Hematopoietic Transplantation Research Articles

The Patient Perspective: Exploring the Meaning of Bedside Handoff on an Inpatient Hematopoietic Cellular Transplant Unit

Topic Significance & Study Purpose/Background/Rationale Delivery of patient-centered care in the hematopoietic cellular transplant (HCT) setting is grounded in communication between patients, caregivers and clinicians. Bedside shift handoff (BSH) provides a consistent forum for this communication and is designed to improve the patient care experience. Surrogate indicators of the patient's perception of care quality at our institution are reflected in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and leadership rounding. Neither source reflects indicators chosen by the patient, but instead by the institution and governing organizations. In 2016, BSH was implemented as an institution-wide initiative; however, HCT nursing staff continue to resist this change. Reasons cited by staff include the unit's consistently high HCAHPS scores and lack of a tailored BSH format for HCT recipients who often have prolonged inpatient stays and consistent nursing care. Nurses report that the current BSH can be “awkward”, “repetitive”, and “disruptive”. In practice, there is a recognized gap between nurses' commitment to meeting both the HCT patient's needs and alignment with the current BSH format. The purpose of this quality improvement initiative is to first understand the value of the current BSH format for patients admitted to the inpatient HCT unit. By collecting this data, we aim to increase staff compliance with and tailor BSH by infusing patient's perception of meaning and preferences. Methods, Intervention, & Analysis Following a review of the literature, two tools were developed. The first is an 11-item structured patient interview adopted from Wakefield, et al. (2012). This tool was designed to evaluate the patient/caregiver's perception of how well key elements of the current BSH were explained. The second tool is a 5-item survey designed to explore the value of key elements of BSH from the patient's perspective. Following review from our Institutional Review Board, these two tools will be offered one time during each admission to all patients admitted to the HCT unit for a period of three consecutive months. Aggregate data will be reviewed to inform development of a revised BSH tool, if indicated, for the HCT unit. Findings & Interpretation Summative data and the revised BSH format will be presented. Discussion & Implications In her theory of Bureaucratic Caring, Ray (1989) outlines unique dominant caring behaviors across clinical care settings. All are elements of the caring dimension, but adapted to the different needs of the patient population. For medical surgical units, the two dominant behaviors are “team” and “involvement”. Though both are clearly supported during BSH, we believe that the “one size fits all” standardized approach may not be optimal. We are looking to our patients with the hope of assigning increased meaning of BSH for both nurses, and most importantly, patients and their caregivers.

Harnessing MSC Osteoprogenitor Subpopulations to Augment Hematopoietic Transplantations

Adjuvant MSC infusions could improve transplantation outcomes via suppression of graft-vs-host reactions and enhancement of HSPC engraftment. However, bone marrow (BM) MSCs are a heterogeneous cell population, particularly when culture expanded to obtain therapeutically relevant cell numbers. A systematic study of expanded subpopulations is hindered by the lack of unique surface markers. In lieu of immunophenotype, we hypothesized and verified that biophysical properties of MSCs can be a useful strategy for isolating unique subpopulations. Here, we will describe a clinically relevant biophysical strategy for deriving different MSC subpopulations and discuss their potential utility in the context of hematopoietic transplantation. Cell diameter, membrane stiffness and nuclear membrane fluctuations are collectively predictive of at least two MSC subpopulations (multipotent and osteoprogenitors). Both MSC subpopulations are distinct in their transcriptome (different signatures of VEGF, IL8, ANG1, etc) and differentiation potential (osteogenic and adipogenic) but no surface marker reliably distinguishes them apart. In functional assays, osteoprogenitor vs multipotent MSCs show stronger capacities for CD34+CD38−HSPC expansion (Day 10: 42.7 ± 6.21 vs 29.1 ± 8.27, n = 5, respectively), but no significant differences (n = 3 biological repeats) in their ability to suppress CD8+T-cell proliferation in mixed lymphocyte reactions. When used as a rescue therapy for lethal irradiation, osteoprogenitors improved survival rates by 30-40% compared to multipotent MSCs. Part of the recovery process was prompted by MSC secretome mediated stimulation of BM tissue repair, including increased cell proliferation, reduced inflammation and the restoration of niche environments. These paracrine effects may be beneficial in fostering favorable post-myeloablative BM environments for donor HSPCs to home, engraft and survive. In murine transplantation models, we observed a higher rate of early engraftment following adjuvant therapy with osteoprogenitors. Week 4 CD45 chimerism in peripheral blood was 2- to 3- fold higher (∼11% vs ∼4%) in the osteoprogenitor treated group compared to the other MSC groups. These results demonstrate heterogeneity in expanded MSCs populations that would lead to inconsistencies in their overall properties. Newer biophysical technologies have the potential for isolating useful subpopulations defined by key quality attributes for specific forms of MSC-therapy; these capabilities may advance MSC-based therapy for regenerative medicine. Here, we demonstrate the augmentation of HSPC transplants in murine models using a biophysically isolated osteogenic MSC subpopulation (osteoprogenitors) which led to the fastest engraftment rates; this may be due to their superior abilities for promoting BM tissue regeneration as well as hematopoietic expansion.

