Development Of Chronic Graft-versus-host Disease Research Articles

Vascular biomarkers reveal a unique toxicity profile of posttransplant cyclophosphamide: secondary analysis of BMT CTN 0402 and 1202

AbstractPosttransplant cyclophosphamide (PTCy)–based graft-versus-host disease (GVHD) prophylaxis regimens are associated with very low rates of severe acute and chronic GVHD after hematopoietic cell transplant (HCT). However, concerns about cardiac and other organ toxicities persist. This study aimed to compare the vascular biomarker profile of PTCy with other GVHD regimens, including tacrolimus/sirolimus (Tac/Sir) and tacrolimus/methotrexate (Tac/MTX), to generate hypotheses for toxicity mitigation strategies. Plasma samples from day +28 after transplant were analyzed against pretransplant baseline measurements in patients receiving PTCy-based GVHD prophylaxis as part of Blood and Marrow Transplant Clinical Trials Network (BMT CTN) 1202 (n = 112) vs Tac/MTX (n = 98) and Tac/Sir (n = 95) regimens from BMT CTN 0402. Compared with Tac/MTX, PTCy was associated with increasing angiopoietin-2 levels and decreasing epidermal growth factor levels at day +28. In contrast, Tac/Sir displayed increasing follistatin and endoglin levels and decreasing vascular endothelial growth factor receptor 2 (VEGFR2) plasma levels after HCT. Across all cohorts, increasing epidermal growth factor was protective from nonrelapse mortality, and decreasing VEGFR2 was associated with subsequent development of extensive chronic GVHD. These distinct biomarker profiles offer insights that could guide strategies to mitigate unique GVHD prophylaxis–associated toxicities.

Impact of Graft-Versus-Host Disease on Relapse and Nonrelapse Mortality Following Posttransplant Cyclophosphamide-Based Transplantation

Following conventional graft-versus-host disease (GVHD) prophylaxis, the development of acute and/or chronic GVHD is associated with lower relapse rates. However, the effects of GVHD on relapse and non-relapse mortality following post-transplant cyclophosphamide (PTCy)-based GVHD prophylaxis have not been well studied. To this end, we analyzed the impact of acute and chronic GVHD following PTCy-based haploidentical donor transplantation (HIDT). The analysis included 335 consecutive HIDT recipients transplanted at a single institution between 2005 and 2021. Landmark analysis (LA) and time-dependent multivariable analysis (MVA) were utilized to study the impact of GVHD development on transplant outcome. Landmarks were defined as Day +100 for acute GVHD and one-year for chronic GVHD. Recipient characteristics included a median age of 50 (19-80) years, most commonly transplanted for acute leukemia[/MDS [242]. PBSC was the graft source in 81%, and regimen intensity was myeloablative in 49%. Median follow-up was 65 (23-207) months. In landmark analysis, development of grade 3 to 4 acute GVHD (versus 0-1) was associated with inferior 3-year overall survival (OS 47% versus 64%, P = .041), due to higher NRM (25% versus 10%, P = .013). In contrast, development of grade 2 acute GVHD had no significant effect on NRM or survival. When restricted to acute leukemia/MDS patients, development of grade II acute GVHD was associated with improved OS (79% versus 58%, P = .027) and a trend towards lower relapse (24% versus 36%, P = .08). Development of moderate-to-severe chronic GVHD resulted in significantly higher NRM (15% versus 4%, P = .010), but had no impact on relapse, DFS or OS. In Cox multivariate analysis (MVA), grade 3 to 4 acute GVHD and moderate-to-severe chronic GVHD were both associated with significantly higher NRM (HR 3.38, P < .001 and HR3.35, P < .001, respectively). In addition, grade 3 to 4 acute GVHD predicted worse OS (HR 1.80, P = .007) and DFS (HR 1.55, P = .041). In contrast, relapse was not impacted by acute or chronic GVHD in MVA. Grade 2 acute GVHD was not associated with transplant outcome in MVA. In summary, both grade 3 to 4 acute and moderate-to-severe chronic GVHD were associated with higher NRM after PTCy-based HIDT, without an effect on relapse risk. Methods of early identification of such patients in order to augment GVHD prophylaxis are clearly needed.

Feasibility and safety of the discontinuation of systemic immunosuppressive treatment after single-unit cord blood transplantation in adults

We retrospectively evaluated the incidence, factors, and clinical outcomes of the discontinuation of immunosuppressive treatment (IST) after single-unit unrelated cord blood transplantation (CBT) in adults receiving cyclosporine-based graft-versus-host disease (GVHD) prophylaxis at our institute. Among the 309 patients who achieved engraftment, 247 were able to discontinue IST with a median follow-up of 121 months for survivors. The cumulative incidence of the discontinuation of IST was 46.2% at 180 days, 72.8% at 2 years, and 79.3% at 5 years post-CBT. In the multivariate analysis, discontinuation of IST after CBT was significantly associated with the requirement for steroid therapy (hazard ratio [HR]: 0.46; P < 0.001) and the recent calendar year of CBT (HR: 1.79; P < 0.001). In the conditional landmark analysis at 180 days, discontinuation of IST was not associated with the development of extensive chronic GVHD (HR: 1.00; P = 0.989), non-relapse mortality (HR: 0.49; P = 0.122), relapse (HR: 1.46; P = 0.388), or overall survival (HR: 1.91; P = 0.065). Our data showed that successful discontinuation of IST is common after single-unit CBT in adults. Discontinuation of IST did not affect subsequent outcomes, suggesting that discontinuation of IST is both feasible and safe in adults undergoing single-unit CBT.

