCBT. Two patients received 4 µg/kg per dose, two received 6 µg/kg per dose, four received 8 µg/kg per dose, and the remaining 12 received 10 µg/kg per dose. Only five patients completed the full six doses of treatment. Of the 15 patients who received fewer than six doses, 12 were due to a platelet count of >100 × 109/L, two were due to platelet count of >400 × 109/L, and one was due to right upper extremity edema without thrombosis. All romiplostim-treated patients achieved platelet engraftment to 20 × 109/L at a median of 45 days post-UCBT compared to 90% of controls at a median of 45 days (P = .08). Similarly, 90% of romiplostim-treated patients achieved platelet engraftment to 50 × 109/L at a median of 48 days compared to 75% of controls at a median of 52 days (P = .09). All dose levels were effective with low toxicity; therefore, the MTD of romiplostim was 10 µg/kg per dose, and romiplostim is a safe and potentially effective therapy to counter delayed platelet recovery post-UCBT.
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Affiliation(s)
| | - Todd E DeFor
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Stefanie Hage
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - John E Wagner
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Michael A Linden
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Claudio Brunstein
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Nelli Bejanyan
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Michael R Verneris
- Division of Hematology, Oncology, and Bone Marrow Transplantation, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Angela R Smith
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota.
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13
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Stefanski HE, Brunstein CG, McKenna DH, Sumstad D, DeFor TE, Blazar BR, Miller JS, Hage SM, Boitano AE, Wilson CG, Raffel GD, Davis JC, Wagner JE. MGTA-456, A CD34 Expanded Cord Blood Product, Permits Selection of Better HLA Matched Units and Results in Rapid Hematopoietic Recovery, Uniform Engraftment and Reduced Graft-Versus-Host Disease in Adults with High-Risk Hematologic Malignancies. Transplant Cell Ther 2021. [DOI: 10.1016/s2666-6367(21)00057-9] [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: 10/22/2022]
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14
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Geller MA, Cooley SA, Wallet M, Valamehr B, Teoh DGK, DeFor TE, Felices M, Miller J. APOLLO: A phase I study of adaptive memory natural killer (NK) cells in recurrent ovarian cancer. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.6044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6044 Background: Human cytomegalovirus (CMV) infection induces a subset of long-lived CD57+NKG2C+ adaptive NK cells that exhibit enhanced antibody-dependent cellular cytotoxicity and resistance to tumor-suppressive mechanisms. We developed a 7-day culture process using a GSK3 inhibitor and IL-15 to manufacture modulated adaptive NK cells (FATE-NK100) from CMV+ haploidentical donors for adoptive transfer. The phase I Apollo trial tests the maximum tolerated dose/maximum feasible dose (MTD/MFD) of FATE-NK100 administered intraperitoneally (IP) to treat platinum-sensitive or -resistant recurrent ovarian, fallopian tube, and primary peritoneal cancer. Methods: FATE-NK100 via IP port was tested using 3 dose cohorts ([DC]; 1 × 107 cells/kg; >1 × 107 cells/kg to ≤3 × 107 cells/kg; or >3 × 107 to ≤10 × 107 cells/kg) after lympho-conditioning with fludarabine 25 mg/m2 IV and cyclophosphamide 300 mg/m2 IV on days −6 and −5. After FATE-NK100 infusion on day 0, rhIL-2 at 6 million IU was given IP 3 times a week for 6 doses for in vivo NK activation. IP fluid and peripheral blood were collected regularly until response assessment (day 28). Patients with stable disease or better were eligible for retreatment. Pre- and post-treatment tumor biopsies were collected. Results: Nine patients were treated with no dose-limiting toxicities (DLTs) to date. Retreatment based on clinical benefit was performed on 3 patients (33%), 2 following stable disease (DC 2) and 1 with partial remission (48% tumor reduction, DC 3). IP samples were collected for PK and functional analysis. FATE-NK100 product was detected by flow cytometry in 5 of 6 patients with evaluable samples (range 4.8%–91.2% donor NK cells at day +5-7). Retreatment samples were available in 1 patient, where FATE-NK100 persisted to day +21, demonstrating that repeated IP dosing did not accelerate clearance of the donor NK cells. In that same patient, measurement of NK cell CD107a degranulation or IFNg production in response to K562 targets demonstrated sustained enhanced in vivo function of FATE-NK100 compared to endogenous patient NK cells (e.g. at Day +12 CD107a+ NK were 39.0% vs. 22.5% cycle 1, and 40.3% vs. 18.2% retreatment cycle 2, and IFNg+ NK were 12.3% vs. 5.9% cycle 1, and 2.4% vs. 0.2% retreatment cycle 2). Conclusions: IP delivery of FATE-NK100 is safe, with clinical benefit in 3/9 patients treated. The allogeneic product cells persist and have enhanced function compared to patient NK cells for up to 21 days, even after retreatment. This phase I study in recurrent/refractory ovarian cancer shows promise for IP NK cell delivery. Clinical trial information: NCT00652899.
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MacMillan ML, DeFor TE, Holtan SG, Rashidi A, Blazar BR, Weisdorf DJ. Validation of Minnesota acute graft- versus-host disease Risk Score. Haematologica 2020; 105:519-524. [PMID: 31320554 PMCID: PMC7012472 DOI: 10.3324/haematol.2019.220970] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/12/2019] [Indexed: 01/24/2023] Open
Abstract
Using multicenter data, we developed a novel acute graft-versus-host disease Risk Score which more accurately predicts response to steroid treatment, survival and transplant related mortality than other published risk scores based upon clinical grading criteria.1 To validate this Risk Score in a contemporary cohort, we examined 355 recent University of Minnesota patients (2007-2016) diagnosed with acute graft-versus-host disease and treated with prednisone 60 mg/m2/day for 14 days, followed by an 8-week taper. Overall response [complete response + partial response] was higher in the 276 standard risk versus 79 high risk graft-versus-host disease patients at day 14 (71% versus 56%, P<0.01), day 28 (74% versus 59%, P=0.02) and day 56 (68% versus 49%, P<0.01) after steroid initiation. Day 28 response did not differ by the initial graft-versus-host disease grade. In multiple regression analysis, patients with high risk graft-versus-host disease were less likely to respond at day 28 (odds ratio 0.5, 95% CI 0.3-0.9, P<0.01) and had higher risks of 2 year transplant related mortality (Hazard Ratio 1.8, 95% CI, 1.0-2.1, P=0.03) and overall mortality (Hazard Ratio 1.7, 95% CI, 1.2-2.4, P<0.01) than patients with a standard risk graft-versus-host disease. This analysis confirms the Minnesota graft-versus-host disease Risk Score as a valuable bedside tool to define risk in patients with acute graft-versus-host disease. A tailored approach to upfront acute graft-versus-host disease therapy based upon the Minnesota Risk Score may improve outcomes and facilitate testing of novel treatments in these patients.
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Affiliation(s)
- Margaret L MacMillan
- Blood and Marrow Transplant Program, University of Minnesota Medical School, Minneapolis, MN .,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Todd E DeFor
- Blood and Marrow Transplant Program, University of Minnesota Medical School, Minneapolis, MN.,Biostatistics and Informatics Core, Masonic Cancer Center, University of Minnesota Medical School, Minneapolis, MN
| | - Shernan G Holtan
- Blood and Marrow Transplant Program, University of Minnesota Medical School, Minneapolis, MN.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Armin Rashidi
- Blood and Marrow Transplant Program, University of Minnesota Medical School, Minneapolis, MN.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Bruce R Blazar
- Blood and Marrow Transplant Program, University of Minnesota Medical School, Minneapolis, MN.,Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Daniel J Weisdorf
- Blood and Marrow Transplant Program, University of Minnesota Medical School, Minneapolis, MN.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
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16
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Lee CH, Huang CY, DeFor TE, Brunstein CG, Weisdorf DJ, Luo X. SEMIPARAMETRIC REGRESSION MODEL FOR RECURRENT BACTERIAL INFECTIONS AFTER HEMATOPOIETIC STEM CELL TRANSPLANTATION. Stat Sin 2019; 29:1489-1509. [PMID: 31511757 DOI: 10.5705/ss.202017.0397] [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] [Indexed: 11/06/2022]
Abstract
Patients who undergo hematopoietic stem cell transplantation (HSCT) often experience multiple bacterial infections during the early post-transplant period. In this article, we consider a semiparametric regression model that correlates patient- and transplant-related risk factors with inter-infection gap times. Existing regression methods for recurrent gap times are not directly applicable to study post-transplant infection because the initiating event (transplant) is different than the recurrent events of interest (post-transplant infections); as a result, the time from transplant to the first infection and the time elapsed between consecutive infections have distinct biological meanings and hence follow different distributions. Moreover, risk factors may have different effects on these two types of gap times. We propose a semiparametric estimation procedure to evaluate the covariate effects on time from transplant to thefirst infection and on gap times between consecutive infections simultaneously. The proposed estimator accounts for dependent censoring induced by within-subject correlation among recurrent gap times and length bias in the last censored gap time due to intercept sampling. We study the finite sample properties through simulations and present an application of the proposed method to the post-HSCT bacterial infection data collected at the University of Minnesota.
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Affiliation(s)
- Chi Hyun Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA 94158, USA
| | - Todd E DeFor
- Division of Hematology, Biostatistics, Oncology and Transplantation, Department of Medicine, Blood and Marrow Transplantation Program, Masonic Cancer Center, Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA
| | - Claudio G Brunstein
- Division of Hematology, Biostatistics, Oncology and Transplantation, Department of Medicine, Blood and Marrow Transplantation Program, Masonic Cancer Center, Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA
| | - Daniel J Weisdorf
- Division of Hematology, Biostatistics, Oncology and Transplantation, Department of Medicine, Blood and Marrow Transplantation Program, Masonic Cancer Center, Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA
| | - Xianghua Luo
- Division of Hematology, Biostatistics, Oncology and Transplantation, Department of Medicine, Blood and Marrow Transplantation Program, Masonic Cancer Center, Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA
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17
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Holtan SG, Zhang L, DeFor TE, Bejanyan N, Arora M, Rashidi A, Lazaryan A, Kotiso F, Blazar BR, Wagner JE, Brunstein CG, MacMillan ML, Weisdorf DJ. Dynamic Graft-versus-Host Disease-Free, Relapse-Free Survival: Multistate Modeling of the Morbidity and Mortality of Allotransplantation. Biol Blood Marrow Transplant 2019; 25:1884-1889. [PMID: 31128328 PMCID: PMC6755055 DOI: 10.1016/j.bbmt.2019.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 03/17/2019] [Revised: 05/06/2019] [Accepted: 05/12/2019] [Indexed: 01/08/2023]
Abstract
Graft-versus-host disease (GVHD)-free, relapse-free survival (GRFS) represents complete, ideal recovery after allogeneic hematopoietic cell transplantation (HCT). However, as originally proposed, this composite endpoint does not account for the possibility that HCT complications may improve after treatment. To more accurately estimate survival with response to GVHD and relapse after HCT, we developed a dynamic multistate GRFS (dGRFS) model with outcomes data from 949 patients undergoing their first allogeneic HCT for hematologic malignancy at the University of Minnesota. Because some patients were successfully treated for GVHD and relapse, dGRFS was higher than the originally defined time-to-event GRFS at 1 year (37.0 versus 27.6%) through 4 years (37.4% versus 22.2%). Mean survival without failure events was .52 years (95% confidence interval, .45 to .58 year) greater in dGRFS compared with the originally defined GRFS. Patient age (P< .001), disease risk (P < .001), conditioning intensity (P = .007), and donor type (P = .003) all significantly influenced dGRFS. The multistate model of dGRFS closely estimates the continuing and prevalent severe morbidity and mortality of allogeneic HCT. To serve the greater HCT community in more accurately modeling recovery from transplantation, we provide our R code for determination of dGRFS with annotations in Supplementary Materials.
