ISSN 1866-8836
Клеточная терапия и трансплантация

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Short reports

The efficacy of empirical antibiotic therapy of febrile neutropenia in patients after allogeneic hematopoietic stem cell transplantation

Veronika I. Pivovarova1,2, Yulia A. Rogacheva1, Marina O. Popova1, Alisa G. Volkova1, Alexander N. Shvetsov1, Ilya Yu. Nikolaev1, Elena I. Darskaya1, Oleg V. Goloshchapov1, Elena V. Morozova1, Maria D. Vladovskaya1, Sergey N. Bondarenko1, Ivan S. Moiseev1, Ludmila S. Zubarovskaya1, Nikolay N. Klimko1,2, Boris V. Afanasyev1

Nivolumab combined with autologous hematopoietic stem cell transplantation in multiple myeloma patients

Olga V. Pirogova, Elena I. Darskaya, Valentina V. Porunova, Olga V. Kudyasheva, Elena V. Babenko, Natalia B. Mikhailova, Boris V. Afanasyev

Reconstitution of CD8+ T-memory cells after different GVHD prophylaxis regimens in acute leukemia patients after allogeneic stem cells transplantation

Natalia N. Popova, Mikhail Y. Drokov, Yulia O. Davydova, Nikolay M. Kapranov, Uliyana V. Maslikova, Ekaterina D. Mikhaltsova, Vera A. Vasilyeva, Olga M. Koroleva, Zoya V. Konova, Anna A. Dmitrova, Maria V. Dovydenko, Olga S. Starikova, Darya S. Dubnyak, Denis V. Kamelskikh, Irina V. Galtseva, Tatyana V. Gaponova, Michael A. Maschan, Larisa A. Kuzmina, Elena N. Parovichnikova, Valery G. Savchenko

Invasive fungal diseases before and after allogeneic hematopoietic stem cell transplantation in children and adults with relapsed/refractory Hodgkin’s lymphoma

Yuliya A. Rogacheva1, Marina O. Popova1, Alisa G. Volkova1, Inna V. Markova1, Alexander N. Shvetsov1, Iliya Y. Nikolaev1, Oleg V. Goloshchapov1, Svetlana M. Ignatieva2, Tatiana S. Bogomolova2, Andrey V. Kozlov1, Kirill V. Lepik1, Yury R. Zalyalov1, Lilia V. Stelmakh1, Asmik G. Gevorgian1, Anastasya V. Beynarovich1, Eugeniya S. Borzenkova1, Elena I. Darskaya1, Elena V. Kondakova1, Natalya B. Mikhailova1, Mariya D. Vladovskaya1, Sergey N. Bondarenko1, Ivan S. Moiseev1, Ludmila S. Zubarovskaya1, Nikolay N. Klimko1,2, Boris V. Afanasyev1

Uniparental disomy found in tumor DNA of de novo diagnosed ALL patients as a factor predicting poor outcome

Natalya V. Risinskaya, Olga A. Gavrilina, Julia A. Chabaeva, Anna A. Yushkova, Andrey B. Sudarikov, Sergei M. Kulikov, Elena N. Parovichnikova, Valery G. Savchenko

Study of multipotent mesenchymal stromal cells as a cellular delivery system for antitumor drugs and their remote control activation

Oleksii O. Peltek, Timofey E. Karpov, Yana V. Tarakanchikova, Mikhail V. Zyuzin, Albert R. Muslimov

Exosome-mediated in vitro BCR-ABL p210 transcript horizontal transfer between leukemic and bone marrow stromal cells

Anna N. Parfenenkova, Ildar M. Barkhatov, Anton A. Kremlev, Boris V. Afanasyev

Polymeric micro- and nano-carriers as a universal platform for delivery of biologically active substances to therapeutically cell populations

Albert R. Muslimov1,3,5, Tatyana V. Mashel6, Oleksii O. Peltek6, Mikhail A. Trofimov5, Igor S. Sergeev5, Yana V. Tarakanchikova4,5, Alexander A. Goncharenko5, Kirill V. Lepik1, Mikhail V. Zyuzin6, Alexander S. Timin1,2,3

Problems of physical activity dosage in pediatric patients receiving HSCT

Nikolay N. Mitrakov1, M. Yu. Zhukov1, Olga A. Laysheva1,2

Results of allogeneic hematopoietic stem cell transplantation in patients with juvenile myelomonocytic leukemia

Anna A. Osipova, Tatyana A. Bykova, Varvara N. Ovechkina, Anastasia S. Borovkova, Olesya V. Paina, Polina V. Kozhokar, Anastasia S. Frolova, Kirill A. Ekushov, Aleхander N. Galimov, Zhemal Z. Rahmanova, Svetlana V. Razumova, Alexander L. Alyanskiy, Elena V. Morozova, Elena V. Babenko, Tatyana L. Gindina, Elena V. Semenova, Ludmila S. Zubarovskaya, Boris V. Afanasyev

Treatment of steroid-refractory acute and chronic graft-versus-host disease with ruxolitinib in children

Olesya V. Paina, Tatyana A. Bykova, Ivan S. Moiseev, Polina V. Kozhokar, Anastasia S. Frolova, Anastasiya S. Borovkova, Anna A. Osipova, Zhemal Z. Rahmanova, Kirill A. Ekushov, Liubov A. Tsvetkova, Inna V. Markova, Elena V. Semenova, Ludmila S. Zubarovskaya, Boris V. Afanasyev

Comparison of allogeneic transplant outcomes using conditioning with different dose of busulfan for children with acute myeloid leukemia

Olesya V. Paina, Zhemal Z. Rahmanova, Liubov A. Tsvetkova, Polina V. Kozhokar, Anastasia S. Frolova, Kirill A. Ekushov, Inna V. Markova, Sergey N. Bondarenko, Elena V. Babenko, Alexander L. Alyanskiy, Ildar M. Barkhatov, Elena V. Semenova, Ludmila S. Zubarovskaya, Boris V. Afanasyev

Administration of nasogastric tubes and gastrostomy in HSCT patients

Natalia G. Saltykova, Nina N. Gurgenidze, Alexander N. Shvetsov, Maksim A. Kucher, Boris V. Afanasyev

Allogeneic haematopoietic stem cell transplantation with myeloablative conditioning regimen based on different dosage of busulfan in children and adolescents with acute lymphoblastic leukemia

Elena V. Semenova, Olesya V. Paina, Liubov A. Tsvetkova, Polina V. Kozhokar, Anastasia S. Frolova, Zhemal Z. Rahmanova, Kirill A. Ekushov, Inna V. Markova, Sergey N. Bondarenko, Elena V. Babenko, Ildar M. Barkhatov, Alexander L. Alyanskiy, Ludmila S. Zubarovskaya, Boris V. Afanasyev

Frontline R-EPOCH in HIV-infected patients with non-Hodgkin’s lymphoma

Ivan V. Tsygankov, Marina O. Popova, Yulia A. Rogacheva, Kirill V. Lepik, Yury R. Zalyalov, Lilia V. Stelmakh, Ivan S. Moiseev, Sergey N. Bondarenko, Natalia B. Mikhaylova, Vadim V. Baykov, Boris V. Afanasyev

Expression of immune checkpoint molecules in bone marrow as a predictor of clinical outcome in myelodysplastic syndrome

Nikolai Y. Tcvetkov, Ivan S. Moiseev, Artem A. Gusak, Vadim V. Baykov, Elena V. Morozova, Boris V. Afanasyev

Anorexia overcoming in patients with cytostatic therapy and hematopoietic stem cell transplantation

Irina N. Zhuk1,2, Polina V. Sheveleva2, Natalya G. Saltykova2, Maksim A. Kucher2, Boris V. Afanasyev2

Complex treatment experience in a cohort of children and adolescents with Hodgkin’s lymphoma

Daria A. Zvyagintseva2, Andrew V. Kozlov1, Asmik G. Gevorgian1, Ilya V. Kazantsev1, Polina S. Tolkunova1, Tatiana V. Iukhta1, Ludmila S. Zubarovskaya1, Boris V. Afanasyev1

Fecal microbiota transplantation in the patients after allogenic bone marrow transplantation with acute graft-versus-host disease and severe gastrointestinal damage

Oleg S. Syuskin, Oleg V. Goloshchapov, Dar’ya V. Churakina, Maksim А. Kucher, Ruslana V. Klementeva, Sergei V. Sidorenko, Vladimir V. Gostev, Vadim Е. Karev, Мariya А. Suvorova, Irina V. Shlyk, Аlexei B. Chukhlovin, Ludmila S. Zubarovskaya, Olga V. Pirogova, Olesya V. Paina, Marina O. Popova, Boris V. Afanasyev

Immunochemotherapy in relapsed or refractory B-cell non-Hodgkin lymphoma

Olesya G. Smykova, Kirill V. Lepik, Elena V. Kondakova, Yury R. Zalyalov, Lilia V. Stelmakh, Elena I. Darskaya, Natalia B. Mikhailova, Boris V. Afanasyev

Infusion of memory T cell (CD45RA-depleted) DLI improves CMV-specific immune response early after αβT cell-depleted HSCT: first results of a prospective randomized trial

Zhanna B. Shekhovtsova, Maria A. Dunaykina, Larisa N. Shelikhova, Dmitry N. Balashov, Elena E. Kurnikova, Yakov O. Muzalevsky, Alexey S. Kazachenok, Elena Yu. Osipova, Viktoria V. Kiseleva, Dmitry E. Pershin, Daria A. Shasheleva, Rimma D. Khismatullina, Sergey L. Blagov, Andrei B. Abrosimov, Irina P. Shipitsina, Elena I. Gutovskaya, Galina A. Novichkova, Alexey A. Maschan, Michael A. Maschan

Intravenous immunoglobulin G effectiveness evaluation for hemorrhagic cystitis treatment in allogeneic hematopoietic stem cell transplantation

Aleksander A. Shcherbakov, Olga N. Zatsepina, Ekaterina S. Kulneva, Irina S. Iarushkina, Maxim A. Kucher, Oleg V. Goloshchapov, Boris V. Afanasyev

Effectiveness of tyrosine kinase inhibitor therapy and allogeneic hematopoietic stem cell transplantation in pediatric patients and adolescents with chronic myeloid leukemia (experience of R. M. Gorbacheva Memorial Research Institute of Children Oncology, Hematology, and Transplantation)

Polina V. Sheveleva, Anna A. Osipova, Tatyana A. Bykova,Varvara N. Ovechkina, Olesya V. Paina, Polina V. Kozhokar, Kirill A. Ekushov, Alexandr N. Galimov,Tatyana L. Gindina, Ildar M. Barkhatov, Alexander L. Alyanskiy, Elena V. Morozova, Elena V. Semenova, Ludmila S. Zubarovskaya, Boris V. Afanasyev

Choice of optimal GVHD prophylaxis regimen in unrelated transplantations of non-manipulated hematopoietic stem cells in children

Natalia V. Sidorova1, Alexey S. Slinin2, Kirill I. Kirgizov1, Ekaterina A. Pristanskova1, Veronika V. Konstantinova1, Alexandra E. Burya1, Elena B. Machneva1, Oxana L. Blagonravova1, Elena V. Skorobogatova1

Treatment of patients with central nervous system lymphoma

Daniil I. Shmidt, Andrey N. Gavrilenko, Alexey Y. Polushin, Elena V. Kondakova, Kirill V. Lepik, Nadezhda V. Medvedeva, Anna V. Klimovich, Yury R. Zalyalov, Natalia B. Mikhailova, Boris V. Afanasyev

Perspectives of clinical video-analysis of movements in pediatric patients receiving HSCT

Nikolay N. Mitrakov1, Artem V. Shcherbuha1, Polina A. Shafran1, Alexey V. Korochkin1,2, Olga A. Laysheva1,2

Effect of donor CD45RA-lymphocyte infusion on the T-cell subpopulation composition in adult patients after transplantation of allogeneic hematopoietic stem cells from a haploidentical donor with TCR αβ-depletion

Ulyana V. Maslikova, Natalia N. Popova, Mikhail Yu. Drokov, Julia O. Davydova, Nikolai M. Kapranov, Ekaterina D. Mikhaltsova, Vera A. Vasilieva, Maria V. Dovydenko, Olga M. Koroleva, Anna A. Dmitrova, Zoya V. Konova, Olga S. Starikova, Daria S. Dubnyak, Denis V. Kamelskikh, Irina V. Galtseva, Tatyana V. Gaponova, Miсhael A. Maschan, Larisa A. Kuzmina, Elena N. Parovichnikova, Valery G. Savchenko

Post-transplant cyclophosphamide for graft-versus-host disease prophylaxis in patients with inherited disorders undergoing allogeneic stem cell transplantation

Tatiana A. Bykova, Anna A. Osipova, Varvara N. Ovechkina, Alexander N. Galimov, Anna A. Dotsenko, Alexander L. Alyanskiy, Ivan S. Moiseev, Elena V. Semenova, Ludmila S. Zubarovskaya, Boris V. Afanasyev

The results of allogeneic hematopoietic stem cell transplantation from HLA-haploidentical donor with post-transplant cyclophosphamide regimen in children

Alexandra E. Burya, Kirill I. Kirgizov, Yulia A. Nikolaeva, Ludmila V. Olhova, Veronica V. Konstantinova, Ekaterina A. Pristanskova, Natalia V. Sidorova, Anastasia V. Mezenceva, Oxana L. Blagonravova, Olga A. Filina, Elena V. Skorobatova

“Sensory conflict” as a possible reason for the violation of the postural stability of children treated for cancer

Serafima M. Chechelnitskaia, Vladimir N. Kasatkin, Dmitrij V. Skvorcov, Marina A. Shurupova, Yury V. Saraikin, Aleksandra V. Baerbakh, Daria V. Zhuk, Vladislav A. Nikulin

Assessment of cytokine levels in the patients with relapsed/refractory Hodgkin’s lyphoma during nivolumab therapy

Andrey M. Chekalov, Kirill V. Lepik, Nikita D. Yolshin, Albert R. Muslimov, Natalia B. Mikhailova, Elena V. Kondakova, Lubov’ A. Tsvetkova, Yury R. Zalyalov, Eugenia S. Borzenkova, Ivan S. Moiseev, Vadim V. Baykov, Boris V. Afanasyev

High-dose chemotherapy and autologous stem cell rescue in children with pediatric malignancies: single center experience

Yulia V. Dinikina, Anna Y. Smirnova, Andrey S. Egorov, Svetlana I. Chernova, Yulia K. Toshina, Margarita B. Belogurova

The relationship of cytometric abnormalities and cytogenetic aberrancies in patients with myelodysplastic syndromes

Yulia O. Davydova, Irina V. Galtseva, Elena N. Parovichnikova, Alina V. Kohno, Nikolay M. Kapranov, Ksenia A. Nikiforova, Tatiana N. Obukhova, Valentina N. Dvirnykh, Alla M. Kovrigina, Vera V. Troitskaya, Elena A. Mikhailova, Tatiana N. Moiseeva, Larisa A. Kuzmina, Elena A. Lukina, Valery G. Savchenko

Results of hematopoietic stem cells transplantation with TCRαβ+/CD19+-depletion from haploidentical donors in pediatric acute leukemia patients in complete remission

Anna A. Bogoyavlenskaya, Larisa N. Shelikhova, Maria A. Ilyushina, Zhanna B. Shekhovtsova, Dmitry N. Balashov, Irina P. Shipitsina, Darya A. Shasheleva, Rimma D. Khismatullina, Sergey L. Blagov, Anna M. Lyvshits, Konstantin V. Mytrakov, Svetlana N. Kozlovskaya, Elena E. Kurnikova, Jakov O. Muzalevsky, Alexey S. Kazachenok, Irina I. Kalinina, Natalya V. Myakova, Galina A. Novichkova, Alexey A. Maschan, Michael A. Maschan

Safety and efficacy of allogeneic stem cell transplantation after Nivolumab therapy for patients with relapsed/refractory classical Hodgkin lymphoma

Anastasiya V. Beynarovich, Kirill V. Lepik, Nataliya B. Mikhailova, Elena V. Kondakova, Yury R. Zalyalov, Eugeniya S. Borzenkova, Elena V. Babenko, Elena I. Darskaya, Ivan S. Moiseev, Boris V. Afanasyev

Nursing care for patients who received monoclonal antibody therapy

Anna A. Apostolova, Olesya V. Paina, Yulia V. Bogoslavskaya

Impact of additional chromosomal abnormalities on survival after allo-HSCT in CML patients

Ksenia S. Afanaseva, Elena V. Morozova, Julia J. Vlasova, Maria V. Barabanshikova, Nikolai Y. Tcvetkov, Tatiana L. Gindina, Ildar M. Barkhatov, Sergey N. Bondarenko, Ivan S. Moiseev, Elena I. Darskaya, Boris V. Afanasyev

Toxicity and efficacy gemtuzumab ozogamicin with chemotherapy in patients with relapses or refractory acute myeloid leukemia

Bella I. Ayubova1, Sergey N. Bondarenko1, Olga S. Uspenskaya2, Elena V. Karyagina3, Elena I. Darskaya1, Irina A. Samorodova1, Anna G. Smirnova1, Olga V. Pirogova1, Elena V. Babenko1, Ildar M. Barkhatov1, Tatyana L. Gindina1, Ivan S. Moiseev1, Alexander D. Kulagin1, Boris V. Afanasyev1

Pharmacokinetics of ruxolitinib administrated before and after allo-HSCT in patients with myelofibrosis

Maria V. Barabanshikova1, Elena V. Morozova1, Ivan S. Moiseev1, Alena I. Shakirova1, Ildar M. Barkhatov1, Inna I. Ushal2, Gennadij G. Rodionov2, Sergey I. Moiseev2, Julia J. Vlasova1, Tatjana A. Rudakova1, Elena I. Darskaya1, Vadim V. Baykov1, Aleksander L. Alyanskiy1, Sergey N. Bondarenko1, Boris V. Afanasyev1

Antiviral immunity in patients after allogeneic hematopoietic stem cell transplantation during the post-engrafment period

Anna A. Dmitrova, Vyacheslav A. Shmarov, Mikhail Y. Drokov, Larisa A. Kuzmina, Natalia N. Popova, Ekaterina D. Mikhaltsova, Vera A. Vasilyeva, Maria V. Dovydenko, Olga M. Koroleva, Darya S. Dubnyak, Zoya V. Konova, Ekaterina V. Usikova, Ulyana V. Maslikova, Olga S. Starikova, Dmitry O. Kiryukhin, Grigoriy A. Efimov, Elena N. Parovichnikova, Valery G. Savchenko

Quality of life and clinical response to brentuximab vedotin in patients with relapsed/refractory Hodgkin lymphoma (RR HL) in the real-world setting

Tatyana I. Ionova1, Boris V. Afanasyev2, Alim A. Amdiev3, Maria I. Andrievskikh4, Elena A. Baryakh5, Eugeniy V. Vasiliev6, Mikhail V. Volkov7, Elena M. Volodicheva8, Vladimir V. Ivanov9, Oksana V. Kaverina10, Kamil D. Kaplanov11, Maria Ya. Kiseleva3, Tatiana Yu. Klitochenko11, Vyacheslav I. Kurakin12, Daria G. Lazareva10, Olga G. Larionova7, Kirill V. Lepik2, Irina B. Lysenko13, Raisa I. Minullina14, Oleg V. Mironov15, Elena N. Misyurina5, Natalia B. Mikhailova2, Nikita Eu. Mochkin16, Tatiana P. Nikitina1, Yuriy S. Osipov9, Tatiana S. Petrova14, Natalia M. Porfirieva1, Oleg A. Rykavitcin17, Rustem N. Safin14, Polina I. Simashova17, Elena G. Smirnova16, Natalia A. Trenina12, Natalia V. Fadeeva4, Gulnara N. Husainova14, Victor L. Chang15, Tatiana V. Shelekhova18, Dmitriy G. Sherstnev18

Underlying disease-specific pattern of pulmonary comorbidity factors in adults before allogeneic HSCT

Egor A. Kulagin1, Alisa G. Volkova2, Ilya Yu. Nikolaev2, Anna G. Smirnova2, Julia D. Rabik3, Vasiliy I. Trofimov1, Boris V. Afanasyev2

The outcomes of second allo-HSCT in a cohort of 50 pediatric patients with high-risk hematological malignancies lacking response or without engraftment after the allo-HSCT

Polina V. Kozhokar, Olesya V. Paina, Anastasia S. Borovkova, Anastasia S. Frolova, Zhemal Z. Rahmanova, Elena V. Semenova, Anna A. Osipova, Kirill A. Ekushov, Elena V. Babenko, Ludmila S. Zubarovskaya, Boris V. Afanasyev

Comparative analysis of the five-locus high-resolution HLA haplotype frequencies in the donors from two Russian registers

Elena V. Kuzmich1, Olga A. Makarenko1, Mikhail N. Vavilov2, Elena I. Shagimardanova3, Raushania F. Gaifullina3, Anna V. Andryushkina1

Treatment of T-cell lymphomas: First Pavlov State Medical University of Saint Petersburg experience

Elena E. Lepik, Andrey V. Kozlov, Eugenia S. Borzenkova, Yury R. Zalyalov, Kirill V. Lepik, Elena V. Kondakova, Vadim V. Baykov, Ivan S. Moiseev, Tatiana V. Schneider, Natalia B. Mikhaylova, Boris V. Afanasyev

Efficacy and safety of nivolumab combinations in patients with relapsed or refractory classical Hodgkin lymphoma

Polina V. Kotselyabina, Natalya B. Mikhailova, Kirill V. Lepik, Elena V. Kondakova, Andrey V. Kozlov, Yury R. Zalyalov, Marina O. Popova, Eugeniya S. Borzenkova, Ivan S. Moiseev, Vadim V. Baykov, Boris V. Afanasyev

Results of a quality control implementation at the stage of dimethyl sulfoxide introduction into autologous transplant of hematopoietic stem cells

Evgeniy V. Korotaev1, Andrey A. Stepanov1, Sergey A. Ponomarev1, Aleksey N. Kosarev1, Svetlana S. Karakalcheva1, Elena E. Zinina2

Сhronic lymphocytic leukemia treatment: a single-centre experience

Olga B. Kalashnikova, Natalia B. Mikhailova, Elena V. Kondakova, Maria O. Ivanova, Boris V. Afanasyev

Allogeneic hematopoietic stem cell transplantation for relapsed and refractory chronic lymphocytic leukemia: single-center experience

Olga B. Kalashnikova, Maria O. Ivanova, Daniil I. Shmidt, Kirill V. Lepik, Eugeniya S. Borzenkova, Vadim N. Nemykin, Elena V. Kondakova, Natalya B. Mikhaylova, Elena I. Darskaya, Boris V. Afanasyev

Comparison of protocols for mobilization and collection of peripheral hematopoietic stem cells by apheresis

Denis V. Kamelskikh, Mikhail Y. Drokov, Valeriia C. Apartseva, Maxim A. Telyashov, Vera A. Vasilyeva, Larisa A. Kuzmina, Tatyana V. Gaponova

High-dose chemotherapy (HDCT) with allogeneic hemopoietic stem cell transplantation (allo-HSCT) in very high-risk patients with neuroblastoma and Ewing sarcoma family tumors: experience of R. Gorbacheva Memorial Institute for Pediatric Oncology, Hematology and Transplantation

Ilya V. Kazantsev, Tatiana V. Iukhta, Asmik G. Gevorgian, Polina S. Tolkunova, Andrew V. Kozlov, Daria A. Zvyagintseva, Anton V. Malorodov, Elena V. Morozova, Andrei P. Litvinov, Alexander N. Shvetsov, Polina S. Kuga, Svetlana S. Safonova, Yuri A. Punanov, Ludmila S. Zubarovskaya, Boris V. Afanasyev

The prognostic effect of minimal residual disease detected by multiparameter flow cytometry before allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia patients in first complete remission

Zoya V. Konova, Elena N. Parovichnikova, Irina V. Galtseva, Yulia O. Davydova, Nikolay M. Kapranov, Vera A. Vasilyeva, Maria V. Dovydenko, Olga M. Koroleva, Uliyana V. Maslikova, Natalia N. Popova, Mikhail Yu. Drokov, Ekaterina D. Mikhaltsova, Anna A. Dmitrova, Olga S. Starikova, Darya S. Dubnyak, Larisa A. Kuzmina, Valery G. Savchenko

Assessment of hematopoetic stem cell molecular engraftment based on STR analysis

Saniya A. Abdrakhmanova, Zhulduz Zh. Zhanzakova, Aida A. Turganbekova, Zhazira K. Saduakas

Short reports

The efficacy of empirical antibiotic therapy of febrile neutropenia in patients after allogeneic hematopoietic stem cell transplantation

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Veronika I. Pivovarova1,2, Yulia A. Rogacheva1, Marina O. Popova1, Alisa G. Volkova1, Alexander N. Shvetsov1, Ilya Yu. Nikolaev1, Elena I. Darskaya1, Oleg V. Goloshchapov1, Elena V. Morozova1, Maria D. Vladovskaya1, Sergey N. Bondarenko1, Ivan S. Moiseev1, Ludmila S. Zubarovskaya1, Nikolay N. Klimko1,2, Boris V. Afanasyev1

1 Raisa Gorbacheva Memorial Research Institute of Pediatric Oncology, Hematology and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia
2 I. I. Mechnikov North-Western State Medical University, St. Petersburg, Russia


Contact: Dr. Marina O. Popova, PhD
E-mail: marina.popova.spb@gmail.com

Infectious complications are the main cause of mortality among patients after allogeneic hematopoietic stem cell transplantation (allo-HSCT). An increase in resistance to antibiotic therapy is a problem of the choice of adequate empirical therapy for patients with febrile neutropenia (FN). Our objective was to analyze and evaluate the efficiency of empirical antibiotic therapy (AB-therapy) at different time periods in the patients after allo-HSCT during the neutropenic phase.

Patients and methods

In a retrospective study at the CIC725 clinic, we included 200 patients after allo-HSCT over the period of 2014-2015 (n=100) and 2018-2019 (n=100), with a median age of 35 years (20-64) and 34 years (19-69), respectively. For both groups, there were significantly more recipients of MUD allogeneic HSCT: over 2014-2015, 64%, and 56% during 2018-2019. Haploidentical (haplo) HSCT was performed in 11% (n=11) vs 24% (n=24) cases, myeloablative conditioning (MAC) was used in 12% (n=12) and 53% (n=53), for 2014-2015 vs 2018-2019, respectively. The ECIL-4 criteria were used for the diagnosis of febrile neutropenia.

Results

Febrile neutropenia developed in 80% (n=80) cases over 2014-2015, and 82% (n=82) during 2018-2019. The median duration of FN from the beginning of agranulocytosis in both groups was 4 days (1 to 6). The starting antibiotics were ineffective in 29% (n=29) and 17% (n=17). Cefoperazone + Sulbactam were used in 40% (n=40), and in 21% (n=21) cases, carbapenems were prescribed in 12% (n=12), and 24% (n=24), combination therapy as the first line was applied in 26% (n=26), and 23% patients (n=23), during 2014-2015 and over 2018-2019 periods, respectively. The starting therapy with cefoperazone + sulbactam was ineffective in 47.5% (n=19) for 2014-2015, and 28.5% (n=6) for 2018-2019 years. The median terms before the shift of starting therapy were 3 (1-35) and 2 (1-21) days, respectively. Sepsis developed in 13% (n=13) of cases in the 2014-2015 group, and 12% (n=12) for 2018-2019. Venous catheter (CVC) replacement was performed in 23% of patients in 2014-2015, and 16% in 2018-2019. The median day from the beginning of FN to the CVC change was 5 (1-54) vs 6 (1-25) days for the groups of 2014-2015 vs 2018-2019 observations. There was no increase in the FN incidence, despite more frequent use of myeloablative conditioning (MAC) (p=0.732), and haplo-HSCT (p=0.656). The overall 30-days survival (OS) from the onset of FN was 93.8% vs 96.3% (p=0.457), OS 12 weeks, 83% vs 85% (p=0.7) in the groups from 2014-2015 and 2018-2019, respectively. OS at 30 days in the group of patients receiving cefoperazone + sulbactam was 91.9% vs 95.2% (p=0.56); OS by 12 weeks was 81.1% vs 85.7% (p=0.649), respectively.

Conclusions

Febrile neutropenia remains an urgent issue in the patients after allo-HSCT and occurs in 80% vs 82% of cases in the 2014-2015 cohort vs 2018-2019. The starting empirical antibiotic therapy was effective in 71% and 83%. There was no increase in the incidence of FN, despite more frequent usage of MAC (p=0.732) and haplo-HSCT (p=0.656). Despite the effectiveness of using sulfaperazone + sulbactam, the OS rates at 30 days were 91.9% vs 95.2%. There is a decreased usage frequency of these antibiotics as a first-line empirical therapy of febrile neutropenia (40% vs 21%).

Keywords

Febrile neutropenia, infectious complications, allo-HSCT, antibiotic therapy, empirical therapy.

Short reports

Nivolumab combined with autologous hematopoietic stem cell transplantation in multiple myeloma patients

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Olga V. Pirogova, Elena I. Darskaya, Valentina V. Porunova, Olga V. Kudyasheva, Elena V. Babenko, Natalia B. Mikhailova, Boris V. Afanasyev

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


Contact: Dr. Olga V. Pirogova
E-mail: dr.pirogova@gmail.com, porunovavv@gmail.com

Patients with multiple myeloma (MM) who do not achieve complete response (CR), or very good partial response (VGPR) after primary therapy, including autologous hematopoietic stem cell transplantation (ASCT), have short time to progression. Preclinical and clinical evidence suggests that the immune checkpoint programmed death-1 (PD-1) receptor/PD-1 ligand axis plays an important role in suppressing immune surveillance against MM, but monotherapy with anti-PD-1 antibody was not effective in patients with MM. We hypothesized that the administration of nivolumab (anti-PD-1 antibody) during the lymphodepleted state post-ASCT can improve therapeutic efficacy in MM. Our aim was to evaluate the efficacy and safety of the checkpoint inhibitor nivoluumab in combination with ASCT.

Patients and methods

We conducted a phase 1-2, single-arm study of nivolumab with ASCT in MM patients who had not achieved pre-AHCT less than VGPR after induction therapy (trial NCT03292263). Nivolumab was administered 100 mg IV at the fixed dose on day -3 before and day +17 after ASCT. The primary endpoint was overall response rate (ORR). Patients aged 18-70 years with MM, of any molecular risk group and with clinical status below VGPR after induction therapy were eligible and received high-dose melphalan (140-200 mg/m2 I.V.). Four patients received tandem ASCT with nivolumab.

