1 An Introduction to HSCTDr. Mustafa CETIN 25th November 2016.

2 How haematopoietic stem cell transplant was born:After the atomic bomb explosion in Japan, ending WW2, many scientists began to explore ways of protecting humans from irradiation. Thomas ED, Blume KG. Historical markers in the development of allogeneic hematopoietic cell transplantation. Biol Blood and Marrow Transplant 1999; 5: 341–346.

3 How haematopoietic stem cell transplant was born:ACUTE RADIATION SYNDROME Haematological syndrome ARS manifestations Irradiated Bone Marrow Gastrointestinal syndrome Combination of clinical syndromes occuring in stages hours to weeks after exposure as injury to various tissues and organs is expressed Irradiated GI Mucosa Neurovascular syndrome Irradiated lung tissue

4 How haematopoietic stem cell transplant was born:ACUTE RADIATION SYNDROME <0.1 Gy, whole body – No detectable difference in exposed vs non-exposed patients Gy, whole body – Detectable increase in chromosome aberrations. No clinical symptoms 0.12 Gy, whole body – Sperm count decreases to minimum about day 45 0.5 Gy, whole body – Detectable bone marrow depression with lymphopenia

5 How haematopoietic stem cell transplant was born:ACUTE RADIATION SYNDROME Normal bone marrow cells If the lymphocyte count in first week below 100 cells/µL, consider treatment with growth factors and BMT Observe HLA compatibility at allogenic BMT. This therapy may be recommended for patients exposed to WB radiation doses exceeding 9 Gy Bone marrow damaged by radiation injury Haematological response to 3 Gy, exposure Successfully used for radiation victims after Goiânia, San Salvador, Israel and Belarus and Istanbul accidents

6 How haematopoietic stem cell transplant was born:E.D. Thomas carried out the first transplants in dogs using high dose irradiation The first experiments were performed in mice and later in dogs by E.D. Thomas. Thomas ED, Collins JA, Herman EC, Ferrebee JW. Marrow transplants in lethally irradiated dogs given methotrexate. Blood 1952; 19: 217–228.

7 How haematopoietic stem cell transplant was born:  As early as 1956, the idea that bone marrow transplant might exert a therapeutic effect against malignancies was proposed by Barnes and Loutit who observed an anti-leukaemic effect of transplanted spleen cells in experimental murine models (2). They also observed that animals that had been given allogeneic rather syngeneic marrow cells died of "wasting disease", which would now be recognised as being graft-versus-host disease (GvHD)    

8 E. Donnall Thomas Milestones of Stem Cell TransplantationThe Nobel Prize, 1990 In 1959, the first human bone marrow transplants gave a proof of concept that infusing bone marrow could provide haematological reconstitution in lethally irradiated patients with acute leukaemia

9 Milestones of Stem Cell TransplantationG. Mathé Milestones of Stem Cell Transplantation G. Mathé gave allogeneic bone marrow for treatment of several patients who had suffered accidental irradiation exposure, most survived with hematopoetic reconstitution. In 1963, First successful complete engraftment and survival of over 1 year, description of acute and chronic GVHD in men In 1965, Mathé was the first to describe long-term engraftment of a sibling bone marrow demonstrating chimerism, tolerance and an anti-leukaemic effect .

10 Milestones ofHLA typingMost of succesful transplantation experiences had been carried out after learning about HLA and their important on tissue compatibility 1958-Dausset First HLA antigen described (A2) 1968-van Rood/Terasaki Modern HLA serologic typing available Secondary disease-runting syndrome-GVHD 1968-Good (Minneapolis) De Vries (Leiden) First successful HLA-matched sibling transplant for SCID

