Matched Sibling Donor Transplantation Research Articles

Comparison of haploidentical hematopoietic stem cell transplantation and matched-sibling donor transplantation for the treatment of paroxysmal nocturnal hemoglobinuria

目的比较单倍型与同胞全相合移植治疗阵发性睡眠性血红蛋白尿症（PNH）的疗效及安全性。方法总结2007年7月至2018年5月40例（单倍型移植25例，同胞全相合移植15例）接受异基因造血干细胞移植的PNH患者临床资料，对两组疗效及安全性进行比较。结果单倍型移植组及同胞全相合移植组患者性别、年龄、PNH-再生障碍性贫血（AA）患者比例、诊断至移植时间差异均无统计学意义（P>0.05）。单倍型移植组及同胞全相合组回输单个核细胞数（MNC）分别为10.74（4.80~22.86）×108/kg与12.19（5.14~17.25）×108/kg（P=0.866），回输CD34+细胞数分别为3.57（0.68~7.80）×106/kg与4.00（3.02~8.42）×106/kg（P=0.151）。所有患者均成功植入，单倍型移植组及同胞全相合移植组粒细胞植入时间分别为12（9~26）d与11（7~15）d（P=0.065），血小板植入时间分别为19（11~75）d与13（11~25）d（P=0.027）。单倍型移植组与同胞全相合移植组Ⅰ~Ⅳ度急性GVHD发生率分别32.0%、20.0%（P=0.343），Ⅱ~Ⅳ度急性GVHD发生率分别为16.0%、13.3%（P=0.759）。慢性GVHD发生率分别为30.7%、24.6%（P=0.418），中重度慢性GVHD发生率分别为12.7%、7.1%（P=0.522）。移植过程中单倍型移植组与同胞全相合移植组感染发生率分别为32.0%（8/25）、26.7%（4/15）（P=1.000），未发生早期死亡。单倍型移植组及同胞全相合移植组预期3年总生存（OS）率分别为（86.5±7.3）%、（93.3±6.4）%（P=0.520），无移植物抗宿主病无失败生存（GFFS）率分别为（78.3± 8.6）%、（92.9 ± 6.9）%（P=0.250）。在随访期内两组患者均无复发。结论单倍型移植用于治疗PNH具有与同胞全相合移植相似的疗效及安全性，在无全相合供者情况下可作为PNH患者有价值的治疗手段。

Antilymphocyte globulin for matched sibling donor transplantation in patients with myelofibrosis.

The use of antihuman T-lymphocyte immunoglobulin in the setting of transplantation from an HLA-matched related donor is still much debated. Acute and chronic graft-versus-host disease are the main causes of morbidity and mortality after allogeneic hematopoietic stem cell transplantation in patients with myelofibrosis. The aim of this study was to evaluate the effect of antihuman T-lymphocyte immunoglobulin in a large cohort of patients with myelofibrosis (n=287). The cumulative incidences of grade II-IV acute graft-versus-host disease among patients who were or were not given antihuman T-lymphocyte immunoglobulin were 26% and 41%, respectively. The corresponding incidences of chronic graft-versus-host disease were 52% and 55%, respectively. Non-adjusted overall survival, disease-free survival and non-relapse mortality rates were 55% versus 53%, 49% versus 45%, and 32% versus 31%, respectively, among the patients who were or were not given antihuman T-lymphocyte immunoglobulin. An adjusted model confirmed that the risk of acute graft-versus-host disease was lower following antihuman T-lymphocyte immunoglobulin (hazard ratio, 0.54; P=0.010) while it did not decrease the risk of chronic graft-versus-host disease. The hazard ratios for overall survival and non-relapse mortality were 0.66 and 0.64, with P-values of 0.05 and 0.09, respectively. Antihuman T-lymphocyte immunoglobulin did not influence disease-free survival, graft-versus-host disease, relapse-free survival or relapse risk. In conclusion, in the setting of matched related transplantation in myelofibrosis patients, this study demonstrates that antihuman T-lymphocyte immunoglobulin decreases the risk of acute graft-versus-host disease without increasing the risk of relapse.

Association of Persistent Minimal Residual Disease with Poor Outcomes of Patients with Acute Myeloid Leukemia Undergoing Allogeneic Hematopoietic Stem Cell Transplantation.

Background:Several studies have shown that detection of minimal residual disease (MRD) in acute myeloid leukemia (AML) is an independent prognostic factor. This study aimed to evaluate the significance of dynamic MRD pretransplantation on outcome of AML patients receiving allogeneic hematopoietic stem cell transplantation (allo-HSCT).Methods:We retrospectively analyzed 145 consecutive AML patients undergoing allo-HSCT in complete remission status between June 2013 and June 2016. MRD was determined with multiparameter flow cytometry after the first and second courses of chemotherapy and pre-HSCT.Results:In matched sibling donor transplantation (MSDT) settings, patients with positive MRD had higher cumulative incidence of relapse (CIR) than those without MRD after the first (32.3 ± 9.7% vs. 7.7 ± 3.1%, χ2 = 3.661, P = 0.055) or second course of chemotherapy (57.1 ± 3.6% vs. 12.5 ± 2.7%, χ2 = 8.759, P = 0.003) or pre-HSCT (50.0 ± 9.7% vs. 23.0 ± 3.2%, χ2 = 5.547, P = 0.019). In haploidentical SCT (haplo-SCT) settings, the MRD status at those timepoints had no significant impact on clinical outcomes. However, patients with persistent positive MRD from chemotherapy to pre-HSCT had higher CIR than those without persistent positive MRD both in MSDT and haplo-SCT settings. Patients with persistent positive MRD underwent MSDT had the highest relapse incidence, followed by those with persistent positive MRD underwent haplo-SCT, those without persistent MRD underwent haplo-SCT, and those without persistent MRD underwent MSDT (66.7 ± 9.2% vs. 38.5 ± 6.0% vs. 18.8 ± 8.7% vs. 12.0 ± 1.0%, χ2 = 20.763, P < 0.001). Multivariate analysis showed that persistent positive MRD before transplantation was associated with higher CIR (hazard ratio [HR] = 1.69, 95% confidence interval [CI]: 1.200–2.382, P = 0.003), worse leukemia-free survival (HR = 1.812, 95% CI: 1.168–2.812, P = 0.008), and overall survival (HR = 2.354, 95% CI: 1.528–3.627, P < 0.001).Conclusion:Our results suggest that persistent positive MRD before transplantation, rather than positive MRD at single timepoint, could predict poor outcome both in MSDT and haplo-SCT settings.

