scholarly journals Genomic Subgroups Impact Post-Transplant Survival in Patients with Myelodysplastic Syndrome: A CIBMTR Analysis

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 3678-3678
Author(s):  
Tao Zhang ◽  
Paul Auer ◽  
Stephen R. Spellman ◽  
Caitrin Fretham ◽  
Wael Saber ◽  
...  
Keyword(s):  
Overall Survival ◽  
Conditioning Regimen ◽  
Molecular Signatures ◽  
Competing Risk Analysis ◽  
Multivariate Models ◽  
Cytogenetic Abnormalities ◽  
Post Transplant ◽  
Recurrent Mutations ◽  
The Individual ◽  
Genomic Clusters

Abstract Background Myelodysplastic syndromes (MDS) are clonal stem cell malignancies characterized by cytopenia, inefficient hematopoiesis, dysplasia in one or more myeloid cell lineages and increased risk of development of acute myeloid leukemia. It has been well appreciated that genomic alterations play a key role in MDS pathogenesis. The Revised International Prognostic Scoring System (IPSS-R) algorithm is commonly used to predict overall survival but may fail to recapitulate reliable prognostic information at the individual patient level, especially at the time of hematopoietic cell transplantation (HCT). Current World Health Organization (WHO) classification includes MDS with isolated 5q deletion as the only genetically defined category. Comprehensive analysis of recurrent genomic features by unsupervised clustering empowers discovery of potential prognostic molecular signatures. Methods Using whole blood samples obtained from 494 MDS patients at the time of HCT, we conducted whole-genome sequencing (WGS) and somatic variant processing via a custom analytic pipeline based on OCTOPUS and a set of annotation databases. Multiple filters allowed for selection and fine-tuning of criteria, including removal of variants with Gnomad allele frequency above 10x10 -06, removal of noncoding variants in low complexity and repetitive regions, those with no functional indications from ANNOVAR annotations, CADD conservative score under 15, and absence in HGMD or COSMIC databases. Highly annotated clinical data, including cytogenetic abnormalities at the latest time point prior to HCT, were obtained from CIBMTR forms. K-means clustering was applied to recurrent mutations and cytogenetic abnormalities to identify clinically relevant genomic subtypes. The optimal cluster number was determined by Gap-status algorithm. Statistics of clinical characteristics were compared among different genomic subgroups by Chi-squared test for categorical variables and Mann-Whitney U test for continuous variables. Overall survival association tests were conducted by Cox multivariate models. Relapse and transplant-related risk were performed by competing risk analysis using Fine-Gray models. Models were adjusted for patient-, disease-, and HCT-related factors. Results The somatic genomic landscape in our MDS cohort was examined for the total count of recurrent mutations at the sample level and gene level. Among 53 recurrently mutated genes in 257 of 494 MDS cases, TP53, TET2, RUNX1, DNMT3A, and ASXL1 were the most frequently mutated genes in our MDS cohort. Based on k-means clustering of the recurrent mutational and cytogenetic data, we detected five clusters that stratified our MDS patient cohort, including one reference cluster with no recurrent somatic mutations or cytogenetic abnormalities. Compared to the reference subgroup, significantly higher cytogenetic scores and IPSS-R scores were observed in genomic clusters with TP53 mutations (cytogenetic score: P=3.42E-07*; IPSS-R score: P= 2.38E-10*) and cytogenetic abnormalities del5q, or tri8p (cytogenetic score: P= 2.38E-10*; IPSS-R score: P=0.09) , or mono7 (cytogenetic score: P=3.29E-13*; IPSS-R score: P=1.38E-05*) (data not shown). Cox multivariate models revealed that genomic clusters with TP53 and del5q mutations (P<0.001*) or tri8p (P=0.02*) mutations have strong associations with post-transplant overall survival outcome (Figure 1A). Furthermore, competing risk analysis confirmed significantly higher risk of relapse in genomic subgroups with TP53 and del5q mutations in the reduced intensity conditioning regimen setting (P=0.01) (Figure 1B), while significantly higher risk of transplant-related mortality was found in the genomic subgroup with tri8p in the myeloablative conditioning regimen setting (P=0.03) (Figure 1C). Conclusion Our study suggests that molecular signatures from MDS patient genomes at HCT may provide an independent prognosis of post-transplant survival. Additionally, our data suggests that the choice of regimen intensity could be informed by knowledge of the individual genomic signature of a given MDS patient. Figure 1 Figure 1. Disclosures Saber: Govt. COI: Other.

Survival after T-Cell Replete Haplo-Identical Related Donor Transplant Using Post-Transplant Cyclophosphamide Compared with Matched Unrelated Donor Transplant for Acute Myeloid Leukemia

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 679-679 ◽  
Author(s):  
Stefan O. Ciurea ◽  
Mei-Jie Zhang ◽  
Andrea Bacigalupo ◽  
Asad Bashey ◽  
Frederick R. Appelbaum ◽  
...  
Keyword(s):  
Overall Survival ◽  
Survival Rates ◽  
Conditioning Regimen ◽  
Unrelated Donor ◽  
Reduced Intensity Conditioning ◽  
Treatment Groups ◽  
Post Transplant ◽  
Gvhd Prophylaxis ◽  
Reduced Intensity ◽  
Donor Transplant

