Allografts Selectively Photodepleted of GvHD Causing T Cells and Followed by Low-Level Immunosuppression: A Novel Method to Improve Disease Control After HLA-Matched Sibling Transplantations.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 515-515
Author(s):  
Stephan Mielke ◽  
Aarthi Shenoy ◽  
Katayoun Rezvani ◽  
Agnes S. M. Yong ◽  
Zachariah A. McIver ◽  
...  
Keyword(s):  
T Cells ◽  
Stem Cell ◽  
High Risk ◽  
The Netherlands ◽  
Acute Gvhd ◽  
Study Cohort ◽  
Post Transplant ◽  
Current Trial ◽  
Donor T Cells ◽  
Grade Iii

Abstract Abstract 515 We established a highly efficient GMP-grade, ex-vivo selective allodepletion process where host-activated donor T cells are eliminated based on their preferential retention of the photosensitizer 4,5-dibromorhodamine 123 (TH9402) and exposure to visible light (Kiadis Pharma, The Netherlands). As relapse of disease largely impairs the overall success of allogeneic stem cell transplantation we aimed to improve this outcome by using selectively T cell depleted allografts in order to reduce post transplant immunosuppression and thereby enhance graft versus malignancy effects. To determine the appropriate level of post transplant immunosuppression we designed a three sequential de-escalation stage trial with grade III-IV acute GvHD as the primary endpoint involving 17 patients per study cohort. Here we report on the first completed study cohort of NIH trial 07-H-0136 where seventeen patients (median age 44 (28-68) years) with hematological malignancies received a CD34-selected (Miltenyi, Germany) stem cell allograft together with 5 × 106/kg selectively depleted donor T cells following an age-adapted, radiation-based preparative regimen (FluCyTBI). Eleven patients had high risk disease (including ALL (Ph+, CR>1), refractory NHL, AML/MDS, AML with chloroma and blast crisis CML). Low-dose cyclosporine was used as sole immunosuppression for 90 days post transplant in the absence of GvHD. At a median follow-up of 385 (119-714) days actuarial probabilities (±SEM) of acute GvHD were 35±12% for grade II-IV and 0% for grade III-IV. Non-relapse mortality (NRM) was low with 17±11%. Overall survival (OS) was 73±12% and relapse-free survival (RFS) was 65±13% with a relapse probability of 21±11% (Figure). A low relapse incidence in a high-risk population suggests functionality of selectively allodepleted T cells. The absence of severe GvHD reflects the efficacy of the allodepletion process. Based on these findings we have initiated recruitment for the next study cohort where post transplant immunosuppression will be limited to 45 days only. Ultimately the aim is to achieve further reduction in immunosuppression in the absence of severe GvHD in order to enhance graft versus malignancy effects and thereby improve the outcome after allogeneic stem cell transplantation especially for patients at high risk for relapse. Disclosures: Mielke: Kiadis Pharma, The Netherlands: Research Funding, The current trial is supported under a clinical trial agreement between NHLBI and Kiadis.. Savani:Kiadis Pharma Inc., The Netherlands: Consultancy. Barrett:Kiadis Pharma, The Netherlands: The current trial is supported under a clinical trial agreement between NHLBI and Kiadis..

Upregulation of Immune Checkpoint Blockade Molecules Post Allogeneic Stem Cell Transplantation Is Necessary but Insufficient to Prevent GvHD

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 1101-1101
Author(s):  
Mohammad Sohrab Hossain ◽  
Ghada M Kunter ◽  
Vicky Fayez Najjar ◽  
David L. Jaye ◽  
Edmund K. Waller
Keyword(s):  
T Cells ◽  
Transcription Factor ◽  
Stem Cell ◽  
T Cell ◽  
Cd8 T Cells ◽  
Acute Gvhd ◽  
Time Points ◽  
Post Transplant ◽  
Donor T Cells ◽  
Over Time

