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Post-transplantation cyclophosphamide combined with tacrolimus and low-dose post-engraftment anti-thymoglobulin as GVHD prophylaxis for patients undergoing peripheral blood stem cell transplantation from haploidentical family donor: A single center analysis
Gao, W. H., Zhu, J. Y., Wang, L. N., Wan, M., Wang, L., Devillier, R., Jiang, J. L., Blaise, D., Hu, J.
Frontiers in medicine. 2023;10:1140217
Abstract
INTRODUCTION Post-transplantation cyclophosphamide (PT-Cy) use is a recent graft-versus-host disease (GVHD) prophylaxis strategy for patients undergoing allogeneic stem cell transplantation (allo-HSCT). PT-Cy combined with two immunosuppressants is now widely used after haplo-identical (haplo) and HLA-matched peripheral blood stem cell (PBSC) transplantations with promising GVHD and relapsefree survival (GRFS) probabilities. Although appealing, these results may benefit from improvement notably outside matched sibling donor transplantation, and should be investigated in various ethnic populations. METHODS Therefore, we report our experience of GVHD prophylaxis regimen combining PT-Cy and tacrolimus with addition of post-engraftment low-dose anti-thymocyte globulin (ATG) in allogeneic stem cell transplantation from haplo-identical donors (Haplo). Sixtyseven patients were included in the analysis. All patients received myeloablative or intensified sequential conditioning regimen. RESULTS The median follow-up was 521 (range, 10~991) days. The cumulative incidences of 100-day grade II-IV acute GVHD was 14.9±4.4%, and no case of grade III-IV acute GVHD was documented. The cumulative incidences of 2-yearchronic GVHD and moderate-to-severe chronic GVHD were 25.4±5.4% and 11.9±4%, respectively. The non-relapse mortality at day+100 and 2year were 7.5±3.2% and 9.0±3.5%, respectively. The cumulative incidence of relapse at 2year was 16±6.4%. The 2-year probability of DFS and OS were 73.8% (95%CI, 61.5~88.4%) and 72.5% (95% CI, 57.1~92.1%), respectively. The 2-year GRFS was estimated as 63.6% (95%CI, 50.6~80%). DISCUSSION Our results suggested that a combination of PT-Cy, tacrolimus, and low-dose post-engraftment ATG was a promising GVHD prophylaxis with low incidence of acute GVHD in the haplo-transplantation setting.
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The association of graft-versus-leukemia effect and graft-versus host disease in haploidentical transplantation with post-transplant cyclophosphamide for AML
Shimoni, A., Labopin, M., Angelucci, E., Blaise, D., Ciceri, F., Koc, Y., Gülbas, Z., Diez-Martin, J. L., Bruno, B., Castagna, L., et al
Bone marrow transplantation. 2022
Abstract
The association of graft-versus-host disease (GVHD) and graft-versus-leukemia effect after stem-cell transplantation (SCT) is well established but with limited data in the setting of haploidentical SCT (haploSCT) with post-transplant cyclophosphamide (PTCy). We used a series of landmark analyses to investigate this association in 805 AML patients following haploSCT. On day +100, 707 patients were alive and leukemia-free, 500 had no prior acute GVHD, 137 had acute GVHD grade II and 70 had grade III-IV. Subsequent relapse rates were 20.3%, 23.2% and 15.0%, respectively (P = 0.52). Subsequent non-relapse mortality (NRM) was 8.6%, 17.8% and 38.6%, respectively (P < 0.0001). Leukemia-free survival (LFS) was 71.0%, 59.0% and 46.3%, respectively (P < 0.0001). Multivariate analysis showed that acute GVHD grade II and grade III-IV were not associated with relapse (HR 1.21, P = 0.37 and HR 1.03, P = 0.94), but were associated with increased NRM (HR 2.09, P = 0.005 and HR 6.41, P < 0.0001) and lower LFS (HR 1.47, P = 0.02 and HR 2.59, P = < 0.0001). Chronic GVHD was not associated with subsequent relapse. Extensive chronic GVHD was associated with higher NRM (HR 6.72, P < 0.0001) and inferior LFS (HR 3.29, P = < 0.0001). GVHD of any type or grade is not associated with lower relapse after haploSCT with PTCy. Severe forms are associated with higher NRM and lower survival.
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Association of Country-Specific Socioeconomic Factors With Survival of Patients Who Experience Severe Classic Acute Graft-vs.-Host Disease After Allogeneic Hematopoietic Cell Transplantation. An Analysis From the Transplant Complications Working Party of the EBMT
Frankiewicz, A., Peczynski, C., Giebel, S., Harrington, A., Socié, G., Niederwieser, D., Scheid, C., Bornhäuser, M., Kröger, N., Elmaagacli, A., et al
Frontiers in immunology. 2020;11:1537
Abstract
Acute graft-vs.-host disease (aGvHD) is one of the most frequent causes of transplant-related mortality (TRM) after allogeneic hematopoietic cell transplantation (alloHCT). Its treatment is complex and costly. The aim of this study was to retrospectively analyze the impact of country-specific socioeconomic factors on outcome of patients who experience severe aGvHD. Adults with hematological malignancies receiving alloHCT from either HLA-matched siblings (n = 1,328) or unrelated donors (n = 2,824) developing grade 3 or 4 aGvHD were included. In univariate analysis, the probability of TRM at 2 years was increased for countries with lower current Health Care Expenditure (HCE, p = 0.04), lower HCE as % of Gross Domestic Product per capita (p = 0.003) and lower values of the Human Development Index (p = 0.02). In a multivariate model, the risk of TRM was most strongly predicted by current HCE (HR = 0.76, p = 0.006). HCE >median was also associated with reduced risk of the overall mortality (HR 0.73, p = 0.0006) and reduced risk of treatment failure (either relapse or TRM; HR 0.77, p = 0.004). We conclude that country-specific socioeconomic factors, in particular current HCE, are strongly associated with survival of patients who experience severe aGvHD.
