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Ramsey SD, Bansal A, Li L, O'Donnell PV, Fuchs EJ, Brunstein CG, Eapen M, Thao V, Roth JA, Steuten L. Cost-Effectiveness of Unrelated Umbilical Cord Blood vs. HLA Haploidentical Related Bone Marrow Transplant: Evidence from BMT CTN 1101. Transplant Cell Ther 2023:S2666-6367(23)01257-5. [PMID: 37120135 DOI: 10.1016/j.jtct.2023.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/06/2023] [Accepted: 04/24/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND BMT CTN 1101 was a Phase III randomized controlled trial comparing reduced intensity conditioning followed by double unrelated umbilical cord blood (UCB) versus HLA-haploidentical related donor bone marrow (haplo-BM) transplantation for patients with high-risk hematologic malignancies. OBJECTIVE The objective of this study is to report the results of a parallel cost-effectiveness analysis. STUDY DESIGN Three hundred sixty-eight patients were randomized to unrelated UCB (n=186) or haplo-BM (n=182) transplant. We estimated healthcare utilization and costs using propensity score-matched BMT patients from the OptumLabsⓇ Data Warehouse for trial participants <65 years and Medicare claims for participants ≥65 years. Weibull models were used to estimate 20-year survival. EQ-5D surveys by trial participants were used estimate Quality-Adjusted Life Years (QALYs). RESULTS At 5-year follow-up, survival was 42% for haplo-BM versus 36% for UCB (P=.06). Over a 20-year time horizon, haplo-BM is expected to be more effective (+0.63 QALY) and more costly +$118,953) for persons under 65. For those over 65, haplo-BM is expected to be more effective and less costly. In one-way uncertainty analyses, for persons <65, the cost per QALY result was most sensitive to life years and health state utilities. For persons ≥65, life years were more influential than costs and health state utilities. CONCLUSION Compared to UCB, haplo-BM was moderately cost-effective for patients aged <65 years, and less costly and more effective for persons ≥65 years. Haplo-BM is a fair value choice for commercially insured patients with high-risk leukemia and lymphoma who require HCT. For Medicare enrollees, haplo-BM is a preferred choice when considering costs and outcomes.
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Affiliation(s)
- S D Ramsey
- Fred Hutchinson Cancer Center, Seattle, WA; University of Washington, Seattle, WA.
| | - A Bansal
- Fred Hutchinson Cancer Center, Seattle, WA; University of Washington, Seattle, WA
| | - L Li
- Fred Hutchinson Cancer Center, Seattle, WA
| | - P V O'Donnell
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - E J Fuchs
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - C G Brunstein
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN
| | - M Eapen
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - V Thao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; OptumLabs, Edina, MN
| | - J A Roth
- University of Washington, Seattle, WA; Pfizer, New York, NY
| | - Lmg Steuten
- Office of Health Economics, London, United Kingdom
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Jurdi NE, Martens MJ, Brunstein CG, O'Donnell P, Lee SJ, D'Souza A, Logan B, Hong S, Singh AK, Sandhu K, Shapiro RM, Horowitz MM, Hamilton BK. Heath-related Quality of Life in Double Umbilical Cord Blood vs. Haploidentical Marrow Transplantation: a QOL Analysis Report of BMT CTN 1101. Transplant Cell Ther 2023:S2666-6367(23)01240-X. [PMID: 37088401 DOI: 10.1016/j.jtct.2023.04.009] [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: 02/06/2023] [Revised: 04/06/2023] [Accepted: 04/10/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION The Blood and Marrow Transplant Clinical Trials Network study 1101 (BMT CTN 1101, NCT01597778) was a multicenter phase III randomized trial comparing the clinical outcomes and quality of life (QOL) of patients with hematological malignancies receiving double umbilical cord blood transplants (dUCBT) or HLA-haploidentical bone marrow transplants (haplo-BM) after reduced intensity conditioning. Five-year follow up found no significant differences in progression free survival (PFS) or overall survival (OS) between the two cohorts. The impact of alternative donor source on QOL, however, is unknown. METHODS English and Spanish speaking patients completed the Functional Assessment of Cancer Therapy-General (FACT-G), SF-36, EQ-5D, and Global QOL patient-reported outcome (PRO) assessments pre-transplant and at 12 and 24 months post-transplant. We compared longitudinal QOL measures between dUCBT and haplo-BMT and investigated the association of QOL and clinical outcomes using an inverse probability weighted-independent estimating equations (IPW-IEE) method accounting for missingness and baseline variables. RESULTS We found no significant differences in any of the QOL scores between the treatment arms at pre-transplant, 12, and 24 months. Pre-transplant scores were the only significant predictors of post-transplant QOL scores. Relapse and Grade III-IV acute graft-versus-host disease (GVHD) were associated with significant declines in mean FACT-BMT and SF-36 physical component scores. Chronic GVHD was associated with a decline in mean EQ-5D utility scores. We found no significant association between pre-transplant QOL scores and OS or PFS. CONCLUSIONS Donor type did not impact post-transplant QOL. Pre-transplant QOL scores and clinical events of GVHD and relapse were the only predictors of post-transplant QOL. QOL was not associated with survival in either treatment arm. PROs may be a valuable tool in pre-transplant risk assessment strategies to improve QOL outcomes.
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Affiliation(s)
- Najla El Jurdi
- Department of Medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN.
| | - Michael J Martens
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI; Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Claudio G Brunstein
- Blood & Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Paul O'Donnell
- Massachusetts General Hospital Cancer Center, Boston, MA
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Anita D'Souza
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Brent Logan
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI; Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Sanghee Hong
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, NC
| | - Anurag K Singh
- Division of Hematologic Malignancies & Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS
| | - Karamjeet Sandhu
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Roman M Shapiro
- Stem Cell Transplantation and Cellular Therapy, Dana-Farber Cancer Institute, Boston, MA
| | - Mary M Horowitz
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Betty K Hamilton
- Blood & Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
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Agarwal N, Hegde P, Hong L, Brunstein CG, Hanna R, Kalaycio ME, Rotz SJ, Sobecks RM, Sauter CS, Hamilton BK. Short- and Long-Term Toxicities of Post-Transplant Cyclophosphamide after Allogeneic Hematopoietic Cell Transplant. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00550-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Lin C, Sajeev G, Stiff PJ, Brunstein CG, Cutler C, Sanz G, Lindemans CA, Rezvani AR, Hanna R, Koh LP, Maziarz RT, Hwang WYK, Song Y, Liu Q, Manghani R, Sivaraman S, Signorovitch J, Horwitz ME, Sung AD. Health-Related Quality of Life Following Allogeneic Hematopoietic Cell Transplantation with Omidubicel versus Umbilical Cord Blood. Transplant Cell Ther 2023; 29:52.e1-52.e9. [PMID: 36179986 PMCID: PMC9825638 DOI: 10.1016/j.jtct.2022.09.018] [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: 08/11/2022] [Accepted: 09/23/2022] [Indexed: 01/11/2023]
Abstract
Omidubicel is an advanced cell therapy derived from umbilical cord blood (UCB) for use in allogeneic hematopoietic cell transplantation (HCT). A recent randomized phase 3 clinical trial demonstrated faster engraftment, shorter length of hospital stays, and lower rates of infection with omidubicel compared with standard UCB transplantation in patients with high-risk hematologic malignancies. Despite the proven clinical benefits of omidubicel, its impact on health-related quality of life (HRQL) from the patient's perspective has not been described. This study analyzed patient-reported HRQL measures collected prospectively in the randomized phase 3 trial comparing omidubicel to standard UCB transplantation. A total of 108 patients at 33 international stem cell transplantation centers underwent myeloablative allogeneic HCT with either omidubicel or standard UCB. Patients completed serial HRQL questionnaires at screening and on days 42, 100, 180, and 365 post-transplantation. The HRQL surveys included the Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT), a 50-item cancer-specific questionnaire assessing physical, functional, emotional, social/family, and HCT-specific well-being, and the EuroQol 5-Dimension 3-Level, a 5-item generic HRQL survey. A mixed model with repeated measures was used to compare changes in HRQL from baseline in the 2 treatment arms. The average change in HRQL scores over time was compared by estimating the difference in the area under the curve (AUC) in each treatment group. Seventy-five patients (omidubicel arm, n = 37; standard UCB arm, n = 38) who completed the FACT-BMT at baseline and on 1 or more follow-up visits were included in this study. Baseline characteristics were similar in the 2 treatment arms. Over the first year post-transplantation, the AUCs of mean changes in physical, functional, and total FACT-BMT scores indicated significantly better HRQL with omidubicel (P < .05), with mean differences across time points ranging from 1.4 to 3.1 points, 1.6 to 3.2 points, and 7.2 to 11.0 points, respectively. The minimal clinically important difference was exceeded at 1 or more time points for each of these measures. The HRQL improvements with omidubicel were observed as early as 42 days post-transplantation and persisted at 1 year, indicating the potential long-term benefits of omidubicel on HRQL. Across all patients, adverse clinical outcomes, such as grade 3 viral infections and lower rates of neutrophil engraftment, were associated with worse HRQL scores. The observed improvements in HRQL measures may reflect the known clinical benefits of omidubicel. Compared with standard UCB, allogeneic HCT with omidubicel resulted in significant and clinically meaningful improvements in patient-reported HRQL measures.
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Affiliation(s)
- Chenyu Lin
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | | | - Patrick J Stiff
- Division of Hematology and Oncology, Loyola University Medical Center, Chicago, Illinois
| | - Claudio G Brunstein
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, Minnesota; Department of Hematology and Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio
| | - Corey Cutler
- Division of Stem Cell Transplantation and Cellular Therapies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Guillermo Sanz
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain; CICERONC, Instituto de Salud Carlos III, Madrid, Spain; IIS La Fe, Valencia, Spain
| | - Caroline A Lindemans
- Department of Pediatric Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Andrew R Rezvani
- Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford University, Stanford, California
| | - Rabi Hanna
- Department of Pediatric Hematology Oncology and Bone Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Liang Piu Koh
- Department of Hematology-Oncology, National University Cancer Institute, Singapore
| | - Richard T Maziarz
- Center for Hematologic Malignancies, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - William Y K Hwang
- Department of Haematology, National Cancer Centre Singapore; Department of Haematology, Singapore General Hospital; Cancer and Stem Cell Biology, Duke-NUS Medical School
| | - Yan Song
- Analysis Group, Inc, Boston, Massachusetts
| | - Qing Liu
- Analysis Group, Inc, Boston, Massachusetts
| | | | | | | | - Mitchell E Horwitz
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Anthony D Sung
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina.
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Brunstein CG, O’Donnell PV, Logan B, Dawson P, Costa L, Cutler C, Craig M, Hogan W, Horowitz MM, Horwitz ME, Karanes C, Magenau JM, Malone A, McCarty J, McGuirk JP, Morris LE, Rezvani AR, Salit R, Vasu S, Eapen M, Fuchs EJ. Impact of Center Experience with Donor Type on Outcomes: A Secondary Analysis, Blood and Marrow Transplant Clinical Trials Network 1101Open for Accrual June 2012Open for Accrual June 2012. Transplant Cell Ther 2022; 28:406.e1-406.e6. [PMID: 35390529 PMCID: PMC9253061 DOI: 10.1016/j.jtct.2022.03.024] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/14/2022] [Accepted: 03/28/2022] [Indexed: 11/26/2022]
Abstract
We previously reported the results of Blood and Marrow Transplant Clinical Trials Network (BMT CTN) 1101, a randomized comparison of hematopoietic cell transplantation (HCT) performed with double umbilical cord blood units (dUCB) or with haploidentical bone marrow (haplo-BMT) with post-transplantation cyclophosphamide (PTCy) in the nonmyeloablative setting. Those results showed similar progression-free survival in the 2 treatment groups but lower nonrelapse mortality and better overall survival in the haplo-BM arm. In this secondary analysis, we sought to investigate whether transplantation center's previous experience with haplo-BM and/or dUCB HCT had an impact on outcomes. All patients randomized in BMT CTN 1101 were included. Center experience was assigned based on the number of transplantations with each platform performed in the year before initiation of the study according to the Center for International Blood and Marrow Transplant Research. Centers were then classified as a dUCB center (>10 dUCB HCTs; n = 117 patients, 10 centers), a haplo-BM center (>10 haplo-BM HCTs and ≤10 dUCB HCTs; n = 110 patients, 2 centers), or other center (≤10 haplo and ≤10 dUCB HCTs; n = 140 patients, 21 centers). After adjusting for age, Karnofsky Performance Status, and Disease Risk Index, we found that haplo-BM centers had lower overall mortality with this donor type compared with dUCB centers (hazard ratio [HR], 2.56; 95% confidence interval [CI], 1.44 to 4.56). In contrast, there were no differences in overall mortality between haplo-BM and dUCB in centers that were experienced with dUCB HCT (HR, 1.02; 95% CI, .59 to 1.79) or had limited to no experience with either dUCB or haplo-BM HCT (HR, 1.36; 95% CI, .83 to 2.21). The higher risk of treatment failure and overall mortality in dUCB HCT in haplo BM-experienced centers was driven by a significantly higher risk of relapse (HR, 1.78; 95% CI, 1.07 to 2.97). With the exception of worse outcomes among dUCB HCT recipients in haplo-BM centers, transplantation center experience in the year before initiation of BMT CTN 1101 had a limited impact on the outcomes of this randomized clinical trial.
