Grade II-IV aGVHD Research Articles

First-in-Human Clinical Trial to Determine the Safety and Potency of Inducible T Regulatory Cells after Allogeneic Hematopoietic Cell Transplantation

Introduction: Adoptive transfer of thymic derived regulatory T-cells (tTregs) or Treg type I cells that arise in the periphery can ameliorate GVHD and autoimmunity in mice. However, high Treg doses (~1:1 with donor T-cells) are required to reproducibly suppress disease. In the periphery, a population of non-Treg CD4+ T-cells can be induced to acquire a Treg phenotype and function. We defined a GMP-compliant method for selecting, inducing and expanding Tregs from peripheral blood CD4+25- T cells with IL-2, sirolimus and TGFß. Sirolimus/TGFß iTregs are as suppressive as cord blood derived tTregs and the potential yield is 50-fold higher in a 2 week culture period. We hypothesized that inducible regulatory T cells (iTregs) will be effective for acute GVHD (aGVHD) prevention without concomitantly increasing the risk of opportunistic infection and relapse.Methods: We performed a phase I single center dose escalation study with an extension at the best available dose to determine the tolerability of inducible regulatory T cells (iTregs) given to adult patients undergoing reduced intensity HLA-identical sibling donor peripheral blood stem cell (PBSC) transplantation for high risk malignancy. The study used a fast track design with 1 patient per iTreg dose cohort (3.0 x 106/kg, 3.0 x 107/kg, 3.0 x 108/kg and 10.0 x 108/kg) along with CSA/MMF GVHD prophylaxis. An extension phase then occurred to total 10 patients at the best available dose, but using sirolimus/MMF as sirolimus is permissive of Treg expansion. HLA-identical sibling donors underwent 2 aphereses. On day -14, an unmobilized 15L apheresis was performed to collect cells for iTreg production. On day 0 (and +1 if needed), G-CSF mobilized 15L apheresis collected PBSCs. All patients received cyclophosphamide 50 mg/kg on day -6, fludarabine 30 mg/m2/day on days -6 to -2, and 200 cGy TBI as a single fraction on day -1. The iTregs were administered on day 0 at least 4 hours before the PBSC infusion.Results: Sixteen patients were enrolled. Two did not receive iTregs as inadequate numbers of cells were produced. 14 patients (7 male,7 female; median age 63 years) received iTregs. One patient each received 3.0 x 106/kg, 3.0 x 107/kg, 3.0 x 108/kg iTregs with a corresponding T effector:iTreg ratio of 86:1, 8:1 and 1:2. As a ratio of 1:1 was considered sufficient to suppress GVHD in mice, dose escalation was halted at 3.0 x 108/kg considering manufacturing costs despite no observed dose limiting toxicities (DLT). After 3 patients received 3.0 x 108/kg with CSA/MMF immunoprophylaxis with no DLTs, 2 patients received 3.0 x 108/kg iTregs using sirolimus/MMF. Both patients developed grade III aGVHD, resulting in suspension of the sirolimus/MMF arm. An additional 7 patients (for a total of 10) received 3.0 x 108/kg iTregs along with CSA/MMF. No severe infusional toxicities occurred in the 14 patients who received iTregs. All achieved neutrophil engraftment at a median of 7 days. Of 10 patients who received 3.0 x 108/kg iTregs using CSA/MMF, 2 developed grade II and 1 grade III aGVHD by day 100. Circulating Foxp3+iTregs were detected early after adoptive transfer, but were not detectable beyond day 28. Higher numbers of iTregs were detected at day 3 in patients who received 3.0 x 108/kg iTregs along with CSA/MMF versus 3.0 x 106/kg or 3.0 x 107/kg (21% +/-3% vs 9% +/- 3% of CD4 cells were Foxp3+CD25+). On day 7, lower numbers were seen in all patients and by day 28 only 3% of CD4+ cells were Foxp3+CD25 in all patients. In a contemporary institutional cohort of 203 adult patients with malignancies receiving the same RIC and GVHD prophylaxis, but without iTregs, the probabilities of grade II-IV aGVHD was 41% (95% CI, 34-48%) and grade III-IV GVHD was 25% (95% CI, 19-31%) suggesting iTreg administration may suppress GVHD to some extent in this small trial (Figure).Conclusions: HLA-identical sibling donor iTregs were safely administered in the setting of HLA-identical sibling PBSCT. 3 x 108/kg iTreg/kg was the best tested dose to suppress GVHD with CSA/MMF immunoprophylaxis. Sirolimus/MMF was ineffective as GVHD prophylaxis in this iTreg clinical trial. Future studies should test the combination of iTregs and tTregs which synergistically induce tolerance in mice. [Display omitted] DisclosuresMacMillan:Angiocrine: Membership on an entity's Board of Directors or advisory committees; CSL Behring: Consultancy; Equillium: Consultancy. Brunstein:Gamidacell: Research Funding. Weisdorf:FATE: Consultancy; SL Behring: Consultancy; Seattle Genetics: Consultancy; Pharmacyclics: Consultancy; Equillium: Consultancy. Blazar:Kadmon Corporation, LLC: Consultancy, Research Funding. Wagner:Magenta Therapeutics: Consultancy, Research Funding; Novartis: Research Funding.

The Comparison of Unmanipulated Bone Marrow Versus Peripheral Blood Haploidentical Stem Cell Transplantation in Adult Acute Leukemia: A Systematic Review and Meta-Analysis

Background:The use of peripheral blood stem cell source (PBSC) continues to grow in the setting of haploidentical hematopoietic stem cell transplantation (haplo-SCT), mainly due to the ease of collection and rapid peripheral blood count recovery. We conducted a systematic review and meta-analysis of the published literature to evaluate the outcomes of unmanipulated bone marrow (BM) and PB haplo-SCT for adult leukemia patients.Method:A comprehensive literature search of electronic databases (Medline, Embase, and Cochrane library) for studies published between 1 January 2004 to 24 June 2018 was conducted. We included the studies of unmanipulated BM and/or PB haplo-SCT in adult acute myeloid leukemia (AML) and acute lymphoblastic leukemia ( ALL) . We excluded the studies which combined PB and BM stem cell sources and the studies which did not report the results of BM and PB haplo-SCT for ALL and AML separately. CMA software v.3 was used for the analysis. Heterogeneity among studies was assessed using the I2 test. Random-effect model was applied. Publication bias was assessed using funnel plots. Primary endpoints were engraftment, 2-year overall survival (OS), disease-free survival (DFS), relapse incidence (RI); grade II-IV, III-IV acute and chronic GVHD.Results: Out of 1548 publications, 3 studies (n = 672 patients; retrospective; multi-center) met our inclusion criteria. The sample size of the studies varied between 71 and 451 patients. The median follow-up ranged from 18 to 46 months. PB haplo-SCT was used in 191 patients (Ruggeri, A. et al. 2018) and BM haplo-SCT was used in 481 patients (Arcese, W. et al. 2015; Ruggeri, A. et al. 2018; Chiusolo, P. et al. 2018). Myeloablative (MA) conditioning was used in majority of patients. The pooled (95%CI) engraftment rate was 93% (88-95) in BM group and 95% (91-97) in PBSC group. The pooled estimates (95%CI) of BM studies showed a 2-year OS rate of 56.1% (51.6-60.4), 2-year DFS of 48.9% (43.5-54.2) and 2-year cumulative RI of 24.6%(20.7-29).There was no heterogeneity in BM group (I2=0%) for 2-year OS, DFS and RI. For PBSC group, the pooled estimates (95%CI) for 2-year OS, DFS and RI were 56 % (48.9-62.9; I2=0%), 54% (46.9-60.9; I2=0%) and 22% (16.7-28.4; I2=0%), respectively. Incidences of grade II-IV, grade III-IV aGVHD and cGVHD from a pooled analysis (95%CI) were 23.1% (17.2-30.3; I2=55%), 5.4% (3.4-8.3; I2=16%) and 19.5% (9.7-35.3; I2=88%) for BM group in comparison to 38% (31.4-45.1; I2=0%), 14% (9.8-19.7; I2=0%) and 32% (25.8-38.9; I2=0%) for PBSC group. Pooled estimates were shown in figure 1.Conclusions:In this analysis, higher pooled rates of grade II-IV aGVHD (38% vs 23.1%), III-IV aGVHD (14% vs 5.4%) and cGVHD (32% vs 19.5%) were observed in PBSC group vs BM group, respectively. Based on comparable OS, DFS and RI, PB haplo-SCT appears to be a good alternative option for adult AML and ALL patients. Large prospective randomized controlled trials are required to confirm these results. DisclosuresNo relevant conflicts of interest to declare.

