Donor Lymphocyte Infusion;

Past, Present and Future

Applications

Christopher Chun MT(ASCP)HP

Quality Assurance Coordinator

Intermountain Blood and Marrow Transplant /

Acute Leukemia Program

at LDS Hospital

Salt Lake City, Utah

Presentation Goals

• Review Historical Perspective

• Major Questions Surrounding DLI

• Describe Current Applications

• Discuss Future Direction of DLI

• Provide Calculation Tool to Project

Target Cell Dose for Collection

Historical Perspective

• 1990 - Kolb et. al. reported first donor

lymphocyte infusion data with MRD CML

patients

• Reports of MUD DLI and CML

• Reports of other diseases treated with DLI

• Major problems encountered with DLI

Complications Associated with DLI

• Graft vs Host Disease

• Aplasia

Complications Associated with DLI

GVHD

• Undesirable side effect and is thought to be

initiated by tissue injury leading to activation

and proliferation alloreactive T-cells

• Postulated that inflammatory cytokines

produced post-transplant activate alloreactive

donor T-cells lower the threshold for GVHD

• Appears to be less incidence and severity of

GVHD post-DLI vs post-ablative SCT

Complications Associated with DLI

Aplasia

• Post DLI, has been reported in 20-40% of

patients with mortality of 5%

• Risk of death due to infections or bleeding

• Mechanism is not known

• Most patients recover counts spontaneously

• More common in hematological relapse of

CML is rarely reported in cytogenetic or

molecular relapse (Collins et al., 1997)

Treatment Outcome with DLI;

General Comments

• Unmanipulated DLI for relapsed disease after

myeloablative SCT:

– Overall incidence of aGVHD is 40-60% ,

affecting 20-35% of patients.

– Chronic GVHD occurs in 33-61% of

patients

– Deaths caused by GVHD is 6-11%

Frey et al., 2008

Treatment Outcome with DLI;

General Comments, Cont.

• CML “chronic phase,” DLI is effective without

therapy

• Advanced phase CML and acute leukemias,

remission rates higher and of shorter duration

• GVT and GVHD responses after DLI are

highly correlative

• Some patients experience GVT w/o GVHD

Frey et al., 2008

Major Questions Surrounding

DLI

• What diseases respond to DLI?

• What is the ideal cell dose for DLI?

• When is the best time to administer DLI?

Diseases/Disorders Studied with DLI

Hematological

Malignancies

• AML

• ALL

• CLL

• CML

• MM

• HL

• NHL

Other Disorders

• SAA

• Thalassemia

Diseases/Disorders Studied with DLI

Hematological

Malignancies

• AML

• ALL

• CLL

• CML

• MM

• HL

• NHL

Other Disorders

• SAA

• Thalassemia

Diseases/Disorders Studied with DLI

Hematological

Malignancies

• AML

• ALL

• CLL

• CML

• MM

• HL

• NHL

Other Disorders

• SAA

• Thalassemia

Diseases and Response to DLI

CML

• Best outcome is in “chronic phase” molecular

or cytogenetic relapse, 75% remission rate

(Kolb et al.)

• In advanced phase, remission rates are

lower, accelerated and blastic phases = 12.5

-33% (Kolb et al.)

• First patient who received DLI, in remission

for > 20 years

• TKI changed the treatment course of CML

CML; Best to Worst Responders to DLI

Molecular Relapse (90-100%)

Cytogenetic Relapse (90%)

Hematologic Relapse

(CP (75%) > AP/BC (36%) > RD (0%)

(Roddie et al., 2011)

Diseases and Response to DLI

AML

• Post-transplant prognosis is generally poor

• Of those achieving remission, duration is

short lived

• Early intervention has the potential to improve

responses and survival

• Low disease burden and favorable

cytogenetics appears to be beneficial

• DLI by itself appears not to be beneficial for

relapsed AML

Diseases and Response to DLI

ALL

• Relapsed ALL has a poor prognosis,

particularly of B-cell or pre B-cell origin

• Remissions are often short in duration

• Achieving remission by receiving pre-DLI

chemotherapy, critical surrogate marker that

predicts overall survival (Collins et al. 2000)

• ALL is a rapidly proliferating disease; DLI is

rarely effective in florid relapse

Diseases and Response to DLI

Lymphoma

• Heterogeneous group of histological

diagnoses; generally classified into indolent

and aggressive groups

• Most commonly treated with autologous SCT;

the role of allogeneic SCT remains

controversial as an upfront treatment

• A small number of patients have been

reported to have undergone DLI, but has

been shown to induce remission for relapse

post-SCT

Diseases and Response to DLI

Lymphoma (cont.)

