Rapid Engraftment Without Significant Graft-Versus-Host Disease After Allogeneic Transplantation of CD34+ Selected Cells From Peripheral Blood

Abstract

We have prospectively evaluated the feasibility and results of the biotin-avidin immunoadsorption method (Ceprate SC system) for a phase I/II study of T-cell depletion of granulocyte colony-stimulating factor (G-CSF ) mobilized peripheral blood progenitor cells (PBPC) for allogeneic transplantation. Twenty consecutive patients, median age, 40 years (21 to 54) and diagnoses of chronic myeloid leukemia in chronic phase (n = 5), acute myeloblastic leukemia (n = 7), acute lymphoblastic leukemia (n = 2), chronic myelomonocytic leukemia (n = 1), refractory anemia with excess of blasts in transformation (n = 3), histiocytosis X (n = 1), and chronic lymphocytic leukemia (n = 1), were conditioned with cyclophosphamide (120 mg/kg) and total body irradiation (13 Gy; 4 fractions). HLA identical sibling donors received G-CSF at 10 μg/kg/d subcutaneously (SC); on days 5 and 6 (19 cases) and days 5 to 8 (1 case) donors underwent 10 L leukapheresis. PBPC were purified by positive selection of CD34+ cells using immunoadsorption biotin-avidin method (Ceprate SC) and were infused in the patients as the sole source of progenitor cells. No growth factors were administered posttransplant. The median recovery of CD34+ cells after the procedure was of 65%. The median number of CD34+ cells infused in the patients was 2.9 (range, 1.5 to 8.6) × 106/kg. The median number of CD3+ cells administered was 0.42 × 106/kg (range, 0.1 to 2). All patients engrafted. Neutrophil counts <500 and <1,000/μL were achieved at a median of 14 days (range, 10 to 18) and 15 days (range, 11 to 27), respectively. Likewise, platelet counts <20,000 and <50,000/μL were observed at a median of 10 days (range, 6 to 23) and 17 days (range, 12 to 130), respectively. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine plus methylprednisolone. No patient developed either grade II to IV acute or extensive chronic GVHD. After a median follow-up of 7.5 months (range, 2 to 22) three patients have relapsed, and one of them is again in hematologic and cytogenetic remission after infusion of the donor lymphocytes. Two patients died in remission: one on day +109 of pulmonary aspergillosis and the other on day +251 of metastasic relapse of a previous breast cancer. Sixteen of the 20 patients are alive in remission after a median follow-up of 7.5 months (range, 2 to 22). In conclusion, despite the small number of patients and limited follow-up, it appears that this method allows a high CD34+ cell recovery from G-CSF mobilized PBPC and is associated with rapid engraftment without significant GVHD, and with low transplant related mortality.

Review

“…Several series of CD34 þ selected PBPC have now been published (Link et al, 1996;Bensinger et al, 1996a;Urbano-Ispizua et al, 1997). Two studies (Link et al, 1996;Bensinger et al, 1996a) reported a high incidence of severe (grade II-IV) acute GVHD (60-80%) in patients receiving a CD3 þ cell dose of approximately 1 × 10 6 /kg when post-transplant cyclosporin alone was used for GVHD prophylaxis.…”

“…Two studies (Link et al, 1996;Bensinger et al, 1996a) reported a high incidence of severe (grade II-IV) acute GVHD (60-80%) in patients receiving a CD3 þ cell dose of approximately 1 × 10 6 /kg when post-transplant cyclosporin alone was used for GVHD prophylaxis. Urbano-Ispizua et al (1997) recently updated the Spanish experience in 20 patients undergoing CD34 þ selected PBSC using CSA combined with prednisolone post-transplant. In this study they infused a median of 4·2 × 10 5 /kg CD3 þ cells and reported good engraftment with no cases of acute GVHD greater than grade I.…”

“…The dose of CD34 þ cells for optimal engraftment is unclear, although most investigators have targeted a CD34 þ dose of > 4 × 10 6 /kg CD34 þ cells, and there is some evidence that patients who receive less than this cell dose have delayed engraftment (Miflin et al, 1997). However, lower cell doses of CD34 þ cells have been utilized and successful engraftment reported with numbers as low as 2 × 10 6 /kg (Miflin et al, 1997;Urbano-Ispizua et al, 1997). In the majority of donors > 4 × 10 6 /kg CD34 þ cells can be obtained following one or two aphereses, with only a minority of donors requiring more.…”

Peripheral Blood Stem Cells for Allogeneic Transplantation: A Review

“…Efforts to enrich PBSCT by ex-vivo CD34 + cell selection (positive selection) have resulted in increased rates of GVHD, possibly by altering the cytokine expression patterns of transplanted cells or changing lymphocyte subsets delivered with the graft [25]. These efforts do not appear to alter engraftment kinetics significantly [25,26]. Negative selection (T cell depletion) clearly leads to lower rates of GVHD, at the expense of a slightly higher incidence of graft rejection.…”

CD34+ cell selection of peripheral blood progenitor cells using the CliniMACS device for allogeneic transplantation: clinical results in 102 patients

“…A potentially highly attractive and effective approach is the positive selection of CD34 + haematopoietic progenitor cells. The first phase II studies with CD34 + cell selected transplants using the Ceprate and Isolex devices were published in 1997 and showed encouraging results in terms of engraftment and GvHD incidence (Handgretinger et al , 1997; Urbano‐Ispizua et al , 1997). These devices are capable of reducing T cells by 3–5 logs and thus permit the use of haploidentical donors with a minimal incidence of GvHD (Reisner & Martelli, 2000; Martelli & Reisner, 2002).…”