Balancing Acute Graft Versus Host Disease (aGVHD) and Survival after Peripheral Allogeneic Stem Cell Transplantation (SCT) in Hematological Malignancies: A Potential for Graft Engineering.

Abstract Purpose: Peripheral allogeneic SCT is used to treat different types of hematologic malignancies. The target CD34 stem cell dose is 2 -5 x 106/Kg. The dose of CD3+ cells in the infusate is not taken into account except in T-depleted transplant. T-cell dose in peripheral blood stem cell collections is at least 10-fold more than that in a bone marrow harvest. Regulatory T cells (CD4+, CD25+), which comprises 5–10% of CD4 + T cells have been correlated with less incidence of aGVHD. In our study we are trying to determine the impact of T-cell dosing on the overall survival and incidence of aGVHD after peripheral allogeneic SCT in a group of patients with hematological malignancy. Methods: A retrospective study of 66 consecutive patients who underwent peripheral allogeneic SCT for hematological malignancy in our institution between January 2003 and April 2006. The median duration of follow up after SCT was 12.6 months (range 0.2–53). Duration of follow up was compromised only in a subset of patients who had early mortality following SCT. Proportional hazard model was used to define the cutoff value of CD3, CD4, and CD8 cell dose that separate 2 groups of patients with highest statistically significant difference in terms of incidence of aGVHD. Kaplan-Meier Survival Analysis was used for correlate the overall survival (calculated from date of transplant) among these groups subdivided in terms of CD3, CD4, and CD8 cell doses. Results: The 66 patients (6 females, and 60 males) with median age of 48 years (range: 19–63 years) had different malignancies; 6 ALL, 34 AML, 1 biphenotypic leukemia, 1 CLL, 11 CML, 5 Hodgkin lymphoma, 8 NHL. The SCT was from matched related donors in 39 patients, and from matched unrelated donors in 27 patients. The incidence of aGVHD (grade 2–4) was statistically significantly less among those who received CD3 dose < 33.5 × 107/kg IBW (P value: 0.04), tended to be less among those who received CD4 dose < 32.6 × 107/kg IBW (P value: 0.06), and was statistically significantly less among those who received CD8 dose < 6.2 × 107/kg IBW (P value: 0.04). Survival analysis showed no statistically significantly difference in the overall survival (OS) among all patients groups. Median OS was 10.5 months for those who received CD3 dose ≤ 33.5 ×107/kg IBW and 17 months for those who received > 33.5 ×107/kg IBW (P value: 0.35). Median OS was 12 months for those who received CD4 dose ≤ 32.6 ×107/kg IBW and 16.3 months for those who received > 32.6 ×107/kg IBW (P value: 0.8). Median OS was 6 months for those who received CD8 dose ≤ 6.2 ×107/kg IBW and 14.4 months for those who received > 6.2 ×107/kg IBW (P value: 0.13). Conclusions: In our series, CD3 dose less than 33.5 ×107/kg IBW and CD8 dose less than 6.2 ×107/kg IBW were associated with statistically significant reduced risk of grade 2–4 acute GVHD following peripheral allogeneic SCT. Overall survival was not statistically different among these groups of patients. These data suggest that, in addition to considering CD34 dose required for engraftment in allogeneic transplant, the CD3 dose and its subsets CD8 and CD4 may need to be considered to try to minimize the risk of acute GVHD without compromising survival after transplant.

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Sirolimus and Tacrolimus as Graft-vs.-Host Disease Prophylaxis in Allogeneic Stem Cell Transplantation: The Dana-Farber Cancer Institute Experience.

Blood ◽

10.1182/blood.v104.11.1227.1227 ◽

2004 ◽

Vol 104 (11) ◽

pp. 1227-1227

Author(s):

Corey Cutler ◽

Shuli Li ◽

Haesook T. Kim ◽

Edwin Alyea ◽

Vincent Ho ◽

...

Keyword(s):

Stem Cells ◽

Overall Survival ◽

Stem Cell ◽

Serum Level ◽

Acute Gvhd ◽

Cell Function ◽

Peripheral Blood Stem Cells ◽

Gvhd Prophylaxis ◽

Blood Stem Cells

Abstract Sirolimus is a novel immunosuppressant similar to tacrolimus, however, sirolimus inhibits T cell function uniquely via FKBP12/mTOR and can impair dendritic cell function. Sirolimus acts synergistically with tacrolimus and has a non-overlapping toxicity profile, making their use in combination attractive. We began employing sirolimus as GVHD prophylaxis in 2000, and herein describe our experience with this compound in the myeloablative transplant setting. Methods: Two clinical trials were performed using sirolimus (target serum level 3–12 ng/ml) and tacrolimus (target serum level 5–10 ng/ml) as primary GVHD prophylaxis. Cytoxan (1800 mg/m2/d x 2) and TBI (14 Gy, 7 fractions) was the conditioning regimen used in all patients. Trial 1 enrolled 76 patients who received HLA-matched, unrelated or 1-Ag mismatched related or unrelated bone marrow or peripheral blood stem cells. Abbreviated methotrexate (20 mg/m2 total) was routinely given post-transplant. Trial 2 enrolled 53 patients who received HLA-matched, related peripheral blood stem cells. No methotrexate was given post-transplant. Results: The median times to neutrophil engraftment (>500/ml) after transplantation were 17 (range 11–32) and 14 (range 9–17) days for trials 1 and 2 respectively. The median times to platelet engraftment (>20,000/ml) after transplantation were 29 (range 11–98) and 12 (range 10–47) days for trials 1 and 2. Grade II–IV acute GVHD occurred in 35% and 19% of patients in the two trials. Grade III–IV acute GVHD occurred in 21% and 4% of patients in the two trials. The median time to first hospital discharge was 33 and 19 days from transplantation for trials 1 and 2. Seven patients in trial 1 (9%) and 3 patients in trial 2 (6%) did not survive to first hospital discharge. The non-actuarial incidence of chronic GVHD in the two trials was 49 and 44%, respectively. Treatment-related mortality at 100 days was 13% and 6% in the trials. At two years, the relapse-free and overall survival estimates for trial 1 are 46 and 48% (Median follow-up of survivors: 27 months). One year relapse-free and overall survival estimates for trial 2 are 71% and 75% (Median follow-up of survivors: 15 months). Overall survival at 2 years is 72%. Toxicity related to the addition of sirolimus was modest. Among all patients (n=129), VOD occurred in 16 patients (12%), idiopathic pneumonia syndrome occurred in 9 patients (7%) and thrombotic microangiopathy occurred in 13 patients (10%). Conclusions: Sirolimus, when added to tacrolimus after allogeneic stem cell transplantation is effective for GVHD prophylaxis. Engraftment is prompt, the incidence and severity of acute GVHD are reduced and transplant-related morbidity and mortality is reduced, regardless of stem cell source and methotrexate use. Early survival estimates are excellent due to reduced GVHD and transplant-related toxicity. Sirolimus is worthy of broader study in allogeneic transplantation.

