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Prospects in β Thalassaemia and

Sickle Cell Disease:


Stem Cell Transplantation

Dr Josu de la Fuente
Imperial College Healthcare
St. Mary’s Hospital
London
Survival of Patients with β Thalassaemia

Borgna Pignatti, Haematologica 2004;89:1187-1193

Modell, Lancet 2000 Telfer, Haematologica 2006;91:1187-1192


Survival of Patients with Sickle Cell Disease

Platt et al, NEJM (1994) 330:1639-1644


SCT in Haemoglobinopathies
CCGL

β Thalassaemia Major Sickle Cell Disease


• Offered to all children ≤ 16 years
• Stroke
with transfusion-dependent
thalassaemia • Recurrent Chest Syndrome*
PLUS
• Recurrent VOC*
• HLA-identical family donor
* if hydroxycarbamide fails
• Consider carefully:
– patients >16 years
Emerging indication:
– previous failed SCT
• CNS disease
• Risk of CNS disease
Imperial College Healthcare
Conditioning Protocol

Hypertransfusion Ciclosporin
MTX

D-9 D-8 D-6 D-5 D-4 D-2 D-1 D0

Busulfan
14 mg/kg Cyclophosphamide
200 mg/kg
Alemtuzumab Stem Cells
0.3 mg/kg 4 – 6 x 108/kg
Imperial College Healthcare
1994 - 2007

• 89 children with haemoglobinopathies:


– 16 with sickle cell disease
– 73 with β thalassaemia major
• Only one death in 1996 when CMV surveillance did
not exist (β thalassaemia)

Overall survival 72 (98.6%)


β Thalassaemia
Event-free survival 67 (91.8%)
Overall survival 16 (100%)
Sickle Cell Disease
Event-free survival 15 (93.7%)
Chimerism

Haemoglobinopathy patients 2001 - 2006 (3 SCD):

69.5%

13%

Total
No patient dropped < 90% donor haemopoiesis beyond D +90
Limitations of SCT
• Lack of donors • Length of Treatment:
– 2 months as an inpatient
– 4 months as outpatient
• Transplant Related Mortality
• Long Term Effects:
– Infertility
– Pubertal failure
– Chronic GvHD
– Organ toxicity
– Secondary malignancy
SCT for β
Thalassaemia Cy = 200 mg/kg

1985 - 2007

Cy < 200 mg/kg


n=515

Lucarelli, Blood Rev 2008 Lucarelli, Blood 1996


Pesaro risk groups
Class III standard Bu/Cy BMT

•Age ≥ 7 years
•Liver ≥5 cm

Matthews, BBMT 2007


Protocol 26 for Pesaro Class 3

•33 patients < 17 years

•Azathioprine and HU to
reduce haemopoiesis
•Fludarabine 100 mg/m2
•Busulfan 14 mg/kg
•Cyclophosphamide 160 mg/kg

Sodani, Blood 2004


Cure of β thalassaemia by SCT is Life-
Long

Schrier & Angelucci, Ann Rev Med 2005


Mixed chimerism

Andreani, Blood 1996


SCT is Associated with Long-Term
Functional Improvement

Masson trichrome stain Perls stain

Muretto, Ann Int Med 2002


n=6
Mariotti, Brit J Haem 1996 n=17
BM is preferred source of stem cells

Cumulative incidence of aGVHD grades II-IV Cumulative incidence of cGVHD

•87 PBSCT v 96 BM Class I-II children


•Bu/Cy with CSA and MTX
•Median time to neutrophil and
platelet recovery faster in PBSCT
patients
Ghavamzadeh, BBMT 2008
OS
Successful HSCT Failed HSCT
(n = 12) (n = 13)

Endogeneous Red marrow area percentage (%) p=0.01


Mean ± SD 90.25 ± 4.14 94.54 ± 2.93
haemopoiesis
and graft Range 85.16−96.36 89.27−98.67
Marrow haemosiderosis
failure Present 5 3
Absent 7 10

