For several decades, allogeneic hematopoietic stem cell trans-plantation (allo-HSCT) has
remained an important strategy in the management of patients with high-risk hematological
malignancies. The acceptance of umbilical cord blood (UCBT) and haploidentical grafts (Haplo)
as viable alternative donors for allo-HSCT has increased the options for patients with no
matched donors and now ensures that a donor can be identified for virtually all patients.
Relapsed disease is a principal threat to these patients and affects 30-50% of them. The
therapeutic options for these relapsing patients are diverse but remain largely ineffective
in altering their long-term outcomes. Therefore, pre-emptive treatment post allo-HSCT is
MHC (major histocompatibility complex) class II molecules are a family of molecules normally
found only on hematopoietic cells. cell-surface proteins are responsible for the regulation
of the immune system in humans and are important in disease defense.
They are the major cause of organ transplant rejections. Different HLA-DPB1 alleles exist in
the general population. HLA-DPB1*04:01 is the most frequent (70.5%) while HLA-DPB1*02:01
represents 32% and HLA-DPB1*03:01 20%. In allo-HSCT, the donor and the recipient may express
different HLA-DPB1 molecules. HLA-DPB1 matching status has an impact on GVL (graft versus
leukemia) and GVHD. In recipients of HSCT, a match for DPB1 is associated with a
significantly increased risk of disease relapse, irrespective of the matching status of other
HLA molecules.. Therefore, one could anticipate that a mismatched of HLA class II could
induce a selective GVL reactivity without GVHD.
HLA-DP-expressing B cell and myeloid malignancies can be recognized and lysed by
HLA-DP-specific T cells. The majority of leukemic cells (Acute Myeloid Leukemia, Acute
Lymphoid Leukemia, Chronic Lymphoid Leukemia) express HLA-DP. A T cell clone recognizing
specifically HLA-DPB1*0401 has been developed as a permanent cell line This clone has been
demonstrated to be able to kill HLA-DPB1*0401 positive leukemic cells. In addition, this
clone harbors a special suicide gene allowing the destruction of the clone in presence of a
specific anti-viral drug named ganciclovir.
We hypothesize that infusion of a third party suicide gene-transduced T cell clone directed
against HLA-DPB1*401 might protect against possible relapse of hematological malignancies.
We propose to inject iv escalating dose of a third party clone recognizing HLA-DPB1*04:01, 4
to 5 months following transplantation (when immunosuppressive drugs have been discontinued)
in patients HLA-DPB1*04:01 positive with a donor HLA-DPB1*04:01 negative to evaluate the
feasibility, toxicity, benefits of this immune intervention.
Rationale Despite graft-versus-tumor effect, relapse remains one of the main causes of
morbidity and mortality in allo-HSCT recipients. Forty to 50% of deaths following allo-HSCT
are due to disease relapse. In case of relapse, the prognosis is very poor and disease burden
remains a challenge for the use of adoptive cellular therapy alone. The 3 year overall
survival (OS) in case of post-transplant relapse is dismal. The post-transplant period is
characterized by a prolonged phase of immunodeficiency leading to increased vulnerability to
infections and risk of relapse. For this reason, maintenance or pre-emptive therapies for
patients in CR (complete remission) are now considered to prevent future relapse. Following
allo-HSCT, the recognition by donor T lymphocytes of recipient HLA antigens may result in
different consequences. On one side, T cells may recognize antigens present on malignant
cells and eradicate residual disease or prevent tumor relapse. On the other side, injection
of unselected T cells may induce a graft-versus-host-disease (GVHD).
HLA-DPB1 is one of MHC class II molecule lying centromeric to other class II loci on
chromosome 6p21.3. Increase recombination events are found in the region between the HLA-DP
loci and other class II loci, explaining the relative lack of linkage disequilibrium (LD)
between HLA-DP (* HLA- DP: Human Leucocytes Antigen (DP allele))and the rest of MHC
haplotype. For this reason, it is difficult to find a donor matched for DPB1 in addition to
other classic HLA molecules. In sibling donors, the rate of incompatibility has been
estimated to be as high as 10.9% and in unrelated donors a mismatch rate can be up to 89%.
