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Castro A, Goodman AM, Rane Z, Talwar JV, Frampton GM, Morris GP, Lippman SM, Zhang X, Kurzrock R, Carter H. Autoimmune HLA Alleles and Neoepitope Presentation Predict Post-Allogenic Transplant Relapse. JOURNAL OF IMMUNOTHERAPY AND PRECISION ONCOLOGY 2023; 6:127-132. [PMID: 37637234 PMCID: PMC10448732 DOI: 10.36401/jipo-22-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 12/20/2022] [Accepted: 03/20/2023] [Indexed: 08/29/2023]
Abstract
Introduction Allogeneic hematopoietic stem cell transplantation (allo-HSCT) can cure patients with high-risk myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). However, many patients relapse or develop debilitating graft-versus-host disease. Transplant restores T-cell reactivity against tumor cells, implicating patient human leukocyte antigen (HLA)-dependent antigen presentation via the major histocompatibility complex as a determinant of response. We sought to identify characteristics of the HLA genotype that influence response in allo-HSCT patients. Methods We collected HLA genotype and panel-based somatic mutation profiles for 55 patients with AML and MDS and available data treated at the University of California San Diego Moores Cancer Center between May 2012 and January 2019. We evaluated characteristics of the HLA genotype relative to relapse-free time and overall survival (OS) post-allo-HSCT using univariable and multivariable regression. Results In multivariable regression, the presence of an autoimmune allele was significantly associated with relapse-free time (hazard ratio [HR], 0.25; p = 0.01) and OS (HR, 0.16; p < 0.005). The better potential of the donor HLA type to present peptides harboring driver mutations trended toward better relapse-free survival (HR, 0.45; p = 0.07) and significantly correlated with longer OS (HR, 0.33; p = 0.01) though only a minority of cases had an HLA mismatch. Conclusion In this single institution retrospective study of patients receiving allo-HSCT for relapsed AML/MDS, characteristics of an individual's HLA genotype (presence of an autoimmune allele and potential of the donor HLA to better present peptides representing driver mutations) were significantly associated with better outcomes. These findings suggest that HLA type may guide the optimal application of allo-HSCT and merit evaluation in larger cohorts. ClinicalTrials.gov Identifier: NCT02478931.
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Affiliation(s)
- Andrea Castro
- Bioinformatics and Systems Biology Program, University of California San Diego, La Jolla, CA, USA
- Division of Medical Genetics, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Aaron M. Goodman
- Division of Blood and Marrow Transplantation, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Zachary Rane
- School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - James V. Talwar
- Bioinformatics and Systems Biology Program, University of California San Diego, La Jolla, CA, USA
- Division of Medical Genetics, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | | | - Gerald P. Morris
- Department of Pathology, University of California San Diego, La Jolla, CA, USA
| | - Scott M. Lippman
- School of Medicine, University of California San Diego, La Jolla, CA, USA
- Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
| | - Xinlian Zhang
- Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
| | - Razelle Kurzrock
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Hannah Carter
- Division of Medical Genetics, Department of Medicine, University of California San Diego, La Jolla, CA, USA
- Moores Cancer Center, University of California San Diego, La Jolla, CA, USA
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2
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Analysis of biological models to predict clinical outcomes based on HLA-DPB1 disparities in unrelated transplantation. Blood Adv 2021; 5:3377-3386. [PMID: 34448833 DOI: 10.1182/bloodadvances.2020003998] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/23/2021] [Indexed: 11/20/2022] Open
Abstract
HLA compatibility is a key factor for survival after unrelated hematopoietic stem cell transplantation (HSCT). HLA-A, -B, -C, -DRB1, and -DQB1 are usually matched between donor and recipient. By contrast, HLA-DPB1 mismatches are frequent, although it is feasible to optimize donor selection and DPB1 matching with prospective typing. Because classical DPB1 allele mismatches are often unavoidable, however, several biological models have been developed to predict the optimal DPB1 mismatch combination for less graft-versus-host disease (GVHD) and better overall survival. In 909 recipient/donor pairs, we analyzed the role of 3 biological models: T-cell epitopes (TCEs) based on the immunogenicity of DPB1, cell surface expression of DPB1 molecules based on a single-nucleotide polymorphism located in the 3' untranslated region, and the Predicted Indirectly ReCognizable HLA Epitopes (PIRCHE) model based on the presentation of allogeneic peptides derived from mismatched HLA, compared with the classical allele mismatch. Matching for both DPB1 alleles remains the best option to prevent acute GVHD. In the situation of one DPB1 allele mismatch, the donor associated with the lowest acute GVHD risks is mismatched for an allele with a low expression profile in the recipient, followed by a permissive TCE3/4 mismatch and/or the absence of PIRCHE II potential against the recipient. In the context of 2 DPB1 mismatches, the same considerations apply for a permissive TCE3/4 mismatch and no PIRCHE II. By combining the biological models, the most favorable DPB1 constellation can be defined. This approach will help optimize donor selection and improve post-HSCT complications and patient prognosis.
