Biology of Blood and Marrow Transplantation
Volume 12, Issue 1 , Pages 102-110, January 2006

Can Only Partial T-Cell Depletion of the Graft before Hematopoietic Stem Cell Transplantation Mitigate Graft-versus-Host Disease While Preserving a Graft-versus-Leukemia Reaction? A Prospective Phase II Study

Presented in part at the Annual Meeting of the American Society of Hematology, San Diego, CA, December 6-9, 2003

  • Yves Chalandon

      Affiliations

    • Hematology Service, Department of Internal Medicine University Hospital, Geneva, Switzerland
    • Corresponding Author InformationCorrespondence and reprint requests: Yves Chalandon, MD, Hematology Service, University Hospital of Geneva, 24 rue Micheli-du-Crest, 1211 Geneva 14, Switzerland.
    • ,
  • Eddy Roosnek

      Affiliations

    • Immunology and Allergology Service, Department of Internal Medicine University Hospital, Geneva, Switzerland
    • ,
  • Bernadette Mermillod

      Affiliations

    • Medical Informatics Service, Department of Internal Medicine University Hospital, Geneva, Switzerland
    • ,
  • Laurent Waelchli

      Affiliations

    • Oncology Service, Department of Internal Medicine University Hospital, Geneva, Switzerland
    • ,
  • Claudine Helg

      Affiliations

    • Hematology Service, Department of Internal Medicine University Hospital, Geneva, Switzerland
    • ,
  • Bernard Chapuis

      Affiliations

    • Hematology Service, Department of Internal Medicine University Hospital, Geneva, Switzerland

Received 29 June 2005; accepted 16 September 2005.

Article Outline

Abstract 

The study comprised 37 consecutive patients who underwent transplantation with a Campath-1H in vitro T cell–depleted granulocyte colony-stimulating factor–mobilized peripheral blood stem cell graft from an HLA-identical sibling, followed 24 hours later by an unmanipulated graft. Acute graft-versus-host disease (GVHD) was limited to grade I to II, whereas chronic graft-versus-host disease occurred in 9 patients, mostly (n = 7) with limited disease. Molecular relapses (8 chronic myeloid leukemia [CML] and 1 non-Hodgkin lymphoma) that occurred not earlier than the sixth month after transplantation were treated with donor lymphocyte infusion (DLI), which induced complete remission in all but 1 CML patient with persistent very low BCR-ABL molecular levels. With a median follow-up of 54 months (range, 29-84 months), the actuarial 5-year overall survival, disease-free survival, and transplant-related mortality are 78% (95% confidence interval [CI], 52%-88%), 78% (95% CI, 52%-86%), and 6% (95% CI, 1.5%-32%), respectively. All CML patients are alive and free of disease. The results of this prospective, nonrandomized study show that incomplete T-cell depletion in vitro with Campath-1H (in combination with DLI for molecular relapses in CML) may decrease the incidence of GVHD and transplant-related mortality with no adverse effect on disease-free survival. The described method decreases the number of T cells to an extent that severe GVHD is prevented while relapse is postponed to a time when the patient can be treated with DLI without severe side effects.

Key words:  Allogeneic stem cell transplantation , Graft-versus-host disease , Transplant-relatedmortality , Donor lymphocyte infusion , Partial in vitro T-cell depletion , Campath-1H

 

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Introduction 

Transplantation with stem cells from an HLA-identical sibling donor is a well-established therapeutic modality for hematologic malignancies [1]. Transplant-related mortality (TRM) is a major factor that influences the outcome of allogeneic hematopoietic stem cell transplantation, with an incidence that ranges from 10% to 50%, depending on the disease and age of the patient and on the type of treatment [2, 3, 4, 5, 6, 7, 8, 9, 10]. The type of treatment can be modified by adapting the preparative regimen, graft-versus-host disease (GVHD) prophylaxis, and supportive therapy to the biologic characteristics of the patient and the condition of the underlying disease [11].

Mature donor T cells in the graft may cause severe forms of GVHD, a major cause of mortality after hematopoietic stem cell transplantation (HSCT) [12]. T-cell depletion diminishes this risk but is associated with an increased frequency of relapse or graft failure, so the outcome is not different from that for HSCT with unmanipulated grafts [10, 13, 14, 15, 16, 17, 18, 19].

Peripheral blood stem cells (PBSCs) are often used as an alternative to bone marrow [20, 21, 22, 23, 24, 25, 26, 27]. Transplantation with PBSCs is associated with a more rapid platelet and neutrophil recovery [24, 25, 26, 27] and possibly also with a better survival in patients with advanced leukemia [27, 28]. However, it is still under debate whether good-risk patients with low relapse rates who undergo transplantation with PBSCs could be at a higher risk of GVHD. With the exception of a recent European Group for Blood and Marrow Transplantation trial [29], most studies have shown identical incidences of acute GVHD (aGVHD) [25, 26, 27, 28, 30]. In contrast, the incidence of chronic GVHD (cGVHD) may be higher with PBSC transplantation [26, 28, 29, 31], although this finding has not been confirmed by others [25, 27, 30].

