T-Cell Reconstitution after Unrelated Donor HSCT Using Immunotherapy with CD25/71 Allodepleted Donor T Cells: Results of the Randomised Icat Study

Karl S Peggs and Sarah J Albon contributed equally to the work and are joint first author Introduction Alemtuzumab reduces the incidence of GVHD after unrelated donor stem cell transplant (MUD SCT) but delays immune reconstitution resulting in high morbidity/mortality from viral infections. Previous studies have suggested that adoptive transfer of allodepleted donor T cells (ADTs) improves immunity after SCT but this has never been tested in a randomised study. We developed a methodology for selective immunomagnetic depletion of alloreactive T-cells upregulating CD25 and CD71 after activation with host dendritic cells (DC) and showed that ADTs retain anti-viral responses with minimal host alloreactivity (Samarasinghe et al Blood 2010). We have now tested whether ADTs can safely be used to improve immune reconstitution after MUD SCT for haematological malignancies in a randomised Phase II multi-centre clinical study; ICAT (NCT01827579). Methods Patients undergoing Alemtuzumab-based peripheral blood SCT from a 9/10 or 10/10 MUD for haematological malignancy were randomised 2:1 to receive either the ATIMP (ADTs) or standard of care. Two weeks prior to SCT, patients randomised to ATIMP underwent a leucapheresis from which DCs were generated. Irradiated patient-derived DCs were then co-cultured with peripheral blood mononuclear cells (PBMC) from an unstimulated leucapheresis/500ml blood draw from the donor to activate alloreactive T cells. Four days later, the co-culture was depleted of CD25+ and CD71+ fractions by immunomagnetic depletion on the CliniMACs, sampled for residual alloreactivity and sterility, and cryopreserved. Patients randomised to the ATIMP were scheduled to receive 3 escalating doses of ADTs (0.1x106/Kg at day 30, 0.3x106/Kg at day 60 and 1x106/Kg at day 90 post-SCT) until either there was >grade 1 aGVHD or they had normal circulating T cells (>700/µL). The primary end-point of the study was circulating CD3+ T cell count at 4 months post-SCT with one-sided 15% significance level. Acute/chronic GVHD were graded using the Seattle/NIH criteria respectively. Results Twenty one patients were treated, 13 on the ATIMP arm and 8 on the control arm. The median age was 53 years and 67% (14) were male. 12 were AML/Myelodysplasia, 5 NHL, 3 CLL/CML and 1 HL. The median follow-up time is 14 months. Five of 13 ATIMP patients received 1 dose of ADTs, 4/13 2 doses and 4/13 all 3 doses. The incidence of acute and chronic GVHD was comparable between the arms. Overall, 7/13 ATIMP patients developed significant (>Grade 2) acute GVHD compared to 4/8 of the control arm (p>0.99). 3/13 patients in the ATIMP arm and 2/8 patients in the control arm developed severe aGVHD (all Grade 3). Three of 13 ATIMP cohort patients developed chronic GVHD (1 mild, 1 moderate, 1 severe), compared to 3/8 (all mild) in the control cohort. At 4 months, the circulating CD3+ T cell count mean was 730/µL (range 10-4080) in the ATIMP group and 212.5/µL (range 10-500) in the control group (1-sided p=0.11). However, the data was not normally distributed (Wilcoxon 1-sided p=0.18). Three ATIMP patients had high CD3+ T cell count at 4 months (>1000/µL). At 6 months, the mean circulating CD3+ T cell count was 833.6/µL (range 20-2690) and 327.5/µL (range 10-860). At month 4, the mean PHA stimulation index in the ATIMP arm was 16.8 (range 0.67- 73.1) vs 3.8 (range 1.1-8.2) in the control group. At 4 and 6 months post-SCT, spectratyping analysis showed no evidence of a difference in Vβ diversity between the 2 arms in both CD4+ and CD8+ cells. The 1-year survival rate in the ATIMP cohort is 92% vs 88% in the control, and 1-year disease free survival rate 67% in the ATIMP cohort vs 70% in the control. Conclusions These data suggest that adoptive transfer of ADTs improves T cell reconstitution in some patients after MUD SCT and that the GVHD rates were similar between ATIMP and control groups. Figure 1: Kinetics of T cell recovery after transplant in ATIMP (blue) and Control (red) patients. Mean +/- SEM shown. Figure 1 Disclosures Peggs: Gilead: Consultancy, Speakers Bureau; Autolus: Membership on an entity's Board of Directors or advisory committees. Ghorashian:UCLB: Patents & Royalties: UCLB; Celgene: Honoraria; novartis: Honoraria. Amrolia:UCLB: Patents & Royalties.

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CD28-Directed T Cell Costimulation Blockade with Abatacept to Prevent GvHD During High-Risk Unrelated HSCT: A First-in-Disease Feasibility Trial,

Blood ◽

10.1182/blood.v118.21.4078.4078 ◽

2011 ◽

Vol 118 (21) ◽

pp. 4078-4078

Author(s):

Leslie S. Kean ◽

Amelia Langston ◽

Muna Qayad ◽

H. Jean Khoury ◽

Divya Tiwari ◽

...

