Biol Blood Marrow Transplant 26 (2020) 1511 1519

Biology of Blood and

Marrow Transplantation
journal homepage: www.bbmt.org

Survivorship

Less Is More: Superior Graft-versus-Host Disease-Free/Relapse-Free

Survival with Reduced-Intensity Conditioning and Dual T Cell Depletion
in Acute Myelogenous Leukemia
Maria Queralt Salas MD1,2,3, Shiyi Chen MD3, Wilson Lam MD1,2, Ivan Pasic MD1,2,
Armin Gerbitz MD1,2, Fotios V. Michelis MD1,2, Dennis (Dong Hwan) Kim MD1,2,
Zeyad Al-Shaibani MD1,2, Jeffrey Howard Lipton MD1,2, Jonas Mattsson MD1,2, Rajat Kumar MD1,2,
Auro Viswabandya MD1,2, Arjun Datt Law MD1,2,
1
Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre,
University Health Network, Toronto, Ontario, Canada
2
Hematology Department, Institut Catala
d'Oncologia-Hospitalet, IDIBELL, Barcelona, Spain
3
Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada

Article history: A B S T R A C T
Received 6 February 2020 In this study, we compared the outcomes of patients with acute myelogenous leukemia (AML) in complete remission
Accepted 18 April 2020 treated with myeloablative conditioning (MAC) and those treated with reduced-intensity conditioning (RIC) before allo-
geneic hematopoietic stem cell transplantation (allo-HCT). In addition, we explored the efficacy of dual T cell depletion
using anti-thymocyte globulin (ATG) and post-transplantation cyclophosphamide (PTCy) for the prevention of graft-ver-
sus-host disease (GVHD) in patients undergoing RIC allo-HCT. Our study cohort comprised 356 adults with AML in com-
plete remission who underwent allo-HCT between 2013 and 2018. One hundred eleven patients (31.2%) received a MAC
regimen, and 245 (68.8%) received an RIC regimen. One hundred seventy-one of the patients who received an RIC regi-
men (68.4%) received ATG, PTCy, and cyclosporine (ATG-PTCY-CsA) for GVHD prophylaxis in accordance with our insti-
tutional protocol. Data were collected retrospectively and updated in July 2019. With a median follow-up of 14.5
months (range, 0 to 76 months), 161 patients (45.2%) died, and 66 (18.5%) relapsed. Two-year overall survival (OS),
relapse-free survival (RFS), and GVHD-free/RFS (GRFS) were 55%, 52.6%, and 35%, respectively. The intensity of the condi-
tioning regimen, with or without ATG-PTCY-CsA, did not have a significant impact on OS and RFS. However, RIC in com-
bination with ATG-PTCY-CsA was associated with a significantly lower cumulative incidence of acute GVHD and chronic
GVHD. The use of RIC with ATG-PTCy-CsA was a significant predictor for higher GRFS secondary to the reduction of clini-
cally relevant GVHD (P= .0001). In patients with AML, RIC allografts and dual T cell modulation with ATG and PTCy led to
superior GRFS. The use of this GVHD prophylaxis strategy, along with mitigation of conditioning toxicity using RIC, may
result in better long-term quality of life for allo-HCT recipients.
© 2020 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.

INTRODUCTION while minimizing TRM. Multiple efforts have been made to

Acute myelogenous leukemia (AML) is the most frequent
indication for allogeneic cell transplantation (allo-HCT) [1].
The development of reduced-intensity conditioning (RIC) regi-
mens has led to a reduction of transplantation-related mortal-
ity (TRM) and has made transplantation accessible to older
patients and patients with associated comorbidities. Nonethe-
less, TRM and relapse continue to be prominent concerns in
patients undergoing allo-HCT for AML [1-4].
An ideal conditioning platform should maximize antileuke-
mia cytotoxicity and the graft-versus-leukemia (GVL) effect
arjun.law@uhn.ca
explore the impact of conditioning regimen intensity in AML;
however, previous studies have reported inconsistent results
[5-9]. RIC provides consistent engraftment and induces a GVL
effect; nevertheless, the effectiveness of RIC in high-risk AML
is not well established [10,11]. Conditioning regimen intensity
is tailored according to patient age and comorbidities [12];
however, the optimal age cutoff has not been determined, and
with refinements of HLA typing, GVHD prophylaxis, and sup-
portive care, TRM in patients with comorbidities has decreased
[13-15].
The present study aimed to evaluate the impact of condi-
tioning regimen in a large cohort of patients diagnosed with