The Optimal Alternative Donor Transplant for Pediatric Patients with Acute Leukemia: A Comparison between Alfa-Beta T-Cell and B-Cell Depleted Haplo-SCT and UCBT

▪Children with acute leukemia (AL) in need of an allograft and lacking an HLA-identical sibling and an HLA-matched unrelated donor, could benefit either from unrelated cord blood transplantation (UCBT) or T-cell depleted haploidentical (haplo) stem cell transplantation (SCT).Different techniques of T-cell depletion have been developed for improving immune reconstitution and for enhancing the graft-versus-leukemia (GvL) effect. Locatelli et al. (Blood 2017) reported remarkable results for children with AL given haplo-SCT after a novel method of graft manipulation based on selective, negative depletion of alfa-beta T and B cells.On behalf of Eurocord, CTIWP, and PDWP of EBMT, we compared outcomes of patients < 18 years with AL undergoing either single-UCBT (n=444) or haplo-SCT after alfa-beta T-cell and B-cell-depletion (n=99) from 2012 to 2016 using a myeloablative conditioning regimen (MAC).Median age at SCT was 6 (range 0.3-18) and 8 (range 0.6-18) years, and median follow-up was 36 and 14 months (p<0.05) for UCBT and haplo-SCT recipients, respectively. Compared to UCBT, haplo-SCT were performed more recently (median year 2016 vs 2012, p<0.05). Acute lymphoblastic leukemia (ALL) was the most frequent diagnosis (62% versus 55%), while 38% and 45% of patients had acute myeloid leukemia (AML) in the UCBT and haplo-SCT group, respectively. Cytogenetics was mainly at intermediate risk for UCBT (54%) and haplo-SCT (73%, p<0.05); 49% and 54% of patients were in CR1 at time of the allograft in UCBT and haplo-SCT group, respectively (p=0.45). In vivo T-cell depletion with ATG was more frequently adopted in haplo-SCT recipients (90% versus 81%, p=0.05). For UCBT recipients, HLA compatibility was 6/6 matched for 19% of patients, 5/6 for 58% and 4/6 for 23%. Cord blood graft contained a median TNC count at cryopreservation of 7.02x10e7/Kg (range 2.63-43) and at infusion of 5.3x10e7/Kg (range 0.3-39).Conditioning regimen varied according to the type of transplant: for haplo-SCT recipients Fludarabine+TBI (28%) and Thiotepa+Busulfan+fludarabine (TBF) (24%) were the most frequent MAC. In UCBT, Busulfan+Cyclophosphamide (Cy), or Cy+Fludarabine+TBI or TBF were used in 19%, 15% and 13% of patients, respectively.Haplo-SCT recipients did not receive any additional pharmacological post-transplant graft-versus-host disease (GvHD) prophylaxis, while CyclosporineA (CSA)+ steroids and CSA+mycophenolate mofetil were used in 38% and 32% of UCBT recipients.The 60-day probability of neutrophil engraftment was 91% vs 93% (p<0.05) for UCBT and haplo-SCT. The cumulative incidence (CI) of grade II-IV and grade III-IV acute (a) GvHD was 38% vs 12% (p<0.05) and 17% vs 4% (p<0.05) in UCBT and haplo-SCT recipients, respectively. The 2-year CI of relapse (RI) was similar following from UCBT and haplo-SCT (22% vs 25%, p=0.75), as well as non-relapse mortality (NRM) (18% vs 10%, p=0.07), respectively. Disease recurrence was the most common causes of death in both groups, with infections and GvHD being the most frequent transplant-related fatalities.According to donor type, no differences were found in overall survival (OS) (65% vs 68%, p=0.17) and leukemia-free survival (LFS) (61% vs 65%, p=0.24), while a lower GvHD-free, relapse-free survival (GRFS) was observed in UCBT compared to haplo-SCT (49% vs 60%, p<0.05). OS was 67% and 58% for patients with AML and ALL respectively, p=0.11.In multivariate analysis, UCBT was associated with higher risk of NRM (HR 2.36, p<0.05), while RI was not associated with type of allograft. Higher risk of grade II-IV aGVHD was observed in UCBT (HR 2.81, p<0.05), with no difference for cGVHD among the two groups (HR 0.68, p=0.31). OS (HR 1.52, p=0.10) and LFS (HR 1.28, p=0.28) were comparable between UCBT and haplo-SCT, while GRFS resulted lower for UCBT (HR 1.58, p<0.05). No others factors were associated with outcomes.Our results showed that RI, LFS, OS and cGVHD were comparable between UCBT and haplo-SCT recipients, while better NRM, aGVHD and GRFS were observed in patients transplanted from a family donor. These data confirm that alfa-beta T-cell and B-cell depleted haplo-SCT is a valid alternative for patients in need of an urgent allograft. Costs of manipulation in the haplo-SCT setting and costs of cord blood procurement should be further investigated. Technical expertise with this refined approach of graft manipulation and center experience are important to optimize patient's outcome. DisclosuresLocatelli:Miltenyi: Honoraria; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Bellicum: Consultancy, Membership on an entity's Board of Directors or advisory committees; bluebird bio: Consultancy; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees. Zecca:Chimerix: Honoraria. Bader:Medac: Patents & Royalties, Research Funding; Cellgene: Consultancy; Neovii: Research Funding; Riemser: Research Funding; Novartis: Consultancy, Speakers Bureau.

Impact of Graft Composition on Graft-Versus-Host Disease in Peripheral Blood HLA-Identical Sibling Transplants: Protective Role of CD8 Cell Dose

