Hematopoietic cell transplantation after CD19-directed CAR T-cell therapy for remission consolidation or relapse treatment in pediatric acute lymphoblastic leukemia.
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Relapse of B-cell acute lymphoblastic leukemia (B-ALL) after CD19-targeted chimeric antigen receptor T-cell therapy (CAR19) remains a substantial challenge. Allogeneic hematopoietic cell transplant (HCT) represents an approach for both post-CAR19 relapse prevention and relapse therapy. However, a paucity of detailed HCT safety and outcome data exists in this population. We conducted a retrospective review of 47 children and young adults with B-ALL who underwent first HCT for post-CAR19 remission consolidation (preemptive cohort, n=26) or relapse therapy (relapse cohort, n=21). With a median follow-up of 4.1 years, 3-year disease-free survival was 90% in the preemptive cohort and 64% in the relapse cohort. Overall survival, cumulative incidence of relapse, and non-relapse mortality at 3 years were 95%, 5%, and 5% in the preemptive cohort, respectively, and 67%, 20%, and 15% in the relapse cohort, respectively. The cumulative incidence of grade III-IV acute graft-versus-host disease (GVHD) was 14% in the preemptive and 19% in the relapse cohort. Chronic GVHD developed in 24% and 14% of patients alive at 100 days in the preemptive and relapse cohorts, respectively. Veno-occlusive disease/sinusoidal obstruction syndrome was the most common non-GVHD severe organ toxicity, with a cumulative incidence of 10% in the preemptive and 31% in the relapse cohort. In appropriate patients, HCT can be an effective strategy for attaining durable B-ALL remission when used preemptively post-CAR19 or as part of post-CAR19 relapse salvage therapy.