Management of acquired aplastic anemia in children

Bone Marrow Transplantation (2013) 48, 191 195 & 2013 Macmillan Publishers Limited All rights reserved 0268-3369/13 www.nature.com/bmt REVIEW Management of acquired aplastic anemia in children ET Korthof 1,4,ANBékássy 2 and AA Hussein 3, on behalf of the SAA-WP of the EBMT The diagnosis of aplastic anemia in children requires exclusion of a variety of inherited or acquired BM failure syndromes with similar phenotypes. An efficient diagnostic plan is important because time from diagnosis to final treatment is directly related to outcome regardless of the therapeutic option chosen. The gold standard of therapy remains hematopoietic SCT with a graft of BM cells for those children with matched sibling donors. Conversely for children without a sibling donor the high response and markedly improved overall survival rates of combined immunosuppressive therapy have proven robust, especially when horse derived anti-thymocyte globuline plus ciclosporine A are used. Incomplete response, relapse and progression to myelodysplasia/ leukemia however have emerged as significant long-term issues. Improvements in outcome of alternative donor transplantation and the use of established and novel immunosuppressive agents provide multiple alternatives for treating refractory or relapsed patients. Regardless of the type of therapeutic approach, patients require centralized treatment in a center of excellence, ongoing monitoring for recurrence of disease and/or therapy-related immediate side effects and long-term effects. Bone Marrow Transplantation (2013) 48, 191 195; doi:10.1038/bmt.2012.235; published online 7 January 2013 Keywords: acquired aplastic anemia; childhood; supportive care; management; hematopoietic SCT; immunosuppressive therapy INTRODUCTION Aplastic anemia in childhood is an uncommon but serious disorder, which affects B2 in 1 000 000 children each year. The majority of these cases are categorized as idiopathic because their primary etiology is unknown. In B15 20% of patients the disease is constitutional/inherited where it can present with one or more somatic abnormalities. DIAGNOSIS All children presenting with pancytopenia should be carefully assessed to establish the cause of the cytopenia, which may be different from causes in adulthood. 1 These causes might include hypocellular ALL, which occurs in 1 2% of cases of childhood ALL; in such cases an overt leukemia usually develops within 3 9 months of the apparent BM failure (BMF). 2,3 The neutropenia is usually more pronounced than the thrombocytopenia and sometimes there is an increase in reticulin within the hypocellular BM. Inherited BMF disorders should also be excluded, such as Fanconi anemia, dyskeratosis congenita, congenital amegakaryocytic thrombocytopenia in the aplastic phase, Diamond Blackfan anemia and Schwachman Diamond syndrome. 4 7 Classical paroxysmal nocturnal hemoglobinuria (PNH), hypoplastic myelodysplastic syndrome (MDS), medications and infection should be ruled out also. 8,9 This may be difficult as patients with AA can present with PNH clones; 10 however, when there is overt hemolysis, the diagnosis will be PNH; if there is no hemolysis, the diagnosis will be AA. Differentiating between AA and hypoplastic MDS may be difficult, particularly when clonal cytogenetic markers are absent. 11 Transient chromosomal abnormalities may be present in AA and may reflect oligoclonality of the stem cell compartment, whereas true clonal expansions are of prognostic significance. Monosomy 7 is the most frequent cytogenetic abnormality observed during such evolution and is associated with a poor prognosis. 12 This evolution is most often associated with persistence of low counts or further worsening of cytopenia. Single-nucleotide polymorphism- or comparative genomic hybridization-array-based cytogenetics may be helpful in distinguishing AA from hypoplastic MDS and/or in the early detection of clonal progression. 3,11,13,14 SUPPORTIVE CARE Provision of information and psychological support to parents and children is of utmost importance. Preventive measures should be taken to avoid infection and bleeding, such as reversed isolation and selective gut decontamination with preferably non-absorbable antibiotic and antifungal drugs, including cotrimoxazole, which prevents Pneumocystis jiroveci pneumonia as well. 15 17 Medical care continues to depend upon meticulous attention to issues of infection and hemorrhagic diathesis, and expectant management of regimen-related toxicities. In cases of neutropenic fever, empiric broad-spectrum antibiotics should be started after taking blood cultures. When fever persists without known cause for more than 2 days after initiation of antibiotics, antifungal therapy should be added. Prophylactic platelet transfusions should be given when the platelet count is o10 10 9 /L (or o20 10 9 /L in the presence of fever). Management of infection should be initiated before giving immunosuppressive therapy (IST) or proceeding with hematological SCT (HSCT), although it may sometimes be necessary to proceed straight to transplantation in the presence of severe infection, as it may offer the best chance of early neutrophil recovery. 