Mini-dose Methotrexate Research Articles

Mini-dose methotrexate combined with methylprednisolone for the initial treatment of acute GVHD: a multicentre, randomized trial

BackgroundThere is an urgent unmet need for effective initial treatment for acute graft-versus-host disease (aGVHD) adding to the standard first-line therapy with corticosteroids after allogeneic haematopoietic stem cell transplantation (allo-HSCT).MethodsWe performed a multicentre, open-label, randomized, phase 3 study. Eligible patients (aged 15 years or older, had received allo-HSCT for a haematological malignancy, developed aGVHD, and received no previous therapies for aGVHD) were randomly assigned (1:1) to receive either 5 mg/m2 MTX on Days 1, 3, or 8 and then combined with corticosteroids or corticosteroids alone weekly.ResultsThe primary endpoint was the overall response rate (ORR) on Day 10. A total of 157 patients were randomly assigned to receive either MTX plus corticosteroids (n = 78; MTX group) or corticosteroids alone (n = 79; control group). The Day 10 ORR was 97% for the MTX group and 81% for the control group (p = .005). Among patients with mild aGVHD, the Day 10 ORR was 100% for the MTX group and 86% for the control group (p = .001). The 1-year estimated failure-free survival was 69% for the MTX group and 41% for the control group (p = .002). There were no differences in treatment-related adverse events between the two groups.ConclusionsIn conclusion, mini-dose MTX combined with corticosteroids can significantly improve the ORR in patients with aGVHD and is well tolerated, although it did not achieve the prespecified 20% improvement with the addition of MTX.Trial registrationThe trial was registered with clinicaltrials.gov (NCT04960644).

Mini-dose methotrexate combined with methylprednisolone as a first-line treatment for acute graft-versus-host disease: A phase 2 trial.

Acute graft-versus-host disease (aGvHD) remains a major complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Methylprednisolone (MP; 1-2 mg/kg/day) remains the standard first-line therapy for aGvHD, although no response is detected in nearly one-half of the patients with aGvHD. This study aimed to investigate the feasibility of mini-dose methotrexate (MTX) combined with standard-dose MP as a front-line therapy for aGvHD. A prospective Phase 2 clinical trial was performed to evaluate the safety and efficacy of 5 mg/m2 MTX combined with 1 mg/kg/day MP as the initial therapy in 31 patients with aGvHD. Moreover, the effects of MTX combined with MP were explored in a humanized xenogeneic murine model of aGvHD. The overall response and complete response rate at 7 days after the initial treatment were 100% and 83%, respectively. The overall response rate on day 28 was 87%. The complete response rates for aGvHD grades I, II, and III were 100% (6/6), 82% (18/22), and 66% (2/3), respectively. Grade 3 toxicities occurred in only three patients presenting with cytopenia. Importantly, MTX and MP demonstrated synergistic effects on ameliorating aGvHD in humanized xenogeneic murine model. The current study suggests that mini-dose MTX combined with standard-dose MP could potentially become a novel first-line therapy for patients with aGvHD.

Significance of Omitting Day 11 Mini-Dose Methotrexate for GVHD Prophylaxis After Unrelated Bone Marrow Transplantation

The combination of calcineurin inhibitors and short-term methotrexate has been used as a standard graft-versus-host-disease (GVHD) prophylaxis in allogeneic hematopoietic stem cell transplantation. Mini-dose methotrexate (mini-MTX), consisting of 5 mg/m2/d on days 1, 3, 6, and 11, is occasionally selected as an alternative considering toxicity. The significance of day 11 administration remains unclear. We performed a retrospective study of 135 cases of unrelated bone marrow transplantation at our institute between 2006 and 2019 and compared the outcomes between day 11 MTX dose omitted (n=72) and full-doses of mini-MTX (n=63). In total cohort, the 4-year overall survival (OS) was 58.7 %, and the omitted group showed poor GVHD/relapse-free-survival (P=.01) with comparable OS (P=.11) and relapse-free survival (P=.11). Human leukocyte antigen (HLA) mismatch is a major risk factor for severe GVHD. We analyzed the impact of omitting day 11 MTX in 2 cohorts from HLA matched or mismatched donors. In both cohorts, the omitted group had a higher risk of severe acute and chronic GVHD. In conclusion, the omission of day 11 MTX was associated with a higher risk of severe GVHD. Therefore the omission of the day 11 dose is not recommended.

Excellent Outcome of Alternative Donor HSCT in Fanconi Anemia Using Chemotherapy Only Regimen: Single Korean Institution Experience

Title) Excellent outcome of alternative donor HSCT in Fanconi anemia using chemotherapy only conditioning regimen: single Korean institution experience.Introduction) Fanconi anemia (FA) is a rare autosomal (or X linked) recessive disorder characterized by bone marrow failure, secondary malignancies, and skeletal anomalies. Hematopoietic stem cell transplantation (HSCT) remains the standard treatment of hematologic disease. Although HSCT from a matched sibling donor (MSD) is the optimal mode of transplant, many patients lack such a donor necessitating alternative donor HSCT (AD-HSCT). Radiation treatment during the conditioning regimen results in a high incidence of post-HSCT complications in FA patients, while serotherapy with alemtuzumab has been reported to increase infectious toxicities. Here, we report on the excellent outcome of 15 FA patients who received AD-HSCT with a fludarabine-based conditioning regimen with in vivo T cell depletion using rabbit anti-thymocyte globulin (ATG).Methods and Results) We reviewed the medical records of FA patients diagnosed by chromosomal breakage test and who received AD-HSCT between September 2007 and December 2016. Median age at transplant was 10.8 years (4.2~18.6) and 7 were male (46.7%). Eleven of 14 patients who received genetic study for FA were found to have mutations (6 with FANC-A mutations (40%), and 5 with FANC-G mutations (33.3%)). Hematologic reasons for HSCT were severe aplastic anemia in 13 (93.3%) and myelodysplastic syndrome in 2 patients (13.3%). One patient received HSCT from a mismatched related donor, while the remaining patients received unrelated HSCT. Seven transplants were human leukocyte antigen (HLA) fully matched (13.3%). Cell sources were as follows: peripheral blood stem cells 9 (60%), cord blood 4 (26.7%), bone marrow 2 (13.3%). Conditioning regimen consisted of fludarabine 30mg/BSA/day x5days (D-8,-7,-6,-5,-4), cyclophosphamide 5mg/kg/day x4days (D-5,-4,-3,-2), rabbit ATG 2.5mg/kg/day x3days (D-3,-2,-1). Graft-versus-host disease prophylaxis consisted of cyclosporine and mini-dose methotrexate. Medians of infused cell doses were as follows: TNC 16.51 x108/kg (5.17~42.4), CD34+ 15.49x106/kg(3.49~33.7).Twelve patients (80%) showed initial engraftment and full donor chimerism according to short tandem repeat polymerase chain reaction (STR-PCR) analysis. Of the 3 patients who showed primary graft failure, one showed autologous recovery, while the remaining 2 received additional HSCs from the same donor and a haploidentical family donor respectively, leading to engraftment. Acute GVHD grade II or above was diagnosed in 8 patients (53.5%) and resolved with steroid therapy. Chronic GVHD developed in two patients, one mild and one of moderate severity. The patient with moderate oral chronic GVHD was diagnosed with squamous cell carcinoma of the tongue 5years after HSCT. She received surgical resection and remains disease-free for 40 months. After transplantation, 5 patients (33.3%) experienced infectious complications including viral reactivation, bacteremia and fungemia but all recovered without complications. At a median follow-up of 59.6 months (6.3~107.9) all 15 FA patients are alive and remain free of hematologic disease.Conclusion) FA patients who received AD-HSCT with fludarabine-based conditioning with in vivo T cell depletion using rabbit ATG showed excellent outcome with a lower rate of infectious toxicities than has been reported with conditioning incorporating alemtuzumab. The incidence of primary graft failure should be monitored in a larger cohort of patients. DisclosuresNo relevant conflicts of interest to declare.

