bluuebunny/crossref_metadata_2025 huggingface dataset:
Relative Value of CD38 and ZAP-70 Versus Immunoglobulin Mutation Status in Predicting Early Disease Progression in Chronic Lymphocytic Leukemia.
Authors: Rassenti Laura Z. , Neuberg Donna S. , Huynh Lang , Wierda William G. , Gribben John G. , Brown Jennifer R. , Flinn Ian W. , Rai Kanti R. , Byrd John C. , Kay Neil E. , Greaves Andrew W. , Kipps Thomas J.
Published: October 2019

We assessed the relative value of CD38 in predicting the need for early treatment in 307 patients with chronic lymphocytic leukemia (CLL) previously characterized for ZAP-70 and immunoglobulin heavy-chain-variable region gene (IgVH) mutational status (NEJM2004, 351;9;893–901). Recursive partitioning by maximally selected chi-square analyses of flow cytometry and clinical data identified the optimal cut-off for designating a CLL sample as CD38+ was at 34%, which was highly similar to the conventional cut-off of 30%. Since these cut-offs identified highly similar cohorts of CD38+ CLL patients (e.g. 32.2% (99/307) vs. 35.5% (109/307)) we chose to use 30% as the cut-off for this analysis. We used the logrank test to compare CD38 expression-status to the time from diagnosis to therapy (TTT), initiated per established NCI-Working Group guidelines. Patients with CLL cells that were CD38-negative by this criterion had a median TTT of 7.8 years; whereas, patients with CD38+ CLL cells had a median TTT of 3.7 years (p<0.0001). There was a significant association between expression of CD38 and ZAP-70 or use of unmutated IgVH genes (p < 0.0001). The median level of CD38 among cases that used mutated IgVH was 4.0%, compared to 27.4% among cases that used unmutated IgVH (p < 0.0001). The median level of CD38 among ZAP-70-negative cases was 5.3% (range from 0.1% to 99.5%), compared to 27.2% among ZAP-70-positive cases (range from 0.1% to 99.4%) (p < 0.0001).

We explored the TTT based only on flow cytometric parameters (CD38 and ZAP-70) and investigated whether addition of mutation status significantly altered our predictions. For most patients, the knowledge of CD38 and ZAP-70 provided a reliable means for predicting the TTT and the knowledge of the IgVH mutation status did not substantially alter the prediction. Only in 41 cases (14% of the total), where the CLL cells were CD38+ but negative for ZAP-70, was the prediction significantly improved by inclusion of IgVH mutation status. The median TTT of this group of 41 patients was 7.8 years. Addition of mutation status identified a subgroup of 20 patients with unmutated IgVH genes for whom median TTT was estimated at 4.6 years; 21 patients with mutated IgVH genes had a median TTT of 8.4 years. For patients with CLL cells that were CD38-negative and either negative or positive ZAP-70, stratification via IgVH mutation status did not identify subgroups within each of these categories that had significantly different median TTT. We conclude that knowledge of CD38 and ZAP-70, as assessed by the CRC, can reliably predict TTT in most patients with CLL. For the 14% of cases that are CD38+ but negative for ZAP-70, determining the IgVH mutation status may provide added value in predicting the time from diagnosis to initial therapy.
The 13q and 11q B-Cell Chronic Lymphocytic Leukemia Deleted Regions Derive from a Common Ancestral Region in the Zebrafish on Linkage Group 9.
Authors: Auer Rebecca L. , Riaz Sophia , Cotter Finbarr E.
Published: October 2019

Loss of the long arm of chromosomes 11 and 13 are the most consistent cytogenetic abnormalities for patients with B-cell chronic lymphocytic leukemia (B-CLL). They suggest the presence of as yet unidentified tumor suppressor genes within well defined minimal deleted regions (MDRs). The use of small vertebrate organisms, such as the zebrafish, as models of diseases associated with chromosomal deletions enables the functional analysis of potential causative genes. Hemopoiesis is well conserved between the zebrafish and human and conserved synteny exists between the two genomes. In this study, the evolutionary conservation between the zebrafish and human genome is investigated for the 13q14 and 11q22-23 regions deleted in B-CLL. Zebrafish orthologs have been identified and radiation hybrid (RH) mapping performed to confirm their chromosomal location and define regions of conserved synteny.We have identified 38 zebrafish orthologs of the human genes in the MDRs in zebrafish cDNA and the syntenic regions for the human deletions in the zebrafish genome. The 13q14 region was syntenic with two main regions in the zebrafish genome, namely linkage group 1 (LG1) and LG9. The majority of zebrafish orthologs to 11q22-23 were found on LG5, LG15 and LG21. One syntenic region, LG9, in the zebrafish genome is of potential interest. Analysis of the smallest critical region of deletion in B-CLL for both 11q22-23 and 13q14 reveals that the human gene equivalents are contained within an area of 22.02 cR on LG9 (approximately 3260 kb). Within LG9, orthologs to two genes to human chromosome 11, three to human chromosome 13 and two chromosome 13 microRNAs (mir-15a and mir-16-1) were identified. The critical region on zebrafish LG9 maps to the MDR for both human chromosomes, suggesting a common ancestry for the B-CLL tumor suppressor genes. This is further supported by analysis of the chicken genome where the same 5 genes from 13q14 and 11q22-23 (C13orf1, RFP2, FLJ11712, FDX1, ARHGAP20) lie within a 10.04 Mb region on chromosome 1. In addition, TILLING for knock-outs of genes in this region of zebrafish embryos will allow analysis of their in vivo potential for lymphoproliferation and may define prime causative genes for B-CLL within human chromosomes 11q and 13q by reverse genetics. Our study provides an explanation for involvement of both 11q and 13q in B-CLL and the potential to develop animal models for this common lymphoproliferative disorder.
Risk Factors of Treatment Related Mortality during Autologous Stem Cell Transplant in Patients with Light Chain Associated Amyloidosis (AL).
Authors: Leung Nelson , Dispenzieri Angela , Lacy Martha Q. , Hayman Suzanne R. , Kumar Shaji , Gertz Morie Abraham
Published: October 2019

Background: High dose melphalan followed by autologous stem cell transplant (ASCT) is an effective treatment of immunoglobulin light chain amyloidosis (AL). However, the high treatment related mortality (TRM, death before day 100) remains a serious concern and is the major drawback of this therapy. A better understanding the risk factors contributing to TRM could help physicians choose the most appropriate therapy for these patients. We performed a retrospective study to identify risk factors that contribute to TRM after ASCT in AL patients.

