Juliet N. Barker, MBBS (Hons), FRACP Associate Attending
Director, Cord Blood Transplant Program Memorial Sloan-Kettering Cancer Center
Double Unit Cord Blood Transplantation for Acute Leukemia
CSA/ MMF -3 -2 -1 -4 -6 -5 30 100 0
Acknowledgements
U of Minnesota John E. Wagner
NYBC
Pablo Rubinstein Cladd Stevens
Machi Scaradavou
MSKCC Staff of Adult & Pediatric
Transplant Search: Courtney Byam, Rosanna Ferrante Debbie Wells, Melissa Sideroff, Sinda Lee
Cell Therapy Lab CB Research Staff: Marissa Lubin Anne Marie Gonzales , Katie Evans
Cellular Immunology Lab: Kathy Smith Pediatrics: Machi Scaradavou
Nancy Kernan & Richard O’Reilly Adult BMT Service: Doris Ponce
Marcel van den Brink & Sergio Giralt
Funding Gabrielle’s Angel Foundation for Cancer Research, the MSKCC Society,
MSKCC Translational and Integrative Medicine Research Grant, P01 CA23766 NCI, NIH.
Original Reasons for Double Unit CB Grafts
• Platform for investigation of expansion or other graft manipulation. • Augment graft cell dose = improve engraftment, reduce TRM, improve survival.
Reasons for Double Unit CB Grafts: Successful?
• Platform for investigation of expansion or other graft manipulation?: YES • Augment graft cell dose = improve engraftment, reduce TRM, improve survival?: YES in adults, children?
Sibling typing → simultaneous URD & CB search
Suitable Sibling or URD: Suitable CB Graft: 4-6/6 A,B antigen, DRB1 allele 2 units: each > 2 x 107 NC/kg
Hi Dose Prep RIC or Mini Children (Young adults)
RIC/ Mini + 10/10 donor
Hi Dose + TCD 9-10/10 donor
MSKCC Donor Algorithm: DCBT Extends Access
Donors identified for > 95% patients.
URD (n=465) CB (n=156) No Graft (n=36)
NW Europe Asian
Eastern Europe African
Southern Europe White Hispanic
Europe Mix Middle Eastern
Non-Europe Mix
Transplant Type by Patient Ancestry (n = 657)
> 50% CBTs non-European
ancestry: DCB extends
access.
2012 update from Barker et al 2010, BBMT
P = NS
Comparable 5-Yr LFS: DCBT, MRD, & URD (U of Minnesota & Fred Hutchinson CRC, n = 536)
Brunstein & Delaney, Blood 2010
DCBT: Lower risk of relapse compensated for higher TRM = comparable LFS to sib & URD.
(Similar results: Ponce et al, BBMT 2011; Dana Farber).
MSKCC DCBT for Acute Leukemia in Adults & Children
• 10/2005 - 5/2012. • High risk acute leukemia in morphologic CR1-4 or aplasia or MDS/ MPD < 5% blasts. • High dose or RIC (both ablative). • Follow-up: median 3.2 years.
Barker et al, ASBMT 2013
High*: Cy 120 Flu 75 TBI 1375
“Midi” is new prep alternative
Mini: Cy 50 Flu 150 TBI 200
Midi**: Cy 50 Thio 10 Flu 150 TBI 400
MSKCC Conditioning for Acute Leukemia/ MDS
* If no TBI: Clo/ Mel/ Thio ** Ponce et al, BBMT 2013
2-Yr DFS in 92 DCBT if Acute Leuk, MDS/MPD
Adults (n = 65, median 47 yrs, 2.7 + 2.0): 65% (95%CI: 55-78)
0.0
0.2
0.4
0.6
0.8
1.0
Months Post-Transplant
Dis
ease
-Fre
e Su
rviv
al
0 6 12 18 24
Children (n = 27, median 7 yrs, 4.4 + 2.9): 73% (95%CI: 56-93)
High rates of 2-year DFS after DCBT- esp. given median 2.1 TNC dose of winner in adults.
