STEM CELL SOURCES

IN ALLOGENIC SCT
Dr. Ashray Kole
topics

 Introduction  Umbilical cord stem cell source

 History  Donor Selection criteria
 Bone marrow stem cell source  Summary
 Bone marrow harvest
 GCSF Primed BM harvest
 Practical aspects
 Peripheral blood stem cell source
 Characteristics
 Bone marrow harvest
 Recommendations
 Practical aspects
INTRODUCTION

 Today, based on data from the National Marrow Donor Program, all 3
sources, BM, mobilized peripheral blood, and UCB, serve as sources
of stem cells for hematopoietic transplantation
 Although all 3 sources of stem cells can reconstitute the
hematopoietic system in recipient after transplant, they have many
inherent differences in cellular constituents and biological and
immunological properties.
 The availability of a suitable stem cell graft is an absolute
prerequisite for the performance of allo-HSCT.
Discovery of HSCs
Biol Blood Marrow Transplant 23 (2017) 1241–1249
BONE MARROW
PROCEDURE

 Under general anesthesia.

 Multiple aspirations are performed along the posterior iliac crest with the
collection
 Each aspiration to a volume of less than 5 mL before transferring the aspirate
through a three-way tap to the collection bag.
 The collection bag contains ACD anticoagulant solution and the syringes are
rinsed with heparin (5.000 U/mL).
 Depletion of RBC or plasma is required for when there is an ABO mismatch.

Biology of Blood and Marrow Transplantation, 2017-08-01, Volume 23, Issue 8, Pages 1241-1249
CELL DOSE

 A nucleated cell dose of 2 x 108/kg is generally considered to be adequate .

 Transplantation-related mortality and five-year survival were significantly
better when the CD34+ cell dose was ≥3.0 x 106/kg
 This generally requires between 700 and 1500 mL of bone marrow for an
adult recipient, depending on recipient weight.
 The volume should not exceed 20ml/kg.
 Rates of hematopoietic recovery were significantly worse when the CD34+
cell dose was <1.2 x 106/kg.

Biology of Blood and Marrow Transplantation, 2017-08-01, Volume 23, Issue 8, Pages 1241-1249
Complications

 Mild back or hip pain, fatigue, and transient changes in peripheral

blood cell counts.
 Serious complications of bone marrow harvest are extremely rare
and involve mechanical injury, complications of anesthesia, infection,
and bleeding.

Biology of Blood and Marrow Transplantation, 2017-08-01, Volume 23, Issue 8, Pages 1241-1249
G-CSF–Primed BM Stem Cell Collection

 G-CSF administration before stem cell collection either from the peripheral
blood or BM is known to increase the CD34 + cell concentration by over 6- to
7-fold
 Hypothesis: to increase a more primitive HSPC population within the BM
while “mobilizing” T cells and differentiated, myeloid-biased progenitors into
peripheral blood.
 This is believed to facilitate engraftment while mitigating GVHD risk.
 Dual side effects associated with G-CSF administration and the risks of
mechanical injury, general anesthesia, and anemia from the biopsy procedure.
Biology of Blood and Marrow Transplantation, 2017-08-01, Volume 23, Issue 8, Pages 1241-1249
Transplants using primed marrow showed faster engraftment and lower/equivalent
rates of acute and chronic GVHD

G-CSF-primed bone marrow as a source of stem cells for allografting: revisiting the concept. Bone Marrow
Transplant 2015; 50: pp. 1150-1156
Comparable or marginally improved engraftment but higher rates of acute and chronic GVHD in
the patients receiving PBSC grafts.
No significant differences were noted in overall survival between the 2 groups
G-CSF-primed bone marrow as a source of stem cells for allografting: revisiting the concept. Bone Marrow Transplant
2015; 50: pp. 1150-1156
PERIPHERAL BLOOD
• 4 to 5 days of G-CSF subcutaneous
administration at a dose of 10
mcg/kg.
• Mobilized stem cells are collected
using an apheresis.
• Vascular access is accomplished by
use of apheresis needle in antecubital
vein.
• An apheresis procedure requires
usually four to five hours
• Citrate is the most commonly used
anticoagulant for apheresis.

