Favorable Immune Reconstitution in Patients Administered Anti-Thymocyte Globulin (ATG) Early in the Course of Reduced Intensity Conditioning for Allogeneic Hematopoietic Cell Transplantation

Anti-thymocyte globulin (ATG) mitigates graft vs host disease (GVHD) risk in patients undergoing allogeneic hematopoietic cell transplantation (HCT). Due to T cell depletion there remains a concern that ATG administration may be associated with an increased risk of malignancy, relapse, and infection in recipients of reduced intensity conditioning (RIC). It was hypothesized that ATG infusion early in the course of conditioning will promote rapid immune reconstitution because of lower levels at the time of graft infusion and will thus help to improve clinical outcomes in RIC. Rabbit ATG (Thymoglobulin, Sanofi Aventis) was administered from day (d) -9 to -7 to HLA matched-unrelated (MUD; 5 mg/kg in divided doses) and -related (MRD; 3.5 mg/kg) donor transplant recipients conditioned with Fludarabine and Melphalan (ATG -9 cohort; N=36). Immune reconstitution and clinical outcomes were compared with a historical control group of patients who received the same doses of ATG from d-3 to -1 (ATG -3 cohort; N=28). Standard GVHD prophylaxis with calcineurin inhibitor and antimetabolite was administered, with CMV and EBV monitoring. ATG -9 cohort had more, MUD recipients 80% vs. 64%; myeloid malignancy (AML, MDS, MPD) 83% vs. 35%. Age (56 vs. 57), graft type (97 vs. 92% PBSC) and CD34+cell dose infused (4.8 vs 4.7 E6/KG) were similar. Immune reconstitution was uniformly superior in ATG -9 cohort, with significantly higher absolute monocyte counts (AMC) at d30, 60 and 90 (P<0.001), as well as higher donor derived CD3+ (ddCD3+) and CD3+/8+ cell counts at d60 and 90 (P<0.01), and CD3+/4+ cells at d90 (P=<0.05). T cell - monocyte interactions were modelled as 2 dimensional vectors in the immune phase space, (Figure 1) with a consistently higher vector magnitude observed in ATG-9 cohort (P<0.01). Rate of T cell reconstitution was determined by calculating the derivative of ddCD3+ cell count as a function of time (dT/dt) post-transplant (Figure 2) and was generally higher in the ATG-9 cohort, particularly at d60. With a median follow up of 14.9 months in the ATG-9 cohort, and 47.2 months in the ATG -3 cohort, there is a non-significant trend for improved survival (72.2% vs. 46.4% at 2 years) and relapse (19.4% vs. 35.7% at 2 years) in the ATG -9 cohort. TRM and acute GVHD were similar, with a trend towards greater risk for chronic GVHD in the ATG -9 cohort, albeit of a lower severity. Given the relatively low number of patients in each cohort, the effect of immune reconstitution on clinical outcomes was evaluated in the pooled population. Survival was improved in those with AMC and ddCD3+ cell counts >200/µL at d60 (P=0.004 & 0.016 respectively), and in patients with T cell - monocyte vector magnitude > median (577.48/µL) at that time (P= 0.008), as well as in those with a calculated dT/dt > median (1.96 cells/µL/day) at d45 (P=0.047). The latter was also associated with a reduction in relapse rate (P=0.04), as was ddCD8+ cell count >145/µL at d60 (P=0.04). Acute GVHD risk was increased when dT/dt was >median (7.60 cells/µL/day) at d15 (P=0.0095), and correspondingly with T cell - monocyte vector magnitude > median (1033.3/µL) at d30 (P=0.017). In conclusion, this retrospective study demonstrates that equal doses of ATG administered earlier (d -9 to -7 as opposed to d-1 to -3) during conditioning yield more rapid and robust immune reconstitution. Monocyte and ddCD3+ cell recovery kinetics have a favorable impact on survival and relapse risk following HLA matched HCT. Patients at risk for acute GVHD may be identified as early as d15 post HCT by analyzing ddCD3+ cell reconstitution kinetics. Different ATG administration schedules should be studied prospectively with a focus on immune reconstitution kinetics as a determinant of clinical outcomes. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: Rabbit anti-thymocyte globulin for GVHD prophylaxis.

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HLA-Haploidentical Familial Donor Hematopoietic Cell Transplantation without Ex Vivo- T Cell Depletion after Reduced-Intensity Conditioning of Busulfan, Fludarabine, and Anti-Thymocyte Globulin: A Preliminary Report.

Blood ◽

10.1182/blood.v110.11.3077.3077 ◽

2007 ◽

Vol 110 (11) ◽

pp. 3077-3077

Author(s):

Kyoo-Hyung Lee ◽

Seong-Jun Choi ◽

Jung-Hee Lee ◽

Ho-Jin Shin ◽

Young-Shin Lee ◽

...

Keyword(s):

