Nonmyeloablative Allogeneic Hematopoietic Stem Cell Transplantation Research Articles

Oral Mucositis Association with Periodontal Status: A Retrospective Analysis of 496 Patients Undergoing Hematopoietic Stem Cell Transplantation

Background: Hematopoietic stem cell transplantation (HSCT) can induce serious oral complications, including oral mucositis (OM). The presence of periodontal inflammation before HSCT is believed to be associated with OM. The aim of our study was to determine the prevalence and severity of OM in patients undergoing HSCT and its relation to periodontal status. Patients and methods: This is a retrospective study of patients who underwent HSCT and a detailed dental examination between 2007 and 2015. The dental and periodontal status of all patients was evaluated by clinical and radiographic examination prior to HSCT. Oral health was assessed with the gingival index, the the community periodontal index, presence of plaque-related gingivitis, and marginal periodontitis. During the HSCT period, patients were examined daily for the presence of OM, which was graded according to World Health Organization (WHO) classification if present. The patients were assigned to the groups according to type of transplantation: autologous HSCT, myeloablative allogeneic HSCT, and non-myeloablative allogeneic HSCT. Results: A total of 496 patients were included in the study. OM was present in 314 of 496 patients (63.3%): 184/251 (73.3%) in the autologous group, 100/151 (66.2%) in the myeloablative allogeneic group, and 30/94 (31.9%) in the nonmyeloablative allogeneic group. Significantly more patients suffered from OM in the autologous and myeloablative groups versus the nonmyeloablative conditioning group (p < 0.001). The presence of periodontal inflammation did not significantly differ among the groups. There was only a borderline trend for the higher prevalence of OM in the non-myeloablative allogeneic nonmyeloablative group when periodontal inflammation was present (0.073939). Conclusions: Oral mucositis prevalence and severity after stem cell transplantation is not widely affected by the oral hygiene and periodontal disease presence before HSCT. We confirmed the wide-known connection of the conditioning regimen intensity to the prevalence of OM.

Safe Non-Myeloablative Allogeneic HSCT for Autoimmune Diabetes Using Donor Derived Veto Cells

The induction of partial tolerance towards pancreatic autoantigens in the treatment of type 1 diabetes mellitus (T1DM), can be attained by autologous hematopoietic stem cell transplantation (HSCT). However, most patients treated by autologous HSCT eventually relapse. Furthermore, allogeneic HSCT which could potentially provide a durable non-autoimmune TCR repertoire is associated with a substantial risk for transplant related mortality. Here, we demonstrate in the NOD mouse model for T1DM a safe transplant modality using allogeneic non-myeloablative T cell depleted HSCT in conjunction with donor derived veto cells. Thus, marked chimerism is attained without any transplant-related mortality, and with a very high rate of diabetes prevention. T cell receptor sequencing of transplanted mice shows marked changes in the T cell repertoire and in the prevalence of specific autoimmune T cell clones. Taken together, our results demonstrate a proof of concept for the treatment of T1DM using veto cell-based TD-HSCT.

Orak Hücre Anemisinde Hematopoetik Kök Hücre Transplantasyonu

Sickle cell anemia is one of the most common hemoglobinopathies in the worldwide. Sickle cell anemia characterized by crises and organ failure develops over time. Myeloablative stem cell transplantation is curative but it has been performed in children younger than 16 years of age. Modest modifications in the conditioning regimen and supportive care have improved outcome such that the majority of children with a suitable HLA-matched sibling donor can expect a cure from this approach. But nonmyeloablative protocols are crucial for the future of Hematopoietic Stem-Cell Transplantation for older sickle cell anemia patients with organ failure. A protocol for nonmyeloablative allogeneic hematopoietic stem-cell transplantation that includes total-body irradiation and treatment with alemtuzumab and sirolimus can achieve stable, mixed donor–recipient chimerism. Stem cell transplantation is recommended in the presence of HLA-matched siblings in patients at risk.

Assessment Of The Endocrine Function Of Patients With Sickle Cell Disease After Allogeneic Hematopoietic Stem Cell Transplantation

