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Allogeneic hematopoietic stem cell transplantation (allo-HSCT) can potentially cure patients with advanced hematologic cancers; however, it can also lead to morbidity and mortality due to graft-versus-host disease (GvHD). αβT cells in grafts can identify recipient alloantigens and promote engraftment by killing host hematopoietic and immune cells, and reduce relapse rates by destroying neoplastic blood cells, thus mediating the graft-versus-leukemia effect. However, alloreactive T cells can also damage host tissues and thus cause GvHD, therefore warranting pharmacologic immunosuppression or T-cell-depleted grafts.
αβT cells include naive (TN), effector (TE), and memory (TM) subsets, which have a distinct surface phenotype. In murine models, it has been demonstrated that TN cause severe GvHD, whereas TM cause mild-to-no GvHD and maintain graft-versus-tumor capability.
Marie Bleakley et al.1 recently published an article in the Journal of Clinical Oncology that analyzed the effects of TN-depleted allo-HSCT on the occurrence of chronic GvHD (cGvHD) in patients with acute leukemia or myelodysplastic syndromes treated in three prospective phase II clinical trials, which are summarized below.
The GvHD Hub has recently published an editorial theme article on the T-cell depletion strategies to reduce incidence of GvHD in pediatric HSCT recipients here.
In total, data from 138 patients from three phase II trials (NCT00914940 [n = 41], NCT01858740 [n = 20], and NCT02220985 [n = 77]) were analyzed. Study designs can be seen in Table 1.
Table 1. Study design and participants*
|
NCT00914940 |
NCT01858740 |
NCT02220985 |
---|---|---|---|
Eligible age, years |
14–55 |
0–21 |
0–60 |
HLA-matched donor type |
MRD |
MRD (n = 2) |
MRD (n = 41) |
Conditioning |
Fludarabine, thiotepa, TBI 13.2 Gy |
Fludarabine, thiotepa, TBI 13.2 Gy |
Fludarabine, thiotepa, TBI 13.2 Gy |
Fludarabine, thiotepa, cyclophosphamide, TBI 4 Gy |
|||
HLA, human leukocyte antigen; MMF, mycophenolate mofetil; MRD, matched-related donors; MTX, methotrexate; MUD, matched-unrelated donors; TBI, total body irradiation. |
Table 2. Patient characteristics*
Characteristic, % (unless otherwise stated) |
TN-depleted PBSC recipients |
---|---|
Median age (range), years |
37 (1–60) |
Sex |
|
Male |
41 |
Female |
59 |
Performance status score† |
|
≥90 |
75 |
<90 |
25 |
Diagnosis |
|
Myeloid |
52 |
AML |
43 |
MDS with excess blasts |
4.4 |
Blastic plasmacytoid dendritic cell neoplasm |
0.7 |
CML with a history of myeloid blast crisis |
1.5 |
Mixed phenotype acute leukemia |
2.9 |
Lymphoid |
48 |
ALL |
46 |
CML with a history of lymphoid blast crisis |
1.5 |
Disease risk |
|
Standard-risk (CR1, no residual disease) |
62 |
High-risk (beyond CR1 and/or residual disease) |
38 |
Donor |
|
HLA-MRD |
61 |
HLA-MUD |
39 |
Conditioning regimen |
|
High intensity |
72 |
Intermediate intensity |
28 |
GvHD pharmacologic prophylaxis |
|
Tacrolimus monotherapy |
29.7 |
Tacrolimus and methotrexate |
43 |
Tacrolimus and MMF |
27.5 |
ALL, acute lymphoid leukemia; AML, acute myeloid leukemia; CML, chronic myelogenous leukemia; CR1, first complete remission; CR2, second complete remission; GvHD, graft-versus-host disease; HLA, human leukocyte antigen; MDS, myelodysplastic syndrome; MMF, mycophenolate mofetil; MRD, matched-related donors; MUD, matched-unrelated donors; PBSC, peripheral blood stem cell; TN, naive T cells. |
The median duration of follow-up for surviving patients was 1,485 days (range, 262–1,826 days). The 3-year cumulative incidence of relapse was 23% (95% CI, 16–30). The median time to relapse was 206 days (interquartile range, 111–343 days).
Relapse rates according to patient subgroups can be seen in Table 3.
Table 3. Relapse rates according to patient subgroups*
Patient group |
Relapse rate, % (95% CI) |
---|---|
Graft type |
|
Received MRD grafts |
27 (17–37) |
Received MUR grafts |
17 (7–27) |
Condition treatment |
|
High intensity |
19 (11–27) |
Intermediate intensity |
35 (18–52) |
Diagnosis |
|
Myeloid malignancy |
27 (17–38) |
Lymphoid leukemia |
19 (9–28) |
Age, years |
|
<30 |
18 (7–29) |
≥30 |
26 (17–36) |
CI, confidence interval; MRD, matched-related donor; MUD, matched-unrelated donor. |
Of the 31 patients who relapsed, 90% were not receiving prednisone at the time and 32.3% had discontinued or were quickly weaned off immunosuppression without developing GvHD. Of these relapsing patients, the median survival from relapse was 273 days (interquartile range, 85–590 days). A total of 21 relapsed patients were given donor lymphocyte infusions or other immunotherapies: 11 reached complete remission for at least 6 months. The survival outcomes of all TN-depleted PBSC recipients are displayed in Table 4.
Table 4. Survival data of TN-depleted PBSC recipients*
|
3-year estimate, % (95% CI) |
|||
---|---|---|---|---|
OS |
RFS |
CRFS |
GRFS |
|
Total group (N = 138) |
77 (71–85) |
69 (61–77) |
68 (61–76) |
64 (56–72) |
Graft type |
|
|
|
|
MRD (n = 84) |
77 (68–86) |
67 (58–78) |
67 (58–78) |
62 (52–74) |
MUD (n = 54) |
79 (69–91) |
72 (61–85) |
70 (59–83) |
66 (55–80) |
Condition treatment |
|
|
|
|
High intensity |
77 (69–86) |
72 (63–81) |
72 (63–81) |
67 (58–77) |
Intermediate intensity (n = 38) |
78 (66–93) |
60 (45–80) |
57 (41–78) |
54 (38–75) |
Diagnosis |
|
|
|
|
Myeloid (n = 72) |
74 (64–85) |
66 (55–78) |
64 (54–77) |
60 (49–73) |
Lymphoid (n = 66) |
81 (72–91) |
72 (62–84) |
72 (62–84) |
68 (57–80) |
Age, years |
|
|
|
|
<30 (n = 49) |
84 (74–95) |
76 (64–89) |
76 (64–89) |
67 (55–82) |
≥30 (n = 89) |
74 (65–84) |
65 (55–76) |
64 (54–75) |
61 (52–73) |
CI, confidence interval; CRFS, chronic graft-versus-host disease-free relapse-free survival; GRFS, graft-versus-host disease-free relapse-free survival; MRD, matched-related donor; MUD, matched-unrelated donor; OS, overall survival; RFS, relapse-free survival. |
The authors demonstrated that the depletion of TN from PBSC allografts results in low incidences of severe aGvHD and cGvHD, without increasing the risks of relapse or NRM.
Limitations to the trial included the possibility that the lower total T-cell dose administered with TN-depleted grafts may be correlated with the cGvHD reduction, and the risk of type 1 errors due to the nature of the single arm study. Therefore, randomized trials will be important to confirm these findings. Indeed, two phase II trials have already been initiated (NCT03970096 and NCT03779854).
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