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Chen L, Hu Y, Zheng B, Luo L, Su Z. Human TCR repertoire in cancer. Cancer Med 2024; 13:e70164. [PMID: 39240157 PMCID: PMC11378360 DOI: 10.1002/cam4.70164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 08/02/2024] [Accepted: 08/19/2024] [Indexed: 09/07/2024] Open
Abstract
BACKGROUND T cells, the "superstar" of the immune system, play a crucial role in antitumor immunity. T-cell receptors (TCR) are crucial molecules that enable T cells to identify antigens and start immunological responses. The body has evolved a unique method for rearrangement, resulting in a vast diversity of TCR repertoires. A healthy TCR repertoire is essential for the particular identification of antigens by T cells. METHODS In this article, we systematically summarized the TCR creation mechanisms and analysis methodologies, particularly focusing on the application of next-generation sequencing (NGS) technology. We explore the TCR repertoire in health and cancer, and discuss the implications of TCR repertoire analysis in understanding carcinogenesis, cancer progression, and treatment. RESULTS The TCR repertoire analysis has enormous potential for monitoring the emergence and progression of malignancies, as well as assessing therapy response and prognosis. The application of NGS has dramatically accelerated our comprehension of TCR diversity and its role in cancer immunity. CONCLUSIONS To substantiate the significance of TCR repertoires as biomarkers, more thorough and exhaustive research should be conducted. The TCR repertoire analysis, enabled by advanced sequencing technologies, is poised to become a crucial tool in the future of cancer diagnosis, monitoring, and therapy evaluation.
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Affiliation(s)
- Lin Chen
- Department of Medical Genetics/Prenatal Diagnostic Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Yuan Hu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
- Department of Anesthesia Nursing, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Bohao Zheng
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Wuxi School of Medicine, Jiangnan University, Wuxi, China
| | - Limei Luo
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Zhenzhen Su
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Chengdu, China
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2
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Saqib M, Shahbaz N, Malik M. Treatment of Rhupus Syndrome With Aplastic Anemia Using Cyclosporine and Hydroxychloroquine: A Case Report. Cureus 2024; 16:e60875. [PMID: 38910697 PMCID: PMC11192584 DOI: 10.7759/cureus.60875] [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] [Accepted: 05/22/2024] [Indexed: 06/25/2024] Open
Abstract
Rhupus syndrome is an autoimmune disorder that combines the symptoms of lupus and rheumatoid arthritis. It is a rare condition that affects the connective tissues of the body such as the joints, muscles, and skin. The symptoms of rhupus syndrome can be similar to those of lupus, including joint pain, fatigue, and skin rashes. However, rhupus syndrome can also cause symptoms of rheumatoid arthritis, such as joint stiffness and swelling. Treatment for rhupus syndrome usually involves a combination of medications and lifestyle changes to manage symptoms and improve the overall quality of life. A 24-year-old female patient was referred by a local physician for evaluation of pancytopenia. Her history dates back to six months when she developed progressive fatigue, dyspnea on mild exertion, and polyarthralgia. Initial laboratory investigations revealed pancytopenia, positive antinuclear antibodies (ANA), anti-double-stranded DNA (anti-dsDNA), and anti-cyclic citrullinated peptide (anti-CCP) antibodies. Bone marrow examination confirmed the diagnosis of aplastic anemia. She was started on cyclosporine with an aim to maintain a trough level between 200 and 250 ng/mL. She responded well with hematological recovery in three to four months. This case highlighted the excellent response to cyclosporine hematologically and clinically in rhupus syndrome complicated with aplastic anemia. Further studies are required to establish the long-term efficacy of cyclosporine in this patient population.
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Affiliation(s)
- Maleeha Saqib
- Internal Medicine, Shifa International Hospital, Islamabad, PAK
| | - Nighat Shahbaz
- Clinical Hematology, National Institute of Bone Marrow Transplant, Rawalpindi, PAK
| | - Mustafa Malik
- Internal Medicine, Shifa International Hospital, Islamabad, PAK
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3
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Ben Hamza A, Welters C, Stadler S, Brüggemann M, Dietze K, Brauns O, Brümmendorf TH, Winkler T, Bullinger L, Blankenstein T, Rosenberger L, Leisegang M, Kammertöns T, Herr W, Moosmann A, Strobel J, Hackstein H, Dornmair K, Beier F, Hansmann L. Virus-reactive T cells expanded in aplastic anemia eliminate hematopoietic progenitor cells by molecular mimicry. Blood 2024; 143:1365-1378. [PMID: 38277625 DOI: 10.1182/blood.2023023142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 01/28/2024] Open
Abstract
ABSTRACT Acquired aplastic anemia is a bone marrow failure syndrome characterized by hypocellular bone marrow and peripheral blood pancytopenia. Frequent clinical responses to calcineurin inhibition and antithymocyte globulin strongly suggest critical roles for hematopoietic stem/progenitor cell-reactive T-cell clones in disease pathophysiology; however, their exact contribution and antigen specificities remain unclear. We determined differentiation states and targets of dominant T-cell clones along with their potential to eliminate hematopoietic progenitor cells in the bone marrow of 15 patients with acquired aplastic anemia. Single-cell sequencing and immunophenotyping revealed oligoclonal expansion and effector differentiation of CD8+ T-cell compartments. We reexpressed 28 dominant T-cell receptors (TCRs) of 9 patients in reporter cell lines to determine reactivity with (1) in vitro-expanded CD34+ bone marrow, (2) CD34- bone marrow, or (3) peptide pools covering immunodominant epitopes of highly prevalent viruses. Besides 5 cytomegalovirus-reactive TCRs, we identified 3 TCRs that recognized antigen presented on hematopoietic progenitor cells. T cells transduced with these TCRs eliminated hematopoietic progenitor cells of the respective patients in vitro. One progenitor cell-reactive TCR (11A5) also recognized an epitope of the Epstein-Barr virus-derived latent membrane protein 1 (LMP1) presented on HLA-A∗02:01. We identified 2 LMP1-related mimotopes within the human proteome as activating targets of TCR 11A5, providing proof of concept that molecular mimicry of viral and self-epitopes can drive T cell-mediated elimination of hematopoietic progenitor cells in aplastic anemia.
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Affiliation(s)
- Amin Ben Hamza
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Carlotta Welters
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Serena Stadler
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Cancer Consortium, Partner Site Berlin, and German Cancer Research Center, Heidelberg, Germany
| | - Monika Brüggemann
- Department of Medicine II, Hematology and Oncology, University Hospital Schleswig Holstein, Kiel, Germany
| | - Kerstin Dietze
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Olaf Brauns
- Miltenyi Biotec B.V. & Co. KG, Bergisch Gladbach, Germany
| | - Tim H Brümmendorf
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf, Aachen, Germany
| | - Thomas Winkler
- Division of Genetics, Department of Biology, Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Lars Bullinger
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Cancer Consortium, Partner Site Berlin, and German Cancer Research Center, Heidelberg, Germany
| | - Thomas Blankenstein
- Molecular Immunology and Gene Therapy, Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Leonie Rosenberger
- Institute of Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Leisegang
- German Cancer Consortium, Partner Site Berlin, and German Cancer Research Center, Heidelberg, Germany
- Institute of Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- David and Etta Jonas Center for Cellular Therapy, The University of Chicago, Chicago, IL
| | - Thomas Kammertöns
- Institute of Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Wolfgang Herr
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Moosmann
- Department of Medicine III, Klinikum der Universität München, Munich, Germany
- German Center for Infection Research, Munich, Germany
- Helmholtz Munich, Munich, Germany
| | - Julian Strobel
- Department of Transfusion Medicine and Hemostaseology, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Holger Hackstein
- Department of Transfusion Medicine and Hemostaseology, University Hospital Erlangen, Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Klaus Dornmair
- Institute of Clinical Neuroimmunology, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
- Biomedical Center, Faculty of Medicine, Ludwig Maximilian University Munich, Martinsried, Germany
| | - Fabian Beier
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf, Aachen, Germany
| | - Leo Hansmann
- Department of Hematology, Oncology and Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Cancer Consortium, Partner Site Berlin, and German Cancer Research Center, Heidelberg, Germany
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
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4
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Youssef MAM, Ahmed ES, Kamal DT, Elsayh KI, Abdelfattah MA, Mahran HH, Embaby MM. Clinical Signs and Treatment of New-Onset Bone Marrow Failure Associated SARS-CoV-2 Infection in Children: A Single Institution Prospective Cohort Study. Mediterr J Hematol Infect Dis 2024; 16:e2024034. [PMID: 38468844 PMCID: PMC10927230 DOI: 10.4084/mjhid.2024.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 02/07/2024] [Indexed: 03/13/2024] Open
Abstract
Background Viral infections can cause direct and indirect damage to hematopoietic stem cells. The objectives of this study were to identify the frequency and severity of aplastic anemia in children infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as well as recognize the response to treatment. Methodology 13 children with newly diagnosed severe aplastic anemia were enrolled in this prospective clinical trial. Blood samples were obtained from all patients to detect SARS-CoV-2 antibodies, and nasopharyngeal swabs were collected for reverse-transcription Polymerase Chain Reaction to detect SARS-CoV-2 viruses. According to the laboratory results, patients were classified as having SARS-CoV-2 positive antibodies and SARS-CoV-2 negative antibodies. Both groups received combined cyclosporine (CsA) + Eltrombopag (E-PAG). The hematological response, either complete response (CR) or partial response (PR), no response (NR), and overall response (OR) rates of combined E-PAG + CsA treatment after 6 months were evaluated. Results Four children were recognized to have aplastic anemia and SARS-CoV-2 positive antibodies. Two patients fulfilled the hematological criteria for CR and no longer required transfusion of packed red blood cells (PRBCs) or platelets, and one had PR and was still PRBC transfusion-dependent but no longer required platelet transfusion. The remaining patient showed NR, and he had died before reaching the top of the HSCT waiting list. Moreover, six patients in the SARS-CoV-2 negative antibodies group had CR, while three patients had PR. The difference in ANC, Hg, and platelet counts between both groups was not significant. Conclusion The SARS-CoV-2 virus is added to several viral infections known to be implicated in the pathogenesis of aplastic anemia. Studies are needed to establish a definitive association and determine whether the response of bone marrow failure to standard therapy differs from that of idiopathic cases.
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Affiliation(s)
- Mervat A M Youssef
- Children Hospital, Hematology Unit, Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - Dalia Tarik Kamal
- Clinical Pathology Department - Faculty of Medicine-Assiut University
| | - Khalid I Elsayh
- Children Hospital, Hematology Unit, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mai A Abdelfattah
- Children Hospital, Hematology Unit, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Hyam Hassan Mahran
- Children Hospital, Hematology Unit, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mostafa M Embaby
- Children Hospital, Hematology Unit, Faculty of Medicine, Assiut University, Assiut, Egypt
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5
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Scheinberg P. Progress in medical therapy in aplastic anemia: why it took so long? Int J Hematol 2024; 119:248-254. [PMID: 38403842 DOI: 10.1007/s12185-024-03713-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/27/2023] [Accepted: 01/15/2024] [Indexed: 02/27/2024]
Abstract
The treatment of aplastic anemia (AA) has significantly advanced in the last 50 years, evolving from a fatal condition to one where survival rates now exceed 80-85%. Hematopoietic stem cell transplantation (HSCT) and immunosuppressive therapy (IST) have become the primary treatments, with the latter widely adopted due to factors like the scarcity of compatible donors, patient age, comorbidities, and limited HSCT access. A therapy breakthrough was the introduction of antithymocyte globulin (ATG), with its effectiveness further boosted by cyclosporine. However, it took years to achieve another major milestone in management. Initially, treatments aimed to intensify immunosuppression following the success of the ATG-cyclosporine combination, but these methods fell short of expectations. A major turning point was combining immunosuppression with stem cell stimulation, surpassing the efficacy of IST alone. Earlier, growth factors had shown limited success in AA treatment, but thrombopoietin receptor agonists represented a significant advancement. Initially applied alone as salvage, these were later combined with IST, forming the most effective current regimen for medically managing SAA. Horse ATG is the preferred formulation combined with cyclosporine and eltrombopag. This progress in AA treatment offers improved outcomes for patients afflicted with this once-lethal disease.
