Unrelated donor transplants Outcomes of unrelated ...

Bone Marrow Transplantation (2004) 34, 129–136 & 2004 Nature Publishing Group All rights reserved 0268-3369/04 $30.00

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Unrelated donor transplants Outcomes of unrelated cord blood transplantation in pediatric recipients J Styczynski1,2, Y-K Cheung3, J Garvin1, DG Savage4, GB Billote1, L Harrison1, D Skerrett5, K Wolownik1, C Wischhover1, R Hawks1, MB Bradley1, G Del Toro1, D George1, D Yamashiro1, C van de Ven1 and MS Cairo1 1

Department of Pediatrics, Children’s Hospital of New York-Presbyterian, Herbert Irving Comprehensive Cancer Center, USA; Department of Pediatric Hematology and Oncology, Medical University Bydgoszcz, Poland; 3Department of Biostatistics, Columbia University, New York, NY, USA; 4Department of Medicine, Columbia University, New York, NY, USA; and 5Department of Pathology, Columbia University, New York, NY, USA 2

Summary: We report results of unrelated cord blood transplants (UCBT) in 29 pediatric recipients in one center and the risk factors associated with survival. Median age: 9 years (0.5–20); diagnosis: ALL (9), AML (4), CML (1), HD (3), HLH (1), NHL (3), NBL (2); B-thal (1), FA (1), FEL (1), Krabbe (1), WAS (1), SAA (1); median follow-up: 11 months; conditioning: total body irradiation (TBI)-ablative (14), chemotherapy-ablative (6) and reduced intensity chemotherapy (9); GVHD prophylaxis: MMF/FK506 (18), cyclosporin A (CsA) þ steroids7MMF (7) or CsA þ methotrexate (MTX) (4); median total nucleated cells (TNC): 3.8 107/kg (1.1–11); median CD34 þ : 2.3 105/kg (0.2–9.9); and HLA match: 2 (6/6), 5 (5/ 6), 22 (4/6). Neutrophil engraftment by cumulative incidence curves 63% (median 28 (95% confidence interval (CI) 18–32)). Probability of Xgrade II acute graft-versus-host disease (aGVHD) by day þ 60 27%, Xgrade III aGVHD 20% and chronic graft-versus-host disease 3%. Estimated 1-year overall survival (OS) 46% (95% CI 30–71) and standard risk 60% (95% CI 29– 100%). Variables associated with improved survival by multivariate analysis include non-TBI-ablative conditioning (P ¼ 0.024), CD34 þ /kg (P ¼ 0.038) and gender (P ¼ 0.048). These results suggest that CD34/kg cell dose and non-TBI-ablative conditioning may be important variables influencing OS following UCBT in pediatric recipients. Given the small number of patients, these results should be viewed cautiously. Bone Marrow Transplantation (2004) 34, 129–136. doi:10.1038/sj.bmt.1704537 Published online 26 April 2004

Correspondence: Professor MS Cairo, Division of Pediatric Hematology and Blood and Marrow Transplantation, Children’s Hospital of New York – Presbyterian, Columbia University, 161 Fort Washington Ave., Irving 7, New York, NY 10032, USA; E-mail: [email protected] Presented in part at the Tandem BMT Meeting, ASBMT, Keystone, Colorado, January 2003 Received 19 June 2003; accepted 22 February 2004 Published online 26 April 2004

Keywords: UCBT; non-TBI conditioning; CD34 cell dose; GVHD; ablative conditioning

Unrelated cord blood (UCB) has been successfully used as an alternative source of allogeneic hematopoietic stem cells for patients with hematologic and nonhematologic malignant diseases, bone marrow failure syndromes, hemoglobinopathies, immunodeficiencies and inborn errors of metabolism.1–6 Transplantation of unrelated allogeneic UCB progenitor cells is now considered to be as effective as that of unrelated bone marrow progenitor cells for children and some adults for whom conventional methods of therapy failed. By July 2002, total worldwide resources of cryopreserved cord blood included over 80 000 cryopreserved units and approximately 2058 UCB transplants (UCBT) have been reported to date (1510 children and 546 adults).7,8 The clinical advantages of UCBT are rapid availability, shorter time of donor search, lower risk of transmission of viral infectious diseases, reduced immunological reactivity, lower risk and severity of acute (AGVHD) and chronic (CGVHD) graft-versus-host disease, and possibly allowing greater degree of HLA mismatching between donor and recipient.2–7 Compared with hematopoietic stem cells from adults, hematopoietic stem cells in cord blood have distinctive proliferative advantages including the capacity to form increased colonies in ex vivo culture systems, a higher cell cycle rate, autocrine production of growth factors and longer telomeres.9,10 There are only a few studies describing the results of a large cohort of UCBTs performed in one center.2,3,11 The majority of reports of UCBT are from cord blood bank registries or cord blood banks.5,12,13 However, in a large single center experience at the University of Minnesota, Wagner et al reported results of transplantation of unrelated donor umbilical cord blood in 102 patients with malignant and nonmalignant diseases.2 The main objective of this study is to report the outcomes, namely, hematological recovery, GVHD, transplantation-related mortality and overall survival (OS) of unrelated cord blood transplants in children performed in one center over the last 5 years. Our secondary objective is to determine risk factors associated with survival.

