STEM CELL TRANSPLANT THERAPY/ IMMUNOSUPPRESSANT THERAPY IN HEMATOLOGICAL MALIGNANCIES

1. STEM CELLTRANSPLANT
THERAPY/ IMMUNOSUPPRESSANT
THERAPY IN HEMATOLOGICAL
MALIGNANCIES
Presenter: Dr. Pooja Dwivedi (JR-2 Pathology)
Moderator: Dr. Geeta Yadav, M.D.
(Associate Professor)
King George’s Medical University
Lucknow, Uttar Pradesh

2. In This
Presentation
 Stem cell
 Hematopoietic stem cell (HSC)
 Definition of Hematopoietic Stem Cell Transplantation
(HSCT)
 Indication of Hematopoietic Stem Cell Transplantation
 Types of Hematopoietic Stem Cell Transplantation
(HSCT)
 Transplant process
 Complication
 Hematopoietic Stem Cell Transplantation in different
hematopoietic malignancies
 Hematopoietic Stem Cell Transplantation in different
non-malignant conditions

3. Population of undifferentiated
cells which are able-
 To divide for indefinite
period
 To self renew
 To generate a functional
progeny of highly specialised
cells
STEM CELL

4. HIERARCHY OF
STEM CELL
1. Totipotent
(fertilised egg)
2. Pluripotent
(embryonic cell)
3. Multipotent
(hematopoietic)

5. HISTORY OF
BONE
MARROW
TRANSPLANT
 1956 – The first successful transplantation was done in
between Identical Twins with total body irradiation
 E. Donnall Thomas first successful Hematopoietic
Stem Cell Transplantation was done in treatment of
Acute Leukemias with complete remission
 E. Donnall Thomas
 The Nobel Prize, 1990

6.  1958 –Allogeneic BMT was not performed on
large scale until Jean Dausset, a French medical
researcher, made a critical discovery about the
human immune system : Human
histocompatibility antigens “HLA”
 1968 – First bone marrow transplant between
HLA matched Siblings.
 Noble prize in 1980

7. HEMATOPOIETIC
STEM CELLS
(HSCs)
 HSCs formation start during embryonic
development
 Found in bone marrow and umbilical cord blood
 Hemati= Greek prefix “blood”
 Poiesis/Poietic= Greek suffix “formation”
 IHC Expression: CD34

8. Hematopoietic
stem cell
 Multipotent ,self
renewing
progenitor cells
give rise to all
blood cells
 Maintain the
production of all
blood cells
throughout life

9. Hematopoietic
Stem Cell
Transplantation
(HSCT)
 Bone Marrow Transplant = Hematopoietic stem
cell transplant (HSCT)
(After the introduction of peripheral blood and
umbilical cord stem cells)
Definition :
 Any procedure where hematopoietic stem cells
of any donor and any source are given to a
recipient with intention of repopulating or
replacing the hematopoietic system in total or in
part

10. Hematopoietic
Stem Cell
Transplantation
(HSCT)
HSCT procedure usually carried out two process:
1. To replace an abnormal but non-malignant lympho-
hematopoietic system with one from a normal donor
2. To treat malignancy by allowing the administration
of higher dose of myelo-suppressive therapy

11. Indications for
Autologous
Transplant
 Non-Hodgkin lymphoma
 Hodgkin’s disease
 Multiple myeloma
 Solid tumours as Neuroblastoma , Ovarian
cancer, Germ-cell tumors

12. Indications for
Allogenic
Transplant
Malignant disorders
 Acute myeloid leukemia
(AML)
 Non-Hodgkin lymphoma
 Hodgkin’s Disease
 Acute lymphoblastic leukemia
(ALL)
 Chronic myeloid leukemia
(CML)
 Chronic lymphoblastic
leukemia (CLL)
 Myeloproliferative disorder
 Myelodysplastic syndromes
 Multiple Myloma
Non-Malignant disorders
 Aplastic anemia
 Thalassemia
 Sickle Cell Disease
 SCID

13. Types of
Transplant
1) Autologous BMT: Patients receive their own
stem cells
2) Allogeneic BMT: related or unrelated donor
 Syngeneic
 From sibling/related donor
 From unrelated donor
Depends on source of stem cell :
Bone marrow
 Peripheral blood
Umbilical cord blood

14. Transplant
Process
 Allogenic donor evaluation
 Stem cell collection
 Cryopreservation of stem cell
 Conditioning of patients
 Stem cell transfusion
 Recovery : Engraftment phase

15. Donor
Selection for
Allogenic
Transplant
 Essential for Allogeneic transplant
 The genes for the HLA proteins are clustered in the major
histocompatibility complex (MHC)
 Located on the short arm of chromosome 6
 HLA antigens are either “high expression” (10/10 match)
such as HLA‐A, B, C (class I), DRB1 (class II), or “low
expression” such as DQB1, DPB1, and DRB3/4/5 (all class II)
 Matched Related Donor (siblings) : 25% chance a sibling will
be full match
 If no matched is available; Search for Matched Unrelated
Donors (MUD) through bone marrow registry databases
Human Leukocyte Antigen (HLA) system ?