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Effect of T-Cell Dose On Outcomes After Peripheral Blood Allogeneic Hematopoietic Cell Transplantation in Hematological Malignancies.

Blood ◽

10.1182/blood.v114.22.1171.1171 ◽

2009 ◽

Vol 114 (22) ◽

pp. 1171-1171

Author(s):

Abraham S Kanate ◽

Farhad Khimani ◽

Aaron Cumpston ◽

Kathy Watkins ◽

Sonia Leadmon ◽

...

Keyword(s):

T Cell ◽

Peripheral Blood ◽

Hematological Malignancies ◽

Acute Gvhd ◽

Hematopoietic Cell ◽

Cell Dose ◽

All Cause Mortality ◽

Cd8 Cell ◽

One Year

Abstract Abstract 1171 Poster Board I-193 Purpose: Peripheral blood allogeneic hematopoietic cell transplant (HCT) is used to treat various types of hematological malignancies. Current knowledge supports that increased CD34 + cell dose in the infusate is associated with earlier leukocyte recovery. The dose of CD3 +, CD4 + and CD8 + cells is largely disregarded except in T-cell depleted transplant. The correlation between various cell doses and outcomes is an area of great interest in HCT. Our analysis focuses on the impact of T-cell subset dosing, on outcomes after HCT, such as acute graft versus host disease (GVHD) and mortality. Methods: Retrospective analysis was conducted on 134 consecutive patients who underwent peripheral blood allogeneic HCT for various hematological malignancies in our institution between January 2003 and December 2008. Statistical analysis was performed using SPSS 15.0. The Chi - square test was used to determine any association between cell doses and the incidence of acute GVHD and all-cause mortality at one year of follow-up after transplant. Results were also compared with the association between CD3+ and CD8+ cell doses and incidence of acute GVHD as reported in 2007 by our institution. Results: A total of 134 patients were included in our analysis, consisting of 49 females and 85 males. The median age was 49 years (range 17-69). HCT was from matched related donors in 68 and from matched unrelated donors in 66 patients. A variety of conditioning regimens were used in preparation for the HCT. Overall survival at 1 year of follow-up was 60%, the incidence of acute GVHD was 52%, and chronic GVHD was 29%. All-cause mortality at one year follow up was found to be significantly higher when the CD3+ cell dose was < 30.5 × 107/kg IBW (49% vs. 29%, P = 0.018). All-cause mortality was also significantly increased when CD8+ cell dose was < 9.2 × 107/kg IBW (50% vs. 33%, P= 0.05). A CD8+ cell dose of < 9.2 × 107/kg IBW was also associated with an increased risk of grades 2-4 acute GVHD (48% vs. 22%, P = 0.026). There was no association of statistical significance between CD3+ and CD4+ cell doses and the incidence of acute GVHD. Conclusion: The data suggests a statistically significant inverse association between mortality and CD3+ cell dose of <30.5 × 107/kg IBW. A CD8+ cell dose of <9.2 × 107/kg IBW was also associated with increased all-cause mortality and acute GVHD (grades 2-4). Our institution reported in 2007, a significant association between the incidence of acute GVHD (grades 2-4) and CD3+ cell dose < 33.5 × 107/kg IBW and CD8+ cell dose of < 6.2 × 107/kg IBW, based on series of 66 patients. As we increased the sample size to 134, the association between CD3+ cell dose and acute GVHD was no more present. We conclude that T-cell dose is an important factor in terms of outcomes after all allogeneic HCT irrespective of preparative regimen. T-cell subsets likely play a pivotal role in transplant results, though it is not well described. Analysis of larger databases is required to substantiate our results. Disclosures: No relevant conflicts of interest to declare.

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Human Herpes Virus 6 Infection in 54 Patients after Allogeneic Hematopoietic Stem Cell Transplantation: Clinical Manifestations and Outcome

Blood ◽

10.1182/blood.v124.21.3899.3899 ◽

2014 ◽

Vol 124 (21) ◽

pp. 3899-3899

Author(s):

Raffaella Greco ◽

Lara Crucitti ◽

Sara Racca ◽

Roee Dvir ◽

Francesca Lorentino ◽

...

Keyword(s):

