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Takahashi N, Mochizuki K, Kobayashi S, Ohara Y, Kudo S, Saito Y, Ikeda K, Ohto H, Kikuta A, Sano H. T-Cell-Replete Haploidentical Hematopoietic Stem Cell Transplantation for a Patient With Tcf3-Hlf-Positive Acute Lymphoblastic Leukemia Extramedullary Relapse After Unrelated Bone Marrow Transplantation. J Pediatr Hematol Oncol 2023; 45:e419-e422. [PMID: 36162014 DOI: 10.1097/mph.0000000000002555] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 07/18/2022] [Indexed: 11/26/2022]
Abstract
TCF3-HLF-positive B-cell precursor acute lymphoblastic leukemia (BCP-ALL) has an extremely poor prognosis. A 2-year-old boy with TCF3-HLF-positive BCP-ALL had an isolated extramedullary relapse in multiple bones after allogeneic hematopoietic stem cells transplantation (HSCT) from a human leukocyte antigen-matched unrelated donor. In this study, he received a T-cell-replete haploidentical HSCT (TCR-haplo-HSCT) from his father when in nonremission state, which resulted in a sustained complete remission for over 3 years. Immune therapies for patients with an extramedullary relapse of TCF3-HLF-positive BCP-ALL have been attempted; however, long-term efficacies of these therapies remain unknown. Our TCR-haplo-HSCT may be an effective therapeutic option for such patients.
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Affiliation(s)
| | | | | | | | | | - Yuya Saito
- Department of Hematology/Oncology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kazuhiko Ikeda
- Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Fukushima
| | - Hitoshi Ohto
- Department of Hematology/Oncology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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Evaluation of a quantitative PCR-based method for chimerism analysis of Japanese donor/recipient pairs. Sci Rep 2022; 12:21328. [PMID: 36494422 PMCID: PMC9734659 DOI: 10.1038/s41598-022-25878-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Chimerism analysis is a surrogate indicator of graft rejection or relapse after allogeneic hematopoietic stem cell transplantation (HSCT). Although short tandem repeat PCR (STR-PCR) is the usual method, limited sensitivity and technical variability are matters of concern. Quantitative PCR-based methods to detect single nucleotide polymorphisms (SNP-qPCR) are more sensitive, but their informativity and quantitative accuracy are highly variable. For accurate and sensitive chimerism analysis, a set of KMR kits (GenDx, Utrecht, Netherlands), based on detection of insertions/deletions (indels) by qPCR, have been developed. Here, we investigated informativity and validated the accuracy of KMR kits in Japanese donor/recipient pairs and virtual samples of DNA mixtures representative of Japanese genetic diversity. We found that at least one recipient-specific marker among 39 KMR-kit markers was informative in all of 65 Japanese donor/recipient pairs. Moreover, the percentage of recipient chimerism estimated by KMRtrack correlated well with ratios of mixed DNA in virtual samples and with the percentage of chimerism in HSCT recipients estimated by STR-PCR/in-house SNP-qPCR. Moreover, KMRtrack showed better sensitivity with high specificity when compared to STR-PCR to detect recipient chimerism. Chimerism analysis with KMR kits can be a standardized, sensitive, and highly informative method to evaluate the graft status of HSCT recipients.
