Update on Cord Blood Transplants

Transcription

1 Update on Cord Blood Transplants Vanderson Rocha, MD, PhD Scientific Director of Eurocord Chair of Cord Blood Subcommittee of EBMT Agence de Biomedecine and Saint Louis Hospital, Paris, France

2 Hematopoietic reconstitution in a patient with Fanconi's anemia by means of umbilical cord blood from an HLA- identical sibling Gluckman E, Broxmeyer HE, Auerbach AD, Freidman HS, Douglas GW, Devergie A, Esperou H, Thierry D, Socié G, Lehn P, Cooper S, English D, Kurtzberg J, Bard J, Boyse EA. N Engl J Med 1989;321:

3 Twenty years later

4

5 Unrelated CBT- Non Malignant Disorders Clinical Results in Children

6 Clinical Results of Unrelated CBT in Children- Non Malignant Disease n=352 n Median FU (m/y) Outcomes Favourable Risk Factors Ref Hurler Syndrome m DFS: 70% Interval Dx-Tx >4.6 m Use of Bu/Cy BBMT 2009 Hemoglobinopathy Thalassemia 35 SCD 16 30m DFS: 21% DFS: 50% Cell dose>5x10 7 /Kg BBMT 2011 Congenital Bone Marrow Failure Syn. (excl FA) m OS: 61% Cell dose>6.1x10 7 /Kg Haemat Aplastic Anemia m OS: 38% Cell dose>3.9x10 7 /Kg BBMT 2010 Fanconi Anemia m OS: 40% Cell dose>4.9x10 7 /Kg Use of Fludarabine Neg CMV serology HLA BBMT 2007

7 Unrelated CBT in Children- Non Malignant Disease 3- year Overall Survival for patients with Severe Aplastic Anemia by cell dose (n=71) 3- year Overall Survival for patients with Fanconi Anemia by cell dose (n=93)

8 Unrelated cord blood transplants in non malignant diseases Cell dose is the most important factor a minimum of 2x10 5 CD34+ cells/kg are necessary for engraftment HLA matching is also important 0 to 1 HLA matched donors with high cells counts must be selected Indications and transplant protocols need international cooperation

9 Unrelated CBT- Malignant Disorders Clinical Results in Children

10 Clinical Results of Unrelated CBT in Children- Malignant Disorders n=1122 n Median FU (m/y) Outcomes AML m DFS: 46% CR1: 63% CR2: 43% Adv: 22% Favourable Risk Factors Favorable karyotype Disease Status Cell dose>4.9x10 7 /Kg Ref ASH2011 Cunha R, Michel G et al MDS m DFS: 39% Monosomy 7 Leukemia 2010 JMML m DFS: 43% No Monosomy 7 Age<1y HLA 0/1 difference ASH 2010 #533 ALL m DFS: 48% CR1: 54% CR2: 42% Adv: 7% Disease Status ASH 2010 #532 Impact of Minimal residual disease in ALL m DFS: MRD-: 54% MRD+:29% Undetectable MRD Disease Status Manuscript in preparation

11 2 years Leukemia-Free Survival All patients (n=390) 46+3 % By disease status at transplant (n=390) p<0.001 CR1: 63+4 % CR2: 43+4 % Advanced: 22+5 % Probability of Leukemia Free Survival Probability of Leukemia Free Survival Months Month s

12 Clinical Results of Unrelated CBT in Children- Malignant Disorders n=1122 n Median FU (m/y) Outcomes AML m DFS: 46% CR1: 63% CR2: 43% Adv: 22% Favourable Risk Factors Favorable karyotype Disease Status Cell dose>4.9x10 7 /Kg Ref EHA 2011 # 1044 MDS m DFS: 39% Monosomy 7 Leukemia 2010 JMML m DFS: 47% No Monosomy 7 Age<1y HLA 0/1 difference ASH 2010 #533 ALL m DFS: 48% CR1: 54% CR2: 42% Adv: 7% Disease Status ASH 2010 #532 Impact of Minimal residual disease in ALL m DFS: MRD-: 54% MRD+:29% Undetectable MRD Disease Status Manuscript in preparation

