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1.  High Risk of Graft Failure in Patients with Anti-HLA Antibodies Undergoing Haploidentical Stem Cell Transplantation 
Transplantation  2009;88(8):1019-1024.
BACKGROUND
While donor-specific anti-HLA antibodies (DSA) have been implicated in graft rejection in solid organ transplantation, their role in hematopoietic stem cell transplantation (HSCT) remains unclear.
METHODS
To address the hypothesis that the presence of DSA contributes to the development graft failure, we tested 24 consecutive patients for the presence of anti-HLA antibodies determined by a highly sensitive and specific solid-phase/single-antigen assay. The study included a total of 28 haploidentical transplants, each with 2–5 HLA allele mismatches, at a single institution, from 9/2005 to 8/2008.
RESULTS
DSA were detected in five patients (21%). Three out of 4 (75%) patients with DSA prior to the first transplant failed to engraft, compared with 1 out of 20 (5%) without DSA (p=0.008). All 4 patients who experienced primary graft failure had second haploidentical transplants. One patient developed a second graft failure with persistent high DSA levels, while 3 engrafted, 2 of them in the absence of DSA. No other known factors that could negatively influence engraftment were associated with the development of graft failure in these patients.
CONCLUSIONS
These results suggest that donor-specific anti-HLA antibodies are associated with a high rate of graft rejection in patients undergoing haploidentical stem cell transplantation. Anti-HLA sensitization should be evaluated routinely in hematopoietic stem cell transplantation with HLA mismatched donors.
doi:10.1097/TP.0b013e3181b9d710
PMCID: PMC4324621  PMID: 19855248
Donor-specific anti-HLA antibodies; primary graft failure; haploidentical stem cell transplantation
2.  The histone deacetylase inhibitor SAHA sensitizes acute myeloid leukemia cells to a combination of nucleoside analogs and the DNA-alkylating agent busulfan 
Leukemia & lymphoma  2014;55(7):1625-1634.
Fludarabine (Flu), clofarabine (Clo) and busulfan (Bu) are used in allogeneic hematopoietic stem cell transplant (allo-HSCT). We reported that combining [Flu + Clo + Bu] had a synergistic cytotoxicity in AML cells. We hypothesized that combining [Flu + Clo + Bu] with the histone deacetylase inhibitor SAHA will further enhance cytotoxicity. We exposed the acute myeloid leukemia (AML) cell lines KBM3/Bu2506 and OCI-AML3 to Flu, Clo, Bu and SAHA alone and in various combinations. [Flu + Clo + Bu + SAHA] resulted in synergistic cytotoxicity, which can be attributed to (1) activated DNA-damage response and cell cycle checkpoint activation through the ATM–CHK2–P53 (or P73) pathway or ATM–CHK2–cdc25–cdc2 pathway, (2) histone modifications and (3) activated apoptosis pathway. The [Flu + Clo + Bu + SAHA] combination causes mitochondrial outer membrane permeabilization, leakage of cytochrome c and Smac/Diablo into the cytosol with caspase activation, and release of apoptosis-inducing factor (AIF) into the nucleus resulting in nuclear fragmentation and cell death. These results provide a mechanistic basis for using SAHA in future clinical trials with double nucleoside analog-busulfan combinations in pretransplant conditioning therapy.
doi:10.3109/10428194.2013.856007
PMCID: PMC4320642  PMID: 24144307
DNA alkylator; nucleoside analog; SAHA; AML; drug cytotoxicity
3.  Improved Early Outcomes Using a T Cell Replete Graft Compared with T Cell Depleted Haploidentical Hematopoietic Stem Cell Transplantation 
Haploidentical stem cell transplantation (SCT) has been generally performed using a T cell depleted (TCD) graft; however, a high rate of nonrelapse mortality (NRM) has been reported, particularly in adult patients. We hypothesized that using a T cell replete (TCR) graft followed by effective posttransplantation immunosuppressive therapy would reduce NRM and improve outcomes. We analyzed 65 consecutive adult patients with hematologic malignancies who received TCR (N = 32) or TCD (N = 33) haploidentical transplants. All patients received a preparative regimen consisting of melphalan, fludarabine, and thiotepa. The TCR group received posttransplantation treatment with cyclophosphamide (Cy), tacrolimus (Tac), and mycophenolate mofetil (MMF). Patients with TCD received antithymocyte globulin followed by infusion of CD34+ selected cells with no posttransplantation immunosuppression. The majority of patients in each group had active disease at the time of transplantation. Outcomes are reported for the TCR and TCD recipients, respectively. Engraftment was achieved in 94% versus 81% (P = NS). NRM at 1 year was 16% versus 42% (P = .02). Actuarial overall survival (OS) and progression-free survival (PFS) rates at 1 year posttransplantation were 64% versus 30% (P = .02) and 50% versus 21% (P = .02). The cumulative incidence of grade II–IV acute graft-versus-host disease (aGVHD) was 20% versus 11% (P = .20), and chronic GVHD (cGVHD) 7% versus 18% (P = .03). Improved reconstitution of T cell subsets and a lower rate of infection were observed in the TCR group. These results indicate that a TCR graft followed by effective control of GVHD posttransplantation may lower NRM and improve survival after haploidentical SCT.
doi:10.1016/j.bbmt.2012.07.003
PMCID: PMC4320643  PMID: 22796535
Haploidentical stem cell transplantation; T cell depletion; T cell replete haploidentical graft; GVHD prevention; High-dose posttransplantation cyclophosphamide
4.  Fucosylation with Fucosyltransferase (FT)-VI or FT-VII Improves Cord Blood Engraftment 
Cytotherapy  2013;16(1):10.1016/j.jcyt.2013.07.003.