Ocular surface expression of inflammatory cytokines in GvHD and their association with disease development and clinical manifestations

The aim of this study was to investigate the tear cytokine profiles of patients with chronic ocular graft versus host disease (GvHD) and evaluate their association with clinical disease severity. Consecutive patients attending the Haematology clinic with a known or suspected diagnosis of chronic ocular GvHD were invited to participate. To be included, patients had to fulfil either or both of the National Institute of Health (NIH) or the International Chronic Ocular Graft‐vs‐Host‐Disease Consensus Group (ICCGvHD) diagnostic criteria.Clinical parameters recorded included best correct visual acuity (BCVA), Schirmers I test, tear break up time (TBUT), and Oxford surface staining (OSS) along with the overall grading of ocular GvHD severity as defined by the ICCGvHD. Ocular tear samples were collected and levels of cytokine production (IFN‐γ, IL‐1β, IL‐2, Il‐4, IL‐6, IL‐8, IL‐10, IL‐12p70, IL‐13, and TNF‐ α) were assayed using Meso Scale Discovery (MSD) multi‐array technology. The results were compared to those of healthy matched controls using unpaired t test. Results were correlated with clinical parameters using Pearson r correlation.Thirteen patients took part in the study (8 male, 61.5%; 5 female, 38.5%) with an average age of 43.9 years (±13.4). With regards to ocular examinations, patients were found to be heavily dependent on lubricant eye drops (average 8.5 times/day). Patients suffered from both aqueous deficient and evaporative DED with an average Schirmer's measurement of 4.2 mm (±5.7, range of 0–21) and average TBUT of 3.8 s (±1.3, range 1–6). The average Oxford surface staining score was 7.9 (±4.2, range of 0–15). According to the ICCGvHD grading system, and using the average data across both eyes, seven of the patients had ‘Mild/Moderate’ disease (53.8%) and the remainder had ‘Severe’ disease (n = 5, 38.5%).The levels of IFN‐γ, IL‐1β, IL‐2, IL‐6, IL‐8, IL‐10, IL‐12p70, IL‐13, and TNF‐ α were found to be statistically elevated when compared to healthy age and gender matched controls (FDR p value&lt;0.05). In those with early‐stage disease (n = 5), IFN‐γ was found to strongly correlate with lubricant usage (0.98, p = 0.03), and IL‐2 with the severity of ocular surface staining grade (1.00, p = 0.03), implying that these cytokines in particular may play a role in the development of chronic ocular GvHD and represent promising treatment targets for patients in the initial stages of disease.This study demonstrates that ocular tear cytokines are elevated in patients with chronic ocular GvHD, reiterating the role of inflammation in the pathogenesis of disease. Furthermore, the correlation of IFN‐γ and IL‐2 with clinical parameters of disease severity suggest that these cytokines play a role in early disease development. These findings support the implementation of anti‐inflammatory treatment such as topical calcineurin inhibitors, in conjunction with tear replacement and preservation to avoid irreparable damage to the ocular surface, and this may be best utilized in the initial stages of the disease development.

The Area Under Tacrolimus Concentrations on Day 14-28 Is the Independent Predictor of the Development of Chronic Gvhd in Patients without Severe Acute Gvhd after Unrelated Allogeneic HSCT

Introduction: In unrelated allogeneic hematopoietic stem cell transplantation (UR-SCT), chronic graft-versus-host disease (GVHD) is a critical complication that affects not only patients' quality of life but also post-transplant outcome. Acute GVHD is a major risk factor for the subsequent development of chronic GVHD. The combination of tacrolimus and short-term methotrexate (TAC+sMTX) has been widely used as a GVHD prophylaxis for UR-SCT in Japan. Previous reports have shown that tacrolimus blood concentrations early after transplantation are associated with the development of acute GVHD, but not with that of chronic GVHD. On the other hand, among UR-SCT recipients who did not develop severe acute GVHD, the relationship between tacrolimus blood concentrations and the development of chronic GVHD remains unclear. Methods: To examine the association between tacrolimus blood concentrations and post-transplant outcomes, the area under the tacrolimus concentration on day 0-14 (AUTC 0-14) and day 14-28 (AUTC 14-28) was calculated simply as the sum of the area of the trapezoid for the corresponding period ( Figure). Tacrolimus was initiated by continuous intravenous administration from day -1 in all patients, and no patients were switched to oral administration prior to day 28. Short-term methotrexate was administered at 10 mg/m 2 on day 1 and 7 mg/m 2 on day 3, day 6, and day 11. Among all 151 adult patients with hematopoietic malignancies who underwent first UR-SCT with GVHD prophylaxis of TAC+sMTX between 2010 and 2022 at the Jikei University Hospital, the following were excluded from the analysis: developing grade III-to-IV acute GVHD, using prednisolone or methyl-prednisolone ≥0.5 mg/kg within day 100, engraftment failure, death before day 100, and relapse before day 100. Results: A total of 68 patients were included in the analysis. Median age was 50.5 (range, 16-68) years. Twenty-seven (40%) patients had acute myeloid leukemia, and 18 (27%) had acute lymphoblastic leukemia. Fifty-five (81%) were in complete remission/chronic phase/early stage. The donor source consisted of 42 (62%) bone marrow transplantation (BMT), 20 (29%) cord blood transplantation (CBT), and 6 (9%) peripheral blood stem cell transplantation (PBSCT). BMT recipients transplanted from 22 (52%) HLA 8/8 matched donor, 19 (45%) HLA 7/8 matched donor, and one (3%) HLA 6/8 matched donor. CBT recipients transplanted from 15 (75%) HLA 4/6 matched donor and 5 (25%) HLA 5/6 matched donor. PBSCT recipients transplanted from 5 (83%) HLA 8/8 matched donor and one (17%) HLA 7/8 matched donor. Fifteen (22%) patients were administered additional low-dose anti-thymocyte globulin (ATG) as GVHD prophylaxis. Fifteen male patients transplanted from female donors (22%). Thirty-nine (57%) patients received myeloablative conditioning regimen. The median time from UR-SCT to neutrophil engraftment was 19 days (range, 11-34). Regarding acute GVHD, 46 patients (68%) developed none, 13 patients (19%) developed grade I, and 9 patients (13%) developed grade II. The median observation period for all 68 patients was 48.2 months (4.0 years). The 4-year cumulative incidence (CI) of chronic GVHD was 51%, of which 24% were moderate-to-severe. The CI of moderate-to-severe chronic GVHD was not associated with age, disease status, donor source, HLA incompatibility, ATG use, female to male, intensity of conditioning regimen, and grade I-to-II acute GVHD development. AUTC 14-28 &amp;lt;200 was the only risk factor (AUTC 14-28&amp;lt;200: 32% vs AUTC 14-28≥200: 11%; p=0.047). Multivariate analysis also showed that AUTC 14-28 &amp;lt;200 was the independent factor for development of moderate-to-severe chronic GVHD ( p=0.04). In all 68 patients, 4-year CI of relapse was 20%, 4-year CI of non-relapse mortality was 10%, 4-year GVHD-free, relapse-free, survival (GRFS) was 50%, and 4-year Overall survival was 80%, all of which did not differ between AUTC 14-28 &amp;lt;200 and AUTC 14-28 ≥200 groups. Conclusion: In UR-SCT, our data showed that AUTC 14-28 &amp;lt;200 may be an independent risk factor for developing moderate-to-severe chronic GVHD, even in patients who did not develop severe acute GVHD.

