ALBERT

Description: Introduction: With improvements in transplant strategy and supportive care, hematopoietic cell transplantation (HCT) is increasingly being used to treat older patients (60-80 years). Frailty is a well-accepted phenomenon in the geriatric population characterized by diminished physiological reserve and increased vulnerability to stress, with strong associations with falls, disability, hospitalization and mortality. Since HCT is a substantial stressor, we hypothesized that the prevalence of frailty and pre-frailty will increase in the immediate post-transplant period, and that frailty will be associated with early (1y) post-transplant non-relapse mortality (NRM). Methods: We conducted a prospective, longitudinal study of 96 patients undergoing HCT at age 40y or older between February 2014 and April 2015, and serially performed a multi-domain geriatric assessment (incorporating function, comorbidity, cognition, psychological state, social activity/support, and nutritional status) in additional to demographic, transplant and disease related variables. Frailty was defined by presence of 3 or more of the following criteria: unintentional weight loss, exhaustion, weakness, slow walking speed and low physical activity; pre-frailty was defined by presence of 1 or 2 of the criteria. Geriatric assessments were performed pre-HCT and at 100 days, 6 months and 1 year post HCT. The prevalence of frailty and pre-frailty was evaluated at each time point in older (60-74y, n=48) vs. younger (40-59y, n=48) recipients. Longitudinal assessments (baseline, 100 days, 6 months, 1 year) of ordinal frailty measures were assessed using random effects and non-linear mixed logistic regression models. Impact of frailty on 1 year NRM was estimated using cumulative incidence estimates. Results: Older patients were more likely to undergo reduced intensity conditioning, and less likely to be employed at HCT. The prevalence of frailty increased with time since HCT: The prevalence of frailty was 8% at baseline and increased to 39% by 6 months (

Description: Background: NK cells have the capacity to kill tumor targets, representing a novel immunotherapeutic approach to cancer. We have shown promising clinical activity in AML with a previous NK cell preparation. Limitations of NK therapies have included specificity, persistence after infusion, and potential for maximal activity of NK cells in vivo. GDA-201 is a cellular product composed of natural killer (NK) cells from healthy donors expanded ex vivo with nicotinamide (NAM) and IL-15; this is a unique ex vivo activation strategy to induce persistence of potent anti-tumor activity. Prior in vitro studies and pre-clinical models demonstrated that NAM-exposed NK cells exhibited augmented resistance against exhaustion and improved killing function, proliferation, and organ retention. We now report safety and efficacy from a phase 1 clinical trial of GDA-201 in patients (pts) with relapsed or refractory (R/R) NHL or MM. Methods: Following donor apheresis, CD3-depleted mononuclear cells were cultured for 14-16 days with NAM (5mM) and IL-15 (20ng/ml), resulting in a 40-fold increase in NK cells and increased expression of CD62L from 2.9% to 21%. GDA-201 contained ~98% NK cells, and CD3 content was maintained at

Description: Key Points KT64/86 artificial antigen–presenting cells culture stimulation provides marked expansion of Tregs. In the context of sirolimus, mycophenolate mofetil immunosuppression, adoptive transfer of Tregs resulted in low risk of acute GVHD.

