1. Hematopoietic stem cell transplantation- HSCT

2. Principle of HSCT Myeloablation and eradication of residual disease with hogh dose conditioning regimen Repopulation of bone marrow by donnor´s hematopoietic stem cells:1. alogenneic 2.syngenneic, 3.autologous

3. Hematopoietic stem cell transplantation Alogenneic Tx 1. subling 2. Alternatve donnors: HLA identical related donnor (MUD) (Haploidentical donnor) Autologous Tx: in vitro purging in vivo purging Syngenneic Tx

4. Human Leukocyte Antigens HLA

5. HLA genes  6. chromosome (6p21)  over 100 coding sequences  most polymorphic area in human genom Genes for class HLA I and II coding transmembrane glykoproteins. Biologic function: allogenneic restriction

6. DPB2 DPA2 DPB1 DPA1 DQB2DQA2DQB3DQB1DQA1 DRB1 DRB2-8 DRB9 DRA HLA-BHLA-CHLA-A qp HLA class II HLA class I HLA Localisation: short arm of 6. chromosome (6p21)

7. HLA I. class -A -B expressed on all -C nucleated cells HLA II. class -DRB1 -DRB3,4,5 -DQB1 -other (např. -DPB1) Expression: B-lymphocytes, activated T- lymphocyte, monocytes, macrophages dendritic cells

8. HLA a HSCT  GvHD – graft versus host disease: donnor´s immune system eliminates incompatible cells of the recipient  + GvL – graft versus leukemia reaction: Transplanted immune cells eradicate residual malignant cells.

9. Sources of hematopoietic stem cells Bone marrow: 10-20ml/kg Repeated punctions at spina & iliac posterior crest Peripheral blood after SC mobilization to the blood: (PBSC – peripheral blood stem cells)

10. Počet HSCT v r. 1990 HSCT in Europe 1990 vs. 2006 Počet HSCT v r. 2006

11. Principles and phases (autologous) of autologous hematopoietic transplantation Harvest of HSC Myelo(imuno)- ablative therapy HSCT transplantation BM (PBSC) (mobilization) Freezing Defrost In vitro purging?? Conditioning regimen

12. HSC mobilization to peripheral blood Autologous donnor (= patient): e.g.- Cyklophosphamide 2,5g/m2 + G-CSF (filgrastim) 10µg/kg. Harvest: cca D8-D10 Alogenneic donnor: G-CSF (filgrastim) 5 µg/kg s.c. D1-5, Harvest: in most cases D5 „stem“ cells: CD34+, Graft quality: CD34+ cells >2,0x10 6 /kg recepient CFU-GM: >1,0 x10 5 /kg recepient Target ammount of SC

13. Conditioning regimens Myeloablative : TBI (10-15 Gy), TBI + cyklofosfamid, Busulfan + Cyklofosfamid, BEAM (BCNU, Etoposid, ARA- C, Melfalan) Non myeloablative: např. Fludarabine + Busulfan + ATG Transplantation with nonmyeloablative regimen: RIC (reduced intensity conditioning)

14. Complications after allo HSCT acute form of GVHD (Graft versus Host Disease): I-IV SOS – sinusoidál obstructive syndrome) Acute alveolitis (TBI) infektions : HSV, CMV, VZV, Adenovirus Candida sp, Aspergillus sp, chronic GVHD

15. Prevention and treatment of GVHD Prevention 1. HLA fully matched donnor 2. Prevention: např. methotrexate + cyclosporine A acute GVHD High dose myethylprednisolone, antilymphocytic globulin (ALG), atd

16. Allogenneic vs. Autologous transplantation in NHL Alogenneic(HLA identical) Mortality up to 30% morbidity: chron. GVHD Relaps: 18-24% GVL efekt + only 30% patients Autologous mortality < 5% morbidity minimal Relaps: 38-69% (graft contamination?) GVL efect: none

17. Alogenneic HSCT HLA identical sibling: genotypic identity: 30% alternative donnors Phenotypicly identical unrelated donnor (MUD) Haploidentical related donnor : parents, children

18. Indications for allogenneic stem cell transplantation In general: Good performance status and age < 60 years Chemosensitive disease Hematologic malignancies Aplastic anaemia Congenital munodeficiency and metabolic diseases

19. Hematologic malignancies – indication for alloSCT AML v 2. remmission or AML in 1. remmission with high risk of relaps (complex karyotype changes) ALL Ph + v 1. remmission, ALL ve 2. remmission CML: resistent to TKI (T315I mutation) CLL – rezistant to fludarabine Hodgkin´s lymphoma: reapeated relaps Nonhodgkin lymphoma: chemosensitive repeated relaps

20. Indication to autologous HSCT Multiple myeloma in 1. i 2. line Agressive NHL (DLBCL) in 2. remmission Follicular lymphoma or MZL 2. (3.) remmission Hodgkin´s lymphoma in ve 2. remmission MCL in 1. remisssion PTCL in 1. a 2. remmission Clinical studies: DLBCL in 1. remmission Autoimune diseases (Multiple sclerosis)