http://www.bloodjournal.org/cgi/content/abstract/2005-09-3827v1?etoc

 "Comparable Results of Umbilical Cord Blood and HLA Matched Sibling Donor Hematopoietic Stem Cell Transplant after Reduced-Intensity Preparative Regimen for Advanced Hodgkin's Lymphoma".

Navneet S. Majhail, Daniel J. Weisdorf, John E. Wagner, Todd E. Defor, Claudio G. Brunstein, and Linda J. Burns*

Blood and Marrow Transplant Program, Divisions of Medical and Pediatric Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, 55455, USA

* Corresponding author;
Linda J. Burns, MD, Associate Professor, Division of Hematology, Oncology and Transplantation,
University of Minnesota, Mayo Mail Code 286, 420 Delaware St SE, Minneapolis, MN 55455, USA,
Phone: +1-612-624-8144; Fax: +1-612-625-9988; email: burns019@umn.edu

UCB – unrelated umbilical cord blood donor; MSD – peripheral blood HLA-matched sibling donor; alloSCT –
allogeneic stem-cell transplant; ASCT – autologous stem cell transplant; Bu – busulfan; Flu – fludarabine; Cy –
cyclophosphamide; TBI – total body irradiation; HLA – human leukocyte antigen; NC – nucleated cells; GVHD
graft-versus-host-disease; CR – complete remission; CI – confidence intervals

We compared the safety and efficacy of allogeneic stem-cell transplantation (alloSCT) after reduced-intensity conditioning using either unrelated umbilical-cord blood (UCB) or matched-sibling donors (MSD) in 21 high-risk adults with advanced Hodgkin's lymphoma (UCB-9, MSD-12). Both groups were comparable except for younger age in UCB cohort (median 28 vs. 42 years, p=0.02). Neutrophil recovery occurred earlier in MSD group (median 7 vs. 10 days, p=0.02). All patients had sustained donor-engraftment by day +60. Cumulative incidence of acute severe graft-versus-host-disease (33% vs. 33%, p=0.99), chronic graft-versus-host-disease (11% vs. 33%, p=0.24) and 100-day treatment-related mortality (11% vs. 17%, p=0.80) were comparable. With a median followup of 17 and 24 months, the 2-year progression-free survival is 25% (95% CI, 0-55%) for UCB vs. 20% (95% CI, 0-44%) for MSD alloSCT (p=0.67). Our results suggest comparable outcomes for reduced-intensity alloSCT using UCB or MSD source in high-risk adults with advanced Hodgkin's lymphoma.

Patients with relapsed or primary-refractory Hodgkin’s lymphoma have very poor
outcomes with conventional salvage chemotherapy regimens. High-dose chemotherapy followed
by autologous stem-cell transplantation (ASCT) leads to prolonged progression-free survival in
nearly half of these high-risk patients [1-3]. Although a clinical graft-versus-lymphoma effect has
been reported in Hodgkin’s lymphoma, results of allogeneic stem-cell transplantation (alloSCT)
with myeloablative conditioning have been disappointing due to the high treatment related
mortality (TRM) observed in this typically heavily pre-treated group of patients [4-6]. AlloSCT
using non-myeloablative or reduced-intensity conditioning (RIC) regimens has been shown to be
feasible, lead to long-term engraftment, exhibit a graft-versus-malignancy effect, and result in
significantly lower TRM in a variety of hematologic and non-hematologic malignancies [7-8].

For patients who lack a human-leukocyte antigen (HLA) matched sibling donor (MSD),
unrelated umbilical cord blood (UCB) offers certain advantages over unrelated donor bone
marrow. Besides being more rapidly available, UCB has the potential benefit of a lower risk of
severe acute graft-versus-host disease (GVHD) despite higher donor-recipient HLA disparity [9-11].
We have previously reported that UCB alloSCT after RIC conditioning produces high rates of
engraftment with tolerable toxicity and acceptable incidence of acute GVHD [12].

We report a pilot study comparing the safety and efficacy of alloSCT after RIC regimen
using either UCB or peripheral blood MSD in adults with advanced Hodgkin’s lymphoma who
were not eligible for myeloablative conditioning.

MATERIALS & METHODS

Patient Characteristics

Data was collected prospectively on 21 consecutive patients with advanced Hodgkin’s
lymphoma (UCB – 9, MSD – 12) who underwent alloSCT after RIC conditioning between July
2000 and May 2005. Patients were considered for UCB alloSCT if they had no HLA-compatible
related donors (5/6 or 6/6 HLA-A, B or DRB1 matches).

Indications for using RIC rather than conventional myeloablative preparative regimen
were (1) age >55 years with MSD (n=4) or age >45 years with UCB donor (n=1), (2) extensive
prior therapy (previous ASCT (n=14), or >12 months of alkylator chemotherapy (n=16)), and/or
(3) poor performance status including major co-morbidity (n=6); 14 patients had two or more of
these high-risk features.