Abstract Donor T-lymphocytes are effective adoptive immunotherapy in the context of allogeneic hematopoietic stem cell transplantation (allo-HSCT), but life threatening complications related to GVHD limits its clinical application. Recent advancement in the field of immunotherapy has directed our interest to enhancing the anti-tumor response of donor T cells by modulating expression of checkpoint blockade molecules including programmed death-1 (PD-1), cytotoxic T-lymphocyte associated antigen-4 (CTLA-4) and foxp3, the transcription factor associated with regulatory T cells. The two ligands of PD-1, PD-L1 or PD-L2 are highly expressed in the presence of inflammatory signal induced by infection or cancer and PD-1/PD-L1 interaction negatively regulates T-cell antigen receptor (TCR) signaling and dampen T cell cytotoxic activity. Herein, we studied the role of PD-1, CTLA-4 and transcription factor foxp3 expressing donor CD4+ and CD8+ T cells in the development of GVHD. Methods: We have used two established allo-HSCT murine GvHD models. Lethally irradiated wild type (WT) B6, PD-L1 knock out (KO) B6 and PD-L2 KO B6 mice were transplanted with 2 x 106 splenic T cells and 2 x 106 T cell depleted bone marrow (TCD BM) cells from H-2Kdonors. Lethally irradiated CB6F1 recipients were similarly transplanted with splenocytes and TCD BM cells from B6 donors. Acute GvHD scores were determined by combining scores obtained from histological tissue sections and weight-loss, posture, activity, fur texture and skin integrity following standard published procedures. The activation status of donor T-cells and BM and host-derived non-T cells in GvHD target organs was analyzed by flow cytometry. Data from allo-HSCT recipients were compared with the respective data obtained from B6 à B6 syngenic HSCT (syn-HSCT) recipients. Serum cytokines were determined by Luminex assay. Results: PD-L1 KO B6 allo-HSCT recipients had significantly increased acute GvHD scores compared with WT B6 allo-HSCT recipients (p<0.0005) and B6 PD-L2 KO allo-HSCT recipients (p<0.0005) measured on day 8 after transplant. All PD-L1 KO allo-HSCT recipients died within 10 days post transplant while WT B6 and PD-L2 KO allo-HSCT recipients had 20% mortality until 36 days post transplant. Increased acute GvHD was associated with increased amount of serum inflammatory cytokines and increased numbers of activated PD-1+CD69+CD4+ donor T cells. Interestingly, PD-1 expression on donor CD4+ T cells significantly increased in the spleen of transplant recipients but not in BM, while PD-1 expression was significantly increased on donor CD8+ T cells in both spleen and BM compartments of allo-HSCT recipients compared with the syn-HSCT recipients. CTLA-4 expression on CD4+ and CD8+ donor T cells were significantly increased in spleen in the first two weeks post transplant but decreased at later time points compared with syn-HSCT. Again, CTLA-4 expression on CD4+ donor T cells in the BM remained significantly higher measured on 100+ days post transplant in allo-HSCT recipients compared with the syn-HSCT but similar levels of CTLA-4 expression on CD8+ T cells were measured in BM between these two HSCT recipients. Foxp3 expression on donor T cells and the numbers of CD4+CD25+foxp3+ regulatory T (Tregs) were markedly suppressed in donor T cells on day 4 post HSCT of allo-HSCT recipients compared with the syn-HSCT recipients. Although total numbers of donor T cells in the spleen of allo-HSCT recipients remained low over time, the percentage of PD-L1-expressing donor T cells in spleen were significantly higher (p<0.005) at early time points (day 4) in allo-HSCT recipients compared with the syn-HSCT. While total numbers of host-derived cells in spleen decreased over time in mice that developed GvHD, host-derived PD-L1 expressing CD3+ T cells persisted at higher levels through day 36 post transplant. Additionally, PD-L1 expression was also increased in donor BM-derived T cells and non-T cells populations over time. Collectively, these data indicate that severe GvHD occurs in allo-HSCT recipients in spite of increased numbers of PD-1, CTLA-4 and PD-L1 expressing donor and host cells. The occurrence of severe GvHD in these allo-HSCT models systems was associated with markedly reduced levels of CTLA-4 and foxp3 transcription factor expressing Tregs indicating that these pathways may be more relevant to controlling GvHD than PD-1:PD-L1 expression. Disclosures No relevant conflicts of interest to declare.

Phase I Clinical Study of Donor Lymphocyte Infusion Depleted of Alloreactive T Cells after Haplotype Mismatched Myeloablative Stem Cell Transplantation To Limit Infections and Malignant Relapse without Causing GVHD.

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 309-309 ◽  
Author(s):  
Denis-Claude Roy ◽  
Sandra Cohen ◽  
Lambert Busque ◽  
Douglas Fish ◽  
Thomas Kiss ◽  
...  
Keyword(s):  
T Cells ◽  
Stem Cell ◽  
T Cell ◽  
High Risk ◽  
Phase I ◽  
Acute Gvhd ◽  
Hematologic Malignancies ◽  
Infectious Complications ◽  
Cell Transplant ◽  
Post Transplant

Abstract Patients with very high risk hematologic malignancies who cannot find an HLA-matched related or unrelated donor can benefit from haplo-mismatched transplantation. The latter is, however, complicated by frequent and severe infectious complications and disease relapse due to delayed immune reconstitution. We have previously reported that photodynamic therapy (PDT) could selectively deplete donor alloreactive populations while preserving lymphocytes for immune responses. Indeed, the dibromorhodamine derivative TH9402 (Celmed BioSciences) has a propensity to accumulate in activated but not resting T cells. We present results of an ongoing Phase I clinical trial of haplo-mismatched allogeneic stem cell transplant (SCT) supplemented with donor lymphocyte infusions (DLIs) PDT depleted of host-reactive T cells. Nine high-risk patients with hematologic malignancies (5 AML relapsed or refractory, 2 MDS, 1 NHL relapsing after autologous SCT, 1 refractory CLL) entered the trial, 7 are evaluable for acute GVHD and reconstitution. Patients (4 M, 3 F) underwent transplantation with donor cells mismatched at 3 HLA Ags: 2 patients; 2Ags: 4 pts, and DR only: 1 pt). Donor mononuclear cells (MNCs) were incubated with recipient MNCs for 4 days, exposed to TH9402 PDT, stored frozen, and administered on day 30±3 after transplant at 3 graded DLI dose levels: 1×104 (1pt), 5×104 (3pts), and 1.3 x105 (3pts) CD3+ cells/kg. Anti-host cytotoxic T lymphocyte precursors (CTLp) were depleted from DLIs by approximately 1.5 logs, and flow cytometry showed greater than 90% elimination of activated T cells (CD4+CD25+ and CD8+CD25+) by TH9402 PDT. All stem cell grafts underwent in vitro immunomagnetic T cell depletion using CD34+ positive cell selection (Miltenyi). Median age at SCT was 57 years (range: 40–58). Five patients were in partial remission or had progressive disease, and 2 patients were in complete remission at the time of SCT. The myeloablative regimen consisted of TBI (1200 cGy), thiotepa (5 mg/kg) and fludarabine (40 mg/m2/day for 5 days) followed by infusion of CD3 depleted HSC grafts. A median of 9.2×106 CD34+ cells/kg were infused on day 0. No GVHD prophylaxis was administered. Evaluable patients showed durable hematologic engraftment: median time to >0.5×109 granulocytes/L was 10.5 days (8–20), and to >20×109 platelets/L without transfusion, 12 days (9–137) and achieved complete donor chimerism. No patient developed acute GVHD (grade II–IV), while 3 patients developed signs of chronic GVHD. Two patients died: one (cohort 1) of a post-transplant lymphoproliferative disease, and one (cohort 2), of relapsed AML. No other patient relapsed. Two pts (1 in cohort 2 and 1 in cohort 3) recovered greater than 0.3×109 CD3+ and CD4+ cells/L at 2 and 5 months post-DLI, and 4 pts had >0.2×109 CD3+ cells/L at 6 mo post-DLI. Although 4 patients developed infectious complications (HSV, CMV, Nocardia, Aspergillus), all resolved rapidly with appropriate therapy. The overall disease-free-survival and survival are 57% at 1 year (median follow-up: 9.4 mo). Our results indicate that the post-transplant infusion of a PDT treated DLI is feasible, does not induce acute GVHD, and may accelerate T cell reconstitution. This PDT strategy could represent an appealing alternative for patients in the higher age range who are at high risk for GVHD.