Background
Advantages associated with the use of cord blood (CB) transplantation include the availability of cryopreserved units, ethnic diversity and lower incidence of graft-versus-host disease when compared to bone marrow or mobilized peripheral blood. However, poor engraftment remains a major obstacle. We and others have found that ex vivo fucosylation can enhance engraftment in murine models and thus ex vivo treatment of CB with fucosyltransferase (FT)-VI prior to transplantation is under clinical evaluation (NCT01471067). However, FT-VII appears to be more relevant to hematopoietic cells and may alter acceptor substrate diversity. In this study, we compare the ability of FT-VI and FT-VII to improve the rapidity, magnitude, multi-lineage and multi-tissue engraftment of human CB hematopoietic stem and progenitor cells (HSPC) in vivo.
Methods
CD34-selected CB HSPC were treated with recombinant FT-VI, FT-VI or mock control, then injected into immunodeficient mice and monitored for multi-lineage and multi-tissue engraftment.
Results
Both FT-VI and FT-VII fucosylated CB CD34+ cells in vitro, and both led to enhanced rates and magnitudes of engraftment when compared to untreated CB CD34+ cells in vivo. Engraftment following treatment with either fucosyltransferase was robust at multiple timepoints, and in multiple tissues, with similar multi-lineage potential. In contrast, only FT-VII was able to fucosylate T- and B-lymphocytes.
Discussion
While we found that FT-VI and FT-VII were similarly able to fucosylate and enhance the engraftment of CB CD34+ cells, differences in their ability to fucosylate lymphocytes cells may modulate graft-versus-tumor and/or graft-versus-host effects and may allow further optimization of CB transplantation.
doi:10.1016/j.jcyt.2013.07.003
PMCID: PMC3883688  PMID: 24094497
5.  Myeloablative reduced-toxicity IV busulfan-fludarabine and allogeneic hematopoietic stem cell transplant for patients with acute myeloid leukemia or myelodysplastic syndrome in the sixth through eighth decades of life 
The optimal pretransplant regimen for acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) in patients ≥55 years of age remains to be determined. The myeloablative reduced-toxicity 4-day regimen IV busulfan (Bu) (130 mg/m2)-IV fludarabine (Flu) (40 mg/m2) is associated with low morbidity and mortality. We analyzed 79 patients ≥55 years of age (median, 58 years) with AML (n=63) or MDS (n=16) treated with IV Bu-Flu conditioning regimens between 2001 and 2009 (median follow-up, 24 months). The patients who received this regimen had a good performance status. The 2-year overall survival rates for patients in first complete remission (CR1), second CR (CR2), refractory disease and for all patients at time of transplantation were 71%, 44%, 32%, and 46%, respectively; 2-year event-free survival rates for patients in CR1, CR2, or refractory disease at time of transplantation and for all patients were 68%, 42%, 30%, and 44%, respectively. One-year transplant-related mortality (TRM) rates for patients who were in CR or who had active disease at the time of transplantation were 19% and 20%, respectively. Grade II-IV acute graft-versus-host disease was diagnosed in 40% of the patients. Our results suggest that age alone should not be the primary reason for exclusion from receiving myeloablative reduced-toxicity conditioning with IV Bu-Flu preceding transplantation in patients with AML/MDS.
doi:10.1016/j.bbmt.2011.02.007
PMCID: PMC4261630  PMID: 21338705
7.  Fludarabine, cyclophosphamide and antithymocyte globulin as total body irradiation-free conditioning for matched related and unrelated allogeneic stem cell transplantation in severe aplastic anemia 
Leukemia & lymphoma  2010;52(1):137-141.
Twenty severe aplastic anemia (SAA) patients underwent allogeneic stem cell transplantation (allo-SCT) with fludarabine (FLU), cyclophosphamide and antithymocyte globulin from a matched related (n=7, age ≥ 40) or unrelated donor (n=13, any age). Median age was 34 years (range 1–59). Median time from diagnosis to allo-SCT was 12 months (range 2–244). Seventeen out of 19 evaluable patients engrafted (90%). There were two secondary graft failures (10%). Median time to neutrophil recovery was 15 days (range 8–30). Chimerism studies indicated ≥90% donor-derived engraftment in 16/19 evaluable patients (75%). Four out of 20 patients (20%) developed acute (grade II–IV) GVHD, and 6/16 evaluable patients (37%) developed chronic GVHD. We observed EBV reactivation and viremia in seven patients, which was successfully treated with rituximab in all but one instance (where it was self-limiting). Thirteen patients (62%) are alive (including eight of the last nine treated) with a median follow-up of 30 months (range 3–112). Seven patients expired (graft rejection n=1, GVHD n=1, multiorgan failure n=1, infection n=2, EBV post-transplant lymphoproliferative disorder/PTLD n=2). Total body irradiation-free, FLU-based conditioning for matched related and unrelated allo-SCT is feasible with high engraftment rates. EBV PTLD remains a drawback of this approach.
doi:10.3109/10428194.2010.524328
PMCID: PMC4238067  PMID: 20939697
Aplastic anemia; bone marrow failure; stem cell transplantation; bone marrow transplantation; conditioning regimen; fludarabine
8.  FLUDARABINE-MELPHALAN AS PREPARATIVE REGIMEN FOR REDUCED-INTENSITY ALLOGENEIC STEM CELL TRANSPLANTATION IN RELAPSED AND REFRACTORY HODGKIN’S LYMPHOMA: THE UPDATED M.D. ANDERSON CANCER CENTER EXPERIENCE 
Haematologica  2008;93(2):257-264.