Allogeneic Hematopoietic Stem Cell Transplantation in Elderly Patients: The Experience of the Spanish Group of Hematopoietic Transplantation and Cell Therapy (GETH-TC)

Introduction Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is associated with significant toxicity and high risk of related mortality in older patients, especially when myeloablative conditioning is used. However, the upper limit of age for this procedure is not clearly defined. The aim of the study is to evaluate the safety and effectiveness of allo-HSCT in a cohort of elderly patients transplanted in Spain, considering non-relapse mortality (NRM), cumulative incidence (CI) of relapse, overall survival (OS) and progression-free survival (PFS). As secondary objectives, we evaluate the potential toxicity of allo-HSCT analyzing the days from infusion to hospital discharge, the number of readmissions within the first year, the CI of graft-versus-host disease (GvHD) and GVHD-free/relapse-free survival (GRFS). Finally, we also looked for prognostic factors significantly impacting OS. Methods We retrospectively analyzed 529 patients ≥65 years of age undergoing a first allo-HSCT between 2011 and 2020 in 17 Spanish centres, regardless of the indication and characteristics of transplantation. Subanalyses were performed according to chronological age (65-69 vs ≥70 years of age) and conditioning intensity (myeloablative vs non-myeloablative). Results Median age was 67.2 years (range 65.0-82.5) and 54 patients were ≥70 years. The most frequent indication was acute leukemia in 260 patients (49.1%). Clinical characteristics are shown in Table 1. Patients ≥70 years were more frequently male and had a lower HCT-CI than patients &amp;lt;70, without any other differences in patients' or transplant characteristics. The median follow-up was 51.2 months (range 9.3-139.6). At 1- and 4-years post-transplant, NRM were 24.3% (95%CI 21-28) and 32.0% (95%CI 28-36), CI of relapse were 21.4% (95%CI 18-25) and 29.1% (95%CI 25-33), OS were 61.2% (95%CI 57-65) and 43.4% (95%CI 39-48) and PFS were 54.3% (95%CI 50-58) and 38.9% (95%CI 35-43), respectively (Figure 1). No differences were found according to age group 65-69 vs ≥70 ( p=0.822, p=0.835, p=0.648 and p=0.743, respectively). Patients who had received myeloablative conditioning had lower CI of relapse (at 4 years post-transplant 19.3% vs. 30.7%, p=0.030), with no differences in NRM ( p=0.308), OS ( p=0.440) or PFS ( p=0.261). Regarding the duration of allo-HSCT admission, 486 patients were discharged alive, with a median number of hospital days from infusion to discharge of 22 (range 8-142). There were no differences based on age group ( p=0.635) or conditioning intensity ( p=0.606). Among 486 patients who were primary discharged, 320 (66.0%) needed a new readmission during the first-year post-transplant, with a median of 1 (range 0-6) up to day +100 and 2 (range 1-10) up to day +365. There were also no differences according to age ( p=0.789 and p=0.779, respectively) or conditioning intensity ( p=0.264 and p=0.818, espectively). Acute GvHD occurred in 265 patients (58.2%), 205 (45.1%) grades I-II and 60 (13.2%) grades III-IV. The CI of acute GvHD grades II-IV and grades III-IV at day +100 was 43.5% and 16.9%, respectively. A total of 174 patients (38.2%) developed chronic GvHD, 66 (14.6%) mild, 49 (10.8%) moderate and 56 (12.4%) severe. The CI of moderate-severe chronic GvHD at 1 and 2 years was 18.2% and 22.4%, respectively. According to age group, there were no differences in the CI of acute GvHD grades II-IV ( p=0.920), acute GvHD grades III-IV ( p=0.853) or chronic moderate-severe GvHD ( p=0.798). At 1- and 4-years after allo-HSCT, GRFS were 37.6% (95%CI 33-42) and 23.7% (95%CI 20-28), with no differences by age group ( p=0.569) or conditioning intensity ( p=0.707). In multivariate analysis, ECOG pretransplant ≥1 (HR 1.32, 95%CI 1-1.7; p=0.028), HCT-CI ≥3 (HR 1.34, 95%CI 1.1-1.7; p=0.016), high/very high DRI (HR 1.62, 95%CI 1.3-2.1; p&amp;lt;0.001) and no development of chronic GvHD (HR 2.99, 95%CI 2.3-3.9; p&amp;lt;0.001) were associated with worse OS. Age, gender, previous lines of treatment or autologous HSCT, donor type, stem cell source, conditioning intensity and development of acute GvHD did not influence OS. Conclusions Allo-HSCT is effective and safe at ages over 65 years, or even 70 years old. Myeloablative conditioning regimen may offer a lower risk of relapse without increasing toxicity. In our experience, ECOG, HCT-CI, DRI and chronic GvHD are more relevant parameters for post-transplant survival than chronological age.

