Algarotti, A.

Balduzzi, A.

Biagi, E.

Biondi, A.

Bonanomi, S.

Capelli, C.

D'Amico, G.

Dander, E.

Gaipa, G.

Golay, J.

Introna, M.

Lucchini, G.

Masciocchi, F.

Perseghin, P.

Rambaldi, A.

Rovelli, A.

Vinci, P.

English

Open Access Repository

S162 Oral Presentationsimproved RFS (P5 0.019) andOS (P5 0.033) compared to the A/Gor G/G genotype. Multivariable analysis, adjusted for stem cellsource (peripheral blood vs. bone marrow), GVHD subtype (clas-sic/overlap vs. acute subtypes/none), and disease risk (low vs. inter-mediate vs. high) were performed to test the association of thesignificant SNPs with RFS and OS. rs4553808 A/A genotype (HR2.44, P 5 0.015), classic/overlap GVHD (HR 2.98, P 5 0.002)and low/intermediate disease risk (HR 2.16, P5 0.03) were indepen-dent predictors of superior OS. rs4553808 A/A genotype (HR 2.39,P 5 0.016), and classic/overlap GVHD (HR 3.84, P 5 0.001) wereindependent predictors of superior RFS.Our study confirms reports that genetic variation in donor CTLA-4 is associated with outcome after allo-HCT and may allow foridentification of patient subsets that may benefit from pre-emptivemodulation of immunosuppressive therapy. Further investigationinto the CTLA-4/ICOS/CD28 and B7 regulation of T cell homeo-stasis is warranted to design a risk adapted approach to decrease themortality for patients with a high risk of relapse.Table 1. Patient characteristics and survival of all patients.(N5164)N(%)VariableGVHD subtypeTotal Cohort(N5164)Classic plusOverlapcGVHD N(%)(N5101)aGVHD subtypesplus No GVHD N(%) (N563)Age, medianin years (range)47(18-69) 49(21-67) 46(18-69)GenderMale (R) 80(49) 49(49) 31(49)Female (R) 84(51) 52(51) 32(51)Female D to male R 31(19) 21(21) 10(19)RaceCaucasian (R/D) 156(95)/153(93) 94(93)/92(91) 62(98)/61(97)DiagnosisAcute Leukemia 86(52) 49(49) 37(59)Chronic Leukemia 19(12) 11(11) 8(13)Lymphoma 54(33) 38(37) 16(25)other 5(93) 3(3) 2(3)Disease Risk #Low 65(40) 38(38) 27(43)Intermediate 30(18) 21(20) 9(14)High 40(24) 25(25) 15(24)Missing 29(18) 17(17) 12(19)Stem Cell SourceMarrow 44(27) 23(22) 21(33)Peripheral Blood 120(73) 78(78) 42(67)Regimen IntensityMyeloablative 111(68) 69(68) 42(67)Other 53(32) 32(32) 21(33)Donor TypeRelated 109(67) 69(68) 40(63)Unrelated 55(33) 32(32) 23(37)HLA MatchHLA identical sibling 108(66) 68(67) 40(63)HLA matched unrelated 55(33) 32(32) 23(37)Other 1(1) 1(1) 0GVHD ProphylaxisCSA/MTX 112(68) 72(71) 40(63)CSA/MMF 50(31) 28(28) 22(36)Other 2(1) 1(1) 1(1)TBIYes 79(48) 52(51) 27(43)No 85(52) 49(49) 36(57)CMVR/D (+/+) 63(38) 35(34) 28(44)R/D (+/-) 19(12) 12(12) 7(11)R/D (-/+) 49(29) 29(29) 18(29)R/D (-/-) 35(21) 25(25) 10(16)Post-transplant Characteristics(Continued )Table 1. (Continued )VariableN(%)GVHD subtypeTotal Cohort(N5164)Classic plusOverlapcGVHD N(%)(N5101)aGVHD subtypesplus No GVHD N(%) (N563)aGVHDVGrade 0-2 vs. 3-4 179(78) vs. 32(20) 78(77) vs. 21(21) 51(81) vs. 11(7)Grade 0-1 vs. 2-4 39(24) vs. 122(74) 39(24) vs. 75(74) 15(24) vs. 47(75)PLT (X10(9)/L atday 100,median (range)110(10-356) 105(17-244) 112(10-356)Total Bilirubin(mg/dL) at day100, median(range)0.8(0-3.6) 0.8(0-2.4) 0.9(0.2-3.6)Survival2 year OS: (95% CI) 63%(56-72) 73%(64-83) 48%(36-64)2 year RFSU: (95% CI) 61%(54-70) 73%(65-83) 41%(30-57)# Disease risk-based on Committee of International Bone MarrowTransplant Registry (CIBMTR) risk criteria; V aGVHD-3 cases missing;U RFS analyses includes death from non-relapse causes as competingrisk. GVHD-graft-versus-host disease; cGVHD-chronic GVHD;aGVHD-acute GVHD; R-recipient; D-donor; HLA-Human