Survival of Older Patients with AML and MDS after Allogeneic Hematopoietic Transplantation Is Best Determined By Combining Disease Risk and Comorbidity Indices

Disease Risk Index (DRI) and Hematopoietic Cell Transplant Comorbidity Index (HCT-CI) are independently validated and powerful pretransplant prognostic tools for overall survival (OS) of patients receiving allogeneic HCT (alloHCT) for hematological malignancies. Here we examined the prognostic significance of the DRI in conjunction with HCT-CI on OS among 341 elderly patients (≥60 years old) with AML (n=214) and MDS (n=127) who received alloHCT from 2005 to 2016. The median age at alloHCT for all patients was 66 (range, 60-76) years: 42% were age 60-64, 43% age 65-69 and 15% age ≥70. DRI classified patients as low/intermediate risk (LR/IR DRI, 63%) or high/very high risk (HR DRI, 37%). Nearly half of the patients had many comorbidities (HCT-CI ≥3) and 30% of all patients had lower Karnofsky Performance Status score (KPS Our findings suggest that most elderly patients with AML and MDS benefit from potentially curative alloHCT. Survival was worse for patients with combined high risk DRI and many comorbidities (HR DRI+ HCTCI ≥3). Thus, combining DRI and HCT-CI can serve as an effective pre-HCT tool to prognosticate survival after alloHCT. Age alone should not be a limiting factor in transplant decision making in otherwise eligible patients with AML and MDS.

CD34+ Selected Hematopoietic Transplant, an Option When Compliance Is a Concern in Pediatric Patients

Background The incidence of non-compliance is as high as 60% in pediatrics, making it a serious concern after hematopoietic stem cell transplant (HSCT), increasing treatment related mortality (TRM), graft versus host disease (GVHD) and decreases overall survival (OS). Risk of GVHD is 30-60%, therefore mitigating this risk when compliance is a concern is crucial. CD34+ selected grafts, have a very low incidence GVHD and can abolish the need for post HSCT immune suppression. Historically T-depleted grafts have been used to reduce incidence of GVHD for patients at risk (e.g. mismatched donor and fanconi anemia (FA) however it has not been studied in the context of compliance. Objectives Assess our institutional experience with pediatric T-depleted HSCT in the setting of risk of non-compliance. We hypothesized that T-depleted grafts result in adequate engraftment without increasing incidence of infections, graft failure and eliminate the risk for GVHD. Methods Retrospective chart review. Patients with FA or a highly mismatched donor were excluded. Results Five pediatric patients' underwent a CD34+ selected HSCT at our institution between 2016 and 2018, using reduced intensity conditioning (alemuzumab, fludarabine, melphalan). Stem cells were collected using the Miltenyi Biotec CliniMACS system. The median age and cell dose at HSCT were 3.4 years and 21.5 × 106 TNC/kg respectively. Demographics are summarized in table 1. All 5 patients had aplastic anemia and severe bone marrow failure. Median day of neutrophil and platelet recovery was day +11 and +12 respectively. No post HSCT calcineurin inhibitors were used and there was no GVHD. Morbidity post HSCT was most commonly transient viral reactivation and stool infections. The OS was 100% with sustained engraftment above 95% in 4, and the median follow up of 747 days. One patient had primary graft failure after 3 stem cell infusions and auto recovered at day +46 after last stem cell infusion and demonstrated adequate immune reconstitution after conditioning and HSCT. Conclusion These data support our hypothesis that T-depleted grafts can be an option for patients' with marrow failure syndromes and who are at risk for non-compliance with acceptable morbidity.

CD45 RA Depletion As an Allogeneic Hematopoietic Transplantation Platform in Children from HLA-Identical Donors

Background In hematopoietic transplantation, graft T lymphocytes play a determining role in promoting hematopoiesis, transferring immunity to pathogens and acting as mediators of the graft-versus-leukemia effect (GVL). However, they are also responsible for graft-versus-host disease (GVHD), the main cause of post-transplant morbidity and mortality. Depletion of CD45 RA lymphocytes, by eliminating naive T lymphocytes from inoculum, aims to conserve GVL without GVHD. Methods Since April 2016, 20 patients (12 boys and 8 girls), with a median age of 8 years, have undergone an allogeneic hematopoietic transplant from an HLA identical donor with CD45 RA depletion. Indication for transplant was: acute lymphoblastic leukemia (n=7), acute myeloblastic leukemia (n=7) and myelodysplasia (n=6). Donor was familiar in 7 cases and unrelated in 13. Conditioning regimen consisted on fludarabine, busulfan and thiotepa. Median of CD34 + cells infused was 6.82 × 106/ Kg. On day 0, +15 and +30 a programmed infusion of 1 × 106 / Kg lymphocytes CD45RA- was performed. Results All patients grafted with a median neutrophil (> 0.5 × 109/ L) and platelet (> 20 × 109/ L) engraftment time of 15 and 10 days, respectively. Only one patient has developed acute GVHD grade I and another patient has developed moderate chronic GVHD. Immune reconstitution was early and rapid in all lymphocyte subsets (see Figure 1). Four patient have relapsed so far. There was no case of toxic mortality. Overall survival was 77 ± 10% with a median follow-up of 1 year (2 months-2 years). At present, 17 patients are alive and doing well (Figure 2). Conclusions Allogeneic transplantation with CD45 lymphocytes RA depletion resulted on encouraging results, with a very low incidence of acute and chronic GVHD, but preserving the GVL effect by infusing CD45 RA- donor lymphocytes. Conflict of interest Miguel Angel Diaz, Marta Gonzalez-Vicent, Blanca Molina, Elena Sebastian, Josune Zubicaray, Julian Sevilla: Nothing to disclose. Keywords CD45RA depletion, Allogeneic transplant, Children

Leucovorin Following Methotrexate Graft-Vs-Host Disease Prophylaxis Shortens the Duration of Mucositis, Time to Neutrophil Engraftment and Length of Hospitalization in Myeloablative Allogeneic Hematopoietic Transplantation