13 ALL DFS n=552 2-y LFS according to disease status at UCBT CR1: 54±4%, n= 188 CR2: 42±4%, n= 254 Advanced: 7±2%, n=110 p=<0.0001

14 Minimal Residual Disease in childhood ALL, (n=170) Ruggeri A, ASH y LFS according to MRD assessment before UCBT MRD-: 54±5%, n=96 MRD+: 29±5%, n=74 p=0.006

15 Clinical Results in Adults Unrelated Cord Blood transplant

16 Clinical Results of Unrelated CBT in Adults (n=1052) n Median FU (m/y) Outcomes Favourable Risk Factors Ref Lymphoid malignancies MDS m DFS: 41% Chemosensitive disease Low-dose TBI Cell dose>2x10 7 /Kg JCO, m DFS: 30% low-risk disease Leukemia, 2010 ALL m DFS: 30% Disease Status Manuscript Acute leukemia- KIR 218 Acute leukemia- RIC 14 m DFS: KIR-MM: 55% KIR-M: 31% KIR-ligand incompatibility HLA 0/1 mismatch m DFS: 51% Disease Status HLA 0/1 mismatch in preparation Leukemia 2009 Manuscript in preparation AML m DFS: CR1: 45% CR2: 41% Adv: 16% Disease Status Ruggeri, A et al, #ASH 2011

17 UCBT for AML 2 y LFS according to disease status CR1 (n=229): 45±4% CR2 and CR3 (n=228): 41±4% p=<0.001 Advanced (n=147): 16±7% Ruggeri, A et al, #1040 EHA 2011

18 Comparative Studies of cord blood transplant with other stem cell sources

19 Comparative study with other stem cell source in Children n Median FU (m/y) Results CBT compared with other sources (multivariate models) Ref Unrelated CBT vs unrelated BMT for acute leukemia UCB: 99 UBM: 442 T-UBM: m 32 m 30 m Delayed engraftment Decrease A and cgvhd Comparable LFS Blood 2001 Unrelated CBT versus haplo Related Transplant for SCID UCB: 74 MMRD: m 83 m Higher agvhd Faster B cell recovery Comparable OS Manuscript in preparation Unrelated CBT versus other SC source for Hurler Syndrome Unr CB: 116 idsib BM: 37 Unr BM: m 62 m 80 m OS of HLA matched UCB comparable to HLA identical sibling HLA 5/6 comparable to 10/10 HLA MUD Manuscript in preparation

20 Comparison of outcomes of haploidentical related stem cell and unrelated cord blood transplants in children with severe T-cell deficiencies 5-year Overall Survival 62 ± 4% Haplo n= ± 6% UCB n=74 P (Cox): 0.61 Fernandes J et al submitted years

21 Comparative study with other stem cell source in Children n Median FU (m/y) Results CBT compared with other sources (multivariate models) Ref Unrelated CBT vs unrelated BMT for acute leukemia UCB: 99 UBM: 442 T-UBM 19 m 32 m 30 m Delayed engraftment Decrease A and cgvhd Comparable LFS Blood 2001 Unrelated CBT versus haplo Related Transplant for SCID UCB: 74 MMRD: m 83 m Higher agvhd Faster B cell recovery Comparable OS Manuscript in preparation Unrelated CBT versus other SC source for Hurler Syndrome Unr CB: 116 idsib BM: 37 Unr BM: m 62 m 80 m OS of HLA matched UCB comparable to HLA identical sibling HLA 5/6 comparable to 10/10 HLA MUD Manuscript in preparation

22 Children with Hurler disease Disease Free Survival by type of donor and HLA 1,0,9 HLA identical sibling 81±6% or HLA 6/6 unrelated CB 81±8%,8,7 HLA matched unrelated donor 10/10 66±7% or CB 5/6 68±6 %,6,5 Unrelated CB 4/6 57±9% ( if high CD34 cell dose EFS=73±13%),4,3 HLA matched low resolution or mismatched (antigen or allelic level) (incl. T cell depleted) 41±7%,2,1 P=0.004, Boelens J and Rocha V on behalf of Eurocord, CIBMTR, Minneapolis and Duke University