Abstract Background: Increasing numbers of haplo-identical transplants are being performed and the most common approach in the United States includes transplantation of an unmanipulated graft with tacrolimus, mycophenolate and post-transplant cyclophosphamide for GVHD prophylaxis. In this analysis we compare the early outcomes after haplo-identical transplantation with this GVHD prophylaxis with that after conventional HLA-matched unrelated donor transplant approaches (MUD). Methods: Included are 2174 patients with AML aged 21-70 years and transplanted between 2008 and 2012. Cox regression models were built for recipients of myeloablative (N=1245 MUD compared with N=104 haplo-identical) and reduced intensity (N=737 MUD compared with 88 haplo-identical) conditioning transplants. Primary endpoint was 2-year overall survival. With median follow-ups of 2-3 years, surviving patients in all treatment groups were censored at 2-years. Results: Characteristics of recipients of myeloablative transplantation were similar across the two treatment groups except peripheral blood (PB) was the predominant graft with calcineurin inhibitor (CNI) with methotrexate the predominant GVHD prophylaxis for the MUD group compared to predominantly BM grafts with CNI, mycophenolate and post-transplant cyclophosphamide for the haplo-identical group. Most regimens were non-irradiation containing, 74% for MUD and 78% for haplo-identical transplants. Characteristics of recipients of reduced intensity conditioning transplants differed by treatment groups; recipients of MUD transplants were older (median age 62 vs. 57 years), more likely to report performance score 80 or lower, be in first complete remission at transplantation and shorter interval from diagnosis to transplantation. PB was the predominant graft for MUD and BM, for haplo-identical transplants. The conditioning regimen for reduced intensity haplo-identical transplants was uniform (TBI 200 cGy, cyclophosphamide, fludarabine) and for MUD transplants, it was predominantly an alkylating agent and fludarabine (79%). Day-30 cumulative incidence of neutrophil recovery was higher after myeloabative MUD compared with haplo-identical transplants (97% vs. 90%, p=0.01). Neutrophil recovery was not different after MUD and haplo-identical reduced intensity conditioning transplants (96% vs. 93%, p=0.25). Table 1 shows the results of multivariate analysis for non-relapse mortality (NRM), relapse and overall survival. Overall survival is not significantly different after haplo-identical and MUD transplants with either the myeloablative or reduced intensity conditioning approaches. The 2-year survival rates adjusted for age, disease status and interval from diagnosis to transplant after myeloablative MUD and haplo-identical transplantation were 54% (95% CI 51-57) and 47% (95% CI 37-57), respectively (p=0.22). The corresponding 2-year survival rates after reduced intensity conditioning transplantation were 49% (95% CI 45-53) and 53% (95% CI 42-63), p=0.25. We also explored for difference in survival with in vivo T-cell depletion in the myeloablative (HR 0.81, p=0.19) and reduced intensity (HR 1.18, p=0.33) MUD groups compared with the corresponding haplo-identical groups (baseline HR 1.00) and found none. We tested for a transplant center effect on survival and found none. Conclusion: With the available data, 2-year survival rates for AML after myeloablative or reduced intensity conditioning transplants are comparable after conventional MUD transplant approaches and haplo-identical transplant with the post-transplant cyclophosphamide approach. Longer follow-up of haplo-identical transplant recipients as well as confirmation of these findings in a larger population, are needed before wide spread adoption of selecting haplo-identical donors over HLA-matched unrelated donors. Table Transplant Conditioning Regimen Outcomes Myeloablative Hazard Ratio Reduced intensity Hazard Ratio NRM Haplo-identical 1.00 1.00 MUD 1.07; p=0.82 2.35; p=0.03 Relapse Haplo-identical 1.00 1.00 MUD 0.88; p=0.40 0.76; p=0.09 Survival Haplo-identical 1.00 1.00 MUD 0.93; p=0.61 1.13; p=0.46 Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

scholarly journals A Novel TBI Free Conditioning Protocol for Haploidentical Transplant in Acquired Aplastic Anemia: (FluCAB-Prime)

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 12-13
Author(s):  
Raheel Iftikhar ◽  
Qamar Un Nisa Chaudhry ◽  
Syed Kamran Mahmood ◽  
Tariq Ghafoor ◽  
Nighat Shahbaz ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Overall Survival ◽  
Aplastic Anemia ◽  
Graft Failure ◽  
Chronic Gvhd ◽  
Conditioning Regimen ◽  
Marrow Transplant ◽  
Free Survival ◽  
Post Transplant ◽  
Primary Graft Failure

