Hospital Universitario La Fe, Valencia, 2009 Criterios de selección de unidades de sangre de cordón umbilical para trasplante Guillermo Sanz Hospital Universitario La Fe, Valencia, 2009

Proceso de selección de DNE adulto Simple y pasivo. Éxito 40 – 60%. Basado exclusivamente en la compatibilidad HLA: Si aparece más de 1 donante (raro): Considerar sexo (y embarazos si mujer), edad, peso, estado serológico a CMV, grupo ABO, ¿país del donante?

Proceso de selección de unidad de SCU Complejo y activo: Éxito en mayoría con varias unidades disponibles (mediana, 5  10): dilema práctico y ético Criterios a considerar (especialmente umbrales) no basados en la evidencia: Basado fundamentalmente en dosis celular y compatibilidad HLA

Problemas del proceso de selección de unidades de SCU Criterios de selección no bien establecidos Necesidad de considerar diversas variables Desconocimiento de la nomenclatura HLA Diferencias en la información ofrecida por los registros (nivel de resolución alelos HLA, cantidad células CD34+, grupo ABO) Ausencia de informes estándar de los bancos de cordón

Factors to consider for malignant diseases Cell dose is the most important factor for outcome HLA mismatches increase the risk of engraftment delays, TRM and chronic GVHD and decreases the risk of relapse resulting of an absence of the role of HLA mismatches for survival The type of HLA mismatches did not influence outcomes. DRB1 matching seems better Increasing cell dose abrogates the effect of HLA mismatches

High-risk AML in CR1 (n = 30) LFS by nucleated cells infused > 2  107/kg (n = 18): 75% at 4 y ≤ 2  107/kg (n = 12): 25% at 4 y P = 0.03 Sanz J et al. Biol Blood Marrow Transplant 2009 (in press) 6 6

Leukemia-free Survival 20 40 60 80 100 CB matched (n=35) 60% CB 1-Ag MM high (n=157) 45% BM matched (n=116) 38% Adjusted Probability, % CB 2-Ag MM (n=267) 33% CB 1-Ag MM low (n=44) 35% 12 24 36 48 60 Months Eapen et al. Lancet 2007

Impact of Cell Dose and HLA Match on Survival New York Blood Center 5/6 Match 4/6 Match 5/6 match 4/6 match Survival Cell Dose (× 107/kg) 70% >10 5.0-9.9 50% 2.5-4.9 30% <2.5 <2.5 Threshold effect Continuous effect

HLA A, B (LR), DRB1 (HR) Match Overall Survival HLA A, B (LR), DRB1 (HR) Match HLA A, B, DRB1 (HR) Match I Probability 0.0 0.2 0.4 0.6 0.8 1.0 Months Post-Transplant 6 12 18 24 30 36 42 5/6 or 6/6, N=104 4/6, N=121 3/6, N=53 5 – 6/6 v 3 – 4/6 P = 0.02 5 – 6/6 v 4/6 v 3/6 P = 0.05 HLA A, B, C, DRB1, DQB1 (HR) Match I 9/10 or 10/10, N=38 6,7 or 8/10, N=173 2-5/10, N=59 Probability 0.0 0.2 0.4 0.6 0.8 1.0 Months Post-Transplant 6 12 18 24 30 36 42 9 – 10/10 v Other P = 0.02 9–10/10 v 6–8/10 v 2–5/10 P = 0.06 5/6 or 6/6, N=147 4/6, N=162 Probability 0.0 0.2 0.4 0.6 0.8 1.0 Months Post-Transplant 6 12 18 24 30 36 42 I P=0.51 I I I I I I I I I I I I Original LR HLA Match p = 0.51 5/6 or 6/6 @ 180 days 72.7 (95% CI 65.4-79.9) 5/6 or 6/6 @ 1 year 63.5 (95% CI 55.6-71.3) 4/6 @ 180 days 66.9 (95% CI 59.7-74.2) 4/6 @ 1 year 58.7 (95% CI 51.0-66.3) Retrospective HR HLA Match out of 6 p = 0.05 5/6 or 6/6 @ 180 days 79.7 (95% CI 71.9-87.4) 5/6 or 6/6 @ 1 year 69.9 (95% CI 61.0-78.7) 4/6 @ 180 days 61.0 (95% CI 52.3-69.7) 4/6 @ 1 year 56.0 (95% CI 47.1-64.8) 3/6 @ 180 days 62.3 (95% CI 49.2-75.3) 3/6 @ 1 year 48.9 (95% CI 35.3-62.4) Retrospective HR HLA Match out of 10 p = 0.06 9/10 or 10/10 @ 180 days 89.5 (95% CI 79.7-99.2) 9/10 or 10/10 @ 1 year 78.8 (95% CI 65.7-91.8) 6,7,8/10 @ 180 days 66.2 (95% CI 59.1-73.3) 6,7,8/10 @ 1 year 60.3 (95% CI 53.0-67.6) 2-5/10 @ 180 days 66.1 (95% CI 54.0-78.2) 2-5/10 @ 1 year 52.4 (95% CI 39.7-65.2) Kurtzberg J et al. Blood 2008