Shen, Eur Radiol 2008


Phlebotomomy
post BMT

Parameter Before Phlebotomy Last Follow-up Two-tailed P Value


AST (times upper level) 2.7 ± 2 1.1 ± 0.6 <.0001
ALT (times upper level) 5.2 ± 3.4 1.7 ± 1.2 <.0001
Liver histology scores:
Piecemeal Necrosis 1 (0-1) 0 (0-1) .0126
Intralobular degeneration 1 (1-3) 0 (0-1) .0001

Portal inflammation 1 (1-3) 1 (1-1) .0063


Fibrosis 3 (3-3) 3 (1-3) .18

Angelucci, E. et al. Blood 1997;90:994-998


Endocrine function
after Bu/Cy

•23 children
•AML

Afify, BMT 2000


Afify BMT 2000
Height after BMT for β thalassaemia

<7 years

≥7 years

<7 years ≥7 years

•47 patients
•Bu 13 mg/kg and Cy
200 mg/kg
•CSA and MTX

de Simone, BMT 2008


de Simone, BMT 2008
Growth and endocrine function
Whole group Age 7 years Age ≤ 7 years
Mean N CI Mean N CI Mean N CI 7 year versus ≤ 7 year,
(SD) (SD) (SD) p value

HtSDS at BMT -1.47 32 -2.01 to -1.99 19 -2.72 to -0.79 13 -1.4 to .027


(1.55) -0.94 (1.6) -1.27 (1.12) -0.18

HtSDS at latest -1.02 32 -1.46 to -1.33 19 -1.95 to -0.56 13 -1.07 to .058


assessment (1.27) -0.57 (1.38) -0.71 (0.95) -0.04 •32 patients
Follow-up (months) 69 (23) 67 (22) 65 (26) .82
•Bu 16 mg/kg and
Change of HtSDS Cy 200 mg/kg
1 year 0.16 32 -0.02 to -0.05 19 -0.26 to 0.48 13 0.2 to 0.76 .003
(0.52) 0.35 (0.46) 0.15 (0.46)

2 year 0.24 30 0.05 to 0.11 18 -0.16 to 0.43 (0.5)12 0.14 to .146


(0.58) 0.43 (0.60) 0.39 0.71

3 year 0.21 30 -0.08 to 0.08 17 -0.37 to 0.38 13 0.04 to .293


(0.81) 0.5 (0.95) 0.53 (0.57) 0.71

4 year 0.35 24 0.05 to 0.37 14 -0.09 to 0.33 10 -0.04 to .911


(0.75) 0.65 (0.88) 0.82 (0.59) 0.69

5 year 0.59 16 0.16 to 0.76 10 0.24 to 0.30 6 -0.43 to .323


(0.86) 1.01 (0.83) 1.27 (0.92) 1.04

Latest change of 0.48 32 0.18 to 0.66 19 0.27 to 0.2 (0.82)13 -0.24 to .166
HtSDS (0.87) 0.78 (0.87) 1.05 0.65

Li, Ped Haem Onc 2004


• The HtSDS gradually improved after BMT and increased by 0.59 (CI
0.16–1.01) at 5 years after BMT.
• 40% patients < 2 SD at time of BMT but this decreased to 15%.
• The hormonal profiles of gonadotrophins, sex hormones, and
thyroid function were assayed regularly after BMT.
• Ovarian failure was universal among the 10 girls evaluable and all
required hormonal replacement.
• Eight of 10 boys had spontaneous puberty but 3 of them had
gonadal impairment.

Li, Ped Haem Onc 2004


Gonadal function after BMT
• 25 patients:
– 13 females and 12 males
– Evaluation at an age that the pubertal process should have started

• Impact of BMT appears to be different in the two sexes:


– Males seem to have higher tolerance:
• all males who were pubertal at the time of BMT had normal testosterone
• all but one normal gonadotropin levels.
– Females:
• prepubertal at BMT: 62% proceeded to normal pubertal development
• post-menarcheal: 100% of the post-menarcheal females exhibited
amenorrhea and elevated gonadotropin levels.

