A survey on cellular and engineered tissue therapies in Europe in 2008

Cellular therapy is an evolving investigational treatment modality in regenerative medicine, but little published information is available on its current use. Starting from the established European group for Blood and Marrow Transplantation activity survey on hematopoietic stem cell transplantation, a joint committee of four major scientific organizations made a coordinated attempt to collect detailed information in Europe for the year 2008. Thirty-three teams from 16 countries reported data on 656 patients to a "novel cellular therapy" survey, which were combined to additional 384 records reported to the standard European group for Blood and Marrow Transplantation survey. Indications were cardiovascular (29%; 100% autologous), musculoskeletal (18%; 97% autologous), neurological (9%; 39% autologous), epithelial/parenchymal (9%; 18% autologous), autoimmune diseases (12%; 77% autologous), or graft-versus-host disease (23%; 13% autologous). Reported cell types were hematopoietic stem cells (39%), mesenchymal stromal cells (47%), chondrocytes (5%), keratinocytes (7%), myoblasts (2%), and others (1%). In 51% of the grafts, cells were delivered after expansion; in 4% of the cases, cells were transduced. Cells were delivered intravenously (31%), intraorgan (45%), on a membrane or gel (14%), or using three-dimensional scaffolds (10%). This data collection platform is expected to capture and foresee trends for novel cellular therapies in Europe, and warrants further consolidation and extension

Dose-adapted post-transplant cyclophosphamide for HLA-haploidentical transplantation in Fanconi anemia.

We developed a haploidentical transplantation protocol with post-transplant cyclophosphamide (CY) for in vivo T-cell depletion (TCD) using a novel adapted-dosing schedule (25 mg/kg on days +3 and +4) for Fanconi anemia (FA). With median follow-up of 3 years (range, 37 days to 6.2 years), all six patients engrafted. Two patients with multiple pre-transplant comorbidities died, one from sepsis and one from sepsis with associated chronic GVHD. Four patients without preexisting comorbidities and early transplant referrals are alive with 100% donor chimerism and excellent performance status. We conclude that adjusted-dosing post-transplant CY is effective in in vivo TCD to promote full donor engraftment in patients with FA

Improving risk stratification of myeloid neoplasm undergoing allogeneic stem cell transplantation

