Haploidentical Hematopoietic Stem Cell Transplantation for Hematological Malignancies

Xiao-Jun Huang M.D. Ph.D.Peking University Institute of Hematology,

Peking University People’s Hospital &Beijing Key Laboratory of HSCT,

Beijing, P.R.China

1

EducationClinic

Research

The Cumulative Hematopoietic Stem Cell Transplantation (HSCT) Cases of PUIH

PUIHThe Largest HSCT center in AsiaNow >400 cases of HSCT per yearNow >60% Allo-HSCT cases are Unmanipulated Haploidentical HSCT

24%24%

• Current Clinical Results

• Strategy to Improve the Clinical Results

Haploidentical Hematopoietic Stem Cell Transplantation for Hematological Malignancies

11

• In vitro T-cell-depleted HSCT

22• Non-Myeloablative Haploidentical HSCT

33• Unmanipulated Myeloablative

Haploidentical HSCT

GIAC protocol

• G: donor treatment with rhG-CSF

• I: intensified immunological suppression

• A: anti-human thymocyte immunoglobulin (ATG)

for the prevention of GVHD

• C: combination of G-PB and G-BM

Huang XJ, et al. Blood, 2006, 107(8):3065-3073Huang XJ, et al. Annals of Medicine, 2008, 40,444-455Huang XJ, et al. Clin Cancer Res. 2009;15:4777-4783Huang XJ, et al. BBMT. 2011 Jun;17(6):821-30.

3. Unmanipulated Haploidentical HSCT

Effects of G-CSF on Bone Marrow in Healthy Donors

HuangXJ, et al. Clin Transplant 2011: 25: 13–23

3. Unmanipulated Haploidentical HSCT

Immunoregulatroy Effects after G-CSF Administration to Healthy Donors

Huang XJ, et al. Biol Blood Marrow Transplant.2011;17(2):197-204

3. Unmanipulated Haploidentical HSCT

400.00300.00200.00100.000.00

Days posttransplant

1.0

0.8

0.6

0.4

0.2

0.0Pro

babi

lity

of e

ngra

ftm

ent (%

)

-censored小于中位值

-censored大于等于中位值

小于中位值

大于等于中位值CD34 ? ?二分 量

400.00300.00200.00100.000.00

Days posttransplant

1.0

0.8

0.6

0.4

0.2

0.0Pro

babi

lity

of e

ngra

ftm

ent (%

)

-censored小于中位值

-censored大于等于中位值

小于中位值

大于等于中位值CD34 ? ?二分 量

Engraftment

Huang XJ, et al. Biol Blood Marrow Transplant,2009, 15(5):632-8

n=348

400.00300.00200.00100.000.00

Day posttransplant

1.0

0.8

0.6

0.4

0.2

0.0Pro

babi

lity

of e

ngra

ftm

ent (%

)

? -censored展期

-censored早期

? 展期

早期? ? ?移植 的疾病

400.00300.00200.00100.000.00

Day posttransplant

1.0

0.8

0.6

0.4

0.2

0.0Pro

babi

lity

of e

ngra

ftm

ent (%

)

? -censored展期

-censored早期

? 展期

早期? ? ?移植 的疾病

P=0.008

n=348

CD34+ cells≥2.19×106/kg

CD34+ cells<2.19×106/kg

P<0.0001

Early stageAdvanced stage

3. Unmanipulated Haploidentical HSCT

Characteristics of the Allo-Grafts

Summary Statistics

TNC108/kg

CD34+×106/kg

CD3+×108/kg

CD4+×107/kg

CD8+×107/kg

CFU-GM×105/kg

BMRange 1.2 ～ 8.3 0.2 ～ 8.8 0.1 ～ 1.1 0.4 ～ 7.3 0.3 ～ 3.7 1.3~9.4

Median 3.53 1.39 0.20 1.10 1.08 2.62

PBRange 1.9 ～ 9.2 0.6 ～ 6.6 0.6 ～ 6.6 1.9 ～ 39.0 2.9 ～ 29.7 1.4~10.5

Median 4.02 1.58 1.46 8.76 7.01 3.03

TRange 5.2~14.2 0.8 ~ 13.4 0.8 ~ 6.7 3.3~39.6 3.7~29.6 2.2 ~ 19.9

Median 7.56 2.65 1.77 10.39 7.87 5.21

Huang XJ, et al. Bone Marrow Transplant, 2006, 38:291

3. Unmanipulated Haploidentical HSCT

Huang XJ, et al. Biol Blood Marrow Transplant 2009, 15(2)Huang XJ, et al. Biol Blood Marrow Transplant 2011; 17(6)

Cumulative incidence of aGVHDafter HLA-mismatched allo-HSCT

Haplo=81

Identical=36

P=0.11

3. Unmanipulated Haploidentical HSCT

Probability of aGVHD with locus disparity

Huang XJ, et al. Bone Marrow Transplant. 2006;38(4):291-7.