T Cell ◽

High Risk ◽

Cell Transplantation ◽

Acute Gvhd ◽

Hematopoietic Cell Transplantation ◽

Hematopoietic Cell ◽

Cell Depletion ◽

Reduced Intensity Conditioning ◽

T Cell Depletion ◽

Reduced Intensity

Abstract Animal hematopoietic cell transplantation (HCT) models and several small clinical trials showed that successful engraftment can be achieved across HLA-haplotype difference after reduced-intensity conditioning (RIC). Furthermore, decreased graft-versus-host disease (GVHD) and transplantation-related mortality (TRM) after RIC was shown in a swine leukocyte antigen-haploidentical HCT experiment. Therefore, a protocol investigating the role of RIC in HLA-haploidentical familial donor HCT was initiated in April 2004 and 20 patients [13 male and 7 female; median age 26.5 years (16–65)] without HLA-matched donor enrolled until June 2007. The diagnosis were AML (n=9), ALL (n=4), acute biphenotypic leukemia (n=1), MDS (n=4), and SAA (n=2), and all patients had high-risk features, i.e. first complete remission (CR) but with high-risk chromosomal abnormality (n=1), first CR after salvage (n=1), second CR (n=6), recurrent/refractory state (n=7), immunotherapy failure (n=4), and high-risk MDS (RAEB-1, n=1). The RIC included iv busulfan 3.2 mg/kg × 2, fludarabine 30 mg/m2 × 6, plus anti-thymocyte globulin [Thymoglobuline 3 mg/kg (n=17) or Lymphoglobuline 15 mg/kg (n=3)] × 4. After receiving G-CSF, the donors (13 mothers; 5 offsprings; and 2 HLA-haploidentical siblings) underwent 2 or 3 daily leukapheresis, and the collected cells were given to patients without T cell depletion [medians of; 7.9 (3.7–12.1)×108/kg MNC, 6.9 (3.6–73.5)×106/kg CD34+ cells, and 4.6 (1.8–8.5)×108/kg CD3+ cells]. GVHD prophylaxis was cyclosporine 3 mg/kg/day iv from day -1 and a short course of methotrexate. As a part of separate phase 1 study, the two most-recently enrolled patients received additional donor CD34+ cell-derived NK cells 6 weeks after HCT. Except one patients with SAA who died due to K. pneumoniae sepsis on day 18, all 19 evaluable patients engrafted with ANC> 500/μl median 17 days (12–53) and platelet> 20,000/μl median 23 days (12–100) after HCT. Eight patients experienced acute GVHD (grades I, II, III, and IV; 2, 3, 2, and 1, respectively). Cumulative incidences (CI) of overall and grade II-IV acute GVHD were 40 and 30%, respectively. Eight patients experienced chronic GVHD (limited, 4; extensive, 4; CI, 51%). Fourteen showed positive CMV antigenemia, while 2 suffered CMV colitis, which resolved after treatment. As early as 2 weeks after HCT, 15 of 16 evaluable patients, and, by 4 weeks, all of 17 evaluable patients showed donor chimerism ≥95% on STR-PCR, which was maintained until 24 weeks in all 11 patients tested. Thirteen patients are alive after median follow-up of 13.6 months (1.5–37.9; Kaplan-Meier survival, 55.6%). Of 16 patients with acute leukemia and high-risk MDS, 8 remain alive without recurrence (event-free-survival, 40.9%). Two patients died of K. pneumoniae sepsis and grade IV acute GVHD, respectively (CI of TRM, 11%). Immune recovery in 10 patients without relapse for > 6 months showed robust lymphocyte contents and immunoglobulin levels at 6 months (means of; 1,060/ul CD3+, 222/ul CD4+, 767/ul CD8+ cells, and 1,317 mg/dl IgG) and 12 months. After RIC, consistent engraftment and durable complete donor hematopoietic chimerism can be achieved from HLA-haploidentical familial donor. The frequencies of GVHD and TRM were low.

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Immune Reconstitution after Haploidentical Hematopoietic Cell Transplantation: Impact of Reduced Intensity Conditioning and CD3/CD19-Depleted Grafts

Blood ◽

10.1182/blood.v112.11.1175.1175 ◽

2008 ◽

Vol 112 (11) ◽

pp. 1175-1175

Author(s):

Birgit Federmann ◽

Matthias Haegele ◽

Christoph Faul ◽

Wichard Vogel ◽

Lothar Kanz ◽

...

Keyword(s):

T Cells ◽

T Cell ◽

Nk Cells ◽

Cell Transplantation ◽

Immune Reconstitution ◽

Hematopoietic Cell Transplantation ◽

Nk Cell ◽

Reduced Intensity Conditioning ◽

Haploidentical Hematopoietic Cell Transplantation ◽

Reduced Intensity

Abstract Haploidentical hematopoietic cell transplantation (HHCT) using CD3/CD19 depleted grafts may lead to faster engraftment and immune reconstitution since grafts contain also graft-facilitating-cells, CD34− progenitors, NK cells, and dendritic cells. Reduced intensity conditioning may also have a positive impact on immune reconstitution following HHCT. 26 adults received CD3/CD19 depleted HHCT after RIC (150–200 mg/m2 fludarabine, 10mg/kg thiothepa, 120 mg/m2 melphalan and 5mg/day OKT-3 (day −5 to +14)) at our institution between 2005–2008. We prospectively evaluated engraftment and immune reconstitution. B-, NK-, T- and T-cell subsets (CD3/8, CD4/8, CD4/45RA/RO), TCR-Vβ repertoire and NK-cell receptors (NKP30, NKP44, NKP46, NKG2D, CD158a/b/e, CD85j, NKG2A, CD161) were analyzed by FACS. Grafts contained 8.8×106 CD34+ (range, 4.3–18.0 ×106), 2.9×104 CD3+ (range, 1.2–9.2×104) and 3.6×107 CD56+ (range, 0.02–23.0 ×107) cells/kg. Engraftment was rapid with a median time to >500 granulocytes/μl of 11 days (range, 9–15) and a median time to >20 000 platelets/μl of 11 days (range, 8–23). Full chimerism was reached on day 14 (median; range, 6–26). NK-cell engraftment was rapid, reaching normal values on day 20 (median of 247 CD16+CD56+CD3− cells/μl (range, 1–886)) with NK cells comprising up to 70% of lymphocytes. B-cell reconstitution was delayed with 81 (range, 0–280) and 335 (range, 11–452) CD19+20+ cells/μl on days 150 and 400, respectively. T-cell reconstitution was impaired with 49 (range, 0–586) and 364 (range, 35–536) CD3+ cells/μl on day 60 and day 150, respectively. We observed an increase of CD3+CD8+ cells in contrast to CD3+CD4+ cells early after HHCT with a median of 24 (range, 0–399) vs 16 (range, 0–257) and 159 (range, 1–402) vs 96 (range, 18–289) cells/μl on day 50 and day 200, respectively. CD4+CD45RA+ T cells increased slowly while CD4+CD45RO+ T cells reconstituted faster with a median of 61 CD4+CD45RO+ cells/μl (range, 0–310) vs 24 CD4+CD45RA+ (range, 0 to 152) on day 100. Within the CD4+CD25+ regulatory T cells there was a slow regeneration with median of 14 CD4+CD25+ cells/μl (range, 0–96) on day 100 and 28 CD4+CD25+ cells/μl (range, 19–160) on day 200. CD14+CD45+ monocytes did not reach normal values within the time of observation with 7 CD14+CD45+ cells/μl (range, 0–21) on day 120 and 7 CD14+CD45+ cells (range, 2–381) on day 400. TCR-Vβ repertoire and NK-cell receptor reconstitution was analyzed so far in 7 and 8 patients, respectively. We found a skewed T-cell repertoire with oligoclonal T-cell expansions to day 100 and normalization after day 200. An increased natural cytotoxicity receptor (NKP30, NKP44, NKP46) and NKG2A, but decreased NKG2D and KIR-expression was observed on NK-cells until day 100. In conclusion, T- and B-cell reconstitution is delayed after HHCT using CD3/CD19 depleted grafts and RIC. However, T-cell reconstitution is faster compared to data published with CD34 selected grafts and myeloablative conditioning. A fast NK-cell reconstitution early after HHCT was observed. Thus a combination of reduced intensity conditioning with CD3/CD19 depleted grafts appears to accelerate the immune recovery after haploidentical stem cell transplantation.