16. Algorithm for
selection of a
graft/donor for
allogeneic
transplant

17. Transplant
process:
Stem cells
collection
Stem cell sources:
1. Bone marrow (BM)
2. Peripheral blood (PBSC) 1986
3. Umbilical cord blood (UCB) 1988

18. Comparison
of three
sources of
stem cells

19. Graft
composition
 There are biological differences among the three sources
of grafts (PB, BM and UCB) due to their different
composition
 These grafts are primarily composed of:
 CD34+ cells, which make ~1% of the entire graft
composition
 Lymphocytes (mainly T-cells, and also B-cells and
natural killer (NK) cells)
 Myeloid precursors
 Monocytes (with potential for cytokine release)
 Other cells (e.g., endothelial progenitor cells and
mesenchymal cells)
The CD34+ cell dose is the primary determinant of
successful engraftment

20. Transplant
process:
Stem cells
collection
1.Bone marrow harvesting:
Under General anaesthesia Or spinal anaesthesia
Site: Aspirated from pelvis
The recommended cell dose in a BM graft is-
4×108 TNC (total nucleated cells)/kg of
recipient weight for hematologic malignancies
A dose of< 2×108 TNC/kg is discouraged
2.Peripheral blood stem cell harvesting

21. Factors to consider when selecting PB or BM graft

22. Peripheral
blood stem
cell harvesting
Administration of mobilisation agents- G-CSF:
 Disease-specific chemotherapy followed by high-dose
G-CSF 10 μg/kg/day SC until peripheral blood CD34
count increases above institutional target levels
 A PB graft is collected by apheresis procedure
 Typically, donors receive growth factor injection for
4 days and then undergo leukapheresis for 1–2 days
 The recommended CD34+ cell dose in a PB graft is at
least 4×106 CD34+ cells/kg of recipient weight
 While a dose of< 2×106 CD34+ cells/kg is
discouraged to avoid risk of engraftment failure

23. Peripheral
blood stem
cell harvesting

24. Mechanism of
action of
G-CSF

25. Advantages and
disadvantages
of Growth factor
mobilization
and Chemotherapy+
growth factor
mobilization
and collection
of CD34+ cells
Advantages Disadvantages
Growth factor mobilization • Shorter time from start
of mobilization to
transplant
• Fewer days of GF
administration
• Onset of collection is
more predictable
• No anti‐tumor activity
(hypothetical loss)
• Fewer CD34+ collected
than with C+GF
Chemotherapy+growth
factor mobilization
• More CD34+ cells
collected than with GF
alone
• Hypothetical gain in
disease control
• Longer stay of
intravascular catheter
• Higher risk of infection
• Neutropenia
• Thrombocytopenia
• Higher risk of
complications requiring
hospitalization
• Higher cost

26. Clinical
consequences and
recommendations
for different
CD34+ cell doses
Cell Dose Implications Recommendation
<1.5×106 CD34+/kg Delayed neutrophil and
platelet recovery, increased
transfusion requirement,
higher risk of engraftment
failure
Contraindicated especially
in myeloablative setting
1.5–3.0×106 CD34+/kg Delay in platelet recovery Discouraged but not
contraindication
3.0–5.0×106 CD34+/kg Adequate neutrophil and
platelet recovery
Adequate cell dose
(comfort zone)
>5.0×106 CD34+/kg Possible minimal gain in
earlier platelet and
neutrophil engraftment.
Possible improvement in
long term platelet recovery,
fewer transfusions
Uncertain benefit

27. Growth factors
utilized
for mobilization
of CD34+ cells
for
transplantation
Growth Factor Dose Comments
Filgrastim • Alone: 10–
16µg/kg/day
• After
chemotherapy:
5–10µg/kg/day
• Most established GF.
• Superior to sargramostim when used after
chemotherapy mobilization
• Cost can be high
Sargramostim 8µg/kg/day or
250µg/m2 /day
• Inferior to filgrastim when used after
chemotherapy mobilization.
• Limited data on use without
chemotherapy.
• Likely more side effects than filgrastim.
Pegfilgrastim • Alone: 6–12mg
single dose
• After
chemotherapy:
6mg single dose
• Superior to filgrastim in retrospective
analysis.
• More convenient to patients since single
injection.
• Cost is high