Description: Introduction: Recessive dystrophic epidermolysis bullosa (RDEB) is a severe, life-limiting systemic genodermatosis, characterized by COL7A1 mutation(s) yielding inadequate type VII collagen to maintain the integrity of the cutaneous basement and mucosal membranes. The mainstay of therapy for RDEB is supportive care to minimize the daily morbidity of blistering/scarring, pain/pruritis, systemic inflammation, and high metabolic demand. Leveraging the pluripotency of bone marrow cells, investigations of BMT as a systemic therapy for RDEB showed promise in pre-clinical murine (Tolar J, et al., Blood 2009, 113(5): 1167-74) as well as early phase human clinical trials utilizing fully myeloablative conditioning (Wagner J, et al., NEJM 2010, 363(7): 629-39). However, regimen-rated toxicity limited dampened enthusiasm for the clinical approach. Methods: In an effort to modulate disease activity with decreased toxicity, we investigated the safety of and preliminary responses to BMT with a reduced-intensity conditioning regimen (rabbit anti-thymocyte globulin 2.5 mg/kg with a methylprednisolone taper, cyclophosphamide 28 mg/kg, fludarabine 150 mg/m2, and low dose total body irradiation 300-400 cGy). Graft-versus-host disease (GvHD) prophylaxis included post-transplant cyclophosphamide (PTCy, 50 mg/kg recipient weight/dose on days +3 and 4) and mycophenylate mofetil from day +5 to 35. All except HLA-matched related donor recipients received tacrolimus from day +5 until tapered at day +100. Immunomodulatory donor-derived mesenchymal stromal cells (MSCs, 2 x 106 cells/kg recipient weight/dose) were infused at 60, 100 and 180 days post-BMT. Skin biopsies, medical photography, and dynamic assessments of RDEB disease activity by providers and parents were completed at baseline, day +100, +180 and 1 year post-BMT. Results: Ten RDEB patients were transplanted at a median age of 9.9 years (range 1.8 to 22.1), with a median follow-up of 16 months (1 year evaluations available for only 4 of 10). Donors were haploidentical related (n=6), HLA-matched related (n=3), and HLA-matched unrelated (n=1). BMT complications included graft failure in 3 patients (2 elected to pursue a 2nd PTCy BMT), veno-occlusive disease in 2, posterior reversible encephalopathy in 1, and chronic GvHD in 1, the latter deceased. Infectious complications in the first 100 days were limited to 3 viremia, 7 bacteremia, and 0 fungemia episodes. No serious adverse events were observed with MSC infusions. In the 9 ultimately engrafted patients, median donor chimerism at day +180 was 100% in both myeloid and lymphoid fractions of peripheral blood and 27% in skin. Skin biopsies at day +180 show stable (n=7) to improved (n=2) type VII collagen protein expression by immunofluorescence (IF) and gain of anchoring fibril components by transmission electron microscopy in 4 of 9 patients. Early clinical response included a trend toward reduced body surface area of blisters/erosions from a median of 45.5% at baseline to 27.5% at day +100 (p=0.05), with parental measures indicating stable quality of life. Select medical photography and skin biopsy results are shown for Patient 1 [IF: 40x merged dapi (blue) and C7 collagen antibody (red); immunoelectron microscopy with C7 collagen-directed immunostain (black)]. Conclusions: BMT using reduced-intensity conditioning, PTCy and donor-derived MSC infusion for RDEB was largely well tolerated with low rates of GvHD and death from regimen-related toxicity in 1 of 10 patients undergoing 12 total BMTs. Early follow-up suggests this treatment modulates RDEB disease activity but requires longer follow-up for evaluation of efficacy. Importantly, the PTCy BMT platform provides a means of attaining immunotolerance for future donor-derived cellular grafts. Figure Figure. Disclosures Wagner: Magenta Therapeutics: Consultancy, Research Funding; Novartis: Research Funding.

Description: Background: Angiogenesis has previously been shown to contribute to acute graft-versus-host disease (aGVHD) post-allogeneic hematopoietic cell transplantation (HCT), but its association with response to therapy is not known. We hypothesized that patients with abundant circulating angiogenic factors (AF) involved in repair/regeneration would have improved outcomes relative those with higher levels of AF involved in damage/inflammation. Patients and Methods: We measured by MILLIPLEX magnetic bead array circulating levels of AF known predominantly for repair/regeneration (epidermal growth factor [EGF], fibroblast growth factor (FGF)-1, FGF-2, heparin binding-EGF-like growth factor, follistatin [FS], vascular endothelial growth factor [VEGF]-A, VEGF-C, and VEGF-D) and those known predominantly for endothelial dysfunction/inflammation (angiopoietin-2 [Ang2], endothelin-1, endoglin [sEng], leptin, placental growth factor [PlGF]) in HCT recipients with grade III-IV acute GVHD (N=17) compared to recipients who did not experience aGVHD post-HCT (N=17) and healthy stem cell donors (HD, N=16). AF demonstrating 1.5-fold difference in median with p‰¤0.1 in the pilot study were validated in a cohort with aGVHD (N=158) enrolled in Blood and Marrow Transplant Clinical Trials Network (BMT CTN) 0802, with samples analyzed at aGVHD onset and day 28 post-GVHD treatment, compared to allogeneic HCT recipients from the University of Minnesota who did not experience aGVHD (N=53). Results: In the pilot study, AF associated with repair/regeneration were altered at aGVHD onset. Specifically, FS was 1.9-fold elevated in patients with aGVHD, while EGF and VEGF-A levels were lower compared to HCT recipients without aGVHD. Three AF that are indicative of damage/inflammation (PlGF, Ang2, and sEng) were elevated in aGVHD patients compared to HD. In the validation cohort (Table), levels of FS were 2-fold higher, and levels of sEng and PlGF were 1.7-fold higher in aGVHD compared to HCT controls. As with the pilot study, levels of EGF and VEGF-A were lower (6-fold and 2.6-fold, respectively) in aGVHD. None of the factors differed by grade or organ stage. Patients who received grafts from matched unrelated donors (URD) had a 50% increase in PlGF levels at aGVHD onset compared to sibling donors HCT with aGVHD (31.3 versus 21.8 pg/mL, p=0.03). Patients with aGVHD who had a complete response (CR) to therapy at day 28 had higher levels of EGF and VEGF-A compared to those who had a partial response or no response (Figure 1). Patients with FS levels 〉85th percentile (〉1,355 pg/mL, Figure 2) had an increased risk of death (RR 2.1, 95% CI 1.1 €“ 3.8, p=0.03). Conclusions: Three AFs were elevated at aGVHD onset: FS, sEng and PlGF. Elevated FS is associated with shortened survival. Although FS is critical for tissue regeneration after injury, excess FS may reflect more extensive tissue damage or loss and has recently been linked to delayed healing in a rodent model. EGF and VEGF-A levels are low in aGVHD and are higher with CR at day 28, which may reflect improved tissue production or reduced losses. PlGF levels are disproportionately elevated in aGVHD after URD HCT. Further studies are evaluating the impact of these 5 angiogenic factors on healing and the regulation of inflammation post-HCT, with a goal to identify novel, non-immunosuppressive treatments to improve outcomes of aGVHD. Table Six angiogenic factors in patients at aGVHD onset compared to those without aGVHD and day 28 post-treatment. Factor (median, pg/mL) Onset (N=158) No aGVHD (N=53) Day 28 (N=158) Follistatin 855 445* 1,022 EGF 18 112* 15 VEGF-A 117 309* 137 Endoglin 1,691 1,013* 1,722** Ang2 3,264 3,590 2,734** PlGF 26 14* 32 Compared to onset, *p

