Disease-Specific Treatment of Relapse after Allogeneic Transplantation

1. Disease-Specific Treatment of Relapse after Allogeneic Transplantation

2. Treatment of Relapse • Cellular Immunotherapy • Withdrawal of immune suppression • DLI ( + chemotherapy) • Second allogeneic SCT • Non-Cellular therapies • Supportive care • Conventional chemotherapy or radiation • Novel cytotoxic agents • Biological agents • Immunotherapy approaches

3. Cellular therapy Withdraw IS Second BMT with same or different donor DLI Activated DLI Manipulated DLI CD8 depleted, CD4 enriched, antigen-specific. Dose titrated DLI NK cells Modified T cells (CARs) Other therapies Conventional chemotherapy or radiation Antibodies CD20, CD33, CD30, CTLA-4, etc… Bispecific antibodies Biological therapy Lenalidomide, thalidomide, bortezomib, azacytadine, decitabine, mTor inhibitors,others. Interferon, IL-2, etc… Vaccines Others Treatment of Relapse

4. Available data for treatment of relapse • CML-CP: DLI restores durable CR in 80% of pts with CP relapse. • Dose, schedule, toxicity well defined. • Role of TKI’s? • AML, ALL, NHL, HL, CLL, MM, CML-AP/BC • DLI response rate, most effective approach, and long term outcomes? • Second SCT ? • Other therapies ? An embarrassing lack of data

5. Excuses (good ones) • Patients are heterogeneous • Age • Impact of prior transplant • Myeloablative vs RIC • GVHD prophylaxis (TCD, alemtuzumab, sirolimus, etc…) • Different grafts • BM vs PBSC • TCD, other manipulation • Donor source and availability (sibling/family, URD, UCB, matched or mismatched) • Different risks, timing to intervention, treatment choice, etc… • Clinical complications and co-morbidities after allogeneic SCT • May not tolerate therapies well • Active GVHD? Acute or chronic? • Use of immune suppression

6. Excuses (good ones) • Disease-related issues are heterogeneous • Timing of relapse: early vs late relapse may be very different • Histology (particularly in NHL) • Disease burden and pace of progression • In indolent diseases residual disease may not require intervention • Influence of prior therapies and likely drug resistance • Small numbers of patients studied with some diseases. • No central database or sample repository to assess interventions. • Reticence for clinical trials in this population (sponsors, cooperative group, FDA, investigators. • Limits access to new compounds

7. Excuses (good ones) • Lack of insurance coverage for clinical trials (and in some cases standard DLI or other therapy) • Bias for: • Treatment selection • Depends on patient, disease activity, donor availability, prior therapies… • Patient selection • Age, co-morbidity, past and present transplant-related complications. • Reporting of outcomes

8. Many issues are common to treatment of relapse of multiple diseases

9. Cell Dose • Is there a dose:response relationship? • In CML, low dose DLI (1 x 10^7/kg) with dose escalation may preserve GVL with limited GVHD. • Is this effective for other indolent relapses (NHL, HL, MM, CLL?) • Not useful for rapidly progressive acute leukemia • Is there a dose:toxicity relationship? • Minimal threshold for GVHD may vary by donor source (haplo vs well matched) • Sibling vs unrelated donor • Often dosed differently but not supported by comparative trials

10. Role of Chimerism • Does mixed or changing chimerism signify relapse? • For CML, mixed chimerism predicts relapse. Role for intervention depends on timing, pace of change, and other factors • Significance in other diseases less clear • May depend on the cellular compartment evaluated (T, NK, myeloid) • Role of intervention for chimerism and influence on outcome not well defined for most diseases. • “Treatment” of mixed chimerism with DLI may prevent relapse in some cases, but not others.

11. Role for Second SCT • Available data is limited and should be reassessed in the “modern” era. • Conventional vs RIC conditioning? • Influence of disease type and extent of relapse? • Same vs alternate donor? • Influence of timing of relapse? • Manipulations to enhance GVT activity of second SCT?

12. Overcoming Limitations • NCI Sponsored Workshop on Relapse after Allogeneic SCT! The first step…… • Define critical issues relating to relapse therapy. • Multicenter and international collaborations to rapidly test and analyze new therapies for relapse.