Disturbance in the reconstitution of distinct T-cell subsets and the incidence of GvHD following allo-HSCT in pediatric patients with non-malignant hematological disorders

BackgroundThe reconstitution of different T-cell subsets following allogeneic hematopoietic stem cell transplantation (allo-HSCT) is critical for efficient pathogen protection and the prevention of graft-versus-host disease (GvHD). In particular, studies have highlighted the importance of balanced ratios of regulatory T-cells (Tregs) and distinct functionally T-cells in preventing acute and chronic GvHD. MethodsWe evaluated the regeneration of CD4 and CD8 T-cell subpopulations in nine pediatric patients with non-malignant disorders following allo-HSCT from a fully HLA-identical donor. ResultsCD4 and CD8 T-cells were higher 12 months after the transplant but still lower than in healthy controls and pre-transplant. However, we found after allo-HSCT, central memory and effector memory cell subsets were the predominant phenotypes in the CD4 and CD8 T-cell populations, respectively. In patients who had developed acute GvHD, there was an increase in the frequency of TEMRA (effector memory T cells that re-express CD45RA) cells within the CD4 T-cell population. Meanwhile, in patients with chronic GvHD, we observed a decrease in Th1 cells in CD4 T-cells and effector memory cells within the CD8 T-cell population. In addition, we found decreased TEMRA cell subsets in CD4 and CD8 T-cell populations in chronic GvHD. ConclusionOur findings suggest a possible relationship between the influence of acute GvHD and its prevention on delayed CD4 T-cell reconstitution and, reciprocally, unbalanced regeneration of CD4 and CD8 T-cell subsets in the development of chronic GvHD.

Role of abatacept in the prevention of graft-versus-host disease: current perspectives.

Administration of abatacept following transplantation has been reported to inhibit graft rejection and graft-versus-host-disease (GvHD) in mouse models associated with allogeneic hematopoietic stem cell transplant (HSCT). This strategy has recently been adopted in clinical practice for GvHD prevention in human allogeneic HSCT and offers a unique approach to optimizing GvHD prophylaxis following alternative donor HSCTs. When combined with calcineurin inhibitors and methotrexate, abatacept had shown to be safe and effective in preventing moderate to severe acute GvHD in myeloablative HSCT using human leukocyte antigen (HLA) unrelated donors. Equivalent results are being reported in recent studies using alternative donors, in reduced-intensity conditioning HSCT and nonmalignant disorders. These observations have led to hypothesizing that even in the setting of increasing donor HLA disparity, abatacept when given with traditional GvHD prophylaxis does not worsen general outcomes. In addition, in limited studies, abatacept have being protective against the development of chronic GvHD through extended dosing and in the treatment of steroid-refractory chronic GvHD. This review summarized all the limited reports of this novels approach in the HSCT setting.

Humoral response and safety of the BNT162b2 and mRNA-1273 COVID-19 vaccines in allogeneic hematopoietic stem cell transplant recipients: An observational study

BackgroundThe effectiveness of mRNA COVID-19 vaccines and the optimal timing of vaccine administration in allogeneic hematopoietic stem cell transplantation (Allo-HSCT) recipients remains inadequately investigated. We examine the effectiveness and safety of mRNA COVID-19 vaccines in allo-HSCT recipients. MethodThis prospective observational study included 44 allo-HSCT recipients and 38 healthy volunteers. The proportion of subjects acquiring anti-S1 IgG antibodies were considered as the primary endpoint. The occurrence of adverse events after vaccination and objective deterioration of chronic graft-versus-host disease (GVHD) were defined as secondary endpoints. In addition, we compared the geometric mean titers (GMT) of anti-S1 antibody titers in subgroups based on time interval between transplantation and vaccination. ResultsA humoral response to the vaccine was evident in 40 (91%) patients and all 38 healthy controls. The GMT of anti-S1 titers in patients and healthy controls were 277 (95% confidence interval [CI]: 120–643) BAU/mL and 532 (95% CI 400–708) BAU/mL, respectively. (p = 0.603). A short time interval between transplantation and vaccination (≤6 months) was associated with low anti-S1 IgG antibody titers. No serious adverse events and deterioration of chronic GVHD were observed. Only one case of new development of mild chronic GVHD was recorded. ConclusionMessenger RNA COVID-19 vaccines induce humoral responses in allo-HSCT recipients and can be administered safely.

Transcription Factor Fli-1 Regulates T Cell Immunity and Tolerance in Gvh and GVL Responses

The E26 transformation-specific (ETS) transcription factor (TF) family member Friend Leukemia Virus Integration 1 (Fli-1) is linked to the oncogenesis of virally induced leukemia and Ewing's Sarcoma, as well as the development of autoimmune diseases including systemic lupus erythematosus and systemic sclerosis. A recent report presents compelling evidence that Fli-1 restrains CD8 effector T cell differentiation and protective immunity against cancer. How Fli-1 regulates primary T cell differentiation and function remain largely elusive. In this study, we investigated the role of Fli-1 in T-cell pathogenicity of graft-versus-host disease (GVHD) and validated Fli-1 as a therapeutic target. Using conditional knock-out models featured as homozygous (Fli-1KO) or heterozygous (Fli-1HET) deficiency of Fli-1 in T cells, we found that Fli-1 dynamically regulates different T-cell subsets in allogeneic responses and pathogenicity in the development of acute and chronic GVHD. Compared to Fli-1KO or Fli-1WT T cells, Fli-1HET T cells induced the mildest aGVHD and cGVHD supported by lowest Th1 and Th17 differentiation (Fig. 1 A-B). In addition, Fli-1HET T cells were able to maintain a strong graft-versus-leukemia (GVL) effect while inducing significantly attenuated GVHD. Fli-1-deficient CD8+ T cells expressed comparable levels of cytolytic molecules, reduced levels of exhaustion markers, and differentiated more into memory precursor effector cells compared to WT CD8 T cells after been transferred into allogeneic recipients. To further understand how Fli-1 regulates T-cell gene transcription and heterogeneity, we performed scRNA seq analysis of donor T cells, including Fli-1WT, Fli-1HET and Fli-1KO, isolated from recipient spleens. The scRNA seq analysis on the donor T cells indicated a major difference in the transcriptional regulation by Fli-1 in CD4 versus CD8 T cells and Fli-1 gene dose dependent modification in transcriptional pathways in Fli-1Het vs Fli-1KOT cells. Fli-1 deemed to play a distinct role in regulating gene transcription in CD4 versus CD8 T cells, in that more activation and less exhaustion gene pathways were enriched in CD8 Fli-1 deficient cells, while fewer genes in Th1/Th17 pathogenic pathways were enriched in CD4 Fli-1 deficient cells (Fig. 1 C-D). Overall, Fli-1 deficiency increased gene enrichment in OXPHOS pathway in both CD4 and CD8 T cells, and reduced gene enrichment in glycolysis pathway majorly in CD4 T cells (Fig. 1 E-F). Consistent with the lowest pathogenicity of Fli-1Het T cells for GVHD induction, Fli-1Het CD4 T cells had the lowest Th1/Th17 pathway gene enrichment and TCR pathway downstream gene expression. Camptothecin, topotecan or etoposide exhibited action as potent Fli-1 inhibitors at low-doses. For translational purpose, we tested these drugs and found that each of these drugs significantly attenuated GVHD severity while preserving the GVL effect. The efficacy of camptothecin or etoposide at low doses was dependent of Fli-1 expression on donor T cells. Mechanistically, blocking Fli-1 suppressed activated effector T cells while sparing Tregs and had no side effect on hematopoietic stem cells. Importantly, using the same treatment schedule as post-transplantation cyclophosphamide (PTCy), two doses of camptothecin or etoposide administered on day 3 and 4 were sufficient for the prevention of GVHD and leukemia relapse, in contrast to GVHD mortality in some of those treated with bendamustine and leukemia relapse in some of those treated with PTCy or cyclosporine (Fig. 1 G-I). In addition, the beneficial effect of camptothecin was extended in GVHD induced by human T cells in a xenograft model. In conclusion, we provide the first evidence that Fli-1 plays a crucial role in alloreactive CD4 T-cell activation and differentiation, and that targeting Fli-1 may be an attractive strategy for treating GVHD without compromising GVL effect. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Is Defibrotide Prophylaxis Effective on Graft Versus Host Disease in Patients with Allogeneic Stem Cell Transplantation?