UCBT in pediatric recipients J Styczynski et al

130

Methods Patients Between August 1997 and September 2002, 29 children and adolescents (17 males and 12 females) aged 0.5–20 years (median age 9 years) with malignant (23 patients) and nonmalignant (six patients) disorders underwent unrelated cord blood transplantation at the Children’s Hospital of New York – Presbyterian, Columbia University. Diagnoses of malignant diseases included acute lymphoblastic leukemia (n ¼ 9), acute myeloid leukemia (n ¼ 4), chronic myeloid leukemia (n ¼ 1), Hodgkin disease (n ¼ 3), nonHodgkin lymphoma (n ¼ 3), neuroblastoma (n ¼ 2) and hemorrhagic lymphohistiocyctosis (n ¼ 1). Diagnoses of nonmalignant diseases were: b-thalassemia, Wiscott– Aldrich syndrome, familiar erythrophagocytic lymphocytosis, Krabbe disease, Fanconi anemia and severe aplastic anemia. Two patients had two UCBTs, thus the total number of transplants was 31. For purposes of further analyses, patients with malignancies were categorized for disease status as having standard- or high-risk disease. Patients in relapse, induction failure, refractory disease or at third or subsequent remission and chronic myelogenous leukemia in accelerated or blast phase were considered high risk. Patients with malignant diseases who did not fulfill these criteria (CR1 and CR2) and all patients with nonmalignant disorders were classified as standard-risk patients. The clinical protocols for transplantation of umbilical cord blood were approved by the Institutional Review Board at Columbia Presbyterian Medical Center and all research protocols were in compliance with the Declaration of Helsinki. Patients were eligible for enrollment if their disease was stable and they lacked an HLAidentical related or unrelated donor or if their disease was unstable and they lacked a related donor and/or an HLAmatched unrelated adult donor. Patients were eligible if they had an HLA matched 6/6, 5/6, 4/6 unrelated cord blood unit available with a minimum dose of X1.0 107 nuc/kg cryopreserved cell count. Written consent was obtained from all patients and/or their guardians.

November 2000, nonmyeloablative cytoreductive regimen was introduced for patients with selected nonmalignant diseases and AML in first and second CR and CML in CP. In all, 14 patients were conditioned with total body irradiation (TBI)-based regimen, six with chemotherapyablative regimens and nine patients received reduced intensity (RI) chemotherapy. A total of 26 patients received rabbit antithymocyte globulin (Thymoglobulins) and two patients received anti-CD52 (Alemtuzumab; CampathIHs, Berlex Laboratories, Richmond, CA, USA) prior to unrelated donor CB transplantation. In all, 14 patients were conditioned with TBI-based myeloablative chemotherapy, combined either with cyclophosphamide (n ¼ 5) or melphalan (n ¼ 9); six patients received myeloablative chemotherapy: Bu/Cy (n ¼ 3) or Bu/ Mel (n ¼ 3); and nine patients received RI chemoimmunotherapy: fludarabine 150 mg/m2, busulfan 6.4–8 mg/kg, Thymoglobulins 8 mg/kg (n ¼ 6), or fludarabine 150 mg/m2, cyclophosphamide 120–200 mg/kg, and Thymoglobulins 8 mg/kg (n ¼ 3) (Table 1).

