Results of Simultaneously Performed Analysis of 48 Gene Variants Reported to Have Influence on Transplant outcome

Abstract Abstract 3047 Up to date, there are many conflicting reports existing in which different gene variants have been proposed to have influence on the outcome of allogeneic transplant. Hereby many of the published studies bare a distressing high weakness in the study set up as for example low number of study patients, large heterogeneity of donor types and/or GVHD prophlyaxis regimens and/or T cell depleting of grafts and/or type of conditioning regimens. In this study we aimed to evaluate in 285 patients and their HLA identical sibling donors the following in table 1 shown 48 different gene variants from which were reported to have influence on the outcome of transplants. Our study group consists of a homogenous group of patients who underwent all a non T cell-depleted transplantation after receiving a myeloablative conditioning regimen and a GVHD prophylaxis with MTX and CSA or CSA and MMF. Patients were transplanted from a HLA-identical sibling donor for various diseases like acute leukemia, CML, MDS, lymphoma and MM between January 2000 and June 2010 at our center We could confirm an influence of gene variants of NOD2 (80, 4% vs 61, 6%, p=0.0013), IL23R, MTHFR1298, and LCT 13910 on the occurrence of acute GVHD grade 1–4 on recipients side, whereas no influence was seen of any gene variant on the occurrence of grade 2–4 acute GVHD. But, NOD2 gene variants had a significant (p=0.041) influence on the occurrence of severe acute GVHD grade 3–4. The occurrence of acute GVHD grade 1–4 was significantly modified by the detection of following gene variants at donors side: CCL5 28 promotor (30, 8% vs 69, 2% p=0.033), GSTP 313 (74, 3% vs 62, 4%, p=0.043);IL23R (69, 9% vs 48%, p=0.049), MTHFR129 (86, 7 vs 37, 3% p=.0.06), MTHFR 677 (53, 8% vs 70%, p=0.05), NOD2 (65, 9% vs 84, 4%, p=0.01). Acute GVHD grade 2 –4 was significantly influenced only by GSTP (p<0.015) and MTHFR129 (p<0.025). Severe acute GVHD grade 3–4 was only influenced by GSTP gene variants (p<0.04). The 5-year TRM was influenced by MTHFR677 (30, 4% vs 19, 2%, p=0.05) at recipient side, and at donor side by the genes IL18 Rap (38, 5% vs 19%, p=0.046) and CYP1B1 (28, 8% vs 15, 6%, p=0.07). IL10 gene variants at recipients side influenced the 5-year OS significantly, at donor side the 5-year OS was influenced by CTLA4 (69, 4 vs 52, 2%, p=0.06) IL23R (53, 6% vs 71, 6%, p=0.044) and MBL2CD55 48, 9% vs 65, 2% p=0.02). In this study we could confirm that the above described gene variants might influence moderately the transplant outcome and may therefore be qualified for screening in patients and their respective donors prior to transplant.CCL5 28 promotor G/Crs1800825MBL2 Codon220rs7096206CCR5 2086 A/Grs1800023MBL2 Codon4rs7095891CCR5 2554 G/Trs2734648MBL2 Codon550rs11003125CP2C19*2rs4244285MBL2[G54D]rs1800450CP2C19*3rs4986893MBL2[G57E]rs1800451CTLA4 A/G pos.49rs231775MBL2[R55C]rs5030737CYP1B1 432rs1056836MCP1 1543 C/Trs13900CYP2C9*2rs1799853mdr1 C3435Trs1045642CYP2C9*3rs1057910MTHFR1298rs1801131CYP2D6*3rs4986774MTHFR677rs1801133CYP2D6*4,rs1800716NFKBIL1rs2857605CYP2D6*6rs5030655NOD2 G908Rrs2066847CYP3A4*1BNOD2 L1007F insCrs2066847CYP3A5*3NOD2 R702Wrs2066844FAS 670 G/Ars4934436TLR2 R753Qrs5743708GSTA1 A567T, 69C 52Grs3957356TLR3rs3775291GSTP1 313A/Grs1695TLR4 [D299G]rs4986790IL10 -1082rs1800896TLR4 [T399I]rs4987233IL10 592 C/Ars1800872TLR5rs764535IL23RTLR6 745C>Trs5743810IL18 137 G/Crs187238TLR9 C-1237Trs5743836IL18 RAPrs917997TLR9 T-1486Crs187084IL6 G174Crs1800795TNF alpha 238 A/Grs361525LTArs2844484VEGF 405G/Crs833061 Disclosures: No relevant conflicts of interest to declare.

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Different Panel of Gene Variants Influence Outcome of Transplant From Sibling Donors Compared to HLA-Identical Unrelated Donors

Blood ◽

10.1182/blood.v120.21.4182.4182 ◽

2012 ◽

Vol 120 (21) ◽

pp. 4182-4182 ◽

Cited By ~ 1

Author(s):

Ahmet H Elmaagacli ◽

Michael Koldehoff ◽

Nina Kristin Steckel ◽

Markus Ditschkowski ◽

Rudolf Trenschel ◽

...