LeukocyteAntigen; CSA-cyclosporine; MTX-methotrexate; MMF-mycophenolatemoefitil; TBI-Total body irradiation; CMV-cytomegalovirus; PLT-platelet;OS-overall survival; RFS-relapse free survival; CI-confidence interval.30IMMUNOMONITORING OF TRANSPLANTED PATIENTS INFUSED WITHMESENCHYMAL STROMAL CELLS (MSC) FOR TREATING STEROID-REFRACTORY GvHDDander, E.1, Lucchini, G.2, Vinci, P.1, Introna, M.3, Bonanomi, S.2,Balduzzi, A.2, Gaipa, G.4, Perseghin, P.5, Masciocchi, F.1, Capelli, C.6,Golay, J.6, Algarotti, A.3, Rambaldi, A.3, Rovelli, A.2, Biondi, A.2,Biagi, E.2, D’Amico, G.1 1 ‘‘M. Tettamanti’’ Research Center, Universityof Milan-Bicocca, Monza (Mi), Italy; 2S. Gerardo Hospital, Monza (Mi),Italy; 3Ospedali Riuniti di Bergamo, Bergamo, Italy; 4Laboratory of CellTherapy ‘‘Stefano Verri’’, S. Gerardo Hospital, Monza (Mi), Italy;5Apheresis Unit, S. Gerardo Hospital, Monza (Mi), Italy; 6Ospedali Riu-niti Bergamo, Bergamo, ItalyAlthough the usage of mesenchymal stromal cells (MSC) as ther-apy for Graft versus Host Disease (GvHD) is constantly increasing,studies on MSC efficacy have been scarcely corroborated by biolog-ical analysis of patient response to cell infusion. We report the im-munological monitoring of 9 patients with steroid-refractoryGvHD, receivingmultiple doses ofMSCs.GvHDpresented as acutein 5 cases and chronic in 4 cases. After MSC therapy, 2 patientsshowed complete response (CR), 4 patients showed partial response(PR) whereas 3 patients did not respond (NR) to MSC infusion.To better comprehend the immunomodulatory effects ofMSC in-fusions, we studied GvHD plasmatic markers, inflammatory cyto-kines and CD41 T-cell subsets circulating in the peripheral blood(PB) of enrolled patients before MSC infusion and at day 7, 14 and28 after cell therapy.In accordance with clinical observations, in CR patients we ob-served a dramatic decrease of three validated GvHD plasmaticmarkers TNFRI, IL2Ra and elafin (Paczesny S et al. Blood 2009)to the mean levels of Healthy Donors (HD). In particular, at day28 after therapy, TNFRI decreased of 2 times, IL2Ra levels de-creased of 1.9 times and elafin decreased of 2.3 times. Moreover, in-vestigating the effect of MSC infusion on lymphocyte counts, weobserved in both CR patients a significant decrease in CD31 andCD41 lymphocyte counts in the PB. Interestingly, after MSC infu-sions, CD41 T-cell subsets changed significantly: Tregs increasedand Th1 and Th17 populations decreased. In particular, Th1/Tregratio decreased of 3.5 times and Th17/Treg ratio decreased of 3.6times. Correspondingly, patient symptoms also gradually improved,Oral Presentations S163suggesting an association between GvHD clinical course and CD41T-cell imbalance. In accordance with the decrease of Th1 CD41 Tcells in the PB of CR patients, we observed a valuable decrease ofIFNg plasma concentrations, which reached the levels typical ofHD. Contrary to CR patients, in PR patients we observed a transientdecrease of GVHD plasmatic markers and Th1/Treg, Th17/Tregratios, while NR patients showed stable or even increasing levels ofall analysed plasmatic and cellular markers.In summary, despite its limited size, the present study suggeststhat MSCs, upon infusion, are able to convert an inflammatory envi-ronment to a more physiological one, both at a cellular level, pro-moting the expansion of circulating Tregs, and at a molecularlevel, diminishing inflammatory cytokines.31PROGNOSTIC FACTORS IN ALLOGENEIC HEMATOPOIETIC CELL TRANS-PLANTATION FROM MATCHED UNRELATED DONORS: LESSONS FROMEXTENDED FOLLOW UP OF A RANDOMIZED TRIAL