Die akute myeloische Leukämie (AML) und das myelodysplastische Syndrom (MDS) stellen heterogene myeloische Neoplasien dar, deren Übergang in einander fließend ist. Während bei der AML ein Differenzierungsblock sowie eine unkontrollierte Proliferation myeloischer Vorläuferzellen dominieren, zeichnet sich das MDS vorrangig durch Dysplasien und variable Zytopenien, sowie ein erhöhtes Risiko der Transformation in eine AML aus. Trotz unseres zunehmenden Verständnisses dieser Erkrankungen ist die Prognose für AML und MDS Patienten noch immer häufig ungünstig. Auch mit der Entwicklung neuer zielgerichteter Therapiekonzepte behält die allogene hämatopoetische Stammzelltransplantation ihre große Bedeutung in der Therapie von AML und MDS. Insbesondere bei Patienten mit prognostisch ungünstigen Merkmalen stellt sie häufig die einzige kurative Therapieoption dar. Entsprechend kommt einer Risikostratifizierung bei Diagnose sowie im Krankheitsverlauf zur individuellen Therapieentscheidung eine große Bedeutung zu um personalisierte Behandlungen zu ermöglichen. Diese kann durch klinische Variablen, Immunphänotypisierung und zyto- oder molekulargenetische Veränderungen erfolgen. Diese Arbeit beschäftigt sich mit neuen klinischen, molekularen und durchflusszytometrischen Markern um die bestehenden Risikoklassifikationssysteme für Patienten mit AML und MDS weiter zu verfeinern und legt ein besonderes Augenmerk auf Patienten, die eine allogene Stammzelltransplantation erhalten. Der erste Abschnitt dieser Arbeit zeigt die prognostische Relevanz der leukämischen Stammzellpopulationen – definiert über die CD34+/CD38- Zellpopulation bzw. die GPR56 Expression - bei Diagnosestellung. Sowohl in der AML als auch im MDS scheint ein hoher Anteil leukämischer Stammzellen eine Subgruppe von Patienten mit ungünstiger Prognose unabhängig von aktuellen Risikostratifikationen und auch trotz Durchführung einer allogenen Stammzelltransplantation identifizieren zu können. Im zweiten Abschnitt wird ein Überblick über die zunehmende Relevanz der Risikostratifikation im Krankheitsverlauf - im Sinne der Bestimmung einer messbaren Resterkrankung (MRD) – erörtert und mit der Expressionshöhe von BAALC und MN1 mögliche neue Marker zur MRD Bestimmung vorgestellt. Der dritte Abschnitt zeigt, dass auch die Wahl des Konsolidierungskonzeptes die initiale molekulargenetische Risikostratifizierung beeinflussen kann. Während eine hohe Expression der AML-assoziierten Gene BAALC und MN1 bei AML Diagnose mit einer ungünstigen Prognose einhergeht, wenn die Patienten mit einer Chemotherapie behandelt werden, scheint eine allogene Stammzelltransplantation diesen prognostischen Einfluss aufzuheben. Außerdem wird die Relevanz einer allogenen Stammzelltransplantation bei älteren Patienten mit der prinzipiell eher günstigen molekulargenetischen Konstellation NPM1 mutiert/FLT3-ITD Wildtyp diskutiert. Im vierten Abschnitt wird der Einfluss klinischer Parameter auf die Prognose von AML und MDS Patienten diskutiert. Patienten mit einer sekundären (nach anderen myeloischen Erkrankungen) oder therapieassoziierten AML (nach vorausgegangener zytostatischer Therapie) weisen unter konventioneller Chemotherapie eine sehr ungünstige Prognose auf. Im Gegensatz dazu legen die Ergebnisse nahe, dass das Überleben nach allogener Stammzelltransplantation – wenn das genetische Risiko beachtet wird - nicht wesentlich schlechter ist als das von Patienten mit de novo AML. Außerdem wird gezeigt, dass sowohl das Vorliegen einer Adipositas zum Zeitpunkt der Diagnose einer AML als auch ein Gewichtsverlust