Background: GATA2 deficiency results in a clinical syndrome known variably as: MonoMAC for the la... more Background: GATA2 deficiency results in a clinical syndrome known variably as: MonoMAC for the lack of monocytes and atypical mycobacterial infections (MAC); DCML, dendritic cell, monocyte and lymphoid cell deficiency; Emberger's syndrome with lymphedema and monosomy 7; and familial myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML). Reconstitution of the deficient cell compartments in GATA2 deficiency with allogeneic hematopoietic stem cell transplant (HSCT) results in reversal of the infection susceptibility and represents the only curative therapy for both the myeloid disease and the virally driven malignancies seen in this disorder. However, only about one-half of patients that require HSCT will have an HLA-matched related or unrelated donor. Moreover, the use of umbilical cord blood has been reported to be suboptimal in this cohort of patients in whom infection susceptibility underlies much of the need for a transplant. Methods: We performed haploidentical, related donor HSCT with high dose post-transplant cyclophosphamide (PT/CY) in 3 patients with GATA2 deficiency in whom a suitable HLA matched donor was not available. All three patients had a first degree relative (sibling) who shared at least 1 HLA-haplotype. The first patient, a 21 year-old Chinese woman presented with Hydroa Vacciniforme like T-cell lymphoma involving her lung, bowel (resulting in multiple small bowel resections and ileostomy), and skin (with large ulcerative lesions); multiple thrombotic cerebral events; and macrophage activation syndrome requiring etoposide and high dose prednisone in the intensive care unit (ICU). The second patient, a 20 year-old Hispanic female, presented with myelodysplasia (MDS), profound neutropenia, an invasive fungal sinusits due to Fusarium sp., and recurrent bacteremias. The third patient, a 45 year-old woman, presented with Emberger’s Syndrome, multiple episodes of bacterial and fungal sepsis and hypocellular MDS. All three patients received cyclophosphamide 14.5mg/kg on day’s -6 and-5; fludarabine 30mg/m2 on day’s -6 through -2; 200cGy of total body irradiation (TBI) on day -1. Patients 2 and 3 also received busulfan 3.2 mg/kg on day’s -4 and -3 because of MDS. All 3 patients received high dose PT/CY 50mg/kg on day’s +3 and +4, and mycophenolate mofetil and tacrolimus starting on day +5. Results: All 3 patients engrafted at a mean of 18 days and all are alive at a median follow-up of 9 months (range, 5 to 13 months). All three patients achieved 100% donor myeloid and lymphoid chimerim by day +100 post-transplant. The first patient had complete resolution of her T-cell lymphoma and macrophage activation syndrome, the second patient has had complete reversal of her hematopoietic and infectious phenotype, and the third patient has had resolution of her infectious complications that required continuous IV Daptomycin for 5 years prior to transplant. In addition, all three patients had complete reconstitution of the monocyte, NK cell, and B-lymphocyte compartments that were severely deficient prior to transplant. The main toxicity was mucositis, which required intravenous narcotics in all three patients.…
Background Heterozygous sporadic or inherited mutations in the GATA2 gene result in a syndrome kn... more Background Heterozygous sporadic or inherited mutations in the GATA2 gene result in a syndrome known variably as: “MonoMAC” for monocytopenia with nontuberculous mycobacterial (NTM) infections; DCML, dendritic cell, monocyte and lymphoid cell deficiency; Emberger's syndrome, lymphedema and MDS with monosomy 7; and familial myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML). Life-threatening opportunistic infections and myeloid transformation constitute the rationale for allogeneic hematopoietic stem cell transplant (HSCT) for GATA2 deficiency. Methods We treated 14 patients with GATA2 deficiency using a nonmyeloablative-conditioning regimen and matched related donors (MRD) (n=4), matched unrelated donors (URD) (n=4), umbilical cord blood (UCB) (n=4), and haploidentical related donor (HD) (n=2) sources. There was considerable pre-transplant morbidity in this cohort of patients. MRD and URD recipients received 200 cGy of total body irradiation (TBI) and 3 days of fludarabine; UCB recipients received 200cGy TBI, cyclophosphamide 50 mg/kg on day -6, and 5 days of fludarabine; HD recipients received 200cGy TBI, cyclophosphamide 14.5 mg/kg on days -6 and -5, and fludarabine for 5 days. MRD, URD, and UCB recipients received tacrolimus and sirolimus for GVHD prophylaxis. HD recipients received cyclophosphamide 50 mg/kg on days + 3 and +4 followed by tacrolimus and mycophenolate mofetil. MRD and URD donor recipients received peripheral blood stem cells (PBSC) and HD donor recipients received bone marrow stem cells. Results ([ table 1 ][1]): The median follow-up in the MRD cohort was 32 months, excluding one early death in a patient on a ventilator at the time of transplant. One patient relapsed one year post-transplant and required re-transplant using a myeloablative regimen. All 4 patients in this cohort developed acute GVHD. In the URD cohort, all patients are alive, however one patient rejected the PBSC graft and required a second URD transplant from a different donor. Two patients developed acute GVHD. In the UCB cohort, there was one early death from sepsis, one graft rejection, and one donor cell leukemia that occurred 2.5 years post-transplant. The remaining patient had a complicated course, but at 3 years post-transplant he is fully engrafted, on no medications, and has no GVHD. In the two patients who received HD transplants, one had progressed to proliferative CMML prior to transplant and died in the immediate post-transplant period. The second patient engrafted and is doing well two months post-transplant with resolution of an EBV-driven T cell lymphoma. All patients who engrafted had complete reconstitution of the monocyte, NK, and B lymphocyte compartments; all had correction of the underlying myeloid malignancy, and reversal of the infection susceptibility phenotype, characteristic of the disease. In particular, there were no recurrences of NTM. View this table: Table1 Outcome of GATA2 HSCT recipients Conclusions Nonmyeloablative HSCT in GATA2 deficiency results in reconstitution of the severely deficient monocyte, B and NK cell populations and correction of the infection susceptibility phenotype. However, 1 of 4 MRD recipients developed a relapse of the original clone, and 1 of 4 URD recipients rejected the donor PBSC. The incidence of relapse and rejection, as well as the unfavorable cytogenetics in many patients, suggests that a more intense conditioning regimen is required to treat these patients. In this regard, we are now using a myeloablative regimen with busulfan and fludarabine. The poor outcome with UCB in this cohort of immunocompromised patients supports the use of HD transplants when a MRD or URD is not available. We anticipate that with increasing use of genetic testing for GATA2 mutations, patients will be transplanted earlier in the course of disease, before significant organ damage or clonal evolution of MDS to AML and CMML occurs, and that the outcome of allogeneic HSCT in these patients will continue to improve with these modifications in the transplant approach. Disclosures: No relevant conflicts of interest to declare. [1]: #T1
