Reduced Intensity Chemotherapy Research Articles

Promising therapy results for lymphoid malignancies in children with chromosomal breakage syndromes (Ataxia teleangiectasia or Nijmegen‐breakage syndrome): a retrospective survey

Children with chromosomal instability syndromes have an increased risk of developing lymphoma and leukaemia. The treatment of these malignancies is hampered by therapy-associated toxicity and infectious complications. This retrospective analysis evaluated the therapy outcome of 38 children with Ataxia teleangiectasia or Nijmegen-breakage syndrome with acute lymphoblastic leukaemia (ALL, n = 9), Non-Hodgkin lymphoma (NHL, n = 28) and Hodgkin lymphoma (HL, n = 1). All patients with NHL or ALL were treated in accordance to Berlin-Frankfurt-Münster (BFM)- or Co-operative study group for childhood ALL (CoALL)-oriented chemotherapy schedules. 22 patients received significantly reduced-intensity chemotherapy. After a median follow-up of 3·7 years the 10-year overall survival was 58%. Dosage-reduction of chemotherapeutic drugs seemed to have no disadvantages and reduced toxic side effects. On the other hand, reduced-intensity chemotherapy did not prevent second malignancies, which occurred in ten patients with a 10-year incidence of 25%. After individual treatment approaches three of these patients with second malignancies were in complete clinical remission for more than 5 years. We conclude that BFM- or CoALL-oriented chemotherapy is effective and can be administered in children with AT or NBS. Moreover, we show that even second lymphoid malignancies can successfully be treated in these patients.

GATA1 Mutation In Transient Leukemia (TL) and Myeloid Leukemia of Down Syndrome

AbstractAbstract 1725Children up to the age of 5 years with trisomy 21 (T21, Down Syndrome) are at a 400-fold excess risk of developing myeloid leukemia (ML-DS). ∼5% of newborns with T21 develop a transient leukemia (TL). The megakaryoblastic phenotype by morphology and immunophenotyping is similar in both leukemias. Mutations in hematopoietic transcription factor GATA1 gene leading to expression of N-terminal truncated protein (GATA1s) have been detected in almost all TL and ML-DS patients and is the diagnostic genetic hallmark of these diseases.Aims: Fast and accurate identification is required to:confirm the diagnosis of TL or ML-DSconfirm the diagnosis of a GATA1s positive leukemia in children with no or little stigmata of Down Syndrome (T21 mosaic)monitor minimal residual disease (MRD)determine the pattern of GATA1 mutation in TL and ML-DS. Patients:Here we report the largest cohort of children (n=229) with TL (n=129) and ML-DS (n=100). The blast percentage of blasts were significant different (TL 43±3% vs. ML-DS 29 ±2%, p<0.03). Methods:The GATA1 mutation screening have been performed in two laboratories, the central reference of the AML-BFM Study Group (Hannover, Germany; TL n=90, ML-DS n=63) and at the Weatherall Institute of Molecular Medicine (Oxford, UK; TL n=39, ML-DS n=37). The AML-BFM Lab conducted direct sequencing. If this failed, sequencing was repeated with sorted blasts. If the result remained negative, subcloning of the blasts was performed (21 out of 137 patients). The Oxford lab screened all samples by WAVE and direct sequencing. The lower limit of blasts which allowed for successful detection of a GATA1 mutation was 2%. Results:GATA1 mutations were identified in 125 out of 129 (96%) newborns with TL and in 97/100 (97%) children with ML-DS. In 99% of cases GATA1 mutations were detected in exon 2; only in 2 cases were exon 3 mutations identified. GATA1 mutation were identified in 13 children with Down mosaic and acute leukemia (TL n=8; ML-DS n=5). The detection of GATA1 prevents intensive chemotherapy in newborns with TL and allowed reduced intensity chemotherapy to be administered in infants with ML-DS.The mutations are diverse: deletions (37%), point mutations (24%), duplications (23%) and insertions (16%). With exception of substitutions, which were uniquely detected in TL (n=2; 1.6%), no differences between TL and ML-DS have been observed. Mutations were predicted to result in a stop codon(66%), affect splicing (16%), produce a frameshift that produced a subsequent stop codon (7%), or alter the start codon (3%). No differences in these predicted outcomes was present between TL and DS-ML. Summary:Rapid detection of GATA1 mutations is possible in almost all children with T1 and mosaic T21 who develop TL or ML-DS with these approaches, even in samples where the blast count is as low as 2%. Mutation detection and conformation of the correct diagnosis is critical to ensure appropriate therapy is administered and to allow patient specific MRD monitoring. Disclosures:No relevant conflicts of interest to declare.