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Affiliation(s)
- Claudio G Brunstein
- Blood and Marrow Transplant Program, University of Minnesota, Mayo Mail Code 480, 420 Delaware Street SE, Minneapolis, MN 55455, United States.
| | | | - Brent Logan
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | | | - Corey Cutler
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | | | - Mary M Horowitz
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | | | | | | | | | | | | | | | - Rachel Salit
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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Steuten LMG, Bansal A, Li L, Brunstein CG, O'Donnell PV, Eapen M, Sangaralingham LR, Thao V, Roth JA, Wright WE, Ramsey SD. Cost effectiveness of reduced intensity conditioning and transplantation of unrelated umbilical cord blood versus HLA haploidentical related bone marrow for adults with hematologic malignancies. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.6591] [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
6591 Background: BMT CTN 1101 was a Phase III randomized controlled trial evaluating the comparative effectiveness of unrelated umbilical cord blood (UCB) versus HLA-haploidentical related donor bone marrow (haplo-BM) cell sources for hematopoietic cell transplantation (HCT) in patients with high-risk hematologic malignancies (leukemias, lymphomas). We report results of an economic evaluation conducted as part of the clinical trial. Methods: 368 patients (90% of planned accrual) enrolled from 33 centers in the U.S. were randomly assigned to unrelated UCB (n=186) or haplo-BM (n=182) transplant. Healthcare utilization and costs were estimated using propensity-score matched cohorts of BMT patients in the OptumLabs Data Warehouse for trial participants <65 years, and Medicare claims for trial participants ≥65 years. Cost-effectiveness was calculated from payer perspectives (commercial, Medicare) over a 20-year time horizon from time of transplant. Weibull models (best fit based on AIC/BIC) were used to extrapolate survival from 5-year trial follow-up data. Trial participant surveys (EQ-5D) were used to derive health state utilities for estimating Quality-Adjusted Life Years (QALYs). One-way and probabilistic sensitivity analyses were conducted to assess uncertainty in results. Outcomes were discounted at 3% annually. Results: At 5-year follow-up, overall survival was 42% for haplo-BM versus 36% for UCB (P=.06). Over a 20-year time horizon, haplo-BM is expected to be more effective and more costly for <65 year-olds and in ≥65 year-olds it is expected to be more effective and less costly. In one-way uncertainty analyses, for persons <65, the cost/QALY result was most sensitive to life years and health state utilities. For persons ≥65, life years were more influential than costs and health state utilities. Using probabilistic sensitivity analysis, for persons <65 there was a 43% chance that haplo-BM was cost-effective using a willingness to pay threshold of $150k/QALY and 52% at a $200K/QALY threshold. Conclusions: Results from a large national clinical trial indicate that compared to UCB, haplo-BM was moderately cost-effective for patients aged <65 years, and less costly and more effective for persons ≥65 years. Haplo-BM is a fair value choice for commercially insured patients with high-risk leukemia and lymphoma who require HCT. For Medicare enrollees, haplo-BM is a preferred choice when considering costs and outcomes. [Table: see text]
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Affiliation(s)
| | | | - Li Li
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Claudio G Brunstein
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN
| | - Paul V. O'Donnell
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Mary Eapen
- Medical College of Wisconsin, Milwaukee, WI
| | - Lindsey R. Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (X.Y., P.A.N., N.D.S.), Mayo Clinic, Rochester, MN
| | - Viengneesee Thao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (X.Y., P.A.N., N.D.S.), Mayo Clinic, Rochester, MN
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Mamo T, Hippen KL, MacMillan ML, Brunstein CG, Miller JS, Wagner JE, Blazar BR, McKenna DH. Regulatory T cells: A review of manufacturing and clinical utility. Transfusion 2022; 62:904-915. [PMID: 35015309 PMCID: PMC8986575 DOI: 10.1111/trf.16797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Tewodros Mamo
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Keli L. Hippen
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Margaret L. MacMillan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Claudio G. Brunstein
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Jeffrey S. Miller
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - John E. Wagner
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Bruce R. Blazar
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - David H. McKenna
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
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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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Horwitz ME, Stiff P, Cutler C, Brunstein CG, Rezvani AR, Hanna R, Khee Hwang WY, Maziarz RT, McGuirk JP, Karras N, Lindemans CA, Valcarcel D, Koh LP, Schiller GJ, Sanz J, Schwarzbach A, Galamidi-Cohen E, Sanz G. Allogeneic Hematopoietic Stem Cell (Allo-HSCT) Transplant with Omidubicel Demonstrates Sustained Clinical Improvement Versus Standard Myeloablative Umbilical Cord Blood Transplantation (UCBT): Final Results of a Phase III Randomized, Multicenter Study. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00247-0] [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: 10/18/2022]
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Horwitz ME, Sajeev G, Stiff P, Brunstein CG, Cutler C, Sanz G, Lindemans CA, Rezvani AR, Hanna R, Koh LP, Maziarz RT, Khee Hwang WY, Song Y, Liu Q, Manghani R, Sivaraman S, Signorovitch J, Galamidi-Cohen E. Health-Related Quality of Life (HRQL) Following Transplantation with Omidubicel Versus Umbilical Cord Blood (UCB) in Patients with Hematologic Malignancies: Results from a Phase III Randomized, Multicenter Study. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00668-6] [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: 11/30/2022]
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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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O’Donnell PV, Brunstein CG, Fuchs EJ, Zhang MJ, Allbee-Johnson M, Antin JH, Leifer ES, Elmariah H, Grunwald MR, Hashmi H, Horowitz MM, Magenau JM, Majhail N, Milano F, Morris LE, Rezvani AR, McGuirk JP, Jones RJ, Eapen M. Umbilical Cord Blood or HLA-Haploidentical Transplantation: Real-World Outcomes versus Randomized Trial Outcomes. Transplant Cell Ther 2022; 28:109.e1-109.e8. [PMID: 34775146 PMCID: PMC8882346 DOI: 10.1016/j.jtct.2021.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [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: 09/27/2021] [Revised: 10/22/2021] [Accepted: 11/03/2021] [Indexed: 02/03/2023]
Abstract
Randomized clinical trials offer the highest-quality data for modifying clinical practice. Results of a phase III randomized trial of nonmyeloablative transplantation for adults with high-risk hematologic malignancies with 2 umbilical cord blood (UCB) units (n = 183) or HLA-haploidentical relative bone marrow (Haplo-BM; n = 154) revealed a 2-year progression-free survival (PFS) of 41% after Haplo-BM transplantation and 35% after 2-unit UCB transplantation (P = .41), with overall survival (OS) of 57% and 46%, respectively (P = .04). We sought to examine the generalizability of BMT CTN 1101 to a contemporaneous cohort beyond the trial's prespecified 2-year outcomes. All transplantations were performed between June 2012 and June 2018 in the United States. We hypothesized that the results of a rigorous phase III randomized trial would be generalizable. Changes in graft selection for HLA-haploidentical relative transplantation during the trial period allowed comparison of outcomes after transplantation with Haplo-BM with those after haploidentical peripheral blood (Haplo-PB). The trial's broad eligibility criteria were applied to the data source of the Center for International Blood and Marrow Transplant Research to select nontrial subjects. Extended follow-up of trial subjects was obtained from this data source. Three separate analyses were performed: (1) trial subjects beyond the trial's 2-year endpoint; (2) comparison of trial subjects with a contemporaneous cohort of nontrial subjects (195 2-unit UCB, 358 Haplo-BM, and 403 Haplo-PB); and (3) comparison of nontrial subjects by donor and graft type. Multivariate analyses were performed using Cox proportional hazards models for comparison of outcomes by treatment groups. With longer follow-up of the trial cohorts, 5-year PFS (37% versus 29%; P = .08) and OS (42% versus 36%; P = .06) were not significantly different between the treatment groups. We then compared the trial results with outcomes of comparable real-world transplantations. Five-year OS did not differ between trial and nontrial 2-unit UCB transplantations (36% versus 41%; P = .48) or between trial and nontrial Haplo-BM transplantations (42% versus 47%; P = .80), confirming generalizability. The randomized trial did not accrue as planned and therefore lacked the statistical power to detect a 15% difference in PFS. With substantially larger numbers of nontrial Haplo-BM transplantations, 5-year survival was higher after nontrial Haplo-BM compared with trial 2-unit UCB (47% versus 36%; P = .012). Nontrial patients who underwent Haplo-PB transplantation had higher 5-year survival (54%) compared with trial Haplo-BM (hazard ratio [HR], 0.76; P = .044) and nontrial Haplo-BM (HR, 0.78; P = .026). Similarly, survival was better after Haplo-PB compared with trial UCB (HR, 0.57; P < .0001) and nontrial UCB (HR, 0.63; P = .0002). When considering alternative donor low-intensity conditioning regimen transplantation, a haploidentical relative is preferred, and PB is the preferred graft source.
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Affiliation(s)
- Paul V. O’Donnell
- Hematopoietic Cell Transplant and Cell Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Claudio G. Brunstein
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Ephraim J. Fuchs
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Mei-Jie Zhang
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Mariam Allbee-Johnson
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Joseph H. Antin
- Department of Hematology/Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Eric S. Leifer
- Office of Biostatistics Research, National Heart Lung and Blood Institute, National Institutes of Health, Rockville, MD
| | - Hany Elmariah
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Michael R. Grunwald
- Department of Hematologic Oncology and Blood Disorders, Atrium Health Levine Cancer Center, Charlotte, NC
| | - Hamza Hashmi
- Division of Hematology Oncology, Medical University of South Carolina, Charleston, SC
| | - Mary M. Horowitz
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - John M. Magenau
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Navneet Majhail
- Blood and Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Filippo Milano
- Adult Blood and Marrow Transplant Program, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Lawrence E. Morris
- Blood and Marrow Transplant Program, Blood and Marrow Transplant Group of Georgia, Northside Hospital, Atlanta, GA
| | - Andrew R. Rezvani
- Division of Blood and Marrow Transplantation, Department of Medicine, Stanford University Medical Center, Stanford, CA
| | | | - Richard J. Jones
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Mary Eapen
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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14
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Gauntner TD, Brunstein CG, Cao Q, Weisdorf D, Warlick ED, Jurdi NE, Maakaron JE, Arora M, Betts BC, Bachanova V, Holtan SG, He FC. Association of CD34 Cell Dose with 5-Year Overall Survival after Peripheral Blood Allogeneic Hematopoietic Cell Transplantation in Adults with Hematologic Malignancies. Transplant Cell Ther 2021; 28:88-95. [PMID: 34774817 DOI: 10.1016/j.jtct.2021.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/14/2021] [Accepted: 11/07/2021] [Indexed: 11/18/2022]
Abstract
Higher CD34 cell dose is associated with improved engraftment after peripheral blood allogeneic hematopoietic stem cell transplantation (alloHCT) but also may increase the risk of long-term complications, such as graft-versus-host disease (GVHD). Prior studies examining the relationship between CD34 cell dose and long-term survival outcomes have yielded conflicting results. In this study, we sought to clarify the prognostic impact of CD34 cell dose by examining a large contemporary cohort of patients undergoing alloHCT with a matched sibling peripheral blood stem cell (PBSC) donor. We retrospectively examined the impact of CD34 cell dose on overall survival (OS), neutrophil engraftment, platelet engraftment, treatment-related mortality, relapse, acute GVHD grade II-IV and III-IV, and chronic GVHD in 377 consecutive patients undergoing alloHCT with a PBSC graft source from a matched sibling donor at the University of Minnesota between 2002 and 2015. The patients were classified into 3 groups based on the tertile (T) of CD34 cell dose received: T1, <5 × 106 cells/kg; T2, 5 to 7.5 × 106 cells/kg; and T3, ≥7.5 × 106 cells/kg. Multivariable analysis demonstrated that high CD34 cell dose was associated with superior 5-year OS (hazard ratio [HR], 0.57; P = .01) and more rapid platelet engraftment (HR, 1.70; P < .01). Higher CD34 cell dose also was associated with improved absolute neutrophil count engraftment (T2: HR, 1.54; T3: HR, 1.52; P < .01). There was no association between CD34 cell dose and TRM or relapse at 5 years. Although higher CD34 cell dose was not associated with acute GVHD grade II-IV, it was associated with chronic GVHD (T2: HR, 1.68; T3: HR, 1.50; P = .04). Our data indicate that higher CD34 cell dose (>7.5 × 106/kg) is associated with superior OS at 5 years and improved engraftment but carries an increased risk of chronic GVHD. These data support a target CD34 cell dose goal of 7.5 × 106/kg for sibling PBSC graft donors.
