bluuebunny/crossref_metadata_2025 huggingface dataset:
Thalidomide +/− Corticosteroids for the Treatment of Multiple Myeloma Patients ≥ 70 Years of Age.
Authors: Reece Donna E. , Chen Christine , Trudel Suzanne , Mikhael Joseph R. , Chang Hong , Stewart A. Keith
Published: April 2020

Between September 2000 and July 2004, 33 multiple myeloma (MM) patients (pts) ≥ 70 years of age were treated with thalidomide (THAL) alone (4 pts) or THAL plus corticosteroids (CS) (29 pts). Two were treated at diagnosis while 31 received THAL +/− CS after a median of 2 (range 1–5) prior regimens. Prophylactic anticoagulation was not routinely given. In most pts, the THAL dose was slowly increased as tolerated to a maximum of 200 mg/day. Initial CS therapy was pulse dexamethasone (DEX) in 14 and prednisone 50–100 mg every 2 days in 15 pts; in 4, the DEX dose was reduced or changed to prednisone when responses were noted and/or CS toxicity was encountered. Median age was 73 (range 70–88) yrs; median beta2-microglobulin level was 403 (range 153–2120) nmol/L and CRP level 4 (range 1–91) mg/L at referral. MM subtype was IgG kappa:lambda (8:12 pts), IgA kappa:lambda (6:4 pts), light chain kappa:lambda (1:1 pts) and IgD kappa (1pt). Initial stage was IIIA:B in 20:5, IIA:B in 3:1 and IA in 4 pts. Cytogenetic studies were available in 11, of whom 1 had t(4;14), 2 complex changes, 1 monosomy 7 and 1 other abnormalities. Eighteen pts had significant cardiac disease, 3 vascular disease and 4 diabetes at the time therapy was initiated. Four had other hematological malignancies noted before/shortly after THAL +/− CS was started, including MDS in 2, essential thrombocytosis in 1 and AML in 1. The median maximum dose of THAL was 150 (range 50–400) mg and the median duration of therapy was 7 (1.5–19+) mos. To date, 14 (42%) pts have achieved PR and 5 (15%) MR; four (12%) experienced stable disease. The median duration of response was 7 (range 1.5–23+) mos. Fatigue/sleepiness (5), syncope (2), peripheral neuropathy (4) and other reasons (4) necessitated THAL dose reductions in 15 pts; 7 pts stopped THAL due to toxicity. Two TIAs and 1 DVT were observed; 2 of these pts received appropriate medical therapy and continued THAL without further vascular complications. No treatment-related deaths occurred. Eleven of 33 (33%) remain on THAL +/−CS. The actuarial overall survival rate was 80% at 1 year and 55% at 2 yrs after starting THAL +/− CS therapy, while the progression-free survival rate was 42% and 20% at 1 and 2 yrs, respectively. We conclude: 1) THAL +/−CS can be given safely in elderly MM pts, although dose reductions are usually needed; 2) MM response/stabilization was achieved in 69%; 3) THAL +/− CS therapy offers a median benefit of 7 mos in poor prognosis elderly MM pts.
Effect of Rituximab on the Incidence of GVHD in Lymphoma Patients who Received the BEAM-Conditioning and an Allogeneic Stem Cell Transplantation.
Authors: Khouri Issa F. , Saliba Rima M. , Couriel Daniel R. , Okoroji Grace-Julia , Acholonu Sandra , Maadani Farzaneh , Champlin Richard E.
Published: April 2020

It has been postulated that B cells functioning as antigen-presenting cells may have an important role in the pathogenesis of GVHD. Depletion of donor cells from B-cells resulted in a low incidence of GVHD in mouse model (Schultz et al. BMT1995:16:289–289). More recently, we observed a lower incidence of chronic (and to a lesser extent acute GVHD) in patients with CLL who received an allogeneic stem cell transplantation after a non-myeloablative conditioning regimen containing rituximab (Exp Hematol32:28–35, 2004). The purpose of this study is to investigate the effect of rituximab on GVHD in the setting of a more intense chemotherapy with BEAM, in patients who received an allogeneic peripheral blood stem cell from HLA-identical siblings.

To test this hypothesis, we retrospectively studied 11 consecutive patients with non-Hodgkin’s lymphoma who received BEAM/Rituximab at the M. D. Anderson Cancer Center. We attempted to match these patients by age, donor-recipient gender, and donor-recipient CMV reactivity to a historical control of 44 patients with lymphoma, who received BEAM alone as a conditioning regimen, without the Rituximab. Tacrolimus and methotrexate were used for GVHD prophylaxis in both groups. A total of 10 patients in the study group, could be matched with 19 patients in the control group and were included in the final analysis. The outcome of the 2 groups is shown below:

Rituximab-Study Group Control Group -value P No. of patients 10 19 Median age 41 44 0.4     (range) (19–55) (19–60) Patient-Donor sex-matched 9(82%) 18(95%) 0.6 Median # CD34 + cells infused (106/kg) 5.1 4.73 0.1 Patient or Donor CMV+ 9(82%) 18(95%) 0.6 Patient and Donor CMV − 1(10%) 1(5%) Median # prior chemoregimens 3 3 0.9     range (1–8) (1–9) Median follow-up 17 38     range (8–48) (27–77) Acute GVHD 2–4 (n,%) 5(50%) 7(37%) 0.5 Acute GVHD 3–4 (n,%) 3(30%) 5(26%) 0.6 Chronic GVHD (n, % cumulative incidence) 8 (90% + 15) 10 (53% + 12 0.01

