TY - JOUR
T1 - Graft-versus-host disease and graft-versus-tumor effects after allogeneic hematopoietic cell transplantation
AU - Storb, Rainer
AU - Gyurkocza, Boglarka
AU - Storer, Barry E.
AU - Sorror, Mohamed L.
AU - Blume, Karl
AU - Niederwieser, Dietger
AU - Chauncey, Thomas R.
AU - Pulsipher, Michael A.
AU - Petersen, Finn B.
AU - Sahebi, Firoozeh
AU - Agura, Edward D.
AU - Hari, Parameswaran
AU - Bruno, Benedetto
AU - McSweeney, Peter A.
AU - Maris, Michael B.
AU - Maziarz, Richard T.
AU - Langston, Amelia A.
AU - Bethge, Wolfgang
AU - Vindeloøv, Lars
AU - Franke, Georg Nikolaus
AU - Laport, Ginna G.
AU - Yeager, Andrew M.
AU - Hübel, Kai
AU - Deeg, H. Joachim
AU - Georges, George E.
AU - Flowers, Mary E.D.
AU - Martin, Paul J.
AU - Mielcarek, Marco
AU - Woolfrey, Ann E.
AU - Maloney, David G.
AU - Sandmaier, Brenda M.
PY - 2013/4/20
Y1 - 2013/4/20
N2 - Purpose We designed a minimal-intensity conditioning regimen for allogeneic hematopoietic cell transplantation (HCT) in patients with advanced hematologic malignancies unable to tolerate high-intensity regimens because of age, serious comorbidities, or previous high-dose HCT. The regimen allows the purest assessment of graft-versus-tumor (GVT) effects apart from conditioning and graftversus- host disease (GVHD) not augmented by regimen-related toxicities. Patients and Methods Patients received low-dose total-body irradiation ± fludarabine before HCT from HLA-matched related (n = 611) or unrelated (n = 481) donors, followed by mycophenolate mofetil and a calcineurin inhibitor to aid engraftment and control GVHD. Median patient age was 56 years (range, 7 to 75 years). Forty-five percent of patients had comorbidity scores of ≥ 3. Median follow-up time was 5 years (range, 0.6 to 12.7 years). Results Depending on disease risk, comorbidities, and GVHD, lasting remissions were seen in 45% to 75% of patients, and 5-year survival ranged from 25% to 60%. At 5 years, the nonrelapse mortality (NRM) rate was 24%, and the relapse mortality rate was 34.5%. Most NRM was a result of GVHD. The most significant factors associated with GVHD-associated NRM were serious comorbidities and grafts from unrelated donors. Most relapses occurred early while the immune system was compromised. GVT effects were comparable after unrelated and related grafts. Chronic GVHD, but not acute GVHD, further increased GVT effects. The potential benefit associated with chronic GVHD was outweighed by increased NRM. Conclusion Allogeneic HCT relying on GVT effects is feasible and results in cures of an appreciable number of malignancies. Improved results could come from methods that control progression of malignancy early after HCT and effectively prevent GVHD.
AB - Purpose We designed a minimal-intensity conditioning regimen for allogeneic hematopoietic cell transplantation (HCT) in patients with advanced hematologic malignancies unable to tolerate high-intensity regimens because of age, serious comorbidities, or previous high-dose HCT. The regimen allows the purest assessment of graft-versus-tumor (GVT) effects apart from conditioning and graftversus- host disease (GVHD) not augmented by regimen-related toxicities. Patients and Methods Patients received low-dose total-body irradiation ± fludarabine before HCT from HLA-matched related (n = 611) or unrelated (n = 481) donors, followed by mycophenolate mofetil and a calcineurin inhibitor to aid engraftment and control GVHD. Median patient age was 56 years (range, 7 to 75 years). Forty-five percent of patients had comorbidity scores of ≥ 3. Median follow-up time was 5 years (range, 0.6 to 12.7 years). Results Depending on disease risk, comorbidities, and GVHD, lasting remissions were seen in 45% to 75% of patients, and 5-year survival ranged from 25% to 60%. At 5 years, the nonrelapse mortality (NRM) rate was 24%, and the relapse mortality rate was 34.5%. Most NRM was a result of GVHD. The most significant factors associated with GVHD-associated NRM were serious comorbidities and grafts from unrelated donors. Most relapses occurred early while the immune system was compromised. GVT effects were comparable after unrelated and related grafts. Chronic GVHD, but not acute GVHD, further increased GVT effects. The potential benefit associated with chronic GVHD was outweighed by increased NRM. Conclusion Allogeneic HCT relying on GVT effects is feasible and results in cures of an appreciable number of malignancies. Improved results could come from methods that control progression of malignancy early after HCT and effectively prevent GVHD.
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U2 - 10.1200/JCO.2012.45.0247
DO - 10.1200/JCO.2012.45.0247
M3 - Article
C2 - 23478054
AN - SCOPUS:84876329801
SN - 0732-183X
VL - 31
SP - 1530
EP - 1538
JO - Journal of Clinical Oncology
JF - Journal of Clinical Oncology
IS - 12
ER -