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Affiliation(s)
| | - Claudio G Brunstein
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Qing Cao
- Department of Medicine and Biostatistics and Informatics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Daniel Weisdorf
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Erica D Warlick
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Najla El Jurdi
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Joseph E Maakaron
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Mukta Arora
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Brian C Betts
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Veronika Bachanova
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Shernan G Holtan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Fiona C He
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota.
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15
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Riedell PA, Hamadani M, Ahn KW, Litovich C, Murthy GSG, Locke FL, Brunstein CG, Merryman RW, Stiff PJ, Pawarode A, Nishihori T, Kharfan-Dabaja MA, Herrera AF, Sauter CS, Smith SM. Outcomes and Utilization Trends of Front-Line Autologous Hematopoietic Cell Transplantation for Mantle Cell Lymphoma. Transplant Cell Ther 2021; 27:911.e1-911.e7. [PMID: 34450333 PMCID: PMC8556305 DOI: 10.1016/j.jtct.2021.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 07/02/2021] [Revised: 08/14/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
Although autologous hematopoietic cell transplantation (auto-HCT) has become a common practice for eligible patients in the front-line setting with mantle cell lymphoma (MCL), there are limited data regarding trends in auto-HCT utilization and associated outcomes. This study used the Center for International Blood and Marrow Transplant Research (CIBMTR) database to evaluate survival outcomes and auto-HCT utilization in adults age ≥18 years who underwent auto-HCT within 12 months of diagnosis of MCL between January 2000 and December 2018. The 19-year period from 2000 to 2018 was divided into 4 separate intervals-2000 to 2004, 2005 to 2009, 2010 to 2014, and 2015 to 2018-and encompassed 5082 patients. To evaluate transplantation utilization patterns, we combined MCL incidence derived from the SEER 21 database with CIBMTR- reported auto-HCT activity within 12 months of diagnosis of MCL. Primary outcomes included overall survival (OS) along with the auto-HCT utilization rate. The cumulative incidence of nonrelapse mortality at 1 year decreased from 7% in the earliest cohort (2000 to 2004) to 2% in the latest cohort (2015 to 2018). Mirroring this trend, OS outcomes improved continually with time, with a 3-year OS of 72% in the earliest cohort improving to 86% in the latest cohort. In addition, we noted an increase in auto-HCT utilization from 2001 to 2018, particularly in patients age ≤65 years. This large retrospective analysis highlights trends in auto-HCT utilization and outcomes in patients with MCL and emphasizes the need to optimize pretransplantation and post-transplantation treatment strategies to enhance survival outcomes.
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Affiliation(s)
- Peter A Riedell
- Division of Hematology and Oncology, University of Chicago Medicine, Chicago, Illinois
| | - Mehdi Hamadani
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; BMT & Cellular Therapy Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Kwang W Ahn
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Carlos Litovich
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Frederick L Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida
| | - Claudio G Brunstein
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Reid W Merryman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Masachusetts
| | - Patrick J Stiff
- Division of Hematology-Oncology, Department of Medicine, Loyola University Stritch School of Medicine, Maywood, Illinois
| | - Attaphol Pawarode
- Blood and Marrow Transplantation Program, Division of Hematology/Oncology, Department of Internal Medicine, The University of Michigan Medical School, Ann Arbor, Michigan
| | - Taiga Nishihori
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, Florida
| | - Alex F Herrera
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Craig S Sauter
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Sonali M Smith
- Division of Hematology and Oncology, University of Chicago Medicine, Chicago, Illinois
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16
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Orfali N, Zhang MJ, Allbee-Johnson M, Boelens JJ, Artz AS, Brunstein CG, McNiece IK, Milano F, Abid MB, Chee L, Diaz MA, Grunwald MR, Hematti P, Hsu J, Lazarus HM, Munshi PN, Prestidge T, Ringden O, Rizzieri D, Riches ML, Seo S, Solh M, Solomon S, Szwajcer D, Yared J, Besien KV, Eapen M. Planned Granulocyte Colony-Stimulating Factor Adversely Impacts Survival after Allogeneic Hematopoietic Cell Transplantation Performed with Thymoglobulin for Myeloid Malignancy. Transplant Cell Ther 2021; 27:993.e1-993.e8. [PMID: 34507002 DOI: 10.1016/j.jtct.2021.08.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 07/17/2021] [Revised: 08/24/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
The in vivo depletion of recipient and donor T lymphocytes using antithymocyte globulin (ATG; Thymoglobulin) is widely adopted in allogeneic hematopoietic stem cell transplantation (HCT) to reduce the incidence of both graft failure and graft-versus-host disease (GVHD). However, excess toxicity to donor lymphocytes may hamper immune reconstitution, compromising antitumor effects and increasing infection. Granulocyte-colony stimulating factor (G-CSF) administered early after HCT may increase ATG-mediated lymphotoxicity. This study aimed to investigate the effect of an interaction between ATG and post-transplantation granulocyte colony-stimulating factor (G-CSF) on allogeneic HCT outcomes, using the Center for International Blood and Marrow Transplant Research (CIBMTR) registry. We studied patients age ≥18 years with acute myelogenous leukemia (AML) and myelodysplastic syndrome (MDS) who received Thymoglobulin-containing preparative regimens for HLA-matched sibling/unrelated or mismatched unrelated donor HCT between 2010 and 2018. The effect of planned G-CSF that was started between pretransplantation day 3 and post-transplantation day 12 was studied in comparison with transplantations that did not include G-CSF. Cox regression models were built to identify risk factors associated with outcomes at 1 year after transplantation. A total of 874 patients met the study eligibility criteria, of whom 459 (53%) received planned G-CSF. HCT with planned G-CSF was associated with a significantly increased risk for nonrelapse mortality (NRM) (hazard ratio [HR] 2.03; P <.0001; 21% versus 12%) compared to HCT without G-CSF. The 6-month incidence of viral infection was higher with G-CSF (56% versus 47%; P = .007), with a particular increase in Epstein-Barr virus infections (19% versus 11%; P = .002). The observed higher NRM with planned G-CSF led to lower overall survival (HR, 1.52; P = .0005; 61% versus 72%). There was no difference in GVHD risk between the treatment groups. We performed 2 subgroup analyses showing that our findings held true in patients age ≥50 years and in centers where G-CSF was used in some, but not all, patients. In allogeneic peripheral blood HCT performed with Thymoglobulin for AML and MDS, G-CSF administered early post-transplantation resulted in a 2-fold increase in NRM and a 10% absolute decrement in survival. The use of planned G-CSF in the early post-transplantation period should be carefully considered on an individual patient basis, weighing any perceived benefits against these risks.
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Affiliation(s)
- Nina Orfali
- Haematology Department, St. James's Hospital, Dublin, Ireland; Department of Medicine, Weill Cornell Medicine, New York, New York.
| | - Mei-Jie Zhang
- Division of Biostatistics, Institute for Heath and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mariam Allbee-Johnson
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jaap Jan Boelens
- Pediatric Transplantation and Cellular Therapy Division, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew S Artz
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Claudio G Brunstein
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Ian K McNiece
- Stem Cell Transplantation and Cellular Therapy Clinical Laboratory, MD Anderson Cancer Center, Houston, Texas
| | - Filippo Milano
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Muhammad Bilal Abid
- Division of Infectious Diseases, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lynette Chee
- Haematology Department, Peter MacCallum Cancer Centre, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Miguel A Diaz
- Pediatric Haematology Division, Hospital Infantil Universitario "Niño Jesus" Madrid, Spain
| | - Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Peiman Hematti
- Division of Hematology, Medical Oncology and Palliative Care, University of Wisconsin, Madison, Wisconsin
| | - Jingmei Hsu
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Hillard M Lazarus
- Department of Hematologic Oncology, Case Western Reserve University, Cleveland, Ohio
| | - Pashna N Munshi
- Stem Cell Transplant and Cellular Immunotherapy division, MedStar Georgetown University Hospital, Washington, DC
| | - Timothy Prestidge
- Blood and Cancer Centre, Starship Hospital, University of Auckland, Auckland, New Zealand
| | - Olle Ringden
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - David Rizzieri
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Marcie L Riches
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Sachiko Seo
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | - Melhem Solh
- Blood and Marrow Transplant Program, Northside Hospital, Atlanta, Georgia
| | - Scott Solomon
- Blood and Marrow Transplant Program, Northside Hospital, Atlanta, Georgia
| | - David Szwajcer
- Department of Hematology and Oncology, Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Jean Yared
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Koen van Besien
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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17
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Riedell PA, Hamadani M, Ahn KW, Litovich C, Brunstein CG, Cashen AF, Cohen JB, Epperla N, Hill BT, Im A, Inwards DJ, Lister J, McCarty JM, Ravi Kiran Pingali S, Shadman M, Shaughnessy P, Solh M, Stiff PJ, Vose JM, Kharfan-Dabaja MA, Herrera AF, Sauter CS, Smith SM. Effect of time to relapse on overall survival in patients with mantle cell lymphoma following autologous haematopoietic cell transplantation. Br J Haematol 2021; 195:757-763. [PMID: 34581433 DOI: 10.1111/bjh.17865] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 11/28/2022]
Abstract
In young and fit patients with mantle cell lymphoma (MCL), intensive induction therapy followed by a consolidative autologous haematopoietic cell transplant (autoHCT) is the standard of care in the front-line setting. Recently, time-to-event analysis has emerged as an important risk assessment tool in lymphoma, though its impact in MCL is not well defined. We utilized the Center for International Blood and Marrow Transplant Research database to evaluate the effect of post-autoHCT time to relapse on overall survival (OS) over time in 461 patients who underwent autoHCT within 12 months of MCL diagnosis. On multivariate analysis, the impact of relapse on OS was greatest at the six-month [hazard ratio (HR) = 7·68], 12-month (HR = 6·68), and 18-month (HR = 5·81) landmark timepoints. Using a dynamic landmark model we demonstrate that adjusted OS at five years following each landmark timepoint improved with time for relapsing and non-relapsing patients. Furthermore, early relapse (<18 months) following autoHCT defines a high-risk group with inferior post-relapse OS. This retrospective analysis highlights the impact of time to relapse on OS in MCL patients undergoing up-front autoHCT and emphasizes the need to consider novel therapeutic approaches for patients suffering early relapse.
