ISSN 1866-8836
Клеточная терапия и трансплантация

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Volume 5, Number 1
03/01/2016
Volume 5, Number 1
Editor-in-Chief
Afanasyev B. V. (St. Petersburg, Russia)
Co-Editors-in-Chief
Wagemaker G. (Rotterdam, Netherlands)
Zander A.R. (Hamburg, Germany)
Deputy Editor
Fehse B. (Hamburg, Germany)
Managing Editor
Chukhlovin A. B. (St. Petersburg, Russia)
Editorial Board
Aleynikova O. V. (Minsk, Belarus)
Baum C. (Hannover, Germany)
Bilko N. M. (Kyiv, Ukraine)
Borset M. (Trondheim, Norway)
Büchner Th. (Münster, Germany)
Chechetkin A. V. (St. Petersburg, Russia)
Fibbe W. (Leiden, Netherlands)
Galibin O. V. (St. Petersburg, Russia)
Gritsaev S. V. (St. Petersburg, Russia)
Hölzer D. (Frankfurt a.M., Germany)
Klimko N. N. (St. Petersburg, Russia)
Kolb H.-J. (München, Germany)
Kröger N. (Hamburg, Germany)
Kulagin A. D. (St. Petersburg, Russia)
Lange C. (Hamburg, Germany)
Mamaev N. N. (St. Petersburg, Russia)
Mikhailova N. B. (St. Petersburg, Russia)
Moiseev I. S. (St. Petersburg, Russia)
Nagler A. (Tel-Aviv, Israel)
Nemkov A. S. (St. Petersburg, Russia)
Paramonov I. V. (Kirov, Russia)
Roumiantsev A. G. (Moscow, Russia)
Savchenko V. G. (Moscow, Russia)
Smirnov A. V. (St. Petersburg, Russia)
Uss A. L. (Minsk, Belarus)
Zubarovskaya L. S., (St.Petersburg, Russia)
In this Issue

Despite a wide scope of the CTT editorial policy, hematopoietic stem cell transplantation (HSCT) and related topics remain central to our readership, due to advanced research in this field. Chronic myeloid leukemia (CML) is the example of such a fast evolution in diagnostics and therapy over last decades. A review article by Rüdiger Hehlmann and Susanne Saußele illustrates differential approaches with tyrosine kinase inhibitors (TKIs) and HSCT as first- and second-line strategies of CML treatment, with regard to individual risk factors, thus providing optimal outcomes in terms of overall survival and achieving molecular remissions.

Clinical efficiency of leukemia treatment is now measured by dropping levels of specific oncogenic markers after the therapy performed. Professor Robert P. Gale presents an elegant article dedicated to accuracy of molecular tests, aiming efficiency evaluation and improved quality of the leukemia relapse prediction. The article will be of value to both clinicians and laboratory hematologists.

The usage of autologous marrow stem cells transplantation for treatment of myocardial disorders still remains under discussion. In spite of positive clinical effects of such treatment in certain cases, there are some controversies concerning engraftment and long-term in situ effects of the stem cells injected. In this respect, the article from a German team lead by Professor Steinhoff is of special interest. A comprehensive description of cardiological effects following auto-HCST of CD133+ cells is given in this review, as based on follow-up of 223 patients from the RTC Registry. A need for further trials is suggested.

A short article Time- and sample-dependent differences in polyomavirus incidence following hematopoietic stem cell transplantation is dedicated to reactivation of polyomaviruses in immunocompromised patients, being a common consequence of the post-HSCT immune deficiency. E. g., the BK virus in urinary cells is generally associated with hemorrhagic cystitis after cytostatic treatment.

This issue also contains a collection of poster communications prepared by the workers from Russia, Belarus, Armenia, and Tajikistan and presented at the VIII Raisa Gorbacheva Memorial Meeting (September
18-22, 2015, Sochi, Russia). These abstracts provide a short view of the topics that are currently in scope of HSCT specialists working in the ex-USSR countries.

The CTT Journal also regrets upon the loss of Professor van Bekkum, a leader in hematopoietic stem cell research. An obituary written by G. Wagemaker is placed in this issue of the Journal.

Regular articles

Time- and sample-dependent differences in polyomavirus incidence following hematopoietic stem cell transplantation

Alexey B. Chukhlovin1, Yury A. Eismont2, Vladimir N. Vavilov1, Ludmilla S. Zubarovskaya1, Boris V. Afanasyev1

Short messages

Effectiveness of high-dose chemotherapy with autologous stem cell transplantation (ASCT) in patients with relapsed and refractory course of Hodgkin’s lymphoma

Elena V. Kondakova, Natalya B. Mikhailova, Evgenia S. Borsenkova, Olga B. Kalashnikova, Nadezhda V. Medvedeva, V. V. Ryabchikova, Boris V. Afanasyev

Hematopoietic stem cell transplantation in patients with neurometabolic diseases: a single center experience

Kirill I. Kirgizov1, 2, Ekaterina A. Pristanskova1, Yulia V. Skvortsova2, Natalia L. Pechatnikova1, Marina Y. Persiantseva2, Natalia V. Sidorova1, Dmitry N. Balashov2, Veronika V. Konstantinova1, Oxana L. Blagonravova1, Svetlana M. Mikhailova1, Elena V. Skorobogatova1, Aleksey A. Maschan2

Aberrant methylation of promoter regions of sox7, p15ink4b and WNT pathway antago- nist genes in patients with myelodysplas- tic syndrome

Ivan I. Kostroma, Sergey V. Gritsaev, Zh. Yu. Sidorova, S. A. Tiranova, S. P. Svitina, Yulia S. Drizhun, Irina S. Martinkevitch, Kudrat M. Abdulkadyrov, Sergej I. Kapustin, Alexander V. Chechetkin

Chimerism analysis after allogeneic hematopoietic stem cell transplantation as a prognostic factor of relapse in hematopoietic malignancies in children

Victoria A. Lavrinenko, Yulia E. Mareiko, Tatsiana V. Savitskaya, Mikhail V. Belevtsev, Olga V. Aleynikova

Low-dose cytarabine and cladribine for treatment of relapsed or refractory acute myeloid leukemia: clinical experience

Sergej V. Gritsaev, Ivan I. Kostroma, Anastasia A. Kuzjaeva, Irina M. Zapreeva, Elena V. Litvinskaya, Lubov V. Steljmashenko, S. A. Tiranova, Irina S. Martinkevitch, Nadezhda A. Potichonova, Kudrat M. Abdulkadyrov.

Mesenchymal stem cells: multilayer polyelectrolyte microcapsules uptake, toxicity and influence upon functional properties

K. V. Lepik1, V. S. Sergeev1, A. R. Muslimov1, D. S. Romanyuk1, R. T. Mikhelashvili1, I. S. Moiseev1, E. V. Popova2,I. L. Radchenko2, A. D. Vilesov1, G. B. Sukhorukov2, 3, B. V. Afanasyev1

Results of high-dose chemotherapy with autologous hematopoietic stem cell transplantation in treatment of pediatric brain tumors

Asmik G. Gevorgian1, Elena V. Morozova1, Ilya V.Kazantsev1, Tatiana V. Iukhta1, Svetlana A. Safonova1, Yury A. Punanov1, Ludmila S. Zubarovskaya1, Olga G. Zheludkova2, Boris V. Afanasyev1

Allogeneic stem cell transplantation in myelofibrosis patients with intermediate-2 and high DIPSSplus risk

Maria V. Barabanshikova, Elena V. Morozova, Vadim V. Baikov, Ludmila S. Zubarovskaya, Boris V. Afanasyev

Epidemiology and risk factors for bacterial infections (BI) in children and adolescents after allogeneic hematopoietic stem cell transplantation (allo-HSCT)

Maria Yu. Averianova1, Vladimir N. Vavilov1, Natalia V. Stancheva1, Svetlana V. Razumova1, Anastasia S. Borovkova1, Olesya V. Paina1, Polina V. Kozhokar1, Kirill A. Ekushov1, Andrey V. Kozlov1, Yulia G. Fedukova1, Inna V. Markova1, Yana V. Gudozhnikova1, Anna A. Spiridonova1, Nadezhda А. Schaliapina2, Svetlana A. Riachovskych2, Anna V. Lubimova2, Ludmila S. Zubarovskaya1, Boris V. Afanasyev1

Prevalence of hematological malignancies in Armenia

Smbat S. Daghbashyan, Nata A. Melkikyan, Lussine.S. Sahakyan, M.V.Saharyan, R.Yolyan

Impact of cytogenetics on outcome of acute myeloid leukemia after allogeneic hematopoietic stem cell transplantation

Tatiana L. Gindina, Nikolay N. Mamaev, Sergey N. Bondarenko, Alexander L. Alyanskiy , Olga A. Slesarchuk, Ivan S. Moiseev, Olga V. Pirogova, Svetlana V. Razumova, Lyudmila S. Zubarovskaya, Boris V. Afanasyev

17q21→17qter jumping translocations in a 13-year-old girl with RUNX1–RUNX1T1- positive acute myeloid leukemia

Tatiana L. Gindina, Nikolay N. Mamaev, Elena S. Nikolaeva, Olga S. Uspenskaya, Irina A. Petrova, Marya Yu. Averyanova, Sergey N. Bondarenko, Boris V.Afanasyev

Influence of co-transplanted mesenchymal stem cell upon immunological recovery after allogeneic hematopoietic cell transplantation in children

Yuliya E. Mareika, Tatiana V. Shman, Yanina I. Isaikina, Nina V. Minakovskaya, Natalia P. Kirsanava, Olga V. Aleynikova

Long-term observations of patients with Fanconi anemia following allogeneic hematopoietic stem cell transplantation: a two-center experience

Elena V. Skorobogatova1, Kirill I. Kirgizov1, Dmitry N. Balashov2, Natalia V. Sidorova1, Ekaterina A. Pristanskova1, Natalia V. Sidorova1, Veronika V. Konstantinova1, Oxana L. Blagonravova1, Pavel E. Trakhtman2, Yulia V. Skvortsova2, Michael A. Maschan2, Aleksey A. Maschan2

Efficiency of antimicrobial surface treated central venous catheters in the prophylaxis of catheter-associated infections in children with oncohematological diseases

Yulia Simakina, Olga Ivanova, Elisa Kubieva, Elena V. Morozova, Ekaterina Goncharova, Ludmila S. Zubarovskaya, Boris V. Afanasyev

10/10 compatibility in hematopoietic stem cell transplantations (HSCT) may improve outcomes as compared to 9/10: a single-center study

Natalia V. Sidorova1, Kirill I. Kirgizov1, Dmitry N. Balashov2, Pavel E. Trachtman2, Marina Y. Persiantseva2, Ekaterina A. Pristanskova1, Veronika V. Konstantinova1, Oxana L. Blagonravova1, Michael A. Maschan2, Elena V. Skorobogatova1, Alexey A. Maschan2

Early diagnostics of acute kidney injury (AKI) associated with hematopoietic stem cell transplantation (HSCT)

Kirill A. Smirnov, Vladimir A. Dobronravov, Boris V. Afanasiev, Olga V. Galkina, Irina M. Zubina, Evdokia O. Bogdanova

Genomic DNA breakpoints in MLL and translocation partner genes: correspondence to clinical parameters and treatment outcome in infants with acute leukemia

Grigory A. Tsaur1, Claus Meyer2, Anatoly M. Kustanovich3, Alexander M. Popov1, Tatiana O. Riger1, Elena W. Fleischman4, Olga I. Sokova4, Yulia V. Olshanskaya5, Elena А. Matveeva5, Olga V. Streneva1, Egor V. Shorikov1, Leonid I. Saveliev6, Rolf Marschalek2, Larisa G. Fechina1

Effective treatment of mixed viral infection in a patient after haploidentical stem cell transplantation

Larisa Vakhonina1, 2, Igor Vyatkin1, 2, Natalya Maysheva1, 2, Grigory Tsaur1, 2, 3, Oleg Medvedev1, 2, Leonid Saveliev1, 2, 3, Larisa Fechina1, 2

Evaluation of bone marrow stromal cells regarding their role in hematopoietic reconstitution

Nikolai Y. Tsvetkov, Ildar M. Barkhatov, Alain I. Shakirova, Dmitri S. Romaniuk, Olesya G. Smykova, Vera V. Teplyashina, Ludmila S. Zubarovskaya, Boris V. Afanasyev

Evaluation of posttransplant relapse risk in patients with acute leukemia using the gene expression markers

Alena I. Shakirova1, Ildar M. Barkhatov1, Olga I. Shakirova2, Dmitry S. Romanyuk1, Alexei V. Evdokimov1,

Sergey N. Bondarenko1, Ludmila S. Zubarovskaya1, Boris V. Afanasyev1

Efficiency of hypoxic hypoxia during idiopathic thrombocytopenic purpura

Abduhalim R. Raimzhanov1, Irina A. Tsopova2, Mary O. Eralieva1, Bahtygul K. Aysarieva3

Instant lysis of therapeutic mesenchymal stem cells after intravenous infusion: role of complement system and in vitro prevention strategies

A. R. Muslimov, R. T. Mikhelashvili, E. V. Volchkov, K. V. Lepik, V. S. Sergeev, B. V. Afanasyev

Treatment of refractory chronic graft-versus-host disease with interleukin-2

Ivan S. Moiseev, E.A. Burmina, Olga V. Pirogova, Olga A. Slesarchuk, Sergej N. Bondarenko, Boris V. Afanasyev

Pharmacokinetic comparison of cyclosporine A and tacrolimus for graft-versus-host disease prophylaxis

Moiseev Ivan S., Muslimov A. R., Pirogova Olga V., Darskaya Elena I., Slesarchuk Olga A., Bondarenko Sergej N., Afanasyev Boris V.

Efficiency and safety of 5-azacitidine administration in acute myeloid leukemia and myelodisplastic syndrome after allogenic hematopoietic stem cell transplantation

Varvara N. Ovechkina, Sergey N. Bondarenko, Elena V. Morozova, Olga A. Slesarchuk, Anna G. Smirnova, Kirill A. Ekushov, Ludmila S. Zubarovskaya, Boris V. Afanasyev

Characteristics of early posttransplant phase in patients with multiple myeloma and different response to standard chemotherapy: single-center analysis of 130 cases

Galina D. Petrova, Kapitolina N. Melkova, Tatiana Z. Chernyavskaya, Nadezhda V. Gorbunova, Valentina N. Kostrykina, Vadim A. Doronin.

Treatment of HIV-associated lymphomas: results of a multicenter retrospective study

Popova M.1, Shneyder T.2, Karaygin I.2, Zuyzgin I.2, 10, Ryabykina O.2, Ruzhinskaya O.2, Uspenskaya O.2, Medvedeva N.3, Klimovich A.3, Potapenko V.3, Kotova N.3, Zinina E.4, Popova N.4, Zhurba Y.4, Myasnikov A.5, Moshnina S.5, Evseev A.5, Kaplanov K.6, Ksenzova T.7, Karyagina E.8, Stolypina Zh.8, Dzola S.9, Levanov A.9, Mel’sitova K.1, Borzenkova E.1, Mikhaylova N.1, Zubarovskaya L.1 and Afanasyev B.1

Graft-versus-host disease prophylaxis with post-transplantation cyclophosphamide

Olga V. Pirogova, Ivan S. Moiseev, Elena I. Darskaya, Sergej N. Bondarenko, Elena V. Babenko, Alexander L. Alyanskiy, Boris V. Afanasyev

Obituary

Regular articles

Long-term results of intramyocardial CD133+ bone marrow stem cell therapy for myocardial ischemia: experience with stem cell register

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Julia Nesteruk, Gustav Steinhoff

Reference and Translation Centre for Cardiac Stem Cell Therapy (RTC), Department of Cardiac Surgery, Medical Faculty, University of Rostock, Rostock, Germany.

Abstract

Standardization of stem cell therapy requires application of appropriate methods to evaluate safety and efficacy, including long-term pharmacovigilance. To accomplish this objective, a long-term registry program was installed in the Regeneration and Translation Center for cardiac stem cell therapy in Rostock, Germany 14 years ago. The registry program in RTC contains parameters for the evaluation of functional outcomes and safety including major adverse cardiovascular and cerebral events (MACCEs). The register follows 223 patients with a total of 1152 patient years, who are observed yearly lifelong after stem cell application or as a control groups. The present study was done in 96 patients (n=73 cell therapy, n=23 control group) with coronary arterial disease and heart failure, treated with coronary artery bypass operation with or without stem cells injections. The analysis revealed, that owing to yearly MACCE registrations, register allow that late probable complications are carefully followed as well as unexpected complication reported, which is required to ensure patient’s safety as the main aspect of Good Clinical Practice. Nevertheless, the registry by itself cannot substitute randomized clinical trials, as patient’s cohort is heterogeneous. However, registry data can be used for long term efficiency and safety evaluation in standardized patient groups. Furthermore, registry program could help to improve patient selection revealing predictors of good response and define patients who did not respond to the stem cell therapy. It is expedient to establish an obligatory common registry program for all centers, carrying stem cell studies.