https://doi.org/10.1016/j.bbmt.2020.04.021
1083-8791/© 2020 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
1512 M.Q. Salas et al. / Biol Blood Marrow Transplant 26 (2020) 1511 1519
AML undergoing allo-HCT at a single institution. In addition,
the study compares the efficacy of antithymocyte globulin
(ATG), post-transplantation cyclophosphamide (PTCy), and
cyclosporine (CsA) with that of other GVHD prophylaxis in
patients with AML.
METHODS
Patient Selection
Between January 2013 and December 2018, 760 adults underwent first
allo-HCT at Princess Margaret Cancer Centre in Toronto. Eligibility criteria for
allo-HCT and the donor selection algorithm are provided in the Supplemen-
tary Material. The study cohort comprised 356 adult patients with AML in
complete remission who underwent T cell-replete peripheral blood stem cell
(PBSC) allo-HCT.
Clinical information was collected through retrospective chart review.
The last follow-up was updated in July 2019. The study was approved by the
University Health Network Research Ethics Board and Cancer Registry Data
Access Committee and was conducted in accordance with the Declaration of
Helsinki.
Conditioning Regimen
Transplantation conditioning regimens were classified as myeloablative
(MAC) or RIC based on published criteria [16]. The evolution of the selection
criteria for conditioning regimens and GVHD prophylaxis over the course of
the study is summarized in Figure 1. Between January 2013 and September
2015, the intensity of the conditioning regimen was adjusted according to
patient age and the presence of relevant comorbidities. Recipients age
>60 years or with noncontrolled comorbidities received RIC. Between Octo-
ber 2015 and May 2018, RIC allo-HCT in combination with ATG, PTCY, and
CsA for GVHD prophylaxis was the institutional standard transplantation
platform for adults with AML irrespective of age, Hematopoietic Cell Trans-
plantation Comorbidity Index (HCT-CI) score, or donor type. After May 2018,
the conditioning regimen intensity was again tailored to age and the pres-
ence of noncontrolled comorbidities.
Overall, between January 2013 and December 2018, 111 patients (31.2%)
received MAC allo-HCT and 245 (68.8%) underwent RIC allo-HCT. MAC con-
sisted of fludarabine (Flu) 50 mg/m2/day i.v. on days -5 to -2, busulfan (Bu)
3.2 mg/kg/day i.v. on days -5 to -2, and 400 cGy total body irradiation admin-
istered on day -1. RIC consisted of Flu 30 mg/m2/day i.v. on days -5 to -2, Bu
3.2 mg/kg/day i.v. on days -3 and -2, and 200 cGy total body irradiation on
day -1. Busulfan pharmacokinetics were not routinely measured.
GVHD Prophylaxis
GVHD prophylaxis is described in Figure 1 and Table 1. Between January
2013 and September 2015, the standard GVHD prophylaxis regimen was
Figure 1. Timeline of the evolution of inclusion criteria, conditioning regimen, and GVHD prophylaxis at our center.
methotrexate (MTX) plus CsA for matched sibling donor (MSD) allo-HCT and
ATG plus MTX and CsA for matched unrelated donor (MUD) allo-HCT. Some
patients who underwent MAC allo-HCT between 2009 and 2015 received
mycophenolate mofetil (MMF) plus CsA for GVHD prophylaxis [17].
In October 2015, ATG plus 50 mg/kg/day of PTCy given on days +3 and +4
and CsA 2.5 mg/kg/12 h from day +5 (ATG-PTCy-CsA) become the standard
GVHD prophylaxis for RIC allo-HCT at our center [18-20]. In May 2018, the
ATG dose was reduced to 2 mg/kg administered on days -2 and -1, with the
aim of reducing the risk of infectious complications occurring as a conse-
quence of the degree of immunosuppression while preserving the ability to
prevent GVHD [20]. Among the 245 patients who underwent RIC allo-HCT,
168 (68.5%) received ATG-PTCy-CsA for GVHD prophylaxis. One hundred and
twenty-eight patients (52.2%) received a total ATG dose of 4.5 mg/kg admin-
istered on days -3, -2, and -1, and 40 patients (16.3%) received a total dose of
2 mg/kg administered on days -2 and -1. Those recipients not eligible to
receive PTCy (ie, those with a left ventricular ejection fraction 45% or severe
cardiac comorbidities) received ATG in combination with MTX and CsA.
Other definitions and parameters are summarized in the Supplementary
Material.
Statistical Methods
The main explanatory variable of interest was the intensity of the condi-
tioning regimen (RIC versus MAC) [16]. The use of ATG-PTCy-CSA compared
with other forms of GVHD prophylaxis was considered an explanatory vari-
able of interest. Main outcome variables were overall survival (OS), relapse-
free survival (RFS), GVHD-free/RFS (GRFS), and the cumulative incidence of
GVHD. Other outcome variables were the cumulative incidence of relapse
(CIR) and nonrelapse mortality (NRM).
Categorical variables are presented as count and percentage; continuous
variables, as median and range. OS and RFS were calculated using the
Kaplan-Meier product-limit method, and the impact of variables was
assessed using the log-rank test. The cumulative incidence of GHVD was esti-
mated accounting for death and relapse as competing events. NRM and CIR
were estimated using the cumulative incidence method of Fine and Gray,
considering relapse as a competing event for NRM and NRM as a competing
event for CIR. The effects of the main explanatory variables on OS, RFS, and
GRFS were explored using both univariate and multivariable Cox propor-
tional hazards regression models. For estimation of the multiple regression
model for OS and RFS, the control variables were age at transplantation, risk
stratification by genetics, donor type, and the development of moderate/
severe chronic GVHD (time-dependent variable). The control variables in the
estimation of the regression model for GRFS were age at transplantation and
donor type.
All P values were 2-sided, and for the statistical analyses, P< .05 was con-
sidered to indicate a statistically significant result. Statistical analysis was
performed using SAS for Windows version 9.4 (SAS Institute, Cary, NC).
 M.Q. Salas et al. / Biol Blood Marrow Transplant 26 (2020) 1511 1519 1513

