bluuebunny/crossref_metadata_2025 huggingface dataset:
Incidence and Characteristics of Infections Following Cord Blood Stem Cell Transplantation in Children.
Authors: Lim Y.J. , Lee Y.H. , Koo H.H. , Yoo K.H. , Sung KW , Chung NG , Cho B. , Kim H.K. , Kang H.J. , Shin H.Y. , Ahn H.S. , Kook H. , Hwang T.J. , Moon H.N. , Seo J.J. , Im H.J. , Park S.K. , Ghim Thad T. , Hah J.O. , Lyu C.J. , Park J.E. , Lee K.C. , Lim Y.T. , Lim J.Y. , Kang I.J.
Published: October 2019

Infection is one of the most important causes of morbidity and mortality after hematopoietic stem cell transplantation. We assessed the incidence and characteristics of infections in 163 cord blood stem cell transplantation (CBT) recipients from 13 transplant centers of Korea between October, 1996 and April, 2005. The patients underwent CBT with standardized conditioning, GVHD prophylaxis and supportive care including pre-emptive ganciclovir therapy for cytomegalovirus (CMV) antigenemia. The median time to neutrophil engraftment was 19 days (10–62 days) and to platelet engraftment was 45 days (14–394 days). Within the post-transplant day 0 to day 30, 81.6% of patients (133/163) experienced febrile episodes with 11.7% (19/163) of clinically documented infection (CDI) and 19.6% (32/163) of microbiologically documented infection (MDI). The neutrophil engraftment was delayed in the patients with CDI and MDI rather than without CDI and MDI (day 26.3 vs day 21.5, P=0.03) before day 30. In the time period of day 30 to 100, febrile episodes, CDI and MDI occurred in 54.3% (82/151), 14.6% (42/151) and 13.2% (20/151), respectively. After day 100, 38.5% of patients (45/117) experienced febrile episodes with 17.9% (21/117) of CDI and 7.7% (9/117) of MDI. Although the incidence of febrile episodes before day 30 was significantly higher than after day 30, the incidence of CDI and MDI was comparable. There were no significant differences of infection rate according to the infused cell dose, the degree of HLA disparity, acute GVHD and chronic GVHD. The overall mortality rate after CBT was 40% (65/163). Infection was considered the primary cause of transplant-related mortality and represented 18.4% (106/163) of the causes of death with the median day of 96.5 (1∼1,081 days). The incidence of pre-transplant CMV-seropositivity was 85.5% of the patients (106/123) and CMV antigenemia developed in 52.7% of CMV-seropositive patients compared to 11.8% of CMV-seronegative patients (P=0.002). CMV disease developed in 25.7% of CMV-seropositive patients and 6.7% of CMV-seronegative patients, which showed statistiacally not significant. Pre-transplant conditioning regimens such as antithymocyte globulin did not affect on the incidence of CMV antigenemia or CMV disease. Based on our study, the infection was still the primary cause of mortality after CBT, particularly in patients with delayed neutrophil engraftment. The high prevalence of CMV seropositive patients in Korea was associated with increased incidence of CMV antigenemia, not with CMV disease.
Chimerism Status as a Possible Marker of Incipient Disease Relapse in Patients with AML.
Authors: Horky Ondrej , Mayer Jiri , Borky Marek , Krejci Marta , Pospisilova Sarka , Dvorakova Dana
Published: October 2019

The connection between chimerism status and occurence of relapse in patients undergoing hematopoietic stem cell transplantation remains controversial. One reason for this seems to be employment of different methods with inherrited different sensitivity and related definition of complete donor chimerism (CDC). We compared an application of fragment analysis (FA) of minisatellite, microsatellite or sex specific regions (limit of quantification ∼1%) with real-time quantitative PCR (RQ-PCR) of insertion/deletion and sex polymorphism (limit of quantification ∼0.1%). Long-term data (follow-up 1.8–7.4 years, median 3.3 years) obtained from two groups of AML patients transplanted in our centre are presented. The first group involves 9 patients that experienced relapse (one of them three times) whereas the second one contains 11 individuals in complete remission. Retrospective chimerism analysis of patients in the first group by RQ-PCR allowed prediction of hematological relapse significantly earlier (p=0.016) than quantification by FA, (35–448 days, median 77 days by RQ-PCR vs. 0–154 days, median 35 days by FA). Beside this, in two cases the incipient relapse was detected only by RQ-PCR and not by FA, 118 and 70 days in advance. Moreover, in two patients with fusion gene, there was detection of molecular relapse recorded simultaneously by either increase of autologous hematopoiesis or conversion of CDC to MC in granulocytes, as revealed by analysis of sorted leukocyte subsets. On the other hand, after achievement of CDC within the group of patients in complete remission, the amount of detectable autologous DNA did not repeatedly exceeded the limit of quantification of RQ-PCR. The CDC was not achieved in one case only, whereas lineage-restricted analysis persistently shows MC in T-lymphocytes (1–3% of autologous origin). Our data demonstrate, that assessment of chimerism by RQ-PCR along with analyses within specific leukocyte subsets can provide an early indication of incipient disease relapse of AML and could be used for residual disease monitoring in cases, where another specific marker is not available.
Bone Marrow Transplant Activity - A Country Report from Pakistan.
Authors: Ullah Khalil , Shamsi Tahir S. , Adil Salman N.
Published: October 2019

