Results of a Prospective Clinical Trial of Pre-DLI Lymphoreduction Using Oral Fludarabine In Patients with Mixed Chimerism Post Allogeneic Transplant.

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 1299-1299
Author(s):  
Bronwen E. Shaw ◽  
Jenny Byrne ◽  
Emma Das-Gupta ◽  
Mark Ethell ◽  
Daniel Figueroa ◽  
...  
Keyword(s):  
Single Dose ◽  
T Cell ◽  
Lymphocyte Count ◽  
Response Rates ◽  
Mixed Chimerism ◽  
Disease Relapse ◽  
Time Points ◽  
Post Transplant ◽  
Donor Chimerism ◽  
Reduced Intensity

Abstract Abstract 1299 Donor leukocyte infusions (DLI) are frequently used following reduced intensity conditioned (RIC) transplants to convert mixed donor chimerism (MC) to full donor chimerism (FDC). In part, due to the significant correlation, which several studies have shown between persisting MC and an increased risk of disease relapse. There are few factors which have been consistently shown to predict for responsiveness. We recently reported response rates (conversion to FDC) of approximately 50% in patients with MC. Patients with a high peripheral blood lymphocyte count pre-DLI were significantly less likely to respond than patients with a low lymphocyte count (33% compared to 89%) (Shaw BE et al, BBMT 2007;13(5):550-9). Based on these and other data we hypothesised that the use of a lymphoreducing agent pre-DLI in those with a high lymphocyte count would enhance DLI responsiveness and hence improve clinical outcomes. We instituted a prospective pilot trial (CCR2942) to investigate this hypothesis. Inclusion criteria were: 1. mixed chimerism in whole blood (< 95% donor), 2. previous reduced intensity transplant for a haematological malignancy or failure to respond to a previous dose of DLI and 3. a lymphocyte count of >1.0 × 109/l. Patients consenting to the trial received three doses of oral fludarabine as an outpatient at 25mg/m2 on day -7, -6 and -5. DLI was given on day 0. The starting dose of DLI for patients with MC alone was 5 × 105 CD3/kg (unrelated donor) or 1 × 106 CD3/kg (sibling donor). Higher doses were used in those with evidence of both disease and MC. Samples were collected at various time points for Ki67 and T cell subset analysis. To date, 15 patients have been entered onto the trial and 13 have reached the study end point (day 90 chimerism) (1 early death due to leukaemia relapse, 1 currently too early for assessment). Each received a single dose of DLI. The disease categories were: AML (8), ALL (1), MDS (2), T-PLL (1), HD (1), DLBCL (1) and MCL (1). Only 2 patients had co-existing evidence of disease (morphological relapse of AML, 2% positive by immunophenotyping in T-PLL). The mean age was 51 years (range: 22–66), 9 males and 6 females. 11 HLA-matched sibling donors and 4 10/10 allele matched unrelated donors. The majority of patients (11) had conditioning with fludarabine, melphalan and alemtuzumab, with cyclosporine post transplant. The median time to DLI post-transplant was 7.2 months (range: 3–11). The median percentage of donor chimerism pre-DLI was 85% (range: 18–93). The median lymphocyte count pre-DLI was 1.3 (range: 1.0–2.7). Of the 13 eligible patients, 9 (69%) have responded to a single dose of DLI (CR=8 (>95%), PR=1 (chimerism 94% donor at study end)). Three patients developed GvHD – grade 1 (liver), grade III (liver/GI), grade IV (liver/skin). GVHD resolved completely in all cases and all patients achieved FDC. 3 patients reactivated a virus (CMV, 2 × EBV), although not all required treatment. The chimerism level pre-transplant was associated with response, with those below the median having a trend towards a worse response rate (p=0.052, Fishers exact test). As only 2 patients had measurable disease at study entry, this parameter was not statistically assessed, however the patient with a frank relapse of AML progressed rapidly despite DLI, suggesting that this strategy may not be sufficiently aggressive in that setting. We analysed the patterns in T cell subsets (CD8, CD4 and Tregs). There was a significant decrease in the absolute numbers of CD8 and CD4 cells between day -7 and day 0, while the absolute number of Tregs was not significantly changed. Interestingly, we found significantly higher absolute counts at all time points in both CD8 and Treg subsets in the DLI responders, compared to non-responders (unpaired t-test, mean: 13.66 vs 0.03, p<0.0001 and mean: 0.018 vs 0.008, p<0.004 respectively). There were no significant differences in CD4 counts. In conclusion, in patients with MC, the use of pre-DLI lymphoreduction results in good response rates, superior to a historical cohort. The incidence of GVHD and adverse events is low. Preliminary finding suggest that both CD8 and Treg subsets may play a role in responsiveness. For patients with very low levels of donor chimerism or frank disease relapse an increased intensity of pre-DLI chemotherapy is likely to be necessary. Larger patient numbers and randomised studies are required to investigate the efficacy of this approach further. Disclosures: No relevant conflicts of interest to declare.

Low Pre-DLI Lymphocytes Counts Are Predictive of Good Disease Responses in Patients with Mixed Chimerism Following Campath-Containing Reduced Intensity Transplants.