First prospective study of allogeneic peripheral blood stem cell (PBSC) transplantation in patients with myelofibrosis in the United States: Interim analysis of MPD-RC 101 protocol.

6535 Background: The Myeloproliferative Disorder-Research Consortium (MPD-RC) designed the first U.S. prospective phase II study of allogeneic PBSC transplantation in patients with primary myelofibrosis (PMF) or MF secondary to essential thrombocythemia (ET-MF) or polycythemia vera (PV-MF). Methods: Between April 2007 and December 2009, 42 patients were transplanted with HLA matched PBSC from related (MRD) (n = 23) or unrelated (MUD) (n = 19) donors. A regimen with fludarabine/melphalan (FluMel) ± ATG was used. Patients with PMF (n = 25), ET-MF (n = 13) or PV-MF (n = 4) were all at intermediate/high risk according to the Lille score system and the majority had grade 3 marrow fibrosis. Median age was 54 years (range: 36-64). Splenomegaly was present in 79% of the patients while 17% had prior splenectomy. Results: Neutrophil and platelet engraftment occurred on d26 (range: 9-57) and d27 (range: 9-365), respectively. Graft failure/rejection occurred in 5 MUD patients. At a median follow-up of 185 days (range: 15-742), 78% of MRD patients are alive; 9 of 19 MUD cases (47%) died and 3 were taken off study. Causes of death in 5 cases in the MRD group were: GVHD (n = 2), hemorrhage, secondary cancer and relapse; and in 9 cases in the MUD group were: GVHD (n = 2), hemorrhage (n = 2), renal failure (n = 2), pulmonary toxicity, venous occlusive disease and infection. Acute GVHD ≥ grade 2 in MRD and MUD was 45% (15% grade 3-4) and 47% (10% grade 3-4), respectively. Overall clinical response according to the International Working Group criteria in patients with > 6 months follow-up in the MRD group was 79%, with CR/PR 47% and clinical improvement 32%.Transplant-related mortality (TRM) was 13%. Analysis of response rate in MUD cases has been limited by the high TRM (47%). Overall and event-free survival were superior in MRD vs MUD transplants (p = 0.005). Conclusions: Our initial findings confirm that FluMel regimen is effective and causes low toxicity in MRD transplant in MF patients. The higher TRM observed in MUD transplants may suggest a need for a more reduced intensity chemotherapy in this setting. No significant financial relationships to disclose.

Outcomes of 40 Adult Patients after Double Cord Blood Transplantation Using a Reduced Intensity Chemotherapy Conditioning Regimen.

