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1 제 대 혈 이 식 길 라 잡 이 보 건 복 지 부 대 한 혈 액 학 회 제대혈이식 길라잡이

2 집필진 강형진국훈권지현김혜리문영철박미림백희조유건희윤성수이영호이정림정소영정준원 서울의대소아청소년과전남의대화순전남대병원소아청소년과충북의대혈액종양내과중앙의대소아청소년과이화의대혈액종양내과충북의대소아청소년과전남의대화순전남대병원소아청소년과성균관의대삼성서울병원소아청소년과서울의대혈액종양내과한양의대소아청소년과대구파티마병원혈액종양내과차의대분당차병원혈액종양내과연세의대혈액내과

3 목차 제 1 장. 개요 1 제 2 장. 제대혈검색방법및공급절차 13 제 3 장. 제대혈선택기준 21 제 4 장. 이식전처치방법 35 I. 성인 37 II. 소아 46 제 5 장. 이식편대숙주병의예방 51 제 6 장. 제대혈주입방법및주의할점 63 제7장. 제대혈이식특이합병증및대처법 73 I. 이식편거부반응 75 II. 생착전증후군 80 III. 감염및모니터링 83 제 8 장. 제대혈이식후면역재구성 89

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5 제 1 장 개요

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7 제 1 장개요 제대혈이식은 1988년판코니빈혈환아에서처음으로시행된이후 30,000건이상이시행되고있으며, 이후약 25년동안의연구결과에서소아및성인의다양한악성 / 비악성질환에대한치료방법으로제대혈이식의안전성과효용성이입증되었다. 제대혈이식을성공적으로수행하기위하여골수혹은말초혈과는구분되는제대혈이식만의장단점을파악하고임상경과를이해하는것이도움이될것이다. 1 제대혈이식의장단점 1) 장점 1 제대혈은행에보관되어있는상태이므로환자가필요로할때는즉시이용할수있다. 2 Human leukoctye antigen (HLA) 가 1 2개정도불일치를보이더라도이식성적에큰영향을미치지않는범위내에서이식원으로선택가능하다. 3 이식편대숙주병의빈도가다른이식원에비해낮다. 4 거대세포바이러스및엡스타인-바바이러스와같은바이러스가이식원으로부터전달될가능성이적다. 5 다른이식원에비해상대적으로조혈모세포의숫자가적더라도생착이가능하다. 2) 단점 1 공여자 1명으로부터얻을수있는조혈모세포의수가한정되어있다. 2 다른이식원에비해늦게생착되며, 생착실패의위험이높다. 3 면역기능회복이느리며, 그에따른감염의위험성이높다. 2 일반적인임상경과 제대혈이식후호중구생착이일어나는시기는이식후 3주전후, 혈소판생착은 40일전후로일어난다. 대개이식후 60일까지생착이이루어지지않으면, 생착실패로간주하고 2차이식을시행한다 [7장. I. 이식편거부반응참조 ]. 급성또는만성이식편대숙주병의빈도는 20 40% 로서상대적으로다른이식방법에비해낮으며, 대개중증보다는경증 (1 2 등급 ) 의경우가많다. 제대혈이식에서는생착지연으로인해상대적으로긴호중구감소기간과림프구기능의늦은회복등으로인한 개요 3

8 감염성합병증의빈도가골수나말초혈을이용한조혈모세포이식에비해높다. 이식관련사망률은 10 40% 정도로보고되고있으며, 주된원인은생착실패및감염이다. 제대혈이식후면역재구성과이식관련합병증에대한임상경과는 [ 그림 1-1] 에나타나있다. [ 그림 1-1] 제대혈이식후면역재구성과이식관련합병증 (Merindol et al., J Leukoc Biol 2011) 3 제대혈이식의국외성적 제대혈이식의치료성적은악성질환과비악성질환에대하여다소차이를보이고있는데, 최근까지발표된국외임상결과들을정리해보면아래와같다. 1) 악성질환악성질환을대상으로한제대혈이식의안전성과효용성은많은연구에서보고되어왔으며, HLA 일치형제공여자가없을경우비혈연골수및말초혈과더불어제대혈은중요한이식원이다. 특히환자의질병경과가초기인경우, 그리고주입된세포수가많은경우, HLA 불일치정도가 2개이하인제대혈을이용할시이식성적이좋으며, 이런조건의제대혈이식을시행시, 비혈연골수이식과비슷한무병생존율및전체생존율을보인다고알려져있다. 여러가지악성질환에서의제대혈이식성적은 [ 표 1-1] 과같다. 4 제 1 장

9 [ 표 1-1] 악성질환에서다른이식원에의한치료성적및제대혈이식성적 Reference HSC source/n Median age (years) Disease/n TRM Grade II-IV GVHD LFS OS CHILDREN Eapen et al. (2006) MUCB/12 MMUCB/69 MUBM/61 MMUBM/24 MSD/ ALL/146 AML/121 31% 15% 6% Acute: RR significantly higher in UBM and UCB (3.03 and 2.45 respectively) compared to MSD (1.0) Chronic: RR significantly higher in URD (3.5) compared to MSD (1.0) 3-year LFS: CR1 URD 54% MSD 49% >CR1 URD 30% MSD 20% 3-year OS: CR1 URD 62% MSD 54% >CR1 URD 33% MSD 35% Eapen et al. (2007) MUCB/35 MMUCB(1L)/44 MMUCB(1H)/157 MMUCB(2)/267 MUBM/116 MMUBM/ ALL/19 AML/16 ALL/36 AML/8 ALL/88 AML/69 ALL/166 AML/101 ALL/80 AML/36 ALL/106 AML/60 6% 43% 29% 46% 21% 31% Acute: 24% Chronic: 30% Acute: 36% Chronic: 18% Acute: 42% Chronic: 18% Acute: 41% Chronic: 15% Acute: 46% Chronic: 32% Acute: 60% Chronic: 40% 5-year LFS 60% 5-year LFS 36% 5-year LFS 45% 5-year LFS 33% 5-year LFS 37% 5-year LFS 38% NA ADULT Laughlin et al. (2004) UCB/150 MUBM/367 MMUBM/ ALL/45 AML/58 ALL/82 AML/115 ALL/17 AML/27 Acute: 41% Chronic: 51% Acute: 48% Chronic: 35% Acute: 52% Chronic: 40% 3-year LFS 23% 3-year LFS 33% 3-year LFS 19% 26% 35% 20% Kumar et al. (2008) UCB/19 MRBM/90 MUBM/15 MMUBM/ ALL/19 ALL/90 ALL/15 ALL/14 3-year 34% 3-year 44% 3-year 53% 3-year 86% Acute: 32% Chronic: 16% Acute: 20% Chronic: 22% Acute: 10% Chronic: 47% Acute: 7% Chronic: 21% 3-year LFS 61% 3-year LFS 27% 3-year LFS 13% 3-year LFS 14% 66% 27% 13% 14% Eapen et al. (2008) UCB/148 MUBM/243 MMUBM/111 MPBSC/518 MMPBSC/ NA 41% 26% 37% 27% 42% 33% 46% 34% 43% 33% 35% 48% 38% 45% 36% Abbreviations: HSC, hematopoietic stem cell; TRM, transplantation-related mortality; GVHD, graft versus host disease; LFS, leukemia free survival; ALL, acute lymphoblastic leukemia; AML, acute myeloid leukemia; CR, complete remission; OS, overall survival; URD, unrelated donor; UBM, unrelated bone marrow; UCB, unrelated cord blood; MUCB, matched unrelated cord blood; MMUCB, mismatched unrelated cord blood; MUBM, matched unrelated bone marrow; MMUBM, mismatched unrelated bone marrow; MSD, matched sibling donor; MPBSC, matched peripheral blood stem cell; MMPBSC, mismatched peripheral blood stem cell; RR, relative risk; NA, not assessed. 2) 비악성질환비악성질환의경우, 다른이식원에비해제대혈이식을시행할경우생착실패의확률이높은것으로보고되고있다. 이를극복하기위해서는충분한세포수를지닌제대혈을사용하는것이중요하며, 다양한전처치방법의사용으로이식성적의향상을꾀하고있다 [4장참조 ]. 개요 5

10 재생불량빈혈의경우제대혈이식후생존율이약 40% 내외로보고되었으며, 최근 EBMT (European blood and marrow transplantation) 연구에서는최소이식세포수를총유핵세포수기준으로 /kg를추천하였다 (Peffault de Latour et al., Bone Marrow Transplant 2013). 여러가지전처치방법이사용되고있으나, 최근 1 Fludarabine (Flu) 120 mg/m 2 +Cyclophosphamide (Cy) 1,200 mg/m 2 +rabbit Antithymocyte globulin (ratg) (30 mg/kg) (Liu et al., Bone Marrow Transplant 2012), 2 Flu 125 mg/m 2 +Melphalan (Mel) 80 mg/m 2 + 전신방사선조사 (Total body irradiation, TBI) 4 Gy (Yamamoto et al., Blood 2011), 3 Flu mg/m 2 +Cy mg/kg or 2,250 mg/m 2 +TBI 2-4 Gy (Yoshimi et al., Biol Blood Marrow Transplant 2008) 등을사용하여제대혈이식후생존율 80% 이상의좋은성적을보고한바있다. 여러가지비악성질환에서의제대혈이식성적은 [ 표 1-2] 과같다. [ 표 1-2] 비악성질환에서다른이식원에의한치료성적및제대혈이식성적 Reference HSC source/n Median age (years) Disease/n TRM/n Grade II-IV GVHD Graft failure/n EFS/OS HEMOGLOBINOPATHIES Locatelli et al. RUCB/44 (2003) (61% MM, 39% M) Adamkiewicz et al. (2007) Jaing et al. (2008) UCB/7 (100% MM) 5 SCD/11 Thal/33 0/44 Acute: 4/44 Chronic: 2/ SCD/7 1/7 Acute: 57% Chronic: 14% UCB/21 ducb/9 5 Thal/30 10 Acute: 40% Chronic: 4% SCD/1 Thal/7 OS 100% EFS 79-90% (2 years) 3 OS 86% EFS 45% (2 years) NA OS: 82% EFS: 78% (3 years) Reference HSC source/n Median age (years) Disease/n TRM/n Grade II-IV GVHD Neutrophil recovery OS FANCONI ANEMIA Gluckman et al. UCB/92 (2007) (13% M, 87% MM) Wagner et al. (2007) UBM/98 (78% M, 22% MM) 8.6 FA+AA/81 FA+MDS/8 FA+AL/4 12 FA+AA/75 FA+MDS/14 FA+AL/7 FA/2 NA Acute: 32% Chronic: 16% NA Acute: 29% Non-Flu +TCD 21% -TCD 70% Flu 16% Chronic: 31% 60% at 60 days 3-year OS 40 +Flu 50% -Flu 25% 78% at 28 days Reference HSC source/n Median age (years) Disease/n TRM/n Grade II-IV GVHD Neutrophil recovery /graft failure OS/EFS INBORN ERRORS OF METABOLISM Martin et al. UCB/69 (2006) (97% MM, 3% M) Boelens et al. (2007) UCB/20 RUCB/3 BM/103 PBSC/20 (66% M, 34% MM) 1.8 LSD+PSD/69 NA Acute: 44% Chronic: 18% 1.5 MPS1/146 19/146 Acute: 16% Chronic: NA Neutrophil recovery 84% at 100 days 4/69 33 patients received a second transplant 3 patients received a third transplant OS 72% (1 year) OS 81% Abbreviations: HSC, hematopoietic stem cell; TRM, transplantation-related mortaility; GVHD, graft versus host disease; EFS, event-free survival; OS, overall survival; RUCB, related umbilical cord blood; UCB, unrelated cord blood; UBM, unrelated bone marrow; PBSC, peripheral blood stem cell; M, matched; MM, mismatched; SCD, sickle cell disease; Thal, thalassemia; FA, Fanconi anemia; AA, aplastic anemia; MDS, myelodysplatic syndrome; AL, acute leukemia; LSD, lysosomal storage disease; PSD, peroxisomal storage disease; MPS1, mucopolysaccharidosis type I; TCD, T cell depletion; OS, overall survival; Flu, fludarabine. 6 제 1 장

11 4 우리나라의제대혈이식현황및성적 1) 소아 2011년, 2013년에보고된바에따르면, 이식의정중연령은약 7세였으며질환별빈도를보면, 대부분악성혈액질환이었으며, 그중급성백혈병이가장많았다. 약 91% 의환아가골수제거전처치를받았으며, 전신방사선조사는 32% 에서행해졌고, 항흉선세포글로불린은약 79% 의환아에게투여되었다. 이식편대숙주병예방으로는 cyclosporin 과스테로이드병합요법이가장많이사용되었다. 소아제대혈이식후 5년생존율은약 50% 였다 [ 그림 1-2]. 두단위제대혈이식의경우약 35% 의환자에서행해졌으며, 한단위제대혈이식과비교시이식성적의차이는보이지않았다. 이식후생존율에나쁜영향을미치는인자로는 1) 전신방사선조사 (TBI-based) 전처치, 2) salvage transplant, 3) failure to achieve early complete chimerism, 4) 거대세포바이러스질환이확인되었다 [ 표 1-3]. 특히우리나라의경우 90% 이상의환자가거대세포바이러스양성혈청반응으로이식후거대세포바이러스재활성화 ( 약 50%) 및질환 (15 20%) 의빈도가높아, 이에대한예방및면밀한추적관찰이필요하다. [ 그림 1-2] 우리나라제대혈이식생존율 (Yoo et al., Am J Hematol 2011) Abbreviations: AL, acute leukemia; IE, inborn errors; MDS, myelodysplastic syndrome; JMML, juvenile myelomonocytic leukemia; SAA, severe aplastic anemia; CML, chronic myelogenous leukemia. 최근국내 3개이식기관 ( 삼성서울병원, 서울대학교어린이병원, 전남의대화순병원 ) 의데이터를분석한결과, 2008년도전후를비교하였을때, 2008년이후제대혈이식성적이유의하게향상되었음을확인할수있었다 [ 그림 1-3] (Unpublished data, 2014). 개요 7

12 [ 그림 1-3] 국내 3 개이식기관제대혈이식성적의 2008 년전후의비교, (A) 전체생존율 (B) 무사건생존율 [ 표 1-3] 우리나라제대혈이식후생존율에영향을미치는인자에대한분석 (Yoo et al., Am J Hematol 2011) Variable Univariate Multivariate 5-year survival rate ± S.E. P Hazard ratio (95% C.I.) P All patients (n = 226) TBI No ± Yes ± ( ) In vivo T-cell depletion No ± Yes ± ( ) 0.15 Salvage transplantation No ± Yes ± ( ) Lack of CC at 1 month No ± Yes ± ( ) < CMV disease No ± Yes ± ( ) Acute leukemia (n = 167) Disease status CR1/CR ± >CR ± < ( ) TBI No ± Yes ± ( ) 0.43 In vivo T-cell depletion No ± Yes ± ( ) 0.10 Lack of CC at 1 month No ± Yes ± ( ) 0.09 CMV disease No ± Yes ± ( ) Abbreviations: CC, complete chimerism; CMV, cytomegalovirus; CR, complete remission; TBI, total body irradiation; UCBT, umbilical cord blood transplantation. 8 제 1 장

13 2) 성인아직까지국내에서성인제대혈이식에대한연구는부족한실정이다. 1998년부터 2013년까지국내 16개기관에서성인제대혈이식이시행된 48명의환자자료를취합하여후향적으로분석한결과 (unpublished), 다변량분석에서통계적으로유의한예후인자는활동도계수 (ECOG performance status 0 or 1) 및총유핵세포수 /kg였다. 전처치로전신방사선조사를시행한경우, 그렇지않은경우보다생존율이높은경향을보였으나통계적으로유의하지않았다. 골수제거전처치와저강도전처치를비교하였을때에도통계적으로유의하지않았다. 따라서, 성인악성혈액종양환자를대상으로제대혈이식을고려할경우, 우선적으로활동도가양호한환자를대상으로충분한세포수 (eg. 총유핵세포수 /kg) 를이식하는것이추천된다. 한단위이식으로충분한수의세포를이식하기어려운경우두단위이식을적극적으로고려할수있다. 5 우리나라제대혈은행및보관제대혈현황 국가지정 7개의기증제대혈은행및민간제대혈은행포함총 16개은행에서 40,000 단위이상의기증제대혈이보관되어있으며, 기증제대혈보관의법적기준인총유핵세포수 이상인제대혈은 28,000단위정도이다. [ 그림 1-4] 우리나라기증제대혈보관현황 ( 제대혈정보센터제공, 2013 년 12 월현재 ) 우리나라의경우, 2013년말현재보관된제대혈의약 1.3% 정도만이이식에사용되었는데, 사용률이저조한주된원인은제대혈단위당세포수가적고, 비용이많이들기때문이다. 따라서양질의제대혈확보및제대혈이식시발생하는비용절감을위한국가적인차원의제도적지원이뒷받침되어야할것이다. 최근 Lee 등 (Transfusion 2013) 이발표한 KoreaCORD 의이식및보관제대혈분석결과를바탕으로총유핵세포수 7억개이상의제대혈만법적으로인정및관리하고있기때문에, 과거보다양질의제대혈을공급받을수있을것으로예상된다 [ 그림 1-5]. 개요 9

14 [ 그림 1-5] 국내기증제대혈은행 (KoreaCORD) 에보관된제대혈단위 ( 회색막대 ) 와이식된제대혈단위 ( ) 의총유핵세포수분포 (Lee et al., Transfusion 2013) 또한, 제대혈공급비용은초창기만하더라도 1단위에 800만원 (2단위 1,200만원 ) 까지환자가부담을했으나, 2014년 10월 1일부터는정부에서기증제대혈제제의비용을 1단위당 206만원으로대폭인하하고, 건강보험에적용하기로하였기때문에, 환자부담은제대혈 1단위에 만원에불과하게되었다. 이와같이지금까지우리나라에서제대혈사용률이저조하였던원인들중에서세포수의부족및고가의제대혈공급비용의장애가조금씩극복됨에따라, 향후여러환자에서의활발한제대혈이식이기대되는바이다. [ 참고문헌 ] 1. Adamkiewicz TV, Szabolcs P, Haight A, et al. Unrelated cord blood transplantation in children with sickle cell disease: review of four-center experience. Pediatr Transplant 2007;11: Boelens JJ, Wynn RF, O'Meara A, et al. Outcomes of hematopoietic stem cell transplantation for Hurler's syndrome in Europe: a risk factor analysis for graft failure. Bone Marrow Transplant 2007;40: Danby R, Rocha V. Improving engraftment and immune reconstitution in umbilical cord blood transplantation. Front Immunol 2014;5: Eapen M, Rubinstein P, Zhang MJ, et al. Comparable long-term survival after unrelated and HLA-matched sibling donor hematopoietic stem cell transplantations for acute leukemia in children younger than 18 months. J Clin Oncol 2006;24: Eapen M, Rubinstein P, Zhang MJ, et al. Outcomes of transplantation of unrelated donor umbilical cord blood and bone marrow in children with acute leukaemia: a comparison study. Lancet 2007;369: Gluckman E, Rocha V, Ionescu I, et al. Results of unrelated cord blood transplant in fanconi anemia patients: risk factor analysis for engraftment and survival. Biol Blood Marrow Transplant 2007;13: Hong KT, Kang HJ, Kim NH, et al. Peri-engraftment syndrome in allogeneic hematopoietic SCT. Bone Marrow Transplant 2013;48: Jaing TH, Tsay PK, Yang CP, et al. Evaluation of readmissionin children receiving allogeneic hematopoietic stem 10 제 1 장

