Overview of Blood and Marrow Transplantation Introduction/Overview Specific Diseases Alternative Stem Cell Transplantation Supportive Measures History of BMT Definitions AML ALL Breast cancer NHL Rationale Stem cell sources MDS Multiple Myeloma Hodgkin’s disease

HEMATOPOIETIC STEM CELL DIFFERENTIATION

Immunologic Marker Expression In Hematopoiesis 7 10,19,24,38 33,61 36 13,15,33,38 9,36,41,42,61 13,16,11b 13,16,33 13,14,15,33 9,10,19,20,24,38 2,3,5,7,38 2,3,5,7 Erythrocyte NK Cell Platelet Monocyte B-Cell T-Cell BFU-E CFU-E Reticulocyte Myeloid SC CFU-Mega Megakaryocyte Eosinophil Basophil Neutrophil 10 Myeloblast Promyelocyte Myelocyte Pluripotent Stem Cell 2,3,5,7 19,20,22 11b,16,56 11b,13,14,15,33,36 Monoblast Promonocyte 56 Lymphoid SC NK Precursor B Progenitor Pre-B CD34+ T Progenitor Sub Cortical Cortical Thymocyte Medullary Thymocyte

HISTORY OF STEM CELL TRANSPLANTATION Turn of the 20th century, scientists began to formulate the idea that a small number of cells in the marrow, referred to as “stem cells”, might be responsible for the development of all blood cells. Marrow injury was an important and potentially lethal side effect of exposure to the atomic bomb or to industrial accidents in the atomic weapons industry. Spurred by the Atomic Energy Commission's and the military’s concern about the spread of nuclear technology and weapons, studies of bone marrow transplantation were initiated.

Lethal TBI Syndromes Cerebral Syndrome Intestinal Syndrome Bone Marrow Syndrome 12,000-1,000,000 cGy 1,200-10,000 cGy 500-700 cGy

Effects of Spleen Shielding on Mice After Total Body Irradiation TBI Dose (cGy) Spleen Shielding Survival 700 1050 1200 Yes No 96.3% 0.0% 30.4%

Treatment Necessary for Cure Rationale for High Dose Therapy and Hematopoietic Stem Cell Transplantation Death due to other organ toxicity Increasing Dose Death due to Marrow toxicity Treatment Necessary for Cure

CONDITIONING (PREPARATIVE) REGIMEN To suppress the patient’s immune system from rejecting the stem cells. To eliminate the cancer

Stem Cell Sources Bone Marrow Blood Umbilical Cord Fetal Liver

TYPES OF STEM CELL TRANSPLANTS AUTOLOGOUS TRANSPLANTS - Patients receive their own stem cells. SYNGENEIC TRANSPLANTS - Patients receive stem cells from their identical twin. ALLOGENEIC TRANSPLANTS - Patients receive stem cells from someone other than the patient or an identical twin.

Potential Stem Cell Sources Autologous stem cells HLA-matched related donors HLA-matched unrelated donors Haploidentical related donors Umbilical cord blood

Autologous Bone Marrow Transplantation Criteria Tumor with dose response curve Tumor sensitive to myelosuppressive agents Purging techniques if marrow is contaminated with tumor - Preserve stem cells - Eradicate tumor Technique for peripheral stem cell collections Minimal tumor burden Marrow ablation

Allogeneic Engraftment Host Immunosuppression Preparative regimen Post-transplant Rx Disease effects Sensitization Graft Stem cell dose T-cell dose (CD8) Graft facilitating cells Stromal stem cells? With reduced immunosuppression in current NST regimen, we rely on graft cells (stem, T- and accessories cells) to overcome rejection.

Allogeneic Engraftment Host Immunosuppression Preparative regimen Post-transplant Rx Disease effects Sensitization Graft Stem cell dose T-cell dose (CD8) Graft facilitating cells Stromal stem cells? With reduced immunosuppression in current NST regimen, we rely on graft cells (stem, T- and accessories cells) to overcome rejection.

Engraftment Host Graft Immunosuppression Preparative regimen Post-transplant Rx Disease effects Sensitization Graft Stem cell dose T-cell dose (CD8) Graft facilitating cells Stromal stem cells? With reduced immunosuppression in current NST regimen, we rely on graft cells (stem, T- and accessories cells) to overcome rejection.

Graph Rejection/ GVHD Recurrent Disease

HUMAN LEUKOCYTE-ASSOCIATED (HLA) ANTIGENS A set of proteins on the surface of their cells. A set of HLA proteins are inherited equally from patients. Chances of having a full match are ~ 1 in 3. The higher the number of matching HLA antigens, the greater the chance that the patient’s body will accept the donor’s stem cells.

HUMAN LEUKOCYTE ANTIGEN INHERRITANCE

IDENTIFICATION OF A RELATED ALLOGENEIC DONOR Identical Twin < 1% HLA-matched Sibling 6 antigen 25 - 30% 5 antigen 10 - 20% 4 antigen 50 - 60% 3 antigen > 90%

Stem Cell Source Allogeneic Autologous Donor Availability Tumor Content GVHD/GVL Tx-related Mortality Limited None Possible 10-40% Majority Possible None 0-10%

Alternatives to HLA-matched Related Donors HLA-matched unrelated donors Cord Blood Transplantation -Related -Unrelated HLA-mismatched related Donors (Haplo-identical) (Autologous stem cell transplantation)

Stem Cell Source Donor Availablity Tumor Content GVHD/GVL Tx-related Mortality Allogeneic Limited None Possible 10-40% Autologous Majority 0-10%