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 261-261
Author(s):  
Bronwen E. Shaw ◽  
Jenny L. Byrne ◽  
Emma Das-Gupta ◽  
Ian Carter ◽  
Nigel H. Russell
Keyword(s):  
Lymphocyte Count ◽  
Residual Disease ◽  
Suppressor Cells ◽  
Mixed Chimerism ◽  
Post Transplant ◽  
Donor Chimerism ◽  
Significant Difference ◽  
Group B ◽  
The Impact ◽  
Reduced Intensity

Abstract Following reduced intensity conditioned (RIC) transplants, donor leukocyte infusions (DLI) are frequently used either to convert mixed chimerism (MC) to full donor chimerism (FDC) or for residual or relapsed disease. Unfortunately, DLI are not universally successful and few factors are known (e. g disease type and level of pre-DLI chimerism) which predict for good responses. We analysed the impact of the chimerism pattern in 125 recipients of (CAMPATH containing) RIC transplants for malignant diseases. Of these, 68 (55%) had FDC (group A), 49 (39%) developed MC and 8 (6%) lost DC and had autologous reconstitution (group D). The patients who developed MC could be further subdivided into those with persisting MC post transplant (27, 55%; group B: non-responders) and MC post transplant with subsequently development of FDC (22, 45%; group C: responders). These two groups were analysed further. The median patient age was 55 (range: 19–71). The donors were siblings (22) or unrelated (27). The diseases were as follows: AML/MDS 14, CML 4, Myeloma, 4, lymphoma/CLL 26, MF 1. Stem cell source was PBSC (38) and bone marrow (11). Conditioning consisted of fludarabine, melphalan and campath (fmc) in 24 patients; fludarabine, busulphan and campath (fbc) in 5; BEAM, campath +/− fludarabine in 18 and FLAG in 2. There were no significant differences in any of these features between groups B and C. 25/49 patients received DLI. This was for disease relapse in10 patients, residual disease in 6 and MC alone in 8 (Unknown in 1). A complete disease response (CDR) was seen in 9/14 (64%) evaluable cases. There was a highly significant difference in CDR between the two groups (group B: 0/4, group C: 9/10, p=0.005). The reason for the difference in response rate was investigated. Median time to DLI was 196 days (range: 57–2123), not significantly different between the groups (p=0.561). The indication for and total number of DLI, the underlying disease and the degree of pre-DLI donor chimerism were not significantly different. In addition there was no significant difference in the incidence of post DLI GvHD (p=0.137), although this was 10/13, 77% in those who responded and 2/5, 40% in those who did not. Conversely, there was a significant difference in the pre-DLI lymphocyte counts (p=0.036). The median count was 2.24 × 109/l. In group B 3/11 (27%) were below this while 10/14 (71%) in group C were below this. The pre-DLI lymphocyte count was not significantly correlated with the time post transplant at which DLI was given, the type of donor, the indication for DLI or the disease, conditioning or post transplant immunosuppression regimen. The predicted overall survival at 2 years was significantly better in group C than in group B (95% versus 57%, p=0.002). This was largely due to the higher relapse risk in group B (77%) compared to group C (32%) (p=0.043). In conclusion, in patients with MC, the development of FDC was significantly associated with a superior OS. In those receiving DLI, the factor most significantly predictive for a ‘responsive’ (C) versus ‘non-responsive’ (B) pattern was the presence of a low pre-DLI lymphocyte count, suggesting that a lack of ‘space’ for expansion or increased suppressor cells in the lymphoid compartment mediate DLI resistance. We postulate that DLI ‘non-responders’ (those with higher lymphocyte counts) may be converted to ‘responders’ by the addition of pre-DLI lymphoreduction, thus reducing relapse and improving outcome.

High Absolute T Regulatory Cell Counts and Resistance of CD8 Central Memory Cells to Killing by Fludarabine Predicts for Poor Responses to DLI in the Context of a Pre-DLI Lymphoreduction Strategy

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 1912-1912
Author(s):  
Sameer Tulpule ◽  
Nigel H. Russell ◽  
Jenny Byrne ◽  
Emma P Das-Gupta ◽  
Mark E Ethell ◽  
...  
Keyword(s):  
Single Dose ◽  
T Cell ◽  
Lymphocyte Count ◽  
T Test ◽  
Central Memory ◽  
Memory Cells ◽  
Time Points ◽  
Post Transplant ◽  
Subset Analysis ◽  
The Absolute