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Affiliation(s)
- Phillip Scheinberg
- Division of Hematology, Hospital A Beneficência Portuguesa, Rua Martiniano de Carvalho, 951, São Paulo, SP, 01321-001, Brazil.
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6
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Chattopadhyay S, Lionel S, Selvarajan S, Devasia AJ, Korula A, Kulkarni U, Aboobacker FN, Lakshmi KM, Srivastava A, Mathews V, Abraham A, George B. Relapse and transformation to myelodysplastic syndrome and acute myeloid leukemia following immunosuppressive therapy for aplastic anemia is more common as compared to allogeneic stem cell transplantation with a negative impact on survival. Ann Hematol 2024; 103:749-758. [PMID: 38242970 DOI: 10.1007/s00277-024-05621-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/08/2024] [Indexed: 01/21/2024]
Abstract
We studied the incidence of relapse, transformation to myelodysplastic syndrome/acute myeloid leukemia, and survival in patients with aplastic anemia (AA) surviving more than 1 year after ATG/ALG-based immunosuppressive therapy (IST) between 1985 and 2020. Four-hundred seventy patients (413 adults and 57 children) were studied, and data were compared with 223 patients who underwent matched sibling donor transplant (MSD HSCT). Median follow-up is 50 months (12-359). Relapse occurred in 21.9% at a median time of 33.5 months (5-228) post IST. Twenty-six (5.5%) patients progressed to PNH, while 20 (4.3%) evolved to MDS/AML. Ten-year estimated overall survival (OS) is 80.9 ± 3% and was significantly better in patients without an event (85.1 ± 4%) compared to relapse (74.6% ± 6.2%) or clonal evolution (12.8% ± 11.8%) (p = 0.024). While the severity of AA (p = 0.011) and type of ATG (p = 0.028) used predicted relapse, only age at IST administration influenced clonal evolution (p = 0.018). Among HSCT recipients, relapse rates were 4.9% with no clonal evolution, and the 10-year OS was 94.5 ± 2%. In patients who survived 1 year following IST, outcomes were good except with clonal evolution to MDS/AML. These outcomes, however, were still inferior compared to matched sibling donor HSCT.
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Affiliation(s)
| | - Sharon Lionel
- Department of Haematology, Christian Medical College, Vellore, India
| | - Sushil Selvarajan
- Department of Haematology, Christian Medical College, Vellore, India
| | - Anup J Devasia
- Department of Haematology, Christian Medical College, Vellore, India
| | - Anu Korula
- Department of Haematology, Christian Medical College, Vellore, India
| | - Uday Kulkarni
- Department of Haematology, Christian Medical College, Vellore, India
| | | | - Kavitha M Lakshmi
- Department of Haematology, Christian Medical College, Vellore, India
| | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | - Vikram Mathews
- Department of Haematology, Christian Medical College, Vellore, India
| | - Aby Abraham
- Department of Haematology, Christian Medical College, Vellore, India
| | - Biju George
- Department of Haematology, Christian Medical College, Vellore, India.
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7
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Wu Z, Young NS. Single-cell genomics in acquired bone marrow failure syndromes. Blood 2023; 142:1193-1207. [PMID: 37478398 PMCID: PMC10644099 DOI: 10.1182/blood.2022018581] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/20/2023] [Accepted: 06/20/2023] [Indexed: 07/23/2023] Open
Abstract
Mechanistic studies of immune bone marrow failure are difficult because of the scarcity of residual cells, the involvement of multiple cell types, and the inherent complexities of hematopoiesis and immunity. Single-cell genomic technologies and bioinformatics allow extensive, multidimensional analysis of a very limited number of cells. We review emerging applications of single-cell techniques, and early results related to disease pathogenesis: effector and target cell populations and relationships, cell-autonomous and nonautonomous phenotypes in clonal hematopoiesis, transcript splicing, chromosomal abnormalities, and T-cell receptor usage and clonality. Dense and complex data from single-cell techniques provide insights into pathophysiology, natural history, and therapeutic drug effects.
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Affiliation(s)
- Zhijie Wu
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Neal S. Young
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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8
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Koldej RM, Prabahran A, Tan CW, Ludford-Menting M, Morgan H, Holzwart N, Davis MJ, Ritchie DS. Spatial proteomics identifies a spectrum of immune dysregulation in acquired bone marrow failure syndromes. Front Immunol 2023; 14:1213560. [PMID: 37818364 PMCID: PMC10560754 DOI: 10.3389/fimmu.2023.1213560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/04/2023] [Indexed: 10/12/2023] Open
Abstract
Poor graft function (PGF), manifested by multilineage cytopenias and complete donor chimerism post-allogeneic stem cell transplantation (alloSCT), and acquired aplastic anaemia (AA) are immune-mediated acquired bone marrow (BM) failure syndromes with a similar clinical presentation. In this study, we used spatial proteomics to compare the immunobiology of the BM microenvironment and identify common mechanisms of immune dysregulation under these conditions. Archival BM trephines from patients exhibited downregulation of the immunoregulatory protein VISTA and the M2 macrophage marker and suppressor of T-cell activation ARG1 with increased expression of the immune checkpoint B7-H3 compared to normal controls. Increased CD163 and CD14 expression suggested monocyte/macrophage skewing, which, combined with dysregulation of STING and VISTA, is indicative of an environment of reduced immunoregulation resulting in the profound suppression of hematopoiesis in these two conditions. There were no changes in the immune microenvironment between paired diagnostic AA and secondary MDS/AML samples suggesting that leukaemic clones develop in the impaired immune microenvironment of AA without the need for further alterations. Of the eight proteins with dysregulated expression shared by diagnostic AA and PGF, the diagnostic AA samples had a greater fold change in expression than PGF, suggesting that these diseases represent a spectrum of immune dysregulation. Unexpectedly, analysis of samples from patients with good graft function post-alloSCT demonstrated significant changes in the immune microenvironment compared to normal controls, with downregulation of CD44, STING, VISTA, and ARG1, suggesting that recovery of multilineage haematopoiesis post-alloSCT does not reflect recovery of immune function and may prime patients for the development of PGF upon further inflammatory insult. The demonstrable similarities in the immunopathology of AA and PGF will allow the design of clinical interventions that include both patient cohorts to accelerate therapeutic discovery and translation.
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Affiliation(s)
- Rachel M. Koldej
- Australian Cancer Research Foundation (ACRF) Translational Research Laboratory, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Ashvind Prabahran
- Australian Cancer Research Foundation (ACRF) Translational Research Laboratory, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Chin Wee Tan
- Bioinformatics Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
- Department of Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Mandy Ludford-Menting
- Australian Cancer Research Foundation (ACRF) Translational Research Laboratory, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Huw Morgan
- Australian Cancer Research Foundation (ACRF) Translational Research Laboratory, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Nicholas Holzwart
- Australian Cancer Research Foundation (ACRF) Translational Research Laboratory, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Melissa J. Davis
- Bioinformatics Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
- Department of Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Department of Clinical Pathology, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - David S. Ritchie
- Australian Cancer Research Foundation (ACRF) Translational Research Laboratory, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
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9
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Gurnari C, Pagliuca S, Maciejewski JP. Clonal evolution in aplastic anemia: failed tumor surveillance or maladaptive recovery? Leuk Lymphoma 2023; 64:1389-1399. [PMID: 37356012 PMCID: PMC11104022 DOI: 10.1080/10428194.2023.2215614] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/10/2023] [Accepted: 05/13/2023] [Indexed: 06/27/2023]
Abstract
Clonal evolution to secondary paroxysmal nocturnal hemoglobinuria (PNH) or myeloid neoplasia (MN) represents one of the long-term complications of patients with aplastic anemia (AA). The recent evidence in the field of immunology and the application of next-generation sequencing have shed light on the molecular underpinnings of these clonal complications, revealing clinical and molecular risk factors as well as potential immunological players. Particularly, whether MN evolution represents a failed tumor surveillance or a maladaptive recovery is still a matter of controversy in the field of bone marrow failure syndromes. However, recent studies have explored the precise dynamics of the immune-molecular forces governing such processes over time, generating knowledge useful for potential early therapeutic strategies. In this review, we will discuss the immune pathophysiology of AA and the emergence of clonal hematopoiesis with regard to the adaptive and maladaptive mechanisms at the basis of secondary evolution trajectories operating under the immune pressure.
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Affiliation(s)
- Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Biomedicine and Prevention, PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Simona Pagliuca
- Sérvice d‘hématologie Clinique, ChRu de Nancy, Nancy, France
- CNRS UMR 7365 IMoPa, Biopôle de l‘Université de Lorraine, France Vandœuvre-lès-Nancy
| | - Jaroslaw P. Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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10
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Drillet G, Pastoret C, Moignet A, Lamy T, Marchand T. Large granular lymphocyte leukemia: An indolent clonal proliferative disease associated with an array of various immunologic disorders. Rev Med Interne 2023:S0248-8663(23)00119-4. [PMID: 37087371 DOI: 10.1016/j.revmed.2023.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/15/2023] [Accepted: 03/31/2023] [Indexed: 04/24/2023]
Abstract
Large granular lymphocyte leukemia (LGLL) is a chronic lymphoproliferative disorder characterized by the proliferation of T or NK cytotoxic cells in the peripheral blood, the spleen and the bone marrow. Neutropenia leading to recurrent infections represents the main manifestation of LGLL. One specificity of LGLL is its frequent association with auto-immune disorders, among them first and foremost rheumatoid arthritis, and other hematologic diseases, including pure red cell aplasia and bone marrow failure. The large spectrum of manifestations and the classical indolent course contribute to the diagnosis difficulties and the frequency of underdiagnosed cases. Of importance, the dysimmune manifestations disappear with the treatment of LGLL as the blood cell counts normalize, giving a strong argument for a pathological link between the two entities. The therapeutic challenge results from the high rate of relapses following the first line of immunosuppressive drugs. New targeted agents, some of which are currently approved in autoimmune diseases, appear to be relevant therapeutic strategies to treat LGLL, by targeting key activated pathways involved in the pathogenesis of the disease, including JAK-STAT signaling.