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Synergy of Unrelated Donor and Full Intensity Conditioning Breaks the Control of Graft Versus Host Disease By Alemtuzumab

Blood ◽

10.1182/blood.v124.21.1206.1206 ◽

2014 ◽

Vol 124 (21) ◽

pp. 1206-1206

Author(s):

Olivia Laverick ◽

Amy Publicover ◽

Laura Jardine ◽

Kile Green ◽

Alan Potter ◽

...

Keyword(s):

T Cell ◽

Acute Gvhd ◽

Chronic Gvhd ◽

Cell Depletion ◽

Reduced Intensity Conditioning ◽

T Cell Depletion ◽

Gvhd Prophylaxis ◽

Full Intensity ◽

Conditioning Intensity ◽

Reduced Intensity

Abstract Many variables influence the risk of graft versus host disease following hematopoietic stem cell transplantation. Comparison between preparative regimens is hampered by the use of many different combinations of chemotherapy and radiotherapy, varying intensity of conditioning, use of T cell depletion and donors who are either siblings or unrelated volunteers. Many reduced intensity regimens also incorporate enhanced GVHD prophylaxis with in vivo T cell depletion. Here we describe a cohort of patients prepared in a modular fashion with either reduced or full intensity conditioning combined with a uniform GVHD prophylaxis regimen for all transplants with sibling donors (alemtuzumab 30mg) and for all with unrelated donors (UD; alemtuzumab 60mg). Thus it was possible to dissect independently the effect of conditioning intensity and sibling or UD type upon GVHD risk in this settig of in vivo T cell depletion. Patients and analysis: the study was a retrospective analysis of 258 sequential transplants performed in adults with hematological malignancy between September 2005 and September 2013 at a single UK institution. Reduced intensity conditioning (n = 221) included fludarabine 150mg/m2 plus melphalan 140mg/m2 or fludarabine 150mg/m2 plus busulfan 9.6mg/kg. Full intensity transplants (n = 37) received 12Gy TBI plus melphalan 140mg/m2, 12Gy TBI plus cyclophosphamide 120mg/kg, or busulfan 16mg/kg plus cyclophosphamide 120mg/kg. All patients with sibling donors received 30mg alemtuzumab and those with UD received a 60mg of alemtuzumab. UD matching was similar in both reduced intensity and full intensity cohorts (92.2% and 86.5% 10/10 matches, respectively) but patients receiving reduced intensity were older than those receiving full intensity conditioning (median age 51 vs 31; p < 0.001). Outcome was analyzed according to EBMT guidelines. Relapse, non-relapse mortality and cGVHD were treated as competing risks and analysed as cumulative incidence. Outcome: the incidence of acute GVHD grades I-IV was comparable between reduced intensity and full intensity sibling transplants (45% vs 45%; p = NS) indicating a lack of effect of conditioning intensity upon GVHD risk in this setting. There was a slight increase in the risk of GVHD between reduced intensity UD compared with reduced intensity sibling donor transplants (57% vs 45%; p = NS) but a marked synergistic increase between UD transplants performed with full intensity compared with reduced intensity conditioning (100% vs 57%; p = < 0.001). The incidence of grades III-IV acute GVHD was also higher in full intensity UD transplants (16%) compared with reduced intensity UD transplants (5%). The incidence of chronic GVHD was also highest in full intensity UD transplants but both conditioning intensity and UD contributed in an additive manner: the rate of chronic GVHD progressed from 33% to 44% in reduced intensity and full intensity sibling transplants respectively and from 57% to 75% for reduced and full intensity UD transplants, respectively. Two year overall survival was comparable in all groups, ranging from 55% to 70%. In keeping with the higher rates of acute GVHD in full intensity transplants performed with UD, this group experienced the lowest relapse risk (15% vs 29% for all the other groups combined; p = 0.04) but the highest non-relapse mortality, reaching 41% at 2 years compared with 28% for all the other groups combined (p = 0.08). Conclusion: these results show that alemtuzumab provides good protection from acute GVHD in reduced intensity transplantation from sibling and UD. In sibling transplants given identical GVHD prophylaxis, full intensity conditioning does not increase the risk of GVHD. In contrast, a slight increase in GVHD risk with UD transplants seen with reduced intensity conditioning, is amplified in a synergistic manner by full intensity conditioning. This is associated with a high non-relapse mortality, even though the median age of full intensity patients is more than 20 years younger than those receiving reduced intensity conditioning. Disclosures No relevant conflicts of interest to declare.

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No Influence of Peripheral Blood CD34+ and CD3+ Graft Cell Counts on Outcomes after Reduced-Intensity Conditioning Transplantation Using Post-Transplant Cyclophosphamide

Blood ◽

10.1182/blood-2018-99-112453 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 4577-4577

Author(s):

Alice Garnier ◽

Thierry Guillaume ◽

Pierre Peterlin ◽

Amandine Le Bourgeois ◽

Alix Duquesne ◽

...