PBSC grafts contain more nucleated cells and CD34+ cells and 1 order of magnitude more T and natural killer cells than do bone marrow grafts [32]. Depleting T cells from the graft is known, however, to increase the risk of relapse. The monoclonal anti-CD52 antibody Campath (Therapeutic Antibody Centre, University of Oxford, UK) has long been used for T-cell depletion [14, 33, 34, 35, 36, 37]. The initial experience with Campath-1M in vitro resulted in a high incidence of graft failure, but the risk was reduced by using Campath-1G in vivo [19]. Other groups did not find a difference regarding the incidence of graft failure between Campath-1M and -1G, but patients received total lymphoid irradiation as part of the conditioning regimen for further immunosuppression and prevention of rejection [36, 37]. Improved survival has been shown by using Campath-1G in vitro for PBSC grafts compared with unmanipulated PBSC infusions [38]. Recently, promising results in a small series of matched related allogeneic PBSC transplant patients were obtained with Campath-1H, the humanized form of this antibody, in vitro [39]. The incidence of aGVHD and cGVHD was 8.7% and 4.4%, respectively, and TRM was 19.1%, but the incidence of relapse was still high (48.7%).

In our single-center prospective study, we tested a protocol of partial T-cell depletion with Campath-1H in combination with donor lymphocyte infusion (DLI) for molecular relapses in chronic myeloid leukemia (CML). The strategy used was to first administer an in vitro T cell–depleted graft of PBSCs consisting of 2 pooled aphereses incubated with Campath-1H for 30 minutes and then washed before infusion into the patient. A third unmanipulated apheresis that contained approximately a third of the total number of T cells was given the next day to prevent graft failure and to decrease the risk of relapse. The residual Campath-1H contained in the first pooled aphereses did not significantly influence the T-cell content of the second unmanipulated apheresis infused 24 hours later. We show that this protocol may decrease the incidence of GVHD and TRM with no adverse effect on disease-free survival (DFS), but at the cost of DLI for molecular relapse in most patients with CML. In this limited collective, no effect on the relapse rate for acute myeloid leukemia (AML) patients was noticed.

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Patients and methods 

Patients 

Between January 1998 and August 2002, 37 successive patients with hematologic diseases received allogeneic PBSC transplants from an HLA-identical sibling at the bone marrow transplantation (BMT) unit of Geneva University Hospital. All patients gave their informed consent, and all the research studies were approved by the university and the institutional review boards.

Conditioning Regimens 

Most patients (n = 31) received cyclophosphamide (CY) combined with fractionated total body irradiation (TBI) (CY 60 mg/kg intravenously [IV] days −6 and −5, followed by fractionated TBI [1000 cGy for patients >40 years old or 1200 cGy for younger patients] [40]) with or without methylprednisolone (MP) 1 g/m2 days −2 and −1 for a total of 3 doses (19 patients with CML, aplastic anemia, multiple myeloma, lymphoma, or myelodysplastic syndrome) with or without antithymocyte globulin (12 patients with CML and aplastic anemia received antithymocyte globulin in order to decrease the risk of rejection). Three patients received a busulfan (BU)–based regimen (BU 1 mg/kg by mouth every 6 hours days −7 to −4 and CY 60 mg/kg IV days −3 and −2, or etoposide 60 mg/kg). Two patients received etoposide (60 mg/kg) combined with TBI or BU and MP. One patient with severe aplastic anemia received CY combined with MP and antithymocyte globulin. Patients receiving BU were given clonazepam as seizure prophylaxis. Uroepithelial prophylaxis with hyperhydration and continuous perfusion of mesna was administered during CY infusion and for 24 hours after the last dose of CY (Table 1).

Table 1. Patient Characteristics (n = 37)
CharacteristicData
Median age, y(range)40(18-60)
Sex(M/F)21(57%)/16(43%)
Diagnosis, n(%)
CML11(30)
AML12(32)
ALL2(5)
MDS3(8)
Lymphoma5(14)
AA2(5)
MM2(5)
Risk status (SR/HR)23(62%)/14(38%)
GVHD prophylaxis (CSA + MTX/CSA)30(81%)/7(19%)
Conditioning regimen, n (%)
With cyclophosphamide34(92)
With busulfan3(8)
With etoposide2(5)
TBI doses(1200/1000/600 cGy)21(57%)/11(30%)/1(3%)
CMV serostatus, n (%)
R−/D−12(32)
R−/D+4(11)
R+/D−4(11)
R+/D+17(46)
ABO incompatibility major, n (%)8(22)
ABO incompatibility minor, n (%)4(11)

CML indicates chronic myeloid leukemia; AML, acute myeloid leukemia; ALL, acute lymphoid leukemia; MDS, myelodysplastic syndrome; AA, aplastic anemia; MM, multiple myeloma; SR, standard risk (patients with acute leukemia in first complete remission, with CML in first chronic phase, or with AA); HR, high risk (all the others); CSA, cyclosporin A; MTX, methotrexate; TBI, total body irradiation; CMV, cytomegalovirus; R, recipient; D, donor.

PBSC Collection and GVHD Prophylaxis 

Mobilized PBSCs were collected with a Cobe Spectra (Cobe Laboratories Inc., Lakewood, CO) cell separator on days 4, 5, and 6 after stimulation with granulocyte colony-stimulating factor (lenograstim 10 μg/kg/d; Granocyte; Aventis Pharma AG, Zürich, Switzerland). The graft was analyzed to assess the number of hematopoietic progenitors (CD34+ cells) and CD3+ cells by using standard flow cytometry procedures and colony assay (colony-forming unit–granulocyte macrophage). Partial in vitro T-cell depletion was performed by treatment of the pooled day 4 and 5 aphereses with 20 mg of humanized anti-CD52 (Campath-1H produced by the Therapeutic Antibody Centre, University of Oxford, Oxford, UK, courtesy of Geoff Hale and Hermann Waldmann) [41] incubated for 30 minutes and then washed by centrifugation before infusion on day 0. The next day (day +1), the day 6 apheresis was infused unmanipulated. Details of the different GVHD prophylaxis regimens are outlined in Table 1. Most patients received cyclosporin and short-course methotrexate 15 mg/m2 day 1 and 10 mg/m2 days 3 and 6 [42, 43]. Treatment of established aGVHD was with prednisone. GVHD was graded according to standard criteria [44].