Our data suggest that the described protective effect of Rituximab against GVHD in mouse models or in the setting of non-myeloablative allogeneic transplantation, may be overcome by the BEAM. This more intense conditioning regimen may induce more GVHD by enhancing T-cell cytokines release and by causing more gastrointestinal toxicity, thus allowing for a greater antigen presentation.
G-CSF Activated Granulocytes Inhibit Experimental Graft-versus-Host Disease.
Authors: Vasconcelos Zilton F.M. , Farache Julia , Grad Bruna M. Santos , Grad Tereza S. Palmeira , Bouzas Luis Fernando , Bonomo Adriana C.
Published: April 2020

Acute Graft versus host diseas (aGVHD) is a major complication of stem cell transplantation. The disease is mediated by T cells and a higher incidence/severity would be expected when higher numbers of T cells are inoculated. However, the incidence of aGVHD in PBST, which carries about 10 times more T cells then BMT, is not higher than the one found in later. This finding indicates a modulatory role for G-CSF over T cell activity. We had previously shown that T cells from G-CSF treated PBSC donors do not produce g-IFN nor IL-4 and that this inhibition was mediated by low density, G-CSF activated, granulocytes. In order to test if in fact G-CSF activated granulocytes could inhibit disease, we first checked if G-CSF could generate low density granulocytes, in vivo and in vitro. Indeed, either in vivo(21mg /day - 5 days) or in vitro (150 ng -12hs) with G-CSF generates low density granulocytes which co-purify with the mononuclear cells in the ficoll® gradient. Moreover, as we had shown in humans, these low density cells, inhibit the production of g-IFN by anti-CD3 activated T cells on flow cytometry studies (17%-T cells alone versus 3% T cells with granulocytes 1:1).

Radiation quimaeras were set with (B6 X BALB/c)F1 as hosts reconstituted with T cell depleted C57Bl6 bone marrow, in the presence or absence of nylon wool selected spleen cells (NWSC), as T cell source, from normal or G-CSF treated mice. As previously shown by others, NWSC from G-CSF treated mice diminishes the incidence of acute disease on day 20 post-transplant, from 75 to 25%. In order to investigate if this inhibition was dependent on the activated granulocytes present in the NWSC from G-CSF treated mice, granulocytes were depleted with anti-GR1 and complement. In this case, the incidence of disease is the same or even higher (75% experiment#1 and 100% in experiment #2) than the one observed on the control group (NWSC from control mice). These results strongly suggest that activated granulocytes could indeed inhibit aGVHD.

We then generated activated granulocytes in vitro, by treating spleen derived high density granulocytes with 150ng of G-CSF for 12 hs. After the incubation period, a new ficoll® gradient was performed and the low density cells were obtained. T cell contamination on the second gradient was eliminated by anti-CD4 and CD8 complement lysis. These activated granulocytes were inoculated together with NWSC from control mice in the radiation quimaeras at a 1:1 ratio. In this case 100% disease inhibition was observed when compared to the positive control group, where 75% of the animals got sick. Our data indicate that activated granulocytes are the major mediators of the G-CSF immunossupressive effects and that these cells can be used as a novel immune modulator in clinical transplantation to prevent acute GVHD.
Lymphocyte Function and Molecular Mechanisms of Enhanced Immune Reconstitution Following Sex Steroid Ablation and Hemopoietic Stem Cell Transplantation (HSCT).
Authors: Goldberg Gabrielle L. , Alpdogan Önder , Muriglan Stephanie J. , Hammett Maree , Milton Morag K. , Eng Jeffrey M. , Hubbard Vanessa M. , Kochman Adam , Willis Lucy M. , Greenberg Andrew S. , Tjoe Kartono H. , Sutherland Jayne S. , Chidgey Ann , Boyd Richard L. , van den Brink Marcel R.M.
Published: April 2020

Age-related thymic atrophy plays a significant role in delayed immune reconstitution in older recipients after hemopoietic stem cell transplantations (HSCT). Sex steroid ablation has been shown to reverse thymic atrophy and previously we have shown that in syngeneic and allogeneic models of HSCT, sex steroid ablation enhances immune reconstitution. Donor-derived HSC numbers, as well as precursor T and B cells are increased in castrated mice following HSCT. These primary changes lead to an increase in both T and B cells in the periphery. The current study examined both the molecular mechanisms behind this enhanced reconstitution and the function of the lymphocytes produced. Bone marrow (BM) and thymic stromal cell (TSCs) populations were analysed using RT-PCR and were tested for the production of growth factors previously implicated in immune reconstitution. Functional studies including proliferation and cytotoxicity assays and intracellular cytokine production showed that on a per cell basis, there was no difference between the T cells from castrated and sham-castrated mice, following allogeneic HSCT. In vivo immune function was assessed using a delayed type hypersensitivity assay. Six weeks after HSCT the DTH response was enhanced in the castrated mice compared to sham-castrated controls. The combination of a) the increased number of donor-derived lymphocytes and b) intact T cell function, result in an overall increase in immune response (as determined by DTH) in castrated recipients of allogeneic HSCT. This enhanced function may be related to changes seen in growth factor production in the thymus and bone marrow.
Current Activities of AsiaCORD: Fast Searching System of the Qualified Cord Blod Units for Asian Patients.
Authors: Takahashi Tsuneo A. , Lin Kai Hsin , Han Hoon , van Binh Tran , Binh Nguyen Tan , Han Zhongchao , Liu Kai Yan , Issaragrisil Surapol , Kodo Hideki , Asano Shigetaka , Lu Dao Pei
Published: April 2020

The necessities of cord blood transplantation and banking are increasing rapidly in Asian countries as well as others around the world. In China nearly 20,000 units are cryopreserved and more than 100 patients have received transplants using these units. In Japan, more than 17,000 units are cryopreserved and archived in Japan Cord Blood Bank Network and 1,700 patients have received transplants using these units. Adoption of this new medical technology is particularly rapid in Asia because of smaller family size, which makes it difficult to find matched bone marrow donors for patients and treat them by bone marrow transplantation. To facilitate cord blood searching and develop cord blood transplantation, the network of cord blood banks in Asia, AsiaCORD, was founded in November 2000 in Bangkok, Thailand.

