bluuebunny/crossref_metadata_2025 huggingface dataset:
Antibodies to the Platelet Factor 4-Heparin Complex and Mortality in Chronic Hemodialysis Patients.
Authors: Carrier Marc , Knoll Greg A. , Fergusson Dean , Doucette Steven , Kovacs Michael J. , Moore Jane , Rodger Marc A.
Published: October 2019

Background: Heparin-induced thrombocytopenia is a serious complication of heparin therapy that can lead to thromboembolism, cardiovascular events or death. Patients with this disorder develop antibodies to the platelet factor 4-heparin (PF4-H) complex. Hemodialysis patients are repeatedly exposed to heparin and are at risk for developing PF4-H antibodies. The clinical impact of asymptomatic PF4-H antibodies in patients on chronic hemodialysis is not known.

Objective: To determine the association between asymptomatic PF4-H antibodies and mortality in a cohort of chronic hemodialysis patients repeatedly exposed to heparin.

Methods: Pre-dialysis blood samples were drawn from 419 asymptomatic patients. All patients received unfractionated heparin (Baxter) while on dialysis. All samples were screened for PF4-H antibodies using an ELISA assay (GTI PF4 Enhanced, GTI Diagnostics). All positive and indeterminate samples were then tested using an IgG-specific PF4-H ELISA assay and a platelet serotonin-release assay. Participants were then followed up prospectively for thromboembolic events, cardiovascular events, or death.

Results: During a median follow-up of 2.5 years there were 129 deaths. After controlling for important potential confounding variables, the relative risk of death was 2.92 (95% CI: 1.18-7.25; P= 0.02) in patients with IgG-specific PF4-H antibodies and 4.08 (95% CI: 1.26–13.2; P= 0.02) in patients with IgG-specific antibodies and an indeterminate serotonin-release assay. Conclusions: PF4-H antibody formation is associated with increased all-cause mortality in patients on chronic hemodialysis. Further investigation is needed to determine if anticoagulation with alternative agents would improve survival in this population.
Combined Immunochemotherapy with Rituximab Improves Overall Survival in Patients with Follicular and Mantle Cell Lymphoma: Updated Meta-Analysis Results.
Authors: Schulz Holger , Bohlius Julia , Skoetz Nicole , Trelle Sven , Reiser Marcel , Kober Thilo , Schwarzer Guido , Herold Michael , Dreyling Martin , Engert Andreas
Published: October 2019

Background

Rituximab (R) has shown impressive response and prolonged progression free survival (PFS) in patients with indolent lymphoma when combined with CHOP. Randomized phase III trials adding rituximab to a variety of different regimen confirmed this benefit in both previously treated and untreated patients with advanced indolent lymphoma. Furthermore these trials indicating a trend towards improved overall survival (OS) for a combined immunochemotherapy with R. Here we report updated results of a comprehensive systematic review in this group of patients comparing R and chemotherapy with chemotherapy alone with respect to OS, disease control, overall response (OR) and toxicity.

Methods

Only randomized controlled trials (RCT) comparing R-chemo with chemotherapy alone in patients with newly diagnosed or relapsed indolent lymphoma and mantle cell lymphoma (MCL) were included. Medical databases (Cochrane Library, MEDLINE, EMBASE) and conference proceedings were searched (1990–2005). We included full-text and abstract publications. Number needed to treat (NNT) were calculated to facilitate interpretation.

Results

We included seven eligible RCTs involving a total of 1943 patients with follicular lymphoma (FL), MCL and other indolent lymphoma. Studies were published as full text (5), and in abstract form (2). OS was statistically significant improved in the R-chemo group when compared to chemotherapy alone (HR; hazard ratio: 0,65; 95% CI 0,54 – 0,78). OR (RR; relative risk: 1.21; 95% CI 1.16–1.27) and disease control (HR: 0.62; 95% CI 0.55–0.71) were also significantly superior after R-chemo. The RR for developing fever and leukocytopenia was significantly higher with R-chemo, but not associated with an increased risk of infection.

Conclusion

The systematic review demonstrated improved OS, OR and disease control for patients with indolent lymphoma and in the subgroups of follicular and mantle cell lymphoma when treated with R-chemo compared to chemotherapy alone.
Bortezomib, Dexamethasone and Rituximab (BDR) Is a Highly Active Regimen in the Primary Therapy of Waldenstrom’s Macroglobulinemia: Planned Interim Results of WMCTG Clinical Trial 05-180.
Authors: Treon Steven P. , Soumerai Jacob D. , Patterson Christopher J. , Hunter Zachary R. , Ghobrial Irene M. , Villarreal Rose , Willen Michael A. , Myers Thomas J.
Published: October 2019

In previous studies, we demonstrated that Rituximab and Bortezomib are active agents as monotherapy in patients with Waldenstrom’s macroglobulinemia (WM), producing response rates of 40–80%. Moreover, we and others have demonstrated synergistic activity for these agents together, and with steroids in preclinical studies. As such, we examined the activity of combined bortezomib, dexamethasone and rituximab in patients with the consensus panel diagnosis of WM. Intended therapy consisted of IV bortezomib at 1.3 mg/m2 and IV dexamethasone 40 mg on days 1,4,8, and 11, and Rituximab at 375 mg/m2 on day 11 which constituted one cycle of therapy. Patients received four consecutive cycles, followed by a three month pause, and then 4 more cycles, each given three months apart. Ten patients are eligible for evaluation at interim analysis. Following a median of 4 cycles of therapy, median serum IgM levels for all evaluable patients declined from 5,095 (range 700–8030 mg/dL) to 2,850 (range 280–3660 mg/dL) (p=0.001). The overall response rate was 100%, with 5 and 5 patients achieving a minor (≥25% decrease in IgM) and major (≥50% decrease in IgM) response, respectively. Responses were prompt, and occurred at a median of 1.1 months. Therapy was well tolerated with III/IV toxicities consisting of sepsis (n=1), pneumonia (n=1), and thrombocytopenia (n=1). Four patients developed herpes zoster while on treatment, resulting in the implementation of prophylaxis for all patients with valcyclovir. At a median of 4 cycles, no sensory or motor neuropathies have occurred. The interim results of this study demonstrate that BDR is a highly active, and well-tolerated regimen in the primary therapy of WM.
A Prognostic Score for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma: Analysis of 2189 Patients.
Authors: Tsimberidou Apostolia-Maria , McLaughlin Peter , O’Brien Susan , Wen Sijin , Wierda William G. , Manning John , Lerner Susan , Hess Mark A. , Kantarjian Hagop , Freireich Emil J. , Keating Michael J.
Published: October 2019