GVHD prophylaxis Acute GVHD prophylaxis consisted of mycophenolate mofetil and tacrolimus (MMF/FK506) (n ¼ 18) as we described previously,16 cyclosporin A and methylprednisolone (CsA/MP) (n ¼ 7) or cyclosporin A and methotrexate (CsA/MTX) (n ¼ 4). Tacrolimus (Prograf) was administered intravenously 0.03 mg/kg/day from day 1 and mycophenolate mofetil (CellCept, Roche) 15 mg/kg/q12 h from day þ 1 and tapered between days 60 and 90, when AGVHD pgrade II. CsA was initiated on day 3 until day 60–90 and tapered thereafter. MP (2 mg/kg/day intravenously) was administered from day þ 5 to þ 19 with a taper thereafter. MTX was administered intravenously on day þ 1 (15 mg/m2) and then on days þ 3, þ 6 and þ 11 (10 mg/m2). The dosage of FK506, MMF and CsA was adjusted to maintain therapeutic trough levels at 10–20 mg/l,

Table 1

Conditioning regimens

Unrelated donor selection and HLA typing

Regimen

HLA-A and HLA-B typing was performed by a two-stage complement-dependent microcytotoxicity assay, and antigens were assigned as defined by the World Health Organization HLA nomenclature committee.14 HLADRB1 type was determined by hybridization of polymerase chain reaction and amplified DNA with sequence-specific oligonucleotide probes.15 Priority was given to select the most closely matched donor unit–recipient pair, and subsequently to the unit with the largest nucleated cell dose. Transplants were classified as HLA mismatched with one or two differences if disparities were detected in HLAA, HLA-B or HLA-DRB1 antigens or alleles.

Nonmyeloablative

Patients

Drugs

Dose

Fludarabine Busulfan Thymoglobulin Fludarabine Cyclophosphamide Thymoglobulin

150 mg/m2 6.4–8 mg/kg 8 mg/kg 150 mg/m2 120–200 mg/kg 8 mg/kg

6

TBI Cyclophosphamide

1200 cGy 120 mg/kg

8

TBI Melphalan

1200 cGy 135 mg/m2

Conditioning regimen

3

Pre-transplant conditioning was dependent on the patient’s disease, risk status and history of prior radiotherapy. From

3

Busulfan Cyclophosphamide Busulfan Melphalan

16 mg/kg 120 mg/kg 16 mg/kg 135 mg/m2

6

3

TBI/ablative

Chemo/ablative

Bone Marrow Transplantation


131

1–3.5 mg/ml and 200–600 ng/ml in whole blood, respectively.

aGVHD and cGVHD aGVHD and cGVHD were graded according to Seattle criteria.17 All patients were considered at risk for developing aGVHD from day þ 3 after transplantation. Only patients with sustained engraftment of donor hematopoiesis and surviving for more than 100 days after transplant were evaluated for the development of chronic GVHD.

Cord blood unit thawing, nucleated cell count and CD34 enumeration Briefly, following the method of Rubinstein et al and COBLT,18,19 the UCB graft was placed in a sterile bag and then thawed in a 381C water bath with gentle agitation. After thawing, an equal volume of dextran/albumin solution was added over 10 min, centrifuged at 400 g for 15 min at 101C and the supernatant removed. The cell pellet was resuspended in dextran/albumin and immediately infused into the patient over 30–60 min. CD34 quantitation was performed by the ProCount method (Becton Dickinson, San Jose, CA, USA). The percent CD34/45 was multiplied by the automated white blood cell count to obtain the total CD34 in the product. The final (postmanipulation) white blood cell count was used to enumerate the absolute number of CD34 cells infused.

Supportive care Patients were hospitalized in single rooms ventilated with high-efficiency particulate air filtration systems. Granulocyte-macrophage/granulocyte colony-stimulating factor was prescribed in all patients from day 0 until absolute neutrophil count (ANC) of 2.5 109/l was achieved for 3 consecutive days. Intravenous immune globulin was administered to each patient at a dose of 500 mg/kg weekly through day 100 and then once every 2–4 weeks during year one. Broad-spectrum antibiotics were administered for fever during neutropenia and amphotericin B was added for documented systemic fungal infections or for persistent fever unresponsive to antibiotic therapy. All patients received fluconazole or AmBisomes for prophylaxis of yeast infection for 100 days as we previously described,20 trimethoprim-sulfamethoxazole twice daily for 2 days each week for prophylaxis of Pneumocystis carinii for 6 months after transplantation and penicillin for prophylaxis of Gram-positive organisms during treatment of GVHD. Patients at high risk for the recurrence of herpes simplex (ie, IgG titers X1:8) received prophylactic intravenous acyclovir. Patients at high risk for the recurrence of cytomegalovirus (CMV) (ie, IgG titers X1:8) received alternating ganciclovir and foscarnet until day 100 as we described previously,21 and those with documented CMV infection were treated with ganciclovir and intravenous IgG. Patients received transfusions of leukocyte-depleted, and irradiated to 3000 cGy, platelets and packed red cells to maintain platelet counts at 20 109/l or greater and hemoglobin levels of 8 gm/dl or more after transplantation.