Abstract 3054 Background: A clearly superior graft-versus-host disease (GVHD) prophylaxis regimen... more Abstract 3054 Background: A clearly superior graft-versus-host disease (GVHD) prophylaxis regimen has not been established for patients undergoing reduced intensity allogeneic hematopoetic stem cell transplantation (HSCT) from matched unrelated donors (URD). Encouraging results have been reported with both the combination of alemtuzumab and cyclosporine (AC) and the regimen of tacrolimus, methotrexate, and sirolimus (TMS) in the URD setting. These two regimens work by biologically distinct mechanisms and may have markedly different effects on immune reconstitution. T-cell receptor (TCR) spectratyping analysis, which provides information on antigen receptor diversity, is a valuable method for monitoring post-transplant immune reconstitution. As part of a randomized pilot study, we prospectively assessed the effects of AC vs. TMS on TCR Vb repertoire diversity in patients undergoing reduced intensity HLA-matched unrelated donor transplantation. Methods: Twenty patients (median age 53 yrs; range 24–70 yrs) with hematologic malignancies received reduced intensity conditioning (fludarabine 30 mg/m2/day and cyclophosphamide 1200 mg/m2/day IV Day -6 to -3) followed by a 10/10 HLA-matched unrelated donor T-cell replete mobilized peripheral blood allograft. Patients were randomized to receive either: AC (n=10): alemtuzumab 20 mg/day IV over 8 hours Days -8 to -4 and cyclosporine starting at Day -1 with a 10% per week taper starting at Day +100 or TMS (n=10): tacrolimus and sirolimus starting at Day -3 with a 33% taper at Day +63 and Day +119 and methotrexate 5 mg/m2 IV, Days +1, +3, +6, and +11. Blood samples were collected from the donor and patient at baseline and the patient at 1, 3, 6 and 12 months post-transplant for TCR spectratyping analysis. All comparisons are based on an exact Wilcoxon rank sum test; p values < 0.01 were significant because of multiple comparisons. Results: Patients on the AC arm had significantly fewer T-cells on Day +14 compared with the TMS arm (median CD3+ = 1 cells/μl vs 356 cells/μl; CD4+ = 0 cells/μl vs 243 cells/μl; CD8+ = 0 cells/μl vs. 59 cells/μl; each…
3033 Background: Alemtuzumab is a humanized monoclonal antibody against CD52 resulting in profoun... more 3033 Background: Alemtuzumab is a humanized monoclonal antibody against CD52 resulting in profound, prolonged T-cell depletion that may be associated with opportunistic infections and reactivation of latent viruses (e.g., CMV). BK virus is a polyomavirus that infects most humans during childhood and remains latent in the urinary tract. Reactivation of BK virus is an important cause of tubular nephropathy following renal transplantation and hemorrhagic cystitis after allogeneic stem cell transplant. Methods: A single institution pilot trial of alemtuzumab and Dose-Adjusted (D-A) Etoposide, Prednisone, Doxorubicin, Vincristine, and Cyclophosphamide (EPOCH) investigating efficacy and toxicity in chemotherapy naïve aggressive T- and NK-cell lymphomas was undertaken. BK virus was detected in urine by polymerase chain reaction (PCR) methods to quantify genomic copies in pts with dysuria and hemorrhagic cystitis. Results: Four of 20 pts treated with alemtuzumab and DA-EPOCH developed five episodes of hemorrhagic cystitis. One had grade 1 and 2 cystitis, two had grade 2 cystitis and one had grade 3 cystitis. In contrast, only one of over 200 pts treated with EPOCH alone or in combination with rituximab developed hemorrhagic cystitis. Hemorrhagic cystitis occurred at a median of 88 days after initiation of therapy and lasted a median of 22 days. Even if considered an unlikely cause, steps to minimize cyclophosphamide toxicity were taken; in one, mesna was given during the fifth cycle and cyclophosphamide was withheld from the final cycle of therapy. Another received a reduced dose of cyclophosphamide during the final cycle of therapy and the third did not receive the final cycle of therapy altogether. The fourth pt developed hemorrhagic cystitis after completion of therapy. PCR for BK virus showed a median of 8.87 x 108 (range 2.3 x 105-8.7 x 109) genomic copies per ml. Conclusions: Hemorrhagic cystitis secondary to BK virus reactivation may occur following Alemtuzumab therapy. Symptoms tend to abate after 1 to 7 weeks with conservative measures alone. [Table: see text] No significant financial relationships to disclose.
Engraftment syndrome (ES), defined as noninfectious fever, rash, and noncardiogenic pulmonary ede... more Engraftment syndrome (ES), defined as noninfectious fever, rash, and noncardiogenic pulmonary edema occurring at the time of hematopoietic recovery after stem cell transplantation, may cause significant morbidity in the peri-transplant period. However, its association with GVHD is unclear, and it remains controversial whether T-cell alloreactivity, nonspecific neutrophil activation, or other factors contribute to the pathogenesis of this syndrome. To study this question, we retrospectively analyzed patients enrolled in 3 separate protocols of reduced-intensity allogeneic hematopoietic stem cell transplantation (RIST). Group A included patients with relapsed/refractory hematologic malignancies undergoing RIST with T-cell replete allografts and cyclosporine for GVHD prophylaxis (n=49). Group B consisted of patients with hematologic malignancies receiving T-cell replete allografts and cyclosporine/methotrexate for GVHD prophylaxis (n=20). Group C included patients with metastatic breast cancer undergoing RIST with T-cell depleted allografts (1 x 105 CD3+ cells/kg) and cyclosporine for GVHD prophylaxis (n=17). All patients received an identical reduced-intensity conditioning regimen with fludarabine and cyclophosphamide, followed by infusion of filgrastim-mobilized peripheral blood stem cells and post-transplantation filgrastim until neutrophil recovery. The incidences of ES and acute GVHD varied according to treatment group (ES: chi-squared test, p=0.066; acute GVHD: chi-squared test, p=NS): Incidence of Engraftment Syndrome and Acute GVHD by Treatment Group Group Graft Composition GVHD Prophylaxis Engraftment Syndrome Acute GVHD, Grades 2–4 A T-cell replete Cyclosporine 24/49 (49%) 32/49 (65%) B T-cell replete Cyclosporine/Methotrexate 5/20 (25%) 9/20 (45%) C T-cell depleted Cyclosporine 4/17 (24%) 8/17 (47%) Logistic regression analysis identified hypoxemia requiring oxygen (OR 38.46, 95% CI 6.51 to 227.1; p=0.002), fever greater than 37 degrees C (OR 6.97, 95% CI 2.47 to 19.7; p<0.0001), and the maximum neutrophil count after engraftment (OR 1.07, 95% CI 1.02 to 1.125; p=0.0093) as factors strongly associated with steroid administration for ES. Subjects with acute GVHD displayed a modest trend toward increased frequency of ES (exact Cochran-Armitage trend test, p=0.103). The association of the intensity of GVHD prophylaxis and the maximum neutrophil count with the incidence of ES implies that both alloreactive T cells and donor granulocytes may play a role in the development of this complication after RIST. These results suggest that additional studies are warranted to explore the contribution of alloreactivity to the pathogenesis, prevention, and treatment of ES.