Bone Marrow transplant activity started in 1999 in Pakistan when Bismillah Taqee Institute of Health Sciences & Blood Diseases Centre started functioning in the southern port city of Karachi, Pakistan. Two years later in year 2001 Armed Forces Bone Marrow Transplant Centre started functioning in the northern part of country, Rawalpindi, Pakistan. In 2004 another transplant centre, started in Aga Khan University Hospital, Karachi, Pakistan. Since the establishment of these transplant centers a total of 349 allogeneic transplants have been carried out for various hematological disorders. The major indications included aplastic anaemia (n=166), β-Thalassaemia major (n=76), chronic myeloid leukaemia (n=57), acute leukaemias (n=37) and misc disorders including MDS, Fanconi anaemia and others (n=13). A total of 22 autologous transplants in lymphomas and multiple myeloma have also been carried out. Since this number is very small, only data of allogeneic transplants is being presented here. Major post transplant complications encountered were neutropenic fever in 92.6% patients with 27% culture positivity (412/1571). Infective complications included bacterial infections (both gram+ive and gram-ive) in 194 patients (56%), fungal infection in 32 patients (10%), CMV infection in 15 patients (5%), herpes infection in 16 patients (5%), tuberculosis in 9 patients (3%) and PCP in 1 patient (0.28%) and malaria in 1 patient (0.28%). So post transplant infections were confirmed in 76.6% (268/349) patients on the basis of clinical assessment, microbiological, virological and histopathological analysis. Non infective post transplant complication included aGvHD (grade II-IV) in 80 patients (23%), cGvHD 46 patients (13.1%), VOD liver in 25 patients (7.2%), haemorrhagic cystitis in 27 patients (7.7%), ARF in 13 patients (3.7%), primary graft failure in 5 patients(1.4%), graft rejection in 17 patients (4.9%) and relapse in 14 patients (4%). Transplant related mortality was observed in 93 patients (26.6%). Infective & non infective causes of mortality included septicemia in 15 patients (4.3%), CMV in 8 patients (2.3%), fungal infections in 8 patients (2.3%), tuberculosis in 2 patient (0.6%). herpes encephalitis in 1 patient (0.3%) VOD in 8 patients (2.3%), aGvHD in 12 patients (3.4%), cGvHD in 7 patients (2.0%), ARF in 8 patients (2.3%) and intracranial haemorrhage in 3 patients (0.9%). Graft related mortality due to graft failure and relapse was observed in 6 patients (1.7%) and 14 patients (4%) respectively. Unrelated accidental death in 1 patient (0.3%). Overall survival was observed in 256 patients (73.3%) and DFS in 250 patients (71.6%). The OS and DFS was 72.7% and 70.9% in BTIHS & BDC patients, whereas OS & DFS was 72.8% and 70.7% respectively in AFBMTC patients. The OS & DFS was 82.6% at AKUH. Disease wise overall survival in aplastic anemia, β-Thalassaemia, CML and acute leukemia was 78.3%, 76.3%, 63.1% and 59.5% respectively.
Two Cases of Chronic Active Epstein-Barr Virus Infection (CAEBV) Successfully Treated with Allogeneic Bone Marrow Transplantation and Induction of Specific Cytotoxic T Lymphocyte (CTL).
Authors: Miyamura Takako , Chayama Kousuke , Wada Tomoaki , Yamaguchi Kazunari , Yamashita Nobuko , Ishida Toshiaki , Washio Kana , Morishita Naoto , Oda Megumi , Morishima Tsuneo
Published: October 2019

Chronic active Epstein-Barr virus infection (CAEBV) is a heterogenous EBV-related disorder, characterized by clonal expansion of EBV-infected T or NK cells. Although CAEBV is a high mortality and morbidity disease with life-threatening complications, effective treatment regimens have not yet been established. The pathogenesis and etiology of CAEBV are not well characterized. The clonal expansion of EBV-associated T or NK cells has been suggested to play important roles in the pathogenesis of CAEBV. It is not clear why EBV-associated abnormal cells cannot be excluded, because of a factor on the virus side or a function on the host side. We report two cases of CAEBV in which allogeneic bone marrow transplantation (BMT) was performed soon after diagnosis. After BMT, the EBV genome titer decreased as cytotoxic T lymphocyte (CTL) activity gradually increased.

Case 1: A five-year-old boy had exhibited prolonged fever, lymphadenopathy, and severe liver dysfunction for more than 6 months. Clonally proliferating EBV-infected T cells and abnormally high titers of EBV-related antibodies were detected. No EBV-specific CTLs were detected. The patient was given a diagnosis of T-cell type CAEBV and he received BMT (the donor was his 1-locus mismatched mother) 6 months after diagnosis. Severe treatment-related toxicity did not occur. After BMT, the EBV genome titer gradually decreased as the CTL activity increased. At 2 months after BMT, the EBV genome titer of the patient was nearly negative.

Case 2: A two-year-old girl had exhibited a persistent fever of unknown etiology and hepatosplenomegaly. Abnormally high titers of EBV-related antibodies were detected and NK cells in her peripheral blood contained a high EBV genome titer. The EBV-specific CTL levels were low. She received BMT from an unrelated donor 3 months after diagnosis. Toxicity other than grade 2 graft-versus-host disease was not detected. After BMT, the EBV genome titers decreased gradually as the CTL activity increased.

Conclusion: These cases suggest that not only high-dose chemotherapy as a preconditioning treatment of BMT, but also that increased CTL activity to eliminate virus-infected cells might be effective. Additional cases should be studied to establish effective treatments.
Non Myeloablative Allogeneic Related Transplant in Patients with Aggressive B Cell Lymphoma: Results of Two Multicenter Spanish Trials. The GELTAMO Group.
Authors: Caballero M.D. , Briones J. , Mateos M.V , Tomás J.F. , Martino R. , de la Serna J. , Díez J.L. , Pérez-Simón J.A. , Sureda A. , Sarrá J. , García-Laraña J. , Ribera J.M. , Sierra J. , Miguel J.F. San
Published: October 2019