Results

Currently, 16 patients were enrolled, including 9 males and 7 females with the median age of 55 (range, 45-62 years old). The median follow-up was 12 months (range, 7-19). Three patients (19%) had light chain MM, three patients (19%) had IgA, ten patients (62%) exhibited IgG MM. All patients received a triple-agent primary therapy, a median of 6 cycles (range, 4-9). Ten patients had partial response (PR), two patients had stable disease (SD) and four had progressive disease (PD) prior to ASCT. Among these 16 patients, grade 4 toxicity was observed in one patient (autoimmune thrombocytopenia after engraftment); grade 3 toxicity was observed in 3 patients (1 patient with infusion reaction, 1 patient with colitis, 1 patient with neurotoxicity). There were no primary or secondary graft failure cases, and the median time to neutrophil and platelet engraftment was 12 days (range, 10-17) and 14 days (range, 9-18), respectively. At day+100 after ASCT, we evaluated response by serology and bone marrow (BM) study (morphology and flow cytometry), ORR was 56% (9/16): the CR rate was 31% (5/16), 19% (3/16) achieved VGPR, one patient (6%) achieved PR. 19% (3/16) maintained PR, 1 patient maintained SD. One of four patients with progressive disease did not achieve response. One of nine patients was relapsed. Two patients received second ASCT without nivolumab, one of them achieved CR after second ASCT. At this time all the patients are alive.

Conclusion

Preliminary results of nivolumab addition to ASCT show relative safety of the therapy. Our pilot study in patients without adequate response before ASCT demonstrate encouraging results of nivolumab combination with ASCT. The efficacy of this combination requires further investigation.

Keywords

Autologous hematopoietic stem cell transplantation, nivolumab, multiple myeloma.

Short reports

Reconstitution of CD8+ T-memory cells after different GVHD prophylaxis regimens in acute leukemia patients after allogeneic stem cells transplantation

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Natalia N. Popova, Mikhail Y. Drokov, Yulia O. Davydova, Nikolay M. Kapranov, Uliyana V. Maslikova, Ekaterina D. Mikhaltsova, Vera A. Vasilyeva, Olga M. Koroleva, Zoya V. Konova, Anna A. Dmitrova, Maria V. Dovydenko, Olga S. Starikova, Darya S. Dubnyak, Denis V. Kamelskikh, Irina V. Galtseva, Tatyana V. Gaponova, Michael A. Maschan, Larisa A. Kuzmina, Elena N. Parovichnikova, Valery G. Savchenko

National Medical Research Center for Hematology, Moscow, Russia


Contact: Dr. Mikhail Yu. Drokov
E-mail: mdrokov@gmail.com

Acute graft-versus-host disease (aGVHD) is the main problem after allogeneic hematopoietic stem cell transplantation (allo-HSCT) effecting patients’ morbidity and mortality.

Alternative aGVHD prophylaxis regimens are based on graft manipulated procedure (TCR αβ-depletion) or posttransplant cyclophosphamide (PT-CY) now available for recipients of mismatched or haploidentical hematopoietic stem cells. However it’s considered that applying of these approaches is accompanying with prolonged immune recovery. But that should be established further. Our aim was to evaluate an impact of different aGVHD prophylaxis regimens on CD8+ T-memory cells reconstitution after allo-HSCT in acute leukemia patients.

Patients and methods

The study comprised 65 leukemia patients who underwent allo-HSCT in National Research Center for Hematology, Russia. All patients were subdivided in 3 groups due to aGVHD prophylaxis regimen. 32 patients (a median age of 33, range 20 to 61 y.o.) received Antithymocyte Globulin (ATG) based immunosuppressive regimen with Cyclosporin A and Mycophenolate Mofetil, 18 patients (a median age of 36, range 23 to 58 y.o.) received ATG with PT-CY on day +3,+4, and 15 patients (a median age of 22, range 17 to 57 y.o.) underwent TCR αβ-depleted transplant. ATG-based regimen was applied in case of matched related and matched unrelated donors. The alternative approaches were used in case of mismatched donors: ATG+PT-CY was administered in patients who underwent allo-HSCT from unrelated mismatched donors or related haploidentical donors, and TCRαβ-depletion was carried out in haploidentical transplants. Acute GVHD with grade II-IV was diagnosed in 13 (40.6%) patients after ATG-based prophylaxis, in 3 (16,7%) – after ATG+PT-CY, in 3 (20%) – after TCR αβ-depletion. Samples of peripheral blood were collected on day +30, +60, +90 and +180 after allo-HSCT in EDTA-tubes. Flow cytometry analysis was performed on BD FACS Canto II (Becton Dickinson, USA) to define CD8+ T-memory subsets: T-naive and T-stem cell memory (Tnv+Tscm) – CD45R0-CCR7+CD28+; T-central memory (Tcm) – CD45R0+CCR7+CD28+; T-transitional memory (Ttm) – CD45R0+CCR7-CD28+; T-effector memory (Tem) – CD45R0+CCR7-CD28-; T-terminal effector (Tte) – CD45R0-CCR7-CD28-. Kruskal-Wallis test was used to determine nonparametric data analysis for 3 independent groups. A p-value less than 0.05 was considered as significant. All data analysis was conducted utilizing SPSS ver. 23. (IBM, Chicago, Ill., USA).

Results

Absolute number of CD8+ Tnv+scm, Tcm, Ttm, Tem, Tte on day +30, +60, +90, +180 is summarized in the Table 1.

Table 1. Absolute number of different CD8+ T-memory cells after allo-HSCT, depending on aGVHD prophylaxis regimens

Popova-tab01.jpg

Conclusion

The lower number of CD8+ Tnv+scm and Tcm after alternative regimens comparing ATG-based prophylaxis in early period (on day +30, +60, +90) after allo-HSCT might reflect severe immunoablation in case of allo-HSCT from mismatched and haploidentical donors. This factor might be crucial in terms of restraining potential aGVHD onset. However, lower number of effector cells (Ttm, Tem, Tte) after TCR αβ-depletion and ATG+PT-CY on day +180, as compared to ATG-based immunosuppression might indicate prolonged immune recovery in mismatched or haploidentical recipients. It’s important to note that the lowest number of all T-cell types after TCR αβ-depletion points to delayed immune recovery after this approach comparing to ATG+PT-CY. That might require providing of different supportive strategies in patients after TCR αβ-depletion, in order to boost their immune recovery.

Disclosures

No relevant conflicts of interest to declare.

Keywords

T-memory cells, immune reconstitution, allogeneic stem cell transplantation, GVHD prophylaxis regimens.


Short reports

A clinical case of the successful use of allogeneic hematopoietic stem cell transplantation as a “salvage treatment” in a patient with multiple myeloma

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Valentina V. Porunova, Olga V. Pirogova, Olga V. Kudyasheva, Elena I. Darskaya, Boris V. Afanasyev

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


Contact: Dr. Valentina V. Porunova
E-mail: porunovavv@gmail.com

Despite recent advances, multiple myeloma remains an incurable disease. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is considered a potentially curative therapeutic option, but remains controversial, due to a significant toxicity associated with the treatment. With this clinical case, we have demonstrated successful application of this therapeutic approach.

Case description

The 44-year old patient was diagnosed with multiple myeloma in August 2013 on the basis of multiple osteolytic lesions, pathological fractures of ribs, left humerus; monoclonal secretion of IgG/kappa (12 g/L); subtotal bone marrow infiltration by plasma cells (92%). According to international prognostic indices, stage II was confirmed; according to II – ISS, II-R-ISS (del13 by FISH). 1st line therapy: induction treatment, PAВ №5, tandem syngeneic transplantation conditioned by melphalan (160 mg/m2), maintenance therapy (bortezomib). Complete response was achieved, with minimal residual disease (MRD+). In February 2016, the relapse was noted: 11% of plasma cells in the bone marrow, lack of M-protein secretion (transformation into a non-secretory form). 2nd line of therapy was based on lenalidomide/prednisolone. In October 2016, a complete response was observed, MRD (+). In May 2017, the second relapse occured: 18.6% of plasma cells in the bone marrow, the development of new focal lesions, local plasmocytomas (L3, right iliac bone). 3rd line therapy included ixazomib/lenalidomide/ prednisolone, radiation therapy to the plasmocytoma region. This treatment resulted into clinical stabilization (23% of plasma cells in the bone marrow, 50% reduction of plasmocytomas in the right iliac bone and decrease by 25% of L3 plasmocytomas). As a “salvage treatment”, allogeneic HSCT was performed from a full HLA-matched sibling (sister) on 24 January 2019. Clinical condition of the disease was stabilized by this time (28% of plasma cells in the bone marrow). Non-myeloablative conditioning regimen was as follows: fludarabine 30 mg/m2, busulfan 8 mg/kg; GVHD prophylaxis regimen: cyclophosphamide 50 mg/kg D+3, D+4, tacrolimus 0.03 mg/kg, MMF 30 mg/kg. Peripheral blood stem cells were used as a graft source. Engraftment was achieved by the D+19, with 46% of plasma cells in the bone marrow, donor chimerism levels were 60-70%. At D+29, a reduction of plasmacytosis (32%), and chimerism 70-79% were also revealed, as well as deletion of chromosome 13 was found in 15% of cells. Immunomodulating therapy with lenalidomide (5 mg per day) was started with D+32, against the background of continued immunosuppressive therapy with tacrolimus. Complete response was revealed on D+60: decrease of plasma cells to 2%, MRD (-), the absence of del13; donor chimerism of 99%. At D+100, we documented a complete PET-negative response, plasmacytomas were not detectable, and immunosuppressive therapy has been canceled. At the present time, more than 6 months after allo-HSCT, we observe chronic GVHD of the skin (1st stage) which does not require systemic immunosuppressive therapy. The immunomodulating therapy with lenalidomide is continued. The quality of life is good.

Discussion

This clinical case demonstrates successful use of allo-HSCT as a “salvage treatment” in a young patient with relapsed form of multiple myeloma. The use of a non-myeloablative conditioning regimen, GVHD prophylaxis with post-transplant cyclophosphamide, as well as immunomodulatory maintenance therapy with lenalidomide in the early post-transplant period, allowed us to achieve a strict complete response by inducing a graft-versus-myeloma reaction (GVM), and to minimize complications associated with transplantation, while maintaining a good quality of life.

Conclusion

Allo-HSCT can be considered a therapeutic option in young patients with a resistant-relapsing form of the disease, when the risk of progression may outweigh the risks associated with transplantation.

Keywords

Allogeneic hematopoietic stem cell transplantation, multiple myeloma, graft-versus-myeloma effect.

Short reports

Invasive fungal diseases before and after allogeneic hematopoietic stem cell transplantation in children and adults with relapsed/refractory Hodgkin’s lymphoma

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Yuliya A. Rogacheva1, Marina O. Popova1, Alisa G. Volkova1, Inna V. Markova1, Alexander N. Shvetsov1, Iliya Y. Nikolaev1, Oleg V. Goloshchapov1, Svetlana M. Ignatieva2, Tatiana S. Bogomolova2, Andrey V. Kozlov1, Kirill V. Lepik1, Yury R. Zalyalov1, Lilia V. Stelmakh1, Asmik G. Gevorgian1, Anastasya V. Beynarovich1, Eugeniya S. Borzenkova1, Elena I. Darskaya1, Elena V. Kondakova1, Natalya B. Mikhailova1, Mariya D. Vladovskaya1, Sergey N. Bondarenko1, Ivan S. Moiseev1, Ludmila S. Zubarovskaya1, Nikolay N. Klimko1,2, Boris V. Afanasyev1

1 Raisa Gorbacheva Memorial Research Institute of Pediatric Oncology, Hematology and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia
2 I. I. Mechnikov North-Western State Medical University, St. Petersburg, Russia


Contact: Dr. Marina O. Popova
E-mail: marina.popova.spb@gmail.com

There is only limited number of publications concerning invasive fungal disease (IFD) in lymphoma patients, especially, after allo-HSCT. There are no data about outcomes of allo-HSCT in lymphoma patients with prior IFD. This study focuses on epidemiology of IFD detected before and after allo-HSCT in children and adults with Hodgkin’s lymphoma (HL).

Patients and methods

A single-center prospective observational study included 86 patients (pts) with classical relapsed/refractory (r/r) HL who received allo-HSCT from 2002 to 2018. The median age was 27 (13-49) y.o., children (<18 yo), 13% (n=11). Allo-HSCT from matched unrelated donors (MUD) was performed in 45.4% (n=39); matched related donors (MRD), in 24.4% (n=21); nonmatched MUD, 15.1% (n=13); haplo, 15.1% (n=13), with reduced-intensity conditioning (RIC) (100%), and predominantly PTCY-based GvHD prophylaxis (71%). Primary antifungal prophylaxis was performed with fluconazole (85%); voriconazole was used as secondary prophylaxis (100%). EORTC/MSG 2008 criteria for diagnosis and response to therapy were used. In the pts with lung lesions at CT-scans before allo-HSCT, bronchoscopy with BAL examination was used. “Active IFD” means IFD diagnosed just before HSCT. Median follow-up time was 12 (1 to 71) months.

Results

Incidence of IFD before allo-HSCT was 12.8% (n=11). Invasive aspergillosis (IA) was found in all cases of IFD prior to HSCT, with lung affection in most cases. Antifungal therapy before allo-HSCT was applied in 81.8% pts with median duration of 2 months. Complete response to antifungal therapy was registered in 45.4% pts, partial response or stabilization, in 36.4%, and 18.2% pts had “active IFD”. Following allo-HSCT, all the pts received voriconazole as antifungal therapy, or secondary prophylaxis. Cumulative incidence of relapse or progression of IA after allo-HSCT was 18.2%, with a median of 49 days [19-79] after HSCT that were successfully treated with voriconazole during the post-HSCT period. Incidence of IFD after allo-HSCT for naïve patients was 17.6% (n=13/74). Etiology of IFD after allo-HSCT was as follows: IA, in 69% of patients; invasive candidiasis (IC), in 15%; mucormycosis, in 8%, and combined IFD caused by Aspergillus fumigatus + Rhizopus stolonifer was diagnosed in 8%. The median day of IFD onset after allo-HSCT was day+114 [1-489]. The main site of infection were lungs (88%), with febrile fever being the main clinical symptom (100%). Antifungal therapy was used in all patients: voriconazole, 59%; micafungin, 17%; posaconazole, in 8% of cases; lipid amphotericin B, 8%, and combination of lipid amphotericin B with caspofungin was applied in 8%. Overall survival (OS) at 12 weeks from the diagnosis of IFD after allo-HSCT was 80%. The 2-year OS in children and adult with HL after allo-HSCT was 73.3%. Development of IFD after allo-HSCT did not reduce the 2-year OS rate (69.2% vs 74%, p=0.77). The impact of prior IFD upon 2-year OS in allo-HSCT recipients was not statistically significant for all groups (63.6% vs 74.7%, p=0.47), like as between children and adults.

Conclusion

Incidence of IFD in children and adults with Hodgkin’s lymphoma before allo-HSCT was 12.8%. IFD incidence after allo-HSCT in patients with Hodgkin’s lymphoma was 17.6%. Aspergillus spp. were the major etiological agents, both before and after allo-HSCT. IFD was a late complication following allo-HSCT. Despite high IFD incidence, this infectious complication didn’t influence overall post-transplant survival in children and adults with r/r Hodgkin lymphoma.

Keywords

Invasive fungal disease, Aspergillus spp., Hodgkin’s lymphoma, infectious complications, mucormycosis, allo-HSCT.

Short reports

Uniparental disomy found in tumor DNA of de novo diagnosed ALL patients as a factor predicting poor outcome

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Natalya V. Risinskaya, Olga A. Gavrilina, Julia A. Chabaeva, Anna A. Yushkova, Andrey B. Sudarikov, Sergei M. Kulikov, Elena N. Parovichnikova, Valery G. Savchenko

National Research Center for Hematology, Moscow, Russia


Contact: Dr. Natalya V. Risinskaya
E-mail: risinska@gmail.com

Uniparental disomy (UPD) or copy neutral Loss of Heterozygosity (cnLOH) was described for many malignancies including acute lymphoblastic leukemia (ALL). UPD leads to homozygous form of the chromosomes or their regions including those probably containing tumor-associated mutations. Unfortunately, standard cytogenetic analysis does not detect UPD. However, a sign of uniparental disomy is the loss of heterozygosity for genetic markers in combination with normal copy number of chromosome. Our objective was to identify UPD in blast cells of patients with de novo ALL using cytogenetic analysis with STR profiling and to analyze the outcome of therapy for this group of patients relative to patients without LOH. If UPD for patients with de novo ALL proves to be an unfavorable prognosis factor, those patients should be considered as high-risk group and first-line candidates for bone marrow transplantation.

Patients and methods

This study included a comparative analysis of the STR DNA profiles of the tumor and normal cells from bone marrow samples in a cohort of 32 patients with de novo diagnosed Ph-negative ALL undergoing treatment according to the “RALL-2016” regimen at the National Research Center for Hematology (Moscow, Russia). Inclusion criteria were as follows: de novo diagnosed Ph-negative acute lymphoblastic leukemia (ALL) patients, 18-55 years old, intermediate risk group without MLL translocation t(4;11)(q21;q23), treatment by RALL-2016 protocol. Exclusion criteria: other diagnosis, adult patients older than 55 years, MLL translocation t(4;11)(q21;q23), pretreatment or treatment by other protocol. The presence of blast cells in bone marrow samples was confirmed morphologically. The tumor karyotype was established by standard cytogenetic analysis. Control DNA samples were taken from blood of patients in complete remission and/or from buccal epithelium. STR-profiles were assessed by PCR with COrDIS Plus multiplex kit for amplification of 19 polymorphic STR markers and amelogenin loci (Gordiz Ltd, Russia). The fragment analysis was performed on ABI3130 Genetic Analyzer. The data processing was accomplished using GeneMapper v.4-0 software. SAS V9/4 was used for statistical analysis of the data. A multivariate survival analysis was used to assess independent impact of the UPD as a risk factor for this cohort of patients. We have chosen Failure Free Survival (FFS) as primary endpoint. Death from any reasons, relapse and second leukemia were chosen as failure events, survival time interval starts from begin of treatment.

Results

Of the 32 patients, six were found with LOH in the certain STR loci (19%). Of these six, two were resistant to therapy and died from disease progression. One patient with LOH is currently in relapse, and one patient with multiple LOH has developed secondary leukemia (Fig. 1a). Only two from six patients are “Failure-Free” now, whereas only three patients from 26 died in group without LOH (two from infectious complications and one from GvHD after BMT). P value <0.05 (Fig. 1b).

Risinskaya_fig01.jpg

Figure 1. Patient’s summary (A) and failure-free survival (FFS) estimates (B)

Conclusions

We have found statistically significant association of clinical failures with the LOH in STR loci measured at the onset of ALL. For all six patients from the “risk group”, LOH in some STR markers was not associated with deletions or monosomy detected by standard cytogenetic analysis. For one patient, UPD was verified by chromosomal microarray (CMA) technique, as shown in Fig. 2. We assume that UPD is an unfavorable prognostic factor for de novo diagnosed ALL patients and could be used for risk stratification and choice of adequate therapy implying allogeneic hematopoietic stem cell transplantation, or modern innovative therapy approaches.

Risinskaya_fig02.jpg

Figure 2. Patient #32 karyotype by CMA. Uniparental disomy of chromosome 3 (pink bar) explains the loss of heterozygosity in the 3p21.3 STR-locus, and deletions or duplications in some chromosomes

Losses (red bars) and gains (blue bars) in a number of chromosomes coincide with the data of cytogenetic analysis. (51,XX,del(1)(p31),+1,del(4)(q28),+5,+8,der(9),del(13)(q14q22),+13,der(15),del(17)(q23),+21[15]/46,XX[15]).

Keywords

Acute lymphoblastic leukemia (ALL), uniparental disomy (UPD), loss of heterozygosity (LOH).


Short reports

Study of multipotent mesenchymal stromal cells as a cellular delivery system for antitumor drugs and their remote control activation

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Oleksii O. Peltek, Timofey E. Karpov, Yana V. Tarakanchikova, Mikhail V. Zyuzin, Albert R. Muslimov

Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia


Contact: Dr. Albert R. Muslimov
E-mail: albert.r.muslimov@gmail.com

The effectiveness of a number of cytotoxic drugs directly depends on the concentration of the active substance in the tumor zone. However, an increase in the administered doses also leads to an increase in side effects in relation to healthy tissues. The solution can be a novel dosage form that would accumulate high local concentrations of cytostatic drugs in the tumor area without affecting the surrounding healthy tissue. To create such a drug delivery system, it is possible to utilize multipotent mesenchymal stromal cells (MMSCs) modified with hybrid polyelectrolyte microcapsules. MMSCs due to the effect of pathotropism are able to ensure active delivery of biologically active substances to the tumor site, while microcapsules have a high loading capacity and can protect carrier cells from the effects of the encapsulated drug. In this work, the microcapsules were additionally modified with gold nanoparticles, which makes them sensitive to infrared radiation and allows to control the release of the drug. In this study, vincristine was used as a model drug with a dose-dependent effect.

Objects and methods

Capsules were synthesized using Layer-by-Layer technique (Polyarginine / Dextran sulfate) and sol-gel synthesis (Tetraethyl orthosilicate). The loading capacity of micrometer (1-2 microns) and submicron (500-600 nm) capsules was evaluated. We demonstrated that without an infrared laser irradiation of the capsules, a release of vincristine was less than 10%. Therefore, these capsules are non-toxic to carrier cells which was confirmed by cytotoxicological experiments. The effect of capsules on spontaneous and directed migration of MMSCs was studied and it was shown that at the ratio of cells to capsules of 1 to 10, there is no significant decrease in the migration potential of carrier cells. Evaluation of spontaneous migration was carried out using scratch wound assay and a monitoring system for living cells Cell-IQ. The effect of vincristine-loaded capsules on directed migration was evaluated using slides for chemotaxis. The invasive potential of MMSC was determined using a Transwell assay. In experiments on directed cell migration, the SDF-1 cytokine, which is expressed by a number of tumors and is considered crucial for the regulation of MMSC migration, was used.

Results

The effectiveness of this delivery system was also investigated on the model of a tumoroid in a collagen gel. The tumor spheroid consisted of melanoma cells expressing SDF-1. It was demonstrated that MMSCs modified with capsules were able to not only migrate towards the tumor site, but also penetrate the tumoroid to a depth of up to 50 μm. Comparison of the efficacy of pure vincristine, vincristine-loaded capsules, and MMSCs modified with vincristine-loaded capsules, showed a significant increase in efficiency in the case of MMSC. It was also demonstrated that the exposure of the capsules to infrared radiation increases the effect by 2-4 times due to the simultaneous release of the vincristine from the capsules.

Conclusions

Thus, we developed a drug delivery system that was able to provide high local concentrations of the active substance in the tumor area and demonstrated several times greater in vitro efficacy compared to the free drug.

Keywords

Micro- and nanocapsules, targeted delivery antitumor drugs, internalization, mesenchymal stromal cells, migration, pharmacokinetics, synthesis, cultivation, carrier cells.

Short reports

Exosome-mediated in vitro BCR-ABL p210 transcript horizontal transfer between leukemic and bone marrow stromal cells

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Anna N. Parfenenkova, Ildar M. Barkhatov, Anton A. Kremlev, Boris V. Afanasyev

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


Contact: Dr. Ildar M. Barkhatov, PhD
E-mail: i.barkhatov@gmail.com, ann.parfenen2018@gmail.com

The key challenge of molecular genetics in oncohematology is determination of molecular markers, which can be applied to malignant cells in diagnostics of the disease is the analysis of molecular markers, which can be applied to malignant cells in diagnostics of the disease, its progression, and relapse risks. One of the most promising test subjects to approach this might be exosomes, extracellular membrane vesicles of 30-150 nm in size, that potentially contain such oncogenic markers. Exosomes are among important players in intercellular communication and are able to transfer a variety of biopolymers, which can potentially affect the results of minimal residual disease (MRD) determination. Since the main role in the regulation of hematopoiesis belongs to mesenchymal stromal cells (MSCs) of the bone marrow, we suggest that the exosomes that persist in the bone marrow, may be asource of the detectable transcript can be as and their migration into stromal microenvironment cells.

Materials and methods

Exosome isolation was performed by differential ultracentrifugation of К562 cell line (Chronic Myeloid Leukemia) conditional media. The isolated exosomal particles were analyzed using laser correlation spectroscopy approach including zeta-potential assessment to ensure electrokinetic capability to interact with biological systems. Transfer of BCR-ABL p210 transcript was performed in a 24-well plate. After that, 300 μl of serum-free growth medium with exosomes (isolated from about 70 millions cells per well) was added. Co-cultivation of K562 and MSC was performed in a 24-well plate with inserts of semi-permeable membrane (pore diameter 0.4 μm).

Results

The largest number of vesicles in the sample corresponded to a presumed size of exosomes with average diameters in the range of 52÷107 nm and a mean value of 79±20 nm. The results of the study showed that the distribution of the average sample size in diameter is in the range of 51.8÷107.0 nm and a mean value of 78.96±20.03 nm. The zeta potential corresponds to stable particles and is on mean equal to 29.±7. mV. According to Real-Time PCR, the relative representation of the BCR-ABL p210 chimeric transcript in exosomes ranged between 44÷864 copies/ml of conditioned medium with a median value of 154 copies. After MSCs co-cultivation with K562, the relative content of BCR-ABL p210 mRNA in recipient mesenchymal cells was between 0.3 to 11.4% of ABL1 level, with a median of 0.29%. As a result of exosome-mediated transfection, the relative content of the chimeric transcript in the MSCs of healthy donors ranged from 0.01 to 15.88%, with a median value of 0.11%.

Conclusions

Exosomal fraction of microvesicules of K562 contain the chimeric BCR-ABL p210 mRNA transcript, a marker of CML, and are able to its transfer to the bone marrow MSCs of healthy donors. It has been confirmed during as experiments of co-cultivation, and direct transfection with exosomes. The amount of transcript transferred to stromal cells is comparable to the one in CML patients with a minimal residual disease, which proves the potential role of exosomes in contribution to the results of MRD determination.

Keywords

Extracellular vesicles, exosomes, tumor exosomes, bone marrow stromal cells, cell-cell interactions.

Short reports

Polymeric micro- and nano-carriers as a universal platform for delivery of biologically active substances to therapeutically cell populations

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Albert R. Muslimov1,3,5, Tatyana V. Mashel6, Oleksii O. Peltek6, Mikhail A. Trofimov5, Igor S. Sergeev5, Yana V. Tarakanchikova4,5, Alexander A. Goncharenko5, Kirill V. Lepik1, Mikhail V. Zyuzin6, Alexander S. Timin1,2,3

1 Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia
2 RASA Center in Tomsk, Tomsk Polytechnic University, Tomsk, Russia
3 Peter The Great Saint Petersburg Polytechnic University, St. Petersburg, Russia
4 Optoelectronics and Measurement Techniques Laboratory, University of Oulu, Oulu, Finland
5 Saint Petersburg Academic University, St. Petersburg, Russia
6 Department of Nanophotonics and Metamaterials, ITMO University, St. Petersburg, Russia


Contact: Dr. Albert R. Muslimov
E-mail: albert.r.muslimov@gmail.com

Gene therapy is one of the most perspective methods of the treatment for a number of hereditary, infectious and oncological diseases. Recently this therapeutic approach has received a new development through the discovery of genome editing tools which have great potential due to their high specificity. However, the absence of safe and effective methods to delivery genetic constructs inside relevant cells is a key limitation for the wide application of this technology in clinical practice. Viral vectors have already been applied in medical practice, but there are several limitations associated with their use, such as immunogenicity, mutagenesis, inflammatory response. The need to comply with specific technical requirements also determine the high cost of the final product. Thus, the development of new non-viral intracellular genetic materials delivery tools is an urgent task. Recently, polyelectrolyte micro- and nanocapsules have been considered as one of the promising carriers for the safe and effective delivery of biologically active compounds. The use of biodegradable nanocapsules provides many advantages compared to other delivery systems: high loading capacity, the relatively cheap manufacturing, low toxicity, and the ability to protect the transferred material from the aggressive effects of biological environments of the body. This work aimed to study the effectiveness of the polyelectrolyte capsules as a platform for genetic material delivery.

Materials and methods

The capsules were prepared by layering of oppositely charged of Polyarginine/Dextran sulfate polymers (PARG/DEXS) using Layer-by-Layer technology on calcium carbonate core obtained by co-precipitation of sodium carbonate and calcium chloride aqueous solutions. The following genetic constructs were used: plasmid DNA and messenger RNA, encoding green fluorescent protein (GFP), messenger RNA, encoding TALEN nuclease which causes the deletion of the dTomato gene, and small interfering RNAs (siRNAs) that inhibit the synthesis of GFP. For evaluate the effectiveness of the genetic material delivery by means of polyelectrolyte capsules HEK293T dTomato, HeLa, Mk4 cell lines, and primary cell cultures of human bone marrow mesenchymal stromal cells (hBMSCs) and macrophages were used.

Results

During the research intracellular genetic material delivery platform at the form of polyelectrolyte capsules with a size 300-500 nm have been developed. Such carriers showed low cytotoxicity (viability of more than 90%) in case of using 25:1 capsule to cell ratio. The transfection efficiency of HEK293T dTomato and hBMSCs was 70% for messenger RNA and 40% for plasmid DNA encoding GFP. In the experiment with mRNA delivery to primary human macrophages, transfection efficiency was 60%. Upon transfection of HEK293T dTomato with messenger RNAs encoding TALEN nuclease, knockout of the dTomato gene was observed in 70% of cells. In an experiment with siRNA, suppression of GFP synthesis was detected in 98% of HEK293T HeLa and MK4. For macrophages, mRNA transfection efficiency was about 50%.

Conclusions

We demonstrated that polyelectrolyte capsules are a highly effective and safe platform for in vitro genetic material delivery to the cells. In the future, it is planned to conduct in vivo experiments to study the opportunity of polyelectrolyte capsules usage for the genetic material delivery.

Acknowledgments

This work was supported by the Russian Foundation for Basic (scientific project No. 19-015-00098). Alexander S. Timin also thanks for support the RFBR (grant No. 18-015-00100). Kirill V. Lepik also thanks for support the RFBR (grant No. 19-29-04025).

Keywords

Polymeric capsules, non-viral delivery systems, cells transfection, nucleic acids, bioactive substances, encapsulation.

Short reports

Problems of physical activity dosage in pediatric patients receiving HSCT

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Nikolay N. Mitrakov1, M. Yu. Zhukov1, Olga A. Laysheva1,2

1 Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
2 Russian Children’s Clinical Hospital Federal State Budgetary Educational Institution of Higher Professional Training, Moscow, Russia
3 N. I. Pirogov Russian National Research Medical University, Moscow, Russia


Contact: Nikolay N. Mitrakov
E-mail: lokomokolya@gmail.com

With each passing year the problem of use of physical therapy methods in pediatric patients receiving hemopoietic stem cell transplantation (HSCT) for the correction of complications occurring in the process of treatment is becoming more and more pressing due to expansion of indications for HSCT and the increasing survival rates of such patients. Current publications dedicated to analysis of physical activity limitation in pediatric patients following HSCT within the framework of physical rehabilitation contain contradictory information and methodological variations that do not provide adequate insight into physical abilities of this category of children. We are aiming to critically review the matter of modern tendencies in physical activity tolerance assessment in children receiving HSCT, and are discussing the alternative approaches to this problem.