Description: We have previously shown that while NK cells are the first lymphocyte reconstituting after allogeneic transplantation, these NK cells are immature and functionally hyporesponsive when exposed to tumor targets. Remarkably, this can be reversed by reactivation of human cytomegalovirus (CMV). A distinct population of natural killer (NK) cells with attributes of immunological memory arises specifically in response to acute CMV infection in healthy individuals or reactivation of latent CMV in hematopoietic cell transplantation (HCT) recipients. These adaptive NK cells are defined by expression of the activating receptor NKG2C and maturation marker CD57 and display a heightened capacity for inflammatory cytokine production and cytolysis in response to target cell recognition. Since the differentiation and maturation of NK cells is dependent upon interactions with cells of the myeloid lineage, including antigen-presenting cells, we hypothesized that the expansion of adaptive NK cells could influence relapse risk, particularly after a reduced intensity conditioning (RIC) regimen where residual host myeloid cells may intensify donor adaptive NK cell expansion in response to CMV reactivation after HCT. Thus, we analyzed 1-year relapse rates in 674 allogeneic HCT recipients at the University of Minnesota (470 umbilical cord blood (UCB) and 204 matched sibling donor (MSD)) between 2001-2013 with AML (n=313), ALL (n=187), MDS (n=85), CML (n=28), NHL (n=42), Hodgkins (n=14) and Multiple Myeloma (n=5) segregated by recipient CMV serostatus (270 seronegative and 404 seropositive). Within the CMV seropositive group, 190 individuals experienced CMV reactivation. We observed no association between CMV reactivation and 1-year relapse rates in recipients of myeloablative conditioning (n=366; 16% [10%-22%] for CMV seronegative vs. 18% [12-24%] for CMV seropositive without CMV reactivation vs. 15% [8%-22%] for CMV seropositive recipients with CMV reactivation). In marked contrast, CMV reactivation was associated with lower 1-year relapse rates following RIC (n=308; 35% [27%-43%] for CMV seronegative vs. 30% [20-40%] for CMV seropositive without CMV reactivation vs. 26% [17%-35%] for CMV seropositive with CMV reactivation [p for trend=0.05, Figure 1A]). In multivariate analyses adjusting for recipient CMV status, conditioning regimen, donor type (MSD vs. UCB), diagnosis (AML [shown to be sensitive to NK cell effects] vs. other), gender, disease risk (standard vs. high) and prior autologous transplant, CMV reactivation was independently associated with lower relapse risk (RR=0.6 [0.4-1.0], p=0.06) and increased DFS (RR=0.7 [0.5-1.0], p=0.05) following RIC, but not myeloablative HCT. Although CMV reactivation led to superior DFS within the entire cohort (RR=0.7 [0.6-1.0], p=0.04), CMV reactivation was not independently associated with lower relapse risk (RR=1.0 [0.5-1.8], p=0.88) with myeloablative conditioning. To determine whether the preparative regimen also influenced adaptive NK cell differentiation post-transplant, we analyzed the percentage of CD56dimCD57+NKG2C+ NK cells. Compared to myeloablative recipients, after RIC, the percentage of circulating CD56dimCD57+NKG2C+ NK cells was significantly higher at 4 weeks post-CMV reactivation (8.58% vs. 4.64%, p=0.02), 8 weeks post-CMV reactivation (7.77% vs. 3.84%, p=0.02), and 6 months post-transplant (14.80% vs. 6.29%, p=0.01) (Figure 1B). Our results demonstrate a relationship between CMV reactivation and enhanced graft-versus-leukemia (GVL) in patients treated with RIC. The association between lower relapse risk and in vivo expansion and survival of adaptive NK cells suggests that these cells may be critical to reducing the risk of relapse. Strategies to isolate and expand adaptive NK cells in order to enhance the GVL effect without clinical CMV reactivation are being actively explored. Figure 1 Figure 1. Disclosures Miller: Coronado: Speakers Bureau; BioSciences: Membership on an entity's Board of Directors or advisory committees; SAB: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

