CHENHUA YAN, MDChina

• Associate Professor, Peking University Institute of Hematology

• Dr. Yan completed her residency from the Peking University People’s Hospital an dcurrently serves as an associate professor at the same institute. Her interests are in hematologic malignancies and clinical trials.

Peking University People’s Hospital & Institute of Hematology

Beijing Key Laboratory of HSCT, Beijing, P.R.China

Chen-hua Yan M.D

Modified donor Lymphocyte Infusion for Relapse of Hematologic Malignancies after Haploidentical

Hematopoietic Stem Cell Transplantation

Content

Establishment of modified donor lymphocyte infusion

Modified donor lymphocyte infusion for the treatment of relapse

1

2

Modified donor lymphocyte infusion for the prevention of relapse3

Relapse remains a major complication after haploidentical transplantation

Lee KH, et al. Blood, 2011,118: 2609-2617Huang XJ, et al. BBMT,2009,15:257-261

Limited efficacy of DLI in the treatment of relapse

Levine JE, et al. BMT. 2008, 42: 201-205Schmid, et al. J Clin Oncol,2007,25:4938-45

Patients receiving DLI (n=228) 21% Patients not receiving DLI (n=171) 9%

P＜ 0.0001

One probable reason for the limited efficacy of DLI

• Higher incidence of severe acute GVHD after DLI

Marks DI, et al. Blood 2002; 100: 3108.Collins Jr RH, et al. J Clin Oncol 1997; 15: 433.Chalandon , et al. BMT 2010; 45: 558.

33%28%

15%

33%

26%

60%

46.40%

22.40%

60.70%

32.10%34%

21.60%

12.50%

25%

15.20%

0%

10%

20%

30%

40%

50%

60%

70%

acute GvHD grade 2-4 acute GvHD

grade 3-4 acute GvHD

chronic GvHD extensive chronic GvHD

RIC-sibling donor

MA-sibling and unrelated

MA-sibling and unrelated

Methods to minimize severe GVHD after DLI

Yan CH, et al. clinical transplant. 2012; 26: 868-876

• Escalating dose of DLI

• CD8+ T cell depleted DLI

• Modified DLI

Part 1

Establishment of modified DLI

• G-CSF could modulate the polarization of T cells from a Th1 to a Th2 phenotype

• G-CSF could indirectly induce T-cell hypo-responsiveness through the selective increase of DC2 cells and monocytes and the down-regulation of the CD28/B7 co-stimulatory signal.

• G-CSF could augment NK-T-cell–dependent CD8+ cytotoxicity

G-CSF moblized peripheral blood stem cell for Infusion

G-CSF maybe separates GVHD and GVL effects

Huang XJ,et al. Haematologica. 2004; 89: 1517-1524Huang XJ, et al. Transpl Immunol. 2007; 17: 193-197.Morris ES, et al. J Clin Invest. 2005; 115: 3093-3103.

• Twenty patients were enrolled. Unstimulate donor lymphocyte infusion (n=11, hematological relapse=5), GPBSCs infusion (n=9, hematological relapse=9).

• DLI: MNC > 1×108/Kg• Acute GVHD after DLI: GPBSCs 5/9 vs. lymphocytes 10/11

(P>0.05)• Grade 3 - 4 acute GVHD after DLI: GPBSCs 0/9 vs. lymphocytes

2/11 (P>0.05)• CR rate after DLI: GPBSCs 7/9 vs. lymphocytes 3/5 (P<0.01)

GPBSCs Infusion vs. unstimulate lymphocytes ifusion

Huang XJ,et al. Chin Med J (Engl). 2003; 116 (5):736-741.

GPBSCs infusion: G-CSF mobilized peripheral blood stem cell infusion

Application of immunosuppressive agents after GPBSCs infusion reduces severe acute GVHD

Huang XJ, et al. Hematologica 2007,92:414-417

In haploidentical DLI: application of immunosuppressive agents after GPBSCs infusion could reduce severe GVHD

Grade 3 - 4 acute GVHD: (P=0.013)•no prophylaxis: 5/9 •with prophylaxis: 1/11

Question?---What is the appropriate duration of immunosuppressive

agents after haploidentical GPBSCs infusion?