28. Proposed
algorithm for
allogeneic
CD34+
mobilization

29. Transplant
process:
Stem cells
collection
Apheresis
 Established thresholds for apheresis initiation is
5 to 20 CD34+ cells/microliter
 Collection – 1st apheresis in as little as 4- 5 days
or in some cases, 2-3 weeks
 Each session last for 2-5 hours for upto 4 days
depending upon CD34+ cells yields

31. Transplant
process:
Stem cells
collection
Umbilical
Cord Blood
Cord blood stem cell either from sibling or cord
blood banks
Advantages:
 Relatively ease of availability
 Criteria for a “match” less stringent; 4/6 match
acceptable
 No donor loss
 Less chances of viral infection & GvHD
Disadvantages:
 Limited no. of stem cell
 Delayed engraftment
 Higher chances of opportunistic infections & organ
failure

32. Transplant
process:
Cryopreservation
 Maintain collected stem cell products in liquid
nitrogen until the time of the patient’s
transplantation
 Cryopreservative used is dimethylsulfoxide
(DMSO)
 DMSO maintains cell viability by preventing ice
crystal formation within the cells during storage
 Maintain temperature of – 80 ⁰ C to – 180⁰ C

33. Transplant
process:
Conditioning
(Chemotherapy
Regimen)
 The conditioning period 7-10 days & during this
time patient is kept in a dedicated isolated room
with High Efficiency Particulate Air filters and all
supportive care
 By delivery of chemotherapy and/or radiation:
 To eliminate malignancy
To suppress the patient’s immune system from
rejecting the new stem cells
 Bone marrow transplantation regimens vary from
one patient to another, and depend upon the type of
cancer

34. CONDITIONING
REGIMENS
AGENTS USED
PRIMARILY
FOR
IMMUNOSUPRESSI
ON:
-Anti-thymocyte
globulin
-Fludarabine
AGENTS USED
FOR BOTH
PURPOSE:
 Total body irradiation
(TBI)
 Cyclophosphamide
AGENTS USED
PRIMARILY FOR
ANTI-
NEOPLASTIC
EFFECTS:
 Busulfan
 Melphalan
 Caboplatin
 Thiotepa

35. Transplant
process:
Stem cells
infusion
 Infusion - 20 minutes to an hour, varies
depending on the volume infused
 Infused through a central venous line CVL,
much like a blood transfusion
 Premedication with acetaminophen,
diphenhydramine and IV steroids
(hydrocortisone 100 mg IV or equivalent) prior
to infusion of both autologous and allogeneic
stem cell products

36. INFUSION

37. Transplant
process:
Recovery:
Engraftment
phase
 Recovery of normal levels cells is called
engraftment
 Engraftment usually begins to be observed after
10-21 days
Engraftment is defined : a minimum criteria of
1. An absolute neutrophil count of ≥500/mm3 for
three consecutive days
2. A platelet count of ≥20,000/mm3 for three
consecutive days (and without transfusions
for 7 days)
3. A haematocrit ≥25% for at least 20 days
(without transfusions)

38. Engraftment
failure
Engraftment failure is defined as a failure to
achieve
 Absolute neutrophil count of< 200/mm3 by day
+21 in autologous transplant
 Absolute neutrophil count<500/mm3 without
evidence of relapse by day +28 post-transplant
in case of allogenic transplant, irrespective of
source of stem cells

39. Supportive
care
 Pain should be assessed every 4 hourly and
more frequently to assess the efficacy of
analgesic regimen
 Pain management: oral narcotics - morphine,
hydromorphone and fentanyl are used early
during transplant course
 For mucositis: oral mouthwash (mixture of
viscous lidocaine + diphenhydramine +
magnesium hydroxide)
 Initiate bowel laxative: bowel movement every
24-48 hourly

40. Supportive
care
Diarrhea:
 Evaluate stool for C. difficile, if positive treat
with antibiotic according to sensitivity
 Once C. difficile ruled out, begin with
antidiarrheals- LOPERAMIDE
 If no response to loperamide, consider for
somatostatin analogue & gastrologist
consultation
 In menstruating females undergoing high-dose
chemotherapy, where resultant
thrombocytopenia predicted, pre-treatment to
induce amenorrhea is indicated

41. Infection
prophylaxis

42. Transfusion
policy:
Red Cells
 Leuko-depleted blood components should be
transfused to all patients with aplastic anaemia
 Blood components should be gamma-irradiated
for PBSC transplant patients during stem cell
mobilisation and collection since transfused
leukocytes might be captured in the PBSC
harvest and subsequently induce GvHD
 Thresholds defined for haemoglobin 8.0 g/dL
and PCV less than 25%, below which red cell
transfusions are always given