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Affiliation(s)
- Shernan G Holtan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota.
| | - Lin Zhang
- Biostatistics and Informatics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Todd E DeFor
- Biostatistics and Informatics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | | | - Mukta Arora
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Armin Rashidi
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | | | | | - Bruce R Blazar
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - John E Wagner
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
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18
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Holtan SG, Shabaneh A, Betts BC, Rashidi A, MacMillan ML, Ustun C, Amin K, Vaughn BP, Howard J, Khoruts A, Arora M, DeFor TE, Johnson D, Blazar BR, Weisdorf DJ, Wang J. Stress responses, M2 macrophages, and a distinct microbial signature in fatal intestinal acute graft-versus-host disease. JCI Insight 2019; 5:129762. [PMID: 31393854 DOI: 10.1172/jci.insight.129762] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Steroid-refractory intestinal acute graft-versus-host disease (aGVHD) is a frequently fatal condition with little known about mechanisms driving failed steroid responses in gut mucosa. To uncover novel molecular insights in steroid-refractory aGVHD, we compared gene expression profiles of rectosigmoid biopsies from patients at diagnosis of clinical stage 3-4 lower intestinal aGVHD (N=22), to repeat biopsies when the patients became steroid refractory (N=22), and normal controls (N=10). We also performed single gene analyses of factors associated with tolerance (programmed death ligand-1 [PDL1], indoleamine 2,3 dioxygenase [IDO1], and T cell immunoreceptor with Ig and ITIM domains [TIGIT]) and found that significantly higher expression levels of these aGVHD inhibitory genes (PDL1, IDO1, TIGIT) at aGVHD onset became decreased in the steroid-refractory state. We examined genes triggered by microbial ligands to stimulate gut repair, amphiregulin (AREG) and the aryl hydrocarbon receptor (AhR), and found that both AREG and AhR gene expression levels were increased at aGVHD onset and remained elevated in steroid-refractory aGVHD. We also identified higher expression levels of metallothioneines, metal-binding enzymes induced in stress responses, and M2 macrophage genes in steroid-refractory aGVHD. We observed no differences in T-cell subsets between onset and steroid-refractory aGVHD. Patients with a rapidly fatal course showed greater DNA damage and a distinct microbial signature at aGVHD onset, whereas patients with more prolonged survival exhibited a gene expression profile consistent with activation of Smoothened. Our results extend the paradigm beyond T cell-centric therapies for steroid-refractory GI aGVHD and highlight new mechanisms for therapeutic exploration.
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Affiliation(s)
| | | | - Brian C Betts
- Blood and Marrow Transplant Program, Department of Medicine
| | - Armin Rashidi
- Blood and Marrow Transplant Program, Department of Medicine
| | - Margaret L MacMillan
- Blood and Marrow Transplant Program, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Celalletin Ustun
- Rush University Blood and Marrow Transplant Program, Chicago, Illinois, USA
| | | | | | - Justin Howard
- Division of Gastroenterology, Department of Medicine
| | | | - Mukta Arora
- Blood and Marrow Transplant Program, Department of Medicine
| | | | | | - Bruce R Blazar
- Blood and Marrow Transplant Program, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Jinhua Wang
- Cancer Bioinformatics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
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Rashidi A, Ebadi M, Shields-Cutler RR, Kruziki K, Manias DA, Barnes AMT, DeFor TE, Ferrieri P, Young JAH, Knights D, Blazar BR, Weisdorf DJ, Dunny GM. Early E. casseliflavus gut colonization and outcomes of allogeneic hematopoietic cell transplantation. PLoS One 2019; 14:e0220850. [PMID: 31393924 PMCID: PMC6687141 DOI: 10.1371/journal.pone.0220850] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 07/24/2019] [Indexed: 12/25/2022] Open
Abstract
Gut dysbiosis has been associated with worse allogeneic hematopoietic cell transplantation (allo-HCT) outcomes. We reported an association between intrinsically vancomycin-resistant enterococci (iVRE: E. gallinarum and E. casseliflavus) gut colonization and lower post-transplant mortality. In this study, using an expanded cohort, we evaluated whether our previously observed association is species-specific. We included allo-HCT recipients with ≥1 positive rectal swab or stool culture for iVRE between days -14 and +14 of transplant. To investigate whether iVRE modulate the gut microbiota, we performed agar diffusion assays. To investigate whether iVRE differ in their ability to activate the aryl hydrocarbon receptor, we analyzed iVRE genomes for enzymes in the shikimate and tryptophan pathways. Sixty six (23 E. casseliflavus and 43 E. gallinarum) of the 908 allograft recipients (2011-2017) met our inclusion criteria. Overall survival was significantly higher in patients with E. casseliflavus (91% vs. 62% at 3 years, P = 0.04). In multivariable analysis, E. casseliflavus gut colonization was significantly associated with reduced all-cause mortality (hazard ratio 0.20, 95% confidence interval 0.04-0.91, P = 0.04). While agar assays were largely unremarkable, genome mining predicted that E. casseliflavus encodes a larger number of enzymes in the tryptophan metabolism pathway. In conclusion, E. casseliflavus gut colonization is associated with reduced post-HCT morality. Further research is needed to understand the mechanisms for this association.
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Affiliation(s)
- Armin Rashidi
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Maryam Ebadi
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States of America
| | - Robin R. Shields-Cutler
- BioTechnology Institute, College of Biological Sciences, University of Minnesota, MN, United States of America
- Department of Biology, Macalester College, Saint Paul, MN, United States of America
| | - Kathryn Kruziki
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN, United States of America
| | - Dawn A. Manias
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN, United States of America
| | - Aaron M. T. Barnes
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN, United States of America
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, United States of America
| | - Todd E. DeFor
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, United States of America
| | - Patricia Ferrieri
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, United States of America
| | - Jo-Anne H. Young
- Division of Infectious Disease and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Dan Knights
- BioTechnology Institute, College of Biological Sciences, University of Minnesota, MN, United States of America
| | - Bruce R. Blazar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States of America
| | - Daniel J. Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Gary M. Dunny
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, MN, United States of America
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20
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Pamukcuoglu M, Bhatia S, Weisdorf DJ, DeFor TE, Ustun C, Nayar M, Holtan SG, Jurdi NE, Thyagarajan B, Brunstein CG, Bachanova V, Warlick ED, Severseike B, Te HS, Lund T, Arora M. Hematopoietic Cell Transplant-Related Toxicities and Mortality in Frail Recipients. Biol Blood Marrow Transplant 2019; 25:2454-2460. [PMID: 31394273 DOI: 10.1016/j.bbmt.2019.07.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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: 05/15/2019] [Revised: 07/07/2019] [Accepted: 07/23/2019] [Indexed: 01/23/2023]
Abstract
Frailty is a state characterized by diminished physiologic reserve and increased vulnerability to stress and adversely affects outcomes in older patients. We aimed to determine the relationship between pre-hematopoietic cell transplant (HCT) frailty and grades 3 to 4 nonhematologic toxicities (Common Terminology Criteria for Adverse Events, version 5.0) and mortality in HCT recipients within 1 year after HCT and also examined whether age at HCT moderated that association. In a prospective longitudinal study of 117 patients aged ≥ 40 years undergoing HCT, we performed formal pre-HCT geriatric assessments. Frailty was assessed using Fried's criteria. Post-HCT toxicities were abstracted through medical record reviews. The prevalence of pre-HCT frailty was 21% and was not different in younger (40 to 59 years) versus older (≥60 years) HCT recipients. Overall, frail recipients (versus nonfrail) had a higher cumulative incidence of any grades 3 to 4 nonhematologic toxicity (86% [95% confidence interval {CI}, 62% to 100%] versus 70% [95% CI, 57% to 83%), P = .03) and more organ-specific grades 3 to 4 toxicities, such as non-neutropenic infections (38% [95% CI, 17% to 59%] versus 13% [95% CI, 6% to 20%], P < .01), nervous system disorders (19% [95% CI, 3% to 35%] versus 4% [95% CI, 0 to 8%], P = .02), and pneumonia (38% [95% CI, 17% to 59%] versus 10% [95% CI, 4% to 17%], P < .01). Frail recipients were 1.9-fold (95% CI, 1.1 to 3.4) more likely to develop any grades 3 to 4 toxicities (P = .03), 4-fold more likely to suffer non-neutropenic infections (95% CI, 1.4 to 11) and pneumonia (95% CI, 1.4 to 12; both P = .01), and 8.6-fold (95% CI, 1.6 to 45.3) more likely to suffer nervous system disorders (P = .01). Frail allogeneic HCT recipients also had a 3.1 times (95% CI, .9 to 9.7; P = .06) higher risk of overall mortality as compared with nonfrail allogeneic HCT recipients. The higher toxicity and mortality observed in frail allogeneic recipients needs to be monitored with high attention. Studies focusing on interventions to reduce frailty and manage morbidities are needed.
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Affiliation(s)
- Merve Pamukcuoglu
- Division of Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, Minnesota
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, Minnesota
| | - Todd E DeFor
- Division of Biostatistics, Clinical Translational Science Institute, University of Minnesota, Minneapolis, Minnesota
| | - Celalettin Ustun
- Division of Hematology Oncology and Transplant, Rush University Medical Center, Chicago, Illinois
| | - Manju Nayar
- Division of Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, Minnesota
| | - Shernan G Holtan
- Division of Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, Minnesota
| | - Najla-El Jurdi
- Division of Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, Minnesota
| | - Bharat Thyagarajan
- Lab Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Division of Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, Minnesota
| | - Veronika Bachanova
- Division of Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, Minnesota
| | - Erica D Warlick
- Division of Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, Minnesota
| | - Ben Severseike
- Department of Pediatrics, Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Hok Sreng Te
- Division of Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, Minnesota
| | - Troy Lund
- Department of Pediatrics, Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Mukta Arora
- Division of Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, Minnesota.
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21
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Rashidi A, DeFor TE, Holtan SG, Blazar BR, Weisdorf DJ, MacMillan ML. Outcomes and Predictors of Response in Steroid-Refractory Acute Graft-versus-Host Disease. Biol Blood Marrow Transplant 2019; 25:2297-2302. [PMID: 31325587 DOI: 10.1016/j.bbmt.2019.07.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [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: 06/05/2019] [Revised: 07/11/2019] [Accepted: 07/11/2019] [Indexed: 11/19/2022]
Abstract
The prognosis of steroid-refractory acute graft-versus-host disease (aGVHD) is poor, and predictors of response and survival are unclear. In an exploratory analysis of 203 steroid-refractory aGVHD patients with prospectively collected GVHD data who received antithymocyte globulin, etanercept, or mycophenolate mofetil (MMF) as second-line treatment, we determined the predictors of day 28 response, 2-year overall survival, and 2-year nonrelapse mortality (NRM). To minimize the risk of finding false-positive results, we used least absolute shrinkage and selection operator regression, aggressively eliminating variables that are unlikely to be associated with outcome. Day 28 response to second-line therapy was 38% (complete response, 23%), with a 2-year overall survival of 25% and a 2-year NRM of 62%. Factors associated with response were GVHD prophylaxis, organ involvement, and initial aGVHD to steroid-refractory aGVHD interval. Specifically, compared with cyclosporine/MMF as GVHD prophylaxis, the odds ratio (OR) for calcineurin inhibitor/methotrexate was .8 and for cyclosporine/prednisone .6. The OR for aGVHD to steroid-refractory aGVHD interval ≥ 14 versus <14 days was 1.3. The ORs for skin only involvement and gut or liver only involvement when compared with multiorgan involvement were 1.4 and 1.2, respectively. The only variable associated with worse survival was age, with a hazard ratio (HR) per decade of 1.04 for overall mortality. Similarly, age was the only variable associated with NRM (HR per decade, 1.02). When compared with complete response, no response at day 28 increased the risk of death (HR, 2.4; 95% confidence interval, 1.5 to 3.7). In conclusion, by means of an underused statistical technique in the field of transplantation, we identified predictors of response and survival in steroid-refractory aGVHD. Our results highlight the importance of developing novel treatment strategies because current treatments yield poor outcomes.
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Affiliation(s)
- Armin Rashidi
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
| | - Todd E DeFor
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Shernan G Holtan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Bruce R Blazar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
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Ebens CL, McGrath JA, Tamai K, Hovnanian A, Wagner JE, Riddle MJ, Keene DR, DeFor TE, Tryon R, Chen M, Woodley DT, Hook K, Tolar J. Bone marrow transplant with post-transplant cyclophosphamide for recessive dystrophic epidermolysis bullosa expands the related donor pool and permits tolerance of nonhaematopoietic cellular grafts. Br J Dermatol 2019; 181:1238-1246. [PMID: 30843184 DOI: 10.1111/bjd.17858] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Recessive dystrophic epidermolysis bullosa (RDEB) is a severe systemic genodermatosis lacking therapies beyond supportive care for its extensive, life-limiting manifestations. OBJECTIVES To report the safety and preliminary responses of 10 patients with RDEB to bone marrow transplant (BMT) with post-transplant cyclophosphamide (PTCy BMT) after reduced-intensity conditioning with infusions of immunomodulatory donor-derived mesenchymal stromal cells (median follow-up 16 months). METHODS BMT toxicities, donor blood and skin engraftment, skin biopsies, photographic and dynamic assessments of RDEB disease activity were obtained at intervals from pre-BMT to 1 year post-BMT. RESULTS Related donors varied from haploidentical (n = 6) to human leucocyte antigen (HLA)-matched (n = 3), with one HLA-matched unrelated donor. Transplant complications included graft failure (n = 3; two pursued a second PTCy BMT), veno-occlusive disease (n = 2), posterior reversible encephalopathy (n = 1) and chronic graft-versus-host disease (n = 1; this patient died). In the nine ultimately engrafted patients, median donor chimerism at 180 days after transplant was 100% in peripheral blood and 27% in skin. Skin biopsies showed stable (n = 7) to improved (n = 2) type VII collagen protein expression by immunofluorescence and gain of anchoring fibril components (n = 3) by transmission electron microscopy. Early signs of clinical response include trends toward reduced body surface area of blisters/erosions from a median of 49·5% to 27·5% at 100 days after BMT (P = 0·05), with parental measures indicating stable quality of life. CONCLUSIONS PTCy BMT in RDEB provides a means of attaining immunotolerance for future donor-derived cellular grafts (ClinicalTrials.gov identifier NCT02582775). What's already known about this topic? Severe, generalized recessive dystrophic epidermolysis bullosa (RDEB) is marked by great morbidity and early death. No cure currently exists for RDEB. Bone marrow transplant (BMT) is the only described systemic therapy for RDEB. What does this study add? The first description of post-transplant cyclophosphamide (PTCy) BMT for RDEB. PTCy was well tolerated and provided excellent graft-versus-host disease prophylaxis, replacing long courses of calcineurin inhibitors in patients receiving human leucocyte antigen-matched sibling BMT. What is the translational message? The PTCy BMT platform permits identification of a suitable related donor for most patients and for subsequent adoptive transfer of donor nonhaematopoietic cells after establishment of immunological tolerance.