Regular articles

Monitoring Therapy-Response in acute myeloid leukemia

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Robert Peter Gale

Haematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, UK.

Summary

Quantification of measurable residual disease (MRD) is increasingly used to determine whether a person with acute myeloid leukaemia (AML) in the 1st complete remission should receive a haematopoietic cell transplant. But how accurate are results of MRD-testing in this setting in predicting likelihood of leukaemia-relapse? There are 2 major determinants of accuracy of results of MRD-testing: (1) adequacy of sampling (sometime referred to as sampling-error); and (2) precision of the MRD-testing being used reflecting sensitivity and specificity of the assay.

Most analyses of the accuracy of MRD-testing are on the cohort level. E.g., most analyses of the accuracy of MRD-testing are on the cohort level. Typically, an outcome such as cumulative incidence of leukaemia-relapse, relapse-free survival for MRD`+ vs MRD- cases. The problem, for example, is that some subjects in a favourable risk cohort may have a worse prognosis than some subjects in an unfavourable risk cohort. One should mean a loss of predictive power with time post-treatment, i. e., the risk-determining variables are less powerful in a person remaining in remission at 3-4 months when a transplant decision is typically made. Other questions arise due to unidentified prognostic variables. Under these conditions, the ROC analysis shows rather low prediction accuracy. This is because of different stochastic events determining probable outcomes of the therapy applied.

Moreover, even a perfect MRD-test (100 percent sensitivity, 100 percent specificity) will have limited precision in predicting leukaemia-relapse in persons with AML in 1st complete remission. This is because of unavoidable sampling error which is further confounded by the high likelihood of leukaemia cells, and especially those causing leukaemia relapse in the blood and bone marrow. This impact would be associated with more common false-negative MRD-test results.

Moreover, AML is a genetically complex neoplasm at diagnosis and even more at the leukaemia relapse. Recently, some marker mutations previously thought to be typical of AML have been found in normal, older persons (e. g., DMNT3A, TET2 and IDH mutations). Their lack of specificity for AML would result in a substantial rate of false-positive MRD-test results.

In conclusion, although results of MRD-testing are correlated with probability of relapse in cohorts of persons with AML in 1st complete remission, there are substantial barriers to applying results of MRD-testing to recommendations for individual therapy.

Regular articles

Time- and sample-dependent differences in polyomavirus incidence following hematopoietic stem cell transplantation

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Alexey B. Chukhlovin1, Yury A. Eismont2, Vladimir N. Vavilov1, Ludmilla S. Zubarovskaya1, Boris V. Afanasyev1

1R. M. Gorbacheva Memorial Institute of Children Oncology, Hematology and Transplantology, and 2Department of Clinical Microbiology, The 1st St.Petersburg State I. Pavlov Medical University, St. Petersburg, Russian Federation

Summary

Introduction. Latent polyomaviruses are frequently activated after hematopoietic stem cell transplantation (HSCT). E.g., BK virus (BKV) infection is associated with hemorrhagic cystitis, whereas JC virus (JCV) may affect brain and other tissues. Time course of the polyomavirus activation after HSCT is poorly understood. Hence, the aim of our study was to compare age- and time dependence of BKV and JCV incidence in various clinical specimens taken from HSCT patients. Patients and Methods. We have observed 87 oncohematological patients (1 to 60 years old) subjected to allogeneic HSCT. Myeloablative conditioning was applied in 42% of cases. The patients received pre-emptive acyclovir treatment and immunosuppressive therapy with cyclosporin A. BKV, JCV, and cytomegalovirus (CMV) were assayed biweekly in blood leukocytes and urine cells, and, if indicated, in cerebrospinal fluid (CSF), or bronchoalveolar lavage (BAL), by means of gene-specific PCR. Results. Overall BKV detection rates in leukocytes, urine, CSF, and BAL were, respectively, 31% and 72%, 16%, and 21%. Appropriate prevalence rates for JC were 16%, 36%, 2%, and 19%. Strong correlations existed between BKV, JCV, and CMV positive tests in the samples. BKV prevalence in urine was increased with patients’ age. Higher BKV incidence in urine was noted at 2-3 months after HSCT. JC frequency in urine peaked at 1-3 months, as well as in BAL samples at 3-4 months post-transplant.

Conclusion

PCR positivity for BKV and JCV depends on patients’ age and time post-transplant, with maximal positivity rates for urinary cell sediments.

Regular articles

First- and second-line strategies in chronic phase CML including hematopoietic stem cell transplantation

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Rüdiger Hehlmann, Susanne Saußele

Heidelberg University, Germany

Summary

The review article is dedicated to the main principles of modern therapy in chronic myeloid leukemia (CML). Current treatment options for the chronic phase (CP) CML include Imatinib at standard or high doses (400 to 800 mg/d) and second-generation tyrosine kinase inhibitors (2-G TKIs), e. g. dasatinib and nilotinib. Hematopoietic stem cell transplantation (HSCT) is generally considered second or third line. Early SCT may be an option for non-high risk patients with low transplantation risks. According to the German CML Study Group the 10-year survival in CML has continuously improved,up to 85% with imatinib introduction. Previously, the survivors after busulfan and hydroxyurea were mostly transplant recipients. CML-Study III and IIIA compared allo-SCT with the best available drug treatment. Most authors who applied TKIs in CML, used imatinib, and HSCT (in some clinical situations). According to CML- Study IV the molecular responses (MR) achieved with imatinib in MR2 situations (an analogue of complete cytogenetic remission) may reach 92% after 10 years of observations. Introduction of the 2G-TKI (dasatinib and nilotinib) is associated with more rapidly occurring and more frequent molecular responses than with imatinib at standard dose (DASISION 5-year final study results, ENESTnd 5-year update). Increased imatinib dosage to 800 mg daily provides more rapid and deep molecular responses, as shown by appropriate meta-analysis of randomized trials, being associated with a 45% higher probability of achieving MMR after 12 months with IM 800 mg or 2G-TKIs, compared to IM 400 mg (p=0,0088).

Second-line strategies

Switching to second-line TKI treatment and/or allogeneic HSCT is recommended in cases of intolerance or drug resistance. E. g., it was concluded in the ENESTcmr Study (Hughes et al., 2014) that such transition caused more molecular responses in terms of BCR-ABL than with permanent imatinib treatment (p=0,009). The best approaches with drug treatment and HSCT at different phases of CML are described in some recent works (Jiang et al., 2011; Jabbour et al., 2011, Khoury et al., 2012). A good efficacy of allo-HSCT was shown in an update of the study by Saussele et al. (2014), with a median follow-up of 78,5 months (Fig. 1). The patients were stratified by risk. In 50-70% of cases unrelated donors served as a source of transplant. The patients transplanted in 1st chronic phase electively or after resistance to TKI therapy have shown a good 5-year survival (80%). Interestingly, the survival probability of the patients transplanted early in chronic phase was similar to that of patients’ treatment with imatinib only.

Conclusion

  • Current first-line treatment includes imatinib, dasatinib and nilotinib.
  • The proportion of patients reaching MMR by 12 months is similar with optimized imatinib and second-generation TKIs.
  • SCT is an option for the 2nd-line treatment.
  • Long-term outcomes after early SCT in chronic phase is similar to the results obtained with imatinib.
  • Early HSCT may be considered in non-high risk CP CML patients with low transplantation risk.

Short messages

Effectiveness of high-dose chemotherapy with autologous stem cell transplantation (ASCT) in patients with relapsed and refractory course of Hodgkin’s lymphoma

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Elena V. Kondakova, Natalya B. Mikhailova, Evgenia S. Borsenkova, Olga B. Kalashnikova, Nadezhda V. Medvedeva, V. V. Ryabchikova, Boris V. Afanasyev

First Pavlov State Medical University of Saint Petersburg, Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology and Transplantation, St. Petersburg, Russia

Introduction

Over last decades, the high-dose chemotherapy (HDCT) followed by autologous stem cell transplantation (ASCT) has become a leading approach to treatment of patients with relapsed and refractory Hodgkin lymphoma.

Materials and Methods

We have retrospectively analyzed a cohort of patients with Hodgkin’s lymphoma who received HDCT with autologous stem cell transplant (ASCT) over the period from September 1990 to August 2015. Treatment was performed at two clinics (SPbState Medical University, 173 patients, and 31st City Hospital, 39 patients). The study included 212 patients with relapsed and refractory Hodgkin’s lymphoma (LH). The observation period was from 6 months to 22 years, a median of 4,5 years. Average age of the patients was 26,3 years, ranging from 5 to 56 years. The study included 111 males (52,3%) and 101 female patients (47,6%).

Results

The diagnosis of Hodgkin’s lymphoma in all patients was confirmed by morphological and immunological studies. The predominant histological variant was nodular sclerosis (79%), mixed-cell variant (16%), and lymphoid depletion or lymphoid prevalence (4% and 1%, respectively), according to the WHO 2001-08 Classification. The majority of patients were at clinical stage IV (n=108), and stage III (n=45), a total of 153 (72,1%) at the time of the disease staging, according to the Ann Arbor 1971. B symptoms were registered in 168 patients (79,2%). Extranodal involvement (lung, bone marrow, bone, liver lesions) were found in 144 patients (67,9%). Early relapse was revealed in 72 (33,9%) of cases; primary-resistance was assessed for 38 patients (17,9%). 102 (48,1%) patients with permanently relapsing course. The number of initial chemotherapy courses ranged from 6 to 22 (a mean of 14 rounds). The number of the chemotherapy lines varied from 1 to 8 (3, at an average). Radiation therapy was performed for 115 patients (54,2%), with total cumulated dose ranging between 20 and 40 Gy. The average time period from diagnosis to auto-HSCT was 29 months (6 to 49 months). Following chemotherapy, a complete remission (CR) was achieved in 54 patients (25,4%), partial remission (PR), in 55 (25,9%). 38 patients (17,9%) had a stable disease (SD), whereas progression of the disease was diagnosed in 65 patients (30,6%). BEAM conditioning regimen was conducted for 101 patients (47,6%), CBV protocol, in 45 cases (21,2%). Since 2005, some other conditioning regimes were performed, e. g., R-BEAM (with Rituximab) was administred to 3 patients (1,4%). Since 2011, BeEAM with bendamustine was used for 48 patients (22,6%). 15 patients received other treatment regimens. Efficiency evaluation of treatment before autologous stem cell transplants (ASCT) was determined by the following criteria: complete remission (CR), partial remission (PR), stabilization (SD) and progression (P), according to Cheson (1999). Since 2007, PET-CT with 18FDG was performed in 89 patients (41%), to assess the remission state. Most HSCT patients (n=128, 60,3%) received peripheral blood stem cells (PBSC), 68 patients (32%) were treated with bone marrow cells, and 16 patients (7,5%) received a combination of PBSC and bone marrow. The number of infused CD34+ cells varied from 1,6 to 17,5×106 (a mean of 3,8×106). Average time of granulocyte engraftment >500×106 was observed from 8 to 69 days (a mean of 18,3 days), recovery of platelets (>20×109) occurred at the mean terms of 17,8 days. Graft failure was registered in 3 patients who died with concomitant infections before the hematopoietic recovery. 123 (58%) patients are still alive, and 89 patients deceased (41,9%). HL progression was the main reason for the death. 24 patients died during the early post-transplant period (till D+100), accounting for 11,3%. Twenty-one patients died from progression of the underlying disease, 3 of infectious complications. Two patients died in remission state (myocardial infarction, 1; tuberculosis, 1). Other causes of death were as follows: progression of sepsis; secondary tumor. Overall survival (OS) depended on the remission status at the time of transplant: for the patients in СR, 79.6%; for the cases of partial remission (PR), 67,7%; for stable disease (SD), 57,8%. HSCT performed in progression was associated with OS of 32,3%. The difference is statistically significant (p=0,0000). Event-free survival in patients with relapsed and refractory Hodgkin lymphoma was over 40%. Twenty-six patients who relapsed after autologous stem cell transplantation (ASCT) were then subjected to allo-HSCT. Of them 16 patients are alive, and 10 died (61,5%). Lethality was associated with disease progression in HL patients (n=7), and single cases of severe GVHD, zygomycosis, aspergillosis.

Conclusions

Overall survival of the patients with relapsed and refractory course of Hodgkin’s lymphoma who received high-dose chemotherapy with autologous stem cell transplantation (ASCT) was 58%. To improve the results of treatment, one may introduce combinations with novel drugs, e.g., anti-PD-1 monoclonal antibodies (Keytruda, Pembrolizumab).

Short messages

Hematopoietic stem cell transplantation in patients with neurometabolic diseases: a single center experience

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Kirill I. Kirgizov1, 2, Ekaterina A. Pristanskova1, Yulia V. Skvortsova2, Natalia L. Pechatnikova1, Marina Y. Persiantseva2, Natalia V. Sidorova1, Dmitry N. Balashov2, Veronika V. Konstantinova1, Oxana L. Blagonravova1, Svetlana M. Mikhailova1, Elena V. Skorobogatova1, Aleksey A. Maschan2

1 The Russian Children’s Research Hospital, Moscow, 2 Dmitry Rogachev Federal Research Center of Pediatric Hematology, Oncology and Immunology, Moscow

Introduction

Allogeneic hematopoietic stem cell transplantation (HSCT) is now increasingly used for the patients with inborn neurodegenerative disorders. It is quite important to provide HSCT for such cases in the early childhood.

Patients and methods

Twenty-seven HSCTs were performed and analysed during the period of 2002 to 2014. The children under study were with Hurler
syndrome (n=19), X-linked adrenoleukodystrophy (ALD) (n=4), metachromatic leukodystrophy (n=3), Krabbe disease (n=1). In 20 cases, a matched unrelated HSCT were performed in 20 cases. Matched related donors were used in 7 cases. In general, HSCT with HLA matching of 9/10 was carried out in 20% of cases (n=4), with 10/10, in 80% (n=16). The sources of stem cells were as follows: bone marrow, 74,1% (n=20); peripheral blood stem cells, in 18,5% (n=5); cord blood cells, 7,4% (n=2). The median of age was 4,1 years. Conditioning regimen included Busulfan/Treosulfan+Fludarabine+Thiotepa/Melphalan, and ATG+Rituximab in cases of MUD HSCT.

Results

Nearly all of the 20 surviving patients developed a complete donor chimerism (n=19), and showed good response to the therapy. A better response correlated with shorter interval from diagnosis to transplant. One patient rejected the graft, however, remaining alive. The causes of death were as follows: infection, 57,1% (n=4); GvHD, 28,6% (n=2); late progression, 14,3% (n=1). Our experience form the last 5 years demonstrates better outcomes, due to more effective infection control and GvHD prevention. Three patients with X-linked ALD exhibited aGvHD grade III-IV, of them only one patient survived at the early terms, however, died 7 years after HSCT because of the disease progression. The long-term observations lasted for a median of 40,5 (7 to 128) months. Estimated probability of overall survival was 51,4%, event-free survival, 49,3%.

Conclusion

Our results suggest that HSCT for the patients with neurometabolic diseases is an effective way to hamper neurodegenerative events, in case of successful transplant outcome. Over last years, the results of HSCT become better, due to improved control of infection and GvHD. The X-linked ALD patients require additional measures for GvHD prevention.

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Aberrant methylation of promoter regions of sox7, p15ink4b and WNT pathway antago- nist genes in patients with myelodysplas- tic syndrome

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Ivan I. Kostroma, Sergey V. Gritsaev, Zh. Yu. Sidorova, S. A. Tiranova, S. P. Svitina, Yulia S. Drizhun, Irina S. Martinkevitch, Kudrat M. Abdulkadyrov, Sergej I. Kapustin, Alexander V. Chechetkin

Russian Research Institute of Hematology and Transfusiology, St. Petersburg, Russian Federation

Introduction

Epigenetic aberrations, including hypermethylation of CpG islands in tumor suppressor genes, are supposed to be a key mechanism of myelodysplastic syndrome (MDS) development. The aim of study was to find out the association between methylation status of SOX7, p15INK4b, SFRP1, SFRP4 and SFRP5 genes and some hematological features and overall survival (OS).

Patients and methods

We have analyzed the data of 46 MDS patients with median age of 67.5 years were analyzed. MDS was diagnosed according to WHO classification. Methylation-specific PCR was used to study the methylation status.