3. Unmanipulated Haploidentical HSCT

DFS & OS compared with HLA Matched Donor

Huang XJ, et al. Blood, 2006, 107(8):3065-3073

3. Unmanipulated Haploidentical HSCT

Relapse compared with Unrelated Donor （ URD）

Huang XJ, et al. Clin Cancer Res, 2009, 15:4777-4783

PMRD=219

URD=78

PMRD=160

URD=60

3. Unmanipulated Haploidentical HSCT

Relapse compared with Identical Sibling （ ISD）

HuangXJ, et al. Biol Blood Marrow Transplant. 2011;17(6)

Haplo=81

Identical=36

3. Unmanipulated Haploidentical HSCT

OS & DFS compared with ISD

PMRD=81

ISD=36P = 0.048 P = 0.029

HuangXJ, et al. Biol Blood Marrow Transplant. 2011;17(6)

Haplo=81

Identical=36

3. Unmanipulated Haploidentical HSCT

Superior Graft-versus-Leukemia effect

HaploidenticalHLA-identical

sibling

High risk acute leukemia

HuangXJ, et al. Biol Blood Marrow Transplant. 2011 ;17(6):821-30

3. Unmanipulated Haploidentical HSCT

No. of Haploidentical HSCT accumulated in PUIH

PUIH data

3. Unmanipulated Haploidentical HSCT

The changing of Composition of Haploidentical allo-HSCT in PUIH from 2007 to 2009

PUIH data

3. Unmanipulated Haploidentical HSCT

Studies on HLA-mismatched/haploidentical stem cell transplantation (GIAC)

Patients (n) Disease Conditioning

GVHDprophylaxis

aGHVD cGVHD TRM Relapse LFS Reference

35 AML/ALL/

CML/DLBCL/ ATL

Standard intensity±TBI

Tacrolimus based 56% 19% 11 pt 9 pt 40% Ichinohe et

al. (2004)

171 ALL/AML/CML/MDS

Bu/Cy/Ara-C/MeCCNU+

CsA/MTX/MMF 55% 21.3% 19% SR @

2yrs SR 12% SR 68% @ 2yrs

Huang et al. (2006)

135 ALL/AML/CML/MDS

Bu/Cy/Ara-C/MeCCNU+ATG

CsA/MTX/MMF

(II-IV) 40% 55% 22% 18% 64% @

yrs Lu et al. (2006)

68 AML/ALL/CML/MDS/ TBI/Cy/Flu Cy/MMF/ (II-IV) 5% * 4% @ 100

days 51% @ 1 yr 34% @ 1yr

Luznik et al. (2008)

29 AML/ALL/CML/NHL/

Flu/Mel/OKT3/thiotepa

CD3/CD19 depletion

(II-IV) 48% 3 pt 20% @ 100

days 12 pt 35% @ 1yr

Bethge et al. (2008)

42 AML/ALL/CML Bu/Cy/Ara-C/

MeCCNU+ATG

CsA/MTX/MMF 57.2% 27.2% 20.4±6.5% @

1yr 21.43% 57.3±8% @ 3yrs

Liu et al. (2008)

93 CML Bu/Cy/Ara-C/MeCCNU+

CsA/MTX/MMF 64.25% 27.16% 28.3% @ 1yr CP1 3.77% 76.5% @

1yr Huang et al.

(2008)

45 AML/ALL/CML/NHL TBI/Cy/Ara-C/ATG CsA/MTX/

MMF/ (II-IV) 9 pt 3 pt 11 pt 24 pt Wang et al. (2009)

46 AML/CML/ALL TBI/Cy/Ara-C/ATG CsA/MTX/MMF (I-II) 10.9% 8.7% @ 2yrs 23.9% @

2yr 70.6% @

2yrs Chen et al.