Introduction: Sinusoidal obstruction syndrome (SOS) is one of the complications of allogeneic stem cell transplantation (allo-SCT). Defibrotide (DF) is used effectively in SOS prophylaxis and treatment. Graft versus host disease (GVHD) is a significant cause of morbidity and mortality in allo-SCT. Here, we retrospectively investigated the effect of DF on the development of GVHD in these patients.&#x0D; Methods: We evaluated 81 allo-transplanted patients due to various diagnoses (benign or malignant), retrospectively. Thirty-four patients used DF as prophylaxis while 47 patients did not receive it. Acute and chronic GVHD assessments were performed at +30/100th day and throughout the life of the patients, respectively.&#x0D; Results: Acute GVHD was more common with DF use (82% vs 61%). There was no statistical significance in terms of the effect on chronic GVHD. We observed that one patient in the non- DF group developed SOS.&#x0D; Conclusions: DF may be beneficial to prevent acute GVHD. However, we observed that GVHD and mortality were more common in patients using DF. This is probably due to the similarity of high-risk criteria between GVHD and SOS. We have not found a significant association between defibrotide use and the development of chronic GVHD.

Comparison of Pulmonary Toxicity after Total Body Irradiation- and Busulfan-Based Myeloablative Conditioning for Allogeneic Hematopoietic Stem Cell Transplantation in Pediatric Patients

Pulmonary toxicity after allogeneic hematopoietic stem cell transplantation (allo-HSCT) for childhood leukemia and myelodysplastic syndrome (MDS), along with the impact of different myeloablative conditioning regimens, remain incompletely described. Here we compared the acute and long-term incidence of pulmonary toxicity (PT) after total body irradiation (TBI)- and busulfan-based myeloablative conditioning. We conducted this retrospective cohort study of 311 consecutive pediatric patients with leukemia or MDS who underwent allo-HSCT at Dana-Farber Cancer Institute/Boston Children's Hospital between 2008 and 2018. PT was graded using Common Terminology Criteria for Adverse Events version 5.0. The primary objective was to compare the cumulative incidence of grade ≥3 and grade 5 PT after TBI-based and busulfan-based myeloablative conditioning using Gray's test. Secondary objectives were to determine factors associated with PT and overall survival (OS) using competing risk analysis and Cox regression analyses, respectively. There was no significant difference between the TBI-conditioned group (n=227) and the busulfan-conditioned group (n=84) in the incidence of grade ≥3 PT (29.2% versus 34.7% at 2 years; P=.26) or grade 5 pulmonary toxicity (6.2% versus 6.1% at 2 years; P=.47). Age (hazard ratio [HR], 1.70, 95% confidence interval [CI], 1.11 to 2.59; P=.01), grade ≥2 PT prior to allo-HSCT or preexisting pulmonary conditions (HR, 1.84, 95% CI, 1.24 to 2.72; P < .01), acute graft-versus-host disease (GVHD) (HR, 2.50; 95% CI, 1.51 to 4.14; P < .01), and chronic GVHD (HR, 2.61; 95% CI, 1.26 to 5.42; P=.01) were associated with grade ≥3 PT on multivariable analysis. Grade ≥3 PT was associated with worse OS (81.1% versus 61.5% at 2 years; P < .01). In pediatric allo-HSCT recipients, rates of PT were similar in recipients of TBI-based and recipients of busulfan-based myeloablative conditioning regimens. Age, the presence of PT or preexisting pulmonary conditions prior to transplantation, and the development of either acute or chronic GVHD were associated with grade ≥3 PT post-transplantation. Furthermore, the occurrence of grade 3-4 PT post-transplantation was associated with inferior OS.

Combining CD34+ stem cell selection with prophylactic pathogen and leukemia directed T-cell immunotherapy to simultaneously reduce graft versus host disease, infection, and leukemia recurrence after allogeneic stem cell transplant.

