Haploidentical Hematopoietic Stem Cell Transplantation for Hematological Malignancies Xiao-Jun Huang M.D. Ph.D. Peking University Institute of Hematology, Peking University People’s Hospital & Beijing Key Laboratory of HSCT, Beijing, P.R.China

1 1 Education Clinic Research

The Cumulative Hematopoietic Stem Cell Transplantation (HSCT) Cases of PUIH PUIH  The Largest HSCT center in Asia  Now >400 cases of HSCT per year  Now >60% Allo-HSCT cases are Unmanipulated Haploidentical HSCT 24%

Current Clinical Results Strategy to Improve the Clinical Results Haploidentical Hematopoietic Stem Cell Transplantation for Hematological Malignancies 1 1 In vitro T-cell-depleted HSCT 2 2 Non-Myeloablative Haploidentical HSCT 3 3 Unmanipulated Myeloablative Haploidentical HSCT

GIAC protocol G: donor treatment with rhG-CSF I: intensified immunological suppression A: anti-human thymocyte immunoglobulin (ATG) for the prevention of GVHD C: combination of G-PB and G-BM Huang XJ, et al. Blood, 2006, 107(8): Huang XJ, et al. Annals of Medicine, 2008, 40, Huang XJ, et al. Clin Cancer Res. 2009;15: Huang XJ, et al. BBMT Jun;17(6): Unmanipulated Haploidentical HSCT

Effects of G-CSF on Bone Marrow in Healthy Donors HuangXJ, et al. Clin Transplant 2011: 25: 13–23 3. Unmanipulated Haploidentical HSCT

Immunoregulatroy Effects after G-CSF Administration to Healthy Donors Huang XJ, et al. Biol Blood Marrow Transplant.2011;17(2): Unmanipulated Haploidentical HSCT

Engraftment Huang XJ, et al. Biol Blood Marrow Transplant,2009, 15(5):632-8 n=348 P=0.008 n=348 CD34+ cells≥2.19×10 6 /kg CD34+ cells<2.19×10 6 /kg P< Early stage Advanced stage 3. Unmanipulated Haploidentical HSCT

Characteristics of the Allo-Grafts Summary Statistics TNC 10 8 /kg CD34+ ×10 6 /kg CD3+ ×10 8 /kg CD4+ ×10 7 /kg CD8+ ×10 7 /kg CFU-GM ×10 5 /kg BM Range 1.2 ～ ～ ～ ～ ～ ~9.4 Median PB Range 1.9 ～ ～ ～ ～ ~10.5 Median T Range5.2~ ~ ~ ~ ~ ~ 19.9 Median Huang XJ, et al. Bone Marrow Transplant, 2006, 38: Unmanipulated Haploidentical HSCT

Huang XJ, et al. Biol Blood Marrow Transplant 2009, 15(2) Huang XJ, et al. Biol Blood Marrow Transplant 2011; 17(6) Cumulative incidence of aGVHD after HLA-mismatched allo-HSCT Haplo=81 Identical=36 P= Unmanipulated Haploidentical HSCT

Probability of aGVHD with locus disparity Huang XJ, et al. Bone Marrow Transplant. 2006;38(4): Unmanipulated Haploidentical HSCT

DFS & OS compared with HLA Matched Donor Huang XJ, et al. Blood, 2006, 107(8): Unmanipulated Haploidentical HSCT

Relapse compared with Unrelated Donor （ URD ） Huang XJ, et al. Clin Cancer Res, 2009, 15: PMRD=219 URD=78 PMRD=160 URD=60 3. Unmanipulated Haploidentical HSCT

Relapse compared with Identical Sibling （ ISD ） HuangXJ, et al. Biol Blood Marrow Transplant. 2011;17(6) Haplo=81 Identical=36 3. Unmanipulated Haploidentical HSCT

OS & DFS compared with ISD PMRD=81 ISD=36 P = P = HuangXJ, et al. Biol Blood Marrow Transplant. 2011;17(6) Haplo=81 Identical=36 3. Unmanipulated Haploidentical HSCT

Superior Graft-versus-Leukemia effect Haploidentical HLA-identical sibling High risk acute leukemia High risk acute leukemia HuangXJ, et al. Biol Blood Marrow Transplant ;17(6): Unmanipulated Haploidentical HSCT

No. of Haploidentical HSCT accumulated in PUIH PUIH data 3. Unmanipulated Haploidentical HSCT

The changing of Composition of Haploidentical allo-HSCT in PUIH from 2007 to 2009 PUIH data 3. Unmanipulated Haploidentical HSCT