ON GVHD PROPHY-LAXIS WITH OR WITHOUT ANTI T-CELL GLOBULIN ATG-FRESENIUS(ATG-F)Finke, J.1, Schmoor, C.2, Bethge, W.A.3, Ottinger, H.4, Stelljes, M.5,Zander, A.6, Volin, L.7, Heim, D.8, Schwerdtfeger, R.9, Bertz, H.1,Grichina, O.2, Socie, G.10 1University Medical Center, Freiburg, Ger-many; 2University Medical Center, Freiburg, Germany; 3UniversityMedical Center, T€ubingen, Germany; 4University Hospital, Essen, Ger-many; 5University Hospital, M€unster, Germany; 6University HospitalEppendorf, Hamburg, Germany; 7University Central Hospital, Helsinki,Finland; 8Kantonsspital, Basel, Switzerland; 9DKD, Wiesbaden,Germany; 10Hospital St. Louis, Paris, FranceGvHD is a major problem in allogeneic hematopoietic cell trans-plantation (HCT) fom unrelated donors (UD). In our prospectiverandomized multicenter trial we could show the efficacy of addi-tional ATG-F to standard GvHD prophylaxis with cyclosporine Aand Mtx in reducing all grades of acute and chronic GvHD withoutnegatively affecting NRM, relapse rate or DFS in 201 adult patients(median age 40 (range 18-60) years) with leukemia or MDS in early(n 5 107) and advanced (n 5 94) disease transplanted after myeloa-blative conditioningwithmarrow (n5 37) or blood (n5 134). (Finkeet al., Lancet Oncol, 2009).Risk factors for the outcome after UD-HCT have been postulatedfrom retrospective analyses of registry data, however data from ran-domized trials are lacking.With an extended follow of median 3 yearswe present mature data on outcome and multivariate analysis of riskfactors: Incidence of grade III-IV aGvHD was 11.7% in the ATG-Fgroup and 25.5% in the control group (p 5 0.039), the incidence ofextensive chronicGvHD (cGvHD) after three years was 12.2% versus45.0% (p\0.0001),DFSwas 48.0%and 38.4%, (p5 0.71), incidenceof relapse was 32.6% and 28.2% (p 5 0.47), incidence of NRM was19.4% and 33.5% (p 5 0.18), and OS was 55.2% and 43.3% in theATG-F and control groups, respectively (p 5 0.39).The following factors were analyzed with regard to OS, DFS,risk of relapse, aGvHD III/IV, extensive cGvHD and NRM: pa-tient age ([. /\ ] 40 y), donor age (. /\ ] 40 y), male patient/ fe-male donor v. other, CMV negative v. seropositive, HLA-Cmismatch, type and status of disease, conditioning regimen (TBIv. no TBI), source of stem cells (marrow v. PBSC), mean cyclospor-ine trough levels during the first months (. /\median 220ng/ml),graft cell count in PBSC (. / \ ] median 7.5x106 CD34/kg). Inmultivariate analyses advanced disease was a negative factor foraGvHD III-IV (HR 5 2.1, p 5 0.018), DFS (HR 1.7, p 5 0.004),relapse (HR5 1.7, p 5 0.038), and OS (HR 5 1.9, p5 0.002). Pa-tient age 40 years or more negatively affected NRM (HR5 1.8. p50.041). Interestingly, donor age 40 years or more adversely affectedthe risk of aGvHD III-IV (HR5 2.6, p5 0.009), extensive cGvHD(HR 5 2.1, p 5 0.021) and OS (HR 5 1.7, p 5 0.016), whereasCMV status, male patient/female donor, HLA-Cmismatch, condi-tioning, graft source, CD34 count or cyclosporine levels had no in-fluence.Conclusion: ATG-F significantly reduces acute and chronicGvHD. By choosing younger donors outcome can be improved inunrelated donor transplantation.32ABROGATION OF DONOR T CELL IL-21 SIGNALING LEADS TO TISSUE-SPECIFIC MODULATION OF IMMUNITY AND SEPARATION OF GVHDFROM GVLHanash, A.M.1, Kappel, L.W.1, Yim, N.L.1, Nejat, R.A.1,Goldberg, G.L.1, Smith, O.M.1, Rao, U.K.1, Dykstra, L.1, Na, I.