Absence Of Acute Graft-versus-host Disease Research Articles

Outcome of Haploidentical Peripheral Blood Allografts Using Post-Transplantation Cyclophosphamide Compared to Matched Sibling and Unrelated Donor Bone Marrow Allografts in Pediatric Patients with Hematologic Malignancies: A Single-Center Analysis

The introduction of post-transplantation cyclophosphamide (PTCy) as graft-versus-host disease (GVHD) prophylaxis has made haploidentical (haplo) hematopoietic stem cell transplantation (HSCT) a common approach in adults, but pediatric experience is limited. Based on the encouraging adult data and with the aim of decreasing the risk of graft failure, our center is increasingly using peripheral blood stem cells (PBSCs) from haplo donors with PTCy. Here we compare outcomes of bone marrow (BM) transplantation with traditional donor choices, including matched sibling donors (MSDs) and 10/10 HLA matched unrelated donors (MUDs), with those of haplo PBSC grafts in pediatric patients with hematologic malignancies. In this retrospective single-center study, the primary endpoint was the comparison of GVHD-free relapse-free survival (GRFS; defined as absence of acute GVHD [aGVHD] grade III-IV, relapse, death, or chronic GVHD [cGVHD] requiring systemic therapy) for the 3 cohorts. Secondary endpoints included overall survival (OS), relapse-free survival (RFS), nonrelapse mortality (NRM), and incidence of aGVHD and cGVHD). A total of 104 consecutive patients underwent first allogeneic (allo)-HSCT for a hematologic malignancy or myelodysplastic syndrome between January 2014 and December 2020 using a haplo family donor (PBSCs; n=26), an MSD (BM; n=31), or an MUD (BM; n=47). Patient demographic and transplantation characteristics were not significantly different across the cohorts, apart from remission status, with the haplo cohort having more patients in third or later complete remission before HSCT (P < .01). The median duration of follow-up for the entire cohort was 573 days. The cumulative incidence of aGVHD (grade II-IV or grade III-IV) was not significantly different among the cohorts; however, the cumulative incidence of cGVHD at 18 months was highest in the MUD cohort (31.7%, versus 10.0% in the MSD cohort and 9.2% in the haplo cohort; P=.02). There were no differences in the 18-month cumulative incidence of relapse or NRM. OS and RFS at 18 months were 80.7% (95% confidence interval [CI], 61.7% to 100%) and 73.8% (95% CI, 55.5% to 98.1%) for the haplo cohort, 83.4% (95% CI, 72.8% to 95.5%) and 70.3% (95% CI, 57.9% to 85.3%) for the MUD cohort, and 80.9% (95% CI, 66.9% to 97.7%) and 66.5% (95% CI, 50.5% to 87.5%) for the MSD cohort, with no statistically significant differences among the cohorts. GRFS at 18 months was 61% (95% CI, 43.3% to 85.9%) for the haplo cohort, 44.6% (95% CI, 31.8% to 62.5%) for the MUD cohort, and 62.1% (95% CI, 45.7% to 84.3%) for the MSD cohort (P=.26). Haploidentical PBSC HSCT with PTCy had comparable outcomes to MSD and MUD BM HSCT and less cGVHD compared with MUD BM HSCT in children. The logistical advantages and lower resource burden of haplo HSCT with PBSCs make it a feasible alternative to MUD HSCT in children with hematologic malignancies. Given that this is a retrospective comparison of transplantation platforms rather than donor types, further prospective studies are warranted. © 2021 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.

Durable Outcomes of a Prospective Double Cord Blood Transplantation Trial in Adults with Acute Lymphoblastic Leukemia: Different Outcomes According to the Presence of Philadelphia Chromosome