(2009)

250 AML/ALL Bu/Cy/Ara-C/

MeCCNU+ ATG CsA/MTX/MMF 45.8% 31.3% AML 11.9%

@ 3yrs AML 19.4%

@ 3yrs AML70.7

%3yrs Huang et al.

(2009)

Composition of HSCT Donor Types in 24 Transplant Units in China

PUIH collected

Mis % 29.9% 30.0% 33.6% 30.8% 30.3% 26.5% 29.7% 29.3%

3. Unmanipulated Haploidentical HSCT

Huang XJ, et al. BMT, 2006, 38:291

Huang XJ, et al. Blood, 2006, 107(8):3065-3073

Huang XJ, et al. Clin Cancer Res, 2009, 15: 4777-4783

Huang XJ, et al. BBMT. 2011 Feb;17(2):197-204

Part I Conclusions

• G-BM combined with PBSC from haploidentical family donors, without in vitro TCD, may be used as a good source of stem cells for allo-HSCT

• There is no difference in OS and LFS between patients receiving allografts from PMRD and URD

3. Unmanipulated Haploidentical HSCT

3.Unmanipulated Haploidentical HSCT

Huang XJ, et al Unpublished ， Blood Reversed

Part II ： Strategy to Improve the Clinical Results

1• Modified Donor Lymphocyte Infusion(DLI)

2• Manipulating the Graft

3• Optimize KIR ligand match/mismatch

4• Improve Immune Reconstitution

3. Unmanipulated Haploidentical HSCT

Relapse Remains a Problem after HSCT

High risk leukemiaHigh risk leukemia

Huang XJ et al, Biol Blood Marrow Transplant. 2009 Feb;15(2)

Especiallyfor advancedleukemia(58%- 74%)

3. Unmanipulated Haploidentical HSCT

Strategy-1 Our modified DLI

G-CSF primed peripheral blood progenitor cells instead of steady

donor lymphocyte harvests

Short-term CsA/MTX for prevention of

DLI-associated GVHD

GPBSCIGPBSCI

Huang XJ et al, LEUKEMIA, 2006 ； 20 ， 365-368Huang XJ et al, Bone Marrow Transplant. 2009;44(5):309-16

3. Unmanipulated Haploidentical HSCT

GVHD prophylaxis Reduced GVHD occurrence

Huang XJ, et al. Hematologica, 2007,92:414-417

None

MTX

3. Unmanipulated Haploidentical HSCT

Prevention of relapse using modified DLI can

significantly increase survival following HLA-

mismatched/Haplo-identical HSCT in patients

with advanced-stage, acute leukemia

3. Unmanipulated Haploidentical HSCT

Huang XJ ,et al. Bone Marrow Transplant. 2011 Sep accepted

Huang XJ ,et al. Bone Marrow Transplant. 2011 Sep accepted

Diagnosis N=75 Jan,2003 - Sep,2010

AMLN=42

>CR2 7

NR+REL 35

ALLN=33

>CR2 8

NR+REL 25

Patients Characteristic

3. Unmanipulated Haploidentical HSCT

Prophylactic GPBPCI

• Performed at 70 (20 ~ 314) d after HSCT

• MNC 1.0 (0.5-2.0) 108/kg • CD3+ 0.93 (0.2-2.12) 108/kg

• No patients had profound and lasting pancytopenia after the prophylactic infusion

3. Unmanipulated Haploidentical HSCT

Cumulative incidence of grade to acute Ⅲ ⅣGVHD

GVHD prophylaxis < 2w: 49.5%

GVHD prophylaxis 2 ～4w: 31.6%

GVHD prophylaxis 4 ～6w: 14.4%

GVHD prophylaxis >6w: 9.3%

The risk factor of DLI-associated acute GVHD

Huang XJ ,et al. Bone Marrow Transplant. 2011 Sep accepted

3. Unmanipulated Haploidentical HSCT

Cumulative incidence of aGVHD

Huang XJ ,et al. Bone Marrow Transplant. 2011 Sep accepted

P=0.55P=0.55

3. Unmanipulated Haploidentical HSCT

Cumulative incidence of cGVHD

Huang XJ ,et al. Bone Marrow Transplant. 2011 Sep accepted

P=0.42P=0.42

3. Unmanipulated Haploidentical HSCT

Cumulative incidence of TRM

Huang XJ ,et al. Bone Marrow Transplant. 2011 Sep accepted

P=0.95P=0.95

3. Unmanipulated Haploidentical HSCT

Cumulative incidence of relapse

Huang XJ ,et al. Bone Marrow Transplant. 2011 Sep accepted

P=0.018P=0.018

3. Unmanipulated Haploidentical HSCT

Probability of OS

Huang XJ ,et al. Bone Marrow Transplant. 2011 Sep accepted

(P=0.013)(P=0.013)