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Affiliation(s)
- G Drillet
- Service d'hématologie clinique, centre hospitalier universitaire de Rennes, Rennes, France.
| | - C Pastoret
- Laboratoire d'hématologie, centre hospitalier universitaire de Rennes, Rennes, France
| | - A Moignet
- Service d'hématologie clinique, centre hospitalier universitaire de Rennes, Rennes, France
| | - T Lamy
- Service d'hématologie clinique, centre hospitalier universitaire de Rennes, Rennes, France; Université Rennes 1, Rennes, France; CIC 1414, Rennes, France; Institut national de la santé et de la recherche médicale (INSERM) U1236, Rennes, France
| | - T Marchand
- Service d'hématologie clinique, centre hospitalier universitaire de Rennes, Rennes, France; Université Rennes 1, Rennes, France; Institut national de la santé et de la recherche médicale (INSERM) U1236, Rennes, France
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11
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Mendez LM, Patnaik MM. Clonal Hematopoiesis: Origins and determinants of evolution. Leuk Res 2023; 129:107076. [PMID: 37075557 DOI: 10.1016/j.leukres.2023.107076] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/22/2023] [Accepted: 04/10/2023] [Indexed: 04/21/2023]
Abstract
The accrual of somatic mutations is a byproduct of aging. When a clone bearing a somatic genetic alteration, conferring comparative competitive advantage, displays sufficient outgrowth to become detectable amongst an otherwise polyclonal background in the hematopoietic system, this is called clonal hematopoiesis (CH). Somatic genetic alterations observed in CH include point mutations in cancer related genes, mosaic chromosomal alterations or a combination of these. Interestingly, clonal hematopoiesis (CH) can also occur with somatic variants in genes without a known role in cancer and in the absence of a somatic genetic alteration through a process that has been described as 'genetic drift'. Clonal hematopoiesis of indeterminate significance (CHIP), is age-related and defined by the presence of somatic point mutations in cancer related genes, in the absence of cytopenias or a diagnosis of hematologic neoplasm, with a variant allele fraction ≥ 2 %. Remarkably, the increased mortality associated with CHIP is largely due to cardiovascular disease. Subsequently, CHIP has been associated with a myriad of age-related conditions such as Alzheimer's Disease, osteoporosis, CVA and COPD. CHIP is associated with an increased risk of hematologic malignancies, particularly myeloid neoplasms, with the risk rising with increasing clone size and clonal complexity. Mechanisms regulating clonal evolution and progression to hematologic malignancies remain to be defined. However, observations on context specific CH arising in the setting of bone marrow failure states, or on exposure to chemotherapy and radiation therapy, suggest that CH reflects context specific selection pressures and constraint-escape mechanisms.
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Affiliation(s)
- Lourdes M Mendez
- Section of Hematology, Department of Internal Medicine, Yale Cancer Center and Smilow Cancer Hospital, Yale University School of Medicine, CT, USA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, MN, USA.
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12
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Zhang J, Liu T, Duan Y, Chang Y, Chang L, Liu C, Chen X, Cheng X, Li T, Yang W, Chen X, Guo Y, Chen Y, Zou Y, Zhang L, Zhu X, Zhang Y. Single-cell analysis highlights a population of Th17-polarized CD4+ naïve T cells showing IL6/JAK3/STAT3 activation in pediatric severe aplastic anemia. J Autoimmun 2023; 136:103026. [PMID: 37001436 DOI: 10.1016/j.jaut.2023.103026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 02/08/2023] [Accepted: 03/04/2023] [Indexed: 03/30/2023]
Abstract
Acquired aplastic anemia (AA) is recognized as an immune-mediated disorder resulting from active destruction of hematopoietic cells in bone marrow (BM) by effector T lymphocytes. Bulk genomic landscape analysis and transcriptomic profiling have contributed to a better understanding of the recurrent cytogenetic abnormalities and immunologic cues associated with the onset of hematopoietic destruction. However, the functional mechanistic determinants underlying the complexity of heterogeneous T lymphocyte populations as well as their correlation with clinical outcomes remain to be elucidated. To uncover dysfunctional mechanisms acting within the heterogeneous marrow-infiltrating immune environment and examine their pathogenic interplay with the hematopoietic stem/progenitor pool, we exploited single-cell mass cytometry for BM mononuclear cells of severe AA (SAA) patients pre- and post-immunosuppressive therapy, in contrast to those of healthy donors. Alignment of BM cellular composition with hematopoietic developmental trajectories revealed potential functional roles for non-canonically activated CD4+ naïve T cells in newly-diagnosed pediatric cases of SAA. Furthermore, single-cell transcriptomic profiling highlighted a population of Th17-polarized CD4+CAMK4+ naïve T cells showing activation of the IL-6/JAK3/STAT3 pathway, while gene signature dissection indicated a predisposition to proinflammatory pathogenesis. Retrospective validation from our SAA cohort of 231 patients revealed high plasma levels of IL-6 as an independent risk factor of delayed hematopoietic response to antithymocyte globulin-based immunosuppressive therapy. Thus, IL-6 warrants further investigation as a putative therapeutic target in SAA.
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13
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Gurnari C, Visconte V. From bone marrow failure syndromes to VEXAS: Disentangling clonal hematopoiesis, immune system, and molecular drivers. Leuk Res 2023; 127:107038. [PMID: 36841022 DOI: 10.1016/j.leukres.2023.107038] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 01/25/2023] [Accepted: 02/09/2023] [Indexed: 02/13/2023]
Abstract
Clonal hematopoiesis (CH) is a result of the selective expansion of hematopoietic stem and progenitor cells (HSPCs) carrying somatic mutations originating from a primary HSC. The advent of modern genomic technologies has helped recognizing that CH is common in elderly healthy subjects as a result of the aging bone marrow (BM). CH in healthy subjects without abnormalities in blood counts is known as CH of indeterminate potential. CH is also seen in BM failure (BMF) disorders. Whether CH alarms for the risk to develop malignant evolution in BMF or creates an adaptation to selective pressure is a matter of controversy. As such, a continuum might exist from pre-malignant to malignant hematopoietic diseases. This review summarizes how somatic mutations and immune derangement in HSCs shape disease evolution and describes the complexity of disorders such as VEXAS as the prototypic tetrad of somatic mutations, morphologic features, inflammatory pathways and immune overshooting. In such a view, we interconnect the axis aging and immune-hematopoietic system, which all convey important clues for the risk to develop malignancies.
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Affiliation(s)
- Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Biomedicine and Prevention, PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Valeria Visconte
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
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14
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Chen L, Ge M, Huo J, Ren X, Shao Y, Li X, Huang J, Wang M, Nie N, Zhang J, Peng J, Zheng Y. Association between human leukocyte antigen and immunosuppressive treatment outcomes in Chinese patients with aplastic anemia. Front Immunol 2023; 14:1056381. [PMID: 36793734 PMCID: PMC9923019 DOI: 10.3389/fimmu.2023.1056381] [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: 09/29/2022] [Accepted: 01/10/2023] [Indexed: 01/31/2023] Open
Abstract
Background Activated cytotoxic T cells (CTLs) recognize the auto-antigens presented on hematopoietic stem/progenitor cells (HSPCs) through class I human leukocyte antigen (HLA) molecules and play an important role in the immune pathogenesis of aplastic anemia (AA). Previous reports demonstrated that HLA was related to the disease susceptibility and response to immunosuppressive therapy (IST) in AA patients. Recent studies have indicated that specific HLA allele deletions, which helped AA patients to evade CTL-driven autoimmune responses and escape from immune surveillance, may lead to high-risk clonal evolution. Therefore, HLA genotyping has a particular predictive value for the response to IST and the risk of clonal evolution. However, there are limited studies on this topic in the Chinese population. Methods To explore the value of HLA genotyping in Chinese patients with AA, 95 AA patients treated with IST were retrospectively investigated. Results The alleles HLA-B*15:18 and HLA-C*04:01 were associated with a superior long-term response to IST (P = 0.025; P = 0.027, respectively), while the allele HLA-B*40:01 indicated an inferior result (P = 0.02). The allele HLA-A*01:01 and HLA-B*54:01 were associated with high-risk clonal evolution (P = 0.032; P = 0.01, respectively), and the former had a higher frequency in very severe AA (VSAA) patients than that in severe AA (SAA) patients (12.7% vs 0%, P = 0.02). The HLA-DQ*03:03 and HLA-DR*09:01 alleles were associated with high-risk clonal evolution and poor long-term survival in patients aged ≥40 years. Such patients may be recommended for early allogeneic hematopoietic stem cell transplantation rather than the routine IST treatment. Conclusion HLA genotype has crucial value in predicting the outcome of IST and long-term survival in AA patients, and thus may assist an individualized treatment strategy.
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Affiliation(s)
| | - Meili Ge
- *Correspondence: Meili Ge, ; Yizhou Zheng,
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15
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Le Floc'h A, Nagashima K, Birchard D, Scott G, Ben LH, Ajithdoss D, Gayvert K, Romero Hernandez A, Herbin O, Tay A, Farrales P, Korgaonkar CK, Pan H, Shah S, Kamat V, Chatterjee I, Popke J, Oyejide A, Lim WK, Kim JH, Huang T, Franklin M, Olson W, Norton T, Perlee L, Yancopoulos GD, Murphy AJ, Sleeman MA, Orengo JM. Blocking common γ chain cytokine signaling ameliorates T cell-mediated pathogenesis in disease models. Sci Transl Med 2023; 15:eabo0205. [PMID: 36630481 DOI: 10.1126/scitranslmed.abo0205] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The common γ chain (γc; IL-2RG) is a subunit of the interleukin (IL) receptors for the γc cytokines IL-2, IL-4, IL-7, IL-9, IL-15, and IL-21. The lack of appropriate neutralizing antibodies recognizing IL-2RG has made it difficult to thoroughly interrogate the role of γc cytokines in inflammatory and autoimmune disease settings. Here, we generated a γc cytokine receptor antibody, REGN7257, to determine whether γc cytokines might be targeted for T cell-mediated disease prevention and treatment. Biochemical, structural, and in vitro analysis showed that REGN7257 binds with high affinity to IL-2RG and potently blocks signaling of all γc cytokines. In nonhuman primates, REGN7257 efficiently suppressed T cells without affecting granulocytes, platelets, or red blood cells. Using REGN7257, we showed that γc cytokines drive T cell-mediated disease in mouse models of graft-versus-host disease (GVHD) and multiple sclerosis by affecting multiple aspects of the pathogenic response. We found that our xenogeneic GVHD mouse model recapitulates hallmarks of acute and chronic GVHD, with T cell expansion/infiltration into tissues and liver fibrosis, as well as hallmarks of immune aplastic anemia, with bone marrow aplasia and peripheral cytopenia. Our findings indicate that γc cytokines contribute to GVHD and aplastic anemia pathology by promoting these characteristic features. By demonstrating that broad inhibition of γc cytokine signaling with REGN7257 protects from immune-mediated disorders, our data provide evidence of γc cytokines as key drivers of pathogenic T cell responses, offering a potential strategy for the management of T cell-mediated diseases.
