improving outcomes after stem cell transplantation

改善干细胞移植后的结果

• 批准号: 8746668
• 负责人: Austin John Barrett
• 金额: $ 178.41万
• 依托单位: NATIONAL HEART, LUNG, AND BLOOD INSTITUTE
• 依托单位国家: 美国
• 资助国家: 美国
• 起止时间: 至
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/8746668
• 关键词: 10 year old; Accelerated Phase; Acute Graft Versus Host Disease; Acute Myelocytic Leukemia; Address; Adenoviruses; Adverse effects; Affect; Age; Allogenic; Allografting; Angiography; Antibodies; BK Virus; Biological Markers; Blast Phase; CD19 gene; CD3 Antigens; CD34 gene; CSF3 gene; Calcium; Cardiovascular system; Cell physiology; Cells; Cellular Immunity; Chronic Myeloid Leukemia; Chronic Phase; Clinical; Clinical Protocols; Clinical Trials; Collaborations; Competence; Coronary; Coronary Arteriosclerosis; Cyclophosphamide; Cytokeratin-18 Staining Method; Cytomegalovirus; Data; Development; Disease remission; Donor Lymphocyte Infusion; Dose; Early Diagnosis; Engraftment; Enrollment; Evaluable Disease; Event; Failure; Female; Frequencies; Goals; Hematologic Neoplasms; Human Herpesvirus 4; IL2 gene; Immune; Immune response; Immunity; Immunobiology; Immunodominant Antigens; Infection; Infectious Agent; Inflammatory; Infusion procedures; Injury; Interleukin-2; Kinetics; Laboratory Finding; Liver; Lung; Magnetism; Malignant Neoplasms; Marrow; Mediastinal Emphysema; Medicine; Mesenchymal; Methods; Modification; Myelogenous; Natural Killer Cells; Organ; Outcome; PI3 gene; Patients; Peptides; Peripheral Blood Stem Cell; Phase I Clinical Trials; Plant Roots; Pneumothorax; Population; Prevention; Procedures; Protocols documentation; Recovery; Refractory; Regimen; Regulatory T-Lymphocyte; Relapse; Research Personnel; Residual state; Resolution; Risk; Safety; Schedule; Siblings; Site; Stem cell transplant; Stem cells; Steroids; Stromal Cells; Survivors; System; T cell therapy; T-Cell Depletion; T-Lymphocyte; Techniques; Tissues; Toxic effect; Transfusion; Translating; Translational Research; Transplant Recipients; Transplantation; United States National Institutes of Health; Virus; Virus Diseases; Whole-Body Irradiation; Work; base; calcification; cardiovascular risk factor; college; conditioning; cytokine; falls; fludarabine; follow-up; gastrointestinal; graft failure; graft vs host disease; healthy volunteer; high risk; improved; leukemia; male; mortality; older patient; pre-clinical; prevent; progenitor; programs; protective effect; reconstitution; response; restoration; scale up; screening; tv watching

1. Immunological profiles affecting stem cell transplant outcome. Recent data suggests that reactivation of cytomegalovirus (CMV) favors relapse free survival after allogeneic stem cell transplantation for acute myelogenous leukemia. We hypothesize that the immune response to CMV through either natural killer cells or T lymphocytes also targets residual leukemia since myeloid-derived cells may be a reservoir for latent CMV. We studied the relationship of CMV reactivation with leukemic relapse in 110 patients with chronic myeloid leukemia (CML) receiving HLA-identical sibling SCT. Seventy nine (72%) were in chronic phase, 5 in second chronic phase, 17 in accelerated phase and 9 in blast phase. CMV reactivation before day 100 was observed in 72 patients (65.5%). At a median follow up of 6 years, CMV reactivation before day 100 was an independent factor associated with decreased relapse. We conclude that CMV reactivation may contribute to a beneficial graft-versus-leukemia effect in CML transplant recipients. 