Educational content on VJHemOnc is intended for healthcare professionals only. By visiting this website and accessing this information you confirm that you are a healthcare professional.

Share this video  

EBMT 2022 | PTCy vs ATG in ALL in haploidentical, unrelated and sibling donor transplantation

Arnon Nagler, MD, Chaim Sheba Medical Center, Tel-Aviv, Israel, compares the use of post-transplant cyclophosphamide (PTCy) and anti-thymocyte globulin (ATG) as graft-versus-host disease (GvHD) prophylaxis in patients with acute lymphoblastic leukemia (ALL). While the benefit of PTCy over ATG has been shown in the haploidentical setting, further data is required to validate the superiority of PTCy in unrelated donor transplantation. Moreover, studies have not shown a benefit in survival for patients treated with PTCy in sibling donor transplantation. This interview took place at the 48th Annual Meeting of the European Group for Blood and Marrow Transplantation (EBMT) 2022, which was held virtually.

Transcript (edited for clarity)

Post-transplant cyclo revolutionized anti GvHD prophylaxis. And I would say revolutionized transplantation biology by knocking down alloreactive T-cells, and upregulating T-regulatory cells. And it was pioneered in haploidentical transplant in AML, but then moved to other disease categories and also to unrelated transplantation and sibling transplant. So for the haploidentical transplant, including in ALL, post-transplant cyclo was beneficial...

Post-transplant cyclo revolutionized anti GvHD prophylaxis. And I would say revolutionized transplantation biology by knocking down alloreactive T-cells, and upregulating T-regulatory cells. And it was pioneered in haploidentical transplant in AML, but then moved to other disease categories and also to unrelated transplantation and sibling transplant. So for the haploidentical transplant, including in ALL, post-transplant cyclo was beneficial. We published it two years ago and there is better leukemia-free survival, overall survival, and GRFS with a post-transplant cyclo compared to ATG, this was haploidentical transplant. For unrelated most of the work there is under clinical studies, it’s not a common practice, but it seems that the post-transplant cyclo drastically reduces transplant related mortality. And it’s maybe reducing chronic GvHD, not acute GvHD, but in our hands chronic GvHD. At the end of the day, it’s beneficial so I would say that I would go for post-transplant cyclo in the unrelated setting. Of course, all the field is waiting for two arm studies in order to define this issue but it looks like the post-transplant cyclo will be beneficial also in unrelated.

In sibling transplantation it is a different story. We have shown that in AML, at least, in sibling transplant, there is no advantage of post-transplant cyclo compared to ATG. And just now in the Presidential Symposium of the EBMT, Professor Sebastian Giebel, which is the head of the ALL sub-committee in the Leukemia Working Party presented work in which he compared post-transplant cyclo to ATG in patients with CLL and showed that although there was less chronic GvHD with ATG post-transplant cyclo improved the leukemia free cell survival, but not the overall survival.

So I would say that I don’t see a major difference in post-transplant cyclo benefits for AML or ALL. Again, it’s revolutionized the field in haploidentical transplant and made it possible after the work of the Baltimore group. In unrelated, I would say that I will go for it, but it’s still under clinical trials. And in siblings, I would say that we should be very careful before using post-transplant cyclo. Of course, in sibling transplant not everybody, although the two-arm study showed a beneficial effect of using ATG for GvHD in sibling transplantation, not all the centers are using ATG for sibling transplant.

Read more...