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Affiliation(s)
- Audrey Le Floc'h
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Kirsten Nagashima
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Dylan Birchard
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - George Scott
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Li-Hong Ben
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Dharani Ajithdoss
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Kaitlyn Gayvert
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | | | - Olivier Herbin
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Amanda Tay
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Pamela Farrales
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | | | - Hao Pan
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Sweta Shah
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Vishal Kamat
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Ishita Chatterjee
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Jon Popke
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Adelekan Oyejide
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Wei Keat Lim
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Jee H Kim
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Tammy Huang
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Matthew Franklin
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - William Olson
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Thomas Norton
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Lorah Perlee
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - George D Yancopoulos
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Andrew J Murphy
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Matthew A Sleeman
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Jamie M Orengo
- Regeneron Pharmaceuticals, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
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16
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Root-Bernstein R, Churchill E, Oliverio S. T Cell Receptor Sequences Amplified during Severe COVID-19 and Multisystem Inflammatory Syndrome in Children Mimic SARS-CoV-2, Its Bacterial Co-Infections and Host Autoantigens. Int J Mol Sci 2023; 24:ijms24021335. [PMID: 36674851 PMCID: PMC9861234 DOI: 10.3390/ijms24021335] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 01/12/2023] Open
Abstract
Published hypervariable region V-beta T cell receptor (TCR) sequences were collected from people with severe COVID-19 characterized by having various autoimmune complications, including blood coagulopathies and cardiac autoimmunity, as well as from patients diagnosed with the Kawasaki disease (KD)-like multisystem inflammatory syndrome in children (MIS-C). These were compared with comparable published v-beta TCR sequences from people diagnosed with KD and from healthy individuals. Since TCR V-beta sequences are supposed to be complementary to antigens that induce clonal expansion, it was surprising that only a quarter of the TCR sequences derived from severe COVID-19 and MIS-C patients mimicked SARS-CoV-2 proteins. Thirty percent of the KD-derived TCR mimicked coronaviruses other than SARS-CoV-2. In contrast, only three percent of the TCR sequences from healthy individuals and those diagnosed with autoimmune myocarditis displayed similarities to any coronavirus. In each disease, significant increases were found in the amount of TCRs from healthy individuals mimicking specific bacterial co-infections (especially Enterococcus faecium, Staphylococcal and Streptococcal antigens) and host autoantigens targeted by autoimmune diseases (especially myosin, collagen, phospholipid-associated proteins, and blood coagulation proteins). Theoretical explanations for these surprising observations and implications to unravel the causes of autoimmune diseases are explored.
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Affiliation(s)
- Robert Root-Bernstein
- Department of Physiology, Michigan State University, East Lansing, MI 48824, USA
- Correspondence:
| | - Elizabeth Churchill
- School of Health Sciences, George Washington University, Washington, DC 20052, USA
| | - Shelby Oliverio
- Department of Physiology, Michigan State University, East Lansing, MI 48824, USA
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17
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Aplastic Anemia as a Roadmap for Bone Marrow Failure: An Overview and a Clinical Workflow. Int J Mol Sci 2022; 23:ijms231911765. [PMID: 36233062 PMCID: PMC9569739 DOI: 10.3390/ijms231911765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/27/2022] Open
Abstract
In recent years, it has become increasingly apparent that bone marrow (BM) failures and myeloid malignancy predisposition syndromes are characterized by a wide phenotypic spectrum and that these diseases must be considered in the differential diagnosis of children and adults with unexplained hematopoiesis defects. Clinically, hypocellular BM failure still represents a challenge in pathobiology-guided treatment. There are three fundamental topics that emerged from our review of the existing data. An exogenous stressor, an immune defect, and a constitutional genetic defect fuel a vicious cycle of hematopoietic stem cells, immune niches, and stroma compartments. A wide phenotypic spectrum exists for inherited and acquired BM failures and predispositions to myeloid malignancies. In order to effectively manage patients, it is crucial to establish the right diagnosis. New theragnostic windows can be revealed by exploring BM failure pathomechanisms.
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18
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Dulmovits BM, Olson TS. Does immune destruction drive all forms of bone marrow failure? J Clin Invest 2022; 132:161288. [PMID: 35912855 PMCID: PMC9337821 DOI: 10.1172/jci161288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Current paradigms of bone marrow failure (BMF) pathophysiology suggest that immune-mediated destruction of hematopoietic stem and progenitor cells (HSPCs) drives acquired aplastic anemia. In contrast, loss of HSPCs due to senescence and/or apoptosis causes BMF in inherited BMF syndromes. In this issue of the JCI, Casado and colleagues challenge this dichotomous conception by demonstrating that NK cell–dependent, immune-mediated hematopoietic suppression and HSPC clearance drive BMF in Fanconi anemia (FA). They show that genotoxic stress upregulates natural killer group 2 member D ligands (NKG2D-L) on FA HSPCs leading to NK cell cytotoxicity through NKG2D receptor activation. Inhibition of NKG2D–NKG2D-L interactions enhanced FA HSPC clonogenic potential and improved cytopenias in vivo. These results provide alternative targets for the development of immunosuppressive therapies to reduce HSPC loss and mitigate the risk of hematologic malignancies in FA.
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Affiliation(s)
- Brian M Dulmovits
- Cell Therapy and Transplant Section, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Timothy S Olson
- Cell Therapy and Transplant Section, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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19
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Persistent Large Granular Lymphocyte Clonal Expansions: “The Root of Many Evils”—And of Some Goodness. Cancers (Basel) 2022; 14:cancers14051340. [PMID: 35267648 PMCID: PMC8909662 DOI: 10.3390/cancers14051340] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 12/21/2022] Open
Abstract
Simple Summary Large granular lymphocyte leukemia (LGLL) is a chronic disorder of either mature T or NK lymphocytes. As clonal expansions of the immune system cells, difficulties in the distinction between a true neoplasia and a physiological reactive process have been common since its description. We review here the different conditions associated with persistent clonal LGL expansions and discuss their potential origin and whether they can modulate the clinical features. Abstract Large granular lymphocyte leukemia (LGLL) is a chronic disease of either mature phenotype cytotoxic CD3+ T lymphocytes or CD3- NK cells. LGLL diagnosis is hampered by the fact that reactive persistent clonal LGL expansions may fulfill the current criteria for LGLL diagnoses. In addition to the presence of characteristic clinical and hematological signs such as anemia or neutropenia, LGLL/LGL clonal expansions have been associated with an array of conditions/disorders. We review here the presence of these persistent clonal expansions in autoimmune, hematological disorders and solid neoplasms and after hematopoietic stem cell transplantation. These associations are a unique translational research framework to discern whether these persistently expanded LGL clones are causes or consequences of the concomitant clinical settings and, more importantly, when they should be targeted.
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20
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HLA class I and II alleles profile in Indian patients with aplastic anemia. GENE REPORTS 2022. [DOI: 10.1016/j.genrep.2022.101527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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21
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Arnold PY. Review: HLA loss and detection in the setting of relapse from HLA-mismatched hematopoietic cell transplant. Hum Immunol 2022; 83:712-720. [DOI: 10.1016/j.humimm.2022.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/09/2022] [Accepted: 03/02/2022] [Indexed: 01/25/2023]
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22
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Li HM, Long ZB, Wang T, Han B. [Efficacy of stanozolol and danazol in the treatment of non-severe aplastic anemia and their effects on CD4(+)CD25(+)Foxp3(+) regulatory T cells]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:157-160. [PMID: 35381679 PMCID: PMC8980652 DOI: 10.3760/cma.j.issn.0253-2727.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Indexed: 11/10/2022]
Affiliation(s)
- H M Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Z B Long
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - T Wang
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - B Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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23
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Giudice V, Selleri C. Aplastic anemia: pathophysiology. Semin Hematol 2022; 59:13-20. [DOI: 10.1053/j.seminhematol.2021.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/25/2021] [Accepted: 12/30/2021] [Indexed: 12/31/2022]
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24
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Patel BA, Townsley DM, Scheinberg P. Immunosuppressive therapy in severe aplastic anemia. Semin Hematol 2022; 59:21-29. [DOI: 10.1053/j.seminhematol.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/11/2022]
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25
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HLA in AA: innocent bystander or culprit? Blood 2021; 138:2744-2745. [PMID: 34967871 DOI: 10.1182/blood.2021014535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 11/03/2021] [Indexed: 11/20/2022] Open
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26
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Pagliuca S, Gurnari C, Awada H, Kishtagari A, Kongkiatkamon S, Terkawi L, Zawit M, Guan Y, LaFramboise T, Jha BK, Patel BJ, Hamilton BK, Majhail NS, Lundgren S, Mustjoki S, Saunthararajah Y, Visconte V, Chan TA, Yang CY, Lenz TL, Maciejewski JP. The similarity of class II HLA genotypes defines patterns of autoreactivity in idiopathic bone marrow failure disorders. Blood 2021; 138:2781-2798. [PMID: 34748628 PMCID: PMC8718627 DOI: 10.1182/blood.2021012900] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/18/2021] [Indexed: 01/01/2023] Open
Abstract
Idiopathic aplastic anemia (IAA) is a rare autoimmune bone marrow failure (BMF) disorder initiated by a human leukocyte antigen (HLA)-restricted T-cell response to unknown antigens. As in other autoimmune disorders, the predilection for certain HLA profiles seems to represent an etiologic factor; however, the structure-function patterns involved in the self-presentation in this disease remain unclear. Herein, we analyzed the molecular landscape of HLA complexes of a cohort of 300 IAA patients and almost 3000 healthy and disease controls by deeply dissecting their genotypic configurations, functional divergence, self-antigen binding capabilities, and T-cell receptor (TCR) repertoire specificities. Specifically, analysis of the evolutionary divergence of HLA genotypes (HED) showed that IAA patients carried class II HLA molecules whose antigen-binding sites were characterized by a high level of structural homology, only partially explained by specific risk allele profiles. This pattern implies reduced HLA binding capabilities, confirmed by binding analysis of hematopoietic stem cell (HSC)-derived self-peptides. IAA phenotype was associated with the enrichment in a few amino acids at specific positions within the peptide-binding groove of DRB1 molecules, affecting the interface HLA-antigen-TCR β and potentially constituting the basis of T-cell dysfunction and autoreactivity. When analyzing associations with clinical outcomes, low HED was associated with risk of malignant progression and worse survival, underlying reduced tumor surveillance in clearing potential neoantigens derived from mechanisms of clonal hematopoiesis. Our data shed light on the immunogenetic risk associated with IAA etiology and clonal evolution and on general pathophysiological mechanisms potentially involved in other autoimmune disorders.