Introduction Grade (gr) 2-4 mucositis complicates myeloablative (MAC) allogeneic hematopoietic transplantation (HCT) in 90% of patients. Methotrexate (MTX) GVHD prophylaxis (ppx) contributes to mucositis and delays engraftment. Severe mucositis increases patient-controlled analgesia (PCA) and TPN (total parenteral nutrition) use, length of stay (LOS) and precludes completion of post HCT MTX. Leucovorin (LCV) following MTX is controversial. Objectives To address exacerbation of mucositis by MTX, we implemented routine LCV post MAC alloHCT and compared outcomes with historical controls. The primary endpoint was the duration of gr 2-4 mucositis. Secondary endpoints were the incidence of gr 3-4 mucositis, time to engraftment, TPN and PCA use, LOS, incidence of GVHD and relapse. Methods Thirty-two consecutive adults received MAC alloHCT and MTX ppx with LCV 15 mg PO q6h x 4 doses, 12 h post d+3, +6, and +11 MTX and were compared to 33 consecutive historical controls. Controls did not receive routine LCV, but may have received ≥ 1 dose post d+6 or +11 MTX at physician discretion. Results Baseline characteristics were similar between the groups. All patients received tacrolimus and MTX GVHD ppx, most with Cy/TBI conditioning. Forty percent received peripheral blood stem cells and 60% had a matched unrelated donor. The median age was 46 y and 50% had AML. Thirty percent of controls received ≥ 1 LCV dose (most post d+11 MTX). The mean duration of gr 2-4 mucositis was shorter with LCV vs. control (7.4 vs. 11 d, p = 0.02). A trend towards lower incidence of gr 3-4 mucositis was observed with LCV (34% vs. 58%, p = 0.08). TPN use was similar between groups (25% vs. 36%, p = 0.4), however duration was shorter with LCV (8.6 vs. 21 d, p = 0.02). A trend towards less frequent PCA use was observed with LCV (34% vs. 58%, p = 0.08). Neutrophil engraftment was faster with LCV (17.6 vs. 20 d, p = 0.04) and a trend towards faster platelet engraftment was observed (15 vs. 20 d, p = 0.06). LOS was shorter with LCV (27 vs. 33 d, p = 0.01). LCV did not impact the incidence of GVHD. Relapse was less common in the LCV group (3% vs. 27%, p = 0.01) albeit with a shorter follow up (mean 202 d vs. 560 d). Conclusion Routine LCV addition to MAC alloHCT with MTX ppx shortened the duration of gr 2-4 mucositis, expedited neutrophil engraftment, shortened TPN and LOS and showed trends towards reduction in clinically important endpoints related to mucositis incidence, severity and associated supportive care. Our small sample size and non-randomized design may limit the strength of these conclusions. Differences between the groups may have been biased towards the null as 30% of controls received ≥ 1 LCV dose. LCV ppx warrants prospective evaluation to assess effects on mucositis, engraftment, GVHD, resource utilization and LOS.

Acute Graft-Versus-Host Disease (aGVHD, Non-Relapse Mortality) Risk Prediction Assay: Validation and Initial Reference Lab Experience

Introduction aGVHD affects 40% to 60% of hematopoietic cellular transplant (HCT) patients, targeting the skin, liver, and gastrointestinal tract with a median onset approximately 1 month after transplant. In 2017, an interpretive algorithm based on serum ST2 and REG3α levels was clinically validated (JCI Insight 2017;2(3):e89798). Objectives This report details validation, inter-lab correlation and initial results from clinical analysis. Methods ST2 and REG3α levels were analyzed in serum using enzyme immunoassays. ST2 and REG3α values are analyzed through an equation to provide an index value that can be used for predicting non-relapse mortality and aGVHD risk for pre-symptomatic (low/high risk), symptomatic onset (low/medium/high risk) and post treatment (low/high risk) HCT patients. Results were compared with the research lab where the equation was established (Mount Sinai Medical Center, MSMC). Results The inter-assay precision ranged from 12 to 26 %CV for ST2 and REG3a, while those for the calculated indices ranged from 17 to 18%. Accuracy was compared against biomarker values and indices reported by MSMC for 106 serum samples. Among samples with biomarker concentrations within the assays' measuring range, the relative error was Conclusions The aGVHD index and its component input assays, ST2 and REG3a, were validated for clinical use. Notably, excellent concordance was observed on a large sample set (106 sera) with MSMC. In addition, initial results indicate that the aGVHD index may prove useful for risk-stratifying HCT patients.

Clinical Outcomes Associated with Expansion of Fcr-Gamma-Deficient Natural Killer Cells in Allogeneic Stem Cell Transplant Patients

Background Natural killer (NK) cells are a part of the innate immune system and play a major role in immunity against viral infections and malignancies. Recently a new subset of NK cells has been discovered that lacks FcRg transmembrane signaling adaptor. These FcRg-deficient NK cells have been termed FcR gamma-negative NK or g-NK cells. The g-NK cells display a robust reaction against CMV and other viral infections in the presence of virus-specific antibodies. Study Objectives A longitudinal, prospective study is being conducted to observe the generation of g-NK cells in allogeneic hematopoietic transplant (AHSCT) patients after reactivation of CMV. The potential effect of g-NK cells on immunity against CMV and other viral infections, graft versus host disease (GVHD) and disease-free survival is being studied. Methods Blood samples from healthy donors and AHSCT patients were obtained pre- and post-transplantation. Flow cytometry was used to identify g-NK cells. Clinical data regarding CMV viremia, viral infections, GVHD and tumor free survival was collected and analyzed for 55 AHSCT patients. Results Of the 55 AHSCT patients, 49 were exposed to CMV and 13/49 (26%) generated g-NK cells. Subjects who were never exposed to CMV did not generate g-NK cells. Among patients with g-NK cell expansion, a higher incidence of Epstein-Barr virus (30.77% vs 19.05%) and adenovirus infections (7.69% vs 0%) was noted. Conversely, a trend towards decreased incidence of BK-virus infection (0% vs 11.9%) and GVHD (61.54% vs 71.43%) was observed. It is premature to comment on survival rate at 180 and 360 days. Conclusions G-NK cells appear in AHSCT recipients in response to CMV exposure. The response to some other common viral infections is variable in subjects with g-NK cell expansion. A slight decrease in incidence of GVHD has been observed in this population.