Overall Survival ◽

Stem Cell ◽

Acute Gvhd ◽

Clinical Manifestations ◽

Rank Test ◽

P Value ◽

Hematopoietic Stem ◽

Clinical Complications ◽

Log Rank Test ◽

Blue Line

Abstract BACKGROUND: Human herpesvirus type 6 (HHV-6) is increasingly recognized as an opportunistic and potentially life-threatening pathogen in recipients of allogeneic hematopoietic stem cell transplantation (AlloSCT). HHV-6 is a member of the beta herpesvirus subfamily (genus Roseolovirus). HHV-6 infection is recognized as the cause of a febrile disease and exanthem subitum in early childhood. Approximately 60% of solid organ transplant and 40% of patients after alloSCT experienced HHV-6 reactivation. Reported clinical manifestations of HHV-6 infection in transplanted patients are skin rash, interstitial pneumonia, bone marrow suppression and encephalitis. Moreover, some clinical reports suggest that HHV-6 can facilitate the occurrence of severe clinical complications of alloSCT, increasing transplant-related mortality. METHODS: From January 2009 to February 2013, we retrospectively evaluated 54 consecutive adult patients (median age 50 years) who developed positivity to HHV-6 after alloSCT for high-risk hematological malignancies. Stem cell donors were family haploidentical (37), HLA identical sibling (8), unrelated volunteer (6), cord blood (3). The viral load was determined by quantitative PCR (Nanogen Advanced Diagnostic S.r.L) in cell-free body fluids such as plasma, bronchoalveolar lavage (BAL), cerebrospinal fluid (CSF), bone marrow (BM) aspirates or in gastrointestinal biopsies. RESULTS: Median time from alloSCT to HHV-6 reactivation was 34 days (range: 0-705). Thirty-one patients presented HHV-6 positive in plasma, 9/54 in BM, 33/54 in gut biopsies or BAL, 7/54 in CSF. At the time of viral positivity all pts were receiving acyclovir as viral prophylaxis except five. Twenty-nine patients had acute graft versus host disease (GvHD). Twenty-two out of these twenty-nine patients experienced a grade III-IV acute GvHD, requiring high dose steroids in twenty-six cases. A concomitant CMV positivity was detected in 15/54 patients. The median absolute count of CD3+ lymphocytes was 207 cells/mcl. In 52/54 cases we reported HHV-6 clinical manifestations: fever (43), skin rash (22), hepatitis (19), diarrhoea (24), encephalitis (10), BM suppression (18), delayed engraftment (11). HHV-6 positivity led to antiviral pharmacological treatment in 37/54 cases, using as first choice therapy foscarnet. Amongst the total fifty-four patients with documented HHV-6 positivity thirty-one solved the clinical event. However the mortality rate was relatively high in this population (overall survival (OS) ±SE at 1 year after HHV-6 reactivation was 38% ± 7%), mainly related to severe infections or GvHD. A better OS is significantly associated with CD3+ cells ≥200/mcl at the time of HHV-6 reactivation (fig 1) (OS at 1 year 63% compared to 11% for patients with CD3 <200/mcl; HR: 0.27, 95% CI 0.12-0.54, p=0.0002). The overall survival of these patients was also positively affected by the absence of acute GvHD grade III-IV at time of viral reactivation (HR: 0.03, 95% CI 1.08-4.03, p=0.03) and by the complete disease remission at time of HSCT (HR:0.26, 95% CI 0.07-0.89, p=0.03). In this analysis the overall survival was not significantly influenced by steroids administration (HR: 1.36, 95% CI 0.71-2.60, p=0.36), time after alloSCT (HR: 1.30, 95% CI 0.51-3.33, p=0.59), type of antiviral prophylaxis (HR: 1.02, 95% CI 0.45-2.33, p=0.96), plasma viral load (HR:1.18, 95% CI 0.51-2.76, p=0.69) and organ involvement (HR:1.14, 95% CI 0.59-2.20, p=0.70). CONCLUSIONS: This retrospective study confirms a correlation of HHV-6 with high morbidity and mortality rates after alloSCT, thus suggesting a regular HHV-6 monitoring in alloSCT recipients. The regular monitoring of HHV-6 DNA, using a real-time PCR assay, may be useful for identifying active HHV-6 infection and for the introduction of a pre-emptive treatment, possibly reducing the incidence of the most severe clinical complications. Despite HHV-6 detection typically occurred early after alloSCT, a better immune reconstitution has the potential to improve clinical outcome. Figure 1: Overall survival after alloSCT in HHV-6 positive patients: green line showed patients with more than 200/mcl CD3+ cells, blue line the ones with less than 200/mcl CD3+ cells at HHV-6 reactivation. P value is provided by Log Rank test. Figure 1:. Overall survival after alloSCT in HHV-6 positive patients: green line showed patients with more than 200/mcl CD3+ cells, blue line the ones with less than 200/mcl CD3+ cells at HHV-6 reactivation. P value is provided by Log Rank test. Disclosures Bonini: MolMed S.p.A.: Consultancy.

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Allogeneic Stem Cell Transplantation (allo-SCT) for Chronic Lymphocytic Leukemia: a Long Term Analysis From the Societe Francaise De Greffe De Moelle Et De Therapie Cellulaire (SFGM-TC).

Blood ◽

10.1182/blood.v114.22.201.201 ◽

2009 ◽

Vol 114 (22) ◽

pp. 201-201

Author(s):

Mohamad Mohty ◽

Jean-Paul Vernant ◽

Ibrahim Yakoub-Agha ◽

Didier Blaise ◽

Gérard Socié ◽

...

Keyword(s):

Overall Survival ◽

Stem Cell ◽

Chronic Lymphocytic Leukemia ◽

Stem Cell Transplantation ◽

Disease Progression ◽

Acute Gvhd ◽

Disease Status ◽

Lymphocytic Leukemia

Abstract Abstract 201 Chronic lymphocytic leukemia (CLL) is a common lymphoid malignancy with a heterogeneous natural history. While some patients never require treatment or can be managed effectively with conventional chemotherapy, others experience early disease progression and death. Allo-SCT is increasingly considered as a therapeutic option for younger patients with poor-risk CLL. This multicenter retrospective analysis assessed the long term outcome of 160 CLL patients who received allo-SCT between 1987 and 2005, and were reported to the SFGM-TC registry. This series included 127 males (79%) and 33 females (20.6%) with a median age at CLL diagnosis of 45.5 (range, 24.4–65.1) y. The median age at time of allo-SCT was 50.9 (range, 29.8–68.3) y. Before allo-SCT, 26 patients (16.3%) received previous stem cell transplantation in the course of their disease. Patients received either a standard myeloablative conditioning regimen (n=58; 38%; Cy-TBI in 90% of cases) or a so-called reduced-intensity conditioning. A matched-related donor was used in 142 cases (89%) and PBSCs were used as source of stem cells in 92 cases (57.5%). At time of allo-SCT, only 10 patients (6.3%) were in CR1, 17 in CR2 and CR3 (10.6%), 27 in first PR (16.9%) and 106 (66.2%) in more advanced phases, including 46 patients (28.8%) in progressive disease. With a median follow-up of 60 (range, 1.6–208) months for surviving patients, 96% of patients engrafted (ANC>500/μL) at a median of 18 (range, 1–41) days after allo-SCT. 71 patients (44.4%) experienced grade 2–4 acute GVHD, including 28 cases (17.5%) of grade 3–4 acute GVHD. 73 patients (56.2%) experienced some form of chronic GVHD. At time of last follow-up, 70 patients (43.8%) were still alive, of whom 24 (34%) were in continuous CR. Disease progression accounted for 24 deaths, while transplant-related causes (infections, n=23; GVHD, n=13; MOF, n=12; other causes, n=18) were observed in 66 cases, for a TRM rate of 41%. The KM estimates of disease-free survival (DFS) at 2, 5, and 10 years after allo-SCT were 44.3%, 39.6%, and 30.5%, respectively. Estimates of overall survival (OS) were 54.4%, 46.2%, and 35.8.1%, respectively. In a Cox multivariate analysis for OS (including demographic features, transplant and donor types, and disease status at time of allo-SCT), disease status at time of allo-SCT (CR or PR) was the most significant parameter associated with improved OS (RR=0.56; 95%CI, 0.36–0.89). We conclude that allo-SCT has the potential to induce long-term disease control and overall survival in patients with high risk or advanced CLL. Disclosures: No relevant conflicts of interest to declare.