Haplo-SCT Mediates Stronger GVL Effect Than HLA-Matched Sibling Allograft By Significantly Reducing Leukemia Burden

For AML patients with positive pre-transplant minimal residual disease (MRD), determined by multicolor flow cytometry (MFC), haploidentical stem cell transplantation (haplo-SCT) could achieve lower CIR rates than human leukocyte antigen (HLA)-matched sibling donor transplantation (MSDT) (J Hematol Oncol. 2017;10(1):134).However, these data only provide indirect evidence supporting the idea that haplo-SCT might have a strong graft-versus-leukemia (GVL) effect compared with MSDT. Therefore, direct evidence is needed to determine whether treating AML with haplo-SCT has a stronger GVL effect.The real time-polymerase chain reaction (RT-PCR) has greater sensitivity and specificity than MFC for detecting leukemia-specific genes, such as RUNX1/RUNX1T1, and provides a better estimation of the leukemia burden. Based on the levels of RUNX1/RUNX1T1 transcripts determined by RT-PCR, our group found that treating high risk cases with t(8;21) AML, who did not achieve major molecular remission (MMR, defined as a >3-log reduction in RUNX1/RUNX1T1 transcripts), with allogeneic stem cell transplantation (allo-SCT) could reduce the CIR compared with chemotherapy alone (22.1% vs 78.9%, P < 0.0001). These findings suggest that allo-SCT is necessary for high-risk t(8;21) AML patients, which provides an opportunity to investigate whether haplo-SCT has a superior GVL effect compared with MSDT in treating AML. Therefore, we focused on t(8;21) AML cases with positive MRD pre-transplant who underwent allogeneic SCT. The purpose of this study was to investigate and provide direct evidence that a haploidentical allograft has superior anti-leukemia effects compared with a HLA-matched sibling allograft.In the present study, One hundred and thirty-five t(8;21) acute myeloid leukemia (AML) patients with positive pre-transplantation minimal residual disease who underwent a haplo-SCT or MSDT were enrolled in this study. The levels of RUNX1/RUNX1T1 transcripts were monitored and quantified by real-time quantitative PCR. The 3-year cumulative incidence of relapse (CIR), non-relapse mortality (NRM), leukemia-free survival (LFS), and overall survival (OS) were 19%, 21%, 60%, and 61%, respectively. The levels of RUNX1/RUNX1T1 were significantly lower in Haplo-SCT patients compared with MSDT patients at 60 (P=0.039) and 90 (P=0.004) days after transplant (Figure 1). Compared with pre-transplant, the leukemia burden in the haplo-SCT group was significantly more reduced than in the MSDT group at 30 (P=0.068), 60 (P=0.005), 90 (P<0.0001), and 180 (P=0.032) days after transplant. The 3-year CIR rates for the haplo-SCT and MSDT patients were 14% and 28%, respectively (P=0.036). The 3-year LFS (68% vs. 47%, P=0.025) and OS (71% vs. 48%, P=0.040) after haplo-SCT were significantly higher than the rates after MSDT. In multivariate analysis, haplo-SCT was associated with a lower incidence of relapse (HR: 0.141; P=0.001) and a better LFS (HR: 0.187; P<0.0001) and OS (HR: 0.215; P=0.001). Our results provide direct evidence that a haplo-SCT has stronger graft-versus-leukemia effects than MSDT in patients with t (8;21) AML by significantly reducing the leukemia burden.Figure 1. Kinetics of log-transformed leukemia burden reduction (evaluated by RT-PCR for RUNX1/RUNX1T1) in all patients and subgroup cases who either received haplo-SCT or MSDT, using a repeated measures ANOVA. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Chidamide-Containing Conditioning Allogenic Hematopoietic Stem Cell Transplantation Improves Prognosis of Acute Lymphoblastic Leukemia with Pre-Transplant Response Less Than Complete Remission

