1. Aetna considers donor lymphocyte infusion (DLI) medically necessary for persons who have a prior, medically necessary allogeneic bone marrow or peripheral stem cell transplantation.

2. Aetna considers the modification of donor lymphocytes (e.g., donor lymphocyte depletion, ex-vivo expansion, expanding antigen-specific T-cell lines, T-cell depletion, genetic modification) experimental and investigational because the clinical value of these approaches in the treatment of malignancies has not been established.

See also CPB 0641 - Adoptive Immunotherapy and Cellular Therapy.

High-dose chemotherapy (HDC) in combination with allogeneic bone marrow transplantation results in remission in significant numbers of patients with chronic myelogenous leukemia (CML), acute myeloid leukemia (AML) or acute lymphocytic leukemia (ALL).  However, disease relapse is a major cause of treatment failure, and salvage treatment options for these patients are limited.  Patients can either be treated with an additional course of conventional chemotherapy or a second round of HDC and repeat allogeneic transplantation.  Conventional chemotherapy is unlikely to result in a complete durable remission, and the morbidity and mortality of a second allogeneic transplant is unacceptably high.  Furthermore, patients with CML have been treated with interferon.  While this treatment can be associated with normalization of peripheral blood counts, interferon fails to eradicate the malignant clone of cells.

Donor lymphocyte infusion (DLI), also known as donor leukocyte or buffy coat infusion, has been used in an attempt to stimulate a donor-versus-leukemia (GVL) reaction and thus eradicate the malignant clone of cells.  Donor lymphocyte infusion entails the collection (from the original donor) of peripheral lymphocytes during an apheresis procedure; donors generally undergo 2 to 8 procedures.  The lymphocytes are then simply infused into the patient either immediately or after frozen storage.  Donor lymphocyte infusion differs from allogeneic bone marrow transplantation in that it is not preceded by chemotherapy and T cells are not depleted.  Lymphocyte infusion with a defined T-cell dose can cause a profound GVL effect and is an effective form of salvage immunotherapy in allogeneic marrow transplanted recipients.  The advantage in using DLI versus second allogeneic transplantation is the lower treatment-related morbidity and mortality.

The GVL effect is a well-described phenomenon, which is associated with the presence of graft-versus-host disease (GVHD).  For example, the likelihood of relapse post-allogeneic transplantation is lower in those patients who experience either acute or chronic GVHD.  In addition, there is a higher rate of relapse in patients receiving a syngeneic (identical twin) transplant compared to allogeneic transplant.  However, the presence of GVL is not dependent on the presence of GVHD.  For example, the rate of leukemic relapse is higher in patients receiving T- cell depleted allogeneic marrow, even after controlling for the degree of GVHD.  This observation suggests that there may be a distinct subset of T cells responsible for GVL.  Donor lymphocyte infusion attempts to harness the anti-leukemic properties of donor T cells.

In a recent review on adoptive allogeneic cellular therapy, Peggs and Mackinnon (2001) stated that DLI is effective in generating anti-tumor responses, especially for relapsed chronic-phase CML.  Response rates and durability appear lower with myeloma, AML and myelodysplasia syndrome, and minimal with ALL.  There is relatively little data on indolent lymphoid malignancies.  This is in agreement with the observation of Slavin and associates (2001) who reported that pre-clinical and clinical studies have indicated that much more effective eradication of the host immunohematopoietic system cells can be attained by adoptive allogeneic cellular therapy with DLI following bone marrow transplantation.  Thus, eradication of blood cancer cells, particularly in patients with CML and, less frequently, in patients with other hematological malignancies, can frequently be achieved despite the complete resistance of such tumor cells to maximally tolerated doses of chemo- and radio-therapy.

In a review on DLI for the treatment of hematologic malignancies in relapse following allogeneic blood or marrow transplantation, Luznik and Fuchs (2002) reported that DLI induces complete remissions in the majority of patients with CML in early-stage relapse and in less than 30 % of patients with relapsed acute leukemia, myelodysplasia, and multiple myeloma.  Remissions of chronic-phase CML induced by DLI are durable, but as many as half of patients with other diseases ultimately relapse.

Pre-planned DLI has also been used as part of transplant protocols in persons with hematologic malignant diseases who have not relapsed.  Donor lymphocyte infusion is intended to facilitate establishment of full donor chimerism (complete donor stem cell grafting in the recipient's bone marrow) and potentiation of anti-tumor effect (graft-versus-tumor reaction) (Cheong et al, 2002).

There is also ongoing research on the genetic modification of donor lymphocytes.  Transplantation of suicide gene modified allogeneic T lymphocytes is an approach to prevent T-cell mediated GVHD while preserving the GVL effect of an allograft.  However, existing techniques allow insufficient transduction of T lymphocytes.  Further investigation is needed to develop more efficient gene transfer protocols and is possible value in the treatment of hematological malignancies.

Beitinjaneh et al (2012) stated that the role of DLI in mediating the graft-versus-myeloma (GVM) effect after allogeneic hematopoietic stem cell transplant (allo-HCT) is not clearly defined.  These investigators evaluated the safety and utility of DLI in patients with either persistent or recurrent multiple myeloma (MM) after allo-HCT.  A total of 23 patients with MM received DLI after allo-HCT between July 1996 and June 2008 were included in this study.  Eight patients received preemptive DLI for residual disease (RD) while 15 patients received DLI for the treatment of recurrent or progressive disease (PD).  These researchers evaluated the response to DLI and the factors that may predict a response.  Median DLI dose was 3.3 × 10(7) CD3 + cells (range of 0.5 to 14.8 × 10(7)).  Grade II to IV acute GVHD was seen in 5 patients (22 %).  Median follow-up in surviving patients was 24 months.  Five of 23 patients (22 %) achieved a complete or a very good partial response (2 CR, 3 VGPR), while 8 patients (34 %) had stable disease (SD) after the DLI.  Patients who received DLI for RD had a higher response rate (greater than or equal to VGPR 50 % versus 7 %, p = 0.03), a longer overall survival (28.3 versus 7.6 months, p = 0.03) and a trend toward longer progression-free survival (11.9 versus 5.2 months, p = 0.1).  In this largest single institution study, the authors concluded that the use of preemptive, non-manipulated DLI for RD after reduced-intensity conditioning allo-HCT is encouraging, and it was associated with a higher response rate and a longer overall survival when given preemptively.  They stated that the role of DLI needs to be further explored in prospective clinical trials.

According to the 2009 edition of Thomas’ Hematopoietic Cell Transplantation, in patients with poor graft function  following allogeneic transplantation, CD34+ selected cell boost following granulocyte-colony stimulating factor (G-CSF) mobilization was associated with a high likelihood of hematopoietic cell recovery and a low risk of GVHD. Patients did not receive conditioning prior to the CD34+ cell boost. It is unclear how long to wait before requesting a second donation of cells.

An UpToDate review on “Immunotherapy for the prevention and treatment of relapse following hematopoietic cell transplantation” (Negrin, 2014) states that “Various techniques have been used to manipulate the donor lymphocyte graft in an effort to increase the lymphocyte specificity to eradicate tumor while minimizing effects on the host.  As yet, these techniques are considered experimental and require further study in humans before they can be widely applied”.