Selective Depletion of Alloreacting CD25+ Cells from Stem Cell Allografts Can Reduce Acute Graft-Versus-Host Disease Following Matched Related Donor Transplantation.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 426-426
Author(s):  
Scott R. Solomon ◽  
Thao Tran ◽  
Charles S. Carter ◽  
Nancy Hensel ◽  
Laura Wisch ◽  
...  
Keyword(s):  
T Cells ◽  
Stem Cell ◽  
Graft Versus Host Disease ◽  
Acute Gvhd ◽  
Cell Transplant ◽  
Host Disease ◽  
Graft Versus Host ◽  
Gvhd Prophylaxis ◽  
Donor T Cells ◽  
Related Donor

Abstract Graft-versus-host disease (GVHD) remains a major cause of morbidity and mortality after allogeneic stem cell transplant (SCT), especially in older patients. We previously showed that host-reactive donor T cells are selectively depleted (SD) from an allograft ex vivo, following a short co-culture of donor cells with irradiated T cell stimulators from the recipient and subsequent treatment with an anti-CD25 immunotoxin. We report a pilot study to test the hypothesis that GVHD could be decreased in a cohort of elderly patients receiving SD allografts from HLA-identical sibling donors. Sixteen patients, median age 65 years (range 51–73), with advanced hematologic malignancies were transplanted following reduced-intensity conditioning with fludarabine and either cyclophosphamide (n=5), melphalan (n=5), or busulfan (n=6). Cyclosporine was used as the only additional GVHD prophylaxis. SD allografts contained a median CD34 dose of 4.5x106/kg (range 3.5–7.3) and an SD CD3 dose of 1.0x108/kg (range 0.2–1.5). Fifteen patients achieved sustained engraftment. The helper T lymphocyte precursor (HTLp) frequency assay demonstrated depletion of host-reactive donor T cells in 9/11 cases tested from a mean of 1/182,089 to 1/822,354 (mean 5.5-fold depletion), while third party responses were conserved. Kaplan-Meier estimates of probability of grade II-IV and grade III-IV acute GVHD were lower than those seen in a historical control group of patients receiving cyclosporine alone for GVHD prophylaxis (35±13% vs. 57±10%, p=0.34) and (7±6% vs. 38±6%, p=0.05), respectively. Of note, the two patients who developed visceral (gut ± liver) GVHD showed ineffective allodepletion by HTLp (figure). Chronic GVHD occurred in five of 14 evaluable patients. At a median follow-up of 212 days (range 60 – 690), seven of sixteen patients remain alive and in remission. Relapse deaths occurred in four patients (refractory AML [2], therapy-related MDS [1], and CMML [1]). Non-relapse mortality in this high-risk cohort of patients included graft failure [1], GVHD [2], infection [1], and myocardial infarction [1]. In summary, CD25-directed allodepletion of stem cell allografts can reduce clinically relevant acute GVHD following matched related donor transplantation. Figure Figure

Killer Immunoglobulin-Like Receptor and NOD2/CARD15 Polymorphisms Independently Influence Survival after Allogeneic Hematopoietic Stem Cell Transplanation.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 2167-2167
Author(s):  
Sebastian Giebel ◽  
Aleksandra Holowecka-Goral ◽  
Izabela Nowak ◽  
Tomasz Czerw ◽  
Jerzy Wojnar ◽  
...  
Keyword(s):  
T Cells ◽  
Stem Cell ◽  
Acute Gvhd ◽  
Chronic Gvhd ◽  
Hematopoietic Stem ◽  
Kir Genes ◽  
Increased Risk ◽  
Grade Ii ◽  
Card15 Gene ◽  
Grade Iii