▪Background: Alternative donor hematopoietic cell transplantation (HCT) is an emerging topic in acute leukemia for patients without matched sibling donors (MSD) or unrelated donors (MUD). Cord blood transplantation (CBT) has been tried for several years in adult acute lymphoblastic leukemia (ALL), and the long-term survival outcomes were comparable to those treated with conventional donor HCT.Aim : We have conducted double CBT (DCBT) in patients without both MSD and MUD for final step, and here, we report our phase 2 study results of clinical outcomes for adult ALL patients treated with DCBT.Methods: During the period between 2005 and 2016, 67 patients (median age, 37 years [range, 16-59 years]; 34 Ph-negative ALL and 33 Ph-positive ALL) were treated with DCBT in CR1 (n=48), CR2 (n=15), and in advanced status (n=4). The indications for DCBT were unavailability of MSD and MUD, agreement for conduction of the transplantation procedure, and proper performance status and organ function to undertake transplantation. The median time to transplant was 198 days (range, 97-1751 days). All patients received DCBT following total body irradiation (TBI) 12.0 Gy plus cytarabine 9.0 g/m2 plus fludarabine 150 mg/m2, and graft versus host disease (GVHD) prophylaxis was attempted by administering tacrolimus plus mycophenolate mofetil. If residual leukemia was detected in the absence of GVHD at 3 months after transplantation, calcineurin inhibitors were rapidly discontinued.Results: The median time for neutrophil and platelet recovery was 25 days (23 days [range, 12-109] for Ph-negative ALL and 26 days [range, 9-59] for Ph-positive ALL, P=0.336) and 34 days (27.5 days [range, 8-123] for Ph-negative ALL and 40 days [range, 9-185] for Ph-positive ALL, P=0.022), respectively. The median CD34+ cell count was 1.21 x 105/kg (range, 0.4-5.85) and TNC was 4.04 x 107/kg (range, 1.58-7.88). In our data, extramedullary involvements were more frequently observed in Ph-negative ALL, while hyperleukocytosis was frequently observed in Ph-positive ALL. Except for 5 patients who died in aplasia, 28 developed acute GVHD (grade II in 23 and grade III in 5), and the cumulative incidence of acute GVHD at 1-year was 41.8%, and the incidence was 9.0% for acute GVHD with grade III-IV. Except for 11 patients with early deaths within 100 days, 17 developed chronic GVHD (11 mild, 4 moderate, 2 severe), resulting in a 4-year cumulative incidence of 23.0% (3.0% for severe chronic GVHD). After a median follow-up duration of 43.7 months (range: 6.5 - 135.3), the 4-year cumulative incidence of relapse (CIR) and non-relapse mortality (NRM) were 15.6% and 29.6% (7.2% and 29.2% for CR1), respectively, and the 4-year disease-free survival (DFS) and overall survival (OS) rates were 52.5% and 53.9% (62.9% and 65.6% for CR1), respectively. The 4-year CIR, NRM and DFS for Ph-negative and Ph-positive subgroup was 9.6% and 21.6% (P=0.140), 21.0% and 38.9% (P=0.107), and 66.5% and 37.7% (P=0.017). The results of Ph-negative and Ph-positive subgroup in CR1 were 4.8% and 9.9% (P=0.357), 19.1% and 43.0% (P=0.088), and 76.1% and 45.0% (P=0.029), respectively. In multivariate analysis, advanced disease status≥CR2 (HR, 5.61; 95% CI, 1.4-22.2; P=0.014) was related with higher CIR rate, and older age (HR, 3.75; 95% CI, 1.5-9.3; P=0.004) and lower CD34+ cell count (HR, 4.96; 95% CI, 1.1-22.3; P=0.037) were related with higher NRM rates. Overall, Ph-chromosome (HR, 2.65; 95% CI, 1.2-5.8; P=0.016), longer time to transplant (HR, 4.18; 95% CI, 1.9-8.9; P <0.001), lower CD34+ cell count (HR, 3.66; 95% CI, 1.4-9.5; P=0.008) and the absence of acute GVHD (HR, 3.19; 95% CI, 1.4-7.4; P=0.006) were related to poorer DFS.Conclusion: Our data showed that DCBT can be a good alternative choice for providing a long-term disease control for adult ALL patients especially in Ph-negative subgroup. Since Ph-positive subgroup was related with poorer DFS and higher NRM rate in our data, another alternative haploidentical HCT should be considered. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Lack of acute xenogeneic graft- versus-host disease, but retention of T-cell function following engraftment of human peripheral blood mononuclear cells in NSG mice deficient in MHC class I and II expression.

Immunodeficient mice engrafted with human peripheral blood mononuclear cells (PBMCs) support preclinical studies of human pathogens, allograft rejection, and human T-cell function. However, a major limitation of PBMC engraftment is development of acute xenogeneic graft- versus-host disease (GVHD) due to human T-cell recognition of murine major histocompatibility complex (MHC). To address this, we created 2 NOD- scid IL-2 receptor subunit γ ( IL2rg) null (NSG) strains that lack murine MHC class I and II [NSG-β-2-microglobulin ( B2M) null ( IA IE)null and NSG -( Kb Db) null ( IAnull)]. We observed rapid human IgG clearance in NSG- B2Mnull ( IA IE) null mice whereas clearance in NSG -( Kb Db) null ( IAnull) mice and NSG mice was comparable. Injection of human PBMCs into both strains enabled long-term engraftment of human CD4+ and CD8+ T cells without acute GVHD. Engrafted human T-cell function was documented by rejection of human islet allografts. Administration of human IL-2 to NSG -( Kb Db) null ( IAnull) mice via adeno-associated virus vector increased human CD45+ cell engraftment, including an increase in human regulatory T cells. However, high IL-2 levels also induced the development of GVHD. These data document that NSG mice deficient in murine MHC support studies of human immunity in the absence of acute GVHD and enable evaluation of human antibody therapeutics targeting human T cells.-Brehm, M. A., Kenney, L. L., Wiles, M. V., Low, B. E., Tisch, R. M., Burzenski, L., Mueller, C., Greiner, D. L., Shultz, L. D. Lack of acute xenogeneic graft- versus-host disease, but retention of T-cell function following engraftment of human peripheral blood mononuclear cells in NSG mice deficient in MHC class I and II expression.

