ALBERT

Description: Key Points Pregnancy recalls short-lived immunity against TAAs mimicking antileukemic responses after allogeneic stem cell transplantation.

Description: Advances in supportive care have reduced early treatment related mortality with ASCT to approximately 1%. Registry data has shown that relapse is the cause of treatment failure in approximately 80% of patients. However, non-relapse mortality (NRM), over time, affects 20% of transplant recipients. Delayed NRM is poorly studied. To characterize the factors associated with NRM, we reviewed 1573 consecutive autologous transplants performed at the Cleveland Clinic from 1/1992 through 12/2005. This analysis included only adult patients (pts) receiving peripheral stem cells, busulfan based preparative regimens, single transplants, and diagnoses of NHL, HD and MM (n = 856). The median age was 49, 62% were male, and 30% received prior radiation therapy. The most common number of prior chemotherapy regimens was 2 (48%); the primary diagnosis was NHL (67%), HD (18%), MM (15%); and 90% had sensitive disease at the time of transplant. 471 (55%) are alive and 385 (45%) have died. Relapse was the most common cause of death, occurring in 303 (79%) patients. Non-relapse mortality occurred in 82 patients (21% of deaths). The most common cause of NRM was pulmonary toxicity, occurring in 26 patients, followed by secondary malignancy in 19 pts, infection (12 pts), cardiac toxicity (7 pts), other organ failure (7 pts), and other causes (11 pts). Patients who died from secondary malignancy were significantly more likely to have received prior radiation therapy (p = 0.004), to require more days of pheresis to collect stem cells (p

Description: There are relatively few reports in the medical literature describing psychosocial assessment of bone marrow transplant patients; what data exists primarily focuses on allogeneic transplant recipients. We have begun to prospectively assess psychosocial parameters of patients undergoing autologous transplantation using the Functional Assessment of Cancer Therapy-BMT (FACT-BMT) tool. The general questions consist of four subscales developed and normed in cancer patients that measure; physical well-being; social/family well-being; emotional well-being; functional well-being; and a specific module to address BMT-specific concerns. Each subscale is positively scored, with higher scores indicating better functioning. A baseline survey is collected by the social worker pre-transplant and a follow-up survey is administered and collected approximately 6 weeks post-transplant by the Transplant Coordinator. 56 consecutive patients undergoing autologous stem cell transplant have FACT-BMT data both pre-transplant and approximately one month post-discharge. Median age was 50. 52% are male; underlying diagnoses include NHL (45%), Hodgkin’s disease (32%), myeloma (16%), AML (5%), testicular cancer (2%). 93% had chemosensitive disease at the time of transplant. All patients received peripheral blood progenitor cells (PBPCs), and all received a chemotherapy-only preparative regimen. All patients were hospitalized for approximately three weeks for the transplant. For most of the variables measured by the FACT-BMT tool, there was no significant difference in pre-transplant and post-transplant scores. The one variable that did change was emotional well-being: patients scored statistically significantly higher post-transplant as compared to the pre-transplant score (p

Description: The kinetics of G-CSF PBPC mobilization are well described. CD34+cells in peripheral blood rise four days after G-CSF administration, and decline after the eighth day. VP-16 is increasingly used with G-CSF as a mobilizing regimen; however, the kinetics of mobilization are sparsely described. We retrospectively reviewed 275 patients (pts) with NHL or HD who received VP-16 plus G-CSF as a primary PBPC mobilizing regimen. 214 (78%) had NHL; 31% received prior radiation therapy; 63% were male; 85% had responsive disease. Pts received VP-16 (2 gm/m2) followed by daily G-CSF (10 mcg/kg). All pts experienced a significant WBC nadir. Pts began pheresis when their WBC recovered to 5,000. Pts were pheresed for at least 2 days or until 7.0 x 106 CD34+ cells/kg were collected; pheresis continued until a minimum of 2.0 x 106 CD34+ cells were collected. WBC nadir occurred day +6 after VP-16 and WBC recovery to 5,000 occurred day +13 (median) after VP-16. Pts were pheresed for a median of 3 days which yielded a median of 9.7 x 106 CD34+ cells/kg (range, 2.0–100.1 x 106). 72% of pts began collection on day +12, day +13, or day +14. The average CD34+ cell collection was maximal on the first 3 days of pheresis, but reasonable yields continued to be obtained for approximately 10 days of pheresis, as shown below: Figure Figure 81% collected ≥ 5 x 106 CD34+ cells/kg, and 72% collected ≥ 7 x 106 CD34+ cells/kg. The platelet count on the first day of pheresis correlated with the ability to collect 5 and 7 x 106 CD34+ cells/kg (p