Background: Allogeneic hematopoietic stem cell transplantation (HSCT) is a curative option currently offered to patients with high-risk or relapsed acute lymphoblastic leukemia (ALL). However, active disease or minimal residual disease (MRD) prior to HSCT is associated with early relapse and poor prognosis with long-term survival less than 30%. We have confirmed that chidamide, a selective histone deacetylase inhibitor (HDACi), work synergistically with cytotoxic agents such as combination of cladribine, gemcitabine and busulfan as conditioning therapy against lymphocytic malignancies. Here, we conducted a clinical trial to evaluate the efficacy of chidamide containing conditioning allo-HSCT in patients with these high-risk ALLs.Methods: Patients with active ALL or MRD received a myeloablative conditioning consisting of chidamide, fludarabine, cytarabine and busulfan (ChiFAB), followed by infusion of peripheral blood hematopoietic stem cells from related or unrelated donors. The ChiFAB was administered as following: chidamide was given orally at 20 mg twice weekly started from D-7 for 3 weeks; fludarabine was given intravenously at 30 mg/m2 D-6 to D-2; cytarabine was given 4 hours after the finish of fludarabine at 1 g/m2 D-6 to D-2; and busulfan was given intravenously once daily at 3.2 mg/kg D-6 to -3. Prophylaxis of acute graft-versus-host-disease were posttransplant cyclophosphamide plus cyclosporine for matched donor transplants, and additional post-transplant anti-thymocyte globulin and mycophenolate mofetil for haplo-HSCT. Donor lymphocyte infusion was not routinely administered in this trial.Results: Twenty-four patients were enrolled with median age of 24.5 (16-61 years). Male to female ratio was 3:1. Six (25%) had a diagnosis of Philadelphia positive acute B cell lymphoblastic leukemia (Ph+B-ALL), 8 (33.3%) had Ph-B-ALL, and 10 (41.7%) had T-ALL. Nineteen (79.2%) patients were MRD positive (blast cells <5% in the bone marrow), while five (20.8%) were with active disease (blast cells ≥5%). Eleven (45.8%) patients underwent matched sibling donor transplant, 4 (16.7%) underwent matched unrelated donor transplant, and 9 (37.5%) received haplo-HSCT. Neutrophils and platelets engrafted at a median of 14 days (12-20 days) and 16 days (12-46 days) post-transplant, respectively. Twenty (83.3%) patients reached MRD negative at 30 days. The median follow-up time of the whole cohort was 9.2 months (2-43.8), estimated 1-year progression free survival (PFS) and overall survival (OS) are 53.1% and 59.4% (Figure-1 A&B). For patients with MRD or active disease, estimated 1-year PFS are 67% and 0% (Figure-1 C), and estimated 1-year OS of these 2 groups of patients are 67.7% and 30% (Figure-1D), respectively. Only one patient (4.2%) developed II° aGvHD within 100 days post-transplant (Figure-1 E). The incidence of non-relapse mortality is 24.6% (Figure -1 F).Conclusions: Chidamide-containing conditioning allo-HSCT may improve the prognosis of ALL with MRD. [Display omitted] DisclosuresLiu:West China Hospital of Sichuan University: Employment.

Higher Incidence of Hemorrhagic Cystitis after Haploidentical Compared to Matched Sibling Donor Transplantation

Introduction: Hemorrhagic cystitis (HC) causes significant morbidity following allogeneic hematopoietic cell transplantation (HCT). Reactivation of BK polyoma virus frequently occurs following transplantation and appears to be the most commonly associated factor, although high dose cyclophosphamide, other viruses, and numerous other factors contribute. A higher incidence of BK HC was reported with the use of matched unrelated or cord blood donors compared to HLA-matched siblings (El-Zimaity M, et al. Blood. 2004), however, the intensity of GVHD prevention regimens varied according to cell source complicating interpretation of these data. The effect of HLA-mismatched donors on the incidence of BK HC has been disputed and a large study of mismatched donors detected no association of HC with mismatched compared to matched donors (Giraud G, et al. Bone Marrow Transplant, 2008; Gilis L, et al. Bone Marrow Transplantation, 2014.)We analyzed a cohort of patients biologically assigned to matched sibling (MSD) or haploidentical family donor (based on presence of a suitable MSD donor) who received identical myeloablative or nonablative conditioning regimens and identical PTCy-based GVHD prevention to directly analyze the association of donor source with HC.Methods: To evaluate the role of haploidentical vs MSD donor source, we analyzed all patients undergoing haploidentical or MSD HCT at the Levine Cancer Institute between March 2014 and June 2018. Patients received identical myeloablative (BuCy) or nonmyeloablative (Flu/Cy/TBI) conditioning regimens followed by peripheral blood stem cell grafts and identical PTCy-based regimens which included tacrolimus and mycophenolate for GVHD prevention. The cumulative incidence of HC was calculated in a competing risk setting with death from any cause as a competing event. Group comparisons of incidences were determined by a Gray's test. Cox regression was conducted to evaluate risk factors for the development of HC. It was also used to evaluate HC as a time-dependent risk factor for overall survival. Fisher's exact test was used to analyze categorical patient characteristics, and two-sample t-test was employed for continuous variables.Results: From March 2014 to June 2018, 39 patients (32%) underwent MSD transplantation and 84 patients (68%) received transplants from haploidentical donors. Baseline characteristics were similar except for younger donor age of haploidentical donors (median 40 yrs vs 54 yrs P< .001). The rates of acute GVHD, Chronic GVHD, NRM and overall survival were similar between the two groups. The cumulative incidence of HC was higher in patients who received cells from haploidentical donors when compared to matched related donors (p=0.05). In multivariate analysis of risk factors associated with HC (Table 1), haploidentical donor (HR: 1.80, 95% CI 0.95-3.44, P= .07) and, grade III-IV acute GVHD (HR: 4.93, 95% CI 1.01-23.93 P = .05), were associated with development of HC. 33/53 HC patients (62%) were tested positive for BK virus. The intensity of the conditioning regimen, disease status at transplant, donor and recipient age were not associated with development of HC. For patients who received cells from haploidentical donors, there was a trend towards severe (grade 3-4) HC, but this did not reach statistical significance (HR 2.71, 95% CI 0.59-12.24 P=.19). The incidence of HC was not associated with overall survival (HR 0.58 95% CI 0.3-1.15 P=0.12), even when severe (grade III-IV) HC events were evaluated (HR 1.79 95% CI 0.75-4.3 P=0.19).Conclusions: In adults undergoing allogenic transplantations using identical conditioning regimens and PTCy based GVHD prevention, the use of a haploidentical donor results in a higher incidence of HC than does a MSD. [Display omitted] DisclosuresGrunwald:Cardinal Health: Consultancy, Membership on an entity's Board of Directors or advisory committees; Forma Therapeutics: Research Funding; Ariad: Consultancy, Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Alexion: Consultancy, Membership on an entity's Board of Directors or advisory committees; Medtronic: Equity Ownership; Genentech: Research Funding; Incyte Corporation: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees; Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees; Merck: Consultancy, Membership on an entity's Board of Directors or advisory committees; Janssen: Research Funding. Jacobs:Genentech: Honoraria. Usmani:Abbvie, Amgen, Celgene, Genmab, Merck, MundiPharma, Janssen, Seattle Genetics: Consultancy; Amgen, BMS, Celgene, Janssen, Merck, Pharmacyclics,Sanofi, Seattle Genetics, Takeda: Research Funding.