Introduction While medical treatment of patients with sickle cell disease (SCD) has improved, hematopoietic stem cell transplantation (HSCT) remains the only curative treatment. Standard myeloablative conditioning regimens frequently lead to endocrine abnormalities of the hypothalamus-pituitary-gonadal, -thyroid and/or -adrenal axes. Methods Our group performed allogeneic HSCT in 14 female (ages 20-47 years) and 17 male (ages 16-64 years) patients with SCD using a non-myeloablative regimen: lower doses of total body irradiation (300 cGy instead of 1200 cGy), alemtuzumab (anti-CD52 monoclonal antibody), and sirolimus. Additionally, the gonads of male patients were shielded with two-sided clamshells to reduce radiation exposure. Endocrine function before, and at various time points up to several years after transplantation was analyzed. Results Thyroid function remained within the normal range at 12 months after HSCT, although free triiodothyronine (FT3) levels rose by 18.3% in six females and 19.9% in eight males [mean before/after HSCT: females: 269.4/318 pg/dL; males: 277.8/333.2 pg/dL]. Correspondingly, thyroid stimulating hormone (TSH) levels 12 months after transplantation were decreased by 24.1% in the six females and 33.7% in the eight males [mean before/after HSCT: females: 2/1.5 mcIU/mL; males: 2.5/1.7 mcIU/mL]. One of the female patient developed Grave's disease 36 months after HSCT, while a second female patient developed post-partum thyroiditis one month after giving birth, with persistent hypothyroidism at 48 months after HSCT. One male patient developed Hashimoto's thyroiditis 36 months after HSCT. The hypothalamus-pituitary-adrenal axes of both genders were not measurably impacted; nor was male gonadal function affected as evidenced by unaffected hormonal levels in most males at 12 months after HSCT [mean levels before/after HSCT: luteinizing hormone (LH) 6.5/6.5 U/L, follicle stimulating hormone (FSH) 9.4/6.5 U/L, total testosterone (TT) 359.9/358.3 ng/dL, calculated free testosterone (cFT) 7.6/7.6 ng/dL]. Three men have not yet reached the 12-months post transplant date. One found to have hypogonadotropic hypogonadism secondary to iron overload one year after HSCT (LH 5.4 U/L, FSH 4.2 U/L, cFT 1.9 ng/dL) and azoospermia, was successfully treated to father a child, while a second fathered two children without medical assistance. Among the remaining 14 males, the desire for fatherhood has not yet been expressed. In contrast, this non-myeloablative HSCT regimen affected the gonadal function of the females analyzed thus far. All women had SCD-related reduced ovarian function before HSCT. At twelve months after HSCT FSH levels were increased a mean of 6.2-fold (range: 2.4- to 15.2-fold) in eight females [mean before/after HSCT: 8.9/55.5 U/L], while LH levels rose a mean of 4.2-fold (range: 1.7- to 8.7-fold) in seven of the eight females [mean before/after HSCT: 11.5/35.9 U/L]. Mean estradiol levels fell at 12 months after HSCT by 62.8% in the eight women [mean before/after HSCT: 88.2/32.8 pg/mL] consistent with reduced/diminished ovarian function. Two females less than 12 months post transplant, have not yet had their gonadal function analyzed. Three natural pregnancies occurred in two women younger than 35 years, while two women over 40 years at the time of HSCT entered menopause thereafter. One woman with hypothalamic hypogonadism was not able to conceive. She underwent infertility evaluation, but did not pursue treatment for economic reasons. Nine women have not yet had a desire to conceive. Conclusion While this non-myeloablative regimen appears to impact the gonadal function of females, but not males, fertility is preserved in a subset of women. Further investigation of these patients is required to understand whether the immunosuppressive drugs administered in the setting of HSCT adversely affect ovarian function, and how to better preserve gonadal function of females undergoing non-myeloablative allogeneic HSCT. In addition, long-term follow-up of patients' thyroid functions beyond three years is advisable, as in our three patients, who developed thyroid dysfunction, the changes became evident not earlier than 36 months after HSCT. Disclosures: No relevant conflicts of interest to declare.

Whole Genome Sequencing On Donor Cell Leukemia in a Patient with Multiple Myeloma Identified Gene Mutations That May Provide Insights to Leukemogenesis.

AbstractAbstract 2414Donor cell leukemia (DCL) is a rare occurrence and refers to leukemia of donor origin in patients who have received allogeneic hematopoietic stem cell transplantation (HSCT). We have previously described a male patient with IgG-κ myeloma who received non-myeloablative allogeneic HSCT from a HLA-matched brother and developed complex karyotype acute myeloid leukemia (AML) of donor origin 10 years after transplantation. He achieved complete remission (CR) with standard induction and consolidation chemotherapy but relapsed one year afterwards. We hypothesized that a comparison of the donor HSC before transplantation (pre-leukemic) and the subsequent AML at whole genome level will provide a unique dataset that may shed light on the pathogenesis of leukemia.DNA was extracted from an aliquot of donor mobilized peripheral blood mononuclear cells (mPBMNC) frozen before transplantation as well as unfractionated and CD34+ myeloblasts of the patient's bone marrow at diagnosis and subsequent relapse of AML. The complete donor origin of the AML was confirmed by PCR based on polymorphic STRs. Whole-genome sequencing (WGS) was performed to sequence paired-end reads generated by Illumina HiSeq 2000. Reads were aligned to the human referecne genome (hg19, NCBI37) by SOAP3 and analysed to detect single nucleotide variants (SNVs), small insertion and deletion (indels) and copy number variations (CNVs). Selected genes after filtering were independently validated by Sanger sequencing.There were 835M and 810M 100bp paried-end reads with insert distance of 500bp generated from donor mPBMNC and CD34+ myeloblasts of the relapsed DCL with respective mean depths of 43.2X and 42.6X after alignment. The digital karytoyping based on the read depth was consistent with that by conventional cytogenetic study. 3,979,582 and 1,020,717 SNVs and indels were detectable from both samples. Based on the Catalog of Somatic Mutations in Cancer (COSMIC) and excluding those asian specific wildtypes annotated in 1000 genome project, 11 SNVs and 15 indels within coding sequence with potential roles as tumor suppressors or oncogenes were identified. On the other hand, there were 128,752 and 56,330 SNVs and indels detected exclusively in DCL. Those putative non-pathogenic SNP and those changes locating outside the gene regions were filtered. Within the gene region, SNVs in introns and synonymous mutations were also filtered. 142 non-synonymous SNVs (139 missense and 3 nonsense mutations) were identified of which 25 were considered as statistically highly confident and 17 of them could be confirmed by Sanger Sequencing. Twelve of these were also identified from the whole BM sample of DCL at diagnosis. These candidates include transcription factor (SALL1), metabolic enzymes (UGT1A5, SPEG), membrane protein (TMC6, SCN3A), cytoskeleton protein (MYH10), ribonucleoprotein (RAVER1), secreted protein (WNT7A), protein involved in DNA damage repair (APLF) and others (PRPF8, ZNF518B and MKRN3). 26 indels were indentified in the coding region of which 5 were considered as statistically highly confident, however, only one indel could be confirmed by Sanger Sequencing in the relapse sample and was not present in the diagnostic sample.The WGS performed in paired pre-leukemic (donor HSC) and leukemic (DCL) human samples has provided us with unique opportunities to dissect the genetic changes in HSC that may contribute to the initiation of AML with complex karyotype. The potential impacts of bone marrow microenvironment in this patient with myeloma in inducing DCL are also being evaluated. Disclosures:No relevant conflicts of interest to declare.

