Allogeneic Hematopoietic Stem Cell Transplant
in Severe Thalassemia Patients:
Time to Transplant
Suradej Hongeng, MD
Professor of Pediatrics
Faculty of Medicine Ramathibodi Hospital,
Mahidol University, Bangkok, Thailand
Outline
Definition of severe thalassemia
Outcome of HSCT thalassemia worldwide
Result of unrelated and haploidentical HSCT in
thalassemia
Result of HSCT in older thalassemia (class 3)
Result of cord blood transplant in thalassemia
How to define the risk group of thalassemia for HSCT
How to improve the outcome HSCT in thalassemia
Splenectomy prior to HSCT ??????
Severe Thalassemia
Onset of disease at one to three years of age
Frequent blood transfusion (monthly)
Hepatosplenomegaly
Hemoglobin level less than 8 gm/dL
(pre-transfusion level)
Thalassemic facies
Thalassemia
α thalassemia disease
Hb bart ( _ _ / _ _ )
Hb H disease ( _ _ /_ α )
β thalassemia disease
Homozygous β thalassemia
Hb E /β thalassemia
Pathophysiology of -Thalassemia/Hb E Disease
 thalassaemia intermedia (Hb E/ thalassaemia)
Courtesy of Dr. Vip Viprakasit, Siriraj Hospital, BKK
Clinical heterogeneity in Hb E/ thalassaemia
Baseline Hb level in Pediatric Patient with HbE/β Thalassemia
0-4 4.1-5 5.1-6 6.1-7 7.1-8 8.1-9 9.1-10 >10
Hb (d/dL)
V. Viprakasit, unpublished data 2007
Fucharoen S, Winichagoon P. Curr Opin Hematol. 2000;7:106-112
Treatments in
Severe Thalassemia
Palliative treatment
Blood transfusion
Iron chelation
Splenectomy
Curative treatment
Hematopoietic stem cell transplant (HSCT)
Gene therapy
HSCT in Thalassemia
 thalassemia
Homozygous β thalassemia
HbE/β thalassemia (only severe cases)
(Hb level range from 2 gm/dL to 9 gm/dL)
 thalassemia ??
HbH and AE Bart’s; some  mutations
Bart’s Hydrops; high level of Portland
hypertransfusion then followed by HSCT
Key Issues for HSCT in Thal
•
•
•
•
Conditioining regimen: Bu + Cy
Donor
Source of HSC
Risk group
Results of MRD in HSCT for Thal Patients
Reference
Patients
OS
TFS
Di Bartolomeo et al.
111
90
86
Argiolu et al.
37
88
88
Clift et al.
68
94
81
Lawson et al.
54
95
82
Ghavamzadehv et al.
60
83
73
Denninson et al.
50
76
68
Lin et al.
28
86
82
Lee et al.
44
86
82
Issaragrisil et al.
