1. Basics of Stem Cell Transplant Prof. Ileana Constantinescu

2. Background First successful transplants—late 1960s First successful transplants—late 1960s 30,000-40,000 transplants performed yearly worldwide 30,000-40,000 transplants performed yearly worldwide >20,000 patients have survived >5 years >20,000 patients have survived >5 years Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

3. Graft Sources Allogeneic: from another person Allogeneic: from another person Syngeneic: from an identical twin Syngeneic: from an identical twin Autologous: from the patient Autologous: from the patient Choice of graft is based on disease type, patient condition, donor compatibility and health Choice of graft is based on disease type, patient condition, donor compatibility and health

4. Graft Sources Autologous Transplant Autologous Transplant –No evidence of disease in the blood or bone marrow –Transplant related mortality (TRM) lowest with autos (<5%) –Relapse rates are higher depending on the disease –Absence of graft versus tumor effects Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

5. Graft Sources Allogeneic Transplants Allogeneic Transplants –High TRM (30-50%) –Lower relapse rates due to graft versus tumor effects –Graft versus host effects Matched Related Donor (siblings) Matched Related Donor (siblings) –25% chance a sibling will be a match –The more siblings a patient has the better chance for a match Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

6. GRAFT VS. HOST DISEASE This disease occurs when an immunologically competent foreign graft containing T cells reacts against the MHC antigens of an immunologically compromised host. This disease occurs when an immunologically competent foreign graft containing T cells reacts against the MHC antigens of an immunologically compromised host. In general, concerns regarding the outcome of transplantation represent a one-way street, namely the potential of the immune system of a transplant recipient or host to reject a transplant. An interesting reversal of the direction of the immune response occurs, however, when immunocompetent cells (spleen cells) are transplanted into a host whose immune system is not functioning properly (irradiated) and is, therefore, immunosuppressed. In general, concerns regarding the outcome of transplantation represent a one-way street, namely the potential of the immune system of a transplant recipient or host to reject a transplant. An interesting reversal of the direction of the immune response occurs, however, when immunocompetent cells (spleen cells) are transplanted into a host whose immune system is not functioning properly (irradiated) and is, therefore, immunosuppressed. In this case, a phenomenon known as graft vs. host disease ensues, where the immunocompetent graft directs an immunological assault against the host, sometimes with fatal consequences. In this case, a phenomenon known as graft vs. host disease ensues, where the immunocompetent graft directs an immunological assault against the host, sometimes with fatal consequences. Graft vs. host disease is, therefore, of particular concern in cases of bone marrow transplantation, where immunocompetent T cells in the graft tissue can direct a graft rejection response against the cell surface MHC antigens of a frequently immunocompromised recipient or host. Graft vs. host disease is, therefore, of particular concern in cases of bone marrow transplantation, where immunocompetent T cells in the graft tissue can direct a graft rejection response against the cell surface MHC antigens of a frequently immunocompromised recipient or host. 6

7. HLA Typing HLA typing became feasible in 1960s HLA typing became feasible in 1960s Linked on chromosome 6 Linked on chromosome 6 Inherited as haplotypes Inherited as haplotypes 1 in 4 chance a sibling will be identical 1 in 4 chance a sibling will be identical Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826.

8. HLA alleles The considerable polymorphism of HLA is well- known. The considerable polymorphism of HLA is well- known. HLA polymorphism is reflected by allelic substitution of many amino acid residues in the polypeptide chains, especially the external domains which contain the peptide binding site. HLA polymorphism is reflected by allelic substitution of many amino acid residues in the polypeptide chains, especially the external domains which contain the peptide binding site. This affects the spectrum of antigenic peptides presented by the different allelic types of HLA molecules and the repertoire of responding T- cells. This affects the spectrum of antigenic peptides presented by the different allelic types of HLA molecules and the repertoire of responding T- cells.

9. The HLA genetics is complex HLA polymorphism HLA polymorphism Expression of HLA polymorphism –Typing Expression of HLA polymorphism –Typing The transplanted graft represents a continuous source of HLA alleles that can induce a rejection response at any time post-transplant. The transplanted graft represents a continuous source of HLA alleles that can induce a rejection response at any time post-transplant. HLA matching can have a dualistic effect on transplant outcome: it reduces rejection but conversely, it may promote other HLA-restricted mechanisms of allograft injury. HLA matching can have a dualistic effect on transplant outcome: it reduces rejection but conversely, it may promote other HLA-restricted mechanisms of allograft injury.

