GVL Effect Research Articles

Female-to-male allogeneic transplantation affects outcomes differently according to the type of haplo-transplantation

Allogeneic hematopoietic stem cell transplantation from a female donor to a male recipient (female-to-male allo-HCT) is a well-established risk factor for chronic graft-versus-host disease (GVHD) and non-relapse mortality (NRM). The inferior outcomes of female-to-male allo-HCT are considered to be due to allo-immunity against H-Y antigens. However, the influence of minor histocompatibility antigens in haplo-identical allo-HCT remains to be elucidated. We investigated the impact of female-to-male allo-HCT according to the haplo-HCT subtype. In the post-transplant cyclophosphamide (PTCY) cohort (n = 660), a female-to-male sex-mismatch was significantly associated with a decreased risk of relapse (HR: 0.70 [95% CI: 0.49–0.99], P = 0.045), but not with overall survival (OS) or NRM (HR: OS 0.89 [95% CI: 0.68–1.16], P = 0.40; NRM 0.98 [95% CI: 0.68–1.41], P = 0.90). On the other hand, in the non-PTCY cohort (n = 219), a female-to-male sex-mismatch was associated with inferior risks of OS and NRM, but was not associated with relapse. These results suggested that the survival impact of the haplo-HCT subtype differed according to the presence of a sex-mismatch. PTCY might be feasible for overcoming the inferiority of female-to-male allo-HCT and might preserve a GVL effect against H-Y antigens.

Early recovery of natural killer cells post T-cell depleted allogeneic stem cell transplantation using alemtuzumab “in the bag”

BackgroundAllogeneic stem cell transplantation (SCT) is a critical therapy for haematological malignancy but may lead to acute and chronic graft versus host disease (GvHD). T-cell depletion with alemtuzumab, either in vivo or ex vivo, reduces the incidence of GvHD but is a risk factor for disease relapse and poor immune reconstitution. Natural killer (NK) cells are the first lymphocytes to recover. Classical NK cells make up >90% of the normal circulating population and can directly kill neoplastic or virally infected cells while the regulatory subset makes up <10%, secretes cytokines and is not cytotoxic. The recovery and balance of these subsets post SCT remains controversial, with most studies analysing patients who received unmanipulated grafts and in vivo immunosuppression. ObjectiveThe aim was to assess the early recovery of NK cells in 18 consecutive patients receiving ex vivo T-cell depleted SCT and to compare the results to 25 individuals receiving haploidentical non-T cell depleted grafts. MethodsAll patients received myeloablative conditioning. After stem cell collection, the stem cells of the T cell depleted group were treated “in the bag” with alemtuzumab (CAMPATH 1H) at a concentration of 1mg/108 mononuclear cells and thereafter immediately infused. For those receiving non-T cell depleted grafts, GvHD prophylaxis was with post infusion therapeutic doses of cyclophosphamide. Blood samples were collected at days 21, 28 and 90. Complete blood counts were performed on an automated analyser while lymphocyte and NK subsets were examined using multiparameter flowcytometry. NK cells were defined as lymphocytes which were CD3-/CD56+. The classical subset was recognised as CD56dim/CD16+ while the regulatory population as CD56bright/CD16-. The results for both transplant types were compared at all time points using SPSS v8 statistical software. ResultsThe recovery of lymphocytes was slow in both groups. Those receiving non-T cell depleted grafts had significantly higher T cell counts at day 21 and 28 when compared to the T cell depleted group (P < 0.05). In contrast, NK cells in the ex vivo T-cell depleted patients recovered rapidly and by day 21 was no different to normal (p > 0.05), while the non-T cell depleted group had significantly decreased numbers (p < 0.001), only recovering at day 90. Both groups had abnormal NK cell subset ratios with significantly elevated percentages of regulatory cells (p < 0.05). However, significant differences were observed between the two groups with those receiving T cell depleted grafts having lower percentages of regulatory cells as well as higher numbers of classical NK cells at day 21 and 28 (p < 0.01). ConclusionThis study of ex vivo T-cell depleted SCT's demonstrates that NK cells recover quicker when compared to those receiving unfractionated grafts. These results may have implications for GvHD and the GvL effect which warrants further study.

Cellular Strategies for Separating GvHD from GvL in Haploidentical Transplantation.

GvHD still remains, despite the continuous improvement of transplantation platforms, a fearful complication of transplantation from allogeneic donors. Being able to separate GvHD from GvL represents the greatest challenge in the allogeneic transplant setting. This may be possible through continuous improvement of cell therapy techniques. In this review, current cell therapies are taken into consideration, which are based on the use of TCR alpha/beta depletion, CD45RA depletion, T regulatory cell enrichment, NK-cell-based immunotherapies, and suicide gene therapies in order to prevent GvHD and maximally amplify the GvL effect in the setting of haploidentical transplantation.

Abatacept and Ptcy Based Gvhd Prophylaxis with CNI/Sirolimus for Haploidentical HCT: Donor KLRC2 Genotype Impacts Outcome

Background: Abatacept (Abata, CTLA4Ig), an inhibitor of a key T cell costimulation pathway has recently been approved for GVHD prophylaxis following unrelated donor HCT in combination with CNI/MTX. In 2015, we had developed a novel protocol combining Abata and PTCy for HCT from haploidentical family donors (HFD). We analysed the impact of donor immunogenetics and immune reconstitution on the long-term outcome of 182 patients receiving HFD-HCT on this protocol. Methods: In patients with nonmalignant diseases (NMD), Abata was administered on days 0, +5, +20, +35 and every 4 weeks thereafter until day +180. PTCy was administered at 50 mg/kg on days +3 and +4 and sirolimus was given from day -7 to 9 months post-HCT (AbaCyS protocol). In those with malignant diseases (MD), PTCy was administered as usual and Abata was administered on day 0 followed by PBSC infusion and on days+7, +21 and +35, followed 6 hours later by donor lymphocyte infusions (DLI). Cyclosporin was administered from day +5 to day +60 (AbaDCyC protocol). NK cell related immunogenetic parameters (KIR genotype/ KIR-ligand/ HLA-B leader peptide dimorphism/ KLRC2 genotype encoding NKG2C receptor, [KLRC2 deletion (del) vs wildtype (wt]) and T and NK cell subset reconstitution were analysed with respect to primary (OS, NRM, Relapse) and secondary (acute &amp; chronic GVHD, CMV reactivation and GVHD &amp; Event-free survival (GVHEFS) endpoints. Results: Primary graft failure was seen in 2/46 with NMD and 1/136 with MD, with median time to engraftment being 16 days (12-26). No secondary graft failure was observed. Incidence of aGVHD 2-4 was 8.5%, 4.7% in NMD and 9.8% in MD (p=0.3). Donor KLRC2del (D-KLRC2del) genotype was the only risk factor (33.8%{12/38} vs 2.2%{3/144} in dKLRC2wt, p&amp;lt;0.001, Figure-1) for aGVHD. This translated to a significantly improved NRM (overall 9.5%) in dKLRC2wt group (5.2% vs 28.9% in dKLRC2del, p&amp;lt;0.001). Incidence of cGVHD (mostly mild-moderate) was 15.3% and was not impacted by NMD vs MD or KLRC2 genotype. Relapse incidence (RI) was 21.4%, with no impact of pretransplant disease status (DRI low vs high) or any immunogenetic factors apart from KIR haplotype (lower RI in donor KIR B haplotype, p=0.01). OS was 84.3% at a median follow-up of 4 years, with a significant impact of dKLRC2 genotype (90% in wt vs 63% in del, p&amp;lt;0.001, Figure-2). The overall GVHEFS was 70% and this was also impacted by dKLRC2 genotype (38.2% vs 77.8%in dKLRC2wt, p&amp;lt;0.001). None of the other immunogenetic parameters had any impact on the outcome. T cell subset reconstitution was robust in both groups, predominantly of memory phenotype, which tended to be more rapid with AbaDCyC protocol in MD. However, recovery of Tregs was more rapid with AbaCyS protocol in NMD and the kinetics of Treg recovery positively correlated with reduced cGVHD in this group. Even though NK cell maturation was brisk in both groups, this was prompter at day+30 in the AbaDCyC protocol group. More importantly, kinetics of NKG2C+adaptive NK cell (ANK) recovery was the only determinant of RI (p&amp;lt;0.01). Conclusion: The combination of Abata and PTCy was extremely effective in reducing the incidence of aGVHD, which was strongly influenced by dKLRCdel genotype, which in turn adversely impacted NRM, OS and GVHEFS. AbaCyS protocol was associated with better recovery of Tregs vis-à-vis reduced cGVHD. Abata-primed DLI as in AbaDCyC was not associated with increase in GVHD and seemed to moderate the RI in patients with advanced malignancy, which was influenced by ANK recovery. Thus, immunogenetics and immune reconstitution related to ANK subset of NK cells strongly influenced the outcome with Aba-PTCy based GVHD prophylaxis. DLI could be safely administered with Abata priming without increase in GVHD and yet result in attenuation of RI, suggesting the potential of this approach to dissociate GVHD from a NK-mediated GVL effect.