Higher Incidence of Graft Rejection in Non-Sibling Fully Matched Related Donor Stem Cell Transplants for Thalassemia Major: A Cautionary Note

▪Only 25-30% of patients with Thalassemia major (TM) will have a suitable HLA-matched sibling donor for an allogeneic SCT. In the absence of a HLA-matched sibling, an extended donor search within the family may yield a suitable donor, especially in societies with a high prevalence of consanguinity. We have previously reported inferior outcomes in patients who had a transplant from a non-sibling family donor. One of the criticisms of this was the issue of low resolution typing, which may have adversely impacted outcomes in some patients. We interrogated this data further to assess whether the poorer outcomes held up to scrutiny with the availability of high resolution HLA typing. Towards this we undertook a retrospective case-control study, adjusting controls for age and Lucarelli risk group (common confounders for clinical outcomes post-transplant in TM) with a 4:1 ratio of controls to cases.All consecutive patients with TM who had a stem cell transplant between the time periods 2007-2017, were included in this retrospective analysis. A total of 371 transplants were done with 281 matched sibling donor, 58 related donors (32 fully matched and 26 with 1-2 antigen mismatch), and 32 MUD donors (24 fully matched (10/10) and 8 with 1-antigen mismatch (9/10)).Subsequent to 2012, high resolution typing was done for all non-sibling related family donors. Of the 58 related donors, high resolution typing was available in 45, with twenty four 10/10 donors, nineteen 9/10 donors and two 8/10 donors. Further analysis was done in this sub-group (excluding the 8/10 donors), with rejection and death being considered as events. A control group from the fully matched sibling donor cohort was generated randomly after adjusting for age and Lucarelli Class.All patients received a myeloablative conditioning regimen (Busulphan/Treosulfan based). In-vivo T-cell depletion was done in 11 (45.8%) of matched related transplants and 54 (56.2%) of matched sibling donor transplants (P=0.359). A PBSC graft was used in 16 (66.7%) of matched related donor transplants compared with 36 (27.5%) of matched sibling donor transplants (P=0.012). There was no difference in the median CD34 cell dose achieved in both groups (Table 1). Table 1 shows baseline characteristics, transplant details and outcomes in the 10/10 matched related donors and fully matched sibling donor groups. Table 2 shows univariate and multivariate analysis for risk factors adversely affecting Thalassemia-free survival (TFS) using Cox regression analysis. The 2-year TFS in the 10/10 matched related donor group, 9/10 matched related donor group and fully matched sibling donor group was 56.8%±10.5%, 56.1%±11.9% and 81.8%±4% respectively (P=0.011) (Figure 1A). The 2-year overall survival (OS) in the 10/10 matched related donor group and 9/10 matched related donor group and the fully matched sibling donor group was 75.4%±9.9%, 64.5%±12.1% and 85.0%±3.7% respectively (P=0.168) (Figure 1B).This data on allogeneic transplants confirms our previous observations that there is a higher risk of graft rejection when the donor is a non-sibling related donor, even if fully matched on high-resolution typing (OR 4.8 ; 95% CI=1.3-18.2 : P=0.02). Transplant physicians must be aware this increased risk and counsel families appropriately. Further modifications in conditioning regimens and GVHD prophylaxis could potentially help in improving these outcomes. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Impact of T-cell depletion strategies on outcomes following hematopoietic stem cell transplantation for idiopathic aplastic anemia: A study on behalf of the European blood and marrow transplant severe aplastic anemia working party.

We retrospectively analyzed the outcomes of 1837 adults and children with severe aplastic anemia (SAA) who underwent matched sibling donor (MSD) and matched unrelated donor (MUD) hemopoietic stem cell transplantation (HSCT) between 2000 and 2013. Patients were grouped by transplant conditioning containing either anti-thymocyte globulin (ATG) (n = 1283), alemtuzumab (n = 261), or no serotherapy (NS) (n = 293). The risks of chronic GvHD were significantly reduced when ATG or alemtuzumab were compared with NS (P = .021 and .003, respectively). Acute GVHD was significantly reduced in favor of alemtuzumab compared with ATG (P = .012) and NS (P < .001). By multivariate analysis, when compared with ATG, alemtuzumab was associated with a lower risk of developing acute (OR 0.262; 95% CI 0.14-0.47; P < .001) and chronic GVHD (HR 0.58; 95% CI 0.35-0.94; P = .027). OS was significantly better in ATG and alemtuzumab patients compared with NS (P = .010 and .025). Our data shows inclusion of serotherapy in MSD and MUD HSCT for patients with SAA reduces chronic GVHD and provides a survival advantage over patients not receiving serotherapy. Notably, alemtuzumab reduced the risk of acute and chronic GvHD compared with ATG and indicates that alemtuzumab might be the serotherapy of choice for MSD and MUD transplants for SAA.

Vaccine-preventable disease following allogeneic haematopoietic stem cell transplant in Western Australia.