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Affiliation(s)
- Peter A Riedell
- Division of Hematology and Oncology, University of Chicago Medicine, Chicago, IL, USA
| | - Mehdi Hamadani
- Department of Medicine, CIBMTR® (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, WI, USA.,BMT & Cellular Therapy Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kwang W Ahn
- Department of Medicine, CIBMTR® (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Carlos Litovich
- Department of Medicine, CIBMTR® (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, WI, USA
| | - Claudio G Brunstein
- Department of Medicine, Adult Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - Amanda F Cashen
- Division of Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jonathon B Cohen
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Narendranath Epperla
- Division of Hematology, Department of Medicine, The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA
| | - Brian T Hill
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Annie Im
- Division of Hematology/Oncology, University of Pittsburgh, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | | | - John Lister
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - John M McCarty
- Bone Marrow Transplant Program, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Mazyar Shadman
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Medical Oncology Division, University of Washington, Seattle, WA, USA
| | - Paul Shaughnessy
- Sarah Cannon Transplant and Cellular Therapy Program Methodist Hospital, San Antonio, TX, USA
| | - Melhem Solh
- The Blood and Marrow Transplant Group of Georgia, Northside Hospital, Atlanta, GA, USA
| | - Patrick J Stiff
- Department of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Julie M Vose
- Division of Hematology/Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Alex F Herrera
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Craig S Sauter
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Sonali M Smith
- Section of Hematology/Oncology, The University of Chicago, Chicago, IL, USA
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18
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Gooptu M, Romee R, St Martin A, Arora M, Al Malki M, Antin JH, Bredeson CN, Brunstein CG, Chhabra S, Fuchs EJ, Ghosh N, Grunwald MR, Kanakry CG, Kekre N, McGuirk JP, McNiece IK, Mehta RS, Mielcarek M, Milano F, Modi D, Reshef R, Solomon SR, Schroeder MA, Waller EK, Inamoto Y, Soiffer RJ, Eapen M. HLA-haploidentical vs matched unrelated donor transplants with posttransplant cyclophosphamide-based prophylaxis. Blood 2021; 138:273-282. [PMID: 34292325 PMCID: PMC8310426 DOI: 10.1182/blood.2021011281] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/30/2021] [Indexed: 12/23/2022] Open
Abstract
Posttransplant cyclophosphamide (PTCy) graft-versus-host disease (GVHD) prophylaxis has enabled haploidentical (Haplo) transplantation to be performed with results similar to those after matched unrelated donor (MUD) transplantation with traditional prophylaxis. The relative value of transplantation with MUD vs Haplo donors when both groups receive PTCy/calcineurin inhibitor/mycophenolate GVHD prophylaxis is not known. We compared outcomes after 2036 Haplo and 284 MUD transplantations with PTCy GVHD prophylaxis for acute leukemia or myelodysplastic syndrome in adults from 2011 through 2018. Cox regression models were built to compare outcomes between donor types. Recipients of myeloablative and reduced-intensity regimens were analyzed separately. Among recipients of reduced-intensity regimens, 2-year graft failure (3% vs 11%), acute grades 2 to 4 GVHD (hazards ratio [HR], 0.70; P = .022), acute grades 3 and 4 GVHD (HR, 0.41; P = .016), and nonrelapse mortality (HR, 0.43; P = .0008) were lower after MUD than with Haplo donor transplantation. Consequently, disease-free (HR, 0.74; P = .008; 55% vs 41%) and overall (HR, 0.65; P = .001; 67% vs 54%) survival were higher with MUD than with Haplo transplants. Among recipients of myeloablative regimens, day-100 platelet recovery (95% vs 88%) was higher and grades 3 and 4 acute (HR, 0.39; P = .07) and chronic GVHD (HR, 0.66; P = .05) were lower after MUD than with Haplo donor transplantation. There were no differences in graft failure, relapse, nonrelapse mortality, and disease-free and overall survival between donor types with myeloablative conditioning regimens. These data extend and confirm the importance of donor-recipient HLA matching for allogeneic transplantation. A MUD is the preferred donor, especially for transplantations with reduced-intensity conditioning regimens.
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Affiliation(s)
- Mahasweta Gooptu
- Department of Hematology/Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Rizwan Romee
- Department of Hematology/Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Andrew St Martin
- Center for International Blood and Marrow Transplant Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mukta Arora
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, MN
| | - Monzr Al Malki
- Department of Hematology/Oncology, City of Hope, Duarte, CA
| | - Joseph H Antin
- Department of Hematology/Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Christopher N Bredeson
- The Ottawa Hospital Blood and Marrow Transplant Program and
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Claudio G Brunstein
- Blood and Marrow Transplant Program-Adults, Department of Hematology/Oncology, University of Minnesota, Minneapolis, MN
| | - Saurabh Chhabra
- Center for International Blood and Marrow Transplant Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Ephraim J Fuchs
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Nilanjan Ghosh
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Christopher G Kanakry
- Experimental Transplantation and Immunotherapy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Natasha Kekre
- The Ottawa Hospital Blood and Marrow Transplant Program and
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | | | - Rohtesh S Mehta
- Division of Hematology/Oncology, MD Anderson Cancer Center, Houston, TX
| | - Marco Mielcarek
- Adult Blood and Marrow Transplant Program, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Fillipo Milano
- Adult Blood and Marrow Transplant Program, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Dipenkumar Modi
- Divison of Hematology/Oncology, Karmanos Cancer Institute, Detroit, MI
| | - Ran Reshef
- Blood and Marrow Transplantation Program and
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY
| | - Scott R Solomon
- Blood and Marrow Transplant Program, Blood and Marrow Transplant (BMT) Group of Georgia, Atlanta, GA
| | | | - Edmund K Waller
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Yoshiro Inamoto
- Adult Blood and Marrow Transplant Program, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Robert J Soiffer
- Department of Hematology/Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Mary Eapen
- Center for International Blood and Marrow Transplant Research (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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19
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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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20
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Metheny L, Politikos I, Ballen KK, Rezvani AR, Milano F, Barker JN, Brunstein CG. Guidelines for Adult Patient Selection and Conditioning Regimens in Cord Blood Transplant Recipients with Hematologic Malignancies and Aplastic Anemia. Transplant Cell Ther 2021; 27:286-291. [PMID: 33836867 DOI: 10.1016/j.jtct.2020.11.008] [Citation(s) in RCA: 7] [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: 11/10/2020] [Accepted: 11/10/2020] [Indexed: 11/16/2022]
Abstract
For cord blood transplantation (CBT), appropriate patient and conditioning regimen selection is necessary to achieve long-term disease-free survival. This review aims to provide comprehensive guidelines on these issues using evidence from the literature and experience at dedicated CBT centers. Topics include patient and disease characteristics that make CBT a good or poor choice and a review of outcomes in commonly used conditioning regimens in CBT. This is accompanied with recommendations on regimen intensity based on disease, organ function, and patient performance status and age. In addition, the use of antithymocyte globulin in CBT is discussed, as is the choice of conditioning in aplastic anemia patients who have access to acceptable CB units.
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Affiliation(s)
- Leland Metheny
- Stem Cell Transplant Program, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio.
| | - Ioannis Politikos
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Karen K Ballen
- University of Virginia Cancer Center, Charlottesville, Virginia
| | - Andrew R Rezvani
- Division of Blood & Marrow Transplantation, Stanford University, Stanford, California
| | - Filippo Milano
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Juliet N Barker
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Claudio G Brunstein
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
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21
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Takahashi T, Scheibner A, Cao Q, Pearson R, Sanghavi K, Weisdorf DJ, Brunstein CG, Rogosheske J, Bachanova V, Warlick ED, Wiseman A, Jacobson PA. Higher Fludarabine and Cyclophosphamide Exposures Lead to Worse Outcomes in Reduced-Intensity Conditioning Hematopoietic Cell Transplantation for Adult Hematologic Malignancy. Transplant Cell Ther 2021; 27:773.e1-773.e8. [PMID: 34044184 DOI: 10.1016/j.jtct.2021.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/15/2021] [Revised: 04/28/2021] [Accepted: 05/13/2021] [Indexed: 11/15/2022]
Abstract
Reduced-intensity conditioning regimens using fludarabine (Flu) and cyclophosphamide (Cy) have been widely used in hematopoietic cell transplantation (HCT) recipients. The optimal exposure of these agents remains to be determined. We aimed to delineate the exposure-outcome associations of Flu and Cy separately and then both combined on HCT outcomes. This is a single-center, observational, pharmacokinetic (PK)-pharmacodynamic (PD) study of Flu and Cy in HCT recipients age ≥18 years who received Cy (50 mg/kg in a single dose), Flu (150 to 200 mg/m2 given as 5 daily doses), and total body irradiation (TBI; 200 cGy). We measured trough concentrations of 9-β-D-arabinosyl-2-fluoradenine (F-ara-A), an active metabolite of Flu, on days -5 and -4 (F-ara-ADay-5 and F-ara-ADay-4, respectively), and measured phosphoramide mustard (PM), the final active metabolite of Cy, and estimated the area under the curve (AUC). The 89 enrolled patients had a nonrelapse mortality (NRM) of 9% (95% confidence interval [CI], 3% to 15%) at day +100 and 15% (95% CI, 7% to 22%) at day +180, and an overall survival (OS) of 73% (95% CI, 63% to 81%) at day +180. In multivariate analysis, higher PM area under the curve (AUC) for 0 to 8 hours (PM AUC0-8 hr) was an independent predictor of worse NRM (P < .01 at both day +100 and day +180) and worse day +180 OS (P < .01), but no associations were identified for F-ara-A trough levels. We observed lower day +100 NRM in those with both high F-ara-ADay-4 trough levels (≥40 ng/mL; >25th percentile) and low PM AUC0-8 hr (<34,235 hr ng/mL; <75th percentile), compared with high exposures to both agents (hazard ratio, 0.06; 95% CI, 0.01 to 0.48). No patients with low F-ara-ADay-4 (<40 ng/mL; <25th percentile) had NRM by day +100, regardless of PM AUC. The interpatient PK variability was large in F-ara-ADay-4 trough and PM AUC0-8 hr (29-fold and 5.0-fold, respectively). Flu exposure alone was not strongly associated with NRM or OS in this reduced Flu dose regimen; however, high exposure to both Flu and Cy was associated with a >16-fold higher NRM. These results warrant further investigation to optimize reduced-intensity regimens based on better PK-PD understanding and possible adaptation to predictable factors influencing drug clearance.
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Affiliation(s)
- Takuto Takahashi
- Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, University of Minnesota, Minneapolis, Minnesota; Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
| | - Aileen Scheibner
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
| | - Qing Cao
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Rachael Pearson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
| | - Kinjal Sanghavi
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - John Rogosheske
- Department of Pharmacy, M Health Fairview, Minneapolis, Minnesota
| | - Veronika Bachanova
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Erica D Warlick
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Anthony Wiseman
- University of Minnesota Medical School, Minneapolis, Minnesota
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota.
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22
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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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23
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Bejanyan N, Vlasova-St Louis I, Mohei H, Cao Q, El Jurdi N, Wagner JE, Miller JS, Brunstein CG. Cytomegalovirus-Specific Immunity Recovers More Slowly after Cord Blood Transplantation Compared with Matched Sibling Donor Allogeneic Transplantation. Transplant Cell Ther 2021; 27:187.e1-187.e4. [PMID: 33718897 DOI: 10.1016/j.jtct.2020.11.014] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Rapid quantitative recovery of NK cells but slower recovery of T-cell subsets along with frequent viral infections are reported after umbilical cord blood (UCB) compared with matched sibling donor (MSD) hematopoietic cell transplantation (HCT). However, it remains unclear whether increased propensity for viral infections is also a result of slower recovery of virus-specific immunity after UCB as compared to MSD HCT. OBJECTIVES We examined the differences in the function of virus-specific peripheral blood mononuclear cells (PBMC) after UCB (N=17) vs. MSD (N=9) using previously collected patient blood samples at various time points after HCT. METHODS Interferon-gamma (IFN-γ) enzyme-linked immune absorbent spot (ELISpot) assay was used to quantify the PBMC frequencies that secrete IFN-γ in response to 11 immunopeptides from 5 common viruses. We included the patients who received the same reduced intensity conditioning regimen without ATG, no systemic glucocorticoids and had no relapse or acute/chronic graft-versus-host disease within 1 year after HCT. RESULTS The CMV-reactive PBMC frequencies were higher in CMV seropositive vs. seronegative patients after HCT. Among CMV seropositive patients, the frequency of CMV-reactive PBMC was lower after UCB compared to MSD throughout one year of HCT. We observed no differences in virus-specific PBMC responses towards HHV6, EBV, BK, and adenovirus antigens between UCB and MSD. CONCLUSION Our data demonstrate that the reconstitution of CMV-specific immunity is slower in CMV seropositive recipients of UCB vs. MSD HCT in contrast to other viruses which had similar recoveries. These study findings support implementation of more potent prophylactic strategies for preventing CMV reactivation in CMV seropositive patients receiving UCB HCT.