Table 1
Baseline Patient Characteristics

Characteristic Overall (N = 356) MAC (N = 111; 31.2%) RIC (N = 245; 68.8%) PV

alue
Age, yr, median (range)Age group 57 (18-73) 48 (23-69) 60 (18-73) <.001
, n (%) 56 (15.7) 28 (25) 28 (11.5)
18-39 yr 222 (62.3) 81 (73) 141 (57.5)
40-64 yr 78 (22) 2 (2) 76 (31)
65+ yr
Male sex, n (%) 183 (51.4) 44 (39.6) 139 (56.7) .03
Leukemia subtype, n (%) <.001
De novo 275 (77.2) 99 (89.2) 176 (71.8)
Secondary AML 40 (11.2) 8 (7.2) 33 (13.5)
Therapy-related AML 41 (11.5) 4 (3.6) 36 (14.7)
Risk stratification by cytogenetics, n (%) .72
Favorable 27 (7.6) 10 (9) 17 (6.9)
Intermediate 243 (62.3) 75 (67.6) 168 (68.6)
Adverse 70 (19.6) 20 (18) 50 (20.4)
Missing 16 (4.5) 6 (5.4) 10 (4.1)
Risk according to ELN 2017, n (%) .84
Favorable 39 (10.9) 13 (11.7) 26 (10.6)
Intermediate 193 (54.2) 59 (53.2) 134 (54.7)
Adverse 102 (28.6) 29 (26.1) 73 (29.7)
Missing 22 (6.1) 10 (9) 12 (4.8)
Stage at transplantation, n (%) .03
CR1 297 (83.4) 85 (76.6) 212 (86.5)
CR2 to CR3 59 (16.6) 26 (23.4) 33 (13.5)
DRI, n (%) .43
Low/moderate 291 (81.7) 88 (79.3) 203 (82.9)
High 45 (12.6) 11 (9.9) 34 (13.9)
Missing 20 (5.6) 12 (10.8) 8 (3.3)
Karnofsky Performance Status, n (%) 90-1 .83
00 208 (58.4) 46 (41.4) 162 (66.1)
70-80 67 (18.8) 14 (12.6) 53 (21.6)
Missing 81 (22.8) 51 (45.9) 30 (12.2)
HCT-CI, n (%) .003
0-2 201 (56.5) 59 (53.2) 142 (58)
3 94 (26.4) 13 (11.7) 81 (33.1)
Missing 61 (17.1) 39 (35.1) 22 (9)
Donor type, n (%) .001
10/10 MSD 110 (30.9) 45 (40.5) 65 (26.5)
10/10 MUD 160 (44.9) 45 (40.5) 115 (46.9)
9/10 MUD 50 (14) 21 (19) 29 (11.8)
Haploidentical 36 (10.1) - 36 (14.7)
GVHD prophylaxis, n (%)* .001
Campath-CsA 71 (19.9) 51 (45.9) 20 (8.2)
MTX-CsA 29 (8.1) 14 (12.6) 15 (6.1)
CsA-MMF 56 (15.7) 38 (34.2) 18 (7.3)
PTCy-CsA 2 (.5) - 2 (.8)
ATG-PTCy-CsA 176 (49.4) 8 (7.2) 168 (68.5)
ATG-CsA-MTX 22 (6.1) - 22 (8.9)
Follow-up, mo, median (range) 14.5 (0-76) 35 (0-74) 13 (1-76) <.001

