Inhibition of Lymphocyte Trafficking Using a CCR5 Antagonist – Final Results of a Phase I/II Study

Abstract Abstract 1011 Inhibition of lymphocyte trafficking early after allogeneic stem cell transplantation (SCT) may prevent GvHD without interfering with GvL activity. Animal models and genomic data in humans indicate that the interaction between CCR5 and its ligands CCL3, CCL4 and RANTES is pivotal in the pathogenesis of GvHD. Maraviroc (MVC; Selzentry®, Pfizer) is the first oral CCR5 antagonist in clinical use. The antiviral properties of MVC in HIV infection are known, but its effects on chemotaxis and immune function in patients without HIV infection have not been explored. We hypothesized that CCR5 inhibition early after allogeneic SCT would reduce lymphocyte chemotaxis and result in low rates of acute GvHD without impairing engraftment or antitumor activity. In vitro, MVC effectively and specifically inhibited CCR5 internalization and reduced RANTES-induced chemotaxis in concentrations achievable in humans, recapitulating a defect observed in homozygotes for the del32-CCR5 polymorphism. MVC had no effect on hematopoietic colony formation, T-cell mediated cytotoxicity and T-cell proliferation. Between May 2009 and March 2011, we enrolled 38 pts in a phase I/II study of reduced intensity conditioned (RIC) allogeneic SCT. Patients had high-risk features by age (median=62, range 21–74), donor source (matched related 34%, matched unrelated 50%, single-antigen mismatch 16%) and comorbidities (comorbidity index: low 55%, intermediate 34%, high 11%). Underlying diseases were AML (15), MDS (6), NHL (8), myelofibrosis (4), aplastic anemia, myeloma, CLL, Hodgkin, CML (1 each). Pts received fludarabine 120mg/m2 and IV busulfan 6.4 mg/kg followed by peripheral blood stem cells. In addition to standard GvHD prophylaxis with tacrolimus and methotrexate, MVC was given from day −2 to +30. Pharmacokinetic analysis on the first 13 pts identified 300 mg bid as the appropriate dose (Reshef, ASH 2010). MVC was well tolerated, and adverse events were similar to the expected toxicity observed in patients undergoing RIC SCT. The median time to ANC>500/μL was 15 d (range 10–27) and to platelets>20k/μL was 19 d (range 9–84). The median whole blood and T-cell donor chimerism at day 100 was 96.5% (range 0–100%) and 85% (range 0–100%) respectively. Median follow-up was 200 days (range 12–760). Among 35 evaluable patients, the cumulative incidences of any acute GvHD and grade III–IV acute GvHD at day 100 were 14.7 ± 6.2% and 2.9 ± 2.9%, respectively. Importantly, in the first 100 days, there were no cases of acute GvHD involving the liver or gut. At day 180, the rate of acute GvHD was 20.7 ± 7.1%, largely confined to the skin with low rates of GvHD in the liver (3 ± 3%) and gut (7.4 ± 5.3%). In evaluable pts who received a graft from their HLA-matched sibling (11), there was no GvHD before day 100 and only two cases of acute GvHD before day 180. We compared these results to a cohort of 38 well-matched consecutive patients treated at our institution with RIC SCT using an identical regimen but without MVC between 2009 and 2011. We observed a similar incidence of acute GvHD (all grades) at day 100 (14.7 ± 6.2 vs. 16 ± 6.1%; P=0.88), but a 64% decrease in the MVC group at day 180 (20.7 ± 7.1 vs. 45.4 ± 9%; P=0.03). The incidence rates of severe GvHD (grade III–IV) were 2.9 ± 2.9% in the MVC group vs. 5.5 ± 3.8% in the comparator group at day 100 (P=0.59) and 6.5 ± 4.5% vs. 18.1 ± 6.8% at day 180 (P=0.15). Treatment-related mortality in pts receiving MVC was low. At 1 year, non-relapse mortality rate was 7.6 ± 5.5% (control group: 15.7 ± 6.6%; P=0.35). Infectious complications were seen at a rate that is expected with RIC SCT. Recovery of lymphocyte counts and lymphocyte subsets was not impaired by MVC. We evaluated whether a protective effect against GvHD was associated with an increase in relapse. In the MVC group, the incidence of relapse was 34.2 ± 8.8% at day 180; this was not significantly different from the comparator group (43.9 ± 8.8%, P=0.44), implying preservation of the graft-versus-tumor effect with MVC. Rates of overall survival and relapse-free survival were similar in both groups. Pharmacodynamic testing revealed that sera from patients taking MVC prevented CCR5 internalization by RANTES and blocked T-cell chemotaxis in vitro, providing evidence for in vivo biological activity and supporting the hypothesized mechanism of action. In summary, inhibition of lymphocyte trafficking is a novel, specific and potentially effective strategy to reduce the incidence of acute GvHD. Disclosures: Off Label Use: Use of maraviroc in GvHD prophylaxis will be discussed. Frey:Pfizer: Speakers Bureau. Vonderheide:Pfizer: Research Funding. Porter:Pfizer: Research Funding.

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Prevention of Graft-Versus-Host Disease by Inhibition of Lymphocyte Trafficking Using a CCR5 Antagonist

Blood ◽

10.1182/blood.v116.21.673.673 ◽

2010 ◽

Vol 116 (21) ◽

pp. 673-673 ◽

Cited By ~ 2

Author(s):

Ran Reshef ◽

Selina M. Luger ◽

Alison W. Loren ◽

Noelle V. Frey ◽

Steven C. Goldstein ◽

...