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Affiliation(s)
- C L Ebens
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, MN, U.S.A
| | - J A McGrath
- St John's Institute of Dermatology, King's College London, London, U.K
| | - K Tamai
- Department of Stem Cell Therapy Science, Graduate School of Medicine, University of Osaka, Osaka, Japan
| | - A Hovnanian
- INSERM UMR1163, Imagine Institute, Department of Genetics, University Paris Descartes, Necker Hospital, Paris, France
| | - J E Wagner
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, MN, U.S.A
| | - M J Riddle
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, MN, U.S.A
| | - D R Keene
- Microimaging Center, Shriners Hospital for Children, Portland, OR, U.S.A
| | - T E DeFor
- Biostatistic Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, U.S.A
| | - R Tryon
- Genetics Division, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, U.S.A
| | - M Chen
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, U.S.A
| | - D T Woodley
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, U.S.A
| | - K Hook
- Department of Dermatology, Medical School, University of Minnesota, Minneapolis, MN, U.S.A
| | - J Tolar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, MN, U.S.A
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23
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Kulkarni A, Kumar M, Pease DF, Wang Y, DeFor TE, Patel M. Impact of antibiotics and proton pump inhibitors on clinical outcomes of immune check point blockers in advanced non-small cell lung cancers and metastatic renal cell cancer. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.e20520] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e20520 Background: Studies have suggested that antibiotics can negatively influence efficacy of immune check-point blockers (ICB) but the results are inconsistent. The impact of concomitant proton pump inhibitors (PPI) is not known. We evaluated whether antibiotic and PPI use in patients with advanced non-small-cell lung cancer (NSCLC) and metastatic renal cell cancer (RCC) affects ICB efficacy. Methods: We identified advanced NSCLC and RCC patients treated with anti-PD1/PD-L1 at our institution between 5/2015 to 1/2019. Data regarding systemic antibiotics and PPI use < 1 month or during ICB treatment were collected. The primary outcome was progression free survival (PFS) per response evaluation criteria in solid tumors (RECIST 1.1). Secondary outcomes were overall survival (OS) and objective response rate (ORR). Logistic regression and cox proportional hazards model were used for statistical analysis. Results: 87/148 (58%) and 40/55 (72%) patients received antibiotics and 57/148 (39%) and 17/55 (31%) received PPI < 1 month or during ICI therapy in NSCLC and RCC respectively. In RCC, antibiotic use was associated with inferior PFS (2.9 v 5.0 months, HR = 2.3 95%CI 1.0-5.0; p = 0.04) but OS and ORR were not affected. In NSCLC, antibiotic exposure was associated with superior PFS (5.0 v 2.5 months, HR = 0.5, 95% CI 0.3-0.7; p < 0.01), OS (13.0 v 8.0 months, HR = 0.5, 95% CI 0.3-0.8; p < 0.01) and ORR (33% v 11%, OR = 4.6, p < 0.01). On univariate analysis, there was trend towards inferior OS in NSCLC (9.0 v 13.0 months, p = 0.05) with PPI use. PPI use was not associated with other primary or secondary outcomes in both the cohorts. The antibiotic effect remained significant for PFS in NSCLC and RCC in multivariate analysis. Conclusions: Antibiotic use significantly affected PFS in both NSCLC and RCC. PPI use did not affect outcomes. In contrast to previous studies, this is the first study to show that antibiotic use was associated with favorable outcomes in NSCLC. More studies are needed to explain this association. Future clinical trials with ICB should consider stratification of patients based on antibiotic exposure.
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Affiliation(s)
| | - Manoj Kumar
- Hennepin County Medical Center, Minneapolis, MN
| | | | - Ying Wang
- University of Minnesota, Minneapolis, MN
| | | | - Manish Patel
- University of Minnesota Medical School, Minneapolis, MN
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24
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Pamukcuoglu M, Bhatia S, Weisdorf DJ, DeFor TE, Ustun C, Nayar M, Holtan S, El Jurdi NH, Thyagarajan B, Brunstein C, Bachanova V, Warlick ED, Arora M. HCT related toxicities and mortality in frail recipients. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.e18534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18534 Background: Frailty is a state characterized by diminished physiological reserve and increased vulnerability to stress, and adversely affects outcomes in older patients with cancer. Geriatric assessments are not routinely used to screen older HCT (hematopoietic cell transplant) recipients. There is limited knowledge of the impact of pre-HCT frailty on severe/ life-threatening (CTCAE, version 5.0) grade 3-4 non-hematologic toxicities within 1y after HCT. We aimed to determine the relationship between pre-HCT frailty and grade 3-4 non-hematologic toxicities and mortality in HCT recipients, and also examined whether age at HCT moderated that association. Methods: In a prospective longitudinal study of 117 patients undergoing HCT at age ≥ 40y, we performed pre-HCT geriatric assessments. Frailty was assessed using Fried’s criteria. Post-HCT toxicities were abstracted through chart reviews Results: Median age at HCT was 60y (40-73). Pre-HCT frailty could be evaluated in 98 (84%) patients [(51 autologous, 47 allogeneic (allo)]. Pre-HCT comorbidity index (CI) was high in 27%, intermediate in 40% and low in 33%. The prevalence of pre-HCT frailty was 21%. Overall, frail recipients (vs. non-frail) had a higher cumulative incidence of any grade 3-4 toxicity [86% (95% CI: 62-100%) vs. 70% (57-83%), p = 0.03]; and the following organ specific grade 3-4 toxicities: non-neutropenic infections [(38% (17-59%) vs. 13% (6-20%), p < 0.01)]; nervous system disorders [(19% (3-35%) vs. 4% (0-8%), p = 0.02)]; and pneumonia [(38% (17-59%) vs. 10% (4-17%), p < 0.01]. Frail recipients also had a higher overall mortality [52%, (30-75%) vs. 19%, (11-28%) (p < 0.01)]. In Cox regression analysis controlling for age, donor type, disease risk, conditioning and HCT-CI, frail recipients were 1.9 fold more likely to suffer any grade 3-4 toxicities (p = 0.03), 4-fold more likely to suffer non-neutropenic infections and pneumonia, both p = 0.01; and 8.6-fold more likely to suffer nervous system disorders, p = 0.01. Frail recipients who underwent an allo-HCT were at 2.7 fold higher risk of death vs. non-frail allo- HCT recipients, p = 0.06. Conclusions: The higher toxicity and mortality in frail recipients needs attention. Studies focusing on pre-HCT interventions to reduce frailty are needed.
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Affiliation(s)
- Merve Pamukcuoglu
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Smita Bhatia
- University of Alabama at Birmingham, Birmingham, AL
| | - Daniel Jordan Weisdorf
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | | | - Celalettin Ustun
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Manju Nayar
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Shernan Holtan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Najla H. El Jurdi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minnesota, MN
| | | | - Claudio Brunstein
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Veronika Bachanova
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Erica D. Warlick
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
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25
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Amin K, Yaqoob U, Schultz B, Vaughn BP, Khoruts A, Howard JR, DeFor TE, Forster C, Meyer C, Gandhi I, Weisdorf DJ, Rashidi A, MacMillan ML, Blazar BR, Panoskaltsis-Mortari A, Holtan SG. Amphiregulin in intestinal acute graft-versus-host disease: a possible diagnostic and prognostic aid. Mod Pathol 2019; 32:560-567. [PMID: 30425334 PMCID: PMC6941942 DOI: 10.1038/s41379-018-0170-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 10/01/2018] [Accepted: 10/02/2018] [Indexed: 12/28/2022]
Abstract
Amphiregulin, a weak epidermal growth factor receptor agonist, is elevated, while epidermal growth factor, a strong epidermal growth factor receptor agonist, is low in the blood of patients with severe acute graft-versus-host disease. However, the tissue expression and function of these epidermal growth factor receptor ligands in acute graft-versus-host disease target organs is unknown. We compared by immunohistochemistry expression of amphiregulin and epidermal growth factor in archived, formalin-fixed, paraffin-embedded intestinal tissues of 48 patients with biopsy-proven gastrointestinal acute graft-versus-host disease to 3 groups: (1) 10 non-hematopoietic cell transplant normal controls, (2) 11 patients with newly diagnosed ulcerative colitis (ulcerative colitis), (3) 8 patients with a clinical diagnosis of acute graft-versus-host disease despite pathologically non-diagnostic biopsies, (4) and 10 cases of cytomegalovirus colitis. We used a semi-quantitative score of 0 (absent) through 3 (strong) to describe the intensity of immunohistochemical staining. We correlated serum and tissue amphiregulin and epidermal growth factor in patients with acute graft-versus-host disease. Gastrointestinal amphiregulin was significantly lower in acute graft-versus-host disease biopsies (median score 1), ulcerative colitis (median score 1.5), and cytomegalovirus colitis (median score 1) than in normal colon (median score 2, p = 0.004, p = 0.03, p = 0.009 respectively). Amphiregulin expression in was low in 74% of acute graft-versus-host disease cases with or without significant apoptosis. Patients with acute graft-versus-host disease exhibiting the pattern of high gastrointestinal amphiregulin but low serum amphiregulin (n = 14) had the best 1-year survival at 71%, but patients with high serum amphiregulin had poorer survival (<30%) regardless of gastrointestinal amphiregulin expression. Overall, our results lead to the hypothesis that amphiregulin is released into the circulation from damaged intestinal epithelium and stroma, although contributions from other cellular sources are likely. Low gastrointestinal amphiregulin expression by immunohistochemistry may be further studied for its utility in the pathologic acute graft-versus-host disease diagnosis without classic apoptotic changes.
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Affiliation(s)
- Khalid Amin
- Department of Laboratory Medicine and Pathology, University
of Minnesota, Minneapolis, MN, USA
| | | | - Brittney Schultz
- Department of Internal Medicine, University of Minnesota,
Minneapolis, MN, USA
| | - Byron P. Vaughn
- Department of Internal Medicine, Division of
Gastroenterology, University of Minnesota, Minneapolis, MN, USA
| | - Alexander Khoruts
- Department of Internal Medicine, Division of
Gastroenterology, University of Minnesota, Minneapolis, MN, USA
| | - Justin R. Howard
- Department of Internal Medicine, Division of
Gastroenterology, University of Minnesota, Minneapolis, MN, USA
| | - Todd E. DeFor
- Biostatistics and Informatics, University of Minnesota,
Minneapolis, MN, USA,Hematology, Oncology and Transplant, University of
Minnesota, Minneapolis, MN, USA
| | - Colleen Forster
- Department of Laboratory Medicine and Pathology, University
of Minnesota, Minneapolis, MN, USA
| | - Carolyn Meyer
- Department of Pediatrics, University of Minnesota,
Minneapolis, MN, USA
| | - Isha Gandhi
- College of Biological Sciences, University of Minnesota,
Minneapolis, MN, USA
| | - Daniel J. Weisdorf
- Hematology, Oncology and Transplant, University of
Minnesota, Minneapolis, MN, USA
| | - Armin Rashidi
- Hematology, Oncology and Transplant, University of
Minnesota, Minneapolis, MN, USA
| | | | - Bruce R. Blazar
- Hematology, Oncology and Transplant, University of
Minnesota, Minneapolis, MN, USA
| | - Angela Panoskaltsis-Mortari
- Department of Pediatrics, University of Minnesota,
Minneapolis, MN, USA,Hematology, Oncology and Transplant, University of
Minnesota, Minneapolis, MN, USA
| | - Shernan G. Holtan
- Hematology, Oncology and Transplant, University of
Minnesota, Minneapolis, MN, USA
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26
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How J, Vij KR, Ebadi M, DeFor TE, Romee R, Dolan MM, Ustun C, Weisdorf DJ, Linden MA, Rashidi A. Prognostic value of prior consolidation in acute myeloid leukemia patients undergoing hematopoietic cell transplantation in minimal residual disease-negative first complete remission. Am J Hematol 2018; 93:E381-E383. [PMID: 30144151 DOI: 10.1002/ajh.25262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 08/20/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Joan How
- Department of Medicine; Washington University School of Medicine; St. Louis Missouri
| | - Kiran R. Vij
- Department of Pathology and Immunology; Washington University School of Medicine; St. Louis Missouri
| | - Maryam Ebadi
- Division of Pediatric Hematology/Oncology, Department of Pediatrics; University of Minnesota; Minneapolis Minnesota
| | - Todd E. DeFor
- Biostatistics Core, Masonic Cancer Center; University of Minnesota; Minneapolis Minnesota
| | - Rizwan Romee
- BMT Program; Dana Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
| | - Michelle M. Dolan
- Division of Hematopathology, Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Celalettin Ustun
- Division of Hematology, Oncology, and Transplantation, Department of Medicine; University of Minnesota; Minneapolis Minnesota
| | - Daniel J. Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine; University of Minnesota; Minneapolis Minnesota
| | - Michael A. Linden
- Division of Hematopathology, Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Armin Rashidi
- Division of Hematology, Oncology, and Transplantation, Department of Medicine; University of Minnesota; Minneapolis Minnesota
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27
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Susnik B, Schneider L, Swenson KK, Krueger J, Braatz C, Lillemoe T, Tsai M, DeFor TE, Knaack M, Rueth N. Predictive value of breast magnetic resonance imaging in detecting mammographically occult contralateral breast cancer: Can we target women more likely to have contralateral breast cancer? J Surg Oncol 2018; 118:221-227. [PMID: 30196538 DOI: 10.1002/jso.25130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 02/06/2018] [Accepted: 05/19/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Preoperative breast magnetic resonance imaging (B-MRI) staging in newly diagnosed breast cancer increases detection of synchronous contralateral findings, but may result in false-positive outcomes. This study objective was to identify women more likely of having mammographically occult, MRI detected contralateral breast cancer (CBC). METHODS We performed a retrospective review of patients who had preoperative B-MRI prior to surgery from 2010 to 2015 and collected patient imaging and clinicopathologic data. Multivariate logistic regression was used to identify predictors of CBC. RESULTS MRI resulted in contralateral findings in 201 of 1894 patients (10.6%). Overall 3.2% (60 of 1894) had synchronous CBC detected on B-MRI. The majority of CBCs (n = 60) were stage 0 or IA (85.0%), hormone receptor positive (94.9%), human epidermal growth factor receptor 2 (HER2/neu) negative (89.7%), and low/intermediate pathological grade (87.2%). Women more likely to have CBC were older (P < .001), had lobular index cancer (P = .03), and estrogen receptor (ER)+ (P = .027) or progesterone receptor (PR)+ (P = .002) tumors. On multivariate analysis (receiver operating characteristic curve area = 0.75), PR + status (P = .022), and older age (P = .004) were predictive of CBC. CONCLUSIONS Preoperative MRI is most effective in detecting early stage, hormone receptor-positive CBC in older women.
