Biol Blood Marrow Transplant 22 (2016) 862e868
`
`Biology of Blood and
`Marrow Transplantation
`
`j o u r n a l h o m e p a g e : w w w . b b m t . o r g
`
`ELSEVIER
`
`Combination Therapy for Graft-versus-Host Disease
`Prophylaxis with Etanercept and Extracorporeal
`Photopheresis: Results of a Phase II Clinical Trial
`Carrie L. Kitko 1,2, *, Thomas Braun 3, Daniel R. Couriel 1, Sung W. Choi 1, James Connelly 1,2,
`Sandra Hoffmann 1, Steven Goldstein 1, John Magenau 1, Attaphol Pawarode 1, Pavan Reddy 1,
`Charles Schuler 4, Gregory A. Yanik 1, James L. Ferrara 5, John E. Levine 1,5
`1 Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan
`2 Pediatric Stem Cell Transplant Program, Vanderbilt University, Nashville, Tennessee
`3 Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
`4 Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
`5 Blood and Marrow Transplant Program, Icahn School of Medicine at Mount Sinai, New York, New York
`
`CrossMark
`
`Article history:
`Received 26 August 2015
`Accepted 2 November 2015
`
`Key Words:
`Graft-versus-host disease
`Prophylaxis
`Etanercept
`Photopheresis
`
`a b s t r a c t
`Reduced-intensity conditioning (RIC) regimens minimize early toxicity after allogeneic hematopoietic cell
`transplantation (HCT) by placing greater reliance on establishing a graft-versus-leukemia effect (GVL).
`Because graft-versus-host disease (GVHD) and GVL are tightly linked, inhibition of T cell populations that
`cause GVHD may lead to an unintended increased risk of relapse in the RIC setting. Although not completely
`understood, etanercept and extracorporeal photopheresis (ECP) are thought to ameliorate GVHD without
`direct T cell inhibition. We hypothesized that adding these 2 agents to a standard GVHD prophylaxis regimen
`of tacrolimus and mycophenolate mofetil (MMF) would improve survival by reducing GVHD-related mortality
`without increasing relapse rates. Therefore, we conducted a prospective phase II clinical trial that incorpo-
`rated tacrolimus, MMF, etanercept, and ECP as GVHD prophylaxis in 48 patients undergoing RIC unrelated
`donor transplantation. The preferred RIC was fludarabine 160 mg/m2 þ busulfan 6.4 mg/kg to 12.8 mg/
`kg  total body irradiation 200 cGy. Etanercept .4 mg/kg (maximum dose, 25 mg) was given subcutaneously
`twice weekly for 8 weeks after HCT and ECP was given for 12 treatments, starting weekly on day 28 weekly
`and tapering off by day 180. The median age of the study patients was 60 (range, 18 to 71) years. Donors were
`7/8 (n ¼ 14, 29%) or 8/8 (n ¼ 34, 71%) HLA matched. All patients engrafted neutrophils at a median of 12 days.
`The cumulative incidence of grades II to IV acute GVHD at day 100 was 46%, but it was typically sensitive to
`initial steroid treatment (84% day 56 complete response/partial response rate). Overall survival at 1 year in
`this older, frequently mismatched unrelated donor setting was excellent (73%) because of low rates of
`nonrelapse mortality (21%) and relapse (19%). However, this strategy was not effective at preventing a high
`incidence of chronic GVHD and late deaths led to a drop in 2-year survival, declining to 56%, reflecting a high
`incidence of chronic GVHD.
`
`Ó 2016 American Society for Blood and Marrow Transplantation.
`
`INTRODUCTION
`is
`(HCT)
`transplant
`cell
`Allogeneic hematopoietic
`increasingly used as a curative option for patients with
`hematologic malignancies as the expansion of reduced-
`intensity conditioning regimens (RIC) has allowed for the
`transplantation of patients who are older and those who
`
`Financial disclosure: See Acknowledgments on page 867.
`* Correspondence and reprint requests: Carrie L. Kitko, MD, 2220 Pierce
`Avenue, 386 Preston Research Building, Nashville, TN 37232-6310.
`E-mail address: carrie.l.kitko@vanderbilt.edu (C.L. Kitko).