23 Comparative study with other stem cell source in Adults n Median FU (m/y) Results CBT compared with other sources (multivariate models) Ref HLA (6/6) UBM versus Single UCB for acute leukemia UBM:584 UCB:98 27 m Delayed myeloid recovery Decreased a and cgvhd Comparable OS and DFS NEJM 2004 HLA (7/8 and 8/8) UBM, PBSC and Single UCB for acute leukemia UBM: 364 UPBSC: 768 UCB: m 24 m 29 m Compared to 8/8 UBM Delayed myeloid recovery Increased NRM but comparable OS and DFS Lancet Onc 2010 RIC -(8/8) Unrelated PBSC versus RIC-UCBT for lymphoid malignancies PBSC: 284 UCB: m 24 m Delayed myeloid recovery Decreased cgvhd Comparable OS and DFS Manuscript in preparation

24 Impact of Stem Cell Source in Adults with Acute Leukemia, n= Leukemia-free Survival -Adjusted for Disease Status at Transplantation Matched BM vs. CB RR 0.87, p=0.254 Matched PBPB vs. CB RR 0.89, p=0.177 BM matched, 41% Probability, % PBPC mismatched, 34% BM mismatched, 34% PBPC matched, 39% CB, 33% Not in remission at HCT, RR 2.40, p< Years 10 Eapen M, Rocha V, Lancet Onc

25 Comparative study with other stem cell source in Adults n Median FU (m/y) Results CBT compared with other sources (multivariate models) Ref HLA (6/6) UBM versus Single UCB for acute leukemia UBM:584 UCB:98 27 m Delayed myeloid recovery Decreased a and cgvhd Comparable OS and DFS NEJM 2004 HLA (7/8 and 8/8) UBM, PBSC and Single UCB for acute leukemia UBM: 364 UPBSC: 768 UCB: m 24 m 29 m Compared to 8/8 UBM Delayed myeloid recovery Increased NRM but comparable OS and DFS Lancet Onc 2010 RIC -(8/8) Unrelated PBSC versus RIC-UCBT for lymphoid malignancies PBSC: 284 UCB: m 24 m Delayed myeloid recovery Decreased cgvhd Comparable OS and DFS Manuscript in preparation

26 Probability (%) RIC-UCBT vs. RIC-MUD Transplantation for Lymphoid Malignancies Months PROGRESSION-FREE SURVIVAL p = ns UCBT (n=75) 38%±6 at 2 y PBSC MUD (n=284) 41%±2 at 2y MULTIVARIATE ANALYSIS HR CI 95% p Use of CB Non-indolent vs. indolent Refractory disease <0.0001

27 Comparison between cord blood and other sources of stem cells Same survival and disease free survival Engraftment is delayed Less acute and chronic GVHD

28 Alternative donor transplantation: results of parallel phase II trials using HLA-mismatched related bone marrow or unrelated umbilical cord blood grafts. Brunstein CG, Fuchs EJ, Carter SL, Karanes C, Costa LJ, Wu J, Devine SM, Wingard JR, Aljitawi OS, Cutler CS, Jagasia MH, Ballen KK, Eapen M, O'Donnell PV. Blood. 2011

29 Demographic and Disease Characteristics Cord (0604) N=50 Haplo (0603) N=50 Median age (range) 58 (16-69) 45 (7-70) Performance status > 90% 40 (80%) 38 (76%) Disease AML (CR1/CR>1) 29 (18/11) 22 (10/12) ALL (CR1/CR>1) 6 (4/2) 6 (3/3) Biphenotypic/undiff leukemia 1 3 Burkitt lymphoma 1 0 Hodgkin lymphoma (CR/PR) 5 (2/3) 7 (3/4) Large cell lymphoma (CR/PR) 3 (2/1) 8 (3/5) Mantle cell lymphoma (CR/PR) 0 3 (1/2) Marginal zone or follicular NHL 5 1 Prior autologous Transplant 6 (12%) 11 (22%)