Vlachopapadopoulou, J Paed Endocrinol Metabolism 2005


Multicenter Investigation of BMT for SCD

1991-1999 n = 50

47 surviving
patients:
• 5 recurrent sickle
cell disease
• 4 stable mixed
chimerism
• 38 full donor
haemopoiesis

Walters, Blood 2000


Results: CNS
26 patients (16 male, 10 female) had at least 2 years of follow-up:

19 evidence of CNS abnormalities: Increased risk of transplant-related


• 13 stroke receiving regular neurologic events:
transfusions • 4/7 initial patients had events (2
• 1 transient ischemic attack intracranial haemorrhages)
• 4 cerebral infarction MRI that was • 21% patients had seizures
clinically silent
• 1 elevated cerebral arterial velocity Preventative measures:
• phenytoin prophylaxis with BU, continued
After SCT: for 6 months or whilst on CSA
• none had a stroke and all had stable • strict control of hypertension
or improved MRI scans • prompt repletion of Mg deficiency
• most had stabilization of underlying • maintenance of Hb 9-11 g/dL and platelets
cerebral vasculopathy > 50 x 109/L.
Results: other organs

Pulmonary Function: Growth and development:


• 22 of 26 had stable or normal pulmonary • 5/7 females adverse ovarian function
function after SCT • Linear growth (median height
• 8 transplanted for recurrent acute chest standard deviation score) improved
syndrome: 7 stable pulmonary function from -0.7 to -0.2 after SCT
after SCT
• None had new episodes of acute chest Quality of Life:
syndrome • GvHD:
• 1 grade III acute GVHD died
from complications of chronic
VOC: GVHD
• None had recurrence of vaso- • 3 developed grade I to III acute
occlusive crises after SCT GvHD and 2 had chronic GvHD
• All but one had Karnofsy or Lansky
Performance Scores of 100%
CIBMTR Outcome n Probability
(95% CI)
Absolute neutrophil count >0·5 × 109/l
At 28 days 67 90 (82–95)
At 100 days 100 (0–100)
Platelet count ≥20 × 109/l
At 100 days 59 96 (91–99)
Acute graft-versus-host disease
At 100 days, 67 10 (4–19)
grades (2–4)
Chronic graft-versus-host disease
At 1 year 67 16 (8–26)
At 3 years 22 (13–34)
At 5 years 22 (13–34)
Disease-free survival
At 1 year 65 85 (74–92)
At 3 years 85 (74–92)
At 5 years 85 (74–92)
Overall survival
At 1 year 67 97 (91–100)
At 3 years 97 (91–100)
At 5 years 97 (91–100)
Panepinto, Brit J Haem 2007
SCT for SCD: Belgium Cohort
n = 50 1986 to 1997

OS: 93%
All patients DFS: 85%
EFS: 82%

OS: 88%
SCT because of DFS: 80%
morbidity
EFS: 76%

OS: 100%
SCT to return to
DFS: 93%
country of origin
EFS: 93%

Vermylen, BMT (1998) 22:1-6


Results

SCD associated manifestations: Splenic Function:


• 45/50 stable engraftment with no • 7/10 improvement
evidence of haemolysis or • Failure to improve in patients with
associated manifestations GvHD or BMT in late teenage years

Growth and Development:


• Growth normal/improved in all but 2 Malignancy:
requiring steroids/ intensive • 1 patient with extensive cGvHD
immunosuppression for cGvHD requiring steroids/CSA/Aza/Thalidomide
• Thyroid function normal 27/28 developed MDS/AML 35 months after
BMT in donor-origin BM
• 1/8 girls developed amenorrhoea
• 6/6 boys normal sexual development but
4/6 low sexual hormones

Vermylen, BMT (1998) 22:1-6


French Cohort

Patients 11/88-01/96 02/96-01/00 01/00-12/04


No. 26 17 44
Phenotype 26 SS 16 SS, 1 Sb0 43 SS, 1 Sb0
Sex (F/M) 13/13 11/6 16/28
Median age (range) 8.8 (2.2-17.1) 8.8 (3.2-20) 9.9 (3.2-22)
Age over 15 y (%) 2 3 5 (11.4)
Median no. of transfusions (range) 21 (2-61) 13 (3-41) 15 (4-51)
Median ferritin level (range) 374 (13-3820) 792 (340-2059) 604 (31-3171)

Bernaudin, Blood 2007


Indications, no. patients

Stroke (%) 9 (34.6) 13 (76.5) 14 (31.8)