10. HLA Matching 6/6, 8/8, or 10/10 6/6, 8/8, or 10/10 –HLA loci on chromosome 6 –HLA-A, HLA-B, HLA-C, HLA-DR, HLA-DQ, HLA-DP ABO incompatibility is not an exclusion ABO incompatibility is not an exclusion Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

11. Interpretation of results Recipient D.F. Donor D.C. HLAHLA A 02-24 B 18-18 C 07-07 DRB1 11-13 DQB1 03-05 KIR – B4 genotype KIR –2DL1, 2DL2, 2DL4, 2DL5B, 2DS2, 2DS3, 2DS4 004, 3DL2, 3DL3, 3DS1, 2DP1, 3DP1

12. Recipient A.C. Donor C.R. HLAHLA A 03-24 B 18-44 C 05-12 DRB1 16-16 DQB1 05-05 DPB1 02-05 KIR – B4 genotype KIR –2DL1, 2DL2, 2DL4, 2DL5B 003-006, 2DS3, 2DS4, 2DL1, 3DL2, 3DL3, 2DP1, 3DP1 003 Interpretation of results

13. Recipient F.C.Donor F.E. HLA A 02-03 B 07-40 C 01-03 DRB1 04-10 DQB1 03-07 KIR – A genotype KIR – 2DL1, 2DL3, 2DL4, 2DS1, 3DL1, 3DL2, 3D33, 2DP1, 3DP1 003 KIR – 2DL1, 2DL3, 2DL4, 2DS4, 3DL1, 3DL2, 3DL3, 2DP1, 3DP1 003

14. Eligibility Age < 65 Age < 65 –Autologous, mini-allo Age < 55 Age < 55 –Myeloablative allogeneic Exclusions Exclusions –CHF, uncontrolled diabetes mellitus, active infections, renal insufficiency

15. Indications Autologous Transplant Multiple myeloma Multiple myeloma NHL NHL Hodgkin’s disease Hodgkin’s disease AML AML Neuroblastoma Neuroblastoma Ovarian cancer Ovarian cancer Germ-cell tumors Germ-cell tumors Autoimmune disorders Autoimmune disorders Amyloidosis Amyloidosis Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826.

16. Indications for Allogeneic Transplant AML AML ALL ALL CML CML MDS MDS MPD MPD NHL NHL Hodgkin’s Disease Hodgkin’s Disease CLL CLL Multiple myeloma Multiple myeloma Juvenile CML Juvenile CML Aplastic anemia Aplastic anemia PNH PNH Fanconi’s anemia Fanconi’s anemia Blackfan-Diamond Blackfan-Diamond Thalessemia major Thalessemia major Sickle cell anemia Sickle cell anemia SCID SCID Wiskott-Aldrich Wiskott-Aldrich Inborn errors of metabolism Inborn errors of metabolism Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813-1826.

17. Preparative Regimens Myeloablative Myeloablative –High doses of chemotherapy +/- radiation –3 goals Eliminate malignancy Eliminate malignancy Immunosuppression to allow engraftment Immunosuppression to allow engraftment Decrease graft versus host effects Decrease graft versus host effects Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409 Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813-1826.

18. Myeloablative Regimens Myeloablative Regimens Myeloablative Regimens –Most common regimens Cyclophosphamide/TBI Cyclophosphamide/TBI Busulfan/Cyclophosphamide Busulfan/Cyclophosphamide Stem cells are essential to restore marrow function Stem cells are essential to restore marrow function Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409 Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813-1826.

19. Myeloablative Regimens Therapy is based on disease Therapy is based on disease Other drugs Other drugs –Etoposide, BCNU, cytarabine, melphalan Graft versus leukemia effects in allogeneic donors Graft versus leukemia effects in allogeneic donors Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826. Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

20. Umbilical Cord Blood 1 st UCB transplant 16 years ago 1 st UCB transplant 16 years ago –Child with Fanconi’s anemia Cell dose is given per recipient weight Cell dose is given per recipient weight –Lower patient weights the high the cell dose –2 x 10 7 nucleated cells/kg –1.7 x 10 7 CD 34+ cells/kg 4/6 match UCB with sufficient cells has a similar outcome to a matched or one antigen mismatched MUD 4/6 match UCB with sufficient cells has a similar outcome to a matched or one antigen mismatched MUD Chao NJ, Emerson SG, Weinberg KI. Stem cell transplantation (Cord Blood Transplants). Am Soc Hematol Ed Book. 2004:354-371.