Introduction Allogeneic hematopoietic stem cell transplant (HSCT) is the standard treatment for patients younger than 40 years with Severe and Very Severe Aplastic Anemia (AA) who have a Matched Related Donor (MRD). For patients lacking a MRD, treatment options include immunosuppressive therapy (IST), matched unrelated donor (MUD) or alternate donor (haploidentical/cord blood) transplant. Pakistan has a population of around 23 million but there is no donor registry for MUD transplants and horse antithyomcyte globulin (hATG) is not available. Over past decade, results of haploidentical transplants have improved remarkably with use of post-transplant cyclophosphamide. However, most of these protocols incorporate total body irradiation (TBI) to improve engraftment and reduce graft failure. TBI is not available in most of the transplant centres across Pakistan. We have developed a novel TBI free conditioning regimen (NCT03955601) for haploidentical HSCT in acquired AA patients lacking a MRD. Materials and Methods We conducted a prospective, single centre, interventional trial (NCT03955601) using novel TBI free conditioning at AF bone marrow transplant centre (AFBMTC)/ National institute of blood and marrow transplant (NIBMT) for patients with acquired severe and very severe AA. Between July 2018 and March 2020, a total of 10 patients received related haploidentical transplant.Study inclusion criteria was diagnosis of severe and very severe AA, patients of both genders, age 2-60 years, Karnofsky performance status>70%. Exclusion criteria was presence of donor specific antibodies (DSA), inherited bone marrow failure syndrome, prior HSCT and severe sepsis. Conditioning regimen used was Fludarabine (Flu) 30 mg/m2 IV daily from day -7 to -3, Cyclophosphamide (Cy) 14.5 mg/kg IV daily on day -6 and -5 , rabbit Antithymocyte globulin (rATG) 5 mg /kg/day from day -6 to day-3; Busulphan (Bu) IV 3.2 mg per kg/day in 04 divided doses on day -3 and day-2, Granulocyte Colony Stimulating factor (GCSF) primed Bone marrow harvest (BMH) and/or PBSC graft on day 0 and day +1 respectively. Graft versus host disease (GVHD) prophylaxis used was post-transplant cyclophosphamide (PTCy) administered at a dose of 50mg/kg/day given daily on days +3 and +5 post-transplant, cyclosporine (CsA) from day +5 and mycophenolate mofetil (MMF) from day+5 to +35. Primary outcome measure was overall survival (OS) while secondary outcome measures included graft failure, treatment related mortality (TRM), disease free survival (DFS), GVHD free relapse free survival (GRFS), acute and chronic GVHD. Results: Ten patients were transplanted, 5 (50%) female and 5 (50%) male (table 1). Median age was 15.5 years (range 5-41 years). Median duration from diagnosis to transplant was 14 months (range 4-51 months). One patient received ATG prior to transplant. Median number of red cell concentrate (RCC) transfusions before transplant were 27 (8-90) and platelet transfusions 100(6-150). Median donor age was 23 years (10-41 years). Donor-recipient major ABO mismatch was present in 2(20%) while four (40%) had minor ABO mismatch. Primed bone marrow harvest (BMH) was used in 3(30%) while primed BM+PBSC was given in 7(70%) patients. Median CD34 dose given was 8 x 106/kg (range 5.1-16). Seven patients (70%) achieved sustained neutrophil engraftment. One patient had primary graft failure, one patient secondary graft failure at day 35 due to Cytomegalovirus infection and one patient (currently day +118) is having poor graft function. Acute skin GVHD stage-2 developed in 1 patient which settled with topical steroids. None of the patient developed chronic GVHD. Cytomegalovirus reactivation was documented in 8 (80%) patients. All donors and recipients were CMV seropositive pre-transplant. One patient (female, 20 years) had primary graft failure and died on day +31 with sepsis and multiorgan dysfunction syndrome (MODS). One patient (female, 14 years) had secondary graft failure due to CMV infection and died on day +44 with intracranial hemorrhage. Conditioning regimen was well tolerated without any treatment related morbidly and mortality. Median follow-up of study was 13 months (range 4-22 months). Overall survival of study cohort is 80%, DFS 70% and GRFS 70%. Conclusion: Our study shows that for countries lacking TBI, use of FluCAB-Prime protocol is feasible and is associated with low rates of acute and chronic GVHD. Disclosures No relevant conflicts of interest to declare.

Role Of Allogeneic Transplant In Poor Risk CLL Patients: A Long-Term Monocentric Experience In 39 Patients

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 5531-5531
Author(s):  
Therese Aurran-Schleinitz ◽  
Anne Wanquet ◽  
Sabine Furst ◽  
Benjamin Esterni ◽  
Reda Bouabdallah ◽  
...  
Keyword(s):  
Overall Survival ◽  
Overall Response Rate ◽  
Response Rate ◽  
Conditioning Regimen ◽  
Complete Response ◽  
Allogeneic Transplant ◽  
Post Transplant ◽  
Overall Response ◽  
Poor Risk ◽  
Median Delay

Abstract Background Allogeneic stem cell transplantation (SCT) remains the only curative option in poor risk chronic lymphocytic leukemia (CLL). Reduced intensity conditioning regimens (RIC) have improved outcome and enlarged number of patients eligible to SCT. However it is still controversial whether patient characteristics, CLL treatment, conditioning regimen or GVH prophylaxis influence the outcome. Here we present the analysis of our cohort of CLL patients who underwent RIC SCT. Patients and methods This is a retrospective single center study Primary endpoint was overall survival; secondary endpoints were cumulated incidence of relapse and non-relapse mortality. Results From 2000 to 2012, Thirty-nine patients with a sex ratio of 2 were transplanted. At time of transplantation, median age was 59 years (27-68), 82% patients displayed performans status (PS) of 0 and 20% had a comorbidity score ≥3. More than half patients (54%) were Fludarabine refractory and FISH 17p deletion was found in 10 out of 23 tested patients (43%). Median delay between diagnosis and transplant was 92 months (4-182). Patients received a median of 3 (1-9) prior therapies. Last treatment before transplant was fludarabine-based in 12 patients, alemtuzumab in 13, and other (RCHOP, R-Bendamustine, RDHAP) in 14. Median delay between the last treatment and transplantation was 2 months (1-33). At time of transplant, overall response rate was 82% including 33% complete response (CR). Four-color phenotypic MRD was negative (<10-4) in 9 patients (23%). Donor type was HLA matched relative for 22 patients, unrelated for 13 and cord blood for 4. Conditioning regimen varied according to protocols and donor. It consisted of fludarabine, busulfan and antithymocyte globulin in 21 patients, fludarabine, TBI and rituximab in 14 patients and fludarabine, cyclophosphamide and total body irradiation (TBI) in 4 and. Graft versus host disease (GVHD) prophylaxis was provided by cyclosporine alone in 54% patients, and cyclosporine and mycophenolate mofetil in 46%. After transplant, overall response rate was 90% with 17 patients evolving from partial response or stable disease to complete response and MRD was negative in 28/33 (85%) patients. Donor chimerism was performed for 27 patients, chimerism >90% was obtained in all patients except one, after a median of 90d (19-180) post transplant. Acute and chronic extensive GVHD occurred in 44% and 38% patients respectively. With a median follow-up of 59 months, median overall survival (OS) was 97 months, 2- and 5-years OS were 72% and 59% respectively. Fifteen patients died, 7 from GVHD, 4 from sepsis, 1 from CLL and 3 from other causes. 2- and 5-years cumulated incidences (CI) of non-relapse mortality (NRM) were 25.6% and 38.3% respectively. Three patients relapsed after transplant, 2 are still alive 82 and 98 months post-transplant. 2- and 5-years cumulated incidences of relapse were 2.8% and 6.8% respectively. In univariate analysis, disease status at transplant and number of prior therapies were significantly associated with better OS (p=0.0009 and p=0.03 respectively), whereas a trend to correlation between PS and OS was observed (p=0.063). In multivariate analysis, PS and achievement of CR or PR before transplant correlated significantly to OS (p=0.015 and p=0.05 respectively). Clearance of MRD before transplant perhaps suggested a better survival (p=0.158). Conclusion This retrospective study highlights the ability of allogeneic transplant to improve OS in otherwise very poor prognosis CLL patients and deserve further investigations. Disclosures: Aurran-Schleinitz: Roche: Honoraria.

