1. “ La storia del trapianto allogenico: dal condizionamento a dosi convenzionali all’allo-RIC ed esperienza torinese ” B Bruno Divisione di Ematologia, Università di Torino, Italy Orvieto, November 2009

2. Allogeneic transplants in MM patients from 1989 to 2009 MUD Pre 198922 1989 - 20081086 TotalMUD 19897 19906 199115 199210 199315 199419 199521 199618 199728 1998341 1999342 2000656 2001818 200211513 200312810 200412922 200510325 20069425 20079430 20087030 Myeloablative Non-Myeloablative New Drugs

3. Myeloablative conditionings Timeline showing single Institutional reports: Seattle 1987 - 1999 Montreal 1990 - 2000 Toronto 1983 - 1995 Michigan 1989 - 1995 Bologna 1989 - 1992 Surrey 1981 - 1998 Arkansas 1992 - 1996 Boston 1996 - 1999 Vancouver 1988 - 1993

4. Patients Median age (range) TRMCR (%) OS (%) months Seattle (Bensinger - 2001) 136 <50 (43-48) 48% day 100 63% 1 year 3422 (60) Montreal (Le Blanc - 2001) 37 47 (25 - 53) 22%5732 (40) Toronto (Couban - 1997 ) 22 43 (25 – 53) 27% day 905032 (36) Michigan (Varterasian - 1997) 24 43 (31 – 56) 25%40 (36) Bologna (Cavo - 1998) 19 43 (36 - 50) 37%4221 (48) Surrey (Gahrton - 2001) 33 38 (30 – 53) 54%3736 (36) Arkansas (Mehta - 1998) 42 45 (29 – 59) 43%4129 (36) Boston (Alyea - 2001) 24 46 (36 – 54) 10%55 (24) Vancouver (Reece - 1995) 26 43 (29 - 55) 19% day 1006247 (36) Myeloablative conditioning

5. Myeloablative conditioning and allogeneic SCT in MM

6. Myeloablative conditionings Most common regimens: CY/TBI BU/CY Intensity BU/CY/TBI 12Gy BU/TBI 12Gy CY/TBI 12Gy BU/CY BU/MEL 20-50% of TRM (Transplant Related Mortality) Regimen related toxicities Infections GVHD (Graft-vs.-Host Disease) Approach limited to medically fit patients <50-60 years

7. Myeloablative conditionings Seattle experience: 136 patients (all < 60 y/o) Treated between 1987 and 1999 Heavily pretreated pts BU/CY TBI Regimen TRM Day 100 48% Infections GVHD Day 365 63% 5 yr SURVIVAL 22% Relapse-free SURVIVAL 14% The reason for high TRM in MM patients remains unknown. Detrimental myeloma effects on baseline organ functions Increased risk of toxicity and infections given the severe immunodeficiency

8. Myeloablative conditionings Impact of patient selection and better supportive care on outcome Garthon G et al, Progress in haematopoietic stem cell transplantation for multiple myeloma, JIM, 2000 EBMT registry data: 690 MM patients TRM ‘83-93‘94-98 6 mo38%21% 2 yr46%30% of infections

9. Garthon G et al, Progress in haematopoietic stem cell transplantation for multiple myeloma, JIM, 2000 Myeloablative conditionings ‘83-93‘94-98 OS at 3 yr 35%55% PFS 7 mo19 mo Outcome: Higher risk of relapse and progression associated with: Male donors > 6 prior chemotherapy RR= 4,3 RR= 4,2 Lower risk of relapse and progression associated with: Female donors but higher GVHD incidence

10. Autologous SCT and Conventional Allogeneic CT Conventional Allogeneic CT Autograft versus Myeloablative allograft SWOG 9321 Barlogie et al. JCO 2006