Abatacept Enhances Natural Killer Cell Cytotoxicity Following Haploidentical HCT: A Novel Platform to Dissociate GVL from Gvhd

Background: Abatacept (Abata, CTLA4 Ig), has been explored for the past 3 decades for blockade of CD28-B7 costimulation pathway in organ transplantation. One of the disadvantages of Abata has been its sparing effect on natural killer (NK) cells, resulting in NK-mediated rejection in preclinical models. However, we explored this caveat of abatacept to augment NK cell mediated anti-leukemia effect without invoking T cell mediated GVHD, where unmodified donor lymphocyte infusions (DLI) were administered 6 hours following administration of abatacept in-vivo (Abata-DLI) to patients with advanced malignancies undergoing haploidentical (Haplo)-HCT on days +7, +21 and +35. An early and rapid proliferation of mature NK cells was observed, which correlated with an improved relapse-free survival, without an increase in GVHD. To explore the mechanistic pathway behind this phenomenon, we studied the effect of Abata on cytotoxicity as well as cytokine profile of NK cells both in-vitro as well as in-vivo (CTRI:REF/2021/08/046552). Methods: NK cells and monocytes were isolated from PBMC of healthy donors. NK cells ± monocytes, were incubated with IL2, IL15 and IL12/15/18 with or without Abata for 72 hours and 7 days. They were assessed for cytotoxicity and IFN-g and perforin expression against K562 cell lines at effector: target (E:T) ratio of 5:1 and 1:1 . In HCT recipients, samples were obtained at day +20 (baseline), +30, +45, +60, and 6, 12 and 18 months. The samples were cryopreserved and both cytotoxicity and cytokine assays were carried out in batches after thawing. Cytokine profile was analysed in total NK cells and in NKG2A+ and NKG2C+ subsets. Results: The study was carried out on 11 healthy donors and 20 haplo-HCT recipients (15 with malignant diseases receiving Abata-DLI and 5 with non-malignant diseases receiving Abata without DLI). NK cells from healthy donors showed significant increase in cytotoxicity at 72 hours in presence of Abata with IL2 and IL15 (Figure1, p&amp;lt;0.01) at E:T ratio of 5:1 as well as 1:1 at both 72 hours as well as 7 days, but not with IL12/15/18. The effect was independent of monocytes. Perforin tended to be upregulated at both 72 hours and 7 days with Abata and IL15. In patients receiving Abata-DLI, cytotoxicity of NK cells was significantly increased at all time points compared to baseline at E:T ratio of 5:1 and 1:1 (Fig 2, P &amp;lt; 0.01). NK-cytotoxicity was significantly higher than the corresponding donor samples at days +45 and +60 (p&amp;lt;0.05). This was particularly so in 11 patients without any event compared to 4 patients with relapse/GVHD. To evaluate if Abata-DLI had greater impact on NK-cytotoxicity, the data was compared with 5 patients who received Abata alone. This showed significantly greater cytotoxicity at days +45 and +60 in the Abata-DLI group, which was more pronounced, when only those without events were analysed from the Abata-DLI group (p&amp;lt;0.01). There was no significant change in cytokine profile in those receiving Abata alone, but in Abata-DLI group, IFN-g was significantly upregulated in the NKG2C+ subset at day +60 at 1:1 ratio. Perforin expression was significantly higher at days+45 and +60 at both 5:1 and 1:1 in the Abata-DLI cohort, for both NKG2C+ and NKG2A+ subsets. In the Abata-DLI group NKG2C+ subset showed significantly higher IFN-g at days+45 and +60 and upregulation of perforin at all time points. 3 patients transplanted with active leukemia, assessed beyond day +60, showed greater cytotoxicity compared to the corresponding donors at 6-18 months. Conclusion: In this study, Abata was shown to increase cytotoxicity of NK cells, independent of monocytes, in the presence of IL2 and IL15, but not with IL12/15/18. This was observed at both high as well as low E:T ratios, with significant upregulation of perforin. In Haplo-HCT with Abata-DLI, there was marked increase in NK-cytotoxicity with upregulation of both IFN-g and Perforin, when compared to baseline as well as in comparison to those receiving Abata without DLI. Our findings suggest that Abatacept directly augments NK-cytotoxicity and provides rationale for exploring Abata-augmented NK cell therapy as a novel approach to augment NK-mediated GVL effect without invoking T cell mediated GVHD

Post-Allograft Romidepsin Maintenance Mitigates Relapse Risk and Stimulates the Graft-Versus-Malignancy Effect through Enhanced NK-Cell Cytotoxicity in Patients with T-Cell Malignancies: Final Results of a Phase I/II Trial