Keyword(s):

Acute Gvhd ◽

Conflicts Of Interest ◽

Favorable Effect ◽

Gene Variants ◽

Allogeneic Transplant ◽

Donor Side ◽

Gvhd Prophylaxis ◽

Il10 Gene ◽

Unrelated Donors

Abstract Abstract 4182 Introduction and methods: In two different study populations with sibling (SIB) or unrelated (URD) HLA-identical donors we evaluated the role of 48 different genes (table1) reported to have influence on the outcome of allogeneic transplant and compared them between the transplant settings. 314 patients and their HLA identical URD and 285 patients and their HLA-identical SIB donors were analyzed after T cell repleted myeloablative transplantation and use of GVHD-prophylaxis with only MTX and CSA or CSA and MMF. Patients were transplanted for acute leukemia, CML, MDS, lymphoma and MM between Jan. 2000 and June 2011 at our center. Results: In the URD-cohort the occurrence of acute GVHD grade 2–4 was influenced adversely by gene variants on recipient side of LTA (40% vs 28%, P=0.013), MBL2 codon550 (47% vs 31%, P= 0.03), MCP1 (69% vs 42%, p=0.03) and NFKBIL1 (51% vs 34%, P=0.02). Further, the occurrence of severe aGVHD 3–4 was influenced adversely by gene variants of MBL codon 550 (10% vs 23%, P= 0.025), MBL2 codon 4 (10% vs 36% P=0.04), LCT13910 (9% vs 26%, P= 0.04) and CYP1B1 (8% vs 20%; P=0.05). Favorable effect was induced by a gene variant of IL6 on aGVHD 3–4 (4% vs 19%, P=0.04) in the URD setting, whereas NOD2 gene variants, but none of these gene variants had influence on aGVHD in the SIB cohort. Further, we found that the rate of 5-year none-relapse mortality (NRM) was associated adversely with the detection of variants of IL16 (60% vs 34%, P=0.01) and MCP1 (58% vs 27%, P=0.02), which influenced the 5-year estimate for overall survival (OS) of patients (MCP1 40% vs 53%, P=0.01 and IL16 46% vs 28%, P=0.03) in the URD setting. On donor side the occurrence of aGVHD grade 2–4 was influenced by MBL2 codon4 (69% vs 32%, P= 0.007), TLR2 (66% vs 41%, P=0.02), TLR5 (75% vs 42%, P=0.041). AGVHD 3–4 was influenced by IL23R favorably (0% vs 20%, p=0.01) and adversely by IL18 (10% vs 36%; p= 0.01) in the URD setting. The 5-year NRM was associated with the detection of gene variants at donor side of CCR5 (53% vs 27%, p=0.01), CTLA4 (23% vs 44%, P=0.02), CYP1B1 (14% vs 26%, P=0.045), TLR2 (34% vs 66%, P=0.025). Also, IL10 gene variants at donor side influenced the 5-year OS significantly (23% vs 54%, p=0.03) as well as the gene variants TLR2 (28% vs 50%, P= 0.04), IL18 Rap (40% vs 72%, P= 0.03) and FAS (60% vs 36%, P=0.04). In SIB cohort the 5-year TRM was influenced by MTHFR677 (30% vs 19%, p=0.05) at recipient side, and at donor side by the genes IL18 Rap (39% vs 19%, p=0.046) and CYP1B1 (29% vs 16%,p=0.07). IL10 gene variants at recipients side influenced the 5-year OS, too. At donor side the 5-year OS was influenced by IL23R (54% vs 72%, p=0.04) and MBL2CD55 49% vs 65% p=0.02). In conclusion we report here that except IL23R and IL10 different panels of gene variants have influence on outcome of transplants from SIB donors compared to transplants from URD. Disclosures: No relevant conflicts of interest to declare.

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Platelets Recovery and Transfusion Needs after Reduced Intensity Conditioning (RIC) Allogeneic Peripheral Blood Stem Cell (PBSC) Transplantation (allo-SCT).

Blood ◽

10.1182/blood.v108.11.2989.2989 ◽

2006 ◽

Vol 108 (11) ◽

pp. 2989-2989

Author(s):

Thomas Prebet ◽

Mohamad Mohty ◽

Patrick Ladaique ◽

Christian Chabannon ◽

Catherine Faucher ◽

...

Keyword(s):

Platelet Count ◽

Acute Gvhd ◽

Univariate Analysis ◽

Conditioning Regimen ◽

Platelet Recovery ◽

Gvhd Prophylaxis ◽

Study Population ◽

Grade 3 ◽

Few Data

Abstract Few data are currently available regarding platelets trasfusion needs and the kinetics and predicitive factors for platelets recovery after RIC allo-SCT. In this study, we analyzed the profile of platelets recovery and transfusion needs in the first 100 days after sibling PBSC RIC in a single institution series of 166 consecutive transplantations. Patients and graft characteristics were: age 49 y. (range: 18–70), diagnoses: 66 myeloid malignancies (40%), 64 lymphoid malignancies (39%), and 36 metastatic solid tumors (21%). 112 pts (67%) received an ATG-based RIC, while 54 pts (33%) received a low dose irradiation-based RIC. 75 pts (45%) developed grade 2–4 acute GVHD. Platelets recovery (>20 G/L) was observed at a median of 9 days (range: 0–99). The kinetics profile of platelets recovery is shown in the figure below. In the whole study population, the nadir was observed around day +7 after allo-SCT, and a plateau was reached about day +35. Filtered and irradiated donor apheresis platelets were used and patients needed a median of 1 unit (range: 0–53). In this series, 83 pts (50%) did not require any platelets transfusion during the follow-up period (median follow-up: 442 days) and 83 patients (50%) received at least one transfusion of platelets (54 were not transfused beyond day +100 after allo-SCT). Platelets count prior to RIC allo-SCT (median count 144 G/L; HR 0.44 (0.28–0.7) p=0.002), conditioning regimen (use of ATG; HR 1.86 (1.08–3.2) p=0.025) and the occurrence of acute (HR 1.54 (1.17–2.01); p=0.001) and severe GVHD (HR 2.36 (1.38–3.05) p=0.0006; 82% of patients with grade 3–4 acute GVHD were transfused) were the parameters significantly associated with platelets transfusion needs in multivariate analysis. In this cohort, 145 pts could be assessed for platelets recovery at day +100: among them, 99 (68%) had a platelet count >99 G/L. Univariate analysis found a significant impact of acute GVHD (p=0.0001) and platelet count prior to conditioning (p=0.012) but only acute GVHD (HR 5.52 (2.48–12.25); p=0.001) was associated with a delayed platelet recovery in a multivariate model. No impacts of pathology, GVHD prophylaxis regimen or CD34+ cell dose were demonstrated. Overall, these observations show a significantly lower rate of platelets transfusions and a quicker kinetic of platelets recovery after RIC allo-SCT and point out the effect of acute GVHD. In addition, considering the low level of myeloablation observed, RIC could be an appropriated field of investigation for the testing of megakaryocytic stimulating agents, towards further improving the safety and outcome of RIC allo-SCT. Platelets recovery after PBSC RIC allo-SCT Platelets recovery after PBSC RIC allo-SCT

