Intrabone transplant provides full stemness of cord blood stem cells with fast hematopoietic recovery and low GVHD rate: results from a prospective study

Francesca Bonifazi, Elisa Dan, Myriam Labopin, Mariarosaria Sessa, Viviana Guadagnuolo, Martina Ferioli, Simonetta Rizzi, Sabrina De Carolis, Barbara Sinigaglia, Maria Rosa Motta, Andrea Bontadini, Valeria Giudice, Giovanni Martinelli, Mario Arpinati, Michele Cavo, Massimiliano Bonafé, Gianluca Storci, Francesca Bonifazi, Elisa Dan, Myriam Labopin, Mariarosaria Sessa, Viviana Guadagnuolo, Martina Ferioli, Simonetta Rizzi, Sabrina De Carolis, Barbara Sinigaglia, Maria Rosa Motta, Andrea Bontadini, Valeria Giudice, Giovanni Martinelli, Mario Arpinati, Michele Cavo, Massimiliano Bonafé, Gianluca Storci

Abstract

Umbilical Cord Blood (UCB) represents a valid option for patients with hematopoietic malignancies lacking an HLA matched donor. To overcome the limitation of the low stem cell dose of UCB, the intrabone (IB) route has been proposed. We report the results of a prospective study on a poor-prognosis cohort of 23 patients receiving intrabone single UCB transplant (Clinicaltrials.gov NCT00886522). Cumulative incidence of hematological recovery at day 90 was 82 ± 9% (ANC > 0.5 × 109/L) and 70 ± 10% (platelet > 50 × 109/L) and correlated with CD34 + cells in the graft. NRM was 20 ± 9%. No severe aGVHD and only one extensive cGVHD occurred, with fast immune reconstitution. To test the hypothesis that the direct IB injection could affect the expression of stem cells regulatory pathways, CD34 + cells from BM aspirates at day + 10, + 20, + 30, processed in hypoxic conditions mimicking the BM-microenvironment (7%pO2), were studied for the expression of c-Mpl, Notch1 and CXCR4. We found that the expression of c-Mpl in CD34 + cells at day + 10 significantly correlated with hematological recovery. In conclusion, IB-UCB transplant success is associated with low incidence of GVHD and high-speed platelet recovery; intrabone route may preserve full hematopoietic stemness by direct delivery of UCB stem cells into the hypoxic HSC niche.

Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
a Cumulative incidence of hematologic recovery (HR). Times to neutrophil (ANC) and platelet (Plt) recovery were defined as time from transplant to > 0.5 × 109/L or, 20 × 109/L and 50 × 109/L, respectively. The cumulative incidence of ANC and platelet recovery were calculated counting deaths from other causes as competing risk. b Cumulative incidence of HR according to CD34 + cells. The hematologic recovery was significantly associated with CD34 + cells (ANC > 0.5 × 109/L p = 0.04; Platelet > 0.5 × 109/L p = 0.07). Median CD34 + cells infused was 0.54 × 105/kg. c Cumulative incidence of non relapse mortality (NRM). The cumulative incidence of NRM was 20  ±9% and was calculated counting deaths from other causes as competing risk. d Cumulative incidence of relapse/progression. Cumulative incidence of relapse/progression was 56  ±10%. In the study protocol, therapy after relapse/progression was free. Two relapses were treated with a further IB-UCB transplant: one was a by phenotypic refractory Acute Leukemia, who achieved a stable complete remission lasting 9 months, then he died for leukemia. The second was a Chronic Myeloid Leukemia patient transplanted in blastic phase, relapsing after 6 months from IB-UCB transplant with hematologic relapse, central nervous system involvement and a solid mass in the breast, which completely responded to Ponatinib. She received a second IB-UCB transplant achieving a further complete remission lasting 5 months; however relapse occurred again resulting in death. e Cumulative incidence of acute GVHD, f Overall survival
Fig. 2
Fig. 2
a Immune reconstitution after IB-UCB transplant. Recovery of CD3 + , CD4 + , CD8 + , CD19 + and CD56 + cells from peripheral blood samples obtained after 30, 90 and 180 days after IB-UCB transplant. b Immune reconstitution after IB-UCB transplant according to ATLG dose. Immune reconstitution from peripheral blood samples according to ATLG dose: patients receiving higher ATLG dose (30 mg/kg) show a more impaired CD3 + , CD4 + and CD8 + cells recovery than that from patients receiving lower dose (15 mg/kg); CD19 + and CD56 + cells recovery didn’t seem to be affected by ATLG dose
Fig. 3
Fig. 3
a Cumulative incidence of neutrophil recovery according to c-Mpl level evaluated on day + 10 in BM aspirates CD34 + cells processed under hypoxic condition. Time to ANC > 0.5 × 109/L according to + 10 BM-derived CD34 + cells c-Mpl mRNA level (low/high classified respect to the median value of Log ddCT:0.69). b Cumulative incidence of platelet recovery according to c-Mpl level evaluated on day + 10 in BM aspirates CD34 + cells. Time to platelet > 20 × 109/L according to + 10 BM-derived CD34 + cells c-Mpl mRNA level (low/high classified respect to the median value of Log ddCT:0.69). c Regression analysis of c-Mpl level at + 10 day vs amount of CD34 + cells at + day 30. In the Box window the expression of Low vs Hi of c-Mpl is significantly associated with the capability of in vivo of CD34 + cells measured by the amount of CD34 + cells at day + 30. (Low/hi were classified as below/above the median value of Log ddCT:0.69)

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