Donor Umbilical Cord Research Articles

#407 Human platelet lysate enhanced angiogenic potential of extracellular vesicles derived from mesenchymal stem cells

Abstract Background and Aims Mesenchymal stem cell-derived extracellular vesicles (MSC-EVs) have emerged as a promising regenerative therapy. However, their clinical application is hampered by the presence of xenogeneic components in the medium. In the present study, we aimed to decipher the regenerative properties of MSC-EVs generated under xeno-free conditions to favor the clinical translation of MSC-EVs. Method MSCs were isolated from human umbilical cord and expanded in fetal bovine serum (FBS) and clinical-grade human platelet lysate (HPL) respectively. MSC-EVs were isolated by differential centrifugation combined with size exclusion chromatography and characterized through transmission electron microscopy, nanoparticle tracking analysis, and exoview. Subsequently, a multi-omics approach, comprising transcriptomics, proteomics, and metabolomics, was employed to investigate the molecular cargo of the MSC-EVs. Finally, in vitro and in vivo functional assays were performed to assess the regenerative potential of MSC-EVs in acute kidney injury. Results Our study demonstrated that HPL promoted MSC-EVs production without compromising EVs characteristics. Multi-omics sequencing revealed the stability of HPL cultured MSC-EVs (H-EVs) from different umbilical cord donors and global functional alterations for MSC-EVs under different culture conditions. In comparison to FBS cultured MSC-EVs (F-EVs), the regenerative potential of H-EVs was enhanced especially angiogenesis associated with increased cargo expression. The in vitro studies demonstrated that H-EVs induced more tube-like structure formation and migration. Further, it significantly reduced kidney capillary sparsity in mice with renal ischemic-reperfusion model. Conclusion Our data provided a comprehensive understanding about H-EVs and demonstrated their potential as a safe and effective regenerative therapy, especially targeting angiogenesis-related disorders.

Long-Term Toxicity after Total Body Irradiation-Based Conditioning Regimens for Allogeneic Stem Cell Transplantation

Total body irradiation (TBI) is an integral component of many conditioning regimens prior to allogeneic hematopoietic stem cell transplantation (HSCT). Few studies have investigated long-term sequelae. A large series of patients undergoing myeloablative and non-myeloablative regimens was studied. Adult patients undergoing allogeneic HSCT utilizing TBI-based conditioning regimens from 1995-2020 at our institution were included. Baseline treatment-related factors and long-term toxicities (developing, or persisting beyond, 6 months after HSCT) were collected. The cumulative incidence of long-term toxicities and overall survival (OS) were calculated. Cox regression was used to assess for predictors of toxicity. Five hundred fifty-two patients were analyzed: 378 myeloablative (typically 13.5 Gy/9fx) and 174 non-myeloablative (typically 2 Gy/1fx) TBI recipients. Median follow-up was 7.4 years for surviving patients. Cumulative incidences of long-term toxicities at 5 and 10 years are included in the Table. The most common toxicities were: pulmonary- infectious pneumonia and respiratory failure NOS; cardiac- heart failure and myocardial infarction; other endocrine- adrenal insufficiency and testosterone deficiency. The most common secondary malignancy was non-melanoma skin cancer. The proportion of all toxicities that were high-grade (3-5) for myeloablative and non-myeloablative regimens, respectively, were: pulmonary (65%, 52%), cardiac (66%, 39%), renal (23%, 27%), and other endocrine (3%, 18%). Increasing number of chemotherapy regimens (p = 0.05) and umbilical cord donor (p = 0.02) were associated with long-term pulmonary toxicity. Male sex (p = 0.03), increasing number of chemotherapy regimens (p<0.01), and elevated creatinine after transplant (p<0.01) were associated with long-term renal toxicity. Cataract development was associated with increasing age at transplant (p = 0.02). OS (5 years) was 40% (42% -myeloablative; 33%-non-myeloablative). Allogeneic HSCT, often preceded by TBI-based conditioning regimens, has significant survivorship challenges. Recipients of non-myeloablative regimens are still at risk of significant long-term multisystem toxicity despite much lower doses of TBI and chemotherapy. Pre-transplant factors such as cumulative chemotherapy exposure and age at transplant were associated with some toxicities.

Collection of umbilical cord blood and the risk of complications in postpartum women after natural labour in the context of the possibility of umbilical cord stem cells usage in clinical practice.

Comparison of changes in peripheral blood venous morphology and the frequency of select complications in patients who underwent umbilical cord blood collection during the third stage of labour by in the utero method compared to patients who did not undergo this procedure. Presentation of current therapeutic possibilities of cord blood stem cells. The study involved 248 patients who had a vaginal delivery and had umbilical cord blood taken by in utero method during the third stage of labour. The control group consisted of the first 400 patients who gave vaginal delivery starting in 2019. Each patient had a venous peripheral blood count taken before delivery and 18 hours after delivery. Changes in the results of laboratory tests and the occurrence of adverse outcomes, such as postpartum curettage, postpartum haemorrhage and manual removal of placenta, in the 3rd and 4th stage delivery periods, were analysed. In the blood donor group there were significantly lower haemoglobin (11.32 g/L vs 11.61 g/L, p = 0.004) and haematocrit (32.83% vs 33.82% p = 0.001) concentrations after delivery. Umbilical cord donors had a greater difference in haemoglobin (postpartum minus prepartum) (-1.4 g/L vs -0.9 g/L, p = 000), and haematocrit (-4.05% vs -2.5% , p = 0.000). The study group had a higher percentage of patients with postpartum anaemia (haemoglobin concentration < 10 g/L) (15.9% vs 10.64%, p = 0.05), but the result were borderline significant. The groups did not differ in terms of the percentage of postpartum curettage, PPH, manual removal of placenta, percentage of severe anaemia (Hb < 7g/L) or transfusion requirement. Collection of umbilical cord blood during the 3rd stage of labour using the in utero method is associated with a statistically significant increase of blood loss and a higher probability of postpartum anaemia. The observed changes are minor and may have little clinical significance in otherwise healthy patients.