The Therapeutic Effect of Lenalidomide Is Enhanced After Allogeneic Stem Cell Transplantation: Results of a Case-Control Study

Abstract 1996 Introduction.Lenalidomide (Len) is a highly effective drug against multiple myeloma (MM). It acts through several mechanisms, such as a direct cytotoxic effect, anti-angiogenesis, microenvironment modifications, and immunomodulation. The latter property is particularly interesting in the allogeneic hematopoietic stem cell transplantation (Allo-HSCT) setting, since Len may interact favourably with the graft-versus-myeloma (GVM) effect. Preliminary results from retrospective studies on heterogeneous patient populations have suggested that Len is more effective when given after Allo-HSCT. In order to verify this observation, we have conducted a case-matched analysis comparing Len after autologous stem cell transplantation (Auto-HSCT) vs. Len after Allo-HSCT. The hypothesis is that Len may be more potent when administered after Allo-HSCT. Methods and results.In this retrospective study the matching criteria was represented by the number of treatment lines received before Len. In an attempt to uniform the treatment regimens, an intra-centre matching was recommended. To April 2011 we collected data from 39 patients in each group. Baseline characteristics between Auto and Allo patients were similar, except for age at diagnosis (53 years, range 39–70, in Auto patients; 47 years, range 29 – 61, in Allo patients). The median number of previous lines of treatment was 3 (range 1–6 ) for both groups. Twenty-one out 39 (54%) Allo patients received Allo-HSCT as second or subsequent line of therapy. Thirty-two (82%) Auto and 35 (90%) Allo patients received bortezomib in previous lines. Similarly, 34 (87%) Auto and 12 (54%) Allo patients were previously treated with thalidomide. Len was always combined with dexamethasone. Median time between Auto-HSCT and Len start was 38 months (range 7–159), and for Allo-HSCT 29 months (range 4–215). Best responses were for Auto and Allo patients as follows: 5 vs. 4 CR, 6 vs. 8 VGPR, 11 vs. 12 PR, 6 vs. 8 SD, 11 vs. 7 PD. Time from Len start to the best response was 4 months for both groups. With a median follow-up of 11.5 months (range 1–39), 1 year and 2 year progression-free survival were 41% and 6% for Auto patients, and 52% and 44% for Allo patients (p=0.03), respectively. Two years overall survival was 48% for Auto and 75% for Allo patients (p=0.03). Similar results were observed regardless of previous thalidomide treatment. No unexpected toxicities were reported. Two (10%) patients had worsening of a pre-existent extensive chronic GVHD. Discussion and Conclusion.The comparison between Auto and Allo patients has shown a benefit in terms of PFS and OS in favor of Len administered after AlloHSCT. This observation supports the hypothesis that Len is synergistic with the GVM effect. Since Len has a potent immunomodulatory effect, this can raise concerns about its use after AlloHSCT. A Dutch prospective study showed that the early administration of Len 10 mg daily after non-myeloablative Allo-HSCT induces late onset acute GVHD in a substantial proportion of patients, causing the premature discontinuation of the study. On the contrary, our retrospective study has shown that a later administration is feasible and safe, without an excess of GVHD, suggesting that a more mature immune system can better tolerate Len. Moreover, since in all cases dexamethasone was given in combination with Len, its immunosuppressive effect may have harnessed the Len-induced immune activation. In conclusion our study suggests that Len is particularly active after AlloHSCT, still retaining a favorable toxicity profile. Disclosures:No relevant conflicts of interest to declare.

