Multicenter Experience Using Total Lymphoid Irradiation and Antithymocyte Globulin as Conditioning for Allografting in Hematological Malignancies

A non myeloablative conditioning with total lymphoid irradiation (TLI) and antithymocyte globulin (ATG) was shown to protect against graft-versus-host disease (GVHD). To evaluate the effects of TLI-ATG in a multicenter study, 45 heavily pretreated patients, median age 51, with lymphoid (n = 38) and myeloid (n = 7) malignancies were enrolled at 9 centers. Twenty-eight patients (62%) received at least 3 lines of treatment before allografting, and 13 (29%) had refractory/relapsed disease at the time of transplantation. Peripheral blood hematopoietic cells were from HLA identical sibling (n = 30), HLA-matched (n = 9), or 1 antigen HLA-mismatched (n = 6) unrelated donors. A cumulative TLI dose of 8 Gy was administered from day −11 through −1 with ATG at the dose of 1.5 mg/kg/day (from day −11 through −7). GVHD prophylaxis consisted of cyclosporine and mycophenolate mofetil. Donor engraftment was reached in 95% of patients. Grade II to IV acute GVHD (aGVHD) developed in 6 patients (13.3%), and in 2 of these patients, it developed beyond day 100. Incidence of chronic GVHD (cGVHD) was 35.8%. One-year nonrelapse mortality was 9.1%. After a median follow-up of 28 months (range, 3-57 months) from transplantation, median overall survival was not reached, whereas median event-free survival was 20 months. This multicenter experience confirms that TLI-ATG protects against GVHD and maintains graft-vs-tumor effects

Treatment of Graft versus Host Disease with Mesenchymal Stromal Cells: A Phase I Study on 40 Adult and Pediatric Patients

Abstract This phase I multicenter study was aimed at assessing the feasibility and safety of intravenous administration of third party bone marrow–derived mesenchymal stromal cells (MSC) expanded in platelet lysate in 40 patients (15 children and 25 adults), experiencing steroid-resistant grade II to IV graft-versus-host disease (GVHD). Patients received a median of 3 MSC infusions after having failed conventional immunosuppressive therapy. A median cell dose of 1.5 × 10 6 /kg per infusion was administered. No acute toxicity was reported. Overall, 86 adverse events and serious adverse events were reported in the study, most of which (72.1%) were of infectious nature. Overall response rate, measured at 28 days after the last MSC injection, was 67.5%, with 27.5% complete response. The latter was significantly more frequent in patients exhibiting grade II GVHD as compared with higher grades (61.5% versus 11.1%, P = .002) and was borderline significant in children as compared with adults (46.7 versus 16.0%, P = .065). Overall survival at 1 and 2 years from the first MSC administration was 50.0% and 38.6%, with a median survival time of 1.1 years. In conclusion, MSC can be safely administered on top of conventional immunosuppression for steroid resistant GVHD treatment. Eudract Number 2008-007869-23, NCT01764100

IFN-γ induced by PHA stimulation as new marker for GVHD prediction in patients undergoing Allogeneic Hematopoietic Stem Cell Transplantation

Background: IFN-γ is crucial in the pathogenesis of GVHD and higher levels are reported to be elevated in patients with active chronic GVHD. Immune-monitoring of INF-levels after alloHSCT could help in the management of GVHD. A recent ELISA based test (QuantiFERON®-CMV) could measure specific (anti-CMV) and aspecific production of IFN-γ in whole blood. Preliminary data suggests that aspecific production of IFN-γ should be associated with GVHD. The aim of this study is to confirm the reliability of QuantiFERON®-CMV for association and prediction of GVHD. Methods: the study was performed in 2 phases. In the fisrt phase of the study, 92 whole blood specimen were collected and analyzed from 29 patients undergoing alloHSCT in order to confirm the preliminary data. QuantiFERON® CMV is an in vitro diagnostic test that use an antigenic human cytomegalovirus proteins (CMV) peptide cocktail to stimulate cells from whole blood. Detection of interferon-γ (IFN-γ) by ELISA is used to identify responses to these peptide antigens. The IFN-γ response in the CMV Ag tube is considered positive if > 0.2 UI/mL as defined by the manufacturer. The Mitogen-stimulated (PHA) plasma sample is used as an IFN-γ positive control for each specimen tested. In order to assess the association between IFN-γ response due to PHA stimulation and GVHD, the positivity of the test was determined according to 2 different cut-off: #1) 0,5 IU/mL as defined by manufacturer, #2) 9 IU/mL as experimentally defined by the median of the observations in our data set. GVHD extension was defined by Seattle criteria and/or the number of involved sites, Chi-square test was used to assess the statistical correlation between IFN-γ production and clinical outcomes. In the second phase 10 patients were observed prospectively with collection of blood samples every 2-3 weeks since engraftment until 4-6 months after SCT in order to study the PHA stimulated IFN-γ production in relationship with the onset of chronic GVHD. Results: among 92 samples 70 were positive for the PHA stimulated IFN-γ production according to the cut-off #1; 61% (43/70) were associated with GVHD whereas 27% (6/22) with lower PHA stimulated IFN-γ production were associated with GVHD: this difference was proved to be significant (p=0.005). Among 92 samples 46 were positive for the PHA stimulated IFN-γ production according to the cut-off #2; 71% (33/46) were associated with GVHD whereas 34% (16/46) with lower PHA stimulated IFN-γ production were associated with GVHD: this difference was proved to be significant (p=0.000). Among the 10 patients observed prospectively during the first 6 months after alloHSCT 7 became positive for the PHA stimulated IFN-γ production: 6/7 developed GVHD in a median time of 100 days according to the cutoff #1 and after a median time of 33 days according the cutoff#2. Four patients received steroid treatment for extensive chronic GVHD and their PHA stimulated IFN-γ production dropped after treatment (figure 1). Conclusions: The PHA stimulated IFN-γ production is strictly associated to GVHD, seems to predict its onset and could help in the modulation of immunesuppressive treatment. However, larger prospective studies are needed

