Cord Blood vs. Unrelated DonorTransplantation

Elizabeth J. Shpall, MD

•

Allogeneic Marrow TransplantationTreatment of choice for selected high-risk patients

with:

• Acute Leukemia (ALL, AML)• Chronic Leukemia (CML, CLL)• Follicular Lymphomas• Aplastic Anemia• Several Genetic and Immunologic Diseases

Less than 30% of patients have a related donor

Increasing use of unrelated and cord blood donors

Potential Advantages of Cord Blood

• Procurement non-invasive

• Expanded donor pool: minorities targeted

• Immediate availability (overnight shipping)

• Requires less stringent HLA matching (4/6, 5/6)

• Less GVHD than marrow transplants

NMDPTransplants by Cell Source1988–2010

4

N=3038Bone marrow Peripheral bloodTransplantsYear 1980 - 2003

N=280Cord blood transplantsYear 1996 - 2010

59%

25%

M. D. Anderson BMT Department Minority Allo-transplants by Stem Cell Source

Rocha, V. et al. N Engl J Med 2004;351:2276-2285

Outcomes after Transplantation of Cord Blood or Bone Marrow from Unrelated Donors in Adults with Acute Leukemia

Eurocord data compared to EBMTR data on MUD bone marrow transplants

Cord blood n = 98Bone marrow n = 584

HLA matching Cord blood: 94% with at least one mismatchBone marrow: 100% matched

Median cell doseCord blood: 0.23 x 108 Bone marrow: 2.9 x 108

Adult Single Myeloablative CB

Investigator N Disease DFS

Ooi 77 AML 63%

Sanz 49 AML 42%

Verneris 84 ALL/AML 40%

Rodrigues 78 lymphoma 36%

Myeloablative CBTFor AML/ ALL

(CR1/ 2): Survival

Years

Prob

abili

ty

p = 0.16

0.0

0.2

0.4

0.6

0.8

1.0

0 1 2 3

II

I I II

I I II

I III

IIII I I I II I I II I I I III

Doubles (n = 29) 72% (56 - 88%)

Singles (n = 67) 47% (51-75%)

Verneris et al, Blood 2005, 106; 93a

Months

p = 0.05

0.00.20.40.60.81.0

0 4 8 12 16 20 24

Double 9% (0 - 21%)Single 30% (16 - 44%)

Relapse

Non-Myeloablative Conditioning

Fludarabine 30 mg/m2/d ATG 1.5 mg/kg/d Melphalan 100 mg/m2/d

Day -8 -7 -6 -5 -4 -3 -2 -1 0

FludarabineATG

Melphalan

TacrolimusSirolimus

DUCBT

1-6 hrs

TacrolimusDay -8 -7 -6 -5 -4 -3 -2 -1 0

FludarabineATG

Melphalan

TacrolimusSirolimus

DUCBT

1-6 hrs

Day -8 -7 -6 -5 -4 -3 -2 -1 0

FludarabineATG

Melphalan

TacrolimusSirolimus

DUCBT

1-6 hrs

DUCBT

1-6 hrs

Tacrolimus TacrolimusTacrolimusSirolimusTacrolimus

MMFCyclosporine

Promising Overall Survival after Nonmyeloablative CB Transplantation

Years

Cum

ulati

ve P

ropo

rtion

0.0

0.2

0.4

0.6

0.8

1.0

0 1 2 3 4 5

IIIIIIII

I III II IIII I I II I I I II I II IIIIII I II I

I III I IIIII II I II I I II II I I II II I I II II I I II I IIIII

45% (95%CI 36-54)

Brunstein et al. Blood 2007

Methods-Eapen et al

• Explored whether there were survival differences by conditioning regimen within each graft source:– survival after dCB with TBI200/Cy/Flu ± ATG vs. dCB

with other regimens– No differences in the PB group

• Therefore 4 treatment groups were created:– MUD (8/8 allele matched unrelated donor)– MMUD (7/8 allele matched unrelated donor)– dCB, TCF – dCB, other