11. Timeline showing advances in myeloma treatment FDA approvation of Thalidomide FDA approvation of Bortezomib in refractory patients FDA approvation of Bortezomib in patients who had recived at least one prior therapy FDA approvation of Bortezomib in first line therapy FDA approvation of Lenalidomide in patients who had recived at least one prior therapy Introduction of non-myeloablative allogeneic SCT regimens in MM (Maloney) TBI-based non-myeloablative allogeneic SCT in hematological malignancies (McSweeney) Introduction of RIC- allogeneic SCT regimens in MM (Kroger)

12. Standard-Allograft Reduction of treatment related mortality from allogeneic SCT High-dose conditioning Autograft Allograft after reduced intensity conditioning Adoptive Immunotherapy (DLI) 2 - 3 Months Allogeneic Immunotherapy

13. Auto-allo tandem transplantation Maloney et al. Blood 2003 Donor G- CSF CSP MMF CytoreductionAutologous phase Allogeneic phase Tumor burden reductionGVM effect HD Mel -4-3-2-1 0 TBI - 200cGy Allogeneic PBSC Autologous PBSC +28 +56 +84 CTX+Taxol VAD HSC harvest

14. Kyle; Rajkumar, NEJM 2004 2. Dramatically reduced toxicity as compared to myeloablative regimens 1. Potentially Curative

15. Blood 2006;107:3474-3480

16. Garban, F. et al. Blood 2006;107:3474-3480 Moreau, P. et al. Blood 2006;107:397-403 Busulphan 2 mg/kg/d x2 days, Fludarabine 25 mg/m2/d x5 days, ATG 2.5 mg/kg -5, -4, -3, -2, -1

17. Garban, F. et al. Blood 2006;107:3474-3480 IFM 99-03/04: Survival according to intention to treat Overall survival Event-free survival Auto–RIC Allo Auto-Auto+anti IL6 Months from start of therapy

18. Garban, F. et al. Blood 2006;107:3474-3480 Months from start of therapy IFM 99-03/04: Survival according to protocol Overall survivalEvent-free survival Auto–RIC Allo Auto-Auto+anti IL6

19. Moreau P, Blood 2008 Long-term follow-up results of IFM99-03 and IFM99-04 trials comparing nonmyeloablative allotransplantation with autologous transplantation in high-risk de novo multiple myeloma.

21. Treatment Assignment * PBSC mobilization Autografting Induction (cyclophosphamide) Autografting Low dose TBI (2Gy) and Allografting (VAD - based regimens) (Melphalan) *Based on presence/abscence of an HLA matched sibling “ Pre ” new drugs!!

22. 60 enrolled in Auto - Allo 59 enrolled in Auto - Auto 199 with siblings 162 HLA-typed 58/60 (97%) completed Program 46/59 (78%) completed Program 245 Newly diagnosed patients<65y No, n=82Yes, n=80 HLA-identical siblings Intent-to-treat 46 no siblings 37 not HLA-typed: Refusal (n=9) Early death/ineligibility for high-dose chemotherapy (n=14) Ineligible donors (n=11) Unknown (n=3) Refusal to allografting as first-line treatment (n=15) Iineligible donors (n=5) Enrolled in intermediate-dose melphalan (n=20) Ineligible for high dose chemotherapy (n=3) By Protocol NEJM 2007

23. Intent-to-treat analysis (80 vs 82 pts) Median follow up: 6 years HLA-identical siblings vs no HLA-identical siblings 52 mo. 29 mo. 35 mo. “Pre” new drugs!!

24. Patients who completed protocols (58 vs 46 pts) Median follow up: 6 years Auto-Allo Vs Auto-Auto 64 mo. 33 mo. 37 mo. “Pre” new drugs!!

