Leukemia (2005) 19, 971–977
& 2005 Nature Publishing Group All rights reserved 0887-6924/05 $30.00
www.nature.com/leu
Donor leukocyte infusion after hematopoietic stem cell transplantation in patients
with juvenile myelomonocytic leukemia
A Yoshimi1, P Bader2, S Matthes-Martin3, J Starý4, P Sedlacek4, U Duffner1, T Klingebiel5, D Dilloo6, W Holter7, F Zintl8,
B Kremens9, K-W Sykora10, C Urban11, H Hasle12, E Korthof13, T Révész14, A Fischer1, P Nöllke1, F Locatelli15 and
CM Niemeyer1, on behalf of European Working Group of MDS in Childhood (EWOG-MDS)
1
Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, University of Freiburg,
Germany; 2University Children’s Hospital, University of Tübingen, Germany; 3St Anna Children’s Hospital, Wien, Austria;
4
Department of Pediatric Hematology and Oncology, University Hospital Motol, Prague, Czech Republic; 5University Children’s
Hospital, University of Frankfurt, Germany; 6Department of Pediatric Hematology and Oncology, Heinrich-Heine-University,
Düsseldorf, Germany; 7University Children’s Hospital, University of Erlangen, Germany; 8University Children’s Hospital,
University of Jena, Germany; 9University Children’s Hospital, University of Essen, Germany; 10Department for Pediatric
Hematology/Oncology, Kinderklinik Medizinische Hochschule, Hannover, Germany; 11Department of Pediatrics and
Adolescence Medicine, Division of Pediatric Hematology/Oncology, University of Graz, Austria; 12Department of Pediatrics,
Skejby Hospital, Aarhus University, Denmark; 13Department of Pediatric Immunology/Hematology and Stem Cell
Transplantation, Leiden University Medical Center, Leiden, Netherlands; 14Hematology-Oncology Unit, Wilhelmina Children’s
Hospital, University Medical Center, Utrecht, Netherlands; and 15Oncoematologia Pediatrica, IRCCS Policlinico San Matteo,
Pavia, Italy
Juvenile myelomonocytic leukemia (JMML) is a clonal myeloproliferative disorder of early childhood. In all, 21 patients with
JMML who received donor leukocyte infusion (DLI) after
allogeneic hematopoietic stem cell transplantation (HSCT) for
either mixed chimerism (MC, n ¼ 7) or relapse (n ¼ 14) were
studied. Six patients had been transplanted from an HLAmatched sibling and 15 from other donors. Six of the 21 patients
(MC: 3/7 patients; relapse: 3/14 patients) responded to DLI.
Response rate was significantly higher in patients receiving a
higher total T-cell dose (X1 107/kg) and in patients with an
abnormal karyotype. None of the six patients receiving DLI from
a matched sibling responded. Response was observed in five of
six patients who did and in one of 15 children who did not
develop acute graft-versus-host disease following DLI
(P ¼ 0.01). The overall outcome was poor even for the responders. Only one of the responders is alive in remission, two
relapsed, and three died of complications. In conclusion, this
study shows that some cases of JMML may be sensitive to DLI,
this providing evidence for a graft-versus-leukemia effect in
JMML. Infusion of a high number of T cells, strategies to reduce
toxicity, and cytoreduction prior to DLI may improve the results.
Leukemia (2005) 19, 971–977. doi:10.1038/sj.leu.2403721
Published online 31 March 2005
Keywords: juvenile myelomonocytic leukemia; allogeneic
hematopoietic stem cell transplantation; mixed chimerism; donor
leukocyte infusion; graft-versus-leukemia effect; graft-versus-host
disease
Introduction
Juvenile myelomonocytic leukemia (JMML) is a clonal myeloproliferative disorder afflicting young children.1–3 Recent studies
elucidate the importance of the RAS-RAF-MAP (mitogenactivated protein) kinase signaling pathway, which is pathologically activated by mutations in RAS, PTPN11, and the gene
encoding neurofibromatosis type 1 (NF1).4–6 Allogeneic hematopoietic stem cell transplantation (HSCT) is the only curative
strategy for children with JMML and it is recommended early in
Correspondence: Dr A Yoshimi, Department of Pediatrics and
Adolescent Medicine, Division of Pediatric Hematology and Oncology, University of Freiburg, Mathildenstrasse 1, Freiburg 79106,
Germany; Fax: þ 49 0761 270 4623;
E-mail: [email protected]
Received 30 November 2004; accepted 4 February 2005; Published
online 31 March 2005
the course of the disease. Recent large studies indicate an eventfree survival of about 50% following HSCT in JMML.7,8 Despite
the improvement in survival rate, relapse remains the major
obstacle and the most common cause of treatment failure,
affecting one-third of patients.7 It occurs early, at a median of
2–6 months from transplantation,9,10 and generally within the
first year following HSCT.