UCBT malignant disorders (n=929) Overall survival according to number of HLA and cell dose P=0.168 20 40 60 80 100 0.0 0.2 0.4 0.6 0.8 1.0 Overall survival 0-1 HLA and cell dose >= 2 3-4 HLA diff and cell dose >= 2 2 HLA diff and cell dose >= 2 0-1 HLA and cell dose < 2 2 HLA diff and cell dose < 2 3-4 HLA diff and cell dose < 2 Months

Factors to consider for non-malignant diseases Requirements for cell dose are higher than for malignant disorders HLA mismatches play a major role for engraftment , GVH and survival It is partially abrogated by increasing cell dose 2 HLA DRB1 mismatches seem to have an adverse effect

Guidelines for UCB unit choice Eurocord 2004 original criteria At least 4/6 HLA match NCs at freezing above 3.0 × 107/kg Gluckman E et al. Exp Haematol 2004; 32:397-407.

Number of CD34+ cells is relevant after different types of SC transplants Autologous transplants Impact on engraftment Quality control of adequate mobilization Allogeneic (HLA-id sibs and MUD) transplants Impact on time to engraftment Long-term outcome

Why CD34+ cell dose was not included in criteria for guiding UCB unit choice? Not enough data to base recommendation Measurement of CD34+ cells is not standardized Great differences in CD34+ counts among units from different CB banks could emerge NC dose could be considered a good surrogate of CD34+ cell dose (good correlation between CD34+ cells and NCs) Economic reason: data not available for more than 50% UCB units worldwide at that time

Number of CD34+ cells is also relevant after UCB transplants Impact on engraftment (children and adults ) Impact on survival (children and adults – some series) Review by Rocha V & Gluckman E on behalf of Eurocord/EBMT. Br J Haematol 2009; 147:262-274.

Results Probability of neutrophil recovery according to number of CD34+ infused (105/kg)* (per percentile) (n=665) CD34+:>3= 94% CD34+: 1.7-2.92= 87% CD34+: < 1.7= 79% * 501/665 pts with available information 16

Results Probability of neutrophil recovery according to number of TNC infused (107/kg) (per percentile) (n=665) TNC 3,91-5,96 = 91% TNC > 5,96= 90% TNC 2,67-3,91= 80% TNC < 2,67= 79% 17

Hospital Universitario La Fe, Valencia, Spain (unpublished) CD34+ cell dose ( 105/kg) and probability of myeloid engraftment after UCBT Hospital Universitario La Fe, Valencia, Spain (unpublished)

Interaction between collected nucleated cells/kg and CD34+ cells/kg 1 2 3 4 5 CD34 Mononucleated cells R = 0.63 (P < 0.0001) 1.0 0.8 Mononucleated cells 0.6 0.4 0.2 0.0 0.0 0.2 0.4 0.6 0.8 1.0 CD34

Guidelines for UCB unit choice Eurocord 2009 criteria for non-malignant disorders UCB unit with 5/6 or 6/6 HLA match Minimum number of NCs at freezing 2.5 × 107/kg, or Minimum CD34+ cells at freezing or infused 1.2 × 105/kg UCB unit with 4/6 HLA match Minimum number of NCs at freezing 4 - 5 × 107/kg, or Minimum CD34+ cells at freezing or infused 2 – 2.5 × 105/kg HLA match should be given priority Rocha V & Gluckman E on behalf of Eurocord/EBMT. Br J Haematol 2009; 147:262-274.