Allogeneic Hematopoietic Stem-Cell Transplantation for Sickle Cell Disease

Myeloablative allogeneic hematopoietic stem-cell transplantation is curative in children with sickle cell disease, but in adults the procedure is unduly toxic. Graft rejection and graft-versus-host disease (GVHD) are additional barriers to its success. We performed nonmyeloablative stem-cell transplantation in adults with sickle cell disease. Ten adults (age range, 16 to 45 years) with severe sickle cell disease underwent nonmyeloablative transplantation with CD34+ peripheral-blood stem cells, mobilized by granulocyte colony-stimulating factor (G-CSF), which were obtained from HLA-matched siblings. The patients received 300 cGy of total-body irradiation plus alemtuzumab before transplantation, and sirolimus was administered afterward. All 10 patients were alive at a median follow-up of 30 months after transplantation (range, 15 to 54). Nine patients had long-term, stable donor lymphohematopoietic engraftment at levels that sufficed to reverse the sickle cell disease phenotype. Mean (+/-SE) donor-recipient chimerism for T cells (CD3+) and myeloid cells (CD14+15+) was 53.3+/-8.6% and 83.3+/-10.3%, respectively, in the nine patients whose grafts were successful. Hemoglobin values before transplantation and at the last follow-up assessment were 9.0+/-0.3 and 12.6+/-0.5 g per deciliter, respectively. Serious adverse events included the narcotic-withdrawal syndrome and sirolimus-associated pneumonitis and arthralgia. Neither acute nor chronic GVHD developed in any patient. A protocol for nonmyeloablative allogeneic hematopoietic stem-cell transplantation that includes total-body irradiation and treatment with alemtuzumab and sirolimus can achieve stable, mixed donor-recipient chimerism and reverse the sickle cell phenotype. (ClinicalTrials.gov number, NCT00061568.)

Long-term follow-up after nonmyeloablative allogeneic hematopoietic stem cell transplantation for systemic sclerosis

Systemic sclerosis (SSc) characteristically consists of fibrotic changes in various organs, and immunological abnormality is the main cause of the disease. Although high-dose immunosuppressive therapies with autologous or allogeneic hematopoietic stem cell support can reverse the disease course, they have a high treatment-related mortality. We report the successful use of nonmyeloablative allogeneic hematopoietic stem cell transplantation (HSCT) for SSc. A 40-year-old woman with diffuse scleroderma and interstitial pneumonia underwent allogeneic peripheral blood stem cell transplantation from an HLA-identical sibling after conditioning with low-dose total-body irradiation and fludarabine. Prophylaxis for graft-versus-host disease (GVHD) consisted of cyclosporine and mycophenolate mofetil. No infection or acute GVHD developed. One year after transplantation, the patient developed membranous glomerulopathy caused by chronic GVHD that was successfully treated with prednisolone. The patient's skin score decreased dramatically, and her pulmonary function is stable 4 years after transplantation. Nonmyeloablative allogeneic HSCT may be more effective than conventional therapies for SSc.

Enhancement of Graft-versus-leukemia Effects by Mesenchymal Stem Cells in Mixed Chimerisim after a Murine Non-myeloablative Hematopoietic Stem Cell Transplantation

Background: Mesenchymal stem cells (MSCs) may be useful for reducing graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). The GVHD and a graft-versus-leukemia (GVL) effect are inversely related. We therefore wanted to determine whether MSCs can preserve the GVL effect following experimental allo-HSCT. Methods: After non-myeloablative allogeneic hematopoietic stem cell transplantation (NM-HSCT) using C57BL/6 (H-2b)→B6D2F1 (H-2b/d), some mice received donor lymphocyte infusion (DLI) for induction of GVL effects by virtue of complete chimerism (CC), while the other groups did not receive DLI with persistence of mixed chimerism (MC). All mice were inoculated subcutaneously with P815 tumor cells and were intravenously treated with either donor MSCs or diluents. Results: Between the DLI-treated groups with CC, tumor-related deaths and tumor growths were comparable irrespective to the infusion of MSCs. On the contrary, among mice without DLI which showed MC, the administration of MSCs significantly delayed tumor-related deaths compared to those without the administration of MSCs (50-day percent survival, 54.5% vs. 18.1%, P=0.0225). In the MC animals, tumor growth seemed to be more delayed in the mice injected with MSCs than in the controls (P=0.09). Donor MSCs injection was associated with increased donor effector/memory CD62L- T cells in MC but not in CC. Conclusion: In spite of the observed immunosuppressive effects of donor MSCs, our results indicate that the GVL effects were not influenced by the injection of MSCs but that under a given condition such as MC, the injection of donor MSCs could result in enhanced GVL effects.

Biologic Assignment Clinical Trials in Hematopoietic Stem Cell Transplantation (HSCT) for Multiple Myeloma: Baseline Characteristics by Treatment Allocation from BMT CTN 0102 According to Availability of an HLA-Matched Sibling Donor.