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Inhibition of DNA-Pkcs As Novel Therapy for the Prevention of Acute Gvhd Following Hematopoietic Stem Cell Transplantation

Blood ◽

10.1182/blood-2021-153672 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 2768-2768

Author(s):

Lauren Appell ◽

Marie Burdine

Keyword(s):

Gene Expression ◽

T Cells ◽

Stem Cell ◽

Cytotoxic Activity ◽

Cd8 T Cells ◽

Acute Gvhd ◽

Therapeutic Option ◽

Cytotoxic T Cells ◽

P Value ◽

Hematopoietic Stem

Abstract Hematopoietic stem cell transplantation (HCT) is an effective therapeutic option for many cancers and disorders of immune dysfunction. However, acute graft versus host disease (GVHD) remains a morbid complication of HCT, caused by donor T cells attacking the recipient's organs. GVHD can be severe, resulting in multiorgan failure and death. Current immunosuppressive therapies remain marginally effective. The DNA-dependent protein kinase catalytic subunit (DNA-PKcs) is emerging as a master regulator of the immune system. It is required for lymphocyte maturation and immune system diversity due to its role in V(D)J recombination. Our published data and others have determined that DNA-PKcs is required for cytokine expression, namely IL2, IL4, IL6, IL10, IFN, and TNF. Therefore, we hypothesized that DNA-PKcs inhibitors could serve as effective immunosuppressants for transplant patients to prevent rejection, which we tested in a murine allogeneic skin graft model. Ear skin from Balb/c mice was transplanted onto the backs of C57bl/6 or DNA-PKcs null mice (KO). C57bl/6 mice were treated with saline, FK506, or NU7441, a potent and selective DNA-PKcs inhibitor. Treatment with NU7441 significantly reduced graft rejection compared to both saline and FK506. Similar levels were observed in the KO mice, with less than 10% rejection after 10 days when a majority of the controls were completely rejected. These results led us to hypothesize that DNA-PKcs is required for cytotoxic activity of T cells, highlighting the potential use of DNA-PKcs inhibitors to prevent and/or treat GVHD in HCT patients . In order to evaluate the role of DNA-PKcs on T cell activation, we isolated CD8+ T cells from mouse spleens using negative selection via magnetic column. The T cells were then activated with anti-CD3/CD28 for 24-48 hours in the presence of NU7441 or vehicle (DMSO), and the cells were analyzed by flow cytometry. A fully activated T cell expresses both CD69 (early) and CD25 (later) on the surface. T cells that had been activated with NU7441 had a higher expression of CD69 and lower expression of CD25 (figures 1&2). These results are even more pronounced after 48 hours, with a much lower percent of cells expressing both CD69 & CD25 compared to T cells that had been activated in the presence of DMSO alone (figure 3). This suggests that DNA-PKcs plays a role in the activation pathway of cytotoxic T cells - the T cells are blocked from becoming completely activated as evidenced by a significant decrease in cells expressing both CD69 and CD25. If DNA-PKcs is required for the complete activation of CD8+ T cells, this may have therapeutic implications in the prevention of GVHD as cytotoxic T cells are required to cause the pathophysiologic manifestations of GVHD. We then addressed whether DNA-PKcs affects the expression of cytotoxic genes in CD8+ T cells. The T cells were isolated and activated in the presence of NU7441 or vehicle as described above. Total RNA was then isolated from the activated T cells, and qPCR was performed to assess the difference in cytotoxic gene expression. Several genes required for cytotoxic function of CD8+ T cells, including perforin-1, granzyme, and eomes. IL2Ra is the gene coding the CD25 surface marker/IL2 receptor. CTLA4 and TGFb are associated with immune tolerance. A statistically significant decrease in gene expression was seen when treating with NU7441 in the expression of granzyme (p-value 0.01), eomes (p-value <0.01), and IL2Ra (p-value 0.04). While other data was not statistically significant, an interesting trend was seen in increased expression of TGFb. Overall, the significant data suggests that DNA-PKcs plays a role in the expression of certain cytotoxic genes, and may lead to overall decreased cytotoxic activity, perhaps by both decreasing expression of certain genes required for cytotoxic activity/cytokine production as well as increasing the expression of other genes involved in immune tolerance. Both of these effects could potentially lead to a favorable outcome in prevention of acute GVHD. This data serves as an excellent proof of concept for testing the hypothesis that DNA-PKcs inhibitors can prevent acute GVHD in an animal model. This preclinical model would potentially lay the foundation to move into preclinical studies and eventually phase I clinical trials to prevent and/or treat GVHD, creating a new therapeutic option for a morbid complication for HCT patients. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

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High Rate of Long Term Complete Remission for Patients with Chronic Lymphocytic Leukemia (CLL) Who Relapse after Allogeneic Stem Cell Transplantation and Receive Salvage with Donor Lymphocyte Infusions (DLI)

Blood ◽

10.1182/blood.v128.22.5860.5860 ◽

2016 ◽

Vol 128 (22) ◽

pp. 5860-5860

Author(s):

Alan P Skarbnik ◽

Mary E DiLorenzo ◽

Tracy Andrews ◽

Phyllis McKiernan ◽

Scott D. Rowley ◽

...

