NIH-defined graft-versus-host disease and evidence for a potent graft-versus-leukemia effect in patients with acute lymphoblastic leukemia

BackgroundThe prognostic value of the NIH consensus criteria for graft-versus-host disease (GVHD) is not well defined yet.Patients and methodsWe analyzed NIH-defined GVHD in 147 acute lymphoblastic leukemia (ALL) patients.ResultsThe cumulative incidence of classic acute GVHD (aGVHD), late aGVHD and chronic GVHD (cGVHD) was 63%, 12% and 41%, respectively. cGVHD was subclassified as classic versus overlap syndrome in 40% versus 60% of cases. In multivariate Cox regression analysis with GVHD as time-dependent covariate, classic aGVHD grade III/IV had a negative impact on overall survival (OS) due to higher non-relapse mortality. cGVHD of any grade was associated with superior OS, which was due to lower relapse incidence. Classic cGVHD versus overlap syndrome had no differential impact. In 44 patients without GVHD after transplant who received donor lymphocyte infusions (DLI), the cumulative incidence of classic aGVHD, late aGVHD or cGVHD was 60%, 5% and 57%. Occurrence of cGVHD after DLI was associated with improved OS due to lower relapse incidence.ConclusionsThe NIH consensus criteria for GVHD clearly define prognostic subgroups in patients transplanted for ALL. The improved OS in patients developing cGVHD after transplant or DLI gives clear evidence for a potent graft-versus-leukemia effect in this indication.     

Autografting followed by nonmyeloablative immunosuppressive chemotherapy and allogeneic peripheral-blood hematopoietic stem-cell transplantation as treatment of resistant Hodgkin's disease and non-Hodgkin's lymphoma.

PURPOSE: To investigate the use of a nonmyeloablative fludarabine-based immunosuppressive regimen to allow engraftment of HLA-sibling donors' mobilized stem cells and induction of a graft-versus-lymphoma effect for patients with advanced resistant Hodgkin's disease and non-Hodgkin's lymphoma. PATIENTS AND METHODS: Fifteen patients with Hodgkin's disease (n = 10) and non-Hodgkin's lymphoma (n = 5) were studied. All patients received cyclophosphamide and granulocyte colony-stimulating factor to mobilize autologous hematopoietic stem cells (HSCs). Subsequently, they received high-dose therapy with carmustine, etoposide, cytarabine, and melphalan and reinfusion of HSCs. At a median of 61 days after engraftment, patients were given fludarabine 30 mg/m(2) with cyclophosphamide 300 mg/m(2) daily for 3 days. Donor-mobilized HSC collections were prepared for fresh infusion and were not T-cell depleted. Methotrexate and cyclosporine were used to prevent graft rejection and as graft-versus-host disease (GVHD) prophylaxis. RESULTS: Combined treatment was well tolerated. After mini-allografting, hematologic recovery was prompt. Thirteen patients had 100% donor cell engraftment. Eleven patients achieved complete remission (CR) after the combined procedure. Nine patients, who were in partial remission after autografting, achieved CR after mini-allografting. Seven patients developed >/= grade 2 acute GVHD (aGVHD) and two developed extensive chronic GVHD (cGVHD). Three patients who received the highest number of donor lymphocyte infusions (DLIs) developed grade 3 GVHD (two patients) and extensive cGVHD (one patient). Ten patients are currently alive, and five are in continuous CR. Seven patients received DLI, with five CRs. Five patients died: one of progressive disease, two of progressive disease combined with aGVHD or cGVHD, one of extensive cGVHD, and one of infection. CONCLUSION: Fludarabine/cyclophosphamide was well tolerated and allowed consistent engraftment in lymphoma allografted patients. Response rates were high in this group of refractory and heavily pretreated patients. This dual procedure seems to be most promising in patients with end-stage malignant lymphomas.     