Results

Aberrant methylation of ≥1 genes was found in 43 patients (93,5%). The most frequent findings was methylation of SOX7 (84,8%), SFRP1 (71,7%) and p15INK4b (54,3%) genes. The methylation of 1, 2, 3, 4 and 5 genes was detected, respectively, in 10,9%, 28,3%, 26,1%, 19,6% and 8,7% of patients. There was no any difference in the number of patients with SFRP1, SFRP4, SOX7 and p15INK4b methylation in the groups with different bone marrow blasts counts. Methylation of SFRP5 gene was more frequently seen in patients with refractory anemia with excess of blasts (RAEB): 43,5% vs 13,0% in patients without excess of blasts; OR=5,1, 95%CI: 1,2-22,3, p=0,047. The patients without excess of blasts were characterized by methylation of 0-1 genes: 26,1% vs 8,7% of RAEB patients, although the difference was not significant. At the same time, there was a tendency for increased number of cases with 3-5 methylated genes in patients with 10-19% blasts, as compared to patients with 5-9% blasts. In total MDS group there was no correlation found between the number of methylated genes and patients’ age, number of bone marrow blasts or karyotype changes. Increased number of methylated genes did not influence the OS values among the MDS patients.

Conclusion

We conclude that MDS progression is associated with enhancement of epigenetic disturbances leading to increased number of methylated genes, in particular, SFRP5.

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Chimerism analysis after allogeneic hematopoietic stem cell transplantation as a prognostic factor of relapse in hematopoietic malignancies in children

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Victoria A. Lavrinenko, Yulia E. Mareiko, Tatsiana V. Savitskaya, Mikhail V. Belevtsev, Olga V. Aleynikova

Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus

Introduction

Allogeneic hematopoietic stem cell transplantation (alloHSCT) has become an important treatment method for many hematopoietic malignancies. Relapse of the underlying disease after alloHSCT remains the most common cause of transplantation failure. It has been shown in many studies that the patients with hematopoietic mixed chimerism (MC) were at higher risk of relapse after alloHSCT. MC was recognized as an important predictor of relapse and can serve as an index for preventive immunotherapy administration which may cause improvement of treatment outcomes in the high-risk patients after alloHSCT. In the majority of studies, the chimerism analysis had a sensitivity of 1 to 5% and depended on the method of its registration. Moreover, there are no exact threshold chimerism values for individual relapse prediction. The aim of this study was to evaluate hematopoietic chimerism in patients after alloHSCT and to determine the threshold chimerism levels which may predict relapse.

Patients and Methods

We have studied chimerism levels in 51 patients with malignant diseases, following 54 HSCT (three patients received 2nd HSCT). The patients with various oncohematological diseases (acute lymphoblastic leukemia, acute myeloid leukemia, myelodysplastic syndrome, non-Hodgkin lymphoma) underwent allogeneic HSCT at the age of 0,6-29 (a median of 10 years old) between May 2009 – May 2015. The chimerism evaluation was performed by polymerase chain reaction of short tandem repeats (STR-PCR) with commercial AmpFlSTR® SGM Plus® PCR Amplification Kit (Applied Biosystems), and capillary electrophoresis (sensitivity 1 to 5%). The samples were taken at the days +30, +45, +60, +80, +100, +140, +180, +245, +365, and bi-annually at later terms. At the chimerism levels of 97-100%, the result was confirmed by a more sensitive method (±0,01%) using real-time PCR detection of insertion/deletion polymorphisms (InDel-PCR). The samples collected at the time of documented relapse and afterwards were excluded from the main analysis.

Results

We determined background levels of recipient DNA in the samples after alloHSCT in 40 patients with successful engraftment, stable chimerism values, or decreasing MC in absence of relapse. The appropriate range of donor chimerism (DC) was 99,0 to 100% on D+30 and 99,7 to 100% at later terms (90th percentile). The DC of 99,7% was established as the threshold value which may be predictive for a relapse. The detectable chimerism levels following alloHSCT could be classified as follows: Mixed chimerism (MC) of >99% on day +30 and very low MC levels at later terms 99,7-100%, n=36; 3 relapses (group A); MC of >99% on day +30, and MC on subsequent days 99,7-100%, with episodes of DC<99,7%, n=9, 6 relapses (group B); MC of<99% on day +30, and decreasing MC on later terms reaching DC of >99,7% on day+45 to day+100, n=3, relapse-free (group B); MC on day +30<99%, then decreased MC on subsequent days, however, not reaching 99,7%, followed by increase in recipient cells, n=1, relapsed (group B); MC<99% on the day +30, followed by increased MC and graft rejection, n=1, relapse-free (high-level minimal residual disease); no engraftment, n=2, 1 relapse. Two patients were not included into analysis, since they had no available markers for InDel-PCR, they exhibited 100% of DC by STR-PCR. According to the individual chimerism dynamics, we have classified the patients as follows: group A – patients with DC >99,7% including those with decreasing MC who reached DC level >99,7% and group B – patients with DC<99,7%, including those with decreasing MC not reached DC level 99,7%. There were 39 alloHSCT patients in group A. Only 3 patients (7,7%) relapsed on the days +195, +255 and +1184. In two cases (relapsed after 200 days) we couldn't predict an impending relapse, due to long time between last DC testing and relapses (>68 days). The patient who relapsed on day +195 received a highly intensive immunosuppression because of treatment complications. Group B consisted of 10 alloHSCTs, with relapse in 7 cases (70%). The time period between relapse and MC increase (DC<99,7%) was 1 to 41 days (a median of 28 days). In two relapse-free children, a reconstitution of DC to >99,7% was observed at later terms, unlike relapsed patients who exhibited increase in recipient cells. The third patient (without relapse) died from the therapy complications at the DC level of 92,9%. There were significant higher probability of relapse in group B (with DC level<99,7%), as compared to the group A patients with DC >99,7% (p=0,0001). The two-year EFS was 16,9% for group B and 93,6% for group A (p=0,00001).

Conclusions

Analysis of chimerism in the patients with hematopoietic malignances requires more sensitive methods (InDel-PCR) than the "golden standard" STR-PCR, in order to predict a developing clinical relapse. Those patients who have not reached chimerism level >99,7%, or showed a reduced DC level of<99,7% after alloHSCT, were at higher risk of relapse. A more frequent chimerism monitoring is recommended for this group of recipients.

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Low-dose cytarabine and cladribine for treatment of relapsed or refractory acute myeloid leukemia: clinical experience

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Sergej V. Gritsaev, Ivan I. Kostroma, Anastasia A. Kuzjaeva, Irina M. Zapreeva, Elena V. Litvinskaya, Lubov V. Steljmashenko, S. A. Tiranova, Irina S. Martinkevitch, Nadezhda A. Potichonova, Kudrat M. Abdulkadyrov.

Russian Research Institute of Hematology and Transfusiology, St.-Petersburg

The aim of this study was to evaluate the efficiency of low-dose cytarabine (Ara-C) combined with cladribine for treatment of relapsed/refractory acute myeloid leukemia (AML) and to determine the factors associated with response to the therapy. Patients and Methods. We have analyzed clinical data of the ten AML patients (26 to 58 years old; median, 48), with the following diagnoses: de novo AML (n=7); secondary AML (n=2), and refractory anemia with excess of blasts (RAEB-2, n=1). Four patients had refractory AML; clinical relapse was revealed in three cases. The ‘7+3’ induction regimen was ineffective in the RAEB-2 patient. There was no response to any therapy applied in the patients with secondary AML. The treatment schedule consisted of Ara-C (10-15 mg/m2 SC twice a day for 1-14 d), and cladribine (5 mg/m2 IV for 1-5 d). The course should be repeated in cases of >50% decrease in marrow blast counts.

Results

According to the protocol, the patients underwent 1-2 courses of the treatment. All the patients received cladribine, according to the protocol. This protocol lasted from 7 to 21 days, depending on the patients’ status or severity of complications. Two patients achieved complete response (CR) and 3, or partial response (PR). Myelosupression was the common complication. All the patients received blood transfusions. The duration of response was 2 to 3 mo. Allogeneic stem cell transplantation was performed in 2 patients with CR. Noteworthy, AML progression in one patient was confirmed at the start of conditioning regimen. All the patients with CR and PR were initially diagnosed with de novo AML; there were no FLT3 or c-KIT mutations, and duration of therapeutic course was >10 days. Conclusion. Low-dose Ara-C combined with cladribine may be a treatment option for some patients with relapsed or refractory de novo AML without FLT3 or c-KIT mutations.

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Mesenchymal stem cells: multilayer polyelectrolyte microcapsules uptake, toxicity and influence upon functional properties

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K. V. Lepik1, V. S. Sergeev1, A. R. Muslimov1, D. S. Romanyuk1, R. T. Mikhelashvili1, I. S. Moiseev1, E. V. Popova2,I. L. Radchenko2, A. D. Vilesov1, G. B. Sukhorukov2, 3, B. V. Afanasyev1

1 The First St. Petersburg State I. Pavlov Medical University, St. Petersburg, Russia.

2 Peter the Great St. Petersburg Polytechnic University, RASA-center, Russia,

3 Queen Mary University of London, UK

Introduction

Multilayer polyelectrolyte microcapsules are gathering an increasing interest as novel mean for drug delivery, a diagnostic and investigational tool. The main advantages of these microcapsules are their well-controlled size and shape, finely tuned wall thickness, and variable wall compositions enabling controlled release of their content via magnetic field, light and/or ultrasound exposure. Ease of surface modification allows further functionalization of the microcapsules. At this point, mesenchymal stem cells (MSCs) represent a popular cell model in the wide range of clinical and scientific trials. Currently, there is a lack of data concerning efficiency of microcapsules uptake by the MSCs, and their influence on functional properties of these cells.

Materials and methods

Bone marrow-derived MSCs were isolated using a standard operating procedure. The cells harvested from the second and third passages were used for further experiments. The study included two main sections: in the first arm, a suspension of magnetic PAH/PSS FITC-labeled microcapsules (3-5 μm in size) were added to the surface-adhered MSCs at the cell/particle ratios of 1:1, 1:5, 1:10, 1:20. In the second arm, the same preparations of microcapsules were added to the MSC suspensions at the same ratios. After 24 h of incubation, the uptake rates were tested by means of confocal microscopy and flow cytometry. Cell morphology and viability was tested by differential counting in haemocytometer using trypan blue and propidium iodide vital dyes. Differentiation capacity of the cells was tested using standard staining for osteogenic and adipogenic differentiation. Magnetic separation of MSCs bound with magnetic-labeled microcapsules was tested using midiMACS cell separation system. Adhesive properties of MSCs were tested as follows: MSC associated with microcapsules at the ratios of 1:5; 1:10; 1:20 were seeded into the cultural flasks at the concentrations of 20x104/cm2 under standard conditions. After 24-h incubation, the culture medium was removed, adherent cells were detached with trypsine/EDTA. Both suspension and adherent cell fraction were counted by means of haemocytometer and normalized agains a control group (without microcapsules).

Results

The cell-capsule association rates correlate with numbers of added capsules and the method applied. Average proportion of adherent cells associated with microparticles is, respectively, 8% (at 1:1 cell/capsule ratio); 18% (1:3 ratio) 32% (1:10 ratio). Similar testing of MSC/particle contacts in suspension phase yielded more impressive results: 90% at the 1:1 ratio; 98% (1:3 ratio); 99% (1:10 ratio). Single cells are able to capture up to 30 microcapsules (at 1:20 cell/capsule ratio). Further increase of the microcapsule concentrations do not lead to significant enhance of their uptake by the cells. A lesser part of capsules are only associated with membrane, but not internalized by cells. Following internalization, the microcapsules are dispersed in cytoplasm, mainly, in the perinuclear compartment. Mean percentage of viable cells after 24 h of incubation of MSCs with microcapsules, normalized for the control group results, was 90% (at the 1:5 cell/capsule ratio); 85% (1:10); 83% (1:20 ratio), 5% (1:100 ratio). The cells, associated with microcapsules can be isolated with high efficiency by routine magnet separation methods. The ability of MSCs for osteogenic and adipogenic differentiation was not significantly affected by the microcapsules uptake. Conclusion. Adhesion assay has shown that adherent fraction of the culture-plated cells treated with capsules was significantly decreased in dose-dependent manner, i. e., average percentage of adherent cells was 85% (1:5 ratio); 64% (1:10 ratio); and 38% (1:20 ratio), in comparison with 85% adherence in untreated control group.

Conclusions

Polyelectrolyte microcapsules can be internalized by MSCs at a high efficiency. Cell suspension provides optimal conditions for effective capsule uptake. Polyelectrolyte microcapsules show very mild toxicity and only minimally influence cell functions under the cell:capsule ratio of<1:10. A significant decrease in cell viability was observed only in experiments with very high (1:100+) cell/capsule ratio. The ability of MSCs for osteogenic and adipogenic differentiation was not impaired by the microcapsules uptake. Adherent fraction of the plated capsule-exposed cells was significantly decreased in a dose-dependent manner. Ingestion of microcapsules at high amounts causes inhibition of MSCs adherence Polyelectrolyte microcapsules may be considered a promising tool for diagnostics, therapeutic interventions and investigational approaches, due to potential ability of controlled cell delivery using external magnetic fields.

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Results of high-dose chemotherapy with autologous hematopoietic stem cell transplantation in treatment of pediatric brain tumors

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Asmik G. Gevorgian1, Elena V. Morozova1, Ilya V.Kazantsev1, Tatiana V. Iukhta1, Svetlana A. Safonova1, Yury A. Punanov1, Ludmila S. Zubarovskaya1, Olga G. Zheludkova2, Boris V. Afanasyev1

1 Gorbacheva Memorial Institute of Children Oncology, Hematology and Transplantation, St. Petersburg Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia 2 Scientific Center of Roentgenoradiology, Moscow, Russia

Aim

Central nervous system (CNS) tumors are the second most common pediatric malignancies, with a ca. 30% rates of 5-year overall survival in the high-risk group. The aim of this study was to assess effectiveness of high-dose chemotherapy (HDCT) with autologous hematopoietic stem-cell transplantation (auto-HSCT) in this patient group.

Methods

From 2008 to 2015, 54 pediatric patients with high-risk or relapsed medulloblastoma (N=32), supratentorial PNET (N=8), germinoma (N=6), pineoblastoma (N=3), atypical teratoid rhabdoid tumor (N=3), choriocarcinoma (N==), ETANTR (N=1) received single or tandem HDCT with auto-HSCT after induction chemotherapy, radiotherapy and surgical treatment. At the moment of HDCT 25 patients were in complete remission (CR), 24 patients were in partial remission (PR) and 5 patients had stable disease (SD). The conditioning regimen for single auto-HDCT (N=47) consisted of Cisplatin, Etoposide, and Ifosfamide, or Carboplatin, Etoposide and Thiotepa +/- intraventricular etoposide, or Thiotepa and Temozolomide. In tandem HDCT (N=7), the first conditioning regimen included carboplatin and etoposide with intraventricular/intrathecal Methotrexate, the second was Thiotepa and Cyclophosphamide with intraventricular/intrathecal Methotrexate.

Results

The median follow-up was 48 months (range, 5–173). The median time to engraftment was day +17 (range, 8–86) after auto-HSCT. Four of 5 patients with SD by the moment of auto-HSCT had disease progression within 8 months after HDCT. Twenty-two of 49 patients with CR or PR relapsed 1 to 24 months after HDCT, the other 27 patients are currently in CR or PR on the maintenance therapy. Cumulative incidence of relapse in 4 years accounted 45% (95% CI 21%-60%). The conditioning regimens had acceptable toxicity. Grade 4 complications (according to COMMON TOXICITY CRITERIA 2014) were observed in 14% of the cases. Four-year overall survival (OS) in the total patient’s group was 67% and disease free survival (DFS), 55%. MB and germ cell tumors were associated with better survival rate (OS 74% and 66%, respectively) in compared to other embrional tumors (DFS 54%, p=0,18).

Conclusions

HDCT with auto-HSCT in pediatric patients with high-risk CNS tumors may be a feasible option for patients in CR or PR after induction chemotherapy. It is ineffective as a salvage therapy in refractory patients. Keywords: medulloblastoma, PNET, germinoma, pineoblastoma, high-dose chemotherapy with autologous hematopoietic stem-cell transplantation.