P2.01-16 TACTICAL: A Phase I/II Trial to Assess the Safety and Efficacy of MSCTRAIL in Metastatic Lung Adenocarcinoma

Mesenchymal stromal cells (MSCs) migrate to and incorporate into tumour stroma, acting as vehicles for delivering anti-cancer therapies. TNF-related apoptosis inducing ligand (TRAIL) selectively induces apoptosis in malignant cells, however its short biological half-life has limited therapeutic efficacy. We have transduced MSCs with a lentiviral vector to express TRAIL (MSCTRAIL), demonstrating efficacy in vitro using co-culture assays and in vivo in orthotopic lung metastasis murine model, showing regression of metastases following treatment with intravenous MSCTRAIL [1] and synergistic activity with other systemic anti-cancer therapies. Given their immune-privileged nature we are now delivering ex vivo MSCTRAIL from pooled third party umbilical cord donors without tissue matching or immunosuppression. TACTICAL is a phase I/II trial assessing safety and efficacy of MSCTRAIL in combination with first line standard of care (SOC); pemetrexed (500mg/m2) and cisplatin (75mg/m2) and/or pembrolizumab (200mg), in treatment-naive patients with stage IIIB/IV metastatic lung adenocarcinoma. Patients have no actionable driver mutations and ECOG performance status 0-1. Phase I is a dose de-escalation study; patients receive SOC on day 1 and 4x108 MSCTRAIL cells on day 2 of a 21-day cycle for 3 cycles, with a Bayesian adaptive design recommending dose reductions if severe toxicities occur (Fig.1A). Primary outcomes are recommended phase II dose (RP2D), safety and tolerability of MSCTRAIL. In phase II, 46 patients will be randomised (1:1) in a double-blind trial to receive SOC and either RP2D of MSCTRAIL or placebo (Fig.1B). Primary outcome is tumour response rate by RECIST (v1.1) at 12 weeks. Translational work will include measuring: biomarkers of response; T, B, NK cell function in reaction to allogeneic MSCs; tracking migration of MSCs radiolabelled with 89Zirconium-oxine through serial PET imaging. TACTICAL is the first clinical trial of this novel cell and gene therapy and if successful will pave the way for future allogeneic MSC cancer therapies. 1. Loebinger, M.R., et al., Mesenchymal stem cell delivery of TRAIL can eliminate metastatic cancer. Cancer Res, 2009. 69(10): p. 4134-42.

Survival outcomes of allogeneic hematopoietic cell transplants with EBV-positive or EBV-negative post-transplant lymphoproliferative disorder, A CIBMTR study.

Post-transplant lymphoproliferative disorders (PTLD) are associated with significant morbidity and mortality following allogeneic hematopoietic cell transplant (alloHCT). Although most PTLD is EBV-positive (EBVpos ), EBV-negative (EBVneg ) PTLD is reported, yet its incidence and clinical impact remain largely undefined. Furthermore, factors at the time of transplant impacting survival following PTLD are not well described. Between 2002 and 2014, 432 cases of PTLD following alloHCT were reported to the Center for International Blood and Marrow Transplant Research (CIBMTR). After exclusions, 267 cases (EBVpos =222, 83%; EBVneg =45, 17%) were analyzed. Two hundred and eight patients (78%) received in vivo T-cell depletion (TCD) with either anti-thymocyte globulin (ATG) or alemtuzumab. Incidence of PTLD was highest using umbilical cord donors (UCB, 1.60%) and lowest using matched related donors (MRD, 0.40%). Clinical features and histology did not significantly differ among EBVpos or EBVneg PTLD cases except that absolute lymphocyte count recovery was slower, and CMV reactivation was later in EBVneg PTLD [EBVpos 32 (5-95) days versus EBVneg 47 (10-70) days, P=.016]. There was no impact on survival by EBV status in multivariable analysis [EBVneg RR 1.42, 95% CI 0.94-2.15, P=.097]. There is no difference in survival outcomes for patients with EBVpos or EBVneg PTLD occurring following alloHCT and 1-year survival is poor. Features of conditioning and use of serotherapy remain important.

Haploidentical transplantation outcomes are comparable with those obtained with identical human leukocyte antigen allogeneic transplantation in Chilean patients with benign and malignant hemopathies

IntroductionPatients with benign or malignant blood disorders, who require allogeneic stem cell transplantation and lack an identical human leukocyte antigen HLA identicalHL sibling donor, could be transplanted with hematopoietic stem cells from unrelated adult or umbilical cord donors. However, in our country, both approaches are costly and time-consuming options. MethodsOver the last few years, haploidentical modalities have been investigated as an alternative donor source, showing similar results to those obtained with identical HLA donors. We started using T-cell-replete haploidentical with post-transplant cyclophosphamide in 2012 and we presented our experience with patients undergoing haploidentical ransplantation compared to SIB. ResultsSince January 2012 to date, 91 allogeneic transplants have been performed, of which 49 were haploidentical and 42 were HLA identical. The mean age of the patients was 35 years (range: 17–62). The mean CD34/kg×106 infused per group was 5.93 and 5.89, respectively. Time to granulocyte and platelet engraftment was 11 and 15 days, respectively, for haploidentical, and 12 and 14 days, respectively, for HLA identical (p=0.10). The 100-day cumulative incidence of global acute GVHD was 34% for haploidentical and 29% for SIHLA identical (p=0.9). The 2-year overall global graft-versus-host disease was 43% for haploidentical and 41% for HLA identical (p=0.8). Overall survival, relapse, and transplant and relapse-related mortality were similar between both groups. ConclusionOur experience showed that haploidentical has similar outcomes to those obtained with HLA idential and can be performed in our country safely.

