Haploidentical Stem Cell Transplantation with Post-Transplant Cyclophosphamide As Graft-Versus-Host Disease Prophylaxis in Pediatric Hematologic Malignancies

Background

Hematopoietic stem cell transplantation (HSCT) is used in pediatric patients with acute leukemia, after a relapse to bone marrow, or in first remission in case of high risk disease. If necessary, 75% of the cases do not have a compatible related donor and it is not always possible to have a compatible unrelated donor or an umbilical cord blood unit. Therefore, using haploidentical alternative donors of hematopoietic stem cells (HSC) is becoming more frequent.

Objective

The purpose of this is to report the results of haploidentical hematopoietic stem cell transplantation with post-transplant cyclophosphamide (PTCy) in a group of pediatric patients, which lacks a related HLA compatible donor, at the National Pediatrics Institute in México City, México, in the period between January 2012 thru December 2016.

Methods

We retrospectively reviewed 27 patients´ files <18 years old, who had been diagnosed with acute lymphoblastic leukemia (ALL, eighteen patients), or acute myeloid leukemia (AML, nine patients), and underwent on haploidentical transplantation with post-transplant cyclophosphamide (PTCy). The group of patients consisted of eighteen men and nine women. Age ranged from one to eighteen years (median age eight years). Sixteen patients were in their first hematologic remission, eight in their second, two in their third and one in their fourth hematologic remission, respectively. All donors were ⩾ 4 HLA loci mismatched parents (mother, n = 17; father, n = 8), or siblings, n = 2. Conditioning was based on a nonmyeloablative regimen comprised of fludarabine 50 mg/m², days -6 to -2, cyclophosphamide 14.5 mg/kg, days -6 and -5, and low-dose total body irradiation 200 cGy at day -1. Graft versus host disease prophylaxis comprised Cy 50 mg/kg intravenous on day 3 and 4 after transplantation, followed by tacrolimus 0.06 mg/kg and mycophenolate mofetil 15 mg/kg, each beginning on day 5. According to the availability of bone marrow harvesting kit, the HSC source was peripheral blood in twenty patients and bone marrow in seven. The median number of CD34+ cells infused was 5.41 × 10⁶/kg (range, 1.27-22.6).

Results

Fourteen patients (51.6%) presented complete and sustained chimerism. Overall survival is presented in Figure 1. Graft failure occurred (48.1%) more frequently in the group of patients in whom bone marrow was used as a source of HSC (p=0.26). Nine patients with complete chimera, whose HSC source turned out to be PB, presented acute-GVHD III-IV (p = 0.06). Four of the patients whom presented full engraftment died, three of them due to infectious processes (cytomegalovirus pneumonia, AH1N1 pneumonia, abdominal sepsis secondary to intestinal perforation and E. coli sepsis), before +100-day post-transplantation. All these patients presented acute-GVHD III-IV. The fourth patient who died, also the cause was infectious (pulmonary sepsis secondary to Morganella morganii), thirteen months after the transplant and without history of GVHD. Of the thirteen patients who presented primary graft failure, seven of them are alive and without evidence of tumoral activity

Discussion

Haploidentical transplantation with PTCy is a feasible therapeutic option in pediatric patients with malignant hematological diseases who require a HSCT and do not have a matched sibling or unrelated donor available.

Conflict-of-interest disclosure: The authors declare they have nothing to disclose.

Correspondence: Gerardo López-Hernández. loherge@gmail.com

Bibliography

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2. González-Llano O, González-López EE, Ramírez-Cázares AC, et al. Haploidentical peripheral blood stem cell transplantation with posttransplant cyclophosphamide in children and adolescents with hematological malignancies. Pediatr Blood Cancer. 2016; 63: 2033-2037.

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