Umbilical Cord Blood Transplantation in Pediatric Patients with Malignant Diseases J Kurtzberg, SL Carter, JE Wagner, LA Baxter-Lowe, D Wall, N Kapoor, E Guinan, S Feig, E Wagner, NA Kernan on behalf of the COBLT Steering Committee Results of a Prospective, Multi-Institutional NHLBI Sponsored Trial

Overview of the COBLT Study Prospective, multi-institutional study sponsored by the NHLBI. –3 banks: DukeJ Kurtzberg UCLAJ Fraser CHOC/GTM Cairo Created inventory of approx 8,000 units 71 % of transplants used COBLT units Transplantation study: Strata for adults, peds ID, metabolic ds & peds malignancies.

The Transplantation Study Common protocol for preparative regimen, GvHD prophylaxis and supportive care. Common criteria for evaluation of risk status at study entry, donor selection, engraftment, GvHD, infection and causes of death.

Study End Points Primary Endpoint 180 day survival Secondary Endpoints Disease-free survival Incidence of neutrophil engraftment Incidence of platelet engraftment Incidence of acute and chronic GVHD Incidence of relapse Analysis of high resolution HLA typing and effect on outcomes.

Definitions Original HLA Matching –Low resolution DNA based typing for Class I, A and B, High resolution DNA typing for Class II, DRB1 Retrospective (final) HLA Matching –High resolution DNA typing for A, B, DRB1 Engraftment –ANC 500/uL with >90% donor chimerism by day 42

Patient Eligibility Pediatric Patients between 1-18 years Hematological malignancies –Exclude CML blast crisis –Exclude ALL relapse No related donor UCB donor delivering >10e7 cells/kg, matching at 4/6 HLA loci by low resolution typing at Class I, or 3/6 with high resolution matching, 1 allele at A, B, DRB1.

Treatment Preparative Regimen –TBI 1350 –Cyclophosphamide 120 –Horse ATG 90 GvHD Prophylaxis –Cyclosporine –Methyprednisolone Supportive Care –Anti viral, fungal and PCP prophylaxis –Antigen/DNA monitoring for CMV –G-CSF from day 0 –IVIG prophylaxis

191 subjects transplanted between Median Age: 7.7 (0.9 – 17.9) years Median Weight: 25.9 ( ) kg 61% Males 58% White/38% Other/5% Unknown 51% CMV+ 77% High Risk Median pre cryo cell dose:5.2x10e7/kg Median CD34 cell dose: 1.52x10e5/kg Demographics Primary DiseaseN(%) ALL109(57) AML57(30) MDS15(8) CML7(4) Bi-Phenotypic2(1) JMML1(1)

HLA Matching at HLA A, B & DRB1 Original HLA Match Final HLA MatchTotal # Patients Enrolled Total # Patients with HR HLA Typing 2 of 63 of 64 of 65 of 66 of 6 N(%) 1 N N N N NN(%) 2 3 of 62(40)2 1(20)0(0)0 55(100) 4 of 68(8)30(29)65(63)0(0) (94) 5 of 61(2)3(5)11(20)37(67)3(5)5955(93) 6 of 60(0)1(6)0(0)3(19)12(75)1716(94) Total11(6)36(20)77(43)40(22)15(8)191179(94) 1 Percent based on number of patients that have been retrospectively typed. 2 Percent based on number enrolled.

Engraftment Cumulative Incidence (CINC) and 1-Kaplan-Meier (1-KM) Neutrophil Engraftment Platelet Engraftment (>50K/mm 3 ) Probability Days Post-Transplant CINC 1-KM Probability Months Post-Transplant CINC 1-KM 153/189 at d42 CI 75.1 (95%CI ) 107/189 at d180 CI 50.5 (95% CI )

Multivariate Analysis Neutrophil Engraftment 1 Original HLA Match 5/6 versus 4/6 CharacteristicHR95% CIP-valueFavorable Characteristics Pre-Cryopreserved TNC (x10 7 /kg) 2.04( )0.05Larger TNC (>=2.5) Gestational Age1.37( )0.07Younger Gestational Age (<38 weeks) HLA Match ( )0.97Not Signficant

Graft Versus Host Disease Cumulative Incidence (CINC) and 1-Kaplan-Meier (1-KM) Acute GVHD Grades III/IV Chronic GVHD Probability Days Post-Transplant CINC 1-KM CINC 1-KM Probability Months Post-Transplant CI at d % (95% CI ) CI at 1 yr 20.4% (95% CI ) 70% Limited

Multivariate Analysis Acute GVHD Grades III/IV CharacteristicHR95% CIP-valueFavorable Characteristics HLA Match ( )0.0075/6 or 6/6 HLA Match 1 Original HLA Match 5/6 or 6/6 versus 3/6 or 4/6

Relapse Cumulative Incidence (CINC) and 1-Kaplan-Meier (1-KM) Probability Months Post-Transplant CINC 1-KM CI at 1 year 19.1 (95% CI )

Causes of Death Primary COD Contributing InfectionNo InfectionTotal NNN(%) Recurrence/Relapse--39(41) Rejection101(1) Graft Failure13518(19) Acute GVHD121022(23) Chronic GVHD617(7) Infection-Bacterial--1(1) Infection-Fungal--1(1) Infection-Viral--2(2) EBV011(1) Organ Failure-Cardiac022(2) Hemorrhage011(1) Total322095(100)

| | | |||||||| Probability Months Post-Transplant | | || | |||| | || ||| | ||| || ||||||| ||||| |||||||||||||||||||||||||||||||||| N=191 Overall Survival 180 days 67.4 (95% CI ) 1 yr 57.3 (95%CI ) Median 24 months