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Affiliation(s)
- Simona Pagliuca
- Translational Hematology and Oncology Research Department, Cleveland Clinic, Cleveland, OH
- University of Paris, Paris, France
| | - Carmelo Gurnari
- Translational Hematology and Oncology Research Department, Cleveland Clinic, Cleveland, OH
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Hassan Awada
- Translational Hematology and Oncology Research Department, Cleveland Clinic, Cleveland, OH
| | - Ashwin Kishtagari
- Translational Hematology and Oncology Research Department, Cleveland Clinic, Cleveland, OH
| | - Sunisa Kongkiatkamon
- Translational Hematology and Oncology Research Department, Cleveland Clinic, Cleveland, OH
| | - Laila Terkawi
- Translational Hematology and Oncology Research Department, Cleveland Clinic, Cleveland, OH
| | - Misam Zawit
- Translational Hematology and Oncology Research Department, Cleveland Clinic, Cleveland, OH
| | - Yihong Guan
- Translational Hematology and Oncology Research Department, Cleveland Clinic, Cleveland, OH
| | - Thomas LaFramboise
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH
| | - Babal K Jha
- Translational Hematology and Oncology Research Department, Cleveland Clinic, Cleveland, OH
| | - Bhumika J Patel
- Leukemia Program, Department of Hematology and Oncology, Cleveland Clinic, Cleveland, OH
| | - Betty K Hamilton
- Blood and Marrow Transplant Program, Department of Hematology and Oncology, Cleveland Clinic, Cleveland, OH
| | - Navneet S Majhail
- Blood and Marrow Transplant Program, Department of Hematology and Oncology, Cleveland Clinic, Cleveland, OH
| | - Sofie Lundgren
- Hematology Research Unit Helsinki, University of Helsinki-Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland
- Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland
| | - Satu Mustjoki
- Hematology Research Unit Helsinki, University of Helsinki-Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland
- Translational Immunology Research Program and Department of Clinical Chemistry and Hematology, University of Helsinki, Helsinki, Finland
- ICAN Digital Precision Cancer Medicine Flagship, Helsinki, Finland
| | - Yogen Saunthararajah
- Translational Hematology and Oncology Research Department, Cleveland Clinic, Cleveland, OH
| | - Valeria Visconte
- Translational Hematology and Oncology Research Department, Cleveland Clinic, Cleveland, OH
| | - Timothy A Chan
- Center for Immunotherapy and Precision Immuno-Oncology, Cleveland Clinic, Cleveland, OH
| | - Chao-Yie Yang
- Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, TN
| | - Tobias L Lenz
- Research Group for Evolutionary Immunogenomics, Max Planck Institute for Evolutionary Biology, Plön, Germany; and
- Research Unit for Evolutionary Immunogenomics, Department of Biology, University of Hamburg, Hamburg, Germany
| | - Jaroslaw P Maciejewski
- Translational Hematology and Oncology Research Department, Cleveland Clinic, Cleveland, OH
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27
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Votavova H, Belickova M. Hypoplastic myelodysplastic syndrome and acquired aplastic anemia: Immune‑mediated bone marrow failure syndromes (Review). Int J Oncol 2021; 60:7. [PMID: 34958107 PMCID: PMC8727136 DOI: 10.3892/ijo.2021.5297] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/01/2021] [Indexed: 11/06/2022] Open
Abstract
Hypoplastic myelodysplastic syndrome (hMDS) and aplastic anemia (AA) are rare hematopoietic disorders characterized by pancytopenia with hypoplastic bone marrow (BM). hMDS and idiopathic AA share overlapping clinicopathological features, making a diagnosis very difficult. The differential diagnosis is mainly based on the presence of dysgranulopoiesis, dysmegakaryocytopoiesis, an increased percentage of blasts, and abnormal karyotype, all favouring the diagnosis of hMDS. An accurate diagnosis has important clinical implications, as the prognosis and treatment can be quite different for these diseases. Patients with hMDS have a greater risk of neoplastic progression, a shorter survival time and a lower response to immunosuppressive therapy compared with patients with AA. There is compelling evidence that these distinct clinical entities share a common pathophysiology based on the damage of hematopoietic stem and progenitor cells (HSPCs) by cytotoxic T cells. Expanded T cells overproduce proinflammatory cytokines (interferon-γ and tumor necrosis factor-α), resulting in decreased proliferation and increased apoptosis of HSPCs. The antigens that trigger this abnormal immune response are not known, but potential candidates have been suggested, including Wilms tumor protein 1 and human leukocyte antigen class I molecules. Our understanding of the molecular pathogenesis of these BM failure syndromes has been improved by next-generation sequencing, which has enabled the identification of a large spectrum of mutations. It has also brought new challenges, such as the interpretation of variants of uncertain significance and clonal hematopoiesis of indeterminate potential. The present review discusses the main clinicopathological differences between hMDS and acquired AA, focuses on the molecular background and highlights the importance of molecular testing.
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Affiliation(s)
- Hana Votavova
- Department of Genomics, Institute of Hematology and Blood Transfusion, Prague 128 00, Czech Republic
| | - Monika Belickova
- Department of Genomics, Institute of Hematology and Blood Transfusion, Prague 128 00, Czech Republic
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28
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Gurnari C, Maciejewski JP. Aplastic anemia: quo vadis? Semin Hematol 2021; 59:54-55. [DOI: 10.1053/j.seminhematol.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/26/2021] [Indexed: 11/11/2022]
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29
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Giudice V, Risitano AM, Selleri C. Infectious Agents and Bone Marrow Failure: A Causal or a Casual Connection? Front Med (Lausanne) 2021; 8:757730. [PMID: 34805223 PMCID: PMC8599277 DOI: 10.3389/fmed.2021.757730] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/05/2021] [Indexed: 12/15/2022] Open
Abstract
Acquired bone marrow failure (BMF) syndromes are considered immune-mediated disorders because hematological recovery after immunosuppressive therapies is the strongest indirect evidence of the involvement of immune cells in marrow failure development. Among pathophysiology hypotheses, immune derangement after chronic antigen exposure or cross-reactivity between viral particles and cellular components are the most accepted; however, epitopes against whom these lymphocytes are directed to remain unknown. In this study, we showed that BMF-associated immunodominant clones, namely the most represented T cells carrying an antigen-specific T-cell receptor (TCR) sequence in a random pool, were frequently associated with those described in various infectious diseases, such as cytomegalovirus (CMV) and Mycobacterium tuberculosis infection. We hypothesize that these pathogens might elicit an autoimmune response triggered by cross-reactivity between pathogen-related components and proteins or might be expanded as an unspecific response to a global immune dysregulation during BMF. However, those frequent intracellular pathogens might not only be passengers in marrow failure development, while playing a central role in starting the autoimmune response against hematopoietic stem cells.
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Affiliation(s)
- Valentina Giudice
- Department of Medicine, Surgery and Dentistry Scuola Medica Salernitana, University of Salerno, Baronissi, Italy.,Hematology and Transplant Center, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Antonio M Risitano
- Hematology and Hematopoietic Stem Cell Transplantation Unit, AORN San Giuseppe Moscati, Avellino, Italy.,Department of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Carmine Selleri
- Department of Medicine, Surgery and Dentistry Scuola Medica Salernitana, University of Salerno, Baronissi, Italy.,Hematology and Transplant Center, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
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30
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Fang M, Song H, Zhang J, Li S, Shen D, Tang Y. Efficacy and safety of immunosuppressive therapy with or without eltrombopag in pediatric patients with acquired aplastic anemia: A Chinese retrospective study. Pediatr Hematol Oncol 2021; 38:633-646. [PMID: 33724146 DOI: 10.1080/08880018.2021.1895924] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
To determine the efficacy and safety of eltrombopag (E-PAG) combined with intensive immunosuppressive therapy (IST) for the treatment of pediatric patients with severe aplastic anemia (SAA). A total of 57 pediatric patients with newly diagnosed severe aplastic anemia were enrolled in this study. Thirty nine patients were treated with IST alone, consisting of porcine anti-human thymocyte globulin (30 mg/kg/day × 5 days) and cyclosporine A (CsA) (treated for 2 years, with a trough concentration maintained at 200-250 ng/mL), and 18 patients were treated with IST + E-PAG (12.5-50 mg/day, maintained for 6 months). We found no statistical difference between the response rates at 3 months for the two groups (CR: 12.8% vs. 22.2% p > 0.05, ORR: 56.4% vs. 77.7% p > 0.05). However, we found a statistical difference between the response rates at 6 months for the two groups (CR: 17.9% vs. 50% p < 0.05, ORR: 69.2% vs. 94.4% p < 0.05). The main side-effect during treatment with E-PAG was having a slightly to moderately elevated bilirubin level, which was temporary and controllable, accounting for approximately 66.6% (12/18) of patients in the IST + E-PAG group vs. 20.5% (8/39) of those in the IST group (p < 0.05). IST + E-PAG therapy appears to be more effective than IST alone for the treatment of pediatric SAA, with good tolerability and compliance. This approach deserves further exploration.
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Affiliation(s)
- Meixin Fang
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
| | - Hua Song
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
| | - Jingying Zhang
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
| | - Sisi Li
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
| | - Diying Shen
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
| | - Yongmin Tang
- Department of Hematology-Oncology, Pediatric Hematology-oncology Center, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center For Child Health, Hangzhou, PR China
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31
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The Value of Flow Cytometry Clonality in Large Granular Lymphocyte Leukemia. Cancers (Basel) 2021; 13:cancers13184513. [PMID: 34572739 PMCID: PMC8468916 DOI: 10.3390/cancers13184513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/01/2021] [Accepted: 09/06/2021] [Indexed: 12/28/2022] Open
Abstract
Simple Summary Large granular lymphocyte (LGL) leukemia, a lymphoproliferative disease, is characterized by an increased frequency of large-sized lymphocytes with typical expression of T-cell receptor (TCR) αβ, CD3, CD8, CD16, CD45RA, and CD57, and with the expansion of one to three subfamilies of the TCR variable β chain reflecting gene rearrangements. Molecular analysis remains the gold standard for confirmation of TCR clonality; however, flow cytometry is time and labor saving, and can be associated with simultaneous investigation of other surface markers. Moreover, Vβ usage by flow cytometry can be employed for monitoring clonal kinetics during treatment and follow-up of LGL leukemia patients. Abstract Large granular lymphocyte (LGL) leukemia is a lymphoproliferative disorder of mature T or NK cells frequently associated with autoimmune disorders and other hematological conditions, such as myelodysplastic syndromes. Immunophenotype of LGL cells is similar to that of effector memory CD8+ T cells with T-cell receptor (TCR) clonality defined by molecular and/or flow cytometric analysis. Vβ usage by flow cytometry can identify clonal TCR rearrangements at the protein level, and is fast, sensitive, and almost always available in every Hematology Center. Moreover, Vβ usage can be associated with immunophenotypic characterization of LGL clone in a multiparametric staining, and clonal kinetics can be easily monitored during treatment and follow-up. Finally, Vβ usage by flow cytometry might identify LGL clones silently underlying other hematological conditions, and routine characterization of Vβ skewing might identify recurrent TCR rearrangements that might trigger aberrant immune responses during hematological or autoimmune conditions.
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32
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Obiorah IE, Patel BA, Groarke EM, Wang W, Trick M, Ombrello AK, Ferrada MA, Wu Z, Gutierrez-Rodrigues F, Lotter J, Wilson L, Hoffmann P, Cardona DO, Patel N, Dulau-Florea A, Kastner DL, Grayson PC, Beck DB, Young NS, Calvo KR. Benign and malignant hematologic manifestations in patients with VEXAS syndrome due to somatic mutations in UBA1. Blood Adv 2021; 5:3203-3215. [PMID: 34427584 PMCID: PMC8405186 DOI: 10.1182/bloodadvances.2021004976] [Citation(s) in RCA: 122] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/04/2021] [Indexed: 11/20/2022] Open
Abstract
Somatic mutations in UBA1 involving hematopoietic stem and myeloid cells have been reported in patients with the newly defined VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome. Here, we report clinical hematologic manifestations and unique bone marrow (BM) features in 16 patients with VEXAS. All patients were male and had a history of severe autoinflammatory and rheumatologic manifestations and a somatic UBA1 mutation (p.Met41). Ten patients had hematologic disorders: myelodysplastic syndrome (MDS; 6 of 16), multiple myeloma (2 of 16), monoclonal gammopathy of undetermined significance (2 of 16), and monoclonal B-cell lymphocytosis (2 of 16), and a few of those patients had 2 co-existing clonal processes. Although macrocytic anemia (100%) and lymphopenia (80%) were prevalent in all patients with VEXAS, thrombocytopenia and neutropenia were more common in patients with progression to MDS. All BMs in VEXAS patients had prominent cytoplasmic vacuoles in myeloid and erythroid precursors. In addition, most BMs were hypercellular with myeloid hyperplasia, erythroid hypoplasia, and varying degrees of dysplasia. All patients diagnosed with MDS were lower risk (low blast count, very good to intermediate cytogenetics) according to standard prognostic scoring with no known progression to leukemia. In addition, 10 of 16 patients had thrombotic events, including venous thromboembolism and arterial stroke. Although VEXAS presents symptomatically as a rheumatologic disease, morbidity and mortality are associated with progression to hematologic disease. Given the increased risk of developing MDS and multiple myeloma, surveillance for disease progression is important.