Our purposes are: 1. Comparative assessment of muscular strength and tolerance to physical activity decrease in patients hospitalized at the HSCT department at various stages of therapy. 2. Analysis of literature data concerning the assessment of muscular strength and tolerance to physical activity decrease in pediatric patients receiving HSCT.

Objects and methods

Prospective comparative non-randomized study was carried out. The object of assessment was the muscular strength and hemodynamic parameters during orthoclinostatic test in patients during various stages of therapy: prior to admission to HSCT department (day -5 of conditioning), after HSCT procedure (+5 days from HSCT), and upon discharge from HSCT department (+30 days from HSCT). For study of muscular strength and tolerance to physical activity in Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology of the Ministry of Healthcare of the Russian Federation (n=27) patients with median age of 9 years old were selected. No rehabilitation measures were taken prior to the admission to HSCT department.

Results

Average time from diagnosis determination in case of patients with acute lymphocytic leukemia (ALL) and acute myeloid leukemia (AML) prior to the inclusion to the study amounted to 3 months; in case of patients with other diagnoses including immune deficiency and aplastic anemia (AA) it amounted to 5 weeks. The analysis of publications is performed according to the following search terms: “physical therapy, hematopoietic stem cell transplantation, physical rehabilitation, physical activity” for the last 10 years is found in PubMed, Elsevier, and ClinicalKey.

Conclusions

Noticeable decrease of both hemodynamic and strength parameters in comparison with other patient groups preparing for HSCT was registered in the group of patients with ALL and AML. Complicated pretransplantation period in the form of prolonged highly toxic therapy was the reason of it. After HSCT was conducted, the patients from both group lost their muscular strength to a greater extent; their tolerance to physical activity also decreased. Physiotherapy allowed to improve controlled parameters of muscular strength and physical activity tolerance, but the optimal level was not achieved. According to evidence from actual publications, the approach of preventive physical therapy appointment for those patients who are preparing for HSCT procedure seems to be the most perspective one.

Keywords

Physical therapy, hematopoietic stem cell transplantation, physical exercise, dosage.

Short reports

Results of allogeneic hematopoietic stem cell transplantation in patients with juvenile myelomonocytic leukemia

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Anna A. Osipova, Tatyana A. Bykova, Varvara N. Ovechkina, Anastasia S. Borovkova, Olesya V. Paina, Polina V. Kozhokar, Anastasia S. Frolova, Kirill A. Ekushov, Aleхander N. Galimov, Zhemal Z. Rahmanova, Svetlana V. Razumova, Alexander L. Alyanskiy, Elena V. Morozova, Elena V. Babenko, Tatyana L. Gindina, Elena V. Semenova, Ludmila S. Zubarovskaya, Boris V. Afanasyev

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


Contact: Dr. Anna A. Osipova
E-mail: md.annarats@gmail.com

Juvenile myelomonocytic leukemia (JMML) is an aggressive malignant disease bearing the features of myeloproliferative disease and myelodysplastic syndrome. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the standard treatment for patients with JMML. Relapses of the disease and non-engraftment remain main causes of the treatment failure.

Our goal was to analyze the effectiveness of HSCT and identify factors affecting the outcome in children with JMML.

Patients and methods

The study included 22 patients (pts), age 8 month to 12 years (median, 4 years) who received 30 allo-HSCT (22 cases, first transplant; 8 cases, second HSCT) from 2002 to 2019. The diagnosis was established in accordance with international criteria. Patients’ gender: boys, 18; girls, 4. Cytogenetic findings: normal karyotype, in 10 pts (45%); monosomy 7, in 7 cases (31%), other cytogenetic changes, in 5 pts (23%). Molecular genetic analysis was performed for 14 pts showing: PTPN11 (n=8), NRAS (n=3), KRAS (n=1), NF1 (n=2), CBL (n=1), SETB1 n=1), ASLХ1 (n=1), RUNX1 (n=1), no detectable mutations (n=1). At the time of diagnosis, platelet (PLT) count was 11 to 419 (median 59×109/l); white blood cells (WBC) 2.6-175.0 (median 28.0×109/L). Most patients received chemotherapy before allo-HSCT. Depending on clinical manifestations at the time of diagnosis they were divided into 2 groups. First group (13 pts) received differentiation therapy: cis-retinoic acid, low dose cytarabine, hypomethylating agent, or hadn’t any previous therapy. The 2nd group (9 pts) received AML-like intensive chemotherapy (FLAM/ADE/HAM). The time from diagnosis to allo-HSCT was 2 to 86 months (median, 8 month). Bone marrow (BM) was used in 20 pts (91%), peripheral blood stem cells (PBSC), in 3 cases (9%). Donors’ type: matched related HSCT, in 5 pts (20%); haploidentical, in 5 cases (20%), and matched unrelated donors were used for 12 pts (60%). Myeloablative conditioning regimen (MAC) was used in 19 pts (86%); reduced-intensity conditioning (RIC), in 3 pts (15 %). Median follow-up continued for 8 months (range 1 to 130).

Results

Four-year overall survival of JMML pts (OS) was 56%. Engraftment was achieved in 12 pts (59%). Full donor chimerism at day 30 was shown in 7 pts (31%). Mixed chimerism appeared with delay in 2 pts (9%), with subsequent loss and development of relapse; one patient (4.5%) had a secondary transplant rejection with further recovery of autologous hemopoiesis. 2nd transplant was made for 8 pts (36%), with subsequent non-engraftment in 4 cases, and loss of the graft, in 4 patients. OS in the group of patients who received high-dose chemotherapy was 78%, with other therapies, 45% (p=0.635). There was a trend for improving OS when an unrelated donor had been used, i.e., 75% versus 0% (p=0.281). When assessing some factors affecting OS, the level of platelets at the time of diagnosis seems to be informative: OS at initial PLT level of >30×109/L was 65%, when compared with OS rates of 30% at initial PLT of <30×109/L (p=0.034). The levels of WBC, fetal hemoglobin, splenomegaly did not affect OS (probably, due to limited data). OS in pts with acute GVHD stage 1-2 was 100%; in cases of GVHD stage 3-4, it was 0%, being 33% in GVHD-free cases (p=0.003).

Conclusion

Allo-HSCT remains the main therapeutic option for patients with JMML. Chemotherapy is justified as a pre-transplant therapy and is considered in each case individually, depending on the degree of myeloproliferative syndrome.

Conflict of interest

No conflict of interest.

Keywords

Juvenile myelomonocytic leukemia, treatment, allo-HSCT.

Short reports

Treatment of steroid-refractory acute and chronic graft-versus-host disease with ruxolitinib in children

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Olesya V. Paina, Tatyana A. Bykova, Ivan S. Moiseev, Polina V. Kozhokar, Anastasia S. Frolova, Anastasiya S. Borovkova, Anna A. Osipova, Zhemal Z. Rahmanova, Kirill A. Ekushov, Liubov A. Tsvetkova, Inna V. Markova, Elena V. Semenova, Ludmila S. Zubarovskaya, Boris V. Afanasyev

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


Contact: Dr. Olesya V. Paina, PhD
E-mail: paina@mail.ru

Steroid-refractory graft-versus-host disease (srGVHD) is a life-threatening complication of allogeneic stem cell transplantation. Currently there is no standard of care for this complication and with existing modalities the survival remains relatively low. The study was conducted in children with steroid-refractory or steroid-dependent acute and chronic GVHD.

Patients and methods

The prospective study included 30 patients, (age 1-18 years, median – 5.5 years old). EBMT/ELN criteria were used for steroid refractory disease (T. Ruutu et al., 2014). Sixteen patients (pts) had acute srGVHD and 14 exhibited moderate or severe chronic steroid-refractory GVHD (srGVHD). Eight pts (27%) had acute myeloid leukemia; 7 pts (23%), acute lymphoblastic leukemia; 12 pts (40%) suffered with non-malignant disorders; 3 (10%), with other malignant diseases. The donor type was as follows: unrelated, in 18 cases (60%); matched related donor, in 1 case (3%); haploidentical donors were used for 11 recipients (37%). Patients with acute GVHD had a median of 2 prior lines of therapy (range 1-2), the patients with chronic GVHD had a median of 3 prior lines (range 1 to 6). 13 of 16 acute GVHD patients had grade III-IV disease, and 12 of 14 chronic GVHD patients had severe (NIH) disease. Ruxolitinib was administered at the starting dose of 0.3 mg/kg/day. Dose modifications were performed in patients in cases with grade 4 hematologic toxicities. Ruxolitinib was continued until complete response or absence of response in 28 days for acute GVHD and six months for chronic GVHD.

Results

Median follow-up for the surviving patients was 20 months (range 6-37). Overall response for acute GVHD was 81%. Complete response (CR) was observed in 11/16 patients with median time to CR 38 days (range 7-122). Three patients were in continuous partial response (PR), and two had progression of the disease. Overall response for chronic GVHD was 100%. 4/14 patients achieved CR after a median of 10.5 months of treatment (range 5-14 months). 10 out of 14 patients achieved PR after a median of 1.3 months of treatment (range 0.2-6.5). Non-relapse mortality occurred in 6/30 patients, GVHD progression was the cause of death in 3 cases, multidrug-resistant sepsis was fatal in 3 cases, and two patients died due to progression of underlying malignancy. Overall survival for patients with aGVHD was 62.5%; for cGVHD, 86%. Dose reduction/drug interruption due to cytopenia was required in 5/16 acute GVHD and 3/14 chronic GVHD patients.

Conclusion

Despite the small group size, our preliminary results indicate that ruxolitinib is a promising agent for managing srGVHD. Randomized prospective studies are required to confirm that ruxolitinib is superior to other approaches.

Keywords

Ruxolitinib, hematopoietic stem cell transplantation, allogeneic, graft-versus-host disease, acute, chronic, children.

Short reports

Comparison of allogeneic transplant outcomes using conditioning with different dose of busulfan for children with acute myeloid leukemia

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Olesya V. Paina, Zhemal Z. Rahmanova, Liubov A. Tsvetkova, Polina V. Kozhokar, Anastasia S. Frolova, Kirill A. Ekushov, Inna V. Markova, Sergey N. Bondarenko, Elena V. Babenko, Alexander L. Alyanskiy, Ildar M. Barkhatov, Elena V. Semenova, Ludmila S. Zubarovskaya, Boris V. Afanasyev

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


Contact: Dr. Olesya V. Paina
E-mail: paina@mail.ru

Allogeneic hematopoietic cell transplantation (HCT) is a potentially curative therapy for pediatric patients with acute myeloid leukemia (AML). The conditioning regimen administered to this group of patients is usually based on busulfan combined with cyclophosphamide (BuCy), fludarabine (BuFlu) or other agents. Comparisons of myeloablative conditioning (MAC) versus reduced intensity conditioning (RIC) in a few studies have demonstrated the contradictory results in relapse and toxicity rates. We evaluated whether dose intensity of busulfan across regimens may affect treatment outcomes. The goal of this retrospective study was to evaluate the impact dose of busulfan to overall survival (OS), transplant-related mortality (TRM), relapse-free survival (RFS), toxicity, the incidence of primary graft failure and acute graft-versus-host disease (GVHD) in transplantation in children and adolescents with AML.

Materials and methods

We analyzed 110 AML pediatric patients with the median age 9 y.o. (range 1-19), who underwent first allo-HSCT with busulfan based (per os and I.V.) conditioning in R. Gorbacheva Memorial Institute from 2002 to 2018. The patients were divided into 3 groups: Bu1 – patients, who received busulfan at the dose 8-10 mg/kg, n=34 (31%); busulfan dose in Bu2 was 12 mg/kg, n=35 (32%); in Bu3, dose of busulfan was >12 mg/kg, n=41 (37%). In Bu1, busulfan was combined with Flu in 31 pts (91%) and Cy in 3 (9%); in Bu2, with Flu in 12 (34%), Cy in 7 (20%), and other agents in 16 (46%); in Bu3, with Cy in 32 (78%), with Flu in 7 (17%) and other agents in 2 pts (5%) (p<0.001). Patients in Bu2 received more Cy-based GVHD prophylaxis regimens (69% vs 44% in Bu1, vs 29% in Bu3, p=0.003), and more HAPLO grafts (51% vs 29% in Bu1, vs 15% in Bu3, p=0.003). The complete remission at the HSCT was observed in 79% in Bu1, 49% in Bu2, 61% in Bu3 p=0.02. Probabilities of OS, RFS, TRM were estimated by using the Kaplan-Meier method. Incidence of toxicity, acute GVHD and primary graft failure was assessed by Mann-Whitney U-test.

Results

Engraftment was achieved in 95 (86%) of patients. Graft failure occurred in 5 patients of Bu1 group (15%), in the 6 pts of Bu2 (17%) and in the 4 pts of Bu3 (10%), p=0.7. Median follow-up was 2 years for Bu1 and Bu3, 1 year for Bu2. OS was similar (Bu1=59% vs Bu2=60% vs Bu3=51%), p=0,7. OS of pts with CR before HSCT was 70% in Bu1, 82% in Bu2, 60% in Bu3, p=0.3 and 14%, 39%, 38% for pts with progressive disease (PD), respectively, p=0,5. RFS was 74% in Bu1, 82% in Bu2, 64% in Bu3 at CR, p=0.4; 43%, 39% and 38% in pts with progression, respectively, p=0.9. Median of RFS were also similar for the pts in PD, (4 months in Bu1, 5 months in Bu2 and Bu3), p=0.9 and not achieved for pts in CR. Grade 3-4 regimen-related toxicity was observed in 35% pts in Bu1, 29% in Bu2, in 54% in Bu3, p=0,04. Mucositis and toxic hepatitis were the most common adverse events. Sinusoidal obstruction syndrome (SOS) was observed in 8 pts from all groups: 4 in Bu2 (11%), 3 in Bu3 (7%) and only 1 pts in Bu1 (3%) who was previously treated of gemtuzumab ozogamicin, p=0.4. Majority of pts with SOS (3/5) had PD at the HSCT. Cumulative incidence of acute GVHD grade 2 (15% vs 14% vs 10%, p=0.8) was not different. Acute GVHD grade 3-4 was observed more often in Bu3 (34%), than in Bu1 (18%) and Bu2 (17%), p=0.09. TRM up to +100 days was also higher in Bu3 (15%), than in Bu2 (6%) and Bu1 (0%), p=0.05.

Conclusions

The transplantation results of children with comparable AML disease status were not associated with significant differences in outcomes according to the dose of busulfan. Higher dose of busulfan may increase incidence of grade 3-4 toxicity (p=0.04), acute grade 3-4 GVHD (p=0.09) and increased early TRM (p=0.05).

Keywords

Busulfan, allo-HSCT, acute myeloid leukemia, children.

Short reports

Administration of nasogastric tubes and gastrostomy in HSCT patients

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Natalia G. Saltykova, Nina N. Gurgenidze, Alexander N. Shvetsov, Maksim A. Kucher, Boris V. Afanasyev

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


Contact: Natalia G. Saltykova, Clinical Nurse
E-mail: saltykova2014@yandex.ru

Nutritional status (NS) is an important factor that can influence overall effectiveness of hematopoietic stem cell transplantation (HSCT) in patients with malignancy. Nowadays NS evaluation and its correction are an integral part of supportive care, which is due to complications in the early post-transplantation period that negatively affect NS, among which are gastrointestinal toxicity: nausea, vomiting, mucositis, enteropathy, and infectious complications, for which enteral nutrition (EN) and/or parenteral nutrition (PN) are frequently administrated. Nutrition therapy effectiveness and safety may vary widely from the level of nursing staff competence and experience.

Materials and methods

On the basis of current state of art in clinical nutrition, worldwide recommendations and our own experience in nutrition support in patients with HSCT, the principles and features of EN implementation are presented.

Results

EN is a process of specialized mixtures of macro- and micronutrients administration by oral way, via feeding tube, or gastrostoma. EN has advantages in comparison with PN: it is more physiological, contributes tp the maintenance of intestinal microenvironment, faster recovery of mucus barrier of gastrointestinal tract and has significantly lower risk of infectious and metabolic complications. The most common method of EN is nasogastric tube, which may be of various length and size, made of polyvinyl chloride, silicone or polyurethane, and which is injected through the nasal lumen into the stomach. In addition, nasogastric tube can be used for gastroparesis treatment (abdominal decompression), poisoning, drugs administrating (unconscious and pediatric patients) and for gastrointestinal bleeding control. In case of decreased nasogastric tube tolerance, long-lasting EN necessity and unless contraindicated, it is possible to install an inert gastrostomy tube. Modern endoscopic and percutaneous methods of gastrostomy installation are minimally invasive surgery and can be used in children with a body mass below 3 kg.

The leading role in patient’s care belongs to the nursing staff, which should regularly takes care of nasogastric or gastrostomy tube, takes preventive measures for bedsore, granulations tissue, dislocation and obstruction prophylaxis, as well as conducting training with the patient and it’s relatives. It is important to keep in mind the patient characteristics, i.e., immunodeficiency (risk of infections), thrombocytopenia (risk of bleeding), mucositis (pain, bleeding), vomiting, diarrhea, which requires additional skills and compliance with nutrition therapy technology. In case of lacking competence, the nurses may incorrectly perform EN, which could lead to increased risk of complications in patients and change of further treatment approaches.

Conclusions

Standard operating procedures (SOPs), which contain documented sets of instructions or algorithms for step-by-step actions, according to which medical staff must strictly follow during implementation of nutrition therapy, should be developed and implemented into clinical practice in every transplant center. Senior nurses and doctors who are responsible for conducting EN should periodically give training lectures and hold workshops for medical staff, patients, and their representatives to increase the level of knowledge and skills, which will improve the efficiency, compliance, and safety of nutrition support.

Keywords

Nutritional support, enteral nutrition, HSCT.

Short reports

Allogeneic haematopoietic stem cell transplantation with myeloablative conditioning regimen based on different dosage of busulfan in children and adolescents with acute lymphoblastic leukemia

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Elena V. Semenova, Olesya V. Paina, Liubov A. Tsvetkova, Polina V. Kozhokar, Anastasia S. Frolova, Zhemal Z. Rahmanova, Kirill A. Ekushov, Inna V. Markova, Sergey N. Bondarenko, Elena V. Babenko, Ildar M. Barkhatov, Alexander L. Alyanskiy, Ludmila S. Zubarovskaya, Boris V. Afanasyev

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


Contact: Dr. Olesya V. Paina
E-mail: paina@mail.ru

Allogeneic haemopoietic stem cell transplantation (allo-HSCT) is an effective option in the treatment of high risk children with acute lymphoblastic leukemia (ALL). Myeloablative busulfan-containing regimens are one of the standards for pre-transplant conditioning in these patients. However, the question of optimal toxicity and effectiveness dose of busulfan is still not resolved. The goal of this study was to evaluate the impact of intensity busulfan (Bu) dose in myeloablative conditioning regimen on overall survival (OS), relapse-free survival (RFS), early transplant-related mortality (TRM), incidence of toxicity, acute graft-versus-host desease (GVHD) and primary graft failure in transplantation in children and adolescents with ALL.

Materials and methods

This study included 144 patients (pts) who were divided into 3 groups: the Bu1 group included children who received Bu in conditioning regimen at a dose of 8 to 10 mg/kg (n=37, 26%), Bu2 group was administered Bu at 12 mg/kg (n=57, 39%); and Bu3 (>14 mg/kg in 50 cases, 35%). The median age at the time of HSCT in Bu1 patients was 15 years (4-18); Bu2, 11 years (2-18); Bu3, 11 (3-18) years old; the respective p levels were: for cohorts 1 vs 2=0.028; 1 vs 3=0.005; 2 vs 3=0.6.

Allo-HSCT in complete remission (CR) of the disease was performed in 29 (78%) Bu1 pts, 32 (56%) Bu2 pts, 36 (72%) Bu3 pts (respective p values were: for cohorts 1 vs 2=0.028; for 1 vs 3=0.5; for 2 vs 3=0.09. In the 1st СR, we observed 10 (27%) Bu1 pts, 11 (19%) Bu2 pts, 7 (14%) Bu3 pts, with respective p values for cohorts 1 vs 2=0.4; for 1 vs 3=0.3; for 2 vs 3=0.9. The main conditioning regimen was a combination of Bu with fludarabine (BuFlu) (n=28, 76%) in Bu1 group, BuFlu (n=28, 49%) and GIAC (n=21, 37%) in Bu2, Bu with cyclophosphamide (n=39, 78%) in Bu3, at p values between groups 1 vs 2=0.05; group 1 vs 3 <0.001, and for groups 2 vs 3=0.4. Cyclophosphamide as GVHD prophylaxis was used in 19 (51%) children in Bu1, 41 (72%) in Bu2, 14 (28%) in Bu3. The p values for the groups were as follows: 1 vs 2=0.04; 1 vs 3=0.027; for groups 2 vs 3 <0.001.

Probabilities of OS, RFS, TRM were estimated by means of Kaplan-Meier method. Incidence of toxicity, acute GVHD and primary graft failure was evaluated by Mann-Whitney U-test.

Results

Effective transplant engraftment was documented in 31 (84%) Bu1 patients, 50 (88%) Bu2, and in 46 (92%) Bu3 patients. The incidence of primary graft failure was similare: 14% in Bu1, 9% in Bu2; 8% in Bu3, respectively, p values for 1 vs 2=0.5; for p 1 vs 3=0.4; p 2 vs 3=0.8. At a median follow-up of 2 years the OS of pts with CR at the time of HSCT was 55% in the Bu1 group, 71% in the Bu2 group and 58% in Bu3, p values were as follows: 1 vs 2=0.4, 1 vs 3=1, 2 vs 3=0.4. At the 1st + 2nd CR, the OS was 52%, 78%, 66%, respectively; p 1 vs 2=0.2, p 1 vs 3=0.4, p 2 vs 3=0.4. The OS of children without CR at the time of HSCT comprised: 25%, 20%, 21%, with p values for 1 vs 2=0.8, p 1 vs 3=0.6, p 2 vs 3=0.2. RFS in pts with CR before HSCT was 62% in Bu1 patients, 70% in Bu2 and 66% in Bu3, with p levels for 1 vs 2=0.9; for 1 vs 3=0.6; for 2 vs 3=0.6. At the 1st + 2nd CR RFS was 57%, 74%, 59%, with p values for 1 vs 2=0.5; for 1 vs 3=0.7; for 2 vs 3=0.6. RFS of children with progression at the time of HSCT was, respectively, 25%, 36%, 21%, with p levels for 1 vs 2=0.9; for 1 vs 3=0.8; for 2 vs 3=0.8. Among children at CR of the disease at the time of HSCT, toxicity of grade 3-4 occurred more often in Bu1 group (n=7, 24% ), than in Bu2 (n=18, 56%) and Bu3 (n=17, 47%), p levels for 1 vs 2=0.008; for 1 vs 3=0.057; for p 2 vs 3=0.4 Severe mucositis was the most frequent complication in these children. Toxicity grade of 3-4 was not different and developed in 4 (50%) children Bu1 with progression of disease: 19 (76%) in Bu2, 10 (71%) in Bu3, with p values for 1 vs 2=0.17; for 1 vs 3=0.4; for 2 vs 3=0.8. Acute GVHD grade 3-4 was observed in 7 children (23%) with Bu1, 10 (20%) in Bu2, 8 (17%) in Bu3, with appropriate p levels for 1 vs 2=0.7; for 1 vs 3=0.6; for 2 vs 3=0.8. TRM up to D+100 was significantly lower in Bu1 (0%), than in Bu2 (13%), and Bu3 (11%) among the pts with CR, with p values for 1 vs 2=0.047; for 1 vs 3=0.067; for 2 vs 3=0.8. Upon the disease progression at allo-HSCT, this index was similar: 25%, 12%, 7%, with p levels for 1 vs 2=0.4; for 1 vs 3=0.2; for 2 vs 3=0.5.

Conclusion

These data demonstrated, that decrease dose of Bu in the myeloablative conditioning regimens is not associated with decline of OS and RFS in children with same status of ALL. However, decrease doses of Bu reduced toxicity and early transplant mortality in pts with ALL in CR before allo-HSCT.

Keywords

Acute lymphoblastic leukemia, busulfan, allo-HSCT, children.

Short reports

Frontline R-EPOCH in HIV-infected patients with non-Hodgkin’s lymphoma

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Ivan V. Tsygankov, Marina O. Popova, Yulia A. Rogacheva, Kirill V. Lepik, Yury R. Zalyalov, Lilia V. Stelmakh, Ivan S. Moiseev, Sergey N. Bondarenko, Natalia B. Mikhaylova, Vadim V. Baykov, Boris V. Afanasyev

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


Contact: Dr. Marina O. Popova
E-mail: marina.popova.spb@gmail.com

Despite widespread use of antiretroviral therapy (cART), risk of cancer, including non-Hodgkin’s lymphomas (NHL) remains high in HIV-infected patients. The use of cART and possibility of its combination with chemotherapy (CT), as well as supportive care made positive changes in management of HIV-associated lymphomas. Immune prevention with cART has changed therapeutic approach to HIV-associated lymphoma, allowing the use of aggressive treatment strategies. The aim of our study was to estimate that R-EPOCH is safe and effective regimen in patients with HIV-related NHL.

Patients and methods

Thirty-two patients with HIV-related NHL (the study group) were treated since 2016 at the R. Gorbacheva Institute of Children Oncology, Haematology and Transplantation with 24-hour infusion of drugs, according to R-EPOCH regimen. The data of non-HIV-infected patients with NHL who received R-EPOCH therapy at the same period of time (control group, n=18) were also collected, in order to compare efficacy and safety of the regimen (2:1 ratio). Most patients (74%) were diagnosed with diffuse large B-cell lymphoma. The patients with plasmablastic lymphoma (PbL) received a modified chemotherapy (ChT): vincristine was replaced by bortezomib. This concerned two PbL patients from the study group, i.e., one patient received 6 courses of ChT, the second patient was treated by 2 ChT rounds. One PbL patient in the control group received 3 courses of ChT. Some patients with HIV-associated NHL (n=15) received two injections of rituximab per a course of ChT (day 1 and day 5 of each cycle). Virological evaluation of the patients before ChT showed that HIV viral load was undetectable (<50 copies/ml). The median number of CD4+ cells was 255 cells/mcl (50-680). 100% of HIV -infected patients received cART, with respect to possible drug interactions. The median follow-up was 19 (3-44) months in both groups. Objective response, toxicity, overall survival (OS), progression-free survival (PFS) were assessed during 24 months from the start of R-EPOCH regimen. Effectiveness of ChT was estimated using PET CT of the whole body and CT. Common Terminology Criteria for Adverse Events (CTCAE 4.0) were used to estimate toxicity. Kaplan-Meier method was used for OS and PFS analysis.

Results

Objective response rate (ORR), i.e. complete remission (CR) + partial remission (PR), was 80% after finishing the ChT, CR comprised 42%. ORR in the study group was 87.5% (CR, 46.8%); in control group, 66.6% (CR, 33.3%). Toxicity assessed by CTCAE scale in both groups was also assessed. Hepatotoxicity in the study group was higher, probably, due to the presence of concomitant viral hepatitis in the group of patients with NHL associated with HIV infection. Overall survival (OS) for both groups (n=50) within 24 months following the ChT with continuous 24-hour infusion of drugs according to the R-EPOCH scheme was 74%. In the group of patients with HIV (study group) it comprised 67.7% against 84.2% among the control group of patients without HIV infection (p=0.182). Progression-free survival in total lymphoma group was 58.0%, being 51.6% among patients with HIV infection, and 68.4% in the control group (p=0.287).

Conclusion

ORR level was 87.5% in patients with HIV-associated lymphoma and 66.6% in patients without HIV. Toxicity rate did not differ between these groups. The 2-year OS from the start of ChT for the patients with HIV-associated lymphoma was 67.7%, and progression-free survival was 51.6%, showing no significant difference from the patients without HIV. These data confirm general safety and efficacy of R-EPOCH regimen in HIV-infected patients, being comparable with those in the group without HIV infection.

Keywords

HIV-related lymphoma, NHL, chemotherapy, overall survival, toxicity, HIV status.

Short reports

Expression of immune checkpoint molecules in bone marrow as a predictor of clinical outcome in myelodysplastic syndrome

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Nikolai Y. Tcvetkov, Ivan S. Moiseev, Artem A. Gusak, Vadim V. Baykov, Elena V. Morozova, Boris V. Afanasyev

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


Contacts: Dr. Nikolai Y. Tcvetkov
E-mail: nikolai.tcvetkov@yandex.ru

Myelodysplastic syndrome (MDS) is a heterogeneous group of hematological malignancies affecting mostly elderly people over 70 years. Lack of effective treatment modalities in the field promotes the search for new treatment options with several ongoing clinical trials. The checkpoint inhibitors are also an option since they are able to affect the bone marrow niche, which is involved in MDS development, although there is still no consensus on the optimal use of this method in MDS settings and treatment criteria. The aim of our single-center retrospective study was to determine whether different expression of checkpoint molecules in bone marrow biopsies at diagnosis may affect clinical course of MDS patients.

Materials and methods

A consecutive cohort of 55 MDS patients treated in our center in 2003 to 2018 was studied. Among 55 adult MDS patients, 27 belonged to high or very high risk group, as based on IPSS-R score values. Twenty-three patients subsequently underwent allogeneic bone marrow transplantation. The median follow-up period was 900 days. We developed a technique able to detect expression of the following antigens: PD-1, PD-L1, PD-L2, LAG-3, Galectin-9, TIM-3, CD80. The relations between expression level and clinical outcomes were analyzed. Three-year overall and relapse-free survival and time-to-progression were assessed as the main clinical outcomes. Our univariate analysis was aimed to assess the possible role of overall checkpoint expression level and age, IPSS/WPSS/IPSS-R scores, blood and blast counts, transfusion dependency. The SAS 9.4 software was used, p-value of less than 0.05 was considered statistically significant. The study was approved by local Ethics Committee.

Results

Intensive expression of TIM-3 was observed in 100% of cases. Also, in most cases, moderate Gal-9 expression was observed on many cells. Our statistical analysis yielded a significant connection between CD80 expression and three-year time-to-progression. At 3-year follow-up disease progression was seen in 72.9% of patients with CD80 level of more than 1 point and 52.1% of patients with CD80 level of less than 1 point (p=0.04). Similar trend was seen for general checkpoint expression level. At 3-year follow-up, 67.2% of patients with checkpoint expression level of more than 1.5 point showed the disease progression, while in the group with checkpoint expression level of less than 1.5 point, the progression was seen only in 33.3% of cases (p=0.059).

Conclusion

Our preliminary study highlighted a potential role of immune checkpoint molecules in MDS pathogenesis and a need for further studies of different immune checkpoint inhibitors.

