Donor Lymphocyte Infusion: Dr. Chenhua Yan

1. CHENHUA YAN, MD
China
• Associate Professor, Peking University Institute of
Hematology
• Dr. Yan completed her residency from the Peking University
People’s Hospital an dcurrently serves as an associate
professor at the same institute. Her interests are in
hematologic malignancies and clinical trials.

2. Peking University People’s Hospital & Institute of Hematology
Beijing Key Laboratory of HSCT, Beijing, P.R.China
Chen-hua Yan M.D
Modified donor Lymphocyte Infusion for Relapse of
Hematologic Malignancies after Haploidentical
Hematopoietic Stem Cell Transplantation

3. Content
Establishment of modified donor
lymphocyte infusion
Modified donor lymphocyte infusion
for the treatment of relapse
1
2
Modified donor lymphocyte infusion
for the prevention of relapse3

4. Relapse remains a major complication after
haploidentical transplantation
Lee KH, et al. Blood, 2011,118: 2609-2617
Huang XJ, et al. BBMT,2009,15:257-261

5. Limited efficacy of DLI in the treatment of relapse
Levine JE, et al. BMT. 2008, 42: 201-205
Schmid, et al. J Clin Oncol,2007,25:4938-45
Patients receiving DLI (n=228) 21%
Patients not receiving DLI (n=171) 9%
P ＜ 0.0001

6. One probable reason for the limited efficacy of DLI
• Higher incidence of severe acute GVHD after DLI
Marks DI, et al. Blood 2002; 100: 3108.
Collins Jr RH, et al. J Clin Oncol 1997; 15: 433.
Chalandon , et al. BMT 2010; 45: 558.
33%
28%
15%
33%
26%
60%
46.40%
22.40%
60.70%
32.10%
34%
21.60%
12.50%
25%
15.20%
0%
10%
20%
30%
40%
50%
60%
70%
acute GvHD grade 2-4 acute
GvHD
grade 3-4 acute
GvHD
chronic GvHD extensive
chronic GvHD
RIC-sibling donor
MA-siblingand unrelated
MA-siblingand unrelated

7. Methods to minimize severe GVHD after DLI
Yan CH, et al. clinical transplant. 2012; 26: 868-876
• Escalating dose of DLI
• CD8+
T cell depleted DLI
• Modified DLI

8. Part 1
Establishment of modified DLI

9. • G-CSF could modulate the polarization of T cells from a Th1 to a
Th2 phenotype
• G-CSF could indirectly induce T-cell hypo-responsiveness through
the selective increase of DC2 cells and monocytes and the down-
regulation of the CD28/B7 co-stimulatory signal.
• G-CSF could augment NK-T-cell–dependent CD8+
cytotoxicity
G-CSF moblized peripheral blood stem cell for Infusion
G-CSF maybe separates GVHD and GVL effects
Huang XJ,et al. Haematologica. 2004; 89: 1517-1524
Huang XJ, et al. Transpl Immunol. 2007; 17: 193-197.
Morris ES, et al. J Clin Invest. 2005; 115: 3093-3103.

10. • Twenty patients were enrolled. Unstimulate donor lymphocyte
infusion (n=11, hematological relapse=5), GPBSCs infusion (n=9,
hematological relapse=9).
• DLI: MNC > 1×108
/Kg
• Acute GVHD after DLI: GPBSCs 5/9 vs. lymphocytes 10/11
(P>0.05)
• Grade 3 - 4 acute GVHD after DLI: GPBSCs 0/9 vs. lymphocytes
2/11 (P>0.05)
• CR rate after DLI: GPBSCs 7/9 vs. lymphocytes 3/5 (P<0.01)
GPBSCs Infusion vs. unstimulate lymphocytes ifusion
Huang XJ,et al. Chin Med J (Engl). 2003; 116 (5):736-741.
GPBSCs infusion: G-CSF mobilized peripheral blood stem cell infusion

11. Application of immunosuppressive agents after GPBSCs
infusion reduces severe acute GVHD
Huang XJ, et al. Hematologica 2007,92:414-417
In haploidentical DLI: application of immunosuppressive agents after
GPBSCs infusion could reduce severe GVHD
Grade 3 - 4 acute GVHD: (P=0.013)
•no prophylaxis: 5/9
•with prophylaxis: 1/11
Question?---What is the appropriate
duration of immunosuppressive
agents after haploidentical GPBSCs
infusion?
Acute GVHD
no prophylaxis
with prophylaxis

12. Application of immunosuppressive agents after GPBSCs
infusion reduces acute GVHD
Yan CH, et al. clinical transplant. 2012; 26: 868-876
49.5%
31.6%
14.4%
9.3%
In haploidentical DLI: prophylaxis 6 - 8 weeks reduced incidence of
grade 3 - 4 acute GVHD

13. Application of immunosuppressive agents after
GPBSCs infusion
Problems?
reducing DLI-associated
acute GVHD
preserving GVL effects?