Introduction and Objective:Acute graft-versus-host disease (aGVHD) is a leading cause of transplant related mortality following allogeneic hematopoietic stem cell transplantation (HSCT). Data on the impact of graft composition, namely CD34 and T-cell subsets, and aGVHD is conflicting. We hypothesized an upper cell dose limit of CD34 would exist predictive of aGVHD without affecting engraftment and sought to explore T-cell subsets and their impact on aGVHD outcomes amongst peripheral blood progenitor cell (PBPC) HLA-identical sibling transplants (Allo-Sib).Methods:In an IRB approved protocol, consecutive Allo-Sib patients underwent HSCT for hematologic malignancy at our center from 1/2004 to 12/2012. Demographic and clinical data were prospectively collected and retrospectively confirmed. Patients received the entire D1 CD34 PBPC collection from their donors and from a second day of collection if necessary to achieve a dose of 4 x 106 CD34/kg cells. aGVHD prophylaxis was uniformly tacrolimus and mini-methotrexate. Tacrolimus was monitored to achieve a trough of 10-15 ng/ml. aGVHD was graded as per the International Bone Marrow Transplant Registry System. Exact binary logistic regression models were used to estimate the odds of aGVHD as a function of patient demographic and clinical data. For the association between cell counts and aGVHD, binary cut scores were determined by finding the point along the receiver operating characteristic curve that maximized sensitivity and specificity. Non-parametric Spearman correlation coefficients were used to estimate the association between CD34, CD3, CD4, and CD8 cell counts.Results:We analyzed 160 consecutive patients. In this mostly male (63%) population, median age was 51 and most patients underwent a myeloablative transplant (93%). Disease risk as per Armand et al 2012 was low 45%, intermediate 13.2%, and high 41.7%. Co-Morbidity Index by Sorror et al (HCT-CI) was 30.5% for 0, 33.8% for 1-2, and 35.8% for > 2. Sixteen patients (10%) developed grade II-IV aGVHD while 9 (6%) developed grade III-IV aGVHD. Median CD34 cell dose infused was 6.27 X 106/kg. Median CD3, CD4, and CD8 cell doses infused were 2.51 X 108/kg, 1.80 X 108/kg, and 0.66 X 108/kg, respectively. In univariate analysis, patients (n=67) receiving > 9.94 x 106 CD34/kg were 12 times more likely to develop grade III-IV aGVHD (odds ratio =12.308; p=0.01)(figure 1). Conversely, patients receiving > 0.50 x 108 CD8/kg were less likely to develop grade II-IV aGVHD (odds ratio = 0.30; p=0.049)(Figure 2), but not Grade III-IV aGVHD. The only other factor associated with aGVHD was a diagnosis of AML, which was protective (p=0.01). CD3 and CD4 cell counts did not correlate with aGVHD in our patient cohort. There was no correlation between engraftment and CD34, CD3, CD4, or CD8 cell dose. Finally, we found no direct correlation between CD34 cells counts and CD3, CD4, or CD8 cell counts.Conclusion:This study represents the largest evaluation examining the correlation between both infused CD34 cells and T-cell composition with aGVHD among patients undergoing strictly matched related donor HSCT. Importantly, the data demonstrates patients receiving > 10 x 106 CD34/kg have increased risk of developing clinically significant aGVHD, a dose that far exceeds adequate engraftment doses and serves now as a cap on CD34 cell dose in our program. Interestingly, our data suggests infusion of > 0.50 x 108 CD8/kg may protect from severe aGVHD whereas prior reports have demonstrated no association between CD8 cells and aGVHD. Further investigation is needed to better characterize the relationship between CD8 cells and aGVHD and better define the correlation between CD8 and CD34 cell doses in the development of aGVHD. DisclosuresNo relevant conflicts of interest to declare.

Significantly Improved Long Term Health Related Quality of Life (HRQL) and Neurocognition Following Familial Haploidentical Stem Cell Transplantation (HISCT) Utilizing CD34 Enrichment and Mononuclear (CD3) Addback in High Risk Patients with Sickle Cell Disease (SCD)

BackgroundSCD is a chronic debilitating disease secondary to frequent veno-occlusive events resulting in chronic organ damage, including cerebral vasculopathy, acute chest syndrome (ACS), pulmonary hypertension and a significantly shortened life-span (Bunn et al, NEJM, 1997; Lanzkron et al, PHR, 2013; Platt et al, NEJM, 1994). Importantly, SCD survivors also develop significant defects in neurocognition, especially processing speed and have a poor HRQL (Stotesbury et al, Neurology, 2018); Vichinsky et al, JAMA, 2010; Panepinto et al, BJH, 2005). To date the only cure for SCD patients has been HLA matched sibling AlloSCT following either myeloablative (MAC) or reduced toxicity conditioning (RTC), (Walters et al, NEJM, 1996; Bhatia/Cairo et al, BMT, 2014; Talano/Cairo et al, EJH, 2015; Gluckman et al, Blood, 2017). Unfortunately, only approximately 15% of patients have an unaffected HLA matched sibling donor (Mentzer et al, AJPHO, 1994). We previously demonstrated the safety and efficacy of CD34 enrichment and mononuclear cell (MNC) addback (2 x 105 CD3/kg) in pediatric matched unrelated donor recipients (Geyer/Cairo et al, BJH, 2012). We now report the long term results of MAC and familial HISCT utilizing CD34 enrichment and MNC (CD3) addback in high risk SCD recipients.MethodsSCD patients with one or more high risk features (cerebral vasculopathy, repetitive ACS, repetitive VOC, abnormal TCD requiring RBC TX) underwent MAC and parental HISCT consisting of hydroxyurea, azathioprine, fludarabine, busulfan, cyclophosphamide, thiotepa, r-ATG and TLI and PBSCT utilizing CD34 enrichment (10x106 CD34/kg) (Miltenyi®) and MNC addback (2x105 CD3/kg) and tacrolimus AGVHD prophylaxis x 100 days as we have previously described (Talano/Cairo et al, ASH, 2017). Donor chimerism in WBC and RBC (CD71) enriched fractions was determined centrally as we have previously described (Geyer/Cairo et al, BJH, 2012). AGVHD & CGVHD were determined utilizing the Glucksberg and NIH consensus criteria, respectively. Transthoracic echocardiogram, TRJ velocity, PFTs, MRI/MRA were performed at baseline and 2 years. Neurocognitive testing utilizing DIVERGT screening was performed at baseline and 2 years as we have previously described (Vichinsky et al, JAMA, 2010; Krull et al, JCO, 2008). HRQL testing utilized the CHRIS-General and CHRIs-HSCT (age appropriate) at baseline and Days +45, 100, 180, 365 and 730 post HISCT as we have previously described (Kelly/Parsons et al, PBC, 2012).ResultsAmong the 19 HISCT recipients, the mean±SEM age was 13.1±1.2 years (3.3-20.0) years, gender 12/7 (M/F). There were 18 parental haploidentical donors with mean±SEM age of 41.3±1.8 (30-55) years, gender 15/3 (F/M). The mean±SEM CD34 enriched PBSC infused was 10.94±0.4x106/kg and MNC addback (2 x 105 CD3/kg). The median time to neutrophil and platelet engraftment was day +9 and +19, respectively. The 1yr mean±SEM whole WBC and RBC (CD71) mixed donor chimerism was 97.1±1.4 and 96.4±2.0%, respectively. The cumulative incidence of grade II-IV AGVHD and CGVHD was 6.2% and 6.7%, respectively (Figure 1A). The probability of 1yr EFS was 90% (CI95 64-97%). In comparison from baseline to 2yr post HISCT, PFTs were stable to improved with a significant improvement in conductance (sGAW) (p<0.026), cardiac SF and TRJ velocity were stable to improved, MRI/MRA showed no new overt and/or silent strokes and no new cerebral vasculopathy. Intellectual functioning, memory, language, and executive function were also stable to improved. Most importantly, processing speed was significantly improved (p<0.026) (Figure 1B), emotional functioning (HRQL) (p<0.03) (Figure 1C) and physical functioning (HRQL) (p<0.01) (Figure 1D) were significantly improved at 2 years vs. pre-HISCT.ConclusionMAC and familial HISCT utilizing parental donors and CD34 enrichment and MNC addback (2 x 105 CD3/kg) in high risk patients with SCD was well tolerated, resulted in rapid hematological reconstitution, long term stable WBC and RBC (CD71) donor chimerism, low cumulative incidence of A+CGVHD and stable to improved pulmonary and cardiac function. There was also a significant improvement in processing speed and emotional and physical HRQL 2yrs post HISCT. This study was registered at clinicaltrials.gov (NCT02675959) and conducted under IND (14359) (MSC) and supported in large part by FDA R01FD004090. [Display omitted] DisclosuresCairo:Janssen: Research Funding. Parsons:Seattle Genetics: Research Funding. Friedman:MedImmune/AstraZeneca: Consultancy, Speakers Bureau. Vichinsky:Global Blood Therapeutics: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; bluebird bio: Membership on an entity's Board of Directors or advisory committees; Protagonist: Research Funding. Walters:Sangamo Therapeutics: Consultancy; bluebird bio: Research Funding; ViaCord Processing Lab: Other: Medical Director; AllCells Inc.: Other: Medical Director. Shenoy:Novartis, Vertex, Bluebird Bio: Honoraria, Membership on an entity's Board of Directors or advisory committees.