This work was supported by Russian Science Foundation, grant № 17-75-20145. Authors confirm the absence of any conflicts of interests.

Keywords

Myelodysplastic syndrome, checkpoint molecules, expression.

Short reports

Low-bacterial diet in children undergoing HSCT: concept, key principles and unresolved issues

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Andrey Yu. Vashura

Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia


Contact: Andrey Yu. Vashura
E-mail: avashura@gmail.com, korobezz@mail.ru

Conditioning regimens before HSCT inevitably lead to immunosupression. Under these conditions, the probability of infections complicating the post-transplant period and negatively affecting the patient’s recovery increases dramatically. Therefore, during neutropenia it is required to protect the patient from the possibility of infection. Lungs and gastrointestinal tract are the key gates of infection: because of the "openness", the vital importance of these systems, the complexity of anti-microbial therapy and huge area of their inner surface. Our aim was to compare different studies in the field.

Objects and methods

As early as in 1960s, the first outlined recommendations on the diet of neutropenia patients were developed (Reimer 1966). Subsequently, the diet under the terms "neutropenic" and "low-microbial" (LMD) became stably included in the guidelines for the support in oncology and hematology. Strict methods of long-term food processing (thermal, hyperbaric, radiation, canning) were used (Aker 1983). The main goal was achieved, but there was a high monotony and taste properties, thus dictating a need for "softening" the regime, and composition of the diet (Preisler 1970). The emergence of a low-bacterial diet (LBD) modified by inclusion of raw, well-washed fruits and vegetables. The effectiveness of LMD, in terms of reducing the risk of infection, begins to be seriously challenged with the 90s.

Results

Foreign experience (Ziegler 1992, Smith 2000, French 2001, Wilson 2002, Moody 2006, Van Thiel 2007, Gardner 2008, Stecher 2008, Trifilio 2012) shows that:
• There exist many LMD modifications;
• A diet including raw fruits and vegetables is psychologically better tolerated by patients whereas "sterile" LMD is an additional "burden";
• No significant differences were found between LMD classic and soft LBD, with respect to duration and presence of infectious complications in patients with neutropenia, including after HSCT;
• There is a reverse effect of "decontamination": invasion of opportunistic and pathogenic microflora of the intestinal surface with a decrease in the number and activity of gut microflora is faster and more aggressive. In Russia, there are logical inconsistencies with LMD. On the one hand, there is too long cooking. The dishes prepared in this way become tasteless and less useful;
• Limitations for heat-treated nuts, dried fruits and honey. There is no basis for such exceptions in the literature, except for general suggestions and "for any case" concepts;
• Prohibition of fresh vegetables, raw fruits (especially, citrus). At present, there is no clear evidence for exclusion of raw fruits in patients after HSCT (Trifilio 2012). On the other hand, the following products are allowed: marmalade, chocolate, cakes and packed non-yeasted bread, bananas, ice cream sorbet. In addition, there is no clear understanding of the principles of low microbial regimen, why LMD is needed, when it is needed and when it should be cancelled;
• There is lack of coherence and universality of dietary approaches, even within one clinic, e.g., usage of LMD for patients being outside the transplantation box, and especially at home.

Conclusions

1. LMD prepared by certain rules of treatment, storage and delivery of food, was developed as an additional way to prevent infection.
2. The diet, generally, has low taste properties and high monotony, thus hard to consume it.
3. The researchers conclude that LMD for patients undergoing HSCT is advisable, but with the inclusion of fresh fruits and vegetables. Rigid restrictions may have the opposite effect.
4. There is no universal diet for children after HSCT.
5. Current LMD is imperfect and not always justified, it is necessary to review and unify it on the basis of logical positions of evidence-based medicine, individual approaches, and harm-benefit ratio.

Keywords

Hematopoietic stem cell transplantation, children, nutrition, neutropenic diet, low-bacterial diet.

Short reports

Anorexia overcoming in patients with cytostatic therapy and hematopoietic stem cell transplantation

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Irina N. Zhuk1,2, Polina V. Sheveleva2, Natalya G. Saltykova2, Maksim A. Kucher2, Boris V. Afanasyev2

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


Сontact: Dr. Maksim A. Kucher, MD
E-mail: doctorkucher@yandex.ru

Cytostatic therapy and hematopoietic stem cell transplantation (HSCT) are treatment options for blood malignancy, often associated with the development of complications, including gastrointestinal toxicity in the early period and endocrine system dysfunction more typical as a late complication. One of the manifestations of which is anorexia, leading to protein-energy malnutrition, body mass wasting, and ultimately cachexia – negative impact factor of overall survival. We aimed to evaluate safety and clinical efficacy of existing appetite stimulants in order to overcome anorexia in the patients.

Patients and methods

Since 2014, 99 patients with acute myeloid leukemia (n=27), acute lymphoblastic leukemia (n=26), solid tumors (n=12), lymphomas (n=10), chronic myeloid leukemia (n=8), inherited (n=4) and other diseases (n=12) were enrolled to the prospective study. The median age was 20.6 years (2 months to 76 years), among them children (n=68) and adults (n=31). The groups included 59 males and 40 females. HSCT was performed in 75 patients: allogeneic unrelated (n=45), related donors (n=11), haploidentical donors (n=16), autologous (n=3); cytostatic therapy was performed in 20 cases; other methods of treatment (n=4). To treat protein-energy malnutrition in which anorexia was the leading syndrome. Appetite stimulant therapy was carried out in 58 patients, i.e., megestrol acetate (Megace, Bristol-Myers Squibb, USA), 40-320 mg/day (0.8-13.3 mg/kg) orally, divided into 2 doses, duration 1-3 months. 19 patients received levocarnitine (Elkar, PEAK-Pharma, Russia) – 0.3-0.9 g/day (0.61 g/day) orally for 1 month. Taking into the account that prednisolone, for which appetite increase is a common side effect, 22 patients who had received Prednisolone 1-2 mg/kg/day as a part of graft-versus-host disease (GvHD) therapy, were also included into the study. The groups of patients were homogeneous for the main clinical parameters (p=0.3).

Results

Appetite was restored in 79.3% of patients (n=46) in megestrol acetate group, р=0.0001; 63.6% (n=14) with prednisolone, р=0.0001; 22.2% (n=4), with levocarnitine. Body mass increase was observed in 81% (n=47) of the patients in megestrol acetate group (p=0.05); 50% (n=11) in prednisolone group (p=0.05) and 15.8% (n=3), among levocarnitine-treated patients. At the beginning of megestrol acetate treatment 27 patients (46.5%) had chronic GvHD of different localization and 29.3% (n=17) had cachexia. Initially, the patients had hypotrophic or cachectic nutritional status, presence or absence of GvHD didn’t affect efficiency appetite stimulants (р=0.3). Prednisolone treatment was associated with more frequent rate of complications, 45.4% (n=10) (metabolic disturbances in 7 patients, catabolism in 7 patients, steroid-induced diabetes mellitus in 3 cases, p=0.0001), in comparison with megestrol acetate (n=1, bronchial spasm), and levocarnitine (n=1, allergic reaction manifested by rash).

Conclusions

Low-dose megestrol acetate is a safe and effective option for anorexia and cachexia treatment in adults and children after HSCT and cytostatic therapy. Use of prednisolone as a GvHD treatment in HSCT recipients was less effective to overcome anorexia, moreover, it was accompanied with enhanced catabolism and metabolic alterations.

Keywords

Hematopoietic stem cell transplantation, graft-versus-host disease, anorexia, appetite stimulants.

Short reports

Complex treatment experience in a cohort of children and adolescents with Hodgkin’s lymphoma

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Daria A. Zvyagintseva2, Andrew V. Kozlov1, Asmik G. Gevorgian1, Ilya V. Kazantsev1, Polina S. Tolkunova1, Tatiana V. Iukhta1, Ludmila S. Zubarovskaya1, Boris V. Afanasyev1

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


Contact: Dr. Daria A. Zvyagintseva
E-mail: 7615773@gmail.com

The use of modern standard risk-adapted therapy programs is accompanied by a relatively favorable prognosis for Hodgkin’s lymphoma (HL) in both adult and pediatric patients. Most patients can be cured, and long-term overall survival (OS) reaches 80-85%. However, 15-20% of patients do not respond to standard therapy, or have a relapse. In these cases, the use of intensive chemotherapy regimens, including high-dose polychemotherapy (HDCT) with autologous hematopoietic stem cell transplantation (auto-HDCT), allows stabilization and a change in the prognosis of the disease. Our aim was to assess the survival of in standard and high-risk Hodgkin’s lymphoma patients based on the therapy received.

Patients and methods

In this study, we analyzed the treatment results of 175 patients aged 3 to 18 years with Hodgkin’s lymphoma. Most patients (n=143) received in 1993-2015 standard treatment regimens according to DAL-HD and SPbHL protocols in Pediatric Oncology Department at the N. N. Petrov Research Institute of Oncology. The induction regimen consisted of 2 to 6 polychemotherapy courses, then local irradiation of primary lesions locations was performed. Some patients (n=32, 18%) with primary resistant or relapsed disease belonged high-risk group and received more intense treatment including high-dose chemotherapy (HDCT) with autologous hemopoietic stem cell transplantation (auto-HSCT) performed in R. M. Gorbacheva Institute of Pediatric Oncology, Hematology and Transplantation in 2012 to 2017. In most cases, BEAM (22%) and BeEAM (63%) HDCT regimens were employed, 15% of patients received other treatment regimens. The median follow-up is 10 years for primary patients and 2.5 years for the HDCT group.

Results

The long-term overall (OS) and event-free survival rates (EFS) of the primary patients treated according to DAL-HD and SPbHL protocols were 88% and 77%, 93% and 87%, accordingly. There were no significant differences in overall and relapse-free survival depending on the treatment protocol used (p=0.5). The immediate treatment toxicity was mostly hematological (Gr IV neutropenia in 23% in DAL-HD and 11.8% of cases in SPbHL therapy regimens recipients). OS and EFS in primary resistant/relapsed patients receiving HDCT with auto-HSCT were 57% and 42%, accordingly. The main cause of death was relapse/progression of the disease (n=3), although 9% of patients died of transplant-related complications. The immediate HDCT toxicity effects were mostly febrile neutropenia (87% of cases), gastrointestinal mucositis of different grade (50%), which was in 6% of cases complicated by bleeding. In one case, a subarachnoid hemorrhage was registered.

Conclusions

Modern programs of complex HL therapy allow curative rates of more than 80% in the patients with HL. Therefore, some further efforts should be devoted to treatment-associated toxicity reduction. However, there is still a group of patients with extremely unfavorable prognosis, in whom the treatment results are still unsatisfactory (57 vs 42%), even after dose-intensive consolidation. The high-risk group treatment programs are also associated with considerable toxicity. These results may be significantly improved by the use of targeted drugs and immunotherapy (immune control checkpoints inhibitors, allogeneic HSCT).

Keywords

Hodgkin lymphoma, children and adolescents, high-dose polychemotherapy, autologous hematopoietic stem cell transplantation, overall and event-free survival, treatment toxicity.

Short reports

Fecal microbiota transplantation in the patients after allogenic bone marrow transplantation with acute graft-versus-host disease and severe gastrointestinal damage

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Oleg S. Syuskin, Oleg V. Goloshchapov, Dar’ya V. Churakina, Maksim А. Kucher, Ruslana V. Klementeva, Sergei V. Sidorenko, Vladimir V. Gostev, Vadim Е. Karev, Мariya А. Suvorova, Irina V. Shlyk, Аlexei B. Chukhlovin, Ludmila S. Zubarovskaya, Olga V. Pirogova, Olesya V. Paina, Marina O. Popova, Boris V. Afanasyev

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


Contacts: Dr. Oleg S. Syuskin
E-mail: solegs84@mail.ru

Allogeneic hematopoetic stem cell transplantation (allo-HSCT) is often accompanied by severe immune and infectious complications refractory to standard immunosuppressive and antibacterial therapy. This is especially true for hard-to-sanitize loci of infection, such as the gastrointestinal tract, which is one of the main target organs in acute graft-versus-host disease (GVHD). Fecal microbiota transplantation (FMT), which has an immunomodulatory effect and is aimed for eradication of antibiotic-resistant pathogenic microbiota, in this case can be considered as a variant of «rescue therapy». Analysis of efficacy and safety of applying FMT in treatment immunocompromising patients in critical condition caused by gastrointestinal GVHD after allo-HSCT was the aim of our work. It may help to optimize therapy in these patients. The aim of our pilot study was to assess efficiency FMT efficiency.

Materials and methods

Two clinical procedures of TFM were performed for the treatment of acute GVHD with intestinal lesions, confirmed by morphological and histological studies, in patients in critical condition, treated at the R. Gorbacheva Memorial Research Institute of Children Oncology, Hematology and Transplantation, i.e., a male recipient 45 years old (patient K.), and a girl 3 years 8 months (patient M.). In both cases, a combination of sepsis, multi-organ dysfunction syndrome and acute grade IV GVHD, was the prevalent syndrome determining the overall severity of the condition which manifested by high-volume secretory diarrhea and severe recurrent gastrointestinal bleeding.

Quantitative changes in the bacterial composition of the fecal microbiota (FM) were evaluated by real-time polymerase chain reaction (PCR). Culturing and isolation of bacteria from biological samples and evaluation of their antibiotic susceptibility was performed using standard disc diffusion methods. The genes encoding carbapenemases of groups КРС, ОХА-48, VIM, IMP, NDM, were detected by PCR in DNA separated from clinical isolates. The effectiveness of the method was evaluated by the clinical state of patients, quantitative and qualitative changes in the bacterial composition of FM.

Results

Clinical condition of the patients after TFM has, generally, shown a similar positive dynamics. In patient K., a reduction in stool volume to 1000 mL/day was recorded at D+14. Termination of intestinal bleeding was observed on D+29. Semi-solid stool was first marked on D+119. The patient was discharged from ICU on D+92; he has left the hospital in satisfactory condition on D+192. Intestinal bleeding in patient M., was stopped at D+14. Volume of the stool was reduced to 500 ml/day on D+25. The well-formed stool was first marked on D+32. The patient was transferred from ICU on D+36, and has left clinic in satisfactory condition on D+82.

In both clinical cases, there was also a similar dynamics of FM. In patient K., the total bacterial mass of FM increased considerably (from 4*10^7/g to 6*10^12/g), due to Lactobacillus spp., Bifidobacterium spp., B. Fragilis, Bacteroides thetaiataomicron, F. Prausnitzii. Together with these changes, there was a decrease in numbers of Citrobacter spp., Enterococcus spp., K. Pneumoniae. Total bacterial mass in patient M. has not changed considerably (5*10^11/g initially, and 2*10^12/g after FMT). However, an increase in Lactobacillus spp., Bifidobacterium spp., F. prausnitzii, B. Fragilis was noted over the period from D+8 to D+30. Also, a decrease in Citrobacter spp., Enterococcus spp., K. pneumoniae, Clostridium difficile was found by D+30. After FMT, in both patients an increased proportion of anaerobic bacteria of the genus Bacteroides spp., Fecalibacterium spp., Lactobacillus spp., Bifidobacterium spp., reduction of representatives of the Enterobacteriaceae family (Citrobacter spp., K. pneumoniae) and Enterococcus spp. Moreover, the multidrug-resistant Pseudomonas spp. (KPC-type carbapenemase gene positive) was not no longer detected after FMT in bronchoalveolar lavage from patient K. Similarly, it caused elimination of K. pneumoniae with carbapenemase NDM- and OXA-48 types expression, being replaced by the carbapenem-sensitive isolate.

Conclusion

FMT can be considered a method of «rescue therapy» in combination treatment of children and adults in critical condition with acute intestinal GVHD combined with sepsis. FMT may increase clinical efficacy of antibacterial drugs by replacing polyresistant strains of K. pneumoniae and Pseudomonas spp. to bacterial strains which did not produce NDM-metalloproteinase, as well as ОХА-48 and КРС serine carbapenemases.

Keywords

Fecal microbiota transplantation, GVHD, sepsis, decolonization, carbapenemases, metalloproteinase, NDM, OXA-48, КРС, Klebsiella pneumoniae, Pseudomonas spp.

Short reports

Immunochemotherapy in relapsed or refractory B-cell non-Hodgkin lymphoma

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Olesya G. Smykova, Kirill V. Lepik, Elena V. Kondakova, Yury R. Zalyalov, Lilia V. Stelmakh, Elena I. Darskaya, Natalia B. Mikhailova, Boris V. Afanasyev

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


Contact: Dr. Olesya G. Smykova
E-mail: olesya.gen@gmail.com

The outcome of patients with relapsed or refractory B-cell non-Hodgkin lymphoma (r/r NHL) remains dismal and therapeutic options for those patients are limited. Immunochemotherapy including nivolumab-based regimens and inotuzumab ozogamicin may be promising treatment for this group of patients.

Patients and methods

We analyzed clinical data of patients with r/r NHL (n=37) including 20 cases with diffuse large B-cell lymphoma (DLBCL), 13 patients with primary mediastinal B-cell lymphoma (PMBCL), and 4 cases of follicular lymphoma (FL). Their median age was 39 (range, 18–64) years. Most patients (n=29, 78%) had primary chemoresistant disease, the rest patients (n=6, 22%) had a relapse. The median of lines of prior therapy was 4 (range, 2-7) lines. Among this patients, n=23 received 1 to 3 cycles of immunochemotherapy with nivolumab, bendamustine, gemcitabine and rituximab, within the frame of BeGeRN sudy (NCT03259529), and 14 patients received 1 to 3 cycles of inotuzumab ozogamicin (IO) treatment.

Results

At the median follow-up of 16 months (2 to 23), an objective response (OR) after BeGeRN treatment was noted in 12 patients (52%), with complete response (CR), and partial response (PR) observed in 7 (30%) and 5 (22%) patients, respectively. Two responding patients underwent autologous HSCT, and two other responding patients received allogeneic hematopoietic stem cells transplantation (allo-HSCT). Median duration of response (DOR) for all 12 patients with OR was 5 months (range, 2 to 23+). Among eight patients who achieved OR without HSCT, only 3 remain alive in remission. Two patients who received auto-HSCT had a relapse. One patient improved the response after allo-HSCT from PR to CR, and the two patients with allo-HSCT remain in CR with no signs of GVHD (for 13 and 15 months). The probabilities of 1-year OS and PFS rates were 54% and 30%, respectively. The regimen was well tolerated, the most common adverse events were hematological toxicity and 1 patient (4%) developed autoimmune cytopenia. Among 14 patients receiving IO, OR was observed in n=6 (43%) patients, CR and PR were registered in 2 (14%) and 4 (29%) patients, respectively. Median DOR for all 6 patients with OR was 2 months (range, 2 to 45). One responding patient underwent allo-HSCT and remains in CR (12 months). The probabilities of 1-year OS and PFS rates were 52% and 21%, respectively. The regimen was well tolerated, the most common adverse events were hematological toxicity, elevated transaminases, and 1 patient (7%) developed veno-occlusive disease.

Conclusions

Immunochemotherapy with nivolumab-based regimens or IO has acceptable toxicity and can lead to an objective response in patients with r/r NHL. However, durability of response to therapy is not long, and consolidation with allo-HSCT is needed.

Keywords

B-cell non-Hodgkin lymphoma, nivolumab, inotuzumab ozogamicin.

Short reports

Infusion of memory T cell (CD45RA-depleted) DLI improves CMV-specific immune response early after αβT cell-depleted HSCT: first results of a prospective randomized trial

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Zhanna B. Shekhovtsova, Maria A. Dunaykina, Larisa N. Shelikhova, Dmitry N. Balashov, Elena E. Kurnikova, Yakov O. Muzalevsky, Alexey S. Kazachenok, Elena Yu. Osipova, Viktoria V. Kiseleva, Dmitry E. Pershin, Daria A. Shasheleva, Rimma D. Khismatullina, Sergey L. Blagov, Andrei B. Abrosimov, Irina P. Shipitsina, Elena I. Gutovskaya, Galina A. Novichkova, Alexey A. Maschan, Michael A. Maschan

Dmitry Rogachev National Medical Centre of Pediatric Hematology, Oncology and Immunology, Moscow, Russia


Contacts: Dr. Zhanna B. Shekhovtsova
E-mail: shekhovtsova@fccho-moscow.ru

αβ T cell depletion effectively prevents severe GVHD in mismatched HSCT, but in a proportion of cases delayed immune recovery leads to increased infection risk and NRM. We’ve shown in a pilot study that infusion of low-dose memory T cells (CD45-RA depleted) is safe after engraftment among recipients of αβ T cell-depleted grafts (PMID:29269793). We initiated a prospective trial to directly test the efficiency of this approach. We report here an interim result of a prospective, randomized, single-centre trial (NCT02942173).

Patients and methods

A total of 100 pediatric patients with malignant disorders (ALL, n=56; AML, n=30; NHL, n=8; acute mixed-lineage leukemia, n=5 and MPD, n=1) were enrolled between October 2016 and September 2018. Patients were randomly assigned to receive CD45RA-depleted DLIs (experimental arm), n=54, or not (control arm), n=46. Median age at HSCT was 8.9 years, m:f ratio – 42:58. The conditioning consisted of either treosulfan (n= 50) or TBI (n= 50) in combination with fludarabine and thiotepa. GVHD prophylaxis included tocilizumab at 8 mg/kg at day 0, abatacept at 10 mg/kg at day 0, +7, +14 and +28, and bortezomib at 1.3 mg/m2 at days -5, -2, +2, +5. Neither anti-thymocyte globulin nor calcineurin inhibitors were used. Donors were HLA-haploidentical (n=94) or matched (n=6). All donors and 76% of the recipients were CMV seropositive. PMBC grafts were split and TCRαβ/CD19 depletion and CD45RA depletion were performed with CliniMACS Prodigy. The median dose of CD34+ cells was 10x106/kg, αβT cells – 28×103/kg. In the experimental arm memory DLIs were infused on day 0 at 25×103/kg and on days +30, +60, +90, +120 at 50×103/kg. In the control arm 8 patients received DLI after engraftment to prevent relapse (n=6) or treat infections (n=2). Primary endpoints were the cumulative incidence (CI) of CMV viremia (>500 copies/ml) by day +100 and the CI of acute GvHD grade ≥ II.

Results

Median follow-up for survivors was 1 year (0.2–2). Engraftment of WBC and platelets was achieved in 99 pts, one patient died at day +8. WBC and platelets engrafted at a median of 11 days and 14 days, respectively. The incidence of CMV viremia was 45% (36-56) overall, 41% (30-56) in the experimental arm vs 50% (38-67) in the control arm, with no significant difference. The CI of aGvHD ≥ grade II was 10% (6-18) overall, 10% (4-23) in the experimental arm vs 9% (4-24) in the control arm (non-significant difference). Two patients died, one per treatment arm, resulting in 2% (0-14) CI of TRM at 1 year among the whole cohort. Causes of death were pre-engraftment bloodstream infection and disseminated adenovirus infection. Patients randomized to experimental arm acquired anti-CMV reactivity significantly earlier, according to IFN-g ELISPOT assay on day +30 after HSCT (p=0.0001).

Conclusions

Co-infusion of donor-derived memory cells (DLI) with the αβ T cell-depleted graft is safe and improves recovery of virus-specific immune responses. Replacement of ATG with targeted blockade of CD28/CD80 costimulation and IL-6 receptor does not compromise engraftment and GVHD control, and is associated with low rate of non-relapse mortality.

Keywords

Leukemia, children, CD45RA, trial, prospective, randomized.

Short reports

Intravenous immunoglobulin G effectiveness evaluation for hemorrhagic cystitis treatment in allogeneic hematopoietic stem cell transplantation

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Aleksander A. Shcherbakov, Olga N. Zatsepina, Ekaterina S. Kulneva, Irina S. Iarushkina, Maxim A. Kucher, Oleg V. Goloshchapov, Boris V. Afanasyev

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


Contact: Dr. Aleksander A. Shcherbakov
E-mail: xihmrx@gmail.com

Hemorrhagic cystitis (HC) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a frequent complication occurring in 11-31% of cases. HC can negatively influences early posttransplantation period, increases the duration and amount of blood transfusion therapy, leads to coagulation abnormalities, as well as to acute and chronic kidney damage and, as a consequence, reduces overall survival, increases the time of hospitalization and the costs of treatment. Currently, there are no available presented algorithms for the treatment with sufficient effectiveness. Aim of the present study was to evaluate the effectiveness of intravenous immunoglobulin G (IVIG) treatment for HC after allo-HSCT.

Patients and methods

From 2015 to 2018, 749 patients who underwent allo-HSCT in Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology and Transplantation were enrolled into the retrospective analysis. HC developed in 10.8% (n=81) of the patients. The study included 49 patients with HC who received their first allo-HSCT and developed a late form of HC not earlier than D+6 after allo-HSCT; a group of patients receiving IVIG, only with early HC treatment performed not later than seven days after the HC onset. The standard accompanying therapy for the hemorrhagic cystitis therapy, such as enhanced infusion therapy, forced diuresis, non-steroidal anti-inflammatory drugs and spasmolytic drugs. Fourteen patients (28.6%) did not receive any specific treatment for HC. As for HC treatment, IVIG was administered in 71.4% (n=35) of the patients, at a dose of 0.4 g/kg once a day for 3-5 consecutive days. Both groups were comparable for age (7-54 years, median, 22 versus 3-54 years, median, 18, p=0.34), primary diagnosis (AML, 35.6% vs 40%; ALL, 50% vs 51.4%, p=0.77), type of transplantation (allo-HSCT, 60% vs 57.2%; haploidentical HSCT, 40% vs 42.8%, p=0.85), conditioning regimen (MAC, 71.2% and 60%; RIC, 28.8% and 40%, p=0.46), and the day of HC manifestation after HSCT (6 to 160 days, median – 41; 7-119 days, median, 38; p=0.75), respectively. HC treatment with IVIG was started 1-7 days after first HC signs, the median was 3 days.

The therapy efficiency was based on HC duration in the group of patients without specific therapy and HC duration from the beginning of IVIG therapy to the end of HC symptoms in group of patients who had received therapy. The criterion for HC completion was the last day of macrohematuria and microhematuria of less than 60 red blood cells per vision field in general urine testing.

Results

There were no statistically significant differences in the median HC duration between the IVIG recipient group (23 days) and patients, who did not receive specific treatment (17 days; p=0.37), as seen from Fig 1.

Shcherbakov_fig01.jpg

Figure 1. Comparative frequency of hemorrhagic cystitis in HSCT patients treated with or without IVIG

Conclusion

With a limited sample size of HSCT patients, we did not reveal any convincing therapeutic activity of IVIG when treating late hemorrhagic cystitis after allo-HSCT.

Keywords

Hematopoietic stem cell transplantation, hemorrhagic cystitis, IVIG.

Short reports

Effectiveness of tyrosine kinase inhibitor therapy and allogeneic hematopoietic stem cell transplantation in pediatric patients and adolescents with chronic myeloid leukemia (experience of R. M. Gorbacheva Memorial Research Institute of Children Oncology, Hematology, and Transplantation)

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Polina V. Sheveleva, Anna A. Osipova, Tatyana A. Bykova,Varvara N. Ovechkina, Olesya V. Paina, Polina V. Kozhokar, Kirill A. Ekushov, Alexandr N. Galimov,Tatyana L. Gindina, Ildar M. Barkhatov, Alexander L. Alyanskiy, Elena V. Morozova, Elena V. Semenova, Ludmila S. Zubarovskaya, Boris V. Afanasyev

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


Contact: Dr. Polina V. Sheveleva
E-mail: sheveleva_p@list.ru

Despite the fact that allogeneic hematopoietic stem cell transplantation (allo-HSCT) is still the only method able to cure the disease completely in pediatric and adolescent patients (pts) with chronic myeloid leukemia (CML), it is associated with life-threatening complications. Therefore, the tyrosine kinase inhibitors (TKIs) are a standard option for first-line therapy. In our study we summarize a single-center experience in TKIs therapy for children and adolescents with CML and try to establish the indications for allo-HSCT in this group.

Patients and methods

A total of 35 children and adolescent with CML received therapy TKIs +/- allo-HSCT at the R. Gorbacheva Memorial Research Institute were included into the analysis from April 2005 to August 2019. 23 males (66%) and 12 females (34%) participated in the study. The median age at the time of diagnosis was 10.7 years (range 7 months to 18 years). At the time of diagnosis 30 patients were in chronic phase (CP), four patients were in accelerated phase (AP), and one, in lymphoid blast crisis (LBC). Before imatinib (IM) treatment was initiated, 21 patients received hydroxycarbamide, five of them were subject to combined therapy with other drugs (α-interferon in two cases). Two of these pts had CHR prior to first-generation TKIs (1G-TKIs) initiation. The median starting IM dose was 300 mg/m2/day. The therapy toxicity was assessed based on WHO criteria according to CTCAE scale. The TKIs therapy response was evaluated according to ELN criteria.

Results

The complete hematological remission (CHR) at the 3rd month (mo) of IM therapy was achieved in 31 cases (89%). Among them, 24 (69%) had subsequently reached CCyR (7, at 3 mo; 8, at 6 mo; 8, at 12 mo; and 1, after12 mo of the therapy). Molecular remission (MR) was achieved in 17 of 35 (49 %) pts. In 7 cases it was the MMR seen at mo 3 in 2, 6 in 1, 12 in 1 and after mos 12 in 3 cases. Ten patients had CMR observed at mo 3 in 2 cases; 12 in 1, and 12 mo later, in 7 cases. The hematological toxicity to 1G – TKIs was seen in 7 (20%) patients, grade I-II non-hematological toxicity in 10 (28%) cases. The optimal response to IM was seen in 10 (29 %), suboptimal in 11 (31%) pts. In 4 (11%) cases, the therapy was interrupted before 1 year, in 10 (29%), the primary treatment failure was observed. Also, 13 (37%) patients had to be switched to 2G -TKIs (dasatinib in 8, and nilotinib in 5) due to toxicity (n=2), primary/secondary resistance (n=11). In 14 (40%) patients, allo-HSCT was performed, in 8 of them, 2G-TKIs were applied. At the moment of allo-HSCT, 5 patients were in CP, 7 in AP, and 2 in LBC. Indications for allo-HSCT were as follows: lack of MR and/or CyR in 4, loss of CHR and CyR and/or MR in 4, LBC in 1; disease progression to AP in 2 cases; disease progression to LBC with M244V and M351 mutation in 1 case; AP with T315I mutation in two cases. Two patients were lost from the follow-up (1 patient developed transformation to AP with Y257C mutation, the extramedullary BC with myeloid lineage in 1 case). Overall survival (OS) in 1G- +/- 2G-TKIs patients (n=21) with a median follow-up of 49 (10-126) months was 100%, OS in allo-HSCT recipients +/- 2G-TKIs was 79% (n=11,) at the median follow-up of 82 (1-140) mo. Three patients died due to transplant-related complications (aGVHD in 1 case, cGVHD in 1 patient, and infection in 1 case).