Randomization in clinical trials involving comparison of patients receiving an allogeneic HSCT versus other treatments is challenged by limitated donor availability. Biologic assignment relies on the availability of suitable donors to determine assignment to allogeneic HSCT. BMT CTN 0102 is a phase III multicenter clinical trial that compares tandem autologous HSCT (auto-auto) to an autologous HSCT followed by a nonmyeloablative allogeneic HSCT (auto-allo) for the treatment of multiple myeloma after initial systemic therapy. Transplant arm assignment was determined by the availability of an HLA-matched sibling donor. Patients were stratified into high and standard risk groups. Absence of chromosome 13 deletion by standard karyotyping and beta-2 microglobulin (B2M) ≤ 4mg/L were defined as standard-risk disease (SRD). The trial was powered to detect differences in 3-year progression-free survival in patients with SRD. A total of 710 patients from 43 centers in the U.S. were enrolled from December 2001 to March 2007. Data from 596 patients with SRD were available for this analysis (sibling donor availability for other 28 SRD patients is not yet determined); 30% (n=178) were assigned to the auto-allo arm. The median ages were 55 and 52 years for the auto-auto and auto-allo arms, respectively (p=0.01). The proportions of African-American patients were 17% and 9% in the auto-auto and auto-allo arms, respectively (p=0.006). Most patients were Durie Salmon Stage III (66% and 70%, p=0.6), in partial remission (86% and 83%, p=0.6) and had Karnofsky Performance Scores ≥ 90 (76% and 77%, p=0.5) at time of study entry. Treatment arms were balanced for B2M, baseline cardiac and hepatic functions and CMV serological status. Median times from diagnosis, initiation of systemic therapy and stem cell mobilization to first transplant were 213, 191 and 27 days, respectively and the same in both arms. The interval from the first to second transplant was 98 days for the auto-auto arm and 105 days for the auto-allo arm (p=0.02). We conclude that biologic assignment resulted in two reasonably comparable treatment groups, although statistically significant differences in age, race and interval between first and second transplant were identified. The differences in age between the groups is related to donor availability, since patients younger than 55 years had on average significantly more living siblings than older patients. Importantly, full-sibling donor availability did not account for differences in race distribution. Because the clinical significance of all detectable differences is unknown, the planned statistical analysis will adjust for these discrepancies. These results confirm that biologic assignment is feasible and might be considered when standard randomization is prohibitive, as in allogeneic HSCT clinical trials.

Results of Alternative Donor Search in Adult Patients with Severe Sickle Cell Disease (SCD) Eligible for Hematopoietic Stem Cell Transplantation (HSCT).

Supportive care has improved the outlook for patients with SCD, but life expectancy remains considerably shorter than those without SCD. The major causes of mortality are end-organ failure, stroke, pulmonary disease, and acute vaso-occlusive crises (VOC). Myeloablative allogeneic HSCT in children under age 16 is curative in the majority. However organ damage that meets severity criteria for HSCT may not become evident until adulthood, at which time conventional myeloablative transplant is no longer an option. Additionally, the great majority of SCD patients do not have a 6/6 HLA-matched sibling donor available. Reduced-intensity conditioning may extend this potentially curative treatment to adults with SCD. Since non-myeloablative transplants may result in mixed donor chimerism, major ABO-mismatch may lead to red cell aplasia, and therefore should be avoided. Finally, cell dose is likely an important parameter in non-myeloablative transplant regimens, potentially further limiting donor availability. We initiated an IRB approved non-myeloablative allogeneic HSCT program for adults with severe SCD for whom a matched sibling donor is available. For those without related donors, we devised a search strategy for alternative donors to establish the feasibility of matched unrelated donor (MUD) or umbilical cord blood (UCB) HSCT. HLA typing was performed for potential donors and patients who on initial screen met at least one the following criteria: stroke, pulmonary hypertension, sickle related nephropathy, or frequent VOC/ACS not improved by HU. Typing at the serologic level was performed for HLA-A,-B, and at the allele level for HLA-DR B1. For patients without matched sibling donors, searches in the National Marrow Donor Program for marrow and cord blood donors were initiated. Since 2003, we performed initial screening in >100 patients, typed 58 potential recipients and 85 donors, and identified 13 potential recipients (age ≥ 16 years) with matched sibling donors. Two were excluded because of major ABO incompatibility. Among the remaining 43, 10 patients who met all study criteria on full screening were selected for alternative donor searching. MUD search results identified a median of 2.5 (range 0–18) 6/6 HLA-matched donor available. Five individuals had 0, four had 4–6, and one had >15 potential donors. UCB search revealed no patient had a 6/6 HLA-matched, two had 15–16 5/6 HLA-matched, and five had 11–190 4/6 potential donor UCB units. The median UCB units containing ≥ 2 × 10e7 nucleated cells per kg were 0 for 6/6 HLA-matched (range 0–1), 0 for 5/6 HLA-matched (range 0–19), and 8.5 for 4/6 HLA-matched (range 0–190). When ethnic haplotype and allelic frequency, the available ABO status, the likelihood of requiring two UCB units for each adult recipient were considered, 5 had neither MUD nor UCB units available, 2 only had potential UCB units available, and 3 had both MUD and UCB units available. The majority of adults with severe SCD who are eligible for non-ablative allo-HSCT do not have matched sibling donors. Our search shows that the minority of African-American adults have potential alternative donors, 10% and 50% MUD and UCB, respectively. These numbers will likely be reduced when major ABO mismatches are excluded. Further, unlike pediatric patients, one cord blood unit may not provide sufficient cells to overcome the barrier of graft rejection in most adults. Given these limitations, the feasibility of haplo-identical family donor allo-HSCT should be investigated.

Comparison of T Cell (CD3+) Chimerism after Myeloablative (MY) and Nonmyeloablative (NM) Allogeneic Hematopoietic Stem Cell Transplantation (AHSCT).