Haploidentical stem cell transplant with post-transplantation cyclophosphamide and mini-dose methotrexate in children

BackgroundHaploidentical stem cell transplantation (haplo‐SCT) is an option for patients without human leukocyte antigen‐matched related or unrelated donor. Post-transplantation cyclophosphamide (PTCy) is an effective method of graft versus host disease (GVHD) prophylaxis and permits the use of T‐cell replete grafts in settings were ex vivo manipulation is not feasible. MethodsA retrospective study among patients younger than 18 years, with a history of hematologic malignancies who underwent haplo-SCT between 2012 and 2016. All patients received a preparative regimen of fludarabine, busulfan, and 400 cGy total body irradiation or melphalan. Post-transplant GvHD prophylaxis consisted either of PTCy (50 mg/kg on Days + 3 and + 4) and cyclosporine (CSA) plus mycophenolate (MMF) (15 mg/kg/dose, thrice daily, per os), or mini-dose methotrexate (MTX; 5 mg/m2 dose) on Days + 5, +7, +10, and + 15. ResultsA total of 52 children were included, whose median age was 9 years (interquartile range, 4.9–14; range, 1.2–17 years), and 63% were males. The most common complications were cytomegalovirus reactivation (57%) and hemorrhagic cystitis (36%). The acute GVHD prophylaxis was PTCy, CSA, and mini-dose MTX in 42 (81%) patients, and 10 (19%) patients received PTCy, CSA, and MMF. The cumulative incidence of acute GvHD II–IV, acute GvHD III–IV, and chronic GvHD were 42%, 8.5%, and 19%, respectively. Grades I–IV acute GvHD occurred in 100% of the patients who received prophylaxis with CSA and MMF, and 62% who received CSA and mini-dose MTX (p = .055). The transplant-related mortality at 100 days was 18%. The 5-year overall and event-free survival were 59% and 57%, respectively. ConclusionsHaplo‐SCT with PT/Cy can be an available, safe, and feasible option for children with hematologic malignancies; meanwhile, the use of mini-dose of MTX was associated with lower rates of acute GVHD. However, our results require further support from prospective randomized studies to improve the efficacy of this prophylactic strategy.

GVHD Prophylaxis Using Tacrolimus and Mini-Dose Methotrexate Improves Engraftment and Reduces Mortality in Cord Blood Transplantation

Background A combination of calcineurin inhibitor and methotrexate (MTX) is one of a standard GVHD prophylaxis in allogeneic hematopoietic stem cell transplantation. However, MTX delays engraftment particularly in cord blood transplantation (CBT). Methods We conducted a retrospective study to evaluate an efficacy of mini-dose of MTX as a GVHD prophylaxis in single unit CBT. We compared the clinical outcome of patients with hematological malignancies in our institution who received standard-dose MTX (St-MTX, 15 mg/m2 of MTX on day 1 and 10 mg/m2 on days 3 and 6) as a GVHD prophylaxis in CBT between 2004 and 2013 and those who received mini-dose MTX (Mini-MTX, 5 mg/m2 of MTX on days 1, 3 and 6) between 2013 and 2018. Results Thirty-two patients received St-MTX and 26 patients received Mini-MTX. There was no statistically significant difference between 2 groups except for patients’ age (St-MTX; 46.5 years, Mini-MTX; 55.0 years, P = 0.0215). Cumulative incidence of neutrophil engraftment was significantly higher in Mini-MTX group (St-MTX; 71.9 %, Mini-MTX; 96.2 %, P = 0.0157). Cumulative incidence of grade II to IV and grade III to IV of acute graft-versus-host disease (GVHD) were 34.4 % and 6.2 % in St-MTX group, and 34.6 % and 7.7 % in Mini-MTX group with no statistical significance. Day 180 non-relapse mortality (NRM) rate was significantly lower in Mini-MTX group compared to St-MTX group (25.0 % vs 3.8 %, P = 0.0279), whereas relapse rate was almost equivalent between these groups. Multivariate analysis also indicated that Mini-MTX significantly improved engraftment (HR, 0.1368; 95% CI, 0.01902 to 0.9841; P = 0.048), and reduced the risk of NRM (HR, 0.1234; 95% CI, 0.01624 to 0.9380; P = 0.043). Day 180 OS were 71.9 % in St-MTX group, and 88.5 % in Mini-MTX group (P = 0.121), and PFS were 62.5 % in St-MTX group, and 80.8 % in Mini-MTX group (P = 0.136). Conclusion Our study suggests that GVHD prophylaxis using mini-dose MTX is feasible and associated with improvement of engraftment and decrease of transplant-related complication early after CBT.

Tacrolimus and Mini-dose Methotrexate for Prevention of Graft-Versus-Host Disease after Unrelated Hematopoietic Stem Cell Transplantation in Children: A Single-center Study in Korea

Background: Currently, data on the role of tacrolimus and mini-dose methotrexate (MTX) in pediatric unrelated hematopoietic stem cell transplantation (HSCT) is limited. We report the outcomes of unrelated hematopoietic stem cell recipients, evaluating engraftment status, incidence of acute and chronic graft-versus-host disease (GVHD) and toxicities after use of tacrolimus and mini-dose MTX for GVHD prophylaxis.