Conclusions

Despite the frequent Grade I-II toxicity (in 28% of cases), the TKIs therapy proved to be still a safe and effective treatment modality in children and adolescents with CML and should be employed as first-line treatment. However, loss of clinical response, toxicity, and resistance-associated additional mutations are possible indications for allo-HSCT, although there are still no universal guidelines, and each case should be viewed individually.

Keywords

Chronic myeloid leukemia, allogeneic hematopoietic stem cell transplantation, tyrosine kinase inhibitors, children, adolescents.

Short reports

Choice of optimal GVHD prophylaxis regimen in unrelated transplantations of non-manipulated hematopoietic stem cells in children

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Natalia V. Sidorova1, Alexey S. Slinin2, Kirill I. Kirgizov1, Ekaterina A. Pristanskova1, Veronika V. Konstantinova1, Alexandra E. Burya1, Elena B. Machneva1, Oxana L. Blagonravova1, Elena V. Skorobogatova1

1 The Russian Children’s Research Hospital of N. I. Pirogov Russian National Medical University, Moscow, Russia
2 Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia

Graft-versus-host disease (GVHD) is one of the most frequent and dangerous complications of allogeneic hematopoietic stem cell transplantation (allo-HSCT). Therefore, the choice of an optimal GVHD prophylaxis is an important component of the supportive care. Hence, the principal aim of our retrospective study was to evaluate different regimens for GVHD prevention following matched unrelated (MUD) allo-HSCT in children.

Patients and methods

During the period of 2003-2019, we performed 256 MUD HSCT in children. Gender distribution was as follows: males, 64.8% (n=166); females, 35.2% (n=90). Median age was 7.1 y.o. (8 months to 17 y.o.). The primary diagnoses were: acquired aplastic anemia (14%, n=36); myeloid leukemias (39%, n=100); lymphoid leukemias (17%, n=43); primary immune deficiency (7%, n=19); congenital storage disorders (13%, n=32); hereditary hematopoetic depression (5%, n=14); hematophagocytic lymphohistiocytosis (2%, n=4); other rare diseases (3%, n=8). 242 HSCTs (94.5%) were carried out for the first time; second HSCTs were performed in 14 cases (5.5%). Stem cell sources for grafting were: bone marrow (BM) was used in 76% of cases (n=174); peripheral blood stem cells (PSC), in 24% (n=62). 204 patients (79.7%) received 10/10 MUD HSCT, and 52 pts (20.3%), were compatible by 9/10. Conditioning regimens contained various agents, thus being consistent with treatment protocols for particular diseases. GVHD prophylaxis included: tacrolimus (Tacro), cyclosporin A (CsA), methotrexate (Mtx), mycophenolic acid (MMF), in combinations: Tacro/Mtx (n=98), Tacro/MMF (n=102), Tacro/Mtx+MMF (n=3), CsA/Mtx (n=24), CsA/Mtx+MMF (n=2), CsA/MMF (n=14). The duration of observation was from 3 months up to 16 years (median of 8.9 years).

Results

Incidence of acute GVHD (aGVHD) in the group with non-manipulated BM grafts was lower in the CsA/Mtx, i.e., 38%, with overall survival (OS) rates of 93% (p=0.039). The aGVHD incidence in patients who received PSC was lower in the Tacro/Mtx, and in Tacro/MMF groups, i.e., 13% in each group, but with the OS rates of 70% and 34%, respectively (p=0.012). Incidence of severe-grade aGVHD (stage 3-4) was most often observed in BM group with the Tacro/MMF prophylaxis regimen (19%), and, in the PSC group, with the CsA/Mtx/MMF prophylaxis regimen (8%), with lower OS levels in these groups. i.e., 49% and 50%, respectively (p=0.12, p=0.257). When using the BM grafts, the rate of the OS showed significant differences, depending on aGVHD prevention regimen (p=0.03). OS value was higher in the PSC-treated group when using CsA/MMF (83%), and CsA/Mtx (78%, p=0.52).

Conclusion

The source of stem cells should be taken into account when choosing a regimen for GVHD prophylaxis during MUD HSCT in children. The CsA/Mtx combination when using BM as a stem cells source was associated with significantly increased OS level in our study, and reduced the incidence of aGVHD, when applying BM as a source of stem cells. We did not find a significant impact upon OS levels when PSCs were used as a source of HSCT, at different aGVHD prophylaxis regimens. However, higher OS levels in the CsA/MMF PSC and CsA/Mtx PSC groups may become significant upon expansion of this clinical study.

Keywords

Allogeneic hematopoietic stem cell transplantation, unrelated donor, acute graft-versus-host disease, GVHD prophylaxis.

Short reports

Treatment of patients with central nervous system lymphoma

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Daniil I. Shmidt, Andrey N. Gavrilenko, Alexey Y. Polushin, Elena V. Kondakova, Kirill V. Lepik, Nadezhda V. Medvedeva, Anna V. Klimovich, Yury R. Zalyalov, Natalia B. Mikhailova, Boris V. Afanasyev

Pavlov First Saint Petersburg State Medical University, State Clinical Hospital №31, St. Petersburg, Russia


Contact: Dr. Daniil I.Schmidt
E-mail: daniilshmidt1997@gmail.com

Primary (PCNSL) and secondary (SCNSL) central nervous system lymphoma still carry a poor prognosis. Treatment of relapsed/refractory (r/r) CNS lymphoma remains a challenge. Biological features of CNS lymphoma determine the opportunity to use checkpoint inhibitors in r/r CNS lymphoma. Our aim was to analyze our clinical experience with these patients.

Patients and methods

Retrospective analysis included 35 patients (pts) with CNS lymphoma treated at the First Pavlov Saint Petersburg State medical University between 2010 and 2019. SCNSL comprised 54% of patients (n=19), PCNSL – 40% (n=14), and 6% (n=2) had CNS involvement in primary testicular lymphoma (PTL). Latter would further be analysed together with PCNSL due to shared biological and clinical characteristics. Median age at a diagnosis was 56 (30-65) in pts with PCNSL and 48 (20-65) in pts with SCNSL. Tumor histology was diffuse large B-cell lymphoma in 83% of cases. Relapsed or refractory CNS lymphoma was the case in 21 pts (60%): PCNSL, 81% (n=13/16); SCNSL, 42% (n=8/19). Nivolumab (nivo) was used in 12 pts: in PCNSL, 44% (n=7/16); SCNSL, 26% (n=5/19). Median follow-up was 16 months (mo) (0-99): 24.5 mo (0-99) for PCNSL, and 12 mo (1-34) for SCNSL pts. One patient had been infected with HIV prior to SCNSL diagnosis.

Results

The lesions affected brain parenchyma in 23 pts (14 with PCNSL and 9 with SCNSL), meningeal layers in 7 pts (1 PTL, 6 SCNSL), the both structures were affected in 5 cases (1 PCNSL, 4 SCNSL). Deep structures were involved in 19 pts (11 PCNSL, 8 SCNSL), and 17 pts had multiple lesions (9 PCNSL, 8 SCNSL. Treatment-related mortality was 11% (n=4/35). One-year overall survival (OS) was 74% in PCNSL, and 69% in SCNSL group. Six-months OS in r/r disease was 75% for PCNSL, and 33% for SCNSL. The patients received nivolumab at the doses of 3 mg/kg (n=3), 1 mg/kg (n=6), 100 mg (n=3) и 200 mg (n=1). Median follow-up in the pts receiving nivo was 7 mo (0-31). Objective response rate was 58% (n=7). Complete response was seen in 6 pts (3 PCNSL, 3 SCNSL), partial response – in 1 PCNSL patient, 4 pts had stable disease (2 PCNSL, 2 SCNSL). The disease progression was the case in 1 patient with PCNSL. Nivo was tolerated well. Grade 2 adverse events (AE) were observed, i.e., immune arthritis and maculopapular rash. No severe AE (grade 3-4) were registered. Eight patients who received nivolumab are alive at the moment of data evaluation. Tumor resection was performed in 8 (23%) pts (6 with PCNSL, and 2, with SCNSL). Consolidation took place in 11 (31%) pts (4 PCNSL, 7 SCNSL). Radiation therapy was performed in 11 pts (31%): 5 PCNSL, 4 SCNSL. Autologous hematopoietic stem cell transplant was performed in 1 patient with PCNSL and 5 pts with SCNSL.

Conclusions

Suboptimal number of pts receives consolidation therapy. Nivolumab therapy is a safe and efficient option in some pts with primary and secondary CNS lymphoma pts. Appropriateness, timing and optimal regimen of nivolumab treatment should be determined in prospective trials.

Keywords

Lymphoma, central nervous system, primary, secondary, nivolumab, therapy.

Short reports

Perspectives of clinical video-analysis of movements in pediatric patients receiving HSCT

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Nikolay N. Mitrakov1, Artem V. Shcherbuha1, Polina A. Shafran1, Alexey V. Korochkin1,2, Olga A. Laysheva1,2

1 Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
2 Russian Children’s Clinical Hospital Federal State Budgetary Educational Institution of Higher Professional Training, Moscow, Russia
3 N. I. Pirogov Russian National Research Medical University, Moscow, Russia


Contact: Dr. Nikolay N. Mitrakov
E-mail: lokomokolya@gmail.com

The problem of use of physical therapy methods in pediatric patients receiving hemopoietic stem cell transplantation (HSCT) for the correction of complications occurring in the process of treatment is becoming more and more pressing due to expansion of indications for HSCT and increasing survival rate of such patients. There are currently no publications dedicated to the analysis of movement disorders’ spectrum in patients who underwent HSCT, as well as methods of physical therapy efficiency control for up to 6 weeks following the beginning of treatment. We are offering a brand-new approach to the diagnostics of movement disorders by video analysis of reflex locomotion of the process of patient verticalisation from back-lying position into standing position with support on both legs. The purpose of this study was development of diagnostics, prevention and control of efficiency of physical therapy carried out for pediatric patients receiving HSCT using clinical video analysis method in order to make the results more objective.

Patients and methods

Our tasks were as follows: 1. Formalization of video criteria of movement test for acyclic locomotor stereotype of verticalization; 2. Research of inter-research variability upon determination of video criteria; 3. Determination of specific signs of typical movement disorders in pediatric patients following HSCT. A total of 230 patients took part in the study: 1. Study group: 64 pediatric patients following HSCT (median age is 10.4) who underwent treatment in Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology in 2017-2018. 2. Control group No. 1: 58 patients with oncological diseases receiving HDCT without HSCT (acute lymphocytic leukemia, n=42 (median age 7.4 years); acute myeloid leukemia: 18 patients (median age, 8.7 years); idiopathic immune deficiency: 21 patients (median age 10 years); neurogliocytomas in posterior cranial fossa: 8 patients (median age, 4.6 years); osteosarcoma of lower extremities’ bones: 11 patients (median age is14); 3. Control group, 87 conditionally healthy children with median age of 10.8 recruited in children’s groups for the first year of education of Russian Aikido Federation; 4. A group of researchers (n=65) formed out of the employees of medical rehabilitation center of Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology. Video materials were recorded using cell phone or tablet PC cameras. Video analysis was carried out using Dartfish software.

Results

The criteria of video representation of invariant characteristics of acyclic locomotive verticalisation stereotype’s video material from back-lying position into standing position on a horizontal surface with support on both legs were determined, formally described and split into stages. Objectification of the analysis of video criteria concerning invariant characteristics of acyclic locomotive verticalisation stereotype was achieved by registering temporary characteristics of locomotive stereotype stages’ video material. Inter-research variability reached 1.2%. Invariant characteristics spectrum of acyclic locomotive verticalisation stereotype’s video material in patients following HSCT in the study group had statistically significant difference (p<0.01) from the similar spectrum of control groups.

Conclusions

1. Determined criteria of locomotive verticalisation stereotype’s video analysis allowed to set the patients who underwent HSCT from both conditionally healthy children and patients with distinct diseases receiving high dose chemotherapy.

2. The results of control of inter-research variability make it possible to hope for automation of the process of video registration of temporary invariant characteristics of the stages of locomotive verticalisation stereotype.

Due to lack of selection homogeneity, small spectrum of conditions included in the study, as well as insufficient number of observations, it is impossible to make firm conclusions on the formation of full criteria for movement disorders’ diagnostics in patients following HSCT based on video images of acyclic locomotive verticalisation stereotype. Further research in this area are currently being conducted.

Keywords

Oncological diseases, treatment, motor rehabilitation, physical therapy, video analysis of movements.

Short reports

Effect of donor CD45RA-lymphocyte infusion on the T-cell subpopulation composition in adult patients after transplantation of allogeneic hematopoietic stem cells from a haploidentical donor with TCR αβ-depletion

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Ulyana V. Maslikova, Natalia N. Popova, Mikhail Yu. Drokov, Julia O. Davydova, Nikolai M. Kapranov, Ekaterina D. Mikhaltsova, Vera A. Vasilieva, Maria V. Dovydenko, Olga M. Koroleva, Anna A. Dmitrova, Zoya V. Konova, Olga S. Starikova, Daria S. Dubnyak, Denis V. Kamelskikh, Irina V. Galtseva, Tatyana V. Gaponova, Miсhael A. Maschan, Larisa A. Kuzmina, Elena N. Parovichnikova, Valery G. Savchenko

National Medical Research Center of Hematology, Moscow, Russia


Contact: Dr. Ulyana V. Maslikova
E-mail: ulyana.maslikova@protonmail.com

Prevention of acute graft-versus-host (GVHD) reaction by means of TCRαβ-depletion technique in patients after allogeneic hematopoietic stem cell transplantation from a haploidentical donor (haplo-HSCT) is based on removal of αβT cells from the graft, thus leading to deep long-term immunodeficiency. Attempts to stimulate recovery of the immune system by transfusion of donor lymphocytes to the patients after haplo-HSCT are associated with extremely high risk of fatal GVHD. In pediatric practice, infusion of CD45RA- lymphocyte fraction allows to resolve this problem. However, effectiveness of this technique and its immunological aspects after haplo-HSCT in adult patients with TCR αβ-depletion are not yet been determined. Our aim was to evaluate the subpopulation composition of peripheral blood T-cells in adult patients after haplo-HSCT with TCR αβ-depletion with and without infusion of donor CD45RA lymphocytes.

Patients and methods

The study included 15 adult patients after haplo-HSCT with TCR αβ-depletion. In three cases, the donor CD45RA- lymphocytes were infused on day 0. To assess the subpopulation composition of T cells, we used flow cytometry technique (BD FACS Canto II, Becton Dickinson, USA). At day +30, the subpopulations of CD4 +, CD8 + T cells were determined in patients’ peripheral blood samples: T-naive and stem cell memory (Tnv + Tscm), i.e., CD45R0-CCR7 + CD28 +; central memory T cells (Tcm) including CD45R0+ CCR7+ CD28+; transitional memory T cells (Ttm) with CD45R0+ CCR7- CD28 + phenotype; T effector memory cells (Tem, CD45R0 + CCR7-CD28-); and terminal effector T cells (Tte) with CD45R0-CCR7-CD28- profile.

Results and conclusion

The subpopulation composition of CD4+, CD8+ T cells in patients after haplo-HSCT with TCR αβ-depletion with and without infusion of donor CD45RA- lymphocytes is shown in Figure 1.

Maslikova_fig01.jpg

Figure 1. The subpopulation composition of patients’ peripheral blood CD4+, CD8+ T cells at +30 days after haplo-HSCT with TCR αβ-depletion (the absolute number of cells per microliter is indicated)

The results showed that, by 30 days after haplo-HSCT, there were no significant differences in the CD4+, CD8+ T cell subpopulations in the patients after haplo-HSCT with TCR αβ-depletion with or without CD45RA- lymphocyte infusion. However, this may be due to a small sample of patients, and therefore it is advisable to conduct further research in this direction.

Keywords

Allogeneic stem cell transplantation, TCR αβ-depletion, immune reconstitution.


Short reports

Post-transplant cyclophosphamide for graft-versus-host disease prophylaxis in patients with inherited disorders undergoing allogeneic stem cell transplantation

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Tatiana A. Bykova, Anna A. Osipova, Varvara N. Ovechkina, Alexander N. Galimov, Anna A. Dotsenko, Alexander L. Alyanskiy, Ivan S. Moiseev, Elena V. Semenova, Ludmila S. Zubarovskaya, Boris V. Afanasyev

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


Contact: Dr. Tatiana A. Bykova
E-mail: dr.bykova@mail.ru

Graft-versus-host disease (GVHD) remains one of the main life-threatening complications after allo-HSCT, especially in patients with non-malignant diseases. The standard GVHD prophylaxis strategy is mostly based on the use of calcineurin inhibitors alone or in combination with other immunosuppressive drugs(IS). Post-transplant cyclophosphamide (PTCy) is effective GVHD prophylaxis option for adult patients (pts), with only limited data for children. The aim of the present study was to evaluate PTCy as GVHD prophylatic option in pediatric pts with inherited disorders undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT).

Patients and methods

The study included 91 pts, most of them being in pediatric age (median age – 3 y.o., range 7 month – 30 y.o.) with different inherited disorders (β-thalassemia, 9; bone marrow failure syndromes, 26; storage diseases, 41; primary immunodeficiency disorders, 15) were enrolled in retrospective study. Donor type was as follows: matched/mismatched unrelated (MUD/MMUD), 67; matched related donor (MRD), 14; haploidentical (haplo), 10 cases. The following conditioning regimens were applied: myeloablative (MAC), 39; reduced-intensity (RIC), 52. Graft source was: bone marrow (BM) in 69 cases, peripheral blood stem cells (PBSC), in 22 patients. PTCy-based GVHD prophylaxis (50 mg/kg on days +3, +4) was administered in 31 cases, standard GVHD prophylaxis based on calcineurin inhibitors was used in 60 pts.

Results

Cumulative incidence (CI) of aGVHD grade 2-4 was 42%, grade 3-4 aGVHD was in 20% of patients. PTCy-based GVHD prophylaxis reduced CI of aGVHD (34% vs 57%, p=0.02). Another factors associated with reduction of aGVHD incidence were as follows: MAC (37% vs 58% among RIC pts, p=0.05); MRD (14% vs 30% in haplo group vs 59% in MUD/MMUD group, p=0.015); BM as a transplant source (41% vs 74% in PBSC group, p=0.02), male donors vs female ones (40 vs 65%, p=0.008). In multivariate analysis, BM graft (HR 2.3 95%CI 1.2-4.3, p=0.009), male donors (HR 0.4 95%CI 0.2-0.7, p=0.005); PTCY (HR 0.4 95%CI 0.2-0.9, p=0.04) were predictive for reduced CI of aGVHD. 5-year overall survival (OS) was 65%. The following factors improved OS, as follows: recipient age at transplant under 5 y.o. (79% vs 39%, p=0.000); time from diagnosis to allo-HSCT less than 22 months (73% vs 37%, p=0.002); long-term stable engraftment (73% vs 18%, p=0.000). In multivariate analysis, only engraftment was predictive for OS rates (HR 0.2, 95%CI 0.1-0.63, p=0.003).

Conclusion

PTCy-based GVHD prophylaxis can be an effective option for reducing risk of acute GVHD. Using related donors, bone marrow as transplant source and MAC regimen can reduce CI of GVHD. Performing allo-HSCT early after the diagnosis and at younger age may improve OS in the patients with inherited disorders.

Keywords

Inherited disorders, children, hematopoietic stem cell transplantation, GvHD prophylaxis, cyclophosphamide.

Short reports

The results of allogeneic hematopoietic stem cell transplantation from HLA-haploidentical donor with post-transplant cyclophosphamide regimen in children

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Alexandra E. Burya, Kirill I. Kirgizov, Yulia A. Nikolaeva, Ludmila V. Olhova, Veronica V. Konstantinova, Ekaterina A. Pristanskova, Natalia V. Sidorova, Anastasia V. Mezenceva, Oxana L. Blagonravova, Olga A. Filina, Elena V. Skorobatova

BMT Department, Russian Children’s Clinical Hospital at the Pirogov Russian National Research Medical University, Moscow, Russia


Contact: Dr. Alexandra E. Burya
E-mail: burya.a.e@gmail.com

Hematopoietic stem cell transplantation (HSCT) is a commonly accepted treatment option for high-risk hematological and immunological patients. The selection and availability of a donor is crucial for the success of the treatment. The strategy of using stem cells of a HLA-haploidentical related donor (haplo-HSC) combined with using post-transplant cyclophosphamide has shown the possibility of controlling the graft-versus-host reaction while maintaining the efficacy of HSCT. The purpose of this study was to summarize the experience of haplo-HSCT transplantation of unmanipulated graft from related donors in children with hematological malignancies and immunological pathology with a modified post-transplant cyclophosphamide regimen (PY-CY).

Materials and methods

During the period from 2013 to 2019, 37 haplo-HSCTs were performed in 34 patients at the BMT department of Russian Children’s Clinical Hospital (RCCH) including: acute lymphoblastic leukemia (n=9), acute myeloid leukemia (n=13), juvenile myelomonocytic leukemia (n=7), high-grade lymphoma (n=1), severe combined immunodeficiency (SCID) (n=3), aplastic anemia (n=1). The average age of the patients was 3.5 years (6 month to 14 years). Stem cell sources were bone marrow (BMT, n=34); peripheral blood stem cells (PBSCs, n=3). Patients received a myeloablative regimen: busulfan-based (n=15), threosulfan-based (n=16), full-dose total body irradiation TBI 12 Gray (n=2); lower-intensity conditioning regimens (n=4). For GVHD prophylaxis, PT-CY was given 100 mg/kg on days +3, +4, with rituximab (n=25), calcineurin inhibitors, mycophenolate (n=28); tacrolimus and sirolimus (n=9), abatacept/tocilizumab (n=26).

Results

The median day for the neutrophil engraftment was 21 days. The risk of primary graft failure was 11%, and it was higher in 3/10 patients (30%) treated with busulfan, compared with 1/19 patients from threosulfan-treated group (5.2%). Of 28 patients, 8 relapsed after haplo-HSCT. Complete donor chimerism on day +30 was achieved in 79% patients (n=27). The following post-transplant complications occurred: oral mucositis: grade 1 (n=7), grade 2 (n=14), grade 3 (n=4); neutropenic enterocolitis grade 1 (n=8), grade 2 (n=18), grade 3 (n=5), grade 4 (n=2); toxic hepatitis (n=15), hemorrhagic cystitis (n=6), systemic inflammatory syndrome (n=8), polyneuropathy (n=2), TMA-HUS (n=2). Viremia: cytomegalovirus (n=8), herpes virus type 6 (n=4), adenovirus (n=4) were detected, followed by negative values within short terms. We have also observed acute GVHD with skin rash symptoms of grade 1 (n=5), grade 2 (n=15), grade 3 (n=5), grade 4 (n=2); GVHD with gastrointestinal manifestation of grade 1 (n=7), grade 2 (n=5), grade 3 (n=5), grade 4 (n=2); hepatic GVHD (n=4) of degree 3 of severity; chronic GVHD form (n=9). The transplant-related lethal outcome occurred in one patient with TMA (incidence of 2.9%). Patients with SCID who had respiratory insufficiency of 2nd-3rd degree before conditioning were improved and resolved their complications up to 45-60 days after HSCT. Relapse in children with hematological malignancies was 29% (8 of 28). Relapse-associated mortality was 21% (6 out of 28). Of 34 patients, 27 are currently alive (79%). Median follow-up has been 3.8 years (range 0.6 – 6 years).

Conclusion

Our experience shows that haplo-HSCT with post-transplant cyclophosphamide regimen is effective treatment for high-risk patients with acceptable toxicity and low transplant-associated mortality rate. Early control of infection and antivirus immune response stimulation are the issues to be resolved in further studies. It is still disputable whether threosulfan-based regimen is beneficial for engraftment. High incidence of GVHD requires administration of adaptive supportive care.

Keywords

Hematopoietic stem cell transplantation, HLA-haploidentical, post-transplant cyclophosphamide.

Short reports

“Sensory conflict” as a possible reason for the violation of the postural stability of children treated for cancer

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Serafima M. Chechelnitskaia, Vladimir N. Kasatkin, Dmitrij V. Skvorcov, Marina A. Shurupova, Yury V. Saraikin, Aleksandra V. Baerbakh, Daria V. Zhuk, Vladislav A. Nikulin

Dmitry Rogachev Research Medical Center for Pediatric Hematology, Oncology, and Immunology; Medical Rehabilitation Research Center “Russkoe pole”, Moscow, Russia


Contact: Prof. Serafima M. Chechelnitskaia
E-mail: dar-2006@bk.ru

The success of modern medicine in cancer treatment suggests studies of the late toxic effects caused by anti-cancer therapy. Among other significant problems, the disturbed stability of vertical posture was described in numerous publications. The control of the vertical posture in a static position is ensured mainly by integration of visual and proprioceptive information, therefore, the oculomotor muscles can play a leading role in these disturbances. Disturbances of the vertical posture stability in children treated for cancer are described in publications elsewhere. The purpose of the study was to identify the dependence of postural control level on activity of the oculomotor muscles in the children treated for cancer.

Materials and methods

The study involved 184 children treated for cancer, and 60 healthy children underwent stabilometry in the Romberg test and Itracking. Stabilometry was used in order to assess stability of the vertical posture. The dynamics of homologous indicators was calculated during the transition from the position with open eyes (EO) to the position with closed eyes (EC). Activity of the oculomotor muscles was evaluated by the Itracking approach. Methods of nonparametric statistics were used for the data evaluation.

Results

We have revealed distinct correlations between the dynamics of individual stabilometric parameters, and saccadic activity. Maximal number of these relationships is characteristic to the scatter of pressure center coordinates and the length of the pressure center trajectory in the frontal plane. The Romberg Integrated Assessment Index has been developed. In 43.2% of children treated for cancer, there was an increase in stability of the postural balance when moving to the EC position, thus, probably, indicating to the leading role of oculomotor muscles in affected stability of the vertical posture in the children.

When moving from EO position to EC, 75.7% of the children of the main group improved their motion estimation; 50% showed an increased stability of the vertical posture in frontal and sagittal planes in the EC position. Correlation analysis revealed the relationship of average strength between the dynamics of individual stabilometry indicators and saccadic activity indexes; a higher negative result of the Romberg test corresponds to higher scatter of the gaze fixation points. Maximal number of the reliable relationships is characteristic to scatter of the center of pressure coordinates and the length of the center of pressure trajectory in the frontal plane, the area of the statokinesiographic ellipse. The degree of correlation is stably moderate, the coefficient of multiple correlation is in the range of 0.35 to 0.62. In our study, the improvement in postural stability during the transition from open to closed eyes can be explained by elimination of disturbing effects of the eyes or their appendages, e.g., oculomotor muscles.

Conclusion

The potential leading role of oculomotor muscles in posttransplant posture control allows us to recommend inclusion of oculography into the examination protocols, as well as a set of exercises for oculomotor muscles in rehabilitation programs for children treated for cancer.

Keywords

Childhood cancer, postural control, late toxic effects of anticancer therapy, oculomotor muscles.

Short reports

Assessment of cytokine levels in the patients with relapsed/refractory Hodgkin’s lyphoma during nivolumab therapy

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Andrey M. Chekalov, Kirill V. Lepik, Nikita D. Yolshin, Albert R. Muslimov, Natalia B. Mikhailova, Elena V. Kondakova, Lubov’ A. Tsvetkova, Yury R. Zalyalov, Eugenia S. Borzenkova, Ivan S. Moiseev, Vadim V. Baykov, Boris V. Afanasyev

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


Contact: Dr. Natalya B. Mikhailova, PhD
E-mail: bmt.lymphoma@gmail.com, a.m.chekalov@gmail.com

PD-1 inhibitors have changed the prognosis of patients with relapsed/refractory Hodgkin’s lymphoma (overall response rate> 65%), however, only a small number of patients achieve a stable remission (2-year progression-free survival (PFS) <50% ) Predicting a response and prognosis could help to optimize the therapy with checkpoint inhibitors. The aim of our study was a search for serum cytokine levels as a predictive marker for response to immunotherapy.

Materials and methods

The study included 80 patients with relapsed/refractory Hodgkin’s lymphoma, who underwent the treatment at the Raisa Gorbacheva Memorial Research Institute of Children Oncology, Hematology and Transplantation, I. P. Pavlov First Saint Petersburg, receiving 3 mg/kg of nivolumab, a PD-1 inhibitory drug. Median age of patients was 32 years, 55% men (n=44), 45% women (n=36), median follow-up was 32 months, overall survival (OS) was 96.3%, 2-year progression-free survival (PFS) was 40 % (median, 18.8 months) As a part of this study, the blood serum samples were taken for subsequent analysis before therapy initiation, at 1.5 months, 3 months, 6 and 12 months post-treatment. An enzyme-linked immunosorbent assay (ELISA) was used to determine the concentrations of interleukin-6 (IL-6) (80 patients), interleukin-15 (IL-15) (30 patients) and PDL-1 (42 patients). Associations between clinical characteristics and outcomes were analyzed in accordance with the level of cytokines at the studied points.

Results

Before starting immune therapy, the mean levels for IL-6, IL-15, and PDL-1 were determined as 7.23 pg/ml, 9.98 pg/ml, and 16.23 pg/ml, respectively. Subsequent evaluation using proportional hazards model revealed a statistically significant relationship between the values of IL-6 (p=0.009), and IL-15 (p=0.018) before therapy; IL-6 levels after 1.5 months (p=0.008), after 3 months (p=0.003), after 6 months (p=0.004), and 2-year progression-free survival (PFS). A positive correlation was revealed between IL-6 and PDL-1 at the points before starting the therapy (p=0.001), after 1.5 months (p=0.023), after 6 months (p=0.011). The values of all studied cytokines significantly decreased after 6 months of therapy (p <0.05). By the U-criterion, a relationship was detected prior to the start of nivolumab therapy between the levels of IL-6, and manifestation of B-symptoms (p=0.004). Using ROC analysis, a cut-off value was determined for IL-6 before therapy (2.5 pg/ml; AUC=0.589). The pre-treatment level of IL-6 exceeding 2.5 pg/ml was associated with decreased 2-year PFS (22.7% versus 50%, the median PFS 12.77 versus 23.17 months, p=0.049).

Conclusion

Our analysis showed that the level of serum IL-6 in patients with relapsed/refractory Hodgkin lymphoma before nivolumab therapy was associated with lower progression-free survival. Despite limited number of observations the level of IL-15 before the start of therapy also had a statistically significant relationship with PFS (p=0.018). A study of the level of PDL-1 did not show any statistical significance in our study.

Keywords

Hodgkin’s lymphoma, nivolumab, ELISA, interleukin-6, interleukin-15, PDL-1.