The members of AsiaCORD are the leading public cord banks in Asia; Bangkok (Thailand), Beijing(China), Ho Chi Minh City (Viet Nam), Seoul (Korea), Taipei (Taiwan), Tianjin (China) and Tokyo (Japan). AsiaCORD has established a statute and standards for cord blood banking that is based on the International Standards of FACT/NETCORD while also reflecting each country’s standards, ethics, historical background and epidemiology. The banks have been inspected by inspectors composed with multi centers of AsiaCORD based on the standards. An electronic search system (http://asiacord.org) has been developed and transplantation were performed through the system. A more advanced interactive web site for transplant physicians to directly search AsiaCORD inventory for their patients is under preparation.

AsiaCORD is open to membership applications from additional cord blood banks in Asia who are able to comply with the standards and share their goal to supply cord blood units of only the highest quality to patients in Asia and also those living in all over the world.

The AsiaCORD Inventory and Use (August2004)

CB BANK Inventory Transplanted Children Adults Beijing 5800 70 44 26 Tianjin 5400 15 10 5 Seoul 32000 84 80 4 Taipei 6700 9 9 0 Ho Chi Minh 1076 7 7 0 Bangkok 315 1 1 0 Tokyo 5563 277 105 172 Total 56854 463 256 207
Quality Control of Cell Processing and Cord Blood Storage Using HALO To Measure Proliferative Potential of Stem and Progenitor Cells.
Authors: Rich Ivan N. , Hall Karren , Bartelmez Stephen H.
Published: April 2020

Prior to the introduction of flow cytometry to detect and measure CD34+ cells in the early 1980s, quality control of stem cell transplants was performed using the granulocyte-macrophage colony-forming assay (GM-CFC). The major disadvantages of this growth potential assay are that progenitor and not stem cells are detected and the assay takes too long to perform. Yet, measurement of the growth potential of proliferating cell populations in vitro is the only technique that guarantees the presence of stem cells after cell processing and may predict engraftment and reconstitution. There are no assays presently that exhibit these characteristics in real-time. However, it is now possible to measure the proliferative potential of stem and progenitor cells after cell processing and/or storage in half the time required by the classical colony-forming assay (CFA). Originally developed for hemotoxicity testing for all stages of drug development, HALO (Hematopoietic/Hemotoxicity Assays via Luminescence Output) can be used as an in-line stem cell processing quality control procedure as well as a method to ensure the growth potential of processed and stored umbilical cord blood. HALO sensitively measures small numbers of proliferating cells and because cell differentiation is not detected, manual enumeration of colonies is not required. The assay is based on the CFA procedure. However, as cells proliferate in response to growth factors, there is a proportional increase in the intracellular ATP concentration. The assay is performed in a 96-well plate and release of intracellular ATP drives a luciferin/luciferase reaction to produce bioluminescence in the form of light measured in a plate luminometer. The kinetics of most hematopoietic proliferating populations, including mature stem cells, allows results to be obtained after 6–7 days in culture. Measurement of luminescence for all 96 well cultures takes about 5 minutes. An ATP standard dose response performed prior to sample measurement not only provides quality control of the reagents used, but intra- and interlaboratory comparison of results. Due to the rapid and easy set-up procedure with high-throughput capability, the proliferative capacity of several stem and progenitor cell populations from either single or large numbers of samples from bone marrow, peripheral blood or cord blood can be analyzed simultaneously. Rapid assay turnaround and multiparameter capability should therefore allow an increased safety factor for patients undergoing stem cell transplantation. Additional studies are underway to further validate this approach.
Analysis of Chimerism Induction Following Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) with a Reduced-Intensity Regimen.
Authors: Kojima Rie , Heike Yuji , Narumi Jun , Yamagata Shizuka , Chizuka Aki , Nosaka Kisato , Kami Masahiro , Mori Shin-ichiro , Tanosaki Ryuji , Tobinai Kensei , Takaue Yoichi
Published: April 2020

 Although the analysis of chimerism induction has become an important diagnostic tool for providing better clinical management of patients undergoing allogeneic HSCT, the techniques have not been fully standardized. Moreover, it is currently unknown whether the onset of graft-versus-host disease (GVHD) is related to the status of mixed chimerism (MC) or complete donor-type chimerism (CDC).

 First, to validate our chimerism analysis system, we performed experiments with artificially mixed cell samples from healthy volunteers to examine the reliability of short tandem repeat (STR) determination by quantitative polymerase chain reaction (PCR). We confirmed a linear correlation between the proportion of mixed cells and the calculated ratio, with a correlation coefficient of 0.99, which enables the detection of target cells at 3% (median standard deviation, 1.6%). Next, using this validated system, we prospectively evaluated the kinetics of chimerism in CD3+, CD19+, and peripheral blood mononuclear cells (PBMC), for correlation with the occurrence of GVHD in 19 patients with various hematological diseases (median age, 53y) who had received allogeneic HSCT from an HLA-identical sibling donor between July 2003 and February 2004. The preparative regimen was fludarabine/busulfan (BU) (n=12) or cladribine/BU (n=7). GVHD prophylaxis consisted of cyclosporin alone (n=8), cyclosporin plus short-term methotrexate (n=7), or tacrolimus (n=4). Chimerism analysis was repeated weekly after transplantation.

 We evaluated 405 consecutive blood samples from these 19 recipients, 12 of whom developed acute GVHD. Six of these 12 patients showed MC, i.e. 91% (83–94%; MC) donor cells in the CD3+ fraction at the onset of GVHD, but all except one subsequently achieved CDC within a median of 15 (7–33) days without additional DLI. The remaining patient showed persistent MC and relapsed 158 days after transplantation.

