Graft-versus-host disease Omission of day +11 methotrexate ... - Nature

Bone Marrow Transplantation (2002) 30, 161–165  2002 Nature Publishing Group All rights reserved 0268–3369/02 $25.00 www.nature.com/bmt

Graft-versus-host disease Omission of day ⴙ11 methotrexate after allogeneic bone marrow transplantation is associated with increased risk of severe acute graftversus-host disease S Kumar1, RC Wolf3, MG Chen2, DA Gastineau1, MA Gertz1, DJ Inwards1, MQ Lacy1, A Tefferi1 and MR Litzow1 1

Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN, USA; 2Division of Radiation Oncology, Mayo Clinic, Rochester, MN, USA; and 3Hospital Pharmacy Services, Mayo Clinic, Rochester, MN, USA

Summary: The combination of CYA and short-course MTX is commonly used for GVHD prophylaxis after allogeneic BMT. Severe mucositis and organ dysfunction early after transplantation often lead to omission of the day +11 dose of MTX. To examine whether this omission increases the risk of acute or chronic GVHD, we reviewed 135 allogeneic BMTs performed at our institution in which CYA and short-course MTX prophylaxis were used. Patients receiving less than three doses of MTX and those who died before day +11 were excluded. Of the 123 eligible patients, 84 received all four doses and 39 received three doses, with the fourth dose withheld because of severe mucositis (n = 27) or hepatic or renal dysfunction (n = 12). Acute GVHD of any grade developed in 23 patients (59%) in the threedose group compared with 57 patients (68%) in the four-dose group (P = 0.33). Chronic GVHD developed in 15 patients (38%) in the three-dose group compared with 31 patients (37%) in the four-dose group (P = 0.87). There was no difference in the overall rate of acute or chronic GVHD between the groups. However, the threedose group was more likely to develop grade III or IV acute GVHD (12 of 39 (31%) ) compared with the fourdose group (12 of 84 (14%); P = 0.03). Relapse-free survival was similar for the two groups. We conclude that omitting day +11 MTX appears to increase the risk of severe acute GVHD. Bone Marrow Transplantation (2002) 30, 161–165. doi:10.1038/sj.bmt.1703616 Keywords: allogeneic; bone marrow transplantation; cyclosporine; graft-versus-host disease; methotrexate; prophylaxis

Blood and marrow transplantation offers the potential of cure for many hematologic malignancies, with a resulting Correspondence: Dr MR Litzow, Division of Hematology and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA Received 8 January 2002; accepted 1 April 2002

increase in the number of allogeneic transplants (BMTs) performed during the past three decades.1 GVHD, both acute and chronic, is an important complication of allogeneic transplantation. Despite post-transplantation prophylaxis, moderate to severe acute GVHD occurs in as many as one-half of the recipients of HLA-identical sibling transplants.2 Acute GVHD after allogeneic transplantation is a double-edged sword: its development decreases the risk of relapse, but severe acute GVHD can cause marked morbidity and mortality. The prevention of severe GVHD remains an integral part of post-transplantation management. During the past two decades, strategies for preventing GVHD have evolved from the use of single agents to the use of various combination regimens. The combination of CYA and short-course MTX, since its introduction by the Seattle Transplant Program in 1986, has remained the most widely used GVHD prophylaxis regimen.3–6 This regimen consists of CYA daily and MTX on days +1, +3, +6 and +11 after transplantation, although various modifications have been described. However, in many patients severe mucositis develops at the beginning of the second week after transplantation, resulting in omission of the day +11 MTX dose. Hepatic dysfunction and renal dysfunction, seen commonly in this group of patients, can also result in omission of this last dose. It is not clear whether omission of the day +11 dose of MTX has a deleterious effect on outcome in terms of relapse or the development of GVHD. Therefore, we retrospectively reviewed the experience at our institution to address this question. Materials and methods We retrospectively reviewed patients who underwent allogeneic BMT at our institution between 1982 and 1997 for various hematologic disorders and identified 135 patients in whom CYA and short-course MTX were used. Patients who died before day +11 and those who received fewer than three doses of MTX were excluded. The decision to omit the day +11 MTX dose was made by the attending physician on the basis of his or her assessment of the patient.

