conditioning regimen for haplo transplant
TRANSCRIPT
05/01/2023 B.S. Andersson
Optimized Induction in Haplos; MAC vs RIC
AUBHO 2015August 28-29, 2015
Borje S. Andersson, MD, Ph.D.Molecular Pharmacology and Translat.
Drug Development Program,Department of Stem Cell Transplantation
UT MD Anderson Cancer Center.
05/01/2023 B.S. Andersson
Myeloablative vs Non-Myeloablative (RIC) Conditioning Regimens
Dose Intensity
FC± RBEAM +/-R2-5
5-10
MF
Non-Ablative RIC
Oral Bu/Cy2, -4>10
TBI/± Cy/ ± F /± TT /± VP16
Oral Bu8/F/± ATG
Ablative
TBI 2GyCyThymicXRT/TLI
100
Day
s , T
RM
%
FlagIda Flu- IV Bu -2, -3 Clo-+/Flu - IV Bu4
Gen. Trend
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What have we learned?
1. Engraftment rate improves with intensive conditioning2. Disease control improves with intensive conditioning3. TRM not necessarily directly related to the intensity of
the conditioning – GFs contribute to TRM. 4. Rational use of mechanistic cytotoxicity information at
the molecular level can be used to design improved conditioning therapy.
Author Conditioning Graft GF (%) TRM (%) EFS (%)
Raiola TT-Bu-Flu BM 4 18 68/37(n=50) Flu-TBI-10Gy
Bashey Cy-Flu-Bu or BM/PBSC n/a 4 60(n=53) Flu-Cy-TBI-2Gy
Ciurea TT-Mel-Flu BM 6 16 50(n=32)
Luznik Flu-Cy-TBI-2Gy BM 13 15 26(n=68) (2 Yrs.)
Wang Ara-C-Bu-Cy- BM/PBSC 1 18 ~60(n=756) MeCCNU (3 Yrs.) (5 Yrs.)
Haplo-Identical SCT for (mainly) Hematological Malignancies
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General Problems with highly HLA-disparate grafts, aka Haplos
1. Treatment- /Regimen-Related Toxicity (“TRM”)2. Graft failure3. Recurrent Disease
Busulfan - Cyclophosphamide Metabolic Interactions
GSTM1
CYP2B6CYP2C9
Sulfolane
CYPsFMO?
-3 -2 -1-4-6 -5 +14 +21 +100 >1800
Graft
Conditioning
Supportive Care
GVHD prophylaxis and therapy
Patient(age, gender, CMV, comorbidities…)
12
3 5
6
4
DiseaseFeatures
Malignant vs.“Non-Malignant”
How to (Optimize Conditioning to) Improve outcome?
1. Nucleoside Analogs (NA) do not utilize CYP450 or GSH/GST-conjugation in their metabolism.
2. Further, when the NA (e.g. fludarabine) is properly time-sequenced with IV busulfan, the conditioning reliably facilitates engraftment of MRD and MUD BM and PBPC grafts in (adult) recipients.
3. NAs and AAs (here, Busulfan) kill primarily by induction of apoptosis and terminal differentiation.
De Lima M., et al. Blood. 2004; 104(3):857-64.
NAs cause histone modifications; enhanced with an alkylator
Valdez et al. Biochem Pharmacol. 2011 Jan 15;81(2):222-32
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[Clof+Flu+Bu] combo activates DNA damage response through the ATM-CHK2 pathway in AML cell line
P -ATM (Ser1981)
ATM
γ -H2AX
P -SMC1(Ser957)
P -CHK2 (Ser33/35)
β -ACTIN
P -ATM (Ser1981)
ATM
-H2AX
P -SMC1(Ser957)
P -CHK2 (Ser33/35)
-ACTIN
P -ATM (Ser1981)
ATM
γ -H2AX
P -SMC1(Ser957)
P -CHK2 (Ser33/35)
β -ACTIN
P -ATM (Ser1981)
ATM
-H2AX
P -SMC1(Ser957)
P -CHK2 (Ser33/35)
-ACTIN
Suggested mechanism of synergisticcytotoxicity of NAs and AAs
Valdez & Andersson. Environ Mol Mutagen. 2010; 51:659-668.
Histone modificns
Chromatin remodelingDNA cross-
linking
DNA damage
Loop of death
DNA alkylating agents (AAs)
DNA synthesis/repair
Nucleoside analogues (NAs)
Apoptosis
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Optimized Conditioning, (Haplos).
RIC or MAC ???
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Normal OrganToxicity
Tumor Load; PK-Guided, Individualized / Standardized Therapy Should Improve Treatment Outcome.
“Therapeutic Windows”
Num
ber
of p
atie
nts
Blue: Fixed-DosingGreen: PK-Guided Dosing in high-risk patients - MAC.Orange: PK-guided dosing - RIC
Leukemia ProgressionCR Pats
aGVHD
Leukemia Progression “Refr. Pats.”