Umbilical cord blood is an alternative stem cell source for patients without matched related or unrelated donors. However, single cord blood unit transplantation in adults is associated with high transplant related mortality, mostly due to infection. In this study, we used a reduced intensity conditioning regimen followed by infusion of two partially matched cord blood units. The conditioning regimen was fludarabine 30mg/m2/day Days -8,-7,-6,-5,-4,-3 (total dose 180mg/m2), melphalan 100mg/m2/day Day -2, and rabbit antithymocyte globulin (thymoglobulin) 1.5 mg/kg/day Days -7,-5,-3,-1 (total dose 6.0 mg/kg). Cord blood units were a 4/6 or better HLA A, B, DR match with each other and with the patient, and contained a minimum combined pre-freeze cell dose of 3.7 x 107NC/kg. GVHD prophylaxis was cyclosporine and mycophenolate mofetil, for the first 21 patients, and tacrolimus and sirolimus for the second cohort of 19 patients. Forty patients, 22 males (55%) and 18 females (45%) with a median age of 48 years (range 19–64 years) were treated. The diagnoses were AML (n=14), ALL (n=1), NHL (n=10), CLL (n=2), MDS (n=5), Hodgkins Disease (n=5), aplastic anemia (n=2), and chronic myelogeneous leukemia (n=1). Thirty-five patients have greater than 100 days of follow-up and are included in this analysis. The cell doses infused were a median of 4.0 x 10 7NC/kg (range 3.0–6.7 x 107) and 1.9 x 10 5 CD34+ cells/kg (range 0.5–10.0 x 105). Two patients (both with MDS complicating aplastic anemia) experienced primary graft failure, and received second cord blood transplants using a different conditioning regimen. Among the remaining patients, the median time to an absolute neutrophil count >500 was 21 days (range 14–70 days). There were two late graft failures. The median time to a platelet count >20,000 unsupported was 43 days (range 21–125 days). The incidence of acute GVHD Grades II–IV was 40% for the patients receiving cyclosporine/MMF and 29% for patients receiving tacrolimus and sirolimus. There were no deaths from acute GVHD in the cyclosporine/MMF group and one death from acute GVHD in the tacrolimus/sirolimus group. Seven patients (20%) developed chronic GVHD. The 100-day transplant related mortality was 14%. Two deaths were related to Epstein Barr virus related lymphoproliferative disorder, and the other deaths were due to a CNS bleed, staphylococcal sepsis, and respiratory failure due to aspergillus infection. Two patients have relapsed and one has progressive disease. With a median follow up of 14 months (range 3–31 months) the overall survival is 74% and the disease-free survival is 67%. Chimerism analysis showed predominance of one cord by Day +100. In 71% of patients, the first cord blood unit infused predominated. In conclusion,engraftment of adult patients appears to be acceptable using double cord blood products and reduced intensity, non TBI conditioning regimen;the risk of serious acute and chronic GVHD is low,survival is excellent in a selected group of patients andrelapse rate is low, suggesting preservation of graft versus leukemia effect despite the low T cell dose.

5: Double Cord Blood Transplantation in Adults Using a Reduced Intensity Chemotherapy Only Conditioning Regimen

5: Double Cord Blood Transplantation in Adults Using a Reduced Intensity Chemotherapy Only Conditioning Regimen

Excellent Disease-Free Survival after Double Cord Blood Transplantation Using a Reduced Intensity Chemotherapy Only Conditioning Regimen in a Diverse Adult Population.

Umbilical cord blood is a useful stem cell source for patients without matched related or unrelated donors. However, single cord blood unit transplantation in adults is associated with high transplant related mortality, mostly due to infection. In this study, we used a reduced intensity conditioning regimen followed by infusion of two partially matched cord blood units. The conditioning regimen was fludarabine 30mg/m2/day x 6 days, melphalan 100mg/m2/day x 1 day, and rabbit antithymocyte globulin 1.5 mg/kg/day x 4 days. Cord blood units were a 4/6 or better HLA match or better with each other and with the patient, and contained a minimum combined pre-freeze cell dose of 3.7 x 107NC/kg. GVHD prophylaxis was cyclosporine and mycophenolate mofetil. Twenty-one patients, 15 males (71%) and 6 females (29%), median age 49 years (range 24–63 years) participated in a Phase I study. The diagnoses were AML (n=8), ALL (n=1), NHL (n=5), CLL (n=2), MDS (n=2), Hodgkins Disease (n=2), and aplastic anemia (n=1). Fifteen percent of patients were non Caucasian. The cell doses infused were a median of 4.0 x107 NC/kg (range 3.0–5.3 x107) and 2.0 X105 CD34+ cells/kg (range 0.6–10.0 x105). Two patients (both with MDS complicating aplastic anemia) experienced primary graft failure, and received successful second cord blood transplants using a different conditioning regimen. Among the remaining 19 patients, the median time to an absolute neutrophil count >500 was 20 days (range 15–34 days). The median time to a platelet count >20,000 unsupported were 41 days (range 21–125 days). One patient experienced a secondary graft failure, and is well following infusion of previously stored autologous cells. 4 patients (21%) experienced Grades II-IV acute GVHD, and only one patient (5%) experienced Grade III GVHD. There were no patients with Grade IV GVHD and no deaths from acute GVHD. Twelve patients were evaluable for chronic GVHD, and 3 patients (25%) had chronic GVHD of which one case was extensive disease. The 100 day transplant related mortality was 14%. The deaths were due to a CNS bleed, Epstein Barr virus lymphoproliferative disorder, and staphylococcal sepsis. Chimerism analysis showed predominance of one cord by Day +100 in 79% of patients evaluable for 100-day follow-up. In 85% of these patients the first cord blood unit infused predominated. One patient has had progressive disease. With a median follow-up of 7 months (range 2–16 months), the overall survival is 79% and the disease-free survival is 64%. The projected one year disease-free survival is 64%. In conclusion, 1) engraftment of adult patients appears to be acceptable using double cord blood products and reduced intensity, non TBI conditioning regimen; 2) the risk of serious acute and chronic GVHD is low, 3) patients with aplastic anemia/MDS may require more intensive immunosuppression to allow engraftment, 4) GVL appears to be preserved despite the low T cell dose.