Assessment of chimerism after AHSCT has been important to monitor donor hematopoietic engraftment and to assess for residual disease or relapse. Achievement of T cell (CD3+) complete donor chimerism (CDC), particularly after NM AHSCT, has been considered important to achieve a graft-vs.-malignancy effect. Formal comparisons of the onset and frequency of T cell CDC in pts treated with MY vs. NM conditioning regimens have not been well described. The current analysis compared rates of achieving T cell CDC for 116 pts transplanted from 1/10/00–5/19/06 who were categorized into the following 4 groups based upon type of transplant conditioning: 1) 200 cGy total body irradiation (TBI) + fludarabine 30 mg/m2/d × 3 days (NM200; n=47); 2) 400 cGy TBI + fludarabine (NM400; n=23); 3) MY AHSCT with busulfan/cyclophosphamide without TBI (MY-noTBI; n=31); 4) MY AHSCT with TBI (MY-TBI; n=15). All NM AHSCT pts received peripheral blood stem cells and all MY AHSCT patients received bone marrow as their stem cell source. The total nucleated cell (TNC) and CD34+ cell doses were higher in the NM AHSCT patients. 36 (31%) pts had matched unrelated donors, all with at least an 8/8 match (HLA-A, -B, -Cw, -DR) by HLA class I and II DNA-based typing [10 (21%) NM200, 7 (30%) NM400, 9 (29%) MY-noTBI, 10 (67%) MY-TBI; p=0.011]. Graft-vs-host disease prophylaxis consisted of mycophenolate mofetil and cyclosporine or tacrolimus for most pts. Short tandem repeat analysis for T cell (CD3+) chimerism was performed on peripheral blood post transplant and CDC was defined as achievement of >95% DNA of donor origin isolated from CD3+ T cells. Post-transplant T cell chimerism was found in both the MY and NM AHSCT groups. The number of pts who achieved CDC and the median time to its occurrence for each group was as follows: NM200 - 34 (72%) at 4 mos; NM400 - 18 (78%) at 2.7 mos; MY-noTBI - 20 (65%) at 3.3 mos; and MY-TBI - 13 (87%) at 1.3 mos.The Kaplan-Meier curves for achievement of CDC are shown above (p=0.23). The group of pts who received MY-TBI developed T cell CDC more rapidly than the NM200 pts (p=0.05). No significant differences were observed between the NM400, MY-noTBI and MY-TBI groups with regards to achieving CDC. NM conditioning with either 200 cGy or 400 cGy TBI did not show a significant difference in rate of achieving T cell CDC as compared to MY conditioning with busulfan/cyclophosphamide without TBI. This may be related in part to the higher TNC and CD34+ cell doses in the NM AHSCT pts. However, the increased TBI doses utilized for MY conditioning may more effectively suppress anti-donor immune effector cells from the recipient, which resulted in the increased CDC compared to the NM200 group. In conclusion, post-transplant monitoring for T cell CDC is important in both MY and NM AHSCT to allow for immune manipulation to maintain a state of donor-host tolerance in order to prevent graft rejection. [Display omitted]

Allogeneic hematopoietic cell transplantation after reduced intense conditioning as adoptive cell therapy in resistant metastatic colorectal carcinoma. The European experience

3596 Background: Allogeneic reduced intense conditioning regimens decreased morbidity and mortality related to hematopoietic stem cell transplantation (HCT), retaining a powerful graft versus tumor effect (GVT). On this basis, it became possible to explore the existence of alloreactivity in solid tumors. A GVT effect was described in metastatic colorectal cancer (CRC). Methods: We report the data on 35 patients with CRC treated with non-myeloablative allogeneic HCT in Europe. Median time from the diagnosis of metastatic disease to transplant was 16 (4–47) months; 25 patients (67%) received at least 2 lines of therapy before transplant. Disease status at transplant was progressive disease (PD) in 31 patients (80%), stable disease (SD) in 6 (14%) and partial response (PR) in 2 (6%). Patients were treated according to different nonmyeloablative regimens. All but one patient received allogeneic peripheral hematopoietic cells [median CD 34+ cells/kg was 6.7 × 106 (2,5–55), median CD3 + cells/kg was 4.9 × 108 (0,11–33)] from HLA identical familiar donors. GVHD prophylaxis consisted of cyclosporine A (CyA) + Mycophenolate Mofetil in 24 (68%), of CyA + methotrexate in 6 (25%) and other CyA regimens in the others (18%). Results: Myelosuppression was mild and all patients engrafted with a median donor chimerism of 90% (45–99) on CD 3 cells on day +60. Transplant-related toxicities were limited. Grades II-IV acute GVHD occurred in 18 patients (51%) and chronic GVHD in 6 patients (25%). Transplant-related mortality was the cause of death in 4 patients (11%). As best tumor response we observed: 1 complete response (3%), 8 PRs (20%) and 9 SDs (29). Overall median survival from the date of transplant was 198 days (6–1020); median overall survival for the responding patients was 353 days (113–1020). Conclusions: Allogeneic HCT after RIC is safe and feasible in metastatic CRC. The results obtained compared favorably with those observed in patients with hematologic malignancies or metastatic CRC beyond second line in terms of transplant-related complications and tumor response respectively. Thus a study of allogeneic cell therapy in a less advanced patient cohort is warranted. No significant financial relationships to disclose.