CR indicates complete remission; MSD, matched sibling donor; MMF, mycophenolate mofetil.

RESULTS
Patient Information
Baseline characteristics are summarized in Table 1. The
median patient age and the proportion of patients with an
HCT-CI score 3 were higher in the RIC group (P< .05). The
percentage of patients who received a matched sibling donor
graft was higher in the MAC group (40.5% versus 26.5%). All
haploidentical transplantations were done with RIC.
Risk stratification according to the European LeukemiaNet
(ELN) (2017) [12] was retrospectively reassessed in all patients
with available information. The proportions of patients with
high-risk AML according to cytogenetic, ELN 2017 classifica-
tion, Disease Risk Index (DRI), and with a Karnofsky Perfor-
mance Status of 70% to 80% were balanced between the 2
cohorts (P> .05).
Engraftment
The median time to neutrophil and platelet engraftment
was 14 days (range, 10 to 32 days) and 10 days (range, 5 to 59
days), respectively, in the MAC group and 16 days (range, 11 to
43 days) and 14 days (range, 8 to 92 days), respectively, in the
RIC group (P< .001).
Main Post-Transplantation Complications
Post-transplantation data are summarized in Table 2. Graft
failure was documented in 14 patients (3.9%), including 3 with
primary failure. Thirteen of these patients (92%) had under-
gone RIC allo-HCT (P= .07), and 7 (50%) had received a graft
from an alternative donor source (2 from a 9/10 MUD and 5
from a haploidentical donor). Six patients (42%) were eligible
to undergo a second allo-HCT, and 4 of these patients then
1514 M.Q. Salas et al. / Biol Blood Marrow Transplant 26 (2020) 1511 1519

Figure 2. Cumulative incidence of GVHD in all patients and according to conditioning regimen intensity and GVHD prophylaxis.

engrafted. Eleven patients (78%) with graft failure died during
follow-up.
Cytomegalovirus (CMV) and Epstein-Barr virus (EBV) reacti-
vation was observed in 207 patients (58.1%) and 201 patients
(56.5%), respectively. The cumulative incidence of CMV reacti-
vation was comparable in the 2 groups (P= .72). The cumula-
tive incidence of EBV reactivation at day +180 was significantly
higher in the RIC group compared with the MAC group (60.4%;
95% confidence interval [CI], 53.5% to 68.1% versus 22.6%; 95%
CI, 17% to 29.9%; P < .001). Eighteen patients (5.1%) were diag-
nosed with post-transplantation lymphoproliferative disease
(PTLD). The incidence of PTLD was not significantly different
between the 2 groups (P= .202).
Among the 168 patients who underwent RIC allo-HCT using
ATG-PTCy-CsA, CMV reactivation, EBV reactivation, and PTLD
was documented in 103 (61.3%), 126 (75%), and 10 (6%), in
agreement with previous reports [17-19]. The rate of EBV reac-
tivation was significantly higher in patients who received this
GVHD prophylaxis regimen compared with the rest of the
cohort (P< .001), but the differences in the rates of CMV reacti-
vation (P= .297) and PTLD (P= .466) did not differ significantly
between these 2 groups.