Introduction: The prognosis of chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) is heterogeneous. The purpose of this study was to assess factors predicting survival in patients with CLL/SLL.

Methods: Characteristics at diagnosis were collected from 2189 patients with CLL/SLL who presented to The University of Texas M. D. Anderson Cancer Center between 1985 and 2005. Univariate and multivariate analyses for survival were performed. Pretreatment parameters that remained independently significant in the multivariate analysis were used to design a model to predict an individual patient’s risk of death: the CLL/SLL score.

Results. The median age of patients was 58 years (range, 17–90 years). Overall, 1052 patients required treatment for CLL/SLL and 853 (81%) received fludarabine-based therapy. A multivariate analysis of 23 prognostic factors identified the following to have independent adverse significance for survival: 17p del and 6q del +/− other genomic aberrations (p<0.0001), age > 60 years (p<0.0001), albumin < 3.5 g/dL (p<0.0001), β2-microglobulin ≥ 2 mg/L (p<0.0001), creatinine ≥ 1.6 mg/dL (p<0.0001), hemoglobin <11 g/dL (p=0.001), presence of hepatomegaly (p=0.005), male sex (p=0.006), and absolute lymphocyte count ≥ 30 x 109/L (p=0.004). Other factors, such as IgVH mutation and CD38 or ZAP-70 expression, did not significantly correlate with survival, probably because these data were not available in enough patients and follow-up from the testing time was relatively short. The top five pretreatment parameters that remained independently significant in the multivariate analysis were used to design the CLL/SLL score in 1564 patients who had available data for all five parameters. Since the relative risks associated with each of the top five independently significant risk factors were comparable, the relative risk of death could be determined by summing the number of risk factors present at diagnosis. At 5 years, 96%, 79%, 69%, 30%, and 16% of patients with 0, 1, 2, 3, or 4 (including 1 patient with a score of 5) risk factors, respectively, are expected to be alive [insert Figure here].

Conclusions: A prognostic score to predict survival in patients with CLL/SLL is proposed. The score is based on the five most statistically significant independent factors, i.e., 17p or 6q del +/− other genomic aberrations; age; and levels of β2-microglobulin, albumin, and creatinine. This score may be used to identify specific risk groups, to improve treatment choices and to compare different therapeutic approaches in patients with CLL/SLL.

Figure Figure
CD38 Expression Identifies an Active Subset of Proliferating Cells within the Clonal Population in Chronic Lymphocytic Leukemia Patients (In Vitro Analysis).
Authors: Damle Rajendra N. , Allen Steven L. , Rai Kanti R. , Chiorazzi Nicholas
Published: October 2019

The prognostic relevance of CD38 expression by clonal B cells from chronic lymphocytic leukemia (B-CLL) cases has been extensively reported. Expression of CD38 by a B cell indicates both its activation status and differentiation stage and remains fairly constant over time in most B-CLL cases although it has been reported to change with time in some cases and this change is associated with change in clinical behavior of the patient. Due to these reasons it has achieved a prominent place among other prognostic indicators such as Ig V gene mutation and ZAP-70 expression in assessment of B-CLL patients. To assess which aspects of the immunobiology of B-CLL cells are impacted by their expression of CD38 by clonal members “within” a B-CLL case we flow-sorted B-CLL cells from peripheral blood of 16 patients (% CD38 expression pre-sort, ranging from 1–90%), into CD38− and CD38+ subsets and quantified telomere lengths as a measure of their replicative history. As a measure of cellular activation we studied telomerase activity in these flow-sorted cells. In addition, expression of CD69 and CD62L (activation-associated), ZAP-70 (signaling-associated) and Ki-67 (cell cycle-associated) were studied on CD38− and CD38+ cell subsets by immunofluorecence and multi-color flow cytometry in 35 cases (including those used for cell sorting experiments). Telomerase activity was markedly higher in the CD38+ subset compared to the CD38− subset in each case (p< 0.01), although telomere lengths of the subsets did not differ significantly within individual cases. Simultaneously, the percentages of cells expressing CD69 and ZAP-70 were significantly higher (p<0.01) and those expressing CD62L (lost after cell activation) were significantly lower (p<0.05) in the CD38+ subset compared to those in the CD38−− subset. Not only did cells from the CD38+ subset exhibit greater percentages of cells with features of “activated cells”, they also identified cells that had recently exited the G0/G1 phase as indicated by differences in Ki-67 expression (p<0.001). Unlike other hematological neoplasms, cell division, noticeable in the peripheral blood, is not a feature of B-CLL. The current findings suggest that the CD38+ fraction of the clone is more “active” than the CD38− fraction, regardless of the initial percentage of CD38+ cells in the clone. Therefore, a detailed phenotypic analysis of CD38-based subpopulations within a B-CLL case could identify even the low level turnover of clonal cells and provide important supplementary information for prediction of prognosis.
The CD45−LIN− Adult Marrow-Derived CXCR4+ SSEA-1+ Oct-4+ Very Small Embryonic-Like (VSEL) Stem Cells Form In Vitro Spheres Which May Differentiate into CD45+ Hematopoietic Cells.
Authors: Ratajczak Janina , Kucia Magda , Zuba-Surma Ewa , Reca Ryan , Ratajczak Mariusz Z.
Published: October 2019