Abstract Background: Activating and inhibitory killer immunoglobulin-like receptors (KIRs) regulate function of NK cells and a subset of T cells. KIR genotype, in particular the content of activating KIR genes is highly polymorphic. NOD2/CARD15 protein is broadly expressed in APCs and lymphocytes. Single nucleotide polymorphisms (SNPs) of this gene have been reported to impair the pathogen elimination and trigger pathologic immunologic reactions like GvHD. The goal of this prospective study was to evaluate the impact of donor’s and recipient’s KIR and NOD2/CARD15 genotypes on outcome after allogeneic hematopoietic stem cell transplantation (alloHSCT). Pateints and methods: One-hundred-two consecutive patients with hematological malignancies, aged 32(18–58)y, treated with alloHSCT from HLA-matched related (n=34) or matched unrelated donor (MUD) (n=68) were included. The conditioning regimen was myeloablative, GVHD prophylaxis consisted of CsA, Mtx, and, in case of MUD-HSCT, pre-transplant ATG. Donors and recipients were tested for 11 KIR genes as well as SNP8,12,13 of the NOD2/CARD15 gene. In addition, immune reconstitution including KIR expression on T cells, was analyzed on days +28, +56, +100, +180, and +360. Results: Overall survival (OS) rate at 2y was significantly lower in alloHSCT with at least one activating KIR mismatch compared to transplants with full compatibility (62% vs. 86%, p=0.01). In particular, the presence of at least one activating KIR in the donor with its absence in the recipient (D+R−) was associated with decreased probability of OS (60% vs. 78%, p=0.01) and DFS (58% vs. 82%, p=0.005), as well as increased incidence of non-relapse mortality (NRM) (27% vs. 7%). KIR2DS1 and KIR3DS1 D+R− mismatches resulted in increased risk of grade II–IV acute GvHD, whereas KIR2DS3 and KIR2DS2 D+R− mismatches were associated with increased risk of chronic GvHD. The presence of at least one activating KIR D+R− mismatch was associated with increased CD8+/CD4+ T cell ratio up to day +100. In all cases of incompatibility regarding KIR2DS1, KIR2DS2 and KIR3DS1, T cells with expression of respective receptors could be detected up to 360 days after alloHSCT. The presence of SNP8 of the NOD2/CARD15 gene in the recipient was associated with decreased probability of OS (20% vs. 70%, p=0.005) and DFS (20% vs. 70%, p=0.01) as well as increased incidence of NRM (60% vs. 17%) and grade III–IV acute GvHD (67% vs. 8%). In a multivariate analysis including KIR and NOD2/CARD15 polymorphisms together with other potential risk factors, increasing number of D+R− activating KIR mismatches as a linear variable appeared to independently influence OS (HR: 1.3, p=0.02), DFS (HR: 1.3, p=0.008), NRM (HR: 1.4, p=0.02), grade II–IV acute GvHD (HR: 1.4, p=0.001), and chronic GvHD (HR: 1.2; p=0.02). Recipient SNP8 of NOD2/CARD15 was predictive for OS (HR: 5.5, p=0.003), DFS (HR: 4.4, p=0.008), NRM (HR: 5.9, p=0.006), grade III–IV acute GvHD (HR: 6.1, p=0.02), and chronic GvHD (HR: 3.7; p=0.03). Conclusions: Both activating KIR D+R− mismatches and recipient SNP8 of NOD2/CARD15 appear to enhance alloreactivity and independently influence survival after alloHSCT. Evaluation of these polymorphisms may contribute to better donor selection and optimization of the alloHCT procedure.

Post-Transplant Cyclophosphamide and Bortezomib Combination for Prevention of GvHD after Allogeneic Blood and Marrow Transplantation Is Feasible and Produces Favorable Outcomes

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 3920-3920
Author(s):  
A. Samer Al-Homsi ◽  
Tara S Roy ◽  
Kelli Cole ◽  
Marlee Bogema ◽  
Stephanie F Williams ◽  
...  
Keyword(s):  
T Cells ◽  
Marrow Transplantation ◽  
Acute Gvhd ◽  
Chronic Gvhd ◽  
Post Transplant ◽  
Blood And Marrow Transplantation ◽  
Gvhd Prophylaxis ◽  
Cmv Reactivation ◽  
Grade Iii

Abstract Graft versus host disease (GvHD) remains a major barrier to the progress of blood and marrow transplantation and limits its wide applicability. Standard prophylactic regimens essentially targeting T lymphocytes are partially effective and burdensome. Cyclophosphamide (Cy) administered post-transplant selectively deletes alloreactive proliferating T cells, promotes expansion of regulatory T cells, and induces long-lasting depletion of intrathymic host-reactive T cells. It is an attractive option for prevention of GvHD and has already been used alone in matched related and unrelated donor transplants. However, despite a low incidence of chronic GvHD, acute GvHD still occurs in 50% of cases and is grade III-IV in 15% of cases. Dendritic cells (DCs) play a pivotal role in the early phase of GvHD. Proteasome inhibitors such as bortezomib (Bor) have a number of immunomodulatory effects including inhibition of DCs maturation and function. We therefore initiated a phase I feasibility study combining post-transplant Cy & Bor. Twelve patients with hematological malignancies undergoing peripheral blood allogeneic transplantation from matched related (n=6) or unrelated (n=6) donors have so far been enrolled. Disease risk index (DRI) was low in 4, intermediate in 3 and high or very high in 5. The conditioning regimen combined fludarabine and busulfan (total 6.4 mg/kg). Patients receiving graft from unrelated donors also received rabbit anti-thymocyte globulin at 5-8 mg/kg. The dose of Bor was escalated in standard fashion. Three patients in each of cohorts 1 and 2 received 0.7 and 1 mg/m2 respectively. The subsequent 6 patients received 1.3 mg/m2. All patients received 2 IV doses, 6 hours after graft infusion and 72 hours thereafter. Cy was given at 50 mg/kg IV on days +3 and +4. Steroids were not allowed after day 0. Engraftment was prompt in all patients. Median time to neutrophil engraftment was 15.5 days (range 14-25). One patient failed to meet criteria for platelet engraftment. The patient had acyclovir-resistant herpes genitalis and CMV reactivation requiring protracted therapy with foscarnet. The remaining patients had a median time to platelet recovery of 28 days (range 15-109). All patients achieved full chimerism by day 20 except one who had residual CLL and did not reach full chimerism until day +119. No patient developed secondary graft failure. Two treatment-related deaths occurred on day +150 due to RSV pneumonitis and on day +200 due to acute sepsis. One patient with recurrent multiple myeloma after autologous transplantation died due to progressive disease. No other Common Toxicity Criteria grade 3 or 4 occurred in any patient. With a median follow-up of 21 months (range 1-27), the overall 2-year predicted disease free survival and overall survival were both 60%. Incidence of acute GvHD in 11 patients with follow-up > 100 days, was 64%: grade I 55%, grade II 9%, and grade III-IV 0%. GI and liver acute GvHD were not encountered. Only 4 patients received systemic steroids for acute GvHD; only one required > 20 mg/day of prednisone. One patient developed chronic GvHD of the liver (biopsy-proven). Another patient developed poor appetite and weight loss on day +138. Endoscopy showed gastric ulceration. No biopsy was obtained. Neither calcineurin nor m-TOR inhibitors were ever used. Two patients developed extensive HSV-genito-rectal ulcers; one had prior history of recurrent flares. When institutional guidelines were changed to start acyclovir at the beginning of conditioning as opposed to day +5, no other cases was noted. Seven patients developed CMV reactivation and required preemptive therapy only. One patient developed BK virus-induced hematuria and 1 patient developed CNS toxoplasmosis. In summary, the calcineurin and m-TOR inhibitor-free post-transplant Cy & Bor combination for GvHD prophylaxis is feasible and safe. Although the small number of patients prevents any definite conclusion, the absence of incidence of grade III-IV acute GvHD and the sparing of the GI tract and liver are promising. Furthermore, the completion of GvHD prophylaxis by day +4 without the need for close renal and drug level monitoring are both practical and appealing. Updated results with longer follow-up will be reported at the meeting. A confirmatory phase II study is underway. Disclosures Al-Homsi: Millennium Pharmaceuticals: Research Funding. Off Label Use: Bortezomib use for aGvHD prevention.

