Indications and outcomes after UD HSCT

Transcription

1 Indications and outcomes after UD HSCT Jakob R Passweg 1 Impact on Outcome: Patient Age, Disease Severity I II III Title: Optimization of Therapy for Severe AplasticAnemia 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. 2 Maciejewski, Ramon V. Tiu, Nancy DiFronzo, Mary M. Horowitz, Joseph H. Antin 1-3 Nov

2 When to start a MUD search in SAA When to do a MUD transplant How would we do such a transplant What outcome would we expect? 3 EBMT Activity Survey on HSCT : changes in Non Malignant Disorders H.B. March Nov

3 EBMT Activity survey on BMF: EBMT Activity survey on HSCT: BMF Nov

4 Unrelated Donors Nov

5 7/8 and 8/8 Allele, Available-Match Rates in the Adult Donor Registry of 8 7 of 8 Causcasian Native American Hispanic Asian African American 9 Unrelated donor transplants Done in CH, F, D, I, NL In Unrelated donors available In the respective national registries CH, F, D, I, NL Nov

6 Patients treated Matched donor HLA A, B low DRB1 high Nov

7 Improved Outcome after MUD transplant? Survival before and after 1998 N 5 year Before % (+8) After % (+8) p=< agvhd, cgvhd and graft failure 1.0 AGVH_CI =1 <1998 >1998 Primary or secondary graft failure 37/142 (26%) 38/338 (11%) p< chronic GvHD (after day 100) 32/85 (38%) 53/245 (22%) p= Cumulative incidence of grade II-IV agvhd p= Nov

8 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 Nov

9 BMT best strategies What we know from sibling donor transplantation: Stem cell source: Conditioning: GvHD Prophylaxis: Marrow Cy + ATG CSA + MTX What about unrelated donor transplantation? 17 agvhd cgvhd Upper age limit? Nov

10 Nov

11 Nov

12 23 Cy 300 mg/m2 + Fludara + Campath Nov

13 25 When to start the search? Nov

14 Unrelated donor transplantation for SAA 2nd line treatment for SAA 27 Immunosuppressive treatment before BMT Nov

15 Fig 1: Study flow chart n=70 who never received ATG-based immunosuppression n=295 n=179 Matched VUD? HLA A-B (low) and DRB1 (high) n=24 incomplete search result n=22 cases revised as constitutional aplastic anemia n=118 >1 matched donor n=61 no matched donor n=68 HSCT n=50 no HSCT n=48 no HSCT n=13 mismatched HSCT Nov

16 Fig2 patients withage< 17 1,0 Donor 0,8 Probability of survival 0,6 0,4 No donor p=0.01 0,2 years after donor search initiation 0, Fig 3 patients with a donor search in recent period ( ) 1,0 0,8 Donor Probability of survival 0,6 0,4 No donor 0,2 P<0.05 0,0 years after donor search initiation Nov

17 Latest News from our database 33 HSCT ; n=1209 1st Tx, unrelated donor, PB or BM 68 10y Nov

18 y vs 72 +4% P= BM PB 70 10y vs % P= Nov

19 From diagnosis To transplant < 1y > 1y 74 10y vs 63 +6% P= Nov

20 P= Use of TBI donor recipient sexmatch Nov

21 Other outcomes 41 Can we predict good response to ATG+CSA? To avoid starting a unecessary donor search Lymphocyte count at diagnosis Reticulocyte count at diganosis Telomere length Platelets and Retics at 3 months after ATG+CSA Is this useful to decide who should have an unrelated donor search and who not? Nov

22 Issues 2nd line treatment Upfront unrelated donor HSCT? (start IS) When to start the donor search (at IS start if <50?) How many courses of IST? (1) Whom to continue on supportive care /2nd line IS / experimental IS? (no donor) How about other donors cord, haplo (?) 43 M E R C Nov