3. 1989 First Cord blood transplant 1989-92Clinical observation that GVHD was reduced in HLA incompatible CBT 1992-93Establishment of Cord blood banks (NY, Paris, Milan and Dusseldorf ) 1993-95 Feasibility of HLA incompatible unrelated cord blood transplants 1995 Establishment of Eurocord group 1997 Nucleated cell dose more important factor for engraftment and survival, influence of HLA on engraftment 1998 Large series of UCBT = confirmation of cell dose and HLA >2000Retrospective comparisons between UBMT and UCBT 2002 Use of cord blood cells in adults with promising results 2003 Criteria of cord blood choice and indications 2003-04 Use of double cord and RIC regimen in adults 2004 Isolation of USSC from umbilical cord blood 2004-05Comparable results between unrelated CBT and UBMT in adults Past and Present of Cord Blood Transplants

4. CORD BLOOD BANKS NETCORD Standards Quality Control Accreditation FACT-Netcord Donor search TRANSPLANT CENTERS (EBMT and non EBMT) NETCORD-EUROCORD INTERACTIONS EUROCORD Registry Protocols Clinical Studies BMDW MUD Registries

5. 2842 cord blood transplantation performed from 1988 to Sep 2006 in 39 countries and 318 transplant centers: - 138 EBMT1700 cases - 180 Non-EBMT 742 cases  Single CB transplant n=2680 Related n= 267 Unrelated n = 2313  Expanded Unit n= 52  Unit for multi cord n= 150  UCB + BM (haplo) n= 14  CB + BM (genoidentical) n= 18  Autologous or gene therapy n=4 EUROCORD Registry

6. Related Cord Blood Transplantation CLINICAL RESULTS

7. Related Cord Blood Transplantation (n=231) Survival according to diagnosis Hbpathies n=63 months 100% Bone marrow failures n=37 78  7 % Inborn Errors n=23 83  8% Malignancies n=109 47  5% 1,0,9,8,7,6,5,4,3,2,1,0 4812 0 24 36 60

8. 544842363024181260 1,0,9,8,7,6,5,4,3,2,1 0,0 5 years EFS according to diagnosis Thalassemia (n=44) 78%+6 Months Sickle cell disease (n=19) 94%+6

9. Related cord blood transplantation for maligancies (n=109) Survival according to status of the disease at CBT

10. International Bone Marrow Transplant Registry and Eurocord V Rocha et al NEJM 342: 1846-1854, 2000 COMPARISON OF GVHD AFTER HLA-IDENTICAL SIBLING CORD BLOOD vs BONE MARROW TRANSPLANTS IN CHILDREN

11. MULTIVARIATE ANALYSIS - GVHD - GVH98_19.ppt RELATIVE RISK ** 0.0 0.2 0.4 0.6 0.8 1.0 Grade II-IV Acute GVHD Chronic GVHD 1.2.001.02 BM n=2018 CB n=113 * Reference Group

12. MULTIVARIATE ANALYSIS - Hematopoietic Recovery & Survival - GVH98_25.ppt RELATIVE RISK ** 0.0 0.2 0.4 0.6 0.8 1.0 Early Late Platelets >20 x 10 9 /L ANC >0.5 x 10 9 /L 1.2.0001 NS BM CB * Reference Group ** Mortality.0001 NS

13. Survie Globale après greffes HLA identiques de SCO comparées aux greffes de MO chez les enfants selon les diagnostiques PROBABILITE DE SURVIE, % ANNEES 0 20 40 60 80 100 012345 Non-malignes, MO (N = 789) Non malignes, SCO (N = 52) Malignes, MO (N = 1,263) Malignes, SCO (N = 61) V Rocha, J Wagner, K Sobosinski et al, NEJM 342: 1846-1854, 2000

14. Indications of cord blood banking for family use Sibling with a disease which can be cured by hematopoietic stem cell transplantation: Poor risk leukemia, aplastic anemia, hereditary disorders. Sibling with a disease which can be cured by hematopoietic stem cell transplantation: Poor risk leukemia, aplastic anemia, hereditary disorders. HLA mismatched transplants with 1, 2 or full haplotype (?) HLA mismatched transplants with 1, 2 or full haplotype (?) Familial predisposition to malignancies Familial predisposition to malignancies Genetic disease (autologous use for gene therapy) Genetic disease (autologous use for gene therapy)

