Successful Bridging to Allogeneic Transplantation With Valemetostat in Two Refractory/relapsed Peripheral T-cell lymphoma patients

We report the case of 2 patients with relapsed/refractory peripheral T-cell lymphoma treated with valemetostat tosylate, a selective dual inhibitor of histone-lysine N-methyltransferases enhancer of zest homolog 1 and 2, and subsequently bridged to allogeneic stem cell transplantation. Valemetostat led to a quick response and was well tolerated, offering a promising bridge therapy to transplantation for patients with relapsed/refractory peripheral T-cell lymphoma, which is still an unmet medical need.

Total marrow irradiation for second allogeneic hematopoietic stem cell transplantation in patients with advanced acute leukemia

BACKGROUND

Second allogeneic hematopoietic stem cell transplantation (HSCT) is a treatment option for patients with acute leukemia relapsing after a first HSCT. While a myeloablative (MA) conditioning regimen before the first HSCT is considered better than reduced intensity (RIC) in terms of disease control in acute leukemia patients, the optimal conditioning regimen for the second allogeneic HSCT remains controversial. The most important prognostic factors are the remission disease phase at the time of the second HSCT and more than 12 months from the first to the second HSCT. Total Marrow Irradiation (TMI) is an advanced high-precision radiation treatment that delivers therapeutic doses over extensively selected targets while substantially reducing radiation to vital organs compared to conventional Total Body Irradiation (TBI). Herein we report the results of a retrospective analysis on second allogeneic transplantation treated with TMI as a myeloablative conditioning regimen, intending to limit toxicity.

OBJECTIVE

We investigated the efficacy of a high dose per fraction TMI in combination with thiotepa, fludarabine and melphalan in 13 consecutive patients with acute leukemia relapsed after a first allogeneic HSCT treated between March 2018 and November 2021.

STUDY DESIGN

Donor type was haploidentical (HAPLO, n=10), unrelated (UD n=2), and HLA-identical sibling (SIB, n=1). The conditioning regimen consisted of TMI 8 Gy in 5 patients on day -8 -7 or TMI 12 Gy in 8 patients on day -9 -8 -7, plus Thiotepa 5 mg/Kg on day -6, Fludarabine 50 mg/mq on day -5 -4 -3, Melphalan 140 mg/mq on day -2. TMI was delivered in a hypofractionated daily single dose of 4 Gy for three consecutive fractions. The median age was 45 years (range, 19-70 years); 7 patients were in remission, and 6 had active disease at the time of the second allogeneic HSCT.

RESULTS

The median time to neutrophil counts of > 0.5×10e9/L was 16 days (range 13-22), and platelet counts of > 20×10e9/L were 20 days (range 14-34), respectively. All patients showed a complete donor chimerism on day 30 after the transplant. The cumulative incidence of grade I II acute GvHD (aGvHD) was 43%, and chronic GvHD (cGVHD) was 30%. The median follow-up was 1121 days (range 200-1540). Day +30 and +100 transplant-related mortality (TRM) was 0. Overall cumulative incidence of TRM, relapse rate, and disease free-survival (DFS) were respectively 27%,7%, and 67%.

CONCLUSIONS

This retrospective study showed the safety and efficacy of a hypofractionated TMI conditioning regimen in patients with acute leukemia receiving second HSCT with encouraging outcomes regarding engraftment, early toxicity, GvHD, and relapse.

Clinical Significance of bZIP in-Frame CEBPA-Mutated Normal Karyotype Acute Myeloid Leukemia

Purpose

We evaluated the characteristics of CEBPA mutations and the significance of a basic leucine zipper in-frame mutation (bZIPin-f) of CEBPA in patients with acute myeloid leukemia with a normal karyotype.

Materials and Methods

Based on updated knowledge of CCAAT/enhancer-binding protein α (CEBPA) mutations, we conducted next-generation sequencing analyses in a previously established real-world cohort.