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BK Virus-Associated Hemorrhagic Cystitis Following Allogeneic Hematopoietic Stem Cell Transplantation; Incidence and Risk Factors

Blood ◽

10.1182/blood.v128.22.5759.5759 ◽

2016 ◽

Vol 128 (22) ◽

pp. 5759-5759

Author(s):

Feras Alfraih ◽

Amjad Alhussaini ◽

Farhan Anjum ◽

Ghuzayel Mubarak Aldawsari ◽

Fahad Alsharif ◽

...

Keyword(s):

Risk Factors ◽

T Cell ◽

Acute Gvhd ◽

Hemorrhagic Cystitis ◽

Conditioning Regimen ◽

Bk Virus ◽

Cell Depletion ◽

T Cell Depletion ◽

Factors Associated ◽

Gvhd Prophylaxis

Abstract Introduction : Hemorrhagic cystitis (HC) is one of common complications after allogeneic hematopoietic SCT (HSCT) with reported incidence varying from 7 to 70%. Several reports have shown that BK is strongly associated with HC (BK-HC) following HSCT. We conducted an institutional retrospective study to analyze the incidence and clinical factors associated with BK-HC following HSCT. Methods : A total of 517 consecutive patients above the age of 14 years receiving HSCT from 2009 and June 2015 were included in this retrospective analysis and evaluated for HC and urinary BK. HC was defined as documented hematuria of any grade and BK viruria was defined as positive at any level by BKV quantitative PCR testing in urine. Patients were stratified, based on hematuria and urinary BK virus, into the following groups (a) BK virus positive hemorrhagic cystitis (BK+HC), (b) BK virus negative hemorrhagic cystitis (BK-HC) and (c) Non-hemorrhagic cystitis (HC-). Screening for microscopic hematuria was performed only for patients with any kind of urinary symptoms. Results: 479 patients (92.6%) were matched related donor and 308 (60%) were male with a median age of 24 (range 14 to 66). Diagnoses were AML for 195 (38%), ALL for 183 (35%) and bone marrow failure for 44 (8.5%). Conditioning regimen was cyclophosphamide based in 427 (82.6%) patients (97%) versus others in 90 (17.4%) patients. GVHD prophylaxis was CSA/MTX for 456 (88.4%) however, T cell depletion was used in 13%. Peripheral blood stem cells were used for 56% of patients. With a median follow-up of 60 months for survivors (range 2 to 116.5 months), 43 (8%) patients showed BK+HC, 264 (51%) BK- HC while 209 (41%) did not have any hematuria (HC- group). Median time from transplantation to BK+ HC was 67 days (range 7 to 1261 days). Univariate analysis for risk factors of BK+ HC showed male, use of T-cell depletion and AML diagnosis were statistically significant factors. Other factors like age, conditioning regimen, GVHD prophylaxis, stem cell source, mismatched and remission status were not statistically significant. BK+ HC group was associated with higher incidence of other infections like CMV viremia (p=0.01) and fungal infection (p<0.01). Incidence of acute GVHD was 62.8% in BK+ HC group, 43% in HC- BK and 33.3% in HC- group (p=<0.01), suggesting higher incidence of acute GVHD in BK+ HC group. There was no difference in incidence of chronic GVHD. Conclusion: Hematuria following allogeneic bone marrow transplantation occurs in almost half of patients (51%) while BK associated HC develops in 8% of patients. Factors associated with BK+ HC were male gender, use of T-cell depletion and AML diagnosis. BK+HC is usually associated with other infections like CMV viremia and fungal infections. Further studies are needed to minimize or prevent BK+ HC following HSCT especially in high risk group. Disclosures No relevant conflicts of interest to declare.

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Risk Factors and Outcome of Children with Relapsed/Refractory Acute Leukemia after T-Cell-Rich Haploidentical Hematopoietic Cell Transplantation

Blood ◽

10.1182/blood.v128.22.4604.4604 ◽

2016 ◽

Vol 128 (22) ◽

pp. 4604-4604

Author(s):

Atsushi Kikuta ◽

Hideki Sano ◽

Kazuhiro Mochizuki ◽

Shogo Kobayashi ◽

Mitsuko Akaihata ◽

...

Keyword(s):

