Unrelated HSCT Research Articles

KIR/HLA-I mismatching and risk of relapse in paediatric patients undergoing non-haploidentical allogeneic haematopoietic stem cell transplantation

In HSCT setting, KIR-driven alloreactivity might be better predicted if the donor KIR genotype is considered in addition to the recipient HLA genotype. The prediction of NK cell alloreactivity relies on the missing ligand in the recipient, a scenario that can be found in HLA-identical and non-identical allotransplants. The aim of this study was to investigate at genetic level the prognostic impact of recipient HLA-I lacking for donor KIR on allotransplanted patients outcome. We analysed donors KIR genotype and HLA genotype of 60 paediatric patients who received related (n=15) or unrelated (n=45) transplantation. When patients were grouped based on the KIR gene type involved in the KIR/HLA-I mismatch, we did not observe any relapse in the group of patients characterized by mismatches involving only inhibitory KIR. On the contrary, all relapses were observed in patients showing at least one activating gene involved in the mismatch (p<0.05). Although the biological mechanism accounting for this putative genetic rule is still to be clarified, we suggest that a careful survey of KIR/HLA-I mismatching should be taken into account in the selection of donor in related and unrelated HSCT.

Effect of Stem Cell Source From Unrelated Donors on Transplant Outcomes In Severe Aplastic Anemia (SAA): a Comparison of Unrelated Bone Marrow (BM) and Peripheral Blood Progenitor Cells (PBPC)

AbstractAbstract 531Unrelated donor HSCT has been considered a therapy of last choice in SAA, because of poor overall survival reported prior to 1998 (32% @ 5-years). This is due in large measure to low resolution donor-recipient HLA typing and the selection of patients. Survival after unrelated donor BM HSCT for SAA has improved in recent years with survival rates of approximately 75% @ 5-years when the donor and recipient are matched at HLA-A, -B, -C and –DRB1. Furthermore, improvements in conditioning regimen may also have reduced the rate of graft rejection. In recent years PBPC instead of BM are increasingly used and PBPC grafts now account for 25% of unrelated donor HSCT for SAA. An earlier report from the CIBMTR and the EBMT identified higher chronic graft-versus-host disease (GVHD) incidence and mortality after transplantation of PBPC from HLA-matched siblings compared to BM in patients with SAA aged ≤20 years. GVHD rates are higher after unrelated adult donor HSCT regardless of graft type, but the effects of PBPC on survival in patients with SAA are not known. Two hundred and forty nine patients transplanted in 2000–2007 received either BM (n=186) or PBPC (n=63) from unrelated adult donors matched at HLA-A, -B, -C, -DRB1. Median follow up was 3 years. Compared with recipients of BM, PBPC recipients were older (median age: 19 vs. 35 years), transplanted in 2006–2007 (37% vs. 46%), more likely to be male (47% vs. 65%), receive non-TBI containing transplant conditioning (fludarabine + cyclophosphamide or busulfan or melphalan ± anti-thymocyte globulin; 34% vs. 55%) and tacrolimus-containing GVHD prophylaxis (29% vs. 57%). Among patients who received TBI-containing regimens, approximately 90% of BM and PB recipients received TBI 200 cGy. There were no differences in patient performance score at HSCT, immunosuppressive treatment prior to HSCT and interval from diagnosis to HSCT (median time to HSCT was 13 months in BM recipients and 11 months, in PBPC recipients). As shown after HLA-matched sibling transplantation, the cumulative incidence of neutrophil recovery (30.5 × 109/L at day-28) and platelet recovery (≥20 × 109/L) was similar in recipients of BM (92% and 83%, respectively) and PBPC (95% and 90%, respectively). The day-100 probability of grades 2–4 acute GVHD was higher after PBPC than after BM (51% vs. 33%, p=0.01). The 3-year probability of chronic GVHD was higher after PBPC than after BM, in patients older than 20 years at HCT (60% vs. 41%, p=0.001) but not in younger patients (23% vs. 26%, p=NS). In multivariate analysis, the risk of mortality was higher after PBPC than after BM (HR 1.79, p=0.02). Other factors that predicted mortality included poor performance score (HR 1.95, p=0.009) and non-TBI transplant conditioning regimens (HR 1.96, p=0.006). Although patient age (>20 vs. ≤20 years) was significantly associated with chronic GVHD there was no significant effect of age on mortality (HR 1.21, p=0.47). The 3-year probability of overall survival adjusted for performance score and transplant conditioning regimen was 76% for BM and 60% for PBPC recipients (p=0.02). These data suggest that: 1) outcomes after URD HSCT for SAA are now similar to outcomes observed in MRD HSCT, 2) BM is the preferred graft source when considering unrelated donor HCT in patients with SAA and 3) the data also support low dose TBI in the preparative regimen for transplant conditioning. Disclosures:No relevant conflicts of interest to declare.

Retrospective Analysis of Hemorrhagic Cystitis After Unrelated Donor Hematopoietic Stem Cell Transplantation In a Chinese Population.