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Allogeneic stem cell transplantation in myelofibrosis patients with intermediate-2 and high DIPSSplus risk

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Maria V. Barabanshikova, Elena V. Morozova, Vadim V. Baikov, Ludmila S. Zubarovskaya, Boris V. Afanasyev

Raisa Gorbacheva Memorial Institute of Children’s Oncology, Hematology and Transplantation

First I. Pavlov State Medical University of St. Petersburg, Russia

Introduction

Myelofibrosis (MF) is BCR-ABL–negative myeloproliferative disorder with progressive clinical course and usually poor prognosis. Current therapeutic options for patients with MF do not demonstrate a significant impact upon the disease course. Allogeneic stem cell transplantation (alloHSCT) is currently the only treatment option with curative potential in patients with MF, especially in case of intermediate and high risk categories. Patients and methods. We analyzed the results of alloHSCT in 10 patients aged 30 to 49 (a median of 41) years. 3 patients were diagnosed with post-PV (Polycythemia Vera) myelofibrosis; 7, with primary myelofibrosis. According to the DIPSSplus score, three patients belonged to intermediate-risk group (2 points), and five patients had a high-risk disease. Two patients received alloHSCT for MF in blast phase. Five patients were positive for JAK2V617F mutation before alloHSCT; one patient had a calreticulin (CALR) mutation. Two patients were pretreated with ruxolitinib for 4 and 6 months, respectively. One patient experienced stabilization and the other, disease progression. A reduced intensity conditioning regimen (fludarabine 180 mg/m2 plus busulfan 8 mg/kg, or FLAMSABu 8 mg/kg) followed by alloHSCT from related (3) and unrelated donors (7) was performed. 7 patients with unrelated donors received ATGAM (lymphocyte immune globulin). Graft-versus-host prophylaxis was performed with Tacrolimus/ Methotrexate in eight patients, Tacrolimus/ Mycophenolate, in one patient, and Cyclosporine A/ Methotrexate, in two cases. The hematopoietic stem cell (HSC) sources were either G-CSF-mobilized peripheral blood progenitor cells for five patients, and bone marrow in five other cases. Median number of CD34+cells was 4,3 × 106 (1,95 – 8,0) per kg weight. Results. Primary HSC engraftment was documented in 8 of 10 patients. One patient developed acute GVHD on day 86 after transplantation, one patient, chronic GVHD, one patient, disease progression. Bone marrow fibrosis regression, development of full donor chimerism, and JAK2V617F-negativity were achieved in four patients after HSCT (Fig. 1). One-year overall survival was 46,7% (Fig. 2).

Conclusion

AlloHSCT is effective treatment modality for myelofibrosis. Patient- and disease- related factors should be taken into account in deciding the optimal time to consider alloHCT in order to gain the greatest benefit to the patient from such a high-risk procedure. Pretransplant JAK2-inhibitors administration may have beneficial effect on the transplant outcome.


Figure 1. Bone marrow fibrosis before alloHSCT. Collagen fibrosis grade 3, megakaryocyte proliferation with cluster formation (a).

Bone marrow histology day 365 after transplantation. Normal megakaryocytes. No sings of bone marrow fibrosis. Magnification X 400. H&E (b).


Fig. 2. Overall survival in patients with myelofibrosis after alloHSCT

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Epidemiology and risk factors for bacterial infections (BI) in children and adolescents after allogeneic hematopoietic stem cell transplantation (allo-HSCT)

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Maria Yu. Averianova1, Vladimir N. Vavilov1, Natalia V. Stancheva1, Svetlana V. Razumova1, Anastasia S. Borovkova1, Olesya V. Paina1, Polina V. Kozhokar1, Kirill A. Ekushov1, Andrey V. Kozlov1, Yulia G. Fedukova1, Inna V. Markova1, Yana V. Gudozhnikova1, Anna A. Spiridonova1, Nadezhda А. Schaliapina2, Svetlana A. Riachovskych2, Anna V. Lubimova2, Ludmila S. Zubarovskaya1, Boris V. Afanasyev1

1 R. M. Gorbacheva Memorial Institute of Children Oncology, Hematology and Transplantation, First Saint Petersburg I. Pavlov State Medical University St. Petersburg, Russian Federation; 2 I. I. Mechnikov Northwest State Medical University, St. Petersburg, Russian Federation

Introduction

Infections are the most common complications in allo-HSCT. Over recent years, the origins of infectious complications have undergone some changes associated with extended indications, usage of alternative HSC sources, introduction of new drugs, e.g., monoclonal antibodies (MAbs) and cytotoxic drugs, which exhibit specific immunosuppressive effects. The aim of present study was to epidemiological survey, evaluation of frequency, and specific features of BI occuring in children and adolescents, during the first year after allo-HSCT of different types. Materials and methods. The study included 155 pediatric and adolescent patients observed following allo-HSCT. Prevention of infectious complications in the allo-HSC recipients was performed in accordance with Recommendations of the European Conference on Infectious Complications in Leukemia (ECIL 1-4th Edition). Identification of the microbial isolates was performed using an automatic analyzer «VITEK-2» (BioMerieux, France). Results. Development of BI after allo-HSCT was registered in 80% of the patients. The five-year overall survival rate among patients undergoing BI versus BI-free patients was, respectively, 36,3% and 87,1% (p<0,001). When analysing pattern of the isolated pathogens, we have revealed an increased proportion of gram-positive (GP) bacteria with time (47% in 2010-2013 vs 42% in 2008-2009, p<0,001), at the expense of Enterococcus spp. (14% in 2008-2009 vs 19,5% in 2010-2013, p=0,015), vancomycin-resistant enterococci (VRE) (4% in 2008-2009 vs 9,5% in 2010-2013, p=0,049). A growing proportion of Enterococcus spp. over 2010-2013 was due to increased number of E.faecalis strains (from 10% to 13%), E.faecium (VRE), from 17,1% to 24,7%, respectively, for 2011 and 2013 (p=0,05). The spectrum of the BI pathogens proved to be dependent on the time period post-HSCT, i. e., Gram-positive agents were prevalent before the HSC engraftment (p=0,037). At the later terms, all the pathogens were found at lower rates, especially, E.coli, Enterobacter spp., Acinetobacter spp., Citrobacter (p=0,001). The BI clinical patterns, generally, did not depend on the period post-HSCT, most often presented with bacteremia (38,7%), respiratory infections (22,5%), ORL-, and soft tissue lesions (14%). Nevertheless, the urinary tract infections proved to be more common at the earlier post-transplant terms as compared to the later period (p = 0,004). The most significant underlying risk factors for BI were as follows: acute leukemia (p=0,044); severe infectious complications preceding allo-HSCT (p=0,001); oral cavity colonization with pathogenic and opportunistic microflora (e. g., Enterococcus spp., Gram-negative bacteria, p=0,015); acute GVHD of grade III-IV (p=0,002); prolonged corticosteroids for treatment of acute GVHD (p=0,008); administration of immunosuppressive MAbs in chronic GVHD (p=0,036); severe hypogammaglobulinemia requiring IVIG replacement therapy (p<0,001); CMV and/or HSV infection after allo-HSCT (resp., p=0,001, and p=0,043). The rate of microbial resistance to ciprofloxacin was 38% over the period of 2008-2009, then followed by increased resistance over 2010-2013 – 65% (p<0,001), especially for Kl.pneumoniae (p<0,001) and Enterobacter spp. (p=0,005), E.coli (p<0,001), as well as GP cocci, i.e., S.epidermidis (p<0,001). Conclusions. There are several important clinical factors associated with the risk of BI observed after allo-HSCT. Epidemiological monitoring of specific pathogens should be also performed. Changes in the microbial pattern and sensitivity to antibiotics among the BI pathogens makes it necessary to revise the intestinal decontamination programs, since gut is a reservoir for 90% of the multidrug-resistant strains. The strategy of empirical and targeted antimicrobial prescription should be considered as well.

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Prevalence of hematological malignancies in Armenia

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Smbat S. Daghbashyan, Nata A. Melkikyan, Lussine.S. Sahakyan, M.V.Saharyan, R.Yolyan

Center of Haematology, Yerevan, Republic of Armenia

Introduction

Growing rates of malignancies represent one of the most topical problems, affecting the interests of the entire mankind. Hematological malignancies make a heterogeneous group of diseases with different incidence, prognosis and etiology. The prevalence rate of hematological malignancies is rather lоw (ca. 10/100,000 per year) and takes the 6-8th place among the entire tumor morbidity (6-7% of total). In developed countries, hematological malignancies make 1% of all death causes. Their share is 6-10% among all causes of death from malignancies, and it makes 50% among younger patients (<30 years of age). When classifying the hematological neoplasms, most researchers distinguish the following groups: Hodgkin’s and non-Hodgkin’s lymphomas (HL and NHL), leukemias (acute and chronic). Taking into account that Armenia is an ethnically homogeneous country (97,9% are Armenians), any epidemiologic study becomes a population or cohort study, thus creating good prospects for conducting experimental and clinical trials.

Aim

The aim of our work was to carry out analysis of the hematological malignancies, i.e., their prevalence, incidence and mortality rates among the Armenian population for the time period of 2004-2014.

Material and methods

The initial data for this survey have been derived from ambulance/dispensary cards, hospitalization journals, and clinical data from the Registry of Blood Diseases at the R.Yolyan Hematology Center, Yerevan, Armenia. The data has been supplemented by the data from the Registry of Oncological Diseases of the V. Fanarjyan NCO, as well as from death certificates. The demographic data has been obtained from the National Statistics Board of Republic of Armenia. The obtained data has been statistically analyzed using EPI INFO-2002 program. “Rough” and standardized indices have been calculated. Appropriate comparisons with the data form national and regional statistics has been conducted with parametric criteria.

Results

Analysis of the data obtained has shown that, in terms of morbidity incidence, we could see that Hodgkin’s and non-Hodgkin’s lymphomas, as well as acute leukemias, take the 1st position (accordingly 3,6; 3,4 and 3,2). In terms of prevalence, the non-Hodgkin’s and Hodgkin’s lymphomas, chronic lymphocytic leukemia (CLL) followed by acute leukemias are the predominant clinical entities (accordingly 20,9; 19,8; 17,4 and 16,6).The prevalence-to-incidence ratio revealed high rates for CLL (14,1), myeloproliferative disease (MPD) (12,4) and CML (9,6), thus reflecting a high survival rate of patients in these groups. The distribution of cases by gender in both events is almost identical (p<0,001). It is important to note that, in female population, hematological malignancies are in the 3rd position, whereas for male cohorts, it is in the 4th place among all oncological diseases in Armenia. In our study, acute leukemias prevailed in childhood, and among patients aged of 15 to 24 yeas old. In the age group of 25 to 34 y. o., HL was predominant, whereas in older age groups, NHL was more frequent (p<0,001). Cases of CLL, MPD and multiple myeloma were not registered in the age groups of 0 to 14 and 15 to 24 y. o. Among all age groups, the cohort >55 y. o. should be mentioned, since the highest morbidity rates of all blood/lymphoid cancers were observed in this age group. When comparing incidence of hematological malignancies in Armenia to appropriate data from abroad, a similarity is revealed with Russia and Germany. If comparing our data to those obtained for 1966-1971 and 1998-2004 periods, one may detect a significantly increased incidence of hematological malignancies among population, due to higher rates of lymphoma and multiple myeloma. The highest mortality rates were revealed among patients with acute leukemias and non-Hodgkin’s lymphomas. Notably, higher morbidity rates in females were observed only for multiple myeloma. With other malignancies, mortality among males was prevalent (p<0,001). Thus, the statistics performed have revealed a significantly increased prevalence of hematological malignancies, due to growing ratio of lymphomas and multiple myeloma. The obtained results may help in optimal implementation of onco-hematological aid in the population and planning of clinical research in the Republic of Armenia.

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Significance of matrix metalloproteinase-9 evaluation in the bone marrow plasma from the patients with acute myeloid leukemia and myelodysplastic syndrome

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I. F. Lesnichenko, Sergej V. Gritsaev, Ivan I. Kostroma

Russian Research Institute of Hematology and Transfusiology, St. Petersburg, Russia

The levels of matrix metalloproteinase-9 (MMP-9) were determined in bone marrow plasma (BMP) of eighty-seven patients, in order to assess clinical significance of this parameter. The study group involved thirty-nine patients with acute myeloid leukemia (AML), including 22 cases in complete remission (AML-CR), and 17 patients in active phase (AML-AP). Moreover, forty-eight patients with myelodysplastic syndrome (MDS) were observed, including 31 cases at high IPSS risk (MDS-HR with >5%<19% blasts in BM), and 17 cases with low IPSS risk (MDS-LR with<5% blasts in BM). Plasma MMP-9 concentrations were determined by means of a Human MMP-9 Immunoassay test kit (R&D Systems, USA). The mean level of MMP-9 in AML-CR was significantly higher than in AML-AP: 426,80±74,85 vs 73,20±51,43 ng/ml (p=0,0001). In MDS group, the mean level of MMP-9 was significantly higher in MDS-LR than in MDS-HR: 274,90±78,93 vs 120,10±38,72 ng/ml (p=0,021).When comparing different AML and MDS subgroups, it was shown that MMP-9 levels in MDS-LR and MDS-HR groups were significantly higher than in AML-AP (p=0,001). This finding was supposed to be associated with higher marrow blast counts in AML patients, than in MDS patients. At the same time, there were no significant differences between MMP-9 levels in MDS-LR and AML-CR (p=0,086). A dynamic MMP-9 monitoring has revealed that the MMP-9 levels in bone marrow plasma of three AML and two MDS patients who have achieved CR following chemotherapy, did increase, respectively, 5-15, and 6-17 times over the initial values. For relapsing patients, an opposite situation was revealed. The results obtained show that MMP-9 levels are associated with size of the malignant clone(s), and, therefore, they could be considered a promising marker for evaluation of treatment efficiency.

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Impact of cytogenetics on outcome of acute myeloid leukemia after allogeneic hematopoietic stem cell transplantation

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Tatiana L. Gindina, Nikolay N. Mamaev, Sergey N. Bondarenko, Alexander L. Alyanskiy , Olga A. Slesarchuk, Ivan S. Moiseev, Olga V. Pirogova, Svetlana V. Razumova, Lyudmila S. Zubarovskaya, Boris V. Afanasyev

Background and aims

Chromosomal abnormalities (CA) seem to be the most important prognostic factor in acute myeloid leukemia (AML). However, it is still not clear whether the cytogenetic risk groups established for the patients, treated by standard chemotherapy, are equally predictive for the patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT). Recent studies have confirmed negative effects of both monosomal and complex karyotypes (MK, CK) on outcomes after allo-HSCT [1, 2]. Meanwhile, some investigators consider that immune effects of allo- HSCT can reduce negative impact of these CA [3]. The aim of this work was to evaluate impact of the CA in AML patients with adverse cytogenetic risk group on outcome after allo-HSCT.

Patients and Methods

In this study we have analyzed clinical outcomes of allo-HSCT for 97 AML patients having been performed at a single institution between 2009 and 2014 years. The group included 53 males and 44 females, mean age, 25 years (1,5 to 60). Cytogenetic changes were as follows: 3q26 rearrangements, 4%, 5q deletion, 10%; monosomy 7. 12%; 7q deletion, 4%; KMT2A translocation excl. t (9;11), 11%; complex karyotype ≥3 CA (58%); monosomal karyotype (19%). Median time from diagnosis to HSCT was 477 days (47 to 3482). 34% of the patients were in complete remission (CR 1 or >2), while 57% had active disease. Bone marrow was a source of HSCs in 56% of cases, peripheral stem cells, in 35% of patients and 9% received the both cell types. Myeloablative conditioning regimen was applied in 36% of cases. A ratio of matched related, unrelated and haploidentical HSCTs was 17:55:28. Probabilities of overall survival (OS), leukemia-free survival (LFS), cumulative incidence of relapse (CIR) were evaluated for different cytogenetic groups.

Results

According to univariate analysis, the probabilities of 4-year OS in patients with 5q-, KMT2A translocations and monosomy 7 were 66%, 59% and 56%, respectively. At the same time, overall survival in the patients with CK, 7q- and 3q26 rearrangements were lower, respectively, 33%, 25% and 25%, (p=0,01). Multivariate analysis showed that clinical stage at HSCT, age and HSC source are independent predictors of overall survival in AML. The 4-year LFS rates varied between the groups with different chromosomal aberrations, with highest LFS values noted in patients with 5q- and KMT2A translocations (66% and 52%, respectively), whereas lower LFS was registered among the patients with 3q26 rearrangements, complex karyotype, monosomy 7 and 7q- (0, 18%, 23% and 37%, respectively). Besides that, LFS differed between the groups with CK+ and CK- (18% vs 41%, p=0,008), as well as for patients with MK+ and MK- (17% vs 30%, p=0,04). Multivariate analysis provided evidence for importance of clinical stage at HSCT, cytogenetic grouping, monosomal karyotype, and number of transplanted CD34+ cells as independent predictors of LFS in AML patients. Cumulative incidence of relapses in the patients transplanted in remission (n=42) was higher than in those with CK+ (55% vs 14%, p=0,03) and MK+ (75% vs 31%, p=0,013).