T Cell ◽

Acute Leukemia ◽

Acute Gvhd ◽

Conflicts Of Interest ◽

Chronic Gvhd ◽

Univariate Analysis ◽

Disease Free Survival ◽

T Cell Therapy ◽

Gvhd Prophylaxis ◽

Significant Difference

Abstract Background: T-cell rich (TCR) HLA-haploidentical SCT (haplo-SCT) is a form of T-cell therapy that has a high degree of efficacy in hematologic malignancies. Previously we reported the safety profile assessing GVHD prophylaxis that was conducted with anti-human thymocyte immunoglobulin (ATG), tacrolimus, methotrexate (MTX) and prednisolone (PSL) in unmanipulated haplo-SCT (Clin Transplant 2010, Transfus Med 2014). We evaluated efficacy and toxicity of TCR haplo-SCT in children with very high risk refractory/relapsed acute leukemia (VHR-R/R AL). Methods: VHR-R/R AL were defined as: relapse after SCT, very early or early relapse, induction failure(2 or more) and relapse of risk factor with MLL rearrangement, Ph+, Mo7 and 5q-. From Aug 2000 to April 2014, consecutive 38 patients (pts) with VHR-R/R AL who underwent TCR-haplo-SCT were included. The median age of pts was 8.2(0.3-19.1) years old. The diagnosis included ALL (n=27), AML (n=8), M/NKL (n=3). The disease status at TCR-haplo-SCT were 18 in CR (positive MRD: 8 pts), 20 in non-CR. HLA disparities were 2/8 in 1pt, 3/8 in 9 pts, 4/8 in 28 pts. Donors included fathers (n=21), mothers (n=14), and siblings (n=3). Thirty one pts received myeloablative conditioning (TBI based: 20 pts, Bu based: 11 pts) and 34 pts of them received ATG (rabbit, thymoglobulin 2.5mg/kg) containing regimen. The GVHD prophylaxis was conducted with tacrolimus, MTX and PSL. Thirty four pts received peripheral blood stem cells and 4 pts received BM. Results: Neutrophil engraftment (defined as >0.5x109/L) was 95% with a median day of 13 (range, 10-15). With a median 1640 days follow-up (range, 320-5510 days) in pts without events, the actuarial 3-year overall survival (OS) and disease-free survival (DFS) were 57% and 39%, respectively. On competing-risk analysis, 1-year cumulative incidences of grade II-IV acute GVHD and chronic GVHD were 71% and 63%, respectively; 3-year cumulative incidences of relapse and non-relapse mortality (NRM) were 40% and 20%. On univariate analysis, 3-year OS in pts with acute GVHD vs. without acute GVHD were 70% vs. 22% (p=.0006), in pts CR vs. non-CR at TCR-SCT were 83% vs. 32% (p=.007), in pts infused CD3 cell doses >=5 x 108/kg vs. <5 x 108/kg were 83% vs. 25% (p=.005), according to age at TCR-SCT <9 vs. >=9 were 79% vs. 34% (.008), respectively. In contrast, the occurrence of acute GVHD had no significant difference in infused CD3 cell doses. Conclusions: These data suggest that TCR haplo-SCT following low-dose ATG containing conditioning combined with our GVHD prophylaxis is well tolerated, facilitates engraftment, and has significant anti-leukemic activity, particularly in pediatric patients with refractory/ relapsed population. Disclosures No relevant conflicts of interest to declare.

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Impact of Modifying Conditioning and Immunosuppressive Strategies in Allogeneic Hematopoietic Stem Cell Transplantation in Children with Acute Lymphoblastic Leukemia

Blood ◽

10.1182/blood-2019-122988 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 5714-5714

Author(s):

Nawar Dakhallah ◽

Mylène Beauchemin ◽

Johanne Richer ◽

Sonia Cellot ◽

Pierre Teira ◽

...

Keyword(s):

Stem Cell ◽

Acute Lymphoblastic Leukemia ◽

T Cell ◽

Acute Gvhd ◽

Lymphoblastic Leukemia ◽

Chronic Gvhd ◽

Conditioning Regimen ◽

Current Approach ◽

Hematopoietic Stem ◽

Gvhd Prophylaxis

Background:Hematopoietic stem cell transplants (HSCT) is indicated for some very high-risk childhood acute lymphoblastic leukemia (ALL) patients in complete remission 1 (CR1) and for patients in >CR2. Relapse remains the most frequent complication after transplant. In 2012, in order to decrease the relapse rate, we modified our conditioning and GVHD prophylaxis regimen. Total body irradiation doses were increased, etoposide removed and fludarabine introduced. Anti-thymocyte globulin (ATG) was removed of GVHD prophylaxis regimen and mycophenolate mofetil was added for unrelated marrow grafts. The aim of this study was to compare outcome between previous (PS) and new strategies (NS) prior and after 2012. Methods: This retrospective study included all 47 patients aged 0 to 18 years old who underwent a first HSCT for ALL at Sainte-Justine University Health Center from 2007 to 2017. Our primary endpoint was 2-year event-free survival (EFS) between PS (n=22) and NS (n=25) groups. Secondary endpoints included overall survival (OS), relapse, GVHD, immunological recovery and infection rates. Results: Demographic parameters and leukemia characteristics were not significantly different between groups. In the PS group, median age was 6.1 years [2.7;13.5] and 41% of patients were female. In the NS group, median age was 7.1 years [2.4;11.4] and 44% of patients were female. B-cell and T-cell lineage leukemias were present in respectively 82% and 18% of PS and 76% and 24% in NS. Fourteen percent of patients were transplanted in CR1 in the PS versus 40 % in the NS group. EFS at 2 and 5 years were respectively 46% and 36% with the PS compared to 60% and 53% with the NS (p=0.170). OS at 5 years was significantly higher with the NS (46% vs 75%, p=0.05). Morphologic relapse rates at 5 years of PS and NS were 55% and 30% (p=0.14). Acute GVHD rate at 6 months was superior with the NS (41% vs 80%, p=0.002). Chronic GVHD rate at 5 years was similar between groups. At least one proven infection at 100 days was documented in 96% compared to 88% of patients with the PS and NS respectively (p=0.08). Neutrophil recovery at 60 days and platelets recovery at 180 days were not significantly different. T-cell Immune recovery at 6 months was superior in the NS. Median (min;max) CD3 counts in PS and NS were respectively 339 (132;1152) versus 946 (284;1944) (p=0.009), CD4 counts were 221 (65;612) versus 594 (238;920) (p=0.046) and CD8 counts were 55 (34;414) versus 320 (210;1104) (p<0.001). Conclusion: Compared to the PS, the NS of conditioning regimen and GVHD prophylaxis shows a significant improvement in OS and a tendency towards decreased relapse and increased EFS. However, we found a significant increase in acute GVHD with this regimen, which is explained by the removal of ATG from the regimen. These results highlight the necessity to adjust our strategy with HSCT ALL with the aim of maintaining graft versus leukemia effect without increasing GVHD. Emerging immunotherapy (such as antibody-based and chimeric antigen receptor T cell therapies) might shift the management of refractory and relapsed ALL and our current approach to HSCT. Disclosures Bittencourt: Novartis: Consultancy; Jazz Pharmaceuticals: Consultancy, Other: Travel, accommodations expenses.