Allogeneic Stem Cell Transplantation Provides Durable Remission in Patients with Primary Mediastinal Large B-Cell Lymphoma

Allogeneic Stem Cell Transplantation Provides Durable Remission in Patients with Primary Mediastinal Large B-Cell Lymphoma

Isolation Methods and Culture Conditions of Human Umbilical Vein Endothelial Cells from Malaysian Women

Human umbilical vein endothelial cell (HUVEC) isolated from umbilical cord is widely used as endothelial cell model. However, HUVEC has been characteristically hard to maintain and showed molecular heterogeneity depending on the umbilical cord donors. Commercial HUVEC is commonly derived from European and Caucasian population which have different molecular characteristics from Asian women. This study aimed to optimize the isolation and culture condition of HUVEC using combinations of growth factors and extracellular matrix components so that the isolated HUVEC will purely represent the population under study. Umbilical cords were obtained from women post-labour. Different incubation times and digestive enzymes were used during endothelial cells isolation process. The culture conditions were optimized based on the coating materials and the media supplements. The results showed that 0.1% collagenase for 40 min incubation was the optimal isolation condition of HUVEC. HUVEC grown in 0.2% gelatin coated plate with 10% heat-inactivated fetal calf serum showed higher proliferative capacity and reduced cell death compared to other conditions (p<0.05). The results generated from this study provide a basic protocol of HUVEC isolation and culture conditions in order to generate working endothelial cell populations purely represent the Malaysian population.

The influence of continuous low-intensity laser radiation at the red (635 nm) and green (525 nm) wavelengths on the human mesenchymal stem cells in vitro: a review of the literature and original investigations

Low-intensity laser radiation can be used as one of the methods for the non-specific regulation of the human mesenchymal stem cell (MSC) activity at the preliminary stage of their in vitro cultivation. The objective of the present study was to estimate the influence of the limiting regimes of continuous low-intensity laser radiation (CLIR) of red (635 nm) and green (525 nm) spectra. The adhesive culture of human mesenchymal stem cells obtained from a donor's umbilical cord tissue was used in the experiments (following 4 passages). They were irradiated using a Lazmik-VLOK laser therapeutic device equipped with the KLO-635-40 (635 nm, 4,9 mW/cm(2)) and KLO-525-50 (525 nm, 5,4 mW/cm(2)) laser diode emitting heads operating in a continuous mode. A special nozzle (jar) for laser and vacuum massage (KB-5, 35 cm in diameter) was employed to fix the heads. The exposure time in all the irradiation regimes was 5 minutes. The study has demonstrated that neither the morphological features nor the viability of mesenchymal stem cells was altered under the influence of laser irradiation at the aforementioned energy and time parameters. The data obtained indicate that laser irradiation with the limiting levels of the chosen energy parameters produces no positive effect on the cell proliferative activity; more than that, it may cause its inhibition.

Transplant Outcome of Pediatric and Young Adult Patients with Aplastic Anemia: St Jude Children’s Research Hospital Experience

Background: Bone marrow transplant (BMT) remains the preferred frontline curative modality for patients with aplastic anemia in the presence of a matched sibling donor (MSD). In the absence of MSD the general consensus is frontline immunosuppressive therapy (IST) followed by BMT from a matched unrelated donor (MUD) in case of failure or relapse. No randomized controlled studies have been performed to compare earlier MUD transplant to 2nd cycle IST in case of failure of response to 1st IST cycle. In the pediatric population a higher percentage of congenital marrow failure syndromes is encountered than in adult world; the diagnosis of many of those is challenging clinically and from the molecular and genetic standpoints.Objectives: Review the outcome of 25 patients younger than 20 years diagnosed with aplastic anemia and recently transplanted at our institution. Compare outcomes of MSD versus MUD versus umbilical cord (UC) BMT in this patient population.Methods: A retrospective analysis was performed on 25 patients diagnosed with aplastic anemia who underwent BMT at St Jude Children’s Research Hospital between 9/1/2009 through 8/31/2013. Initial diagnosis and treatment, patients’ characteristics, transplant data, overall survival, and complications were analyzed.Results: Of the 25 patients reviewed, 15 patients were diagnosed with acquired aplastic anemia and 10 with congenital marrow failure, including 7 with dyskeratosis congenita (DKC), 1 with Shwachman Diamond syndrome (SDS), and 2 with congenital marrow failure not otherwise specified (negative genetic testing, but age, family history, and presentation consistent with congenital marrow failure). All 7 DKC patients had telomere lengths less than first percentile, and 2 had documented genetic mutations; of the 7 patients 2 received MSD, 3 received MUD and 2 received UC transplants.Most donors were MUD (13/25), 2 were UC donors as there were no other available donors, and 10 were MSD. All MSD recipients are alive, engrafted and disease free. There were 3 deaths. One MUD recipient with acquired aplastic anemia died of uncontrolled sepsis. Both UC recipients died; one had failure of engraftment and later died of acute myeloid leukemia that had developed on day +224 of transplant while on Danazol and G-CSF, and the other died of pulmonary and hepatic failure. The latter was the only patient who received TBI (2 Gy) as part of his conditioning regimen, engrafted on day +27 and died on day +33. There was no statistical difference in overall survival (OS) between MSD and MUD transplant (100% vs 92.3% at 3 years, respectively, p value = 0.38).Acute graft versus host disease (aGVHD) developed in 5 patients; 3 had received MUD transplant and 2 had received MSD. Two of these 5 patients also developed chronic graft versus host disease (cGVHD), which was limited in both cases. There was no statistically significant difference in engraftment or GVHD occurrence between the MSD and MUD patients.Conclusions: In our recent experience aplastic anemia in children,outcomes from MUD BMT were comparable to MSD BMT, especially with improved supportive care and GVHD prevention and treatment. Cord blood as an alternative donor source remains very challenging in this patient population from the engraftment and toxicity standpoints especially in certain congenital marrow failure syndromes. These data suggest that BMT should be considered earlier when there is MUD availability for patients with aplastic anemia. [Display omitted] P unrelated vs cord = 0.0007P sibling vs cord = 0.0002P unrelated vs sibling = 0.38 DisclosuresReiss:Alexion Pharm: Research Funding.