Patient CharacteristicsVariables MUD MMUD dCB,

TCFdCB, other P-value

Number of patients 313 111 121 40

Median age (years) 59 58 55 48 <0.0001

CMV Seropositive 56 % 60% 68 % 78 % 0.021

Performance score < 90% 39% 40% 27% 43% 0.036

Year of transplant 2000-2004 31% 26% 21% 8% 0.0061

2005-2009 69% 74% 79% 92%

Median follow-up of survivors (months) 35 25 25 25

Disease CharacteristicsVariables MUD MMUD dCB,

TCFdCB, other P-value

Number of patients 313 111 121 40

AML 94% 90% 82% 75% <0.0001

ALL 6% 10% 18% 25%

CR1 53% 48% 61% 25% <0.0001

CR2 21% 17% 27% 43% CR3+ 3% 5% 6% 5%PIF, relapse 24% 30% 6% 28%

Conditioning RegimensVariables MUD MMUD dCB,

TCFdCB, other

P-value

Number of patients 313 111 121 40

TBI + CY + FLU ± ATG 0 0 100% 0 <0.0001

TBI + FLU ± ATG 24% 18% 0 5% TBI + FLU + BU ± ATG 3% 5% 0 15%

BU + FLU ± ATG 38% 41% 0 5% MEL+ FLU ± ATG 27% 27% 0 70% CY + FLU ± ATG 8% 9% 0 5%

Neutrophil Recovery

Fk10_54.ppt

Cum

ulat

ive

Inci

denc

e, %

Days0 7 14 422821

100

0

20

40

60

80

90

10

30

50

70

0

100

20

40

60

80

90

10

30

50

70

35

MMUD: 95%

MUD: 96%

P=0.0007

dCB, TCF: 83%

dCB, other: 83%

Platelet RecoveryC

umul

ativ

e In

cide

nce,

%

Months0 1 2 643

100

0

20

40

60

80

90

10

30

50

70

0

100

20

40

60

80

90

10

30

50

70

Fk10_53.ppt

5

MMUD: 89%

MUD: 90%

dCB, TCF: 66%

dCB, other: 58%

P <0.0001

Grade 3-4 Acute GVHDC

umul

ativ

e In

cide

nce,

%

Months0 1 2 643

100

0

20

40

60

80

90

10

30

50

70

0

100

20

40

60

80

90

10

30

50

70

Fk10_51.ppt

5

MMUD: 22%

MUD: 13%

dCB, TCF: 17%

dCB, other: 18%

P=NS

Chronic Graft vs. Host DiseaseC

umul

ativ

e In

cide

nce,

%

Months0 6 12 362418

100

0

20

40

60

80

90

10

30

50

70

0

100

20

40

60

80

90

10

30

50

70

Fk10_50.ppt

30

MMUD: 54%

MUD: 56%

dCB, TCF: 34%

dCB, other: 36%

P<0.0001

Leukemia-Free SurvivalP

roba

bilit

y, %

Months0 6 12 362418

100

0

20

40

60

80

90

10

30

50

70

0

100

20

40

60

80

90

10

30

50

70

Fk10_49.ppt

30

MMUD: 25%

MUD: 31%

dCB, TCF: 26%

dCB, other: 9%

P=0.017MUD vs. dCB other 0.68 (0.47 – 0.99) 0.046

N=536CBT 128MRD 204MUD 152MMUD 52

P=NSP<0.01

MRD p<0.01MUD p=0.13MMUD p<0.01

Double CBT LFS is comparable to MRD and MUDFred Hutchison Ca Center and Univ Minnesota

Brunstein and Delaney, Blood 2010

• Low Cell Dose• Delayed Engraftment• Delayed Immune Reconstitution • Increased Graft Failure

Disadvantages of Cord Blood vs. Bone Marrow or Peripheral Blood Progenitor Cell (PBPC)

Transplantation

PBPC remains the “gold standard” against which performance of CB compared:• Neutrophil engraftment (>500/µl) 11 days• Platelets engraftment (>20,000/µl) 13 days• Engraftment failure rate <1%

Mesenchymal Stem Cells (MSC)

• MSC are a stromal componentof the hematopoietic microenvironment.

• They provide cellular and extracellular components of the stem cell “niche”.

• When isolated and used in vitro

in combination with cytokines, MSC markedly increase the expansion of CB hematopoietic progenitors.

Day 1- 7 co-culture

SCFG-CSFFlt-3LTPO

T150

Day 14: Non-

adherent cells washed and infused

1 liter

Day 7-14 culture

FrozenCB unit

CB MNCthawed

and washed

14 day ex vivo expansion culture

10 bags

10 flasks

M. D. Anderson CB Expansion Trial with“off-the-shelf” Angioblast MPC (N=24)

4 days

Single vial ofAngioblast MSC

+

Day 0Infuse unmanipulated CB (CB#2)

ANDEx vivo expanded CB (CB#1)

Day –8 to –2 High-Dose TherapyG-CSF

Thaw & washunmanipulated CB

(CB#2)

Day -14Thaw &

wash CB#1

Ex vivo CB#1-MSC co-culture expansion for 14 days

0

Day 0Infuse unmanipulated CB (CB#2)

ANDEx vivo expanded CB (CB#1)

Day –8 to –2 High-Dose TherapyG-CSF

Thaw & washunmanipulated CB

(CB#2)

Day -14Thaw &

wash CB#1

Ex vivo CB#1-MSC co-culture expansion for 14 days

0

Day Preparative regimen -9 Hydration Therapy-8 Melphalan 140 mg/m2

-7 Thiotepa 10 mg / Kg -6 Fludarabine 40 mg/m2

-5 Fludarabine 40 mg/m2

-4 Fludarabine 40 mg/m2 Rabbit-ATG -3 Fludarabine 40 mg/m2 Rabbit-ATG -2 Rest-1 Rest0 CB Infusions