Keyword(s):

Overall Survival ◽

Stem Cell ◽

Board Of Directors ◽

Research Funding ◽

Acute Gvhd ◽

Chronic Gvhd ◽

Disease Status ◽

Advisory Committees

Abstract Background: Allogeneic stem cell transplantation (SCT) remains the only curative option for CLL, in part due to allogeneic graft-vs-leukemia effect (GVL), which can lead to complete suppression of the CLL clone (Schetelig et al, JCO 2003). Management of post-SCT relapse remains challenging, and DLI has been successfully used as salvage, due to its potential to induce GVL (Delgado et al, Blood 2009). We evaluated outcomes of SCT for patients (pts) with a diagnosis of CLL transplanted at our center. Methods: 36 consecutive pts transplanted between 2004 and 2015 were reviewed. Kaplan Meier survival curves were produced to examine overall survival (OS), time to progression (TTP) and post-DLI survival. Univariate Cox Proportionate hazard models were also estimated to assess the impact of pt characteristics on the risk of survival and progression. Bivariate frequencies with Fisher exact tests, correlation analysis, and independent samples t-tests were performed to test associations across outcomes. Results: Sample was 72% male. Median age at time of SCT was 57 yo (range 42-74). Pts had a median time of 70 months (mos) between diagnosis (Dx) of CLL and SCT. Median follow-up post-SCT was 32 mos (range 1-118). Of the 30 pts with known disease status at the time of SCT, 16.7% were in complete remission (CR), 20% had stable disease (SD), 50% were in partial remission (PR) and 13.3% had progressive disease (PD). Median number of lines of therapy pre-SCT was 3 (range 1-8). Thirteen pts (36%) were refractory to their first line of therapy. 10 pts (27.8%) had del(17p), 11 pts (30.6%) had del(11q) and 8 pts (22.2%) had complex cytogenetics. Most patients (72%) received pre-SCT conditioning with FCR (Khouri et al, Exp Hematol 2004). 16 pts (44.4%) received rATG as part of their conditioning regimen. Graft-vs-host disease (GVHD) prophylaxis consisted of methotrexate and tacrolimus. 20 (55.6%) pts had acute GVHD and 19 (52.8%) had chronic GVHD. 5 (13.8%) pts had grade 3/4 acute GVHD and 1 (2.7%) had extensive chronic GVHD. When comparing pts who received SCT from unrelated donors (MUD, 24 pts) vs sibling donors (sib, 10 pts) there were no differences in rates of GVHD, disease progression or overall survival. Twenty-seven pts (75%) were in CR at first disease evaluation after SCT (CR conversion rate of 58.3%) and 2 pts (5.5%) had PD. On follow-up, another 15 pts (41.7%) presented PD. Median TTP was 14 months, with only 3 pts relapsing after 2 years from SCT. Eight pts who had PD and one patient who had a PR post-SCT received short-term anti-CLL therapy for disease debulking, followed by DLI. Six (66.6%) out of the 9 pts who received DLI achieved CR and are currently alive and in CR. Median follow-up post-DLI was 43 months and median duration of response to DLI was 47 mos (range 6-85 mos). Ultimately, 13 (36.1%) pts died, 8 (22.2%) were lost to follow-up, and 15 (41.7%) were alive at last contact. Disease progression was the most common cause of death (5 pts, 13.9%). Transplant-related mortality (TRM) was 13.9% (3 deaths due to infection, 2 deaths due to chronic GVHD). Only 2 deaths (5.5%) occurred during the first 100 days post-SCT, both due to infection. No deaths occurred due to acute GVHD. Median OS was 84 months. PFS (not accounting for pts who relapsed post-SCT but achieved CR with DLI) was 58% in the first year and 25% at five years. The median PFS was 19 months. Univariate and multivariate analysis of pre-SCT pt characteristics (age, time from Dx to SCT, number of therapies, stage, presence of adenopathy, MUD vs sib donor, cytogenetic abnormalities, ABO mismatch, disease status at SCT) did not show any statistically significant correlation with OS, PFS or GVHD rates. Conclusion: SCT remains the only curative option for CLL. Our experience shows that pts may achieve long-term survival with this approach. TRM was low (13.8%) and rates of acute and chronic GVHD were compatible with previous reports (Sorror et al, JCO 2005; Dreger et al, Blood 2010). Type of donor (MUD vs sib) did not impact outcomes, suggesting that patients without a matched sibling should not be denied transplantation if a MUD is available. Although 47% of the patients eventually progressed after transplantation, 66% of patients who received DLI for salvage were able to achieve CR and remain progression-free for a prolonged period of time, underlining the importance of the GVL effect. Most relapses occurred within the first 2 years post SCT and late relapses were rare. Figure 2 Figure 2. Figure 3 Figure 3. Disclosures Skarbnik: Gilead Sciences: Speakers Bureau; Seattle Genetics: Speakers Bureau; Genentech: Speakers Bureau; Abbvie: Consultancy; Pharmacyclics: Consultancy. Vesole:Celgene: Speakers Bureau; Takeda: Speakers Bureau; Janssen: Speakers Bureau; Amgen: Speakers Bureau; Novartis: Speakers Bureau. Goy:Pharmacyclics: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Writing support, Speakers Bureau; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Genentech: Research Funding; Janssen: Consultancy, Honoraria, Research Funding, Speakers Bureau; Infinity: Consultancy, Membership on an entity's Board of Directors or advisory committees; Acerta: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees. Feldman:Pharmacyclics: Speakers Bureau; Celgene: Speakers Bureau; Seattle Genetics: Consultancy, Speakers Bureau; Abbvie: Consultancy, Speakers Bureau. Leslie:Seattle Genetics: Speakers Bureau; Celgene: Speakers Bureau. Leslie:Seattle Genetics: Speakers Bureau; Celgene: Speakers Bureau.

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High Serum Level of APRIL Is Related to Increased Risk of Acute Gvhd

Blood ◽

10.1182/blood.v120.21.4161.4161 ◽

2012 ◽

Vol 120 (21) ◽

pp. 4161-4161

Author(s):

Soo-Jeong Kim ◽

Yundeok Kim ◽

Shin Young Hyun ◽

Ji Eun Jang ◽

Doh Yu Hwang ◽

...