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Affiliation(s)
| | - Lisa Schneider
- Consulting Radiologists Ltd, Piper Breast Center, Virginia Piper Cancer Institute, Minneapolis, Minnesota
| | - Karen K Swenson
- Allina Health System, Virginia Piper Cancer Institute, Minneapolis, Minnesota
| | - Janet Krueger
- Allina Health System, Virginia Piper Cancer Institute, Minneapolis, Minnesota
| | - Christina Braatz
- Consulting Radiologists Ltd, Piper Breast Center, Virginia Piper Cancer Institute, Minneapolis, Minnesota
| | | | - Michaela Tsai
- Allina Health System, Virginia Piper Cancer Institute, Minneapolis, Minnesota
| | - Todd E DeFor
- Biostatistics Core, University of Minnesota, Minneapolis, Minnesota
| | - Monica Knaack
- Allina Health System, Virginia Piper Cancer Institute, Minneapolis, Minnesota
| | - Natasha Rueth
- Allina Health System, Virginia Piper Cancer Institute, Minneapolis, Minnesota
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28
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Holtan SG, DeFor TE, Panoskaltsis-Mortari A, Khera N, Levine JE, Flowers MED, Lee SJ, Inamoto Y, Chen GL, Mayer S, Arora M, Palmer J, Cutler CS, Arai S, Lazaryan A, Newell LF, Jagasia MH, Pusic I, Wood WA, Renteria AS, Yanik G, Hogan WJ, Hexner E, Ayuk F, Holler E, Bunworasate U, Efebera YA, Ferrara JLM, Pidala J, Howard A, Wu J, Bolaños-Meade J, Ho V, Alousi A, Blazar BR, Weisdorf DJ, MacMillan ML. Amphiregulin modifies the Minnesota Acute Graft-versus-Host Disease Risk Score: results from BMT CTN 0302/0802. Blood Adv 2018; 2:1882-1888. [PMID: 30087106 PMCID: PMC6093743 DOI: 10.1182/bloodadvances.2018017343] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 02/12/2018] [Accepted: 06/26/2018] [Indexed: 01/07/2023] Open
Abstract
Amphiregulin (AREG) is an epidermal growth factor receptor ligand that can restore integrity to damaged intestinal mucosa in murine models of acute graft-versus-host disease (aGVHD). We previously reported that circulating AREG is elevated in late-onset aGVHD (occurring after 100 days posttransplant), but its clinical relevance in the context of aGVHD risk is unknown. We measured AREG in 251 aGVHD onset blood samples from Blood and Marrow Clinical Trials Network (BMT CTN) primary treatment trials and determined their association with GVHD severity, day 28 complete or partial response (CR/PR) to first-line therapy, overall survival (OS), and nonrelapse mortality (NRM). Every doubling of plasma AREG was associated with a 33% decrease in the odds of day 28 CR/PR (odds ratio [OR], 0.67; P < .01). An AREG threshold of 33 pg/mL or greater divided patients with Minnesota standard-risk (SR) aGVHD into a distinct group with a significantly lower likelihood of: day 28 CR/PR (72% vs 85%; P = .02); greater 2-year NRM (42% vs 15%; P < .01); and inferior OS (40% vs 66%; P < .01). High AREG ≥ 33 pg/mL also stratified patients with Minnesota high-risk (HR) aGVHD: day 28 CR/PR (54% vs 83%; P = .03) and 2-year NRM (53% vs 11%; P < .01), with a trend toward inferior 2-year OS (37% vs 60%; P = .09). High-circulating AREG (≥33 pg/mL) reclassifies patients into HR subgroups and thereby further refines the Minnesota aGVHD clinical risk score.
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Affiliation(s)
- Shernan G Holtan
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
| | - Todd E DeFor
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
| | | | | | - John E Levine
- Blood and Marrow Transplantation Program, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Yoshihiro Inamoto
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - George L Chen
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY
| | - Sebastian Mayer
- Department of Medicine, Weill Cornell Medical Center, New York, NY
| | - Mukta Arora
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
| | | | - Corey S Cutler
- Hematologic Malignancies, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Sally Arai
- Division of Blood and Marrow Transplantation, Stanford University Medical Center, Stanford, CA
| | - Aleksandr Lazaryan
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
| | - Laura F Newell
- Center for Hematologic Malignancies, Oregon Health and Science University, Portland, OR
| | - Madan H Jagasia
- Division of Hematology/Oncology, Stem Cell Transplantation, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Iskra Pusic
- Medical Oncology, Washington University Medical Center, St. Louis, MO
| | - William A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Anne S Renteria
- Blood and Marrow Transplantation Program, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gregory Yanik
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI
| | - William J Hogan
- Blood and Marrow Transplantation Program, Mayo Clinic, Rochester, MN
| | - Elizabeth Hexner
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center, Hamburg-Eppendorf, Germany
| | - Ernst Holler
- Blood and Marrow Transplantation Program, University of Regensburg, Regensburg, Germany
| | - Udomsak Bunworasate
- Blood and Marrow Transplantation Program, Chulalongkorn University, Bangkok, Thailand
| | - Yvonne A Efebera
- Blood and Marrow Transplantation Program, The Ohio State University, Columbus, OH
| | - James L M Ferrara
- Blood and Marrow Transplantation Program, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joseph Pidala
- Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Alan Howard
- National Marrow Donor Program, Minneapolis, MN
| | - Juan Wu
- The EMMES Corporation, Rockville, MD
| | - Javier Bolaños-Meade
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD; and
| | - Vincent Ho
- Division of Blood and Marrow Transplantation, Stanford University Medical Center, Stanford, CA
| | | | - Bruce R Blazar
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
| | - Daniel J Weisdorf
- Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN
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29
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Warlick ED, DeFor TE, Bejanyan N, Holtan S, MacMillan M, Blazar BR, Dusenbery K, Arora M, Bachanova V, Cooley S, Lazaryan A, McGlave P, Miller JS, Rashidi A, Slungaard A, Vercellotti G, Ustun C, Brunsein C, Weisdorf D. Reduced-Intensity Conditioning Followed by Related and Unrelated Allografts for Hematologic Malignancies: Expanded Analysis and Long-Term Follow-Up. Biol Blood Marrow Transplant 2018; 25:56-62. [PMID: 30077015 DOI: 10.1016/j.bbmt.2018.07.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 04/16/2018] [Accepted: 07/23/2018] [Indexed: 01/27/2023]
Abstract
Reduced-intensity conditioning (RIC) extends the curative potential of allogeneic hematopoietic cell transplantation (HCT) to patients with hematologic malignancies unable to withstand myeloablative conditioning. We prospectively analyzed the outcomes of 292 consecutive patients, median age 58 years (range, 19 to 75) with hematologic malignancies treated with a uniform RIC regimen of cyclophosphamide, fludarabine, and total body irradiation (200 cGy) with or without antithymocyte globulin and cyclosporine and mycophenolate mofetil graft-versus-host disease (GVHD) prophylaxis followed by allogeneic HCT at the University of Minnesota from 2002 to 6. Probability of 5-year overall survival was 78% for patients with indolent non-Hodgkin lymphoma, 53% for chronic myelogenous leukemia, 55% for Hodgkin lymphoma, 40% for acute myelogenous leukemia, 37% for myelodysplastic syndrome, 29% for myeloma, and 14% for myeloproliferative neoplasms. Corresponding outcomes for relapse were 0%, 13%, 53%, 37%, 39%, 75%, and 29%, respectively. Disease risk index (DRI) predicted both survival and relapse with superior survival (64%) and lowest relapse (16%) in those with low risk score compared with 24% survival and 57% relapse in those with high/very-high risk scores. Recipient cytomegalovirus (CMV)-positive serostatus was protective from relapse with the lowest rates in those also receiving a CMV-positive donor graft (29%). The cumulative incidence of 2-year nonrelapse mortality was 26% and was lowest in those receiving a matched sibling graft at 21%, with low (21%) or intermediate (18%) HCT-specific comorbidity index, and was similar across age groups. The incidence of grades II to IV acute GVHD was 43% and grades III to IV 27%; the highest rates were found in those receiving an unrelated donor (URD) peripheral blood stem cell (PBSC) graft, at 50%. Chronic GVHD at 1 year was 36%. Future approaches incorporating alternative GVHD prophylaxis, particularly for URD PBSC grafts, and targeted post-transplant antineoplastic therapies for those with high DRI are indicated to improve these outcomes.
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Affiliation(s)
- Erica Dahl Warlick
- Department of Medicine, Division of Hematology, Oncology and Transplant, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota.