43. Transfusion
policy:
Platelet
concentrates
 Threshold of 10 x 109/L in stable
thrombocytopenic patients is optimal for
prophylactic platelet transfusion
 A higher threshold of 20 x 109/L should be used
in patients with fever, sepsis, splenomegaly and
other well-established causes of increased
platelet consumption
 If an invasive procedure is planned, e.g. central
line insertion, the platelet count should be >50 x
109/L
 PCs should be transfused when there is
significant clinical bleeding, irrespective of the
platelet count

44. Transfusion
policy:
Granulocyte
transfusions
 Granulocyte transfusions are probably best
reserved for patients with granulocyte counts
less than 0.2 x 109/L, and
 Documented bacterial or fungal infections not
responding to at least 3 days of appropriate
antimicrobial therapy, in situations where the
granulocyte count is not expected to recover
within 7 days

45. Complications:
Major
syndromes

47. Pathophysiology
of GvHD

48. Clinical staging
and grading of
acute GvHD

49. Treatment for
acute GvHD
 Methyl-predenisolone (MP) - 2 mg/kg/day is
best initial therapy
 Calcineurin inhibitor can be given along with
MP for 7-14 days, then tapered slowly if
complete response to therapy
 Complete responses occur in 25 to 40% of
patients with grade II to IV aGvHD
Failure of therapy is usually defined as:
 Progression after 3 days, or
 No change after 7 days, or
 Incomplete response after 14 days

50. Treatment for
acute GvHD
 Second line treatment of steroid-refractory aGvHD
 Methylprednisolone (2–5 mg/kg)
 Immunosuppressive drugs: - Tacrolimus,
Mycophenolate mofetil, sirolimus
 Oral non-absorbable steroids (in case of GI
involvement)
 Anti-thymocyte globulin
 Monoclonal antibodies
 Pentostatin:- Inhibitor of adenosine-deaminase

51. Chronic GvHD
“Diagnostic signs”
 Poikiloderma
 Lichen planus like skin
lesion
 Lichen planus lesion of
mouth & genitalia
 Oesophageal stricture
 Bronchiolitis obliterans
 Joints contracture &
fascitis
“Distinctive signs”
 Skin depigmentation
 Nail dystrophy
 Xerostomia
 Alopecia
 Kerato-conjunctivitis
sicca
 Myositis

52. Treatment for
chronic GvHD
Standard frontline therapy: A combination of
Cyclosporine A and prednisolone
 Steroid dose: 1 to 1.5 mg/kg/day at least 2
weeks followed by tapering, according to
response
 Usually continuing for up to 12 months
No standard second-line therapy
 Therapy of Low dose total lymphoid irradiation,
PUVA therapy, extracorporeal
photochemotherapy, Mycophenolate mofetil,
tacrolimus, and thalidomide have been reported
to improve clinical menifestations

53. Assessment of
HSCT in
different
hematological
diseases
A. PATIENT FACTORS-
 Age,
 Performance status-
Given by Eastern cooperative oncology group(ECOG)-
grading 0-5
0- Fully active
5- Dead
 Comorbidity
B . DISEASE FACTORS
C. DONOR EVALUATION
D. CONDITIONING THERAPY
E. POST ALLO-TRANSPLANT THERAPY

54. Stem cell
therapy in
different
hematological
malignacies
Hematopoietic Cell Transplantation
for Acute Lymphoblastic Leukemia
Hematopoietic Cell Transplantation
for Acute Myeloid Leukemia
Hematopoietic Cell Transplantation
for Chronic Myeloid Leukemia
Hematopoietic Cell Transplantation
for Myelofibrosis
Hematopoietic Cell Transplantation
for Chronic Lymphocytic Leukemia
Hematopoietic Cell Transplantation
for Multiple Myeloma

55. Variables for
decision making
prior to allo‐HCT
in adultAcute
Lymphoblastic
Leukemia
patients in
Clinical
Remission 1
(CR1)
Acute lymphoblastic leukemia
*MRD: Minimal residual disease, *TRM: Transplant related mortality

56. Basic ALL
prognostic
parameters
currently used
in various
protocols
to define
“high‐risk”
Clinical Genetic
Adverse risk factors used
to determine who might
have “upfront” allo‐HCT
• Advancing age
• High Presenting
WBC:
o B‐cell phenotype; >30
× 109 /L
o T-cell phenotype; >100
× 109 /L
• Persistence of MRD
at a protocol‐relevant
timepoint
• BCR‐ABL1
translocation
• MLL‐AF4
translocation
• Complex (≥5 unrelated
chromosomal
abnormalities without
other established
abnormality)
• Low‐hypodiploid
(30–39 chromosomes)/
• Near‐triploid (60 to
78 chromosomes)

