造血干细胞移植研究和应用的回顾与展望

 结合第54届美国血液学会年会教育论坛的相关内容着重复习造血干细胞移植（HSCT）领域的一些进展。在论述人类白细胞抗原（HLA）配型技术和供者来源扩展的基础上,分别简述了各类HSCT（HLA-相合同胞供者移植、脐带血移植、无关供者移植、 HLA-单倍型相合的移植）疗效的提升,也回顾了疾病种类和病期对HSCT结局的影响;结合自身的理解与经验,强调确保供者安全的注意事项与意义。     

骨髓移植供体19例分析

本文分析了19例22例次各类骨髓供体的自身状况,重点讨论了供体髓采集质量及并发症,并与正常供体作了比较。结果表明,骨髓采集的部位选择,麻醉选择及骨髓采集量均无自身影响并且可直接进入BMT。并认为多次供髓,其间隔时间越长对有核细胞数影响越小。22例次发生并发症10次。FUO在自体供者中易发生(13％)。所有并发症均历时短暂,可迅速恢复。7例次异体正常供者血液学随访1～3年无异常。对今后临床BMT工作提供了参考依据。     

Risk-adapted donor lymphocyte infusion based on chimerism and donor source in pediatric leukemia

Donor lymphocyte infusion (DLI) is commonly used to treat leukemia relapse following stem cell transplantation. In florid relapse, however, the efficacy of DLI is limited with substantial risk of severe graft-versus-host disease (GvHD). Here, we develop a novel risk-adapted strategy characterized by pre-emptive DLI initiated at the time of mixed chimerism, a small starting dose based on donor source, dose-escalation guided by real-time chimerism monitoring and withholding of DLI immediately in patients achieving full donor chimerism. A total of 178 DLIs were given to 38 patients with mixed chimerism; thereafter, 33 patients (86.8%) had donor chimerism successfully increased, including 30 (78.9%) who had chimerism fully converted back to 100% donor. Cumulative incidence of relapse was significantly lower (P=0.00004) and overall survival higher (P=0.0003) in patients with chimerism fully corrected as compared with those of patients whose chimerism remained mixed. Only 13.2% of the patients developed acute grade III-IV GvHD with no associated mortality. In conclusion, the risk-adapted DLI strategy is useful in minimizing the risk of childhood leukemia relapse, GvHD and death.     

造血干细胞移植人人都有供者*

造血干细胞移植（hematopoietic stem cell transplantation,HSCT）是一种有效的,有时是唯一的根治性治疗某些血液疾病的治疗方法。单倍型HSCT已在国际上实行约20余年,在过去的10年中,中国原创的非体外去T 细胞单倍型移植体系为单倍型HSCT的改进做出突出贡献,使得HSCT实现人人都有供者。本文旨在描述当前HSCT的状况,并展望中国HSCT体系的未来前景。      

两种异基因造血干细胞移植治疗白血病的临床观察

目的 比较HLA单倍型供者造血干细胞移植(HLA-haploidentical RD-HSCT)和非血缘供者造血干细胞移植(URD-HSCT)治疗白血病的疗效.方法 分析93例接受异基因造血干细胞移植(allo-HSCT)白血病患者的资料,其中51例患者接受HLA-haploidentical RD-HSCT,42例接受URD-HSCT.HLA-haploidentical RD-HSCT组中42例患者予氟达拉滨(Flu)+白消安(Bu)+阿糖胞苷(Ara-C)预处理方案,9例予全身照射(TBI) +Flu+Ara-C预处理方案;URD-HSCT组患者中35例接受改良白消安/环磷酰胺(Bu/Cy)方案预处理,7例予TBI+Flu方案.结果 HLA-haploidentical RD-HSCT和URD-HSCT组中性粒细胞数＞ 0.5×109/L时间分别为移植后12.5 d(11 ～17d)和16.2 d(12～21 d),血小板计数＞20× 109/L时间分别为移植后17.5 d(16～25 d)和20.3 d(17～28 d),两组中性粒细胞和血小板重建时间差异均有统计学意义(P值分别为0.008、0.023).HLA-haploidentical RD-HSCT组与URD-HSCT组2～4度急性移植物抗宿主病(GVHD)发生率分别为46.0％(23/50)和51.2 ％(21/41),慢性GVHD总发生率分别为46.0％(23/50)和63.4％(26/41),GVHD致死率分别为6.0％(3/50)和17.1％(7/41),差异均无统计学意义(P值分别为0.773、0.529、0.113).两组移植后复发率分别为17.6％(9/51)和11.9％(5/42)(P=0.653).3年总生存率分别为(56.3±7.0)％和(63.1±5.8)％(P=0.318),无病生存率分别为(48.2±7.7)％和(62.3±9.4)％(P=0.661).结论 采用加强预处理及免疫抑制剂的HLA-haploidentical RD-HSCT治疗白血病,在不增加感染和GVHD发生率的基础上,可取得与URD-HSCT近似的疗效.     

