Alternative Donor Transplantation Research Articles

A Novel Protocol Decreased Incidence of Hepatic Veno-Occlusive Disease and Improved Results in Hematopoietic Cell Transplantation for Patients with b-Thalassemia Major

▪Hepatic veno-occlusive disease (VOD) is a common complication of hematopoietic cell transplantation (HCT), especially patients with β-thalassemia major (TM). To estimate whether incidence of VOD recently decreased after using NF-08-TM protocol (NP), 311 TM-HCTs performed from February 2003 to June 2013 were analyzed. 241 patients received NP in or after 2009 and 70 received non-NP before 2009. VOD was diagnosed by Seattle criteria (SC) or Baltimore Criteria (BC). Patients were stratified by Nanfang (NF) criteria. A total of 31(10.0%) and 14 (4.5%) HCTs developed VOD (6 and 5 developed severe VOD) in SC and BC cohorts, respectively. The incidence of VOD was significantly lower in NP versus non-NP groups and in Class 2 versus Class 3 groups. Overall survival was significantly higher in NP versus non-NP cohorts. Rate of VOD in alternative donor transplant (ADT) was similar to that in matched sibling transplant (MST). Requirement of platelet and value of D-dimer significantly increased in the VOD patients. Our study showed the incidence of VOD significantly decreased in our center after using NP. ADT was similar to MST on rate of VOD. NF criteria of stratification can indicate occurrence of VOD. The SC can be more suitable criteria for early diagnosis. DisclosuresNo relevant conflicts of interest to declare.

Unrelated Alternative Donor Transplants for Severe Acquired Aplastic Anemia: A 12-Year Retrospective Study from the French Society of Bone Marrow Transplantation and Cell Therapies (SFGM-TC)

In the absence of a matched sibling donor for patients with severe aplastic anemia (SAA), allogeneic hematopoietic stem cell transplantation (Allo-HSCT) from an HLA-matched unrelated donor (UD) is considered after immune suppressive therapy (IST) failure. Outcome after UD Allo-HSCT for SAA has significantly improved in the last 2 decades because of optimization of HLA typing, as well as better conditioning regimens and improved GVHD prophylaxis (Maury Haematologica 2007; Bacigalupo Haematologica 2010). However, the age limit, the impact of extensive HLA typing (12 loci) as well as the best timing for UD Allo-HSCT remain unclear. We thus analyzed all patients in France who received a first Allo-HSCT for idiopathic SAA from a UD between 2000 and 2012. Clinical data were prospectively collected using ProMISe (Project Manager Internet Server), an internet-based data registry system shared by all centers of the French Society of Bone Marrow Transplantation and Cell Therapies (SFGM-TC). The French national ethics board (CCTIRS) approved this study. Written informed consent was obtained from all patients before Allo-HSCT.One-hundred and thirty-nine consecutive patients (64 male (46%)) were included. Median age was 23 years (range: 1-66). Most patients (81%) received in vivo T-cell depletion using antithymocyte globulins or alemtuzumab. Total body irradiation was used in 64 patients (46%), using low dose in 58 cases (91%). GVHD prophylaxis combined Cyclosporine A and methotrexate in 68% of cases. Respectively 113 (81%) patients and 26 (19%) patients were transplanted using a 10/10 and a 9/10 HLA-matched UD (according to HLA A, B, C, DRB1 and DQB1 allelic matching). Ten patients (7%) experienced primary graft failure. Forty-eight patients developed grade II-IV acute GVHD, leading to a day-100 cumulative incidence of 35%. The cumulative incidence of chronic GVHD was 24% at 4 years (extensive GVHD, 8%) with no specific risk factor identified. With a median follow-up of 51 months, the 4-year overall survival (OS) was 66% for the whole cohort. In multivariate analyses, worst OS was observed for patients transplanted before 2006 (HR=2.45 [1.23-4.88]; p=0.011, Figure 1A), with a CD34+ cell dose < 4 x 106/kg (HR=2.62 [1.31-5.25]; p=0.006), with time from diagnosis to Allo-HSCT > 12 months (HR=2.16 [1.02-4.60]; p=0.046) and who received a 9/10 matched UD (HR=2.27 [1.05-4.91]; p=0.038). Of note, there was a trend for higher mortality in patients older than 40 years of age (HR=1.97 [0.95-4.09]; p=0.069). There was no difference in OS according to conditioning regimen or GVHD prophylaxis. Ninety-eight out of 139 patients had extensive HLA typing on 12 loci (HLA A, B, C, DRB1, DQB1 and DPB1), respectively 82 and 16 patients from the 10/10 and 9/10 HLA-matched groups. Zero, 1 and 2 DPB1 matched alleles were found in 36 (37%), 52 (53%) and 10 (10%) patients, respectively. Of note, we found no difference in 4-year OS according to DPB1 matching among the 82 evaluable 10/10 HLA-matched patients (0 (n=27) vs. 1 or 2 matched DPB1 alleles (n=55): 74% vs. 66%, p=0.466). However, patients transplanted with a 9/10 HLA-matched donor with no matched DPB1 allele reached a significantly lower 4-year OS (0 (n=9) vs. 1 or 2 matched DPB1 alleles (n=7): 22% vs. 86%, p = 0.029, Figure 1B).In conclusion, outcome after UD Allo-HSCT for idiopathic SAA continues to improve with best results seen after 2005. In the presence of a 10/10 matched UD (allelic level), patients less than 40 years of age should be transplanted as quickly as possible if refractory to IST, at least in the first year after the time of diagnosis. Given the excellent OS in the recent period and the particularly low rate of chronic GVHD, Allo-HSCT could be discussed as front line therapy in selected young patients with SAA for whom a 10/10 UD is readily available in the absence of a matched family donor. Moreover, in the absence of a 10/10 HLA-matched UD, Allo-HSCT from a 9/10 HLA-matched UD in the presence of 1 or 2 matched DPB1 alleles is promising and merits further evaluation. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Haploidentical Versus Autologous Stem Cell Transplantation in Adult Acute Leukemia: A Matched Pair Analysis from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation (EBMT)