Keyword(s):

Board Of Directors ◽

Acute Gvhd ◽

Chronic Gvhd ◽

Reduced Intensity Conditioning ◽

Advisory Committees ◽

Cell Content ◽

Post Transplant ◽

Cell Counts ◽

Gvhd Prophylaxis ◽

Reduced Intensity

Abstract Introduction Although associated with a higher incidence of acute GVHD, peripheral blood stem cells (PBSC) are increasingly used for haploidentical allogeneic transplantation with post-transplant cyclophosphamide (PTCY). Data reporting whether or not the composition of the PBSC graft impacts outcomes of patients receiving PTCY are still scarce. Materials and Methods This retrospective study included all adults allografted in our department who received a PBSC allotransplant after reduced-intensity conditioning (RIC) with PTCY. Grafts originated from a matched or haploidentical donor and recipients received a Baltimore-based or a Clo-Baltimore (where fludarabine is replaced by clofarabine)-based RIC regimen. All patients received cyclosporine + mycophenolate mofetyl and PTCY as GVHD prophylaxis. CD34+ and CD3+ graft cell contents were considered to study their potential impact on the following outcomes: OS, DFS, GRFS, acute grade 2-4 and 3-4 GHVD and chronic GVHD, early immune reconstitution (IR, lymphocytes and monocytes counts at days+30 and +100 post-transplant, CD4+, CD8+, NK and B cells at day+100 post-transplant). Results Between November 2013 and May 2017, 77 patients met the inclusion criteria. There were 48 males and 29 females with a median age of 58 years (range: 22-71) and a median follow-up for alive patients of 29.2 months (range: 8.4-53.2). Initial diagnoses were mainly acute myeloid (n=21) or lymphoid (n=6) leukemia, lymphoma (n=13), myelodysplastic syndrome (SMD, n=12), myelofibrosis (n=9). Thirty-eight patients were in complete remission at time of transplant (CR1 n=23; CR2 n=12, CR3 n=3) while 22 had active disease and 17 were in partial remission. Donors were sibling in 6 cases, matched unrelated (MUD) in 14, 9/10 mismatched unrelated in 1 and haploidentical in 56. Forty patients received a Baltimore RIC regimen and 37 a Clo-Baltimore RIC regimen. Analyses were performed in July 2018. Median infused CD34+ and CD3+ graft cell counts, based on recipients' weight, were 7.8 106/Kg (range: 1.45-14.24) and 22.23 107/kg (range: 1.95-66.75), respectively. All patients but three engrafted, the latter being 1 patient transplanted with a haplodonor, 1 with a MUD and 1 who died of infection during induction. Two-year OS, DFS and GRFS were 62.6% (52-74), 51.5% (40-63) and 36.6% (27-49), respectively. The incidences of grade 2-4 and 3-4 acute GVHD were 46.7% and 14.2%, respectively, while the incidence of moderate + severe chronic GVHD was 14%. Relapse occurred in 26 patients and non-relapse mortality (NRM) was 15.5%. Baltimore vs Clo-Baltimore patients shared similar median infused CD34+ and CD3+ graft cell counts and outcomes. The same was observed for patients allografted with a haplodonor or not, except for the incidence of grade 2-4 acute GVHD which was significantly higher for the haplo group at 57.1% vs 19% (p=0.006). This difference was first attributed to the higher CD3+ cell content infused in this group (median: 24.05 vs 18.85 107/kg, p=0.04). However, using the median of CD3+ cell graft content as threshold, the incidence of acute grade 2-4 GVHD was not different between low vs high groups when considering haplo patients. This suggests that it was rather the type of donor that did influence acute GVHD occurrence and that PTCY is of particular interest for GVHD prophylaxis when using matched donors. Partitioning the patients according to the median level of CD34+ cells, there was no difference in terms of 2-year OS (57.1% vs 60.7%, p=0.53), DFS (44.5% vs 55.6%, p=0.47) , GRFS (31.7% vs 44.3%, p=0.32), acute grade 2-4 (59% vs 39%, p=0.13) and 3-4 GVHD (17% vs 6.4%, p=0.29), and moderate + severe chronic GVHD (19.5% vs 20%, p=0.57). Similarly, partitioning patients according to median graft CD3+ cell content, outcomes were similar for 2-year OS (64.8% vs 55.8%,p=0.45), DFS (46.3% vs 55.8%, p=0.62), GRFS (36.3% vs 40.4%, p=0.63), acute grade 2-4 (44.7% vs 56.4%, p=0.42) and 3-4 GVHD (10.5% vs 15.3%, p=0.76), and moderate + severe chronic GVHD (14% vs 17.6%, p=0.91). Finally, early IR was not influenced by CD34+ and CD3+ graft cell contents. Conclusion: PBSC CD34+ and CD3+ graft cell contents have no impact on survivals, GVHD incidence nor early IR after a RIC allotransplant using PTCY as GVHD prophylaxis. As a consequence, there is no need to manipulate the graft nor cap the stem cells dose to be infused. These data have to be confirmed prospectively on a larger cohort of patients. Disclosures Gastinne: Millennium/Takeda: Honoraria. Moreau:Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees; Abbvie: Honoraria, Membership on an entity's Board of Directors or advisory committees.

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Immune Reconstitution after Allogeneic Hematopoietic Cell Transplantation: Comparing Post-Transplant Cyclophosphamide Versus Anti-T-Lymphocyte Globulin As Graft-Versus-Host Disease Prophylaxis in a Retrospective Cohort Study

Blood ◽

10.1182/blood-2019-130623 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3289-3289

Author(s):

Rashit Bogdanov ◽

Saskia Leserer ◽

Evren Bayraktar ◽

Nikolaos Tsachakis-Mück ◽

Lara Kasperidus ◽

...

