1. The document discusses optimizing pretransplant conditioning regimens for hematopoietic cell transplantation, comparing myeloablative conditioning (MAC) to reduced-intensity conditioning (RIC). 2. It suggests that MAC improves disease control and engraftment rates compared to RIC, but toxicity is not necessarily higher with MAC if growth factors are controlled. 3. Personalized conditioning based on pharmacokinetic monitoring may improve outcomes by better balancing antitumor effects and toxicity.

1. 2015/8/28 B.S. Andersson
Optimized Induction in
Haplos; MAC vs RIC
AUBHO 2015
August 28-29, 2015
Borje S. Andersson, MD, Ph.D.
Molecular Pharmacology and Translat.
Drug Development Program,
Department of Stem Cell Transplantation
UT MD Anderson Cancer Center.

2. 8/28/2015 B.S. Andersson
Myeloablative vs Non-Myeloablative (RIC) Conditioning
Regimens
Dose Intensity
FC± R
BEAM +/-R2-5
5-10
MF
Non-Ablative RIC
Oral Bu/Cy2, -4>10
TBI/± Cy/ ± F /± TT /
± VP16
Oral Bu8/F/±
ATG
Ablative
TBI 2Gy
CyThymicXRT/TLI
FlagIda Flu- IV Bu -2, -3 Clo-+/Flu - IV Bu4

3. 2015/8/28 B.S. Andersson
What have we learned?
1. Engraftment rate improves with intensive conditioning
2. Disease control improves with intensive conditioning
3. TRM not necessarily directly related to the intensity of
the conditioning – GFs contribute to TRM.
4. Rational use of mechanistic cytotoxicity information at
the molecular level can be used to design improved
conditioning therapy.

4. Author Conditioning Graft GF (%) TRM (%) EFS (%)
Raiola TT-Bu-Flu BM 4 18 68/37
(n=50) Flu-TBI-10Gy
Bashey Cy-Flu-Bu or BM/PBSC n/a 4 60
(n=53) Flu-Cy-TBI-2Gy
Ciurea TT-Mel-Flu BM 6 16 50
(n=32)
Luznik Flu-Cy-TBI-2Gy BM 13 15 26
(n=68) (2 Yrs.)
Wang Ara-C-Bu-Cy- BM/PBSC 1 18 ~60
(n=756) MeCCNU (3 Yrs.) (5 Yrs.)
Haplo-Identical SCT for (mainly) Hematological Malignancies

5. 2015/8/28 B.S. Andersson
General Problems with highly HLA-disparate
grafts, aka Haplos
1. Treatment- /Regimen-Related Toxicity (“TRM”)
2. Graft failure
3. Recurrent Disease

6. Busulfan - Cyclophosphamide Metabolic Interactions
GSTM1
CYP2B6
CYP2C9
Sulfolane
CYPs
FMO?

7. -3 -2 -1-4-6 -5 +14 +21 +100 >1800
Graft
Conditioning
Supportive Care
GVHD prophylaxis and therapy
Patient
(age, gender, CMV,
comorbidities…)
12
3 5
6
4
Disease
Features
Malignant vs.
“Non-Malignant”
How to (Optimize Conditioning to) Improve outcome?

8. 1. Nucleoside Analogs (NA) do not utilize CYP450
or GSH/GST-conjugation in their metabolism.
2. Further, when the NA (e.g. fludarabine) is properly
time-sequenced with IV busulfan, the conditioning
reliably facilitates engraftment of MRD and MUD
BM and PBPC grafts in (adult) recipients.
3. NAs and AAs (here, Busulfan) kill primarily by
induction of apoptosis and terminal differentiation.
De Lima M., et al. Blood. 2004; 104(3):857-64.