AbstractAbstract 4546Hemorrhagic cystitis (HC), occurring mostly within first month after allogeneic hematopoietic stem cell transplantation (allo-HSCT), is a common complication which often requires prolonged hospitalization, considerable expense, and occasionally causes significant morbidity. The data from different transplantation centers about this complication are different in the incidence, risk factors, therapeatic strategies and outcome. In this study, we retrospectively analyzed the incidence, risk factors, prophylaxis and treatment regimens of HC after unrelated donor HSCT(URD-HSCT)in our center From October 2000 to February 2008, 168 consecutive patients underwent URD-HSCT were enrolled,including 113 male patients and 55 female patients. The median age was 26 years (range,8-52 years). The main myeloablative conditioning regimens used were busulfan/cyclophosphamide (BuCy) without total body irradiation (TBI); Reduced-intensity conditioning regimens (RIC) were predominantly fludarabine-based combinations without irradiation. Anti-thymocyte globulin(ATG) were added to the conditioning regimen in the patients receiving HLA-mismatched URD-HSCT. The prophylaxis regimen for HC included intravenous mesna,hyperhydration and intermittent diuretic. The diagnosis of HC was based on the presence of sustained microscopic or macroscopic hematuria in the absence of other clinical conditions such as urinary bacteria and fungi infection. It could be clinically graded to I to IV according to hematuria and divided into early onset (EOHC) and delayed (LOHC) according to the time of onset. In total, 27 of 168 patients (16.1%) developed HC at a median interval of 40 days post engraftment (range, 8–89 days). Among them,11 patients developed grade I (6.5%), 10 patients developed grade II (6.0%), 6 patients developed grade III (3.6%), while no patients with grade IV. Five patients(2.98%) presented EOHC and 22 patients (13.17%) presented LOHC. We discovered that in 27 patients with HC only 3 were female (11.1%), however in 141 patients without HC, 52(36.9%) were female (P<0.05). Patients with HC had a higher incidence of acute graft-versus-host disease (aGVHD) (92.6% vs 47.5%, P<0.001) and grades II-IV aGVHD (P<0.001), which is consist with previous reports. Furthermore, 16 patients (59.3%) with HC were ≥30-year-old, 50 patients (35.5%) without HC, were ≥30-year-old (P<0.05). Multivariate analysis showed that primary disease type, donor ‘s gender or age, stem cell source, myeloablative or nonmyeloablative conditioning regimen, HLA or ABO blood mismatching, the existence of CMV seropositivity were not significantly associated with the risk of HC. All patients achieved excellent response after being treated with alkalinization of the urine, hyperhydration with intravenous fluid. Several patients also received urethral catheterization to bladder washout. No patient died of HC. In conclusion, our results demonstrated that recipient ‘s gender, aGVHD and recipient's age(≥30-year-old), were three risk factors associated with HC. Other risk factors which had been reported to be related to HC in literatures did not show significant impact in our study. Although effective prophylaxis has significantly decreased the incidence of HC, up to date, the precise pathogenesis of HC has not been well elucidated. More clinical and mechanisms researches should to be explored. Disclosures:No relevant conflicts of interest to declare.

Phase II Prospective Multicenter Study of Treosulfan Based Reduced Intensity Conditioning In Allogeneic Hematopoietic Stem Cell Transplantation for Hematological Malignancies From 10/10 HLA Identical Unrelated Donor

AbstractAbstract 2353 Background:The key point in allogeneic hematopoietic stem cell transplantation (allo-HSCT) is to find the optimal balance between the graft-versus-host disease (GVHD) and the graft-versus-leukemia (GVL) effect particularly in the unrelated HSCT settings, without forgetting the important role of conditioning. Objective:To evaluate the toxicity and efficacy of a new reduced intensity conditioning regimen including Treosulfan, followed by allo-HSCT from a 10/10 HLA identical unrelated donor. Materials and Methods:This prospective study included adult patients presenting a hematological malignancy in need of allo-HSCT using a 10/10 HLA identical unrelated donor. Accepted diagnoses were: CML in 1st chronic phase (CP) resistant to imatinib, in 2nd CP or in complete remission (CR) after blast crisis. Multiple myeloma (MM) or chronic lymphocytic leukemia (CLL) in stage B or C in response after relapse post-auto-HSCT. Acute lymphocytic or myeloid leukemia (ALL, AML) patients in CR1 at high risk or <CR1. Myelodysplasic syndrome (MDS) with poor prognostic factors. The conditioning included:Treosulfan 12g/m2/day intra-venous (day-6 to day-4), fludarabine 30mg/m2/day intra-venous (day-6 to day -2) and ATG 2.5 mg/kg/day (day-2 to day-1). GVHD prophylaxis used cyclosporine A oral (5mg/kg/day) or iv. (3mg/kg/day) from day-1. Peripheral stem cells after mobilization by G-CSF were used as HSC source. Results:Between February 2005 and July 2009, 56 patients were included in 5 different French centers, 30 (54%) males and 26 females with a median age of 57 years (18-65.5). There were 38 (68%) myeloproliferative disorders [29 AML (14 in CR1, 14 CR2 & 1<CR), 8 MDS (1CR1 and 7<CR) and 1 CML in CR1] and 18 (32%) lymphoprolifative disorders [9 MM in PR, 6 CLL (2CR1 & 4PR) and 3 ALL(1CR1 & 2CR2)]. Among 45 explored for cytogenetics, 23 (51%) were normal and 22 with poor prognostic. Before transplantation, two patients did not receive any previous treatment, 21 received 1 line, 22 two lines and 11 > 2 lines. For sex-matching, 49% of patients were sex-mismatched (half of them were F>M). For CMV, 43% were -/-, 25% +/+, 28% +/− and 1% -/+. For ABO matching, 52% were compatible, 24% major incomp. & 24% minor incopm. The median time between diagnosis and allograft was 15 months (4-168). The median number of infused CD34+ cells was 6.5 × 106/Kg(1-17.2)Fifty-four (96%) patients engrafted with a median time to neutrophils (>0.5G/l), and platelets (>50G/l) recovery of 16 days (4-86), 11 (4-82) respectively. Seventeen patients developed aGVHD grade ≥II (8 grade II, 2 grade III & 7 grade IV) with a cumulative incidence at 3 months of 31% (25-38). The cumulative incidence of cGVHD was, at 12 months: 32% (25-39) limited and 6% (2-10) extensive; at 18 months: 34% (27-47) limited and 8% (5-12) extensive. After a median follow-up of 13 months (1-57), the median overall survival (OS) was not reached with a 3 years probability of 52% (38-71). The median time of event free survival (EFS) was 15 months (8 - 57) with a 3-years probability of 47% (35-64). The cumulative incidence of relapse at 3 years was 25% (19-31) and the cumulative incidence of transplant-related mortality (TRM) at 12, 18 and 36 months was 20% (16-27), 23% (16-29) (same at 18 & 36 months) respectively. At the last follow-up, 22 patients died, 7 due to relapse and 15 due to TRM (5 pneumonia, 4 GVHD, 1 secondary malignancy and 6 other causes). We showed in a univariate analysis a higher 3-years OS of patients in CR1 (65%) compared to those <CR1 (44%) at transplantation with a significant better benefit for AML patients (76%). Patients with active cGVHD seem to benefit for the GVL effect on OS with a high significant difference (HR=0.2 (0.1-0.6) p=0.002). The multivariate analysis studying age, sex matching, ABO compatibility, CMV matching, type of disease, CD34+ cells number, cytogenetics, number of previous treatments, disease status and interval diagnosis-allo-HSCT showed: a negative significant impact of both minor ABO incompatibility (p<0.001) and CMV+/− (p=0.01) on OS, a negative significant impact of patients <CR (p=0.03) on relapse. There was no impact of studied factors on TRM. Conclusion:We showed very promising results in terms of OS, relapse and TRM with an impressive GVL effect, in heavily pre-treated patients and transplanted using unrelated donors. Treosulfan appears to be a good choice for conditioning especially with a better outcome in AML patients in CR1. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