Background and Objective
The role of reduced-intensity conditioning (RIC) allogeneic stem cell transplantation (allo-SCT) in relapsed/refractory (R/R) Hodgkin’s lymphoma (HL) remains poorly defined. We hereby present an update of our single-center experience with fludarabine-melphalan (FM) as preparative regimen.
Design and Methods
Fifty-eight patients with R/R HL underwent RIC and allo-SCT from a matched related donor (MRD; n=25) or a matched unrelated donor (MUD; n=33). Forty-eight (83%) had received a prior autologous SCT. Disease status at transplant was refractory relapse (n=28) or sensitive relapse (n=30).
Results
Cumulative day 100 and 2-year transplant-related mortality (TRM) were 7% and 15%, respectively (day 100 TRM MRD vs. MUD 8% vs. 6%, p=ns; 2-year MRD vs. MUD 13% vs. 16%, p=ns). The cumulative incidence of acute (grade II–IV) GVHD (first 100 days) was 28% (MRD vs. MUD 12% vs. 39%, p=0.04). The cumulative incidence of chronic GVHD at any time was 73% (MRD vs. MUD 57% vs. 85%, p=0.006). Projected 2-year overall (OS) and progression-free (PFS) survival are 64% (49–76) and 32% (20–45), with 2-year disease progression/relapse (PD) at 55% (43–70). There was no statistically significant difference between MRD and MUD transplants in OS, PFS and PD. There was a trend for the response status pretransplant to favorably impact PFS (p=0.07) and PD (p=0.049), but not OS (p=0.4).
Interpretation and Conclusions
FM as preparative regimen for RIC allo-SCT in R/R HL is associated with a significant reduction in TRM, with comparable results in MRD and MUD allografts. Optimizing pretransplant response status may improve patient outcome.
doi:10.3324/haematol.11828
PMCID: PMC4238917  PMID: 18223284
Hodgkin’s lymphoma; Hodgkin’s disease; allogeneic stem cell transplantation; bone marrow transplantation; peripheral blood stem cell transplantation
9.  Lymphocyte Recovery Predicts Outcomes in Cord Blood and T Cell–Depleted Haploidentical Stem Cell Transplantation 
Alternative donor stem cell transplantation from cord blood or haploidentical peripheral blood donors is increasingly being used for patients who lack a matched related or unrelated donor. A higher nonrelapse mortality (NRM) rate has been noted with these 2 types of transplants, primarily because of infectious complications. Here, we hypothesized that the time to lymphocyte recovery (absolute lymphocyte count [ALC] of ≥ 1000/μL for the first 3 consecutive days) after transplant correlates with outcomes. We retrospectively analyzed 65 consecutive patients treated at our institution with cord blood (n = 37) and haploidentical (n = 28) transplantation with myeloablative fludarabine, melphalan, and thiotepa conditioning. Patients with lymphocyte recovery at day 60 posttransplant were more likely to survive long term than those without lymphocyte recovery. In multivariate analysis, ALC recovery was the only independent prognostic factor associated with mortality; patients without ALC recovery were 10.5 times (95% confidence interval [CI]: 4.3–25.4) more likely to die than those with ALC recovery (P < .0001). This difference appeared to be related to NRM (hazard ratio [HR] =0.1, 95% CI: 0.02–0.6, P = .008), whereas ALC recovery did not influence the rate of disease relapse. These results suggest that ALC recovery is an important prognostic indicator for patients treated with cord blood and T cell–depleted peripheral haploidentical transplants.
doi:10.1016/j.bbmt.2010.11.020
PMCID: PMC4231815  PMID: 21126598
Lymphocyte recovery; Nonrelapse mortality; Cord blood transplantation; T cell–depleted haploidentical stem cell transplantation
10.  Once Daily IV Busulfan and Fludarabine (IV Bu-Flu) Compares Favorably with IV Busulfan and Cyclophosphamide (IV BuCy2) as Pretransplant Conditioning Therapy in AML/MDS 
Summary
We postulated that fludarabine (Flu) instead of cyclophosphamide (Cy) combined with IV busulfan (Bu) as preconditioning for allogeneic hematopoietic stem cell transplantation (HSCT) would improve safety and retain antileukemic efficacy. 67 patients received BuCy2 and subsequently 148 patients received Bu-Flu. We used a Bayesian method to compare outcomes between these non-randomized patients. The groups had comparable pretreatment characteristics, except that Bu-Flu patients were older (46 vs. 39 years, p< 0.01), more often had unrelated donors (47.3% vs. 20.9%, p< 0.0003), and had shorter median follow-up (39.7 vs. 74.6 months). To account for improved supportive care and other unidentified factors that may affect outcome (“period” effects), 78 AML patients receiving Melphalan-Flu (“MF”), treated in parallel during this time (1997 to 2004) were used to estimate the period effect; The MF patients’ outcomes worsened during this period. Therefore, the period effect is unlikely to explain the greatly improved outcome with Bu-Flu. Patients transplanted with Bu-Flu in CR1 had a 3-year overall survival and event-free-survival (EFS) of 78% and 74%, respectively, while CR1 patients younger than age 41 had a 3-year EFS of 89%. These results support replacing BuCy±ATG with Bu-Flu±rabbit-ATG, and warrant a prospective comparison between allogeneic HSCT and conventional induction/consolidation chemotherapy for AML in CR1.