15. Unrelated Cord Blood Transplantation

16. Estimate number of patients with an indication of an allogeneic hematopoietic stem cell transplants (9 or 10 out of 10)

17. Searching and identifying an unrelated stem cell donor BMCB Information of A+B (serology) +DRB1(DNA) typed 16-56% 40-80% Median search time3-6 mon <1mon Donors identified but not available30% ~1(?)% Rare Haplotypes represented2-10%20% Major limiting factors to graft acquisitionHLA match Cell Dose Ease of rearranging date of cell infusionDifficultEasy Potential for second HSC graft or DLIYes No from the same donor Potential for viral transmission to recipientYes No congenital diseasesNoYes Risk to donor YesNo Advantages and disadvantages Grewal S et al, modified Blood 2003

18. UNRELATED TRANSPLANTS BY RECIPIENT AGE - Registered with CIBMTR, 1996 to 2003 - CBT04_11.ppt 0 20 40 60 80 100 TRANSPLANTS, % 1996-19992000-20031996-19992000-2003 Bone Marrow Peripheral Blood Cord Blood Age < 20 yrsAge > 20 yrs 3% 72% 50% 90% 25% 14% 56% 6% 36% 39% 5% 4%

19. Number of Unrelated CBT / year reported to Eurocord Unrelated n=2172 *Still collecting data 2005

20. Number of Unrelated Donor CBT according to the recipient age/year reported to Eurocord Children (1320) Adults (693) * 2005

21. Eurocord Registry UNRELATED CORD BLOOD TRANSPLANT IN CHILDREN EUROCORD

22. UCBT in children with AML (n=154) Leukemia free survival according to the status of the disease at transplant G Michel updated, Blood 2003

23. Outcome after Unrelated Umbilical Cord Blood Transplants for Children with Acute Lymphoblastic Leukemia Eurocord and Acute Leukemia Working Party of EBMT Eurocord and Acute Leukemia Working Party of EBMT Hôpital Saint-Louis, Paris V Rocha, M Labopin, G Michel, N Kabbara, W Arcese, J Ortega, A P Iori, L Madero K- W Chan, F Locatelli, F Garnier, I Ionescu, P Wernet, E Gluckman

24. N Median age at UCBT < 1 year < 1 year +CMV Recipient Previous autograft Duration of first CR Patient and disease characteristics (n=361) Patient and disease characteristics (n=361) CR1 87 4.7 (0.4-16) 18% 43% 0 - CR2 152 6.7 (0.7-16) <1% 44% 2% 21 mo Advanced 122 8.0 (0.5-16) <1% 58% 10% 23 mo

25. Pre-BBTNullBiphenotypic Poor risk Cytogenetics t (9;22), t (4;11) Disease Characteristics Disease Characteristics CR1 (n= 87) 47% 21% 17% 7% 8% 89% CR2 (n=152) 56% 19% 16% 3% 6% 38% Advanced (n=122) 66% 12% 14% 6% 2% 39%

26. Outcomes after UCBT for children with ALL (n=361)

27. Cumulative incidence of neutrophil recovery according to number of cells infused (10 7 /kg) (per quartiles) (n=361) UCBT for Children with ALL UCBT for Children with ALL 0102030405060 0.0 0.2 0.4 0.6 0.8 1.0 days < 2.6 63% 2.6-3.8 73% 3.8-5.7 81% >5.7 88% P (gray test) <0.001

28. UCBT for Children with ALL UCBT for Children with ALL

29. Risk factors of outcomes after UCBT for children with ALL in 2 nd CR (n=152)

30. UCBT for Children with ALL in CR2 (n=152) UCBT for Children with ALL in CR2 (n=152) 0102030405060 0.0 0.2 0.4 0.6 0.8 1.0 Relapse incidence according to previous relapse on or off chemotherapy on therapy n=73 39 ± 4% off therapy n=65 14 ± 7% months P (gray test) =0.001