The Genotype of T-Cell Costimulatory Molecule Is Associated with Relapse Incidence In Patients with Acute Myeloid Leukemia After Allogeneic Hematopoietic Cell Transplantation

AbstractAbstract 684 Background:Disease relapse is one of the leading causes of death following allogeneic hematopoietic stem cell transplantation (allo-HSCT). Donor T lymphocytes play a critical role in alloimmune recognition and their ability to detect non-self-antigens can lead to graft-versus-host disease (GVHD) or contribute to relapse prevention through recognition and elimination of minimal residual disease. CD28 is the primary T-cell costimulatory molecule constitutively expressed on the majority of T cells. Upon interaction with its ligands B7, CD28 transduces a signal that enhances the activation and proliferation of T cells. Another member of the CD28 family is inducible co-stimulator (ICOS). Although not constitutively expressed, ICOS is rapidly upregulated on T lymphocytes upon activation. Cytotoxic T-lymphocyte antigen 4 (CTLA-4), a homologous molecule of CD28, is a key factor in regulating and maintaining self-tolerance, providing a negative signal to T cells. Although several single-nucleotide polymorphisms (SNPs) within those costimulatory molecule genes have been identified to be associated with the risk of autoimmune disease, their association with outcome after allo-HSCT has yet to be explored. This present study was designed to investigate the influence of CD28, ICOS and CTLA-4 genes polymorphisms on the outcome of patients with acute myeloid leukemia (AML) after allo-HSCT. Methods:The entire study population consisted of 86 consecutive AML patients and their donors who were transplanted from 2001 to 2009 in our Unit. Genomic DNA was extracted from peripheral blood samples obtained from recipients and donors before transplantation. Five SNPs of CD28 -594(A/G), ICOS -693(G/A) and CTLA-4 -1722(A/G), +49(A/G) and CT60(A/G) were analyzed. Results:(1) The media age of the patients was 27 years (range, 12–49 years). At the time of transplantation, 70 patients were in first complete remission (CR), 10 patients in second CR, 3 patients in third CR and 3 patients in progressive status. 33 patients underwent HLA-matched sibling HSCT and 53 patients underwent unrelated HSCT. All patients received myeloablative conditioning based on busulfan/cyclophosphamide (BuCy) without total body irradiation (TBI). The GVHD prophylaxis is consisted of cyclosporin A, a short-term methotrexate and mycophenolate mofetil. (2) Only one patient experienced engraftment failure. 18(20.9%), 20(23.3%) and 3(3.5%) patients respectively developed grade I, II and severe acute GVHD (aGVHD). 16(18.6%) and 15(17.4%) patients developed limited and extensive chronic GVHD (cGVHD). (3) 17 patients (19.8%) experienced relapse, the media time was 15.6 months after allo-HSCT (range, 2–24 months). (4) Patients receiving stem cells from a donor with AA genotype in position +49 or CT60 of CTLA-4 gene relapsed more frequently than those with AG/GG genotypes (for +49: 50% vs 14.1%, P=0.012; for CT60: 80% vs 16%, P<0.0001). (5) Patients receiving stem cells from a donor with CD28 -594 AA genotype had a lower incidence of relapse than those with other genotypes (0 vs 25%, P=0.04), due to a higher incidence of aGVHD (83.3% vs 38.2%, P=0.004). (6) In multivariate analysis, donor with CTLA-4 CT60 AA genotype (RR=13.411, 95%CI: 3.808–47.233, P<0.0001), and absence of cGVHD (RR=2.12, 95%CI: 1.112–4.042, P=0.022) were found to significantly contribute to the risk of relapse after allo-HSCT. Furthermore, patients receiving CTLA-4 CT60 AA genotype donor had worse overall survival at 7 years (20% vs 77.8%, RR=10, 95%CI: 3.761–16.239, P<0.0001). The polymorphic sites CTLA-4 -1722 and ICOS -693 did not correlate with the risk of relapse. Nor did patient 5 polymorphic sites genotype. Conclusions:These results, which is the first report of T-cell costimulatory molecule genes polymorphic features with the risk of leukemia relapse in AML patients after allo-HSCT, suggest an interaction between donor CTLA-4 CT60 AA genotype and the risk of relapse. The CTLA-4 CT60 AA genotype has been reported to increase the production of soluble form of CTLA-4, suggesting that increased expression of CTLA-4 would be associated with a decrease ability of the immune system to detect and eliminate tumor associated antigens. According to our results, anti-CTLA-4 antibodies may be a promising therapeutic strategy in leukemia relapse after allo-HSCT at least in patients receiving CTLA-4 CT60 AA genotype donor. Disclosures:No relevant conflicts of interest to declare.

