1. Upfront Transplant Strategies in Aplastic Anemia
Seiji Kojima MD. PhD.
Department of Pediatrics
Nagoya University Graduate School of Medicine
Chairman of the Severe Aplastic Anemia Working Party
Asia-Pacific Blood and Marrow Transplantation Group

2. APHCON Treatment Guideline for SAA
Yes No #2 #1 #3
APHCON Treatment Guideline for SAA

3. Today’s Topics
Use of rabbit ATG can be justified as a front-line therapy?
Comparable outcome can be expected between MRD and 1MMD?
Second course of ATG + CSA should be indicated if no alternative donor is available?

4. Experience of rabbit ATG for SAA
Long term outcome of AA children treated with horse ATG or rabbit ATG
Rabbit ATG experience in Nagoya University
小児再生不良性貧血においては、HLA一致血縁者間骨髄移植が治療の第1選択であり、HLA一致血縁ドナーが得られない場合には、免疫抑制療法を選択することが過去30年間にわたって標準的な治療方針とされてきた。
このような治療選択の指針は、主に1980年代における両治療法の治療成績の比較に基づいている。しかし、骨髄移植と同様に免疫抑制療法の治療成績の向上も著しい。
今日の治療選択の指針を作成するために、エビデンスのアップデートが必要である。

5. horse vs rabbit ATG n= 33 n= 29 n= 22 n= 69 n= 32 n= 79 n= 35 n= 10524 n= 46 n= 29 n= 42 n= 60 n= 60

6. Seiji Kojima MD Department of Pediatrics
Nagoya University Graduate School of Medicine

7. Patient Characteristics
Total cohort (N=455)
horse ATG (n=297)
rabbit ATG (n=158)
P-value
Median age at diagnosis (range), years
8 (0 - 17)
6.5 (1 - 16)
0.005
Gender, male/female
246 / 209
172 / 125
74 / 84
0.024
Etiology, n of patients (%)
<0.001
Idiopathic
386 (85)
242 (81)
144 (91)
Hepatitis
53 (12)
47 (16)
6 (4)
Others
16 (3)
8 (3)
8 (5)
Severity of AA, n of patients (%)
0.02
VSAA
272 (60)
166 (56)
106 (67)
SAA
183 (40)
131 (44)
52 (33)
Interval between diagnosis and IST
<18days ≧ 18days
224 / 231
160 / 137
64 / 94
0.01
Median WBC count (range), x109/L
2,100 (4 - 21,020)
1,900 (20 - 8,500)
3,100 (4 -21,020)
≥ 2.0 x 109/L, n of patients (%)
246
136
110
< 2.0 x 109/L, n of patients (%)
200
160 40

8. Response at 6M NE NR PR CR
horse ATG
rabbit ATG

9. Predictive factor for response at 6months
Covariates
Univariate analysis
Multivariate analysis
Hazard Ratio
( 95% CI)
p-value
95% CI
Horse ATG vs. rabbit ATG
0.995
( )
0.981 -
Gender
1.560
( )
0.025
1.823
( )
0.004
Severity (VSAA vs. SAA)
0.983
( )
0.930
Etiology (Hepatits vs. others
1.130
( )
0.689
Days from diagnosis to IST
<30days vs. ≥30days
1.603
( )
0.042
<180days vs. ≥180days
2.362
( )
0.349
WBC count
<2000 vs. ≥2000
1.163
( )
0.449
Reticulocyte count
<25000 vs. ≥25000
1.465
( )
0.088
Platelet count
<20000 vs. ≥20000
1.792
( )
0.021
1.734
( )
0.051

10. OS
horse ATG 92%
rabbit ATG 84%

11. Causes of death horse ATG (n=297) rabbit ATG (n=158) TRM of SCT 7 4
MDS/AML 3
Infection 8
Hemochromatosis 1
Hemolysis
Accident
Bleeding 6

12. Immunosuppressive Therapy
Japan AA 97
Horse ATG: 15 mg /kg/day x 5 days
CSA: 6 mg/kg/day adjusted to blood level
G-CSF: Only when ANC < 0.2 x 109/L
Nagoya Univ in Thymoglobulin era
( 2009 Aug ~ Now )
Rabbit ATG: mg /kg/day x 5 days
CSA: 6 mg/kg/day adjusted to blood level
G-CSF: Only when ANC < 0.2 x 109/L
Immunosuppressive therapy consisted of horse ATG (Lymphoglobulin from Genzyme) at a dose of 15 mg/kg/day and CSA. In the Japanese study the ATG had been given for 5 days, in the German study for 8 days. G-CSF was administered to patients with less than 200 neutrophils/µl in the Japanese group and less than 500/µL in the German cohort.