Infection is an important and frequent cause of mortality and morbidity following allogeneic haematopoietic stem cell transplantation (HSCT). This study was conducted to determine the epidemiology and clinical phenotype of vaccine-preventable disease in children who have undergone HSCT following the implementation of a standard revaccination programme. Children receiving first allogeneic HSCT in Western Australia between January 2005 and December 2014 were eligible for recruitment. Patients received standard antimicrobial prophylaxis and were vaccinated according to the West Australian post-HSCT immunisation schedule, commencing 6 months following HSCT. Children who developed any illness post-HSCT were reviewed, and investigations for infectious disease were undertaken as clinically indicated. Positive identification of vaccine-preventable disease was documented with the clinical course of the illness. A total of 71 patients were enrolled in the study. The overall incidence of vaccine-preventable disease following HSCT was 19.7%; influenza accounted for 50% of all cases, herpes zoster for 42.9%. All episodes occurred late, beyond day 100 post-HSCT. Overall survival for matched-sibling donor transplants was 83.3 and 75.0% at 1 and 5 years, respectively, and was 72.3 and 63.3% for alternative donor transplants. Mortality due to vaccine-preventable disease was low, with one death from disseminated herpes zoster. There is a high incidence of vaccine-preventable morbidity post-allogeneic HSCT in West Australian children. Viral aetiology constitutes the main burden, namely, influenza infection and varicella zoster virus reactivation. Further efforts are required to identify the most appropriate preventative strategies.

Graft Failure after Matched Sibling Donor Transplant for Sever Aplastic Anemia

Graft Failure after Matched Sibling Donor Transplant for Sever Aplastic Anemia

Outcomes of hematopoietic stem cell transplantation from unmanipulated haploidentical versus matched sibling donor in patients with acute myeloid leukemia in first complete remission with intermediate or high-risk cytogenetics: a study from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation.

Allogeneic hematopoietic stem cell transplantation is the optimal care for patients with high-risk or intermediate - acute myeloid leukemia. In patients lacking matched sibling donor, haploidentical donors are an option. We compared outcomes of unmanipulated (Haplo) to matched sibling donor transplant in acute myeloid leukemia patients in first complete remission. Included were intermediate and high-risk acute myeloid leukemia in first complete remission undergoing Haplo and matched sibling donor transplant from 2007–2015, and reported to the ALWP of the EBMT. A propensity score technique was used to confirm results of main analysis: 2 matched sibling donors were matched with 1 Haplo. We identified 2654 pts (Haplo =185; matched sibling donor =2469), 2010 with intermediate acute myeloid leukemia (Haplo=122; matched sibling donor =1888) and 644 with high-risk acute myeloid leukemia (Haplo =63; matched sibling donor =581). Median follow up was 30 (range 1–116) months. In multivariate analysis, in intermediate - acute myeloid leukemia patients, Haplo resulted in lower leukemia-free survival (Hazard Ratio 1.74; P<0.01), overall-survival (HR 1.80; P<0.01) and GvHD-free-relapse-free survival (Hazard Ratio 1.32; P<0.05) and higher graft-versus-host disease (GvHD) non-relapse mortality (Hazard Ratio 3.03; P<0.01) as compared to matched sibling donor. In high-risk acute myeloid leukemia, no differences were found in leukemia-free survival, overall-survival, and GvHD-free- relapse-free survival according to donor type. Higher grade II-IV acute GvHD was observed for Haplo in both high-risk (Hazard Ratio 2.20; P<0.01) and intermediate risk (Hazard Ratio 1.84; P<0.01). A trend for a lower Relapse-Incidence was observed in Haplo among high-risk acute myeloid leukemia (Hazard Ratio 0.56; P=0.06). The propensity score analysis confirmed results. Our results underline that matched sibling donor is the first choice for acute myeloid leukemia patients in first complete remission. On the other hand, results of Haplo transplants are similar to matched sibling donor transplants in acute myeloid leukemia patients with high risk cytogenetics.

Post-Transplantation Cyclophosphamide-Based Haploidentical Transplantation as Alternative to Matched Sibling or Unrelated Donor Transplantation for Hodgkin Lymphoma: A Registry Study of the Lymphoma Working Party of the European Society for Blood and Marrow Transplantation.

Purpose To compare the outcome of patients with Hodgkin lymphoma who received post-transplantation cyclophosphamide-based haploidentical (HAPLO) allogeneic hematopoietic cell transplantation with the outcome of patients who received conventional HLA-matched sibling donor (SIB) and HLA-matched unrelated donor (MUD). Patients and Methods We retrospectively evaluated 709 adult patients with Hodgkin lymphoma who were registered in the European Society for Blood and Marrow Transplantation database who received HAPLO (n = 98), SIB (n = 338), or MUD (n = 273) transplantation. Results Median follow-up of survivors was 29 months. No differences were observed between groups in the incidence of acute graft-versus-host disease (GVHD). HAPLO was associated with a lower risk of chronic GVHD (26%) compared with MUD (41%; P = .04). Cumulative incidence of nonrelapse mortality at 1 year was 17%, 13%, and 21% in HAPLO, SIB, and MUD, respectively, and corresponding 2-year cumulative incidence of relapse or progression was 39%, 49%, and 32%, respectively. On multivariable analysis, relative to SIB, nonrelapse mortality was similar in HAPLO ( P = .26) and higher in MUD ( P = .003), and risk of relapse was lower in both HAPLO ( P = .047) and MUD ( P < .001). Two-year overall survival and progression-free survival were 67% and 43% for HAPLO, 71% and 38% for SIB, and 62% and 45% for MUD, respectively. There were no significant differences in overall survival or progression-free survival between HAPLO and SIB or MUD. The rate of the composite end point of extensive chronic GVHD and relapse-free survival was significantly better for HAPLO (40%) compared with SIB (28%; P = .049) and similar to MUD (38%; P = .59). Conclusion Post-transplantation cyclophosphamide-based HAPLO transplantation results in similar survival outcomes compared with SIB and MUD, which confirms its suitability when no conventional donor is available. Our results also suggest that HAPLO results in a lower risk of chronic GVHD than MUD transplantation.