Donor leukocyte infusion (DLI) has been administered to
patients who suffered a relapse following HSCT for various
hematological malignancies. The efficacy of DLI depends on
several factors including the sensitivity of the underlying
disorder to a graft-versus-leukemia (GVL) effect. In JMML, the
role of DLI for the management of recurrent disease remains
uncertain; only a few relapsed patients successfully treated by
DLI have been reported.11–14 In this study, we summarize the
experience with DLI in 21 children with JMML, enrolled in
studies of the European Working Group of MDS in Childhood
(EWOG-MDS), and relapsed after allogeneic HSCT.
Patients and methods
In all, 21 patients with JMML transplanted from June 1996 to
August 2002 received DLI from their original donor for mixed
chimerism (MC) or relapse after first (n ¼ 17) or second (n ¼ 4)
HSCT for JMML. The patients had been transplanted in 14
centers in Germany (n ¼ 11), Austria (n ¼ 4), the Czech Republic
(n ¼ 2), the Netherlands (n ¼ 2), Denmark (n ¼ 1), and Italy
(n ¼ 1). Data on administration and response to DLI, chimerism
analyses, and therapy other than DLI were retrospectively
collected by a standardized questionnaire in August 2003.
Details on one patient (A014) have been reported previously.11
Informed parental consent for participation in EWOG-MDS
studies had been obtained for all patients. The median follow-up
period was 18 months (range 0.9–78) after DLI.
Patient characteristics
The median age at the time of diagnosis of JMML was 35 months
(Table 1). Chromosomal analyses of leukemic cells showed
monosomy 7 in two patients, other abnormalities in four, and a
DLI in children with JMML relapsing after HSCT
A Yoshimi et al
972
Table 1
Patient characteristics (n ¼ 21)
Gender (M/F)
Median age (range) at diagnosis (months)
Median age (range) at last HSCT prior to DLI
(months)
Median interval (range) between diagnosis and
initial HSCT (months)
Median interval (range) between diagnosis and
last HSCT prior to DLI (months)
Karyotype
Normal karyotype
Monosomy 7
Trisomy 8
46, XX, dup(22)
49, XY, +X, +8, +19
Complex karyotype with 45 aberrations
Splenectomy before last HSCT
Table 2
12/9
35 (2–62)
45 (8–99)
8 (2–37)
9 (2–37)
15
2
1
1
1
1
10
HSCT ¼ hematopoietic stem cell transplantation; DLI ¼ donor leukocyte infusion.
Procedure of HSCT prior to DLI (n ¼ 21)
First/second HSCT
Donor
HLA-identical sibling
HLA-matched cousin
HLA-mismatched family donor
(3/6, 4/6)
HLA-matched unrelated donor
(6/6)
HLA-mismatched unrelated donor
(5/6)
Preparative regimens
The transplant procedure is detailed in Table 2. The donor was
an HLA-matched or -mismatched family member in nine cases,
while 12 patients received a graft from an unrelated donor (UD).
All but one patient who were given DLI after their first HSCT
received a preparative regimen consisting of busulfan (BU) 4 mg/
kg/day for 4 days, cyclophosphamide (CY) 60 mg/kg/day for
2 days, and melphalan 140 mg/m2/day for 1 day, as described
previously7 (Table 2). The patient transplanted from his haploidentical father was given CY 60 mg/kg/day for 2 days and
thiotepa 10 mg/kg/day for 1 day. The preparative regimen of the
first HSCT for the four patients who received DLI after the
second HSCT included BU in three and total body irradiation
(TBI) in one. For the second grafting procedure, the four patients
received a pretransplant therapy including CY 60 mg/kg/day for
2 days and fludarabine 40 mg/m2/day for 5 days (n ¼ 1), BU
4 mg/kg/day for 4 days and melphalan 140 mg/m2/day for 1 day
(n ¼ 1), and CY 60 mg/kg/day for 2 days and TBI 14.4 Gy (n ¼ 1),
and CY 60 mg/kg/day for 2 days and thiotepa 10 mg/kg/day for 1
day (n ¼ 1). Source of stem cells was BM or cord blood in all
patients transplanted from an HLA-matched sibling, while six of
the remaining 15 patients received peripheral blood (PB) stem
cells. Four patients, one transplanted from his haplo-identical
father and three from a matched UD, received a T-cell-depleted
graft.
