异基因外周血干细胞移植和异基因骨髓移植的临床疗效观察

OBJECTIVE: To compare the clinical outcome of allogeneic peripheral blood stem cell transplantation(PBSCT) with that of bone marrow transplantation(BMT). METHODS: Twenty-six patients received allo-BMT and 24 received allo-PBSCT in our hospital between August 1991 and September 1998. Conditioning regimens were CY 120 mg/kg plus STBI 9-10 Gy or BU 16 mg/kg or Mel 140-160 mg/m2 plus CY 120 mg/kg. RESULTS: Twenty-three patients of PBSCT and 24 of BMT group engrafted successfully. The median follow-up duration was 352(19-745) days for the PBSCT group and 546(19-2,329) days for the BMT group. Transplant-related death was 4(16.7%) patients in the PBSCT and 7(26.9%) in BMT group (P = 0.38). Three(12.5%) patients in PBSCT and 5(19.2%) in BMT group relapsed(P = 0.27). The 2-year probabilities of disease-free survival(DFS) for PBSCT and BMT group were (67.9 +/- 11.3)% and (57.7 +/- 9.7)%, respectively(P = 0.24). aGVHD occurred in 6(25%) patients in the PBSCT and 6 (23.1%) in the BMT group (P = 0.624), while cGVHD did in 13(56.5%) and 1 (3.85%), respectively (P = 0.0002). CONCLUSION: The clinical outcome of allo-PBSCT is similar to allo-BMT, except for a higher incidence of cGVHD.     

无血缘关系供者外周血干细胞移植和骨髓移植治疗白血病的比较

目的比较无血缘关系供者外周血干细胞移植和骨髓移植在造血重建、T 细胞重建、感染、移植物抗宿主病(GVHD)及疗效等的差异。方法 53例白血病患者中,21例接受无血缘关系供者外周血干细胞移植(PBSCT 组),32例接受无血缘关系供者骨髓移植(BMT 组)。统计分析二者移植后白细胞和血小板重建时间、T 细胞重建、感染率、GVHD、白血病复发、无病生存(DFS)情况。结果PBSCT 组和 BMT 组移植后白细胞重建时间分别为(12.43±3.67)天和(16.16±2.99)天(P<0.01),血小板重建时间分别为(14.67±6.19)天和(21.23±8.25)天(P<0.01)。PBSCT 组和 BMT 组移植后1,3,6,9及12个月的 T 细胞重建差异无统计学意义。PBSCT 组和 BMT 组移植后早期感染率分别为42.86%和53.13%(P>0.05)。PBSCT 组与 BMT 组急性 GVHD 的发生率分别为61.90% 和71.885(P>0.05);在可统计的患者中,慢性 GVHD 的发生率在 PBSCT 组和 BMT 组分别为47.06%和43.48%(P>0.05)。PBSCT 组与 BMT 组移植后分别有4例和2例复发,二者复发率差异无统计学意义(P>0.05);PBSCT 组与 BMT 组移植后2年 DFS 率分别为(50.14±12.00)% 和(59.81±8.99)%,二者差异也无统计学意义(P>0.05)。结论无血缘关系供者 PBSCT 后的造血重建比BMT,但二者移植后 T 细胞重建、感染发生率、GVHD 及 DFS 的差异均无统计学意义。     

Ultrasonographic studies on abdominal complications in patients receiving marrow-ablative chemotherapy and bone marrow or blood stem cell transplantation.

Abdominal complications were evaluated with ultrasonography in 20 patients who received marrow-ablative chemotherapy and bone marrow or blood stem cell transplantation for the treatment of hematologic malignancies. Ultrasonographic findings compatible with veno-occlusive disease of the liver, cytomegalovirus infection of the colon, hepatic lesion of graft-versus-host disease, and cyclophosphamide-induced hemorrhagic cystitis were demonstrated in 6 of these patients. In addition, ascites, pleural effusion, gall bladder wall thickening, and hepatosplenomegaly were easily detected. Since ultrasonography is noninvasive and can be repeated, ultrasonographic studies are useful for evaluating and monitoring abdominal complications which are frequently encountered in these transplant patients.     