Keyword(s):

T Cells ◽

Stem Cell ◽

Serum Level ◽

Stem Cell Transplantation ◽

Allogeneic Stem Cell Transplantation ◽

Acute Gvhd ◽

Blood Samples ◽

Cell Dose ◽

Increased Risk ◽

Matched Sibling

Abstract Abstract 4161 Introduction: Traditionally T cells were recognized as main effector of acute graft-versus-host disease. Many studies revealed that grafted T cell dose and activity or repertoire development of T cell is related to GVHD. Recently, the role of B-cells in pathogenesis of acute GVHD is actively investigated. BAFF and APRIL is known to be related to increased activity of many autoimmune diseases. APRIL (a proliferation-inducing ligand) is a cytokine of the tumor necrosis factor superfamily secreted by myeloid cells, dendritic cells and T cells. We studied on serum level of APRIL at early transplantation period for investigation of relationship between APRIL concentration and risk of acute GVHD. Materials and Methods: Forty-six patients who received HLA-matched sibling allogeneic stem cell transplantation in Severance Hospital From September 2003 to September 2009 with remaining stored blood samples were selected. Blood samples were collected at day 0 and day 14. After clot formation, sera were separated at 1,000 g for 3 minutes then stored at -80°C for analysis. Samples were measured by commercial ELISA kit for APRIL (Bender MedSystems, Vienna, Austria) according to the manufacturer's recommendations. Grading of acute GVHD followed IBMTR severity index. Result: Age at transplantation ranged from 16 to 52 years(median 35.5 yrs). Bone marrow was used in 7 patients (15.2%) and PB in 39(84.8%). Myeloablative conditioning regimen was used in 18 patients (39.1%) and total body irradiation in 6 patients (13.0%), 28 patients used reduced intensity conditioning regimens. Disease status at SCT was CR 29 patients (63%), non-CR 14(30.4%). Incidence of all grade of acute GVHD was 56.5% (26 patients) and incidence of aGVHD exceeding grade 1 was 34.8% (16 patients). Serum APRIL concentration ranged from 1.859 to 6.219 (median 3.101 ng/mL) for day0 sera and 1.822 to 15.507 (median 3.683 ng/mL) for day14 sera. Patients with higher level than median concentration showed correlation with increased tendency of acute GVHD by χ2 test in both day 0 (P=0.021) and day 14 (P=0.147). And then, patients were divided into two groups, one group included patients with steady higher level than median in both day 0 and day 14 (group1), while the others constituted group2. By χ2 test, group 1 showed correlation with acute GVHD (P=0.037). In multivariate analysis, conditioning intensity, donor-patient sex mismatch, stem cell dose, CD3+ cell dose, donor parity were included with steady higher APRIL level as variables. Higher APRIL was strongest variable for increased risk of acute GVHD (hazard ratio 64.67, P=0.005). Conclusion: Our data suggest that higher level of APRIL at early phase of allogeneic stem cell transplantation with HLA-matched sibling donor can be used as predictor of acute GVHD. Confirm of our hypothesis should be done also in larger patient data including alternative donors. Disclosures: No relevant conflicts of interest to declare.

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The Addition Of Sirolimus To The Gvhd Prophylaxis Regimen In Reduced Intensity Allogeneic Stem Cell Transplantation For Lymphoma: A Multicenter Randomized Trial

Blood ◽

10.1182/blood.v122.21.704.704 ◽

2013 ◽

Vol 122 (21) ◽

pp. 704-704 ◽

Cited By ~ 2

Author(s):

Philippe Armand ◽

Haesook T Kim ◽

Marie-Michele Sainvil ◽

Veronika Bachanova ◽

Steven M. Devine ◽

...

Keyword(s):

Overall Survival ◽

Stem Cell ◽

Stem Cell Transplantation ◽

Cumulative Incidence ◽

Acute Gvhd ◽

Chronic Gvhd ◽

Gvhd Prophylaxis ◽

Significant Difference ◽

Reduced Intensity

Abstract The mTOR inhibitor sirolimus has been used in the prevention and treatment of GVHD after allogeneic hematopoietic stem cell transplantation (HSCT). In parallel, mTOR inhibitors have demonstrated clinical activity against various lymphoma histologies. In a retrospective study, we found that patients with lymphoma undergoing reduced intensity conditioning (RIC) HSCT who received a sirolimus-containing GVHD prophylaxis regimen had a lower rate of relapse (Armand et al, J Clin Oncol. 2008;26(35):5767). We therefore performed a multicenter, phase III, open label randomized trial comparing tacrolimus, sirolimus and methotrexate (Tac/Sir/Mtx, with sirolimus starting on day -3 of HSCT) for GVHD prophylaxis to conventional sirolimus-free regimens (tacrolimus + methotrexate (Tac/Mtx) or cyclosporine + MMF (Csa/MMF), pre-specified by center), in patients undergoing RIC HSCT for any lymphoma except Burkitt lymphoma. The primary endpoint was 2-year overall survival (OS); progression-free survival (PFS), acute and chronic GVHD were among the secondary endpoints. 139 patients were enrolled at five institutions between June 2009 and September 2012. The median age was 57 years (range, 23-70). 42 patients had aggressive B-NHL, 31 indolent B-NHL, 28 CLL, 19 T-NHL and 19 Hodgkin lymphoma. 66 were assigned to the Tac/Sir/Mtx arm, and 73 to the control arm (67 to Tac/Mtx and 7 to Csa/MMF). All patients but 1 received the allocated intervention, and all received peripheral blood stem cell products, as mandated by the protocol. Based on a planned interim analysis, the DSMB recommended reporting of the interim results at this time. Median follow-up for survivors is 22 months, and only 12% of living patients have less than 12 months of follow-up. There was no evidence of increased toxicity in the Tac/Sir/Mtx arm. At the time of this analysis, the Kaplan-Meier estimate of 2-year OS by intent to treat (Figure 1A) is 66% (95CI, 51-77) in the Tac/Sir/Mtx arm vs. 71% (95CI, 58-81) in the control arm (p=0.7); the corresponding 2-y PFS (Figure 1B) is 62% (95CI, 48-73) vs. 56% (95CI, 43-68) (p=0.9). The conditional power for finding a significant difference in the primary endpoint of 2y OS is <1%, prompting the current report. There was no significant difference in non-relapse mortality (2y cumulative incidence 14% in both groups, p=0.9) or cumulative incidence of relapse (2y incidence 25% vs. 30%, p=0.8). However, the addition of sirolimus resulted in a significant decrease in the cumulative incidence of grade 2-4 acute GVHD (6-month cumulative incidence 9% vs. 25%, p=0.014; Figure 1C), even after excluding patients who received Csa/MMF. This was apparent in both patients receiving matched related and those receiving matched unrelated grafts. There was no significant difference in the incidence of grade 3-4 acute GVHD (3% vs. 4% at 6 months, p=0.7) or chronic GVHD (2-year cumulative incidence 59% vs. 55%, p=0.5; Figure 1D).Figure 1Figure 1. In conclusion, the addition of sirolimus to the GVHD prophylaxis regimen in patients with lymphoma undergoing RIC HSCT is associated with a significant decrease in grade 2-4 acute GVHD after transplantation, without impacting toxicity, severe acute GVHD, chronic GVHD, progression-free or overall survival. These results should be broadly applicable to all recipients of RIC HSCT using T-cell-replete peripheral blood stem cells, and suggest that tacrolimus, sirolimus and methotrexate could be a preferred regimen in this patient population. Pre-specified subgroup analyses by histology and correlative studies will be performed when follow-up is complete in late 2014. Disclosures: Off Label Use: Sirolimus, tacrolimus, methotrexate, cyclosporin, mycophenolate for GVHD prophylaxis.