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Affiliation(s)
- Ifeyinwa Emmanuela Obiorah
- Hematopathology Section, Laboratory of Pathology, Center for Cancer Research, National Cancer Institute
- Hematology Section, Department of Laboratory Medicine, Clinical Center
| | | | - Emma M Groarke
- Hematology Branch, National Heart, Lung, and Blood Institute
| | - Weixin Wang
- Hematology Section, Department of Laboratory Medicine, Clinical Center
| | - Megan Trick
- Hematology Section, Department of Laboratory Medicine, Clinical Center
| | - Amanda K Ombrello
- Metabolic, Cardiovascular, and Inflammatory Disease Genomics Branch, National Human Genome Research Institute, and
| | - Marcela A Ferrada
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD
| | - Zhijie Wu
- Hematology Branch, National Heart, Lung, and Blood Institute
| | | | - Jennifer Lotter
- Hematology Branch, National Heart, Lung, and Blood Institute
| | - Lorena Wilson
- Metabolic, Cardiovascular, and Inflammatory Disease Genomics Branch, National Human Genome Research Institute, and
| | - Patrycja Hoffmann
- Metabolic, Cardiovascular, and Inflammatory Disease Genomics Branch, National Human Genome Research Institute, and
| | - Daniela Ospina Cardona
- Metabolic, Cardiovascular, and Inflammatory Disease Genomics Branch, National Human Genome Research Institute, and
| | - Nisha Patel
- Hematology Section, Department of Laboratory Medicine, Clinical Center
| | | | - Daniel L Kastner
- Metabolic, Cardiovascular, and Inflammatory Disease Genomics Branch, National Human Genome Research Institute, and
| | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD
| | - David B Beck
- Metabolic, Cardiovascular, and Inflammatory Disease Genomics Branch, National Human Genome Research Institute, and
| | - Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute
| | - Katherine R Calvo
- Hematology Section, Department of Laboratory Medicine, Clinical Center
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33
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The predictive value of PNH clones, 6p CN-LOH, and clonal TCR gene rearrangement for aplastic anemia diagnosis. Blood Adv 2021; 5:3216-3226. [PMID: 34427585 DOI: 10.1182/bloodadvances.2021004201] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 05/12/2021] [Indexed: 12/29/2022] Open
Abstract
Acquired aplastic anemia (AA) is a life-threatening bone marrow aplasia caused by the autoimmune destruction of hematopoietic stem and progenitor cells. There are no existing diagnostic tests that definitively establish AA, and diagnosis is currently made via systematic exclusion of various alternative etiologies, including inherited bone marrow failure syndromes (IBMFSs). The exclusion of IBMFSs, which requires syndrome-specific functional and genetic testing, can substantially delay treatment. AA and IBMFSs can have mimicking clinical presentations, and their distinction has significant implications for treatment and family planning, making accurate and prompt diagnosis imperative to optimal patient outcomes. We hypothesized that AA could be distinguished from IBMFSs using 3 laboratory findings specific to the autoimmune pathogenesis of AA: paroxysmal nocturnal hemoglobinuria (PNH) clones, copy-number-neutral loss of heterozygosity in chromosome arm 6p (6p CN-LOH), and clonal T-cell receptor (TCR) γ gene (TRG) rearrangement. To test our hypothesis, we determined the prevalence of PNH, acquired 6p CN-LOH, and clonal TRG rearrangement in 454 consecutive pediatric and adult patients diagnosed with AA, IBMFSs, and other hematologic diseases. Our results indicated that PNH and acquired 6p CN-LOH clones encompassing HLA genes have ∽100% positive predictive value for AA, and they can facilitate diagnosis in approximately one-half of AA patients. In contrast, clonal TRG rearrangement is not specific for AA. Our analysis demonstrates that PNH and 6p CN-LOH clones effectively distinguish AA from IBMFSs, and both measures should be incorporated early in the diagnostic evaluation of suspected AA using the included Bayesian nomogram to inform clinical application.
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34
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Immunologic effects on the haematopoietic stem cell in marrow failure. Best Pract Res Clin Haematol 2021; 34:101276. [PMID: 34404528 DOI: 10.1016/j.beha.2021.101276] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023]
Abstract
Acquired bone marrow failure (BMF) syndromes comprise a diverse group of diseases with variable clinical manifestations but overlapping features of immune activation, resulting in haematopoietic stem and progenitor cells (HSPC) damage and destruction. This review focuses on clinical presentation, pathophysiology, and treatment of four BMF: acquired aplastic anaemia, large granular lymphocytic leukaemia, paroxysmal nocturnal haemoglobinuria, and hypoplastic myelodysplastic syndrome. Autoantigens are speculated to be the inciting event that result in immune activation in all of these diseases, but specific pathogenic antigens have not been identified. Oligoclonal cytotoxic T cell expansion and an active role of proinflammatory cytokines, primarily interferon gamma (IFN-γ) and tumor necrosis factor alpha (TNF-α), are two main contributors to HSPC growth inhibition and apoptosis in BMF. Emerging evidence also suggests involvement of the innate immune system.
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35
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Diversity, localization, and (patho)physiology of mature lymphocyte populations in the bone marrow. Blood 2021; 137:3015-3026. [PMID: 33684935 DOI: 10.1182/blood.2020007592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 02/25/2021] [Indexed: 02/07/2023] Open
Abstract
The bone marrow (BM) is responsible for generating and maintaining lifelong output of blood and immune cells. In addition to its key hematopoietic function, the BM acts as an important lymphoid organ, hosting a large variety of mature lymphocyte populations, including B cells, T cells, natural killer T cells, and innate lymphoid cells. Many of these cell types are thought to visit the BM only transiently, but for others, like plasma cells and memory T cells, the BM provides supportive niches that promote their long-term survival. Interestingly, accumulating evidence points toward an important role for mature lymphocytes in the regulation of hematopoietic stem cells (HSCs) and hematopoiesis in health and disease. In this review, we describe the diversity, migration, localization, and function of mature lymphocyte populations in murine and human BM, focusing on their role in immunity and hematopoiesis. We also address how various BM lymphocyte subsets contribute to the development of aplastic anemia and immune thrombocytopenia, illustrating the complexity of these BM disorders and the underlying similarities and differences in their disease pathophysiology. Finally, we summarize the interactions between mature lymphocytes and BM resident cells in HSC transplantation and graft-versus-host disease. A better understanding of the mechanisms by which mature lymphocyte populations regulate BM function will likely improve future therapies for patients with benign and malignant hematologic disorders.
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36
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Mizumaki H, Hosomichi K, Hosokawa K, Yoroidaka T, Imi T, Zaimoku Y, Katagiri T, Anh Thi Nguyen M, Cao Tran D, Ibrahim Yousef Elbadry M, Chonabayashi K, Yoshida Y, Takamatsu H, Ozawa T, Azuma F, Kishi H, Fujii Y, Ogawa S, Tajima A, Nakao S. A frequent nonsense mutation in exon 1 across certain HLA-A and -B alleles in leukocytes of patients with acquired aplastic anemia. Haematologica 2021; 106:1581-1590. [PMID: 32439725 PMCID: PMC8168509 DOI: 10.3324/haematol.2020.247809] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Indexed: 12/24/2022] Open
Abstract
Leukocytes that lack HLA allelic expression are frequently detected in patients with acquired aplastic anemia (AA) who respond to immunosuppressive therapy (IST), although the exact mechanisms underlying the HLA loss and HLA allele repertoire likely to acquire loss-of-function mutations are unknown. We identified a common nonsense mutation at position 19 (c.19C>T, p.R7X) in exon 1 (Exon1mut) of different HLA-A and -B alleles in HLA-lacking granulocytes from AA patients. A droplet digital PCR (ddPCR) assay capable of detecting as few as 0.07% Exon1mut HLA alleles in total DNA revealed the mutation was present in 29% (101/353) of AA patients, with a median allele frequency of 0.42% (range, 0.071% to 21.3%). Exon1mut occurred in only 12 different HLA-A (n=4) and HLA-B (n=8) alleles, including B*40:02 (n=31) and A*02:06 (n=15), which correspond to 4 HLA supertypes (A02, A03, B07, and B44). The percentages of patients who possessed at least one of these 12 HLA alleles were significantly higher in the 353 AA patients (92%, P.
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Affiliation(s)
- Hiroki Mizumaki
- Department of Hematology, Kanazawa University, Kanazawa, Japan
| | - Kazuyoshi Hosomichi
- Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Japan
| | - Kohei Hosokawa
- Department of Hematology, Kanazawa University, Kanazawa, Japan
| | | | - Tatsuya Imi
- Department of Hematology, Kanazawa University, Kanazawa, Japan
| | | | - Takamasa Katagiri
- Clinical Laboratory Sciences, Kanazawa University Graduate School, Kanazawa, Japan
| | | | - Dung Cao Tran
- Department of Hematology, Kanazawa University, Kanazawa, Japan
| | | | | | - Yoshinori Yoshida
- Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
| | | | - Tatsuhiko Ozawa
- Department of Immunology, University of Toyama, Toyama, Japan
| | - Fumihiro Azuma
- HLA Laboratory, Japanese Red Cross Kanto-Koshinetsu Block Blood Center, Kotoku, Japan
| | - Hiroyuki Kishi
- Department of Immunology, University of Toyama, Toyama, Japan
| | - Yoichi Fujii
- Dept. of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Japan
| | - Seishi Ogawa
- Dept. of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Japan
| | - Atsushi Tajima
- Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Shinji Nakao
- Department of Hematology, Kanazawa University, Kanazawa, Japan
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37
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Li H, Long Z, Wang T, Han B. Stanozolol and Danazol Have Different Effects on Hematopoiesis in the Murine Model of Immune-Mediated Bone Marrow Failure. Front Med (Lausanne) 2021; 8:615195. [PMID: 34124083 PMCID: PMC8193361 DOI: 10.3389/fmed.2021.615195] [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] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 04/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Stanozolol and danazol are widely used in the treatment of aplastic anemia; however, their mechanisms of action are unclear. Methods: Bone marrow mononuclear cells from 10 patients newly diagnosed with aplastic anemia and 10 healthy volunteers were collected and cultured together with stanozolol, danazol, or blank control separately for marrow colony assays. K562 cell lines that had been incubated with stanozolol, danazol, or blank control were tested for erythroid or megakaryocytic differentiation. Meanwhile, CB6F1/Crl mice were injected with 1 × 106 C57BL/6 donor-originated lymphocytes after irradiation with 5 Gy total body irradiation to establish a model for immune-mediated bone marrow failure (aplastic anemia mouse model). Mice with aplastic anemia were treated with cyclosporin A monotherapy, cyclosporin A in combination with stanozolol, and cyclosporin A in combination with danazol for 30 days. Peripheral blood cell counts once a week and bone marrow colony assays at the end of 1 month were performed. The proportion of T cell subsets, level of inflammatory factors, erythropoietin, and thrombopoietin were detected before and after treatment. The levels of erythropoietin receptors on bone marrow mononuclear cells after treatment were tested using western blotting. Results: In the ex vivo experiments, the number of burst-forming units-erythroid; colony-forming units-granulocyte and macrophage; and colony-forming units-granulocyte, erythrocyte, monocyte, and megakaryocyte in the patients with aplastic anemia were significantly lower than that in the normal controls (P < 0.05). However, the number of colonies and mean fluorescence intensity of CD235a or CD41 expression in the harvested cultured cells were not significantly different among the different treatment groups in the patients with aplastic anemia, normal controls, and K562 cell lines. These results show that stanozolol and danazol produce no direct hematopoiesis-stimulating effects on progenitor cells. In the in vivo experiment, the mice with aplastic anemia treated with cyclosporin A and danazol exhibited the most rapid recovery of platelet; the platelet count returned to normal levels after 3 weeks of treatment, which was at least 1 week earlier than in the other groups. In contrast, mice treated with cyclosporin A and stanozolol exhibited the highest hemoglobin level at the end of treatment (P < 0.05). Bone marrow colony assays at 30 days showed that the number of burst-forming units-erythroid was the highest in mice treated with cyclosporin A and stanozolol, while the number of colony-forming units-granulocyte and macrophage was the highest in those treated with cyclosporin A and danazol. Compared to cyclosporin A monotherapy, additional stanozolol and danazol can both increase the level of regulatory T cells and upregulate interleukin-10, inhibiting the expression of tumor necrosis factor-α (P < 0.05). However, IL-2 was more effectively reduced by danazol than by stanozolol (P < 0.05). The cyclosporin A- and stanozolol-treated mice showed higher serum erythropoietin (corrected by hemoglobin level) and higher erythropoietin receptor levels in bone marrow mononuclear cells than the other groups (P < 0.05). Conclusions: Neither stanozolol nor danazol directly stimulated hematopoiesis in vitro. However, in vivo, stanozolol may exhibit an advantage in improving erythropoiesis, while danazol may induce stronger effects on platelets. Both danazol and stanozolol exhibited immunosuppressive roles. Stanozolol could enhance the secretion of erythropoietin and expression of erythropoietin receptor in bone marrow mononuclear cells.