Systemic Drug Exposure
“Safe Upper Limit”, Syst.Exposure
0 10 20 30 40 50 60 70 80
Months Post Transplant
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0C
umul
ativ
e P
ropo
rtion
Sur
vivi
ng P
rogr
essi
on F
ree Active Disease at Transplant
Adjusted, N=40
Fixed, N=46
P 0.03
Progression-Free Survival, Active Dx - Patients
0 10 20 30 40 50 60 70 80
Months Post Transplant
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Cum
ulat
ive
Pro
porti
on S
urvi
ving
Pro
gres
sion
Fre
e
Adjusted, N=71
Fixed, N=68
P 0.4Remission at Transplant
Progression-Free Survival, CR- Patients
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Successful Conditioning includes several components:
1. Killing malignant cells2. A. Killing cell populations that are mediate (acute)
graft rejection (T-cells and other) , B. Killing immature, progenitor/stem cells that can mediate regeneration of ancillary immuno-competent cells that mediate secondary graft failure.
3. Removal of reproductively dead, yet still functional cell subpopulations that mediate rejection
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Normal Organ
ToxicityNum
ber
of p
atie
nts
Blue: Fixed-DosingGreen: PK-Guided Dosing, high-risk patients.
aGVHD
Systemic Drug Exposure
Leukemia Pats. Immunosuppressed
Hemglobinopathies/ e.g. Thalassemia Immunocompetent Pat.
“Immuno-ablative Therapeutic Interval”
“Safe Upper Limit”, Syst.Exposure
SCID
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Optimizing Pretransplant Conditioning.
We suggest, that one should pay close attention to:
1. Time-Sequence of the drugs in the conditioning program,
2. Consider adding either (a) cytotoxic agent(s) that provide a radiomimetic, “interphase-death-inducing”, effect on the T-cells, such as Thiotepa, low-dose TBI, or
3. use of “early” ATG to eliminate mature host T-cells.
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“Genetic Diseases and Haplo Tx” !(Hemoglobinopathies)
- Intact, (hyper-) active immune system- Iron overload/subclinical organ failure- “Benign hemoglobinopathy”
-3 -2 -1-4-6 -5 +14 +21 +100 >1800
Graft
Conditioning
GVHD prophylaxis and therapy
Patient(age, gender, CMV, comorbidities…)
12
3 5
6
4
Diseasefeatures
Hypothesis: Personalized Conditioning Improves outcome !
05/01/2023 B.S. Andersson
Optimizing Pretransplant Conditioning Therapy.
We suggest, that one should pay close attention to:
1. Time-Sequence of the drugs in the conditioning program,
2. Consider adding either (a) cytotoxic agent(s) that provide a radiomimetic, “interphase-death-inducing”, effect on the T-cells, such as Thiotepa, low-dose TBI, or
3. use of “early” ATG to eliminate mature host T-cells.4. To further promote engraftment of highly HLA-
disparate grafts (“haplos”) consider using pharmacological Pretransplant ImmunoSuppression Therapy (“PTIS”) in the pre-conditioning phase.
05/01/2023 B.S. Andersson
Normal Organ
ToxicityNum
ber
of p
atie
nts
Blue: Fixed-DosingGreen: PK-Guided Dosing, MAC.Orange: PK-guided dosing, RIC
aGVHD
Systemic Drug Exposure
Hemglobinopathies/ e.g. Thalassemia Immunocompetent Pat.
“Immuno-ablative Therapeutic Intervals”
“Safe Upper Limit”, Syst.Exposure
Thalassemia After PTIS.
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Thalassemia (Pre-) Transplant Platform
Day -56 -54 -52 -28 -26 -24 -21 -14 -12 -10 -8 -7 -6 -5 -4 -3 -2 -1 0 +3 +4
Modifying the Conditioning Platform
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1 2 3,45
Flu - Bu ± ATG HSC Post Tx – Cy
Clinical Consideration Points
1. Pre – “PTIS” 2. + “Early ATG” alt. “Necrosis-inducing agent”3. PK-TDM new standard4. Post Tx Intervention, Post-Cy, demethylating agents, vaccines, etc.
Modifying the Platform, Post-Tx-Cyclophosphamide.
Platform Technology
Summary, RIC vs MAC/RTC
1. Malignant Disease, - Tumor Load: CR: RIC = MAC
Active Dx: RIC < MAC
- Engraftment: Consider pretreatment level of immunosuppression, need to modify?
2. Genetic Disease (hemoglobinopathy vs SCID):Immunol. active/hyperactive/suppressed: May need modified (pre-) conditioning to secure engraftment, otherwise RIC since no malignancy.
-3 -2 -1-4-6 -5 +14 +21 +100 >1800
Graft
Conditioning
Supportive Care
GVHD prophylaxis and therapy
Patient(age, gender, CMV, comorbidities…)
12
3 5
6
4
Diseasefeatures
Summary: Personalized Conditioning Improves outcome !
05/01/2023 B.S. Andersson
CollaboratorsUT MD Anderson
Clinical:EJ Shpall Roy Jones Yago Nieto Partow Kebriaei Muzaffar Qazilbash Chitra Hosing Laura Worth Dean Lee Richard Champlin Lab:Ben Valdez, Guiyun Wang Yan Liu Yang LiBiostatistics: Peter F. Thall
Ramathibodi Hospital, Bangkok, Thailand: Suradej Hongeng
Institut Paoli Calmette, Marseille, France: Didier Blaise
Karolinska Institute, Stockholm, Sweden: Moustapha Hassan
U Alberta, Calgary, AB, CA: James Russell
05/01/2023 B.S. Andersson
Questions, Please