Median TNC winner: Peds 4.3, Adults 2.1
Barker et al, ASBMT 2013
Early analyses: • No relationship: TNC or CD34+ dose. Association with higher CD3+ dose. • No relationship: HLA-match to patient.
Why Does One Unit Win?*
Barker et al, Blood 2005
% of Viable CD34+ Cells
Winner (n = 44)
Loser (n = 44)
< 75% (n = 16) 1 15
≥ 75% (n = 72) 43 29
Engraftment in 44 Double Unit CBT Recipients By Post-Thaw CD34+ Cell Viability (n = 88 Units)
Using threshold of 75% viable CD34+s (mean-2SD), all but one (43/44) engrafting units had
CD34+ viability > 75% (p = 0.0006). ie Only 1/16 poor viability units engrafted.
Poor CD34+ viability correlated with lower CFUs (p = 0.02).
Scaradavou, BBMT 2010
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
NYBC (n=149)
Other US (n=123)
International (n=94)
% Viable CD34+s Post-Thaw by Bank (n = 366 units) Median
94% (68-99)
Median 89%
(34-98)
Median 92%
(34-98)
% V
iabi
lity
CD
34+s
(7-
AA
D)
Variability in viability by unit & bank: potential problem for single unit transplants. Emphasizes importance of post-thaw
potency as critical unit release criteria.
DCB with CD34pos
#1 #2
DCB with MNC
MNC #1
MNC #2
CD34pos Selection
Sacrifice mice weeks 4-8 Correlate murine & patient engraftment.
Double Unit CBT in NSG Mice Using Samples from Patient Grafts
Eldjerou et al, Blood, 2010
DCB with CD34pos
#1 #2
DCB with MNC
MNC #1
MNC #2
CD34pos Selection
Unit dominance. Clinical correlation.
Double Unit CBT in NSG Mice Using Samples from Patient Grafts
Eldjerou et al, Blood, 2010
No unit dominance. No clinical correlation.
DCB with CD34pos
CD34neg #2
+Add-back CD34neg #2
#1 #2MNC #1
MNC #2
CD34neg #1
+Add-back CD34neg #1
CD34pos Selection
Added CD34 negs - clinically engrafting unit: 100% murine engraftment with that unit.
Added CD34 negs - clinically NON-engrafting unit: 100% murine engraftment with that unit.
Double Unit CBT in NSG Mice Using Samples from Patient Grafts
Eldjerou et al, Blood, 2010
Double Unit CBT: NSG Murine Model
Eldjerou et al 2010, Blood
• Murine-patient correlation suggests host factors not relevant. • Unit dominance mediated by CD34- fraction.
If either unit has engraftment potential (majority but not all),
unit dominance is immune mediated.
In 9/10 DCBT Recipients: Development of IFN-γ–Secreting CD8+ T-cells Recognizing Allo-antigens
Expressed by Non-engrafting Unit
Gutman et al, Blood 2010
Unit dominance is mediated by effector
CD8+ T-cells
developed from naïve precursors in winner
In 9/10 DCBT Recipients: Development of IFN-γ–Secreting CD8+ T-cells Recognizing Allo-antigens
Expressed by Non-engrafting Unit
Gutman et al, Blood 2010
Unit dominance correlated
with higher naïve CD8+
T-cell dose:
Milano et al, BBMT 2012
Day post-CBT
N (%) with loser detected
Unit-unit match: 1-6/10
Unit-unit match: 7-10/10
P
+21 (n = 83) 2/ 56 (4%) 14/ 27 (52%) < 0.0001
+28 (n = 79) 0/ 54 (0%) 14/ 25 (56%) < 0.0001
+60 (n = 72) 0/ 47 (0%) 8/ 25 (32%) < 0.0001
+100 (n = 68) 0/ 45 (0%) 3/ 23 (13%) 0.04
+365 (n = 43) 0/ 30 (0%) 1/ 13 (8%) 0.30
Serial Detection of Losing Unit After DCBT by Unit-Unit HLA-match (n = 83)
Higher level of unit-unit HLA-match associated with co-engraftment of both units.