We designed a trial to simultaneously address the problems of graft versus host disease (GVHD), infection, and recurrence of malignancy after allogeneic stem cell transplantation. CD34+ stem cell isolation was used to minimize the development of acute and chronic GVHD. Two prophylactic infusions, one combining donor-derived cytomegalovirus, Epstein-Barr virus, and Aspergillus fumigatus specific T-cells and the other comprising donor-derived CD19 directed chimeric antigen receptor (CAR) bearing T-cells, were given 21-28 days after transplant. Two patients were transplanted for acute lymphoblastic leukemia from HLA identical siblings using standard doses of cyclophosphamide and total body irradiation without antilymphocyte globulin. Patients received no post-transplant immune suppression and were given no pre-CAR T-cell lymphodepletion. Neutrophil and platelet engraftment was prompt. Following adoptive T-cell infusions, there was rapid appearance of antigen-experienced CD8+ and to a lesser extent CD4+ T-cells. Tetramer-positive T-cells targeting CMV and EBV appeared rapidly after T-cell infusion and persisted for at least 1 year. CAR T-cell expansion occurred and persisted for up to 3months. T-cell receptor tracking confirmed the presence of product-derived T-cell clones in blood targeting all three pathogens. Both patients are alive over 3 years post-transplant without evidence of GVHD or disease recurrence. Combining robust donor T-cell depletion with directed T-cell adoptive immunotherapy targeting infectious and malignant antigens permits independent modulation of GVHD, infection, and disease recurrence. The combination may separate GVHD from the graft versus tumor effect, accelerate immune reconstitution, and improve transplant tolerability.

Unrelated donor α/β T cell– and B cell–depleted HSCT for the treatment of pediatric acute leukemia

Unrelated donor (URD) hematopoietic stem cell transplant (HSCT) is associated with an increased risk of severe graft-versus-host disease (GVHD). TCRαβ/CD19 depletion may reduce this risk, whereas maintaining graft-versus-leukemia. Outcome data with TCRαβ/CD19 depletion generally describe haploidentical donors, with relatively few URDs. We hypothesized that TCRαβ/CD19-depletion would attenuate the risks of GVHD and relapse for URD HSCT. Sixty pediatric and young adult (YA) patients with hematologic malignancies who lacked a matched-related donor were enrolled at 2 large pediatric transplantation centers between October 2014 and September 2019. All patients with acute leukemia had minimal residual disease testing, and DP typing was available for 77%. All patients received myeloablative total body irradiation– or busulfan-based conditioning with no posttransplant immune suppression. Engraftment occurred in 98%. Four-year overall survival was 69% (95% confidence interval [CI], 52%-81%), and leukemia-free survival was 64% (95% CI, 48%-76%), with no difference between lymphoid and myeloid malignancies (P = .6297 and P = .5441, respectively). One patient (1.7%) experienced primary graft failure. Relapse occurred in 11 patients (3-year cumulative incidence, 21%; 95% CI, 11-34), and 8 patients (cumulative incidence, 15%; 95% CI, 6.7-26) experienced nonrelapse mortality. Grade III to IV acute GVHD was seen in 8 patients (13%), and 14 patients (26%) developed chronic GVHD, of which 6 (11%) had extensive disease. Nonpermissive DP mismatch was associated with higher likelihood of acute GVHD (odds ratio, 16.50; 95% CI, 1.67-163.42; P = .0166) but not with the development of chronic GVHD. URD TCRαβ/CD19-depleted peripheral HSCT is a safe and effective approach to transplantation for children/YAs with leukemia. This trial was registered at www.clinicaltrials.gov as #NCT02323867.

Role of Extracorporeal Photopheresis in Prevention of Graft-Versus-Host Disease in Patients Treated with Allogeneic Hematopoietic Stem Cell Transplantation: A Randomized Controlled Trial

IntroductionIn many patients diagnosed with a hematological malignancy, the disease cannot be totally eradicated by conventional therapeutic approaches, and for them allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the only curative option. A major complication of allo-HSCT is graft-versus-host disease (GvHD), affecting about 50% of transplant recipients. In addition to increased risk of death and long-lasting debilitating conditions, severe GvHD also impairs health-related quality of life. High-dose systemic steroids is the first line treatment for GvHD, but treatment failure is common, and steroid-refractoriness is a major cause of non-relapse mortality after allo-HSCT. While there is no established second line GvHD-treatment, extracorporeal photophoresis (ECP) has emerged as an attractive and increasingly applied alternative, partly due to its favourable safety profile. However, the use of ECP in preventing GvHD is sparse and data are inconclusive due to lack of randomized controlled trials (RCT). We therefore conducted a RCT to study if ECP given post transplantation could prevent the development of GvHD.MethodsBetween June 2017 and February 2020, we enrolled 157 patients (> 18 years) diagnosed with a hematological malignancy and treated with an allo-HSCT in first remission into an intention-to-treat open RCT. Ethical and IRB approvals were granted, and the RCT was registered with Clinical Trials (ID NCT03204721). The sample size (76 in intervention group and 81 controls) was calculated based on a reduction of 25% in the total number of patients diagnosed with any form of GvHD within the first year of allo-HCST (primary end-point) as clinically relevant. The patients were stratified according to whether they received myeloablative or reduced intensity conditioning (Table 1), and they were given GvHD prophylaxis as shown in Table 1. ECP (Therakos Cellex ®, Mallinckrodt Pharm., NJ) was initiated when patients had engrafted (i.e. leukocytes > 1 x 10 9/L and platelets > 20 x 10 9/L), and, according to the study protocol, we planned for ECP on two consecutive days/week for two weeks, then weekly for four weeks to a total eight treatments for each patient in the intervention group. Chi-square test was used to test differences between the two study groups.ResultsTable 1 shows that patient characteristics were well balanced among the two study groups. Four patients did not receive ECP while 39 received all the eight treatments. One year after allo-HCST, the proportion of GvHD was 45/76 (59%) in the intervention group and 52/81 (64%) in the controls (p=0.52). There were no significant differences between the intervention and control group regarding development of acute (45% vs. 48%) or chronic (39% vs. 40%) GvHD. Neither did we detect any statistical differences between the two study groups regarding organ involvement or severity of the GvHD manifestations (data not shown). During the one-year observation period, 16/76 (21%) and 10/81 (12%) relapsed in the intervention and control group, respectively (p=0.14). The corresponding numbers of deaths were 12/76 (16%) and 16/81 (20%), respectively (p=0.52). Six patients in the intervention group experienced mild to moderate temporary, adverse events that could possibly be related to the ECP-procedure.ConclusionIn this first RCT addressing ECP as GvHD prophylaxis in allo-HSCT for hematological malignancy, we found no significant difference in the numbers, types, organ involvement, or severity of GvHD between the intervention and the control group. Thus, our study does not support the use of ECP as an adjunct to GvHD-prophylaxis based on cyclosporine and methotrexate, mycophenolate mofetil, or sirolimus. However, ECP did not seem to be harmful in this setting. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Increased efficacy of dual proinflammatory cytokine blockade on acute GVHD while maintaining GVT effects