Although autologous transplant is the election in poor prognosis patients with Non Hodgkin agressive histologies, some patients relapse, for others collection of progenitor cells is not possible and in some categories as Mantle Cell Lymphoma results after autologous transplant are dismal. From 1999, three prospective multicenter trials with non-myeloablative allogeneic transplant in hematological malignancies have been performed in Spain. Up to now, 36 patients have been registered in these trials. From them,28 (58%)had aDBLCL,1 (3%) a transformed MZL,1 (3%) a BL and 14 (37%) a MCL. The conditioning regimen consisted of fludarabine 30 mg /m2 intravenously (IV) on days −8 to −4 followed by melphalan 70–140 mg/m2 IV on days −3 and−2. The last 25 patients enrolled in the latest trial received rituximab 375mg/ m2;on days −8, −1,+8 and +15 as part of conditioning; filgrastim stimulated peripheral blood stem cells were infused on day 0. GVHD prophylaxis consisted of cyclosporine A (CsA) from day −7 plus short-course methotrexate (MTX) (10mg/m2, days +1, +3, +6), followed by folinic acid rescue. Median age was 51 years (range 27–68);at transplant 5 (13%) of the patients were in CR1, 4 (11%) in a later CR and 29 (76%) had active disease 18 (47%) had sensitive disease and 11 (29%) resistant disease. Days to reach more than 500x 109 granulocytes and more than 20000x109 platelets were +14 (range 10–93) and +12(range 8–18). At a median time of 25 days (range 19–97), 19 patients (50%) developed acute GVHD (13 patients (34%) grade II–IV). At a median time of 107 days(80–267), 68% out of 19 patients at risk developed cGVH being extensive in 11 (39%)Disease was evaluated at day +100 and at that moment 23 patients(65%) were in CR (including 4 / 8 patients transplanted on PGR), 4% in PR and 23% have died due to NRM(Non relapse mortality). With a median follow up of 31 months (range: 6–67 months), 19 patients (50%) are alive, 17 disease free and 19(50%) have died, 10(26%) due to NRM and 8 (21%) due to progression with a proyected NRM at 1 year of 22%. OS and EFS at 5 years of of 43 and 36% respectively. None of the variables analysed influenced on NRM. Regarding efficacy of transplant in different histologies, OS and DFS for MCL were 71% and for BDLCL, 31% and 20% respectively. In this preliminary analysis results in MCL are quite good however for patients with DLBCL should be improved. severe toxicity is still present and to date it should be performed only in the setting of well designed clinical trials.
Unrelated Donor (URD) Searches in African-Americans with Hematologic Malignancies: Paucity of HLA Identical Donors.
Authors: Dew Alexander , Collins-Jones Demetria , Artz Andrew , Rich Elizabeth Shima , Stock Wendy , van Besien Koen
Published: October 2019

Recent analyses have demonstrated the importance of molecular matching in HLA-A, B, C and DRB1 (8/8) for the success of adult URD hematopoetic stem cell transplantation (HSCT). Little is known about the likelihood of identifying an 8/8 HLA identical URD in pts of African-American (AA) descent. From 2/2002 to 5/2007, we performed 51 preliminary (PRLM) URD searches for AA pts using the National Marrow Donor Program (NMDP) and its cooperative international registries. The median age was 38 (range, 1–73), and diseases included AML (n=18), MDS (n=1), ALL (n=1), CLL (n=4), CML (n=4), Hodgkin lymphoma (n=4), NHL (n=4), MM (n=1), severe aplastic anemia (n=4), sickle cell anemia (n=6), and other (n=4). Of the 51 PRLM searches, 13 (25%) pts had at least 1 potential HLA-A, B, and DRB1 (6/6) URD and 37 pts had at least 1 potential URD with a single allele or antigen mismatch at HLA-A, B, or DRB1 (5/6). Of the 13 pts with potential 6/6 donors, 12 proceeded to a formal URD search. After a median formal search duration of 5 months (range 1–39), 3 pts were found to have a high resolution 8/8 HLA identical URD (6% of total AA searches, 25% of formal searches with 6/6), and 2 were found to have an URD with a single allele or antigen mismatch at one of the 8 HLA loci (7/8). Two of the 3 pts with an 8/8 HLA identical URD were transplanted. Twenty-four of the 37 AA pts with a potential 5/6 URD proceeded to formal URD search. The median formal search duration for this group was also 5 months (range 1–29). Eight pts were found to have a high resolution 7/8 HLA URD (33% of formal searches with 5/6), but only 1 went on to HSCT using the 7/8 HLA URD. 275 donors were activated, and 133 were unavailable (48%). These data illustrate the difficulty in locating an appropriate URD in AA pts. In order to allow more AA pts to proceed to HSCT in a timely manner, alternative donor procurement strategies (e.g. haplo-identical or umbilical cord transplantation) should be investigated.

Table 1 URD searches in African-Americans with hematologic malignancies Preliminary search n Formal search 8/8 7/8 <7/8 Transplanted 6/6 13 12 3 2 7 2 5/6 37 24 8 16 1 <5/6 1 Total 51 36 3 10 23 3
The Outcome of Hematopoietic Stem Cell Transplantation in Pediatric Patients with Hemophagocytic Lymphohistiocytosis in Korea.
Authors: Lee Jae Hee , Yoon Hoi Soo , Song Joon Sup , Im Ho Jun , Moon Hyung Nam , Ghim Thad T. , Kang Hyeong Jin , Shin Hee Young , Ahn Hyo Seop , Yoo Keon Hee , Sung Ki Woong , Koo Hong Hoe , Cho Bin , Kim Hack Ki , Jeong Dae Chul , Lee Mee Jung , Kook Hoon , Hwang Tai Ju , Seo Jong Jin
Published: October 2019

Objective: Chemoimmunotherapy based treatments improved the survival of patients with hemophagocytic lymphohistiocytosis (HLH), but the outcome is still unsatisfactory. We analyzed the outcome of pediatric patients with HLH after hematopoietic stem cell transplantation (HSCT) in a nation-wide HLH registry.

Methods: Retrospective nation-wide data recruitment for HLH pediatric patients diagnosed between 1996 and 2005 was carried out by Histiocytosis Working Party of the KSH and KSPHO. Sixteen patients who received HSCT among enrolled 129 pediatric patients with HLH were analyzed for transplant related variables and events.

