Dose-reduced Allogeneic Stem Cell Transplantation Research Articles

Lenalidomide plus donor-lymphocytes infusion after allogeneic stem-cell transplantation with reduced-intensity conditioning in patients with high-risk multiple myeloma

Myeloma relapse is the main cause of death after allogeneic stem cell transplantation. The aim of our observational study was to evaluate the anti-myeloma effect of lenalidomide followed by donor-lymphocyte infusion (DLI) as post-transplantation adoptive immunotherapy. Twelve patients with refractory myeloma were analyzed. The median age at transplantation was 56 years (range, 46-64 years). All patients received reduced-intensity conditioning. Patients were included if progressive or residual disease was observed at day +100 and if no signs of graft-vs-host disease were evident. DLIs were administered after two cycles of lenalidomide. Median dose of lenalidomide was 15 mg (range, 10-25 mg). Patients received a median of six cycles (range, 1-10 cycles). Nine patients (60%) received an escalating dose of DLI. The 1 and 2-year probability of progression-free survival was 75% and 50%, and overall survival was 83% and 69%, respectively. Median overall survival was not reached and median progression-free survival was 23 months. Lenalidomide is well tolerated after allogeneic stem cell transplantation; the combination with DLI did not cause a higher risk of graft-vs-host disease; an immunological synergistic effect was probably present with this strategy. This combination should be evaluated further in a larger cohort of patients.

Rapid regression of bone marrow fibrosis after dose-reduced allogeneic stem cell transplantation in patients with primary myelofibrosis

To investigate the effect of a busulfan/fludarabine-based reduced intensity conditioning followed by allogeneic stem cell transplantation on regression of bone marrow fibrosis in patients with myelofibrosis. Twenty-four patients (male, n = 16; female, n = 8) with a median age of 52 years (range, 32-63 years) were included. Six patients were transplanted from human leukocyte antigen-identical siblings and 18 patients from matched unrelated donors. Diagnosis was primary myelofibrosis in 18 patients and secondary myelofibrosis in 6 patients; in 4 of them, primary myelofibrosis evolved from polycythemia vera, and in 2 of them from essential thrombocythemia. Using the European Consensus on grading bone marrow fibrosis, all patients had advanced marrow fibrosis MF-2 (n = 13) or MF-3 (n = 11) before allografting According to the Lille Risk Factor Scoring System, patients were classified as low risk (n = 5), intermediate risk (n = 16), or high risk (n = 3). After stem cell transplantation, a complete (MF-0) or nearly complete (MF-1) regression of bone marrow fibrosis was seen in 59% at day +100, in 90% at day +180, and in 100% at day +360. No correlation between occurrence of acute graft-vs-host disease and fibrosis regression on day +180 was observed. This study shows that allogeneic stem cell transplantation after reduced-intensity conditioning resulted in rapid regression of bone-marrow fibrosis.

Monitoring of the JAK2-V617F mutation by highly sensitive quantitative real-time PCR after allogeneic stem cell transplantation in patients with myelofibrosis

AbstractThe JAK2-V617F mutation occurs in about 50% of patients with myelofibrosis and might be a reliable marker to monitor residual disease after allogeneic stem cell transplantation. We describe a new, highly sensitive (≥ 0.01%) real-time polymerase chain reaction (PCR) to monitor and quantify V617F-JAK2–positive cells after dose-reduced allogeneic stem cell transplantation. After 22 allogeneic stem cell transplantation procedures in 21 JAK2-positive patients with myelofibrosis, 78% became PCR negative. In 15 of 17 patients (88%), JAK2 remained negative after a median follow-up of 20 months. JAK2 negativity was achieved after a median of 89 days after allograft (range, 19-750 days). A significant inverse correlation was seen for JAK2 positivity and donor-cell chimerism (r: −0.91, P < .001). Four of 5 patients who never achieved JAK2 negativity fulfilled during the entire follow-up all criteria for complete remission recently proposed by the International Working Group, suggesting a major role for JAK2 measurement to determine depths of remission. In one case, residual JAK2-positive cells were successfully eliminated by donor lymphocyte infusion. In conclusion, allogeneic stem cell transplantation after dose-reduced conditioning induces high rates of molecular remission in JAK2-positive patients with myelofibrosis, and quantification of V617F-JAK2 mutation by real-time PCR allows the detection of minimal residual disease to guide adoptive immunotherapy.

No Adverse Impact of 13q14 and P53 Deletion, t(4;14)(p16;q32) or Overrepresentation of CMYC(8q24) as Detected by Fluorescence In Situ Hybridization on Outcome in Patients with Multiple Myeloma Following Dose-Reduced Allogeneic Stem Cell Transplantation.

