1. Cord blood selection, release, and transplantation 6th World Congress Tissue Banking Barcelona, Spain, 10 November 2011 Guillermo Sanz Hospital Universitari i Politecnic La Fe Valencia, Spain

2. Main conclusions of studies comparing UCB and BM from MUD as graft sources for hematologic malignancies An adequate UCB unit selection is critical for success

3. Probability, % Months 100 0 20 40 60 80 90 10 30 50 70 0 100 20 40 60 80 90 10 30 50 70 CB, 37% 0122481620 PBPC matched, 43% PBPC mismatched, 35% BM matched, 47% 4 BM mismatched, 38% Eapen M at al. Lancet Oncol 2010 Unrelated UCB (NC dose >2.5 x 10 7 /kg), BM or MPB transplants in adults with acute leukemia Overall survival

4. Should we use in children and adults the same criteria for UCB unit choice? Not at all

5. Main prognostic factors after UCBT in children with hematologic malignancies Cell dose HLA match Interaction cell dose – HLA match present A higher cell dose can overcome the negative impact of a lower degree of HLA matching

6. Cumulative incidence (CI) of PMN engraftment according to TNC (×10 7 /kg) and HLA match Barker J N et al. Blood 2010;115:1843-1849

7. Main prognostic factors after UCBT in adults with hematologic malignancies Cell dose Status of disease at transplant HLA match does not impact outcomes Cell dose is the major obstacle and criteria

8. High-risk AML in CR1 (n = 30) LFS by nucleated cells infused > 2  10 7 /kg (n = 18): 75% at 4 y ≤ 2  10 7 /kg (n = 12): 25% at 4 y P = 0.03 Sanz J et al. Biol Blood Marrow Transplant 2010; 16: 86-94.

9. Policy on cell dose for UCB unit choice Most transplant centers use the number of collected TNC as the only cell dose criteria for unit choice –Greater TNC dose threshold for higher degree of HLA mismatch 2.5 – 3.5 × 10 7 /kg if 0 or 1 HLA mismatches 3.5 – 5 × 10 7 /kg if 2 HLA mismatches Is this policy reasonable? No, use both collected TNC and CD34+ cells

10. CD34+ measurement is now almost standardized CD34+ quantification performed at NetCord CB banks according to a uniform protocol (ISHAGE) Quality control available and likely required for accreditation in near future –i.e. Proficiency testing UKNEQAS

11. Prognostic value of infused CD34+ cells (× 10 5 /kg) after myeloablative UCBT in adults with hematologic malignancies 1 N Engl J Med 2001;344:1815-22. 2 Br J Haematol 2007;139:464-74. 3 Biol Blood Marrow Transplant 2008;14:1341-7. 4 Biol Blood Marrow Transplant 2010;16:86-94. 5 Biol Blood Marrow Transplant 2010;16:1589-95. Reference PMN engraftmentDFS Cut-off point P value Cut-off point P value Laughlin, 2001 1 1.20.05NS Van Heekeren, 2007 2 NSHigher0.015 Ooi, 2008 3 NS1.0< 0.0001 Sanz, 2010 4 NS1.50.009 Sanz, 2010 5 NS0.60.02

12. CD34 + > 1.5 x 10 5 /kg (n = 92) CI: 96% Median: 20 days CD34 + ≤ 1.5 x 10 5 /kg (n = 73) CI: 90% Median: 23 days P = 0.007 Myeloid engraftment after myeloablative single UCBT in adults with malignant disorders (n = 165) by collected CD34+ cells

13. Correlation between collected and infused CD34+ cells after myeloablative single UCBT in adults with malignant disorders (n = 164)