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Affiliation(s)
- Hongmin Li
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Zhangbiao Long
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
| | - Tao Wang
- Institute of Basic Medical Sciences, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science, Beijing, China
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38
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Scheinberg P. Acquired severe aplastic anaemia: how medical therapy evolved in the 20th and 21st centuries. Br J Haematol 2021; 194:954-969. [PMID: 33855695 DOI: 10.1111/bjh.17403] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Abstract
The progress in aplastic anaemia (AA) management is one of success. Once an obscure entity resulting in death in most affected can now be successfully treated with either haematopoietic stem cell transplantation (HSCT) or immunosuppressive therapy (IST). The mechanisms that underly the diminution of haematopoietic stem cells (HSCs) are now better elucidated, and include genetics and immunological alterations. Advances in supportive care with better antimicrobials, safer blood products and iron chelation have greatly impacted AA outcomes. Working somewhat 'mysteriously', anti-thymocyte globulin (ATG) forms the base for both HSCT and IST protocols. Efforts to augment immunosuppression potency have not, unfortunately, led to better outcomes. Stimulating HSCs, an often-sought approach, has not been effective historically. The thrombopoietin receptor agonists (Tpo-RA) have been effective in stimulating early HSCs in AA despite the high endogenous Tpo levels. Dosing, timing and best combinations with Tpo-RAs are being defined to improve HSCs expansion in AA with minimal added toxicity. The more comprehensive access and advances in HSCT and IST protocols are likely to benefit AA patients worldwide. The focus of this review will be on the medical treatment advances in AA.
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Affiliation(s)
- Phillip Scheinberg
- Division of Haematology, Hospital A Beneficência Portuguesa, São Paulo, Brazil
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39
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Somatic mutations in lymphocytes in patients with immune-mediated aplastic anemia. Leukemia 2021; 35:1365-1379. [PMID: 33785863 PMCID: PMC8102188 DOI: 10.1038/s41375-021-01231-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 02/04/2021] [Accepted: 03/12/2021] [Indexed: 12/31/2022]
Abstract
The prevalence and functional impact of somatic mutations in nonleukemic T cells is not well characterized, although clonal T-cell expansions are common. In immune-mediated aplastic anemia (AA), cytotoxic T-cell expansions are shown to participate in disease pathogenesis. We investigated the mutation profiles of T cells in AA by a custom panel of 2533 genes. We sequenced CD4+ and CD8+ T cells of 24 AA patients and compared the results to 20 healthy controls and whole-exome sequencing of 37 patients with AA. Somatic variants were common both in patients and healthy controls but enriched to AA patients’ CD8+ T cells, which accumulated most mutations on JAK-STAT and MAPK pathways. Mutation burden was associated with CD8+ T-cell clonality, assessed by T-cell receptor beta sequencing. To understand the effect of mutations, we performed single-cell sequencing of AA patients carrying STAT3 or other mutations in CD8+ T cells. STAT3 mutated clone was cytotoxic, clearly distinguishable from other CD8+ T cells, and attenuated by successful immunosuppressive treatment. Our results suggest that somatic mutations in T cells are common, associate with clonality, and can alter T-cell phenotype, warranting further investigation of their role in the pathogenesis of AA.
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Liu B, Zeng L, Shao Y, Fu R. Expression and function of SLAMF6 in CD8 + T lymphocytes of patients with severe aplastic anemia. Cell Immunol 2021; 364:104343. [PMID: 33774556 DOI: 10.1016/j.cellimm.2021.104343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/22/2021] [Accepted: 03/01/2021] [Indexed: 10/21/2022]
Abstract
This study investigated the expression status of signaling lymphocytic activation molecule family 6 (SLAMF6) in CD8+ T lymphocytes of patients with severe aplastic anemia (SAA) and its association with the clinical indicators and immune status of the disease. The effects of SLAMF6 on the function and apoptosis of CD8+ T lymphocytes were also investigated. Levels of SLAMF6 and SLAM-associated protein in the CD8+ T lymphocytes of SAA patients were significantly lower than the normal controls, and they were positively correlated with hematopoietic-related indicators but negatively correlated with the levels of functional molecules of CD8+ T lymphocytes. After blocking SLAMF6, CD8+ T lymphocyte functional molecule secretion was upregulated and RICD was downregulated in SAA patients, suggesting that SLAMF6, is involved in the pathogenetic mechanism of SAA by regulating CD8+ T lymphocyte functional molecule secretion and RICD levels. SLAMF6 may be a novel target for the regulation of CD8+ T lymphocyte homeostasis.
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Affiliation(s)
- Bingnan Liu
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin 300052, PR China
| | - Lijie Zeng
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin 300052, PR China
| | - Yuanyuan Shao
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin 300052, PR China
| | - Rong Fu
- Department of Hematology, Tianjin Medical University General Hospital, 154 Anshan Street, Heping District, Tianjin 300052, PR China.
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When Should We Think of Myelodysplasia or Bone Marrow Failure in a Thrombocytopenic Patient? A Practical Approach to Diagnosis. J Clin Med 2021; 10:jcm10051026. [PMID: 33801484 PMCID: PMC7958851 DOI: 10.3390/jcm10051026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/11/2021] [Accepted: 02/17/2021] [Indexed: 12/15/2022] Open
Abstract
Thrombocytopenia can arise from various conditions, including myelodysplastic syndromes (MDS) and bone marrow failure (BMF) syndromes. Meticulous assessment of the peripheral blood smear, identification of accompanying clinical conditions, and characterization of the clinical course are important for initial assessment of unexplained thrombocytopenia. Increased awareness is required to identify patients with suspected MDS or BMF, who are in need of further investigations by a step-wise approach. Bone marrow cytomorphology, histopathology, and cytogenetics are complemented by myeloid next-generation sequencing (NGS) panels. Such panels are helpful to distinguish reactive cytopenia from clonal conditions. MDS are caused by mutations in the hematopoietic stem/progenitor cells, characterized by cytopenia and dysplasia, and an inherent risk of leukemic progression. Aplastic anemia (AA), the most frequent acquired BMF, is immunologically driven and characterized by an empty bone marrow. Diagnosis remains challenging due to overlaps with other hematological disorders. Congenital BMF, certainly rare in adulthood, can present atypically with thrombocytopenia and can be misdiagnosed. Analyses for chromosome fragility, telomere length, and germline gene sequencing are needed. Interdisciplinary expert teams contribute to diagnosis, prognostication, and choice of therapy for patients with suspected MDS and BMF. With this review we aim to increase the awareness and provide practical approaches for diagnosis of these conditions in suspicious cases presenting with thrombocytopenia.
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Kasinathan G, Lee BS, Sathar J. Very severe aplastic anemia in an 80-year-old man. Clin Case Rep 2021; 9:1330-1333. [PMID: 33768838 PMCID: PMC7981752 DOI: 10.1002/ccr3.3757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/18/2020] [Accepted: 10/20/2020] [Indexed: 12/04/2022] Open
Abstract
Although the patient with very severe aplastic anemia might be a fit elderly receiving standard therapy, there are factors which contribute to an adverse outcome such as severity of pancytopenia, absence of minor paroxysmal nocturnal hemoglobinuria clone and infective complications of therapy.
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Affiliation(s)
| | - Bee Sun Lee
- Department of HematologyAmpang HospitalAmpangMalaysia
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Giudice V, Cardamone C, Triggiani M, Selleri C. Bone Marrow Failure Syndromes, Overlapping Diseases with a Common Cytokine Signature. Int J Mol Sci 2021; 22:ijms22020705. [PMID: 33445786 PMCID: PMC7828244 DOI: 10.3390/ijms22020705] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/06/2021] [Accepted: 01/09/2021] [Indexed: 12/19/2022] Open
Abstract
Bone marrow failure (BMF) syndromes are a heterogenous group of non-malignant hematologic diseases characterized by single- or multi-lineage cytopenia(s) with either inherited or acquired pathogenesis. Aberrant T or B cells or innate immune responses are variously involved in the pathophysiology of BMF, and hematological improvement after standard immunosuppressive or anti-complement therapies is the main indirect evidence of the central role of the immune system in BMF development. As part of this immune derangement, pro-inflammatory cytokines play an important role in shaping the immune responses and in sustaining inflammation during marrow failure. In this review, we summarize current knowledge of cytokine signatures in BMF syndromes.
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Affiliation(s)
- Valentina Giudice
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy; (V.G.); (C.C.); (C.S.)
- Clinical Pharmacology, University Hospital “San Giovanni di Dio e Ruggi D’Aragona”, 84131 Salerno, Italy
- Hematology and Transplant Center, University Hospital “San Giovanni di Dio e Ruggi D’Aragona”, 84131 Salerno, Italy
| | - Chiara Cardamone
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy; (V.G.); (C.C.); (C.S.)
- Internal Medicine and Clinical Immunology, University Hospital “San Giovanni di Dio e Ruggi D’Aragona”, 84131 Salerno, Italy
| | - Massimo Triggiani
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy; (V.G.); (C.C.); (C.S.)
- Internal Medicine and Clinical Immunology, University Hospital “San Giovanni di Dio e Ruggi D’Aragona”, 84131 Salerno, Italy
- Correspondence: ; Tel.: +39-089-672810
| | - Carmine Selleri
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, 84081 Salerno, Italy; (V.G.); (C.C.); (C.S.)
