Pre-transplant MRD negativity predicts favorable outcomes of CAR-T therapy followed by haploidentical HSCT for relapsed/refractory acute lymphoblastic leukemia: a multi-center retrospective study

Abstract

Background: Consolidative allogeneic hematopoietic stem cell transplantation is a controversial option for patients with relapsed/refractory acute lymphoblastic leukemia after chimeric antigen receptor T cell (CAR-T) therapy. We performed a multicenter retrospective study to assess whether patients can benefit from haploidentical hematopoietic stem cell transplantation after CAR-T therapy.

Methods: A total of 122 patients after CAR-T therapy were enrolled, including 67 patients without subsequent transplantation (non-transplant group) and 55 patients with subsequent haploidentical hematopoietic stem cell transplantation (transplant group). Long-term outcome was assessed, as was its association with baseline patient characteristics.

Results: Compared with the non-transplant group, transplantation recipients had a higher 2-year overall survival (OS; 77.0% versus 36.4%; P < 0.001) and leukemia-free survival (LFS; 65.6% versus 32.8%; P < 0.001). Multivariate analysis showed that minimal residual disease (MRD) positivity at transplantation is an independent factor associated with poor LFS (P = 0.005), OS (P = 0.035), and high cumulative incidence rate of relapse (P = 0.045). Pre-transplant MRD-negative recipients (MRD- group) had a lower cumulative incidence of relapse (17.3%) than those in the non-transplant group (67.2%; P < 0.001) and pre-transplant MRD-positive recipients (MRD+ group) (65.8%; P = 0.006). The cumulative incidence of relapse in MRD+ and non-transplant groups did not differ significantly (P = 0.139). The 2-year LFS in the non-transplant, MRD+, and MRD- groups was 32.8%, 27.6%, and 76.1%, respectively. The MRD- group had a higher LFS than the non-transplantation group (P < 0.001) and MRD+ group (P = 0.007), whereas the LFS in the MRD+ and non-transplant groups did not differ significantly (P = 0.305). The 2-year OS of the MRD- group was higher than that of the non-transplant group (83.3% versus 36.4%; P < 0.001) but did not differ from that of the MRD+ group (83.3% versus 62.7%; P = 0.069). The OS in the non-transplant and MRD+ groups did not differ significantly (P = 0.231).

Conclusion: Haploidentical hematopoietic stem cell transplantation with pre-transplant MRD negativity after CAR-T therapy could greatly improve LFS and OS in patients with relapsed/refractory acute lymphoblastic leukemia.

Trial registration: The study was registered in the Chinese clinical trial registry (ChiCTR1900023957).

Keywords: Chimeric antigen receptor T cell therapy; Haploidentical hematopoietic stem cell transplantation; Leukemia-free survival; Minimal residual disease negativity; Overall survival; Relapsed/refractory acute lymphoblastic leukemia.

Fig. 1

Patient enrollment flow chart

Fig. 2

Landmark analysis, cumulative incidence of relapse, non-relapse mortality, leukemia-free survival (LFS) and overall survival (OS) between the non-transplant group and the transplant group. The cut-off value was set at the median time from CAR-T cell infusion to haplo-HSCT (2.23 months). No HSCT: non-transplant group, HSCT: transplant group

Fig. 3

Landmark analysis, cumulative incidence of relapse, non-relapse mortality, leukemia-free survival (LFS) and overall survival (OS) among the non-transplant group, MRD+ group and MRD- group. The cut-off value was set at the median time from CAR-T cell infusion to haplo-HSCT (2.23 months). No HSCT: non-transplant group, MRD+: MRD+ group, MRD-: MRD- group