`
`have more comorbidities. According to the National Marrow
`Donor Program, there was greater than a 4-fold increase in
`the number of patients over the age of 60 who received an
`unrelated donor (URD) HCT from 2005 to 2009 compared
`with from 2000 to 2004 [1]. Although utilization of trans-
`plantation has increased, there has not been a reduction in
`the rates of GVHD, and the 3-year survival remains unsatis-
`factory at around 35% [1]. The major reasons for treatment
`failure are relapse and graft-versus-host disease (GVHD), the
`latter of which leads to significant morbidity and mortality.
`As acute GVHD severity worsens, so does survival, as
`
`http://dx.doi.org/10.1016/j.bbmt.2015.11.002
`1083-8791/Ó 2016 American Society for Blood and Marrow Transplantation.
`
`

`

`C.L. Kitko et al. / Biol Blood Marrow Transplant 22 (2016) 862e868
`
`863
`
`demonstrated by previous studies that show limited mor-
`tality after grades I and II acute GVHD and mortality rates
`that approach 75% with grade III to IV acute GVHD [2]. The
`large difference in outcomes can be explained by the higher
`rates of steroid-resistant GVHD, seen with more severe
`GVHD [3-5]. However, GVHD severity cannot be predicted
`before transplantation, and as a result, prevention strategies
`are designed to limit its occurrence rather than its severity.
`Traditional GVHD prevention strategies rely on combi-
`nations of immunosuppressants that block T cell expansion
`and cytotoxicity. A common GVHD prophylaxis regimen after
`RIC includes the calcineurin inhibitor tacrolimus plus
`mycophenolate mofetil (MMF) and results in rates of GVHD
`grades II to IV of 54% to 79% [6-8]. However, further aug-
`menting GVHD prophylaxis with additional agents that
`directly target T cells, such as antithymocyte globulin, in-
`creases the risk of relapse, graft failure, and/or infection,
`which may be especially relevant in the context of RIC [9-11].
`We have previously explored whether we could offset the
`risks from GVHD and its treatment by adding agents to the
`prophylaxis regimen that have indirect effects on T cell
`function. In our prior study, tumor necrosis factor alpha
`(TNF-a) blockade with etanercept was given from admission
`through day 56 after HCT to a standard tacrolimus and
`methotrexate backbone in the myeloablative setting. This
`approach did not reduce the cumulative incidence of GVHD
`grades II to IV from 45%, but an exceptionally high proportion
`(93%) of those patients who required treatment for GVHD
`achieved a complete response (CR) [12], which compared
`favorably to the expected CR rates of 40% to 50% [13,14].
`These results led us to speculate that TNF inhibition
`during the early post-HCT period increased the steroid-
`responsiveness of GVHD when it developed.
`Extracorporeal photopheresis (ECP) is an immunomodu-
`latory approach that appears to ameliorate GVHD without
`increasing relapse and infection rates [15-21]. ECP has not
`been well studied for GVHD prophylaxis, but in 1 study, ECP
`treatment before HCT, followed by cyclosporine, metho-
`trexate, and MMF, resulted in high rates of donor engraft-
`ment (98%), low rates of nonrelapse mortality (NRM) at day
`100 (11%), and unexpectedly low rates of acute GVHD (9%)
`[22]. The effectiveness of ECP delivered after HCT for the
`prevention of acute GVHD has not been studied.
`Given the extensive data to support the importance of
`TNF-a in the initiation of the GVHD reaction [23-25] and the
`potential for additional immune modulation via ECP therapy,
`we decided to study standard GVHD prophylaxis (tacrolimus
`and MMF) in combination with etanercept and ECP in older
`patients receiving a RIC unrelated donor HCT. Our hypothesis
`was that augmenting GVHD prophylaxis in this way would
`reduce the incidence of steroid-refractory GVHD and NRM
`yet preserve the graft-versus-leukemia (GVL) effect, thereby
`leading to improved overall survival. To further study this
`question, we explored whether a novel endpoint of steroid-
`free, relapse-free survival at 6 months after HCT could
`serve as a surrogate endpoint for long-term survival in a
`GVHD prophylaxis study.
