Allogeneic Hematopoietic Stem Cell Transplant in Severe Thalassemia Patients:

Time to Transplant

Suradej Hongeng, MD

Professor of Pediatrics

Faculty of Medicine Ramathibodi Hospital,

Mahidol University, Bangkok, Thailand

Outline

Definition of severe thalassemia

Outcome of HSCT thalassemia worldwide

Result of unrelated and haploidentical HSCT in thalassemia

Result of HSCT in older thalassemia (class 3)

Result of cord blood transplant in thalassemia

How to define the risk group of thalassemia for HSCT

How to improve the outcome HSCT in thalassemia

Splenectomy prior to HSCT ??????

Severe Thalassemia

Onset of disease at one to three years of ageFrequent blood transfusion (monthly)HepatosplenomegalyHemoglobin level less than 8 gm/dL

(pre-transfusion level)Thalassemic facies

Thalassemia

α thalassemia disease

Hb bart ( _ _ / _ _ )

Hb H disease ( _ _ /_ α )

β thalassemia disease

Homozygous β thalassemia

Hb E /β thalassemia

Pathophysiology of -Thalassemia/Hb E Disease

thalassaemia intermedia (Hb E/ thalassaemia)

Courtesy of Dr. Vip Viprakasit, Siriraj Hospital, BKK

Clinical heterogeneity in Hb E/ thalassaemia

V. Viprakasit, unpublished data 2007Fucharoen S, Winichagoon P. Curr Opin Hematol. 2000;7:106-112

0-4 4.1-5 5.1-6 6.1-7 7.1-8 8.1-9 9.1-10 >10 Hb (d/dL)

Baseline Hb level in Pediatric Patient with HbE/β Thalassemia

Treatments in Severe Thalassemia

Palliative treatment Blood transfusion Iron chelation SplenectomyCurative treatment Hematopoietic stem cell transplant (HSCT)

Gene therapy

HSCT in Thalassemia thalassemiaHomozygous β thalassemiaHbE/β thalassemia (only severe cases) (Hb level range from 2 gm/dL to 9 gm/dL)

thalassemia ??HbH and AE Bart’s; some mutations Bart’s Hydrops; high level of Portland

hypertransfusion then followed by HSCT

Key Issues for HSCT in Thal

• Conditioining regimen: Bu + Cy• Donor• Source of HSC• Risk group

Results of MRD in HSCT for Thal Patients

Reference Patients OS TFS

Di Bartolomeo et al. 111 90 86

Argiolu et al. 37 88 88

Clift et al. 68 94 81

Lawson et al. 54 95 82

Ghavamzadehv et al. 60 83 73

Denninson et al. 50 76 68

Lin et al. 28 86 82

Lee et al. 44 86 82

Issaragrisil et al. 21 70 53

BMT in Thalassemia

Risk factors for BMT in thalassemia

Chelation Regular vs IrregularHepatomegaly Absent vs PresentLiver fibrosis Absent vs Present

Risk classes for BMT in thalassemia

Chelation Hepatomegaly Fibrosis

Class1 Regular NO NOClass2 Reg/Irreg NO/YES NO/YESClass3 Irregular YES YES

Lucarelli G et al. N Engl J Med 1990

Dilemma in HSCT in Thalassemia

Searching for a suitable donor

Class 3 (older patients)

Dilemma 1

Searching a suitable donor

Unrelated donor

Haploidentical donor

Unrelated Donor BMT in Thalassemia

• 68 patients• Median age of 15 yrs (2-37 yrs)

• Conditioning regimens:• BUCY 17 (25%)• BUTTCY 42 (62%)• BUTTFLU 9 (13%)

• GVHD prophylaxis:• CsA+MTX 52 (75%)• CsA+MTX+ATG 17 (25%)

• aGVHD gr II-IV 24/59 (40%)• cGVHD 10/56 (18%)

La Nasa et al. Ann NY Acad Sci 2005

Unrelated Donor BMT in Thalassemia

Class 1 and 230 patients, median age 8 yearsaGVHD gr II-IV 29%cGVHD 11%

Class 338 patients, median age 19 yearsaGVHD gr II-IV 56%cGVHD 27%

La Nasa et al. Ann NY Acad Sci 2005

Treosulfan, Thiotepa, Fludarabine, ATG (unrelated) Blood; 2012

HSCT in Thalassemia at Ramathibodi

Related n=28, Unrelated n=21 Total 49 patients

Overall survival (OS) and thalassemia free survival (TFS) in Thai children

Hongeng S et al. Biol Blood Marrow Transplant 2006

82%

71%

92%

82%

HSCT in Thalassemia at Ramathibodi

1989-2011

Thalassemia ( n = 102 pts)