Clinical risks and healthcare utilization of hematopoietic cell transplantation for sickle cell disease in the USA using merged databases.

Advances in allogeneic hematopoietic cell transplantation for sickle cell disease have improved outcomes, but there is limited analysis of healthcare utilization in this setting. We hypothesized that, compared to late transplantation, early transplantation (at age <10 years) improves outcomes and decreases healthcare utilization. We performed a retrospective study of children transplanted for sickle cell disease in the USA during 2000–2013 using two large databases. Univariate and Cox models were used to estimate associations of demographics, sickle cell disease severity, and transplant-related variables with mortality and chronic graft-versus-host disease, while Wilcoxon, Kruskal-Wallis, or linear trend tests were applied for the estimates of healthcare utilization. Among 161 patients with a 2-year overall survival rate of 90% (95% confidence interval [CI] 85–95%) mortality was significantly higher in those who underwent late transplantation versus early (hazard ratio (HR) 21, 95% CI 2.8–160.8, P=0.003) and unrelated compared to matched sibling donor transplantation (HR 5.9, 95% CI 1.7–20.2, P=0.005). Chronic graftversus host disease was significantly more frequent among those translanted late (HR 1.9, 95% CI 1.0–3.5, P=0.034) and those who received an unrelated graft (HR 2.5, 95% CI 1.2–5.4; P=0.017). Merged data for 176 patients showed that the median total adjusted transplant cost per patient was $467,747 (range: $344,029–$799,219). Healthcare utilization was lower among recipients of matched sibling donor grafts and those with low severity disease compared to those with other types of donor and disease severity types (P<0.001 and P=0.022, respectively); no association was demonstrated with late transplantation (P=0.775). Among patients with 2-year pre- and post-transplant data (n=41), early transplantation was associated with significant reductions in admissions (P<0.001), length of stay (P<0.001), and cost (P=0.008). Early transplant outcomes need to be studied prospectively in young children without severe disease and an available matched sibling to provide conclusive evidence for the superiority of this approach. Reduced post-transplant healthcare utilization inpatient care indicates that transplantation may provide a sustained decrease in healthcare costs over time.

How I manage patients with Fanconi anaemia.

Fanconi Anaemia is a rare, genetic heterogeneous multisystem disease that is the most common congenital syndrome of marrow failure. Twenty genes have been reported to cause the disease. Remarkable progress has been made over the last 20years in the understanding of the genetic and pathophysiological mechanisms. Unfortunately, these advances have not been completely paralleled by advances in medical treatment, where the most important component remains stem cell transplantation. This therapy, although contributing to long-term negative effects, such as increased occurrence of late malignancies, is the only current option capable of prolonging the survival of patients. In spite of relevant recent progress in matched unrelated donor transplants, the largest studies with longer follow-up still show a superiority of matched sibling donor transplants with a success rate, in selected cohorts, of over 90%. This article reviews different aspects of the disease, including genetics, diagnosis and treatment options, with special focus on stem cell transplantation, comprehensive post-diagnosis management, decision-making processes and long-term follow-up.

Haploidentical Hematopoietic Stem Cell Transplant Compared with Matched Sibling and Unrelated Transplants in Adults with Philadelphia-Negative Acute Lymphoblastic Leukemia in First Complete Remission

Matched-sibling donor (MSD) and matched unrelated donors (MUD) hematopoietic stem-cell transplantation (HSCT) have been recommended for the adults with acute lymphoblastic leukemia (ALL) in first complete remission (CR1). However, it is not defined for this portion of patients whether HLA haploidentical donor (HID) transplants can achieve equivalent outcomes compared to MSD and MUD transplants. From 2009 to 2014, 379 adult patients with Ph-negative ALL in CR1 underwent HID HSCT (n = 159), or MSD HSCT (n = 135), or MUD HSCT (n = 85). Among HID, MSD and MUD transplants, the 100-day incidences of acute graft-versus-host disease (aGVHD) Grade III-IV were 11.0%, 8.4% and 10.6% respectively (P>0.05), and 2-year chronic GVHD (cGVHD) were 38.9%, 28.5% and 35.6% respectively ( P>0.05 ). At 5 years, the incidences of relapse were 19.0%, 24.0% and 23.4% in HID, MSD and MUD transplants respectively (P>0.05). The 5-year transplant related mortality (TRM) of HID was higher than MSD transplants (16.5% vs 10.9%, P = 0.032), and no difference compared with MUD transplants (16.5% vs 18.1%, P > 0.05). However, the 5-year overall survival (OS), disease-free survival (DFS) did not differ among HID, MSD and MUD transplants (OS 70.9%, 72.0%, 65.4% respectively, P > 0.05; DFS 67.3%, 66.0%, 62.0%, respectively, P > 0.05).Our results indicate that outcomes of adult patients with Ph-negative ALL in CR1 from HID transplants are comparable to MSD and MUD transplants. DisclosuresLin:National Natural Science Foundation of China 81400141: Research Funding; National Natural Science Foundation of China 81270647: Research Funding; Science and technology planning project of Guangdong Province 2014B020226004: Research Funding; The project of health collaborative innovation of Guangzhou City 201400000003-4: Research Funding.