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Synergistic Effect of Anti-CD3 and Vorinostat in the Prevention of Acute Gvhd and Retention of GVL in a Radiation-Free Conditioning Regimen.

Blood ◽

10.1182/blood.v114.22.3562.3562 ◽

2009 ◽

Vol 114 (22) ◽

pp. 3562-3562

Author(s):

Wei He ◽

Mark Kirschbaum ◽

Nainong Li ◽

Tangsheng Yi ◽

Hong-Jun Liu ◽

...

Keyword(s):

T Cell ◽

Chemokine Receptors ◽

Acute Gvhd ◽

Conflicts Of Interest ◽

Conditioning Regimen ◽

Dependent Manner ◽

T Cell Migration ◽

Total Body ◽

Cell Expression

Abstract Abstract 3562 Poster Board III-499 A radiation-free conditioning regimen with anti-T cell globulin (ATG) + Busulfan (B) + Fludarabin (F) (ATG + BF) could replace sublethal total body irradiation (TBI) in clinic, but this regimen did not prevent induction of severe acute graft versus host disease (GVHD). We recently reported that anti-CD3 preconditioning markedly ameliorated acute GVHD in recipients conditioned with sublethal TBI in a mouse model of MHC-mismatched C57BL/6 (H-2b) donor to BALB/c (H-2d) host. In the current studies, we test whether replacing ATG with anti-CD3 prevented acute GVHD. We found that, when spleen and BM cells (50×106, each) from donors were transplanted, the recipients conditioned with ATG + BF developed severe acute GVHD and all (12/12) of them died by 30 days after transplantation, in contrast, the recipients conditioned with anti-CD3 + BF developed only moderate acute GVHD and 50% (6/12) of the recipients survived for more than 100 days. When the donor cells were titrated down to 25, 12.5, or 6.25 ×106, we found that none (0/8) of the recipients conditioned with ATG + BF developed chimerism, in contrast, all (8/8) of the recipients conditioned with anti-CD3 + BF developed complete chimerism, although the recipients showed mild to moderate clinical GVHD in a dose-dependent manner. Next, we tested whether depletion of donor CD4+ T cells could completely prevented GVHD in recipients conditioned with anti-CD3 + BF, and we found that, although all (8/8) of the recipients given 12.5 or 6.25×106 CD4+ T-depleted spleen (CD4−-SPL) cells developed complete chimerism and all survived for more than 100 days, the recipients still showed mild to moderate clinical GVHD (i.e. hair loss). Because vorinostat (V), a histone deacetylase inhibitor was previously reported to inhibit tissue release of proinflammatory cytokines, we tested whether replacing F with V could further ameliorated GVHD. We found when donor CD4−-SPL cells and BM cells (12.5 ×106 each) were transplanted, the recipients conditioned with anti-CD3 + BV showed no clinical GVHD, although the recipients conditioned with anti-CD3 + BF showed mild to moderate clinical GVHD. Furthermore, we found that donor CD4−-SPL and BM cells eliminated luciferase transfected BCL1 leukemia/lymphoma cells much more efficiently in the recipients conditioned with anti-CD3 + BV than in the recipients conditioned with anti-CD3 + BF, as revealed by in vivo bioluminescent imaging. In addition, we observed that the separation of GVL from GVHD was associated with prevention of donor T cell migration into GVHD target tissues, which resulted from reduction of CCR7+ DCs that induce donor T cell expression of tissue homing and chemokine receptors (i.e. a4b7, CCR9, E-Ligand, P-Ligand, CCR4, CCR10) in the recipients conditioned with anti-CD3 + BV. Taken together, anti-CD3 and vorinostat synergistically promote prevention of GVHD and retention of GVL in a clinically applicable radiation-free conditioning regimen. This work was supported by Marcus foundation. Disclosures: No relevant conflicts of interest to declare.

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Acute Gvhd Is a Strong Predictor of Full Donor cd3+ t Cells Chimerism (TCC) After Reduced Intensity Conditioning (RIC) for Allogeneic Stem Cell Transplantation (Allo-SCT)

Blood ◽

10.1182/blood.v118.21.4545.4545 ◽

2011 ◽

Vol 118 (21) ◽

pp. 4545-4545

Author(s):

Jean El-Cheikh ◽

Alberto Vazquez ◽

Roberto Crocchiolo ◽

Sabine Furst ◽

Luca Castagna ◽

...

Keyword(s):