Supportive Care 

Patients were treated at the BMT unit of the Geneva University Hospital in a single isolation room with laminar air flow. Permanent central catheters (Groshong; Bard Medica SA, Geneva, Switzerland) were used routinely. Empiric IV antibiotics, liposomal amphotericin B (AmBisome; Fresenius Medical Care AG, Stans, Switzerland), acyclovir, filtrated cytomegalovirus (CMV)–negative blood products, and total parenteral nutrition were given as required. Fungal prophylaxis was fluconazole IV 200 mg/d. Pneumocystis carinii prophylaxis included trimethoprim/sulfamethoxazole administered before transplantation and as soon as the absolute neutrophil count exceeded 1 × 109/L. Patients were screened twice weekly for CMV by pp65 assay, and, upon positive findings, preemptive ganciclovir therapy was given at a dose of 5 mg/kg IV twice daily for 14 days and then at 5 mg/kg daily or as adjusted for renal impairment for 2 weeks (or longer in case of persistent CMV antigenemia) [45]. In case of neutropenia, foscarnet was given at 90 mg/kg IV twice daily for 2 weeks and then at 90 mg/kg daily or as adjusted for renal impairment for 2 weeks (or longer in case of persistent CMV antigenemia). Growth factors were used for drug-induced neutropenia and persistent febrile neutropenia. Low-dose heparin (5000 or 10000 IU IV continuously for 24 hours according to patient weight) was given routinely for hepatic veno-occlusive disease prevention [46]. Starting in October 1999, as part of another study, patients also received defibrotide as veno-occlusive disease prophylaxis [47].

Statistical Analysis 

Overall survival (OS), event-free survival (EFS; relapse or death from whatever cause), DFS (defined as survival without evidence of disease after DLI [if necessary]), transplant-related mortality (TRM), relapse, aGVHD, and cGVHD probabilities were calculated by using the product-limit method of Kaplan and Meier [48]; surviving patients were censored on December 15, 2004. Survival curves were compared by using the log-rank test. Variables are described by means of median and range.

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Results 

Patient Characteristics 

Patient characteristics are shown in Table 1. All CML patients and 8 (66%) of 12 AML patients were in the standard-risk group. All patients received PBSCs partially depleted in vitro with Campath-1H from an HLA-identical sibling. Thirty-one patients (84%) received a CY/TBI conditioning regimen, 3 patients received a BU-based regimen, and 2 patients received an etoposide-based regimen. The median time from diagnosis to PBSC transplantation was 6 months (range, 2.5-49 months).

Collection and Characteristics of Hematopoietic Stem Cell Products 

The goal of leukapheresis was to harvest a minimum of 4 × 106 CD34+ cells per kilogram of recipient body weight. All donors had 3 leukaphereses, but 7 donors (19%) did not reach the target, and the corresponding patients received a median of 3.2 × 106 CD34+ cells per kilogram of body weight (range, 2.9 × 106 to 3.9 × 106 cells). No serious adverse events were observed during PBSC collection.

Engraftment 

All patients engrafted successfully. The median time to neutrophil recovery (absolute neutrophil count of at least 0.5 Giga/liter or 109/liter [G/L]) was 14 days (range, 8-21 days; Table 2). The median time to platelet recovery (at least 50 G/L) was 13.5 days (range, 8-27 days). One patient died of infection before neutrophil and platelet recovery, at day 9 after transplantation.

Table 2. Engraftment of In Vitro T Cell–Depleted Hematopoietic Stem Cell Allograft with Campath-1H
VariableMedian (range)
Total nucleated cells infused (×108/kg)13.2(5.3-32.3)
CD34+ cells infused (×106/kg)9.6(3-49)
CFU-GM infused (×104/kg)50(3-580)
CD3+ cells infused (×106/kg)111(23-304)
ANC >0.5 G/L (d)14(8-21)
Platelets >50 G/L (d)13.5(8-27)

CFU-GM indicates colony-forming unit–granulocyte macrophage; ANC, absolute neutrophil count Giga/liter or 109/liter (G/L).

Incidence of GVHD 

The cumulative incidence of aGVHD grade I and II was 39% (14 patients) at day +100 after transplantation. Most (11 patients; 79%) had grade I aGVHD, and 3 patients had grade II disease (Figure 1A). None of the patients developed aGVHD grade III or IV. The cumulative incidence of cGVHD at 5 years after transplantation was 26% (9 patients). Most (78%) of the patients had limited disease (7 patients), 1 patient had extensive disease, and 1 patient developed bronchiolitis obliterans–organizing pneumonia, with a favorable outcome (Figure 1B).

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  • Figure 1. 

    A, Incidence of aGVHD grade I and II (○) and grade II only (•). B, Incidence of cGVHD (limited and extensive) after allogeneic PBSC transplantation partially T-cell depleted in vitro with Campath-1H.

