Donor lymphocyte infusions for patients who relapse after allogeneic stem cell transplantation for chronic myeloid...

The understanding of the use of donor lymphocyte infusions (DLI) for graft-versus-leukaemia (GVL) in the treatment of chronic myeloid leukaemia (CML) post haemopoietic stem cell transplant (HSCT) has advanced during the last years. In relapsed leukaemia post-stem cell transplant, DLI can achieve durable remissions in 60-73% patients. Technical improvements in molecular methods of detection of the BCR-ABL transcripts permit the prediction of relapse with increased sensitivity and reproducibility. Use of DLI early at relapse is important since responses to DLI are less likely in the face of bulky or blast-phase disease. Exogenous interleukin-2 may enhance the response to DLI but total cell dose is also relevant to the efficacy of DLI with the effective cell dose (ECD) required being lower in HLA matched unrelated DLI donors compared to siblings. Donor T-lymphocytes target minor histocompatibility (H) antigens and the relative tissue distribution of these may influence the toxicity of DLI, which includes graft-versus-host-disease (GVHD). Modified methods of delivery such as selective deletion of CD8+ cells or escalating cell dosage regimens have reduced the incidence of serious morbidity due to GVHD without compromising the GVL effect mediated by DLI. These approaches have not removed the risk of GVHD entirely and conditional suicide protocols utilising the HSV-tk or fas receptor derived genes are being developed in the clinic. Since significant morbidity and mortality is attributable to the conditioning regimen used prior to HSCT, awareness of the potency of DLI has driven the development of reduced intensity conditioning (RIC) regimens. The purpose of RIC is to enhance tolerisation of the host to the graft while permitting the establishment of donor haemopoiesis. DLI may then be used subsequently to enhance the GVL effect.