9. NAs cause histone modifications; enhanced with an
alkylator
Valdez et al. Biochem Pharmacol. 2011 Jan 15;81(2):222-32

10. 2015/8/28 B.S. Andersson
[Clof+Flu+Bu] combo activates DNA damage response
through the ATM-CHK2 pathway in AML cell line
P -ATM (Ser1981)
ATM
C
ontrol20
µ
g/m
lB
u
0.015
µM
C
lof
0.6
µ
M
Flu
B
u+C
lof
B
u+
FluC
lof+Flu
C
lof+Flu+B
u
γ -H2AX
P -SMC1(Ser957)
P -CHK2 (Ser33/35)
β -ACTIN
P -ATM (Ser1981)
ATM
C
ontrol20
µ
g/m
lB
u
0.015
µM
C
lof
0.6
µ
M
Flu
B
u+C
lof
B
u+
FluC
lof+Flu
C
lof+Flu+B
u
-H2AX
P -SMC1(Ser957)
P -CHK2 (Ser33/35)
-ACTIN
P -ATM (Ser1981)
ATM
C
ontrol20
µ
g/m
lB
u
0.015
µM
C
lof
0.6
µ
M
Flu
B
u+C
lof
B
u+
FluC
lof+Flu
C
lof+Flu+B
u
γ -H2AX
P -SMC1(Ser957)
P -CHK2 (Ser33/35)
β -ACTIN
P -ATM (Ser1981)
ATM
C
ontrol20
µ
g/m
lB
u
0.015
µM
C
lof
0.6
µ
M
Flu
B
u+C
lof
B
u+
FluC
lof+Flu
C
lof+Flu+B
u
-H2AX
P -SMC1(Ser957)
P -CHK2 (Ser33/35)
-ACTIN

11. Suggested mechanism of synergistic
cytotoxicity of NAs and AAs
Valdez & Andersson. Environ Mol Mutagen. 2010; 51:659-668.
Histone
modificns
Chromatin
remodeling
DNA cross-
linking
DNA
damage
Loop of death
DNA alkylating agents
(AAs)
DNA synthesis/repair
Nucleoside analogues (NAs)
Apoptosis

12. 2015/8/28 B.S. Andersson
Optimized Conditioning, (Haplos).
RIC or MAC ???

13. 8/28/2015 B.S. Andersson
Normal Organ
Toxicity
Tumor Load; PK-Guided, Individualized / Standardized Therapy Should
Improve Treatment Outcome.
“Therapeutic Windows”
Numberofpatients
Blue: Fixed-Dosing
Green: PK-Guided Dosing in
high-risk patients - MAC.
Orange: PK-guided dosing -
RIC
Leukemia
Progression
CR Pats
aGVHD
Leukemia
Progression
“Refr. Pats.”
Systemic Drug
Exposure
“Safe Upper Limit”,
Syst.Exposure

14. 0 10 20 30 40 50 60 70 80
Months Post Transplant
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
CumulativeProportionSurvivingProgressionFree Active Disease at Transplant
Adjusted, N=40
Fixed, N=46
P 0.03
Progression-Free Survival, Active Dx - Patients

15. 0 10 20 30 40 50 60 70 80
Months Post Transplant
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
CumulativeProportionSurvivingProgressionFree
Adjusted, N=71
Fixed, N=68
P 0.4Remission at Transplant
Progression-Free Survival, CR- Patients

16. 2015/8/28 B.S. Andersson
Successful Conditioning includes several components:
1. Killing malignant cells
2. A. Killing cell populations that are mediate (acute)
graft rejection (T-cells and other) ,
B. Killing immature, progenitor/stem cells that can
mediate regeneration of ancillary immuno-competent
cells that mediate secondary graft failure.
3. Removal of reproductively dead, yet still functional
cell subpopulations that mediate rejection

17. 8/28/2015 B.S. Andersson
Normal Organ
Toxicity
Numberofpatients
Blue: Fixed-Dosing
Green: PK-Guided Dosing,
high-risk patients.
aGVHD
Systemic Drug
Exposure
Leukemia Pats.
Immunosuppressed
Hemglobinopathies/ e.g.
Thalassemia
Immunocompetent Pat.
“Immuno-ablative Therapeutic Interval”
“Safe Upper Limit”,
Syst.Exposure
SCID

18. 2015/8/28 B.S. Andersson
Optimizing Pretransplant Conditioning.
We suggest, that one should pay close attention to:
1. Time-Sequence of the drugs in the conditioning
program,
2. Consider adding either (a) cytotoxic agent(s) that
provide a radiomimetic, “interphase-death-inducing”,
effect on the T-cells, such as Thiotepa, low-dose TBI, or
3. use of “early” ATG to eliminate mature host T-cells.