14. Guidelines for UCB unit choice Guidelines for UCB unit choice Eurocord 2009 criteria for malignant disorders UCB unit with 5/6 or 6/6 HLA match –Collected TNC > 2.5 × 10 7 /kg –Collected/infused CD34+ cells > 1.2 × 10 5 /kg UCB unit with 4/6 HLA match –Collected TNC > 3.5 × 10 7 /kg –Collected/infused CD34+ cells > 1.7 × 10 5 /kg Rocha V & Gluckman E on behalf of Eurocord/EBMT. Br J Haematol 2009; 147:262-274. These thresholds are difficult to achieve for many adults

15. Capacity of Eurocord 2009 criteria of reaching a target number of infused CD34+ cells (1 × 10 5 /kg) Experience in 164 UCB transplants Eurocord 2009 criteria No. of patients (%) No. of patients (%) with infused CD34+ cells > 1 × 10 5 /kg Fulfilled65 (40)52 (80) Absent99 (60)53 (54) Thresholds may be excessive/inappropriate

16. Capacity of current Hospital La Fe criteria* for CB unit choice of reaching a target number of infused CD34+ cells (1 × 10 5 /kg) Experience in 164 UCB transplants Hospital La Fe criteria* No. of patients (%) No. of patients (%) with infused CD34+ cells > 1 × 10 5 /kg Fulfilled129 (79)52 (74) Absent35 (21)10 (29) * Collected TNC > 2 × 10 7 /kg and collected CD34+ cells > 1 × 10 5 /kg Criteria as efficient as Eurocord 2009 criteria (74% vs 80%) and accessible to a higher number of patients (79% vs 40%)

17. Protocol UCBT GETH 2005 (n = 89) Myeloid engraftment (PMN > 0.5  10 9 /L) GETH cooperative group. Unpublished data Cumulative incidence: 94% Median: 19 days

18. Protocol UCBT GETH 2005 (n = 89) Early non-relapse mortality (NRM) GETH cooperative group. Unpublished data NRM100: 15% NRM180: 22%

19. Protocol UCBT GETH 2005 (n = 89) DFS at 2 yr by status of disease at transplant P = 0.003 Early (n = 46): 52% Intermediate (n = 23): 38% Advanced (n = 20): 18 % GETH cooperative group. Unpublished data Median follow-up (range): 33 (8 – 49) mo

20.  TNC > 2 × 10 7 /kg and > 150 × 10 7  CD34+ cells > 1 × 10 5 /kg and > 70 × 10 6 Current cell dose criteria (at freezing) for UCB unit choice at Hospital La Fe Both cell dose criteria required

21.  Only functional test available  Not standardized  No threshold available Other criteria for UCB unit choice CFU assay Always perform CFU assay Do not use units with no or very small growth

22.  Poorer engraftment rate and shorter overall survival when major ABO incompatibility present (Eurocord registry) Other criteria for UCB unit choice ABO match Avoid units with major ABO mismatch if possible For units with similar cell dose select those units ABO compatible or with minor ABO incompatibility

23.  No data on impact of CBB in outcomes available  Not all CBB standards are equal; nor speed of response Other criteria for UCB unit choice CB bank NetCord-accredited banks preferred Geographical proximity preferred

24.  No superiority of units frozen in more recent years demonstrated  Units stored in more recent years have followed higher quality standards Other criteria for UCB unit choice Year of storage More recent units preferred

25.  Potential relationship with CFU assay and 7-AAD CD34+ cell viability (preliminary data) Other criteria for UCB unit choice Time from UCB collection to freezing Lower than 48 h required (lower than 24 h preferred)

26.  High-resolution HLA match  HLA-C match  NIMA match  KIR mismatch  GVH direction match Other criteria for UCB unit choice Currently not used (pending confirmatory data)

27. Concluding remarks Selection of an adequate UCB unit is essential for success of UCB transplants The number of collected CD34+ cells must be included among the cell dose criteria Currently accepted thresholds for collected TNC and CD34+ cells need to be properly reviewed Additional criteria for UCB choice may be valuable but always remember that the major advantage of UCB is fast availability: do not delay transplant by adding more and more criteria