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