Avery et al, Blood 2011
Why does one unit win?*: Hematopoietic potential of each unit.
Unit vs unit immune interactions (T-cell mediated).
As important:
What attributes of graft determine engraftment success,
GVHD & survival after DCBT?
Infused Doses of Winner & Neutrophil Engraftment
Avery S et al, Blood 2011 Infused viable CD34+ cell dose of winner determines engraftment
Inf. Total Doses (Both Units Combined) & Engraftment
Total TNC & CD3+ cell dose also have dose dependent effects.
Avery S et al, Blood 2011
Neutrophil Engraftment after 92 DCBT by Infused Viable CD34+ Cell Dose x 105/kg of Winner*
0.0
0.2
0.4
0.6
0.8
1.0
Days Post-Transplant
Cum
ulat
ive
Inci
denc
e
0 10 20 30 40
< 0.50 (n = 23)
0.51-1.00 (n = 27)
1.01-1.50 (n = 19)
> 1.51 (n = 23)
100% engraftment
success if winning unit had viable CD34+ cell dose > 1.0.
* Unit predominating in assessment of hematopoiesis in 1st month post DCBT
P < 0.001 Barker et al, ASBMT 2013
Day 180 Platelet Engraftment to 20,000 (n = 92)
0.0
0.2
0.4
0.6
0.8
1.0
Days Post-Transplant
Cum
ulat
ive
Inci
denc
e
0 45 90 135 180
Children: 85% (95%CI: 63-95) Median 50 days (range 29-118)
Adults: 83% (95%CI: 71-90) Median 48 days (range 29-162)
High rates of platelet engraftment by CBT standards.
93% if winning unit infused CD34+ cell dose > 1.0 x 105/kg
(vs 78% if lower, p = 0.01)
Barker et al, ASBMT 2013
20
40
60
80
100
0
4-6/6 Allele 1-3/6 Allele
Months Post-Transplant 0
100
80
60
40
20
0
1-7/10 Allele
8-9/10 Allele
1 2 3 4 5 6 0 1 2 3 4 5 6
Ponce, D., BBMT 2013
Gr. III-IV Acute GVHD after DCBT by Winning Unit HLA-Allele Match to Patient (n = 115)
HLA-allele match of winning unit to patient is important.
Comparison 2-Yr DFS P Value Age 0-15 years (n = 27)
> 16 years (n = 65) 73% 65%
0.32
Ancestry Europeans (n = 40) Non-Europeans (n = 52)
69% 66%
0.86
Remission Status
CR1 (n = 49) All others (n = 43)
66% 69%
0.98
Conditioning Intensity
High-dose (n = 54) RIC (n = 38)
70% 64%
0.60
Recipient CMV Sero-status
CMV+ (n = 51) CMV- (n = 41)
54% 85%
0.01
2-Yr DFS after DCBT for Acute Leukemia By Recipient Characteristics (n = 92)
• Comparable DFS in Europeans & non-Europeans. • RIC (“midi”) promising alternative to high dose prep. • Recipient CMV+ remains challenging.
Barker et al, ASBMT 2013
Comparison 2-Yr DFS P Value HLA-match
Dominant Unit 2-5/10 (n = 34) 6-7/10 (n = 39) 8-9/10 (n = 19)
69% 65% 68%
0.84
Inf. CD34+ Dose Dominant Unit
< 1.0 (n = 50) > 1.0 (n = 52)
64% 72%
0.13
Inf. TNC Dominant Unit
< 2.0 (n = 34) 2.0-2.85 (n = 27) > 2.85 (n = 31)
62% 74% 68%
0.29
• Mismatch had no impact on DFS. • Suggestion of improved DFS if winner had higher CD34+
dose.