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3
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Hunziker M, Passweg J, Medinger M. Influence of HLA-DPB1 mismatches on outcome after allogeneic hematopoietic stem cell transplantation. Leuk Res Rep 2021; 16:100259. [PMID: 34345585 PMCID: PMC8319557 DOI: 10.1016/j.lrr.2021.100259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/04/2021] [Accepted: 07/11/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Mireille Hunziker
- Division of Hematology, Department of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Jakob Passweg
- Division of Hematology, Department of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Michael Medinger
- Division of Hematology, Department of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland.,Division of Internal Medicine, Department of Medicine, University Hospital Basel, and University of Basel, Basel, Switzerland
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4
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Petersdorf EW, Bengtsson M, De Santis D, Dubois V, Fleischhauer K, Gooley T, Horowitz M, Madrigal JA, Malkki M, McKallor C, Morishima Y, Oudshoorn M, Spellman SR, Villard J, Stevenson P, Carrington M. Role of HLA-DP Expression in Graft-Versus-Host Disease After Unrelated Donor Transplantation. J Clin Oncol 2020; 38:2712-2718. [PMID: 32479188 PMCID: PMC7430213 DOI: 10.1200/jco.20.00265] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2020] [Indexed: 01/15/2023] Open
Abstract
PURPOSE The main aim of this study was to evaluate the significance of HLA-DPB1 expression in acute graft-versus-host disease (GVHD) after hematopoietic cell transplantation (HCT) from HLA-A, -B, -C, -DRB1, -DQB1-matched and -mismatched unrelated donors. PATIENTS AND METHODS Between January 1, 2017, and January 10, 2019, we assessed 19,136 patients who received HCT from an HLA-A, -B, -C, -DRB1, -DQB1-matched or -mismatched unrelated donor performed in Australia, the European Union, Japan, North America, and the United Kingdom between 1988 and 2016. Among transplant recipients with one HLA-DPB1 mismatch, the patient's mismatched HLA-DPB1 allotype was defined as low or high expression. Multivariable regression models were used to assess risks of GVHD associated with high expression relative to low expression HLA-DPB1 mismatches. The effect of increasing numbers of HLA-DPB1 mismatches on clinical outcome was assessed in HLA-mismatched transplant recipients. RESULTS In HLA-A, -B, -C, -DRB1,-DQB1-matched transplant recipients, donor mismatching against one high-expression patient HLA-DPB1 increased moderate (odds ratio [OR], 1.36; P = .001) and severe acute GVHD (OR, 1.32; P = .0016) relative to low-expression patient mismatches, regardless of the expression level of the donor's mismatched HLA-DPB1. Among transplant recipients with one HLA-A, -B, -C, -DRB1, or -DQB1 mismatch, the odds of acute GVHD increased with increasing numbers of HLA-DPB1 mismatches (OR, 1.23 for one; OR, 1.40 for two mismatches relative to zero mismatches for moderate GVHD; OR, 1.19 for one; OR, 1.40 for two mismatches relative to zero for severe GVHD), but not with the level of expression of the patient's mismatched HLA-DPB1 allotype. CONCLUSION The level of expression of patient HLA-DPB1 mismatches informs the risk of GVHD after HLA-A, -B, -C, -DRB1, -DQB1-matched unrelated HCT, and the total number of HLA-DPB1 mismatches informs the risk of GVHD after HLA-mismatched unrelated HCT. Prospective consideration of HLA-DPB1 may help to lower GVHD risks after transplantation.