scholarly journals A Cytogenetic Model Predicts Relapse Risk and Survival in Patients with Acute Myeloid Leukemia Undergoing Hematopoietic Stem Cell Transplantation in Morphologic Complete Remission

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 2545-2545
Author(s):  
Armin Rashidi ◽  
Amanda F Cashen
Keyword(s):  
Overall Survival ◽  
Risk Group ◽  
Univariate Analysis ◽  
Conditioning Regimen ◽  
Cumulative Risk ◽  
Relapse Free Survival ◽  
Hematopoietic Stem ◽  
Free Survival ◽  
Cytogenetic Abnormalities ◽  
Reduced Intensity

Abstract Objectives: Up to one third of patients with acute myeloid leukemia (AML) and abnormal cytogenetics have persistent cytogenetic abnormalities (pCytAbnl) at morphologic complete remission (mCR). We hypothesized that the prognostic significance of pCytAbnl in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) in mCR varies with the cytogenetic risk group. Previous studies on the subject have been small, inconclusive, or inconsistent. Methods: We analyzed the data from a large cohort of patients (n = 118) with AML and abnormal cytogenetics who underwent allo-HSCT in mCR, and developed a simple risk stratification model based on pCytAbnl and cytogenetic risk group to compare time to relapse (TTR), relapse-free survival (RFS), and overall survival (OS). Results: The mean (standard deviation) age of patients was 51 (14) years, and 58% were male. AML was therapy-related in 21 (31%) patients. The most frequent FAB subtypes were M0/M1/M2 (46%), followed by M4/M5 (26%). Favorable, intermediate and unfavorable cytogenetic risk disease was present in 18%, 28%, and 54% of patients, respectively. The majority (73%) of patients were in CR1. Conditioning was myeloablative in 67% of patients and reduced-intensity in the remainder. The groups with or without pCytAbnl were similar in all baseline and transplant characteristics except age, CR number and cytogenetic risk group. Specifically, patients with pCytAbnl were significantly older (56 ± 12 vs. 48 ± 15 years; P = 0.004), were in first CR more frequently (86% vs. 67%; P = 0.042), and were more likely to have unfavorable risk cytogenetics (P = 0.027) than patients without pCytAbnl. Univariate analysis was performed using the following variables: age, gender, therapy-related AML (present vs. absent), pCytAbnl (present vs. absent), cytogenetic risk group (unfavorable vs. intermediate/favorable), CR number (≥2 vs. 1), conditioning regimen (myeloablative vs. reduced intensity), and donor type (matched unrelated vs. sibling). There was a significant association between outcome (OS, RFS, and TTR) and the following variables: pCytAbnl, cytogenetic risk group, and the conditioning regimen. Additionally, CR number was significantly associated with TTR. In multivariate regression analysis with these four variables (Table 1), only pCytAbnl, cytogenetic risk group, and the conditioning regimen had a significant impact on outcome. A risk scoring system was then built using pCytAbnl and cytogenetic risk group. The model distinguished 3 groups of patients with distinct outcomes (Figure 1). The group with pCytAbnl and unfavorable risk cytogenetics (R2, n = 24) had the shortest median TTR (3 months), RFS (3 months), and OS (7 months). The group with favorable/intermediate risk cytogenetics and without pCytAbnl (R0, n = 47) had the longest median TTR (not reached), RFS (57 months), and OS (57 months). The group with pCytAbnl and favorable/intermediate risk cytogenetics, or without pCytAbnl but with unfavorable risk cytogenetics (R1, n = 47) experienced intermediate TTR (18 months), RFS (9 months), and OS (14 months). Conclusions: A composite cytogenetic risk model identifies patients with AML in mCR with distinct relapse, RFS, and OS rates following allo-HSCT. Table 1:Multivariate analysis for survival outcomes using variables with a significant association in univariate analysis OS RFS TTRHR (95% CI)PHR (95% CI)PHR (95% CI)PpCytAbnl + vs. -0.54 (0.32-0.91)0.0200.53 (0.32-0.86)0.0100.44 (0.24-0.80)0.007Cytogenetic risk U vs. F/I0.60 (0.36-0.99)0.0470.55 (0.34-0.98)0.0140.45 (0.23-0.95)0.023CR number ≥2 vs. 1----1.51 (0.58-3.95)0.404Conditioning MA vs. RI1.71 (1.04-2.81)0.0352.04 (1.27-3.27)0.0032.85 (1.57-5.15)0.001 CI: confidence interval; F/I: Favorable/Intermediate; HR: hazard ratio; MA: myeloablative; RI: reduced intensity; U: unfavorable Figure 1: Cumulative risk of relapse (A), relapse free survival (B) and overall survival (C) based on persistent cytogenetic abnormalities and cytogenetics. R0, R1, and R2 are defined in the text. Figure 1:. Cumulative risk of relapse (A), relapse free survival (B) and overall survival (C) based on persistent cytogenetic abnormalities and cytogenetics. R0, R1, and R2 are defined in the text. Disclosures No relevant conflicts of interest to declare.