`
`METHODS
`Study Population
`The study was designed to target patients at high risk for NRM after
`unrelated donor HCT. Patients who lacked related donors were eligible if
`they were older than 50 years or if they had comorbid conditions that
`precluded intensive conditioning regimens regardless of age. Single alle-
`leelevel HLA mismatches (ie, 7/8 matches) of the HLA-A, -B, -C, and -DRB1
`loci by high-resolution typing were allowed when peripheral blood or bone
`
`marrow were used. Cord blood units were required to match for at least 4/6
`loci (intermediate-resolution typing for the HLA-A and -B loci; high-
`resolution typing for HLA-DR). Patients with infections not responsive to
`treatment or who were unlikely to tolerate the fluid shifts associated with
`ECP were ineligible. The protocol and informed consents were approved by
`the institutional review board at the University of Michigan. All patients
`gave informed consent per the Declaration of Helsinki.
`
`Study Design
`The study was conducted as an open-label, nonrandomized phase II
`clinical trial (registered at ClinicalTrials.gov; NCT00639717). Pre-HCT con-
`ditioning was selected according to institutional practice given the under-
`lying disease, previous therapy, and comorbidities, provided the regimen
`was recognized as reduced intensity or reduced toxicity, according to the
`established literature [26]. The preferred regimen was fludarabine þ intra-
`venous busulfan [27-30].
`The GVHD prophylaxis schema is shown in Figure 1 and consisted of a
`standard backbone supplemented by the investigational agents. The back-
`bone consisted of the widely used regimen of tacrolimus and MMF [31,32].
`Tacrolimus was begun on day -3 before HCT, titrated to a therapeutic trough
`level of 8 ng/mL to 12 ng/mL, and tapered by 25% per month starting 56 days
`after HCT in the absence of GVHD. Cyclosporine was substituted for patients
`who could not tolerate tacrolimus. MMF 10 mg/kg/dose (max dose, 1 gm)
`was administered either orally or intravenously every 8 hours from day
`0 through day 28.
`The investigational agents were administered on an overlapping
`schedule such that patients received at least 1 study agent continuously
`through the first 180 days after HCT. Etanercept was given subcutaneously
`twice weekly (.4 mg/kg; max dose, 25 mg) at least 72 hours apart, from day
`0 to day 56 for a total of 16 doses. To mitigate risk of infectious-related
`complications, etanercept was held for persistent bacteremia (>1 positive
`blood cultures on separate days) until appropriate antimicrobial treatment
`was started, hemodynamic instability until resolved for 24 hours, newly
`diagnosed fungal or mycobacterial infection until 7 days of effective treat-
`ment were administered, rising cytomegalovirus viral copy number despite
`appropriate treatment, or fever 102F daily for > 5 days until afebrile
`(<100.5F) for 24 hours. Etanercept was not held for uncomplicated fever <
`102F. Missed doses of etanercept were not made up unless due to patient
`error. Failure to receive all 16 doses did not require removal from the study.
`For practical reasons, ECP could not be administered before white blood
`cell engraftment. Institutional minimum criteria for hematocrit (>28%) to
`ensure an adequate separation of red blood cells, white blood cells, and
`plasma and for platelet count (>35,000/mL) to mitigate risk of bleeding
`when heparin was used for anticoagulation during ECP treatments were
`followed. To minimize the need for transfusions to meet these criteria, once
`weekly ECP was scheduled to begin no earlier than day þ28 (5 days) for 7
`treatments until day þ70, then tapered to every other week  2 treatments,
`then monthly until discontinuation at day þ180 (2 to 3 treatments).
`Depending on the start and end dates, patients received 11 or 12 total ECP
`treatments. All patients received ECP treatment with the Therakos UVAR
`XTS photopheresis system (Mallinckrodt Pharmaceuticals [formerly Ther-
`akos, Inc.], West Chester, PA); according to the manufacturer’s instructions.
`A treatment consisted of collection of leukocytes, methoxypsoralen incu-
`bation, photoactivation, and reinfusion of activated cells via intravenous
`access. ECP could be given more often at the discretion of the treating
`physician in the event of GVHD and the patient remained on study to be
`assessed for primary and secondary endpoints. Transfusion and/or cytokine
`
`D Tacrolimus D Myc~o~:~tate D Etanercept ■
`
`Extra corporeal
`Photopheresis
`
`-3 0
`
`28
`
`56
`
`100
`70
`Days Post Transplant
`
`180
`
`Figure 1. Graft-versus-host disease prophylaxis schema.