Outpatient Haploidentical Peripheral Blood Stem-Cell Transplantation with Post-Transplant Cyclophosphamide in Children and Adolescents

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 4389-4389
Author(s):  
Oscar Gonzalez-Llano ◽  
Elias Eugenio Gonzalez-Lopez ◽  
Ana Carolina Ramirez-Cazares ◽  
Edson Rene Marcos-Ramirez ◽  
Guillermo J. Ruiz-Arguelles ◽  
...  
Keyword(s):  
Stem Cell ◽  
T Cell ◽  
High Risk ◽  
Children And Adolescents ◽  
Hematological Malignancies ◽  
Acute Gvhd ◽  
Chronic Gvhd ◽  
High Dose ◽  
Post Transplant

Abstract Patients with high-risk hematological malignancies have a poor prognosis without a hematopoietic stem cell transplant. An HLA- haploidentical donor is available in 95% of the cases, and post-transplant cyclophosphamide permits the use of T-cell replete grafts in settings were ex-vivo manipulation is not available. The experience with HLA-haploidentical HSCT with PBSC and post-tranplant Cy in the pediatric and adolescent population is limited; we report the following experience. We retrospectively collected data on 25 patients (0 to 21 years old) with hematological malignancies, who underwent ambulatory haploidentical HSCT with post-transplant Cy from November 2011 to November 2014. The different conditioning regimens are described in Table 1. All patients received high-dose Cy(50mg/kg) on days +3 and +4. Cyclosporine A (CYA; 6mg/kg/d per os) and mycophenolate mofetil (MMF; 15mg/kg two times daily per os) were started on day +5. MMF was discontinued on day +35 and tapering of cyclosporin started day +90 in the absence of GVHD. All patients received anti-microbial prophylaxis for bacteria, fungal, herpes infection and Pneumocystis jiroveci according to institutional practices. First chimerism was performed at day +30, and second chimerism at day +100. Primary graft failure was defined when neutrophil counts did not exceed 0.5 x 109/L by day +30. Acute and chronic GVHD were graded according to NIH criteria. Patient, donor and stem-cell harvest characteristics are described in Table 1. All patients had high risk hematological malignancies. There were 5 patients who underwent their first transplant on 1st CR, 4 with ALL with high risk cytogenetics and 1 with AML. All other patients were defined as high risk because they were refractory/relapsed. Twenty-three patients (92%) had neutrophil engraftment after a median 17 (7-24) days. Platelet engraftment was observed in 20 (80%) patients after a median of 14.5 (11-23) days, 3 (12%) patients did not have platelet counts below 20,000/mcL. One patient was catalogued as a primary failure for not achieving neutrophil and platelet engraftment by day +30. One patient died before engraftment at day +10 of septic shock. Four patients (16%) died before day +30. The only patient that did not have a complete chimerism, had a diagnosis of AML and 30% of donor cells by day +30, by day +45 relapse of disease was documented. After a median follow-up of 157 days, 13 patients (52%) remain alive, with an estimated 1-year OS of 52% (95%CI: 30.4 - 65.6%).Nine patients (36%) died of complications (mainly infectious) not related to relapse at a median time of 66 days (10-579 days) from stem cell infusion. Nine patients (36%) relapsed in a median time of 105 days (45-288 days); three of those patients died at days +150, +113 and + 370 from transplant. Estimated 1 year event-free survival is 40.2% (95%CI: 41.3 - 75.8%) (Figures 1 and 2). Patients transplanted on 1st CR had a median follow-up of 664 days with an OS and EFS of 80% (4 patients), which was statistically different from the rest of the population (p=0.03) (Figure 3). Among those who engrafted (n=21), 9 cases (42.9%) had grade 2-4 acute GVHD and 4 cases (19%) of grade 3-4 acute GVHD. Three patients (14.3%) developed chronic GVHD, two had mild skin or liver cGVHD. One patient had severe (NIH stage 3) skin cGVHD, she was alive and with a grade 2 cGVHD until last follow up at day +893. Outpatient procedure, HLA-haploidentical HSCT including PBSC as a stem cell source, and post-transplant T-cell in vivo depletion using high-dose cyclophosphamide is feasible in children and adolescents, with acceptable rates of response and GVHD. Table 1. Patient, donor and harvest characteristics Variable N=25 Age, median(range in years) 10 (1-21) Gender, n(%) Male Female 17 (68%) 8 (32%) Diagnosis, n(%) ALL-B ALL-T AML CML 16 (64%) 2 (8%) 5 (20%) 2 (8%) Time from diagnosis to transplant (months) 17.2 (1.9-153.5) Conditioning regimen, n(%) Cy 1500mg/m2 + Flu 75mg/m2 + Bu 9.6mg/kg (IV) Cy 1050mg/m2 + Flu 75mg/m2 + Bu 12 mg/kg (oral) Cy/VP-16/RT Cy/Flu/Mel 16 (64%) 6 (24%) 2 (8%) 1 (4%) Donor, n(%) Mother Father Sister 20 (80%) 3 (12%) 2 (8%) Donor age, median(range in years) 38 (17-49) Infused CD34+ x 106/kg, median(range) 11 (3.2-20) Disclosures No relevant conflicts of interest to declare.