Keyword(s):

Research Funding ◽

Acute Gvhd ◽

Off Label Use ◽

Lymphocyte Trafficking ◽

Off Label ◽

Gvhd Prophylaxis ◽

Cd34 Cells ◽

Novel Strategy ◽

Dose Levels

Abstract Abstract 673 Inhibition of lymphocyte trafficking early after allogeneic stem cell transplantation (SCT) could limit T cell interactions with antigen-presenting cells and migration to target tissues. This represents a novel strategy to prevent GvHD without interfering with GvL activity. CCR5 is a chemokine receptor expressed on effector T-cells and immature dendritic cells and binds 3 ligands - CCL3, CCL4 and RANTES (CCL5). Accumulating evidence from animal models and clinical observations implicates CCR5 as pivotal in the pathogenesis of GvHD. Genomic analyses suggest that the same CCR5 polymorphisms that confer resistance to HIV infection also correlate with a lower susceptibility to acute GvHD. Maraviroc (MVC; Selzentry®, Pfizer) is the first oral CCR5 antagonist in clinical use. We hypothesized that modulating T-cell trafficking early after allogeneic SCT via CCR5 blockade would limit GvHD. We therefore performed preclinical and clinical testing of MVC as GvHD prophylaxis. Our goals were to 1) determine in vitro activity of MVC on chemotaxis, 2) determine the feasibility, safety and appropriate dose of MVC as part of GvHD prophylaxis, and 3) demonstrate biological activity of MVC through immune pharmacodynamic assays. In vitro, MVC fully inhibited CCR5 internalization by CCL3 and RANTES even at concentrations as low as 1 μM. Using RANTES as a chemotactic trigger, MVC caused dose-dependent inhibition of lymphocyte chemotaxis by up to 53% at MVC 1mM. To address concerns that MVC might impair hematopoiesis, we demonstrated that CCR5 was not expressed on the surface of bone marrow- and peripheral blood-derived CD34+ cells. Moreover, when CD34+ cells were plated in methylcellulose, formation of CFU-GEMM and CFU-GM was not affected by the presence of MVC 1μM; CFU-E and BFU-E were slightly decreased compared to controls. Based on these and other data, we enrolled 19 pts in a phase I/II study of reduced intensity conditioned allogeneic SCT with MVC GvHD prophylaxis. Pts received fludarabine 120mg/m2 and IV busulfan 6.4 mg/kg followed by peripheral blood stem cells from matched related (n=6), matched unrelated (n=10) and 1-antigen mismatched unrelated (n=3) donors. In addition to standard GvHD prophylaxis with tacrolimus and methotrexate, MVC at escalating dose levels was given from day -2 to +30. Median age was 63 (range 21–74). Indications for SCT were AML/MDS (9), NHL (4), myelofibrosis (2), CLL, aplastic anemia, Hodgkin lymphoma and myeloma (1 each). Pharmacokinetic analysis on 6 pts at each dose revealed that the 300 mg and 150 mg bid dose levels resulted in mean Cavg of 536 and 118 ng/ml, respectively. 3/6 patients at 150mg did not reach the targeted minimum Cavg (100 ng/ml), while the 300mg dose level resulted in adequate Cavg in 6/6 patients and was used as the phase II dose. MVC was well tolerated; 3 pts did not complete the entire course because of transient LFT abnormalities (1) or mucositis (2). The median time to ANC>500/μL was 15 d (range 10–21) and to platelets>20k/μL was 13 d (range 11–24) with no graft rejections. The median donor chimerism at day 100 was 97% (range 83–100%). A day 100-landmark analysis in evaluable pts demonstrated that the cumulative incidence of acute GvHD grade 2–4 was 27% (grade 3–4; 9%) in this high-risk population. Importantly, by day 100 all cases of acute GvHD involved only the skin without liver or intestinal involvement. At a median follow up of 186 days, 3/19 patients relapsed (2 AML, 1 NHL) and 6/19 patients died (3 disease-related, 1 neutropenic sepsis, 1 SOS, 1 unrelated). There were no GvHD-related deaths. To explore potential mechanisms, we tested the capacity of patient serum to inhibit CCR5 internalization and chemotaxis. Patient serum from multiple time points (trough, 1, 2, 3, 4, 6 hr post dose) effectively prevented internalization of CCR5 by RANTES. In addition, in vitro chemotaxis of normal donor T-cells in response to RANTES was significantly impaired in the presence of patient serum from day 0 (on MVC) as compared to day 60 (off MVC). In summary, inhibition of lymphocyte trafficking to peripheral tissues represents a novel strategy to modulate and possibly reduce acute GvHD in allogeneic SCT. MVC at 300mg bid was well tolerated and biologically active in pharmacodynamic assays. Patients receiving MVC exhibited limited GvHD by day 100 without excessive relapses. The phase II portion of the trial is ongoing. Disclosures: Off Label Use: Off label use of maraviroc (Selzentry) will be discussed. Frey:Pfizer, Inc.: Speakers Bureau. Vonderheide:Pfizer, Inc.: Research Funding. Porter:Pfizer, Inc.: Research Funding.