15 cell transplantation: an institutional experience. Transplant Proc 2008;40: Kumar P, Defor TE, Brunstein C, et al. Allogeneic hematopoietic stem cell transplantation in adult acute lymphocytic leukemia: impact of donor source on survival. Biol Blood Marrow Transplant 2008;14: Laughlin MJ, Eapen M, Rubinstein P, et al. Outcomes after transplantation of cord blood or bone marrow from unrelated donors in adults with leukemia. N Engl J Med 2004;351: Lee YH, Kim JY, Mun YC, et al. A proposal for improvement in the utilization rate of banked cord blood. Blood Res 2013;48: Lee YH, Kwon YH, Hwang K, et al. Analysis of stored and transplanted cord blood units from KoreaCORD: reappraisal of banking guidelines and selection strategy. Transfusion 2013;53: Liu HL, Sun ZM, Geng LQ, et al. Unrelated cord blood transplantation for newly diagnosed patients with severe acquired aplastic anemia using a reduced-intensity conditioning: high graft rejection, but good survival. Bone Marrow Transplant 2012;47: Locatelli F, Rocha V, Reed W, et al. Related umbilical cord blood transplantation in patients with thalassemia and sickle cell disease. Blood 2003;101: Martin PL, Carter SL, Kernan NA, et al. Results of the cord blood transplantation study (COBLT): outcomes of unrelated donor umbilical cord blood transplantation in pediatric patients with lysosomal and peroxisomalstorage diseases. Biol Blood Marrow Transplant 2006;12: Merindol N, Charrier E, Duval M, et al. Complementary and contrasting roles of NK cells and T cells in pediatric umbilical cord blood transplantation. J Leukoc Biol 2011;90: Park M, Lee SH, Lee YH, et al. Pre-engraftment syndrome after unrelated cord blood transplantation: a predictor of engraftment and acute graft-versus-host disease. Biol Blood Marrow Transplant 2013;19: Peffault de Latour R, Rocha V, Socié G. Cord blood transplantation in aplastic anemia. Bone Marrow Transplant 2013;48: Spitzer TR. Engraftment syndrome following hematopoietic stem cell transplantation. Bone Marrow Transplant 2001;27: Takahashi S, Iseki T, Ooi J, et al. Single-institute comparative analysis of unrelated bone marrow transplantation and cord blood transplantation for adult patients with hematologic malignancies. Blood 2004;104: Takahashi S, Ooi J, Tomonari A, et al. Comparative single-institute analysis of cord blood transplantation from unrelated donors with bone marrow or peripheral blood stem-cell transplants from related donors in adult patients with hematologic malignancies after myeloablative conditioning regimen. Blood 2007;109: Wagner JE, Eapen M, MacMillan ML, et al. Unrelated donor bone marrow transplantation for the treatment of Fanconi anemia. Blood 2007;109: Yamamoto H, Kato D, Uchida N, et al. Successful sustained engraftment after reduced-intensity umbilical cord blood transplantation for adult patients with severe aplastic anemia. Blood 2011;117: Yoo KH, Lee SH, Sung KW, et al. Current status of pediatric umbilical cord blood transplantation in Korea: a multicenter retrospective analysis of 236 cases. Am J Hematol 2011;86: Yoshimi A, Kojima S, Taniguchi S, et al. Unrelated cord blood transplantation for severe aplastic anemia. Biol Blood Marrow Transplant 2008;14: 개요 11

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17 제 2 장 제대혈검색방법및공급절차

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19 제 2 장제대혈검색방법및공급절차 국내에서는 1997년최초로민간제대혈은행이설립ㆍ운영되기시작하였고 2005년 8월보건복지부에서 제대혈은행표준업무지침 을마련하여보급하였다 년 3월에는 제대혈관리및연구에관한법률 이제정되었으며이를 2011 년 7월 1일부터시행하였다. 질병관리본부의장기이식관리센터 (Korean Network for Organ Sharing, KONOS) 에서제대혈정보센터의역할을겸하여 2012년 3월 26일에는제대혈정보센터의관리체계및제대혈데이터베이스구축이시행되었다. 이에국내기증제대혈의등록및공급절차에대해간략히소개하고자한다. 제대혈정보센터의제대혈등록및공급절차 기증제대혈등의효과적인관리를위해제대혈정보센터를설립 운영하고자하는목적하에 제대혈관리및연구에관한법률 에근거하여관리되고있으며, 기증제대혈업무흐름도는 [ 표 2-1] 과같다. 제대혈검색방법및공급절차 15

20 [ 표 2-1] 기증제대혈업무흐름도 업무단계이식의료기관제대혈정보센터제대혈은행 검색 상세정보요청 확인검체요청 공급요청 이식결과통보 이식대기자등록 제대혈매칭후상세정보요청 - 최대 6 건 ( 반환후추가요청가능 ) 상세정보확인 ( 기한 3 개월 + 연장 1 회 ) - 확인검체요청 ( 요청일은최소 2 3 일후 ) - 반환사유등록 확인검사후결과등록 ( 제대혈정보센터에등록요청가능 ) 공급요청등록 ( 먼저, 공급제외되는제대혈상세정보반환 ) - 공급일변경은제대혈정보센터에연락 제대혈공급비용 : 이식조정기관 (CHSCB 혹은 KMDP 에 제대혈공급요청서 송부 ( 서울시제대혈은행은고지서가환자앞으로발부 ) 공급신고서 제대혈정보센터에통보 기증또는가족제대혈이식결과등록 - 이식통보서제대혈정보센터에통보 조혈모세포이식관리 / 비혈연이식대기자와 HLA 등록 제대혈이식관리 / 매칭결과관리 제대혈상세정보요청관리 - 제대혈은행에통보 제대혈확인검사관리 - 제대혈은행에통보 제대혈공급요청관리 - 공급일시변경요청내용을수정하고제대혈은행에통보 제대혈업무관리 - 이식의료기관요청미처리사항조회 기증제대혈관리 - 이식적합제대혈정보등록 제대혈정보요청승인관리 - 상세정보요청된제대혈정보보완후열람승인 (1 2 일소요 ) - 확인검체이송정보확인후승인 - 확인검체이송 제대혈공급관리 - 공급요청된제대혈접수 - 제대혈공급후공급완료처리 공급된가족제대혈등록 제대혈공급내용신고서 제대혈정보센터에통보 조혈모세포이식관리 / 이식자관리 / 이식결과 제대혈국외반출과부적격제대혈 ( 연구용 ) 공급은제대혈정보센터승인필요 1 기증제대혈등록 1 제대혈기증동의및채취동의후제대혈채취 2 제대혈및제대혈제제의부적격기준, 검사방법및판정기준에따른검사시행 3 적격으로판정된기증제대혈은제대혈정보센터에등록 ( 기증제대혈고유번호, 총유핵세포수, CD34양성세포수, 혈액형, HLA, 보관일 ) 2 기증제대혈의검색 공급단계 1 이식의료기관에서제대혈정보센터에국내제대혈검색 ( 전자 ) 요청 2 제대혈정보센터는이식의료기관과해당제대혈은행에검색결과 ( 전자 ) 통보 34 이식의료기관은제대혈정보센터에필요한상세정보 ( 전자 ) 요청하여 ( 전자 ) 통보받음 5 이식의료기관은제대혈정보센터에확인검사용검체를 ( 전자 ) 요청 6 제대혈은행은이식의료기관에확인검사용검체를공급 16 제 2 장

21 7 이식의료기관은제대혈정보센터에제대혈공급요청 8 제대혈은행은이식의료기관에제대혈공급 3 기증제대혈의결과보고단계 1 제대혈은행은제대혈및제대혈제제를공급한경우제대혈정보센터에신고 2 기증제대혈제제를공급받은이식의료기관에서는제대혈정보센터에공급받은기증제대혈에대한내용을신고 3 이식의료기관에서제대혈이식에관한정보를제대혈정보센터에통보 4 제대혈제제의국가간이동 BMDW (Bone Marrow Donor Worldwide) 는전세계의조혈모세포기증희망자및기증제대혈을등록하고검색교류하는국제네트워크이다. 제대혈정보센터는여기에가입하여조혈모세포기증희망자와기증제대혈데이터를제공하고이식조정은한국조혈모세포은행협회 (Korea Marrow Donor Program, KMDP), 가톨릭조혈모세포은행 (Catholic Hematopoietic Stem Cell Bank, CHSCB) 에서수행하고있다. 1) 국외에서국내로제대혈제제반입 1 이식의료기관은제대혈정보센터에국외제대혈검색 ( 전자 ) 요청 2 제대혈정보센터는국외제대혈검색결과를이식의료기관에 ( 전자 ) 통보 3 이식의료기관은제대혈정보센터에국외제대혈공급 ( 전자 ) 요청 제대혈검색방법및공급절차 17

22 4 이식조정기관은제대혈정보센터를대신하여국외제대혈은행및정보관리기관에제대혈공급요청 5 국외제대혈은행에서국내제대혈이식의료기관으로제대혈공급 6 국외제대혈을공급받은이식의료기관에서는제대혈정보센터에반입신고 7 이식의료기관에서제대혈이식에관한정보를제대혈정보센터에통보 2) 국내에서국외로제대혈제제반출 1 국외제대혈은행또는제대혈정보관리기관에서이식조정기관으로제대혈검색요청 23 이식조정기관은제대혈정보센터에제대혈검색 ( 전자 ) 요청제대혈정보센터는국외제대혈검색결과를이식의료기관에 ( 전자 ) 통보이식의료기관은제대혈정보센터에국외제대혈공급 ( 전자 ) 요청 통보받음 4 이식조정기관은국외제대혈은행또는제대혈정보관리기관에검색결과통보 5 외국의제대혈은행또는제대혈정보관리기관은이식조정기관에제대혈공급요청 6 이식조정기관은제대혈정보센터와제대혈은행에각각제대혈공급요청 7 제대혈은행은제대혈정보센터에제대혈제제의외국공급승인요청 8 제대혈정보센터는승인여부를결정하여제대혈은행에통보 9 제대혈은행은이식조정기관과협조하여국외이식의료기관으로국내제대혈공급 10 제대혈제제를외국으로공급한제대혈은행의장은이동내용을제대혈정보센터에신고 18 제 2 장

23 5 가족제대혈의결과보고 1 이식의료기관에서직접제대혈은행에가족제대혈공급요청 2 제대혈은행은이식의료기관에가족제대혈공급 3 제대혈은행은가족제대혈및제대혈제재를공급한경우제대혈정보센터에신고 4 이식의료기관은제대혈이식후에제대혈정보센터에이식통보 6 부적격제대혈및제대혈제제의공급절차 1 제대혈연구기관에서연구및의약품제조등의목적으로부적격제대혈을사용하고자하는경우구비서류를제대혈은행에제출 2 제대혈은행에서는부적격제대혈공급승인요청서를구비서류와함께제대혈정보센터에제출 3 제대혈정보센터는부적격제대혈및제대혈제제공급에대한승인또는불승인통보 4 제대혈은행은제대혈연구기관에부적격제대혈공급 5 제대혈은행은부적격제대혈을연구기관에공급한경우제대혈정보센터에신고 6 제대혈연구기관은연구가중단되거나종료되어제대혈등을폐기한때에는제대혈은행과제대혈정보센터에통보 제대혈검색방법및공급절차 19

24

25 제 3 장 제대혈선택기준

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27 제 3 장제대혈선택기준 제대혈이식의가장큰한계로인식되고있는높은비재발사망률이나치료연관사망률을극복하기위해서는이식에적합한최적의제대혈을선택하는것이최우선적인요건이다. 일반적으로세포수가많고, HLA 일치도가높은제대혈을우선적으로선택한다. 최근에는세포수와 HLA 일치도외에도다양한기준들이성공적인제대혈이식을위해고려되고있으며, 서구의여러이식기관이나등록기관에서나름의체계적인제대혈선택기준을마련하여지침을주고있다. 이러한배경에서, 제대혈선택지침에대한최근의업데이트된연구결과및국내자료를소개하고, 국내현실을고려하여개발한실용적인제대혈선택알고리즘과세부선택지침에대해제언하고자한다. 1 제대혈선택시고려사항 1) 세포수단위당세포수가적다는것은제대혈의근본적인단점이지만제대혈의조혈모세포는클론원성잠재력 (clonogenic potential) 이다른이식원에비해우수해상대적으로적은수로도환자의골수에생착이가능하다. 그러나, 환자의체중이클수록상대적으로체중당세포수는줄어들수밖에없으므로체중이많이나가는청소년이나성인에서는적은세포수로인한생착지연과생착부전이성공적이식을위한큰장애물로작용한다. 따라서, 세포수는제대혈을선택함에있어서가장우선적으로고려하는기준이다. 대개총유핵세포수를기준으로하며최소 /kg 이상이되는제대혈을선택할것이권장되고있다. 골수와가동화된말초혈액의경우처럼제대혈이식에서도 CD34양성세포수를선택기준으로삼는경우도있지만 CD34 양성세포수측정법의표준화문제로제대혈이식에서만큼은아직총유핵세포수의기준이더보편적으로이용되고있다. 그러나, 이론적으로총유핵세포수보다는 CD34양성세포수가기능적인조혈모세포의함량을더잘반영하는것이사실이므로이에대한고려도함께이루어지고있으며, 일반적으로해동전 CD34양성세포수가 /kg 이상이되는제대혈을선택할것이권장된다. 2) HLA 일치도환자와공여제대혈간 HLA 일치도에대한현재의표준은 A, B는항원수준 (antigen level; low or intermediate resolution), DRB1 은유전자수준 (allele level; high resolution) 으로하여총 6자리에서의일치도를기준으로하고있다. 이중최소 4자리이상이일치하는제대혈을사용해야하며, 불일치수가늘어날수록더많은세포수가요구된다. 또한, 비악성질환의경우이식편을거부할수있는힘이상대적으로더강하기때문에성공적인생착을위해서는악성질환에비해더많은세포를이식해주어야한다. 따라서, 환자의질환과 HLA 일치도를함께고려하여제대혈이식에필요한 제대혈선택기준 23

28 최소세포수를제시하는지침이필요하다. 비혈연골수이식에있어서는 HLA-C 의불일치가 A, B, DRB1 등과마찬가지로이식결과에악영향을미침이이미 2004 년에보고되었고, 현재는공여자선택기준에 HLA-C 일치여부도보편적기준으로포함되어있다. 한편, 제대혈이식에서는 HLA-C 일치여부의중요성은최근에야제시된바, 불일치시더높은치료연관사망률과더낮은무사건생존율을보임이보고되었다 (Flomenberg et al., Blood 2004). 그러나, 이보고이후에는 HLA-C 자체의의미를검증한연구가없는데, 이는기존에 6자리를기준으로한표준 HLA 일치도에서단순히 HLA-C 일치여부의의미를추가로보는것에서나아가총 8자리 (HLA-A, B, C, DRB1) 모두유전자수준, 즉고해상도 HLA 분석법에의거한결과로제대혈과환자간의 HLA 일치도를고려하려는시도때문인것으로보인다. Eapen 등 (Blood 2014) 은최근제대혈이식에서 8자리유전자수준의일치도가이식결과에미치는영향에대해보고하였다. 1,568예의한단위제대혈이식을후향적으로분석하였는데, 이중 8/8 일치는 7% 에불과하였고, 7/8 일치 15%, 6/8 일치 26%, 5/8 일치 30%, 4/8 일치 16% 이었으며, 3/8 일치인경우도 5% 에달했다. 1 2 allele 불일치의경우 allele 일치이식과생착속도에차이를보이지않았으나, 3 5 allele 불일치이식에서는각각 allele 일치이식에비해유의하게호중구생착이지연되었다. 3 5 allele 불일치시 1 2 allele 불일치와비교해도유의하게생착지연을보였다. 또한, 모든 allele 일치시비재발사망률이 9% 에불과하였음에비해 1 2 allele 불일치 26%, 3 allele 불일치 34%, 4 allele 불일치 37%, 5 allele 불일치 41% 등으로 allele 불일치도가증가할수록비재발사망률이증가하는경향을보였다. 생존율은모든 allele 일치시 52% 로가장좋았고 1 4 allele 불일치군간에는 41 47% 로비슷하였으며, 5 allele 불일치시 34% 로가장저조하였다. 이결과는 1 2 allele 불일치시 3 4 allele 불일치에비해환자의합병증이적으며, 5 allele 불일치제대혈은사용하지않아야한다는것을보여준다. 이러한배경에서현재유럽그룹에서는가능하면 6/8 allele 일치도이상을보이는제대혈을선택하려는추세이다 (personal communication with Dr. Rocha, November 23, 2013). 그러나, 이식용제대혈공급이비교적제한적인국내의상황을고려할때, allele 수준에서 6/8 이상일치되는제대혈을선택하기위해순차적으로치루어야하는많은비용과시간을생각하면아직이를일반적지침으로제시하기에는현실적인어려움이있어보인다. Barker 등 (Blood 2010) 은 HLA 일치도가낮을수록더많은세포수가요구됨을발표한바있으며 [ 그림 3-1], 세포수와 HLA 일치도를함께고려한제대혈선택기준확립이필요함을역설한바있다. 종합해볼때환자의질환종류, 세포수, HLA 일치도등을모두고려한제대혈선택기준을마련하는것이중요하다고하겠다. 24 제 3 장

29 [ 그림 3-1] 악성혈액질환에서총유핵세포수 (TNC, 10 7 /kg) 와 HLA 일치도의조합이제대혈이식의결과에미치는영향 (Barker et al., Blood 2010). 세포수와 HLA 일치도모두호중구생착에영향을미침. 세포수가많을수록, HLA 일치도가높을수록이식관련사망의누적발생률이낮음을보여줌 (A, B). 세포수와 HLA 일치도의여러조합에따른이식관련사망 (C) 및무질병생존율 (D) 을보여줌. HLA 1 자리또는 2 자리불일치의경우세포수범주에따라분석되었으나, 일치또는 2 자리불일치의경우세포수의평균만제시되었음. Abbreviation: MM, mismatched; TNC, total nucleated cells. 3) HLA 불일치방향불일치제대혈이식시대부분의경우는불일치하는 HLA가환자와기증제대혈에모두존재하며, 이경우 양방향 (bidirectional) 불일치 라고한다 (e.g. 제대혈 HLA-B8, B45 & 환자 HLA-B8, B50). [ 표 3-1] 의예에서보듯이, 제대혈이제대혈선택기준 25

30 어떤 HLA 자리에서동형접합성 (homozygous) 이고환자는그자리에두개의항원이있다면 (e.g. 제대혈 HLA-A2, - & 환자 HLA-A2, A30), 제대혈에는환자의세포가표적으로삼을수있는항원이없고환자에게만제대혈의표적이되는항원이존재하므로이경우불일치방향은 graft-versus-host direction only (GVH-O) 라고한다. 반대로환자가어떤 HLA 자리에서동형접합성이고제대혈은그자리에두개의항원이있다면마찬가지논리로해석하여불일치방향은 host-versus-graft direction only (HVG-O) 또는 rejection direction only (R-O) 라고한다. 마찬가지방법으로두자리불일치시 HLA 불일치방향은총 6가지조합이가능하다. [ 표 3-1] HLA 불일치방향예시 A A B B DRB1 DRB1 Pt CB Pt CB Pt CB Pt CB Pt CB Pt CB 1-MM, BD MM, GVH-O MM, HVG-O (=R-O) MM, both BD MM, GVH-O MM, HVG-O MM, 1 BD & 1 GVH MM, 1 BD & 1 HVG MM, 1 GVH & 1 HVG Abbreviations: GVH-O, graft-versus-host direction only; HVG-O, host-versus-graft direction only; R-O, rejection direction only; BD, bidirectional; MM, mismatched; Pt, patient; CB, cord blood. New York 그룹의보고에서는 GVH-O 불일치시 1-bidirectional 불일치에비해유의하게호중구의생착이빠르고이는완전일치의경우와비슷한수준이었음에반해 R-O 불일치시에는반대로생착률이낮았음을보고한바있다. 또한, GVH-O 불일치그룹에서이식관련사망과치사율, 치료실패율등이모두낮은반면 R-O 불일치그룹에서는재발위험이더높았다. 그러나, 약 3,000명을대상으로한일본그룹과가장최근에보고된유럽그룹의연구에서는동일한결과를보이지않았다. 따라서, 현재로서는제대혈의선택지침으로서기존의세포수와 HLA 불일치정도외에 HLA 불일치방향을추가로포함시켜야한다는주장을지지할만한증거는없다. 4) ABO 불일치 Eurocord-Netcord 이식그룹에서는 ABO 불일치가무사건생존율및생존율에나쁜영향을미치는것으로보고한바있다. 그러나이보고는 171명의환자를대상으로한소규모연구로서이후대규모연구에서확인되지는않았다. 따라서, 현재로서 ABO 불일치여부를제대혈선택의기준으로삼는것은적절하지않다. 5) 비유전된어머니항원 (Non-inherited matermal antigen, NIMA) HLA 항원은부모로부터태아에게각각일배체형 (haplotype) 으로유전된다. 부모로부터유전된항원은각각유전된아버지항원 (inherited paternal antigen, IPA) 과유전된어머니항원 (inherited maternal antigen, IMA) 으로명명된다. 26 제 3 장