Intravenous Immunoglobulin Post Allogeneic Stem Cell Transplantation Is Associated with Lower Levels of CMV Reactivation

▪IntroductionCytomegalovirus (CMV) reactivation is a common complication of allogeneic stem cell transplantation (ASCT), particularly within the first 100 days after stem cell infusion (D+100). It results in significant cost, morbidity and potentially mortality in the case of severe CMV disease.Intravenous polyvalent immunoglobulin (IVIg) has been used to support immunoglobulin levels post-ASCT in an attempt to reduce opportunistic infection and graft versus host disease (GVHD). Historically we employed routine IVIg therapy (0.5g/kg weekly for the first 12 weeks) as standard post-ASCT care. In July 2012 funding was withdrawn for IVIg for this indication.Since 2001 we have been using weekly quantitative polymerase chain reaction (PCR) analysis to monitor for CMV reactivation during the first 100 days after ASCT.We investigated whether the omission of post-ASCT IVIg altered the rate or consequences of CMV reactivation in the immediate post-ASCT setting.MethodsWe analysed sequential ASCT recipients from 2010 to 2014 and identified 100 patients who met the predetermined eligibility criteria. These subjects were then divided into two uniformly treated populations: ASCT recipients who either received (Group A, n=50) or did not receive (Group B, n=50) IVIg as part of their post-ASCT care.Inclusion criteria: matched adult unrelated or sibling donor source, age ≥18 years and CMV positive recipient by serology within 3 months prior to ASCT or CMV positive donor by serology.Exclusion criteria: CMV negative donor and recipient (D-/R-), umbilical cord donor source, death before day 100 or incomplete data available for analysis.CMV reactivation was defined as any detectable level by quantitative CMV PCR in the peripheral blood. The lower limit of detection for the assay was 20 copies/mL.A plasma CMV viral load of ≥400 copies/mL resulted in treatment with intravenous ganciclovir (5mg/kg twice daily) which was continued for a minimum of 2 weeks and was thereafter guided by weekly CMV viral load response. Patients with a CMV viral load of <400 copies/mL were observed with no specific treatment.CMV reactivation was recorded as minor (not requiring ganciclovir treatment) if CMV viral load remained <400 copies/mL and as major (requiring treatment) if CMV viral load reached ≥400 copies/mL within a single episode of infection. Time to first CMV reactivation and cumulative days of major CMV reactivation were also recorded.ResultsA total of 169 consecutive subjects were screened for study entry. Abstract 2482. Table 1:Cohort compositionsTotal screenedD-/R-Death <D+100Umbilical cord donorIncomplete dataTotal includedGroup A (IVIg)84206*8050Group B (non-IVIg)85215#8150*: 1 subject had active CMV infection at time of death#: 2 subjects had active CMV infection at time of deathDemographics were similar between Group A and Group B in terms of age (median 51.0 vs 48.5 years), sex (male: 33 vs 29) and transplant indication (acute leukaemia/MDS 28 vs 28; lymphoma 11 vs 11) and D+/R- transplants (9 vs 11).Comparing Group A and Group B, the number of subjects who had a CMV reactivation was 37 vs 39 and for minor reactivations the number was 28 vs 25. The median time to CMV infection was likewise similar: D+38 vs D+35.The number of patients with a major reactivation, however, was significantly different between Group A and Group B (13 vs 25 – RR 0.52, 95% CI [0.30-0.90], p 0.018), as was the cumulative number of days of major reactivation (181 vs 604 – RR 0.30, 95% CI [0.25-0.35], p <0.0001). The median number of days of major reactivation per patient was 13 vs 21 respectively.ConclusionRoutine IVIg use in the immediate post-ASCT period did not reduce the rate or latency of CMV reactivation but was associated with a lower magnitude of CMV reactivation and a reduced requirement for anti-CMV therapy. These findings suggest that the use of IVIg post-ASCT may assist in reducing CMV viral burden. DisclosuresNo relevant conflicts of interest to declare.