Combination of low-dose mycophenolate mofetil with cyclosporine and methotrexate as GVHD prophylaxis in unrelated donor allogeneic stem cell transplantation

We report the results of HLA-matched unrelated donor allogeneic stem cell transplantation with new GVHD prophylaxis regimen consisted of cyclosporine, methotrexate and low-dose mycophenolate mofetil in 139 patients with hematologic malignancies. The incidence of grades II–IV and III–IV acute GVHD were 43.0% and 17.3%, respectively. The incidence of chronic GVHD was 42.1%, with 16.5% extensive grade. The cumulative incidence of transplant-related mortality at 100 days and 3 years were 7.9% and 29.7%, respectively. Three-year overall survival, disease-free survival and relapse incidence were 58.7%, 55.3% and 19.6%, respectively. These results suggest the new regime may be effective for the prophylaxis of acute and chronic GVHD in unrelated donor transplantation.     

Donor Lymphocyte Infusion for the Treatment of Relapse after Allogeneic Hematopoietic Stem Cell Transplantation

The results of donor lymphocyte infusion (DLI) for treatment of relapse after bone marrow transplantation (BMT) are reviewed. Durable complete remission can be achieved at the molecular level for a majority (more than 70%) of patients with CML, when treated at early relapse. Results are less favourable for acute leukemias, although useful responses have been reported. Data are scarce though promising for myelodysplastic syndromes and multiple myeloma. Major treatment-associated toxicities are GVHD and bone marrow aplasia. The latter complication can be predicted by evaluating the level of residual donor-derived hematopoiesis. Modification of infused cells (CD8 negative selection or transduction with a suicide gene), addition of peripheral blood stem cells, and early implementation of escalating doses may counteract the complications and increase the response rate. Response rate is variably influenced by the presence of chronic GVHD after initial BMT, T-cell depleted BMT, underlying disease and stage at relapse, and the level of mixed chimerism. DLI is a direct demonstration of the graft-versus-leukemia effect (GVL). Because GVL after BMT is sometimes the predominant cause of cure, it may be advisable in such situations to redirect the conditioning regimens for BMT towards engraftment and less immediate cytotoxicity.     

Intensified conditioning regimens improved disease-free survival and engraftment after unrelated single-unit cord blood transplantation but not after matched sibling or matched unrelated donor allogeneic hematopoietic cell transplantation

The impact of conditioning intensity on different donor groups has been unclear in allogeneic transplantation. The objective of this study was to clarify the effect of conditioning intensity on disease-free survival (DFS), relapse, non-relapse mortality (NRM), neutrophil engraftment, and graft-versus-host disease for each donor type. We retrospectively evaluated the effect of conditioning intensity on transplant outcomes for patients with acute leukemia or myelodysplastic syndrome aged between 16 and 60 years in Japan using the transplant conditioning intensity (TCI) scoring system. A total of 8526 patients who received first allogeneic transplantation from 6/6 antigen-matched sibling donor (MSD, n = 2768), 8/8 allele-matched unrelated donor (MUD, n = 2357), and unrelated single-cord blood (UCB, n = 3401) were eligible for the analyses. Compared to conditioning with TCI score 4.0, which was corresponds to conventional myeloablative conditioning, including cyclophosphamide with total body irradiation 12 Gy or busulfan 12.8 mg, and was considered as the reference group in the multivariate analyses, intensified conditioning with TCI score ≥4.5 improved DFS (hazard ratio [HR],0.81, P < 0.001) and relapse rate (HR, 0.70, P < 0.001) but only after UCB transplants and not MSD and MUD transplants. In contrast, NRM was higher after intensified conditioning with TCI score ≥4.5 for MSD (HR, 1.39, P = 0.008) and MUD (HR, 1.47, P = 0.002) transplants but not UCB transplants (HR, 1.12, P = 0.240). Neutrophil engraftment was also significantly higher after intensified conditioning with TCI score ≥4.5 but only for UCB transplants (HR, 1.24, P < 0.001), whereas it was significantly lower after reduced-intensity conditioning with TCI score ≤3.5 for MSD transplants only (HR, 0.82, P < 0.001). These data demonstrated that an intensified conditioning regimen improved survival and engraftment rate only after a UCB transplants. Therefore, TCI scoring system could enable the optimization of conditioning intensity according to donor type, particularly in terms of survival and engraftment.     

