Natasha A. Jain

A multigene array for measurable residual disease detection in AML patients undergoing SCT

AML is a diagnosis encompassing a diverse group of myeloid malignancies. Heterogeneous genetic etiology, together with the potential for oligoclonality within the individual patient, have made the identification of a single high-sensitivity marker of disease burden challenging. We developed a multiple gene measurable residual disease (MG-MRD) RQ–PCR array for the high-sensitivity detection of AML, retrospectively tested on 74 patients who underwent allo-SCT at the NHLBI in the period 1994–2012. MG-MRD testing on peripheral blood samples prior to transplantation demonstrated excellent concordance with traditional BM-based evaluation and improved risk stratification for post-transplant relapse and OS outcomes. Pre-SCT assessment by MG-MRD predicted all clinical relapses occurring in the first 100 days after allo-SCT compared with 57% sensitivity using WT1 RQ–PCR alone. Nine patients who were negative for WT1 prior to transplantation were correctly reclassified into a high-risk MG-MRD-positive group, associated with 100% post-transplant mortality. This study provides proof of principle that a multiple gene approach may be superior to the use of WT1 expression alone for AML residual disease detection.

Expression of putative targets of immunotherapy in acute myeloid leukemia and healthy tissues

The ability to target myeloid malignancies using immunotherapy through means other than allogeneic transplantation depends on the capability to target leukemic clones while sparing normal tissues. It is now possible to generate clinical grade ex-vivo expanded T cells specific for leukemia-associated antigens (LAAs) for use in adoptive cell therapy.1 Although a variety of putative LAAs in acute myeloid leukemia (AML) have been identified for use as potential targets for immunotherapy2, 3, 4, 5, 6, 7, 8 and consensus panels have attempted to prioritize generic cancer antigens,9 a comprehensive evidence-based list of AML antigen targets has not yet been established. As a first step toward this goal, we therefore analyzed, using quantitative real-time PCR, the gene expression of 65 potential LAAs (Supplementary Table S1) in de-identified, clinically annotated samples from 48 newly diagnosed untreated AML patients that were collected under institutional review board-approved protocols from three NCCN cancer centers.

Male survivors of allogeneic hematopoietic stem cell transplantation have a long term persisting risk of cardiovascular events

Long-term survivors of allogeneic stem cell transplantation (SCT) have increased risk of cardiovascular disease. We retrospectively studied cardiovascular risk factors (CVRFs) in 109 SCT survivors (62 males, 47 females; median age 34 years) five years or more after bone marrow (15) or T cell-depleted peripheral blood (94) SCT for CML (56), acute leukemia (29), MDS (13), and others (11). One death and two cardiovascular events were reported. At five and ten years after SCT, respectively, 44% and 52% had abnormal lipid profiles; 23% of 5-year survivors met the Adult Treatment Panel III threshold for dyslipidemia treatment, which is substantially higher than the age-matched general population. There were significant increases in prevalence of hypertension (p < 0.001), diabetes (p = 0.018), and body mass index (p = 0.044) after SCT compared with baseline. The Framingham general cardiovascular risk score (FGCRS) in males at five years after SCT projected a doubling (median 10.4% vs. 5.4%) in the 10-year risk of cardiovascular events. Females received HRT after SCT, and none had increased FGCRS. Chronic GVHD and C-reactive protein were not associated with CVRF at any time. All CVRFs stabilized between five and ten years after SCT. Thus, SCT survivors have sustained elevations in CVRFs. Males have a significantly increased risk of cardiovascular events in their second and third decade after SCT.

Contrast enhanced cardiac CT reveals coronary artery disease in 45% of asymptomatic allo-SCT long-term survivors.

Contrast enhanced cardiac CT reveals coronary artery disease in 45% of asymptomatic allo-SCT long-term survivors

Repair of Impaired Pulmonary Function Is Possible in Very-Long-Term Allogeneic Stem Cell Transplantation Survivors

Both early- and late-onset noninfectious pulmonary injury are important contributors to the nonrelapse mortality seen after allogeneic stem cell transplantation (allo-SCT), particularly in subjects conditioned with high-dose total body irradiation (TBI). To characterize the kinetics of recovery from pulmonary injury in long-term survivors, we collected data on 138 subjects who survived > 3 years (median survival, 10.2 years) after predominantly TBI-based allo-SCT from their HLA-matched siblings. Baseline pulmonary function tests served as the reference for subsequent measurements at 3, 5, 10, and 15 years for each survivor. The only parameter showing a clinically and statistically significant decline post-transplant was adjusted diffusion capacity of lung for carbon monoxide (DLCO), which reached a nadir at 5 years but surprisingly normalized at the 10-year mark. Multivariable modeling identified chronic graft-versus-host disease (P < .02) and abnormal baseline-adjusted DLCO (P < .03) as the only significant factors associated with the decline in adjusted DLCO at 5 years but excluded smoking, conditioning intensity, baseline C-reactive protein level, TBI dose to the lungs, disease, and demographic variables. In conclusion, pulmonary injury as monitored by the adjusted DLCO continues to deteriorate in the first 5 years after allo-SCT but recovers at 10 years.

