A Successful Haploidentical Transplant By TCR Alpha Beta And CD45 RA Depletion :

A Novel Method To Do High Risk HSCT

BANSAL Shweta 1, SHAH Sameer 1 , BALSEKAR Mahesh 2, DANDEKAR Prasad 3, NACHANKAR Ankita 3, REGI Joyce 4, SHIVPRAKASH Shashikala 5 , VAZIFDAR Archana 6, DESAI Meena 6, DAVER Gustad 7

1. Department of Hemato-Oncology Sir HN Reliance Founda�on Hospital and Research Centre (HNRFH) 2. Department of Pediatrics, Sir HNRFH 3.Department of radia�on oncology, Sir HNRFH 4. Department of Transfusion Medicine, Sir HNRFH 5.department of microbiology, Sir HNRFH 6.

Department of Laboratory Medicine, Sir HNRFH 7. Medical Director, Sir HNRFH, Mumbai, IndiaE-mail: Shweta.bansal@r�ospital.org

Hope and teamwork/collaboration can take you long way ! Acknowledgements Ÿ Dr. Naveen Khattry ( Head BMT, Tata memorial Hospital, TMH )Ÿ Dr Meenakshi (TMH)Ÿ Dr. Prashant Tembhare ( TMH)Ÿ Dr. Tan Poh Lin ( Head BMT, NUH Singapore )Ÿ Prof Allen Yeoh (Head , Ped Onco , NUH , Singapore)Ÿ Prof Wing LeungŸ Nedun Chezian/ Miltenyi Biotech

Case Study

Treatment Given

Ÿ In March 2016: 2 year old baby presented with HB-6.0mg/dl, WBC-31,900/cumm, Platelet count- 7,000/cumm with 88%

blasts in peripheral blood Ÿ First BME on 08/03/2016 : Precursor B lineage Acute Lymphoblastic Leukemia

Ÿ Molecular cytogenetics : high hyperdiploidy (Tetrasomy of chromosome 21 in 90% cells and Trisomy of chromosomes 4.10.17 and 12 in 75-90% cells) No pattern showed evidence of BCR-ABL1 fusion, MLL translocation and TCF3/PBX fusion: t (1; 19).

Final Diagnosis: Standard Risk B cell ALL, with hyperdiploidy

Disease response

Relapsed Treatment

Ÿ Relapse ALLR3 protocol Ÿ Week 1-4 Etoposide + cyclophosphamide first cycle

Ÿ Week 5 : Dexa + VCR Ÿ Week 6 : HDMTX Ÿ Week 7 : VCR + Dexa Ÿ Week 8 : Inj mitoxantrone over 2 days

Relapsed Treatment complications

Ÿ Admitted in July 2017 with high grade fever

Ÿ However, few days later develop cough, mild respiratory distress and high spiking fevers

Ÿ Viral panel showed parainfluenza 4Ÿ There was pancytopenia Ÿ Serum ferritin ⍩ 10,000Ÿ SECONDARY HLH – to viral infections /to residual disease

Haploidentical Transplant- Pre transplant issues

Ÿ : Heavily pretreated , on Pre Transplantlong term heavy doses of steroids

Ÿ – MRD was negative Disease statusŸ – non myeloablative Desired planregimen , minimal GvHD , rapid immune reconstituition and good GVL effect

Approach to Haplo Transplant – what to choose

Ÿ Myeloid engraftment : D9Ÿ Platelet engraftment : D10Ÿ Chimerism D14 : 100% , D30: 100% , D60:100%

Ÿ GVHD : acute GvHD skin grade II, responded to local and oral steroids

Ÿ Infections : HHV6 + , responded to oral ganciclovir

Ÿ CMV /EBV – no reactivation

In our patient

Ÿ Conditioning Regimen : TLI/Flu/CY/TT/Melphalan and rituximab

Ÿ Cell dose :

Post transplant Immune reconstitution

4 drug Induction

- Tolerated well - Had poor tolerance to 6MP and had late counts recovery - TPMT heterozygous

HDMTX 2.5 gm/m2 x 4 doses

- Tolerated well

Reinduction – 4 drugs

- Tolerated well - MRD positive 0.03%

Consolidation

- Low dose Arac and 6MP as per BFM protoco

Delayed Intensification

- MRD negative

Started on maintenance therapy - Peripheral blasts seen after 2nd cycle of maintenance