Current recommendations for the management of TTTS

The paper presents current views and recommendations for pregnancy complicated by TTTS. The symptoms that should attract our attention during the first-trimester ultrasound, i.e. CRL asymmetry NT > 95th percentile, or 20% or more of the NT difference between the fetuses, absent or reversed A wave in DV, and TV regurgitation, are discussed and presented. Similarly symptoms that should attract our attention in the second trimester such as amniotic fluid volume imbalance, asymmetry in the size of the urinary bladders, abdominal circumferences discordance, inter-twin membrane folding, membranous attachment of the donor's umbilical cord, different placental echogenicity and abnormal Doppler measurements, are listed. The paper presents the principle of monitoring based on ultrasound examination, including Doppler studies. The necessity and usefulness of echocardiography is underlined. It is also stressed that the frequency of monitoring depends on the severity of hemodynamic changes and the check-up rate varies from once a week to daily monitoring in extreme cases. This paper presents a variety of therapeutic options, including conservative management, septostomy amnioreduction, laser and selective fetoreduction. Taking into account the level of disease severity stages I and V can be managed conservatively. Fetoscopic laser coagulation of anastomoses, which can be used almost in all stages of TTTS (I-IV), remains to be the treatment of choice. However the current level of evidence does not yet allow us to determine whether laser coagulation increases or reduces the risk of neurodevelopmental delay and mental retardation in children, as compared to other types of therapy. Amnioreduction may be recommended in cases when laser therapy is unavailable or as first-line therapy before transporting the patient to the intrauterine therapy center.

Myeloablative Conditioning With Intravenous Busulfan and Pentostatin (Bu/Pent) Vs. Total Body Irradiation and Cyclophosphamide (TBI/Cy) For Elderly Patients With Acute Myeloid Leukemia Or Myelodysplasia

BackgroundAllogeneic hematopoietic stem cell transplantation (HDT) in the elderly patient with acute myeloid leukemia (AML) or myelodysplasia (MDS) continues to pose a challenge due to treatment failure and treatment related toxicity. TBI/Cy, allows for engraftment and tolerance while maximizing anti-tumor activity, but can be a difficult regimen in elderly patients due to its associated toxicity profile. The introduction of reduced intensity conditioning regimens (RIC) and improved supportive care has led to decreased mortality following HDT in the elderly. However, for patients at high risk for relapse, RIC may not achieve prolonged disease control. For these patients, an ablative HDT with reduced toxicity (RT-SCT) may be beneficial by controlling disease with acceptable toxicity while allowing a GVL effect. We evaluated a novel conditioning regimen in an open label phase II study consisting of Bu/Pent aimed at improving toxicity, relapse rate, and overall survival (OS) in elderly patients with AML or MDS, and compared them with an elderly group who received TBI/Cy. MethodsWe treated 54 patients with AML/MDS over the age of 55, who were recipients of HDT from fully matched related donor (MRD), umbilical cord donor, or matched unrelated donor (MUD). We defined elderly as greater than 55 years of age. The median age in the Bu/Pent group was 64, 61% had adverse prognostic features including cytogenetics, relapsed, treatment related or transformed disease, or high IPSS score, 39% were in the intermediate group. There were 60% MRD and 40% unrelated HDT. In the TBI group median age was 59, 48% had adverse features and 52% intermediate, 48% MRD and 52% unrelated HDT.The Bu/Pent group (n=23) was conditioned with intravenous busulfan 1.6mg/kg every 12 hours day -7 to -4 and pentostatin 4mg/m2 on day -3 and day-2 prior to SCT on day 0. GVHD prophylaxis was methotrexate 10mg/m2 on day 1 and 5mg/m2 on days 3 and 6. Tacrolimus was started on day -2 and tapered over 1 month after day +100. Relapse, survival and toxicity data was compared with a historical control group at our institution who received 12 Gy TBI/Cy (60 mg/kg x 2) (n=31). Controls were selected by retrospective chart review of patients with a diagnosis of MDS or AML who had received an allogeneic transplant with a TBI/Cy based conditioning regimen after the age of 55.There was no graft failure reported in either group. The OS at 100 days and 1-year post HDT was significantly better for the Bu/Pent group vs. TBI group (82.6% vs. 51.6% and 43.5% vs. 25.8% respectively; p value= 0.029). Progression free survival (PFS) was also significantly better in the elderly population receiving Bu/Pent; 43.5% at 1 year versus 22.6% in the TBI group with a p value of .021. The rate of relapse was comparable regardless of conditioning regimen with 34% in the Bu/Pent group (8/23) and 29% in the TBI/Cy group (9/31) relapsing.Transplant related mortality (TRM) accounted for 13% (3/23) of the deaths in the Bu/Pent group, and 38% (12/31) in the TBI/Cy group. Of the three deaths in the Bu/Pent group, 2 were due to GVHD and 1 was secondary to sepsis within 100 days. Other significant nonfatal toxicities such as mucositis and nausea/vomiting were medically managed and rates of GVHD were similar in the two groups; 10/23 (43%) in the Bu/Pent group and 14/31 (45%) in the TBI group. Of the 10 GVHD patients in the Bu/Pent group, 7 had chronic (cGVHD) (30%). None of the patients in the Bu/Pent group and 3/31 in the TBI group developed VOD.Upon sub-group analysis, elderly CIBMTR high-risk AML/MDS patients who received Bu/Pent had an 86% 100 day survival versus 60% in the TBI/Cy group; 1 year survival was 43% and 33% respectively. In the elderly CIBMTR intermediate risk group, Bu/Pent 100 day survival was 78% vs. 44% in the TBI group. At 1 year, patients in the intermediate group who received Bu/Pent had 45% survival vs. 19% in the TBI group. ConclusionWe found that OS and PFS at 100 days and 1 year were significantly better in the Bu/Pent group due to a much lower TRM. The Bu/Pent based regimen appears to be superior for patients over the age of 55 with MDS or AML undergoing HDT when compared with TBI based regimens. With a low toxicity profile, Bu/Pent patients had a lower incidence of TRM when compared with a prospective study of patients receiving RIC-SCT busulfan/fludarabine (20%) and a lower incidence of cGVHD(53%) (Valcarcel et al). This regimen warrants further prospective evaluation. [Display omitted] p value= 0.029 [Display omitted] p value= 0.021 Disclosures:Smith:Seattle Genetics, Inc.: Research Funding; Spectrum: Consultancy; Cephalon: Consultancy, Speakers Bureau; Celgene: Consultancy, Speakers Bureau; GlaxoSmith Kline: Speakers Bureau. Rodriguez:otsuka: Honoraria, Research Funding.