Enric Carreras. The EBMT Handbook (p. 119)

PERIPHERAL BLOOD STEM CELL
HARVEST

 The measurement of CD34+ cells in the PB before leukapheresis is not

mandatory but could help to estimate the expected collection yield.
 The duration should not exceed 5 h.
 If the number of cells collected is inadequate, mobilization with G-CSF may be
continued for 1–2 days.
 Depletion of RBC or plasma is not required.
 Apheresis volume : 2.7–3.5 times the patient’s total blood volume.

Enric Carreras. The EBMT Handbook (p. 119).

POOR MOBILIZER

 Patients with less than 2 × 10^6 CD34+ cells/kg collected or patients

mobilizing less than 10–20 CD34+ cells/μl into the PB.
 Below 10 CD34+ cells/μl, the use of plerixafor is clearly indicated to avoid
mobilization failure.
 If it is not possible to collect at least one third of the collection goal with the
first apheresis, plerixafor should be given

Proposed definition of 'poor mobilizer' in lymphoma and multiple myeloma: an analytic hierarchy process by ad hoc working
group Gruppo ItalianoTrapianto di Midollo Osseo Bone Marrow Transplant. 2012;47:342–51.
Bone Marrow Transplant. 2018;53:246–54.
 PB BM Cord Blood
Donor characteristics
Transplant donor type Haploidentical donor, * Haploidentical donor, MSD, MUD
MSD, MUD MUD

Collection risk † Apheresis related severe Surgical risk (severe Postdelivery

adverse events adverse events) Absent/none reported
~1/1000 ~1/100

Graft characteristics
Relative CD34 content 50× 10× 1×

Relative T cell content 100× 10× 1× (naive T cells)

Minimum cell dose for Autologous: 2 × Same as for PB grafts Single cord: 2.5 × 10 7 TNC/kg
engraftment ‡ 10 6 CD34 + cells/kg Dual cord: 1.7 × 10 7 TNC/kg/cord unit
Allogeneic: 4 ×
10 6 CD34 + cells/kg

Collection volume, mL ~300 ~1000 ~100

Relative graft procurement ~2× ~2.3× ~1-2×

cost §

HLA matching criteria ‖ 6/6 (MSD) Similar to PB 4-6/6

7/8 (haploidentical donor)
8/8-12/12 (MUD)

Recipient characteristics

Disease type Preferred source for Preferred source for non- Used for either
malignant disease ¶ malignant disease

Speed of engraftment Faster Moderate Slower

Anti-tumor effect Higher Lower Higher

Acute/chronic GVHD risk Higher Moderate Lower
Biology of Blood and Marrow Transplantation, 2017-08-01, Volume 23, Issue 8, Pages 1241-1249
UMBILICAL CORD BLOOD
UCB HARVEST

 Donor recruitment usually starts during the antenatal period,

 Collection must not interfere with normal delivery.
 Two main techniques to collect UCB from the cord vein: before the placenta is
delivered (in utero) or after the placenta is delivered (ex utero).
 A UCB collection typically involves cord clamping disinfection,
venipuncturing of umbilical vein and draining by gravity avoiding clotting.
 UCB units are transported to the processing facility within 48 h of collection

The EBMT Handbook: Hematopoietic Stem Cell Transplantation and Cellular Therapies [Internet]. 7th edition
 Advantages

 Expanded donor pool

 Ease of procurement and lack of donor attrition
 Favorable outcomes:
 The incidence and severity of acute and chronic GVHD in UCB graft recipients are lower than those associated with MUD
or partially-matched related bone marrow grafts.
 Similar overall survival (OS) and improved GVHD-free/relapse-free survival (GRFS), compared with matched related or
unrelated grafts.
 Safety for donors and recipients
 does not put the mother or newborn at risk.
 Reduced likelihood of transmitting infections (eg, cytomegalovirus) from the donor to the recipient.