21. Umbilical Cord Blood Umbilical Cord Blood Umbilical Cord Blood –Cryopreserved –Small number of stem cells –Higher incidence of engraftment failure Using more than one unit in adults Using more than one unit in adults –Lower risk of GVHD –Degree of matching not as stringent Chao NJ, Emerson SG, Weinberg KI. Stem cell transplantation (Cord Blood Transplants). Am Soc Hematol Ed Book. 2004:354-371.

22. Umbilical Cord Blood Lower GVHD Lower GVHD TRM not different than MUD TRM not different than MUD Can be used with myeloablative or nonmyeloablative conditioning (on a clinical trial) Can be used with myeloablative or nonmyeloablative conditioning (on a clinical trial) Chao NJ, Emerson SG, Weinberg KI. Stem cell transplantation (Cord Blood Transplants). Am Soc Hematol Ed Book. 2004:354-371.

23. Complications Early Early –Mucositis –Sinusoidal obstructive syndrome (VOD) Fluid retention, jaundice, hepatomegaly Fluid retention, jaundice, hepatomegaly –Transplant related infections Damage to mouth, gut and skin Damage to mouth, gut and skin Prolonged neutropenia Prolonged neutropenia Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826.

24. Complications Early Early –Pancytopenia PRBC and platelet transfusions PRBC and platelet transfusions Broad spectrum antimicrobials Broad spectrum antimicrobials Antifungals if prolonged fevers 3-5 days Antifungals if prolonged fevers 3-5 days Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

25. Complications Early Early –Graft Versus Host Disease Acute GVHD to day 100 Acute GVHD to day 100 –Skin, GI tract, liver Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409 Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826.

26. GVHD In GVH diseases donor-derived immuno-competent lymphocytes react with HLA incompatible recipient cells and induce inflammatory responses in host tissues such as the skin and gastrointestinal tract. In GVH diseases donor-derived immuno-competent lymphocytes react with HLA incompatible recipient cells and induce inflammatory responses in host tissues such as the skin and gastrointestinal tract. GVH disease seems more likely in cases whereby the donor is well matched for the patient. GVH disease seems more likely in cases whereby the donor is well matched for the patient. Direct and indirect HLA allorecognition mediate GVH reactions if immunocompetent donor cells recognize recipient incompatibilities. Direct and indirect HLA allorecognition mediate GVH reactions if immunocompetent donor cells recognize recipient incompatibilities. During infection, microbial antigens are processed by APC and presented via HLA molecules to T-cells that elicit cytotoxic and DTH- like inflammatory reactions in the allograft. During infection, microbial antigens are processed by APC and presented via HLA molecules to T-cells that elicit cytotoxic and DTH- like inflammatory reactions in the allograft.

27. Complications Early Early –Graft Rejection Host versus graft Host versus graft Drug injury to marrow Drug injury to marrow Viral infections: CMV, HHV-6 & 8 Viral infections: CMV, HHV-6 & 8 –Interstitial Pneumonitis Diffuse alveolar hemorrhage Diffuse alveolar hemorrhage Too few donor stem cells Too few donor stem cells ARDS often caused by CMV ARDS often caused by CMV Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

28. Complications Delayed Delayed –Chronic GVHD Scleroderma or Sjogrens syndrome Scleroderma or Sjogrens syndrome Bronchiolitis Bronchiolitis Keratoconjunctivitis Keratoconjunctivitis Malabsorption Malabsorption Cholestasis Cholestasis Esophageal stricture Esophageal stricture Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826.