Methods: All patients who underwent ASCT for AL at our institution from 7/96 to 12/04 were studied. Data were collected on age, sex, septal thickness, glomerular filtration rate (GFR), B2M, CRP, proteinuria, albumin, cardiac troponin T (cTnT) and alkaline phosphate.

Results: A total of 218 patients underwent ASCT for AL during this time period. One patient refused consent for this study. Pretransplant cTnT was available on 161 (73.9%) patients. The overall TRM rate for the 217 patients was 12.4%. By univariate analysis, septal thickness, GFR, albumin, alkaline phosphatase and cTnT were found to be associated with TRM. In the multivariate analysis, only albumin, alkaline phosphatase and cTnT remained independent predictors of TRM. Cutoffs were identified using receiver-operator characteristic (ROC) curve. The cutoff for albumin was 2.85 g/dL, 249 U/L for alkaline phosphatase and 0.02 ng/mL for cTnT. The percentage of patients with low albumin, elevated cTnT and alkaline phosphatase were 51.1%, 20.5% and 12.4% respectively. The TRM rate of patients with low albumin was 18.0%, 27.3% for elevated cTnT and 29.6% for high alkaline phosphatase. Risk of TRM increased significantly with each additional risk factor (Table).

Discussion: In our AL population, low serum albumin, elevated alkaline phosphatase and cTnT were independent risk factors of TRM after ASCT. Patients with 2 or more risk factors are at significant risk of TRM during ASCT. In these high risk patients, alternative therapy should be considered in order to avoid excessively high incidence of TRM.

Treatment Related Mortality by Number of Risk Factors Risk Factors 0 1 2 3 Rate of TRM 1.8% 8.4% 35.0% 66.0% Odds Ratio 5.0 29.1 108.0
Phase I Study of BB-10901 (huN901-DM1) in Patients with Relapsed and Relapsed/Refractory CD56-Positive Multiple Myeloma.
Authors: Chanan-Khan Asher Alban , Jagannath Sundar , Schlossman Robert L. , Fram Robert J. , Falzone Richard M. , Ruberti Mary F. , Welch Samantha K. , DePaolo Dawn , Anderson Kenneth C. , Munshi Nikhil C.
Published: October 2019

Background: BB-10901 is a humanized monoclonal antibody that binds with high affinity to CD56 and is covalently linked to a novel cytotoxic maytansinoid DM1. Once bound to CD56, the conjugate is internalized and releases DM1. CD56 is expressed on a variety of tumor types such as small cell lung carcinoma, neuroendocrine tumors and hematological malignancies including multiple myeloma (MM) and acute leukemia. About 70% of MM patients have evidence of CD56 expression. Based on our preliminary results that BB-10901 has significant in vitro and in vivo anti-myeloma activity in a murine model, we have now initiated a phase I clinical study.

Objectives: To determine the maximum tolerated dose (MTD), the dose limiting toxicities (DLTs), and pharmacokinetics (PK) of BB-10901 given on a weekly schedule.

Methods: Relapsed or relapsed/refractory MM patients who have failed at least one prior therapy and have CD56 expressing myeloma received a single IV infusion of BB-10901 on 2 consecutive weeks every 3 weeks. Subjects are enrolled in cohorts of 3 at each dose level. The starting dose was 40 mg/m2/week based on experience from a prior phase I trial in solid tumors.

Results: Five patients have received BB-10901, 3 at 40 mg/m2/week and 2 at 60 mg/m2/week. No patients have experienced DLTs and no serious adverse events related to study drug were observed. In addition, no patients have experienced serious hypersensitivity reactions or evidence of HAHA or HADA formation. Our preliminary PK findings demonstrate that there is no evidence of accumulation of BB-10901. Detailed PK analysis and updated toxicity and efficacy data will be presented. Immunohistochemistry performed on marrow aspirates about 24 hours after huN901-DM1 infusion at 40 mg/m2 confirmed the presence of huN901-DM1 on myeloma cells in the marrow. Two patients treated at 60 mg/m2/week and who had failed multiple prior therapies including bortezomib, thalidomide and/or lenalidomide demonstrated anti-tumor response with a decrease in M proteins of 90% and 33%, respectively. Both patients received a fifth cycle of therapy and one continues on study.

Conclusions: This phase I study provides preliminary evidence of safety and clinical activity of BB-10901 in patients with CD56-positive MM who have failed established MM treatments. Targeting of BB-10901 to myeloma cells in the marrow was confirmed. The MTD is not yet defined and enrollment is ongoing.
JAK2 Inhibitors for the Treatment of Myeloprolifertive Disorders.
Authors: Hood John , Cao Jon , Hanna Ehab , Lohse Dan , Mak Chi Ching , McPherson Andrew , Noronha Glenn , Renick Joel , Zheng Binqi , Zhu Hong , Soll Richard
Published: October 2019