AbstractAllogeneic hematopoietic stem cell transplantation (allo-HSCT) remains a potential curative option for treating a variety of hematologic diseases, but acute and chronic graft-versus-host disease (GVHD) remain major barriers limiting efficacy. Acute gut GVHD occurs with marked increases in proinflammatory cytokines (including TNF and IL-6), which we recently demonstrated was exacerbated in obesity resulting in severe gastrointestinal pathology. Given the pleiotropic and overlapping effects of these 2 cytokines, we assessed the impact of dual TNF and IL-6R blockade on GVHD as well as graft-versus tumor (GVT) effects in different mouse GVHD models. Early administration of combined blockade resulted in greater protection and survival from acute gut GVHD compared with single blockade regimens and even development of later chronic skin GVHD. Importantly, double cytokine blockade preserved GVT effects reinforcing that GVT and GVHD can be delineated and may result in greater efficacy in allo-HSCT.

Final Analysis of the Phase I/II Study of CC-486 (Oral Azacitidine) Maintenance Therapy after Allogeneic Stem Cell Transplantation (Allo-SCT) in Patients with Acute Myeloid Leukemia (AML) or Myelodysplastic Syndromes (MDS)

Final Analysis of the Phase I/II Study of CC-486 (Oral Azacitidine) Maintenance Therapy after Allogeneic Stem Cell Transplantation (Allo-SCT) in Patients with Acute Myeloid Leukemia (AML) or Myelodysplastic Syndromes (MDS)

Invasive Fungal Disease in Allogeneic Hematopoietic Stem Cell Transplant Recipients Is an Important Risk Factor Not Only for Acute Graft-Versus-Host Disease but Also for Chronic Graft-Versus-Host Disease

Introduction: Infections and graft-versus-host disease (GVHD) are the leading causes of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). And their close relationship is gaining more and more attentions in recent years. Although it has been demonstrated that invasive fungal disease (IFD) is associated with an increased risk of acute GVHD, the link between IFD and chronic GVHD is rarely reported. This large retrospective study was performed to assess the relationship between IFD and GVHD, especially chronic GVHD.Methods: A total of 684 patients with hematologic malignancies who underwent allo-HSCT at Nanfang Hospital between January 2011 and December 2015 were enrolled in the retrospective study. We defined IFD according to the European Organization for Research and Treatment of Cancer and Mycoses Study Group (EORTC/MSG) revised definitions of 2008 (De Pauw B et. al. Clin Infect Dis 2008) and included proven and probable cases for analysis. Cases of possible IFD were also included if initial antifungal treatments were considered effective, otherwise possible cases were excluded. Acute GVHD was graded from 0 to IV and chronic GVHD was defined as no, limited or extensive chronic GVHD according to standard criteria (Przepiorka D et. al. Bone Marrow Transplant 1995; Sullivan KM et. al. Semin Hematol 1991). Cumulative incidence of acute GVHD, chronic GVHD, non-relapse mortality (NRM) and overall survival (OS) were estimated by the Kaplan-Meier and comparison was done by a log- rank test. Risk factors associated with chronic GVHD after allo-HSCT were identified in a multivariable Cox regression model.Results: Within 1 year post-transplantation, 191 patients developed IFD (42 proven, 98 probable and 51 possible), including 39 patients with a history of IFD pre-transplantation. Of the 39 patients, 32 patients had stable IFD and 7 patients had active IFD at the time of their transplantation. The 1-year cumulative incidence of IFD was 25.3% ±1.7%. The cumulative incidence of grades II to IV acute GVHD at 100 days was 47.8% ± 4.4% in IFD group and 25.8% ±2.0% in non-IFD group, respectively (P < .001). The 2-year cumulative incidence of chronic GVHD and extensive chronic GVHD were significantly higher in patients with IFD compared to those without IFD (66.6% ± 5.0% versus 41.5% ± 2.4%, P < .001; 31.6% ± 4.8% versus 9.4% ± 1.4%, P < .001). Besides, patients with IFD also had higher 5-year NRM and lower 5-year OS compared to patients without IFD (29.2 ± 3.6% versus 10.9% ± 1.6%, P < .001 and 53.6 ± 3.8% versus 69.3% ± 2.2%, P < .001). Multivariate analyses showed that IFD was a significant risk factor for chronic GVHD, independent of other risk factors (hazard ratio [HR], 1.502; 95% confidence interval [CI], 1.127-2.001; P=0.005).Conclusions: The occurrence of IFD confers a high risk for acute GVHD and chronic GVHD development. This may provide new insights that allo-HSCT patients might benefit most from early and prolonged antifungal prophylaxis and immediate antifungal therapy. DisclosuresNo relevant conflicts of interest to declare.