Description: Purpose: An overwhelming amount of information is given to patients/caregivers undergoing Bone Marrow Transplantation at all phases of the treatment. It is difficult for many to comprehend the information and retain it. We observed that patients, while eager to be discharged home, often become apprehensive about leaving the 24 hour care given in the hospital. Based on the experience of other BMT centers, we developed a post-transplant education group for the 17 bed inpatient unit, to increase patient and family/caregiver knowledge of care and precautions that are required post-discharge as well as coping with life after transplant. Methods: The Cleveland Clinic BMT team recently designed a Bone Marrow Transplant Education Binder specific to our BMT program. Although this is used to supplement the face to face contact with the patient/caregiver, the information can still be overwhelming. The post-transplant group was designed to increase knowledge and confidence while reinforcing the information in the education binder. The information presented was designed by nursing and social work. The initial group session took place in May 2005 and has been repeated monthly since. The post-transplant information was initially presented by an outpatient BMT nurse coordinator and a BMT social worker. After 7 months the program was improved by having an inpatient BMT nurse also assist in presenting the information. All participants sign an attendance form indicating if they are the patient, family member or caregiver. The group covers topics such as coping with life after transplant, preventing infections, resuming physical and sexual activity, nutrition guidelines and graft vs. host disease. At the conclusion of the group, participants evaluate the session. The evaluation includes overall rating of the session, whether information was helpful, if participants feel better prepared for discharge, and suggestions to improve the program. Results: The post-transplant education session has been well attended by patients/caregivers with an average monthly attendance of 10 (range 6–15). The number of patients versus family members or caregivers was nearly equal. The evaluations have shown that patients/caregivers feel they are better prepared for discharge and have increased knowledge of what is required after transplant. A total of 138 evaluations were completed and 99.3% of the participants rated the session as good or excellent. Suggestions offered to improve the session included providing more detailed information about nutrition after transplant and inclusion of the dietician in the sessions. Conclusion/Recommendations: The post-transplant education group has enhanced the education of our patients/caregivers, increased their confidence and knowledge, and has become a helpful tool in new team member orientation. The recommendation of patients and caregivers to include a dietician will be implemented to improve the nutrition information provided. The benefits of this group may encourage other centers to implement similar programs. Based on the success of our post-transplant education group the possibility of a pre-transplant education group will be explored.