Impact of Donor IL-7Rα Polymorphism On Recipient Plasma IL-7 levels and Acute Gvhd Following Allogeneic Stem Cell Transplantation.

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 1464-1464
Author(s):  
Stephanie Thiant ◽  
Zaiba Shamim ◽  
Lars Peter ◽  
Valérie Coiteux ◽  
Jean Paul Dessaint ◽  
...  
Keyword(s):  
T Cells ◽  
Stem Cell ◽  
Cd8 T Cells ◽  
Plasma Levels ◽  
Acute Gvhd ◽  
Memory T Cells ◽  
Effector Memory ◽  
Post Transplant ◽  
Α Chain ◽  
Central Effector

Abstract Abstract 1464 IL-7 is one of essential driving forces for homeostatic peripheral expansion of T lymphocytes that are responsible, not only for GVL effects but also for acute GVHD, a major post-transplant complication. High plasma levels of IL-7 in the early phase post-transplant, has been associated with high incidence of severe acute GVHD regardless the intensity of conditioning regimen. Inter-individual variations have also been reported. Here we aimed to identify factors that could have an impact on IL-7 level and, therefore, on acute GVHD. This prompted us to prospectively investigate plasma levels of IL-7, T-cell subsets recovery, T cells’ IL-7Rα chain expression, and IL-7Rα chain polymorphism in 100 pts who underwent fully HLA-matched allogeneic stem cell transplantation in our unit. Pts received either myeloablative (n= 60) or nonmyeloablative (n=40). Forty donors were unrelated. Source of stem cells, was bone marrow in 71 pts and PBCS in 29. Sex ratio (M/F) was (66/34) and median age at transplant was of 49 years. Plasma IL-7 level was determined by ELISA at enrolment, on day 0 before grafting, every three days during the first month, and then on days 60 and 90. CD3+, CD4+, CD8+ T-cells and NK cells counts at day 30, 60 and 90 post-graft were obtained by flow-cytometry-based technique. Expression of IL-7Rα (% and MFI) was evaluated on each subset of naïve and memory T-cells, categorized according to their expression of CD45RA and CCR7 markers. The detection of IL-7Ra single nucleotide polymorphism (SNPs) by sequence specific PCR (SSP), in donors, was carried out as described by Shamim et al, (BMT 2006). IL-7 receptor consisted of γc-chain and specific α-chain. A range of IL7R α-chain SNPs was reported (+510 C/T, +1237 A/G, +2087 T/C which all resulted in amino-acid substitution). At the time of analysis, 40 (40%) recipients had developed grade 2–4 acute GVHD (aGVHD) with a median time of 33 days post transplant. As expected, IL-7 levels peaked around the second week at median of 11.5 pg/mL (0.4-30.2) after transplant. Kinetic courses of plasma IL-7 levels, evolved inversely to lymphocyte counts up to d+30 (p<.001). The cumulative incidence of aGVHD was higher if by day+18 pts had IL-7 levels above the median concentration (p= .046). A higher level of IL-7 at day+18 was confirmed as a predictive factor of subsequent risk of aGVHD (HR= 1,079; 95% CI: 1.022 – 1.139; p= .006). By calculating the area under the curve of IL-7 between d-15 and d+30, we observe that a high exposure to IL-7 during the first month is correlated with the risk of aGVHD (p=.002). IL-7 plasma levels were inversely correlated with IL-7Rα expression only on central/effector memory CD4+ and central/effector memory CD8+, and terminally differentiated CD8+ T-cells (p =.006, .013, .044, .001 and .028, respectively). Of note, at d+30, pts had 85% (34-99) and 86% (23-99) of CD4+ and CD8+ memory T cells, respectively. Contrary to +1237 A/G and +2087 T/C, donor's +510 CC or CT was the only polymorphism to be associated with higher level of plasma IL-7 in recipients during the first month post-transplant in particular at d+18, predictive date for aGVHD (p = .026). In multivariate analysis, pts who received graft from donor with +510CC or CT experienced more often grade 2–4 aGVHD than those with +510 TT (P = .049). Collectively, this study confirms the role of IL-7 in grade 2–4 aGVHD. Indeed, the high level of IL-7 that down regulates IL-7Rα, could suggest activation and consumption of IL-7 by alloreactive T cells, including those involved in aGVHD development. By difference in affinity and cytokine consumption, the polymorphism +510 of donor t-cell IL-7R α-chain might explain, in part, the wide variation of IL-7 level among pts. Disclosures: No relevant conflicts of interest to declare.

Prospective Phase II Study of Prophylactic Azacitidine and Donor Lymphocyte Infusions Following Allogeneic Hematopoietic Stem Cell Transplantation for High Risk Acute Myeloid Leukemia and Myelodysplastic Syndrome

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 1162-1162 ◽  
Author(s):  
Thierry Guillaume ◽  
Ibrahim Yakoub-Agha ◽  
Reza Tabrizi ◽  
Cecile Borel ◽  
Patrice Chevallier ◽  
...  
Keyword(s):  
Heart Failure ◽  
Immune Response ◽  
Stem Cell ◽  
High Risk ◽  
Prophylactic Treatment ◽  
Acute Gvhd ◽  
Chronic Gvhd ◽  
Post Transplantation ◽  
Hematopoietic Stem ◽  
Post Transplant