Abstract 3091 Background: Recently, sporadic and heritable mutations in the zinc finger transcrip... more Abstract 3091 Background: Recently, sporadic and heritable mutations in the zinc finger transcription factor GATA2 were shown to be responsible for four different syndromes in young adults coupling opportunistic infection with a predilection to develop myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML). These four syndromes are: MonoMAC, monocytopenia with nontuberculous mycobacterial (NTM) infections; DCML, dendritic cell, monocyte and lymphoid cell deficiency; Emberger's syndrome, lymphedema and MDS with monosomy 7; and familial MDS/AML. Life-threatening infections, and the transformation to AML, either alone or together, constitute a rationale for allogeneic hematopoietic stem cell transplant (HSCT) for GATA2 deficiency. Methods: We evaluated matched related, unrelated, and umbilical cord blood as donor sources for nonmyeloablative conditioning for HSCT in GATA2 deficiency. Twelve patients with GATA2 deficiency underwent allogeneic transplant: 4 received peripheral blood stem cells (PBSCs) from matched related-donors (MRD), 4 received PBSC from matched unrelated-donors (MUD), and 4 received umbilical cord blood (UCB) units. Recipients of MRD and MUD transplant received fludarabine and 200cGy of total body irradiation (TBI), while UCB recipients received cyclophosphamide 50 mg/kg, fludarabine, and 200cGy of TBI. All patients received tacrolimus and sirolimus for GVHD prophylaxis. This cohort of patients had considerable pre-transplant morbidity: two patients required baseline oxygen for pulmonary alveolar proteinosis, one of whom was on a ventilator at the time of transplant; one patient had active hepatitis C that was not responding to therapy; one patient had RAEB-2; two patients were platelet transfusion-dependent; one patient had recurrent strokes and culture negative endocarditis two months before transplant. Results: Median follow-up for patients was 14.4 months (range 0.2–38.2 months). Ten of 11 patients engrafted at a median of 10 days (range 0–76); engraftment was not evaluable in a recipient of an UCB transplant due to death early in the post-transplant period. One rejection occurred in a recipient of a double UCB transplant who had been heavily transfused pre-transplant. All patients who engrafted had complete reconstitution of the monocyte, NK, and B-lymphocyte compartments, the three cell compartments that were severely deficient pre-transplant, and all had reversal of the infection susceptibility phenotype, characteristic of the disease. In particular, there were no recurrences of NTM infection and extensive human papilloma virus infections regressed starting around 6 months post transplant. Two patients required a single cycle of pre-transplant chemotherapy for RAEB-1 and RAEB-2, respectively. In both patients the monosomy 6 and monosomy 7 clones have not recurred, now 2.5 years and 9 months following single UCB and MUD transplant, respectively. Three patients died, two early after transplant. One recipient of UCB, who had pre-transplant hepatitis C, died on day+7 of fulminant liver failure and sepsis. A second patient,…
Abstract 471 Lymphoma progression remains an obstacle after allogeneic HCT, particularly after no... more Abstract 471 Lymphoma progression remains an obstacle after allogeneic HCT, particularly after non-myeloablative conditioning in patients with high-risk histology (non-indolent; Kahl et al; Blood, 2007) and chemotherapy refractory disease (Bishop et al; Cancer, 2010). In murine models, rapamycin-resistant T cells favorably modulated the balance between GVHD, graft rejection, and GVT effects. To translate this, we conducted a multi-center phase II trial (NCT0074490) of T-Rapa cells infused as a pre-emptive DLI after low-intensity allogeneic HCT; here, we report overall outcome of patients with high-risk lymphoma diagnoses, many of whom were chemotherapy refractory. T-Rapa cells were manufactured by ex vivo culture of donor CD4+ T cells using CD3/CD28 co-stimulation and IL-4, IL-2, and rapamycin for 12-days (T-Rapa12) or 6-days (T-Rapa6), and administered (2.5 × 107 cells/kg) at d14 post-HCT. Both populations of T-Rapa cells expressed a mixed Th2/Th1 phenotype with minimal T-Reg content. Patients (n=42) received outpatient-intensity chemotherapy (typically, EPOCH-FR) until CD4 count was < 200 cells/μl, and then received an HLA-matched sibling mobilized allograft and GVHD prophylaxis of cyclosporine plus short-course sirolimus (to d14 post-HCT); conditioning consisted of fludarabine (120 mg/m2) and cyclophosphamide (1200 mg/m2). Table I details the high-risk diagnoses, pre-treatment history (median of 4 prior regimens), remission status at time of HCT (7/42 [17%] in CR), and presence of chemotherapy refractory disease (stable or progressive disease to prior therapy: 23/42 pts, 55%). T-Rapa cell infusion was relatively safe, with no engraftment syndrome or d100 TRM; incidences of grade II-IV acute, late acute, and classical chronic GVHD were 17%, 34%, and 36%, respectively. Initial mixed donor/host chimerism converted to predominate donor chimerism after T-Rapa cell DLI (Table I). Overall median survival probability at 24 months post-HCT is 85.7% for patients with chemotherapy sensitive disease vs. 39.1% for patients with chemotherapy refractory disease (Fig. 1; p=0.0008). All deaths were due to progressive disease except for 2 infection-related deaths at days 162 and 359 post-HCT; all surviving patients are in CR. Survival was not statistically significantly influenced by DLI type (T-Rapa12 vs. T-Rapa6) or histology-type (NHL vs. HD). Pre-emptive DLI using donor T-Rapa cells after low-intensity conditioning is safe and very effective in patients with high-risk lymphoma diagnoses and chemotherapy sensitive disease; for such patients, future randomized trials should compare low-intensity T-Rapa cell therapy to other transplantation regimens. For patients with high-risk lymphoma diagnoses and chemotherapy-refractory disease, we are evaluating a modification to the current platform that incorporates high-dose sirolimus therapy. Table I Patient Characteristics Chimerism Resultsc CD3 CD15 Number of Patients n = 42 Day 14 post-HCT 57 (12-97) 46 (8-94) Age (median, range) 44 (23-68) Day 28 post-HCT 77 (37-100) 76 (29-98) Sex (male/female) (26/16) # of Prior Therapies (mean, range) 4 (1-6) Day 100 post-HCT 89 (51-100) 93 (35-100) Histologya n=26 total (62%) Survival Resultsd 24 Mo. Surv. Prob. NHL Category n=12 ChemoSens/T-R12 78.6% (n=7) DLBCL n=5 ChemoSens/T-R6 85.7% (n=12) DLBCL-tr n=2 ChemoRefr/T-R12 41.7% (n=11) DLBCL-EBV n=3 ChemoRefr/T-R6 36.4% (n=12) PlasmacytoidDC n=3 All NHL 57.4% (n=26) T Cell n=16 total (38%) All HD/Grey Zone 68.8% (n=16) HD Category n=12 HD n=4 Grey Zone Chemo. Responseb 23/42 (55%) Refractory (SD/PD) 19/42 (45%) Sensitive (PR/CR) Complete Remission 7/42 (17%) At Time of HCT DLBCL, diffuse large B cell lymphoma; DLBCL-tr, transformed; DLBCL-EBV, Epstein Barr Virus related; Plasmacytoid DC, dendritic cell; HD, Hodgkins Disease; SD, stable disease; PD, progressive disease; PR/CR is partial or complete response. a Grey Zone Lymphoma and Hodgkins Disease were pooled for statistical analyses. b Chemotherapyresponse, as determined after last regimen prior to study entry. c Chimerism determined by VNTR-PCR at days 14, 28, and 100 post-HCT (mean and range of values shown); CD3, T cell chimerism; CD15, myeloid cell chimerism. d Survival by Kaplan-Meier analysis; 24 month median survival probability values shown; T-R12 and T-R6 indicates recipient of T-Rapa cells manufactured for 12 days vs. 6 days. Disclosures: Levine: TxCell: Consultancy, Membership on an entity's Board of Directors or advisory committees; University of Pennsylvania: financial interest due to intellectual property and patents in the field of cell and gene therapy. Conflict of interest is managed in accordance with University of Pennsylvania policy and oversight, financial interest due to intellectual property and patents in the field of cell and gene therapy. Conflict of interest is managed in accordance with University of Pennsylvania policy and oversight Patents…
6540 Background: Significant variation in host immune status may influence outcomes after reduced... more 6540 Background: Significant variation in host immune status may influence outcomes after reduced-intensity (RI) allogeneic stem cell transplantation (alloSCT). We have investigated a strategy of targeted immune depletion (TID) with conventional chemotherapy to deplete host T cells and achieve a minimal disease state prior to RI alloSCT. The aim of TID is to rapidly establish complete donor chimerism after RI alloSCT in order to potentiate a graft-versus-tumor (GVT) effect. In a prospective phase II trial (NIH 03-C-0077), we evaluated the effect of TID on donor chimerism, acute graft-versus-host disease (GVHD), and clinical outcome. Methods: Thirty-one patients (pts) with relapsed and refractory hematologic malignancies (NHL = 16; HL = 4; CLL/PLL = 4; MDS/AML = 3; other = 4) were enrolled. Median age was 57 years (range: 31–71). All pts received EPOCH-F (etoposide, prednisone, vincristine, cyclophosphamide, adriamycin, fludarabine) ± rituximab (R) as TID to deplete host CD4+ cells <100/μL. All pts then received a RI conditioning regimen consisting of fludarabine and cyclophosphamide followed by a T-cell replete allograft from HLA-matched siblings. GVHD prophylaxis consisted of cyclosporine plus short-course mini-methotrexate. Results: EPOCH-F(R) achieved the target host T-cell level in 74% of pts. All 31 pts engrafted after RI alloSCT. Complete donor chimerism (> 95%) was observed in 74% and 81% of pts at day +14 and +28 post-transplant, respectively. The incidence of grade II-III acute GVHD was 42% with no cases of grade IV acute GVHD. The median potential follow-up from transplant is 25 months. Actuarial treatment-related mortality at 1 and 2 years was 3% and 8%, respectively. Event-free survival probabilities at 1 and 2 years post-transplant are 65% and 49%, respectively. Ten pts are alive and event-free >24 months post-transplant. The overall survival probabilities at 1 and 2 years are 84% and 64%, respectively. Conclusions: TID prior to RI alloSCT results in rapid, complete donor engraftment and may potentiate GVT effects. This treatment strategy was associated with very low TRM and favorable outcomes in an older patient population with advanced hematologic malignancies. No significant financial relationships to disclose.