• Significant responses attained in more

aggressive lymphomas with addition of

chemotherapy

• Hodgkins- Response rates have been

disappointing (~30-40%) and of limited

duration

Diseases and Response to DLI

MM

• Autologous transplants are the preferred

treatment

• 60% of patients achieving CR with DLI

experienced long-term survival

• Published studies of “Prophylactic” DLI and

CR rate of 43-85%

• It is unclear whether DLI will add to durability

of response once patients achieve chemo-

induced remission

Hematologic Diseases; Best to Worst

Responders to DLI

CML

Lymphomas

Multiple Myeloma

Acute Leukemias

Cell Dose and DLI

• Best evidence of optimal cell dose has been

established in CML

• Optimal cell dose in most hematological

malignancies have yet to be determined

• CML with cytogenetic or molecular relapse

and unrelated donor transplants respond to

lower doses of DLI (< 1 x 107 CD3 / Kg)

• Escalating dose regimens are most effective

in CML

• The popular range of cell dose appears to be

0.01 to 1 x 108 CD3 / Kg

(Collins et al., 2000)

Cell Dose and DLI

(Roddie et al., 2011)

Cell Dose and DLI

(Doel et al., 2011)

Cell Dose and DLI

Timing of DLI Administration

• Some reports suggest distancing

administration of DLI from the inflammatory

effects of cytotoxic regimens

• In the setting of dose escalation (DE)

regimens, Mackinnon et al. recommended a

minimum of 3 months between DE infusions

• Optimal timing has been difficult to prove!

(Chang et al., 2013)

Timing of DLI Administration

Current Applications

• Reserved for patients without active GVHD

and given without prophylactic

immunosuppression

• Rapid Expansion of NST and RIC prompts

further investigation into DLI

• Due to lower intensity regimens, RIC and

NST leading cause of treatment failure is

relapse- DLI to enhance tumor response

Indications for DLI

• Treat Relapsed Disease after SCT

• Prophylactic DLI to prevent relapse and viral

reactivation

• Induce full donor chimerism

• Enhance immune reconstitution

• Treat viral infection after SCT

• Treat post-transplant lymphoproliferative

disorder

Haplo-identical SCTs and DLI

• Limited reports on outcomes of DLI after

Haploidentical SCT

• Study reports of DLI administered

conventionally and/or prophylactically

• Various cell doses and schedules have been

evaluated

Future Direction of DLI Therapy

• Therapeutic, preemptive and

prophylactic DLI administration

• Suicide gene transfected donor T-cells

• Activated DLI

• mHAg-specific CTLs

• Immunomagnetic cell selection /

depletion

Therapeutic and Prophylactic DLI

(Chang et al., 2013)

Therapeutic and Preemptive DLI

(Chang et al., 2013)

Immunomagnetic Cell Selection Devices

CliniMacs Isolex 3000i

Tools and Calculations to

Tailor DLI Collections

• Types of collection sources

• Obtaining pre-collection donor clinical

laboratory history

• Predicting CD3 cell yields

Types of Collection Sources

• Whole Blood

• Leukapheresis

– Conventional DLI

– Mobilized DLI

Considerations for Product

Source Selection-Whole Blood

Whole Blood

• Desired cell dose

• Urgency of product collection

• Accessibility of donor

• Location of donor

• Processing performed by Cell Therapy Laboratory

• Donor-recipient ABO matching

• Donor whole blood collection qualification issues by

Donor Center

Peripheral Blood Leukocyte Reference

Ranges for Adults

• WBC = 3.6 – 10.6 (x 103/uL)

• LYM% = 22 - 44

• CD3% = 49 - 80

Estimated CD3 Cell Dose Range

Whole Blood

Total CD3 cell range: 1.94 x 108 – 18.65 x 108

Adult recipient weight range: 40 Kg – 90 Kg

CD3 cell/Kg range: 2.16 x 106/Kg – 4.66 x 107/Kg

Very unlikely to get > 5 x 107/Kg with WB

Considerations for Product

Source Selection- Leukapheresis

Leukapheresis

• Conventional DLI

― Desired cell dose

― Timing of collection

• Mobilized DLI

― Desired Cell dose

― Addition of stem cell component (boost)

― Availability of stored aliquots

― Donor issues regarding remobilization

Effect of GCSF on Peripheral Blood CBC

(Stroncek et al., 1996)

Conventional vs GCSF-Mobilized DLI

(Abbi et al., 2013)

Conventional vs GCSF-Mobilized DLI (cont.)