Nonmyeloablative stem cell transplantation with CD8-depleted or CD34-selected peripheral blood stem cells

To decrease the incidence of graft-versus-host disease (GVHD) observed after nonmyeloablative stem cell transplantation (NMSCT), we studied the feasibility of CD8-depleted or CD34-selected NMSCT followed by CD8-depleted preemptive donor lymphocyte infusion (DLI) given in incremental doses on days 40 and 80. Fourteen patients with high-risk malignancies and an HLA-identical sibling (n = 8) or alternative donor (n = 6) but ineligible for a conventional transplant were included. Nonmyeloablative conditioning regimen consisted in 2 Gy total body irradiation (TBI) alone, 2 Gy TBI and fludarabine (previously untreated patients) or cyclophosphamide and fludarabine (patients who had previously received > or =12 Gy TBI). Patients 1-4 (controls) received unmanipulated peripheral blood stem cells (PBSC) and DLI and patients 5-14 CD8-depleted or CD34-selected PBSC followed by CD8-depleted DLI. Post-transplant immunosuppression was carried out with cyclosporine A (CsA) and mycophenolate mofetil (MMF). Initial engraftment was seen in all patients, but 1 patient (7%) later rejected her graft. The actuarial 180-day incidence of grades II-IV acute GVHD was 75% for patients 1-4 versus 0% for patients 5-14 (p = 0.0019). Five of 14 patients were in complete remission (CR) 180 days after the transplant and 6/14 had partial responses. The 1-year survival rate was 69%, and nonrelapse and relapse mortality rates were 16 and 18%, respectively. We conclude that CD8-depleted or CD34-selected NMSCT followed by CD8-depleted DLI is feasible and considerably decreases the incidence of acute GVHD while preserving engraftment and apparently also the graft-versus-leukemia (GVL) effect. Further studies are needed to confirm this encouraging preliminary report.     

Faster engraftment but no reduction in infectious complications after peripheral blood stem cell transplantation compared to autologous bone marrow transplantation

Patients who receive transplants of autologous peripheral stem cells have a shorter duration of neutropenia than patients who receive autologous bone marrow transplants. There is conflicting evidence regarding the risk of infections. A retrospective analysis on 123 patients who received transplants of either auto- logous bone marrow or peripheral blood stem cells for multiple myeloma or breast cancer was performed to study whether this shorter duration of neutropenia can influence the risk of and the severity of infection. Patients who underwent peripheral blood stem cell transplantation (PBSCT) had faster engraftment than the group treated with autologous bone marrow transplantation (ABMT). Furthermore, the requirement for transfusions of red blood cells and platelets was a reduced. The number of days needed in hospital was significantly lower in PBSCT patients. No reduction in the frequency of infectious complications was found in PBSCT as compared with ABMT patients, but the numbers of days with fever and with antibiotic treatment were significantly lower in the PBSCT patients. Breast cancer patients had significantly faster engraftment but no fewer infectious complications than myeloma patients, regardless of the type of transplantation. Significantly lower numbers of clinically verified infections were found in the group of patients receiving colony-stimulating factors (CSF) after transplantation even though there was no difference in the duration of neutropenia. The need for antibiotic treatment was also significantly less in the group treated with CSF.     