Reduced-intensity conditioning is less potently tumoricidal than myeloablative regimens; thus, RI... more Reduced-intensity conditioning is less potently tumoricidal than myeloablative regimens; thus, RIST relies more upon graft-versus-tumor (GVT) effects for disease eradication. However, variation in baseline host immune status contributes to inconsistent donor engraftment and may impede maximal GVT effects after RIST. We hypothesized that targeted immune depletion (TID) with conventional-dose chemotherapy before RIST might facilitate donor engraftment, thereby potentiating GVT effects. Thus, we evaluated dose-adjusted (DA-) EPOCH-F, a novel regimen of etoposide, prednisone, vincristine, cyclophosphamide (Cy), doxorubicin, and fludarabine (Flu), in a phase II manner in 83 pts with lymphoid malignancies undergoing RIST on 3 sequential, prospective clinical trials between 1999 and 2005. Pts received at least 1 and no more than 3 cycles of DA-EPOCH-F, targeting a peripheral blood CD4+ T cell count < 100 cells/μL. Pts achieving this CD4 count after only 1 or 2 cycles then proceeded to Flu/Cy conditioning and RIST from HLA-matched related donors. Pts otherwise proceeded to RIST after 3 cycles or if disease progression occurred during DA-EPOCH-F, regardless of CD4 count. After 2002, pts with CD20+ malignancies (n=28) also received rituximab (R) on day 1 of each DA-EPOCH-F cycle. Pt characteristics: median age 50 yrs; diagnoses Hodgkin lymphoma (14%), DLBCL (28%), other aggressive NHL (37%), follicular NHL (12%), CLL or other indolent NHL (8%); chemosensitive disease in 48%; median 3 prior regimens, prior autologous stem cell transplant in 28%; poor-risk IPI, FLIPI, IPF score, or Rai stage in 36%. Pts received 1 (n=26), 2 (n=20), or 3 (n=37) cycles of DA-EPOCH-F before RIST. Median CD4 count declined from 284 cells/μL at enrollment to 79 cells/μL after DA-EPOCH-F, which similarly depleted CD8+ T cells and B cells. DA-EPOCH-F toxicities were mainly hematologic and transient. Responses to DA-EPOCH-F were CR/CRu (11%), PR (27%), SD (35%), and PD (23%). Response rates differed by histology (P=0.006); DLBCL or other aggressive NHL were less likely to respond. Baseline CD4 counts were higher in DA-EPOCH-F responders than in non-responders (median 374 vs. 181 cells/μL; P=0.003), despite a similar extent of prior therapy. Full donor chimerism was present by day 14 after RIST in 85% of pts; no graft rejection occurred. The absolute lymphocyte count (ALC) after DA-EPOCH-F was more strongly associated with donor chimerism after RIST (P=0.02) than was CD4+ or other lymphocyte subsets. We retrospectively compared immune depletion in DA-EPOCH-F recipients with that observed in 17 previously untreated pts receiving 6 cycles of DA-EPOCH-R for mantle cell NHL. Although pts receiving DA-EPOCH-F before RIST had lower baseline ALC and all lymphocyte subsets except NKT cells, relative depletion of ALC, T and B cells from baseline levels was surprisingly similar with DA-EPOCH-F and DA-EPOCH-R. We conclude that DA-EPOCH-F effectively provides TID and disease control or stability in most pts with lymphoid malignancies prior to RIST. This strategy is associated with rapid conversion to full donor chimerism and may be useful to enhance potential GVT effects after RIST.
Background: Mutations in the zinc finger transcription factor GATA2 are responsible for: MonoMAC,... more Background: Mutations in the zinc finger transcription factor GATA2 are responsible for: MonoMAC, monocytopenia with nontuberculous mycobacterial (NTM) infections; DCML, dendritic cell, monocyte and lymphoid cell deficiency; Emberger's syndrome with lymphedema and monosomy 7; and familial myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML). Allogeneic hematopoietic stem cell transplant (HSCT) is the only definitive therapy for GATA2 deficiency. Methods: We used matched related donors (MRD), matched unrelated donors (URD), umbilical cord blood (UCB), and haploidentical related donors in allogeneic HSCT for GATA2 deficiency. Fourteen patients received a nonmyeloablative conditioning regimen (4 MRD, 4 URD, 4 UCB, and 2 haplo donors). Five patients received a myeloablative conditioning regimen (1 MRD, 2 URD, and 2 haplo donors). In the nonmyeloablative group, MRD and MUD recipients received fludarabine and 200cGy of total body irradiation (TBI), UCB recipients received cyclophosphamide 50mg/kg, fludarabine 150 mg/m2, and 200cGy of TBI, and haploidentical related donor recipients received cyclophosphamide 29 mg/kg, fludarabine 150 mg/m2, and 200 cGy TBI. In the myeloablative group, MRD and URD received busulfan 12.8 mg/kg and fludarabine 160 mg/m2, and haploidentical related donors received the same regimen as in the nonmyeloablative regimen except for the addition of two days of busulfan 6.4 mg/kg total dose. Nonmyeloablative MRD and URD recipients received tacrolimus and sirolimus post-transplant, and myeloablative MRD and URD recipients received tacrolimus and short course methotrexate post-transplant. All haploidentical related donor recipients received cyclophosphamide 50 mg/kg/day on days + 3 and +4 followed by tacrolimus and mycophenolate mofetil. Three patients in the nonmyeloablative cohort required one or more rounds of pre-transplant chemotherapy because of an increased number of blasts, whereas none of the 5 patients in the myeloablative arm required pre-transplant chemotherapy. Results: In the nonmyeloablative cohort, 8 of 14 (57%) of patients are alive at a median follow-up of 3.7 years (range 12 months to 5 years). One MRD recipient died of GVHD and one relapsed, one URD recipient rejected the donor stem cells and died, three UCB recipient died (one rejection, one early death, and one donor cell leukemia), and one haploidentical recipient died from regimen-related toxicity. All 5 patients (100%) in the myeloablative group, including two recipients of haploidentical related donors, are alive at a median follow-up of 9.2 months (range 6 to 12 months). All patients who survived had complete reconstitution of the monocyte, NK, and B-lymphocyte compartments, the three cell compartments that were severely deficient pre-transplant, and all had reversal of the infection susceptibility phenotype, characteristic of the disease. In particular, there were no recurrences of non-tuberculous mycobacterial (NTM) infections. Conclusions: Nonmyeloablative HSCT results in reversal of the hematologic and clinical manifestations of GATA2 deficiency. However, a more intensive conditioning regimen with busulfan resulted in more uniform engraftment, a reduced risk of relapse, avoidance of pre-transplant chemotherapy, and a low regimen-related toxicity. We anticipate that with the use of a high-dose regimen with busulfan, the replacement of UCB with haploidentical related donors, and HSCT earlier in the clinical course, before significant organ damage or clonal evolution of MDS to AML or CMML, the outcome of allogeneic HSCT in patients with GATA2 deficiency will continue to improve. Disclosures No relevant conflicts of interest to declare.