Description: The reactivity of NK cells and some T cell populations is regulated by KIR interactions with HLA class I molecules. Such interactions have been suggested to influence outcomes after myeloablative allogeneic HSCT. However, in NMHSCT the effect of KIR interactions on outcomes including the development of CDC has not been well described. We analyzed 51 pts who received related donor NMHSCT at our institution from 1/10/00–10/25/05. All pts received fludarabine 30 mg/m2/d x 3 days followed by total body irradiation 200 cGy (n=35) or 400 cGy (n=16) for conditioning. The median age was 54 (range, 21–64). Short tandem repeat analysis for T cell (CD3+) chimerism was performed on peripheral blood and CDC was defined as achievement of 〉95% DNA of donor origin in the CD3+ T cells. 37 (73%) of patients achieved CDC at a median time of 3.3 mos (range, 0.4–11.2). KIR genotypes were determined for recipients by PCR-rSSOP analysis. Donor HLA KIR ligands were categorized as: HLA-Cw groups C1 (+ or −); C2 (+ or −); HLA-Bw4 (+ or −); and HLA-A3 or -A11 (+ or −) [as reviewed by Farag et al. Blood2002; 100:1935–47]. Recipient KIR genotype and donor HLA KIR ligands were used to generate an inhibitory KIR score for pts from 1 to 4 corresponding to the potential number of inhibitory KIRs engaged. 7 pts had a score of 1, 27 had a score of 2, 14 had a score of 3 and 3 had a score of 4. Figure Figure The Kaplan-Meier method was used to estimate the achievement of CDC by inhibitory KIR score (figure, p=0.09). Pts with a score of 1 were less likely to achieve CDC compared to those with a score of 2 (p=0.02), while those with a score of 2 tended to be less likely to develop CDC than those with a score of 4 (p=0.07). There were no differences in CD34+ or CD3+ cell doses between any of the groups. When combined with the inhibitory KIR score data the presence of single or multiple activating KIR’s was not found to influence the development of CDC. Thus, pts with lower inhibitory KIR scores may have more active anti-donor effector cells (NK cells and T cell subsets) that may reduce donor cell chimerism. Conversely, those with higher inhibitory KIR scores may have less active populations and be more likely to achieve CDC. Given the genotypic potential to inhibit all NK cells KIR expression may be variable among different clones, and may affect the development of CDC. Further investigation of KIR expression at the cellular level rather than by genotyping alone should be pursued.

Description: Assessment of chimerism after AHSCT has been important to monitor donor hematopoietic engraftment and to assess for residual disease or relapse. Achievement of T cell (CD3+) complete donor chimerism (CDC), particularly after NM AHSCT, has been considered important to achieve a graft-vs.-malignancy effect. Formal comparisons of the onset and frequency of T cell CDC in pts treated with MY vs. NM conditioning regimens have not been well described. The current analysis compared rates of achieving T cell CDC for 116 pts transplanted from 1/10/00–5/19/06 who were categorized into the following 4 groups based upon type of transplant conditioning: 1) 200 cGy total body irradiation (TBI) + fludarabine 30 mg/m2/d × 3 days (NM200; n=47); 2) 400 cGy TBI + fludarabine (NM400; n=23); 3) MY AHSCT with busulfan/cyclophosphamide without TBI (MY-noTBI; n=31); 4) MY AHSCT with TBI (MY-TBI; n=15). All NM AHSCT pts received peripheral blood stem cells and all MY AHSCT patients received bone marrow as their stem cell source. The total nucleated cell (TNC) and CD34+ cell doses were higher in the NM AHSCT patients. 36 (31%) pts had matched unrelated donors, all with at least an 8/8 match (HLA-A, -B, -Cw, -DR) by HLA class I and II DNA-based typing [10 (21%) NM200, 7 (30%) NM400, 9 (29%) MY-noTBI, 10 (67%) MY-TBI; p=0.011]. Graft-vs-host disease prophylaxis consisted of mycophenolate mofetil and cyclosporine or tacrolimus for most pts. Short tandem repeat analysis for T cell (CD3+) chimerism was performed on peripheral blood post transplant and CDC was defined as achievement of 〉95% DNA of donor origin isolated from CD3+ T cells. Post-transplant T cell chimerism was found in both the MY and NM AHSCT groups. The number of pts who achieved CDC and the median time to its occurrence for each group was as follows: NM200 - 34 (72%) at 4 mos; NM400 - 18 (78%) at 2.7 mos; MY-noTBI - 20 (65%) at 3.3 mos; and MY-TBI - 13 (87%) at 1.3 mos. The Kaplan-Meier curves for achievement of CDC are shown above (p=0.23). The group of pts who received MY-TBI developed T cell CDC more rapidly than the NM200 pts (p=0.05). No significant differences were observed between the NM400, MY-noTBI and MY-TBI groups with regards to achieving CDC. NM conditioning with either 200 cGy or 400 cGy TBI did not show a significant difference in rate of achieving T cell CDC as compared to MY conditioning with busulfan/cyclophosphamide without TBI. This may be related in part to the higher TNC and CD34+ cell doses in the NM AHSCT pts. However, the increased TBI doses utilized for MY conditioning may more effectively suppress anti-donor immune effector cells from the recipient, which resulted in the increased CDC compared to the NM200 group. In conclusion, post-transplant monitoring for T cell CDC is important in both MY and NM AHSCT to allow for immune manipulation to maintain a state of donor-host tolerance in order to prevent graft rejection. Figure Figure