Donor miR‐196a‐2 polymorphism is associated with hepatocellular carcinoma recurrence after liver transplantation in a Han Chinese population

Recurrence of hepatocellular carcinoma (HCC) is one of the leading causes of death after liver transplantation (LT). We aim to evaluate the association of donor and recipient single nucleotide polymorphisms (SNPs) with the risk of HCC recurrence after LT. A total of 155 adult patients who underwent primary LT for HCC were enrolled. Ten SNPs associated with HCC susceptibility were genotyped. Patients who received donor livers with the rs11614913 homozygous CC variant presented significantly higher recurrence rates of HCC (41.7 vs. 15.3%, p = 0.009) and lower cumulative tumor‐free survival (p = 0.005) than those who received TT wild‐type donor livers. The donor rs11614913 genetic variant was an independent risk factor for HCC recurrence (odds ratio = 2 per each C allele, p < 0.05) and could significantly improve the predictive abilities of clinical models (Milan, UCSF and Hangzhou criteria). Donor livers homozygous for rs11614913 CC were associated with a higher miR‐196a expression than TT (p = 0.002). In a lentiviral infection of mouse liver and orthotopic mouse model of HCC, the liver miR‐196a overexpression group showed a significantly larger tumor size than the control group (p = 0.001). There is a close association between the tumor size and expression of miR‐196a in the liver (r = 0.693, p = 0.001). In conclusion, the donor miR‐196a‐2 rs11614913 polymorphism is associated with HCC recurrence after LT and improves the predictive value of clinical models. The overexpression of miR‐196a in the liver might provide a tumor‐favorable environment for the development of HCC.     

非清髓性异基因骨髓移植治疗白血病的动物实验研究

[目的]探讨非清髓性异基因骨髓移植及加供者淋巴细胞输注治疗小鼠白血病的疗效.[方法]荷L7212白血病的615(H-2K)小鼠,于接种白血病细胞后第2天接受60Co-γ射线全身照射(TBI 8.5Gy或5Gy)分为若干组,照射当天移植供鼠BALB/C(H-2d)小鼠的骨髓细胞(5×106)和脾细胞(1.5×107),移植后第2天腹腔注射环磷酰胺(200mg/kg);供者淋巴细胞输注组分别于移植后第7天、14天、21天再次输注供鼠脾细胞5×106、1×107、2×107,观察受鼠的移植物植入、移植物抗宿主病(GVHD)、受鼠生存时间及移植相关并发症等.[结果]非清髓性预处理能保证移植物的稳定植入,非清髓性异基因骨髓移植组小鼠生存时间为22.3±4.8天,与非清髓空白组14.7±3.4天和传统移植组18.3±3.2天比较均有显著性差异(P＜0.05),供者淋巴细胞输注(DLI)组小鼠平均生存时间明显延长,为34.3±2.5天,与非清髓移植组比较均有显著性差异(P＜0.05),且无明显GVHD表现和病理学改变,移植相关并发症减少.[结论]非清髓性异基因骨髓移植能在减轻GVHD的同时保留一定的移植物抗白血病(GVL)效应,移植后行DLI可在减轻移植相关并发症的基础上进一步增强GVL效应.     

Preparations for unrelated donor transplantation

This mini-review briefly describes some of the issues that are important for a transplant physician preparing a patient for an unrelated donor (UD) stem cell transplant. It is primarily directed at referring hemato-oncologists and trainees in transplantation and aims to provide them with the information they require to deal with these patients appropriately and efficiently. It discusses search strategies, the need for urgency and early identification of the major problems that will determine the outcome of the transplant. Excellent communication with the histocompatibility and immunogenetics laboratory and the referring physician are emphasized. Many of the recommendations are derived from personal experience; there is a need for more of an evidence base to aid decision-making.     

Role of allogeneic stem cell transplantation in multiple myeloma

Multiple myeloma is currently incurable using standard treatment regimens. While the introduction of high-dose chemotherapy with autologous stem cell rescue has been shown to increase overall survival when compared with chemotherapy alone, this strategy is palliative. Allogeneic stem cell transplantation provides the potential for long-term disease-free survival in a small proportion of patients, although its application has been limited by procedure-related mortality, reflecting the intensive myeloablative conditioning given. Recently, reduced intensity conditioning regimens have been developed in an attempt to reduce toxicity whilst preserving the allogeneic graft-versus-myeloma effect, therefore maintaining the potential for disease eradication. This review aims to examine the current position of allogeneic transplantation in the management of myeloma.     