doi:10.1016/j.bbmt.2008.03.009
PMCID: PMC4230823  PMID: 18489993
IV Busulfan; Fludarabine; Cyclophosphamide; AML; MDS; Allogeneic Stem Cell Transplantation
11.  Fludarabine, Melphalan, Thiotepa and ATG Conditioning for Unrelated Cord Blood Transplantation 
Leukemia & lymphoma  2012;53(5):901-906.
Unrelated cord blood transplantation (CBT) is an alternative treatment option for patients who lack a matched donor. However, the optimal type and intensity of the preparative regimen remains unclear. We evaluated the toxicity and outcomes of a conditioning regimen consisting of melphalan 140 mg/m2 (day −8), thiotepa 10 mg/kg (day −7), fludarabine 160 mg/m2 over 4 days (days −6 to −3), and rabbit ATG 1.25 mg/kg (day −4) and 1.75 mg/kg (day −3) (FMT). Forty-seven patients with advanced hematologic malignancies with a median age of 23 years (30 adults and 17 children) were treated. Sixty percent of patients were in remission at transplant. Ninety-one percent of the patients engrafted neutrophils after a median of 22 days, and all but one of the patients achieving donor engraftment had hematopoietic recovery with 100% cord blood-derived cells. Grade 3 gastrointestinal toxicity was the major non-hematopoietic toxicity occurring in 32% of patients. Cumulative incidence of day-100 grade II-IV aGVHD and cGVHD were 53% and 34%, respectively, and non-relapse mortality at day 100 and 2 years was 11% and 40%. Two-year disease-free and overall survival rates were 31% and 44%, respectively. These results suggest that FMT is a feasible conditioning regimen for patients undergoing CBT.
doi:10.3109/10428194.2011.631159
PMCID: PMC4225703  PMID: 21988645
Unrelated cord blood transplantation; reduced-intensity conditioning; fludarabine; melphalan; thiotepa
12.  Hematopoietic progenitor cell collection in patients with chronic myelogenous leukemia in complete cytogenetic remission after imatinib mesylate therapy 
Leukemia & lymphoma  2010;51(8):1478-1484.
The introduction of BCR–ABL tyrosine kinase inhibitors such as imatinib has changed the treatment of chronic myelogenous leukemia (CML). More than 75% of patients achieve complete cytogenetic remission (CCR) after treatment with imatinib, which provides an opportunity to collect minimally involved hematopoietic progenitor stem cell (HPC) products. In order to assess the feasibility of HPC collection in patients with CML, we prospectively enrolled 24 patients who achieved CCR on therapy with imatinib. Two patients could not undergo HPC collection because of coagulopathy. A CD34+ cell yield of ≥2.0 × 106/kg body weight was obtained in 16/22 (73%) patients. Patients who stopped imatinib for at least 3 weeks prior to HPC collection had significantly higher CD34+ cell yields (median: 6.52 × 106/kg body weight) when compared with patients who continued imatinib through the collection (median: 3.74 × 106/kg body weight). Mobilization with granulocyte colony-stimulating factor (G-CSF) did not increase the levels of BCR–ABL transcript. With a mean follow-up of 46 months, all patients but one were in CCR. In conclusion, a significant number of CD34+ cells can be safely collected in patients with CML who are on imatinib therapy, but CD34+ cell yields improve when imatinib is temporarily withheld.
doi:10.3109/10428194.2010.501534
PMCID: PMC4188823  PMID: 20658954
CML; imatinib; hematopoietic progenitor cell
13.  Mechanistic studies on the synergistic cytotoxicity of the nucleoside analogs gemcitabine and clofarabine in multiple myeloma: Relevance of p53 and its clinical implications 
Experimental hematology  2013;41(8):719-730.
Hematopoietic stem cell transplantation (HSCT) is an established treatment for multiple myeloma (MM), a plasma cell malignancy. To identify an improved pretransplant conditioning regimen, we investigated the cytotoxicity of gemcitabine (Gem) and clofarabine (Clo) combinations toward MM cell lines and patient cell samples. A strong synergism of the two nucleoside analogs, when combined at their approximate IC10 concentrations, was observed. This synergism could be partly due to the observed Gem-mediated phosphorylation and activation of deoxycytidine kinase, resulting in enhanced phosphorylation of Gem and Clo. Their cytotoxicity correlated with a robust activation of the DNA damage response pathway. [Gem+Clo] decreased the mitochondrial membrane potential with a concomitant release of proapoptotic factors into the cytoplasm and nucleus and the activation of apoptosis. Exposure of MM cells to [Gem+Clo] also decreased the level of ribosomal RNA (rRNA), which might have resulted in nucleolar stress, as reported previously, and caused a p53-dependent cell death. A reduction by approximately 50% in the cytotoxicity of Gem and Clo was observed in the presence of pifithrin α, a p53 inhibitor. Furthermore, MM cell lines with mutant p53 exhibited greater resistance to Gem and Clo, supporting a role for the p53 protein in these cytotoxic responses. Our results provide a rationale for clinical trials incorporating [Gem+Clo] combinations as part of conditioning therapy for high-risk patients with MM undergoing HSCT.