T Cells ◽

T Cell ◽

Tandem Repeats ◽

Acute Gvhd ◽

Conflicts Of Interest ◽

Strong Predictor ◽

Standard Procedure ◽

Conditioning Regimen ◽

Mixed Chimerism ◽

The Impact

Abstract Abstract 4545 The monitoring of chimerism is a standard procedure for assessing hematopoietic engraftment and achievement of full donor lymphoid chimerism after RIC based Allo-SCT. Post graft donor lymphocyte infusions are often decided on this evaluation. These studies have however a cost issue, all the more no consensus presently exists on when and how often to perform them. We retrospectively analysed the impact of acute GvHD in the prediction of allograft chimerism in our RIC program where TCC was serially assessed at 30, 60 and 90 days after Allo-SCT. We selected patients with hematologic malignancies (with the exclusion of myelofibrosis) transplanted between 2001 and 2010 after Fludarabine-Busulfan-ATG RIC from a HLA identical donor. 115 patients fulfilled all criteria including at least one T cells chimerism (TCC) determination between day 30 and 120. Allo-SCT was performed from familial donor in 92 patients (80%) and from MUD in 23 patients (20%). The conditioning regimen consisted of fludarabine (90 to 180 mg / m2), Busulfan (8 mg / kg orally or 6.4 mg / kg IV) and rabbit anti-thymocyte globulin (ATG) (2.5 or 5 mg /kg). As for chimerism study, recipient peripheral blood T lymphocytes were positively sorted by a mix of anti-CD4 and CD8 immunomagnetic beads (Dynal, Compiègne, France). T-cell purity was controlled by flow cytometry and was always > or =95%. Genomic DNA was amplified using fluorescent PCR primers for polymorphic variable number tandem repeats (VNTR) or short tandem repeats (STR). Mixed T-cell chimerism was defined as between 5 and 94% recipient cells, and full chimerism was defined as the presence of more than 95% donor cells. Full TCC was achieved in 94 patients (82%) at a median of 77 (30–120) days post transplant. Fifty eight patients (50.4%) developed acute GvHD. The cumulative incidence of Grade 2–4 GvHD in our population is 32% (95% CI 23–41). Overall the results showed that each of the 37 patients developing grade ≥ 2 AGVHD had a Full TCC prior day 120. On the other hand, all mixed chimerism were documented in patients not presenting Grade≥2 AGVHD (21 of the 78 patients (27%) without grade ≥ 2 AGVHD) (p=.002). No other parameter (ATG dose, Donor type…) achieved this level of individual prediction. These results, in a very homogenous population, are in line with the concept that full TCC is more likely to occur when patient develops significant aGVHD. Although they deserve further and deeper confirmation in different populations, they address the value of systematic routine chimerism surveillance (outside clinical studies) in patients presenting acute GvHD following RIC Allo-SCT. The modulation of TCC determination might represent an interesting cost and resources saving. Disclosures: No relevant conflicts of interest to declare.

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First Reported Case Series of Concomitant Ruxolitinib and Ibrutinib for Graft-Versus-Host Disease (GVHD)

Blood ◽

10.1182/blood-2021-148071 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 4885-4885

Author(s):

Thomas A Gagliardi ◽

Jordan Milner ◽

Cassey Paula ◽

Mehmet Ozkayank ◽

Oya Levendoglu-Tugal ◽

...

Keyword(s):

Board Of Directors ◽

Lung Biopsy ◽

Acute Gvhd ◽

Chronic Gvhd ◽

Conditioning Regimen ◽

Case Series ◽

Advisory Committees ◽

Graft Versus Host ◽

Gvhd Prophylaxis ◽

Grade 3

Abstract Background: Graft-versus-Host Disease (GVHD) is a complication that occurs in 30-70% of hematologic malignancy patients post-hematopoietic stem cell transplant (HCT) (Flowers, February 2021). Steroid refractory GVHD has led to studies approving ruxolitinib and ibrutinib as the first FDA approved therapies for steroid refractory GVHD. Ruxolitinib is approved to treat acute GVHD (aGVHD) and inhibits Janus associated kinase (JAK). Ibrutinib is approved to treat chronic GVHD (cGVHD) and functions by inhibiting Bruton's tyrosine kinase (BTK). Here we describe 2 cases of patients who received both drugs for their GVHD. Patient #1 was a 4-year-old female who had a diagnosis of NK cell dysfunction. The patient underwent a conditioning regimen with melphalan 140 mg/m2, fludarabine 30 mg/m2 X5, and alemtuzumab for 5 days. The allogeneic HCT was performed with cells from a 9/10 NMDP donor and received a CD34+ enrichment with T cell addback of 2.1 x10^5 CD3/kg. Tacrolimus was given for GVHD prophylaxis. The patient developed aGVHD stage 2, grade 3 of the gut on day +148. Patient received steroids, extracorporeal photopheresis (ECP), and cellcept, and the GVHD resolved. The patient then developed skin GVHD on day +189 (stage 1, grade 3) that resolved. Approximately 15 months post-transplant there was concern the patient was developing cGVHD of the skin and gut (chronic though stable diarrhea), and therefore ibrutinib was initiated day +490 at 140 mg daily. The cGVHD persisted despite ibrutinib, ECP, tacrolimus, and sirolimus. Ruxolitinib was then initiated 2.5 mg bid on day +883. Patient demonstrated stable to slightly improved GVHD and tapered ibrutinib to 110 mg between days +951 and +980. The patient remained on ruxolitnib and ibrutinib as of day +1172. Patient #2 was a 1-year-old male with sickle cell anemia. The patient was transplanted under a haploidentical protocol from the mother, receiving a CD34+ enrichment with T cell addback of 2x10^5 CD3/kg. The conditioning regimen was busulfan 2 mg/kg, fludarabine 30 mg/m2, cyclophosphamide 50 mg/kg, and thymoglobulin 2 mg/kg with tacrolimus as GVHD prophylaxis. Patient was experiencing fevers, dyspnea and CT was concerning for an infiltrative process. Broad spectrum antibiotics did not improve symptoms. A lung biopsy was performed and bronchiolitis obliterans organizing pneumonia (BOOP) was diagnosed on day +217 (pathology confirmed GVHD). The pathology report was reviewed at an outside institution, raising the question of thrombotic microangiopathy (TMA) in context of hemolysis markers (high LDH and low platelets). Patient was placed on Fluticasone, Azithromycin, and Montelukast (FAM). Due to persisting BOOP confirmed on lung biopsy on day +407, the patient started ibrutinib 140 mg daily on day +411 and was started on ruxolitinib 2.5 mg bid on day +412. ECP commenced on day +414. Within 1 month, symptoms improved. Lung CT imaging appeared stable since initiation of these modalities. Patient continued with ruxolitinib, ibrutinib and ECP (twice per week) for GVHD, though the ruxolitinib dose was tapered in half starting day +477. Symptoms have improved. Discussion: To our knowledge this is the first reported case series of concomitant use of ruxolitinib and ibrutinib. A literature search (PubMed and abstracts in society meetings) was conducted that found 1 paper focused on ruxolitinib for cGVHD with 3 patients on concomitant ibrutinib, but without further details (Ferreira et al., June 2021). Our cases represent a proof-of-concept approach to GVHD management and demonstrate the feasibility of administrating both agents. The combination was well-tolerated with no significant adverse events noted. Neither patient had to discontinue due to poor tolerance or interactions. We expect this dual-drug therapy will become more common going forward given FDA approvals for both ruxolitinib and ibrutinib. Recently, ruxolitinib underwent a successful trial for glucocorticoid-refractory cGVHD when compared to best available therapies, including ibrutinib, though the drugs were not tested in combination (Zeiser et al., July 2021). These findings may open the door for further concomitant use, especially if ruxolitinib is approved by the FDA for cGVHD. We propose further investigation into dual therapy of these drugs in cGVHD either compared to steroids or as a second line option. Disclosures Cairo: Jazz Pharmaceutical: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Amgen: Speakers Bureau; Sanofi: Speakers Bureau; Servier: Speakers Bureau; Sobi: Speakers Bureau; Omeros: Membership on an entity's Board of Directors or advisory committees; Nektar: Membership on an entity's Board of Directors or advisory committees. OffLabel Disclosure: Ruxolitinib is being used here for chronic GVHD, while it is FDA approved for acute GVHD.