Abstract Abstract 1912 The response to donor leukocyte infusions (DLI) can be improved by the use of pre-DLI lymphoreduction. The mechanism underlying this is poorly explained. In order to investigate this further we examined the T cell subsets in patients entered into a clinical trial testing the utility of pre-DLI lymphoreduction using fludarabine. Inclusion criteria were: 1. mixed chimerism (MC) in whole blood (< 95% donor), 2. previous reduced intensity transplant for a haematological malignancy or failure to respond to a previous dose of DLI and 3. a lymphocyte count of >1.0 × 109/l. Patients consenting to the trial received three doses of oral fludarabine as an outpatient at 25mg/m2 on day −7, −6 and −5. DLI was given on day 0. The starting dose of DLI for patients with MC alone was 5 × 105 CD3/kg (unrelated donor) or 1 × 106 CD3/kg (sibling donor). Higher doses were used in those with evidence of both disease and MC. Samples were collected at D-7, D0, D+7, D+28, D+60 and D90 for T cell subset analysis. Samples were analysed for a combination of markers for CD4, CD8 and T regs using multicolour flow cytometry. CD4 and CD8 were analysed for subset: central memory (CM 62L+RA-), effector memory (EM 62L-RA-), naïve (N 62L+RA+) and effectors (EFF 62L-RA+). Tregs were characterised as CD4+25hi127loFOXP3+. The study was a phase II pilot study with 18 patients required. At the end of the trial, 17 patients were eligible for analysis (1 early death due to leukaemia relapse). The disease categories were: AML (7), ALL (1), MDS (4), T-PLL (1), HD (2), DLBCL (1) and MCL (1). Only 2 patients had co-existing evidence of disease (morphological relapse of AML, 2% positive by immunophenotyping in T-PLL). The median age was 55 years (range: 22–66). There were 10 males and 7 females. 12 patients had HLA-matched sibling donors and 5 had 10/10 matched unrelated donors (UD). The majority of patients (13) had conditioning with fludarabine, melphalan and alemtuzumab, with cyclosporine post transplant. Each received a single dose of DLI on the trial. The median time to DLI post-transplant was 7.4 months (range: 4–11.7). The median percentage of donor chimerism pre-DLI was 85% (range: 18–93). The median lymphocyte count pre-DLI was 1.3 (range: 1.0–3.8). Of the 17 eligible patients, 11 (65%) responded to a single dose of DLI (CR=9 (>95%), PR=2 (chimerism 94% donor at study end)). Five patients developed GvHD – grade 1 (n=2), grade 2 (n=1), grade III/IV (n=2). GVHD resolved completely in all cases. 3 patients reactivated a virus (CMV, 2 × EBV), although not all required treatment. No pre-DLI clinical factor had a significant impact on DLI responsiveness including: disease type, age, gender, donor type, product source (sibling, UD), pre-DLI chimerism, pre-DLI lymphocyte count, time to DLI or source of DLI (mobilised or non-mobilised cells). Post DLI GvHD did not have a significant association with response. There was a significant decrease in the lymphocyte count, as well as the absolute numbers of CD8 (unpaired t test, p<0.0001) and CD4 (unpaired t test, p<0.005) cells between day D-7 and D0 in all patients. The absolute number of Tregs was not significantly different between D-7 and D0, however, DLI responders had a significantly higher absolute Treg count at all time points compared to non-responders (unpaired t test, p<0.005). In addition, DLI responders had a significantly higher Treg/CD8 ratio of means compared to non-responders at all time points (unpaired t test p<0.05). There were no significant differences in CD4 or CD8 counts between responders and non-responders. CD8 subset analysis showed a significant reduction in the CD8 CM cells in the responders (unpaired t test, p<0.001) between D-7 and D0, while this was not seen in the non-responders (p=0.3). In conclusion, lymphoreduction with fludarabine pre-DLI is associated with high response rates to a single dose of DLI and a low incidence of GvHD. Interestingly, Treg counts do not appear to be reduced by fludarabine and higher Tregs counts at all time points were associated with responsiveness to DLI. Conversely, CD8 subsets were reduced following fludarabine, but relative resistance in CD8 memory cells was associated with poor responses to DLI. These findings suggest future strategies to test novel delivery of DLI as well as potential mechanisms of action. Disclosures: No relevant conflicts of interest to declare.

Donor Lymphocyte Infusions Induce High Response Rates and Durable Salvage in Relapsed Hodgkin Lymphoma Post T Cell Depleted Allogeneic Transplantation.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 200-200
Author(s):  
Karl S Peggs ◽  
Kirsty Thomson ◽  
Emma Morris ◽  
Noha Chowdhry ◽  
Stephanie Verfuerth ◽  
...  
Keyword(s):  
T Cell ◽  
Hodgkin Lymphoma ◽  
Cumulative Incidence ◽  
Response Rates ◽  
High Response ◽  
Mixed Chimerism ◽  
Term Survival ◽  
Post Transplant ◽  
Relapse Rates

