This document summarizes research on risk stratification, prevention, and management of leukemia relapse after hematopoietic stem cell transplantation (HSCT). It discusses: 1. Use of modified donor lymphocyte infusions to establish graft-versus-leukemia effects without severe graft-versus-host disease. 2. Research in t(8;21) acute myeloid leukemia showing allo-HSCT can improve outcomes for high-risk patients, and minimal residual disease monitoring post-HSCT better predicts risk than c-KIT mutations. 3. Studies demonstrating imatinib after allo-HSCT from related donors improves outcomes for Philadelphia chromosome-positive leukemias by preventing relapse when guided by

1. risk stratification, prevention and
management of leukemia relapse
after HSCT
Yu Wang
Peking University People’s Hospital &
Institute of Hematology

2. Contents
1
• Modified DLI
2
• t(8;21)
3
• Ph+ leukemia

3. Establishment of Modified DLI
G-CSF primed peripheral blood
progenitor cells instead of steady
donor lymphocyte harvests
Short-term CsA/MTX
for prevention of
DLI-associated GVHD
mDLI
Huang XJ,et al, Leukemia, 2006,20:365-368
Huang XJ, et al. Hematologica 2007,92:414-417
Huang XJ,et al, Bone Marrow Transplant. 2009;44(5):309-16
Yan CH, et al. clinical transplant. 2012; 26: 868-876

4. Therapeutic mDLI
Multivariate analysis for
relapse:
Chronic GVHD (P=0.000, OR=5.932)
Chemo+ DLI (P=0.037, OR=1.877)
Characteristics Chemo (n=32) Chemo + DLI
chemo+DLI
Relapse
chemo
P=0.000
(n=50)
P
Acute GVHD post-intervention (%) 40.6 66.0 0.048
Grade 2 - 4 29.9 62.7 0.032
Grade 3 - 4 16.5 40.3 0.112
Chronic GVHD post-intervention (%) 3.1 44.3 0.000
Extensive 3.1 41.8 0.000
TRM at 1 year post-intervention (%) 0.0 14.0 0.118
P=0.000
DFS
Huang XJ, et al. Leukemia 2006, 20: 365 European Journal of Haematology 91 (304–314)

5. Risk directed mDLI
Interventional mDLI
Multivariate analysis P OR
MRD-negative posttransplant 0.000 0.255
Receiving DLI 0.000 0.269
Multivariate analysis P OR
MRD-negative posttransplant 0.001 0.511
Receiving DLI 0.006 0.436
Huang XJ, et al. Blood,2012,119(14):3256-62

6. Prophylactic mDLI
Control66%
DLI46%
P=0.02
P=0.001
DLI 36%
Control 11%
Huang XJ ,et al. J Clin Immunol. 2008;28
Huang XJ, et al. J Clin Immunol. 2008;28:276-83；
P=0.001
DLI 30.5%
Control 11.1%
P=0.017
Control 55%
DLI 36%
Wang Y , et al. Bone Marrow Transplant2012 ;47:1099
Wang Y, et al. Clin Transplant. 2012 ;26:835
OS Relapse
ISD HID

7. Multi-Center Clinical Trials
Xinqiao Hospital affiliated to
Third Military Medical University
Peking University
People`s Hospital
The First affiliated Hospital
of Soochow University
The First affiliated Hospital
of Zhejiang University
Nanfang Hospital
Southern Medical University
Strategy to improve the clinical results
 Significantly decrease GVHD
 Did not compromise GVL effect
 Improvement on safety of DLI

8. Contents
1
• Modified DLI
2
• t(8;21)
3
• Ph+ leukemia

9. Trial Design
Low-risk
High-risk High-risk
Non risk-directed
Risk-directed
Huang XJ, et al. Blood 2013; 121 4056

10. Patients Enrollment

11. Risk stratification treatment improves outcome
0 20 40 60 80 100
100
80
60
40
20
0
risk-stratification(n=69)
82.7%
Time(months)
Overall Survival(%)

12. Multivariate analysis
Results
CIR DFS OS
p p p
MRD status
high- vs. low-risk 0.003 0.002 0.02
Treatment choice
risk- vs. non risk-directed 0.026 0.036 0.037
KIT status
mutation vs. wild-type 0.049 ns ns
• MRD-directed risk-stratification treatment could improve
outcome of t(8;21) AML in CR1.
• Allo-HSCT benefited high-risk patients and had potential to
Huang XJ, et al. Blood 2013; 121 4056
benefit KIT-mutated patients

13. RUNX1/RUNX1T1-based MRD-monitoring
early after allogeneic transplantation
rather than c-KIT mutations in adult t(8;21) AML
allows further risk stratification
Blood. 2014 Jul 31. pii: blood-2014-03-563403
• MRD might be used to further distinguish
between t(8;21)patients with low and high
risks of relapse after allo-HSCT
• the level of MRD in t (8; 21) AML guide post-
HSCT therapy in the future

14. Results
Impact of MRD at 1 month after SCT on outcomes
CIR p=.02
42.8%
<3 log reduction n=7
16.8%
MRD positive post SCT p<.001
<3 log reduction n=7
85.7%
44.7%
>3 log reduction n=53
LFS p>.05
<3 log reduction n=7
>3 log reduction n=53
<3 log reduction n=7
60.8%
41.7%
OS p>.05
>3 log reduction n=53
85.7%
44.7%
>3 log reduction n=53
42.8%
16.8%
CIR p=.02

