1. 2 nd International Conference on Hematology & Blood Disorders （ Sep. 29-Oct. 01, 2014 Baltimore, USA ） Hyogo College of Medicine Graft-versus-GVHD, a second transplantation from another donor for the rescue from refractory acute GVHD Kazuhiro Ikegame

2. liver gut skin joint muscle DNA Self-reactive lymphocytes Donor lymphocyte Autoimmune GVHD alloreactive cell therapy nerve Graft-versus-Autoimmunity (GVA) Graft-versus-GVHD (GvGVHD) Concept of Graft-versus-GVHD (GvGVHD)

3. alloBMT Days after transplantation 020406080100 10 10 2 10 3 10 4 WBC(x10 6 /l) Plts(x10 6 /l) 5 10 15 20 skin rash WBC Plts MMF FLU+CY+TBI ATGMTX BM relapse on day 144 after 2 nd autoPBSCT ALG 8mg/kg Autologous PBSCT for severe GVHD diarrhea hemorrhagic cystitis mPSL TBI 2Gy TT 10mg/kg autoPBSCT tacrolimus Taniguchi Y, et al. Haematologica. 2003; 88.

4. Bone Marrow Transplantation (2004) 34, 995–998 Case reports of autologous PBSCT for GVHD

5. 1st BMT ( b / d )2nd BMT ( b / k ) 2weeks BM 1×10 7 spleen 3×10 7 Recipient ( b / k ） TBI 8.5Gy ( B6C3F1) ( BDF1)(B6C3F1) TBI 0, 2, 3, 4, 5 Gy BM 1×10 7 spleen 3×10 7 AutoSCT for GVHD (mouse model) Taniguchi Y, et al. Exp Hematol. 2008; 36:1216.

6. 2 nd SCT B6C3F1→(B6C3F1→B6C3F1) B6C3F1→(BDF1→B6C3F1) TBI 4Gy B6C3F1→(BDF1→B6C3F1) TBI 5Gy TBI toxicity BDF1→B6C3F1 TBI 3Gy BDF1→B6C3F1 GVHD B6C3F1→(BDF1→B6C3F1) TBI 3Gy TBI BDF1→B6C3F1 TBI 3Gy B6C3F1→(BDF1→B6C3F1) TBI 3Gy B6C3F1→(BDF1→B6C3F1) TBI 4Gy B6C3F1→(B6C3F1→B6C3F1) GVHD

7. Problems of AutoSCT for GVHD 1) Difficult to engraft （ GVH clones are rejecting clones ） 2) Risk of relapse （ Loss of GVL effect ） B6C3F1 (b/k) normal tissue B6C3F1 (b/k) stem cells B6C3F1 (b/k) leukemic cells B6C3F1 (b/k) leukemic cells BDF1 (b/d) lymphocytes k k k k k k b b b b bb b b b b d d d d GVL GVHD Rejection No GVL

8. 第 17 回クリニカルヘマトオンコロジー 5/14/2010 Allogeneic is better than autologous for severe GVHD?

9. 1st BMT ( b / d )2nd BMT ( b / s ) 1, 2, 3 weeks BM 1×10 7 spleen 3×10 7 Recipient ( b / k ） TBI 8.5Gy ( B6C3F1) ( BDF1)(B6B10F1) TBI 0, 2, 3, 4, 5 Gy BM 1×10 7 spleen 3×10 7 AlloSCT for GVHD (mouse model)

11. Experiment 1 2 3 4 5 6 7 SCT sequence TBI dose For 2 nd SCT Day 7Day 14 Improvement in GVHD score 3Gy 4Gy 3Gy 0 0 47 ± 20 99 ± 0.8 99 ± 0.9 25 ± 10 2.6 ± 2.5 40 ± 7.1 78 ± 8.6 95 ± 3.4 99 ± 1.1 18 ± 18 1.8 ± 3.6 25 ± 3.1 96 ± 2.5 + + + - - - + T cell chimerism of 1 st and 2 nd donors after 2 nd SCT 3Gy is not enough when GVHD clones are rejecting clones TBI is indispensable in homo-to-hetero (hybrid resistance?) B6C3F1→(BDF1→B6C3F1) B6C3F1→(BDF1→B6C3F1) B6B10F1→(BDF1→B6C3F1) B6B10F1→(BDF1→B6C3F1) C3DF1→(BDF1→B6C3F1) DBA/2→(BDF1→B6C3F1) DBA/2→(BDF1→B6C3F1) ± b/kb/db/k b/db/k b/sb/db/k b/sb/db/k d/kb/db/k d/db/db/k d/db/db/k 2 nd donor chimerism

12. Human is more important than mouse?

13. Recovery from established graft-vs- host disease achieved by bone marrow transplantation from a third-party allogeneic donor. Taniguchi Y, et al. Exp Hematol. 2008. Allogeneic stem cell transplantation as treatment for heavily treated, refractory acute graft-versus-host disease after HLA-mismatched stem cell transplantation. Ikegame K, et al. Exp Hematol. 2011. Second SCT for refractory acute GVHD from another haploidentical donor (n=15 cases) Engraftment 11, rejection 4 OS@3yr 53% in engraftment cases, early death of GVHD in all rejected cases Mouse model Clinical Graft-versus-GVHD

14. -7-6-5-4-3-201234 FLU30mg/m 2 ATG F 2mg/kg day Tacrolimus civ (9-11ng/ml) mPSL 1mg/kg PBSCT TBI3Gy Representative regimen of GvGVHD

15. skin 0 102030-100102030-10 gut 0102030-10 liver 0102030-10 0 102030-10 0 102030-10 0 102030-10 0 102030-10 0 102030-10 0 102030-10 0 102030-10 0 102030-10 0 102030-10 0 102030-10 0 102030- 10 1020301020300102030-10 No. 1 No. 4 No. 5 No. 6 No. 8 No. 9 Change of GVHD stage along time course before and after GvGVHD in engrafted cases 0-100

16. Patients with complete response (%) Response and survival after GvGVHD engraftment rejection engraftment rejection

17. Fujioka (SB) Okada (CB) Taniguchi K (FW) Ikegame (MF) Inoue (graduate student) Lineup of HCM (Acknowlegement) Ward (clinical) Lab. (research) (Coach) Kato (graduate student) Soma (GK) Ishi (FW) Kaida (FW) Yoshihara (MF) Taniguchi Y (SB) NursesDoctors Pain control team Clinical psychiatrists pharmacists PT Tamaki (CB)