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HLA-haploidentical peripheral blood stem cell transplantation following reduced-intensity conditioning with very low-dose antithymocyte globulin for relapsed/refractory acute leukemia in pediatric patients: a single-institution retrospective analysis. Int J Hematol 2022; 115:406-413. [PMID: 35028882 DOI: 10.1007/s12185-021-03270-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 10/19/2022]
Abstract
The prognosis of relapsed/refractory (R/R) pediatric acute leukemia is extremely poor. We retrospectively reviewed 20 consecutive pediatric patients with R/R acute leukemia who underwent a first HLA-haploidentical peripheral blood stem cell transplantation following reduced-intensity conditioning (haplo-RIC-PBSCT) with very low-dose antithymocyte globulin (ATG) between 2012 and 2019. Of these 20 patients, 7 patients had acute lymphoblastic leukemia, and 13 had acute myeloid leukemia. At the time of haplo-RIC-PBSCT, 15 patients had active disease. The median follow-up duration for survivors was 56 months (range 22-108 months). Graft-versus-host disease (GVHD) prophylaxis consisted of tacrolimus, short-term methotrexate, methylprednisolone, and ATG 1.25 mg/kg on day-2. The 2-year cumulative incidence of transplant-related mortality and relapse were 5.0% [95% confidence interval (CI) 0.7-30.5%)] and 57.8% (95% CI 37.4-79.6%), respectively. Among the 20 patients, 16 (80.0%) developed grade III-IV acute GVHD, and 2 developed severe chronic GVHD. The 2-year event-free survival and overall survival rates were 40.0% (95% CI 19.3-60.0%) and 50.0% (95% CI 27.1-69.2%), respectively. Although the sample size is small, the survival outcomes of the present study are encouraging.
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Kobayashi S, Sano H, Mochizuki K, Ohara Y, Takahashi N, Kudo S, Ikeda K, Ohto H, Kikuta A. Effects of second transplantation with T-cell-replete haploidentical graft using low-dose anti-thymocyte globulin on long-term overall survival in pediatric patients with relapse of leukemia after first allogeneic transplantation. Int J Hematol 2021; 115:414-423. [PMID: 34822127 DOI: 10.1007/s12185-021-03266-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the preferred treatment for children with high-risk hematologic malignancies, but post-allo-HSCT relapse has a poor prognosis and limited treatment options. We evaluated the feasibility, outcome, and risk factors influencing survival after T-cell-replete haploidentical HSCT with low-dose anti-thymocyte globulin (ATG) in 30 patients with post-allo-HSCT relapse of acute lymphoblastic leukemia and acute myeloid leukemia. Overall, 50% of the patients had complete remission (CR) before the second transplant and the overall survival (OS) rate was 52%. In surviving patients (median follow-up 614 days), Kaplan-Meier analysis revealed estimated 2-year leukemia-free survival and OS rates of 48.1% and 61.1%, respectively. Cumulative incidences of 2-year non-relapse mortality and relapse were 24.7% and 36.3%, respectively. Achieving CR before the second allo-HSCT was a predominant independent prognostic factor identified in the multivariate analysis, with a significantly improved 2-year OS rate of 86.7%. T-cell-replete haplo-HSCT with low-dose ATG for second allo-HSCT may benefit a selected patient population.
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Affiliation(s)
- Shogo Kobayashi
- Department of Pediatric Oncology, Fukushima Medical University School of Medicine, 1 Hikariga-oka, Fukushima City, Fukushima, 960-1295, Japan.
| | - Hideki Sano
- Department of Pediatric Oncology, Fukushima Medical University School of Medicine, 1 Hikariga-oka, Fukushima City, Fukushima, 960-1295, Japan
| | - Kazuhiro Mochizuki
- Department of Pediatric Oncology, Fukushima Medical University School of Medicine, 1 Hikariga-oka, Fukushima City, Fukushima, 960-1295, Japan
| | - Yoshihiro Ohara
- Department of Pediatric Oncology, Fukushima Medical University School of Medicine, 1 Hikariga-oka, Fukushima City, Fukushima, 960-1295, Japan
| | - Nobuhisa Takahashi
- Department of Pediatric Oncology, Fukushima Medical University School of Medicine, 1 Hikariga-oka, Fukushima City, Fukushima, 960-1295, Japan
| | - Shingo Kudo
- Department of Pediatric Oncology, Fukushima Medical University School of Medicine, 1 Hikariga-oka, Fukushima City, Fukushima, 960-1295, Japan
| | - Kazuhiko Ikeda
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Hitoshi Ohto
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Atsushi Kikuta
- Department of Pediatric Oncology, Fukushima Medical University School of Medicine, 1 Hikariga-oka, Fukushima City, Fukushima, 960-1295, Japan