-K.2,Holland, A.M.1, Liu, C.3, Murphy, G.F.4, Leonard, W.J.5, Heller, G.1,van den Brink, M.R.M.1 1Memorial Sloan-Kettering Cancer Center,New York, NY; 2Charite CBF - Universit€atsmedizin Berlin, Berlin, Ger-many; 3University of Florida College of Medicine, Gainesville, FL; 4Brig-ham and Women’s Hospital, Harvard Medical School, Boston, MA;5National Heart, Lung, and Blood Institute, National Institutions ofHealth, Bethesda, MDInterleukin 21 (IL-21) is a pro-inflammatory cytokine producedby Th17 helper T cells, and abrogation of IL-21 signaling has re-cently been shown to reduce GVHD while retaining GVL. How-ever, mechanisms by which IL-21 may lead to a separation ofGVHD and GVL are incompletely understood. To characterizeits effect on GVH and GVL T cell responses, we comparedwild type (WT) and IL-21 receptor knockout (IL-21R KO) donorT cells in a C57BL/6 into BALB/c murine MHC-mismatchedbone marrow transplant (BMT) model. Lethally irradiated BMTrecipients of IL-21R KO T cells demonstrated decreasedGVHD-related morbidity (p \ .05) and mortality (p \ .01) anddecreased histopathologic evidence of GVHD within the smallbowel (p \ .05). While this reduced GVHD was associated withincreased donor regulatory T cells two to three weeks post-BMT (p \ .001), transplanting selected T cell subsets indicatedthat IL-21 signaling in both donor CD4 and CD8 T cells contrib-uted to GVHD mortality (CD4, p\ .01; CD8, p\ .05), althougheffects on CD8 T cells occurred only in the presence of CD4s.KO and WT donor T cells demonstrated equivalent alloactiva-tion, as evidenced by proliferation (p \ .001), upregulation ofCD25 (p \ .001), and downregulation of CD62L (p \ .01 forCD8 T cells) in allogeneic vs. syngeneic recipients. However,IL-21R KO T cells demonstrated decreased infiltration withinthe small bowel (p \ .05) and mesenteric lymph nodes (MLN;CD8, p\ .05; CD4, p\ .001), and decreased inflammatory cyto-kine-producing CD4 T cells within MLN (IFN-g, p\ .01; TNF-a, p\ .001). Consistent with this, transplanted IL-21R KO donorT cells demonstrated decreased expression of a4b7 integrin(LPAM, p \ .05), a molecule known to be involved in homingof GVHD-mediating donor T cells to the gut. However, in con-trast to the reduced inflammatory cytokine-producing CD4 Tcells observed in MLN, IL-21R KO helper T cell cytokine pro-duction was maintained in spleen and peripheral lymph nodes,and IL-21R KO T cells were able to protect recipient micefrom lethality due to A20 lymphoma (p\ .001). In summary, ab-rogation of IL-21 signaling in donor T cells leads to tissue-spe-cific modulation of immunity, such that gastrointestinal GVHDis reduced, but peripheral T cell function and GVL capacity areretained. Targeting IL-21 for therapeutic intervention is an excit-ing strategy to separate GVHD from GVL, and this novel ap-proach should be considered for clinical investigation toimprove transplant outcomes and prevent malignant relapse.33REG3a IS A BIOMARKER OF GRAFT VERSUS HOST DISEASE OF THEGASTROINTESTINAL TRACTHarris, A.C.1, Ferrara, J.L.M.1, Levine, J.E.1, Braun, T.1, Hogan, J.2,Crawford, J.1, Pitteri, S.2, Wang, H.2, Chin, A.2, Zhang, Q.2,Granger, J.1, Vander Lugt, M.1, Byersdorfer, C.1, Magenau, J.1,Gomez, A.1, Choi, S.1, Kitko, C.1, Yanik, G.1, Peres, E.1,Pawarode, A.1, Mineishi, S.1, Reddy, P.1, Couriel, D.R.1, Hanash, S.2,Paczesny, S.1 1University of Michigan, Ann Arbor,MI; 2Fred HutchinsonCancer Research Center, Seattle, WAThere are no validated plasma biomarkers specific to graft versushost disease (GVHD) of the gastrointestinal (GI) tract. We have pre-viously identified and validated elafin as a plasma biomarker for skinGVHD(ScienceTranslMed, 2:50-57).Using an unbiased proteomics