Quantitative and Qualitative CD4 T Cell Immune Responses Related to Adenovirus DNAemia in Hematopoietic Stem Cell Transplantation

The nature of adenovirus (AdV)-specific T cells that could best predict the capacity of immunocompromised host to fight AdV is unclear. To this aim, 47 pediatric patients were enrolled for at least 3 months either at allogeneic bone marrow transplantation (BMT) (23 genoidentical, 18 unrelated of which 9 were 10/10 and 9 were 9/10 HLA-matched) or at unrelated cord blood transplantation (n = 6). Enumeration of AdV-specific CD4 T cells secreting cytokines (flow cytometry) and proliferative responses to AdV ((3)HT-incorporation) were compared to AdV-DNAemia. A total of 44/47 patients did not evidence AdV-DNAemia. Thirty-two of 44 (73%) developed CD4-mediated interferon-gamma (IFN-γ) responses to AdV (median 0.36 CD4/μL of blood) since the first month post-HSCT (n = 11: 8 genoidentical and 3 unrelated) or the third month (n = 21 additional patients). At 3 months, both incidence and level intensities of AdV-specific CD4 appeared similar in genoidentical and unrelated BMT (70% and 80%; 0.36 and 0.21 CD4/μL, respectively) and not statistically different from age-matched controls (76%; 1.35 CD4/μL), whereas cord blood transplanted patients exhibited similar incidence but higher level intensities (67%; 1.49 CD4/μL). Polyfunctional (IL2 + IFN-γ) and proliferative responses appeared later, after the third month. Three of 4 9/10 HLA-matched unrelated HSCT that did not develop immunity to AdV presented chemotherapy-resistant AdV-DNAemia at 3 to 5 months post-hematopoietic stem cell transplantation (HSCT). Two were successfully treated with AdV-specific CTL infusion. Monitoring, since month 1 post-HSCT, of IFN-γ-secreting AdV-specific CD4 appears suitable for early detection of at-risk patients especially in 9/10 HLA-matched unrelated HSCT and preferable to monitoring of more delayed IL2- and proliferative responses.

111-P: Loss of Mismatched HLA in Family Haploidentical and Unrelated HSCT

111-P: Loss of Mismatched HLA in Family Haploidentical and Unrelated HSCT

A cost-utility and budget impact analysis of allogeneic hematopoietic stem cell transplantation for severe thalassemic patients in Thailand

BackgroundHematopoietic stem cell transplantation (HSCT) is the only curative treatment available to severe thalassemic patients. The treatment, however, is very costly, particularly in the context of low and middle income countries, and no studies have been carried out to explore its economic justifiability. This study aimed to estimate the cost-utility of HSCT compared with blood transfusions combined with iron chelating therapy (BT-ICT) for severe thalassemia in Thailand, and to investigate the affordability of HSCT using a budget impact analysis.MethodsA Markov model was used to estimate the relevant costs and health outcomes over the patients' lifetimes taking a societal perspective as recommended by Thailand's health technology assessment guidelines. All future costs and outcomes were discounted at a rate of 3% per annum. Primary outcomes of interest were lifetime costs, quality adjusted life years (QALYs) gained, and the incremental cost-effectiveness ratio (ICER) in Thai baht (THB) per QALY gained.ResultsCompared to BT-ICT, the incremental cost-effectiveness ratio increased with patient age from 80,700 to 183,000 THB per QALY gained for related HSCT and 209,000 to 953,000 THB per QALY gained for unrelated HSCT among patients aged 1 to 15 years (US$1= 34 THB). The governmental budget impact analysis showed that providing 200 related HSCT to patients aged 1 to 10 years, in accordance with the current infrastructure limitations, would initially require approximately 90 million additional THB per year.ConclusionsAt a societal willingness to pay of 100,000 THB per QALY gained, related HSCT was likely to be a cost-effective and affordable treatment for young children with severe thalassemia in Thailand.

HHV-6 encephalitis in pediatric unrelated umbilical cord transplantation: A role for ganciclovir prophylaxis?