Conclusions

Our study has shown that 4-year OS in the AML patients with 5q-, KMT2A translocations and monosomy 7 was significantly different from those with CK, 7q- and 3q26 rearrangements. Furthermore, OS depended on clinical stage at HSCT, patient’s age and HSC source. On the other hand, LFS differed between the mentioned cytogenetic groups, including MK. Finally, LFS was dependant on clinical stage at allo-HSCT and number of transplanted CD34+ cells. On the basis of this data, a conclusion may be drawn that allo-HSCT in AML patients with adverse CA should be performed in complete remission, using bone marrow as HSC source, and sufficient amounts of transplanted CD34+ cells.

References

  1. Hemmatti et al. Eur J Haematol 2013; 92: 102-110.
  2. Fang et al. Blood 2011; 118: 1490-1494
  3. Guo et al. Biol Blood Marrow Transplant 2014; 20: 690-695.

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17q21→17qter jumping translocations in a 13-year-old girl with RUNX1–RUNX1T1- positive acute myeloid leukemia

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Tatiana L. Gindina, Nikolay N. Mamaev, Elena S. Nikolaeva, Olga S. Uspenskaya, Irina A. Petrova, Marya Yu. Averyanova, Sergey N. Bondarenko, Boris V.Afanasyev

R.M.Gorbacheva Me morial Institute of Children Oncology, Hematology and Transplantation at First Pavlov State Medical University of St.Petersburg, Russia

Introduction

Jumping chromosomal translocation (JT) is a rare cytogenetic phenomenon, meaning a translocation of the same segment of a donor chromosome to various recipient chromosomes, creating multiple related clones in an individual. The JTs have been described as a constitutional abnormality in solid neoplasms and, rarely, in various hematological malignancies including acute myeloid leukemia (AML), acute lymphoblastic leukemia, primary myelofibrosis, chronic myeloid leukemia, lymphomas, and multiple myeloma [1, 2]. In these patients, JTs occurred as secondary genetic events associated with disease progression. They are also detectable in secondary AML evolving from a preceding myeloproliferative neoplasm or myelodysplastic syndrome, or in relapsing acute leukemia.

JTs proved to be common at the elderly age.

Patient and Methods

We have reported a rare case of JT occurring in a 13-year-old girl with RUNX1–RUNX1T1-positive AML and WT1+ hyperexpression. JTs were revealed in bone marrow blast cells examined at the time of first relapse of AML that was completely resistant to previous chemotherapy. Conventional cytogenetics findings were confirmed by fluorescence in situ hybridization (FISH). To assign the chromosomal segments involved in JTs, multicolor FISH approach was chosen (MetaSystems, Germany). Cytogenetic analysis revealed JTs with chromosomal segments 17q21-17qter translocated to the pericentromeric regions of chromosomes 13,14,15 and to the 1p36 and 2q37regions. The patient was transplanted from haploidentical donor, but died after leukemia progression at day +40. (Fig. 1, 2, 3). Conclusion. Jumping translocations form a heterogeneous group of rare genetic events which seem to involve random chromosomal segments and may reflect a general chromosomal instability of the malignant cells. However, precise analysis of chromosomal breakpoints involved in JTs on a large series of patients helps to understand their mechanism and connection with pathogenesis together with the determination of clinical significance of these aberrations.


References

  1. 1. P. McGrattan et al, Med Oncol 2010; 27 (3): 667-672
  2. 2. K. Manola et al, Cancer Genet Cytogenet 2008; 187 (2): 85-94


Fig. 1, 2, 3. GTG---banded (A) and multicolor FISH (B) karyograms demonstrate reciprocal translocations t(8;21)(q22;q22) and jumping translocations producing the derivative chromosomes: der(1)t(1;17), der(2)t(2;17) and der(14)t(14;17). Karyotype: 45,X,---X, der(2)t(2;17)(q37;q21), t(8;21)(q22;q22)[7]/45,X,---X, der(14)t(14;17)(p13;q21), t(8;21)[6]/45,X,---X, der (1)t(1;17)(p36;q21), t(8;21)[4]/45,X,---X, der(13) t(13;17)(p13;q21), t(8;21)[2]/45,X,---X, der(15) t(15;17)(p13;q21), t(8;21)[2].

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Influence of co-transplanted mesenchymal stem cell upon immunological recovery after allogeneic hematopoietic cell transplantation in children

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Yuliya E. Mareika, Tatiana V. Shman, Yanina I. Isaikina, Nina V. Minakovskaya, Natalia P. Kirsanava, Olga V. Aleynikova

Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus

The aim of this study was to evaluate effects of mesenchymal stem cells (MSCs) co-transplantation upon dynamics of immunological reconstitution during post-transplant period after allogeneic hematopoietic cell transplantation (allo-HSCT) in children.

Patients and Methods

Twenty-two patients aged 3 to 18 years were included into the single randomised study. Ten patients comprised a МSC+ group, having been transplanted with HSC and co-transplanted with mesenchymal stem cells (acute lymphoblastic leukemia, 5 children; acute myeloid leukaemia, 2 patients; acquired aplastic anemia, 3 cases). The median number of MSCs infused was 1,56±0,4×106/kg. Twelve patients (acute lymphoblastic leukemia, 5 children; acute myeloid leukaemia, 2; acquired aplastic anemia, 4; severe congenital neutropenia, 1) were transplanted with HSC without MSC cotransplantation (МSC- group). Patients from the both groups were identical by nosological forms of the disease, age, sex, donors type, conditioning regiment, graft-versus-host disease (GVHD) prophylaxis and graft composition. MSCs were derived from donors bone marrow. Immunological recovery was evaluated: В-cells by expression СD19+; natural killers (NK) cells – by CD3-/CD16CD56+, Т-cells - by CD3+, Т helper cells – by CD3+CD4+, cytotoxic T-cells – by CD3+CD8+; activated T-cells – by CD3+HLA-DR+ with flow cytometry. Assessment of immunological parameters in both groups was performed on +30, +60, +100 +180 и +365 days after allogeneic HSCT.

Results

Previously we have shown that the recovery of leukocytes, neutrophils and platelets was significantly faster in the patients co-transplantated with MSCs.The incidence of acute GVHD stage II-IV in the «MSC+»group was 20% (2 patients of 10) versus 58% in the «MSC-»group (7/12). The incidence of chronic GVHD in the «MSC+» group was 30% (3/10), being diagnosed as limited forms only, whereas in the «MSC-» group, 25% (3/12), all of them exhibited extensive chronic GVHD. We have found lower percentages of T-cells in the group of patients co-transplanted with MSCs from day +30 to day +100, as compared with the «MSC» group. The quantity of activated T-cells in the «MSC+» group was also lower at all observation terms. Similarly, a decreased level of cytotoxic T-cells was revealed in the «MSC+» group when compared with «MSC-» group up to day +180. The NK cell quantity was also increased from +30 to +180 days in the «MSC+» group. I.e., the NK absolute counts at +30 day in the «MSC+» group were 0,06 (0,06-0,17)×109/l, whereas in the «MSC-» group, 0,037 (0,02-0,04)×109/l (р=0,03). The group of patients with MSC co-transplantation differs by earlier recovery of B-cells that it got significant up to +100 day. B-cells absolute count at +100 day in the «MSC+» group was 0,1 (0,06-0,2)×109/l, whereas in the «MSC-» group – 0,02 (0,002-0,1)×109/l (р=0,05) due to lower volume immunosuppressive therapy in «MSC+» group. Conclusion. Over the early period after HSCT, the MSCs co-transplantation prevents excessive activation of immune system and leads to lower rates of grade II-IV acute GVHD. At the later post-transplant period, it results into earlier reconstitution of humoral immunity and prevents severe extensive chronic GVHD.

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Long-term observations of patients with Fanconi anemia following allogeneic hematopoietic stem cell transplantation: a two-center experience

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Elena V. Skorobogatova1, Kirill I. Kirgizov1, Dmitry N. Balashov2, Natalia V. Sidorova1, Ekaterina A. Pristanskova1, Natalia V. Sidorova1, Veronika V. Konstantinova1, Oxana L. Blagonravova1, Pavel E. Trakhtman2, Yulia V. Skvortsova2, Michael A. Maschan2, Aleksey A. Maschan2

1 The Russian Pediatric Clinical Hospital, Moscow

2 Dmitry Rogachev Federal Research Center of Pediatric Hematology, Oncology and Immunology, Moscow

Introduction

Fanconi anemia (FA) is a rare disease characterized by inborn anomalies, hematopoietic aplasia and high incidence of malignancies. Hematopoietic stem cell transplantation (HSCT) is the only approach to hematopoiesis correction in these patients. However, high-dose chemotherapy is highly toxic in FA patients. Our aim was to evaluate the results of a long-time follow-up which is important for individual prognosis.

Materials and methods

Twenty-nine children with FA (11 males, 18 females), median age 9,5 (3,7-15,4) years, underwent HSCT from November 1994 to April 2014. In 17 cases (58,6%), HLA-matched sibling donors (MRD), and for 12 children (41,4%), matched unrelated donors (MUD) were employed. Graft sources were as follows: bone marrow (n=18); peripheral blood stem cells (n=7), bone marrow+cord blood (n=3), umbilical cord blood (n=1). There was a 9/10-HLA match in one case of related HSCT, and in two patients subjected to MUD HSCT. Two patients were transplanted after development of a secondary myelodysplastic syndrome. The conditioning regimens included: in MUD, Busulfan, 4 mg/kg, Cyclophosphamide (20 mg/kg), Fludarabine, 150 mg/m2, and ATG treatment; with MRD, Busulfan 4 mg/kg, Fludarabine, 150 mg/m2, and ATG injections. GvHD prophylaxis was donor-dependent, i.e., CsA-based regimen for MRD HSCT, or Tacrolimus-based therapy for MUD HSCT. TCR alpha/beta transplant depletion was performed in three MUD HSC recipients.

Results

All the patients were successfully engrafted. The rejection rate was 13,8% (n=4) which occured by 1, 2, 6, 12 months after HSCT. Second HSCT was performed in all these cases. Two patients survived after the 2nd HSCT with good engraftment; two patients deceased after 2nd HSCT, due to GvHD and adenovirus pneumonia, respectively. Direct toxicity of the conditioning regimens was minimal. No signs of GvHD were observed in 16 patients (55,2%), grade I-II aGVHD. in 8 patients (27,6%), severe GvHD was observed in 5 cases (17,2%). Limited cGvHD was diagnosed in 3 recipients, extensive cGvHD, in 2 cases. A median follow-up was 31,9 months (3,8 to 246). The estimated probability of 5-year overall survival was 67,4%, event-free survival, 62,7%. Two patients developed oral cavity malignancies. The causes of death were GvHD+infection (n=5), infection (n=3), including adenoviral pneumonia, graft-versus-host disease (n=2), and tongue cancer (n=1).

Conclusion

Our results suggest that HSCT is a valid therapeutic option for treating the patients with FA. Post-HSCT course is characterized by rather high incidence of GvHD and infectious complications. Second HSCT is associated with high risk of refractory infections and GvHD. Cancer may be a cause of late mortality.

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Efficiency of antimicrobial surface treated central venous catheters in the prophylaxis of catheter-associated infections in children with oncohematological diseases

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Yulia Simakina, Olga Ivanova, Elisa Kubieva, Elena V. Morozova, Ekaterina Goncharova, Ludmila S. Zubarovskaya, Boris V. Afanasyev

Raisa Gorbacheva Memorial Institute of Children Oncology Hematology and Transplantation, First St. Petersburg I. Pavlov State Medical University, St. Petersburg, Russia

Introduction

Bloodstream infections are among the most common nosocomial infections worldwide. Up to one-third of all primary bloodstream infections are associated with central venous catheters (CVC), as well as various general and local infectious complications. There are different pathogenetic mechanisms of the Central Line-Associated BloodStream Infections (CLABSI). The insertion site contamination, pathogen migration along external surface, intraluminal colonization of the catheter hub, and hematogenous spread are among the main reasons for these conditions. Risk factors of infectious complications include emergent catheterization, active infection process, bacteremia, disease state, comorbidities, duration of catheterization and professional skills of surgeons and nurses. The goal of this study was to evaluate characteristics of central vein cathetherization in children with oncohematological diseases (3 to 15 years old), searching for ways to minimize the CLABSI risks.

Patients and methods

A group of 59 patients with oncohematological diseases was enrolled into the study. In most cases, CVC was installed upon admission to the hospital. All the patients received CVC via subclavian approach. There were no early complications associated with CVC insertion. There were different indications for catheterization, i.e., hematopoietic stem cell transplantation (HSCT) in 33 patients, polychemotherapy (PCT), in 19 cases, and extracorporeal photopheresis in 7 patients. Antimicrobial surface-treated CVCs Certofix® Protect (B. Braun) were used in 30 patients. A control group included 29 patients with non-antimicrobial surface treated polyurethane CVC Certofix®.- B. Braun. The tasks of our study were as follows: evaluation of dwelling time for the CVC and efficiency assessment of the antimicrobial Certofix® Protect CVCs for the CLABSI prophylaxis in oncohematological patients treated by polychemocherapy (PCT) or stem cell transplantation (SCT) with high risk for infectious complications. Febrile temperature without local infection and/or positive hemoculture in peripheral blood were attributed to CLABSI. Comparison of CVC blood culture with peripheral blood culture or CVC tip culture were used to confirm the diagnosis. Visual observation of the CVC insertion site was performed on daily basis.

Results

It was demonstrated that the number of catheter lumens was not directly associated with the incidence of CLABSI. Average dwelling time of antimicrobial surface treated CVC Certofix® Protect was 21 days (ranging from 2 to 48), and in control group, 18 days (ranging from 1 to 39). CLABSI was indication for cathether removal in 1 patient (3,3%) in the studied group, and in 5 patients (17,2%) in control group. Microbiological confirmation of CVC contamination was noted in 1 case (3,3%) in first group and in 4 cases (13,8%) in controls. Microbiological cultures demonstrated a broad spectrum of CLABSI. The most common infectious agents were St.aureus, Enterococcus spp., St. epidermidis, Kl.pneumoniae. Less common microorganisms were Acinetobacter spp., Enterobacter spp., Pseudomonas aeruginosae, Candida spp.

Conclusion

Antimicrobial surface-treated Certofix® Protect – B. Braun CVCs in patients with oncohematological diseases represents a rational option for applications in the PCT and HSCT patients, being associated with a statistically significant decrease of CLABSI rates. Disclaimer. This is not an advertisement of the В.Braun catheters. However, overview of publications in the area allows us to choose this type of CVC as the most effective one in the prophylaxis of infectious complications.

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10/10 compatibility in hematopoietic stem cell transplantations (HSCT) may improve outcomes as compared to 9/10: a single-center study

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Natalia V. Sidorova1, Kirill I. Kirgizov1, Dmitry N. Balashov2, Pavel E. Trachtman2, Marina Y. Persiantseva2, Ekaterina A. Pristanskova1, Veronika V. Konstantinova1, Oxana L. Blagonravova1, Michael A. Maschan2, Elena V. Skorobogatova1, Alexey A. Maschan2

1 The Russian Clinical Children’s Hospital, Moscow

2 Dmitry Rogachev Federal Research Center of Pediatric Hematology, Oncology and Immunology, Moscow

Introduction

HSCT from matched unrelated donors (MUD) is routine therapy approach in wide variety of disorders. However, current probability of finding a fully HLA-matched donor is only 70-75%. Hence, the aim of our study was to evaluate HSCT results in children from the fully matched (10/10) versus 9/10 compatible donors using retrospective data.

Patients and methods

159 HSCT from 9/10- and 10/10-compatible MUD were performed over the period of 2003-2014. The patients were diagnosed with AML, 43% (n=68); ALL, 19% (n=31); aplastic anemia, 12% (n=24); inherited metabolic disorders, 10% (n=16); PID syndromes, 4% (n=6), and others, 8% (n=14). Male-to-female ratio was 107:52 (2:1), median of age was 7,6 (1-17 years old). Stem cell sources were as follows: bone marrow, 77% (n=122), peripheral blood stem cells, 23% (n=37). 126 patients (79%) received 10/10 MUD HSCT, and 33 patients (21%) underwent 9/10 MUD HSCT. Conditioning regimens contained different agents, depending on the therapeutic protocol and type of disease.

