Partially matched, nonmyeloablative allogeneic transplantation: clinical outcomes and immune reconstitution.

PURPOSE: Allogeneic transplantation is typically limited to younger patients having a matched donor. To allow a donor to be found for nearly all patients, we have used a nonmyeloablative conditioning regimen in conjunction with stem cells from a related donor with one fully mismatched HLA haplotype. PATIENTS AND METHODS: Fludarabine, cyclophosphamide, and alemtuzumab were used as the preparatory regimen. Additional graft-versus-host disease (GVHD) prophylaxis included mycophenolate with or without cyclosporine. Patients with persistence of disease had a donor lymphocyte boost planned. Toxicities, engraftment, response, survival, and immune recovery are reported. RESULTS: Forty-nine patients with hematologic malignancies or marrow failure and no other available donors were enrolled. Ninety-four percent of patients had successful engraftment, and 8% had secondary graft failure. The treatment-related mortality rate was 10.2%, and 8% of patients had severe GVHD. Encouraging evidence of quantitative lymphocyte recovery through expansion of transplanted T cells was noted by 3 to 6 months. Seventy-five percent of patients attained a complete remission, and 1-year survival rate was 31% (95% CI, 18% to 44%). A standard-risk group of 19 patients with aplasia or in remission at transplantation demonstrated a 63% 1-year survival rate (95% CI, 38% to 80%) and 2.9-year median overall survival time (95% CI, 6.2 to 48 months). CONCLUSION: Nonmyeloablative therapy using haploidentical family member donors is feasible because the main obstacles of GVHD and graft rejection are manageable, allowing readily available stem-cell donors to be found for nearly all patients. Further qualitative and quantitative improvement in immune recovery is needed to address the high rate of relapse and risk of severe infections.

Duke Scholars

Author Carlos Manuel de Castro III Medicine, Hematologic Malignancies and Cellular Therapy

Author Gwynn Douglas Long Medicine, Hematologic Malignancies and Cellular Therapy

Author Cristina Gasparetto Medicine, Hematologic Malignancies and Cellular Therapy

Author Keith Michael Sullivan Medicine, Hematologic Malignancies and Cellular Therapy

Author Mitchell Eric Horwitz Medicine, Hematologic Malignancies and Cellular Therapy

Author Anand Shreeram Lagoo Pathology

Author Donna Niedzwiecki Biostatistics & Bioinformatics, Division of Biostatistics

Author Jon Paul Gockerman Medicine, Hematologic Malignancies and Cellular Therapy

Author Joseph Odell Moore Medicine, Hematological Malignancies

Author Nelson Jen An Chao Medicine, Hematologic Malignancies and Cellular Therapy