慢性髓细胞白血病异基因外周血联合骨髓造血干细胞移植后NK细胞及受体谱重建的研究

目的 观察慢性髓细胞白血病(CML)患者进行异基因外周血联合骨髓造血干细胞移植(allo-PBSCT+BMT)后NK细胞及其受体谱重建的规律.方法 11例CML患者采用同胞异基因HLA6/6位点相合的allo-PBSCT+BMT,使用流式细胞术检测移植后受者不同时问的NK细胞及其受体谱的变化和重建的规律.结果 NK细胞在早期造血重建时就开始重建并很快达到正常值水平,移植30 d NK细胞绝对值达到高峰.约占淋巴细胞的(37.1±7.06)%,后逐渐下降,移植120 d比例基本正常.植入时CD3-CD56bright细胞占淋巴细胞的(3.6±1.25)%,移植30 d时CD3-CD56bright细胞短暂上升,占淋巴细胞的(8.3±4.13)%左右.移植60 d CD3- CD56bright细胞基本稳定在正常水平.CD94在移植后1年始终处于高水平,NKG2A在植入时占淋巴细胞的(90.3±5.35)%,移植60 d后下降到(45.8±12.36)%,而NKG2D迅速由植入时的(36.7±14.33)%上升到移植60 d的(82.3±8.64)%,NKP46在移植30-90 d下降较快.CD158a、CD158b植入时表达较低,CD158b逐渐上升,移植60 d达到淋巴细胞的(58.5±6.58)%.CD158a始终在低水平.结论 相对于其他移植方式,allo-PBSCT+BMT后NK细胞比例可能略少,但是成熟较早,可能发挥重要的移植物抗白血病效应及诱导免疫耐受作用.     

自体外周血造血干细胞移植患者的护理

目的探讨对行自体外周血造血干细胞移植的患者在不同阶段实施的相应护理措施。方法选取我院2005年10月至2008年12月进行APBSCT治疗的恶性肿瘤患者60例,根据其移植的各个阶段采取相应的护理措施。结果通过施行全环境保护、合理饮食、全身皮肤黏膜清洁消毒、心理支持等护理活动,有效地减少了移植过程中各种并发症的发生率。结论在进行APBSCT治疗的患者中,护理质量的优劣是直接影响APBSCT成败和患者预后好坏的重要因素,良好的护理使癌症患者的生命得到真正的延长。     

自体骨髓间充质干细胞联合外周血干细胞移植治疗非霍奇金淋巴瘤2例（英文）

背景：为了解决造血微环境受损导致造血重建延迟或失败这一常见难题,国内外研究开始尝试外周血干细胞移植联合骨髓间充质干细胞治疗。目的：探讨自体骨髓间充质干细胞联合外周血干细胞移植治疗非霍奇金淋巴瘤的安全性和疗效。方法：对2例确诊为非霍奇金淋巴瘤的患者,采用R-CHOP方案（利妥昔单抗、环磷酰胺、长春新碱、泼尼松）化疗5或6个周期。在自体外周血干细胞动员前取自体骨髓培养骨髓间充质干细胞。动员方案为环磷酰胺、粒细胞集落刺激因子或利妥昔单抗、环磷酰胺、粒细胞集落刺激因子。预处理方案为利妥昔单抗、环磷酰胺、足叶乙甙或利妥昔单抗、环磷酰胺、脂质体阿霉素、地塞米松。回输单个核细胞2.98×106/kg,3.84×108/kg,骨髓间充质干细胞为3.8×106/kg,3.96×106/kg。结果与结论：例1移植后10d白细胞下降至最低值,为0.1×109L-1,中性粒细胞为0×109L-1,移植后12d血小板下降至最低值45×109L-1,外周血象恢复正常时间为移植后15d。例2移植后白细胞和血小板低谷时间为移植后5d,外周血象恢复正常时间为移植后9d。移植相关并发症为急性上呼吸道感染,外痔感染,经过相应处理感染控制。结果说明自体骨髓间充质干细胞联合外周血干细胞移植治疗后造血重建快,肿块或肿大淋巴结消失,近期疗效可,长期疗效有待进一步观察。     

Transfusion of donor peripheral blood buffy coat cells as effective treatment for relapsed acute leukemia after transplantation of allogeneic bone marrow or peripheral blood stem cells from the same donor