The Role of Anti-Thymocyte Globulin (ATG) in Patients with AML Transplanted in CR1 from Sibling and Unrelated Donors with or without Measurable Residual Disease (MRD) at the Time of Allogeneic Stem Cell Transplantation: A Study on Behalf of the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation

Background: Measurable residual disease (MRD) status pre-allogeneic stem cell transplantation (alloSCT) has been shown to predict outcome after transplant. Nonetheless, the impact of MRD persistence pre-alloSCT (MRD+) on transplant outcome might be modulated by relevant procedure features, such as conditioning intensity (Am J Hem 2018) or the use of anti thymocyte globulin (ATG) to prevent chronic graft versus host disease (cGVHD). Thus, since cGVHD is associated with graft versus leukemia effect (GVL), there is a concern that ATG may hamper GVL and increase relapse after transplant, especial in patients (pts) with a higher risk such as MRD+. For this purpose, we investigated whether MRD status pre-alloSCT modifies the effect of ATG on AML relapse post alloSCT in a large cohort of pts undergoing alloSCT in CR1, adjusting for other important variables on outcome.Methods: Inclusion criteria were adult AML pts with intermediate or adverse risk cytogenetics according to MRC and known FLT3-ITD status undergoing alloSCT in CR1 from either a HLA matched sibling (MSD) or (10/10) matched unrelated donors (MUD) during 2006-2017 period. First, we assessed the impact of MRD status, cytogenetics, FLT3-ITD and ATG as part of the conditioning in the whole population. Then, we studied the impact of ATG in accordance to MRD status at time of transplantation. Results are given at 2 years.Results: 1509 pts (1083 MRD negative (MRD-) and 426 MRD+) met the inclusion criteria. In the MRD- group, 552 (48%) pts did not receive ATG and 561 (52%) received ATG, whereas within MRD+ cohort, 187 (44%) received no ATG and 239 (58%) received ATG. Median age was 51 (range 18-73) years, 51% were females. Median year of alloSCT was 2014; 85% and 15% of the pts harbored intermediate and adverse risk cytogenetics, respectively. FLT3-ITD was identified in 51% of the pts, and NPM1 was mutated in 689 (56%). 59% of the pts underwent alloSCT from MSD while 41% from MUD. 82% of the pts received PB grafts; 58% received myeloablative (MAC) while 42% reduced intensity conditioning (RIC). The GVHD prophylaxis was CSA/MTX followed by CSA/MMF in the majority of the pts (75 %). 24% of pts developed grade II-IV while 7% grade III-IV acute (a) GVHD. cGVHD occurred in 30% of the pts, being extensive in half of them.In the overall population, aGVHD grade III-IV, cGVHD total and extensive were significantly lower in pts who received ATG in comparison to those who did not (6% vs 9%, p=0.04; 30% vs 45%, p<10-5; 15% vs 25%, p<10-4, respectively), translating into better GVHD-relapse-free survival (GRFS; 52% vs 43%, p=0.007). Non relapse mortality (NRM), relapse (RI), leukemia-free survival (LFS) and overall survival (OS) did not differ statistically between pts who received or did not receive ATG. Focusing on the influence of MRD status, RI was higher in MRD+ (39% vs. 23%, p<10-5), and LFS, OS and GRFS were all significantly superior in the MRD- cohort (66% vs 51% p<10-5; 73% vs 60% p=<10-5 and 51% vs 37% p<10-5, respectively). In contrast, NRM and GVHD did not differ between the groups.Then, we investigated the effect of ATG separately in MRD- and MRD+pts. By multivariate analysis, in MRD- pts, ATG did not affect RI (24% vs. 21% in no ATG and ATG; HR 0.80, P=0.17), but was associated with lower incidence of grade II-IV aGVHD, grade III-IV aGVHD, cGVHD, extensive cGVHD and NRM (HR 0.71 P=0.04, HR 0.37 P<10-3; HR 0.55 p<10-4, HR 0.42 P<10-4 and HR 0.66 p=0.05, respectively). As a consequence, ATG was associated with improved LFS, OS and GRFS (HR 0.74 P=0.02, HR 0.69 P=0.01 and HR 0.62 P<10-3). In MRD+ pts, ATG was associated with lower incidence of cGVHD and extensive cGVHD (HR 0.56 p= 0.03, HR 0.40 P=0.01, respectively), without a significant impact on any other alloSCT outcome parameters, including RI (39% vs 39% in no ATG and ATG; HR 1.02 P=0.92). FLT3 was associated with a higher RI in both MRD- and MRD+ pts. Finally, in both MRD- and MRD+groups, there was no interaction between ATG and cytogenetics, FLT3 and donor type as neither of these 3 factors influenced significantly the effect of ATG.Conclusions: ATG reduces severe (grade II-IV) acute and both chronic and extensive chronic GVHD in AML pts undergoing alloSCT in CR1, resulting in improved GRFS. Most importantly, the clinical benefit of ATG in terms of GVHD prevention was not achieved at the expense of an increased relapse incidence including in MRD+ pts pre-alloSCT. [Display omitted] DisclosuresMohty:MaaT Pharma: Consultancy, Honoraria.

Administration of Rimiducid Following Haploidentical BPX-501 Cells in Children with Malignant or Non-Malignant Disorders Who Develop Graft-Versus-Host-Disease (GvHD)