Stenoses 1 0 5
Abnormal TCD without stenosis 0 0 2
Cognitive deficiency / silent infarcts 2 0 11
3 or more VOC/ACSs per y 14 4 10
> 2 red cell alloimmunizations 0 0 2
Stem-cell source, no. patients

Bone marrow (%) 25 17 32


Cord blood (%) 1 0 11
Peripheral blood cells (%) 0 0 1
Donor mismatches (%) 0 4 0
Outcome, no. patients

Deaths 2 4 0
Rejections/nonengraftment 5 0 2
aGVHD grade 2 or above (%) 5 (19.2) 7 (41) 5 (11)
cGVHD (%) 4 5 2

Bernaudin, Blood 2007


Bernaudin, Blood 2007
Chimerism

Bernaudin, Blood 2007


Mixed Chimerism
n = 59
•Level
Stableofmixed
donorchimerism
chimerismHb
≥6 Smonths
levels
post-BMT
similar to donor
in peripheral
levels blood:
• Only
8 patients:
1 patient
90%required
to 99% adonor
red blood
cells cell
transfusion
• 5 patients:beyond
11% to90 days
74% post-BMT
donor cells
• None of the
• Hb: patients
11.2 to 14.2have
g/dLexperienced
painful events or other clinical
• Donors Hb A: S level were 0%,
complications port-BMT
0%, and 7% (donor chimerism 67%,
74%, and 11%)
• Donors sickle trait: S level 36%
and 37% (donor chimerism 25% and
60%)

Walters et al, BBMT (2001) 7: 665-673


Recovery of Splenic Function

3
months

• 3 patients 10, 11, and 14 years of age.


• Before BMT loss of splenic function.

12
• Assessed by the presence of Howell-Jolly bodies on
months blood films and (99mTc) splenic uptake.
• After BMT: Howell-Jolly bodies disappeared whereas
99mTc isotopic scan found normal isotope uptake.

Fester, Blood 1993


Multicenter Study: growth

Eggleston, Bri J Haem 2007; 136: 673-676


Belgium Cohort:
growth

Boys

Girls

Brachet, J Paed Haematol Onc 2007


Belgium Cohort: gonadal function

Girls

Boys
CB Graft Characteristics

• Much smaller in volume (50-200mL) and cellularity.


• Higher numbers and proliferative capacity of the progenitor cells (CFU-GM,
BFU-E, CFU-GEMM) (Broxmeyer, et al 1992, Mayani, et al 1998).
• Higher quantity and the quality of repopulating cells in SCID-NOD mice
transplant models (Wang, et al 1997).
• Lower numbers of CB cells can effectively restore a full haematopoietic
repertoire after transplant.
• Lower numbers of CD4+, CD8+ and CD3+ T-cells, with a higher CD4/CD8
ratio and a higher proportion of naïve CD45RA+ T-cells (producing lower
amounts of Th1-type cytokines) and NK-cells with higher cytotoxic activity.
• Together these immunological differences are likely to be responsible for
the lower rates of GVHD and preserved GVL responses (Gardiner, et al
1998, Harris, Nomura, et al 2001).
Eurocord Study: β thalassaemia
• Largest series, multicentre study: 33 patients with β -thalassaemia major
and 11 patients with SCD.
• The median age for the whole group was 5 years (range 1-20 years).
• Pesaro staging:
– Class I: 20/33
– Class II: 13/33
– Class III: 0/33
• Donor cells:
– All were transplanted with family donors: 32/33 were fully matched, one being A
locus mismatch.
– median number of TNC infused: 4.0 x 107/kg (range 1.2-13)
• Conditioning regimens:
– Bu/Cy: 26 patients (10 with added ATG)
– Added thiotepa: 16 patients
• GvHD prophylaxis: 12 methotrexate

Locatelli, Blood 2003


• Engraftment:
– 7/33 patients experienced graft failure including the patient who received the
class I mismatched CBT.
– TNC doses given to the patients who experienced graft failure varied from 1.2 to
10 x 107/kg (median 5.0).
– They were subsequently rescued with either re-injection of autologous back-up
marrow or BMT when the matched sibling donors could donate marrow cells.
– Neutrophil and platelet recovery kinetics occurred as standard.
– Persistent mixed chimerism: 3/33, but transfusion-independent.