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Affiliation(s)
- Effie W. Petersdorf
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, University of Washington, Seattle, WA
| | - Mats Bengtsson
- Department of Immunology, Genetics, and Pathology, University of Uppsala, Uppsala, Sweden
| | | | - Valerie Dubois
- Etablissement Français du Sang Auvergne Rhône Alpes, site de Lyon, Décines, France
| | - Katharina Fleischhauer
- Institute for Experimental Cellular Therapy, University of Duisburg-Essen, Essen, Germany
| | - Ted Gooley
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Mary Horowitz
- Center for International Blood and Marrow Transplant Research, Milwaukee, WI
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
| | | | - Mari Malkki
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Caroline McKallor
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Yasuo Morishima
- Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| | - Machteld Oudshoorn
- Leiden University Medical Centre, Department Immunohematology and Blood Transfusion, Leiden, the Netherlands
- Matchis Foundation, Leiden, the Netherlands
| | - Stephen R. Spellman
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | | | - Phil Stevenson
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Mary Carrington
- Basic Science Program, Frederick National Laboratory for Cancer Research, Frederick, MD
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Cambridge, MA
| | - on behalf of the
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, University of Washington, Seattle, WA
- Department of Immunology, Genetics, and Pathology, University of Uppsala, Uppsala, Sweden
- PathWest, Fiona Stanley Hospital, Perth, WA, Australia
- Etablissement Français du Sang Auvergne Rhône Alpes, site de Lyon, Décines, France
- Institute for Experimental Cellular Therapy, University of Duisburg-Essen, Essen, Germany
- Center for International Blood and Marrow Transplant Research, Milwaukee, WI
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
- Anthony Nolan Research Institute, Royal Free Hospital, London, United Kingdom
- Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
- Leiden University Medical Centre, Department Immunohematology and Blood Transfusion, Leiden, the Netherlands
- Matchis Foundation, Leiden, the Netherlands
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
- Geneva University Hospital, Geneva, Switzerland
- Basic Science Program, Frederick National Laboratory for Cancer Research, Frederick, MD
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Cambridge, MA
| | - International Histocompatibility Working Group in Hematopoietic-Cell Transplantation
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, University of Washington, Seattle, WA
- Department of Immunology, Genetics, and Pathology, University of Uppsala, Uppsala, Sweden
- PathWest, Fiona Stanley Hospital, Perth, WA, Australia
- Etablissement Français du Sang Auvergne Rhône Alpes, site de Lyon, Décines, France
- Institute for Experimental Cellular Therapy, University of Duisburg-Essen, Essen, Germany
- Center for International Blood and Marrow Transplant Research, Milwaukee, WI
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
- Anthony Nolan Research Institute, Royal Free Hospital, London, United Kingdom
- Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
- Leiden University Medical Centre, Department Immunohematology and Blood Transfusion, Leiden, the Netherlands
- Matchis Foundation, Leiden, the Netherlands
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
- Geneva University Hospital, Geneva, Switzerland
- Basic Science Program, Frederick National Laboratory for Cancer Research, Frederick, MD
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Cambridge, MA
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5
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Stenger W, Künkele A, Niemann M, Todorova K, Pruß A, Schulte JH, Eggert A, Oevermann L. Donor selection in a pediatric stem cell transplantation cohort using PIRCHE and HLA-DPB1 typing. Pediatr Blood Cancer 2020; 67:e28127. [PMID: 31850671 DOI: 10.1002/pbc.28127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 11/24/2019] [Accepted: 11/25/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND New strategies to optimize donor selection for hematopoietic stem cell transplantation (HSCT) have mainly been evaluated in adults, but the disease spectrum requiring HSCT differs significantly in children and has consequences for the risk of complications, such as graft-versus-host disease (GvHD). PROCEDURES Here we evaluated whether HLA-DPB1 and Predicted Indirectly ReCognizable HLA-Epitope (PIRCHE) matching can improve donor selection and minimize risks specific for a pediatric cohort undergoing HSCT in Berlin between 2014 and 2016. RESULTS The percentage of HLA-DPB1-mismatched HSCT in the pediatric cohort was in line with the general distribution among matched unrelated donor HSCT. Nonpermissive HLA-DPB1 mismatches were not associated with a higher incidence of GvHD, but the incidence of relapse was higher in patients undergoing HSCT from HLA-DPB1-matched transplantations. High PIRCHE-I scores were associated with a significantly higher risk for developing GvHD in patients undergoing HSCT from nine of ten matched unrelated donors. This finding persisted after including HLA-DPB1 into the PIRCHE analysis. CONCLUSIONS Implementing PIRCHE typing in the donor selection process for HSCT in children could particularly benefit children with nonmalignant diseases and support further validation of PIRCHE-based donor selection in a larger number of children treated at different sites.