Recently we identified in murine BM a homogenous population of rare (~0.01% of BMMNC) Sca-1+ lin− CD45− cells that express by RQ-PCR and immunhistochemistry markers of pluripotent stem cells (PSC) such as SSEA-1, Oct-4, Nanog and Rex-1 and highly express Rif-1 telomerase protein (Leukemia2006;20,857–869). Direct electronmicroscopical analysis revealed that these cells display several features typical for primary embryonic stem cells such as i) a small size (~2–4 μm in diameter), ii) a large nuclei surrounded by a narrow rim of cytoplasm, and iii) open-type chromatin (euchromatin). These cells isolated freshly from the BM neither grow hematopoietic colonies nor radioprotect lethally irradiated recipients. Recently, however, we noticed that purified VSELs in co-cultures with C2C12 murine sarcoma supportive feeder-layer grow spheres and cells from these VSEL-derived spheres (VSEL-DS) are composed of immature cells with large nuclei containing euchromatin, and similarly as VSELs are CXCR4+SSEA-1+Oct-4+. We found that cells from VSEL-DS after re-plating over C2C12 cells may again (up to 5–7 passages) grow new embryoid-like bodies or if plated into cultures promoting tissue differentiation show pluripotency and expand into cells from all three germ-cell layers. Based on this we tested if CD45− VSEL-DS cells could also differentiate into the hematopoietic lineage. To address this issue we employed similar culture conditions that are employed for hematopoietic differentiation of established embryonic stem cell lines. We noticed that VSEL-DS cells if cultured/passaged in methylocellulose cultures supplemented with hematopoietic growth factors (KL, IL-3, EpO and GM-CSF) give rise to colonies composed of myeloid (CD45+ Gr-1+) and erythroid (Terr-119+) hematopoietic cells. The hematopoietic differentiation of VSEL-DS cells was accompanied by upregulation of mRNA for several genes regulating hematopoiesis (e.g. PU-1, c-myb, LMO2, Ikaros). Based on this we postulate that VSELs that reside in bone marrow may contribute to hematopoiesis. We also provide direct evidence that CD45+ cells may derive from a CD45− population. We postulate that VSELs are closely related to a population of long-term engrafting hematopoietic stem cells and currently we are testing this possibility in animal models.
IL-21 Plus CpG ODN Induces Granzyme B-Dependent Induction of Apoptosis in CD5-Positive B Cells Including B-CLL Cells.
Authors: Blackwell Sue E. , Jahrsdoerfer Bernd , Wooldridge James E. , Huang Jian , Andreski Melinda W. , Jacobus Laura S. , Taylor Christiana M. , Weiner George J.
Published: October 2019

Interleukin 21 (IL-21), a recently discovered cytokine with structural homology to IL-2, IL-4 and IL-15, has pleiotropic effects on lymphocyte populations including NK, T and B cells and is currently undergoing early clinical evaluation. We explored the effect of the combination of IL-21 and immunostimulatory CpG ODN on B chronic lymphocytic leukemia (B-CLL), and other CD5-positive B cells. IL-21 plus CpG ODN were synergistic in their ability to induce apoptosis of the B-CLL cells, and also induced production and secretion of granzyme B from the B-CLL cells. B-CLL cells treated with IL-21 and CpG ODN were capable of inducing apoptosis of untreated autologous B-CLL cells. This bystander killing was inhibited by anti-granzyme B antibodies. The effect was observed in all cases of CD5-positive B-CLL, but not in CD5-negative B-CLL samples. IL-21 plus CpG ODN also induced granzyme B production and apoptosis of benign CD5-positive B1 cells obtained from umbilical cord blood. In contrast, the number of CD5-negative B2 cells increased in the same samples during in vitro culture, resulting in a decreased ratio of CD5-positive to CD5-negative cord blood B cells (Fig. 1). Our results indicate the combination of IL-21 and CpG ODN is able to induce apoptosis of both benign and malignant CD5-positive B cells. Given the suspected role of B1 cells in autoimmune diseases, our findings could have important implications for the understanding of their pathogenetic mechanisms. These results might also open new avenues for the development of novel therapies for both autoimmune dieseases and CD5-positive B-CLL.

Figure 1. IL- 21 and CpG ODN therapy selectively eliminates CD5 positive B cells in cord blood. Figure 1. IL- 21 and CpG ODN therapy selectively eliminates CD5 positive B cells in cord blood.
Hexon Specific T-Cells for Adoptive T-Cell Transfer as a Treatment of Adenovirus Infection after Allogeneic Stem Cell Transplantation.
Authors: Feuchtinger Tobias , Richard Celine , Handgretinger Rupert , Braun Christiane , Schumm Michael , Lang Peter
Published: October 2019