The molecular pathogenesis of the myeloproliferative disorders (MPDs) polycythemia vera, essential thrombocytosis, and myelofibrosis with myeloid metaplasia has been conclusively linked to a single mutation in JAK2 (Janus Associated Kinase 2). A G-T transversion event in exon 14 that translates into a substitution of phenylalanine for valine at amino residue 617 leads to constitutive activation of JAK2V617F in a majority of these MPD cases. Assays in several laboratories indicate that between 90–100% of patients with polycythemia vera harbor this allele. Because the JAK2.V617F gain-of-function mutant affects such a large patient population, pharmacologically targeting the mutated JAK2 is highly clinically relevant. In order to address this unmet clinical need we designed and synthesized a series of structurally novel compounds for their capacity to inhibit JAK2.V617F. Compounds were identified which potently inhibited JAK2 enzyme, with enzymatic IC50s as low as 1 nM. Subsets of this group were subsequently identified which were highly selectivity against undesirable off-target kinases, including up to 100X selectivity versus the highly homologous JAK3 kinase. Compounds were then advanced into in vitro assays in JAK2.V617F transformed cell lines in which compounds were identified with proliferation EC50s as low as 60 nM (representative compounds listed in Table below). Compounds from this series were subsequently shown to be orally available and efficacious in rodent models of MPD driven disease.

Conclusion: TargeGen has synthesized a series of JAK2.V617F inhibitors with promising potency, selectivity and pharmaceutical properties for utility in the treatment of myeloproliferative disorders.

Representative JAK2 Inhibitors Compound Primary Target Selectivity Profile Cell EC50 JAK2 IC50 JAK2 vs JAK3 (X-fold selectivity) BaF3:JAK2.V617F TG101192 3.8 15 140 TG101209 6 28 279 TGs101348 12.5 83 297 JAK Inhibitor I (Calbiochem) 10 1.5 320
Gelatin-Coated Insert-Well Culture Markedly Improved In Vitro Culture of Primary Myeloma Cells.
Authors: Abroun Saeid , Otsuyama Ken-Ichiro , Shamsasenjan Karim , Islam Khademul , Amin Jaki , Asaoku Hideki , Kawano Michio M.
Published: October 2019

In order to clarify the pathogenesis of multiple myeloma (MM) and identify the molecular target for MM treatment, it is important to understand the biology and molecular mechanism of survival and proliferation of myeloma cells in vitro and in vivo. Still, it is hard to keep primary myeloma cells viable at least for 2 weeks in vitro, and these cells rapidly enter apoptosis even in the presence of IL-6. Co-culture with BM stromal cells is considered to be one of the most important factors as well as addition of cytokines for improvement of in vitro culture of primary myeloma cells. Based on our previous data, we devised a new method where bone marrow mononuclear cells (BMMNC) from BM aspirates were put inside insert-wells (8.0 um pore size, #3182, BD) coated with gelatin in the presence of the mixture of cytokines (galectin-1, SDF-1, IL-6 and IGF-1) in the serum-free synthetic medium; addition of galectin-1 and SDF-1 was essential especially at the beginning of this culture. By this method, we observed that BM stromal cells attached to gelatin and survived well with rather low proliferation; myeloma cells interacted well with these stromal cells. Thus, we could maintain viability of primary myeloma cells at least for 4 weeks and the recovery of viable myeloma cells (CD38++ cell) appeared to be about 80% in 30 cases of MM we examined. Phenotypic data also showed that ratio of immature (MPC-1−) and mature (MPC-1+) myeloma cells in the BMMNC before culture was approximately maintained after 2 or 4 weeks in this method. Therefore, these results suggest that gelatin-coated insert-well culture can control the viability of stromal cells and thus maintain the culture of primary myeloma cells in vitro. This new method would contribute to the further understanding of biology and drug sensitivity of primary myeloma cells.
Hepcidin Overproduction Mediates the Anemia of Multiple Myeloma.
Authors: Sharma Sanjai , Nemeth Elizabeta , Chen Yi-Hsiang , Huston Alissa , Roodman G.D. , Goodnough Julia , Ganz Tomas , Lichtenstein Alan
Published: October 2019

Hepcidin is a liver-produced protein that has been implicated in the anemia of chronic inflammatory/infectious disease. Hepcidin expression is stimulated during infection/inflammation and, by downregulating the iron exporter ferroportin, hepcidin prevents release of iron from macrophages and enterocytes. This results in a decrease in delivery of iron to maturing erythrocytes and significant anemia. Since IL-6 is the major cytokine upregulating hepcidin expression during inflammation/infection and, since high levels of IL-6 are often present in multiple myeloma (MM), we initiated the current study examining a role of hepcidin in the anemia of MM. Pretreatment urinary hepcidin levels were determined in 44 patients with stage III MM. The mean level of hepcidin (191ng/mg of creatinine) was significantly higher than normal controls (64.5ng/mg of creatinine). In contrast, patients with MGUS did not demonstrate elevated hepcidin levels. In the subset of MM patients without renal insufficiency (n=27) a marked inverse correlation was seen between hemoglobin level at diagnosis and hepcidin level (r= −0.46, p=0.014). This correlation is even more impressive because anemia in general (when not due to hepcidin overexpression) results in a decrease in hepcidin levels. These data strongly supported hepcidin upregulation as a major cause of anemia of MM. The hepcidin level also correlated with serum ferritin levels (n=28, r=0.37, p=0.048). A role for IL-6 in hepcidin upregulation was suggested by a significant correlation between hepcidin levels and C-reactive protein, an IL-6 targeted gene (n=28, r= 0.57, p=0.0012). However a correlation between hepcidin and serum IL-6 levels just missed significance (n=27, r= 0.36, p= 0.0599). Furthermore, real time PCR in vitro studies also suggested that IL-6 played a role but could not completely account for all cases of hepcidin upregulation. As compared to normal serum, sera from six MM patients (with known elevated hepcidin levels) significantly induced hepcidin RNA in a liver cell line, Hep3B. In the patients with co-existing high IL-6 levels, the serum-induced hepcidin RNA was prevented by anti-IL-6 and anti-IL6 receptor antibodies. However, in the patients with lower IL-6 levels, these blocking antibodies were unable to prevent sera-induced hepcidin RNA. Additional studies on myeloma cells isolated from marrow of a patient with high hepcidin level demonstrated an absence of hepcidin RNA in the resting or IL-6 stimulated state, indicating that the MM cells themselves do not participate in the increased production of hepcidin. These data strongly support the notion that enhanced expression of hepcidin is an important cause of the anemia of MM and suggest a role of IL-6 and other, yet to be identified, serum factors in the hepcidin upregulation.
Cyclosporine-Induced Nephrotoxicity and Dose Adjustments in Bone Marrow Transplantation.
Authors: Piran Sanaz , Piran Siavash , Stanley Fiona , Walker Irwin
Published: October 2019