Studies on HLA-mismatched/haploidentical stem cell transplantation (GIAC) Patie nts (n) DiseaseConditioning GVHD prophylaxis aGHVDcGVHDTRMRelapseLFSReference 35 AML/ALL/CML /DLBCL/ ATL Standard intensity±TBI Tacrolimus based 56%19%11 pt9 pt40% Ichinohe et al. (2004) 171 ALL/AML/CML /MDS Bu/Cy/Ara- C/MeCCNU+ CsA/MTX/M MF 55%21.3% 19% 2yrs SR 12% SR 2yrs Huang et al. (2006) 135 ALL/AML/CML /MDS Bu/Cy/Ara- C/MeCCNU+ATG CsA/MTX/M MF (II-IV) 40% 55%22%18% yrs Lu et al. (2006) 68 AML/ALL/CML /MDS/ TBI/Cy/FluCy/MMF/(II-IV)5% * 100 days 1 yr 1yr Luznik et al. (2008) 29 AML/ALL/CML /NHL/ Flu/Mel/OKT3/thio tepa CD3/CD19 depletion (II-IV) 48% 3 pt 100 days 12 pt 1yr Bethge et al. (2008) 42AML/ALL/CML Bu/Cy/Ara- C/MeCCNU+ATG CsA/MTX/M MF 57.2%27.2% 1yr 21.43% 3yrs Liu et al. (2008) 93CML Bu/Cy/Ara- C/MeCCNU+ CsA/MTX/M MF 1yrCP1 3.77% 1yr Huang et al. (2008) 45 AML/ALL/CML /NHL TBI/Cy/Ara-C/ATG CsA/MTX/M MF/ (II-IV)9 pt3 pt11 pt24 pt Wang et al. (2009) 46AML/CML/ALLTBI/Cy/Ara-C/ATG CsA/MTX/M MF 2yrs 2yr 2yrs Chen et al. (2009) 250AML/ALL Bu/Cy/Ara- C/MeCCNU+ ATG CsA/MTX/M MF 45.8%31.3% AML 3yrs AML 3yrs AML70.7 %3yrs Huang et al. (2009)

Composition of HSCT Donor Types in 24 Transplant Units in China PUIH collected Mis %29.9%30.0%33.6%30.8%30.3%26.5%29.7%29.3% 3. Unmanipulated Haploidentical HSCT

Huang XJ, et al. BMT, 2006, 38:291 Huang XJ, et al. Blood, 2006, 107(8): Huang XJ, et al. Clin Cancer Res, 2009, 15: Huang XJ, et al. BBMT Feb;17(2): Part I Conclusions G-BM combined with PBSC from haploidentical family donors, without in vitro TCD, may be used as a good source of stem cells for allo-HSCT There is no difference in OS and LFS between patients receiving allografts from PMRD and URD 3. Unmanipulated Haploidentical HSCT

Huang XJ, et al Unpublished ， Blood Reversed

Part II ： Strategy to Improve the Clinical Results 1 1 Modified Donor Lymphocyte Infusion(DLI) 2 2 Manipulating the Graft 3 3 Optimize KIR ligand match/mismatch 4 4 Improve Immune Reconstitution 3. Unmanipulated Haploidentical HSCT

Relapse Remains a Problem after HSCT High risk leukemia Huang XJ et al, Biol Blood Marrow Transplant Feb;15(2) Especially for advanced leukemia (58%- 74%) 3. Unmanipulated Haploidentical HSCT

Strategy-1 Our modified DLI G-CSF primed peripheral blood progenitor cells instead of steady donor lymphocyte harvests G-CSF primed peripheral blood progenitor cells instead of steady donor lymphocyte harvests Short-term CsA/MTX for prevention of DLI-associated GVHD Short-term CsA/MTX for prevention of DLI-associated GVHD GPBSCI Huang XJ et al, LEUKEMIA, 2006 ； 20 ， Huang XJ et al, Bone Marrow Transplant. 2009;44(5): Unmanipulated Haploidentical HSCT

GVHD prophylaxis Reduced GVHD occurrence Huang XJ, et al. Hematologica, 2007,92: None MTX 3. Unmanipulated Haploidentical HSCT

Prevention of relapse using modified DLI can significantly increase survival following HLA- mismatched/Haplo-identical HSCT in patients with advanced-stage, acute leukemia 3. Unmanipulated Haploidentical HSCT Huang XJ,et al. Bone Marrow Transplant Sep accepted

DiagnosisN=75 Jan, Sep,2010 AML N=42 >CR27 NR+REL35 ALL N=33 >CR28 NR+REL25 Patients Characteristic 3. Unmanipulated Haploidentical HSCT

Prophylactic GPBPCI Performed at 70 (20 ~ 314) d after HSCT MNC 1.0 ( )  10 8 /kg CD ( )  10 8 /kg No patients had profound and lasting pancytopenia after the prophylactic infusion 3. Unmanipulated Haploidentical HSCT

Cumulative incidence of grade Ⅲ to Ⅳ acute GVHD GVHD prophylaxis < 2w: 49.5% GVHD prophylaxis 2 ～ 4w: 31.6% GVHD prophylaxis 4 ～ 6w: 14.4% GVHD prophylaxis >6w: 9.3% The risk factor of DLI-associated acute GVHD Huang XJ,et al. Bone Marrow Transplant Sep accepted 3. Unmanipulated Haploidentical HSCT