Allo- HSCT for Advanced Myelodysplastic Syndrome:MSKCC Vs MDACC

Allogeneic hematopoietic stem cell transplantation (Allo-HSCT) is the only curative treatment for myelodysplastic syndrome (MDS). Relapse, infections and graft-versus-host disease (GvHD) are the main causes of treatment failure. We compared the outcomes of patients receiving T cell depleted (TCD) grafts at Memorial Sloan-Kettering Cancer Center (MSKCC) with patients receiving unmodified grafts at MD Anderson Cancer Center (MDACC) for advanced MDS (RAEB-1 and 2).Adult patients transplanted between 2001 -2012 were included in this retrospective analysis. All recipients of TCD grafts (N=60) received myeloablative conditioning (MAC) and antithymocyte globulin (ATG) to prevent graft rejection. None of them received post-transplant GvHD prophylaxis. Of the 129 recipients of unmodified grafts, 87 received MAC and 42 reduced intensity conditioning (RIC); GvHD prophylaxis consisted of tacrolimus and mini-dose methotrexate in the majority of patients (N=113). ATG was given to all matched unrelated donor (MUD) recipients. Patients in the unmodified group had more therapy-related MDS (MDS-t), very poor risk cytogenetics by IPSS-R at diagnosis and bone marrow (BM) blast count >5% at transplant. Only the TCD group had mismatched donors (Table 1).Univariate analysis identified a lower incidence of grade II-IV acute GvHD in the TCD group with 100-day cumulative incidence (CI) of 13.3% vs. 34.1% in the unmodified group (p=0.031). There was no difference in grade III-IV acute GvHD with a 10% CI in both groups at day-100 (p=0.546). The incidence of chronic GvHD was lower in the TCD group with a CI at 3-yrs of 3.4% vs. 44.3% in the unmodified group (p < 0.001). The non-relapse mortality (NRM) in both groups was similar. CIs at day 100, 1yr, and 3 yrs in the TCD group were 8.3%, 20.2% and 32.7% vs. 12.4%, 22.5% and 28.1% in the unmodified group (p=0.628). Relapse was lower in the TCD group, with CI at 1 and 3 yrs of 8.5% and 15.5%, vs. 31.0% and 39.4% in the unmodified group (p=0.002). Since the unmodified recipients had worse disease characteristics, further analyses in patients with good/intermediate risk cytogenetic showed that the relapse incidence was similar between these subgroups, with 3-yr CIs of 7.9% in TCD vs. 18% in unmodified group (p=0.185). The most common causes of death in the TCD group were infections (32%) and relapse (28%), while in the unmodified group it was relapse (55%), GVHD (20%) and infections (13%). Considering the differences in disease characteristics between the groups, multivariate regression models were performed for relapse-free survival (RFS) and overall survival (OS) adjusting for MDS-t, high-risk cytogenetics at diagnosis and high blast count at HSCT. No significant differences were observed between the groups for RFS (HR=1.44, p=0.128) and OS (HR= 1.35, p=0.236) (Table 2). High-risk cytogenetics at diagnosis (very poor risk) was the only significant prognostic factor for RFS (HR=5.32, p<0.001) and OS (HR=4.81, p<0.001).Allo-HSCT is an effective treatment for patients with MDS with similar long term survival with either unmodified or TCD allografts. TCD is associated with a lower incidence of acute and chronic GVHD and without an increased risk of relapse.Table 1CharacteristicsTCD (N=60)Unmodified (N= 129)p-valueMedian follow-up, months (range)43.4 (3.8-119.5)49.4 (12.2-136.3)Age, years (range)57.1 (21.9-72.0)57.0 (19.0-72.0)0.769Female gender34 (56.7%)45 (34.9%)0.008MDS-t7 (11.7%)43 (33.3%)0.003Cytogenetic risk at diagnosis ( IPSS-R)0.009Good25 (42.4%)48 (37.2%)Intermediate15 (25.4%)19 (14.7%)Poor11 (18.6%)15 (11.6%)Very poor8 (13.6%)47 (36.4%)Missing1Blasts at transplant< 0.001< 5%48 (81.4%)57 (46.3%)5-9%11 (18.6%)35 (28.5%)10-19%031 (25.2%)Missing16Donor type< 0.001MRD21 (35.0%)65 (50.4%)MUD25 (41.7%)64 (49.6%)MMD14 (23.3%)0Stem cell source0.002BM5 (8.3%)46 (35.7%)PB55 (91.7%)83 (64.3%)Table 2:Multivariate analysisVariablesOS HR (95% CI)RFS HR (95% CI)Disease etiology0.5180.511De novo11MDS-t0.87 (0.56-1.34)0.87 (0.56-1.33)Cytogenetic risk at diagnosis IPSS-R)< 0.001 < 0.001 Good11Intermediate1.41 (0.74-2.68)1.39 (0.73-2.64)Poor2.06 (1.13-3.73)2.49 (1.40-4.44)Very poor4.81 (2.88-8.02)5.32 (3.22-8.80)Blasts at transplant0.2860.502< 5%115-9%1.11 (0.70-1.77)1.03 (0.65-1.62)10-19%1.57 (0.91-2.71)1.37 (0.80-2.34)Type of transplant0.2360.128TCD11Unmodified1.35 (0.82-2.19)1.44 (0.90-2.31) DisclosuresNo relevant conflicts of interest to declare.

Outcomes In Patients With Acute Lymphoblastic Leukemia In First Or Second Complete Remission Receiving Ex-Vivo T-Cell Depleted Or Unmodified Allografts: Comparison Of Results At Two Institutions

Ex vivo T-cell depleted (TCD) allogeneic hematopoietic stem cell transplants (HCT) in patients with acute myeloid leukemia in complete remission (CR)lead to survival and relapse rates comparable to those with unmodified grafts, but with significantly less graft versus host disease (GVHD). TCD-HCT is also effective in patients with acute lymphoblastic leukemia (ALL), however it is not known how outcomes compare with those of patients receiving conventional grafts. In this study we compared the outcomes of patients receiving TCD-HCT at Memorial Sloan-Kettering Cancer Center (MSKCC) with patients receiving conventional grafts at MD Anderson Cancer Center (MDACC) for ALL in first or second CR.Patients 18 years of age or older, undergoing HCT between 2000 and 2010 were included in this retrospective analysis. 52 patients at MSKCC received TCD grafts and 129 patients at MDACC received conventional grafts. All patients at MSKCC received myeloablative HCT conditioning (MAC). No GVHD prophylaxis was given. At MDACC, 115 patients received MAC and 14 received reduced intensity conditioning; GVHD prophylaxis consisted of tacrolimus and mini-dose methotrexate, plus antithymocyte globulin for total dose 4 mg/kg for unrelated donors.Patient characteristics and outcomes are summarized in the Table. A greater percentage of patients in the conventional graft group received transplants from a matched related donor and from bone marrow as a stem cell source. Patients in the TCD group almost exclusively received grafts from peripheral blood. [Display omitted] A significant difference in acute GVHD incidence was observed between the TCD and conventional groups, with 100-day cumulative incidence estimates of 17.3% and 40.3%, respectively (Gray's test p-value=0.007). A significant difference was also observed in chronic GVHD rates, with three-year estimates of 13.5% and 34.8% for the TCD and unmodified groups, respectively (Gray's test p-value=0.004). There was no statistical difference between TCD and unmodified groups with regards to OS (log-rank p-value=0.89, 3 year estimates 42.6% vs. 43.2%) or RFS (log-rank p-value=0.64, 3 year estimates 42.8% and 36.0%). The NRM at day 100, 1 year and 3 years were 15.4%, 26.9% and 37.8% in the TCD group and 10.1%, 23.5% and 28% in the unmodified group (Gray's test p-value=0.22). There was a lower relapse rate among patients who received TCD versus unmodified grafts (3 year estimates 19.4% vs. 36.0%, Gray's test p-value=0.05). Age >50 and was the only factor associated with inferior RFS (HR=1.74, p=0.01) and OS (HR=1.85, p=0.006).HCT is an effective treatment modality for patients with ALL with favorable results with either conventional or TCD allografts. Although the relapse rate was significantly lower after TCD-HCT, this would need to be confirmed in a prospective study. While 3-year OS rates are similar in both groups, TCD effectively reduces the rate of both acute and chronic GVHD.*: Median (range)* *: P-values were estimated using a chi-square test or Fisher's exact test for categorical variables and a Wilcoxon rank-sum test for continuous variables. OS and RFS were compared using a logrank statistics, while NRM, aGVHD and cGHVD were compared using Gray's test.^: Good risk: Hyperdiploidy, del(9p); poor risk: Ph+, t(4;11), t(8;14); complex karyotype (≥5 abnormalities), hypodiploidy/near triploidy; standard risk: other.TCD-T-cell depleted; CR- Complete Remission; TKI- Tyrosine Kinase Inhibitors; RIC-Reduced Intensity Conditioning; MAC- Myeloablative Conditioning; RFS-Relapse Free Survival; OS- Overall Survival; NRM- Non-Relapse Mortality; aGVHD- acute Graft Versus Host Disease; cGVHD- chronic Graft Versus Host Disease [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Evaluation of risk for graft-versus-host disease in children who receive less than the full doses of mini-dose methotrexate for graft-versus-host disease prophylaxis in allogeneic hematopoietic stem cell transplantation