Allogeneic Lymphocytes Induce Tumor Regression of Advanced Metastatic Breast Cancer

Allogeneic T lymphocytes can induce regression of metastatic breast cancer through an immune-mediated graft-versus-tumor (GVT) effect in murine models. To determine if a clinical GVT effect exists against metastatic breast cancer, allogeneic lymphocytes were used as adoptive cellular therapy after a reduced-intensity chemotherapy conditioning regimen and allogeneic hematopoietic stem-cell transplantation (HSCT) from human leukocyte antigen-matched siblings. Sixteen patients with metastatic breast cancer that had progressed after treatment with anthracyclines, taxanes, hormonal agents, and trastuzumab, received allogeneic HSCT. The reduced-intensity transplant conditioning regimen consisted of cyclophosphamide and fludarabine. To distinguish an immunological GVT effect from any antitumor effect of cytotoxic chemotherapy in the transplant-conditioning regimen, allogeneic T lymphocytes were removed from the stem-cell graft and were subsequently administered late postallogeneic HSCT. Allogeneic lymphocytes containing 1 x 10(6), 5 x 10(6), and 10 x 10(6) CD3(+) cells/kg were infused on days +42, +70, and +98 post-allogeneic HSCT, respectively. Objective tumor regressions occurred after day +28 post-allogeneic HSCT in six patients and were attributed to allogeneic lymphocyte infusions. Two of these responding patients had disease progression post-allogeneic HSCT before subsequent tumor regression. Tumor regressions occurred concomitantly with the establishment of complete donor T-lymphoid engraftment, were associated with the development of graft-versus-host disease (GVHD), and were abrogated by subsequent systemic immunosuppression for GVHD. Allogeneic lymphocytes can induce regression of advanced metastatic breast cancer. These results indicate that an immunological GVT effect from allogeneic lymphocytes exists against metastatic breast cancer and provide rationale for further development of allogeneic cellular therapy for this largely incurable disease.

Allogeneic blood stem cell transplantation after a reduced‐intensity, preparative regimen

BACKGROUND The immune-mediated graft-versus-tumor (GVT) effect plays a therapeutic role in the treatment of patients with hematologic malignancies who undergo allogeneic hematopoietic stem cell transplantation (HSCT). More recently, it was reported that a GVT effect also occurred in patients who underwent transplantation for metastatic renal carcinoma. The authors carried out a pilot trial of allogeneic transplantation after a reduced-intensity, preparative regimen in patients with refractory malignancies, including solid tumors. The objectives of the current study were to evaluate the feasibility of this approach in terms of toxicity and engraftment and to document evidence of GVT effects. METHODS Seventeen patients with Stage IV malignancies (7 patients with renal cell carcinoma, 3 patients with sarcoma, 2 patients with breast carcinoma, 2 patients with Hodgkin disease, 1 patient with ovarian carcinoma, 1 patient with melanoma, and 1 patient with both melanoma and renal cell carcinoma) that were not amenable to further conventional treatment were enrolled. The median patient age was 43 years (range, 10–60 years). The Eastern Cooperative Oncology Group performance status (PS) was 0–1 in 11 patients and 2–3 in 6 patients. Preparative treatment consisted of reduced-intensity chemotherapy with fludarabine (30 mg/m2 per day for 4 consecutive days) and cyclophosphamide (30 mg/Kg per day for 2 consecutive days) prior to allogeneic HSCT from a human leukocyte antigen-identical sibling. The median number of CD34+ cells infused was 6.06 × 106/kg (range, 1.5–14.0 × 106/kg). Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporin-A and short-term methotrexate. RESULTS Patients who had a PS of 2–3 prior to undergoing HSCT experienced Grade 4 hematologic toxicities and Grade ≥ 3 organ toxicities and died of either treatment-related complications or disease progression within 100 days from transplantation. By contrast, 10 of 11 patients who had a PS of 0–1 prior to undergoing HSCT experienced only short-lasting, Grade ≤ 3 neutropenia and thrombocytopenia and no organ toxicity; 1 of 10 patients died of graft failure on Day +29 after undergoing HSCT. By Day +90, 100% donor chimerism was documented in all patients with a past history of heavy chemotherapy, whereas mixed donor chimerism was observed in the 4 patients with a past history of only 1 line of chemotherapy and/or immunotherapy prior to entering the HSCT program. Grade 2–3 acute GVHD occurred in 5 patients. Among patients with a follow-up > 100 days, 2 complete responses and 3 transitory partial responses were recorded. CONCLUSIONS With this conditioning regimen, full donor chimerism was achieved rapidly only in patients who had received previous intensive chemotherapy. In a proportion of patients with refractory malignancies, allogeneic transplantation resulted in tumor regression. This novel therapeutic strategy may provide little benefit in patients with poor PS and rapidly progressing disease. Cancer 2002;94:2409–15. © 2002 American Cancer Society. DOI 10.1002/cncr.10491