MTX dose and acute GVHD after allogeneic BMT S Kumar et al

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Of the 123 patients included, 84 received all four doses of MTX and 39 received three doses. The three-dose group and the four-dose group did not differ significantly except in disease types (Table 1). Of the 123 patients, 59 (48%) had nonadvanced disease (acute leukemia in first remission or chronic myeloid leukemia in first chronic phase) and 64 had advanced disease. There was a complete HLA match in 110 (89%) of the transplant recipients; the other 13 had a one-antigen mismatch. CMV mismatch, defined as a seropositive donor and a seronegative recipient, was present in 20 recipients (16%). GVHD prophylaxis was in the form of CYA 2.5 mg/kg given intravenously twice daily on day ⫺1 and 1.5 mg/kg twice daily thereafter to maintain blood levels of 100 to 300 ng/ml. MTX was given at a dose of 15 mg/m2 on day +1 and 10 mg/m2 on days +3, +6 and +11, as previously described.3 The reason for omitting the day +11 MTX dose was identified from the medical records. Patients who did not receive MTX on day +11 were divided into two groups, one in which the dose was omitted because of severe mucositis (n = 27) and one in which it was omitted because of hepatic or renal dysfunction (n = 12). The conditioning regimen used most frequently was CY (120 mg/kg) with fractionated TBI (1320 cGy). The other preparative regimens included busulfan (BU) (16 mg/kg) and cyclophosphamide (CY) (120 mg/kg) or etoposide (60 mg/kg) with TBI. All patients were treated in single rooms with high-efficiency particulate air filters. Standard precautions were observed for patients with neutropenia. Fever with neutropenia prompted immediate institution of a thirdgeneration cephalosporin and the addition of vancomycin

and amphotericin B sequentially for the next 48 to 72 h, according to the response to initial therapy. Antibiotic therapy was tailored further according to the results of blood culture analysis. Transfusions of RBCs and platelets were given to maintain concentrations of Hb greater than 8 g/dl and platelet counts of at least 10 000/mm3. CMV-negative or leukocyte-reduced blood products were used for CMVnegative patient–donor pairs, and all cellular products were irradiated. The end points analyzed were development of acute and chronic GVHD and time to relapse or death. Acute GVHD was graded I to IV according to established criteria.7,8 Chronic GVHD was diagnosed according to established clinical and histologic criteria. Remission and relapse were defined by conventional criteria. Treatment-related mortality was defined as death related directly to toxicity from the conditioning regimen or to other causes associated with the transplantation process in patients free of disease (or both). Statistical analysis was performed using Statview software (SAS Institute, Cary, NC, USA). The Fisher exact test or the ␹2 test was used to compare nominal variables as appropriate; the t-test was used to compare continuous variables. Relapse-free survival and the 95% confidence interval for the estimate were estimated using the Kaplan– Meier method;9 survival curves were compared using the log-rank test. Logistic regression was used for multivariate analysis of factors affecting the incidence of acute GVHD. This study was approved by the Mayo Foundation Institutional Review Board. Results

Table 1 Baseline characteristics of patients receiving three or four doses of MTX after BMTa Characteristic

Patients Adult Pediatric Male Female Age, median, years Disease ALL Acute myelocytic leukemia Chronic myeloid leukemia Non-Hodgkin’s lymphoma Aplastic anemia Other Disease status Nonadvanced Advanced HLA status Identical 1-antigen mismatch Conditioning regimen Cytoxan + TBI BU + cytoxan Other CMV mismatch

Doses of MTX received

P

3 (n = 39)

4 (n = 84)

37 (95) 2 (5) 24 (62) 15 (38) 33.3

81 (96) 3 (4) 44 (52) 40 (48) 35.5

0.684

14 13 6 2 0 4

16 15 30 8 6 9

(19) (18) (36) (10) (7) (11)

0.045

20 (51) 19 (49)

39 (46) 45 (54)

0.616

33 (85) 6 (15)

77 (92) 7 (8)

0.237

27 6 6 7

60 13 11 13

0.942

0.342

The study group consisted of 123 patients who were followed for a median of 33 months. Of these, 84 (68%) received all four doses of MTX and 39 (32%) received only three doses. Between the two groups, there was no significant difference in the overall risk of developing acute GVHD. In the three-dose group, acute GVHD of any grade (I–IV) developed in 23 patients (59%) compared with 57 patients (68%) in the four-dose group; the difference was not statistically significant (P = 0.33). This distribution is shown in Table 2. The mean time to onset of acute GVHD

0.280 Table 2

(36) (33) (15) (5) (0) (10)

(69) (15) (15) (18)

(71) (15) (13) (15)

Characteristic

Values are number (percentage) unless otherwise indicated.