Factors influencing the late phase of recovery after bone mineral density loss in allogeneic stem cell transplantation survivors.

Accelerated bone mineral density loss (BMDL) occurs early after allogeneic stem cell transplantation (SCT) and is related to factors such as steroids and chronic GvHD. In order to understand the natural history of BMDL of SCT in the longer term, we evaluated a longitudinal cohort of 148 survivors with a median follow-up of 12 years (range 3–22 years). All women received hormone replacement therapy, and routine calcium/vitamin D supplementation was recommended but ∼50% of patients still had suboptimal vitamin D levels and bisphosphonates were rarely utilized. BMD significantly improved from 5 to 20+ years but the femoral neck and forearm remained vulnerable sites. Younger age, higher pretransplant body mass index (BMI) and increment in BMI post transplant were significantly associated with increased BMD and protected against osteopenia/osteoporosis. These findings support consideration of BMD loss in SCT survivors in two phases, an early phase of BMD loss (3–5 years) followed by a later phase of BMD recovery, with different protective and aggravating factors. Treatment- and transplant-related factors (such as steroids, immunosuppressives, chronic GvHD, vitamin D) are known to impact the early phase of BMD loss but age and BMI are more influential in the late phase of BMD recovery.

Clinical and biological predictors of outcome following relapse of CML post-allo-SCT.

While there are now fewer allogeneic stem cell transplants (allo-SCT) performed for chronic myeloid leukemia (CML), leukemic relapse post-transplant remains a persistent problem. To better define clinical and biological parameters determining post-relapse outcome, we studied 59 patients with CML relapsing after HLA-identical sibling allo-SCT between 1993 and 2008. Eighteen (30.5%) were transplanted in advanced phase and 41(69.5%) in chronic phase. With a median follow up from relapse of 7.9 years, 5-year post-relapse survival (PRS) was 62%. Multivariate analysis found disease status at transplant, time to diagnosis of relapse from transplant, and pre- transplant TKI use as significant factors associated with PRS. Analysis of BCR-ABL transcript expression in the hematopoietic progenitor compartment was performed in 36 patients (22 relapsed, 8 non-relapsed, and 6 TKI alone controls). Patients with BCR-ABL expression in their early hematopoietic stem cell compartment (HSC: Lineage−CD34+CD38-CD90+) had worse survival irrespective of the disease status. We conclude disease status remains the strongest clinical prognostic factor for PRS in CML following allo-SCT. The persistence of BCR-ABL expression in the progenitor cell compartment in some patients after SCT emphasizes the need to target CML-leukemia stem cells.Although there are now fewer allo-SCTs performed for CML, leukemic relapse post transplant remains a persistent problem. To better define clinical and biological parameters determining postrelapse outcome, we studied 59 patients with CML relapsing after HLA-identical sibling allo-SCT between 1993 and 2008. Eighteen (30.5%) were transplanted in advanced phase and 41 (69.5%) in chronic phase. With a median follow-up from relapse of 7.9 years, 5-year post relapse survival (PRS) was 62%. Multivariate analysis found disease status at transplant, time to diagnosis of relapse from transplant and pretransplant tyrosine kinase inhibitor (TKI) use as significant factors associated with PRS. Analysis of BCR-ABL transcript expression in the hematopoietic progenitor compartment was performed in 36 patients (22 relapsed, 8 non-relapsed and 6 TKI alone controls). Patients with BCR-ABL expression in their early hematopoietic stem cell compartment (Lineage−CD34+CD38−CD90+) had worse survival irrespective of the disease status. We conclude that disease status remains the strongest clinical prognostic factor for PRS in CML following allo-SCT. The persistence of BCR-ABL expression in the progenitor cell compartment in some patients after SCT emphasizes the need to target CML-leukemia stem cells.