Adult patients with acute leukemia in need of a transplant but with no genoidentical donor, are nowadays usually considered upfront for an alternative donor transplant, while autologous stem cell transplantation is seldom done. The purpose of this study was to compare the outcome after T cell-replete haploidentical transplant and autologous transplant. We used data from the European Society for Blood and Marrow Transplantation (EBMT) registry. From January 2007 to December 2012, 234 adult patients with acute leukemia, transplanted with marrow from a haploidentical family donor, and 2259 autografted patients were reported to the EBMT registry. We performed a matched pair analysis on 188 haploidentical and 356 autologous transplants using age, diagnosis, disease status, cytogenetics, and interval from diagnosis to transplant as matching factors. The median follow-up was 15 months.The two-year non-relapse mortality rate was higher post-haploidentical transplant ( 27% versus 4%; p <10-5 ) [hazard ratio (HR): 0.16, p<0.0001], and the relapse incidence was higher after autologous transplantation ( 49% versus 31%, p <10-4) (HR: 1.69, p=0.02). Regarding LFS, there was no difference between haploidentical transplants and ASCT (Figure 1 A and 1 C). Overall survival was higher after autologous transplantation (HR: 0.69, p=0.02) with 63% versus 53% (p=0.01) in all patients, 67% versus 54% (p=0.006) in patients transplanted in first complete remission (Figure 1B), and 45% versus 47% in second complete remission (Figure 1 D). Thirty-six patients with Ph+ ALL received an autograft and 19 received a haploidentical transplant. ASCT was associated with better NRM (8% versus 46%; p=0.002), LFS (53% versus 22%; p= 0.01), and OS (70% versus 19%; p 0.001), while RI was identical (39% versus 32%; p=0.83).When comparing haploidentical transplants performed in “haplo expert” centers to ASCT, there was no difference in LFS (haplo: 53% versus ASCT 46%, p=0.17) and OS (haplo: 59% versus ASCT 63%, p=0.58) (Figure 2).These findings indicate that autologous stem cell transplantation remains a valuable therapeutic option for patients with no identical donors. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Graft-Versus-Host Disease after Haploidentical Stem Cell Transplantation in High Risk Haematological Diseases: A 10-Years Evaluation at San Raffaele Scientific Institute

Introduction Haematopoietic stem cell transplantation (HSCT) is the only curative option for patients (pts) affected by high-risk haematological diseases (HRHD). However, the availability of a match donor is still an unmet-medical need. Recently alternative donor transplantations have been broadly exploited, reaching results similar to transplants from a well match donor. Anyway, whoever the donor is, the most important complication remains Graft-versus-Host Disease (GvHD).Aim of the study We evaluated incidence, characterization, stratification, treatment, treatment response and outcome at medium and long-term follow-up for both acute (a-) and chronic (c-) GvHD in haploidentical setting. We also evaluated the impact of the NIH consensus criteria on GvHD in a routine clinical application to confirm their feasibility in daily practice and not only in clinical trials use.Methods A population of 257 pts was selected from our Institutional database on the basis of their having an HRHD with indication to allogeneic HSCT and having received a HSCT from an haploidentical family donor without exclusion. HSCT were performed between January 2004 and December 2013 at our Center. No distinction between first HSCT or subsequent one was made, all consecutive haploidentical HSCT were captured.Results Time of median follow-up was 10 months; 1-year overall-survival (OS) was 46%, with better outcome for pts transplanted in complete remission (p 0.0001) confirming disease status as the leading factor for overall outcome. Transplant related mortality was estimated to be 30% at 1 year and the leading cause of death was infections.The 6-months a-GvHD incidence was 45% (119/257) - median day of presentation 21 post HSCT (range 8-89). Late-onset a-GvHD was documented in 15 pts. Grade I GvHD was documented in 33 pts (27.7%), grade II in 44 (37%), grade III-IV in 36 (30.3%) – 6 not evaluable. Skin was the most frequently involved organ (77.3%), both as single manifestation or combined. One-hundred and five pts received a first line therapy based on high-dose prednisone (2mg/Kg) and 37/105 completely abrogated the a-GvHD. At a 3-months evaluation 46% of affected pts showed complete resolution of a-GvHD, while the mortality rate was 29%.C-GvHD affected 69/257 pts and 1-year risk of onset was 25% - median day of presentation was 139 post HSCT (range 40-809) and 36/69 pts were off immunosuppressive therapy (52.3%) at presentation.According to onset presentation 53.7% were de novo, 24.6% progressive and 18.8% quiescent GvHD. Forty-one pts (59.5%) presented at declaration with overlap features.The most frequent involved organ was skin (grade I to III), as reported in 53 pts (76.8%). Skin lesions were usually accompanied with mouth lesions (35 pts – 50.7%), liver (23 pts – 33.3%) or eyes (27 pts – 39.1%) dysfunctions. The median number of involved organs was 3 (range 1-7).Mild c-GvHD was diagnosed in 10 pts (14.5%), who received topical therapy. Fifty-nine pts – diagnosed with moderate (32, 46.4%) or severe (27, 39.1%) - received a systemic treatment for c-GvHD: prednisone 1 mg/Kg alone or 0,5 mg/kg plus mTOR- or calcineurin-inhibitor for pts that were not likely to tolerate high dose steroid due to comorbidity (namely active infections, diabetes, cardiovascular diseases).At a 12-months evaluation the overall response was 48% (complete resolution 25%, partial resolution 23%), while the mortality rate was 36%.The Landmark analysis of OS at 3 months after HSCT shows that a-GvHD affected pts had a worse outcome (p= 0,068), on the contrary the Landmark analysis of OS at 18 months shows that c-GvHD did not associate with a worse outcome (p ns) but the follow up is still short. Confirming previous reports, overlap c-GvHD was related to worse survival in comparison with classic c-GvHD (p 0.0098).Conclusion Haploidentical HSCT is a valid and feasible option for pts in need of a transplant. GvHD is manageable after haploidentical HSCT, as in full matched setting. Better knowledge and insight in a/c-GvHD are providing advance in improving pts outcome. The NIH-consensus criteria are manageable in daily clinical practice and able to translate in a tailored approach to GvHD with benefit on general outcome. Further advance in the development of specific biomarkers for GvHD will provide additional crucial information for management, diagnosis and prognostication in GvHD. [Display omitted] DisclosuresBonini:MolMed S.p.A.: Consultancy. Bordignon:MolMed: Employment.