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Affiliation(s)
- N Bejanyan
- Department of Medicine. University of Minnesota, Minneapolis, Minnesota
| | - I Vlasova-St Louis
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - H Mohei
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Q Cao
- Biostatistics Core, Masonic Cancer Center. Adult and Pediatric Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - N El Jurdi
- Department of Medicine. University of Minnesota, Minneapolis, Minnesota
| | - J E Wagner
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - J S Miller
- Department of Medicine. University of Minnesota, Minneapolis, Minnesota
| | - C G Brunstein
- Department of Medicine. University of Minnesota, Minneapolis, Minnesota
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24
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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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25
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Elmariah H, Brunstein CG, Bejanyan N. Immune Reconstitution after Haploidentical Donor and Umbilical Cord Blood Allogeneic Hematopoietic Cell Transplantation. Life (Basel) 2021; 11:102. [PMID: 33572932 PMCID: PMC7911120 DOI: 10.3390/life11020102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/19/2021] [Accepted: 01/25/2021] [Indexed: 02/07/2023] Open
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is the only potentially curative therapy for a variety of hematologic diseases. However, this therapeutic platform is limited by an initial period when patients are profoundly immunocompromised. There is gradual immune recovery over time, that varies by transplant platform. Here, we review immune reconstitution after allogeneic HCT with a specific focus on two alternative donor platforms that have dramatically improved access to allogeneic HCT for patients who lack an HLA-matched related or unrelated donor: haploidentical and umbilical cord blood HCT. Despite challenges, interventions are available to mitigate the risks during the immunocompromised period including antimicrobial prophylaxis, modified immune suppression strategies, graft manipulation, and emerging adoptive cell therapies. Such interventions can improve the potential for long-term overall survival after allogeneic HCT.
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Affiliation(s)
- Hany Elmariah
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL 33612, USA;
| | - Claudio G. Brunstein
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Nelli Bejanyan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL 33612, USA;
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26
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Fuchs EJ, O'Donnell PV, Eapen M, Logan B, Antin JH, Dawson P, Devine S, Horowitz MM, Horwitz ME, Karanes C, Leifer E, Magenau JM, McGuirk JP, Morris LE, Rezvani AR, Jones RJ, Brunstein CG. Double unrelated umbilical cord blood vs HLA-haploidentical bone marrow transplantation: the BMT CTN 1101 trial. Blood 2021; 137:420-428. [PMID: 33475736 PMCID: PMC7819761 DOI: 10.1182/blood.2020007535] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/16/2020] [Indexed: 12/11/2022] Open
Abstract
Results of 2 parallel phase 2 trials of transplantation of unrelated umbilical cord blood (UCB) or bone marrow (BM) from HLA-haploidentical relatives provided equipoise for direct comparison of these donor sources. Between June 2012 and June 2018, 368 patients aged 18 to 70 years with chemotherapy-sensitive lymphoma or acute leukemia in remission were randomly assigned to undergo UCB (n = 186) or haploidentical (n = 182) transplant. Reduced-intensity conditioning comprised total-body irradiation with cyclophosphamide and fludarabine for both donor types. Graft-versus-host disease prophylaxis for UCB transplantation was cyclosporine and mycophenolate mofetil (MMF) and for haploidentical transplantation, posttransplant cyclophosphamide, tacrolimus, and MMF. The primary end point was 2-year progression-free survival (PFS). Treatment groups had similar age, sex, self-reported ethnic origin, performance status, disease, and disease status at randomization. Two-year PFS was 35% (95% confidence interval [CI], 28% to 42%) compared with 41% (95% CI, 34% to 48%) after UCB and haploidentical transplants, respectively (P = .41). Prespecified analysis of secondary end points recorded higher 2-year nonrelapse mortality after UCB, 18% (95% CI, 13% to 24%), compared with haploidentical transplantation, 11% (95% CI, 6% to 16%), P = .04. This led to lower 2-year overall survival (OS) after UCB compared with haploidentical transplantation, 46% (95% CI, 38-53) and 57% (95% CI 49% to 64%), respectively (P = .04). The trial did not demonstrate a statistically significant difference in the primary end point, 2-year PFS, between the donor sources. Although both donor sources extend access to reduced-intensity transplantation, analyses of secondary end points, including OS, favor haploidentical BM donors. This trial was registered at www.clinicaltrials.gov as #NCT01597778.
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Affiliation(s)
- Ephraim J Fuchs
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Paul V O'Donnell
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, and
| | - Brent Logan
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Joseph H Antin
- Department of Hematologic Malignancies, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | | | - Mary M Horowitz
- Center for International Blood and Marrow Transplant Research, Department of Medicine, and
| | - Mitchell E Horwitz
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Chatchada Karanes
- Department of Hematology/Hematopoietic Cell Transplantation (HCT), City of Hope National Medical Center, Duarte, CA
| | - Eric Leifer
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - John M Magenau
- Michigan Medicine Bone Marrow Transplant and Leukemia, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Joseph P McGuirk
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Cancer Center, Kansas City, KS
| | - Lawrence E Morris
- Blood and Marrow Transplant Program, Northside Hospital, Atlanta, GA
| | - Andrew R Rezvani
- Division of Blood and Marrow Transplantation, Department of Medicine, Stanford University Medical Center, Stanford, CA; and
| | - Richard J Jones
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Claudio G Brunstein
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN
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27
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Okoev G, Weisdorf DJ, Wagner JE, Blazar BR, MacMillan ML, DeFor T, Lazaryan A, El Jurdi N, Holtan SG, Brunstein CG, Betts BC, Takahashi T, Bachanova V, Warlick ED, Rashidi A, Arora M. Outcomes of chronic graft-versus-host disease following matched sibling donor versus umbilical cord blood transplant. Bone Marrow Transplant 2021; 56:1373-1380. [PMID: 33420387 DOI: 10.1038/s41409-020-01195-5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/26/2020] [Accepted: 12/08/2020] [Indexed: 12/30/2022]
Abstract
We compared chronic graft-versus-host disease (cGvHD) following umbilical cord blood (UCBT) and matched sibling donor peripheral blood transplant (MSD). 145 patients (2010-2017) with cGvHD after MSD (n = 104) and UCBT (n = 41) were included. Prior acute GvHD was less frequent in MSD (55% vs. 85%; p = 0.01). Severe cGvHD (32% vs. 15%, p = 0.01) and de-novo onset (45% vs. 15%, p < 0.01) were more frequent following MSD. Liver was more frequently involved in MSD recipients (38% vs. 6%); and GI in UCBT (33% vs. 63%), both p < 0.01. Overall response (CR + PR) was similar between both cohorts. 2-year CR was higher in UCBT (14% vs 33%, p = 0.02). Karnofsky score (KPS) ≥ 90 at cGvHD diagnosis was associated with higher odds of response (95%CI: 1.42-10, p < 0.01). The cumulative incidence of durable discontinuation of immune-suppressive therapy, failure-free survival (FFS) and NRM at 2-years were similar between cohorts. KPS < 90 (95%CI: 3.1-24.9, p < 0.01) and platelets <100 × 10e9/L (95%CI: 1.25-10, p = 0.01) were associated with higher risk of NRM. UCBT patients were more likely to have a prior acute GvHD, less severe cGvHD and more likely to attain CR. Despite differences, both cohorts had similar NRM and FFS. High-risk groups, including those with platelets <100 × 10e9/L and KPS < 90, need careful monitoring and intensified therapy.
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Affiliation(s)
- Grigori Okoev
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA.
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - John E Wagner
- Department of Pediatrics, Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Bruce R Blazar
- Department of Pediatrics, Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Margaret L MacMillan
- Department of Pediatrics, Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Todd DeFor
- Division of Biostatistics, Clinical Translational Science Institute (CTSI), University of Minnesota, Minneapolis, MN, USA
| | - Aleksandr Lazaryan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Najla El Jurdi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Shernan G Holtan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Claudio G Brunstein
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Brian C Betts
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Takuto Takahashi
- Department of Pediatrics, Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Veronika Bachanova
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Erica D Warlick
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Armin Rashidi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
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El Jurdi N, Fair C, Rogosheske J, Shanley R, Arora M, Bachanova V, Betts B, He F, Holtan S, Janakiram M, Maakaron J, Rashidi A, Warlick E, Weisdorf D, Brunstein CG. Effect of Keratinocyte Growth Factor on Hospital Readmission and Regimen-Related Toxicities after Autologous Hematopoietic Cell Transplantation for Lymphoma. Transplant Cell Ther 2020; 27:179.e1-179.e4. [PMID: 33830033 DOI: 10.1016/j.jtct.2020.11.005] [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: 09/23/2020] [Revised: 11/02/2020] [Accepted: 11/15/2020] [Indexed: 10/22/2022]
Abstract
Regimen-related toxicities with high-dose therapy followed by hematopoietic cell rescue leads to considerable patient distress, morbidity, and high readmission rates. Palifermin is a recombinant keratinocyte growth factor that is Food and Drug Administration-approved to decrease severe oral mucositis (OM) associated with autologous hematopoietic cell transplantation (ASCT) for hematologic malignancies. We added palifermin as a supportive care measure for patients with lymphoma undergoing ASCT with BEAM conditioning. We compared patients receiving palifermin (n = 35) with historical controls (n = 38) for toxicity and readmission outcomes. The cumulative incidence of OM of any grade was 23% in the palifermin-treated patients and 42% in the control group. Patients receiving palifermin were less likely to be readmitted (57% versus 82%; P = .04), had fewer hospital readmission days (median, 4 days versus 7 days; P < .01), and had fewer total days in the hospital through day +30 after ASCT (median, 12 days versus 15 days; P = .05). Fewer patients in the palifermin group had >20 days in the hospital through day +30 (9% in the palifermin group versus 23% of controls). Adverse events associated with palifermin were mild and transient. The addition of palifermin limits severe regimen-related toxicities and decreases readmissions and duration of hospital stay. This and other measures are needed to identify comprehensive and cost-effective approaches, possibly including palifermin, to prevent severe regimen-related toxicities and decrease health care resource utilization.
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Affiliation(s)
- Najla El Jurdi
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota.
| | - Christina Fair
- Department of Pharmacy, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - John Rogosheske
- Department of Pharmacy, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Ryan Shanley
- Biostatistics and Informatics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Mukta Arora
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Veronika Bachanova
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Brian Betts
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Fiona He
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Shernan Holtan
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Murali Janakiram
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Joseph Maakaron
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Armin Rashidi
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Erica Warlick
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Daniel Weisdorf
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
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Bejanyan N, Rogosheske J, Cao Q, Lazaryan A, Holtan S, Ustun C, Jacobson P, MacMillan M, Weisdorf DJ, Wagner J, Arora M, Brunstein CG. Weight-based mycophenolate mofetil dosing predicts acute GVHD and relapse after allogeneic hematopoietic cell transplantation. Eur J Haematol 2020; 106:205-212. [PMID: 33084139 DOI: 10.1111/ejh.13537] [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: 08/30/2020] [Revised: 10/15/2020] [Accepted: 10/17/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Higher MMF dose can reduce acute GVHD risk after allogeneic hematopoietic cell transplantation (HCT). We examined the effect of MMF dose, relative to patient actual body weight (mg/kg/day), on outcomes of 680 adults after HCT. METHODS MMF was combined with cyclosporine (n = 599) or sirolimus (n = 81). We divided MMF dose/kg/day in quartiles. RESULTS The median time to grade II-IV acute GVHD was 32 days. The incidence of grade II-IV acute GVHD at day 30 was 30% in 1st (<29), 20% in 2nd (29-34), 16% in 3rd (35-41), and 19% in 4th (≥42) quartile (P < .01). Corresponding relapse incidence at 1 year was 16%, 25%, 27%, and 31%, respectively (P = .01). In multivariate analysis, as compared to 1st quartile, higher dose of weight-based MMF reduced grade II-IV acute GVHD (HR = 0.64 for 2nd, HR = 0.48 for 3rd, and HR = 0.55 for 4th quartile), but increased the risk of relapse (HR = 1.63 for 2nd, HR = 1.75 for 3rd, and HR = 2.31 for 4th quartile). CONCLUSIONS Weight-based MMF dose had no significant impact on engraftment, chronic GVHD, or survival. These data suggest that higher weight-based MMF dose reduces the risk of acute GVHD at the expense of increased relapse and supports conducting prospective studies to optimize MMF dosing after HCT.