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Affiliation(s)
- Wiebke Stenger
- Department of Pediatric Oncology and Hematology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Annette Künkele
- Department of Pediatric Oncology and Hematology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,German Cancer Consortium (DKTK), Berlin, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Kremena Todorova
- Center for Transfusion Medicine and Cell Therapies Berlin, Berlin, Germany
| | - Axel Pruß
- Center for Transfusion Medicine and Cell Therapies Berlin, Berlin, Germany
| | - Johannes H Schulte
- Department of Pediatric Oncology and Hematology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Cancer Consortium (DKTK), Berlin, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Angelika Eggert
- Department of Pediatric Oncology and Hematology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,German Cancer Consortium (DKTK), Berlin, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lena Oevermann
- Department of Pediatric Oncology and Hematology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,German Cancer Consortium (DKTK), Berlin, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany
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6
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Grønvold B, Ali MM, Remberger M, Mattsson J, Egeland T, Lundin KU, Myhre AE, Abrahamsen IW, Heldal D, Dybedal I, Tjønnfjord GE, Fløisand Y, Gedde-Dahl T. HLA-DPB1 mismatch reduce relapse and improve survival in T-cell replete unrelated donor allogeneic stem cell transplantation. Bone Marrow Transplant 2020; 55:1658-1661. [PMID: 32054997 DOI: 10.1038/s41409-020-0827-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 01/16/2020] [Accepted: 02/03/2020] [Indexed: 11/09/2022]
Affiliation(s)
- B Grønvold
- Department of Haematology, Oslo University Hospital, Oslo, Norway.
| | - M M Ali
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - M Remberger
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Department of Medical Sciences, Uppsala University and KFUE, Uppsala University Hospital, Uppsala, Sweden
| | - J Mattsson
- Gloria and Seymour Epstein Chair in Cell Therapy and Transplantation, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - T Egeland
- Institute of Immunology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - K U Lundin
- Institute of Immunology, Oslo University Hospital, Oslo, Norway
| | - A E Myhre
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - I W Abrahamsen
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - D Heldal
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - I Dybedal
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - G E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Y Fløisand
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Centre for Cancer Cell Reprogramming, Department of Molecular Cell Biology, Oslo University Hospital, Oslo, Norway
| | - T Gedde-Dahl
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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7
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Lorentino F, Sacchi N, Oldani E, Miotti V, Picardi A, Gallina AM, Crivello P, Bernasconi P, Saccardi R, Farina L, Benedetti F, Cerno M, Grassi A, Bruno B, Patriarca F, Ciceri F, Fleischhauer K, Vago L, Bonifazi F. Comparative evaluation of biological human leukocyte antigen DPB1 mismatch models for survival and graft- versus-host disease prediction after unrelated donor hematopoietic cell transplantation. Haematologica 2019; 105:e186-e189. [PMID: 31471374 DOI: 10.3324/haematol.2019.225177] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Francesca Lorentino
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Nicoletta Sacchi
- Italian Bone Marrow Donor Registry, E.O. Galliera, Genova, Italy
| | - Elena Oldani
- Hematology and BMT Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Valeria Miotti
- Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Alessandra Picardi
- Biomedicine and Prevention Department, Tor Vergata University, Roma, Italy.,Hematology with Stem Cell Transplant Unit, AORN A. Cardarelli, Napoli, Italy
| | | | - Pietro Crivello
- Institute for Experimental Cellular Therapy, Essen University Hospital, Essen, Germany
| | - Paolo Bernasconi
- Bone Marrow Transplant Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Lucia Farina
- Hematology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Fabio Benedetti
- Department of Medicine, Section of Hematology and Bone Marrow Transplant Unit, University of Verona, Verona, Italy
| | - Michela Cerno
- Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Anna Grassi
- Hematology and BMT Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Benedetto Bruno
- Department of Oncology, AOU Città della Salute e della Scienza, Torino, Italy.,Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | | | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Vita-Salute San Raffaele University, Milano, Italy