Keyword(s):

T Cells ◽

T Cell ◽

Acute Gvhd ◽

Chronic Gvhd ◽

Hematologic Malignancies ◽

Feasibility Trial ◽

Effector Memory ◽

Unrelated Donor ◽

Gvhd Prophylaxis ◽

The Mean

Abstract Abstract 4078 Background: Acute GvHD remains the major cause of complications and death following unrelated-donor HSCT. In a non-human primate model, we have previously shown that in vivo costimulatory blockade of donor T-cells could provide effective protection against GVHD. To begin to explore its clinical utility, we are conducting a trial (Clinical Trials.Org # NCT01012492) to determine the feasibility of combining abatacept (CTLA4-Ig) with cyclosporine and methotrexate as acute GVHD prophylaxis for patients undergoing unrelated marrow and peripheral blood stem cell transplants for hematologic malignancies. Methods: Patients older than 12 with advanced hematologic malignancies, conditioned with either TBI/Cytoxan, Busulfan/Cytoxan or Fludarabine/Melphalan are eligible. Abatacept is administered IV on days −1, +5, +14, and +28 at 10 mg/kg in addition to standard GvHD prophylaxis consisting of cyclosporine (day −2 to day 100), and methotrexate (15 mg/m2 on day +1 and 10 mg/m2 on days +3, 6 and 11). Patients are then followed for clinical outcomes and immunologic reconstitution through day +365. Results: 9 patients (planned enrollment = 11 patients) have thus far been enrolled on the study of which 5 are evaluable for engraftment, toxicity and acute GvHD. The other four patients consist of 2 who are currently receiving abatacept, 1 who was discovered to have an ongoing viral infection at the start of the first abatacept infusion so was removed from the treatment regimen, and 1 who is awaiting transplant. The median age for the 5 evaluable patients is 47 years (17–74 years). 3 patients had AML and 2 had ALL. Patients were conditioned with Bu/Cy (n=1), TBI/Cy (n=2) and Flu/Melphalan (n=2). 4 donor-recipient pairs were allele matched at 9 of 10 loci (A, B, C, DRB1 and DQB1), while 1 was fully matched. Four of the 5 patients are currently alive and in remission and 1 relapsed at day +98 (and died on day +121 with refractory AML). The four other patients are surviving without relapse with a follow-up of 155–313 days. All 5 patients received the 4 scheduled abatacept doses. No infusional side effects were noted. All patients achieved neutrophil engraftment (median day +20 (11–47). 4 of 5 patients have achieved platelet engraftment (median day +27 (14–35). Donor engraftment (100% CD33 and 99–100% CD3 at Day +30) occurred in all cases. All patients have demonstrated rapid lymphocyte engraftment, with the mean ALC reconstituting to >500 cells/μL by day +21 post-transplant. At day +100, the mean CD3+ count was 673 +/− 251 cells/μL. Both CD8+ and CD4+ T cells reconstituted by day 100, with the mean CD8+ count = 384 +/− 148 cells/μL and the mean CD4+ count = 229 +/− 119 cells/μL. T cell reconstitution was accompanied by a shift away from naïve (Tn, CCR7+/CD45RA+) toward a CCR7-/CD45RA- effector memory (Tem)-predominant phenotype. Thus, the average proportion of CD4+ Tem cells in the recipient increased from 22 +/− 6% pre-transplant to 46 +/− 7% at day +100 with a concomitant loss of CD4+ Tn cells. Likewise, the proportion of CD8+ Tem also significantly increased, from an average of 15 +/− 4% pre-transplant to 32 +/− 7% at day +100, also with a reciprocal decrease in CD8+ Tn cells. One patient developed steroid responsive grade 3 acute GVHD involving the skin and the liver, followed by steroid responsive liver chronic GvHD. This patient is currently weaning corticosteroids. Another patient developed steroid responsive late-onset (day +217) acute GVHD (liver and GI) during cyclosporine weaning, which was also steroid responsive, and is also currently weaning corticosteroids. No other systemic acute or chronic GvHD has occurred. No unexpected complications or life-threatening infections were observed. 3 patients have experienced 5 episodes of CMV reactivation, all responsive to antiviral therapy. One patient developed polyclonal EBV-related PTLD (plasmacytic hyperplasia) in the absence of EBV viremia, which regressed without intervention. No other EBV-related disease has occurred. Conclusions: These preliminary data suggest that abatacept can be safely added to cyclosporine and methotrexate for GVHD prophylaxis in recipients of hematopoietic grafts from unrelated donors, with encouraging rates of acute GVHD. As such, they support the conduct of a larger, randomized phase 2 study. Disclosures: Off Label Use: Abatacept: It is an immunosuppressive agent that targets the CD28/B7 T cell costimulation pathway. It is approved for use in Rheumatoid arthritis.

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Outcome of alloanergized haploidentical bone marrow transplantation after ex vivo costimulatory blockade: results of 2 phase 1 studies

Blood ◽

10.1182/blood-2008-03-143636 ◽

2008 ◽

Vol 112 (6) ◽

pp. 2232-2241 ◽

Cited By ~ 48

Author(s):

Jeff K. Davies ◽

John G. Gribben ◽

Lisa L. Brennan ◽

Dongin Yuk ◽

Lee M. Nadler ◽

...

Keyword(s):

Bone Marrow ◽

T Cells ◽

Bone Marrow Transplantation ◽

T Cell ◽

Marrow Transplantation ◽

Viral Infections ◽

Ex Vivo ◽

Chronic Gvhd ◽

Costimulatory Blockade ◽

Donor T Cells

AbstractWe report the outcomes of 24 patients with high-risk hematologic malignancies or bone marrow failure (BMF) who received haploidentical bone marrow transplantation (BMT) after ex vivo induction of alloantigen-specific anergy in donor T cells by allostimulation in the presence of costimulatory blockade. Ninety-five percent of evaluable patients engrafted and achieved full donor chimerism. Despite receiving a median T-cell dose of 29 ×106/kg, only 5 of 21 evaluable patients developed grade C (n = 4) or D (n = 1) acute graft-versus-host disease (GVHD), with only one attributable death. Twelve patients died from treatment-related mortality (TRM). Patients reconstituted T-cell subsets and immunoglobulin levels rapidly with evidence of in vivo expansion of pathogen-specific T cells in the early posttransplantation period. Five patients reactivated cytomegalovirus (CMV), only one of whom required extended antiviral treatment. No deaths were attributable to CMV or other viral infections. Only 1 of 12 evaluable patients developed chronic GVHD. Eight patients survive disease-free with normal performance scores (median follow-up, 7 years). Thus, despite significant early TRM, ex vivo alloanergization can support administration of large numbers of haploidentical donor T cells, resulting in rapid immune reconstitution with very few viral infections. Surviving patients have excellent performance status and a low rate of chronic GVHD.