zwischen Diagnose und allogener Stammzelltransplantation mit einer ungünstigen Prognose einhergehen. Zuletzt werden zwei Konditionierungsintensitäten vor Stammzelltransplantation in MDS Patienten verglichen und gezeigt, dass vor allem bei jüngeren Patienten intensivere Protokolle bessere Ergebnisse erzielen. Zusammenfassend zeigt diese Arbeit neue Möglichkeiten auf, die Risikostratifizierung für Patienten mit myeloischen Erkankungen sowohl bei Diagnose als auch im Krankheitsverlauf zu verbessern und leistet somit einen wichtigen Beitrag zur weiteren Personalisierung der Therapie von AML und MDS.:1. INTRODUCTION / EINLEITUNG 5 1.1 AML 5 1.1.1 DIAGNOSIS AND DISEASE CLASSIFICATION 5 1.1.2 RISK STRATIFICATION AT DIAGNOSIS 6 1.1.3 TREATMENT 8 1.2 MDS 9 1.2.1 DIAGNOSIS AND DISEASE CLASSIFICATION 9 1.2.2 RISK STRATIFICATION AT DIAGNOSIS 10 1.2.3 TREATMENT 12 1.3 ALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANTATION 13 2. FREQUENCY OF LEUKEMIA INITIATING CELL POPULATIONS AT DIAGNOSIS OF AML AND MDS 14 2.1 BACKGROUND 14 2.2 OWN CONTRIBUTION 14 Prognostic Impact of the CD34+/CD38- Cell Burden in Patients with Acute Myeloid Leukemia receiving Allogeneic Stem Cell Transplantation. Am J Hematol 2017; 92: 388-396. 15 High expression of the stem cell marker GPR56 at diagnosis identifies acute myeloid leukemia patients at higher relapse risk after allogeneic stem cell transplantation in context with the CD34+/CD38- population. Haematologica 2020. 105: 229260 15 The pre-treatment CD34+/CD38- cell burden as prognostic factor in MDS patients receiving allogeneic stem cell transplantation. Biol Blood Marrow Transplant 2019; 25: 1560-1566. 15 3 MEASURABLE RESIDUAL DISEASE DETECTION IN AML 37 3.1 BACKGROUND 37 3.2 OWN CONTRIBUTION 37 High Blood BAALC Copy Numbers at Allogeneic Transplantation Predict Early Relapse in Patients with Acute Myeloid Leukemia. Oncotarget 2017; 8:87944-87954. 38 Prognostic impact of blood MN1 copy numbers before allogeneic stem cell transplantation in patients with acute myeloid leukemia. HemaSphere 2019; 3: e167. 38 4. THE USE OF ALLOGENEIC HSCT IMPACTS THE RELEVANCE OF GENETIC PROGNOSTICATORS AT AML DIAGNOSIS 59 4.1 BACKGROUND 59 4.2 OWN CONTRIBUTION 59 Outcomes of older patients with NPM1 mutated and FLT3-ITD negative acute myeloid leukemia receiving allogeneic transplantation. HemaSphere 2020. 3; 4: e326. 59 Allogeneic stem cell transplantation mitigates the adverse prognostic impact of high diagnostic BAALC and MN1 expression in AML. Ann Hematol 2020. 99: 2417-2427. 60 5. CLINICAL AND TREATMENT-ASSOCIATED PROGNOSTICATORS IN AML AND MDS 76 5.1 BACKGROUND 76 5.2 OWN CONTRIBUTION 77 ELN risk stratification and outcomes in secondary and therapy-related AML patients consolidated with allogeneic stem cell transplantation. Bone Marrow Transplant. 2020 Nov 19. doi: 10.1038/s41409-020-01129-1. [Online ahead of print] 77 Nutritional status at diagnosis and weight changes impact outcomes in acute myeloid leukemia patients receiving allogeneic hematopoietic stem cell transplantation HemaSphere 2021. 5:2(e532). 77 Comparison of non-myeloablative and reduced-intensity allogeneic stem cell transplantation in older patients with myelodysplastic syndromes. Am J Hematol 2019; 94:1344-1352. 77 6. CONCLUSION / ZUSAMMENFASSUNG 106 7. REFERENCES / REFERENZEN 108 8. INDEX OF ABBREVIATIONS / INHALTSVERZEICHNIS 114 9. EIDESSTATTLICHE ERKLÄRUNG ZUR VORGELEGTEN HABILITATIONSSCHRIFT 116 10. COMPLETE LIST OF PUBLICATIONS / PUBLIKATIONSVERZEICHNIS 117 11. CURRICULUM VITAE / LEBENSLAUF 129 12. ACKNOWLEDGEMENTS / DANKSAGUNG 13