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A Phase I/II Trial of Intravenous Azacitidine for Acute Gvhd Prophylaxis in Patients Undergoing Matched Unrelated Stem Cell Transplantation: Phase I Results

Blood ◽

10.1182/blood.v126.23.1935.1935 ◽

2015 ◽

Vol 126 (23) ◽

pp. 1935-1935 ◽

Cited By ~ 1

Author(s):

Mark A. Schroeder ◽

Jaebok Choi ◽

Matthew L Cooper ◽

David Schwab ◽

Sarah Willey ◽

...

Keyword(s):

T Cells ◽

T Cell ◽

Regulatory T Cells ◽

Phase I ◽

Phase Ii ◽

Research Funding ◽

Acute Gvhd ◽

Gvhd Prophylaxis ◽

Primary Graft Failure ◽

Final Cohort

Abstract Background The negative impact of acute graft-versus-host disease (GvHD) on morbidity and mortality after allogeneic transplant is significant; thus, finding a means to harness the beneficial Graft versus tumor effect (GVT) while reducing or eliminating GvHD is a major goal of transplant trials. Alterations in immune subsets present after transplant can work to suppress allo-reactive T-cell responses by increasing regulatory T-cells and suppressing allo-reactive T-cell proliferation. Azacitidine (AZA) treatment in pre-clincal models resulted in an increase in regulatory T-cells, a decrease in allo-reactive T-cell proliferation and prevention of acute GvHD while preserving GVT effects. (Choi et al. Blood 2010). Based on these results a phase I/II study was designed to test the safety and efficacy of AZA administered shortly after transplant for the prevention/prophylaxis of acute GvHD and relapse in subjects receiving transplants from matched unrelated stem cell donors. We report the results for the Phase I portion of this trial. Methods Patients with hematologic malignancies in remission age 18 - 70 were eligible. Myeloablative or reduced intensity conditioning without antithymocyte globulin was used. All recipients were required to receive at least 2 x 106 CD34/kg and have at least 1 x 106 CD34/kg cryopreserved as back up in case of primary graft failure. AZA was administered intravenously on day +7 for five consecutive days and repeated every 28 days for a total of 4 cycles after allogeneic transplant from a 10/10 HLA matched unrelated donor. Standard GvHD prophylaxis with mini-methotrexate and tacrolimus was given. A Phase I, 3+3 dose escalation design of 4 cohorts (AZA dose levels 15, 30, 37.5, and 45 mg/m2) was used to determine toxicity and recommended phase II dose. The primary outcome for phase II is the rate of grade II - IV acute GvHD at day 180 after transplant. Results We have transplanted 16 subjects on trial, 15 have received study drug. Recipient characteristics include: median age 57, 67% male, and diagnoses of AML in CR (9), ALL in CR (2), or MDS (4). One DLT was observed in the final cohort of 6 subjects. The DLT experienced in the final cohort was primary graft failure. The subject had developed Clostridium difficile colitis during conditioning and fungemia shortly after transplant. A total CD34 dose of 2 x 106/kg was infused after myeloablative conditioning of Busulfan and Cytoxan. The subject received the cryopreserved back up donor leukocyte infusion at day +28 but died at day 29 of sepsis without evidence of neutrophil engraftment. Contributing causes to the DLT were thought to be the CD34 dose infused, sepsis, severe colitis and possibly AZA administration. For the remainder of subjects treated in phase I the median CD34 dose infused was 5 x 106/kg (range 2 - 5), median ANC engraftment was 14 days (range 10 - 22 days). Median platelet engraftment was 22 days (range 14 - 70). No grade III/IV acute GvHD has been observed. Grades 1 and 2 skin and gut GvHD have been observed, and all cases have responded to steroids except one case of steroid refractory GvHD in cohort 1 (15mg/m2 AZA). At the recommended phase 2 dose of 45mg/m2 AZA, 3 cases of skin GvHD were observed occurring just prior to or at the time of cycle 2 of treatment. All responded to steroids. With a median follow up of 233 days (range 29 - 784), only 2 subjects have relapsed and 11 (73%) remain alive. The most common non-hematologic grade 3 or 4 AEs were gastrointestinal toxicity (mucositis, nausea and diarrhea), electrolyte abnormalities, and infections. In conclusion, AZA can be given safely starting at day +7 after MUD transplant up to a dose of 45mg/m2 tested. Phase II is currently enrolling subjects. Because of the DLT experienced in phase I, the infused CD34 dose will be increased to a minimum of 4 x 106 CD34/kg with 1 x 106 CD34/kg cryopreserved in backup. Correlative studies from banked Phase I biospecimens evaluating dynamics of regulatory T-cells, T-cell subsets and methylation before and after treatment are being analyzed and will be reported. Disclosures Schroeder: Incyte: Consultancy; Celgene: Other: Azacitidine provided for this trial by Celgene. Off Label Use: Azacitidine for GVHD prophylaxis. Abboud:Gerson Lehman Group: Consultancy; Pharmacyclics: Membership on an entity's Board of Directors or advisory committees; Novartis: Research Funding; Pfizer: Research Funding; Merck: Research Funding; Teva Pharmaceuticals: Research Funding. Vij:Onyx: Consultancy, Honoraria, Research Funding, Speakers Bureau; Millennium: Honoraria, Speakers Bureau; Celgene: Consultancy, Honoraria, Research Funding, Speakers Bureau; BMS: Consultancy; Takeda: Consultancy, Research Funding; Novartis: Consultancy; Sanofi: Consultancy; Janssen: Consultancy; Merck: Consultancy.