13. ‘Neutrophil dip’ after rabbit ATG
CyA
WBC
Neutr

14. EBV Reactivated Patient’s Clinical Course
180,000
Rituximab 375 mg/m2
140,000
[copies / mL (whole blood)]
EBV copy number
100,000
60,000
20,000 7 14 21 28 35 45 49 56
Days after administration of rabbit ATG

15. Side effects Transient decline of Neutrophil (Y/N) 10 / 0
rabbit ATG + CSA (n=10)
Transient decline of Neutrophil (Y/N)
10 / 0
CMV reactivation (Y/N)
5 / 5
GCV treatment (Y/N)
EBV reactivation (Y/N)
3 / 7
Rituximab treatment (Y/N)
2 / 8

16. COLON

17. EBV –LPD after immunosuppressive therapy in Japan
Patient No.
Age
First/Second IST
ATG
Onset (week)
EBV-DNA (105/ml)
Outcome 1 4
First
horse ATG 10 ー
Dead 2 79
rabbit ATG 5
9.1 3 69
7.0
Alive 63 7
5.0 56
14.0 6 65
45.0

18. Today’s Topics
Use of rabbit ATG can be justified as a front-line therapy?
Comparable outcome can be expected between MRD and 1MMD?
Second course of ATG + CSA should be indicated if no alternative donor is available?

19. PATIENTS (N = 578) Grouped by SEROLOGICAL
Matched unrelated
Donor (MUD) (n=213)
Class I (n =32)
MMRD (n=53)
class II (n=12)
Matched related donor
(MRD) (n=312)
2-3 MMRD (n=9)
Grouped by SEROLOGICAL
HLA typing data (A, B, and DR)
To supply a gap of evidence for transplantation from HLA mismatched family donor,
We planned and analyzed 578 pediatric AA patients received Bone marrow transplantation between and 2009, and get registered in the database of the Japan Society for Hematopoietic Cell transplantation.
Of course, majority of patients are transplanted from HLA matched related donor or matched unrelated donor, but
A substantial number of patients are transplanted from serologically HLA mismatched related donor, MMRD.
Among 53 mismatched related transplantation,
32 patients transplanted from donor who is 1locus mismatched in HLA Class I,
and 12 patients from 1 locus mismatched in class II.
9 patients are transplanted from 2-3 loci mismatched donor, that is to say, Haploidentical transplantation donor.
578 children (0-19 y) with AA
Received BMT between
Available for serological HLA data (A, B, and DR)
Registered to The Japan Society for Hematopoietic Cell Transplantation

20. PATIENT CHARACTERISTICS
MRD
1MMRD
2-3 MMRD
MUD
Class I
Class II n
312 32 12 9
213
Donor, n (%)
Sibling
294 (94%)
22 (69%)
4 (33%)
1 (11%) -
Others Related
18 (6%)
10 (31%)
8 (67%)
8 (89%)
Unrelated donor
213 (100%)
Gender, n (%)
Male
176 (56%)
19 (59%)
7 (58%)
3 (33%)
120 (56%)
Female
136 (44%)
13 (41%)
5 (42%)
6 (67%)
93 (44%)
Age, median (range)
11.5 (0 - 19)
9 (1 - 16)
9 (1 - 19)
10 (1 - 17)
11 (1 - 19)
Age, n (%)
< 10 y
106 (34%)
17 (53%)
4 (44%)
87 (41%)
10y - 19 y
206 (66%)
15 (47%)
5 (56%)
126 (59%)
This slide shows the patient characteristics.
Patients’ gender and age are equally distributed among each group.
But, as expected, sibling donor percentage is unsymmetrical.

21. 5-year OVERALL SURVIVAL
MRD (n=312) /- 1.5%
Class-I 1MMRD (n=32) /- 4.6%
Class-II 1MMRD (n=12) /- 8.0%
1.00
0.75
MUD (n=213) /- 2.9%
2-3 MMRD (n=9) /- 12.2%
probability of surivival
0.50
0.25
This slide shows the 5 year overall survival of each patient group.
Compared to matched related donor, matched unrelated donor and 2-3 loci mismatched related donor were significantly worse outcomes, while class I and class II 1 locus mismatched donor groups showed perfectly superimposed survival curves to matched related donor group.
0.00
2000
4000
6000
8000
days after transplantation

22. MULTIVARIATE ANALYSIS OF OS
HR (95% CI)
P-value
Age
<10 1
0.002
>=10
2.647 ( )
Period of SCT
2.210 ( )
0.001
Donor
MRD
1MMRD (Class I)
0.847 ( ) NS
1MMRD (Class II)
1.930 ( )
2-3 MMRD
6.238 ( )
0.003
MUD
4.308 ( )
<0.001
In multivariate analysis, age over 10 years, and transplanted before 2000 and 2-3 loci mismatched related donor and unrelated donor are identified independent risk factors for poor survival.