Figure 3. Kaplan-Meier plots of OS and RFS and cumulative incidence plots of NRM and relapse.
 M.Q. Salas et al. / Biol Blood Marrow Transplant 26 (2020) 1511 1519
Figure 4. Kaplan-Meier plot of GRFS according to conditioning regimen intensity.
GVHD
GVHD was more prevalent in the MAC group compared
with the RIC group (Table 2). We further compared the cumu-
lative incidence of GVHD between patients in the RIC group
who received ATG-PTCy-CsA (RIC + ATG-PTCy-CsA) and those
who received other GVHD prophylaxis (RIC + others); the
results are summarized in the Figure 2. The cumulative inci-
dence of GVHD differed significantly among the 3 groups (P<
.0001). The combination of RIC + ATG-PTCy-CsA was associated
with significantly reduced clinically relevant GVHD compared
with RIC + other GVHD prophylaxis or MAC (Figure 1). The
cumulative incidences of grade II-IV and III-IV acute GVHD at
day +100 and of moderate/severe chronic GVHD at 1 year
among patients receiving RIC + ATG-PTCy-CsA was 14.13%
(95% CI, 9.92% to 20.14%), 7.34% (3.38% to 15.95%), and 8.35%
(95% CI, 5.09% to 13.71%), respectively.
Patients who developed GVHD after a donor lymphocyte
infusion or a second allo-HCT were excluded from the cumula-
tive incidence analysis. Twenty-two patients (6.1%) died from
steroid-refractory acute GVHD. Among the 168 patients
(68.5%) who received RIC + ATG-PTCy-CsA, 3 (1.8%) died sec-
ondary to GVHD.
Outcome
Main outcome information is summarized in Table 2 and
Figures 3 and 4. With a median follow-up of 14.5 months
(range, 0 to 76 months), 161 patients (45.2%) died and 66
(18.5%) relapsed. The most frequent causes of death were
relapse (17.1%) and infection (15.1%). The intensity of the con-
ditioning regimen did not have a significant impact on OS or
RFS (P< .1). There were nonsignificant trends toward higher
NRM (P= .23) and lower CIR (P= .15) in the MAC group com-
pared with the RIC group.
The impact of the conditioning regimen was explored
among recipients age <60 years and the subgroup of patients
1515
with higher-risk disease (ie, complex or high-risk cytogenetic,
high-risk disease according to the ELN 2017 classification, and
high DRI) (Supplementary Table S1). NRM was significantly
lower in the RIC group (P= .004). The between-group differen-
ces in OS, RFS, and CIR were not statistically significant in
younger patients or higher-risk patients.
Risk factors for OS and RFS are shown in Supplementary
Table S2 (univariate analysis) and Table 3 (multivariate analy-
sis). The use of RIC did not have a significant impact on OS (P=
.98) and RFS (P= .66) in the multivariate analysis. In addition,
patient age of 40 to 64 years and 65 years, high DRI at diag-
nosis, and use of a 9/10 MUD were identified as significant risk
factors for lower OS and RFS.
Risk factors for GRFS are summarized in Supplementary
Table S2 and Table 4. The use of RIC + ATG-PTCy-CsA was sig-
nificantly associated with higher GRFS in univariate and multi-
variate analyses. Based on the analysis of the cumulative
incidence of GVHD analysis (Figure 2), and considering that all
patients who received ATG-PTCy-CsA underwent RIC allo-HCT,
the effect of the combination of RIC + ATG-PTCy-CsA on GRFS
was explored and found to be strongly associated (P= .0001)
with higher GRFS (Table 4). In addition, older age (40 to 64
years and 65 years) and use of a haploidentical donor were
significant risk factors for lower GRFS (P < .05).
DISCUSSION
In our study cohort, conditioning regimen intensity did not
have a significant impact on OS or RFS. However, the combina-
tion of RIC + ATG-PTCy-CsA was associated with significantly
increased GRFS in patients with AML secondary to the reduc-
tion of clinically relevant acute and chronic GVHD.
Baseline characteristics related to AML risk stratification
were well balanced between the RIC and MAC groups; how-
ever, patients in the RIC group were older and had more
comorbidities. Despite these differences, the survival rate did
1516 M.Q. Salas et al. / Biol Blood Marrow Transplant 26 (2020) 1511 1519