31 반면유전되지않은부모의항원을각각비유전된아버지항원 (non-inherited paternal antigen, NIPA) 과비유전된어머니항원 (non-inherited maternal antigen, NIMA) 으로칭한다. 태아는경태반이동 (transplacental trafficking) 을통해어머니의세포에노출되어 NIMA에대한조절 T 세포 (regulatory T cells) 를형성하게된다. 예를들어환자와제대혈의 HLA가 A 항원에서한자리불일치라고가정하자 (e.g. 환자 A1, A2; 제대혈 A1, A3). 이경우만일제대혈의어머니가 A2 항원을가지고있다면, 비록제대혈에는환자가가지고있는 A2 항원이없지만, 제대혈내에는 NIMA에해당하는 A2 항원에대한조절 T 세포가있을것이므로환자의 A2 항원에대해어느정도의관용 (tolerance) 을갖게됨으로써이식후의면역학적갈등이적어질수있다는개념이다. 이러한 NIMA 효과는이미검증되어, HLA 불일치제대혈이식에서 NIMA 일치인경우치료연관사망률이낮고생착이빠르며더높은생존율을보이고있다. 6) 항HLA 항체 (Anti-HLA antibody) 제대혈이식에서항HLA 항체의역할은최근크게주목받고있는이슈이다 년일본그룹이최초로보고하였는데, 이식전시행한검사에서환자가항HLA 항체를가지고있는경우에그렇지않은경우에비해호중구와혈소판의생착이지연되고생존율도낮은경향을보였다. 특히, 항HLA 항체가제대혈의 HLA에특이적이었던경우그차이가더욱현저하였다. 이렇게제대혈 HLA 에특이적인환자의항HLA 항체를공여자특이적항HLA 항체 (donor-specific anti-hla antibody, DSA) 라고하는데, DSA 가미치는악영향은두단위제대혈이식에서도증명이되었다. Culter 등 (Blood Rev 2012) 의보고에의하면, DSA 가없을때, 1개의제대혈에대해서만있을때, 2개의제대혈에대해모두있을때등의생착실패율이각각 5.5%, 18.2%, 57.1% 등으로큰차이를보였다. 2개의제대혈에대해서모두 DSA 가있을경우는사망하거나재발할가능성도 71.4% 여서 1개에대해 DSA 를가지는경우의 36.4% 와 DSA 가없을때의 23.6% 에비해현저하게높았다. 최근까지도 DSA 의존재가생착및생존율에악영향을끼치는것이일관적으로보고되어, DSA 를가지는제대혈은선택에서배제해야한다. 먼저 HLA class I과 class II에대한항체의존재유무를보기위해선별검사를실시한후이에대해양성인경우특정 HLA 항체를규명하기위해추가검사를시행하며, 항HLA 항체검사방법및비용을간단히요약하면다음과같다. 항 HLA 항체검사방법및비용 1. HLA class I과 class II에대한 panel reactive antibody screening 시행 - Luminex 법 (bead-based immunoassay) - 보험수가약 14만원 2. Screening 결과가양성인경우에한해확진을위한 HLA Ab single identification 시행 - Luminex 법 (bead-based immunoassay) - HLA class I과 class II panel 검사에각각 30만원내외 ( 비급여 ) 7) 두단위선택시고려사항한단위로는이식에필요한최소세포수를만족시킬수없는경우두단위이식을고려해볼수있다. 이경우두단위의세포수합이총유핵세포수 > /kg 이거나 CD34양성세포수 > /kg가되도록선택하면되겠다. HLA의경우각단위별로한단위이식에서의기준을동일하게만족하되, 가능한두단위간에도 2자리이상의불일치는허용하지않는것이일반적지침이다. 제대혈선택기준 27

32 2 국내제대혈선택의현실 국내에서제대혈이식이과거에비해위축되어있는현실은높은생착실패율, 기대보다높은이식편대숙주병빈도와중증도, 그리고골수나가동화말초혈액을이용한이식보다대체적으로낮은생존율등에기인한다. 그밖에도생착지연이나생착부전등이발생하게되면무균실의장기입실이필요한데, 이는비용의증가를초래할뿐아니라다음으로이어지는이식스케줄에도영향을줄수있다. Yoo 등 (Am J Hematol 2011) 이국내소아환자를대상으로한 236 예의제대혈이식결과를 2011년보고한바에의하면, 호중구의회복률은 90.7%, 급성및만성이식편대숙주병빈도가각각 41.1% 와 36.1%, 5년생존율이 47.5% 이었다. 한단위이식에서 HLA 불일치도를보면 1자리불일치가 73.5% 로가장많았으나, 이는 6자리모두항원수준을기준으로한것으로, 전술한현재의세계적표준 (A, B는항원수준, DRB1 은유전자수준 ) 과는차이가있다. 즉, 현재의표준기준을적용할경우불일치도가더높아질것임을의미한다. 서구의보고들에비해상대적으로이식편대숙주병의빈도가높은것도실제적인 HLA 불일치도가높을것임을추정하면설명이가능하다. 따라서, 제대혈선택기준을강화하여더좋은제대혈을선택하도록하는정책으로제대혈이식의성적을어느정도향상시킬수있을것이다. 최근에는국내에서도많은기관에서 HLA 일치도를세계적표준기준에따르고있다. HLA 8개자리모두유전자수준을고려하여선택기준으로삼기에는아직국내기증제대혈의공급이제한적이고비용과시간의측면을고려할때현실적인제약이있다. 한편, NIMA와항HLA 항체의경우도국내의현실적제약때문에아직제대혈선택을위한실질적기준에고려되지못하고있다. NIMA에대한정보를확보하기위해서는제대혈은행에기증제대혈의산모혈액이보관되어있어야하며이에대한검사를위한비용이확보되어야하는문제가있다. 항HLA 항체검사는제대혈이식이가능한모든기관의검사실에서시행가능하게되도록적극독려할필요성이있다. 3 제대혈선택알고리즘및지침개발 최적의제대혈을선택하는것은제대혈이식의성패를좌우하는가장중요한요건이다. 국내현실에맞는제대혈선택알고리즘및지침을개발하고자하는목적으로문헌고찰과함께국내 3개의이식기관 ( 삼성서울병원, 서울대학교어린이병원, 전남의대화순병원 ) 에서 2002년부터 2011년까지시행된 189예의소아제대혈이식에대해분석하였고 ( 서울특별시제대혈은행학술연구용역사업지원, ) 그내용을학술지에보고하였다. 제대혈의냉동전과해동후의세포수를비교하였을때총유핵세포수와 CD34양성세포수는각각평균 80.4% 와 66.7% 의회복률을보였다 [ 표 3-2]. [ 표 3-2] 제대혈냉동전ㆍ후의세포수비교 ( 국내 3개이식기관자료 ) At freezing Post-thaw P Yield TNC±SE ( 10 7 /kg) 5.40± ±3.13 < % CD34+ cell count±se ( 10 5 /kg) 2.73± ±1.63 < % 따라서, 이식기관에서는제대혈의해동후세포수의소실을감안하여실제주입될세포수를추정해야한다. 실제주입된세포수에따른생착속도를비교해보았을때총유핵세포수는상관관계를보이지않았으며 CD34양성세포수가 28 제 3 장

33 /kg 이상일때그이하였던군에비해유의하게빠른생착을보였다 (P=0.0044). 반면, CD34양성세포수가 /kg 이상이어도 /kg이었던경우와통계적차이는없었다. 이는실제해동후주입된 CD34양성세포수 /kg가빠른생착을위한최소요구량의기준으로사용될수있음을시사한다. 이기준은해동전 CD34 양성세포수의일반적인최소권장치인 /kg에서해동후 33.3% 의소실을감안하여계산된수치와정확히일치한다. 한단위제대혈이식 85예중 40예만이 HLA 일치도표준기준 (A, B는항원수준, DRB1은유전자수준 ) 으로분석이가능했는데, 모두항원수준에서평가하였을때는 HLA 일치도에따른생존율의차이가없었으나표준기준으로적용하였을때극명한차이를보여주었다. 또한, 1 2 자리불일치이식중에서 HLA-C 정보가확인가능했던 24예중에는 HLA-C 가일치하였던경우 (n=5) 와불일치하였던경우 (n=19) 의생존율이각각 100% 와 46.8% 로유의한차이를보였다 (P=0.025). 전체 5년생존율은 56.8%, 무사건생존율은 48.6% 이었고, 두단위이식 (n=104) 이한단위이식에비해생존율이다소높은경향 (60.7% vs. 52.6%) 이있었으나통계적으로유의하지는않았다 (P=0.293). 본분석은비교적대상환자수가적은점, HLA-DRB1 에대한고해상도검사가대상환자군중에제한적으로이루어져있다는것, 그리고 NIMA 및항HLA 항체에대한자료가전무한점등의한계를가지고있다. 따라서, 현재로서는국내의자료에만근거를둔제대혈선택지침을마련하는것은불가능해보인다. 이에검증된해외자료들을참고하여국내현실을반영한간단하고실용적인제대혈선택알고리즘과세부지침을제안하였다 [ 그림 3-2]. 주목할것은세포수의기준을총유핵세포수뿐아니라 CD34양성세포수를함께고려하기로정한것인데, 이는앞서소개한국내자료분석결과를반영한것이다. 본지침에서 NIMA가배제되어있는이유는현실적으로선택기준으로삼기가불가능하기때문이다. 그러나기증제대혈은행에서기증받은제대혈의어머니혈액을적극적으로유치하고이에대한 HLA 검사를시행할수있도록안정적인재원이마련된다면향후국내에서도 NIMA 일치여부가제대혈선택지침에포함될수있을것이다. 1. Perform confirm test with high resolution typing at 10 loci (-A, -B, -C, -DRB1, -DQB1) for future retrospective analysis. 2. The number of HLA mismatch should be based on at antigen-level for -A, -B, and allele-level for -DRB1. DRB1 matching is always preferred over -A or -B matching among units having the same number of mismatch and similar cell dose, and those mismatched at 3 or more loci should not be used. 3. Cell dose reference should be either TNC or CD34+ cell count, and the minimum required doses are different according to the number of HLA mismatch and patients underlying diseases (see algorithm). 4. If the cell dose & HLA matching degree at -A, -B, and -DRB1 are similar, HLA-C matched unit is preferred. 5. Double unit transplant is considered if a best available unit does not meet the cell dose requirements. 6. In double unit transplants, each unit should be at least 4/6 matched to the recipient. 7. Check anti-hla antibodies if available before transplant, and avoid units where preformed host donor-specific antibodies exist. [ 그림 3-2] 제안된국내제대혈선택알고리즘및가이드라인 제대혈선택기준 29

34 EBMT 가이드라인 1. At selection, the diagnosis and presence of patient HLA antibodies against the HLA antigens (Takenashi et al., 2009) of the CB unit should be taken into consideration, HLA compatibility is more important for patients with non-malignant disorders than for those with malignant disorders (Rocha & Locatelli 2008). 2. If the below criteria for a single UCBT is not achieved, a double cord blood transplantation should be discussed in prospective trials. HLA definition: based on HLA antigenic for -A and -B and allelic typing for HLA-DRB1, Avoid cord blood units with 3 or 4 HLA disparities. Recommendations for HLA and cell dose (in spite of absence of strong evidence on cell dose cut off and number of HLA disparities) 1) CB unit with 6/6 or 5/6 HLA match HLA-A or HLA-B mismatches are preferable to DRB1 mismatches. HLA-DRB1 mismatch could probably lead to high graft-versus-leukemia (GVL) effect in patients transplanted in non remission (Based on Eurocord unpublished and preliminary data). Malignant disorders: Nucleated cell dose: at freezing, minimum cell dose 2.5 to /kg after thawing, minimum 2.0 to /kg* *If the nucleated cell dose infused is less than /kg, an immediate second transplant should be considered because the early mortality associated to this cell around 70%. *If the nucleated cell dose infused is between 1.0 to /kg, we recommend that the number of CD34 + cells and CFU-GM should be taken into consideration in order to predict the probability of neutrophil recovery and to consider a second transplant. If both cell doses are lower than recommended, a bone marrow aspirate and chimerism analysis should be performed between day +20 and day +28 to confirm the absence of engraftment and to indicate a second transplant. CD34 + cell dose: at freezing or after thawing, approximately 1.2 to /kg Colony forming units assay: when available, the cord blood bank should inform the value and technique of CFU-GM counting. Nonmalignant disorders: same total and CD34 + cell dose requested, but HLA match should always be selected and avoid DRB1 mismatching. 2) CB unit with 4/6 HLA match (this recommendation is not proved by retrospective studies, but based on transplant algorithm for CB unit selection and unpublished Eurocord data) HLA-A or HLA-B mismatches are better than HLA-DRB1 mismatches. HLA-DRB1 mismatch could probably lead to high GVL effect in advanced phase of the disease (Based on Eruocord unpublished and preliminary data) Malignant disorders Nucleated cell dose: at freezing, minimum cell dose /kg after thawing, minimum /kg CD34 + cell dose: at freezing or after thawing, approximately > /kg Colony forming units assay: when available, the cord blood bank should provide the CFU-GM count and the method used to determine this. Nonmalignant disorders (based on unpublished Eurocord study) Nucleated cell dose: at freezing, minimum cell dose 4 to /kg after thawing, minimum /kg CD34 + cell dose: no available data, but should be higher than 2 to /kg Colony forming units assay: when available, the cord blood bank should provide the CFU-GM count and the method used to determine this. 3) CB units with 3/6 HLA match should be avoided, but in extremely severe cases for patients with malignant disorders should be considered with high nucleated cell dose. Not recommended for patients with non malignant disorders. Other considerations: If a number of cord blood units are available that fit the above criteria, the following probably need to be taken into consideration: 1) Accredited Cord blood bank and location 2) ABO compatibility 3) Allele HLA typing of HLA-A and -B 30 제 3 장 (Rocha et al., BJH 2009)

35 Memorial Sloan-Kettering Cancer Center 가이드라인 Criteria Comments TNC dose/kg HLA match: HLA-A,-B antigens, -DRB1 alleles TNC dose and HLA match for double unit grafts Exact threshold for acceptable dose unknown but clearly varies according to HLA match (the greater the mismatch, the higher the required TNC)* Do not use units < /kg with 1 or 2 mismatch as single-unit grafts* A maximum of 2 mismatches is acceptable because of the very hight TRM associated with greater mismatch* As either unit could engraft, use same unit principles for selection of each units of the graft* Our policy is to give preference to HLA match above a TNC threshold of ~ /kg (We do not consider HLA match of units to each other) Bank of origin Quality may vary from unit to unit and bank to bank* FACT and/or AABB accredited banks are preferred Be aware that turnaround time, speed of responses, reliability of units information, and fees for unit testing can vary Confirmatory HLA typing form Only way to confirm units identity, unless rapid HLA typing is performed after thaw* an attached segment IDMs Ensure completeness of testing to expedite units acquisition, and avoid shipment before results are available Hemoglobinopathy screen Ensure screening is completed before units shipment FACT indicates Foundation for the Accreditation of Cellular Therapy; and AABB, American of Blood Banks. *Recommendation based on peer-reviewed literature. Recommendation is MSKCC institutional policy based on MSKCC experience, and MSKCC/New York Blood Center unpublished data. (Barker et al., Blood 2011) 제대혈선택기준 31

36 4 결론 제대혈은 HLA 일치혈연공여자가없는환자에게골수나가동화된말초혈액과마찬가지로유용한비혈연이식의공급원으로사용할수있다. 다만, 제대혈이가지고있는근본적단점을극복하기위해각환자의상황에따른최적의제대혈을선택하는것이매우중요하다. 본지침의적극적활용으로최적의제대혈선택에도움이되고, 나아가국내제대혈이식의활성화와치료성적의향상으로이어지길기대한다. 제대혈선택시고려사항 1. 세포수 ( 해동전 ) 1) 6/6 or 5/6 HLA 일치제대혈, 악성질환 : 총유핵세포수 > /kg and/or CD34양성세포수 > /kg 2) 6/6 or 5/6 HLA 일치제대혈, 비악성질환 : 총유핵세포수 > /kg and/or CD34 양성세포수 > /kg 3) 4/6 HLA 일치제대혈, 악성질환 : 총유핵세포수 > /kg and/or CD34양성세포수 > /kg 4) 4/6 HLA 일치제대혈, 비악성질환 : 총유핵세포수 > /kg and/or CD34양성세포수 > /kg 2. HLA 일치도 1) 현재세계적인표준 : -A와 -B는항원수준, -DRB1은유전자수준에서일치도를평가. 6자리중 4자리이상이일치할때이식가능 2) 최근추세 : -A, -B, -C, -DRB1 등 8자리모두유전자수준에서일치도를평가. 6자리이상이일치하는제대혈을선택하도록권유 3. 항HLA 항체 : 환자에게존재하는항HLA 항체에특이적인 HLA 항원을가지는제대혈은선택에서배제 4. 두단위이식시고려사항 : 1) 두단위의합이위의세포수기준에부합 2) 환자와각단위의 HLA 일치도가한단위의기준을각각만족 3) 제대혈두단위간에 2자리이하의불일치만허용 [ 참고문헌 ] 1. Arcese W, Rocha V, Lab opin M, et al. Unrelated cord blood transplants in adults with hematologic malignancies. Haematologica 2006;91: Barker JN, Scaradavou A, Stevens CE. Combined effect of total nucleated cell dose and HLA match on transplantation outcome in 1061 cord blood recipients with hematologic malignancies. Blood 2010;115: Barker JN, Byam C, Scaradavou A. How I treat: the selection and acquisition of unrelated cord blood grafts. Blood 2011;117: Boo M, Ballen K, Maiers M. Cord blood unit access and selection: 2010 and beyond: best practices and emerging trends in cord blood unit selection. Biol Blood Marrow Transplant 2011;17(1 Suppl):S46-S 제 3 장

37 5. Cunha R, Loiseau P, Ruggeri A, et al. Impact of HLA mismatch direction on outcomes after umbilical cord blood transplantation for hematological malignant disorders: a retrospective Eurocord-EBMT analysis. Bone Marrow Transplant 2014;49: Cutler C, Kim HT, Sun L, et al. Donor-specific anti-hla antibodies predict outcome in double umbilical cord blood transplantation. Blood 2011;118: Cutler C, Ballen KK. Improving outcomes in umbilical cord blood transplantation: state of the art. Blood Rev 2012;26: Dutta P, Burlingham WJ. Microchimerism: tolerance vs. sensitization. Curr Opin Organ Transplant 2011;16: Eapen M, Klein JP, Sanz GF, et al. Effect of donor-recipient HLA matching at HLA A, B, C, and DRB1 on outcomes after umbilical-cord blood transplantation for leukaemia and myelodysplastic syndrome: a retrospective analysis. Lancet Oncol 2011;12: Eapen M, Klein JP, Ruggeri A, et al. Impact of allele-level HLA matching on outcomes after myeloablative single unit umbilical cord blood transplantation for hematologic malignancy. Blood 2014;123: Flomenberg N, Baxter-Lowe LA, Confer D, et al. Impact of HLA class I and class II high-resolution matching on outcomes of unrelated donor bone marrow transplantation: HLA-C mismatching is associated with a strong adverse effect on transplantation outcome. Blood 2004;104: Kanda J, Atsuta Y, Wake A, et al. Impact of the direction of HLA mismatch on transplantation outcomes in single unrelated cord blood transplantation. Biol Blood Marrow Transplant 2013;19: Rocha V, Gluckman E. Improving outcomes of cord blood transplantation: HLA matching, cell dose and other graft- and transplantation-related factors. Br J Haematol 2009;147: Rocha V, Spellman S, Zhang MJ, et al. Effect of HLA-matching recipients to donor noninherited maternal antigens on outcomes after mismatched umbilical cord blood transplantation for hematologic malignancy. Biol Blood Marrow Transplant 2012;18: Ruggeri A, Rocha V, Masson E, et al. Impact of donor-specific anti-hla antibodies on graft failure and survival after reduced intensity conditioning-unrelated cord blood transplantation: a Eurocord, SociétéFrancophone d'histocompatibilité et d'immunogénétique (SFHI) and Société Française de Greffe de Moelle et de Thérapie Cellulaire (SFGM-TC) analysis. Haematologica 2013;98: Shaw BE, Veys P, Pagliuca A, et al. Recommendations for a standard UK approach to incorporating umbilical cord blood into clinical transplantation practice: conditioning protocols and donor selection algorithms. Bone Marrow Transplant 2009;44: Stevens CE, Carrier C, Carpenter C, et al. HLA mismatch direction in cord blood transplantation: impact on outcome and implications for cord blood unit selection. Blood 2011;118: Takanashi M, Atsuta Y, Fujiwara K, et al. The impact of anti-hla antibodies on unrelated cord blood transplantations. Blood 2010;116: van Rood JJ, Stevens CE, Smits J, et al. Reexposure of cord blood to noninherited maternal HLA antigens improves transplant outcome in hematological malignancies. Proc Natl Acad Sci U S A 2009;106: Yoo KH, Lee SH, Sung KW, et al. Current status of pediatric umbilical cord blood transplantation in Korea: a multicenter retrospective analysis of 236 cases. Am J Hematol 2011;86: Yoo KH. Optimal Selection of Cord Blood for Hematopoietic Stem Cell Transplantation. Korean J Med 2014;86: 제대혈선택기준 33