Hematopoietic stem cell transplantation in pediatric patients with β-thalassemia and sickle cell disease: An experience of the Spanish Working Group for Bone Marrow Transplantation in Children (GETMON)

Background and objectivesA recently occurring increase of the prevalence of haemoglobinopathies, β-thalassaemia major (TM) and sickle cell disease (SCD) over the last two decades in our country has generated new needs in terms of medical resources for both prevention and treatment of these patients. Allogeneic haematopoietic stem cell transplant (allo-HSCT) is a curative treatment available for patients who have severe haemoglobinopathies. The main objective of this study was to evaluate the results of allo-HSCT in paediatric patients with TM or SCD performed in paediatric haematopoietic transplant units within the Spanish Group of Bone Marrow Transplantation in Children (GETMON). Material and methodsRetrospective review of patients undergoing HSCT in the GETMON units until 2015. ResultsA total of 65 patients were analysed (43 patients were affected with TM and 22 with SCD), who received allo-HSCT in 6 GETMON units between November 1989 and December 2014. Event-free survival three years post-transplant was 81% and overall survival 92% in patients with TM. Event-free survival three years post-transplant was 79% and overall survival 85% in patients with SCD. ConclusionsThe results of this series are comparable to the results of other international series and offer a platform from which to continue trying to improve the evolution of these patients.

Mesenchymal Stem Cells as a Salvage Treatment for Severe Refractory Graft-vs-Host Disease in Children After Bone Marrow Transplantation

Application of mesenchymal stem cells (MSC) enables a novel approach to the therapy of graft- vs-host disease (GVHD) after hematopoietic stem cell transplantation. Herein we present our preliminary experience with the use of allogeneic bone marrow‒derived MSC in 9 pediatric patients after hematopoietic transplantation complicated by severe acute or chronic GVHD (aGVHD, cGVHD) resistant to steroids and second-line immunosuppressants. The MSC therapy was applied concurrently with immunosuppressive treatment in 5 patients as a single infusion, in four patients as 2-6 infusions. The median dose of cells per infusion was 1.9 × 106/kg of recipient body weight (range, 0.1–6.5 × 106/kg). The median quantity of cells applied to patients was 1.2 × 106/kg (range, 0.2–30.9 × 106/kg). We did not observe any adverse symptoms of MSC therapy. Overall, partial, or complete remission (PR and CR, respectively) was obtained in 56% of patients after the first MSC infusions, and 44% after completing therapy. In those with skin involvement 50% achieved permanent CR, 38% in those with gastrointestinal manifestations, and 33% in those with liver GVHD. Three patients with overlap syndrome had amelioration, but none had permanent remission. Long-term improvement after consecutive MSC doses was observed in 3 patients. In the 4- to 8-year follow-up, 3 patients are alive and 2 have attained permanent remission. Six patients died during follow-up: 4 with aGVHD and 2 with infectous complications. Co-treatment of streoid-resistant GVHD with MSC and conventional immunosuppression can improve the outcome, although therapy regimens remain to be established.

Impact of Day 14 Peripheral Blood Chimerism after Allogeneic Hematopoietic Stem Cell Bone Transplantation on the Treatment Outcome of Non-Malignant Disease.

BackgroundThe impact of early peripheral blood chimerism on the outcome of allogeneic hematopoietic stem cell transplantation (allo-HSCT) is unclear. We aimed to determine whether day 14 peripheral blood chimerism after allo-HSCT predicts outcomes in patients with non-malignant diseases.MethodsData from 56 patients who received allo-HSCT between April 2007 and March 2016 were retrospectively analyzed. Chimerism was evaluated using short-tandem repeat polymerase chain reaction, with mixed chimerism (MC) defined as greater than 1% recipient cells which was further categorized into low-level MC (> 1% and < 15% of recipient-derived cells) and high-level MC (≥ 15% of the recipient-derived cells).ResultsThirty-six patients showed complete donor chimerism (CC), 14 low-level MC, and 6 high-level MC at day 14 post-transplant. The estimated 5-year event-free survival (EFS) was higher in the CC or low-level MC groups than in the high-level MC group (86.1% vs. 71.4% vs. 33.3%; P = 0.001). In BM or peripheral blood stem cell (BM/PBSC) transplants, the 5-year EFS was higher in the CC or low-level MC group than in the high-level MC group (93.1% vs. 66.7% vs. 0%; P < 0.001). However, in cord blood transplants, the 5-year OS and EFS according to the day 14 peripheral blood chimerism did not reach statistical significance.ConclusionAlthough CC is not always necessary after allo-HSCT for non-malignant diseases, our data suggest that day 14 peripheral blood chimerism may predict outcomes in patients with non-malignant diseases who underwent BM/PBSC transplants.