Background: For patients with high risk, and relapsed/refractory T-cell malignancies allogeneic stem cell transplant (allo-SCT) is the only available potentially curative therapy. The efficacy of allo-SCT is limited in this population by high rates of relapse, with rates up to 55-60% post-allo-SCT. We designed a phase I/II trial, evaluating the combination of the histone deacetylases inhibitor romidepsin (rom) with busulfan/fludarabine (BuFlu) conditioning, followed by romidepsin maintenance (m-rom) in patients receiving allo-SCT for T-cell malignancies (NCT02512497). Here we present final clinical results of this therapeutic approach, including an evaluation of the stimulatory effects of m-rom on the graft-versus-malignancy effect through NK-cells post-allo-SCT. Methods: This was a phase I/II clinical trial. Eligible patients had: a diagnosis of T-cell leukemia (including T-acute lymphoblastic leukemia) or T-cell lymphoma (TCL, cutaneous or peripheral) in at least a partial remission requiring an allo-SCT, &amp;lt;70 years of age, with a matched sibling/unrelated donor. Patients received myeloablative (20K) or reduced intensity (16K) BuFlu with rom, followed by standard tacrolimus/methotrexate GVHD prophylaxis and anti-thymocyte globulin for unrelated donors (MUD). An expansion cohort of up to 30 patients (total) was included. M-rom was initiated between day +28 and +100 for 1 year (2 nd year optional), with built in dose reductions for toxicity. An efficacy endpoint of 20% reduction in relapse risk at 1-year in the whole cohort or any individual disease cohort was set based upon historical/CIBMTR (Center for Blood and Marrow Transplant Research) controls was pre-specified. The effect of m-rom on NK-cell cytotoxicity was assessed on samples taken pre-transplant, and 1, 3, 6, 12 months post allo-SCT. NK cytotoxicity was assessed by isolating mononuclear cells from patient samples at each timepoint, comparing those on m-rom (n=13) versus those who did BuFlu controls who did not receive m-rom (n=16). Cells were targeted against K562 targets using the calcein-AM assay. K-M and Fine-Gray models were used to estimate PFS, OS, and cumulative incidence, and compare survival across groups. Results: 28 patients were enrolled on this trial (Table). With a median follow-up time of 15 months, the median OS is 3.3 years (95% CI: 0.85-not reached), with a 1 and 3 year OS probability of 68% and 54%. The median PFS is 2.3 years (95% CI: 0.6-not reached), with 1 and 3-year PFS of 61% and 41%. Cumulative incidence (CI) of NRM at day 100 and 1 year were 14.3% and 21.4%. CI of grade II-IV aGHVD and extensive cGVHD were 46.4% and 38%. The CI of relapse (CIR) was 18.1% at 1 year and 33% at 3 -years. There was no difference between PFS among patients with MRD versus those without MRD prior to transplant (p=0.43). The CIR of patients with TCL was 9.3% at 1 and 3 years, whereas the CIR of patients with leukemia was 25% at 1 year and 48% at 3 years. No patients with PTCL relapsed, 1/2 patients with CTCL relapsed, and 4/6 patients with T-PLL are alive, disease free. Pre-specified general CIR was 55% for all patients. With an overall CIR of 18% at 1 year, and 33% at 3-years, this trial met its pre-specified endpoint of decreasing relapse by 20% at 1-year, and performed well compared to published CIBMTR control populations. Matched propensity score analysis across disease subsets with CIBMTR controls will be presented. 18/28 (64%) of patients received m-rom with a median number of 13 cycles (range 1-47). 8 patients experienced grade 3/4 adverse events (AE), and 1 patient discontinued m-rom due to toxicity, unlikely related to romidepsin (loss of CD3 chimerism). When NK-cytotoxicity was assessed between the two groups after starting maintenance, NK-cytotoxicity in the m-rom group was significantly higher than in those without m-rom (p&amp;lt;0.0001) (Figure). Conclusions: BuFluRom with m-rom is effective at decreasing relapse in patients with T-cell malignancies, with 1-year CI relapse below expected relapse rates for this set of diseases, meeting the pre-specified efficacy endpoint. NK-cell cytotoxicity data in a large sample set of trial patients demonstrates that m-rom enhances NK-cell cytotoxicity post allo-SCT, augmenting the GVL effect and likely accounting for at a minimum, some of the decrease in relapse seen on this trial. M-rom should be considered a new option post allo-SCT to mitigate relapse in patients with T-cell malignancies.

Maintenance Ruxolitinib Is Associated with Low Rates of Chronic Gvhd Requiring Systemic Treatment in Older Adults with AML/MDS Undergoing Allogeneic HCT: Results of a Phase II Multicenter Trial

Introduction: Despite recent advances in graft-versus-host disease (GVHD) prophylaxis, novel approaches to effective prevention of chronic GVHD remain of utmost importance. This is particularly true for older transplant recipients,for whom high-dose cyclophosphamide or prolonged treatment with corticosteroids is challenging. Ruxolitinib, an oral selective inhibitor of JAK1/2, is FDA-approved for the treatment of refractory acute and chronic GVHD. However, the clinical efficacy of JAK inhibition in preventing severe chronic GVHD is not well characterized. Methods: In this prospective, multicenter phase II trial (NCT03286530), older adult subjects (age 60-80) with AML in CR1 or MDS undergoing RIC allogeneic HCT were enrolled. Transplants could be conducted from HLA-matched related donors or 7/8 or 8/8 HLA-matched unrelated donors. Transplants were required to use busulfan- or melphalan-based reduced intensity conditioning and peripheral blood stem cells. Standard GVHD prophylaxis consisted of tacrolimus and methotrexate (5-10 mg/m 2 on Days +1, +3, and +6 ± +11). Subjects were enrolled prior to transplant. Ruxolitinib therapy could begin between Day +30 and Day +100, after meeting pre-treatment criteria, which included: donor engraftment, ongoing remission confirmed by biopsy, adequate hematopoietic recovery (Hgb ≥8 g/dL, PLT ≥50K/uL), and the absence of progressive acute GVHD. Ruxolitinib was administered at 10 mg BID continuously in 28-day cycles (allowing for dose reductions due to drug interactions or cytopenias), for up to 24 cycles. The primary objective was to evaluate the GRFS at 1-year after HCT. Key secondary objectives included the cumulative incidence of chronic GVHD, acute GVHD, and relapse, as well as overall survival. Results: Seventy-eight subjects were enrolled, and 63 subjects received ruxolitinib on trial. The reasons for not initiating ruxolitinib were acute GVHD (n=4), physician discretion (n=3), disease relapse (n=2), low chimerism (n=2), death (n=2), primary graft failure (n=1), and subject withdrawal (n=1). In the treated subjects, the median age was 68 years (range, 61-79). Fifty-five (87.3%) subjects had AML and 8 (12.7%) had MDS. Transplants were performed from HLA-matched related (n=16, 25.4%) or unrelated (n=47, 74.6%) donors with either Fludarabine/Melphalan (n=34, 54%) or Fludarabine/Busulfan (n=29, 46%). The median start date of ruxolitinib after HCT was day 45 (range, 32-93). The median follow-up of survivors was 19 months (range, 3-64) at last cutoff (2/14/23). At the time of analysis, the median number of cycles on treatment is 14 (range, 1-24). 17 subjects remain on therapy; the reasons for discontinuation include completed treatment (n=21), disease relapse (n=13), adverse events (n=7), and physician discretion (n=5). The most common (severe grade ≥3) adverse events experienced while on ruxolitinib were neutropenia (n=18, 29% of subjects), thrombocytopenia (n=17, 27% of subjects), and anemia (n=16, 25% of subjects). Seven subjects experienced grade ≥3 infectious events; no fungal infections have occurred. In subjects receiving ruxolitinib, the 6-month cumulative incidence of Grade II-IV acute GVHD was 14% (95%CI, 7-24) and Grade III-IV acute GVHD was 4.8% (95%CI, 1.3-12), with three cases of grade II-IV GVHD occurring prior to initiation of ruxolitinib. While the 12-month incidence of all cases of chronic GVHD is 27% (95%CI, 17-39), the 12-month incidence of chronic GVHD requiring systemic therapy is 8.4% (95%CI, 3.1-17). The 18-month cumulative incidence of NRM is 5.6% (95%CI, 1.4-14); with only one death attributed to GVHD and one death due to infection (COVID-19), thus far. The 18-month cumulative incidence of disease relapse is 27% (95%CI, 16-39). The 12-month GRFS (primary endpoint) is 70% (95%CI, 56-80). The 18-month OS, PFS, and CRFS are 78% (95%CI, 64-88), 68% (95%CI, 53-78) and 64% (95%CI, 50-76), respectively ( Figure 1). Conclusion: Prolonged administration of ruxolitinib following allogeneic HCT is associated with low rates of chronic GVHD requiring systemic treatment. The incidence of relapse is comparable to historical rates, suggesting no compromise of GVL effect. Despite the anticipated cytopenias with therapy, most subjects were able to remain on treatment. The incorporation of JAK inhibition into GVHD prevention approaches warrants further investigation.