`
`

`

`864
`
`C.L. Kitko et al. / Biol Blood Marrow Transplant 22 (2016) 862e868
`
`support were administered when necessary to allow ECP treatment. To
`mitigate risks associated with ECP delivery, treatments were not given
`within 72 hours of a positive blood culture, within 24 hours of fever >
`100.5F or hemodynamic instability, within 12 hours of clinically significant
`bleeding, or on the same day as surgical procedures except bone marrow
`biopsy and other low bleeding risk procedures. Missed treatments were
`made up within 1 week. Patients who received < 2 ECP treatments were
`deemed inevaluable, removed from the study, and replaced. Physicians were
`allowed but not required to treat GVHD with increased frequency of ECP
`treatments.
`
`Infections
`Infections were identified based on positive blood or body fluid cultures
`or by detection of viral DNA or RNA in plasma or body fluid by quantitative
`PCR. Severity was graded according to Blood and Marrow Transplant Clinical
`Trials Network Technical Manual of Procedures, Version 3.0 [33]. Grade 3
`infections were defined as bacteremia with deep organ involvement; severe
`sepsis with bacteremia;
`fasciitis requiring debridement; pneumonia
`requiring intubation; brain abscess or meningitis without bacteremia;
`Clostridium difficile toxin positive stool with toxic dilation; fungemia
`including Candidemia; Pneumocystis jiroveci pneumonia; proven or prob-
`able invasive fungal infections; disseminated infections with Histoplasmo-
`sis, Blastomycosis, Coccidiomycosis or Cryptococcus; severe varicella zoster
`virus infection; cytomegalovirus infection with end-organ involvement;
`Epstein-Barr viruseassociated post-transplantation lymphoproliferative
`disorder; adenovirus with end-organ involvement; lower tract respiratory
`viruses; any viral encephalitis/meningitis; and end-organ toxoplasmosis.
`
`GVHD Scoring and Treatment
`A limited number of observers scored acute GVHD according to the
`modified Glucksberg criteria [34]. The diagnosis of GVHD was made clini-
`cally but confirmatory biopsies of affected organs were usually obtained.
`GVHD was graded weekly until day þ100 or resolution of acute GVHD,
`whichever occurred later. Scores were reviewed by an independent inves-
`tigator and discrepancies were adjudicated by a study investigator (C.K.)
`when necessary. Grades II to IV acute GVHD were initially treated with 2 mg/
`kg/day of methylprednisolone or prednisone equivalent, then tapered at the
`discretion of the treating physician. Patients continued study treatment
`after development of acute GVHD except where toxicities precluded doing
`so. Treating physicians were permitted to increase ECP frequency or add
`additional treatments at their discretion. Chronic GVHD was assessed ac-
`cording to the National Institutes of Health Consensus criteria [35].
`
`Primary and Secondary Endpoints
`We reasoned that a novel endpoint (alive, in remission, and on no more
`than low-dose steroids [4 mg methylprednisolone or equivalent] for treat-
`ment of acute GVHD) at 6 months after transplantation could serve as an
`acceptable surrogate for long-term survival for patients undergoing RIC
`URD. We calculated that a sample size of 48 evaluable subjects would pro-
`vide 80% power to detect an improvement in the proportion of patients who
`met all these criteria for success from 40% (the historical rate in patient who
`met study eligibility criteria at our center) to 60% with an alpha level of .05.
`Secondary endpoints included the incidence of acute GVHD grades II to IV,
`the incidence of steroid-refractory GVHD, the incidence of chronic GVHD,
`NRM, and overall survival.
`
`Statistical Analysis
`Continuous patient characteristics were summarized with medians and
`ranges, and categorical patient characteristics were summarized with pro-
`portions. Overall survival was estimated using Kaplan-Meier methods and
`the cumulative incidences of GVHD, relapse, and NRM were estimated using
`Gray’s method. All analyses were done in the statistical package R, Version
`3.0.1.