Background: GATA2 deficiency results in a clinical syndrome known variably as: MonoMAC for the la... more Background: GATA2 deficiency results in a clinical syndrome known variably as: MonoMAC for the lack of monocytes and atypical mycobacterial infections (MAC); DCML, dendritic cell, monocyte and lymphoid cell deficiency; Emberger's syndrome with lymphedema and monosomy 7; and familial myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML). Reconstitution of the deficient cell compartments in GATA2 deficiency with allogeneic hematopoietic stem cell transplant (HSCT) results in reversal of the infection susceptibility and represents the only curative therapy for both the myeloid disease and the virally driven malignancies seen in this disorder. However, only about one-half of patients that require HSCT will have an HLA-matched related or unrelated donor. Moreover, the use of umbilical cord blood has been reported to be suboptimal in this cohort of patients in whom infection susceptibility underlies much of the need for a transplant. Methods: We performed haploidentical, related donor HSCT with high dose post-transplant cyclophosphamide (PT/CY) in 3 patients with GATA2 deficiency in whom a suitable HLA matched donor was not available. All three patients had a first degree relative (sibling) who shared at least 1 HLA-haplotype. The first patient, a 21 year-old Chinese woman presented with Hydroa Vacciniforme like T-cell lymphoma involving her lung, bowel (resulting in multiple small bowel resections and ileostomy), and skin (with large ulcerative lesions); multiple thrombotic cerebral events; and macrophage activation syndrome requiring etoposide and high dose prednisone in the intensive care unit (ICU). The second patient, a 20 year-old Hispanic female, presented with myelodysplasia (MDS), profound neutropenia, an invasive fungal sinusits due to Fusarium sp., and recurrent bacteremias. The third patient, a 45 year-old woman, presented with Emberger’s Syndrome, multiple episodes of bacterial and fungal sepsis and hypocellular MDS. All three patients received cyclophosphamide 14.5mg/kg on day’s -6 and-5; fludarabine 30mg/m2 on day’s -6 through -2; 200cGy of total body irradiation (TBI) on day -1. Patients 2 and 3 also received busulfan 3.2 mg/kg on day’s -4 and -3 because of MDS. All 3 patients received high dose PT/CY 50mg/kg on day’s +3 and +4, and mycophenolate mofetil and tacrolimus starting on day +5. Results: All 3 patients engrafted at a mean of 18 days and all are alive at a median follow-up of 9 months (range, 5 to 13 months). All three patients achieved 100% donor myeloid and lymphoid chimerim by day +100 post-transplant. The first patient had complete resolution of her T-cell lymphoma and macrophage activation syndrome, the second patient has had complete reversal of her hematopoietic and infectious phenotype, and the third patient has had resolution of her infectious complications that required continuous IV Daptomycin for 5 years prior to transplant. In addition, all three patients had complete reconstitution of the monocyte, NK cell, and B-lymphocyte compartments that were severely deficient prior to transplant. The main toxicity was mucositis, which required intravenous narcotics in all three patients.…
Background Heterozygous sporadic or inherited mutations in the GATA2 gene result in a syndrome kn... more Background Heterozygous sporadic or inherited mutations in the GATA2 gene result in a syndrome known variably as: “MonoMAC” for monocytopenia with nontuberculous mycobacterial (NTM) infections; DCML, dendritic cell, monocyte and lymphoid cell deficiency; Emberger's syndrome, lymphedema and MDS with monosomy 7; and familial myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML). Life-threatening opportunistic infections and myeloid transformation constitute the rationale for allogeneic hematopoietic stem cell transplant (HSCT) for GATA2 deficiency. Methods We treated 14 patients with GATA2 deficiency using a nonmyeloablative-conditioning regimen and matched related donors (MRD) (n=4), matched unrelated donors (URD) (n=4), umbilical cord blood (UCB) (n=4), and haploidentical related donor (HD) (n=2) sources. There was considerable pre-transplant morbidity in this cohort of patients. MRD and URD recipients received 200 cGy of total body irradiation (TBI) and 3 days of fludarabine; UCB recipients received 200cGy TBI, cyclophosphamide 50 mg/kg on day -6, and 5 days of fludarabine; HD recipients received 200cGy TBI, cyclophosphamide 14.5 mg/kg on days -6 and -5, and fludarabine for 5 days. MRD, URD, and UCB recipients received tacrolimus and sirolimus for GVHD prophylaxis. HD recipients received cyclophosphamide 50 mg/kg on days + 3 and +4 followed by tacrolimus and mycophenolate mofetil. MRD and URD donor recipients received peripheral blood stem cells (PBSC) and HD donor recipients received bone marrow stem cells. Results ([ table 1 ][1]): The median follow-up in the MRD cohort was 32 months, excluding one early death in a patient on a ventilator at the time of transplant. One patient relapsed one year post-transplant and required re-transplant using a myeloablative regimen. All 4 patients in this cohort developed acute GVHD. In the URD cohort, all patients are alive, however one patient rejected the PBSC graft and required a second URD transplant from a different donor. Two patients developed acute GVHD. In the UCB cohort, there was one early death from sepsis, one graft rejection, and one donor cell leukemia that occurred 2.5 years post-transplant. The remaining patient had a complicated course, but at 3 years post-transplant he is fully engrafted, on no medications, and has no GVHD. In the two patients who received HD transplants, one had progressed to proliferative CMML prior to transplant and died in the immediate post-transplant period. The second patient engrafted and is doing well two months post-transplant with resolution of an EBV-driven T cell lymphoma. All patients who engrafted had complete reconstitution of the monocyte, NK, and B lymphocyte compartments; all had correction of the underlying myeloid malignancy, and reversal of the infection susceptibility phenotype, characteristic of the disease. In particular, there were no recurrences of NTM. View this table: Table1 Outcome of GATA2 HSCT recipients Conclusions Nonmyeloablative HSCT in GATA2 deficiency results in reconstitution of the severely deficient monocyte, B and NK cell populations and correction of the infection susceptibility phenotype. However, 1 of 4 MRD recipients developed a relapse of the original clone, and 1 of 4 URD recipients rejected the donor PBSC. The incidence of relapse and rejection, as well as the unfavorable cytogenetics in many patients, suggests that a more intense conditioning regimen is required to treat these patients. In this regard, we are now using a myeloablative regimen with busulfan and fludarabine. The poor outcome with UCB in this cohort of immunocompromised patients supports the use of HD transplants when a MRD or URD is not available. We anticipate that with increasing use of genetic testing for GATA2 mutations, patients will be transplanted earlier in the course of disease, before significant organ damage or clonal evolution of MDS to AML and CMML occurs, and that the outcome of allogeneic HSCT in these patients will continue to improve with these modifications in the transplant approach. Disclosures: No relevant conflicts of interest to declare. [1]: #T1