Abstract 5665: NOD-scid IL2rg null (NSG) mice deficient in murine MHC Class I and Class II expression support engraftment of functional human T cells in the absence of acute xenogeneic GVHD following injection of PBMC

Abstract The study of human immune system-tumor interactions has been limited historically by a paucity of models that fully reproduce human immune system function. Humanized mice are emerging as an exciting platform to study human immuno-oncology and provide preclinical tools to test cutting edge immunotherapies. An effective and simplistic approach to engraft immunodeficient mice with functional human T cells is the injection of human peripheral blood mononuclear cells (PBMC). This PBMC engraftment model (termed Hu-PBL-SCID mice) has supported studies of human infectious agents, allograft rejection, and human T cell immune function. The Hu-PBL-SCID model has also supported studies of human immune system-tumor interactions following injection of human PBMC into immunodeficient mice implanted with patient-derived (PDX) tumors. However, a major limitation of this model is the development of acute xenogeneic graft-versus-host disease (GVHD) due to human T cell recognition of murine MHC class I and class II. To address this limitation, we created two strains of NSG mice that lack murine MHC antigens, one by crossing NSG-B2Mnull with NSG-(IA IEnull) mice, the second by knocking out the MHC class II IAb gene in NSG-(Kb Db)null mice using TALEN technology. We observed that human IgG clearance was rapid in NSG-B2Mnull (IA IEnull) mice that lack functional FcRn activity whereas clearance in NSG-(Kb Db)null (IAnull) mice was comparable to that observed in NSG mice. Injection of human PBMC into both strains led to engraftment of human T cells that exhibited an approximate 3:1 CD4:CD8 ratio with long term engraftment and without development of acute GVHD. The engrafted human T cells were functional as documented by their ability to reject human islet allografts. Administration of human recombinant IL2 using AAV-IL2 to NSG-(Kb Db)null (IAnull) mice resulted in increased human CD45 cell engraftment, including heightened levels of human Tregs. However, high IL2 levels led to the development of acute GVHD. Moreover, NSG-(Kb Db)null (IAnull) mice injected with a PDX tumor and PBMC from an allogeneic donor supported significant tumor growth in the absence of acute GVHD. These data document that NSG mice deficient in murine MHC class I and class II can support studies of human immune system-tumor interactions in the absence of acute GVHD and provide a model for evaluation of human antibody therapeutics. Citation Format: Michael A. Brehm, Michael Wiles, Laurie Kenney, Ben Low, Roland M. Tisch, Lisa Burzenski, James G. Keck, Dale L. Greiner, Leonard D. Shultz. NOD-scid IL2rgnull (NSG) mice deficient in murine MHC Class I and Class II expression support engraftment of functional human T cells in the absence of acute xenogeneic GVHD following injection of PBMC [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5665.

II. Challenges in the management of post-transplant lymphoproliferative disorder.

II. Challenges in the management of post-transplant lymphoproliferative disorder.

Acute Graft Versus Host Disease after Donor Lymphocyte Infusion: A Single Center Analysis

Donor lymphocyte infusion (DLI) is an option for relapsed hematologic malignancies following allogeneic hematopoietic cell transplantation (HCT). We analyzed the incidence and manifestations of acute graft versus host disease (GVHD) in patients with malignant and non-malignant conditions treated with DLI. At the University of Minnesota, we gave 171 DLI to 120 patients from 1995-2013. The cumulative incidence of grade II-IV acute GVHD was 31.6% (CI 25-42%,n = 40); grade III-IV 23.3% (CI 16-32%,n = 29). GVHD after DLI (n = 46) included involvement of skin in 70% (n = 32), lower gastrointestinal (GI) 65% (n = 30), upper GI 43% (n = 20), and liver 35% (n = 16). Patients receiving chemotherapy prior to DLI (chemo-DLI) had more frequent acute GVHD and GI GVHD. Significant risk factors for grade II-IV acute GVHD included: age > 40, chemo-DLI, malignant disease, and time from HCT to DLI < 200 days. Response to treatment of acute GVHD at 8 weeks was complete in 40% and complete/partial in 52%.Patients developing GVHD had frequent disease response. In chronic myelogenous leukemia (CML) patients, responses were excellent (80%) with or without GVHD. The CR rate was 34% for non-CML malignancies; only 9% achieved CR without acute GVHD. Non-malignant diseases showed poor prognosis following acute GVHD and good prognosis without. Overall survival at 2 years for CML patients was similar (83% vs 79%, p = 0.89) with or without grade II-IV acute GVHD, but in non-CML malignancies survival was better in absence of acute GVHD (41% vs 22%, p = 0.04).We observed frequent, yet therapy-responsive acute GVHD following DLI. DLI often induced remission in CML, but less so for non-CML malignancies without chemo-DLI, particularly in absence of acute GVHD. Improvements in DLI efficacy and GVHD management are still needed. DisclosuresNo relevant conflicts of interest to declare.