Background and hypothesis: Cyclosporine is administered to all patients undergoing allogeneic bone marrow transplantation in Hamilton. It is given intravenously at first then orally after engraftment. The manufacturer’s recommendation is to use a dose ratio of 1:3, IV to oral; the Hamilton unit uses a ratio of 1:2, yet has observed frequent rises of cyclosporine to toxic levels. We wished to confirm that the dose conversion ratio of 1:2 is associated with significantly high cyclosporine levels and nephrotoxicity.

Methods and Results: Thirty-five consecutive patients undergoing allogeneic bone marrow transplantation at McMaster University Medical Centre were studied. We included patients who were diagnosed with a hematological cancer i.e. leukemia (76%), lymphoma (18%), or myelodysplastic syndrome (6%), and who underwent chemotherapy. The patients’ plasma cyclosporine levels were measured 4–5 days after its initiation and with every dose adjustment, and serum creatinine levels were measured daily. Forty four percent of the patients were males. In 53% of the patients 1:2 IV to oral conversion ratio caused elevation of plasma cyclosporine levels to the toxic range (p<0.001). The toxic cyclosporine levels were seen 5+/−2 days post IV to oral dose adjustment. Furthermore, 43% of these patients developed acute renal failure and significant elevation of their serum creatinine levels (p<0.001).

Conclusion: The traditional conversion rate of 1:2–3 for intravenous to oral cyclosporine is associated with rises in plasma cyclosporine to toxic levels and significant rises in serum creatinine level. We recommend that this conversion rate be lowered to 1:4/3 and further studied.
Severity, Frequency, and Risk Factors for Oral Mucositis after BEAM High-Dose Chemotherapy and Autologous Peripheral Blood Stem Cell Transplantation and Preliminary Results with Palifermin Versus Best Supportive Care.
Authors: Strobel Eva-Susanne , Bauchmüller Kris , Ihorst Gabriele , Engelhardt Monika
Published: October 2019

Mucositis being an adverse effect of high-dose chemotherapy (hd CTx) may compromise results of peripheral blood stem cell transplantation (PBSCT). Keratinocyte growth factor can effectively decrease its severity and frequency. Here, the mucositis rate after BEAM hd CTx followed by auto-PBSCT was analyzed. A total of 50 patients (median age: 55 years, range; 19–70) with high-risk, refractory or relapsed lymphoma were included in a prospective analysis at our center, and mucositis was graded according to WHO. After BEAM-hd CTx, WHO grade 2 mucositis developed in 30%, grade 3 in 10% and grade 4 in 4%. Odds ratios (OR) for mucositis grade 2 or higher were increased to 2.1 (95% CI 0.6–6.7) for female sex, to 1.9 (CI 0.5–6.7) for higher pretreatment (>8 CTx-cycles), and 3.1 (CI 0.9–10.5) with previous mucositis. We found no association for older age, lymphoma type (indolent vs. high-grade NHL/Hodgkin’s disease), previous radiotherapy, Karnofsky index, oral hygiene or leukopenia prior to auto-PBSCT. The OR for mucositis with parental nutrition was estimated with 2.2 (CI 0.6–7.7) and for opioid use with 8.7 (CI 2.2–33.7) (p=0.0025), both being directly influenced by the extend and severity of oral mucositis. As expected, myelosuppression was the main toxicity of hd-BEAM: WBC >1.000/ml were reached after a median of 10 days (range 7–15), platelets >20.000/ml after 11 days (range 7–45). The median numbers of red blood cell and platelet units transfused were 5 (range 1–21) and 4 (range 1–35), respectively. The event free survival at 6, 12 and 24 months was 81.9% (CI 71.2–92.6%), 70.5% (CI 57.3–83.6%), and 66% (CI 51.2–80.9%), and the overall survival 83.9% (CI 73.7–94.1%), 79.2% (CI 67.7–90.8%) and 79.2% (CI 67.7–90.8%), respectively. Subsequently, 10 lymphoma patients have been accrued in the follow-up study comparing palifermin to best supportive care (BSC) after hd-BEAM conditioning. All 5 patients receiving palifermin showed only WHO grad 1 mucositis, whereas in the control group one patient each had grade 1, 2 and 3 mucositis and 2 patients are still being treated. In conclusion, we found females, extensive pretreatment and previous mucositis as potential risk factors for the development of mucositis, the latter greatly influencing parental nutrition and opioid use. Although the incidence of grade 2–4 mucositis varies with different CTx-schedules and -intensity, it severely affects supportive measures. Decrease in its severity and duration will substantially reduce side-effects of PBSCT further.
Adding Palifermin in Allogeneic and Autologous Stem Cell Transplantation Resulted in Reduced Oral Mucositis and Enhanced Intestinal Mucosal Recovery Measured by Citrulline Serum Levels.
Authors: Langner Stefan , Staber Philipp B. , Zebisch Armin , Zinke-Cerwenka Wilma , Sill Heinz , Linkesch Werner , Greinix Hildegard , Kalhs Peter , Rabitsch Werner , Neumeister Peter
Published: October 2019

Background: In this ongoing prospective open label study we evaluate the effect of Palifermin on the development of oral and intestinal mucositis in 25 patients undergoing allogeneic or autologous hematopoietic stem cell transplantation (allo/auto-HSCT).