2. Long term follow-up: Our stem cell transplantation program has now accumulated 20 years of follow-up on protocol 05-H-0130. Currently over 140 patients are being followed long term. Our present focus is on outcomes in the second decade after SCT. We found that males have an increased risk of cardiovascular events and have a cardiovascular age 10 years over their actual age. To further investigate this we studied 16 asymptomatic post allo-SCT survivors (11 males; 5 females) median age of 45 years at transplant who underwent coronary calcium scoring and contrast enhanced coronary CT angiograms at a median follow up of 5 years post transplant. Framingham cardiovascular risk scores were also calculated at time of screening. Two were high risk, 1 intermediate and 13 low risk. Non-obstructive coronary artery disease was detected in seven (44%) patients. Additionally, four (25%) had aortic root calcification. Coronary artery disease was detected in 4 of 13 (30.8%) low risk patients. We conclude that coronary calcium score with or without CT angiogram is a safe, feasible, highly sensitive study in transplant survivors; and even asymptomatic, low-risk survivors may benefit from screening. 3.Optimizing immune reconstitution after SCT: In 2012 we completed a T cell depletion SCT protocol (protocol 07-H-0248): sixty patients (median age 43 years) with hematologic malignancies underwent SCT from their HLA-identical siblings. G-CSF mobilized peripheral blood stem cells from the donor were CD34+ selected using the Miltenyi CliniMacs system. At a median follow up of 3.6 years, Kaplan-Meier estimates of relapse, non relapse mortality and overall survival were 35%, 33% and 44% respectively. We elected to conduct a further T cell depletion study to address some of the shortcomings of the trial 07-H-0248. In protocol 12-H-0028 the T cell depletion technique was changed so as to negatively select for CD34 cells using a CD3 CD19 antibody magnetic separation approach from Miltenyi Corporation under an investigator IND. The transplant product contains a mixed population of CD34 cells more mature progenitors and NK cells. It was anticipated that hematological reconstitution would be more rapid and robust with this method. Subjects received myeloablative conditioning with cyclophosphamide (60 mg/kg/dose x 2), fludarabine (25 mg/m2/dose x 5) and total body irradiation (12 Gy divided in 8 fractions, with lung shielding to 6 Gy). (ii) No planned donor lymphocyte infusion DLI given; ( DLI was reserved only for patients with graft failure or relapsed leukemia) (iii) Older patients receive 600cGy instead of 400cGy to improve engraftment since a number of older patients had engraftment failure in the previous protocol. This protocol accrued 20 patients and is now closed. Hematological recovery was prompt. However we noted increased frequency of grade II-IV acute graft-versus-host disease (GVHD) and graft failure requiring second transplantation in four. Full