Interindividual HLA Evolutionary Divergence in Single HLA-Mismatched Unrelated Donor Hematopoietic Cell Transplantation for Malignant Hematological Disorders: A Report on Behalf of the Cellular Therapy and Immunobiology Working Party of the EBMT

In allogeneic hematopoietic cell transplantation (allo-HCT), alloreactive T-cell responses (graft versus leukemia - GvL and graft versus host disease - GvHD) are mediated by the interaction between recipient antigens and donor lymphocytes via human leukocyte antigen (HLA) molecules. HLA evolutionary divergence (HED) is a metric recently implemented as a functional proxy for the structural variability between two homologous HLA alleles at their peptide binding sites, mirroring quantitative differences in pathogen and cancer-related immunopeptidomes ( A). 1 Here, we hypothesize that differences in and between donor and recipient HEDs at given loci may modulate the direction and the intensity of alloreactivity, informing on post-transplant outcomes. We tested this hypothesis in onco-hematologic patients undergoing allo-HCT from a single HLA-A, -B, -C, -DRB1, or -DQB1 (9/10) mismatched unrelated donor (MMUD) at EBMT centers. We included patients with selected hematological malignancies, receiving a thymoglobulin-based T cell depletion, for whom complete clinical and HLA information was available in the EBMT database. We deployed individual locus-specific recipient/donor HED (HED-R, HED-D) metrics as previously described 1, and conceptualized two novel interindividual HED scores accounting for functional differences at the mismatched HLA loci ( A). The latter were considered as: 1) DeltaHED, quantifying the relative directional difference between HED-D and HED-R and informing on differences in immunopeptidome sizes, potentially capturing the direction and the intensity of the alloreactive response (GvH or HvG); 2) HEDmismatch, describing the HED of the mismatched locus as a proxy for the qualitative differences in immunopeptidomes between donor and recipient ( B). Using multivariable Cox regression (cause-specific) models adjusted for relevant clinical variables, we investigated the associations of HED-R, DeltaHED and HEDmismatch, analyzed as continuous variables, with relapse free survival (RFS), overall survival (OS), non-relapse mortality (NRM), relapse and grade II-IV acute and chronic GvHD. For each outcome and in each mismatched subgroup, we built separate models for these immunogenetic parameters and checked for proportional hazards assumption (PHA). To account for multiple comparisons, only p-values &amp;lt;0.01 were considered significant. Overall, 4639 adult patients, with available HLA data, received a 9/10 MMUD allo-HCT between 2010 and 2019 for acute leukemia (N=3853, 83%), myelodysplastic syndromes or myeloproliferative neoplasms (N=786, 17%). Median recipient age was 53.5 (IQR 40.2-61.9) with a male/female ratio of 1.28, whilst median donor age was 33.1 (IQR 24.5-40). Majority of patients (90%) received peripheral blood stem cells and were mismatched with their donors for locus A (33%), followed by C (21%), B (15%), DQB1 (14%) and DRB1 (6%). When analyzing the impact of HED-related parameters in each model, we observed that most recurrent associations with outcomes occurred with DRB1-related metrics. In the DRB1-mismatched subgroup (N=276), a time-varying association was found for HEDmismatch of DRB1 locus with higher HEDmismatch leading to worse RFS [HR:1.25 at t=0, (95% CI 1.1-1.42), p&amp;lt;0.001] and lower OS [HR:1.23 at t=0, (95%CI 1.08-1.41), p=0.002]. The strength of this associations declined over time for both endpoints (respectively RFS: HR:0.91, 95% CI 0.86-0.97, p=0.005 and OS: HR:0.93, 95% CI 0.88-0.98, p=0.013). The (directional) DeltaHED DRB1 measure instead did not display any impact on outcomes. In the same subgroup, higher HED-R in the locus C showed also a time-varying association with NRM at transplant [HR:1.89, (95% CI 1.29-2.85), p=0.002], progressively declining over time (HR:0.77, 95% CI 0.65-0.92, p=0.003). Furthermore, DRB1 HED-R modulated the probability of survival in B-mismatched subgroup, being higher scores associated with reduced OS [HR:1.03, (95%CI 1.01-1.06), p=0.009]. Here, we provide an immunogenetic benchmark to explore donor-recipient interactions in MMUD allo-HCT, demonstrating how different HLA configurations within the mismatched loci, in particular for DRB1 genes, can influence post-transplant outcomes. Given the peculiar associations observed, HED may have a role in driving early GvL effects, informing on future donor selection strategies in high-risk patients.

Prednisolone Intake Differentially Regulates IL12p40 and IL18 - Impact on Severe Chronic Gvhd, Relapse and Mortality

Background: Chronic graft-versus-host disease (cGVHD) is an immune-mediated complication after allogeneic stem cell transplantation (alloSCT). It is associated with graft-versus-leukemia effects and lower relapse rates, but in its severe form also with increased morbidity and mortality. The early interferon-gamma (IFNγ)-response marker CXCL9 is increased in mild and severe cGVHD and strongly correlates with IDO activity (1). Interleukin (IL)-18 is an innate, IFNγ inducing cytokine that associates with poor outcome of allografted patients (2), and with severe fibrosing cGVHD (1). The adaptive immunological arm of IFNγ induction relies on IL12 that is produced during cognate interactions between dendritic cells and T cells. IL12 kinetics is poorly characterized after alloSCT. We hypothesized that adaptive (IL12p40) and innate (IL18) immune mediators and their modulation by immunosuppressive drugs (ATG, prednisolone) impact cGVHD severity and outcome. Methods: Patients before alloSCT were included in an observational study allowing collection of clinical data and blood before and for one year after alloSCT. The training cohort included 350 patients transplanted before 2018 at our institution. The validation cohort consisted of 205 patients transplanted after 2018. Patients were eligible if they were not relapsed and did not receive donor leukocyte infusions (DLI) until d180, and did not develop refractory acute GVHD. Cytokines that belonged to the IFNγ pathway (IFNγ, CXCL9, CXCL10, IL12p40, IL12EBI3, IL17, IL18, IL23) or to innate inflammatory pathways (TNFa, IFNa, IL1b, activin, follistatin) were measured by R&amp;D ELISAs. Cumulative (equivalent) prednisolone dosages between d0 and d100 after alloSCT were calculated from electronic patient records. Flow cytometry of PBMC of 100 patients on day+180/onset cGVHD were performed using 24-gate multicolor staining. Mild, severe fibrosing and severe gastro-intestinal (GI) cGVHD were diagnosed according to simplified NIH criteria (training cohort only). Overall survival, non-relapse mortality and time to relapse from time of blood sampling were calculated by multivariable Cox regression analyses. Results: Median time of blood sampling at onset of cGVHD (n=180) was day +168 (range 41-723). Control patients (n=169) were collected on day +180 (171-183). Mild cGVHD was recorded in 133 patients, severe fibrosing cGVHD in 39 patients, and isolated GI-cGVHD in 8 patients. Receiver-operator characteristic (ROC) curves showed that only CXCL9, IL18 and IL12p40 were significantly linked to severe cGVHD. IL18 was associated with severe fibrosing cGVHD, whereas CXCL9 and IL12p40 were correlated to any grade cGVHD. In multivariable Cox analyses including IL12p40, IL18, age, mismatch, recipient and donor gender, disease stage, ATG, MTX, and diagnosis, IL18 associated with poor OS (HR per log2 increase 1.81 (1.19-2.74, p=0.005), whereas IL12p40 associated with superior OS (HR 0.53 (0.35-0.81), p=0.003). This could be validated in the independent cohort. Time course analyses of serum levels of CXCL9, IL12p40 and IL18 revealed a strong increase of CXCL9 and IL12p40 toward onset of cGVHD, but no stimulation of IL18 levels. Cumulative prednisolone intake&amp;gt;100 mg until day+100 significantly reduced IL12p40 serum levels on d180/at onset of cGVHD, without influencing IL18 production (Figure 1). In contrast, ATG reduced both, IL18 and IL12p40 at day180/onset of cGVHD. This might explain the reduced incidence of severe fibrosing cGVHD in patients receiving ATG prophylaxis (days-3 to -1 before alloSCT, 4% vs. 23%, p&amp;lt;0.001, n=343), whereas no effect of early prednisolone intake was noticed (p=0.916, n=137). Multicolor flow cytometry showed that IL12p40, but not IL18 correlated with blood counts of T-lymphocyte populations, including CD4+, CD8+ and γδ-Tcells. IL12p40 and γδ-Tcells were associated with reduced relapse rates. In summary, CXCL9, IL12p40 and IL18 are associated with severe cGVHD. IL18 correlated with severe fibrosing cGVHD and increased mortality, whereas IL12p40 was associated with reduced NRM, reduced relapse risk, improved lymphocyte recovery and γδ-T-cells, and was affected by prednisolone intake but not ATG. Conclusion: These results may help to understand and potentially separate the GVL effects from mortality/morbidity that associate with cGVHD. 1)PMID34755129 2)PMID31680001