Hematological reconstitution and graft failure Neutrophil engraftment was defined as the first of 2 consecutive days when the ANC was X0.5. 109/l with the evidence of donor hematopoiesis. Platelet engraftment was defined as the first day to reach a sustained platelet count X20 109/l in the absence of platelet transfusion for 7 consecutive days. Primary graft failure was defined as p50% donor-derived myeloid cells in patients with ANC p0.5 109/l by day þ 60. Patients receiving a second transplant for nonengraftment were censored at the time of the second transplant.

Outcome and survival Relapse was indicated by morphological and/or radiological evidence of malignant disease in any site and was considered as time interval between UCBT and relapse, with censoring at death or complete remission. Transplantrelated mortality was defined as all causes of nonrelapse death before 100 days after transplant. Transplant-related complications were death, autologous reconstitution or infusion of a second graft. OS was the time between transplantation and death due to any cause or between transplantation and the day of last follow-up.

Statistical analysis Baseline characteristics of all patients were summarized using descriptive statistics. The median survival of this patient group was estimated with a 95% confidence interval (CI). Kaplan–Meier curves were used to summarize survival, cumulative incidence functions were used to summarize time to engraftment and time to GVHD. Cox’s proportional-hazards regression model was used to correlate each potential prognostic factor with a survival in univariate analysis. The factors that appeared to be important were then fitted together and dropped one at a time in a backward stepwise manner using the likelihood ratio test at a 0.05 level until all factors in the model were significant. A final check was made to ensure that no excluded factors would improve the fit. This variable selection procedure was based on the recommendation of Collett.22

Results Demographics In all, 29 patients underwent transplantation, with two patients receiving two transplants. The median age of patients was 9 years (range, 0.5–20) and median weight 27 kg (range, 8–95 kg). There were 17 males and 12 females. Donor sources and HLA match were: two matched (6/6), five mismatched in one locus (5/6) and 22 mismatched in two loci (4/6) (Table 2). The demographics of donor HLA disparity, maximal aGVHD and cGVHD and engraftment and survival are summarized by patient in Table 3. Bone Marrow Transplantation


132 Table 2

Demographics

Patient characteristics

Number

Median age (years) (range) Median weight (kg) (range) Gender (male:female)

9.0 (0.5–20) 27 (8–95) 17 (59%):12 (41%)

Diagnosis and status Malignant disease Standard risk Poor risk Nonmalignant disease Previous transplants

23 (79%) 17 6 6 (21%) 4 auto-HSCT

HLA disparity Identical (6/6) One difference (5/6) Two differences (4/6)

2 (7%) 5 (17%) 22 (76%)

Class mismatch (%) No mismatch Class I Class II Classes I and II

2 14 2 11

Conditioning regimens TBI ablative Chemotherapy ablative Nonmyeloablative

14 (48%) 6 (21%) 9 (31%)

GVHD prophylaxis CsA+steroids CsA+MTX FK506+MMF

7 (24%) 4 (14%) 18 (62%)

(7%) (48%) (7%) (38%)

Hematopoietic recovery and engraftment The median number of total nucleated cells (TNC) and CD34 þ cells infused was 3.8 107/kg (range, 1.1–11) and 2.3 105/kg (range, 0.2–9.9), respectively. The median time to myeloid engraftment (ANC X0.5 109/l) was 28 days. Eight of 29 patients died before day þ 60. The cumulative incidence estimate for neutrophil recovery at day þ 60 was 63%. Six out of 29 patients died prior to neutrophil engraftment (day þ 30) and 2/23 had neutrophil engraftment after day þ 60 (delayed hematological engraftment). Two patients had primary graft failure (2/23) (8.7%). By univariate analysis, nonmalignant disease (hazard ratio: leukemia 0.44; solid tumor 0.96) and HLA disparity in two loci (hazard ratio: HLA 4/6, 1.0; 5/6 and 6/6, 1.76) were significantly associated with neutrophil engraftment (P ¼ 0.006 and 0.028, respectively). The cumulative incidence estimate for platelet recovery at day þ 180 was 44%, with no difference between patients with malignant vs nonmalignant diseases. By univariate analysis, there was no single factor that significantly influenced platelet engraftment (data not shown).