14. Application of immunosuppressive agents for 6 - 8 weeks
reduced acute GVHD after haploidentical DLI
67.7%
39.0%
63.6%
32.7%
32.9%
8.2%
Yan CH, et al. Chin Med J (Engl) 2014: 127: 3602-3609.
acute GVHD
Grade 2 - 4 acute
GVHD
Grade 3 - 4 acute
GVHD
prophylaxis <6w prophylaxis <6w
prophylaxis <6w
prophylaxis 6 - 8w
prophylaxis 6 - 8w
prophylaxis 6 - 8w
P=0.020 P=0.012 P=0.005
prophylaxis for 6 - 8 w (n=52)
prophylaxis <6 w (n=51)

15. Application of immunosuppressive agents for 6 - 8 weeks did
not influence relapse rate after haploidentical DLI
Total patients (n=103) Hematological relapsed
(n=54)
MRD-positive (n=49)
69.0%
26.6%
80.0%
55.6% 51.5%
17.3%
Yan CH, et al. Chin Med J (Engl) 2014: 127: 3602-3609.
prophylaxis for 6 - 8 w (n=52)
prophylaxis <6 w (n=51)

16. Yan CH, et al. Chin Med J (Engl) 2014: 127: 3602-3609.
Application of immunosuppressive agents for 6 - 8 weeks
improved survival after haploidentical DLI
Total patients (n=103) Hematological relapsed
(n=54)
MRD-positive (n=49)
prophylaxis for 6 - 8 w (n=52)
prophylaxis <6 w (n=51)

17. Establishment of modified donor lymphocyte
infusion (mDLI)
G-CSF mobilized peripheral blood
stem cells (GPBSCs) infusion
Application of immuno-
suppressive agents for 6 - 8 weeks after
haploidentical GPBSCs infusion
mDLI

18. Part 1.2
Modified DLI for the treatment of
relapsed hematological malignancies
after haploidentical HSCT

19. Poor results of DLI alone for relapsed acute leukemia
after HSCT
Probable reason: A heavier burdens of leukemic cells in relapsed
acute leukemia
Schmid C, et al. J Clin Oncol. 2007; 25: 4938-4945.

20. Choi SJ, et al. Leukemia. 2004; 18 (11): 1789-1797.
Huang, et al. Haematologica,2007,92(3):414-417
Chemotherapy followed by DLI could increase CR rate and
improve survival in patients with relapsed acute leukemia
◆ 16 AML patients were enrolled. chemotherapy
followed by GPBSCs infusion
◆ CR after DLI: 10/16 (62.5%) patients
◆ OS at 2-year after DLI: 31%.
◆ 20 patients were enrolled. chemotherapy followed by GPBSCs
infusion
◆ CR after DLI: 13/20 (65.0%)
◆ LFS at 2-year after DLI: 40%.

21. Chemotherapy followed by mDLI vs. chemotherapy alone
Characteristics Chemo
(n=32)
Chemo + DLI
(n=50)
P
CR rate post-intervention (%) 4 (12.5) 32 (64.0) 0.000
Median time of onset of CR post-
intervention (months) (range)
1.00 (0.70 -
1.00)
1.00 (0.50 -
4.90)
0.258
Duration of CR post-intervention
(months) (range)
2.05 (2.00 -
3.00)
12.00 (1.00 -
109.90)
0.009
Yan CH, et al. Eur J Haematol. 2013; 91 (4): 304-314.