30 RIC-Treatment Schemas Cord * Haplo * *May substitute other CNI

31 Relapse and Non-Relapse Mortality Cord (0604) Haplo (0603)

32 Overall and Disease-free Survival Cord (0604) Haplo (0603) 95% CI, 38-67% 95% CI, 44%

33 Overall Survival 73% ± 8 at 1 yr 62% ±10 CR1 +CR2 (n=30) 19% ±12 advanced n=12 p= year Overall Survival Haplo BMT in 42 AML Rome Transplant Network years from BMT CR1+CR2 (n=77) 2-year Overall Survival 63±8% CBT in 98 AML EUROCORD Overall Survival 8±7% Advanced (n=21) months

34 New developments Engraftment Choice of the donor Immune reconstitution GVH prevention Prevention of relapse UCBT Double cord Ex vivo expansion Intrabone NIMA KIR HLA-C NK CTL Tregs T regs MSC NK Haplo Unmanipulated primed graft: BM +PBSC Mother NIMA KIR NK CTL T regs Tregs MSC NK DLI

35 Improving Outcomes after CBT Current problems: engraftment and immune reconstitution

36 Experimental and clinical approaches to improve engraftment after UCB transplantation (V Rocha and H Broxmeyer, BBMT 2010) Increase number of cells at cord blood collection Banking cord blood units with greater volume and high number of CD34+ cells Per fusing the placental vessels after draining the blood from the cord Enhance homing of cord blood cells Inhibiting the enzymatic activity of CD26/Dipeptidylpeptidase IV (DPPIV) In vivo direct injection of cord blood cells into the iliac crest (Phase II clinical trials) In vitro and in vivo expansion of cord blood cells Using of SDF-1/CXCL12 associated to Diprotin A and/or other cytokines Using Notch-ligand Delta 1 (Phase II clinical trials) Using Copper chelator tetraethylenepentamine (TEPA) (Phase II clinical trials) Identification of modifiable prognostic factors for engraftment Choosing the best cord blood unit based on cell dose, HLA, diagnosis, screening for antibodies against HLA, quality of cord blood units Modifying the conditioning regimen and GVHD prophylaxis Increase number of cells at infusion Using double cord blood transplantation (on going prospective and observational studies) Using third party mobilized T cell depleted haploidentical cells (Phase II trials) Decreasing toxicity and shorten time of aplasia Using reduced conditioning regimen (on going prospective and observational studies) Co-infusion of cord blood cells with accessory cells Using multipotent mesenchymal stromal cells (Phase I/ II trials)

37 Experimental and clinical approaches to improve engraftment after UCB transplantation (V Rocha and H Broxmeyer, BBMT 2010) Increase number of cells at cord blood collection Banking cord blood units with greater volume and high number of CD34+ cells Per fusing the placental vessels after draining the blood from the cord Enhance homing of cord blood cells Inhibiting the enzymatic activity of CD26/Dipeptidylpeptidase IV (DPPIV) In vivo direct injection of cord blood cells into the iliac crest (Phase II clinical trials) In vitro and in vivo expansion of cord blood cells Using of SDF-1/CXCL12 associated to Diprotin A and/or other cytokines Using Notch-ligand Delta 1 (Phase II clinical trials) Using Copper chelator tetraethylenepentamine (TEPA) (Phase II clinical trials) Identification of modifiable prognostic factors for engraftment Choosing the best cord blood unit based on cell dose, HLA, diagnosis, screening for antibodies against HLA, quality of cord blood units Modifying the conditioning regimen and GVHD prophylaxis Increase number of cells at infusion Using double cord blood transplantation (on going prospective and observational studies) Using third party mobilized T cell depleted haploidentical cells (Phase II trials) Decreasing toxicity and shorten time of aplasia Using reduced conditioning regimen (on going prospective and observational studies) Co-infusion of cord blood cells with accessory cells Using multipotent mesenchymal stromal cells (Phase I/ II trials)