aGVHD and cGVHD The cumulative incidence estimation of Xgrade II aGVHD risk at day þ 60 was 27%; the cumulative incidence estimation of aGVHD grade XIII risk at day þ 60 was Bone Marrow Transplantation

20% (Figure 1). One patient who survived over day þ 100 developed extensive cGVHD. The cumulative incidence estimate of cGVHD risk at day þ 180 was 3% (Figure 1). No factor, other than recipient gender, significantly influenced the incidence of aGVHD.

Overall survival Probability of 1-year OS for all patients was 46% (95% CI 30–71%). Probability of 1-year OS for standard-risk patients was 60% (95% CI 29–100%) and for poor-risk patients was 0%. Factors predicting positive outcome by univariate Cox’s regression (Table 4) included disease status (standard risk) (hazard ratio 2.21) (P ¼ 0.010), nonablative conditioning (hazard ratio 0.93) (P ¼ 0.033), female gender (hazard ratio males 3.62) (P ¼ 0.031), number of TNC/kg (hazard ratio 0.82) (P ¼ 0.042) and CD34/kg cells (hazard ratio 0.682) (P ¼ 0.010) (Figure 2). Using the variable selection procedure described above, the risk factors associated with a significant improvement in OS in a multivariate analysis were CD34 (P ¼ 0.038) (Table 5), non-TBI-ablative conditioning (P ¼ 0.024) (Figure 3a and b), and female gender (P ¼ 0.048) (Table 5). The Kaplan–Meier estimate of the median follow-up was 11 months. The causes of death in all 14 patients were: respiratory failure (eight patients, including multiorgan failure in three patients and pulmonary hemorrhage in one patient), sepsis (two patients), progression of disease (two patients), CNS hemorrhage (one patient) and extensive cGVHD of the gut (one patient).

Discussion We report the results of UCBT performed in a single center and its associated risk factors for survival in this population. Umbilical cord blood contains sufficient concentrations of competent hematopoietic stem and progenitor cells to reconstitute pediatric and adult patients following full myeloablation.2–6,23,24 In most studies reported to date, cell dose/kg of the weight of the recipient as defined by nucleated cells 107/kg has been the single most important factor influencing time to hematological reconstitution.5,13 More recently, Wagner et al 2 demonstrated CD34 cell dose/kg as a significant variable for not only hematopoietic reconstitution but also for OS. Patients with a CD34/kg dose of X2.6 105 had a significantly improved chance of survival (2.6 (1.3–5.4)) (Po0.01) compared to those with o1.7 105 CD34/kg.2 Our results are complimentary to Wagner et al,2 suggesting a dose of X2.3 105 CD34/kg is associated with improved survival following UCBT. In the current study, probability of neutrophil and platelet recovery and median time to engraftment were similar to results reported by other groups.2,6 In this study, nonmalignant disease and HLA disparity of two loci were associated with a significant decrease in neutrophil engraftment. However, Wagner et al2 did not demonstrate that HLA disparity was associated with neutrophil or platelet engraftment, but secondary graft failure, however, was restricted to nonmalignant disease in their study.

Table 3

Patient demographics, HLA match, cell dose, incidence of GVHD and preparative regimen for UCBT patients