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Mini-Allogeneic Transplantation in Multiple Myeloma: A Single-Center Ten-Year Experience

Blood ◽

10.1182/blood.v124.21.5928.5928 ◽

2014 ◽

Vol 124 (21) ◽

pp. 5928-5928

Author(s):

Lorenzo Iovino ◽

Enrico Orciuolo ◽

Gabriele Buda ◽

Francesco Caracciolo ◽

Francesco Mazziotta ◽

...

Keyword(s):

Stem Cell ◽

Acute Gvhd ◽

Chronic Gvhd ◽

Allogeneic Transplantation ◽

New Drugs ◽

P Value ◽

Stage At Diagnosis ◽

Previously Treated ◽

Reduced Intensity

Abstract Allogeneic stem-cell transplantation is a potential curative option in multiple myeloma (MM). Reduced-intensity conditioning regimens (allo-RIC) result in a lower transplant related mortality (TRM) compared to conventional conditioning, despite of a higher relapse rate. Several prospective studies compared single or tandem autologous stem cell transplantation (SCT) with planned tandem autologous-reduced intensity allogeneic SCT, with discordant results in overall and progression-free survival (OS and PFS). Many studies were conducted using a “mini-allo-SCT”, a regimen containing a low-dose total body irradiation (TBI) and Fludarabine (Flu). Moreover, introduction of new drugs (bortezomib, thalidomide or lenalidomide) in the first decade of 2000 changed the biological history of MM. We analyzed the results of ten-year experience with mini-allo-SCT in patients with MM in our institution. Patients, materials and methods: Between June 2000 and December 2010, 21 patients (9 M, 12 F, median age 54 – range 36-66) received a mini-allo-SCT, 17 from an HLA identical sibling donor, 4 from a MUD full-matched. The source of stem cell was the peripheral blood in all patients. All grafts were not manipulated. At the time of diagnosis, Durie-Salmon (DS) stage was I in 5 patients (23.8%), II in 3 patients and III in 13 patients (61.9%). Disease status at the time of transplant was partial response (PR) in 17 patients (81%), 13 of them in first PR, 4 in second or more PR; 4 patients received allo-SCT as salvage therapy in active ore refractory disease. Eleven patients (52.4%) underwent to transplant after one line of treatment, 5 patients after 2 lines, 5 patients after 3 or more lines. Five patients (23.8%) were treated with new drugs. Auto-SCT is included in previous lines. Nine patients received one auto-SCT before the mini-allo-SCT; ten patients (47.6%) underwent transplantation after two auto-SCT. Two patients were allo-grafted frontline. Conditioning regimen was Flu-TBI in all patients. Graft versus Host Disease (GvHD) prophylaxis consisted on cyclosporine and MMF in all. Results: Overall response rate was 76%, 5 PR and 11 complete remission (CR). One patient developed progression next allo-SCT. Four patients died in the first 100 days after allo-SCT, and they are censored for OS and PFS analyses. Of 17 pre-transplant PR, 11 achieved CR (64%), 4 maintained PR, 2 died before response evaluation. Of 4 patients who underwent allo-SCT in active disease, only 1 obtained a PR, whereas the other 3 patients developed progression or were not-valuable. Six patients (28.6%) developed acute GvHD, but no one died for complicated acute GvHD. Eleven patients (52.4%) had chronic GvHD. Follow up range was from 4 to 96 months. The median time was 19 months. The relapse/progression rate in course of follow up was 29%. Two patients progressed after PR (40%), 3 after CR (5.9%). At the time of the last follow-up 8 patients died (47%), 3 of them for progression of MM. Survival analyses: TRM at 1 and 3 years was respectively 24% and 31%. OS at five years was 51%, with a plateau trend after 3 years (Fig. 1). In univariate statistical analysis, early DS stage at diagnosis (I-II), double auto-transplant, development of chronic GvHD have a significant impact (p value <.05) on OS. PFS at 3 years was 39%, at 6 years was near 20% (Fig 1). Early DS stage at diagnosis (I-II), double auto-transplant, and development of chronic GvHD have a significant impact (p value <.05) on PFS. Both in OS than in PFS, the previous treatment with new drugs did not result in statistical significant improvement, but the curves are spaced (Fig. 3 a and b), with a better performance for patients treated with new drugs. Conclusions: Use of allogeneic transplantation in MM is limited because of high TRM. Mini-allo reduces the TRM. We observed 50% of long term survivors. DS stage at diagnosis, double auto-SCT and development of chronic GvHD impact on survival. New drugs demonstrate better trend in OS and PFS, despite the number of patients is too small to obtain a clear conclusion. This finding suggests the execution of further studies in this regard. Fig 1: OS and PFS curves Fig 1:. OS and PFS curves Fig 2: PFS for patients who developed or not chronic GvHD Fig 2:. PFS for patients who developed or not chronic GvHD Fig. 3a: OS in patients previously treated or not with new drugs ( p value > .05 ); Fig. 3b: PFS in patients previously treated or not with new drugs ( p value > .05 ) Fig. 3a:. OS in patients previously treated or not with new drugs ( p value > .05 ); Fig. 3b: PFS in patients previously treated or not with new drugs ( p value > .05 ) Disclosures No relevant conflicts of interest to declare.