Tuberculosis: A Complication after Hematopoietic Stem Cell Therapy (HSCT) and Bone Marrow Transplant

Tuberculosis: A Complication after Hematopoietic Stem Cell Therapy (HSCT) and Bone Marrow Transplant

Rapid Acquisition of Cytomegalovirus-Specific T Cells with a Differentiated Phenotype, in Nonviremic Hematopoietic Stem Transplant Recipients Vaccinated with CMVPepVax

Early cytomegalovirus (CMV) reactivation remains a significant cause of morbidity and mortality in allogeneic hematopoietic cell transplant (HCT) recipients. CMVPepVax is an investigational peptide vaccine designed to control CMV infection in HCT recipients seropositive for CMV by stimulating the expansion of T cell subsets that target the CMV tegument protein pp65. In a randomized Phase Ib pilot trial (ClinicalTrials.gov NCT01588015), two injections of CMVPepVax (at days 28 and 56 post-HCT) demonstrated safety, immunogenicity, increased relapse-free survival, and reduced CMV reactivation and use of antivirals. In the present study, we assessed the phenotypes and time courses of the pp65-specific CD8 T cell subsets that expanded in response to CMVPepVax vaccination. The functionality and antiviral role of CMV-specific T cells have been linked to immune reconstitution profiles characterized predominantly by differentiated effector memory T (TEM) subsets that have lost membrane expression of the costimulatory molecule CD28 and often reexpress the RA isoform of CD45 (TEMRA). Major histocompatibility complex class I pp65495-503 multimers, as well as CD28 and CD45 memory markers, were used to detect immune reconstitution in blood specimens from HCT recipients enrolled in the Phase Ib clinical trial. Specimens from the 10 (out of 18) vaccinated patients who had adequate (≥.2%) multimer binding to allow for memory analysis showed highly differentiated TEM and TEMRA phenotypes for pp65495-503-specific CD8 T cells during the first 100days post-transplantation. In particular, by day 70, during the period of highest risk for CMV reactivation, combined TEM and TEMRA phenotypes constituted a median of 90% of pp65495-503-specific CD8 T cells in these vaccinated patients. CMV viremia was not detectable in the patients who received CMVPepVax, although their pp65495-503-specific CD8 T cell profiles were strikingly similar to those observed in viremic patients who did not receive the vaccine. Collectively, our findings indicate that in the absence of clinically relevant viremia, CMVPepVax reconstituted significant levels of differentiated pp65495-503-specific CD8 TEMs early post-HCT. Our data indicate that the rapid reconstitution of CMV-specific T cells with marked levels of effector phenotypes may have been key to the favorable outcomes of the CMVPepVax clinical trial.

A retrospective analysis of haplo-identical HLA-mismatch hematopoietic transplantation without posttransplantation cyclophosphamide for GVHD prophylaxis in patients with adult T-cell leukemia-lymphoma.

Currently, allogeneic hematopoietic stem cell transplantation (allo-HCT) is the only available curative modality for patients with adult T-cell leukemia-lymphoma (ATL). When used in conjunction with posttransplantation cyclophosphamide (PTCY) for graft-versus-host disease prophylaxis, allo-HCT from an HLA haplo-identical donor yields promising outcomes for many diseases other than ATL. However, appropriate comparisons with other donor sources, especially cord blood and conventional HLA haplo-identical donors, are needed to validate the safety and efficacy of this modality. In this study, we retrospectively evaluated the outcome of allo-HCT without PTCY in patients with ATL registered in the Japan Society for Hematopoietic Cell Transplantation TRUMP database between 1985 and 2015. During that period, 46 patients received allo-HCT without PTCY and survivors were followed for a median of 2316.5 days (range: 220-3884 days). Although the estimated 1- and 5-year overall survival rates of the entire cohort were 34.5% and 17.7%, respectively, the cumulative 1- and 5-year non-ATL mortality rates of 41.3% and 55.8%, respectively, were high. The results of our study will serve as a platform for discussions of the safety and efficacy of haplo-HCT for future clinical trials in patients with ATL.

Cost Analysis of Hematopoietic Autologous Transplantation with and without DMSO Cryopreservation

Introduction.The use of cryopreservation of hematopoietic precursors for autologous or allogeneic transplantation with DMSO is a procedure commonly used in many countries, but it is expensive and is not exempt of risks, since serious adverse events have been described. Our group recently published a comparative study between two centers and showed that avoiding DMSO cryopreservation favors better transplantation tolerance, significantly shorter hospitalizations, fewer episodes of febrile neutropenia and mucositis. In this report we show the financial analysis of both modalities of CRYO and Non CRYO preserved transplants.MethodologyDatabase of the adult hematopoietic transplant program of our institution was retrospectively analyzed. Since Non CRYO modality was initiated in our institution on 2015, we compared 3 years before and after that date, assigning two groups (CRYO and Non CRYO). Costs data of mobilization, apheresis, hospitalization, freezing and blood banking were analyzed.ResultsBetween 2013 and 2018, 90 autologous hematopoietic transplants were performed, 41 CRYO and 49 Non CRYO. The average cost of mobilization therapy with filgrastim and the use of plerixafor did not differ between groups (p = 0.26). The number of apheresis needed to achieve a satisfactory count was higher in CRYO (median 1.5 vs 1.2 p = 0.001) with 55% higher cost on average. The cost of transplant hospitalization including antibiotics costs, blood banking costs, analgesics requirements and nutritional parenteral support was lower in Non CRYO (minimum cost USD 8000, maximum USD 160000 average value USD 20.000) than in CRYO (minimum cost USD 11.000, maximum USD 200.000, average value USD 32000) (p = 0.001).ConclusionsIn addition to promoting better patient tolerance, Non CRYO modality in our country has lower cost. This information has important relevance for health systems of developing countries and can promote better access to transplant. DisclosuresNo relevant conflicts of interest to declare.