Keyword(s):

T Cells ◽

T Cell ◽

Immune Reconstitution ◽

Hematopoietic Cell Transplantation ◽

Cytotoxic T Cells ◽

Cell Receptor ◽

Helper T Cells ◽

Graft Versus Host ◽

Cell Counts ◽

Gvhd Prophylaxis

Introduction: Both post-transplant cyclophosphamide (PT-Cy) and anti-T-lymphocyte globulin (ATLG) eliminate proliferating allo-reactive T cells after allogeneic hematopoietic cell transplantation (HCT) and therefore contribute to reduce the incidence of graft-versus-host disease (GVHD). Exposure to ATLG has been previously associated with delayed T cell reconstitution (Gooptu et al. BBMT 2018). Yet, no study has compared PT-Cy to ATLG for its effect on cellular immune reconstitution and only one small study compared it to anti-thymocyte globulin (Retiere et al. Oncotarget 2018). Hence, we analyzed the dynamics of immune reconstitution after HCT in patients that received either PT-Cy or ATLG as additional GVHD prophylaxis. Methods: We retrospectively analyzed 247 patients (138 male, 109 female) from a single-center, who received HCT from HLA-identical siblings (n=29), haploidentical family donors (n=21), or matched unrelated donors (n=197) between January 2017 and December 2018. All patients were transplanted for hematologic malignancies (49% acute myeloid leukemia). Median age was 56 (range, 18-76) years. Myeloablative conditioning regimen was performed in 119 patients and reduced intensity conditioning in 128 patients. PT-Cy (n=59) was dosed 50 mg/kg/day intravenously (i.v.) on days HCT +3 and +4, followed by tacrolimus in combination with mycophenolate mofetil from day +5. In 188 patients, ATLG was administered at 10 mg/kg bodyweight i.v. on days -3, -2 and -1 in combination with cyclosporine 3 mg/kg i.v. from day -1 and methotrexate (15 mg/m2 on day +1 and 10mg/m2 on days +3, +6, and +11 i.v.). All patients received HCT using peripheral blood stem cells with amedian dose of 6.3x106CD34+ cells/kg (range, 1.3 to 25). Blood samples were collected on days +30, +90, +180, +270 and +365 and analyzed by multiparametric flow cytometry for the following cell subsets: T lymphocytes (CD3+), T helper cells (CD3+/CD4+); cytotoxic T cells (CD3+/CD8+), regulatory T cells (CD3+/CD4+/CD25+/CD127+), T cell receptor αβ(CD3+/TCRαβ), T cell receptor γδ(CD3+/TCRγδ), NK T-cells (CD3+/CD16+/CD56+), NK-cells (CD3-/CD16+/CD56+), naïve helper T cell (CD4+/CD45RA), memory helper T cells (CD4+/CD45RO) and B cells (CD19+). Results: Immune cell reconstitution differed significantly between the PT-Cy and the ATLG cohorts. The use of PT-Cy associated with significantly higher median counts of helper T cells during the first 6 months after HCT (p<0.0001, Fig. 1A). In particular, naïve helper T cells (Fig. 1B; median absolute (abs.) cell counts of PT-Cy versus (vs) ATLG cohort: month 1, 15 cells/µL vs 12 cells/µL , p<0.0001; month 3, 13 vs 3 cells/µL, p<0.0001; month 6, 25 vs 4 cells/µL, p<0.0001) and memory helper T cells (median abs. counts month 1, 94 vs 3 cells/µL, p<0.0001; month 3, 116 vs 64 cells/µL, p<0.0001; month 6, 189 vs 89 cells/µL, p =0.004) were significantly higher in the PT-Cy cohort. Cytotoxic T cells (Fig. 1C) and NK cells did not differ between PT-Cy and ATLG cohorts. Interestingly, γδ T cells were significantly higher in the ATLG cohort (Fig. 1D; median abs. counts month 1, 14 cells/µL vs 3 cells/µL; p =0.019). For B cells or NKT cells the use of PT-Cy associated with earlier immune reconstitution with significant differences only at month 1 after HCT (median abs. cell counts 10 cells/µL vs 1 cell/µL, p=0.007 and 11 vs 2 cells/µL, p=0.03, respectively), regulatory T cells differed significantly in months 3 and 6 (median abs. count 9 vs 2 cells/µL, p<0.0001; 10 vs 4 cells/µL, p<0.0001). The incidence of grade II to IV acute GVHD was significantly lower in the PT-Cy cohort as compared to the ATLG cohort (Hazard ratio 0.48, 95% Confidence interval, 0.30-0.78, p=0.003). Within a median follow up of 11 months, no significant differences in overall survival, relapse incidence and non-relapse mortality were observed between the PT-Cy and ATLG cohorts. Conclusions: Our data suggest that the choice of the additional T cell depleting regimen using either ATLG or PT-Cy significantly affects immune reconstitution after HCT. Knowledge of the distinct immune reconstitution profiles should assist clinical decision-making and help optimizing GVHD prophylaxis. Disclosures Bogdanov: Jazz Pharmaceuticals, MSD.: Other: Travel subsidies. Beelen:Medac GmbH Wedel Germany: Consultancy, Honoraria. Turki:Jazz Pharmaceuticals, CSL Behring, MSD.: Consultancy; Neovii Biotech, all outside the submitted work: Other: Travel subsidies.

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CD8-Depleted Donor Lymphocyte Infusions Can Boost Immune Reconstitution after Haploidentical Stem Cell Transplantation Following Reduced-Intensity Conditioning Regimen.

Blood ◽

10.1182/blood.v108.11.3138.3138 ◽

2006 ◽

Vol 108 (11) ◽

pp. 3138-3138 ◽

Cited By ~ 1

Author(s):

Paolo Corradini ◽

Anna Raganato ◽

Cristiana Carniti ◽

Matteo Carrabba ◽

Farina Lucia ◽

...