Deletions of chromosome bands 13q14 and 17p13 (P53) as well as t(4;14)(p16;q32) or overrepresentation of CMYC are known to be adverse prognostic factors for time to progression (TTP) and overall survival (OS) in myeloma patients receiving conventional or high-dose chemotherapy followed by autologous stem cell transplantation. We investigated the impact of these chromosomal abnormalities as detected by fluorescence in situ hybridization combined with immunofluorescent cytoplasm immunoglobulin staining (cIg-FISH) on outcome after dose-reduced melphalan/fludarabin based allogeneic stem cell transplantation (SCT) in 64 patients (pts) with multiple myeloma (MM). Median age was 52 years (34 – 67 ys.), 38 patients were male, 26 female. 45 pts received stem cell graft from an unrelated donor and 19 pts from HLA-identical sibling. Deletion of 13q14 was found in 35 out of 64 pts (55%), P53 deletion in 7 out of 64 pts (11%), t(4;14)(p16;q32) in 11 out of 56 pts (20%) and trisomy of CMYC in 12 out of 55 pts (22%). The following strong correlations among the genetic changes have been seen: six out of seven pts with P53 deletion also showed deletion in chromosome band 13q14 (86%), which was also found in nine out of eleven pts with t(4;14) (82% del 13) and nine out of twelve pts with CMYC trisomy (75% del 13). The estimated event-free (EFS) and overall survival (OS) at four years for the entire study population was 48% and 57%, respectively. No significant difference of the estimated event-free survival at 3 years was seen for pts with del 13 (42% vs 54%, p=0,4), with P53 deletion (43% vs 49%, p=0,27) and for pts with t(4;14) (46% vs 62%, p=0,69) or CMYC overrepresentation (37% vs 50%, p=0,35). Comparison of pts showing both del 13 and P53 deletion, del 13 and t(4;14), del 13 and trisomy of CMYC or t(4;14) and CMYC trisomy with the rest of the study population did not show a significantly reduced EFS either. Even the comparison of pts with any chromosomal abnormalities and pts without any genetic changes detected by FISH did not show a significant difference in EFS (48% vs 50%, p=0,8). These preliminary data suggest that the negative prognostic impact of chromosomal abnormalities such as deletion of 13q14, P53 deletion, t(4;14) and overrepresentation of CMYC may be overcome by allogeneic SCT probably due to the graft versus myeloma effect.

Rapid Regression of Bone Marrow Fibrosis after Dose-Reduced Allogeneic Stem Cell Transplantation in Patients with Myelofibrosis.

Myelofibrosis with myeloid metaplasia [MMM] is a myeloproliferative disease of which bone marrow histology is characterized by substantial collagen fibrosis and osteosclerosis. Bone marrow histology changes in MMM are reactive and cytokine mediated. Studies suggested a pathogenic role of transforming growth factor β [TGF-β], platelet derived growth factor, and basic fibroblast growth factor. In the current study we investigated the dynamic and kinetic of fibrosis regression in 18 patients with myelofibrosis who underwent allogeneic stem cell transplantation after a dose-reduced conditioning. The conditioning regimen consisted of Busulfan 10 mg/kg, Fludarabin 180 mg/m2, and Antithymocyte globulin 30 – 60 mg/kg followed by peripheral stem cell transplantation (SCT). 18 patients with a median age of 45 [range 35 to 64] were included and bone marrow histology was investigated prior SCT, between day+30 and +40 after engraftment, on day+100, and 1 year after stem cell transplantation. The grading of myelofibrosis [MF] was performed according to the recently published European Consensus on Grading Bone Marrow Fibrosis [Thiele et al., Haematologica 2005; 90:1125–1132]. This consensus distinguishes between:MF - 0 Scattered linear reticulin with no intersections [cross-overs] corresponding to normal bone marrowMF - 1 Loose network of reticulin with many intersections, especially in perivascular areasMF - 2 Diffuse and dense increase in reticulin with extensive intersections, occasionally with only focal bundles of collagen and/or focal osteosclerosisMF - 3 Diffuse and dense increase in reticulin with extensive intersections with coarse bundles of collagen, often associated with significant osteosclerosisAt time of transplantation all patients suffered from advanced myelofibrosis 2° [39 %] or 3° [61 %], resulting in a median MF grade of 3 [range 2–3]. After engraftment on day+30 a regression of MF grade to a median of 2 [range 0–3] was observed. Grade 2 or less was observed in 80 % and grade 1 or 0 in 40 % of the patients. On day+100 the median grade of MF was 1 [range 0–3] and 93 % of the patients had an MF-grade of 2 or less, while 73 % of the patients had MF grade-1 or 0. One year after transplantation the median MF-grade was 0 [range 0–2] and 100 % of the patients had a MF-grade of 2 or less and 92 % of the patients had MF grade 1 or 0. We conclude that allogeneic stem cell transplantation after a dose-reduced conditioning induces a rapid and nearly complete regression of bone marrow fibrosis within the first year after transplantation.