Survival, Relapse, and TRM 

The median follow-up was 54 months (range, 29-84 months for surviving patients). Eight patients died (Table 3), and the actuarial 5-year probabilities for OS (Figure 2) and EFS (Figure 3A) were 78% (95% confidence interval [CI], 52%-88%) and 53% (95% CI, 32%-69%), respectively. The most common events were either persistent molecular disease or relapse in CML patients. The actuarial 5-year probability of relapse (molecular or hematologic) for the entire group was 43% (95% CI, 28%-65%; Figure 3B). Despite these molecular relapses, the actuarial 5-year probability of OS was 100% (95% CI, 44%-100%) for CML patients. This probability was statistically significantly different from that of the rest of the patients, with an estimated OS at 5 years of 68% (95% CI, 40%-83%; P = .045; Figure 4). Follow-up of patients with CML was between 44 and 84 months after transplantation. Conversely, regarding AML patients, the other main group of patients who underwent transplantation with this protocol (n = 12), the 5-year probability of relapse was lower than in CML patients: 28% (95% CI, 2%-54%) as compared with 63% (95% CI, 37%-89%).

Table 3. Causes of Death in Patients Who Received In Vitro T Cell–Depleted Hematopoietic Stem Cell Allografts with Campath-1H
Status at TransplantationCause of DeathSurvival Time (d)
AML CR1Infection9
AML CR1GVHD + infection223
AML primary IFR/P94
AML first relapseR/P191
Secondary AML CR1R/P488
DLBCL CR2R/P532
RAEBt CR2R/P742
MM first PRR/P1369

AML indicates acute myeloid leukemia; RAEBt, refractory anemia with excess of blasts in transformation; DLBCL, diffuse large B-cell lymphoma; GVHD, graft-versus-host disease; CR, complete remission; PR, partial remission; IF, induction failure; R/P, relapse or progression; MM, multiple myeloma.

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  • Figure 4. 

    OS after allogeneic PBSC transplantation partially T-cell depleted in vitro with Campath-1H in patients with CML (○) and in patients with other diseases (•).

For the entire group of patients, the cumulative incidence of TRM (2 patients) was 3% at 100 days (95% CI, 0.5%-14%) and 6% at 5 years (95% CI, 1.5%-32%) (Figure 2). Because of the low number of deaths in our patients, we limited our analysis of risk factors to EFS. There was a trend for a lower EFS in patients older than 40 years compared with younger patients (P = .052) and a lower EFS in CML patients (n = 11) compared with patients with other diseases (n = 26; P = .014). Risk status (P = .98) and CMV serostatus (P = .80) had no influence on EFS.

Outcome of Relapsing Patients 

Ten of fifteen patients who had persistent disease or who relapsed received DLI. Five patients could not be treated: 2 patients died of sepsis during reinduction chemotherapy, 1 had active GVHD at the time of relapse, 1 had a second transplantation, and 1 with residual extrahematopoietic disease at the time of transplantation experienced progressive disease immediately after transplantation despite a reduction of immunosuppression. The eligible 8 of 11 CML patients either with persistent molecular residual disease or in molecular relapse were treated when the BCR-ABL/ABL ratio increased 2 times at 1-month intervals in 2 consecutive determinations (between 6 and 15 months [median, 8.5 months] after transplantation). They received escalating doses of DLI (first dose, 106; second dose, 5 × 106; third dose, 107; fourth dose, 5 × 107; and up to 108 CD3+ T cells per kilogram of body weight, depending on the response) until a decrease of the BCR-ABL ratio. The median number of doses needed to obtain these results was 3 DLIs (range, 1-6).

After treatment (the median length of follow-up after DLI was 16.5 months; range, 6-50 months), 7 of 8 patients were in complete molecular remission, whereas 1 patient had persistent molecular residual disease with a stable BCR-ABL/ABL ratio <0.05% during 4 consecutive measurements at least 1 month apart. All patients converted to full donor chimerism a median of 7.4 months after DLI (range, 5.8-11.5 months).

Only 1 of the CML patients experienced GVHD after DLI, and it was mild and responded well to topical therapy. The 2 patients with relapsing multiple myeloma and non-Hodgkin lymphoma (mantle cell lymphoma) received higher starting doses of DLI (107 CD3+ cells per kilogram). The non-Hodgkin lymphoma patient went into complete remission with cutaneous GVHD after DLI, whereas the patient with multiple myeloma died from progression despite treatment. As a whole, the actuarial 5-year probability of DFS for all patients was 78% (95% CI, 52%-86%; Figure 5), and this was 100% (95% CI, 44%-100%) for the CML patients.

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Discussion 

Mortality and morbidity related to GVHD remain significant problems after HSCT. T-cell depletion decreases the risk of GVHD but increases the risk of rejection and relapse. The higher relapse rates are due to the fact that the T cells depleted to prevent GVHD are also responsible for the graft-versus-leukemia (GVL) effect. Although these 2 phenomena may be inseparable, GVL can occur without a manifest GVHD because, particularly in CML patients, the leukemic cells are more sensitive to an allogeneic reaction. The T-cell dose that induces GVL without initiating GVHD has been established in animal models [49, 50, 51] but has unfortunately proven to be much harder to determine in humans. At present, 1 × 105 T cells per kilogram is considered the critical dose, but the clinical studies in which these doses have been used have not yielded consistent results [52, 53, 54]. We followed a transplantation protocol that consisted of a first infusion of PBSCs treated in vitro with Campath-1H followed by an unmanipulated apheresis 24 hours later. The main goal was to infuse a minimum of 4 × 106 CD34+ cells per kilogram to decrease the risk of rejection and, at the same time, to increase the potential tolerizing effect associated with high doses of stem cells [55]. This goal (≥4 × 106 CD34+ cells per kilogram) was reached in 80% of the patients, whereas in the other 20%, the lowest number of CD34+ cells infused was 2.9 × 106 CD34+ cells per kilogram. No signs of rejection have been observed, and there was a low incidence of aGVHD.

