Donor Lymphocyte Infusions in the Pediatric Population

1
Donor Lymphocyte Infusionsin the Pediatric
Population

• Sharon McDonald, MD
• Pediatric Hematology/Oncology Fellow
• Grand Rounds
• April 11, 2008

2
What is a donor lymphocyte infusion?

• First described by Kolb in 1990 for recurrent CML
  after transplant transfusion of viable buffy
  coat cells from the marrow donor
• Given to 3 patients without additional
  chemotherapy or radiotherapy.
• Patient 1 22 yr, HLA identical brother, no GVHD,
  recurred after 3 years in chronic phase. Received
  4 DLIs (4.4x108 nucl cells/kg), developed GVHD
  that responded to immunosuppression, Ph chr
  cleared from the marrow
• Patient 2 39 yr, HLA identical brother, no GVHD,
  recurred after 3 years in chronic phase. Received
  4 DLIs (7.4x108 nucl cells/kg), developed GVHD
  that responded to immunosuppression, Ph chr
  cleared from the marrow
• Patient 3 30 yr, brother, no GVHD, recurred
  after 2 years in chronic phase. Received 5 DLIs
  (5.1x108 nucl cells/kg), did not develop GVHD, Ph
  chr cleared from the marrow.
• Clear evidence of a graft-versus-leukemia effect
• So you may ask

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What is graft-versus-leukemia effect?

• First suggested based on murine study in 1956 by
  Barnes and Loutit described an antitumor effect
  that was not explained by chemotherapy or
  radiation treatment alone.
• Mediated by donor T cells and NK cells
• Initially seemed to be associated with GVHD
• Also, patients with GVHD had a lower risk of
  relapse.
• Increased in donor-host chimerism indicated a
  graft vs hematopoietic host response as basis for
  GVL (supported by studies showing stronger GVL
  effect with DLI when mixed rather than complete
  donor chimer)

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Graft-versus-leukemia effect
Porter DL, Antin JH. Best Pract Research Clin
Hem 2006 19(4)737-755.
5
Risk of Relapse

• Horowitz in 1990 retrospective study of gt2200
  patients with ALL/AML/CML and risk of relapse
• Showed an antileukemic effect both with GVHD and
  independent of GVHD

6
Risk of Relapse
Horowitz MM, Gale RP, et al. Blood Feb 1990
75(3)555-562
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So how does DLI work?

• GVL effector mechanisms
• T cells, NK cells effector cells
• Target antigens major histocompatibility complex
  antigens (MHC), minor histocompatibility complex
  antigens (miHC), and tumor associated antigens
  (TAA)
• miHC polymorphic regions of cellular proteins
  that are presented with MHC complex to T cells

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Effector Mechanisms

• Bonnet in 1999
• CD8 minor H antigen-specific CTL clones isolated
  from recipients of MHC matched allo-HSCT
• DRN-7 and DRN-11 specific for distinct minor H
  antigens presented in association with Class I
  HLA A3 and B7 - respectively
• AML cells from 5 refractory/relapsed patients
  were isolated and tested one (10885) lysed in
  the presence of DRN-7 but not DRN-11 (indicating
  presence of minor HLA A3)
• Cells from 10885 were transplanted into nonobese
  diabetic/severe combined immune deficient
  (NOD/SCID mice) (alone or incubated with DRN-7 or
  DRN-11)
• Bone marrow from mice assessed for engraftment
  of AML cells
  at 30 and 60 days
• 10885 cells alone/with DRN-11 27-36 engraftment
• 10885 cells with DRN-7 lt3 engraftment

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Minor histocompatibility antigens
Bleakley M, Riddell S. Nat Rev Cancer May 2004
4371-380.
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Non-HLA immunogenetics

• Other genes with polymorphisms
• Cytokine and cytokine receptors TNF-alpha,
  TNFRII, IL-1, IL-Ra, IL-6, IL-10
• Vitamin D receptor, estrogen receptor

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Tumor-associated antigens

• Antigens aberrantly expresed by tumor cells
• Can elicit specific antitumor immune response
• Can result from
• Mutation (ex BCR-ABL mutation in CML)
• Overexpression (ex Proteinase 3,
  myeloperoxidase)
• Tissue-specific expression (ex PSA in prostate
  CA, melanoma-associated antigen in testicular CA,
  Wilms tumor antigen, survivin inhibitor of
  apoptosis seen in some tumors)

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NK cells role

• Ruggeri 2002 looked at patients with AML
• Transplantation with NK alloreactive donors
  enhanced engraftment
• Rejection rate 9 without NK alloreactivity and
  2 with it
• Protected from GVHD (10 vs 3)
• Probability of relapse 79 in non-NK
  alloreactivity and 17 with it

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Where does DLI work?