Patient, disease and transplant characteristics were comparable except for younger age
and shorter duration of first complete remission in the UCB group (Table-1). One patient was in
complete remission and all patients had chemosensitive disease prior to alloSCT.

Treatment plan

Until September 2001, patients (n=8) underwent conditioning with a Bu/Flu/TBI
regimen that included busulfan (Bu) 2 mg/kg orally every 12 hours for 4 doses (days –8, –7),
fludarabine (Flu) 40 mg/m² intravenously daily (days –6 through –2) and 200 cGy total body
irradiation (TBI) (day –1). Subsequently, all patients received a Cy/Flu/TBI regimen where
cyclophosphamide (Cy) 50 mg/kg intravenously (day –6) was substituted for busulfan. All
patients received GVHD prophylaxis with cyclosporine-A (day –3 to +180) and mycophenolate
mofetil (day –3 to +30). The treatment protocol was approved by the University of Minnesota
institutional review board and all patients gave written informed consent prior to transplantation.

UCB grafts

UCB grafts had at least 4 of 6 HLA-A, B, DRB1 antigens that were matched to the
recipient, and if two donor units were infused, to each other as well. Each unit had a
cryopreserved cell dose of at least 1.5 ×10⁷ nucleated-cells per kilogram of recipient body weight
(NC/kg). Seven (78%) patients received grafts consisting of two UCB units to optimize cell dose.
All patients undergoing UCB alloSCT received one to two HLA-antigen mismatched grafts.
Both patients with a single UCB unit received 4/6 HLA-antigen matched grafts. Five patients
with double UCB transplants received at least one 6/6 (n=1) or 5/6 (n=4) HLA-matched unit
while two patients received a graft with both units 4/6 HLA-antigen matched to the recipient.
The median infused cell dose was 3.8 × 10⁷ NC/kg.

Donor chimerism analysis

Donor chimerism was performed on days +21-28, +60, +100, +180, +360 and then
annually using quantitative polymerase chain reaction of informative polymorphic variable-number
tandem repeat or short tandem repeat regions.

Statistical analyses

Sustained donor engraftment was defined as sustained neutrophil recovery and donor
hematopoiesis beyond day +42 after alloSCT. Time of neutrophil engraftment was first of three
consecutive days with absolute neutrophil count >0.5 ×10⁹ /L. Complete donor chimerism was
defined as bone marrow reconstitution of >90% donor. The Kaplan-Meier method was used to
calculate survival curves for progression-free survival (PFS) and overall survival (OS) [13].
Cumulative incidence calculations were performed for TRM, engraftment, GVHD, and relapse.
Event times were measured from date of transplantation to date of death or last contact.
Comparison of patient and transplant characteristics was performed using chi-square, Fisher’s
exact or Wilcoxon’s rank sum test as appropriate. The analysis was performed as of August
2005.

RESULTS & DISCUSSION

Neutrophil engraftment (Table-1) was observed to occur sooner in the MSD compared to
UCB cohort (median 7 vs. 10 days, p=0.02). The cumulative incidence of sustained donor
engraftment was 100% for both donor groups; there were no graft failures. Complete donor
chimerism was seen in all patients by day +60.

TABLE 1: Patient, Disease and Transplant Characteristics and Post-transplant Outcomes.

UCB – unrelated umbilical cord blood donor; MSD – peripheral blood HLA-matched sibling donor; alloSCT –
allogeneic stem-cell transplant; ASCT – autologous stem cell transplant; Bu – busulfan; Flu – fludarabine; Cy –
cyclophosphamide; TBI – total body irradiation; HLA – human leukocyte antigen; NC – nucleated cells; GVHD
graft-versus-host-disease; CR – complete remission; CI – confidence intervals

¹ Excludes two patients each from UCB and MSD groups with primary refractory disease

The cumulative incidence of severe acute (grade III/IV) GVHD was 33% (95%
confidence-interval (CI), 2–64%) for UCB and 33% (95% CI, 6–60%) for MSD groups (p=0.99).
The cumulative incidence of chronic GVHD at 1-year is 11% (95% CI, 0–31%) for UCB and
33% (95% CI, 7–59%) for MSD cohorts (p=0.24).

The 2-year PFS was 25% (95% CI, 0–55%) in patients receiving UCB compared to 20%
(95% CI, 0–44%) in those receiving MSD (Table-1, Figure-1).

FIGURE 1: Progression-free and overall survival for unrelated umbilical cord blood (UCB) and matched
sibling donor (MSD) allogeneic stem cell transplantation using reduced-intensity conditioning.