Adoptive Therapy with EBV-Specific T Cells for Treatment of CNS EBV Post-Transplant Lymphoproliferative Disease Arising after Hematopoietic Stem Cell Transplant or Solid Organ Transplant

Adoptive immunotherapy with EBV-specific T-cells (EBV-CTLs) derived from primary hematopoietic transplant donors is effective in the treatment of EBV disease complicating allogeneic hematopoietic stem cell transplant (HCT). In addition, third party donor-derived EBV-CTLs (tabelecleucel) have demonstrated efficacy in the treatment of EBV post-transplant lymphoproliferative in the setting of both HCT and solid organ transplant (SOT). While the introduction of first line therapy with rituximab has reduced the mortality associated with EBV-PTLD, EBV PTLD involving the central nervous system (CNS) remains a particularly ominous event as the efficacy of rituximab for CNS disease is limited by poor CNS bioavailability.Between 1996 and 2016 we treated nineteen patients for EBV-PTLD involving the CNS arising after HCT (12) or SOT (7). These patients received EBV-CTLs from their primary transplant donor (7), tabelecleucel from a third-party donor (11) or from both types of donor (1). Patients were treated for either isolated CNS disease (10) or CNS and systemic disease (9). Patients developing EBV-PTLD after HCT were recipients of T Cell Depleted (N=6), cord blood (N=3) and conventional (N=3) transplant. Those developing EBV-PTLD after SOT had undergone renal (N=4) heart (1) liver (1) and heart/liver (1) transplants.All of these patients had received prior therapy including rituximab (N=17), radiation therapy (N=6), and chemotherapy (N=9).Primary donor EBV-CTLs were generated from EBV seropositive hematopoietic transplant donors at the time of or after the patient underwent transplant. Third party tabelecleucel were selected from a bank of 330 lines generated under GMP conditions from normal HCT donors who specifically consented to use of their T cells in patients other than their designated transplant recipient. Selection of third party tabelecleucel lines was made on the basis of HLA restriction by at least one HLA allele shared by the patient's tumor and the HCT donor, and matching for ≥ 2/10 recipient alleles. Patients received 3 weekly infusions of approximately 1-2x106 T cells/kg/infusion. Patients were sequentially evaluated for clinical and radiographic response, and quantifications of EBV DNA by PCR. Patients not achieving a complete response to an initial cycle of EBV directed cellular therapy were eligible to receive subsequent cycles of cells from either the same or a different donor. Responses were assessed 21-35 days after the first of each cycle of EBV-CTLs. Responses were evaluated based on Lugano criteria with CNS disease being assessed by MRI, CSF or thalium scan. Two patients treated for CNS and systemic disease had simultaneous therapy of their CNS disease and achieved responses of both CNS and systemic disease but the CNS specific response could not be attributed to cell therapy alone.Of the 19 patients, 7 achieved complete responses and 5 durable partial responses for an overall response rate of 63%. The one-year overall survival (OS) for this cohort of 19 patients was 60% with responding patients experiencing one year OS of 91.7% and non-responding patients one year OS of just 14.3%. Eight of the 10 patients treated for isolated CNS disease responded to adoptive EBV directed T cell therapy. One-year overall survival for patients treated for isolated CNS disease is 70% and with CNS and systemic disease is 55.6%. Toxicities associated with infusions in this cohort are limited with 8 patients experiencing adverse events of ≥ grade 3 severity with one patient experiencing a possibly related grade 3 eventThis study demonstrates a high response rate among patients with otherwise refractory EBV PTLD affecting the CNS. Adoptive therapy with EBV directed cellular therapy (primary donor or third party derived) can effectively treat this otherwise frequently lethal complication. The availability of 3rd party tabelecleucel enables treatment early in the course of disease and may thereby improve response rates while minimizing toxicity from chemotherapy.Atara Biotherapeutics holds the IND and has a license to develop and commercialize the EBV and CMV cell therapy programs at Memorial Sloan Kettering. MSKCC and several MSK investigators hold a financial interest in Atara Biotherapeutics. DisclosuresProckop:Atara Biotherapeutics: Research Funding; Mesoblast: Research Funding. Doubrovina:Atara Biotherapeutics: Consultancy, Patents & Royalties, Research Funding. Sauter:Juno Therapeutics: Consultancy, Research Funding; Sanofi-Genzyme: Consultancy, Research Funding; Spectrum Pharmaceuticals: Consultancy; Novartis: Consultancy; Precision Biosciences: Consultancy; Kite: Consultancy. O'Reilly:Atara Biotherapeutics: Consultancy, Patents & Royalties, Research Funding.

How Adoptive Immunotherapy with Conventional T and Regulatory T Cells Exerts a Gvl Effect without GvHD, after Haploidentical Hematopoietic Transplantation