Role of reduced-intensity conditioning allogeneic hematopoietic stem-cell transplantation in older patients with de novo myelodysplastic syndromes: an international collaborative decision analysis.

Myelodysplastic syndromes (MDS) are clonal hematopoietic disorders that are more common in patients aged ≥ 60 years and are incurable with conventional therapies. Reduced-intensity conditioning (RIC) allogeneic hematopoietic stem-cell transplantation is potentially curative but has additional mortality risk. We evaluated RIC transplantation versus nontransplantation therapies in older patients with MDS stratified by International Prognostic Scoring System (IPSS) risk. A Markov decision model with quality-of-life utility estimates for different MDS and transplantation states was assessed. Outcomes were life expectancy (LE) and quality-adjusted life expectancy (QALE). A total of 514 patients with de novo MDS aged 60 to 70 years were evaluated. Chronic myelomonocytic leukemia, isolated 5q- syndrome, unclassifiable, and therapy-related MDS were excluded. Transplantation using T-cell depletion or HLA-mismatched or umbilical cord donors was also excluded. RIC transplantation (n = 132) stratified by IPSS risk was compared with best supportive care for patients with nonanemic low/intermediate-1 IPSS (n = 123), hematopoietic growth factors for patients with anemic low/intermediate-1 IPSS (n = 94), and hypomethylating agents for patients with intermediate-2/high IPSS (n = 165). For patients with low/intermediate-1 IPSS MDS, RIC transplantation LE was 38 months versus 77 months with nontransplantation approaches. QALE and sensitivity analysis did not favor RIC transplantation across plausible utility estimates. For intermediate-2/high IPSS MDS, RIC transplantation LE was 36 months versus 28 months for nontransplantation therapies. QALE and sensitivity analysis favored RIC transplantation across plausible utility estimates. For patients with de novo MDS aged 60 to 70 years, favored treatments vary with IPSS risk. For low/intermediate-1 IPSS, nontransplantation approaches are preferred. For intermediate-2/high IPSS, RIC transplantation offers overall and quality-adjusted survival benefit.

Aplastic anemia: therapeutic updates in immunosuppression and transplantation

Abstract Advances in hematopoietic stem cell transplantation (HSCT) and immunosuppressive therapy (IST) have improved survival in severe aplastic anemia (SAA) from 10%-20% in the 1960s to 80%-90% today. A matched sibling HSCT is the treatment of choice in younger patients, whereas IST is often used in older patients or in those who lack a histocompatible sibling. Graft rejection, GVHD, and poor immune reconstitution (with associated infectious complications) limit the success of HSCT, whereas lack of response, relapse, and clonal evolution limit the success of IST. The historically high rate of graft rejection in SAA is now less problematic in the matched setting, but with greater rates observed with unrelated and umbilical cord donors. The correlation of increasing age with the risk of GVHD and the significant morbidity and mortality of this transplantation complication continue to affect the decision to pursue HSCT versus IST as initial therapy in adults with SAA. Outcomes with matched unrelated donor HSCT have improved, likely due to better donor selection, supportive care, and improved transplantation protocols. Results with mismatched unrelated donor and umbilical HSCT are not as favorable, with higher rates of graft rejection, GVHD, and infectious complications. Investigation of several upfront alternative IST protocols has not improved outcomes beyond horse antithymocyte globulin and cyclosporine. More recently, the role of alemtuzumab in SAA has been better defined and an oral thrombomimetic, eltrombopag, is showing promising activity in refractory cases. The most recent advances in HSCT and IST in SAA are discussed in this review.

Aplastic anemia: therapeutic updates in immunosuppression and transplantation.

Advances in hematopoietic stem cell transplantation (HSCT) and immunosuppressive therapy (IST) have improved survival in severe aplastic anemia (SAA) from 10%-20% in the 1960s to 80%-90% today. A matched sibling HSCT is the treatment of choice in younger patients, whereas IST is often used in older patients or in those who lack a histocompatible sibling. Graft rejection, GVHD, and poor immune reconstitution (with associated infectious complications) limit the success of HSCT, whereas lack of response, relapse, and clonal evolution limit the success of IST. The historically high rate of graft rejection in SAA is now less problematic in the matched setting, but with greater rates observed with unrelated and umbilical cord donors. The correlation of increasing age with the risk of GVHD and the significant morbidity and mortality of this transplantation complication continue to affect the decision to pursue HSCT versus IST as initial therapy in adults with SAA. Outcomes with matched unrelated donor HSCT have improved, likely due to better donor selection, supportive care, and improved transplantation protocols. Results with mismatched unrelated donor and umbilical HSCT are not as favorable, with higher rates of graft rejection, GVHD, and infectious complications. Investigation of several upfront alternative IST protocols has not improved outcomes beyond horse antithymocyte globulin and cyclosporine. More recently, the role of alemtuzumab in SAA has been better defined and an oral thrombomimetic, eltrombopag, is showing promising activity in refractory cases. The most recent advances in HSCT and IST in SAA are discussed in this review.