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Itolizumab As a Potential Therapeutic for the Prevention and Treatment of Graft Vs Host Disease

Blood ◽

10.1182/blood-2019-122787 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 5603-5603 ◽

Cited By ~ 1

Author(s):

Cherie Tracy Ng ◽

Jeanette Ampudia ◽

Robert J. Soiffer ◽

Jerome Ritz ◽

Stephen Connelly

Keyword(s):

Weight Loss ◽

T Cells ◽

T Cell ◽

Peripheral Blood ◽

Research Funding ◽

Chronic Gvhd ◽

Vehicle Control ◽

Control Group ◽

Employment Equity ◽

Equity Ownership

Background: CD6 is a co-stimulatory receptor, predominantly expressed on T cells, that binds to activated leukocyte cell adhesion molecule (ALCAM), a ligand expressed on antigen presentation cells and various epithelial and endothelial tissues. The CD6-ALCAM pathway plays an integral role in modulating T cell activation, proliferation, differentiation and trafficking and is central to inflammation. While effector T cell (Teff) are CD6hi and upregulate expression upon activation, regulatory T cells (Treg) remain CD6lo/-, making this an attractive target to modulate Teff activity while preserving Treg activity. Early studies by Soiffer and colleagues demonstrated using T12, an anti-CD6 monoclonal antibody (mAb) that ex-vivo depletion of CD6+ donor cells prior to transplantation decreased the incidence of both acute and chronic GVHD, highlighting the importance of CD6+ cells in GVHD pathogenesis and validating it as a therapeutic target. However, it remains to be shown whether modulating the CD6-ALCAM pathway in vivo can attenuate GVHD. We investigated the use of itolizumab, a humanized anti-CD6 mAb that has demonstrated clinical efficacy in other autoimmune diseases, as both a preventive and therapeutic treatment for GVHD, using a humanized xenograft mouse model. Methods: Humanized xenograft mice were generated by intravenous transfer of 2x10^7 human PBMCs into 6-8 weeks old NOD/SCID IL2rγ-null (NSG). To investigate the ability of itolizumab to prevent GVHD, mice were dosed with either 60μg or 300μg of itolizumab, 150μg of abatacept (CTLA4-Ig), or vehicle, starting one day prior to PBMC transplantation. To investigate the therapeutic effect of itolizumab, mice were dosed with either 150μg of itolizumab or vehicle, starting at Day 5 post-PBMC transfer, when transplanted T cells are already activated. All treatments were administered IP every other day. Weight and disease scores were monitored throughout the study. At Days 18 and 35, peripheral blood was evaluated by flow cytometry to examine T cell prevalence, and tissues were collected for histological examination of pathology and T cell infiltration. Results: When administered as prevention (Day -1), treatment with either 60μg or 300μg of itolizumab significantly decreased mortality compared to the vehicle control (100% vs. 10%); this decrease was similar to the positive control group treated with abatacept (Figure 1). At 60μg, itolizumab-treated mice demonstrated significant reductions in the prevalence of human T cells in peripheral blood vs. vehicle-treated mice at Day 18 (<0.2% vs. 74.5%; p < 0.001). The reduction in peripheral T cells was accompanied by reductions in tissue-infiltrating T cells in lung (85-fold) and gut (9.5-fold), as well as reductions in disease scores and weight loss. When administered therapeutically, treatment with itolizumab was associated with a survival rate of 50% compared to 10% in the control group (Figure 2). Similarly, peripheral T cell prevalence (34.3% vs. 65.1%; p < 0.001), weight loss, and disease scores were inhibited by itolizumab compared to vehicle control mice. Conclusions: These data suggest that systemic treatment with itolizumab can modulate pathogenic Teff cell activity, establishing this antibody as a potential therapeutic for patents with GvHD. A phase I/II study using itolizumab as first line treatment in combination with steroids for patients with aGVHD is currently ongoing (NCT03763318). Disclosures Ng: Equillium: Employment, Equity Ownership. Ampudia:Equillium: Employment. Soiffer:Mana therapeutic: Consultancy; Kiadis: Other: supervisory board; Gilead, Mana therapeutic, Cugene, Jazz: Consultancy; Juno, kiadis: Membership on an entity's Board of Directors or advisory committees, Other: DSMB; Cugene: Consultancy; Jazz: Consultancy. Ritz:Equillium: Research Funding; Merck: Research Funding; Avrobio: Consultancy; TScan Therapeutics: Consultancy; Talaris Therapeutics: Consultancy; Draper Labs: Consultancy; LifeVault Bio: Consultancy; Celgene: Consultancy; Aleta Biotherapeutics: Consultancy; Kite Pharma: Research Funding. Connelly:Equillium: Employment, Equity Ownership.

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Adoptive Transfer of CMV-Specific Donor T Cells Following Allogeneic Transplantation Leads to Rapid and Safe Systemic Reconstitution.

Blood ◽

10.1182/blood.v114.22.44.44 ◽

2009 ◽

Vol 114 (22) ◽

pp. 44-44

Author(s):

Karl S Peggs ◽

Kirsty Thomson ◽

Edward Samuel ◽

Gemma Dyer ◽

Julie Armoogum ◽

...