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Affiliation(s)
- Nelli Bejanyan
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - John Rogosheske
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Qing Cao
- Biostatistics Core, Masonic Cancer Center. Adult and Pediatric Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - Aleksandr Lazaryan
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Shernan Holtan
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Celalettin Ustun
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Pamala Jacobson
- Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Margaret MacMillan
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - John Wagner
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Claudio G Brunstein
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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El Jurdi N, Rogosheske J, DeFor T, Bejanyan N, Arora M, Bachanova V, Betts B, He F, Holtan S, Janakiram M, Larson S, Maakaron J, Rashidi A, Warlick E, Wagner JE, Young JAH, Weisdorf D, Brunstein CG. Prophylactic Foscarnet for Human Herpesvirus 6: Effect on Hematopoietic Engraftment after Reduced-Intensity Conditioning Umbilical Cord Blood Transplantation. Transplant Cell Ther 2020; 27:84.e1-84.e5. [PMID: 33053448 DOI: 10.1016/j.bbmt.2020.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 08/20/2020] [Revised: 09/17/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
The high incidence of human herpesvirus-6 (HHV-6) reactivation, potentially interfering with engraftment after umbilical cord blood (UCB) hematopoietic cell transplantation (HCT), remains a major challenge. To potentially address this problem, we evaluated the effect of prophylactic foscarnet administered twice daily beginning on day +7 and continuing through engraftment in 25 patients. To determine the impact of foscarnet on HHV-6, engraftment, and other transplantation outcomes, we compared results in 61 identically treated patients with hematologic malignancies. Treatment and control groups underwent reduced-intensity conditioning UCB HCT with a conditioning regimen of fludarabine, cyclophosphamide, and total body irradiation 200 cGy with or without antithymocyte globulin (ATG), using sirolimus plus mycophenolate mofetil immune suppression. The treatment and control groups were similar in terms of age, disease risk, use of ATG, Hematopoietic Cell Transplantation Comorbidity Index, and graft CD34 cell dose; however, foscarnet-treated patients were less likely to receive a double UCB graft and to be treated more recently (2016 to 2018). The cumulative incidence of HHV-6 reactivation by day +100 was 63% for all patients (95% confidence interval [CI], 51% to 75%) and was not significantly different between the 2 groups. HHV-6 reactivation occurred at a median of 34 days in the foscarnet group and 25.5 days in the control group. The incidence of neutrophil engraftment at day 42 was higher in the foscarnet group compared with the control group (96%; [95% CI, 83% to 100%] versus 75% [95% CI, 64% to 85%]; P< .01). The cumulative incidence of platelet engraftment by 6 months was 92% (95% CI, 69% to 100%) for the foscarnet group versus 75% (95% CI, 60% to 90%) for the control group (P= .08), and multivariate analysis identified the use of foscarnet as an independent predictor of better platelet engraftment. No patients died as a result of graft failure in recipients of foscarnet, whereas 5 patients died from graft failure in the control group. Six-month overall survival (OS) and nonrelapse mortality (NRM) were better in the foscarnet group (96% versus 72% [P= .02] and 4% versus 18% [P= .07], respectively). Even though foscarnet prophylaxis did not prevent HHV-6 viremia, we observed a delay in time to HHV-6 reactivation, a trend toward differences in engraftment, NRM, and OS compared with historical controls.
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Affiliation(s)
- Najla El Jurdi
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
| | - John Rogosheske
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Todd DeFor
- Biostatistics and Informatics, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota
| | - Nelli Bejanyan
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Mukta Arora
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Veronika Bachanova
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Brian Betts
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Fiona He
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Shernan Holtan
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Murali Janakiram
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Samantha Larson
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Joseph Maakaron
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Armin Rashidi
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Erica Warlick
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - John E Wagner
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Jo-Anne H Young
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota; Division of Infectious Diseases, University of Minnesota, Minneapolis, Minnesota
| | - Daniel Weisdorf
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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31
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El Jurdi N, DeFor T, Adamusiak AM, Brunstein CG, Pruett T, Weisdorf DJ. Hematopoietic Cell and Solid Organ Transplantation in the Same Patient: Long-Term Experience at the University of Minnesota. Transplant Cell Ther 2020; 27:87.e1-87.e6. [PMID: 32949755 DOI: 10.1016/j.bbmt.2020.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 07/02/2020] [Revised: 08/21/2020] [Accepted: 09/10/2020] [Indexed: 11/17/2022]
Abstract
There is a growing population of transplant survivors receiving both a solid organ transplantation (SOT) and a hematopoietic cell transplantation (HCT). This group remains underreported and not well described. We conducted a single-center retrospective study aimed at assessing safety and long-term survival outcomes of 40 patients receiving both HCT and SOT at the University of Minnesota. Twenty-seven patients underwent HCT followed by SOT (13 kidney, 10 lung, 2 liver, 1 heart, 1 heart/kidney) with a median age of 40 years (range, 5 to 72) at the time of SOT at a median of 88 months (range, 24 to 302) following the HCT. The 1-, 5-, and 10-year overall survival (OS) from the SOT was 93%, 76%, and 49%, respectively, with only 4 organ failures reported. Thirteen other patients received a HCT following a prior kidney (n = 8), liver (n = 4), or pancreas/kidney (n = 1) SOT with a median age of 42 years (range, 3 to 66) at the time of the HCT and a median 154 months (range, 1 to 304) from the SOT. The 1-, 5-, and 10-year OS from HCT were 46%, 46%, and 17% respectively. In patients receiving SOT followed by HCT, survival outcomes were better in kidney transplant recipients and patients subsequently requiring an autologous rather than an allogeneic HCT. There were no HCT engraftment failures. Our findings show that in a select patient population, undergoing a second transplant at a specialized center can lead to favorable outcomes with long-term survival and low incidence of graft rejection, organ failure, and malignant disease relapse. A large-scale study is needed to determine the incidence and risk factors preferred for a successful subsequent SOT or HCT. Those studies are crucial to further guide selection and management of patients who would benefit most from a second transplant.
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Affiliation(s)
- Najla El Jurdi
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
| | - Todd DeFor
- Biostatistics and Informatics, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota
| | - Anna M Adamusiak
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Timothy Pruett
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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32
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Politikos I, Davis E, Nhaissi M, Wagner JE, Brunstein CG, Cohen S, Shpall EJ, Milano F, Scaradavou A, Barker JN. Guidelines for Cord Blood Unit Selection. Biol Blood Marrow Transplant 2020; 26:2190-2196. [PMID: 32736011 DOI: 10.1016/j.bbmt.2020.07.030] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [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: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022]
Abstract
Optimal cord blood (CB) unit selection is critical to maximize the likelihood of successful engraftment and survival after CB transplantation (CBT). However, unit selection can be complex because multiple characteristics must be considered including unit cell dose, donor-recipient human leukocyte antigen (HLA) match, and unit quality. This review provides evidence-based and experience-based comprehensive guidelines for CB unit selection. Topics addressed include the use of both the TNC and the CD34+ cell dose, as well as the CD34+ cell to TNC content ratio to evaluate unit progenitor cell content and engraftment potential, the acceptable TNC and CD34+ cell dose criteria that define an adequate single-unit graft, and the indication and acceptable cell dose criteria for double-unit grafts. The acceptable criteria for 6-loci (HLA-A, -B antigen, -DRB1 allele) and 8-allele (HLA-A, -B, -C, -DRB1) donor-recipient HLA match, the evaluation of patients with donor-specific HLA antibodies, and the multiple determinants of unit quality are also reviewed in detail. Finally, a practical step-by-step guide to CB searches and the principles that guide ultimate graft selection are outlined.
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Affiliation(s)
- Ioannis Politikos
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Eric Davis
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa Nhaissi
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John E Wagner
- Blood and Marrow Transplant Program, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Sandra Cohen
- Division of Hematology, Department of Medicine, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada
| | - Elizabeth J Shpall
- Department of Stem Cell Transplant and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Filippo Milano
- Clinical Research Division, Fred Hutchinson Cancer Research Center & Department of Medicine, University of Washington, Seattle, Washington
| | | | - Juliet N Barker
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Bhargava D, Defor TE, Brunstein CG, Thyagarajan B, Arora M, El Jurdi N, Holtan S, Rashidi A, Warlick E, Ramesh V, Rogosheske J, Bhatia S, Weisdorf DJ. Increasing Use of Potentially Inappropriate Medications in Older Allogeneic HCT Recipients Leads to Higher NRM. Biol Blood Marrow Transplant 2020. [DOI: 10.1016/j.bbmt.2019.12.656] [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: 10/25/2022]
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Christakopoulos GE, Defor TE, Hage SM, Wagner JE, Linden MA, Brunstein CG, Bejanyan N, Verneris MR, Smith AR. Romiplostim Improves Platelet Recovery after UCB Transplant. Biol Blood Marrow Transplant 2020. [DOI: 10.1016/j.bbmt.2019.12.654] [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: 10/25/2022]
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35
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Wagner JE, Brunstein CG, McKenna DH, Sumstad D, Miller JS, Blazar BR, Defor TE, Boitano AE, Cooke MP, Raffel GD, Davis JC, Stefanski H. Mgta-456, a Cell Therapy Utilizing Expansion of CD34+ Hematopoietic Stem Cells (HSC), Improves HLA Matching for Adult Recipients, Promotes Faster Hematopoietic Recovery and Enables Uniform Engraftment with Less Acute Graft-Vs-Host Disease (GVHD). Biol Blood Marrow Transplant 2020. [DOI: 10.1016/j.bbmt.2019.12.222] [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: 11/24/2022]
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36
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Hussein E, DeFor T, Wagner JE, Sumstad D, Brunstein CG, McKenna DH. Evaluation of post-thaw CFU-GM: clinical utility and role in quality assessment of umbilical cord blood in patients receiving single unit transplant. Transfusion 2019; 60:144-154. [PMID: 31756003 DOI: 10.1111/trf.15592] [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: 07/12/2019] [Revised: 10/06/2019] [Accepted: 10/06/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The CFU assay is considered the only in vitro assay that assesses the biologic function of hematopoietic stem and progenitor cells (HSPC). STUDY DESIGN AND METHODS To investigate the impact of post-thaw CFU-GM counts on the quality of umbilical cord blood (UCB), we studied transplant outcomes in 269 patients receiving single UCB transplant. We also correlated the post-thaw CFU-GM counts of 1912 units with the pre-freeze and post-thaw graft characteristics, hoping to optimize selection criteria of UCB. Data analysis included: total nucleated cells, viability, CD34+, nucleated red blood cells (NRBC), hematocrit, frozen storage time, and cord blood bank (CBB). RESULTS We demonstrated an association between post-thaw CFU-GM dose and the speed of neutrophil and platelet engraftment (p < 0.01). Higher post-thaw CFU-GM dose showed an increased benefit for neutrophil and platelet engraftment (p < 0.01). Post-thaw CD34+ cell dose and CFU-GM dose were strongly correlated (r = 0.78). However, CFU-GM dose showed additional benefit for patients receiving the lowest quartile of CD34+ dose. HLA disparity did not adversely impact either neutrophil or platelet engraftment. Post-thaw CFU-GM/million nucleated cells plated showed moderate correlation with pre-freeze and post-thaw CD34+ and weak correlation with other parameters. Post-thaw CFU-GM was not influenced by storage time, but was impacted by the CBB from which the unit is obtained (p < 0.01). CONCLUSION Post-thaw CFU-GM is an effective measure of the quality and efficacy of the UCB graft, particularly adding valuable clinical information when the CD34+ cell dose is low. Consideration of pre-freeze CD34+ cell content and CBB as additional selection criteria is warranted.