Abstract 3054 Background: A clearly superior graft-versus-host disease (GVHD) prophylaxis regimen... more Abstract 3054 Background: A clearly superior graft-versus-host disease (GVHD) prophylaxis regimen has not been established for patients undergoing reduced intensity allogeneic hematopoetic stem cell transplantation (HSCT) from matched unrelated donors (URD). Encouraging results have been reported with both the combination of alemtuzumab and cyclosporine (AC) and the regimen of tacrolimus, methotrexate, and sirolimus (TMS) in the URD setting. These two regimens work by biologically distinct mechanisms and may have markedly different effects on immune reconstitution. T-cell receptor (TCR) spectratyping analysis, which provides information on antigen receptor diversity, is a valuable method for monitoring post-transplant immune reconstitution. As part of a randomized pilot study, we prospectively assessed the effects of AC vs. TMS on TCR Vb repertoire diversity in patients undergoing reduced intensity HLA-matched unrelated donor transplantation. Methods: Twenty patients (median age 53 yrs; range 24–70 yrs) with hematologic malignancies received reduced intensity conditioning (fludarabine 30 mg/m2/day and cyclophosphamide 1200 mg/m2/day IV Day -6 to -3) followed by a 10/10 HLA-matched unrelated donor T-cell replete mobilized peripheral blood allograft. Patients were randomized to receive either: AC (n=10): alemtuzumab 20 mg/day IV over 8 hours Days -8 to -4 and cyclosporine starting at Day -1 with a 10% per week taper starting at Day +100 or TMS (n=10): tacrolimus and sirolimus starting at Day -3 with a 33% taper at Day +63 and Day +119 and methotrexate 5 mg/m2 IV, Days +1, +3, +6, and +11. Blood samples were collected from the donor and patient at baseline and the patient at 1, 3, 6 and 12 months post-transplant for TCR spectratyping analysis. All comparisons are based on an exact Wilcoxon rank sum test; p values < 0.01 were significant because of multiple comparisons. Results: Patients on the AC arm had significantly fewer T-cells on Day +14 compared with the TMS arm (median CD3+ = 1 cells/μl vs 356 cells/μl; CD4+ = 0 cells/μl vs 243 cells/μl; CD8+ = 0 cells/μl vs. 59 cells/μl; each…
3033 Background: Alemtuzumab is a humanized monoclonal antibody against CD52 resulting in profoun... more 3033 Background: Alemtuzumab is a humanized monoclonal antibody against CD52 resulting in profound, prolonged T-cell depletion that may be associated with opportunistic infections and reactivation of latent viruses (e.g., CMV). BK virus is a polyomavirus that infects most humans during childhood and remains latent in the urinary tract. Reactivation of BK virus is an important cause of tubular nephropathy following renal transplantation and hemorrhagic cystitis after allogeneic stem cell transplant. Methods: A single institution pilot trial of alemtuzumab and Dose-Adjusted (D-A) Etoposide, Prednisone, Doxorubicin, Vincristine, and Cyclophosphamide (EPOCH) investigating efficacy and toxicity in chemotherapy naïve aggressive T- and NK-cell lymphomas was undertaken. BK virus was detected in urine by polymerase chain reaction (PCR) methods to quantify genomic copies in pts with dysuria and hemorrhagic cystitis. Results: Four of 20 pts treated with alemtuzumab and DA-EPOCH developed five episodes of hemorrhagic cystitis. One had grade 1 and 2 cystitis, two had grade 2 cystitis and one had grade 3 cystitis. In contrast, only one of over 200 pts treated with EPOCH alone or in combination with rituximab developed hemorrhagic cystitis. Hemorrhagic cystitis occurred at a median of 88 days after initiation of therapy and lasted a median of 22 days. Even if considered an unlikely cause, steps to minimize cyclophosphamide toxicity were taken; in one, mesna was given during the fifth cycle and cyclophosphamide was withheld from the final cycle of therapy. Another received a reduced dose of cyclophosphamide during the final cycle of therapy and the third did not receive the final cycle of therapy altogether. The fourth pt developed hemorrhagic cystitis after completion of therapy. PCR for BK virus showed a median of 8.87 x 108 (range 2.3 x 105-8.7 x 109) genomic copies per ml. Conclusions: Hemorrhagic cystitis secondary to BK virus reactivation may occur following Alemtuzumab therapy. Symptoms tend to abate after 1 to 7 weeks with conservative measures alone. [Table: see text] No significant financial relationships to disclose.
Engraftment syndrome (ES), defined as noninfectious fever, rash, and noncardiogenic pulmonary ede... more Engraftment syndrome (ES), defined as noninfectious fever, rash, and noncardiogenic pulmonary edema occurring at the time of hematopoietic recovery after stem cell transplantation, may cause significant morbidity in the peri-transplant period. However, its association with GVHD is unclear, and it remains controversial whether T-cell alloreactivity, nonspecific neutrophil activation, or other factors contribute to the pathogenesis of this syndrome. To study this question, we retrospectively analyzed patients enrolled in 3 separate protocols of reduced-intensity allogeneic hematopoietic stem cell transplantation (RIST). Group A included patients with relapsed/refractory hematologic malignancies undergoing RIST with T-cell replete allografts and cyclosporine for GVHD prophylaxis (n=49). Group B consisted of patients with hematologic malignancies receiving T-cell replete allografts and cyclosporine/methotrexate for GVHD prophylaxis (n=20). Group C included patients with metastatic breast cancer undergoing RIST with T-cell depleted allografts (1 x 105 CD3+ cells/kg) and cyclosporine for GVHD prophylaxis (n=17). All patients received an identical reduced-intensity conditioning regimen with fludarabine and cyclophosphamide, followed by infusion of filgrastim-mobilized peripheral blood stem cells and post-transplantation filgrastim until neutrophil recovery. The incidences of ES and acute GVHD varied according to treatment group (ES: chi-squared test, p=0.066; acute GVHD: chi-squared test, p=NS): Incidence of Engraftment Syndrome and Acute GVHD by Treatment Group Group Graft Composition GVHD Prophylaxis Engraftment Syndrome Acute GVHD, Grades 2–4 A T-cell replete Cyclosporine 24/49 (49%) 32/49 (65%) B T-cell replete Cyclosporine/Methotrexate 5/20 (25%) 9/20 (45%) C T-cell depleted Cyclosporine 4/17 (24%) 8/17 (47%) Logistic regression analysis identified hypoxemia requiring oxygen (OR 38.46, 95% CI 6.51 to 227.1; p=0.002), fever greater than 37 degrees C (OR 6.97, 95% CI 2.47 to 19.7; p<0.0001), and the maximum neutrophil count after engraftment (OR 1.07, 95% CI 1.02 to 1.125; p=0.0093) as factors strongly associated with steroid administration for ES. Subjects with acute GVHD displayed a modest trend toward increased frequency of ES (exact Cochran-Armitage trend test, p=0.103). The association of the intensity of GVHD prophylaxis and the maximum neutrophil count with the incidence of ES implies that both alloreactive T cells and donor granulocytes may play a role in the development of this complication after RIST. These results suggest that additional studies are warranted to explore the contribution of alloreactivity to the pathogenesis, prevention, and treatment of ES.