▪BackgroundAllogeneic Hematopoietic Stem Cell Transplantation (HSCT) constitutes a curative treatment for children with malignant and non-malignant disorders. HLA-partially matched haploidentical (haplo) donors represent a viable alternative option for those children who lack an HLA-compatible donor. T-cell depletion approaches with positive (CD34 selection) or negative selection (alpha/beta T-cell and CD19+ B-cell-depletion) may allow engraftment of donor cells with a low risk of GvHD; however, success is limited by delayed immune recovery, increasing the risk of fatal infections. Infusion of unmanipulated donor T cells (DLI) to accelerate immune recovery is associated with high risk of fatal GVHD. In contrast, adoptive transfer of donor T cells genetically manipulated to include a safety switch can be a suitable strategy to render DLI safer and more widely applicable.BPX-501 is an allogeneic product consisting of T cells modified to express the inducible caspase-9 (iC9) safety switch. The polyclonal natural of these modified T cells can provide viral immunity following stem cell transplant, with the unique ability to promptly and durably resolve GvHD symptoms following the administration of rimiducid, an inert, lipid-permeable compound that rapidly induces dimerization and activation of iC9, inducing apoptosis of the gene modified T cells.AimsTo evaluate the safety and efficacy of rimiducid in the treatment of GvHD following administration of BPX-501 T cells in pediatric patients with malignant or non-malignant disorders given an αβ T-cell receptor and B-cell depleted haplo-HSCT. A key objective of this study is to assess the activity of rimiducid infusion following onset of GvHD which is refractory to standard of care therapies.MethodsTwo multicenter (US [NCT03301168] and EU [NCT02065869]), prospective trials utilized αβ-T-cell and B-cell-depleted haplo-HSCT followed by infusion of a titrated number of donor lymphocytes genetically modified with iC9 (BPX-501 T cells) in patients with malignant or non-malignant disorders. BPX-501 T-cells were planned to be infused on day14+/-4 after the allograft. No post-transplant pharmacological GvHD prophylaxis was employed. Patients who develop GvHD resistant to conventional steroid therapy could receive ≥1 dose of dimerizing rimiducid to activate the iC9 safety gene.The efficacy evaluable population is defined as any patient who received ≥ 1 dose of rimiducid for the treatment of GvHD and had a follow up response assessment.ResultsAt the time of clinical cut-off (June 30th, 2018) 249 patients with a malignant (41.4%) or non-malignant disorder (58.6%) were enrolled. The conditioning regimens varied according to the original disease and were Treosulfan-based (14.9%), Busulfan-based (28.9%), TBI-based (34.9%) or other (19.3%). The donor was a parent in 229 children (92 %), a sibling in 17 (6.8 %), and a half-sibling in the remaining 3 (1.2 %). The median time to BPX-501 infusion was 18 days (10 - 66 days).Fifty-two patients developed Grade I-IV aGvHD (cumulative incidence [CI] 21.9 % [95% confidence interval (CoI): 16.7 - 27.2]). Twenty-six patients developed Grade II-IV aGvHD (CI 10.9 %). Five patients developed Grade III-IV aGvHD (CI 2.1 %). Eight patients developed cGvHD (CI of 4.6% [95% CoI: 1.3 - 7.8]).Twenty-one patients met the rimiducid efficacy evaluable population definition. An overall clinical response rate of 86% was observed. A CR or PR to rimiducid was observed in 12 and 6 patients, respectively. Median time to initial response was 2 days (1-61 days). Median number of doses received was 1 (1 - 2). At a median follow-up of 7.8 months (2.3 - 30.8 months), 77% of the initial responders were still in either complete (n=8) or partial response (n=6).ConclusionThese data suggest that administration of rimiducid for treatment of steroid-refractory GvHD represents a novel and highly effective treatment approach in pediatric patients with non-malignant or malignant disorders who received a αβ-T-cell and B-cell depleted haplo-HSCT followed by infusion of BPX-501 cells. The administration of rimiducid in children given BPX-501 T cells allows for effective control of GvHD occurring after the adoptive transfer of genetically modified T cells. DisclosuresSlatter:Medac: Other: Travel assistance. Merli:Neovii Biotech: Honoraria; AMGEN: Honoraria. Aldinger:Bellicum Pharmaceuticals, Inc.: Employment. Locatelli:Bellicum: Consultancy, Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Miltenyi: Honoraria; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; bluebird bio: Consultancy.

Outcomes of Salvage Haploidentical Transplant with Post-Transplant Cyclophosphamide for Rescuing Primary Graft Failure Patients : A Report By the SFGM-TC

Abstract Prognosis of graft failure patients is dismal, and another transplant is the sole option for long-term survival. Currently, there is no consensus concerning the best option for treating patients undergoing primary graft failure and finding a new donor within an acceptable delay is challenging. In the last years, haploidentical transplants with post-transplant cyclophosphamide (PT-Cy) have shown acceptable results in the treatment of many hematological diseases, including some cases of graft failure. To address the interest of haploidentical transplants as a salvage option in this context, we retrospectively collected and analyzed data from 26 primary graft failure (PGF) patients transplanted between 2011 and 2017 in 15 centers belonging to the Francophone Society for Bone Marrow Transplantation and Cellular Therapy (SFGM-TC). Inclusion criteria were the occurrence of PGF defined as non-achievement of a minimum absolute neutrophil count of 500/μL without evidence of disease relapse at D+28 after transplantation and the use of a haploidentical transplantation with PT-Cy as graft-versus-host-disease (GvHD) prophylaxis. Continuous variables are presented as medians and inter-quartile range. They were compared between groups using the Wilcoxon rank sum. Categorical variables are presented with counts and percentages and were compared using the Fisher exact test. All tests were 2-sided, and a p-value below 0.05 was considered to be significant. Analyses were performed using the R statistical platform (version 3.4.1). This study was performed according to the Declaration of Helsinki and was approved by the SFGM-TC scientific council. Nineteen patients had a diagnosis of myeloid malignancy (8 acute myeloid leukemias, 4 myelodysplastic syndromes, 4 myeloproliferative neoplasms, 1 unclassified myeloid disorder), 3 had a lymphoid neoplasm, and 4 had a bone marrow failure syndrome (2 acquired and 2 congenital). Twenty-four patients had previously received an allogeneic transplantation, and 2 had already failed two previous allogeneic transplants. Male/female ratio was 2.25. Median age at haploidentical transplant was 42 years (2-58). Fifteen patients received peripheral blood as stem cell source, and 11 received bone marrow. Eleven transplants were female to male. Twelve patients received an ABO-matched graft, 6 had a major ABO-incompatibility, 7 a minor incompatibility and one missing data. The median number of infused CD34+ cells was 5.2 x106/kg (1.2 - 12.5). There was no ex-vivomanipulation of cells. CMV matching was available for 22 transplantations, of which 6 were high-risk (seropositive recipient with a seronegative donor). Fludarabine-based reduced intensity conditioning was used in all but one patient who received clofarabine + 4Gy TBI. Twenty patients received TBI 2Gy. Three patients received ATG. Fourteen patients received the Baltimore regimen (53%). The median delay between the previous and the salvage transplantation was 77 days (39-1161). All patients received PT-Cy associated with cyclosporine, and 24 patients also received MMF for GvHD prophylaxis. Median follow up was 487 (16-2010) days. The cumulative incidence (CI) of neutrophil recovery at day 30 was 81%, and the median time to neutrophil engraftment was 19 (13-34) days. Four patients (15%) presented primary graft failure and died within a median time of 5 (3-8) weeks after transplantation of infectious complications. Cumulative incidence of grade II-IV aGvHD at day-100 was 13%, and 1-year CI of cGvHD was 32%. One-year CI of relapse was 16%. Overall survival was 58% at 1 year (Figure 1; confidence interval: 39-85). Among the 22 patients who engrafted, 6 patients died. HSCT complications accounted for 80% of the causes of deaths (4 multiorgan failure, 1 GvHD, 1 interstitial pneumonitis, 1 bacterial infection, 1 post-transplant lymphoproliferative disorder). To the best of our knowledge, this is the first cohort describing the outcomes of haploidentical transplants with PT-Cy rescuing patients with primary graft failure. Our cohort presents promising outcomes in a particularly challenging situation, suggesting that haploidentical transplants with PT-Cy might appear as a valid salvage strategy for patients with PGF. Prospective well-designed trials are urgently needed before the inclusion of Haplo-PT-Cy in the treatment strategy of patients with PGF. Figure 1. Figure 1. Disclosures Mohty: MaaT Pharma: Consultancy, Honoraria. Peffault De Latour:Pfizer Inc.: Consultancy, Honoraria, Research Funding; Alexion Pharmaceuticals, Inc.: Consultancy, Honoraria, Research Funding; Amgen Inc.: Research Funding; Novartis: Consultancy, Honoraria, Research Funding.

The effect of NIMA matching in adult unrelated mismatched hematopoietic stem cell transplantation - a joint study of the Acute Leukemia Working Party of the EBMT and the CIBMTR.