25. Estimates of cumulative incidence rates

26. Diagnosis Induction treatment (VAD or equiv) Response SD, PR or CR HLA-typing Autologous stem cell harvest HD-Melphalan + auto SCT STUDY INCLUSION HLA-id siblingNo HLA-id sibling RIC-allo transplant No treatment or 2nd HDM + auto SCT(optional) CR Continuous No treatment Relapse PR Treatment DLI Study design

27. BMT-CTN 0102: Schema Melphalan 200 mg/m 2 Auto HCT Melphalan 200 mg/m 2 Auto HCT TBI 200 cGy MMF/CSP Allo HCT Maintenance Thalidomide and Dexamethasone for 1 yr Observation Assigned based on HLA-ID sib Randomized Observation age <70 At least 3 months of systemic therapy 3-9 months from start of therapy Autologous PBSC graft of > 2 x 10 6 CD34 cells/kg per auto transplant Maloney 2006

28. 110 MM pts Less than near CR after autologous transplant 2° ABMT 85 pts Allo-RIC 25 pts Blade J, Blood, 2008

29. Figure 1A: progression-free survival from second transplant (median: 31 months for 2nd ASCT and not reached for Allo-RIC, p=0.08). Figure 1B: event-free survival (p=0.4) Blade J, Blood, 2008

30. Figure 1C: Panel C: overall survival from second transplant (median: 58 months for 2nd ASCT and not reached for Allo-RIC,p=0.9)

31. Blade J, Blood, 2008

32. Blood, 2009

33. A: Acute Graft vs Host Disease B: Transplant Related Mortality Blood, 2009

34. A: Overall Survival B: Event Free Survival Blood, 2009

35. A: OS by Kaplan-Meier B: EFS by Klein C: EFS by Kaplan-Meier A B C Blood, 2009 DLI with/without new drugs

36. Cox models for overall survival and event free survival Blood, 2009

37. New drugs after allografting in myeloma 50% (20 mo) NR66%NR Len (4) Len+Dex (20) Relapse/ refractory 59 (37-70) 24 Lehmann et al 2008 NR NR§NR Vel (7) Thal (9) Vel+Thal (5) No response to DLI NR21/63 Niels et al 2006 32% (36 mo) ^^^ 17% (36 mo) ^^^ NR- Thal (NR) Vel (NR) Len (NR) Relapse/ refractory ^^ 56 (44-64)) 23/36 Schmitt et al 2008 95% (7 mo) § 89% (7 mo) § NR8 moVel SD, PR or CR ^ 49 (32-68) 18 Kroger et al 2006 50% (13 mo) 50% (11 mo) 87%NR Len (8) Len+Dex (8) Relapse/ refractory 58 (43-67) 16 Minnema et al 2008 90% vs. 62%*** (56 mo) 58% vs. 35%*** (56 mo) 59%**NR Thal (15) Vel (8) Len (2) No CR after DLI * 50 (35-68) 25/32 Kroger et al 2009 65% (18 mo) NR73%20 mo Vel (11) Vel+Dex (26) Relapse/ efractory 49 (27-64) 37 El-Cheikh et al 2008 NR 50% (6 mo) 61%20 mo Vel (9) Vel+Dex (14) Relapse/ refractory 64 (48-85) 23 Bruno et al 2006 50% ~ 15 mo § NR 29%NRThal Relapse/ refractory 54 (39-64) 31 Mohty et al 2004 OS after salvage treatment PFS after salvage treatment OR (at least PR) Median time to salvage Drug Disease status Median age Pts NR: not reported; § see text; * DLI was administrated in 32 patients who achieved only partial remission after allogeneic SCT; ** percentage of CR obtained after DLI and treatment with new drugs; *** patient who achieved CR versus patients who did not achieve CR; ^ obtained after RIC allogeneic SCT; ^^ obtained before RIC allogeneic SCT; ^^^ calculated on all 36 patients.