Impact of Multiple Minor Histocompatibility Antigen Differences on Graft-Versus-Host Disease and Relapse Risk in Pediatric Allogeneic Hematopoietic Cell Transplantation Recipients

BACKGROUND Success of allogeneic hematopoietic cell transplantation (alloHCT) is sharped by alloreactivity, i.e. the ability of donor T-cells to recognize particular recipient motifs as non-self and get activated. Donor T-cells recognizing recipient tissue can cause harmful graft-versus-host disease (GvHD) while activity against leukemic blasts can protect against relapse (GvL). In HLA-matched alloHCT, alloreacticity is driven by subtle nonpathogenic variants in natural proteins, socalled minor histocompatibility antigens (miHAgs), however, not all variants are immunogenic. METHODS To analyze the impact of mHAgs-differences on alloHCT outcomes, we selected a purely pediatric cohort of 102 HLA-matched allo HCTs transplanted between 2003 and 2017. Panel sequencing of 46 validated miHAgs was performed using Ilumina MiSeq, only variants in the graft-versus-host direction were considered. RESULTS In a logistic regression model for the whole cohort acute GvHD incidence was significantly dependent on the proportion of miHAg mismatches (all genes) with an 95%-CI 1.0263-1.1998, p=.01 and an odds ratio of 1.1066. From all variants tested, only mismatches in TRIM42 were significant as a predictor with a FDR &amp;lt;.05. Furthermore, proportion of mismatches was a predictor of all-cause mortality. Risk of relapse was evaluated by regression analysis for competing risks: proportion of miHAg mismatches failed to be predictive for relapse ( p=.37). However, looking at patients with acute lymphobastic leukemia (ALL) only (n=36), mismatches in hematopoiesis-restricted genes protected from relapse (95%-CI 1.0016-1.0712, p=.04, hazard ratio 1.0358). CONCLUSION Thus, in children GvHD and mortality seem to be related to the overall number of miHAg-differences whereas variants in hematopoiesis-restriced genes protect from ALL relapse. These data implicate that selection of TCRs with a specificity for hematopoietic miHAgs could be a way to improve GvL effect without increasing the risk of GvhD.

Treg-targeted IL-2/anti-IL-2 complex controls graft-versus-host disease and supports anti-tumor effect in allogeneic hematopoietic stem cell transplantation.

Modulating an immune response in opposite directions represents the holy grail in allogeneic hematopoietic stem cell transplantation (allo-HSCT) to avoid insufficient reactivity of donor T cells and hematologic malignancy relapse while controlling the potential development of graft-versus-host disease (GVHD), in which donor T cells attack the recipient's tissues. IL-2/anti-IL-2 complexes (IL-2Cx) represent a therapeutic option to selectively accentuate or dampen the immune response. In dedicated experimental models of allo-HSCT, including also human cells injected in immunodeficient NSG mice, we evaluated side-by-side the therapeutic effect of two IL-2Cx designed either to boost regulatory T cells (Treg) or alternatively to activate effector T cells (Teff), on GVHD occurrence and tumor relapse. We also evaluated the effect of the complexes on the phenotype and function of immune cells in vivo. Unexpectedly, both pro-Treg and pro-Teff IL-2Cx prevented GVHD development. They both induced Treg expansion and reduced CD8+ T-cell numbers, compared to untreated mice. However, only mice treated with the pro-Treg IL-2Cx, showed a dramatic reduction of exhausted CD8+ T cells, consistent with a potent anti-tumor effect. When evaluated on human cells, pro-Treg IL-2Cx also preferentially induced Treg expansion in vitro and in vivo, while allowing the development of a potent anti-tumor effect in NSG mice. Our results demonstrate the clinical relevance of using a pro-Treg, but not a pro-Teff IL2Cx to modulate alloreactivity after HSCT, while promoting a graft-versus-leukemia effect.

Immunology of cord blood T-cells favors augmented disease response during clinical pediatric stem cell transplantation for acute leukemia.

Allogeneic hematopoietic stem cell transplantation (HSCT) has been an important and efficacious treatment for acute leukemia in children for over 60 years. It works primarily through the graft-vs.-leukemia (GVL) effect, in which donor T-cells and other immune cells act to eliminate residual leukemia. Cord blood is an alternative source of stem cells for transplantation, with distinct biological and immunological characteristics. Retrospective clinical studies report superior relapse rates with cord blood transplantation (CBT), when compared to other stem cell sources, particularly for patients with high-risk leukemia. Xenograft models also support the superiority of cord blood T-cells in eradicating malignancy, when compared to those derived from peripheral blood. Conversely, CBT has historically been associated with an increased risk of transplant-related mortality (TRM) and morbidity, particularly from infection. Here we discuss clinical aspects of CBT, the unique immunology of cord blood T-cells, their role in the GVL effect and future methods to maximize their utility in cellular therapies for leukemia, honing and harnessing their antitumor properties whilst managing the risks of TRM.

Withaferin-A alleviates acute graft versus host disease without compromising graft versus leukemia effect.

Acute graft versus host disease (aGvHD) contributes to a significant proportion of non-relapse mortality and morbidity in patients undergoing allogeneic hematopoietic stem cell transplantation (alloHSCT). Withaferin-A (WA), a phytomolecule obtained from Withania somnifera (Ashwagandha), is known to have anti-inflammatory, anti-proliferative and immunomodulatory properties. The efficacy of WA for the prevention and treatment of aGvHD was evaluated using a murine model of alloHSCT. Prophylactic administration of WA to mice mitigated the clinical symptoms of aGvHD and improved survival significantly compared to the GvHD control [HR=0.07 (0.01-0.35); P<0.001]. Furthermore, WA group had better overall survival compared to standard prophylactic regimen of CSA+MTX [HR=0.19 (0.03-1.1), P<0.05]. At the same time, WA did not compromise the beneficial GvL effect. In addition, WA administered to animals after the onset of aGvHD could reverse the clinical severity and improved survival, thus establishing its therapeutic potential. Our findings suggest that WA reduced the systemic levels of Th1, Th2 and Th17 inflammatory cytokine and increased the anti-inflammatory cytokine IL-10 levels significantly (P<0.05). WA also inhibited lymphocytes migration to gut, liver, skin and lung and protected these organs from damage. Ex-vivo, WA inhibited proliferation of human peripheral blood mononuclear cells (hPBMCs), modulated immune cell phenotype and decreased cytokine release. In addition, WA inhibited pJAK2 and pSTAT3 protein levels in mouse splenocytes and hPBMCs. In conclusion, our study demonstrates the utility of WA for the prevention and treatment of aGvHD, which should be further evaluated in a clinical setting.