Influence Of Acute and Chronic Graft-Versus-Host Disease On Outcome After Allogeneic Hematopoietic Stem Cell Transplantation For Chronic Myelomonocytic Leukemia

▪ IntroductionAllogeneic hematopoietic stem cell transplantation (allo-HSCT) is a therapeutic option for chronic myelomonocytic leukemia (CMML), with the possibility that the graft-versus-CMML (GvL) effect has an important role for survival after allo-HSCT. In a clinical situation, GvL effect was assumed to closely correlate with graft-versus-host disease (GVHD). This study aimed to evaluate the influence of acute and chronic GVHD on long-term outcomes for patients with CMML that were treated with allo-HSCT. Patients and MethodsData were obtained from the Transplant Registry Unified Management Program, which includes three data sources of the Japan Society for Hematopoietic Cell Transplantation, the Japan Marrow Donor Program, and the Japan Cord Blood Bank Network. There was a total of 177 records of CMML patients who were 16 years of age or older and had received allo-HSCT between January 1, 1987 and December 31, 2010. Of those, 141 patients had received allo-HSCT without in-vivo or ex-vivo T-cell depletion, and survived with neutrophil engraftment, which were subjects for this analysis. The probability of overall survival (OS) was estimated by Kaplan-Meier method. Disease-associated mortality was estimated with the use of cumulative incidence curves to accommodate the competing events. Semi-landmark plots were used to illustrate the effects of GVHD on OS and cumulative incidence of disease-associated mortality using the median days of the occurrence of GVHD. Univariate and multivariate Cox proportional hazards regression models were used to evaluate variables potentially affecting OS. Fine and Gray proportional hazards models were used to evaluate variables potentially affecting disease-associated mortality. In these hazard models, the occurrence of GVHD was treated as time-varying covariate. ResultThe median age of recipients was 49 years old. There were 68 transplants from HLA-matched related donor, 10 from HLA-mismatched related donor, 53 from unrelated bone marrow donor, and 10 using unrelated cord blood. One hundred one and 40 patients received myeloabrative and reduced intensity conditioning, respectively. Median survival times after allo-HSCT was 2.8 years. Estimated OS and cumulative disease-associated mortality at 3 years after allo-HSCT were 47.3% (95% confidential interval, 38.5-55.7) and 18.2% (12.2-25.1), respectively. Acute GVHD of grades 1 and 2-4 occurred in 25 and 62 patients, respectively. The median onset of acute GVHD of any grade after allo-HSCT was 22 days (range, 6-80). The analysis using semi-landmark plots revealed that the development of grade 1 acute GVHD was significantly associated with a better OS (p=0.015) and a lower disease-associated mortality (p=0.012) compared with the absence of acute GVHD. However, in multivariate analysis, the emergence of grade 1 acute GVHD was not associated with OS (Hazard ratio (HR) [95% confidential interval], 2.12 [0.69-6.51]; P=0.189) and disease-associated mortality (HR, 1.71 [0.60-4.86]; p=0.31). With a median day of chronic GVHD occurrence after allo-HSCT of 138 (range, 57-669), limited and extensive chronic GVHDs occurred in 17 and 39 patients, respectively. The analysis using semi-landmark plots revealed that the development of limited chronic GVHD related to better OS (p<0.001) and lower disease-associated mortality (p<0.001) compared with the absence and extensive chronic GVHD. In multivariate analysis, OS tended to be better for patients with limited chronic GVHD than the absence of chronic GVHD (HR, 3.86 [0.83-17.9]; P=0.085), while the absence of chronic GVHD possibly affected with the higher disease-associated mortality compared with the emergence of limited chronic GVHD, with a borderline statistical significance (HR, 3.92 [0.91-16.9]; P=0.067). ConclusionOur results showed the efficacy of allo-HSCT for patients with CMML and suggested an important role of GvL linked to chronic GVHD on the better outcome of the patients after receiving allo-HSCT. Disclosures:Fukuda:the Japanese Ministry of Health, Labour, and Welfare: Research Funding.

A Pilot Study Of Continuous Infusion Mycophenolate Mofetil For Graft Versus Host Disease Prophylaxis