PurposeThe use of cyclosporine and mini-dose methotrexate (MTX) is a common strategy for graft-versus-host disease (GVHD) prophylaxis in allogeneic transplants. We investigated whether patients who receive fewer than the planned MTX doses are at increased risk for GVHD.MethodsThe study cohort included 103 patients who received allogeneic transplants at the Department of Pediatrics of The Catholic University of Korea College of Medicine, from January 2010 to December 2011. MTX was administered on days 1, 3, 6, and 11 after transplant at a dose of 5 mg/m2 each. Within the cohort, 76 patients (74%) received all 4 doses of MTX [MTX(4) group], while 27 patients (26%) received 0-3 doses [MTX(0-3) group].ResultsAlthough there was no difference in neutrophil engraftment between the 2 groups, platelet engraftment was significantly faster in the MTX(4) group (median, 15 days), compared to the MTX(0-3) group (median, 25 days; P=0.034). The incidence of grades II-IV acute GVHD was not different between the MTX(4) and MTX(0-3) groups (P=0.417). In the multivariate study, human leukocyte antigen mismatch was the most significant factor causing grades II-IV acute GVHD (P=0.002), followed by female donor to male recipient transplant (P=0.034). No difference was found between the MTX(4) and MTX (0-3) groups regarding grades III-IV acute GVHD, chronic GVHD, and disease-free survival.ConclusionOur results indicate that deviations from the full dose schedule of MTX for GVHD prophylaxis do not lead to increased incidence of either acute or chronic GVHD.

A Matched Controlled Analysis of Post-Transplant Cyclophosphamide (CY) Versus Tacrolimus and Mini-Dose Methotrexate in Matched Sibling and Unrelated Donor Transplant Recipients Receiving Reduced-Intensity Conditioning: Post-Transplant CY Is Associated with Higher Rates of Acute Gvhd

AbstractAbstract 4200Graft-vs.-Host Disease (GVHD) remains a common complication following matched sibling and unrelated donor hematopoietic cell transplantation (HCT). Standard GVHD prophylaxis calls for prolonged immune suppression, typically with a calcineurin-inhibitor. Recently, post-transplant cyclophosphamide (CY) has been studied as sole prophylaxis in matched related and unrelated bone marrow (BM) transplant recipients following an ablative conditioning regimen with busulfan (Bu) and CY and demonstrated comparable rates of acute GVHD and lower rates of chronic GVHD as traditional GVHD prophylaxis regimens. We recently conducted a phase II study of post-transplant CY following a reduced-intensity conditioning (RIC) regimen of Busulfan (Bu) and Fludaribine (Flu) in matched related and unrelated donor transplants and performed a matched-control analysis comparing their results with patients who received traditional GVHD prophylaxis with tacrolimus and mini-dose methotrexate (MTX) during the same time period.Forty-nine (49) patients were enrolled onto this study. They received Flu at a dose of 40mg/m2 over 1hour followed by intravenous Bu over 3 hours targeting a daily AUC of 4,000 microMol-min on days –6 to –3. Recipients of unrelated transplants received ATG on days –3 to –1 (total dose 4 mg/kg). CY was given as sole GVHD prophylaxis at a dose of 50 mg/kg on days +3 and +4. During the same period of time, 133 patients received a RIC regimen with intravenous Bu/Flu or Flu and melphalan (Mel) and received GVHD prophylaxis with tacrolimus plus mini-dose MTX (10mg/m2 on day +1, 5mg/m2on days +3, +6, +11). Unrelated donor transplants also received ATG. A computer generated algorithm was used to identify a comparable control group from our departmental database matching, in order of priority, on age, diagnosis, disease status, donor (matched-related versus unrelated) and graft source (PB versus BM). Matched controls (control group) were successfully identified for 37 study patients (Post-Cy group). Results:The median age for the Post- CY group and control group was 61 (range, 39–72) and 62 years (range, 37–72). Eight-one (81) % of patients in both groups had AML or MDS, 3% had ALL and 16% had NHL or CLL. Fifty-nine (59) % of patients in both groups had unrelated donors and received ATG in the conditioning. Disease status for the Post-CY and control groups respectively were CR1: 14 and 14%, CR2: 8 and 11%, >CR2: 38 and 32% and Primary Induction Failure / Untreated: 40 and 32%. Seventy (70) % of the post-CY group received BM versus 48% of the control group, whereas sex mismatching (Male donor for Female patient) occurred in 22% of the post-Cy and 8% of the control group. The cumulative incidence of grade II-IV acute GVHD and chronic GVHD in the post-CY and control groups were: 46% versus 19% (Hazard Ratio (HR): 2.8, 95% CI, 1.1–6.7; p=0.02) and 14% versus 21% (HR: 0.8, 95% CI, 0.2–2.6, p=0.7). Grades III/IV acute GVHD occurred in 14% (95% CI, 6–32) of the patients in the post-CY group whereas there were no cases of grade III/IV in the control group (p=0.02). Overall, progression-free and non-relapse mortality at 2-years are shown in the table below. Conclusion:Post-transplant CY following RIC is associated with higher rates of acute GVHD, with resultant trends for higher non-relapse mortality and lower overall survival when compared to tacrolimus and mini-dose MTX. The use of post-transplant CY as a sole GVHD prophylaxis regimen should be avoided following RIC transplant in matched-related and unrelated donors.Post-Transplant CYTacrolimus and MethotrexateHazard Ratio (95% CI, p- value)Acute GVHD Grade II-IV46% (32–66)19% (10–37)2.8 (1.1–6.7, 0.02)Chronic GVHD @ 1-year14% (6–32)21% (11–43)0.8 (0.2–2.6, 0.7)Non-Relapse Mortality @ 2-years36% (23–55)16% (7–35)2.4 (0.8–6.7, 0.1)Progression-Free Survival @ 2-years22% (10–37)33% (16–51)1.3 (0.7–2.3, 0.4)Overall Survival @ 2 years26% (13–42)46% (26–64)1.8 (0.9–3.3, 0.08) Disclosures:Off Label Use: azacitidine: off-label use as maintenance therapy following allogeneic stem cell transplant for MDS/AML.