NR BMT#

Sex

Age Diagnosis (years) and disease status

HLA match

TNC 107/kg

CD34 105/kg

FK/MMF FK/MMF FK/MMF FK/MMF FK/MMF FK/MMF

2.85 6.8 4.9 3.77 9.5 10.4

1 1.65 4.4 1.96 5.32 2.26

NO G3 G3 NO NO NO

NO NO NO NO NO NO

17 6.5 11 6 4 6

Red Int Chem/ABL

FK/MMF Mtx,CsA

1.61 5.2

0.77 4.32

NO NO

NO NA

11 63

TBI/ABL Chem/ABL TBI/ABL

ST,CsA CsA,ST Mtx,CsA

2.2 9.8 8.17

0.21 9.9 9.41

NO G3 G1

NO Limited NO

0.3 53 50

TBI/ABL Chem/ABL TBI/ABL

ST,CsA(FK) ST,CsA Mtx,CsA,ST

7.7 1.5 3.2

3.1 0.84 4.4

NO NO NO

NO NO NO

1 2.5 0.4

TBI/ABL TBI/ABL TBI/ABL TBI/ABL TBI/ABL

Mtx,CsA,ST ST,CsA,MMF CsA,MMF FK/MMF,CsA ST,CsA

2.1 2.1 3.37 6.5 6

2.33 1.2 2.01 3.76 2.8

G1 G2 NO NO NO

NO NO NO NO NO

4 28 0.5 11 1.1

TBI/ABL TBI/ABL TBI/ABL TBI/ABL Red Int Red Int Chem/ABL Chem/ABL Chem/ABL Red Int

FK/MMF FK/MMF FK/MMF FK/MMF FK/MMF FK/MMF FK/MMF FK/MMF FK/MMF/ST FK/MMF

1.12 1.42 3.67 3.81 1.64 6.78 2.13 11 7.96 8.09

0.6 0.43 3.1 2.8 0.89 2.14 1.28 8.48 2.96 2.93

NO NO G2 G4 NO G3 NO NO G3 NO

NO NO NO NO NO Limited NO NO NO NO

0.5 1 20 1.5 2.6 7.5 7 8 3 1

Preparative regimen

Conditioning GVHD regimen prophylaxis

FLU 150 mg/m2, Bu 6.4 mg/kg FLU 150 mg/m2, Bu 6.4 mg/kg FLU 150 mg/m2, Bu 6.4 mg/kg FLU 150 mg/m2, Bu 6.4 mg/kg FLU 150 mg/m2, Bu 8 mg/kg Bu 16 mg/mg, Cy 120 mg/kg, VP 30 mg/kg FLU 150 mg/m2, Bu 6.4 mg/kg Bu 16 mg/kg, Cy 200 mg/kg, VP 30 mg/kg TBI 1200 cGy, Mel 135 mg/m2 Bu 16 mg/kg, Cy 200 mg/kg TBI 1200 cGy, Cy 120 mg/kg, VP 40 mg/kg TBI 1200 cGy, Mel 135 mg/m2 Bu 16 mg/kg, Mel 135 mg/m2 TBI 1200 cGy, Cy 120 mg/kg, VP 40 mg/kg TBI 1200 cGy, Mel 135 mg/m2 TBI 1200 cGy, Mel 135 mg/m2 TBI 1200 cGy, Mel 135 mg/m2 TBI 1200 cGy, Mel 135 mg/m2 TBI 450 cGy, FLU 150 mg/m2, Cy 800 mg/m2 TBI 1200 cGy, Mel 135 mg/m2 TBI 1200 cGy, Cy 120 mg/kg TBI 1200 cGy, Cy 120 mg/kg TBI 1200 cGy, Cy 120 mg/kg FLU 150 mg/m2, Cy 900 mg/m2 FLU 150 mg/m2, Cy 120 mg/kg TBI 1200 cGy, Mel 135 mg/m2 Bu 16 mg/kg, Mel 135 mg/kg Bu 16 mg/kg, Mel 135 mg/m2 FLU 180 mg/m2, Cy 200 mg/kg