38 Criteria of donor choice Recommendations First look at the number of cells in MAC, RIC, single and double CBT : collected >2.5x10 7 NC/kg et/ou>1.5x10 5 CD34+/kg Infused >2.0x10 7 NC/kg 2. Search for antibodies against HLA 2. Second look at HLA 0-1 mm better than 2 avoid 3-4 mm Prefer class I mismatches than class II (does not matter in advanced phase of disease?) If no choice increase the number of cells It seems that in double CBT number of HLA disparities and ABO compatibility is also important 3. Then adapt to graft indication Malignant diseases: cell dose is the best prognostic factor because HLA differences reduce relapse (GVL) Non malignant diseases: increase cell dose (>4.0x10 7 NC/kg and >2.0x10 5 CD34/kg ) and find the best HLA match

39 Criteria of CB unit choice Which is the best cell count marker : NC? CD34? CFU-GM? Is viability of NC or CD34 associated with engraftment? Is HLA allele typing important in CBT? Is HLA-C important in the selection of the cord blood unit? Is NIMA important? Double and RIC: Cell dose and HLA? Other? Are there other factors related to the CB unit that can improve outcomes? KIR? Years of Cord Blood Unit storage? ABO compatibility? Donor gender? Bank effect? and standards?

41 Lancet Oncology

42 Study Objectives This analysis focused on two questions: What is the impact on outcomes if matching at HLA-A, -B, -C, -DRB1 is considered? What is the impact on outcomes if matching at the HLA-C locus is considered in addition to matching at HLA-A, -B, DRB1?

43 Study Population N = 803 donor-recipient pairs Leukemia or MDS 85% had acute leukemia 65% were aged <16 years Disease status at transplantation 35% - 1 st CR, CP 40% - 2 nd CR, CP, AP 25% - active disease

44 Study Population All received single CB unit Myeloablative conditioning regimen 55% - TBI containing regimens 75% - anti-thymocyte globulin All most all patients received cyclosporine containing GVHD prophylaxis Median infused TNC 3.8 x 10 7 /kg Median follow-up, 2 years

45 Statistical Analysis Donor-recipient HLA match was examined in five separate models: Model 1: HLA-match at A, B, C, DRB1 (8/8 vs. 7/8 vs. 6/8 vs. 5/8 vs. 4/8) Model 2: HLA-C match vs. HLA-C MM in donor-recipient pairs either matched, 1- locus MM, 2-loci MM or 3-loci MM at HLA-A, -B or DRB1 Models 3, 4,5: three additional models, similar to model 2 but considered the individual effect of HLA-A, -B or DRB1 rather than HLA-C

46 Donor-recipient recipient HLA match Matching at 8-loci 8/8 HLA match = 69 (9%) 7/8 HLA match = 147 (18%) 6/8 HLA match = 259 (32%) 5/8 HLA match = 253 (32%) 4/8 HLA match = 75 (9%) HLA typing was performed using molecular techniques with a minimum of antigen-split level resolution for HLA-A, -B, -C Allele-level resolution for HLA-DRB1

47 Donor-recipient recipient HLA match 65% of donor-recipient pairs were mismatched at HLA-C 75% were associated with a mismatch at HLA-B Isolated mismatches uncommon: 3% each at HLA-B and -C 7% each at HLA-A and -DRB1 Among the remaining 15%: Mismatch at HLA-A + B was the most common

48 Objective I What is the impact on outcomes if matching at HLA-A, -B, -C, -DRB1 is considered?

49 Transplant-related related Mortality Incidence, % % 8/8 HLA match 7/8 HLA match 6/8 HLA match 5/8 HLA match 4/8 HLA match 33% Years 31% 19% 9% 20 0

50 Relapse Incidence, % % 8/8 HLA match 7/8 HLA match 6/8 HLA match 5/8 HLA match 4/8 HLA match 44% 31% % 26% Years 0

51 Overall Survival Probability, % % 8/8 HLA match 7/8 HLA match 6/8 HLA match 5/8 HLA match 4/8 HLA match 51% 37% % 49% Years 0