For the entire cohort, alloSCT for primary-refractory disease and short duration of
complete remission (CR) following ASCT were associated with poor PFS. The 2-year PFS for
patients transplanted for primary-refractory and relapsed disease was 0% and 29% (95% CI, 5-
53%) (p<0.01); patients with </=12 months of CR following ASCT had 2-year PFS of 0%
compared to 67% (95% CI, 30-100%) for those with CR duration of >12 months (p=0.04).

These results indicate comparable outcomes with RIC alloSCT for advanced Hodgkin’s
lymphoma using either UCB or MSD as a donor source. Patients with advanced Hodgkin’s
lymphoma typically receive extensive chemotherapy including ASCT prior to consideration for
alloSCT, thereby making them poor candidates for myeloablative conditioning. The lower
regimen-related toxicity of RIC preparative regimens extends the opportunity for alloSCT and its
graft-versus-lymphoma effect to this group of patients. Since many patients lack a matched
related or unrelated donor, UCB grafts, despite the limitations of low cell dose and lack of donor
availability for DLI, can serve to expand the donor pool and provide an effective and safe
alternative.

In this high-risk and heavily pretreated patient group, five patients had durable and
prolonged PFS (median follow-up 30 months (range, 9–53 months)). This observation along with
the responses following donor-lymphocyte infusion further suggests the presence of a graft-versus-
lymphoma effect in advanced Hodgkin’s lymphoma. More studies are needed to identify
patients who would benefit most from this treatment approach.

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Hodgkin Lymphoma (Hodgkin's Disease) is a lethal neoplasm of young adults (1), which can be cured by combining surgery, radiotherapy and chemotherapy. Some cured patients will later die of their therapy, with radiation-induced fibrosis, chemotherapy-induced leukemia, and/or therapy-induced second neoplasms, but now new therapies against the lymphoma are being tested, and are found to be effective, utilizing activated T-cell lymphocytes, umbilical cord blood stem cells, or peripheral blood stem cells, during transplantation. Additional approaches, utilizing microRNA sequences (2), whole bone marrow RNA (3), or antisense RNA (4) are under investigation for treating human neoplasms.

1. Frenster JH, "Hodgkin Lymphoma Immuno-Pathology":

2. Eder M, and Scherr M, "MicroRNA and Lung Cancer".

3. DeCarvalho S, "Effect of RNA from Normal Human Marrow on Leukaemic Marrow In-Vivo".

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5. Janz M, Hummel M, Truss M, Wollert-Wulf B, Mathas S, Johrens K, Hagemeier C, Bommert K, Stein H, Dorken B, and Bargou RC, "Classical Hodgkin lymphoma is characterized by high constitutive expression of activating transcription factor 3 (ATF3) which promotes viability of Hodgkin/Reed-Sternberg cells".

1. Janz M, Hummel M, Truss M, Wollert-Wulf B, Mathas S, Johrens K, Hagemeier C, Bommert K, Stein H, Dorken B, and Bargou RC, "Classical Hodgkin lymphoma is characterized by high constitutive expression of activating transcription factor 3 (ATF3) which promotes viability of Hodgkin/Reed-Sternberg cells".

2. Bollard CM, Aguilar L, Straathof KC, Gahn B, Huls MH, Rousseau A, Sixbey J, Gresik MV, Carrum G, Hudson M, Dilloo D, Gee A, Brenner MK, Rooney CM, and Heslop HE, "Cytotoxic T Lymphocyte Therapy for Epstein-Barr Virus⁺ Hodgkin's Disease",  J. Exp. Med. 2004 200: 1623-1633.

3. Coughlin CM, Vance BA, Grupp SA, and Vonderheide RH, "RNA-transfected CD40-activated B cells induce functional T-cell responses against viral and tumor antigen targets: implications for pediatric immunotherapy", Blood First Edition Paper, prepublished online November 20, 2003;
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4. Faulkner RD, Craddock C, Byrne JL, Mahendra P, Haynes AP, Prentice HG, Potter M, Pagliuca A, Ho A, Devereux S, McQuaker G, Mufti G, Yin JL, and Russell NH, "BEAM-Campath reduced intensity allogeneic stem cell transplantation for lymphoproliferative disease: GVHD, toxicity and survival in 65 patients". Blood First Edition Paper, prepublished online September 11, 2003; DOI 10.1182/blood-2003-05-1406.

5. Carella AM, "Stem Cell Transplantation for Hodgkin's Disease: A Review of the Literature", Clinical Lymphoma, vol. 2, no. 4, pp. 212-221 (March, 2002).

6. Frenster JH, "Uni-Polar Clustering of Lymphocyte DNA Templates Toward Neoplastic Target Cells within Hodgkin's Disease Lymph Nodes", Proc. Am. Assoc. Cancer Res. vol. 43, p. 1134 (March, 2002).

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