The second goal was to decrease the number of T cells infused to prevent GVHD to a level that would still preserve the GVL effect. It should be noted that with the protocol used, it is impossible to know exactly how many donor T cells persist in the patient after the 2 infusions. First, not all donor T cells are lysed by the treatment with Campath-1H in vitro, and it is difficult to estimate how many will still be lysed after these cells that are coated with antibody are infused into the patient. Moreover, even after the second infusion that contains the unmanipulated apheresis, with a mean of 129 × 106 CD3+ cells per kilogram, T-cell depletion may continue in vivo because at that moment, the Campath-1H antibody coinfused with the first graft is still present at 0.21 ± 0.07 μg/mL, as measured in 5 patients by a Campath-1H–specific enzyme-linked immunosorbent assay.

However, several observations indicate that the T-cell depletion achieved with this protocol (including in vivo lysis of the third T cell–replete apheresis by residual Campath-1H) is only partial. First, there is a somewhat noticeable incidence of aGVHD that is, nevertheless, not severe (34% grade I and II aGVHD). Second, in approximately one third of our patients, some recipient T cells persisted for the first 1 to 2 months after transplantation (data not shown). Therefore, although the concentration of Campath-1H present at the time of the last infusion has been reported to be cytolytic [56], its efficacy at these borderline concentrations (0.21 ± 0.07 μg/mL) may not be complete. Third, and more important, regarding CML patients, this putative in vivo T-cell depletion may have been incomplete because full hematologic relapses during the first 6 months were not seen, whereas they occurred early in 5 (24%) of 21 CML patients who underwent transplantation previously at our institution with completely T cell–depleted grafts and with Campath-1M in vitro. We believe that this is the most significant advantage of our protocol, which translates into a high DFS rate with little morbidity. Although the frequency of CML relapses in the recipients of fully and partially depleted grafts was comparable, none of the molecular relapses in the CML patients in our current protocol occurred earlier than 6 months after transplantation. This allowed us to give the DLI at a time when the patient would suffer less from the adverse effects of this treatment, thus significantly increasing the chance of success. The lower incidence of DLI-associated GVHD observed in our study may also be related to the combination of low starting doses (106 CD3+ cells per kilogram as compared with 107 CD3+ cells per kilogram in the study of Schaap et al. [57]) and the timing of DLI (started more than 6 months after transplantation as compared with 30 days after transplantation in the study of Barrett et al. [58] or even earlier in the study of Naparstek et al. [36]). This dose- and time-dependent development of GVHD after DLI, which enables the use of protocols that result in GVL without severe clinical signs of GVHD, has also been reported by others [55, 59, 60, 61, 62].

Although not complete, the depletion was efficient enough to prevent GVHD grade III and IV. This compares very favorably to results in patients who received unmanipulated grafts [2, 4, 5, 6, 27, 28, 30] and is not worse than results in patients who received fully T cell–depleted grafts [10, 13, 14, 15, 16, 17, 18, 19, 39]. The same holds true for the occurrence of cGVHD. With only 2 patients experiencing extensive disease or bronchiolitis obliterans–organizing pneumonia, the results seem to be significantly better than those in protocols without T-cell depletion [27, 28, 30].

T cell–depleted allogeneic BMT from an HLA-identical sibling for acute leukemia using a slightly different strategy with Campath-1M in vitro or Campath-1G “in the bag” followed in a subgroup of patients by an early administration of DLI (escalating doses starting on day +1 after transplantation up to day +84) was described previously in a larger number of patients [36]. To decrease rejection, total lymphoid irradiation was added to the conditioning regimen. The results were promising, with a leukemia relapse-free survival at 2 years of 83% in patients who underwent transplantation in first complete remission, 76% in patients who underwent transplantation in second complete remission, and 42% in patients who underwent transplantation in advanced leukemia. These rates are comparable to those obtained in this study. However, the results did show a higher incidence of graft failure (6.8% versus 0%) and higher TRM (82 patients [56%] died out of 146 patients who underwent transplantation [24 from leukemic relapse and the rest from graft failure or TRM], versus 6% TRM at 5 years in our study). Moreover, with the strategy of early DLI, there was a high incidence of GVHD that nevertheless correlated with a decreased relapse rate. More recently, the same group reported their experience with Campath-1 in vitro in 216 recipients of T cell–depleted allogeneic HLA-identical sibling BMT for hematologic malignancies and nonhematologic disorders (severe aplastic anemia and hemoglobinopathies) [37]. They still found a high incidence of graft failure (11%) that was correlated with a higher concentration of Campath in vitro and in vivo.

When compared with the results of the Campath-1H “in the bag” complete T-cell depletion study of Chakrabarti et al. [39], our results are similar regarding the 3-year OS (73.1% versus 80% in our study), the relapse incidence (48.7% versus 43%), and the incidence of aGVHD grade II (8.7% versus 8.1%), but they may compare favorably regarding TRM (19.1% versus 6%). In contrast, the 26% incidence of (limited) cGVHD seemed higher than the 4.2% incidence in the complete T-cell depletion study. However, the incidence of post-DLI GVHD in the present study was less frequent and less severe; there was a 10% incidence of grade I GVHD as compared with a 25% incidence of grade II and III.