Immunomonitoring of Transplanted Patients Infused With Mesenchymal Stromal Cells (MSC) for Treating Steroid-Refractory GVHD

Elsevier - Publisher Connector 

S162 Oral Presentationsimproved RFS (P5 0.019) andOS (P5 0.033) compared to the A/G
or G/G genotype. Multivariable analysis, adjusted for stem cell
source (peripheral blood vs. bone marrow), GVHD subtype (clas-
sic/overlap vs. acute subtypes/none), and disease risk (low vs. inter-
mediate vs. high) were performed to test the association of the
significant SNPs with RFS and OS. rs4553808 A/A genotype (HR
2.44, P 5 0.015), classic/overlap GVHD (HR 2.98, P 5 0.002)
and low/intermediate disease risk (HR 2.16, P5 0.03) were indepen-
dent predictors of superior OS. rs4553808 A/A genotype (HR 2.39,
P 5 0.016), and classic/overlap GVHD (HR 3.84, P 5 0.001) were
independent predictors of superior RFS.
Our study confirms reports that genetic variation in donor CTLA-
4 is associated with outcome after allo-HCT and may allow for
identification of patient subsets that may benefit from pre-emptive
modulation of immunosuppressive therapy. Further investigation
into the CTLA-4/ICOS/CD28 and B7 regulation of T cell homeo-
stasis is warranted to design a risk adapted approach to decrease the
mortality for patients with a high risk of relapse.
Table 1. Patient characteristics and survival of all patients.
(N5164)
N(%)VariableGVHD subtypeTotal Cohort
(N5164)Classic plus
Overlap
cGVHD N(%)
(N5101)aGVHD subtypes
plus No GVHD N
(%) (N563)Age, median
in years (range)47(18-69) 49(21-67) 46(18-69)GenderMale (R) 80(49) 49(49) 31(49)Female (R) 84(51) 52(51) 32(51)Female D to male R 31(19) 21(21) 10(19)RaceCaucasian (R/D) 156(95)/153(93) 94(93)/92(91) 62(98)/61(97)DiagnosisAcute Leukemia 86(52) 49(49) 37(59)Chronic Leukemia 19(12) 11(11) 8(13)Lymphoma 54(33) 38(37) 16(25)other 5(93) 3(3) 2(3)Disease Risk #Low 65(40) 38(38) 27(43)Intermediate 30(18) 21(20) 9(14)High 40(24) 25(25) 15(24)Missing 29(18) 17(17) 12(19)Stem Cell SourceMarrow 44(27) 23(22) 21(33)Peripheral Blood 120(73) 78(78) 42(67)Regimen IntensityMyeloablative 111(68) 69(68) 42(67)Other 53(32) 32(32) 21(33)Donor TypeRelated 109(67) 69(68) 40(63)Unrelated 55(33) 32(32) 23(37)HLA MatchHLA identical sibling 108(66) 68(67) 40(63)HLA matched unrelated 55(33) 32(32) 23(37)Other 1(1) 1(1) 0GVHD ProphylaxisCSA/MTX 112(68) 72(71) 40(63)CSA/MMF 50(31) 28(28) 22(36)Other 2(1) 1(1) 1(1)TBIYes 79(48) 52(51) 27(43)No 85(52) 49(49) 36(57)CMVR/D (+/+) 63(38) 35(34) 28(44)R/D (+/-) 19(12) 12(12) 7(11)R/D (-/+) 49(29) 29(29) 18(29)R/D (-/-) 35(21) 25(25) 10(16)Post-transplant Characteristics
(Continued )Table 1. (Continued )VariableN(%)
GVHD subtypeTotal Cohort
(N5164)Classic plus
Overlap
cGVHD N(%)
(N5101)aGVHD subtypes
plus No GVHD N
(%) (N563)aGVHDVGrade 0-2 vs. 3-4 179(78) vs. 32(20) 78(77) vs. 21(21) 51(81) vs. 11(7)Grade 0-1 vs. 2-4 39(24) vs. 122(74) 39(24) vs. 75(74) 15(24) vs. 47(75)PLT (X10(9)/L at
day 100,
median (range)110(10-356) 105(17-244) 112(10-356)Total Bilirubin
(mg/dL) at day
100, median(range)0.8(0-3.6) 0.8(0-2.4) 0.9(0.2-3.6)Survival2 year OS: (95% CI) 63%(56-72) 73%(64-83) 48%(36-64)2 year RFSU: (95% CI) 61%(54-70) 73%(65-83) 41%(30-57)# Disease risk-based on Committee of International Bone Marrow
Transplant Registry (CIBMTR) risk criteria; V aGVHD-3 cases missing;
U RFS analyses includes death from non-relapse causes as competing
risk. GVHD-graft-versus-host disease; cGVHD-chronic GVHD;
aGVHD-acute GVHD; R-recipient; D-donor; HLA-Human Leukocyte
Antigen; CSA-cyclosporine; MTX-methotrexate; MMF-mycophenolate
moefitil; TBI-Total body irradiation; CMV-cytomegalovirus; PLT-platelet;
OS-overall survival; RFS-relapse free survival; CI-confidence interval.30