Mycophenolate mofetil (MMF), an ester prodrug of mycophenolic acid (MPA) has been used successfully for graft-versus-host disease (GVHD) prophylaxis. Most MMF dosing regimens and pharmacokinetic (PK) parameters have been established in solid organ transplant recipients. Empiric fixed-dose-escalation strategies have failed to achieve target MPA exposure, especially in the early period following conditioning therapy. We hypothesized that a PK-based dosing approach using a novel continuous infusion (CI) method of MMF will be able to achieve and maintain target MPA exposure. The objective of this study was to evaluate the safety and feasibility of this MMF dosing approach in pediatric BMT recipients. Fifteen patients were enrolled in the study. The median age at transplant was 8.4 years (0.9 – 21.5); eight were female and seven were male. Thirteen patients were transplanted for hematologic malignancies and two patients for nonmalignant diseases. Stem cell sources included matched-sibling bone marrow in seven, 10/10 allele matched donor bone marrow in four, and unrelated cord blood in four cases. All patients received a myeloablative conditioning regimen with either cyclophosphamide-TBI (n=8) or busulfan-cyclophosphamide (n=7). In addition, of eight unrelated donor transplants, six patients received equine ATG and two received fludarabine. All patients received cyclosporine A and MMF for GVHD prophylaxis. Intravenous (IV) cyclosporine was initiated on day -2 as a continuous infusion (target blood level: 160 to 250 ng/mL). IV MMF was started on day “0” in a dose of 15 mg/kg every 8 hours. After a minimum of five doses, serial blood samples were collected within one dosing interval for the 1st PK analysis. Using these results, MMF was converted from intermittent IV to CI administration to target total MPA AUC0-24 of 40-80 mcg/mL/hr. MMF dose was adjusted to maintain a total MPA steady-state concentration (Css) of 1.7-3.3 mcg/mL. CI MMF was converted to every-8-hour oral dosing when patients were tolerating oral medications. A 2nd PK study was performed after a minimum of five oral doses, and dose adjustments were made to maintain a total MPA trough concentration (Ctrough) of 1-3.5 mcg/mL. MMF was continued until day 42, and in the absence of acute GVHD, tapered off over 8 weeks. On the initial 15 mg/kg q8 IV MMF dose schedule, MPA half-life was 1.3±1.3 hrs and AUC0-24 was 44.3±60.3 mg* hr/L. During the CI schedule, MMF dose was 44±16 mg/kg/day and MPA AUC0-24 38.4±20.7 mg* hr/L, and thirteen of fifteen (87%) patients achieved MPA Css within target of 1.7–3.3 mcg/mL. On conversion to oral route, median MMF dose was 45±19mg/kg/day, MPA half-life 1.95±2.3 hrs and AUC0-24 38.3±16.0 mg* hr/L. MPA clearance was 17±14 ml/min/kg. Higher steady state MPA concentrations were achieved with CI method (Css 1.6 ±0.9 mcg/mL) compared with intermittent IV or oral dosing (Ctrough 0.7±0.9 mcg/mL). All patients achieved neutrophil engraftment at 13 ± 11 days post-transplant, and platelet engraftment at 45 ± 72 days post-transplant. Seven out of 15 patients (47%) developed stage I-IV acute GVHD. Three patients had stage III-IV aGVHD (20%); they were steroid-refractory but went into remission with additional therapy. For 11 patients with a minimum of one year follow-up post-transplant, one (9%) developed “overlap” chronic GVHD. MMF was discontinued without weaning in four patients: in three of them due to concern of delay in blood count recovery and all of them achieved hematopoietic engraftment, and in one patient with severe aGVHD due to potential concern for MMF gut toxicity. One patient with severe congenital neutropenia developed autologous hematopoietic recovery by day 52. One patient with ALL died of relapse 150 days after transplant. With a median follow-up of 23 months (range 100 days to 3.6 y), 14 out of 15 patients are alive, and one-year event-free survival and overall survival are 83% and 92% respectively. In conclusion, we show that continuous infusion of MMF is feasible and well-tolerated. In this pilot PK study, we observed no toxic deaths, excellent engraftment, and low rates of grade III-IV aGVHD and cGVHD. The PK studies showed significantly lower half-life and higher drug clearance in pediatric BMT recipients compared to stable pediatric renal transplant patients. This regimen deserves further validation in a larger cohort of pediatric patients undergoing myeloablative transplantation. Disclosures: Off Label Use: Use of Mycophenolate Mofetil for Graft versus Host Disease Prophylaxis.

Impact of graft-versus-host disease on outcomes after allogeneic hematopoietic cell transplantation for adult T-cell leukemia: a retrospective cohort study

AbstractAllogeneic hematopoietic cell transplantation (HCT) is an effective treatment for adult T-cell leukemia (ATL), raising the question about the role of graft-versus-leukemia effect against ATL. In this study, we retrospectively analyzed the effects of acute and chronic graft-versus-host disease (GVHD) on overall survival, disease-associated mortality, and treatment-related mortality among 294 ATL patients who received allogeneic HCT and survived at least 30 days posttransplant with sustained engraftment. Multivariate analyses treating the occurrence of GVHD as a time-varying covariate demonstrated that the development of grade 1-2 acute GVHD was significantly associated with higher overall survival (hazard ratio [HR] for death, 0.65; P = .018) compared with the absence of acute GVHD. Occurrence of either grade 1-2 or grade 3-4 acute GVHD was associated with lower disease-associated mortality compared with the absence of acute GVHD, whereas grade 3-4 acute GVHD was associated with a higher risk for treatment-related mortality (HR, 3.50; P < .001). The development of extensive chronic GVHD was associated with higher treatment-related mortality (HR, 2.75; P = .006) compared with the absence of chronic GVHD. Collectively, these results indicate that the development of mild-to-moderate acute GVHD confers a lower risk of disease progression and a beneficial influence on survival of allografted patients with ATL.

Reduced Intensity Conditioning with Thiotepa and Fludarabine for Allogeneic Transplantation: Evidence for Low Toxicity and Long-Lasting Disease Control in MDS with Low/Intermediate-1 IPSS Score and in AML from MDS in Complete Remission.