Keyword(s):

Stem Cell ◽

T Cell ◽

High Risk ◽

Stem Cell Transplantation ◽

Cell Transplantation ◽

Immune Reconstitution ◽

Acute Gvhd ◽

Mean Value ◽

Reduced Intensity Conditioning ◽

Reduced Intensity

Abstract Haploidentical stem cell transplantation (SCT) can be used in relapsed haematological malignancies for patients lacking a matched sibling or unrelated donor. Major barriers of this strategy are the poor immune reconstitution and the high risk of relapse. Here, we report results of a phase I–II trial evaluating early add-backs of CD8-depleted donor lymphocytes (DLIs) (from 1x10^4 up to 1x10^5 cells/kg starting at day+45 up to day +105 at monthly intervals) after a reduced intensity conditioning (RIC) regimen [thiotepa (10 mg/kg), fludarabine (120 mg/sqm), cyclophosphamide (60 mg/kg) and TBI (2 Gy)]. Ex-vivo and in-vivo TCD were carried out by CD34+ cell selection using the CliniMACS device and alemtuzumab (15mg/m2, day-2), respectively. Twenty-one patients [n= 10 NHL (n=5 CLL, n=5 high-grade NHL), n=7 HL, n=1 MM, n=1 ALL, n=2 AML] were transplanted with advanced disease: 16 (76%) failed a previous autograft and 13 (62%) had refractory disease. A median of 10.4x10^6/Kg CD34+, 1x10^4/kg CD3+, 10x10^4/kg CD19+, 0.9 x10^4/kg NK+ were infused. All patients engrafted with full donor chimerism from day +90. At a median follow-up of 12 months (range, 4–41 months), 12 of 21 pts are alive (7 CR, 2 PR and 3 PD) and 9 died [n=3 infection with GVHD (+610, +187, +253), n=6 disease]. The estimated 2-year overall survival was 49%: pts transplanted in remission had better outcome (83% versus 31%, p=0.13). The estimated 2-year cumulative incidence of TRM and relapse were 27% and 58%, respectively. CMV reactivation and hospital readmissions for opportunistic infections occurred in 76% and 57% of patients, respectively. For CD8 depletion of donor leukaphereses, a new depletion protocol using clinical grade CD8 microbeads (Miltenyi) was applied. This procedure is efficient to reduce the content of CD8 T cells by 3 logs while the median cell recovery of CD3+, CD4+, CD56+/CD3+, CD 20+ was 60%, 86%, 54%, 72%, respectively. Before DLIs, only 2 of 21 patients (10%) developed acute GVHD (no grade III–IV). A total of 36 CD8-depleted DLIs were administered to 17 pts without any acute toxicity. Following DLIs, 6 pts (35%) developed acute GVHD (grade II) and 5 (30%) chronic GVHD (n=2 limited, n=3 extensive). Overall, the incidence of acute GVHD is higher (50% vs 22%, p=0.33) in pts receving larger numbers of donor cells (10–15x10^4/kg versus 3–5x10^4/kg CD8-depleted DLIs). The median values of CD4+/uL, CD8+/uL and NK+ were 100, 280 and 680 at 4 months and 220, 200, 500 at 6 months after SCT in patients receiving CD8-depleted DLIs. Measurable TREC/ucg DNA (mean value 316; mean value donors 3740) and polyclonal T cell repertoire, evaluated by spectratyping, were observed at 9 months in patients younger than 40 years and/or without GVHD. Our results suggest that: haploidentical SCT with RIC regimen provides high engraftment rate T-cell addback allows the achievement of more than 100/uL CD4+ at 4 months after SCT in the majority of patients Survival rate is promising in patients who had transplantation in remission suggesting that this strategy should be evaluated earlier in high risk haematological diseases.

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TCR-Alpha/Beta and CD19 Depleted Haploidentical Stem Cell Transplantation Following Reduced Intensity Conditioning in Children: First Results of a Prospective Multicenter Phase I/II Clinical Trial

Blood ◽

10.1182/blood.v128.22.389.389 ◽

2016 ◽

Vol 128 (22) ◽

pp. 389-389 ◽

Cited By ~ 7

Author(s):

Peter J. Lang ◽

Paul G. Schlegel ◽

Roland Meisel ◽

Ansgar S. Schulz ◽

Johann Greil ◽

...

Keyword(s):