 We found that the presence of MC in the CD3+ fraction is rather common at the onset of acute GVHD, but GVHD subsequently eradicates residual host hematopoietic cells. Alternatively, GVHD is part of a clinical manifestation of an immune reaction that is related to the induction of CDC.
Rapid Ex Vivo Expansion of CMV Specific CTL Suitable for Clinical Immunotherapy Using CpG-DNA Matured PBMC Infected with Recombinant MVA.
Authors: Diamond Don J. , Wang Zhongde , Lacey Simon F. , La Rosa Corinna
Published: April 2020

Adoptive transfer of ex vivo expanded CMV-specific T cells is an effective approach, and an attractive alternative to using anti-virals to manage CMV infection for HSCT recipients. We recently published a robust approach to expanding CMV-specific CTL based on infection of autologous EBV-LCL with the attenuated poxvirus, Modified Vaccinia Ankara (MVA), expressing CMV pp65, pp150, and IE1 proteins. This approach causes vigorous, up to 500fold expansions in as little as 12–14 days of memory CD8+ T cells specific for these immunodominant antigens. In order to improve the specificity of the expanded T cells, a method was sought to derive effective antigen presenting cells (APC) that avoided the use of EBV-LCL. Of equal importance is to develop an expansion approach that avoids the need to involve virally infected APC in developing a clinical product. Our preliminary observation is that rMVA can infect PBMC in vitro, causing high levels of expression of recombinant CMV antigens. To be permissible for high level expression from rMVA, fresh PBMC were treated with different combinations of single-stranded CpG-containing phosphorothioate backbone oligonucleotides (ODN). A three-day incubation with a combination of two ODN (ODN # 2006 and 2216) which are known to stimulate both plasmacytoid dendritic and B-cells were found to reproducibly generate a highly rMVA infectable population of PBMC. In all five healthy CMV-positive donors tested, CpG ODN treated autologous PBMC, infected with recombinant rMVA, elicited a 20-fold average expansion of CMV-specific CD8+ T cells, in 10 days. Several different rMVA expressing CMV genes were evaluated, including a novel vector expressing the UL44 gene product, an immunodominant target of the host cellular immune response. The expanded T cell populations showed minimal alloreactivity, and exhibited high levels of CMV-specific MHC Class I tetramer binding, epitope-specific cytokine production, and cytotoxic activity. The availability of a source of autologous professional APC that can be used after only 3 days of priming, enhances the attractiveness of using rMVA for adoptive immunotherapy for HSCT recipients or donor vaccination.
Comparison of Lung Function after Nonmyeloablative Versus Myeloablative Allogeneic Hematopoietic Stem Cell Transplantation.
Authors: Chien Jason W. , Maris Michael B. , Parimon Tanyalak , Sandmaier Brenda M. , Maloney David G. , Storb Rainer F. , Clark Joan G.
Published: April 2020

Lung function decline is a well-recognized occurrence after myeloablative hematopoietic stem cell transplantation (HCT) that has not been studied after nonmyeloablative conditioning regimens. We examined the lung function of patients before and after receiving nonmyeloablative and myeloablative preparative regimens. Before HCT, nonmyeloablative patients had lower baseline values of percent of predicted FEV1 (pFEV1) and FVC (pFVC), reflecting their greater ages and often, poorer, medical conditions. However, nonmyeloablative patients experienced a slower overall rate of pFEV1 decline after HCT (4% ± 17 versus 12.7% ± 32 per year, P = 0.001), with patients >50 years of age having the lowest risk for rapid pFEV1 decline in a multivariable model. Rapid pFEV1 decline was associated with both total body irradiation (TBI) and non-TBI based myeloablative regimens. These findings were evident even one year or more after HCT. Myeloablative patients had a higher risk for death based upon pretransplant pFEV1 (HR 7.2 versus 3.9), with a 2-year survival rate of 0% among myeloablative patients with a pretransplant pFEV1 <60% (30% among nonmyeloablative patients). These results suggested that despite having worse lung function, patients receiving the nonmyeloablative regimen might experience less pulmonary toxicity and had a lower risk of mortality associated with abnormal pretransplant lung function.
Comparison of Gel Versus Capillary Electrophoresis for Chimerism Monitoring by PCR Amplification of Microsatellite Markers after Allogeneic Hematopoietic Cell Transplantation.
Authors: Zeiser Robert , Spyridonidis Alexandros , Waesch Ralph , Bertz Hartmut , Finke Jurgen
Published: April 2020

Hematopoietic chimerism has been demonstrated to be relevant for donor cell engraftment and detection of minimal residual disease after allogeneic hematopoietic cell transplantation (aHCT). In the light of increasing numbers of aHCT as a treatment modality, rapid, reliable and cost effective chimerism monitoring techniques acquire novel relevance. We evaluated the informativeness of five microsatellite markers in 376 donor/recipient pairs and compared the ability of polyacrylamide gel electrophoresis (GE) and capillary electrophoresis (CE) to detect mixed chimerism (MC) after aHCT. The sensitivity for GE and CE with respect to different markers was determined by limiting dilution assays with MC samples containing defined amounts of cells or DNA. Furthermore, CE was applied in 37 retrospectively selected patients with a MC detected by GE, having undergone aHCT for different hematological diseases and initially achieving a complete donor chimerism. The sensitivity and accuracy quantified by limiting dilution was higher CE as compared to GE with all microsatellites. Potential pitfalls with the combined application of CE was preferential amplification, leading to the misdiagnosis of CC in the presence of MC and the occurrence of stutter peaks in the representative area. In case of preferential amplification with the initially applied marker D1S80, evaluation with a second microsatellite was beneficial. Investigation of the selected pts samples demonstrated that detection of an increasing MC was earlier with CE as compared to GE. The detected recipient genotype by CE examination, despite a negative GE result, ranged from 0.7% to 7.1%.