Short reports

High-dose chemotherapy and autologous stem cell rescue in children with pediatric malignancies: single center experience

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Yulia V. Dinikina, Anna Y. Smirnova, Andrey S. Egorov, Svetlana I. Chernova, Yulia K. Toshina, Margarita B. Belogurova

Department of Chemotherapy for Oncohematological Diseases and SCT, V. Almazov National Medical Research Center; Department of Oncology, Pediatric Oncology and Radiotherapy, St. Petersburg State Pediatric Medical University, St. Petersburg, Russia


Contact: Dr. Yulia V. Dinikina
E-mail: dinikinayulia@mail.ru

Prognosis of high-risk pediatric malignant tumors remains not satisfactory today. To improve the outcome of these patients (pts) high-dose chemotherapy (HDCT) with autologous stem cell rescue (ASCR) as consolidation therapy is used. Toxicity profile and survival benefits of it should be determined carefully. Our aim was to evaluate the feasibility, toxicity and tumor response of HDCT with ASCT in pts with high-risk pediatric malignancies.

Patients and methods

The retrospective review of 36 HDCT courses with ASCR in 27 patients (pts) summarizes our single-center experience from 2016 to 2019. The most frequent HDCT regimens were: Carbo/Eto, 10 cases; Thiotepa/Cyc, 8; Thiotepa/Carbo/Eto, 7; Bu(Treo)/Mel, in 6 patients. The CTCAE 5.0 criteria were used for the toxicity estimation.

Results

Median age of pts was 3 years (range 0.1-18 years), males – 70.3%. Six pts received HDCT as second-line regimen for relapsed malignancies, 10 pts underwent tandem HDC. Tumors types included: 27 – malignant CNS tumors, 3 – neuroblastoma, 3 – Ewing sarcoma, 1 – Hodgkin’s lymphoma, 1 – Non-Hodgkin’s lymphoma, 1 – Wilms tumor. In 33 cases, peripheral blood stem cells (PBSC) were used, in 3, bone marrow was transplanted. Collecting of PBSC was efficaciously carried out in all cases with a single leukapheresis procedure in 88.8%, in other – with 2 rounds. Mean number of 9.9×106 CD34+ cells/kg (range 2.74-26.6) body weight was achieved. Twelve of 27 pts were transplanted while in CR. Common toxicities included myelosuppression (100%), grade II-III stomatitis (64.4%), diarrhea grade II-III (61.1%). Among infectious episodes, the most frequent were enterocolitis (55.5%), febrile neutropenia (36.1%), bloodstream infections (13.8%). 75% of infections were microbiologically identified, thus Gram-negative bacteria predominated (60%). CMV reactivation was diagnosed in 29.6% of pts, among them: DNAaemia in 62.6%, and CMV disease, in 37.5% of the cases. 75% of pts with CMV-reactivation received antiviral therapy with ganciclovir, two pts had effective treatment (12.5%) with CMVIg. The median time to neutrophil engraftment was 11 days (range, 8-17) and to platelet recovery, 13 days (range, 9 to 29). Graft failure occurred in 5.5% of pts, and autologous cells were reinfused as a rescue. There were no cases of transplant-related deaths. CR after HDC/ASCR was achieved in 16.6% of the pts. In post-transplant period, 58.3% of the pts received radiotherapy. Median follow-up time was 13 months (range, 2-36). The 1-year OS and PFS are 81.4% and 62.9% respectively.

Conclusions

Our experience confirms that treatment regimens of HDC/ASCR demonstrate a chance of prolonged survival and are relatively well tolerated. The main profile of adverse events comprised bacterial infections with predominantly Gram-negative strains. Future prospective trials are needed to compare outcomes in pts after HDCT/ASCR with those receiving standard therapy in specific high-risk patient population.

Keywords

High-dose chemotherapy, children, autologous stem cell rescue, high-risk malignancies.


Short reports

The relationship of cytometric abnormalities and cytogenetic aberrancies in patients with myelodysplastic syndromes

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Yulia O. Davydova, Irina V. Galtseva, Elena N. Parovichnikova, Alina V. Kohno, Nikolay M. Kapranov, Ksenia A. Nikiforova, Tatiana N. Obukhova, Valentina N. Dvirnykh, Alla M. Kovrigina, Vera V. Troitskaya, Elena A. Mikhailova, Tatiana N. Moiseeva, Larisa A. Kuzmina, Elena A. Lukina, Valery G. Savchenko

National Research Center for Hematology, Moscow, Russian Federation


Contact: Dr. Yulia O. Davydova
E-mail: davydova.y@blood.ru, juliya89mur@yandex.ru

Diagnosis of myelodysplastic syndromes (MDS) could be a challenge, especially in the absence of obvious morphological features of MDS such as excess of blasts and ring sideroblasts (≥15%). Therefore, it is recommended to carry out cytogenetic, histological and multicolor flow cytometric (MFC) studies of bone marrow (BM). However, there is not enough data on the relationship of cytogenetic aberrations (CGA) and cytometric abnormalities. Our aim was to evaluate sensitivity and specificity of MFC in the MDS without excess of blasts and ring sideroblasts and to study the MFC abnormalities depending on the CGA.

Patients and methods

The study included 41 MDS patients (M/F ratio of 1:1.9; median age, 62 years): 8 MDS cases with 5q-, 4 – MDS with single lineage dysplasia; 29 had MDS with multilineage dysplasia. Of these, there were 19 patients without CGA; 8, with isolated del(5q); 7, with recurrent typical abnormalities (-7/del (7q), del(13q) , t(1; 3), or del(5q) in complex karyotype), and 7 showed non-specific aberrancies (-Y, t (2; 3), del (20q), +8). The control group included 83 patients with cytopenia (aplastic anemias, PNH, iron-deficient anemias, immune thrombocytopenias etc.). MFC examination of BM was performed according to European Leukemia Net recommendations on BD FACSCanto II. The reference values were obtained from BM data of 35 healthy donors. The final conclusion was made in accordance with the integrated flow cytometric scale (iFCS), i.e.: A, no signs of MDS; B, some signs of MDS; C, corresponds to MDS.

Results

The frequencies of B and C were higher in all MDS compared with control group, but there were no significant differences depending on CGA (Fig. 1). The sensitivity and specificity of MFC were 73.2% and 86.7%, respectively. In compartment of early precursors proportions of CD34+ and CD117+ myeloid cells were higher in MDS with typical CGA than in control group. The normal proportion of CD34+ B-cell precursors was preserved in MDS without CGA and with non-specific chromosomal aberrancies. The proportion of CD7+CD34+ was higher in MDS with typical CGA and in MDS with 5q- compared to controls, and in MDS with 5q- compared to MDS without CGA.

Davydova-fig1.jpg

Figure 1. Distribution of “ABC” scores according to an integrated flow cytometry scale

The smallest proportion of granulocytes was observed in MDS with typical GCA. The lower granularity index and increased proportion of CD10+ granulocytes, were more typical for MDS with 5q-. Abnormal maturation patterns and high expression of CD56 in granulocytes were more intrinsic for MDS with typical GCA (Table 1). There were no differences in the monocytes.

Conclusion

Even with MDS free of obvious morphological signs of MDS, MFC retains a fairly high sensitivity, regardless of CGA. MDS with 5q- was characterized by a low number of CD34+ B-cell precursors, a high proportion of CD7+ and CD117+ cells and a low granularity index. MDS with typical CGA was characterized by high proportion of CD34+ and CD117+ cells, a low proportion of granulocytes with pronounced abnormal cytometric abnormalities. This indicates that there is probably a relationship between the CGA and the MFC dysplastic features.

Keywords

Myelodysplastic syndrome, cytogenetic aberrancies, flow cytometry, dysplasia assessment.


Short reports

Results of hematopoietic stem cells transplantation with TCRαβ+/CD19+-depletion from haploidentical donors in pediatric acute leukemia patients in complete remission

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Anna A. Bogoyavlenskaya, Larisa N. Shelikhova, Maria A. Ilyushina, Zhanna B. Shekhovtsova, Dmitry N. Balashov, Irina P. Shipitsina, Darya A. Shasheleva, Rimma D. Khismatullina, Sergey L. Blagov, Anna M. Lyvshits, Konstantin V. Mytrakov, Svetlana N. Kozlovskaya, Elena E. Kurnikova, Jakov O. Muzalevsky, Alexey S. Kazachenok, Irina I. Kalinina, Natalya V. Myakova, Galina A. Novichkova, Alexey A. Maschan, Michael A. Maschan

Dmitry Rogachev National Medical Research Centre for Pediatric Hematology, Oncology and Immunology, Moscow, Russia


Contact: Dr. Anna A. Bogoyavlenskaya
E-mail: analecs@gmail.com

Relapse, graft-versus-host disease (GvHD) and associated non-relapse mortality are the main obstacles to successful HSCT in children with leukemia. αβ T cell depletion was developed to prevent GvHD and improve immune reconstitution.

Patients and methods

A total of 89 children with AL (38AML, 51ALL, 36 female, 53 male, median age 8,7y) underwent allo-HSCT from haploidentical donor between 15.06.2012 and 19.07.2017. All the patients (pts) were in complete remission (CR1=43, CR2=34, CR>2=12). 64 pts received treosulfan-based conditioning, 25 – TBI-based (all ALL). Either melphalan (n=41), or thiophosphamide (n=31), or etoposide (n=16) were added as a second agent. Fludarabine was used in all pts. Two types of GVHD prophylaxis were used: Type1 (n=18): hATG 50 mg/kg and post-HSCT tacro/mtx, type2 (n=71): thymoglobulin (rATG) 5 mg/kg, rituximab 200 mg/m2 with either bortezomib on days +2, +5 (n=62), or tacrolimus (n=6), or without them (n=3). aβT-cell depletion with CliniMACS was used in all cases. The median dose of CD34+ cells was 8x106/kg, aβT cells dose was 16x103/kg. Median time of follow-up for survivors was 3 years (range, 1.3 to 6.3).

Results

Five patients (5.6%) died before engraftment due to septic event. Primary engraftment was achieved in all evaluable pts (100%) with full donor chimerism, the median time to neutrophil and platelet recovery was 12 and 15 days. Among the whole cohort, the CI of GvHD grades II-IV and III-IV was 17.9% (95% CI:12-28) and 3.4% (95% CI:1-10), respectively. The CI for cGvHD was 19% (95% CI: 12.5-29). CI for aGvHD was significantly lower in a group with type 2 of GvHD prophylaxis: 11.2% (95% CI:6-22) vs 44% (95% CI:26-74), p=0.002. rATG was also effective in prevention of cGvHD: CI at 2 year after HSCT was 15% vs 33%, p=0.08. 3-year pTRM was 12.3% (95%CI: 7-21) and CI of relapse was 19.8% (95%CI: 13-31) without different between rATG and hATG. Three-year pEFS was 68% (95%CI:59-78), in AML pts 83% (95%CI:69-96), versus 57% (95%CI:43-70) in ALL, p=0.007, without difference between rATG and hATG. Among ALL pts, who received TBI-containing regimen, pEFS was 68% (95%CI:50-86), as compared to 46% (95%CI:27-65) among those conditioned without TBI, p=0.044 and pOS was 74% (95%CI:62-86). In the group with available immune reconstitution data (n=68) αβT cell recovery at day +30 was associated with a trend to decreased incidence of relapse, CI of relapse was 29% (95% CI:15-54) in those with αβ-T cell count below median vs 15 % (95% CI:6-38) in those with αβ-cell count above median, p=0.25 and decreased TRM: 16% (95% CI:6.5-39) among αβ T”low“ vs pTRM 0% among αβ T”high” (p=0.036). pEFS among αβ T”high” was 85% (+/-10) vs 55% (+/-14) among αβ T”low“, p=0,019, pOS 89% (+/-10) vs 59% (+/-20) respectively. Recovery of the NK and jd-T cell was not associated with improved survival.

Conclusions

We confirm that the depletion of αβT cells from haploidentical graft in combination with intensive conditioning regimen provides a high chance of long-term survival in a cohort of children with high-risk AL in remission, especially for AML pts. Our analysis suggests that early αβT cell recovery is associated with a relatively low non-relapse mortality and relapse rate.

Keywords

Acute leukemia, αβ T cell depletion, haploidentical, GvHD prophylaxis, αβ T cell recovery.

Short reports

Safety and efficacy of allogeneic stem cell transplantation after Nivolumab therapy for patients with relapsed/refractory classical Hodgkin lymphoma

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Anastasiya V. Beynarovich, Kirill V. Lepik, Nataliya B. Mikhailova, Elena V. Kondakova, Yury R. Zalyalov, Eugeniya S. Borzenkova, Elena V. Babenko, Elena I. Darskaya, Ivan S. Moiseev, Boris V. Afanasyev

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


Contacts: Dr. Anastasiya V. Beynarovich
E-mail: beynarovichn@gmail.com

The programmed-death 1 blockade with nivolumab demonstrated high efficiency in patients with relapsed and refractory Hodgkin lymphoma (rrHL) with acceptable toxicity profile. However, most of patients treated with immune checkpoint inhibitor (CPIs) will eventually progress on these therapies. Allogeneic hematopoietic stem cells transplantation (allo-HSCT) is a potentially curative option for patients with rrHL. Therefore, allo-HSCT is a consideration for selected patients with HL after treatment with CPIs. There are concerns that CPIs before allo-HSCT may increase the incidence of graft-versus-host disease, immune-related adverse events, and nonrelapse mortality (NRM). At present, there is no consensus regarding the optimal transplant strategy for patients previously treated with immune checkpoint blockade. The aim of this study was evaluate outcomes in patients with rrHL who received CPIs as a bridge to allo-HSCT.

Patients and methods

We retrospectively evaluated the results of allo-HSCT in 20 patients who had been transplanted after prior PD-1 blockade between 2017 and 2019 at the R. Gorbacheva Memorial Research Institute of Children Oncology, Hematology and Transplantology at the First St. Petersburg State I. Pavlov Medical University (CIC 725). All the patients received a reduced-intensity conditioning regimen (FluBe, fludarabine 30 mg/m2, bendamustine 130 mg/m2 per day for 3 days), and post-transplant cyclophosphamide-based GvHD prophylaxis (PTCy). Before allo-HSCT, the patients received immune checkpoint inhibitors (CPI) as a single-agent nivolumab, or in combination with brentuximab vedotin, or chemotherapy. The best registered response to PD-1 therapy was a complete response (CR) in 9 patients, partial response in 4 patients. Five patients received transplant during the disease progression, and 2 patients were transplanted in indetermined response, according to the LYRIC criteria. The patients received a median of 20 (range, 6-32) cycles of a PD-1 inhibitor. The median time from the last dose of anti-PD-1 therapy to HSCT was 83 days (range, 50-350).

Results

At the time of analysis, median follow-up was 14 months (range, 1-26 months). All the patients showed full hematological recovery after allo-HSCT. The one-year overall survival and event-free survival were 95% and 85%, respectively, whereas the one-year cumulative incidences of relapse and non-relapse mortality were 10% and 5%, respectively. Two patients with relapse after allo-HSCT were treated with donor lymphocyte infusion (DLI) in combination with chemotherapy. At the median follow-up of 30 days, all the patients remain alive. 4/20 patients developed grade 2 GvHD, and all responded to steroids. 4/20 patients developed severe, grade 3-4 GvHD, and only one patient responded to steroids. The cumulative incidence of chronic GVHD (cGVHD) was 35%, including 3 patients with severe, steroid-refractory cGVHD. There were no other immune-related adverse events. No cases of sinusoidal obstruction syndrome were observed.

Conclusions

Our study demonstrates that HSCT after PD-1 blockade is feasible and not associated with higher mortality. We suggest that prior PD-1 blockade should not be considered a contraindication to HSCT in patients with relapsed and refractory Hodgkin lymphoma. The rate of severe acute and chronic GvHD was relatively higher than previously reported for PTCy-based prophylaxis, but was manageable in the majority of cases. The time between anti-PD-1 therapy and allo-HSCT and PTCy is likely to be important in the successful outcome of the transplant.

Keywords

Hodgkin’s lymphoma, hematopoietic stem cells transplantation, allogeneic, immune checkpoint inhibitor, nivolumab, overall survival, event-free survival, graft-versus-host disease, post-transplant cyclophosphamide.

Short reports

Nursing care for patients who received monoclonal antibody therapy

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Anna A. Apostolova, Olesya V. Paina, Yulia V. Bogoslavskaya

Raisa Gorbacheva Memorial Research Institute of Pediatric Oncology, Hematology and Transplantation (CIC 725), Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia


Contact: Anna A. Apostolova, clinical nurse
E-mail: apostolova94@yandex.ru

Immunotherapy with monoclonal antibodies is a new type of leukemia treatment, gradually introduced into the practice of Russian hematological clinics. Most drugs are part of the extended access group, and do not have instructions in Russian. Aim of our work was to consider management and care of patients who received therapy with monoclonal antibodies, suggestion of recommendations for the nurses working with monoclonal antibody-based drugs.

Materials and methods

The study included 45 patients. All patients received treatment and were observed at the department of bone marrow transplantation No.1. The median of age was 8.7 years (4 months to 17 years). Acute lymphoblastic leukemia (ALL) was diagnosed in 80% (n=36), acute myeloblastic leukemia (AML) was found in 13.3% (n=6), and acute biphenotypic leukemia was detected in 6.7% (n=3) (ABL). The therapy with Blinatumomab was applied to 36 patients, Mylotarg – to 6 people, and 5 patients received Inotuzumab ozogamicin.

Results

62.2% of patients (n=28) had the febrile fever. After therapy with monoclonal AB, a compatible related hematopoietic stem cell transplantation (HSCT) was performed for 35.5% of patients (n=16), 26.7% of patients (n=12) received haploidentical HSCT, and 37.8% (n=17) did not receive HSCT. As of August 2018, 64.4% (n=29) of patients were alive.

Conclusions

Most patients were treated with monoclonal antibodies as the third line of therapy. The treatment and care of such patients require special attention. Also, in the absence of instructions in Russian, it is necessary to compile a procedure for preparing a solution with a monoclonal AB.

Keywords

Immunotherapy, Mylotarg, monoclonal antibodies, Blinatumomab, Inotuzumab.

Short reports

Impact of additional chromosomal abnormalities on survival after allo-HSCT in CML patients

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Ksenia S. Afanaseva, Elena V. Morozova, Julia J. Vlasova, Maria V. Barabanshikova, Nikolai Y. Tcvetkov, Tatiana L. Gindina, Ildar M. Barkhatov, Sergey N. Bondarenko, Ivan S. Moiseev, Elena I. Darskaya, Boris V. Afanasyev

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


Contact: Dr. Ksenia S. Afanaseva
E-mail: afanasevaksenya11@gmail.com

Widespread use of targeted therapy with 2nd and 3rd generation tyrosine kinase inhibitors (TKIs) and appropriate revision of indications for allogeneic hematopoietic stem cell transplantation (allo-HSCT) allowed to achieve optimal therapeutic responses in the majority of chronic myelogenous leukemia (CML) patients. Nevertheless, inadequate therapeutic response and relapses, which are in most cases associated with additional chromosomal aberrations (ACAs) and mutations in BCR-ABL kinase domain (BCR-ABL KD), still remain a problem leading to decreased overall survival (OS) in patients. Moreover, there is still no comprehensive concept delineating ACAs role and prognostic value on therapy responses. There are scarce data on the role of ACAs in allo-HSCT outcomes. The aim of our study was to evaluate the ACAs impact upon long-term OS in allo-HSCT recipients.

Patients and methods

This study included retrospective data on the cohort of 101 CML patients with median age of 38 years (range, 19-61) undergoing allo-HSCT from HLA-matched sibling (n=26), haploidentical donor (n=14), or unrelated donor (n=61) in the R. M. Gorbacheva Memorial Institute between 2010 and 2019. By the time of allo-HSCT, 11 of these patients (11%) were in chronic phase 1 (CP1); 58 (57%), in CP>1; 23, in acceleration phase (AP, 23%), and 9 (9%) were in blast crisis (BC). All the patients received 1st, 2nd or 3rd generation TKIs prior to allo-HSCT. 39 patients (39% of the total) had BCR-ABL KD mutations, whereas T315I mutation was found in 15 of them (15%). All the patients were divided into prognostic groups, depending on ACAs, according to revision of ACAs prognostic value on therapy results. 34 patients (34%) had any ACAs in Ph+ cells at any given moment starting from diagnosis, 22 (22%) of these patients had high risk group ACAs (single i(17)(q10), -7/del7q or 3q26.2 or as a component of complex ACAs and complex ACAs without these three chromosomal abnormalities). Sixteen patients (16%) had both BCR-ABL KD mutations and ACAs. A cytogenetic study of bone marrow was carried out according to standard cytogenetic procedure, mutation analysis was performed by Sanger sequencing. OS were estimated by Kaplan-Meier (long-rank test).

Results

Monosomy 7 (50%), del7q (14%), and i(17) (9%) were most frequent findings among the patients with high-risk group ACAs. Other complex karyotypes were found in 27% of patients. None of the patients in our study had 3q26.2 abberation. Post allo-HSCT OS in patients with any ACAs was lower compared to patients without additional aberrations, 33.5% vs 46.7%, accordingly. There was also a trend to lower OS in patients of high risk compared to low risk group, 24.6% vs 47.7%, accordingly. The long-term OS after allo-HSCT in patients who had both high-risk ACAs and BCR/ABL KD mutations was significantly lower compared to low-risk group patients: 18.2% vs 44.8%, accordingly (p=0.048). The 10-year OS was not reached in group 3. OS in group 3 was 15% lower compared to patients from high-risk group with ACAs.

Conclusion

The detection of ACAs in CML patients is considered an unfavorable prognostic factor in terms to response to TKIs therapy. However, the influence of ACAs on results of allo-HSCT has not been comprehensively characterized. In our study, we have not obtained statistically significant differences between recipients from high- and low-risk ACA groups, but were able to demonstrate that BCR/ABL KD mutations in high-risk group ACAs patients are an additional adverse prognostic factor and lead to lower OS rates in allo-HSCT recipients.

Keywords

Chronic myelogenous leukemia, Ph chromosome, additional chromosomal abnormalities, BCR-ABL, allo-HSCT.

Short reports

Toxicity and efficacy gemtuzumab ozogamicin with chemotherapy in patients with relapses or refractory acute myeloid leukemia

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Bella I. Ayubova1, Sergey N. Bondarenko1, Olga S. Uspenskaya2, Elena V. Karyagina3, Elena I. Darskaya1, Irina A. Samorodova1, Anna G. Smirnova1, Olga V. Pirogova1, Elena V. Babenko1, Ildar M. Barkhatov1, Tatyana L. Gindina1, Ivan S. Moiseev1, Alexander D. Kulagin1, Boris V. Afanasyev1

1 Raisa Gorbacheva Memorial Research Institute of Pediatric Oncology, Hematology and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia
2 Leningrad Regional Clinical Hospital, St. Petersburg
3 City Hospital No.15, St. Petersburg, Russia


Contact: Dr. Bella I. Ayubova
E-mail: bella_ayubova@mail.ru

The remission rate in patients (pts) with acute myeloid leukemia (AML) is achieved approximately in 70-80% after induction chemotherapy (CT). In pts with relapsed AML the main goal of therapy is to achieve remission followed by allogeneic bone marrow transplantation (allo-HSCT). However, the frequency of second remission rate in the refractory/relapsed AML (RR AML) does not exceed 50%. Introduction of targeted drugs is the most promising strategy in modern therapy of hematological malignancies, in particular RR AML. Gemtuzumab ozogamicin (GO) is a recombinant, humanized anti-CD33 monoclonal antibody covalently attached to the cytotoxic antitumor antibiotic calicheamicin, which effectiveness depends on more than 75% expression of CD33-glycoprotein on leukemic blasts. The aim of this work was evaluation of GO effects in combination with chemotherapy in AML treatment.

Patients and methods

The study included 75 pts with RR AML. The median age was 36 (18-76) years. 30 (40%) pts were with primary refractory (Ref) AML, 45 (60%) pts were with relapsed AML. Pts with the first relapse (Rel1) comprised 73% (33), with the second or subsequent relapse (Rel≥2), 27% (12); the early relapse (eRel) was observed in 34 (76%) of cases, and late relapse (lRel) were registered in 11 (23%) of cases. The following distribution of ELN-2017 molecular genetic risk groups was observed: favorable, 15 (20%) pts; intermediate, 28 (37%) pts; unfavorable, 32 (43%) pts. All the pts received GO at the dose of 3 mg/m2 per administration (no more than 5 mg) from 1 to 3 times [one/two times – 26 (35%) pts, three times – 49 (65%) pts], in combination with high-dose CT (HDCT) (FLAG + Ida, HAM, HDAC, ICE, HAI) or standard and low doses of CT (SLCT) (7 + 3, LDAC, AzaIdaAraC, MetA) in 46 (61%), and 29 (39%) pts, respectively. Allo-HSCT was performed after GO in 21 pts (3 – related, 7 – unrelated, 11 – haplo), including 3 second allo-HSCTs from another donor. In 10 pts GO therapy was performed in a relapse of AML after allo-HSCT. The median timing of HSCT after GO therapy was 67 (17-157) days.

Results

The 2-year OS was 34% (95%CI 17-51). The overall response (OR) was 52% (39/75): complete remission was achieved in 23 (31%) pts, complete remission with incomplete hematologic recovery – 13 (17%) pts, partial remission – 3 (4%) pts. The median duration of the OR was 81 (6-701) days. OR in the group which received one/two doses of GO was achieved in 31% (8/26), after three doses of GO, in 63% (31/49), p=0.007. In combination of GO and SLCT, the OR was 35% (10/29); with GO+HDCT, 63% (29/46), p=0.016. Dependence on the ELN 2017 risk group: in favorable group OR was obtained in 93% (14/15) pts, in the intermediate group, in 40% (14/28) pts; in unfavorable, in 34% (11/32) pts, p=0.006. OR was achieved in 30% (9/30) of pts with Ref AML, 64% (21/33) in Rel1 and 75% (9/12) in Rel>2, p=0.006. No statistically significant correlation was found in OR occurence between eRel or LRel (65% vs 73%, p=0.624), and for different CD33 expression on blast cells for the pts with CD33 levels over 60% or below 60% (40% vs 52%, 0.496). Depending on the timing of relapse: OR was 65% (22/34) in the pts with eRel, whereas it was 8/11 (73%) in pts with lRel. The pts with CD33 level on blasts of <60% OR was 40% (4/10), and with a level of >60%, 52% (32/62). The 2-year OS and 2-year RFS values of the pts with OR censored by allo-HSCT were 70% (95% CI 43-97) and 41% (95% CI 16-66), respectively. The relapse rate was 28% (95%CI 12-47). Hepatotoxicity manifested as a transient increase in transaminase levels (<10 ULN). Sinusoidal obstruction syndrome and long QT syndrome during induction did not occur in any of the patients. Neutropenia of 3-4 grade in the group with one/two doses of GO was observed in 88% (22/26), while being 98% (48/49) with three doses of GO. Neutropenia frequency of 3-4 grade and thrombocytopenia (grade 3-4 grade) in the pts who received GO +SLCT, occurred in 87% and 73%, respectively. In the GO + HDCT group, such complications were noted in all pts. Early mortality was 11% (95%CI 3-24). The causes of death were leukemia progression (4 pts), infectious complications (3 pts), intracerebral hemorrhage (1 pts). No direct association with the GO and death was observed.

Conclusions

Addition of GO to standard CT regimen for patients with RR AML demonstrated the efficacy and acceptable toxicity, which provides the basis for inclusion of GO in the combination salvage chemotherapy.

Keywords

Acute myeloid leukemia, target therapy, gemtuzumab ozogamicin.

Short reports

Pharmacokinetics of ruxolitinib administrated before and after allo-HSCT in patients with myelofibrosis

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Maria V. Barabanshikova1, Elena V. Morozova1, Ivan S. Moiseev1, Alena I. Shakirova1, Ildar M. Barkhatov1, Inna I. Ushal2, Gennadij G. Rodionov2, Sergey I. Moiseev2, Julia J. Vlasova1, Tatjana A. Rudakova1, Elena I. Darskaya1, Vadim V. Baykov1, Aleksander L. Alyanskiy1, Sergey N. Bondarenko1, Boris V. Afanasyev1

1 Raisa Gorbacheva Memorial Research Institute of Pediatric Oncology, Hematology and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia
2 Nikiforov Russian Center of Emergency and Radiation Medicine, St. Petersburg, Russia


Contact: Dr. Maria V. Barabanshikova
E-mail: mashaprian@mail.ru

Janus kinase 1 and 2 (JAK1/2) inhibitor ruxolitinib reduces splenomegaly, constitutional symptoms, bone marrow fibrosis and confers survival benefit in some MF-patients and is effectively used for the treatment of acute and chronic graft-versus-host disease (GVHD). However, there is no prospective data on the administration of ruxolitinib as GVHD prophylaxis and relapse prevention.

Patients and methods

Between 2015 and 2018, 20 patients with primary myelofibrosis (PMF), post-essential thrombocythemia (post-ET-MF) and post-polycythemia myelofibrosis (post-PV-MF) were enrolled in the pilot prospective study (NCT02806375, clinicaltrials.gov) in Pavlov First Saint Petersburg State Medical University (Table 1). All the patients were treated with pretransplant ruxolitinib with median time 7.4 months (2.6-22.3) and continued to receive ruxolitinib 45 mg/day from day -7 until day -2. Reduced intensity conditioning was performed with fludarabine 180 mg/m2 and busulfan 10 mg/kg. GVHD prophylaxis included cyclophosphamide (PTCy) 50 mg/kg on days +3, +4 and ruxolitinib 15 mg/day starting day +5 to +100. Peripheral blood was collected from 20 patients at D0, D+3, D+7, D+21, D+30, D+60. A high-performance liquid chromatography–tandem mass spectrometry (HPLC–MS/MS) method was developed for the determination of ruxolitinib in human plasma in Research Laboratory of Toxicology and Drug Monitoring, The Nikiforov Russian Center of Emergency and Radiation Medicine, EMERCOM of Russia. Analyzes were performed using HPLC Agilent 1200 with triple quadrupole mass-spectrometer Agilent 6460 with ionization – electro spray system (Agilent technology, USA).

Results

The median follow-up was 22 (3-41) months. Primary engraftment was documented in 17 patients. Median time to neutrophil engraftment, on day 27 (18-44); platelet engraftment, day 38 (15-219), RBC transfusion independence, by 59 (20-540) days. Two patients died before engraftment due to severe Pseudomonas aeruginosae sepsis (1) and gastrointestinal bleeding (1). One patient experienced poor graft function (PGF). One patient died at day+115 due to thrombotic microangiopathy and infectious complications after cyclosporine A and steroid therapy, due to acute GVHD grade 3. Fifty-five percent of the patients (11) experienced severe PGF (SPGF), as shown in Fig. 1. In two patients, SPGF resolved without changing ruxolitinib dose. Ruxolitinib dose reduction from 15 to 10 mg/day was performed in eight patients with SPGF. In one of them, SPGF resolved only at day+77, in one another – after ruxolitinib discontinuation at day+100. Three patients required СD34+ boost administration, 3 – donor lymphocyte infusion to treat SPGF.