Clinical comorbidity predictive measures in ex vivo T-cell-depleted allogeneic hematopoietic stem cell transplantation

Clinical comorbidity predictive measures in ex vivo T-cell-depleted allogeneic hematopoietic stem cell transplantation

Premature coronary artery disease following allogeneic stem cell transplantation: an NHLBI Cohort Study

Recipients of allogeneic hematopoietic cell transplantation (HCT) are now surviving longer due to impressive reductions in early transplant-related mortality [1]. Delayed transplant-related mortality in long-term allogeneic HCT survivors now exceeds relapse-related mortality [2, 3]. For such patients surviving at 2 years, the probability of surviving 10 years beyond HCT is 85% [3]. However, survivors of allogeneic HCT have a threefold higher incidence of arterial events than after autologous HCT [4]. The traditional cardiovascular risk factors (hypertension, dyslipidemia, smoking, diabetes, and obesity) are associated with higher rates of arterial events in these patients and these occur relatively early, at a median age of 53 years [5]. Concurrent chemotherapy, radiation, chronic graft versus host disease, steroids, and other immunosuppressants are believed to modulate these risk factors, through endothelial damage, leading to premature atherosclerosis [4–7]. We created a prediction risk stratification model that incorporated specific risk factors associated with allogeneic HCT, using coronary stenosis as measured using cardiac computed tomography angiography (CCTA) to determine the presence of coronary artery disease (CAD). CCTA is a low-risk, non-invasive and highly sensitive diagnostic tool to assess coronary atherosclerotic burden [8, 9]. We selected patients from a cohort of long-term survivors of allogeneic HCT initially recruited between the years 1993 and 2012 at the National Heart, Lung and Blood Institute. All patients included in the survivorship cohort had to have survived ≥3 years post-transplant [median follow-up 8 years (IQR 4–13)]. All patients received total body irradiation (TBI) and a 3–4 log ex vivo T-cell-depleted graft. Patients were recruited into our study if they presented for follow-up in our outpatient clinic between January 2015 and September 2017 and had no CAD history and could undergo CCTA [10]. Our end point was the presence of CAD as demonstrated by the CCTA-based segment involvement score that quantifies coronary artery plaque burden [11]. Each of the 16 coronary segments was assigned a score of 1 if any stenosis (plaque) was identified, regardless of severity. A total score was generated by adding the total number of coronary segments with plaque [11]. Patients were considered to have CAD if their score was ≥1. Our predictive model included: smoking, arterial hypertension, obesity (BMI > 30), diabetes, CAD family history, dyslipidemia, age, ethnicity/race, sex, and these allogeneic HCT risk factors: chronic graft versus host disease; ≥3 years steroid or other immunosuppressive treatment; immunosuppression at the time of CCTA (immunomodulators and/or systemic steroids); TSH/ hypothyroidism; chronic kidney disease (CKD) stage/glomerular filtration rate (GFR); high sensitivity C-reactive protein (hs-CRP); and any proteinuria. We used stepwise logistic regression analysis to examine the association of these risk factors with the presence of plaque on CCTA. Our model incorporated traditional cardiovascular risk factors as well as HCT-specific clinical variables that best fit our data. The area under the ROC curve (C-statistic) was used to assess the strength of the model. * Kimberley Doucette kimberley.doucette@medstar.net

Radiation exposure from diagnostic procedures following allogeneic stem cell transplantation – How much is acceptable?

Abstract Background Frequent diagnostic radiology procedures in allogeneic stem cell transplantation (SCT) recipients raise concern about the potential harm from incidental radiation. Objectives To determine the cumulative radiation dose from diagnostic studies in allogeneic SCT and its impact on clinical outcome. Patients and methods This retrospective cohort study was conducted to determine the cumulative radiation dose from diagnostic studies following SCT. Sixty-four consecutive patients with hematological malignancies in a single tertiary care institution underwent total body irradiation (TBI)-based myeloablative conditioning followed by six of six human leukocyte antigen (HLA)-identical sibling allogeneic SCT. The median follow-up was 3 years. The cumulative effective dose in mSv from diagnostic radiological studies in the peri-transplant period from day −30 to day +200 was calculated for each patient and its impact on overall survival and non-relapse mortality was determined. Results The median cumulative radiation exposure from diagnostic radiological procedures was 92 mSv (range 1.2–300), representing about 30× the normal annual background radiation for the population and 10% of the 1200 cGy TBI dose used in conditioning. Sixty-five percent of the cumulative radiation exposure was delivered between day +1 and day 100 and computed tomography scans contributed 88%. In multivariate analysis, diagnostic procedures did not significantly impact clinical outcomes. Conclusions While radiation exposure from diagnostic procedures did not impact clinical outcomes the risk of secondary cancers in long-term survivors is likely to be increased. Our results indicate that patients who are acutely ill for prolonged periods can receive clinically significant radiation doses during their hospital care. Our findings should prompt attempts to limit radiation exposure from diagnostic procedures in post-SCT recipients