IMMUNOMONITORING OF TRANSPLANTED PATIENTS INFUSED WITH
MESENCHYMAL STROMAL CELLS (MSC) FOR TREATING STEROID-
REFRACTORY GvHD
Dander, E.1, Lucchini, G.2, Vinci, P.1, Introna, M.3, Bonanomi, S.2,
Balduzzi, A.2, Gaipa, G.4, Perseghin, P.5, Masciocchi, F.1, Capelli, C.6,
Golay, J.6, Algarotti, A.3, Rambaldi, A.3, Rovelli, A.2, Biondi, A.2,
Biagi, E.2, D’Amico, G.1 1 ‘‘M. Tettamanti’’ Research Center, University
of Milan-Bicocca, Monza (Mi), Italy; 2S. Gerardo Hospital, Monza (Mi),
Italy; 3Ospedali Riuniti di Bergamo, Bergamo, Italy; 4Laboratory of Cell
Therapy ‘‘Stefano Verri’’, S. Gerardo Hospital, Monza (Mi), Italy;
5Apheresis Unit, S. Gerardo Hospital, Monza (Mi), Italy; 6Ospedali Riu-
niti Bergamo, Bergamo, Italy
Although the usage of mesenchymal stromal cells (MSC) as ther-
apy for Graft versus Host Disease (GvHD) is constantly increasing,
studies on MSC efficacy have been scarcely corroborated by biolog-
ical analysis of patient response to cell infusion. We report the im-
munological monitoring of 9 patients with steroid-refractory
GvHD, receivingmultiple doses ofMSCs.GvHDpresented as acute
in 5 cases and chronic in 4 cases. After MSC therapy, 2 patients
showed complete response (CR), 4 patients showed partial response
(PR) whereas 3 patients did not respond (NR) to MSC infusion.
To better comprehend the immunomodulatory effects ofMSC in-
fusions, we studied GvHD plasmatic markers, inflammatory cyto-
kines and CD41 T-cell subsets circulating in the peripheral blood
(PB) of enrolled patients before MSC infusion and at day 7, 14 and
28 after cell therapy.
In accordance with clinical observations, in CR patients we ob-
served a dramatic decrease of three validated GvHD plasmatic
markers TNFRI, IL2Ra and elafin (Paczesny S et al. Blood 2009)
to the mean levels of Healthy Donors (HD). In particular, at day
28 after therapy, TNFRI decreased of 2 times, IL2Ra levels de-
creased of 1.9 times and elafin decreased of 2.3 times. Moreover, in-
vestigating the effect of MSC infusion on lymphocyte counts, we
observed in both CR patients a significant decrease in CD31 and
CD41 lymphocyte counts in the PB. Interestingly, after MSC infu-
sions, CD41 T-cell subsets changed significantly: Tregs increased
and Th1 and Th17 populations decreased. In particular, Th1/Treg
ratio decreased of 3.5 times and Th17/Treg ratio decreased of 3.6
times. Correspondingly, patient symptoms also gradually improved,
Oral Presentations S163suggesting an association between GvHD clinical course and CD41
T-cell imbalance. In accordance with the decrease of Th1 CD41 T
cells in the PB of CR patients, we observed a valuable decrease of
IFNg plasma concentrations, which reached the levels typical of
HD. Contrary to CR patients, in PR patients we observed a transient
decrease of GVHD plasmatic markers and Th1/Treg, Th17/Treg
ratios, while NR patients showed stable or even increasing levels of
all analysed plasmatic and cellular markers.
In summary, despite its limited size, the present study suggests
that MSCs, upon infusion, are able to convert an inflammatory envi-
ronment to a more physiological one, both at a cellular level, pro-
moting the expansion of circulating Tregs, and at a molecular
level, diminishing inflammatory cytokines.31
PROGNOSTIC FACTORS IN ALLOGENEIC HEMATOPOIETIC CELL TRANS-
PLANTATION FROM MATCHED UNRELATED DONORS: LESSONS FROM
EXTENDED FOLLOW UP OF A RANDOMIZED TRIAL ON GVHD PROPHY-
LAXIS WITH OR WITHOUT ANTI T-CELL GLOBULIN ATG-FRESENIUS
(ATG-F)
Finke, J.1, Schmoor, C.2, Bethge, W.A.3, Ottinger, H.4, Stelljes, M.5,
Zander, A.6, Volin, L.7, Heim, D.8, Schwerdtfeger, R.9, Bertz, H.1,