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Kada A, Kikuta A, Saito AM, Kato K, Iguchi A, Yabe H, Ishida H, Hyakuna N, Takahashi Y, Nagasawa M, Hashii Y, Umeda K, Matsumoto K, Fujisaki H, Yano M, Nakazawa Y, Sano H. Single-Arm Non-Blinded Multicenter Clinical Trial on T-Cell-Replete Haploidentical Stem Cell Transplantation Using Low-Dose Antithymocyte Globulin for Relapsed and Refractory Pediatric Acute Leukemia. Kurume Med J 2021; 66:161-168. [PMID: 34421094 DOI: 10.2739/kurumemedj.ms663004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Although approximately 70% of pediatric hematological malignancies are curable, approximately 30% remain fatal. No standard treatment is available in patients showing relapse and those with refractory disease. Although different methods are adopted in different hospitals, its efficacy is extremely limited. In recent years, haploidentical stem cell transplantation, involving high-dose cyclophosphamide administration post-transplanta tion, has been used, mainly in adults; however, its application is limited to removal of alloreactive T cells. Multicenter single-arm clinical trials of T-cell replete haploidentical stem cell transplantation (TCR-haplo-SCT) will be conducted in children with relapsed and refractory acute leukemia. After myeloablative conditioning using total body irradiation or busulfan, intensive graft versus host disease prophylaxis is administered, consisting of low-dose rabbit anti-human thymocyte globulin, tacrolimus, methotrexate, and prednisolone. An external control group is set up for the study. The treatment period is around 3 months, and the follow-up period is 2 years from transplantation completion.The aim of this study is to verify the efficacy and safety of TCR-haplo-SCT and present it as a new immune cell therapy for improving survival rate in children with relapsed and refractory acute leukemia.
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Affiliation(s)
- Akiko Kada
- Clinical Research Center, National Hospital Organization Nagoya Medical Center
| | - Atsushi Kikuta
- Department of Pediatric Oncology, Fukushima Medical University Hospital
| | - Akiko M Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center
| | - Koji Kato
- Department of Hematology and Oncology, Children's Medical Center, Japanese Red Cross Nagoya First Hospital
| | | | - Hiromasa Yabe
- Department of Cell Transplantation and Regenerative Medicine, Tokai University School of Medicine
| | | | | | - Yoshiyuki Takahashi
- Department of Pediatrics/Developmental Pediatrics, Nagoya University Graduate School of Medicine
| | | | - Yoshiko Hashii
- Department of Pediatrics, Osaka University Graduate School of Medicine
| | | | - Kimikazu Matsumoto
- Children's Cancer Center, National Center for Child Health and Development
| | - Hiroyuki Fujisaki
- Department of Pediatrics Hematology/Oncology, Osaka City General Hospital
| | | | - Yozo Nakazawa
- Department of Pediatrics, Shinshu University School of Medicine
| | - Hideki Sano
- Department of Pediatric Oncology, Fukushima Medical University Hospital
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Takahashi N, Mochizuki K, Sano H, Kobayashi S, Ohara Y, Ikeda K, Ohto H, Kikuta A. Decline of serum albumin precedes severe acute GVHD after haploidentical HSCT. Pediatr Int 2021; 63:1048-1054. [PMID: 33253440 DOI: 10.1111/ped.14564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 10/26/2020] [Accepted: 11/25/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Haploidentical hematopoietic stem cell transplantation (HSCT) is a useful therapy for relapsed/refractory acute leukemia or lymphoma because of the strong graft-vs-leukemia (GVL) effect. However, it is often accompanied by severe acute graft-versus-host disease (aGVHD), which is the most serious complication after haploidentical HSCT. Thus, it is important to control the severity of aGVHD while maintaining the GVL effect. In our experience of pediatric haploidentical HSCT, it takes several days for aGVHD to become severe after the appearance of initial symptoms, mostly skin rashes. In this study, we aimed to identify useful biomarkers at the onset of aGVHD that predict subsequent development of severe aGVHD. METHODS Forty-five consecutive children with relapsed/refractory acute leukemia or lymphoma who developed aGVHD after haploidentical HSCT were enrolled. We analyzed possible biomarkers from samples collected at the onset of acute GVHD. RESULTS Nineteen patients developed grade 1-2 aGVHD, and 26 patients developed grade 3-4 aGVHD. There was no significant difference in patient characteristics between the two groups. Transplant-related mortality occurred only in the grade 3-4 aGVHD group (34.5%). Multivariate analysis revealed that serum albumin was an independent biomarker for predicting the severity of aGVHD (P = 0.009). The area under the receiver operating characteristic curve of serum albumin was 0.864. CONCLUSIONS The serum albumin level at the onset of aGvHD could be a useful biomarker for the development of subsequent severe aGVHD in pediatric patients after haploidentical HSCT.
