Search

•Use of total marrow and lymphoid irradiation (TMLI) is associated with good survival in patients undergoing hematopoietic stem cell transplantation for acute lymphoblastic leukemia.•The Day 100 non-relapse mortality is low at 15.5%•Overall and disease-free survival is superior in patients undergoing haplo-identical transplants compared with myeloablative fludarabine/busulfan.•Outcomes of TMLI and total body irradiation are equivalent in patients undergoing matched sibling donor transplants.

Haploidentical stem cell transplantation (SCT) using post-transplantation cyclophosphamide for graft-versus-host disease (GVHD) prophylaxis is a reasonable therapeutic option for patients who do not have a matched sibling donor. Between 2010 and June 2020, 257 patients underwent 269 Haploidentical transplantations, including 122 children. Indications included both malignant (56.8%) and non-malignant (43.2%) diseases. Conditioning regimens included both myeloablative (57.6%) and nonmyeloablative regimens (42.4%). Peripheral blood stem cells were the predominant graft source (96.2%). Based on the disease risk index, patients were classified into early-, intermediate-, and late-stage disease. Engraftment was seen in 205 patients (76.2%) whereas 39 (14.4%) died before engraftment and 23 (8.6%) had primary graft failure. The cumulative incidence of grade II-IV acute GVHD was 47.8% with a 23.9% incidence of grade III-IV acute GVHD. Chronic GVHD was seen in 41.9% with a 15.4% incidence of extensive chronic GVHD. More than 90% had at least 1 documented infection with a 44% incidence of bacterial, 71% viral, and 38% fungal infection. The 2-year overall survival is 40.5% ± 3.2% with a higher survival among children (48.2% ± 3.4%) compared to adults (34.2% ± 4.1%). Survival was poor with late-stage disease (23.6% ± 4.3%) compared to early- (62.5% ± 7.5%) and intermediate-stage (50.3% ± 4.3%). Factors adversely affecting survival included older age of patient (P = .007), late disease status (P = .000), nonmyeloablative conditioning regimen (P = .003), bone marrow as graft source (P = .006), presence of acute GVHD (P = .069), primary graft failure (P = .000), and presence of a documented bacterial (P = .000) and fungal infection (P = .000). On multivariate analysis, older age (P = .027), presence of acute GVHD (P = .033), documented bacterial infection (P = .000), documented fungal infection (P = .000) and primary graft failure (P = .012) continued to remain significant. Haploidentical SCT offers a reasonable chance of cure for patients with both malignant and nonmalignant hematological diseases. Strategies to reduce aGVHD and infection related mortality needs to be explored further.

Introduction

Introduction:The optimal induction regimen for an allogeneic hematopoietic cell transplant (allo-HCT) for a young adult patient diagnosed with acute myeloid leukemia (AML) remains to be defined. Among reduced intensity regimens (RIC), retrospective registry data from both CIBMTR and EBMT would suggest that a Fludarabine / Melphalan (Flu/Mel) regimen was superior to a Fludarabine / Busulfan x 2 (Flu/Bu2) regimen. The need for a myeloablative conditioning regimen over a RIC has been evaluated in at least six randomized clinical trials (RCT), and the results have yet to be uniform. Published meta-analysis suggests equipoise. The studies are further limited by including a heterogenous group of conditioning regimens, especially in the reduced intensity arm; they all come from developed countries, a mix of AML and MDS in most studies, and variation in age groups enrolled in them. In India and developing countries, there remain significant challenges with multi-drug resistant infections, financial constraints, and challenges with intensive care support. We hypothesize that in this setting, a reduced toxicity regimen, such as a combination of Fludarabine with Melphalan (140 mg/m 2) (Flu/Mel), may be preferable to a myeloablative regimen.

Introduction:Drug resistance and relapse are considered to be the major reasons for treatment failure in acute myeloid leukemia (AML). There is limited data on the role of ABC transporter expression on in vitrosensitivity to cytarabine (Ara-C) and daunorubicin (Dnr) in primary AML cells. Patients & methods:RNA expression levels of 12 ABC transporters were analyzed by real-time quantitative PCR in 233 de novoadult acute myeloid leukemia patients. Based on cytarabine or Dnr IC50, the samples were categorized as sensitive, intermediate and resistant. Role of candidate ABC transporter RNA expression on in vitrocytotoxicity, treatment outcome post therapy as well as the influence of various prognostic markers on ABC transporter expression were analyzed. Results:Expression of ABCC3and ABCB6were significantly higher in Dnr-resistant samples when compared with Dnr-sensitive samples. Increased ABCC1expression was associated with poor disease-free survival in this cohort of patients. Conclusion:This comprehensive analysis suggests ABCC1, ABCC3, ABCB6and ABCA5as probable targets which can be modulated for improving chemotherapeutic responses.