Homozygous β thalassemia 26 pts

HbE / β thalassemia 74 pts

Alpha thalassemia 2 pts

Conditioning Regimens and GVHD Prophylaxis

Related group and age < 10 yrs

Cyclo 200 mg/kg, Bu 14-16 mg/kg PO/IV

CSA + MTX (CB; pred)

Unrelated group and < 10 yrs

Cyclo 200 mg/kg, Bu 14-16 mg/kg PO/IV, Fludara 210 mg/m2

and ATG (Fresenius) 40 mg/kg

FK506 + MTX (CB; Pred)

Related and Unrelated age > 10 yrs

RIC regimen; Busulfan, Fludara and ATG (Thymoglobulin)

CSA or FK 506 + MMF

0.00

0.25

0.50

0.75

1.00

0 50 100 150 200

analysis time

89% (95%CI:70-93)

TFS 102 Thal Patients at Ramathibodi

(Update 2012) Related = 67, Unrelated = 35

(month)

0.00

0.25

0.50

0.75

1.00

0 50 100 150 200analysis time

Kaplan-Meier survival estimate

OS 102 Thal Patients at Ramathibodi

(Update 2012) Related 67, Unrelated 35

92 % (95%CI:77-94)

(month)

TFS (Related and Unrelated) Update 2012

at Ramathibodi (n = 102)

94% (95%CI:72-96) n = 67

81% (95%CI:49-84) n = 35

OS (Related and Unrelated) Update 2012at Ramathibodi (n=102)

97%(95%CI:81-99) n = 67 84%(95%CI:57-91) n = 35

Unrelated HSCT at Ramathibodi

Previous

HLA matching: Intermediate to high resolution: HLA A B DRB1

21 pts: TFS and OS; 71% and 82%

Recent

HLA matching: Strictly matched high resolution: HLA A B C DRB1

14 pts: TFS and OS = 94%

Haploidentical HSCT (34+ selection)

31 pts

Myeloablative regimen; Cyclo, Bu, Flu,Thiotepa and ATG

GVHD prophylaxis

CSA

Sodani et al, Pediatr Rep

2011

Dilemma 2

Class 3 patients

All class 3 patients are the same?

What should be done for this group?

BMT in Class 1 and 2

• 515 class 1 and 2 aged less than 17 years• BU 14 mg/kg and CY 200 mg/kg

Lucarelli G and Gaziev J. Blood Rev 2008

BMT in Class 3 Thalassemia

56 children aged < 17 yearsMRD, BU14CY200

95 children aged < 17 yearsMRD, BU14CY<200

Lucarelli G et al. Blood 1996

BMT in Adult Thalassemia

• 107 patients aged 17 – 35 years, MRD BMT• Class 2 (n=18), BU14 CY200; class 3 BU14-16 CY120-160• Reduced dose intensity of conditioning was not associated with higher rejection rate• Adult patients could be given less intensive conditioning to overcome excessive TRM.

Gaziev J, et al. Ann N Y Acad Sci 2005

High risk; age > 7 and hepatomegaly BBMT; 2007

Sabloff et al. ICBMTR, Blood 2011

What Kind of Conditioning Regimen?

Myeloablation

Reduced intensity

Non-ablation

New Approach for BMT in Children with Class 3

Protocol 26• DF 40 mg/kg cont IV, d – 45 to – 11• PRC every 3 days, Hb 14 – 15 g/dL• HU 30 mg/kg daily• Azathioprine 3 mg/kg daily• FLU 20 mg/m2/d, d – 17 to – 13• BU14CY160

33 class 3 patients Aged less than 17 years;

70% of pts age < 10 yrOS 93%, TFS 83% rejection rate 8%

Sodani P et al. Blood 2004

Protocol 26 for BMT in Adult Patients

• Protocol 26 in adult thalassemia (n=15)• Decreased CY90• Decreased TRM from 37% to 27% (still high)• Low rejection rate• Adult patients may be suitable for reduced intensity regimen

Gaziev J, et al. Ann N Y Acad Sci 2005

RIC SCT in Thalassemia

• A RIC SCT for thalassemia performed by Resnick et al (BMT 2007)

• 20 patients, median age 5.6 yrs (2.4 – 23.3 yrs)• 11/20 (55%) at least class 2• Conditioning regimen

– Fludarabine 30 mg/m2/day x 6 days (day -9 to -4)– BU 8 mg/kg (2 pts), 16 mg/kg (6 pts); IVBU 3.2 mg/kg/day x 4

days (day -7 to -4) – ATG-F 10 mg/kg/day x 4 days (day -4 to -1)