Chimerism analyses
Chimerism analyses using unseparated PB or BM were
performed by a microsatellite PCR system in 19 patients in six
different laboratories15–20 and by FISH analysis in two patients
with a sex-disparate donor. Analyses were performed at regular
intervals after HSCT in 18 patients (weekly: n ¼ 11; every 1–3
Leukemia
11
1
Second
HSCT(n ¼ 4)
0
1
1
1
1
Other (n ¼ 15)
BM
PB
Cord blood
Matched sibling
(n ¼ 6)
5
0
1
Other (n ¼ 15)
T-cell depletion
Matched sibling
(n ¼ 6)
0
Matched sibling
(n ¼ 6)
1
3
1
0
1
0
0
Other (n ¼ 15)
BU/CY/Mel
CY/thiotepa
CY/fludarabine
BU/Mel
CY/TBI
GVHD prophylaxis
Transplant procedure
6
1
2
First HSCT
(n ¼ 17)
16
1
0
0
0
Stem cell source
normal karyotype in 15 children. A clinical diagnosis of NF1
was made in two patients. In total, 10 patients had been
splenectomized prior to first (n ¼ 9) or second (n ¼ 1) HSCT.
PTPN11 and RAS mutations were examined as previously
reported4,6 in 17 children. At the time of first HSCT, all patients
had active disease with a median blast count in the bone
marrow (BM) of 15% (1–85).
17/4
None
CSA
MTX
ATG
CSA+MTX
CSA+ATG
CSA+MTX+ATG
9
6
0
4
0
0
0
2
1
4
8
BU ¼ busulfan; CY ¼ cyclophosphamide; Mel ¼ melphalan; TBI ¼ total
body irradiation; GVHD ¼ graft-versus-host disease; CSA ¼ cyclosporin
A; MTX ¼ methotrexate; ATG ¼ antithymocyte globulin; HSCT ¼ hematopoietic stem cell transplantation; DLI ¼ donor leukocyte infusion.
months: n ¼ 7). In three patients, the first chimerism analysis was
performed at the time of hematological relapse.
Definition
Engraftment after HSCT was defined by leukocytes 41 109/l in
PB. Hematological relapse was diagnosed in the presence
of an increased number of blast cells in PB or BM, or clinical
signs of relapse with BM hypercellularity or absence of
megakaryocytes. Acute graft-versus-host disease (aGVHD)
and chronic GVHD (cGVHD) were diagnosed and scored
according to standard clinical criteria.21,22 Patients were
considered evaluable for aGVHD and cGVHD as a complication of DLI if they survived for 30 and 100 days post-DLI,
respectively. Administration of DLI on multiple occasions less
than 7 days apart was analyzed as one infusion. Complete
response (CR) following DLI was defined by achievement of
persistent complete chimerism (CC), without evidence of
relapse. BM aplasia following DLI was defined as cytopenia
1.1 10
119
No
MUD
Relapse
D370
MC ¼ mixed chimerism; MUD ¼ HLA-matched unrelated donor; 1Ag MMUD ¼ HLA 1 antigen mismatched unrelated donor; MFD ¼ HLA-matched familial donor; a/cGVHD ¼ acute/chronic graftversus-host disease; TCD ¼ infused T-cell dose; PB ¼ peripheral blood; BM ¼ bone marrow; HSCT ¼ hematopoietic stem cell transplantation; HES ¼ hypereosinophilic syndrome; CMV ¼ cytomecytomegalovirus; CR ¼ complete remission.
a
The patient suffered the first relapse on day 82 after HSCT. Following the withdrawal of immunosuppressive agents and therapy with 6-MP the patient achieved CR. He suffered the second relapse on day 353.
b
HLA-matched cousine.