31. UCBT for Children with ALL in CR2 (n=152) UCBT for Children with ALL in CR2 (n=152)

32. p value RR95%CI Acute GVHD (II-IV) Use of Serotherapy 0,030,420.19-0.93 TRM no factor no factor Relapse Off therapy 0,030,330.12-0.92 LFS 0,020,570.36-0.92 Results of multivariate analysis in CR2 patients

33. Causes of death (n=86) UCBT for Children with ALL in CR2 (n=152) UCBT for Children with ALL in CR2 (n=152)

34. ENGRAFTMENT ACUTE GVHD CHRONIC GVHD EARLY TRM RELAPSE SURVIVAL Cord blood vs Bone Marrow Comparative studies between UCBT and UBMT in children (V Rocha Blood 2001, J Barker Blood 2001, H Dalle BMT 2004, Jacobson BMT 2004, P Rubinstein ASH 2005)

35. Non malignant diseases in children

36. Overall survival after UCBT in patients with bone marrow failure syndromes 3633302724211815129630 1,0,8,6,4,2 0,0 Congenital aplastic anemia n=16 63% Severe aplastic anemia n= 1921% Fanconi anemia n= 9234%

37. Survival after UCBT for Fanconi anemia (n=92) according to number of HLA differences (A, B antigen and DRB1 allelic)

38. Overall survival after UCBT in children with metabolic disorders

39. Overall survival of children with Primary Immunodeficiencies according to Number of HLA differences (n=93) 050010001500200025003000 0.0 0.2 0.4 0.6 0.8 1.0 Days P(Survival) 58%58% 78 % HLA Identical or one difference out of 6 2 or 3 HLA differences out of 6

40. Eurocord Registry UNRELATED CORD BLOOD TRANSPLANT IN ADULTS Results EUROCORD

41. Overall Survival after UCBT for adults with hematologic malignancies n= 457 60544842363024181260 1,0,8,6,4,2 0,0 before 1998 18±6% (n=44) after 1998 35±3% (n=413) P <0.0001

42. 363024181260 1,0,8,6,4,2 0,0 CR1 n=23: 60%+13 CR2 n=17: 51%+15 Others n=47: 15%+5 Leukemia Free Survival after UCBT fr adults with AML according to the disease status (n=87)

43. Leukemia Free Survival after UCBT for adults with ALL according to the disease status (n=113) CR1 n=39: 31%+8 CR2 n=26: 42%+10 Others n=48: 18%+6 363024181260 1,0,8,6,4,2 0,0

44. Outcomes of Unrelated Cord Blood Transplants compared to Unrelated Bone Marrow Transplants in Adults with Acute Leukemia A retrospective based registry study V Rocha on behalf of Eurocord and Acute Leukemia Working Party-EBMT New England Journal of Medecine, Nov 2004 EUROCORD

45. 210 1.0.8.6.4.2 0.0 Leukemia Free survival UCBT versus UBMT in adults with acute leukemias years 35 %  2 32 %  6 P (log rank)= 0.09

46. MULTIVARIATE ANALYSIS - Hematopoietic Recovery & GVHD - RELATIVE RISK ** 0.0 0.2 0.4 0.6 0.8 1.0 Platelets >50 x 10 9 /L ANC >0.5 x 10 9 /L 1.2 P<0.0001 UBMT UCBT * Reference Group ** Chronic GVHD P>0.0014 P=0.17 Acute GVHD P=0.01

47. MULTIVARIATE ANALYSIS - TRM, RELAPSE AND LFS - UBMT UCBT RELATIVE RISK * * 0.0 0.2 0.4 0.6 0.8 1.0 Relapse TRM 1.2 P=0.29 * Reference Group P=0.46 Leukemia Free Survival 0.70*

48. NO HLA identical sibling NO HLA matched unrelated donor Unrelated Cord Blood Haplo Identical T-cell depleted PBSC Indication for allogeneic HSCT