Table 2
Post-Transplantation Outcomes

Outcome Overall (N = 356) MAC (N = 111; 31.2%) RIC (N = 245; 68.8%) P Value
Graft failure 14 (3.9) 1 (.9) 14 (5.7) .07
Viral activation
CMV reactivation, n (%) 207 (58.1) 63 (56.7) 144 (58.8) .72
CIR of CMV reactivation at day +180, median (range) - 52.6 (44.7-61.9) 57.2 (51-64.1) .33
EBV reactivation, n (%) 201 (56.5) 34 (30.6) 167 (68.2) <.001
CIR of EBV reactivation at day +180, median (range) - 22.6 (17-29.9) 60.4 (53.5-68.1) <.001
PTLD, n (%) 18 (5.1) 3 (2.7) 15 (6.1) .2
Rate of acute GVHD, n (%)
Grade I-II G 124 (34.8) 42 (58.3) 85 (74.5) .03
rade III-IV 59 (16.5) 30 (26.1) 29 (11.8) .02
Rate of chronic GVHD, n (%)
Mild 27 (7.5) 8 (7.2) 19 (7.7) <.001
Moderate/severe 78 (21.9) 44 (39.6) 34 (13.9) <.001
Cumulative incidence analysis, % (95% CI)
Grade II-IV aGVHD 28.8 (24.7-33.6) 47 (38.9-56-6) 21.1 (16.4-27) <.001
Grade III-IV aGVHD 20.9 (16-27.1) 29.1 (20.2-41.8) 15.8 (10.9-22.7)
Moderate/severe Cgvhd 18.3 (13.9-24.3) 31.5 (24.6-40.5) 12 (8.4-17.1)
Relapse, n (%) 66 (18.5) 17 (15.3) 49 (20) .29
Death, n (%) 161 (45.2) 56 (50.5) 105 (42.9) .18
Cause of death, n (%)
Relapse 61(17.1) 21 (19) 40 (16.3)
Infection 54 (15.1) 16 (14) 38 (15.5)
Graft failure 7 (1.9) - 7 (2.9)
Steroid-refractory GVHD 22 (6.1) 12 (11) 10 (4.1)
Massive hemorrhage 3 (.8) - 3 (1.2)
Secondary malignancy 2 (.5) 1 (.9) 1 (.4)
Miscellaneous 12 (3.3) 6 (5.4) 6 (2.4)

OS, % (95% CI)

1 yr 62.9 (57.6-67.7) 63.8 (51.2-72) 62.5 (56-68.3) .959
2 yr 55 (49.5-60.3) 54.7 (44.9-63.4) 55.3 (48.4-61.7)
RFS, % (95% CI)
1 yr 57.8 (52.5-62.8) 59.3 (49.6-67.8) 57.2 (50.6-63.2)
2 yr 52.6 (47.1-57.9) 52.9 (43.2-61.7) 52.6 (45.7-59) .708
NRM, % (95% CI)
1 yr 25.3 (21.2-30.1) 28.9 (22.3-37.5) 23.6 (19-29)
2 yr 29.3 (25-34.4) 33.3 (26.3-42.3) 27.3 (22.3-33.6) .23
CIR, % (95% CI)
1 yr 16.7 (13.2-21.2) 12.8 (8-20.5) 18.6 (14.8-23.3)
2 yr 17.9 (14.7-21.8) 13.7 (9.4-20) 19.9 (15.3-25.9) .15
GRFS, % (95% CI)
37.7 (32.6-42.8) 20.5 (13.6-28.5) 45.5 (39.1-51.7) <.001
1 yr 35 (29.9-40.1) 17.7 (11.2-25.4) 42.9 (36.4-49.2)
2 yr