52 Objective II The impact of mismatching at specific HLA-loci was examined: HLA-C match vs. HLA-C mismatch in donor-recipient pairs either matched or 1, 2 or 3-loci mismatched at HLA-A, -B or DRB1 Matching at HLA-A, -B, or DRB1 rather than HLA-C was examined in a similar manner

53 Treatment-related related Mortality Incidence, % /6 + C matched 6/6 + C mismatched 5/6 + C matched 5/6 + C mismatched 31% Years 26% 19% 9% 20 0

54 Overall Survival /6 + C matched 6/6 + C mismatched 5/6 + C matched 5/6 + C mismatched 54% 51% 80 Probability, % % 51% Years 0

55 Other Factors Associated with Survival Higher mortality Patients older than 16 years CMV seropositivity Disease status Not in remission at transplantation Disease status is the only one potentially modifiable by the physician by performing transplantation early in the course of disease

56 Summary Higher TRM after transplants mismatched at any two or more loci Higher TRM after transplants mismatched at HLA-C Matched at HLA A, B, DRB1 (6/6) Mismatched at a single A, B or DRB1 locus (5/6) Higher TRM after transplants mismatched at HLA DRB1 Mismatched at a single A, B, or C locus

57 Conclusion Altering current selection strategies for cord blood units may ameliorate some of the excess TRM Consideration of matching at HLA-C in addition to HLA-A, -B and DRB1 is warranted in some situations Consulting an HLA expert at the time of initial search can help develop a search strategy based on the patient s HLA-type that will maximize the likelihood of identifying a unit matched at HLA-C

59 Impact of Matching at NIMA on Outcomes after 5/6 or 4/6 Mismatched UCBT for Malignant Hematological Diseases. A matched pair analysis on behalf of Eurocord, Netcord, NMDP and CIBMTR V Rocha, D Purtill, M-J Zhang, S Spellman, A Ruggeri, V Prasad, C Navarette, G Koegler, E Beaudoux, L Baxter-Lowe, MM Horowitz, JJ van Rood, J Kurtzberg, E Gluckman, M Eapen

60 Background It is speculated that in utero exposure to NIMA antigens induces partial tolerance to NIMA in a significant proportion of individuals In kidney and Haplo HSC transplantaion recipients grafts donated by the mother have better outcomes Haploidentical bone marrow transplantation: less GVHD and less TRM in group mismatched for NIMA (approx. 50% of cases) rather than NIPA haplotype (van Rood et al. Blood 2002) Unrelated Cord Blood Transplantation (7% of NIMA matched) better neutrophil recovery, trend of lower relapse (marginal effect only in AML), decreased non-relapse mortality after NIMA-matched UCBT (van Rood et al; PNAS 2009)

61 NIMA matched in unrelated cord blood transplantation Mother of cord IMA A 24 NIMA A 32 Cord Patient IMA A 24 IPA A 2 Haplotype 1 A 24 Haplotype 2 A 32

62 NIMA matched in unrelated cord blood transplantation Mother of cord IMA A 24 NIMA A 32 Cord Patient IMA A 24 IPA A 2 Haplotype 1 A 24 Haplotype 2 A 32

63 Objectives and selection criteria To analyze the effect of NIMA-matching on outcomes after UCBT Donor maternal typing was available for 508 donor-recipient pairs All transplants were 5/6 or 4/6 HLAmatched

64 Study Population Donor-recipient pairs N = 52 NIMA matched (10%) N = 456 NIMA mismatched Due to relatively low frequency of NIMAmatched transplants, a matched-pair analysis was performed Variables for matching were determined by multivariate analysis for non-relapse mortality

65 Methodology Cases/controls were matched on Age HLA-match Disease status Intensity of conditioning regimen Additionally, cases were matched on Disease Infused total nucleated cell dose/kg

66 Study Population 48 NIMA matched recipients were matched to 116 NIMA mismatched recipients Four NIMA matched recipients were excluded Unable to identify appropriate controls