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39 제 4 장 이식전처치방법

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41 제 4 장이식전처치방법 I. 성인 성인제대혈이식의안전성과유효성은 2004년, 미네소타대학과뉴욕혈액센터를중심으로한 Center for International Blood & Marrow Transplant Research (CIBMTR) 과유럽연합을중심으로한 Eurocord, NetCord Registry 및일본동경대학의과학연구소등의보고로인정되고발전되어왔다. 성인제대혈이식의결과를향상시키기위한대표적인시도로는제한된세포수의문제를극복하기위한두단위제대혈이식 (double units cord blood transplantation, ducbt) 과고령및동반질환 (comorbidity) 에따른비재발사망률 (non-relapse mortality, NRM) 을줄이기위한저강도전처치 (reduced intensity conditioning, RIC) 등이있다. 그러나생착실패율을고려한다면전신방사선요법 (total body irradiation, TBI) 를포함하는골수제거전처치가선호되지만, 성인제대혈이식에서표준전처치요법은아직정립되어있지않다. 따라서각이식센터의경험과장비, 이식기간, 환자의병기, 병의종류, 연령및동반질환등에의해결정할수있을것이다. 1 골수제거전처치 (Myeloablative Conditioning, MAC) 표준골수제거전처치는 TBI (>6 Gy) 이나 busulfan (>8 mg/kg PO, >6.4 mg/kg IV) 과 cyclophosphamide의병합요법이다. 성인제대혈이식의골수제거전처치는크게 TBI-based 와 busulfan-based 로나눌수있다. 1) TBI-based regimen TBI-based regimen 중대표적인것으로는동경대학의과학연구소의 TBI/Cy/Ara-C 와 Minnesota 그룹의 TBI/Cy/Flu (Brunstein et al., Blood 2010) 등이있으며, 모두 TBI 1,200 1,320 cgy를사용하여우수한결과를보고하였다. TBI는면역억제및항종양효과가강력하기때문에, 성인제대혈이식에서생착실패가상대적으로높다는점과재발후공여자림프구주입술 (donor lymphocyte infusion, DLI) 을할수없다는점을고려하면, TBI-based regimen은여전히성인제대혈이식의전처치요법으로선호되고있다. 2) Busulfan (Bu)-based regimen Bu-based regimen은 cyclophosphamide 를 fludarabine로대치한 Bu/Flu를사용하여독성은줄이고치료성적은 이식전처치방법 37

42 향상시킬수있었다. Valencia 그룹 (Sanz et al., Bone Marrow Transplant 2010) 에서는 Bu/Flu 에 thiotepa (TBF) 를추가하여면역억제력및강도의향상을포함한우수한결과를보고하였으며 [ 표 4-1], 현재가장대표적인전처치요법이되었다. [ 표 4-1] 골수제거전처치를이용한성인제대혈이식연구결과들 Authors Preparation Regimen Median age Infused TNC ( 10 7 /kg) Infused CD34 ( 10 5 /kg) Median days to ANC>500 Graft failure (%) agvhd (%) cgvhd (%) Relapse rate (%) TRM (%) DFS (%) Takahashi et al. (2007) TBI/Cy/Ara C at 1 yr 70 at 3 yrs Brunstein et al. (2010) TBI/Cy/Flu /1.6 NA 26 NA at 5 yrs Ponce et al. (2011) Sanz et al. (2012) TBI (57%) Thio/Bu/Flu NA NA at 5 yrs Abbreviations: ANC, absolute neutrophil count; GVHD, graft versus host disease; TRM, transplantation-related mortality; DFS, disease free survival. Sanz 등 (Biol Blood Marrow Transplant 2013) 이골수제거전처치를이용한제대혈이식에서 TBI-based (Minnesota platform) 과 Bu-ATG-based (Valencia platform) 을비교하였다. 재발, 무병생존율및비재발사망률은양군에서비슷하였고, 생착및급성이식편대숙주병에서 Bu-ATG 군이유리했으나 3등급이상의급성이식편대숙주병과만성이식편대숙주병에는차이가없었다. 급성골수성백혈병과급성림프모구백혈병에서도무병생존율은차이가없었으나급성림프모구백혈병에서두단위제대혈이식, TBI-based 전처치에서재발률이유의하게낮았다. 또한양그룹에서 sucbt (single unit umbilical cord blood transplantation) 와 ducbt (double unit umbilical cord blood transplantation) 모두비슷한결과를보였다. 또한, 최근 Eurocord/EBMT 그룹은후향적으로일차완전관해된급성백혈병환자 (n=239) 에서전처치종류와이식원에따라 3개의그룹으로나누어이식결과를비교하였다 (Ruggeri et al., Leukemia 2014). Group 1: TBI- or Bu-based ± Flu for sucbt (n=68) Group 2: Thiotepa/Bu/Flu for sucbt (n=88) Group 3: TBI12 Gy/Cy ± Flu for ducbt (n=83) 그결과는호중구회복및비재발사망률과재발률은세그룹에서비슷하였으나 2등급이상의급성이식편대숙주병은두단위제대혈이식에서더높았다. 무병생존율은 Group 1과 Group 2 & 3 비교시 1) 30%, 2) 48%, 3) 48% ( 각각 P=0.02, P=0.03) 였으나, Group 2와 Group 3의비교시유의하지않았다. 이들은한단위제대혈이식이라도세포수 (TNC > /kg) 만충분하다면전처치로 Bu/Flu/Thiotepa 는효과적인골수제거전처치요법이라고결론지었다 [ 표 4-2]. 또한, GETH/GITMO 보고에의하면이요법은필라델피아염색체양성급성림프모구백혈병에서도 5년재발률, 무사건생존율및전체생존율이각각 31%, 36%, 44% 로보고되어, 급성림프모구백혈병에서도 TBI-based 요법을대신하여사용될수있는가능성을시사하였다. 38 제 4 장

43 [ 표 4-2] 골수제거전처치를이용한한단위또는두단위이식결과의비교 (Eurocord/EBMT 후향적연구결과 ) (n=239) HR 95% Cl P-value Leukemia free survival Conditioning regimen and graft source Group 1 vs. group Group 2 vs. group Group 1 vs. group Relapse Conditioning regimen and graft source Group 1 vs. group Group 2 vs. group Group 1 vs. group Neutrophil Engraftment TNC > /kg Acute GVHD Graft type, sucbt Grouping TBI or Bu based±fludarabine (Flu) (n=68, Group 1) for sucbt, Thiotepa/Bu/Flu (TBF) (n=88, Group 2) for sucbt, TBI12 Gy/Cy±Flu (n=83, Group 3) for ducbt. 여러가지골수제거전처치요법들 Minnesota Fludarabine 25 mg/m 2 /day IV 3 days, total dose 75 mg/m 2 (days -8 to -6) Cyclophosphamide 60 mg/kg/day IV 2 days, total dose 120 mg/m 2 (days -7 and -6) after fludarabine TBI 165 cgy twice daily 4 days (days -4 to -1), total dose 1,320 cgy (days -4 and -1) Day Preparative therapy Supportive care -8 Fludarabine 25 mg/m 2 IV over 1 hour -7 Fludarabine 25 mg/m 2 IV over 1 hour Cyclophosphamide 60 mg/kg IV -6 Fludarabine 25 mg/m 2 IV over 1 hour Cyclophosphamide 60 mg/kg IV -5 Rest -4 TBI 165 cgy twice daily -3 TBI 165 cgy twice daily Begin CSA, MMF -2 TBI 165 cgy twice daily -1 TBI 165 cgy twice daily 0 UCBT +1 Begin G-CSF 이식전처치방법 39

44 Institute of Medical Science the University of Tokyo TBI 200 cgy twice daily 3 days, total dose 1,200 cgy (Day -7 to -5) Ara-C 3 g/m 2 IV q 12 hrs 2 days, total dose 12 g/m 2 (Day -5 to -4) Cyclophosphamide 60 mg/kg IV 2 days, total dose 120 mg/kg (Day -3, -2) Day Preparative therapy Supportive care -7 TBI 200 cgy twice daily -6 TBI 200 cgy twice daily -5 TBI 200 cgy twice daily *IV G-CSF (5μg/ kg ), MP 62.5 mg IV q 12 hrs Ara-C 3 g/m 2 IV q 12 hrs -4 Ara-C 3 g/m 2 IV q 12 hrs IV G-CSF (5μg/ kg ), MP 62.5 mg IV q 12 hrs -3 Cyclophosphamide 60 mg/kg IV G-CSF (5μg/ kg ), MP 62.5 mg IV q 12 hrs -2 Cyclophosphamide 60 mg/kg -1 CSA 0 UCBT Begin G-CSF (5μg/ kg ) +1 **MTX 15 mg/m 2 (D1), 10 mg/m 2 (D3,6) *G-CSF 5 g/kg/ Day before 12 hrs of Ara-C until the completion for priming for myeloid but no priming for lymphoid **IV MTX 15 mg/m 2, Day1, 10 mg/m 2, Day 3 & Day 6 (short MTX) MP, methylprednisolone Le Fe, Valancia regimen by Dr. Sanz Thiotepa 5 mg/kg/day IV 2 days, total dose 10 mg/kg (days -7, -6) Busulfan 3.2 mg/kg/day IV, total dose 9.6 mg/kg 3 days (days -5, -4, -3) Fludarabine 50 mg/m 2 /day IV 3 days, total dose 150 mg/m 2 (days -5, -4, -3) ±Antithymocyte Globulin 2 mg/kg/day 4 days, total dose 8 mg/kg (days -7, -5, -3, -1) Day Preparative therapy Supportive care -7 Thiotepa 5 mg/kg/day *±Antithymocyte Globulin 2 mg/kg/day -6 Thiotepa 5 mg/kg/day -5 Busulfan 3.2 mg/kg/day Fludarabine 50 mg/m 2 /day ±Antithymocyte Globulin 2mg/kg/day -4 Busulfan 3.2 mg/kg/day Fludarabine 50 mg/m 2 /day -3 Busulfan 3.2 mg/kg/day Fludarabine 50 mg/m 2 /day ±Antithymocyte Globulin 2 mg/kg/day Begin CSA, MMF** -2-1 ±Antithymocyte Globulin 2mg/kg/day 0 UCBT +1 Begin G-CSF *Original Valencia regimen: ATG 8mg/kg **non ATG regimen should reinforce GVHD prophylaxis CSA: post 100 days, tapering 10%/wk until 180 days without GVHD, MMF: 1 gm b.i.d. if > 50 mg or 15 mg/kg if < 50 mg begining Day-3 unitil 50 days, tapering 10% until 100 days without GVHD ( 국내에선 PO MMF 로 dose calculation) 40 제 4 장

45 2 저강도전처치 (Reduced Intensity Conditioning, RIC) 2007년 Brunstein 이저강도전처치를성인제대혈이식에사용한후, 고령의환자와동반질환이있는환자에서저강도전처치의사용이증가하고있다. 그러나, 현재까지표준저강도전처치는확립되어있지않다. 그동안다양한센터에서다양한요법이보고되어왔으며, 지금까지가장대규모의연구는 Minnesota 그룹의연구이다. 전통적으로저용량 TBI-based 요법이고 ATG 를포함하고있으나최근에는 non-tbi-based 와 non-atg-based regimen 의연구가진행중이다 [ 표 4-3]. [ 표 4-3] 저강도전처치를이용한성인제대혈이식연구결과들 Author Preparative Regimen Infused TNC ( 10 7 /kg) (range) Infused CD34 cell dose ( 10 5 )/kg (range) Median time to ANC> 500/ L (days) Graft failure (%) agvhd II-IV (%) cgvhd (%) Relapse rate (%) TRM (%) Survival (%) Barker et al.*(2003) BuFluTBI 2.6 ( ) 3.7 ( ) NR 48 at 100ds 39 at 1 yr CyFluTBI 3.2 ( ) 4.3 (1.1-10) NR 28 at 100ds Brunstein et al. (2005) CyFluTBI 3.6 ( ) 4.5 ( ) at 180ds 44 at 2 yrs Morii et al. (2005) CyFluTBI 2.6 ( ) NR NR 19 37% at 1 yr BuFluTBI Missavva et al. (2006) CyFluTBI 2.55 ( ) 0.91 ( ) NR 41.7 NR Rocha et al. (2006) Multiple 2.4 NR NR NR 46 NR Miyakoshi et al. (2004) FluMelTBI 3.1 ( ) 0.7 ( ) at 1 yr Ballen et al. (2007) FluMelATG 4.0 ( ) 1.9 ( ) at 180ds 71 at 2 yrs Ostrtonoff et al. (2013) Yamamoto et al. (2013) FluCyTBI NR at 1 yr FluMelBu at 100ds 62 at 2 yrs Adapted from Brunstein CG & Wagner JE. Vox Sanguinis 2006, 91: *The 22 patients who receive Cy/Flu/TBI in the series by Barker et al. are included in the series by Brunstein et al. +Study included patients receiving multiple unit UCB grafts. The incidence of grade II-IV acute GVHD for patient who received tracrolimus/sirolimus posttransplantation immunosuppression was 29%. Cyclophosphamide (Cy)/fludarabine (Flu)/total body irradiation 2 Gy (TBI) was given to 33 patients, Flu/Cy or Melphalan (Mel) in 11. Flu+Bu (<8 mg/kg) associated or not to other drugs in 13. Flu/TBI (2 Gy) in 3 and other. MAC 1) Non-ATG-based regimen 전처치에서이식결과에영향을주는주요한인자는 ATG 의포함여부이다. Minnesota 그룹은이전부터저강도전처치에서 ATG 를사용하였는데, ATG 는생착실패율은줄일수있어도 180일째비재발사망률 (38% vs. 12% in non-atg group, P=0.02) 을증가시켰다. 이에, 최근 BMT-CTN 064, 1101 study, Fred Hutchinson 그룹에서는 ATG 를저강도전처치에서사용하지않고있다. ATG 를사용하지않고있는이유로는 1) T-cell 회복이늦음, 2) 바이러스감염의증가, 3) 항백혈병효과 (Graft versus Leukemia, GVL) 소실, 4) 주입반응등이있다. Non-ATG-based 저강도전처치요법연구에서는주로저용량 TBI가사용되었고, Minnesota 그룹 200 cgy (ducbt), FHCRC (Fred Hutchinson Cancer Research Center) 그룹 cgy (ducbt), Toranomon 병원 400 cgy (sucbt) 등에서연구되었다. FHCRC 의보고에따르면 non-atg-based 저강도전처치요법은 ATG-based 전처치와비교시급 / 만성이식편대숙주병, 비재발사망률및생존율은비슷하고, 일차생착실패는없었다. 이들은 ATG 를사용하지않음으로인한생착실패와급성이식편대숙주병을줄이기위해이식후면역억제를강화하였다. 즉, mycophenolate mofetil 이식전처치방법 41

46 15 mg/kg 하루두번에서세번으로증량하였고, 사용기간을연장하기도하였으며, fludarabine 용량을 150 mg (Minnesota platform) 에서 200 mg (BMT-CTN 0604) 으로증량하기도하였다 (Yamamoto et al., Blood 2013, Abstract). Ruggeri 등 (Leukemia 2014) 은특히 ATG 를사용하지않은두단위제대혈이식군에서급성이식편대숙주병의증가를우려하였으나, 주로 2등급이하의피부병변이어서사망률의증가는없었다고보고하였다. Valencia 그룹은노인에서 ATG 를 8 mg/kg에서 2.5 mg/kg로감량하여사용하고있다 (personal communication with Sanz). 따라서, 저강도전처치에 ATG 를사용하지않거나, 용량을줄이면서면역억제를적절히강화한다면, 생착실패나이식편대숙주병, 면역회복에영향을주지않으면서비재발사망률을줄일수있어서현재선호되는추세이다. 그러나, 이경우항백혈병효과에대한연구는아직보고된바가없다. 2) Non-TBI-based regimen 대표적으로 Dana-Farber / Harvard Cancer Center 의 Flu/Mel-ATG 와 Toranomon Hospital의 FluMelBu 등이있다 (Ballen et al., Biol Blood Marrow Transplant 2007; Yamamoto et al., Blood 2013, Abstract). 여러가지저강도전처치요법들 RIC at Minnesota (BMT-CTN 0604) Fludarabine 40 mg/m 2 IV, total dose 200 mg/m 2 (days -6, -5, -4, -3, -2) Cyclophosphamide 50 mg/kg IV, total dose 50 mg/kg (days -6) TBI 200 cgy total dose 200 cgy (days -1) Day Preparative therapy Supportive care -6 Fludarabine 40 mg/m 2 IV over 1 hour Cyclophosphamide 50 mg/kg IV over 2 hours -5 Fludarabine 40 mg/m 2 IV over 1 hour -4 Fludarabine 40 mg/m 2 IV over 1 hour -3 Fludarabine 40 mg/m 2 IV over 1 hour Begin CSA, MMF -2 Fludarabine 40 mg/m 2 IV over 1 hour -1 TBI 200 cgy 0 UCBT +1 Begin G-CSF 42 제 4 장

47 RIC at Dana Farber Cancer Institute Fludarabine 30 mg/m 2 /day IV 6 days, total dose 180 mg/m 2 (days -8 to -3) Melphalan 100 mg/m 2 /day IV 1 day, total dose 100 mg/m 2 (days -2) Antithymocyte Globulin 1 mg/kg/day 4 days, total dose 4 mg/kg (days -7, -5, -3, -1) Day Preparative therapy Supportive care -8 Fludarabine 30 mg/m 2 /day IV 6 days -7 Fludarabine 30 mg/m 2 /day IV 6 days Antithymocyte Globulin 1 mg/kg/day -6 Fludarabine 30 mg/m 2 /day IV 6 days Fludarabine 30 mg/m 2 /day IV 6 days -5 Antithymocyte Globulin 1 mg/kg/day 4 Fludarabine 30 mg/m 2 /day IV 6 days -3 Fludarabine 30 mg/m 2 /day IV 6 days Antithymocyte Globulin 1 mg/kg/day Begin tacrolimus, sirolimus -2 Melphalan 100 mg/m 2 /day IV 1 day -1 Antithymocyte Globulin 1 mg/kg/day 0 UCBT +5 Begin G-CSF Sirolimus 12 mg qd PO Day -3 followed by 4 mg qd Day -2, target range 3-12 ng/ml Tacrolimus, 0.05 mg/kg PO b.i.d. Day -3, target range 5-10 ng/ml Japanese RIC at Toranomon Hospital Fludarabine 30 mg/m 2 /day IV 6 days, total dose 180 mg/m 2 (days -7 to -2) Busulfan 3.2 mg/kg/day IV 4 days, total dose 12.8 mg/kg (days -7 to -4) Melphalan 40 mg/m 2 /day IV 2 days, total dose 80 mg/m 2 (days -3, -2) Day Preparative therapy Supportive care -7 Fludarabine (30 mg/m 2 /day) IV Busulfan (3.2 mg/kg/day) -6 Fludarabine (30 mg/m 2 /day) IV Busulfan (3.2 mg/kg/day) -5 Fludarabine (30 mg/m 2 /day) IV Busulfan (3.2 mg/kg/day) -4 Fludarabine (30 mg/m 2 /day) IV Busulfan (3.2 mg/kg/day) -3 Fludarabine (30 mg/m 2 /day) Begin tacrolimus, MMF Melphalan (40 mg/m 2 /day) -2 Fludarabine (30 mg/m 2 /day) Melphalan (40 mg/m 2 /day) -1 0 UCBT +1 Begin G-CSF 이식전처치방법 43

48 1. 성인제대혈이식의표준전처치요법은아직확립되어있지않기때문에, 각이식센터에서환자의상태를고려하여시행한다. 2. 세계적으로는 TBI/non-ATG-based 전처치 (e.g. TBI/Ara-C/Cy for MAC; TBI/Flu/Cy for RIC) 를선호하고있다. 3. 대표적인 TBI-based, Non-TBI-based for MAC 전처치는다음과같다. 1) TBI-based: TBI 12Gy + high dose ara-c + Cy 2) Non-TBI-based: thiotepa (5 mg/kg/day, day -7 ~ -6), busulfan (3.2 mg/kg/day, day -5 ~ -3), fludarabine (50 mg/m 2 /day, day -5 ~ -3) 에서 ATG 없이추천된다. 이경우 ATG 를사용하지않기에, cyclosporine 과경구 mycophenolate mofetil로 GVHD 예방요법의강화를권장한다. [ 참고문헌 ] 1. Ballen KK, Spitzer TR, Yeap BY, et al. Double unrelated reduced-intensity umbilical cord blood transplantation in adults. Biol Blood Marrow Transplant 2007;13: Barker JN, Weisdorf DJ, Wagner JE. Creation of a double chimera after the transplantation of umbilical-cord blood from two partially matched unrelated donors. N Engl J Med 2001;344: Barker JN, Weisdorf DJ, DeFor TE, et al. Rapid and complete donor chimerism in adult recipients of unrelated donor umbilical cord blood transplantation after reduced-intensity conditioning. Blood 2003;102: Barker JN, Weisdorf DJ, DeFor TE, et al. Transplantation of 2 partially HLA-matched umbilical cord blood units to enhance engraftment in adults with hematologic malignancy. Blood 2005;105: Brunstein CG, Barker JN, DeFor TE, et al. Non-myeloablative (NMA) umbilical cord blood transplantation (UCBT); promising disease-free survival in 95 consecutive patients. Blood 2005;106:166a. 6. Brunstein CG, Barker JN, Weisdorf DJ, et al. Umbilical cord blood transplantation after nonmyeloablative conditioning: impact on transplantation outcomes in 110 adults with hematologic disease. Blood 2007;110: Brunstein CG, Gutman JA, Weisdorf DJ, et al. Allogeneic hematopoietic cell transplantation for hematologic malignancy: relative risks and benefits of double umbilical cord blood. Blood 2010;116: Eapen M, Rocha V, Sanz G, et al. Effect of graft source on unrelated donor haemopoietic stem-cell transplantation in adults with acute leukaemia: a retrospective analysis. Lancet Oncol 2010;11: Laughlin MJ, Eapen M, Rubinstein P, et al. Outcomes after transplantation of cord blood or bone marrow from unrelated donors in adults with leukemia. N Engl J Med 2004;351: Misawa M, Kai S, Okada M, et al. Reduced-intensity conditioning followed by unrelated umbilical cord blood transplantation for advanced hematologic malignancies: rapid engraftment in bone marrow. Int J Hematol 2006;83: Miyakoshi S, Yuji K, Kami M, et al. Successful engraftment after reduced-intensity umbilical cord blood transplantation for adult patients with advanced hematological diseases. Clin Cancer Res 2004;10: Morii T, Amano I, Tanaka H, et al. Reduced-intensity unrelated cord blood transplantation (RICBT) in adult patients with high-risk hematological malignancies. Blood 2005;106:444b. 13. Ostronoff F, Milano F, Gooley T, et al. Double umbilical cord blood transplantation in patients with hematologic malignancies using a reduced-intensity preparative regimen without antithymocyte globulin. Bone Marrow Transplant 2013;48: 제 4 장