Barabanschikova_fig01.jpg

Figure 1. Incidence of severe poor graft function was assessed after engraftment and was gradually resolved in all cases

Mild veno-occlusive disease (VOD) was observed in one patient. Sepsis was documented in 35% (7) of patients, invasive mycosis – in 1 patient. Forty five percent (9) experienced any type of the viral reactivation or infection (CMV reactivation – 6, HHV type 6 reactivation – 3, HHV type 1,2 – 2, BK – 1, parvovirus B19 – 1). Three patients experienced viral hemorrhagic cystitis. The incidence of acute GVHD grade II-IV was 25% (5), and severe GVHD grade III-IV – 15% (3). The overall rate of chronic GVHD was 40% (8), moderate – 20% (4), mild – 20% (4). All engrafted patients achieved full donor chimerism hematological, molecular remission, splenomegaly regression. Sixty five percent of patients achieved near complete bone marrow fibrosis resolution at day 398 (range 131-748). Molecular and hematological relapse was documented in 1 patient at day+665. Two-year NRM was 15% (95%CI 4-34%), 2-year OS – 85% (95%CI 60-93%), 2-year EFS – 72% (95%CI 45-87%) (Fig. 2).

Barabanschikova_fig02.jpg

Figure 2. Two-year overall and event-free survival among our patients treated with ruxolitinib

Analysis of Cthrough concentrations of ruxolitinib demonstrated accumulation of the drug from day +7 (median 17.7 ng/ml) to day +14 (median 43.8 ng/ml, p=0.028) and subsequent stable concentrations (Fig. 3). Therefore, dose reduction from 15 to 10 mg/day might be reasonable after D+20 due to achievement of stable concentration. The anticipated adverse effect of ruxolitinib upon donor stem cells was eliminated by interruption of the drug intake from day -1 to +4. Thereby, ruxolitinib value was not detected at day 0 in all samples.

Barabanschikova_fig03.jpg

Figure 3. Time dynamics of ruxolitinib concentration in the patients under study

Conclusion

Replacement of calcineurin inhibitors and mycophenolate mofetil by ruxolitinib as an additional component of PTCy-based prophylaxis resulted in low toxicity, good acute and chronic GVHD control and low relapse incidence. However, relatively high rate of SPGF should be taken in to account, which possibly might be mitigated by ruxolitinib dose reduction.

Keywords

Myelofibrosis, ruxolitinib, allogeneic hematopoietic stem cell transplantation.


Short reports

Comparative analysis of in vitro activity of a CD20-specific CART cells based on the human monoclonal antibody ofatumumab

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Tatyana N. Belovezhets

Institute of Molecular and Cellular Biology, Siberian Branch, Russian Academy of Sciences, Novosibirsk, Russia


Contact: Dr. Tatyana N. Belovezhets
E-mail: ochotanya@gmail.com

Despite the armamentarium of highly efficacious therapeutic approaches to treat patients with haemotological malignancies, the choice of therapies to help those with relapsing forms of leukemia and lymphoma has been limited. The goal of the present study was to design a novel CD20-specific CAR and perform a side-by-side comparison of its in vitro activity with that of the published CD20-specific CARs.

Materials and methods

To this end, we produced lentiviral constructs encoding two reference CARs based on the murine mAbs 1F5 and Leu16, as well as the CAR based on the sequence of a fully human mAb ofatumumab (2F2). In these CARs, structure of the hinge region was additionally varied, and alternative designs encompassing a hinge derived from human IgG or lacking a spacer altogether were tested. T cells from a healthy donor were isolated, activated, and transduced with the psedotyped lentiviral particles obtained with the above constructs.

Results

Positive control CAR T cells transduced with a “gold standard” CD19-specific CAR identical to the one used in Kymriah CAR T cell product were also produced (Fig. 1). Next, we asked whether the CAR T cells obtained displayed any differences in cytotoxicity against CD20-positive Raji cells. FACS-based cytotoxicity data shown in Figure 2 indicate that regardless of the CAR design, all CAR T cells were highly active. Nevertheless, this type of analysis merely represents a snapshot of cytotoxic activity at a selected time point (4 hrs), so we proceeded to measure the CAR T cell cytotoxicity in real time by running impedance-based cell proliferation assays (RTCA, iCelligence). Notably, RTCA platform typically requires that target cells be adherent, so we turned to HEK 293T cells overexpressing CD20 as a model. RTCA data collected over 24 hrs indicate that T cells expressing a hingeless version of the 2F2-based CAR outperform the cells expressing other CAR designs at time points past 4 hr, consistent with the FACS data.

Belovezhec_fig01.jpg

Figure 1. Primary human T cells transduced with the indicated CAR constructs display robust surface expression of the CAR

Belovezhec_fig02.jpg

Figure 2. CAR T cells show a significant cytotoxicity against target Raji cells upon 4-hour co-incubation. As negative controls, non-transduced T cells from healthy donors were used

Conclusion

Thus, our second-generation hingeless 2F2-based CAR is a promising candidate for in vivo experiments, given its pronounced CD20-specific in vitro activity and the important advantage of a fully human sequence used as the antigen-recognition module.

This study was supported by the RFBR grant № 19-415-543015 р_мол_а.

Keywords

Т cells, chimeric antigen receptor, CAR T cell therapy, ofatumumab.


Short reports

Antiviral immunity in patients after allogeneic hematopoietic stem cell transplantation during the post-engrafment period

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Anna A. Dmitrova, Vyacheslav A. Shmarov, Mikhail Y. Drokov, Larisa A. Kuzmina, Natalia N. Popova, Ekaterina D. Mikhaltsova, Vera A. Vasilyeva, Maria V. Dovydenko, Olga M. Koroleva, Darya S. Dubnyak, Zoya V. Konova, Ekaterina V. Usikova, Ulyana V. Maslikova, Olga S. Starikova, Dmitry O. Kiryukhin, Grigoriy A. Efimov, Elena N. Parovichnikova, Valery G. Savchenko

National Medical Research Center of Hematology, Moscow, Russia


Contact: Dr. Anna A. Dmitrova
E-mail: dr.admitrova@gmail.com

Cytomegalovirus (CMV) is a common virus that persists asymptomatically in 70-90% of healthy population. CMV infection is one of most frequent infectious complications in patients after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Despite treatment of CMV infection with antiviral drugs, CMV reactivation remains a major problem because it reduces the overall survival of patients after allo-HSCT.

Materials and methods

We analyzed cytotoxic T-lymphocytes (CTLs) in peripheral blood of 39 patients on day +30 after allo-HSCT. Leukocyte cell suspension after preliminary red blood cells lysis were incubated with a protein tyrosine kinase inhibitor (Dasatinib) for 1 hour at 37°С in order to increase surface expression of both TCR and CD8. CMV-specific CTLs were identified by flow cytometry using fluorochrome-labeled monoclonal antibodies against CD3, CD8, CD45 molecules, viability reagent and tetramers consisting of in-house produced MHC class I monomers loaded with one of two immunodominant epitopes of viral pp65 protein (NLVPMVATV (NLV) and TPRVTGGGAM (TPR) peptides that are present in HLA-A*02 and -B*07 antigens, respectively, bound to phycoerythrin-conjugated streptavidin. Two-platform method was used to calculate absolute CMV (NLV/TPR)-specific CD3+CD8+ cell counts in peripheral blood. The patients subjected to allo-HSCT included in the analysis were HLA-A*02- (n=22), HLA-B*07- (n=11), or HLA-A*02-B*07-positive (n=6). Their clinical and transplant characteristics are presented in Table 1.

Results

Figure 1 shows the number of CMV-specific T cells at the day +30 after allo-HSCT in patients with various modes of GVHD prophylaxis. Patients with more “aggressive” GVHD prophylaxis regimens (based on the use of high doses of post-transplant cyclophosphamide, T-cell depletion) have less CMV-specific T cells at +30 days after allo-HSCT.

Conclusion

The patients with “aggressive” GVHD prophylaxis are the most likely candidates for cell therapy. The use of prophylactic infusion of selected lymphocytes (CD45RA- fraction, CMV-specific T-lymphocytes) probably can improve the reconstitution of antiviral immunity, reduce the frequency of reactivation and increase overall survival in these categories of patients.

Keywords

Allogeneic hematopoietic stem cell transplantation, cytomegalovirus, antiviral drugs, adoptive cellular therapy, CMV-specific T cells.

Short reports

Quality of life and clinical response to brentuximab vedotin in patients with relapsed/refractory Hodgkin lymphoma (RR HL) in the real-world setting

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Tatyana I. Ionova1, Boris V. Afanasyev2, Alim A. Amdiev3, Maria I. Andrievskikh4, Elena A. Baryakh5, Eugeniy V. Vasiliev6, Mikhail V. Volkov7, Elena M. Volodicheva8, Vladimir V. Ivanov9, Oksana V. Kaverina10, Kamil D. Kaplanov11, Maria Ya. Kiseleva3, Tatiana Yu. Klitochenko11, Vyacheslav I. Kurakin12, Daria G. Lazareva10, Olga G. Larionova7, Kirill V. Lepik2, Irina B. Lysenko13, Raisa I. Minullina14, Oleg V. Mironov15, Elena N. Misyurina5, Natalia B. Mikhailova2, Nikita Eu. Mochkin16, Tatiana P. Nikitina1, Yuriy S. Osipov9, Tatiana S. Petrova14, Natalia M. Porfirieva1, Oleg A. Rykavitcin17, Rustem N. Safin14, Polina I. Simashova17, Elena G. Smirnova16, Natalia A. Trenina12, Natalia V. Fadeeva4, Gulnara N. Husainova14, Victor L. Chang15, Tatiana V. Shelekhova18, Dmitriy G. Sherstnev18

1 Multinational Center for Quality of Life Research, St. Petersburg, Russia
2 Raisa Gorbacheva Memorial Research Institute of Pediatric Oncology, Hematology and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia
3 V. M. Efetov Crimean Republican Oncology Center, Simferopol, Russia
4 Chelyabinsk Regional Clinical Center of Oncology and Nuclear Medicine, Chelyabinsk, Russia
5 City Clinical Hospital №52, Moscow, Russia
6 Regional Clinical Hospital, Krasnoyarsk, Russia
7 Primorskiy Regional Oncologic Center, Vladivostok, Russia
8 Tula Regional Clinical Hospital, Tula, Russia
9 Almazov National Medical Research Centre, Saint-Petersburg, Russia
10 Altai Regional Oncology Center, Barnaul, Russia
11 Volgograd Regional Clinical Oncological Center, Volgograd, Russia
12 Clinical Onclological Center, Omsk, Russia
13 Rostov Research Institute of Oncology, Rostov-on-Don, Russia
14 Republican Clinical Oncology Center of the Ministry of Health of the Republic of Tatarstan, Kazan, Russia
15 Tambov Regional Oncological Clinical Center, Tambov, Russia
16 N. I. Pirogov National Medical Surgical Center, Moscow, Russia
17 N. N. Burdenko Principal Military Clinical Hospital, Moscow, Russia
18 Department of Occupational Pathology, Hematology and Clinical Pharmacology, V. I. Rasymovsky Saratov State Medical University, Saratov, Russia


Contacts: Dr. Tatyana I. Ionova
E-mail: tion16@mail.ru

There is a continued unmet medical need in pts with relapsed/refractory Hodgkin’s lymphoma (RR HL). There are data available indicating that brentuximab vedotin (BV) has proven effectiveness and safety and brings considerable promise for the treatment of pts with RR HL. Information about BV treatment effectiveness and tolerability both from physician’s and patient’s perspective is worthwhile in this difficult patient population. We aimed to evaluate clinical and patient-reported outcomes in RR HL patients receiving BV as >2nd treatment line in the real world setting.

Patients and methods

Pts with RR HL who received BV 1.8 mg/kg q3w were included in the multicenter observational real-world study. Treatment response was assessed using RECIST criteria v. 1.0. Adverse events (AEs) were assessed in accordance with NCI CTCAE v. 4. For QoL assessment pts filled out RAND SF-36, for symptom assessment – ESAS-R questionnaire before BV treatment start and in 3 mos after; also pts filled out PGIC scale for self-assessment of changes in their health in 3 mos after BV treatment start. For QoL analysis paired t-test, Wilcoxon test and χ2 were used.

Results

The analysis was performed in the group of 55 pts RR HL (median age – 28 years, range 18-67, 54.5% males) who were involved in the study: 63.6% pts had advanced stage (III–IV) at diagnosis; 58.2% pts had Bsymptoms; 81.8% pts – ECOG 0-1. All the pts received a median of 3 previous treatment lines (2-10); half of pts were primary chemotherapy-resistant (49%); 25.5% pts failed to ASCT in the past. Before BV treatment start QoL was dramatically worsened, the most QoL impairment was revealed for role functioning, vitality and general health (Means: 33-48 scores out from 100 scores). All the pts experienced symptoms, 83.3% pts had moderate-to-severe symptoms (≥4 scores out from 10 scores). More than half pts had moderate-to-severe tiredness, drowsiness, lack of appetite, depression and worsened wellbeing before BV treatment start. After 3 mos of BV treatment objective response was registered in 55% pts with 27.5% complete response. Adverse events of grade I-II were reported in 8 pts (20%) and were consistent with known toxicities. In 3 mos after BV treatment start meaningful QoL Improvement and symptom decrease were revealed. Significant QoL improvement was observed for all SF-36 scales (p<0.05) excluding mental health. Integral QoL Index significantly increased at 3 mos after treatment start as compared to baseline: 0.260 at baseline vs 0.390 at 3 mos (p<0.001). QoL response to treatment in terms of stabilization or improvement was registered in 85% pts; in 50% pts the twice increase of Integral QoL Index was registered. The most pronounced meaningful improvement was revealed for role functioning scales (Δ>20.0). The severity of the vast majority of symptoms excluding depression significantly decreased during 3 mos of treatment (p<0.05). Total Symptom Score by ESAS-R significantly decreased at 3 mos after BV treatment start (35.8 vs 25.4, p<0.05). In 3 mo after BV treatment start the vast majority of pts (90%) noted the improvement of their health according to PGIC.

Conclusion

The first results obtained in this study demonstrate notable effectiveness and safety of BV as a treatment modality for RR HL in a real world setting. BV treatment was accompanied with QoL response in terms of QoL stabilization/improvement and significant decrease of symptom burden in the majority of pts already in 3 mos after the treatment was started.

Keywords

Relapsed/refractory Hodgkin lymphoma, brentuximab vedotin, quality of life, clinical response, real world setting.

Short reports

Underlying disease-specific pattern of pulmonary comorbidity factors in adults before allogeneic HSCT

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Egor A. Kulagin1, Alisa G. Volkova2, Ilya Yu. Nikolaev2, Anna G. Smirnova2, Julia D. Rabik3, Vasiliy I. Trofimov1, Boris V. Afanasyev2

1 M. Chernorutskiy Department of Hospital Therapy, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia
2 Raisa Gorbacheva Memorial Research Institute of Pediatric Oncology, Hematology and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia
3 Department of Functional Diagnostics №2, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia


Contact: Dr. Egor A. Kulagin
E-mail: egor.kulagin.spb@gmail.com

Pulmonary comorbidity is one of the key factors determining the risk of complications and non-relapse mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). The unified criteria included in the HSCT-specific index (HCT-CI) do not reflect potential disease-specific pulmonary comorbidity factors. The aim of this study was to characterize the frequency and structure of pulmonary comorbidity factors in adult patients receiving allo-HSCT for various diseases.

Patients and methods

The study included 355 patients (median age 33 years, 18-66) examined before allo-HSCT. Potential pulmonary comorbidity factors have been documented (smoking, broncho-obstructive diseases, infections, pulmonary toxic chemotherapy, mediastinal radiation therapy, etc.). Impairment of the pulmonary function tests (PFT) was documented by the parameters of FEV1 and the diffusing capacity of carbon monoxide (DLco), adjusted for hemoglobin. The analysis was carried out in groups of patients with acute myeloid and lymphoblastic leukemia (n=215), lymphomas (n=59), myelodysplastic syndrome (MDS) and myeloproliferative diseases (MPD) (n=54), acquired aplastic anemia (AA) (n=27).

Results

The factors of lung compromise before allo-HSCT were as follows: smoking (32%), broncho-obstructive diseases (5%), pulmonary infections (45%), pulmonary toxic chemotherapy (79%), immune checkpoint inhibitors (5%), previous autologous HSCT (8%) and radiation therapy (6%). Risk factors associated with prior treatment were most often realized in patients with lymphomas (pulmonary toxic chemotherapy (80%), autologous HSCT (47%), radiation therapy (32%), and immune checkpoint inhibitors (32%). Patients with acute leukemia had a high frequency of cytarabine therapy (94%). Potential drug pulmonary toxicity was not detected in AA. The frequency of infections involving lungs did not statistically significantly differ depending on the diagnosis and amounted to 30%, 47%, 51%, and 37% for AA, acute leukemia, lymphomas and MDS/MPD, respectively (p=0.1637). The proportion of smokers was slightly higher among patients with lymphomas (41%) and MDS/MPD (39%) compared with the group of acute leukemia (30%) and, especially, AA (19%) (p=0.1260). A smoker index of more than 20 packs/year was observed in 48% of smokers diagnosed with MDS and MPD, which was significantly higher than in acute leukemia (22%) and lymphomas (21%) (p=0.0461). Concomitant COPD was detected more often among patients with MDS and MPD (13%) compared with AA (0%), acute leukemia (2%) and lymphomas (5%) (p=0.0038).

A decrease in FEV1 occurred in 90 (25%) patients, including 14%, 9% and 2% of mild, moderate and severe degrees, respectively. DLco disorders were detected in 69% of patients, including 29%, 28%, and 12% of mild, moderate, and severe, respectively. More frequent bronchial obstruction according to the median FEV1/VC parameter was observed in patients with MDS and MPD, while disorders of pulmonary diffusing capacity according to the median adjusted DLco were more pronounced in patients with lymphomas.

The revealed patterns are partially explained by differences in the age of patients and the duration of the disease at the time of allo-HSCT. The median age of patients with AA, acute leukemia, lymphomas, and MDS/MPD was 28, 32, 37, and 45 years, respectively (p <0.0001). Accordingly, the median of disease duration before allo-HSCT was 1.9, 1.1, 3.6 and 1.4 years (p <0.0001).

Conclusions

Adult recipients of allogeneic HSCs have a wide range of potential causes and a high frequency of pulmonary comorbidity, which is confirmed by the PFT data. Pulmonary comorbidity factors and the PFT disorders have underlying disease-specific features.

Keywords

Allogeneic hematopoietic stem cell transplantation, adults, underlying disease, pulmonary comorbidity, pulmonary functional tests.

Short reports

The outcomes of second allo-HSCT in a cohort of 50 pediatric patients with high-risk hematological malignancies lacking response or without engraftment after the allo-HSCT

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Polina V. Kozhokar, Olesya V. Paina, Anastasia S. Borovkova, Anastasia S. Frolova, Zhemal Z. Rahmanova, Elena V. Semenova, Anna A. Osipova, Kirill A. Ekushov, Elena V. Babenko, Ludmila S. Zubarovskaya, Boris V. Afanasyev

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


Contact: Dr. Polina Kozhokar
E-mail: kozhokar.polina@gmail.com

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the standard of treatment in high risk hematological malignancies. Nevertheless, the relapse rates range from 10% to 70%. There are no optimal treatment options of the disease recurrence after allo-HSCT. Possible therapeutic options include reinduction chemotherapy, immuadoptive therapy (DLI), targeted therapy, immunotherapy (CAR-T) and second allo-HSCT. The presented study presents a retrospective single-center experience of second allo-HSCT in patients (pts) with refractory hematological diseases or graft failure in high-risk patients. The aims of this study were to evaluate the efficiency and factors affecting the outcome after second allo-HSCT in children that relapsed or had a graft failure after first allo-HSCT.

Materials and methods

We analyzed clinical outcomes in 50 children after second allo-HSCT with hematological malignancies: ALL – 24 pts, AML – 15 pts, MPL/MDS – 11 pts. First allo-HSCT was performed in 1st clinical remission – 16 pts, in 2nd, 3rd and more remissions, in 18 pts; active disease, in 16 pts. Allo-HSCT was performed from MUD in 20 pts, MRD in 14 pts, haplo-donors in 14 pts, singeneic – 2 pts. Condition regimen was MAC in 34 pts, RIC in 16 pts. Median age at the time of the first allo-HSCT was 5 y.o. (1-18), median remission duration after 1st allo-HSCT was 148 days (31-1084), median time between 1st and 2nd allo-HSCT was 7.3 month (1-48). Indications for the second allo-HSCT were relapse or progression of the disease in 36 pts, primary graft failure, in 11 pts, secondary graft rejection, in 2 pts, transplant hypofunction, in 1 case. Median age at second HSCT was 7 y.o. (1.0-20).The conditioning regimens prior to second allo-HSCT were RIC in 40 pts and MAC in 10 pts, included post-transplant cyclophosphamide on Days +3, +4 in 31 pts, ATG-based GVHD prophylaxis was used in 11 pts; combination Tx-based GVHD prophylaxis, in 38 pts; Sirolimus, in 31 pts, Cyclosporin A, in 7 pts; monothyerapy with calcineurin inhibitors, in 7 pts. The 2nd allo-HSCT was performed from haploidentical donors in 44 pts (3 pts with the same haploidentical donor, as at in 1st allo-HSCT). In other pts: MUD (without donor substitution), in 4 pts; MRD (without donor substitution), in 2 pts. Different kinds of therapy prior to second HSCT were performed in 38 pts, 12 pts were transplanted in aplasia (transplant rejection/hypofunction). FLAG/BFM was administred in 24 pts; target therapy (hypomethylating agents/monoclonal antibodies), in 7 pts, combination of chemotherapy and targeted drugs was used in 7 pts. There was no clinical response in 16 pts, 10 pts achieved remission and cytoreduction of blasts (<20% blasts) was achieved in 12 pts. Thirty-one pts underwent post-transplant therapy: immunoadoptive therapy (DLI), 9 pts; maintenance therapy/HMA/MA, 13 pts; DLI + combined CT was performed in 9 pts.

Results

Forty-four patients achieved engraftment, with median neutrophil reconstitution time of 21 days (12-41). Clinical remission was achieved in 44 pts (88%). OS in the whole group was determined by Kaplan-Meier method as 48%; LFS was 60%. Median follow-up was 3.9 years. OS in ALL group was 46.2%; in AML group, 53.3%; in myeloproliferative disorders it was 44.4%. OS in patients with graft failure/rejection was 71.4% (14 pts). OS in pts with remission, 80%, and it 50% in cases of cytoreduction. Meanwhile, OS in pts who did not achieve remission or cytoreduction was 12% (p=0.05).There was no statistically significant impact of conditioning regimen upon OS, i.e., 50% vs 47% for MAC vs RIC, respectively (p=0.6). Donor type didn’t affect OS, with or without donor substitution (50% vs 47%, p=0.4). Impact of aGVHD grade II and III upon OS was marginal: 61%, vs overall survival in pts who didn’t have clinical manifistation of aGVHD, i.e., 21% (p=0.09). Mild and moderate chronic GVHD (cGVHD) was detected in 29 pts (65%). OS in pts with cGVHD significantly exceeded OS values in cases without cGVHD (72.4% vs 12.5%, p=0.000). Causes of death were as follows: relapse/progression, in 17 pts (65%); TRM, in 9 pts (20%). OS in patients with post transplant therapy: only DLI, 55.6%; usage of HMA, target therapy/maintenance therapy, 46.2%; combination of DLI+CT, 22.2%, as compared to patients without therapy (but with aGVHD incidence) 84.6%, p=0.08).

Conclusion

Second allo-HSCT is an effective treatment option of relapse after 1st allo-HSCT. The patients that achieved remission or even blast cytoreduction prior to 2nd allo-HSCT had improved outcome. Clinical manifestation of chronic GVHD can significantly improve the OS. RIC in 2nd allo-HSCT was comparable to MAC. Post transplant therapy is required to improve results after 2nd HSCT.

Keywords

Hematopoietic stem cell transplantation, repeated, children, overall survival, clinical outcomes.

Short reports

Comparative analysis of the five-locus high-resolution HLA haplotype frequencies in the donors from two Russian registers

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Elena V. Kuzmich1, Olga A. Makarenko1, Mikhail N. Vavilov2, Elena I. Shagimardanova3, Raushania F. Gaifullina3, Anna V. Andryushkina1

1 Vasya Perevoshchikov National Bone Marrow Donors Registry, Moscow, Russia
2 Chelyabinsk State University, Chelyabinsk, Russia
3 Institute of Fundamental Medicine and Biology, Kazan (Volga Region) Federal University, Kazan, Russia


Contacts: Dr. Elena V. Kuzmich, PhD
E-mail: yelenakuzmich@gmail.com

Expansion of the Russian donor registries network is an important task seeking for increase of the unrelated donor search efficiency for Russian patients. Different strategies need to be applied for recruiting a larger number of potential donors as well for increasing HLA diversity of the pool. The aim of our study was to compare the haplotype frequencies based on five-locus high-resolution typing of potential donors from two Russian registers.

Materials and methods

A cohort of the Vasya Perevoshchikov National Bone Marrow Donors Registry (National BMDR) included 1563 donors. HLA-typing was performed by the Next Generation Sequencing (NGS technique). The data analysis was carried out by Harlequinе program version 3.5 with using the expectation-maximization algorithm for the determination of five-locus haplotype frequencies. The data published by the Bone Marrow Donors Registry of I. Pavlov First Saint-Petersburg State Medical University (Registry of I. P. Pavlov SPbSMU) were used for comparative analysis [1]. The results of HLA typing by monoallelic Sanger sequencing for 1000 donors are presented in this study.

Results

1439 different haplotypes were detected in the National BMDR donors’ group. In the cohort of the I. Pavlov SPbSMU Registry, 1352 haplotypes were defined. A*01:01:01-B*08:01:01-C*07:01:01-DRB1*03:01:01-DQB1*02:01:01 proved to be the most frequent haplotype in the comparison groups (Table 1). This haplotype is mostly represented in the majority of European populations (http://www.allelefrequencies.net). The A*02:01:01-B*13:02:01-C*06:02:01-DRB1*07:01:01-DQB1*02:02:01 haplotype is more common in the cohort of National BMDR (2.66% versus 1.01%, p=0.00005). There is a trend for higher frequency of A*03:01:01-B*07:02:01-C*07:02:01-DRB1*15:01:01-DQB1*06:02:01 haplotype in the cohort from I. Pavlov SPbSMU Registry (3.12% versus 2.43%, p=0.15). A*30:01:01-B*13:02:01-C*06:02:01-DRB1*07:01:01-DQB1*02:02:01 haplotype is common among the National BMDR donors. This haplotype is, however, not frequent among donors of I. Pavlov SPbSMU Registry.

Table 1. Most common 5-locus haplotype frequencies obtained by high-resolution typing (%) in the donors of two Russian registries

Kuzmich_tab01.jpg

Conclusion

Both registers attract volunteers from the Russian Federation regions, nevertheless, there are some differences in the five-haplotype haplotypes distribution. Collaborative work of all Russian registries is a way to increase the HLA pool represented in the Russian search systems and to increase the efficiency of the unrelated donor search for Russian patients.

Reference

E.V. Kuzmich, A.L. Alyanskiy, V.V. Ermolina et al. Experience of the sequencing method application for the immunogenetic testing of the potential donors in the Bone Marrow Donor Registry of I. P. Pavlov SPbSMU. Transfusiologiya. 2018; 19 (4):49-58 (In Russian).

Keywords

Bone marrow donor, registry, HLA haplotypes, frequency.


Short reports

Treatment of T-cell lymphomas: First Pavlov State Medical University of Saint Petersburg experience

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Elena E. Lepik, Andrey V. Kozlov, Eugenia S. Borzenkova, Yury R. Zalyalov, Kirill V. Lepik, Elena V. Kondakova, Vadim V. Baykov, Ivan S. Moiseev, Tatiana V. Schneider, Natalia B. Mikhaylova, Boris V. Afanasyev

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


Contact: Dr. Elena E. Lepik
E-mail: ee.dav@mail.ru

T-cell lymphomas represent rare and heterogeneous group of aggressive non-Hodgkin lymphomas. Almost 70% of patients undergoing first-line therapy develop a relapse or refractory disease. There are currently no standards for the treatment of relapsed/refractory T-cell lymphomas (r/r TCL). A number of novel therapy approaches are aimed for improvement of outcomes in patients with r/r TCL. This report summarizes the First I. Pavlov State Medical University experience in the treatment of patients with T-cell lymphomas.

Patients and methods

We analyzed data of 42 patients with TCL eligible for stem cells transplantation treated in First Saint-Petersburg state medical University from 2005 to 2019. Among them n=10 with anaplastic large cell lymphoma (ALK+), n=3 with anaplastic large cell lymphoma (ALK-), n=4 with angioimmunoblastic T-cell lymphoma, n=4 with hepatosplenic T-cell lymphoma, n=1 with γδ-T cell lymphoma, n=17 with PTCL not otherwise specified (PTCL-NOS), n=1 with mycosis fungoides (MF), n=1 with primary cutaneous CD4+ T-cell lymphoma and n=1 with subcutaneous panniculitis-like T-cell lymphoma (SPTCL). The median age was 43 years (range 1 – 72 years).

Median time from initial diagnosis to relapse or progression after primary therapy was 1.3 months (0-61.6). Among them, 23 patients (55%) had a primary chemoresistant disease, while other patients (n=18, 43%) had a relapse after initial treatment. The treatment was tailored according to biological factors presented in patients. In eight patients with CD30+ PTCL, brentuximab vedotine was used. One patient with ALK+ anaplastic lymphoma received ALK inhibitor crizotinib. In three patients with PD-L1 hyperexpression, nivolumab treatment was applied. The responses were consolidated with hematopoietic stem cells transplantation (HSCT). Overall 23 patients underwent SCT: high-dose chemotherapy with autologous hematopoietic SCT was performed in 16 patients, 12 patients were subject to allogeneic SCT (among them, 5 patients with relapses after auto-SCT).

Results

At the time of analysis, 32 patients remained alive. The median follow-up of surviving patients was 38 months (7-124 mo). The median overall survival was not reached, and the 3-year survival rate was 68%. The disease status at the last follow-up was complete remission (CR) in 11 patients, partial response in 3 patients, and disease progression in 21 cases. Among different factors, lower ECOG performance status at the time of diagnosis was significantly associated with adverse prognosis (p=0.05). Patients that had undergo salvage SCT showed significantly better disease status at the moment of last follow-up: 15/18 (83%) were in CR, versus 3/14 (21%) in the patients who did not undergo SCT. Progression-free survival rate was 43% for the patients with T-cell lymphoma after salvage SCT.