The role of ganciclovir as HHV-6 prophylaxis in unrelated HSCT setting remains controversial. We performed an eight-yr retrospective review of patients received unrelated HSCT from January 2000 to September 2008. From January 2002, ganciclovir prophylaxis 5 mg/kg twice daily for seven days for all unrelated HSCT before transplant was adopted. The prevalence of HHV-6 encephalitis was studied before and after the change in policy. Fifty-four unrelated HSCT were performed from January 2000 to September 2008. Four cases (7.4%) of HHV-6 encephalitis were diagnosed. All of them were due to variant B infection. Two cases out of 16 cases (12.5%) were diagnosed before adoption of the policy; two cases out of 38 cases (5.3%) were diagnosed afterward. All of them were unrelated UCB transplant recipients. They were all seropositive to HHV-6 before transplant. Two cases complicated with significant residual neurological deficit and refractory seizure. The other two cases died of other transplant-related mortalities. We conclude that HHV-6 encephalitis is still a rare complication of unrelated HSCT and may be more common in unrelated UCB transplant. Routine use of ganciclovir as HHV-6 prophylaxis in all unrelated HSCT recipients may not be justified but may have a role in unrelated UCB transplant.

Low-Dose Anti-T-Lymphocyte Globulin (ATG-Fresius) Significantly Reduces Acute Gvhd And Non-Relapse Mortality (NRM) After Reduced-Intensity Unrelated BMT

Unrelated HSCT with a reduced-intensity conditioning regimen (RIC) is now widely performed as an alternative to HLA-matched related HSCT. However, the optimal regimen has not yet been well established in Japan, where peripheral blood stem cell transplantation is not yet allowed for unrelated pairs. In this retrospective analysis of unrelated RIC BMT, we evaluated the feasibility of a regimen using a lower dose of rabbit ATG (Fresius) and TBI.

Relation Of TNFA, TNFB And TNFRII Gene Polymorphisms To Outcomes After Unrelated Haematopoietic Cell Transplantation Within Chinese Population

The genes code TNFα (TNFA), TNFβ (TNFB) and TNF receptor II (TNFRII) contain multiple single nucleotide polymorphisms (SNPs). The present study was designed to test association of these genes polymorphisms with outcomes after unrelated HSCT within Chinese population.

Excessive Rate of Late Infections and Treatment Related Mortality Associated with the Use of Alemtuzumab in Reduced Intensity Conditioning for Allogeneic Hematopoietic Stem Cell Transplantation: Results of a Prospective Trial.

Abstract 2230Poster Board II-207 Background:Reduced intensity conditioning (RIC) for allogeneic hematopoietic stem cell (HSC) transplantation is a well established therapy for patients with advanced hematological malignancies who are not suitable candidates for fully myeloablative conditioning. The use of alemtuzumab as part of RIC has been associated with decrease in incidence and severity of graft versus host disease (GVHD), particularly in unrelated donor transplants. Methods:This is a single center, prospective study. Patients with relapsed or refractory hematological malignancies who were not candidates for fully myeloablative conditioning regimens received an non-alemtuzumab (nA) containing RIC regimen or an alemtuzumab-containing regimen (A) based on the use of a matched sibling or an allele-matched unrelated donor, respectively. Patients in the nA group were conditioned with either Fludarabine 30mg/m2/day for 5 days and total body irradiation 200cG or Fludarabine 25mg/m2/day for 5 days and Melphalan 70mg/m2/day for 2 days. Patients in the A group received alemtuzumab 20 mg/m2/day for 2 days, Fludarabine 30mg/m2/day for 5 days and Melphalan 70mg/m2/day for 2 days. All patients received peripheral blood HSC grafts. Prophylaxis against graft versus host disease with cyclosporine and mycophenolate mofetil as well as infectious disease prophylaxis and supportive care guidelines were standard across both groups. Results:From January 2003 to March 2009, 56 patients were enrolled in the study and 50 patients who actually received a HSCT are the subject of this analysis. Twenty nine patients were in group nA and 21 in group A. Median age of the patients in the entire cohort was 55 years (range 14-65). Eighteen patients had AML, 12 NHL, 8 MDS, 6 CML, 3 CLL and 3 MM. Twenty-three patients were considered to be at high-risk for post transplant relapse (45% of group nA vs. 47% of group A, P= 0.84). All patients in group nA had hematological engraftment while 2 patients in A (9.5%) failed to engraft. Despite the fact that all patients in group A received a transplant from an unrelated donor, the incidence of severe (grades C or D) acute GVHD was significantly higher in group nA (20.7% vs. 0%, P=0.03). Day 100 mortality was similar between the 2 groups (20.7% for nA vs 33.1% for A, P=0.31). Cumulative incidence of progression did not differ between the two groups (P=0.7) while the cumulative incidence of treatment related mortality was higher in group A (P=0.02, Figure 1). Both median overall survival (OS) (44.1 vs. 5.3 months; P=0.01, figure 2) and progression-free survival (PFS) (8.7 vs 5.3 months, P= 0.02) were superior in group nA. Cox regression analysis including conditioning regimen, age and risk of post-transplant relapse showed that conditioning with alemtuzumab was the only variable significantly associated with inferior OS (RR 2.8, P=0.009) and PFS (RR 2.42, P= 0.01). Group A had a higher incidence of late (after Day 100) infectious complications resulting in death (43% vs.10%, p=0.01). [Display omitted] [Display omitted] Conclusion:Even though alemtuzumab-based RIC in unrelated HSCT has a protective effect against acute GVHD and risk of D+100 TRM comparable with non-alemtuzumab containing RIC regimens in related donor transplant, its beneficial effect is overcome by excessive late infectious complications. Disclosures:Fouts:Genzime: Consultancy.