doi:10.1016/j.exphem.2013.04.009
PMCID: PMC3769691  PMID: 23648290
14.  Outcomes in Patients With Relapsed or Refractory Acute Promyelocytic Leukemia Treated With or Without Autologous or Allogeneic Hematopoietic Stem Cell Transplantation 
Outcomes in patients with acute promyelocytic leukemia have improved; however, a subset of patients relapse despite receiving all-trans-retinoic acid and/or arsenic-based therapies. Among 40 patients with acute promyelocytic leukemia who were treated at our institution (1980–2010), 24 received hematopoietic stem cell transplantation (HCT) (autologous HCT, 7; allogeneic HCT, 14; both, 3); 16 received chemotherapy only. All 3 strategies (autologous HCT, allogeneic HCT, chemotherapy) were feasible in patients with relapsed acute promyelocytic leukemia and result in long-term disease control in selected patients.
Background
Outcomes in patients with acute promyelocytic leukemia (APL) have improved; however, a significant number of patients still relapse despite receiving all-trans-retinoic acid (ATRA) and arsenic-based therapies.
Patients and Methods
Outcomes of patients with relapsed APL who were treated at our institution (1980–2010) and who received HCT were compared with those who received chemotherapy (CT) only.
Results
Among 40 patients, 24 received HCT (autologous [auto] HCT, 7; allogeneic [allo] HCT, 14; both, 3); 16 received CT only. The median age at diagnosis was 36 years (range, 13–50 years), 31 years (range, 16–58 years), and 44 years (range, 24–79 years) for the auto-HCT, allo-HCT, and CT groups, respectively. Ten (100%) patients who received auto-HCT and 12 (71%) who received allo-HCT were in complete remission at the time of the HCT. The median follow-ups in the auto-HCT, allo-HCT, and CT groups were 74 months (range, 26–135 months), 118 months (range, 28–284 months), and 122 months (range, 32–216 months), respectively. Transplantation-related mortality (1 year) after auto-HCT and allo-HCT were 10% and 29%, respectively. The 7-year event-free survival after auto-HCT and allo-HCT was 68.6% and 40.6%, respectively (P = .45). The 7-year overall survival was 85.7%, 49.4%, and 40% in the auto-HCT, allo-HCT, and CT groups, respectively (P = .48).
Conclusion
Both auto-HCT and allo-HCT are associated with durable remission and prolonged survival. All 3 strategies (auto-HCT, allo-HCT, CT) were found to be feasible in the relapsed APL setting and result in long-term disease control in selected patients. In this retrospective analysis, overall survival for patients who received HCT was not significantly better than patients who received CT only, but a trend toward better outcomes was seen in patients who underwent auto-HCT, although not statistically significant.
doi:10.1016/j.clml.2013.02.023
PMCID: PMC4112369  PMID: 23769669
Acute myeloid leukemia; Acute promyelocytic leukemia; Allogeneic transplantation; Autologous transplantation; Bone marrow transplantation; Stem cell transplantation
15.  Increasing Chimerism Following Allogeneic Stem Cell Transplantation is Associated with Longer Survival Time 
Donor chimerism following allogeneic stem cell transplantation (allo-SCT) commonly is used to predict overall survival (OS) and disease-free survival (DFS) time. Because chimerism is observed at one or more times after allo-SCT, and not at baseline, if chimerism is in fact associated with OS or DFS then the occurrence of either disease progression or death informatively censors (terminates) the observed chimerism process. This violates the assumptions underlying standard statistical regression methods for survival analysis, which may lead to biased conclusions. To assess association between the longitudinal post-allo-SCT donor chimerism process and OS or DFS, we analyzed data from 195 patients with acute myelogenous leukemia (n=157) or myelodysplastic syndrome (n=38) who achieved complete remission after allo-SCT following a reduced-toxicity conditioning regimen of fludarabine/intravenous busulfan. Median follow-up was 31 months (range, 1.1–105 months). Fitted joint longitudinal-survival time models showed that a binary indicator of complete (100%) donor chimerism, and increasing percent donor T-cells, both were significantly associated with longer OS, while decreasing percent donor T-cells was highly significantly associated with shorter OS. Our analyses illustrate the usefulness of modeling repeated post-allo-SCT chimerism measurements as individual longitudinal processes jointly with OS and DFS in order to estimate their relationships.