57. The who,
when, and how
of allo‐HCT
for Acute
Lymphoblastic
Leukemia
A. PATIENT FACTORS:
• Age: < 70 years.
consider biological over chronological age
performance status (PS)
comorbidities
age‐ specific life expectancy
other disease‐related high‐risk features
• Performance status and Comorbidity: Eastern cooperative
oncology group(ECOG) PS 0–1 and with no substantial
comorbidities
B . DISEASE FACTORS:
Newly diagnosed ALL:
Relapsed ALL: Allo‐HCT is offered only upon achieving
morphologic Clinical Remission

58. C. DONOR EVALUATION:
Ideal: HLA‐matched sibling donor followed by HLA‐MUD mismatched unrelated
donor
Alternative donor: Single‐antigen HLA‐ mismatched or haploidentical donor
D. CONDITIONING THERAPY:
• ≤ 40 years patients: TBI‐based Myeloablative conditioning(MAC) regimen
• > 40 years patients: Reduced intensity conditioning(RIC) regimen
• MAC regimen can be considered for high‐risk patients aged up to 45 if fit
E. POST ALLOTRANSPLANT THERAPY:
• For Reduced intensity conditioning(RIC) allo‐HCT recipients: 3‐monthly prophylactic
intrathecal methotrexate for 2 years post‐transplant
• For CNS prophylaxis starting 3 months post‐transplant
• Donor Lymphocyte Infusion may be given for mixed‐chimera and/ or Measurable
Residual Disease (MRD)‐positivity
• Do not routinely restart TKI post‐allo‐HCT for Ph+ ALL without evidence of molecular
relapse

59. Timing of
allogeneic
transplant for
AML
Acute Myeloid Leukemia
*CR1: Clinical remission 1
*CR2: Clinical remission 2
*REF:

60. European
Leukemia net
risk groups:
Based on
cytogenetics
and molecular
testing
Genetic Group Subset
Favorable • t(8;21); RUNX1‐RUNX‐1T1,
• inv(16), t(16;16); CBFB‐MYH
• Mutated NPM1 without FLT3‐ITD (normal
karyotype)
• Mutated CEBPA(CCAAT‐enhancer‐binding protein
alpha) (normal karyotype)
Intermediate I • Mutated NPM1 with FLT3‐ITD (normal karyotype)
• Wild‐type NPM1 with or without FLT3‐ITD
(normal karyotype)
Intermediate II • t(9;11); MLLT3‐MLL
• Cytogenetic abnormalities not classified as favorable
or adverse
Adverse • inv(3) or t(3;3); RPN1‐EVI1
• t(6;9); DEK‐NUP214
• t(v;11) ; MLL rearranged
• −5 or del (5q); −7; abnl (17p); complex karyotype

61. The who,
when, and how
of allogeneic
HCT for AML
A. PATIENT FACTORS
• Age
• Adequate baseline functional status
B. DISEASE FACTORS
• Intermediate or poor‐risk disease (based on cytogenetics and
molecular testing)
• Those with favorable risk are usually not transplanted in first
remission, until the time of relapse or if they have concurrent
cytogenetic or genetic abnormalities such as c‐KIT
• Transplants for refractory disease have poor outcomes
C. DONOR EVALUATION
• Ideal donor: HLA‐ matched sibling(Best)
• Or matched unrelated donor matched at all HLAA, B, C, and
DRB1 loci (inferior outcomes)

62. D. CONDITIONING THERAPY
• Busulfan and Cyclophosphamide
• Cyclophosphamide and Total Body Irradiation (TBI)
• RIC results in higher relapse rates but does not appear to reduce
Transplant Related Mortality (TRM)
E. POST ALLOTRANSPLANT THERAPY
• No intervention has been proven to reduce relapse risk

63. Hematopoietic
Stem Cell
Transplantation
for Chronic
Myeloid
Leukemia
Disease Phase Indications for Transplant
Chronic phase • After failure of second line TKI therapy
• After failure of first lineTKI therapy with
T315I (if ponatinib not available)
• Intolerance of TKIs
Accelerated phase • In newly diagnosed patients, after failure of
TKI therapy
• If accelerated phase develops while on TKI
therapy
Blast crisis • Following treatment with chemotherapy and
TKI (best outcomes if transplanted in 2nd
chronic phase)
Suggested indications for allogeneic hematopoietic cell
transplantation in CML by disease phase

64. The who,
when, and how
of allogeneic
HCT for CML
A. PATIENT FACTORS
• Age:
• Performance Status (PS) and Comorbidity:
• As we have availability of good pharmaceutical
(non‐transplant) treatment options so HCT restricted to those
with excellent PS
 Fully myeloablative regimens: preferred in younger patients,
Patients with CML (<65years) who have indications for
transplant and with good PS and low co‐morbidity scores
Reduced‐intensity and non‐myeloablative conditioning
regimens: allow HCT to older patients with comorbidities or
borderline PS, appropriate indications (e.g., TKI failure,
advanced phase disease)