15. Multivariate analysis Results
Outcome
Hazard ratio
(95%Confidence interval)
P
Relapse
Achieving MMR at all the first 3 months yes vs
no
0.07(0.02-0.26.)
0.001
Courses to achieve CR 1 vs >1 0.17(0.04-0.64) 0.009
Interventional DLI yes vs no 0.09(0.02-0.43) 0.002
Leukemia free survival
Achieving MMR at all the first 3 months yes vs
0.13(0.05-0.34)
0.001
no
Courses to achieve CR 1 vs >1 0.36(0.14-0.90) 0.03
Interventional DLI yes vs no 0.20(0.06-0.60) 0.004
• A > 3 log reduction at the first 3 months after HSCT in RUNX1/RUNX1T1
transcripts is highly predicative
• Rather than c-KIT, regular MRD monitoring early after HSCT in t (8;21) AML
allows further risk identification
• MRD monitoring could now be incorporated in clinical trials to evaluate the role of
risk directed prophylactic/preemptive therapy after HSCT

16. • t(8;21)AML is a heterogeneous disease
• Allo-HSCT can improve outcome of high-risk t(8;21)AML
• Rather than c-KIT, MRD post-HSCT allows further risk stratification
MMR
Allo-HSCT
non-MMR
Baseline
Diagnosis Lose MMR
Ind 1-2 Cons 1 Cons 2
Con 3 Cons 4 Cons 5 Cons 6 Cons 7 Cons 8
KIT-KIT+
Recommendation
MRD
MRD
DLI/CT
and might direct further treatment

17. Contents
1
• Modified DLI
2
• t(8;21)
3
• Ph+ leukemia

18. Eligibility
• (1) ANC >1000/uL w/o G-CSF & PLT>50000 /uL, regardless of BCR-ABL; or
• (2) BCR-ABL in BM detectable and increased for 2 consecutive tests, or
≥10-2 after the initial engraftment, although ANC/PLT below the values
• (3) tolerate oral imatinib without gut GVHD or life-threatening infection
Imatinib was scheduled for 3–12m after HCT, until
• BCR-ABL negative ≥ 3 consecutive tests or CMR sustained ≥ 3m
Withdrawn, if
• grade 3 or 4 toxicity sustained >2w, despite interrupting imatinib

19. Imatinib improve outcomes
Relapse: 10%vs 33%
DFS: 81% vs 33%
OS: 86% vs 34%
FU: 31(2.5-76) vs 25 (4-72)m post-HCT
Grade 3–4 AEs: 17.7%
Ten (16.1%) terminated IM (<3m)

20. Individualized intervention guided by
BCR-ABL transcript levels after HLA-identical
sibling donor HSCT improves
HSCT outcomes for patients with CML
Huang XJ, et al. Biol Blood Marrow Transplant 2011 17: 649-656
Low-risk: 1 of following
 > 2log red from base at +1m & cont to decline
 MMoR & stable within +3m & cont to decline
 II-IV aG or ext. cG & stable in MMoR within 1y
 CMoR within +1 year
Intervention priority order in high risk patients
1: IS-W if not so early /no GVHD/CSA pro
2: IM if early and good engraftment
3: mDLI if not so good response to IS-W/IM
Pre-HSCT +1m +2m +3m +6m +9m +12m +18m +24m

21. post-HCT individualized-intervention based on serial
monitoring of BCR-ABL transcripts improve outcome
Intervention reversed the rising
trends of BCR/ABL within 2m
-1 0 1 2 3 4
1 .0 0
0 .9 0
0 .8 0
0 .7 0
0 .6 0
0 .5 0
0 .4 0
0 .3 0
0 .2 0
0 .1 0
0 .0 0
BCR/ABL(%)
Time s from o n e s e t o f in te rve n t io n (mo n th s )
Intervention: high-risk n=28
• 1/28 stable molecular disease graft
failure and 2nd HSCT ,DFS 3y
• 25/28 (89%) CMR:
median 49d ( 18-232)
remained in CMR 1427d(1040-1794
Non- intervention: low-risk n=56
• BCR-ABL to 0: median +4m
• 55/56 CMR , FU 1522(1055-1791)d
RI 3.9%
TRM 3.6% vs 8.9%
LFS 89.3% vs 89.1%

22. 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
Lan-Ping Xu
Xiao-Hui Zhang
Huan Chen Wei Han
Yu-Hong Chen Feng-Rong Wang
Jing-Zhi Wang Yu Wang
Chen-Hua Yan Yuan-Yuan Zhang
Yu Ji Yu-Qian Sun
Laboratory of PUIH
Dan Li
Ya-Zhen Qin
Yan-Rong Liu
Yue-Yun Lai

23. challenges Chinese HSCT face
• identifying the underlying mechanisms of well-developed
clinical models, such as haplo-HSCT
• translational researches of clinical significance
(molecular aspects of target therapy for various
complications after HSCT), such as:
immune tolerance in HLA-mismatched HSCT
the distinction between GVHD and GVL
the association between infection and chronic immunologic imbalance

24. need for a FACT-like accreditation program
• Standardization of “best practice”: dissemination of
techniques from major centers to smaller units
• under well-developed registries: role in multi-center
clinical trials and data management
• Training: talented personnel/inspectors

25. meaningful international collaborations
• Academic technique collaboration
• Bench to bed practice: promote the connection
between basic research and clinical practice
• Training and visit