Abstract Abstract 200 The feasibility of performing allogeneic HSCT in patients with Hodgkin Lymphoma using reduced intensity conditioning (RIC) is well established. By reducing non-relapse mortality, these approaches have seemingly improved post-transplant survival outcomes compared to conventional myeloablative strategies. An EBMT registry analysis comparing outcomes with fully ablative protocols confirmed an overall survival advantage for RIC in adult patients (Sureda et al, JCO, 2008). Relapse rates, however, were higher following RIC, and relapse now represents the major cause for treatment failure following allogeneic transplant in HL. Identifying strategies that reduce relapse rates or more effectively salvage relapsing patients is therefore an imperative. There is no consensus regarding these issues, and little published evidence to guide practice. We have performed 72 RIC allografts for HL (38 matched sibling, 34 unrelated donor) incorporating T cell depletion with alemtuzumab at our institution. This high risk cohort included 33 primary refractory or salvage-refractory patients, and 53 had failed a prior autograft. Patients were monitored for lineage-specific chimerism using a PCR-based STR assay, and disease status assessed by CT-PET, potentially allowing earlier intervention for relapse. Patients received a dose-escalating donor lymphocyte protocol from 6 months post transplant for mixed chimerism or residual disease/progression. Relapse was defined by recurrence or progression of FDG-avid lesions in sites of prior disease, with or without new sites. In cases where FDG-avid lesions occurred only in new sites relapse was confirmed by biopsy if accessible (n=3), otherwise an interval scan was performed at 6–8 weeks to confirm progression in the absence of other potential pathology. Cyclosporine was withdrawn prior to consideration of DLI, which was not given to patients with active GvHD. Non-relapse mortality was 13% at 1 year and 15% at 3 years post transplant. Cumulative incidence of relapse was 46% at 3 years. Forty patients have received a total of 78 DLIs (median 2 doses, range 1–5). Median CD3+ T cell dose was 3×10e7/kg (range 1×10e6–3×10e8/kg). Treatment was given for mixed chimerism alone in 19 patients, with up to 90% recipient chimerism. This group included 9 who were primary refractory or salvage refractory prior to transplant. DLI resulted in conversion to full donor status in 12/15 evaluable patients, 2 continue to show falling recipient chimerism, and 1 failed to convert. Three are currently too early to assess and 1 died prior to evaluation. Nine remain free from GvHD, suggesting that conversion can occur in its absence. Only 1 patient in this cohort subsequently relapsed (cumulative incidence 7% at 3 years from initial DLI), and this occurred in the setting of persistent mixed chimerism. The patient received further DLI following cytoreductive chemotherapy. Disease relapse was treated in 22 patients with DLI either alone (n=15) or following debulking chemo-radiotherapy (n=7). Five relapsed/progressive patients did not receive DLI, either because of early progression within 3 months of transplant, concurrent GvHD, or lack of donor availability. Median starting doses of DLI were 1×10e6 and 1×10e7 CD3+ T cells/kg in unrelated and related donors respectively, and median maximal doses 3×10e6 and 3×10e7/kg respectively. Complete responses were seen in 10 (50%) and partial responses in 5; overall response 75% of 20 evaluable patients. The majority of responders (9/10 CR, 4/5 PR) developed GvHD (5 acute grade III–IV, 4 extensive chronic). CR is maintained in 6 patients at a median of 4.8 years (range 1.3–7.5 years) from last DLI (5/6 received DLI alone at relapse, and 4 have no current GvHD), 3 died in CR of complications of GvHD, and only 1 progressed (at 2.3 years). 2/5 with PR progressed, and follow-up in the others is short (<12 months). With a median follow-up of 2.5 years from relapse the projected 3 year OS and PFS from time of relapse are 62% and 52% in this cohort of 22 patients. The OS and current PFS for the entire cohort (n=72) are both 45% at 6 years. In conclusion, the data demonstrate favorable long term survival in this heavily pre-treated cohort, a strikingly low relapse incidence in those receiving DLI for mixed chimerism, and the ability of DLI guided by CT-PET restaging to induce high response rates and durable salvage in the setting of relapse post T cell depleted transplantation in HL. Disclosures: No relevant conflicts of interest to declare.

Dendritic Cells Recovery and Chimerism after Reduced Intensity Hematopoietic Stem Cell Transplantation.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 5341-5341
Author(s):  
Reza Tabrizi ◽  
Francis Belloc ◽  
Xavier Lafarge ◽  
Virginie Perreau ◽  
Krimo Bouabdallah ◽  
...  
Keyword(s):  
T Cells ◽  
Dendritic Cells ◽  
Stem Cell ◽  
Conditioning Regimen ◽  
Mixed Chimerism ◽  
Hematopoietic Stem ◽  
Post Transplant ◽  
Sibling Donor ◽  
Donor Chimerism ◽  
Reduced Intensity

Abstract The circulating dendritic cells (DC) are known to have an immunoregulatory role after allogeneic HSC transplantation, and recipient DC have been shown to be important in the development of GVHD in animal model. We studied the DC chimerism of 21 patients (pts) transplanted with reduced intensity conditioning regimen between January 2004 and August 2005. The blood was sampled at days -1, 15, 28 and 56 after transplantation. A series of 17 control normal bloods were also analyzed. DC were identified as ILT3-expressing cells negative for CD14. These cells were sorted by flow cytometry and chimerism was analyzed by PCR of Short Tandem Repeat motifs. Preliminary experiments showed that at least 500 sorted cells were necessary to perform chimerism analysis. Eight females and 13 males (median of age: 54 yrs; 25–61) were enrolled in the study. Diagnoses were 6 AML, 2 sAML, 1 MDS, 3 ALL, 6 MM, 2 NHL and 1 CML. Fifteen pts had high-risk disease. As conditioning regimen, all but 3 pts received cumulative dose of ATG (Thymoglobulin, Genzyme, Lyon, France) (2.5 mg/kg for sibling and 7.5 mg/kg for MUD), in addition to Busulfan 8 mg/kg and Fludarabine 150mg/m2. Eight pts received stem cells from a 10/10 MUD, 2 pts from 9/10 MUD, and 11 pts from sibling donor. For all but one patient, the stem cell source was blood. CsA alone was used for 11 pts, CsA with methotrexate for 8 pts and CsA with MMF for 2 pts. In the absence of aGVHD, the immunosuppressive therapy was tapered within 4 weeks (after day 28 in sibling donor and after day 90 for MUD). The kinetics of the absolute number of DC showed significantly lower count of circulating DC than in control samples at day -1, and a rapid increase, reaching normal values at day 15 post-transplant while the other leukocytes remained at a low value. To determine the origin of post-transplant blood DC, chimerism was analyzed on sorted DC. From 20 pts DC chimerism at day 15 was of full donor origin for 8 pts, mixed in 10 pts. Two pts had no detectable DC. At day 28 from 18 pts, only 4 pts had mixed chimerism. Of these 4 pts, 3 presented at day 56 a full donor chimerism and one patient died from relapse. For T cells at day 15, only one/17 pt had full donor chimerism, and one had no detectable circulating T cells. At day 28, 7/20 pts had full donor chimerism and one without detectable T cells. Only 2/17 had still mixed chimerism at 3 months. Six out of 21 pts relapsed and 3 died from relapse. Among these 6 pts, all but one reached full donor T cells, 3 had a full donor DC at day 28. Six pts from 21 had grade ≥ 2 aGVHD and 3 died from aGVHD. 7/17 evaluable pts had cGVHD. We didn’t found any correlation between DC chimerism and engraftment or relapse. At day 15, the median percentage of recipient DC was lower in pts who developed cGVHD (P&lt;0.017) while it was higher in those with aGVHD (but p not significant). In conclusion, this study demonstrates that the circulating DC pool is rapidly reconstituted from both donor and recipient origins. Thereafter at day 28, donor engraftment of DC became predominant. The median of recipient DC was significantly higher in pts without cGVHD. An analysis on a larger series would be useful to determine if the chimerism in DC could be predictive for cGVHD.