Advancements in Allogeneic Stem Cell Transplantation Alternative donors - Unrelated bone marrow donors - Stored cord blood Ganciclovir Hematopoietic growth factors Blood as stem cell product Donor lymphocyte infusions

Stem Cell Donor Availability HLA-matched relative Unrelated donor Cord blood HLA-mismatched relative 25-30% 10-40% 50% 10% 90% 1 Ag 2 Ag 3 Ag

Alternatives to HLA-matched Related Donors HLA-matched unrelated donors Cord blood transplantation - Related - Unrelated HLA-mismatched related donors (Haplo-identical) Autologous stem cell transplantation

The NMDP Network 98 Donor Center (8 foreign) Coordinating Center Minneapolis, MN 114 Collection Centers (15 foreign) 112 Transplant Centers (23 foreign) ASCO 1998

Volunteer Marrow Donors 40 Total Donors 3,134,601 30 Volunteers in Registry (Millions) 20 Fully Typed Donors 10 89 90 91 92 93 94 88 95 96 97 98 Year ASCO 1998

Probability of Finding a Six-antigen HLA Matched Donor North America Caucasian Pool Size Japanese 100 1000 10,000 100,000 500,000 1,000,000 0.0% 11.9% 54.2% 90.6% 99.9% 0.0% 3.3% 20.7% 60.0% 85.7% 93.7%

DR Typing Confirmatory Typing Work-Up Transplant Formal Search Preliminary Search 1.6% 15.8% 20.2% 43.5% 54.7% 7.2% 2.1% 25.6% Beatty et al., 1995

Cord Blood Transplantation Advantages Disadvantages Waste product of normal deliveries Readily available Increased availability for minorities Decreased transmission of viruses (e.g. CMV) One unit rescues one patient/no DLI Theoretical risk of genetic disease transmission Theoretical risk of maternal cell contamination (GVHD) Efficacy in adults unknown

Haplo-identical HSCT Advantages Disadvantages Nearly all patients have a donor Share major (e.g. HLA-C) and minor hitocompatibility antigens Immediate donor availability HLA Barriers: -Graft rejection -GVHD -Immune dysregulation

Strategy for Donor Selection BMT No Urgent Referral Simultaneous Search URD, BM and UCB Non-urgent or Non-malignant Diagnosis Yes UCBT 6/6 HLA-matched BM Donor Available? 4-6 HLA-matched UCB(s) Identified with Cell Dose >1.5 x 107 NC/kg?

Choice of Stem Cell Source Diagnosis Urgency of transplant HLA typing Cell dose available in UC units(s) Age Chemo-sensitivity

Diseases Treated by Bone Marrow Transplantation Aplastic anemia Thalassemia Sickle cell anemia Immunodeficiency disorders Acute myelogenous leukemia Myelodysplastic syndrome Multiple myeloma Acute lymphocytic leukemia Chronic myelogenous leukemia Chronic lymphocytic leukemia Non-Hodgkin’s lymphoma Hodgkin’s disease Armitage, NEJM 1994

Indications for Blood and Marrow Transplantation in North America (2000) 4,500 4,000 Allogeneic (Total N=67,000) Autologous (Total N=11,000) 3,500 3,000 2,500 Transplants 2,000 1,500 1,000 500 Non- Hodgkin Lymphoma AML Hodgkin Disease CML MDS/ Other Leukemia CLL Multiple Myeloma Breast Cancer Other Cancer ALL Non- Malignant Disease Ovarian Cancer

Annual Numbers of Blood and Marrow Transplants Worldwide (1970-2000) 40 30 Autologous Number of Transplants (Thousands) 20 10 Allogeneic 1970 1975 1980 1985 1990 1995 2000 Year

Advancements in Allogeneic Stem Cell Transplantation Alternative donors Unrelated bone marrow donors Stored cord blood Ganciclovir Hematopoietic growth factors Blood as a stem cell product Donor lymphocyte infusions

Donor Lymphocyte Infusions Efficacy varies: High incidence of GVHD (40-60%) High correlation of GVHD and response Optimal dose, frequency and timing remain undetermined CML = 50-90% AML = 25-50%

Allogeneic Hematopoietic Stem Cell Transplantation Old Paradigm New Paradigm The allograft is a rescue product to replace the defective stem cells following ablation with cytotoxic therapy. Main therapeutic component of an allogeneic stem cell transplant is the “graft vs. leukemia” effect mediated by T-cells in the allograft.

Non-myeloablative Regimens in Allo SCT Advantages: -Decreased acute toxicity -Application to older and/or morbid patients -Application to broader spectrum of diseases Disadvantages: -Toxicity of the procedure (GVHD) -Loss/decrease in anti-tumor activity from cytotoxic chemotherapy/radiation

Non-myeloablative Hematopoietic Cell Transplant ± DLI HSCT A B AL Recipient Donor Mixed Chimera Complete Host Preparative Regimen

CLINICAL COURSE ON ABP1 (CC 00-C-0119)

Hematopoetic Stem Cell Transplantation for Auto-immune Diseases Multiple Sclerosis Rheumatoid Arthritis Scleroderma

ETIB RESEARCH HEMATOPOIETIC STEM CELL TRANSPLANTATION Strategy Tactic  Rejection Immune-depleting chemo Tc2 cells GVHD Th2 cells GVL Tc2 cells Id vaccines Immune reconstitution Cytokines (IL-7)

“Diseases desperate grown By disparate appliance Are reliev’d, Or not at all” After Shakespeare