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Graft-Versus-Host Disease (GVHD) Prophylaxis with Post-Transplant Cyclophosphamide (PTCY) Induces a More Tolerant Immune Response after Allogeneic Hematopoietic Cell Transplantation (Allo-HCT) in Patients Previously Exposed to Nivolumab

Blood ◽

10.1182/blood-2018-99-114887 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 3402-3402

Author(s):

Juan C Nieto ◽

Elisa Roldan ◽

Isabel Jiménez ◽

Laura Fox ◽

Júlia Carabia ◽

...

Keyword(s):

Immune Response ◽

T Cells ◽

T Cell ◽

Cd8 T Cells ◽

Acute Gvhd ◽

Early Immune Response ◽

Gvhd Prophylaxis ◽

Ifn Γ ◽

Grade 3 ◽

Classical Monocytes

Abstract Allo-HCT has been shown to be feasible in patients previously exposed to anti-PD-1 monoclonal antibodies, albeit their use has been associated with a more frequent and more severe acute GVHD. Our aim was to study the effect of pre-transplant exposure to the anti-PD1 nivolumab on early immune response after allo-HCT and how this response becomes modulated by the use of PTCY. Twelve patients diagnosed with lymphoproliferative neoplasms who underwent an allo-HCT from HLA matched related or unrelated donors were analyzed. Considering pre-HCT exposure to nivolumab and type of GVHD prophylaxis, patients were classified into 4 groups: previous nivolumab and GVHD prophylaxis with PTCY (Nivo-PTCY, n=3), previous nivolumab and standard GVHD prophylaxis with tacrolimus and sirolimous (Nivo-TacSiro, n=3), no previous nivolumab and GVHD prophylaxis with PTCY (Control-PTCY, n=3) and no previous nivolumab and standard GVHD prophylaxis (Control-TacSiro, n=3). Patients exposed to nivolumab received a median of 8.5 (range 4-16) doses at 3mg/Kg, being the median time from the last dose of nivolumab to allo-HCT of 84 (range, 34-154) days. With a median of 29 (range 23-37) days, all 3 patients in the Nivo-TacSiro group experienced fatal grade 3-4 acute GVHD. No other grade 3-4 GVHD was observed in the other patients and only 2 (1 in each control group) had grade 2 acute GVHD. All 12 patients were in full-donor chimera on day +21. Concentration of nivolumab in plasma was measured on Day 0 (allo-HCT), +7, +14, +21, +28 and +56 by ELISA. Early immune response on day +21 was assessed by flow cytometry analyzing changes in the T-cell repertoire, variations on the expression of PD-1 and other inhibitory receptors (TIM-3 and LAG-3), and modifications in the myeloid compartment. Residual nivolumab was detected as late as 56 days after allo-HCT in the plasma from all 6 patients exposed to the drug (Figure 1A). In addition PD-1 expression on CD4+ and CD8+ T cells on day +21 was found to be lower in these patients compared to control groups, pointing out that residual nivolumab was able to block PD-1 on donor-derived T-cells after allo-HCT (Figure 1B). We then analyzed the effect of pre-transplant nivolumab on early (day +21) immune response after allo-HCT by comparing groups of patients with the same GVHD prophylaxis. Hence, patients in the Nivo-TacSiro subgroup presented a lower CD4+/CD8+ ratio, lower counts of naïve CD8+ T cells (Figure 1C), higher percentage of IFN-γ-producing CD4+ and CD8+ T cells, lower expression of TIM-3 on CD4+ an CD8+ T cells as well as promotion of Th1 differentiation after allo-HCT than Control-TacSiro patients. Also, these patients had a higher proportion of classical monocytes and higher expression of the activation marker CD86 than patients not exposed to anti-PD1 (Figure 1D). All this immune activation was in line with the clinical scenario of severe GVHD observed later on in the 3 patients of the Nivo-TacSiro subgroup. Conversely, patients in the Nivo-PTYC subgroup had similar proportions of T-cell subpopulations (especially in the CD8 compartment), Th1 differentiation, and monocyte profile at day +21 than patients in the Control-PTYC subgroup, indicating that previous nivolumab exposure has little influence on the effect of PTCY. Finally, a direct comparison of the two GVHD prophylaxis schemes used in the 6 patients previously exposed to nivolumab revealed that Nivo-PTCY patients had a higher CD4+/CD8+ ratio, higher proportion of CD4+ and CD8+ effector memory T-cells (Figure 1C), lower percentage of IFN-γ-producing T cells, as well as an attenuated Th1 response and a lower proportion of classical monocytes (Figure 1D) after allo-HCT compared with Nivo-TacSiro patients. In conclusion, pre-transplant nivolumab is detectable in plasma of patients within 2 months following allo-HCT and it seems to be responsible for an altered early T-cell and monocyte activation status in patients receiving standard GVHD prophylaxis. PTCY seems capable of inducing a more tolerant profile of immune cells in patients previously exposed to nivolumab. Therefore, the use of PTCY as GVHD prophylaxis in patients previously exposed to immune checkpoint inhibitors warrants further investigation. Disclosures Iacoboni: Roche: Honoraria; Celgene: Other: Travel funding.