Prognostic Impact of the CD34+/CD38- Cell Burden in Patients with Acute Myeloid Leukemia receiving Allogeneic Stem Cell Transplantation

Introduction: In acute myeloid leukemia (AML), leukemia initiating cells exist within the CD34+/CD38- cell compartment. They are assumed to be more resistant to chemotherapy, enriched in minimal residual disease cell populations, and responsible for relapse. Purpose: We evaluated clinical and biological associations and the prognostic impact of a high diagnostic CD34+/CD38- cell burden in AML patients receiving an allogeneic stem cell transplantation (HSCT) in complete remission. Here, the therapeutic approach is mainly based on immunological graft-versus-leukemia effects. Methods: Percentage of bone marrow CD34+/CD38- cell burden in 169 AML patients at diagnosis was measured using flow cytometry. The optimal cutoff of 6% was applied and used to evaluate the impact of a high CD34+/CD38- cell burden on outcome. Results: The CD34+/CD38- cell burden and was highly variable (median 0.5%, range 0-89% of all mononuclear cells). A high CD34+/CD38- cell burden at diagnosis associated with worse genetic risk and secondary AML. Patients with a high CD34+/CD38- cell burden had shorter relapse-free and overall survival, which may be mediated by residual leukemia initiating cells in the CD34+/CD38- cell population, escaping the graft-versus-leukemia effect after allogeneic HSCT. Conclusion: Evaluating the CD34+/CD38- cell burden at diagnosis may help to identify patients at high risk of relapse after allogeneic HSCT. Further studies to understand leukemia initiating cell biology and develop targeting therapies to improve outcomes of AML patients are needed.:Bibliographische Beschreibung / Bibliographic description 1 Einleitung / Introduction 2 Epidemiology and AML diagnosis 2 Therapeutic options in AML 3 Genetic risk classification for therapeutic decisions in AML 6 Immunophenotyping in AML 10 Leukemia Initiating Cells 11 Objectives of the here presented study 13 Publikation / Publication 14 Anlage / Supplemental Material 23 Zusammenfassung / Summary 48 Weiterführende Arbeiten / Future developments GPR56 as new LIC marker 52 Referenzen / References 55 Referenz der Publikation / Reference of the publication 60 Erklärung über die eigenständige Abfassung der Arbeit 61 Curriculum Vitae 62 Komplette Publikationsliste 65 Danksagung 7

Outcomes of haploidentical stem cell transplantation for chronic lymphocytic leukemia: a retrospective study on behalf of the chronic malignancies working party of the EBMT

Allogeneic hematopoietic stem cell transplantation (HCT) may result in long-term disease control in high-risk chronic lymphocytic leukemia (CLL). Recently, haploidentical HCT is gaining interest because of better outcomes with post-transplantation cyclophosphamide (PTCY). We analyzed patients with CLL who received an allogeneic HCT with a haploidentical donor and whose data were available in the EBMT registry. In total 117 patients (74% males) were included; 38% received PTCY as GVHD prophylaxis. For the whole study cohort OS at 2 and 5 yrs was 48 and 38%, respectively. PFS at 2 and 5 yrs was 38 and 31%, respectively. Cumulative incidence (CI) of NRM in the whole group at 2 and 5 years were 40 and 44%, respectively. CI of relapse at 2 and 5 yrs were 22 and 26%, respectively. All outcomes were not statistically different in patients who received PTCY compared to other types of GVHD prophylaxis. In conclusion, results of haploidentical HCT in CLL seem almost identical to those with HLA-matched donors. Thereby, haploidentical HCT is an appropriate alternative in high risk CLL patients with a transplant indication but no available HLA-matched donor. Despite the use of PTCY, the CI of relapse seems not higher than observed after HLA-matched HCT

Optimization of the indications for allogeneic stem cell transplantation in Acute Myeloid Leukemia based on interactive diagnostic strategies

The indications for allogeneic stem cell transplantation (SCT) in Acute Myeloid Leukemia (AML) represent a real challenge due to the clinical and genetic heterogeneity of the disorder. Therefore, an optimized indication for SCT in AML first requires the determination of the individual relapse risk based on diverse chromosomal and molecular prognosis-defining aberrations. A broad panel of diagnostic methods is needed to allow such subclassification and prognostic stratification: cytomorphology, cytogenetics, molecular genetics, and immunophenotyping by multiparameter flow cytometry. These methods should not be seen as isolated techniques but as parts of an integral network with hierarchies and interactions. Examples for a poor risk constellation as a clear indication for allogeneic SCT are provided by anomalies of chromosome 7, complex aberrations, or FLT3-length mutations. In contrast, the favorable reciprocal translocations such as the t(15;17)/PML-RARA or t(8;21)/AML1-ETO are not indications for SCT in first remission due to the rather good prognosis after standard therapy. Further, the indication for SCT should include the results of minimal residual disease (MRD) diagnostics by polymerase chain reaction (PCR) or flow cytometry. New aspects for a safe and fast risk stratification as basis for an optimized indication for SCT in AML might be provided by novel technologies such as microarray-based gene expression profiling. Keywords: Acute Myeloid Leukemia (AML), Allogeneic Stem Cell Transplantation (SCT), Indication, Cytogenetics, Polymerase Chain Reaction (PCR

