Transplantation of Ex-vivo Expanded Cord Blood Stems Cells (GRAPA)

• feasibility of expansion [ Time Frame: during and after expansion ] [ Designated as safety issue: No ]
• Immediate tolerance of a graft amplified injection. Determined by measurement of vital parameters during injection of the graft and within 3 hours of observation and clinical tolerance. [ Time Frame: during injection of the graft and within 3 hours of observation ] [ Designated as safety issue: Yes ]
• The payback of a platelet count> 20 000/microlitre bloodless. Measured by the blood count and platelet daily during hospitalization and at least 2 times a week. [ Time Frame: until the payback of the platelet count : measured daily during hospitalization and at least 2 times a week after ] [ Designated as safety issue: Yes ]
• The length of hospitalization since the beginning of conditioning until the first exit for more than 2 days. [ Time Frame: lenght of hospitalization since the beginning of conditioning ] [ Designated as safety issue: No ]
• The number of transfusions of red blood cells and platelets during the 1st hospitalization [ Time Frame: during the first hospitalization ] [ Designated as safety issue: No ]
• The incidence of graft loss or rejection within 6 months after transplantation, defined as the installation of a central cytopenia with loss of chimerism [ Time Frame: Within 6 months after transplantation ] [ Designated as safety issue: Yes ]
• The incidence of acute and chronic GVHD,determined by clinical examination Biopsies of target organs(skin, intestine, liver) will be conducted to confirm the diagnosis if possible. [ Time Frame: daily during hospitalization and at least twice weekly until D 100 after transplantation and then weekly or bi-monthly until one year post transplant. ] [ Designated as safety issue: Yes ]
• The mortality rate for transplantation in the year following the transplant, [ Time Frame: in the year following the transplant ] [ Designated as safety issue: Yes ]
• The incidence of relapse of hematologic malignancies, [ Time Frame: in the year following the transplant ] [ Designated as safety issue: Yes ]
• survival and disease-free survival in the year following the transplant [ Time Frame: in the year following the transplant ] [ Designated as safety issue: Yes ]
• Monitoring of immune reconstitution. This reconstruction will be followed by determining the rate of immunoglobulin G, M and A and the number of T lymphocytes CD3 +, CD4 + and CD8 + (assessments on days 15, 42, 60, 100, 180, 360). [ Time Frame: on days 15, 42, 60, 100, 180, 360 ] [ Designated as safety issue: Yes ]

This program offers the opportunity to receive an allogeneic transplant to try to control the malignant hematologic in the absence of acceptable conventional donor and with a risk-benefit ratio equivalent to that which would be expected with a transplant from a more conventional donor.

An economy of means in that this method could serve as an alternative to 2 units of placental blood transplantation. The current cost of disposal of a unit of placental blood from a bank is approximately 22000 € (Source: Biomedicine Agency, 2007 rates). The amplification process as controlled by "EFSAL" is 12000 €. Therefore, buying a unit and ex-vivo amplification is more economical. Moreover, the availability of placental blood is not infinite, and the use of one unit per patient will also save resources that can be valuable for certain groups of patients.

In the longer term, methods of amplification of specific immunocompetent cells (from the fraction of CD 34 neg cells) are already being evaluated in the laboratory. They allow to consider a faster recovery, better and more targeted, including cells against the disease for which transplantation is performed.

This is a multicenter prospective non randomized phase 2 clinical trial.

The primary objective is defined by getting a neutrophil count above 500/ml for 3 consecutive days at day 42 after transplantation, in association with complete or partial chimerism on T cells (10 % to 90%).

The secondary objectives are:

• the feasibility of expansion,
• tolerance immediate injection of a graft amplified,
• the payback of a platelet count> 20 000/microlitre without transfusion,
• Incidence of graft loss or rejection within 6 months following transplantation,
• the incidence of acute and chronic GVHD,
• the mortality rate associated with transplantation,
• the incidence of relapse of hematologic malignancies,
• Overall survival,
• Disease-free survival at 1 year post transplant.