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GvHD Prophylaxis with Everolimus and Mycophenolate in Allogeneic Hematopoietic Cell Transplantation - A Phase I/II Study.

Blood ◽

10.1182/blood.v114.22.4642.4642 ◽

2009 ◽

Vol 114 (22) ◽

pp. 4642-4642

Author(s):

Reinhard Marks ◽

Alf Zerweck ◽

Razvan George Racila ◽

Hartmut Bertz ◽

Jürgen Finke

Keyword(s):

T Cells ◽

T Cell ◽

Research Funding ◽

Malignant Disease ◽

Acute Gvhd ◽

Hematopoietic Cell Transplantation ◽

Chronic Gvhd ◽

Tolerance Induction ◽

Treg Function ◽

Gvhd Prophylaxis

Abstract Abstract 4642 Next to the control of malignant disease, tolerance induction of the grafted cells remain to be a critical issue for longterm survivors after allogeneic hematopoietic cell transplantation (HCT). Regulatory T cells (Tregs) are believed to be involved in the process of tolerance induction to solid organ grafts and in the regulation of alloreactivity, e.g. graft versus host disease (GvHD) and graft versus leukemia effect (GvL), after allogeneic HCT. Since GvHD causes substantial morbidity, medication with calcineurin inhibitors (CI) like cyclosporine are established prophylactic measures for the prevention of GvHD after HCT. Next to the substantial renal toxicity of CI, tolerance induction might be hampered in HCT patients due to deteriorated Treg function. In contrast, data from in vitro and animal experiments suggest that inhibition of the mammalian target of rapamycin (mTOR) has not only an antiproliferative effect on many malignant cell lines but also results in an inhibition of proliferation of alloreactive T cells with sustained Treg function in a murine HCT model. Therefore we initiated a phase I/II, monocenter trial using everolimus and mycophenolate sodium (MMF-Na) as GvHD prophylaxis in patients undergoing allogeneic HCT with peripheral stem cell (PBSC) grafts after conditioning with fludarabine, melphalan, and BCNU (FBM). No additional T cell depleting agents were used for conditioning/GvHD prophylaxis. Enrolment was started in april 2008, and up to august 2009 10 patients were included (median age: 50.7 years, range: 26-64). The diagnoses included de novo AML (n=3), sAML (n=4), RAEB II (n=1), CML (n=1), T-PLL (n=1). 6/10 patients were regarded as high risk (not in CR1) for early relapse. PBSC grafts were obtained from unrelated (n=5) and related (n=5) HLA-matched donors. With no graft failures, engraftment kinetics for myeloid cells were normal, and reconstitution of the T cell compartment reached median cell counts of 251 CD4+ cells/μl and 163 CD8+ cells/μl at day +30. No grade IV/V toxicities (according to CTC criteria) were observed due to the study medication. After a median follow-up of 6 month two patients have died. The causes were acute GvHD, refractory to several lines of treatment, in a patient with CML, and severe pulmonary toxicity/BOOP in a patient with sAML. Out of 9 patients reaching CR after HCT, only one high risk patient relapsed after 6 month. In total 6 patients are alive and show complete donor chimerism for time periods of 1-14 months post transplant. The observed early recovery of T cell immunity correlated in 8/10 patients with an early brief period of acute GvHD, with 4 patients experiencing grade III/IV severities. Most of the cases could be controlled with steroids alone. Chronic GvHD could be observed in 6/7 patients, with mild to moderate forms in 5 cases, mainly involving skin, mucosa and liver. Interestingly, while early tapering of MMF-Na did not cause any problems, reduction of everolimus earlier as 6 month after HCT resulted in an induction of GvHD symptoms. Although viral reactivation (CMV, HHV6) did occur in patients receiving additional immunosuppression with steroids, no severe bacterial or fungal infections were observed even in cases with prolonged everolimus treatment. In conclusion, GvHD prophylaxis with everolimus and MMF-Na is feasible but results in an increased frequency of mild to moderate chronic GvHD. Since this sustained mild alloreactivity might reduce the risk of relapse, this GvHD prophylaxis could well be suited for patients undergoing HCT with advanced or uncontrolled malignant disease. Disclosures: Marks: Novartis: Research Funding. Off Label Use: Everolimus for prophylaxis of GvHD. Finke:Novartis: Research Funding.

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Phase I/II Study of Reduced Dosing of Post-Transplantation Cyclophosphamide (PTCy) after HLA-Haploidentical Bone Marrow Transplantation

Blood ◽

10.1182/blood-2021-146997 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 101-101

Author(s):

Meredith J. McAdams ◽

Mustafa Hyder ◽

Dimana Dimitrova ◽

Jennifer L. Sadler ◽

Christi McKeown ◽

...