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The new refined minnesota risk score for acute graft-versus-host disease predicts overall survival and non-relapse mortality after T cell-replete haploidentical stem cell transplant with post-transplant cyclophosphamide
Mariotti, J., Granata, A., Bramanti, S., Devillier, R., Furst, S., Sarina, B., Harbi, S., Legrand, F., Faucher, C., Weiller, P. J., et al
Bone marrow transplantation. 2019
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Editor's Choice
Abstract
We propose to test whether the new refined Minnesota risk score, which represents a new tool for acute Graft-versus-Host-Disease (aGVHD) grading, may be useful to predict the final outcome of patients with aGVHD after haploidentical stem cell transplantation (Haplo-SCT) with post-transplant cyclophosphamide (PT-Cy). Hundred consecutive patients with grade 2-4 aGVHD were included. Twenty-two percent of the patients had high-risk (HR) aGVHD and had a lower chance to respond at day 28: 41% of non-responders (NR) were in the HR vs 13% in the standard-risk (SR) group (p = 0.003). By multivariate analysis, grade 3-4 aGVHD according to the traditional Keystone classification was the main independent predictor of non-response to front-line treatment at day 28, while HR aGVHD by the new refined Minnesota score remained the main independent variable associated with adverse NRM and OS. The new Minnesota refined risk score is a useful tool to predict the outcome of patients with aGVHD after Haplo-SCT with PT-Cy. Due to the few patients exchanging between categories in the two classifications, it is not possible to discriminate which system better predicts the outcome of patients with aGVHD in the setting of Haplo-SCT. Extending these preliminary observations to a larger cohort is warranted.
PICO Summary
Population
100 patients with grade 2-4 aGvHD after haploidentical stem cell transplantation with post-transplant cyclophosphamide.
Intervention
Use of refined Minnesota risk score for aGvHD grading
Comparison
Keystone classification
Outcome
Grade 3-4 aGVHD according to the traditional Keystone classification was the main independent predictor of non-response to front-line treatment at day 28, while HR aGVHD by the new refined Minnesota score remained the main independent variable associated with adverse NRM and OS. It is not possible with this sample size to discriminate which system better predicts the outcome of patients with aGVHD in the setting of Haplo-SCT.
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Low incidence of chronic GVHD after HLA-haploidentical peripheral blood stem cell transplantation with post-transplantation cyclophosphamide in older patients
Devillier, R., Granata, A., Furst, S., Harbi, S., Faucher, C., Weiller, P. J., Chabannon, C., Castagna, L., Blaise, D.
British Journal of Haematology. 2017;176(1):132-135
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Rituximab-based first line treatment for chronic GVHD after allogeneic SCT: results of a phase 2 study
Malard, F., Labopin, M., Yakoub-Agha, I., Chantepie, S., Guillaume, T., Blaise, D., Tabrizi, R., Magro, L., Vanhove, B., Blancho, G., et al
Blood. 2017
Abstract
Chronic graft-versus-host disease (cGVHD) is the main cause of late non-relapse mortality and morbidity after allogeneic stem-cell transplantation (allo-SCT). In order to improve such patients' outcome, we conducted a phase 2, prospective, multicenter trial to test the efficacy of addition of rituximab to corticosteroid and cyclosporine A as first line therapy for newly diagnosed cGVHD after allo-SCT. Twenty-four patients (median age, 47 years) with mild (n=2), moderate (n=7) or severe (n=15) cGVHD were included. All patients received rituximab 375 mg/m2 weekly for 4 weeks, followed in patients with partial response by a second course 1 month later. Twenty of 24 patients (83%) were in response at one year. Furthermore, among 19 evaluable patients, 14 (74%) were off corticosteroids. The estimated one-year overall survival was 83% and the one-year cumulative incidence of non-relapse mortality was 14%. One patient died from progressive multifocal leukoencephalopathy. While PD-L1hi naive B cells were significantly decreased at diagnosis of cGVHD, they increased after anti-CD20 B cell depletion. In contrast, activated ICOShi PD-1hi circulating follicular helper T cells decreased after rituximab treatment. Overall, addition of rituximab to corticosteroid and cyclosporine A appeared to be safe and effective for first line treatment of cGVHD. Furthermore, our data suggest that this efficacy may be, in part, related to an effect on PD-L1hi B cells and follicular helper T cell. This study was registered at www.clinicaltrials.gov, identifier number: NCT01135641. Copyright © 2017 American Society of Hematology.