(Abbi et al., 2013)

Conventional vs GCSF-Mobilized DLI (cont.)

(Abbi et al., 2013)

Peripheral Blood Leukocyte Ranges

Comparison Intermountain BMT

Limited Experience

Non-Mobilized (n=14)

• WBC = 5.8 (x 103/uL)

[4.5-10.1]

• LYM = 25.0% (n=11)

[14.0-43.1]

• CD3 = N/A

GCSF-Mobilized (n=12)

• WBC = 38.4 (x 103/uL)

[27.7-78.5]

• LYM = 9.0% (n=10)

[3.0-16.0]

• CD3 = N/A

Estimated Lymphocyte Collection

Calculation Equation

Required Data:

• Recipient Weight (Rw)

• Donor WBC Count (Dwbc)

• Donor Lymphocyte Percentage (DL%)

• Donor Peripheral CD3 Percentage(Dcd3%)

• Blood Volume Processed/Collected (BV)

Estimated Lymphocyte Collection

Calculation Equation

Given:

• Donor WBC Ct. [106/mL] (Dwbc)

• Donor Lymph %

(DLym%)

• Donor Periph CD3 %

(Dcd3%)

• Blood Vol. Proc. [mL]

(BV)

• Recip. Wgt. [Kg]

(Rw)

• Aph. Corr. Factor

(Ac)

Equation:

Dwbc x AC x BV x Dlym% x Dcd3%

Rw

EXAMPLE

Estimated Lymphocyte Collection

Calculation: “Whole Blood Product”

Given:

Dwbc = 5.0 x 106/mL

Dlym%= 40.0 %

Dcd3%= 77.0 %

BV = 450.0 mL

Rw = 70.0 Kg

Ac = 1.0

Equation:

(5.0 x 106/mL)(1)(450.0mL)(.40)(.77)

70 Kg

Estimated CD3 Collection:

~ 9.9 x 106 cells / Kg

EXAMPLE

Estimated Lymphocyte Collection

Calculation: “Leukapheresis Product”

Given:

Dwbc = 50.0 x 106/mL

Dlym%= 20.0 %

Dcd3%= 40.0 %

BV = 12000.0 mL

Rw = 70.0 Kg

Ac = 0.45

Equation:

(50.0 x 106/mL)(0.45)(12000.0mL)(0.20)(0.40)

70.0 Kg

Estimated CD3 Collection:

~3.09 x 108 cells / Kg

Summary

• Best evidence of DLI with positive response is

in CML (cytogenetic and molecular relapse)

• The best cell dose for many hematological

malignancies have yet to be determined

• The timing of DLI is affected by the pre-DLI

conditioning regimen

• Given pre-collection historical lab values,

calculated prediction can be useful in tailoring

collection endpoints

Conclusion

“One thing that becomes increasingly

apparent when reviewing the literature on

DLI is that there are many more questions

than answers”

Recently Published Articles

(March-April 2013)

Reference Review Articles for Presentation

• Deol A, Lum L. Role of donor lymphocyte infusions in relapsed

hematological malignancies after stem cell transplantation revisited.

Cancer Treat Rev 2010 Nov;36(7):528-538

• Chang Y, Huang X. Donor lymphocyte infusions for relapse after

allogeneic transplantation. When, if and for whom? Blood Reviews

2013;27:55-62

• Roddie C, Peggs K. Donor lymphocyte infusion following allogeneic

hematopoietic stem cell transplantation. Expert Opin Biol Ther

2011;11(4):473-487

• Frey N, Porter D. Graft-versus-host disease after donor leukocyte

infusions: presentation and management. Best Pract Res Clin

Haematol 2008 Jun;21(2):205-222

• Abbi K, Zhu J, Ehmann, et al. G-CSF mobilized vs conventional donor

lymphocytes for therapy of relapse or incomplete engraftment after

allogeneic hematopoietic transplantation. Bone Marrow Transplantation

2013:48:357-362

THANK YOU!