1. Bor-Sheng Ko ( 柯博升 ), M.D. BMT Unit and Hematology Division Department of Internal Medicine National Taiwan University Hospital

2. Outlines  GvHD  Definition and Pathogenesis  Acute GVHD (aGvHD)  Clinical spectrum  Prevention and management  Chronic GVHD (cGvHD)  Clinical spectrum  Prevention and Management  Prevention and Management of tumor relapse  Monitoring Relapse  Graft-versus-tumor (GvT) effects  Donor lymphocyte infusion (DLI) and immunotherapy

3.  GvHD  Definition and Pathogenesis  Acute GVHD (aGvHD)  Clinical spectrum  Prevention and management  Chronic GVHD (cGvHD)  Clinical spectrum  Prevention and Management  Prevention and Management of tumor relapse  Monitoring Relapse  Graft-versus-tumor (GvT) effects  Donor lymphocyte infusion (DLI) and immunotherapy

4. Graft-versus-Host Disease (GvHD)  A major complication after alloHSCT  Distinguished from other organ transplantation Donor Immunity Recipient Immunity Graft RejectionGvHD

5. Pathogenesis Bone Marrow Transplantation 2008;41:S68-64

6. Acute vs. Chronic GvHD Blood 1995;86:3247-56 Artificial Boundary AcuteChronic cGVHD in IBMTR: 20-30% progressive 30-40% interrupted 35% de novo Overlaping syndrome

7.  GvHD  Definition and Pathogenesis  Acute GVHD (aGvHD)  Clinical spectrum  Prevention and management  Chronic GVHD (cGvHD)  Clinical spectrum  Prevention and Management  Prevention and Management of tumor relapse  Monitoring Relapse  Graft-versus-tumor (GvT) effects  Donor lymphocyte infusion (DLI) and immunotherapy

8. Clinical Presentations of Acute GvHD (aGvHD)  Started from D+2-5 wk, in 10-90% cases..  Varied because of risk factors  Target organs  Skin  GI tract: Upper and Lower  Liver: Bile duct epithelium  Immune system  Airways  Vascular endothelium  Tumor cells  Sometimes rapid progression! Potentially fatal !

9. Skin aGVHD Dermatology 2008;216:287-304

10. Colon GvHD Endoscopy 2005;37:346-50

11. Risk Factors for aGvHD  Histoincompatibilities  Patient age/Donor age  Gender mismatch (Female donor to male recipient)  Stem cell sources  Number of transfused cells  Type of prophylatic regimens  Cytokine polymorphism  Conditioning regimens  Donor CMV positivities

12. Diagnosis of aGvHD  Clinical symptoms are not reliable  Too many diagnosis to be differentiated…….  Obtain Pathological diagnosis as possible!  Though histological severity is not correlated well with clinical severity  Clinical judgment with history, clinical signs, laboratory data and pathological diagnosis

13. Grading of aGvHD Lancet 2009;373:1550-61

14. Prognostic Implications of aGvHD Br J Haematol 1997;96:855-64 IBMTR results

15. For aGvHD: Prevention is BETTER than Treatment !!

16. Prevention of aGvHD (1)  Donor selection/ Conditioning/ Host factors  In vitro prophylaxis  T-cell depletion..  In vivo prophylaxis  Anti-T-cell antibodies:  Anti-thymocyte immunoglobulin  Other antibodies  Pharmacological prophylaxis  ……………………………………….

17.  In vivo prophylaxis  Pharmacological prophylaxis  MTX 15mg/m2 D+1, 10mg/m2 D+3,+6,+11  Calcineurin inhibitors: CsA, Tacrolimus (FK506)  CsA: serum level 150-400 ng/mL, tapering till D+6m to 12m  Tacrolimus: ≧ CsA, serumlevel below 15 ng/mL  MMF (Mycophenolate mofetil)  In mini-alloHSCT  mTOR inhibitor: sirolimus (rapamycin) Prevention of aGvHD (2)

18. Treatment of aGvHD  Gr II-IV aGvHD  First line: Methylprednisolone 2mg/Kg/D for 14 days or more  Steroid non-responsive: Bone Marrow Transplantation 2008;41:S65-70

19.  GvHD  Definition and Pathogenesis  Acute GVHD (aGvHD)  Clinical spectrum  Prevention and management  Chronic GVHD (cGvHD)  Clinical spectrum  Prevention and Management  Prevention and Management of tumor relapse  Monitoring Relapse  Graft-versus-tumor (GvT) effects  Donor lymphocyte infusion (DLI) and immunotherapy