We conclude that chimerism assessment with our five microsatellites identified informative alleles in 99% of all donor/recipient pairs. CE displayed a higher sensitivity and accuracy when compared to GE and additionally allowed for detection of an increasing MC suggestive for relapse. Prospective clinical investigation with CE for the predictive value of an increasing MC for graft failure or relapse is necessary.

Informativeness of the institutional microsatellite marker panel

No of pairs/ markers D1S80 THO1 D14S120 YNZ22 SE33 Numbers indicate patients were the marker was informative (ratio in %). rel: related donor; unrel: unrelated donor; n.t.: not tested; non inf.: non-informative. 165 rel/211 unrel 87 (53%)/145 (69%) n.t. n.t. n.t. n.t. 78 rel/66 unrel non inf. 22 (22%)/20 (30%) n.t. n.t. n.t. 56 rel/46 unrel non inf. non inf. 18 (32%)/16 (35%) n.t. n.t. 38 rel/20unrel non inf. non inf. non inf. 17 (45%)/15 (75%) n.t. 21 rel/5 unrel non inf. non inf. non inf. non inf. 19 (90%)/4 (80%) rel vs unrel 163/165 (98%) vs 210/211 (99%)
Safety and Potential Efficacy of Low Dose Methotrexate for Treatment of Chronic Graft-Versus-Host Disease.
Authors: Flowers Mary E.D. , Giaccone Luisa , Funke Vaneuza , Carpenter Paul A. , Moravec Carina , Hooper Heather , Storb Rainer F. , Martin Paul J.
Published: April 2020

Low dose methotrexate (MTX) is widely used for treatment of autoimmune diseases because of its anti-inflammatory activity. Encouraged by this practice, we have administered low dose MTX for treatment of refractory chronic GVHD, with the goal of reducing the amount of prednisone needed to control the disease. Fourteen patients with refractory chronic GVHD were treated with MTX at a dose of 7.5 mg/m2 per week for 3–50 weeks. All patients had involvement of the oral cavity and 11 of the 14 (78%) had skin involvement, often with scleroderma or fasciitis. The median duration of chronic GVHD at the start of MTX therapy was 38 (range 1–135) months. In this retrospective review, we found no grade 3–4 toxicities, and none of the patients required blood transfusion or treatment with hematopoietic growth factors. In 10 patients (71%), chronic GVHD could be adequately controlled with prednisone at doses below 1 mg/kg every other day without the addition of other immunosuppressive agents. Four patients decreased the amount of concomitant immunosuppressive treatment, 5 continued with the same regimen, 4 required an increase in immunosuppressive treatment, and one decided to discontinue all treatment. Improvement or resolution was observed most frequently in the gastrointestinal tract (80%) and skin (50%). From this preliminary analysis, MTX appears to be a well tolerated, inexpensive and possibly steroid-sparing immunosuppressive agent that is worthy of further evaluation in prospective trials for treatment of chronic GVHD.
High Incidence of Extramedullary Relapses Following Allogeneic Bone Marrow Transplant (Allo-BMT) in Adults with Acute Lymphoblastic Leukemia.
Authors: Absi Ahmed , Bolwell Brian J. , Sobecks Ronald , Pohlman Brad , Andresen Steve , Rybicki Lisa , Kalaycio Matt
Published: April 2020

Allo-BMT represents a curative therapy for certain patients with ALL. Unfortunately, leukemia relapse still represents a major problem following allo-BMT. Studying the pattern of relapses following allo-BMT may shed some light into the exact mechanisms of such relapses and suggest better ways to prevent them. Extramedullary relapses have been reported following allo-BMT for ALL. We investigated the pattern of ALL relapses in 57 patients after allo-BMT. All donors were HLA matched serologically at HLA A, B, and DR. All patients were treated with high-dose busulfan (16 mg/kg) combined with cyclophosphamide (120 mg/kg) with or without etoposide (50 mg/kg) and all received GVHD prophylaxis, excluding T-cell depletion. We identified 57 patients with ALL treated with BMT between 1987 and 2001. 45 patients (78.9%) had a matched related donor (MRD) and the rest had matched unrelated donors (MUD). 22 patients (39%) relapsed, 8 patients had an isolated extramedullary (IEM) relapse and 14 patients had bone marrow relapse (BM-R) with or without an isolated extramedullary relapse. The median time to relapse for the IEM relapses was 432 days with a range of 139–1422. This was significantly longer than the median time to relapse with BM (median 192 days and range 40–498) P=0.016. The following table shows the characteristics of both groups:

Number Ph + B-cell ALL CR-1 Extensive GVHD BM-R 22 3 (14%) 7 (32%) 5 (23%) 4 (18%) IEM-R 8 3 (37%) 5 (62%) 2 (25%) 2 (25%)

IEM relapses occurred in different organs including mastoid sinus, mediastinum, pericardium, nasopharyngeal lymphoid tissue, bone, CNS, and breast. Hematopoietic chimerism was determined utilizing the polymerase chain reaction (PCR) amplification of Short Tandem Repeat (STR) loci on DNA extracted from peripheral blood leukocytes compared with Pre-Transplant STR loci of donors and recipients. At the time of relapse all the patients with IEM relapses had 100% donor chimerism. Treatment plans for those IEM relapses included donor lymphocytes infusion (DLI), local radiation therapy, reinduction chemotherapy, imatinib for Ph+ patients, and one patient had an additional Allo-BMT. Only one patient in the IEM relapse group eventually had a relapse in the bone marrow, only 2 patients (25%) were alive more than 2 years following relapse and 3 patients died due to transplant complications.

