Post-Transplantation Cyclophosphamide-Based Graft-versus-Host Disease Prophylaxis.
Adult
Humans
Bronchiolitis Obliterans Syndrome
/ etiology
Cyclophosphamide
/ administration & dosage
Graft vs Host Disease
/ prevention & control
Hematopoietic Stem Cell Transplantation
/ adverse effects
Methotrexate
/ administration & dosage
Mycophenolic Acid
/ administration & dosage
Neoplasm Recurrence, Local
/ drug therapy
Tacrolimus
/ administration & dosage
Unrelated Donors
Hematologic Neoplasms
/ surgery
Antineoplastic Combined Chemotherapy Protocols
/ therapeutic use
Journal
The New England journal of medicine
ISSN: 1533-4406
Titre abrégé: N Engl J Med
Pays: United States
ID NLM: 0255562
Informations de publication
Date de publication:
22 Jun 2023
22 Jun 2023
Historique:
pmc-release:
22
12
2023
medline:
23
6
2023
pubmed:
21
6
2023
entrez:
21
6
2023
Statut:
ppublish
Résumé
In patients undergoing allogeneic hematopoietic stem-cell transplantation (HSCT), a calcineurin inhibitor plus methotrexate has been a standard prophylaxis against graft-versus-host disease (GVHD). A phase 2 study indicated the potential superiority of a post-transplantation regimen of cyclophosphamide, tacrolimus, and mycophenolate mofetil. In a phase 3 trial, we randomly assigned adults with hematologic cancers in a 1:1 ratio to receive cyclophosphamide-tacrolimus-mycophenolate mofetil (experimental prophylaxis) or tacrolimus-methotrexate (standard prophylaxis). The patients underwent HSCT from an HLA-matched related donor or a matched or 7/8 mismatched (i.e., mismatched at only one of the In a multivariate Cox regression analysis, GVHD-free, relapse-free survival was significantly more common among the 214 patients in the experimental-prophylaxis group than among the 217 patients in the standard-prophylaxis group (hazard ratio for grade III or IV acute GVHD, chronic GVHD, disease relapse or progression, or death, 0.64; 95% confidence interval [CI], 0.49 to 0.83; P = 0.001). At 1 year, the adjusted GVHD-free, relapse-free survival was 52.7% (95% CI, 45.8 to 59.2) with experimental prophylaxis and 34.9% (95% CI, 28.6 to 41.3) with standard prophylaxis. Patients in the experimental-prophylaxis group appeared to have less severe acute or chronic GVHD and a higher incidence of immunosuppression-free survival at 1 year. Overall and disease-free survival, relapse, transplantation-related death, and engraftment did not differ substantially between the groups. Among patients undergoing allogeneic HLA-matched HSCT with reduced-intensity conditioning, GVHD-free, relapse-free survival at 1 year was significantly more common among those who received cyclophosphamide-tacrolimus-mycophenolate mofetil than among those who received tacrolimus-methotrexate. (Funded by the National Heart, Lung, and Blood Institute and others; BMT CTN 1703 ClinicalTrials.gov number, NCT03959241.).
Sections du résumé
BACKGROUND
BACKGROUND
In patients undergoing allogeneic hematopoietic stem-cell transplantation (HSCT), a calcineurin inhibitor plus methotrexate has been a standard prophylaxis against graft-versus-host disease (GVHD). A phase 2 study indicated the potential superiority of a post-transplantation regimen of cyclophosphamide, tacrolimus, and mycophenolate mofetil.