Abstract Although allogeneic hematopoietic stem cell transplantation is presently the only curative option for many patients with AML or MDS, relapse remains the main cause of morbidity and mortality. Strategies are therefore developed to prevent relapse. Post-transplant immune intervention with administration of prophylactic or pre-emptive donor lymphocyte infusion (DLI) and/or chemotherapy maintenance using DNA-demethylating agents such as azacitidine (aza) is being investigated. The exact mechanism of action of aza remains obscure and might be due in part to tumor antigen upregulation or other gene induction by tumor cells causing an immune response. We enrolled, in a clinical trial (ClinicalTrials.gov Identifier:NCT01541280), patients (pts) with high risk AML or MDS and candidates for allo-HSCT transplantation to receive azacitidine (aza) and DLI post-transplant as prophylactic treatment with the primary objective to reduce the relapse rate at 2 years following allo-HSCT and secondary objectives to increase disease free survival at 2 years post-transplant, increase overall survival at 2 years, investigate feasibility and safety of maintenance strategy combining chemotherapy and immunotherapy and follow the incidence and severity of acute and chronic GVHD. High risk AML was defined as AML in CR1 with unfavorable cytogenetics, AML in CR2 or greater remission, refractory AML or in relapse prior allogeneic transplantation. High risk MDS was defined as MDS with intermediate-2 group and higher risk group according to IPSS criteria. Aza was scheduled to begin between d+56 and d+112 post-transplant at the doses of 32 mg/m²/d sc for 5 days every 28 days for up to a total of 12 cycles if the pt had not acute GVHD >1 or severe infection. The first DLI was started following 3 cycles of aza and discontinuation of immunosuppressive prophylaxis, and if the pt had no clinical signs of GVHD, uncontrolled infection or a recent history of gr>2 acute GVHD. Two other DLI were scheduled every 8 weeks after the 5th and 7th cycle of aza. The doses of DLI 1, 2 and 3 were respectively 5x106, 1x107, 5x107 CD3+cells/kg for related donor, and 1x106, 5x106, 1x107 CD3+cells/kg for unrelated donor. Sixty-four patients were pre-included prior transplantation, 30 pts were subsequently included, 20 pts with AML and 10 pts with MDS, median age 58 y (22-70). The status at transplantation was: CR1 = 16 pts (53%), CR2 = 6 pts (20%), refractory = 5 pts (16%), upfront transplantation for MDS = 3 pts (10%). Cytogenetics was normal or intermediate for 15 pts and unfavorable for 15 pts (namely 8 pts with complex caryotype). Conditioning was myeloablative for 11 pts, reduced for 19 pts (including 2 sequential). Donors were unrelated volunteers in 18 pts (60%).The time between allografting and first aza cycle was 66 days (38-93). The median number of cycles of aza administered was 5 (1-12) with 10 pts (33%) completing the 12 cycles. Forty one DLI were injected in 17 pts: 5 pts received one DLI, 2 pts received 2 DLI, 8 pts received 3 DLI. Two additional pts received 4 and 5 DLI because of a mixed chimerism. The first DLI was given at a median of 142 d (129-221) post transplantation. Aza was well tolerated, but was discontinued in 20 pts: because of GVHD (n=11), relapse (n=5), GVHD/infection (1pt), sudden death due to heart failure (n=1), withdrawal of consent (n=2, one after 1 cycle and another after 5 cycles). Four months following transplantation, 24 (80%) demonstrated full donor chimerism (>95%) in CD3+ cells. Nine patients developed grade 1 to 3 acute GVHD (CI 29.8±9%), 6 who did not receive DLI and 3 following DLI (grade 1 n=2, grade 2 n=3, grade 3 n=4). No grade 4 acute GVHD was observed. Nine pts developed chronic GVHD (2 limited, 7 extensive), 3 who did not receive DLI, 6 following DLI. Twenty patients are alive. With a median follow-up from the allotransplant for those alive of 36 months (range 12 - 46 months), the survival at three years is 66%. Causes of death were infection (n=1), relapse (n=8), sudden death due to heart failure (n=1). The median time to relapse was 5 months (2.5-9) and the cumulative incidence of relapse at 3 years 28.1±8.5%. These results confirm that aza is well tolerated as a prophylactic treatment to reduce the risk of post-transplantation relapse. The incidence of GVHD following aza + DLI was not overwhelming. Analysis of T cell population and immune response as well as comparison to matched-pair control are currently performed and will be presented. Disclosures Moreau: Amgen: Honoraria; Novartis: Honoraria; Janssen: Honoraria, Speakers Bureau; Takeda: Honoraria; Bristol-Myers Squibb: Honoraria; Celgene: Honoraria.

Biomarkers Predicting Acute GvHD and Transplant Outcomes in 120 Consecutive Allogeneic HSCT Recipients

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 2240-2240
Author(s):  
Raffaella Greco ◽  
Francesca Lorentino ◽  
Maria Teresa Lupo Stanghellini ◽  
Linda Cheyenne Vaccari ◽  
Rosamaria Nitti ◽  
...  
Keyword(s):  
Stem Cells ◽  
Stem Cell ◽  
High Risk ◽  
Risk Index ◽  
Haematopoietic Stem Cell ◽  
Post Transplant ◽  
Gvhd Prophylaxis ◽  
Prophylactic Measures ◽  
Very High ◽  
Grade Iii