Results: The probability of 3-year survival after HSCT was 81.2% with median follow-up of 27.5 months compared to the 35.2% for patients who were treated with chemoimmunotherapy only (P=0.03). The reasons for HSCT were active disease at 2 months after treatment (n=8), relapsed disease (n=5), and familial HLH (n=3). Eight patients received transplants from matched unrelated donors, 5 from matched siblings and 3 using unrelated cord blood units. Stem cell sources were bone marrow for all the 13 allogeneic transplants other than 3 cord blood transplants. Conditioning regimens were busulphan, cytoxan, and VP-16 with (5) or without (7) antithymocyte globulin (ATG) in 12 patients, fludarabin and melphalan in 3, and other regimen in 1. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine (CSA) + MTX in 11 patients, CSA +MMF in 2, and others in 2. Twelve patients are alive in complete remission state, 3 patients died of infection and graft failure at early post-transplant period, and 1 patient relapsed at post-transplant 30 days. The relapsed patient developed tuberculous encephalitis after retreatment with chemoimmunotherapy, and alive with supportive care. After HSCT, acute GVHD developed in 5 patients, infection in 5, veno-occlusive disease (VOD) in 2, graft failure in 2, and post-transplant lymphoproliferative disease (PTLD) in 1. Acute lymphoblastic leukemia developed in 1 patient about 2 years after HSCT. Variables such as age at diagnosis, etiology of HLH (familial or secondary), central nervous system (CNS) involvement, disease state after 8 weeks of initial treatment, conditioning regimens, and stem cell sources were not associated with significant difference with regard to 3-year overall survival after HSCT.

Conclusion: HSCT revealed excellent outcome for patients with familial, relapsed, or severe and persistent secondary HLH in Korean nation-wide HLH registry.
Haplo-Identical Allogeneic Stem Cell Transplantation Using GCSF-Mobilized Marrow Plus Blood Stem Cells from Parent Donors for Children with High-Risk Leukemia.
Authors: Lu Quanyi , Niu Xiaoqing , Zhang Peng , Liu Delong
Published: October 2019

Increasing number of patients in China have difficulty of finding sibling donors due to limited number of siblings. We therefore explored the feasibility using haploidentical parent donors for allogeneic hematopoietic stem cell transplantation. Eight leukemia patients were studied in our hospital. These included 2 CML-BC, 2 MDS-RAEB, 3 relapsed ALL and 1 relapsed AML. The median age was 12 (7–17). GCSF- mobilized bone marrow and peripheral blood stem cells were collected from parents (1 to 3 locus mismatched). The conditioning regimen consisted of fludarabine (30mg/m2/d x5), bulsulfan (4mg/kg/d x3) and cyclophosphamide (50mg/kg/d x2). Cyclosporin A, mycophenolate mofetil, methotrexate, and ATG were used for GVHD prophylaxis. The total number of CD34+ cell in the grafts ranged between 5–10 x 106/kg. The median follow- up was 13 months (6–24). One patient failed to engraft, the other 7 patients achieved full donor chimerism at day 28. The incidence of acute GVHD (grade II-IV) was 57.1% (4 of 7). The incidence of chronic GVHD of limited stage occurred in the same 4 patients. One patient died of lung complication at 17th month, another patient with CML-BC relapsed 10 months after transplantation. The rest 6 patients are alive without disease. These results suggested that parents could be considered as stem cell donors in the absence of alternative donors for young patients with high-risk diseases. GCSF-primed bone marrow plus peripheral blood stem cells might be beneficial to reduce the risk of GVHD for leukemia children in China. More patients are needed to further study this approach.
Low Transplant Related Mortality Following Matched Unrelated Donor Allogeneic Transplantation in High Risk Patients Utilizing Low Dose Subcutaneous Campath.
Authors: Solomon Scott R. , Manion Karen , Bashey Asad , Morris Lawrence E. , Holland H. Kent
Published: October 2019

The administration of alemtuzumab (Campath 1H) as part of the conditioning regimen prior to allogeneic stem cell transplantation (ASCT) results in a low incidence of acute and chronic GVHD. However, intravenous Campath administration is also associated with significant infusional toxicities and a higher risk of infectious complications post-transplant. We evaluated the role of low-dose subcutaneous Campath prior to unrelated donor ASCT in 13 patients deemed to be at high risk for mortality (age>40years, significant comorbidity, or prior autologous transplant). Median age of transplant recipients was 54 (37–61) years and three patients had a prior autograft. Diseases included secondary/poor risk AML-5, CML-1, MPS-2, relapsed HD-1, NHL-3, and CLL-1. The preparative regimen consisted of fludarabine and targeted oral busulfan (myeloid malignancies) or cytoxan±rituximab (lymphoid malignancies). Campath was administered subcutaneously from d-5 to d-3 at a total dose of 43mg. Low dose Campath was well tolerated with no untoward toxicity. Early mixed T cell chimerism generally occurred (median day +100 donor CD3 60% (8–100) and CD33 100% (67–100)), requiring door lymphocyte infusion (DLI) in 10 of 13 patients. Ten of 11 evaluable patients achieved complete donor chimerism at a median of 112 days (32–260), and no graft failures have occurred. Acute graft-versus-host disease (GVHD) occurred in 5/13 patients (38%) at median day +58 (23–152) (grade I[1] and II[4]). Chronic GVHD occurred in 6/12 evaluable patients (3 limited, 3 extensive) and no GVHD mortality has occurred. CMV reactivation occurred in 5 of 9 at-risk patients (55%) with a median day to reactivation of day +25 (9–38), median number of reactivations of 2 (1–4), but no CMV disease or mortality. After a median follow-up of 340 (84–631) days, eleven of thirteen patients survive for a one year actuarial survival of 83%. No patient has died from treatment-related mortality. Relapse occurred in 5/13 patients resulting in the death of two patients. Low dose subcutaneous campath administered during conditioning results in low TRM and promising survival in older high risk patients undergoing unrelated donor ASCT.

Figure Figure
Total Body Irradiation (TBI) Based Versus Chemotherapy-Based Preparative Regimens Before Autologous Stem Cell Transplant for Non-Hodgkin’s Lymphoma.
Authors: Liu Hongwei , Seftel Matthew , Demers Allain , Nugent Zoann , Schroeder Garry , Butler Jim , Rubinger Morel
Published: October 2019

OBJECTIVES: The optimum high dose preparative regimen for non-Hodgkin lymphoma (NHL) patients undergoing autologous stem cell transplantation (ASCT) is unknown. We compared the radiation-based regimen of cyclophosphamide, etoposide and 12 Gy total body irradiation (CY/E/TBI) to carmustine, etoposide, cytarabine and melphalan (BEAM) in NHL patients who received ASCT. We investigated acute and long-term toxicities, disease free survival (DFS), overall survival (OS) of these two regimens.