21
70
53
BMT in Thalassemia
Risk factors for BMT in thalassemia
Chelation
Hepatomegaly
Liver fibrosis
Regular vs Irregular
Absent vs Present
Absent vs Present
Risk classes for BMT in thalassemia
Class1
Class2
Class3
Chelation
Hepatomegaly
Fibrosis
Regular
Reg/Irreg
Irregular
NO
NO/YES
YES
NO
NO/YES
YES
Lucarelli G et al. N Engl J Med 1990
Dilemma in HSCT in Thalassemia
Searching for a suitable donor
Class 3 (older patients)
Dilemma 1
Searching a suitable donor
Unrelated donor
Haploidentical donor
Unrelated Donor BMT in Thalassemia
• 68 patients
• Median age of 15 yrs (2-37 yrs)
• Conditioning regimens:
• BUCY
17 (25%)
• BUTTCY
42 (62%)
• BUTTFLU
9 (13%)
• GVHD prophylaxis:
• CsA+MTX
52 (75%)
• CsA+MTX+ATG
17 (25%)
• aGVHD gr II-IV 24/59 (40%)
• cGVHD 10/56 (18%)
La Nasa et al. Ann NY Acad Sci 2005
Unrelated Donor BMT in Thalassemia
Class 1 and 2
30 patients, median age 8 years
aGVHD gr II-IV 29%
cGVHD 11%
Class 3
38 patients, median age 19 years
aGVHD gr II-IV 56%
cGVHD 27%
La Nasa et al. Ann NY Acad Sci 2005
Treosulfan, Thiotepa, Fludarabine, ATG (unrelated)
Blood; 2012
HSCT in Thalassemia at Ramathibodi
Related n=28, Unrelated n=21 Total 49 patients
92%
82%
82%
71%
Overall survival (OS) and thalassemia free survival (TFS) in Thai children
Hongeng S et al. Biol Blood Marrow Transplant 2006
HSCT in Thalassemia at Ramathibodi
1989-2011
Thalassemia ( n = 102 pts)
Homozygous β thalassemia 26 pts
HbE / β thalassemia
74 pts
Alpha thalassemia
2 pts
Conditioning Regimens
and GVHD Prophylaxis
Related group and age < 10 yrs
Cyclo 200 mg/kg, Bu 14-16 mg/kg PO/IV
CSA + MTX (CB; pred)
Unrelated group and < 10 yrs
Cyclo 200 mg/kg, Bu 14-16 mg/kg PO/IV, Fludara 210 mg/m2
and ATG (Fresenius) 40 mg/kg
FK506 + MTX (CB; Pred)
Related and Unrelated age > 10 yrs
RIC regimen; Busulfan, Fludara and ATG (Thymoglobulin)
CSA or FK 506 + MMF
TFS 102 Thal Patients at Ramathibodi
0.75
1.00
(Update 2012) Related = 67, Unrelated = 35
0.25
0.50
89% (95%CI:70-93)
0.00
analysis time
0
50
100
(month)
150
200
OS 102 Thal Patients at Ramathibodi
(Update 2012) Related 67, Unrelated 35
0.75
1.00
Kaplan-Meier survival estimate
0.00
0.25
0.50
92 % (95%CI:77-94)
0
50
100
analysis time
(month)
150
200
TFS (Related and Unrelated) Update 2012
at Ramathibodi (n = 102)
94% (95%CI:72-96) n = 67
81% (95%CI:49-84) n = 35
OS (Related and Unrelated) Update 2012
at Ramathibodi (n=102)
97%(95%CI:81-99) n = 67
84%(95%CI:57-91) n = 35
Unrelated HSCT at Ramathibodi
Previous
HLA matching: Intermediate to high resolution:
HLA A B DRB1
21 pts: TFS and OS; 71% and 82%
Recent
HLA matching: Strictly matched high resolution:
HLA A B C DRB1
14 pts: TFS and OS = 94%
Haploidentical HSCT (34+ selection)
31 pts
Myeloablative
regimen; Cyclo, Bu,
Flu,Thiotepa and
ATG
GVHD prophylaxis
CSA
Sodani et al, Pediatr Rep
2011
Dilemma 2
Class 3 patients
All class 3 patients are the same?
What should be done for this group?
BMT in Class 1 and 2
• 515 class 1 and 2 aged less than 17 years
• BU 14 mg/kg and CY 200 mg/kg
Lucarelli G and Gaziev J. Blood Rev 2008
BMT in Class 3 Thalassemia
56 children aged < 17 years
MRD, BU14CY200
95 children aged < 17 years
MRD, BU14CY<200
Lucarelli G et al. Blood 1996
BMT in Adult Thalassemia
• 107 patients aged 17 – 35 years, MRD BMT
• Class 2 (n=18), BU14 CY200; class 3 BU14-16 CY120-160
• Reduced dose intensity of conditioning was not associated with higher
rejection rate
• Adult patients could be given less intensive conditioning to overcome
excessive TRM.