Overall Survival Recipient Gender Donor Gender Donor/Recipient Gender | | | | || || |||||||||| | | | ||| | ||| |||| || 1.0 Probability Months Post-Transplant | || ||| | || || ||| ||||||||||||||||| | | | |||||||||| Male, N=116 Female, N=75 P<0.01 | | ||| |||| | | || ||||| |||||| | | | ||||| | || || | ||| Male, N=102 Female, N=85 Probability Months Post-Transplant | |||| ||||| |||||||||||||| | | | | || || |||||||||||| P=0.65 | | | || ||||||||| | | | | | ||||| | ||| | Probability Months Post-Transplant | | ||| |||||||||||||| | | || || | || | |||||||||||||||| M/M or F/F, N=96 M/F or F/M, N=91 P=0.30

Overall Survival Recipient Cytomegalovirus Serostatus | | | ||| | | ||

|| | ||| | | | || ||| || |||| Probability Months Post-Transplant | | | |||| ||||| || ||||||||| | ||||| |||||||||||||| | || |||||||||| <2.5, N= , N= , N=54 >7.5, N=47 P=0.03 || | | | | |||| Probability Months Post-Transplant | ||| | ||| ||||||||||||| || ||| | || || |||||||||||||||||||||||||| P=0.73 <1.51, N=69 >=1.51, N=91 Overall Survival Pre-Cryopreserved TNC (x10 7 /kg) Pre-Cryopreserved CD34+ (x10 5 /kg)

Overall Survival Original HLA Match Retrospective HLA Match | | | ||| | | | | Probability Months Post-Transplant | | | ||| |||||||||||||| | ||||| | | ||| |||| ||||||||||||||||||||| 5/6, N=59 4/6, N=110 P=0.92 | |||| | 5/6, N=40 4/6, N=77 Probability Months Post-Transplant || | ||||||||||||| ||| | ||||| ||||||||||||||||| P=0.37

Multivariate Analysis For Survival CharacteristicHR95% CIP-valueFavorable Characteristics ANC Engraftment ( )<0.001Early Engrafter Recipient Cytomegalovirus Serostatus 0.50( )0.002Negative Recipient Gender1.64( )0.01Male 1 Time Dependent Covariate

Summary The COBLT Study represents the first prospective, multi-institutional study of cord blood transplantation –Standard treatment protocol –Standard supportive care –Standard outcome definitions and assessments –Analysis of retrospective high resolution HLA typing on outcomes (with 34% of patients having greater disparity than original typing)

Conclusions Incidence of engraftment is 75% which correlated with nucleated cell dose and donor gestational age. Incidence of acute grade III/IV acute GVHD was 19%; chronic GVHD was 20% (70% limited) and GVHD was cause of death in 30% of fatalities. Incidence of relapse was 25% (77% of pts were high risk ).

Conclusions Overall survival was 55% with early engraftment, recipient CMV seronegative status and male gender being favorable risk factors. Notably, level of HLA match (original or high resolution) and risk status at diagnoses did not impact survival.

Acknowledgements Cardinal Glennon Children's Hospital - Dr. Michael Kelly Case Western Reserve University Hospital - Dr. Mary Laughlin Children's Hospital – Los Angeles - Dr. Neena Kapoor Children's Hospital – New Orleans - Dr. Lolie Yu Children's Hospital – Orange County - Dr. Steven Neudorf Children's Hospital – Philadelphia - Dr. Nancy Bunin Children's Hospital – Pittsburgh - Dr. Rakesh Goyal Children's Medical Center of Dallas - Drs. Victor Aquino & Donna Wall Children's Mercy Hospital - Dr. Andrew Gilman Children's National Medical Center - Dr. Naynesh Kamani City of Hope National Medical Center - Dr. Joseph Rosenthal Dana Farber Cancer Institute - Drs. Eva Guinan & Leslie Lehmann DeVos Children's Hospital - Dr. Daniel Pietryga Fred Hutchinson Cancer Research Center - Dr. Colleen Delaney Hackensack University Medical Center - Drs. Joel Brochstein & Stuart Goldberg Indiana University Cancer Center - Dr. Paul Haut North Texas Hospital for Children - Dr. Joel Weinthal Roswell Park Cancer Institute - Drs. Philip McCarthy & Barbara Bambach Schneider Children's Hospital - Dr. Indira Sahdev Texas Transplant Institute - Drs. Carlos Bachier & Donna Wall University of California, Los Angeles - Dr. Stephen Feig University of California, San Francisco - Drs. Morton Cowan & Biljana Horn University of Florida - Dr. Steven Hunger University of Minnesota - Dr. John Wagner University of Rochester - Drs. John Horan & Jane Liesveld Vanderbilt University - Dr. Haydar Frangoul The EMMES Corporation – Dr. Shelly Carter & Mr. Adam Mendizabal National Heart, Lung and Blood Institute – Dr. Luiz Barbosa, Ms. Liz Wagner & Dr. LeeAnn Jensen Dr. Nancy A. Kernan, Steering Committee Chair