Cyclooxygenase-2 (Cox-2) expression in lymphomas

Lymphoma is a malign disease of the lymphoid system. A variety of risk factors have been described in pathogenesis of disease. We investigated the role of Cyclooxygenase-2 (Cox-2) in malign lymphomas. A total of 52 patients who were admitted to the Oncology Unit of Mersin University with histologically diagnosed lymphoma were enrolled to this study. Ten of the patients had Hodgkin's disease (HD), and 42 had non-Hodgkin's lymphoma (NHL). An immunuhistochemical method was used for Cox-2 expression. Cox-2 expression was detected in 24 of the 42 patients (57%) with NHL, and it was found in seven of the 10 patients (70%) with HD. The mean patient age expressing Cox-2 was 50.2 ± 16.6 years and 48.0 ± 15.5 years for patients without Cox-2 expression. This difference was not statistically significant (P = 0.660). The overall survival of Cox-2-positive patients was less than for those without Cox-2 expression but the difference was not significant statistically (16.4 ± 11.4 vs. 14.7 ± 8.2 months, respectively, P = 0.552) in NHL. There was a correlation between Cox-2 and stage of disease. As the stage increased the Cox-2 expression increased (P = 0.037) in NHL. The complete response rate to therapy was significantly higher in Cox-2-negative patients than the Cox-2-positive group (70.6% vs. 20.8%, respectively, P = 0.001) in NHL. There was no correlation between Cox-2 expression and IPI score, extranodal involvement, tumor grade, and B symptoms. Our findings demonstrate that there is a clinical correlation between the Cox-2 expression and prognostic factors in lymphoma patients. The combination of Cox-2 inhibitors with standard chemotherapeutics may enhance the potential of treatment options for malign lymphomas.     

Internal tandem duplications of Flt3 gene (Flt3/ITD) predicts a poor post-remission outcome in adult patients with acute non-promyelocytic leukemia

Despite progress in AML therapy, most patients eventually relapse, even the ones with normal or favorable karyotype. Since survival is poor once relapse occurs, new genetic tools above karyotype at diagnosis are needed to predict leukemia free survival. Recently, Flt3/ITD has been reported as an independent marker for clinical outcome in most studies concerning adult AML patients. To assess the prognostic relevance of activating mutations of Flt3, pretreatment samples of 100 not-M3 AML patients, all of them subjected to an intensive chemotherapy regimen, were analyzed for Flt3/ITD; 25/100 patients had one or more Flt3-ITD. Flt3/ITD patients had higher WBC count (P = 0.005) , a lower incidence of a preceding MDS (P = 0.004) and most of them had a normal karyotype. Flt3/ITD had no impact on CR achievement while karyotype remained the most powerful prognostic factor (HR 2.8 95% CI 1.2 - 6.3). However, post-remission outcome was significantly worsened by the presence of Flt3/ITD. Median RFS of the Flt3/ITD patients was 5 vs. 27 months compared to the patients with wild-type Flt3 (P = 0.0002); moreover, Flt3/ITD patients had a significantly poorer post-remission survival (11 vs. 38 months, P = 0.01). On multivariate analysis, the presence of Flt3-ITD significantly affected relapse free survival and post-remission survival (HR 3.1 and 2.1, respectively). Thus, post-remission outcome highly depends on Flt3 status. Flt3 mutations identify patients at high risk of relapse, who should prospectively receive, according to age, either more aggressive or alternative therapeutic approaches.     

The Use of Post-transplantation Cyclophosphamide in Peripheral Blood HLA-matched Stem Cell Transplantation as Graft-versus-host Disease Prophylaxis in Patients With Malignant or Non-malignant Hematologic Disorders: A Single-center Experience of 52 Patients