• Transplant-related complications:
– OS: 100%
– EFS at 2 years:
• Pesaro class I: 89%
• Pesaro class II: 62%
– No cases of life-threatening infection
– GvHD:
• Acute: 11%
• Chronic: 6%
Locatelli, Blood 2003
Locatelli, Blood 2003
Zhongshan University Experience
• 9 Chinese patients with β -thalassaemia major who underwent sibling CBT.
• Median age at transplant: 5.5 years (range 3.5-10)
• Pesaro risk:
– Class 2: 6/9
– Pesaro 3: 3/9
• HLA matching:
– HLA identical: 6/9
– 1 Ag mismatch: 1/9
– 3 Ag mismatch: 2/9
• Conditioning regimen:
– BU (~14-20 mg/kg) / CY (~160-200 mg/kg) / melphalan (90 mg/m2) / ATG
– escalating doses were adopted with successive patients, due to early findings of graft failure
• GVHD prophylaxis:
– CSA and methylprednisolone: 6/9
– CSA and MTX: 3/9
• Cell dose: 6.6 x 107 TNC/Kg (range 3.4-12.7). Two patients supplemented with
neonatal blood (to increase cell dose by 20-30%).

Fang, Paed Haematol Onc 2004


• Results:
– OS: 8/9
– DFS: 4/9
– 2/9 primary graft failure with autologous reconstitution (both
mismatched siblings, and TNC of 5.3 and 5.9 x 107/kg)
– 2/9 patients with mixed chimerism rejected their grafts by day
60.
– One patient who had received a 3-antigen mismatched CB had
full donor engraftment but died of grade IV aGVHD day +30
– Three other patients had grade I-II aGVHD and one developed
skin/gut cGVHD.

Fang, Paed Haematol Onc 2004


Eurocord Study: SCD
• 11 patients with SCD:
– CNS disease (n=4)
– Acute chest syndrome and VOC (n=3)
– Acute chest syndrome and splenic sequestration (n=1)
– Multiple (>6) VOC with associated osteomyelitis (n=2)
– One transplanted early before development of major complications
• HLA matching:
– 9/11 full matching
– 2/11 were mismatched for HLA-A locus
• Conditioning regimen:
– Bu / Cy: 18 with (added ATG in 1 patient)
– Bu / Flu / TT: 1 patient
• GvHD prophylaxis: CSA alone (in most cases) or added MTX.

Locatelli, Blood 2003


• Outcome:
– All the patients survived (actuarial OS 100%)
– 2-year EFS: 90%
– One patient experienced graft failure with autologous
reconstitution, the only risk factor use of MTX
– 4 persistent mixed chimerism but disease-free
– Updated analysis (Rocha & Locatelli, 2007; personal
communication):
• 19 SCD patients
• 5-year EFS rate of 94% ± 6, median follow up of 32 months (2.1-
116.6 months)

Locatelli, Blood 2003


Unrelated CBT for SCD
• 7 children (aged 3.4 to 16.8 years) on chronic transfusions post-stroke
• Unrelated (1/2-antigen mismatches) CBT in four different centres in the US
• Conditioning regimen:
– 4/7: Bu (640 mg/m2 or 14 mg/Kg) / CY (200 mg/Kg or 120 mg/Kg) and ATG; one
also having Flu 90 mg/m2
– 3/7: reduced-intensity conditioning regimen with Flu (170 mg/m2), ATG, TLI (200
to 750cGy) and Bu (8 mg/Kg) or CY (200 mg/Kg).
– GvHD prophylaxis: CSA or tacrolimus with MP and/or MMF.
– TNC dose:1.5 to 9.3 x 107/kg and G-CSF until engraftment.

• Outcome:
– 4/7: primary graft failure with autologous reconstitution (1/4 following
myeloablative conditioning and 3/3 after RIC).
– Of the 3 patients with donor engraftment: 1 died of multiorgan failure and 2
remain alive and well, free of disease and transfusion-independent.
– 1/3 primary graft failure after RIC received a second unrelated CBT (TBI) and is
alive and well, free of disease.