In conclusion, our protocol might be regarded as a simple substitute for more sophisticated cell-selection procedures because the incidence of severe GVHD was abrogated without increasing the frequency of relapse for AML patients. Furthermore, the occurrence of molecular resurgence in CML patients was postponed to a time when the patients could be successfully rescued by low-initial-dose DLI. With a 5-year OS of 78% (95% CI, 52%-88%), a DFS of 78% (95% CI, 52%-86%), no severe GVHD, and DLIs with only mild morbidities, we believe that this protocol finds a good compromise between the beneficial and harmful effects of allogeneic T cells and, even in the era of imatinib mesylate [63], makes allogeneic transplantation a valuable therapeutic option for CML.

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Acknowledgments 

We acknowledge the contribution of the medical and nursing staff of the 5FL+ Ward of the Hematology Division and the Medical Day Care Unit of the Oncology Division of Geneva University Hospital. We also thank Jean Ringrose for her assistance with writing the manuscript and Corinne Charrin and Colette Grand for excellent technical assistance in the stem cell laboratory. E.R. is supported by a grant from the Swiss National Science Foundation (grant no. 3100-65’357.01), by the Dr. Henri Dubois-Ferrière Dinu Lipatti Foundation, and by the Fondation pour la Lutte contre le Cancer.

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References 

  1. Armitage JO . Bone marrow transplantation . N Engl J Med . 1994;330:827–838
  2. Bearman SI , Appelbaum FR , Buckner CD , et al.   Regimen-related toxicity in patients undergoing bone marrow transplantation . J Clin Oncol . 1988;6:1562–1568
  3. Clift RA , Buckner CD , Appelbaum FR , et al.   Allogeneic marrow transplantation in patients with chronic myeloid leukemia in the chronic phase (a randomized trial of two irradiation regimens) . Blood . 1991;77:1660–1665
  4. Clift RA , Buckner CD , Appelbaum FR , et al.   Allogeneic marrow transplantation in patients with acute myeloid leukemia in first remission (a randomized trial of two irradiation regimens) . Blood . 1990;76:1867–1871
  5. Anderson JE , Appelbaum FR , Fisher LD , et al.   Allogeneic bone marrow transplantation for 93 patients with myelodysplastic syndrome . Blood . 1993;82:677–681
  6. Ringden O , Ruutu T , Remberger M , et al.   A randomized trial comparing busulfan with total body irradiation as conditioning in allogeneic marrow transplant recipients with leukemia (a report from the Nordic Bone Marrow Transplantation Group) . Blood . 1994;83:2723–2730
  7. Storb R , Etzioni R , Anasetti C , et al.   Cyclophosphamide combined with antithymocyte globulin in preparation for allogeneic marrow transplants in patients with aplastic anemia . Blood . 1994;84:941–949
  8. Mehta J , Powles R , Horton C , et al.   Bone marrow transplantation for primary refractory acute leukaemia . Bone Marrow Transplant . 1994;14:415–418
  9. Bjorkstrand BB , Ljungman P , Svensson H , et al.   Allogeneic bone marrow transplantation versus autologous stem cell transplantation in multiple myeloma (a retrospective case-matched study from the European Group for Blood and Marrow Transplantation) . Blood . 1996;88:4711–4718
  10. Soiffer RJ , Fairclough D , Robertson M , et al.   CD6-depleted allogeneic bone marrow transplantation for acute leukemia in first complete remission . Blood . 1997;89:3039–3047
  11. Mehta J , Powles R , Singhal S , et al.   Autologous bone marrow transplantation for acute myeloid leukemia in first remission (identification of modifiable prognostic factors) . Bone Marrow Transplant . 1995;16:499–506
  12. Ferrara JL , Deeg HJ . Graft-versus-host disease . N Engl J Med . 1991;324:667–674
  13. Prentice HG , Blacklock HA , Janossy G , et al.   Depletion of T lymphocytes in donor marrow prevents significant graft-versus-host disease in matched allogeneic leukaemic marrow transplant recipients . Lancet . 1984;1:472–476
  14. Waldmann H , Polliak A , Hale G , et al.   Elimination of graft-versus-host disease by in-vitro depletion of alloreactive lymphocytes with a monoclonal rat anti-human lymphocyte antibody (CAMPATH-1) . Lancet . 1984;2:483–486
  15. Martin PJ , Hansen JA , Buckner CD , et al.   Effects of in vitro depletion of T cells in HLA-identical allogeneic marrow grafts . Blood . 1985;66:664–672
  16. Martin PJ , Hansen JA , Torok-Storb B , et al.   Graft failure in patients receiving T cell-depleted HLA-identical allogeneic marrow transplants . Bone Marrow Transplant . 1988;3:445–456
  17. Goldman JM , Gale RP , Horowitz MM , et al.   Bone marrow transplantation for chronic myelogenous leukemia in chronic phase. Increased risk for relapse associated with T-cell depletion . Ann Intern Med . 1988;108:806–814
  18. Sehn LH , Alyea EP , Weller E , et al.   Comparative outcomes of T-cell-depleted and non-T-cell-depleted allogeneic bone marrow transplantation for chronic myelogenous leukemia (impact of donor lymphocyte infusion) . J Clin Oncol . 1999;17:561–568
  19. Hale G , Zhang M-J , Bunjes D , et al.   Improving the outcome of bone marrow transplantation by using CD52 monoclonal antibodies to prevent graft-versus-host disease and graft rejection . Blood . 1998;92:4581–4590