| | - Katharina Fleischhauer
- Institute for Experimental Cellular Therapy, Essen University Hospital, Essen, Germany .,German Cancer Consortium, Heidelberg, Germany
| | - Luca Vago
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy.,Unit of Immunogenetics, Leukemia Genomics and Immunobiology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Francesca Bonifazi
- Institute of Hematology "L. and A. Seràgnoli", University Hospital S. Orsola-Malpighi, Bologna, Italy
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8
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Ducreux S, Dubois V, Amokrane K, Yakoub-Agha I, Labalette M, Michallet M, Rubio MT, Kennel A, Forcade E, Lafarge X, Bulabois CE, Masson D, Daguindau E, Devys A, Moalic V, Quelvennec E, Boudifa A, Picard C, Van Endert P, de Matteis M, Delbos F, Filloux M, Pedron B, Renac V, Hau F, Bonneau J, Parissiadis A, Fort M, Dormoy A, Maillard N, Jollet I, Chevallier P, Cesbron A, Bay JO, Quainon F, Garnier F, Socié G, Loiseau P, Porcher R, Peffault de Latour R. HLA-DRB3/4/5 mismatches are associated with increased risk of acute GVHD in 10/10 matched unrelated donor hematopoietic cell transplantation. Am J Hematol 2018; 93:994-1001. [PMID: 29726580 DOI: 10.1002/ajh.25133] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/11/2018] [Accepted: 05/01/2018] [Indexed: 11/11/2022]
Abstract
Matching for HLA-A, -B, -C, and -DRB1 loci (8/8 match) is currently the gold standard for unrelated donor hematopoietic cell transplantation (HCT). In Europe, patients are also matched at the HLA-DQB1 loci (10/10 match). However, there is increasing evidence that matching at HLA-DRB3/4/5 loci may help to lower transplant-related morbidity and mortality. We therefore investigated the impact of HLA-DRB3/4/5 mismatches on outcomes in 1975 patients who received a first 10/10 matched unrelated donor (MUD) HCT in France from 2000 to 2012 for a hematological malignancy. High-resolution typing was performed at HLA-A, -B, -C, -DRB1, -DQB1, -DPB1, and -DRB3/4/5 loci for all donor/recipient pairs. Compared with DRB3/4/5-matched pairs, patients who received a MUD HCT from a DRB3/4/5 mismatched donor had a significantly increased risk of grade II-IV acute graft-versus-host disease (aGVHD) (Adjusted Hazard Ratio (HR) 1.43 (1.07 to 1.90)) associated with lower graft-versus-host disease-free and relapse-free survival (GRFS) (Adjusted HR 1.20 (1.02 to 1.42)). Conversely, we observed no differences in terms of chronic GVHD, nonrelapse mortality, relapse and overall survival. However, we believe that patients stand to benefit from DRB3/4/5 loci being considered for unrelated donor selection to improve GRFS and then quality of life after unrelated HCT.
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Affiliation(s)
- Stéphanie Ducreux
- EFS Auvergne Rhône Alpes, Laboratoire d'histocompatibilité, Lyon, France
| | - Valérie Dubois
- EFS Auvergne Rhône Alpes, Laboratoire d'histocompatibilité, Lyon, France
| | - Kahina Amokrane
- AP-HP, Hôpital Saint Louis, Laboratoire d'histocompatibilité, Paris, France
| | | | | | - Mauricette Michallet
- Centre Léon Bérard, Hôpital Lyon Sud, Service d'hématologie clinique, Lyon, France
| | | | - Anne Kennel
- CHRU de Nancy, Laboratoire d'histocompatibilité, Nancy, France
| | - Edouard Forcade
- CHU de Bordeaux, Service d'hématologie clinique, Bordeaux, France
| | - Xavier Lafarge
- EFS Aquitaine Limousin, Laboratoire d'histocompatibilité, Bordeaux, France
| | | | - Dominique Masson
- EFS Auvergne Rhône Alpes, Laboratoire d'histocompatibilité, Grenoble, France
| | | | - Anne Devys
- EFS Pays de Loire, Laboratoire d'histocompatibilité, Angers, France
| | - Virginie Moalic
- CHRU de Brest, Laboratoire de Génétique Moléculaire et d'Histocompatibilité, Brest, France
| | | | - Abdelali Boudifa
- AP-HP, Groupe Hospitalier Pitié Salpetrière, Laboratoire d'Immunologie Cellulaire et Tissulaire, Paris, France
| | - Christophe Picard
- EFS Provence Alpes Côte d'Azur Corse, Laboratoire d'histocompatibilité, Marseille, France
| | | | | | - Florent Delbos
- EFS Ile de France, Laboratoire d'histocompatibilité, Créteil, France
| | | | - Béatrice Pedron
- AP-HP, Hôpital Robert Debré, Laboratoire d'immunologie, Paris, France
| | - Virginie Renac
- EFS Bretagne, Laboratoire d'histocompatibilité et d'immunogénétique, Rennes, France
| | - Françoise Hau
- EFS Normandie, Laboratoire d'histocompatibilité, Rouen, France
| | - Julie Bonneau
- EFS Auvergne Rhône Alpes, Laboratoire d'histocompatibilité, Saint Etienne, France
| | - Anne Parissiadis
- EFS Grand Est, Laboratoire d'histocompatibilité, Strasbourg, France
| | - Marylise Fort
- CHU Toulouse, Laboratoire d'Immunologie, Toulouse, France
| | - Anne Dormoy
- EFS Bourgogne Franche Comté, Laboratoire d'histocompatibilité, Besançon, France
| | | | - Isabelle Jollet
- EFS Centre Atlantique, Laboratoire d'histocompatibilité, Poitiers, France