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Affiliation(s)
- Nobuhisa Takahashi
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima City, Japan
| | - Kazuhiro Mochizuki
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima City, Japan
| | - Hideki Sano
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima City, Japan
| | - Shogo Kobayashi
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima City, Japan
| | - Yoshihiro Ohara
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima City, Japan
| | - Kazuhiko Ikeda
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University Hospital, Fukushima City, Japan
| | - Hitoshi Ohto
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University Hospital, Fukushima City, Japan
| | - Atsushi Kikuta
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima City, Japan
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Sano H, Mochizuki K, Kobayashi S, Ohara Y, Takahashi N, Kudo S, Ikeda K, Ohto H, Kikuta A. T-cell replete haploidentical stem cell transplantation with low dose anti-thymocyte globulin for relapsed/refractory Ewing sarcoma family tumors. Cancer Rep (Hoboken) 2021; 5:e1519. [PMID: 34291886 PMCID: PMC9327660 DOI: 10.1002/cnr2.1519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/02/2022] Open
Abstract
Background Despite intensive multimodal therapies, the prognosis of relapsed/ refractory Ewing sarcoma family tumors (RR‐ESFTs) is dismal. Some case reports using allogeneic stem cell transplantation (allo SCT) for RR‐ESFTs have been reported, however, the efficacy of allo SCT is yet to be established. Aim The purpose of this study was to evaluate the response and toxicity of T‐cell replete haploidentical SCT (TCR‐haplo‐SCT) in RR‐ESFTs. Methods and results In this study, we retrospectively analyzed six patients with RR‐ESFTs who received TCR‐haplo‐SCT. Four patients had relapsed and two patients had refractory Ewing sarcoma. Before the TCR‐haplo‐SCT, all patients received a reduced intensity‐conditioning regimen containing fludarabine, melphalan, and low‐dose rabbit anti‐thymocyte globulin (2.5 mg/kg), as well as graft‐versus‐host disease (GVHD) prophylaxis, which consisted of tacrolimus, methotrexate, and prednisolone. Primary neutrophil engraftment was achieved in all the patients. Four patients developed acute GVHD (aGVHD) (grade I, 1; grade II, 1; grade III, 2), and two patients developed chronic GVHD (cGVHD). Among the four that developed aGVHD, three survived for 14, 116, and 129 months without relapse, while one died due to a transplant‐related complication. In contrast, the two patients who did not develop aGVHD experienced relapse early after TCR‐haplo‐SCT. Conclusions In this study, three of the six patients with RR‐ESFTs survived for more than one year without relapse, and the treatment toxicity was considered acceptable even for patients who underwent high‐intensity pretreatment. TCR‐haplo‐SCT could be a potential therapeutic option for patients with RR‐ESFTs.