  20. Korbling M , Przepiorka D , Huh YO , et al.   Allogeneic blood stem cell transplantation for refractory leukemia and lymphoma (potential advantage of blood over marrow allografts) . Blood . 1995;85:1659–1665
  21. Bensinger WI , Weaver CH , Appelbaum FR , et al.   Transplantation of allogeneic peripheral blood stem cells mobilized by recombinant human granulocyte colony-stimulating factor . Blood . 1995;85:1655–1658
  22. Schmitz N , Dreger P , Suttorp M , et al.   Primary transplantation of allogeneic peripheral blood progenitor cells mobilized by filgrastim (granulocyte colony-stimulating factor) . Blood . 1995;85:1666–1672
  23. Bensinger WI , Clift R , Martin P , et al.   Allogeneic peripheral blood stem cell transplantation in patients with advanced hematologic malignancies (a retrospective comparison with marrow transplantation) . Blood . 1996;88:2794–2800
  24. Schmitz N , Bacigalupo A , Hasenclever D , et al.   Allogeneic bone marrow transplantation vs filgrastim-mobilised peripheral blood progenitor cell transplantation in patients with early leukaemia (first results of a randomised multicentre trial of the European Group for Blood and Marrow Transplantation) . Bone Marrow Transplant . 1998;21:995–1003
  25. Powles R , Mehta J , Kulkarni S , et al.   Allogeneic blood and bone-marrow stem-cell transplantation in haematological malignant diseases (a randomised trial) . Lancet . 2000;355:1231–1237
  26. Blaise D , Kuentz M , Fortanier C , et al.   Randomized trial of bone marrow versus lenograstim-primed blood cell allogeneic transplantation in patients with early-stage leukemia (a report from the Societe Francaise de Greffe de Moelle) . J Clin Oncol . 2000;18:537–546
  27. Bensinger WI , Martin PJ , Storer B , et al.   Transplantation of bone marrow as compared with peripheral-blood cells from HLA-identical relatives in patients with hematologic cancers . N Engl J Med . 2001;344:175–181
  28. Champlin RE , Schmitz N , Horowitz MM , et al.   Blood stem cells compared with bone marrow as a source of hematopoietic cells for allogeneic transplantation. IBMTR Histocompatibility and Stem Cell Sources Working Committee and the European Group for Blood and Marrow Transplantation (EBMT) . Blood . 2000;95:3702–3709
  29. Schmitz N , Beksac M , Hasenclever D , et al.   Transplantation of mobilized peripheral blood cells to HLA-identical siblings with standard-risk leukemia . Blood . 2002;100:761–767
  30. Couban S , Simpson DR , Barnett MJ , et al.   A randomized multicenter comparison of bone marrow and peripheral blood in recipients of matched sibling allogeneic transplants for myeloid malignancies . Blood . 2002;100:1525–1531
  31. Ringden O , Labopin M , Bacigalupo A , et al.   Transplantation of peripheral blood stem cells as compared with bone marrow from HLA-identical siblings in adult patients with acute myeloid leukemia and acute lymphoblastic leukemia . J Clin Oncol . 2002;20:4655–4664
  32. Korbling M , Anderlini P . Peripheral blood stem cell versus bone marrow allotransplantation (does the source of hematopoietic stem cells matter?) . Blood . 2001;98:2900–2908
  33. Slavin S , Or R , Weiss L , et al.   Elimination of graft versus host disease in matched allogeneic leukemic transplant recipients using CAMPATH-1 . Adv Exp Med Biol . 1985;186:813–818
  34. Hale G , Cobbold S , Waldmann H . T cell depletion with CAMPATH-1 in allogeneic bone marrow transplantation . Transplantation . 1988;45:753–759
  35. Hale G , Waldmann H . Recent results using CAMPATH-1 antibodies to control GVHD and graft rejection . Bone Marrow Transplant . 1996;17:305–308
  36. Naparstek E , Or R , Nagler A , et al.   T-cell-depleted allogeneic bone marrow transplantation for acute leukaemia using Campath-1 antibodies and post-transplant administration of donor’s peripheral blood lymphocytes for prevention of relapse . Br J Haematol . 1995;89:506–515
  37. Naparstek E , Delukina M , Or R , et al.   Engraftment of marrow allografts treated with Campath-1 monoclonal antibodies . Exp Hematol . 1999;27:1210–1218
  38. Barge RM , Brouwer RE , Beersma MF , et al.   Comparison of allogeneic T cell-depleted peripheral blood stem cell and bone marrow transplantation (effect of stem cell source on short- and long-term outcome) . Bone Marrow Transplant . 2001;27:1053–1058
  39. Chakrabarti S , Macdonald D , Hale G , et al.   T-cell depletion with Campath-1H “in the bag” for matched related allogeneic peripheral blood stem cell transplantation is associated with reduced graft-versus-host disease, rapid immune constitution and improved survival . Br J Haematol . 2003;121:109–118
  40. Bieri S , Helg C , Chapuis B , Miralbell R . Total body irradiation before allogeneic bone marrow transplantation (is more dose better?) . Int J Radiat Oncol Biol Phys . 2001;49:1071–1077
  41. Kottaridis PD , Milligan DW , Chopra R , et al.   In vivo CAMPATH-1H prevents graft-versus-host disease following nonmyeloablative stem cell transplantation . Blood . 2000;96:2419–2425