HLA-DPB1 is often not taken into consideration in donor selection. However HLA-DPB1 matching
status has an impact on GVL and GVHD. In recipients of HSCT, a match for DPB1 is associated
with a significantly increased risk of disease relapse, irrespective of the matching status
of other HLA molecules. HLA class II molecules expression is mainly restricted to
hematopoietic cells. Therefore, one could anticipate that a mismatched of HLA class II could
induce a selective GVL reactivity without GVHD. However, HLA class II expression can be
upregulated on various tissues following exposure to pro-inflammatory cytokines with a risk
of GVHD as it is the case following some conditioning regimens or infections.
The frequency of the different HLA-DPB1 alleles in the general population is well known:
HLA-DPB1*04:01 is the most frequent (70.5%) HLA-DPB1*02:01 and and HLA-DPB1*03:01 represent
32% and 20% respectively. 96% of leukemic cells could potentially be targeted with only three
CTL clones directed against HLA-DPB1*04:01, 03:01 and 02:01.
HLA-DP-expressing B cell and myeloid malignancies can be recognized and lysed by
HLA-DP-specific CD4+ cells ( CD4+ : cluster of differentiation 4+). The majority of leukemic
cells (AML, ALL, CLL) express HLA-DP. CD4+ cytotoxic T cell (CTL) clones recognizing
specifically HLA-DPB1*04:01 can be identified and have been demonstrated to be able to kill
HLA-DPB1*04:01 positive leukemic cells.
In addition, it has already been shown that HLA-DP-specific CD4+ T cells can induce
graft-versus-leukemia reactivity in the presence or absence of graft-versus-host disease. In
this study the presence of HLA-DP-specific CD4+ T cells correlated with the clinical response
The team of the Inserm unit 1232 (H. Vié, B. Clemenceau, both co-investigators of this
project) has developed a suicide gene-transduced CD4+ T cell clone that recognizes the
HLA-DPB1*401, which is the most frequent HLA-DPB1 allele expressed by leukemic blasts (70%).
This clone has been described in detailed in :"The doubling potential of T lymphocytes allows
clinical-grade production of a bank of genetically modified monoclonal T-cell populations" by
Vivien R et al. Cytotherapy. 2018 Mar;20(3):436-452.
Several clinical trials have evaluated the possibility to inject, following allo-HSCT, donor
lymphocytes transduced with a suicide gene either to treat tumor relapse or to accelerate the
immune reconstitution. No acute infusion-related toxicity has been reported. Ganciclovir was
used in some patients to control GVHD, leading to a rapid elimination of TK+ cells (tyrosine
The clone was obtained by performing a mixed lymphocytes culture (MLR) between two
populations differing only by HLA-DP, and subsequently by transducing reactive T cells with
high efficiency, and finally cloning them directly, before selecting each clone for the
desired characteristics. Thanks to a clinical grade Herpes-simplex-virus-TK vector, the clone
harbors a suicide gene and can be killed in presence of ganciclovir (GCV).
This clone presents several important characteristics in terms of efficiency and safety. The
clone is stable following thawing. It can be grown and amplified in vitro following thawing
(at least more than one million times), while maintaining its cytotoxic capacity. It produces
TH1-type cytokines in large amounts.
Regarding the safety of the CTL antiDP under study, we emphasized on two major points:
Specificity and sensitivity to ganciclovir:
Specificity. The clone is specific for HLA-DPB1*04:01. The clone was selected against a donor
homozygous for HLA-DPB1*04:01 (and identical for HLA-A, B, C, DQ, DR). Specificity testing
confirmed the recognition of HLA-DPB1*:04:01. Yet, HLA-DPB1 alleles described are numerous
(447 proteins to date IMGT (ImMunoGeneTics database)/HLA release,
www.ebi.ac.uk/ipd/index.html), and it is just impossible to anticipate the cross reactions
exhaustively (beyond some against HLA-DPB1*04:02 and HLA-DPB1*05:01 that have been observed
against particular cell lines). The risk, since we are in a context of allo-HSCT, would be
the recognition of donor cells and thus a possibility of graft rejection. For this reason, we
will perform a pre-inclusion testing where donor cells will be used as targets for the clone.