Cumulative incidence of aGVHD Huang XJ,et al. Bone Marrow Transplant Sep accepted P= Unmanipulated Haploidentical HSCT

Cumulative incidence of cGVHD Huang XJ,et al. Bone Marrow Transplant Sep accepted P= Unmanipulated Haploidentical HSCT

Cumulative incidence of TRM Huang XJ,et al. Bone Marrow Transplant Sep accepted P= Unmanipulated Haploidentical HSCT

Cumulative incidence of relapse Huang XJ,et al. Bone Marrow Transplant Sep accepted P= Unmanipulated Haploidentical HSCT

Probability of OS Huang XJ,et al. Bone Marrow Transplant Sep accepted (P=0.013) 3. Unmanipulated Haploidentical HSCT

Lower relapse rate, a similar NRM, and a higher survival probability compared with non-DLI Can significantly increase the survival of patients with advanced-stage, acute leukemia even after HLA-mismatched, T-cell-replete HSCT Modified prophylactic DLI after HLA-mismatched/Haplo-identical HSCT Huang XJ,et al. Bone Marrow Transplant Sep accepted 3. Unmanipulated Haploidentical HSCT

Risk stratification-directed DLI could reduce relapse of standard-risk acute leukemia after allo-HSCT Institute of Hematology Peking University Beijing, China ASH 2111 Oral Presentation

Efficacy of intervention Groups 3yr-Relapse TRMOSLFS A 18.1% 19.7% 66.0% 61.6% B 68.0% 11.2% 23.9% 20.8% C 29.8% 15.6% 55.4% 52.5% ASH 2111 Oral Presentation

Strategy-1 Conclusion m-DLI can be used for the treatment and prophylaxis of relapse after haplo-identical HSCT 3. Unmanipulated Haploidentical HSCT

p=0.005 p= p=0.001 （ n=12 ） （ n=17 ） （ n=12 ） HuangXJ ， et al, Eur J Immunol Feb;41(2): Predictive value of Th17 cells and Tc17 cells in allo-graft on acute GVHD

Treating donor mice with rhIL-11 and rhG-CSF promotes transplant- tolerance and preserves the effects of GVL after allogeneic bone marrow transplantation HuangXJ, et al. Leuk Res Jan;33(1):123-8 Effects of different cytokines treatment on the recipients’ T cells proliferation activity in response to host alloantigens +14 d after BMT.

Strategy-2 Conclusion We may decrease the incidence of GVHD by manipulating the cell contents or function of graft? Mobilization with IL- 11 plus G-CSF ? 3. Unmanipulated Haploidentical HSCT

Strategy-3 KIR ligand match/mismatch to outcome on pretransplantation category aGVHD TRM Relapse OS KIR mismatch KIR match Huang XJ, et al. Biol Bone Marrow Transplant, 2008,14(3)

Strategy-3 Conclusion KIR ligand mismatch is associated with higher aGVHD, a greater relapse rate, and inferior survival in our haploidentical GIAC protocol---Donor Slection ? 3. Unmanipulated Haploidentical HSCT

ALC-30 ＞ 300/ul ALC- 30≤300/ul P<0.001 n=206 Strategy-4 Immune Reconstitution Huang XJ, et al. Bone Marrow Transplant, 2009,43: TRM 3. Unmanipulated Haploidentical HSCT ALC-30>300/ul ALC-30≤300/ul

** The counts of reconstituted CD3+ cells (cells/μl ) were significantly lower in HLA- mismatched patients at days 30 than those in HLA-matched patients, which reached normal level at days 60 in both HLA-matched and -mismatched patients. ** P ＜ HuangXJ, J Cli Imm Online Publication Comparison of Reconstituted T cells subgroup between HLA match and mismatch

** ** The counts of reconstituted CD4+ cells (cells/μl ) were significantly lower in HLA- mismatched patients at days 30, 60, 90, and 120 than those in HLA-matched patients, which did not reached normal level until 360 in both HLA-matched and mismatched patients, respectively. * P ＜ 0.05, ** P ＜ HuangXJ, J Cli Imm Online Publication Comparison of Reconstituted T cells subgroup between HLA match and mismatch

Strategy-4 Conclusion Novel approach to improve the recovery of immune reconstitution are greatly required. IL-2 after HSCT ? A Randomized Clinical Trial Is Undergoing For Evaluing IL-2 After Haplo-identical HSCT In PUIH 3. Unmanipulated Haploidentical HSCT

Acknowledgements Stem cell collection center Hai-Yin Zheng Hong Xu Qing Zhao Su Wang Department of Bone Marrow Transplant Dai-Hong Liu Feng-Rong Wang Huan Chen Jing-Zhi Wang Kai-Yan Liu Lan-Ping Xu Wei Han Xiao-Hui Zhang Yu-Hong Chen Yu Wang Laboratory of PUIH Dan Li Ya-Zhen Qin Yan-Rong Liu Yue-Yun Lai