67 Characteristics of Matched Pairs 74% were aged 16 years 52% were male Disease 88% had acute leukemia; half had AML 9% had MDS; 2% NHL and 1% CML Disease status 25% early; 50% interm.; 25% advanced 80% received myeloablative regimens 85% received CsA; 15% tacrolimus

68 Results - Multivariate Analysis Hazard Ratio ANC recovery Acute GVHD Chronic GVHD Me11_10.ppt

69 Non-Relapse Mortality Incidence, % NIMA mismatched HCT, 32% NIMA matched HCT, 18% Years Me11_13.ppt

70 Results - Multivariate Analysis Hazard Ratio P = P = NRM Relapse

71 Relapse Incidence, % NIMA mismatched HCT, 33% NIMA matched HCT, 31% Years Me11_14.ppt

72 Results - Multivariate Analysis Hazard Ratio P = P = NRM Relapse

73 Overall Survival Probability, % NIMA matched HCT, 55% NIMA mismatched HCT, 38% Years

74 Leukemia-free Survival Probability, % NIMA matched HCT, 52% NIMA-mismatched HCT, 35% Years Me11_11.ppt

75 Results - Multivariate Analysis Hazard Ratio P = 0.06 P = LFS OS Me11_8.ppt

76 Conclusion We confirmed the previous analysis of the impact of NIMA matched on NRM, OS and DFS but not on relapse or neutrophil recovery The importance of other factors such as HLA disparity, cell dose and transplantation of NIMA matched grafts must be examined in a larger series of patients Should we consider NIMA matching as a selection criteria for CB grafts, considering the low frequency of NIMA match (7% to 10%)?

77 Experimental and clinical approaches to improve engraftment after UCB transplantation (V Rocha and H Broxmeyer, BBMT 2010) Increase number of cells at cord blood collection Banking cord blood units with greater volume and high number of CD34+ cells Per fusing the placental vessels after draining the blood from the cord Enhance homing of cord blood cells Inhibiting the enzymatic activity of CD26/Dipeptidylpeptidase IV (DPPIV) In vivo direct injection of cord blood cells into the iliac crest In vitro and in vivo expansion of cord blood cells Using of SDF-1/CXCL12 associated to Diprotin A and/or other cytokines Using Notch-ligand Delta 1 (Phase II clinical trials) Using Copper chelator tetraethylenepentamine (TEPA) (Phase II clinical trials) Identification of modifiable prognostic factors for engraftment Choosing the best cord blood unit based on cell dose, HLA, diagnosis, screening for antibodies against HLA, quality of cord blood units Modifying the conditioning regimen and GVHD prophylaxis Increase number of cells at infusion Using double cord blood transplantation (on going prospective and observational studies) Using third party mobilized T cell depleted haploidentical cells (Phase II trials) Decreasing toxicity and shorten time of aplasia Using reduced conditioning regimen (on going prospective and observational studies) Co-infusion of cord blood cells with accessory cells Using multipotent mesenchymal stromal cells (Phase I/ II trials)

78 Unrelated Cord Blood Transplantation: Comparison After Single Unit Cord Blood Intrabone Injection and Double Unit Cord Blood Transplantation In Patients with Hematological Malignant Disorders. A Eurocord-EBMT Analysis Vanderson Rocha, Myriam Labopin, Annalisa Ruggeri, Marina Podestà, Dolores Caballero, Francesca Bonifazi, Rovira Montserrat, Andrea Gallamini, Gerard Socié, E Nikiforakis, Mauricette Michalet, Erik Deconinck, Mohamad Mohty, Andrea Bacigalupo, Eliane Gluckman, Francesco Frassoni

79 Intrabone single UCBT (ICBC) versus Double UCBT (ducbt) after MAC in patients with hematological malignancies Cumulative Incidence of Neutrophil recovery (>=500) IBCB N=87 Median days: 23 P=0.001 ducbt N=149 Median days: 28 90% 90% days