▪Post-transplant relapse is still a major cause of treatment failure in high-risk acute leukemia (AL) patients. Attempts to manipulate donor T cell alloreactivity to spare normal tissues while killing leukemic cells have been largely unsuccessful. In the search for strategies to separate the GvL effect from GVHD, we investigated the role of a thymic-derived CD4+CD25+ FoxP3+ regulatory T-cell subpopulation (Tregs) that physiologically helps maintain immunological self-tolerance and immune homeostasis. Evidence from murine bone marrow (BM) transplantation across major histocompatibility barriers showed co-infusion of conventional T lymphocytes (Tcons) with Tregs suppressed lethal GVHD without impairing Tcon activity against malignant diseases. In 69 high-risk AL patients who had received an HLA haploidentical T cell-depleted hematopoietic transplant and no post-transplant immunosuppressive GvHD prophylaxis, adoptive immunotherapy with donor Tregs (2 × 106/kg) and Tcons (1 × 106/kg) protected patients from GvHD (Di Ianni et al., Blood 2011) and largely prevented post-transplant leukemia relapse. In fact, only 5% of patients relapsed (Martelli et al., Blood 2014). However, also because such patients had advanced stage disease, TRM was still in the range of that of T cell-depleted haplo transplants, (i.e. 40%, Aversa et al., JCO 2005). A current cohort of AL patients was conditioned with total body irradiation (TBI) (8Gy as single dose TBI or 13.5 Gy as fractionated TBI), cyclophosphamide (30mg/kg), thiotepa (8mg/kg) and fludarabine (200mg/m2). To date, 24 high-risk AL patients (7 ALL, 17 AML) have been enrolled. Twenty-two of the 24 patients engrafted, one AML patient relapsed, 4/22 developed aGvHD (4/4 are alive) and one developed cGvHD, TRM was exceptionally low (Fig. 1). At a median follow up of 2 years, 19 patients are alive. Consequently, probabilities of leukemia-free and leukemia/cGVHD-free survivals are good (Fig. 1). Hypotheses have been put forward to explain the ability of Tregs to prevent of GvHD while preserving the GvL effect mediated by Tcons. However, the mechanism is still unknown. In humans, naïve CD45RA+ Tregs express CXCR4 BM homing receptor and preferentially localize to the BM while memory CD45RO+ Tregs display lower CXCR4 expression and home to the periphery (Booth et al., J Immunol. 2010). Since Tregs that are recovered from peripheral blood and are used for adoptive immunotherapy are CD45RO+ and largely CxCR4 negative, we hypothesized that GvL without GvHD might be due to unopposed Tcon alloreactivity in the BM combined with regulated T cell alloreactivity at the periphery. In order to verify such hypothesis, we infused NSG mice with human leukemia and human Tregs and Tcons. Mice that received leukemia and haploidentical Tcons (without Tregs) cleared leukemia but died of GvHD. T cells harvested from their BM, spleen and liver were predominantly CD8+ and displayed alloreactivity against leukemia. Mice that received leukemia and Tcons plus Tregs were rescued from leukemia and survived without GvHD. T cells harvested from spleen and liver were composed of CD8+ T cells (40%) and CD4+T cells (60%). Purified CD4+ T cells had retained their regulatory function as they inhibited mixed lymphocyte reaction. Purified CD8+ T cells displayed no alloreactivity against leukemia. In contrast, T cells harvested from BM were still predominantly CD8+ and still displayed alloreactivity against leukemia suggesting Tcons had retained their alloantigen recognition. Finally, in mice treated with Tregs alone, T cells were recovered only in the spleen and liver, they displayed a CD4+ phenotype and inhibited mixed lymphocyte reaction. No T cells were found in the BM. In contrast, when we infused human purified CD45RA+ naïve Tregs (that display the CXCR4 BM homing receptor), mice died of leukemia progression despite the co-infusion of large doses of Tcons. In the BM we isolated CD8+ T cells that displayed no ability to kill leukemia and CD4+ T cells that displayed regulatory function. Thus, naïve Tregs homed to the BM and blocked the GvL effect of T cons. When CXCR4 was blocked with an anti-CXCR4 antibody, naïve Tregs could not home to the BM and T cons killed leukemia. In conclusion, Treg-Tcon adoptive immunotherapy confines the graft-versus-host alloreaction to the hematopoietic system and, consequently, allows a GvL effect without GvHD. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Leucovorin Following Methotrexate Graft-Vs-Host Disease Prophylaxis in Myeloablative Allogeneic Hematopoietic Transplantation Shortens the Duration of Mucositis and Hospitalization

Leucovorin Following Methotrexate Graft-Vs-Host Disease Prophylaxis in Myeloablative Allogeneic Hematopoietic Transplantation Shortens the Duration of Mucositis and Hospitalization

Post-Transplantation Cyclophosphamide Versus Low Doses ATG Fresenius As Part of Two Immunosuppression Regimens for Graft Versus Host Disease Prophylaxis: Low Severe Graft Versus Host Disease (GVHD) Incidence and y Similar Gvhd-Free and Relapse-Free Survival (GRFS)