Hematological malignancies can be cured by unrelated donor allogeneic HSCT and outcomes are optimized by high-resolution HLA matching at HLA-A, -B, -C, -DRB1 and -DQB1 (10/10 match). If a 10/10 match is unavailable, 9/10 matches may be suitable. Fetal exposure to non-inherited maternal antigens (NIMA) may impart lifelong NIMA tolerance modulating the immune response, as shown in adult haploidentical transplantation. In cord blood transplantation, NIMA matching lowered rates of aGvHD and TRM; in haploidentical transplantation, sibling donors with non-shared maternal antigens showed less grade II-IV aGvHD. This retrospective analysis examined if 9/10 matched unrelated donor HSCT benefits from NIMA matching. DKMS contacted 1,735 donors and obtained 733 (42%) maternal samples. NIMA-matched and -mismatched cases with a minimum follow-up of 1 year were compared by univariate and multivariate analyses adjusted for co-variates for OS, DFS, relapse, TRM and a/cGvHD. The study population (N = 445) comprised 31 NIMA-matched and 414 NIMA-mismatched cases. No significant differences between NIMA-matched and NIMA-mismatched groups were found for any outcomes with similar OS and TRM rates within both groups. This study provides the proof of principle that NIMA matching is possible in the unrelated donor HSCT setting; larger studies may be able to provide significant results.

Effect of Graft Composition on Acute Graft-Versus-Host Disease in Aplastic Anemia after Haploidentical Hematopoietic Stem Cell Transplantation

To investigate the relationship between acute graft-versus-host disease and graft composition in patients with aplastic anemia(AA) after haploidentical hematopoietic stem cell transplantation. Fifty-seven cases of AA after haploidentical hematopoietic stem cell transplantation were retrospectively analyzed. All the patients were divided into 2 groups according to whether presence or absence grade Ⅱ-Ⅳ aGVHD, the relationship between aGVHD and graft composition was analyzed by comparing the differences of graft components between the 2 groups. Fourteen out of 57 patients had grade Ⅱ-Ⅳ aGVHD and the other 43 did not have grade Ⅱ-Ⅳ aGVHD. The mononuclear cells, CD3+, CD4+, CD8+, NK cells, NKT cells, B cells and Treg cells were not significantly different between the 2 groups (P>0.05), the CD34+ cell count in the patients with grade Ⅱ-Ⅳ aGVHD was 3.85（1.73-10.61）×106/kg, which was significantly lower than that without grade Ⅱ-ⅣaGVHD: 6.31（2.98-19.35）×106/kg (P<0.05). The incidence of grade Ⅱ-Ⅳ aGVHD may be related with CD34+ cell count in AA after haploidentical hematopoietic stem cell transplantation..

Associations between febrile neutropenia-related parameters and the risk of acute GVHD or non-relapse mortality after allogeneic hematopoietic stem cell transplantation.

Infection and inflammation can induce acute graft-vs.-host disease (aGVHD). We hypothesized that febrile neutropenia early after allogeneic hematopoietic cell transplantation (HCT) would increase the risk of aGVHD and non-relapse mortality (NRM). We retrospectively evaluated the impact of fever, C-reactive protein (CRP) concentration and blood stream infection (BSI) early after HCT on the incidence of grade II-IV aGVHD and NRM in 227 patients. Within 7 days after HCT, 91 (40.1%) patients experienced fever for at least 2 days (early-FN group). BSI occurred in 27 (11.9%) patients and the maximum CRP concentration was 2.57 mg/dl in the median. In a multivariate analysis, early-FN (hazard ratio (HR) 1.81, P = 0.007) and older recipient age (HR 1.68, P = 0.019) were significantly associated with the incidence of grade II-IV aGVHD. High-CRP and BSI were not significant risk factors for grade II-IV aGVHD. On the other hand, high-CRP was significantly associated with the incidence of NRM (HR 2.67, P = 0.004) in a multivariate analysis. In conclusion, although fever, CRP elevation and BSI are considered to be closely related events, they had different effects on the incidence of aGVHD and NRM. The development of early-FN after HCT may predict the risk of aGVHD.

Recipient single nucleotide polymorphisms in Paneth cell antimicrobial peptide genes and acute graft-versus-host disease: analysis of BMT CTN-0201 and -0901 samples.

Host genetics shape the gut microbiota, and gut dysbiosis increases the risk of acute graft-versus-host disease (aGVHD). Paneth cells and microbiota have interactions that contribute to immune regulation. α-defensin-5 (HD5) and regenerating islet-derived protein 3 alpha (Reg3A) are the most abundant Paneth cell antimicrobial peptides (AMPs). We hypothesized that single nucleotide polymorphisms (SNPs) in the genes for HD5 (DEFA5) and Reg3A (REG3A) predict aGVHD risk. We analysed pre-transplant recipient peripheral blood mononuclear cell samples from randomized Blood and Marrow Transplant Clinical Trials Network (BMT CTN) studies 0201 (94 patients with bone marrow and 93 with peripheral blood grafts) and 0901 (86 patients with myeloablative and 77 with reduced-intensity conditioning; all using peripheral blood grafts). In multivariable analysis (with a SNP×graft source interaction term in CTN-0201 and a SNP×conditioning intensity term in CTN-0901), DEFA5 rs4415345 and rs4610776 were associated with altered incidence of aGVHD grade II-IV [rs4415345 G vs. C: hazard ratio (HR) 0·58, 95% confidence interval (95% CI) 0·37-0·92, P=0·02; rs4610776 T vs. A: HR 1·53, 95% CI 1·01-2·32, P=0·05] in CTN-0201, but not CTN-0901, suggesting a stronger effect in bone marrow allografts. REG3A SNP was not associated with aGVHD. Host genetics may influence aGVHD risk by modulating Paneth cell function.

Soluble interleukin-27 receptor alpha is a valuable prognostic biomarker for acute graft-versus-host disease after allogeneic haematopoietic stem cell transplantation

Acute graft-versus-host disease (aGVHD) is a major life-threatening complication after allogeneic haematopoietic stem cell transplantation. Interleukin-27 receptor alpha (IL-27Rα) is a co-receptor of IL-27, an inflammatory cytokine that possesses extensive immunological functions. It has been reported that IL-27Rα can exist in its soluble form (sIL-27Rα) in human serum and can function as a natural IL-27 antagonist. In this study, we examined serum sIL-27Rα levels and evaluated their prognostic value in aGVHD. A total of 152 subjects were prospectively recruited and separated into the training group (n = 72) and the validation group (n = 80). Serum sIL-27Rα at neutrophil engraftment was measured by ELISA. In the training set, a cut-off value of sIL-27Rα = 59.40 ng/ml was identified to predict grade II–IV aGVHD (AUC = 0.735, 95% CI 0.618–0.853, P = 0.001). Cumulative incidences of grade II–IV aGVHD (P = 0.004), relapse rate (P = 0.008), and non-relapse mortality (P = 0.008) in patients with low serum sIL-27Rα (≥59.40 ng/ml) were significantly higher than those of patients with high serum sIL-27Rα (<59.40 ng/ml). Multivariate analysis confirmed that low sIL-27Rα level (HR = 2.83 95% CI 1.29–6.19, P < 0.01) was an independent risk factor for predicting grade II-IV aGVHD. In addition, serum sIL-27Rα was positively correlated with IL-27 (R = 0.27, P = 0.029), IL-10 (R = 0.37, P = 0.0015) and HGF (R = 0.27, P = 0.0208), but was negatively correlated with TNFR1 (R = −0.365, P = 0.0022) and ST2 (R = −0.334, P = 0.0041), elafin (R = −0.29, P = 0.0117), and REG3α (R = −0.417, P = 0.0003). More importantly, the threshold value of sIL-27Rα was then validated in an independent cohort of 80 patients (AUC = 0.790, 95% CI 0.688–0.892, P < 0.001). Taken together, our findings suggested that serum sIL-27Rα at neutrophil engraftment maybe a valuable prognostic biomarker in predicting the incidence of moderate-to-severe aGVHD.