49. Comparison of outcomes after Unrelated Cord Blood or Haploidentical T-cell depleted Peripheral Blood Stem Cells in Adults with High Risk Acute Leukemia EUROCORD V Rocha, F Aversa, M Labopin, G Sanz, F Ciceri, W Arcese, D Bunjes, J Rowe, P Di Bartolomeo, F Frassoni, M Martelli and E Gluckman on behalf of the Eurocord-Netcord and Acute Leukemia Working Party EBMT

50. Patients From 1998-2002 229 haplo and 139 UCBT were performed for adults with high risk acute leukemia (AML and ALL) Two different analysis were performed AML patients Haplo= 154 UCBT= 66 ALL patients Haplo= 75 UCBT= 73

51. N 154 66 Status at transplant 0.9 CR1 33 (21%) 15 (23%) CR2 32 (21%) 12 (18%) More advanced 89 (58%) 39 (59%) Previous autologous transplant 21% 25% 0.61 Interval from diag-transplant 333 d 384 d 0.16 Median year of transplantation 2000 2000 0.21 Haplo UCBT P AML Patients and Disease characteristics

52. Haplo versus UCBT for adult patients with AML Leukemia Free Survival 24±4% years Haplo (n=154) 30±6% UCBT (n=66) P=0.39 3210 1.0.8.6.4.2 0.0

53. Haplo versus UCBT for adult patients with AML 2 year-LFS according to status of the disease HaploUCBT P CR1 48±9% 48±14% 0.94 CR2 42±10% 44±16%0.70 Advanced 8±3% 20±6%0.29

54. HaploUCBT P N75 73 Age (y)Median 27 20 0.007 Range15-56 15-55 CMV+ 65%62% 0.76 Cytogenetics abnormality t (9;22) 41% 34% 0.57 ALL Patients and Disease characteristics

55. N 75 73 Status at transplant 0.79 CR1 23 (31%) 15 (29%) CR2 18 (24%) 12 (20%) More advanced 34 (45%) 39 (51%) Previous autologous transplant 13% 14% 0.90 Interval from diag-transplant 419 d 415 d 0.10 Median year of transplantation 2000 2000 0.23 Haplo UCBT P ALL Patients and Disease characteristics

56. 3210 1.0.8.6.4.2 0.0 13±4% years Haplo (n=75) 36±6% CB (n=73) P=0.01 Haplo versus UCBT for adult patients with ALL Leukemia Free Survival

57. Haplo versus UCBT for adult patients with ALL Unadjusted 2 year-LFS according to status of the disease HaploUCBT P CR1 32±10% 38±11% 0.92 CR2 15±9% 40±13%0.16 Advanced 0% 33±8%0.0004

58. Haplo UCBT RELATIVE RISK * * 0.0 0.2 0.4 0.6 0.8 1.0 Relapse TRM 1.2 P=0.13 * Reference Group P=0.15 Leukemia Free Survival 0.005 * Haplo versus UCBT for adult patients with ALL Multivariate analysis –TRM, Relapse and LFS 0.2 1.41.4

59. Conclusions In this retrospective registry-based analysis in adults patients with high risk acute leukemia, outcomes of HLA mismatched UCBT compared to T- cell depleted Haploidentical PBSC have shown Delayed neutrophil recovery Increased incidence of acute GVHD Same incidence of chronic GVHD in ALL and increased incidence in AML In patients with AML, TRM, relapse rate and LFS were similar between UCBT and Haplo transplants. In patients with ALL, LFS is increased in UCBT recipients compared to Haplo transplants

60. How to improve engraftment? Donor choice How to choose the best unit? Strategies of Cord Blood Banks Collection of units containing high number of cells Under investigation Use of hematopoietic growth factors at day 0 Ex vivo expansion of cord blood cells Intrabone injection of cord blood cells Co-infusion of mesenchymal cells Reduced intensity conditioning regimen using cord blood cells Use of double transplants

61. How to improve engraftment? Donor choice How to choose the best unit? Strategies of Cord Blood Banks Collection of units containing high number of cells Under investigation Use of hematopoietic growth factors at day 0 Ex vivo expansion of cord blood cells Intrabone injection of cord blood cells Co-infusion of mesenchymal cells Reduced intensity conditioning regimen using cord blood cells Use of double transplants