Results

Among 78 of a total of 395 patients (19.7%), 50 had bZIPin-f CEBPA, and 28 had non-bZIPin-f CEBPA. In the multivariate analysis, patients with NPM1mut, those with bZIPin-f CEBPA, and those who underwent allogeneic hematopoietic cell transplantation (allo-HCT) had favorable overall survival (OS), but FLT3-ITDmut was a poor prognostic indicator. For relapse-free survival (RFS) and cumulative incidence of relapse, bZIPin-f CEBPA, and allo-HCT were associated with favorable outcomes; FLT3-ITDpos was associated with worse outcomes. In the CEBPA double-mutated group (CEBPAdm), bZIPin-f CEBPA was associated with superior outcomes in terms of OS (p=0.007) and RFS (p=0.007) compared with non-bZIPin-f CEBPA. Of 50 patients with bZIPin-f CEBPA, 36 patients had at least one mutation. When grouped by the presence of mutations in chromatic/DNA modifiers (C), cohesion complex (C), and splicing genes (S) (CCS mutations), CCS-mutated bZIPin-f CEBPA was associated with poor OS (p=0.020, hazard ratio (HR):2.775) and a trend in inferior RFS (p=0.106, HR:2.106).

Conclusion

Only bZIPin-f CEBPA was associated with favorable outcomes in patients with CEBPAdm. However, some mutations accompanying bZIPin-f CEBPA showed inferior OS; thus, further studies with larger numbers of patients are required for clear conclusions of the significance of bZIPin-f CEBPA.

Salvage haploidentical or cord-blood allogeneic stem cell transplantation after a prior alternative allograft in hematologic malignancies: a retrospective study from the SFGM-TC

BACKGROUND

Haploidentical (haplo-) donors and cord-blood (CB) stem cells provide alternative transplant options in patients lacking an HLA-matched donor. In case of relapse or graft failure after a first alternative allogeneic hematopoietic stem cell transplant (HSCT), a second alternative HSCT (HSCT2) is rarely considered due to a high risk of toxicity.

METHODS

A retrospective French multicenter study was performed, including patients with hematologic malignancies who underwent two consecutive HSCT from alternative donors. All data were exported from the national ProMISE database between 2000 and 2016.

RESULTS

Forty-three patients (61.4%) received a CB-HSCT2 and 27 (38.6%) a haplo-HSCT2. Indications for HSCT were graft failure (51.4%) or disease progression (48.6%). Two-years probabilities of overall survival, progression-free survival and toxicity-related mortality were 18.5%, 17.8% and 55.8%, respectively. In multivariate analysis, complete remission status at HSCT2 and year of HSCT2 ≥2012 were significantly associated with a better outcome (with respectively hazard ratio (HR)=0.42, p=0.002 and HR=0.5, p=0.051).

CONCLUSIONS

Neither the indication of HSCT2 nor the source of stem cell was more advantageous towards overall patient survival. A salvage haploidentical or cord-blood stem cell transplantation is a high-risk procedure, that may be considered for patients achieving a complete remission before receiving the second HSCT.

Allogeneic haematopoietic cell transplant services in Australia and New Zealand in the first year of the COVID-19 pandemic: A report from Australia and New Zealand Transplant and Cellular Therapies

BACKGROUND

The COVID-19 pandemic has caused major disruption to health systems, with allogeneic haematopoietic cell transplant (alloHCT) services a particularly vulnerable area. Ongoing provision of alloHCT has required dynamic responses at national and local levels. In Australia and New Zealand (ANZ), a high reliance on unrelated donors from overseas registries has posed an additional challenge.

AIMS

To describe the impact of COVID-19 on alloHCT services in ANZ in the first year of the pandemic.

METHODS

Data from the national alloHCT recipient and unrelated donor registries was extracted for a 2-year time frame. Comparisons were made between a pre-pandemic period of 1st March 2019 to 29th February 2020 and the corresponding dates during the pandemic, 1st March 2020 to 28th February 2021.

RESULTS

There was a 13% decrease in the number of allogeneic transplants, a reversal of steady increases in previous years, with the largest decrease in unrelated donor transplants. Local donors supplied a greater proportion of unrelated stem cell products. With a switch to universal cryopreservation, the time from request of a product to infusion increased by a median of 25.5 days for overseas products and 14 days for local products. There was a significant increase in the number of products collected but not used.