65. B. DISEASE FACTORS
• Phase of disease in newly diagnosed CML:
1) Blast phase: Patients presenting with blast phase disease should, if at all possible,
be reverted back to second chronic phase followed by immediate HCT
2) Accelerated phase: Long‐term TKI therapy
3) Chronic phase: Initial therapy with TKIs
• Primary or secondary TKI failure:
1) Switching to an alternative TKI
2) Patients with T315I mutation should be considered for HCT
3) Patients who develop accelerated phase disease while on TKI therapy should be
referred for HCT

66. C. DONOR EVALUATION
• Ideal donor: Matched sibling donor, or an unrelated donor matched at all A, B, C,
DRB1 loci using high resolution typing
• Alternative donor: Umbilical cord blood, HLA‐haploidentical, or
‐antigen‐mismatched donors may be considered in those without a
matched‐related or ‐unrelated donor
D. CONDITIONING THERAPY:
• Myeloablative conditioning ( targeted busulfan + cyclophosphamide)
• Fludarabine‐ or Total Body Irradiation(TBI)‐based non‐myeloablative or other
Reduced‐intensity regimens
E. POST ALLOTRANSPLANT THERAPY:
• Post‐transplant relapse: TKI, Donor leukocyte infusion(DLI){Best}, and
interferon therapy
• Prophylactic use of TKIs in the early post‐transplant period for persistent positive
BCR‐ABL candidates.

67. Decision for
allogeneic
HCT and JAK
inhibitor
treatment in
Myelofibrosis
*DIPSS-Dynamic International Prognostic Scoring System

68. Scenario of
allogeneic
HCT in
Myelofibrosis

69. The who,
when, and how
of allo‐HCT
for Pre-
Myelofibrosis
A. PATIENT FACTORS
1. Age: Not a deciding factor
2. Comorbidities and functional status: should be considered due
to the higher Non Relapse Mortality(NRM) (eg: Portal
hypertension is a risk factor for NRM)
3. Any measure that improves the patient’s PS and that reduces
the individual transplant‐specific risk should be considered in
the pre‐transplant phase (reduction of spleen size with JAK
inhibitor or chelation in case of iron overload)
B. DISEASE FACTORS
1. Intermediate‐2 or high‐risk according to DIPSS are
considered for transplant
2. Allo‐HCT in blastic phase: worse outcome
3. Factors that influence outcome in transplant decision beside
the risk factors included in dynamic IPSS (DIPSS)-
• Cytogenetic
• Thrombocytopenia

70. C. DONOR EVALUATION
1. HLA‐identical sibling donors
2. Second choice: 10/10 HLA‐matched unrelated donors
3. Worse outcome: Mismatched unrelated donors
4. High rate of graft failure: Cord blood
D. CONDITIONING THERAPY
1. Lower intensity regimen : For patients with older age or with comorbidities, or both
2. More intensive regimen: For patients with advanced disease and good performance status
E. POST ALLOTRANSPLANT THERAPY
1. Disease‐specific markers such as JAK2V617F, CALR, and MPL mutations should be monitored to
detect MRD after allo‐HCT
2. Patients with MRD or with decreasing donor cell chimerism after transplantation: Strategies to
avoid clinical relapse
a) Discontinuation of immune‐suppressive drugs
b) Donor Leukocyte Infusion or
c) Both
3. For patients with poor graft function: CD34+ selected cell boost

71. The who,
when, and how
of allogeneic
HCT
for patients
with Chronic
Lymphocytic
Leukemia
A. PATIENT FACTORS:
Age: not a determining factor
Performance Status (PS) and Comorbidity:
• Patients with CLL (< 75years) having-
High‐risk disease features, good PS, low co‐morbidity scores
are considered allo‐HCT eligible
PS and co‐morbidity score used as exclusion criteria to lower
TRM

72. B. DISEASE FACTORS
 Newly diagnosed CLL:
 Risk Stratification:
1) Younger patients with progressive disease and del17 or TP53 mutations will undergo
tissue typing to identify potential donors
Currently revised guidelines suggest we should defer allo‐HCT in first remission for
these patients if novel agents are available and well tolerated
2) Primary refractory CLL – patients who are refractory to front‐line
chemo‐immunotherapy are candidates for allogeneic
 Relapsed CLL:
4) Early relapse after chemo‐immunotherapy: those relapsing with clinical disease
within 2 years after induction or salvage therapy
5) Failure of, or intolerance of novel agents
Allo‐HCT for patients fulfilling the above criteria