13. Fred Falkenburg Joseph Antin Marcos de Lima Eli Estey John Levine Jacob Rowe Alan Wayne David Maloney Koen van Besien Karl Peggs David Porter Jose Leis Nancy Hardy Nicolaus Kröger Edwin Alyea Disease-Specific Treatment of Relapse after Allogeneic Transplantation CML HL AML CLL MM ALL NHL

15. Treatment of CML relapse after allogeneic SCTFred FalkenburgJoseph Antin

16. Treatment of relapsed Chronic Phase CML with DLI after Allogeneic Hematopoietic Stem Cell Transplantation (SCT) • Complete remissions in 80-90 % of cases • Relatively low doses of DLI required • Time interval between treatment and response is dose and disease state dependent • Interferon may potentiate onset and effect • Target recognition may determine balance between GVHD and GVL

17. Hematopoiesis-associated minor histocompatibility antigens (mHag) and GVL reactivity • In HLA-identical transplantation donor T cells recognizing hematopoiesis-specific antigens on recipient cells eliminate normal and malignant hematopoietic cells of recipient origin • GVL-reactivity • (Complete) donor chimerism • Hematopoiesis-specific mHag may be targets for GVL reactivity with limited induction of GVHD

18. BCR-ABL/PBGD ratio BCR/ABL expression in bone marrow after DLI 1 * =negative 0,1 0,01 0,001 0,0001 * * * * * * < 0,00001 +3 +5 +6 +7 +8 +9 +26 +10 +11 +13 +15 +18 +22 +1.5 DLI SCT+12 SCT+28 weeks post treatment RZ

19. Kinetics of immune responses after DLI RZ

20. Treatment of relapsed Chronic Phase CML with DLI after Allogeneic Hematopoietic Stem Cell Transplantation (SCT) • Which antigens need to be targeted to provoke a GVL response without GVHD • Targeting hematopoiesis restricted antigens results in specific GVL? • Are over-expressed self antigens targets of high avidity T cell responses?

21. Persistance of BCR/ABL despite repeated DLI CML chronic phase, allogeneic SCT from HLA identical brother Hematological relapse: DLI 3x10E7 T cells/kg: hematological remission, molecular persistence Molecular persistence of disease despite escalating doses of DLI: Localized myeloid blast crise in epidural space: Systemic chemotherapy Radiotherapy + DLI 1.5x10E8 T cells/kg,

22. Persistance of BCR/ABL despite repeated DLI isolation of CML reactive CTL clones Chemotherapy DLI 100 1 0.1 80 0.01 % Donor chimerism 60 BCR-ABL 0.001 40 0.0001 20 0.00001 * * * 0 0.000001 negative 0 10 20 30 40 50 Time (months) * too low to quantify

23. Non-maturated immature CD34 CML cells

24. Maturated CML cells after culture with cytokines: myelocytes, metamyelocytes, monocytes and granulocytes

25. Maturated CML cells incubated with T cell clones for 50 hours HA-1 C6-1 no T-cells

26. immature CML cells incubated with T cell clones for 50 hours HA-1 C6-1 no T-cells

27. Conclusions CD8+ mHag specific CTL recognizing only maturation associated antigens not present on CD34 positive stem or early progenitor cells may result in persistence of disease Should CML stem cells be targeted?

28. Cellular immunotherapy and TKI • Are leukemic stem cells residing after imatinib treatment susceptible targets for cellular immunotherapeutic interventions? • Should allo-SCT performed for persistent CML be combined with continuous treatment with tyrosine kinase inhibitors?

29. Quantitative flow cytometric analysis of phenotype and proliferative status of CML precursor cells • Isolation of CD34+ CML precursor cells from PB or BM by MACS • Cytokines: GM-CSF, G-CSF, IL-3, SCF, EPO • CFSE/PKH labeling of the target cell population • Ab labeling of specific cell populations (FITC, PE & APC) • Exclusion of death cells using propidium iodide • Addition and acquisition of a fixed amount of fluorescent beads 2 1 counts CD34 3 0 CFSE CFSE

30. Specific kill of proliferating CML precursor cells by Imatinib control 100 mM imatinib ↑ CD34 CFSE 6 days

31. Cross-resistance of Imatinib pre-treated CML precursor cells to cell death induced by cytotoxic T cells 100mM Imatinib + mHag spec. CTL control CFSE 6 days pretreated 48 hours CTL exposure (HLA-A2 restricted mHag-specific CD8+ clone; E/T 3/1)

32. Quiescent CML precursor cells are resistant to cell death induced by cytotoxic T cells no pre-treatment control + mHag spec. CTL CD34 CFSE 6 days CTL exposure (HLA-A2 restricted mHag-specific CD8+ clone; E/T 3/1)

33. Conclusions • Quiescent leukemic stem cells are protected from the cytotoxic effect of tyrosine kinase inhibitors • This population of quiescent leukemic stem cells shows cross-resistance to cytotoxic T cells involved in the GVL effect after allo-SCT, • The anti-proliferative effect of tyrosine kinase inhibitors on both the leukemic cells and the T cells may potentially hamper the potentially curative immune response after allo-SCT • If cellular immunotherapy is combined with TKI, should treatment be intermittent?