Stem Cell ◽

Research Funding ◽

Graft Failure ◽

Immune Reconstitution ◽

Acute Gvhd ◽

Reduced Intensity Conditioning ◽

Gvhd Prophylaxis ◽

Cd34 Cells ◽

Alpha Beta ◽

Reduced Intensity

Abstract We report the first prospective, multi-center, open-label, single-arm phase I/II clinical trial that assesses the safety and feasibility of stem cell transplantation with TCRalpha/beta and CD19-depleted haploidentical grafts generated with the CliniMACS plus System (Miltenyi Biotec, Germany) in combination with a reduced-intensity conditioning in pediatric patients suffering from various malignant and non-malignant diseases (www.clinicaltrialsregister.org; 2011-005562-38). All patients received single agent MMF as short-term GVHD prophylaxis (40mg/kg/day for 30 days). The speed of immune reconstitution was measured in two core labs using standardized methods and the MACSQuant flow cytometry device (Miltenyi Biotec, Germany). Results: Thirty patients from six hospitals were treated (13 female, 17 male; median age 7 years, range 1 - 17 years). Of the 30 recipients, 10 had ALL, 8 had AML, 6 had solid tumors (soft tissue sarcomas and neuroblastomas), 3 had MDS/MPS, and 1 each with lysosomal storage disorder, SCID, and Wiskott Aldrich syndrome. Disease status in acute leukemias/MDS was: CR1 (n=4), relapsed/refractory (n=17). 5/6 patients with solid tumors had relapsed metastatic disease. The conditioning regimen consisted of 15 or 30 mg ATG (Fresenius/Grafalon) or 7 Gy total nodal irradiation, 160 mg/m2 fludarabine, 10 mg/kg thiotepa, and 140 mg/m2 melphalan. The median number of CD34+ cells, TCRalpha/beta+ cells and CD20+ cells infused was 14.6 x 106 (range, 4 - 54.9), 14 x 103 (range, 0.62 - 40.6) and 0.55 x 105 (range, 0.04 - 1.85), respectively. In addition, significant numbers of NK and TCRgd+ cells/kg were infused - 6.67 x 107 (median; range, 0.68 - 18.2) and 1.58 x 107 (median; range, 0.13 - 4.7), respectively. All 30 patients tolerated the infusion of haploidentical stem cell grafts well. Twenty-five patients had primary engraftment of ANC > 500 cells/µL at a median of 12 days (range, 10 - 18) and PLT > 20,000 cells/µL at a median of 15 days (range, 11 - 27). Peripheral T-cell chimerism at the time of engraftment was completely donor in 19/25 patients (76%), mixed in 3 (12%), and not measured in three. Five patients experienced primary graft failure and 2 had secondary graft failure. All except of one were successfully re-transplanted. None of the recipients developed severe acute GVHD grades III - IV. Only 1 patient had acute GVHD grade II that started on day 22. The vast majority of patients (96.7%) experienced no or only grade I acute GVHD despite minimal GVHD prophylaxis after transplantation. Samples from 24/25 patients with primary engraftment were evaluable for immune reconstitution (Figure 1). On day 28, the majority of WBC were NK cells (median 309 cells/µL; range, 64 - 1026). The second main type of cells were CD3+ cells (median 151 cells/µL; range, 9 - 953), mostly TCRgd+ (median 87 cells/µL; range, 7 - 891). At day 100, TCRab+ cells equalled TCgd+ cells (median 108 vs. 116 cells/µL). B cells recovered more slowly, with a median of 255.5 cells/µL (range, 1 - 1218) on day 63. ADV reactivation contributed most to infectious complications following transplantation. In total, 16/30 patients had ADV DNAemia or were positive in stool. Additionally, seven patients were tested positive for CMV (blood or urine). BK virus was present in 5 patients with 3 patients experiencing cystitis. No EBV reactivation was observed. Two patients had bacterial sepsis, 1 moderate, 1 fatal (due to non-engraftment).No fatal viral infection occurred within 100 days. One molecular relapse was observed within 100 days post transplantation that was treated with blinatumomab. Two of the 30 transplanted patients died within 100 days after transplantation: 1 patient due to sepsis following graft failure (non-relapse mortality) and 1 due to relapse. On day 100, chimerism was completely donor in 20 patients and mixed in two. Conclusions: The CliniMACS depletion system of TCRab+ and CD19+ cells yielded a large number of CD34+ cells, NK cells and TCRgd+ cells, that could be infused safely into pediatric patients with minimal risk of severe acute GVHD. The immune reconstitution was rapid and there was no TRM associated with viral or fungal infections. Coupled with a reduced-intensity regimen, the overall TRM was low. Longer follow up will provide essential information on chronic GVHD and survival outcomes. Figure 1 Immune Reconstitution after transplantation of TCR-alpha/beta and CD19 depleted haploidentical stem cell grafts Figure 1. Immune Reconstitution after transplantation of TCR-alpha/beta and CD19 depleted haploidentical stem cell grafts Disclosures Bader: Riemser: Research Funding; Neovii Biotech: Research Funding; Servier: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Medac: Consultancy, Research Funding. Karitzky:Miltenyi Biotec: Employment. Holtkamp:Miltenyi Biotec: Employment. Siewert:Miltenyi Biotec: Employment. Bönig:Miltenyi Biotec: Consultancy, Honoraria, Research Funding. Handgretinger:Miltenyi Biotec: Patents & Royalties: Co-Patentholder of TcRalpha/beta depletion technology.

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Poor Outcomes of HLA-Mismatched Allogeneic Hematopoietic Cell Transplantation and High Ferritin Levels after a Reduced-Intensity Conditioning Regimen in Patients with Advanced Myelofibrosis

Blood ◽

10.1182/blood-2019-130338 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 5742-5742

Author(s):

Han Bi Lee ◽

Jae-Ho Yoon ◽

Gi June Min ◽

Sung-Soo Park ◽

Silvia Park ◽

...

Keyword(s):

Board Of Directors ◽

Cell Transplantation ◽

Research Funding ◽

Acute Gvhd ◽

Hematopoietic Cell Transplantation ◽

Hematopoietic Cell ◽

Allogeneic Hematopoietic Cell Transplantation ◽

Reduced Intensity Conditioning ◽

Advisory Committees ◽

Reduced Intensity

Allogeneic hematopoietic cell transplantation (allo-HCT) preconditioning intensity, donor choice, and graft-versus-host disease (GVHD) prophylaxis for advanced myelofibrosis (MF) have not been fully elucidated. Thirty-five patients with advanced MF were treated with reduced-intensity conditioning (RIC) allo-HCT. We searched for matched sibling (n=16) followed by matched (n=10) or mismatched (n=5) unrelated and familial mismatched donors (n=4). Preconditioning regimen consisted of fludarabine (total 150 mg/m2) and busulfan (total 6.4 mg/kg) with total body irradiation≤ 400cGy. All showed engraftments, but four (11.4%) showed either leukemic relapse (n=3) or delayed graft failure (n=1). Two-year overall survival (OS) and non-relapse mortality (NRM) was 60.0% and 29.9%, respectively. Acute GVHD was observed in 19 patients, and grade III-IV acute GVHD was higher with HLA-mismatch (70% vs. 20%, p=0.008). Significant hepatic GVHD was observed in nine patients (5 acute, 4 chronic), and six of them died. Multivariate analysis revealed inferior OS with HLA-mismatch (HR=6.40, 95%CI 1.6-25.7, p=0.009) and in patients with high ferritin level at post-HCT D+21 (HR=7.22, 95%CI 1.9-27.5, p=0.004), which were related to hepatic GVHD and high NRM. RIC allo-HCT can be a valid choice for advanced MF. However, HLA-mismatch and high post-HCT ferritin levels related to significant hepatic GVHD should be regarded as poor-risk parameters. Disclosures Kim: Handok: Honoraria; Amgen: Honoraria; Celgene: Consultancy, Honoraria; Astellas: Consultancy, Honoraria; Hanmi: Consultancy, Honoraria; AGP: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; SL VaxiGen: Consultancy, Honoraria; Novartis: Consultancy; Janssen: Honoraria; Daiichi Sankyo: Honoraria, Membership on an entity's Board of Directors or advisory committees; Otsuka: Honoraria; BL & H: Research Funding; Chugai: Honoraria; Yuhan: Honoraria; Sanofi-Genzyme: Honoraria, Research Funding; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees. Lee:Alexion: Consultancy, Honoraria, Research Funding; Achillion: Research Funding.