Adamkiewicz, Paed Transplant 2007


Sibling Donor Cord Blood Program
• National CB bank for medically indicated banking of sibling CB in the US
• More than 1600 CB collections over a period of 6 years since 1998:
– Thalassaemia: 6%
– SCD: 28%
• 32/96 (33%) donor-recipient pairs with β -thalassaemia were HLA identical
and 14 of them (44%) received a CBT
– Eleven survived free of disease with a median follow up of 12.4 months.
– Fewer than 1 in 6 have so far been used, mainly because of HLA-incompatibility.
• Experience similar for SCD, although the number of cords banked is much
greater and the usage even lower:
– 163 CB units collected and stored
– 4 (2%) used. Median age at the time of transplant was 8.3 years (range 2 to 13.6
years) and median cell dose 4.4 x 107 TNC/kg (range 1.67 to 9.15).
– All 4 patients engrafted and 3/4 survived, all disease-free, median follow-up of
22.3 months (range 5.2 to 25.4 months).
– 2005 report: total number of CB banked from SCD families had risen to more
than 450 but the number used for CBT (8) remained low (2%).
Walters, Blood 2005
Directed Sibling CB in the NBS
• 10 year experience
• Based at NBS Oxford
• 44 units collected from newborn siblings from families
with major haemoglobinopathies:
– Thalassaemia: 36
– SCD: 8
• Usage:
– Thalassaemia: 7 (20%).
• All patients alive and well
• One secondary graft rejection but engrafted after BMT from the
same donor and is alive well more than 10 years post-BMT
– SCD: 0/8

Smyth, Stem Cells 2007


CB and BM

A B C

Age (years) 4 15 13

Donor with β -thal trait No Yes Yes

Major ABO Yes Yes No


incompatibility
CD34+/kg 0.6 x 105 1.7 x 105 0.5 x 105

Number of BM TNC/kg 0.7 x 108 1.6 x 108 1.7 x 108

Goussetis, Pediat Hemat Onc 2000


Unrelated allografts for β thalassaemia

•Pesaro class I: 4
•Pesaro class II: 11
•Pesaro class III: 17

Grade II-IV aGvHD: 11 (41%)


cGvHD: 6 (25%)

HLA-A, B, C, DRB1, DRB3, DRB4,DRB5, DQA1, and DQB1 loci

BU14-TT10-CY120
La Nasa, Blood 2002
RIC for Sickle Cell Disease

• Less risk of morbidity and mortality from conditioning-related toxicity:


– Infertility
– Neurodevelopmental effects
– Impaired growth
– Endocrine dysfunction
– Secondary malignancy

• Problems: Iannone BBMT 2003:


– Intact immune function Flu/ATG/200 cGy TBI BMT/PBSCT
– Expanded haemopoietic compartment n=7
– Red cell alloimmunisation
– GvHD completely undesirable complication
RIC for Sickle Cell Disease

n=2

TBI 200 cGy / Flu / Cy Horwitz, BBMT 2007


RIC for β Thalassaemia

Honghen, Am J Hem 2007


Stem Cell Transplantation for
Haemoglobinopathies

• Feasible with low mortality and long-term permanent cure with


functional improvement.
• Growth is preserved or improved in most patients.
• Main long-term effect to be resolved is infertility.
• Unavailable for the majority of the affected children as modality
which offers results consistent with modern medical treatment is
related bone marrow transplantation.
Stem Cell Transplantation for
Haemoglobinopathies

• Outcome of related CBT is increasingly approaching the results for


BM.
• Main complication CBT is graft rejection, which may be reduced by
increasing pre-transplant immune suppression and modifying
existing GvHD prophylaxis.
• Combination CB and BM is extremely useful when there is a large
weight and size difference between donor and patient.
• Unrelated donor BMT and CBT, and RIC allografts have resulted in
successful outcomes in a very small number of patients, albeit with
a higher mortality and morbidity than conventional transplantation.
Dr. Josu de la Fuente
Professor Irene Roberts
Dr. Helen New
Dr. Ayad Atra
Ms. Nancy O’Brien
Mrs. Mary Conboy
Miss Ana Cabrera
Mr. Kirtash Patel
Miss Farah O’Boyle

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