Keyword(s):

Phase I ◽

Dose Level ◽

Phase Ii ◽

Primary Endpoint ◽

Acute Gvhd ◽

Post Transplantation ◽

Graft Versus Host ◽

Gvhd Prophylaxis ◽

Grade Iii

Abstract Background: Post-transplantation cyclophosphamide (PTCy) is widely used for graft-versus-host-disease (GVHD) prophylaxis after hematopoietic cell transplantation (HCT). However, the standard PTCy dose (50 mg/kg/day) and timing (given on days +3 and +4) were largely extrapolated from murine skin allografting models, and these have never been rigorously tested to determine if they are optimal. We have shown in murine HCT models that an intermediate PTCy dose of 25 mg/kg/day on days +3/+4 is superior at preventing severe GVHD compared with 50 mg/kg/day on days +3/+4 (Wachsmuth et al., JCI. 2019). Furthermore, PTCy 25 mg/kg/day given on day +4 alone is equivalent to 25 mg/kg/day given on days +3/+4 at preventing severe GVHD (Wachsmuth et al. BBMT. 2019). Thus, the standard clinical dosing may be higher than necessary and potentially come at the cost of increased toxicity, delayed engraftment, and impaired immune reconstitution. Methods: This is a single institutional prospective phase I/II study (NCT03983850) to de-escalate PTCy exposure for adult patients with hematologic malignancies. All patients received myeloablative conditioning with IV daily busulfan/fludarabine, HLA-haploidentical bone marrow, and GVHD prophylaxis with PTCy (dose and timing based on Dose Level (DL)), mycophenolate mofetil (days +5 to +35), and sirolimus (days +5 to +80). The first 5 patients received PTCy 50 mg/kg/day on days +3/+4 (standard dosing, Dose Level 1) for comparative data. This was followed by a 3+3 dose de-escalation design testing 25 mg/kg/day on days +3/+4 (experimental, Dose Level 2) and 25 mg/kg on day +4 only (experimental, Dose Level 3), followed by a phase II expansion cohort at the better experimental dose level. The primary endpoint and dose limiting toxicity for the dose de-escalation was grade III-IV acute GVHD. Results: Phase I enrolled 19 patients, and the phase II expansion has enrolled 13 of 14 patients, 9 of whom have sufficient follow-up (60 days) to be considered evaluable for the primary endpoint; median follow-up of survivors evaluable for the primary endpoint is 288 (range 60-676) days. Patient and disease characteristics and outcomes for these patients are summarized in Table 1. No grade III-IV acute GVHD was seen at either experimental DL, and there have been no cases of grade II-IV acute GVHD at DL2 (Figure 1). Based on more reliable early engraftment (see below) but less intense and shorter duration of engraftment fevers, DL2 was taken to phase II. Engraftment was faster at the experimental DLs but was most consistent with DL2. Median neutrophil engraftment was at day 14 at DL2 compared with day 19 at the standard dosing (p=0.0004) (Figure 2A). Median platelet engraftment was at day 23 at DL2 compared with day 33 at the standard dosing (p=0.026) (Figure 2B). Correspondingly, transfusional requirements were lessened with DL2 (Figure 2C-D). Engraftment syndrome, manifesting as fever, rash, and mild transaminitis, occurred in 1 patient at DL2 and 2 patients at DL3, but resolved rapidly without intervention in all cases. Primary graft failure was seen in 1 patient at DL2, and relapse prior to engraftment was seen in 1 patient at DL3. Mucositis was less severe and shorter in duration for both experimental DLs when compared with standard PTCy dosing (Figure 2E). CMV reactivation requiring pre-emptive therapy was less frequently seen after lower PTCy dosing (Figure 3A). Symptomatic BK virus-associated cystitis in at-risk patients was shorter in duration for patients receiving lower PTCy; median duration was 74 days for the standard DL versus 26 days at DL2 and 7 days at DL3 (Figure 3B). At DL2, there have been 3 cases to date of chronic GVHD requiring systemic immunosuppression among the 13 engrafting patients with at least 100 days of follow-up. Conclusions: De-escalating PTCy exposure is feasible and effective in maintaining protection against severe acute GVHD while promoting more rapid engraftment and less early post-transplant toxicity. Two-day dosing of 25 mg/kg/day PTCy appears to allow for more consistent early engraftment and protection against protracted engraftment fevers compared with day +4 only. Longer follow-up and comparative studies are needed to understand if de-escalated PTCy is superior to the standard dosing schedule. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: The use of cyclophosphamide as graft-versus-host disease prophylaxis

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Clinical Outcome after Adoptive Infusion of BPX-501 Cells (donor T cells transduced with iC9 suicide gene) in Children Given Alpha/Beta T-Cell Depleted HLA-Haploidentical Hematopoietic Stem Cell Transplantation (haplo-HSCT): Preliminary Results of a Phase I-II Trial

Blood ◽

10.1182/blood.v126.23.1931.1931 ◽

2015 ◽

Vol 126 (23) ◽

pp. 1931-1931 ◽

Cited By ~ 2

Author(s):

Franco Locatelli ◽

Pietro Merli ◽

Giuseppina Li Pira ◽

Valentina Bertaina ◽

Barbarella Lucarelli ◽

...

Keyword(s):