3. Unmanipulated Haploidentical HSCT

Lower relapse rate, a similar NRM, and a higher

survival probability compared with non-DLI

Can significantly increase the survival of

patients with advanced-stage, acute leukemia

even after HLA-mismatched, T-cell-replete HSCT

Modified prophylactic DLI after HLA-mismatched/Haplo-identical HSCT

Huang XJ ,et al. Bone Marrow Transplant. 2011 Sep accepted

3. Unmanipulated Haploidentical HSCT

Risk stratification-directed DLI could reduce relapse of standard-risk acute

leukemia after allo-HSCT

Institute of Hematology Peking UniversityBeijing, China

ASH 2111 Oral Presentation

Efficacy of intervention

Groups 3yr-Relapse TRM OS LFSA 18.1% 19.7% 66.0% 61.6% B 68.0% 11.2% 23.9% 20.8% C 29.8% 15.6% 55.4% 52.5%

ASH 2111 Oral Presentation

Strategy-1 Conclusion

m-DLI can be used for the

treatment and prophylaxis of relapse

after haplo-identical HSCT

3. Unmanipulated Haploidentical HSCT

Dose of Th17 and GVHD

0 50 100 1500

20

40

60

80

Low Th17 groupHigh Th17 group

days after transplantation

Cu

mu

lati

ve in

cid

en

ce Dose of Th17 and GVHD

0 50 100 1500

20

40

60

80

Low Th17 groupHigh Th17 group

days after transplantation

Cu

mu

lati

ve in

cid

en

ce

Tc17 dose and GVHD

0 50 100 1500

20

40

60

80Low Tc17 groupHigh Tc17 group

days after transplantation

Cu

mu

lati

ve in

cid

en

ce Tc17 dose and GVHD

0 50 100 1500

20

40

60

80Low Tc17 groupHigh Tc17 group

days after transplantation

Cu

mu

lati

ve in

cid

en

ce

0 50 100 1500

20

40

60

80

100

Low dose

other dose

High dose

days after transplantation

Cum

ulat

ive

inci

denc

e0 50 100 150

0

20

40

60

80

100

Low dose

other dose

High dose

days after transplantation

Cum

ulat

ive

inci

denc

ep=0.005

p=0.00017

p=0.001

（ n=12）

（ n=17）

（ n=12）

HuangXJ ， et al,

Eur J Immunol. 2011 Feb;41(2):514-26

Predictive value of Th17 cells and Tc17 cells in allo-graft on acute GVHD

Treating donor mice with rhIL-11 and rhG-CSF promotes transplant-tolerance and preserves the effects of GVL after allogeneic bone

marrow transplantation

HuangXJ, et al. Leuk Res. 2009 Jan;33(1):123-8

Effects of different cytokines treatment on the recipients’ T cells proliferation activity in response to host alloantigens +14 d after BMT.

Effects of different cytokines treatment on the recipients’ T cells proliferation activity in response to host alloantigens +14 d after BMT.

Strategy-2 Conclusion

We may decrease the incidence of GVHD by manipulating the cell contents or function of graft? Mobilization with IL-11 plus G-CSF ?

3. Unmanipulated Haploidentical HSCT

Strategy-3 KIR ligand match/mismatch to outcome on pretransplantation category

aGVHD TRM Relapse

OS

KIR mismatchKIR mismatch

KIR matchKIR match

Huang XJ, et al. Biol Bone Marrow Transplant, 2008,14(3)

Strategy-3 Conclusion

• KIR ligand mismatch is associated with higher aGVHD, a greater relapse rate, and inferior survival in our haploidentical GIAC protocol---Donor Slection ?