scholarly journals Use of Thymoglobulin with Lower Dose of Busulfan Results in Less Acute Gvhd Following Unrelated Donor Allogeneic Stem Cell Transplantation for AML without Affecting Relapse-Free and Overall Survival

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4488-4488
Author(s):  
Dipenkumar Modi ◽  
Vijendra Singh ◽  
Seongho Kim ◽  
Abhinav Deol ◽  
Asif Alavi ◽  
...  
Keyword(s):  
Overall Survival ◽  
Acute Gvhd ◽  
Chronic Gvhd ◽  
Conditioning Regimen ◽  
Advisory Board ◽  
Unrelated Donor ◽  
Hla Matching ◽  
Reduced Intensity Conditioning ◽  
Post Transplant ◽  
Reduced Intensity

Introduction: Post-transplant relapse and GVHD are two major barriers of success of allogeneic hematopoietic stem cell transplantation (AHSCT) for AML. These outcomes are often dependent on the complex interaction between the post-transplant immunosuppression and the conditioning regimen. We as well as others have used rabbit thymoglobulin for the reduction of both acute and chronic GVHD in unrelated transplant in AML. The interaction between different conditioning regimens and thymoglobulin may play an important role in the outcomes, but it has not been fully investigated. In this study, we compared outcomes of patients undergoing unrelated donor AHSCT for AML using thymoglobulin with either a myeloablative or reduced intensity conditioning regimen. Patients received busulfan/fludarabine (Bu/Flu)-based myeloablative conditioning (MAC) regimen with 4 days of busulfan or reduced intensity conditioning (RIC) regimen using 2 days of busulfan with fludarabine. Since 2 days of busulfan as RIC may have a higher relapse rate, we added low dose TBI (200cGY) to the RIC regimen (Bu/Flu/TBI). Methods: We retrospectively evaluated outcomes of adult AML patients who underwent unrelated donor AHSCT utilizing tacrolimus, mycophenolate (MMF) and thymoglobulin as GVHD prophylaxis. All patients received either a Bu/Flu/TBI-based RIC or a Bu/Fu-based MAC regimen. Thymoglobulin was administered at a total dose of 4.5mg/kg in divided fashion (0.5mg/kg on day-3, 1.5mg/kg on day -2, 2.5mg/kg on day -1). Tacrolimus and MMF were started on day -3. The objectives were to determine the rates of acute and chronic GVHD, overall survival (OS), relapse free survival (RFS) and non-relapse mortality (NRM) using Cox proportional hazard regression and competing risk models. Results: One hundred twenty-two patients with AML received unrelated donor AHSCT between January 2005 and December 2017. Of these, 88 (72%) patients had de-novo and 34 (28%) had secondary AML. Sixty-four patients received Bu/Flu/TBI-based RIC, and 58 received Bu/Flu as MAC regimen. All patients received peripheral blood stem cells. The patients receiving RIC regimen were older (median age 66 vs 53 years, p<0.001), had higher proportion of patients with normal cytogenetics (47% vs 31%, p=0.02) and 8/8 HLA match (88% vs 64%, p=0.004) as compared to MAC regimen. The 6-month cumulative incidence rate (CIR) of grade III-IV acute GVHD (aGVHD) was 6% in RIC and 26% in MAC regimen (p=0.004). The 2-year CIR of chronic extensive GVHD was 35% and 29% in RIC and MAC regimen, respectively (p=0.50). Median follow-up of surviving patients after RIC and MAC regimen was 4.4 years and 4 years, respectively. Two-year OS after RIC and MAC regimen was 50% and 49%, respectively (p=0.69). Two-year relapse rate with RIC and MAC was 37% and 24%, respectively (p=0.25), whereas two-year NRM with RIC and MAC was 21% and 31%, respectively (p=0.41). Two-year RFS was 43% with RIC and 45% with MAC regimen (p=0.80). In all, CMV and EBV reactivation rates were 34% and 7%, respectively. Eight patients (7%) developed gastrointestinal CMV disease. Multivariable analysis revealed that relapsed and refractory AML at AHSCT was associated with adverse OS (HR 1.71, p=0.04), RFS (HR 1.84, p=0.01) and higher NRM (SHR 2.96, p=0.006) compared to first complete remission. Secondary AML was associated with higher NRM (HR 2.44, p=0.02). No impact of HLA matching and conditioning regimen on OS, relapse, NRM and RFS was observed. Subgroup analysis showed that HLA matching had an interaction with the conditioning regimen for RFS (p=0.03). Otherwise, none of the factors appeared to have any significant interaction with the conditioning regimen for survival outcomes. Conclusion: Our study shows that thymoglobulin when used with lower dose of busulfan (in the form of Bu/Flu/TBI-based RIC regimen) provided significantly lower rate of acute GVHD compared to Bu/Flu-based MAC in AML patients undergoing unrelated donor AHSCT without affecting leukemia-free and overall survival. Disease status at transplant remains a significant predictor of post-transplant outcomes. Disclosures Deol: Novartis: Other: Advisory board; Kite: Other: Advisory board; Agios: Other: Advisory board.

scholarly journals Comparison of Peripheral Blood Stem Cells (PBSC) to Bone Marrow (BM) for T-Replete HLA-Haploidentical Donor Transplantation Using Post-Transplant Cyclophosphamide

