Successful Second Allogeneic Stem Cell Transplantation From a Sibling Donor for Relapse of Myelodysplastic Syndrome in a Recipient of a Renal Transplant From His Mother: Case Report

There have been few reports on allogeneic stem cell transplantation in patients who have previously undergone solid organ transplantation. The clinical course of such patients is not yet well recognized. Therefore, appropriate immunosuppressive prophylaxis for the rejection of a solid organ graft or for graft-versus-host disease has not yet been established. We present the case of a successful allogeneic stem cell transplantation in a patient who relapsed after a first allogeneic stem cell transplantation for myelodysplastic syndrome and who had previously undergone renal transplantation. The prophylaxis in this case for graft-versus-host disease and rejection of the transplanted kidney was mycophenolate mofetil and tacrolimus. No hyperacute rejection of the transplanted kidney was observed. However, the patient's renal function deteriorated after the cessation of the mycophenolate mofetil and the reduction of the tacrolimus. This deterioration seemed to be due to rejection with humoral immunity of donor lymphocytes, and we were able to control it by resuming the mycophenolate mofetil and local graft irradiation.

Assessment of the safety and efficacy of percutaneous cryoablation for lung tumors

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Background: Percutaneous cryoablation using high resolution fluoroscopic CT guidance under local anesthesia offers a potential tool for local control of lung tumors in combination with systemic treatments. In this study, we retrospectively analyzed the safety, and efficacy of percutaneous cryoablation for lung tumors (PCLT). Methods: This study was approved by the institutional review board. From October 2002, PCLT was performed in patients who either did not oncologically fulfill the indications for resection, or refused resection. CT scan was examined every 3 months after PCLT. >20% increase in the treated lesion size was diagnosed as local failure. Survival analysis was done by Kaplan-Meier. Results: There were 147 patients (95 male, 52 female, mean age 60, 20 primary lung cancer, metastases; 29 of lung cancer, 35 of colorectal cancer, 63 of other sites). 251 sessions were done for 462 tumors. Mean tumor diameter was 18.3mm. PCLT was well tolerated in most patients. In 1 case, broncho-thoracic fistula occurred in the treated region which lead to empyema. Other complications were pneumothorax (153 sessions, 61%, chest tube required in 23 sessions), pleural effusion (160 sessions, 64%), and transient hemoptysis (82 sessions, 33%). Overall one- and two-year local control rates were 81.0% and 59.1%, respectively. Overall one- and two-year survival rates were 80.0% and 54.5%, respectively. In the 1–20 mm sized (n=362) vs. over 21mm sized (n=100) lesions, the local control rates at one year were 84% vs. 56% (p=0.0007), and at two years were 63% vs. 35% (p=0.017), respectively. There were no differences in local control between primary and metastatic tumors, carcinomas and sarcomas. Survival of patients whose lesions were limited to 1–20mm (n=89) was prolonged vs. those who had at least one over 21mm lesion (n=58) (p=0.01). However, one, and two-year survival rates did not differ significantly between these groups (one-year; 85.5% vs. 71.7% (p=0.07), two-year; 60.7% vs. 46.5% (p=0.16)). Conclusions: PCLT was minimally invasive and safe. 1–20mm tumors were good candidates. Contribution of PCLT to survival was not clear in this mixed patient population. To improve local control in over 20 mm tumors, we are computer simulating freezing kinetics to optimize the number and the positioning of the probes.

No significant financial relationships to disclose.

Unrelated cord blood transplantation after myeloablative conditioning in adults with ALL

We analyzed the disease-specific outcomes of adult ALL treated with cord blood transplantation (CBT) after myeloablative conditioning. Between October 2000 and November 2007, 27 adult patients with ALL were treated with unrelated CBT. All patients received four fractionated 12 Gy TBI and chemotherapy as myeloablative conditioning. The median age was 36 years, the median weight was 57 kg and the median number of nucleated cells was 2.47 x 10(7)/kg. All patients received a single and HLA-mismatched cord blood unit. The cumulative incidence of neutrophil recovery at day 30 and platelet recovery at day 200 was 92.6 and 92.3%, respectively. With a median follow-up of 47 months, the probability of EFS at 5 years was 57.2%. The 5-year cumulative incidence of TRM and relapse was 3.7 and 27.4%, respectively. These results suggest that unrelated CBT after myeloablative conditioning could be safely and effectively used for adult patients with ALL.