Gaziev J, et al. Ann N Y Acad Sci 2005
High risk; age > 7 and hepatomegaly
BBMT; 2007
Sabloff et al. ICBMTR, Blood 2011
What Kind of
Conditioning Regimen?
Myeloablation
Reduced intensity
Non-ablation
New Approach for BMT in
Children with Class 3
Protocol 26
• DF 40 mg/kg cont IV, d – 45 to – 11
• PRC every 3 days, Hb 14 – 15 g/dL
• HU 30 mg/kg daily
• Azathioprine 3 mg/kg daily
• FLU 20 mg/m2/d, d – 17 to – 13
• BU14CY160
33 class 3 patients
Aged less than 17 years;
70% of pts age < 10 yr
OS 93%, TFS 83% rejection rate 8%
Sodani P et al. Blood 2004
Protocol 26 for BMT in Adult Patients
• Protocol 26 in adult thalassemia (n=15)
• Decreased CY90
• Decreased TRM from 37% to 27% (still high)
• Low rejection rate
• Adult patients may be suitable for reduced intensity regimen
Gaziev J, et al. Ann N Y Acad Sci 2005
RIC SCT in Thalassemia
• A RIC SCT for thalassemia performed by Resnick et al
(BMT 2007)
• 20 patients, median age 5.6 yrs (2.4 – 23.3 yrs)
• 11/20 (55%) at least class 2
• Conditioning regimen
– Fludarabine 30 mg/m2/day x 6 days (day -9 to -4)
– BU 8 mg/kg (2 pts), 16 mg/kg (6 pts); IVBU 3.2 mg/kg/day x 4 days
(day -7 to -4)
– ATG-F 10 mg/kg/day x 4 days (day -4 to -1)
• Donors: MSD 17, MFD 1, MUD 2
• Stem cells: PBSC 8, BM 12
• GVHD prophylaxis: CsA
Resnick et al. BMT 2007
RIC SCT in Thalassemia
• 19/20 primary engraftment
• Graft rejection = 3
• Stable mixed chimerism = 3
• aGVHD gr I – II = 25%
• cGVHD = 25%
• Substitution of HD CY by FLU and ATG is effective.
• Weekly monitoring chimerism and gradual withdrawal of immunosuppressive
• BM is a preferred source in the future (no GVHD from MSD BM)
Resnick et al. BMT 2007
Treosulfan, Thiotepa, Fludarabine, ATG (unrelated)
Blood; 2012
Our Approach for Patients with Class 3
and Older than 10 yrs
High Risk Class 3 Patients
Definition
Older patients
Age > 10 yrs
Hepatomegaly
Class 3 Lucarelli
(Age > 10 y and Hepatomegaly)
Pre-transplant Management
Hypertransfusion in order to decrease erythroid
expansion especially to decrease spleen size
Regular iron chelation for at least 6-12 months
Hydroxyurea (Hb F enhancer) in order to decrease
erythroid expansion: 20 mg/kg/day for at least
6-12 months
Sodani P et al. Blood 2004
Hongeng S et al. Am J Hematol 2007
Conditioning Regimen for
Patients Older than 10 yrs
Past
Combination of cyclophosphamide and busulfan
Too much alkylating agent regimen
Too toxic
Long term toxicities; gonadal toxicity
? 2nd malignancies
Therefore
Finding a novel approach
Patient Characteristics
Total 24 patients
All patients aged older than 10 yrs.