23. ACUTE GVHD (grade III – IV)
1.00
MRD /- 1.4 %
1MMRD (class I) /- 10.1% p < .001
1MMRD (class II) /- 11.9% p = .03
2-3 MMRD 0.0% p = NS
MUD /- 2.9% p < .001
0.75
0.50
1MMRD (Class I)
0.25
1MMRD (Class II)
MUD
Compared to HLA matched related donor, the incidence of Acute GVHD grade III – IV is significantly higher in 1 locus HLA mismatched related donor and matched unrelated donor.
Unexpectedly, none of the patients transplanted from haploidentical donor developed severe acute GVHD, despite patient number is very small, only 9.
MRD
0.00
2-3 MMRD 20 40 60 80
100
Days after transplantation

24. CHRONIC GVHD (Extensive)
1.00
0.75
MRD /- 1.7 %
1MMRD (class I) /- 5.5%
1MMRD (class II) %
2-3 MMRD /- 11%
MUD /- 2.8%
0.50
0.25
0.00
This slide shows the cumulative incidence of extensive chronic GVHD. In any donor group, severe chronic GVHD is occurred in very small percentage of patients, and there is no statistical significance.
2000
4000
6000
8000
Days after transplantation
P= Not significant

25. TREATMENT ALGORISM FOR CHILDREN WITH AA
BMT from MRD/1MMRD
BMT from MUD
Newly diagnosed AA
MRD/1MMRD(+)
MUD(+)
MRD/1MMRD(-) NR
MUD(-)
If the newly diagnosed aplastic anemia patient have matched related donor OR 1 LOCUS MISMATCHED RELATED DONOR, first line therapy would be BMT. And IST indication should be narrowed.
IST
2nd IST or
HAPLO / CBT
CR/PR
FIRST LINE THERAPY
SECOND LINE THERAPY

26. Today’s Topics
Use of rabbit ATG can be justified as a front-line therapy?
Comparable outcome can be expected between MRD and 1MMD?
Second course of ATG + CSA should be indicated if no alternative donor is available?

30. Preconditioning Regimen from Haploidentical Donor
day–7　　–6　　–5　　–4　 –3　　–2　　–1　　0　　+1　　+2　　+3　　+4　　+5　　+6
BMT
PBSCT
Flu(30mg/ m2 ×４)
　　　○ 　 ○ 　 ○ ○
ATG (2.5mg/kg ×４)
　　　　　　　 ○ ○　○ ○ 　　 (5mg/kg ×１) ○
L-PAM(70mg/m2 ×２)　　 ○　 ○
TBI(2.5Gy ×２)　　　　　　　　　　 ○
BU (1mg/kg×4/day)×2days day –7 , -6　
L-PAM (60mg/m2/day)×3days day –5 ~ -3　
ATG (2.5mg/kg/day)×2days day –3 , -2
ATG (5mg/kg/day) day +4
TBI (12Gy,4分割) 眼球半遮蔽 day –2 , -1
2/2 BMT 　総細胞数：3.6×10^8/kg　CD34(+)細胞数 0.7%：2.55×10^6/kg
2/7 PBSCT 1日目　総細胞数：1.67×10^9/kg　CD34(+)45(+)細胞数：5.0×10^6/kg
2/8 PBSCT 2日目　総細胞数：6.5×10^8/kg　CD34(+)45(+)細胞数 0.4%：2.6×10^6/kg
GVHD Prophylaxis：FK506+sMTX
Nagoya University

31. Patient Characteristics
Pt.
Patient
Donor
HLA disparity
NCC (×108/kg)
CD34+cells (×106/kg)
Age / Sex 1
9 / F
36 / F
4 / 6
11.0
4.2 2
4 / F
35 / M
30.3
35.0 3
12 / F
15 / M
5.4
6.0 4
15 / F
47 / M
4 / 9
5.8
3.3

32. Outcome Pt. Neutr >500/μl(day) acute GVHD chronic GVHD
other complication
Survival (mo) 1 29
（−）
> 105 2 15
III
CMV, EBV, TMA
> 71 3 20
CMV, EBV
> 42 4
（+）
> 8

33. Conclusion
Use of rabbit ATG as a front-line therapy is justified when horse ATG is not available.
When 1MMD donor is available, bone marrow transplantation is the first choice of treatment for SAA children.
Haploidentical transplantation can be indicated if HLA-mached unrelated donor is not found for non-responder to immunosuppressive therapy.

34. Acknowledgement
Asian Pacific Blood and Marrow Transplantation Group : Childhood Aplastic Anemia Study Group Dao Chul Jeong, Xiao Fan Zhu
The Japan Society for Hematopoietic Cell Transplantation Childhood Aplastic Anemia Working Group Hideki Muramatsu, Hiromasa Yabe, Akira Kikuchi, Ryoji Kobayashi
Japan Childhood Aplastic Anemia Study Group Nao Yoshida, Yoshiyuki Takahashi, Akira Ohara