STAT3 is a key mediator of inflammation, and is associated with murine auto- and alloreactivity. Germline and somatic activating STAT3 mutations have correlated with human inflammatory disorders, ...including colitis and polyendocrinopathy. STAT3 phosphorylation is required for pathogenic Th17 differentiation, and antagonizes beneficial Treg development. We show that CD4+ T-cell STAT3 activity is elevated early after allogeneic hematopoietic cell transplantation (HCT) compared with healthy non-HCT controls, and identifies patients at risk of developing grade II-IV acute graft-versus-host disease (GVHD) before the onset of symptoms. Using human in vitro and murine in vivo systems, we demonstrate that STAT3 phosphorylation may be selectively targeted with S3I-201 to suppress the alloresponse while preserving graft-versus-leukemia (GVL). Peripheral blood T-cells were obtained on day +21 from consented HCT recipients lacking any signs of acute GVHD (n=5 non-HCT controls, n=18 HCTs). T-cell STAT3 Y705 activity was stimulated with a pulse of IL-6 (4000 IU/ml, 15 minutes) and measured by flow cytometry. Patients were followed for acute GVHD onset from day +22 to day +100. While resting STAT3 activity was very low in all groups, stimulated CD4+ STAT3 phosphorylation significantly increased among the patients that later developed acute GVHD during the observation period (Fig 1 A: non-HCT control: 8.83%; n=10 grade 0-I: 28.8%; n=8 grade II-IV: 67.6% median pSTAT3+/CD4+; P<.05 and <.001; Fig 1 B: representative histograms show day +21 STAT3 activity in a patient that never acquired GVHD v a patient that later developed grade II GVHD at day +43). The absolute number of pSTAT3+ CD4+ T-cells on day +21 was also increased among the patients that acquired grade II-IV acute GVHD (grade 0-1: 45.5; grade II-IV: 83.5 CD4+ T-cells/ul; P<.05). The total absolute number of CD4+ T-cells, and number and degree of pSTAT3+ CD8+ T-cells, was similar among all HCT groups. We previously demonstrated that S3I-201 suppressed human DC-allostimulated T-cells, selectively polarized STAT5 activity while inhibiting STAT3, abrogated Th17 responses, and permitted the expansion of potent antigen-specific inducible Treg (Betts et al, Journal of Leukocyte Biology, 2014). We now show S3I-201 prevents GVHD in vivo, where Balb/c mice received myeloablative irradiation (850 cGy) followed by an allograft of T-cell depleted or replete (1x10e6) C57BL/6 bone marrow (5x10e6). S3I-201 (2.5mg/kg or DMSO control) was given i.p. from day 0 to +7. S3I-201 significantly delayed GVHD onset and improved survival (Fig 2, 10 mice/group, 0% v 56% alive at day +60, P<.0001, n=2). To determine the effect of S3I-201 on GVL, similarly transplanted Balb/c mice additionally received 2000 luciferase-expressing A20 cells. In this pilot experiment, median survival for the vehicle-treated BM-A20 and T cell-A20 groups was 26 days, 40.5 days for S3I-BM-A20, and not reached for S3I-T cell-A20 (67% alive at day +60). Bioluminescence (IVIS 200) remained undetectable in both the T cell-A20 and S3I-T cell-A20 groups during the experiment. Moreover, as mTOR and STAT3 signaling both influence Th17 differentiation we show that concurrent exposure of human T-cells to rapamycin and S3I-201 optimally suppresses RORgammaT expression and enhances allo-inactivation (Fig 3 A: P<.05, <.001, n=3, Fig 3 B: colorimetric proliferation assay, DC:T 1:30, P<.05, n=4). Ongoing experiments are underway to study the effect of combined rapamycin and S3I-201 on GVHD and GVL in vivo. Our preclinical data implicates STAT3 activation early in the onset of acute GVHD, where its selective inhibition with S3I-201 controls alloreactivity without untoward impairment of Treg or GVL. Future investigation of this approach will incorporate specific STAT3 inhibition with rapamycin to develop novel GVHD prevention strategies, and validate the association of STAT3 activity with acute GVHD risk in a large cohort of patients.
Display omitted
No relevant conflicts of interest to declare.