Results

Overall incidence of aGvHD (grade I-IV) in the 10/10 group was 83% (n=107), and 82% (n=27), in the 9/10 group. Frequency of severe aGvHD (grade III-IV) was, respectively, 17,5% (n=22), and 21% (n=7). We have revealed that the mode of GvHD prevention can significantly improve outcome, e. g., Tacrolimus/MTX prevention proved to be favorable, in comparison with other prophylaxis modes (Tacro/MMF etc.). The Tacrolimus/MTX schedule was associated with decreased probability of aGvHD in the both HSCT groups: in cases with 10/10 matches, from 16% to 1,5%; for 9/10 group – from 18% to 3%. Infectious episodes did not significantly differ between the 9/10 and 10/10 groups. Upon a long-term follow-up (a median of 11 years), an estimated probability of overall survival was 60.2% in the 10/10 group, as compared to 41,8% for the 9/10 group.

Conclusions

Our results suggest that 10/10-matched transplants are associated with better outcome and lower incidence of severe aGvHD. In our experience, the results of 9/10-matched HSCTs tend to improve over past several years. Hence, the 9/10-matched transplants present a good option, if a 10/10-matched donor is not available.

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Early diagnostics of acute kidney injury (AKI) associated with hematopoietic stem cell transplantation (HSCT)

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Kirill A. Smirnov, Vladimir A. Dobronravov, Boris V. Afanasiev, Olga V. Galkina, Irina M. Zubina, Evdokia O. Bogdanova

The First St. Petersburg I. Pavlov State Medical University, St. Petersburg, Russia

Introduction

The patients undergoing hematopoietic stem cell transplantation (HCT) are at a high risk of acute kidney injury (AKI), which is further associated with significantly prolonged hospital stay, higher mortality and costs. A conventional diagnostics of AKI is based on functional parameters: >1,5-fold increase of serum creatinine, as a marker of glomerular filtration rate (GFR), and the rate of diuresis decline (AKIN classification – Acute Kidney Injury Network). However, the use of these criteria in clinical practice does not solve the problem of early diagnostics, as it reflects the development of advanced AKI lesions. Early stages of AKI (with potentially reversible structural alterations) are associated with up-regulation of biomarker (BMKI) molecules synthesized by resident and immune cells, which takes place during the first hours following the damage. The aim of our study was to determine diagnostic value of some biomarkers for early AKI detection in patients following hematopoietic stem cell transplantation (HSCT), as compared to routine methods.

Methods

The study involved 30 patients who underwent allogeneic HSCT. The AKIN criteria were limited to serum creatinine monitoring, since common HSCT treatment protocols require intensive hydration, maintaining the diuresis rates at 3-4 L. The urine samples were taken 7 days prior to HSCT (week 0), in the 1st, 2nd ,3rd, and 4th weeks post-transplant. Concentrations of the biomarker molecules (calbindin, clusterin, IL-18, KIM-1, GST-n, MCP-1) were measured in the samples.

Results

Diagnostics according to the AKIN criteria yielded the following results: proportion of AKI (AKIN) cases in the 1st and 2nd weeks after HSCT was 7%, by the 3rd week, 17%; in the 4th week, 54% (p<0,05). Prevalence of cases with, at least, one increased BMKI was 79% in the 1st week, and 85% in the 2nd week, further remaining approximately at the same level. A proportion of cases with simultaneous elevation of several biomarkers was increased from 6% (pre-transplant) to 23% (week 1), 27% (week 2), 31% (week 3), and up to 38% 4 weeks after HSCT. In the 4th week, only 6% of cases did not show any increase of the BMKI, while the cumulative proportion of cases without clinical AKI (AKIN) comprised 40%. AKI (AKIN) is clearly related to the number of simultaneously elevated BMKI. The proportion of AKI cases (AKIN) with increase in 1 biomarker was 5%, with >4 biomarkers, 29%. ROC analysis showed that the number of elevated biomarkers has sufficient sensitivity, with regard to prediction of a clinical AKI (AKIN). SAUC= 0,69 (p=0,006).

Conclusion

1) Prevalence of increased biomarker concentrations following HSCT-related kidney damage is extremely high (93%).

2) Rising concentrations of the biomarkers precede clinical AKI (AKIN) manifestations.

3) The studied biomarkers exhibit a high predictive value, in terms of AKI (AKIN) development. The study was sponsored by the Committee on Science and Higher Education of the St. Petersburg Government.

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Genomic DNA breakpoints in MLL and translocation partner genes: correspondence to clinical parameters and treatment outcome in infants with acute leukemia

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Grigory A. Tsaur1, Claus Meyer2, Anatoly M. Kustanovich3, Alexander M. Popov1, Tatiana O. Riger1, Elena W. Fleischman4, Olga I. Sokova4, Yulia V. Olshanskaya5, Elena А. Matveeva5, Olga V. Streneva1, Egor V. Shorikov1, Leonid I. Saveliev6, Rolf Marschalek2, Larisa G. Fechina1

1 Regional Children’s Hospital N 1, Research Institute of Medical Cell Technologies, Ekaterinburg, Russian Federation

2 Diagnostic Center of Acute Leukemia, Institute of Pharmaceutical Biology/ZAFES, Goethe-University of Frankfurt,

Frankfurt/Main, Germany

3 Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus

4 N. N. Blokhin Russian Cancer Research Center Russian Academy of Medical Science, Moscow, Russian Federation

5 D. Rogachev Federal Research Institute of Pediatric Hematology, Oncology and Immunology, Moscow, Russian Federation

6 Ural State Medical University, Ekaterinburg, Russian Federation

Purpose

To evaluate the relation between genomic DNA breakpoints in MLL and translocation partner genes (TPG) and clinical parameters of infant AL.

Methods

87 infants (32 boys and 55 girls with median age of 4,9 mo) with MLL-rearranged acute lymphoblastic leukemia (ALL) (n=63), acute myeloid leukemia (AML) (n=22) and mixed phenotype acute leukemia (MPAL) (n=2) were included in the current study. Genomic DNA breakpoint detection in MLL gene and translocation partner genes (TPGs) was performed by long-distance inverse PCR (LDI-PCR). Exon-intron numbering of MLL gene was done according to I. Nilson et al, 1996.

Results

Majority of ALL cases was characterized by presence of MLL-AF4 fusion gene (FG) (n=35; 55%), less frequently MLL-MLLT1 (n=12; 22%), MLL-MLLT3 (n=8; 13%) and others were found. The most common breakpoint location within MLL gene in ALL patients was intron 11, detected in 31 cases (49%), less frequently breakpoints in intron 10 (n=13; 21%) and intron 9 (n=9; 14%) were found. The highest variability of MLL breakpoints was found in MLL-AF4-positive patients: only 15 of 35 (43%) had breakpoints in intron 11. The most stable pattern of MLL genomic DNA breakpoints was observed in MLL-MLLT1-positive patients: 9 of 14 (64%) had breakpoints in intron 11. In AML patients the most prevalent FG was MLL-MLLT3 (n=8; 36%). The most frequent breakpoint location was intron 9 (n=10; 45%), less often they were found in intron 10 (n=5; 23%) and 11 (n=4; 18%). The most stable pattern was revealed for MLL-MLLT10 FG: MLL breakpoints in 4 of 5 (80%) cases were found in intron 9. In TPGs the most frequent breakpoint locations were as follows: in AF4 – intron 3 (n=25; 69%) and intron 4 (n=7; 19%); in MLLT1 – non-coding region between ACER1 and MLLT1 (n=9; 60%) and intron 1 (n=5; 33%); in MLLT3 – intron 5 (n=13; 81%); in MLLT10 – intron 8 and intron 9 (n=2; 33% each); in EPS15 – intron 1 (n=3; 75%). The pattern of breakpoints locations in TPGs was similar in ALL, AML and MPAL cases. Distribution of DNA breakpoints in MLL gene was similar in boys and girls and did not depend on type of TPG. ALL patients who had breakpoints in intron 11 were significantly younger than all other patients (3,1 vs 5,6 mo p=0,035), mainly due to the difference to intron 9 patients (3,1 vs 6,6 mo p=0,040). We did not find any correlation between gender and initial white blood count to the MLL breakpoints distribution. In AML cases there was not any correlation between age, gender, initial white blood count and specific locations of breakpoints in MLL gene. We evaluated prognostic significance of MLL breakpoint locations in 46 cases of infant ALL homogenously treated by MLL-Baby protocol. 5-year EFS was significantly lower in patients with breakpoints in intron 11 (n=29) in comparison to patients with breakpoint localized from intron 7 to exon 11 (n=17) (0,16±0,07 vs 0,38±0,14 p=0,039). While cumulative incidence of relapse was remarkably higher in the first group of patients (0,74±0,09 vs 0,52±0,17 p=0,045). Median follow-up time was 36 months (range 20–94). Although in Cox regression model including breakpoint location in intron 11 together with age, immunophenotype, initial white blood cell count, initial CNS involvement, type of MLL rearrangements, absolute blast number at day 8 of dexamethasone pro-phase, minimal residual disease (MRD) at time point 4 (TP4) of MLL-Baby protocol, the only significant covariate was the presence of MRD at TP4 (HR 5.994, 95% CI 2,209-16,263, p<0,001).

Conclusions

Among MLL TPG the most stable distribution of breakpoints was in MLLT1, the most heterogeneous in AF4 и MLLT10. The most common breakpoint position in MLL gene in infants with ALL was intron 11, in AML intron 9. Breakpoints in intron 11 of MLL gene led to significantly worse outcome in infants with ALL, treated by MLL-Baby protocol, although this parameter was overcome by MRD-positivity at TP4. The latter one was the only independent covariate in multivariate analysis. Our data provide additional information of molecular genetic features of MLL-rearranged infant AL.

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Effective treatment of mixed viral infection in a patient after haploidentical stem cell transplantation

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Larisa Vakhonina1, 2, Igor Vyatkin1, 2, Natalya Maysheva1, 2, Grigory Tsaur1, 2, 3, Oleg Medvedev1, 2, Leonid Saveliev1, 2, 3, Larisa Fechina1, 2

1 Regional Children’s Hospital No.1, Ekaterinburg, Russia

2 Research Institute of Medical Cell Technologies, Ekaterinburg, Russia

3 Ural State Medical University, Ekaterinburg, Russia

Background

Haploidentical stem cell transplantation (haplo-SCT) is often associated with reactivation of viral infections. Many of them do not have specific treatment approaches, especially in case of mixed viral infection. The aim of present study was to estimate the efficacy of diagnostics and treatment algoritm in a patient with mixed viral infection (Human herpesvirus 6, adenovirus, BK virus) after haplo-SCT. Methods. A 14-year boy with high-risk ALL underwent a haploidentical SCT being performed in the first remission. The transplant was depleted of TCRαβ/CD19 and infused after myeloablative conditioning regimen with Treosulfan 42g/m2, Fludarabin 150mg/m2, Melphalan 140g/m2, ATGAM 50 mg/kg. Post-transplant immusupression included Prograf 0.02 mk/kg started at day -1, Methotrexate 5mg/m2 at days +1, +3, +6. Antiviral prophylaxis consisted of intravenous acyclovir. Post-transplant viral monitoring (CMV, EBV, HHV6, adenovirus, BK virus in peripheral blood (PB), adenovirus in stool, BK virus in urine) was performed by both qualitative and quantitative PCR once a week.

Results

At the day +22, the HHV6 load equivalent to 2100 copies/ml was detected in peripheral blood, adenovirus found in stool, and BK virus was revealed in urine. Hemorrhagic cystitis grade I was noted, along with skin rush, and signs of meningoencephalitis (tremor, headache, 50х103 leucocytes/ml of liquor). Acute skin GVHD grade I was observed and confirmed by the skin biopsies. Simultaneously HHV6 was revealed by PCR at the same skin biopsy. Ganciclovir i.v. was initiated at a dose of 10mg/kg/day. Additionally, IVIG was administratered once in 14 days. This therapy led to slow recovery of meningoencephalitis and hemorrhagic cystitis symptoms. Meanwhile, HHV 6 was detected in liquor and persistence of adenovirus in stool and BK virus were observed by PCR. After a 3-week course of Ganciclovir in addition to HHV6 (2000 copies/ml), adenovirus and BK were found in PB. Cidofovir 5μg/kg i.v. was administered once a week together with Valacyclovir 500 mg b. i. d. After 1 week of Cidofovir administration, a significant reduction of HHV6 in PB was noted, whereas adenovirus and BK virus in PB were not detected anymore. A total of 5 Cidofovir injections were performed. Despite long persistence of BK virus in urine, the symptoms of hemorrhagic cystitis were not noted. Signs of meningoencephalitis resolved after 1 month of Cidofovir administration. HHV6 disappeared from liquor 2 month later. At present time, the patient is alive, with follow-up time of 2 years with established immunological reconstitution and lack of chronic GVHD.

Conclusions

In our Ganciclovir-resistant case with mixed viral infection, the Cidofovir treatment was highly curative. A systematic PCR monitoring helped us to timely launching of antiviral treatment and to monitor its efficacy.

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Evaluation of bone marrow stromal cells regarding their role in hematopoietic reconstitution

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Nikolai Y. Tsvetkov, Ildar M. Barkhatov, Alain I. Shakirova, Dmitri S. Romaniuk, Olesya G. Smykova, Vera V. Teplyashina, Ludmila S. Zubarovskaya, Boris V. Afanasyev

1R. M. Gorbacheva Memorial Institute of Children Oncology, Hematology and Transplantation, First Pavlov St. Petersburg State Medical University, 2St. Petersburg State Polytechnical University, St. Petersburg, Russian Federation

Introduction

The role of stromal microenvironment in hematopoietic stem cell transplantation (HSCT) is based on their nonlineage-specific effects upon proliferation and differentiation of HSCs. Deficient graft functioning observed in some cases necessitates development of functional tests for the stromal cells, in order to prove clinical indications for co-transplanting of hematopoietic and stromal cells (SC), and, probably, introduction of alternative therapeutic approaches.

The aim of this study was to investigate the role of bone marrow stromal cells in the course of donor marrow cells engraftment and its significance for post-transplant complications.

Materials and methods

The study included clinical observations of post-transplant course in ten patients with acute myeloid leukemia (AML) and 7 healthy donors. Bone marrow nucleated cells were selectively harvested two weeks prior to BMT, followed by monolayer culture in alpha-MEM culture medium with 20% fetal bovine serum. Upon growth of fibroblast-like cell colonies (CFU-F), their hematopoiesis-supporting activity was determined in agar-drop/liquid culture system, along with their differentiating ability towards adipogenic and osteogenic pathways. We have also measured the relative expression of selectin and CXCR4 genes in these populations.

Results

When comparing functional characteristics of SC from healthy donors and AML patients, an increased hemostimulating activity of the later was noted, as reflected by an increase in large and small CFU-GM numbers (p<0,02). In addition, an increase in convential differentiation ability was observed in AML patients (p=0,03). Moreover, the number of CFU-Fs, capable for adipogenic differentiation showed inverse correlation with platelet recovery terms (p=0,05). By the contrast, higher numbers of osteogenic colonies in culture was associated with increased terms of leukocyte lineage engraftment (p=0,05). Furthermore, a direct correlation was observed between CFU-F capable of osteogenic differentiation, and the number of blast cells at the time of transplantation (p=0,05). When analyzing gene expression in SC population, we have that a decreased expression of CXCR4 gene responsible for the homing effect proved to be dependent on the patient’s age (p=0,05). It was also revealed that higher selectin gene expression in SC population of AML patients was significantly higher than in the cells from healthy donors.

Conclusion. Stromal cells derived from the patients’ bone marrow exhibit higher proliferative activity and marked expression of molecules mediating HSC homing, as compared with a group of healthy donors. That finding could be explained by affection of stromal cells by previous chemotherapy and myelosuppression. BMSC from AML patients taken before bone marrow transplantation are characterized by a more pronounced capacity to osteogenic and adipogenic differentiation than those from healthy donors. Increased adipogenic differentiation ability of the SCs is associated with a more rapid recovery of hematopoiesis.

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Evaluation of posttransplant relapse risk in patients with acute leukemia using the gene expression markers

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Alena I. Shakirova1, Ildar M. Barkhatov1, Olga I. Shakirova2, Dmitry S. Romanyuk1, Alexei V. Evdokimov1,

Sergey N. Bondarenko1, Ludmila S. Zubarovskaya1, Boris V. Afanasyev1

1 R. M. Gorbacheva Memorial Institute of Children Oncology, Hematology and Transplantation, First St. Petersburg State
I. Pavlov Medical University

2 St. Petersburg State Polytechnic University, St. Petersburg, Russian Federation

Introduction

It is known that up to 50 percent of cases of acute myeloid leukemia (AML) do not have informative genetic markers. At the same time, the studies of donor chimerism do not fully indicate the degree of tumor cells elimination and not always allows to estimate the risk of post-transplant relapse. Thus, finding of universal markers allowing for adequate therapy in post-transplant period, is quite important. WT1, BAALC, EVI1 and PRAME gene expression analysis is one of the possible approaches is this field.