Abstract 3091 Background: Recently, sporadic and heritable mutations in the zinc finger transcrip... more Abstract 3091 Background: Recently, sporadic and heritable mutations in the zinc finger transcription factor GATA2 were shown to be responsible for four different syndromes in young adults coupling opportunistic infection with a predilection to develop myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML). These four syndromes are: MonoMAC, monocytopenia with nontuberculous mycobacterial (NTM) infections; DCML, dendritic cell, monocyte and lymphoid cell deficiency; Emberger's syndrome, lymphedema and MDS with monosomy 7; and familial MDS/AML. Life-threatening infections, and the transformation to AML, either alone or together, constitute a rationale for allogeneic hematopoietic stem cell transplant (HSCT) for GATA2 deficiency. Methods: We evaluated matched related, unrelated, and umbilical cord blood as donor sources for nonmyeloablative conditioning for HSCT in GATA2 deficiency. Twelve patients with GATA2 deficiency underwent allogeneic transplant: 4 received peripheral blood stem cells (PBSCs) from matched related-donors (MRD), 4 received PBSC from matched unrelated-donors (MUD), and 4 received umbilical cord blood (UCB) units. Recipients of MRD and MUD transplant received fludarabine and 200cGy of total body irradiation (TBI), while UCB recipients received cyclophosphamide 50 mg/kg, fludarabine, and 200cGy of TBI. All patients received tacrolimus and sirolimus for GVHD prophylaxis. This cohort of patients had considerable pre-transplant morbidity: two patients required baseline oxygen for pulmonary alveolar proteinosis, one of whom was on a ventilator at the time of transplant; one patient had active hepatitis C that was not responding to therapy; one patient had RAEB-2; two patients were platelet transfusion-dependent; one patient had recurrent strokes and culture negative endocarditis two months before transplant. Results: Median follow-up for patients was 14.4 months (range 0.2–38.2 months). Ten of 11 patients engrafted at a median of 10 days (range 0–76); engraftment was not evaluable in a recipient of an UCB transplant due to death early in the post-transplant period. One rejection occurred in a recipient of a double UCB transplant who had been heavily transfused pre-transplant. All patients who engrafted had complete reconstitution of the monocyte, NK, and B-lymphocyte compartments, the three cell compartments that were severely deficient pre-transplant, and all had reversal of the infection susceptibility phenotype, characteristic of the disease. In particular, there were no recurrences of NTM infection and extensive human papilloma virus infections regressed starting around 6 months post transplant. Two patients required a single cycle of pre-transplant chemotherapy for RAEB-1 and RAEB-2, respectively. In both patients the monosomy 6 and monosomy 7 clones have not recurred, now 2.5 years and 9 months following single UCB and MUD transplant, respectively. Three patients died, two early after transplant. One recipient of UCB, who had pre-transplant hepatitis C, died on day+7 of fulminant liver failure and sepsis. A second patient,…
Abstract 471 Lymphoma progression remains an obstacle after allogeneic HCT, particularly after no... more Abstract 471 Lymphoma progression remains an obstacle after allogeneic HCT, particularly after non-myeloablative conditioning in patients with high-risk histology (non-indolent; Kahl et al; Blood, 2007) and chemotherapy refractory disease (Bishop et al; Cancer, 2010). In murine models, rapamycin-resistant T cells favorably modulated the balance between GVHD, graft rejection, and GVT effects. To translate this, we conducted a multi-center phase II trial (NCT0074490) of T-Rapa cells infused as a pre-emptive DLI after low-intensity allogeneic HCT; here, we report overall outcome of patients with high-risk lymphoma diagnoses, many of whom were chemotherapy refractory. T-Rapa cells were manufactured by ex vivo culture of donor CD4+ T cells using CD3/CD28 co-stimulation and IL-4, IL-2, and rapamycin for 12-days (T-Rapa12) or 6-days (T-Rapa6), and administered (2.5 × 107 cells/kg) at d14 post-HCT. Both populations of T-Rapa cells expressed a mixed Th2/Th1 phenotype with minimal T-Reg content. Patients (n=42) received outpatient-intensity chemotherapy (typically, EPOCH-FR) until CD4 count was < 200 cells/μl, and then received an HLA-matched sibling mobilized allograft and GVHD prophylaxis of cyclosporine plus short-course sirolimus (to d14 post-HCT); conditioning consisted of fludarabine (120 mg/m2) and cyclophosphamide (1200 mg/m2). Table I details the high-risk diagnoses, pre-treatment history (median of 4 prior regimens), remission status at time of HCT (7/42 [17%] in CR), and presence of chemotherapy refractory disease (stable or progressive disease to prior therapy: 23/42 pts, 55%). T-Rapa cell infusion was relatively safe, with no engraftment syndrome or d100 TRM; incidences of grade II-IV acute, late acute, and classical chronic GVHD were 17%, 34%, and 36%, respectively. Initial mixed donor/host chimerism converted to predominate donor chimerism after T-Rapa cell DLI (Table I). Overall median survival probability at 24 months post-HCT is 85.7% for patients with chemotherapy sensitive disease vs. 39.1% for patients with chemotherapy refractory disease (Fig. 1; p=0.0008). All deaths were due to progressive disease except for 2 infection-related deaths at days 162 and 359 post-HCT; all surviving patients are in CR. Survival was not statistically significantly influenced by DLI type (T-Rapa12 vs. T-Rapa6) or histology-type (NHL vs. HD). Pre-emptive DLI using donor T-Rapa cells after low-intensity conditioning is safe and very effective in patients with high-risk lymphoma diagnoses and chemotherapy sensitive disease; for such patients, future randomized trials should compare low-intensity T-Rapa cell therapy to other transplantation regimens. For patients with high-risk lymphoma diagnoses and chemotherapy-refractory disease, we are evaluating a modification to the current platform that incorporates high-dose sirolimus therapy. Table I Patient Characteristics Chimerism Resultsc CD3 CD15 Number of Patients n = 42 Day 14 post-HCT 57 (12-97) 46 (8-94) Age (median, range) 44 (23-68) Day 28 post-HCT 77 (37-100) 76 (29-98) Sex (male/female) (26/16) # of Prior Therapies (mean, range) 4 (1-6) Day 100 post-HCT 89 (51-100) 93 (35-100) Histologya n=26 total (62%) Survival Resultsd 24 Mo. Surv. Prob. NHL Category n=12 ChemoSens/T-R12 78.6% (n=7) DLBCL n=5 ChemoSens/T-R6 85.7% (n=12) DLBCL-tr n=2 ChemoRefr/T-R12 41.7% (n=11) DLBCL-EBV n=3 ChemoRefr/T-R6 36.4% (n=12) PlasmacytoidDC n=3 All NHL 57.4% (n=26) T Cell n=16 total (38%) All HD/Grey Zone 68.8% (n=16) HD Category n=12 HD n=4 Grey Zone Chemo. Responseb 23/42 (55%) Refractory (SD/PD) 19/42 (45%) Sensitive (PR/CR) Complete Remission 7/42 (17%) At Time of HCT DLBCL, diffuse large B cell lymphoma; DLBCL-tr, transformed; DLBCL-EBV, Epstein Barr Virus related; Plasmacytoid DC, dendritic cell; HD, Hodgkins Disease; SD, stable disease; PD, progressive disease; PR/CR is partial or complete response. a Grey Zone Lymphoma and Hodgkins Disease were pooled for statistical analyses. b Chemotherapyresponse, as determined after last regimen prior to study entry. c Chimerism determined by VNTR-PCR at days 14, 28, and 100 post-HCT (mean and range of values shown); CD3, T cell chimerism; CD15, myeloid cell chimerism. d Survival by Kaplan-Meier analysis; 24 month median survival probability values shown; T-R12 and T-R6 indicates recipient of T-Rapa cells manufactured for 12 days vs. 6 days. Disclosures: Levine: TxCell: Consultancy, Membership on an entity's Board of Directors or advisory committees; University of Pennsylvania: financial interest due to intellectual property and patents in the field of cell and gene therapy. Conflict of interest is managed in accordance with University of Pennsylvania policy and oversight, financial interest due to intellectual property and patents in the field of cell and gene therapy. Conflict of interest is managed in accordance with University of Pennsylvania policy and oversight Patents…
6540 Background: Significant variation in host immune status may influence outcomes after reduced... more 6540 Background: Significant variation in host immune status may influence outcomes after reduced-intensity (RI) allogeneic stem cell transplantation (alloSCT). We have investigated a strategy of targeted immune depletion (TID) with conventional chemotherapy to deplete host T cells and achieve a minimal disease state prior to RI alloSCT. The aim of TID is to rapidly establish complete donor chimerism after RI alloSCT in order to potentiate a graft-versus-tumor (GVT) effect. In a prospective phase II trial (NIH 03-C-0077), we evaluated the effect of TID on donor chimerism, acute graft-versus-host disease (GVHD), and clinical outcome. Methods: Thirty-one patients (pts) with relapsed and refractory hematologic malignancies (NHL = 16; HL = 4; CLL/PLL = 4; MDS/AML = 3; other = 4) were enrolled. Median age was 57 years (range: 31–71). All pts received EPOCH-F (etoposide, prednisone, vincristine, cyclophosphamide, adriamycin, fludarabine) ± rituximab (R) as TID to deplete host CD4+ cells <100/μL. All pts then received a RI conditioning regimen consisting of fludarabine and cyclophosphamide followed by a T-cell replete allograft from HLA-matched siblings. GVHD prophylaxis consisted of cyclosporine plus short-course mini-methotrexate. Results: EPOCH-F(R) achieved the target host T-cell level in 74% of pts. All 31 pts engrafted after RI alloSCT. Complete donor chimerism (> 95%) was observed in 74% and 81% of pts at day +14 and +28 post-transplant, respectively. The incidence of grade II-III acute GVHD was 42% with no cases of grade IV acute GVHD. The median potential follow-up from transplant is 25 months. Actuarial treatment-related mortality at 1 and 2 years was 3% and 8%, respectively. Event-free survival probabilities at 1 and 2 years post-transplant are 65% and 49%, respectively. Ten pts are alive and event-free >24 months post-transplant. The overall survival probabilities at 1 and 2 years are 84% and 64%, respectively. Conclusions: TID prior to RI alloSCT results in rapid, complete donor engraftment and may potentiate GVT effects. This treatment strategy was associated with very low TRM and favorable outcomes in an older patient population with advanced hematologic malignancies. No significant financial relationships to disclose.