62. Impact of number and type of HLA incompatibilities and cell dose on outcomes of unrelated cord blood transplants for patients with malignant and non-malignant disorders An Eurocord registry analysis

63. P< 0.0001 0-1 HLA and cell dose >= 2 020406080100 0.0 0.2 0.4 0.6 0.8 1.0 Days Cumulative incidence 2 HLA diff and cell dose >= 2 3-4 HLA diff and cell dose >= 2 0-1 HLA and cell dose < 2 2 HLA diff and cell dose < 2 3-4 HLA diff and cell dose < 2 UCBT malignant disorders (n=929) TRM according to number of HLA and cell dose

64. UCBT malignant disorders (n=929) Relapse according to number of HLA P= 0.01 020406080100 0.0 0.2 0.4 0.6 0.8 1.0 Months Cumulative incidence HLA identical 1 diff 4 diff 3 diff 2 diff P= 0.002 0-1 diff 2 diff 3-4 diff 020406080100 0.0 0.2 0.4 0.6 0.8 1.0 Months

65. P=0.168 020406080100 0.0 0.2 0.4 0.6 0.8 1.0 Overall survival 0-1 HLA and cell dose >= 2 3-4 HLA diff and cell dose >= 2 2 HLA diff and cell dose >= 2 0-1 HLA and cell dose < 2 2 HLA diff and cell dose < 2 3-4 HLA diff and cell dose < 2 UCBT malignant disorders (n=929) Overall survival according to number of HLA and cell dose Months

66. Interaction between HLA mismatches, number of cells and outcomes after unrelated CBT for malignant diseases Number of HLA MM 0-1 vs 2 vs 3-4 Type of HLA MM Class I vs class II Interaction with number of cells PMN engraftment LessSame Worse 3-4 MM and <3x10 7 NC/kg Platelet engraftment LessSame Worse 3-4 MM and <3x10 7 NC/kg TRMMore More 2 DR MM Worse 3-4 MM and <3x10 7 NC/kg AGVHMore More 2 DR MM Same CGVHMoreSame Decreased cells RelapseLess Less 2 DR MM Increased cells OS, EFS SameSame Decreased >MM and MM and <cells

67. P= 0.00287 0-1 difference 2 differences 3 differences 020406080100 0.0 0.2 0.4 0.6 0.8 1.0 Days Cumulative incidence UCBT in non-malignant disorders (n=268) TRM according to number of HLA

68. P=0.00065 020406080100 0.0 0.2 0.4 0.6 0.8 1.0 Days Cumulative incidence UCBT in non-malignant disorders (n=268) TRM according to number of HLA and cell dose 2 and 3 HLA diff and cell dose < 3.5 (n=30) 0 and 1 HLA diff and cell dose < 3.5 (n=28) 2 and 3 HLA diff and cell dose >= 3.5 (n=62) 0 and 1 HLA diff and cell dose >= 3.5 (n=117)

69. P< 0.0001 020406080100120 0.0 0.2 0.4 0.6 0.8 1.0 Months Overall survival 2 and 3 HLA diff and cell dose < 3.5 (n=30) 0 and 1 HLA diff and cell dose < 3.5 (n=28) 2 and 3 HLA diff and cell dose >= 3.5 (n=62) 0 and 1 HLA diff and cell dose >= 3.5 (n=117) UCBT in non-malignant disorders (n=268) Overall survival according to HLA and cell dose

70. Number of HLA MM 0-1 vs 2 vs 3-4 Type of HLA MM Class I vs class II Interaction with number of cells PMN engraftment Less More 1 HLA-B # Less 2 DRB1= Less <cells and more MM Platelet engraftment Less More 1 HLA-B # Less 2 DRB1= Less <cells and more MM TRMMore More 2 DRB1= Less <cells and more MM AGVHMoreSame More >cells and>MM CGVHMoreSame OS, EFS Less Less with DRB1 Worse if HLA MM>2 and NC 2 and NC< 3.5NC/kg Interaction between HLA mismatches, number of cells and outcomes after unrelated CBT for non malignant diseases