11 Bone Marrow Transplantation takes off!!The 1970’s Bone Marrow Transplantation takes off!!

12 Blood Apr;49(4): One hundred patients with acute leukemia treated by chemotherapy, total body irradiation, and allogeneic marrow transplantation. Thomas ED, Buckner CD, Banaji M, Clift RA, Fefer A, Flournoy N, Goodell BW, Hickman RO, Lerner KG, Neiman PE, Sale GE, Sanders JE, Singer J, 94 patients were engrafted and only one patient rejected the graft. …… Thirteen patients are alive with a marrow graft, on no maintenance antileukemic therapy, and without recurrent leukemia yr after transplantation. This observation, coupled with the observation that some patients may be cured of their disease, indicates that marrow transplantation should now be undertaken earlier in the management of patients with acute leukemia who have an HLA-matched sibling

13 Tracking and documenting transplants in EuropeEBMT Tracking and documenting transplants in Europe Maastricht. Three teams were present, The Leiden group with J. Vossen and Rood, The Basel group with B. Speck The Paris group with E. Gluckman. 1974 EBMT (European Group for Blood and Marrow Transplantation) was born in 1974 when the number of bone marrow transplants was very small and results quite encouraging

14 IBMTR - CIBMTR Tracking transplants world-wideMary M. Horowitz Scientific Director, Mortimer M. Bortin Scientific Director, IBMTR 1991- IBMTR Dr. Mortimer M. Bortin and several colleagues established the IBMTR at the Medical College of Wisconsin to do just that. Physicians in the field agreed to voluntarily contribute their patient data to this outcomes registry. At the time, there were only about 12 transplant centers and fewer than 50 patients per year worldwide receiving a transplant. M. Horowitz the current director has developed the database and this worldwide database now includes data on 500,000 autologous, related and unrelated donor transplant recipients. CIBMTR is 35also performing both observational and prospective research

15 Annual Numbers of Hematopoietic Stem Cell Transplants WorldwideIBMTR - CIBMTR Annual Numbers of Hematopoietic Stem Cell Transplants Worldwide 45,000 Number of Transplants 40,000 35,000 Autologous 30,000 25,000 IBMTR - CIBMTR 20,000 15,000 10,000 Allogeneic 5,000 1970 1975 1980 1985 1990 1995 2000 Year

16 EBMT Transplantation Activity, 2014A record number of hematopoietic stem cell transplantation (HSCT) in patients ( allogeneic (43%), autologous (57%)) were reported by 656 centers in 47 countries to the 2014 survey.

17 WMDA (World Marrow Donor Association)December 1987. NMDP (National Marrow Donor Program) was founded in 1986 and the first NMDP-facilitated transplant took place in December Today the registry is called Be the Match Registry and has grown to 9 million donors and nearly umbilical cord blood units. WMDA (World Marrow Donor Association). On March 10th 1988 an ad hoc committee was formed to discuss international collaboration for identification of matched unrelated donors, initially started as the Cooperative Marrow Donor Programme. The founders of this group were: Prof. J.J. van Rood, Prof. J. Goldman and Prof. E.D. Thomas. Prof. J. Goldman proposed a change in the name of the organisation from Cooperative Marrow Donor Programme to World Marrow Donor Association (WMDA).The WMDA is a voluntary organisation of representatives of bone marrow donor registries, cord blood banks, other organisations and individuals, with an interest in haematopoietic stem cell transplantation. It provides a forum for mutual discussion of all issues regarding the clinical use of haematopoietic stem cells from unrelated donors across international boundaries. These discussions, which take place in working groups, make it possible to formulate guidelines on logistics, quality control, accreditation, ethics, finances and registry accreditation. It works in close association with BMDW (Bone Marrow Donors Worldwide). BMDW is continuing the effort to collect the HLA phenotypes and other relevant data of volunteer stem cell donors and cord blood units. The current number of donors is 17,596,872 and cord blood units 482,451. Eurocord is a registry of cord blood transplants which works in close collaboration with cord blood banks (members of Netcord) to analyse results of cord blood transplant and provide quality standards and accreditation to the unrelated cord blood banks. It has collected more than 7,000 cord blood transplant from 483 centres, 50 countries and 54 cord blood banks.