1 Department of Pediatrics/Willem-Alexander Children s Hospital, Division of Stem Cell Transplantation, Leiden University Medical Center, Leiden, The Netherlands; 2 Department of Pediatrics, University Hospital, Lund, Sweden; 3 Bone Marrow and Stem Cell Transplantation program, King Hussein Cancer Center, Amman, Jordan and 4 Sanquin-LUMC Jon J van Rood Centre for Clinical Transfusion Research, Leiden University Medical Center, Leiden, The Netherlands. Correspondence: Dr ET Korthof, Sanquin-LUMC Jon J van Rood Centre for Clinical Transfusion Research, Leiden University Medical Center, Plesmanlaan 1a, Leiden 2333BZ, The Netherlands. E-mail: l.korthof@sanquin.nl Received 11 October 2012; accepted 11 October 2012; published online 7 January 2013

192 RBCs should be given in the case of anemia (Hb o4.5 mmol/l, or o5.5 mmol/l in cases of anemic problems) and platelet concentrates in case of thrombocytopenic bleeding. 1,5,18 Pre-storage leukoreduction/-depletion of RBC and platelet concentrates to prevent HLA alloimmunization should be used for every patient with AA. Irradiation of blood products is current praxis to prevent transfusion-associated GvHD and to reduce sensitization to HLA and non-hla antigens from multiple transfusions in patients who are candidates for transplant and for anti-thymocyte globuline (ATG) treatment, during and after these treatments, until the lymphocyte count recovers 41.0 10 9 /L. 19 Transfusion of irradiated granulocyte transfusions may be considered in patients with life-threatening neutropenic sepsis. 20 A short course of G-CSF may be considered for severe systemic infection that is not responding to i.v. antibiotics and anti-fungal drugs, but should be discontinued after 1 week if there is no increase in the neutrophil count. Iron chelation therapy should be considered when the serum ferritin is 41000 mg/l. 21 Expectant, cautious management is urged in regard to renal impairment, especially if there is concomitant use of nephrotoxic immunosuppressive drugs. Daily chelation with oral deferasirox has been studied prospectively in a large number of AA patients with iron overload. 22 24 Treatment was well tolerated and effective in decreasing serum ferritin and transaminases. In addition to producing desired improvements in organ function in a few cases, chelation with either deferasirox or deferoxamine has also intriguingly been associated with significant hematologic improvement. 25,26 The routine use of rhuepo in AA is not recommended. Prednisolone alone should not be used to treat children with AA because it is ineffective and encourages bacterial and fungal infection. DEFINITIVE TREATMENT HSCT and IST are the main treatment options for children with AA of which HSCT is the only curative one. This makes HSCT the recommended first-line therapy when an HLA-matched sibling donor is available, although short- and middle-term treatment outcomes of both modalities do not differ that much. 27 30 As AA is a rare disease, it is most important either to centralize treatment or, second-best, to follow treatment protocols of (inter-)national groups specialized in treatment of BMF syndromes, such as the Severe Aplastic Anemia Working Party of the European Blood and Marrow Transplantation group (EBMT). MATCHED SIBLING HSCT HSCT with an HLA-identical sibling donor is the initial treatment for newly diagnosed children with severe or very severe AA. Pediatric survival rates after matched sibling HSCT for SAA are excellent, being 90% and even higher in some series. 30 32 The mainstay of conditioning is CY with or without additional agents, but there is no indication for irradiation in the regimen for HLA-identical sibling transplantation. 27,29 Children with SAA remain at increased risk for late graft rejection, and immunosuppressive agents used for GVHD prophylaxis posttransplantation should be weaned with great caution. The recommended source of stem cells for transplantation in AA is BM. 33 Pediatric reports of PBSC transplantations describe rapid engraftment and increased chronic GVHD. The improved survival upon PBSC transplantation seen in some adult studies does not carry over to the pediatric population, however. Schrezenmeier et al. 33 reviewed outcomes of almost 700 patients undergoing HLA-matched sibling BMT for SAA and found that in patients under age 20 years, significantly increased mortality and chronic GVHD was associated with PBSC transplantation. IMMUNOSUPPRESSIVE THERAPY For patients with (very) severe AA lacking a matched sibling donor or with non-severe AA who are transfusion-dependent IST is indicated. The multi-agent regimen of anti thymocyte globulin (ATG) and CsA (generally accompanied by a brief course of corticosteroids) is the standard immunosuppressive regimen. 34,35 Substantial data as to the relative efficacy of the preparations have shown the superior effect of the horse ATG. 36,37 CsA should be continued for at least 12 months after achieving maximal hematological response, followed by a very slow tapering to reduce the risk of relapse. 