Graft-versus-Host Disease: State of the Science

Despite concerted research efforts, prevention and treatment of graft-versus-host disease (GVHD) have not changed significantly over the past 3 decades. The goal of this session is to provide an outline of the current state of the science with respect to the prevention, treatment, and evaluation of acute and chronic GVHD. In addition, we detail those strategies most likely to be at the forefront of clinical research in the upcoming years.

The effectiveness of tacrolimus and minidose methotrexate in the prevention of acute graft-versus-host disease following allogeneic hematopoietic stem cell transplantation in children: a single-center study in Korea

BackgroundKnowledge of the roles of tacrolimus and minidose methotrexate (MTX) in the prevention of acute graft-versus-host disease (aGVHD) in pediatric allogeneic hematopoietic stem cell transplantation (HSCT) is limited. We retrospectively evaluated the engraftment status, incidence of aGVHD and chronic GVHD (cGVHD), and toxicities of tacrolimus and minidose MTX in aGVHD prophylaxis in children undergoing allogeneic HSCT.MethodsSeventeen children, who underwent allogeneic HSCT and received tacrolimus and minidose MTX as GVHD prophylaxis from March 2003 to February 2011, were reviewed retrospectively. All the patients received tacrolimus since the day before transplantation at a dose of 0.03 mg/kg/day and MTX at a dose of 5 mg/m2 on days 1, 3, 6, and 11.ResultsOf the 17 patients, 9 received human leukocyte antigen (HLA)-matched related donor transplants, and 8 received HLA-matched, or partially mismatched unrelated donor transplants. The median time for follow-up was 55 months. The incidence of aGVHD in the related and unrelated donor groups was 22.2% and 42.9%, respectively. cGVHD was not observed. To maintain therapeutic blood levels of tacrolimus, the younger group (<8 years of age) required an increased mean dose compared to the older group (≥8 years) (P=0.0075). The adverse events commonly associated with tacrolimus included hypomagnesemia (88%), nephrotoxicity (23%), and hyperglycemia (23%).ConclusionTacrolimus and minidose MTX were well tolerated and effective in GVHD prophylaxis in pediatric patients undergoing allogeneic HSCT. Children <8 years of age undergoing HSCT required increased doses of tacrolimus to achieve therapeutic levels.

Gemcitabine, Fludarabine, and Melphalan (G-FM) as Reduced-Intensity Conditioning (RIC) Regimen for Allogeneic Stem Cell Transplantation (Allo-SCT) in Relapsed and Refractory Hodgkin Lymphoma (HL)

Abstract 3003▪FN2▪This icon denotes a clinically relevant abstract Objective:Progressive disease (PD) remains the main cause of treatment failure following RIC allo-SCT in HL (Peggs KS et al, BJH 2008: 143; 468). We elected to explore the feasibility of adding gemcitabine (G), a highly active agent in relapsed/refractory HL (Santoro A et al, JCO 2000 :18; 2615), to our standard fludarabine (F) - melphalan (M) RIC in patients with relapsed and refractory HL undergoing allo-SCT, with the ultimate goal to augment cytoreduction and reduce the incidence of PD. Main G-associated non-hematologic toxicities include pulmonary, skin toxicities and mucositis. Patients and Methods: Between 8/07 and 3/11, fifteen consecutive HL patients (Unique Patient Number/UPNs 1–15) underwent an allo-SCT with the G-FM regimen. They had failed multiple conventional treatments (median prior chemotherapy regimens: 4; range 2–9), radiation therapy (6/15) and a prior auto-SCT (7/15). The median age was 33 years (range 20–46). Disease status at SCT was chemosensitive relapse (n=4), untreated relapse (n=1), induction failure chemosensitive (n=2), complete remission undetermined (CRU1 and CRU2) (n=8). The median time to PD after auto-SCT was 10 months (range 3–19). The donor was an HLA-identical sibling (n=10) or matched unrelated donor (MUD; n=5, with UPN 6 having a 9/10 match). The conditioning regimen was G 800 mg/m sq IV x1 at day -7 (two patients, UPN 6 and UPN 7 received G 1000 mg/m sq IV x2, day -5 and day -2 as part of a dose escalation attempt stopped for excess toxicity), F (32 mg/m sq IV x4, day -5 to day -2), M (70 mg/m sq IV x2, day -3 and day -2; total dose 140 mg/m sq). Thymoglobulin (4 mg/kg IV) was added in MUD allografts. Graft-vs-host disease (GVHD) prophylaxis included tacrolimus and mini-dose methotrexate (5 mg/m sq). Results: Myeloid recovery was prompt, with an absolute neutrophil count (ANC)>500/mcL at day +12 (range 11–20). Median platelet recovery at 20K/mcL was at day +14 (range 9–26). Chimerism studies indicate 100% donor-derived engraftment in 13/13 evaluable patients (100%). Day 100/overall transplant-related mortality (TRM) were 2/15 (13%) and 2/15 (13%), respectively. Acute GVHD (grade II-IV) occurred in 8/14 evaluable patients, chronic GVHD in 7/13 evaluable patients (extensive in 7). Pulmonary toxicity was seen in four patients (26%). Grade 4 pulmonary toxicity was seen in UPN 6. Otherwise it was grade 1–2 (n=3). Cutaneous toxicity (skin rash, responsive to steroid therapy) was seen in five patients (33%: grade 3 n=1; grade 1–2 n=4). Mucositis was seen in nine patients (60%). It was grade 3 (n=1); grade 1–2 (n=8). Other organ toxicities were not seemingly markedly different from the ones seen with FM140 only. Three patients expired (graft rejection n=1, in UPN 6; CMV pneumonia n=1; PD n=1). Twelve patients are alive (ten progression-free, eleven in CR/CRU) with a median follow-up of 18 months (range 2–33). Actuarial rates of overall survival (OS) and progression-free survival (PFS) at 24 months are 87% (95% CI: 56–96) and 49% (95% CI: 18–74), respectively (see Figure). While a formal comparison with our historical experience with the FM140 regimen is clearly not possible, OS and PFS (actuarial estimates) at 24 months were 64% (95% CI: 49–76), and 32% (95% CI: 20–45), respectively (Anderlini et al, Haematol 2008; 93 :257). Conclusions: The addition of G to FM140 is feasible. Pulmonary, cutaneous toxicities, as well as mucositis, while clinically significant, were manageable and did not contribute to mortality in the patients treated with only one G dose. While quite encouraging, these data remain preliminary. The G-FM regimen deserves further study in a larger cohort of patients. [Display omitted] Disclosures:Off Label Use: Gemcitabine, fludarabine and melphalan as part of conditioning regimen for allogeneic stem cell transplantation.