Dead after infection following 2nd
HSCT (162) for BM suppression
BM suppression (144)
Grade IV aGVHD (IV) (153)
60 (90)
102
153
Alive in CR (42213)
De novo cGVHD (304)
18
20
1 107
29
No
Relapse
D055
MFDb
8
77
Alive with disease (41574)
Grade II aGVHD (408),
cGVHD (717)
3 (15)
Relapse
CZ019
Grade II
MC
D125
MUD
368
2.1 108
82, 353a
410
Dead after GVHD following DLI
(112)
Grade IV aGVHD (84)
20
30
MC
CZ034
1Ag
MMUD
No
54
68
1 104
1 107
68
110
Alive in CR after 2nd HSCT (336) for
relapse
Grade III aGVHD (215)
16
8
MC
A021
1Ag
MMUD
Grade II
211
265
1 106
1 107
244
218
Dead after
CMV pneumonia (424)
HES (350)
No
277
305
334
1 10
1 108
1 108
50
50
0
302
329
(day after HSCT)
7
MUD
A-GVHD prior to
DLI
Donor
Status prior
to DLI
ID
Table 3
Details of the responders of DLI
Date of DLI after HSCT
TCD (/kg)
% of autologous cells in
PB (BM) at DLI
Relapse
Response
Complication
Outcome
DLI in children with JMML relapsing after HSCT
A Yoshimi et al
(neutrophils o0.5 109/l and platelets o20 109/l) unrelated
to leukemia or chemotherapy.
973
Statistics
The Fisher’s exact test was used to examine the statistical
significance of a relationship between the response to DLI and
categorized factors.23 A nonparametric rank test (Mann–
Whitney U-test) was performed to evaluate the difference
between responses to DLI in quantitative factors.24 P-values
less than 0.05 were considered to indicate statistical significance, whereas values greater than 0.05 were reported as
nonsignificant (NS).
Results
Disease status and chimerism at DLI
All patients had achieved stable engraftment after the HSCT that
preceded DLI. The median time to engraftment was 17 (8–35)
days. aGVHD Xgrade II had developed in five patients after the
allograft, while no patient had suffered cGVHD.
The median time from HSCT to MC and from MC to first DLI
was 160 days (14–793) and 57 days (4–225), respectively. At
first DLI, seven patients had neither clinical nor cytogenetic
signs of relapse. For the 14 patients with hematological (n ¼ 13)
or cytogenetic (n ¼ 1) relapse prior to first DLI median time
between relapse and DLI was 15 days (1–57). The percentage of
autologous cells at first DLI varied between 3 and 100% (median
40) in PB (n ¼ 19) and between 15 and 90 % (median 48) in BM
(n ¼ 8). For the six patients in whom data on MC in both PB and
BM at first DLI were available, the percentage of autologous
cells was comparable in both tissues, with the exception of one
patient who had 60 and 90% autologous cells in PB and BM,
respectively.
Procedure of DLI
Five patients received a single DLI, and 16 patients were given
two to six infusions (median 3). The number of infused cells was
reported as CD3 þ T-cell dose in 18 patients and as mononuclear cell (MNCs) dose in three patients. In the 18 evaluable
patients, the number of CD3 þ T cells given with each infusion
varied from 1 104 to 2.4 108/kg, and the total number of
T cells administered ranged from 9 104 to 2.4 108/kg.
Cyclosporine A (CSA) had been stopped prior to DLI in all
patients. None of the patients had received chemotherapy
between engraftment and administration of DLI. Three patients
were given chemotherapy with 6-mercaptopurine (6-MP)7
cytosine arabinoside or thioguanine within 1 month following
DLI. Another six patients received chemotherapy and/or
cytokine treatment including interferon-alpha more than 1
month after DLI because of disease progression.
One patient (CZ019) was given DLI after the second relapse
following HSCT. This patient developed MC on day 73 after
HSCT. On day 82, hematological relapse with 52% blasts in BM
and an abnormal karyotope 44–45, XY, der(5)t(5;17)del(11)(p)
was diagnosed. Following the withdrawal of immunosuppressive agents (CSA, mycophenolate mofetil, steroids) and initiation
of 6-MP therapy, the patient achieved CR on day 108. However,
he suffered MC and cytogenetic relapse occurring on day 353,
after which DLI was given on day 368.
