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359 No Survival Advantage After Double Umbilical Cord Blood (UCB) Compared to Single UCB Transplant in Children with Hematological Malignancy: Results of the Blood and Marrow Transplant Clinical Trials Network (BMT CTN 0501) Randomized TrialClinically Relevant Abstract

Program: Oral and Poster Abstracts
Type: Oral
Session: 731. Clinical Allogeneic and Autologous Transplantation - Results: Allogeneic Transplantation for Leukemia and MDS
Monday, December 10, 2012: 8:00 AM
B312-B313a, Level 3, Building B (Georgia World Congress Center)

John E. Wagner, MD1,2,3, Mary Eapen, MBBS4, Shelly L Carter, ScD5*, Paul R. Haut, MD6*, Edward Peres, MD7*, Kirk R. Schultz, MD8, Jason Thompson9*, Donna A. Wall, MD10 and Joanne Kurtzberg, MD11

1Pediatric Blood and Marrow Transplant Program, University of Minnesota Medical Center, Minneapolis, MN
2Blood and Marrow Transplant Program, Pediatrics, University of Minnesota, Minneapolis, MN
3Pediatric Blood and Marrow Transplantation Program, University of Minnesota, Minneapolis, MN
4Medical College of Wisconsin, Milwaukee, WI
5The EMMES Corporation, Rockville, MD
6Department of Pediatrics, Division of Hematology/Oncology, Indiana University Simon Cancer Center, Indianapolis, IN
7University of Michigan, Ann Arbor, MI
8B.C. Children's Hospital, University of British Columbia, Vancouver, Canada
9EMMES Corporation, Rockville, MD
10University of Manitoba, Winnipeg, MB, Canada
11Duke University Medical Center, Durham, NC

Background: On the basis of pilot data in adults with acute leukemia suggesting that the co-infusion of two UCB units was safe and associated with survival rates comparable to that in children, a randomized trial was proposed to determine whether the transplantation of two units might confer a survival advantage since cell dose is a critical determinant of hematopoietic recovery, non relapse mortality (NRM) and survival.   Because adults are not as likely to have an adequate single unit, the study was performed in children.

Patients and Methods: The BMT CTN, sponsored by NHLBI and NCI, conducted a multi-center, randomized, phase III trial with a primary objective of comparing one-year overall survival in the two study arms using an intent-to-treat analysis.  Secondary objectives included comparisons of engraftment, acute and chronic graft-versus-host disease (GVHD), NRM, relapse and disease-free survival (DFS). Thirty-eight BMT CTN, PBMTC or COG centers enrolled patients between December 2006 and February 2012.  All patients had to have available two UCB units; unit 1 was the best available HLA-matched unit to the patient with ≥2.5 x 107 total nucleated cell / kg patient weight; unit 2 was the next best HLA-matched unit with ≥1.5 x 107 total nucleated cell /kg.  Each unit had to be at least 4/6 HLA-matched to the patient and 3/6 matched between units (at intermediate resolution for HLA-A, -B and allele-level for HLA-DRB1).  Patients were randomized to receive a conventional single (n=113) or double (n=111) UCB transplant with randomization stratified by transplant center and patient age.  Compliance was >95% in both treatment groups.  Of those randomized to a single UCB transplant, 2.7% crossed over to a double and of those randomized to a double UCB transplant, 1.0% crossed over to single; 1.8% in both groups were not transplanted.  Patient primary disease (AML, ALL, MDS, CML), disease risk, gender, age, race, ethnicity, CMV serology, performance score and HLA-match were balanced between the two study groups; ALL was the predominant diagnosis (half) in both study groups. All patients received a uniform conditioning regimen (fludarabine 75mg/m2, TBI 1320 cGy, cyclophosphamide 120 mg/kg) and GVHD prophylaxis (cyclosporine and mycophenolate mofetil).

Results: The median follow-up of surviving patients is 25 months (both study arms).  Overall, 92% patients were in remission with 60% of these in second or subsequent remission.  Most units were mismatched at one or two HLA-loci (45% and 40% of single UCB and 42% and 45% of double UCB transplants, respectively).  The median pre-cryopreserved total nucleated cell dose was 4.8 and 8.9 x 107/kg for recipients of single and double UCB transplants, respectively.  Except for a higher risk of grade III-IV acute GVHD in recipients of a double UCB transplant, all outcomes were similar between the two groups (Table 1).  The primary causes of death on both arms were similar with most due to relapse and GVHD.

Conclusion: In children with hematological malignancies, outcomes were similar with no survival advantage in recipients of a double UCB transplant as compared to those transplanted with an adequately dosed single UCB unit.  While recipients of two units had a higher incidence of acute GVHD, relapse risk was unchanged. Therefore, on the basis of these results, single UCB transplant should be the standard approach in children for whom a single unit containing ≥2.5 x 107nucleated cells/ kg matched at zero, one or two HLA-loci is available.  Double UCB transplant however remains a suitable alternative in the absence of an adequately dosed single UCB unit in children with hematologic malignancies.

Table 1.

 

Single UCB Transplant

Double UCB Transplant

P-value

Intent-to-treat

 

 

 

   Overall survival at 1-year

71%

(62 – 79)%

65%

(55 – 73)%

0.13

Transplanted

 

 

 

  Overall survival at 1-year

71%

(61 – 79)%

66%

(56 – 74)%

0.12

  DFS at 1-year

68%

(58 – 76)%

64%

(54 – 73)%

0.20

  Relapse at 1-year

12%

(6 – 18)%

14%

(7 – 20)%

0.37

  NRM at 1-year

20%

(12 – 27)%

22%

(14 – 30)%

0.45

  Neutrophil recovery at day-42

89%

(83 – 95)%

87%

(80 – 93)%

0.08

  Platelet recovery at day-180

80%

(72 – 88)%

72%

(63 -82)%

0.06

  Acute grade II-IV GVHD at day-100

57%

(48 – 67)%

57%

(48 – 67)%

0.94

  Acute grade III-IV GVHD at day-100

14%

(7 – 20)%

23%

(15 – 32)%

0.03

  Any chronic GVHD at 1-year

32%

(23 – 41)%

30%

(20 – 39)%

0.64

Disclosures: No relevant conflicts of interest to declare.

*signifies non-member of ASH