Latest results of sibling HSCT in acquired AA. Jakob R Passweg

Transcription

1 Latest results of sibling HSCT in acquired AA Jakob R Passweg

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3 Impact on Outcome: Patient Age, Disease Severity Title: Optimization of Therapy for Severe Aplastic Anemia Based on Clinical, Biological and Treatment Response Parameters: Conclusions of an International Working Group on Severe Aplastic Anemia Michael A. Pulsipher, Neal S. Young, Jakub Tolar, Antonio M. Risitano, H.Joachim Deeg, Paolo Anderlini, Rodrigo Calado, Seiji Kojima, Mary Eapen, Richard Harris, Phillip Scheinberg, Sharon Savage, Jaroslaw P. Maciejewski, Ramon V. Tiu, Nancy DiFronzo, Mary M. Horowitz, Joseph H. Antin

4 EBMT Activity Survey on HSCT : changes in Non Malignant Disorders H S C T

5 HSCT for Bone Marrow Failure in 2006 Transplant Rates (=number of HSCT per 1 million inhabitants) for Bone Marrow Failure, by Continental Region No of HSCT pro 1 Milion. 0 or no report < >0.84 America Europe Asia EMRO / Africa Worldwide Network for Blood and Marrow Transplantation

6 > _ Years

7 1.0 < 20 yrs yrs yrs yrs 0.4 >50 yrs Years 3 4 5

8 BMT Standard Strategies

9 n=60; 5 yy OS 80% n=70 ; 5 yy OS 74% P=0.4

10 HLA id sibling transplantation 10 yr OS by use of ATG in the conditioning regimen > ,000 0,750 ATG =786 85% No ATG = % survival 0,500 0,250 P= ,000 0,0 1000,0 2000,0 3000,0 4000,0 DD_FUP

11 Stem Cell Source PLATELET RECOVERY 100 CUMULATIVE INCIDENCE, % PB median = 15d BM median = 25d DAYS Frl03_11.ppt

12 Stem Cell Source: BMT vs. PBSCT in SAA allo-hsct from HLA matchedsibling donor Chronic GVHD Overall survival Higher rate of chronic GVHD and mortality after PBSCT compared to BMT in younger patients cooperative retrospective study of EBMT and CIBMTR Schrezenmeier H, et al Blood, 2007

13 Use of Stem Cell Source, sibling transplantation, EBMT activity survey

14 HLA-identical sibling SCT GvHD Prophylaxis: CsA alone vs. CsA + MTX Conditioning: CY 50 mg/kg /day x4 + ATG Locatelli et al., Blood 2000; 96: 1690

15 Dry eyes Bronchiolitis obliterans Oral lesions Loss of bile ducts Nail dystrophy Fasciitis Skin sclerosis Deep sclerosis Infections Endocrine Metabolism Nutrition Pain Quality of life Disability Skin ulcers manifestations of cgvhd

16 Issues in sibling transplantation Sibling transplant after failed IS in patients > 50, when and how Conditioning Cy200 + ATG vs Fludarabine and lower doses of Cy What would happen if transplant were only second line treatment ATG dose and type (infectious risk vs graft failure risk Is Campath the answer? The donor who does not want to donate marrow Duration of posttransplant CNI 2nd transplant after graft failure? Syngeneic donor: to condition or not to condition

17 1,0 0,8 Flu + Cy ± ATG N=30 Probability of survival 0,6 0,4 Cy ± ATG N=239 0,2 0,0 p=0.04 (age-adjusted Cox model) years after HSCT

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19 N= HSCT: 30 IS: 70

20 immunosuppressive treatment before BMT sib Transplant as 2 nd line treatment: There is a price to pay

21 Transplant as 2 nd line treatment: There is a price to pay HLA id sibling HSCT years OS by waiting time to transplant prior IS therapy 1,000 <100 dd from Dx; n= % 1,000 No prev IST = % survival 0,750 0,500 =>100 dd from Dx; n= % survival 0,750 0,500 Pre IST = % 0,250 P< ,000 0,0 1000,0 2000,0 3000,0 4000,0 DD_FUP 0,250 P= 0.1 0,000 0,0 1000,0 2000,0 3000,0 4000,0 DD_FUP

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23 Issues in sibling transplantation Sibling transplant after failed IS in patients > 50, when and how Conditioning Cy200 + ATG vs Fludarabine and lower doses of Cy What would happen if transplant were only second line treatment ATG dose and type (infectious risk vs graft failure risk Is Campath the answer? The donor who does not want to donate marrow Duration of posttransplant CNI 2nd transplant after graft failure? Syngeneic donor: to condition or not to condition

24 ATG ATG-F 3 x 20 mg/kg ATG-F 5 x 5 mg/kg Thymo 4 x 3.75 mg/kg Thymo 2 x 3.75 mg/kg Issues: Duration of immunosuppressive effects Duration of GvHD protection Duration of immune reconsitution / infectious risks

25 Cy 300 mg/m2 + Fludara + Campath

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27 Chimerism, Mononuclear Cell Fraction, Geneva (Cy+ATG+Campath in the bag) 100 % of donor chimerism UPN 187 UPN 293 UPN 301 UPN 327 UPN 343 UPN 346 UPN UPN 372 UPN 403 UPN 425 days post HSCT

28 Issues in sibling transplantation Sibling transplant after failed IS in patients > 50, when and how Conditioning Cy200 + ATG vs Fludarabine and lower doses of Cy What would happen if transplant were only second line treatment ATG dose and type (infectious risk vs graft failure risk Is Campath the answer? The donor who does not want to donate marrow Duration of posttransplant CNI 2nd transplant after graft failure? Syngeneic donor: to condition or not to condition

29 N=77; syngeneic HSCT Cum Survival years

30 Influence of conditioning on survival Chemo/TBI/Both No conditioning Unknown

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32 M E R C I