Outcomes of Autologous Stem Cell Transplant Consolidation in Primary CNS Lymphoma: A Mayo Clinic Experience
Biology of blood and marrow transplantation : journal of the American Society for Blood and Marrow Transplantation. 2020
A paucity of randomized phase 3 clinical trials in primary central nervous system lymphoma (PCNSL) has resulted in no uniform consensus on the optimal strategy for consolidation and conditioning regimens for autologous stem cell transplant (ASCT). The last two decades have witnessed a preference for thiotepa-based conditioning regimens due to superior CNS penetration. We retrospectively evaluated outcomes of PCNSL patients who underwent ASCT at Mayo Clinic, Rochester over the last two decades, and the impact of thiotepa (TT) based conditioning regimens. Fifty-six patients underwent transplant for PCNS lymphoma, with 25 and 31 patients receiving BEAM (non-thiotepa) and BCNU/TT based conditioning, respectively. All patients received high-dose methotrexate based induction therapy. While the BCNU/TT group had higher risk disease features such as high International Extranodal Lymphoma Study Group (IELSG) prognostic score, elevated CSF protein and older patient population, there was no significant difference at 2 years post-transplant in PFS (BEAM 68.0% [46.1-82.5] vs. BCNU/TT, 65.5% [45.2-79.8], (p?=?0.99)), or OS (84.0% [62.8-93.7] in the BEAM group vs. 81.6% [61.3-91.9] in the BCNU/TT group, (p?=?0.95)). Disease response status before transplant significantly impacted the outcomes as those in complete remission(CR) had an OS at 2 years post-transplant of 94.7% (68.1-99.2) in BEAM group and 90.5% (67.0-97.5) in BCNU/TT group as compared to those in partial response (PR), 57.1% (17.2-83.7) in BCNU/TT group, and 50.0% (11.1-80.4) in the BEAM group, respectively (p <0.0001). Our retrospective cohort adds to the currently available literature and identifies the disease status before transplant as a significant factor impacting survival.
Characteristics of late transplant-associated thrombotic microangiopathy (TA-TMA) in patients who underwent allogeneic hematopoietic stem cell transplantation
American journal of hematology. 2020
Maintenance Therapies for Hodgkin and Non-Hodgkin Lymphomas After Autologous Transplantation: A Consensus Project of ASBMT, CIBMTR, and the Lymphoma Working Party of EBMT
JAMA oncology. 2019
Importance: Maintenance therapies are often considered as a therapeutic strategy in patients with lymphoma following autologous hematopoietic cell transplantation (auto-HCT) to mitigate the risk of disease relapse. With an evolving therapeutic landscape, where novel drugs are moving earlier in therapy lines, evidence relevant to contemporary practice is increasingly limited. The American Society for Blood and Marrow Transplantation (ASBMT), Center for International Blood and Marrow Transplant Research (CIBMTR), and European Society for Blood and Marrow Transplantation (EBMT) jointly convened an expert panel with diverse expertise and geographical representation to formulate consensus recommendations regarding the use of maintenance and/or consolidation therapies after auto-HCT in patients with lymphoma. Observations: The RAND-modified Delphi method was used to generate consensus statements where at least 75% vote in favor of a recommendation was considered as consensus. The process included 3 online surveys moderated by an independent methodological expert to ensure anonymity and an in-person meeting. The panel recommended restricting the histologic categories covered in this project to Hodgkin lymphoma (HL), mantle cell lymphoma (MCL), diffuse large B-cell lymphoma (DLBCL), and follicular lymphoma. On completion of the voting process, the panel generated 22 consensus statements regarding post auto-HCT maintenance and/or consolidation therapies. The grade A recommendations included endorsement of: (1) brentuximab vedotin (BV) maintenance and/or consolidation in BV-naive high-risk HL, (2) rituximab maintenance in MCL undergoing auto-HCT after first-line therapy, (3) rituximab maintenance in rituximab-naive FL, and (4) No post auto-HCT maintenance was recommended in DLBCL. The panel also developed consensus statements for important real-world clinical scenarios, where randomized data are lacking to guide clinical practice. Conclusions and Relevance: In the absence of contemporary evidence-based data, the panel found RAND-modified Delphi methodology effective in providing a rigorous framework for developing consensus recommendations for post auto-HCT maintenance and/or consolidation therapies in lymphoma.