`
`RESULTS
`Study Feasibility and Population
`The study enrolled 52 patients from April 2, 2009 to July
`11, 2012 to obtain 48 patients who received at least 2 ECP
`treatments and were, therefore, evaluable. Thus, the study
`treatment plan was feasible in 92% of all patients who pro-
`vided consent. Per study design, 4 patients were removed
`from study treatment secondary to failure to receive ECP;
`primary graft failure (n ¼ 1), noncompliance (n ¼ 1), severe
`veno-occlusive disease with thrombocytopenia that pre-
`cluded initiating ECP (n ¼ 1), and early relapse (n ¼ 1). These
`
`patients did not receive any ECP treatments and were
`excluded from this analysis. Table 1 shows the baseline de-
`mographic and clinical characteristics of the 48 evaluable
`patients. By design, the study population was composed of
`patients at high risk for NRM. The primary risk factors were
`advanced age (median age, 60 years; range, 18 to 71 years),
`high (n ¼ 28, 58%) or intermediate (n ¼ 16, 34%) HCT
`comorbidity index [36,37], and frequent use of HLA-
`mismatched donors (n ¼ 14, 29%). All but 2 patients
`received peripheral blood stem cells; there was 1 bone
`marrow transplantation and 1 cord blood transplantation.
`
`Engraftment, Chimerism, and Toxicities
`We did not find evidence that etanercept or ECP affected
`neutrophil or T cell engraftment. The median time to
`neutrophil engraftment of 12 days (range, 8 to 26 days) was
`consistent with expectations [38-40]. The median donor
`þ
`chimerism for CD3
`T cells at day 30 was 93% (range, 48% to
`100%) and increased to 100% at 1 year (range, 91% to 100%).
`Exact date of platelet engraftment was difficult to determine
`based on need for platelets transfusions to perform ECP in
`some patients.
`Both etanercept and ECP were generally well tolerated.
`No deaths were attributed to study treatment. An early
`lymphoma relapse at day 99 after HCT was considered
`possibly related to study treatment because the etanercept
`package insert describes the development of lymphoma in
`nontransplantation patients treated with the drug. Two pa-
`tients who experienced chest pain without electrocardio-
`gram changes during their sixth and eighth ECP procedure
`were removed from study treatment as a precaution. No
`etiology for the chest pain was identified. No other toxicities
`were considered to be related to ECP. Two early deaths
`(sudden death at home on day 151, 5 days after an ECP
`
`Table 1
`Patients’ Clinical Characteristics
`
`Characteristic
`Age of recipient, median (range), yr
`Female
`Diagnosis
`Acute myeloid leukemia
`Myelodysplastic syndrome
`Non-Hodgkin lymphoma
`Acute lymphoblastic leukemia
`Myeloproliferative disorder
`Chronic lymphocytic leukemia
`Multiple myeloma
`Disease status
`Low
`Intermediate
`High
`Comorbidity index
`Low (0)
`Intermediate (1 or 2)
`High ( 3)
`HLA matching*
`8/8 HLAematched unrelated donor
`7/8 HLAemismatched unrelated donor
`Cytomegalovirus status
`R D
`R Dþ
`Rþ D
`Rþ Dþ
`þ
`count, median (range), 106 cells per kg*
`CD34
`
`Value
`60 (18-71)
`22 (46%)
`
`19 (40%)
`12 (25%)
`8 (17%)
`4 (8%)
`3 (6%)
`1 (2%)
`1 (2%)
`
`19 (40%)
`18 (37%)
`11 (23%)
`
`4 (8%)
`16 (34%)
`28 (58%)
`
`34 (72%)
`13 (28%)
`
`18 (38%)
`2 (4%)
`17 (35%)
`11 (23%)
`5.45 (.7-9.8)
`
`R indicates recipient; D, donor.
`* Excludes 1 cord blood recipient who received 2 5/6 HLAemismatched
`cord blood units.
`
`

`

`C.L. Kitko et al. / Biol Blood Marrow Transplant 22 (2016) 862e868
`
`865
`
`treatment and a fatal intracranial hemorrhage on day 55
`from profound thrombocytopenia 8 days after ECP treat-
`ment) were deemed unrelated to study treatment based on
`their timing. Other Common Terminology Criteria grade 3
`and 4 toxicities are summarized in Table 2 but none of these
`toxicities were considered related to the study interventions
`by the investigators or after review by the University of
`Michigan Cancer Center Data and Safety Monitoring Board.