(median 18; range 11-22)
All have hepatomegaly; > 5 cms
Previous RIC Regimen
(Early 8 Patients)
Busulfan oral (8-12 mg/kg)
Fludarabine (210 mg/m2)
ATG (Fresinius 20 mg/kg)
+TLI 500 cGy
+ Thiotepa 10 mg/kg
+ Melphalan 100 mg/m2
GVHD prophylaxis
CSA or FK506 and MMF
Am J Hematol, 2007
2 Iannone R, et al. BBMT 2003
3 Horan JT, et al. BMT 2005
4 Jacobsohn DA, et al. Lancet 2004
5 Krishnamurti L, et al. BMT 2006
TFS and OS of RIT in 24 Thal Patients
0.75
1.00
probability survival estimates
0.00
0.25
0.50
92 % (95%CI:50-96)
time (months)
0
20
40
60
EFS
OS
80
Novel Reduced Toxicity Regimen for Transplantation
in Older Severe Thalassemia Patients:
Sequential Immunoablation
Suradej Hongeng, Samart Pakakasama, Usanarat Anurathapan,
Duantida Songdej, Nongnuch Sirachainan,
Ampaiwan Chuansumrit
Dept. Pediatrics, Faculty of Medicine Ramathibodi Hospital,
Mahidol University, Bangkok, Thailand
Sequential Immunoablative Program
Fludarabine 40 mg/m2 x 5 days
Dexamethsone 25 mg/m2 x 5 days
28-day cycle prior to conditioning regimen
Ten patients received 1 cycle
Eight patients received 2 cycles
Conditioning Regimen
Fludarabine 35 mg/m2; d-9,-8,-7,-6,-5,-4
Busulfex 130 mg/m2; d-9,-8,-7,-6
ATG (Thymoglobulin) 1.5 mg/kg; d-3,-2,-1
GvHD Prophylaxis
CSA or FK506
MMF for 60 days
Patient Characteristics
Eighteen patients were included in this study.
Two out of 18 had second HSCT.
Homozygous β thal = 4; β thal/HbE = 14
Age; median = 14 yr (10-18 yr)
Male 7; Female 11
Splenectomy = 7 (Referral hospital)
All patients had liver > 5 cm below costal margin
Ferritin level; median = 2892 ng/mL (869-8350)
All were class 3. (High risk class 3)
Graft
17 patients received PBSC
1 patient received BM
Median CD34+ dose 9.43 cells/kg (4.67-19.26)
MRD 11 MMRD 2 (DRB1)
MUD 3 MMUD 2 (C)
Engraftment
All were engrafted.
PMN engraftment; median d+12 (11-18)
Platelet engraftment; median d+18 (12-47)
GvHD
Acute GvHD
gr II-IV
4 patients (22%)
Gr III-IV
none
Chronic GvHD
Mild
5 patients (28%)
Extensive
none
Complications
Mild VOD
3 patients (16%)
Mucositis gr 1
3 patients (16%)
Infections
CMV reactivation 3 patients
BK reactivation
1 patient
BK cystitis
1 patient
Herpes zoster
Chicken pox
1 patient
1 patient
Sequential Immunoablative Concept
We have tested T cell function by PHA
stimulation before and after Flu Dex
administration.
CSFE CD4 cell proliferation
Stimulation index (SI)
Percentage of CFSElowCD4 cells (PHA)
Percentage of CFSElowCD4 cells (Neg control = no PHA)
Venken et al.Journal of Immunological Methods 322 (2007) 1–11
CD4 cells proliferation
140
Stimulation index
120
100
80
No.1
No.2
60
No.3
40
20
0
1
2
3
4
No.1 = KC
No.2 = AK
No.3 = AS
Outcome
Two patients died.
1 Cerebellar hemorrhage from motorcycle
accident.