Survival Outcomes of Younger Patients With Mantle Cell Lymphoma Treated in the Rituximab Era
Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2019;:Jco1800690
PURPOSE Mantle cell lymphoma (MCL) is a B-cell lymphoma characterized by cyclin D1 expression. Autologous hematopoietic cell transplantation (AHCT) consolidation after induction chemotherapy is often used for eligible patients; however, the benefit remains uncertain in the rituximab era. Herein we retrospectively assessed the impact of AHCT consolidation on survival in a large cohort of transplantation-eligible patients age 65 years or younger. PATIENTS AND METHODS We retrospectively studied transplantation-eligible adults age 65 years or younger with newly diagnosed MCL treated between 2000 and 2015. The primary objective was to assess for improved progression-free survival (PFS) with AHCT consolidation and secondarily to assess for improved overall survival (OS). Cox multivariable regression analysis and propensity score-weighted (PSW) analysis were performed. RESULTS Data were collected from 25 medical centers for 1,254 patients; 1,029 met inclusion criteria. Median follow-up for the cohort was 76 months. Median PFS and OS were 62 and 139 months, respectively. On unadjusted analysis, AHCT was associated with improved PFS (75 v 44 months with v without AHCT, respectively; P < .01) and OS (147 v 115 months with v without AHCT, respectively; P < .05). On multivariable regression analysis, AHCT was associated with improved PFS (hazard ratio [HR], 0.54; 95% CI, 0.44 to 0.66; P < .01) and a trend toward improved OS (HR, 0.77; 95% CI, 0.59 to 1.01; P = .06). After PSW analysis, AHCT remained associated with improved PFS (HR, 0.70; 95% CI, 0.59 to 0.84; P < .05) but not improved OS (HR, 0.87; 95% CI, 0.69 to 1.1; P = .2). CONCLUSION In this large cohort of younger, transplantation-eligible patients with MCL, AHCT consolidation after induction was associated with significantly improved PFS but not OS after PSW analysis. Within the limitations of a retrospective analysis, our findings suggest that in younger, fit patients, AHCT consolidation may improve PFS.
Autograft immune content and survival in non-Hodgkin's lymphoma: A post hoc analysis
Leukemia research. 2019;81:1-9
The infusion of autograft absolute lymphocyte and monocyte counts affect survival in patients undergoing autologous peripheral hematopoietic stem cell transplantation (APHSCT). However, the specific autograft immune effector cells affecting survival post-APHSCT are unknown. Thus, we performed an ad hoc analysis from our published double-blind, randomized phase III clinical trial in non-Hodgkin's lymphoma (NHL) patients, looking at the infused autograft immune effector cells and their relationship with clinical outcomes post-APHSCT. Between December 2007 and October 2010, we performed a double-blind phase III randomized study registered with ClinicalTrials.gov, number NCT00566228. A total of 111 patients finished the trial and apheresis collection samples were analyzed for immune effector cells. Overall survival (OS) and progression-free survival (PFS) were calculated from the date of APHSCT. With a median follow-up of 82.8 months (range: 2.1-122.3 months), we identified by univariate analysis that the autograft numbers of macrophage type 1 (M 1), macrophage type 2 (M 2), dendritic cell type 1 (DC 1), dendritic cell type 2 (DC 2), myeloid-derived suppressor cells (MDSC), CD4+PD-1-, CD4+PD-1+, CD8+PD-1-, CD8+PD-1+, lymphocyte to monocyte ratio (A-LMR), NKp30, and KIR2DL2, were predictors for OS and PFS. Multivariate analysis revealed that A-LMR, MDSC, NKp30, KIR2DL2 and lactate dehydrogenase were independent predictors for OS. Independent predictors for PFS identified by multivariate analysis included DC1, MDSC, NKp30, CD4+PD-1- and M 2. Our findings indicate that the number of specific infused autograft immune effector cells affect survival ; thus providing a platform to develop an immunocompetent autograft with direct impact on clinical outcomes in NHL post-APHSCT.
A phase 1 trial of <sup>90</sup>Y-Zevalin radioimmunotherapy with autologous stem cell transplant for multiple myeloma
Bone Marrow Transplantation. 2017;52(10):1372-1377
This phase 1 study (clinical trial NCT00477815) was conducted to determine the maximum tolerated dose (MTD) of yttrium-90 ibritumomab tiuxetan (90Y-Zevalin) with high dose melphalan (HDM) therapy in multiple myeloma (MM) patients undergoing autologous stem cell transplantation (ASCT). In a 3+3 trial design, 30 patients received rituximab 250mg/m2 with indium-111 ibritumomab tiuxetan (111In-Zevalin) for dosimetry (day -22); rituximab 250mg/m2 with escalating doses of 90Y-Zevalin (day -14); melphalan 100mg/m2 (days -2,-1) followed by ASCT (day 0) and sargramostim (GM-CSF, day 0) until neutrophil engraftment. Each patient's 111In-Zevalin dosimetry data were used to calculate the dose of 90Y-Zevalin (in mCi) to deliver 10, 12, 14, 16, 18 or 20Gy to the liver. Dose limiting toxicities were seen in 3 patients. The overall response rate was 73% (22/30) with stringent complete response in 2 patients; complete response, 5; very good partial response, 12; and partial response, 3. The median PFS was 16.5 months and the median overall survival was 63.4 months. In MM, the MTD of 90Y-Zevalin with HDM is 18Gy to the liver. The addition of radiation with novel delivery methods such as radioimmunotherapy combined with standard transplant regimens warrants further study.