38 The routine use of long-term G-CSF or other hematopoietic growth factors is not recommended. 39 Response rates to IST in children are favorable, with survival ranging from 68% in one institution to 80% in another retrospective study at 10 years, with 89% survival if the analysis is confined to responders to IST. 40 42 There are data demonstrating the risk for malignant evolution over time with IST therapy, with rates of MDS/acute myelogenous leukemia ranging from 8 to 25%. 9,43 Modifications to the conventional IST regimen, including addition of danazol, mycophenolate mofetil, sirolimus or hematopoietic growth factors, have not significantly improved response or decreased relapse rates. 44,45 Such agents currently have no place in primary therapy, although a few studies suggest that the addition of danazol or growth factors has altered relapse rates. Very little information is available about the substitution of tacrolimus for CsA. Alternative immunosuppressive regimens, such as alemtuzumab with or without CsA, also show promise. 46 For children refractory to IST or who relapse after successful IST, evolution to MDS, AML or PNH should be ruled out first. In case of real refractoriness or relapse treatment with an additional course of ATG-based IST is possible; 47,48 however, HSCT with a matched unrelated donor (MUD) donor has become a preferred option. Results of a second course of IST are generally disappointing, with only a 30% overall response rate. 48 A prospective trial in 52 pediatric patients failing initial IST compared a second course of IST with unrelated donor HSCT and found an 11% response rate to IST with a 5-year failure-free survival rate of 9.5% in the former group, compared with an 84% 5-year failure-free survival rate in the latter group. 49 Moreover, a higher risk of clonal evolution over time is associated with repeat IST. 9,43 ALTERNATIVE DONOR HSCT The above choice is heavily influenced by the recent significant improvement in the outcome of alternative donor transplantation, using either matched or mismatched unrelated donors or mismatched related donors. 50 54 Four-year survival data for unrelated transplants equal those of identical sibling transplants. 51,53 In a multivariate analysis of the European registry data, in which actuarial survival after alternative donor HSCT improved from 32 to 57% in the periods 1990 1997 and 1998 2005, respectively, only year of transplantation was associated with increased survival. It is likely that progressive changes in dimensions such as improved performance status, decreased number of prior transfusions, decreased interval from diagnosis to transplantation, improved supportive care, better donor recipient matching, and use of less-intensive (particularly low-dose radiation or radiation free) regimens contributed to this association and to the improved results in other recent studies. Stem cell source should be preferably BM, although cord blood transplantation is being used when no other donor is available. 55,56 Overall better-matched patients have superior outcomes after alternative donor HSCT in pediatric patients. The optimal conditioning regimen for MUD HSCT is uncertain, but currently a fludarabine, non-irradiation-based regimen is favored for pediatric Bone Marrow Transplantation (2013) 191 195 & 2013 Macmillan Publishers Limited

patients less than 14 years of age, whereas for patients older than 14 years of age low-dose TBI is added. The preparative regimen included fludarabine, CY, and ATG with CsA and MTX for GVHD prophylaxis. 51 FOLLOW-UP Patients with AA should be followed life-long: after IST because of the risk on malignant evolution of the BM, 57 after HSCT on a solid tumor and other common transplant-related late effects. 58 60 Patients undergoing HSCT for acquired AA are at significant risk for malignancy, most commonly carcinoma of the skin and oral mucosa. Major risk factors that have been identified are the development of chronic GVHD and the use of radiation-based conditioning regimens. Children who receive non-tbi-containing transplantation regimens for acquired AA demonstrate normal growth, with attainment of final adult height close to that predicted from parental height, normal thyroid and adrenal function, and preserved fertility. Regardless of the preparative regimen used, all patients undergoing HSCT should receive routine monitoring of growth and development, endocrine and pulmonary function and bone density, and patients receiving radiation-containing regimens should receive fertility counseling as well before proceeding to transplant to offer fertility preserving measures if possible. TREATMENT ALGORITHM (A) Matched related donor allogeneic HSCT 1. Severe and very severe AA as the first-line therapy. 2. Transfusion-dependent non-severe AA after failure of first-line IST (IST-1). Conditioning regimen: CY/ATG: CY 50 mg/kg/day i.v. for 4 days and ATG (either horse ATG at 30 mg/kg/day i.v. for 5 days, or rabbit ATG at 2.5 mg/kg/day i.v. for 4 days). Stem cell source: BM. GVHD prophylaxis: CsA (start i.v.) and short course of MTX (10 mg/m 2 /day i.v. at day þ 1, þ 3 and þ 6). Continue full dose of CsA (trough level between 100 and 200 ng/ml) up to 9 months, then taper off in 3 months and stop it at 1 year post transplant if there is no GVHD. (B) IST: ATG/CSA 1. Severe and very severe AA for patients without a matched related donor. 