18 TURKOK Turkish Donor Registry Program

19 Barriers for stem cell transplantationThe 1980’s: Extending the indications The 1990’s: Older and debilitated patients Extending the donor pool The last decade: Safer transplants The next decade: More cures

20 Extending the indicationsThe 1980’s Extending the indications 1970s 1980s 1990s Acute leukemia CML CLL Myeloma Lymphoma MDS Solide Cancer Aplastic anemia and immunodeficiency diseases Hemoglobinopathies Inborn errors

21 Timeline of Hematopoetic Stem Cell Transplantation Timeline of Hematopoetic Stem Cell Transplantation

22 What are the Hematopoetic Stem Cells?(HSCs) What are the Hematopoetic Stem Cells?

23 (HSCs) Sources of Stem Cells Bone Marrow Peripheral Blood Cord Blood

24 Stem Cell Sources

25 The Major Histocompatibility ComplexMHC The Major Histocompatibility Complex HLA is a protein – or marker – found on most cells in your body. Your immune system uses HLA markers to know which cells belong in your body and which do not. .

26 The Major Histocompatibility ComplexMHC The Major Histocompatibility Complex HLA is a protein – or marker – found on most cells in your body. Your immune system uses HLA markers to know which cells belong in your body and which do not. .

27 The Major Histocompatibility Complex & Antigen recognitionMHC Donor Selection The Major Histocompatibility Complex & Antigen recognition Allogeneic transplants are the most common type of transplant used to treat certain forms of leukemia. The best chance for the closest match is often a sibling. Unfortunately, there is only a 25-percent chance of a sibling match Immune system uses HLA markers to know which cells belong in your body and which do not.

28 HLA matches (SIBLINGS)Mother Father Half of your HLA markers are inherited from your mother and half from your father. Each brother and sister has a 25%, or 1 in 4, chance of matching you, if you have the same mother and father. It is highly unlikely that other family members will match you. Under very rare circumstances, family members other than siblings may be tested. Patient Sibling 1 Sibling 2 Sibling 3 Sibling 4 HLA matched Half of your HLA markers are inherited from your mother and half from your father. Each brother and sister has a 25%, or 1 in 4, chance of matching you, if you have the same mother and father.

29 HLA matching (UNRELATED)There are many HLA markers. Each HLA marker has a name. The names are letters or combinations of letters and numbers. Doctors review at least 8 HLA markers for these minimum requirements: two A markers, two B markers, two C markers, and two DRB1 markers. Some doctors look for an additional marker, called DQ, to match. An adult donor must match at least 6 of these 8 HLA markers. Many transplant centers require at least a 7 of 8 match. Because cord blood cells are less mature than adult donor cells they have less strict matching criteria. A cord blood unit must match at least 4 of 6 markers at HLA-A, -B, and -DRB1. These guidelines are based on scientific studies of transplant results. Example A shows that the patient's markers match the donor's. When HLA markers A, B, C, and DRB1 from the patient and the donor match, it is called an 8 of 8 match. When A, B, C, DRB1, and DQ markers all match, it’s called a 10 of 10 match. Example B shows that one of the patient's A markers does not match one of the donor's A markers. Therefore, this is a 7 of 8 match or, if the DQ marker matches, a 9 of 10 match.

30 Transplant Procedure

31 Autologous Haematopoietic Stem Cell Transplantation(Auto-SCT) Autologous Haematopoietic Stem Cell Transplantation Mobilisation Apheresis Conditioning HSC Infusion Aplastic Phase RECOVERY

32 Allogenic Haematopoietic Stem Cell Transplantation(Allo-SCT) Allogenic Haematopoietic Stem Cell Transplantation Allogeneic – from another person Sibling donor – HLA matched brother or sister Syngeneic – from an identical twin Unrelated donor – found using a donor registry Haploidentical – half-matched family member Patient Conditioning CT Transplantation ENGRAFTMANT

33 Conditioning Therapy The first stage of the transplant.May be given in one dose or over several days. Necessary for: Supressing the patients immune system to lessen the chance of graft rejection Destroying remaining cancer cells Creating room in the bone marrow for the transplanted stem cells Conditioning regimen is dependent on the type of disease, the type of transplant, co-morbidities and age.