BACKGROUND AND OBJECTIVES.Post transplantation High dose Cyclophosphamide (PTCY) used in haploidentical hematopoietic transplantations, has a high effectivity in acute Graft versus Host Disease (aGVHD), and chronic Graft versus Host Disease prophylaxis (cGVHD), however it is associated with high relapse rates. On the other hand, Anti-T-Lymphocyte Globulin (ATG-Fresenius ®) is also effective as immunosuppressive (IS) drug, but its benefit on Overall Survival (OS) and Relapse Free Survival (RFS) is unclear.The aim of this study was to compare the effectiveness of two GVHD prophylaxis regimes used in high risk transplantation: PTCY used in Haploidentical transplantation and ATG used for peripheral blood, non-related, related and mismatched donors.The primary endpoint was to evaluate the incidence of aGVHD and cGVHD, and its severity in both groups. As secondary endpoints we analyse the OS, RFS and GRFS (recorded adverse events include grade 3-4 aGVHD, systemic therapy-requiring cGVHD, relapse or death during median follow-up). We also consider transplantation related mortality (TRM) and post-transplantation complications.PATIENTS AND METHODS.We retrospectively analyse 111 allo-transplantations performed at our institution between 2012 and 2017. We analyse two cohorts: 49 haploidentical transplantation with PTCY (50 mg/kg, on day +3, +4) followed by Tacrolimus and Mycophenolate; and 62 peripheral blood related, non-related and mismatched with low dose ATG Fresenius (7mgr/Kg on days -3, -2, -1) associated with Tacrolimus/Cyclosporine starting on day -1 with a short course Methotrexate (on day +1, +3, +6) or Mycophenolate. Mycophenolate was stopped on day +28 and Cyclosporine or Tacrolimus were tapered on day +50.RESULTS.There were no differences in patients' age (49 vs 51), sex or pre-transplantation HCTI-score ≥ 3 (30 vs 26) between PTCY and ATG groups. We found differences between diagnosis (lymphoproliferative disorders (16 vs 4, p= 0.003), high DRI-score (18 vs 11, p = 0.04), number of previous transplantations (12 vs 5, p= 0.02), reduced intensity conditioning regimen (36 vs 20, p < 0.001) and bone marrow as stem cells source (38 vs 9, p < 0.001) between PTCY and ATG groups.The median time to neutrophil engraftment (>500/uL) was similar: 17 days [13-34] for PTCY and 16 days [9-33] for ATG. Median time to platelet recovery was higher in PTCY cohort (33 vs 18 days, p= 0.016). There were 3 secondary graft failures in PTCY group vs 4 graft failures in ATG (3 primary, 1 secondary).The were no differences in grade 2 - 4 aGVHD incidence between groups (PTCY:30.6% vs ATG:36.4%), but we found differences in grades 3 - 4 aGVHD (PTCY:4.1% vs ATG: 9%, p=ns).The global incidence of any NIH grade cGVHD was 56.1% in PTCY vs 66% in ATG group. Mild, moderate and severe cGVHD incidence were 31.7%, 19.5% and 4.8% for PTCY vs 28%, 26% and 12% in ATG (p=ns).The median duration of IS in alive patients with cGVHD was 6.5 months [3-19] in PTCY patients and 10 [3-34] in ATG group. Among moderate and severe forms, the median IS duration was 10 and 5 months in PTCY group vs 13 and 12 months in ATG respectively.PTCY cohort developed more non-infectious complications, especially, cardiac, lung, digestive and neurologic complications, (p=0.086), however there were not differences in infectious complications (Table 1).TRM was similar between groups, 18.4% for PTCY vs 22.5% for ATG, (p=0.250). We didn´t find differences in early toxic mortality (<100 days): 16.3% for PTCY and 14.5% for ATG (p=0,421).With a median follow-up of 27 months in alive patients (28 months for PTCY and 22 months for ATG) we report an 67.8 % and 61% OS at 12 and 24 months for PTCY and 68.8% and 59.9% for ATG (Log Rank=0.971). Relapse free survival at 12 and 24 months was 61% and 57.9% for PTCY and 69% and 54% for ATG (Log Rank=0.839).GRFS at 12 and 24 months was 46.5% and 42.9% for PTCY patients and 40.7% and 33% for ATG patients, (Log Rank = 0.433).CONCLUSIONS.Regardless the different scenarios between transplantation cohorts, the use of PTCY and low dose ATG are equally effective in the prophylaxis of severe forms of aGVHD and cGVHD, offering similar GRFS. PTCY shows higher early toxicity but a similar rate of infectious events. In order to validate these results, it would be necessary to carry out a randomized controlled trial. DisclosuresNo relevant conflicts of interest to declare.

Impact of t(11;14) on the Outcome of Autologous Transplantation in Multiple Myeloma: A Matched-Pair Analysis

Abstract:Background:The translocation t(11;14)(q13;q32) is the most common chromosomal translocation in multiple myeloma (MM) with a reported frequency of 15-20%. Most, but not all, reports in the literature have identified this translocation with a relatively favorable outcome. In a smaller cohort, we had previously reported the impact of t(11;14) on the outcomes of MM patients who underwent autologous hematopoietic transplantation (auto-HCT) at our institution1. In this study, we present an updated analysis with a larger cohort of t(11;14) patients, and compared their outcomes to a propensity-matched control group of MM patients with normal diploid cytogenetics and no high-risk abnormalities detected by Fluorescence in Situ Hybridization (FISH).Methods and patients:A total of 1365 MM patients underwent auto-HCT at our institution from 2007 to 2015. We identified 95 patients with t(11;14) by FISH before auto-HCT. Out of these 95 patients, 44 had t(11;14) alone, 26 had co-existent high-risk abnormalities and remaining 25 had standard-risk abnormalities. The control group included 287 MM patients with normal diploid cytogenetics and no abnormalities detected by FISH. From the above two cohorts, using a 1:1 propensity score-matched analysis without replacement, we identified matched controls for 79 patients with t(11;14). Clinical response, relapse, and progression were defined by the International Myeloma Working group criteria. The FISH technique was performed using a LSI IGH/CCND1 XT dual color, dual fusion translocation probe from Abbott Molecular, Inc. The normal cut off for IGH/MYEOV/CCND1 rearrangement using LSI IGH/CCND1 XT probe established at 95 (P<0.05) confidence level in the our Cytogenetics Laboratory is 0.4% for 1R1G2F; 1.1% for 2R2G1F; 3.4% for 3R2G; 7.4% for 2R3G and 0% for 1R3F signal patterns.Results:Table 1 includes the baseline characteristics of the matched doublets. Patients in both groups were well matched for age, ISS stage, serum creatinine, response to induction therapy, induction and preparative regimens, and maintenance therapy. The median follow-up time for the cohort was 48.1 months (range: 0.8-124.6). The overall response rate (CR+VGPR+PR) after auto-HCT was 77/79 (97%) and 78/79 (99%) patients in the t(11;14) and the control group, respectively (P = 1.00). Twenty eight (35%) and 37 (47%) patients achieved a CR in the t(11;14) and the control group, respectively. VGPR rate in the t(11;14) and the control group was 35 (44%) and 31 (39%), respectively. The median PFS for the t(11;14) and the control groups were 33.3 (95%CI: 25.8-not reached) and 39.7 (95%CI: 36.6-not reached) months, respectively (p = 0.24, stratified log-rank test). The median OS has not been reached for both groups (p=0.35). The 4-year PFS rates in the t(11;14) and the control groups were 42% (95%CI: 31%-57%) and 50% (95%CI: 38%-65%), respectively (Fig. A). The 4-year OS rates in the t(11;14) and the control groups were 76% (95%CI: 65%-90%) and 87% (95%CI: 79%-97%), respectively (Fig. B).Conclusions:On a propensity score matching analysis, multiple myeloma patients with translocation t(11;14) had similar response rates, PFS and OS to auto-HCT as standard-risk patients with normal cytogenetics or FISH studies.