We concluded from our review that IEM relapse following Allo-BMT for ALL is not an uncommon occurrence. These relapses may have a wide-range of clinical presentations depending on the organ affected which makes the diagnosis of this type of relapse challenging. These relapses have, usually, a late occurrence compared to BM-R, and their pathogenesis is poorly understood. Full donor chimerism does not exclude the possibility of IEM relapse.
Role of Chemotherapy before Allogeneic Stem Cell Transplantation (ALLO-SCT) from an HLA-Identical Sibling Donor for Myelodysplastic Syndrome (MDS).
Authors: Nakai Kunihisa , Kanda Yoshinobu , Fukuhara Shirou , Sakamaki Hisashi , Okamoto Shinichiro , Kodera Yoshihisa , Tanosaki Ryuji , Takahashi Satoshi , Matsushima Takafumi , Atsuta Yoshiko , Hamajima Nobuyuki , Kasai Masaharu , Kato Shunichi
Published: April 2020

The role of chemotherapy before allo-SCT remains unclear. We analyzed the data of 283 patients (median age 41 years, range 16–65 years) who underwent allo-SCT from an HLA-identical sibling donor for MDS that were reported to the Japan Society for Hematopoietic Cell Transplantation. One hundred eighty-eight patients had received chemotherapy before allo-SCT (Chemo group), whereas 95 had not (NoChemo group). The Chemo group included significantly higher proportion of patients with advanced disease and poor karyotype than the NoChemo group, (p<0.0001 and p=0.004, respectively). Overall survival (OS) at 5 and 10 years was 48.8% and 42.5%, respectively. Multivariate analyses identified karyotype, FAB classification, and the history of chemotherapy before allo-SCT as significant predictors for OS. The cumulative incidence (CI) of grade II–IV and III–IV acute GVHD among those who achieved engraftment was 33% and 10%, respectively. Chronic GVHD developed in 110 (53%) among 209 patients who survived more than 100 days. The CI of relapse in those who developed grade II–IV acute GVHD and those who did not was 39.6% and 19.5%, respectively (p=0.086). The CI of relapse in those who developed chronic GVHD and those who did not was 22.0% and 20.8%, respectively (p=0.82). Then, we analyzed only 139 patients with RAEBt or leukemic transformation (LT). Twenty-eight patients belong to the NoChemo group and 111 patients belong to the Chemo group. The proportion of patients with a poor karyotype was equivalent between the two groups (p=0.44). The duration from diagnosis to allo-SCT was shorter in the NoChemo group, with marginal significance (161 days vs. 248 days in median, p=0.07). The OS curves of the NoChemo group and CR patients in the Chemo group were superimposed (57% vs. 54%, p=0.81). The CI of relapse was 26.2% in the NoChemo group and 27.6% in CR patients in the Chemo group (p=0.83). Non-relapse mortality was also similar between the two groups (18.8% vs. 17.8%, p=0.86). In conclusion, this study confirmed that allo-SCT from an HLA-identical sibling donor offers the potential for long-term survival in patients with MDS. It seems that allo-SCT may be beneficial as primary treatment for patients with a low blast cell count or those with an advanced MDS but with an indolent course. GVHD did not appear to have a clear beneficial effect on the CI of relapse.
Reduced Intensity Conditioning in Acute Leukemias: Long Term Follow-Up Confirms Sustained Complete Remissions.
Authors: Massenkeil Gero , Neuburger Stefan , Tamm Ingo , Lutz Christoph , Nagy Marion , Le Coutre Philipp , Doerken Bernd , Arnold Renate
Published: April 2020

Introduction:

Reduced intensity conditioning (RIC) now accounts for approximately one fourth of all allogeneic stem cell transplantations (SCT) worldwide (IBMTR database 2002). A reduction of transplant-related mortality has been observed in uncontrolled trials of patients with MDS, CLL, NHL and M. Hodgkin, but at the same time some of these trials revealed an increased relapse rate. Long term follow-up of acute leukemias after RIC has not been reported so far. Own results have demonstrated continuous complete remissions in patients with ALL transplanted early in the course of disease (Arnold 2002).

Patients and Methods:

Between August 1998 and December 2003, 40 pts with high-risk ALL (n = 11) or AML (n = 29) received allogeneic SCT after RIC with fludarabine, busulfan and ATG because of contraindications against standard high-dose conditioning (age > 50 years, prior allogeneic SCT, fungal infections, low performance status). 8/40 had already relapsed prior standard SCT. 13 pts were in CR-1, 7 were in subsequent CR and 20 had uncontrolled disease. Median age was 48 years (range 19 – 67), 24 were male and 16 were female. All but one patient with 1 HLA-class I mismatch were transplanted from HLA-identical related (n = 23) or unrelated (n = 17) donors. Stem cell sources were mobilized peripheral blood in 37 and bone marrow in 3 patients. Patients received 5.0 x 10E6 CD34+ cells/kg bw in median (range 2.1 – 19.8). GvHD-prophylaxis was performed with cyclosporine A (CSA) alone (n = 23) or CSA + mycophenolate mofetil (n = 17).

Results:

37/40 pts reconstituted and reached CR including 17/20 patients with uncontrolled disease before SCT. 1/40 had a primary graft failure and was successfully retransplanted; two patients had refractory disease. After a median follow-up of 14 months (range 2 – 64 months), cumulative transplant-related mortality is 8 % ( 3/40 patients). 9/40 patients had developed acute GvHD III–IV and 11/24 patients had chronic extensive disease. 19 patients relapsed (including 2 refractory patients and 7/8 patients with salvage transplantation). Probability of disease-free survival at 3 years is 49 %. Overall survival at 3-year is 37 %. Median survival for patients with ALL is 13 months (95% C.I., 1 – 26) and for AML 14 months (95% C.I. 4 – 24) (n.s.). Among 18 survivors in CR, 8 were transplanted in CR-1 and 10 with advanced disease.