49 14. Ponce DM, Zheng J, Gonzales AM, et al. Reduced late mortality risk contributes to similar survival after double-unit cord blood transplantation compared with related and unrelated donor hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2011;17: Rocha V, Labopin M, Sanz G, et al. Transplants of umbilical-cord blood or bone marrow from unrelated donors in adults with acute leukemia. N Engl J Med 2004;351: Rocha V, Rio B, Garnier F, et al. Reduced intensity conditioning regimen in single unrelated cord blood transplantation in adults with hematological malignant disorders. An Eurocord-Netcord and SFGM-TC survey. Blood 2006;108:897a. 17. Ruggeri A, Sanz G, Bittencourt H, et al. Comparison of outcomes after single or double cord blood transplantation in adults with acute leukemia using different types of myeloablative conditioning regimen, a retrospective study on behalf of Eurocord and the Acute Leukemia Working Party of EBMT. Leukemia 2014;28: Sanz J, Boluda JC, Martín C, et al. Single-unit umbilical cord blood transplantation from unrelated donors in patients with hematological malignancy using busulfan, thiotepa, fludarabine and ATG as myeloablative conditioning regimen. Bone Marrow Transplant 2012;47: Sanz J, Wagner JE, Sanz MA, et al. Myeloablative cord blood transplantation in adults with acute leukemia: comparison of two different transplant platforms. Biol Blood Marrow Transplant 2013;19: Takahashi S, Iseki T, Ooi J, et al. Single-institute comparative analysis of unrelated bone marrow transplantation and cord blood transplantation for adult patients with hematologic malignancies. Blood 2004;104: Takahashi S, Ooi J, Tomonari A, et al. Comparative single-institute analysis of cord blood transplantation from unrelated donors with bone marrow or peripheral blood stem-cell transplants from related donors in adult patients with hematologic malignancies after myeloablative conditioning regimen. Blood 2007;109: Wagner JE, Eapen M, Carter SL, et al. No survival advantage after double vs single cord blood transplantation in children with hematologic malignancy. Blood 2012;120:359a. 23. Yamamoto H, Uchida N, Kageyama K, et al. A novel reduced-toxicity myeloablative conditioning using full-dose busulfan and melphalan for cord blood transplantation provided durable engraftment and remission without increasing non-relapse mortality in advanced myeloid malignancies. Blood 2013;2042a. 이식전처치방법 45

50 II. 소아 소아제대혈이식에서최적의전처치요법은아직정해진것이없으며, 각기관마다고유의전처치요법을개발하여이용하고있다. 1 골수제거전처치 제대혈이식초기에는골수제거전처치를적용한결과가주로발표되었는데, TBI 또는 busulfan 과 cyclophosphamide 의병합요법이근간을이루고있으며, 기관에따라 melphalan, etoposide, thiotepa 등이포함된다. 전처치요법에포함되는방사선조사량과항암제의용량산출은성인과크게다르지않다. 2008년 COBLT 에서발표한결과에따르면 (Kurtzberg et al., Blood 2008), 191명의소아혈액암환아를대상으로총 1,350 cgy의 TBI와 cyclophosphamide, ATG 병합전처치요법후제대혈이식을시행하였을때 43일째생착률은 79.9% 였으며 3등급이상의급성이식편대숙주반응의발생률은 19.5% 였다. 그러나초기사망률이비교적높아 6개월생존율 67.4%, 2년생존율은 49.5% 였다. TBI는치료독성이크고이식성공후에도성장장애, 불임등장기부작용의빈도가높은데, 특히 2세미만의소아는이러한위험을피하기위해방사선조사가포함되지않은전처치요법이선호된다. 따라서방사선조사를대신할수있는부설판을비롯한알킬화제의병합요법이연구되었다. Wall 등 (Biol Blood Marrow Transplant 2005) 이 4세미만의소아를대상으로 busulfan 과 melphalan, ATG 를병합한전처치요법을시행한결과를발표하였으며, Sanz 등 (Bone Marrow Transplant 2012) 은 TBI 대신 busulfan과 thiotepa, fludarabine, ATG 전처치요법의성적을발표하였는데, 총 88명의혈액암환자중 18명의소아환자가포함되어있었으며 1명을제외하고모두생착에성공하였다. 초기생착률은 94%, 5년재발률 18%, 5년비재발사망률은 44% 였다. 비악성질환에서는 159명의유전성대사질환소아에서 busulfan, cyclophosphamide, ATG 병합전처치요법을적용했을때호중구와혈소판각각 87.1%, 71% 의생착률을보였고환자의 97% 에서높은 (>90%) 공여자키메리즘을얻었으며 1년생존율 71.8%, 5년생존율 58.2% 의성적을보였다 (Prasad et al., Blood 2008). 46 제 4 장

51 [ 표 4-4] 소아제대혈이식에서골수제거전처치요법 Author Preparation regimen Median age (yrs) Infused TNC ( 10 7 /kg) Infused CD34 ( 10 5 /kg) Median days to ANC >500 Graft failure (%) agvhd (%) cgvhd (%) Relapse rate (%) TRM (%) Survival (%) MALIGNANT DISEASE Wagner Acute leukemia: et al. TBI 1,320 (AML) or 1,375 (ALL) cgy (1996) Cyclophosphamide 120 mg/kg ATG (atgam) 60 mg/kg NA 24 2 Gr 3,4: 11% NA 11% mo OS: 65% in high risk patients Kurtzberg et al. (1996) Kurtzberg et al. (2008) Wall et al. (2005) Verneris et al. (2009) Sanz et al. (2012) Mo et al. (2014) BM failure syndromes: TBI 750 cgy Cyclophosphamide 120 mg/kg Busulfan 320 mg/m 2 ATG (atgam) 60 mg/kg TBI or Busulfan Melphalan Cyclophosphamide ATG TBI 1,350 cgy Cyclophosphamide 60 mg/kg D-3,2 ATG (atgam) 90 mg/kg Busulfan Melphalan ATG Cyclophosphamide 120 mg/kg Fludarabine 75 mg/m 2 TBI 1,320 cgy Thiotepa 10 mg/kg Busulfan 9.6 mg/kg Fludarabine 150 mg/m 2 ratg 8 mg/kg Cytarabine 8 g/m 2 Busulfan 9.6 mg/kg IV Cyclophosphamide 3.6 g/m 2 Simustine 250 mg/m 2 ratg 10 mg/kg NON-MALIGNANT DISEASE Prasad Busulfan et al. Cyclophosphamide 200 mg/kg (2008) ATG 90 mg/kg % (Gr3:2) Gr 3,4: 38% Gr 3,4: 25% Gr 2-4: 48% 28 (pediatrics: 18 pts) 2% 8% d OS: 64% 20.8% at 2yr 19.9% at 2yr 26% 31% at 2yr 18% 19% at 5yr 56 pts, 25.8% at 6mo 29% at 1yr % 41.4% 18% 14% at 100d, 23% at 180d, 44% at 5yr 9 18 Gr 2-4: 42.3% Gr 2-4: 40% 20.5% at 2yr 10.8% at 2yr 35.1% at 2yr 30.7% NA 45 pts, 23.6% 6mo OS: 67.4% 2yr OS: 49.5% 1yr OS: 47% 5yr LFS at 51% 5yr DFS: 37% 1yr OS: 56.8% 2yr OS: 53.9% 1yr OS: 71.8% 5yr OS: 58.2% Abbreviations: ANC, absolute neutrophil count; agvhd, acute graft versus host disease; cgvhd, chronic graft versus host disease; TRM, transplantation-related mortality; OS, overall survival; LFS, leukemia free survival. 2 저강도전처치 제대혈이식에서골수제거전처치는성공적인치료사례를많이남겼지만, 치료관련합병증으로인한초기사망률이높으며장기적으로는성장장애, 불임, 이차암등치명적인후유증을남길수있어특히소아환자의삶의질을저하시킨다. 이를극복하기위해저강도전처치가개발되었다. 이는특히혼합키메리즘으로인한재발위험이크지않은비악성질환에서유용할것으로기대를모았다. 그러나이전에세포독성항암제에노출되지않은비악성질환의제대혈이식은이식되는세포수가적은데반해숙주의면역체계가비교적온전하여, 이식실패의비율이높은것으로나타났다. 반면수차례 이식전처치방법 47

52 항암치료를받은환자에게서는독성을줄이면서도빠른생착을유도하여합병증을줄일수있는방법으로기대를모으고있다. 이러한단점을극복하기위해골수억제로인한합병증을최소화하면서면역억제의강도를높여제대혈내줄기세포의생착을촉진하는새로운전처치요법개발을위한노력이계속되고있다. 아직전향적비교연구를통해우월함이증명된약제조합은없으나, 몇몇후향적분석에서 fludarabine 을포함시킨경우에좀더좋은성적을보였으며, 전신방사선조사가포함되지않은경우비재발사망률이낮았다. 일본에서시행한후향적분석결과, 제대혈이식은골수이식에비해성적이뒤지지않았으며, 저강도전처치로는고용량의 melphalan 과 fludarabine, ATG 의병합요법이가장적절한것으로나타났다 (Sawada et al., Int J Hematol 2013). 비악성질환에서는높은이식실패율을낮추기위해서주입되는세포수를증가시키는방법이외에, 항T세포항체를포함시키는방법이사용되었으며, 최근에는 ATG 보다강하고선택적인효과를보이는 alemtuzumab을병합하는요법이주로소개되고있다. 최근 Parikh 등 (Parikh et al., Biol Blood Marrow Transplant 2014) 은 22명의소아비악성혈액질환환자에서저강도전처치후제대혈이식에대한제1상임상시험결과를발표하였다. 이연구에서전처치요법프로토콜은다음과같다 ; alemtuzumab 1 mg/kg/dose IV. from D-21 to D-19, hydroxyurea 30 mg/kg/day orally from D-22 [ 표 4-5] 소아제대혈이식에서저강도전처치요법 Author Preparation regimen Median age (yrs) Infused TNC ( 10 7 /kg) Infused CD34 ( 10 5 /kg) Median ANC >500 Graft failure agvhd cgvhd Relapse rate (%) TRM (%) Survival (%) MALIGNANT DISEASE Bradley Fludarabine mg/m 2 or et al. 5 6 mg/kg if <10 kg (2007) Busulfan 8 mg/kg<4 years, 6.4 mg/kg >4 years ATG 8 mg/kg or Fludarabine mg/m 2 or 5 6 mg/kg if <10 kg Cyclophosphamide mg/kg Etoposide 900 mg/m 2 ATG 8 mg/kg Brunstein et al. (2011) Fludarabine 200 mg/m 2 Cyclophosphamide 50 mg/kg TBI 2 Gy NON-MALIGNANT DISEASE Kamani Alemtuzumab et al. Fludarabine 150 mg/m 2 (2012) Melphalan 140 mg/m 2 Radhakrishnan et al. (2013) Parikh et al. (2014) Busulfan (3.2 to 4 mg/kg/day IV divided BID, days -8 to -5) Fludarabine (30 mg/m 2 /day IV, days -8 to -3) Alemtuzumab (2 mg/m 2 day -6, 6 mg/m 2 days -5,-4, and 20 mg/m 2 days -3, -2; 54 mg/m 2 total dose, days -6 to -2) Alemtuzumab 3 mg/kg Hydroxyurea 390 mg/kg Fludarabine 150 mg/m 2 Melphalan 140 mg/m 2 Thiotepa 200 mg/m Gr 2-4: 28.6% 58 (16-69) Gr 2-4: 40% 16.7% 23.8% 5yr OS % at 1yr 31% at 1yr 24% at 1yr 1yr OS pts 1 pts 1 pts 1yr EFS (Total 8 patients) % 1 pt 37.5% 2yr OS % 9.1% yr OS 77.3 Abbreviations: TNC, total nucleated cell; ANC, absolute neutrophil count; agvhd, acute graft versus host disease; cgvhd, chronic graft versus host disease; TRM, transplantation-related mortality; OS, overall survival; EFS, event-free survival. 48 제 4 장

53 to D-10, fludarabine 30 mg/m 2 /day IV from D-9 to D-5, melphalan 70 mg/m 2 /day IV from D-4 to D-3, thiotepa 200 mg/m 2 IV on D-2. 이연구에서 20일째의중성구생착률은 86.4% 였고 3명의환자가생착에실패한것으로나타났다. 3등급이상의급성이식편대숙주반응발생은 13.6% 였으며, 1년생존율 77.3% 였다. 국내에서비악성질환제대혈이식시저강도전처치요법으로많이사용된것은 fludarabine ( mg/m 2 ) 과 cyclophosphamide ( mg/kg) 의병합요법과 cyclophosphamide mg/kg 요법으로나타났다 (Park et al. Pediatr Transplant 2014). 이는제대혈이식외에다른조혈모세포이식에서도일반적으로이용되는요법들을차용한것으로, 국내에서도제대혈이식에좀더최적화된전처치요법의개발과임상적용이필요할것으로보인다. 소아에서사용되고있는대표적인전처치방법은다음과같다. 1. 골수제거전처치 1) TBI (13.5 Gy) + cyclophosphamide (120 mg/kg) ± ATG or fludarabine 2) Busulfan (9.6 mg/kg) + cyclophosphamide (120 mg/kg) ± ATG or fludarabine 3) Busulfan (9.6 mg/kg) + melphalan ± ATG 2. 악성질환에서저강도전처치 1) Fludarabine + cyclophosphamide 2) Busulfan (6.4 mg/m 2 ) + fludarabine + ATG 3) TBI (2 Gy) + cyclophosphamide 3. 비악성질환에서저강도전처치 1) Fludarabine/melphalan/busulfan (low dose) + alemtuzumab [ 참고문헌 ] 1. Bradley MB, Satwani P, Baldinger L, et al. Reduced intensity allogeneic umbilical cord blood transplantation in children and adolescent recipients with malignant and non-malignant diseases. Bone Marrow Transplant 2007;40: Brunstein CG, Fuchs EJ, Carter SL, et al. Alternative donor transplantation after reduced intensity conditioning: results of parallel phase 2 trials using partially HLA-mismatched related bone marrow or unrelated double umbilical cord blood grafts. Blood 2011;118: Kamani NR, Walters MC, Carter S, et al. Unrelated donor cord blood transplantation for children with severe sickle cell disease: results of one cohort from the phase II study from the Blood and Marrow Transplant Clinical Trials Network (BMT CTN). Biol Blood Marrow Transplant 2012;18: Kurtzberg J, Laughlin M, Graham ML, et al. Placental blood as a source of hematopoietic stem cells for transplantation into unrelated recipients. N Engl J Med 1996;335: Kurtzberg J, Prasad VK, Carter SL, et al. Results of the Cord Blood Transplantation Study (COBLT): clinical outcomes of unrelated donor umbilical cord blood transplantation in pediatric patients with hematologic malignancies. Blood 2008;112: 이식전처치방법 49

54 6. Mo, X.D., Xhao XY, Liu DH, et al., Umbilical cord blood transplantation and unmanipulated haploidentical hematopoietic SCT for pediatric hematologic malignances. Bone Marrow Transplant, Parikh SH, Mendizabal A, Benjamin CL, et al. A novel reduced-intensity conditioning regimen for unrelated umbilical cord blood transplantation in children with nonmalignant diseases. Biol Blood Marrow Transplant 2014;20: Park M, Lee YH, Kang HR, et al. Unrelated donor cord blood transplantation for non-malignant disorders in children and adolescents. Pediatr Transplant 2014;18: Prasad VK, Mendizabal A, Parikh SH, et al. Unrelated donor umbilical cord blood transplantation for inherited metabolic disorders in 159 pediatric patients from a single center: influence of cellular composition of the graft on transplantation outcomes. Blood 2008;112: Radhakrishnan K, Bhatia M, Geyer MB, et al. Busulfan, fludarabine, and alemtuzumab conditioning and unrelated cord blood transplantation in children with sickle cell disease. Biol Blood Marrow Transplant 2013;19: Ruggeri A, Eapen M, Scaravadou A, et al. Umbilical cord blood transplantation for children with thalassemia and sickle cell disease. Biol Blood Marrow Transplant 2011;17: Sanz J, Boluda JC, Martín C, et al. Single-unit umbilical cord blood transplantation from unrelated donors in patients with hematological malignancy using busulfan, thiotepa, fludarabine and ATG as myeloablative conditioning regimen. Bone Marrow Transplant 2012;47: Sawada A, Ohga S, Ishii E, et al. Feasibility of reduced-intensity conditioning followed by unrelated cord blood transplantation for primary hemophagocytic lymphohistiocytosis: a nationwide retrospective analysis in Japan. Int J Hematol 2013;98: Satwani P, Jin Z, Duffy D, et al. Transplantation-related mortality, graft failure, and survival after reduced-toxicity conditioning and allogeneic hematopoietic stem cell transplantation in 100 consecutive pediatric recipients. Biol Blood Marrow Transplant 2013;19: Verneris MR, Brunstein CG, Barker J, et al. Relapse risk after umbilical cord blood transplantation: enhanced graft-versus-leukemia effect in recipients of 2 units. Blood 2009;114: Wagner JE, Rosenthal J, Sweetman R, et al. Successful transplantation of HLA-matched and HLA-mismatched umbilical cord blood from unrelated donors: analysis of engraftment and acute graft-versus-host disease. Blood 1996;88: Wall DA, Carter SL, Kernan NA, et al. Busulfan/melphalan/antithymocyte globulin followed by unrelated donor cord blood transplantation for treatment of infant leukemia and leukemia in young children: the Cord Blood Transplantation study (COBLT) experience. Biol Blood Marrow Transplant 2005;11: 제 4 장

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56

57 제 5 장이식편대숙주병의예방 제대혈에는세포독성을가지는 CD3양성 T세포가다른조혈모세포원에비하여미성숙하고, 동종항원반응을일으킬수있는 CD54/CD58 항원을가지는세포의수가적기때문에제대혈의동종항원에대한거부반응이약하게일어난다. 이에 HLA가일치하지않는경우에도제대혈이식시에는다른조혈모세포이식에비하여이식편대숙주병의빈도가낮다. 그러나다른조혈모세포이식에비하여생착이오래걸리며, 이식관련사망률이높다는단점이있다. 따라서, 이와같은제대혈이식의특성을고려하여시행해야한다. 제대혈이식에서는저강도전처치를이용한이식의경우와마찬가지로 methotrexate (MTX) 를이식편대숙주병의예방을위해사용하는경우, MTX로인해생착에영향을주거나점막염등을일으킬수있기때문에, 대부분의기관에서는 MTX대신 mycophenolate mofetil (MMF) 을사용하고있다. 그러나아직제대혈이식에서 calcineurin 억제제 +MTX 와 calcineurin 억제제 +MMF 중어떤요법이더나은지에대한전향적비교연구는없는상태이다. 기존보고된이식관련연구에서의이식편대숙주병의예방요법및그결과는 [ 표 5-1] 과같다. [ 표 5-1] 기존에보고된이식관련연구에서의전처치요법, 이식편대숙주병예방요법, 및결과 Author Patients No. patients Conditioning GVHD prophylaxis Cord info Primary GF (%) Neutrophil Engraft (days) PLT Engraft (days) Gr II-IV agvhd (%) Overall survival (%) Wagner et al. (1995) Wagner et al. (1996) Wagner et al. (2002) Kurtzberg et al. (2008) Pediatric 44 sucbt (1.6 yr) Pediatric 18 MA CSA±mPD/ATGAM sucbt (6 mon) Pediatric 102 MA CSA+mPD/ATGAM sucbt (1 yr) CSA+MTX/ATGAM Pediatric 101 MA CSA±mPD/rATG sucbt (50K) (2 yr) Laughlin et al. (2001) 68 MA CSA±mPD/ATGAM sucbt (40 mon) Sanz et al. (2001) Adult 22 NMA CSA+PD/hATG sucbt (8 mon) Takahashi et al. (2004) Rocha et al. (2004) Adult 68 MA CSA+MTX CSA+mPD TAC+MTX Adult 98 CSA CSA+corticosteroids CSA+MTX sucbt (2 yr DFS) sucbt (2 yr) Cornetta et al. (2005) Adult 34 CSA+mPD sucbt (6 mon) Brunstein et al. Adult 110 RI CSA+MMF/rATG 85% ducbt 6 22 (50K) (3 yr) (2007) 15% sucbt Ballen et al. (2007) Adult 21 RI CSA+MMF/rATG ducbt (2 yr) Abbreviations: GVHD, graft versus host disease; GF, graft failure; PLT, platelet; MA, myeloablative; NMA, non-myeloablative; RI, reduced intensity; CSA, cyclosporin; mpd, methylprednisolone; MTX, methotrexate; PD, prednisolone; ratg, rabbitatg; hatg, horseatg; TAC, tacrolimus; MMF, mycophenolate mofetil; sucbt, single unit cord blood transplantation; ducbt, double unit cord blood transplantation; DFS, disease free survival. 이식편대숙주병의예방 53