Data on minimal residual disease (MRD) monitoring in acute promyelocytic leukemia (APL) are available only in the context of conventional all-trans retinoic acid plus chemotherapy regimens. It is recognized that the kinetics of leukemia clearance is different with the use of arsenic trioxide (ATO) in the treatment of APL. We undertook a prospective peripheral blood RT-PCR–based MRD monitoring study on patients with APL treated with a single agent ATO regimen. A total of 151 patients were enrolled in this study. A positive RT-PCR reading at the end of induction therapy was significantly associated on a multivariate analysis with an increased risk of relapse (relative risk = 4.9; P = .034). None of the good risk patients who were RT-PCR negative at the end of induction relapsed. The majority of the relapses (91%) happened within 3 years of completion of treatment. After achievement of molecular remission, the current MRD monitoring strategy was able to predict relapse in 60% of cases with an overall sensitivity and specificity of 60% and 93.2%, respectively. High-risk group patients and those that remain RT-PCR positive at the end of induction are likely to benefit from serial MRD monitoring by RT-PCR for a period of 3 years from completion of therapy.

Data on minimal residual disease (MRD) monitoring in acute promyelocytic leukemia (APL) are available only in the context of conventional all-transretinoic acid plus chemotherapy regimens. It is recognized that the kinetics of leukemia clearance is different with the use of arsenic trioxide (ATO) in the treatment of APL. We undertook a prospective peripheral blood RT-PCR–based MRD monitoring study on patients with APL treated with a single agent ATO regimen. A total of 151 patients were enrolled in this study. A positive RT-PCR reading at the end of induction therapy was significantly associated on a multivariate analysis with an increased risk of relapse (relative risk = 4.9; P= .034). None of the good risk patients who were RT-PCR negative at the end of induction relapsed. The majority of the relapses (91%) happened within 3 years of completion of treatment. After achievement of molecular remission, the current MRD monitoring strategy was able to predict relapse in 60% of cases with an overall sensitivity and specificity of 60% and 93.2%, respectively. High-risk group patients and those that remain RT-PCR positive at the end of induction are likely to benefit from serial MRD monitoring by RT-PCR for a period of 3 years from completion of therapy.

No relevant conflicts of interest to declare.

Patients and methods

Arsenic trioxide, as a single agent, has proven efficacy in inducing molecular remission in patients with acute promyelocytic leukemia (APL). There is limited long-term outcome data with single-agent As2O3 in the management of newly diagnosed cases of APL. Between January 1998 to December 2004, 72 newly diagnosed cases of APL were treated with a regimen of single-agent As2O3 at our center. Complete hematologic remission was achieved in 86.1%. At a median follow-up of 25 months (range: 8-92 months), the 3-year Kaplan-Meier estimate of EFS, DFS, and OS was 74.87% ± 5.6%, 87.21% ± 4.93%, and 86.11% ± 4.08%, respectively. Patients presenting with a white blood cell (WBC) count lower than 5 × 109/L and a platelet count higher than 20 × 109/L at diagnosis (n = 22 [30.6%]) have an excellent prognosis with this regimen (EFS, OS, and DFS of 100%). The toxicity profile, in the majority, was mild and reversible. After remission induction, this regimen was administered on an outpatient basis. Single-agent As2O3, as used in this series, in the management of newly diagnosed cases of APL, is associated with responses comparable with conventional chemotherapy regimens. Additionally, this regimen has minimal toxicity and can be administered on an outpatient basis after remission induction.

Arsenic trioxide, as a single agent, has proven efficacy in inducing molecular remission in patients with acute promyelocytic leukemia (APL). There is limited long-term outcome data with single-agent As2O3in the management of newly diagnosed cases of APL. Between January 1998 to December 2004, 72 newly diagnosed cases of APL were treated with a regimen of single-agent As2O3at our center. Complete hematologic remission was achieved in 86.1%. At a median follow-up of 25 months (range: 8-92 months), the 3-year Kaplan-Meier estimate of EFS, DFS, and OS was 74.87% ± 5.6%, 87.21% ± 4.93%, and 86.11% ± 4.08%, respectively. Patients presenting with a white blood cell (WBC) count lower than 5 × 109/L and a platelet count higher than 20 × 109/L at diagnosis (n = 22 [30.6%]) have an excellent prognosis with this regimen (EFS, OS, and DFS of 100%). The toxicity profile, in the majority, was mild and reversible. After remission induction, this regimen was administered on an outpatient basis. Single-agent As2O3, as used in this series, in the management of newly diagnosed cases of APL, is associated with responses comparable with conventional chemotherapy regimens. Additionally, this regimen has minimal toxicity and can be administered on an outpatient basis after remission induction.

