Introduction:

Haploidentical (HI) HSCT offers a curative option to patients (pts) who lack an HLA matched donor. In the 2-step approach, pts receive a relatively large, fixed T-cell dose (2 x 108/kg) followed 2 days later by cyclophosphamide (CY). CY eradicates only the alloreactive T-cells, thus inducing bidirectional tolerance. CD34-selected stem cells are then infused and are not exposed to CY. Unlike T-cell depleted approaches, the 2 step regimen allows for rapid immune recovery and lower infectious complications. Coupled with acceptable GVHD rates, this approach has been associated with low non-relapse mortality. Given the consistent T-cell dose utilized in all pts, we investigated the effects of the variable CD34 stem cells on clinical outcomes and immune recovery.

Methods:

We retrospectively analyzed data from 148 pts who underwent a 2-step approach to haploidentical peripheral blood HSCT at Thomas Jefferson University between February 2006 and February 2014. The myeloablative (MA) conditioning regimen consisted of 12 Gy of TBI administered over 4 days, while the reduced intensity conditioning (RIC) regimen consisted of fludarabine (30 mg/m2 D1-4) + cytarabine (2 gm/m2 D1-4)/or thiotepa (5 mg/kg D1-3) and a fraction of 2 Gy TBI (D6). Conditioning was followed by an infusion of 2 x 108 CD3+ cells/kg donor T cells (step 1). CY 60 mg/kg/d x 2 was given starting 2-3 days after the T cell infusion. A CD34 selected product was then infused (step 2). Tacrolimus and MMF were utilized for immune suppression. In a prior multivariate analysis in patients older than 60, we identified CD34 dose as affecting survival. Using recursive partitioning, a dose of 5.2 x106 was identified as the cutoff point demarcating differences in survival. This analysis compares differences in outcome in all patients who underwent the 2-step haploidentical HSCT regardless of age, using a cutoff CD34 dose of 5.2x106 to demarcate both groups.

Results:

Eighty-five pts received a CD34 dose < 5.2 x 106(low dose- LD) and 61 received a dose > 5.2 x 108 (high dose- HD). Pts characteristics are shown in the table. Median follow up was 19 months. HD group had a faster platelet recovery (p=0.007) and more rapid CD3/4 and CD3/8 recovery by day 30 (p=0.001). The incidence of grades II-IV GVHD was not statistically different between both groups (p= 0.76). Probability of overall survival (OS) at 5 years was 50% and 62% in the LD and HD groups, respectively (log-rank= 0.14) with relapsed disease being the major cause of death in both groups. OS was significantly better in the HD in a subset of patients above the age of 60 (n=57, log-rank= 0.032). The 5-year cumulative incidence of relapse related mortality and non-relapse related mortality were not statistically significant between both groups; RRM: LD= 27%, HD= 20% (p=0.45); NRM: LD= 24%, HD=17% (p=0.32).

Conclusion:

Based on a platform of identical T cell dosing, the higher CD34 stem cell dose group had more rapid platelet engraftment, earlier immune recovery and better overall survival in a subset of patients above the age of 60. There were no differences in GVHD rates between both groups, which favors the use of a higher CD34 stem cell dose in this approach.

Table
Lower Dose
(<5.2 x 106)
Higher Dose
(>5.2 x 106)
Number 85 61 
Age (range) 58 (19-74) 52 (19-78) 
Sex (M/F) 49/36 36/25 
Median CD3/4 day 30 (cells/ uL) 34 71 
Median CD3/8 day 30 (cells/ uL) 30 57 
Median CD34 cells
[x 106/kg] (range) 
3.52 (1.4-5.18) 7.31 (5.3-10.6) 
Disease status at time of HSCT  
Remission (%) 38 (45) 24 (39) 
Active disease (%) 47 (55) 37 (61) 
Disease  
Myeloid Malignancy (%) 58 (68) 31 (51) 
ALL (%) 11 (13) 11 (18) 
NHL (%) 11 (13) 13 (21) 
Others (%) 5 (6) 6 (10) 
Conditioning   
MA (%) 52 (61) 34 (56) 
RIC (%) 33 (39) 27 (44) 
Outcomes:  
Median ANC recovery [days] 12 11 
Median Platelet recovery [days] 19 17 
aGVHD II-IV (%) 33 (39) 26 (43) 
aGVHD III-IV (%) 8 (9.4) 4 (6.5) 
cGVHD (%) 14 (16) 2 (3) 
Relapse (%) 25 (29.4) 14 (23) 
Deaths (%) 41 (48) 20 (33) 
Relapse 21 10 
Infection 
Toxicity 10 
GVHD 
CMV Reactivation 41 (48) 25 (41) 
Lower Dose
(<5.2 x 106)
Higher Dose
(>5.2 x 106)
Number 85 61 
Age (range) 58 (19-74) 52 (19-78) 
Sex (M/F) 49/36 36/25 
Median CD3/4 day 30 (cells/ uL) 34 71 
Median CD3/8 day 30 (cells/ uL) 30 57 
Median CD34 cells
[x 106/kg] (range) 
3.52 (1.4-5.18) 7.31 (5.3-10.6) 
Disease status at time of HSCT  
Remission (%) 38 (45) 24 (39) 
Active disease (%) 47 (55) 37 (61) 
Disease  
Myeloid Malignancy (%) 58 (68) 31 (51) 
ALL (%) 11 (13) 11 (18) 
NHL (%) 11 (13) 13 (21) 
Others (%) 5 (6) 6 (10) 
Conditioning   
MA (%) 52 (61) 34 (56) 
RIC (%) 33 (39) 27 (44) 
Outcomes:  
Median ANC recovery [days] 12 11 
Median Platelet recovery [days] 19 17 
aGVHD II-IV (%) 33 (39) 26 (43) 
aGVHD III-IV (%) 8 (9.4) 4 (6.5) 
cGVHD (%) 14 (16) 2 (3) 
Relapse (%) 25 (29.4) 14 (23) 
Deaths (%) 41 (48) 20 (33) 
Relapse 21 10 
Infection 
Toxicity 10 
GVHD 
CMV Reactivation 41 (48) 25 (41) 

Disclosures

No relevant conflicts of interest to declare.

Author notes

*

Asterisk with author names denotes non-ASH members.

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