Hematopoietic cell transplantation in older patients with hematologic malignancies: Replacing high-dose cytotoxic therapy with graft-versus-tumor effects

Peter A. McSweeney*, Dietger Niederwieser, Judith A. Shizuru, Brenda M. Sandmaier, Arthur J. Molina, David G. Maloney, Thomas R. Chauncey, Theodore A. Gooley, Ute Hegenbart, Richard A. Nash, Jerald Radich, John L. Wagner, Steven Minor, Frederick R. Appelbaum, William I. Bensinger, Eileen Bryant, Mary E.D. Flowers, George E. Georges, F. Carl Grumet, Hans Peter KiemBeverly Torok-Storb, Cong Yu, Karl G. Blume, Rainer F. Storb

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

1265 Scopus citations

Abstract

Toxicities have limited the use of allogeneic hematopoietic cell transplantation (HCT) to younger, medically fit patients. In a canine HCT model, a combination of postgrafting mycophenolate mofetil (MMF) and cyclosporine (CSP) allowed stable allogeneic engraftment after minimally toxic conditioning with low-dose (200 cGy) total-body irradiation (TBI). These findings, together with the known antitumor effects of donor leukocyte infusions (DLIs), led to the design of this trial. Forty-five patients (median age 56 years) with hematologic malignancies, HLA-identical sibling donors, and relative contraindications to conventional HCT were treated. Immunosuppression involved TBI of 200 cGy before and CSP/MMF after HCT. DLIs were given after HCT for persistent malignancy, mixed chimerism, or both. Regimen toxicities and myelosuppression were mild, allowing 53% of eligible patients to have entirely outpatient transplantations. Nonfatal graft rejection occurred in 20% of patients. Grades II to III acute graft-versus-host disease (GVHD) occurred in 47% of patients with sustained engraftment. With median follow-up of 417 days, survival was 66.7%, nonrelapse mortality 6.7%, and relapse mortality 26.7%. Fifty-three percent of patients with sustained engraftment were in complete remission, including 8 with molecular remissions. This novel allografting approach, based on the use of post-grafting immunosuppression to control graft rejection and GVHD, has dramatically reduced the acute toxicities of allografting. HCT with the induction of potent graft-versus-tumor effects can be performed in previously ineligible patients, largely in an outpatient setting. Future protocol modifications should reduce rejection and GVHD, thereby facilitating studies of allogeneic immunotherapy for a variety of malignancies.

Original languageEnglish (US)
Pages (from-to)3390-3400
Number of pages11
JournalBlood
Volume97
Issue number11
DOIs
StatePublished - Jun 1 2001

ASJC Scopus subject areas

  • Hematology
  • Biochemistry
  • Cell Biology
  • Immunology

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