Methods: Twenty-five patients, transplanted for acute or chronic leukemia (n=20) and non-Hodgkin’s lymphoma (NHL, n=5) received 60 μg Palifermin per kilogram of body weight per day for three consecutive days before the initiation of conditioning therapy and immediately after HSCT. The control group comprised 9 patients diagnosed with acute leukaemia (n=6) and NHL (n=3). In the Palifermin group the distribution between allo- and auto-HSCT was 16 and 9 compared to 5 and 4 in the control group. Conditioning therapy consisted of fractionated total-body irradiation/Cyclophosphamide in case of leukemia and chemotherapy only based regimens in NHL patients. Oral mucositis was graded daily according to World Health Organisation (WHO) criteria. The intestinal mucosal barrier damage was assessed by analyzing Citrulline serum levels on HSCT days -12, -6, 0, +7, +14 and +21.

Results: No severe side effects were observed in our patient cohort. Our preliminary analysis demonstrates a significant decrease in the incidence of oral mucositis WHO grade 3 or 4 with 24 percent in the Palifermin group as opposed to 78 percent in the control group (p=0,013). The median duration of mucositis was 4,7 days (range 0–19) in the Palifermin group compared to 9,3 days (range 0–19) in controls (p=0,037). Whereas 17 evaluable patients in both groups showed a similar decline in Citrulline serum concentrations until day +7 - reflecting a maximal intestinal mucosal barrier injury at this timepoint - a significantly faster recovery of Citrulline levels (18,5 vs 13,8 μM, p=0,04) in Palifermin recipients at day +21 could be found. The use of opioid analgesics as determined by morphine equivalents (median 105mg vs 112mg) was almost equal. However, there was a trend in the duration of total parenteral nutrition (14 vs 18 days, p=ns) in favor of the Palifermin group. Acute graft versus host disease grade I-IV was observed in 29%, grade III-IV in 21% of Palifermin treated patients after an allo-HSCT.

Conclusions: Palifermin was generally well tolerated and reduces the incidence and duration of WHO grade 3 and 4 oral mucositis. Further, it promotes a faster recovery of intestinal mucosal damage in allogeneic and autologous HSCT recipients.
Chronic Graft-Versus-Host Disease-Related Membranous Nephropathy: Report of 3 Cases.
Authors: Zhu Kanger , Zhu Wei-jian , Zhang Tao
Published: October 2019

Objective: To investigate the clinical manifestation, pathological features, management and prognosis of chronic graft-versus-host disease (cGVHD)-related membranous nephropathy following allogeneic hematopoietic stem cell transplantation (allo-HSCT).

Methods: Clinical and pathological data from 3 patients with nephrotic syndrome following allo-HSCT were retrospectively analyzed.

Results: cGVHD-related membranous nephropathy occurred in 3 out of 150 patients (2%) undergoing allo-HSCT in our BMT unit. 3 patients, with two male and one female, median age of 15 years, and median interval of 11 months between diagnosis and post-transplantation, typically presented with full nephrotic syndrome, including heavy proteinuria (median 8.1 g/24h), edema, hypoalbuminemia (median 29.6 g/L), and hypercholesterolemia (median 11.7 mmolL). A major finding of renal biopsy that was consistent with membranous nephropathy in early stage was diffusely thickened glomerular basement membranes (GBMs) with deposits of IgG along it. All patients showed evidence of cGVHD. Two patients responded well to steroid, with gradual improvement of clinical symptoms and disappearance of proteinuria, and are still alive without evidence of relapse. But the other one died of disseminated hemorrhagic varicella one month following immunosuppressive therapy.

Conclusion: These findings suggest that the kidney may be the target organ of alloimmunity, and membranous nephropathy may be one of clinical manifestations of cGVHD, which is response to steroid, resulting in disappearance of proteinuria. It is necessary for transplant physicians to keep in mind the possibility of cGVHD-related membranous nephropathy when a case of nephritic syndrome is encountered.
Isolated Oral Lichen Planus as Manifestation of Chronic GvHD Predicts Improved Survival after Reduced Intensity Allogeneic Stem Cell Transplantation.
Authors: Visser Otto J. , Kara Sema , Leidekker Maaike , Janssen Jeroen J.W.M. , van der Waal Isaac
Published: October 2019

In reduced intensity allogeneic stem cell transplantation an increasing incidence of a lichen planus-like disorder of the oral cavity as manifestation of chronic graft versus host disease (cGvHD) has been reported, sometimes combined with a similar condition in the genital area. Oral lichen planus GVHD (OLP-GvHD) can occur as a single manifestation of cGvHD, without other organs affected. It resembles classic oral lichen planus both clinically and histologically. Clinical symptoms are a painful, burning sensation, diminished taste, loss of appetite and hyposalivation, sometimes resulting in problems with medication intake. Clinical examination is the main key in the diagnosis of OLP-GvHD. In some cases (modest) alterations of liver function can be detected as well. Apparently, no GvHD of the skin or digestive tract is present.

From January 2004 to March 2006, we performed a total of 96 RIST transplantations. All patients systematically underwent pretransplantation examination, including high quality photographs of the oral mucosa, by an oral medicine specialist. During follow up, 24 patients (25%) were diagnosed with OLP-GvHD without concomitant cGvHD of other organs. The diagnosis was based on clinical features, histopathology and by exclusion of any other causes (e.g. viral or yeast infections). Digital photographs of the oral lesions were compared with routinely taken pretransplantation photographs. Isolated OLP-GvHD (+/− modest liver function tests), was treated with topical dexamethasone elixer (0.11 mg/ml), if not successful (7/25 patients) also with tacrolimus ointment (0.1% + hypromellose 4000 mpa). After a median follow up of 12 months, a significant improvement of overall survival was seen in patients diagnosed with OLP-GvHD as compared with those with more extensive cGvHD or no cGvHD. The mean duration of local therapy of the oral cavity was 135 days and nearly all symptoms disappeared.