This study investigated Thiotepa (TT) and Fludarabine (Fluda) as a preparative regimen for allogeneic peripheral stem cell transplantation in patients with myelodysplastic syndrome (MDS) or acute leukemia from MDS (MDS-AML) older than 50 or with comorbidities contraindicating standard conditioning. Patients were prepared with TT, given over 3 hours as an i.v. infusion at a dose of 10 mg/kg over two days (day -8 and day -7) and Fluda at the dose of 125 mg/m2 i.v. over five days ( from day -7 to day -3). Fresh or cryopreserved allogeneic peripheral stem cells were infused on day 0 or +1. Graft-versus-Host Disease (GvHD) prophylaxis consisted of cyclosporine A (CyA) at the dose of 1.5 mg/kg day as a continuous iv infusion from day -5 until engraftment. The CyA was then administered orally at the dose of 3 mg/kg twice a day. Doses were adjusted to maintain plasma level concentrations between 150–350 mg/dL. From day +60, in the absence of acute GvHD, the CyA was tapered down by 20% every 2 weeks until withdrawal. In addition, patients received methotrexate 10 mg/m2 on day +1, and 8 mg/m2 on days + 3, +6 and +11 after transplantation. At the time of transplantation, patients were classified in two risk groups (low vs high risk) according to IPSS score (low/intermediate-1 vs. intermediate-2/high) for MDS patients, and disease status (CR vs. not CR) for MDS-AML. Kaplan-Meier survival analysis was carried out to compare Overall Survival (OS), Transplant-Related Mortality (TRM) and probability of relapse. Fifty patients (29 males, 21 females) entered the study; the median age was 54 years (range 38–71). Sixteen MDS patients had a low/intermediate 1 score according to the International Prognostic Score System (IPSS), 16 had an intermediate 2/high IPSS score, 18 had MDS-AML. Thirty patients underwent transplantation as front-line therapy, 20 received one or more cycles of chemotherapy before transplant. Among the latter, nine with MDS-AML were in complete remission at the time of their transplant, while four were in a partial remission. The interval from diagnosis to transplantation ranged from 1 to 52 months (median value 11 months). Contraindications to a standard conditioning regimen were liver disease, hypertrophic cardiomyopathy secondary to hypertension or valvular stenosis, cardiac arrhythmia, diabetes mellitus, hypothyroidism, previous CNS bleeding, and a history of sepsis. All but one patient achieved engraftment, with full donor chimerism by day +30. Patients were followed up for a median time of 21 months (range 0.2–87). TRM at 1 and 2 years after transplantation was 25% and 33%; the 5-year probability of relapse was 27%. Twenty-six patients are alive in complete remission, and the 5-year OS is 50%. The 5-year OS was 73% and 28% in low- and high-risk patients respectively (p=0.002). TRM at 1 and 2 years after transplantation was 13% and 21% in the low-risk group and 39% and 45% in the high-risk group (p=0.046); the 5-year probability of relapse was 10% and 50% in the low- and high-risk group respectively (p=0.015). In a multivariate Cox regression, risk group retained a borderline significance (HR=2.6, p=0.07) when adjusted by age at transplantation (p=0.03) and interval from diagnosis to transplant (n.s.). The combination of Thiotepa and Fludarabine is an effective and well-tolerated conditioning regimen in patients with MDS or MDS-AML who are poor candidates for standard myeloablative transplantation, particularly in MDS patients with low/intermediate-1 IPSS score and MDS-AML patients in CR.

Allografting for Adult T-Cell Leukemia/Lymphoma: A Nationwide Retrospective Analysis.

Background: Adult T-cell leukemia/lymphoma (ATL) is a mature T-cell neoplasm developing in a minority of individuals infected with human T-cell leukemia virus type I (HTLV-I). Although the results of conventional chemotherapy remain unsatisfactory for the management of ATL, allogeneic hematopoietic stem-cell transplantation (allo-SCT) is emerging as a promising alternative which can provide long-term remission in selected patients.Methods: To evaluate the efficacy of allo-SCT for the treatment of ATL, data on 397 patients (pts) with ATL who had received allo-SCT between 01/1996 and 12/2005 were collected through JSHCT, JMDP and JCBBN. We analyzed pts who did not have a history of previous stem-cell transplantation; who received a T-cell-replete graft; who had data on age at transplantation, sex, donor type, stem-cell source, conditioning regimen, and graft-versus-host disease (GVHD) prophylaxis. A total of 363 pts, with a median age of 51 yrs (range, 18–79), 201 males and 162 females, fulfilled these criteria: 175 received bone marrow and/or peripheral blood from a related donor; 188 received marrow or cord blood from an unrelated donor. At the time of transplantation, 91 pts were in complete remission (CR) and 226 were not in CR. Risk factors which potentially affect the survival outcomes were analyzed using proportional-hazards models.Results: The median follow-up was 21.6 months (range, 1.5–102). The unadjusted 3-year overall survival, disease-associated mortality, and treatment-related mortality (95% confidence interval [CI]) for pts in CR at transplantation were 48% (35–59%), 16% (8–27%), and 35% (24–45%), respectively, while those for pts not in CR were 22% (16–29%), 35% (28–42%), and 41% (34–48%), respectively. Multivariable analyses revealed four significant factors which adversely affected survival: older recipient age (>50 yrs)(adjusted hazard ratio [HR] 1.71; 95% CI, 1.24–2.38; P=0.001), male recipient (HR 1.46; 95% CI, 1.10–1.93; P=0.009), disease status other than CR (HR 2.21; 95% CI, 1.57–3.12; P<0.001), and donor type: HRs for death after allo-SCT using a family donor other than an HLA-matched sibling (n=45), an unrelated marrow donor (n=98), and an unrelated cord blood unit (n=90), as compared with an HLA-matched sibling (n=130), were 1.64 (95% CI, 1.05–2.55; P=0.028), 1.24 (95% CI, 0.85–1.80; P=0.26), and 1.85 (95% CI, 1.29–2.66; P=0.001), respectively. Among 156 pts who received allo-SCT not in CR and survived more than 30 days with sustained engraftment, development of grade I-II acute GVHD, as compared with absence of acute GVHD, was associated with a lower risk of death (HR 0.54; 95% CI, 0.34–0.86; P=0.01) in multivariable Cox models including the occurrence of acute GVHD as a time-dependent covariate.Conclusions: Allo-SCT is effective therapy which confers long-term survival in a substantial proportion of patients with ATL but at the cost of significant treatment-related mortality. Favorable outcomes after developing mild acute GVHD in patients not in CR at transplantation suggest the presence of a graft-versus-ATL effect.