Red Int Red Int Red Int Red Int Red Int Chem/ABL

1 2 3 4 5 6

501-001 599-085 501-003 501-004 503-001 599-095

F F F M F M

17.5 5 18.5 10 0.5 0.7

HD CR2 NBL-PD HD PR2 ALCL PR b-Thal HLH

4/6 4/6 4/6 4/6 5/6 6/6

Double Double Double Double Class I 0

class class class class

I I I I

7 8

505-001 599-032

M F

13 1.2

CML CP FEL

4/6 4/6

Double class I Classes I and II

9 10 11

599-036 599-039 599-043

F F M

13 0.9 4

AML2 KRAB T-NHL

5/6 5/6 4/6

Class II Class I Classes I and II

12 13 14

599-048 599-051 599-057

M M M

2.1 14 8

ALL2 ALL3 ALL2

4/6 4/6 4/6

Classes I and II Classes I and II Double class I

15 16 17 18 19

599-058 599-062 599-064 599-068 599-070

F F M M M

11 15.5 13 2.3 9

ALL2 ALL ALL IF ALL CR2 FA

4/6 4/6 4/6 4/6 5/6

Classes I and II Classes I and II Classes I and II Double class II Class I

20 21 22 23 24 25 26 27 28 29

599-073 599-079 599-080 599-081 599-083 599-088 599-091 599-099 599-106 599-003

M M F F M M M M F M

15 18.5 11 9 20 2.5 11 1.5 5 4.5

AML IF AML CR2 NHL CR2 ALL CR2 HD IF WAS ALL CR3 AML CR2 NBL CR1 SAA

4/6 4/6 4/6 4/6 4/6 4/6 5/6 4/6 6/6 5/6

Class I Classes I and II Classes I and II Double class I Double class I Classes I and II Class I Double class I 0 Class II

aGVHD grade

cGVHD

Survival (months)


HLA mismatch

133


HD ¼ Hodgkin’s disease; NBL ¼ neuroblastoma; ALCL ¼ anaplastic large-cell lymphoma; b-Thal ¼ beta-thalassemia; HLH ¼ hemorrhagic lymphohistiocytosis; CML ¼ chronic myelogenous leukemia; FEL ¼ familiar erythrophagocytic lymphocytosis; AML ¼ acute myelogenous leukemia; Krab ¼ Krabbe disease; T-NHL ¼ T-cell non-Hodgkin’s lymphoma; ALL ¼ acute lymphoblastic leukemia; FA ¼ Fanconi anemia; NHL ¼ non-Hodgkin’s lymphoma; WAS ¼ Wiscott–Aldrich syndrome; SAA ¼ severe aplastic anemia; CR2 ¼ complete second remission; PD ¼ progressive disease; IF ¼ induction failure; Red Int ¼ reduced intensity conditioning; Chem/ABL ¼ chemotherapy-ablative conditioning; TBI/ABL ¼ TBI-ablative conditioning; FK/MMF ¼ FK506 and mycophenolate mofetil; MTX ¼ methotrexate; CsA ¼ cysclosporine A; ST ¼ steroids; G ¼ grade of GVHD; L ¼ limited cGVHD; E ¼ extensive GVHD; NA ¼ not applicable.


134

Figure 1

Probability of developing aGVHD or cGVHD. Probability of developing aGVHD grade II–IV (——) or grade III–IV ( - - - - - ) or cGVHD (– – ) as determined by the cumulative incidence method in patients receiving UCB transplantation.

Table 4 Univariate analysis of factors associated with survival in Cox regression model Variable Age (years) Weight Sex Female Male

12 17

Hazard ratio

95% CI

P-value

1.05 1.02

(0.97, 1.14) (1.00, 1.04)

0.259 0.110

1 3.62

(1, 13.1)

0.031 0.103

Diagnosis Nonmalignant Leukemia Solid tumor

6 15 8

1 1.65 0.76

Disease status Standard risk Poor risk

23 6

1 2.21

(1.24, 3.91)

0.820 0.682

(0.17, 1.01) (0.47, 0.99)

(0.34, 1.51)

(0.77, 3.52) (0.45, 1.28)

0.210 0.760

CD34 þ cell dose as determined by Kaplan–Meier and Cox’s regression multivariate analysis in patients receiving UCB transplantation. CD34 þ at or above 2.3 105 ( - - - - ); CD34 þ less than 2.3 105 (——) (P ¼ 0.010, 42.3 vs o2.3 105/kg).

Table 5

Multivariate analysis for overall survival

Variable Sex Female Male

12 17

CD34/kg Conditioning regimen TBI ablative Non-TBI ablative Nonablative

14 6 9

Hazard ratio

95% CI

P-value

1 3.78

(1.01–14.2)

0.67

(0.46–0.98)

0.038

1 0.46 0.76

(0.16–1.29) (0.45–1.29

0.024

0.048

TNC/kg ¼ total nucleated cell count/kg of recipient.

TNC/kg CD34/kg HLA match 4/6 5/6 and 6/6

22 7

1 0.71

Conditioning regimen TBI ablative Chemoablative Nonablative

14 6 9

1 0.39 0.93

0.010

0.42 0.010

0.339

0.033

0.249 GVHD prophylaxis FK/MMF CSA/MTX CSA/steroids

18 4 7

1 0.77 1.46

Incidence of GVHD None or Grade I Grade II or above

21 8

1 0.50

(0.27, 2.18) (0.92, 2.30) 0.265 (0.14, 1.81)

TNC/kg ¼ total nucleated cell count/kg of recipient.