not differ significantly between the 2 groups (when controlling
for other risk factors). The lack of statistical significance must
be interpreted carefully, however. This study's retrospective
design, the lack of homogeneity between the groups, and the
small number of patients with high-risk AML are relevant limi-
tations of the study.
The feasibility of using RIC in adults with AML is supported
by several previous studies [4,10,21,22]. Multiple studies have
attempted to define an ideal conditioning regimen intensity
for patients with AML, with mixed results [5-9,23-28]. The
lack of uniformity raises important questions regarding the
impact of intensifying the conditioning regimen to maximize
cytotoxic effects on reducing the risk of relapse. Achieving
meaningful reductions in relapse without compromising NRM
remains challenging [29]; therefore, novel strategies moving
beyond simply intensifying the preparative regimen are
needed to prevent disease recurrence [30]. Enhancing donor T
cell activity to promote the GVL effect may be possible with
early discontinuation of immunosuppressive agents or the use
of donor lymphocyte infusion [31,32]. The use of targeted ther-
apy or preemptive post-transplantation treatments also may
decrease the relapse rate in patients with AML [33-36]. Stan-
dardized techniques to measure minimal residual disease
(MRD) after allo-HCT may be used to define preemptive inter-
ventions [37-39].
Increasing age was found to be a significant risk factor for
worse OS and RFS. Several previous studies have shown that
older patients benefit from RIC to overcome TRM [13,40,41];
however, age itself is not an accurate parameter for assessing
frailty [42-44]. A patient’s physiological reserve can be signifi-
cantly impaired after the numerous intensive treatments
required to achieve disease control independent of biological
age [14]. Geriatric assessments can potentially be used to
improve transplant eligibility and to select vulnerable recipi-
ents across all ages, rather than implement an arbitrary age
cutoff to define conditioning intensity [45-47].
No statistically significant differences in OS and RFS were
found between the conditioning groups in patients age 18 to
 M.Q. Salas et al. / Biol Blood Marrow Transplant 26 (2020) 1511 1519 1517

Table 3
Multivariate Model for OS, RFS, and GRFS

Variable OS RFS GRFS

Multivariate analysis, P value Multivariate analy- P value Multivariate analysis P value
HR (95% CI) sis HR (95% CI) HR (95% CI)
Conditioning regimen: .94 (.60-1.47) .78 1.05 (.68-1.64) .82 .65 (.46-.91) .01
RIC (vs MAC)
GVHD prophylaxis: .68 (.45-1.05) .08 .77 (.51-1.16) .21 .43 (.30-.61) <.001
ATG-PTCy-CsA (vs
other GVHD prophy-
laxis)

Age at transplanta- <.001 .002 .01

tion: 4.15 (2.07-8.31) 3.07 (1.62-5.8) 1.35 (.91-1.99)
40-64 yr (vs 18-39 yr) 1.55 (1.02-2.35) 1.43 (.96-2.13) 1.96 (1.23-3.13)
65 yr (vs 18-39 yr)

Donor type: .02 .03

10/10 MUD (vs MSD) 1.15 (.76-1.74) 1.12 (.75-1.67) .88 (.64-1.20) 1.27 (.86-1.87) 2.11 (1.24-3.57) .002
9/10 MUD (vs MSD) 1.97 (1.24-3.13) 1.91 (1.21-3.01)
Haploidentical (vs 1.77 (.93-3.39) 1.47 (.79-2.76)
MSD)

Cytogenetic risk:
High (vs favorable/ 1.61 (1.11-2.32) .01 1.62 (1.13-2.32) .008 - -
intermediate)
1.62 (.99-2.61) .05 1.92 (1.19-3.10) .007
cGVHD (time-depen-
dent variable):*m
oderate/severe (vs mild
or absence)
Patients included all 3 multivariate analyses: 336. Number of events in the OS model: 150 (42.1%). Number of events in the RFS model: 160 (44.9%). Number of events
in the GRFS model: 216 (60.7%). Patients included in the GRFS model: 356. Number of events in the GRFS model: 230 (64.6%).
HR indicates hazard ratio.

Table 4
Multivariate model for GRFS

Variable Multivariate Analysis HR P Value

(95% CI)
Conditioning regimen/GVHD prophylaxis: MAC vs 3.41 (2.38 -4.88); 2.33 (1.60- <.0001
RIC + ATG-PTCy-CSA RIC + other GVHD prophylaxis vs 3.39)
RIC + ATG-PTCy-CSA
Age at transplantation: 40-64 yr (vs 18-39 yr ); 65 yr (vs 1.46 (1.04-2.06); 1.99 (1.25- .01
18-39 yr) 3.18)
Donor type: 10/10 MUD (vs MSD); 9/10 MUD (vs MSD); .84 (.61-1.14); 1.27 (.86- .0016
haploidentical (vs MSD) 1.88); 2.06 (1.21- 3.49)
RIC versus MAC and the use of ATG-PTCY-CsA for GVHD prophylaxis were found to be significant variables for GRFS in the univariate analysis. ATG-PTCY-CsA was
mainly used in RIC allo-HCT (95.5%) during the study period of time. According to the results obtained from the cumulative incidence of GVHD found among the MAC
cohort, RIC in combination with ATG-PTCY-CsA, and RIC in combination with other GVHD prophylaxis, the variable conditioning regimen and GVHD prophylaxis was
combined in this analysis to explore their individual effect on GRFS.
Patients included all 3 multivariate analyses: 356. Number of events in the GRFS model: 230 (64.6%).