20. Clinical Features of cGvHD  30-50% sibling alloHSCT and 50-70% URD-HSCT  Chronic course, usually not fatal but impaired QOL  More like autoimmune disease  Widespread organ involvement: Blood 2002;100:406-14

21. Cutaneous cGvHD Dermatology 2008;216:287-304

22. cGvHD in Lung: Brochiolitis Obliterans (BO) and Organizing Pneumonia (OP)

23. Classification and Scoring of cGvHD  Seattle classification:  Limited: Only skin or liver  Extensive  NIH-cGvHD Consensus Project Working Gp:  Scoring 0-3 for each organ/system  Mild: 1-2 organ/system with maximum score 1  Moderate: 3+ organ/system or maximum score 2  Severe: any organ/system scoring 3  Lung score: 1= moderate, 2-3=severe Biol Blood Marrow Transplantation 2005;91:945—55

24. NIH Classification System for cGvHD

25. Risk Factors for cGvHD  Stem cell sources  Histocompatibilities  Gender mismatch  T-cell depletion(?)  Ethnicity: Japanese  Donor lymphocyte infusion  aGvHD  Age  High CD34+ cells in alloPBSCT  Tapering of immunosuppresants

26. Prevention and Therapy for cGvHD  No effective prophylatic regimens  Therapy:  First line: CsA + Corticosteroid  Salvage regimens: Variable

27. Salvage Therapy for cGvHD (1) Lancet 2009;373:1550-61

28. Salvage Therapy for cGvHD (2) Lancet 2009;373:1550-61

29.  GvHD  Definition and Pathogenesis  Acute GVHD (aGvHD)  Clinical spectrum  Prevention and management  Chronic GVHD (cGvHD)  Clinical spectrum  Prevention and Management  Prevention and Management of tumor relapse  Monitoring Relapse  Graft-versus-tumor (GvT) effects  Donor lymphocyte infusion (DLI) and immunotherapy

30. Tumor Relapse  Major reason of failure in alloHSCT for malignant disease  Most relapsed from recipient cells  Risk factors:  Pre-transplant disease condition  Conditioning Regimens (??)  Immune status: ex., T-cell depletion

31. T-cell Depletion and Relapse Blood 1991;78:2120-30 Early LeukemiaAdvanced Leukemia

32. Monitoring of Leukemia(Tumor) Relapse  Monitor chimerism  Fluorescence in situ hybridization (FiSH) for sex chromosome (1-5%)  Short tandem repeat (STR) (1-10%)  Monitor disease markers: Minimal residual disease (MRD)  Cytogenetics (~5%)  FiSH (1-5%)  Flow cytometry (0.1-0.01%)  Molecular tools (0.1-0.001%)  Reverse transcriptase-polymerise chain reaction (RT-PCR)  Quantitative real-time RT-PCR (QRT-PCR)

33.  GvHD  Definition and Pathogenesis  Acute GVHD (aGvHD)  Clinical spectrum  Prevention and management  Chronic GVHD (cGvHD)  Clinical spectrum  Prevention and Management  Prevention and Management of tumor relapse  Monitoring Relapse  Graft-versus-tumor (GvT) effects  Donor lymphocyte infusion (DLI) and immunotherapy

34. GvHD and Relapse: Evidences of GvT Blood 1989;73:1720-8 N=154, Relapsed ALL/AML N=123, CML, CPN=45, CML, AP/ABC

35. Donor Lymphocyte Infusion (DLI)  Donor buffy coat infusion  Prepared by leukaphresis, not mobilized with G-CSF  Adoptive cellular immunotherapy  Presented as CD3+T-cell dosage

36. Direct Evidences of GvT Blood 1997;90:4206-11

37. Effects of DLI  Major determinants for treating tumor relapse  CD3+T-cell dosage  Diagnosis  Pre-DLI disease status  Major Complication: GvHD  Seperating GvL from GvHD ?!  Other applications for DLI  Adoptive immunotherapy for viral infections

38. Effects of Pre-DLI Status on Response: CML Chap.28 Hematopoietic Stem Cell Transplantation CML in A.Molecular relapse B.Cytogenetic relapse C.Chronic phase D.Accelerated phase E.Blastic phase

39. Effects of Disease Types on DLI Response EBMT data 1997

40. Strategies to Modify DLI Chap.28 Hematopoietic Stem Cell Transplantation

41. Pre-emptive DLI High-risk AML GvHD(-) on D+120 J Clin Oncol 2005;23:5675-87

42. Schemes of Non-myeloablative HSCT New Engl J Med 2006;27:1813-26 Hematology 2001:375

43. Renal Cell Carcinoma with NM-HSCT New Engl J Med 2000;343:750-8

44. Thanks for Your Attention Questions and Discussion…..