| | - Todd E DeFor
- Biostatistics and Informatics Core, Masonic Cancer Center, Minneapolis, Minnesota
| | - Nelli Bejanyan
- Department of Medicine, Division of Hematology, Oncology and Transplant, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Shernan Holtan
- Department of Medicine, Division of Hematology, Oncology and Transplant, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Margaret MacMillan
- Department of Pediatrics, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Bruce R Blazar
- Department of Pediatrics, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Kathryn Dusenbery
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota
| | - Mukta Arora
- Department of Medicine, Division of Hematology, Oncology and Transplant, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Veronika Bachanova
- Department of Medicine, Division of Hematology, Oncology and Transplant, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Sarah Cooley
- Department of Medicine, Division of Hematology, Oncology and Transplant, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Aleksandr Lazaryan
- Department of Medicine, Division of Hematology, Oncology and Transplant, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Philip McGlave
- Department of Medicine, Division of Hematology, Oncology and Transplant, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Jeffrey S Miller
- Department of Medicine, Division of Hematology, Oncology and Transplant, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Armin Rashidi
- Department of Medicine, Division of Hematology, Oncology and Transplant, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Arne Slungaard
- Department of Medicine, Division of Hematology, Oncology and Transplant, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Gregory Vercellotti
- Department of Medicine, Division of Hematology, Oncology and Transplant, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Celalettin Ustun
- Department of Medicine, Division of Hematology, Oncology and Transplant, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Claudio Brunsein
- Department of Medicine, Division of Hematology, Oncology and Transplant, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Daniel Weisdorf
- Department of Medicine, Division of Hematology, Oncology and Transplant, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
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Romee R, Cooley S, Berrien-Elliott MM, Westervelt P, Verneris MR, Wagner JE, Weisdorf DJ, Blazar BR, Ustun C, DeFor TE, Vivek S, Peck L, DiPersio JF, Cashen AF, Kyllo R, Musiek A, Schaffer A, Anadkat MJ, Rosman I, Miller D, Egan JO, Jeng EK, Rock A, Wong HC, Fehniger TA, Miller JS. First-in-human phase 1 clinical study of the IL-15 superagonist complex ALT-803 to treat relapse after transplantation. Blood 2018; 131:2515-2527. [PMID: 29463563 PMCID: PMC5992862 DOI: 10.1182/blood-2017-12-823757] [Citation(s) in RCA: 268] [Impact Index Per Article: 44.7] [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: 12/23/2017] [Accepted: 02/13/2018] [Indexed: 01/15/2023] Open
Abstract
New therapies for patients with hematologic malignancies who relapse after allogeneic hematopoietic cell transplantation (allo-HCT) are needed. Interleukin 15 (IL-15) is a cytokine that stimulates CD8+ T-cell and natural killer (NK) cell antitumor responses, and we hypothesized this cytokine may augment antileukemia/antilymphoma immunity in vivo. To test this, we performed a first-in-human multicenter phase 1 trial of the IL-15 superagonist complex ALT-803 in patients who relapsed >60 days after allo-HCT. ALT-803 was administered to 33 patients via the IV or subcutaneous (SQ) routes once weekly for 4 doses (dose levels of 1, 3, 6, and 10 μg/kg). ALT-803 was well tolerated, and no dose-limiting toxicities or treatment-emergent graft-versus-host disease requiring systemic therapy was observed in this clinical setting. Adverse events following IV administration included constitutional symptoms temporally related to increased serum IL-6 and interferon-γ. To mitigate these effects, the SQ route was tested. SQ delivery resulted in self-limited injection site rashes infiltrated with lymphocytes without acute constitutional symptoms. Pharmacokinetic analysis revealed prolonged (>96 hour) serum concentrations following SQ, but not IV, injection. ALT-803 stimulated the activation, proliferation, and expansion of NK cells and CD8+ T cells without increasing regulatory T cells. Responses were observed in 19% of evaluable patients, including 1 complete remission lasting 7 months. Thus, ALT-803 is a safe, well-tolerated agent that significantly increased NK and CD8+ T cell numbers and function. This immunostimulatory IL-15 superagonist warrants further investigation to augment antitumor immunity alone and combined with other immunotherapies. This trial was registered at www.clinicaltrials.gov as #NCT01885897.
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Affiliation(s)
- Rizwan Romee
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | | | - Melissa M Berrien-Elliott
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Peter Westervelt
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | | | | | | | | | | | | | - Sithara Vivek
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Lindsey Peck
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - John F DiPersio
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Amanda F Cashen
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Rachel Kyllo
- Division of Dermatology, Department of Medicine, and
| | - Amy Musiek
- Division of Dermatology, Department of Medicine, and
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO
| | | | - Milan J Anadkat
- Division of Dermatology, Department of Medicine, and
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO
| | - Ilana Rosman
- Division of Dermatology, Department of Medicine, and
| | - Daniel Miller
- Department of Dermatology, University of Minnesota, Minneapolis, MN; and
| | - Jack O Egan
- Altor BioScience, a Nantworks company, Miramar, FL
| | - Emily K Jeng
- Altor BioScience, a Nantworks company, Miramar, FL
| | - Amy Rock
- Altor BioScience, a Nantworks company, Miramar, FL
| | - Hing C Wong
- Altor BioScience, a Nantworks company, Miramar, FL
| | - Todd A Fehniger
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
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31
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Salem B, Mitchell R, DeFor TE, Tryon R, Wagner JE, MacMillan ML. Elevations in serum alpha fetoprotein levels in patients with Fanconi anaemia. Br J Haematol 2018; 184:1032-1035. [PMID: 29676781 DOI: 10.1111/bjh.15223] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Baheyeldin Salem
- Blood and Marrow Transplant Program, Masonic Cancer Center, Minneapolis, MN, USA.,Department of Pediatrics, Masonic Cancer Center, Minneapolis, MN, USA
| | - Richard Mitchell
- Blood and Marrow Transplant Program, Masonic Cancer Center, Minneapolis, MN, USA.,Department of Pediatrics, Masonic Cancer Center, Minneapolis, MN, USA
| | - Todd E DeFor
- Blood and Marrow Transplant Program, Masonic Cancer Center, Minneapolis, MN, USA.,Department of Biostatistics and Bioinformatics Core, Masonic Cancer Center, Minneapolis, MN, USA
| | - Rebecca Tryon
- Department of Genetics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - John E Wagner
- Blood and Marrow Transplant Program, Masonic Cancer Center, Minneapolis, MN, USA.,Department of Pediatrics, Masonic Cancer Center, Minneapolis, MN, USA
| | - Margaret L MacMillan
- Blood and Marrow Transplant Program, Masonic Cancer Center, Minneapolis, MN, USA.,Department of Pediatrics, Masonic Cancer Center, Minneapolis, MN, USA
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32
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Bachanova V, Sarhan D, DeFor TE, Cooley S, Panoskaltsis-Mortari A, Blazar BR, Curtsinger JM, Burns L, Weisdorf DJ, Miller JS. Haploidentical natural killer cells induce remissions in non-Hodgkin lymphoma patients with low levels of immune-suppressor cells. Cancer Immunol Immunother 2018; 67:483-494. [PMID: 29218366 PMCID: PMC6055922 DOI: 10.1007/s00262-017-2100-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [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: 05/01/2017] [Accepted: 11/24/2017] [Indexed: 12/24/2022]
Abstract
We report a novel phase 2 clinical trial in patients with poor prognosis refractory non-Hodgkin lymphoma (NHL) testing the efficacy of haploidentical donor natural killer (NK) cell therapy (NK dose 0.5-3.27 × 107 NK cells/kg) with rituximab and IL-2 (clinicaltrials.gov NCT01181258). Therapy was tolerated without graft-versus-host disease, cytokine release syndrome, or neurotoxicity. Of 14 evaluable patients, 4 had objective responses (29%; 95% CI 12-55%) at 2 months: 2 had complete response lasting 3 and 9 months. Circulating donor NK cells persisted for at least 7 days after infusion at the level 0.6-16 donor NK cells/µl or 0.35-90% of total CD56 cells. Responding patients had lower levels of circulating host-derived Tregs (17 ± 4 vs. 307 ± 152 cells/µL; p = 0.008) and myeloid-derived suppressor cells at baseline (6.6 ± 1.4% vs. 13.0 ± 2.7%; p = 0.06) than non-responding patients. Lower circulating Tregs correlated with low serum levels of IL-10 (R 2 = 0.64; p < 0.003; n = 11), suggestive of less immunosuppressive milieu. Low expression of PD-1 on recipient T cells before therapy was associated with response. Endogenous IL-15 levels were higher in responders than non-responding patients at the day of NK cell infusion (mean ± SEM: 30 ± 4; n = 4 vs. 19.0 ± 4.0 pg/ml; n = 8; p = 0.02) and correlated with day 14 NK cytotoxicity as measured by expression of CD107a (R 2 = 0.74; p = 0.0009; n = 12). In summary, our observations support development of donor NK cellular therapies for advanced NHL as a strategy to overcome chemoresistance. Therapeutic efficacy may be further improved through disruption of the immunosuppressive environment and infusion of exogenous IL-15.
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Affiliation(s)
- Veronika Bachanova
- Blood and Marrow Transplant Program, University of Minnesota, MMC 480, 420 Delaware Street, Minneapolis, MN, 55455, USA.
| | - Dhifaf Sarhan
- Blood and Marrow Transplant Program, University of Minnesota, MMC 480, 420 Delaware Street, Minneapolis, MN, 55455, USA
| | - Todd E DeFor
- Blood and Marrow Transplant Program, University of Minnesota, MMC 480, 420 Delaware Street, Minneapolis, MN, 55455, USA
| | - Sarah Cooley
- Blood and Marrow Transplant Program, University of Minnesota, MMC 480, 420 Delaware Street, Minneapolis, MN, 55455, USA
| | - Angela Panoskaltsis-Mortari
- Blood and Marrow Transplant Program, University of Minnesota, MMC 480, 420 Delaware Street, Minneapolis, MN, 55455, USA
| | - Bruce R Blazar
- Blood and Marrow Transplant Program, University of Minnesota, MMC 480, 420 Delaware Street, Minneapolis, MN, 55455, USA
| | - Julie M Curtsinger
- Blood and Marrow Transplant Program, University of Minnesota, MMC 480, 420 Delaware Street, Minneapolis, MN, 55455, USA
| | - Linda Burns
- National Marrow Donor Program, Minnesota, MN, USA
| | - Daniel J Weisdorf
- Blood and Marrow Transplant Program, University of Minnesota, MMC 480, 420 Delaware Street, Minneapolis, MN, 55455, USA
| | - Jeffrey S Miller
- Blood and Marrow Transplant Program, University of Minnesota, MMC 480, 420 Delaware Street, Minneapolis, MN, 55455, USA
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33
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Rashidi A, Ebadi M, Shields-Cutler RR, DeFor TE, Al-Ghalith GA, Ferrieri P, Young JAH, Dunny GM, Knights D, Weisdorf DJ. Pretransplant Gut Colonization with Intrinsically Vancomycin-Resistant Enterococci (E. gallinarum and E. casseliflavus) and Outcomes of Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2018; 24:1260-1263. [PMID: 29407252 DOI: 10.1016/j.bbmt.2018.01.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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: 11/22/2017] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Abstract
Pretransplant gut colonization with intrinsically vancomycin-resistant enterococci (iVRE) (Enterococcus gallinarum and Enterococcus casseliflavus) is uncommon and with unknown clinical impact. In a matched-pairs analysis of patients with versus without iVRE colonization (n = 18 in each group), we demonstrated significantly higher 2-year overall survival (86% [95% confidence interval, 52% to 96%] versus 35% [95% confidence interval, 8% to 65]; P <.01) and lower nonrelapse mortality (P <.01) among colonized patients. Putative metabolomes differentiated iVRE from E. faecalis/faecium and may contribute to a healthier gut microbiome in iVRE-colonized patients.
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Affiliation(s)
- Armin Rashidi
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
| | - Maryam Ebadi
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Robin R Shields-Cutler
- BioTechnology Institute, College of Biological Sciences, University of Minnesota, Minnesota
| | - Todd E DeFor
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Gabriel A Al-Ghalith
- BioTechnology Institute, College of Biological Sciences, University of Minnesota, Minnesota
| | - Patricia Ferrieri
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Jo-Anne H Young
- Division of Infectious Disease and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Gary M Dunny
- Department of Microbiology and Immunology, University of Minnesota, Minneapolis, Minnesota
| | - Dan Knights
- BioTechnology Institute, College of Biological Sciences, University of Minnesota, Minnesota
| | - Daniel J Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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34
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Ebens CL, DeFor TE, Tryon R, Wagner JE, MacMillan ML. Comparable Outcomes after HLA-Matched Sibling and Alternative Donor Hematopoietic Cell Transplantation for Children with Fanconi Anemia and Severe Aplastic Anemia. Biol Blood Marrow Transplant 2017; 24:765-771. [PMID: 29203412 DOI: 10.1016/j.bbmt.2017.11.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [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: 09/27/2017] [Accepted: 11/28/2017] [Indexed: 01/05/2023]
Abstract
Fanconi anemia (FA)-associated severe aplastic anemia (SAA) requires allogeneic hematopoietic cell transplantation (HCT) for cure. With the evolution of conditioning regimens over time, outcomes of alternative donor HCT (AD-HCT) have improved dramatically. We compared outcomes of HLA-matched sibling donor HCT (MSD-HCT; n = 17) and AD-HCT (n = 57) performed for FA-associated SAA at a single institution between 2001 and 2016. Overall survival at 5 years was 94% for MSD-HCT versus 86% for AD-HCT, neutrophil engraftment was 100% versus 95%, platelet recovery was 100% versus 89%, grade II-IV acute graft-versus-host disease (GVHD) was 6% versus 12%, grade III-IV acute GVHD was 6% versus 4%, and chronic GVHD was 0 versus 7%, with no statistically significant differences by type of transplant. The use of UCB was associated with decreased rates of neutrophil recovery in AD-HCT and platelet recovery in both MSD-HCT and AD-HCT. A trend toward a higher serious infection density before day +100 post-HCT was observed in AD-HCT compared with MSD-HCT (P = .02). These data demonstrate that AD-HCT should be considered at the same time as MSD-HCT for patients with FA-associated SAA.