Highly Sensitive Real-Time PCR of V617F-JAK2-Mutation To Monitor Minimal Residual Disease and Guide Donor Lymphocte Infusion after Allogeneic Stem Cell Transplantation in Patients with Myelofibrosis.

The V617F-JAK2-mutation occurs in about 50 % of patients with myelofibrosis and is a reliable marker to monitor residual disease after allogeneic stem cell transplantation. The establishment of valid complete remission criteria for myelofibrosis especially after allogeneic stem cell transplantation remains a major issue. We developed a new, highly sensitive real-time PCR to monitor and quantify V617F-JAK2-positive cells after dose-reduced allogeneic stem cell transplantation. The mutated differs from the wild-type JAK2 allele by just one nucleotide exchange (G à T) leading to the valine to phenylalanine (V à F) transition. Using PrimerExpress® we designed a TaqMan® PCR where the reverse primer (RP) terminates at the (3′) nucleotide corresponding to this point mutation. Thus, this reverse primer should bind with higher affinity to the mutated than to the wild-type allele. To increase the specificity while conserving optimal sensitivity of the MRD-specific PCR we generated a set of primers shortened each time by one nucleotide at their 5' end. In parallel, all those shortened primers were designed to contain an additional mutation at the third to last 3' position. This allowed us to identify the reverse primer combining high specificity with so far not reported sensitivity(0.01 %). After 22 allogeneic stem cell transplantation procedures in 21 JAK2-positive patients with myelofibrosis, 78 % became PCR-negative. In 15 out of 17 patients (88 %), JAK2 remained negative after a median follow-up of 20 months. JAK2-negativity was achieved after a median of 89 days post allograft (range, 19 – 750 days). A significant inverse correlation was seen for JAK2 positivity and donor cell chimerism (r: −0.91, p<0.001). Four of five patients who never achieved JAK2-negativity fulfilled during the entire follow-up all criteria for complete remission recently proposed by the International Working Group, suggesting a major role for JAK2 measurement to determine depths of remission. In one case, residual JAK2 positive cells could be eliminated by donor lymphocyte infusion, supporting the graft versus myelofibrosis effect. In conclusion, allogeneic stem cell transplantation after dose-reduced conditioning induces high rates of molecular remission in JAK2-positive myelofibrosis-patients and quantification. V617F-JAK2 mutation by real-time PCR allows detecting minimal residual disease to guide adoptive immunotherapy.

Bortezomib after dose-reduced allogeneic stem cell transplantation for multiple myeloma to enhance or maintain remission status

We investigated the effect of at least two cycles of bortezomib (1.3 mg/m(2) intravenously, days 1, 4, 8, and 11) after dose-reduced allogeneic stem cell transplantation (SCT) on toxicity, CD3(+) cells, graft-versus-host disease (GvHD), and response in patients with multiple myeloma. Eighteen patients with multiple myeloma without progressive disease were included. The proteasome inhibitor was given at median of 8 months after allografting to enhance or maintain remission status. Fourteen patients (78%) completed the proposed two cycles. Four patients had to discontinue therapy due to neurotoxicity (n = 3) or gastrointestinal toxicity (n = 1). Severe grade III/IV toxicity was seen for thrombocytopenia (50%), leukopenia (17%), or neuropathy (17%), which was more often seen in patients treated concomitantly with cyclosporine (p = 0.06). The median circulating CD3(+) cells decreased during treatment from 550 muL to 438 muL (p = 0.03), resulting in herpes zoster infection in three patients (17%). In three patients, a mild aggravation of existing acute or chronic GvHD of the skin, and in one patient de novo skin grade I acute GvHD was noted. In patients with measurable disease, complete remission, partial remission, and minor response was seen in 3 (30%), 5 (50%), and 2 (20%) patients, respective. Bortezomib after allogeneic SCT is effective but further studies are needed to balance the efficacy with potential hazards such as infectious complications, aggravation of GvHD, and neurotoxicity.