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Rapid Immune Reconstitution after a Reduced-Intensity Conditioning Regimen and a CD3-Depleted Haploidentical Stem Cell Graft for Pediatric Refractory Hematologic Malignancies.

Blood ◽

10.1182/blood.v108.11.5311.5311 ◽

2006 ◽

Vol 108 (11) ◽

pp. 5311-5311

Author(s):

Xiaohua Chen ◽

Gregory A. Hale ◽

Raymond C. Barfield ◽

Ely Benaim ◽

Wing H. Leung ◽

...

Keyword(s):

Stem Cell ◽

Nk Cells ◽

Immune Reconstitution ◽

Acute Gvhd ◽

Conditioning Regimen ◽

Hematologic Malignancies ◽

Reduced Intensity Conditioning ◽

Hematopoietic Stem ◽

Reduced Intensity Conditioning Regimen ◽

Reduced Intensity

Abstract Haploidentical hematopoietic stem cell transplantation (HaploHSCT) from a mismatched family member (MMFM) donor offers an alternative option for patients who lack an HLA-matched donor. The main obstacles to successful haploidentical hematopoietic stem cell transplantation from a mismatched family member donor are delayed immune reconstitution, vulnerability to infections, and severe graft-versus-host disease (GvHD). Method: We designed a reduced-intensity conditioning regimen that excluded total body irradiation and anti-thymocyte globulin. The graft was immunomagnetically depleted of CD3+ T-cells (CD3 negative selection) and contained a large number of both CD34+ and CD34− stem cells and most other immune cells especailly NK cells. This protocol was used to treat 22 pediatric patients with refractory hematologic malignancies. Results and Discussion: After transplantation, 91% of the patients achieved full donor chimerism. They also showed rapid recovery of CD3+ T-cells, T-cell receptor excision circle counts, TCRβ repertoire diversity and NK-cells during first four months post-transplantation. The incidence and extent of viremia were limited and no lethal infection was seen. Only 9% of patients had grade 3 acute GvHD, while 27% patients had grade 1 and another 27% had grade 2 acute GvHD. This well-tolerated regimen appears to accelerate immune recovery and shorten the duration of early post-transplant immunodeficiency, thereby reducing susceptibility to viral infections. Rapid T-cell reconstitution, retention of NK-cells in the graft, and induction of low grade GvHD may also enhance the potential anti-cancer immune effect.

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Myeloablative Conditioning Followed by T-Cell Depletion Is Associated with Low Treatment Related Mortality.

Blood ◽

10.1182/blood.v108.11.5221.5221 ◽

2006 ◽

Vol 108 (11) ◽

pp. 5221-5221

Author(s):

Nicolas Novitzky ◽

Valda Thomas ◽

Cecile du Toit ◽

Andrew McDonald

Keyword(s):

Stem Cell ◽

T Cell ◽

Disease Recurrence ◽

Haematological Malignancies ◽

Reduced Intensity Conditioning ◽

Myeloablative Conditioning ◽

Gvhd Prophylaxis ◽

Reduced Intensity ◽

Treatment Related Mortality ◽

Related Mortality

Abstract Introduction: Classically the conditioning for transplantation in haematological malignancies has been with myeloablative doses of radiation or chemotherapy, and was followed by variable immunosuppression for the prevention of GvHD. This strategy has been associated with substantial transplant related mortality from regimen toxicity and GvHD, which were most pronounced in older patients. Reduced intensity conditioning programs that are mainly immunosuppressive allow engraftment and predisposed to donor chimerism and appear to have lower TRM, but seem associated to higher rates of GvHD and disease recurrence. To better apportion conditioning strategies for patients undergoing allogeneic stem cell transplantation, we studied the outcome of 81 patients who received similar GvHD prophylaxis with T-cell depletion and immunosuppression, after myeloablative conditioning. Patients & methods: Patients with haematological malignancies, in remission or still responsive to chemotherapy who had an HLA identical sibling were offered T-cell depleted stem cell grafts. Conditioning was with ablative doses of either chemotherapy or total body radiotherapy. Stem cells were mobilised into the blood (PBPC) with G-CSF (5–10ug/kg × 5) and grafts were harvested by large volume (30 litres) apheresis. GvHD prophylaxis was by ex vivo depletion of lymphocytes from the graft with CAMPATH-1 H antibodies followed by therapeutic doses of cyclosporin until day 90. End points were TRM, disease recurrence rate and overall survival time. Results: 90 consecutive patients with median age of 45 (17–62) years were studied. The diagnosis included acute leukaemia (ALL in 7) in CR in 38, myeloproliferative disorders in 16, lymphoproliferative diseases in 26 and multiple myeloma in 10. Post transplantation, patients with CML received, in addition, escalating doses of lymphocytes at 6 months (maximum 1 × 107/kg CD3) or imatinib for 12 months. Median CD34+ cell number was 2.7 (1–12.3) and the median dose of campath-1H was 10 (range 7.5–45) mg. Median time to engraftment was 11 days. Overall, 20 (22%) individuals died while treatment related mortality occurred in 17% (n= 15; VOD 3, infections in 8, pneumonitis in 1, EBV lymphoma in 1 and GvHD in 2). GvHD (> grade1) occurred in 7 patients, was controlled with further immunosuppression but lead to death from infections in 6. Disease recurrence was seen in 12, but 7 with CML or myeloma responded to DLI. At a median follow up of 688 days, 77 survive; 75% in unsustained remission. Conclusions: Myeloablative conditioning is well tolerated in patients receiving T-cell depleted grafts, and treatment related mortality of <20% can be expected consistently with this strategy. This information is useful to more precisely select patients who would benefit most from reduced intensity conditioning schedules.

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