Discussion:

RIC results in sustained complete remissions in patients with high-risk acute leukemias. Even advanced diseases can be cured by allogeneic SCT after RIC. The high relapse rate is worrisome and calls for effective post-transplant strategies like prophylactic DLI or maintenance therapy to reduce relapse risk. TRM is comparably low in this group despite intensive pre-treatment and high rates of GvHD.
Characterization of the Binding Interaction between ADAMTS13 and von Willebrand Factor (VWF).
Authors: Majerus Elaine M. , Anderson Patricia J. , Sadler J. Evan
Published: April 2020

VWF multimers are cleaved into smaller less thrombogenic fragments in plasma by ADAMTS13. Deficiency of ADAMTS13 activity leads to thombotic thrombocytopenic purpura (TTP), a disease characterized by thrombocytopenia, microangiopathic hemolytic anemia, fever, neurological decline, and renal insufficiency. ADAMTS13 is a member of the A Disintegrin and Metalloprotease with ThromboSpondin repeats family that has characteristic motifs including a signal sequence, a propeptide, a catalytic metalloprotease domain, a disintegrin domain, a thrombospondin-1 (TSP1) repeat, a cysteine-rich region, and a spacer domain. These domains are followed in ADAMTS13 by seven additional TSP1 repeats and two C-terminal CUB domains. Previous work has shown that ADAMTS13 truncated after the spacer domain retains proteolytic activity towards VWF, but little is known about the potential role of the additional C-terminal TSP1 and CUB domains in VWF binding or cleavage. We therefore developed an enzyme-linked immunosorbent assay (ELISA)-based system to study ADAMTS13-VWF binding. VWF was immobilized in microtiter wells and incubated with plasma or recombinant ADAMTS13 variants. Bound ADAMTS13 was detected directly by solubilization and Western blotting, or indirectly by ELISA. ADAMTS13 proteolytic activity towards VWF is enhanced by denaturation of VWF with urea or guanidine, but ADAMTS13 bound specifically to VWF without prior denaturation. EDTA increased the binding of ADAMTS13 to VWF and prevented proteolysis of the immobilized VWF. Binding was saturable and time-dependent with maximal binding in two hours. Binding was reversible with a half-time for dissociation of four hours. ADAMTS13 in normal human plasma but not in plasma from a patient with TTP bound immobilized VWF. The stoichiometry of VWF monomers to ADAMTS13 at saturation was approximately 2 (range 1–4) and the Kd of recombinant ADAMTS13 binding to VWF was 12 nM (range 5–26 nM). This Kd for binding is similar to the Km for VWF cleavage of 16 nM determined independently, and both are comparable to the estimated plasma ADAMTS13 concentration of 8 nM. The properties of C-terminally truncated ADAMTS13 constructs suggest a regulatory function for certain domains. Truncation after the 8th TSP1 domain decreased the Kd 2-fold. Further truncation after either the 6th or 7th TSP1 domain increased the Kd 2-fold relative to full-length ADAMTS13. Truncation after the spacer domain gave binding properties indistinguishable from full-length ADAMTS13. Truncation after the metalloprotease domain gave no detectable binding to VWF. Therefore, binding of ADAMTS13 to VWF requires sequences in the cysteine-rich or spacer domains, and is modulated by sequences in at least the 8th TSP1 repeat and the CUB domains.
Allogeneic BMT Followed by Substrate Deprivation Therapy with N-butyldeoxynojirimycin in a Child with Tay-Sachs Disease.
Authors: Jacobs Hans J.F.M. , Willemsen Michel M.A.A.P. , Groot-Loonen Jacqueline J.J. , Wevers Ron R.A. , Hoogerbrugge Peter P.M.
Published: April 2020

Introduction: Tay-Sachs Disease (GM2 gangliosidosis) is a lysosomal storage disorder caused by beta-hexosaminidase A (Hex-A) deficiency, which leads to severe and progressive neurological damage. BMT has been used successfully as treatment strategy in some storage disorders. GM2 gangliosidosis mouse models demonstrate that after BMT donor-derived metabolically competent cells infiltrate the CNS leading to delayed onset of symptoms and prolonged survival. Further enhancement of survival has been reported in mice receiving a combination of substrate deprivation therapy and BMT. To our knowledge data on the effects of BMT in children with Tay-Sachs disease are lacking.

Patient: A three-year-old girl was diagnosed with Tay-Sachs disease with minimal clinical symptoms, after the same diagnosis was made in her symptomatic older sister. Pre-BMT conditioning consisted of busulfan, cyclophosphamide and ATG. She received T-cell depleted marrow from an HLA identical unrelated donor. Ciclosporin-A (CsA) was given as GvHD prophylaxis. Follow-up is 2.5 years.

Results: Hex-A levels in leukocytes increased initially to donor levels and decreased to a steady level of 30% of controls for the last 1.5 years, indicating stable mixed chimerism. Also the enzyme levels in serum increased to 10% of controls, indicating release of enzyme into serum. Shortly after BMT, rapid progression of neurological symptoms occurred (MRI, EEG and neuro-psychological tests). Some neurological symptoms partially improved, others stabilized after CsA was stopped, suggesting that CsA had contributed to the neurological deterioration. Experimental substrate deprivation therapy with N-butyldeoxynojirimycin was started 1.5 years after BMT. No adverse effects of this drug were observed.