Infusion of autograft natural killer cell/CD14<sup>+</sup>HLA-DR<sup>DIM</sup> cell ratio predicts survival in lymphoma post autologous stem cell transplantation
Bone Marrow Transplantation. 2017
The infusion of autograft absolute lymphocyte count (A-ALC) and autograft natural killer cells (A-NKC) are prognostic factors for overall survival (OS) and PFS in non-Hodgkin's lymphoma (NHL) patients undergoing autologous peripheral blood hematopoietic stem cell transplantation (APBHSCT). The human monocytic CD14+HLA-DRDIM cells are associated with worse prognosis in NHL. Thus, we investigated whether the autograft A-NKC/A-CD14+HLA-DRDIM ratio predicts survival in NHL. In a total of 111 NHL patients, we analyzed apheresis collection samples for the content of A-NKC and A-CD14+HLA-DRDIM. With a median follow-up of 57.2 months (range: 2.1-84.6 months), patients with an A-NKC/A-CD14+HLA-DRDIM ratio of 0.29 experienced superior OS (5-year OS rates of 84% (95% confidence interval (CI), 72-91%) vs 48% (95% CI, 34-62%), P<0.0002, respectively) and PFS (5-year PFS rates of 59% (95% CI, 47-71%) vs 32% (95% CI, 20-48%), P<0.002, respectively). Multivariate analysis revealed that A-NKC/A-CD14+HLA-DRDIM ratio was an independent predictor for PFS (hazard ratio (HR)=0.56, 95% CI, 0.32-0.96, P<0.03) and OS (HR=0.34, 95% CI, 0.16-0.68, P<0.002). The A-NKC/A-CD14+HLA-DRDIM ratio provides a platform to target specific autograft immune effector cells to improve clinical outcomes in NHL patients undergoing APBHSCT.Bone Marrow Transplantation advance online publication, 16 October 2017; doi:10.1038/bmt.2017.225.
Immunologic Autograft Engineering and Survival in Non-Hodgkin Lymphoma
Biology of Blood & Marrow Transplantation. 2016;22(6):1017-23
Retrospective studies have reported that the collected and infused autograft absolute lymphocyte count (A-ALC) affects clinical outcomes after autologous peripheral hematopoietic stem cell transplantation (APHSCT). We hypothesized that manipulation of the apheresis machine to target a higher A-ALC dose would translate into prolonged progression-free survival (PFS) in patients with non-Hodgkin lymphoma (NHL) undergoing APHSCT. Between December 2007 and October 2010, we performed a double-blind, phase III, randomized study randomly assigning 122 patients with NHL to undergo collection with the Fenwal Amicus Apheresis system with our standard settings (mononuclear cells offset of 1.5 and RBC offset of 5.0) or at modified settings (mononuclear cells offset of 1.5 and RBC of 6.0). The primary endpoint was PFS. Neither PFS (hazard ratio [HR] of modified to standard, 1.13; 95% confidence interval [CI], .62 to 2.08; P = .70) nor overall survival (OS) (HR modified to standard, .85; 95% CI, .39 to 1.86; P = .68) were found to differ by collection method. Collection of A-ALC between both methods was similar. Both PFS (P = .0025; HR, 2.77; 95% CI, 1.39 to 5.52) and OS (P = .004; HR, 3.38; 95% CI, 1.27 to 9.01) were inferior in patients infused with an A-ALC < .5 x 10(9) lymphocytes/kg compared with patients infused with an A-ALC > .5 x 10(9) lymphocytes/kg, regardless of the method of collection. We did not detect significant differences in clinical outcomes or in the A-ALC collection between the modified and the standard Fenwal Amicus settings; however, despite physician discretion on primary number of collections and range of cells infused, higher A-ALC infused dose were associated with better survival after APHSCT. Copyright © 2016 The American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.