Antibody-mediated pathogenesis of chronic GVHD through DBY/HLA class II complexes and induction of a GVL effect

AbstractChronic graft-versus-host disease (cGVHD) is a multiorgan syndrome with clinical features resembling those of autoimmune diseases. Thus, understanding commonalities in the pathophysiology of cGVHD and autoimmune diseases, such as the presence of disease-risk HLA alleles, is imperative for developing novel therapies against cGVHD. Alloantibodies against H-Y antigens encoded on the Y-chromosome are well-described risk factors for cGVHD in female-to-male transplantation. However, because H-Y antigens generally localize intracellularly in the male reproductive organs, how they emerge at affected organ levels remains elusive. Here, by analyzing nationwide registry data stratified per donor–recipient sex, we identified specific HLA class II alleles that contributed to susceptibility to male cGVHD after transplantation from HLA-identical female siblings (HLA-DRB1∗15:02: hazard ratio, 1.28; 95% confidence interval, 1.03-1.58; P = .025). Coexpression of HLA-DRB1∗15:02 efficiently transported full-length H-Y antigens, especially DBY, to the surface. The presence of alloantibodies against DBY/HLA class II complexes significantly predicted the occurrence of cGVHD (68.8% vs 31.7% at 1 year; P = .002). Notably, the ability of HLA class II molecules to transport and present DBY to alloantibodies was closely associated with the susceptibility of HLA class II alleles to cGVHD. DBY specifically colocalized with HLA class II molecules on the dermal vascular endothelium in cGVHD and provoked complement-dependent cytotoxicity. Moreover, these complexes were observed in some male leukemic cells. Altogether, these findings suggest that vascular endothelial cells facilitate alloantibody-mediated cGVHD and highlight that alloantibodies against DBY/HLA class II complexes could be common targets for cGVHD and a graft-versus-leukemia effect.

Current Trends in Transplantation of Patients with Hematological Malignancies

Hematopoietic stem cell transplantation (HSCT) is widely used to treat hematological malignancies and nonmalignant hematological disorders. Many advances have been made in improving the success of bone marrow transplantation. However, lack of available matched related or matched sibling donors has posed a significant challenges to the availability and proper utilization of hematopoietic stem cell transplantation in patients with hematological malignancies. The rising availability of alternative donors, particularly haploidentical donors (HIDs), has propelled the rapid rise of allo-HSCT. The aim of this review is to highlight and evaluate the recent advances in the development of HSCT, focusing mainly on the selection of suitable hematopoietic stem cell donors, HID-HSCT and some current advances in the use of umbilical cord blood cells as an alternative graft source. Haplo-HSCT has shown a promising result and better outcomes due to the number of advantages, including a wide range of stem cell sources, increased GVL effects, improved immunologic reconstitution, and positive clinical outcomes. In the near future, haplo-HSCT is likely to be considered as a better option for patient donor selection particularly in AML patients while HLA matching is unlikely to be the most important factor in AML patient donor selection. In addition, the use of umbilical cord blood cells has shown a promising role as an alternative source of HSCT even with other available sources such as bone marrow and peripheral blood. Other transplantation procedures, such as T-cell depletion allografts, Post-transplant cyclophosphamide (PTCY), G-CSF-mobilized allografts, and antithymocyte globulin, have contributed to significant improvements in haplo-HSCT outcomes in recent decades.

Endothelial Cells Activate Alloreactive CD4+ T Cells to Initiate Acute Graft-Versus-Host Disease

Allogeneic donor T cells can exert an anti-leukemic response (GvL effect) after hematopoietic cell transplantation (allo-HCT). However, allogeneic donor T cells can also cause life-threatening acute graft-versus-host disease (aGvHD). Therefore, donor T cell priming is considered as a crucial event determining allo-HCT outcome. In aGvHD, donor CD4+ T cells are activated by antigen presenting cells (APCs), proliferate, differentiate and migrate to cause tissue damage. However, non-hematopoietic APCs have been shown to drive aGvHD pathology, making hematopoietic APCs dispensable in the initiation of aGvHD (Toubai et al., Blood 2012, Koyama et al., Nat Med 2012). During the aGvHD initiation phase allogenic T cells exclusively migrate to secondary lymphoid organs (SLOs) before they enter target tissues in the aGvHD effector phase (Beilhack et al., Blood 2005, Beilhack et al., Blood 2008). These observations led us to investigate the role of MHC class II mediated antigen presentation by non-hematopoietic lymph node (LN) stromal (SCs) and endothelial cells (ECs) in aGvHD. Recently we learned that alloreactive CD4+ T cells are activated in SLOs by non-hematopoietic APCs independently from Ccl19 expressing SCs, while these SCs provide protective niches to donor Tregs mitigating GvHD. Consequently, here we explored MHCII mediated antigen presentation by SLO blood endothelial cells (BECs) and lymph endothelial cells (LECs). BECs and LECs expressed endogenous MHCII, costimulatory receptors CD80/CD86 and acquired MHCII from dendritic cells via trogocytosis. Upon myeloablative irradiation, BECs and LECs upregulated CD80 and CD86 whereas MHCII expression decreased upon loss of radiosensitive host DCs. scRNA-seq revealed, BECs and LECs subsets expressing genes involved in MHCII antigen presentation (e.g. Cd74, Ctss, Ctsl, Tap2, H2-Aa, H2-Ab1, H2-Eb1) leading to exogenous antigen presentation (DQ-OVA) by EC subsets. To elucidate MHCII antigen presentation in ECs we crossed Cdh5-Cre to H2-Ab1fl mice to conditionally knockout MHCII on ECs (MHCIIΔCdh5). Allo-HCT in MHCIIΔCdh5 recipients utilizing an MHC major mismatched model (FVB→B6) did not alter allogeneic CD4+ T cell activation during aGvHD initiation. However, MHCIIΔCdh5 showed marginally reduced aGvHD and better survival. Notably, MHCIIΔCdh5 recipients retained functional hematopoietic APCs presenting alloantigens via MHCII. Therefore, we generated bone marrow (BM) chimeras by syngeneic (syn) HCT from MHCII-deficient (MHCIIΔ) donors into B6.WT mice. After allo-HCT of these BM chimeras, donor CD4+ T cells got activated in SLOs during the aGvHD initiation phase. However, to our surprise also syngeneic BM chimeric animals spontaneously developed GvHD-like symptoms making them unsuitable for studying MHCII mediated non-hematopoietic antigen presentation after allo-HCT. This striking phenotype could be explained by a defective CD44hiCD62Llow CD4+ T cell memory development in MHCIIΔ BM chimeras (Huang et al., J Immunol. 2014). Utilizing our scRNA seq dataset we identified Tie2 and Vav1 to be expressed on cells of hematopoietic lineage, however Tie2 expression was observed on ECs of the LNs. Therefore, we generated MHCIIΔVav1 mice by crossing Vav1-Cre to H2-Ab1fl. CD45- LNs cells from these animals activated CD4+ T cell in mixed lymphocyte reaction as well as in vivo. MHCIIΔVav1 mice developed less aGvHD with delayed kinetics. Subsequently, we surgically transplanted LNs from syngeneic MHCIIΔVav1 mice into complete MHCIIΔ mice. After MHCIIΔVav1 LN engraftment, these MHCIIΔ recipients underwent allo-HCT with allogenic CD4+ T cells. Alloreactive donor CD4+ T cells expressed more IFNγ and TNFα compared to controls. These experiments proved that non-hematopoietic cells in LNs can activate alloreactive CD4+ T cells to initiate aGvHD. Ultimately, we crossed MHCIIΔCdh5 to MHCIIΔVav1, resulting in mice deficient for MHCII in the entire hematopoietic and endothelial compartments. After allo-HCT MHCIIΔVav1ΔCdh5 were significantly better protected from aGvHD than littermate controls, revealing a previously unidentified role of ECs in initiating CD4+ T cell mediated aGvHD. Based on these findings we propose ECs as important non-hematopoietic APCs to activate alloreactive CD4+ T cells to trigger aGvHD suited for therapeutic interventions after allo-HCT.