Prospective comparison of autologous stem cell transplantation followed by dose-reduced allograft (IFM99-03 trial) with tandem autologous stem cell transplantation (IFM99-04 trial) in high-risk de novo multiple myeloma

The Intergroupe Francophone du Myélome (IFM) initiated 2 trials in 1999 to study patients with high-risk (beta2-microglobulin level greater than 3 mg/L and chromosome 13 deletion at diagnosis) de novo multiple myeloma. In both protocols, the induction regimen consisted of vincristine, doxorubicin, and dexamethasone (VAD) followed by first autologous stem cell transplantation (ASCT) prepared by melphalan 200 mg/m(2). Patients with an HLA-identical sibling donor were subsequently treated with dose-reduced allogeneic stem cell transplantation (IFM99-03 trial), and patients without an HLA-identical sibling donor were randomly assigned to undergo second ASCT prepared by melphalan 220 mg/m(2) and 160 mg dexamethasone with or without anti-IL-6 monoclonal antibody (IFM99-04 protocol). Two hundred eighty-four patients-65 in the IFM99-03 trial and 219 in the IFM99-04 trial-were prospectively treated and received at least one course of VAD. On an intent-to-treat basis, overall survival (OS) and event-free survival (EFS) did not differ significantly in the studies (medians 35 and 25 months in the IFM99-03 trial vs 41 and 30 months in the IFM99-04 trial, respectively). With a median follow-up time of 24 months, the EFS of the 166 patients randomly assigned in the tandem ASCT protocol was similar to the EFS of the 46 patients who underwent the entire IFM99-03 program (median, 35 vs 31.7 months), with a trend for a better OS in patients treated with tandem ASCT (median, 47.2 vs 35 months; P = .07). In patients with high-risk de novo MM, the combination of ASCT followed by dose-reduced allogeneic transplantation was not superior to tandem dose-intensified, melphalan-based ASCT.

High-dose melphalan is an effective salvage therapy in acute myeloid leukaemia patients with refractory relapse and relapse after autologous stem cell transplantation

In a pilot study high-dose melphalan (HD-Mel, 200 mg/m2) and autologous stem cell transplantation (ASCT) were administered to 14 patients (median age 52, range 29-60 years) with acute myeloid leukaemia (AML) in first relapse after a previous ASCT in first complete remission (n=11) or chemotherapy (n=3). A first cohort of five patients received HD-Mel as salvage therapy after a previous cycle of mitoxantrone, topotecan and cytarabine (MTC) had failed in four out of five patients, while a second cohort of nine patients received HD-Mel in untreated relapse. Thirteen (93%) of 14 patients achieved a second complete remission (CR2), including all four patients who had been refractory to MTC. No treatment-related mortality was observed after HD-Mel. Thirteen (93%) patients were able to proceed to a dose-reduced allogeneic stem cell transplantation (allo-SCT) from human-leucocyte-antigens-compatible unrelated (n=12) or sibling donors (n=1) in CR2 (n=11) or poor recovery/relapse (n=2) after a median of 2 (1.7-4.5) months following HD-Mel. Three MTC-refractory patients, but none of the upfront HD-Mel patients, died due to an allograft-related non-relapse cause. Nine patients are alive in CR2 after a median of 6 (2-49) months after HD-Mel and a median of 4 (0.6-47) months after a sequential allo-SCT. Although median follow-up is still short, the proportion of patients achieving a CR2, as well as of those proceeding to a subsequent reduced-intensity-conditioning-allo-SCT, is superior to those previously reported. Our results highly encourage to further investigate HD-Mel and ASCT as a promising salvage regimen for relapsed AML patients for whom autologous peripheral blood stem cells are available.

Prognostic Significance of Molecular Remission Determined by Highly Specific PCR after Dose-Reduced Allogeneic Stem Cell Transplantation (SCT) in Patients with Multiple Myeloma.