| | | | - Anne Cesbron
- EFS Pays de la Loire, Laboratoire d'histocompatibilité, Nantes, France
| | - Jacques-Olivier Bay
- CHU Clermont Ferrand, Service d'hématologie clinique, Clermont Ferrand, France
| | - Fabienne Quainon
- EFS Auvergne Rhône Alpes, Laboratoire d'histocompatibilité, Clermont Ferrand, France
| | - Federico Garnier
- Agence de la biomédecine, Registre France Greffe de Moelle, Saint Denis, France
| | - Gérard Socié
- AP-HP, Hôpital Saint Louis, Service d'hématologie clinique, Paris, France
| | - Pascale Loiseau
- AP-HP, Hôpital Saint Louis, Laboratoire d'histocompatibilité, Paris, France
| | - Raphaël Porcher
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel-Dieu, Paris, France
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Effect of nonpermissive HLA-DPB1 mismatches after unrelated allogeneic transplantation with in vivo T-cell depletion. Blood 2018; 131:1248-1257. [PMID: 29386198 PMCID: PMC6031309 DOI: 10.1182/blood-2017-07-798751] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 01/19/2018] [Indexed: 02/03/2023] Open
Abstract
We investigated the impact of donor-recipient HLA-DPB1 matching on outcomes of allogeneic hematopoietic stem cell transplantation with in vivo T-cell depletion using antithymocyte globulin (ATG) for patients with hematological malignancies. All donor-recipient pairs had high-resolution typing for HLA-A, HLA-B, HLA-C, HLA-DRB1, HLA-DQB1, HLA-DPB1, and HLA-DRB3/4/5 and were matched at HLA-A, HLA-B, HLA-C, and HLA-DRB1. HLA-DPB1 mismatches were categorized by immunogenicity of the DPB1 matching using the DPB T-cell epitope tool. Of 1004 donor-recipient pairs, 210 (21%) were DPB1 matched, 443 (44%) had permissive mismatches, 184 (18%) had nonpermissive mismatches, in graft-versus-host (GVH) direction, and 167 (17%) had nonpermissive mismatches in host-versus-graft (HVG) direction. Compared with HLA-DPB1 permissive mismatched pairs, nonpermissive GVH mismatched pairs had the highest risk for grade II to IV acute graft-versus-host disease (aGVHD) (hazard ratio [HR], 1.4; P = .01) whereas matched pairs had the lowest risk (HR, 0.5; P < .001). Grade III to IV aGVHD was only increased with HLA-DPB1 nonpermissive GVH mismatched pairs (HR, 2.3; P = .005). The risk for disease progression was lower with any HLA-DPB1 mismatches, permissive or nonpermissive. However, the favorable prognosis of HLA-DPB1 mismatches on disease progression was observed only in peripheral blood stem cell recipients who were in the intermediate-risk group by the Disease Risk Index (HR, 0.4; P = .001) but no other risk groups. Our results suggest avoidance of nonpermissive GVH HLA-DPB1 mismatches for lowering the risk for grade II to IV and III to IV aGVHD. Permissive or nonpermissive HVG HLA-DPB1 mismatches may be preferred over HLA-DPB1 matches in the intermediate-risk patients to decrease the risk for disease progression.
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10
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Tie R, Zhang T, Yang B, Fu H, Han B, Yu J, Tan Y, Huang H. Clinical implications of HLA locus mismatching in unrelated donor hematopoietic cell transplantation: a meta-analysis. Oncotarget 2018; 8:27645-27660. [PMID: 28206973 PMCID: PMC5432365 DOI: 10.18632/oncotarget.15291] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 01/26/2017] [Indexed: 01/10/2023] Open
Abstract
It remains controversial that the impacts of individual HLA locus mismatches on clinical outcomes of patients receiving unrelated-donor hematopoietic cell transplantation (HCT), as compared to HLA allele matched controls. We conducted a meta-analysis to address these issues. Four databases (PubMed, Embase, Web of Science and the Cochrane Library) were searched to select eligible studies. All donor-recipient pairs were high-resolution typing for HLA-A, -B, -C, -DRB1, DQB1 and DPB1 loci. Multivariate-adjusted hazard ratios (HRs) were extracted and pooled using a random-effects model. A total of 36 studies were included, with 100,072 patients receiving HCT. Surprisingly, we found that HLA-DQB1 locus mismatches had no significantly increased risk of multiple outcomes including acute and chronic graft-versus-host disease (GVHD), overall mortality and disease relapse (HR, 1.07; P = .153; HR, 1.07; P = .271; HR, 1.09; P = .230; HR, 1.07; P = .142 and HR, 1.02; P = .806, respectively). Mismatched HLA-DPB1 was significantly associated with a reduced risk of disease relapse (HR, 0.74; P < .001) but not with increased risks of transplant-related mortality (TRM) and overall mortality (HR, 1.09; P = .591; I2 = 74.2% and HR, 1.03; P = .460, respectively). In conclusion, HLA-DQB1 locus mismatches is a permissive mismatching. HLA-DPB1 locus mismatches significantly protect against leukemia relapse. Refining effects of individual HLA locus mismatches contributes to predicting prognosis of patients receiving unrelated donor HCT.