Leukemia
DLI in children with JMML relapsing after HSCT
A Yoshimi et al
974
Table 4
DLI
Analysis of factors with possible influence on response to
No of
patients
Response to DLI
(+)
()
Sex of patient
Male
Female
12
9
4
2
8
7
Cytogenetics
Normal
Abnormal
Monosomy 7
Other abnormalities
15
6
2
4
2
4
1
3
13
2
1
1
9
3
2
3
3
1
0
0
No. of HSCT
First
Second
17
4
Sex of donor
Male
Female
Response to DLI
(+)
NS
o
Age (months)
Interval HSCT-DLI (days)
Interval MC-DLI (days)
% of autologous cells at first DLI
47
165
15
20
(9–99)
(29–368)
(7–127)
(3–60)
()
41
233
53
37
(8–70)
(47–801)
(4–225)
(17–100)
NS
NS
NS
NS
P ¼ 0.03
Data are expressed as median and range.
DLI ¼ donor leukocyte infusion; HSCT ¼ hematopoietic stem cell transplantation; MC: mixed chimerism. NS ¼ Statistically non-significant.
6
2
2
3
NS
3
3
14
1
NS
13
8
5
1
8
7
NS
Sex match with the donor
Matched
Mismatched
10
11
3
3
7
8
NS
Donor
Matched sibling
Other
6
15
0
6
6
9
NS
Of the seven patients who had MC but no clinical signs of
hematological relapse at the start of DLI, three achieved CC.
One of these (CZ034) achieved CC after the first DLI with 1x106/
kg T cells (Table 3). However, 6 days before DLI, CSA had been
stopped. The patient suffered hematological relapse 26 days
after the first DLI and did not respond to the second DLI with
1 107/kg T cells. Thus, withdrawal of immunosuppressive
therapy might have contributed to the response noted after the
first DLI. The other two patients did not respond to the first DLI,
progressed to hematological relapse and achieved CC after the
second DLI (Table 3). Three of 14 patients with hematological
relapse at first DLI achieved CC and CR after a single infusion of
more that 1 107/T cells/kg (Table 3). Except patient CZ034
described above, no other patient who received less than
1 107/kg T cells responded. Only one of the six responding
patients had received concomitant chemotherapy; this patient
was given 6-MP for 30 days between the second and third DLI.
aGVHD after HSCT
Grade 0–I
Grade II–IV
16
5
4
2
12
3
NS
Disease status at DLI
Mixed chimerism
Hematological relapse
7
14
3
3
4
11
NS
Total number of infused T cells (n ¼ 18)
8
o107/kg
10
X107/kg
0
6
8
4
P ¼ 0.01
aGVHD after DLI
Grade 0–I
Grade II–IV
1
5
14
1
P ¼ 0.01
Molecular analysis (n ¼ 17)
PTPN 11 mutation
RAS mutation
Clinical NF1
Neither
15
6
NF1 ¼ neurofibromatosis 1; HSCT ¼ hematopoietic stem cell transplantation; GVHD ¼ graft-versus-host disease; NS ¼ statistically nonsignificant.
Response to DLI
Six of 21 patients responded to DLI and achieved CC at a
median of 45 days (7–56) after DLI (Table 3). The analysis of
factors with possible influence on response to DLI is shown in
Tables 4 and 5. Response was observed irrespectively of
karyotype, but the response rate in patients with abnormal
karyotype was higher than in patients with normal karyotype.
Although the number of patients is small, it is notable that none
of the patients grafted and given DLI from a matched sibling
donor achieved CC. The responding patients had received DLI
from a matched cousin (n ¼ 1) or matched (6/6, n ¼ 4) and
mismatched (5/6, n ¼ 1) UD.
Leukemia
Table 5
Response to DLI according to age, time from HSCT, and %
of autologous cells
Complications after DLI
Complications after DLI were observed in six of six responding
and one of 15 nonresponding patients. In four of the six
responders, aGVHD (grade II: n ¼ 2; grade IV: n ¼ 2) was
diagnosed 4–40 days after the initiation of DLI. Steroid and/or
CSA were given in these patients. Grade IV aGVHD was treated
intensively with additional high-dose steroid, ATG or OKT3,
although it was fatal in one patient. One nonresponder
developed aGVHD grade II 20 days after the last of six DLI
administered between days 47 and 167 post-HSCT. cGVHD
developed in two of 16 evaluable patients. Both patients were
responders and had received a single dose of DLI. One of those
developed cGVHD 349 days after DLI and following aGVHD,
the other suffered de novo cGVHD 275 days after DLI.