Guidelines for UCB unit choice Eurocord 2009 criteria for malignant disorders UCB unit with 5/6 or 6/6 HLA match Minimum number of NCs at freezing 2.5 × 107/kg, or Minimum CD34+ cells at freezing or infused 1.2 × 105/kg UCB unit with 4/6 HLA match Minimum number of NCs at freezing 3.5 × 107/kg, or Minimum CD34+ cells at freezing or infused 1.7 × 105/kg Rocha V & Gluckman E on behalf of Eurocord/EBMT. Br J Haematol 2009; 147:262-274.

Guidelines for UCB unit choice Eurocord 2009 criteria These thresholds in cell dose imply to recommend double cord transplants for most adult patients

Should it be possible to use a lower CN and CD34+ threshold for UCB transplants in adults with a single unit if BOTH cell dose criteria are included in UCB unit choice? Protocol UCBT GETH 2005

Protocol UCBT GETH 2005 UCB unit criteria HLA compatibility ≥ 4/6 HLA-A and -B (antigen level) DRB1 (allele level) Cell dose at cryopreservation (both criteria) Nucleated cells (NCs) > 1.5  107/kg and CD34+ cells > 0.6  105/kg (> 1  105/kg if NCs between 1.5 and 2.0  107/kg) GETH cooperative group. Unpublished data

Protocol UCBT GETH 2005 Rationale for conditioning regimen Good engraftment after unrelated UCBT in adults with thiotepa, oral busulfan, cyclophosphamide, and ATG1 Less toxicity and similar efficacy with single daily dose IV busulfan and fludarabine compared to oral busulfan and cyclophosphamide2 1 Sanz GF et al. Blood 2001; 98: 2332-8. 2 De Lima M et al. Blood 2004;104: 857-64.

Protocol UCBT GETH 2005 Conditioning regimen -7 -6 -5 -4 -3 -2 -1 0 BU FLU ATG TT Thiotepa 5 mg/kg/d IV in 4 hs, days -7 and -6 Busulfan 3.2 mg/kg IV in 3 hs, days -5, -4, and -3 Fludarabine 50 mg/m2/d IV in 1 h, days -5, -4, and -3 Thymoglobulin 2 mg/kg/d days -5, -4, -3, and -2 GETH cooperative group. Unpublished data 26

Cumulative incidence: 94% Protocol UCBT GETH 2005 (n = 89) Myeloid engraftment (PMN > 0.5  109/L) Cumulative incidence: 94% Median: 19 days GETH cooperative group. Unpublished data 27

Cumulative incidence: 80% Protocol UCBT GETH 2005 (n = 89) Platelet engraftment (platelets > 20  109/L) Cumulative incidence: 80% Median: 44 days GETH cooperative group. Unpublished data 28

Protocol UCBT GETH 2005 (n = 89) Acute GVHD Grade II – IV: 24% Grade III – IV: 11% Grade II – IV: 26% Grade III – IV: 13% GETH cooperative group. Unpublished data 29

Protocol UCBT GETH 2005 (n = 89) Early non-relapse mortality (NRM) GETH cooperative group. Unpublished data 30

Protocol UCBT GETH 2005 (n = 89) Relapse risk (RR) RR at 3 yr: 18% GETH cooperative group. Unpublished data 31

Protocol UCBT GETH 2005 (n = 89) Disease-free survival (DFS) DFS at 3 yr : 41% Median follow-up (range): 33 (8 – 49) mo GETH cooperative group. Unpublished data 32

Protocol UCBT GETH 2005 (n = 89) DFS at 2 yr by status of disease at transplant Early (n = 46): 52% Intermediate (n = 23): 38% Advanced (n = 20): 18 % GETH cooperative group. Unpublished data 33