73. C. DONOR EVALUATION:
• Ideal donor: HLA‐MSD or HLA‐MUD at all A, B, C, DRB1 loci using high resolution
typing
• Alternative donor: HLA‐haploidentical
D. CONDITIONING THERAPY:
• Non‐myeloablative regimens are used
E. POST ALLOTRANSPLANT THERAPY:
• After stopping immune suppressive therapy at 100 days post transplant, patients with
no GvHD and adequate PS will be considered for DLI, particularly if mixed donor
chimerism or if there are rising levels of MRD

74. The who,
when, and how
of allogeneic
HCT
for Multiple
Myeloma
A. PATIENT FACTORS:
Age:
Performance Status (PS) and Comorbidity:
• We use PS and comorbidity score as exclusion criteria to
lower TRM
• Younger patients with MM (<55 years) with good PS and low
comorbidity scores should be considered allo‐HCT eligible
B. DISEASE FACTORS:
Newly diagnosed MM:
Myeloma Risk Stratification in allo‐HCT eligible patients at
diagnosis:
• Karyotyping
• Plasma cell enriched FISH
• Gene Expression Profiling (GEP)

75. If any of the following are discovered – we proceed to donor search:
1. Ultra‐high‐risk MM – defined by Revised Multiple Myeloma‐International Scoring System stage 3 or a
high plasma cell proliferation index and
the presence of any or a combination of the following specific genetic changes:
• del(17p)
• chromosome 1 q gains
• t(14:20)
• t(14:16)
• high‐risk gene expression profile
2. Primary Plasma Cell Leukemia
3. Primary Refractory MM: patients who are refractory to or progressing on combination therapy involving
both full doses of Lenalidomide and a proteasome inhibitor (bortezomib/carfilzomib) after four cycles
Relapsed MM:
4. Early relapse after AHCT: defined as those relapsing with clinical disease (NOT biochemical progression)
within 18 months after induction and AHCT
• These patients are considered if they achieve a VGPR or better disease status with salvage therapy
• We offer allo‐HCT consultation to eligible patients fulfilling the above criteria for short survival with current
therapies and AHCT

76. C. DONOR EVALUATION:
• Ideal donor: Matched Sibling or an unrelated donor matched at all A, B, C, DRB1 loci
using high resolution typing
• Alternative donor: haploidentical or other mismatched donor
D. CONDITIONING THERAPY:
• We offer fludarabine and melphalan based reduced intensity regimens
• Non‐myeloablative regimens with low dose Total Body Irradiation are not used
• For patients receiving allo‐HCT as their first ever transplant (e.g., primary plasma cell
leukemia), myeloablative regimens have been used
E. POST‐ALLOTRANSPLANT THERAPY:
• At day 100, patients with no GvHD and adequate PS: initiate maintenance therapy with
lenalidomide or bortezomib with intent to continue such therapy for 3 years

77. Stem cell
therapy in
different Non-
malignant
hematological
diseases
Hematopoietic Cell Transplantation for
Aplastic Anemia
Hematopoietic Cell Transplantation for
Sickle Cell Anemia
Hematopoietic Cell Transplantation for
Thalassemia
Hematopoietic Cell Transplantation for
Primary Immunodeficiency

78. Hematopoietic
Cell
Transplantation
for Aplastic
Anemia
Treatment algorithm for adult patients with SAA
*IBMFS: Inherited Bone Marrow Failure Syndromes
*IST: Immunosuppressive Therapy

79. Treatment
algorithm for
pediatric
patients with
SAA

80. Indications for
transplantation
in Sickle Cell
Disease
HLA‐Matched Sibling Donor HLA‐Matched Unrelated Donor or
Haploidentical Donor
Consider early transplant: With onset of
symptoms
Stroke
Stroke – overt or silent Elevated TCD velocity unresponsive to transfusions
Elevated Transcranial Doppler
(TCD)velocity
Recurrent ACS despite supportive care
Recurrent acute chest syndrome Recurrent severe venocclusive episode(VOE)
despite supportive care
Recurrent VOE requiring medications Red cell alloimmunization+indication for chronic
red cell transfusion therapy
Indication for chronic red cell transfusion
therapy
Pulmonary hypertension
Pulmonary hypertension Sickle nephropathy
Recurrent priapism
Sickle nephropathy
Bone and joint involvement
Sickle retinopathy tricuspid regurgitation
velocity(TRV) >2.5m/s
Sickle related liver injury or iron overload

81. Who, when,
and how
of allo‐HCT
for Sickle Cell
Disease
Patient related variables:
1 Age – excellent results in pediatric transplant
Adult transplants are rarely undertaken due to anticipated toxicity
2 Indications:
(i) CNS−Stroke most important indication
(ii) Other manifestations based on severity include
 ACS
 pain episodes
 priapism/bone/joint disease
 nephropathy
 Retinopathy
(iii) Red cell alloimmunization despite the need for chronic transfusion therapy
 In general, the severity of symptoms and quality of life are balanced with
donor availability and transplant risks based on the type of transplant