Allogeneic blood stem cell transplantation after a reduced-intensity, preparative regimen: a pilot study in patients with refractory malignancies.

The immune-mediated graft-versus-tumor (GVT) effect plays a therapeutic role in the treatment of patients with hematologic malignancies who undergo allogeneic hematopoietic stem cell transplantation (HSCT). More recently, it was reported that a GVT effect also occurred in patients who underwent transplantation for metastatic renal carcinoma. The authors carried out a pilot trial of allogeneic transplantation after a reduced-intensity, preparative regimen in patients with refractory malignancies, including solid tumors. The objectives of the current study were to evaluate the feasibility of this approach in terms of toxicity and engraftment and to document evidence of GVT effects. Seventeen patients with Stage IV malignancies (7 patients with renal cell carcinoma, 3 patients with sarcoma, 2 patients with breast carcinoma, 2 patients with Hodgkin disease, 1 patient with ovarian carcinoma, 1 patient with melanoma, and 1 patient with both melanoma and renal cell carcinoma) that were not amenable to further conventional treatment were enrolled. The median patient age was 43 years (range, 10-60 years). The Eastern Cooperative Oncology Group performance status (PS) was 0-1 in 11 patients and 2-3 in 6 patients. Preparative treatment consisted of reduced-intensity chemotherapy with fludarabine (30 mg/m(2) per day for 4 consecutive days) and cyclophosphamide (30 mg/Kg per day for 2 consecutive days) prior to allogeneic HSCT from a human leukocyte antigen-identical sibling. The median number of CD34+ cells infused was 6.06 x 10(6)/kg (range, 1.5-14.0 x 10(6)/kg). Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporin-A and short-term methotrexate. Patients who had a PS of 2-3 prior to undergoing HSCT experienced Grade 4 hematologic toxicities and Grade > or = 3 organ toxicities and died of either treatment-related complications or disease progression within 100 days from transplantation. By contrast, 10 of 11 patients who had a PS of 0-1 prior to undergoing HSCT experienced only short-lasting, Grade < or = 3 neutropenia and thrombocytopenia and no organ toxicity; 1 of 10 patients died of graft failure on Day +29 after undergoing HSCT. By Day +90, 100% donor chimerism was documented in all patients with a past history of heavy chemotherapy, whereas mixed donor chimerism was observed in the 4 patients with a past history of only 1 line of chemotherapy and/or immunotherapy prior to entering the HSCT program. Grade 2-3 acute GVHD occurred in 5 patients. Among patients with a follow-up > 100 days, 2 complete responses and 3 transitory partial responses were recorded. With this conditioning regimen, full donor chimerism was achieved rapidly only in patients who had received previous intensive chemotherapy. In a proportion of patients with refractory malignancies, allogeneic transplantation resulted in tumor regression. This novel therapeutic strategy may provide little benefit in patients with poor PS and rapidly progressing disease.

Allogeneic peripheral blood stem cell transplantation following reduced-intensity chemotherapy for refractory sarcoma

Allogeneic peripheral blood stem cell transplantation following reduced-intensity chemotherapy for refractory sarcoma