It has been reported in prospective randomized trials that antithymocyte globulin (ATG)-based graft-versus-host disease (GVHD) prophylaxis has benefits in the setting of allogeneic hematopoietic stem cell transplantation (allo-HSCT) with unrelated donors (UDs). However, the optimal GVHD prophylaxis strategy has been challenged recently by the increasing use of posttransplant cyclophosphamide (PTCY). We report from the European Society for Blood and Marrow Transplantation registry the outcomes of 960 patients with myelodysplastic neoplasms who underwent allo-HSCT from UD with PTCY or ATG as GVHD prophylaxis. The primary outcomes were overall survival (OS) and progression-free survival (PFS). The disease characteristics were similar in both groups. Day 28 neutrophil engraftment was significantly better with ATG (93% vs 85%). Over a median follow-up of 4.4 years, the 5-year OS was 58% with PTCY, and 49% in the ATG group. The 5-year PFS was higher for PTCY at 53% vs 44% for ATG. Grade 2 to 4 acute GVHD incidence was lower when PTCY was used (23%), whereas there was no difference in the incidence of chronic GVHD at 5 years. Multivariable analyses confirmed better OS and PFS with PTCY with a hazard ratio (HR) for ATG of 1.32 (1-1.74) and a better PFS for PTCY with a HR for ATG of 1.33. This study suggests that GVHD prophylaxis using PTCY instead of ATG in this setting remains a valid option. Further prospective randomized studies would be essential to confirm these results.

Bone Marrow Transplantation Unit Haematology Department Institute of Haematology and Oncology IDIBAPS Hospital Clinic University of Barcelona Barcelona Spain

CHU de Lille Univ Lille INSERM U1286 INFINITE 59000 Lille France

Demiroglu Bilim University Istanbul Florence Nightingale Hospital Istanbul Turkey

Department of Biomedicine and Prevention University of Rome Tor Vergata Rome Italy

Department of Oncology and Hematology University of Milan and Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII Bergamo Italy

EBMT Leiden Statistical Unit Leiden The Netherlands

EBMT Leiden Study Unit Leiden The Netherlands

Fundeni Clinical Institute Bucharest Romania

Hematology and BMT Unit ASST Fatebenefratelli Sacco University of Milan Milan Italy

Hôpital Saint Louis APHP Université de Paris Cité Paris France

Hôpitaux Universitaires de Genève and Faculty of Medicine University of Geneva Geneva Switzerland

Institute of Hematology and Blood Transfusion Prague Czech Republic

King's College Hospital London United Kingdom

Oslo University Hospital Rikshospitalet Oslo Oslo Norway

Ospedale San Raffaele s r l Milan Italy

RM Gorbacheva Research Institute Pavlov University St Petersburg Russia

Turku University Hospital Turku Finland

University Clinical Centre Medical University of Warsaw Warsaw Poland

University College London Hospitals NHS Foundation Trust London United Kingdom

University Hospital Basel Basel Switzerland

University Hospital Eppendorf Hamburg Germany

University of Cologne Cologne Germany

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