Grichina, O.2, Socie, G.10 1University Medical Center, Freiburg, Ger-
many; 2University Medical Center, Freiburg, Germany; 3University
Medical Center, T€ubingen, Germany; 4University Hospital, Essen, Ger-
many; 5University Hospital, M€unster, Germany; 6University Hospital
Eppendorf, Hamburg, Germany; 7University Central Hospital, Helsinki,
Finland; 8Kantonsspital, Basel, Switzerland; 9DKD, Wiesbaden,
Germany; 10Hospital St. Louis, Paris, France
GvHD is a major problem in allogeneic hematopoietic cell trans-
plantation (HCT) fom unrelated donors (UD). In our prospective
randomized multicenter trial we could show the efficacy of addi-
tional ATG-F to standard GvHD prophylaxis with cyclosporine A
and Mtx in reducing all grades of acute and chronic GvHD without
negatively affecting NRM, relapse rate or DFS in 201 adult patients
(median age 40 (range 18-60) years) with leukemia or MDS in early
(n 5 107) and advanced (n 5 94) disease transplanted after myeloa-
blative conditioningwithmarrow (n5 37) or blood (n5 134). (Finke
et al., Lancet Oncol, 2009).
Risk factors for the outcome after UD-HCT have been postulated
from retrospective analyses of registry data, however data from ran-
domized trials are lacking.With an extended follow of median 3 years
we present mature data on outcome and multivariate analysis of risk
factors: Incidence of grade III-IV aGvHD was 11.7% in the ATG-F
group and 25.5% in the control group (p 5 0.039), the incidence of
extensive chronicGvHD (cGvHD) after three years was 12.2% versus
45.0% (p\0.0001),DFSwas 48.0%and 38.4%, (p5 0.71), incidence
of relapse was 32.6% and 28.2% (p 5 0.47), incidence of NRM was
19.4% and 33.5% (p 5 0.18), and OS was 55.2% and 43.3% in the
ATG-F and control groups, respectively (p 5 0.39).
The following factors were analyzed with regard to OS, DFS,
risk of relapse, aGvHD III/IV, extensive cGvHD and NRM: pa-
tient age ([. /\ ] 40 y), donor age (. /\ ] 40 y), male patient/ fe-
male donor v. other, CMV negative v. seropositive, HLA-C
mismatch, type and status of disease, conditioning regimen (TBI
v. no TBI), source of stem cells (marrow v. PBSC), mean cyclospor-
ine trough levels during the first months (. /\median 220ng/ml),
graft cell count in PBSC (. /\ ] median 7.5x106 CD34/kg). In
multivariate analyses advanced disease was a negative factor for
aGvHD III-IV (HR 5 2.1, p 5 0.018), DFS (HR 1.7, p 5 0.004),
relapse (HR5 1.7, p 5 0.038), and OS (HR 5 1.9, p5 0.002). Pa-
tient age 40 years or more negatively affected NRM (HR5 1.8. p5
0.041). Interestingly, donor age 40 years or more adversely affected
the risk of aGvHD III-IV (HR5 2.6, p5 0.009), extensive cGvHD
(HR 5 2.1, p 5 0.021) and OS (HR 5 1.7, p 5 0.016), whereas
CMV status, male patient/female donor, HLA-Cmismatch, condi-
tioning, graft source, CD34 count or cyclosporine levels had no in-
fluence.
Conclusion: ATG-F significantly reduces acute and chronic
GvHD. By choosing younger donors outcome can be improved in
unrelated donor transplantation.32
ABROGATION OF DONOR T CELL IL-21 SIGNALING LEADS TO TISSUE-
SPECIFIC MODULATION OF IMMUNITY AND SEPARATION OF GVHD
FROM GVL
Hanash, A.M.1, Kappel, L.W.1, Yim, N.L.1, Nejat, R.A.1,
Goldberg, G.L.1, Smith, O.M.1, Rao, U.K.1, Dykstra, L.1, Na, I.-K.2,
Holland, A.M.1, Liu, C.3, Murphy, G.F.4, Leonard, W.J.5, Heller, G.1,
van den Brink, M.R.M.1 1Memorial Sloan-Kettering Cancer Center,
New York, NY; 2Charite CBF - Universit€atsmedizin Berlin, Berlin, Ger-
many; 3University of Florida College of Medicine, Gainesville, FL; 4Brig-
ham and Women’s Hospital, Harvard Medical School, Boston, MA;
5National Heart, Lung, and Blood Institute, National Institutions of
Health, Bethesda, MD