Patients and methods

Our study included 63 patients with AML (1 to 60 years old) (M0-2pts, M1-11pts, M2-13pts, M3-2pts, M4-21pts, M5-11pts, M6-1pt, M7-2pts ) who underwent allogeneic transplantation of hematopoietic stem cells (allo-HSCT). In 24 patients myeloablative conditioning regimen were used, 39 – received reduced toxicity protocols. Assessing the levels of WT1, BAALC, EVI1, PRAME gene expression and the level of chimeric transcripts was performed by means of RQ-PCR with normalization for ABL gene expression. For the donor chimerism monitoring a panel of STR-markers was used.

Results

As based on gene expression in healthy donors, we have established cut-off overexpression (gene exp. / ABL exp. X100) values for the genes: WT1 – 250, EVI1-10, BAALC – 20, PRAME – 200. For the present patient setting, we found no statistically significant differences in WT1, BAALC, EVI1, PRAME genes expression between the patients with different FAB variants of AML. However we were able to identify a trend to higher values of PRAME and BAALC gene expression in patients with M1 variant, and WT1 gene values among patients with M4 variant of AML. In patients who underwent transplantation in relapse state, we have noted a significant overexpression of EVI1 (p=0,006), WT1 (p<0,001), BAALC (p<0,001). A similar trend was observed for PRAME gene (p=0,08). EVI1 gene overexpression was revealed for 6 patients (33%), WT1 in 13 cases (72%), BAALC in 10 patients (55%) and PRAME in 4 patients (22%). When comparing the data on chimeric transcripts expression, we detected a correlation between expression levels of the studied genes and chimeric transcripts (PML-RARa and RUNX1-RUNX1T1, p<0,05) as well as with donor chimerism levels. At the same time, we did not find this relationship, when comparing with data about of expression of a CBFB-MYH11 chimeric gene. When evaluating the test sensitivity and specificity analysis we revealed a bellow-cutoff value of the expressed genes in presence of the chimeric transcript less than 2%.

Conclusion

Evaluation of universal gene marker expression is an attractive approach for assessing efficiency of therapy in patients with AML. Thus, their use in early diagnostics of relapse in post-transplant period is quite promising. However, due to low specificity caused by basal expression in normal cells, futrher application of these markers is limited, when detecting minimal residual disease levels.

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Efficiency of hypoxic hypoxia during idiopathic thrombocytopenic purpura

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Abduhalim R. Raimzhanov1, Irina A. Tsopova2, Mary O. Eralieva1, Bahtygul K. Aysarieva3

1 Kyrgyz Scientific Center of Hematology

2 Kyrgyz-Russian Slavic University, Bishkek, Kyrgyzstan

3 Osh Regional Hospital, Osh, Kyrgyzstan

Objective

To provide available medical assistance to the patients with idiopathic thrombocytopenic purpura (ITP).

Patients and Methods

We have applied high-altitude climate therapy (HACT) as an alternative to conventional methods of treatment of ITP. Generally, this approach creates conditions of chronic hypoxic hypoxia for the patient over 40 days, using a following schedule: travelling up to a height of 3200 m above the sea level; bed rest (1 to 5 days); semi-strict bed rest (5 to 7 days); increased physical activity (7 to 20 days); mountain walks (20-40 days). We studied the data of the performance-induced platelet functions with a “Biola” aggregometer; evaluation of IL-2, IL-6 and tumor necrosis factor (TNF) by means of ELISA testing (manufactured by the “Protein Contour”). The study involved 24 patients with ITP. The 1st group consisted of 14 patients in remission state who received only high-altitude climatotherapy; the 2nd group included 10 patients with ITP, who received hormonal therapy in the foothill region, and continued this treatment at the high altitude. We evaluated both clinical and hematological improvement, and long-term outcomes.

Results

When studying platelet aggregation in patients with ITP at the altitude of 760 m , a sharp decrease of ADP-induced aggregation was revealed (20% versus 82% in healthy persons). Upon adaptation to high altitudes, the changes in platelet aggregation were registered from the 20th day of HACT. They included increase in the platelet aggregation, as shown with ristomycin, collagen and ADP, by 3,2, 2,7 and 2,3-fold increase (p<0,05) in the 1st group of ITP patients, and 3,6, 3,4 and 3,0-fold acceleration (p<0,05) in the 2nd group. The 1,3-fold increase of ADP-induced platelet aggregation was observed on the 20th day of the therapy, and on 40th day such increase was 1,5 times in the both ITP groups (p<0,05). A similar pattern was observed with other aggregation inducers. Initial concentrations of IL-6 in ITP patients exceeded the levels of healthy persons by 6.0 times (1st group) and 3,2 times (2nd group) (P<0,001). During HACT there was a significant (4-fold) decrease of its levels in the both groups. The IL-2 levels upon initial examination were 346,9±23 pg/ml in group 1, and 1264,2±31 pg/ml in the 2nd group, as compared with 92,0±14,8 pg/ml in healthy persons. By the day 40 of the study, the levels of IL-2, which showed a 2-fold decrease in both groups by the day 20, increased in group 1, however, remaining 1,5-fold below the initial values (p<0,001). Among the 2nd group of ITP patients, the levels of this cytokine after adaptation for the high altitude were significantly reduced by 3,6 times against initial values. TNF values during the high-altitude therapy decreased among the patients of 1st group by 2,9 times on the day 20 of treatment (p<0,001), and 2,7-fold in the 2nd group (p<0,001), remaining unchanged by the end of adaptation. Stabilization of the platelet functions (both quantitatively and qualitatively) among the ITP patients under the influence of high-altitude climatotherapy is retained after the descent up to 3 months for ITP patients in the 2nd group, and up to 6 months among the patients in the 1st group. Hemorrhagic syndrome was documented in 20% of cases of ITP patients (1st group) before HACT treatment. On the day 40 of altitude adaptation, the local bleedings were not observed, and average platelet counts increased from 35 to 109 ×109/l. All the patients from the 2nd group, except of 4 cases, exhibited hemorrhagic signs before the mountain travel. The level of platelets among them was critical (12,2 to 18,0×109/l). After HACT, these levels increased to a mean of 62,8×109/l, and hemorrhagic syndrome faded away.

Conclusion

Hence, a stress situation produced at high altitudes, along with activation and release of adrenal glucocorticoids, may potentially induce a destructive effect upon anti-platelet antibodies in the ITP patients. A possible immunomodulatory effect of high-altitude hypoxia may suppress synthesis of pro-inflammatory cytokines, promote their return to the balanced state, as reflected by improvement of clinical pattern and seems to be favorable to clinical outcomes, when using HACT as an alternative therapeutic method for the patients with this disease.

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Instant lysis of therapeutic mesenchymal stem cells after intravenous infusion: role of complement system and in vitro prevention strategies

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A. R. Muslimov, R. T. Mikhelashvili, E. V. Volchkov, K. V. Lepik, V. S. Sergeev, B. V. Afanasyev

R. M. Gorbacheva Memorial Institute of Children Oncology, Hematology and Transplantation, The First St. Petersburg State I. Pavlov Medical University, St.Petersburg, Russia.

Introduction

Multipotent mesenchymal stromal cells (MSCs) harbor great potential for cellular and tissue therapy, and are currently under investigation in numerous clinical trials, the majority thereof relying on systemic infusion. A major drawback in MSC‐therapy appears to be in the incomplete understanding of fate and function of MSCs following systemic administration. In recent years, new evidence indicates a low biocompatibility of MSC during intravenous infusion. Experimental data may suggest that up to 50% of ex vivo cultured MSCs undergo a complement-dependent lysis upon interaction between the cells and intact human serum. Meanwhile, the data concerning this issue is limited and controversial in some instances. The goal of present study was to assess the MSC viability during intravenous infusion, to confirm the complement-mediated lysis of MSCs, searching for possible ways to overcome this damage.

Materials and methods

Bone marrow-derived MSCs were obtained from healthy donors. Parallel cultures of MSCs from each donor were performed in two types of media: 1) MEM-α containing 10% FBS, and 2) MEM-α containing 7,5% platelet lysate (PL). When the cultures became near-confluent (>80%), the cells were detached by treatment with trypsin and EDTA. The harvested cells from different media (either PL-, or FBS-supplied) were divided into 3 sub-groups. Group 1: One-hour MSC incubation with 200µl of native (active) serum (a pool of 4 AB(IV), Rh+ donors). Group 2: One-hour incubation of MSCs with serum pre-treated with anti-C5 monoclonal antibody (Soliris®, Eculizumab, Alexion Pharmaceuticals Inc.) at the dose of 50µg/ml. Group 3: One-hour MSC incubation with EDTA-inactivated serum (controls).

Cytotoxicity analysis was performed by means of flow cytometry (7-AAD was used for the cell viability assays).

Results

In our preliminarily study, we revealed a statistical significant differences between all 3 groups of cells which were cultured in media containing 10% of FBS. About 30% of freshly harvested MSCs were lysed after 1 hour of contact with active AB(IV) serum. This effect was inhibited with EDTA or Eculizumab, a specific C5 inhibitor, thus providing evidence for a complement-dependent cell lysis. In the series incubated incubated with fetal bovine serum, the average cytotoxicity was 27,9% (subgroup 1), 15,4% (subgroup 2), and 10,7% (subgroup 3, p=0,00015). Meanwhile, we could not demonstrate any significant differences between the 3 subgroups of cells cultured with 7,5% human platelet lysate (PL). The average cytotoxicity in the 13.1% for subgroup 1; 15,5% for subgroup 2, and 7,5% for the subgroup 3 (p=0,32).

Conclusions

Our results confirm a phenomenon of pronounced complement-dependent lysis of pre-cultivated MSCs after contact with native serum. By the contrary, MSCs supplemented with human platelet lysate during cultivation showed much lesser (if any) susceptibility to the complement-dependent lysis. Lack of xenoantigens in the PL-containing media may be a possible explanation for this experimental finding.

We also report that pre-treatment of native sera with anti-C5 monoclonal antibody Eculizumab caused a significant reduction of in vitro MSC lysis after their culture in fetal bovine serum, thus suggesting a definite proof for applications of Eculizumab in different areas of cell therapy and transplantation.

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Treatment of refractory chronic graft-versus-host disease with interleukin-2

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Ivan S. Moiseev, E.A. Burmina, Olga V. Pirogova, Olga A. Slesarchuk, Sergej N. Bondarenko, Boris V. Afanasyev

R. M. Gorbacheva Memorial Institute of Children Hematology and Transplantation, First St. Petersburg I. Pavlov State Medical University, St. Petersburg, Russia

Introduction

Refractory or relapsed chronic graft-versus-host disease (cGVHD) is the complication of allogeneic hematopoietic stem cell transplantation (HCT) that significantly affects life quality, may be associated with morbidity and mortality and has limited treatment options. After promising results from Dana-Farber Cancer Institute about treatment of steroid-refractory cGVHD with interleukin-2 (IL-2) [1] and a number of in vitro studies, we commenced a pilot trial of IL-2 in this group of patients (pts). Patients and methods: 16 adult pts (median age 22, range 16-51 y.o.) with refractory cGVHD were enrolled. Six pts were on steroids upon inclusion. 11 patients had severe (NIH) cGVHD, 6, moderate. Eight pts developed bronchiolitis obliterans (BO). Pts received IL-2 as subcutaneous injections (1 MIU 3 times a week) and continued other cGVHD treatments (a median of 2 medications, range 1 to 3). Median duration of treatment was 2,5 moths (range 1 to 8 months). Response was assessed by physician assessment (clinical response), improvement in NIH scores and Karnofsky score. Any objective positive response was defined as improvement, in either NIH or Karnofsky scores. Results: Partial clinical response was observed in 5 pts, complete response in 2 pts with overall response of 44%. 4/6 patients discontinued steroids and 2 patients with complete response discontinued all cGVHD medications. In general, there was an improvement of Karnofsky Index in 25% of cases (median change 0%, range -20 to +20%), reduction in NIH severity scores in 37.5% of pts (median change 0, range -8 to +5), stable %FEV1 level (mean change -2, range -22 to +17%), and any objective response in 44% of pts. There were no statistically significant clinical predictive parameters for the response. During the treatment, there was a median of 1 bacterial infection (range 0-3), 0 opportunistic viral (range 0-2), 0 invasive fungal (range 0-1) infectious episodes. Non-relapse mortality was 12% (2 pts) over a median 21-month follow-up. Conclusion: Our preliminary data indicate that a proportion of patients respond well to IL-2 therapy, but absence of clinical predictive parameters for response requires further studies to elucidate biomarkers to redict response.

References.

  1. Koreth J, Matsuoka K, Kim HT et al. Interleukin-2 and regulatory T cells in graft-versus-host disease. N Engl J Med. 2011; 365 (22): 2055-66.

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Pharmacokinetic comparison of cyclosporine A and tacrolimus for graft-versus-host disease prophylaxis

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Moiseev Ivan S., Muslimov A. R., Pirogova Olga V., Darskaya Elena I., Slesarchuk Olga A., Bondarenko Sergej N., Afanasyev Boris V.

R. M. Gorbacheva Memorial Institute of Children Hematology and Transplantation, First State Medical University named I. P. Pavlov, Saint-Petersburg, Russia

Introduction

There is a number of studies that compare cyclosporine A (CsA) and tacrolimus (Tac) for graft-versus-host disease (GVHD) prophylaxis after allogeneic hematopoietic stem cell transplantation (HSCT). Several large studies demonstrate superiority of Tac [1, 2]. Also a number of studies highlight pharmacokinetics (PK) significance for both CsA and Tac [3,4]. Nevertheless, a comparison of CsA and Tac along with PK analysis was not performed.

Patients and methods

Data from 93 patients (pts) with CsA and 209 pts with Tac GVHD prophylaxis was retrospectively analyzed. Detailed pts characteristics are presented in table 1. As the second component, a short-term course of methotrexate or MMF was used. Unrelated graft recipients also received horse ATG at the dose of 60 mg/kg. CsA and Tac concentrations were measured at least 2 times a week. Receiver operating curve (ROC) analysis was done to determine the most significant time frame of concentrations for GVHD development and cutoff values for CsA and Tac concentrations. Based on multivariate hazard ratio weights that included concentrations and number of time points with low concentrations, 3 groups of GVHD risk were distinguished and CsA and Tac pts were compared within these groups.

Results

In related HSCTs, here was no difference between CsA and Tac in the incidence of aGVHD grade II-IV (21% vs 22%, p=0,8) and grade III-IV (15% vs 14%, p=0,7), while in unrelated HSCT, GVHD grade II-IV incidence was comparable (49% vs 42%, p=0,2), and GVHD grade III-IV was lower with Tac (36% vs 23%, p=0,028). For CsA, the highest predictive value for aGVHD had median concentration within 30 days (AUC=0,62), and for Tac, a median within 21 days (AUC=0,62). The cutoff value for CsA was 163 ng/ml, and 9 ng/ml for Tac. For the same time frames, numbers of low concentrations of CsA (p=0,024) and Tac (p=0,021) were predictive for aGVHD. Based on these parameters, aGVHD II-IV rate was significantly different for CsA in the 3 model risk groups (27% vs 35% vs 60%, p=0,003) and Tac (23% vs 38% vs 48%, p=0,005). With intergroup comparison of unrelated grafts, there was no difference between CsA and Tac for aGVHD incidence in the low-risk (27% vs 23%, p=0,7) and intermediate-risk groups (35% vs 38%, p=0,8), whereas in the high-risk group, incidence of aGVHD II-IV (60% vs 48%, p=0,12) and aGVHD III-IV (45% vs 25%, p=0,041) was higher with CsA.

Conclusions

CsA and Tac have comparable efficacy as GVHD prophylaxis in related grafts. Superior efficacy of Tac in unrelated grafts is attributed to less severe impact of low drug concentrations on the incidence of aGVHD early post-transplant. Their efficacy is comparable if maintained within therapeutic limits >163 ng/ml for CsA and 9 ng/ml for Tac.