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Affiliation(s)
- Eiman Hussein
- Department of Laboratory medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Todd DeFor
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - John E Wagner
- Blood and Marrow Transplant Program, Department of Pediatrics, Minneapolis, Minnesota
| | - Darin Sumstad
- Department of Laboratory medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - David H McKenna
- Department of Laboratory medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
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Savani M, Gencturk M, Shanley R, Cayci Z, Wilke C, Warlick ED, He F, Janakiram M, Weisdorf DJ, Brunstein CG, Bachanova V. Surveillance Imaging after Autologous Hematopoietic Cell Transplantation Predicts Survival in Patients with Diffuse Large B Cell Lymphoma. Biol Blood Marrow Transplant 2019; 26:272-277. [PMID: 31669174 DOI: 10.1016/j.bbmt.2019.10.013] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/02/2019] [Accepted: 10/12/2019] [Indexed: 11/29/2022]
Abstract
The utility of surveillance imaging after autologous hematopoietic cell transplantation (AHCT) in relapsed/refractory diffuse large B cell lymphoma (DLBCL) remains unclear. The purpose of this study was to determine whether surveillance imaging predicts survival after AHCT. At the University of Minnesota, serial imaging for early relapse detection has been used prospectively for all consecutive AHCT recipients treated since 2010. The present analysis included 91 AHCT recipients with DLBCL who underwent 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) scan at day +100 post-AHCT. 18F-FDG-PET parameters included the Deauville (D) 5-point scale, peak standardized uptake values (SUVmax), total legion glycolysis (TLG), and total metabolic tumor volume (TMTV). Survival of patients with clinically symptomatic versus asymptomatic radiographically detected relapsed DLBCL after AHCT was compared. Sixty patients experienced relapse; 35% was detected on day +100 surveillance PET scan. 5-year overall survival (OS) by 18F-FDG-PET scan at day +100 post-AHCT was significantly lower in D4 and D5 patients (37%; 95% confidence interval [CI], 14% to 100% versus 25%; 95% CI, 43% to 89%) compared with patients with D1 and D2 (62%; 95% CI, 43% to 89% versus 62%; 95% CI, 46% to 84%). TLG and TMTV were not prognostic. SUVmax at day +100 varied from 1.5 (D1) to 17.9 (D5). In multivariate analysis, only SUVmax was predictive of relapse and OS; mortality increased 1.8-fold with each SUVmax doubling (hazard ratio [HR], 1.8; 95% CI, 1.3 to 2.3; P < .01). At a median follow-up of 3.3 years (range, 1 to 12 years), lymphoma-related mortality was 1.8-fold higher among patients whose relapse was detected clinically (symptomatic) versus radiographically on surveillance scan (HR, 1.8; 95% CI, .9 to 3.4; P = .08). In patients with relapsed/refractory DLBCL, a routine PET imaging at day +100 post-AHCT detects asymptomatic relapse and high SUVmax identifies patients with poor expected survival of less than 1 year. Identifying this high-risk cohort can potentially highlight patients who might benefit from preemptive interventions to prevent or delay relapse.
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Affiliation(s)
- Malvi Savani
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Mehmet Gencturk
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Ryan Shanley
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Zuzan Cayci
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Christopher Wilke
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Erica D Warlick
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Fiona He
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Murali Janakiram
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Daniel J Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Claudio G Brunstein
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Veronika Bachanova
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA.
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38
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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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39
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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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40
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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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41
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Gastecki K, Shanley R, Welbig J, Cohn C, Brunstein CG. Red blood cell product utilization in patients undergoing allogeneic stem cell transplantation. Transfusion 2019; 59:2301-2307. [PMID: 30957250 DOI: 10.1111/trf.15285] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 02/28/2019] [Accepted: 03/03/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND The risk of transfusion reactions (TR) and the cost of blood has led to efforts to reduce blood use. We changed our practice to transfuse just one instead of two units of red blood cells (RBC) when hemoglobin ≤8 g/dL due to patient blood management (PBM) recommendations. METHODS AND MATERIALS We compared RBC utilization in patients receiving allogeneic HCT in the 10 months before (control arm) and 13 months after implementation of this new practice (intervention arm). We used regression models to estimate the independent effect of transfusion practice, length of hospitalization, the conditioning regimen, and donor type for patients who received at least one RBC unit. The outcome variable was total number of inpatient transfusions. In addition, a survey assessed the impact of this. RESULTS Cohorts were matched for age, primary diagnosis, graft source, and conditioning regimen. The median number of RBC units transfused/patient was identical in both arms (4; interquartile range 19 units/patient). Using the regression model, only length of stay (relative increase of 1.035 units/day; 95%CI, 1.0271.043) was an independent predictor of the number of RBC units a patient received. When data were normalized/1000 patient days, the control arm received 240 units vs the intervention arm, which received 193 units, resulting in a reduction of 47 units transfused/1000-patient-days, which was not statistically significant (p-value = 0.32). The survey of RNs showed that it positively affected the workflow. CONCLUSIONS There was a modest reduction in RBC utilization based on units transfused/1000-patient-days. There was a positive impact on RN workflow.
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Affiliation(s)
- Karen Gastecki
- Blood and Marrow Transplant Program, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Ryan Shanley
- Masonic Cancer Center Biostatistics Core, University of Minnesota, Minneapolis, Minnesota
| | - Julie Welbig
- Blood Bank Transfusion Safety Officer, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Claudia Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Blood and Marrow Transplant Program, University of Minnesota Medical Center, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
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42
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Green JS, Shanley RM, Brunstein CG, Young JAH, Verneris MR. Mixed vs full donor engraftment early after hematopoietic cell transplant: Impact on incidence and control of cytomegalovirus infection. Transpl Infect Dis 2019; 21:e13070. [PMID: 30864271 DOI: 10.1111/tid.13070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 11/02/2018] [Revised: 12/31/2018] [Accepted: 02/15/2019] [Indexed: 12/11/2022]
Abstract
Recovery of cytomegalovirus (CMV)-specific immunity after hematopoietic cell transplantation (HCT) is essential in controlling CMV infection. We hypothesize that mixed donor engraftment as measured by chimerism at day 30 in CMV D(+) HCTs and full chimerism in CMV D(-) HCTs will be predictive of CMV reactivation. Prospectively collected data for 407 CMV R+ HCT recipients transplanted from 2006 to 2014 at the University of Minnesota were retrospectively analyzed. Full and mixed donor engraftment were defined as ≥95% or <95% donor cells at day 30, respectively. Source of engraftment determination included preferentially peripheral blood CD3 fraction, then myeloid cell fraction (CD15+), then bone marrow. In 407 CMV R+ subjects, 77% (n = 313) were CMV D(-) cells from umbilical cord blood (n = 209), peripheral blood (n = 58) or marrow (n = 46). Fifty three per cent received reduced intensity conditioning (RIC). At day +30, full donor engraftment was seen in 82% of myeloablative and 55% of RIC transplants. The cumulative incidence of CMV infection 1-year after transplant was not different in patients with full (54%, n = 276) or mixed (53%, n = 131) donor engraftment. Control of CMV did not significantly differ among the two groups. In multiple regression analysis, there was no significant association between donor engraftment (mixed or full) and incidence or control of CMV.
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Affiliation(s)
- Jaime S Green
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Ryan M Shanley
- Masonic Cancer Center Biostatistics Core, University of Minnesota, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Division of Hematology, Oncology and Transplantation, Department of Medicine, Program in Blood and Marrow Transplant, University of Minnesota, Minneapolis, Minnesota
| | - Jo-Anne H Young
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Michael R Verneris
- Division of Hematology, Oncology and Transplantation, Department of Medicine, Program in Blood and Marrow Transplant, University of Minnesota, Minneapolis, Minnesota
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43
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Jurdi NE, Bejanyan N, Defor TE, Arora M, Bachanova V, Betts BC, Cooley S, He F, Holtan SG, Miller JS, Rashidi A, Slungaard A, Vercellotti GM, Warlick ED, Weisdorf DJ, Brunstein CG. Modified Reduced Intensity Conditioning (RIC) of HLA-Haploidentical Related Hematopoietic Cell Transplantation (HAPLO-HCT) for Patients with Hematological Malignancies: Interim Analysis of an Age- and Risk-Adapted Phase II Trial. Biol Blood Marrow Transplant 2019. [DOI: 10.1016/j.bbmt.2018.12.784] [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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44
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Holtan SG, Hoeschen A, Cao Q, Arora M, Bachanova V, Brunstein CG, Cooley S, Miller JS, Ustun C, Vercellotti GM, Warlick E, Defor TE, Wagner JE, Blazar BR, Jacobson P, Panoskaltsis-Mortari A, MacMillan ML, Weisdorf DJ. Facilitating Resolution of Life-Threatening Acute Graft-Versus-Host Disease By Supplementation of Human Chorionic Gonadotropin and Epidermal Growth Factor (Pregnyl®): A Phase I Study. Biol Blood Marrow Transplant 2019. [DOI: 10.1016/j.bbmt.2018.12.236] [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: 10/27/2022]
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45
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Savani M, Gencturk M, Shanley R, Cayci Z, Wilke C, Warlick E, Weisdorf DJ, Brunstein CG, Bachanova V. Surveillance PET 100 Days after Autologous Hematopoietic Cell Transplantation Identifies Diffuse Large B Cell Lymphoma Patients with Extremely Poor Survival. Biol Blood Marrow Transplant 2019. [DOI: 10.1016/j.bbmt.2018.12.834] [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: 10/27/2022]
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46
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Brunstein CG, Pasquini MC, Kim S, Fei M, Adekola K, Ahmed I, Aljurf M, Agrawal V, Auletta JJ, Battiwalla M, Bejanyan N, Bubalo J, Cerny J, Chee L, Ciurea SO, Freytes C, Gadalla SM, Gale RP, Ganguly S, Hashmi SK, Hematti P, Hildebrandt G, Holmberg LA, Lahoud OB, Landau H, Lazarus HM, de Lima M, Mathews V, Maziarz R, Nishihori T, Norkin M, Olsson R, Reshef R, Rotz S, Savani B, Schouten HC, Seo S, Wirk BM, Yared J, Mineishi S, Rogosheske J, Perales MA. Effect of Conditioning Regimen Dose Reduction in Obese Patients Undergoing Autologous Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2018; 25:480-487. [PMID: 30423481 DOI: 10.1016/j.bbmt.2018.11.005] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 11/06/2018] [Indexed: 01/09/2023]
Abstract
Data are limited on whether to adjust high-dose chemotherapy before autologous hematopoietic cell transplant (autoHCT) in obese patients. This study explores the effects of dose adjustment on the outcomes of obese patients, defined as body mass index (BMI) ≥ 30 kg/m2. Dose adjustment was defined as a reduction in standard dosing ≥20%, based on ideal, reported dosing and actual weights. We included 2 groups of US patients who had received autoHCT between 2008 and 2014. Specifically, we included patients with multiple myeloma (MM, n = 1696) treated with high-dose melphalan and patients with Hodgkin or non-Hodgkin lymphomas (n = 781) who received carmustine, etoposide, cytarabine, and melphalan conditioning. Chemotherapy dose was adjusted in 1324 patients (78%) with MM and 608 patients (78%) with lymphoma. Age, sex, BMI, race, performance score, comorbidity index, and disease features (stage at diagnosis, disease status, and time to transplant) were similar between dose groups. In multivariate analyses for MM, adjusting for melphalan dose and for center effect had no impact on overall survival (P = .894) and treatment-related mortality (TRM) (P = .62), progression (P = .12), and progression-free survival (PFS; P = .178). In multivariate analyses for lymphoma, adjusting chemotherapy doses did not affect survival (P = .176), TRM (P = .802), relapse (P = .633), or PFS (P = .812). No center effect was observed in lymphoma. This study demonstrates that adjusting chemotherapy dose before autoHCT in obese patients with MM and lymphoma does not influence mortality. These results do not support adjusting chemotherapy dose in this population.