Conclusions

The results of analysis show that introduction of novel agents and consolidation with high-dose chemotherapy and autologous stem cells transplantation, or allogeneic stem cells transplantation in selected cases, may improve outcomes in patients with relapsed and refractory T-cell lymphomas. Brentuximab vedotine-based regimens may be successfully used as a bridge therapy before stem cells transplantation.

Keywords

T-cell lymphoma, autologous hematopoietic stem cells transplantation, allogeneic hematopoietic stem cells transplantation, Brentuximab vedotine.

Short reports

Artificial neural network in total survival predicting of multiple myeloma patients

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Maria V. Markovtseva1, Vadim V. Shishkin2

1 Ulyanovsk State University, Ulyanovsk, Russia
2 Ulyanovsk State Technical University, Ulyanovsk, Russia


Contact: Maria V. Markovtseva
E-mail: mmark7@yandex.ru

At the present stage, the prediction of total survival (TS) in multiple myeloma (MM) is usually carried out by the ISS staging system (2005). In real clinical practice, the parameters can significantly differ from the expected, while some patients overcome it, and some do not reach it.The more accurate prediction of the patients TS will optimize the therapeutic tactics choice and take into account the patient`s individual characteristics. The latter reflects the personalized medicine principles, which are the basis of modern trends in therapeutic science. The aim of this work was a study of artificial neural network (ANN), in order to predict TS in patients with MM, because the ANN has the properties of a universal classifier, clusterization and can be used for regression analysis.

Methods

There were examined 135 patients MM I-III stage with known TS data. At the time of diagnosis, gender, age, Charlson comorbidity index were taken into account, and biochemical parameters such as total protein, albumin, ß2-microglobulin, creatinine, glomerular filtration rate by MDRD, urea, uric acid, lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, total bilirubin, indirect bilirubin, glucose were studied. It was necessary to develop the ANN for TS predicting on available clinical data. The ANN based on simple perceptrons was chosen for the study, implemented in the language of artificial intelligence Python. As input, the two Excel spreadsheets were used, storing the initial data on the clinical performance of patients and data on the clinical performance of patients with known TS.

As an output document for the information system, an Excel spreadsheet was also used, in which, as a result of the ANN work, the prognostic value of the patient’s TS was determined. The information system is implemented in the form of a doctor automated place, with the ability to transfer information to the hospital information system.

Results

The two modes of operation were implemented in the system: training and forecasting. In the training mode, the results of clinical data and TS were fed to the input of the neural network and neuron weights were adjusted. ANN training was conducted on all known patients (135 people) and was repeated 100 thousand times to more accurately adjust the significance of clinical parameters affecting TS. In the forecast mode, clinical data results were fed to the input of the neural network and forecasts were formed. The ANN experimental studies are showing the results with artificial neural network (Table 1).

Table 1. The artificial neural network for myeloma: experimental testing

Markovtseva_tab01.jpg

Conclusions

The experiment showed more accurate TS prediction using ANN, compared to the currently adopted ISS system. In addition, the ANN provides for the study of existing relationships on ready-made models, does not require assumptions of the main distribution of the population, and is able to work with incomplete and fuzzy data. The use of intellectual information technologies opens up new opportunities in the study of dynamic problems in the field of medicine.

Keywords

Artificial neural network, multiple myeloma, total survival, prognosis.

Short reports

Efficacy and safety of nivolumab combinations in patients with relapsed or refractory classical Hodgkin lymphoma

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Polina V. Kotselyabina, Natalya B. Mikhailova, Kirill V. Lepik, Elena V. Kondakova, Andrey V. Kozlov, Yury R. Zalyalov, Marina O. Popova, Eugeniya S. Borzenkova, Ivan S. Moiseev, Vadim V. Baykov, Boris V. Afanasyev

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


Contact: Dr. Polina V. Kotselyabina
E-mail: jewelpoulina@gmail.com

Therapy with immune checkpoint inhibitors had shown significant activity in patients with relapsed or refractory classical Hodgkin lymphoma (r/r cHL). However, disease relapse or progression is later observed in the majority of patients. One potential approach to enhance the effect of anti-PD1 therapy is a combination with chemotherapy and targeted therapy.

The aim of this analysis was to evaluate the safety and the efficacy of nivolumab (nivo) in combination(nivo) with bendamustine (benda), vinblastine (vin) and brentuximab vedotine (BV) in patients with relapsed r/r cHL after failure of nivo monotherapy.

Patients and methods

This analysis included 3 groups of adult patients. History and clinical status of the patients at the moment of combination therapy were summarized (Table 1) and evaluated according to LYRIC criteria. The first group (n=42) received nivo and benda. Patients were treated in a 28-day cycle for up to 3 cycles. Benda (90 mg/m2) was infused on day 1.2, and nivo (3 mg/kg) on day 1 of the cycle. The second group (n=16) received nivo and vin. The patients were treated in a 14-day cycle for up to 3 cycles. Vin (10 mg/m2) was infused on day 1, 2, and nivo (3 mg/kg), on day 1 of the cycle. The third group (n=11) received nivo and BV. Patients were treated in a 28-day cycle for up to 3 cycles. BV (1.8 mg/m2) was infused on day 1, and nivo (3 mg/kg) was administered on day 1 and14 of the cycle. Toxicity was graded according to the NCI CTCAE (version 4.03). After treatment completion, the clinical responses were evaluated by PET-CT scan and assessed by investigators using LYRIC criteria.

Results

Median follow-up time for first group (nivo/benda) was 24 months (8-33) from the start of the combined treatment. Median OS was not reached, 40/42 (95%) of patients were alive at the time of analysis. Median PFS was 10.6 months (7-14) with 31% of patients alive and free of disease progression (Table 2). Adverse events (AE) during treatment were observed in 40 (95%) of patients. The most common AE were fatigue (74%), nausea (64%), dyspnea (38%). Grade 3-4 adverse events included of severe fatigue, leukopenia, thrombocytopenia, uveitis, colitis, pneumonia, infusion reaction in 1 case each. All cases of immune related AE resolved completely after treatment with glucocorticosteroids. Median follow-up time for second group (nivo/vin) was 13 months (7-16) from the start of combined treatment. All the patients were alive at the time of the follow-up evaluation. Median PFS was 10 months (1-16), 38% of patients free of disease progression. AE during treatment were observed in 12 (75%) of patients. The most common AE were fatigue (63%), nausea (38%) and pruritus (38%). Grade 3-4 AE included of pneumonia in 1 case. Median follow-up time for first group (nivo/bv) was 27 months (10-30) from the start of combined treatment. At the time of analysis 10/11 (91%) of patients were alive. Median PFS was 12 months (4-30), 45% of patients free of disease progression. AE during treatment were observed in 8 (73%) of patients. The most common AEs were creatinine increase (55%), nausea (27%), fatigue (18%). Grade 3-4 AE included 2 cases of anemia and thrombocytopenia, and leukopenia in 1 case.

Conclusions

The results of analysis demonstrate that the nivolumab combinations have promising activity in the treatment of r/r cHL with a manageable toxicity profile.

Keywords

Hodgkin’s lymphoma, classical, PD-1, salvage treatment.

Short reports

Results of a quality control implementation at the stage of dimethyl sulfoxide introduction into autologous transplant of hematopoietic stem cells

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Evgeniy V. Korotaev1, Andrey A. Stepanov1, Sergey A. Ponomarev1, Aleksey N. Kosarev1, Svetlana S. Karakalcheva1, Elena E. Zinina2

1 Yugra Research Institute of Cellular Technologies/Stem Cell Bank, Khanty-Mansiysk, Russia
2 Surgut Regional Clinical Hospital, Surgut, Russia


Contacts: Dr. Evgeniy V. Korotaev
E-mail: Korotaev_j@mail.ru

When conducting autologous hematopoietic stem cell transplantation (Auto-HSCT), the decrease in HSC safety at the stage of introducing cryoprotectant is usually not taken into account. Meanwhile, introduction of concentrated dimethyl sulfoxide (DMSO) negatively affects cell membranes, which leads to the death of HSCs. Implementation of quality control at this stage should optimize the safety of HSCs. Our aim was to improve the safety of HSCs by introducing quality control at the stage of introducing DMSO into the HSC leukoconcentrate.

Materials and methods

The study was conducted with 467 HSC concentrates obtained by means of peripheral blood leukapheresis from 86 patients with hemoblastoses. 167 concentrates comprised the group before optimization, the experimental group included 300 samples. The final DMSO concentration in cell suspension was 7.5%. Persistence of HSCs and their total colony forming activity (CFU) was expressed as a ratio of cellular indexes after addition of cryoprotectant to the cryopackage and before it. The number of HSCs was assessed as CD34+/CD45dim/7AAD phenotype by flow cytometry (ISHAGE protocol). CFU numbers in HSC population were evaluated after 14-day cultures in (Methocult H4435). Nucleated white blood cells (WBC) were routinelycounted by the light microscopy.

Results

The safety of HSCs was 79.4±29.0% in the group prior to optimization. Correlation analysis showed that the safety of HSCs, CFU and the integrity of cell membranes depends on the concentration of WBC (Fig. 1).

In the group of experiments with increased WBC counts (150-370)×109/L, the safety of HSCs averaged 35.5±28%. To resolve this problem, we suggest optimizing this stage, i.e., before cryoprotectant addition, we diluted the cell suspensions with a plasma expander (rheopolyglukin), in which the concentration of WBC was more than 150×109/L. The added rheopolyglucin volume was sufficient to adjust the WBC numbers to <150×109 cells/L. After this procedure, the safety of HSCs was increased (p≤0.05) to 91±14.0% (Fig. 2).

Conclusion

The safety of HSC at the stage of DMSO introducing depends on the concentration of HSC in the leukoconcentrate. Control of WBC numbers and dilution of leukoconcentrates may increase the HSC viability.

Keywords

Cryopreservation, dimethyl sulfoxide, quality control, hematopoietic stem cells, autologous transplantation.

Short reports

Сhronic lymphocytic leukemia treatment: a single-centre experience

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Olga B. Kalashnikova, Natalia B. Mikhailova, Elena V. Kondakova, Maria O. Ivanova, Boris V. Afanasyev

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


Contact: Dr. Olga B. Kalashnikova
E-mail: o4290@yandex.ru

Chronic lymphocytic leukemia (CLL) is the most common variant of adult leukemia, characterized by the accumulation of mature lymphocytes expressing CD19, CD23, CD20, CD5 markers. Approximately 40% of patients have a slow-progression course of CLL, with a life expectancy close to that of the general population. The presence of such group of patients justifies the waiting observation before the appearance of indications for therapy. Standard fludarabine-containing treatment regimens give good results in the first line of therapy with the median progression-free survival of 6.4 years (30.9%-12.8 years), but recurrence of the disease is inevitable for most patients. The results of chemoimmunotherapy (CIT) in the second and subsequent lines are not as successful, especially for patients with adverse prognosis (del17p/mutTP53, U-CLL, early relapse less than 24 months). Introduction of new targeted drugs allowed to improve the overall (OS) and progression-free survival (PFS) significantly in this category of patients. Purpose of the present work was to analyze the experience of therapy CLL patients in First State Pavlov Medical University.

Materials and methods

972 patients are available for the analysis of OS: 455 men, 517 women; median age is 65 years (23-94). The median period of observation was 64 months (0-367). Median OS – 80 months (6.7 years); 5-years-OS – 63%; 10-years-OS – 29%. 20% of patients had indications for therapy initiation at the time of diagnosis. Stage estimation at the moment of diagnosis is available in 798 patients (CLL – 783, LML – 15). Stage 0 was detected in 327 patients (42%) for CLL according to the Rai stage-system; therapy during the observation period was started in 58 patients (18%), median time before therapy initiation was 52 months (0.0-332). Stages I-II – 379 people (48%), of these, 244 (64%) needed treatment, the median time before therapy initiation was 11 months (0.0-227). Stages III-IV – 77 patients (10%), 72 (93.5%) of them started treatment, the median time before therapy initiation 4 months (0.0-65.4 months). Cytogenetic testing was performed in 220 patients (24.7%). Isolated del17p/mutTP53 (14%) was detected in 31 patients, complex karyotype in 16 (7%), complex karyotype with del17p/mutTP53 in 8 (4%), 2 aberrations, including del17p/mutTP53 in 23 (10%). The mutational status of IGHV was studied in 49 patients: M-CLL – 18 (37%); U-CLL – 31 (63%). Therapy was provided to 386 out of 798 patients available for analysis (48%). Of these, 64 (17%) died and 322 (83%) were alive. The median follow-up period was 78 months (ca. 6.5 years). 219 patients received only one line of therapy; 81 patients, 2 lines; 40, 3 lines; 46 patients, 4 lines.

Results

The most effective first-line treatment options were Ibrutinib (ORR, 100%) and fludarabine-containing regimens (ORR, 81%). All patients receiving Ibrutinib as the first line remained without signs of disease progression; 51 out of 96 patients who received 4 to 6 courses of fludarabine-containing regimens remain without therapy so far. In the group of patients who received more than 1 line of therapy, the median time to progression was 20 months.

The efficiency of further lines of the therapy was much lower: ORR in the 2nd and the following lines of therapy in standard CIT regimens was steadily decreasing to 64% in the second line, and to <25% in the fourth one. Only ibrutinib showed good efficacy with ORR=85% in the 2nd and up to 50% in the fourth line of therapy. Out of 52 patients treated with ibrutinib, 45 (86.5%) are still alive, and 42 of them still continue the therapy. The median follow-up upon the therapy was 31 months (0-62), OS is 82%, PFS is 77%.

Conclusions

Standard CIT modes are not effective enough in patients with relapsed and refractory CLL. Ibrutinib demonstrates a sufficiently high efficacy in this category of patients. A more thorough approach to identifying a high-risk group is needed to select the most appropriate therapeutic option.

Keywords

Chronic lymphocytic leukemia, IGHV mutation status, del17p/mutTP53, ibrutinib.

Short reports

Allogeneic hematopoietic stem cell transplantation for relapsed and refractory chronic lymphocytic leukemia: single-center experience

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Olga B. Kalashnikova, Maria O. Ivanova, Daniil I. Shmidt, Kirill V. Lepik, Eugeniya S. Borzenkova, Vadim N. Nemykin, Elena V. Kondakova, Natalya B. Mikhaylova, Elena I. Darskaya, Boris V. Afanasyev

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


Contact: Dr. Daniil I. Shmidt
E-mail: daniilshmidt1997@gmail.com

Chronic lymphocytic leukemia (CLL) is one of the most common types of lymphoma. While the development of novel agents shifted the paradigm of CLL management, allogeneic stem cell transplantation (allo-HSCT) is the only treatment that offers the possibility of a cure for relapsed/refractory (r/r) cases. Allo-HSCT is also possesses the risk of severe complications and mortality, therefore the optimization of allo-HSCT patient selection, timing, and preparative regimens is an actual problem. This report presents an analysis of Pavlov University experience in allo-HSCT for r/r CLL.

Patients and methods

Retrospective analysis included 23 patients (pts) diagnosed with CLL who underwent allo-HSCT at the First Pavlov Saint Petersburg State Medical University between 2006 and 2019. The male-to-female ratio was 20:3. Median age at HSCT was 48 years (33-66). In 30% of pts (7 pts) TP53 disruption was detected prior to HSCT, 22% (5 pts) had del11q, 48% (11 pts) had aberrant karyotypes. There was no cytogenetic data in one case. Mutation status was properly defined in 4 pts (all had unmutated IGHV). Among 9 patients with assessed CD38 expression, 6 was CD38+. One patient had Richter syndrome. One patient developed fludarabine-induced bone marrow aplasia prior to HSCT. Median number of therapy lines prior HSCT was 3 (1-8). Disease status prior to transplant was CR in 4 pts, PR in 10 pts, SD in 2 pts and PD in 7 pts. Novel agents were used as bridge therapy to allo-HSCT in 7 pts (6 received ibrutinib, 1 received venetoclax). Prior to transplant, 11 pts had resistance to chemoimmunotherapy and 2 pts were resistant to ibrutinib. Median EBMT score was 5 (1-7). The median time to transplant was 46 months (2 to 132).

Results

Eight pts (35%) had fully matched related donor HSCT, while 15 pts (65%) had unrelated donor HSCT (10 fully matched, 4 mismatches, 1 unknown). Most pts had fludarabine- and bendamustine-based conditioning regimen (65%, n=15): 7 pts had FBR (fludarabine, bendamustine, rituximab) regimen, 8 pts had Flu+Benda only. In 13 transplanted patients, cyclophosphamide was used as acute graft-versus-host disease (aGVHD) prevention strategy. aGVHD developed in 17 pts (74%). Of these, 12 pts (52%) developed grade 1-2 and 5 pts (22%) had grade 3-4 aGVHD. Median follow-up was 21 months. Median follow-up of surviving pts was 112 months. Two-year overall survival (OS) rate was 62%. Two-year progression-free survival (PFS) was 53%. Non-relapse mortality was 22% (5 pts). The factors that significantly influenced OS in univariate analysis were as follows: best response to HSCT (p<0.001), stage 3-4 aGVHD (p=0.0002), disease status at the time of HSCT (p=0.0008), fludarabine and bendamustine-containing regimen along with post-transplant cyclophosphamide (p=0.0059), сyclophosphamide-based GVHD prophylaxis (p=0.05), resistance to chemoimmunotherapy prior to HSCT (p=0.05), and del13q (p=0.0144).

Conclusion

Allo-HSCT is a feasible treatment method for patients with r/r CLL. Patients who respond to treatment tend to do better on HSCT. Disease status prior to transplant is an important modifiable prognostic factor. Fludarabine and bendamustine along with cyclophosphamide-based GVHD prophylaxis regimen improve survival. NRM is of major concern in this setting.

Keywords

Allogeneic hematopoietic stem cell transplantation, chronic lymphocytic leukemia.

Short reports

Comparison of protocols for mobilization and collection of peripheral hematopoietic stem cells by apheresis

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Denis V. Kamelskikh, Mikhail Y. Drokov, Valeriia C. Apartseva, Maxim A. Telyashov, Vera A. Vasilyeva, Larisa A. Kuzmina, Tatyana V. Gaponova

National Research Center for Hematology, Moscow, Russia


Contact: Dr. Denis V. Kamelskikh
E-mail: kamelskih@yandex.ru, apartsevavk@gmail.com

Growth of allogeneic stem cell transplantations (allo-HSCT) is a global trend. Nowadays two kinds of protocols for a mobilization and cell collecting are practiced in National Research Center for Hematology, which include implementation of apheresis for a cell collecting on the fourth day after stimulation using granulocyte colony-stimulating factor for the first protocol and a cell collecting on the fifth day for the second protocol. The dose of G-CSF is 10 mcg/kg subcutaneously once a day according to the first protocol and 5 mcg/kg subcutaneously twice a day according to the second protocol. The aim of this study was to determine an optimal protocol for mobilization and apheresis of peripheral hematopoietic stem cells for allo-HSCT.

Materials and methods

An efficiency of protocols for mobilization was analyzed retrospectively in 63 donors of allogeneic peripheral blood stem cells. Details are attached in table 1. Statistics and data interpretation was made by the IBM SPSS v.23 (USA). The Shapiro-Wilk test was applied for getting knowledge about the normality of sample distribution. According to the abnormal sample distribution usage of Mann-Whitney U-test took place. Fisher test was used for analysis of contingency tables due to a small sample size. Statistics are presented using a midpoint, minimum and maximum values.

Results

No significant differences were founded in donors’ parameters such as age, sex, height, weight, a circulating blood volume, a count of leukocytes for the first day of apheresis though it was proposed that these parameters would influence on the efficiency of mobilization. However, the higher efficiency of the mobilization using the second protocol (G-CSF 5 mcg/kg subcutaneously twice a day) was shown. This way of mobilization had yielded to collect more CD34-positive cells per one kg donor’s body weight after a procedure of apheresis on the fifth day from the beginning of the mobilization. The results are attached in Table 1.

Conclusion

The study has demonstrated that protocol for the mobilization and cell collecting, which includes use of G-CSF 5 mcg/kg subcutaneously twice a day and an implementation of apheresis on the fifth day, is more effective than the another protocol (G-CSF 10 mcg/kg subcutaneously once a day and an apheresis for a cell collecting on the fourth day after stimulation). The more efficient protocol has made it possible to achieve a larger percentage of CD34-positive cells in a peripheral blood in donors on a day of the first apheresis, a larger percentage of CD34-positive cells in a product of apheresis and as a result an increased quantity of CD34-positive cells per one kg donor’s body weight.

Keywords

Allogeneic stem cell transplantation, hematopoietic stem cells, peripheral blood stem cells, mobilization, cell collecting, apheresis, donor.

Short reports

High-dose chemotherapy (HDCT) with allogeneic hemopoietic stem cell transplantation (allo-HSCT) in very high-risk patients with neuroblastoma and Ewing sarcoma family tumors: experience of R. Gorbacheva Memorial Institute for Pediatric Oncology, Hematology and Transplantation

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Ilya V. Kazantsev, Tatiana V. Iukhta, Asmik G. Gevorgian, Polina S. Tolkunova, Andrew V. Kozlov, Daria A. Zvyagintseva, Anton V. Malorodov, Elena V. Morozova, Andrei P. Litvinov, Alexander N. Shvetsov, Polina S. Kuga, Svetlana S. Safonova, Yuri A. Punanov, Ludmila S. Zubarovskaya, Boris V. Afanasyev

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


Contact: Dr. Ilya Kazantsev
Phone: +7 (963) 348 0524
E-mail: Ilya_Kazantsev@inbox.ru

In spite of a relatively good prognosis of most neuroblastoma (NB) and localized Ewing sarcoma family tumors (ESFT), there is a subgroup of patients with unfavorable biological and clinical features, in which the outcomes are still poor. Patients with several high-risk features together with primary resistance and systemic relapse cases form an “ultrahigh” risk subgroup, in which most currently existing treatment modalities are ineffective. As allogeneic hemopoietic stem cell transplantation (allo-HSCT) and other forms of immune therapy have no cross-resistance mechanisms with chemotherapy it is a potentially effective option in these cases.

Patients and methods

The results in a consecutive cohort of 29 allo-HSCT recipients (23 patients with very high-risk NB and 6 patients with ESFT) were analyzed. The median follow-up was 18 (3-103) months. The indications for allo-HSCT were very high risk of relapse (n=2), primary chemoresistance (n=4) and systemic relapse (n=23). At the moment of allo-HSCT most patients were in complete (n=14) or very good partial remission (n=11), 4 patients had disease stabilization. In most patients (n=26) an allo-HSCT was performed from KIR-mismatched haploidentical family donor. All patients received non-myeloablative fludarabine-based conditioning regiments. In 15 patients transplant modification was used (CD34+ selection, n=3; CD3+19+ depletion, n=10; TCRαβ depletion, n=2), 14 patients received unmodified transplant with post-transplant cyclophosphamide (PTCM). In most cases one or several post-transplant interventions were performed: local control (n=4), combined chemo- and targeted therapy (n=6), donor lymphocyte infusions (n=4), donor NK-cells infusions (n=4) or other forms of immune therapy (n=6).

Results

The 2-year overall (OS) and disease-free survival (DFS) in patients with neuroblastoma were 39% and 21%, accordingly. Most (27 of 29) cases successfully engrafted, 2 patients died of transplant-related complications before engraftment. Ten patients are currently alive, 6 are in complete remission. All ESFT patients died of transplant-related complications (n=2) or disease progression (n=4). All patients with disease stabilization at the time of transplant progressed died shortly after allo-HSCT. The cumulative risk of transplant related death was 14% and death due to complications 67%, accordingly. All patients with long-term response received one or several post-transplant interventions. In spite of a longer median time to engraftment in PTCM group compared to transplant modification group (D+23 vs D+17) there was no statistically significant difference in SO, DFS, relapse or transplant complications rate between these groups.

Conclusion

Allo-HSCT combined with post-transplant therapy may yield prolonged response in some of neuroblastoma patients. The optimal post-transplant therapy regimen is still to be determined. There is still no data in favor of allo-HSCT effectiveness in the small cohort of extreme-risk Ewing sarcoma. The larger study cohort could, perhaps, provide the data on potentially sensitive ESFT patients subgroup.

Keywords

Neuroblastoma, Ewing sarcoma family tumors, ultra-high risk group, primary resistance and relapse, allogeneic hematopoietic stem cell transplantation.

Short reports

The prognostic effect of minimal residual disease detected by multiparameter flow cytometry before allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia patients in first complete remission

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Zoya V. Konova, Elena N. Parovichnikova, Irina V. Galtseva, Yulia O. Davydova, Nikolay M. Kapranov, Vera A. Vasilyeva, Maria V. Dovydenko, Olga M. Koroleva, Uliyana V. Maslikova, Natalia N. Popova, Mikhail Yu. Drokov, Ekaterina D. Mikhaltsova, Anna A. Dmitrova, Olga S. Starikova, Darya S. Dubnyak, Larisa A. Kuzmina, Valery G. Savchenko

National Research Center for Hematology, Moscow, Russia


Contact: Dr. Zoya V. Konova
E-mail: konova.zoya@gmail.com

One of the main causes of treatment failure after allogeneic hematopoietic stem cell transplantation (allo-HSCT) for acute myeloid leukemia (AML) is the disease relapse. Identification of the patients with high relapse risk after allo-HSCT is an important approach to improve the clinical outcome by administration of preemptive posttransplantation treatment. Over recent years, minimal residual disease (MRD) detected by multiparameter flow cytometry (MFC) has been widely used to identify patients with poor prognosis due to its simplicity and wide availability. Aim of this work was to evaluate the prognostic effect of MRD status before allo-HSCT on clinical outcomes for AML patients.

Patients and methods

In our statistical analysis we included 60 AML patients who underwent allo-HSCT in National Research Center for Hematology between July 2016 and July 2019. Patient’s characteristics are summarized in Table 1. All these patients were in first complete morphologic remission at the time of allo-HSCT. Bone marrow samples were obtained before allo-HSCT and were analyzed by the 6-color MFC (BD FACS Canto II, USA). Positive MRD was identified as a cell population deviating from the normal patterns of antigen expression in distinct cell lineages at specific stages of maturation for all patients. For patients with LAIP at diagnosis, positive MRD was also defined as a cell population carrying LAIP markers at diagnosis. The probabilities of overall survival (OS) and relapse free survival (RFS) were estimated using the Kaplan-Meier method.

Table 1. Patient’s characteristics

Konova_tab01.jpg

Results

13 patients (21.7%) before allo-HSCT were identified as MRD positive (MRD+). Subsequently 6 of them (46.2%) relapsed. The relapse was also registered in 2 out of 47 MRD negative (MRD-) patients (4.3%). Statistical analysis revealed significant differences between MRD- and MRD+ patients: MRD+ had much worse OS (42% vs 89%, p=0.0120, Fig. 1A) and RFS (32% vs 94%, p<0.0001, Fig. 1B). The relapse probability was extremely high among MRD+ patients (68% vs 6%, p<0.0001, Fig. 1C).

Conclusions

MRD detected by MFC is a strong prognostic factor of increased risk of relapse and may reflect OS and RFS in patients with AML after allo-HSCT. Despite the presence of morphological CR before allo-HSCT, MRD persistence before allo-HSCT was associated with high relapse risk. Accordingly, testing for MRD before allo-HSCT may help to identify a subgroup of patients who need preemptive treatment after allo-HSCT.

Disclosures

No relevant conflicts of interest to declare.

Keywords

Minimal residual disease, allogeneic hematopoietic stem cell transplantation, acute myeloid leukemia.


Short reports

Assessment of hematopoetic stem cell molecular engraftment based on STR analysis

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Saniya A. Abdrakhmanova, Zhulduz Zh. Zhanzakova, Aida A. Turganbekova, Zhazira K. Saduakas

Scientific Production Center of Transfusiology, Ministry of Healthcare, Nur-Sultan, Republic of Kazakhstan


Contact: Dr. Saniya A. Abdrakhmanova
E-mail: A.saniya@mail.ru

Donor chimerism monitoring is the main way to control the process of hematopoietic engraftment. Assessment of the engraftment course in oncohematological patients is important for the choice of treatment strategy and further management of the patient.

Patients and methods

In order to assess engraftment, 38 patients with oncohematologic diseases were analyzed who underwent 38 hematopoietic stem cell transplantations (HSCT) from 2017 to 2019, including 13 women (34%) and 25 men (66%). The median age at the time of transplantation was 33 (2-47) years. The gender distribution among donors was 19 women (50%), and 19 males (50%). The patients were divided into two groups: 26 patients (68%) after allogeneic compatible HSCT (allo-HSCT), and 12 patients (32%), after haploidentical HSCT (haplo-HSCT). The donor chimerism was determined by polymerase chain reaction of short tandem repeats (STR-PCR) in peripheral blood on days +30, +60, and +100 after HSCT. The study was conducted more frequently in cases of mixed chimerism detection. For amplification of STR markers, the commercial AmpFlSTR® Identifiler® Plus Kit (UK) kit was used; PCR products were separated by capillary electrophoresis on a 3500 Genetic Analyzer (HITACHI Applied Biosystems, Japan). The alleles were identified using the Chimer Marker v3.1.0 software.

Results

Concerning ratios of donor/recipient pairs, the female donor/male recipient combinations (15 pairs), and male donor/male recipient transplants (13 pairs) were more common than male donor/female recipient and female donor/female recipient combinations. When assessing the stem cell engraftment, all markers were informative for the studied donor/recipient pairs. According to the degree of significance, the loci in the allo-HSCT pairs were distributed as follows: D13S317 / D18S51> D5S818 / D16S539 / D21S11 /D7S820> TH01 / AMEL / FGA / D8s1179 / D2S1338> CSF1PO / D3S1358 / TPOX> D19S433 / W19A. The numbers of informative genetic loci in the donor/recipient pairs varied from 4 to 13. For haplo-HSCT pairs, the distribution of loci was as follows: D13S317 / D7S820 / AMEL> D16S539 / D2S1338 / D18S51> D5S818 / FGA>D8s1179 / D21S11 / CSF1PO / D3S1358 / VWA> D19S433> TH01 / TPOX, with 1 to 8 informative loci. According to the results of our analysis, complete donor chimerism (99-100%) in haplo-HSCT was found in 2 patients (18%) on the day +30 after HSCT, according to HLA matching degree of 5/10 and 6/10; the remaining ten cases showed mixed chimerism. On day +100, 2 out of 10 reached full donor chimerism. Complete chimerism was revealed in 11 pairs with allo-HSCT, among them, the HLA matching degree was 10/10 in 9 pairs, and 5/10, in two pairs. By 100 days, 3 patients developed a transition from mixed to complete chimerism.

Conclusion

The analysis showed an association between HLA typing results, and the type of performed HSCT (allo- or haplo-HSCT). Chimerism monitoring after transplantation is an integral part of more effective prognosis for relapse and factor of improved survival for the patients after HSCT.

Keywords

Chimerism, engraftment, hematopoietic stem cell transplantation, STR loci.