METHODS: A historical cohort study was performed at a provincial cancer centre. Cause specific survival was determined with the Kaplan-Meier method. Survival between groups was compared using the log-rank test.

RESULTS: From Mar-1991 to Sep-2005, 79 patients received CY/E/TBI (n=32) or BEAM (n=47). Histology was indolent in 30 and aggressive in 49 patients. Cell source was bone marrow in six and 73 received peripheral blood progenitor cells. Prior to ASCT, ten patients were in complete remission, 47 had chemo-sensitive disease and 22 had chemo-resistant disease. There were only two cases of interstitial pneumonitis, with one in each preparative regimen group. There were six transplant related deaths; two in the BEAM group and four were in TBI group. The TBI based group has a higher mean mucosits score (p=0.03). Five year DFS was 47% and 51% in the TBI and BEAM groups, respectively (p=0.41). Five year OS was 50% and 64% for the TBI and BEAM based groups (p=0.07). Multivariate analyzes revealed that patients with more advanced disease and raised LDH at ASCT independently predicted inferior DFS. There was one case of acute myeloid leukemia and two of prostate cancer, all of whom were in the TBI group.

CONCLUSIONS: In this study, a 12 Gy TBI-based regimen resulted in a similar DFS but a trend toward poorer OS and higher second malignancies than a BEAM-based regimen. However, there did not appear to be excess pulmonary acute toxicities in the TBI based group.
Late Relapses Characterize Autologous Transplantation (ASCT) in First Complete Remission (CR) for Peripheral T-Cell Lymphoma (PTCL).
Authors: Kewalramani Tarun , Horwitz Steve , Zelenetz Andrew D. , Nimer Stephen D. , Moskowitz Craig H.
Published: October 2019

With the exception of ALK-positive anaplastic large cell lymphoma (ALCL), standard-dose chemotherapy is curative in a minority of patients (pts) with PTCL, and most pts have progressive disease less than 2 years from completing treatment. Several studies suggest that ASCT in 1st CR significantly improves the short-term outcome of pts with PTCL, but its long-term efficacy is not known. To address this, we assessed the outcome of sequential patients who underwent ASCT in 1st CR (n=15). Histologic subtypes were PTCL, unspecified, in 6 pts, angioimmunoblastic T-cell lymphoma in 5 pts, ALK-negative ALCL in 3 pts and hepatosplenic gamma delta T-cell lymphoma in 1 pt. Induction chemotherapy was CHOP (n=2) or CHOP-ICE hybrid (n=12) in 93% of pts. The age-adjusted IPI (AAIPI) was 2–3 in 9 of 14 assessable patients (64%), and 11 pts (73%) had stage III–IV disease. The conditioning regimen consisted of BEAM or CBV in 10 pts and TBI/Cy/VP-16 in 5 pts. All patients received peripheral blood progenitor cells for hematopoietic support. The median follow-up of all patients is 24 months (range 4.5–70). Five pts (33%) have progressed, with a median time to progression of 50 months (range 10–70). Four of the 5 pts who progressed did so more than 2 years from ASCT; they comprise 57% of patients with more than 2-years of follow-up. Four of 5 patients with progressive disease have died, with a median time from progression to death of 1 month (0.6–14.6). In this small series the AAIPI was not predictive of PFS or OS. While our results confirm the that ASCT in 1st CR significantly delays the time to progression, they suggest that it may not be curative in the majority of patients. If confirmed in ongoing larger prospective studies, this observation warrants trials of post-ASCT maintenance treatment and, for younger patients, trials of allogeneic transplantation in 1st CR or sequential ASCT followed by allogeneic transplantation.

Figure Figure
Single and Tandem Autologous Peripheral Blood Stem Cell Transplantation for Patients with Multiple Myeloma: A Korean Multicenter Retrospective Study.
Authors: Sym Sun Jin , Kwak Jae Yong , Min Chang Ki , Won Jong Ho , Lee Seung-Tae , Kim Kihyun , Suh Cheolwon
Published: October 2019

High-dose therapy with autologous stem cell transplantation (ASCT) is now considered the standard of care in patients with multiple myeloma (MM). This retrospective case analysis evaluated the prognostic influence of pre-transplant characteristics, transplant modalities, and disease status at post ASCT on survival to define patients with better prognosis. A total of 269 MM patients (median age: 53 years) who were transplanted between 1997 and 2007 from 6 centers in Korea were analyzed. All patients received peripheral blood stem cell support after conditioning with melphalan 140 mg/m2 or 200 mg/m2. In all, 190 patients received single ASCT and 79 patients received tandem ASCT. After a median follow-up of 28.5 months for surviving patients form single transplant, median progression-free survival (EFS) and overall survival (OS) were 19.2 months (95% CI, 15.9–22.6 months) and 71.3 months (95%CI, 56.9–85.7 months) with 18% and 55% probabilities of being progression-free and survival after 5 years, respectively. Treatment-related mortality within 90 days after ASCT was occurred in 12 patients (4.4%). Univariate analysis revealed that significant prognostic factor of PFS included age ≤ 50 at ASCT (p=0.024) and tandem ASCT (p<0.001). Significant prognostic factor for OS was tandem ASCT (p=0.029). The absence of unfavorable cytogenetic abnormalities was marginally significant for OS (p=0.074). In Cox analysis, it was seen that significantly longer PFS occurred for patients who received tandem ASCT (p=0.002). Age ≤ 50 at the time of ASCT was marginally significant prolonged PFS (p=0.054). Tandem ASCT independently correlated with better OS (p=0.044). We conclude that tandem ASCT independently correlated with better PFS and OS.
Development of Megakaryocyte-Specific Lentiviral Vectors for Gene Therapy of Platelet Disorders.
Authors: De Waele Liesbeth , Freson Kathleen , Thys Chantal , Van Geet Christel , Collen Désiré , VandenDriessche Thierry , Chuah Marinee
Published: October 2019