19. 2015/8/28 B.S. Andersson
“Genetic Diseases and Haplo Tx” !
(Hemoglobinopathies)
- Intact, (hyper-) active immune system
- Iron overload/subclinical organ failure
- “Benign hemoglobinopathy”

20. -3 -2 -1-4-6 -5 +14 +21 +100 >1800
Graft
Conditioning
GVHD prophylaxis and therapy
Patient
(age, gender, CMV,
comorbidities…)
12
3 5
6
4
Disease
features
Hypothesis: Personalized Conditioning Improves outcome
!

21. 2015/8/28 B.S. Andersson
Optimizing Pretransplant Conditioning Therapy.
We suggest, that one should pay close attention to:
1. Time-Sequence of the drugs in the conditioning
program,
2. Consider adding either (a) cytotoxic agent(s) that
provide a radiomimetic, “interphase-death-inducing”,
effect on the T-cells, such as Thiotepa, low-dose TBI, or
3. use of “early” ATG to eliminate mature host T-cells.
4. To further promote engraftment of highly HLA-
disparate grafts (“haplos”) consider using
pharmacological Pretransplant ImmunoSuppression
Therapy (“PTIS”) in the pre-conditioning phase.

22. 8/28/2015 B.S. Andersson
Normal Organ
Toxicity
Numberofpatients
Blue: Fixed-Dosing
Green: PK-Guided Dosing, MAC.
Orange: PK-guided dosing, RIC
aGVHD
Systemic Drug
Exposure
Hemglobinopathies/ e.g.
Thalassemia
Immunocompetent Pat.
“Immuno-ablative Therapeutic Intervals”
“Safe Upper Limit”,
Syst.Exposure
Thalassemia
After PTIS.

23. 2015/8/28 B.S. Andersson
Thalassemia
(Pre-) Transplant Platform
ay -56 -54 -52 -28 -26 -24 -21 -14 -12 -10 -8 -7 -6 -5 -4 -3 -2 -1 0 +3 +4
Modifying the Conditioning Platform

24. 8/28/2015 B.S. Andersson
1 2 3,4 5
Flu - Bu ± ATG HSC Post Tx – Cy
Clinical Consideration Points
1. Pre – “PTIS”
2. + “Early ATG” alt. “Necrosis-inducing agent”
3. PK-TDM new standard
4. Post Tx Intervention, Post-Cy, demethylating agents, vaccines, etc.
Modifying the Platform, Post-Tx-Cyclophosphamide.
Platform Technology

25. Summary, RIC vs MAC/RTC
1. Malignant Disease,
- Tumor Load: CR: RIC = MAC
Active Dx: RIC < MAC
- Engraftment: Consider pretreatment level of
immunosuppression, need to modify?
2. Genetic Disease (hemoglobinopathy vs SCID):
Immunol. active/hyperactive/suppressed: May need
modified (pre-) conditioning to secure engraftment,
otherwise RIC since no malignancy.

26. -3 -2 -1-4-6 -5 +14 +21 +100 >1800
Graft
Conditioning
Supportive Care
GVHD prophylaxis and therapy
Patient
(age, gender, CMV,
comorbidities…)
12
3 5
6
4
Disease
features
Summary: Personalized Conditioning Improves outcome !

27. 8/28/2015 B.S. Andersson
Collaborators
UT MD Anderson
Clinical:
EJ Shpall Roy Jones Yago Nieto Partow Kebriaei
Muzaffar Qazilbash Chitra Hosing Laura Worth Dean Lee
Richard Champlin
Lab:
Ben Valdez, Guiyun Wang Yan Liu Yang Li
Biostatistics: Peter F. Thall
Ramathibodi Hospital, Bangkok, Thailand: Suradej Hongeng
Institut Paoli Calmette, Marseille, France: Didier Blaise
Karolinska Institute, Stockholm, Sweden: Moustapha Hassan
U Alberta, Calgary, AB, CA: James Russell

28. 2015/8/28 B.S. Andersson
Questions, Please