Description: We have anecdotally observed that many patients mobilized with Etoposide (VP) + filgrastim (G) collect very high numbers of CD34+ cells for autologous stem cell transplantation (ASCT). Some BMT centers have suggested that the cellular composition of an autologous graft may influence ASCT outcome. We therefore queried whether patients collecting high numbers of PBPCs (“super-mobilizers”) have a better outcome than other patients. We retrospectively reviewed 693 consecutive adult patients with Non-Hodgkin Lymphoma (NHL) or Hodgkin Lymphoma (HL) receiving an ASCT from 1/1994 through 12/2005 treated with a uniform preparative regimen of Busulfan, Cyclophosphamide and Etoposide (Bu/Cy/VP). Of these 693 patients, 350 were mobilized with VP (2 gm/m2) + G and comprised the study population. After receiving VP+G, patients were collected for a minimum of 2 days with a collection goal of 7 × 106 CD34+ cells/kg. A minimum collection of 2.0 × 106 cells was required to proceed to ASCT. Super-mobilizers were defined as collecting, and infusing, greater than 8 × 106 CD34+ cells/kg. 203 patients were super-mobilizers, while 147 collected between 2.0 and 7.95 CD34+ cells/kg. Pre-transplant performance status, LVEF, and DLCO were similar between the two groups. Super-mobilizers were slightly younger (mean 47 years old vs. 51 years old, p=0.003) and more likely to have received 2 or fewer prior chemotherapy regimens, (80% vs. 63%, p

Description: The decision to offer or not offer high dose therapy with ASCT to an individual lymphoma patient is sometimes (but perhaps mistakenly) based on the specific histology alone and not necessarily on patient characteristics, clinical manifestations, or disease behavior. Therefore, we reviewed the long-term outcome of FL, dnDLBL, and tDLBL patients, who received high dose chemotherapy (CT) with ASCT at the Cleveland Clinic, to determine if the specific histology is important. Between June 1991 and July 2004, 235 patients with FL, dnDLBL, or tDLBL in second or third remission received high dose CBV (n=7), BuCy (n=1), or BuCyVP (n=227) with ASCT. The median follow-up among survivors is 3.4 (.1–11.4) years. Patient, disease, and ASCT characteristics and outcome according to histology Variable FL (n=88) dnDLBL (n=123) tDLBL (n=24) p-value Age: median (range) 51(33–69) 50(22–71) 56(40–70) 0.021 Male sex: N (%) 47(53) 73(59) 12(50) 0.56 Years from diagnosis to ASCT: median (range) 2.6(0.4–17.5) 1.5(0.3–15.6) 3.4(1–14.0) 10 cm at ASCT: N (%) 14(16) 27(23) 4(17) 0.46 Disease progression: N (%) 35(40) 55(45) 10(42) – Death from lymphoma: N (%) 21(24) 42(34) 7(29) – Death from any cause: N (%) 31(35) 58(47) 13(54) – Kaplan-Meier freedom from progression curves accarding to histology are shown: Figure Figure Kaplan-Meier overall survival curves according to histology are shown: Figure Figure There is no significant difference in freedom from progression between FL, dnDLBL, and tDLBL patients transplanted in second or third remission. By Cox proportional univariate analysis, only male sex predicted a higher risk of progression while male sex, older age, and dnDLBL or tDLBL (compared to FL) predicted a higher risk of death. By Cox proportional multivariate analysis, no factor predicted a higher risk of progression while older age, male sex, and dnDLBL predicted a higher risk of death. In conclusion, high dose chemotherapy with ASCT leads to long-term remissions in 40–50% of FL, dnDLBL, and tDLBL patients in second or third remission. These results suggest that the distinction between these three histologies is less important than other factors in determining patient eligibility for ASCT.