IntroductionStudies addressing the utilization of post-transplant cyclophosphamide (CY) as graft-versus-host disease (GVHD) prophylaxis in allogeneic hemopoietic stem cell transplantation from matched sibling donors are limited and with controversial results. Chronic GVHD incidence necessitating systemic treatment is around 35% in peripheral blood stem cell transplantation (PBSCT) from human leukocyte antigen-matched sibling donors.Patients and MethodsIn this study, high-dose CY was added to PBSCT aiming to reduce the incidence of GVHD to reach a lower figure compared with standard GVHD prophylaxis. Fifty-two patients with either benign or malignant hematologic disorders who underwent stem cell transplantation at Nasser Institute Hospital in Egypt from November 2017 to October 2018 were enrolled in this study. Fifty patients had fully human leukocyte antigen-matched siblings, whereas the remaining 2 patients had 1 locus class I mismatched donors. Pre-transplant conditioning regimen was fludarabine and busulfan (FLU/BU) in malignant cases (73.1%) and FLU/CY in benign hematologic disorders (26.9%) and 1 patient with hypocellular myelodysplastic syndrome. For GVHD prophylaxis, CY was given at a dose of 50 mg/kg/day on days 3 and 4 post-transplantation, and cyclosporine (CSA) starting day 5 in 96.1% of patients. For the 1-locus mismatched patients, both CSA and mycophenolate mofetil were administered starting day 5.ResultsThe 1-year incidence of acute GVHD (aGVHD) was 15.3% and for chronic GVHD (cGVHD) was 13.4%. Historical data of GVHD prophylaxis at our center using CSA and methotrexate showed an incidence of 37% for aGVHD and 33.9% for cGVHD.ConclusionsPost-transplant CY GVHD prophylaxis led to significantly less aGVHD (P = .03) and cGVHD (P = .04).     

Fluorescence in situ hybridization detection of cytogenetic abnormalities in B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma

Routine cytogenetic analysis of B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma (B-CLL/SLL) frequently fails to identify an abnormal clone due to the low rate of spontaneous mitoses and poor response to mitogen stimulation. Recent studies utilizing interphase fluorescence in situ hybridization (FISH) suggest that prognostically significant chromosomal abnormalities occur more frequently in B-CLL/SLL than has been previously recognized. The purpose of this study was to compare the chromosomal abnormalities detected by karyotyping and FISH in cases of B-CLL/SLL, and to correlate these with clinical features and survival. Seventy-two cases were studied for chromosome 3, 12 or 18 aneuploidy, and for rearrangements involving 11q13, 11q23, 13q14, 14q32 and 17p13. The median age of the patients was 54 years (range, 30 - 87 years). Clinical staging of B-CLL patients showed that 70% of the patients were Rai stage 0, 1, or 2, and 30% stage 3 or 4. Karyotyping identified chromosomal abnormalities in 31% of the cases, whereas FISH studies were abnormal in 72% of cases including 64% of the cases with normal karyotypes. The most common abnormalities were deletion 13q14 (46%), trisomy 12 (21%), and 14q32 rearrangements (21%). At diagnosis, patients with trisomy 12 were more likely to have a high LDH (P = 0.04), but no other significant differences in the clinical or laboratory features, Rai stage, or survival were found among patients with normal cytogenetics vs. those with chromosomal abnormalities. Univariate analysis showed that B-symptoms (P = 0.044), anemia (P = 0.0006), absolute lymphocytosis ≥ 30,000/mm³ (P = 0.029), and Rai stage 3 or 4 (P = 0.0038) at initial presentation were associated with an increased risk of death, but only Rai stage 3 or 4 (P = 0.0038) was significant in multivariate analysis. Interphase FISH studies improve the cytogenetic diagnosis when performed in conjunction with karyotyping in B-CLL/SLL, but the prognostic relevance of various abnormalities could not be confirmed in this study.     

Clinical significance of peripheral blood erythroblastosis after hematopoietic stem cell transplantation

Erythroblasts (EBL) are normally not observed in peripheral blood, but may be found in patients suffering from a variety of severe diseases. The detection of EBL in peripheral blood has been shown to be associated with a poor prognosis. However, the clinical significance of peripheral erythroblastosis after hematopoietic stem cell transplantation (HSCT) has not been evaluated. We retrospectively analyzed the records of 161 patients who underwent HSCT at our hospital from June 1995 to October 2001. EBL at any level were detected in 94% of the patients. Forty-four and 11 patients experienced erythroblastosis exceeding 200 and 1,000/ul, respectively. The erythroblast count was higher in patients who died than in the survivors (geometric mean value 184 vs. 100/ul, P = 0.01). High-level erythroblastosis ( > 1,000/ul) within 180 days after HSCT was associated with an extremely poor prognosis (median survival 22.5 days). Among the possible confounding factors, the use of total body irradiation (RR 2.35, 95% CI 1.22 - 4.54, P = 0.011) and the disease status before transplantation (RR 2.51, 95% CI 1.15 - 5.49, P = 0.021) were independent significant factors for erythroblastosis after HSCT. As for post-transplant events, a high EBL concentration was frequently preceded by graft-vs.-host disease, thrombotic microangiopathy, hypoxia, and hematological relapse.     