Allogeneic stem cell transplantation (SCT) is a curative treatment for beta-thalassemia major. The Pesaro risk stratification classifies patients with thalassemia into three groups (class I, II, and III) to predict the transplant-related mortality (TRM) and graft rejection after myeloablative conditioning with busulfan and cyclophosphamide. However, in developing countries, where inadequate chelation therapy prior to transplant is common, most patients would fall under the class III category. There is heterogeneity in the clinical outcomes in this group. Hence, our center introduced a further refinement in this risk stratification, identifying a subset of “class III high risk” as those with age greater than or equal to 7 years and liver size > 5cm (Mathews V et al. BBMT 2007). Subsequently, we showed that the use of a conditioning regimen containing thiotepa, treosulfan, and fludarabine (TTF) along with a peripheral blood stem cell graft led to improved outcomes in this subset with a reduction in early TRM from 46% (with busulfan-cyclophosphamide) to 13% (Mathews V et al. PLoS One 2013). There is still a need to identify predictors of poor clinical outcomes to optimize further the clinical outcomes of these class III high-risk thalassemia patients. Endothelial activation and stress index (EASIX) is a simple biomarker calculated using lactate dehydrogenase, creatinine, and platelet counts. EASIX has been shown to be predictive of overall survival in various settings like GVHD following reduced-intensity transplants for malignancies in adults, veno-occlusive disease, and nonrelapse mortality following SCT (Luft T et al. Lancet Haem 2017; Jiang S et al. Haematologica 2021; Luft T et al. BMT 2020). Here, we evaluated the role of EASIX (measured before conditioning therapy) as a biomarker in predicting early TRM in patients with thalassemia major who have undergone SCT with a uniform conditioning regimen using TTF at our center. During the study period from January 2012 to December 2019, 281 patients with thalassemia major underwent SCT with a uniform TTF protocol at our center. The median age was nine years (range 1 to 25 years). One hundred and nine (38.8%) were females. As per Pesaro classification (with Vellore modification), three (1.1%) were class I, 34 (12.1%) were class II, 134 (47.7%) were class III low risk, and 110 (39.1%) were class III high risk. The stem cell donors were matched sibling (n=218, 77.6%), matched related non-sibling (n=23, 8.2%), or matched unrelated donors (n=40, 14.2%). The stem cell donor was HLA matched in all cases except 21 (7.5%), wherein there was a mismatch at one locus. Five (1.8%) had a bone marrow graft, while others had peripheral blood stem cell grafts. Thirty-eight (13.5%) patients had transplant-related mortality by day 100 (TRM100). The median follow-up of the cohort was 31 months (range 0 to 103 months). EASIX score pre-transplant was available for 184 (65.5%) patients. There was no difference in the rate of TRM100 in patients where EASIX was available compared to those where EASIX was not available (14.7% versus 11.3%, p 0.47). Also, there was no difference in overall mortality rate in patients where EASIX was available compared to those where EASIX was not available (21.2% versus 17.5%, p 0.53). Among patients with TRM100 vis-à-vis those who did not, the median EASIX score was significantly higher (1.09 versus 0.75, p 0.008). We then plotted a receiver operating characteristics (ROC) curve for predicting TRM100 using the EASIX score. The area under the curve was 0.661 (Figure 1a). A cut-off of 0.85 for the EASIX score had a 70.4% sensitivity and 62% specificity for predicting TRM100. The TRM100 for patients with EASIX above 0.85 was significantly higher than those with EASIX less than 0.85 (24.4% versus 7.5%, p 0.003). On multivariable logistic regression analysis, the factors independently predicting TRM100 were pre-transplant EASIX score, pre-transplant ferritin, unrelated donor source, and chimerism at day 60 (Figure 1b). In patients with thalassemia major undergoing SCT using a uniform TTF conditioning, EASIX score measured pre-transplant can identify patients at greater risk for Day100 TRM.

Introduction

Mathews: Christian Medical College: Patents & Royalties: US 2020/0345770 A1 - Pub.Date Nov.5, 2020; AML: Other: Co-Inventor.

Mathews: Christian Medical College: Patents & Royalties: US 2020/0345770 A1 - Pub.Date Nov.5, 2020; AML: Other: Co-Inventor.