71. How to improve engraftment? Donor choice How to choose the best unit? Strategies of Cord Blood Banks Collection of units containing high number of cells Under investigation Use of hematopoietic growth factors at day 0 Ex vivo expansion of cord blood cells Intrabone injection of cord blood cells Co-infusion of mesenchymal cells Use of double transplants Reduced intensity conditioning regimen using cord blood cells

73. % of French CB units accoring to the number of NC/Kg 100,0 99,6 96,0 86,1 71,2 53,4 100,0 99,6 92,1 71,2 45,5 27,4 15,0 100,0 96,0 71,2 38,8 18,6 8,2 3,4 0 20 40 60 80 100 120 10203040506070 Weight (Kg) Pourcentage (%) % CB units > 2E+07 CNT/Kg % CB units> 3E+07 CNT/Kg % CB units> 4E+07 CNT/Kg

74. How to improve engraftment? Donor choice How to choose the best unit? Strategies of Cord Blood Banks Collection of units containing high number of cells Under investigation Use of hematopoietic growth factors at day 0 Ex vivo expansion of cord blood cells Intrabone injection of cord blood cells Co-infusion of mesenchymal cells Use of double transplants Reduced intensity conditioning regimen using cord blood cells

77. Increased graft cell dose will improve engraftment & survival (Each unit will not reject the other) Double Unit UCBT: Hypothesis

78. Myeloablative Treatment Schema Mycophenolate - 3 to + 30 G-CSF CSA - 3 to > +100 -3 -2-4-8-7-6-5+14+21+100+1800 UCB #2 UCB #1 Eligibility: High-risk hematologic malignancy No single 4-6/6 UCB > 2.5 x 10 7 NC/kg (later increased to 3.5)

79. Minimum allowed cell dose 1.0 x 10 7 NC/kg 0-2 mismatch UCB #1 UCB #2 Minimum allowed cell dose 0.5 x 10 7 NC/kg Goal : maximize graft cell dose 1 o Endpoint: Donor Engraftment 0-2 mismatch Double Unit Selection

80. Patient Characteristics Total N 23 Tx date2000-2003 Age 24 yrs (13-53) Wt 73 kg (48-120) Diagnosis AML13 (56%) CML2 (9%) ALL8 (35%) Conditioning Cy120/ TBI 1320/ ATG 2 (9%) Cy120/ TBI 1320/ Flu7521 (91%) Median Follow-Up10 months (4 - 30)

81. Cell Doses using Double UCB Tx Infused TNC3.5 x 10 7 /kg (1.1-6.3) Larger Unit 1.9 (0.6-3.6) Smaller Unit 1.5 (0.5-2.7) Infused CD34+ 4.3 x 10 5 /kg (0.9-14.3) Larger Unit 2.7 (0.5-10.4) Smaller Unit 1.2 (0.4-4.7)

82. HLA match in Double UCB Tx N = 23 2 (9%) one 6/6 unit (2nd unit: 6/6 n = 1, 5/6 n = 1) 11 (48%) one 5/6 unit (2nd unit: 5/6 n = 4, 4/6 n = 7) 10 (43%) both units 4/6 N = 23 2 5 16 Best Match to Recipient 6/6 5/6 4/6 Match to Each Other 6/6 5/6 4/6

83. Neutrophil Engraftment (n = 21) Days Cumulative Incidence 0.0 0.2 0.4 0.6 0.8 1.0 071421283542 I I Median: 23 days (range 15-41) 100%

84. Do Both Units Contribute to Hematopoiesis?

85. Do Both Units Contribute to Hematopoiesis? NO Only 1 unit is sustained

86. Day +21 +100 Chimerism Complete donor chimerism was rapid and sustained. Sustained hematopoiesis accounted for by only 1 unit. Double (n = 23) 91% (64-100) 24%: 2 units present 74% (42-85) vs. 20% (15-40) 76%: 1 unit 100%