Etanercept Therapy for Late-Onset Idiopathic Pneumonia Syndrome After Nonmyeloablative Allogeneic Hematopoietic Stem Cell Transplantation

Idiopathic pneumonia syndrome (IPS) is a noninfectious pulmonary complication of allogeneic hematopoietic stem cell transplantation (AHSCT), which usually develops within the first 100 days after transplantation. Donor T-cell-derived tumor necrosis factor-α (TNF-α) may play a crucial role in the pathogenesis of IPS, and inhibition of TNF-α has been used as a therapeutic option. We report two patients who had late-onset IPS about day 150 after nonmyeloablative AHSCT (NMA-AHSCT). They responded well to etanercept in combination with standard immunosuppressive drugs. Both patients had relapses and responded to retreatment with etanercept-based therapy. One patient was alive at 30 months after the initial diagnosis on long-term maintenance therapy with etanercept. The second patient was lost to follow-up at our institution but died 13 months after the onset of IPS. Our two cases showed that IPS could develop late after NMA-AHSCT and inhibition of TNF-α activity can be therapeutically effective.

Engraftment Syndrome after Nonmyeloablative Allogeneic Hematopoietic Stem Cell Transplantation: Incidence and Effects on Survival

Engraftment syndrome (ES) encompasses a constellation of symptoms that occur during neutrophil recovery after both autologous and allogeneic hematopoietic stem cell transplantation (HCT). Although it is well characterized after conventional myeloablative procedures, limited data exist on this complication after nonmyeloablative allogeneic HCT. The clinical manifestations, incidence, and risk factors associated with ES were investigated in a consecutive series of patients undergoing cyclophosphamide/fludarabine-based nonmyeloablative allogeneic HCT from a related HLA-compatible donor. Fifteen (10%) of 149 patients (median age, 53 years; range, 27–66 years) developed ES; the onset of symptoms occurred at a median of 10 days (range, 3–14 days), and they consisted of fever (100%), cough (53%), diffuse pulmonary infiltrates (100%), rash (13%), and room air hypoxia (87%). ES was more likely to develop in patients who received empiric amphotericin formulations after transplant conditioning (Fisher exact test; P = .007). In a multivariate analysis, older patient age, female sex, and treatment with amphotericin were predictors for the development of ES. Intravenous methylprednisolone led to the rapid resolution of ES; however, transplant-related mortality was significantly higher (cumulative incidence, 49% versus 16%; P = .0005), and median survival was significantly shorter (168 versus 418 days; P = .005) in patients with ES compared with non-ES patients. In conclusion, ES occurs commonly after cyclophosphamide/fludarabine-based nonmyeloablative transplantation and responds rapidly to corticosteroid treatment, but it is associated with a higher risk of nonrelapse mortality and with shorter overall survival.

Relatively favorable outcomes of post‐transplant pulmonary function in patients with chronic myeloid leukemia receiving non‐myeloablative allogeneic hematopoietic stem cell transplantation

Pulmonary function tests were performed in 20 patients with chronic myeloid leukemia before and after human leukocyte antigen-matched allogeneic sibling hematopoietic stem cell transplantation (HSCT) to identify any conditioning treatment effects on post-transplant function from January 1995 to December 2002. Of 20 patients, eight received non-myeloablative conditioning treatment and 12 received conventional myeloablative conditioning treatment. Pulmonary function tests including forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and diffusion capacity for carbon monoxide (DLCO) were performed pretransplant, 6 and 12 months post-transplant. Possible pre-HSCT and post-HSCT risk factors were evaluated for association with pulmonary function. The results showed that myeloablative conditioning treatment had greater negative impact on FEV1, FVC, and DLCO than non-myeloablative conditioning therapy. We conclude that non-myeloablative allogeneic HSCT may apply a better transplant choice in patients who need special concern with post-transplant pulmonary function changes.

Clinical observation of patients with hematologic malignancies treated with hematopoietic stem cell transplantation.

To evaluate the therapeutic effect of hematopoietic stem cell transplantation (HSCT), we performed HSCT in 30 patients with hematologic maligancies. Of the 30 patients, 10 underwent autologous peripheral blood stem cell transplantation (auto-PBSCT), 13 underwent myeloablative allogeneic HSCT while 7 underwent nonmyeloablative allogeneic HSCT, which were designated as autologous group, myeloablative group and nonmyeloablative group, respectively. All patients except the one who underwent cord blood transplantation, were successfully engrafted. Median time for the granulocytes > or = 0.5 x 10(9)/L and platelets > or = 20 x 10(9)/L were 12 days and 13 days respectively in autologous group, 16 days and 19 days in myeloablative group, 15 days and 12 days in nonmyeloablative group. In myeloablative group, acute graft-versus-host diseases (aGVHD) was observed in 3 patients, all of which were I-II grade. Oral mucous cGVHD was observed in 1 patient. In nonmyeloablative group, 1 patient developed intestinal aGVHD grade IV and cutaneous cGVHD was induced by donor lymphocyte infusions (DLI) in 3 patients. 1 patient had hematological relapse in autologous group. 1 patient had cytogenetic relapse in myeloablative group. In nonmyeloablative group 3 patients had cytogenetic relapse and were cured by DLI, 1 patient had hematological relapse. 4 of the 30 patients died of infection (2 patients), grade IV aGVHD (1) and relapse (1) respectively. 26 patients are still alive. 3 years overall survival (OS) and 3 years disease free survival (DFS) were 100% and 64.81% respectively in autologous group, 78.75% and 63% respectively in myeloablative group while both 66.67% in nonmyeloablative group. In conclusion, autologous group had less transplant-related complications and mortality. Active prophylaxis of relapse could significantly promote DFS. The transplant-related mortality limited DFS in myeloablative group. More relapses occurred in nonmyeloablative group, but could be cured by DLI.