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Affiliation(s)
- Hideki Sano
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Kazuhiro Mochizuki
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Shogo Kobayashi
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Yoshihiro Ohara
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Nobuhisa Takahashi
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Shingo Kudo
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Kazuhiko Ikeda
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hitoshi Ohto
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Atsushi Kikuta
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
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Sano H, Mochizuki K, Kobayashi S, Ohara Y, Takahashi N, Kudo S, Waragai T, Ikeda K, Ohto H, Kikuta A. Effectiveness of T-Cell Replete Haploidentical Hematopoietic Stem Cell Transplantation for Refractory/Relapsed B Cell Acute Lymphoblastic Leukemia in Children and Adolescents. Front Pediatr 2021; 9:743294. [PMID: 34722423 PMCID: PMC8549544 DOI: 10.3389/fped.2021.743294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 09/17/2021] [Indexed: 12/19/2022] Open
Abstract
Background: The prognosis of refractory/relapsed B-cell precursor acute lymphoblastic leukemia (BCP-ALL) remains dismal owing to acquired resistance to chemotherapeutic agents. This study aimed to evaluate the efficacy of T-cell replete HLA haploidentical hematopoietic stem cell transplantation (TCR-haplo-HSCT) for pediatric refractory/relapsed BCP-ALL (RR-BCP-ALL). Methods: Nineteen pediatric patients with RR-BCP-ALL underwent TCR-haplo-HSCT between 2010 and 2019 at the Fukushima Medical University Hospital. The disease status at TCR-haplo-HSCT included complete remission (CR) in eight patients and non-CR with active disease in 11 patients. Total body irradiation-based, busulfan-based, and reduced-intensity conditioning regimens were employed in 11, 6, and 2 patients, respectively. Low-dose anti-thymocyte globulin (thymoglobulin, 2.5 mg/kg) was used in all patients. Graft-vs.-host disease (GVHD) prophylaxis was administered with tacrolimus, methotrexate, and prednisolone. Results: All patients received peripheral blood stem cells as the stem cell source. The HLA disparities in graft vs. host directions were 2/8 in one, 3/8 in five, and 4/8 in 13 patients. Among 18 patients who achieved primary engraftment, acute GVHD occurred in all 18 evaluable patients (grade II, 9; grade III, 8; grade IV, 1), and chronic GVHD was observed in 10 out of 15 evaluable patients. Three patients died because of transplant-related mortality. The 3-year overall survival (OS) and leukemia-free survival rates were 57.4 and 42.1%, respectively. Compared to patients older than 10 years in age (N = 10), those younger than 10 years in age (N = 9) showed an excellent OS rate (3-year OS rate: patients < 10 years old, 100%; patients > 10 years old, 20% [95% confidence interval, 3.1-47.5]; p = 0.002). Conclusions: We suggest that TCR haplo-HSCT with low-dose ATG conditioning has the potential to improve the transplantation outcomes in patients with RR-BCP.
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Affiliation(s)
- Hideki Sano
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Kazuhiro Mochizuki
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Shogo Kobayashi
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Yoshihiro Ohara
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Nobuhisa Takahashi
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Shingo Kudo
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Tomoko Waragai
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Kazuhiko Ikeda
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hitoshi Ohto
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Atsushi Kikuta
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
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Two Occurrences of Leukemia Relapse Due to Mismatched HLA Loss After Haploidentical Stem Cell Transplantation From Different Family Donors With KIR Ligand Mismatch. J Pediatr Hematol Oncol 2020; 42:e104-e106. [PMID: 30807398 DOI: 10.1097/mph.0000000000001443] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Mismatched HLA loss is a cause of leukemia relapse after HLA-haploidentical stem cell transplantation (haplo-SCT). We report a patient with a history of 2 occurrences of leukemia relapse due to mismatched HLA loss after haplo-SCT. He received haplo-SCT from his father but showed leukemia relapse with loss of the maternal HLA haplotype. He then underwent haplo-SCT from his mother, and developed relapse with loss of the paternal HLA haplotype. Both donors had killer cell immunoglobulin-like receptor-ligand mismatch but alloreactive natural killer cells could not prevent relapse. Second haplo-SCT should be conducted carefully for patients with relapse due to mismatched HLA loss.
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