Keyword(s):

T Cells ◽

Drug Therapy ◽

T Cell ◽

Peripheral Blood ◽

Chronic Gvhd ◽

Antiviral Drug ◽

Donor T Cells ◽

Post Infusion ◽

Cmv Reactivation

Abstract Abstract 44 Reactivation of CMV remains a significant problem following allogeneic hematopoietic stem cell transplantation. Antiviral drug therapy is effective but toxic, and resistant strains of CMV are increasingly being reported. Virus-specific T lymphocytes are necessary for the control of viral reactivation. Adoptive transfer of donor derived CMV-specific T cells has been reported previously but most methods to produce such cells have involved several weeks of in vitro culture or have produced a therapeutic product restricted to CD8 T cells. The current method involves a short incubation of donor peripheral blood mononuclear cells with either CMV-pp65 protein (20 hours) or a pool of peptides from pp65 (6 hours) with subsequent isolation of interferon-gamma secreting cells by CliniMACS using IFNψ capture microbeads (Miltenyi Biotec). This technique permits rapid isolation of an enriched IFNψ secreting T cell product, manufactured to clinical grade, which is then cryopreserved in dosed aliquots for subsequent infusion. Here we report the outcome of a single arm phase I/II in which CMV-T cells given pre-emptively at first detection (qPCR) of CMV DNA in peripheral blood, or at day +40-60 as prophylaxis. CMV replication was monitored by weekly PCR and reconstitution of CMV-specific T cells by pentamer labelling and/or IFNψ secretion assay. Conventional antiviral drug therapy was instituted if the viral load rose above institutional threshold. 30 recipients of T cell depleted low intensity transplants from HLA-matched CMV-seropositive related donors were enrolled between 2006 and 2008. Donors underwent a second, short apheresis procedure approximately 15 days after collection of the mobilised HPC-A for the collection of CMV-T cells. 26 clinical-grade products were produced to full cGMP standards; four donors were unsuitable or withdrew. The mean yield of cells following enrichment was 41.7% with a median purity of 43.9% (range 1.4-81.8). Adequate CMV-T cells were isolated from all donors. Both pp65 and peptide stimulated products contained both CD4 and CD8 reactive T cells. Median dose of CMV-specific CD4 T cells was 2840/kg and of CMV-specific CD8 was 630/kg. Eighteen patients received a single dose of 1×10^4 CD3+/kg; 13 were CMV seropositive; 11 were treated pre-emptively and 7 prophylactically. 83% had received T cell deplete regimens. Within 2 weeks of infusion in vivo expansion of CMV-T cells was observed in 17 of 18 patients. One patient required 4 weeks to generate detectable CMV-T cell in his peripheral blood. TCR-BV usage of the CMV-T cells post infusion matched that of the cells which had been infused. The 7 patients who had cells infused prophylactically all showed expansions of CMV-T cells in the absence of detectable viral DNA in peripheral blood. Subsequent low level CMV-reactivation was seen in one of these and was associated with rapid CMV-T cell expansion with clearance of virus without anti-viral drug therapy. One developed subsequent extensive chronic GvHD and required antiviral treatment for multiple reactivation episodes following introduction of steroids. Of the 11 patients treated pre-emptively, 9 received antiviral therapy for the initial reactivation, although in 7 patients this was required for only 7-15 days. (compared to a median of 21 days in historical controls). Three patients had a further CMV reactivation event. One followed prednisolone therapy for acute grade II GvHD. The second was the patient who had shown poor T cell expansion post infusion and had required prolonged anti-viral therapy (33 days) for the initial CMV reactivation. The third patient received no treatment and cleared virus following a further in vivo expansion of CMV-reactive T cells, suggesting the presence of a functional memory population. GVHD incidence and severity was no worse than seen in comparable historical controls. 3 patients suffered grade 2-3 acute GvHD. 3/17 evaluable patients developed extensive chronic GvHD (2 were recipients of T replete grafts). 16/18 patients were alive at the end of the 6 month monitoring period and CMV-reactive T cells were detectable in all 16. CMV-specific donor T cells can be readily produced to cGMP compliance which can be safely infused and lead to early immune reconstitution in at-risk patients. Cells expand in response to subsequent CMV-reactivation and patients appear to require fewer anti-viral treatment episodes which is being tested in an ongoing phase III trial. Disclosures: Lowdell: Cell Medica Ltd: Consultancy, Equity Ownership, Membership on an entity's Board of Directors or advisory committees.

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Role of Adoptive T- Cell Therapy in Post Hematopoietic Stem Cells Transplant Viral Infections-: A Systemic Review

Blood ◽

10.1182/blood-2020-139284 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 14-16

Author(s):

Hassaan Imtiaz ◽

Muhammad Saad Farooqi ◽

Unaiza Faizan ◽

Saad Ur Rehman ◽

Muhammed Hamza Arshad ◽

...

Keyword(s):