• Donors: MSD 17, MFD 1, MUD 2• Stem cells: PBSC 8, BM 12• GVHD prophylaxis: CsA

Resnick et al. BMT 2007

RIC SCT in Thalassemia

• 19/20 primary engraftment

• Graft rejection = 3

• Stable mixed chimerism = 3

• aGVHD gr I – II = 25%

• cGVHD = 25%

• Substitution of HD CY by FLU and ATG is effective.• Weekly monitoring chimerism and gradual withdrawal of immunosuppressive• BM is a preferred source in the future (no GVHD from MSD BM)

Resnick et al. BMT 2007

Treosulfan, Thiotepa, Fludarabine, ATG (unrelated) Blood; 2012

Our Approach for Patients with Class 3 and Older than 10 yrs

High Risk Class 3 Patients

Definition

Older patients

Age > 10 yrs

Hepatomegaly

Class 3 Lucarelli (Age > 10 y and Hepatomegaly) Pre-transplant Management

Hypertransfusion in order to decrease erythroid expansion especially to decrease spleen size

Regular iron chelation for at least 6-12 months

Hydroxyurea (Hb F enhancer) in order to decrease erythroid expansion: 20 mg/kg/day for at least

6-12 months

Sodani P et al. Blood 2004Hongeng S et al. Am J Hematol 2007

Conditioning Regimen for Patients Older than 10 yrs

Past

Combination of cyclophosphamide and busulfan

Too much alkylating agent regimen

Too toxic

Long term toxicities; gonadal toxicity

? 2nd malignancies

Therefore

Finding a novel approach

Patient Characteristics

Total 24 patients

All patients aged older than 10 yrs.

(median 18; range 11-22)

All have hepatomegaly; > 5 cms

Previous RIC Regimen(Early 8 Patients)

Busulfan oral (8-12 mg/kg)

Fludarabine (210 mg/m2)

ATG (Fresinius 20 mg/kg)

+TLI 500 cGy

+ Thiotepa 10 mg/kg

+ Melphalan 100 mg/m2

GVHD prophylaxis

CSA or FK506 and MMF

2 Iannone R, et al. BBMT 2003

3 Horan JT, et al. BMT 2005

4 Jacobsohn DA, et al. Lancet 2004

5 Krishnamurti L, et al. BMT 2006

Am J Hematol, 2007

TFS and OS of RIT in 24 Thal Patients

0.00

0.25

0.50

0.75

1.00

0 20 40 60 80

time (months)

EFS OS

probability survival estimates

92 % (95%CI:50-96)

Novel Reduced Toxicity Regimen for Transplantation in Older Severe Thalassemia Patients:

Sequential Immunoablation

Suradej Hongeng, Samart Pakakasama, Usanarat Anurathapan, Duantida Songdej, Nongnuch Sirachainan,

Ampaiwan Chuansumrit

Dept. Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

Sequential Immunoablative Program

Fludarabine 40 mg/m2 x 5 days

Dexamethsone 25 mg/m2 x 5 days

28-day cycle prior to conditioning regimen

Ten patients received 1 cycle

Eight patients received 2 cycles

Conditioning Regimen

Fludarabine 35 mg/m2; d-9,-8,-7,-6,-5,-4

Busulfex 130 mg/m2; d-9,-8,-7,-6

ATG (Thymoglobulin) 1.5 mg/kg; d-3,-2,-1

GvHD Prophylaxis

CSA or FK506

MMF for 60 days

Patient Characteristics

Eighteen patients were included in this study.

Two out of 18 had second HSCT.

Homozygous β thal = 4; β thal/HbE = 14

Age; median = 14 yr (10-18 yr)

Male 7; Female 11

Splenectomy = 7 (Referral hospital)

All patients had liver > 5 cm below costal margin

Ferritin level; median = 2892 ng/mL (869-8350)

All were class 3. (High risk class 3)

Graft

17 patients received PBSC

1 patient received BM

Median CD34+ dose 9.43 cells/kg (4.67-19.26)

MRD 11 MMRD 2 (DRB1)

MUD 3 MMUD 2 (C)

Engraftment

All were engrafted.

PMN engraftment; median d+12 (11-18)

Platelet engraftment; median d+18 (12-47)

GvHD

Acute GvHD

gr II-IV 4 patients (22%)

Gr III-IV none

Chronic GvHD

Mild 5 patients (28%)

Extensive none

Complications

Mild VOD 3 patients (16%)

Mucositis gr 1 3 patients (16%)

Infections

CMV reactivation 3 patients

BK reactivation 1 patient

BK cystitis 1 patient

Herpes zoster 1 patient

Chicken pox 1 patient

Sequential Immunoablative Concept

We have tested T cell function by PHA stimulation before and after Flu Dex administration.