Acute GVHD

no prophylaxis

with prophylaxis

Application of immunosuppressive agents after GPBSCs infusion reduces acute GVHD

Yan CH, et al. clinical transplant. 2012; 26: 868-876

49.5%

31.6%

14.4%

9.3%

In haploidentical DLI: prophylaxis 6 - 8 weeks reduced incidence of grade 3 - 4 acute GVHD

Application of immunosuppressive agents after GPBSCs infusion

Problems?

reducing DLI-associated acute GVHD

preserving GVL effects?

Application of immunosuppressive agents for 6 - 8 weeks reduced acute GVHD after haploidentical DLI

67.7%

39.0%

63.6%

32.7%32.9%

8.2%

Yan CH, et al. Chin Med J (Engl) 2014: 127: 3602-3609.

acute GVHDGrade 2 - 4 acute

GVHDGrade 3 - 4 acute

GVHD

prophylaxis <6w prophylaxis <6w

prophylaxis <6w

prophylaxis 6 - 8w

prophylaxis 6 - 8wprophylaxis 6 - 8w

P=0.020 P=0.012 P=0.005

prophylaxis for 6 - 8 w (n=52)prophylaxis <6 w (n=51)

Application of immunosuppressive agents for 6 - 8 weeks did not influence relapse rate after haploidentical DLI

Total patients (n=103) Hematological relapsed (n=54)

MRD-positive (n=49)

69.0%

26.6%

80.0%

55.6% 51.5%

17.3%

Yan CH, et al. Chin Med J (Engl) 2014: 127: 3602-3609.

prophylaxis for 6 - 8 w (n=52)prophylaxis <6 w (n=51)

Yan CH, et al. Chin Med J (Engl) 2014: 127: 3602-3609.

Application of immunosuppressive agents for 6 - 8 weeks improved survival after haploidentical DLI

Total patients (n=103) Hematological relapsed (n=54)

MRD-positive (n=49)

prophylaxis for 6 - 8 w (n=52)prophylaxis <6 w (n=51)

Establishment of modified donor lymphocyte infusion (mDLI)

G-CSF mobilized peripheral blood stem cells (GPBSCs) infusion

Application of immuno-suppressive agents for 6 - 8 weeks after

haploidentical GPBSCs infusion

mDLI

Part 1.2

Modified DLI for the treatment of relapsed hematological malignancies after haploidentical HSCT

Poor results of DLI alone for relapsed acute leukemia after HSCT

Probable reason: A heavier burdens of leukemic cells in relapsed acute leukemia

Schmid C, et al. J Clin Oncol. 2007; 25: 4938-4945.

Choi SJ, et al. Leukemia. 2004; 18 (11): 1789-1797.Huang, et al. Haematologica,2007,92(3):414-417

Chemotherapy followed by DLI could increase CR rate and improve survival in patients with relapsed acute leukemia

◆ 16 AML patients were enrolled. chemotherapy

followed by GPBSCs infusion

◆ CR after DLI: 10/16 (62.5%) patients

◆ OS at 2-year after DLI: 31%.

◆ 20 patients were enrolled. chemotherapy followed by GPBSCs

infusion

◆ CR after DLI: 13/20 (65.0%)

◆ LFS at 2-year after DLI: 40%.

Chemotherapy followed by mDLI vs. chemotherapy alone

Characteristics Chemo (n=32)

Chemo + DLI (n=50)

P

CR rate post-intervention (%) 4 (12.5) 32 (64.0) 0.000

Median time of onset of CR post-intervention (months) (range)

1.00 (0.70 - 1.00)

1.00 (0.50 - 4.90)

0.258

Duration of CR post-intervention (months) (range)

2.05 (2.00 - 3.00)

12.00 (1.00 - 109.90)

0.009

Yan CH, et al. Eur J Haematol. 2013; 91 (4): 304-314.

DFSP=0.000

chemo+DLI

chemo

chemo+DLI

chemoP=0.000

Chemotherapy followed by mDLI vs. chemotherapy alone

Yan CH, et al. Eur J Haematol. 2013; 91 (4): 304-314.

How to improve survival further?