2-Yr DFS after DCBT for Acute Leukemia By Winning Unit Characteristics (n = 92)
Barker et al, ASBMT 2013
Due to unit vs unit
interactions? Verneris et al, Blood 2009
Double CBT: Reduced Relapse? Myeloablative DCBT for Acute Leukemia, U of MN
Supported by multiple other analyses: Brunstein, Blood 2007; Rodrigues, JCO 2009; Brunstein, Blood 2010;
Kindwall-Keller BMT 2012; Rocha, ASH abs 2012.
2-year DFS after RIC CBT in Adult Acute Leukemia - CR1
P = 0.03
In multivariate analysis,
double CBT associated
with improved DFS (p = 0.04).
Advantage attributed to reduced relapse risk.
Double CBT (n = 136): 51 ± 5%
Single CBT (n = 76): 32 ± 3%
Slide courtesy of V. Rocha, 2013
Overall Survival after Doubles (n = 303) & Adequately Dosed Singles (n = 106, TNC > 2.5)
Scaradavou A et al. Blood 2013
• Myeloablative & RIC. • Median inf. TNC: singles 2.8, doubles 3.7.
DCBT extends access to those without an adequate single.
100
0
20
40
60
80
0
100
20
40
60
80
Prob
abili
ty, %
Months 0 3 6 9 12
Double CBT: 64% (54 – 72)
Single CBT: 68% (58 – 76)
BMT CTN 0501 Pediatric Ablative Randomized Trial: 1-Yr Disease-free Survival
P = 0.22
Slide Courtesy of Dr J. Wagner, ASH 2012
No DFS advantage after myeloablative DCBT in children
Median cryo. TNC: singles 4.8, doubles 8.9.
-7 0 +100
U of MN Changes to Prep & IS for DCBT
Cy 120/ Flu 75/ TBI 1320
CSA/ MP
CB #2
CB #1
-8 0 +100
Cy 120/ ATG/ TBI 1320
CB #2
CB #1
CSA/ MMF Prep & IS changes contributed to DCBT benefit
Barker et al, Blood 2005
Unit Type N Units Transplanted (N = 26)
Median (Range) Cost Per Unit
NMDP-International 4 (15%) $41,338 (38,233 – 46,418) NMDP-Domestic (excl. NYBC)
14 (54%) $38,570 (33,150 - 40,230)
NYBC-Direct 7 (27%) $42,500 NCBI NYBC via NMDP 1 (4%)* $48,725
Charges to MSKCC for CB Units Jan-April 2013
Approximate cost of double unit graft with 6 units typed: $90,000.
* NCBI unit = must be purchased via NMDP.
• 13 DCBT (n = 26 units). • Median 6 units typed per patient (range 4-13).
DFS After DCBT in Engrafting Adults by Speed of Neutrophil Recovery: Day 45 Landmark (n = 61)
P = 0.02
0.0
0.2
0.4
0.6
0.8
1.0
Time Post-Transplant
DFS
45 days 6mo 12mo 18mo 24mo
Neut. recovery < 25 days (n = 32): 84% (95%CI: 72-98)
Neut. recovery > 25 days (n = 29): 54% (95%CI: 39-76)
Marked survival advantage if rapid engraftment: need to speed engraftment for all.
-8 0 +1 +28 +100
Compare engraftment (speed, success, chimerism) to DCB controls
Hi dose or midi myeloablative
MSK Approach to Speed Neutrophil Recovery: DCBT + Haplo
Graft > 100k-but earlier neutrophil recovery = less resources + earlier discharge compensates.
34+ selected PBSC
(Miltenyi)
Haplo-identical family member
Double Unit CBT: Conclusions • Extends access.
• Insurance policy against poor viability unit.
• Facilitates engraftment in low dose setting: oImplies loser has biologic activity. oWinner determines engraftment & GVHD. oAs compared with singles, need to analyze doubles based on characteristics of winner: is loser doing anything?
(or if better unit had been given alone??). • High rates of DFS in acute leukemics. • Preliminary data: Europeans & non-Europeans comparable DFS. • Multiple series: DCBTs comparable DFS with URDs.
• Problems: o2 un-manipulated units not enough. oEscalating cost is a major problem.