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Affiliation(s)
- Ruxiu Tie
- Bone Marrow Transplantation Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Tiansong Zhang
- Department of Traditional Chinese Medicine, Jing'an District Central Hospital, Shanghai, China
| | - Bo Yang
- School of Public Health, Wenzhou Medical University, Wenzhou, China
| | - Huarui Fu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Biqing Han
- Bone Marrow Transplantation Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jian Yu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yamin Tan
- Bone Marrow Transplantation Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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11
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Burek Kamenaric M, Maskalan M, Grubic Z, Mikulic M, Serventi Seiwerth R, Durakovic N, Vrhovac R, Stingl Jankovic K, Zunec R. HLA-DPB1 matching in unrelated hematopoietic stem cell transplantation program contributes to a higher incidence of disease relapse. Hum Immunol 2017; 78:665-671. [DOI: 10.1016/j.humimm.2017.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 08/24/2017] [Accepted: 08/24/2017] [Indexed: 11/24/2022]
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12
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Moyer AM, Hashmi SK, Kroning CM, Kremers WK, De Goey SR, Patnaik M, Litzow M, Gastineau DA, Hogan WJ, Jacob EK, Kreuter JD, Wakefield LL, Gandhi MJ. Clinical outcomes of HLA-DPB1 mismatches in 10/10 HLA-matched unrelated donor-recipient pairs undergoing allogeneic stem cell transplant. Eur J Haematol 2017. [PMID: 28632323 DOI: 10.1111/ejh.12916] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE HLA-DPB1 matching may impact allogeneic hematopoietic stem cell transplantation (ASCT) outcomes; however, this locus is not in linkage disequilibrium with the remainder of the HLA genes. After classifying HLA-DPB1 mismatches based on T-cell epitope, avoiding non-permissive mismatches may impact survival. We tested this hypothesis at a single academic institution. METHODS Retrospective HLA-DPB1 genotyping was performed on 153 adult patients who underwent ASCT and unrelated donors matched for HLA-A, B, C, DRB1, and DQB1 loci (10/10). Using the ImMunoGeneTics/HLA T-cell epitope matching algorithm, mismatch status was classified as permissive or non-permissive. RESULTS Of 153 donor-recipient pairs, 22 (14.4%) were HLA-DPB1 matches, 64 (42.8%) permissive mismatches, and 67 (43.8%) non-permissive mismatches. DPB1 mismatch increased risk of chronic graft-versus-host disease (cGVHD; RR 2.89 [1.19-9.53], P=.016) compared with DPB1-matched transplants, but there were no differences in overall mortality, risk of relapse, or acute GVHD (aGVHD). Combining matches and permissive mismatches and comparing to non-permissive mismatches, there was no significant difference in overall survival or relapse; however, patients receiving non-permissive mismatched transplants experienced greater risk of aGVHD overall and severe aGVHD (RR 1.66 [1.13-2.44], P=.010 and RR 1.97 [1.10-3.59], P=.024, respectively). CONCLUSION In this single-center study, HLA-DPB1 matching influenced outcomes of patients undergoing ASCT for hematologic malignancy.
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Affiliation(s)
- Ann M Moyer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Cynthia M Kroning
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Walter K Kremers
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Steven R De Goey
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Mark Litzow
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Dennis A Gastineau
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.,Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - Eapen K Jacob
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Justin D Kreuter
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Laurie L Wakefield
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Manish J Gandhi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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13
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HLA-DP in unrelated hematopoietic cell transplantation revisited: challenges and opportunities. Blood 2017; 130:1089-1096. [PMID: 28667011 DOI: 10.1182/blood-2017-03-742346] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 06/17/2017] [Indexed: 11/20/2022] Open
Abstract
When considering HLA-matched hematopoietic cell transplantation (HCT), sibling and unrelated donors (UDs) are biologically different because UD-HCT is typically performed across HLA-DP disparities absent in sibling HCT. Mismatched HLA-DP is targeted by direct alloreactive T cell responses with important implications for graft-versus-host disease and graft-versus-leukemia. This concise review details special features of HLA-DP as model antigens for clinically permissive mismatches mediating limited T-cell alloreactivity with minimal toxicity, and describes future avenues for their exploitation in cellular immunotherapy of malignant blood disorders.