Investigate the risk factors of relapse after chemotherapy followed by modified DLI

Multivariate analysis for higher relapse rate:Lack of chronic GVHD after DLI (P=0.039, OR=2.471) MRD (-) < 4 months after DLI (P=0.001, OR=40.342)

Risk-stratification

50 patients

No risk factors = 11

One of risk factor = 11

Two risk factors = 28

Low-risk

Intermediate-risk

High-risk

Risk factors of relapse for chemotherapy followed by mDLI

Yan CH, et al. Eur J Haematol. 2013; 91 (4): 304-314.

Relapse, OS, and DFS for low-risk, intermediate-risk and high-risk patients

Relapse OS DFS

Yan CH, et al. Eur J Haematol. 2013; 91 (4): 304-314.

How to improve survival further?

Repeated chemotherapy followed by modified DLI based on the status of MRD and GVHD post-DLI

Part 1.3.1

Modified DLI for the prevention of relapse: risk-stratification directed modified DLI in patients with positive status of MRD post-transplant

The levels of WT1 and LAIPs could predict relapse of acute leukemia

Huang XJ, et al. Ann Hematol. 2012;91:183-192.Huang XJ, et al. BMT. 2012;47:499-507

Patients with Leukemia

MRD monitoring

MRD (-) MRD (+)

Risk-stratification directed mDLI

Decrease relapse ?Improve survival ?

Hypothesis

after HSCT

Risk-stratification directed mDLI could reduce relapse

Total (n=814): 22.0% (95% CI 18.4-25.6%)

MRD (-) (n=709): 18.1% (95% CI 14.6-21.6%)

MRD (+)-IL-2 (n=49): 64.4%(95% CI 44.8-84.0%)

MRD (+)-DLI (n=56): 27.8% (95% CI 12.1-43.5%)Yan CH, et al. Blood,2012,119(14):3256-62

MRD (+) vs. MRD (-): P<0.001DLI vs. IL-2: P=0.001DLI vs. MRD (-): P=0.269

Yan CH, et al. Blood,2012,119(14):3256-62

Risk-stratification directed mDLI could improve survival

Risk-stratification directed mDLI could reduce relapse and improve survival after haploidentical HSCT

MRD (+) vs. MRD (-): P=0.041DLI vs. IL-2: P=0.002DLI vs. MRD (-): P=0.688

Part 1.3.2

Modified DLI for the prevention of relapse: prophylactic modified DLI in patients with relapsed/refractory acute leukemia at transplant

Prophylactic mDLI could reduce relapse and improve survival of patients with relapsed/refractory acute leukemia at haploidentical HSCT

Wang Yu, et al. BMT. 2012; 47 (8): 1099-104

Prophylactic mDLI could reduce relapse and improve survival

• Modified DLI could reduce incidence of acute GVHD, but did not compromise GVL Effects.

• Modified DLI was a potentially effective therapeutic option for relapsed acute leukemia after haploidentical HSCT and chemotherapy followed by modified DLI is superior to chemotherapy alone.

• Risk stratification-directed modified DLI could prevent relapse and improve survival after HSCT.

• Prophylactic modified DLI could prevent relapse and improve survival in patients with relapsed/refractory acute leukemia at haploidentical HSCT.

Summary

Questions remained?

• appropriate dose of CD3+ T cells in haploidentical

modified DLI

• appropriate drug used as immunosuppressive

agents after haploidentical modified DLI, such as

CSA or MTX

• appropriate time for prophylactic modified DLI

Acknowledgements

Stem cell collection centerHai-Yin ZhengHong XuQing ZhaoSu Wang

Department of bone marrow transplant Xiao-Jun Huang Kai-Yan Liu Dai-Hong Liu Lan-Ping XuHuan Chen Wei HanXiao-Hui Zhang Ying-Jun ChangYu-Hong Chen Feng-Rong Wang Jing-Zhi Wang Yu WangChen-Hua Yan Yuan-Yuan ZhangYu Ji Yu-Qian SunXiang-Yu Zhao Xiao-Su Zhao

Laboratory of PUIHDan LiYa-Zhen QinYan-Rong LiuYue-Yun Lai