Unrelated Cord Blood Transplantation (UCBT) in Adults with MDS or Secondary Acute Myeloblastic Leukemia (sAML): a Survey On Behalf of Eurocord and CLWP of EBMT.

Abstract 1198Poster Board I-220 Background:Unrelated cord blood transplantation is an alternative option to treat patients with high risk hematologic malignancies in the absence of an HLA identical donor. Results of UCBT in patients with MDS or secondary leukaemia (sAML) have been scarcely published. Method:We performed a survey to identify predictors of outcomes in a large cohort of 108 adults with MDS or sAML reported to Eurocord-Promise data bases (62 centres in 17 countries in Europe) and transplanted with an UCBT from 1998 to 2007. Sixty-seven patients were transplanted for sAML (secondary to MDS in 42 cases) and 41 for MDS. Worst status before UCBT for MDS was RA in 4, RAEB1 in 10, RAEB2 in 14, CMML or RAEBt in 9, unclassified in 4 patients. IPSS classification at transplantation was low, intermediate 1, intermediate 2, high or missing in 8, 12, 7, 6 and 8 patients, respectively. For patients with sAML, 48% were transplanted in CR1 at UCBT. Median age at UCBT was 43 years (from 18 to 72 years). Median time from diagnosis to UCBT was 10 months. Transplant characteristics:77 patients received a single and 31 a double UCBT. UCB grafts had ≥ 2/6 HLA mismatched in 60 % of cases. Myeloablative conditioning regimen (MAC) was given to 57 patients whereas 51 patients received a reduced intensity conditioning regimen (RIC). GVHD prophylaxis consisted in CSA+MMF in 52, CSA+steroids in 43 and other combinations in 13 patients. Median number of collected nucleated cells was 3.4 for single and 4.6 × 107/kg for double UCBT. Median follow-up was 25 months. Results:cumulative incidence (CI) of neutrophil recovery at day 60 was 82±4% with a median time to achieve more than 500 ANC/mm3 of 23 days. Neutrophil recovery was independently associated with number of CD34+ cells/kg (> 1.1 × 105, Hazard Ratio (HR), 1.79; P= .02) and advanced disease status (intermediate 2 or high MDS and sAML not in CR; HR, 1.92; P= .007). CI of grade II-IV acute GVHD at day 100 and chronic GVHD at 2 years were 26±4% (II n=18, III n=6, IV n =6) and 42%±8, respectively. Two-year non-relapse mortality was significantly higher after MAC (62% vs. 34%, p=0.009). In counterpart, 2-year relapse rate was higher after RIC (14% vs 29%, p=0.02). Two-year DFS and OS were 30 and 34%, respectively. In univariate analysis, among patient-, disease- and transplant- factors studied only patients with high risk disease at maximal pre-transplant stage or transplanted > 18 months after diagnosis had significant poorer DFS (disease risk: 49% vs. 22%; time: 35% vs. 15%). However, in multivariate analysis, the only factor associated with decreased DFS was advanced disease (HR: 2.05; p= .01). Conclusion:These data indicate that UCBT is an acceptable alternative option to treat adults with high risk MDS or sAML without a HLA-matched related or unrelated bone marrow donor. Controlled disease at time of transplantation improves outcome. More investigations are needed to compare these results with outcomes after other stem cell sources from unrelated HSCT donor. Disclosures:No relevant conflicts of interest to declare.

The Combination of Tacrolimus (T), Sirolimus (S), and Rabbit Anti-Thymocyte Globulin (Thymoglobulin Thymo) to Prevent Acute Graft-Vs-Host Disease (aGVHD) in Patients (pts) Receiving Unrelated Hematopoietic Stem Cell Transplantation (UHSCT).