Clinical grading in chronic graft-versus-host disease: is it time for change?

Many hematologic disorders, leukemias and lymphomas in particular, can be cured with allogeneic hematopoietic stem cell transplantation (allo-SCT). However, chronic graft-versus-host disease (cGVHD) appears to remain as a major determinant of long term outcome and quality of life following allo-SCT. The gradual increase in the incidence of cGVHD over the past decade has recently gained another momentum along with the use of blood as a source of stem cells. Donor lymphocyte infusion (DLI) is also associated with a progressive form of cGVHD, mostly refractory to treatment. Prediction of the outcome of patients with newly diagnosed chronic GVHD may be important in identifying those who are likely to benefit from reduced treatment and patients who are unlikely to have a sustained response to standard treatment. In addition, a reliable predictive model could allow us to design better clinical trials and facilitate the communication among the centers. Although it is highly reproducible, the current system of grading in cGVHD is of limited utility since it does not stratify patients for outcome. It divides patients into those needing treatment (extensive cGVHD) and those who do not (limited cGVHD). Therefore, a new clinical grading system is needed to classify all patients based on their prognosis so like patients with similar features can be grouped for study and clinical management purposes. Using multivariate analysis, we recently identified three independent risk factors affecting the survival without recurrent malignancy. These factors are extensive skin involvement (>50% BSA), thrombocytopenia, and progressive-type onset of cGVHD. We are in the process of validating this prognostic model in three other cohorts from different institutions. We expect that the new grading system, based on this model, may allow us to identify the diversity of outcome within "extensive stage" cGVHD.     

协同刺激因子在移植物抗宿主病发生中作用的初步研究

 目的　探讨协同刺激因子（CM）在异基因造血干细胞移植（allo-HSCT）相关移植物抗宿主病（GVHD）中的作用。方法　根据预处理方案不同,将21例行allo-HSCT的血液病和实体瘤患者分为A组（NST组）和B组（清髓性HSCT组）;所有患者在移植前后不同时间,应用流式细胞术（FCM）检测外周血CD+4 T细胞表面CM（CD28、CD80、CD152）的表达;用短串联重复序列聚合酶链反应（STR-PCR）方法检测微卫星嵌合体形成。结果　21例患者移植后均获得造血功能重建,经STR-PCR检测均转为混合嵌合体（MC）或完全嵌合体（CC）;不同预处理方案GVHD发生率差异无统计学意义（χ2＝3.711,P＝0.144）;COX回归分析结果显示：CD+4 CD+152能明显影响GVHD发生（χ2＝13.128,P＜0.0001）;术后,外周血T细胞表面CD+4 CD+28、CD+4 CD+80表达逐渐增高,GVHD时达高峰,经过治疗和控制GVHD后,逐渐下降;而T细胞表面CD+4 CD+152表达则逐渐降低,GVHD时最低,经治疗和控制GVHD后,又逐渐上升。结论　清髓性HSCT和NST的GVHD发生率无差别;T细胞表面CM的表达与GVHD发生有关,并且在清髓性HSCT和NST的表达不同;B7-CD28／CD152共刺激途径在GVHD发生中起重要作用。     