MSC-CB Expansion Trial

GvHD Prophylaxis:Tacrolimus and MMF

Day 0Infuse unmanipulated CB unit

ANDEx vivo expanded CB unit

Median time to engraftment (range)

Neutrophil (>500/µl) 15 days (range 9-42)Platelet (>20,000/µl)40 days (range 13-62)

Cumulative Incidence of Engraftment

Neutrophil (>500/µl) 97% (n=31)Platelet (>20,000/µl) 81% (n=26)

- One patient died before engraftment

MSC-CB Expansion Trial Engraftment Data

de Lima et al. Blood (ASH Annual Meeting Abstracts), 2010; 116: 362

0

20

40

60

80

100

0 6 12 18 24 30 36 42

Days after Transplant

Cum

ulat

ive

Inci

denc

e (%

)

CIBMTR (@26 days, 53%, N=80)

Angioblast(@26 days, 88%, N=24)

@26 daysP<0.0001

M. Horowitz et al.

Cumulative Incidence of Neutrophil Recovery

0

20

40

60

80

100

0 6 12 18 24 30 36 42 48 54 60

Days after Transplant

Cum

ulat

ive

Inci

denc

e (%

)

CIBMTR(@60 days, 31%, N=80)

Angioblast (@60 days, 67%, N=24)

@26 daysP=0.0008

M. Horowitz et al.

Cumulative Incidence of Platelet Recovery

Obstacles to Successful Outcomes after Cord Blood Transplantation: GVHD

Potential Solution:• Cord Blood Regulatory T cells (Tregs) co-

expressing CD4/CD25 have been shown to inhibit alloreactive T cell function

• We hypothesized that prophylactic infusion of 3rd party CB Tregs would abrogate GVHD

CD4+25+ CB cells isolated magnetically and cultured with IL2

and• Xcyte Bead CD3/28 co-expression (cell:

bead=1:3) or• Clone 4 K562-APCs (cell:bead=1:4)

APC

CD64

OKT3 IL-15

CD187c

CD86

CD69

Parmar et al.

Expanded CD25+ cells show phenotype consistent with Tregs

Ex vivo expanded CB Tregs reduce GVHD and enhance survival in mice

Treg+PBMC

PBMC alone p < 10-4

Days post Transplant

Log rank test

0

1

2

3

4

AV. GVHD score

PBMC ONLY

PBMC + Treg

Parmar et al.

Recipients of Tregs do not show signs of GVHD – Parmar et al.

NO Treg WITH Treg NO Treg WITH Treg

LUN

GLI

VE

R

A clinical trial with CB Tregs is being designed

Obstacles to Successful Outcomes after Cord Blood Transplantation: Relapse

• Large granular lymphocytes, comprising 10-15% of all peripheral blood lymphocytes

• CD56+CD3-

• Have the ability to directly kill target cells in an MHC-independent manner

• GVL without GVH

Potential Solution:Expansion of CB-NK cells

1

10

100

1000

10000

CD56+ alone Frozen cord, APC Fresh cord, APC

Nina Shah et al

CB-derived NK Cells can kill Primary CLL

Cells in vitro – Bollard Laboratory

-3 -2 -1-4-6 -5 30 1000

Specific cell populations will be generated in the GMP Lab:

Future Directions: Cord Blood Transplantation in the Next 5 Years

Viral-TumorSpecificCB T cells

MSC-Expansion +/- FTVI for neut and plat engraftment Adeno

CMVEBV

Tumor-SpecificCB NK cells

B Cell MyeloidTumors

CB#1 CB#2

CB Tregs

Acknowledgements

Richard Champlin Marcos de Lima Elizabeth ShpallLaurence Cooper Frank Marini John McMannisSimrit Parmar Chitra Hosing Nina ShahBorje Andersson Michael Andreeff Simon RobinsonSteven Kornblau Sergio Giralt Hong Yang Roy Jones Peter Thall Dongxia Xing Martin Korbling Paolo Anderlini William Decker Amin Alousi Issa Khouri Michael ThomasNaoto Ueno Jeffrey Molldrem Patrick ZweidelerPartow Kebriaei Muzaffar Qazilbash Tara SadeghiLaura Worth Demetri Petropoulos Indreshpal KaurMark Munsell Marcelo Fernandez-Viña Sufang LiJingjing Ng Ping Fu Jared BurksDoyle Bosque Lori Griffin Susan KellyGabriela Rondon Rima Saliba Sufira Kiran

Paul SimmonsNatalie Brouard

Funding NCI : R01- CA061508NCI : PO1- CA148600CPRIT: RP100469CPRIT: RP 100430CLL Global Research FoundHRSA: 234200737

Catherine BollardGianpietro Dotti

Ann LeenBarbara Savoldo

Mary HorowitzMary Eapen

Ian McNieceKrishna Komanduri