The prevalence of congenital platelet disorders has not been established but for some life-threatening bleeding disorders the current therapies are not adequate, justifying the development of alternative strategies as gene therapy. In the case of platelet dysfunction and thrombocytopenia as described for GATA1 deficiency, potentially lethal internal bleedings can occur. The objective of the study is to develop improved lentiviral vectors for megakaryocyte(MK)-specific long term gene expression by ex vivo transduction of hematopoietic stem cells (HSC) to ultimately use for congenital thrombopathies as GATA1 deficiency. Self-inactivating lentiviral vectors were constructed expressing GFP driven by the murine (m) or human (h) GPIIb promoter. These promoters contain multiple Ets and GATA binding sites directing MK-specificity. To evaluate the cell lineage-specificity and transgene expression potential of the vectors, murine Sca1+ and human CD34+ HSC were transduced in vitro with Lenti-hGPIIb-GFP and Lenti-mGPIIb-GFP vectors. After transduction the HSC were induced to differentiate in vitro along the MK and non-MK lineages. The mGPIIb and hGPIIb promoters drove GFP expression at overall higher levels (20% in murine cells and 25% in human cells) than the ubiquitous CMV (cytomegalovirus) or PGK (phosphoglycerate kinase) promoters, and this exclusively in the MK lineage. Interestingly, in both human and murine HSC the hGPIIb promoter with an extra RUNX and GATA binding site, was more potent in the MK lineage compared to the mGPIIb promoter. Since FLI1 and GATA1 are the main transcription factors regulating GPIIb expression, we tested the Lenti-hGPIIb-GFP construct in GATA1 deficient HSC and obtained comparable transduction efficiencies as for wild-type HSC. To assess the MK-specificity of the lentiviral vectors in vivo, we transplanted irradiated wild-type C57Bl/6 mice with Sca1+ HSC transduced with the Lenti-hGPIIb-GFP constructs. Six months after transplantation we could detect 6% GFP positive platelets without a GFP signal in other cell lineages.

Conclusion: In vitro and in vivo MK-specific transgene expression driven by the hGPIIb and mGPIIb promoters could be obtained after ex vivo genetic engineering of HSC by improved lentiviral vectors. Studies are ongoing to study whether this approach can induce phenotypic correction of GATA1 deficient mice by transplantation of ex vivo Lenti-hGPIIb-GATA1 transduced HSC.
LFA1 Mediated Attachment of Primary Human Monocytes to Activated Brain Microvascular Endothelial Cells Is Regulated by SDF-1α through the SRC Family Kinase Lyn; Potential Involvement of This Signaling Pathway in HIV-Associated Dementia.
Authors: Malik Mobeen , Chen Ying-Yu , Kienzle Martha F. , Collman Ronald G. , Ptasznik Andrzej
Published: October 2019

Infiltration of activated monocytes into the brain of HIV-infected patients is a prerequisite for the development of HIV-associated dementia (HAD). The chemokine stromal derived factor-1α (SDF-1α) is expressed at increased levels in the central nervous system (CNS) of HAD patients and elicits chemotaxis and other cellular effects through its receptor CXCR4. In this project, we investigated the intracellular signaling pathway by which SDF-1α mediates the movement and attachment of monocytes to brain microvascular endothelia, and which may contribute to their infiltration into the CNS in HAD. We demonstrated that SDF-1α stimulates migration of primary human monocytes through its receptor CXCR4, and decreases monocyte adherence to surfaces coated with ICAM-1. SDF-1α also decreases monocyte adherence to brain microvascular endothelial cells (BMVEC) activated with the pro-inflammatory cytokines TNF-α or IL-1β, or with recombinant HIV-1 envelope glycoprotein (gp120), which increase endothelial cells expression of ICAM-1. The decreased monocyte adherence was linked to down regulation of the activation-dependent epitope of the β2 integrin LFA-1 which is a ligand for ICAM-1. We then demonstrated that the Src family kinase Lyn is a central modulator of migration and LFA-1-mediated adhesion of SDF-1α-stimulated primary monocytes. Using siRNA knockdown we achieved 80% down regulation of Lyn kinase in human monocytes. Lyn down regulation decreased SDF-1α-mediated migration and prevented its inhibition of monocyte attachment to ICAM-1 coated surfaces and activated BMVEC. These data indicate that in SDF-1α-stimulated primary human monocytes Lyn is a positive regulator of cell migration, and a negative regulator of cell adhesion to BMVEC by inhibiting the ICAM-1 binding activity of the LFA-1 integrin. Thus, CXCR4-triggered inside-out integrin signaling, through Lyn, inhibits adherence and stimulates movement of monocytes towards SDF-1α gradient on BMVEC monolayers. These results provide new insight into the intracellular signaling cascade that controls primary human monocytes movement and attachment at the blood brain barrier.
The Economic Impact of Anamnestic Response in the Management of Hemophilia Patients with Inhibitors Undergoing Immune Tolerance Induction in Germany.
Authors: Odeyemi Isaac , Møller Anne D.
Published: October 2019