Haploidentical Transplantation with Post-Transplant Cyclophosphamide in Children with Malignant and Non-Malignant Diseases

▪Background: HLA haploidentical stem cell transplantation with T-replete grafts and post-transplant immunosuppression with high-dose cyclophosphamide after reduced intensity conditioning has evolved into an increasingly accepted method of alternative donor transplantations in adults. Reported transplantation related mortality, GVHD and relapse rates are at least comparable to those of HLA matched donor transplantations.Purpose: To assess the feasibility of this approach in children as a first or second allogeneic transplantation after myeloablative or reduced toxicity conditioning.Patients/methods: Ten consecutive transplantations in children with either malignant (n=6) or non-malignant diseases (n=4) at a single institution transplanted with unmanipulated bone marrow from parental HLA haploidentical donors were analyzed. In the malignant cohort (3 ALL, 2 AML, 1 MDS) four patients were in advanced disease status (2 NR, 2 CR3) and three had received a prior allogeneic transplantation (2 relapses, 1 rejection). Conditioning in these patients was either TBI-VP16 (n=3) or myeloablative treosulfan-based (n=3). Among the non-malignant patients (2 IL10R deficiency, 1 sickle cell disease, 1 XIAP), one had rejected a prior T-cell depleted HLA haploidentical transplantation. These patients were conditioned with alemtuzumab, treosulfan, fludarabine ± thiotepa. All patients in both groups received cyclophosphamide 14,5mg/kg on days -3 and -2. GVHD prophylaxis consisted of cyclophosphamide 50mg/kg on days +3 and +4, tacrolimus and MMF from day +5. In the absence of GvHD MMF was stopped on day +35, tacrolimus tapered from day +60 (malignant) or day+100 (non-malignant).Results: After a median follow-up of 6 months (1-25), 9 of 10 patients are fully engrafted, alive and free of disease. One patient with AML not in remission at transplantation died from pulmonary hemorrhage on day +24. He was also treated for CMV viremia pre-existing before transplantation. One ADV reactivation requiring pre-emptive treatment and no invasive fungal infections were noted in the other patients. Engraftment was recorded at a median of 17 days (neutrophils) and 26 days (platelets). Only in one patient transient acute skin GVHD (overall grade II) was observed, while no patient developed chronic GVHD. Mean CD3 counts of 310/µl, 937/µl and 1868/µl, CD4 115/µl, 291/µl and 1010/µl, CD8 176/µl, 589/µl and 802/µl and CD19 102/µl, 360/µl and 641/µl were measured on days +100, +180 and +365 respectively.Conclusion: HLA haploidentical transplantation with post-transplant cyclophosphamide appears to be a safe and promising approach with very low GVHD rates and excellent immune reconstitution in children with malignant as well as non-malignant diseases. This may be combined with myeloablative as well as reduced toxicity conditioning regimes and is a promising approach even as a second allogeneic procedure after relapse or rejection following a first allogeneic transplant. DisclosuresNo relevant conflicts of interest to declare.

