1. What is the Expected Clinical Outcome after BMT ?

2. Blood Counts for BMT Recipients Surviving more than 15 Years ParametersMeanSD Hemoglobin138.916.4 Platelets243.165.1 WBC6.61.7 Neutrophils4.63.4 Lymphocytes1.90.7

3. Clonogenic Progenitors in the Graft and the Recipient post BMT

4. Overall Survival of all Patients Receiving an Allogeneic BMT at PMH Days after BMT Survival

5. Outcome by Disease Status at BMT in Recipients Transplanted since 1986 Days after BMT Survival CR1 / CP1 ----- Other ___

6. Long-term Survival of Patients alive 6 Years by Disease Status at BMT Days after BMT Survival AML/CML CR1/CP1 ------ AML/CML other - - - -

8. The Probability of Survival Remains lower than that of the Normative Population even more than a Decade after BMT

9. Lessons learned for Allogeneic Transplants High transplant related morbidity and mortality Low relapse rate Disease control predominantly related to anti-tumor effects by donor derived cells of the immune system

10. Evidence for Graft vs Malignancy Effects (GvM) High relapse rate in syngeneic transplants. Increased relapse rate in T cell depleted transplants in some diseases Lower relapse rate in patients with GvHD compared to patients without Leukocyte Infusions (DLI) in recipients relapsing after a transplant may result in remissions and long-term disease control

11. Strategies to provide treatment for more patients in need of a transplant Matched Unrelated Donors Cord Blood Transplants Haplo-identical Donors Reduced Intensity Transplants

12. Unrelated donor registries

13. Matched unrelated donors 13 million donors worldwide Improved donor recruitment Improved HLA-typing Outstanding international cooperation International standards Outcomes similar to those achieved with related donors

14. Donor availability for allogeneic transplants

15. (O’Brien TA et al MJA 2006; 184: 407 – 410)

16. Cord Blood Transplants Principles: Utilization of a waste product High proportion of primitive progenitors Presence of mainly naïve T cells Product readily available

17. Outcome of CBT from related donors by diagnosis Months Survival (Rocha V et al EUROCORD)

18. Lessons learned Cord blood cells are a viable alternative source of hemopoietic progenitor cells In the pediatric age group CBT may be preferable because of decreased acute and chronic GvHD and the requirement for a lesser degree of HLA matching The outcome of mismatched transplants can be overcome by higher cell doses Cell dose remains a limiting problem particularly for adults. This problem is being addressed by the use of double cords.

19. Transplants from Haplo-identical Donors Principles: Intensive preparation High stem cell numbers Extensive T cell depletion Preparation with regimens that maintain regulatory T cell populations Availability of donors for nearly everyone

20. Aversa et al Rev Clin Hematol Event-free Survival by Disease Status

21. Non-myeloablative Transplants Principles: Immune suppression with purine analog based regimens of low intensity Slow replacement of recipient marrow by donor cells Engraftment fostered by decreasing immune suppression and administration of DLI Reduction of early transplant related toxicity Reliance on a GvM effect as mechanism of disease control

22. Engraftment Process after Non-myeloablative Allografting Recipient Donor Mixed Chimera Full Chimera Immune- suppression DLI

23. Non-myeloablative Transplants

24. Decrease of early transplant related toxicity Broadened eligibility to include patients with otherwise non-permissive co- morbidities Inclusion of patients with chronic non life threatening diseases Reliance on a GvM effect for disease control in patients with malignancies

25. Disease-free Survival of Patients with AML/MDS by Disease Status Giralt In: NST, 2000

26. Novel Strategies for Allogeneic BMT

27. Objectives Reduction of other TRM Avoidance of GvHD Disease Elimination

28. Risk factors for Transplantation Recipient Donor Graft Transplant Procedure

29. Risk factors for Transplantation Recipient Donor Graft Transplant Procedure Age Disease (AA, CML) HLA compatibility Minor histocompatibility antigens Non-HLA immunogenic polymorphisms Gender Immune status PBSC Cord blood Cell count T cell depletion Tregs Age HLA compatibility Gender (F M) Unrelated donor Preparative Regimen GvHD Prophylaxis and Management

30. Malignant stem cells and their protective microenvironment Mobilization Reestablishment of potential to undergo apoptosis Myeloablative therapy and transplant

31. Events during mobilization (Winkler I, Levesque JP Exp Hematol 2006; 34: 996 – 1009) Steady stateMobilization with G-CSF

32. LSC

33. Allogeneic transplants: A platform for Cell therapy

34. Donor derived Cells after BMT can be found in strange places Myelopoiesis Lymphopoiesis von Kupffer cells Pulmonary alveolar macrophages Langerhans cells Osteoclasts Macro and Microglia Hepatocytes

35. Male recipient cells in female cardiac allografts (Schwartz and Curfman NEJM 2002; 346: 2 – 4)

36. Intracoronary Mononuclear Marrow Cell Transplantation Strauer BE et al Circulation 106: 1913 – 1918, 2002

37. Intracoronary injection of BM cells in acute myocardial infarction Lunde K et al (NEJM 2006; 355: 1199 – 1209) 100 patients randomized to marrow cell injections or no intervention NO differences in global left ventricular function Schachinger V et al (NEJM 2006; 355: 1210 – 1221) 204 patients randomized to marrow cell injections or placebo Improved recovery of left ventricular contractility after marrow cell infusion Assmus B et al (NEJM 2006; 355: 1222 – 1232) 75 patients randomized to circulating blood cells, marrow, or no cells Moderate but significant improvement of left ventricular ejection fraction after marrow cell infusion

38. Stem cell recruitment to ischemic infarcts (Kim DE et al Stroke 2004; 35: 952 – 957) Cells positive for neuronal marker NeuN

39. Neurogenic Regions in the Mouse Subventricular zoneDentate gyrus (DG) (Seaberg R, van der Kooy D J.Neurosci 2002; 22: 1784 – 1793)

40. Newly generated cells in the subventricular zone with EGF or EGF plus EPO a BrdU LV Str BrdU LV Str EGF EGF + EPO Courtesy Sam Weiss, Calgary

41. Histological analyses reveal new tissue in the lesion cavity of rats that received EGF+EPO infusions No Lesion Lesion + EGF/EPO Lesion Courtesy Sam Weiss, Calgary

42. Embryonal Stem Cells (Langston JW J Clin Invest 2005; 115: 23 – 25)

43. The promise of stem cell research

44. Conclusions (I) Stem cell transplants are a major treatment modality for patients with marrow failure, hemopoietic malignancies and diseases with immune dysfunction Stem cell sources include marrow, peripheral blood and cord blood Stem cells can be derived from autologous and allogeneic sources Currently available strategies facilitate their use for patients with more advanced age

45. Conclusions (II) Advances are being made to test whether or not stem cells may facilitate repair of defective organs in general

47. BM PBSC Months post Transplant P=0.036 Probability of Survival

48. BM PBSC Months post Transplant Survival of Patients with more Advanced Disease