Parameter

CsA group, N=93

Tacro group, N=209

p-value

Male/Female

53/47%

49/51%

0,6

Age, median (range)

27 (18-60)

35 (18-67)

0,03

Donor

Related

Unrelated

Haploidentical

 

39%

59%

2%

 

32%

64%

4%

 

0,4

Graft source

Bone marrow

PBSC

 

37%

63%

 

35%

65%

 

0,9

HLA-mismatch

12%

8%

0,3

Diagnosis

AML

ALL

CML

MDS

other

 

46%

29%

16%

9%

0%

 

54%

33%

5%

5%

3%

 

0,06

Salvage, %

23%

23%

1,0

RIC/MAC

35%/65%

28%/72%

0,17

CD34+ x 106/kg

4,9±4,2

4,4±5,2

0,4

Table 1. Characteristics of groups.

References

  1. Nash RA, Antin JH, Karanes C et al. Blood. 2000; 96 (6): 2062-2068.
  2. Yanada M1, Emi N, Naoe T et al. Bone Marrow Trans- plant. 2004; 34 (4): 331-337.
  3. Mori T, Kato J, Shimizu T et al. Biol Blood Marrow Trans- plant. 2012; 18 (2): 229-234.
  4. Wilhelm AJ, de Graaf P, Veldkamp AI et al. Br J Clin Pharmacol. 2012; 73 (4): 553-563.

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Efficiency and safety of 5-azacitidine administration in acute myeloid leukemia and myelodisplastic syndrome after allogenic hematopoietic stem cell transplantation

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Varvara N. Ovechkina, Sergey N. Bondarenko, Elena V. Morozova, Olga A. Slesarchuk, Anna G. Smirnova, Kirill A. Ekushov, Ludmila S. Zubarovskaya, Boris V. Afanasyev

Raisa Gorbacheva Memorial Institute of Children Oncology, Hematology and Transplantation, CIC 725, The First I. Pavlov State Medical University of St. Petersburg, Russia

Introduction

The aim of this study was to estimate overall survival (OS), relapse incidence (RI), non-relapse mortality and frequency of acute and chronic graft versus host disease (aGvHD, cGvHD) of patients with AML and MDS after hematopoietic stem cell transplantation (alloHSCT), receiving 5-azacitidine (5-aza).

Patients and methods

We performed pair-matched analysis of 116 patients with myeloid malignancies (AML 88%, MDS 12% ). Half of them received 5-aza after alloHSCT. In the group of patients, who received 5-aza median age was 28 years, range 2-68, 34 male, 24 female. 12 patients were grafted from matched family donor, 35 – matched/mismatched unrelated donor, 11 – haploidentical. Conditioning regimen was myeloablative in 16 (27%) cases, reduced intensity conditioning was used in 42 cases (73%). 27 patients (46%) had advanced disease at the moment of alloHSCT. Unfavorable cytogenetic before alloHSCT was detected in 14 (24%) cases. 7 (12%) patients had the minimal residual disease before alloHSCT. In the group of comparison, median age was 29 years, range 2-60, 31 males, 27 females. 22 patients were grafted from matched family donor; 28, matched/mismatched unrelated donor; 8 patients received haploidentical grafts. Conditioning regimen was myeloablative in 17 cases (30%), a reduced-intensity conditioning was used in 41 cases (70%). Advanced disease at the moment of alloHSCT had 23 patients (43%). Unfavorable cytogenetic before alloHSCT was detected in 10 (18%) cases. 5 patients (9%) had detectable minimal residual disease before alloHSCT. Median time for the 5-aza administration was day +253 (27-861) after alloHSCT; 5-aza was injected subcutaneously 35mg/m2/daily, 5 days of 28-day cycle, the median number of 5-aza cycles administrated was 2,5 (1-8). 5-aza was combined with donor lymphocyte infusions in 36% (21).

Results

Three-year OS rates in the group with 5-aza therapy were 38% vs 22% in the group of comparison (p=0,08). A 3-year RI in the group with 5-aza therapy was 35%, in the group of comparison, 57% (p=0,2), the results were estimated for patients without post-transplant cell therapy. The 2-year NRM in the group with 5-aza therapy was as low as 7% vs 22% in the group of comparison (p=0,05). Frequency of the grade III-IV aGvHD in the group with 5-aza therapy was documented as 6%, in the group of comparison, 26% (p=0,007). The one-year GvHD- and relapse-free survival (GRFS) in the group with 5-aza therapy comprised 35% vs 16% in the group of comparison (p=0,04).

Conclusions

As based on our data analysis, the usage of 5-aza shows a tendency for prevention of relapses and improvement of overall survival in the high-risk group. Administration of 5-aza may decrease the risk of severe aGVHD and cGvHD. This drug has low toxicity and can be used in early post-transplant period. Extended randomized trials are needed in future for more reliable conclusions.

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Characteristics of early posttransplant phase in patients with multiple myeloma and different response to standard chemotherapy: single-center analysis of 130 cases

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Galina D. Petrova, Kapitolina N. Melkova, Tatiana Z. Chernyavskaya, Nadezhda V. Gorbunova, Valentina N. Kostrykina, Vadim A. Doronin.

N. N. Blokhin Russian Cancer Research Center, Moscow, Russia

Introduction

The prognostic impact of chemosensitivity to prior lines of standard chemotherapy (ChT) on outcome after autologous stem cell transplantation (ASCT) is ascertained in majority of haematological malignancies. ASCT is a standard treatment in newly diagnosed young patients (pts) with multiple myeloma (MM). The aim of this study was to analyse the influence of response to standard ChT on characteristics of early post-transplant phase in patients with MM.

Patients and methods

Between 2007 and 2015 102 consecutive pts with MM (49 males) were enrolled in the study. Peripheral blood stem cells (PBSC) were collected and ASCT was performed independently of response to standard CT. If less than complete response (CR)/very good partial response (PR) after the first ASCT had been achieved, the second ASCT was recommended. The same decision was taken in a case of CR/very good PR after 1st ASCT followed by disease relapse/progression (PD).

Results

The first ASCT was administered to 102 pts, 28 pts received the second ASCT (totally 130 ASCT). Median age at ASCT was 51 years (range 29-64). The time interval between diagnosis setting and first ASCT was 5-43 mo (median 10 mo); in 24% cases this interval was more than 1 year. In a period of 3,5-41 mo (median 7 mo), 28 pts received the second ASCT. The disease status at ASCT was: 12% CR, 50% PR, 16% stable disease (SD), 22% PD. Preparative regimen consisted of melphalan (200 mg/m2) in most cases; in 4 cases, the dose was reduced to 100-120 mg/m2, due to severe renal insufficiency. Peripheral blood stem cells (PBSC) grafting was performed in all the cases. Median number of infused PBSC was 4.3 ×106 CD34+cells/kg (range, 2-14,8). Analysis of early post-ASCT phase did not reveal significant hematological and non-hematological toxicity (grade 1-2) in most cases. The median time of neutrophil recovery to >0,5×109/l was 14 days (range, 10-28 days). The median time to platelet recovery to >20×109/l and >50×109/l was 12 days (range, 8-92 days) and 13 days (range, 9-180 days), respectively. Median duration of hospitalization was 22 days (range, 14-83 days). There were no cases of transplant-related mortality. After ASCT, most patients were dynamically followed-up, only 12% received thalidomide, lenalidomide, or bortezomib as maintenance therapy. The subgroup analysis revealed that hematological recovery, intensity of hematological and non-hematological toxicity, duration of hospitalization after ASCT didn’t vary significantly among the patients with different types of response to standard ChT (р>0,05).

Conclusion

ASCT should be performed in all newly diagnosed patients with ММ under 70 years, without absolute contraindications to high-dose CT, regardless of response to standard CT owing to safety of this treatment option and lack of significant differences in early post ASCT phase. This information can have important implication for extension of eligibility to transplantation and maintenance therapy which ultimately would allow for better treatment outcomes in the multiple myeloma patients.

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Treatment of HIV-associated lymphomas: results of a multicenter retrospective study

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Popova M.1, Shneyder T.2, Karaygin I.2, Zuyzgin I.2, 10, Ryabykina O.2, Ruzhinskaya O.2, Uspenskaya O.2, Medvedeva N.3, Klimovich A.3, Potapenko V.3, Kotova N.3, Zinina E.4, Popova N.4, Zhurba Y.4, Myasnikov A.5, Moshnina S.5, Evseev A.5, Kaplanov K.6, Ksenzova T.7, Karyagina E.8, Stolypina Zh.8, Dzola S.9, Levanov A.9, Mel’sitova K.1, Borzenkova E.1, Mikhaylova N.1, Zubarovskaya L.1 and Afanasyev B.1

1 Raisa Gorbacheva Institute of Children Oncology, Hematology and Transplantation, The First St. Petersburg State I. Pavlov Medical University, St. Petersburg, Russia

2 Leningrad Regional Clinical Hospital, St. Petersburg, Russia

3 City Clinical Hospital №31, St. Petersburg, Russia

4 Surgut District Clinical Hospital, Surgut, Russia

5 Republican Clinical Hospital, Petrozavodsk, Russia

6 Volgograd Regional Clinical Oncologycal Hospital, Volgograd, Russia;

7 Regional Clinical Hospital, Tumen’, Russia

8 City Clinical Hospital №15, St. Petersburg, Russia

9 Clinic of Profpathology and Hematology, Saratov State Medical University, Saratov, Russia

10 Petrov Research Institute of Oncology, St. Petersburg, Russia

Introduction

Since the beginning of AIDS epidemic, almost 70 million of human population have been infected with HIV, and about 35 million have died of AIDS. 35 millions of people around the world were living with HIV by the end of 2013. The HIV-infected patients are at risk of cancer, including lymphomas, despite a widespread accessibility of highly active antiretroviral therapy (HAART). In parallel with increasing number of people living with HIV, the number of patients suffering from HIV-associated malignancies of hematopoietic and lymphoid tissues has increased as well, as a result of their immunodeficiency state.

Methods

We have performed a retrospective multicenter study. Diagnosis of lymphoma in a HIV infected patient was the inclusion criterion. This study focuses on the outcomes in HIV-infected patients with lymphomas. Forty-seven patients were enrolled within the period from May 2006 to February 2015. We have analyzed the data on medical history, results of laboratory testing as well as treatment in hematological departments and AIDS-centers, as based on the established practice of Russian health care. The median follow-up of patients was 24 (3 to 106) months.

Results

The patients’ characteristics are depicted in Table 1. In 78% of the patients, HIV infection was detected before the diagnosis of lymphoma. CD4+ cell counts and viral load at the diagnosis of lymphoma were assessed only in 30% of cases. The levels of CD4+ cell counts were<200 cells/mm (50-420) in 70% of patients. The viral loads in 50% of the patients were<1000 RNA copies/mL (0-800 thousand copies/mL). The HIV-infected persons with lymphoma received 1 to 8 cycles of chemotherapy (ChT); 50% patients underwent > 5 ChT cycles. The lymphoma treatment regimens are shown in Table 2. Generally, cytostatic ChT in combination with Rituximab and HAART was not associated with excessive toxicity. Overall survival in HIV-infected patients with lymphomas was 70% at 2 years of observation. Appropriate rates for specific entities are as follows: HL, 80%; BL, 78,6%; DLBCL, 68,4%; intermediate BL/DLBCL lymphoma, 33,3%; undifferentiated aggressive B-cell lymphoma, 33,3%, and a patient with follicular lymphoma is still alive. Significant improvement of the overall survival rate is associated with administration of ChT in combination with HAART (75% vs 43%, p=0,024), and application of adequate ChT (83,3% vs 47,1%, p=0,013). Usage of ChT plus Rituximab improves overall survival (81,5% vs 33,3%, p=0,01) and reduces the probability of progression (11% vs 44,4%, p=0,02) of CD20+ B-cell lymphoma (n=36). LDH level above 500 U/l was a poor prognostic factor (56% vs 86,4%, p =0,01). The patient’s age, ECOG status, disease stage, presence of B symptoms and International Prognostic Index (IPI) had no impact on the outcome, thus suggesting influence of other factors that may include HIV-state (CD4+ cell levels and viral load).

Conclusions

HIV-infected patients were more often affected with DLBCL which was characterized by aggressive clinical course. The 2-year overall survival of the HIV-infected lymphoma patients with HIV was 70%. ChT in combination with HAART (75%) and adequate to diagnosis ChT (81.5%) improved overall survival. Usage of Rituximab reduced the probability of progression and improved overall survival of CD20+ B cell lymphoma in HIV infected individuals. The levels of LDH above 500 U/l are associated with unfavorable prognosis. HIV status seems to play an important prognostic role.

Patients and chemotherapy characteristics

n=47

Age, median

37 (22-66)

Male/female

27/20

ECOG 3-4

17%

Ann Arbor 3-4

78%

B symptoms

45%

LDH (>2X)

56%

Extra lymphatic diseases

98,5%

Number of CT courses, median

5 (1-8)

ABVD

2

BEACOPP

3

CHOP like

21

EPOCH

10

Hyper-CVAD / BFM

11

CT +R

27

CT without R

9

CT +HAART

40

CT without HAART

7

Table 1. Characteristics of the lymphoma patients under study


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Graft-versus-host disease prophylaxis with post-transplantation cyclophosphamide

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Olga V. Pirogova, Ivan S. Moiseev, Elena I. Darskaya, Sergej N. Bondarenko, Elena V. Babenko, Alexander L. Alyanskiy, Boris V. Afanasyev

R. M. Gorbacheva Memorial Institute of Children Hematology, Oncology and Transplantation, First I. Pavlov St. Petersburg State Medical University, St. Petersburg, Russia

Introduction

Improvement of current graft-versus-host disease (GVHD) treatment remains the important goal in allogeneic hematopoietic stem cell transplantation (alloHSCT). Following impressive results of high-dose posttransplant cyclophosphamide GVHD prophylaxis presented by the research team from Johns Hopkins University [1] we performed a pilot study with this prophylaxis after alloHSCT.

Methods

111 adult patients undergoing alloHSCT from matched unrelated donors (MUD) (69 pts), mismatched unrelated (MMUD) (28 pts) and haploidentical donors (Haplo) (14 pts) were included in the analysis. GVHD prophylaxis consisted of Cy 50 mg/kg/day on day +3 and +4, tacrolimus starting on day +5 and mycophenolate mofetil from day +5 until day +35. Detailed patients’ characteristics and analysis of groups’ differences are presented in table 1.

Results

Cumulative incidences of the grades II to IV acute GVHD were not significantly different between the groups: 15,9% vs 17,9% vs 14,3% (p>0,05) for MUD, MMUD and Haplo, respectively. The cumulative incidence of chronic GVHD was 11,6% vs 21,4% vs 14,4% (p>0,05) for MUD, MMUD and Haplo, respectively. One-year GVHD – and relapse-free survival was 65,2 % vs 60,7% vs 28,6% (p<0,001) for MUD, MMUD and Haplo, respectively. One-year non-relapse mortality (7,4% vs 0% vs 28,6%, p=0,004) was higher, and 1-year overall survival (78,3% vs 75,0% vs 35,7%, p<0,001) and event-free survival (68,1% vs 67,9% vs 28,6, p<0,001) were lower in Haplo-group.

Conclusion

This new regimen of GVHD prophylaxis demonstrates lower levels of acute GVHD for all types of donors. Poor overall survival and high non-relapse mortality in Haplo-group were due to the predominance of salvage patients, but not due to GVHD.

References

1. Luznik L at al. Biol Blood Marrow Transplant.
2008; 14 (6): 641–650.

Characteristics

MUD (N=69)

MMUD (N=28)

Haplo (N=14)

Median follow-up (days)

243

304

125

Disease status

Active disease at transplantation

 

14 (20,2%)

 

6 (21,4%)

 

8 (57%)

Age at transplantation

Median (range)

34 (18–59)

32 (19–58)

27 (20–51)

Sex, female

31 (45%)

9 (32%)

8 (57%)

Diagnosis

AML

ALL

MDS

CML

 

36 (52,7%)

23 (33,3%)

4 (5,8%)

6 (8,2%)

 

11 (39,3%)

10 (35,7%)

1 (3,5%)

6 (21,5%)

 

10 (78,5%)

2 (14,2%)

0 (0%)

1 (7,3%)

Conditioning

Myeloablative

Reduced-intensity

 

18 (26%)

51 (74%)

 

3 (10,7%)

25 (89,3%)

 

2 (14,2%)

12 (85,8%)

Table 1. Detailed characteristics of the patients and analysis of the inter-group differences

Obituary

Dirk Willem van Bekkum 30 Juli 1925 - 17 Juli 2015

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Gerard Wagemaker

Erasmus University Rotterdam, The Netherlands

Raisa Gorbacheva Memorial Institute of Children Oncology,

Hematology and Transplantation, St.Petersburg, Russia

Center for Stem Cell Research and Development,

Hacettepe University, Ankara, Turkey