`We considered the possibility that the addition of eta-
`nercept and ECP would increase infection risk and, therefore,
`patients were carefully monitored for signs and symptoms of
`infection at least weekly. The majority of patients (34 of 48,
`71%) developed at least 1 infection that required treatment
`during the 180-day study period (Table 3). Although the exact
`contributions of etanercept and ECP to the risk of infection is
`difficult to quantify, the incidence of grade 3 infections
`observed on study was similar to that reported in the litera-
`ture [12,41] and similar to the rates of infection that occurred
`in nonstudy patients during approximately the same time as
`the study period (unpublished data). Two patients died from
`infectionsd1 from Human herpesvirus 6 encephalitis on day
`83 and 1 from fungal pneumonia (Aspergillus fumigatus and
`Rhizopus) on day 88. We observed 12 grade 3 nonfatal in-
`fections in 7 (15%) patients, 4 of who were also on systemic
`steroid treatment for GVHD at the time, which is a well-
`known major risk factor for post-HCT infection [42,43].
`Grade 3 viral infections developed in 3 patients (all cyto-
`megalovirus end-organ disease, complicated in 1 case by
`simultaneous Human herpesvirus 6, adenovirus, and
`Epstein-Barr virus infection). There were 4 grade 3 bacterial
`infections (1 each of Streptococcus mitis sepsis, Corynebacte-
`rium striatum septic joint hardware, Achromobacter pneu-
`monia, Staphylococcus aureus pneumonia). In addition to the
`fatal fungal pneumonia, there were 2 cases of nonlethal grade
`3 fungal pneumonia (1 case of Aspergillus fumigatus and 1
`probable case based on radiographic findings and positive
`galactomannen result from bronchoalveolar lavage). Study
`treatment was held per study design for severe infections and
`then resumed in patients who had an appropriate response to
`therapy. All other infections were either grade 1 or 2 and
`resolved with appropriate antimicrobial therapy.
`ECP appeared to have little impact on transfusion re-
`quirements. Study subjects received a median of 3 packed
`
`Table 2
`Grade 3 and 4 non-hematological toxicity according to Common Terminol-
`ogy Criteria
`
`Event
`Cardiac events
`
`Deep vein thrombosis
`Altered mental status secondary
`to calcineurin inhibitor
`Musculoskeletal abnormality
`
`Electrolyte abnormality
`Acute cholecystitis
`Depression
`Diverticulitis
`Evan’s syndrome
`Headache
`Hematemesis
`Renal calculi
`
`n
`5 (2 episodes atrial fibrillation, 1
`each syncope, orthostatic
`hypotension, NSTEMI)
`4
`3
`
`3 (1 each daptomycin-associated
`rhabdomyolysis, trauma-associated
`ankle pain, steroid myopathy)
`2
`1
`1
`1
`1
`1
`1
`1
`
`CTC indicates Common Terminology Criteria for Adverse Events; NSTEMI,
`Non-ST segment elevation myocardial infarction.
`
`Table 3
`Infectious Complications
`
`Type of Infection
`Bacterial*
`y
`Viral
`Fungal
`Acid fast bacilli
`
`z
`
`Grade I
`21
`10
`e
`e
`
`Grade II
`17
`22
`e
`3
`
`Grade III
`4
`6
`2
`e
`
`* Grade 1: bacteremia with coagulase negative Staph or Corynebacterium,
`uncomplicated urinary tract infections; grade 2: bacteremia other than
`grade 1 and without severe sepsis.
`y
`Grade 1: Herpes simplex virus mucositis, asymptomatic cytomegalo-
`virus (CMV) viremia with appropriate viral load decline with therapy; grade
`2: Epstein-Barr virus reactivation treated with rituximab, documented viral
`upper respiratory infection, symptomatic CMV or CMV not responding to
`appropriate therapy within 14 days, BK viremia or viruria requiring therapy
`or surgical intervention.
`z
`Grade 2: Acid fast bacilli recovered from bronchoalveolar lavage or
`bacteremia.
`
`red blood cell transfusions and 1 pooled platelet transfusion
`during the 5 months of ECP administration.