Despite improvements in prevention and treatment of acute graft‐versus‐host disease (GVHD), chronic GVHD (cGVHD) remains a significant contributor to morbidity and mortality of allogeneic transplant ...patients. Chronic GVHD remains a leading cause of late complications posttransplant and is impacted by donor‐, patient‐, and transplant‐related (hematopoietic cell transplant HCT) factors. Advances in the biological understanding of cGVHD have provided opportunities to improve clinical interventions for prevention and treatment. Expansion of posttransplantation cyclophosphamide beyond haploidentical HCTs has transformed alternative donor, matched, and mismatch GVHD outcomes and is currently being investigated in two upcoming clinical trials network prophylaxis studies. Although corticosteroids remain the cornerstone therapy, several clinical trials are prospectively investigating the utility of using novel agents in combination with corticosteroids as upfront therapy to mitigate prolonged steroid exposure. Several treatment options for patients with steroid‐refractory cGVHD are currently being investigated, and advances have resulted in ibrutinib becoming the first cGVHD agent approved by the U.S. Food and Drug Administration. We review recent advances in understanding of cGVHD pathophysiology and new approaches for the prevention and treatment of cGVHD.
The clinical syndrome of acute upper gastrointestinal graft-versus-host disease (UGI aGvHD) is historically seen in 13% of MRD transplants and in 31% of recipients developing acute GvHD (aGvHD). UGI ...aGvHD is classified as a Grade II manifestation in the modified consensus criteria and often treated with systemic immunosuppressive therapy. We undertook a review of the CIBMTR database to assess prognostic implications of and outcomes after UGI aGvHD both in isolation and when present with other manifestations of aGvHD.
Methods: 8567 adult recipients of myeloablative allogeneic HSCTs receiving T-cell replete PBSC or bone marrow grafts from siblings, well- or partially-matched unrelated donors for AML, ALL, CML or MDS between 2000 and 2012 were analyzed. The primary outcome was survival; secondary outcomes were DFS, TRM, relapse, and cGvHD. Isolated UGI aGvHD: we performed individual pairwise comparisons between recipients with isolated UGI (iUGI) aGvHD and those with no aGvHD, Grade I, Grade II or Grades III/IV aGvHD without UGI symptoms. UGI aGvHD in Addition to Other aGvHD Manifestations: we performed pairwise comparisons between recipients with aGvHD of the same grade, with and without UGI involvement. Recipients with Grade II aGvHD were reclassified for analysis based on non-UGI manifestations. Diagnoses of UGI aGvHD did not require biopsy confirmation. Analyzed covariates included age, race, KPS score, malignancy, disease stage, time from diagnosis to transplant, graft source, HLA-matching, sex match, CMV status, GvHD prophylaxis, and year of transplant. Analyses were adjusted for effect of transplant center on outcomes. Given the number of comparisons, a p value <0.01 determined significance. Recipients without aGvHD included those experiencing early death; Kaplan-Meier and incidence curves were analyzed from time of aGvHD onset.
Results: 251 centers contributed. Median age of recipients was 42 years (range, 18-72). 49% of recipients received stem cells from HLA-matched siblings, 38% from well-matched and 13% from partially-matched unrelated donors. 20% of donor/recipient pairs were female->male. 71% received PBSCs. Isolated UGI aGvHD: 229 individuals had iUGI aGvHD. MRD recipients with iUGI aGvHD had the same prognoses for OS, DFS, TRM, relapse and chronic GvHD as recipients with Grades 0, I or II aGvHD without UGI symptoms in pairwise comparisons. URD recipients with iUGI aGvHD had decreased TRM and trended towards improved OS and DFS compared to recipients with Grade II aGvHD without UGI involvement (HR 2.70, p=0.0021; HR 1.59, p=0.0166; HR 1.52, p=0.0294; Table, Figure 1). Outcomes of URD recipients with iUGI aGvHD were similar to those with Grades 0 or I aGvHD in pairwise comparisons. UGI aGvHD in Addition to Other aGvHD Manifestations: UGI involvement added no significant prognostic information to analyzed outcomes when present in addition to Grades I or II aGvHD of skin or hepatic/lower GI origin (Figure 2). If UGI symptoms were removed from grading, 229 recipients would be reclassified as No aGvHD; 196 recipients would be reclassified as Grade I. The percentage of recipients with Grades 0/I GvHD would increase from 55.7% to 60.1%.
Conclusions: The presence of isolated UGI aGvHD imparted limited prognostic information after MRD or URD transplantation in terms of OS, DFS, TRM, relapse or chronic GvHD when compared to recipients without aGvHD or those with Grade I or II manifestations other than UGI. Defining isolated UGI aGvHD as a Grade II entity is not supported by this analysis. The presence of UGI aGvHD in addition to other Grade I or Grade II manifestations within a given recipient likewise had minimal prognostic impact on clinical outcomes after MRD or URD HSCT. Inclusion of UGI symptoms in the current aGvHD grading schema warrants re-evaluation in light of the results of this analysis.