The probability of Xgrade II and Xgrade III GVHD at day þ 60 was 27 and 20%, respectively. This observation is similar to results obtained in other studies of UCBT and is strikingly lower than the results of less-HLA-disparate Bone Marrow Transplantation

Figure 2 Probability of OS by CD34 þ cell dose. Probability of OS by

unrelated bone marrow transplants performed in children.2,6,7,12,23 We observed that neither the extent of HLA disparity nor the type of HLA class mismatch influenced the incidence of acute GVHD. We did observe, however, a very small increase in hazard ratio for the incidence of aGVHD in recipients of UCBT with two mismatched HLA loci. Most studies have previously demonstrated that the incidence of GVHD following UCBT is very low with 6/6 matched UCBT units. However, the incidence increases to approximately 40% for 5/6 and 4/6 HLA-disparate UCBT grafts. For 3/6 HLA UCBT-disparate grafts, the incidence reaches as high as 70%.1,3,23 Furthermore, only one patient (cumulative incidence 3%) had extensive cGVHD in our current series. Most of the studies demonstrate the incidence of cGVHD following UCBT to be in the range 9–38%.2,12,23 In comparison, cGVHD develops in 55–75% of patients receiving HLA-matched bone marrow transplants from unrelated donors.25–27 The incidence of 8.7% primary graft failure after UCBT in our study is similar to other larger reported UCBT studies and commonly occurs in patients with selected nonmalignant diseases, including marrow failure syndromes, hemoglobinopathies and/or CML. Furthermore, both of our primary graft failures occurred following RI conditioning. Barker et al 28 recently reported the results of


135

ablative conditioning (P ¼ 0.024), CD34 þ/kg (P ¼ 0.038) and gender (P ¼ 0.048). In summary, our results reconfirm that UCBT in pediatric recipients is associated with a low incidence and severity of aGVHD and cGVHD. We further suggest that non-TBI-ablative conditioning, CD34/kg and gender may be important factors associated with OS. The interpretation of this study is limited by the small number of patients and events analyzed, the heterogeneity of the diagnosis and different methods of conditioning, GVHD prophylaxis and short follow-up. This retrospective describes preliminary results that need to be confirmed in larger prospective trials. Future studies will be required to determine the optimal conditioning regimens in specific disease states and disease risk status and, secondly, the requisite CD34/kg UCB dose that is required to optimally improve long-term OS of pediatric recipients of UCBT.

Acknowledgements This work was supported in part by the Pediatric Cancer Research Foundation, Triple C Foundation, Swim Across America and Children’s Medical Care Foundation (JS). We thank the nursing staff on 5Tower (Inpatient) and Irving 7 (Outpatient) and the Pediatric BMT Team at the Morgan Stanley Children’s Hospital of New York – Presbyterian for their outstanding support and care of our patients. We also like to thank Linda Rahl for her expert editorial assistance in the preparation of this paper.

Figure 3 (a) Probability of OS by conditioning regimen. Probability of OS as determined by Kaplan–Meier and Cox’s regression multivariate analyses by conditioning regimen: TBI-ablative (—), non-TBI-ablative ( ) and RI conditioning (– – – ); TBI ablative vs non-TBI ablative, P ¼ 0.033. (b) Probability of OS by ablative vs nonablative conditioning therapy. Probability of OS as determined by Cox’s regression multivariate analyses by the intensity of conditioning regimen: Ablative (—) and nonablative ( ) conditioning (P ¼ 0.219).

RI conditioning and UCBT (0–2 antigen disparate) in adult recipients. The cumulative incidence of sustained donor engraftment ranged from 76 to 94% and depended on the intensity of the conditioning regimen.28 Their experience of RI UCBT is different from the current study because they have no pediatric recipients and more than 50% received two UCBT grafts compared to our study that had only pediatric recipients receiving one UCBT graft during their initial treatment. Estimated 1-year OS after UCBT in our series was 46% (95% CI 30–71). OS in our study appears to be improved in a subgroup of patients with standard-risk diseases (60%, 95% CI 29–100%), comparable to the results of other studies.2,24 Wagner et al2 reported a 60% 2-year OS for patients with nonmalignant diseases following UCBT. In a multivariate analysis, the results associated with a significantly improved OS in our group included: non-TBI-

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