• Petersdorf EW. Risk assessment in haematopoietic stem cell transplantation: histocompatibility. Best Pract Res Clin Haematol. 2007 Jun;20(2):155-70. Review.
• Koh LP, Chao NJ. Umbilical cord blood transplantation in adults using myeloablative and nonmyeloablative preparative regimens. Biol Blood Marrow Transplant. 2004 Jan;10(1):1-22. Review.
• Barker JN, Weisdorf DJ, DeFor TE, Blazar BR, McGlave PB, Miller JS, Verfaillie CM, Wagner JE. Transplantation of 2 partially HLA-matched umbilical cord blood units to enhance engraftment in adults with hematologic malignancy. Blood. 2005 Feb 1;105(3):1343-7. Epub 2004 Oct 5.
• Castello S, Podestà M, Menditto VG, Ibatici A, Pitto A, Figari O, Scarpati D, Magrassi L, Bacigalupo A, Piaggio G, Frassoni F. Intra-bone marrow injection of bone marrow and cord blood cells: an alternative way of transplantation associated with a higher seeding efficiency. Exp Hematol. 2004 Aug;32(8):782-7.
• Shpall EJ, Quinones R, Giller R, Zeng C, Baron AE, Jones RB, Bearman SI, Nieto Y, Freed B, Madinger N, Hogan CJ, Slat-Vasquez V, Russell P, Blunk B, Schissel D, Hild E, Malcolm J, Ward W, McNiece IK. Transplantation of ex vivo expanded cord blood. Biol Blood Marrow Transplant. 2002;8(7):368-76.
• Ljungman P, Urbano-Ispizua A, Cavazzana-Calvo M, Demirer T, Dini G, Einsele H, Gratwohl A, Madrigal A, Niederwieser D, Passweg J, Rocha V, Saccardi R, Schouten H, Schmitz N, Socie G, Sureda A, Apperley J; European Group for Blood and Marrow. Allogeneic and autologous transplantation for haematological diseases, solid tumours and immune disorders: definitions and current practice in Europe. Bone Marrow Transplant. 2006 Mar;37(5):439-49.
• Brunstein CG, Barker JN, Weisdorf DJ, DeFor TE, Miller JS, Blazar BR, McGlave PB, Wagner JE. Umbilical cord blood transplantation after nonmyeloablative conditioning: impact on transplantation outcomes in 110 adults with hematologic disease. Blood. 2007 Oct 15;110(8):3064-70. Epub 2007 Jun 14.
• Gluckman E, Rocha V. Donor selection for unrelated cord blood transplants. Curr Opin Immunol. 2006 Oct;18(5):565-70. Epub 2006 Aug 8. Review.
• Takahashi S. Leukemia: cord blood for allogeneic stem cell transplantation. Curr Opin Oncol. 2007 Nov;19(6):667-72. Review.
• Kobari L, Pflumio F, Giarratana M, Li X, Titeux M, Izac B, Leteurtre F, Coulombel L, Douay L. In vitro and in vivo evidence for the long-term multilineage (myeloid, B, NK, and T) reconstitution capacity of ex vivo expanded human CD34(+) cord blood cells. Exp Hematol. 2000 Dec;28(12):1470-80.
• Duchez P, Dazey B, Douay L, Vezon G, Ivanovic Z. An efficient large-scale thawing procedure for cord blood cells destined for selection and ex vivo expansion of CD34+ cells. J Hematother Stem Cell Res. 2003 Oct;12(5):587-9. No abstract available.
• Dazey B, Duchez P, Letellier C, Vezon G, Ivanovic Z; French Cord Blood Network. Cord blood processing by using a standard manual technique and automated closed system "Sepax" (Kit CS-530). Stem Cells Dev. 2005 Feb;14(1):6-10. No abstract available.
• Ivanovic Z, Duchez P, Dazey B, Hermitte F, Lamrissi-Garcia I, Mazurier F, Praloran V, Reiffers J, Vezon G, Boiron JM. A clinical-scale expansion of mobilized CD 34+ hematopoietic stem and progenitor cells by use of a new serum-free medium. Transfusion. 2006 Jan;46(1):126-31.
• Barker JN, Weisdorf DJ, DeFor TE, Blazar BR, Miller JS, Wagner JE. Rapid and complete donor chimerism in adult recipients of unrelated donor umbilical cord blood transplantation after reduced-intensity conditioning. Blood. 2003 Sep 1;102(5):1915-9. Epub 2003 May 8.
• Ljungman P, Bregni M, Brune M, Cornelissen J, Witte TD, Dini G, Einsele H, Gaspar HB, Gratwohl A, Passweg J, Peters C, Rocha V, Saccardi R, Schouten H, Sureda A, Tichelli A, Velardi A, Niederwieser D. Allogeneic and autologous transplantation for haematological diseases, solid tumours and immune disorders: current practice in Europe 2009. Bone Marrow Transplant. 2009 Jul 6; [Epub ahead of print]