Consolidative CD8+ Memory T-Cell Donor Lymphocyte Infusion Augments Donor Chimerism with a Low Risk of Gvhd Following Matched Related Donor Hematopoietic Cell Transplantation

IntroductionMixed chimerism (MC) after allogeneic hematopoietic cell transplantation (HCT) is associated with an increased risk of disease relapse. An unmanipulated donor lymphocyte infusion (DLI) can convert MC to full donor chimerism (FC) but can also precipitate severe acute graft-versus-host disease (GVHD). We recently showed in a phase I trial that a subset of purified CD8+CD44hi memory T cells derived from HLA-matched sibling donors may induce graft-versus-tumor reactions in patients with relapsed hematologic malignancies following allogeneic HCT with objective responses in 25% of patients and a low incidence of GVHD (Muffly et al, 2016 ASH Abstract #4615). Here we report on the preliminary results of a phase II study using CD8+ memory T-cell DLI as consolidative therapy early after transplant for patients with MC to assess the rate of conversion to FC, the risk of GVHD, and the prevention of disease relapse.MethodsPatients: Eligible patients were 18-75 years of age with a high-risk or refractory hematologic malignancy who underwent nonmyeloablative allogeneic HCT from a matched sibling donor using total lymphoid irradiation and antithymocyte globulin conditioning, and who had MC (<95% donor CD3+ cells) at day +30. Patients were without acute GVHD at the time of the CD8+ memory T-cell DLI and were on tacrolimus or cyclosporine monotherapy for GVHD prophylaxis at the time of DLI.CD8+ memory T cells: Phenotypic CD8+ memory T cells were isolated from matched sibling donors following two days of unmobilized apheresis using a tandem immunomagnetic selection strategy including CD45RA depletion followed by CD8+ enrichment on the CliniMACS Plus instrument. Cell purity was determined by flow cytometry analysis. CD8+ memory T cells were infused between day +30 and day +70 at a dose of 5 x 106 cells/kg, which was determined in the prior phase I trial to be the maximum dose that could be collected from two apheresis products.Study Endpoints: Following DLI, patients were assessed for the development of acute and chronic GVHD, conversion from MC to FC (≥95% donor CD3+ chimerism) within three months, and for disease relapse. Secondary outcomes included the incidence of adverse events, invasive infections, non-relapse mortality, overall survival, and disease-free survival.ResultsPatient characteristics and outcomes after DLI are summarized in Table 1. Nine patients received CD8+ memory T-cell DLI at a median of 42 days post-HCT (range 33-62 days). The cell product was highly enriched for CD8+/CD45RA-/CD45RO+ cells, and flow analysis confirmed the selected cells were phenotypically consistent with the CD8+ T effector memory subset with a post enrichment purity of ≥96% (range 96.4-98.8%) in all patients. Median age of the patients was 60 years (range 30-71 years) with a median follow up of 306 days post-HCT (range 131-747 days). Diagnoses included non-Hodgkin lymphoma (n=5), acute myeloid leukemia (n=2), myelodysplastic syndrome (n=1), and Hodgkin lymphoma (n=1). Median donor CD3+ chimerism at day +30 was 88% (range 23-93%).CD8+ memory T-cell DLI was well tolerated with no adverse events. Six of the nine patients (67%) converted from MC to FC within three months post-DLI with a median donor CD3+ chimerism of 97% (range 95-100%). Two patients developed grade II acute GVHD (skin only) that was treated to resolution. One patient developed mild chronic GVHD. No patients developed severe acute GVHD (grade III-IV) or extensive chronic GVHD. No patients developed invasive infections, and non-relapse mortality was 0%. Of the three patients who failed to convert from MC to FC, two had residual disease at the time of transplant, one of whom had early disease relapse at day +88. Four of the six patients who converted to FC were in complete remission (CR) at the last follow up. One of the three patients with persistent MC was in CR at the last follow up. For the entire study cohort, the median disease-free survival is 1.1 years and the median overall survival is not yet reached.ConclusionsConsolidative CD8+ memory T-cell DLI following nonmyeloablative matched related donor HCT is well tolerated, converted six of nine patients (67%) with MC to FC, and was associated with a low rate of GVHD with no cases of severe acute or extensive chronic GVHD in this study. Patients continue to accrue to trial, and further accrual and longer follow up are needed to determine if this strategy will reduce relapse rates for high-risk patients with MC. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Association of recipient and donor interleukin 6 polymorphisms 174 and 597 with outcome after allogeneic hematopoietic stem cell transplantation in children

PurposeThe success of allogeneic hematopoietic stem cell transplantation (HSCT) is compromised by complications such as infection, relapse, and graft-versus-host disease (GVHD). The investigation of non-HLA immunogenetics, particularly of cytokines, could identify predictors of an unfavorable outcome after allogeneic HSCT. In this study, we examined the impact of single nucleotide polymorphisms (SNPs) within the promoter region of interleukin 6 (IL6) on the development of GVHD after pediatric allogeneic HSCT.MethodsIn this retrospective analysis, we included 320 pediatric patients with a median age of 10 years who underwent an allogeneic HSCT and their respective donors. We used TaqMan real-time polymerase chain reaction to analyze the SNPs IL6-174 (G/C) and IL6-597 (G/A). The IL6-174 polymorphism was examined in 300 recipients and 295 donors. The IL6-597 polymorphism was analyzed in 299 recipients and 296 donors. We investigated the influence of the IL6-174 and IL6-597 polymorphisms on overall survival, event-free survival, relapse incidence, transplant-related mortality, and the occurrence of GVHD.ResultsG polymorphism at position 174 of the recipient IL6 gene was associated with a higher incidence of acute GVHD (GG vs. GC/CC; P = 0.024). Patients with IL6-597 GG genotype developed acute GVHD more frequently than individuals with an A allele (GG vs. GA vs. AA; P = 0.013). IL6-174 GG homozygous recipients had a more frequent occurrence of chronic GVHD (GG vs. GC/CC; P = 0.049). We observed a significant increased risk of chronic GVHD in recipients with IL6-597 GG genotype (GG vs. GA vs. AA; P = 0.043). Polymorphisms of donors did not affect the incidence of acute GVHD and chronic GVHD. In multivariate analysis, the IL6-174 and IL6-597 SNPs were independent significant risk factors for acute GVHD (P = 0.030; P = 0.007, respectively) as well as for chronic GVHD (P = 0.045; P = 0.015, respectively). In addition, older age at time of transplantation turned out to be a significant risk factor for chronic GVHD (P = 0.003).ConclusionOur study identified the IL6-174 and IL6-597 GG genotypes of pediatric allogeneic HSCT recipients as genetic risk factors for the development of acute GVHD and chronic GVHD. After evaluations in further studies, these findings could implicate the adjustment of prophylactic measures to reduce the occurrence of acute GVHD and chronic GVHD.