Protocol UCBT GETH 2005 Concluding remarks The inclusion of CD34+ cell dose among the criteria for UCB unit choice and the use of new less toxic myeloablative conditioning regimens improves engraftment and early NRM and results in comparable long-term outcomes to those reported with double UCB transplants Single-unit UCB transplants remains an acceptable alternative for most adult patients with hematologic malignancies

Variables a considerar en la selección de la unidad de SCU para adultos con neoplasias hematológicas (HU La Fe, 2009)

Variables a considerar en la selección de la unidad de SCU Dosis celular: CNs y células CD34+ Compatibilidad HLA Otras CFU-GM y viabilidad CD34+ Compatibilidad ABO Banco de SCU Año de congelación ¿Incompatibilidad KIR?

Dosis Celular de la Unidad

Dosis celular Criterio fundamental de selección Considerar células nucleadas y células CD34+ (criterio de calidad de la unidad) Dosis mínima a la congelación de ambas: Células nucleadas: 150 × 109 ó 2 × 107/kg Células CD34+: 7 × 106 ó 1 × 105/kg Relación células nucleadas/CD34+ adecuada (0,1% - 1%)

Compatibilidad HLA

Compatibilidad HLA Al menos 4 de 6, considerando A y B a nivel antigénico y DRB1 a nivel alélico Dirección HvG (rechazo) más importante: homocigosidad en unidad de SCU preferible A igualdad de dosis celular: seleccionar la HLA más compatible A igualdad dosis celular y compatibilidad HLA baja resolución: seleccionar la más compatible por alta resolución Evitar doble disparidad en DRB1 en casos con compatibilidad 4 de 6

Otros factores

CFU-GM y viabilidad CD34+ Mejor criterio de viabilidad de las CPH Clara relación con prendimiento Evitar unidades con escaso número de CFU-GM y preferir aquellas en las que se dispone del dato Relación con CD34+ de 1/10 Viabilidad CD34+ Los estudios actuales de viabilidad celular no detectan células CD34+ en estadios precoces de apoptosis Viabilidad por anexina 5 inferior al 75% predice unidad que injerta en doble TSCU

Compatibilidad ABO Incompatibilidad ABO mayor se asocia a peor injerto y supervivencia A igualdad de dosis celular elegir ABO compatible

PMN Engraftment after UCBT (n=409) ABO compatibility 1.0 76% Compatible or minor (n=274) 0.8 %69 0.6 0.4 Major (n=135) Probability 0.2 P= 0.035 0.0 10 20 30 40 50 60 Years

Survival after UCBT (n=409) 1,0 Survival after UCBT (n=409) ABO compatibility ,8 Identical (n=171) Minor (n=103) ,6 Major (n=135) 45% 44% ,4 40% ,2 0,0 6 12 18 24 30 36 42 48

Banco de cordón y año de congelación Criterio de calidad Preferible banco acreditado NetCord Año de congelación Mayor automatización y mejores estándares de calidad en unidades congeladas recientemente Preferible unidad congelada recientemente

Incompatibilidad KIR La incompatibilidad KIR se asocia a menor tasa de recaída y mayor supervivencia en pacientes con LMA en remisión (Eurocord 2009) No contrastado en otras series

Effect of KIR Ligand Mismatching on GVH Direction after UCBT: LFS in AML and ALL Willemze R et al. Leukemia 2009

Cumulative relapse incidence 1.0 0.8 0.6 without KIR-ligand incompatibility in the GvH direction (n=149) 37%±4 at 2 yrs 0.4 0.2 with KIR-ligand incompatibility (n=69) 20%±5 at 2 yrs 0.0 12 24 36 48 Months

Recomendaciones finales en la selección de la mejor unidad de SCU para trasplante Siempre que haya varias unidades que cumplan los criterios establecidos, la selección de una de ellas no es tan relevante Es mejor llegar al trasplante que perder al paciente durante la búsqueda: es preciso optimizar el proceso y reducir el tiempo de búsqueda