T Cells ◽

T Cell ◽

Phase I ◽

Research Funding ◽

Acute Gvhd ◽

Suicide Gene ◽

T Cell Immunity ◽

Cell Immunity ◽

Equity Ownership ◽

Historical Controls

Abstract Background: We recently completed a prospective study (ClinicalTrial.gov identifier: NCT01810120) which showed that haplo-HSCT after depletion of α/β T cells is an effective option for those children in need of an allograft and lacking an immediately available HLA-identical related or unrelated donor. However, recovery of adaptive T-cell immunity remains suboptimal and some patients died due to viral infections in the early post-transplant period. Thus, strategies aimed at accelerating early recovery of adaptive T-cell immunity are desirable. Study design and patients: We designed a phase I/II trial aimed at testing the safety and the efficacy of post-transplant infusion of donor-derived T cells transduced with the new iC9 suicide gene (BPX-501) in children with malignant or non-malignant disorders (ClinicalTrials.gov identifier: NCT02065869); enrollment started in December 2014. Cells are administered within 14 + 4 days after haplo-HSCT. The phase I portion of the trial consists of a classical 3+3 design with 3 cohorts, receiving escalating doses of BPX-501 cells of 2.5 x 105, 5 x105, and 1x106 cells/kg, respectively. Patients included in the phase II portion received the highest dose identified during the phase I portion of the study for a maximum of 60 children in both phase I/II portions of the study. As of July 25th 2015, 25 children have been screened and included in the study: 23 have been infused with BPX-501 cells. The analysis refers to the 16 patients with a minimum follow-up of 90 days after transplantation; they had acute lymphoblastic leukemia (ALL, 6), acute myeloid leukemia (1), severe combined immune-deficiency (4), Wiskott-Aldrich syndrome (3) and Fanconi Anemia (2). All children with acute leukemia were transplanted in morphological complete remission (CR). Median age at haplo-HSCT was 3.5 years (range, 03-17.8); 7 patients (44%) were females. All children received >10x106 CD34+ cells/Kg and <1x105 αβ+ T cells/Kg. There was no difference in graft composition between these 16 patients and those who were previously included in the study on haplo-HSCT after depletion of α/β T cells (historical controls). Results: BPX-501 cells were infused at a median time of 16 days (range 13-18); median cell viability post-thaw was 91% (range 65-97). Treatment was well tolerated and no infusion-related side effects were recorded. The recommended dose identified during the phase I of the trial to be used for the phase II portion was 1x106 cells/kg. Four children developed grade I-II skin only acute graft-versus-host disease (GvHD) at 16, 20, 22 and 34 days after haplo-HSCT, respectively, which resolved with topical steroids; no patient had either gut or liver acute GvHD. The 100-day cumulative incidence (CI) of skin-only grade I-II acute GvHD was 25% (SE 3.6); it was 30% (SE 2.1) in the historical controls (Figure 1 - Panel A). No patient developed chronic GvHD. In 4 patients, mixed chimerism present at time of BPX-501 cell infusion completely reverted to full donor chimerism. None of the 16 patients included in the analysis had graft failure or died of transplant-related complications. Two patients, both with ALL transplanted in CR3, relapsed at 86 and 153 days after the allograft, respectively. Median time to discharge after haplo-HSCT was 28 days (range, 19-86) as compared to 38 days (range, 18-174) in the historical controls (p=0.08). Four patients were re-hospitalized due to: cytomegalovirus (CMV) infection (2), fever of unknown origin (1) and valganciclovir-induced neutropenia (1). BPX-501 cells progressively expanded over time and are still persisting, potentially contributing to the recovery of adaptive T-cell immunity. The mean number of both CD3+ and BPX-501 cells at the different time-points are reported in Figure 1 - Panel B, which also details the data of historical controls. Conclusions: Overall, these data indicate that the infusion of BPX-501 cells is safe and well tolerated. The 100-day CI of skin-only grade I-II acute GvHD observed in these patients is similar to that of children included in the previous trial of haplo-HSCT after depletion of α/β T cells. BPX-501 cells expand in vivo and persist over time, potentially contributing to accelerate the recovery of adaptive T-cell immunity, with improved clinical outcome. The iC9 cell-suicide system may increase the implementation of cellular therapy approaches aimed at optimizing immune recovery after transplantation. Figure 1. Figure 1. Disclosures Qasim: Cell Medica: Research Funding; Autolus Ltd: Consultancy, Equity Ownership, Research Funding; Miltenyi Biotec GmbH: Research Funding; Cellectis: Research Funding. Moseley:Bellicum Pharmaceuticals: Employment, Equity Ownership.

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Reduced Cellular Susceptibility to In Vitro HIV Infection Is Associated with CD4+ T Cell Quiescence

PLoS ONE ◽

10.1371/journal.pone.0045911 ◽

2012 ◽

Vol 7 (9) ◽

pp. e45911 ◽

Cited By ~ 20

Author(s):

Catherine M. Card ◽

W. John Rutherford ◽

Suzie Ramdahin ◽

Xiaojian Yao ◽

Makobu Kimani ◽

...

Keyword(s):

T Cell ◽

Hiv Infection ◽

Cd4 T Cell ◽

Cell Quiescence

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HIV infection is associated with reduced serum alpha-1-antitrypsin concentrations

Clinical & Investigative Medicine ◽

10.25011/cim.v33i6.14589 ◽

2010 ◽

Vol 33 (6) ◽

pp. 384 ◽

Cited By ~ 24

Author(s):

Courtney L Bryan ◽

K Scott Beard ◽

Gregory B Pott ◽

Jeremy Rahkola ◽

Edward M Gardner ◽

...