Interleukin 21 (IL-21) is a pro-inflammatory cytokine produced
by Th17 helper T cells, and abrogation of IL-21 signaling has re-
cently been shown to reduce GVHD while retaining GVL. How-
ever, mechanisms by which IL-21 may lead to a separation of
GVHD and GVL are incompletely understood. To characterize
its effect on GVH and GVL T cell responses, we compared
wild type (WT) and IL-21 receptor knockout (IL-21R KO) donor
T cells in a C57BL/6 into BALB/c murine MHC-mismatched
bone marrow transplant (BMT) model. Lethally irradiated BMT
recipients of IL-21R KO T cells demonstrated decreased
GVHD-related morbidity (p\ .05) and mortality (p\ .01) and
decreased histopathologic evidence of GVHD within the small
bowel (p\ .05). While this reduced GVHD was associated with
increased donor regulatory T cells two to three weeks post-
BMT (p \ .001), transplanting selected T cell subsets indicated
that IL-21 signaling in both donor CD4 and CD8 T cells contrib-
uted to GVHD mortality (CD4, p\ .01; CD8, p\ .05), although
effects on CD8 T cells occurred only in the presence of CD4s.
KO and WT donor T cells demonstrated equivalent alloactiva-
tion, as evidenced by proliferation (p \ .001), upregulation of
CD25 (p \ .001), and downregulation of CD62L (p \ .01 for
CD8 T cells) in allogeneic vs. syngeneic recipients. However,
IL-21R KO T cells demonstrated decreased infiltration within
the small bowel (p \ .05) and mesenteric lymph nodes (MLN;
CD8, p\ .05; CD4, p\ .001), and decreased inflammatory cyto-
kine-producing CD4 T cells within MLN (IFN-g, p\ .01; TNF-
a, p\ .001). Consistent with this, transplanted IL-21R KO donor
T cells demonstrated decreased expression of a4b7 integrin
(LPAM, p \ .05), a molecule known to be involved in homing
of GVHD-mediating donor T cells to the gut. However, in con-
trast to the reduced inflammatory cytokine-producing CD4 T
cells observed in MLN, IL-21R KO helper T cell cytokine pro-
duction was maintained in spleen and peripheral lymph nodes,
and IL-21R KO T cells were able to protect recipient mice
from lethality due to A20 lymphoma (p\ .001). In summary, ab-
rogation of IL-21 signaling in donor T cells leads to tissue-spe-
cific modulation of immunity, such that gastrointestinal GVHD
is reduced, but peripheral T cell function and GVL capacity are
retained. Targeting IL-21 for therapeutic intervention is an excit-
ing strategy to separate GVHD from GVL, and this novel ap-
proach should be considered for clinical investigation to
improve transplant outcomes and prevent malignant relapse.33
REG3a IS A BIOMARKER OF GRAFT VERSUS HOST DISEASE OF THE
GASTROINTESTINAL TRACT
Harris, A.C.1, Ferrara, J.L.M.1, Levine, J.E.1, Braun, T.1, Hogan, J.2,
Crawford, J.1, Pitteri, S.2, Wang, H.2, Chin, A.2, Zhang, Q.2,
Granger, J.1, Vander Lugt, M.1, Byersdorfer, C.1, Magenau, J.1,
Gomez, A.1, Choi, S.1, Kitko, C.1, Yanik, G.1, Peres, E.1,
Pawarode, A.1, Mineishi, S.1, Reddy, P.1, Couriel, D.R.1, Hanash, S.2,
Paczesny, S.1 1University of Michigan, Ann Arbor,MI; 2Fred Hutchinson
Cancer Research Center, Seattle, WA
There are no validated plasma biomarkers specific to graft versus
host disease (GVHD) of the gastrointestinal (GI) tract. We have pre-
viously identified and validated elafin as a plasma biomarker for skin
GVHD(ScienceTranslMed, 2:50-57).Using an unbiased proteomics


Immunomonitoring of Transplanted Patients Infused With Mesenchymal Stromal Cells (MSC) for Treating Steroid-Refractory GVHD 

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Immunomonitoring of Transplanted Patients Infused With Mesenchymal Stromal Cells (MSC) for Treating Steroid-Refractory GVHD

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