`
`GVHD
`The median day of onset of GVHD grades II to IV was
`47 days (range, 9 to 201) and GVHD occurred before the
`initiation of ECP in 10 patients. The cumulative incidence of
`grades II to IV GVHD by 6 months after URD HCT ranges from
`50% to 59% [44,45], and, as expected, the cumulative inci-
`dence in this study fell into that range (57%, 95% confidence
`interval [CI], 42% to 71%) (Figure 2A), with 19% experiencing
`severe GVHD (overall grades III to IV) by 6 months (95% CI, 8%
`to 30%). However, as hoped for, we observed a predominance
`of moderate GVHD (overall grade II, 20 of 29) and these cases
`of GVHD were highly steroid sensitive (day 56 CR/partial
`response ¼ 84). Given the steroid-sensitive nature of the
`GVHD, it is not surprising that the median steroid dose
`reduction by day 56 was 88% (range, 65% to 94%). Steroid-
`refractory gastrointestinal GVHD is the primary cause of
`NRM after HCT [46]. The cumulative incidence of steroid-
`refractory gastrointestinal GVHD was 23% by 6 months af-
`ter HCT (95% CI, 13% to 38%) (Figure 2B), which may explain
`the low incidence of NRM at 1 year (21%; 95% CI, 9% to 32%)
`(Figure 2C). Notably, attenuation of GVHD severity did not
`appear to influence the GVL effect, given the cumulative
`incidence of relapse at 1 year was low at 19% (95% CI, 8% to
`30%) (Figure 2D). Thus, low rates of lethal acute GVHD and
`relapse contributed to excellent 1-year survival in this high-
`risk population (73%; 95% CI, 61% to 87%) (Figure 2E).
`Unfortunately, the apparent survival benefit was not durable,
`as by 2 years, survival declined to 56% (95% CI, 44% to 72%).
`Chronic GVHD was a major contributor to deaths that
`occurred after 1 year (Table 4). The median day of onset of
`chronic GVHD was 209 days (range, 99 to 1248), which was
`shortly after the study intervention completed. The cumu-
`lative incidences of moderate-to-severe chronic GVHD ac-
`cording the National Institutes of Health consensus criteria
`[35] at 1 and 2 years were 42% (95% CI, 27% to 56%) and
`58% (95% CI, 44% to 73%), respectively (Figure 2F).
`The proportion of patients who were alive, in remission,
`and not requiring steroid therapy for treatment of acute
`GVHD (defined as more than 4 mg methylprednisolone or
`equivalent) at 6 months after URD HCT was 58% (n ¼ 28),
`which was below the 60% required to demonstrate a statis-
`tically significant improvement over historical control rate of
`40% to support our novel primary endpoint. When use of
`steroids for any cause was used to redefine endpoint failure,
`the rate of success fell to 42% (n ¼ 20), reflecting a high
`
`

`

`866
`
`C.L. Kitko et al. / Biol Blood Marrow Transplant 22 (2016) 862e868
`
`A
`100
`
`> 80
`4
`"'
`Cl> 60
`-0
`l:'
`C,
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`::c:
`>
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`
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`
`D
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`
`80
`
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`a.
`ai
`a: 40
`
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`
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`
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`Figure 2. (A) Cumulative incidence of acute GVHD at day 100 was 46% (95% CI, 32% to 60%) and at day 180 was 57% (95% CI, 42% to 71%). (B) Cumulative incidence of
`steroid-refractory gastrointestinal GVHD at day 180 was 23% (95% CI, 13% to 38%). (C) Cumulative incidence of NRM at 1 year was 21% (95% CI, 14% to 27%) and at
`2 years was 27% (95% CI, 14% to 40%). (D) Cumulative incidence of relapse at 1 year was 19% (95% CI, 8% to 30%) and at 2 years was 21% (95% CI, 9% to 32%). (E) Overall
`survival at 1 year was 73% (95% CI, 61% to 87%) and at 2 years was 56% (95% CI, 44% to 72%). (F) Cumulative incidence of chronic GVHD at 1 year was 42% (95% CI, 27%
`to 56%) and at 2 years was 58% (95% CI, 44% to 73%).
`
`proportion of patients receiving treatment for chronic GVHD
`at 6 months after HCT. The proportion of patients who had
`discontinued steroid treatment was 57% at 1 year after HCT
`and 60% at 2 years after HCT.