•An antithymocyte globulin-free protocol using fludarabine and cyclophosphamide as conditioning for matched sibling donor transplantation in patients with aplastic anemia was evaluated.•Overall survival was reasonable at 75%, with >80% survival in patients age <20 years.•The incidence of graft-versus-host disease (GVHD) was low at 27.6% for acute GVHD and 41.6% for chronic GVHD.•Most patients (80%) were free of immunosuppression at 5 years post-transplantation.•The rate of long-term complications was very low.

No relevant conflicts of interest to declare.

A toxicity reduced conditioning regimen containing Treosulfan (Treo), Fludarabine (Flu), Thiotepa in patients with class III high risk thalassemia major (TM) has significantly improved transplant outcomes compared to the historical Busulfan/cyclophosphamide based myeloablative regimen (Mathews et al, 2013).However, complications related to mixed chimerism, rejection and regimen related toxicity remain. Analysis of Treo pharmacokinetics (PK) in TM showed significant inter individual variation but no association with HSCT outcome (Mohanan et al, 2018).This may be attributed to the fact that only the pro-drug Treo was measured and not its active metabolites. Treo, administered as a prodrug, is converted non-enzymatically to its active metabolite monoepoxide 2S, 3S-1,2-epoxybutane-3,4-diol-4-methanesulfonate (S, S-EBDM) and (2S,3S)- 1,2:3,4-diepoxybutane (S, S-DEB) that causes cytotoxicity. We have now assessed the PK of both Treo and S, S-EBDM and the factors which may influence the inter-individual variation in PK, and their impact on HSCT outcome in patients with TM.

Among transplant related complications, graft versus host disease (GvHD) significantly affects survival among patients undergoing allogeneic hematopoietic stem cell transplantation (aHSCT). There is limited data on GvHD and its impact on outcomes of aHSCT in patients with thalassemia major (TM). We have reviewed the incidence and outcome of GVHD among patients with TM who underwent aHSCT at our center.

No relevant conflicts of interest to declare.

Background: Fludarabine based conditioning protocols are increasingly being used for transplant (SCT) in patients with aplastic anaemia (AA) especially in those who have received multiple transfusions.

No relevant conflicts of interest to declare.

No relevant conflicts of interest to declare.

No relevant conflicts of interest to declare.

No relevant conflicts of interest to declare.

No relevant conflicts of interest to declare.

No relevant conflicts of interest to declare.

Targeted intravenous (IV) Busulfan (TBu) in combination with cyclophosphamide (Cy) is widely used as a preparative regimen in children with thalassemia major undergoing matched allogeneic haematopoietic stem cell transplantation (HSCT) to reduce toxicity. At our centre, we have been using TBu/Cy regimen since 2011 for very young children (Pesaro class I/II risk status) and with matched related donors. We have compared the outcome of HSCT in this group of patients with a retrospective cohort (from 1995-2009) of age and risk status matched patients receiving fixed dose oral Bu without PK monitoring.

The development of inhibitors is the most serious adverse effect of replacement theray with clotting factor concentrates (CFC) in hemophilia. Its eradication is also difficult, usually requiring months of frequent exposure to high doses of the CFC - immune tolerance induction (ITI). There is limited data on use of extended half-life (EHL) CFC for ITI. A limited program of ITI was made possible in India with some of the rFVIIIFc (Eloctate™) provided through the humanitarian aid program of the World Federation of Hemophilia. This report summarizes the interim outcome of ITI in these patients treated at three centers participating in this program.

Introduction: Haploidentical transplants are increasingly being used in patients who need a transplant but do not have a matched sibling or unrelated donor. The easy availability of a family donor makes it very attractive but it is associated with its own specific complications. We present the outcomes of haplo-identical transplants from a single centre in India

Introduction:After successful allogeneic hematopoetic stem cell transplantation (aHSCT) for thalassemia major (TM), these “ex-thalassemics” require effective management of pre-existing transfusion related complications. Reduction of iron overload which is prevalent in almost all of these patients is one of the major goals of this therapy. Even though several thousand aHSCTs have been done for TM, there is very limited data on the approach to iron reduction therapy (IRT) and its outcome. We report the outcome of IRT in the largest cohort of ex-thalassemics to be reported so far.

Introduction:Even though episodic replacement of clotting factor concentrate (CFC) at doses ranging from 1000-2000 IU/kg/year does alter the natural bleeding profile of patients with hemophilia in a way that can prevent long term musculoskeletal damage (Poonnoose et al, Haemophilia, 2017), it continues to be widely used around the world because most patients do not have access to standard dose prophylaxis with 30-40 IU/kg of CFC 2-3 times/week. We have prospectively evaluated the effectiveness of prophylaxis at lower doses in minimally treated young children with severe hemophilia.