No occurrence of Pneumocystis jiroveci (carinii) pneumonia in 120 adults undergoing myeloablative unrelated cord blood transplantation

The incidence of pneumonia caused by Pneumocystis carinii (PCP) (organism now renamed Pneumocystis jiroveci) during the early period after cord blood transplantation (CBT) was studied in 120 adults. Initially 89 patients (74%) received oral administration of 2 single-strength trimethoprim-sulfamethoxazole (TMP-SMZ) tablets twice daily from day -21. In 45 of 89 patients (51%), TMP-SMZ administration for a scheduled duration was completed. In the remaining 44 patients (49%), however, TMP-SMZ administration was discontinued prior to day -3 because of toxicity. Among these patients, 42 subsequently received aerosolized pentamidine (AP) on a median of day -13 (range, -20 to -6). Thirty-one patients (26%) received AP without TMP-SMZ administration on a median of day -14 (range, -21 to -9). None of the 120 patients were diagnosed with PCP within 100 days or 2 years after CBT; however, one patient who received AP before CBT but no prophylaxis after CBT developed cerebral toxoplasmosis on day +91. Pre-transplant prophylaxis against PCP did not significantly affect transplantation-related mortality or disease-free survival at 2 years after CBT. The results suggest that PCP during the early period after CBT can be effectively prevented by any pre-transplant prophylactic method.

Risk factors for acute graft-versus-host disease after allogeneic hematopoietic stem cell transplantation: retrospective analysis of 73 patients who received cyclosporin A

Cyclosporin A (CsA) has been used most widely as an immunosuppressive agent for preventing graft-versus-host disease (GVHD). To explore the risk factors including CsA blood levels for grades II-IV acute GVHD, we retrospectively analyzed the data of patients who underwent allogeneic hematopoietic stem cell transplantation in our hospital between March 1989 and July 2001. Seventy-three patients (47 males and 26 females) received CsA and short-term methotrexate for GVHD prophylaxis. CsA 1.5 mg/kg was administered as a 3-h infusion twice daily from day 1 until the patient recovered from the toxic gastrointestinal complication. Methotrexate was given at a dose of 15 mg/m(2) on day 1 and 10 mg/m(2) on days 3, 6 and 11. Grades II-IV acute GVHD occurred in 18 patients (24.7%). Multivariate Cox regression analysis revealed that higher C(5) (the whole-blood CsA concentration at 5 h after the start of infusion) before the onset of acute GVHD reduced the onset of grades II-IV acute GVHD with a hazard ratio of 0.994 (95% confidence interval 0.989-0.999) for every increase of 1 ng/ml. Our data indicate that inadequate exposures of CsA can be a vital risk for developing acute GVHD. From our results, we consider that precise monitoring of CsA concentrations and adjustment of CsA dose using the concentration may be effective to prevent the onset of severe acute GVHD. To confirm this finding, further prospective study will be needed.

Impact of ABO incompatibility on engraftment and transfusion requirement after unrelated cord blood transplantation: a single institute experience in Japan

The impact of ABO incompatibility between donor and recipient on engraftment and transfusion requirement was studied in 95 adults who underwent unrelated cord blood transplantation (CBT). The patients included 27 ABO-identical, 29 minor, 21 major and 18 bidirectional ABO-incompatible recipients. Neutrophil engraftment did not differ between ABO-identical/minor ABO-incompatible and major/bidirectional ABO-incompatible recipients (hazard ratio (HR) 1.17, P=0.48). Cumulative incidence of platelet engraftment in ABO-identical/minor ABO-incompatible recipients was higher than in major/bidirectional ABO-incompatible recipients (HR 1.88, P=0.013). In addition, fewer platelet transfusions were required during the first 60 days after CBT in ABO-identical/minor ABO-incompatible recipients (HR 0.80, P=0.040). RBC engraftment did not differ between the two groups (HR 1.25, P=0.33). However, fewer RBC transfusions were required in ABO-identical/minor ABO-incompatible recipients than in major/bidirectional ABO-incompatible recipients (HR 0.74, P<0.005). No patients developed pure red-cell aplasia after CBT. These results indicate that ABO incompatibility affected platelet engraftment and transfusion requirement of RBC and platelet in CBT recipients. Further studies including larger patient numbers are required to elucidate the impact of ABO incompatibility on the clinical outcome of CBT.

Effect of prostaglandin E2, lipopolysaccharide, IFN-gamma and cytokines on the generation and function of fast-DC

BACKGROUND

Recent reports have described a new strategy for differentiation and maturation of monocyte-derived DC within only 48 h of in vitro culture (fast-DC). We compared the ability of various maturation stimuli with the generation of Ag-specific T-cell responses and generation of functional fast-DC.

METHODS

CD14+ cells were treated with GM-CSF and IL-4 for 1 day to generate immature DC, and were then matured with either inflammatory cytokines or a combination of lipopolysaccharide (LPS) and INF-gamma. Mature DC were then used to study the effect of prostaglandin E2 (PGE2) on the stimulatory function of fast-DC.

RESULTS

fast-DC were CD14- and expressed mature DC surface markers, and maintained this phenotype after withdrawing the cytokine from culture. Treatment of fast-DC with a combination of LPS and INF-gamma promoted the maturation of highly uniform fast-DC. The T-cell proliferative response to DC was enhanced by inclusion of PGE2 in the MCM-mimic (TNF-a, IL-1 a, IL-6, PGE2) cocktail.

DISCUSSION

fast-DC are very effective; they not only reduce the labor, cost and time required for in vitro DC development, but may also represent a model more closely resembling DC differentiation from monocytes in vivo.