We conclude that after reduced intensity allogeneic stem cell transplantation the occurrence of OLP-GvHD predicts superior survival rates. Local treatment is sufficiently effective.

Figure Figure
Rapid Immune Reconstitution after a Reduced-Intensity Conditioning Regimen and a CD3-Depleted Haploidentical Stem Cell Graft for Pediatric Refractory Hematologic Malignancies.
Authors: Chen Xiaohua , Hale Gregory A. , Barfield Raymond C. , Benaim Ely , Leung Wing H. , Knowles James , Horwitz Edwin M. , Woodard Paul , Kasow Kimberly A. , Yusuf Usman , Behm Fred G. , Hayden Randall T. , Shurtleff Sheila A. , Turner Victoria , Srivastava Deo Kumar , Handgretinger Rupert
Published: October 2019

Haploidentical hematopoietic stem cell transplantation (HaploHSCT) from a mismatched family member (MMFM) donor offers an alternative option for patients who lack an HLA-matched donor. The main obstacles to successful haploidentical hematopoietic stem cell transplantation from a mismatched family member donor are delayed immune reconstitution, vulnerability to infections, and severe graft-versus-host disease (GvHD).

Method: We designed a reduced-intensity conditioning regimen that excluded total body irradiation and anti-thymocyte globulin. The graft was immunomagnetically depleted of CD3+ T-cells (CD3 negative selection) and contained a large number of both CD34+ and CD34− stem cells and most other immune cells especailly NK cells. This protocol was used to treat 22 pediatric patients with refractory hematologic malignancies.

Results and Discussion: After transplantation, 91% of the patients achieved full donor chimerism. They also showed rapid recovery of CD3+ T-cells, T-cell receptor excision circle counts, TCRβ repertoire diversity and NK-cells during first four months post-transplantation. The incidence and extent of viremia were limited and no lethal infection was seen. Only 9% of patients had grade 3 acute GvHD, while 27% patients had grade 1 and another 27% had grade 2 acute GvHD. This well-tolerated regimen appears to accelerate immune recovery and shorten the duration of early post-transplant immunodeficiency, thereby reducing susceptibility to viral infections. Rapid T-cell reconstitution, retention of NK-cells in the graft, and induction of low grade GvHD may also enhance the potential anti-cancer immune effect.
Lymphoma and Peripheral Neuropathy: Sudden Weakness in a Patient with T-Cell Lymphoma.
Authors: Muslimani Alaa , Daw Hamed
Published: October 2019

Introduction: Lymphomas (both Hodgkin’s and Non-Hodgkin’s [NHL]) can affect the peripheral nervous system and cause peripheral neuropathies in 5–8 % of patients. The mechanisms by which this can occur include directly infiltrating nerves, paraneoplastic mechanism, metabolic and infectious processes, and side effects of treatment. Most neurological complications occur in NHL, the majority being B-cell NHL. Only few cases have been reported T-cell NHL and acute inflammatory demyelinating polyradiculopathy. We report once such case.

Case: A 70-year-old female initially presented with left nostril lockage and maxillary sinus pressure. Examination revealed a black mass in the left nostril and swelling of the nose, including left nasal-lacrimal area. The rest of the physical exam was unremarkable. Biopsy revealed natural killer/T-cell (NK/T-cell) lymphoma nasal type, an aggressive but uncommon lymphoma in the United States. She underwent CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone) chemotherapy. Positron emission tomography (PET) scan was negative for lesions in chest, abdomen and pelvis. Three weeks after completing chemotherapy, she presented with acute lower extremity paraparesis. On examination, she had absent lower extremity reflexes. A computed tomography scan of the brain revealed a tumor infiltrating the left orbit. After undergoing numerous investigations including, lumbar puncture and magnetic resonance imaging (MRI) cervical and thoracic spine, electromyography and nerve conduction studies revealed abnormal findings suggestive of inflammatory demyelinating polyradiculopathy.

She was treated with intravenous immunoglobulin without significant improvement. Soon after, she had facial nerve involvement that was confirmed on an MRI of the brain. Six months after the initial diagnosis of nasal NK/T-cell lymphoma, the patient’s symptoms worsened and she was referred to hospice and expired.

Conclusion: Nasal NK/T-cell lymphoma often follows an aggressive course. The majority of peripheral neuropathy cases in NHL are chemotherapy related. Although most cases of peripheral neuropathy occur in B-cell NHL, this is a case of T-cell NHL associated with acute inflammatory demyelinating polyradiculopathy.
Pre-Transplant Smoking and Transplant-Related Mortality from Pulmonary Causes in Recipients of Allogeneic Stem Cell Transplants.
Authors: Magalhaes-Silverma Margarida , Leopold Christina , Cater Thomas , Hohl Raymond , Gingrich Roger
Published: October 2019

BACKGROUND: The success of allogeneic stem cell transplantation (SCT) is limited by transplant-related mortality (TRM). Death from pulmonary causes is a major contributor to TRM. Several factors influence TRM from pulmonary causes. We have analyzed the effect of cigarette smoking on pulmonary related TRM.

METHODS: From January 2000 through April 2006 240 patients (pts) underwent allogeneic related or unrelated SCT. Diagnosis included ALL in 22 pts, AML in 90 pts, CLL in 11 pts, CML in 11 pts, Lymphoma in 49 pts, MDS in 29 pts, MM in 9 pts, SSA in 4 pts, solid tumors in 5 pts, other in 4 pts; median age of the pts was 50 years (range 18–70); 148 were males and 92 females; 48 pts received a reduced intensity regimen and 192 an ablative regimen; 117 pts received TBI; 123 pts were non-smokers (Group I) and 117 pts smokers. Amongst the smokers 86 pts provided pack/year information. In this group 46 pts (Group II) had a pack/year history < 30 and 40 pts (Group III) of ≥ 30.