34 Regimen Intensity Conditioning Therapy Low Intensity High IntensityFlu / Cy BEAM Cy / TBI Less regimen related toxicity Rely on later graft versus disease effect Increase in regimen related toxicities Increased level of disease control

35 Regimen Intensity Conditioning Therapy Myeolablative conditioningIrreversibly destroys the haemopoietic function of the bone marrow with high doses of chemotherapy +/- TBI. Higher level of disease control Younger patients with a good performance status Quicker engraftment of donor cells Higher toxicities associated with higher transplant related mortality Reduced intensity conditioning Regimens that have been developed to reduce the morbidity and mortality of allogeneic transplant. It aims to use enough immunosuppression to allow donor cells to engraft without completely eradicating the recipients bone marrow. Can be given to older patients Less regimen related toxicities Reduction in morbidity and transplant related mortality

36 Stem Cell Re-infusion At least 24 hour after the conditioning will be given on Day 0. These are generally given through a central line and takes approximately 30 minutes. Stem cells are either cryopreserved or fresh. Cryopreserved Usually for autologous transplants Most common side effects are reactions to DMSO Fresh Usually for allogeneic transplants Administered much like a blood transfusion Generally better tolerated than frozen cells.

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38 ENGRAFTMENT Blood Count RecoveryNeutrophil engraftment occurs when neutrophils ≥ 0.5 x 109 Platelet engraftment occurs when platelets ≥ 20 x 109 Thomson B G et al. Blood 2000;96:

39 Early Complications of HSCTEarly Complications (Major cause of morbidity and mortality) Infections: Haemorrhagic cystitis Bacterial Hepatic veno-occlusive disease Viral Capillary leak syndrome Fungal Diffuse alveolar haemorrhage Acute GvHD Idiopathic pneumonia syndrome Multi-organ dysfuntion syndrome

40 Graft versus Host DiseaseAcute Usually occurs before D100 Organs affected – skin, gut, liver Chronic Usually develops after D100 Can involve skin, gut, liver, eyes, lungs, connective tissues More prone to opportunistic infections Quality of Life Risk Factors Prior history of Acute GvHD Unrelated donor Mismatched transplants Male recipients of female donors Older age of recipient or donor

41 Graft versus Host DiseasePrevention HLA matching Reduced intensity conditioning regimens Drugs – Ciclosporin, Methotrexate, Mycophenolate mofetil T-cell depletion (i.e. Campath) Treatment Steroids with ciclosporin ATG Extracorporeal photopheresis (ECP)

42 Late Effects Late Effects Chronic GvHD Back to work issuesLate infection and immune defects Secondary MDS / leukaemia / malignancy Pulmonary late effects including restrictive lung diseases and COPD Late graft failure Late liver complications (i.e. Hepatitis B,C and iron overload) Relapsed disease Late ocular effects including cataracts Infertility / sexual dysfunction QoL and neuropsychological functioning including intellectual and / or concentration issues Endocrine abnormalities e.g. hypothyroidism Emotional issues Cardiac failure Fatigue Dental late effects

43 Patient Outcomes Disease status after HSCT Patient outcome? D100 TRMBest response and at last contact?, Relapse or progression? Patient outcome? D100 TRM 1, 2 and 5 year TRM Most transplant related deaths occur within the first year of transplant TRM is likely to increase with Allogeneic transplant Advanced disease status at time of transplant Type of donor Intensity of conditioning regimen Patient age

44 The MED-A form

45 First report – 100 days after HSCTMED-A: First report – 100 days after HSCT

46 MED-A: Introduction Minimum Essential DataCompletion of the MED-A form is a requirement for all EBMT members. JACIE requirement B The clinical programme shall collect all the data necessary to complete the Transplant Essential Data forms of the CIBMTR or the Minimum Essential data-A forms of the EBMT First report should be submitted as soon as possible after D100 Follow up report should be submitted annually Patient must give consent for data submission

47 Thank you! Any Questions?