Influence of Pre-Transplant Cytomegalovirus (CMV) Serostatus on Post-Transplant Viral Reactivation after Allogeneic Stem Cell Transplantation in Patients Receiving Post-Transplant Cyclophosphamide for Gvhd Prophylaxis

▪Introduction/BackgroundHuman cytomegalovirus (CMV) infection remains one of the major complications affecting the transplant outcomes as it is associated with considerable morbidity and mortality. Pre-transplant CMV serostatus is considered as an important determinant of CMV reactivation after allogeneic HSCT. In 2012 we started using post-transplant cyclophosphamide (post-CY) as GVHD prophylaxis for matched and mismatched unrelated transplant (CY 1 dose) and haploidentical transplant (CY 2 doses). In this study we compared the incidence of CMV reactivation based on donor and recipient pre-transplant serostatus in patients who received post-CY and who did not.Methods and ResultsPost-transplant CMV reactivation was analyzed in relation to donor/recipient CMV serostatus in 117 patients who underwent alternative donor transplant at UAB between 2009 and 2014. Donors were matched unrelated (94), mismatched unrelated (11) and haploidentical (12) (Table 1). The study patients had at least two months of follow up after the transplant. Graft source was peripheral blood and bone marrow stem cells in 95 (81%) and 22 (19%) patients respectively. Two doses of CY at 50 mg/kg/day was administered on days 3 and 4 following haploidentical and a single dose on day 3 following unrelated donor transplant as a part of GVHD prophylaxis in addition to mycophenolate mofetil (MMF) and tacrolimus. Serial weekly monitoring for CMV viremia was performed using a PP65 antigenemia testing or quantitiative polymerase chain reaction (PCR). Sixty-four (55%) patients received post-CY (group C), 37 (32%) patients received anti-thymocyte globulin (ATG, group A) and 16 (13%) patients received neither ATG nor post-CY (group N). Forty-seven (40%) patients were found to have reactivation of CMV. The majority (99%) in this group had CMV reactivation by day 60 and only 8 of them received more than 7 days of systemic steroid by the time of CMV reactivation. Analyses were performed including these cases. Conclusions have been the same with or without these cases. There have been no CMV diseases in this group. The risk of CMV reactivation appears to be higher in group C (48%) when compared to group A (27%) or group N (37%) but it was not significant (p=0.104). Once CMV reactivated, the peak values of CMV PCR were the same regardless of the group (11,173 copies/ml and 12,173 in group C and group A+N, respectively, p=0.949). If the recipient (R) is seronegative (-), transplant from a seronegative donor (D-) is associated with lower CMV reactivation (0/26 and 2/8 in R-D- and R-D+, respectively, p=0.009). However, if the recipient is seropositive (R+), CMV reactivation incidence tends to be the same whether transplanted from D- or D+ (10/19 and 35/64 in R+D- and R+D+, respectively, p=0.874). In the group C, R+D+ tends to have higher incidence of CMV reactivation than R+D- (24/36 vs 6/12 in R+D+ vs R+D-, respectively, p=0.302). (Table 2)Conclusion:Post-CY has higher risk of CMV reactivation when compared to other GVHD prophylaxis, but once CMV is reactivated the peak values of CMV-PCR have been the similar. In CMV seropositive post-CY patients, transplant from a seropositive donor tends to higher incidence of CMV reactivation rather than from a seronegative donor. This result contradicts to previous publication (Luznik et al, Blood. 2010 Apr 22; 115(16):3224-30.). Our GVHD prophylaxis used only one dose of CY for unrelated donor transplant as opposed to previous publication (2 doses), and also we used tacrolimus and MMF after day 5, which may have caused this difference. Our results warrant further investigation in the mechanism of CMV reactivation in post-CY patients.Table 1GroupCMV Reactivation Post TransplantNYCountCountA B C27 33 1010 31 6P=0.104 [Display omitted] [Display omitted] DisclosuresOff Label Use: Cytoxan for GVHD prophylaxis.

Allogeneic Hematopoietic Cell Transplantation Outcomes in Acute Myeloid Leukemia: Similar Outcomes Regardless of Donor Type

The use of alternative donor transplants is increasing as the transplantation-eligible population ages and sibling donors are less available. We evaluated the impact of donor source on transplantation outcomes for adults with acute myeloid leukemia undergoing myeloablative (MA) or reduced-intensity conditioning (RIC) transplantation. Between January 2000 and December 2010, 414 consecutive adult patients with acute myeloid leukemia in remission received MA or RIC allogeneic transplantation from either a matched related donor (n = 187), unrelated donor (n = 76), or umbilical cord blood donor (n = 151) at the University of Minnesota or Hôpital St. Louis in Paris. We noted similar 6-year overall survival across donor types: matched related donor, 47% (95% confidence interval [CI], 39% to 54%); umbilical cord blood, 36% (95% CI, 28% to 44%); matched unrelated donor, 54% (95% CI, 40% to 66%); and mismatched unrelated donor, 51% (95% CI, 28% to 70%) (P < .11). Survival differed based on conditioning intensity and age, with 6-year survival of 57% (95% CI, 47% to 65%), 39% (95% CI, 28% to 49%), 23% (95% CI, 6% to 47%), 47% (95% CI, 36% to 57%), and 28% (95% CI, 17% to 41%) for MA age 18 to 39, MA age 40+, or RIC ages 18 to 39, 40 to 56, and 57 to 74, respectively (P < .01). Relapse was increased with RIC and lowest in younger patients receiving MA conditioning (hazard ratio, 1.0 versus 2.5 or above for all RIC age cohorts), P < .01. Transplantation-related mortality was similar across donor types. In summary, our data support the use of alternative donors as a graft source with MA or RIC for patients with acute myeloid leukemia when a sibling donor is unavailable.