Abstract Background: Allogeneic haematopoietic stem cell transplantation (allo-HSCT) is the only curative treatment for many haematological diseases. Despite advances in supportive therapies, acute Graft-versus-Host Disease (aGvHD) remains the leading cause of early morbidity and mortality. There are shortcomings in the prediction of aGVHD, indicating the urgent need for non-invasive and reliable laboratory tests to allow a precision-medicine tailored prophylactic approach. Aims: We conducted a prospective observational study to ascertain the potential usefulness of the levels of eleven biomarkers, measured pre- and at +7 days post-alloHSCT, in predicting the development and severity of aGvHD in allo-HSCT patients. These time-points were chosen as early risk stratification may provide a window for additional prophylactic measures. Methods: We collected data from 120 consecutive patients (41 female and 79 male; median age 52, range 19-77 years) who underwent allo-HSCT at our institute between 2014 and 2015. Most patients were affected by myeloid malignancies (AML=52%, MDS=11%, MPN=5%) while 32% were of lymphoid origin (ALL, MM and lymphomas). Revised disease-risk index (DRI, Armand et al.) was low or intermediate for 41% of pts, high for 44% and very high for 15% of them. Most patients (n=101) received peripheral blood stem cells (PBSC). Stem cell donors were unrelated (n=39, HLA matching 9/10 in 14 and 10/10 in 25), family haploidentical (n=56), HLA-identical sibling (n=21), or cord blood (n=4). Post-transplant GvHD prophylaxis was PT-Cy-bases in 65 patients, ATG-bases in 28 patients, both agents in 18 cases whilst 9 patients received neither. Additionally, sirolimus and MMF were used as additional GvHD prophylaxis according to institutional guidelines. The following biomarkers were measured 7 days pre- and post-transplant: interleukin-6 (IL6), Ceruloplasmin(CER), Cholinesterase (CHE), Albumin, Immunoglobulin A, Gammaglutamyl-transferase (GGT), White Blood Cells, Neutrophils, Haemoglobin,Platelets and Glycaemia. ROC curves were used to define optimal cut-offs of the biochemical variables to predict 100-day severe aGvHD and 100-days TRM by logistic regression. Then cumulative incidences curves (CI) for aGvHD and TRM and overall-survival (OS) curves were computed comparing patients under and over the identified cut offs for the variables with the best reported sensitivity and specificity. Multivariate Cox proportional hazard regression was finally applied. Results: The 100-days CI of grade III-IV aGvHD was 13.5%, with a 100-days CI of TRM of 12%. The 1-year OS was 64%. Death was reported in 49 of the total 120 patients: 5/49 deaths were attributable to aGvHD. At baseline, IL6 threshold value of 2.5 pg/ml was significantly associated with the prediction of 100-days severe aGVHD (sens 65%, spec 61%) and TRM (sens 75%, spec 61%). Patients with IL-6 concentration equal or superior to 2.5 pg/ml had higher 100-days CI of severe aGvHD (16% Vs 6%, p 0,03) and TRM (12% Vs 3%, p 0,06). Interestingly, higher IL6 concentrations were associated to worse 1-year OS (42% Vs 82%, p<0,001) and were able to better stratify OS also in patients with the same DRI class (OS in low-intermediate risk: 58% vs 85%; high-risk 39% vs 78%; very high-risk 21% vs 49%; p 0,01). At 7 days after HSCT, GGT values were raised in patients who later developed grade III-IV GvHD (cut-off 129 U/l by ROC analysis, sens 69%, spec 67%). Indeed, patients with GGT>= 129 U/l levels had higher 100-days CI of severe aGVHD (15% vs 7%, p 0,16) and TRM (13% vs 4%, p 0,01), in addition to worse OS (53% vs 71% at 1y, p 0,03). By multivariate analysis (adjusting for age, DRI, Sorror comorbidity index, type of donor, source of stem cells, and backbone of GvHD prophylaxis) pre-transplant IL6 concentrations were significantly associated to severe aGvHD (HR 3, p 0.04), TRM (HR 3, p 0.06), and OS (HR 2.6, p 0,004). Conclusion: In our series, baseline IL6 levels are predictors of aGvHD, especially with regards to grade III/IV aGvHD and translate in a higher risk of TRM and worse OS. This biomarker could be incorporated in a treatment algorithm to increase primary GvHD prophylaxis in patients at risk of severe aGVHD, potentially improving the final outcome of allo-HSCT. Disclosures Ciceri: MolMed SpA: Consultancy.

scholarly journals Selective depletion of alloreactive donor lymphocytes: a novel method to reduce the severity of graft-versus-host disease in older patients undergoing matched sibling donor stem cell transplantation

Blood ◽  
2005 ◽  
Vol 106 (3) ◽  
pp. 1123-1129 ◽  
Author(s):  
Scott R. Solomon ◽  
Stephan Mielke ◽  
Bipin N. Savani ◽  
Aldemar Montero ◽  
Laura Wisch ◽  
...  
Keyword(s):  
T Cells ◽  
Stem Cell ◽  
Graft Versus Host Disease ◽  
Older Patients ◽  
Acute Gvhd ◽  
Ex Vivo ◽  
Host Disease ◽  
Graft Versus Host ◽  
Cd34 Cells ◽  
Donor T Cells

AbstractWe have selectively depleted host-reactive donor T cells from peripheral blood stem cell (PBSC) transplant allografts ex vivo using an anti-CD25 immunotoxin. We report a clinical trial to decrease graft-versus-host disease (GVHD) in elderly patients receiving selectively depleted PBSC transplants from HLA-identical sibling donors. Sixteen patients (median age, 65 years [range, 51-73 years]), with advanced hematologic malignancies underwent transplantation following reduced-intensity conditioning with fludarabine and either cyclophosphamide (n = 5), melphalan (n = 5), or busulfan (n = 6). Cyclosporine was used as sole GVHD prophylaxis. The allograft contained a median of 4.5 × 106 CD34 cells/kg (range, 3.4-7.3 × 106 CD34 cells/kg) and 1.0 × 108/kg (range, 0.2-1.5 × 108/kg) selectively depleted T cells. Fifteen patients achieved sustained engraftment. The helper T-lymphocyte precursor (HTLp) frequency assay demonstrated successful (mean, 5-fold) depletion of host-reactive donor T cells, with conservation of third-party response in 9 of 11 cases tested. Actuarial rates of acute GVHD were 46% ± 13% for grades II to IV and 12% ± 8% for grades III to IV. These results suggest that allodepletion of donor cells ex vivo is clinically feasible in older patients and may reduce the rate of severe acute GVHD. Further studies with selectively depleted transplants to evaluate graft-versus-leukemia (GVL) and survival are warranted.

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