38. A: Overall Survival B: Event Free Survival del13q No del13q del13q 13 pts. 26 pts. 13 pts. 26 pts. Blood, 2009

40. Pros…. Depth of Response Molecular Remissions ? Eradication

41. EBMT study: Pcr Neg Pcr Mixed Pcr pos Patient number: 16 19 13 Relapse at 5 years 0% 33% 100% Corradini, Blood, 2003 Molecular Remissions after Myeloablative Transplants Corradini, JCO, 1999 Allografting Autologous Molecular CR 50% 7% Ladetto, JCO in press Autologous + Maintenance with Thal-Vel-Dex Molecular CR 5/22 patients

42. 0 3 6 9 12 15 18 21 24 months Pt-3 Pt-5 Pt-4 Pt-7 Pt-1 Pt-2 Pt-6 40 MONTHS 60 MONTHS Autograft Allograft Molecular Remissions after Auto-Allo Transplants Pcr posPcr neg

43. M.W. Dgn +29 +29 +100 +100 +230 +230 +390 +390 +601 +601 Neg No M.W. BM PB BM PB BM PB BM PB BM PB BM Contr DNA Graft vs. Myeloma Effects after Auto-Allo Transplants Plasma Cell Infiltration > 90% (d +20)Graft-versus-Host Disease (d +50) Graft-versus-Myeloma (d +60) Skin Biopsies (H&E)

44. Timing ….  Tandem AutoAllo in newly diagnosed patients  Allo at relapse  Need to reduce disease (pre-tx therapy/ more intense conditioning)  Risk of higher toxicity and less response - Higher rates of CR and less toxicity

45. Graft versus Hematological Malignancies immune failure tumor escape earlier phases Donor immune-competent cells later phases Plasma cells Siegel S et al J Immunol 2006

46. Stem Cell Harvesting Mini-Allo AutoTx HLA Typing Induction “New drugs” Velcade-thalidomide or lenalidomide MEL 200 TBI2G y Tandem transplant phase Post transplant phase Maintenance Lenalidomide (10 mg daily continuously)

47. Preliminary results 25 patients enrolled, 11 at least 1 month post allografting Overall response rate 81% (9/11) at the time of allografting After a median follow-up of 11 months (2-26), all patients are alive and the overall response rate was 91% (10/11). Incidence of grade II-IV GVHD was 34% (4/11) Chronic GVHD was observed in 40% (4/10) of patients with at least 3 months of follow-up. Conclusions: Induction with lenalidomide, thalidomide or bortezomib does not impact feasibility and safety of tandem auto-allo.

48. Conclusions  Subgroup analyses are IMPERATIVE  30-35% in continuos CR (including molecular CR), median follow-up of 5-6 years  Only prospective clinical trials can establish their role in the setting of allografting  Most studies were designed before the introduction of new drugs  Allografting remains a treatment option for myeloma patients with a potential donor  New drugs are NOT mutually exclusive with an allograft, may decrease tumor burden and increase long term disease control post-transplant

49. Acknowledgments: Divisions of Hematology Alessandria (Dr Levis/Dr Allione) Candiolo (Prof Aglietta/Dr Carnevale-Schianca) Cuneo (Dr Gallamini/Dr Mordini) Bolzano (Prof Coser/Dr Casini) Pescara (Dr Di Bartolomeo/Dr.ssa Bavaro) Pisa (Prof Petrini/Dr.Benedetti) Udine (Prof Fanin/Dr.ssa Patriarca) Bergamo (Dr Rambaldi/Dr.ssa Barbui) Monza (Prof Pogliani/Dr Parma) MI-Osped. Maggiore (Prof Soligo) MI- Ist.Tumori (Prof Corradini/ Dr Montefusco) Rozzano- Humanitas (Dr Santoro/Dr. Castagna) Roma - Tor Vergata (Prof De Fabritiis) Roma -La Sapienza (Prof Foa, Dr.ssa Iori) Torino (Dr Vitolo/Dr Falda) Torino Universita (Prof Boccadoro/ Dr. B. Bruno ) FHCRC, Seattle R. Storb D. Maloney B. Sandmaier Thank you for your attention ! IBMDR, Genova S. Pollichieni R. Oneto B. Bruno N. Sacchi