Adenovirus infection (ADV) after allogeneic hematopoietic stem cell transplantation (HSCT) is an emerging pathogen causing relevant morbidity and mortality, with preponderance in children. Since a sufficient host T-cell response has been shown essential to clear the virus, diagnostic procedures for detection of virus-specific T-cells have recently developed to asses the specific cellular immune response. Furthermore adoptive immunotherapy is a new treatment option for patients with absent specific T-cell response and present systemic adenoviral infection. The possibility of an adoptive T-cell transfer depends on the availability of GMP compatible protocols and reagents. The adenoviral hexon protein was shown a immunodominant T-cell target within the viral capsid. In the present study we investigate the presence of Hexon-specific T-cell responses in HSCT donors, i.e. the availability of donors for an adoptive T-cell transfer. Secondly, the emergence of Hexon-specific T-cells in recipients post HSCT was analyzed. Thirdly, a protocol was established under GMP-conditions for adoptive T-cell immunotherapy through isolation of IFN-γ secreting T-cells after ex-vivo stimulation with the adenoviral Hexon protein. This procedure resulted in a mixed population of CD4 and CD8 positive T-cells with an effector memory phenotype and Th1 cytokine pattern (n=8). Isolated Hexon-specific T-cells show a strong expansion potential in vitro as well as specific cytotoxic activity. The availability of a donor was evaluated in 76 HSCT donors. Only 17.1% of donors had no ADV-specific T-cell response and 72.4% of donors were eligible for an adoptive T-cell transfer using the presented approach. The Hexon protein was responsible for almost the complete response to ADV, since no significant difference was seen against ADV lysate and the Hexon protein. In 76% HSCT recipients Hexon directed T-cell responses were evaluated and were shown to be responsible for clearance of the viral infection. In conclusion feasibility of an adoptive T-cell transfer for the treatment of ADV infection post HSCT is shown in accordance to current GMP regulations.
Validation of Serum Aspergillus Galactomannan Index as a Surrogate Endpoint for Outcome of Invasive Aspergillosis: Clinical and Research Implications.
Authors: Woods Gail , Miceli Marisa , Grazziutti Monica , Krishna Somashekar , Syed Nayyar , Kiwan Elias , Rahman Mazhar , Barlogie Bart , Anaissie Elias
Published: October 2019

Background: Assessing clinical outcome of aspergillosis with conventional clinical and laboratory criteria is difficult. A composite “global outcome response” (clinical, radiologic, pathologic and microbiologic criteria) is frequently used but suffers from poor sensitivity and specificity, and has not been standardized or validated. A reliable, quantitative, non-invasive, and easy to measure laboratory test than can substitute for this composite endpoint, i.e. serve as a surrogate endpoint for aspergillosis outcome is highly desirable. Galactomannan (GM) is an Aspergillus-specific polysaccharide released during aspergillosis and detected by the serum GM test. The test which is reported as an index of optical density (OD) is an accepted diagnostic marker for aspergillosis and preliminary data suggest a correlation between GM index (GMI) and outcome.

Purpose: To evaluate serum GMI as a surrogate endpoint for outcome of invasive aspergillosis in patients with hematological cancer.

Patients and Methods: patients at risk for aspergillosis (11/03-2/06) underwent GMI screening during periods at risk. The clinical and laboratory findings of patients with ≥ 2 (+) GMI (OD ≥ 0.5) were reviewed. To validate GMI as a surrogate endpoint for aspergillosis, a k correlation concordance coefficient test between GMI and an objective clinical outcome of aspergillosis (death) was applied. The correlation is considered perfect when k is 1.0; excellent when ≥ 0.75.

Results: 30 patients had GMI (+) aspergillosis of the respiratory tract [myeloma 92%; median age: 59 years (27–75); 15 males]. Aspergillosis developed following stem cell transplantation [autologous (11), allogeneic (1)], or after conventional chemotherapy (18). Among 25 neutropenic patients (<1000/ml), persistent GMI elevation was associated with death (5/5 patients) while return to negative values predicted survival (20/20 patients). Among 5 non-neutropenic patients, 1 with persistently elevated GMI died compared to no death among the remaining 4 whose GMI became negative. Overall, the GMI correlated with clinical outcome in all 30 patients with a perfect 1.0 k correlation concordance coefficient.

Conclusion: we have validated GMI as an excellent surrogate endpoint for the outcome of invasive aspergillosis among patients with hematological cancer. This FDA-approved test is reproducible, quantitative, non-invasive, easy to measure and widely available. These findings have important implications for patient care and for the design of clinical trials of mould-active antifungal agents.
Single Nucleotide Polymorphism of CC Chemokine Ligand 5 Promoter Gene in Recipient May Affect on the Development of Chronic Graft-Versus-Host Disease and Its Severity after Allogeneic Transplantation.
Authors: Kim Dong Hwan , Sohn Sang Kyun , Kuruvilla John , Gupta Vikas , Lipton Jeffrey , Messner Hans
Published: October 2019

Background: The leukocyte trafficking, which is critically regulated by chemokine ligands and their receptors, has been known to be involved in the pathogenesis of graft-versus-host disease (GVHD). CC ligand 5 (CCL5; previously called as RANTES) is expressed on antigen-presenting cells, endothelium, and epithelium, while CC receptor 5 (CCR5) is expressed on type 1 T-cells. The current study analyzed the association of CCR5/CCL5 gene single nucleotide polymorphisms (SNPs) on both side of recipients and donors with acute or chronic GVHD (cGVHD) after allogeneic transplantation.

Methods and patients: We evaluated the SNPs of CCL5 promoter gene at loci −28/−403 and CCR5 gene at 59029 in 72 recipients and 107 donors using PCR/RFLP methods with genomic DNAs. The associations of acute/cGVHD and its severity with CCL5/CCR5 SNPs of recipients/donors were examined using chi-square test, while the incidences of acute/cGVHD were also compared by Log-rank test.

Results: With a median follow up of 924 days for survivors (range 48~2,360 days), the CG genotype of CCL5 gene −28 loci of recipients was significantly associated with a higher incidence of overall cGVHD (p=0.004), extensive cGVHD (p=0.038 by Seattle criteria) and severe grade of cGVHD at presentation compared to CC genotype (p=0.017 by prognostic grading by Apkek et al). The patients with AG haplotype of CCL5 SNP of recipients also showed a higher incidence of overall cGVHD (p=0.003), extensive cGVHD (p=0.023), and more severe grade of cGVHD (p=0.020). However, the CG genotype at CCL5, −28 and AG haplotype did not correlate with the clinical course of cGVHD in terms of GVHD-specific survival or the duration of systemic immunosuppressive therapy. In addition, an association of CCL5/CCR5 SNPs with acute GVHD was not noted. The SNP of CCL5/CCR5 of donors did not influence the occurrence of cGVHD.

Conclusion: The CCL5 promoter gene polymorphism of recipients may be associated with the development of cGVHD and its severity. The current study suggested an involvement of CCL5 in leukocyte trafficking for the development of cGVHD.
Asymmetric Reconstitution of γδ T Cell Subsets after Haemopoietic Stem Cell Transplantation.
Authors: Travers Paul J. , Knight Andrea , Grace Sarah , Kottaridis Panos , Mackinnon Stephen , Madrigal J. Alejandro
Published: October 2019

In previous studies we and others have shown that the production of new T cells from the thymus declines after the third decade and that while patients below the age of 30 reconstitute primarily new T cells, those over thirty reconstitute primarily by expansion of pre-existing mature T cells. However little attention has been paid to the γδ subset of T cells, which form an important component of mucosal immune protection and which represent approximately 5% of peripheral T cells. Two major subsets of γδ T cells are defined by the expression of Vδ1 versus Vδ2, with Vδ1+ cells predominating in the fetal circulation and in mucosal sites, while Vδ2+ cells predominate in adult life and in the peripheral circulation. In light of the differerential preponderance of the two subsets in the fetal versus adult circulation, we have examined the reconstitution of these two subsets of γδ T cells following hemopoietic stem cell transplantation in a cohort of 28 patients sampled at 3 monthly intervals to ask whether both subsets recover adequately from adult stem cells.

In 44 normal individuals, the median levels of Vδ1 and Vδ2 cells are 12.46 (0.22 to 167.8) and 32.78 (4.48 to 190.1) cells/mm3 respectively. In patients under 30, the reconstitution of the Vδ1 and Vδ2 subsets follow similar kinetics, reaching a plateau at 9 months post transplant with comparable numbers of Vδ1 and Vδ2 cells (note that the normal ratio of Vδ1 to Vδ2 is 0.38, so in the patients there is a significant increase in the proportion of Vδ1 cells in the peripheral circulation). In patients over 30 years of age, there is an even more significant disparity in the reconstitution of the two subsets. The Vδ1 subset recovers with similar kinetics as is seen in the patients under 30, although to slightly lower final levels. The Vδ2 subset, however, shows very little recover y, reaching a plateau at 6 months at the bottom of the normal range for up to 2 years post transplant. In these patients the ratio between Vδ1 and Vδ2 is inverted with an increasingly greater proportion of Vδ1 cells at longer times after transplant, with ratios in excess of 10 by 24 months post transplant, a 30-fold increase in the normal proportion of Vδ1 + T cells. Given that the Vδ1 subset shows a very restricted repertoire compared to the Vδ2 subset, the overall capacity of the circulating γδ T cell population to recognise and respond to antigen will be significantly compromised in older transplant recipients.
Day 15 Natural Killer (NK) Cell Recovery Predicts Progression Free Survival after Autologous Stem Cell Transplantation in Non-Hodgkin’s Lymphoma.
Authors: Siddiqui Mustaqeem A. , Markovic Svetomir N. , Nevala Wendy K. , Uhl Cindy B. , Morice William G. , Porrata Luis F.
Published: October 2019

The peripheral blood absolute lymphocyte count (ALC) on day 15 after autologous stem cell transplantation (ASCT) has been shown to be an independent predictor for overall survival (OS) for many malignancies including acute myelogenous leukemia (AML), breast cancer, multiple myeloma (MM), primary systemic amyloidosis, and Hodgkin’s and non-Hodgkin’s lymphoma (NHL). However, due to the retrospective nature of previous studies, the peripheral blood lymphocyte subpopulations that predict survival are unknown. To prospectively correlate peripheral blood lymphocyte subpopulations after ASCT and progression free survival, peripheral blood lymphocytes collected from patients before and on day 15 after ASCT were analyzed by four color flow cytometry for CD3, CD4, CD8, CD16, CD 19, and CD56. Patients were then dichotomized into two groups: patients achieving normal numbers of lymphocyte subset (i.e. CD4, CD8, CD19, CD16/56) count versus those who did not. Progression free survival was then analyzed by the Kaplan-Mier method. In our cohort of 14 patients, 9 were male and 5 were female. Nine patients were diagnosed with diffuse large cell B cell lymphoma, two with mantle cell, two with follicular, and one with peripheral T cell lymphoma. On presentation, one patient had stage I, four patients had stage II, four had stage III, and five patients had stage IV disease. The median age at ASCT was 53 years (range: 26–70). The preliminary data from this ongoing prospective study of 14 patients shows that on day 15 after ASCT, 4/14 (29%) of patients achieved a normal CD3 count (median 321, range: 69–2069 cells/ml) 3/14 (21%) achieved a normal CD4 count (median 206, range: 31–1091 cells/ml), 6/14 (43%) achieved a normal CD 8 count (median 88.5, range: 13–813 cells/ml) 1/14 (7%) achieved a normal CD19 count (median 2, range:0–227 cells/ml), and 8/14 (57%) achieved a normal CD16/56 count (median 85.5, range: 10–744 cells/ml). The median follow-up was 12 months (range: 3–45 months). On univariate analysis, patients achieving an absolute NK cell count of ≥ 80 cells/μ on day 15 had significantly improved progression free survival compared to those who did not (not reached vs 3 months, p<0.006, respectively). Similar analysis evaluating the absolute CD3, CD4, CD8, and CD 19 count was not significant (p=0.1, p=0.258, p= 0.06, and p=0.55, respectively). To our knowledge, this is the first report detailing the critical role of NK cell immune reconstitution after ASCT in progression free survival.

Figure Figure
Double Cord Blood Transplantation for Patients with High Risk Hematological Diseases: Delayed Immune Recovery and High Incidence of Infections.
Authors: Rocha Vanderson , Madureira Adrienne , Robin Marie , Carmagnat Marievonick , Fernandes Juliana F. , de Latour Regis P. , Ferry Christele , Traineau Richard , Ribaud Patricia , Devergie Agnes , Rabian Claire , Gluckman Eliane , Socie Gerard
Published: October 2019

The possibility to perform double cord blood transplantation (dCBT) has extended its use in adults with high risk hematological disease; however there is no data on immune recovery and report on infections complications. We have performed a phase II study on 16 dCBT from 2004 to 2006. Ten patients had high risk malignant disorders (ALL=1, AML+MDS=6, CML=3) and 6 high risk of rejection (SAA=4, PNH=1 and Fanconi Anemia=1). Among those patients, 4 (25%) received a dBCT as a rescue of previous non-engrafted transplants (2 SAA, 1 AML and 1 CML). Analyses of T, B and NK cells phenotype were performed once a month during the first 3 months and ever two months until 12 months. The median age was 21 years (11–42), the median weight 63 kg (30–90) and the median follow-up was 6 months (3–18). Conditioning regimen varied according to disease (myeloablative) or second transplant (reduced intensity), all but two patients have received ATG. GVHD prophylaxis consisted in CsA + steroids in 12 patients and associated to MMF in 4.

Results: 2 patients did not engraft (both with SAA), one patient relapsed 8 days after dCBT, and 12 patients engrafted at a median of 23 days (14–42). Chimerism available in 12 patients before day 100 showed both CB units in 7 patients. After day 100, in 8 evaluable patients, 3 patients had evidence of both CB units engraftement. Acute GVHD was observed in 5 patients (grade II in 4 and grade III in 1) and chronic GVHD in 7 out of 12 at risk. During the first 100 days, 9 CMV reactivations were diagnosed; 4 HSV (resistant to acyclovir); 3 HHV6 infections; 3 EBV reactivations; 2 adenovirus diseases, 4 VRS infections, 2 septicaemias, 3 fungal infections, 1 disseminated toxoplasmosis. After day 100, we observed 4 CMV reactivations, 1 CMV disease, 1 HSV, 1 adenovirus disease and 1 EBV-PTLD. Important lymphopenia was observed in all patients (median of 259mm3 at 3 months (n=14); 389 at 6 months (n=13) and 480 at 12 months (n=8). Median numbers of CD3/CD4 at 3, 6 and 12 months were: 8, 15 and 46 mm3 respectively; of NK cells 203, 249 and 115mm3, and of B cells were 0, 0 and 110 mm3, respectively. At 6 months overall survival was 58±14% and event-free survival was 52±14%. Six patients died: 2 of relapse and 4 from infections. Three out of 4 patients have been rescued of previous non-engraftment and are alive and well (4–18 months). In conclusion, despite the short follow-up dBCT seems to be an option to treat patients with high risk diseases and without a suitable compatible HLA donor. High incidence of infections and delayed immune recovery are major problems after dCBT.
Improving the Pharmacokinetic Analysis of the Once Daily IV Busulfan Regimen for Allogeneic Stem-Cell Transplants: A Scientific Method Modification.
Authors: Naveed Farrukh , Kangarloo Shahbal , Chaudhry Ahsan , Geddes Michelle , Quinlan Diana , Russell James
Published: October 2019

Derivitization, a chemical technique used to transform a compound into a similar product with a different structure required by certain detection methods, was carried out for the detection of Busulfan (Bu) in human plasma. Using a proficient scientific method and enhancing its clinical association our method furthered the pre-column derivitization technique based on isocratic high performance liquid chromatography with ultraviolet detection (HPLC-UV). In-house adjustments have been made over the course of the last two years in order to increase the efficiency and turn-around of the method assay for clinical purposes. The concentration of drug in human plasma was measured with UV detection at 278nm by employing a Waters Nov-Pak C-18 analytical column heated to 40°C. The mobile phase, run at 1.5mL/min, consisted of a mixture of 20:80 deionized water and methanol respectively. All concentration-time plasma Bu data were analyzed by a non-compartmental analysis employing linear kinetics using WinNonlin Version 4.1 software (Pharsight Corporation, Mountain View, CA, USA). Analyses were performed on 155 allogeneic Stem-Cell Transplant (SCT) patients (pts). All pts received fludarabine 50mg/m2 on days -6 to -2 and IV Bu at a “myeloablative” dose of 3.2mg/kg daily, on days -5 to -2 inclusive. Additional TBI 200cGy × 2 was given to 74 pts. Graft-vs.-host disease prophylaxis for all pts comprised cyclosporine A, “short course” methotrexate with folinic acid and Thymoglobulin (Genzyme) 4.5mg/kg administered in divided doses over 3 consecutive days pre-transplant finishing on D0. The range of area under the curve (AUC) per dose was 2184 to 7513μM·min (median 4509μM·min). Twenty nine pts (19%) had AUC < 3600μM·min and 17 (11%) had AUC > 6000μM·min. The remaining 109 (70%) were between 3600 and 6000μM·min, equivalent to an exposure of 900 – 1500μM·min per dose established as desirable from studies of qid oral Bu given with cyclophosphamide. We found that IV Bu resulted in a 3–4 fold variability in AUC with a significant number of pts with exposures deemed either too high or low. High exposures (> 6000uM*min) increase the risk of transplant-related death and there is justification for therapeutic monitoring. Our predicted adjustments obtained from a streamlined method are based on day -5 Bu doses. The adjusted doses are administered on days -3 and -2, allowing for a 24 hour turn around time between days -5 and -3.
Defibrotide Effectively Prevents Veno-Occlusive Disease of the Liver (VOD) after Allogeneic Stem Cell Transplantation. An Extended Study.
Authors: Chalandon Yves , Roosnek Eddy , Helg Claudine , Verholen Frank , Knipp Sabine , Ozsahin Hulya , Passweg Jakob R.
Published: October 2019

VOD of the liver is reported to occur in 10–30% of patients after allogeneic HSCT, with mortality rates up to 50%. We previously reported a pilot study of defibrotide (Prociclide® Crinos, Como, Italy) VOD prophylaxis showing a significantly lower rate of VOD as compared to historical controls. We now report the results of an extended study.

Between 2000 and 2005, 157 consecutive patients were transplanted for hematological diseases. Median age was 43 y (range 5–61 y), M/F: 96/61; diagnosis was AML=42, ALL=19, CML=28, MDS/MPS=24, lymphoma=22, MM=12, AA=7, solid tumor=3. Donors were HLA-identical siblings (65%), unrelated (32%) mismatched relatives (3%). Stem cell source was peripheral blood (87%) and bone marrow (13%). The transplants were T-cell depleted by CAMPATH-1H in vitro, with (69%) or without (7%) T-cell add-back or left unmanipulated (24%). Conditioning was myeloablative with CyTBI (50%), BuCy (9%) other myeloablative (11%) or non-myeloablative (30%) using Fludara/Bu/ATG. GVHD prophylaxis was CSA with or without MTX or MMF. Nine pts received a second transplant for relapse or graft failure.

Defibrotide was given intravenously 6 hourly starting prior to conditioning up to day +20 posttransplant (dose range 20–30 mg/kg) in addition to low dose heparin. The Baltimore criteria were used to score VOD.

Results: No VOD was observed after 165 transplants. Defibrotide was well tolerated and no side effects were attributed to this medication. Median peak levels of bilirubin were 21 umol/l (range 9–286 umol/l), aPTT: 35 sec (range 24–83 sec) and fibrinogen: 7.1 g/l (range 3.1–9.5 g/l). Day 100 survival was 91±5%. With a median follow-up of 25 mths (range 3–80 mths), 1 year OS, TRM and RR were 74±7%, 13±5% and 29±8% respectively. The incidence of aGVHD >=II was 32±7 %.

Conclusion: The results of this study suggest that defibrotide is an effective prophylaxis for VOD.
The Use of Recombinant Human Erythropoietin (rHuEpo) after Reduced Intensity Conditioning (RIC) Allogeneic Hematopoietic Peripheral Blood Stem Cell Transplantation (ASCT) Reduce Red Blood Cell (RBC) Transfusion Requirements.
Authors: Ivanov Vadim , El Cheikh Jean , Faucher Catherine , Furst Sabine , Mohty Mohamad , Ladaique Patrick , Lemarie Claude , Charbonnier Aude , Coso Diane , Schiano Jean Marc , Viret Frederic , Blaise Didier
Published: October 2019

We previously reported that hemoglobin (Hb) recovery was hastened after RIC ASCT as compared with ASCT after myeloablative conditioning (Transfusion, 44:501–8, 2004). In this setting pretransplant Hb level becomes the major predictive factor for early Hb recovery posttransplant and RBC transfusion (RBCT) requirements. We subsequently reported the efficacy of early rHuEpo administration after RIC ASCT to hasten Hb reconstitution (BMT, 36:901–6, 2005). Here we further confirm the efficacy of early posttransplant administration of rHuEpo after RIC reducing RBC requirements and maintaining high levels of posttransplant Hb in the 2 months following transplant.Forty patients surviving at least 60 days were analyzed. Patients characteristics were as follow: age: 50 (27–64); M/F: 28/12; with myeloid (4), lymphoid (29) or solid (7) malignancies. They received a RIC (Fludarabin (150 mg/m²; Busulfan (8mg/kg) and thymoglobulin (2.5 to 5 mg/kg)) followed with an ASCT (all PBSC) from a HLA identical sibling. Aranesp® (Amgen, France) was started on day 1. The 20 first patients received an infusion of 150 mcg/week while the 20 last patients were subsequently treated with 500 mcg/3 weeks. Aranesp® was administered intravenously when inpatient and subcutaneously when outpatient. Aranesp® administration was sustained until day 60 or when patients reached a Hb level of 140 g/L, whichever occurred first. Overall patients were treated for a median of 7 weeks post transplant. No serious adverse effect or thrombosis episode related to Aranesp® was reported in these patients. This cohort of 40 patients experienced a quicker Hb recovery and lower RBCT requirements than a historical and comparable control group of 27 patients (Day +30 Hb: 114 (94–141) vs. 100 (80–129), p<.0001; patients with 0 or 1 RBCT: 83% vs. 55% (p=.02)). Thirteen of the 40 patients (33%) presented with an Hb level of 120 g/L or more prior to conditioning. Over the first 60 days, these patients received 0 (0–2) RBCT as compared with 1 (0–2) RBCT for patients with a pre-RIC Hb level < 120 g/L (p=.05). On this basis, we hypothesized the interest of increasing Hb level prior to RIC by adequate rHuEpo stimulation. With this perspective, we have treated 13 patients with Aranesp® (500 mcg, SC) 3 weeks prior RIC. Nine of these 13 pts (69%) reached an Hb level of 120 g/L or more on day −7 as compared to 35% in patients not receiving Aranesp ® prior to RIC (p=.04). This indicates that Aranesp® post RIC ASCT is efficient to hasten Hb recovery and decrease RBCTs. In addition, a comprehensive strategy to minimize RBCT in this setting might include pre-transplant stimulation. We will prospectively assess this hypothesis.
Platelets Recovery and Transfusion Needs after Reduced Intensity Conditioning (RIC) Allogeneic Peripheral Blood Stem Cell (PBSC) Transplantation (allo-SCT).
Authors: Prebet Thomas , Mohty Mohamad , Ladaique Patrick , Chabannon Christian , Faucher Catherine , Furst Sabine , de Lavallade Hugues , El-Cheikh Jean , Viens Patrice , Gastaut Jean-Albert , Blaise Didier
Published: October 2019