Ex Vivo Generation and Infusion of Anti-Minor Histocompatibility Antigen Expanded T Cells for Patients Who Relapse after Allogeneic HLA-Matched Stem Cell Transplantation

Rationale Long-term clinical remissions of hematologic malignancies after allogeneic hematopoietic stem cell transplantation (HSCT) largely rely on the graft-versus-leukemia effect (GVL). In a fully HLA-matched setting, the GVL effect is mediated primarily by T cell immune responses against host minor histocompatibility antigens (MiHAs) found on the surface of malignant cells. Upon relapse of leukemia following HSCT, donor lymphocyte infusions (DLI) have unfortunately failed to exert efficient GVL activity. This is likely due to the insufficient number of anti-MiHA T cells within DLIs and to the risk of graft-vs-host disease (GVHD) that prevents the administration of high numbers of T cells. To generate potent and selective anti-leukemia activity, we have developed a strategy for the ex vivo selection and expansion of T cells targeting MiHAs preferentially expressed on hematopoietic cells (Perreault, Leukemia 2016). Thus, these cells should display augmented GVL immune reactivity while harboring a low risk of causing GVHD. To our knowledge, this is the first clinical study targeting several different molecularly defined MiHAs and on different HLA molecules. Patients and Methods In an open-label, multi-center phase 1 clinical trial (CR-MIHA-001; NCT 03091933), patients with hematologic malignancies who relapsed after an allogeneic HLA-matched HSCT were treated with sibling donor-derived, ex vivo- expanded T cells selected and expanded for reactivity toward tissue-restricted recipient MiHAs (GLIDE: Guided Lymphocyte Immunopeptide Derived Expansion). After donor cell collection, patients received fludarabine 30 mg/m2 and cyclophosphamide 300 mg/m2 for 3 days followed by infusion of GLIDE, consisting of donor T-lymphocytes expanded ex vivo following exposure to dendritic cells coated with immunogenic peptides (MiHAs) present on the surface of host hematopoietic cells, at a single target dose of 4x107 viable T-cells/m2. A second dose of GLIDE, aiming at 3-5 times the original dose, could be administered to patients at a minimum of 6 weeks after the first infusion. GLIDE cell characteristics were evaluated using multi-parameter flow cytometry and TCR sequencing. Patients were followed up for one year post-GLIDE infusion for toxicity and clinical outcome measures. Results Ten patients, median age of 58 (range 33-69), 4 females/6 males with AML (n=7), NHL (1), CLL (1), and myelofibrosis (1) were treated with GLIDE. These patients had relapsed at a median of 12 months (range 5-126 mo) after allogeneic HSCT. GLIDE cells were personalized to target single MiHAs in 9 patients and two MiHAs in 1 patient. Overall, GLIDE cell products were directed at 9 different MiHAs on 6 different HLA-class 1 molecules (HLA-A02:01, A24:02, B07:02, B18:01, B44:02, and B44:03). A first dose of GLIDE was administered at 4.0x107 CD3+ cells/m2 to 8 patients, and 2 patients received slightly lower doses (2.6 and 3.7 x 107 CD3+ cells/m2). Final GLIDE products consisted mainly of T-cells (median: 98,7%), with CD8>CD4>NKT>NK cells. Most CD8+ T cells were effector memory and central memory T cells (Figure 1). At the end of the expansion period, CD8+ T cells expressed activation markers (CD25+ = 67%) with low levels of PD1+, PDL1+, CD57+ and KLRG1+ as markers of exhaustion. Not surprisingly, GLIDE cells had a more restricted TCR β chain profile than initial lymphopheresis cells. Six patients received a second dose of GLIDE (mean: 12 x 107 CD3+ cells/m2) at 53 days after the first infusion (median, range: 48-118 days). There were no infusional toxicities, and cells were well-tolerated by patients. Only one patient developed thrombocytopenia and subsequent chronic GVHD. There were no other adverse events potentially related to GLIDE. According to TCR β sequencing data, T cells present in the adoptively transferred anti-MiHA GLIDE product persisted in peripheral blood up to one year after infusion. Survival at one year was observed in 4 patients with 3 patients in sustained remission (Figure 2). Conclusion This pilot study demonstrates the feasibility of anti-MiHA T cell ex vivo generation (GLIDE) and safety of its administration to patients relapsing after allogeneic HSCT, as well as the clinical potential of these cells. The persistent remissions and low occurrence of GVHD support further development of GLIDE to target acute myeloid leukemia and other hematologic malignancies. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Post-Allograft Romidepsin Maintenance Mitigates Relapse Risk and Stimulates the Graft-Versus-Malignancy Effect through Enhanced NK-Cell Cytotoxicity in Patients with Aggressive T-Cell Malignancies in a Phase I/II Trial

Background: For patients with high risk, and relapsed/refractory T-cell malignancies allogeneic stem cell transplant (allo-SCT) is the only available potentially curative therapy. The efficacy of allo-SCT is limited in this population by high rates of relapse, with rates up to 55-60% post-allo-SCT. We designed a phase I/II trial, evaluating the combination of the histone deacetylases inhibitor romidepsin (rom) with FluBu conditioning, followed by romidepsin maintenance (m-rom) in patients receiving allo-SCT for T-cell malignancies (NCT02512497). Here we present an evaluation of the stimulatory effects of m-rom on the graft-versus-malignancy effect through NK-cells post-allo-SCT in the context of clinical results. Methods: This is a phase I/II clinical trial of patients with T-leukemia/lymphoma in at least a partial remission requiring an allo-SCT, <70 years of age, with a MRD/MUD donor. Patients received BuFlu (AUC 20000 or 16000) with rom, followed by tacrolimus/methotrexate GVHD prophylaxis with ATG for MUDs. An expansion cohort of up to 30 patients (total) was included. M-rom was initiated between day +28 and +100 for 1 year (2nd year optional), with built in dose reductions for toxicity. The effect of m-rom on NK-cell cytotoxicity was assessed on samples taken pre-transplant, and 1, 3, 6, 12 months post allo-SCT. NK cytotoxicity was assessed by isolating mononuclear cells from patient samples at each timepoint, comparing those on m-rom (n=10) versus those who did not receive m-Rom (n=5). Cells were targeted against K562 and T-cell lymphoma targets using the calcein-AM assay. Fine-Gray models were used to estimate PFS, OS, and cumulative incidence, and compare survival across groups. Results: To date, 28 patients have been enrolled, with a median age at transplant of 55, 50% female, 75% received MUD donor, and 68% utilized PB marrow source with 32% receiving BM. 16/28 (57%) had a diagnosis of T-cell leukemia, while 12/28 (42%) had a diagnosis of lymphoma. These included: T-ALL (18%), ETP-ALL (14%), ATLL (4%), T-PLL (21%), CTCL (7%), and PTCL (36%). 18% of patients entered transplant in a PR, while the remaining entered transplant in CR1 (61%) or CR2+ (21%). With a median follow-up time of 12 months, the median OS is 40 months (95% CI: 7.5-not reached), with a 1 and 3 year OS probability of 67% and 56%. The median PFS is 28.2 months (95% CI: 6.5-not reached), with 1 and 3-year PFS of 58% and 32%. Cumulative incidence (CI) of NRM at day 100 and 1 year were 15.6% and 19.8%. CI of grade II-IV aGHVD and extensive cGVHD were 42.9% and 19.1%. The CI of relapse (CIR) was 22.2% at 1 year (95% CI: 7.7-41.3%). There was no difference between PFS among patients with MRD versus those without MRD prior to transplant (p=0.71), and no difference in 1-year CIR (p=0.83). PFS at 1 year was substantially better in the lymphoma versus leukemia patients (78% vs 44%, p=0.02), though CIR at 1 year was not significantly different (13% vs 29%, p=0.12). No patients with PTCL relapsed, and 4/6 patients with T-PLL are alive, disease free. 16/28 (57%) of patients received m-rom with a median number of 12 cycles (range 1-39). 8 patients experienced grade 3/4 adverse events (AE), and 1 patient discontinued m-rom due to toxicity, unlikely related to romidepsin (loss of CD3 chimerism). NK-cytotoxicity was significantly higher at each time point in patients who received m-rom compared to those who did not (p<0.01). Further, when NK-cytotoxicity was assessed between the two groups after starting maintenance, NK-cytotoxicity in the m-rom group was significantly higher than in those without m-rom (p<0.0001) (Figure). Studies evaluating NK-cytotoxicity against patient T-cells are ongoing and will be presented at the ASH meeting. Conclusions: BuFluRom with m-rom is effective at decreasing relapse in patients with T-cell malignancies, with 1-year CI relapse below expected relapse rates for this set of diseases. NK-cell cytotoxicity data in a large sample set of trial patients demonstrates that m-rom enhances NK-cell cytotoxicity post allo-SCT, augmenting the GVL effect and likely accounting for at a minimum, some of the decrease in relapse seen on this trial. These results suggest long-term romidepsin past one year may decrease late relapse. Long-term follow-up is needed to evaluate these results, but these results suggest the BuFluRom regimen with m-rom should be strongly considered in patients receiving allo-SCT for T-cell malignancies to mitigate relapse. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Graft-Versus-Leukemia Effect Is Independent from Graft-Versus-Host Disease Following Ptcy-Based HLA-Haploidentical Transplantation