• CML where initially studied
• Two large retrospective analyses (Kolb in 1995
  and Collins in 1997)
• 76-79 complete cytogenetic remission in chronic
  phase
• Only 12-28 remission in accelerated phase or
  blast crisis

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CML

• Guglielmi 2002 298 pts with CML
• 3 groups based on dose 0.1 vs 1 vs 3.5x108/kg
• Overall GVHD in 46 of patients,
  myelosuppression in 19
• Lowest dose best survival
• Dose gt0.2x108/kg with significant
  morbidity/mortality
• North American Registry long term f/u in 1999
• EFS at 1 year 79, at 2 and 3 years 73
• Relapse seen in 2 of to 32 patients followed

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Acute Leukemia

• AML relapse after transplant associated with
  poor prognosis
• Reinduction chemo remission in 30-40 but not
  durable
• DLI 15-29 remission but also not durable
• DLI with chemo 42-63 remission (40 relapse
  rate)
• Choi et al in 2004 looked at relapsed AML s/p BMT
• DLI (median dose 4.5x108/kg) then chemotherapy
  (cytarabine 1g/m2/d, idarubicin 12mg/m2/d,
  etoposide 150mg/m2/d)
• Showed CR of 63 and 2 yr OS 31
• High incidence of GVHD (did not use post-DLI GVHD
  prophylaxis)
• Problem high rate of extramedullary relapse
  without bone marrow involvement

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Acute Leukemia (AML)
Post-transplant remission gt6 months before
relapse had significantly better survival.
Choi SJ, Lee JH, et al. Leuk 2004 181789-97.
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Acute Leukemia (ALL)

• Collins in 1997 11 patients with 18.52 CR with
  no concomitant chemo given
• Shiobara in 2000 CR achieved with DLI in 25 (6
  of 23), but no pts were in CR at 3 yrs

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MDS

• Relapse after allo-BMT major cause of treatment
  failure and responsible for 50 of deaths
• Second BMT minimally effective
• DLI 14-40 response
• Shiobara in 2000 11 patients 5 with CR, with
  33 durable CR at 3 years.
• Levine in 2002 7 patients DLI chemo. Only 2
  in CR at 6 mos.
• Depil reported in 2004 on 14 patients with
  relapsed MDS after transplant who got DLI (wide
  range of doses 1-29x108) median f/u 49mo with
  6 alive with two in CR. 7 developed DLI-induced
  GVHD.
• Campregher in 2007 reported on 16 patients 3 pts
  with CR with only 2 disease free gt5 yrs.

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Overall survival
Collins RH, Shpilberg O, Drobyski WR, et al. J
Clin Onc Feb 1997 15(2)433-444
Shiobara S, et al. BMT 2000 26769-774.
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How is DLI dosed?

• Dosing not standardized

Choi SJ, Lee JH, et al. Leuk 2004 181789-97.
21
DLI dosing
Shiobara S, et al. BMT 2000 26769-774.
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What are the toxicities of DLI?

• Acute/Chronic GVHD
• Reported in 60 of patients
• Marrow aplasia
• Seen in 18-50 of patients (sustained in only
  2-5)
• Increased if host hematopoietic progenitors are
  still hanging around (chimerism)

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How to get GVL effect with minimal or no GVHD?

• Delayed DLI
• Serial or dose-escalating DLI
• DLI of selected effector cell populations

24
Delayed DLI

• Billiau in 2002 looking at transplanted mice
• DLI in the first week induced GVHD
• Thought secondary to over-stimulation of donor T
  cells by the post-conditioning cytokine storm
• DLI at week 3 no GVHD, but GVL effect
• DLI at week 12 neither GVHD or GVL seen

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Serial / Dose-escalating DLI

• Serial infusions with increasing dose induces GVL
  at lower doses without GVHD
• Relapsed CML 2 year incidence of GVHD lower with
  dose escalating DLI vs single dose DLI with
  similar cytogenetic remission rates
• Other studies show similar results with lower
  incidence of GVHD and same remission rate

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DLI of selected effector cells

• T cell subsets
• Direct role of CD4 and CD8 cells with some
  positive results with CD8 T cell depleted DLI
  showing reduced GVHD with same GVL effects
• Alloreactive donor T cell depletion
• Selective depletion of allreactive T cells seems
  to stop alloreactivity while keeping anti-viral
  and anti-tumor effects intact
• Specific CTL
• In vitro studies of CTLs specific for tumor
  antigens or miHC antigens
• Clinical data very limited
• Interesting Marjit et al 3 allo-HSCT patients
  with relapsed HA-1 or HA-2 positive malignancies
  treated with DLI from HA-1 or HA-2 negative
  donors. All 3 in CR with detectable levels of
  HA-1 and HA-2 specific CD8 cells.
• Suicide-gene-transfected donor T cells
• Herpes simplex virus thymidine kinase gene
  transfused donor T cells
• DLI irradiation
• Phase I trial with multiple infusions of
  irradiatied allo-lymphocytes (no follow-up data
  as of yet)