BACKGROUND: The transfusion of same-donor peripheral blood buffy coat (PBBC) cells to chronic myelocytic leukemia patients in relapse after bone marrow transplantation has been increasingly used as an effective antileukemic therapy. A graft-versus-leukemia effect mediated by immunocompetent donor T cells underlies its success. In acute leukemia, however, the effect of this adoptive cellular immunotherapy has not been established, and the results are generally poor. STUDY DESIGN AND METHODS: Five patients, three with acute lymphoblastic leukemia and two with acute myelocytic leukemia, who relapsed within 6 months after allogeneic marrow transplantation were enrolled in a nonrandomized pilot study to receive donor PBBC cell transfusions either before or after undergoing cytoreductive chemotherapy. ABO genotyping and polymerase chain reaction amplification of human tetrameric short tandem repeats DNA typing were used to test for marrow chimerism. RESULTS: Two acute lymphoblastic leukemia patients-both of whom underwent chemotherapy before PBBC cell transfusions, experienced a complete remission, and developed acute and then chronic, extensive graft-versus-host disease-have been leukemia-free for 9 and 7 months, respectively. Repeated molecular studies of their marrow as early as 2 weeks to 8 months after treatment confirmed that the marrow was of donor origin. The other three patients, who chose not to undergo chemotherapy before PBBC cell transfusions, failed to achieve remission and died 14, 16, and 30 days, respectively, after leukemia relapse. CONCLUSION: Adoptive cellular immunotherapy may be effective for acute lymphoblastic leukemia patients in relapse after bone marrow transplantation if chemotherapy is administered before PBBC cell transfusions are initiated.     

Efficacy of peripheral blood stem cell transplantation

With the advancement in apheresis technique and collection, the role of peripheral blood stem cell (PBSC) transplantation has emerged. PBSC are now being utilized either alone to reconstitute hematopoiesis following high-dose myeloablative therapy, or in combination with autologous bone marrow transplantation to enhance hematopoietic recovery, or as supportive therapy to allow dose-intensity of conventional chemotherapy. The role and efficacy of PBSC transplantation will be reviewed in the article.     

Cyclophosphamide mobilization of peripheral blood stem cells for use in autologous transplantation after high-dose chemotherapy: clinical results in patients with contaminated or hypocellular bone marrow.

Peripheral blood stem cells (PBSC) can be used for hematopoietic reconstitution in patients who have received high-dose chemotherapy (HDC). Previously, we reported 18 such patients who had nonmobilized PBSC harvested in steady state. We have now performed PBSC reinfusion in 24 patients with hypocellular or tumor-involved marrow who received cyclophosphamide (Cy) mobilization (4 grams/m2) prior to PBSC collection. The PBSC were collected upon rebound hematopoietic recovery by continuous-flow leukapheresis and subsequently cryoproserved. A median of 3.17 x 10(8) mononuclear cells/kg (range 1.47-3.95 x 10(8)) were collected. Patients underwent a median of 6 apheresis procedures (range 5-12). To date all 24 patients have undergone PBSC reinfusion after HDC. Fourteen patients received post-reinfusion granulocyte/macrophage colony-stimulating factor. Granulocyte recovery (> 500 x 10(6)/ml) has occurred at a median of 13.5 days (range 7-39) and platelet recovery (> 50 x 10(9)/ml without transfusion support) has occurred in 20 patients at a median of 33 days (range 7-121 days). Four other patients have platelet counts of greater than 20K and are transfusion independent, but have still not achieved counts of 50K. PBSC collection after Cy mobilization is feasible and effective for hematopoietic reconstitution after HDC and reinfusion. All 24 patients demonstrated trilineage engraftment. Although neutrophil recovery was not significantly hastened (as compared with our nonmobilized or steady-state data), time to platelet engraftment was foreshortened.     