Adult cord blood transplant results in comparable overall survival and improved GRFS vs matched related transplant. Blood Adv. 2020 May
26;4(10):2227-2235
Graft-versus-host disease in children who have received a cord-blood or bone marrow transplant from an HLA-identical sibling. N Engl J Med. 2000 Jun
22;342(25):1846-54
 Disadvantages

 Increased risk of graft failure

 Increased infections
 slower neutrophil recovery
 other effects on immune reconstitution, which may be related to use of antithymocyte globulin (ATG)
 Unavailability for additional donations
 Subsequent donor lymphocyte infusions or other cell-based therapies.
 Possible transplantation with a hematologic disorder
 Theoretically, there remains an increased risk of transmitting undetected hematologic diseases
 Incidence of post-HCT autoimmune disorders
Alternative haematopoietic stem cell sources for transplantation: place of umbilical cord blood. Br J Haematol. 2009 Oct
New autoimmune diseases after cord blood transplantation: a retrospective study of EUROCORD and the Autoimmune Disease Working Party of
the European Group for Blood and Marrow Transplantation. Blood. 2013 Feb 7;121(6):1059-64
DONOR SELECTION
MATCHED RELATED TRANSPLANT

 When a 6/6 medically eligible matched sibling donor (MSD) is identified, the
allo-HCT may proceed
 For related allogeneic donors other than biological siblings, high resolution
HLA is required.
 Whenever more than one MRD is available, other characteristics such as
donor's age, CMV status (matching for CMV status preferred), gender (males
and nulliparous females preferred), and blood type can be considered.

Guidelines from the NMDP/CIBMTR; Blood, 134 (12) (2019)

DONOR SELECTION IN
HAPLOIDENTICAL STEM CELL
TRANSPLANT
 Donor-specific anti-HLA antibodies
 Age
 Gender
 ABO compatibility
 NK cell alloreactivity
 Donor–recipient CMV serostatus
 Degree of HLA-mismatch

The European Society for Blood and Marrow Transplantation (EBMT) consensus recommendations for donor selection in haploidentical hematopoietic ce
transplantation. Bone Marrow Transplant. 2020 Jan
DONOR SPECIFIC ANTI-HLA
ANTIBODIES

 The incidence of DSAs in HHCT ranges between ~10–21%

 Study from MDACC reported outcomes of 122 patients treated with both TCD and TCR HHCT and
showed a high incidence of DSAs (18%) and a strong association with primary graft failure
 Time to engraftment was significantly delayed.
 Yoshihara and colleagues revealed that a high level of DSAs (>5000 MFI) was the only significant risk
factor for graft failure in recipients of unmanipulated HHCT
 Primary poor graft function
 EBMT now recommends routine testing for DSAs before choosing haploidentical donors for
transplantation

The European Society for Blood and Marrow Transplantation (EBMT) consensus recommendations for donor selection in haploidentical hematopoietic ce
transplantation. Bone Marrow Transplant. 2020 Jan
Donor age

 Younger donor is strongly associated with a lower incidence of both acute and chronic GVHD, as well
as with better survival
 Donors <30 years were significantly associated with lower NRM and better survival compared with
older donors.
 Ciurea et al. found that younger donor age (</=40 years) was an independent predictor for better OS in
older patients (>/=55 years) with AML and MDS receiving HHCT using PTCy for GVHD prophylaxis.
 Better CD34+ yield especially with BM graft.
 Lower likelihood of clonal haematopoeisis.
 Stem cell collection is tolerated better.

The European Society for Blood and Marrow Transplantation (EBMT) consensus recommendations for donor selection in haploidentical hematopoietic ce
transplantation. Bone Marrow Transplant. 2020 Jan
Gender

 Kasamon et al. found that transplantation using a female donor to a male recipient resulted in lower
survival after TCR HHCT using PTCy for GVHD prophylaxis.
 Mothers seem to be a poor donor choice for child recipients when using the Beijing protocol - higher
rate of GVHD, NRM, and poor survival.
 TCD HHST - relapse rate and NRM were lower, resulting into better EFS in acute leukemia young
patients from a mother than from a father donor.
 TCD HHST - Haploidentical siblings, donor sex had no influence on outcome.
 Donor relationship rather than donor gender has a stronger influence on transplant outcomes.