`
`DISCUSSION
`The majority of GVHD-related deaths occur in allogeneic
`HCT recipients who develop steroid-refractory or steroid-
`dependent GVHD [5,47]. Older and/or infirm recipients,
`especially of unrelated donor HCT, are particularly suscepti-
`ble to the toxic effects of steroid treatment and in need of
`new GVHD prevention strategies that can decrease steroid
`exposure without further suppressing T cell activity, which
`could compromise the GVL effect and increase the incidence
`of graft failure and severe infections. The 73% 1-year survival
`in the high-risk study population of older and infirm pa-
`tients, who underwent unrelated donor HCT, often mis-
`matched, compares favorably to the 53% 1-year survival
`reported for a large series of patients who recently
`
`Table 4
`Causes of Death Greater than 1 Year post-HCT
`
`Day of Death after HCT
`419
`457
`563
`795
`915
`
`Primary Cause
`cGVHD
`cGVHD
`cGVHD
`cGVHD
`cGVHD
`
`Secondary Cause
`Fungal pneumonia
`Fungal pneumonia
`Failure to thrive
`Pulmonary failure
`Pulmonary embolism
`
`cGVHD indicates chronic graft-versus-host disease.
`
`underwent transplantation patients > 60 years facilitated by
`the National Marrow Donor Program [1]. Unfortunately, the
`possible benefit from the investigational approach tested in
`this study appeared to be relatively short-lived, as a signifi-
`cant number of deaths continued to occur after 1 year after
`HCT.
`We speculate that the possible early survival advantage
`we observed may be related to the high incidence of steroid-
`responsive GVHD, which was almost double that expected
`[13,14]. Although all GVHD developed during or after eta-
`nercept treatment, in the small number of cases of early
`onset before day 28, the initiation of ECP can rightly be
`considered early treatment. It is possible that some of the
`observed steroid sensitivity may be related to the benefit of
`early treatment with ECP. Acute GVHD is a well-described
`risk factor for the development of chronic GVHD [48]. In
`this study, concurrent or shortly after completion of inves-
`tigational
`therapy,
`the majority of patients developed
`chronic GVHD. Thus, it is possible that whatever reduction in
`steroid-refractory acute GVHD achieved by our treatment
`strategy was offset by the development of steroid-dependent
`chronic GVHD, which was the primary cause of most deaths
`that occurred more than 1 year after HCT.
`Our study design did not allow us to independently assess
`the potential benefit of augmenting GVHD prophylaxis with
`etanercept alone, as we previously studied [12], or ECP alone
`in this study population. However, late treatment failures
`were the major contributor to the lack of sustained
`improvement in long-term survival, raising the possibility
`
`

`

`C.L. Kitko et al. / Biol Blood Marrow Transplant 22 (2016) 862e868
`
`867
`
`that alternative ECP schedules might have a more durable
`impact on GVHD outcomes. More intensive ECP treatments
`have been shown to improve long-term survival in patients
`with severe acute GVHD [17]; therefore, 1 strategy for opti-
`mizing outcomes could include more frequent ECP treat-
`ments around the median time to acute GVHD development.
`Although we do not know if it would have been useful, ECP
`could have been started shortly after engraftment, up to
`2 weeks earlier than the selected start of day 28 on this trial.
`Such an approach may have further attenuated acute GVHD.
`We are encouraged by the high rate of steroid responsiveness
`observed in our patients, but it is important to note that very
`few interventions that decrease acute GVHD incidence have
`translated into decreased incidence of chronic GVHD [49,50],
`suggesting that although acute GVHD is a risk factor for
`chronic GVHD, the pathogenic mechanisms are likely to be
`different; thus, requiring distinct strategies. Although ECP
`has been used for therapy of acute and chronic GVHD, its
`value in prophylaxis of chronic GVHD has never been offi-
`cially tested and, thus, remains unknown. Furthermore, on
`this trial, ECP stopped at day 180, which is close to the me-
`dian time to chronic GVHD onset. Although speculative, it is
`possible that a more prolonged course of treatment might
`impact the rate or severity of chronic GVHD that we were
`otherwise not able to alter in this study. It is important to
`note that our prophylaxis strategy did not appear to impact
`relapse rates, but further intensification of the number or
`duration of treatments might affect GVL. It is also possible
`that more intensive ECP schedules will not confer benefit and
`the desired long-term outcomes that we did not achieve in
`this study will remain elusive with alt