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 683-683 ◽  
Author(s):  
Asad Bashey ◽  
MeiJie Zhang ◽  
Shannon R. McCurdy ◽  
Stefan O. Ciurea ◽  
Andrew St. Martin ◽  
...  
Keyword(s):  
Overall Survival ◽  
Board Of Directors ◽  
Disease Risk ◽  
Risk Index ◽  
Chronic Gvhd ◽  
Conditioning Regimen ◽  
Advisory Committees ◽  
Mortality Risks ◽  
Post Transplant

Abstract T cell-replete haploidentical donor transplants (HAPLO-HCT) using post-transplant cyclophosphamide for control of alloreactivity is now being increasingly utilized. HAPLO-HCTs were originally performed using BM grafts. However, recently, a few single center studies have reported good outcomes using G-CSF mobilized PBSC grafts for HAPLO-HCT. No prospective randomized comparisons of BM to PBSC grafts for HAPLO-HCT have been performed. Therefore, we analyzed outcomes for 687 adults (496 BM, 191 PBSC) who received HAPLO-HCT for hematologic malignancies using post-transplant cyclophosphamide + mycophenolate + calcineurin inhibitor for GVHD prophylaxis between 2009 and 2014 in the United States. The primary outcome was overall survival. The characteristics of recipients of BM and PBSC were similar except BM recipients were older, more likely to have a performance score ≥90, HCT-CI index ≤2, be CMV seronegative, have a lymphoid malignancy and receive reduced-intensity conditioning. Most PBSC transplants occurred between 2012 and 2014. The median follow-up was 35 and 20 months for recipients of BM and PBSC grafts, respectively. Cox regression models were built to study the effect of graft type adjusted for other significant factors on overall mortality, non-relapse mortality, relapse and graft-versus-host disease (GVHD) and outcomes censored at 2-years to accommodate differential follow-up between treatment groups (Table 1). After adjusting for age, CMV serostatus, disease risk index (disease type/disease status for myeloid and lymphoid malignancy and cytogenetic risk for acute leukemia and myelodysplastic syndrome) and transplant conditioning regimen there were no significant differences in risks for overall mortality (HR 1.00, p= 0.98; 2-year overall survival: 54% and 57%) or non-relapse mortality (HR 0.92, p=0.74; 2-year non-relapse mortality: 17% and 16%) after transplantation of BM compared to PBSC, respectively. However, relapse risks were higher after transplantation of BM compared to PBSC (HR 1.49, p=0.009; 2-year relapse: 45% and 28%). Subset analyses explored the effect of graft type separately for myeloablative and reduced intensity conditioning regimen adjusting for age, CMV serostatus and disease risk index. Consistent with the main analysis there were no differences in overall or non-relapse mortality risks and relapse risks were higher with BM compared to PBSC with myeloablative regimens (Table 1). Although this may in part be explained by lower chronic GVHD risks with transplantation of BM grafts, chronic GVHD was not significantly predictive of relapse risk when modeled as a time-dependent covariate (HR= 0.73, p=0.49). Grade II-IV acute GVHD risks (HR 0.45, p<0.001; 22% and 37%), adjusted for conditioning regimen were lower after transplantation of BM compared to PBSC. Chronic GVHD risks adjusted for age and performance score were also lower after transplantation of BM compared to PBSC (HR 0.35, p<0.001; 20% and 41%) but rates of moderate and severe chronic GVHD were not significantly different (28% and 32%). There were no differences in incidence of hematopoietic recovery by graft type. In conclusion, compared to BM grafts HAPLO-HCT with PBSC are associated with similar overall survival and non-relapse mortality risks but lower relapse risks with myeloablative conditioning regimens. Longer follow up is needed to ascertain whether survival differences may occur later. The observed adverse effect of BM grafts on relapse with myeloablative regimens must be studied further in the setting of carefully controlled trials. Table 1. Table 1. Disclosures Ciurea: Cyto-Sen Therapeutics: Equity Ownership; Spectrum Pharmaceuticals: Other: Advisory Board. Hamadani:Takeda: Research Funding. Soiffer:Kiadis: Membership on an entity's Board of Directors or advisory committees; Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Juno: Membership on an entity's Board of Directors or advisory committees. Wingard:Ansun: Consultancy; Gilead: Consultancy; Astellas: Consultancy; Fate Therapeutics: Consultancy; Merck: Consultancy.

scholarly journals Radical Hemithoracic Radiotherapy Induces Systemic Metabolomics Changes That Are Associated with the Clinical Outcome of Malignant Pleural Mesothelioma Patients

Cancers ◽  
2021 ◽  
Vol 13 (3) ◽  
pp. 508
Author(s):  
Emanuela Di Gregorio ◽  
Gianmaria Miolo ◽  
Asia Saorin ◽  
Elena Muraro ◽  
Michela Cangemi ◽  
...  
Keyword(s):  
Amino Acids ◽  
Overall Survival ◽  
Clinical Outcome ◽  
Malignant Pleural Mesothelioma ◽  
Therapeutic Option ◽  
Enrichment Analysis ◽  
Metabolic Effects ◽  
Pleural Mesothelioma ◽  
Polyamine Biosynthesis ◽  
The Individual

Radical hemithoracic radiotherapy (RHRT) represents an advanced therapeutic option able to improve overall survival of malignant pleural mesothelioma patients. This study aims to investigate the systemic effects of this radiotherapy modality on the serum metabolome and their potential implications in determining the individual clinical outcome. Nineteen patients undergoing RHRT at the dose of 50 Gy in 25 fractions were enrolled. Serum targeted metabolomics profiles were investigated at baseline and the end of radiotherapy by liquid chromatography and tandem mass spectrometry. Univariate and multivariate OPLS-DA analyses were applied to study the serum metabolomics changes induced by RHRT while PLS regression analysis to evaluate the association between such changes and overall survival. RHRT was found to affect almost all investigated metabolites classes, in particular, the amino acids citrulline and taurine, the C14, C18:1 and C18:2 acyl-carnitines as well as the unsaturated long chain phosphatidylcholines PC ae 42:5, PC ae 44:5 and PC ae 44:6 were significantly decreased. The enrichment analysis showed arginine metabolism and the polyamine biosynthesis as the most perturbed pathways. Moreover, specific metabolic changes encompassing the amino acids and acyl-carnitines resulted in association with the clinical outcome accounting for about 60% of the interpatients overall survival variability. This study highlighted that RHRT can induce profound systemic metabolic effects some of which may have a significant prognostic value. The integration of metabolomics in the clinical assessment of the malignant pleural mesothelioma could be useful to better identify the patients who can achieve the best benefit from the RHRT treatment.