Long-Term Follow-up of Reduced Intensity Allogeneic Hematopoietic Stem Cell Transplantation for Severe Paroxysmal Nocturnal Hemoglobinuria

AbstractAbstract 3505Paroxysmal nocturnal hemoglobinuria (PNH) is a non-malignant clonal disorder of hematopoietic stem cells characterized by erythrocyte susceptibility to complement-mediated lysis. Untreated, patients with PNH have a reduced life expectancy compared with age-matched controls. The development of cytopenias with infections related to neutropenia, bleeding associated with thrombocytopenia, and vascular thrombosis all contribute to morbidity and mortality. We previously reported that engrafting donor T-cells mediating graft-vs-host hematopoietic effects can eradicate PNH following reduced intensity (RIC) allogeneic hematopoietic cell transplantation (HCT). Here we present long term follow up data on 16 patients with severe PNH who received a RIC peripheral blood HCT at the NHLBI from May 1999 through January 2007. Eligibility for transplantation included a diagnosis of PNH associated with one or more of the following: 1) Transfusion dependence 2) Prior thrombotic episodes 3) Recurrent debilitating hemolytic crisis. Marrow failure, personal preference or unavailability of the drug precluded the use of eculizumab in all patients. Patients received a T-cell replete G-CSF mobilized blood stem cell transplant from an HLA-matched related donor following conditioning with cyclophosphamide (120mg/kg) and fludarabine (125mg/m2). Patients with a significant transfusion history had equine ATG (40mg/kg/day × 4) added to the conditioning regimen (n= 14). The median CD34+ cell dose was 6.9 × 106cells/kg (range 3.1 to 21.1 × 106) and the median CD3+ cell dose was 2.5 × 108cells/kg (range 1.4 to 4.3 × 108). CSA given alone (n=1) or in combination with either MMF (n=4) or mini-dose methotrexate (n=11) was used as GVHD prophylaxis. FACS analysis on blood samples was performed on all patients at baseline and at multiples time-points post-transplant to measure the percentage of GPI negative PNH-type neutrophils (CD15+/CD66b-/CD16-); the median % of GPI-anchored-protein negative neutrophils pre-transplant was 80.1% (range 5.5%-99%). Half of the patients (n=8) were HLA alloimmunized prior to transplantation with a median 76.5% PRA (range 45%-100%). Neutrophil and platelet recovery occurred at a median 14 days (range 9 to 18) and 12 days (range 5 to 15), respectively. Chimerism assessed in T-cell (CD3) and myeloid (CD14,15) lineages by PCR of short tandem repeats (STR) revealed sustained donor engraftment occurred in both myeloid and T-cell lineages in all patients; the median time to achievement of full donor (>= 95%) myeloid and T-cell chimerism was 15 and 30 days respectively. FACS analysis on blood samples collected sequentially after transplant revealed evidence for donor immune-mediated eradication of PNH; although GPI-anchored-protein negative neutrophils were detectable early after transplant, over time these populations declined in size and eventually disappeared in all patients at a median 100 days (range 30 to 150) post transplant. Two patients died, one from complications related to acute GVHD (day 169) and one from complications related to a peptic ulcer disease (2.8 years). The cumulative incidence of grade 2–4 acute GVHD was 50% (n=8) and the cumulative incidence of chronic GVHD was 68.8% (n=10). With a median follow-up of nearly 6 years (range 2.6–11 years), 14 patients (87.1%) survive without any evidence of PNH, transfusion independent and off all anticoagulation. Conclusion:Graft-vs-PNH effects that occur after RIC allogeneic HCT result in durable remission and can achieve excellent long-term survival in patients with debilitating PNH. Allogeneic HCT using RIC should be considered a viable treatment option for PNH patients who have failed or are not candidates for eculizumab treatment. Disclosures:No relevant conflicts of interest to declare.

Absence of Graft Failure and Excellent Long Term Survival Following Fludarabine-Based Reduced Intensity Hematopoietic Stem Cell Transplantation In Heavily Transfused Patients with ATG-Refractory Severe Aplastic Anemia and Other Bone Marrow Failure Syndromes

AbstractAbstract 517Heavily transfused and alloimmunized patients with bone marrow failure syndromes including aplastic anemia have an increased risk of graft rejection following conventional allogeneic bone marrow transplantation. Results from pilot trials suggest the addition of fludarabine to the conditioning regimen reduces the risk of graft rejection in patients at high risk for this complication. Here we report the results of a fludarabine-based transplant approach in 56 patients with severe aplastic anemia (SAA) or other bone marrow failure syndromes (SAA n=31, MDS-RA n=6, PNH n=16, PRCA n=2, DBA n=1) who were transplanted from May 1999 to November 2008 at the NHLBI. Forty one percent of patients were found to be alloimmunized (median 82% PRA) prior to transplantation as a consequence of prior transfusions. Seventy three percent of patients had received antibody-based immunesuppressive therapy at a median of 303 days (range 21 to 2588) prior to transplantation (horse-ATG n=34, rabbit-ATG n=5, alemtuzumab n=1 and daclizumab n=1). Conditioning with fludarabine (25 mg/m2 × 5 days), ATG (40mg/kg × 4 days) and cyclophosphamide (60mg/kg × 2 days) was followed by infusion of an un-manipulated G-CSF mobilized allograft from an HLA matched (n=52) or single antigen mismatched (n=4) relative. GVHD prophylaxis consisted of cyclosporine (CSA) either alone (n=2) or combined with mycophenolate mofetil (n=10) or mini-dose methotrexate (n=44). The median CD34+ cell dose was 6.6 × 106 cells/kg (range 1.7 to 21.1 × 106 cells/kg) and the median CD3+ cell dose was 2.6 × 108 cells/kg (range 0.5 to 6.9 x108 cells/kg). Nearly half (46 %) of patients received an ABO incompatible allograft (major mismatch n=15; minor mismatch n=11). Despite a high prevalence of pre-transplant alloimmunization, graft rejection and/or graft failure did not occur, with all patients achieving sustained donor engraftment in both myeloid and T-cell lineages. The median time to achievement of full donor (>= 95%) myeloid and T-cell chimerism was 15 and 30 days respectively. Neutrophil and platelet recovery occurred at a median 15 (range 6 to 24) and 12 (range 5 to 168) days respectively. Major ABO incompatibility was associated with delayed donor erythropoiesis; reticulocyte recovery (> 60 K/μ L on two occasions) occurred at a median 17 days in those without major ABO incompatibility and 42 days in the recipients of a major ABO mismatched graft, where clearance anti-donor isohemagglutinins was delayed a median 171 days following transplantation. CMV reactivation occurred in 31/50 (62%) patients at risk although no patients died from CMV related mortality. With a median follow-up of 4.5 years (range 1.8–11 years) in surviving patients, overall survival was 87.1%. There were 5 treatment related deaths with two attributable to steroid refractory acute GVHD and one attributable to extensive chronic GVHD. The cumulative incidence of Grade II-IV, III-IV and steroid refractory acute GVHD was 51.8%, 30.4% and 21.4% respectively. The cumulative incidence of chronic GVHD was 72% (23.2% limited and 48.9% extensive), with 42.5% who developed cGVHD having resolution of symptoms allowing discontinuation of systemic immunosuppressive therapy. Conclusion: Fludarabine-based allogeneic peripheral blood stem cell transplantation achieves excellent donor engraftment and long-term disease free survival in heavily transfused and alloimmunized patients with ATG refractory SAA and other nonmalignant hematological disorders associated with bone marrow failure. Efforts to reduce the high incidence of GVHD associated with this approach without increasing the risk of graft failure by manipulating the cellular content of the allograft are currently being explored. Disclosures:No relevant conflicts of interest to declare.

