Introduction to a How I Treat series on management of high-risk patients following allogeneic transplant

Author(s): Robert Zeiser
Source: Blood (2023) 141 (1): 1.
Original Article
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Dr. Anjan Patel's Thoughts

Interesting prospective study assessing outcomes in ITP in pregnant women while measuring neonatal ITP in the developing child, with a control of non-pregnant women for comparison.  Pregnancy-ITP was associated with a 2.7x higher rate of recurrent disease. However, bleeding was similar in pregnant vs. non-pregnant women. NITP risk was associated with more severe ITP disease in the mother and the severity of the disease, as well as prior h/o ITP in the mother.
To improve the therapeutic success of allogeneic hematopoietic cell transplantation (allo-HCT), the management of high-risk patients is essential. High risk means high likelihood for development of graft-versus-host disease (GVHD), for relapse of the underlying malignancy, and for severe infectious complications. The following How I Treat series describes state-of-the art and major recent developments in the management of prevention of relapse with cellular therapies or maintenance-based approaches and GVHD prophylaxis.
  • Alexander Biederstädt and Katayoun Rezvani, “How I treat high-risk acute myeloid leukemia using preemptive adoptive cellular immunotherapy”
  • Zachariah DeFilipp and Yi-Bin Chen, “How I treat with maintenance therapy after allogeneic HCT”
  • Joseph Rimando, Shannon R. McCurdy, and Leo Luznik, “How I treat GVHD in high-risk patients: posttransplant cyclophosphamide and beyond”
Relapse of high-risk leukemia after allo-HCT remains a major clinical challenge. The article on the use of preemptive T-cell/natural killer cell transfer highlights cellular therapies that can be used to prevent or treat relapse. Response rates of relapsed acute myeloid leukemia and acute lymphoblastic leukemia to donor lymphocyte infusions (DLIs) are low, and the role of preemptive DLI on detection of measurable residual disease (MRD) is unclear due to the lack of prospective randomized studies. Biederstädt and Rezvani discuss the challenges of MRD-triggered DLI treatment after allo-HCT. They outline novel approaches of post-allo-HCT cellular therapies, including the role of chimeric antigen receptor−redirected cellular therapy and T-cell receptor gene therapy. In addition, a practical structure for the decision-making process whether to use preemptive cellular therapy or not for patients with high-risk leukemia is provided. Read more here.

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