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Affiliation(s)
- Christen L Ebens
- Division of Blood and Marrow Transplant, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota.
| | - Todd E DeFor
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Rebecca Tryon
- University of Minnesota Health, Minneapolis, Minnesota
| | - John E Wagner
- Division of Blood and Marrow Transplant, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Division of Blood and Marrow Transplant, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
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35
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Turcotte LM, DeFor TE, Newell LF, Cutler CS, Verneris MR, Wu J, Howard A, MacMillan ML, Antin JH, Vercellotti GM, Slungaard A, Blazar BR, Weisdorf DJ, Panoskaltsis-Mortari A, Holtan SG. Donor and recipient plasma follistatin levels are associated with acute GvHD in Blood and Marrow Transplant Clinical Trials Network 0402. Bone Marrow Transplant 2017; 53:64-68. [PMID: 29058696 PMCID: PMC5752567 DOI: 10.1038/bmt.2017.236] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 08/25/2017] [Accepted: 09/13/2017] [Indexed: 12/13/2022]
Abstract
Follistatin is an angiogenic factor elevated in the circulation after
allogeneic hematopoietic cell transplantation (HCT). Elevations in follistatin
plasma concentrations are associated with the onset of and poor survival after
acute graft versus host disease (aGVHD). Using data from the Blood and Marrow
Transplant Clinical Trials Network 0402 study (n=247), we sought to
further quantify the longitudinal associations between plasma follistatin levels
in transplant recipients, as well as baseline HCT donor follistatin levels, and
allogeneic HCT outcomes. Higher recipient baseline follistatin levels were
predictive of development of aGVHD (P=0.04). High donor
follistatin levels were also associated with the incidence of aGVHD
(P<0.01). Elevated follistatin levels on day 28 were
associated with the onset of grade II–IV aGVHD prior to day 28, higher
one-year non-relapse mortality, (NRM), and lower overall survival (OS). In
multivariate analyses, individuals with follistatin levels >1088 pg/mL at day
28 had a four-fold increased risk for NRM (RR=4.3, 95% CI
1.9–9.9, P<0.01) and a nearly three-fold increased
overall risk for mortality (RR=2.8, 95% CI 1.5–5.2,
P<0.01). Given the multiple roles of follistatin in
tissue inflammation and repair, and the confirmation that this biomarker is
predictive of important HCT outcomes, the pathobiology of these relationships
need further study.
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Affiliation(s)
- L M Turcotte
- Division of Pediatric Hematology/Oncology, University of Minnesota, Minneapolis, MN, USA
| | - T E DeFor
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA.,Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
| | - L F Newell
- Center for Hematologic Malignancies, Oregon Health & Science University, Portland, OR, USA
| | - C S Cutler
- Hematologic Malignancy Program, Dana Farber Cancer Institute, Boston, MA, USA
| | - M R Verneris
- Pediatric BMT and Cell Therapy, University of Colorado Anschutz Medical Campus and Children's Hospital, Denver, CO, USA
| | - J Wu
- The EMMES Corporation, Rockville, MD, USA
| | - A Howard
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN, USA
| | - M L MacMillan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - J H Antin
- Hematologic Malignancy Program, Dana Farber Cancer Institute, Boston, MA, USA
| | - G M Vercellotti
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - Ane Slungaard
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - B R Blazar
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - D J Weisdorf
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | | | - S G Holtan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
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36
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Rashidi A, Linden MA, DeFor TE, Warlick E, Bejanyan N, Yohe S, Weisdorf DJ, Ustun C. History of consolidation is prognostic in acute myeloid leukemia patients undergoing allogeneic hematopoietic cell transplantation in minimal residual disease-negative first complete remission. Am J Hematol 2017. [PMID: 28646534 DOI: 10.1002/ajh.24834] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Prognostic factors among acute myeloid leukemia (AML) patients undergoing allogeneic hematopoietic cell transplantation (allo-HCT) in minimal residual disease (MRD)-negative first complete remission (CR1) are unknown. We retrospectively attempted to answer the following question: In AML patients undergoing allo-HCT in MRD-negative CR1, does a history of prior consolidation provide additional prognostic information? METHODS The inclusion criteria were: (i) Age > 18 years, (ii) AML in CR1 after 1-2 cycles of intensive induction chemotherapy, with or without consolidation, (iii) Allo-HCT between 1/2003 and 4/2016 at our institution, (iv) Available standard-sensitivity 4-color flow cytometry results from a bone marrow aspiration at diagnosis and after completion of all previous chemotherapy within one month prior to HCT, (v) Flow cytometry-based MRD-negative status at the time of HCT. RESULTS A history of prior consolidation was associated with favorable overall survival (Hazard Ratio [95% Confidence Interval]: 0.59 [0.35-0.99], P = .046), relapse-free survival (0.60 [0.37-0.96], P = .036), and relapse (0.50 [0.27-0.92], P = .025). Analysis of potential sources of bias was unrevealing. CONCLUSIONS In AML patients undergoing allo-HCT in MRD-negative CR1, a history of prior consolidation was associated with favorable outcomes. If the path to pre-HCT MRD negativity includes consolidation, it may identify patients with improved prognosis following HCT in MRD-negative state. These results warrant validation in larger cohorts.
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Affiliation(s)
- Armin Rashidi
- Division of Hematology; Oncology, and Transplantation, Department of Medicine, University of Minnesota; Minneapolis Minnesota
| | - Michael A. Linden
- Division of Hematopathology; Department of Laboratory Medicine and Pathology, University of Minnesota; Minneapolis Minnesota
| | - Todd E. DeFor
- Biostatistics Core, Masonic Cancer Center, University of Minnesota; Minneapolis Minnesota
| | - Erica Warlick
- Division of Hematology; Oncology, and Transplantation, Department of Medicine, University of Minnesota; Minneapolis Minnesota
| | - Nelli Bejanyan
- Division of Hematology; Oncology, and Transplantation, Department of Medicine, University of Minnesota; Minneapolis Minnesota
| | - Sophia Yohe
- Division of Hematopathology; Department of Laboratory Medicine and Pathology, University of Minnesota; Minneapolis Minnesota
| | - Daniel J. Weisdorf
- Division of Hematology; Oncology, and Transplantation, Department of Medicine, University of Minnesota; Minneapolis Minnesota
| | - Celalettin Ustun
- Division of Hematology; Oncology, and Transplantation, Department of Medicine, University of Minnesota; Minneapolis Minnesota
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37
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Dunn DH, Johnson EM, Anderson CA, Krueger JL, DeFor TE, Morphew JA, Banerji N. Operative and survival outcomes in a series of 100 consecutive cases of robot-assisted transhiatal esophagectomies. Dis Esophagus 2017; 30:1-7. [PMID: 28859385 DOI: 10.1093/dote/dox045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 04/04/2017] [Indexed: 12/11/2022]
Abstract
Robotic-assisted transhiatal esophagectomy (RATE) is a technically complex procedure with potential for improved postoperative outcomes. In this report, we describe our experience with RATE in a large case series. A retrospective review was conducted to collect clinical, outcomes, and survival data for 100 consecutive patients with esophageal cancer (n = 98) and benign (n = 2) conditions undergoing RATE between March 2007 and December 2014. Progression-free (PFS) and overall (OS) survival were estimated using the Kaplan-Meier curves with comparisons by log-rank tests. Median operative time and estimated blood loss were 264 minutes and 75 mL, respectively. Median intensive care unit stay was 1 day and median length of hospital stay was 8 days. Postoperative complications commonly observed were nonmalignant pleural effusion (38%) and recurrent laryngeal nerve injury (33%); 30 day mortality rate was 2%. Median number of lymph nodes removed during RATE was 17 and R0 resection was achieved in 97.8% patients. At the end of the median follow-up period of 27.7 months, median PFS was 41 months and median OS was 54 months. 1-year and 3-year PFS rates were 82% (95% CI, 75%-89%) and 53% (95% CI, 42%-62%), respectively, and OS rates were 95% (95% CI, 91%-99%) and 57% (95% CI, 46%-67%). In our experience, RATE is an effective and safe oncologic surgical procedure in a carefully selected group of patients with acceptable operative time, minimal blood loss, standard postoperative morbidity and adequate PFS and OS profiles.
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Affiliation(s)
- D H Dunn
- VPCI Esophageal and Gastric Cancer Program
| | | | | | | | - T E DeFor
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - N Banerji
- JNNI Research, Abbott Northwestern Hospital
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Ustun C, DeFor TE, Rashidi A, Devine S, Miller J, Weisdorf D. Time-to-Event Ratio to Predict Outcome in Patients with Acute Myeloid Leukemia Undergoing Allogeneic Hematopoietic Cell Transplantation? Biol Blood Marrow Transplant 2017; 23:1804-1808. [PMID: 28688918 DOI: 10.1016/j.bbmt.2017.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 06/20/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Celalettin Ustun
- Division of Hematology-Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
| | - Todd E DeFor
- Biostatistics and Bioinformatics, University of Minnesota, Minneapolis, Minnesota
| | - Armin Rashidi
- Division of Hematology-Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Steven Devine
- Division of Hematology, Ohio State University, Columbus, Ohio
| | - Jeffrey Miller
- Division of Hematology-Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Daniel Weisdorf
- Division of Hematology-Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Buckley SA, Wood BL, Othus M, Hourigan CS, Ustun C, Linden MA, DeFor TE, Malagola M, Anthias C, Valkova V, Kanakry CG, Gruhn B, Buccisano F, Devine B, Walter RB. Minimal residual disease prior to allogeneic hematopoietic cell transplantation in acute myeloid leukemia: a meta-analysis. Haematologica 2017; 102:865-873. [PMID: 28126965 PMCID: PMC5477605 DOI: 10.3324/haematol.2016.159343] [Citation(s) in RCA: 183] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 01/20/2017] [Indexed: 12/16/2022] Open
Abstract
Minimal residual disease prior to allogeneic hematopoietic cell transplantation has been associated with increased risk of relapse and death in patients with acute myeloid leukemia, but detection methodologies and results vary widely. We performed a systematic review and meta-analysis evaluating the prognostic role of minimal residual disease detected by polymerase chain reaction or multiparametric flow cytometry before transplant. We identified 19 articles published between January 2005 and June 2016 and extracted hazard ratios for leukemia-free survival, overall survival, and cumulative incidences of relapse and non-relapse mortality. Pre-transplant minimal residual disease was associated with worse leukemia-free survival (hazard ratio=2.76 [1.90-4.00]), overall survival (hazard ratio=2.36 [1.73-3.22]), and cumulative incidence of relapse (hazard ratio=3.65 [2.53-5.27]), but not non-relapse mortality (hazard ratio=1.12 [0.81-1.55]). These associations held regardless of detection method, conditioning intensity, and patient age. Adverse cytogenetics was not an independent risk factor for death or relapse. There was more heterogeneity among studies using flow cytometry-based than WT1 polymerase chain reaction-based detection (I2=75.1% vs. <0.1% for leukemia-free survival, 67.8% vs. <0.1% for overall survival, and 22.1% vs. <0.1% for cumulative incidence of relapse). These results demonstrate a strong relationship between pre-transplant minimal residual disease and post-transplant relapse and survival. Outcome heterogeneity among studies using flow-based methods may underscore site-specific methodological differences or differences in test performance and interpretation.
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Affiliation(s)
- Sarah A Buckley
- Hematology/Oncology Fellowship Program, University of Washington, Seattle, WA, USA
| | - Brent L Wood
- Division of Hematopathology, Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Christopher S Hourigan
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Celalettin Ustun
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Michael A Linden
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Todd E DeFor
- Biostatistics and Bioinformatics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
| | - Michele Malagola
- Unit of Blood Diseases and Stem Cell Transplantation, University of Brescia, A.O. Spedali Civili, Italy
| | - Chloe Anthias
- Anthony Nolan Research Institute, London, UK.,Royal Marsden Hospital, London, UK
| | - Veronika Valkova
- Institute of Haematology and Blood Transfusion, Prague, Czech Republic
| | - Christopher G Kanakry
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Experimental Transplantation and Immunology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Bernd Gruhn
- Department of Pediatrics, Jena University Hospital, Germany
| | | | - Beth Devine
- Pharmaceutical Outcomes Research and Policy Program, University of Washington, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA.,Department of Biomedical Informatics, University of Washington, Seattle, WA, USA
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
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Brunstein CG, Cutler CS, DeFor TE, Kim H, Bejanyan N, Garfall A, Verneris MR, Chen YB, Warlick ED, Spitzer T, Miller JS, Antin JH, Weisdorf DJ, Soiffer R, Wagner JE, Ballen KK. Matching at Human Leukocyte Antigen-C Improved the Outcomes after Double Umbilical Cord Blood Transplantation for Recipients of Two to Four of Six Human Leukocyte Antigen-Matched Grafts. Biol Blood Marrow Transplant 2016; 23:126-133. [PMID: 27989929 DOI: 10.1016/j.bbmt.2016.10.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 08/30/2016] [Accepted: 10/22/2016] [Indexed: 10/20/2022]
Abstract
We studied the effect of HLA-C matching in 515 patients after double umbilical cord blood (UCB) transplantation. After HLA matching HLA-A, -B, and -DRB1 at the allele level, we scored patients according to number of donor-recipient HLA-C matches at 4 possible loci: 2 from each donor unit, at the allele level. Given a direct interaction between HLA-A, -B, and -DRB1 matching and HLA-C score, we analyzed HLA-C matching in those receiving at least 1 2/6 to 4/6 HLA-matched unit (n = 389) versus those receiving only 5/6 or 6/6-matched units (n = 126). In those with at least 1 2/6 to 4/6 HLA-matched unit, a better HLA-C matching score was associated with significantly lower risk of death of any cause and nonrelapse mortality and better disease-free survival. There was no association with the risk of relapse, acute and chronic graft-versus-host disease, and hematopoietic recovery. In contrast, among patients receiving only allele-level 5/6 or 6/6 HLA-matched UCB units, HLA-C match had no demonstrable effect on any outcome. For patients receiving at least 1 allele-level 2/6 to 4/6 HLA-matched UCB unit, matching at HLA-C reduces nonrelapse mortality and improves survival.