The European Society for Blood and Marrow Transplantation (EBMT) consensus recommendations for donor selection in haploidentical hematopoietic ce
transplantation. Bone Marrow Transplant. 2020 Jan
 Impact of ABO mismatching on the outcomes of allogeneic related and unrelated blood and marrow stem cell transplantations for hematologic malignancies: IPD-based
meta-analysis of cohort studies. Transfusion. 2009;49:624–35

ABO
compatibility
ABO mismatched transplantation did not
impact overall survival in HLA matched
transplants
Minor and bi-directional ABO mismatched
graft was associated with poor overall
survival in patients receiving unrelated
AHCT
Major ABO mismatched grafts had
decreased OS in BM grafts, while ABO
compatibility had no impact in patients
who received PB grafts in HHCT
Major ABO mismatch can also lead to
hemolytic anemia, delayed red cell
engraftment as well as pure red cell
aplasia.
Published in Biology of blood and marrow transplantation : journal of the American Society for Blood
and Marrow Transplantation 2016

A peripheral blood graft is preferred in case of transplant from a major/minor ABO

incompatible donor when other donors are not available
NK CELL ALLOREACTIVITY

 NK cells are an important component of human innate immunity, recover early post-transplant
and provide antitumor and antiviral effects during the period of severe lymphopenia
 Provide better antitumor effect, as documented by lower relapse rates and better survival in
patients with higher NK cell numbers early post-transplant.
 A donor with alloreactive NK cells appears to be a preferred choice for patients receiving TCD
HHCT, while more studies are needed to clarify this issue in TCR HHCT, especially when
PTCy-based GVHD prophylaxis is employed

The European Society for Blood and Marrow Transplantation (EBMT) consensus recommendations for donor selection in haploidentical hematopoietic ce
transplantation. Bone Marrow Transplant. 2020 Jan
Donor–recipient CMV serostatus

 Donor CMV-negative serostatus was associated with inferior survival, while

a protective effect of a CMV-seropositive donor was limited to CMV-
seropositive recipients.
 983 CMV seropositive recipients of TCR HHCT with PTCy from the EBMT
group revealed that donor CMV serostatus did not influence NRM or OS
 Difficult to conclude and make recommendations on TCR haploidentical
donor selection based on donor–recipient CMV serostatus.

The European Society for Blood and Marrow Transplantation (EBMT) consensus recommendations for donor selection in haploidentical hematopoietic ce
transplantation. Bone Marrow Transplant. 2020 Jan
Degree of HLA-mismatch

 Higher degree of HLA-mismatch between donor and recipient has been associated with a
significantly increased TRM and poor survival after AHCT from both related and unrelated
donors using conventional GVHD prophylaxis
 Non-myeloablative conditioning with PTCy for GVHD prophylaxis, the presence of a greater
number of HLA mismatches did not worsen overall outcomes with regards to GVHD, relapse
and NRM.
 Taken together, these data do not support selection of haploidentical donors based on the
degree of HLA mismatch.

The European Society for Blood and Marrow Transplantation (EBMT) consensus recommendations for donor selection in haploidentical hematopoietic ce
transplantation. Bone Marrow Transplant. 2020 Jan
HLA-haplo donor selection criteria
Donor must be medically, socially, and psychologically fit to donate

The patient must lack clinically significant antibodies against donor HLA
molecules

Donor age <40 years preferred over donor age ≥40 years
No major ABO incompatibility between donor and recipient
Matched CMV IgG serologic status between donor and recipient

•For a recipient who is CMV IgG negative, use a CMV IgG negative donor
•For a recipient who is CMV IgG positive, use a CMV IgG positive donor

Use an ABO compatible donor over a minor ABO incompatible donor

Other donor characteristics (in no order of priority)

•Donor age ≥18 preferred over donor <18

•Among donors ≥18 years, prefer younger and lighter donors
•For male recipients, male donors are preferred over nulliparous female donors
who are preferred over multiparous female donors

blood® 21 NOVEMBER 2019 | VOLUME 134, NUMBER 21

thank you