Allogeneic hematopoietic cell transplantation for acute myeloid leukemia during first complete remission: a clinical perspective.

Allogeneic hematopoietic cell transplantation (HCT) is the most potent therapy for preventing relapse of acute myeloid leukemia (AML). Although its efficacy is compromised by a high risk of treatment-related morbidity and mortality, an accumulating body of evidence has led to the general recommendation favoring allogeneic HCT from a matched sibling donor during first complete remission (CR1) for younger patients with cytogenetically intermediate- or high-risk AML. Over the past few decades, this field has seen a great many advancements. The indications for allogeneic HCT have been refined by taking into account the molecular profiles of leukemic cells and the degree of comorbidities. The introduction of high-resolution human leukocyte antigen-typing technology and advances in immunosuppressive therapy and supportive care measures have improved outcomes in alternative donor transplantation, while the parallel growth of unrelated donor registries and greater use of umbilical cord blood and haploidentical donors have considerably improved the chance of finding an alternative donor. The development of reduced-intensity and non-myeloablative conditioning has made it possible to receive allogeneic HCT for patients who might once have been considered ineligible due to advanced age or comorbidities. Thanks to these advances, the role of allogeneic HCT during CR1 has become progressively more important in the treatment of AML.

Are Alternative Donors Really Still “Alternative?”

Are Alternative Donors Really Still “Alternative?”

Experts' considerations on HLA-haploidentical stem cell transplantation.

Recently, novel strategies to control graft-versus-host disease and facilitate engraftment have allowed an increasing number of human leukocyte antigen (HLA)-haploidentical hematopoietic stem cell transplantation (haploHSCT) to be performed. A meeting was convened to review the biological rationale and the clinical results of various T-cell-depleted (TCD) and T-cell-replete (TCR) HLA-haploidentical 'transplant platforms'. The objective of the meeting was to promote discussion and consent among leading researchers in the field on three main crucial issues for haploHSCT: (i) eligibility criteria, (ii) choice of the most suitable donor, and (iii) choice of the most appropriate transplant platform. The experts in attendance agreed that a patient who is eligible for an allogeneic transplant and lacks an HLA-identical sibling or an HLA-matched unrelated donor should be considered for an alternative donor transplant. Together with the experience of the individual center, the most important decision criteria in choosing an alternative donor source should be the rapidity of transplantation so as to avoid disease relapse/progression. The choice of the mismatched donor should be driven by younger age, ABO blood group compatibility, and Cytomegalovirus status. If a TCD transplant is planned, NK-alloreactive donors and/or the mother should be preferred. Prospective comparative studies are needed to establish the relative efficacy of different transplant platforms. However, expertise in stem cell manipulation and in adoptive immunotherapy is essential if a TCD transplant platform is chosen.

Alternative Donor Transplantation for Older Patients with Acute Myeloid Leukemia in First Complete Remission: A Center for International Blood and Marrow Transplant Research-Eurocord Analysis

We studied patients with acute myeloid leukemia (AML) over age 50 and in first complete remission (CR1) after adult unrelated donor (URD) (n = 441, 8/8 HLA matched; n = 94, 7/8 HLA matched) or umbilical cord blood (UCB; n = 205) transplantations. UCB recipients achieved CR1 within 8 weeks less often, and received reduced-intensity conditioning and cyclosporine-based graft-versus-host disease (GVHD) prophylaxis more often. Neutrophil recovery was slower in UCB (69% by day 28) compared with 8/8 HLA-matched URD (97%) and 7/8 HLA-matched (91%) (P < .001) recipients. Three-year transplantation-related mortality (TRM) was higher and leukemia-free survival (LFS) lower with UCB (35% and 28%, respectively) versus 8/8 HLA-matched URD (27% and 39%, respectively). TRM was higher in 7/8 HLA-matched URD (41%, P = .01), but LFS was similar at 34% (P = .39). Three-year chronic GVHD was the lowest in UCB (28%) versus 53% and 59% in 8/8 and 7/8 HLA-matched URD recipients, respectively. Three-year survival was 43% in 8/8 HLA-matched URD (95% confidence interval [CI], 38% to 48%), 30% in UCB (95% CI, 23% to 37%) (P = .002) and 37% in 7/8 URD (95% CI, 27 to 46). Allotransplantation for AML in CR1 with any of these grafts extends LFS for over one third of older patients. In the absence of an 8/8 HLA-matched URD or when transplantation is needed urgently, UCB can provide extended survival. Less frequent chronic GVHD with UCB transplantation may be of particular value for older patients.

Haploidentical vs cord blood transplantation for adults with acute myelogenous leukemia.

Hematopoeitic cell transplantation is established as a curative treatment for patients w acute myelogenous leukemia. Haploidentical family donor and umbilical cord blood (UCB) are alternative sources of stem cells for patients lacking a matched sibling or unrelated donor. The early challenges of transplant complications related to poor engraftment and graft-vs-host disease have been overcome with new strategies such as using 2 units and increased cell dose in UCB and T-cell depletion and post transplantation cyclophosphamide in haploidentical transplantation. The outcomes of alternative transplantation for acute leukemia were compared to other traditional graft sources. For patients lacking a matched sibling or unrelated donor, either strategy is a suitable option. The choice should rely mostly on the urgency of the transplantation and the available cell dose as well as the expertise available at the transplant center. This manuscript reviews the options of alternative donor transplantation and highlights recent advances in each of these promising transplantation options.