Display omitted Display omitted Display omitted
Alousi:Therakos, Inc: Research Funding.
Background: It is unclear if persistent splenomegaly prior to allogeneic hematopoietic cell transplant (allo-HCT) influences post-transplant outcomes for lymphoid malignancies. Our study explores the ...significance of splenomegaly along with splenic PET avidity and its impact on allogeneic HCT outcomes in patients with lymphoid malignancies.
Methods: We retrospectively reviewed records of patients who underwent allo-HCT for lymphoid malignancies (n=152) between 2008 and 2013 at the Moffitt Cancer Center. Clinical data were captured through our research database and were supplemented with individual patient electronic medical record review. Pre-transplant CT and PET images of all patients were reviewed. Spleen volume (SV) was measured using the freehand volume segmentation tool in AW Workstation software (General Electric, Waukesha, WI, USA) on CT images. Splenic index (SI) was calculated as a product of width (W), thickness (Th) and length (L) of the spleen. Normal SV and SI was defined as SV < 314.5 cm3 and SI ≤ 480 cm3 as described in the literature. Spleen and liver mean standardized uptake value (SUV) s were calculated to document spleen PET avidity using region of interest measurements over the spleen and liver with standard radiology techniques. Spleens with mean SUV of lower value than liver were considered negative. Statistical analysis was performed using SPSS v.21.0.
Results: Among the study population 42.8% received an allo-HCT from an HLA-matched related donor, 36.2% from a matched unrelated donor, 12.5% from a mismatched unrelated donor, and 8.6% received a double-umbilical cord blood transplants. Most patients (61.8%) received myeloablative conditioning. Median age at transplantation was 52(range 21-68) years. Pre-HCT spleen CT and PET images were available on 88% (n=134) and 70.3% (n=107) patients, respectively. Spleen volumes ranged from 90 cm3 to 4684 cm3 with a median of 290.5 cm3 and a mean of 400.3 cm3. SI calculation showed SI ranging from 50.3 cm3 to 8276.4 cm3 with a median of 582.1 cm3 and a mean of 771.2 cm3. Majority of patients (83.1%) had PET negative spleen pre-HCT. Stratified analysis and survival plots were obtained based on pre-transplant SV, SI and spleen PET status. The 2-year overall survival (OS) and progression-free survival (PFS) were 57.3% and 44.9%, respectively for all patients. 2-year OS and PFS for patients with SV ≥ 314.5 cm3 was 57.6% (95%CI 44.2-68.8) and 43.2% (95%CI 30.7-55.1), respectively, whereas for patients with SV < 314.5 cm3 was 58.1% (95%CI 45.8-68.5) and 48.4% (95%CI 36.4-59.3), respectively, with no significant differences in OS (p=0.82) or PFS (p=0.63). There were no differences among higher SV or SI vs. normal SV or SI in PET positive population but among PET negative group there was a suggestion of a favorable OS and PFS with normal SV and SI. (Figures 1&2).
Conclusions: There were no significant associations between spleen size or spleen PET status and allo-HCT outcomes (PFS or OS) in patients with lymphoid malignancy. Sample size is limited in our study. Future studies using registry data or larger prospective studies are required to evaluate the impact of splenomegaly and its PET avidity on allo-HCT outcomes in lymphoid malignancies.
Display omitted Display omitted
Locke:Kite Pharma: Other: Scientific Advisory Boards.
•Cyclosporine (CSA) + mycophenolate mofetil (MMF) is associated with increased severe acute graft-versus-host disease GVHD in myeloablative hematopoietic cell transplantation (HCT).•CSA+MMF is ...associated with worse transplantation-related mortality and inferior survival in myeloablative HCT.•Tacrolimus (Tac) + MMF may be a reasonable substitute for Tac+MTX, but only in matched sibling donor myeloablative HCT.•MMF-based regimens are associated with worse graft-versus-host disease-free, relapse-free survival compared with MTX regimens in myeloablative HCT.