非血缘造血干细胞移植中抗胸腺细胞球蛋白预防移植物抗宿主病的疗效分析

 【摘要】　  目的　探讨非血缘造血干细胞移植中应用抗胸腺细胞球蛋白（ATG）预防移植物抗宿主病（GVHD）的临床疗效。方法　回顾性分析1999年1月至2011年12月行非血缘造血干细胞移植患者治疗的恶性血液病（包括白血病、骨髓增生异常综合征、淋巴瘤）92例患者资料。分为ATG预防组（66例）和无ATG组（26例）。ATG剂量为1.5 mg／kg,移植前第4天至移植前第1天。比较两组急性GVHD（aGVHD）和慢性GVHD（cGVHD）发生率,分析aGVHD与cGVHD发生的危险因素,并比较ATG预防对移植后总生存（OS）、治疗相关死亡（TRM）率、复发率的影响。结果　Ⅱ～Ⅳ度aGVHD和Ⅲ～Ⅳ度aGVHD发生率差异无统计学意义[26.7 %（16／60）比44.0 %（11／25）,P＝0.12;13.3 %（8／60）比 8.0 %（2／25）,P＝0.74]。ATG组cGVHD及广泛型cGVHD发生率明显低于无ATG组[ 34.0 %（17／50）比 72.2 %（13／18）,P＝0.005;10.0 %（5／50）比44.4 %（8／18）,P＝0.005]。多因素分析显示ATG预防能降低cGVHD发生[相对危险度（RR）＝0.22,95 % CI 0.081～0.599;P＝0.003],人类白细胞抗原（HLA）不完全相合增加cGVDH发生率（RR＝3.25,95 % CI 1.39～7.61;P＝0.007）。并且ATG预防显著降低广泛型cGVHD发生（RR＝0.05,95 % CI 0.009～0.240;P＜0.001）。92例患者中位随访时间12个月（1～84个月）。ATG预防组和无ATG组间OS率（60.4 % 比43.1 %,P＝0.41）、TRM率（19.8 %比34.3 %,P＝0.43）、复发率（40.6 % 比33.6 %,P＝0.54）差异均无统计学意义。结论　总量6 mg／kg的ATG预防可显著降低非血缘造血干细胞移植患者cGVHD及广泛型cGVHD的发生率,不增加疾病复发,对OS及TRM亦无影响。     

Oligoclonal T cell expansion in myelodysplastic syndrome: evidence for an autoimmune process

There is accumulating evidence that the marrow-failure of myelodysplastic syndrome (MDS) is immune-mediated. We studied patients with MDS to look for oligoclonal or clonal expansion in T cells indicative of an autoimmune process. We used a PCR-based technique (spectratyping) to characterize the T cell repertoire in MDS (n=15; 9 RA, 4 RARS, 2 RAEB) and compared results with age-matched healthy donors (n=20) and transfusion-dependent (TD) patients with hemoglobinopathy (n=5). We found a significantly higher number of skewed Vβ profiles in the MDS patients compared with controls. In peripheral blood T cells, 60/345 Vβ profiles examined were skewed in MDS patients compared with 3/115 Vβ profiles in TD controls (P<0.0001), and 58/460 Vβ profiles in age-matched controls (P=0.05). A study of Jβ region within the skewed Vβ profiles revealed preferential usage of Jβ 2.1 in MDS in contrast with a wide distribution over the entire Jβ spectrum in controls, consistent with non-random T cell clonal expansion in MDS. These findings provide further evidence that T cell mediated immune processes are a feature of MDS.     

TCR spectratyping revealed T lymphocytes associated with graft-versus-host disease after allogeneic hematopoietic stem cell transplantation

Clonal expansion of T cells after allogeneic hematopoietic stem cell transplantation (allo-HSCT) has been observed, but their characteristics remain to be fully elucidated. We report here that CD8(+) T cells were the dominant T lymphocytes seen and T-cell repertoire diversity decreased dramatically during the first 3 months after allo-HSCT. Patients with GVHD grade II - IV had significantly lower T-cell repertoire diversity compared with non-GVHD patients. TCR beta variable gene (TCRBV) subfamily 8, 5.1, 5.2, 4, and 13 were the five most frequently expanded subfamilies among these patients. Among the 49 over-expanded clones identified, clonotype "TCR3-5" and "TCR18-5" were isolated from four patients with HLA-A2 allele and skin GVHD. Their frequencies correlated well with skin symptoms (i.e. rash). Moreover, they were detected in donors but not detected in recipients before transplantation. Lastly, three common TCRBV CDR3 motifs shared by T cells related with GVHD were discovered: TGDS, GLAG, and GGG. These findings suggest that TCR spectratyping is helpful for revealing GVHD-related T cells and may have utility in early diagnosis.     