Description: Background The therapeutic potential of allogeneic hematopoietic stem cell transplantation (HSCT) mainly relies on graft-versus-leukemia effects mediated by donor-derived T cells targeting both minor histocompatibility antigens and tumor-associated antigens (TAAs). The efficacy of TAA-mediated immune responses particularly depends on the level of antigen expression in the target tissue and the presence of a proinflammatory immune environment allowing donor-derived T cells to overcome peripheral tolerance and to attack the malignant cells in a selective manner. As several TAAs with clinical relevance in tumor and/or transplant immunotherapy such as Mucin 1 (MUC-1), Preferentially expressed antigen of melanoma (PRAME), Wilms tumor protein 1 (WT1) and Human epidermal growth factor receptor 2 (HER2/neu) are highly expressed in the placental tissue we investigated the effects of pregnancy on the frequency of immune responses against these TAAs in a prospective study. A cross-sectional analysis in a previously reported group of 114 healthy volunteer blood donors revealed no significant effects of prior pregnancies. Here, we present the results of the longitudinal analysis in women during and after their first pregnancy. Materials and Methods After local ethical approval and written informed consent a total of 44 HLA-A*02:01-positive women during their first pregnancy were enrolled in this prospective study. Immune responses against TAAs were assessed at four different time points: First or second trimester (Time point A, n=43), 1 to 3 days after delivery (Time point B, n=31), 6 to 8 weeks after delivery (Time point C, n=34) and after completed nursing (Time point D, n=14). At each time point peripheral blood was drawn and peripheral blood mononuclear cells (PBMCs) were collected by density gradient centrifugation. Isolated CD8+ T cells were stimulated with irradiated T2 cells which were loaded with immunodominant peptides (0.1 and 10 µM) of HER2/neu, MUC-1, PRAME, and WT1. Interferon-gamma (IFN-γ) mRNA expression was measured by quantitative polymerase chain reaction (qPCR) after extraction of total RNA. IFN-γ mRNA expression was calculated as relative fold change compared to the irrelevant melanoma antigen Glycoprotein 100 (gp100). A two-fold change was considered as cut-off for positive results. A HLA-A*02:01 restricted CMV peptide was used as positive control. Results All results are presented in Figure 1. Positive immune responses are presented above the cut-off line. A significant number of positive immune responses against MUC-1, PRAME and WT1 were found during pregnancy (Group A) and early after delivery (Group B). The frequency of positive immune responses against these TAAs decreased during and/or after the period of nursing leaving only one borderline significant finding behind (Group C and D). Against HER2/neu there were none or only single events of immune responses detectable in any group. Conclusions The results from this longitudinal analysis show that immune responses against the transplant-relevant TAAs MUC-1, PRAME and WT1 are detectable in pregnant women but are lost after delivery. These findings are in line with our observations from the inter-individual cross-sectional study where women with prior pregnancy did not have a significantly increased frequency of immune responses against TAAs compared to women without prior pregnancies. The abrogation of the immune response as shown in a longitudinal manner is likely to be a result of an immunosuppressive environment induced by increasing levels of steroid hormones during pregnancy. As immune responses against TAAs can be found also in non-pregnant women we assume that the overexpression of TAAs in the placenta induces a boost in autoimmune responses that is consequently compromised by the immunosuppressive environment. Therefore pregnancy may be a useful model for the boost and the regulation of immune responses against TAAs with implications for immunotherapy. Disclosures: No relevant conflicts of interest to declare.