Mycophenolate mofetil combined with tacrolimus and minidose methotrexate after unrelated donor bone marrow transplantation with reduced-intensity conditioning

We evaluated the efficacy of a post-grafting immunosuppressive regimen consisting of tacrolimus, methotrexate, and mycophenolate mofetil (MMF) in 21 adults (median age, 55 years) with poor-risk hematologic malignancy who underwent unrelated bone marrow transplantation after fludarabine-based reduced-intensity conditioning (RIC). In combination with intravenous tacrolimus and minidose methotrexate (5 mg/m2 on days 1, 3, and 6), MMF was orally administered at 30 mg/kg daily in three divided doses between days 7 and 27. All patients achieved neutrophil recovery with donor-type chimerism at a median of 19 days (range, 13-35). Cumulative incidences of grades II-IV and III-IV acute graft-versus-host disease (GVHD) were 33% (95% CI, 15-53%) and 5% (95% CI, 0.3-20%), respectively. Five of 20 evaluable patients developed extensive chronic GVHD. Toxicities associated with the use of MMF were acceptable, although one patient experienced intractable GVHD immediately after the cessation of MMF. With a median follow-up of 24 months, overall survival at 3 years was 38% (95% CI, 14-63%). No late graft failure was observed. In conclusion, post-transplant MMF combined with tacrolimus and methotrexate was well tolerated and conferred stable donor cell engraftment, low risk of severe acute GVHD, and encouraging overall survival in unrelated donor marrow transplantation after RIC regimens.

Reduced Intensity Conditioning (RIC) Regimen Followed by Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) in Adult Patients with Acute Lymphoblastic Leukemia (ALL)

Background: RIC regimens are less myelosuppressive, but remain adequately immunosuppressive, allowing for successful engraftment with acceptable treatment-related mortality (TRM) in older or more frail patients (pts) who otherwise would not be suitable candidates for HSCT. This is particularly relevant in ALL, since pts often sustain toxicity from dose-intense upfront regimens or may be diagnosed in advanced age. The antitumor effect of this approach is not well-established in ALL.Methods: We evaluated outcomes of 30 advanced ALL pts (19 M/11 F) treated from August 1996 to May 2008 with FM140 (fludarabine 120 mg/m2, melphalan 140 mg/m2) and unmanipulated stem cells. Graft vs. host disease (GVHD) prophylaxis consisted of tacrolimus and mini-dose methotrexate in all but 1 pt who received cyclosporine. Anti-thymocyte-globulin was added to matched unrelated pts.Results: The median age was 44 years (range 23–64). ECOG performance status at time of HSCT was 0 (n=16), 1 (n=10) or 2 (n=4) with median co-morbidity score of 3 (range 0–7) by Charlson Comorbidity Index (CCI). Twenty-four pts had B-lineage and 6 had T-lineage disease. Cytogenetic data were available for 26 pts; 19 had high-risk cytogenetics, including 9 with Ph+ disease. Disease stage at time of study entry was CR1 (n=5), ≥CR1 (n=12), or primary or refractory relapse (n=13), with median 2 prior chemotherapy regimens (range 1–4); five pts had a prior allogeneic HSCT. Donor type was matched related (n=13) or matched unrelated (n=17) and stem cell source was bone marrow (n=14) or peripheral blood (n=16). The median total nucleated cell dose and CD34+ cell dose were 3.80 × 108 cells (range 0.68–17.16) and 4.15 × 106 cells (range 1.78–12.03), respectively. Median time to ANC 0.5 × 109/L was 13 days (range 10–24). Median time to platelet count 20 × 109/L was 18 days (range 10–57). Eight pts were alive at a median follow up of 12 months from HSCT (range 3–59). OS and DFS were 32% and 29%, respectively, at 1 year. Of note, only 1 among 5 pts in CR1 had disease progression, compared to 8 among 13 with refractory disease at time of HSCT. The cumulative incidence of acute GVHD, grades II–IV and III–IV were 40% and 13%, respectively, and chronic GVHD was 22% (7% for extensive). The cumulative incidence of TRM at 100 days and 1 year were 17% and 33%, respectively. Among 22 deaths, 14 were related to disease recurrence, 4 related to infection and 4 related to GVHD.Conclusion: RIC HSCT can provide disease control in patients with ALL, and merits further evaluation. Alternative treatment strategies need to be explored in pts with advanced disease. The observed TRM rate is comparable to what has been previously reported for this regimen in heavily pretreated leukemia patients.