Complications other than GVHD were seen in two responders;
fatal BM failure diagnosed 26 days after DLI in one and a
hypereosinophilic syndrome (HES) successfully treated with
steroid in another. In total, two patients, all responders,
succumbed to complications of DLI.
Clinical course and outcome
Of the six patients who responded to DLI, one patient is alive in
CR with persistent CC 72 months after DLI. This patient is
suffering from extensive de novo cGVHD. Two responding
patients experienced a subsequent hematological relapse, one
54 months after DLI as gastric chloroma and the other patient
(CZ034) is alive in CR after a second HSCT.
DLI in children with JMML relapsing after HSCT
A Yoshimi et al
Of the 17 patients suffering progression of disease after DLI,
seven underwent a second HSCT. Prior to second HSCT, six
patients received none or low-dose chemotherapy; the only
patient given AML-like therapy did not achieve CR. The median
time from first HSCT, first DLI and last DLI to second HSCT was
401 days (162–907), 105 days (43–153), and 87 days (43–153),
respectively. The preparative regimen for second HSCT following DLI included TBI in all patients. One patient was
transplanted from the twin sister of the original UD; all other
patients received a graft from the original donor. Intensity of
GVHD prophylaxis was reduced compared to the first HSCT in
five patients. aGVHD (Xgrade II) and cGVHD were observed in
five and two patients after second SCT, respectively. Five of the
seven patients who have undergone a second transplant
procedure for disease progression after DLI are alive in CR with
a median follow-up of 13 months (4–74) after second HSCT.
Discussion
Treatment options for patients relapsing with leukemia after
HSCT are limited. Withdrawal of immunosuppressive drugs is
usually the first measure, which by itself can control leukemia in
a limited number of patients. Several reports25–30 and the
clinical course of patient CZ019 in this series indicate the
efficacy of withdrawal of immunosuppressive therapy in some
patients with relapsed JMML, suggesting a GVL effect in JMML.
In the case of nonresponse and for patients suffering disease
recurrence after discontinuation of immunosuppressive agents,
DLI or second HSCT may be considered.
Matthes-Martin et al11 reported the first case of JMML with
monosomy 7 successfully treated with DLI. MC and monosomy
7 were detected in PB 14 days prior to DLI and morphology of
BM on the day of DLI was suggestive of relapse. The patient is
alive in CR 73 months after DLI. However, a subsequent
retrospective analysis demonstrated CC in CD34 þ positive cells
at the initiation of DLI in this patient (S Matthes-Martin, personal
communication, November 2004). As the effect of DLI is
difficult to evaluate in this situation, we excluded the patient
from this study. In the literature, there are three other cases of
successful therapy with DLI of relapsed JMML.12–14 Two of the
three patients had a normal karyotype, and one monosomy 7.
Following chemotherapy (n ¼ 2) or splenectomy (n ¼ 1), DLI
from the matched (n ¼ 2) or one HLA locus mismatched (n ¼ 1)
UD were administered. GVHD was observed in two patients,
BM failure in one, and all patients were alive at the time of
reporting. These case reports suggest that at least some relapsed
JMML patients can benefit from DLI. However, the overall
efficacy of DLI in relapsed JMML is unknown; reporting bias is
likely to exaggerate the benefit of this form of therapy in single
successful cases. In this multicenter retrospective study of 21
children given DLI for MC or hematological relapse following
HSCT for JMML, six patients responded and achieved CC. While
three responders died due to complications and two subsequently relapsed, one patient remains in CR with extensive
cGVHD.
Several factors correlated with response to DLI in our study.
First, the T-cell dose had a significant impact on response to DLI.