Influence of Age on Risk for Acute and Chronic Graft Versus Host Disease in Children Receiving HLA Identical Sibling Bone Marrow Transplantation

Introduction: In adult HLA matched sibling donor (MSD) hematopoietic cell transplantation, both recipient and donor age have been shown to be a risk factors for graft versus host disease (GVHD). While it is widely recognized that pediatric patients are at lower risk for GVHD than adults, the importance of age within the pediatric age group in MSD transplantation has not been examined. We, therefore, assessed the impact of age on GVHD risk after MSD bone marrow transplantation (BMT) in 477 pediatric patients with acute leukemia.Methods: This is a Center for International Blood and Marrow Transplantation registry study. Patients younger than 18 years with acute myeloid leukemia (AML) or acute lymphoblastic leukemia (ALL) in 1st or 2nd complete remission (CR), who received myeloablative conditioining, T cell-replete HLA MSD BMT and calcineurin inhibitor based GVHD prophylaxis between 2000-2013 were included. Patients who received a lymphocyte depleting antibody were excluded. Because donor and recipient ages were highly correlated, their effects could not be independently assessed. We, therefore, assessed only recipient age.Results: The transplants were drawn from 101 centers. The median age of the recipients was 10.1 years. 21% had ALL in 1st CR, 24% ALL in 2nd CR, 47% AML in 1st CR and 8% AML in 2nd CR. 73% received cyclosporine and Methotrexate for GVHD prophylaxis. In a preliminary model, using grade 3-4 acute GVHD as the endpoint, we identified two cut points, 2 years and 13 years using the likelihood ratio test. In all final models, three age groups were used to define recipient age: < 2 years (n=60), 2 to 12.99 (n=255) years and 13-17.99 years (n=162). The cumulative incidence of grade 2-4 acute GVHD at 100 days post-transplant was 19% (95% confidence interval, CI, 16-23%); 24% (95% CI 14-35%), 13% (95% CI 9-18%) and 28% (95% CI 21-35%) for recipients <2 years, 2-12.99 years, and 13-17.99 years of age, respectively (p-value=0.001). For grade 3-4 acute GVHD, the cumulative incidence estimate at 100 days was 8% (95% CI 3-17%), 3% (95% CI 1-6%) and 14% (95% CI 9-20%) (p <0.001) and the cumulative incidence estimate for chronic GVHD at 1 year was 15% (95% CI 7-25%), 10% (95% CI 7-14%) and 27% (95% CI 20-34%) (p <0.001) for recipients <2 years, 2-12.99 years, and 13-17.99 years of age, respectively (Figures 1-3). In the multivariate analyses, using age 13-17.99 as the baseline and .01 as the threshold for significance, age 2-12.99 years (HR 0.43, 95% CI 0.26-0.71, p=0.001), but not age < 2 years (HR 0.59, 95% CI 0.3-1.18, p=0.14), was associated with a lower risk for grade 2-4 acute GVHD (after adjustment for GVHD prophylaxis, performance score and year of transplant). For grade 3-4 acute GVHD, again age 2-12.99 years (HR 0.24, 95% CI 0.1-0.56, p=0.001), but not age < 2 years (HR 0.75, 95% CI 0.29-1.94, p=0.55), was associated with a lower risk, after adjustment for year of transplant. For chronic GVHD (after adjustment for donor-recipient birth order, and GVHD prophylaxis), age 2-12.99 years (HR 0.32, 95% CI 0.19-0.54, p<0.001) was associated with lower risk; the effect was similar in age < 2 years, but did not reach significance (HR 0.36, 95% CI 0.16-0.82, p=0.016). Year of transplant had a strong effect on acute, but not chronic GVHD. Its effect did not appear to be mediated by changes in GVHD prophylaxis. Using 2000-2004 as the baseline, the HR for grade 2-4 acute GVHD was 0.38 (95% CI 0.20-0.64, p=0.0006) and 0.28 (95% CI 0.13-0.59, p=0.0008) for 2005-2008 and 2009-2013, respectively. For grade 3-4 acute GVHD, they were 0.23 (95% CI 0.08-0.65, p=0.0057) and 0.23 (95% CI 0.07-0.78, p=0.0183) for these periods, respectively. There was no difference in overall survival, leukemia-free survival or transplant related mortality between the age groups.Conclusion:Our results indicate that children 2-12.99 years have a lower risk for acute and chronic GVHD than those 13 years and older. Children less than 2 years may also have a reduced risk for chronic GVHD, but this possibility needs to be re-examined in a larger sample. It is plausible that pubertal changes underlie the rise in risk for GVHD during adolescence. An important limitation of our study was that we were unable to examine the impact of donor age because of the strong correlation between donor and recipient age. A study with a larger sample is also needed to further investigate this matter. [Display omitted] [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

HLA-Mismatched Stem Cell Microtransplantation Compared to Matched-Sibling Donor Transplantation for Acute Myeloid Leukemia in First Complete Remission

HLA-mismatched stem cell microtransplantation is a new transplantation which has been reported in recent years. We treated 41 patients with intermediate- or high-risk acute myelogenous leukemia (AML) in first complete remission (CR1) undergoing HLA-mismatched stem cell microtransplantation and compared with 56 patients undergoing HLA-matched sibling donor (MSD) transplantation at the same period in our center from July 2012 to August 2015. The estimated leukemia-free survival (LFS) at 2-year was 65.6% ± 9.5% in the MSD group and 27.6% ± 14.0% in the microtransplantation group (P = 0.011). The estimated overall survival (OS) at 2-year was 73.6% ± 8.6% in the MSD group and 46.2% ± 15.6% in the microtransplantation group (P = 0.056). The cumulative incidences of relapse were 22.5% and 58.7% among MSD and microtransplantation groups (P = 0.011). The cumulative incidence of nonrelapse mortality was 7.8% in MSD group, and no nonrelapse mortality in microtransplantation group (P = 0.265). Hematopoietic recovery time was shorter in the microtransplantation group than MSD group (P < 0.05). The infection rate of MSD group was higher than in the microtransplantation group (91.1% vs 75.6%, P = 0.037). The preliminary results suggest that LFS of microtransplantation is inferior to MSD transplantation and a trend toward the OS of microtransplantation was lower than MSD transplantation for intermediate- or high-risk AML in CR1. DisclosuresNo relevant conflicts of interest to declare.