Keyword(s):

T Cell ◽

Hiv Infection ◽

Fluid Phase ◽

Cross Sectional Study ◽

Infected Group ◽

Cd4 T Cell ◽

Cross Sectional ◽

Clinically Significant ◽

Alpha 1 Antitrypsin

Purpose: Several observations suggest the presence of HIV-suppressive factors in the fluid phase of blood. Alpha-1-antitrypsin (AAT), the most abundant serine protease inhibitor in the circulation, has potent anti-HIV activity in vitro, and may function as an endogenous HIV suppressor. Therefore, we assessed serum AAT concentrations for association with HIV infection. Methods: In this cross-sectional study, serum AAT concentrations were measured in 66 persons with HIV infection and in 45 healthy persons (Controls). In the HIV-infected group, antiretroviral therapy (ART) use was assessed and CD4+ T cell levels and plasma HIV RNA were quantified. Results: Median AAT concentration was significantly lower in the HIV-infected group (1.64 mg/mL) in comparison with Controls (1.94 mg/mL; p=0.001). AAT reduction was most pronounced in the HIV-infected subgroup with CD4+ T cell levels > 200 cells/µL in comparison with Controls (p < 0.01). Serum AAT concentrations < 1.0 mg/mL are clinically significant, and concentrations below this level were identified in 4.5% of the HIV-infected group and in no Control subjects. No association between AAT levels and viral load or use of ART was observed in HIV-infected subjects. Conclusion: The association between reduced serum AAT concentration and HIV infection is consistent with a role for AAT as an endogenous HIV suppressor.

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Single Cell Transcriptome Analysis Reveals Disease-Defining T Cell Subsets in the Tumor Microenvironment of Classic Hodgkin Lymphoma

Blood ◽

10.1182/blood-2019-121584 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 547-547

Author(s):

Tomohiro Aoki ◽

Lauren C. Chong ◽

Katsuyoshi Takata ◽

Katy Milne ◽

Monirath Hav ◽

...

Keyword(s):

T Cells ◽

T Cell ◽

Single Cell ◽

Research Funding ◽

Cell Clusters ◽

Mhc Ii ◽

Spatial Profiling ◽

Classic Hodgkin Lymphoma ◽

Cellular Components

INTRODUCTION: Classic Hodgkin lymphoma (cHL) is uniquely characterized by an extensively dominant microenvironment composed primarily of different types of non-cancerous immune cells with a rare population (~1%) of tumor cells. Detailed characterization of these cellular components and their spatial relationship is crucial to understand crosstalk and therapeutic targeting in the cellular ecosystem of the tumor microenvironment (TME). METHODS: In this study, we performed high dimensional and spatial profiling of immune cells in the TME of cHL. Single cell RNA sequencing (scRNA-seq) was performed with the 10x Genomics platform on cell suspensions collected from lymph nodes of 22 cHL patients, including 12 of nodular sclerosis subtype, 9 of mixed cellularity subtype and 1 of lymphocyte-rich subtype, with 5 reactive lymph nodes (RLNs) serving as normal controls. Illumina sequencing (HiSeq 2500) was performed to yield single-cell expression profiles for 127,786 cells. We also performed multicolor IHC and imaging mass cytometry (IMC) on TMA slides from the same patients. RESULTS: Unsupervised clustering using PhenoGraph identified 22 cell clusters including 12 T cell clusters, 7 B cell clusters and 1 macrophage cluster. While most immune cell populations were common between cHL and RLN, we observed an enrichment of cells from cHL in all 3 regulatory T cell (Treg) clusters. The most cHL-enriched cluster was characterized by high expression of LAG3, in addition to common Treg markers such as IL2RA (CD25) and TNFRSF18 (GITR), but lacked expression of FOXP3, consistent with a type 1 regulatory (Tr1) T cell population. LAG3+ T cells in cHL had high expression of immune-suppressive cytokines IL-10 and TGF-b . In vitro exposure of T cells to cHL cell line supernatant induced significantly higher levels of LAG3 in naïve T cells compared to co-culture with other lymphoma cell line supernatant or medium only. CD4+ LAG3+ T cells isolated by FACS also suppressed the proliferation of responder CD4+ T cells when co-cultured in vitro. Additionally, Luminex analysis revealed that cHL cell lines secrete substantial amounts of cytokines and chemokines that can promote Tr1 cell differentiation (e.g. IL-6). Our scRNA-seq analysis revealed that LAG3 expression was significantly higher in cHL cases with loss of major histocompatibility class II (MHC-II) expression on HRS cells as compared to MHC-II positive cases (P = 0.019), but was not correlated with EBV status or histological subtype. Strikingly, LAG3 was identified as the most up-regulated gene in cells from MHC-II negative cases compared to MHC-II positive cases. Topological analysis using multicolor IHC and IMC revealed that in MHC-II negative cases, HRS cells were surrounded by LAG3+ T cells. In these cases, the density of LAG3+ T cells in HRS cell-rich regions was significantly increased, and the average distance between an HRS cell and its closest LAG3+ T cell neighbor was significantly shorter. These associations were confirmed in an independent cohort of 166 cHL patients. Finally, we observed a trend towards an inferior disease-specific survival (DSS; P = 0.072) and overall survival (OS; P = 0.12) in cases with an increased number of LAG3+ T cells. A high proportion of LAG3+ T cells (> 20%) was identified as an independent prognostic factor for DSS by multivariate Cox regression. CONCLUSIONS: Our results reveal a diverse TME composition with inflammatory and immunosuppressive cellular components that are linked to MHC class II expression status on HRS cells (Figure). Unprecedented transcriptional and spatial profiling at the single cell level has established the pathogenic importance of HRS cell-induced CD4+ LAG3+ T cells as a mediator of immunosuppression in cHL, with potential implications for novel therapeutic approaches. Figure Disclosures Savage: Seattle Genetics, Inc.: Consultancy, Honoraria, Research Funding; BMS, Merck, Novartis, Verastem, Abbvie, Servier, and Seattle Genetics: Consultancy, Honoraria. Scott:Roche/Genentech: Research Funding; Celgene: Consultancy; Janssen: Consultancy, Research Funding; NanoString: Patents & Royalties: Named inventor on a patent licensed to NanoSting [Institution], Research Funding. Steidl:Bristol-Myers Squibb: Research Funding; Nanostring: Patents & Royalties: Filed patent on behalf of BC Cancer; Roche: Consultancy; Seattle Genetics: Consultancy; Bayer: Consultancy; Juno Therapeutics: Consultancy; Tioma: Research Funding.