Donor Lymphocyte Infusion for Mixed Chimerism or Residual Disease after Reduced-Intensity T Cell Depleted Stem Cell Transplantation Results in Conversion to Full Donor Chimerism Combined with Graft Versus Tumor Responses and Limited GVHD.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 1652-1652 ◽  
Author(s):  
Peter A. von dem Borne ◽  
Ingrid Starrenburg ◽  
Erik W.A. Marijt ◽  
Stijn Halkes ◽  
J.H. Frederik Falkenburg ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Stem Cell ◽  
T Cell ◽  
Chronic Gvhd ◽  
Bone Marrow Involvement ◽  
Mixed Chimerism ◽  
Donor Chimerism ◽  
Measurable Disease ◽  
Unrelated Donors ◽  
Reduced Intensity

Abstract We perform reduced intensity allogeneic stem cell transplantation (SCT) with HLA identical sibling and matched unrelated donors using a conditioning regimen consisting of fludarabine, busulphan and ATG combined with alemtuzumab added to the stem cell graft for extensive donor T cell depletion. With this regimen hardly any acute and chronic graft versus host disease (GVHD) are observed after SCT and mixed chimerism is induced in most patients (Barge et al, Exp Hematol 2003). In patients transplanted for malignant disease, donor lymphocytes (DLI) are administered in escalating doses from 6 to 9 months to convert mixed into complete donor chimerism and to induce graft versus tumor (GVT) responses. We report results of chimerism analysis, clinical antitumor response and GVHD after DLI. 41 patients (median age 54 years, range 37–65) transplanted with stem cells from sibling donors (29) or matched unrelated donors (12) for various malignancies received DLI with a median dose of 5 × 106 CD3+ cells/kg (range 1–5) at a median time point of 7 months after SCT (range 5.1–15). After DLI administration 35 of 38 evaluable patients (92%) developed an immune response as defined as a major decrease in patient chimerism. In 26 patients full donor chimerism was achieved, in 9 patients a low patient signal remained present (1–2%). Patient chimerism decreased from median 12% (range 1 to 86%) to 0% (range 0–2%). In most patients conversion occurred after the first DLI, in 4 patients after the second and in 1 patient after the third DLI. In 31 of 38 patients measurable disease was present before DLI. In 22 of these patients conversion from mixed to full donor chimerism coincided with clinical GVT responses. Seven patients with active myeloid disease all achieved complete remission (4 AML/MDS patients with 8–65% blasts, 2 patients with progressive CML and 1 with active CMMOL). All these patients are still in CR after a median time of 22 months. In 8 myeloma patients with measurable disease 5 complete and 1 partial response were observed. However, most responding myeloma patients subsequently developed bone or extramedullary relapses without evidence of bone marrow involvement. In 13 patients with lymphoid disease 9 responses were observed. One patient with an immunocytoma and one with T-PLL achieved CR. In 7 CLL patients 3 CR and 1 PR were observed, notably two CR occurred in patients with massive bone marrow involvement. Two of four patients with aggressive NHL showed a CR to DLI in combination with rituximab and one patient a PR to DLI. Although no regression of tumor was observed in three patients with renal cell carcinoma after DLI, disease progression was halted for several years. Grade 3–4 acute GVHD developed in 22% of patients, grade 1–2 in 39%. Limited or extensive chronic GVHD was observed in 30 and 23% of patients, respectively. GVHD responded to therapy in most patients, only in 9% of patients chronic GVHD did not resolve. Mortality due to acute and chronic GVHD was 10%. In conclusion, after T cell depleted reduced intensity SCT a state of mixed chimerism is induced in most patients, which can be converted into full donor chimerism with DLI in more than 90% of patients. Conversion to full donor chimerism is accompanied with clinical GVT responses in a high percentage of patients with acceptable GVHD.