Conclusion: BMT followed by substrate deprivation therapy in our patient with early stage of Tay-Sachs disease resulted in Hex-A enzyme levels in leukocytes and serum of 30% and 10% of normal levels respectively. Neurological deterioration occurred shortly after BMT and seemed to stabilize thereafter, but follow-up is too short to draw firm conclusions yet.
A Pilot Study for Haploidentical Transplant Using a Chemotherapy only Preparative Regimen eith T-Cell Depleted Haploidentical Transplant and Intensive Antibiotic Prophylaxis To Treat Advanced Leukemia Patients (pts).
Authors: Gajewski James L. , Saliba Rima , McMannis John D. , Shpall Elizabeth J. , Ippoliti Cindy , Giralt Sergio A. , Jones Roy B. , Khouri Issa F. , Hosing Chitra M. , Korbling Martin J. , Donato Michele L. , Champlin Richard E.
Published: April 2020

We present preliminary data of haploidentical transplant for 12 patients (pts) with relapse of refractory acute leukemia using a chemotherapy only preparative regimen of 140 mg/m2 Melphalan on day −8; 10 mg/kg Thiotepa on day −7; 160 mg/m2 Fludarabine on days −6, −5, −4, −3; 1.5 mg/kg of rabbit ATG/day days −6, −5, −4, −3 and T-cell depleted peripheral blood progenitor cells, processed using the CliniMACS® device. All products had <1 x 104 CD3+ T-cells/kg recipient body weight and needed a minimum of 5 x 106 CD34+ cells/kg but preferably >1 x 107 CD34+ cells/kg recipient body weight. Pts received: intensive PCP prophylaxis with bactrim and pentamidine prior to transplant and during pancytopenia; CMV prophylaxis with valcyte during the BMT prep and foscarnet while pancytopenic; and with ambisone for fungus. The last 4 pts enrolled were treated with cancidas prophylactically instead of ambisome. 10 of 12 pts engrafted (83%). 2 pts had protocol deviations and primary graft failure - 1 survived disease free and 1 relapsed. Median time to engraftment was 14 days (range, 9–26) to 500 neutrophils and 13 days to platelets 20,000 (range, 10–25). Among engrafting patients, two died within 100 days due to disease progression and multiple organ failure. Six-month overall survival is 50% (21–74). One year overall and progression-free survival is 33% (95% CI 10–59). 7 pts had disease relapse at a median of 10 months (range 2–13 months). Two of 10 pts who engrafted developed grade 1 acute graft-versus-host disease (GVHD) and 4/8 pts who engrafted and survived beyond day 100 had chronic GVHD. The 2 patients who engrafted and survived beyond 1 year post transplant had chronic GVHD. This report for haploidentical transplant demonstrates that a chemotherapy only preparative regimen achieved a high rate of engraftment. Infectious complications were minimal. 25% of patients survived progression free. If these results are sustained in a larger study, haploidentical transplant may offer hope of allogeneic transplant for every individual needing such therapy.
Biology-Driven Classification of Childhood Acute Lymphoblastic Leukemia: A Combined Analysis of Prognostic Markers from the Pediatric Oncology Group (POG) and Children’s Cancer Group (CCG).
Authors: Schultz Kirk R. , Pullen Jeanette , Sather Harland , Shuster Jonathan , Borowitz Michael J. , Heerema Nyla A. , Carroll Andrew J. , Gaynon Paul S. , Camitta Bruce M.
Published: April 2020

Risk adapted therapy, tailoring treatment to the likelihood of relapse, has constituted a significant advance in the treatment of childhood ALL. The recent merger of the POG and CCG provided an opportunity to reassess previous approaches and to develop a new biology driven classification system based on data from both legacy groups. All children (age 12 months to 21.99 years) with newly diagnosed B-precursor (ALL), consecutively enrolled on CCG (December 1988 to August 1995, N = 3056) and POG (January 1986 to November 1999, N = 6800) protocols, were evaluated for the impact of numerous clinical and laboratory variables on event free survival at 5 and 8 years in each group separately, thereby superseding differences in treatment approaches. Infants and patients with a T- cell phenotype were excluded from the analyses. Very high risk was defined as the group for which myeloablative therapy might be indicated with an anticipated 5 year EFS <45%, while a reduction in therapy could be justified for the lowest risk patients with a >85% 5 year EFS. Patients identified as being at very high risk for relapse had hypodiploidy (<45 chromosomes) (CCG 34.8%, POG 46.5% - 5 year EFS), induction failure (CCG 11.3% 5 year EFS) or t(9;22) or BCR/ABL (POG 27.5%, CCG 29.6% 5 year EFS). Patients identified as low risk for relapse were NCI standard risk patients with either t(12;21) (TEL-AML1) (CCG 86%, POG 85% 5 year EFS) or all three trisomies of 4, 10, and 17 (CCG 91.5%, POG 89.3% 5 year EFS). Certain NCI high risk patients were identified as having a higher risk for relapse but did not fall into the VHR category: t(4;11)(POG 49.9%, CCG 50.0% 5 year EFS),CNS3 (CCG 59.3%, POG 67.8% 5 year EFS) and slow early response (SER) defined by M2/3 at day 14 (Standard risk 66% SER versus 84% and for high risk ALL 63% SER versus 75%). Other potential VHR factors that require confirmation included, slow early responder t(4;11) (CCG 11.1% 5 year EFS) and monosomy 7 (CCG 44%, POG 66.6% 5 year EFS). A balanced t(1;19) had only a minor unfavorable effect on EFS. The COG has identified a risk classification system that builds on the previous NCI risk classification system for childhood ALL, incorporating the cytogenetic and molecular genetic features of the blasts, as well as rapidity of clinical response. The division of B-precursor ALL patients into low risk (18%), standard risk (49%), high risk (30%) and very high risk (3%) groups will : 1) identify those patients for whom therapy might be reduced without sacrificing overall cure rates, 2) determine those patients who will require intensified therapy and 3) suggest underlying biological pathways that mediate cure or treatment failure.