22. DFS
P=0.000
chemo+DLI
chemo
chemo+DLI
chemo
P=0.000
Chemotherapy followed by mDLI vs. chemotherapy alone
Yan CH, et al. Eur J Haematol. 2013; 91 (4): 304-314.
How to improve survival further?
Investigate the risk factors of relapse after chemotherapy followed by
modified DLI

23. Multivariate analysis for higher relapse rate:
Lack of chronic GVHD after DLI (P=0.039, OR=2.471)
MRD (-) < 4 months after DLI (P=0.001, OR=40.342)
Risk-stratification
50 patients
No risk factors = 11
One of risk factor = 11
Two risk factors = 28
Low-risk
Intermediate-risk
High-risk
Risk factors of relapse for chemotherapy followed by mDLI
Yan CH, et al. Eur J Haematol. 2013; 91 (4): 304-314.

24. Relapse, OS, and DFS for low-risk, intermediate-risk and
high-risk patients
Relapse OS DFS
Yan CH, et al. Eur J Haematol. 2013; 91 (4): 304-314.
How to improve survival further?
Repeated chemotherapy followed by modified DLI based on the status of
MRD and GVHD post-DLI

25. Part 1.3.1
Modified DLI for the prevention of
relapse: risk-stratification directed
modified DLI in patients with positive
status of MRD post-transplant

26. The levels of WT1 and LAIPs could predict relapse
of acute leukemia
Huang XJ, et al. Ann Hematol. 2012;91:183-192.
Huang XJ, et al. BMT. 2012;47:499-507

27. Patients with Leukemia
MRD monitoring
MRD (-) MRD (+)
Risk-stratification
directed mDLI
Decrease relapse ?
Improve survival ?
Hypothesis
after HSCT

28. Risk-stratification directed mDLI could reduce relapse
Total (n=814): 22.0% (95% CI 18.4-25.6%)
MRD (-) (n=709): 18.1% (95% CI 14.6-21.6%)
MRD (+)-IL-2 (n=49): 64.4%(95% CI 44.8-84.0%)
MRD (+)-DLI (n=56): 27.8% (95% CI 12.1-43.5%)
Yan CH, et al. Blood,2012,119(14):3256-62
MRD (+) vs. MRD (-): P<0.001
DLI vs. IL-2: P=0.001
DLI vs. MRD (-): P=0.269

29. Yan CH, et al. Blood,2012,119(14):3256-62
Risk-stratification directed mDLI could improve survival
Risk-stratification directed mDLI could reduce relapse and improve
survival after haploidentical HSCT
MRD (+) vs. MRD (-): P=0.041
DLI vs. IL-2: P=0.002
DLI vs. MRD (-): P=0.688

30. Part 1.3.2
Modified DLI for the prevention of
relapse: prophylactic modified DLI in
patients with relapsed/refractory
acute leukemia at transplant

31. Prophylactic mDLI could reduce relapse and improve survival of patients
with relapsed/refractory acute leukemia at haploidentical HSCT
Wang Yu, et al. BMT. 2012; 47 (8): 1099-104
Prophylactic mDLI could reduce relapse and improve
survival

32. • Modified DLI could reduce incidence of acute GVHD, but did
not compromise GVL Effects.
• Modified DLI was a potentially effective therapeutic option
for relapsed acute leukemia after haploidentical HSCT and
chemotherapy followed by modified DLI is superior to
chemotherapy alone.
• Risk stratification-directed modified DLI could prevent
relapse and improve survival after HSCT.
• Prophylactic modified DLI could prevent relapse and improve
survival in patients with relapsed/refractory acute leukemia
at haploidentical HSCT.
Summary

33. Questions remained?
• appropriate dose of CD3+
T cells in haploidentical
modified DLI
• appropriate drug used as immunosuppressive
agents after haploidentical modified DLI, such as
CSA or MTX
• appropriate time for prophylactic modified DLI

34. Acknowledgements
Stem cell collection center
Hai-Yin Zheng
Hong Xu
Qing Zhao
Su Wang
Department of bone marrow transplant
Xiao-Jun Huang Kai-Yan Liu
Dai-Hong Liu Lan-Ping Xu
Huan Chen Wei Han
Xiao-Hui Zhang Ying-Jun Chang
Yu-Hong Chen Feng-Rong Wang
Jing-Zhi Wang Yu Wang
Chen-Hua Yan Yuan-Yuan Zhang
Yu Ji Yu-Qian Sun
Xiang-Yu Zhao Xiao-Su Zhao
Laboratory of PUIH
Dan Li
Ya-Zhen Qin
Yan-Rong Liu
Yue-Yun Lai