82. 3. Contraindications – these are relative
• Established pulmonary hypertension
• Liver cirrhosis
• Patients with poor performance status secondary to CNS events
• Established irreversible lung or cardiac disease
• HLA antibodies targeted against donor are a high risk for graft rejection
Donor related variables:
• Recent studies used G‐CSF mobilized peripheral blood(Best source for stem cells)
• Other source for stem cell: Marrow
• UCB has a higher chance of rejection
• We prefer bone marrow for matched sibling donor transplantation
• In the absence of a sibling donor, identify a HLA-matched unrelated donor (15–20%)

83. Preparative regimens:
• RICs for all SCD transplants
• Use immunosuppression with fludarabine/cyclophosphamide and ATG followed
by a boost of CD34+ selected cells in an patient with falling myeloid donor
chimerism after MSD HCT
• If a RIC regimen results in complete graft rejection, MAC may be necessary to
ensure achieve engraftment
Supportive care pearls:
• Seizure prophylaxis,
• Strict hypertension control to within 10% of normal for the SCD
• Strict fluid and electrolyte balance maintenance
• Relative isolation during period of recovery,
• Good management of thrombocytopenia

84. Factors that
must be
considered for
individual
decision making
about allo-HCT
for Thalassemia

85. The who,
when, and how
of allo‐HCT
for
Thalassemia
A. PATIENT FACTORS:
All patients affected by transfusion dependent thalassemia
Age:
• Excellent results: pediatric patients
• Less satisfactory results: adult patients
B. DISEASE FACTORS:
Significant risk factor for transplant outcome
• Age >14 years
• Iron overload due to repeated transfusion
• Patients belonging to the Pesaro low risk category, >90% of
transplant success is predicted
• Life long optimal transfusion and chelation therapy is the
key for a successful transplant

86. Pesaro risk
factors
for allo‐HCT
in Thalassemia
1 Quality of chelation
received for the
entire life span
before
transplantation
Regular vs irregular
2 Hepatomegaly ≤2cm from the costal
arch vs>2cm
3 Liver fibrosis at
pre‐transplant liver
biopsy
Absent vs present

87. C. DONOR EVALUATION:
 Source of graft: Bone marrow or cord blood (HLA‐identical sibling) derived cell are
preferred
Peripheral blood graft should be avoided
D. CONDITIONING THERAPY AND TRANSPLANT MANAGEMENT:
• Always considered in determining the risk/benefit ratio and therapeutic decision in
non-malignancies
Fully myeloablative regimens without radiotherapy is the standard in all patients
E. POST‐ALLOTRANSPLANT THERAPY:
• Early mixed chimerism is a risk factor for thalassemia recurrence
• Long‐term follow‐up after successful transplant should be performed
• In case of thalassemia recurrence, a second transplant is usually not recommended

88. Iron overload –
Treatment
after allo‐HCT
Phlebotomy 6ml/kg whole blood
every 14 days
Deferoxamine 20–40mg/kg is a valid
alternative to
phlebotomy for heavily
iron loaded patients
Deferasirox 10–20mg/kg (once day
oral administration) is
efficacious and safe but
still limited experience
(7–14mg/kg with the
new formulation
already released in few
countries)

89. Balancing the risks
of an uncorrected
Primary
Immunodeficiency
with the risks of
allo‐HCT

90. Finding the right answer
beging with asking the
question…

91. 1. What is the
least invasive
source of stem
cells from
human body?
A) Cord blood
B) Adipose tissue
C) Bone marrow
D) Mesenchymal cell

92. 2. Both
autologous and
allogenic
hematopoietic
stem cells can
be done in?
A) Severe Combined Immunodeficiency
B) Multiple Myeloma
C) Solid Tumors
D) Severe Aplastic Anemia

93. 3. Required CD
34+ dose in
peripheral blood
stem cell
transplantation?
A) 4-6 × 106/Kg
B) 2-3× 106/Kg
C) 3 × 106/Kg
D) 6-7 × 106/Kg

94. 4. Which one is
not a basic
genetic
parameter for
ALL to
define it as
high risk?
A) BCR‐ABL1 translocation
B) MLL‐AF4 translocation
C) Low hyperdiploid
D) Near triploid

95. 5.Pesaro risk
factors
for allo‐HCT
in thalassemia
does not
include?
A) Hepatomegaly
B) Quality of chelation received
C) Liver fibrosis
D) Capability and compliance of patient

96. THANKYOU!