analysis of outcome awaits longer follow-up. This trial was terminated because of the high frequency of GVHD and graft failure which precluded its use as a platform for T cell therapy. In 2013 a new T cell depletion protocol was initiated Peripheral Blood Stem Cell Allotransplantation for Hematological Malignancies Using Ex Vivo CD34 Selection - A Platform for Adoptive Cellular Therapy. This uses a modified version of protocol 07-H-0248 (incorporating modifications ii and iii as above). Currently two patient are enrolled. 4. Prevention of viral infection after SCT. In collaboration with Dr Catherine Bollard (Baylor College) and Dr David Stroncek (DTM) we have developed a robust system to expand multivirus specific T cells recognizing CMV, EBV, Adenovirus and BK virus which commonly complicate the outcome after SCT. Using a peptide mix of common immunodominant antigens from these viruses we have induced multivirus specific T cells in high frequencies. Currently standard operating procedures have been set up and pre-clinical scale up studies are ongoing in the Cell Processing Section of the Department of Transfusion Medicine. A pre-IND discussion with the FDA has facilitated the completion of a clinical protocol which will be submitted for regulatory approval in 2013. It is anticipated this trial will commence in 2014. 5. Prevention and treatment of GVHD and post transplant complications with mesenchymal stromal cells: In 2013 we completed a phase I trial using third party, early passage, mesenchymal stromal cells (MSC) generated in the NIH Cell Processing Section for patients with steroid-refractory liver or gastrointestinal GVHD, tissue injury or marrow failure following SCT to investigate safety and clinical responses following MSC infusion. Ten subjects were infused 2 x 106 MSC /kg weekly for 3 doses. There was no treatment related toxicity. Eight subjects were evaluable for response assessment at 4 weeks after the last infusion. Five of the seven patients with steroid-refractory acute GVHD achieved complete remission (CR), two of two patients with tissue injury (pneumomediastinum/ pneumothorax) achieved resolution but there was no response in two subjects with delayed marrow failure. Rapid reductions in inflammatory cytokines occurred after the first MSC infusion. Clinical responses correlated with a fall in biomarkers (Reg 3α, CK18, and Elafin) relevant for the site of GVHD, or CK18 for PM. The GVHD complete responders survived significantly longer (>300 days vs a median of 33 days). Cytokine changes also segregated with survival. These results confirm that MSC are associated with rapid clinical responses and biomarker normalization in steroid-refractory GVHD and PM. Early detection and MSC treatment appear important in patients with refractory GVHD. 6. Prevention of GVHD through induction of regulatory T cells (Tregs) by interleukin-2 (IL-2): We completed a study of low dose IL-2 in healthy volunteers to determine the kinetics of Treg and NK expansion. We found a twofold or greater increase in Tregs and also in natural Tregs by 7 days. IL-2 at the lowest dose of 100,000u/m2 daily for 5 days was optimal. This schedule was without significant side effects. On the basis of these results we now propose to evaluate the protective effect of LD IL2 in haploidentical SCT. Donors will receive LD IL2 together with G-CSF to mobilize stem cells. The transplant will be partially depleted of T lymphocytes to a dose of 1 x 106 CD3 cells/kg . Recipients will receive LD IL-2 from day 2 for 12 weeks. The main study end point will be the development of grade II-IV acute GVHD with stopping rules for unacceptable day 100 mortality.