3. Unmanipulated Haploidentical HSCT

70.0060.0050.0040.0030.0020.0010.000.00

Months posttransplant

1.0

0.8

0.6

0.4

0.2

0.0Prop

ortio

ns o

f pat

ient

s (%

)

300/ul-小于censored

300/ul-大于等于censored

300/ul小于

300/ul大于等于

Cutoff ?按照 值 划分

70.0060.0050.0040.0030.0020.0010.000.00

Months posttransplant

1.0

0.8

0.6

0.4

0.2

0.0Prop

ortio

ns o

f pat

ient

s (%

)

300/ul-小于censored

300/ul-大于等于censored

300/ul小于

300/ul大于等于

Cutoff ?按照 值 划分

ALC-30 ＞300/ul

ALC-30 ＞300/ul

ALC-30≤300/ul

ALC-30≤300/ul

P<0.001P<0.001 n=206n=206

Strategy-4 Immune Reconstitution

Huang XJ, et al. Bone Marrow Transplant, 2009,43: 29-36

TRM

3. Unmanipulated Haploidentical HSCT

70.0060.0050.0040.0030.0020.0010.000.00

Months posttransplant

1.0

0.8

0.6

0.4

0.2

0.0

Leuk

emia

-fre

e su

rvival

300/ul-censored小于

300/ul-大于等于censored

300/ul小于

300/ul大于等于Cutoff ?按照 值 划分

70.0060.0050.0040.0030.0020.0010.000.00

Months posttransplant

1.0

0.8

0.6

0.4

0.2

0.0

Leuk

emia

-fre

e su

rvival

300/ul-censored小于

300/ul-大于等于censored

300/ul小于

300/ul大于等于Cutoff ?按照 值 划分

ALC-30>300/ulALC-30>300/ul

ALC-30≤300/ulALC-30≤300/ul

0

200

400

600

800

1000

1200

1400

1600

1800

2000

30 60 90 120 180 270 360

CD3+

cel

ls/u

l

Days f rom transpl antati on

HLA matchHLA mi smatchNormal

**

The counts of reconstituted CD3+ cells (cells/μl ) were significantly lower in HLA-mismatched patients at days 30 than those in HLA-matched patients, which reached normal level at days 60 in both HLA-matched and -mismatched patients. ** P ＜ 0.001

The counts of reconstituted CD3+ cells (cells/μl ) were significantly lower in HLA-mismatched patients at days 30 than those in HLA-matched patients, which reached normal level at days 60 in both HLA-matched and -mismatched patients. ** P ＜ 0.001

HuangXJ, J Cli Imm Online Publication

Comparison of Reconstituted T cells subgroup between HLA match and mismatch

0

100

200

300

400

500

600

700

800

30 60 90 120 180 270 360Days af ter transpl antati on

CD4+

cel

ls/u

lHLA matchHLA mi smatchNormal

** * ***

The counts of reconstituted CD4+ cells (cells/μl ) were significantly lower in HLA-mismatched patients at days 30, 60, 90, and 120 than those in HLA-matched patients, which did not reached normal level until 360 in both HLA-matched and mismatched patients, respectively. * P ＜ 0.05, ** P ＜ 0.001

The counts of reconstituted CD4+ cells (cells/μl ) were significantly lower in HLA-mismatched patients at days 30, 60, 90, and 120 than those in HLA-matched patients, which did not reached normal level until 360 in both HLA-matched and mismatched patients, respectively. * P ＜ 0.05, ** P ＜ 0.001

HuangXJ, J Cli Imm Online Publication

Comparison of Reconstituted T cells subgroup between HLA match and mismatch

Strategy-4 Conclusion

Novel approach to improve the recovery of immune reconstitution are greatly required. IL-2 after HSCT ?

A Randomized Clinical Trial Is Undergoing For Evaluing IL-2 After Haplo-identical HSCT In PUIH

3. Unmanipulated Haploidentical HSCT

Acknowledgements

Stem cell collection centerHai-Yin ZhengHong XuQing ZhaoSu Wang

Department of Bone Marrow Transplant Dai-Hong LiuFeng-Rong WangHuan ChenJing-Zhi WangKai-Yan LiuLan-Ping XuWei HanXiao-Hui ZhangYu-Hong ChenYu Wang

Laboratory of PUIHDan LiYa-Zhen QinYan-Rong LiuYue-Yun Lai