RESULTS: 70/123 pts in Group I are deceased with 44% surviving. In this group causes of death included disease progression/relapse in 17 pts, infection in 17 pts, organ failure in 13 pts, GVHD in 11 pts, other in 3 pts and pulmonary related TRM in 8 pts (6.5 ± 4%). 29/46 pts in Group II are deceased with 36% surviving. In this group causes of death included diseaseprogression/relapse in 10 pts, infection in 8 pts, organ failure in 1pt, GVHD in 3 pts, other in 2 pts and pulmonary related TRM in 5 pts (10.9 ± 9%). 31/40 pts in Group III are deceased with 22% surviving. In this group causes of death included disease progression/relapse in 11 pts, infection in 6 pts, organ failure in 5 pts, GVHD in 2 pts, other in 2 pts and pulmonary related TRM in 5 pts (12.5 ± 10 %).

CONCLUSION: Smoking contributes to transplant-related mortality from pulmonary causes after allogeneic stem cell transplantation in a dose-related manner. In future analysis the interaction between smoking and other variables will be explored.

Smoking and Outcomes Pt Group Surviving Pts (%) Deceased Pts (%) Pulmonary TRM Group I ( n=123) 44% 56% 6.5% Group Ii (n=46) 36% 64% 10.9% Group III ( n=40) 22% 78% 12.5%
Stem Cell Transplantation (SCT) for Acute Myeloid Leukemia (AML): A Single Center in over 25 Years Experience.
Authors: Santarone Stella , Di Bartolomeo Erminia , Di Bartolomeo Paolo
Published: October 2019

In this study we report the results of SCT in 116 patients (M51, F65) with AML transplanted from HLA identical (n=111) or 1 antigen mismatched (n=5) related donors between 1981 and 2006. The median age was 33 years (1–63). At time of SCT, 76 patients were in CR1, 23 in CR2 and 17 in CR>2 or in relapse. The stem cell source was bone marrow for 94 patients, PBSC for 21 and cord blood for 1. The conditioning regimen was myeloablative for 110 patients (BU CY for 87 and TBI CY for 23) and not-myeloablative for 6 (Thiotepa CY). For GvHD prophylaxis, 30 patients received cyclosporine (CSA) alone and 86 were given CSA and short course methotrexate. All patients engrafted with a median time to achieve 0.5 ×109/L neutrophils and 50×109/L platelets of 20 (10–37) and 22 (11–103) days respectively. One patients lost the graft six months after SCT and was successfully retransplanted. Acute GvHD grade II–IV occurred in 24%. Chronic GvHD occurred in 21% (9% limited, 12% extensive). The overall transplant related mortality (TRM) was 15.5% at 12 months (14,4% in CR1, 8,7% in CR2 and 29% in CR>2 or in relapse). Causes of death were: GvHD in 6 patients, infection in 6, multiorgan failure in 3, renal insufficiency in 1, encephalopathy in 1, pancreatitis in 1. The overall incidence of relapse was 29% (25% in CR1, 26% in CR2, 53% in CR>2). Twelve patients (1 in CR1, 5 in CR2 and 6 in >CR2 or relapse) underwent a second SCT from the same donor after a median interval from the first and second SCT of 456 (203–1946) days. The TRM post-second SCT was 16%. Nine of 12 patients are now living and cured after a median follow-up of 5,4 years (1–16,8). Overall, after a median follow-up of 8.08 (0.3–22) years, 71 out of 116 patients (61%) are living and cured. The 20 years probability of disease free survival is 68% for patients in CR1, 74% for patients in CR2 and 18% for patients in CR>2 or relapse (Fig. 1). In univariate analysis the patient age < 30 years, the BUCY regimen as compared to the TBI regimen and a dose of marrow cells > 3.0 × 108/Kg are associated with a better survival. We conclude that SCT is a curative treatment for patients with AML. In our experience second SCT gives results comparable to those of first transplant.

Fig 1. Probability of DFS according to phase of disease at SCT Fig 1. Probability of DFS according to phase of disease at SCT
Successful Bone Marrow Transplantation with an Intensively Immunosuppressive Conditioning with Low Toxicity for High-Risk Chronic Granulomatous Disease Patients.
Authors: Miki Mizuka , Kajiume Teruyuki , Nakamura Kazuhiro , Kawaguchi Hiroshi , Sato Takashi , Kurita Emi , Onodera Rie , Hiraoka Asako , Mizukami Tomoyuki , Nunoi Hiroyuki , Kobayashi Masao
Published: October 2019

Chronic granulomatous disease (CGD) is an inherited disorder characterized by recurrent bacterial and fungal infections, often resulting in impaired quality of life and death. Allogeneic hematopoietic stem cell transplantation (HSCT) is the curative therapy for patients with CGD. HSCT in certain CGD patients is associated with a significant risk of therapy-related morbidity due to toxicity, rejection, GVHD, and/or infectious complications. Recently successful HSCT with nonmyeloablative conditioning for CGD patients has been developed. However, the results of HSCT in adult CGD patients have been insufficient in adult patients with CGD. In this study 5 patients with adult CGD underwent bone marrow transplantation after undergoing an intensive immunosuppressive regimen with reducing toxicity and optional donor lymphocyte infusion (DLI). All patients were diagnosed by the absence of oxidase activity and confirmed by the lack of the expression of 91phox using monoclonal antibody by flow cytometry. All patients were more than twenty years of age and suffered from critical and life-threatening infections, such as brain abscess, osteomyelitis, and granulomatous colitis at transplantation. Patients underwent a conditioning regimen consisting of cyclophosphamide (30 mg/Kg × 4), fludarabine (30 mg/m2 × 5), anti-lymphocyte globulin (15 mg/Kg × 4), and low-dose (3 Gy) of total body irradiation. Four of five patients were transplanted from HLA-identical siblings and one patient from HLA-haploidentical brother presenting microchimerism between donor and recipients. After transplantation prompt engraftment with mixed chimerism was observed without severe conditioning-related complications in all patients. Their infections were immediately improved within one month after transplantation during the period of mixed chimerism. The degree of chimerism was serially assessed by microsatellite DNA sequences and by the presence of 91phox-positive neutrophils using flow cytometry. Based on the chimerism assay, DLI was performed in two patients without developing GVHD. All patients have achieved complete chimerism without therapy-related complications. These results using an intensively immunosuppressive conditioning with low toxicity is a promising treatment modality for high-risk patients with CGD.
Peripheral Blood Stem Cell Transplantation in Children with Thalassemia.
Authors: Tezcan Gulsun , Uygun Vedat , Kupesiz Alphan , Hazar Volkan , Yesilipek Akif
Published: October 2019