Reduced-intensity conditioning is less potently tumoricidal than myeloablative regimens; thus, RI... more Reduced-intensity conditioning is less potently tumoricidal than myeloablative regimens; thus, RIST relies more upon graft-versus-tumor (GVT) effects for disease eradication. However, variation in baseline host immune status contributes to inconsistent donor engraftment and may impede maximal GVT effects after RIST. We hypothesized that targeted immune depletion (TID) with conventional-dose chemotherapy before RIST might facilitate donor engraftment, thereby potentiating GVT effects. Thus, we evaluated dose-adjusted (DA-) EPOCH-F, a novel regimen of etoposide, prednisone, vincristine, cyclophosphamide (Cy), doxorubicin, and fludarabine (Flu), in a phase II manner in 83 pts with lymphoid malignancies undergoing RIST on 3 sequential, prospective clinical trials between 1999 and 2005. Pts received at least 1 and no more than 3 cycles of DA-EPOCH-F, targeting a peripheral blood CD4+ T cell count < 100 cells/μL. Pts achieving this CD4 count after only 1 or 2 cycles then proceeded to Flu/Cy conditioning and RIST from HLA-matched related donors. Pts otherwise proceeded to RIST after 3 cycles or if disease progression occurred during DA-EPOCH-F, regardless of CD4 count. After 2002, pts with CD20+ malignancies (n=28) also received rituximab (R) on day 1 of each DA-EPOCH-F cycle. Pt characteristics: median age 50 yrs; diagnoses Hodgkin lymphoma (14%), DLBCL (28%), other aggressive NHL (37%), follicular NHL (12%), CLL or other indolent NHL (8%); chemosensitive disease in 48%; median 3 prior regimens, prior autologous stem cell transplant in 28%; poor-risk IPI, FLIPI, IPF score, or Rai stage in 36%. Pts received 1 (n=26), 2 (n=20), or 3 (n=37) cycles of DA-EPOCH-F before RIST. Median CD4 count declined from 284 cells/μL at enrollment to 79 cells/μL after DA-EPOCH-F, which similarly depleted CD8+ T cells and B cells. DA-EPOCH-F toxicities were mainly hematologic and transient. Responses to DA-EPOCH-F were CR/CRu (11%), PR (27%), SD (35%), and PD (23%). Response rates differed by histology (P=0.006); DLBCL or other aggressive NHL were less likely to respond. Baseline CD4 counts were higher in DA-EPOCH-F responders than in non-responders (median 374 vs. 181 cells/μL; P=0.003), despite a similar extent of prior therapy. Full donor chimerism was present by day 14 after RIST in 85% of pts; no graft rejection occurred. The absolute lymphocyte count (ALC) after DA-EPOCH-F was more strongly associated with donor chimerism after RIST (P=0.02) than was CD4+ or other lymphocyte subsets. We retrospectively compared immune depletion in DA-EPOCH-F recipients with that observed in 17 previously untreated pts receiving 6 cycles of DA-EPOCH-R for mantle cell NHL. Although pts receiving DA-EPOCH-F before RIST had lower baseline ALC and all lymphocyte subsets except NKT cells, relative depletion of ALC, T and B cells from baseline levels was surprisingly similar with DA-EPOCH-F and DA-EPOCH-R. We conclude that DA-EPOCH-F effectively provides TID and disease control or stability in most pts with lymphoid malignancies prior to RIST. This strategy is associated with rapid conversion to full donor chimerism and may be useful to enhance potential GVT effects after RIST.
Background: Mutations in the zinc finger transcription factor GATA2 are responsible for: MonoMAC,... more Background: Mutations in the zinc finger transcription factor GATA2 are responsible for: MonoMAC, monocytopenia with nontuberculous mycobacterial (NTM) infections; DCML, dendritic cell, monocyte and lymphoid cell deficiency; Emberger's syndrome with lymphedema and monosomy 7; and familial myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML). Allogeneic hematopoietic stem cell transplant (HSCT) is the only definitive therapy for GATA2 deficiency. Methods: We used matched related donors (MRD), matched unrelated donors (URD), umbilical cord blood (UCB), and haploidentical related donors in allogeneic HSCT for GATA2 deficiency. Fourteen patients received a nonmyeloablative conditioning regimen (4 MRD, 4 URD, 4 UCB, and 2 haplo donors). Five patients received a myeloablative conditioning regimen (1 MRD, 2 URD, and 2 haplo donors). In the nonmyeloablative group, MRD and MUD recipients received fludarabine and 200cGy of total body irradiation (TBI), UCB recipients received cyclophosphamide 50mg/kg, fludarabine 150 mg/m2, and 200cGy of TBI, and haploidentical related donor recipients received cyclophosphamide 29 mg/kg, fludarabine 150 mg/m2, and 200 cGy TBI. In the myeloablative group, MRD and URD received busulfan 12.8 mg/kg and fludarabine 160 mg/m2, and haploidentical related donors received the same regimen as in the nonmyeloablative regimen except for the addition of two days of busulfan 6.4 mg/kg total dose. Nonmyeloablative MRD and URD recipients received tacrolimus and sirolimus post-transplant, and myeloablative MRD and URD recipients received tacrolimus and short course methotrexate post-transplant. All haploidentical related donor recipients received cyclophosphamide 50 mg/kg/day on days + 3 and +4 followed by tacrolimus and mycophenolate mofetil. Three patients in the nonmyeloablative cohort required one or more rounds of pre-transplant chemotherapy because of an increased number of blasts, whereas none of the 5 patients in the myeloablative arm required pre-transplant chemotherapy. Results: In the nonmyeloablative cohort, 8 of 14 (57%) of patients are alive at a median follow-up of 3.7 years (range 12 months to 5 years). One MRD recipient died of GVHD and one relapsed, one URD recipient rejected the donor stem cells and died, three UCB recipient died (one rejection, one early death, and one donor cell leukemia), and one haploidentical recipient died from regimen-related toxicity. All 5 patients (100%) in the myeloablative group, including two recipients of haploidentical related donors, are alive at a median follow-up of 9.2 months (range 6 to 12 months). All patients who survived had complete reconstitution of the monocyte, NK, and B-lymphocyte compartments, the three cell compartments that were severely deficient pre-transplant, and all had reversal of the infection susceptibility phenotype, characteristic of the disease. In particular, there were no recurrences of non-tuberculous mycobacterial (NTM) infections. Conclusions: Nonmyeloablative HSCT results in reversal of the hematologic and clinical manifestations of GATA2 deficiency. However, a more intensive conditioning regimen with busulfan resulted in more uniform engraftment, a reduced risk of relapse, avoidance of pre-transplant chemotherapy, and a low regimen-related toxicity. We anticipate that with the use of a high-dose regimen with busulfan, the replacement of UCB with haploidentical related donors, and HSCT earlier in the clinical course, before significant organ damage or clonal evolution of MDS to AML or CMML, the outcome of allogeneic HSCT in patients with GATA2 deficiency will continue to improve. Disclosures No relevant conflicts of interest to declare.
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Papers by Juan Gea-Banacloche