Immunosuppressive therapy with horse anti-thymocyte globulin and cyclosporine as treatment for fulminant aplastic anemia in children

Patients with severe aplastic anemia (SAA) and an absolute neutrophil count (ANC) of 0 typically have fatal outcomes. We defined fulminant AA (FAA) as ANC = 0 for at least 2weeks prior to and after immunosuppressive therapy (IST). We analyzed the outcomes of 35 children with FAA among 288 children who enrolled in a prospective study for AA (AA-97 study). AA was classified as FAA (n = 35), very SAA (vSAA; n = 129), or SAA (n = 124). All of the children received the IST with horse anti-thymocyte globulin (ATG) and cyclosporine (CsA). A significantly lower response rate at 6months was seen in children with FAA when compared to those with vSAA or SAA (40.0, 63.6, and 63.7%, respectively; p = 0.027). Of 20 nonresponder patients in the FAA group, 11 were rescued by alternative donor transplantation, and 5 patients showed a late response after 6months. Consequently, no significant difference was noted in overall survival when comparing the FAA, vSAA, and SAA groups (88.5, 95.8, and 96.8%). These findings indicate that IST with ATG and CsA is justified as a first-line treatment for children with FAA who lack a human leukocyte antigen-matched sibling donor.

Management of the refractory aplastic anemia patient: what are the options?

Refractory aplastic anemia (AA) is defined as a lack of response to first-line immunosuppressive therapy (IST) with antithymocyte globulin and cyclosporin and is manifested as persistence of severe cytopenias at 6 months after IST. Although supportive care is critical for AA patients, it is of paramount importance for refractory disease in view of the longer duration of pancytopenia and susceptibility to life-threatening infections due to IST. Improvements in supportive care have largely contributed to better outcome over the past 2 decades, with 5-year overall survival reaching 57% during 2002 to 2008 for patients with AA unresponsive to initial IST. Exclusion of hypocellular myelodysplastic syndrome and constitutional BM failure masquerading as apparent idiopathic AA should be done in conjunction with centers of excellence. Hematopoietic stem cell transplantation is indicated if refractory AA patients are fit and have a suitably matched donor, either a sibling (>40-50 years) or unrelated donor. Patients lacking a fully matched donor should be considered for a second course of antithymocyte globulin plus cyclosporin, although response in the refractory setting is only ∼30% to 35%. Response may also occur with alemtuzumab or the thrombopoietin mimetic eltrombopag in refractory AA. The emerging data for alternate donor (cord or haploidentical) transplantation in AA has provided additional therapeutic choices to consider in refractory disease.

Alternative Donor Stem Cell Transplantation In Aplastic Anemias and Refractory Cytopenias Is Save and Feasible With T- and B-Cell Depleted Haploidentical Grafts

Allogeneic stem cell transplantation is still the curative treatment option for the majority of patients with severe aplastic anemia and refractory cytopenias. However, a HLA-matched donor is not available for all patients. Alternative donor transplantation has been an experimental treatment option, limited by high rejection rates and transplant related mortality. We performed a prospective clinical trial to evaluate the safety and feasibility of haploidentical stem cell transplantation, since haploidentical family members are always available donors. We investigated a cohort of 10 pediatric patients with severe aplastic anemia or myelodysplatic syndrome transplanted (refractory cytopenia) with T-cell depleted grafts between 2004 and 2011. 7 patients had myelodyslastic syndrome with refractory cytopenia (MDS-RC), 3 had severe aplastic anemias (SAA) refractory to immunosuppresive treatment. 3 patients received a 2nd SCT after rejecting the graft from matched donors. Median age was 11.4 years. Standard conditioning regimen consisted of Fludarabin 3-4x40mg/m2, Thiotepa 1-3x5mg/kg, Melphalan 2x70mg/m2 (n=8) and serotherapy using OKT3 (n=5) and ATG (n=5). 8 patients received additional total lymphoid irradiation (TLI 7 Gy) to prevent graft rejection. In vitro graft manipulation was carried out by direct depletion using antiCD3/19 magnetic microbeads. A median number of 10.1x106 CD34+ progenitor cells and 27x103 T-cells/kg body weight (BW) were transfused. Pharmacological GvHD prophylaxis (graft vs. host disease) was carried out with Mycofenolate until day 60, if residual T-cells in the graft exceeded 25000/kg BW. Primary engraftment occurred in all patients Median time to reach 500/µl neutrophiles was 9 days (9-11). Independence from platelet substitution was reached after 13 days (8-16). Three patients rejected the graft later on. 6/10 patients had no signs of acute GvHD or GvHD grade I, 2 patients had GvHD grade II. TRM at day +100 and after 1 year was 0% and 20%, respectively. Event free survival (EFS) at 3 years was 80%. Conclusions Haploidentical SCT with T-cell depleted grafts is a therapeutic option for refractory cytopenias and severe aplastic anemia after nonresponse to immunosuppressive treatment if no HLA-matched donor is available. Recovery of neutrophiles and platelets were fast and TRM was low, even if retransplantation was necessary. Since spontaneous outcome of these conditions are poor, alternative donor SCT is a realistic option for these patients. Disclosures: No relevant conflicts of interest to declare.