The Clinical Significance of Diagnostic Red Cell Distribution Width in Patients with Acute Myeloid Leukemia

Introduction: Acute myeloid leukemia (AML) is a highly heterogeneous disease which renders risk stratification at diagnosis of high importance to personalize therapy. Allogeneic hematopoietic stem cell transplantation (HSCT) offers the highest chance for sustained remission in most AML patients, but usually comes at the risk of a significant treatment-related mortality. The red cell distribution width (RDW) is an universally accessible parameter that identifies individuals with a higher mortality in many diseases, including some hematological entities. However, the impact of diagnostic RDW levels in AML – especially in the context of a HSCT consolidation - has not been evaluated so far. Purpose: To evaluate the prognostic impact of RDW levels at AML diagnosis. Methods: A total of 294 newly diagnosed AML patients (median age 60.6, range 14.3-76.5 years), with available diagnostic RDW levels were retrospectively included in this analysis. All patients received a consolidation therapy with an allogeneic HSCT in curative intention between August 2007 and December 2020 at the University Medical Center Leipzig. The RDW was measured in all patients at AML diagnosis before the start of cytoreductive therapies. Results: RDW levels at diagnosis were highly variable (median 16.6%, range 12%-30.6%) and above the upper level of normal (>15%) in 73% of the analyzed AML patients. Patients with RDW levels above 15% did not have worse outcomes compared to patients with low diagnostic RDW levels. However, when the cohort was dichotomized according to a receiver operating characteristic (ROC)-based optimal cut-point (20.7%), patients with high RDW levels had a significantly higher non-relapse mortality (NRM), shorter overall survival and a trend for shorter event-free survival, while the risk of relapse or disease progression was similar in both groups. In multivariate analyses, the RDW remained an independent prognostic factor for higher NRM after adjustment for the body mass index at diagnosis. Patients with a higher RDW were more likely to harbor a secondary AML, as well as to harbor secondary AML-associated gene mutations (i.e. JAK2, ASXL1, or spliceosome mutations, especially SRSF2). Conclusion: High RDW levels at diagnosis represent an independent risk marker for a higher mortality following allogeneic HSCT. When confirmed in prospective clinical trials, the RDW might help to personalize AML consolidation therapy including conditioning regimens before allogeneic HSCT.:1. Bibliographische Beschreibung 2. Abkürzungsverzeichnis 3. Einführung / Introduction 3.1. Acute Myeloid Leukemia 3.1.1. Definition 3.1.2. Epidemiology and etiology 3.1.3. Clinical presentation 3.1.4. Diagnosis of AML 3.1.4.1. Morphology 3.1.4.2. Immunophenotyping 3.1.4.3. Cytogenetic and molecular analyses 3.1.5. AML classification according to WHO classification 3.1.6. Prognostic factors in AML 3.1.6.1. Patient-related risk factors 3.1.6.2. Genetic risk factors 3.1.6.3. Measurable residual disease 3.1.7. Treatment of AML 3.1.7.1. Induction therapy in curative intention 3.1.7.2. Consolidation therapies 3.1.7.3. Palliative treatment approaches 3.1.7.4. New substances 3.2. Allogeneic HSCT 3.2.1. Principles of allogeneic HSCT 3.2.2. Conditioning regimens 3.3. Red cell distribution width 4. Aufgabenstellung / Objectives 5. Materialien und Methoden / Materials and Methods 5.1. Patients and treatments 5.1.1. Treatment protocols 5.1.2. Allogeneic HSCT and immunosuppression 5.1.3. Assessment of GvHD 5.2. Disease characterization 5.2.1. Evaluation at AML diagnosis 5.2.1.1. Morphology 5.2.1.2. Flow cytometry 5.2.1.3. Genetic analyses 5.2.1.4. Evaluation of RDW levels 5.2.2. Evaluation at HSCT 5.2.2.1. Definition of remission status at HSCT 5.2.2.2. Evaluation of measurable residual disease at HSCT 5.3. Statistical Analyses 5.3.1. Associations 5.3.2. Clinical endpoints 5.3.3. Definition of an optimal cut-point for RDW levels 5.3.4. Multivariate analyses 6. Ergebnisse / Results 6.1. Overall outcomes of the patient cohort 6.2. RDW levels at AML diagnosis regarded as continous parameter 6.3. The role of RDW levels at diagnosis as a predictor for outcomes after allogeneic HSCT 6.4. Associations of RDW levels at diagnosis 7. Diskussion / Discussion 8. Zusammenfassung / Summary 9. Literaturverzeichnis / References 10. Erklärung über die eigenständige Abfassung der Arbeit 11. Curriculum Vitae 12. Komplette Publikationsliste (Peer-reviewed) 13. Danksagun