doi:10.1016/j.bbmt.2014.04.003
PMCID: PMC4099297  PMID: 24727332
Chimerism; Allogeneic stem cell transplantation; AML; MDS
16.  Autologous Hematopoietic Stem Cell Transplantation May Reverse Renal Failure in Patients with Multiple Myeloma 
Approximately 20% of patients with multiple myeloma (MM) have renal failure at diagnosis, and about 5% are dialysis-dependent. Many of these patients are considered ineligible for autologous hematopoietic stem cell transplantation (auto-HSCT) because of a high risk of treatment-related toxicity. We evaluated the outcome of 46 patient with MM and renal failure, defined as serum creatinine >2 mg/dL sustained for >1 month before the start of preparative regimen. Patients received auto-HSCT at our institution between September 1997 and September 2006. Median serum creatinine and creatinine clearance (CrCl) at auto-HSCT were 2.9 mg/dL (range: 2.0–12.5) and 33 mL/min (range: 8.7–63), respectively. Ten patients (21%) were dialysis-dependent. Median follow-up in surviving patients was 34 months (range: 5–81). Complete (CR) and partial responses (PR) after auto-HSCT were seen in 9 (22%) and 22 (53%) of the 41 evaluable patients, with an overall response rate of 75%. Two patients (4%) died within 100 days of auto-HSCT. Grade 2–4 nonhematologic adverse events were seen in 18 patients (39%) and included cardiac arrythmias, pulmonary edema, and hyperbilirubinemia. Significant improvement in renal function, defined as an increase in flomerular filtration rate (GFR) by 25% above baseline, was seen in 15 patients (32%). Kaplan-Meier estimates of 3-year progression-free survival (PFS) and overall survival (OS) were 36% and 64%, respectively. In conclusion, auto HSCT can be offered to patients with MM and renal failure with acceptable toxicity and with a significant improvement in renal function in approximately one-third of the transplanted patients. In this analysis, a melphalan (Mel) dose of 200 mg/m2 was not associated with an increase in toxicity or nonrelapse (Mel) mortality (NRM).
doi:10.1016/j.bbmt.2009.03.021
PMCID: PMC4112358  PMID: 19539212
Myeloma; Renal failure; Autologous
17.  Outcomes of Patients with Myeloid Malignancies Treated with Allogeneic Hematopoietic Stem Cell Transplantation from Matched Unrelated Donors Compared with One Human Leukocyte Antigen Mismatched Related Donors Using HLA Typing at 10 Loci 
Most candidates for hematopoietic stem cell transplantation (HSCT) lack a human leukocyte antigen (HLA)-identical sibling donor. Some patients may have a related donor with whom they are mismatched at 1 antigen/allele. It is not known whether such a match is preferable to a matched unrelated donor (MUD). We evaluated the outcomes (survival, relapse, nonrelapse mortality [NRM]) of all 28 patients with a single HLA antigen/allele mismatch identified through high-resolution HLA typing at HLA-A, -B, -C, -DRB1, and -DQB1, and all 318 patients with myeloid malignancies who received transplants from a 10/10 MUD treated during the same period of time at a single institution. Overall, outcomes for patients treated from a 1-antigen/allele mismatch related donor were significantly worse than from a MUD, primarily because of increased NRM. Overall survival (OS) rates at 3 years for 1-antigen/allele mismatched related donor and MUD transplant recipients were 19% and 45% (P =.007), and NRM rates were 40% and 26% (P =.05), respectively. Patients with class I mismatches appeared to have poorer OS than did patients with class II mismatches. A higher incidence of graft rejection was identified in the mismatched related donor group (P =.02). These results indicate that transplant outcomes are better with a MUD than with a 1 antigen/allele-mismatched related donor.
doi:10.1016/j.bbmt.2010.10.017
PMCID: PMC4112359  PMID: 20969970
Hematopoietic stem cell transplantation; HLA matched unrelated donors; 9/10 matched related donors; Class I HLA mismatch; Class II HLA mismatch
18.  Outcome of Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Low Left Ventricular Ejection Fraction 
A high risk of regimen-related toxicity with allogeneic hematopoietic stem cell transplantation (allo-HSCT) limits this potentially curative treatment for patients with a left ventricular ejection fraction (LVEF) of ≥50%. We evaluated the frequency of cardiac complications and 100-day nonrelapse mortality (NRM) in 56 patients with a LVEF of ≤45%, who received allo HCTat our institution. The results were retrospectively compared with a matched control group with LVEF of ≥50%, which received an allogeneic stem cell transplantation (allo-SCT). After a median follow-up of 29 months in the study group, grade ≥2 cardiac complications were seen in 7 of 56 (12.5%) patients and cumulative incidence of 100-day NRM was 12.5% with no deaths from cardiac causes. In contrast, after a median follow-up of 49 months in the control group, grade >2 cardiac complications were seen in 19 of 161 patients (11.8%; P = 1.00) and cumulative incidence of 100-day NRM was 14.9% (P =.82). The presence of at least 1 of the 7 pretransplant cardiac risk factors (past history of smoking, hypertension, hyperlipidemia, coronary artery disease, arrhythmia, prior myocardial infarction, and congestive heart failure) was associated with a higher cardiac complication rate in the study group (P = .03). In conclusion, selected patients with a LVEF of ≤45% can safely receive allo-HCT without a significant increase in cardiac toxicity or NRM.
doi:10.1016/j.bbmt.2009.06.001
PMCID: PMC4112360  PMID: 19747634
Allogeneic hematopoietic stem cell transplantation; Low ejection fraction
19.  Poor hematopoietic stem cell mobilizers: A single institution study of incidence and risk factors in patients with recurrent or relapsed lymphoma 
American journal of hematology  2009;84(6):335-337.