Abstract 2239Poster Board II-216 Background:Acute graft versus host disease aGVHD continues to affect approximately 60% or more of patients undergoing UHSCT, with significant mortality and morbidity. Furthermore viral infections such as Cytomegalo virus (CMV) affect approximately two thirds of these patients. Methods:In a phase II trial, we prospectively evaluated whether adding Thymo (4.5 mg/kg divided doses on days -1,-2, and -3) to Tacrolimus and Sirolimus combination for aGVHD prophylaxis in recipients of UHSCT would decrease the rate of aGVHD. The primary endpoint is aGVHD, which is calculated as cumulative incidence. Since infections are a concern after T cell depletion, the incidence of infections and adverse events were monitored closely. Results:There were 25 patients (pts) with median age of 51(20-70) years enrolled in the protocol, 10 females and 15 males. There were 10 AML (5CR1, 5CR2), 7 MDS (untreated), 2 ALL (CR1), 1 ALL/AML (uCR1), 1 CML (CP), 1 CMML (untreated), 1 granulocytic Sarcoma (CR1), 1 NKT cell lymphoma (CR3), and 1 DLBCL(CR2). Preparative regimens included Bu/Flu (21 pts), VP16/TBI (2 pts) R-BEAM (1 pt), and Flu/MEL (1 pt). All patients received peripheral blood hematopoietic stem cells (PBHSC) mobilized with granulocyte colony stimulating factor G-CSF with an average CD34+ dose of 8.24×10 6/kg (3.7-14.3). All patients received daily G-CSF starting day +6 till engraftment. After molecular typing, 11 of 25 patients received HLA fully matched graft, 11 of 25 received a 1 antigen (Ag) mismatched graft, and 3 of 25 received a 2 Ag mismatched unrelated PBHSC graft. All patients' engrafted. Median engraftment day is 12 (9,13). Eighteen patients had passed the day 100 time point; seven pts did not reach day 100. Three deaths occurred, due to: relapse (1), multi organ failure (1), and pneumonia (1). Two patients experienced disease relapse. Both went into complete remission once immune suppression was withdrawn, demonstrating clear graft versus Leukemia (GVL) effect, before day 100.Seven of 25 pts developed aGVHD, 1 developed aGVHD after relapse. Three developed grade 1 aGVHD, 3 pts developed grade 2 aGVHD. One pt developed grade 4 aGVHD after immune suppression withdrawal due to disease relapse. Five patients needed systemic steroids, maximum duration 36 days. All aGVHD cases have responded to therapy. The cumulative incidence rate for aGVHD at 100 days is 0.258 ( 0.101, 0.448); the cumulative incidence rates of competing events: relapse is 0.146 (0.034, 0.334) and death without GVHD or relapse 0.050 (0.003, 0.212).Patients tolerated Thymo well. Two patients developed thrombotic thrombocytopenic purpura (TTP), one patient after day 100 that required discontinuation of tacrolimus and sirolimus. Four patients developed CMV PCR sub-clinical activation 16% (95% CI 5.7-33.6%), which resolved with treatment. Six patients developed PCR sub-clinical Epstien-barr virus (EBV) activation 20% (95% CI 8.2-38.4), 5/6 needed Rituximab. Three patients developed Herpese simplex virus (HSV) stomatitis, two rhinovirus upper respiratory tract infections, and 3 BK viral cystitis. 14 patients had a documented bacterial infection all resolved. Apart from 2 oral candidiasis, no fungal infections observed. All infections have resolved. Conclusion:These early results suggest that the combination of Tacrolimus/Sirolimus and Thymo in pts undergoing unrelated HSCT is well tolerated and is associated with a low rate and severity of acute GVHD, and early GVL effect as demonstrated in two patients. Low rates of CMV viral infections were seen. Further accrual and a longer follow-up will be needed to confirm these encouraging results.patientGVHDViral infectionTTPStatus10NNalive22NNalive30EBV/HSVNalive40NNalive52EBVNalive60CMV/BK/HSVNalive72EBV/HSVYesalive80NNalive94NNalive100NNalive110NNalive120NYesalive130NNalive140BKNalive150BKNdied/relapse160CMV/EBVNalive171CMV/EBV/RhinoNalive180EBV/rhinoNdied/multi-organ failure190NNAlive200NNAlive210NNAlive222CMVNdied/pneumonia231NNalive240NNalive250NNalive Disclosures:Al-Kadhimi:Genzyme pharmacutical: Research Funding. Off Label Use: Thymoglobulin is used to prevent graft versus host disease in unrelated transplant in this protocol. That is an off lable drug use.. Abidi:Merck Pharmaceuticals: Research Funding.

Viral-load and B-lymphocyte monitoring of EBV reactivation after allogeneic hemopoietic SCT in children

EBV-associated post transplant lymphoproliferative disease (EBV-PTLD) is a life-threatening complication that may occur after hemopoietic SCT. We prospectively screened 80 children on a weekly basis using nested quantitative PCR to evaluate EBV genome copies. EBV viral load <1000 copies per 10(5) PBMC was observed in 63% of transplants, whereas it was between 1000 and 9999 copies per 10(5) PBMC in 13%, and between 10 000 and 19 999 in 10%, with no significant increase in percentage of CD20+ lymphocytes. Viral load reached > or = 20 000 copies per 10(5) PBMC in 14% of patients, and rituximab was administered to 75% of them. None of the patients except one developed a lymphoproliferative disease. Our study found that only 13% of unrelated donor HSCT recipients had a very high risk of EBV-PTLD defined as > or = 20 000 geq per 10(5) PBMC associated with an increase in CD20+ lymphocyte. We suggest that rituximab could be administered in the presence of very high levels of EBV-DNA viral load or in the presence of mid levels of EBV-DNA viral load associated with an increase in the percentage of CD20+ lymphocytes. Through this approach, we significantly reduced the number of patients treated with rituximab, and consequently the acute and chronic adverse events related to this treatment.

Outcome of hematopoietic stem cell transplantation of children with very high risk acute lymphoblastic leukemia in first complete remission

Approximately 10% of children with ALL present at diagnosis with VHR for relapse if treated with chemotherapy alone. They may benefit from allogeneic HSCT in CR1. We have reviewed the outcome of this population in our institution. Forty-three patients (median age: 8.9 yr) with VHR ALL in CR1 underwent HSCT from October 1994 to April 2006. VHR features included Philadelphia chromosome (n = 17), induction failure (n = 9), hypodiploidy (n = 6), MLL gene rearrangement (n = 5), and others (n = 6). All patients received TBI (1200 cGy) with either CY and/or etoposide. Stem cell source was unrelated (n = 24) and related (n = 19). Incidence of grade III-IV acute GVHD and chronic extensive GVHD were 25% and 16%, respectively. Twelve patients relapsed (eight received related HSCT). Eleven patients died due to transplant-related mortality (eight received unrelated HSCT). For a median follow up of 39 months (range 11-110), the event free survival and OS were 0.49 (95% CI: 0.31-0.67) and 0.53 (CI: 0.44-0.71), respectively. Outcomes of children with VHR ALL receiving HSCT in CR1 remain unsatisfactory. Relapse, mainly after related HSCT, and TRM, mainly after unrelated HSCT, continue to be major problems.