T Cells ◽

T Cell ◽

Cell Therapy ◽

Phase I ◽

Viral Infections ◽

Adoptive T Cell Therapy ◽

Control Group ◽

T Cell Therapy ◽

And Control ◽

Cmv Reactivation

Introduction Allogenic hematopoietic stem cell transplantation (Allo-HSCT) used for the treatment of multiple hematological malignancies requires immunosuppression, that can lead to the reactivation of viruses like EBV, CMV, adenovirus (AdV). These viruses pose a life-threatening risk to an individual like Graft vs Host Disease (GVHD) and other virus-specific complications. Adoptive T cell therapy (ATC) is an approach to treat refractory post-Allo-HSCT transplant viral infections. The aim of this study is to assess the efficacy of various ATCs being developed against various viruses. Methods A systematic search on PubMed, Embase, Clinicaltrials.gov, and Web of Science was performed for adoptive immunotherapy in viral infections after stem cell transplantation from inception to May 28, 2020. Out of 604 studies, 13 phase I and II clinical trials were selected for the systematic review. Results A total of 13 studies were included of which two studies included data on the pediatric population (n=13). A total of 335 patients (pts) were enrolled in 13 studies of which 264 were evaluable. CMV Perruccio et al. (2005) in a randomized controlled trial (RCT) assessed the efficacy of ATC against both Aspergillus and CMV after alloSCT. Median follow up (f/u) was six months. For Aspergillus (n=23), 90% and 54% achieved clearance, while for CMV (n=68) 92% and 9% didn't develop CMV reactivation in treatment and control group respectively. Overall Survival (OS) and progression-free survival (PFS) rate at two years were 92% and 80% respectively. Smith et al. (2018) (n=21) in a phase I trial studied the transfusion of virus-specific T cells (VST) (n=13) against CMV infection after undergoing alloSCT. After a median f/u of 28 weeks, overall response rate (ORR) was 85%. Bao et al. (2012) (n=10) conducted a study with VST transfusion against CMV infection (n=7). ORR was 85% of which 3 pts who were on immunosuppressive had shown reactivation. Miej et al. (2012) in phase I/II study (n=6) assessed the response of VST against refractory CMV with CR of 100% Neuenhahn et al. (2017) studied a phase I/II prospective trial (n=17) (CMV Seropositive graft donor (D+) 9/17 and CMV Seronegative graft donor (D-) 8/17) with CR of 62% in D+ group. In D- group only 37% developed T cells after Third-Party Donor transfer and only these achieved CR, while pts with no T cell detection in D- group (63%), only one achieved CR. Micklethwaite et al. (2008) did a phase I clinical trial (n=12) of CMV specific T cells given prophylactically. Only four pts showed CMV reactivation. Adenovirus Feucht et al. (2019) performed a phase I/II clinical trial (n=30) of VST against refractory AdV infection. 47% showed CR, 13% with negative blood AdV cleared virus from other sites, 10% showed PR. OS at six months was 71%. Winnie et al. (2018) (n=8) conducted phase I/II RCT among pediatric pts. Median f/u was six months. All patients have shown a decrease in AdV viral load. Qasim et al. (2013) conducted a prospective trial (n=5) among pediatric pts with CR of 60% until six weeks f/u. 20% died due to AdV viremia. Multi-virus CTLs Gerdemann et al. (2013) (n=36) did a clinical trial by infusing multi-virus cytotoxic T lymphocytes (CTLs) (n=10), reactive against CMV, EBV, and AdV. CR in 80% of the pts. Muranski et al. (2017) performed a phase I trial (n=9) and infused multi-virus CTLs prophylactically. No AdV, BK, or EBV related disease was observed in any pts while 11% pts had asymptomatic AdV viremia. Only those pts who received steroid therapy had CMV reactivation (44%). Ma et al. (2015) performed a phase I/II RCT with an intervention group (n=19, evaluable=10) and control group (n=33) with an infusion of multi-virus CTLs against CMV, EBV, AdV, and VZV after alloSCT, prophylactically. Pts in the intervention group had no reactivation of EBV, AdV, or VZV. 6 (60%) pts with CMV had reactivation; four before T cell therapy and two in the context of steroid therapy. OS at one year was 89% and 81% in the intervention and control group respectively. Third-Party Donor T-cells Tzannou et al. (2017) (n=37) in a phase II study demonstrated ORR of 92% (95% CI, 78.1% to 98.3%) in various viruses with ORR for BK virus 100%, CMV 94%, Adv 71%, EBV 100% and HHV-6 67%. Conclusion Adoptive T cell therapy for viral infections has shown efficacy in Post- allo-SCT pts who achieved complete clearance of infection in many cases, showed only minimal adverse events, and no major risk for GVHD related to this therapy was noted. Disclosures Anwer: Incyte, Seattle Genetics, Acetylon Pharmaceuticals, AbbVie Pharma, Astellas Pharma, Celegene, Millennium Pharmaceuticals.: Honoraria, Research Funding, Speakers Bureau.

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Allogeneic Genetically Modified T Cells (HSV-TK) As Adjunctive Treatment in Haploidentical Hematopoietic Stem-Cell Transplantation (haplo-HSCT) of Adult Patients with High-Risk Hematological Malignancies: A Pair-Matched Analysis from the Acute Leukemia Working Party of EBMT

Blood ◽

10.1182/blood.v128.22.672.672 ◽

2016 ◽

Vol 128 (22) ◽

pp. 672-672 ◽

Cited By ~ 3

Author(s):

Mohamad Mohty ◽

Myriam Labopin ◽

Andrea Velardi ◽

Maria Teresa van Lint ◽

Donald Bunjes ◽

...

Keyword(s):