Campath-1H-Containing Reduced Intensity Regimen Followed by Unrelated Allogeneic Stem Cell Transplantation in Patients with Advanced Hematologic Malignancies.

BACKGROUND: Graft versus host disease (GVHD) remains a major cause of mortality after unrelated transplants. Reduced intensity conditioning regimens (RIC) followed by allogeneic stem cell transplantation (SCT) with in vivo T-cell depletion using Campath-1H have been shown to decrease the incidence of GVHD. We report our experience with such an approach in 19 patients (pts) with advanced hematologic malignacies who undergone unrelated SCT.PATIENTS AND METHODS: Between October 2001 and June 2003, 19 pts with a median age of 56 years (range 18–70) not eligible for ablative SCT received Campath-1H 20 mg/m2, fludarabine 25 mg/m2 × 5 days and either cyclophosphamide 1 g/m2 × 2 days (n=16pts), melphalan 140mg/m2 (1 pt) or busulfan 0.8 mg/m2 × 8 doses (n=2pts) followed by G-CSF stimulated peripheral blood (n=13) or unmanipulated bone marrow (n=6). GVHD prophylaxis consisted of cyclosporin at least until T+60 and mycophenolate mofetil through T+30. DLI was allowed for residual disease/progressive disease or mixed chimerism after T+ 60, in the absence of acute GVHD. Seven pts had a previous autologous transplant. Ten pts had myeloid diseases (AML=6, CML Ph negative=1, CML accelerated phase =1, therapy related MDS=1, myelofibrosis=1); 9 pts lymphoid (HD=3, NHD=5, PLL=1); Only 5 pts were in CR at transplant. Six pts received bone marrow witha median CD34+ cells infused of 3.7 × 106/Kg, and 13 pts received peripheral blood with a median of 4.5 × 106/Kg CD34+ cells infused.RESULTS:19 pts achieved ANC>0.5 × 106/L within a median of 12 days (range 8–16); 2 pts rejected the graft and 1 had autologous reconstitutuion; 10/19 pts achieved sustained platelet engraftment at a median of 16 days (range7–27). 2/17 pts with sustained engraftment developed acute GVHD (grade IV T+30 and grade III T+53); 7/14 at risk pts had CMV reactivation; TRM at T+100 was 16% (disease progression in 2 and GVHD in 1). Nine pts received DLI (5 for mixed chimerism and 4 pts for persistent/progressive disease). After DLI, 5 pts had GVHD limited to skin. None of the pts receiving DLI for persistent/progressive disease responded. Response to transplant was as follows: CR in 3/6 AML pts, CR in 1/1 pt with myelofibrosis, CR in 3/3 HD pts, CR in 3/5 NHL pts. Five pts (26%) remain alive in CR at T+ 36, 42, 50, 56 and 66 months. Causes of death include disease progression/relapse in 7 pts, CMV disease in 1 pt, sepsis in 2 pts, GVHD in 3 pts (2 underwent a second transplant), other malignancy in 1 pt.CONCLUSION: These results confirm that unrelated SCT with in vivo T -cell depletion using Campath-1H is well tolerated. This approach is associated with low TRM even in pts with advanced disease, and some can achieve long-term disease control. Disease progression/relapse remains a major impediment to this approach.

The fate of human Langerhans cells in hematopoietic stem cell transplantation

Langerhans cells (LC) and other antigen-presenting cells are believed to be critical in initiating graft versus host responses that influence the outcome of allogeneic hematopoietic stem cell transplantation. However, their fate in humans is poorly understood. We have sought to define the effect of conditioning regimes and graft versus host disease (GVHD) on the survival of recipient LC and reconstitution of donor cells after transplant. Confocal microscopy of epidermal sheets shows that full intensity transplant (FIT) depletes LC more rapidly than reduced intensity transplant (RIT) at day 0, although the nadir is similar in both at 14–21 d. Recovery occurs rapidly within 40 d in the absence of acute GVHD, but is delayed beyond 100 d when GVHD is active. LC chimerism was determined in sex-mismatched transplants using a two-step Giemsa/fluorescence in situ hybridization assay on isolated cells. Acquisition of donor chimerism at 40 d is more rapid after FIT (97%) than RIT (36.5%), irrespective of blood myeloid engraftment. At 100 d, all transplants achieve at least 90% LC donor chimerism and over half achieve 100%. Complete donor chimerism is associated with prior acute cutaneous GVHD, suggesting a role for allogeneic T cells in promoting LC engraftment.