Combination therapy with a calcineurin inhibitor (CNI), such as cyclosporine (CSA) or tacrolimus (Tac), and methotrexate (MTX) or mycophenolate mofetil (MMF) is a widely used approach to graft-versus-host disease (GVHD) prevention. Data on the comparative effectiveness of MMF compared with MTX are limited and conflicting, however. We analyzed data from the Center for International Blood and Marrow Transplant Research for adult patients undergoing first myeloablative hematopoietic cell transplantation (HCT) from an HLA-identical matched related donor (MRD; n = 3979) or matched unrelated donor (URD; n = 4163) using CSA+MMF, CSA+MTX, Tac+MMF, or Tac+MTX for GVHD prevention between 2000 and 2013. Within the MRD cohort, 2252 patients received CSA+MTX, 1391 received Tac+MTX, 114 received CSA+MMF, and 222 received Tac+MMF. Recipients of CSA+MMF had a higher incidence of acute GVHD grade II-IV (hazard ratio HR, 1.65; 95% confidence interval CI, 1.24 to 2.20; P < .001) and grade III-IV (HR, 1.92; 95% CI, 1.31 to 2.83; P < .001) compared with Tac+MTX. The use of CSA+MMF was also associated with inferior overall survival (OS) (HR, 2.31; 95% CI, 1.73 to 3.09; P < .001) due to higher transplantation-related mortality (TRM) (HR, 4.03; 95% CI, 2.61 to 6.23; P < .001) compared with Tac+MTX. Within the URD cohort, 974 patients received CSA+MTX, 2697 received Tac+MTX, 68 received CSA+MMF, and 424 received Tac+MMF. CSA+MMF was again significantly associated with a higher incidence of grade III-IV acute GVHD (HR, 2.31; 95% CI, 1.57 to 3.42; P <0001), worse OS (HR, 2.36; 95% CI, 1.67 to 3.35; P < .001), and higher TRM (HR, 3.09; 95% CI, 2.00 to 4.77; P < .001), compared with Tac+MTX and other regimens. Thus, this large retrospective comparison of MMF versus MTX in combination with CSA or Tac demonstrates significantly worse GVHD and survival outcomes with CSA+MMF compared with Tac+MTX.
Introduction: Fludarabine (Flu)-based conditioning regimens, combined with either melphalan (Mel) or intravenous busulfan (Bu), are often utilized in patients undergoing allogeneic hematopoietic cell ...transplantation (HCT) for acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS). While recent data supports that a myeloablative conditioning (MAC) strategy improves survival in patients who are able to tolerate this approach, the optimal regimen for patients elderly or unfit for MAC remains unclear. A single-center retrospective analysis was performed to evaluate outcomes in patients with AML or MDS deemed eligible only for reduced intensity regimens.
Methods: Patients with AML and MDS who underwent peripheral blood mobilized allogeneic HCT at a single institution between January 2008 and December 2014 were identified. Of those, patients who received conditioning with either once-daily Bu (75-95 mg/m2) targeted to an area under the curve of 3500 µM*L/min and Flu 160 mg/m2 (Flu/Bu 3500) or Mel 140 mg/m2 plus Flu 120-160 mg/m2 (Flu/Mel) were evaluated and compared. All disease statuses (complete remission (CR), second CR, or with active disease) at time of HCT were included. Regimen toxicities, cumulative incidences of acute and chronic graft-versus-host disease (GVHD), non-relapse mortality (NRM), cumulative incidence of relapse (CIR), progression free survival (PFS), and overall survival (OS) were evaluated.
Results: We identified 150 consecutive patients who received Flu/Bu 3500 (n=81) or Flu/Mel (n=69). Regimens were selected at physicians’ discretion. The median ages for Flu/Bu 3500 and Flu/Mel were similar (66.9 (range, 48.2-75.9) and 65.8 (40.9-75.2) (p=0.14)). No differences were detected between the two groups with regard to recipient and donor gender, primary disease, donor type, recipient and donor cytomegalovirus (CMV) status, and Karnofsky performance status. Additionally, there were no differences between either groups in disease specific prognostic variables such as Disease Risk Index (Armand et al.), blast percentage at time of HCT, International Prognostic Scoring System (IPSS) and revised IPSS scoring in MDS patients, or AML cytogenetics at time of HCT. Patients receiving Flu/Mel had higher HCT-specific comorbidity index (HCT-CI, >3) when compared to Flu/Bu 3500 prior to transplantation (66.7% versus 46.9%, p=0.02). OS was similar between both arms (p=0.1) as was NRM (Hazard ratio (HR) 0.61 (CI, 0.34 - 1.1, p=0.1)) and PFS, HR 1.26 (CI, 0.83 - 1.94, p=0.2). However, CIR at 2 years post-allograft was significantly higher in the Flu/Bu 3500 arm, HR 2.54 (CI, 1.4 - 4.6, p=0.002) in comparison to Flu/Mel regimen (Figure 1). There was no difference detected in the cumulative incidences of either grades 2-4 acute GVHD, HR 1.00 (CI, 0.66 - 1.55, p=1.0), or grades 3-4 acute GVHD, HR 0.66 (CI, 0.27 - 1.57, p=0.3) between either conditioning regimen. The cumulative incidence of chronic GVHD was also similar, HR 1.27 (CI, 0.84 - 1.92, p=0.2). With regard to toxicity, diarrhea occurred more frequently in the Flu/Mel arm (p=0.0003) in the first 20 days following transplant. However, in the same period, mucositis occurred more frequently in the Flu/Bu 3500 arm (p=0.005). No differences were noted between the arms when assessing incidence of sinusoidal obstructive syndrome, diffuse alveolar hemorrhage, or thrombotic microangiopathy up to 90 days. Amongst patients receiving Flu/Mel, the most common cause of death was pneumonia or pulmonary failure (n=7) whereas the most common cause of death in the Flu/Bu 3500 arm was disease related (n=31).