Clinical Significance of HLA-E*0103 Homozygosity on Survival After Allogeneic Hematopoietic Stem-Cell Transplantation

Hematopoietic stem-cell transplantation is a well-established treatment in various hematologic malignancies, but the outcome depends on disease relapse, infections, and the development and severity of acute and chronic graft-versus-host disease. Some evidence has revealed an important role for the nonclassical major histocompatibility complex class I molecules in transplantation, most notably human leukocyte antigen (HLA)-E. This study evaluates the impact of HLA-E alleles on transplantation outcome after HLA-matched allogeneic HSCT. We genotyped DNA for HLA-E polymorphism from 83 recipients and their respective donors by real-time polymerase chain reaction after melting curve analysis and compared the results with clinical outcome. HLA-E*0103 homozygous patients showed a higher probability of overall survival (P=0.003) and disease-free survival (P=0.001) in a univariate model. Cox regression analysis confirmed HLA-E*0103, 0103 (P=0.006; relative risk 1.12; 95% confidence interval 0.31-1.94) and early stage of disease (P=0.005; relative risk 1.16; 95% confidence interval 0.45-1.86) as independent factors improving overall survival. Moreover, homozygosity for HLA-E*0103 was associated with a significant decreased incidence of transplant-related mortality (P=0.01). We found an association between HLA-E*0103 homozygosity and the significant reduction of transplant-related mortality in related and unrelated HSCT. The risk of posttransplant complications was significantly reduced when the donor possesses the HLA-E*0103, 0103 genotype, and this was translated in a better overall survival.

Low toxicity of a conditioning with 8‐Gy total body irradiation, fludarabine and cyclophosphamide as preparative regimen for allogeneic hematopoietic stem cell transplantation in pediatric hematological malignancies

We here report the efficacy and toxicity of a conditioning regimen with fractionated 8-Gy TBI, fludarabine, and cyclophosphamide in allogeneic HSCT for pediatric hematological malignancies. Among 22 children who received related or unrelated HSCT, nine were transplanted with refractory disease and/or from HLA two or more loci-mismatched family donors. None of the patients developed graft failure. The Seattle grading system revealed that 18 patients had no RRT, and the remaining patients had grade I gastrointestinal toxicity alone. The estimated overall survival and leukemia-free survival at two yr were 57.1% and 48.0%, respectively, in 10 patients with acute lymphoblastic leukemia; 91.7% and 71.3%, respectively, in 12 patients with myeloid leukemia. The incidence of TRM was 4.8% at two yr. The rates of RRT above grade II and TRM in an 8-Gy TBI-containing regimen were significantly lower than the data of historical control patients who underwent 12-Gy TBI and cyclophosphamide with or without etoposide. The intermediate-dose TBI-based conditioning regimen may confer successful engraftment combined with minimized RRT, although its efficacy should be further evaluated.

Unrelated hematopoietic stem cell transplantation for Cernunnos‐XLF deficiency

Cernunnos-XLF deficiency is a rare CI characterized by a defective DNA DSB repair mechanism. Its clinical manifestations are growth retardation, dysmorphic features, malformations, and severe B- and T-cell lymphopenia. BM failure may complicate the clinical picture. To date, there have been no described patients with CSy undergoing allogeneic HSCT. We report a case of CSy treated successfully with unrelated allogeneic HSCT after a reduced-intensity conditioning regimen. Two yr after HSCT, the patient maintains full donor engraftment, normal hematopoiesis, and progressively improving immune competence, thus suggesting that HSCT may be the treatment of choice for CSy.

Unrelated donor stem cell transplantation in acquired severe aplastic anemia: a systematic review

Acquired severe aplastic anemia is a rare disease characterized by an immune-mediated functional impairment of hematopoietic stem cells. Transplantation of these cells from unrelated donors is a treatment option frequently offered to patients after failed immunosuppressive therapy. The aim was to investigate the outcome of these patients treated with unrelated donor transplants. Systematic literature searches were performed in MEDLINE, EMBASE, and The Cochrane Library. All databases were searched from inception to June 2009. Only full-text publications and studies including at least 10 patients were considered. The primary outcome was 5-year overall survival from the day of transplantation and the secondary outcomes were graft failure and graft-versus-host disease. A meta-analysis of survival estimates was conducted and heterogeneity was investigated. A total of 18 studies, one controlled trial and 17 case series were identified. The overall survival at five years and the corresponding confidence interval was stated in 8 studies and ranged from 28% to 94%. A meta-analysis revealed considerable heterogeneity between the studies that could not be explained and was also present in subgroups of the studies. The proportion of acute graft failure was 45% in one study using only umbilical cord blood, and it was reported to be 0-26% in 15 studies using mainly bone marrow as stem cell source after different follow-up periods. Acute GVHD grade II-IV was reported for 8-86% and extensive chronic GVHD for 0-38% of the evaluated patients in 16 studies. Recipient age, human leukocyte antigen match, performance status, year of transplantation, and conditioning with serotherapy were identified as significant factors for improved survival. Unrelated donor hematopoietic stem cell transplantation in patients with acquired severe aplastic anemia after failure to immunosuppressive therapy is a treatment option. A stable physical condition of the patients before receiving the transplant (for example, performance and age) may be associated with a better survival. Detailed HLA-matching facilitated by DNA-based typing, among other factors, may have contributed to recent improvements on survival after unrelated donor HSCT as a second-line treatment.