T cell (CD3+) chimerism after non-myeloablative allogeneic hematopoietic stem cell transplantation (NMHSCT)

T cell (CD3+) chimerism after non-myeloablative allogeneic hematopoietic stem cell transplantation (NMHSCT)

Graft-vs.-Lymphoma Effect in Various Histologies of Non-Hodgkin's Lymphoma

Generally, there is a significantly lower risk of lymphoma relapse following allogeneic than after autologous stem cell transplant. Factors contributing to this lower risk of relapse include an absence of the use of ablative conditioning, with a tumor-free graft, and the generation of a graft-vs.-tumor (GVT) immune response. Allogeneic transplantation, however, has the possibility of graft-vs.-host disease (GVHD). The use of autologous and conventional allogeneic hematopoietic stem cell transplantation (HSCT) in follicular lymphoma, diffuse large cell lymphoma, chronic lymphocytic leukemia and multiple myeloma is discussed. Due to a 1-year transplant-related mortality of 30 – 40% and complications caused by GVHD, conventional, myeloablative, allogeneic transplantation is a high-risk option for low-grade lymphoproliferative disorders. Novel applications of allogeneic HSCT are described that take advantage of a GVT effect while reducing the risk of GVHD. Minimally myelotoxic pretransplant conditioning regimens allow host antigen-presenting cells to persist, enabling presentation of host minor histocompatibility antigens to donor T cells, causing a GVT response. Although complications may arise due to GVHD, non-myeloablative HSCT can be offered to patients previously ineligible for conventional high-dose treatment. A protocol developed in Seattle using a low-dose total body irradiation (TBI)-based conditioning regimen with immunosuppression using mycophenolate mofetil in combination with cyclosporin has been used in a multicenter trial. To overcome the problem of graft rejection fludarabine was later added to the protocol. A second protocol from a smaller trial used a preparative, conventional-dose regimen of fludarabine, given with cyclophosphamide. Rituximab was also given to provide synergistic action with the chemotherapy to enhance tumor control in the early post-transplant period to allow time for the establishment of the GVT effect. Following transplantation, GVHD prophylaxis was given using tacrolimus with methotrexate. A trial of a further variation of allogeneic HSCT, tandem auto/allo transplants, is described. First, high-dose therapy with autologous PBSC rescue was used to cytoreduce the disease. This was followed by a reduced-intensity or non-myeloablative allogeneic graft. This procedure was devised to take advantage of high-dose therapy and allogeneic HSCT. Results for non-myeloablative allogeneic HSCT are particularly promising in low-grade NHL and the GVT effect may augment response and delay or prevent relapse. However, for aggressive disease, non-myeloablative regimens are only indicated for patients with minimal disease, as the non-myeloablative regimens are unable to control the tumor before the generation of a GVT effect, and/or lack the ability to control rapidly proliferating disease. Patients with relapsed disease may require a higher-dose regimen or tandem transplant approach.

Risks and outcomes of invasive fungal infections in recipients of allogeneic hematopoietic stem cell transplants after nonmyeloablative conditioning

AbstractThe incidence of invasive mold infections has increased during the 1990s among patients undergoing allogeneic hematopoietic stem cell transplantation (HCT) after myeloablative conditioning. In this study, we determined risk factors for invasive mold infection and mold infection-related death among 163 patients undergoing allogeneic HCT with nonmyeloablative conditioning. The cumulative incidence rates of proven or probable invasive fungal infections, invasive mold infections, invasive aspergillosis, and invasive candidiasis during the first year after allogeneic HCT with nonmyeloablative conditioning were 19%, 15%, 14%, and 5%, respectively, which were similar to those after conventional myeloablative HCT. Invasive mold infections occurred late after nonmyeloablative conditioning (median, day 107), with primary risk factors including severe acute graft-versus-host disease (GVHD), chronic extensive GVHD, and cytomegalovirus (CMV) disease. The 1-year survival after diagnosis of mold infections was 32%. High-dose corticosteroid therapy at diagnosis of mold infection was associated with an increased risk for mold infection–related death. Overall, nonrelapse mortality was estimated at 22% (36 patients) after nonmyeloablative conditioning, of which 39% (14 patients) were mold infection-related (9% of the overall mortality). More effective strategies are needed to prevent invasive mold infections, which currently account for a notable proportion of nonrelapse mortality after nonmyeloablative allogeneic HCT.