Conclusion: Flu/Mel resulted in a lower CIR at 2 years post-HCT compared to patients receiving Flu/Bu 3500 conditioning. Regarding toxicity, Flu/Mel produced more diarrhea but significantly less mucositis in comparison to Flu/Bu 3500; otherwise toxicity was comparable. Though there were no differences in OS and NRM between the two conditioning regimens, we speculate that the impact of the higher HCT-CI in the Flu/Mel arm may have contributed negatively to the lack of benefit in NRM and OS.
Locke:Kite: Membership on an entity's Board of Directors or advisory committees. Nishihori:Signal Genetics: Research Funding; Novartis: Research Funding. Fernandez:Chimerix: Honoraria; Otsuka: Honoraria; Sanofi: Speakers Bureau.
•A significant proportion of allogeneic hematopoietic cell transplantation patients with chronic graft-versus-host disease experience financial burden despite being insured. Nonwhite race, lower ...mental functioning, and lower activity score are associated with a higher likelihood of financial burden.•Patients with financial burden had poor psychosocial outcomes, such as greater depression/anxiety and difficulty sleeping.
Understanding the socioeconomic impact of chronic graft-versus-host disease (GVHD) on affected patients is essential to help improve their overall well-being. Using data from the Chronic GVHD Consortium, we describe the insurance, employment, and financial challenges faced by these patients and the factors associated with the ability to work/attend school and associated financial burdens. A 15-item cross-sectional questionnaire designed to measure financial concerns, income, employment, and insurance was completed by 190 patients (response rate, 68%; 10 centers) enrolled on a multicenter Chronic GVHD Consortium Response Measures Validation Study. Multivariable logistic regression models examined the factors associated with financial burden and ability to work/attend school. The median age of respondents was 56years, and 87% of the patients were white. A higher proportion of nonrespondents had lower income before hematopoietic cell transplantation and less than a college degree. All but 1 patient had insurance, 34% had faced delayed/denied insurance coverage for chronic GVHD treatments, and 66% reported a financial burden. Patients with a financial burden had greater depression/anxiety and difficulty sleeping. Nonwhite race, lower mental functioning, and lower activity score were associated with a greater likelihood of financial burden. Younger age, early risk disease, and higher mental functioning were associated with a greater likelihood of being able to work/attend school. In this multicenter cohort of patients with chronic GVHD, significant negative effects on finances were observed even with health insurance coverage. Future research should investigate potential interventions to provide optimal and affordable care to at-risk patients and prevent long-term adverse financial outcomes in this vulnerable group.
In this issue of
Blood,
Crivello et al
report a novel approach to characterize HLA-DPB1 mismatches between donor and recipients that are better tolerated than others after hematopoietic cell ...transplantation (HCT) from unrelated volunteer donors.
1
We have been able to isolate several phytotoxic compounds from aqueous extracts and leachates of cattails (Typha domingensis) using activated charcoal as an absorbant, followed by successive ...extraction with organic solvents, analysis by GC/MS, and structural elucidation by NMR spectroscopy when possible. The phytotoxins were identified as essential fatty acids (linoleic acid and alpha-linolenic acid) and phenolic compounds of known phytotoxic activity (caffeic acid from the aqueous extracts; caffeic, p-coumaric, and gallic acid from the leachates). Both extracts and the phytotoxins in the extracts have the potential of inhibiting the growth and chlorophyll production of several ecologically relevant species.
PDF