34. Treatment of relapsed CML after Allogeneic Hematopoietic Stem Cell Transplantation (SCT) • Identification of target cells and/or antigens to be targeted • Separation of DLI into fractions (CD4 T cells) • Targeting minor histocompatiblity antigens or leukemia associated antigens by adoptive transfer if purified T cells • Vaccination of patient with mHag, APC. • Vaccination of donor with mHag • Interferon may potentiate onset and effect • Are TKI useful, or harmful? • How to treat extramedullary relapses

36. Treatment of relapsed acute myelogenous leukemia after allogeneic stem cell transplantation Marcos de Lima, MD M. D Anderson Cancer Center John Levine, MD University of Michigan Elihu Estey, MD Fred Hutchinson Cancer Research Center

37. AML Probability of relapse: 20% - 60% - definition of relapse is key. All results reflect (to a great extent) patient selection. Major co-variates predicting relapse: - disease stage / cytogenetics - preparative regimen intensity Ringdén et al. J Clin Oncol; 27; 2009: 4570-4577 Trends affecting comparison with historic data: - better prognostication for diploid patients (FLT3, NPM) - treatment of older patients - use of reduced-intensity regimens Oran et al. Leukemia (2007) 21, 2540–2544. Eapen et al. BMT 2004;34:721-727

38. Donor Lymphocyte Infusions Addition of chemotherapy improves response rate but not long-term disease control. GVHD in 10-60% of patients Marrow aplasia in 5-20%. TRM: 0-50% Most series : adults, using mostly related donors. Responses frequently do not translate into long-term survival, due to GVHD, pancytopenia, infections, and disease relapse. Donor availability and presence of GVHD are major impediments.

39. Donor lymphocyte infusion alone Kolb H. Blood 1995;86:2041-2050 Loren A, Porter DL. Bone Marrow Transplantation (2008) 41, 483–493. Porter DL et al. Blood 2000;95:1214-1221.

40. D L I and chemotherapy Porter DL. Leukemia 2003;17:1035-1037. Levine J. Bone Marrow Transplant 2008;42:201-205. Choi S. Leukemia 2004;18:1789-1797.

41. Donor lymphocyte infusion EBMT analysis 399 patients with AML in first hematological relapse after HSCT DLI = n=171 versus no DLI (n = 228) Median follow-up was 27 and 40 months Schmid, C. et al. J Clin Oncol; 25:4938-4945 2007

42. Fig 1. Unadjusted survival of patients with first hematological relapse of acute myeloid leukemia after allogeneic hematopoietic stem-cell transplantation (HSCT) Multivariate analysis 1- age < 37 years (P = .008) 2- longer CR after HSCT (> 5 months; (P < .0001) 3- use of DLI (P = .04). Schmid, C. et al. J Clin Oncol; 25:4938-4945 2007

43. Risk Factors for Survival Among Patients Receiving DLI for Treatment of Hematological Relapse After HSCT for AML (n = 171) Schmid, C. et al. J Clin Oncol; 25:4938-4945 2007

44. Second transplant

45. Second transplants – matched related donor – CIBMTR analysis 6% of patients with recurrent leukemia receive a 2nd HSCT Eapen et al. Bone Marrow Transplant 2004;34:721-727

46. Second transplants – matched related donor – CIBMTR analysis RIC was associated with more relapses. Eapen et al. Bone Marrow Transplant 2004;34:721-727

47. Disease burden may identify patients more likely to benefit from second allogeneic hematopoietic stem cell transplantation to treat relapsed acute myelogenous leukemia C Hosing et al. BMT (2005) 36, 157–162 847 patients with AML, MDS, or myeloid blast crisis of CML received transplants between May 1989 and November 2003 at MDACC. 346 patients relapsed (41%). 72 of 346 (21%) underwent a 2nd HSCT from the same or different donor for AML. Disease status at second transplant: Refractory relapse 39% Untested relapse 56% CR 5% no circulating blasts / <=  5% bone marrow blasts vs circulating blasts + >5% bone marrow blasts

48. Oran et al. Leukemia (2007) 21, 2540–2544.

49. Oran et al. Leukemia (2007) 21, 2540–2544;

50. Salvage chemotherapy