29. Late Complications Secondary Tumors Secondary Tumors –Acute leukemias, solid tumors, MDS –Months to years after transplant –Increased incidence with TBI Late Infections Late Infections –Bacterial, viral fungal –Months after transplant –Associated with GVHD –Need repeat vaccinations Pneumovax, Hep B, Hemophilus influenza b, poliovirus, diphtheria/tetanus, flu Pneumovax, Hep B, Hemophilus influenza b, poliovirus, diphtheria/tetanus, flu Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

30. Human herpesvirus 6 infection in hematopoietic cell transplant recipients Human herpesvirus 6 (HHV-6) is a member of the Roseolovirus genus of the beta-herpesvirus subfamily of human herpesviruses. There are two HHV-6 variants, HHV-6A and HHV-6B. Based on their distinctive biological properties and genome sequences, the Herpesvirales Study Group of the International Committee on Taxonomy of Viruses has classified HHV-6A and HHV-6B as two distinct herpesvirus species. Human herpesvirus 6 (HHV-6) is a member of the Roseolovirus genus of the beta-herpesvirus subfamily of human herpesviruses. There are two HHV-6 variants, HHV-6A and HHV-6B. Based on their distinctive biological properties and genome sequences, the Herpesvirales Study Group of the International Committee on Taxonomy of Viruses has classified HHV-6A and HHV-6B as two distinct herpesvirus species. The vast majority of documented primary infections and reactivation events are due to HHV-6B. HHV- 6B infects most children within the first three years of life and, like other herpesviruses, it establishes latency after primary infection. HHV-6B may reactivate in immunocompromised hosts, especially following allogeneic hematopoietic cell transplantation (HCT). Encephalitis is the most clearly established clinical manifestation of HHV-6 reactivation in allogeneic HCT recipients, and may result in substantial morbidity. Little is known about the epidemiology or clinical implications of HHV-6A. The vast majority of documented primary infections and reactivation events are due to HHV-6B. HHV- 6B infects most children within the first three years of life and, like other herpesviruses, it establishes latency after primary infection. HHV-6B may reactivate in immunocompromised hosts, especially following allogeneic hematopoietic cell transplantation (HCT). Encephalitis is the most clearly established clinical manifestation of HHV-6 reactivation in allogeneic HCT recipients, and may result in substantial morbidity. Little is known about the epidemiology or clinical implications of HHV-6A. The epidemiology, clinical manifestations, diagnosis, and treatment of HHV-6 infections in HCT recipients will be discussed here. HHV-6 infections in patients who are not HCT recipients are presented separately. The epidemiology, clinical manifestations, diagnosis, and treatment of HHV-6 infections in HCT recipients will be discussed here. HHV-6 infections in patients who are not HCT recipients are presented separately.EPIDEMIOLOGY Human herpesvirus 6 (HHV-6) reactivation occurs in 30 to 70 percent of patients undergoing allogeneic hematopoietic cell transplantation (HCT), with encephalitis occurring in only a small subset of these patients. HHV-6 reactivation often manifests as HHV-6 viremia, and typically occurs between two and four weeks after transplantation. HHV-6B accounts for most reactivations, with HHV-6A accounting for fewer than 3 percent of cases. Human herpesvirus 6 (HHV-6) reactivation occurs in 30 to 70 percent of patients undergoing allogeneic hematopoietic cell transplantation (HCT), with encephalitis occurring in only a small subset of these patients. HHV-6 reactivation often manifests as HHV-6 viremia, and typically occurs between two and four weeks after transplantation. HHV-6B accounts for most reactivations, with HHV-6A accounting for fewer than 3 percent of cases. Risk factors — Both demographic and clinical factors may influence the risk of HHV-6 reactivation. As an example, recipients of allogeneic HCT are at higher risk of HHV-6 reactivation than recipients of autologous HCT; among allogeneic HCT recipients, those who receive transplants from unrelated or HLA-mismatched donors are at particularly increased risk. Risk factors — Both demographic and clinical factors may influence the risk of HHV-6 reactivation. As an example, recipients of allogeneic HCT are at higher risk of HHV-6 reactivation than recipients of autologous HCT; among allogeneic HCT recipients, those who receive transplants from unrelated or HLA-mismatched donors are at particularly increased risk.

31. Romanian BMR Started in 2003 Started in 2003 EFI Accredited in 2006 EFI Accredited in 2006 Holds details of stem cell donors and cord donations from Moldavia, Transilvania, Banat, Black Sea Coast, Walachia. Holds details of stem cell donors and cord donations from Moldavia, Transilvania, Banat, Black Sea Coast, Walachia. We need to contiue to recruit more donors, particularly from ethnic communities We need to contiue to recruit more donors, particularly from ethnic communities HLA DNA 2 digits typed for HLA A, B, C, DRB1 and DQB1 HLA DNA 2 digits typed for HLA A, B, C, DRB1 and DQB1