METHODS
METHODS
In a phase 3 trial, we randomly assigned adults with hematologic cancers in a 1:1 ratio to receive cyclophosphamide-tacrolimus-mycophenolate mofetil (experimental prophylaxis) or tacrolimus-methotrexate (standard prophylaxis). The patients underwent HSCT from an HLA-matched related donor or a matched or 7/8 mismatched (i.e., mismatched at only one of the
RESULTS
RESULTS
In a multivariate Cox regression analysis, GVHD-free, relapse-free survival was significantly more common among the 214 patients in the experimental-prophylaxis group than among the 217 patients in the standard-prophylaxis group (hazard ratio for grade III or IV acute GVHD, chronic GVHD, disease relapse or progression, or death, 0.64; 95% confidence interval [CI], 0.49 to 0.83; P = 0.001). At 1 year, the adjusted GVHD-free, relapse-free survival was 52.7% (95% CI, 45.8 to 59.2) with experimental prophylaxis and 34.9% (95% CI, 28.6 to 41.3) with standard prophylaxis. Patients in the experimental-prophylaxis group appeared to have less severe acute or chronic GVHD and a higher incidence of immunosuppression-free survival at 1 year. Overall and disease-free survival, relapse, transplantation-related death, and engraftment did not differ substantially between the groups.
CONCLUSIONS
CONCLUSIONS
Among patients undergoing allogeneic HLA-matched HSCT with reduced-intensity conditioning, GVHD-free, relapse-free survival at 1 year was significantly more common among those who received cyclophosphamide-tacrolimus-mycophenolate mofetil than among those who received tacrolimus-methotrexate. (Funded by the National Heart, Lung, and Blood Institute and others; BMT CTN 1703 ClinicalTrials.gov number, NCT03959241.).
Identifiants
pubmed: 37342922
doi: 10.1056/NEJMoa2215943
pmc: PMC10575613
mid: NIHMS1911536
doi:
Substances chimiques
Cyclophosphamide
8N3DW7272P
Methotrexate
YL5FZ2Y5U1
Mycophenolic Acid
HU9DX48N0T
Tacrolimus
WM0HAQ4WNM
Banques de données
ClinicalTrials.gov
['NCT03959241']
Types de publication
Clinical Trial, Phase III
Journal Article
Randomized Controlled Trial
Langues
eng
Sous-ensembles de citation
IM
Pagination
2338-2348Subventions
Organisme : NHLBI NIH HHS
ID : U10 HL069294
Pays : United States
Organisme : NHLBI NIH HHS
ID : #U10HL069294
Pays : United States
Organisme : NCI NIH HHS
ID : #U24HL138660
Pays : United States
Organisme : NCI NIH HHS
ID : P30 CA008748
Pays : United States
Organisme : NCI NIH HHS
ID : U24 CA076518
Pays : United States
Organisme : NHLBI NIH HHS
ID : U24 HL138660
Pays : United States
Investigateurs
Karilyn Larkin
(K)
LaQuisa Hill
(L)
Monzr Al Malki
(M)
Betty Hamilton
(B)
Mahasweta Gooptu
(M)
Mitchell Horwitz
(M)
Edmund Waller
(E)
Masumi Ueda Oshimaa
(M)
Hany Elmariah
(H)
Anand Tandra
(A)
Sherif Farag
(S)
Javier Bolaños-Meade
(J)
Leyla Shune
(L)
Joseph Uberti
(J)
Patrick Stiff
(P)
Amin Alousi
(A)
Yi-Bin Cehn
(YB)
Zacharia DeFilipp
(Z)
William Hogan
(W)
Lindsey Runaas
(L)
Amarendra Neppalli
(A)
Brian Shaffer
(B)
Aaron Etra
(A)
Arpita Gandhi
(A)
Andrew Rezvani
(A)
Ami Bhatt
(A)
Melhem Solh
(M)
Molly Gallogly
(M)
Omer Jamy
(O)
Lloyd Damon
(L)
Satyajit Kosuri
(S)
John Wingard
(J)
Margarida Silverman
(M)
Trent Wang
(T)
Mary Riwes
(M)
Najla El Jurdi
(N)
William Wood
(W)
Alison Loren
(A)
Aric Hall
(A)
William Clark
(W)
Peter Westervelt
(P)
Informations de copyright
Copyright © 2023 Massachusetts Medical Society.
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