scholarly journals Cytokine Overproduction and Immune System Dysregulation in alloHSCT and COVID-19 Patients

2021 ◽  
Vol 12 ◽  
Author(s):  
Andrzej Lange ◽  
Janusz Lange ◽  
Emilia Jaskuła
Keyword(s):  
Immune System ◽  
Adaptive Immunity ◽  
Inflammatory Cytokines ◽  
Cytokine Production ◽  
Conditioning Regimen ◽  
Laboratory Data ◽  
Hematopoietic Stem ◽  
Post Transplant ◽  
Sequence Of Events ◽  
The Impact

The COVID-19 pathomechanism depends on (i) the pathogenicity of the virus, (ii) ability of the immune system to respond to the cytopathic effect of the virus infection, (iii) co-morbidities. Inflammatory cytokine production constitutes a hallmark of COVID-19 that is facilitated by inability of adaptive immunity to control virus invasion. The effect of cytokine release syndrome is deleterious, but the severity of it depends on other confounding factors: age and comorbidities. In this study, we analyze the literature data on the post-transplant course of allogeneic hematopoietic stem cell transplanted (alloHSCT) patients, which is affected by generated inflammatory cytokines. The sequence of events boosting cytokine production was analyzed in relation to clinical and laboratory data highlighting the impact of cytokine generation on the post-transplant course. The collected data were compared to those from studies on COVID-19 patients. The similarities are: (i) the damage/pathogen-associated molecular pattern (DAMP/PAMP) stage is similar except for the initiation hit being sterile in alloHSCT (toxic damage of conditioning regimen) and viral in COVID-19; (ii) genetic host-derived factors play a role; (iii) adaptive immunity fails, DAMP signal(s) increases, over-production of cytokines occurs; (iv) monocytes lacking HLADR expression emerge, being suppressor cells hampering adaptive immunity; (v) immune system homeostasis is broken, the patient’s status deteriorates to bed dependency, leading to hypo-oxygenation and malnutrition, which in turn stimulates the intracellular alert pathways with vigorous transcription of cytokine genes. All starts with the interaction between DAMPs with appropriate receptors, which leads to the production of pro-inflammatory cytokines, the inflammatory process spreads, tissue is damaged, DAMPs are released and a vicious cycle occurs. Attempts to modify intracellular signaling pathways in patients with post-alloHSCT graft vs host disease have already been undertaken. The similarities documented in this study show that this approach may also be used in COVID-19 patients for tuning signal transduction processes to interrupt the cycle that powers the cytokine overproduction.

scholarly journals Absolute Lymphocyte Count (ALC) Less Than 100 Predicts Adverse Transplant Outcomes with Rabbit Thymoglobulin in Patients Undergoing Matched Unrelated Allogeneic Hematopoietic Stem Cell Transplantation

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4527-4527
Author(s):  
Dipenkumar Modi ◽  
Malini Surapaneni ◽  
Seongho Kim ◽  
Lois Ayash ◽  
Asif Alavi ◽  
...  
Keyword(s):  
T Cell ◽  
Relapse Rate ◽  
Peripheral Blood ◽  
Conditioning Regimen ◽  
Advisory Board ◽  
Hematopoietic Stem ◽  
Post Transplant ◽  
Transplant Outcomes ◽  
Gvhd Prophylaxis