骨髓间充质干细胞治疗慢性移植物抗宿主病后患者外周血T细胞受体Vβ亚家族谱系变化研究

 目的　研究输注骨髓间充质干细胞（MSC）治疗慢性移植物抗宿主病（cGVHD）后患者外周血T细胞受体（TCR）Vβ基因谱系变化及克隆性增殖情况。方法　1例经异基因造血干细胞移植（allo-HSCT）后发生cGVHD的患者接受MSC治疗,分别于第1次输注MSC后第1、5天及第2次输注MSC后第1、10、20天采集外周血,同时将输注的MSC作为对照,利用反转录-聚合酶链反应（RT-PCR）方法扩增单个核细胞中24个TCR Vβ基因的互补决定区3（CDR3）,PCR 产物经荧光标记和基因扫描分析CDR3长度,从而确定T细胞的克隆性。结果　患者输注的MSC不表达全部TCR Vβ亚家族,第1次输注MSC后第1天也未发现TCR Vβ亚家族的表达,随后的时间点分别出现了3、10、14、10个Vβ亚家族的克隆增殖T细胞,增殖形式以寡克隆、多克隆为主;临床判断cGVHD表现减轻。结论　MSC对allo-HSCT后患者免疫功能的恢复有一定作用,并能减轻cGVHD效应;TCR Vβ亚家族谱系分析提示有部分优势表达。     

HLA半相合造血干细胞移植治疗恶性血液病的临床观察

背景与目的:异基因造血干细胞移植(allogeneichematopoieticstemcelltransplantation,allo-HSCT)是目前治疗恶性血液系统疾病的最有效手段。但仅有25%～30%的患者能找到人类白细胞抗原(humanleukocyteantigen,HLA)相合的亲缘供者;在无关人群中找到相合供者的概率是1/5万～1/10万,甚至更低。若进行HLA半相合造血干细胞移植(hematopoieticstemcelltransplantation,HSCT),则有90%的患者能找到供者,本文旨在探索HLA半相合HSCT治疗恶性血液病的可行性。方法:25例恶性血液病患者进行HLA半相合(其中单倍体20例)的亲缘供者HSCT。采用延长、强化联合免疫抑制促进植入及使用抗胸腺细胞球蛋白(antithymocyteglobulin,ATG)和/或加舒莱(抗CD25单抗)加强预防移植物抗宿主病(graft-versus-hostdisease,GVHD),粒细胞集落刺激因子(granulocytecolonystimulatinfactor,G-CSF)动员的骨髓(bonemarrow,BM)或加外周血干细胞(peripheralbloodstemcell,PBSC)混合移植方案。结果:所有患者均获得造血重建及达完全供者植入。21例(21/25)发生急性GVHD(aGVHD),其中Ⅰ度8例,Ⅱ度6例,Ⅲ度2例,Ⅳ度5例(其中3例为同胞部分相合),Ⅱ～Ⅳ度和Ⅲ～Ⅳ度aGVHD累积发生率分别为48.0%和28.6%。12例(12/25)发生慢性(c)GVHD,均为局限性。16例患者无病生存,1年预计无病生存率(disease-freesurvival,DFS)为(64.00±2.98)%,1年预计总生存率(overallsurvival,OS)为(64.0±3.08)%。9例死亡,其中1例死于复发,8例死于移植相关合并症,其中肺部感染4例,Ⅳ度GVHD3例,白质脑病1例。结论:HLA配型半相合的HSCT是治疗无亲缘和无关供体全相合的高危恶性血液病的有效方法,但风险较大,需在严密监测下慎重使用。     