The purpose of this retrospective study was to determine the incidence and predictive factors if any, of mobilization failure in lymphoma patients referred for autologous stem cell transplantation. A total of 588 lymphoma patients were referred for transplant consultation from January 2003 to December 2004. Predictors of mobilization failure were evaluated using logistic regression analysis including diagnosis, mobilization regimen, age, sex, type and number of prior chemotherapies, bone marrow cellularity, platelet count, white count, prior bone marrow involvement with malignancy, and prior radiation therapy. Two hundred and six patients were eligible for transplantation and underwent stem cell mobilization. Twenty-nine (14%) patients failed to mobilize adequate stem cells after the first attempt. For the entire group age (≥60 versus <60 years), diagnosis (Hodgkin’s versus non-Hodgkin’s lymphoma), use of cytokines alone, platelet count <150 × 109/L, and bone marrow cellularity <30% were significant predictors for mobilization failure on univariate analysis. In view of small number of patients multivariate analysis was not possible. However, a low platelet count (150 × 109/L) was the only significant predictor when the analysis was restricted to non-Hodgkin’s lymphoma patients who were mobilized with chemotherapy. Mobilization failure rates are higher in patients with non-Hodgkin’s lymphoma compared with those with Hodgkin’s lymphoma. In the subset of patients who undergo chemomobilization for non-Hodgkin’s lymphoma platelet count at the time of mobilization is a predictor of mobilization failure.
doi:10.1002/ajh.21400
PMCID: PMC4112361  PMID: 19384931
20.  Arsenic Trioxide with Ascorbic Acid and High-Dose Melphalan: Results of a Phase II Randomized Trial 
Arsenic trioxide (ATO) is synergistic with ascorbic acid (AA) and melphalan against myeloma both in vitro and in vivo. The aim of this randomized phase II trial was to determine the safety and efficacy of a combination of ATO, melphalan, and AA as preparative regimen in 48 patients undergoing autologous hematopoietic stem cell transplantation (ASCT) for multiple myeloma (MM). Forty-eight patients received melphalan 200 mg/m2 i.v. over 2 days and AA 1000 mg i.v. over 7 days in 3 treatment arms: no ATO (arm 1), ATO 0.15 mg/kg i.v. × 7 days (arm 2), and ATO 0.25 mg/kg i.v. × 7 days (arm 3). No dose-limiting toxicity, engraftment failure, or non-relapse mortality (NRM) was seen in the first 100 days post-ASCT. Complete responses (CR) were seen in 12 of 48 patients (25%), with an overall response rate (ORR = CR + PR) of 85%. Median progression-free survival (PFS) was 25 months; median overall survival (OS) has not yet been reached. There was no significant difference in CR, PFS, or OS among the 3 treatment arms, and no adverse effect of ATO on melphalan pharmacokinetics. Addition of ATO +AA to high-dose melphalan is safe and well tolerated as a preparative regimen for MM.
doi:10.1016/j.bbmt.2008.09.019
PMCID: PMC4112362  PMID: 19041063
Myeloma; Arsnic trioxide; Autologous Introduction
21.  A high throughput microelectroporation device to introduce a chimeric antigen receptor to redirect the specificity of human T cells 
Biomedical microdevices  2010;12(5):855-863.
It has been demonstrated that a chimeric antigen receptor (CAR) can directly recognize the CD19 molecule expressed on the cell surface of B-cell malignancies independent of major histocompatibility complex (MHC). Although T-cell therapy of tumors using CD19-specific CAR is promising, this approach relies on using expression vectors that stably integrate the CAR into T-cell chromosomes. To circumvent the potential genotoxicity that may occur from expressing integrating transgenes, we have expressed the CD19-specific CAR transgene from mRNA using a high throughput microelectroporation device. This research was accomplished using a microelectroporator to achieve efficient and high throughput non-viral gene transfer of in vitro transcribed CAR mRNA into human T cells that had been numerically expanded ex vivo. Electro-transfer of mRNA avoids the potential genotoxicity associated with vector and transgene integration and the high throughput capacity overcomes the expected transient CAR expression, as repeated rounds of electroporation can replace T cells that have lost transgene expression. We fabricated and tested a high throughput microelectroporator that can electroporate a stream of 2×108 primary T cells within 10 min. After electroporation, up to 80% of the passaged T cells expressed the CD19-specific CAR. Video time-lapse microscopy (VTLM) demonstrated the redirected effector function of the genetically manipulated T cells to specifically lyse CD19+ tumor cells. Our biomedical micro-device, in which T cells are transiently and safely modified to be tumor-specific and then can be re-infused, offers a method for redirecting T-cell specificity, that has implications for the development of adoptive immunotherapy.
doi:10.1007/s10544-010-9440-3
PMCID: PMC4109048  PMID: 20574820
Electroporation; Cancer; High throughput; mRNA; Chimeric antigen receptor; T cells
22.  Feasibility of Allografting in Patients with Advanced Acute Lymphoblastic Leukemia After Salvage Therapy With Inotuzumab Ozogamicin 
Inotuzumab ozogamicin (IO) is a CD22 monoclonal antibody that targets B lymphocytes in early stages of development, successfully inducing remission in patients with relapsed acute lymphoblastic leukemia (ALL). We report our experience of 26 patients who were treated with IO followed by allogeneic stem cell transplantation (SCT).
Background
No highly effective salvage therapy exists for patients with relapsed acute lymphoblastic leukemia (ALL). Inotuzumab ozogamicin (IO) is a CD22 monoclonal antibody attached to calicheamycin that targets B lymphocytes in early stages of development, successfully inducing remission in patients with multiply relapsed ALL.
Methods
We describe our findings in 26 patients who received allogeneic hematopoietic stem cell transplantation (SCT) after treatment with IO between September 2010 and October 2011.