Inclusion Criteria:

• Age ≥ 18 and < 66 years
• Patient with acute myeloid leukemia (AML) high risk in 1st complete remission:
• CR1 obtained by 2 cycles of chemotherapy,
• unfavorable Cytogenetics
• FLT3 Duplication,
• Or acute myeloid leukemia (AML) in 2nd complete remission,
• Or acute lymphoblastic leukemia (ALL) High-risk 1st complete remission:
• Presence of the translocation t (9; 22),
• Or acute lymphoblastic leukemia (ALL) in 2nd complete remission,
• Or Chronic Myeloid Leukemia (LCM) beyond the 1st chronic phase
• Or Myelodysplasia or with IPSS score with 2 or more
• Or Hodgkin's disease in sensitive relapse or beyond the 2nd complete remission. or following types of lymphoma :
• Diffuse large B lymphoma cells relapsed or refractory after two lines of treatment or after a line with autologous hematopoietic stem cell, or
• Mantle cell lymphoma relapsed or refractory after two lines of treatment or after a line with autologous hematopoietic stem cell
• Others aggressive lymphoma for which an indication of allograft is selected (Burkitt lymphoma, lymphoblastic lymphoma, intravascular lymphoma, ...)
• Lymphoma (low-grade follicular lymphoma, marginal zone lymphoma) in histological transformation.
• Low-grade lymphoma for which an indication of allograft is retained
• Unable to receive myeloablative conditioning because of age (> 45 years) and/or the existence of co-morbidities precluding a myeloablative conditioning (status ECOG > / = 2, DLCO <50%, fungal infection proven or probable in the previous 60 days) and / or prior treatment with total body irradiation at doses above 2 Gy or busulfan doses> 8 mg/kg
• No contra-indication for a transplant in allogeneic non-myeloablative conditioning,
• No HLA-identical sibling,
• Absence of an unrelated donor on national or international registering with a 10/10 allelic matching or a 9/10 allelic matching with the only tolerated mismatches being: HLA-C.
• No unit of placental blood available fulfilling the characteristics of compatibility (HLA compatible at least 4/6 allele or generic) and richness
• Provision of at least 2 units of placental blood, whose compatibility is 4/6, 5/6 or 6/6 and whose richness is before thawing, > 2 x 107 and < 3 to 4 x 107 nucleated cells per/kg.
• Patient affiliated to a social security scheme,
• Free and informed consent signed by the patient and the investigator.

Exclusion Criteria:

• Age <18 and ≥ 66 years
• Malignant myeloid or lymphoid acute or chronic disease without indication for an allogeneic transplant according to the criteria of European Bone Marrow Transplantation Group.
• Able to receive a myeloablative conditioning because of age (<45 years) and the absence of co morbidities (status ECOG> / = 2, DLCO <50%, fungal infection proven or probable in 60 preceding days) and the absence of prior treatment with total body irradiation at doses above 2 Gy or busulfan doses> 8 mg / kg
• Contra indication for a non-myeloablative conditioning,
• HLA-identical sibling available
• Availability of an unrelated donor on a national or international register with 10/10 or 9/10 HLA matching (HLA-C Mismatch tolerated).
• At least one unit of cord blood available with the characteristics of compatibility (HLA compatible at least 4/6 allelic or generic) and richness (before thawing> / = 3 to 4 x 107 nucleated cells/kg recipient, by degree of compatibility)
• Absence of at least 2 units of placental blood, whose compatibility is 4/6, 5/6 / or 6/6 and whose richness before thawing is > 2 x 107 and < 4 x 107 nucleated cells per/kg of recipient.
• Women of childbearing age not using contraception, pregnant or lactating