2 IPA
16/18 patients survived without thalassemia
symptom. Median follow up time 30 months
1.00
0.75
0.00
0.25
0.50
88% (95% CI, 0.5327 - 0.9621)
0
2
4
6
Years
Overall survival
Thalassemia Free-survival
Survival and Thalassemia-Free Survivals of Patients Treated with
Novel Reduced Toxicity HSCT (unpublished data)
Source of HSC for HSCT in
Thal
• BM
• PBSC
• CB
Related Donor CBT for Thalassemia
• Multicenter study (Eurocord group)
• 33 patients with  thal major (11 SCD)
• Class1 = 20, class2 = 13
• Full matched HLA (32), 5/6 (1)
• Conditioning regimen:
BU16CY200, ATG/ALG
BUCY+/-FLU+/-TT
• Median TNC 4 x 10^7/kg
• Engraftment: 7/33 primary graft failure
3 persistent MC
Locatelli F et al. Blood 2003
Related Donor CBT for Thalassemia
• Transplant related complications
• No life threatening infection
• aGVHD 11%, cGVHD 6%
• 2 yr EFS 79%
class1 (89%), class2 (62%)
• MTX decreased EFS
Locatelli F et al. Blood 2003
Unrelated Donor CBT for Thalassemia
( n= 35)
Jaing et al, BMT 2012
UCBT in Thal and SCD
Cell dose > 5 x 10(7) /kg; Better outcome
Ruggeri et al. EBMT data, BBMT 2011
Post HSCT Management to
Prevent Rejection
Mixed Chimerism After BMT
Lucarelli Group
BMT 335 thalassemic patients
Chimerism status at 2 months
Complete chimerism
227 (67.8%)
CC
218 (96%)
PMC
9 (4%)
Mixed chimerism
108 (32.2%)
PMC
73 (67.6%)
GR
35 (32.4%)
Andreani M, BMT 2000
Mixed Chimerism After BMT
Lucarelli Group
108 mixed chimerism
MC1 (RHCs<10%)
61 (56.5%)
CC
57%
PMC
30%
GR
13%
MC2 (RHCs 10-25%)
27 (25%)
CC
44%
PMC
15%
GR
41%
MC3 (RHCs>25%)
20 (18.5%)
CC
0%
PMC
10%
GR
90%
Andreani M, BMT 2000
Management for Mixed Chimerism
Chimerism study weekly after engraftment for 3
months
If MC with recipient > 10-25%
Decrease immunosuppressive agents
MC with recipient > 25%
Donor lymphocyte infusion
or
Minimal conditioning regimen: fludarabine
+ busulfan followed by PBSC infusion
Pediatr Transplantation, 2011
Effect of Splenectomy in HSCT for
Thalassemia
Mathew V, et al. BBMT 2007
Conclusion
Outcomes of both related- and unrelated-donor
HSCT with severe thalassemia seemed to be
favorable.
Favorable result in unrelated transplantation
patients is due to high resolution HLA
matching (8/8; ABC and DRB1)
Conclusion
Conditioning regimen:
Bu Cy (Full dose)
Bu Cy (Reduced dose) Flu Thiotepa
Bu Flu (Full dose)
Treo Flu Thiotepa
+ ATG (unrelated or PBSC)
High risk class 3: age > 7 and hepatomegaly
Bu Flu ATG plus sequential immunoablation with
Flu Dex
Bu Cy (Reduced dose) Flu Thiotepa + ATG (unrelated)
Treo Flu Thiotepa + ATG (unrelated)
Conclusion
Mixed chimerism management program seems to help
to maintain sustainable engraftment.
Related CBT
High graft failure rate
No MTX for GVHD prophylaxis
Adequate cell dose (> 5 x 107/kg nucleated cell)
Unrelated CBT and Haploidentical Tx
High TRM and graft failure
Uncertain role in thalassemia
Cord blood expansion for future use
New approach for haploidentical HSCT
Acknowledgement
Samart Pakakasama
Ampaiwan Chuansumrit
Nongnuch Sirachainan
Usanarat Anurathapan
Duanthida Songdej
HLA lab and BMT nurses
Somtawain Sirirueng
Wanpen Pantangkool
Saengsuree Jootar
Artit Ungkanont
Vinai Suvattee
Suthat Fucharoen
Surapol Issaragrisil
Borje Andrersson
Srinakarind Hospital
Suandok Hospital
Songklanakarin Hospital