Description: Effectiveness of double umbilical cord blood (dUCB) grafts relative to conventional marrow and mobilized peripheral blood from related and unrelated donors has yet to be established. We studied 536 patients at the Fred Hutchinson Cancer Research Center and University of Minnesota with malignant disease who underwent transplantation with an human leukocyte antigen (HLA)–matched related donor (MRD, n = 204), HLA allele–matched unrelated donor (MUD, n = 152) or 1-antigen–mismatched unrelated adult donor (MMUD, n = 52) or 4-6/6 HLA matched dUCB (n = 128) graft after myeloablative conditioning. Leukemia-free survival at 5 years was similar for each donor type (dUCB 51% [95% confidence interval (CI), 41%-59%]; MRD 33% [95% CI, 26%-41%]; MUD 48% [40%-56%]; MMUD 38% [95% CI, 25%-51%]). The risk of relapse was lower in recipients of dUCB (15%, 95% CI, 9%-22%) compared with MRD (43%, 95% CI, 35%-52%), MUD (37%, 95% CI, 29%-46%) and MMUD (35%, 95% CI, 21%-48%), yet nonrelapse mortality was higher for dUCB (34%, 95% CI, 25%-42%), MRD (24% (95% CI, 17%-39%), and MUD (14%, 95% CI, 9%-20%). We conclude that leukemia-free survival after dUCB transplantation is comparable with that observed after MRD and MUD transplantation. For patients without an available HLA matched donor, the use of 2 partially HLA-matched UCB units is a suitable alternative.

Description: Chronic graft versus host disease (CGVHD) is classically defined as occurring more than 100 days after hematopoietic cell transplant (HCT). But, with newer donor types and transplant strategies being used [eg. non myeloablative (NMA) and reduced intensity conditioning (RIC)] the presentation of the syndrome is changing. Clinical syndromes resembling acute GVHD (aGVHD) are often recognized beyond 100 days after HCT; possibly misdiagnosed as CGVHD. Additionally, the old grading system of limited versus extensive GVHD was designed to identify patients likely to benefit from systemic immune suppression and does not capture the severity of organ involvement. The Diagnosis and Staging Working Group of the NIH Consensus Development Project on Criteria for Clinical Trials in chronic graft-versus-host-disease proposed criteria for diagnosis and assessment of overall CGVHD severity. We retrospectively reviewed 197 patients who underwent sibling donor transplant between January 2002 to December 2005 to assess the applicability of the new criteria in predicting survival and transplant related mortality (TRM). Fifty four patients were diagnosed with CGVHD [cumulative incidence 28% (95% CI 22–34%)]. Of these, 8 [cumulative incidence 4% (95% CI 2–6%)] were reclassified as Late aGVHD; 31 [cumulative incidence 16% (95% CI 11–21%) had classic CGVHD and 15 [cumulative incidence 8% (95% CI 5–11%] had Overlap syndrome. Forty six patients with Overlap syndrome and classic CGVHD were graded. Six patients (13%) had Mild, 29 (63%) Moderate and 11 (24%) Severe CGVHD. After a median follow up of 35 months (range 4.3–59.2mo), 3 year probability of overall survival was significantly worse in Late aGVHD [25%(95% confidence interval 4–56%)] as compared to Overlap [87%(56–96%)] or CGVHD [75%(54–87%), p=0.001].). Amongst patients with Overlap and CGVHD (n = 46), similar survival was seen between mild or moderate disease. However, patients with severe disease had a trend to worse survival. [Mild-moderate 3 year probability of survival 85% (68–94%) versus Severe 57%(21–82%)]. Additonally, 3 year cumulative incidence of TRM was higher in patients with Late aGVHD [38% (9–67%)] versus Overlap syndrome [13%(0–27%)] or CGVHD [7%(0–13%)], p= 0.003. A trend towards greater TRM was seen in patients with severe GVHD [18%(0–36] versus mild+ moderate GVHD [6%(0–14%)]. This analysis indicates that the consensus guidelines are applicable to related donor HCT recipients and more reliably predicts survival and TRM than older classification of CGVHD. Prospective validation and testing in alternative donor cohorts is still needed before widespread acceptance is justified.