The aim of this analysis was to estimate the economic impact of bleed control treatments prior to immune tolerance induction (ITI) in patients with hemophilia with inhibitors in Germany. “Poor risk” hemophilia patients presenting at ITI are more costly to manage as they require higher-dose factor VIII treatment over a longer period, compared to “good risk” patients. Thus, factors that improve patient risk status for ITI, and permit the lowering of factor usage during ITI while maintaining clinical efficacy, are expected to result in cost-effective outcomes. The phenomenon of anamnestic response (AR) which occurs following treatment of hemophilia bleeds with immunogenic products results in significant elevation of titer levels, conferring a “poor risk” status on these patients at ITI. We therefore hypothesize that the prevention of AR pre-ITI, by avoiding immunogenic agents, would result in fewer “poor risk” patients requiring high-dose regimen during ITI, resulting in a cost-effective outcome. A cost-minimization model compared two strategies for the management of patients with severe hemophilia A with inhibitors. One strategy involved management of bleeds with a bypassing agent (activated prothrombin complex concentrates; aPCC) prior to ITI, while the other involved management of bleeds by use of a product which does not provoke AR (recombinant activated factor VII; rFVIIa) prior to ITI. Data on resource use and probabilities of clinical outcomes were derived from published literature, and the model validated by clinical experts with experience in managing inhibitor patients. The mean cost of ITI in inhibitor patients previously treated with rFVIIa is €1,073,327 compared to €1,420,825 for patients previously treated with aPCC. The model also estimated the incremental cost attributable to anamnesis in the management of a hemophilia patient who has undergone ITI to be €186,665. Sensitivity analyses suggest that the model is robust to the price of aPCC, but sensitive to the proportion of patients with AR post-aPCC treatment and the cost and dosage of FVIII at ITI. Anamnestic response is an unpredictable but avoidable consequence of managing bleeding episodes in inhibitor patients and confers significant additional costs to the management of high-responding inhibitor patients undergoing ITI. Avoiding AR prior to ITI by managing spontaneous bleeding episodes with bypassing agents which do not provoke AR has the potential for significant cost savings.
Promoting Patient (pt) Adherence (PA) with Imatinib Treatment (IMRx) in Chronic Myeloid Leukemia (CML): Physicians (MD) Perceptions of Utility (Effectiveness [FX], Feasibility [FB], Cost [CO]) and Rankings of Clinical Applicability (CAPL) of 13 Adherence-Enhancing Strategies (AESs) - Results from the ADAGIO Study.
Authors: van Lierde Marie-Anne , Strobbe Eric , De Rop Larissa , Serra Filipo , MacDonald MacDonald , Vancayzeele Stefaan , De Geest Sabina , Letvak Laurie , Albrecht Tara , Abraham Ivo
Published: October 2019

BACKGROUND. Patterns, prevalence, and associated pt variables of CML pts’ nonadherence (PNA) with ImRx are being better understood. Reducing ImRx PNA may impact on treatment outcomes. Various AESs have been proposed but their perceived value and clinical applicability to treating MDs are unknown.

OBJECTIVES. 1. Describe the perceptions of ImRx prescribing MDs of the utility (in terms of FX, FB, CO) of 13 AESs. 2. Describe MD rankings of the applicability in daily practice of each AES.

DESIGN AND SUBJECTS. MD data subset from prospective, 90d observational, open-label, multicenter study [1]. 51 evaluable MDs: age 45.6±11.2 years (ys); ys of practice 17.7±8.1; 74% hematologists, 26% oncologists; 65.3% practicing in university(-affiliated) hospital, 34.7% in other hospitals.

MEASUREMENTS. Utility rated 0=none to 3=high. For applicability to daily practice, MDs were asked to give top 5 AESs (5=most applicable); nonranked AESs were given zero value.

RESULTS. See Table 1.

CONCLUSIONS. MDs tended to rate the utility and applicability of AESs higher if an AES involved active MD participation or decision-making. AESs requiring significant patient involvement, behaviorally or through assistive devices, were perceived as less helpful and applicable in clinical practice. Importantly, the critical role of patient education was recognized, thus challenging clinicians to accept greater responsibility for this AES. Nurses in particular may prove pivotal in patient education. These findings provide significant direction for interdisciplinary healthcare education, especially in terms of chronic illness management. Further research is needed to elucidate the physician-centric approach to adherence enhancement in CML pts on ImRx.

Table 1 - Physician Utility Ratings and Applicability Rankings of Adherence-Enhancing Strategies Utility (0–3) Applicability FX FB CO in Practice (0–5) M±SD M±SD M±SD M±SD Rx selection per pt characteristics 1.9±1.1 1.6±1.1 1.3±1.0 1.0±1.5 Pt education 2.6±0.6 2.1±0.8 1.4±0.8 3.1±1.9 Improved pt-MD communication 2.7±0.5 2.3±0.8 1.3±0.8 2.8±1.7 Simplifying Rx regimen 2.5±0.7 2.3±0.7 1.6±0.9 2.3±1.9 Pt self-monitoring 1.7±0.8 1.5±0.8 1.1±0.9 0.4±1.1 Pt health status diary 1.7±0.8 1.5±0.8 1.0±0.8 0.5±1.3 Memory aids 1.7±0.8 1.9±0.8 1.0±0.8 0.6±1.3 Spouse/family involved 2.2±0.9 2.0±0.9 0.6±0.8 1.3±1.4 Regular MD contact 2.4±0.5 2.2±0.7 1.7±0.8 2.2±1.8 MD monitoring of PA 2.2±0.7 1.8±0.9 1.4±0.8 0.7±1.1 Electronic reminders 1.5±0.9 1.2±0.8 2.3±0.9 0.3±1.1 Electronic Rx monitoring 1.6±0.9 1.3±0.7 2.3±0.9 0.3±1.1 Rewards for good PA 1.4±1.0 1.3±0.8 1.8±0.9 0.5±1.4
Identification and Characterization of a Series of Novel Jak2 Small Molecule Inhibitor Compounds.
Authors: Sayyah Jacqueline , Allen Robert W. , Braylan Raul C. , Keseru Gyorgy M. , Sayeski Peter P.
Published: October 2019