Converting Mixed Chimerism to Full Donor Chimerism in Recipients of Campath-Containing Reduced Intensity Transplants Reduces the Relapse Risk and Results in Significantly Improved Survival Compared to Those with Persistent Full Donor Chimerism.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 2026-2026
Author(s):  
Bronwen E. Shaw ◽  
Jenny L. Byrne ◽  
Emma Das-Gupta ◽  
Ian Carter ◽  
Nigel H. Russell
Keyword(s):  
Residual Disease ◽  
Complete Response ◽  
Disease Relapse ◽  
Post Transplant ◽  
Donor Chimerism ◽  
Group A ◽  
Group B ◽  
The Impact ◽  
Group D ◽  
Reduced Intensity

Abstract Donor leucocyte infusions (DLI) are frequently required following reduced intensity conditioned (RIC) allografts to convert mixed donor chimerism (MC) to full donor chimerism (FDC). The rationale is to prevent tolerance developing and therefore to maximise the graft versus tumour (GvT) responses. However, the impact that the chimeric state has on disease relapse and transplant outcome remains controversial. To address this we analysed the impact of the complete (global) chimerism pattern in 125 recipients of RIC transplants. The transplants were performed for a broad range of malignant haematological diseases. Conditioning regimens consisted of fludarabine, melphalan, campath (65), fludarabine, busulphan, campath (13), BEAM, campath +/− fludarabine (38) and other (9). The donors were HLA matched siblings (62, 50%), HLA mismatched siblings (6, 5%), matched unrelated (29, 23%) and mismatched unrelated (28, 22%). The median patient age was 52 and donor age was 42. The median follow up was 823 days (range 99–2674). Four patterns of chimerism were seen: A. always 100% donor chimerism (68, 54%), B. persisting MC post transplant including cases refractory to DLI (27, 22%) C. MC post transplant with subsequently development of FDC either spontaneously or post DLI (22, 18%), D. lost DC and had autologous reconstitution (8, 6%). A number of patients in both groups B and C had FDC early post transplant. In group A 18 (26%) patients received DLI for relapse or residual disease. A complete response was achieved in 6 (35%). In group B 10 (37%) patients had DLI: 4 for MC, 1 for residual disease, 2 for relapse and 3 for both MC and relapse; only partial responses were seen (20%). In group C DLI was given in 14 (64%) patients: 4 for MC, 5 for residual disease, 3 for relapse and 2 for both MC and relapse. A complete response was achieved in 12 (86%). The risk of relapse at 2 years was significantly associated with the pattern of chimerism (p=0.012) and was greatest for group D (75%). Patients in group C (DLI responders) had a relapse rate of 24% compared to 61% in group B (DLI non-responders). In group A it was 37%. This resulted in a significant survival advantage for patients in group C as compared to all other groups (p=0.009). Predicted overall survival at 2 years was 95% in group C, but 54% in group A, 57% in group B, and 58% in group D. We conclude that patients with MC who later achieve FDC have a lower incidence of disease relapse than those with persistent MC, supporting the use of DLI in this group. However the observation that the patients receiving DLI to achieve FDC have a superior outcome to those patients with persistent FDC (group A) suggests that this group may have benefited from a GvT effect against minimal residual disease. The use of pre-emptive DLI in this group (despite FDC) may reduce the risk of relapse and improve transplant outcome.

Use of Pre-Emptive Donor Lymphocyte Infusions To Achieve Durable Remission Following Alemtuzumab Based Reduced Intensity Conditioning (RIC) Transplantation for AML or MDS.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 1124-1124
Author(s):  
ZiYi Lim ◽  
Laurence Pearce ◽  
Wendy Ingram ◽  
Rafael Duarte ◽  
Stephen Devereux ◽  
...  
Keyword(s):  
T Cell ◽  
Advanced Disease ◽  
Disease Stage ◽  
Mixed Chimerism ◽  
Donor Chimerism ◽  
Significant Difference ◽  
Cell Source ◽  
Recipient Age ◽  
The Impact

Abstract Use of alemtuzumab in RIC HSCT reduces the incidence of graft rejection and graft vs host disease(GvHD). However, there can be a delay in full T-cell donor engraftment. As a dominant donor T-cell chimerism may be important to achieve a strong graft vs leukaemia effect(GvL), we examined the impact of pre-emptive DLI (pDLI) on patients with falling donor chimerism. 76 patients with AML or MDS were treated with RIC HSCT (fludarabine 150mg/m2, busulphan 8mg/kg, alemtuzumab 100mg). Complete sublineage chimerism data up to day +100 was available on all patients. The underlying diagnoses were AML n=27, MDS n=49. 33 patients had early disease vs 44 advanced disease (advanced disease as defined by AML &gt;CR1, MDS RAEB or AML with multilineage dysplasia). The median recipient age was 51.6 years (range:19–72), with median follow-up of 526 days (range:137–1256). There were 30 sibling and 50 VUD allografts. Stem cell source was 61 PBSC vs 15 BM. 62 patients were fully HLA matched and 14 patients were HLA mismatched. CD15 engraftment occurred rapidly with 95% of patients achieving full donor chimerism(FDC) at day 30 and 96% at day 100. In contrast, CD3 engraftment was significantly delayed, with only 50% of patients FDC at day 30, 47% at day 100. Incremental doses of pDLI were considered for patients with falling donor chimerism (&lt;50% donor) after day 100. Patients had immunosuppresion withdrawn, and had to have no GvHD. 20 patients received a total of 55 doses of pDLI. 10/20 had advanced disease, and 6/20 had unfavourable cytogenetics. Median donor CD3 chimerism at time of pDLI was 31.5%(range:7–59). The median CD3 dose of pDLI was 8.4x106/kg, with the first dose given at a median of day +176 (range:104–494). The median interval between pDLI was 8 weeks(range:4–22). 15 patients had FDC restored at median of 130 days following first doses of pDLI (range:36–523). 8/20 developed acute Gd II-IV GvHD following pDLI, with 2 patients dying of GvHD related complications. 2 patients relapsed with AML following treatment: with 1 death, and 1 patient currently undergoing treatment. 2 patients had not reached FDC at follow-up. A further 9 patients received DLI for cytogenetic or morphological relapse. Time to first dose of DLI was 257 days (range:76–837). The median CD3 dose was 1.67 x 107/kg. 3 patients were FDC and 6 patients MDC at time of relapse. All 3 patients with FDC failed to respond to DLI. Complete remission was seen in 3/6 patients with MDC. 4/9 patients developed acute Gd II-IV GvHD. 5/9 patients have died(all of underlying AML). The outcome of patients receiving pDLI was compared with patients with FDC(n=28), and stable mixed chimerism(defined as donor CD3 chimerism &gt;70%) who did not receive DLI(n=18). There was no significant difference in recipient age, disease, disease stage, HLA type, cell source or cell dose between groups. However, there were more sibling donors in the group receiving pDLI(p=0.02). The 2 year DFS, OS and relapse rate was comparable between patients with FDC, stable chimerism and those receiving pDLI (59% vs 83% vs 67% p=0.22), (62% vs 88% vs 75% p=0.13), (12% vs 17% vs 15% p=0.74) respectively. In summary, pre-emptive DLI is effective in reversing falling donor chimerism, and can induce prolonged remission, even in a sub-group of patients with high risk disease. A dominant donor CD3 chimerism(&gt;70%) may be sufficient to acheive an allo-immune effect in majority of patients.