经门静脉外周血干细胞移植失代偿期肝硬化患者甲胎蛋白及甲胎蛋白异质体3的监测

背景: 自体干细胞移植治疗肝硬化在临床上已有诸多报道,但迄今为止,关于干细胞与移植后肝硬化的预后转归,干细胞在受损肝内定向分化及恶性学表型等一直是临床专家关注的热点.目的: 动态监测经门静脉外周血干细胞移植治疗失代偿期肝硬化患者的血清甲胎蛋白及甲胎蛋白异质体3变化,评估治疗方法的安全性.方法: 纳入2007-04来解放军总参谋部总医院行经门静脉外周血干细胞移植治疗的失代偿期肝硬化患者44例,以化学发光法检测患者术前及术后血清甲胎蛋白和甲胎蛋白异质体3水平的变化,以甲胎蛋白异质体3(%)≥10%作为阳性判断标准,分析干细胞移植治疗失代偿期肝硬化与肝癌恶性表型的关系.结果与结论: 干细胞移植2个月,患者血清甲胎蛋白出现一过性升高,移植前、后患者血清甲胎蛋白异质体3(%)水平差异无显著性意义(P>0.05),且不同甲胎蛋白浓度患者的甲胎蛋白异质体3阳性率及甲胎蛋白异质体3(%)差异无显著性意义(P>0.05).说明失代偿期肝硬化患者经外周血干细胞移植后临床症状及肝功能得到一定程度恢复.检测肝癌血清学标记物甲胎蛋白异质体3未提示在短期内有恶性生物学表型行为出现.     

PCR-STR用于异基因造血干细胞移植后的骨髓和外周血嵌合状态的监测及作用

目的用PCR-STR检测观察比较异基因造血干细胞移植术后,骨髓和外周血嵌合状态和植入状态。方法提取17例异基因造血干细胞移植术中的供者外周血及受者移植前后各阶段外周血和骨髓的DNA,PCR PCR-STR检测扩增15个基因位点,和1个性别位点AMEL。用遗传分析仪进行毛细管电泳,确定基因位点,根据基因型的差异选择嵌合率计算公式,分析植入情况和嵌合状态。结果12名患者完全植入,骨髓和外周血的PCR-STR结果一致;1名患者骨髓PCR-STR显示为持续未植入,外周血PCR-STR显示为短期混合植入;4名患者骨髓和外周血PCR-STR显示嵌合状态时间不一致,骨髓PCR-STR显示嵌合状态时间明显早于外周血(P<0.05)。结论PCR-STR是分析异基因造血干细胞移植后供体是否植入的灵敏、准确度高的方法,骨髓嵌合状态的变化的出现早于外周血,混合嵌合状态对白血病复发有预警作用,骨髓嵌合状态的早期变化对实施临床干预治疗尤为重要。     

Hematopoietic recovery in cancer patients after transplantation of autologous peripheral blood CD34+ cells or unmanipulated peripheral blood stem and progenitor cells

BACKGROUND: A study of CD34+ cell selection and transplantation was carried out with particular emphasis on characteristics of short- and long-term hematopoietic recovery. STUDY DESIGN AND METHODS: Peripheral blood stem and progenitor cells (PBPCs) were collected from 32 patients, and 17 CD34+ cell-selection procedures were carried out in 15 of the 32. One patient in whom two procedures failed to provide 1 × 10(6) CD34+ cells per kg was excluded from further analysis. After conditioning, patients received CD34+ cells (n = 10, CD34 group) or unmanipulated (n = 17, PBPC group) PBPCs containing equivalent amounts of CD34+ cells or progenitors. RESULTS: The yield of CD34+ cells was 53 percent (18–100) with a purity of 63 percent (49–82). The CD34+ fraction contained 66 percent of colony-forming units-granulocyte- macrophage (CFU-GM) and 58 percent of CFU of mixed lineages, but only 33 percent of burst-forming units-erythroid (BFU-E) (p < 0.05). Early recovery of neutrophils and reticulocytes was identical in the two groups, although a slight delay in platelet recovery may be seen with CD34+ cell selection. Late hematopoietic reconstitution, up to 1.5 years after transplant, was also similar. The two groups were thus combined for analyses of dose effects. A dose of 40 × 10(4) CFU-GM per kg ensured recovery of neutrophils to a level of 1 × 10(9) per L within 11 days, 15 × 10(4) CFU of mixed lineages per kg was associated with platelet independence within 11 days, and 100 × 10(4) BFU-E per kg predicted red cell independence within 13 days. However, a continuous effect of cell dose well beyond these thresholds was apparent, at least for neutrophil recovery. CONCLUSION: CD34+ cell selection, despite lower efficiency in collecting BFU-E, provides a suitable graft with hematopoietic capacity comparable to that of unmanipulated PBPCs. In both groups, all patients will eventually show hematopoietic recovery of all three lineages with 1 × 10(6) CD34+ cells per kg or 5 × 10(4) CFU-GM per kg, but a dose of 5 × 10(6) CD34+ cells or 40 × 10(4) CFU-GM per kg is critical to ensure rapid recovery.     