A Decision Analysis of Reduced-Intensity Conditioning Allogeneic Hematopoietic Stem Cell Transplantation for Older Patients with De-Novo Myelodysplastic Syndrome (MDS): Early Transplantation Offers Survival Benefit in Higher-Risk MDS

Abstract 115Reduced-intensity conditioning (RIC) allogeneic hematopoietic stem cell transplantation is a curative approach for older patients with myelodysplastic syndrome (MDS), but is associated with early mortality risk. We previously used decision modeling to define the role of myeloablative transplantation in younger MDS patients aged <60 years, stratified by IPSS risk (Cutler et al, Blood 2004). We thereafter undertook a similar analysis to define the role of RIC transplantation in older MDS patients.We constructed a Markov decision model in de-novo MDS patients aged 60–70 years to evaluate life expectancy after a strategy of early T-replete RIC transplantation versus standard-of-care non-transplantation approaches. Patients with chronic myelomonocytic leukemia, isolated 5q-, unclassifiable and therapy-related MDS were excluded. Patients undergoing transplantation with anti-thymocyte globulin or alemtuzumab-based conditioning or HLA mismatched or umbilical cord donors were also excluded. We undertook adjustments for quality-of-life (QoL) using standard utility estimates for different MDS and transplantation states (0.84: RBC transfusion-independent low/intermediate-1 MDS; 0.6: RBC transfusion-dependent low/intermediate-1 MDS; 0.53: intermediate-2/high MDS; 0.92: post transplantation-overall; 0.6: post transplantation-GVHD)We evaluated survival of 92 patients after HLA matched RIC transplantation (Dana-Farber, Fred Hutchinson and CIBMTR datasets) stratified by IPSS risk state, versus survival with: best supportive care for 183 non-anemic low/intermediate-1 IPSS patients (IMRAW and Pavia datasets); hematopoietic growth factors for 78 anemic low/intermediate-1 IPSS patients (Nordic MDS Group and GFM datasets); and hypomethylating agents for 160 intermediate-2/high IPSS risk patients (Celgene AZA-001, GFM compassionate use azacytidine and M. D. Anderson decitabine datasets).For older patients with low/intermediate-1 IPSS risk, early RIC transplantation impaired life expectancy compared to non-transplantation approaches (Table). Excluding patients transplanted beyond 12 months from diagnosis did not alter the conclusion. QoL adjustment narrowed the gap in quality adjusted life expectancy (QALE), but sensitivity analysis did not support RIC transplantation as the preferred strategy across a broad range of possible utility estimates (0.5–1), indicating that MDS-associated morbidity (e.g. RBC transfusion-dependence) does not favor early transplantation unless its QoL impact is substantial (state utility <0.4).For older patients with intermediate-2/high IPSS risk, early RIC transplantation improved life expectancy compared with hypomethylating agents (Table). Excluding patients transplanted beyond 12 months from diagnosis did not alter the conclusion. However, transplantation is associated with early mortality such that the life expectancy benefit was apparent only after modeling survival beyond 5 years. Importantly, QoL adjusted survival benefit of transplantation was apparent both at 5 years and beyond, highlighting the morbidity of higher-risk MDS. In sensitivity analyses, QoL adjustment across the range of plausible transplantation-associated utility estimates (0.5–1) did not change the conclusion of QALE benefit.We conclude that for de-novo MDS patients aged 60–70 years with low/intermediate-1 disease, early transplantation is not the preferred strategy unless MDS-associated QoL impairment is substantial. For intermediate-2/high IPSS risk, early RIC transplantation offers a life expectancy benefit, with quality adjusted survival benefit detectable earlier.TableEarly RIC transplantationNo early RIC transplantationLow/intermediate-1 IPSSOverall Life Expectancy (months)3877QALE: Transfusion-independent MDS morbidity (months)3565QALE: Transfusion-dependent MDS morbidity (months)3546Intermediate-2/high IPSSOverall Life Expectancy (months)3628QALE: Higher-risk MDS morbidity (months)3315QALE: GVHD morbidity (months)2215 Disclosures:Fenaux:Celgene: Honoraria, Research Funding. Hellstrom-Lindberg:Celgene: Consultancy, Research Funding. Gale:celgene: Employment; unitedhealthcare: Consultancy; oxford health plans: Consultancy. Beach:celgene: Employment. Greenberg:novartis: Consultancy, Research Funding; glaxosmithkline: Research Funding; onconova: Research Funding; amgen: Consultancy, Research Funding.

The Occurrence of Cytomegalovirus Gastrointestinal Disease in Patients with Gastrointestinal Graft-Versus-Host Disease and Its Related Clinical Outcomes in the Era of Preemptive Therapy for Cytomegalovirus Infection