Bone Marrow Transplantation

Doses of MTX received 3 (n = 39)

Acute GVHD (grades I–IV) Acute GVHD (grades II–IV) Acute GVHD (grades III–IV) Acute GVHD (grades III–IV, excluding patients with organ dysfunction) No. of days to ANC ⬎0.5 ⫻ 109/l, mean Chronic GVHD Extensive chronic GVHD

23 18 12 9

(59) (46) (31) (33)b

P

4 (n = 84) 57 28 12 12

(68) (33) (14) (14)

0.330 0.172 0.032 0.028

19

21

0.035

15 (38) 11 (28)

31 (37) 14 (17)

0.868 0.089

0.730 a

a

Clinical results after treatment with MTXa

Values are number (percentage) unless otherwise indicated. Based on n of 27 (after exclusion of patients with organ dysfunction).

b


163 100

90

Cumulative probability of survival, %


100

80 70 60 50

3 doses

40

4 doses

30 20 10 0

90 80 70 60 50 40

3 doses

30

4 doses

20 10 0

0

20

40 60 80 100 120 Time after transplantation, months

140

160

Figure 1 Kaplan–Meier plot for relapse-free survival.

0

20

40 60 80 100 120 Time after transplantaion, months

140

160

Figure 2 Kaplan–Meier plot for overall survival, four-dose group vs three-dose group.

in the three-dose group was 17 days compared with 22 days in the four-dose group. Comparison of incidence of severe acute GVHD (grades III and IV) between the two groups revealed a higher incidence for the three-dose group (12 patients (31%) vs 12 patients (14%); P = 0.032). Even after exclusion of the 12 patients in whom MTX was withheld for organ dysfunction, the difference remained significant (9 (33%) vs 12 (14%); P = 0.028). In a multivariate model incorporating number of doses of MTX, CMV mismatch, HLA mismatch, sex mismatch, and disease status, the threedose group still had an increased risk of severe acute GVHD (grades III and IV). Chronic GVHD developed in 46 patients after a mean time of 131 days, 15 (38%) in the three-dose group and 31 (37%) in the four-dose group, a difference that was not statistically significant (P = 0.87). De novo chronic GVHD developed in eight patients, quiescent chronic GVHD in 19 patients, and progressive chronic GVHD in the remaining patients. Eleven patients (28%) in the three-dose group had extensive GVHD compared with 14 (17%) in the four-dose group, a statistically insignificant (P = 0.09) trend toward more extensive GVHD in the three-dose group. The two groups did not significantly differ in terms of relapse-free survival. The actuarial relapse-free survival at 5 years (Figure 1) was 77% for the three-dose group compared with 71% for the four-dose group (P = 0.51 by logrank comparison). The difference was not significant even when the group with organ dysfunction was considered separately. Overall survival was lower in the three-dose group (P = 0.033 by log-rank comparison), with most of the difference resulting from increased mortality among patients with organ dysfunction (Figures 2 and 3). At 5 years, the survival was 62% in the four-dose group, compared with 48% in the three-dose group. The four-dose group had a slightly slower neutrophil recovery, with a mean time to neutrophil recovery of 21 days compared with 19 days for the three-dose group (P = 0.035).


100 90 80 70 60 50 40

3 doses, mucositis

30 20

3 doses, organ dysfunction

10

4 doses

0 0

20

40 60 80 100 120 Time after transplantation, months

140

160

Figure 3 Kaplan–Meier plot for overall survival, four-dose group vs two subgroups of three-dose group.

Discussion First introduced in 1986,3 the combination of CYA and short-course MTX has resulted in marked improvement in survival because of decreased acute GVHD. However, higher gastrointestinal, hepatic, and renal toxicities were observed in the initial studies evaluating this combination.3 Studies done before introduction of the short-course MTX regimen had compared it to longer courses (until day +100) of weekly MTX but failed to show benefit for prolonged MTX.10 Since then, several modifications of this regimen have been tried, including different dosages of CYA and MTX as well as a decreased number of MTX doses. In their study comparing different conditioning regimens, Deeg et al11 noted that MTX (10 mg/m2) given on days +1, +3 and +6 did not result in higher rates of acute GVHD compared to historically reported rates. Atkinson and Downs12 retrospectively investigated the effect of omitting the day +11 MTX dose and did not find any difference in the incidence of grades II to IV acute GVHD. In a review of 446 transBone Marrow Transplantation