CD4+ and CD8+ T-Cell Skewness in Classic Kaposi Sarcoma

It is widely accepted that a deranged immune system plays a key role in the onset and evolution of classic Kaposi sarcoma (CKS). Nevertheless, the usage of the T-cell receptor (TCR) β-variable (BV) chain repertoire expressed by peripheral blood lymphocytes in patients with CKS is still unknown. With the aim of providing some further insights into the complex role of the immune system in CKS pathogenesis, we performed an extensive analysis of the TCR BV repertoire in both CD4⁺ and CD8⁺ T cells in 30 human herpesvirus 8-positive Sardinian patients with CKS and an equal number of age-matched healthy controls. We used a panel of monoclonal antibodies covering approximately 70% of human BV subfamilies and third complementarity determining region (CDR3) spectratyping. Patients with CKS showed an increased frequency of BV expansions in both CD4⁺ and CD8⁺ lymphocytes, with no prevalent clones. On spectratyping analysis, most of the 720 BV CDR3 profiles obtained from both CD4⁺ and CD8⁺ T cells in patients with CKS were skewed. In particular, the surprising increase of BV skewing observed in CD4⁺ lymphocytes mimics the pattern of progressive TCR BV narrowing described in responses to persistent viral antigen stimulations. Our findings support the hypothesis that CKS evolution is associated with inadequate activation rather than impairment of the immune system.     

Prognostic factors in patients with post-transplant lymphoproliferative disorders (PTLD) in the rituximab era

To assess the effect of rituximab therapy and other prognostic factors on overall survival in patients with post-transplant lymphoproliferative disorders (PTLD) after solid organ transplantation, 30 consecutive patients diagnosed with PTLD between 1999 and 2002 were analyzed. Fifteen (50%) patients received rituximab (375 mg/m² once a week). Fifteen (50%) patients had other interventions including observation, immunosuppression reduction, surgery, chemotherapy, radiation or a combination of these. Patients receiving rituximab vs. non-rituximab differed in the following variables: age at diagnosis of PTLD (P = 0.009), days to PTLD (P = 0.0005), Epstein-Barr virus (EBV) in situ hybridization status (P = 0.02) and CD20-positive status (P = 0.006). At the time of last follow-up, 10 (33%) patients in the rituximab group and 5 (17%) in the non-rituximab group were alive. On univariate analysis for overall survival of all 30 patients, the significant factors were: treatment with rituximab (P = 0.03), response to treatment (P = 0.005), CD20 positive (P = 0.0004), low international prognostic index (IPI; P = 0.02) and good performance status (P = 0.009). Multivariate analysis of all patients was significant for CD20-positive status (P = 0.0007) and low performance status (P = 0.006). On multivariate analysis for overall survival in patients with CD20-positive PTLD, low IPI (P = 0.004) and rituximab therapy (P = 0.03) were significant. Low IPI and rituximab therapy led to an improved overall survival in patients with CD20-positive PTLD.     

乳腺癌淋巴结微转移患者克隆性T细胞TCRα链CDR3谱型分析

目的 分析乳腺癌微转移淋巴结T细胞克隆性增生及TCR α链谱型偏移情况,了解抗肿瘤T细胞克隆的分子特征。方法 利用RT-PCR扩增10例乳腺癌微转移淋巴结T细胞32个TCR可变区（AV）亚家族的基因,基因扫描检测T细胞克隆性及TCR AV亚家族取用情况,对单克隆家族行PCR扩增TCR α链全长序列,构建重组质粒后测序,分析互补决定区（CDR3）序列。结果 乳腺癌淋巴结微转移患者T细胞呈单、寡克隆、寡克隆趋势和多克隆增生,不同患者表达1～4个TCR AV亚家族。克隆性T细胞的CDR3氨基酸序列不同,但是病例4和病例8含有相同的CDR3氨基酸基序：AM和DDKII。结论 乳腺癌TCR AV基因表达具有多样性特点,TCR AV家族的取用可能与乳腺癌肿瘤抗原的多样性和不同个体的免疫应答反应有关。相同CDR3氨基酸基序的发现可能对乳腺癌的T细胞介导免疫治疗提供帮助。     