Description: Conventional allogeneic hematopoietic stem cell transplantation (HSCT) is limited by lack of rapidly available HLA-matched donors and excess transplant-related mortality (TRM). Therefore, we investigated the use of unrelated UCBT after NMA conditioning in patients (pts) with high-risk hematologic malignancy. From 10/01 to 06/05, 95 consecutive adults [median age 50 yrs (range 18-69), median weight 78 kg (range 50-134)] received a NMA prior to UCBT. Pts were eligible if aged 〉45 yrs (n=70; 74%), or had extensive prior therapy (n=25; 26% with 17 having had a prior autologous HSCT). Therapy consisted of cyclophosphamide (50 mg/kg), fludarabine (200 mg/m2) and TBI (200 cGy), with cyclosporine A and mycophenolate mofetil immune prophylaxis. Thirty pts (32%) without prior autologous transplant or chemotherapy in the last 3 months also received anti-thymocyte globulin (ATG). Pts received one (n=17) or two (n=78) 4–6/6 HLA A,B, and DRB1 matched UCB units (109 units were 4/6, 53 were 5/6, and 11 were 6/6 HLA matched with the pt) with a median infused cell dose of 3.6 x 107 NC/kg (range 1.1–6.8). Units were 4–5/6 HLA matched to each other in instances of double UCBT. Four pts died prior to day 28. Median follow-up is 14 mos. (range 3.3–42.7). Median time to neutrophil recovery after UCBT was 12 days (range 0–32) with an incidence of sustained donor engraftment of 87% (95%CI: 80–94). Complete chimerism was achieved by day 100 in 96% of pts. Graft failure occurred in 11 (6 primary, 5 secondary), with autologous recovery in 8. In univariate analysis neither the number of donor units, age, disease risk, ATG in the preparative regimen, CMV serostatus, HLA matching, in the 3 months prior to transplant, CD34 cell dose, diagnosis, and prior autologous transplant were independent predictors of sustained donor engraftment. Multivariate analysis identified no independent predictors of sustained engraftment. Incidence of grade II-IV & III-IV acute GVHD at day 100 and chronic GVHD at 1 yr were 61% (95%CI: 49–73), 25% (95%CI: 14–36) and 25% (95%CI: 15–35), respectively. Incidence of acute GVHD was lower among recipients receiving of ATG, but the difference was not statistically significant (II-IV=46% vs. 68%, p=.19; III-IV=13% vs. 27%, p=.24). Incidence of treatment related mortality (TRM) at day 180 and relapse/disease progression at 2 years was 18% (95%CI: 10–26) and 32% (95%CI: 22–42), respectively. In multivariate analysis, only age 〉 45 yrs (RR 0.3; 95%CI: 0.1–0.9, p=.03) and no chemotherapy within the 3 months prior to transplant were independent predictors of lower TRM (RR 0.36; 95%CI: 0.13–1.0, p=.05). Overall and progression-free survival were 52% (95%CI: 39–65) and 46% (95%CI: 35–57) at 1 yr, and 44% (95%CI: 30–58) and 43% (95%CI: 31–55) at 2 yrs, respectively. In Cox regression, age 〉45 yrs (RR of death 0.5; 95%CI: 0.2–0.9, p=.02) and chemotherapy in the 3 months prior to transplant was associated with improved survival (RR of death 0.53; 95%CI: 0.28–1.0, p=.05). In summary, with our graft selection strategy, a NMA UCBT is readily available for 〉90% of patients. NMA UCBT is associated with low TRM, and prompt neutrophil recovery, with progression free survival rates comparable to reported studies with HLA matched unrelated marrow HSCT. In the largest US series to date, these data suggest that age is not a limitation to allogeneic HSCT using UCB, in particular if it is the only reason for the patient to undergo a NMA transplant.

Description: Key Points Depletion of host regulatory T cells with IL2DT improves efficacy of haploidentical NK cell therapy for refractory acute myeloid leukemia. Depletion of Treg and persistence of NK cells for ≥7 days after NK cell adoptive transfer predicts beneficial clinical responses.