Recent work from our lab has been aimed at identifying novel Jak2 tyrosine kinase inhibitor molecules. Here, we refined our previous Jak2 molecular model using information obtained from the crystal structures of the Jak2 and Jak3 kinase domains. A total of 223,481 compounds within the NIH small molecule database were then screened in silico using FlexX 1.13.2 in order to identify compounds that specifically bind and inhibit Jak2. In what is now our third generation of Jak2 inhibitors, analysis of the highest scoring compounds identified a set of structurally diverse molecules that potently inhibited Jak2 autophosphorylation not only at Tyr 1007, but at all 49 tyrosine residues. These compounds significantly inhibited proliferation of the human erythroleukemia (HEL) cells, which express the Jak2-V617F mutation on both alleles (Fig. 1). One compound in particular, herein designated as G6, was further examined in greater detail. The mechanism by which G6 inhibits Jak2-V617F dependent cell growth is via a marked increase in cellular apoptosis (Fig. 2). We found that G6 does not inhibit c-Src and Tyk2 autophosphorylation at doses that completely inhibit Jak2, therefore suggesting a high degree of specificity. We found that both the G6 and the G13 compounds significantly reduced ex vivo megakaryocyte colony formation of cells taken from a patient diagnosed with essential thrombocythemia and harboring the Jak2-V617F mutation. Finally, we examined the ability of G6 to inhibit red blood cell formation in C57BL/6 mice following acute hemolytic anemia. We found that treatment of animals with G6 (10 mg/kg/day for five days, IP) resulted in a marked inability of these animals to increase their hematocrits following acute anemia when compared to vehicle control animals. Additionally, histological analysis of the bone marrow of G6 injected animals exhibited erythroid hypoplasia resulting in a skewed M:E ratio when compared to vehicle control animals. Collectively, our data demonstrate that these small molecule compounds inhibit Jak2 function in vitro, ex vivo, and in vivo. As such, they may have therapeutic value in treating diseases that are caused by aberrant Jak2 kinase function.

Figure 1 Figure 1. Figure 2 Figure 2.
A Novel Assay for Juvenile Myelomonocytic Leukemia Based on Aberrant Signaling Networks Measured Via Phospho-Specific Flow Cytometry Reduces Diagnosis Time from Weeks to Days.
Authors: Kotecha Nikesh , Flores Nikki J. , Irish Jonathan M. , Sakaguchi Debbie , Archambeault Sophie , Diaz-Flores Ernesto , Coram Marc , Shannon Kevin M. , Nolan Garry P. , Loh Mignon L.
Published: October 2019

Juvenile myelomonocytic leukemia (JMML) is an aggressive clonal malignancy characterized by over-production of myeloid lineage cells that infiltrate hematopoietic and non-hematopoietic tissues. The diagnosis and treatment of JMML can present great challenges for clinicians. Infants or young children are suspected of having this disease when presenting with hepatosplenomegaly and a peripheral blood monocytosis - criteria that are often present in more prevalent but potentially less lethal conditions such as viral infections. The diagnostic workup includes several clinical tests as well as the confirmation of abnormal numbers of granulocyte-macrophage colony forming units (CFU-GM) grown in low concentrations of granulocyte-macrophage colony stimulating factor (GM-CSF). The colony assays are laborious and can take up to 4–6 weeks for results. Using phospho-specific flow cytometry, a technique that allows simultaneous single cell measurements of cell type and signal, we have developed an assay that shows a specific cell signature in JMML patients that can reduce diagnosis time from weeks to days. The assay combines traditional surface marker phenotyping with signaling responses in low doses of GM-CSF to identify a population of CD38 intermediate cells that hyper-phosphorylate Stat 5 (pStat5). We applied this assay to primary cells obtained from 10 JMML patients and demonstrate that the cell signature is specific to JMML with respect to a wide panel of other diagnoses. For comparison purposes, we developed a statistical measure to summarize the signature and monitor its expression across varying doses of GM-CSF. The measure also ensures consistency by eliminating the need for additional manual data processing steps (e.g. gating) prior to comparison—an important step towards developing a diagnostic tool. In addition, this characteristic phospho-specific flow signature disappeared in patient samples in remission and reappeared at relapse—indicating that the signature may indeed be representative of the malignant population in JMML. Further characterization of these cells is ongoing. We conclude that phospho-specific flow cytometry is a robust methodology that can be used in primary human cells as a method to rapidly diagnosis JMML as well as to follow patients on therapy. Importantly, it is a powerful technical tool that will allow improved understanding of the complex signaling pathways that are perturbed in cancer cells.
Efficacy of TG101348, a Selective JAK2 Inhibitor, in Treatment of a Murine Model of JAK2V617F-Induced Polycythemia Vera.
Authors: Wernig Gerlinde , Kharas Michael G. , Okabe Rachel , Moore Sandra A. , Leeman Dena S. , Cullen Dana E. , Gozo Maricel , McDowell Elizabeth P. , Levine Ross L. , Doukas John , Mak Chi Ching , Noronha Glenn , Martin Michael , Ko Yon D. , Lee Benjamin H. , Soll Richard , Tefferi Ayalew , Hood John D. , Gilliland D. Gary
Published: October 2019

The JAK2V617F mutation is present in the majority of cases of myeloproliferative disease, including polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF), and is an attractive candidate for molecularly targeted therapy. However, the potential toxicities of JAK2 inhibition in vivo, and identification of appropriate surrogate endpoints for response, are challenges that may limit clinical usefulness in treatment of these relatively indolent diseases. We report efficacy and assessment of surrogate endpoints for response of a small molecule JAK2 inhibitor, TG101348 in a murine model of polycythemia vera. TG101348 is selective for JAK2 with an in vitro IC50 of ∼3 nM that is ∼334 fold more potent than for inhibition of JAK3. TG101348 showed therapeutic efficacy in the murine model of PV that included a statistically significant reduction in hematocrit, normalization of white blood cell count, a dose dependent reduction/elimination of extramedullary hematopoiesis in the spleen and liver, and marked attenuation of myelofibrosis. Consistent with its selective inhibition of JAK2 and not JAK3, there was no significant change in T-cell number in treated animals. These clinical responses correlated with surrogate endpoints for response, including reduction or elimination of JAK2V617F expressing clones based on quantitative genomic PCR, suppression of JAK2V617F positive endogenous erythroid colony growth of JAK2V617F MPD bone marrow, and inhibition of JAK-STAT signal transduction as assessed by phosphoflow cytometry for phosphorylated STAT5. Thus, TG101348 is efficacious in treatment of a murine model of PV, and surrogate endpoints have been identified that may be of value in clinical trials in humans.