Body mass index does not impact on molecular response rate of chronic myeloid leukaemia patients treated frontline with second generation tyrosine kinase inhibitors.

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Standardization of molecular monitoring for chronic myeloid leukemia in Latin America using locally produced secondary cellular calibrators

Residual disease in chronic myeloid leukemia (CML) patients undergoing therapy with tyrosine kinase inhibitors (TKIs) is measured by assessing the quantity of transcripts of the BCR-ABL1 fusion gene in peripheral white blood cells. This analysis is based on reverse-transcription quantitative PCR (RT–qPCR) technology; however, the wide array of methods used worldwide has led to large variation in quantitative BCR-ABL1 measurements, which hamper inter-laboratory comparative studiesFil: Ruiz, María Sol. Fundación Cáncer. Centro de Investigaciones Oncológicas; ArgentinaFil: Medina, M.. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Medicina Experimental. Academia Nacional de Medicina de Buenos Aires. Instituto de Medicina Experimental; ArgentinaFil: Tapia, I.. Fundación Cáncer. Centro de Investigaciones Oncológicas; ArgentinaFil: Mordoh, Jose. Fundación Cáncer. Centro de Investigaciones Oncológicas; ArgentinaFil: Cross, N. C. P.. Universidad de Southampton Uk; Reino UnidoFil: Larripa, Irene Beatriz. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Medicina Experimental. Academia Nacional de Medicina de Buenos Aires. Instituto de Medicina Experimental; ArgentinaFil: Bianchini, Michele. Fundación Cáncer. Centro de Investigaciones Oncológicas; Argentin

Safe discontinuation of nilotinib in a patient with chronic myeloid leukemia: a case report

Case presentation. We report the case of a 64-year-old Caucasian man diagnosed with chronic-phase chronic myeloid leukemia in April 2005. After 4 years of treatment with imatinib, he became intolerant to the drug and was switched to nilotinib. Two years later, he decided to stop nilotinib. Undetectable molecular response persisted for 30 months after discontinuation of the drug. Introduction. Although there is a considerable amount of data in the literature on safe discontinuation of first-generation tyrosine kinase inhibitor therapy in patients with chronic myeloid leukemia, little is known about discontinuation of second-generation tyrosine kinase inhibitor therapy. Most previous studies have been focused on dasatinib, and the few cases of nilotinib withdrawal that have been reported had a median follow-up of 12 months. To the best of our knowledge, the present report is the first to describe nilotinib withdrawal with 30 months of follow-up. Conclusion: Our present case suggests that nilotinib withdrawal is safe for patients with chronic myeloid leukemia who achieve a stable undetectable molecular response. Our patient was homozygous for killer immunoglobulin-like receptor haplotype A, previously reported to be a promising immunogenetic marker for undetectable molecular response. We recommend additional studies to investigate patient immunogenetic profiles and their potential role in complete response to therap