Lymphodepletion followed by donor lymphocyte infusion (DLI) causes significantly more acute graft-versus-host disease than DLI alone

Abstract

Donor lymphocyte infusions (DLIs) can produce lasting remissions in patients with relapsed chronic myeloid leukemia (CML), but are less effective in non-CML diseases. We hypothesized that lymphodepletion, achieved with cyclophosphamide (Cy) and fludarabine (Flu), would promote in vivo expansion of the infused lymphocytes enhancing their immunologic effects. Fifteen patients with relapsed non-CML disease who received Cy/Flu/DLI were compared with 63 controls who received DLI without chemotherapy. Only the patients receiving Cy/Flu/DLI became lymphopenic at the time of DLI. Compared with controls, patients who received Cy/Flu/DLI developed significantly more grades II to IV (60% vs 24%, P = .01) and grades III to IV acute graft-versus-host disease (GVHD) (47% vs 14%, P = .01) with greater GVHD lethality. In Cy/Flu/DLI patients, T-cell proliferation was elevated at 14 days after DLI. Although these data suggest that chemotherapy-induced lymphodepletion enhances activation of donor lymphocytes, the toxicity needs to be managed before testing whether better disease control can be achieved. This trial was registered at www.clinicaltrials.gov as no. NCT00303693 and www.cancer.gov/clinicaltrials as no. NCT00167180.

Figures

Figure 1

Lymphodepleting chemotherapy prior to DLI induces greater immune activation than does DLI alone and is manifested as more severe acute GVHD. The Cy/Flu/DLI cohort (n = 15) consisted of 14 matched sibling donors (93%) and one 5 of 6 mismatched HLA-A, -B, -DR (high-resolution typing) unrelated donor. The control cohort receiving DLI without chemotherapy (n = 63) consisted of 49 matched sibling donors (79%, P = NS), 1 single antigen mismatched sibling donor, and 13 unrelated donors (10 6/6 matched and 3 mismatched). GVHD (A-C) and overall survival (D) are shown for patients who received Cy/Flu/DLI compared with those receiving DLI alone for all patients (A-B) or for those patients with non-CML diseases only (n = 35, C-D).

Figure 2

T lymphocytes expand in vivo in patients who receive Cy/Flu/DLI. Peripheral blood mononuclear cells were collected from the DLI donor and from patients prior to initiating chemotherapy (pre-DLI) and 14 days, 28 days, 2 months, and 3 months after Cy/Flu/DLI therapy. (A) The absolute lymphocyte counts (ALCs) from the clinical complete blood count were used to calculate absolute CD4+ and CD8+ counts at all time points. (B) Cells were stained for the intracellular Ki-67 antigen as a marker for proliferating T cells. Results are shown as the percentage Ki-67-positive cells gated on CD3+, CD3+/CD4+, and CD3+/CD8+ cells. Error bars indicate SEM.