Results
Patients with a median age of 33 years (range, 5-70 years) received an allogeneic matched sibling donor (n = 9), matched- or 1-antigen mismatched unrelated donor (n = 16), or cord blood donor SCT (n = 1) while in complete remission (n = 23) or with active disease (n = 3). At the time of SCT, 15 patients were in complete remission without evidence of minimal residual disease (MRD) measured by multiparameter flow cytometry. Patients were heavily pretreated, including 5 patients who had received previous allogeneic SCT. Patients received a median of 3 courses of IO (range, 1-5 courses) before SCT. Seven patients are alive at a median follow-up of 13 months (range, 5-16 months), with 1-year event-free and overall survival (OS) of 22% and 20%, respectively. Patients without MRD at time of SCT had a markedly better 1-year OS of 42%. The cumulative incidence of nonrelapse mortality (NRM) at 6 months and 1 year were 40% and 60%, respectively, with 5 deaths attributed to venoocclusive disease (VOD).
Conclusions
Treatment with IO allows more patients to undergo transplantation while in remission, with favorable overall survival in patients without MRD who undergo transplantation. Reduction in hepatic toxicity is needed to improve overall results.
doi:10.1016/j.clml.2012.12.003
PMCID: PMC4102410  PMID: 23313065
Acute lymphoblastic leukemia; Allogeneic hematopoietic stem cell transplantation; Inotuzumab ozogamicin; Venoocclusive disease
23.  The hyperactive Sleeping Beauty transposase SB100X improves the genetic modification of T cells to express a chimeric antigen receptor1 
Gene therapy  2011;18(9):849-856.
Sleeping Beauty (SB3) transposon and transposase constitute a DNA plasmid system used for therapeutic human cell genetic engineering. Here we report a comparison of SB100X, a newly developed hyperactive SB transposase, to a previous generation SB11 transposase to achieve stable expression of a CD19-specific chimeric antigen receptor (CAR3) in primary human T cells. The electro-transfer of SB100X expressed from a DNA plasmid or as an introduced mRNA species had superior transposase activity in T cells based on measurement of excision circles released after transposition and emergence of CAR expression on T cells selectively propagated upon CD19+ artificial antigen presenting cells. Given that T cells modified with SB100X and SB11 integrate on average one copy of the CAR transposon in each T-cell genome, the improved transposition mediated by SB100X apparently leads to an augmented founder effect of electroporated T cells with durable integration of CAR. In aggregate, SB100X improves SB transposition in primary human T cells and can be titrated with a SB transposon plasmid to improve the generation of CD19-specific CAR+ T cells.
doi:10.1038/gt.2011.40
PMCID: PMC4083583  PMID: 21451576
Chimeric antigen receptor; T cells; Sleeping Beauty; transposase; transposon; SB11; SB100X; CD19
24.  Donor Selection in T Cell—Replete Haploidentical Hematopoietic Stem Cell Transplantation: Knowns, Unknowns, and Controversies 
Multiple donors are generally available for haploidentical hematopoietic stem cell transplantation. Here we discuss the factors that should be considered when selecting donors for this type of transplantation according to the currently available evidence. Donor-specific anti-HLA antibodies (DSAs) increase the risk of graft failure and should be avoided whenever possible. Strategies to manage recipients with DSAs are discussed. One should choose a full haplotype mismatch rather than a better-matched donor and maximize the dose of infused hematopoietic cells. Donor age and sex are other important factors. Other factors, including predicted natural killer cell alloreactivity and consideration of noninherited maternal alleles, are more controversial. Larger studies are needed to further clarify the role of these factors for donor selection in haploidentical hematopoietic stem cell transplantation.
doi:10.1016/j.bbmt.2012.08.007
PMCID: PMC4085130  PMID: 22892554
Haploidentical stem cell; transplantation; Anti-HLA antibodies; Donor selection
25.  Unrelated Donor Transplantation for Acute Myelogenous Leukemia in First Remission 
We retrospectively analyzed the outcomes of all acute myelogenous leukemia (AML) patients in first remission (n = 44; median age = 48 years; high-risk cytogenetics = 59%) who received unrelated donor hematopoietic cell transplantation (HCT) with myeloablative conditioning regimen of i.v. busulfan, fludarabine, and antithymocyte globulin (ATG) between January 2002 and November 2009 at our institution. Donor-recipient pairs were matched by high-resolution HLA-A, -B, -C, -DRB1, and -DQB1 typing (10/10 matches, n = 41; 9/10 matches, n = 3). With a median follow-up of 34 months, actuarial 3-year event-free survival (EFS) and overall survival (OS) is 70% and 78%, respectively. The 3-year EFS and OS in patients with and without poor risk cytogenetics is similar (63% versus 82%, P = 0.43 and 78% versus 82%, P =.89, respectively). The 3-year EFS and OS is also similar in patients above age 55 year versus patients age 55 year or younger (80% versus 67%, P =.47 and 80% versus 78%, P =.81, respectively). The 100-day and 3-year cumulative incidence of transplant-related mortality is 5% and 15%, respectively. Six patients have relapsed, and 3 of them are alive and in remission after salvage therapy, with a median follow-up of 23 months. These results indicate that the majority of AML patients eligible for this treatment can achieve long-term disease control.
doi:10.1016/j.bbmt.2010.11.012
PMCID: PMC4080632  PMID: 21087679
AML; MDS; Leukemia; Allogeneic transplant

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