CSFE CD4 cell proliferation

Stimulation index (SI)Percentage of CFSElowCD4 cells (PHA)

Percentage of CFSElowCD4 cells (Neg control = no PHA)

Venken et al.Journal of Immunological Methods 322 (2007) 1–11

No.1 = KCNo.2 = AKNo.3 = AS

Outcome

Two patients died.

1Cerebellar hemorrhage from motorcycle accident.

2IPA

16/18 patients survived without thalassemia symptom. Median follow up time 30 months

0.0

00.2

50.5

00.7

51.0

0P

rob

ab

ility

0 2 4 6Years

Overall survival Thalassemia Free-survival

Survival and Thalassemia-Free Survivals of Patients Treated with Novel Reduced Toxicity HSCT (unpublished data)

88% (95% CI, 0.5327 - 0.9621)

Source of HSC for HSCT in Thal

• BM

• PBSC

• CB

Related Donor CBT for Thalassemia

• Multicenter study (Eurocord group)

• 33 patients with thal major (11 SCD)

• Class1 = 20, class2 = 13

• Full matched HLA (32), 5/6 (1)

• Conditioning regimen: BU16CY200, ATG/ALG BUCY+/-FLU+/-TT

• Median TNC 4 x 10^7/kg

• Engraftment: 7/33 primary graft failure 3 persistent MC

Locatelli F et al. Blood 2003

Related Donor CBT for Thalassemia

• Transplant related complications

• No life threatening infection

• aGVHD 11%, cGVHD 6%

• 2 yr EFS 79% class1 (89%), class2 (62%)

• MTX decreased EFS

Locatelli F et al. Blood 2003

Unrelated Donor CBT for Thalassemia( n= 35)

Jaing et al, BMT 2012

UCBT in Thal and SCD

Cell dose > 5 x 10(7) /kg; Better outcome

Ruggeri et al. EBMT data, BBMT 2011

Post HSCT Management to Prevent Rejection

Mixed Chimerism After BMTLucarelli Group

BMT 335 thalassemic patients

Chimerism status at 2 months

Complete chimerism227 (67.8%)

Mixed chimerism108 (32.2%)

CC218 (96%)

PMC9 (4%)

PMC73 (67.6%)

GR35 (32.4%)

Andreani M, BMT 2000

Mixed Chimerism After BMTLucarelli Group

108 mixed chimerism

MC1 (RHCs<10%)61 (56.5%)

MC2 (RHCs 10-25%)27 (25%)

MC3 (RHCs>25%)20 (18.5%)

CC57%

CC44%

CC0%

PMC30%

PMC15%

PMC10%

GR13%

GR41%

GR90%

Andreani M, BMT 2000

Management for Mixed Chimerism

Chimerism study weekly after engraftment for 3 months

If MC with recipient > 10-25%

Decrease immunosuppressive agents

MC with recipient > 25%

Donor lymphocyte infusion

or

Minimal conditioning regimen: fludarabine

+ busulfan followed by PBSC infusion

Pediatr Transplantation, 2011

Effect of Splenectomy in HSCT for Thalassemia

Mathew V, et al. BBMT 2007

Conclusion

Outcomes of both related- and unrelated-donor HSCT with severe thalassemia seemed to be favorable.

Favorable result in unrelated transplantation patients is due to high resolution HLA matching (8/8; ABC and DRB1)

ConclusionConditioning regimen:

Bu Cy (Full dose)

Bu Cy (Reduced dose) Flu Thiotepa

Bu Flu (Full dose)

Treo Flu Thiotepa

+ ATG (unrelated or PBSC)

High risk class 3: age > 7 and hepatomegaly

Bu Flu ATG plus sequential immunoablation with

Flu Dex

Bu Cy (Reduced dose) Flu Thiotepa + ATG (unrelated)

Treo Flu Thiotepa + ATG (unrelated)

ConclusionMixed chimerism management program seems to help to maintain sustainable engraftment.

Related CBTHigh graft failure rateNo MTX for GVHD prophylaxisAdequate cell dose (> 5 x 107/kg nucleated cell)

Unrelated CBT and Haploidentical TxHigh TRM and graft failureUncertain role in thalassemia

Cord blood expansion for future useNew approach for haploidentical HSCT

AcknowledgementSamart Pakakasama

Ampaiwan Chuansumrit

Nongnuch Sirachainan

Usanarat Anurathapan

Duanthida Songdej

HLA lab and BMT nurses

Somtawain Sirirueng

Wanpen Pantangkool

Saengsuree Jootar

Artit Ungkanont

Vinai Suvattee

Suthat Fucharoen

Surapol Issaragrisil

Borje Andrersson

Srinakarind Hospital

Suandok Hospital

Songklanakarin Hospital