P116 Immune reconstitution in Hematopoietic Stem Cell Transplanted Patients (HSCT): Assessing immune cell subsets and chimerisms at different periods post-transplant

Aim HSCT is an important procedure for treating patients with malignancies and other diseases, by redirecting the immune system to establish normal hematopoiesis. Immune reconstitution occurs at different times, being a slow process that may take up to two years for B cells, one year for NKs and for different subsets of T cells. We evaluated post-transplant immune reconstitution of matched sibling donor transplants and unrelated transplanted patients by evaluating B, NK, T, Th and Tc subsets. We analyzed post-transplant immune reconstitution of sibling donor and unrelated transplanted patients by assessing B, NK, T, Th and Tc subsets correlated with patients’ engraftment. Material and methods A total of 14 cases were included: 10 leukemia patients transplanted with a sibling matched donor and 4, with an unrelated donor were included. Subsets were monitored during four post-transplant chimerism follow-ups, by flow cytometry (MACSQuant®) using monoclonal antibodies: lymphocytes (CD45-VioBlue); T (CD3-APC); Th(CD4-PerCP), Tc(CD8-APC-Vio770); B(CD19-PE-Vio770); NK (CD56-PE). Kruskal-Wallis test was used for statistical assessment. Results Patients had 4–13 months post-transplant. Related cases showed lymphocytes recovery since the 3d post-transplant; T cells where within normal limits earlier (1.-52%; 2.-63%; 3.-68%; 4.-58%). B(1.-2.6; 2.-9.4%; 3.-6.6%; 4.-18%) and Th cells(1.-41%; 2.-35%; 3.-34%; 4.-28%) were low. Tc were normal since the 2nd post-transplant (1.-15%; 2.-27%; 3.-34%; 4.-26%). NKs had variable numbers, raised rapidly but did not reach normal values (1.-29%; 2.-16%; 3.-17%; 4.-12%). Unrelated behave differently. Conclusions The initial diagnosis was relevant for unrelated transplants. The AML had 100% engraftment with excellent immune reconstitution; all subpopulations were normal except for B/Th cells, that recovered after one year post-transplant. The aplastic anemia unrelated donor transplanted case was 100% engrafted with variable cell reconstitution, having low B, Th & T total cells. The immunodeficiency case had only low counts of Th cells. Our data are consistent with the literature, showing that immune reconstitution must be monitored systematically, offering the background for the use of immunotherapeutic approaches in the pre and post-transplant setting.

Long-Term Outcomes of Hematopoietic Stem Cell Transplantation for ZAP70 Deficiency.

ZAP70 deficiency is a rare T + B + NK+ combined immunodeficiency with limited outcome data to help guide decisions around hematopoietic stem cell transplant (HSCT). We sought to understand the long-term clinical and immunologic outcomes of both conditioned and unconditioned HSCT for ZAP70 deficiency following transplant from a variety of graft sources. We performed a retrospective, single center review of all cases of HSCT for genetically confirmed ZAP70 deficiency since 1992. At a median of 13.5-year post-HSCT, 8/8 (100%) patients are alive. Three received unconditioned bone marrow transplants from human leukocyte antigen (HLA)-matched siblings and achieved stable mixed donor-recipient T cell chimerism but low B cell (4-9%) and absent to near-absent myeloid donor engraftment. Despite this, all three have normal immunoglobulin levels, have developed specific protective antibody responses to post-HSCT vaccinations, and have discontinued immunoglobulin replacement. Five patients received myeloablative conditioning (three T cell-depleted haploidentical and two unrelated cord blood) and have full donor chimerism for T and B cells and myeloid lineages. One patient experienced primary graft failure after serotherapy only. CD8 T cell count is normal in 5/8, high in 1/8, and low in 2/8. Infectious complications in 5/5 and autoimmune thrombocytopenia in one patient resolved post-HSCT. Mitogen proliferation to phytohemagglutinin was normal after HSCT in 8/8 patients. In total, seven have discontinued immunoglobulin replacement. In conclusion, HSCT using a variety of graft sources and approaches, including unconditioned matched sibling donor transplant, is a life-saving therapy for ZAP70 deficiency, providing excellent long-term immune function and resolution of clinical problems.

Somatic, hematologic phenotype, long-term outcome, and effect of hematopoietic stem cell transplantation. An analysis of 97 Fanconi anemia patients from the Italian national database on behalf of the Marrow Failure Study Group of the AIEOP (Italian Association of Pediatric Hematology-Oncology).

We analyzed 97 Fanconi anemia patients from a clinic/biological database for genotype, somatic, and hematologic phenotype, adverse hematological events, solid tumors, and treatment. Seventy-two patients belonged to complementation group A. Eighty percent of patients presented with mild/moderate somatic phenotype and most with cytopenia. No correlation was seen between somatic/hematologic phenotype and number of missense mutations of FANCA alleles. Over follow-up, 33% of patients improved or maintained mild/moderate cytopenia or normal blood count, whereas remaining worsened cytopenia. Eleven patients developed a hematological adverse event (MDS, AML, pathological cytogenetics) and three developed solid tumors. 10 years cumulative risk of death of the whole cohort was 25.6% with median follow-up 5.8 years. In patients eligible to hematopoietic stem cell transplantation because of moderate cytopenia, mortality was significantly higher in subjects transplanted from matched unrelated donor over nontransplanted subjects, whereas there was no significant difference between matched sibling donor transplants and nontransplanted patients. In patients eligible to transplant because of severe cytopenia and clonal disease, mortality risk was not significantly different in transplanted from matched unrelated versus matched sibling donor versus nontransplanted subjects. The decision to transplant should rely on various elements including, type of donor, HLA matching, patient comorbidities, impairment, and clonal evolution of hematopoiesis. Am. J. Hematol. 91:666-671, 2016. © 2016 Wiley Periodicals, Inc.