Bone Marrow Transplantation For Thalassemia Using Related Other Than HLA- Identical Siblings: Improved Transplant Outcomes With a Novel Approach

BackgroundAlthough in some areas of the world a chance of finding a related HLA- matched non sibling donor could be as high as 13% to 18%, and approximately 13% of patients could have a one-antigen mismatched related donor, the role of such alternative donor HSCT in thalassemia is not well established. Our previous study (BMT 2000,25:815) examining alternative related BMT for thalassemia was not successful due to a high graft failure, GVHD, and low disease-free survival rates. In 2005 we adopted a new transplant approach for alternative related donor transplantation in thalassemia and here we report transplant outcomes. Patients and MethodsHere we used a new treatment protocol (Pc 26.1) in 16 thalassemia patients (median age 9.6 years; range 1.4-24 years) to perform BMT using phenotypically HLA-identical or one-antigen mismatched related donors (related donors-RDs). We compared these results with HLA matched sibling donor (matched sibling donors-MSDs) BMT in 66 patients (median age 10 years; range, 1.8-27 years). The two groups were similar in terms of disease and demographic characteristics. Patients in the RD group received pre transplant cytoreduction/immunosuppression with hydroxyurea, azathioprine from day -45 pretransplant, and fludarabine from day -16 through day -12. Their conditioning regimen consisted of weight based targeted i.v. Busulfan (Bu), thiotepa (TT) (10 mg/kg), Cyclophosphamide (CY) (200 mg/kg), and Thymoglobulin 10 mg/kg. The conditioning regimen in the MSD group consisted of BuCY200 ±TT10 for class 2 patients and BuCY90-160 preceded by preconditioning cytoreduction/immunosuppression for class 3 patients. All patients received cyclosporine, methylprednisolone, and methotrexate as GVHD prophylaxis. Most patients in both groups were heavily transfused before transplantation and had moderately severe iron overload and liver fibrosis. In the RD group 11 of 16 donors were HLA-phenotypically identical (parents eight, cousin two, and uncle one), and 5 were one-antigen mismatched (siblings three, mother or aunt one). ResultsIn total, 16 patients in the RD and 58 (88%) in the MSD group had sustained engraftment. The median times to an ANC>0.5 x 109/L or to a platelet count >20 x 109/L were similar in both groups. Graft rejection occurred in 8 MSD group patients but in none of the RD group patients. The cumulative incidence of rejection was 12% (95% CI, 6–21%) in the MSD group and 0% in the RD group, which was not statistically significant (P = 0.15). The cumulative incidence of acute GVHD (grades 2–4) in the RD group (19%; 95% CI, 4–41%) was less than that in the MSD group (36%; 95% CI, 24–48%), but the difference was not statistically significant (P = 0.21). Two patients in the RD group and six in the MSD group had chronic extensive GVHD. At present, all patients are off immunosuppressive medication. The cumulative incidence of transplant-related mortality (TRM) at 100 days and 1 year was 0% and 6% (95%CI 1-26%) in the RD and 8% and 8% (95% CI, 3–16%) in the MSD group, respectively (P = 0.77). At the time of survival analysis, 15 patients (94%) in the RD group and 61 patients in the MSD group (92%) were alive, with median follow-up durations of 72 months (range, 17–93 months) and 80 months (range, 25–107 months), respectively. The probabilities of overall survival were 94% (95% CI, 63–99%) for the RD group and 92% (95% CI, 83–97%) for the MSD group (P = 0.83). The respective probabilities of thalassemia-free survival were 94% (95% CI, 63–99%) and 82% (95% CI, 70–89%), with no statistically significant difference (P = 0.24). Despite the preexisting disease and treatment-related organ damage this intensified preparative regimen was well tolerated as no significant toxicity was observed. The treatment-related toxicities were similar for the two group of patients, and none of the patients experienced grade 4 toxicity. ConclusionThe novel treatment protocol Pc 26.1 effectively and safely prevented graft rejection and ensured a high thalassemia-free survival rate in patients who received BMT from related donors who were not HLA-matched siblings. Our data show that thalassemia patients treated with Pc26.1 and receiving RD transplant have similar outcomes (rates of OS, TFS, GVHD, and TRM) to recipients of MSD transplantation. These findings are significant because they expand the availability of the treatment to more patients. Disclosures:No relevant conflicts of interest to declare.

Chimerism in Children With Primary Immunodeficiencies is Influenced by Number of Activating Killer Cell Immunoglobulin-Like Receptor Genes in the Donor and/or Killer Cell Immunoglobulin-Like Receptor Ligand Mismatch

BackgroundStem cell transplantation (SCT) is a curative treatment for children with primary immunodeficiencies. MethodsThe present retrospective analysis describes the long-term outcomes at a median follow-up of 9 years of 29 patients with immunodeficiency after SCT; 5 sibling and 24 alternative donor transplantations. T-cell engraftment emphazed on thymic dependent signal-joint T-cell receptor excision circles (sjTREC) generation and donor chimerism in relation to killer cell immunoglobulin-like receptor genes and their ligands. ResultsAll children except two were reconstituted successfully from grafted material, including 9 and 18 cases of mixed chimerism (MC) and complete chimerism (CC), respectively. Univariate analyses showed that the number of activating KIR genes or HLA-C1/C2 ligand mismatches (P = .048) and possibly transplantation from an alternative donor (P = .054) facilitated CC development. Multivariate analysis showed that the presence of donor KIR haplotype B or incompatibility within C1/C2 ligands (relative risk, 6.1; 95% confidence interval, 1.08–34.69; P = .025) were significantly associated with the development of CC. ConclusionsThese results suggested that the donor-activating KIR gene repertoire affected successful engraftment.