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Affiliation(s)
- Claudio G Brunstein
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota.
| | | | - Todd E DeFor
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Haesook Kim
- The Dana Farber Cancer Institute, Boston, Massachusetts
| | - Nelli Bejanyan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | | | - Michael R Verneris
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Yi-Bin Chen
- Massachusetts General Hospital, Boston, Massachusetts
| | - Erica D Warlick
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | | | - Jeffrey S Miller
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | | | - Daniel J Weisdorf
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | | | - John E Wagner
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
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Mallhi KK, Smith AR, DeFor TE, Lund TC, Orchard PJ, Miller WP. Allele-Level HLA Matching Impacts Key Outcomes Following Umbilical Cord Blood Transplantation for Inherited Metabolic Disorders. Biol Blood Marrow Transplant 2016; 23:119-125. [PMID: 27989932 DOI: 10.1016/j.bbmt.2016.10.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [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: 09/30/2016] [Accepted: 10/25/2016] [Indexed: 01/06/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation has demonstrated efficacy for numerous inherited metabolic disorders (IMDs). Umbilical cord blood transplant (UCBT) is increasingly used as a graft source in IMDs, but little is known of the impact of cord blood unit (CBU)/recipient HLA allelic disparity on key outcomes following UCBT for IMD. We reviewed outcomes of 106 consecutive first, single UCBTs for IMD at the University of Minnesota with regard to CBU/recipient HLA allelic matching (HLA-A, -B, -C, and -DRB1). The median age at UCBT was 1 year, and 87 patients (82%) received myeloablative conditioning. Primary diagnoses were Hurler syndrome (41%), cerebral adrenoleukodystrophy (35%), metachromatic leukodystrophy/globoid cell leukodystrophy (9%), and other (16%). The 5-year overall survival (OS) for the entire cohort was 70% (95% confidence interval, 59% to 79%). Rates of severe acute and chronic graft-versus-host disease were low (6% for each). CBU/recipient HLA conventional matching was based on antigen-level matching at HLA-A and -B, and on allele-level matching at HLA-DRB1. Of 46 conventional matched UCBTs, 20 (43%) were mismatched at 1 or more alleles. Of 49 conventional 5/6 UCBTs, 30 (61%) were mismatched at ≥2 alleles and 19 (39%) were mismatched at ≥3 alleles. Within the 6/6 conventional match stratum, comparisons of key outcomes between allele-matched and allele-mismatched UCBT were as follows: 5-year OS, 88% versus 42% (P < .01); 1-year engrafted survival (ES) with ≥90% donor chimerism, 73% versus 60% (P = .33); graft failure, 8% versus 30% (P = .05); and transplantation-related mortality (TRM), 8% versus 30% (P = .04). For patients undergoing conventional 5/6 HLA-matched UCBT, better allelic matching was associated with similar outcomes: 5-year OS, 77% versus 74% (P = .72); 1-year ES, 73% versus 47% (P = .06); graft failure, 17% versus 42% (P = .05); and TRM, 10% versus 16% (P = .54). On multivariable analyses, fewer allele-level mismatches within each conventional match stratum continued to predict more favorable outcomes following UCBT. These data provide evidence that allele-level HLA matching considerations within a conventional HLA match stratum may better predict outcomes of interest after UCBT for IMD. Larger studies are warranted to confirm these findings and explore other allele-level HLA match dynamics.
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Affiliation(s)
- Kanwaldeep K Mallhi
- Division of Pediatric Blood and Marrow Transplant, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Angela R Smith
- Division of Pediatric Blood and Marrow Transplant, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Todd E DeFor
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Troy C Lund
- Division of Pediatric Blood and Marrow Transplant, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Paul J Orchard
- Division of Pediatric Blood and Marrow Transplant, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Weston P Miller
- Division of Pediatric Blood and Marrow Transplant, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota.
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Bejanyan N, Rogosheske J, DeFor TE, Lazaryan A, Arora M, Holtan SG, Jacobson PA, MacMillan ML, Verneris MR, Blazar BR, Weisdorf DJ, Wagner JE, Brunstein CG. Sirolimus and Mycophenolate Mofetil as Calcineurin Inhibitor-Free Graft-versus-Host Disease Prophylaxis for Reduced-Intensity Conditioning Umbilical Cord Blood Transplantation. Biol Blood Marrow Transplant 2016; 22:2025-2030. [PMID: 27519278 DOI: 10.1016/j.bbmt.2016.08.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [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: 06/28/2016] [Accepted: 08/05/2016] [Indexed: 11/25/2022]
Abstract
The use of calcineurin inhibitors (CNIs) to reduce the risk of graft-versus-host disease (GVHD) after hematopoietic cell transplantation (HCT) requires intensive post-transplantation toxicity monitoring. Sirolimus-based GVHD prophylaxis is associated with a favorable toxicity profile and requires less intensive monitoring. However, the efficacy of sirolimus-based regimen compared with CNI-based regimen has not been evaluated in the setting of reduced-intensity conditioning (RIC) double umbilical cord blood (UCB) HCT. We compared outcomes of patients receiving sirolimus/mycophenolate mofetil (MMF) (n = 37) or cyclosporine (CSA)/MMF (n = 123) in an ongoing phase II study of RIC UCB transplantation. In multiple regression analysis, sirolimus/MMF did not influence the risk of grades II to IV or grades III and IV acute GVHD. In addition, there was no association between type of GVHD prophylaxis and hematopoietic engraftment. Infection density analysis found a significantly lower risk of infections with sirolimus/MMF between days +46 and +180 after HCT compared with CSA/MMF (3.4 versus 6.3 per 1000 patient-days, P = .03); however, no difference was observed before day +45. Sirolimus/MMF use resulted in no thrombotic microangiopathy, fewer instances of elevated serum creatinine >2 mg/dL (14% versus 45%; P <.01), and similar rates of sinusoidal obstruction syndrome (2.7% versus 4%; P = .68), compared with CSA/MMF. Disease-free survival at 1 year was 51% for sirolimus/MMF and 41% for CSA/MMF (P = .41), and sirolimus/MMF use did not influence the risk of nonrelapse mortality or survival. In conclusion, sirolimus/MMF GVHD prophylaxis was better tolerated and resulted in similar rates of GVHD and survival as compared to CSA/MMF after RIC double UCB transplantation.
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Affiliation(s)
- Nelli Bejanyan
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota.
| | - John Rogosheske
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Todd E DeFor
- Adult and Pediatric Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Aleksandr Lazaryan
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Mukta Arora
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Shernan G Holtan
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Pamala A Jacobson
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Michael R Verneris
- Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Bruce R Blazar
- Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - John E Wagner
- Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
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Phelan R, Mann E, Napurski C, DeFor TE, Petryk A, Miller WP, Wagner JE, Verneris MR, Smith AR. Ovarian function after hematopoietic cell transplantation: a descriptive study following the use of GnRH agonists for myeloablative conditioning and observation only for reduced-intensity conditioning. Bone Marrow Transplant 2016; 51:1369-1375. [PMID: 27272448 DOI: 10.1038/bmt.2016.150] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 04/21/2016] [Accepted: 04/22/2016] [Indexed: 12/11/2022]
Abstract
Gonadal failure is a health and quality-of-life concern in hematopoietic cell transplant (HCT) survivors. While ovarian dysfunction is nearly universal following myeloablative (MA) conditioning, the risk is unclear after reduced-intensity conditioning (RIC). Gonadotropin-releasing hormone agonists decrease ovarian failure rates following conventional chemotherapy, but little is known about its effectiveness with HCT. We investigated the impact of leuprolide on ovarian function after MA conditioning and monitored ovarian function after RIC in this descriptive pilot study. Post-menarchal females <50 years undergoing HCT with adequate baseline ovarian function (follicle-stimulating hormone (FSH) level <40 mIU/mL and normal menstruation) were eligible. Prior to MA conditioning, leuprolide was administered. Those undergoing RIC were observed. FSH was measured at various time points. Seventeen women aged 12-45 years were evaluated (7 in the intervention group and 10 in the observation group). Compared to the historical high rate of ovarian failure after MA conditioning, 3 of 7 evaluable Lupron recipients had ovarian failure at a median of 703 days post transplant. Ovarian failure occurred in 1 of 10 recipients of RIC at a median follow-up of 901 days. In conclusion, leuprolide may protect ovarian function after MA conditioning. Additionally, RIC with cyclophosphamide, fludarabine and low-dose TBI has a low risk of ovarian failure.
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Affiliation(s)
- R Phelan
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - E Mann
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - C Napurski
- Cancer Survivorship Program, University of Minnesota, Minneapolis, MN, USA
| | - T E DeFor
- BMT Research Program, University of Minnesota, Minneapolis, MN, USA
| | - A Petryk
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - W P Miller
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - J E Wagner
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - M R Verneris
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - A R Smith
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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Mescher CA, Ding C, DeFor TE, Shenoy C, Konety S, Blaes AH. Left ventricular ejection fraction (EF) screening in metastatic HER2 positive breast cancer. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.e12074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Barnum JL, Petryk A, Zhang L, DeFor TE, Baker KS, Steinberger J, Nathan B, Wagner JE, MacMillan ML. Endocrinopathies, Bone Health, and Insulin Resistance in Patients with Fanconi Anemia after Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:1487-1492. [PMID: 27180116 DOI: 10.1016/j.bbmt.2016.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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: 02/08/2016] [Accepted: 05/03/2016] [Indexed: 01/25/2023]
Abstract
A number of endocrinopathies have been described after hematopoietic cell transplantation (HCT), but data are limited in patients with Fanconi anemia (FA). We report several endocrine-based disorders in a cohort of 44 patients with FA after HCT compared with both 74 patients who received HCT for hematologic malignancies and with 275 healthy controls. Endocrinopathies assessed included hypothyroidism, hypogonadism, short stature, dyslipidemia, insulin resistance, abnormalities in body composition, and bone health. Most (86%) patients with FA had at least 1 endocrinopathy, with 11% having 3 or more. Hypothyroidism was seen in 57%, hypogonadism in 27%, short stature in 50%, and reduced total body and lumbar spine bone mineral density (BMD) (height adjusted Z-score < -1) in 57% and 21%, respectively. Vitamin D deficiency was seen in 71%. Short stature was associated with younger age at HCT and gonadal failure was associated with older age at HCT. Insulin resistance was associated with increased percent fat mass and increased android/gynoid ratio by dual energy X-ray absorptiometry. Hypothyroidism, short stature, and reduced total body BMD were more prevalent in patients with FA compared with patients with hematologic malignancies. We recommend an assessment before transplantation and close follow-up afterwards to ensure proper clinical management. Future studies should continue to explore the impact of HCT on endocrinopathies in FA patients.
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Affiliation(s)
- Jessie L Barnum
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Anna Petryk
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota; Division of Endocrinology, University of Minnesota, Minneapolis, Minnesota
| | - Lei Zhang
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota
| | - Todd E DeFor
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Biostatistics and Informatics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - K Scott Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Julia Steinberger
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota; Division of Pediatric Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Brandon Nathan
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota; Division of Endocrinology, University of Minnesota, Minneapolis, Minnesota
| | - John E Wagner
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota.
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Gallaher IS, Watanabe Y, DeFor TE, Dusenbery KE, Lee CK, Hunt MA, Lin HY, Yuan J. BRAF Mutation Is Associated with Improved Local Control of Melanoma Brain Metastases Treated with Gamma Knife Radiosurgery. Front Oncol 2016; 6:107. [PMID: 27200295 PMCID: PMC4852277 DOI: 10.3389/fonc.2016.00107] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 04/15/2016] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Evidence has implicated a possible role of tumor mutation status on local control (LC) with radiotherapy. BRAF is a proto-oncogene that is mutated in approximately 50% of patients with melanoma. We sought to analyze the influence of BRAF status on LC of melanoma brain metastases (MBM) following Gamma Knife radiosurgery (GK). METHODS Among 125 patients treated with GK for MBM at our institution between 2006 and 2015, we identified 19 patients with 69 evaluable metastases whose BRAF mutation status was known and follow-up imaging was available. LC of individual metastases was compared based on BRAF mutation status using statistical techniques to control for measurements of multiple metastases within each patient. CNS progression was defined as either local failure or development of new lesions. RESULTS Of the 69 metastases, BRAF was mutated in 30 and wild-type in 39. With a median follow-up of 30 months for all patients and a median follow-up of 5.5 months for treated lesions, 1-year LC was significantly better among metastases with mutated vs. wild-type BRAF (69 vs. 34%, RR = 0.3, 95% CI = 0.1-0.7, p = 0.01). BRAF mutation was found to be a significant predictor of LC after stereotactic radiosurgery (SRS) in both univariate [RR = 0.3 (95% CI 0.1-0.7, p = 0.01)] and multivariate [RR = 0.2 (95% CI 0.1-0.7, p = 0.01)] analyses. There was also a trend toward improved CNS progression free survival (PFS) at 1 year (26 vs. 0%, p = 0.06), favoring BRAF-mutated patients. CONCLUSION In this retrospective study, MBM treated with GK had significantly improved LC for patients with BRAF mutation vs. wild-type. Our data suggest that BRAF mutation may sensitize tumors to radiosurgery, and that BRAF wild-type tumors may be more radioresistant.