58 1 제대혈이식에서 methotrexate 투여시연구결과 제대혈이식을시행받은 147 명의환자를대상으로한 EUROCORD 의연구에따르면 (Herr et al., Blood 2010), MTX 를사용하지않고 calcineurin 억제제만사용한환자군과 MTX와 cyclosporin 을병용한환자군에서호중구회복의정도의차이가있었다. 그결과 MTX를사용한군에서의미있게생착누적률이낮음을확인하였다 [ 그림 5-1]. Hazard Ratio of 0.48 (95% CI, ; P<0.001) on multivariate analysis [ 그림 5-1] 제대혈이식시 methotrexate (MTX) 사용유무에따른호중구회복률 (Herr et al., Blood 2010) 비골수제거전처치를사용하는경우에는 MTX의독성을최소화하기위하여 calcineurin 억제제+MMF를사용하기도한다. 그러나, 제대혈이식에서는 calcineurin 억제제+MTX 혹은 calcineurin 억제제+MMF를전향적으로비교한연구는없다. 대부분의기관에서는 MTX 의사용시생착이지연될위험이있어, 제대혈이식시에는 MTX대신에 MMF를사용하고있다. 2 Calcineurin inhibitor 와병합시 MMF 혹은스테로이드중선택 Minnesota 그룹에서제대혈이식을받은 265명의환자에서시행한연구에따르면 (MacMillan et al., Blood 2009), calcineurin 억제제에 methylprednisolone, MTX, MMF 중어떤약제를선택하는것이이식편대숙주병의위험을더줄일수있는지에대한분석을시행하였다 [ 표 5-2]. 분석결과에따르면, MMF 투여군에서는 ATG 를사용하지않았음에도불구하고 methylprednisolone 등을사용했던환자군에비하여급성이식편대숙주병의낮은위험도를보였다 [ 표 5-3]. 54 제 5 장

59 [ 표 5-2] 제대혈이식을받은해당환자군의특징 (n=265) (MacMillan et al. Blood 2009) 분류한단위두단위 P 전체환자수 N=80 N=185 전처치 <0.01 골수제거 61 (76%) 78 (42%) 비골수제거 19 (24%) 107 (58%) 전처치에서 ATG사용여부 <0.01 사용 (MMF를받지않은환자만투여받음 ) 46 (58%) 49 (26%) 사용안함 34 (43%) 136 (74%) 이식편대숙주병예방요법 <0.01 cyclosporin/methylprednisolone 46 (58%) 4 (2%) cyclosporin/mycophenolate mofetil 33 (41%) 181 (98%) cyclosporin/methotrexate 1 (1%) 0 [ 표 5-3] 이식편대숙주병의위험도분석결과 (n=265) (MacMillan et al. Blood 2009) 이식편대숙주병의위험도분석결과 2-4 등급급성이식편대숙주병과관련된요인 : 다변량분석 요인 상대위험도 (95% 신뢰구간 ) P 전처치중 ATG 의사용사용안함 1.0 사용함 0.5 ( ) 0.02 이식편대숙주병예방요법중 MMF 사용안함 1.0 사용함 0.5 ( ) 0.14 Giaccone 등 (Blood 2005) 은비골수제거전처치요법후비혈연일치공여자로부터이식을받은환자 85명을대상으로 MMF에대한약동학연구를시행하였다. 연구결과, MMF의대사물인 mycophenolic acid (MPA) 의혈중농도가낮을수록공여자 T세포키메리즘이불량하였다. MPA 의혈중농도는하루 2회용법보다는 3회용법에서더높았으며, 따라서 3회용법시에더우수한 T세포키메리즘을보였다 [ 그림 5-2]. [ 그림 5-2] MMF 투여용법에따른 T 세포키메리즘의비교 (Giaccone et al., Blood 2005) Abbreviation: Css, concentration steady state. 이식편대숙주병의예방 55

60 그러나혈중비결합 MPA 농도가높을수록거대세포바이러스재활성화의빈도가높았으며, MMF는혈중농도에비례하여호중구감소의발생위험이높은것으로알려져있다 (Okamura et al., Bone Marrow Transplant 2011) [ 표 5-4]. 또한, 두가지용법에서급성이식편대숙주병의빈도차이는없었다. 따라서제대혈이식에서 MMF의하루 2회용법과 3회용법중어떤용법이더우수한지에대해서는추가적인연구가필요하다. [ 표 5-4] 제대혈이식과골수이식시 MMF 용법에따른중성구생착기간의비교 (Okamura et al., Bone Marrow Transplant 2011) Single-unit cord blood transplant Bone marrow transplantation b.i.d. Dosing t.i.d. Dosing b.i.d. Dosing t.i.d. Dosing No. of patients Median age (range), yrs 49 (21-66) 52 (20-66) 42 (32-58) 48.5 (35-59) Sex, male/female 5/8 3/2 2/1 3/1 Diagnosis Acute myeloid leukemia Acute lymphoblastic leukemia Myelodysplastic syndrome Non-Hodgkin lymphoma Others Conditioning Myeloablative Non-myeloablative Median CD34 + cells, 10 6 /kg (range) ( ) 0.09 ( ) 1.30 ( ) 1.05 ( ) P Neutrophil Engraftment Median, days 17 (14-18) 22 (14-41) 11 (9-17) 11 (8-14) P 제대혈이식에서 ATG 사용 이식편대숙주병예방에있어, 면역억제제를단독으로투여하는것에비하여, T세포고갈요법을병합하였을때, 3-4 등급급성이식편대숙주병은감소하는것이알려져있다 (Antin et al., Blood 2011). HLA 8/8 일치비혈연공여자로부터동종조혈모세포이식를받은환자에대한대규모연구에서 cyclosporin/methotrexate 만이용한군과 cyclosporin/methotrexate 에 rabbit ATG 를포함한군으로무작위배정되었고, ATG 를받은군에서 2-4등급 /3-4등급급성이식편대숙주병의발생률이각각 51%/24.5% 와 33%/11.7% 로감소할수있었다 (Socié et al., Blood 2011). 또한이연구에서는 ATG 투여군에서또한광범위만성이식편대숙주병의 3년발생률이 45% 및 12.2% 로감소하였으며, 장기추적관찰시에도 ATG 사용군에서후기폐합병증이감소하는효과가있었다. 현재골수제거전처치를사용한이식에서는대부분 ATG 를전처치요법에포함하여투여하고있다. 저강도전처치요법을이용한동종조혈모세포이식의경우에는재발을감소시키는이식편대종양반응이이식의성공에중요하기때문에 ATG 에대한연구는많지않다. CIBMTR의후향적연구에따르면, 저강도전처치이후 ATG 를받은경우, 원발종양재발, 비재발성사망률, 엡스타인-바바이러스림프증식성질환등의위험이더높았으며, 생존율과무병생존율이더불량하였다 (Soiffer et al., Blood 2011). 향후저강도전처치를이용한경우에는 ATG 의역할과적정용법에대한 56 제 5 장

61 전향적연구가필요하다. 제대혈이식에서도 ATG 를사용한후 2-4등급급성이식편대숙주병의빈도가 50% 이하로감소하여, 급성이식편대숙주병의예방에효과적임이확인되고있다. 그러나 ATG 를사용시에감염이증가하고면역회복이지연될위험이있다. 이와관련하여 Memorial Sloan-Kettering Cancer Center 에서는 ATG 를사용하지않고두단위제대혈이식을받은 72명의성인환자에대하여감염과면역회복에대한연구를발표하였다 (Sauter et al., Biol Blood Marrow Transplant 2011). 그결과생착은 ATG 의사용여부에따라영향을받지않았으며, 2-4등급급성이식편대숙주병의 cumulative incidence 는 43% 로다른두단위제대혈이식의연구와비슷한결과를보였다. 그러나 ATG 사용하지않은경우라하더라도, 이식편대숙주병이발생시치료중에발생하는바이러스감염은여전히빈도가높았으며, 후기거대세포바이러스감염도이식편대숙주병의치료중에발생하였다. 현재까지 ATG 의사용에대한의견일치는이루어지지않은상태이다. ATG 를사용하지않는경우특히 3-4등급급성이식편대숙주병의발생이증가하며, 이식편대숙주병이발생하는경우치료중에감염의위험이오히려증가하기때문에, 감염의위험을줄이기위하여 ATG 를사용하지않는것은근거가없는상태이다. 4 제대혈이식에서 sirolimus 의사용 mtor 억제제인 sirolimus도최근이식편대숙주병예방을위한병합요법으로사용되고있으며, 제대혈이식에서도결과가보고되고있다. 두단위제대혈이식을시행받은 32명의성인환자에대한 Dana Faber Cancer Institute 등의연구에따르면, 저강도전처치를이용한제대혈이식에서 tacrolimus 와 sirolimus의병합요법은효과적으로이식편대숙주병을예방할수있었다 [ 표 5-3] (Cutler et al., Bone Marrow Transplant 2011). [ 표 5-3] Tacrolimus 와 sirolimus 의병합요법의예 (Cutler et al., Bone Marrow Transplant 2011) 이식 8 일전 7 일전 6 일전 5 일전 4 일전 3 일전 2 일전 1 일전이식일 Fludarabine 30 mg/m 2 /day Melphalan 100 mg/m 2 /day ATG 1.5 mg/kg Tacrolimus ( 지속주입 ) ( 목표혈중농도 5-10 ng/ml) Sirolimus ( 하루 1회경구복용 ) ( 목표혈중농도 3-12 ng/ml) 12 mg 이식편대숙주병이없는경우, 예방요법은이식후 100 일부터감량을시작하여, 180 일까지감량한다. 본연구에따르면, 이식후 100일째급성이식편대숙주병의빈도는 9.4%, 만성이식편대숙주병의빈도는 12.5% 였으며, 이식편대숙주병으로사망하거나, 혈전미세혈관병증, 정맥폐색성질환등이발생한경우는없었다 [ 그림 5-3]. 이와같은결과는기존의 cyclosporine+mmf의병합요법과비견하여, 주목할만한결과를보여주는것으로향후추가적인연구결과가기대되고있다. Sirolimus는성인에서는이식 3일전에 12 mg을경구로투여하고, 다음날부터 4 mg을하루한번투여하며, 혈중최저혈중농도를 3 12 ng/ml 로조절하는용법이주로사용되고있다. 이식편대숙주병의예방 57

62 [ 그림 5-3] 두단위제대혈이식에서 tacrolimus 와 sirolimus 병합요법을시행한경우호중구및혈소판생착률 (Cutler et al., Bone Marrow Transplant 2011) 소아에서는 sirolimus 의사용에대한보고가거의없는상태이나, 최근 tacrolimus 와 MTX의병합요법에 sirolimus 를추가하는용법에대한임상 3단계연구결과가발표되었으며, 본연구에 13명의환아가제대혈이식을시행받았다 (Pulsipher MA et al., Blood 2014). 본연구에서는제대혈이식시 [ 표 5-4] 와같이이식편대숙주병예방요법을시행하였다. [ 표 5-4] 소아에서 tacrolimus, methotrexate, sirolimus의병합요법의예 (Pulsipher MA et al. Blood 2014). 비교군 실험군 목표혈중농도 감량 Tacrolimus 이식 2일전시작. 지속정주 5~12 ng/ml 이식후 100일시작, 180일까지 Methotrexate 5 mg/m 2 정맥주입 ( 이식후 1, 3, 6일 ) Sirolimus - 이식일부터 ~ 4 mg/m 2 하루 1회 3~12 ng/ml 본연구에서는공여자종류별로결과및독성이제시되지는않았으나, 기존 tacrolimus/mtx 에 sirolimus를추가한군에서 2-3등급급성이식편대숙주병이감소하였고, 생존율에는영향이없었다. 향후소아에서 sirolimus 의사용에대해서는추가적인연구가필요하다. 58 제 5 장

63 제대혈이식에서급성이식편대숙주병의예방을위해사용하는용법 : EBMT-ELN working group 의추천용법 : (Ruutu et al, Bone Marrow Transplant 2014) Cyclosporine The initial dose is 3 mg/kg/day. The administration is initiated on the day preceding the infusion of the graft (day 1). In case of two or more graft products given on more than one day, the day of the first product is counted as day 0. The drug is given as short intravenous (IV) bolus infusion in two daily doses. The administration is changed to oral route when oral intake is possible. The first oral dose is twice the IV dose, administered in two daily doses. The dose is adapted according to whole blood cyclosporine concentration or toxicity (renal insufficiency, microangiopathy, neurological problems) necessitating change of dosage. The cyclosporine target concentration is 200 to 300 /L during the first three to four weeks, then 100 to 200 micrograms/l until three months after transplantation if there is no graft versus host disease or toxicity. Cyclosporine concentrations are measured from whole blood at 12 hours after a dose (trough level before the next infusion/dose). The duration of cyclosporine prophylaxis is six months in the absence of graft versus host disease. The dose is tapered from three months onwards if no graft versus host disease is present. The dose is not tapered as long as there are signs of acute graft versus host disease or signs of chronic graft versus host disease exceeding mild skin disease. Mycophenolate mofetil The dose is 30 mg/kg/day, given orally in two doses. The administration is started on day +1. The dose is adapted according to toxicity. The duration of mycophenolate mofetil prophylaxis is one month in sibling transplantations, three months in transplantations from unrelated or mismatched donor. In case of persistent disease or relapse (sub-population chimerism or other sensitive method) prevention should be reduced earlier. Antithymocyte globulin (rabbit) The brand is ATG-F or Thymoglobulin. The dose of ATG-F is 10 mg/kg on three days (total 30 mg/kg) and that of Thymoglobulin is 2.5 mg/kg on three days (total 7.5 mg/kg). Antithymocyte globulin is administered on days 3, 2 and 제대혈이식의이식편대숙주병예방용법으로는 cyclosporin+mycophenolate mofetil ( 하루두번용법 ) 의조합이가장많이이용되고있다. 2. 대부분의기관에서는 methotrexate 사용시생착이지연될위험이있어, 제대혈이식시에는 methotrexate 대신에 mycophenolate mofetil 을사용하고있다. Mycophenolate mofetil의하루 3회용법과 2회용법의비교 : 하루 3회복용시 2회용법에비하여 1) 약물의혈중농도높이고 2) 공여자 T세포키메리즘이우수하다는장점이있으나, 3) 혈중농도가높을수록거대세포바이러스재활성화와호중구감소증의위험이높다. 3. 제대혈이식에서 ATG 를사용하면급성이식편대숙주병의예방에효과적이나, 감염의위험등으로인하여제대혈이식에서는아직논란의여지가있다. 4. 제대혈이식에서 sirolimus가성공적으로이식편대숙주병예방요법으로사용되었다는보고가늘고있다. 이식편대숙주병의예방 59

64 [ 참고문헌 ] 1. Alyea EP, Li S, Kim HT, et al. Sirolimus, tacrolimus, and low-dose methotrexate as graft-versus-host disease prophylaxis in related and unrelated donor reduced-intensity conditioning allogeneic peripheral blood stem cell transplantation. Biol Blood Marrow Transplant 2008;14: Antin JH. T-cell depletion in GVHD: less is more? Blood 2011;117: Ballen KK, Spitzer TR, Yeap BY, et al. Double unrelated reduced-intensity umbilical cord blood transplantation in adults. Biol Blood Marrow Transplant 2007;13: Brunstein CG, Barker JN, Weisdorf DJ, et al. Umbilical cord blood transplantation after nonmyeloablative conditioning: impact on transplantation outcomes in 110 adults with hematologic disease. Blood 2007;110: Cornetta K, Laughlin M, Carter S, et al. Umbilical cord blood transplantation in adults: results of the prospective Cord Blood Transplantation (COBLT). Biol Blood Marrow Transplant 2005;11: Cutler C, Stevenson K, Kim HT, et al. Double umbilical cord blood transplantation with reduced intensity conditioning and sirolimus-based GVHD prophylaxis. Bone Marrow Transplant 2011;46: Cutler C, Logan B, Nakamura R, et al. Tacrolimus/sirolimus vs tacrolimus/methotrexate as GVHD prophylaxis after matched, related donor allogeneic HCT. Blood 2014;124: Giaccone L, McCune JS, Maris MB, et al. Pharmacodynamics of mycophenolate mofetil after nonmyeloablative conditioning and unrelated donor hematopoietic cell transplantation. Blood 2005;106: Herr AL, Kabbara N, Bonfim CM, et al. Long-term follow-up and factors influencing outcomes after related HLA-identical cord blood transplantation for patients with malignancies: an analysis on behalf of Eurocord-EBMT. Blood 2010;116: Ho VT, Aldridge J, Kim HT, et al. Comparison of Tacrolimus and Sirolimus (Tac/Sir) versus Tacrolimus, Sirolimus, and mini-methotrexate (Tac/Sir/MTX) as acute graft-versus-host disease prophylaxis after reduced-intensity conditioning allogeneic peripheral blood stem cell transplantation. Biol Blood Marrow Transplant 2009;15: Inamoto Y, Flowers ME, Appelbaum FR, et al. A retrospective comparison of tacrolimus versus cyclosporine with methotrexate for immunosuppression after allogeneic hematopoietic cell transplantation with mobilized blood cells. Biol Blood Marrow Transplant 2011;17: Kurtzberg J, Prasad VK, Carter SL, et al. Results of the Cord Blood Transplantation Study (COBLT): clinical outcomes of unrelated donor umbilical cord blood transplantation in pediatric patients with hematologic malignancies. Blood 2008;112: Laughlin MJ, Barker J, Bambach B, et al. Hematopoietic engraftment and survival in adult recipients of umbilical-cord blood from unrelated donors. N Engl J Med 2001;344: MacMillan ML, Weisdorf DJ, Brunstein CG, et al. Acute graft-versus-host disease after unrelated donor umbilical cord blood transplantation: analysis of risk factors. Blood 2009;113: Nash RA, Pineiro LA, Storb R, et al. FK506 in combination with methotrexate for the prevention of graft-versus-host disease after marrow transplantation from matched unrelated donors. Blood 1996;88: Okamura A, Shimoyama M, Ishii S, et al. Delayed neutrophil engraftment in cord blood transplantation with intensive administration of mycophenolate mofetil for GVHD prophylaxis. Bone Marrow Transplant 2011;46: 제 5 장