T Cells ◽

Stem Cell ◽

High Risk ◽

Chronic Gvhd ◽

Working Party ◽

Suicide Gene ◽

Adjunctive Treatment ◽

Control Group ◽

Baseline Characteristics ◽

And Control

Abstract Introduction. Current approaches to haplo-HSCT rely either on T-cell depletion to overcome the HLA disparity or on the administration of the lymphotoxic agent cyclophosphamide several days after stem cell infusion, with the goal of selectively depleting activated alloreactive lymphocytes in vivo. In both approaches, haplo-HSCT can be associated with prolonged immunodeficiency post-transplantation. Thus, effective approaches to hastening immune reconstitution following transplantation are needed. Zalmoxis¨ is an Advanced Therapy Medicinal Product based on somatic T-cells genetically modified to express the Herpes Simplex Thymidine Kinase (HSV-TK) suicide gene and a truncated form of the human Low Affinity Nerve Growth Factor Receptor (ΔLNGFR) genes (for identification of transduced cells). The expression of the HSV-TK gene, as a suicide gene allows the selective killing of dividing cells upon administration of the pro-drug ganciclovir (GCV). If GvHD occurs, ganciclovir/valganciclovir can be administered. Here we report the results of a pair-matched analysis which compared the outcome of patients who received HSV-TK cells infusion post haplo-HSCT versus those who did not receive any cellular therapy post-transplant. Patients and Methods. The HSV-TK patients' group included 45 patients who were treated as part of 2 prospective trials with various types of high-risk hematologic malignancies. These patients were compared to patients treated with haplo-HSCT reported to the acute leukemia working party registry of the EBMT. Inclusion criteria for the pair-matched analysis encompassed haplo-HSCT transplants performed in adult patients diagnosed with AML/ALL/sAML in CR or relapse at transplantation. To equate the distribution of baseline characteristics between the HSV-TK and control group and to reduce bias in treatment effect estimation, a pair-matched analysis was performed. This analysis, in which pairs of HSV-TK and control subjects sharing similar baseline characteristics were formed, used the following parameters as pair matching factors: patient age, diagnosis (AML, ALL and sAML), disease status at HSCT (CR1, CR2, CR3 or relapse) and time from diagnosis to HSCT. The planned ratio of HSV-TK patients to control patients was one to four. Efficacy outcome measures of this pair-matched analysis were OS, LFS, NRM and relapse incidence (RI). Cumulative incidence rates of chronic GVHD were also analyzed. Results. Overall, 37 HSV-TK-treated patients matched with 140 controls (71 from PT-Cy cohort and 69 from TCD cohort transplanted between 2005 and 2013). The recommended dose and schedule of HSV-TK cells was 1x107 cells/kg given as IV infusion every 30 days for a maximum of 4 times until a circulating T-cell count higher than 100 per μL. The 1st administration should occur between day 21 to day 49 after HSCT. Baseline characteristics of the HSV-TK treated and the control patient population are summarized in the below table. OS at 1-year was significantly improved in the HSV-TK-group compared with the control group (p=0.01). The survival rates were 49% and 37% for HSV-TK- and control group, respectively. The NRM at 1-year was also improved upon treatment with HSV-TK, with 43% for the control group and 22% for the HSV-TK-group (p=0.014). A difference in favor of the HSV-TK-group could also be observed for the 1-year incidence of chronic GvHD with 25% for the control group vs 9% for the HSV-TK-group (p=0.04). The LFS and the RI were not different between the groups. Interestingly, these differences remained similar whether considering the TCD or the PT-CY subgroups). Together the data suggest that the benefit seen in OS is driven by a reduction in the NRM. A further analysis of NRM data revealed that in the control group 34 of 140 (24%) patients died due to infection and 8 of 140 (6%) succumbed due to GvHD. In the HSV-TK population 4 (11%) patients died because of infection and no patient died due to GvHD. This suggests that the reduction in NRM mortality in the HSV-TK population is caused both by a reduction in death due to infection and due to GvHD. Concerning safety, no death was attributed to HSV-TK cells. Acute GvHD resolved in all cases, and activation of the suicide gene by treatment with GCV has contributed to the control of GvHD. Conclusion. The above pair-matched analyzis confirmed the positive impact and benefit of HSV-TK cells as adjunctive treatment in haplo-HSCT with an acceptable safety pattern. Table. Table. Disclosures Bonini: Molmed SpA: Consultancy; TxCell: Membership on an entity's Board of Directors or advisory committees. Ciceri:MolMed SpA: Consultancy.

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Upregulation of TCRζ Chain Overcome T Cell Immunodeficiency in Patients with Chronic Myeloid Leukemia

Blood ◽

10.1182/blood.v118.21.4719.4719 ◽

2011 ◽

Vol 118 (21) ◽

pp. 4719-4719

Author(s):

Xianfeng Zha ◽

Shaohua Chen ◽

Lijian Yang ◽

Bo Li ◽

Yu Chen ◽

...

Keyword(s):

T Cells ◽

T Cell ◽

Natural Science ◽

Myeloid Leukemia ◽

Transfection Efficiency ◽

Guangdong Province ◽

Control Group ◽

Control Vector ◽

T Cell Immunodeficiency ◽

And Control

Abstract Abstract 4719 TCRζ chain is the key molecular of TCR signaling, the defective TCRζ chain not only decreases the expression of TCR on the T cell surface and the quantity of circulation T cells, but also influences T cell activation and proliferation. Previous studies indicated that the obvious downregulation of TCRζ chain was one of main factors which caused T cell immunodeficiency in patients with chronic myeloid leukemia (CML), which lead to dysfunction of immune supervision to tumor. This study was undertaken to explore the possibility that forced expression of TCRζ chain may restored the T cell immune function. In present study, the freshly CD3 + T cells were isolated by MACS from de novo CML patients; freshly T cells were transfected with TCRζ chain recombinant vector (TCRζ-IRES-EGFP) and control vector (pIRES2-EGFP) by nucleoporation technique. The transfection efficiency was detected by FCM at 18 hours post-transfection, and TCRζ chain protein and its phosphorylation were detected by Western blotting after activation with OKT3 antibody for 1 minute. The supernatants and RNA were collected from transfected cells stimulated with OKT3 and anti-CD28 antibody, for analysis of IL-2 levels and the mRNA expression of ZAP70 and NF-κB. The results showed the transfection efficiency of TCRζ chain vector and control vector construct was 72.16±6.95% and 73.4±7.90% in CML T cells from different patients respectively. In T cells transfected with TCRζ chain, the expression of TCR chain was increased, the IL-2 production induced by OKT3 and anti-CD28 antibody in TCRζ chain transfected T cells (175.1±66.3pg/mL) were higher than that from control group (107.6±65.5pg/mL) (n=6, p=0.039). The bother expression levels of ZAP-70 and NF-κ B in the experimental group was higher than the control group (n = 4, p < 0.05), moreover the expression level between ZAP-70 and NF-κB showed linear correlation (n = 4, p = 0.013, r = 0.98). In conclusion, the results indicate that upregulation of deficient TCRζ chain may reverse the TCR/CD3-mediated signaling abnormalities, which may improve the T cell immune function in patients with CML. This study was supported by grant from the Key project of Natural Science Foundation of Guangdong Province, China (No. 9251063201000001). Disclosures: Zha: This study was supported by grant from the Key project of Natural Science Foundation of Guangdong Province, China (No. 9251063201000001): Research Funding. Li:the Key project of Natural Science Foundation of Guangdong Province: Research Funding.

