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全身照射对伴有中枢神经系统累及的儿童急性髓系白血病造血细胞移植结局的影响。

Effects of Total Body Irradiation on Hematopoietic Cell Transplantation Outcomes in Pediatric Acute Myeloid Leukemia with Prior Central Nervous System Involvement.

机构信息

Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts.

Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts.

出版信息

Transplant Cell Ther. 2024 Aug;30(8):812.e1-812.e11. doi: 10.1016/j.jtct.2024.05.014. Epub 2024 May 18.

Abstract

The implications of previous central nervous system (CNS) involvement in children with acute myeloid leukemia (AML) undergoing hematopoietic cell transplantation (HCT) remain inadequately understood. Patients with CNS disease require more upfront CNS-directed intrathecal therapy, but little is known about whether transplant conditioning regimens should be intensified or if previous CNS involvement impacts post-HCT outcomes. While total body irradiation (TBI) remains standard for pediatric acute lymphoblastic leukemia myeloablative conditioning, it has been largely replaced with chemotherapy-only myeloablation in pediatric AML, primarily due to toxicity and late effects associated with TBI. In the setting of previous CNS involvement, it has been suggested that TBI-based myeloablation may have advantages due to superior CNS tissue penetration and thus decreased rates of AML relapse post-HCT. We analyzed a publicly available dataset derived from the Center for International Blood and Marrow Transplantation Research (CIBMTR) registry to characterize the impact of TBI in HCT preparative regimens in pediatric AML patients with a history of CNS involvement. The study dataset was obtained from the CIBMTR data repository. The study cohort included patients aged ≤21 years who underwent initial allogeneic HCT with myeloablative conditioning for de novo AML in the first or second complete remission (CR) between 2008 and 2016, who provided consent for research. Patients with mismatched related donor transplants and noncalcineurin inhibitor graft-versus-host disease (GVHD) prophylaxis were excluded. The dataset was further modified by excluding patients with missing disease site data or those with non-CNS extramedullary disease. Patients were categorized as CNS-positive or -negative AML (AML-CNS(+) and AML-CNS(-), respectively) based on the disease status at diagnosis. The Cox regression model and Fine-Grey methods were employed to delineate the effects of TBI and CNS disease on key HCT outcomes. The study cohort comprised 550 pediatric AML patients, of which 25% (n = 136) were AML-CNS(+). CNS involvement was more prevalent in patients aged 0 to 3 years, patients who were in the second CR, and those with a mismatched unrelated donor or umbilical cord blood. AML-CNS(+) patients demonstrated a lower relapse rate (hazard ratio: 0.50, 95% confidence interval: 0.33 to 0.76) compared to AML-CNS(-) patients, with comparable disease-free survival (DFS) and overall survival (OS) (P = .10 and 0.20, respectively) in the two cohorts. The entire TBI-treated cohort showed an association with increased risks of grade 2 to 4 acute GVHD, bloodstream infections, and endocrine dysfunction. TBI use within the AML-CNS(+) cohort was associated with a lower relapse rate but increased risks of nonrelapse mortality and a trend of higher grade 3 to 4 acute GVHD. In this population-based analysis of pediatric patients with de novo AML undergoing HCT, TBI-based conditioning regimens did not confer an advantage in DFS or OS compared to non-TBI regimens, irrespective of CNS disease status. However, TBI use was associated with increased risks of short- and long-term comorbidities. These findings underscore the need for careful consideration of TBI in pediatric AML.

摘要

先前中枢神经系统(CNS)受累对接受造血细胞移植(HCT)的儿童急性髓系白血病(AML)的影响仍未得到充分理解。患有 CNS 疾病的患者需要更多的 upfront CNS 导向的鞘内治疗,但对于移植预处理方案是否应该强化,或者先前的 CNS 受累是否会影响 HCT 后结果,知之甚少。虽然全脑照射(TBI)仍然是儿科急性淋巴细胞白血病髓细胞消除预处理的标准,但在儿科 AML 中,它已基本被仅用化疗的髓细胞消除所取代,主要是由于 TBI 相关的毒性和晚期效应。在先前 CNS 受累的情况下,有人提出 TBI 为基础的髓细胞消除可能具有优势,因为它具有更好的 CNS 组织穿透性,从而降低 HCT 后 AML 复发的几率。我们分析了一个来自国际血液和骨髓移植研究中心(CIBMTR)登记处的公开数据集,以描述 TBI 在儿科 AML 患者中具有 CNS 受累史的 HCT 预处理方案中的影响。该研究数据集来自 CIBMTR 数据存储库。研究队列包括年龄≤21 岁的患者,他们在 2008 年至 2016 年期间首次或第二次完全缓解(CR)中接受了异基因 HCT 治疗,并接受了新诊断 AML 的髓细胞消除预处理。排除了匹配相关供体移植和非钙调神经磷酸酶抑制剂移植物抗宿主病(GVHD)预防的患者。进一步通过排除疾病部位数据缺失或非 CNS 髓外疾病的患者来修改数据集。根据诊断时的疾病状态,将患者分为 CNS 阳性或阴性 AML(AML-CNS(+)和 AML-CNS(-))。Cox 回归模型和 Fine-Grey 方法用于描绘 TBI 和 CNS 疾病对关键 HCT 结局的影响。该研究队列包括 550 名儿科 AML 患者,其中 25%(n = 136)为 AML-CNS(+)。CNS 受累在 0 至 3 岁的患者、处于第二次 CR 的患者以及接受不匹配的无关供体或脐带血移植的患者中更为常见。与 AML-CNS(-)患者相比,AML-CNS(+)患者的复发率较低(风险比:0.50,95%置信区间:0.33 至 0.76),但两组患者的无病生存(DFS)和总生存(OS)相似(P =.10 和 0.20)。整个 TBI 治疗组与 2 级至 4 级急性 GVHD、血流感染和内分泌功能障碍的风险增加相关。AML-CNS(+)组中 TBI 的使用与较低的复发率相关,但非复发死亡率的风险增加,3 级至 4 级急性 GVHD 的发生率呈上升趋势。在这项对接受 HCT 的新诊断 AML 儿科患者的基于人群的分析中,与非 TBI 方案相比,TBI 为基础的预处理方案在 DFS 或 OS 方面并未显示出优势,无论 CNS 疾病状态如何。然而,TBI 的使用与短期和长期合并症的风险增加有关。这些发现强调了在儿科 AML 中需要仔细考虑 TBI 的使用。

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