80 Intrabone single UCBT (ICBC) versus DoubleUCBT (ducbt) after MAC in patients with hematological malignancies Cumulative Incidence of Platelets recovery (>=20.000) IBCB N=87 81% % days ducbt N=149 P<

81 Intrabone single UCBT (ICBC) versus DoubleUCBT (ducbt) after MAC in patients with hematological malignancies Cumulative Incidence of Acute GVHD (II-IV) ducbt N=149 47% IBCB N=87 19% P< days

82 Intrabone single UCBT (ICBC) versus DoubleUCBT (ducbt) after MAC in patients with hematological malignancies Disease Free Survival IBCB N=87 47% ducbt N=149 37% months

83 Experimental and clinical approaches to improve engraftment after UCB transplantation (V Rocha and H Broxmeyer, BBMT 2010) Increase number of cells at cord blood collection Banking cord blood units with greater volume and high number of CD34+ cells Per fusing the placental vessels after draining the blood from the cord Enhance homing of cord blood cells Inhibiting the enzymatic activity of CD26/Dipeptidylpeptidase IV (DPPIV) In vivo direct injection of cord blood cells into the iliac crest (Phase II clinical trials) In vitro and in vivo expansion of cord blood cells Using of SDF-1/CXCL12 associated to Diprotin A and/or other cytokines Using Notch-ligand Delta 1 (Phase II clinical trials) Using Copper chelator tetraethylenepentamine (TEPA) (Phase II clinical trials) Identification of modifiable prognostic factors for engraftment Choosing the best cord blood unit based on cell dose, HLA, diagnosis, screening for antibodies against HLA, quality of cord blood units Modifying the conditioning regimen and GVHD prophylaxis Increase number of cells at infusion Using double cord blood transplantation Using third party mobilized T cell depleted haploidentical cells (Phase II trials) Decreasing toxicity and shorten time of aplasia Using reduced conditioning regimen (on going prospective and observational studies) Co-infusion of cord blood cells with accessory cells Using multipotent mesenchymal stromal cells (Phase I/ II trials)

84 Outcomes After Double Unit Unrelated Cord Blood Transplantation (UCBT) Compared with Single UCBT in Adults with Acute Leukemia in Remission. An Eurocord and Acute Leukemia Working Party EBMT Collaboration Study [Abstract # 910] Vanderson Rocha, Miriam Labopin, Mohamad Mothy, Guillermo Sanz, Bernard Rio, Sabine Furst, Anne Sirvent, Gérard Socié, Reza Tabrizzi, Ybrahim Yakoub-Agha, Eric Deconinck, J.J Cornelissen, William Arcese, Josep Maria Ribera, Emmanouel Nikiforakis, Mauricette Michallet, Alessandro Crotta, Annalisa Ruggeri, Eliane Gluckman

85 Acute GVHD and relapse after single (n=378 ) versus double UCBT (n=213 ) in adults with acute leukemia 100 day CI of Acute GVHD II-IV ducbt 39 ±3% sucbt 21 ±2% P< years Relapse incidence in CR1 sucbt 25 ±3% ducbt 15±4% P= months

86 2 years LFS after single (n=378) versus double UCBT (n=213) in adults with acute leukemia In First Complete Remission In Second or Third Complete Remission ducbt 53±5% sucbt 39±4% ducbt 35±5% months In a multivariate analysis adjusted for differences and risk factors: Double CBT was associated with improved LFS rates [p=0.04 HR=0.67 ( )] sucbt 31±4% months

87 Conclusion and questions HLA mismatched HSCT transplants are feasible, this means that there is no shortage of donors Is MUD=CB=Haplo? All retrospective studies in children and adults with acute leukemia showed that alternative sources such as UBMT, UCBT or Haplo, can treat a number of patients with some different outcomes but similar LFS Comparative registry-based studies are still necessary Collaborative Protocols should explore new methods to improve results The final choice of the SC source will depend on expertise and policy of each center

88 Acknowledgments EBMT, CIBMTR, Netcord 480 transplant centers in 49 countries (data managers, nurses and physicians) 64 Cord Blood Banks

89