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HLA-Identical Sibling-Matched, CD34+ Selected, T Cell Depleted Peripheral Blood Stem Cells Following Myeloablative Conditioning for First or Second Remission Acute Myeloid Leukemia (AML): Results of Blood and Marrow Transplant Clinical Trials Network (BMT CTN) Protocol 0303.

Blood ◽

10.1182/blood.v114.22.655.655 ◽

2009 ◽

Vol 114 (22) ◽

pp. 655-655 ◽

Cited By ~ 1

Author(s):

Steven M. Devine ◽

Robert J Soiffer ◽

Marcelo C. Pasquini ◽

Shelly Carter ◽

Parameswaran N Hari ◽

...

Keyword(s):

T Cell ◽

Hematopoietic Cell Transplantation ◽

Conflicts Of Interest ◽

Chronic Gvhd ◽

Conditioning Regimen ◽

Disease Free Survival ◽

Unrelated Donor ◽

Post Transplant ◽

Gvhd Prophylaxis

Abstract Abstract 655 Allogeneic hematopoietic cell transplantation (HCT) is the most effective means to prevent relapse in patients (pts) with AML in complete remission (CR). However, quality of life and overall survival (OS) are often affected by both acute and chronic graft versus host disease (GVHD). GVHD is most effectively prevented by ex vivo T cell depletion (TCD) of the allograft, but has been limited in its use by logistical difficulties, lack of an FDA-approved method, and concerns regarding potential risk of graft rejection, post transplant infections, and leukemic relapse. Most reported TCD studies represent single centers, multiple disease types and processing methods with varying degrees of TCD, all of which affect outcome. Therefore we designed a trial using a single processing method providing extensive TCD that did not require post transplant GVHD prophylaxis involving adult pts with AML in first or second CR. We hypothesized that the undesired side effects of TCD HCT would be reduced if combined with a conditioning regimen that was highly immunosuppressive and anti-leukemic. The primary objective was to achieve a disease-free survival (DFS) rate at 6 months (mos) post transplant that exceeded 75%. Secondary objectives included assessments of engraftment, transplant related mortality (TRM), GVHD, relapse, and performance of a single TCD method (CD34+ cell selection using the Miltenyi CliniMACS device) at participating centers. From 10/2005 to 12/2008, 47 pts were enrolled and 44 transplanted at 8 different centers. Median age was 48.5 years (range 21-59) with 28 female and 16 male pts. Of 37 AML CR1 pts, 49% had an unfavorable cytogenetic or molecular risk profile. The conditioning regimen consisted of hyperfractionated total body irradiation (1375cGy in 11 fractions) with partial lung shielding, thiotepa (10mg/kg), cyclophosphamide (120mg/kg), and rabbit antithymocyte globulin (2.5mg/kg). The donors, all HLA-identical siblings, were given G-CSF for mobilization and scheduled to undergo at least 2 leukapheresis procedures to ensure a graft with a high CD34+ cell content. All allografts were CD34-enriched and were targeted to contain ≥ 5×10e6 CD34+ cells/kg and < 1.0×10e5 CD3+ cells/kg. The median CD34+ and CD3+ doses achieved were 8.1 × 10e6/kg (range 2.4-46.2) and 0.07 × 10e5/kg (range 0.01-0.85), respectively. The majority (81%) of pts received the targeted CD34+ cell dose and no pt received > 1.0×10e5 CD3+ cells/kg. No pharmacological GVHD prophylaxis was given post transplant. There were no significant toxicities related to infusion of the CD34 enriched allografts. The most common grade 3-5 regimen-related toxicities included grades 3 or 4 mucositis (39%) and grades 3-5 pulmonary abnormalities (11%). Only 1 pt experienced hepatic veno-occlusive disease. All pts engrafted rapidly with a median time to neutrophil recovery (ANC > 500/ul) of 11 days (range 9-19). There was 1 secondary graft failure. The assessed outcomes are shown below.Estimate (95% Confidence Interval)Outcome100 Days6 Months12 MonthsAcute GVHD II-IV20.5% (8.7 – 23.3%)Acute GVHD III-IV4.5% (0 – 10.6%)Chronic GVHD17.7% (5.8-29.6%)Extensive Chronic GVHD7.6% (0-15.7%)TRM17.8% (5.8-29.8%)Overall Relapse18.2% (5.9-30.5%)Relapse 1st CR9.6% (0- 19.8%%)Relapse 2nd CR64.3% (27.5-100%)DFS81.3% (66.1-90.2%)64.0% (46.5-77.1%)DFS 1st CR89.2% (73.7-95.8%)72.1% (53.0-84.6%)OS74.3% (57.3-85.4%) The absolute peripheral CD4+ cell count remained on average below 200/ul until day +365. Donor cell chimerism increased in the CD3+ cell compartment through day +365. There were 14 deaths. The most common causes of death were relapse (N=5) and pulmonary toxicity (N=4). The median follow-up of survivors is 489 days (range 96-776). There was no difference in OS or DFS for pts above or below the median age of 48.5 years. We conclude that TCD HCT following myeloablative chemoradiotherapy can be performed in a multi-center setting using a single TCD method without additional post transplant prophylaxis with excellent DFS and OS, consistent engraftment, low TRM, and low incidence of relapse even in pts with unfavorable risk AML in CR1. The low incidences of acute and chronic GVHD in the absence of post transplant prophylaxis were particularly encouraging. A follow-up study of TCD HCT in AML recipients of unrelated donor allografts is being planned by the BMT CTN Disclosures: No relevant conflicts of interest to declare.

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