Background. The potential link between graft-versus-host disease (GVHD) occurrence and acute myeloid leukemia (AML) relapse in patients given human leukocyte antigen (HLA)-haploidentical allogeneic hematopoietic stem cell transplantation (Haplo-HCT) with post-transplant cyclophosphamide (PTCy)-based GVHD prophylaxis has remained debated. Here, we addressed this issue in a large cohort of AML patients with active AML at transplantation, a group of patients who mainly depends on graft-versus-leukemia (GVL) effects for tumor eradication. Methods. Population selection criteria for this study consisted of adults (>= 18 years old), first Haplo-HCT between 2010 and 2020 using PTCy-based GVHD prophylaxis, and primary refractory or relapsed AML (i.e. all patients had active disease at the time of transplant conditioning initiation). Twelve serial Landmark analyses from day 30 to day 365 were generated to assess the impact of GVHD on transplantation outcomes (dynamic landmarking). Results. A total of 803 patients met the population selection criteria. One hundred and thirty-three of them were excluded from the analyses because they died before achieving engraftment (n=90), received a second transplantation for graft failure (n=10) or because missing data in the registry on GVHD (n=31) or missing conditioning intensity (n=2). Therefore, the analyses were carried out in a cohort of 670 patients who were alive and had engrafted. Status at transplantation was primary refractory (55%), first relapse (35%) or second or more advanced relapse (10%). Conditioning was myeloablative in 289 patients. Two-year relapse and nonrelapse mortality incidences were 49% and 19%, respectively. Two-year leukemia-free survival (LFS) was 32%. There were no associations between acute nor chronic GVHD of any grade and lower relapse incidence. In contrast, each grade III-IV acute (HR=3.79, P<0.0001) and extensive chronic (HR=3.23, P<0.0001) GVHD correlated with higher nonrelapse mortality, translating to decreased LFS (HR=1.51, P=0.008 for grade III-IV acute and HR=1.90, P=0.0008, for extensive chronic GVHD, respectively). Conclusions. Our study suggests a dissociation of GvL effects from GVHD in patients with active AML given PTCy-based Haplo-HCT.

Comparison of Allogeneic Hematopoietic Cell Transplantation Outcomes from Younger Matched Unrelated Donor Versus Older Sibling Donor for Acute Myeloid Leukemia

Background: Aging population has resulted in an increase in the incidence of acute myeloid leukemia (AML). The median age of diagnosis for AML is 68 years. Allogeneic hematopoietic cell transplant (alloHCT) is a curative modality for patients with AML, however, disease relapse remains a major issue. Human leukocyte antigen (HLA)-matched sibling donors (MSD) are considered the preferred donor type in clinical practice. However, with increasing median age of patients, sibling donors for these patients are likely to be older as well, often with higher comorbidities. Prior registry studies demonstrated that older donor age is associated with inferior survival. A recent study in older MDS patients demonstrated reduced relapse risk with improved disease-free survival (DFS) with younger matched unrelated donors (MUD). However, the impact of donor age and type on alloHCT outcomes in AML patients remains unknown. Methods: This retrospective cohort study accessed data from the Center for International Blood and Marrow Transplant Research database (CIBMTR) in AML patients 50 years or older undergoing alloHCT from older (>50) MSDs or younger (<35) MUDs between 2011 and 2018. The study included common allograft types, conditioning regimens, and graft-versus-host-disease (GVHD) prophylaxis strategies. Other exclusion criteria were recipients of ex vivo T-cell depleted grafts, mismatched unrelated donor, cord blood or identical twin transplants. The primary outcome, compared between the 2 donor age groups, was relapse risk, and secondary outcomes included non-relapse mortality (NRM), DFS, and overall survival (OS). Cumulative incidence estimates were calculated for competing risks outcomes. To evaluate potential risk factors, multivariable cox regression was used, and relevant transplant-related covariates were considered. Interactions between the main effect (donor age group) and significant risk factors were tested. Fine and gray model was used for NRM and relapse. Results: Among 4684 eligible patients in the study cohort, 1736 underwent alloHCT with an older MSD (median age, 61 [range: 50-80]) whereas 2948 received transplant from a younger MUD (median age, 63 [range: 50-84]). In multivariable analysis, younger MUDs conferred a significantly decreased risk of relapse (HR 0.86; 95% CI, 0.77-0.96; p=.005) as compared to older MSDs (Table 1; Figure 1). The adjusted cumulative incidence of relapse at 5 years was significantly lower with younger MUDs (35%; 95% CI, 33-37%) versus older MSDs (41%; 95% CI, 38%-43%) (p=.003) (Table 2). NRM was reported in 2 subgroups of transplant years (2011-2015 and 2016-2018) as there was significant interaction between the main effect (MUD vs MSD) and alloHCT year (p=.003). Younger MUDs conferred an increased NRM (HR 1.24; 95% CI, 1.04-1.49; p=.016) compared to older MSDs in the earlier period of 2011-2015, whereas the NRM was lower with younger MUDs in the latter period of 2016-2018 (HR, 0.78, 95% CI, 0.64-0.96; p=.017) (Table1; Figure 1). While there was no difference in the adjusted cumulative incidence of NRM at 5 years in the latter period (17% vs 20%; p=.147), NRM was significantly higher in AML patients who underwent alloHCT between 2011 and 2015 from a younger MUD (28%; 95% CI, 25-30%) compared to older MSDs (24%; 95% CI, 20%-27%; p=.045) (Table2). There was no difference in OS or DFS rates of alloHCT with younger MUDs vs older MSDs (OS: HR 1.02; 95% CI, 0.94-1.12; p=.607; DFS: HR 0.92; 95% CI, 0.85-1.01; p=.073) (Table 1; Figure 1). While the adjusted 5-year OS probability was 47% in each of the 2 cohorts (p=0.95), the adjusted 5-year DFS probability was 44% with younger MUDs (95% CI, 42%-46%) as compared to 41% with older MSDs (95% CI, 38%-43%; p=.04) (Table2). Conclusions: This large study from a prospectively collected registry data found significant relapse reduction in AML patients who underwent alloHCT with younger MUDs as compared to older MSDs and highlights that a younger MUD donor type exerts a stronger GVL effect and should be preferred when available. The higher NRM associated with younger MUDs has decreased in recent years, likely due to enhanced GVHD prophylaxis, infection preemption and preventative strategies, and supportive cares measures translating into improved leukemia-free survival. The results aid in donor selection and younger MUDs should be preferred in AML patients at a higher risk for post-alloHCT relapse. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal