bluuebunny/crossref_metadata_2025 huggingface dataset:
Pegfilgrastrim Compared with Filgrastim after Autologous Hematopoietic Peripheral Blood Stem Cell Transplantation.
Authors: Vanstraelen Gaetan , Frère Pascale , Ngirabacu Marie-Christine , Willems Evelyne , Fillet Georges , Beguin Yves
Published: April 2020

In order to assess the effect of Pegfilgrastim on the duration of neutropenia and clinical outcome of patients after autologous peripheral blood stem cell transplantation (PBSCT), we compared 20 consecutive patients with lymphoma or multiple myeloma receiving a single 6 mg dose of Pegfilgrastim on day 1 posttransplant to a historical control group of 60 patients receiving daily Filgrastim 5 μg/kg starting on day 1 posttransplant. There were 54 M and 26 F, 30 patients with lymphoma and 50 with myeloma, 26 in CR and 54 not in CR. Mean age was 55±10 yrs and 25 had already received a previous autologous transplant. The two groups were matched for disease and disease status, transplant number, age and sex. Cell dose infused tended to be higher in the Pegfilgrastim group (7.16±3.82 vs 10.03±6.25 x106 CD34+ cells/kg, p=0.0575). There were no differences (p>0.05) in time to 0.5 (8 vs 9 days) or 1 (9 vs 9 days) x109/L neutrophils; to 1 % reticulocytes (13 vs 15 days) or 9 (12 vs 14 days) or 10 (30 vs 25 days) g/dL Hb; to 20 (9 vs 9 days) or 100 (20 vs 31 days) x 109/L platelets. The number of days with fever (2.7±2.3 vs 2.3±2.4 days), incidence of infections (all infections; bacteremia; bacterial, fungal or viral infections; FUO), duration of antibiotic therapy (8.7±5.9 vs 8.4±5.9 days), RBC (1.1±1.6 vs 0.9±1.6) and platelet (1.0±1.7 vs 1.2±1.8) transfusions, and time to hospital discharge (14.5±5.3 vs 15.4±5.8 days) were similar in the Pegfilgrastim compared to the Filgrastim group. However, after initial hematopoietic recovery, several differences between the groups became apparent, with the group always showing higher counts compared to the Filgrastim group (p values <0.05 to <0.001). Neutrophils remained significantly higher in the Pegfilgrastim group between days 14–30, lymphocytes between days 56–90, monocytes between days 21–24, reticulocytes between days 17–42 and platelets between days 35–90, respectively. These differences had no impact on clinical outcome after day 30 due to the low incidence of infectious events after engraftment. We conclude that Pegfilgrastim administrated on day 1 posttransplant facilitates early hematopoietic reconstitution comparable to daily Filgrastim. However, despite a trend towards fewer CD34+ cells transplanted, the Pegfilgrastim group enjoyed higher trilineage cell counts for some time after initial engraftment. This should be further tested in prospective randomized trials.
Successful Autologous Stem Cell Transplantation in Patients with Non-Hodgkin’s Lymphoma over the Age of 70 Years.
Authors: Yusuf Rushdia Z. , McAfee Steve , Dey Bimalangshu R. , Yeap Beow , Spitzer Thomas R. , Ballen Karen K.
Published: April 2020

Autologous stem cell transplantation (SCT) is a potentially curative procedure for patients with relapsed lymphoma (NHL). Over 60% of the cases arise in adults over 60 years of age. We retrospectively analyzed the outcomes of patients >60 years old who received high dose busulfan (Bu) and cyclophosphamide (Cy) and autologous SCT for NHL. Stem cells were mobilized with G-CSF with or without chemotherapy. Patients received a dose-adjusted regimen of Bu 0.8 mg/kg IV (n=17) or 1mg/kg po (n=9) q 6 hours x 14 doses starting on Day -7 and Cy 60 mg/kg IV q day on days -3 and -2. In overweight patients, IV Bu doses were calculated based on ideal body weight and oral Bu doses and Cy doses were calculated on an adjusted body weight. All patients were treated as inpatients and received our usual supportive care including transfusion support, pneumocystis prophylaxis, antiviral prophylaxis, growth factor support and broad-spectrum antibiotic coverage for febrile neutropenia. 26 consecutive patients > 60 with relapsed NHL underwent autologous SCT at Massachusetts General Hospital between 1995 and February 2005. The median age of the population was 66 (range 60–78) years. 17 (65%) of the 26 patients were females. 15 patients had large cell lymphoma, 2 immunoblastic lymphoma, 3 follicular lymphoma, and 6 mixed small cleaved cell and large cell. All patients had recurrent disease; 7 patients were in a CR and 19 patients in a PR at the time of transplant. The median time from diagnosis to transplant was 32 months. All patients engrafted. The median time to absolute neutrophil count > 500/uL was 10 days (range 9–11) days. The median time to platelet count > 50,000/uL unsupported was 15 (range 12–39) days. The 100-day transplant related mortality was 0%. Patients experienced the following serious toxicities: interstitial lung disease (n=1), seizures in a patient with CNS lymphoma (n=1), venoocclusive disease which resolved (n=2), and transient atrial fibrillation (n=3). With a median follow-up of 22 months (range 4 months–9.5 years), the two year overall survival is 63% and two year progression-free survival is 42%. Six patients above the age of 70 years have been transplanted. 100-day transplant related mortality was 0%. With a median follow up of 25 months, all 6 patients are alive and 3 of 6 are progression free. In conclusion, 1) Bu/Cy is a well-tolerated conditioning regimen for patients with NHL above the age of 60 years, including selected patients over the age of 70; 2) Age alone should therefore not be used as an exclusion criterion for autologous SCT.
Subclinical Alterations in Coagulation in Patients during Conditioning Regimen before Allogeneic Hematopoietic Stem Cell Transplantation.
Authors: Jiang Qian , Huang Xiao Jun , Liu Kaiyan , Chen Huan , Chen Yuhong , Cao Zhiyong , Lu Daopei
Published: April 2020

Objective To evaluate the alterations in coagulation in patients during modified busulfan plus cyclophosphamide (BUCY) ± antithymocyte globulin (ATG) before allogeneic hematopoietic stem cell transplantation (allo-HSCT), and to assess the effect of ATG on coagulation system as part of conditioning regimen.

Methods Thirty-five patients with various hematological malignancies undergoing allo-HSCT were assessed. Nineteen patients from HLA-identical siblings (group A) were conditioned with modified BUCY regimen, included cytarabine (2g/m2 i.v., day -9), busulfan (4mg/kg p.o. in divided doses daily, day -8 to day -6), cyclophosphamide (1.8g/m2 i.v., day -5 and day -4) and Me-CCNU (250mg/ m2 p.o., day -3). Sixteen patients from HLA-mismatched family members or HLA-matched unreleated donors (group B) were conditioned with modified BUCY + ATG regimen, added cytarabine (4g/m2 i.v., day -10 and -9) and rabbit ATG (2.5mg/kg i.v., day -5 to day -2, SangStat S.A.S., France). Blood samples were obtained before the start of regimen until day +1 after allo-HSCT. The following laboratory parameters were measured: prothrombin time (PT), active partial thromboplastin time (APTT), Fgrinogen (Fg), antithrombin (AT), D-Dimer, Fgrin degradation product (FDP), platelet (PLT), liver enzymes and bilirubin. VIII:C, IX:C, XI:C and XII:C in some blood samples with prolonged APTT were determined. Clinical hemorrhagic symptoms were monitored.

Results From day -5 of conditioning regimens, temporary lengthening of APTT, which peaked on day -3, occurred in 16/19 (84.2%) patients in group A and 19/19 (100%) patients in group B, continued rise in Fg occurred in 17/19 (89.5%) patients in group A and 19/19 (100%) patients in group B, a progressive decrease of PLT was observed in all patients of two groups. Alterations of Fg and PLT were more significant in group B compared to those in group A. Transient D-Dimer increase was detected only in group B on day -3. Among intrinsic pathway coagulation factors, XII:C and XI:C were decreased commonly and significantly when APTT was prolonged. No difference between the two groups could be found with regard to PT, FDP, AT and liver parameters which remained nearly in normal ranges. Most of patients in two groups did not have overt bleeding manifestations.

Conclusions Modified BUCY ± ATG conditioning regimen can induce subclinical alterations in coagulation. The regimen contained ATG has more significant effect on coagulation parameters.
Pharmacokinetics (PK) of 2 Dosing Regimens of Palifermin in Patients (Pts) with Hematologic Malignancies (HM) Undergoing High-Dose Chemoradiotherapy and Hematopoietic Stem Cell Transplantation (HSCT).
Authors: Zia-Amirhosseini Parnian , Salfi Margaret , Elhardt Dieter , Aycock Jeff , Cheah Tsui Chern , Cesano Alessandra , Hurd David D.
Published: April 2020

For pts with HM undergoing HSCT, oral mucositis (OM) is a frequent and debilitating complication that negatively impacts treatment outcomes, patient quality of life, and healthcare resources. Palifermin reduces the incidence and duration of severe OM in the HSCT setting. This phase 1 open-label study assessed the PK of 2 palifermin dosing regimens. Methods: Pts were 18 to 76 years old with HM and a Karnofsky performance score ≥70%. Palifermin was administered intravenously once daily as follows: 60 mcg/kg/day [d] for 3 consecutive days on d -11, -10, and -9 before conditioning (total body irradiation [TBI] + etoposide + cyclophosphamide) and following HSCT on d 0, 1 and 2 (part A) and a single dose of 180 mcg/kg (part B) before conditioning on d -11 and after HSCT on d 0. In part A (6 total doses), PK parameters were assessed after the 1st, 3rd, 4th, and 6th doses. In part B (2 total doses), assessments were made after each dose administration (d -11 and d 0). Results: In part A, 13 pts received palifermin; in part B, 12 pts received the single dose on d -11 and 11 pts received the single dose on d 0. For both dosing regimens, palifermin concentrations declined rapidly (≥98% decrease) in the first 30 minutes postdose, followed by a slight increase in mean concentrations between 1 and 4 hours and then a terminal decay phase. Respective mean (SD) PK parameter values for the 2 dosing regimens are shown in Table 1. In part A, mean AUC0-t values were comparable between doses 1 and 3 (within 15%) and 1 and 4 (within 1%). In part B, mean PK parameter values were similar (within 10% of each other) between doses 1 and 2. The mean AUC after the first 180 mcg/kg dose in part B was approximately 4-fold higher than that after the first 60 mcg/kg dose in part A. Mean half-life values ranged between 3.3 to 5.7 hours in part A and the value was 5.4 hours in part B. Conclusion: The PK data in pts receiving HSCT were consistent with approximately dose-linear PK in the dose range of 60 and 180 mcg/kg, with no observed accumulation, based on AUC, after 3 daily doses of 60 mcg/kg in this pt population in the HSCT setting.

Table 1 Dose Number (Dosing Day) n AUC0-t (hr x ng/mL) mean (SD) Clearance (mL/hr/kg) mean (SD) Vss (mL/kg) mean (SD) a Accurate computations of clearance (CL) and volume of distribution at steady state (Vss) were not possible for some concentration-time profiles. Part A - 60 mcg/kg/day x 3 consecutive days 1st dose (day -11) 9–13 34.3 (15.9) 1730a (497) 5320a (2330) 3rd dose(day -9) 13 39.8 (36.4) - - 4th dose(day 0) 11–13 34.8 (22.5) 2030a (862) 3870a (2080) 6th dose(day 2) 13 21.2 (15.1) - - Part B - 180 mcg/kg/day x 1 day 1st dose(day -11) 12 140 (50.9) 1460 (600) 4290 (3270) 2nd dose(day 0) 11 143 (71.8) 1770 (1290) 4270 (4700)
Developing an Algorithm for Monitoring Chimerism after Allogeneic Bone Marrow Transplantation - A Single Centre Experience.
Authors: Chandy Mammen , Shanmugapriya S. , Balasubramaniam Poonkuzhali , SatheeshKumar S. , Shaji R.V. , Mathews Vikram , George Biju , Vishwabandya Auro , Srivastava Alok
Published: April 2020

Analysis of chimerism for the evaluation of engraftment and rejection after allogeneic stem cell transplantation is now standard practice (ASCT). The most common technique used is PCR amplification of short tandem repeats (STRs) and variable number of tandem repeats (VNTRs). Data on informativeness of various VNTRs or STRs in HLA identical recipient donor pairs in a population is essential to establish a scheme of sequential testing. To determine the informativeness in our population, we screened five STRs namely FES, THO 1, VWA, ACTBP2, and F13A1 and 1 VNTR, APOB, in allogeneic bone marrow transplant patients with their HLA identical donors. Samples from 310 patients who underwent haematopoietic stem cell transplantation (HSCT) during the period 1993–2005 were analyzed. All donors were HLA identical siblings or related family members of the patient. Of the 310 patients, 120 (39%) were from southern India, 88 (28%), 25(8%), and 59 (19%) from northern, eastern and western parts of India respectively. Seventeen (5%) patients were from other countries (Maldives (n=4), Oman (n=4), Sri Lanka (n=2), Singapore (n=1), Mauritius (n=1), Pakistan (n=3), Bhutan (n=2)). For 15 (5%) of these 310 patients only amelogenin PCR results were available. The other 295(95%) patients and donors were studied by PCR for one or more of the polymorphic repeat sequences, (STRs or VNTR) namely FES, THO 1, VWA, ACTBP2, F13A1 and APOB. Of all the six markers used THO1 was the most informative (55%) and F13A1 the least (20%). Informativeness of the markers THO1+VWF, THO1+VWF+ACTBP2, THO1+VWF+ACTBP2+FES was 79, 87, and 92 percent respectively. By combining one, two or three markers, we could discriminate between 68 to 92 percent of the patient donor pairs. Addition of marker APOB to this panel discriminated 95% of the HLA identical patient donor pairs. Usage of Genescan analysis in practice to evaluate chimerism status has improved the utility of these markers from 95% to 97%. Using a combination of all these markers along with a polymorphic marker in the b-globin gene and Y chromosome specific amelogenin marker, we were able to discriminate 99% of the patient donor pairs. We have established an algorithm for evaluating chimerism in the Indian population using molecular markers in 310 patients and their HLA identical related donors. This data may be useful for transplant centers in adopting a strategy for evaluating chimerism following HLA identical ASCT.
Mitochondrial DNA Microsatellites as New Markers for the Quantitative Determination of Hematopoietic Chimerism after Allogeneic Stem Cell Transplantation.
Authors: Shin Myung-Geun , Kim Hyeoung-Joon , Kim Hye-Ran , Lee Il-Kwon , Lee Je-Jung , Kook Hoon , Hwang Tai-Ju , Cho Duck , Kee Seung-Jung , Shin Jong-Hee , Suh Soon-Pal , Ryang Dong-Wook
Published: April 2020

Variable number tandem repeat (VNTR) and short tandem repeat (STR) markers of nuclear DNA are increasingly used for monitoring the engraftment of donor cells after stem cell transplantation (SCT). Mitochondria are the only organelles of animal cells other than the nucleus that contain DNA as well as their own machinery for RNA and protein synthesis. Mitochondrial DNA (mtDNA) is present in multiple copies (usually 103 to 104 copies per cell) (Blood2004;103:4466–77). We reported new markers using the analysis of mtDNA control region and microsatellites (mtMS) for monitoring donor cell engraftment in marrow transplant recipients. MtDNA control regions (nucleotide position (np) 16024 to 16569 and 1 to 576) and six mtMS (np 303–315 poly C, np 16184–16193 poly C, CA repeat starting at np 514, np 3566–3572 poly C, np 12385–12391 poly C and np 12418–12426 poly A) from total DNA samples from 25 sets of cases (donor, recipient and after SCT) were amplified using designated specific primers and PCR. We directly sequenced the control region which includes hypervariable regions, then carried out a qualitative and quantitative profiling mtDNA length heteroplasmies of six mtMS using size-based PCR product separation by capillary electrophoresis (ABI 3100 Genetic Analyzer and ABI Prism Genotyper version 3.1). The results were compared to those from six VNTR markers (D12S391, D1S80, F13A1, HUM RENA-4, HUM FABP2 and D18S51–5). MtDNA control region polymorphisms lead to the identification of an informative marker in 88% (22 cases) of all cases. Among six mtMS markers, the result of informativeness from np 303–315 and np 16184–16193 poly C mtMSs was 63% and 67% respectively. The combination of mtDNA control region direct sequencing, np 303–315 and np 16184–16193 poly C length heteroplasmies completely distinguished donor cells from recipients. In data from a typical mixing experiment for the determination of sensitivity, the detection limit (DL) of gene scan analysis in a mtDNA mixture was visible at 1% heteroplasmy in np 303–315 poly C mtMS marker; however DL from D12S391 in the same mixing experiment was 5–10% heteroplasmy. MtDNA control region sequencing and the length heteroplasmies of np 303–315 and np 16184–16193 poly C tracts can provide sensitive, accurate and quantitative determination of mixed chimerism after SCT.
Allogeneic Hematopoietic Stem Cell Transplantation after Combination Therapy with Imatinib and Intensive Chemotherapy for Newly Diagnosed Philadelphia Chromosome Positive (Ph+) Acute Lymphoblastic Leukemia.
Authors: Usui Noriko , Yano Shingo , Takahara Shinobu , Asai Osamu , Dobashi Nobuaki , Osawa Hiroshi , Takei Yutaka , Ogasawara Yoji , Otubo Hiroko , Yamaguchi Yuko , Saito Takeshi , Minami Jiro , Kaito Ken , Kobayashi Masayuki
Published: April 2020

[Background] In JALSG Ph + ALL protocol(IDEAMOP) study, combination therapy with conventional intensive chemotherapy with imatinib (600mg/day) provided high quality of hematologic and cytogenetic (94%) and molecular (77%) complete remission (CR) for the patients with newly diagnosed Ph + ALL(Blood2004;104:748a #2736). However, a few of patients attained molecular CR relapsed subsequently, and allogeneic hematopoietic stem cell transplantation (allo-HSCT) should be considered for younger patients as possible as they can. In order to investigate a role of allo-HSCT post IDEAMOP therapy, three patients treated in our institute were analyzed efficacy and toxicity of allo-HSCT.

[Patients and Methods] Those three newly diagnosed Ph + ALL patients (M/F:2/1 Age:30,31,38 y.o.) were treated with IDEAMOP between Jan 28,2003 and Feb 13,2004. All patients attained CR after single course of induction therapy and median time of CR was 21 (19–27) days. During consolidation therapies, two of them found HLA-matched unrelated donors and one patient chose to receive cord blood transplantation. As conditioning regimen for allo-HSCT, all of them received total body irradiation, high-dose cyclophosphamide and high-dose etoposide before allo-SCT.

[Results] Allo-HSCT was undergoing during their first CR(CR1). Regimen related toxicity and complications of the transplantation were well tolerated. The reconstitutions of bone marrow function were similar to other patients with Ph-negative ALL treated by allo-HSCT. Although two patients presented with either limited or extensive chronic GvHD, they were clinically controlled with or without steroid. Minimal residual disease (MRD), measured by RQ-PCR assay, was detected in two of three patients before allo-HSCT. However, MRD was not detected in any of the patients after allo-HSCT. All of three patients remain in CR at a median follow-up time of 25 (18–31) months.

Allo-HSCT post JALSG-Ph+ALL (IDEAMOP)protocol Patient Status at HSCT MRD pre HSCT Cell Source MRD postHSCT cGvHD Outcome OS(M) 30Y M CR1 yes Cord Blood no limited alive 31+ 31Y M CR1 no MUD no extensive alive 25+ 38Y F CR1 yes MUD no extensive alive 18+

[Conclusion] Although the number of patients are small, imatinib (600mg/day) with intensive chemotherapy as remission induction for newly diagnosed Ph + ALL may have benefit for rapid control of disease, and may provide better outcome of allo-HSCT without additional severe toxicities.
Population Pharmacokinetic of Oral Busulfan in Japanese Undergoing Hematopoietic Stem Cell Transplantation.
Authors: Sasaki Noriaki , Ogata Kentaro , Yamauchi Keita , Takamatsu Yasushi , Suzumiya Junji , Tamura Kazuo , Yukawa Eiji , Hara Shuuji , Ono Nobufumi
Published: April 2020

We previous evaluated busulfan (BU) pharmacokinetics (PK) in seven Japanese adult patients who underwent allogenic hematopoietic stem cell transplantation (HSCT) at Fukuoka University Hospital. We showed that the average plasma BU concentrations at steady state (Css) ranged from 745 to 2422 ng/mL. BU population PK (PPK) parameters for Caucasian have already been reported. However, few data are available for Asian people.

We therefore investigated the PPK parameters of BU in 82 Japanese adult patients (51 males and 31 females) who underwent HSCT following a BU-containing conditioning regimen. Their average age was 43.4 years, ranging from 16 to 68 years. Blood samples were collected in heparinized tubes at 0.5,1,2,4 and 6 hours after the oral administration of BU, and the plasma BU concentrations were measured by high performance liquid chromatography (HPLC). A one compartment open model with first-order absorption was used. We estimated individual BU doses by using Bayesian, and PK parameters by using nonlinear mixed effects modeling (NONMEM) computer program.

Since Oral clearance (L/h/kg) (CL/F) and distribution volumes (L/kg) (Vd/F) were proportional to total body weight, so we set the following formulas. The final PPK parameters were CL/F = 0.139•TBW•1.14GEN •1.09VPA •1.52TBIL≥1.2, Vd/F = 0.76•TBW•0.902GEN, absorption rate constant (h−1) (ka) = 2.58. TBW is total body weight (kg), VPA = 1 for concomitant administration of valproic acid and 0 for another anticonvulsant, GEN = 1 for patients gender female and 0 for male, TBIL≥1.2 = 1 for total bilirubin above 1.2 mg/dL and 0 for below.

CL/F in Japanese and Caucasian were 0.139 and 0.149, respectively, Vd/F were 0.76 and 0.64, respectively, and ka were 2.58 and 1.68, respectively.

These data showed that CL/F and Vd/F were almost same between Japanese and Caucasian, but ka was larger. We also found that high serum levels of total bilirubin and administration of VPA induced the increase of CL/F at 52 % and 9 %, respectively. The interindividual variabilities in CL/F, Vd/F and ka were 21.9%, 20.9% and 82.3%, respectively, and the residual variability was 18.4% as coefficient of variation.

This study represented that oral BU PPK parameters in Japanese were different from that in Caucasian. BU PPK parameters were influenced by gender, serum levels of total bilirubin and administration of VPA. Our study showed that BU PPK differed between Japanese and Caucasian.
Differential Regulation of bFGF- and VEGF-Induced Angiogenesis in Mice Lacking Junctional Adhesion Molecule-A.
Authors: Naik Meghna U. , Naik Ulhas P.
Published: April 2020

Angiogenesis, the formation of new blood vessels from preexisting vessels, is a complex process involving vascular endothelial cell activation, proliferation, migration, and tube formation. Several growth factors have been shown to induce this process. Among them vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) are most widely studied. These two growth factors are believed to induce angiogenesis through distinct signaling pathways. Recently, we have shown that signaling through junctional adhesion molecule-A (JAM-A) is required for bFGF-induced angiogenesis. Here, we present evidence that JAM-A differentially regulates both bFGF-induced and VEGF-induced angiogenic responses. Using human umbilical cord vein endothelial cells (HUVEC) we found that bFGF-induced but not VEGF-induced migration was inhibited by function blocking anti-JAM-A antibody. We also found that mutant JAM-A blocked bFGF-induced but not VEGF-induced MAP kinase activation. To conclusively determine the role of JAM-A in angiogenic signaling, we generated JAM-A null mice. Endothelial cells isolated from JAM-A null mice failed to migrate in response to bFGF stimulation, but showed enhanced cell migration in response to VEGF. Further, using aortic ring and Matrigel® plug assays, we found that bFGF failed to induce blood vessel formation in JAM-A null mice. Interestingly, an increase in the number of blood vessels was observed in response to VEGF in these mice suggesting that in the absence of JAM-A bFGF-induced angiogenic pathway is impaired, but VEGF-induced pathway is upregulated to compensate. We next determined the effect of increased angiogenesis on tumor growth. We found that B16F0 melanoma growth was enhanced at least by two-fold in JAM-A null mice compared to wild-type mice. To understand the mechanism of hypersensitivity of JAM-A null mice to VEGF, we determined the expression of VEGF receptors on endothelial cells. We found that surface expression of VEGFR-2 is upregulated in endothelial cells isolated from JAM-A null mice. These results suggest that signaling through JAM-A is essential for the bFGF-induced pathway and when this pathway is impaired, the VEGF-induced pathway is upregulated which leads to enhanced angiogenesis and tumor growth.
Pulse Cyclophosphamide in the Treatment of Liver GvHD Unresponsive to Steroids.
Authors: Mayer Jiri , Krejci Marta , Doubek Michael , Brychtova Yvona
Published: April 2020

Introduction: Steroids provide an active but inadequate therapy for acute GvHD. Corticosteroid-resistant acute GvHD is extremely difficult to manage and is associated with very high morbidity and mortality. Cyclophosphamide (Cy) has been used for a long time as an immunosuppressive drug for the treatment of many autoimmune disorders, as a cytotoxic drug, and Cy is also a part of both classical conditioning regimens, Cy+TBI and Cy+busulfan. Pulse Cy at a dose of 1 g/m2 is now an established mainstay in the treatment of lupus nephritis. Therefore, we hypothesized that this pulse treatment can be used also for steroid-refractory GvHD. In a previous work, we showed that intestinal GvHD responded poorly to pulse Cy, whilst liver, skin, and oral GvHD responded very well. Since steroid-refractory acute skin GvHD is not frequent, in this report, we analyzed our new data concerning liver GvHD.

Patients (pts) and methods: This is a retrospective study of 17 pts: 11 pts had acute GvHD, 3 pts had chronic GvHD (albeit progressing from acute GvHD), and 4 pts developed liver GvHD upon DLI. Seven pts had hepatitic variant of liver GvHD (serum aminotransferase ALT or AST elevation >10 times the upper normal limit). Seven pts had steroids plus another previous therapy before receiving Cy pulse.

Results and Conclusions: There were 21 Cy administrations at the dose of about 1 g/m2 (460 mg/m2 – 1500 mg/m2, median dose: 1000 mg/m2). The dose was empirically decreased or increased because of fear of myelosuppression, or previous incomplete response, respectively. There were 47% CR (8/17), 18% (3/17) PR, and 35% (6/17) NR. However, in 4 pts with NR their clinical status stabilized and they responded to another treatment. Four pts died: 2 from intractable liver and intestinal GvHD, 1 from intestinal GvHD with liver GvHD in PR, and 1 from relapsing leukemia. All GvHD related deaths occurred in pts with acute GvHD, whereas all but one pts (relapsing AML) with post-DLI or chronic GvHD survived. Concomitant severe gut GvHD seems to be the risk factor for not reaching CR in liver GvHD, and death. On the other hand, however, 6/7 pts (86%) with hepatitic GvHD reached CR. Pulse Cy exerts a good toxicity profile, except for a manageable, short-term myelosuppression in some patients, and does not appear to increase the risk of opportunistic infections, mixed chimerism, relapses, or posttransplant lymphoproliferative disease. The cost of the drug is negligible.
Risk Factor Analysis for Predicting Chronic Graft-Versus-Host Disease of Progressive or Quiescent Type in a Cohort of Patients with a History of Acute Graft-Versus-Host Disease after Allogeneic Stem Cell Transplantation.
Authors: Sohn Sang Kyun , Kim Dong Hwan , Baek Jin Ho , Kim Jong Gwang , Lee Kyu Bo , Lee Kyoo-Hyung , Lee Je-Hwan , Choi Seong-Jun , Lee Jung-Hee
Published: April 2020

Background: As a series of our previous investigation (Haematologica, 2005. 90: 939–48) identifying poor prognostic factors (lymphocytopenia and visceral involvement) at the onset of acute GVHD (aGVHD) in patients with a history of aGVHD after allogeneic stem cell transplantation (SCT), we tried to identify variables that could predict the development of chronic GVHD of progressive or quiescent type (pq cGVHD) and patients’ outcome after the diagnosis of cGVHD in cohort of 99 patients who experienced aGVHD after allogeneic SCT.

Patients and Methods: We evaluated the risk factors for cGVHD of pq cGVHD with various clinical parameters in patient group with a history of aGVHD and also the prognostic significance of various clinical parameters at diagnosis of cGVHD to determine the prognostic factor for GVHD-specific survival (GSS) in patients with pq cGVHD.

Results: From 118 patient experienced aGVHD of any degree, 99 patients were evaluated for cGVHD. The cumulative incidence of overall and extensive pq cGVHD at 2 years was estimated as 84.4% and 63.1%, respectively. In univariate analyses for risk factors of pq cGVHD, severe grade 3,4 aGVHD, primary treatment failure (PTF), lymphocytopenia (≤100/μl), elevated ALP (>160IU/l), visceral involvement, hepatic or gut involvement were identified. Especially, severe aGVHD (p=0.022 and <0.001), PTF (p=0.009 and 0.010) for overall and extensive pq cGVHD, lymphocytopenia (p=0.031) for extensive pq cGVHD, and elevated ALP (p=0.001) for overall pq cGVHD were independent risk factors. The prediction model of subsequent pq cGVHD validated these risk factors with respect to the incidences of overall pq cGVHD (48.6% versus 91.9% for no risk factor versus 1~3 risk factor(s)) and of extensive pq cGVHD (34.2% versus 59.6% versus 92.2% for no / 1 / 2~3 risk factors). HLA-disparity and stem cell source did not influence on the development of pq cGVHD in this cohort. The GSS and probability of systemic immunosuppressive treatment at 2 year after diagnosis of cGVHD was estimated as 55.9% and 51.9%. The GSS was significantly associated with the performance status (p=0.004) and lymphocytopenia (≤ 1,000/μl, p=0.022) at diagnosis of cGVHD by Cox’s proportional hazard model.

Conclusion: Severe aGVHD, PTF, lymphocytopenia and elevated ALP may be useful predictive factors for the development of pq cGVHD in a cohort of patients who experienced a GVHD after allogeneic SCT.

Figure. The significance of the predictive model for the development of overall (A) or extensive chronic graft-versus-host disease (GVHD; B) after occurence of acute GVHD Figure. The significance of the predictive model for the development of overall (A) or extensive chronic graft-versus-host disease (GVHD; B) after occurence of acute GVHD
Allogeneic-SCT in Patients with Hematological Malignancies Aged 60 Years or Older: Importance of HLA-Matching.
Authors: Schleuning Michael , Judith Dirk , Kaltenhaeuser Joerg , Baurmann Herrad , Schwerdtfeger Rainer
Published: April 2020

Despite the introduction of toxicity-reduced conditioning there is still much debate if patients aged 60 years or more should be considered as candidates for allogeneic stem cell transplantation (allo-SCT) and the experience with this patient group remains limited. This report summarizes our cumulative experience in a cohort of 31 consecutive elderly patients (age 60–69, median 61 years) with hematological malignancies treated with, depending on the underlying disease, a variety of toxicity-reduced conditioning regimens followed by allo-SCT. All but four patients received mobilized peripheral blood stem cells as graft and 12 patients had a sibling and 19 an unrelated donor (MUD), respectively. In the majority of patients the underlying disease was acute leukemia or progressive MDS (n=2) with only 25% being in complete remission at the time of transplant. The remaining 8 patients suffered from either chronic leukemia (CML, n=3; CLL, n=1), osteomyelofibrosis (n=3) and multiple myeloma (n=1). For this patient cohort the conditioning regimens applied were all myeloablative as evidenced by full donor chimerism at day +30 in all patients. The time to recovery of absolute neutrophil count >/=0.5 x 10(9)/l was 10-34 days (median 19 days). Despite the high relapse risk in the majority of patients we observed only 4 deaths because of recurrent leukemia. Severe acute GVHD (grade 3 and 4) occurred in 26% and the non relapse mortality was 39% with 5 patients dying from GVHD, 6 from infection and one from toxicity. With a median follow-up of 16 months (range 2 – 66m) for surviving patients the Kaplan-Meyer procedure estimates a 39% probability of survival at 4 y after transplantation. Interestingly, there is no difference what so ever in survival if patients had an identical sibling donor or a MUD. Patients with acute leukaemia had a trend to inferior survival as compared to the others; however, the remission status of these patients had no impact on survival. The most important risk factor for inferior survival was an incomplete HLA-match (8/8). None of the patients who received a mismatched graft survived more than 13 months, whereas in fully HLA-matched transplantations 56% of patients are currently alive and the Kaplan-Meier estimate for survival is 49% at 4 years. Our data support the notion that toxicity-reduced conditioning followed by allo-SCT may be still myeloablative in the elderly, nevertheless it can safely be applied and has excellent anti-leukemic efficacy. However, further efforts are needed for control of GVHD and infectious complications, especially in this high-risk population. A first step in that direction would be, to only accept fully HLA-matched donors.
Analysis of TREC (T Cell Receptor Excision Circles) Levels in CD94 Expressing CD8 T Cells in Chronic GVHD.
Authors: Iwao Noriaki , Tanaka Junji , Kato Naoko , Kondo Takeshi , Miura Yoko , Toubai Tomomi , Shigematsu Akio , Kondo Keiichi , Ohta Shuichi , Asaka Masahiro , Imamura Masahiro
Published: April 2020

CD94 is one of the C-type lectin family members, forms a heterodimer with NKG2 gene family, and CD94 /NKG2A are inhibitory receptors. Not only NK cells but a subset of T cells express CD94/NKG2A, and previously we revealed the proportion of CD94/NKG2A expressing CD8 T cells were higher in patients with chronic graft versus host disease (GVHD), and CD94 expressing T cells have suppressive effects on mixed lymphocyte culture(MLC). We focus on CD94 positive T cell during T cell reconstitution after allogeneic hematopietic stem cell transplantation (allo-HSCT). T cell receptor excision circles (TREC) are suggested to be a useful marker of recent thymic output. In this study, we attempt to study TREC-containing CD8 T cell subset expressing CD94, and to examine the relation of TREC DNA level in CD94 expressing CD8 T cell and GVHD. We analyzed peripheral blood mononuclear cells (PBMCs) isolated from 24 patients (82 samples) undergone allo-HSCT including 15 patients with bone marrow transplantation and 9 patients with non-myeloablative stem cell transplantation. Informed consent was obtained from all patients. CD4 positive T cells were separated from PBMCs by magnetic cell sorting, and CD4 negative cell population was divided into CD94 positive CD8 T cells and CD94 negative CD8 T cells by fluorescence activated cell sorter. Genomic DNA was extracted from these separated T cell subsets. TREC DNA copy numbers per 105 isolated T cells (TREC level) were quantified by real time PCR. We investigated TREC levels in clinical status with pre-allo-HSCT, no episodes of GVHD or before manifestation of GVHD (No GVHD), chronic GVHD on disease (C-GVHD), and no symptoms and remission status of GVHD after immunosuppressive therapy (R-GVHD). Statical analyses were carried out by Mann-Whitney U test. There were no significant differences in TREC level of sorted CD4 positive T cells in C-GVHD compared with No GVHD (p=0.75) and R-GVHD (p=0.61), and also CD94 negative CD8 T cells in C-GVHD compared with No GVHD (p=0.79) and R-GVHD (p=0.20). On the other hand, TREC level of CD94 positive CD8 T cells in C-GVHD decreased in comparison with No GVHD (p=0.015) and R-GVHD (p=0.0019). The reduction of TREC level is thought to be induced not only by low thymic output but also by dilution of TREC concentration due to peripheral T cell expansion without duplications of TREC. These results may suggest that CD94 positive T cells play a role in modulation of GVHD, and proliferate during chronic GVHD with dilution of TREC in CD94 positive CD8 T cells. It is suggested that TREC level of CD94 expressing CD8 T cells may be useful markers of chronic GVHD.
Cytomegalovirus Viraemia after Allogeneic Transplant: A Prospective Study of a Risk-Adapted Strategy in a Single Transplant Unit.
Authors: Johnston Amanda J. , Dodds Anthony J. , Ma David D. , Milliken Samuel T. , Fay Keith C. , Cunningham Philip H. , Moore John J.
Published: April 2020

CMV infection causes significant morbidity and mortality following allogeneic transplantation. In 2003, the NSW Bone Marrow Transplant network adopted a uniform CMV prevention policy. This prospective study aimed to evaluate the impact of the policy on the rate, management and outcome of CMV reactivation in allogeneic transplant recipients at St Vincent’s Hospital, Sydney. All patients at high risk for CMV reactivation (recipient and/or donor CMV seropositive pre-transplant) had weekly blood samples screened using nucleic acid tests for CMV RNA and DNA. Patients with a related donor were screened from day +21 to +84 post-transplant and received antiviral treatment for CMV only if reactivation was detected. Patients with an unrelated donor received ganciclovir 5mg/kg 3x/week from day +21 to +84, in addition to screening tests. Between October 2003 and June 2005, 40 patients (median age 44 years, range 20-67) received allogeneic transplants, with 21 (53%) originating from an unrelated donor. Thirty-six (90%) patients were high risk for CMV disease and 13 (33%) developed CMV viraemia at a median of 39 days (range 16–101) post-transplant. Six of the 13 (46%) PCR positive patients had unrelated donors, and three had severe, steroid resistant GVHD requiring monoclonal antibody therapy. The median CMV viral load was 3200 copies/mL (range 870 to >100,000) and three of the 13 patients had CMV disease (all biopsy-proven CMV enteritis). All viraemic patients were treated with ganciclovir 5mg/kg BD for a median of 2 weeks, with clinical improvement and reduction in viral load in 10 patients. Overall survival of the CMV viraemia group was 85% at a median of 303 days follow up, compared with 78% for the whole group (p = NS). The described risk-adapted CMV preventive strategy is associated with acceptable rates of viral reactivation and low morbidity and mortality post-allogeneic transplant.
Eosinophilia, Positive ANA, and Hypergammaglobulinemia at Presentation of Extensive Chronic GVHD in Children: A Children’s Oncology Group Study.
Authors: Jacobsohn David A. , Schultz Kirk R. , Goldman Frederick , Wall Donna A. , Krailo Mark , Chen Zhengjia , Lipton Jeffrey M. , Sanders Jean E. , Gilman Andrew L.
Published: April 2020

Because of the variable and often protean manifestations of chronic GVHD, its diagnosis is difficult and based solely on clinical features. As part of a Children’s Oncology Group multi-institutional clinical trial (ASCT0031 - a randomized study of hydroxychloroquine plus standard therapy for children with newly-diagnosed extensive chronic GVHD), we prospectively evaluated laboratory markers that have been previously reported in single-institution studies to be associated with chronic GVHD. Fifty-four patients were enrolled: median age 12 (1–21) yrs: 37M/17F. The diagnosis of extensive chronic GVHD was made at a median of 210 days (range 82–914) following transplant. Eighteen of 45(40%) patients had eosinophilia (absolute eosinophil count (AEC)≥500/μL). Twelve of 43 (28%) patients had an anti-nuclear antibody (ANA) titer ≥1:80 and 9 of these (21%) had a titer ≥1:160. Finally, 11 of 48 (23%) patients had an elevated IgG level. At presentation, 67% of patients had one or more of eosinophilia, ANA≥1:80, and hyper-IgG. A Th-2 predominance is suggested by eosinophilia (↑ IL-5) and hyper-IgG and positive ANA (↑ IL-4). Of note, of 9 patients with sclerodermatous chronic GVHD, 6 had hyper-IgG and 5 had eosinophilia. These results support a Th2 predominance in a major subset of children presenting with chronic GVHD. These results emphasize the importance of including evaluation of eosinophil count, ANA, and IgG level as tests supportive of the diagnosis of chronic GVHD in children.
Immunological, Molecular and Cytokine Changes after Reduced Intensity Bone Marrow Transplantation for PNH: A 2 Years Follow-Up.
Authors: Barcellini Wilma , Imperiali Francesca G. , Zaninoni Anna , Fermo Elisa , Boschetti Carla , Soligo Davide , Deliliers Giorgio Lambertenghi , Zanella Alberto
Published: April 2020

We describe the clinical, immunological and molecular characteristics of a 39 yrs-old male with 8 yrs story of paroxysmal nocturnal hemoglobinuria (PNH) who underwent a reduced intensity conditioning bone marrow transplantation (RIC-BMT) from identical sibling donor. The patient was pancytopenic, transfusion-dependent and had suffered from Budd-Chiari syndrome. We already reported that that RIC-BMT restored clonogenic erythroid activity and cytokine production (IL-2, IFN-gamma and TNF-alpha) in BM. Likewise, IL-2, TNF-alpha and TGF-beta formerly increased in both BM and peripheral blood (PB), became normal after BMT. Finally, the PNH clone was no more detectable in both BM and PB cells by molecular analysis 1 year after RIC-BMT. At 2 years after the transplant the patient is well, with Hb levels of 15.2 g/dL, but with low WBC (2.7x109/L) and platelets (71x109/L). The number of CFU-GM and BFU-E in BM further increased and none of the CFU-GM and BFU-E showed the original PIG-A gene mutation. Likewise, none of the PB granulocytes showed the original PIG-A gene mutation also 2 years after BMT. These immunological, molecular and cytokine changes observed 2 years after RIC-BMT support the curative action of a donor immune-mediated “graft versus PNH” effect.

Patient before BMT 1mo after BMT 6mo after BMT 12mo after BMT 24mo after BMT Controls (mean±SE) CFU-GM 7 10 7 10 13 21±9 BFU-E 12 23 46 108 115 62±18
Graft Versus Leukemia (GVL) Effect in the Central Nervous System Sanctuary: Successful Treatment with Donor Lymphocyte Infusion (DLI) in a Patient with Resistant Ph1+ Acute Lymphoblastic Leukemia.
Authors: Ostronoff Mauricio , Domingues Mariana Coutinho , Ostronoff Fabiana , Calixto Rodolfo , Souto Ana Patricia , Sucupira Alexandre , Florêncio Rodrigo , Matias Kleber , Tagliari Clemente
Published: April 2020

Ph1+ ALL requires allo- BMT in first CR, however disease relapse continues to be a concern. We report a patient with refractory ALL Ph+1 treated with conventional allo-BMT who had an isolated CNS relapse 2 years later successfully rescued with chemotherapy followed by DLI. In September 2002 a 35-year-old male patient presented with deep venous thrombosis of the right popliteal vein. The WBC was 84X109 / l (52% blasts). Bone marrow: ALL Ph1+, bcr/abl, pre-B CALLA+. CSF: normal. Induction chemotherapy according to LAL-adult French protocol included idarubicin, vincristine, cytoxan, corticosteroids and MADIT weekly. CR obtained D+28. CHOP + MADIT were then administered. In the next 2 weeks he had a marrow relapse (39% blasts) just before start allo-BMT conditioning and we decided together to go on: FTBI (12 Gy-6 fractions) + CTX 120mg/kg, GVHD prophylaxis with CSA alone and infusion of 3,5 X 106 CD34/kg of peripheral stem cell from his HLA identical brother. Chronic extensive GVHD was observed 6 months later treated with a short course of corticosteroids. 2 years after BMT pt presented severe radicular pain and weakness in his right leg. Bone marrow showed persistent cytologic, cytogenetic and molecular CR. VNTR 100% donor. CSF was infiltrated with blasts (bcr / abl +) and MRI showed a paravertebral tumor at L4 level. 4 cycles of salvage chemotherapy with high dose methotrexate (3g/m2) and ara-C (2g/m2 x 2 x 3 days) + MADIT obtained clinical and CSF CR. DLI from the same donor was performed twice at 1 month interval without GVHD. One year has elapsed since then and he is in continuous CR. We conclude that DLI might induce a GVL effect on CNS acute leukemia and therefore DLI should be helpful in achieving higher donor immunoreactivity and a better GVL effect.

Lymphocyte counts in first and second DLI DLI I total 1,3x108 CD8 0,4x108 CD3 0,97x108 DLI II total 0,6x108 CD8 0,21x108 CD3 0,47x108
Clinical Relevance of CRp in Untreated AML.
Authors: Estey Elihu H. , Garcia-Manero Guillermo , Giles Francis J. , Cortes Jorge , O’Brien Susan , Kantarjian Hagop M.
Published: April 2020

For many years response to induction therapy for AML was classified as CR or no CR. Recently, responses less than CR, e.g. CR with incomplete platelet recovery (CRp), have also been recognized. Attaining CRp suggests that a treatment is more “active” than if neither CR nor CRp had occurred (“resistant”). However, the question of whether CRp conveys clinical benefit has received relatively little attention; in particular, what is the effect of CRp on subsequent survival probability (“SSP”) relative to CR or resistant? The database we used to address this question consisted of 1051 consecutive pts with untreated AML (APL excepted) or high-risk MDS (> 10% blasts) considered for induction therapy at MDA from 2000 through 2004. 5% of the pts declined therapy, 45% achieved CR and 5% CRp, as usually defined, while 29% were resistant, i.e. they survived at least 1 month after beginning therapy, without ever achieving CR or CRp, or showed obvious reappearance of blasts before the end of this month; the remaining pts were called “early deaths” and were not further considered. CRp rates were higher among pts with abnormalities of chromosomes 5 and/or 7 (−5/−7; 15% CRp in 264 pts) than among other cytogenetic subsets (CRp rate 4–6%), with the following number of CRps for every 100 CRs: −5/−7 53.6, inv (16) or t(8;21) 5.5, normal karyotype 7.5, other cytogenetic abnormalities 15.4.The median number of days to CR was 31, CRp 44, and resistant 40, while the 75th percentiles were 38, 60, and 59 respectively. Although many induction regimens were used, we, for simplicity, classified these as either “higher” or “lower” intensity, with the former (HI, 914 pts) corresponding to “chemotherapy” and the latter (LI) to “targeted therapy”, as commonly accepted. CR and CRp rates were 51% and 5% for HI and 5% and < 1% for LI. In general, pts continued to receive their initial induction regimen regardless of whether their reponse was considered CR or CRp. Because 75% of pts who eventually achieved CRp did so within 60 days of starting induction therapy, as did 90% of the CR pts, we categorized pts alive on day 60 according to whether they ultimately achieved CR, CRp, or neither (resistant). We then dated SSP from day 60:

Figure Figure

Sensitivity analyses dating SSP from day 30 or day 90, rather than day 60, produced similar results. We are: (1) doing a multivariate analysis examining the relative effects on SSP of response, cytogenetics (given the association of poor prognosis cytogenetics with CRp), and treatment after relapse, and (2) assessing whether the effects of CR vs CRp vary according to induction treatment. Our current results, however, constitute the first demonstration that CRp is of clinical relevance in untreated AML.