87. Cell Doses using Double UCB Tx Infused TNC3.5 x 10 7 /kg (1.1-6.3) Larger Unit 1.9 (0.6-3.6) Smaller Unit 1.5 (0.5-2.7) Infused CD34+ 4.3 x 10 5 /kg (0.9-14.3) Larger Unit 2.7 (0.5-10.4) Smaller Unit 1.2 (0.4-4.7) Infused CD3+ 1.0 x 10 7 /kg (0.5-2.2) Larger Unit 0.6 (0.3-1.3) Smaller Unit 0.4 (0.1-0.9)

88. Acute GVHD Days Cumulative Incidence 0.0 0.2 0.4 0.6 0.8 1.0 020406080 100 Grade II-IV: 65% (95% CI: 42-88) Grade III-IV: 17% (95% CI: 2-32)

89. Transplant Related Mortality Months Cumulative Incidence 0.0 0.2 0.4 0.6 0.8 1.0 0123456 22% (95% CI: 5-39%)

90. Disease-Free Survival Months Probability 0.0 0.2 0.4 0.6 0.8 1.0 024681012 I IIIIIIIIII II I Tx in Relapse (n = 8): 25% (95% CI: 0-64) Tx in Remission (n = 15): 72% (95% CI: 49-95) p = 0.04

91. How to improve engraftment? Donor choice How to choose the best unit? Strategies of Cord Blood Banks Collection of units containing high number of cells Under investigation Use of hematopoietic growth factors at day 0 Ex vivo expansion of cord blood cells Intrabone injection of cord blood cells Co-infusion of mesenchymal cells Use of double transplants Reduced intensity conditioning regimen using cord blood cells

92. MMF (30mg/kg/day)- 3 to + 30 G-CSF CSA ( level>200µg/L) - 3 to > +100 -3 -2-4-8-7-6-5+14+21+100+1800 UCB Eligibility: High-risk hematological malignancy 4-6/6 UCB > 2.5 x 10 7 NC/kg (at collection) Fludarabine 40mg/m2/day Endoxan 50mg/kg Non-myeloablative regimen for UCBT in adults (n=18) 2Gy (J Barker and J Wagner)

93. Transplants performed from 1999-2005 (75% in the last 3 years) with single units Follow-up: 8 months (3-26) Median age: 47 years ( 16-76) Median weight:60 kg (40-110kg) CMV+: 63% Diagnosis Reduced Intensity conditioning regimen in Unrelated cord blood transplants for patients with hematological malignancies (n=65) Patients and disease characteristics Previous autologous transplant: 39% (n=26)

94. Fludarabine+TBI (2Gy)3 Fludarabine+Endoxan (or mephalan)11 Fludarabine+Endoxan+TBI (2y)33 Fludarabine+Bussulfan(<8mg/kg)± other9 Fludarabine+Bussulfan(<8mg/kg)+TBI (<5y)4 Other5 Anti T antibodies (ATG/ALG or MonoAb)26% Hematopoietic growth factors (<Day 8)87% Reduced Intensity conditioning regimen in Unrelated cord blood transplants for patients with hematological malignancies (n=65) Conditioning

95. RESULTS Neutrophils recovery Median days:20 days (0-56) Chimerism at 3 months (available in 71% of the patients) Full donor67% Mixte chimerism9% Autologous reconstitution 24% Platelets recovery 35 days (9-63) 706050403020100 1,0,8,6,4,2 0,0 85±6%

96. RESULTS Acute GVHD Grade 28 (13%) Grade 34 (7%) Grade 44 (7%) 100806040200 1,0,9,8,7,6,5,4,3,2,1 0,0 24±5% 7206004803602401200 1,0,9,8,7,6,5,4,3,2,1 0,0 28±9% Chronic GVHD

97. 129630 1,0,8,6,4,2 0,0 DFS after RIC UCBT according to number of HLA disparities 0-1 HLA disparities n=28 42%+12 2 HLA disparities n=34 27%+9 3-4 HLA disparities n=9 P=0.08 months

98. DFS after RIC UCBT according to conditioning TBI+FLU+ENDX n=26 43%+11 others n=38 16%+7 P=0.005 months

99. DFS after RIC UCBT according to number of cells infused 129630 1,0,8,6,4,2 0,0 >2.4 x 10 7 /Kg 31%+12 < 2.4 x 10 7 /Kg 14%+8 P=0.05 months