  42. Storb R , Pepe M , Anasetti C , et al.   What role for prednisone in prevention of acute graft-versus-host disease in patients undergoing marrow transplants? . Blood . 1990;76:1037–1045
  43. Storb R , Deeg HJ , Whitehead J , et al.   Methotrexate and cyclosporine compared with cyclosporine alone for prophylaxis of acute graft versus host disease after marrow transplantation for leukemia . N Engl J Med . 1986;314:729–735
  44. Glucksberg H , Storb R , Fefer A , et al.   Clinical manifestations of graft-versus-host disease in human recipients of marrow from HL-A-matched sibling donors . Transplantation . 1974;18:295–304
  45. Einsele H , Ehninger G , Hebart H , et al.   Polymerase chain reaction monitoring reduces the incidence of cytomegalovirus disease and the duration and side effects of antiviral therapy after bone marrow transplantation . Blood . 1995;86:2815–2820
  46. Attal M , Huguet F , Rubie H , et al.   Prevention of hepatic veno-occlusive disease after bone marrow transplantation by continuous infusion of low-dose heparin (a prospective, randomized trial) . Blood . 1992;79:2834–2840
  47. Chalandon Y , Roosnek E , Mermillod B , et al.   Prevention of veno-occlusive disease with defibrotide after allogeneic stem cell transplantation . Biol Blood Marrow Transplant . 2004;10:347–354
  48. Kaplan EL , Meier O . Nonparametric estimation from incomplete observations . J Am Stat Assoc . 1958;53:457–481
  49. Korngold R , Leighton C , Manser T . Graft-versus-myeloid leukemia responses following syngeneic and allogeneic bone marrow transplantation . Transplantation . 1994;58:278–287
  50. OKunewick JP , Kociban DL , Machen LL , Buffo MJ . The role of CD4 and CD8 T cells in the graft-versus-leukemia response in Rauscher murine leukemia . Bone Marrow Transplant . 1991;8:445–452
  51. Truitt RL , Atasoylu AA . Contribution of CD4+ and CD8+ T cells to graft-versus-host disease and graft-versus-leukemia reactivity after transplantation of MHC-compatible bone marrow . Bone Marrow Transplant . 1991;8:51–58
  52. Kernan NA , Collins NH , Juliano L , Cartagena T , Dupont B , O’Reilly RJ . Clonable T lymphocytes in T cell-depleted bone marrow transplants correlate with development of graft-v-host disease . Blood . 1986;68:770–773
  53. Verdonck LF , Dekker AW , de Gast GC , van Kempen ML , Lokhorst HM , Nieuwenhuis HK . Allogeneic bone marrow transplantation with a fixed low number of T cells in the marrow graft . Blood . 1994;83:3090–3096
  54. Cornelissen JJ , van der Holt B , Petersen EJ , et al.   A randomized multicenter comparison of CD34(+)-selected progenitor cells from blood vs from bone marrow in recipients of HLA-identical allogeneic transplants for hematological malignancies . Exp Hematol . 2003;31:855–864
  55. Johnson BD , Truitt RL . Delayed infusion of immunocompetent donor cells after bone marrow transplantation breaks graft-host tolerance allows for persistent antileukemic reactivity without severe graft-versus-host disease . Blood . 1995;85:3302–3312
  56. Morris EC , Rebello P , Thomson KJ , et al.   Pharmacokinetics of alemtuzumab used for in vivo and in vitro T-cell depletion in allogeneic transplantations (relevance for early adoptive immunotherapy and infectious complications) . Blood . 2003;102:404–406
  57. Schaap N , Schattenberg A , Bar B , Preijers F , van de Wiel van Kemenade E , de Witte T . Induction of graft-versus-leukemia to prevent relapse after partially lymphocyte-depleted allogeneic bone marrow transplantation by pre-emptive donor leukocyte infusions . Leukemia . 2001;15:1339–1346
  58. Barrett AJ , Mavroudis D , Tisdale J , et al.   T cell-depleted bone marrow transplantation and delayed T cell add-back to control acute GVHD and conserve a graft-versus-leukemia effect . Bone Marrow Transplant . 1998;21:543–551
  59. Sullivan KM , Storb R , Buckner CD , et al.   Graft-versus-host disease as adoptive immunotherapy in patients with advanced hematologic neoplasms . N Engl J Med . 1989;320:828–834
  60. Mackinnon S , Papadopoulos EB , Carabasi MH , Reich L , Collins NH , O’Reilly RJ . Adoptive immunotherapy using donor leukocytes following bone marrow transplantation for chronic myeloid leukemia (is T cell dose important in determining biological response?) . Bone Marrow Transplant . 1995;15:591–594
  61. Drobyski WR , Keever CA , Roth MS , et al.   Salvage immunotherapy using donor leukocyte infusions as treatment for relapsed chronic myelogenous leukemia after allogeneic bone marrow transplantation (efficacy and toxicity of a defined T-cell dose) . Blood . 1993;82:2310–2318
  62. Kolb HJ , Schattenberg A , Goldman JM , et al.   Graft-versus-leukemia effect of donor lymphocyte transfusions in marrow grafted patients. European Group for Blood and Marrow Transplantation Working Party Chronic Leukemia . Blood . 1995;86:2041–2050
  63. Druker BJ , Talpaz M , Resta DJ , et al.   Efficacy and safety of a specific inhibitor of the BCR-ABL tyrosine kinase in chronic myeloid leukemia . N Engl J Med . 2001;344:1031–1037

PII: S1083-8791(05)00674-9

doi:10.1016/j.bbmt.2005.09.010

Biology of Blood and Marrow Transplantation
Volume 12, Issue 1 , Pages 102-110, January 2006

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