Introduction: Rabbit thymoglobulin, an in-vivo T-cell depleting agent, is widely used as a part of GVHD prophylaxis regimen. Current dosing of thymoglobulin is often weight based and does not consider patient related factors. This results in highly variable exposure of thymoglobulin. Although higher doses (>7mg/kg) of thymoglobulin have shown to reduce the risk of GVHD, it is associated with increased rate of opportunistic infections and disease recurrence. Conversely, lower dose (2.5mg/kg) of thymoglobulin is associated with increased risk of GVHD. Thus, optimum dosing of thymoglobulin remains undefined. We hypothesized that recipient peripheral blood ALC on the first day of thymoglobulin infusion would interact with the dose of thymoglobulin administered and predict post-transplant outcomes. We plan to identify association of thymoglobulin dose with the ALC on the first day of thymoglobulin. Methods: We retrospectively evaluated clinical outcomes of adult patients (pts) who underwent matched unrelated donor AHSCT and received tacrolimus, mycophenolate (cellcept) and thymoglobulin as GVHD prophylaxis. Thymoglobulin was given at a total dose of 4.5mg/kg in divided fashion (0.5mg/kg on day -3, 1.5mg/kg on day -2 and 2.5mg/kg on day -1). The objectives were to determine rate of GVHD, overall survival (OS), relapse-free survival (RFS), relapse rate and non-relapse mortality (NRM) following AHSCT using Cox proportional hazard regression and competing risk models. Results: Between January 2005 and December 2017, 217 pts underwent AHSCT. The most common indications for AHSCT were AML (n=95, 44%), MDS (n=57, 26%), non-Hodgkin's lymphoma (n=23, 11%), and ALL (n=22, 10%). Median age of pts was 60 years (range, 18-79). All pts received peripheral blood stem cells. Ninety-eight pts (45%) received full intensity conditioning regimen and 119 pts (55%) received reduced intensity regimen. The median ALC on the first day of thymoglobulin administration was 200 K/cubic millimeter. The 6-month cumulative incidence rate (CIR) of grade III-IV acute GVHD was 14.8% and the 2-year CIR of chronic extensive GVHD was 35.4%. With a median follow up of 3.82 years for surviving patients, the 2-year RFS, OS, relapse and NRM were 50%, 57.1, 20.1%, and 30.2%, respectively. CMV and EBV reactivation rates were 37% and 11%, respectively. Four pts developed CMV disease. By our lowest ALC cutoff of 100 K/cubic millimeter, pts were divided into two groups (ALC ≤ 100 vs. ALC > 100). Multivariable analysis revealed that ALC > 100 was associated with significantly superior OS (HR 0.51, 95% CI 0.33-0.79, p=0.002), RFS (HR 0.49, 95% CI 0.33-0.74, p=0.001) and lower NRM (SHR 0.57, 95% CI 0.34-0.97, p=0.038) and marginally lower relapse rate (SHR 0.57, 95% CI 0.31-1.05, p=0.070). In addition, higher infused total nucleated cells was associated with higher NRM (SHR 1.70, 95% CI 1.02-2.83, p=0.041). No impact of disease risk index, KPS, conditioning regimen, infused CD34 cells on NRM, relapse, RFS or OS was observed. Conclusion: Our study indicates that ALC ≤ 100 is associated with adverse post-transplant outcomes when thymoglobulin dose of 4.5mg/kg is used for in-vivo T cell depletion. This finding may indicate that in pts with lower ALC, thymoglobulin dose may need to be adjusted to optimize its efficacy and avoid toxicities. In the future prospective studies, which evaluate dose reduction of thymoglobulin in pts with low ALC need to be planned to confirm these results. Disclosures Deol: Agios: Other: Advisory board; Novartis: Other: Advisory board; Kite: Other: Advisory board.

scholarly journals Early Immune Reconstitution after Haplo-Identical Hematopoietic Stem Cell Transplantation (HCT) with Post-Transplant Cyclophosphamide (PTCY) Does Not Improve Overall Survival Compared to Matched Unrelated Donor HCT Recipients Receiving Thymoglobulin Prophylaxis (ATG)

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 5676-5676
Author(s):  
Yasser Khaled ◽  
Joshua Boss ◽  
Poojitha Valasareddy ◽  
Arnel Pallera ◽  
Robert Johnson ◽  
...  
Keyword(s):  
Cell Proliferation ◽  
Overall Survival ◽  
T Cell ◽  
Graft Failure ◽  
Immune Reconstitution ◽  
T Cell Proliferation ◽  
First Year ◽  
Post Transplant ◽  
Allogeneic Hct ◽  
Primary Graft Failure

Recent retrospective studies demonstrated similar overall survival (OS) and relapse rate after allogeneic HCT using matched unrelated or haplo-identical donors. However, differences in graft versus host disease (GVHD) prevention protocols using ATG or PTCY may have influenced the results. In addition, there is little knowledge about immune reconstitution after PTCY compared to ATG. We examined the outcomes of 73 consecutive patients who received allogeneic HCT from 5/2015 to 4/2019 (39 Haplo, 34 MUD). Patient's Characteristics shown in table-1. The two groups matched except for donor age, CD34 dose infused and race. Conditioning regimens shown in table-1. MUD recipients received GVHD prophylaxis with Tacrolimus/ Mycophenolate (Tacro/MMF) in addition to ATG (24 Patients) or PTCY (10 Patients) while Haploidentical patient received Tacro/MMF with PTCY. A panel of immune reconstitution markers collected at day 100 post- transplant for CD3, CD4, CD8, Activated T cell ( HLA- DR3+ CD3+)and NK cells ( CD56+) was obtained for 29 MUD and 28 Haploidentical recipients. We observed pronounced proliferation and recovery in all T cell subsets in Haploidentical patients compared to MUD patients at day 100 as shown in Fig-1. This robust T cell recovery in Haploidentical transplant patients with PTCY was statistically significant for CD3, CD4 and CD8. When Immune reconstitution for Haploidentical patients compared to MUD patients who received PTCY, it maintained its robust effect on T cell proliferation (Fig-2) although it did not reach statistical significance. The overall survival at one-year with median duration of follow up of 22.6 months was 61.5% and 82.3% for Haploidentical and MUD recipients respectively; P=0.14. There were 15 deaths during the first year in the Haploidentical patients (3 = relapse, 5 = severe cytokine release syndrome (CRS), 1=Veno-occlusive disease, 3= infection, 2=GVHD and 1 = primary graft failure). In contrast there were only six deaths in MUD patients (2= relapse, 3= GVHD and 1= infection). There was no deaths in MUD PTCY patients in the first year. There was no primary graft failure in either arm, however secondary graft failure occurred in 2 Haploidentical and 1 MUD patients. Median time to engraftment was 18 days for Haploidentical (range, 12-57) and 11.6 days for MUD (range, 10-18). Acute GVHD grade 2-4 developed in 35% in MUD and 23% in Haploidentical patients. Conclusions: We found robust early immune recovery after Haploidentical HCT compared to MUD HCT. The degree of HLA mismatch with Haploidentical HCT and antigen presentation may have contributed to pronounced T cell proliferation as the same effects was not observed in MUD HCT with PTCY. Despite the early recovery of T cells after Haploidentical HCT the overall survival did not exceed the overall survival with MUD HCT. Severe CRS contributed to the increased mortality seen in Haploidentical HCT patients. Further strategies are needed to decrease treatment related mortality with Haploidentical HCT. Disclosures No relevant conflicts of interest to declare.

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