100. DFS after RIC UCBT according to status of disease 129630 1,0,8,6,4,2 0,0 In remission31%+9 Non remission 22%+8 P=0.07 months

101. HOW TO CHOOSE AN ALTERNATIVE STEM CELL TRANSPLANT DONOR ??

102. High resolution HLA typing of the patient (adults and children) Simultaneous search Strategy of alternative stem cell donor for patients with malignant disorders Bone Marrow donor registries Cord Blood Banks HLA 10/10 or 9/10 3 months for AL) UCBT UBMT To be considered Haplo T-depleted in AML? Cell dose to be increased with nb of mismatches (single or double) >3.5x10 7 /kg HLA < 3/6

103. High resolution HLA typing of the patient (mostly children) Simultaneous search ( metabolic disorders, PID, BMFS ) Strategy of alternative stem cell donor for non malignant disorders Bone Marrow donor registries Cord Blood Banks HLA 10/10 or 9/10< 8/10 or urgency UCBT UBMT To be considered Haplo T-depleted? Yes for PID Cell dose to be increased with nb of mismatches (double systematically?) >4.5x10 7 /kg (?) HLA < 2/6

104. Cord Blood is an established source of hematopoietic stem cell for allogeneic transplantation in children and adults with malignant and non malignant disorders Nowadays, an alternative HSC donor can be found for almost all patients The indication of using UCB cells will depend on the urgency of transplantion, number of cells in a unit and number of HLA disparities Main questions to be answered : the immune reconstitution (mainly for adults) and long term follow up New technologies using cord blood cells such as RIC and double transplants are still in an investigational phase Conclusions

105. ABECASIS M ABELLA E ADKINS D AMADORI S ARCESE W BADELL SERRA I BAKER D BEGUIN Y BEKASSY A BEKSAC M BENGT S BENOIT Y BERNAUDIN F BERTRAND Y BLAISE D BLAYLOCK J BOGDANIC V BORDIGONI P BOSI A BRICHARD B CAHN JY CAIRO M CHAMPAGNE M CHAN KW CHAPUIS B CHI KONG LI COWAN M DALLORSO S DEMEOQ F DELLIERS LG DI BARTOLOMEO P DICKINSON A DIEZ B DINI G DOKAL I EAMES G EBELL W FAGIOLI F FAVRE C FERNANDEZ MN FERREIRA E FIBBEN W FILIPOVICH A FISCHER A FISCHER S GIBSON B GOLDBERG S GRAFAKOS S GRAHAM M GRANENA A GRATECOS N HARHALAKIS N JACOBS H JACOBSEN N JEDRZEJCZACK W JOUET JP KATO S KAWANO Y KEESLER C KINOSHITA A KOBYLKA P KOZINER B KREMENS B KUSMINSKY G LAMBERTENGHI G LAPORTE JP LEUNG L LI X LIMA M and GIRALT S LOCATELLI F LUTZ P MADERO LM EUROCORD EUROCORD CENTERS MARTINEZ-RUBIO A MASSZI T MESSINA C MICHEL G MILLER J MILONE J MILOVIC V MILPIED N MOORE T MUÑOZ VILLA A NAGLER A NIGEL P NURNBERGER W O’MARCAIGH A ORTEGA J PASQUINI R PEREZ-OYTEZA J PESSION A PETERS C PETRYGA D PIHKALA U PIMENTEL P PLOUVIER E PRITCHARD D QUINONES R RABUSIN M RAJA T REIFFERS J RIO B ROBERTS I ROITTMAN S ROSSBACH F ROSSBACH T ROWE J RUBIN A SANZ G SADOUN A SASLAVSKY J SCHULTZ A SCIME R SHAW P SHPALL EJ SIEVERS E SMITH F SOCIE G SPRUCE W STARY J STIFF P TAKAHASHI T TIEDEMANN K TOREN A UDERZO C URBAN C VERDEGUER A VERDONCK L VEYS P VILMER E VORA A VOWELS M WALL D WAWER A WILL A WOOD J YANIV I YEAGER A ZANDER A ZANESCO L ZINTL F