- Hematology and Transplant Center, University Hospital “San Giovanni di Dio e Ruggi D’Aragona”, 84131 Salerno, Italy
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Hypoplastic Myelodysplastic Syndromes: Just an Overlap Syndrome? Cancers (Basel) 2021; 13:cancers13010132. [PMID: 33401595 PMCID: PMC7795441 DOI: 10.3390/cancers13010132] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 12/29/2020] [Accepted: 12/29/2020] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Hypoplastic myelodysplastic syndromes (hMDS) represent a diagnostic conundrum. They share morphologic and clinical features of both MDS (dysplasia, genetic lesions and cytopenias) and aplastic anemia (AA; i.e., hypocellularity and autoimmunity) and are not comprised in the last WHO classification. In this review we recapitulate the main clinical, pathogenic and therapeutic aspects of hypo-MDS and discuss why they deserve to be distinguished from normo/hypercellular MDS and AA. We conclude that hMDS may present in two phenotypes: one more proinflammatory and autoimmune, more similar to AA, responding to immunosuppression; and one MDS-like dominated by genetic lesions, suppression of immune surveillance, and tumor escape, more prone to leukemic evolution. Abstract Myelodysplasias with hypocellular bone marrow (hMDS) represent about 10–15% of MDS and are defined by reduced bone marrow cellularity (i.e., <25% or an inappropriately reduced cellularity for their age in young patients). Their diagnosis is still an object of debate and has not been clearly established in the recent WHO classification. Clinical and morphological overlaps with both normo/hypercellular MDS and aplastic anemia include cytopenias, the presence of marrow hypocellularity and dysplasia, and cytogenetic and molecular alterations. Activation of the immune system against the hematopoietic precursors, typical of aplastic anemia, is reckoned even in hMDS and may account for the response to immunosuppressive treatment. Finally, the hMDS outcome seems more favorable than that of normo/hypercellular MDS patients. In this review, we analyze the available literature on hMDS, focusing on clinical, immunological, and molecular features. We show that hMDS pathogenesis and clinical presentation are peculiar, albeit in-between aplastic anemia (AA) and normo/hypercellular MDS. Two different hMDS phenotypes may be encountered: one featured by inflammation and immune activation, with increased cytotoxic T cells, increased T and B regulatory cells, and better response to immunosuppression; and the other, resembling MDS, where T and B regulatory/suppressor cells prevail, leading to genetic clonal selection and an increased risk of leukemic evolution. The identification of the prevailing hMDS phenotype might assist treatment choice, inform prognosis, and suggest personalized monitoring.
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Aplastic anemia in a patient with CVID due to NFKB1 haploinsufficiency. Cold Spring Harb Mol Case Stud 2020; 6:mcs.a005769. [PMID: 32972988 PMCID: PMC7784489 DOI: 10.1101/mcs.a005769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/04/2020] [Indexed: 12/13/2022] Open
Abstract
Acquired aplastic anemia (AA) is a life-threatening bone marrow failure caused by an autoimmune cytotoxic T lymphocyte attack on hematopoietic stem and progenitor cells. Factors contributing to aberrant autoimmune activation in AA include a deficit of T regulatory cells and high levels of inflammatory cytokines. Several acquired conditions of immune dysregulation and genetic polymorphisms in inflammatory cytokines and human leukocyte antigen genes have been linked to an increased risk of AA. However, AA has not been reported in patients with Mendelian disorders of immune regulation. Here we report a patient with familial common variable immunodeficiency (CVID) caused by a pathogenic variant in NFKB1, who developed AA as an adult. The patient had a difficult clinical course and was unable to tolerate standard AA therapy with cyclosporine A and eltrombopag, with complications attributed in part to the effect of cyclosporine A on NF-κB signaling. Our case suggests a novel link between genetic disorders of immune regulation and AA and highlights the importance of recognizing inherited autoimmunity syndromes in AA patients for the selection of optimal therapy and prognostic counseling.
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Mikhaylova EA, Fidarova ZT, Abramova AV, Luchkin AV, Troitskaya VV, Dvirnyk VN, Galtseva IV, Kliasova GA, Kovrigina AM, Kulikov SM, Chabaeva YА, Parovichnikova EN, Savchenko VG, Obukhova TN. [Immunosupressive therapy of aplastic anemia patients: successes and failures (single center experiment 2007-2016)]. TERAPEVT ARKH 2020; 92:4-9. [PMID: 33346440 DOI: 10.26442/00403660.2020.07.000756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Indexed: 11/22/2022]
Abstract
Treatment programs for patients with acquired aplastic anemia include two main therapeutic options: allogeneic bone marrow transplantation and combined immunosuppressive therapy (IST). However, combined IST remains the method of choice for most adult AA patients. This study included 120 AA patients who received IST at the National Research Center for Hematology in 20072016. The analysis was applied to 120 patients. Median age was 25 (1765) years, M/F: 66/54, SAA/NSAA: 66%/34%. Effectiveness of IST was carried out in 120 patients with AA. This group did not include 8 SAA patients who died during the first 3 months from the start of treatment from severe infectious complications (early deaths 6.2%) and 2 AA patients who dropped out of surveillance. The observation time was 55 (6120) months. Paroxysmal nocturnal hemoglobinuria (PNH clone) was detected in 67% of AA patients. The median PNH clone size (granulocytes) was 2.5 (0.0199.5)%. The treatment was according to the classical protocol of combined IST: horse antithymocytic globulin and cyclosporin A. Most of patients (87%) responded to combined immunosuppressive therapy. To achieve a positive response, it was sufficient to conduct one course of ATG to 64% of patients, two courses of ATG 24% of patients and 2% of patients responded only after the third course of ATG. A positive response after the first course was obtained in 64% of patients included in the analysis. Most of the responding patients (93%) achieve a positive response after 36 months from the start of treatment. Therefore, the 3rd6th months after the first course of ATG in the absence of an answer to the first line of therapy can be considered the optimal time for the second course of ATG. This tactic allows to get an answer in another 58% of patients who did not respond to the first course of ATG. The probability of an overall 10-year survival rate was 90% (95% confidence interval 83.696.2).
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Mesenchymal Stem Cells in Aplastic Anemia and Myelodysplastic Syndromes: The "Seed and Soil" Crosstalk. Int J Mol Sci 2020; 21:ijms21155438. [PMID: 32751628 PMCID: PMC7432231 DOI: 10.3390/ijms21155438] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/28/2020] [Accepted: 07/28/2020] [Indexed: 12/20/2022] Open
Abstract
There is growing interest in the contribution of the marrow niche to the pathogenesis of bone marrow failure syndromes, i.e., aplastic anemia (AA) and myelodysplastic syndromes (MDSs). In particular, mesenchymal stem cells (MSCs) are multipotent cells that contribute to the organization and function of the hematopoietic niche through their repopulating and supporting abilities, as well as immunomodulatory properties. The latter are of great interest in MDSs and, particularly, AA, where an immune attack against hematopoietic stem cells is the key pathogenic player. We, therefore, conducted Medline research, including all available evidence from the last 10 years concerning the role of MSCs in these two diseases. The data presented show that MSCs display morphologic, functional, and genetic alterations in AA and MDSs and contribute to immune imbalance, ineffective hematopoiesis, and leukemic evolution. Importantly, adoptive MSC infusion from healthy donors can be exploited to heal the "sick" niche, with even better outcomes if cotransplanted with allogeneic hematopoietic stem cells. Finally, future studies on MSCs and the whole microenvironment will further elucidate AA and MDS pathogenesis and possibly improve treatment.
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Kulasekararaj AG. Regulatory cells in immune-mediated aplastic anaemia - not T regs but B regs. Br J Haematol 2020; 190:486-487. [PMID: 32583450 DOI: 10.1111/bjh.16713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/12/2020] [Indexed: 01/29/2023]
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Huang G, Zhang Y, Wei X, Yu Z, Lai J, Shen Q, Chen X, Tan G, Chen C, Luo W, Li Y, Zhou M, Li Y, Li B. CD8+GITR+ T cells may negatively regulate T cell overactivation in aplastic anemia. Immunol Invest 2020; 50:406-415. [PMID: 32462957 DOI: 10.1080/08820139.2020.1770785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Guixuan Huang
- Institute of Hematology, School of Medicine, Jinan University, Guangzhou, China
| | - Yuping Zhang
- Department of Hematology, Guangzhou First People’s Hospital, the Second Affiliated Hospital of South China University of Technology, Guangzhou, China
| | - Xiaolei Wei
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhi Yu
- Department of Hematology, First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Jing Lai
- Department of Hematology, First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Qi Shen
- Department of Hematology, Second Clinical Medical College of Jinan University (Shenzhen People’s Hospital), Shengzhen, China
| | - Xiaohui Chen
- Institute of Hematology, School of Medicine, Jinan University, Guangzhou, China
| | - Guangxiao Tan
- Institute of Hematology, School of Medicine, Jinan University, Guangzhou, China
| | - Cunte Chen
- Institute of Hematology, School of Medicine, Jinan University, Guangzhou, China
| | | | - Yumiao Li
- Department of Hematology, Guangzhou First People’s Hospital, the Second Affiliated Hospital of South China University of Technology, Guangzhou, China
| | - Ming Zhou
- Department of Hematology, Guangzhou First People’s Hospital, the Second Affiliated Hospital of South China University of Technology, Guangzhou, China
| | - Yangqiu Li
- Institute of Hematology, School of Medicine, Jinan University, Guangzhou, China
| | - Bo Li
- Institute of Hematology, School of Medicine, Jinan University, Guangzhou, China
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Zaimoku Y, Patel BA, Kajigaya S, Feng X, Alemu L, Quinones Raffo D, Groarke EM, Young NS. Deficit of circulating CD19 + CD24 hi CD38 hi regulatory B cells in severe aplastic anaemia. Br J Haematol 2020; 190:610-617. [PMID: 32311088 PMCID: PMC7496711 DOI: 10.1111/bjh.16651] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/10/2020] [Accepted: 03/18/2020] [Indexed: 12/12/2022]
Abstract
Immune aplastic anaemia (AA) is caused by cytotoxic T lymphocytes (CTLs) that destroy haematopoietic stem and progenitor cells. Enhanced type 1 T helper (Th1) responses and reduced regulatory T cells (Tregs) are involved in the immune pathophysiology. CD24hiCD38hi regulatory B cells (Bregs) suppress CTLs and Th1 responses, and induce Tregs via interleukin 10 (IL‐10). We investigated circulating B‐cell subpopulations, including CD24hiCD38hi Bregs, as well as total B cells, CD4+ T cells, CD8+ T cells and natural killer cells in 104 untreated patients with severe and very severe AA, aged ≥18 years. All patients were treated with standard immunosuppressive therapy (IST) plus eltrombopag. CD24hiCD38hi Bregs were markedly reduced in patients with AA compared to healthy individuals, especially in very severe AA, but residual Bregs remained functional, capable of producing IL‐10; total B‐cell counts and the other B‐cell subpopulations were similar to those of healthy individuals. CD24hiCD38hi Bregs did not correlate with responses to IST, and they recovered to levels present in healthy individuals after therapy. Mature naïve B‐cell counts were unexpectedly associated with IST response. Markedly reduced CD24hiCD38hi Bregs, especially in very severe AA, with recovery after IST suggest Breg deficits may contribute to the pathophysiology of immune AA.
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Affiliation(s)
- Yoshitaka Zaimoku
- Hematology Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
| | - Bhavisha A Patel
- Hematology Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
| | - Sachiko Kajigaya
- Hematology Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
| | - Xingmin Feng
- Hematology Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
| | - Lemlem Alemu
- Hematology Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
| | - Diego Quinones Raffo
- Hematology Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
| | - Emma M Groarke
- Hematology Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
| | - Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
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