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Clinical Outcomes of 2-Step Approach to Haploidentical Hematopoietic Stem Cell Transplantation (HSCT): Effects of CD34 Stem Cell Dose in the Setting of a Consistent T-Cell Dose

Blood ◽

10.1182/blood.v124.21.1212.1212 ◽

2014 ◽

Vol 124 (21) ◽

pp. 1212-1212

Author(s):

Sameh Gaballa ◽

Neil D. Palmisiano ◽

Onder Alpdogan ◽

Matthew Carabasi ◽

Joanne Filicko-O'Hara ◽

...

Keyword(s):

Stem Cells ◽

Overall Survival ◽

T Cells ◽

Stem Cell ◽

T Cell ◽

Clinical Outcomes ◽

Immune Recovery ◽

Platelet Recovery ◽

Cell Dose ◽

Related Mortality

Abstract Introduction: Haploidentical (HI) HSCT offers a curative option to patients (pts) who lack an HLA matched donor. In the 2-step approach, pts receive a relatively large, fixed T-cell dose (2 x 108/kg) followed 2 days later by cyclophosphamide (CY). CY eradicates only the alloreactive T-cells, thus inducing bidirectional tolerance. CD34-selected stem cells are then infused and are not exposed to CY. Unlike T-cell depleted approaches, the 2 step regimen allows for rapid immune recovery and lower infectious complications. Coupled with acceptable GVHD rates, this approach has been associated with low non-relapse mortality. Given the consistent T-cell dose utilized in all pts, we investigated the effects of the variable CD34 stem cells on clinical outcomes and immune recovery. Methods: We retrospectively analyzed data from 148 pts who underwent a 2-step approach to haploidentical peripheral blood HSCT at Thomas Jefferson University between February 2006 and February 2014. The myeloablative (MA) conditioning regimen consisted of 12 Gy of TBI administered over 4 days, while the reduced intensity conditioning (RIC) regimen consisted of fludarabine (30 mg/m2 D1-4) + cytarabine (2 gm/m2 D1-4)/or thiotepa (5 mg/kg D1-3) and a fraction of 2 Gy TBI (D6). Conditioning was followed by an infusion of 2 x 108 CD3+ cells/kg donor T cells (step 1). CY 60 mg/kg/d x 2 was given starting 2-3 days after the T cell infusion. A CD34 selected product was then infused (step 2). Tacrolimus and MMF were utilized for immune suppression. In a prior multivariate analysis in patients older than 60, we identified CD34 dose as affecting survival. Using recursive partitioning, a dose of 5.2 x106 was identified as the cutoff point demarcating differences in survival. This analysis compares differences in outcome in all patients who underwent the 2-step haploidentical HSCT regardless of age, using a cutoff CD34 dose of 5.2x106 to demarcate both groups. Results: Eighty-five pts received a CD34 dose < 5.2 x 106(low dose- LD) and 61 received a dose > 5.2 x 108 (high dose- HD). Pts characteristics are shown in the table. Median follow up was 19 months. HD group had a faster platelet recovery (p=0.007) and more rapid CD3/4 and CD3/8 recovery by day 30 (p=0.001). The incidence of grades II-IV GVHD was not statistically different between both groups (p= 0.76). Probability of overall survival (OS) at 5 years was 50% and 62% in the LD and HD groups, respectively (log-rank= 0.14) with relapsed disease being the major cause of death in both groups. OS was significantly better in the HD in a subset of patients above the age of 60 (n=57, log-rank= 0.032). The 5-year cumulative incidence of relapse related mortality and non-relapse related mortality were not statistically significant between both groups; RRM: LD= 27%, HD= 20% (p=0.45); NRM: LD= 24%, HD=17% (p=0.32). Conclusion: Based on a platform of identical T cell dosing, the higher CD34 stem cell dose group had more rapid platelet engraftment, earlier immune recovery and better overall survival in a subset of patients above the age of 60. There were no differences in GVHD rates between both groups, which favors the use of a higher CD34 stem cell dose in this approach. Table Lower Dose (<5.2 x 106) Higher Dose (>5.2 x 106) Number 85 61 Age (range) 58 (19-74) 52 (19-78) Sex (M/F) 49/36 36/25 Median CD3/4 day 30 (cells/ uL) 34 71 Median CD3/8 day 30 (cells/ uL) 30 57 Median CD34 cells [x 106/kg] (range) 3.52 (1.4-5.18) 7.31 (5.3-10.6) Disease status at time of HSCT Remission (%) 38 (45) 24 (39) Active disease (%) 47 (55) 37 (61) Disease Myeloid Malignancy (%) 58 (68) 31 (51) ALL (%) 11 (13) 11 (18) NHL (%) 11 (13) 13 (21) Others (%) 5 (6) 6 (10) Conditioning MA (%) 52 (61) 34 (56) RIC (%) 33 (39) 27 (44) Outcomes: Median ANC recovery [days] 12 11 Median Platelet recovery [days] 19 17 aGVHD II-IV (%) 33 (39) 26 (43) aGVHD III-IV (%) 8 (9.4) 4 (6.5) cGVHD (%) 14 (16) 2 (3) Relapse (%) 25 (29.4) 14 (23) Deaths (%) 41 (48) 20 (33) Relapse 21 10 Infection 6 3 Toxicity 10 7 GVHD 4 0 CMV Reactivation 41 (48) 25 (41) Figure 1 Figure 1. Figure 2 Figure 2. Disclosures No relevant conflicts of interest to declare.

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