Prediction of acute GVHD and relapse by metabolic biomarkers after allogeneic hematopoietic stem cell transplantation.

There are very few studies investigating metabolic biomarkers to predict acute graft-versus-host disease (aGVHD) after allogeneic hematopoietic stem cell transplantation (HSCT). Metabolic models can provide a framework for analyzing the information-rich omics data sets in this setting. Four hundred and fifty-six samples from one hundred and fourteen consecutive patients who underwent HSCT from January 2012 to May 2014 were collected for this study. The changes in serum metabolite levels were investigated using a gas chromatography-mass spectrometry-based metabolomics approach and underwent statistical analysis. Significant metabolic changes were observed on day 7. The stearic acid/palmitic acid (SA/PA) ratio was effective in the diagnosis of grade II-IV aGVHD. Multivariate analysis showed that patients with high SA/PA ratios on day 7 after HSCT were less likely to develop II-IV aGVHD than patients with low SA/PA ratios (odds ratio [OR] = 0.06, 95% CI 0.02-0.18, P < 0.001). After the adjustment for clinical characteristics, the SA/PA ratio had no significant effect on overall survival (hazard ratio [HR] = 1.95, 95% CI 0.92-4.14, P = 0.08), and patients in the high SA/PA ratio group were significantly more likely to relapse than those in the low ratio group (HR = 2.26, 95% CI 1.04-4.91, P = 0.04). Our findings suggest that the SA/PA ratio on day 7 after HSCT is an excellent biomarker to predict both aGVHD and relapse. The serum SA/PA ratio measured on day 7 after transplantation may improve risk stratification for aGVHD and relapse after allogeneic stem cell transplantation. National Natural Science Foundation of China (81470346, 81773361), Priority Academic Program Development of Jiangsu Higher Education Institutions, Jiangsu Natural Science Foundation (BK20161204), Innovation Capability Development Project of Jiangsu Province (BM2015004), Jiangsu Medical Junior Talent Person award (QNRC2016707), and NIH (AI129582 and NS106170).

Influence of donor-recipient sex matching on outcomes of haploidentical hematopoietic stem cell transplantation for acute leukemia

目的观察供受者性别组合对单倍体相合造血干细胞移植（haplo-HSCT）治疗急性白血病预后的影响。方法回顾性分析2002年4月至2014年12月在北京大学血液病研究所接受haplo-HSCT的1 160例急性白血病患者的临床资料，根据供受者性别组合分为供受者性别相合组、不合组，并进一步分为男供男、女供男、女供女、男供女4个亚组。比较各组移植后造血重建、移植物抗宿主病（GVHD）、复发、非复发死亡率（NRM）、无病生存（DFS）以及总生存（OS）情况，并行单因素及多因素分析。结果供受者性别不合组3、5年累积NRM均高于性别相合组[21.7%（95%CI 20.4%~23.0%）对15.8%（95% CI 14.8%~16.8%），P=0.010；22.6%（95% CI 21.1%~24.1%）对16.8%（95% CI 15.8%~17.8%），P=0.013]，其他预后指标差异无统计学意义。女供男组与男供男组比较，3年及5年NRM较高[25.5%（95%CI 23.2%~27.8%）对16.1%（95%CI 14.9%~17.3%），P=0.002；27.1%（95%CI 24.7%~29.5%）对17.3%（95% CI 15.9%~18.7%），P=0.002]，5年DFS率、3年OS率较低[56.9%（95% CI 51.2%~63.0%）对64.4%（95%CI 60.0%~69.0%），P=0.044；62.6%（95%CI 57.1%~68.5%）对69.8%（95%CI 65.7%~74.2%），P=0.045]，3年DFS率及5年OS率差异无统计学意义（P>0.05），Ⅱ~Ⅳ度急性GVHD、慢性GVHD累积发生率差异无统计学意义（P>0.05）。女供女组与男供女组比较，Ⅱ~Ⅳ度急性GVHD累积发生率较高[43.9%（95%CI 40.5%~47.3%）对34.6%（95%CI 31.7%~37.5%），P=0.047]，慢性GVHD累积发生率、复发率、NRM、DFS率、OS率差异均无统计学意义（P>0.05）。多因素分析显示女供男性别组合是影响NRM、OS的独立危险因素。结论女供男是haplo-HSCT治疗急性白血病预后较差的性别组合，男性患者应优先选择男性供者。

Impact of mycophenolate mofetil prophylaxis duration on acute graft-versus-host disease after haploidentical stem cell transplantation

目的分析霉酚酸酯（MMF）预防疗程对于“北京方案”单倍体相合造血干细胞移植（haplo-HSCT）后急性移植物抗宿主病（GVHD）的影响。方法回顾性分析2016年9月至2017年3月在北京大学血液病研究所接受haplo-HSCT的237例标危成人（≥14岁）血液肿瘤患者，男140例（59.1%），女97例（40.9%），中位年龄30（14~60）岁。根据MMF疗程分为长疗程组（MMF 500 mg/d口服，−9 d开始，+30 d减半，+45~+60 d停药，合并CMV血症、EBV血症或迟发出血性膀胱炎者提前停用）和短疗程组（MMF 500 mg/d口服，−9 d开始，中性粒细胞植活后停药）。结果长疗程组（102例）、短疗程组（135例）MMF中位用药时间分别为27（7~71）、15（9~24）d。两组患者在性别、年龄、疾病类型、HLA不合位点、供受者关系、供受者血型、供者性别、供者年龄方面差异均无统计学意义。长疗程组、短疗程组Ⅱ~Ⅳ度急性GVHD发生率分别为31.1%、17.6%（P=0.018）、Ⅲ/Ⅳ度急性GVHD发生率分别为7.4%、7.8%（P=0.900）。多因素分析未发现MMF预防疗程长短对Ⅱ~Ⅳ度急性GVHD有显著影响。两组CMV血症、EBV血症、出血性膀胱炎发生率及总生存率差异均无统计学意义（P值均>0.05）。结论短疗程MMF预防并未增加“北京方案”haplo-HSCT患者急性GVHD发生率，对总生存亦无显著影响，可能是一种安全可行的方案。

Application of low-dose ATG for GVHD prophylaxis in patients undergoing PBSCT aged over forty years old