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Affiliation(s)
- Claudio G Brunstein
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - Marcelo C Pasquini
- CIBMTR(®) (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Soyoung Kim
- CIBMTR(®) (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mingwei Fei
- CIBMTR(®) (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kehinde Adekola
- Division of Hematology/Oncology, Department of Medicine and Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ibrahim Ahmed
- Department of Hematology Oncology and Bone Marrow Transplantation, The Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Vaibhav Agrawal
- Division of Hematology/Oncology, Indiana University Simon Cancer Center, Indianapolis, IN, USA
| | - Jeffrey J Auletta
- Blood and Marrow Transplant Program and Host Defense Program, Divisions of Hematology/Oncology/Bone Marrow Transplant and Infectious Diseases, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Nelli Bejanyan
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Joseph Bubalo
- Adult Blood and Marrow Stem Cell Transplant Program, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Jan Cerny
- Division of Hematology/Oncology, Department of Medicine, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Lynette Chee
- The Royal Melbourne Hospital, Melbourne, Australia
| | - Stefan O Ciurea
- University of Texas and MD Anderson Cancer Center, Houston, TX, USA
| | | | - Shahinaz M Gadalla
- Division of Cancer Epidemiology & Genetics, NIH-NCI Clinical Genetics Branch, Rockville, MD, USA
| | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Siddhartha Ganguly
- Division of Hematological Malignancy and Cellular Therapeutics, University of Kansas Health System, Kansas City, KS, USA
| | - Shahrukh K Hashmi
- Department of Internal Medicine, Mayo Clinic, MN, USA; Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Peiman Hematti
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Medicine, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | | | | | - Oscar B Lahoud
- Bone Marrow Transplant Service, Division of Hematology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Heather Landau
- Bone Marrow Transplant Service, Division of Hematology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Marcos de Lima
- Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Vikram Mathews
- Department of Hematology, Christian Medical College & Hospital, Vellore, India
| | - Richard Maziarz
- Adult Blood and Marrow Stem Cell Transplant Program, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Maxim Norkin
- Division of Hematology/Oncology, University Florida College of Medicine, Gainesville, FL, USA
| | - Richard Olsson
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Ran Reshef
- Blood and Marrow Transplantation Program and Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY, USA
| | - Seth Rotz
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bipin Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Harry C Schouten
- Department of Hematology, Academische Ziekenhuis, Maastricht, Netherlands
| | - Sachiko Seo
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Baldeep M Wirk
- Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Jean Yared
- Blood & Marrow Transplantation Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Cancer Center, University of Maryland, Baltimore, MD, USA
| | - Shin Mineishi
- Penn State Health Hershey Medical Center, Hershey, PA, USA
| | - John Rogosheske
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Services, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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47
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Keklik F, Alrawi EB, Cao Q, Bejanyan N, Rashidi A, Lazaryan A, Arndt P, Dincer EH, Bachanova V, Warlick ED, MacMillan ML, Arora M, Miller J, Brunstein CG, Weisdorf DJ, Ustun C. Diffuse alveolar hemorrhage is most often fatal and is affected by graft source, conditioning regimen toxicity, and engraftment kinetics. Haematologica 2018; 103:2109-2115. [PMID: 30076172 PMCID: PMC6269296 DOI: 10.3324/haematol.2018.189134] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 01/23/2018] [Accepted: 07/27/2018] [Indexed: 12/30/2022] Open
Abstract
Diffuse alveolar hemorrhage after hematopoietic stem cell transplantation is a frequently fatal complication with no standard therapy. Although significant changes in supportive and intensive care measures for patients undergoing hematopoietic stem cell transplantation have been made over the past decades, the impact of these changes on the incidence and outcome of patients with diffuse alveolar hemorrhage has not been examined. We analyzed 1228 patients who underwent allogeneic hematopoietic stem cell transplantation between 2008-2015 at the University of Minnesota to study the incidence, risk factors, and outcomes of diffuse alveolar hemorrhage. Diffuse alveolar hemorrhage developed in 5% of allogeneic hematopoietic stem cell transplant recipients, at a median of 30 days (range +3 to +168 days) after transplantation. The incidence of diffuse alveolar hemorrhage was significantly greater in recipients of umbilical cord blood than peripheral blood or bone marrow grafts (HR: 2.08, 95% CI: 1.16-3.74; P=0.01). In multivariate analysis, delayed neutrophil engraftment or primary graft failure was a risk factor for diffuse alveolar hemorrhage following peripheral blood or bone marrow hematopoietic stem cell transplants (HR: 5.51, 95% CI: 1.26-24; P=0.02) and delayed platelet engraftment was associated with significantly increased diffuse alveolar hemorrhage in umbilical cord blood transplant recipients (HR: 6.96, 95% CI: 2.39-20.29; P<0.05). Myeloablative regimens including total body irradiation were also risk factors for diffuse alveolar hemorrhage (HR: 1.8, 95% CI: 1.03-3.13, P=0.05) in both peripheral blood or bone marrow and umbilical cord blood hematopoietic stem cell transplants (HR: 1.87, 95% CI: 0.95-3.71). Patients with diffuse alveolar hemorrhage had an inferior 6-month treatment-related mortality (HR: 6.09, 95% CI: 4.33-8.56, P<0.01) and 2-year overall survival (HR: 4.16, 95% CI: 3.06-5.64; P<0.01) using either graft source. The etiology of diffuse alveolar hemorrhage is multifactorial, involving lung injury influenced by high-dose total body irradiation, graft source, and delayed engraftment or graft failure. The survival of patients with diffuse alveolar hemorrhage after hematopoietic stem cell transplantation remains poor. Clinical interventions or experimental studies (e.g., cell expansion for umbilical cord blood transplants or thrombopoietin use) that modulate these risk factors may limit the incidence and improve the outcomes of diffuse alveolar hemorrhage.
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Affiliation(s)
- Fatma Keklik
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | | | - Qing Cao
- Biostatistics and Bioinformatics
| | - Nelli Bejanyan
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | - Armin Rashidi
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | - Aleksandr Lazaryan
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | - Patrick Arndt
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine
| | - Erhan H Dincer
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine
| | - Veronika Bachanova
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | - Erica D Warlick
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | - Margaret L MacMillan
- Division of Pediatric Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Mukta Arora
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | - Jeffrey Miller
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | | | - Daniel J Weisdorf
- Division of Hematology-Oncology and Transplantation, Department of Medicine
| | - Celalettin Ustun
- Division of Hematology-Oncology and Transplantation, Department of Medicine
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48
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Hegerova L, Bachan A, Cao Q, Vu HX, Rogosheske J, Reding MT, Brunstein CG, Arora M, Ustun C, Vercellotti GM, Bachanova V. Catheter-Related Thrombosis in Patients with Lymphoma or Myeloma Undergoing Autologous Stem Cell Transplantation. Biol Blood Marrow Transplant 2018; 24:e20-e25. [PMID: 30053647 DOI: 10.1016/j.bbmt.2018.07.028] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 07/17/2018] [Indexed: 01/21/2023]
Abstract
Catheter-related thrombosis (CRT) occurs frequently during autologous hematopoietic cell transplantation (AHCT) and data regarding the incidence, risk factors, and management are understudied. We evaluated 789 consecutive patients with lymphoma and myeloma that underwent AHCT over 10 years (2006 to 2016) and detected the incidence of CRT was 6.3%; only 32% of CRT were symptomatic. The majority occurred within 100 days of AHCT (86%) and median time from tunneled line placement to CRT was 44 days (range, 11 to 89 days). Outcomes of these 50 patients with CRT were compared with age- and disease-matched AHCT control subjects to identify risk factors. History of prior venous thromboembolism (VTE) (20.9% versus 7.0%, P = .02) was the only significant risk factor. Treatment with low-molecular-weight heparin was tolerated with rare minor bleeding (4%), although CRT recurrence or extension (10%) and subsequent VTE (12%) were common. CRT did not impact on nonrelapse mortality or risk of relapse; 2-year progression-free survival was 55% in CRT cases versus 54% in control subjects (P = .42). CRT appears to be common in patients with lymphoma and myeloma undergoing AHCT and significantly contributes to morbidity. Further study to determine mitigating strategies and modify risk factors for CRT is warranted.
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Affiliation(s)
- Livia Hegerova
- Center for Blood Disorders and Stem Cell Transplantation, Swedish Cancer Institute, Seattle, Washington.
| | - Adam Bachan
- Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Qing Cao
- Biostatistics Core, Masonic Cancer Center, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Huong X Vu
- Department of Clinical Pharmacology, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - John Rogosheske
- Department of Clinical Pharmacology, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Mark T Reding
- Center for Bleeding and Clotting Disorders, University of Minnesota Medical Center, Minneapolis, Minnesota; Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, Minnesota; Blood and Marrow Transplantation Program, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, Minnesota; Blood and Marrow Transplantation Program, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Celalettin Ustun
- Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, Minnesota; Blood and Marrow Transplantation Program, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Gregory M Vercellotti
- Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, Minnesota; Blood and Marrow Transplantation Program, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Veronika Bachanova
- Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, Minnesota; Blood and Marrow Transplantation Program, University of Minnesota Medical Center, Minneapolis, Minnesota
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49
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Rashidi A, Ebadi M, Said B, Cao Q, Shanley R, Curtsinger J, Bejanyan N, Warlick ED, Green JS, Brunstein CG, Miller JS, Weisdorf DJ. Absence of early HHV-6 reactivation after cord blood allograft predicts powerful graft-versus-tumor effect. Am J Hematol 2018; 93:10.1002/ajh.25141. [PMID: 29756385 PMCID: PMC6235732 DOI: 10.1002/ajh.25141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 04/30/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 11/08/2022]
Abstract
Approximately 75% of cord blood transplant (CBT) recipients experience human herpes virus-6 (HHV-6) reactivation. Considering the immunomodulatory effects of HHV-6, we hypothesized that early HHV-6 reactivation may influence the risk of relapse of the underlying hematologic malignancy. In 152 CBT recipients with hematological malignancies, we determined the association between HHV-6 reactivation by day +28 and 2-year cumulative incidence of relapse. In univariate analysis, the absence of HHV-6 reactivation (n = 32) was associated with less relapse (26 [18-35]% vs. 7 [0-17]% in groups with vs. without HHV-6 reactivation, respectively; P = .03). This difference was due to a remarkably low relapse incidence among patients without HHV-6 reactivation. In multivariable analysis, the absence of HHV-6 reactivation was associated with less relapse (hazard ratio [95% confidence interval]: 0.2 [0.05-0.9], P = .03). This association was independent of patient-, disease-, and transplant-related characteristics known to influence the risk of relapse. Natural killer cell and T-cell reconstitution at day +28 were similar between patients with vs. without HHV-6 reactivation. Our results suggest that CB allografts not complicated by HHV-6 reactivation by day +28 have a powerful graft-versus-tumor effect. Knowledge about early HHV-6 reactivation may stratify patients at day +28 into low vs. high relapse risk groups.
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Affiliation(s)
- Armin Rashidi
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Maryam Ebadi
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Bassil Said
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Qing Cao
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Ryan Shanley
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | | | - Nelli Bejanyan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Erica D. Warlick
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Jaime S. Green
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN
| | - Claudio G. Brunstein
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Jeffrey S. Miller
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Daniel J. Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
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50
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Wagner JE, Brunstein CG, Defor TE, Boitano AE, McKenna DH, Sumstad D, Sanna B, Bleul CC, Cooke M. Single Cord Blood Units (CBU) Expanded with an Aryl Hydrocarbon Receptor (AHR) Antagonist, Demonstrate Uniform Engraftment and Rapid Hematopoietic Recovery. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.016] [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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