Addition of Umbilical Cord Blood (UCB) Unit to Reduced Intensity Conditioning (RIC) Regimen to Augment Graft Versus Tumor (GVT) in Patients (pts) with Advanced Hematologic Malignancies

Allogeneic stem cell transplantation (SCT) is associated with a potent GVT effect, mediated by donor immunocompetant cells. The major risk of SCT is graft versus host disease (GVHD), and a major goal is to separate GVT from GVHD. UCB is an effective alternative source of hematopoietic stem cells for transplantation. UCB T-cells have a lower potential to produce GVHD despite transplantation of HLA partially mismatched units, and confer potent GVT effects. We hypothesized that cord blood could be an effective cell source for adoptive immunotherapy. We examined the efficacy of adding one HLA partially mismatched UCB unit to a conventional RIC peripheral blood (PB) SCT from an HLA matched sibling donor in efforts to augment GVT without increasing the rate of GVHD.Methods: The conditioning regimen consists of Fludarabine 30 mg/m2 administered daily for 4 days (days -10 to -7) followed by one dose of Melphalan 140mg/m2 (day -7). One UCB unit, 4/6 HLA matched with pt, containing at least 1.5 x 107TNC/kg is infused on day -5, followed by infusion of HLA-matched sibling PBSC 5 days later (day 0). Patients with CD20+ disease receive rituximab 375 mg/m2 x 4 doses on day -7, -1, +7, +14. GVHD prophylaxis consists of tacrolimus and mini-dose methotrexate for all pts. Hematopoietic chimerism was evaluated in bone marrow and in GVHD biopsy specimens by restriction fragment length polymorphisms for existing recipient and donor cells (PBSC and cord).Results: 14 pts (10 M/4 F) with median age 54 years (range 21–67) have been enrolled to date: ALL (n=4), AML or MDS (n=6), MM (n=1), NHL (n=1), CLL (n=2). The median number of prior chemotherapy regimens was 3 (range 1–7), with 8 pts having had a prior allogeneic SCT. At time of study entry, 2 pts were beyond CR1, 3 were in sensitive relapse, 8 were in refractory relapse, and 1 in PR with concurrent NHL and therapy-related AML. The median PB CD34+ cell dose infused was 4.85 x 106/kg (range 2.6–7.7). The median UCB TNC dose infused was 2.8 x 107/kg (range 1.5–4.6). Median time to ANC ≥ 0.5 x 109/L and platelet count ≥ 20 x 109/L were 15 days (range 11–22) and 25 days (range 16–92), respectively. All pts achieved full donor chimerism from the matched sibling donor at a median of 18 days (range 15–147), except for 1 pt with primary graft failure. This patient had slower engraftment from the cord blood unit. UCB cells were noted in the day 30 chimerism analysis of only 1 other pt: 96% sibling donor, 3% recipient, 1% UCB. Of note, this pt relapsed at day 100 post SCT. Six pts are alive at a median follow-up of 4.4 months from SCT (range 1–16.6). The incidence of acute GVHD, grades II–IV and III–IV were 50% and 21%, respectively; 4 pts developed hyperacute GVHD, manifested by fever and diffuse skin rash, occurring 3 to 10 days following SCT (8 to 15 days following UCB infusion); symptoms resolved promptly with initiation of steroids. UCB cells were noted in the GVHD biopsies of 1 pt who developed GI GVHD at day 14, and 1 pt who developed skin GVHD at day 44. The incidence of TRM at 100 days was 21%. Five pts progressed at a median of 4.3 months (range 1.3–11). Among 8 deaths, 2 were related to disease recurrence, 4 related to infection and 2 related to GVHD.Conclusion: This novel SCT approach is feasible, with a favorable toxicity profile, and without excess GVHD, as compared to the historic data for the FM140 regimen [Giralt et al. Blood 1997, 89(12):4531]. Hyperacute GVHD occurring shortly after UCB infusion suggests an immunologic effect of the cord blood cells. Preliminary data suggests favorable disease control for pts with advanced disease. Longer follow-up is needed to assess the long-term efficacy of this approach.

Reduced Incidence of Acute Graft Versus Host Disease (GVHD) and Transplant-Related Mortality (TRM) with the Addition of Short-Course Mini-Dose Methotrexate (MTX) to Cyclosporine (CSA) as GVHD Prophylaxis Following Nonmyeloablative Hematopoietic Stem Cell Transplantation (NST).

Acute GVHD is a major cause of morbidity and mortality following NST. A high incidence of aGVHD occurs when CSA alone is used as prophylaxis. We investigated the effect of combining either mycophenolate mofetil (MMF) or an abbreviated course of low dose MTX with CSA on the incidence and severity of aGVHD. Between 11/97 and 07/07, 230 consecutive patients (pts) (solid tumors n=127, hematologic malignancies n=57, non-malignant hematologic disorders n=46) underwent conditioning with fludarabine (125mg/m2) and cyclophosphamide (120mg/kg), followed by a G-CSF mobilized PBSC transplant from an HLA identical (n=222: 96%) or 5/6 HLA-matched (n=8: 4%) related donor. Forty-eight pts with a history of heavy RBC transfusions or those receiving a 5/6 HLA-matched transplant had ATG (40mg/kg/d × 4 days) added to their conditioning. The initial cohort of pts (Group 1, n=66), received CSA alone (dose adjusted to maintain therapeutic serum levels) as GVHD prophylaxis. Due to the high incidence of severe aGVHD in this group, subsequent pts received CSA with either MMF (1 gram po bid; Group 2, n=82) or an abbreviated course of mini-dose MTX (5mg/m2 days +1, +3, +6; Group 3, n=82). In all three groups, decisions regarding discontinuation of CSA and MMF were based on donor T cell chimerism, presence of GVHD, and disease status. With a median follow-up of 2963, 2317 and 894 days in the three consecutive cohorts, a comparison was undertaken using competing risk analysis. The incidence of grades II–IV and III–IV GVHD was significantly higher in pts receiving CSA alone or CSA+MMF compared to those receiving CSA+MTX; the cumulative incidence of grades II–IV GVHD in the three groups was 56%, 59%, and 37% (p=0.05) while grades III–IV GVHD occurred in 30%, 34%, and 15% (p=0.019) respectively. The incidence of chronic GVHD (45% vs. 57% vs. 46%, p=0.27) was similar in the three groups. The lower incidence of aGVHD associated with MTX use was accompanied by a significantly improved TRM in group 3 pts; transplant related mortality was 21% in group 1, 21% in group 2 and 5% in group 3 pts (p=0.019). The impact of adding MMF or MTX to CSA on disease-specific outcome in pts with different malignant diseases could not be assessed due to small sample sizes.Conclusion: The addition of an abbreviated course of mini-dose methotrexate to CSA was associated with a significantly lower incidence of grades II–IV and III–IV aGVHD as well as lower TRM compared with CSA used alone or in combination with MMF in pts undergoing NST. To our knowledge this is the first report demonstrating a benefit of adding mini-dose MTX for GVHD prophylaxis in patients undergoing NST.Group 1 (N=66)Group 2 (N=82)Group 3 (N=82)P valueCumulative Incidence of Grade II–IV aGVHD (95% CI)56% (44%–68%)59%(48%–70%)37%(25%–49%)0.05Cumulative Incidence of Grade III–IV aGVHD (95% CI)30%(19%–41%)34%(22%–46%)15%(7%–23%)0.019Transplant Related Mortality(95% CI)21%(11%–31%)21%(12%–30%)5%(0%–7%)0.019Proportion of Evaluable Pts with Chronic GVHD (%)24/53 (45%)43/75(57%)34/74(46%)0.274