Introduction

Telomeres are nucleotide repeats at the ends of the chromosomes that function as protective caps to prevent erosion of genomic DNA during cell division. With each mitotic division, telomeric DNA becomes shorter and at a critically short length, cells become senescent or undergo apoptosis. Idiopathic aplastic anemia (AA) is a bone marrow failure disorder characterized by peripheral blood pancytopenia and bone marrow aplasia. Studies have shown that 30-50% of patients with aplastic anaemia will have short telomeres and these short telomeres are associated with relapse, clonal evolution and poor survival following immunosuppressive therapy. We analysed the telomere length in patients with aplastic anaemia from a single centre in India.

Introduction:We have shown before that treosulfan based conditioning improves outcome of allogeneic hematopoietic stem cell transplantation (aHSCT) in patients with thalassemia major (TM), particularly in those with class 3 high risk disease. (Mathews et al, PLoS ONE, 2013) Treosulfan is a bi-functional alkylating agent, similar to busulfan except for two additional hydroxyl moieties. Unlike busulfan, treosulfan is a prodrug which non-enzymatically converts into its mono and di-epoxide active derivatives. Treosulfan (Medac, GmbH, Germany) (TreoM) is the only product currently available. Its cost accounts for nearly 20-25% of the total cost of aHSCT in India. There is limited data on the pharmacokinetics (PK) of Treosulfan in thalassemia major or its correlation with clinical outcomes and toxicities. In this analysis, we have evaluated the PK of Treosulfan with two different Treosulfan formulations, TreoM and Treosulfan (Emcure, Pune, India) (TreoE), in patients with TM undergoing aHSCT at our center and correlated them with outcomes.

BK virus (BKV) is a human polyomavirus that usually causes asymptomatic or mild respiratory illness in childhood and thereafter remains latent in renal epithelial cells. With decreased cell-mediated immunity, reactivation of BKV causing haemorrhagic cystitis (HC) is a well-known complication of haematopoietic stem cell transplantation (HSCT) that is associated with increased morbidity, mortality, longer hospital stays and increased hospital costs. This analysis was done to ascertain etiological risk factors, incidence and outcomes of BKV induced HC following HSCT.

No relevant conflicts of interest to declare.

No relevant conflicts of interest to declare.

No relevant conflicts of interest to declare.

No relevant conflicts of interest to declare.

Introduction:

Graft rejection (GR) following an allo-SCT occurs in 10-20% of patients with β thalassemia major (TM). The reported clinical outcome following second transplants have been associated with a high incidence of graft rejection, treatment related mortality, and graft versus host disease [Haematologica 2009; 94(9)]. There is limited data on the clinical profile and long term outcome of patients who have had a graft rejection. We undertook a retrospective analysis of patients who had a graft failure post allogeneic SCT for TM at our center.

An allogeneic stem cell transplant (SCT) remains the only curative option for patients with β thalassemia major (TM). Conventional pre-transplant risk stratification is limited by its subjective nature of definition of hepatomegaly, adequacy of chelation therapy and also the need for an invasive liver biopsy. We have previously reported on the significant limitations in applying this risk stratification in our population (developing country) where the majority will fall into the high risk Class III group and further there is significant heterogeneity within this Class III subset that is not recognized by the conventional risk stratification (BBMT 2007;13:889). The major determinant of pre-transplant risk in patients with TM is related to iron overload, in organs such as the liver and heart. T2* magnetic resonance imaging (T2*MRI) has been widely utilized as a non-invasive measure of iron overload in these organs and has been reported to predict organ dysfunction and to guide adequacy of therapy. There is however no data available on the role of T2*MRI in pre-transplant risk assessment of patients with TM.

▪

No relevant conflicts of interest to declare.

Allogeneic hematopoietic stem cell transplantation (Allo-SCT) with fludarabine based reduced intensity or toxicity reduced conditioning regimen with Busulfan or Melphalan (Flu/Bu; Flu/Mel) has improved HSCT outcome in patients with AML. Limited reports on the PK of Flu in patients with malignant hematological diseases undergoing Allo-SCT suggest that Flu AUC is associated with transplant related mortality (TRM) (Long-Boyle et al, 2011). We prospectively analyzed the PK and pharmacogenetics (PG) of Flu and Bu on Allo-SCT outcome in patients with AML receiving Flu/Bu or Flu/Mel based regimen.

No relevant conflicts of interest to declare.

No relevant conflicts of interest to declare.

No relevant conflicts of interest to declare.