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Impact of Severity of Acute Graft-Versus-Host Disease on Healthcare Resource Utilization, Cost and Outcomes

Blood ◽

10.1182/blood-2020-137824 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 37-38

Author(s):

Nosha Farhadfar ◽

Helen L Leather ◽

Shu Wang ◽

Nathan Burton ◽

Vivian Irizarry Gatell ◽

...

Keyword(s):

Electronic Medical Records ◽

Medical Records ◽

Research Funding ◽

Acute Gvhd ◽

Healthcare Resource Utilization ◽

Total Cost ◽

Icu Admission ◽

The Mean ◽

Hospital Days ◽

Grade Iii

Introduction: Acute GVHD (aGVHD) contributes to poor outcomes and increased healthcare resource utilization (HRU) after allogeneic stem cell transplantation (allo-HCT). However, HRU and the economic burden of aGVHD based on severity of the disease and organ involvement is not well characterized. We examined the HRU, cost and mortality associated with aGVHD severity from initial hospitalization (index admission) up to 100 days post allo-HCT. Methods: Study cohort included 290 adult (≥ age 18) recipients of a first allo-HCT at the University of Florida between 1/2010 and 1/2019. The electronic medical records were reviewed for all patients who developed aGVHD as well as 116 patients without aGVHD who lived at least 1 month after HCT. Clinical measures that characterize the severity of aGVHD and extent of organ involvement were collected from electronic medical records. Medical costs and total hospital days were retrieved from administrative data that allocate costs to services based on departmental input for resource use and were adjusted to 2018 dollars. Wilcoxon rank sum test was used to compare number of inpatient days and total cost. Chi-squared test was used to compare ICU admission rate. Multivariable linear regression was fitted on log transformed cost. Results are shown as cost multipliers that represent ratios on original cost scale. Results: Of the 290 patients, 174 developed aGVHD within 100 days of allo-HCT. A higher proportion of patients with aGVHD had a Karnofsky performance status <80%, underwent matched unrelated donor HCT, and received calcineurin based GVHD prophylaxis. The mean number of days in the hospital for patients with aGVHD compared to those without aGVHD was 28 vs. 22 days, P<0.001 (Figure 1A). The mean number of hospital days for patients with grade I-II compared to those without aGVHD was 25 days vs. 22 days (P= 0.04) and for grade III-IV the mean number of days in the hospital compared to those without aGVHD was 48 days vs. 22 days (p < 0.001). In addition, presence of Lower gastrointestinal (GI) aGVHD was associated with more mean number of days in the hospital compared with those without aGVHD (43 vs. 22 days, P< 0.001). The ICU admission rates in patients with and without aGVHD were 13.2% and 6%, respectively (P=0.07) (Figure 1B). Analysis of ICU admissions based on grade of aGVHD revealed a significantly higher rate of ICU admission among patients with higher grade (grade III-IV) acute GVHD compared to those without aGVHD (22.3% vs. 6.0%, P=0.002). The early mortality rate in the first 100 days in aGVHD patients was twice that of the no aGVHD patients (14.9% vs. 7.8%; P=0.09). Compared to patients without aGVHD, early mortality was significantly higher in patients with aGVHD grade III-IV (7.8% vs. 33.9%; P< 0.001) and lower GI aGVHD (7.8% vs. 25.7%; P=0.001). Development of aGVHD was associated with a significantly higher total (inpatient and outpatient) cost. The mean total cost for patients with and without aGVHD were $226,545 and $165,622, respectively (P<0.001). Mean total costs associated with grades I, II and III-IV aGVHD were $183,693 (p = 0.44), $201,737 (p = 0.04) and $286,551 (<0.001), respectively (compared to $165,622 for those without aGVHD). Acute GVHD with GI involvement was significantly associated with higher mean total cost compared with aGVHD without GI involvement ($255,283 vs. $177,151, P<0.001). Among aGVHD cohort with GI involvement (Lower and/or upper GI), the mean cost was higher in patients with lower GI (LGI) compared with those without LGI aGVHD ($280,290 vs. $203,879, P=0.04). A multivariable analysis of risk factors for HCT cost identified presence of aGVHD, younger age at HCT, higher comorbidity index, and donor other than matched related donor as being associated with significantly higher costs (Table 1). Conclusion: HRU, cost, and clinical outcomes were associated with the severity of aGVHD. Development of higher grades of aGVHD and LGI aGVHD were associated with a poor clinical outcome and considerably increased healthcare economic burden. Given these clinical and economic risks it is imperative that new therapeutic strategies are developed for this patient population. Disclosures Farhadfar: Incyte pharmaceutical: Other: Member of GVHD advisory forum; CSL Behring: Research Funding. Leather:CSL Behring: Research Funding. Itzler:CSL Behring: Current Employment, Current equity holder in private company. Wingard:CSL Behring: Research Funding.

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