Allograft T Cell Content Influences Early Engraftment after Reduced-Intensity Stem Cell Transplantation (RIST).

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 3662-3662
Author(s):  
Robert M. Dean ◽  
Daniel H. Fowler ◽  
Nancy M. Hardy ◽  
Jeanne Odom ◽  
Kathleen Castro ◽  
...  
Keyword(s):  
T Cells ◽  
T Cell ◽  
Ex Vivo ◽  
Group Iii ◽  
Donor Chimerism ◽  
Group I ◽  
Gvhd Prophylaxis ◽  
Donor T Cells ◽  
Reduced Intensity

Abstract Allogeneic hematopoietic stem cells (HSC) generally engraft rapidly and completely after myeloablative conditioning. However, with reduced-intensity conditioning (RIC), mixed chimerism and graft failure are more common. Host immune status and HSC number are factors known to affect engraftment after reduced-intensity stem cell transplantation (RIST). In addition, donor T cells within the allograft may also influencethe kinetics of donor engraftment after RIST. To evaluate this, we performed a controlled comparison of engraftment outcomes among 3 groups undergoing RIST, varying by ex vivo T cell depletion (TCD) or in vivo depletion of activated T cells with methotrexate (MTX) to prevent graft-versus-host disease (GVHD). Group I (n = 50) received T cell replete (TCR) peripheral blood stem cells (PBSC) with cyclosporine (CSA) alone for GVHD prophylaxis. Group II (n = 17) received ex vivo TCD PBSC (positive/negative selection with T cell add-back to uniform dose of 1 x 105 CD3+ cells/kg) with CSA alone for GVHD prophylaxis. Group III (n = 31) received TCR PBSC with CSA plus MTX (5 mg/m2 IV x 4 doses) for GVHD prophylaxis. The 3 groups were similarly immunosuppressed from prior therapy before RIST (median absolute lymphocyte counts 330/μL, 260/μL, and 307/μL for Groups I, II, and III, respectively), and received an identical RIC regimen (fludarabine/cyclophosphamide) plus comparable numbers of filgrastim-mobilized PBSC from HLA-matched sibling donors (median 7.9 x 106, 7.6 x 106, and 6.8 x 106 CD34+ cells/kg, respectively; median 3.6 x 108, 1.0 x 105, and 3.2 x 108 CD3+ cells/kg, respectively). Hematopoietic recovery was slowest in Group III, consistent with the myelosuppressive effects of MTX (Table). A greater proportion of patients in Group I achieved complete donor chimerism (≥ 95%) by day +28 than in Groups II or III (P &lt; 0.025), and at day +100, mixed donor chimerism persisted more often in Groups II and III than in Group I patients (P &lt; 0.01). Correspondingly, early (&lt; day +42) occurrence of grade 3–4 acute GVHD, before initiation of planned sequential donor lymphocyte infusions (DLI) in Group II, was more frequent in Group I than in either Groups II or III (p=0.08). Table: Hematopoietic Recovery, Engraftment, and GVHD Group Days to ANC &gt; 500, median (range) Days to plt &gt; 100, median (range) Donor chimerism ≥ 95% Early acute GVHD, grades 3–4 Day +28 Day +100 I 9 (7–13) 15.5 (12-42) 37/44 (84%) 36/38 (95%) 9/50 (18%) II 9 (7–10) 17.5 (11–40) 8/17 (47%) 9/14 (65%) 0/17 (0%) III 14 (7–21) 21.5 (12–85) 23/31 (74%) 21/31 (68%) 2/31 (6%) Thus, the deletion of T cells by either ex vivo TCD or in vivo MTX administration measurably alters the kinetics and degree of donor T cell engraftment after RIST. These observations provide evidence that donor T cells are an independent factor affecting engraftment of allogeneic HSC after RIST by compensating for incomplete host immune ablation. These data also support the hypothesis that a graft-versus-host effect plays a significant role in engraftment after RIST. Manipulation of donor T cells through graft engineering techniques may be a useful strategy to enhance engraftment in the setting of RIST.