1. 影响干细胞移植结果的免疫学特征。最近的数据表明，巨细胞病毒（CMV）的重新激活有利于急性髓性白血病同种异体干细胞移植后的无复发生存。我们假设，通过自然杀伤细胞或 T 淋巴细胞对 CMV 的免疫反应也针对残留的白血病，因为骨髓来源的细胞可能是潜在 CMV 的储存库。我们研究了 110 名接受 HLA 相合同胞 SCT 的慢性粒细胞白血病 (CML) 患者的 CMV 再激活与白血病复发的关系。 79 例 (72%) 处于慢性期，5 例处于第二慢性期，17 例处于加速期，9 例处于急变期。在 72 名患者 (65.5%) 中观察到第 100 天前 CMV 再激活。在中位随访 6 年中，第 100 天之前 CMV 重新激活是与减少复发相关的独立因素。 我们的结论是，CMV 重新激活可能有助于 CML 移植受者的移植物抗白血病效应。 2.长期随访：我们的干细胞移植项目目前已在方案05-H-0130上积累了20年的随访。目前有超过 140 名患者正在接受长期随访。我们目前的重点是 SCT 后第二个十年的结果。我们发现男性发生心血管事件的风险增加，且心血管年龄比实际年龄高10岁。为了进一步研究这一点，我们研究了 16 名无症状异基因 SCT 幸存者（11 名男性；5 名女性），移植时平均年龄为 45 岁，他们在移植后中位随访 5 年时接受了冠状动脉钙评分和对比增强冠状动脉 CT 血管造影。筛查时还计算了弗雷明汉心血管风险评分。 2 例为高风险，1 例为中风险，13 例为低风险。七名 (44%) 患者检测出非阻塞性冠状动脉疾病。此外，四人（25%）有主动脉根部钙化。 13 名低风险患者中有 4 名 (30.8%) 检测出冠状动脉疾病。我们的结论是，无论是否伴有 CT 血管造影，冠状动脉钙化评分对于移植幸存者来说都是一项安全、可行、高度敏感的研究；即使是无症状、低风险的幸存者也可能从筛查中受益。 3.优化SCT后的免疫重建：2012年，我们完成了T细胞耗竭SCT方案（方案07-H-0248）：60名患有血液恶性肿瘤的患者（中位年龄43岁）接受了来自其HLA相同兄弟姐妹的SCT。使用 Miltenyi CliniMacs 系统对来自捐赠者的 G-CSF 动员外周血干细胞进行 CD34+ 选择。中位随访时间为 3.6 年，Kaplan-Meier 估计的复发率、非复发死亡率和总生存率分别为 35%、33% 和 44%。我们选择进行进一步的 T 细胞耗竭研究，以解决试验 07-H-0248 的一些缺点。在方案12-H-0028中，T细胞耗竭技术被改变，以便使用来自Miltenyi Corporation的CD3 CD19抗体磁性分离方法在研究者IND下对CD34细胞进行阴性选择。移植产品包含 CD34+ 细胞、更成熟的祖细胞和 NK 细胞的混合群体。预计使用这种方法，血液学重建将更加快速和稳健。受试者接受环磷酰胺（60 mg/kg/剂量 x 2）、氟达拉滨（25 mg/m2/剂量 x 5）和全身照射（12 Gy 分为 8 次，肺屏蔽至 6 Gy）的清髓调理。 (ii) 未计划进行供体淋巴细胞输注 DLI； （DLI 仅适用于移植失败或复发性白血病的患者）（iii）老年患者接受 600cGy 而不是 400cGy 以改善植入，因为许多老年患者在之前的方案中出现植入失败。该方案已招募 20 名患者，现已结束。血液学恢复迅速。然而，我们注意到 4 例患者出现 II-IV 级急性移植物抗宿主病 (GVHD) 和移植物失败的频率增加，需要进行第二次移植。对结果的全面分析有待更长时间的随访。该试验因 GVHD 和移植物失败的高发生率而终止，这妨碍了其作为 T 细胞治疗平台的使用。 2013 年，启动了一项新的 T 细胞耗竭方案：使用体外 CD34 选择的外周血干细胞同种异体移植治疗血液恶性肿瘤 - 过继细胞治疗平台。这使用协议 07-H-0248 的修改版本（包含上述修改 ii 和 iii）。目前有两名患者入组。 4. SCT后预防病毒感染。我们与 Catherine Bollard 博士（贝勒学院）和 David Stroncek 博士（DTM）合作，开发了一个强大的系统来扩展识别 CMV、EBV、腺病毒和 BK 病毒的多病毒特异性 T 细胞，这些病毒通常会使 SCT 后的结果复杂化。使用来自这些病毒的常见免疫显性抗原的肽混合物，我们高频率地诱导了多病毒特异性 T 细胞。目前，输血医学部细胞处理科已经制定了标准操作程序，并正在进行临床前放大研究。与 FDA 的 IND 前讨论促进了临床方案的完成，该方案将于 2013 年提交监管部门批准。预计该试验将于 2014 年开始。 5. 利用间充质基质细胞预防和治疗 GVHD 和移植后并发症：2013 年，我们使用 NIH 细胞处理部门生成的第三方早期传代间充质基质细胞 (MSC) 完成了一项针对类固醇难治性患者的 I 期试验SCT 后肝脏或胃肠道 GVHD、组织损伤或骨髓衰竭，以研究 MSC 输注后的安全性和临床反应。十名受试者每周输注 2 x 106 MSC/kg，共 3 剂。没有与治疗相关的毒性。最后一次输注后 4 周，八名受试者可进行反应评估。七名类固醇难治性急性 GVHD 患者中的五名达到完全缓解 (CR)，两名组织损伤（纵隔气肿/气胸）患者中的两名达到缓解，但两名迟发性骨髓衰竭受试者没有缓解。第一次 MSC 输注后，炎症细胞因子迅速减少。临床反应与 GVHD 部位相关的生物标志物（Reg 3α、CK18 和 Elafin）或 PM 的 CK18 下降相关。 GVHD 完全缓解者的存活时间明显更长（> 300 天，中位数为 33 天）。细胞因子的变化也与存活率相关。这些结果证实 MSC 与类固醇难治性 GVHD 和 PM 的快速临床反应和生物标志物正常化相关。早期检测和 MSC 治疗对于难治性 GVHD 患者显得很重要。 6. 通过白介素-2 (IL-2) 诱导调节性 T 细胞 (Treg) 预防 GVHD：我们在健康志愿者中完成了一项低剂量 IL-2 的研究，以确定 Treg 和 NK 扩增的动力学。我们发现 7 天后 Tregs 和自然 Tregs 增加了一倍或更多。 IL-2 的最佳剂量为每日 100,000u/m2，持续 5 天。这个时间表没有明显的副作用。基于这些结果，我们现在建议评估 LD IL2 在半相合 SCT 中的保护作用。捐赠者将接受 LD IL2 和 G-CSF 来动员干细胞。移植物将部分去除 T 淋巴细胞，剂量为 1 x 106 CD3 细胞/kg。接受者将从第 2 天开始接受 LD IL-2，持续 12 周。主要研究终点将是 II-IV 级急性 GVHD 的发展，并针对不可接受的第 100 天死亡率制定停止规则。