CONCLUSIONS

A strong public health response and coordinated transplant community activities allowed for safe provision of alloHCT in ANZ, however our data suggests that the timely delivery of allogeneic transplants was affected by the COVID-19 pandemic. Continued dedicated efforts are required to minimise further impacts. This article is protected by copyright. All rights reserved.

Improved Healing of Colonic Anastomosis with Allotransplantation of Axillary Skin Fibroblasts in Rats

Objective

Colonic anastomosis is associated with serious complications leading to significant morbidity and mortality. Fibroblasts have recently been introduced as a practical alternative to stem cells because of their differentiation capacity, anti-inflammatory, and regenerative properties. The aim of this study was to evaluate the effects of intramural injection of fibroblasts on the healing of colonic anastomosis in rats.

Materials and Methods

Inbred mature male Wistar rats were used in this experimental study (n=36). Fibroblasts were isolated from the axillary skin of a donor rat. In the sham group, manipulation on descending colon was done during laparotomy. A 5 mm segment of the colon was resected, and end-to-end anastomosis was performed. In the control group, 0.5 ml of phosphate buffer saline (PBS) was injected into the colonic wall and in the treatment group, 1×106 fibroblasts were transplanted. Following euthanasia on day 7, intra-abdominal adhesion, leakage and peritonitis were evaluated by necropsy. Mechanical properties were assessed using bursting pressure and tensile tests. Inflammation, angiogenesis, and collagen deposition were examined histopathologically.

Results

The mean scores for adhesion and leakage were decreased in the treatment group versus control samples. Lower infiltration of inflammatory cells was observed in the treatment group (P=0.03). Angiogenesis and collagen deposition scores were significantly increased in the fibroblast transplanted group (P=0.03). Tensile mechanical properties of the colon were significantly increased in the treatment group compared to the control sample (P=0.01). There was no significant difference between the control and treatment groups in terms of bursting pressure (P=0.10). Positive weight changes were found in sham and treatment groups, but the control rats lost weight after 7 days.

Conclusion

The results suggested that allotransplantation of dermal fibroblasts could improve the necroscopic, histopathological, and biomechanical indices of colonic anastomosis repair in rats.

Allogeneic transplant for FLT3-ITD mutated AML: a focus on FLT3 inhibitors before, during, and after transplant

FMS-like tyrosine kinase 3 (FLT3) mutations are one of the most frequently encountered genetic alterations in acute myeloid leukemia (AML), and are generally associated with unfavorable outcomes. Several tools are currently available to provide an accurate prognosis for patients with these mutations, including FLT3 mutation type (internal tandem duplication versus tyrosine kinase domain), mutation allelic ratio (high versus low), and concurrent nucleophosmin-1 (NPM1) mutation, to help decide on optimal treatment. Recent advances in targeted therapies have paved the way for modern treatment strategies, such as the development of FLT3 kinase inhibitors. These novel drugs can be incorporated into any treatment component, including induction and consolidation, the relapse/refractory setting, bridging for transplant, salvage post-transplant, and as prophylactic long-term post-transplant maintenance. Many challenges remain though, such as their intolerability with high-dose chemotherapy in frail patients; whether their optimal use involves watchful waiting for molecular or hematologic relapse compared with prophylactic use as maintenance; and the exact role and indication for allogeneic stem cell transplantation, which arguably remains the only curative option for these high-risk patients.

Ascites as a Manifestation of GVHD: a Rare Phenomenon

Graft versus host disease (GVHD) usually have involvement of classical target organs. Manifestations of Chronic GVHD (cGVHD) are much more protean than acute GVHD. NIH consensus criterion for cGVHD proposes different diagnostic and distinctive features of cGVHD. It acknowledges certain uncommon manifestations that can be attributed to cGVHD only when they are associated with more specific features. Patients rarely may develop such manifestations which are not diagnostic of cGVHD themselves. In the absence of more specific features of cGVHD, they may pose diagnostic challenge. Amongst the rare reported manifestations of cGVHD is serositis manifesting as pleural effusion, pericardial effusion or ascites. We report two patients developing ascites as an isolated manifestation of cGVHD.