Production of IL-10 by alloreactive sibling donor cells and its influence on the development of acute GVHD

Graft-versus-host disease (GVHD) is a major complication of allogeneic hematopoietic stem cell transplantation. Pretransplant conditioning regimes cause release of proinflammatory cytokines that stimulate alloreactive donor T cells to attack recipient tissues. IL-10 has been shown to directly downregulate CD4+ T cells by suppressing IL-2 secretion and a critical role played by regulatory T cells has been demonstrated in animal models. One defining cytokine profile for regulatory T cells is the production of IL-10. Release of specific cytokines (IL-10, IL-4 and IFN-gamma) was detected using ELISPOT technology, following stimulation of donor peripheral blood mononuclear cells by recipient (human leukocyte antigen-matched sibling) alloantigen or by mitogen. Correlation between the frequency of cytokine-releasing cells and the development of acute GVHD was investigated. A high frequency of donor cells producing IL-10 in response to recipient alloantigen stimulation correlated with absence of acute GVHD after bone marrow transplant (BMT), while low frequency was strongly associated with severe GVHD. This study presents strong evidence that estimating the frequency of donor alloreactive cells producing IL-10 in response to recipient antigens will provide valuable information prior to BMT regarding potential transplant outcome.

Combination of tacrolimus, methotrexate, and methylprednisolone prevents acute but not chronic graft-versus-host disease in unrelated bone marrow transplantation.

Graft-versus-host disease (GVHD) is still a major problem in allogeneic bone marrow transplantation (BMT). Prophylactic regimens used against GVHD in unrelated BMT, including cyclosporine (CsA)-plus-methotrexate (MTX), CsA-plus-MTX-plus-prednisone, and tacrolimus (FK506)-plus-MTX, are still unsatisfactory (34-70% occurrence of grades II-IV GVHD). To address this problem, we examined the efficacy of FK506-plus-MTX-plus-methylprednisolone (mPSL) in 20 patients who underwent BMT from unrelated donors. All patients received FK506 beginning the day before transplantation at a dose of 0.03 mg/kg per day by continuous intravenous (IV) infusion. MTX was administered at a dose of 10 mg/m(2) IV on day 1, and 7 mg/m(2) on days 3, 6, and 11. Intravenous administration of mPSL was started at a dose of 2 mg/kg per day on day 1. In the absence of acute GVHD, mPSL was gradually tapered from day 29. Development of acute GVHD was almost completely suppressed (one patient with grade I, none with grades II-IV). However, the incidence and severity of chronic GVHD did not decrease. Eight of 12 patients with extensive chronic GVHD died of thrombotic microangiopathy or infection. A vigorous fluctuation (>100 U/mL per 10 days) of the soluble interleukin 2 receptor level in the serum after engraftment was highly related to the occurrence of chronic GVHD. An FK506-plus(+)-MTX-plus(+)-mPSL prophylactic regimen could almost completely suppress acute GVHD but not chronic GVHD in unrelated BMT. In this GVHD prophylactic system, the extent of the change of soluble interleukin 2 receptor level may be a good predictor of development of chronic GVHD.

Improvement in outcome for children receiving allogeneic bone marrow transplantation in first remission of acute myeloid leukemia: a report from the Groupe d'Etude des Greffes de Moelle Osseuse.

We retrospectively analyzed the outcome of children with acute myeloid leukemia (AML) in first complete remission (CR) who received HLA-identical bone marrow transplantation (BMT) in 13 French transplant centers. Seventy-four children were treated from June 1979 through December 1990. The conditioning regimen included total-body irradiation (TBI) in 54 cases and busulfan in 20. Prophylaxis of graft-versus-host disease (GVHD) consisted of cyclosporine (CycloA) plus methotrexate (MTX) for 38 patients, MTX for 17, CycloA for 18, and T depletion without other prophylaxis for one. The mean value of the interval from diagnosis to transplantation was 167 days. Sixteen patients died of transplant-related complications, 12 relapsed, and 46 are alive in continuous remission with a median follow-up of 46 months. We examined results obtained over three successive periods: 1979 to 1982 (n = 14 children), 1983 to 1986 (n = 29), and 1987 to 1990 (n = 31). Probabilities of event-free survival (EFS) were 43%, 48%, and 82% for the three successive periods, respectively (P < .02). This improvement in EFS was linked to a decreased risk of transplant-related mortality: 36%, 36%, and 3%, respectively (P < .01). Other factors associated with a better EFS in the univariate analysis were a short time interval from diagnosis to transplant (< 120 days), the absence of significant (grade > or = 2) acute GVHD, and the absence of chronic GVHD. In the multivariate analysis, two factors had a favorable impact on long-term survival: the year of transplantation (years 1987 to 1990 v others) and the absence of acute GVHD. The outcome for children receiving allogeneic BMT in first CR of AML has improved in France during recent years.