目的探讨在供、受者年龄均≥40岁同胞相合外周血干细胞移植（MSD-PBSCT）移植物抗宿主病（GVHD）预防方案中增加低剂量抗胸腺细胞球蛋白（ATG）的效果。方法回顾性分析2013年3月至2017年4月行MSD-PBSCT且供、受者年龄均≥40岁恶性血液病患者的临床资料。43例患者在常规急性GVHD预防方案（环孢素A或他克莫司联合短疗程甲氨蝶呤）中加入ATG 1.5 mg·kg−1·d−1×3 d（ATG组），55例患者应用常规GVHD预防方案（对照组）。结果①ATG组中性粒细胞植入中位时间短于对照组[13（11~17）d对14（12~24）d，P=0.001]，血小板植入中位时间差异无统计学意义[14（11~43）d对15（11~42）d，P=0.071）]。②ATG组+100 d内急性GVHD累积发生率低于对照组[25.6%（95%CI 13.7%~39.3%）对49.1%（95%CI 35.2%~61.6%），P=0.018]，Ⅱ~Ⅳ度急性GVHD、慢性GVHD发生率差异无统计学意义[18.6%（95%CI 8.6%~31.5%）对23.6%（95%CI 13.4%~35.6%），P=0.509；49.6%（95%CI 31.6%~65.3%）对56.4%（95%CI 41.4%~69.0%），P=0.221]。③ATG组与对照组移植后1年巨细胞病毒血症累积发生率差异无统计学意义[21.1%（95%CI 10.3%~34.5%）对31.1%（95%CI 18.8%~44.2%），P=0.429]。④ATG组及对照组移植后2年累积复发率[24.0%（95%CI 11.5%~38.9%）对24.0%（95%CI 12.1%~38.2%），P=0.608]、非复发死亡率[10.2%（95%CI 3.1%~22.1%）对21.6%（95%CI 9.4%~37.0%），P=0.411]及无病生存率[65.8%（95%CI 50.3%~81.3%）对54.4%（95%CI 37.7%~71.1%），P=0.955]差异均无统计学意义，但ATG组移植后2年总生存率优于对照组[83.8%（95%CI 71.8%~90.0%）对58.0%（95%CI 42.2%~73.9%），P=0.019]。结论对于年龄较大的MSD-PBSCT患者，在常规GVHD预防方案基础上加入低剂量ATG可以显著降低移植后急性GVHD发生率、改善OS率，病毒感染发生率和复发率无明显增加。

Interleukin-27: a biomarker for prediction of acute graft-versus-host disease after allogeneic hematopoietic stem cell transplantation from unrelated donors

Objective To analyze the predictive value of serum interleukin-27 (IL-27) for acute graft-versus-host disease (aGVHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) from unrelated donors. Methods Serum samples were collected from 72 patients after receiving allo-HSCT from unrelated donors during January to December 2012. Serum samples collected from 70 patients received allo-HSCT in 2013 were used for confirmation. All patients received myeloablative conditioning regimen prior to allo-HSCT. Cyclosporin A (CsA)+ mycophenolate mofetil (MMF)+ short-term methotrexate (MTX) were used for GVHD prophylaxis. Serum IL-27 levels in patients with aGVHD were measured by ELISA. The predictive value of IL-27 index, defined as the ratio of serum IL-27 level at neutrophil engraftment to that before pre-conditioning regimen, for allogeneic HSCT was retrospectively analyzed. Results Serum IL-27 index was significantly decreased in patients with grade Ⅱ-Ⅳ aGVHD (grade 0-Ⅰ∶1.89±0.68 vs grade Ⅱ-Ⅳ∶1.26±0.49; P<0.000 1). IL-27 index had good value for grade Ⅱ-Ⅳ aGVHD (AUC=0.782, 95% CI: 0.675-0.889, P<0.001). Patients with a lower serum IL-27 index (<1.33) were more likely to have a higher cumulative incidence of grade Ⅱ-Ⅳ aGVHD than those with a higher serum IL-27 index (P<0.001). Multivariate analysis confirmed that low IL-27 index was the most significant risk factor for grade Ⅱ-Ⅳ aGVHD (HR=4.50, 95% CI: 2.1-9.8, P<0.01). These findings were consistent with the results found in the serum samples collected in 2013. Conclusion Low IL-27 index could be used to predict the incidence of grade Ⅱ-Ⅳ acute GVHD after allo-HSCT from unrelated donors. Key words: Biomarker; Graft-versus-host disease; IL-27; Unrelated donor transplantation

Impact of cyclosporine‐A concentration in T‐cell replete haploidentical allogeneic stem cell transplantation

This paper aims to study whether cyclosporine-A (CSA) levels have an impact on the clinical outcome of patients with T-cell replete haploidentical allogeneic hematopoietic stem cell transplantation (allo-HSCT). We analyzed 140 consecutive patients who had been given T-cell replete haploidentical allo-HSCT in our institute to assess the effect of CSA concentration in the early stages of allo-HSCT on clinical outcomes, such as hematopoietic recovery, acute graft vs host disease (aGVHD), infection, disease-free survival (DFS), and overall survival (OS). The median concentrations of CSA in the blood in the 1st, 2nd, 3rd, and 4th week after allo-HSCT were 218, 235, 263, and 270ng/mL, respectively. Additionally, 46%, 40%, 27%, and 18% of the patients had CSA blood levels below 200ng/mL during those weeks. In total, 39 patients developed aGVHD (grade II-IV), for a cumulative incidence of 27.8%, at a median of 32days. Patients having a low CSA concentration (below 200ng/mL) in the 3rd week had a higher cumulative incidence of grade II-IV aGVHD (P=.02). In addition, multivariate logistic regression analysis showed that low CSA concentration (below 200ng/mL) in the 3rd week was an independent risk factor of grade II-IV aGVHD (P=.02; odds ratio=2.66; 95% CI, 1.15-6.17). However, CSA levels during the first 4weeks did not have a significant impact on the patients' hematopoietic recovery, infection, DFS, and OS. Our data indicated that adequate management of CSA levels during the peri-engraftment period might improve clinical outcomes for those with T-cell replete haploidentical allo-HSCT.

Allogeneic Stem Cell Transplantation for Advanced Myelodysplastic Syndrome: Comparison of Outcomes between CD34+ Selected and Unmodified Hematopoietic Stem Cell Transplantation

In this study, we compared transplantation outcomes of allogeneic hematopoietic stem cell transplantation (HSCT) in patients with advanced myelodysplastic syndrome (MDS) who received a CD34+ cell-selected and those who received an unmodified allograft. This analysis initially included 181 patients, 60 who received a CD34+ cell-selected transplant and 121 who received an unmodified transplant. Owing to significant differences in disease characteristics, the analysis was limited to patients with <10% blasts before HSCT (n = 145). Two groups were defined: low risk, with low- and intermediate-risk cytogenetics (CD34+, n = 39; unmodified, n = 46), and high risk: poor and very poor risk cytogenetics (CD34+, n = 19; unmodified, n = 41). In the low-risk group, the incidence of grade II-IV acute graft-versus-host disease (aGVHD) at 1 year post-transplantation was 18% in the CD34+ subgroup versus 41.3% in the unmodified subgroup (P = .015). There were no differences between the subgroups in the incidence of grade III-IV aGVHD. The incidence of chronic graft-versus-host disease (cGVHD) at 3 years in the 2 subgroups was 5.3% and 56%, respectively (P < .001). At 3 years post-transplantation, relapse, overall survival (OS), and relapse-free survival (RFS) were similar in the CD34+ and unmodified subgroups: 8.1% versus 19.4% (P = .187), 58.5% versus 53.7% (P = .51), and 59.5% versus 52.4% (P = .448). However, the composite outcome combining extensive cGVHD-free status and relapse-free status (CRFS) at 3 years was 59.5% in the CD34+ group versus 19.2% in the unmodified group (P < .001). In the high-risk group, grade II-IV aGVHD at 1 year was 31.6% in the CD34+ subgroup versus 24.4% in the unmodified subgroup (P = .752). There were no differences between the subgroups in the incidence of grade III-IV aGVHD. The incidence of cGVHD at 3 years in the 2 subgroups was 0% versus 27.6% (P = .013). At 3 years post-transplantation, relapse, OS, RFS, and CRFS in the 2 subgroups were 31.6% versus 69.3% (P = .007), 35.5% versus 14.5% (P = .068), 31.6% versus 10.7% (P = .045), and 31.6% versus 6.1% (P = .001), respectively. Cytogenetic abnormalities at diagnosis and transplant type had significant univariate associations with RFS in the high-risk cohort. Only cytogenetics (P = .03) remained associated with this outcome in a multivariate model. OS was similar in the 2 transplant groups; however, CRFS was superior in the CD34+ cell-selected transplant group.