60 years; however, NRM was lower in younger recipients of
RIC allo-HCT. These findings suggest that RIC can potentially
lead to comparable outcomes as MAC in young adults and
older patients without comorbidities. Prospective studies are
needed to explore whether RIC allo-HCT combined with post-
transplantation measures to decrease relapse could result in
comparable outcomes as seen with MAC regimens in fit
patients with high-risk AML.
MRD before transplantation has been identified as a risk
factor for disease relapse in patients undergoing allo-HCT [48-
50]. All recipients included in the study were in morphological
complete remission; however, MRD data were not available.
The presence of MRD before allo-HCT, rather than patient age
or comorbidities alone, may potentially guide the choice of
higher-intensity conditioning [48-50]. Prospective studies
focused on MRD status-guided conditioning regimens may
address this issue.
The most important finding of the present study is the ben-
eficial effect of dual T cell depletion combined with CsA in RIC
allo-HCT on preventing clinically relevant GVHD (Figure 1),
resulting in significantly improved GRFS. A composite end-
point focused on survival without relapse and the absence of
clinically relevant GVHD, GRFS can be considered a surrogate
marker of optimal quality of life post-transplantation [51,52].
Allo-HCT is a complex postremission strategy aimed at con-
trolling disease relapse in high-risk hematologic malignancies
1518 M.Q. Salas et al. / Biol Blood Marrow Transplant 26 (2020) 1511 1519
that is associated with relevant morbidity and mortality [53].
Although survival and the mitigation of relapse rates are
clearly defined goals, the impact of such complications as
chronic GVHD on long-term survival are less well understood.
Our group has previously reported the efficacy of this novel
combination in patients undergoing haploidentical cell trans-
plantation [19,54], patients diagnosed with AML [18], and
patients with other hematologic disorders using different
donor types [20]. The main concern with the use of this novel
prophylaxis is an increased incidence of viral reactivation and
PTLD [18-20].
In May 2018, this novel GVHD prophylaxis was internally
reviewed, and the ATG dose was reduced to 2 mg/kg with the
aim of preserving GVHD control and decreasing transplanta-
tion-related toxicity (due mainly due to infectious complica-
tions) [20]. Further improvements to this protocol are ongoing
to improve its safety while preserving its efficacy. To account
for patients who received RIC with different GVHD prophylaxis
strategies, we classified patients into MAC, RIC + ATG-PTCY-
CsA, and RIC + other GVHD prophylaxis to explore the combi-
natorial effect of conditioning regimen and GVHD prophylaxis
on GRFS. The results revealed a greater beneficial effect of
RIC + ATG-PTCy-CsA compared with other treatment combina-
tions in reducing aGVHD and cGVHD (Figure 1).
The present study compared the degree of GVHD control pro-
vided by the ATG-PTCy-CsA combination with RIC allo-HCT and
other GVHD prophylaxis strategies combined with MAC or RIC.
ATG-PTCY-CsA is a well-tolerated strategy that limits transplanta-
tion-related toxicity, allows consistent engraftment, and provides
good control of acute and chronic GVHD [18,19,20,55]. In addition,
when this approach is used in patients with AML, we hypothesize
that the use of PTCy may intensify the cytotoxic effect of the con-
ditioning regimen and reduce disease relapse [18-20]. Secondary
to the observed control of clinically relevant GVHD [18-20], this
combination has been incorporated more recently in patients
undergoing MAC allo-HCT with grafts from unrelated and haploi-
dentical donors.
In conclusion, MAC and RIC allo-HCT provided comparable
post-transplantation outcomes in our study cohort, calling
into question the rationale for intensifying conditioning in
younger patients for marginal benefits. The use of dual T cell
depletion with ATG-PTCy-CsA in RIC allo-HCT was beneficial
for significantly higher GRFS, which likely translates into
meaningful improvements in quality of life. Further investiga-
tions are underway to explore the efficacy of this prophylaxis
strategy in MAC allo-HCT.
SUPPLEMENTARY MATERIALS
Supplementary material associated with this article can be
found in the online version at doi:10.1016/j.bbmt.2020.04.021.
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