Although improvements in conventional treatment have enhanced the prognosis of thalassaemia, stem cell transplantation remains the only cure. Studies have shown that peripheral blood stem cell transplantation (PBSCT) results in rapid hematological and immunological recovery but increased risk for graft versus host disease (GVHD). We report the PBSCT experience of Akdeniz University School of Medicine Pediatric Hematology&Oncology department concerning 54 patients with beta-thalessemia. Median age was 6 years (1–18 years), 26 were girls, 28 were boys. Thirteen were Class I, twenty-two were Class II, nineteen were Class III according to Pesaro criteria. 12 patients were given BU+CY and 39 BU+CY plus ATG as conditioning regimen. Three Class III patients were conditioned with Pesaro protocol 26. BU dosage was 16 mg/kg for Class I and Class II patients followed by CY 200 mg/kg totally. Class III patients received 14 mg/kg BU and 160 mg/kg CY. All patients received MTX (+1, +3, +6) and CsA for GVHD prophylaxis. All of the donors were HLA identical (51 sibling, 3 parents). Median age of the donors was 7 years (range: 2–40 years). G-CSF was given for 5 days with the dosage of 5 μgr/kg/day to child and 10 μgr/kg/day to adult donors for peripheral blood stem cell mobilization. Stem cell apheresis was performed on fifth day, but continued to day 7 if adequate cell count was not achieved. In older children and parents if appropriate, antecubital veins were used for harvesting but for younger donors, femoral dual lumen catheters were emplaced. Fresenius AS. TEC204 or Haemonetics MCS+ cell separators were used for apheresis. The median apheresis count was 1 (range 1–3). Median transfused MNC and CD34 cell counts were 10.1×108/kg (range:5.3–27.7×108/kg) and 4,65×106/kg (range:1.1–29.4×106 /kg) respectively. Median neutrophil and platelet engraftment times were day 14 and day 15, respectively. Grade II–IV acute GVHD were observed in five patients, chronic GVHD were in four of two were extensive. One patient died on posttransplant day 32 because of acute GVHD. Death because of chronic GVHD was not observed. At a median follow-up of 26 months (1–92 months), overall survival for the whole group is 92.6 % and evet-free survival is %80.4. Autologous reconstitution developed in six patients and graft failure in two.
Protein 4.1R Exon 16 Splicing Mediated by Regulated Expression of RBM9 and PTB during Erythroid Differentiation.
Authors: Yang Guang , Huang Shu-Ching , Benz Edward J.
Published: October 2019

Protein 4.1R (4.1R), a vital component of the red cell membrane cytoskeleton, stabilizes the spectrin-actin lattice and attaches it to the embedded membrane proteins. The inclusion of exon 16, which encodes peptides critical for spectrin/actin binding, occurs via an intricate interplay between the auxiliary cis-elements and transacting factors. An intronic splicing enhancer, UGCAUG, is present in triplicate and is situated between two polypyrimidinetract-binding (PTB) sites, TCTT, in the intron downstream of exon 16. In addition, PTB binding sites are also present in triplicate in the upstream intron of exon 16. In this study, we characterized the splicing factors that orchestrate the erythroid differentiation stage-specific switch in exon 16 splicing through these cis-elements using two cell systems: mouse erythroleukemia cells (MELC) that can be induced to erythroid differentiation and G1E-ER cells that undergo synchronous erythroid maturation after induced GATA-1 expression. We identified two RBM9 isoforms (RBM9-1A and RBM9-1F) with distinct amino-termini that interact with the intronic splicing enhancer UGCAUG. The expression of RBM9-1A is erythroid-specific while RBM9-1F can be detected in a wide variety of cell types. Real-time PCR and Western blot analyses showed that RBM9-1A expression is significantly increased while RBM9-1F is reduced during induced erythroid differentiation in both MELC and G1E-ER4 cells. The up-regulation of RBM9-1A correlated with exon 16 inclusion in differentiated cells. Furthermore, the inhibition of RBM9 expression by isoform specific-shRNA reversed 1A enhancing activity, but not that of 1F on exon 16 inclusion in differentiated cells. Thus, exon 16 splicing is mediated by a cell type-specific RBM9 isoform and its up-regulation in late erythroid differentiation is vital for exon 16 splicing. However, over-expression of PTB completely diminished the enhancing effect of RBM9-1A on exon 16 splicing in both differentiated MELC and G1E-ER4 cells, suggesting that PTB plays a role in exon 16 splicing. We analyzed PTB expression and its effect on the exon 16 splicing switch during erythroid differentiation. PTB, a repressive regulator of alternative splicing, binds to the exon 16 upstream and downstream intronic silencers. Its over-expression reduced exon 16 inclusion in both endogenous 4.1R and transfected exon 16 minigenes. Moreover, PTB expression was down-regulated and coincided with increased exon 16 splicing during erythroid differentiation suggesting that regulated expression of repressor PTB mediates exon 16 splicing. Our results further suggest that the differentiation-specific exon 16 splicing switch is achieved by varying the amount of either ubiquitously expressed or cell-type specific activators and inhibitors, and hence the relative efficiency of spliceosome recruitment in the exon inclusion pathway.