Abstract 492Diagnosis and therapeutic decision of gastrointestinal (GI)-graft-versus-host disease (GVHD) mainly rely upon clinical symptoms and exclusion of other causes of GI dysfunction. Particularly, the presence of CMV-GI-disease should be examined with immunostaining of biopsy. However, there have been few reports about the occurrence of CMV-GI-disease in patients with GI-GVHD in the era of preemptive therapy for CMV infection with real-time quantitative polymerase chain reaction (RQ-PCR) and its related outcomes.Between January 2008 to December 2010, 392 adult patients with AML, ALL, MDS, and CML underwent allogeneic stem cell transplantation (SCT) and all had serial monitoring for CMV DNA based on RQ-PCR followed by initiation of preemptive therapy. Ninety-seven percent of recipients and 84% of donors were CMV-seropositive before SCT. Clinical GI-GVHD based on symptoms, stool studies, and endoscopic findings developed in 114 patients (29%) and they were treated by high-dose systemic steroid. Of these patients, 103 patients performed endoscopic biopsies not only at the time of onset of clinical symptoms but also during the clinical course of GI-GVHD in the absence of response to steroid, and all samples from biopsies were immunohistochemically stained. The median age of the 103 patients was 40 years (range, 15–70). These patients consisted of AML (n=59), ALL (n=29), MDS (n=12), and CML (n=3) transplanted from sibling (n=45), unrelated (n=48), familial-mismatched donors (n=8), and umbilical cord donors (n=2). Conditioning regimens consisted of myeloablative (76%) and reduced-intensity regimens (24%). Anti-thymocyte globulin was given as a part of conditioning in 41 patients (40%). GVHD prophylaxis was based on administering calcineurin inhibitor with short-course methotrexate. GI-GVHD was developed as a manifestation of not only acute GVHD (aGVHD, 87%) but also overlap syndrome (13%). Isolated GI-GVHD was 30%. Eighty-nine patients (86%) initially presented with GI-GVHD, whereas 14 patients (14%) developed GI-GVHD after the treatment of GVHD of other organs.Of the 103 patients, 60 (58%) had histologic findings for GI-GVHD (lower gut, n=41, 40%; lower gut + upper gut, n=10, 10%; upper gut, n=9, 8%) and 26 (25%) had positive immunohistochemical stain for CMV-GI-disease (lower gut, n=13, 13%; lower gut + upper gut, n=4, 4%; upper gut, n=9, 8%). The CMV-GI-disease developed at a median time of 56 days after SCT (range, 20–403). Multivariate analyses revealed that older age over 30 years (RR 4.42, 95%CI 1.10–17.84), HLA-mismatched donors (RR 3.41, 95%CI 1.21–9.60), and higher grade of GVHD (grade III+IV aGVHD or severe cGVHD, RR 3.24, 95% CI 1.22–8.60) were significant risk factors for CMV-GI-disease. Most patients (73%) developed CMV-GI-disease after the treatment of GI-GVHD or other organs of GVHD, whereas CMV-GI-disease developed concurrently with GI-GVHD in other 27%. After the anti-viral therapy with ganciclovir or foscarnet, 14 patients (54%) showed complete resolution of CMV-GI-disease, while 12 patients (46%) failed to show any response.There were 4 patterns of development of pathologically proven GI-GVHD and CMV-GI-disease (Figure). GVHD-specific survival of patients with CMV-GI-disease was significantly lower than patients without CMV-GI-disease (36.2% vs. 79.3%, P = 0.002). Patients with both GI-GVHD and CMV-GI-disease (n=18) had significantly inferior GVHD-specific survival than other 3 patterns of development of GI-GVHD and CMV-GI-disease (24.5% vs. 78.2%, P = 0.001).Our data demonstrate 25 percent of patients with clinical GI-GVHD developed CMV-GI-disease during the treatment or at the time of diagnosis of GI-GVHD even in the era of preemptive therapy for CMV disease based on RQ-PCR, especially in older patients, HAL-mismatched transplants, and higher grade of GVHD. Patients with CMV-GI-disease, especially who concurrently had pathologically proven GVHD, had inferior GVHD-specific survival. Thus, we reemphasize the need of endoscopic biopsy with immunohistochemical stain for CMV disease if ever possible at the diagnosis of GI-GVHD as well as in the absence of response to treatment of GVHD, especially in high risk groups, which can facilitate proper selection of treatment. Additionally, novel prophylactic measures such as immunotherapy and drug prophylaxis should be considered in this specific group of patients. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Inefficient dystrophin expression after cord blood transplantation in Duchenne muscular dystrophy

We report a boy who received two allogeneic stem cell transplantations from umbilical cord donors to treat chronic granulomatous disease (CGD). The CGD was cured after the second transplantation, but 2.5 years later he was diagnosed with Duchenne muscular dystrophy (DMD). Examinations of his DNA, muscle tissue, and myoblast cultures derived from muscle tissue were performed to determine whether any donor dystrophin was being expressed. The boy was found to have a large-scale deletion on the X chromosome that spanned the loci for CYBB and DMD. The absence of dystrophin led to muscle histology characteristic of DMD. Analysis of myofibers demonstrated no definite donor cell engraftment. This case suggests that umbilical cord-derived hematopoietic stem cell transplantation will not be efficacious in the therapy of DMD without additional interventions that induce engraftment of donor cells in skeletal muscle.

Influence of obstetric factors on osteogenic potential of umbilical cord-derived mesenchymal stem cells

Wharton's jelly from the umbilical cord is a noncontroversial source of mesenchymal stem cells (WJMSCs) with high plasticity, proliferation rate and ability to differentiate towards multiple lineages. WJMSCs from different donors have been characterized for their osteogenic potential. Although there is large evidence of WJMSCs plasticity, recently scientific debate has focused on MSCs selection, establishing predictable elements to discriminate the cells with most promising osteoprogenitor cell potential.In the present study a comparative study between the presence of osteoblastic markers and different parameters that pertain to both the newborn and the mother was performed. Umbilical cords were collected after all patients signed the informed consent and local ethical commettee approved the study. Obstetric parameters, including baby's gender and birth weight, mother's age at delivery, gestational stage at parturition and mode of delivery were examined. After characterization and expansion, WJMSCs were analyzed for two osteoblastic markers, alkaline phosphatase (ALP) activity, and the expression level of RUNX-2 transcription factor, and for their ability to deposit mineralized matrix after osteogenic induction.We found that osteoblastic potential was not influenced by baby's gender and mode of delivery. On the contrary, the highest degree of osteoblastic potential has been shown by WJMSCs with RUNX-2 high basal levels, selected from umbilical cords of the heaviest term babies.Even if further evaluation is required, our hypothesis is that our findings may help in selecting the optimal umbilical cord donors and in collecting high potential Wharton's jelly-derived osteoprogenitors efficiently.