65 Perkins J, Field T, Kim J, et al. A randomized phase II trial comparing tacrolimus and mycophenolate mofetil to tacrolimus and methotrexate for acute graft-versus-host disease prophylaxis. Biol Blood Marrow Transplant 2010;16: Pulsipher MA, Langholz B, Wall DA, et al. The addition of sirolimus to tacrolimus/methotrexate GVHD prophylaxis in children with ALL: a phase 3 Children's Oncology Group/Pediatric Blood and Marrow Transplant Consortium trial. Blood 2014;123: Ringdén O, Klaesson S, Sundberg B, et al. Decreased incidence of graft-versus-host disease and improved survival with methotrexate combined with cyclosporin compared with monotherapy in recipients of bone marrow from donors other than HLA identical siblings. Bone Marrow Transplant 1992;9: Rocha V, Labopin M, Sanz G, et al. Transplants of umbilical-cord blood or bone marrow from unrelated donors in adults with acute leukemia. N Engl J Med 2004;351: Ruutu T, van Biezen A, Hertenstein B, et al. Prophylaxis and treatment of GVHD after allogeneic haematopoietic SCT: a survey of centre strategies by the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant 2012;47: Ruutu T, Gratwohl A, de Witte T, et al. Prophylaxis and treatment of GVHD: EBMT-ELN working group recommendations for a standardized practice. Bone Marrow Transplant 2014;49: Sanz GF, Saavedra S, Planelles D, et al. Standardized, unrelated donor cord blood transplantation in adults with hematologic malignancies. Blood 2001;98: Sauter C, Abboud M, Jia X, et al. Serious infection risk and immune recovery after double-unit cord blood transplantation without antithymocyte globulin. Biol Blood Marrow Transplant 2011;17: Socié G, Schmoor C, Bethge WA, et al. Chronic graft-versus-host disease: long-term results from a randomized trial on graft-versus-host disease prophylaxis with or without anti-t-cell globulin ATG-Fresenius. Blood 2011;117: Soiffer RJ, Lerademacher J, Ho V, et al. Impact of immune modulation with anti-t-cell antibodies on the outcome of reduced-intensity allogeneic hematopoietic stem cell transplantation for hematologic malignancies. Blood 2011;117: Storb R, Deeg HJ, Whitehead J, et al. Methotrexate and cyclosporine compared with cyclosporine alone for prophylaxis of acute graft versus host disease after marrow transplantation for leukemia. N Engl J Med 1986;314: Storb R, Deeg HJ, Pepe M, et al. Methotrexate and cyclosporine versus cyclosporine alone for prophylaxis of graft-versus-host disease in patients given HLA-identical marrow grafts for leukemia: long-term follow-up of a controlled trial. Blood 1989;73: Takahashi S, Iseki T, Ooi J, et al. Single-institute comparative analysis of unrelated bone marrow transplantation and cord blood transplantation for adult patients with hematologic malignancies. Blood 2004;104: Wagner JE, Kernan NA, Steinbuch M, et al. Allogeneic sibling umbilical-cord-blood transplantation in children with malignant and non-malignant disease. Lancet 1995;346: Wagner JE, Rosenthal J, Sweetman R, et al. Successful transplantation of HLA-matched and HLA-mismatched umbilical cord blood from unrelated donors: analysis of engraftment and acute graft-versus-host disease. Blood 1996;88: Wagner JE, Barker JN, DeFor TE, et al. Transplantation of unrelated donor umbilical cord blood in 102 patients 이식편대숙주병의예방 61

66 with malignant and nonmalignant diseases: influence of CD34 cell dose and HLA disparity on treatment-related mortality and survival. Blood 2002;100: 제 5 장

67 제 6 장 제대혈주입방법및주의할점

68

69 제 6 장제대혈주입방법및주의할점 1 제대혈보관과주입시 DMSO 의역할과영향 제대혈의냉동시세포보존제로추가되는 dimethyl sulfoxide (DMSO) 는세포동결인자로서장기간동결보관시세포손상을최소화하기위하여반드시필요하다. 일반적으로얼려두었던제대혈을녹여서환자에게주입하는방법은가능한빨리녹인후 DMSO와함께환자에게주는것이다. 가능한빨리주는이유는해동하면서파괴된세포가 DNA 응괴를이루어혈전을유발할가능성이높기때문이다 (Lee et al., J Korean Pediatr Soc 2000). 그러나이와같은경우혼합된 DMSO는여러가지부작용을일으킬수있다. DMSO는주입되는조혈전구세포에삼투압충격을유발하여세포의생존력에손상을줄수있다 (Nagamura-Inoue et al., Transfusion 2003). 또한환자에게 DMSO 가주입되는경우오심, 구토, 발열, 오한, 호흡곤란, 심혈관계부작용, 사망등의부작용을유발할수있으며, 이와같은부작용은소아에서빈도가더높다 (Sanchez-Salinas et al., Transfusion 2012). 2 해동 (Thawing) 하는방법 1) 전통적인방법 (Conventional method, Rubinstein method) 본방법은 5% 알부민 / 덱스트란을이용한해동방법으로제대혈단위의부피와동일한양의덱스트란과알부민을이용하여해동과세척을하는방법이다. 이방법은가장전통적인방법으로, 이방법으로총유핵세포수의회복이 35% 에서 61% 까지증가할수있었으며, 집락형성단위 (colony forming unit, CFU) 손실이매우적은장점이있다 (Rubinstein et al., Proc Nat Acad Sci USA 1995). 또한 DMSO를제거할수있어독성을최소화하며, ABO 부적합적혈구와혈장제거할수있다는장점이있다. 그러나과정이복잡하며, 시간이오래걸리고경험이있는인력과필수적인시설및장비가많다는단점이있다. 제대혈주입방법및주의할점 65

70 >>> 과정 1 제대혈을미지근한식염수수조에서충분히녹인다. 2 채혈부위에커플러 (coupler) 나트랜스퍼백 (transfer bag) 를삽입하고, 세척액 ( 알부민 + 덱스트란 ) 의반을주입한다. 3 트랜스퍼백으로옮기고, 남은세척액으로백을헹구어서하여드레인백 (drain bag) 으로옮긴다 ml 덱스트란 +50 ml 25% 알부민을혼합한세척액을추출하여트랜스퍼백에옮겨트랜스퍼백의부피를총 150 ml로맞춰준다 o C에서 1,200 rpm으로 10분간원심분리하고, 이후에 30 ml (12.5 ml 덱스트란 ml의상층액 ) 을제거한다. 상층액은세포수및활성도검사에사용한다. 6 아래농축된제대혈제제를뽑아서주입용으로준비하고, 백에남은제대혈제제는세척액으로헹구어배양검사등에이용한다. 2) 희석법 (Dilution method) 이방법은해동후알부민이나덱스트란을첨가하여희석하고원심분리는시행하지않는방법이다. 해동후의삼투압차이를최소화하여세포의파괴를막아제대혈제제를안정화시키는목적으로시행하며, 전통적인방법에서시행되는조작시의위험을피할수있으며, 조작하는시간을단축시킬수있다. 또한전통적인방법에비하여조작하는중에세포의손실을줄일수있다는장점이있다. 3) 직접해동법 (Direct Thaw) 환자옆에서직접미지근한수조에서해동하고주입하는방법으로 (Hahn et al., Bone Marrow Treansplant 2003), 냉동보관된자가조혈모세포를해동할때와동일하게, 살균된 지퍼락 (zip-lock) 백에넣고공기를뺀뒤단단히봉하여, 역시살균된 37±1 o C의식염수를넣은수조에서서서히흔들어녹인다. 66 제 6 장

71 4) 해동방법의비교 해동방법 장점 단점 전통적인방법 80% 의 DMSO 와적혈구용혈산물이제거됨. 원심분리시세포손실의위험이큼 ( 백파열, 세포응집등 ) 희석법 이론적으로해동후의삼투압차이를최소화하여세포의파괴를최소화함. 환자에게주입되는제대혈제제의부피가큼. DMSO 가많이주입되고, 적혈구 / 백혈구용혈산물이많이포함됨. 직접해동법 연구실관련문제가없음. 다른냉동제제를다루는방법과동일함. 침상옆에서시행해야한다는점에서공간적인문제. 해동한즉시주입해야함. DMSO 가많이주입되고, 적혈구 / 백혈구용혈산물이많이포함됨. 어떤해동방법을사용하는가의결정은 DMSO 또는적혈구의양이나, 환자의체중등의요소를고려하여결정할수있으나, 대부분은해당이식기관의의료진의선호도나특히경험이있는인력과필수적인시설및장비가구비되어있는지에달려있는경우가많다. DMSO 가전구세포에섞여서주입될경우세포의손상을일으켜서생착지연을유발할위험이있다는보고가있었으나, 실제로세척을한경우와하지않은경우, 두가지의제대혈제제를이식한결과, 골수생착속도에차이가없었다 (Nagamura-Inoue et al., Transfusion 2003). 또한세포의생존율, 총유핵세포수, CD34양성세포수, 집락형성단위의회복의경우에도직접해동법과희석법간의큰차이가없었으나, 총유핵세포수회복은전통적인방법이직접해동법적용시에비하여낮았다 (Regan et al., Biol Blood Marrow Transplant 2006). 세가지해동방법을비교한연구에서도호중구생착속도의차이가없었다 [ 그림 6-1] (Regan et al., Transfusion 2010). 또한 DMSO 세척없이직접해동을한경우에도소아에서부작용이더증가했다는비교자료는아직없는상태이다. 따라서이러한연구들의결과, 제대혈의냉동보관전에적혈구나혈장을추출한경우에는, 해동이후에 DMSO나적혈구를추가로제거하는것이큰의미가없다고판단된다. 제대혈주입방법및주의할점 67

72 [ 그림 6-1] 해동방법에따른호중구생착률의비교 1. 제대혈의해동방법은대표적으로 3가지가있으며, 특히환자와세포생존율에부작용을유발할위험이있는세포동결제인 DMSO를세척하는지, 하지않는지에따라나눌수있다. 2. DMSO를세척하는전통적인방법은절차가복잡하고시간이오래걸리며, 경험이많은연구인력과복잡한시설이필수적으로실제수행할수있는기관이많지않다. 3. DMSO를세척하지않고, 직접해동후주입하는경우에도세포수나생착의속도에전혀차이가없어, 실제임상현장에서는실온에서 DMSO에의한전구세포손상을최소화하기위해세척을하지않고직접해동을하여가능한빨리주입하는것이권장된다. 3 제대혈해동시발생할수있는응급상황대처법 제대혈의안전한보관은성공적인이식을위해서필수적이며, 특히보관백이안전하게유지되는것은세포손실을막아주고, 오염을막기위하여매우중요하다. 제대혈보관백이보관중에파열되는비율은 3.5% 정도로보고되어있으며, 특히 2년이상냉동보관되어있는제대혈에서더많았다 (Thyagarajan et al., Transfusion 2008). 위의연구에서파열된 24개의제대혈에서시행한배양검사는모두음성이었다. 또한실제로파열된백으로이식을받은환자는이식결과에서특이소견은없었다. 제대혈을이식센터침대옆에서직접해동하는과정은냉동보관된자가조혈모세포를해동할때와동일하게살균된 지퍼락 (zip-lock) 백에넣고공기를뺀뒤단단히봉하여, 역시살균된 37±1 o C의식염수수조에서서서히흔들어녹인다. 해동되면서혹시혈액성분이파열된틈을통해빠져나오는지잘살펴야한다. 만일파열이발견되면, 파열된부분을확인하고추가적인누출이되지않도록해당부위를위쪽으로세우고남은해동절차를완료한다. 해동이완료되면, 파열된부위를확인하고헤모스탯 (hemostat) 으로막아서내부물질의유출을막는다. 만일연구실에서해동을하는경우라면파열된백을바로 ( 가능한생물안전작업대안에서 ) 더큰살균된트랜스퍼백으로옮겨담거나, 살균된주사기로뽑아내는것을권장하고, 해당제대혈로반드시그람염색과배양검사를시행한다. 68 제 6 장

73 파열된제대혈을이식받은경우, 예방적으로광범위항생제를사용하는것을고려한다 (Unniversity of Minnesota 에서는 ceftriaxone 과 vancomycin의병합요법을 3일간사용하였다 ). 예방적항생제는, 제대혈배양검사가음성일경우중단할수있다. 1. 환자의침대옆에서이식직전에해동을하는중에, 제대혈백의손상이발견되면, 즉시파열부위를확인하고추가적인누출이되지않도록해당부위를위쪽으로세우고남은해동절차를완료한다. 2. 해동이완료되면, 파열된부위를확인하고헤모스탯 (hemostat) 으로막아서내부물질의유출을막는다. 3. 제대혈주입전반드시그람염색과배양검사를시행한다. 4. 파열된제대혈을이식받은경우, 예방적으로광범위항생제를사용하는것을고려한다. 예방적항생제는, 제대혈배양검사가음성일경우중단할수있다. 4 냉동보관전제대혈데이터와이식기관에서해동시의제대혈데이터가다른경우의대처방법 제대혈은다른조혈모세포공급원에비하여약 10% 의조혈모세포 ( 총유핵세포수, CD34 양성세포, 집락형성단위 ) 용량을포함하고있으며, 모든단위가냉동보관되고있는특성이있다. 따라서해동이후세포손실을최소화하는것이중요하다. 대부분의제대혈에서해동후세포수의손실이발생하여총유핵세포수의 35% 까지도감소될수있음이보고되고있다 (Laroche et al., Transfusion 2005). 냉동전ㆍ후총유핵세포수와 CD34 양성세포수의감소는대부분나타나게되며, 총유핵세포수의감소는거의필수적이지만상대적으로 CD34양성세포수의감소는거의없다는보고도있다. 냉동전의수치가냉동후의수치와대부분비례하고 [ 그림 6-2], CD34양성세포수의검사방법의가장좋은방법을확인되지않은상태로, 현재까지는냉동보관전최대한세포수가높은제대혈을선택하는것이세포수손실을극복하는가장중요한방법으로보인다. [ 그림 6-2] 해동전후의세포수관계. (A) 해동후총유핵세포수는해동전세포수와비례한다 (n=71; r=0.90, P<0.001). (B) 해동후 CD34 양성세포수는해동전세포수와비례한다 (n=38; r=0.87, P<0.001) (Yoo et al. Bone Marrow Transplant 2007). 제대혈주입방법및주의할점 69

74 만일예상보다해동후세포수가터무니없이적게보고되었다면, 검체가응괴되지는않았는지, 검체의희석계수가잘못계산되었는지등을먼저확인한다. 재검및재확인후일단일반적인이식후절차를진행하여생착을기다린다. 또한여러연구에따르면냉동전ㆍ후제대혈제제정보에서호중구와혈소판의생착에중요한예측인자중하나가집락형성단위의수이다 (Page et al., Biol Blood Marrow Transplant 2011; Yoo et al., Bone Marrow Transplant 2007). 따라서세포수측정시과립구대식구집락형성단위분석을같이시행하는것이생착실패에대한예측에도움이될수있다 [ 그림 6-3]. [ 그림 6-3] 호중구생착에영향을주는인자분석. 투여된과립구대식구 - 집락형성단위와 CD34 양성세포수가생착된환자군에서더높았음 (A 와 C), 그러나총유핵세포수와 CD3 양성세포수는두그룹에서큰차이가없었다 (B 와 D). (Yoo et al. Bone Marrow Transplant 2007) [ 참고문헌 ] 1. Hahn T, Bunworasate U, George MC, et al. Use of nonvolume-reduced (unmanipulated after thawing) umbilical cord blood stem cells for allogeneic transplantation results in safe engraftment. Bone Marrow Transplant 2003;32: Laroche V, McKenna DH, Moroff G, et al. Cell loss and recovery in umbilical cord blood processing: a comparison of postthaw and postwash samples. Transfusion 2005;45: Lee HK, Ryu KH, Whang IT, et al. The improvement of cell viability due to dilution and removal of DMSO in thawing of stem cells. J Korean Pediatr Soc 2000;43: Nagamura-Inoue T, Shioya M, Sugo M, et al. Wash-out of DMSO does not improve the speed of engraftment of cord blood transplantation: follow-up of 46 adult patients with units shipped from a single cord blood bank. 70 제 6 장

75 Transfusion 2003;43: Page KM, Zhang L, Mendizabal A et al. Total colony-forming units are a strong independent predictor of neutrophil and platelet engraftment after unrelated umbilical cord blood transplantation : a single-center analysis of 435 cord blood transplants. 2011;17: Regan DM, Grunzinger Nelms LM, Wofford JD, et al. Comparison of cord blood product thawing methods on cell recovery and progenitor integrity. Biol Blood Marrow Transplant 2006;12: Regan DM, Wofford JD, Wall DA. Comparison of cord blood thawing methods on cell recovery, potency, and infusion. Transfusion 2010;50: Rubinstein P, Dobrila L, Rosenfield RE, et al. Processing and cryopreservation of placental/umbilical cord blood for unrelated bone marrow reconstitution. Proc Natl Acad Sci U S A 1995;92: Sánchez-Salinas A, Cabañas-Perianes V, Blanquer M, et al. An automatic wash method for dimethyl sulfoxide removal in autologous hematopoietic stem cell transplantation decreases the adverse effects related to infusion. Transfusion 2012;52: Thyagarajan B, Berger M, Sumstad D, et al. Loss of integrity of umbilical cord blood unit freezing bags: description and consequences. Transfusion 2008;48: Yoo KH, Lee SH, Kim HJ, et al. The impact of post-thaw colony-forming units-granulocyte/macrophage on engraftment following unrelated cord blood transplantation in pediatric recipients. Bone Marrow Transplant 2007;39: 제대혈주입방법및주의할점 71

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77 제 7 장 제대혈이식특이합병증및대처법

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79 제 7 장제대혈이식특이합병증및대처법 I. 이식편거부반응 (Graft rejection) 1 정의 생착실패 (graft failure) 는공여자세포가처음부터생착이안되거나, 처음에생착이되었다가소실되어나타난다. 이식편거부반응 (graft rejection) 은생착실패의주된원인으로공여자세포에대한환자의면역반응에의한다. 생착실패는조혈모세포의부족, 손상, 바이러스감염, 약물독성, 패혈증등에의해서도발생할수있다. 제대혈이식은생착지연이흔하므로언제부터생착실패로판단해야하는지결정하기어려우나여러연구들에서이식 28일째호중구 500/ L 미만이면서공여자유래조혈이없는경우생착실패로정의하고있다. 2 빈도 동종제대혈이식의경우환자와공여자간의 HLA 불일치정도가높고, 낮은세포수로인해생착실패의확률이높아, 초기에는한단위제대혈이식후 20% 이상의생착실패를보였다 (Barker et al., Blood 2010). 새로운전처치의도입과두단위이식의도입으로나아지기는하였으나아직도다른동종이식에비해높은생착실패율을보이고있다. 좋은이식성적을보인일본의한연구에서는골수제거전처치후한단위이식을시행하여 91% 에서백혈구회복을보였고, 5% 에서일차생착실패를보였다 (Takahashi et al., Blood 2007). 두단위이식초기연구에서골수제거전처치후이식을시행한경우백혈구생착은중앙값 23일 (15 41) 에이루어졌고, 성인비골수제거전처치를이용한이식의경우엔백혈구생착은 12일 (0 32) 에이루어졌으며, 이식 42일까지 92% 에서백혈구회복을보였다. 1차및 2차생착실패가 6.4% 와 7.3% 의환자에서발생하였으며, 지속적인생착의누적빈도는 85% 이었다 (Barker et al., Blood 2005; Brunstein et al., Blood 2007). 국내 236명소아환자에대한제대혈이식연구에서호중구생착은 18일 (11 84) 에되었고, 이식 60일까지백혈구회복률은 90.7% 이었다 (Yoo et al., Am J Hematol 2011). 따라서적어도 10% 15% 정도까지의생착실패율을염두에두어야할것으로생각된다. 제대혈이식특이합병증및대처법 75

80 3 위험인자 1) 세포수생착실패의위험을줄이기위해충분한수의세포를주입하는것이중요하며, 이전연구에서한단위이식을시행한경우주입된 CD34 양성세포수가 /kg 미만인경우백혈구생착에나쁜영향을미치는것으로밝혀졌다 (Wagner et al., Blood 2002). 국내연구에서도해동후주입된 CD34양성세포수가 /kg 이상일때, 그이하였던군에비해생착이유의하게빠른것을보여주었다. 따라서, 해동에따른소실률을고려하여충분한 CD34양성세포수를가지는제대혈을선택하는것이권장된다 (Yoo et al., Korean J Med 2014). 혈액종양질환에서골수제거전처치후한단위제대혈이식을받은환자들을 HLA 일치정도에따라분석하여보았을때이식 28일째호중구회복의확률은 8/8 HLA 일치이식에비해 3-5개불일치의경우낮았으며, 1-2 불일치의경우유의한차이는없었다 (Eapen et al., Blood 2014). 2) 공여자특이항HLA 항체면역학적거부반응은제대혈 HLA에특이적인환자의공여자특이항HLA 항체 (donor-specific anti-hla antibody, DSA) 등에의해발생할수있으며, 환자가가지고있지않은 HLA 에감작되어발생한다. 일본에서혈액종양으로골수제거전처치를이용한한단위제대혈이식을받은 386명환자들을후향적으로분석하여, 이식 60일호중구회복율이 HLA 항체가없는경우 83%, HLA 항체가있는경우 73% 였고, 특히 DSA 항체가있는경우 32% 로유의하게낮았다고보고하였다 (Takanashi et al., Blood 2010). 두단위이식에서 DSA의영향에대한한연구에서, 72% 의환자가저강도전처치를받았으며, DSA가없을때, 한개의제대혈에대해서있을때, 두개의제대혈에대해있을때생착실패율이각각 5.5%, 18.2%, 57.1% 으로유의한차이가있다고보고하였다 (Cutler et al., Blood 2011). 프랑스연구에선 294명의환자에서저강도전처치제대혈이식을받은환자를후향적으로분석한연구에서이식 60일째호중구생착의누적빈도는 DSA가있었던환자에서 44%, DSA가없었던환자에서 81% 로차이가있었다 (Ruggeri et al., Haematologica 2013), 그러나최근두단위제대혈이식을받은 DSA 양성환자에서지속적인공여자생착이가능하다는결과도발표되었다. 82명의혈액종양환자에서골수제거전처치후두단위제대혈이식을시행하였으며, HLA 항체가없었던경우 95% 에서지속적인공여자생착을보였고 ( 중앙값 23일 ), 비특이적 HLA 항체가있었던경우는 100% ( 중앙값 23일 ), DSA가있었던경우는 92% ( 중앙값 31일, P=0.48) 에서지속적인공여자생착을보였다. 두단위에대한 HLA 항체를가졌던 6명에서 1명은 100% 공여자키메리즘을보였으나생착실패되었고, 5명은한단위가생착되어환자가 DSA 를가지더라도골수제거전처치후두단위이식으로성공적인생착을할수있다고하였다 (Dahi et al., Biol Blood Marrow Transplant 2014). 논란의여지는있으나가능하면 HLA 항체를가지고있는환자의경우이에대한항원을가지는제대혈은선택에서배제하는것이좋겠다. 76 제 7 장