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References

• Barnes DWH, Loutit JF. Treatment of murine
  leukaemia with x-rays and homologous bone marrow.
  Br Med J Sept 1956 2626.
• Billiau AD, Fevery S, Rutgeerts O, et al. Crucial
  role of timing of donor lymphocyte infusion in
  generating dissociated graft-versus-host and
  graft-versus-leukemia responses in mice receiving
  allogeneic bone marrow transplants. Blood Sept
  2002 100(5)1894-1902.
• Bleakley M, Riddell S. Molecules and mechanisms
  of the graft versus leukemia effect. Nat Rev
  Cancer May 2004 4371-380.
• Bonnet D, Warren EH, Greenberg PD, et al. CD8
  minor histocompatibility antigen-specific
  cytotoxic T lymphocyte clones eliminate human
  acute myeloid leukemia stem cells. Proc Natl Acad
  Sci USA 1999 96(15)8639-8644.
• Campregher PV, Gooley T, et al. Results of donor
  lymphocyte infusions for relapsed myelodysplastic
  syndrome after hematopoietic cell
  transplantation. Bone Marrow Transplantation
  2007 40965-971.
• Choi SJ, Lee JH, et al. Treatment of relapsed
  acute myeloid leukemia after allogeneic bone
  marrow transplantation with chemotherapy followed
  by G-CSF-primed donor leukocyte infusion a high
  incidence of isolated extramedullary relapse.
  Leuk 2004 181789-97.
• Collins RH, Shpilberg O, Drobyski WR, et al.
  Donor leukocyte infusions in 140 patients with
  relapsed malignancy after allogeneic bone marrow
  transplantation. J Clin Onc Feb 1997
  15(2)433-444.
• Depil S, Deconinck E, Milpied N. Donor lymphocyte
  infusion to treat relapse after allogeneic bone
  marrow transplantation for myelodysplastic
  syndrome. Bone Marrow Transplantation 2004
  33531-4.
• Guglielmi C, Arcese W, Dazzi F, et al. Donor
  lymphocyte infusion for relapsed chronic
  myelogenous leukemia prognostic relevance of the
  initial cell dose. Blood 2002 100397-405.
• Horowitz MM, Gale RP, et al. Graft-versus-leukemia
  reactions after bone marrow transplantation.
  Blood Feb 1990 75(3)555-562.
• Kolb H, Mittermuller J, et al. Donor leukocyte
  transfusions for treatment of recurrent chronic
  myelogenous leukemia in marrow transplant
  patients. Blood 1990 762462-2465.
• Kolb HJ, Schattenberg A, et al.
  Graft-versus-leukemia effect of donor lymphocyte
  infusions in marrow grafted patients. Blood Sept
  1995 86(5)2041-50.
• Levine JE, Braun T, et al. Prospective trial of
  chemotherapy and donor leukocyte infusions for
  relapse of advanced myeloid malignancies after
  allogeneic stem cell transplantation. J Clin Onc
  Jan 2002 20(2)405-412.
• Loren AW, Porter DL. Donor leukocyte infusions
  after unrelated donor hematopoietic stem cell
  transplantation. Curr Op Onc 2006 18107-114.
• Munker R, Schmid C, et al. An update on
  graft-versus-host and graft-versus-leukemia
  reactions a summary of the sixth International
  Symposium held in Schloss Ellmau, German, January
  22-24, 2004. 2004 34767-780.
• Or R, Hadar E, et al. Safety and efficacy of
  donor lymphocyte infuions following mismatched
  stem cell transplantation. Bio Blood Marrow
  Transplantation 2006 121295-1301.
• Porter DL, Antin JH. Donor leukocyte infusions in
  myeloid malignancies new strategies. Best Pract
  Research Clin Hem 2006 19(4)737-755.
• Porter D, Collins R, Hard C, et al. Treatment of
  relapsed leukemia after unrelated donor marrow
  transplantation with unrelated donor leukocyte
  infusions. Blood 2000 951214-1221.
• Porter D, Collins R, Shpilberg O et al. Long-term
  follow-up of patients who achieved complete
  remission after donor leukocyte infusions.
  Biology of Blood and Marrow Transplantation J Am
  Society for Blood and Marrow Transplantation
  1999 5 253-261.

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