A Comparative Analysis of Immune Reconstitution Following Reduced Intensity Conditioning with CAMPATH-1H and Total Lymphoid Irradiation/Anti-Thymocyte Globulin Prior to Allogeneic Stem Cell Transplantation.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 1148-1148
Author(s):  
Brett Glotzbecker ◽  
Heidi Mills ◽  
Jacalyn Rosenblatt ◽  
Zekui Wu ◽  
Kerry Wellenstein ◽  
...  
Keyword(s):  
T Cells ◽  
T Cell ◽  
Cd8 T Cells ◽  
Cell Depletion ◽  
T Cell Proliferation ◽  
Reduced Intensity Conditioning ◽  
T Cell Depletion ◽  
Post Transplant ◽  
Initial Cohort ◽  
Reduced Intensity

Abstract Abstract 1148 Poster Board I-170 Graft versus host disease (GVHD) remains a significant cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HCT). In vivo quantitative T-cell depletion using CAMPATH-1h (anti-CD52) has been explored in an effort to prevent acute GVHD. More recently, a regimen consisting of total lymphoid irradiation and anti-thymocyte globulin (ATG) has been shown to polarize T cells towards an inhibitory phenotype potentially reducing the associated risk for GVHD. However, these strategies may be associated with impaired post-transplant immune reconstitution, increased risk of tumor relapse and opportunistic infection. In this study we examined the pattern of cellular immune recovery following T cell depletion with CAMPATH-1h and compared results with an initial cohort of patients undergoing reduced intensity conditioning with TLI and ATG. Immunologic analyses were performed on twenty patients undergoing reduced intensity conditioning in conjunction with low dose CAMPATH -1h (50 mg) and an initial cohort of 5 patients treated with TLI/ATG. Conditioning with CAMPATH-1h resulted in the significant depletion of CD3, CD4, and CD8 T cells in the early post-transplant period and persistence of CD4 T cell depletion (< 200 cells /uL) for more than 6 months. Following TLI/ATG, persistent depletion of CD4+ T cells was also observed but no significant decrease in CD8 T cells was seen. A two-fold increase in circulating CD56+ NK cells, 21.8 to 41.6% (p=0.004), was seen following TLI-ATG, which was not noted following Campath conditioning. CAMPATH-1h conditioning was associated with a significant decrease in mean CD45RO+ memory T cells in the early post-transplant period (27.2 to 5.7% of the total population of nonadherent peripheral blood mononuclear cells, p=0.034). Relative percentages of naïve T cells (CD45RA+), central memory (CD45RO+CD62L+CCR7+) (CM), and effector memory (CD45RO+CD62L-CCR7-) (EM) T cells remained stable in the pre- and post-transplantation period. The CM:EM was 0.6 pre-transplant and at day 60, respectively. In contrast, T cell recovery in early post-transplant following the TLI/ATG regimen was associated with no reduction in CD45RO+ memory T cells. A significant rise in the relative percentages of naïve T cells from 39 to 61.3% (p=0.04), CM cells from 12 to 32.8% (p=0.05), a corresponding fall in EM cells from 57.9 to 32.5% (p=0.10), and a significant change in the CM:EM levels (0.2 pre-transplant, 1.0 day 60 post-transplant) was noted after TLI/ATG. The mean percentage of regulatory T cells as defined by the percentage of CD4+/CD25+ cells that express FoxP3 rose in the early post-transplant period following both regimens (8 to 20.7% at Day 30, p=0.003 in the CAMPATH group; 5.6 to 16.9% at Day 30, p=0.03 in the ATG/TLI group). Functional analyses demonstrated that the T cell proliferative response to the mitogen, Phytohemagglutinin (PHA), was profoundly depressed following CAMPATH-1h with mean SI decreasing from 34 pre-transplant to 1.4 at Day 30. In contrast, treatment with TLI/ATG resulted in no significant change in T cell proliferation in response to PHA with SI only decreasing from 45 pre-transplant to 36 at Day 30. Assessment of T cell polarization following stimulation with PHA or phorbol-ester (PMA)/ionomycin, recipient derived dendritic cells (DCs) or third party DCs demonstrated a rise of CD8+ T cells expressing, IL-4 and IL-10 consistent with a suppressor phenotype. Minimal T cell proliferation was observed following stimulation with patient derived DCs, which is consistent with suppression of the expansion of alloreactive T cells. In summary, both CAMPATH and TLI/ATG result in CD4+ T cell depletion but TLI/ATG resulted in relative preservation of CD8+ T cells, persistence of memory cells, relative preservation of central memory as compared to memory effector cells and intact response to mitogens. TLI/ATG therapy was also associated with the polarization of CD8+ T cells towards a Tc2 phenotype and lack of proliferation in response to recipient derived DCs. As such, TLI/ATG appears to be associated with more modest level of functional T cell depletion characterized by Tc2 polarization and suppression of host/donor alloreactivity. Disclosures Spitzer: Genzyme: Consultancy. Avigan:Genzyme: Consultancy.

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