None of the eight patients who received a total T-cell dose
o1 107/kg showed a sustained response. In the previously
published reports detailed above,12–14 the JMML patient given
DLI from a mismatched UD responded to 1 106/kg T cells, the
other two patients were given 1x107/kg or 1x108/kg T cells from
a matched UD. Although we cannot draw definite conclusions
due to the small number of patients, we suggest that at least
1 107/kg T cells are necessary for response to DLI in JMML,
except for cases with HLA-mismatched donors. Second, the
response rate to DLI was significantly higher when leukemic
cells harbored an abnormal karyotype (Table 3). Worth et al12
had already hypothesized that JMML cells with monosomy 7
may be more sensitive to DLI. Patients with monosomy 7 may
represent a subset of patients with different biology, although
studies showed the cytogenetic abnormalities including monosomy 7 are not predictive of outcome after first HSCT.7,31 Third,
consistent with previous reports in CML,32,33 occurrence of
GVHD correlated with response to DLI, suggesting a substantial
overlap between the GVL effect and GVHD occurrence. It is
also noteworthy that in this series of JMML, none of the patients
given DLI from a matched sibling donor responded. Moreover,
in all the three previously reported JMML patients successfully
treated by DLI, the donor was an unrelated volunteer.12–14 In
contrast, in CML, there is no apparent major difference in
efficacy of DLI in patients receiving lymphocytes from an HLAmatched sibling compared to a matched UD.32,34,35 Modifications of the procedure will be needed for DLI from a matched
sibling in JMML. Recombinant interleukin-2 increases the
response rate with improved survival in a proportion of patients
with other leukemias who relapse after HSCT and do not
respond well to DLI alone. It may be worth to evaluate IL-2 as
adjuvant therapy in conjunction with DLI in JMML.36,37
Both disease burden and phase of disease have a strong
impact on response to DLI, as shown by the high success rate of
cellular therapy implemented early in the course of recurrent
CML.32,33,38 In CML, early intervention is feasible because the
bcr-abl gene serves as a molecular marker for the detection of
minimal residual disease (MRD). In JMML, like in some other
leukemias, disease-specific markers for MRD are not available
and therapeutic interventions will be based on sequential
chimerism studies. In JMML (Yoshimi A et al. Blood 2003;
102: 706, abstract), patients with persistent MC have a high risk
of relapse.39,40 In fact, in this study, all patients with MC
experienced a hematological relapse. However, possibly due to
the poor overall response rate to DLI, we were unable to
demonstrate a higher success rate in cases of early intervention.
Several studies are currently investigating whether cytoreduction prior to DLI is advisable for leukemia patients with a high
disease burden. Previous reports suggested a role of chemotherapy-induced cytoreduction or cytokine treatment with interferon-alpha along with DLI in JMML.13,14 As none of the patients
studied here received chemotherapy or splenectomy between
last SCT and initiation of DLI, we cannot comment on the
efficacy of this strategy in JMML. Like the use of cytokines, the
role of cytoreduction with chemotherapy or novel drugs such as
E21R41 will have to be studied in well-designed clinical trials of
cellular therapy in relapsed JMML.
Second HSCT is another treatment option for patients
experiencing relapse after an allograft. In this study, seven
patients, six nonresponders and one responder with recurrent
disease after DLI, underwent a second HSCT. Five of these seven
patients are alive in CR. This surprisingly favorable outcome
after second HSCT even with the same donor might be
explained by difference in the preparative regimen, reduced
GVHD prophylaxis, and increased aGVHD and cGVHD
following the second graft.
In conclusion, this study shows that JMML can be sensitive to
DLI, providing evidence for a GVL effect also in this
malignancy. Response to DLI requires a critical number of T
cells and correlates with a high risk of GVHD. However, due to
complications and relapse, the overall outcome of patients
responding to DLI was poor. It is currently unknown whether
975
Leukemia
DLI in children with JMML relapsing after HSCT
A Yoshimi et al
976
DLI or early second HSCT should be favored as a rescue
treatment for children with JMML relapsing after a first grafting
procedure. The results of DLI might be improved by modifications, such as the administration of adequate number of T cells,
use of chemotherapy, or of concomitant cytokines. On the other
hand, by overestimating the effect of DLI in relapsed JMML the
opportunity for a second HSCT might be missed.
Acknowledgements
We thank the affected individuals and their families who
participated in this study, the physicians who referred the patients,
Dr I Baumann and Dr G Kerndrup for reference morphology
review, Dr O Haas, Dr J Harbott, Dr K Michalova and Dr B
Beverloo for reference review of cytogenetic studies. This work
was supported by the Deutsche José Carreras Leukämie-Stiftung
e.V., München, Germany, the Deutsche Krebshilfe, Bonn,
Germany, and the Alexander von Humboldt-Stiftung, Bonn,
Germany.
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