Sensitivity to ganciclovir (GCV) : The proliferation tests in the presence of GCV confirms
the efficacy of GCV with sufficient margin according to GCV blood levels reached during a
Data from our colleagues show a low number of T cells detectable during the first months
post-transplant, with a relative increased of Treg cells meaning that the clone may not be
eliminated rapidly by donor T-cells.
The reasons to administer a suicide gene-transduced CD4+ T cell clone recognizing
HLA-DPB1*04:01 following allogeneic transplantation can be summarized in the following points
1. Relapse of the hematological malignancy remains a serious concern in these types of
3. The immune reconstitution is very delayed allowing for injection of a third party T cell
4. In case of GVHD following the CTL infusion, the CTL clone can be rapidly eliminated using
Hypothesis We hypothesize that the infusion of a third party suicide gene-transduced T cell
clone directed against HLA-DPB1*04:01 following allogeneic transplantation can be safe and
might protect against possible relapse of hematological malignancies
Detailed description of the methodology (number of necessary subjects) Patients candidate for
allogeneic transplantation who are both HLA-DPB1*04:01 and with aHLA-DPB1*04:01-expressing
hematological malignancy (almost 100% of cases) with a donor HLA-DPB1*04:01 negative, will be
proposed to receive one single infusion of the T cell clone at 4-5 months
post-transplantation, once the immunosuppression by cyclosporine and/or mycophenolate mofetil
has been discontinued. The expression of HLA-DPB1* by tumor cells will be checked by
cytometry or immunohistochemistry. Any possible cross-reactivity of the clone against donor
cells will also be excluded
A standard 3 + 3 phase 1 dose-escalation study will be used:
Level 1: 1 x 104 cells/kg of recipient, Level 2: 5 x 104 cells/kg, Level 3: 25 x 104
cells/kg, Level 4: 50 x 104 cells/kg, Level 5: 100 x 104 cells/kg.
Conditioning regimens : no restriction
The use of DLI in case of mixed chimerism or relapse is permitted after the clone infusion if
necessary. In case of acute GVHD post CTL clone infusion, ganciclovir will be administered
(at the dose of 5 mg/kg twice daily) for 14 days.
- Patients HLA-DPB1*04:01 positive, with confirmed diagnosis of hematologic malignancies
(AML, Myelodysplasic syndrome, ALL, non-Hodgkin's lymphoma, Hodgkin's disease, CLL),
undergoing an allo-HSCT using a HLA-DPB1*04:01 negative donor.
- The graft can be PBSC (peripheric blood stem cells) or bone marrow.
- Patients aged between 18-75 years.
- Patients in complete remission or >50% of response (for lymphoma) at time of
- have a donor with no contra-indications for mobilization of peripheral blood stem
cells using G-CSF (colony-stimulating factors)
- Affiliation number to the National Health Care System
- Lack of reactivity of the clone against the donor's cells (PHA-blasts prepared for
- For cord blood transplants: cord blood must be HLA-DPB1*04:01 negative and the HLA
compatibility (A, B, DR) between the cord blood and the recipient must be 4/6, 5/6 or
- ECOG <=2 or Karnofsky >60%
- neutrophils ≥ 1 000 cells /μl and/or platelets ≥ 50 000 cells/μl (growth factor
- pregnant or breastfeeding woman
- patient refusing contraception measure
- Adult patients under guardianship, curatorship or justice protection
- Patients with post-transplant relapse within the clone injection time (before D100)
- Karnofsky performance score below 60%or ECOG >2
- Acute and chronic heart failure (NYHA Class III or IV) or symptomatic ischemic heart
- Severe liver failure (bilirubin >30 µmoles/L, SGPT (Serum Glutamo-Oxalacetic
Transaminase)> 4 X upper limit of normal).
- Impaired renal function (creatinine clearance < 30 ml/min)
- Acute GVHD > grade 1
- Active uncontrolled infection.
- Denied to provide informed consent
- Severe neurological or psychiatric disorders as determined by the study physician.
- Treatment with other investigational drugs following allogeneic transplantation.