急性髓性白血病混合造血干细胞移植后DLI＋IL-2治疗的临床研究

目的：探讨急性髓性白血病（acute myeloid leukemia,AML）患者在接受自体外周血干细胞混合人类白细胞抗原（human leukocyte antigen,HLA）半相合异体骨髓移植（Mixed-HSCT）后,继予供体淋巴细胞输注＋白介素2（DLI＋IL-2）治疗的疗效。方法：对23例AML患者在完全缓解期采用TBI＋VEMAC预处理方案,实施Mixed-HSCT。造血恢复后给予DLI＋IL-2治疗1-8次。结果：所有患者均获得造血重建,中性粒细胞（ANC）≧0.5×109/L的中位时间为14（12-17）天,白细胞（WBC）≧4.0×108/L的中位时间为17（16-21）天。血小板（PLT）≧20×108/L的中位时间为21（19-23）天,PLT≧50×108/L的中位时间为25（24-27）天。＋16至＋21天时骨髓检查示恢复期骨髓象,无移植物抗宿主病（graft versus host disease,GVHD）发生,有6例形成混合嵌合体（46XX/46XY）。经过3年以上随访,存活15例,长期无病存活率（DFS）为65.2%。结论：Mixed-HSCT后应用DLI＋IL-2治疗对急性髓性白血病患者的长期无病生存有积极意义。     

混合造血干细胞移植联合DLI-IL-2治疗急性髓性白血病的疗效

目的:探讨急性髓性白血病(acute myelogenous leukemia,AML)患者采用自体外周血干细胞混合HLA半相合异体骨髓移植(autologous peripheral blood stem cell mixed with HLA haploidentical allogeneic bone marrow transplantation,Mixed-HSCT)联合供体淋巴细胞输注+白介素2(donor lymphocyte infusion combined interleukin-2,DLI-IL-2)治疗的疗效。方法:采用联合治疗方案的试验组23例AML患者中男性15例、女性8例,中位年龄22(17～41)岁;采用单纯移植治疗的对照组14例AML患者中男性10例、女性4例,中位年龄21(19～40)岁。两组患者在完全缓解期采用TBI+VEMAC方案预处理,对照组患者接受单纯Mixed-HSCT移植,试验组患者接受Mixed-HSCT且造血重建后继续DLI-IL-2治疗1～8次;各组在治疗前后进行染色体核型分析及骨髓检查。随访时间>3年。结果:两组患者均获得造血重建,无移植物抗宿主病(graft-versus-host disease,GVHD)发生。试验组有6例形成混合嵌合体(46XX/46XY),随访显示存活15例,长期无病存活率(disease-free survival,DFS)为65.2%;对照组有3例形成混合嵌合体(46XX/46XY),随访显示存活7例,DFS为50.0%。两组患者治疗后的不良反应(口腔溃疡、出血性膀胱炎、发热等)相似。结论:Mixed-HSCT联合DLI-IL-2治疗对AML患者长期无病生存有积极意义,无严重不良反应。     

Salvage Therapy for Relapsed Mediastinal B-Cell Lymphoma with Allogeneic HLA-Identical Related Donor Bone Marrow Transplantation, Donor Lymphocyte Infusion and IDEC-C2B8

Primary B-cell lymphoma of the mediastinum is an aggressive non-Hodgkin's lymphoma with distinct clinicopathologic features. Response rates are between 60-80% following intensive chemotherapy regimens. Poor responders or patients with an early relapse usually do not achieve a prolonged second remission with conventional salvage therapy protocols and therefore qualify for intensive or experimental approaches. Here we describe two patients of same age, gender and stage with primary mediastinal B-cell lymphoma and an early relapse after the first courses of combination chemotherapy and irradiation of the mediastinum. One patient relapsed after a salvage therapy with allogeneic donor-related bone marrow transplantation and donor lymphocyte infusion but responded again with a continuing good partial remission after infusion of the chimeric anti-CD20 antibody IDEC-C2B8. For the other patient an allogeneic bone marrow transplantation was not possible. He finally failed to respond to salvage therapy with IDEC-C2B8 and died of progressive disease. The anti-CD20 antibody IDEC-C2B8 induced a partial remission in a patient with primary mediastinal B-cell lymphoma refractory to other therapeutic approaches, including allogeneic bone marrow transplanatation (alloBMT), donor lymphocyte infusion (DLI) and irradiation. The role of IDEC-C2B8 as a component of salvage regimens appears to be worthy for further evaluation in high-risk patients with primary mediastinal B-cell lymphoma