81 4 생착실패시대처방안 제대혈이식후생착지연은흔한현상으로생착지연과생착실패를명확히구별하는것은어려운문제이다. 자가조혈의회복이없다면생착실패의유일한완치방법은 2차조혈모세포이식으로어떤조혈모세포와전처치가적합한지명확하지않다. 공여자생착의가능성이없는경우에는 2차이식에대한빠른결정이필요하며, 대부분이다른공여자가없어서제대혈이식을한경우이므로 HLA 반일치혹은불일치혈연간이식이나, 2차제대혈이식을고려할수있다. 110명의소아를대상으로한연구에서, 이식 28일째호중구 500/ L 미만인경우생착지연으로, 공여자유래조혈이없는경우생착실패로정의하고이연구에서는이식 3주경에말초혈액으로키메리즘검사를시행하고, 호중구감소가계속되거나공여자세포가 5 95% 인혼합키메리즘을보이는환자들에선검사를반복하였다. 완전공여자키메리즘을보이는경우는적절한지지요법을하면서기다려보고, 혼합키메리즘을보인경우는검사를매주반복하여, 공여자생착이없거나감소하는경우에는이식으로진행하였다. 제대혈이식 28일째까지백혈구생착이되지않았던 33명의환자중 20명은이후에생착이되었고, 생착이되지않았던 10명에서일차이식후 일에 2차제대혈이식을시행하여 9명에서생착되었으며, 8명에서완전공여자키메리즘을보였고 6명이생존하였다. 처음키메리즘검사에서 5% 이하의공여자세포를보였던경우는이후비가역적인이식편소실을보였다고보고하였다 (Chan et al., Bone Marrow Transplant 2008). 생착실패에대한 2차이식으로 HLA 불일치혈연간이식을시행할수있다. T세포제거 HLA 불일치혈연간말초혈액조혈모세포이식을생착실패에대한 2차이식으로시행한연구에서는 1차제대혈이식후 14일, 28일째골수로키메리즘검사를시행하여이식 28일째공여자키메리즘이검출되지않은경우는생착실패로판단하고즉시가족공여자검색을시작하고, 혼합키메리즘의경우엔 1주마다키메리즘검사를시행하였다. 제대혈이식후생착실패한 11명에서 1차이식후 일에 2차이식을시행하여 7명에서중앙값 10일 ( 범위 : 일 ) 에생착되었으며, 생착되었던모든환자에서혈소판은 22일 (15 55) 에회복되었다. 이식 28일째생착누적빈도는 68% 이었고 2년전체생존율은 36% 를보였다 (Moscardo et al., Biol Blood Marrow Transplant 2014). 일본의레지스트리데이터를분석한후향적연구에서는제대혈이식후생착실패한 220명에서생착실패 3개월이내에 2차제대혈이식을받은 180명과말초혈액조혈모세포이식 24명, 골수이식 16명의성적을비교하였다. 공여자는대부분이혈연이고, 대부분이반일치공여자였다. 이식 30일에호중구생착의누적빈도는제대혈에서 39%, 말초혈액에서 71%, 골수에서 75% 로유의한차이를보였으며, 호중구생착일도각각 21일 (12 97), 18일 (0 37), 14.5일 (9 26) 이었다. 1년생존율은각각 25%, 58%, 38% 로말초혈액조혈모세포이식이제대혈이식에비해우수한것으로보고하였다 (Fuji et al., Biol Blood Marrow Transplant 2012). 생착지연시 [ 그림 7-1] 과같은접근방법을고려할수있을것으로생각된다. 여러연구들에서일차적으로이식 28일을기준으로생착실패를판단하고있으나, 제대혈이식시백혈구생착일중앙값이늦고, 지연성생착을고려하여야하므로, 일괄적인이차이식시점을정하기는어렵다. 환자의이식후공여자키메리즘의정도와추적검사에서공여자키메리즘의변화방향을고려하여, 이식 21일경, 혹은 28일에시행한검사에서공여자키메리즘이없는경우에는조기에 2차이식을준비하고, 혼합키메리즘인경우에는검사를반복하면서공여자키메리즘이감소하거나소실되는경우에는 2차이식으로진행하는것이좋을것으로생각한다. 제대혈이식특이합병증및대처법 77

82 [ 그림 7-1] 이식실패시키메리즘에따른대처방안 5 2 차이식시전처치 1차제대혈이식시사용한전처치및이식편거부반응을고려하여전처치가선택될것이므로어떤전처치를특별히추천할수는없으나, 면역억제효과가충분한전처치가필요하다. 참고로이전연구들에서사용했던 2차이식의전처치는 [ 표 7-1] 와같다. [ 표 7-1] 2 차이식의전처치예시 Reference Chan et al. (2008) Moscardó et al. (2014) Fernandes et al. (2007) Conditioning - CY 50 mg/kg (D-6)+ Flu 35 mg/m 2 (D-6 D-2) + TBI 2 Gy (D-1) +/- ATG 30 mg/kg (D-4 D-2) - TBI 6 Gy + Cy 120 mg/kg + extracorporeal photopheresis or Alemtuzumab 1 mg/kg (Aplastic anemia) - Flu 50 mg/m 2 (D-5 D-3) + ATG 2 mg/kg (D-5 D-2) (T cell depleted haploidentical PBSCT) - CY 50 mg/kg + Flu 90 mg/m 2 + TBI 2 Gy - CY 35 mg/kg + Flu 120 mg/m 2 + ATG 5 mg/kg [ 참고문헌 ] 1. Barker JN, Weisdorf DJ, DeFor TE, et al. Transplantation of 2 partially HLA-matched umbilical cord blood units to enhance engraftment in adults with hematologic malignancy. Blood 2005;105: Barker JN, Scaradavou A, Stevens CE. Combined effect of total nucleated cell dose and HLA match on transplantation outcome in 1061 cord blood recipients with hematologic malignancies. Blood 2010;115: Brunstein CG, Barker JN, Weisdorf DJ, et al. Umbilical cord blood transplantation after nonmyeloablative conditioning: impact on transplantation outcomes in 110 adults with hematologic disease. Blood 2007;110: Chan KW, Grimley MS, Taylor C, et al. Early identification and management of graft failure after unrelated cord blood transplantation. Bone Marrow Transplant 2008;42: Cutler C, Kim HT, Sun L, et al. Donor-specific anti-hla antibodies predict outcome in double umbilical cord 78 제7장

83 blood transplantation. Blood 2011;118: Dahi PB, Barone J, Devlin SM, et al. Sustained donor engraftment in recipients of double-unit cord blood transplantation is possible despite donor-specific human leukoctye antigen antibodies. Biol Blood Marrow Transplant 2014;20: Eapen M, Klein JP, Ruggeri A, et al. Impact of allele-level HLA matching on outcomes after myeloablative single unit umbilical cord blood transplantation for hematologic malignancy. Blood 2014;123: Fernandes J, Rocha V, Robin M, de et al. Second transplant with two unrelated cord blood units for early graft failure after haematopoietic stem cell transplantation. Br J Haematol 2007;137: Fuji S, Nakamura F, Hatanaka K, et al. Peripheral blood as a preferable source of stem cells for salvage transplantation in patients with graft failure after cord blood transplantation: a retrospective analysis of the registry data of the Japanese Society for Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2012;18: Moscardó F, Romero S, Sanz J, et al. T cell-depleted related HLA-mismatched peripheral blood stem cell transplantation as salvage therapy for graft failure after single unit unrelated donor umbilical cord blood transplantation. Biol Blood Marrow Transplant 2014;20: Ruggeri A, Rocha V, Masson E, et al. Impact of donor-specific anti-hla antibodies on graft failure and survival after reduced intensity conditioning-unrelated cord blood transplantation: a Eurocord, Société Francophone d'histocompatibilité et d'immunogénétique (SFHI) and Société Française de Greffe de Moelle et de Thérapie Cellulaire (SFGM-TC) analysis. Haematologica 2013;98: Takahashi S, Ooi J, Tomonari A, et al. Comparative single-institute analysis of cord blood transplantation from unrelated donors with bone marrow or peripheral blood stem-cell transplants from related donors in adult patients with hematologic malignancies after myeloablative conditioning regimen. Blood 2007;109: Takanashi M, Atsuta Y, Fujiwara K, et al. The impact of anti-hla antibodies on engraftment of unrelated cord blood transplantations. Blood 2010:116: Wagner JE, Barker JN, DeFor TE, et al. Transplantation of unrelated donor umbilical cord blood in 102 patients with malignant and nonmalignant diseases: influence of CD34 cell dose and HLA disparity on treatment-related mortality and survival. Blood 2002;100: Yoo KH, Lee SH, Sung KW, et al. Current status of pediatric umbilical cord blood transplantation in Korea: a multicenter retrospective analysis of 236 cases. Am J Hematol 2011;86: Yoo KH. Optimal selection of cord blood for hematopoietic stem cell transplantation. Korean J Med 2014;86: Yoshihara S, Ikegame K, Taniguchi K, et al. Salvage haploidentical transplantation for graft failure using reduced-intensity conditioning. Bone Marrow Transplant 2012;47: 제대혈이식특이합병증및대처법 79

84 II. 생착전증후군 (Pre-engraftment syndrome) 1 정의 Unexplained fever 38.3 o C not associated with documented infection and/or unexplained erythematous skin rash resembling that of acute GVHD, with either the fever or the rash occurring before or at neutrophil recovery 생착전증후군은특정병리조직학적소견및생화학적표지자가없는, 임상적현상을토대로하는용어이다. 이는 Kishi 등 (Transplantation 2005) 에의해 Pre-engraftment immune reaction 이라는명칭으로처음으로기술되었으며, 제대혈이식을시행받은성인들의약 78% 에서생착전 (before or at neutrophil recovery) 면역학적반응으로생각되어지는다양한임상양상을보고하였다. 이후여러문헌에서 early immune reaction, early inflammatory syndrome 등다양한명칭으로비슷한현상에대해보고하였고, 현재는 Patel 등 (Biol Blood Marrow Transplant 2010) 에의해제안된정의를사용하고있다. 2 발병원인 발병원인은명확하게밝혀져있지는않으나, 주입된제대혈과숙주와의면역반응이라여겨지며, cytokine storm의일종이라보는견해가지배적이다. 생착전증후군은제대혈이식에서만발생하는것은아니며, 골수및말초혈조혈모세포이식에서도보일수있으나, 주로제대혈이식에서보고되고있다. 일부에서는, 제대혈이식후발생하는면역반응을생착전후시기에따라생착전증후군 (PES), 생착증후군 (engraftment syndrome, ES), 생착후면역반응 (post-engraftment immune reaction) 으로구분하기도한다. 또한 Hong 등 (Bone Marrow Transplant 2013) 은 PES와 ES가임상적으로유사한점에착안해 Spitzer 등 (Bone Marrow Transplant 2001) 이제안한진단기준을따르되임상양상과호중구회복의시간관계를고려하지않고, peri-engraftment syndrome 이라는용어를정의하기도하였다. 3 빈도및임상양상 제대혈이식후생착전증후군의빈도는약 20 70% 정도로보고되고있으며, 2013년보고 (Park et al., Biol Blood Marrow Transplant 2013) 에따르면, 우리나라제대혈이식환자에서는약 26.8% 의빈도를보였다. 대개이식후약 1 2 주사이에일어나며, 원인불명의고열 ( 38.3 o C), 피부발진, 폐부종, 설사, 황달및전신부종으로인한체중증가 ( 이식전에비해 3% 이상증가 ) 등의임상양상을보인다 [ 그림 7-2]. 마치급성이식편대숙주병과 80 제 7 장

85 비슷한양상으로나타날수있으나, 이는발생하는시기가달라서구분할수있다. 일부에서는급성뇌증과같은신경증상을보이기도한다. [ 그림 7-2] 우리나라제대혈이식후발생한생착전증후군의후향적분석에서보인임상양상 (Park et al., Biol Blood Marrow Transplant 2013) 또한생착전증후군의경우감염에서보일수있는증세와비슷하므로, 반드시감염에대한전반적검사에서음성이어야하며, 광범위항생제에반응이없는경우에국한되어야하며, 약물관련알레르기반응또한배제되어야한다. 4 발생위험요인 위험요인으로거론되는것은다양하나, 일반적으로골수제거전처치요법을사용한경우, 주입된유핵세포가많을경우생착전증후군발생위험이더높은것으로알려져있다. 그외, HLA 불일치이식, 나이가어린경우생착전증후군발생위험증가와관계가있으며, 이식편대숙주병예방을위해 methotrexate 혹은스테로이드를사용한경우생착전증후군의빈도가낮았다고일부문헌들에서보고하고있다. 5 치료및예후 생착전증후군이임상적으로심할경우, 스테로이드를단기간사용해볼수있으며 (methylprednisolone IV 1 mg/kg/day, 3 7 일간 ) 대개 48시간이내에발열이호전되며, 이후다른증상들도점차호전을보인다. 고용량의장기간스테로이드의사용은감염발생률을증가시킬수있어추천되지않는다. 제대혈이식후생착전증후군을경험한환자들의경우, 세균및바이러스감염의증가, 급 / 만성이식편대숙주병의증가등과관계가있다는연구결과들이있다. 또한일부에서는생착전증후군의발생이생착의예측인자로사용될수도있다는보고를하였다. 하지만, 현재여러연구에비추어볼때질환의재발혹은이식후생존율에영향을미치지는않는것으로생각된다 [ 그림 7-3]. 제대혈이식특이합병증및대처법 81

86 [ 그림 7-3] 우리나라제대혈이식후생착전증후군 (pre-engraftment syndrome, PES) 발생여부에따른생존율곡선 (Park et al., Biol Blood Marrow Transplant 2013) [ 참고문헌 ] 1. Frangoul H, Wang L, Harrell FE Jr, et al. Preengraftment syndrome after unrelated cord blood transplant is a strong predictor of acute and chronic graft-versus-host disease. Biol Blood Marrow Transplant 2009;15: Hong KT, Kang HJ, Kim NH, et al. Peri-engraftment syndrome in allogeneic hematopoietic SCT. Bone Marrow Transplant 2013;48: Kishi Y, Kami M, Miyakoshi S, et al. Early immune reaction after reduced-intensity cord-blood transplantation for adult patients. Transplantation 2005;80: Lee SW, Lee YH, Noh KT, et al. Pre-engraftment syndrome in allogeneic hematopoietic stem cell transplantation. Korean J Pediatr Hematol Oncol 2005;12: Lee YH, Lee SW, Noh KT, et al. Early inflammatory syndrome following cord blood stem cell transplantation. Korean J Hematol 2004;39: Narimatsu H, Terakura S, Matsuo K, et al. Short-term methotrexate could reduce early immune reactions and improve outcomes in umbilical cord blood transplantation for adults. Bone Marrow Transplant 2007;39: Park M, Lee SH, Lee YH, et al. Pre-engraftment syndrome after unrelated cord blood transplantation: a predictor of engraftment and acute graft-versus-host disease. Biol Blood Marrow Transplant 2013;19: Patel KJ, Rice RD, Hawke R, et al. Pre-engraftment syndrome after double-unit cord blood transplantation: a distinct syndrome not associated with acute graft-versus-host disease. Biol Blood Marrow Transplant 2010;16: Saliba RM, de Lima M, Giralt S, et al. Hyperacute GVHD: risk factors, outcomes, and clinical implications. Blood 2007;109: Spitzer TR. Engraftment syndrome following hematopoietic stem cell transplantation. Bone Marrow Transplant 2001;27: Wang X, Liu H, Li L, et al. Pre-engraftment syndrome after unrelated donor umbilical cord blood transplantation in patients with hematologic malignancies. Eur J Haematol 2012;88: 제 7 장

87 III. 감염및모니터링 1 제대혈이식과감염 조혈모세포이식을시행받는환자들은대부분난치성혈액질환이나종양질환, 또는면역계질환을가진환자들로감염성합병증발생에취약하며, 조혈모세포이식시에는더욱심한면역저하가동반되기에감염성합병증의예방과치료가중요하게고려되어야한다. 하지만, 감염에대한적극적인예방, 치료제의개선, 진단법의발전, 그리고이식관련기술의향상등에도불구하고, 감염성합병증은조혈모세포이식을시행받은환자들의재원기간을연장시키거나사망에이르게하는주된이유들중하나이다 (Gratwohl et al., Bone Marrow Transplant 2005). 특히골수나말초혈조혈모세포를이용하는이식에비해제대혈이식에서는생착지연으로인해상대적으로긴호중구감소기간과더딘림프구회복등으로감염성합병증으로인한사망률이더욱높다 (Laughlin et al., N Engl J Med 2004) 따라서제대혈이식시에는감염성합병증의발생에영향을줄수있는여러가지임상요소, 예를들어환자의나이, 소아와성인, 이식된조혈모세포의수, 생착지연의정도, 이식편대숙주병의유무및정도, 기저질환의치료정도, 이식후경과기간등을전체적으로고려하여발생률이높을것으로예상되는감염질환들에대해적절한예방과조기발견을위한정기적감시검사를시행하는것이중요하다 (Safdar et al., Medicine 2007). 2 동종조혈모세포이식에서의시기에따라고려해야하는감염원 제대혈이식에서도동종조혈모세포이식에서일반적으로고려되어야하는다양한감염원들에대한예방과감시지침을동일하게따르는것이권장되며, 추가적으로제대혈이식에서좀더호발하는몇몇감염성질환들에대한적절한지침을가지는것이중요하겠다. 따라서, 현재제대혈이식시예방적치료가통상시행되지는않지만임상적으로중요한감염에관한감시, 예방, 및선제치료에대해다루고자한다. 제대혈이식을포함하는동종조혈모세포이식에서고려해야하는감염원을시기별로정리하면 [ 그림 7-4] 과같다. 제대혈이식특이합병증및대처법 83

88 [ 그림 7-4] 동종조혈모세포이식후시기별로발생하는감염원 (Tomblyn et al., Biol Blood Marrow Transplant 2009) 1) 거대세포바이러스 (Cytomegalovirus, CMV) CMV 는헤르페스바이러스 5형 (Herpes virus type 5) 에해당하는바이러스로국가와인종에따라차이가있으나일반적으로약 40 80% 의사람들이소아기에감염되며, 감염후잠복상태로체내에서존재하다가이식시와같이면역이저하되는경우에재활성화되어질병을일으키게된다. 최근에는예방또는선제치료가이루어지고있어이전에비해발병률이감소하긴했지만, 아직까지이식환자의주요사망원인들중하나이다 (Boeckh et al., Blood 2004). CMV- 혈청양성인공여자로부터 CMV- 혈청음성인환자에게이식이이루어지는경우, 감염률이더증가하여 CMV질환예방의대상이되는것으로알려져있고특히제대혈이식시에 CMV-혈청양성제대혈로부터이식받는경우이식후 CMV감염이증가하는것으로보고되고있다 (Mikulska et al., Biol Blood Marrow Transplant 2012; Matsumura et al., Biol Blood Marrow Transplant 2007). 하지만현실적으로국내정상인의 CMV- 혈청양성률이매우높아공여자와환자모두혈청양성인경우가대부분이다 (Hahn et al., Korean J Blood Transfus 1990). (1) 감시및진단 (screening and diagnosis) CMV 감염 / 재활성화를확인하는진단법으로는백혈구내 CMV항원을확인하는항원검사, RT-PCR 을이용하여 CMV-DNA 를질적또는양적으로측정하는검사가대표적이며이중후자의민감도가가장높다 (Boeckh et al., J Clin Microbiol 2004). 항체를확인하는혈청학검사는 CMV 감염 / 재활성화를확진하기에부족하며이식전공여자와환자의혈청양성여부를확인함으로써감염 / 재활성화의위험도를예측하는정도로만이용된다. 이외조직에서 CMV에감염된세포를확인하거나 mrna를확인하는방법등도있다. 이식을시행하는기관에서는백혈구내 CMV 항원, CMV-DNA, 84 제 7 장