UNRELATED DONOR TRANSPLANTS A Bacigalupo, Ospedale San Martino, Genova, Italy Donor Safety 5/36317 RELATED 0/14706 UNRELATED deaths /10.000 donations BM 27770 PB 23254 death 1 4 2 1,8 1,6 1,4 1,2 1 0,8 0,6 0,4 0,2 0 1,72 0,36 BM PB One additional death in Unrelated Donor Age = Gender= Cause = repiratory insufficiency after attempted insertion of CVC , and bilateral pneumothorax BM 27770 PB 23254 SAE 12 25 SAE /10.000 donations 12 10,76 10 8 6 4,32 4 2 0 BM PB DONOR SAFETY 1.HSC donations carries a small, but proven hazard: we must be cautious (VERY) in selecting HSC donor 2. PB donations are not safer than BM Higher death rate and signficantly higher SAE rate for PB vs BM donations. Informed consent should say so 3. Accurate donor screening will reduce risk of lethal complications Lower death risk occurred in UNRELATED donations Donor Safety Graft versus Host Disease Preventing acute GvHD II-IV 80 74 70 % of patients 60 56 51 50 40 33 30 23 17 20 10 0 FK+M/ CsA+M Blood 2000 96:2062 FK+M+S BBMT 2008; 14:920 C+M+ATG Lancet Onc 2009:10 C+M+Camp BJH 2011 march 8 Reduction of GvHD in alternative donor TX for 402 Myeloid Leukemias: Genova San Martino 80 70 % of patients 60 P<0.0001 69 P<0.0001 58 50 40 <95 <2000 2000+ 32 26 30 18 20 10 4 0 GvHD II+ GvHD III-IV Preventing Chronic GvHD 80 70 76 70 % of patients 60 50 42 47 40 30 20 10 0 FK+M/ CsA+M Blood 2000 96:2062 FK+M+S BBMT 2008; 14:920 C+M+Camp BJH 2011 march 8 % of patients with chronic GvHD Biol Blood Marrow Transpl ; 2006 ; 12: 560 Chronic GvHD P<0.0001 70 60 60 50 40 37 41 non ATG ATG 30 20 15 10 0 Same results with ATG Thymo Or ATG Fresenius extensive chronic GvHD % of patients with chronic GvHD chronic GvHD Lancet Oncol 2009; 10:855 70 60 P<0.0001 59 50 40 42 non ATG ATG 31 30 20 12 10 0 chronic GvHD extensive chronic GvHD UD or SIB BM Tx BU 3.2 mg/kg x4 Day -7 -6 -5 -4 CY 50 mg /kg CY 50 mg/kg x2 -3 -2 -1 0 +3 CY 50 mg /kg +4 GvHD 1.Prophylaxis with 2 drugs (C+M, T+M) is associated with significant acute+chronic GvHD 2. A third agent (ATG or CAMPATH or SIROLIMUS) signifanctly REDUCES acute +GvHD 3. ATG significantly reduces chronic GvHD 4. High dose CY post-Transplant may be a promising new option with or without C+M Donor Safety Graft versus Host Disease Does reduction of GvHD translate in better OS? OS not significantly different (not inferior) with ATG vs no ATG GITMO trial (Thymo) BBMT 2006; 12:560 German trial (Thymo) Lancet Onc ; 2009 Very long follow up (over 10 years) , may allow for late complications of chronic GvHD (in particular lung complications) to become clinically relevant Donor Safety Graft versus Host Disease Does eduction of GvHD translate in better OS? HLA matching criteria Worse outcomes with Any single locus mismatch n RR (95% CI) P-value Survival 952 1.18 (1.07-1.30) 0.0009 DFS 945 1.16 (1.03-1.31) 0.004 TRM 945 1.34 (1.16-1.54) <0.0001 Relapse 945 0.90 (0.81-1.00) 0.04 Engraftment 956 OR 0.90 (0.80-1.01) 0.06 Acute GVHD 957 1.38 (1.13-1.63) 0.0008 Chronic GVHD 910 0.96 (0.91-1.03) 0.25 A single mismatch is associated with worse survival, DFS, TRM, acute GVHD Early Stage Disease: Adverse impact of HLA mismatch HLA-A ,B, C, DR 1,0 0,9 S u r v i v a l 0,8 8/8 HLA Matched (n=835) 0,7 7/8 HLA Matched (n=379) 0,6 0,5 0,4 0,3 6/8 HLA Matched (n=241) 0,2 0,1 Log-rank p-value = < 0.0001 0,0 0 12 24 36 48 60 Months after transplant Each mm yield 10-11% worse survival Lee et al, 2007 Advanced Disease: Limited impact of HLA mismatch HLA-A ,B, C, DR 1,0 0,9 S u r v i v a l 0,8 Log-rank p-value = 0.02 0,7 0,6 0,5 8/8 HLA Matched (n=327) 0,4 7/8 HLA Matched (n=195) 0,3 6/8 HLA Matched (n=123) 0,2 0,1 0,0 0 12 24 36 48 Months after transplant Delay had worse consequences than MMLee et al, 2007 60 Study Reference N.patients Diagnosis Survival Type of mismatch disadvantage in One should avoid mismatched pairs Seattlle Petersdorf Blood 1249 Leukemia Early dis C locus 3860 AML ALL MDS Early dis A or DRB1 2004; 104: 2976 NMDP Lee CIBMTR Blood 2007 JMDP Takakazu CML 5210 Blood 2007 110; Malignant and All patients non malignant C locus Non permissive 2235 mismatches positions 