One-unit versus two-unit cord-blood transplantation for hematologic cancers

Abstract

Background: Umbilical-cord blood has been used as the source of hematopoietic stem cells in an estimated 30,000 transplants. The limited number of hematopoietic cells in a single cord-blood unit prevents its use in recipients with larger body mass and results in delayed hematopoietic recovery and higher mortality. Therefore, we hypothesized that the greater numbers of hematopoietic cells in two units of cord blood would be associated with improved outcomes after transplantation.

Methods: Between December 1, 2006, and February 24, 2012, a total of 224 patients 1 to 21 years of age with hematologic cancer were randomly assigned to undergo double-unit (111 patients) or single-unit (113 patients) cord-blood transplantation after a uniform myeloablative conditioning regimen and immunoprophylaxis for graft-versus-host disease (GVHD). The primary end point was 1-year overall survival.

Results: Treatment groups were matched for age, sex, self-reported race (white vs. nonwhite), performance status, degree of donor-recipient HLA matching, and disease type and status at transplantation. The 1-year overall survival rate was 65% (95% confidence interval [CI], 56 to 74) and 73% (95% CI, 63 to 80) among recipients of double and single cord-blood units, respectively (P=0.17). Similar outcomes in the two groups were also observed with respect to the rates of disease-free survival, neutrophil recovery, transplantation-related death, relapse, infections, immunologic reconstitution, and grade II-IV acute GVHD. However, improved platelet recovery and lower incidences of grade III and IV acute and extensive chronic GVHD were observed among recipients of a single cord-blood unit.

Conclusions: We found that among children and adolescents with hematologic cancer, survival rates were similar after single-unit and double-unit cord-blood transplantation; however, a single-unit cord-blood transplant was associated with better platelet recovery and a lower risk of GVHD. (Funded by the National Heart, Lung, and Blood Institute and the National Cancer Institute; ClinicalTrials.gov number, NCT00412360.).

Figure 1. Treatment Plan

Eligible patients were at least 1 and less than 22 years of age and had a performance status of 70 or higher on the Lansky scale or the Karnofsky scale, adequate organ function, two HLA-matched cord-blood units of adequate cell dose available, and a diagnosis of high-risk acute leukemia, chronic myeloid leukemia, or myelodysplastic syndrome. CSA denotes cyclosporine, CY cyclophosphamide, FLU fludarabine, G-CSF granulocyte colony-stimulating factor, MMF mycophenolate mofetil, TBI total-body irradiation, and TNC total nucleated cells.

Figure 2. Survival after Randomization

The probability of overall survival is shown for the two treatment groups in the intention-to-treat analysis.

Figure 3

Incidence of Major Complications.