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

Blood ◽

10.1182/blood.v120.21.4200.4200 ◽

2012 ◽

Vol 120 (21) ◽

pp. 4200-4200 ◽

Cited By ~ 2

Author(s):

Amin M. Alousi ◽

Rima M Saliba ◽

Julianne Chen ◽

Borje S Andersson ◽

Issa Khouri ◽

...

Keyword(s):

Acute Gvhd ◽

Chronic Gvhd ◽

Disease Status ◽

Control Group ◽

Unrelated Donor ◽

Post Transplant ◽

Gvhd Prophylaxis ◽

Unrelated Donors ◽

Matched Sibling ◽

And Control

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

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In Allogeneic Transplant Recipients Th17 Cells Originate From Donor Stem Cells and Reside In Target Organs of Chronic Graft-Versus-Host Disease

Blood ◽

10.1182/blood.v122.21.5425.5425 ◽

2013 ◽

Vol 122 (21) ◽

pp. 5425-5425

Author(s):

Antonia MS Mueller ◽

Mareike Florek ◽

Natascha J Kuepper ◽

Jessica Poyser ◽

Judith A. Shizuru

Keyword(s):

T Cells ◽

T Cell ◽

Th17 Cells ◽

Acute Gvhd ◽

Chronic Gvhd ◽

Cell Infiltration ◽

Host Disease ◽

T Cell Infiltration ◽

Target Organs ◽

Donor T Cells

Abstract Graft-vs-host disease (GVHD) remains a major complication of allogeneic hematopoietic cell transplantation (HCT). Acute GVHD results from activated donor T cells that infiltrate and damage target organs, producing an inflammatory state. In contrast, the pathophysiology of chronic graft-vs-host disease (cGVHD) remains poorly understood. cGVHD can follow acute GVHD or emerge de novo (>d+100). The clinical picture varies and manifestations can resemble autoimmune disorders. Because IL-17 has emerged as a principal cytokine involved in autoimmunity, Th17 cells have attracted much attention in the transplant community. While IFNg-producing Th1 cells appear to drive acute GVHD, the role of Th17 cells in the pathophysiology of GVHD has not been fully clarified. Here, we used an established minor-antigen disparate mouse model of acute and chronic GVHD to examine the emergence of IL-17+CD4+ Th17 cells post-HCT. Lethally irradiated BALB.B mice received pure hematopoietic stem cells (HSC; cKIT+Thy1.1loSca1+Lin-) or HSC plus splenic T cells from C57BL/6 donors (HSC: GFP; TC: CD45.1+). At several time points lymphoid and GVHD target organs were analyzed for donor T cell infiltration and T cell IL-17 expression. In this model recipients of HSC + T cells developed acute GVHD with intestinal involvement (diarrhea, weight loss) and a mortality of ∼30%, while mice given pure HSC remained healthy. Survivors stabilized around d45, but developed clinically evident chronic GVHD after 6-12 mo manifested by sclerodermatous skin excoriations and liver fibrosis/cirrhosis. Donor T cell infiltration of tissues (spleen, lymph nodes (LN), liver, intestines) was high at 2 and 4 wks post-HCT, but there was no detectable IL-17 production by CD4 cells during acute GVHD. The degree of donor T cell infiltration decreased (as acute GVHD improved) in these tissues. However, at 2 mo post-HCT higher percentages CD4+IL-17+ cells were observed, first in intestines and mesenteric LN, followed by liver and skin. At all time points post-HCT proportions of Th17 cells were higher in HCT recipients (of HSC +/- T cells) as compared to normal wild-type (WT) tissues. To summarize, our key findings are: (i) In our model acute GVHD was driven by adoptively transferred mature (CD4+) T cells that acquired a Th1 phenotype, whereas IL-17 producing donor cells were not detectable during this period. IFNg and T-bet are negative regulators of RORgT, the master regulator of Th17. Thus, this observation is consistent with the idea that in the presence of donor Th1 cells the development of Th17 cells is suppressed. (ii) The effect of Th1-related suppression of Th17 persisted beyond the acute phase: recipients of T-cell replete grafts that survived acute GVHD but later developed chronic GVHD did not demonstrate increased CD4+IL-17+ cells. In these mice, organ-infiltrating donor T cells were primarily adoptively transferred T cells, supporting the postulation that no plasticity exists between committed Th1 and Th17 cells. (iii) Signs of chronic GVHD were observed in animals that had not suffered from severe acute GVHD. In particular, in groups without acute GVHD we observed CD4+IL-17+ cells starting at 2 mo, peaking around 6 mo and which stabilized >1 yr post-HCT. In spleen and peripheral LN of these mice only low levels of CD4+IL-17+ cells were detectable, but their proportion was high in GVHD target organs (liver, intestines, skin). The susceptibility of organs appeared to change post-HCT with high proportions of CD4+IL-17+ cells in the intestines at 2 mo post-HCT that decreased over time. In contrast, CD4+IL-17+ cells in the liver increased later in the time course (Figures). (iv) A centrally important observation was that CD4+IL-17+ cells primarily originated from donor HSC, even in recipients of mature donor T cells. Likewise, recipients of pure HSC showed increasing proportions of Th17 cells over time, and could also manifest signs of cGVHD. From our model we conclude that IL-17 does not contribute to acute inflammatory GVHD. However, IL-17 can be involved in an alternative pathophysiologic mode of chronic GVHD development in the absence of acute inflammation. Since CD4+IL-17+ cells derive from donor HSC and undergo maturation in the host this form of GVHD is delayed, and the emergence and activity of these cells appears to constitute a true autoimmune phenomenon. Our novel hypothesis may explain parts of the complex and obscure pathophysiology of chronic GVHD. Disclosures: No relevant conflicts of interest to declare.