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Affiliation(s)
- Ian S Gallaher
- Department of Radiation Oncology, University of Minnesota , Minneapolis, MN , USA
| | - Yoichi Watanabe
- Department of Radiation Oncology, University of Minnesota , Minneapolis, MN , USA
| | - Todd E DeFor
- Clinical and Translational Science Institute, University of Minnesota , Minneapolis, MN , USA
| | - Kathryn E Dusenbery
- Department of Radiation Oncology, University of Minnesota , Minneapolis, MN , USA
| | - Chung K Lee
- Department of Radiation Oncology, University of Minnesota , Minneapolis, MN , USA
| | - Matthew A Hunt
- Department of Neurosurgery, University of Minnesota , Minneapolis, MN , USA
| | - Hong-Yiou Lin
- Department of Radiation Oncology, Beaumont Health System , Detroit, MI , USA
| | - Jianling Yuan
- Department of Radiation Oncology, University of Minnesota , Minneapolis, MN , USA
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Mehta RS, Peffault de Latour R, DeFor TE, Robin M, Lazaryan A, Xhaard A, Bejanyan N, de Fontbrune FS, Arora M, Brunstein CG, Blazar BR, Weisdorf DJ, MacMillan ML, Socie G, Holtan SG. Improved graft-versus-host disease-free, relapse-free survival associated with bone marrow as the stem cell source in adults. Haematologica 2016; 101:764-72. [PMID: 27036159 DOI: 10.3324/haematol.2015.138990] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 03/22/2016] [Indexed: 01/22/2023] Open
Abstract
We previously reported that bone marrow grafts from matched sibling donors resulted in best graft-versus-host disease-free, relapse-free survival at 1-year post allogeneic hematopoietic cell transplantation. However, pediatric patients comprised the majority of bone marrow graft recipients in that study. To better define this outcome in adults and pediatric patients at 1- and 2-years post- allogeneic hematopoietic cell transplantation, we pooled data from the University of Minnesota and the Hôpital Saint-Louis in Paris, France (n=1901). Graft-versus-host disease-free, relapse-free survival was defined as the absence of grade III-IV acute graft-versus-host disease, chronic graft-versus-host disease (requiring systemic therapy or extensive stage), relapse and death. In adults, bone marrow from matched sibling donors (n=123) had best graft-versus-host disease-free, relapse-free survival at 1- and 2-years, compared with peripheral blood stem cell from matched sibling donors (n=540) or other graft/donor types. In multivariate analysis, peripheral blood stem cells from matched sibling donors resulted in a 50% increased risk of events contributing to graft-versus-host disease-free, relapse-free survival at 1- and 2-years than bone marrow from matched sibling donors. With limited numbers of peripheral blood stem cell grafts in pediatric patients (n=12), graft-versus-host disease-free, relapse-free survival did not differ between bone marrow and peripheral blood stem cell graft from any donor. While not all patients have a matched sibling donor, graft-versus-host disease-free, relapse-free survival may be improved by the preferential use of bone marrow for adults with malignant diseases. Alternatively, novel graft-versus-host disease prophylaxis regimens are needed to substantially impact graft-versus-host disease-free, relapse-free survival with the use of peripheral blood stem cell.
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Affiliation(s)
- Rohtesh S Mehta
- Hematology, Oncology, Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Todd E DeFor
- Hematology, Oncology, Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Marie Robin
- Haematology, Hôpital Saint-Louis, Paris, France
| | - Aleksandr Lazaryan
- Hematology, Oncology, Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Nelli Bejanyan
- Hematology, Oncology, Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Mukta Arora
- Hematology, Oncology, Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Claudio G Brunstein
- Hematology, Oncology, Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Bruce R Blazar
- Blood and Marrow Transplant Program, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Daniel J Weisdorf
- Hematology, Oncology, Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Margaret L MacMillan
- Blood and Marrow Transplant Program, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | | | - Shernan G Holtan
- Hematology, Oncology, Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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48
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Brunstein CG, Miller JS, McKenna DH, Hippen KL, DeFor TE, Sumstad D, Curtsinger J, Verneris MR, MacMillan ML, Levine BL, Riley JL, June CH, Le C, Weisdorf DJ, McGlave PB, Blazar BR, Wagner JE. Umbilical cord blood-derived T regulatory cells to prevent GVHD: kinetics, toxicity profile, and clinical effect. Blood 2016; 127:1044-51. [PMID: 26563133 PMCID: PMC4768428 DOI: 10.1182/blood-2015-06-653667] [Citation(s) in RCA: 286] [Impact Index Per Article: 35.8] [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: 06/24/2015] [Accepted: 10/29/2015] [Indexed: 01/05/2023] Open
Abstract
We studied the safety and clinical outcomes of patients treated with umbilical cord blood (UCB)-derived regulatory T cells (Tregs) that expanded in cultures stimulated with K562 cells modified to express the high-affinity Fc receptor (CD64) and CD86, the natural ligand of CD28 (KT64/86). Eleven patients were treated with Treg doses from 3-100 × 10(6) Treg/kg. The median proportion of CD4(+)FoxP3(+)CD127(-) in the infused product was 87% (range, 78%-95%), and we observed no dose-limiting infusional adverse events. Clinical outcomes were compared with contemporary controls (n = 22) who received the same conditioning regimen with sirolimus and mycophenolate mofetil immune suppression. The incidence of grade II-IV acute graft-versus-host disease (GVHD) at 100 days was 9% (95% confidence interval [CI], 0-25) vs 45% (95% CI, 24-67) in controls (P = .05). Chronic GVHD at 1 year was zero in Tregs and 14% in controls. Hematopoietic recovery and chimerism, cumulative density of infections, nonrelapse mortality, relapse, and disease-free survival were similar in the Treg recipients and controls. KT64/86-expanded UCB Tregs were safe and resulted in low risk of acute GVHD.
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Affiliation(s)
- Claudio G Brunstein
- University of Minnesota Blood and Marrow Transplant Program, Division of Hematology, Oncology and Transplantation
| | - Jeffrey S Miller
- University of Minnesota Blood and Marrow Transplant Program, Division of Hematology, Oncology and Transplantation
| | - David H McKenna
- Department of Laboratory Medicine and Pathology, Molecular and Cellular Therapeutics Facility
| | - Keli L Hippen
- University of Minnesota Blood and Marrow Transplant Program, Division of Pediatric Blood and Marrow Transplantation, and
| | - Todd E DeFor
- University of Minnesota Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Darin Sumstad
- University of Minnesota Blood and Marrow Transplant Program, Molecular and Cellular Therapeutics Facility
| | - Julie Curtsinger
- University of Minnesota Blood and Marrow Transplant Program, Division of Pediatric Blood and Marrow Transplantation, and
| | - Michael R Verneris
- University of Minnesota Blood and Marrow Transplant Program, Division of Pediatric Blood and Marrow Transplantation, and
| | - Margaret L MacMillan
- University of Minnesota Blood and Marrow Transplant Program, Division of Pediatric Blood and Marrow Transplantation, and
| | - Bruce L Levine
- Department of Pathology and Laboratory Medicine and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; and
| | - James L Riley
- Department of Pathology and Laboratory Medicine and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; and
| | - Carl H June
- Department of Pathology and Laboratory Medicine and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; and
| | - Chap Le
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN; Division of Biostatistics, University of Minnesota, Minneapolis, MN
| | - Daniel J Weisdorf
- University of Minnesota Blood and Marrow Transplant Program, Division of Hematology, Oncology and Transplantation
| | - Philip B McGlave
- University of Minnesota Blood and Marrow Transplant Program, Division of Hematology, Oncology and Transplantation
| | - Bruce R Blazar
- University of Minnesota Blood and Marrow Transplant Program, Division of Pediatric Blood and Marrow Transplantation, and
| | - John E Wagner
- University of Minnesota Blood and Marrow Transplant Program, Division of Pediatric Blood and Marrow Transplantation, and
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49
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Wagner JE, Brunstein CG, Boitano AE, DeFor TE, McKenna D, Sumstad D, Blazar BR, Tolar J, Le C, Jones J, Cooke MP, Bleul CC. Phase I/II Trial of StemRegenin-1 Expanded Umbilical Cord Blood Hematopoietic Stem Cells Supports Testing as a Stand-Alone Graft. Cell Stem Cell 2015; 18:144-55. [PMID: 26669897 DOI: 10.1016/j.stem.2015.10.004] [Citation(s) in RCA: 244] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/12/2015] [Accepted: 10/19/2015] [Indexed: 01/17/2023]
Abstract
Clinical application of umbilical cord blood (UCB) as a source of hematopoietic stem cells for transplantation is limited by low CD34+ cell dose, increased risk of graft failure, and slow hematopoietic recovery. While the cell dose limitation is partially mitigated by using two UCB units, larger-dosed single units would be preferable. We have evaluated the feasibility and safety of StemRegenin-1 (SR-1), an aryl hydrocarbon receptor antagonist that expands CD34+ cells, by placing one of the two units in expansion culture. SR-1 produced a 330-fold increase in CD34+ cells and led to engraftment in 17/17 patients at a median of 15 days for neutrophils and 49 days for platelets, significantly faster than in patients treated with unmanipulated UCB. Taken together, the marked expansion, absence of graft failure, and enhanced hematopoietic recovery support testing of SR-1 expansion as a stand-alone graft and suggest it may ameliorate a limitation of UCB transplant.
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Affiliation(s)
- John E Wagner
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN 55455, USA; Molecular and Cellular Therapeutics Facility, University of Minnesota, Minneapolis, MN 55108, USA.
| | - Claudio G Brunstein
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN 55455, USA
| | - Anthony E Boitano
- Genomics Institute of the Novartis Research Foundation, San Diego, CA 92121, USA
| | - Todd E DeFor
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN 55455, USA
| | - David McKenna
- Molecular and Cellular Therapeutics Facility, University of Minnesota, Minneapolis, MN 55108, USA
| | - Darin Sumstad
- Molecular and Cellular Therapeutics Facility, University of Minnesota, Minneapolis, MN 55108, USA
| | - Bruce R Blazar
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN 55455, USA
| | - Jakub Tolar
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN 55455, USA
| | - Chap Le
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN 55455, USA
| | - Julie Jones
- Novartis Institutes for BioMedical Research, Basel 4000, Switzerland
| | - Michael P Cooke
- Genomics Institute of the Novartis Research Foundation, San Diego, CA 92121, USA
| | - Conrad C Bleul
- Novartis Institutes for BioMedical Research, Basel 4000, Switzerland
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50
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Lee CH, Luo X, Huang CY, DeFor TE, Brunstein CG, Weisdorf DJ. Nonparametric methods for analyzing recurrent gap time data with application to infections after hematopoietic cell transplant. Biometrics 2015; 72:535-45. [PMID: 26575402 DOI: 10.1111/biom.12439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 03/01/2014] [Revised: 09/01/2015] [Accepted: 09/01/2015] [Indexed: 12/01/2022]
Abstract
Infection is one of the most common complications after hematopoietic cell transplantation. Many patients experience infectious complications repeatedly after transplant. Existing statistical methods for recurrent gap time data typically assume that patients are enrolled due to the occurrence of an event of interest, and subsequently experience recurrent events of the same type; moreover, for one-sample estimation, the gap times between consecutive events are usually assumed to be identically distributed. Applying these methods to analyze the post-transplant infection data will inevitably lead to incorrect inferential results because the time from transplant to the first infection has a different biological meaning than the gap times between consecutive recurrent infections. Some unbiased yet inefficient methods include univariate survival analysis methods based on data from the first infection or bivariate serial event data methods based on the first and second infections. In this article, we propose a nonparametric estimator of the joint distribution of time from transplant to the first infection and the gap times between consecutive infections. The proposed estimator takes into account the potentially different distributions of the two types of gap times and better uses the recurrent infection data. Asymptotic properties of the proposed estimators are established.
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Affiliation(s)
- Chi Hyun Lee
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota 55455, U.S.A
| | - Xianghua Luo
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota 55455, U.S.A.,Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota 55455, U.S.A
| | - Chiung-Yu Huang
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland 21205, U.S.A
| | - Todd E DeFor
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota 55455, U.S.A
| | - Claudio G Brunstein
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota 55455, U.S.A.,Blood and Marrow Transplantation Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota 55455, U.S.A
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota 55455, U.S.A.,Blood and Marrow Transplantation Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota 55455, U.S.A
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