Peripheral blood stem cell transplantation for breast cancer patients with bone marrow metastases using GM-CSF priming

Twenty-seven patients with metastastic breast cancer to the bone marrow underwent successful collection of peripheral blood progenitor cells (PBPC) following GM-CSF cytokine priming and were engrafted following courses of high-dose chemotherapy. Myeloid engraftment was observed in a median of 12 days, with a range of 8-29 days. The cell dose infused correlated, although weakly, with days to engraftment, although assays of CFU-GM and CD34+ cells did not, suggesting refinement in such assays is needed. The failure to observe complete remission of the tumor suggests alternative chemotherapy regimens should be investigated.     

银屑病患者骨髓基质细胞分泌干细胞因子和粒细胞集落刺激因子的水平

背景:课题组在前期研究中发现银屑病患者骨髓造血细胞活性存在异常.目的:观察银屑病患者骨髓基质细胞分泌干细胞因子和粒细胞集落刺激因子的水平.设计、时间及地点:病例一对照观察,于2007-10/2008-08在太原市中心医院皮肤科实验室完成.对象:选择太原市中心医院皮肤科临床及病理确诊为寻常型锹屑病的门诊患者24例,男16例,女8例;年龄16-59岁;另取血液科骨穿后经筛选的正常骨髓20例作为对照组,性别、年龄与银屑病患者匹配.方法:采用密度梯度离心法分离银屑病患者与对照组骨髓单一核细胞,通过贴壁法培养骨髓基质细胞,收集传了3代后又培养72 h的骨髓基质细胞及培养上清.主要观察指标:流式细胞仪检测细胞表面标志并用ELISA法榆测上清液中干细胞因子和粒细胞集落刺激因子的水平.结果:流式细胞仪检测结果显示,90%以上细胞表面抗原高表达CD29,而CD34、CD45及HLA-DR表达阴性,即骨髓基质细胞纯度在90%以上.银屑病组骨髓基质细胞培养上清液的干细胞因子和粒细胞集落刺激因子表达均显著高于对照组(P＜0.01).结论:银屑病患者骨髓基质细胞分泌干细胞因子和粒细胞集落刺激因子存在异常,提示银屑病患者骨髓造血微环境发生了改变.     

Haploidentical stem cell transplantation-bone marrow vs peripheral blood

Hematopoietic stem cells may be obtained by collection of bone marrow, mobilization and collection of peripheral blood stem cells or umbilical cord blood. Transplantation of peripheral blood hematopoietic cells has increased due to faster engraftment and practicability in both the related, unrelated or haploidentical setting. We reviewed the question of which stem cell source - bone marrow (BM) or peripheral blood (PBSC) - is the most suitable for individuals undergoing haploidentical stem cell transplantation. BM or PBSC could be safely used as allograft sources for haploidentical transplantation with good outcomes and acceptable rates of GVHD and graft failure. Prospective randomized studies are needed to evaluate the effect of PB vs BM in haploidentical settings.