9,77,80,99,116,156 Seattle Petersdorf 246 Leukemia All patients Plos Med 2007; 4: Haplotype Mismatched 59 GITMO Crocchiolo, Blood 537 Leukemia All patients 2009, 114:1437 CIBMTR Cooley, Blood 2010, 116:2411 DP non permissive mismacth 1409 Leukemia AML Donor B gene content <2 KIR genes on Chromosome 19 Segregate indep. From HLA A group (inhibitory receptors) B group (activating receptors) A/A= homozygous for A B/x (at least one B) Lancet February 15, 2012 HLA 10/10 match DP permiss mm # same TRM as DP= # lower TRM as DP non perm mm # lower Relapse as DP= V V Faster Registration on International Donor Registries and Shorter Time to Allogeneic Hematopoietic Stem Cell Transplantation After Having Found a Donor Confers Better Outcome In Acute Leukemia Patients Mauricette Michallet1, Lyon Abstract 2371 ASH 2010; Patients = 251 with acute leukemia and active donor search 2000-2008 The 3years OS for SD allo-HSCT 59% UD allo-HSCT early registration: UD allo-HSCT late registration: 47% 29% Donor selection EARLY DISEASE 1.Choose 8/8 = A,B,C,DRB1 donors 2. permissive DP mm should be preferred of non permissive mm 3.In AML patients , if possible, with a NK -B cent haplotype ADVANCED DISEASE The earlier, the better Donor Registries Donor Safety Graft versus Host Disease Does eduction of GvHD translate in better OS? HLA matching criteria Stem cell source Patient Selection Transplants in 2000-2003 PB = 451 BM = 781 Age, 18-60 yrs ALL, AML, MDS and CML Excluded: T-cell depleted grafts Reduced Intensity Conditioning Median follow-up: PB, 34 months BM, 38 months Eapen et al, Biol Blood Marrow Transplant, 2007 PBG05_3.ppt Transplant-Related Mortality Cumulative Incidence, % 100 80 60 BM (N=781; 46%) 40 PB (N=451; 45%) 20 0 0 12 24 36 Months Eapen et al, Biol Blood Marrow Transplant, 2007 Relapse Cumulative Incidence, % 100 80 60 40 PB (N=451; 26%) 20 0 BM (N=781; 24%) 0 12 24 36 Months Eapen et al, Biol Blood Marrow Transplant, 2007 Leukemia-free Survival 100 Probability, % 80 60 BM (N=781; 31%) 40 PB (N=451; 29%) 20 0 Months: 0 No at Risk PB: 451 BM: 781 12 24 36 179 306 127 230 48 146 Eapen et al, Biol Blood Marrow Transplant, 2007 Randomized CTN trial (Anasetti et al ASH 2011) Median follow up 36 months Peripheral BLOOD 273 MARROW 278 P Overall survival OS transplanted DFS transplanted 51% 52% 47% 46% 48% 44% 0.3 0.3 0.6 Relapse NRM ANC 500 day 100 28% 26% 95% 28% 27% 86% 0.8 0,6 0.09 aGvHD II-IV aGvHD III-IV 47% 16% 46% 14% 0.8 0.3 cGvHD Ext cGvHD 53% 46% 40% 31% 0.02 0.01 Stem cell source 1.Same TRM /relapse / LFS 2.More chronic GvHD Both in retrospective and prospective trials PERIPHERAL BLOOD TRANSPLANTS DONORS # more SAE for PB donations (significant) # more deaths (ns) # should be stated in the informed consent PATIENTS # no protection against relapse # same TRM; same LFS # more chronic GvHD Should we continue to use PB grafts routinely? ?? Donor Registries Donor Safety Graft versus Host Disease HLA matching criteria Stem cell source Outcome ACUTE LEUKAEMIA REGISTRY ADULTS TRANSPLANTED FROM 2000 TO 2010 MATCHED UNRELATED DONOR / OS at 5 years AML n=2901 ALL n=1655 50%±1 40%±2 CR1 (n=1117) CR2 (n=879) 21%±2 ADV (n=905) 46%±2 CR1 (n=804) 28%±2 13%±2 CR2 (n=510) ADV (n=341) Matched Unrelated Transplants for SAA Effect of transplant era 10 year OS >2000 (752) (230) >1980 (27) 1971-80 (1) 67% 44% 29% 0% Survival Plot >1990 1,000 Survival 0,750 >2000 P<0.0001 1991-00 0,500 1981-90 P=0.1 0,250 1971-80 0,000 0,0 2000,0 4000,0 6000,0 daysDD_FUP from transplant 8000,0 Conclusions 1.Caution required for donor harvest (BM and especially PB) 2.Several options for HLA /non HLA donor selection 3.Three agents (C+M+other) for appropriate GvHD prophylaxis 4.Time to transplant= crucial factor 5. Should we continue to use PB?? Donor Registries WMDA 2012 Activations 2009 2010 44201 46919 BMT Tx 3445 (8%) 3574 (8%) PB Tx 8162 (18%) 9248 (20%) CB 3792 (9%) TOT transpl 15399 (35%) 4036 (9%) 16858 (37%) REGISTRIES: Large Donor pool Searches Activated : UD Transplants = 44201 : 12822 = We are transplanting 1/3 of patients who activate a donor search (optimistically 50%)