Achieving molecular remission after standard allogeneic stem cell transplantation in multiple myeloma is associated with long term freedom of disease and possible cure. We recently reported a high rate of complete remission after an auto-allo tandem approach using fludarabine (150 mg/m²), melphalan (140 mg/m²) and anti-thymocyte globulin (ATG: 3 x 10–20mg/kg) three months after a cytoreductive autograft (melphalan 200 mg/m²). To determine the incidence of molecular remission we tried to develop allele-specific oligonucleotides (ASO) based upon the clonal rearrangement of immunoglobulin heavy chain genes and ASO - polymerase chain reaction (ASO-PCR) for each patient who achieved complete remission with negative immunofixation after SCT (n=27). The specificity of the ASO-PCR was tested using patient and control DNA. Patient DNA isolated from bone marrow (BM) samples obtained at diagnosis and after allografting at variable time points was used for further molecular analysis. For nine patients we were able to generate specific primers and MRD diagnostics have been performed for a median of two years after SCT. Molecular remission was strictly defined by the absence of any PCR-positivity. In 6 patients nested PCR remained negative after a median follow up of 22 months (range 10–24). Only one of these patients relapsed with extramedullary disease (14 months) still being PCR-negative in his bone marrow. In contrast, all those patients with complete remission but positive PCR (n=3) relapsed (at 11, 14 and 16 months after SCT, respectively) thus underlining the importance of achieving molecular remission after allo-SCT. We suppose that quantitative real-time PCR might be a useful tool to closely monitor MRD kinetics post allo-transplantation in order to verify efficiency of various treatment regimens, e.g. donor lymphocyte infusions.

Impact of deletion 13q14 detected by fluorescence in situ hybridization on outcome after dose-reduced allogeneic stem transplantation in patients with multiple myeloma

6536 Background: We investigated in a retrospective multicenter study the impact of deletion 13q by fluorescence in situ hybridization (FISH) on outcome after dose-reduced allografting in patients with multiple myeloma. Patients and Methods: In 68 out of 140 patients data on deletion 13q detected by FISH were available: 37 patients were FISH negative and 31 FISH positive for deletion 13q14. Patients in both groups were well balanced regarding age, β2-microglobulin, relapse after a prior autograft, donor sex, related and unrelated donor, graft source, CD34+ cell dose, and chemosensitivity at time of transplantation. Results: Patients with deletion 13 had a worse event-free survival and overall survival than patients without deletion 13 (18% vs 42%, p=0.05 and 18% vs 67% p=0.03, respectively). Patients with deletion 13 experienced a higher relapse rate (82% vs 58%, p=0.05), but similar incidence of treatment related mortality at one year (24 vs 18%). In the multivariate analysis, deletion 13q remained a significant risk factor for higher relapse-rate (HR 3.28; 95% CI: 1.31–8.24; p=0.01) and for event-free survival (HR 1.94; 95% CI: 1.03–3.67; p=0.04). For overall survival, two or more prior high-dose chemotherapies were associated with a significant higher probabilty of death (HR: 2.48; 95% CI: 1.19–5.17, p=0.02), while patients with deletion 13q had a nearly two times higher risk for death after after dose-reduced allogeneic stem cell transplantation (HR: 1.94; 95% CI: 0.95–3.98, p=0.07). Conclusion: Deletion 13q14 is an unfavourable factor for outcome after dose-reduced conditioning followed by allogeneic stem cell transplantation in multiple myeloma No significant financial relationships to disclose.

Deletion of chromosome band 13q14 as detected by fluorescence in situ hybridization is a prognostic factor in patients with multiple myeloma who are receiving allogeneic dose-reduced stem cell transplantation

AbstractWe investigated in a retrospective multicenter study the impact of chromosome arm 13q deletion (13q-) as detected by fluorescence in situ hybridization (FISH) on outcome after dose-reduced allografting in patients with multiple myeloma. In 68 of 140 patients, data on chromosome 13q status were available. Most patients included had advanced myeloma. At 2 years, patients with 13q deletion (n = 31) had a shorter event-free (18% vs 42%; P = .05) and overall survival (18% vs 67%; P = .03) than patients without 13q- (n = 37). Patients with 13q- experienced a higher relapse rate (77% vs 44%; P < .001) but a similar incidence of transplantation-related mortality at one year (24% vs 18%). In a multivariate analysis, 13q- remained a significant risk factor for a higher relapse rate (hazard ratio [HR], 3.28; 95% confidence interval [CI], 1.31-8.24; P = .01) and a shorter event-free survival (HR, 1.94; 95% CI, 1.03-3.67; P = .04). Concerning overall survival, 2 or more cycles of prior high-dose chemotherapy were associated with a significantly higher probability of death (HR, 2.48; 95% CI, 1.19-5.17; P = .02), while patients with deletion 13q had a nearly 2 times higher risk of death (HR, 1.94; 95% CI, 0.95-3.98; P = .07) after dose-reduced allogeneic stem cell transplantation.

Risk-factors of melphalan/fludarabine dose-reduced allogeneic stem cell transplantation in patients with multiple myeloma

Risk-factors of melphalan/fludarabine dose-reduced allogeneic stem cell transplantation in patients with multiple myeloma