Few data are currently available regarding platelets trasfusion needs and the kinetics and predicitive factors for platelets recovery after RIC allo-SCT. In this study, we analyzed the profile of platelets recovery and transfusion needs in the first 100 days after sibling PBSC RIC in a single institution series of 166 consecutive transplantations. Patients and graft characteristics were: age 49 y. (range: 18–70), diagnoses: 66 myeloid malignancies (40%), 64 lymphoid malignancies (39%), and 36 metastatic solid tumors (21%). 112 pts (67%) received an ATG-based RIC, while 54 pts (33%) received a low dose irradiation-based RIC. 75 pts (45%) developed grade 2–4 acute GVHD. Platelets recovery (>20 G/L) was observed at a median of 9 days (range: 0–99). The kinetics profile of platelets recovery is shown in the figure below. In the whole study population, the nadir was observed around day +7 after allo-SCT, and a plateau was reached about day +35. Filtered and irradiated donor apheresis platelets were used and patients needed a median of 1 unit (range: 0–53). In this series, 83 pts (50%) did not require any platelets transfusion during the follow-up period (median follow-up: 442 days) and 83 patients (50%) received at least one transfusion of platelets (54 were not transfused beyond day +100 after allo-SCT). Platelets count prior to RIC allo-SCT (median count 144 G/L; HR 0.44 (0.28–0.7) p=0.002), conditioning regimen (use of ATG; HR 1.86 (1.08–3.2) p=0.025) and the occurrence of acute (HR 1.54 (1.17–2.01); p=0.001) and severe GVHD (HR 2.36 (1.38–3.05) p=0.0006; 82% of patients with grade 3–4 acute GVHD were transfused) were the parameters significantly associated with platelets transfusion needs in multivariate analysis. In this cohort, 145 pts could be assessed for platelets recovery at day +100: among them, 99 (68%) had a platelet count >99 G/L. Univariate analysis found a significant impact of acute GVHD (p=0.0001) and platelet count prior to conditioning (p=0.012) but only acute GVHD (HR 5.52 (2.48–12.25); p=0.001) was associated with a delayed platelet recovery in a multivariate model. No impacts of pathology, GVHD prophylaxis regimen or CD34+ cell dose were demonstrated.

Overall, these observations show a significantly lower rate of platelets transfusions and a quicker kinetic of platelets recovery after RIC allo-SCT and point out the effect of acute GVHD. In addition, considering the low level of myeloablation observed, RIC could be an appropriated field of investigation for the testing of megakaryocytic stimulating agents, towards further improving the safety and outcome of RIC allo-SCT.

Platelets recovery after PBSC RIC allo-SCT Platelets recovery after PBSC RIC allo-SCT
Allogeneic Stem Cell Transplantation with Reduced Intensity Conditionning Regimen (RIC) for Adult Patients with AML: Same Results in Secondary and De Novo AML.
Authors: Milpied Noel-Jean , Tabrizi Reza , Guillaume Thierry , Chevallier Patrice , Pigneux Arnaud , Boiron Jean Michel , Moreau Philippe , Mahe Beatrice , Leguay Thibaut , Bouabdallah Krimo , Morineau Nadine , Delaunay Jacques , Melot Cyril , Saulquin Beatrice , Marit Gerald , Harousseau Jean Luc
Published: October 2019

We have evaluated the outcome of RIC in 114 adult pts with AML either de novo (74) or secondary to cancer or MDS (40). There were 43 men, median age was 55 yo (22–65). Cytogenetic was available in 104 and was abnormal in 55 (favorable: 13; intermediate: 21; poor: 21). Pts had received a median of 1 line of Tx before RIC (0–3). Twenty had a previous autologous transplant. At time of RIC, 28 patients were refractory or in relapse while 71 were in CR (1st: 48; 2d: 20). The donor was an id sib for 80 and a MUD in 34 (with1allelic mismatch in 6). The cond regimen was of Slavin type in 56, only 11 pts received the Seattle program. Overall 74 had ATG as part of cond reg. GVHD prophylaxis consisted of CSA or CSA-MTX in 95 pts, 14 had CSA-MMF.

With a median FU of surviving pts of 21 m (3–73) the 3y survival (OS) and EFS are 40% and 38% respectively. Sixty pts died with the main cause of death being relapse. The probability of TRM at 100 d and 1 y are 7% and 14% respectively. The 2y probability of relapse is 50%. These figures are strictly superimposable for pts with de-novo or secondary AML.

The factors affecting significantly (p<0.05) the 3y OS and EFS were: disease status at time of RIC (50% vs 0 to 24% in pts in CR vs not), the N° of previous lines of Tx (55% vs 0 to 24% after one line vs more), an id sib as donor ( 45% vs 32% for OS and 44% vs 19% for EFS), having an aGVHD grade 1 or 2 ( OS: 75% vs 25% if aGVHD grade 3–4 vs 38% if no aGVHD), and a CGVHD limited or extensive (OS: 50% or 78% respectively vs 29% if no CGVHD; EFS: 50% or 56% respectively vs 29% if no CGVHD). The single factors that affected the risk of relapse was the occurence of an acute and or chronic GVHD. The TRM was significantly increased in pts with previous autologous transplant, a MUD, an aGVHD and a female donor.

Conclusion: RIC allo is well tolerated ( max TRM :14% at 1 y) and allows the same result in de-novo and secondary AML. The best results are achieved in patients in CR1 ( 3y OS and EFS: 63% and 62% respectively) whatever was the type of donor. As most of the pts beyond CR1 were transplanted with a MUD, it is not possible to separate the negative impact of advanced disease or MUD. An active search of a donor at the time of diagnosis, particularly in patients with secondary AML, could allow early RIC with MUD in pts with an indication of allogeneic stem cell transplantation.