2. Transfusion-dependent non-severe AA. Treatment scheme: horse ATG, CsA, methylprednisolone, G-CSF. Horse ATG (Atgam) 40 mg/kg/day i.v. in a 12- to 18-h infusion, for 4 days (d1 4). CsA 5 mg/kg/day orally from day 5 (trough level between 150 and 250 ng/ml) up to 1 year, then taper off if complete response has been achieved by 5 10% of dose/month up to month þ 24. If no complete response at 1 year, continue CSA. Methylprednisolone (or prednisone) 1 2 mg/kg/day from day 1 to day 5 as a 30-min i.v. bolus 30 min before horse ATG; 1 mg/kg/day orally from day 6 to day 14 and tapering off over the next 14 days. G-CSF (lenograstim or filgrastim) 5 mg/kg/day i.v. continuously or s.c. once daily during the first 30 days; thereafter it may be considered during febrile or infectious episodes when ANC o0.5 10 9 /L. (C) Matched unrelated or cord blood HSCT 1. Very severe and severe AA after failure (no response or relapse) of IST-1. 2. Transfusion-dependent non-severe AA after failure (no response or relapse) of IST-1 and 2. Conditioning regimen: Fludarabine 30 mg/m 2 /day i.v. for 5 days (days 7 to 3); CY 50 mg/kg/day i.v. for 4 days (days 5to 2) and ATG (either horse ATG at 30 mg/kg/day i.v. or rabbit ATG) at 2.5 mg/kg/day i.v. for 4 days (days 5to 2). Stem cell source: BM as first choice, peripheral blood or cord blood as second choice. GVHD prophylaxis: CsA and short course of MTX (10 mg/m 2 at day þ 1, þ 3 and þ 6) for MUD; CsA, mycophenolate mofetil for unrelated cord blood transplantation. Continue full dose of CsA (trough level between 100 and 200 ng/ml) up to 9 months, then taper off in 3 months and stop it at 1 year post transplant if there is no GVHD. (D) Haploidentical HSCT 1. Rescue for primary graft failure following unrelated cord blood transplantation. 2. Patients failing IST-1 and -2 and having no available related, unrelated or cord blood donor. 3. Patients in need of urgent recovery of neutrophils for whom no other stem cell donor will be available in due time. There are insufficient data to make a definite recommendation regarding conditioning regimen and graft composition in haploidentical HSCT for SAA. It should be performed in a specialist center with major experience with HSCT procedures (please see the section on haploidentical transplant in this issue). Following is the scheme we adhere to. Conditioning regimen: Fludarabine 30 mg/m 2 /day for 5 days (day 7to 3); CY 50 mg/kg/day for 4 days (day 5to 2) and rabbit ATG at 2.5 mg/kg/day for 4 days (day 5to 2). Stem cell source and dose: BM CD34 þ selection by Clinimacs to reach 6 8 10 6 CD34 þ cells/kg patient body weight, with a maximum of CD3 þ cells of 5 10 4 /kg patient body weight. Graft versus host prophylaxis: with CsA (MTX is not needed). Continue full dose of CsA (trough level between 100 and 200 ng/ml) up to 9 months, then taper off in 3 months and stop it at 1 year post transplant if there is no GVHD. Unrelated donor search in pediatric patients Unrelated donor search should be initiated at primary work up and decision making for IST when it is clear that a matched sibling donor is not available. If a search prognosis indicates that a MUD will be found easily, it is reasonable to wait with a complete search until it is clear that a transplant has to be done at evaluation at 3 months after the start of IST. But remember: BMF is a medical emergency, thus IST should immediately be started after the second diagnostic BM puncture has been done if no matched sibling donor is available. Hierarchy of donor preferences in alternative donor HSCT should be as follows: 1. MUD. 2. 1 Ag m/m MUD. 3. Depending on the centers experience: matched or minimally m/m cord blood or haploidentical donor. SUMMARY Incremental gains have been made in both the diagnosis and management of AA. Greater understanding of regimen-related 193 & 2013 Macmillan Publishers Limited Bone Marrow Transplantation (2013) 191 195

194 toxicities, either acute or delayed and potentially chronic, provides an impetus for the improvement of therapeutic strategies. Matched sibling HSCT is the treatment of choice with excellent results. Current immunosuppressive treatment induces durable remissions in 70 80% of patients with AA and results in 70% longterm survival. In recent years, the survival of refractory patients has also improved. Apart from relapse and refractoriness to IST, evolution of clonal diseases, including PNH and MDS, is the most serious long-term complication and constitutes a strong argument for definitive therapy with HSCT if possible. Consequently, the detection of diagnostic chromosomal abnormalities (mostly monosomy 7) is of great clinical importance. Alternative donor HSCT surely has gained a firm place in the treatment of children with AA. CONFLICT OF INTEREST The authors declare no conflict of interest. REFERENCES 1 Guinan EC. Diagnosis and management of aplastic anemia. 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