Survivin expression in acute leukemias and myelodysplastic syndromes

We analyzed by immunocytochemistry the expression of survivin in bone marrow cells from 36 acute myeloid leukemia (AML) cases, from 98 patients with myelodysplastic syndrome (MDS), and from 41 non hemopathic subjects. Our aim was to evaluate whether abnormalites in survivin expression were associated with peculiar laboratory and clinical findings, altered apoptosis levels or altered proliferative rate. In normal samples survivin was never detectable. It was detected in almost all AML and MDS cases. In AML and in MDS with more than 5% bone marrow blasts survivin levels higher than in RA and RARS were observed (P = 0.04). In MDS a tendential inverse correlation between survivin and TUNEL positivity was identified (P = 0.08), whereas survivin expression was independent of the proliferative rate. Survivin levels did not predict disease progression in MDS; among AML patients treated with intensive polichemotherapy, survivin expression was significantly higher in resistant cases (P = 0.01). Our findings confirm the high incidence of survivin expression in AML. Its abnormal expression also in MDS may play a role in promoting aberrantly increased cell viability and contribute to the altered homeostatic balance between cell growth and cell death.     

B细胞非霍奇金淋巴瘤TCR基因重排及CDR3谱型分析

 目的　分析B细胞淋巴瘤穿刺标本中T细胞受体（TCR）β链克隆性基因重排及互补决定区3（CDR3）谱型。方法　应用RT-PCR扩增TCR Vβ24个亚家族的CDR3区基因,并经基因扫描确定T细胞克隆性,对提示单克隆或寡克隆增生亚家族的PCR产物进行测序。结果　3例淋巴瘤患者TCR存在限制性取用,仅表达2～5个Vβ亚家族。所有患者均存在克隆性增生T细胞,增生形式包括寡克隆及寡克隆增生趋势。CDR3区序列分析证实增生的T细胞克隆具有不同的氨基酸序列。结论　B细胞淋巴瘤患者存在T细胞克隆性增生,其TCR Vβ呈限制性取用,不同克隆T细胞的CDR3序列不同。     

异基因造血干细胞移植治疗恶性血液病20例临床疗效观察

 【摘要】　目的　探讨异基因造血干细胞移植（allo-HSCT）治疗恶性血液病的疗效,观察造血重建、移植物抗宿主病（GVHD）发生、移植相关并发症及疾病的转归。方法　回顾性分析allo-HSCT治疗恶性血液病患者20例,男15例,女5例,中位年龄39岁（8～59岁）。供者于移植前3 d采用重组人粒细胞集落刺激因子（rhG-CSF）行干细胞动员;预处理方案：人类白细胞抗原（HLA）亲缘全相合移植患者采用改良Bu／Cy方案;HLA亲缘不全相合者采用改良Bu／Cy+ATG方案;急性T淋巴细胞白血病（T-ALL）和多发性骨髓瘤（MM）患者采用Flu+Bu／Cy方案。GVHD预防方案：麦考酚酸酯+环孢素+短疗程甲氨蝶呤。结果　20例患者均成功获得造血重建,中性粒细胞计数＞0.5×109／L的中位时间为13 d（12～17 d）,血小板＞20×109／L的中位时间为16 d（12～23 d）,且供者CD+34 细胞采集量＞2.5×106／kg（受者体质量）或单个核细胞采集量＞5.0×108／kg（受者体质量）所移植的患者造血重建较快。12例供受者血型不合,移植后未出现严重溶血反应;11例（55 %）发生急性GVHD（aGVHD）,包括Ⅰ度4例,Ⅱ度4例,Ⅲ度2例,Ⅳ度1例,均经治疗后好转。移植后所有患者均达到完全缓解（CR）,中位随访6个月（2～14个月）,1例白血病患者移植后5个月复发死亡,1例移植后4个月因自行停用环孢素发生自身免疫性溶血、慢性GVHD（cGVHD）、多器官衰竭死亡,其余患者仍处于CR状态。结论　allo-HSCT是治疗恶性血液病的有效方法。造血重建与采集物中造血干细胞的数量密切相关。ABO血型不合不是移植的障碍。复发、GVHD、感染是移植后死亡的重要原因。