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Partial T-Cell Depletion By Low-Dose Anti-Thymocyte Globulin to Reduce Severe Acute and Chronic Graft-Versus-Host Disease after Allogeneic Stem Cell Transplantation

Blood ◽

10.1182/blood.v126.23.5470.5470 ◽

2015 ◽

Vol 126 (23) ◽

pp. 5470-5470

Author(s):

Osamu Imataki ◽

Yumiko Ohbayashi ◽

Yukiko Ohue ◽

Harumi Matsuka ◽

Makiko Uemura ◽

...

Keyword(s):

T Cells ◽

Stem Cell ◽

T Cell ◽

Low Dose ◽

Chronic Gvhd ◽

Cell Depletion ◽

Control Group ◽

T Cell Depletion ◽

Stem Cell Source ◽

Gvhd Prophylaxis

Abstract Background: T cells from a stem cell source are inevitably contaminated, and over 5.0×104/kg T cells are thought to induce graft-versus-host disease (GVHD) in HLA-mismatched or haplo-identical stem cell transplantations (SCTs) [4]. To suppress GVHD reactions, a procedure for T-cell depletion (TCD) was developed over the past several decades, especially for HLA-mismatched and haplo-identical SCTs, which are at high risk for GVHD. To reduce the incidence of GVHD, a potentially effective agent is anti-thymocyte globulin (ATG), which is generally administered at a dose of ≥ 5-10 mg/kg. Based on data regarding the use of ATG for the treatment of aplastic anemia, we hypothesized that ATG might accommodate engraftment and inhibit GVHD. We attempted to use a lower dose of ATG to decrease non-relapse mortality (NRM) in Japanese patients undergoing an HLA-matched SCT. Patients and method: We treated patients with hematological diseases who underwent an allogeneic SCT after March 2010 without or with 2.5 mg/kg ATG. The inclusion criteria for underlying disease included both hematological malignancies and bone marrow failures. All consecutive patients transplanted from an allogeneic related or unrelated donor were included. Cord blood transplantations were omitted from this analysis. The patients who underwent an SCT before February 2010 (n=20) were examined as the control group without ATG treatment. ATG was administered 1 day prior to the transplantation day at 2.5 mg/kg with 500 mg/body methylpredonisolone as a preconditioning procedure. GVHD prophylaxis, tacrolimus 0.03 mg/kg and short-term MTX (10-7-7 mg/m2) was adapted for both the ATG group and the control group. Results: Thirty-nine (21 male, 18 female) recipients were recruited (median age 49 yrs, range 19-64 yrs). Their underlying diseases were acute myeloid leukemia (n=14), acute lymphoblastic leukemia (n=10), myelodysplastic syndrome (n=5), lymphoma (n=7), and myeloma, aplastic anemia, and other malignancy (n=1 each). Preparation regimens were myeloablative for 17 patients (14 cyclophosphamide [CY]/total body irradiation [TBI], two busulfan [BU]/CY, and another) and non-myeloablative for the other 22 patients (14 fludarabine/melphalan [Flu/Mel] and eight Flu/BU). All but one patient achieved engraftment, and one secondary graft failure was observed. The overall incidences of acute and chronic GVHD were 63.2% and 15.8% for the ATG-treated patients (40.0% and 25.0% for the control cohort), respectively. Acute GVHD (grades II to IV and III to IV) in the recipients who received ATG occurred in 21.1% and 0.0% (control cohort, 10.0% and 5.0%), respectively. The estimated probability of overall survival (OS) 2.5 yrs after transplantation was 77.8% for the ATG group (controls, 57.1%). The relapse rate 2.5 yrs after transplantation was 21.1% and 20.0% in the ATG and control groups, respectively. The NRM rate was decreased after ATG treatment: 25.0% vs. 10.5% (not significant). The causes of mortality with or without ATG were recurrent diseases (n=1 and 2), infection (n=1 and 0), and adverse events caused by transplant-related complication (n=1 and 5), respectively. No deaths due to acute or chronic GVHD occurred. Discussion: Low-dose ATG could suppress the incidence of severe acute GVHD and chronic GVHD without increasing the NRM, although our study design did not have enough power to make a conclusion about the efficacy of low-dose ATG. However, partial T-cell depletion may be effective for HLA-matched SCT recipients. Our results show that ATG at 2.5 mg/kg can be used safely for the Japanese transplant population of HLA-matched donors. Low-dose ATG is a potential treatment to partially disempower T cells from a stem cell source, which are inevitably contaminated. Recent developments in the prophylaxis for GVHD, such as selective cytotoxic T-cell depletion by using a post-transplant CY regimen, are promising strategies to fully suppress T cells as the GVHD enhancer. Previous studies revealed the clinical efficacy of GVHD prophylaxis but did not clarify the significance of its survival benefit. Likewise, our present findings indicated a lack of survival benefit by ATG treatment in this small study. However, the low-dose ATG contributed to a reduction of severe GVHD. Although early mortality after transplantation is decreasing, late-onset comorbidity including chronic GVHD remains a significant problem. Disclosures No relevant conflicts of interest to declare.

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