DateMorphology /

HistologyFlow BM Cytogenetics MRD PCR CSF

th08 March 2016

Diagnosis by BMA Precursor B lineage Acute

Lymphoblastic Leukemia

high hyperdiploidytetrasomy 21, and trisomy 4,10, 17

Negative

th11 April 2016 Post Induction

Bone marrow in remission 03% blasts

Dilute bone marrow no

definitive evidence of residual disease

No tetrasomy 21, and no trisomy 4,10, 17 - diploidy in 100%

cells

-34 x 10

(done at NUH) retrospectively

Negative

th9 November 2016 Post

Reinduction

Bone marrow in remission

Hyper granular myeloid series seen 04% blasts

Revealed 0.06% residual B cell ALL-3

3 x 10 Negative

th24 Jan 2017 Post Delayed intensification

01% blasts / hematogones Dilute marrow No evidence of any

abnormality -4 <1 x 10 Negative

th17 April 2017 2nd cycle of maintenance

therapy

21% blasts Consistent with relapse of Pre B

cell ALL

CDK2NA positive FLT3 and IKAROZ

negativeRelapsed Negative

DateMorphology / Histology

Flow BM

CytogeneticsMRD PCR

CSF

th24 July 2017

In remission 0.006% ND ND Negative

CELL manipulation

Pre processing

Post processing

Recovery/ log depletion

Cd34 cells given

TCR Depleted product

TCR a/b /ul 58290 5 -/4 log

TCR g/d /ul 5520 (1.85%) 2210 (2.39%) 40%

CD34/ul 2830 1185 40% (15.46 million cells)

CD45 RA depleted product

Cd45 RA + 12700 3 -/3.6 log

Cd45 RO + 51450 (64%) 474 (1.98%)

Cd3 + 64620/ul 1130

Cd19Cd4

counts/mm3Cd8

counts/mm3NK cells

counts/mm3

D+10 0 180 217 50

D+30 0 147 314 67

D+60 0 90 247 76

Relative advantages and disadvantages of each approach to haploBMT

Clinical Outcome T-cell depletion GIAC protocol PTCy

Engraftment 2-3 1 2-3

Acute GVHD 1 3 2

Chronic GVHD 1-2 3 1-2

Infection/death from infection 3 2 1

Nonrelapse Mortality 3 2 1

Relapse 2-3 1 2-3

1 indicates most favourable; 2,intemediate; 3,least favourable. When more definitive ratings are unclear, a rangeis shown with the probable rating indicated in bold. Ratings take into account the findings of the available published studies (Table 1), but are unable to account for many factors that influence outcomes, such as differences between studies in patient characteristics or the malignant disease types, features or pretransplantation remission status.Abbrevations: GVHD, graft-versus-host-disease; haploBMT, human leukocyte antigen-haploidentical allogeneic blood or bone-marrow transplantation; PTCy, post-transplantation cyclophosphamide

Rapid memory T-cell reconstitution recapitulating CD45RA-depleted haploidentical transplant graft content in patients with hematologic malignancies

This article has been corrected since Advance Online Publication and a corrigendum is also printed in this issue.1,2 1,2 1 1 3 1,2 1,2 1,2 1

BM Triplett , DR Shook , P Eldridge , Y Li , G Kang , M Dallas , C Hartford , A Srinivasan , WK Chan , D 1 2,4 5 2,4 1,2Suwannasaen , H Inaba , TE Merchant , C-H Pui and W Leung

T-cell depletion of an HLA-haploidentical graft is often used to prevent GVHD, but the procedure may lead to increased graft failure, relapse and infections due to delayed immune recovery. We hypothesized that selective depletion of the CD45RA+ subset can effectively reduce GVHD through removal of naive T cells, while providing improved donor immune reconstitution through adoptive transfer of CD45RA– memory T cells. Herein, we present results from the first 17 patients with poor-prognosis hematologic malignancy, who received haploidentical donor transplantation with CD45RA-depleted progenitor cell grafts following a novel reduced intensity conditioning regimen without TBI or serotherapy. Extensive depletion of CD45RA+ T cells and B cells, with preservation of abundant memory T cells, was consistently achieved in all 17 products. Neutrophil engraftment (median day +10) and full donor chimerism (median day +11) was rapidly achieved post transplantation. Early T-cell reconstitution directly correlatedwith the CD45RA-depleted graft content. T-cell function recovered rapidly with broad TCR Vβ spectra. There was no infection related

mortality in this heavily pretreated population, and no patient developed acute GVHD despite infusion of a median of 4100 million per kilogram haploidentical T cells.Bone Marrow Transplantation (2015) 50, 968–977; doi:10.1038/bmt.2014.324; published online 9 February 2015

How I treat relapsed childhood acute lymphoblastic leukemiaFranco Locatelli, Martin Schrappe, Maria Ester Bernardo and Sergio Rutella

2012 120: 2807-2816Prepublished online August 15, 2012;doi: 10. 1182/blood-2012-02-265884

Very Early , Isolated Bone marrow relapse