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plants done at one institution, Nash et al13 found an increased risk of grades II to IV acute GVHD associated with reduction in MTX to less than 80% of the planned dose, decreased dose of CYA, sex mismatch, and increased dose of TBI. Other investigators have studied the effect of modifying CYA doses. Compared with higher doses, lower doses of CsA have resulted in a higher risk of acute GVHD but with a decreased risk of relapse.14 Others have demonstrated a decreased risk of both acute GVHD and relapse when therapeutic CsA levels are rapidly attained through careful monitoring of levels early after transplantation.15 In our study, we found no difference in the overall incidence of acute GVHD (grades I to IV) between patients who received all four doses of MTX and those who received only three doses. There was no difference even when we considered acute GVHD grades II to IV. However, when severe GVHD (grades III and IV) was considered, we did find a significant difference. Studies have shown that patients with the longest relapse-free survival after allogeneic stem cell transplantation are those in whom grade I GVHD develops.16,17 Although risk of relapse decreases with increasing grades of GVHD, higher grades, especially grades III and IV, are associated with high transplant-related mortality and hence are undesirable. From a clinical standpoint, it is severe GVHD (grades III and IV) that has an adverse effect on survival and is therefore the most important to prevent. This finding would argue against omission of day +11 MTX. In our multivariate analysis, we could not confirm the influence of other risk factors for acute GVHD that previously have been described, such as sex mismatch and TBI.13 Parity of female donors could not be studied in our cohort of patients. It is possible that some of these differences could be attributed to the smaller number of patients in our study. In their review, Atkinson and Downs12 did not find any effect of omitting the fourth dose of MTX. However, in that study the incidence of acute GVHD grades II to IV was compared between the two groups, and the effect on severe acute GVHD (grades III and IV) was not specifically examined. Similarly, in our study we did not observe any difference when comparing acute GVHD grades II to IV. However, when severe GVHD (grades III and IV), which is more important from the clinical standpoint, was examined, we found a significant difference between the groups in our study. Moreover, the dose of MTX used in that study was 7.5 mg/m2 on days +1, +3, +6 and +11, which is considerably lower than the dose used in our study. The overall incidence of acute GVHD in their study (71% and 84% for the three- and four-dose groups, respectively) is higher than that which we observed (59% and 68%) and is probably related to the lower total dose. It is possible that the difference in MTX dose intensity and the resulting higher overall incidence of acute GVHD in their study could partly explain the difference in findings. However, our data are certainly consistent with the finding by Nash et al13 (in their review of a large number of patients) of an increased incidence of acute GVHD associated with an MTX reduction of more than 80%. Like previous researchers, we did not find a difference in the incidence of chronic GVHD related to the number of MTX doses, but the trend toward extensive chronic


GVHD with omission of day +11 MTX is intriguing. For patients who are alive 2 to 3 months after transplantation, the development of chronic GVHD has the greatest effect on quality of life. Extensive chronic GVHD contributes to long-term morbidity among patients undergoing stem cell transplantation. GVHD alone or in combination with infection accounts for many late transplant-related deaths in patients free of disease. A study with greater numbers of patients may be able to investigate this trend more definitively. We did not observe any difference in relapse-free survival between the two groups. This is consistent with the lack of difference in overall incidence of acute GVHD. The decreased overall survival in the three-dose group appears to be related to increased mortality from organ dysfunction, which, in fact, had led to omission of the day +11 MTX. Evaluation of factors predisposing to acute GVHD has clearly demonstrated the role of increased conditioningrelated toxicity in its etiology.11 Increased doses of radiation have been associated with an increased incidence of acute GVHD.13 Thus, one could argue that omission of day +11 MTX is a surrogate marker for patients who had higher conditioning-related toxicity and hence were destined to have more severe acute GVHD. A retrospective study cannot refute this possibility. However, the lack of a higher overall incidence of acute GVHD in the three-dose group would argue against this hypothesis. Our results should prompt prospective evaluation of this question. Given the increasing use of peripheral blood as a source of stem cells, this question begs examination in that setting, especially considering the differences demonstrated in immunologic phenotype between different stem cell sources. Until this question is more definitively examined, we should maintain a high threshold for omitting the day +11 MTX dose, and every attempt should be made to complete the full course of therapy.

Acknowledgements We are indebted to Ms Norine E Huneke for her expert assistance with the BMT data management.

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