Absence of Post-Transplantation Lymphoproliferative Disorder after Allogeneic Blood or Marrow Transplantation Using Post-Transplantation Cyclophosphamide as Graft-versus-Host Disease Prophylaxis

Immunosuppressive regimens that effectively prevent graft-versus-host disease (GVHD) after allogeneic blood or marrow transplantation (allo-BMT) have been associated with an increased incidence of post-transplantation lymphoproliferative disorder (PTLD) in the first year after transplantation. We evaluated the incidence of PTLD associated with the use of high-dose post-transplantation cyclophosphamide (PTCy) as GVHD prophylaxis. Between 2000 and 2011, a total of 785 adult allo-BMT recipients were given PTCy as GVHD prophylaxis at the Johns Hopkins Hospital, including 313 patients who received PTCy as sole GVHD prophylaxis. HLA-haploidentical or unrelated donor graft transplantation was performed in 526 patients (67%). No cases of PTLD occurred during the first year after allo-BMT in this series. PTLD is a rare occurrence after allo-BMT using PTCy, even in high-risk alternative donor transplantations.

Philadelphia chromosome positive precursor T acute lymphoblastic leukemia.

To the Editor, 26 year old male presented with generalized bulky lymphadenopathy, raised white blood cell count, anemia and thrombocytopenia in December of 2009. The peripheral smear and bone marrow were morphologically consistent with acute lymphoblastic leukaemia. Immunophenotype showed that the blast cells were positive for CD3 and CD7. All the B lineage markers were absent. In addition the blast cells were positive for CD13 and CD 33, but negative for CD117 and cytoplasmic myeloperoxidase. Cytoplasmic CD 3 was positive. We therefore made a diagnosis of acute T lymphoblastic leukemia with aberrant myeloid antigen expression. Conventional cytogenetics showed 9;22 translocation. Reverse transcriptase polymerase chain reaction (RT-PCR) confirmed the presence of minor BCR–ABL transcript at high levels which is shown in the Fig. 1. Fig. 1 Band at 106 bp is patient’s sample which is positive for minor break point e1a2 (lane 5) corresponding to p190KD protein. The previous lane (lane 4) showing the band at 330 bp is internal control for the ABL region of the patient’s ... T lymphoblastic leukemia with Philadelphia positivity is very rarely reported in the literature [1–4]. There is a debate whether it is de novo leukemia or blastic phase of chronic myeloid leukemia [5]. Our patient did not have a palpable spleen. Absence of splenomegaly and the presence of minor BCR–ABL transcript probably favours an acute lymphoblastic leukemia of precursor T cell lineage. The presence of aberrant myeloid markers makes our case more interesting. The patient was treated with a combination of chemotherapy and imatinib. He achieved morphologic remission but has not achieved molecular remission and hence switched over to second line tyrosine kinase inhibitor dasatinib. There was no BCR–ABL mutation detected. Bone marrow transplantation could not be offered as the patient does not have a histocompatible sibling and an alternative donor transplantation was not feasible due to various logistic constraints.

Long-term survival after alternative donor transplantation in children with acute leukemia.

10006 Background: Most reports describing long-term survival after allogeneic transplantation are in adults after transplantation of bone marrow (BM) from HLA-matched siblings. This report compares long-term survival after transplantation of unrelated donor BM to that after umbilical cord blood (UCB) in children with acute leukemia. Methods: Included were patients aged less than 18 years with acute myeloid or lymphoblastic leukemia, alive and leukemia-free for at least 1 year after transplantation. Transplants occurred 2000-2009. Patients received BM grafts that were HLA-matched (N = 205) or mismatched at 1-HLA locus (N = 112) and UCB grafts that were matched (N = 55) or mismatched at 1 (N = 160) or 2 HLA-loci (N = 134). Multivariate Cox regression models were constructed to explore differences in survival between groups. UCB transplants were treated as a single group as there were no significant differences between HLA-matched and mismatched UCB grafts. Multivariate models held 3 treatment groups: HLA-matched BM, HLA-mismatched BM and UCB grafts. Results: The disease characteristics of the three groups were similar. There were differences in patient and transplant characteristics. Recipients of UCB transplants were younger, more likely non-Caucasian, and more likely to have received a non-irradiation-containing conditioning regimen, in-vivo T-cell depletion and GVHD prophylaxis with cyclosporine and either prednisone or mycophenolate. In multivariate analysis, the risks of long-term mortality were not significantly different after UCB and HLA-matched BM transplants (HR 0.83, p=0.41). Mortality risks were significantly higher after HLA-mismatched BM transplants compared to UCB (HR 1.66, p=0.03) and HLA-matched BM transplants (HR 2.00, p=0.008). In this cohort, surviving disease-free at least 1-year after transplantation, the 8-year probabilities of overall survival after UCB, HLA-matched and HLA-mismatched BM transplants were 78%, 81% and 68%. Conclusions: This is the first report to document long-term durability of UCB grafts. The data continue to support the use of UCB grafts either in the absence of an HLA-matched donor or when transplantation is needed urgently for children with acute leukemia.