Day100 Score predicts moderate-severe cGVHD, transplant mortality, and survival after hematopoietic cell transplantation

: The aim of this study was to develop a predictive score for moderate-severe chronic graft-versus-host disease (cGVHD) on day +100 after allogeneic stem cell transplantation (HSCT). We studied 1292 patients allografted between 1990 and 2016, alive on day +100 after transplant, without cGvHD, and with full biochemistry laboratory values available. Patients were randomly assigned to a training and a validation cohort (ratio 1:1). In the training cohort, a multivariate analysis identified four independent predictors of moderate-severe cGvHD: gammaglutamyltransferase 6575 UI/l, creatinine 651 mg/dl, cholinesterase 644576 UI/l and albumin 644 g/dl. A score of 1 was assigned to each variable, producing a low (0-1), intermediate (2-3) and high (4) score. The cumulative incidence (CI) of moderate-severe cGvHD was 12%, 20% and 52% (p<0.0001) in the training cohort, and 13%, 24% and 33% (p=0.002) in the validation cohort. The 5 year CI of transplant related mortality (TRM) was 5%, 14%, 27%(p<0.0001) and 5%, 16%, 31%(p<0.0001), respectively. The 5 year survival was 64%, 57%, 54%(p=0.009) and 70%, 59%, 42%(p=0.0008) in the two cohorts respectively . In conclusion, Day100 score predicts cGvHD, TRM and survival, and, if validated in a separate group of patients, could be considered for trials of pre-emptive therapy

phase ii study of sequential infusion of donor lymphocyte infusion and cytokine induced killer cells for patients relapsed after allogeneic hematopoietic stem cell transplantation

Abstract Seventy-four patients who relapsed after allogeneic stem cell transplantation were enrolled in a phase IIA study and treated with the sequential infusion of donor lymphocyte infusion (DLI) followed by cytokine-induced killer (CIK) cells. Seventy-three patients were available for the intention to treat analysis. At least 1 infusion of CIK cells was given to 59 patients, whereas 43 patients received the complete cell therapy planned (58%). Overall, 12 patients (16%) developed acute graft-versus-host disease (aGVHD) of grades I to II in 7 cases and grades III to IV in 5). In 8 of 12 cases, aGVHD developed during DLI treatment, leading to interruption of the cellular program in 3 patients, whereas in the remaining 5 cases aGVHD was controlled by steroids treatment, thus allowing the subsequent planned administration of CIK cells. Chronic GVHD (cGVHD) was observed in 11 patients (15%). A complete response was observed in 19 (26%), partial response in 3 (4%), stable disease in 8 (11%), early death in 2 (3%), and disease progression in 41 (56%). At 1 and 3 years, rates of progression-free survival were 31% and 29%, whereas rates of overall survival were 51% and 40%, respectively. By multivariate analysis, the type of relapse, the presence of cGVHD, and a short

High Throughput Molecular Characterization of Normal Karyotype Acute Myeloid Leukemia in the Context of the Prospective Trial 02/06 of the Northern Italy Leukemia Group (NILG)

By way of a Next-Generation Sequencing NGS high throughput approach, we defined the mutational profile in a cohort of 221 normal karyotype acute myeloid leukemia (NK-AML) enrolled into a prospective randomized clinical trial, designed to evaluate an intensified chemotherapy program for remission induction. NPM1, DNMT3A, and FLT3-ITD were the most frequently mutated genes while DNMT3A, FLT3, IDH1, PTPN11, and RAD21 mutations were more common in the NPM1 mutated patients (p < 0.05). IDH1 R132H mutation was strictly associated with NPM1 mutation and mutually exclusive with RUNX1 and ASXL1. In the whole cohort of NK-AML, no matter the induction chemotherapy used, by multivariate analysis, the achievement of complete remission was negatively affected by the SRSF2 mutation. Alterations of FLT3 (FLT3-ITD) and U2AF1 were associated with a worse overall and disease-free survival (p < 0.05). FLT3-ITD positive patients who proceeded to alloHSCT had a survival probability similar to FLT3-ITD negative patients and the transplant outcome was no different when comparing high and low-AR-FLT3-ITD subgroups in terms of both OS and DFS. In conclusion, a comprehensive molecular profile for NK-AML allows for the identification of genetic lesions associated to different clinical outcomes and the selection of the most appropriate and effective treatment strategies, including stem cell transplantation and targeted therapies