Nonmyeloablative transplants: preclinical and clinical results

Conditioning regimens have been intensified to a level at which organ toxicties are dose-limiting, which restricts the application of hematopoietic stem cell transplants to relatively young patients in otherwise good clinical condition. Studies done in a canine model have demonstrated that stable allogeneic mixed donor/host hematopoietic chimerism can be established by the administration of a sublethal dose of 2.0 Gy total body irradiation followed by immunosuppression with mycophenolate mofetil and cyclosporine after major histocompatibility complex-identical marrow transplantation. Both host-versus-graft and graft-versus-host reactions are controlled with mycophenolate mofetil and cyclosporine, which results in a stable state of graft/host tolerance manifested by stable mixed donor/ host hematopoietic chimerism. Current efforts are directed at replacing pretransplant radiation by anti-T-cell reagents, such as antibodies to T cells, or by purine antagonists, such as pentostatin (Nipent; SuperGen, San Ramon, CA). Given the minimal toxicity of this approach in dogs, a clinical study was initiated that uses an almost identical conditioning regimen. Thus far, 26 patients have been treated. Results to date indicate that this is a well-tolerated procedure that can be performed entirely in an outpatient setting. All patients have shown primary engraftment with persistence of mixed or full donor chimerism present through at least 2 months after transplant. Three patients experienced nonfatal graft rejection between 2 and 3 months after transplant, with a return to baseline peripheral counts over the subsequent 1 to 2 months. Acute graft-versus-host disease developed in 10 of 24 evaluable patients, occurring only after discontinuation of mycophenolate mofetil, and was controlled with additional immunosuppression in all cases. Overall, this novel nonmyeloablative conditioning regimen has been well tolerated and has encouraged us to investigate these transplants in other clinical settings, including using HLA-matched unrelated donors.