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14
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Yang F, Lu D, Hu Y, Huang X, Huang H, Chen J, Wu D, Wang J, Wang C, Han M, Chen H. Risk Factors for Graft-Versus-Host Disease After Transplantation of Hematopoietic Stem Cells from Unrelated Donors in the China Marrow Donor Program. Ann Transplant 2017; 22:384-401. [PMID: 28652564 PMCID: PMC6248289 DOI: 10.12659/aot.902805] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background We identified risk factors for acute and chronic graft-versus-host disease (aGVHD and cGVHD, respectively) in recipients after hematopoietic stem cell transplantation (HSCT) from unrelated donors in the China Marrow Donor Program (CMDP). Material/Methods We analyzed follow-up clinical information from 1824 patients who underwent HSCT between 2001 and 2010. Results The incidence of aGVHD and cGVHD after transplantation was 49.29% and 27.3%, respectively. aGVHD incidence decreased as HLA matching increased (p<0.001). Incidence of aGVHD and cGVHD was higher in 2 HLA-A locus donor/recipient groups (02: 01/02: 06 and 02: 01/02: 07; p≤0.022). aGVHD incidence was associated with patient age, absence of rabbit anti-thymocyte globulin (ATG) pretreatment, and disease status (p≤0.040). aGVHD appeared to be a risk factor for cGVHD, and total body irradiation (TBI) was also associated with cGVHD. Patients with cGVHD after transplantation had a higher survival rate than patients without cGVHD (p<0.001), which may be due to reduced relapse rates. Survival was also associated with ATG prophylaxis and disease status. Conclusions The incidence of GVHD after HSCT from unrelated donors in the Chinese population is similar to the results reported from other countries. A high degree of HLA matching, a conditioning regimen without TBI, and the use of ATG may reduce the incidence of aGVHD.
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Affiliation(s)
- Fan Yang
- Department of Hematopoietic Stem Cell Transplantation, Affiliated Hospital to Academy of Military Medical Sciences, Beijing, China (mainland)
| | - Daopei Lu
- Hebei Yanda Ludaopei Hospital, Langfang, Hebei, China (mainland)
| | - Yu Hu
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Xiaojun Huang
- Peking University People's Hospital, Beijing, China (mainland)
| | - He Huang
- The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China (mainland)
| | - Jing Chen
- Shanghai Children's Medical Center, Shanghai, China (mainland)
| | - Depei Wu
- The First Affiliated Hospital of Soochow University, Suzhou, Zhejiang, China (mainland)
| | - Jianmin Wang
- Changhai Hospital of Shanghai, Shanghai, China (mainland)
| | - Chun Wang
- ShangHai General Hospital, Shanghai, China (mainland)
| | - Mingzhe Han
- Institute of Hematology and Hospital of Blood Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China (mainland)
| | - Hu Chen
- Department of Hematopoietic Stem Cell Transplantation, Affiliated Hospital to Academy of Military Medical Sciences, , China (mainland)
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15
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Polymorphisme des gènes HLA et KIR et l’impact sur le devenir de la greffe et le choix du donneur non apparenté de cellules souche hématopoïétiques : recommandations de la Société francophone de greffe de moelle et de thérapie cellulaire (SFGM-TC). Bull Cancer 2016; 103:S243-S247. [DOI: 10.1016/j.bulcan.2016.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 09/01/2016] [Indexed: 02/02/2023]
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16
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Functional distance between recipient and donor HLA-DPB1 determines nonpermissive mismatches in unrelated HCT. Blood 2016; 128:120-9. [PMID: 27162243 DOI: 10.1182/blood-2015-12-686238] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 04/28/2016] [Indexed: 12/25/2022] Open
Abstract
The role of HLA amino acid (AA) polymorphism for the outcome of hematopoietic cell transplantation (HCT) is controversial, in particular for HLA class II. Here, we investigated this question in nonpermissive HLA-DPB1 T-cell epitope (TCE) mismatches reflected by numerical functional distance (FD) scores, assignable to all HLA-DPB1 alleles based on the combined impact of 12 polymorphic AAs. We calculated the difference in FD scores (ΔFD) of mismatched HLA-DPB1 alleles in patients and their 10/10 HLA-matched unrelated donors of 379 HCTs performed at our center for acute leukemia or myelodysplastic syndrome. Receiver-operator curve-based stratification into 2 ΔFD subgroups showed a significantly higher percentage of nonpermissive TCE mismatches for ΔFD >2.665, compared with ΔFD ≤2.665 (88% vs 25%, P < .0001). In multivariate analysis, ΔFD >2.665 was significantly associated with overall survival (hazard ratio [HR], 1.40; 95% confidence interval [CI], 1.05-1.87; P < .021) and event-free survival (HR, 1.39; 95% CI, 1.05-1.82; P < .021), compared with ΔFD ≤2.665. These associations were stronger than those observed for TCE mismatches. There was a marked but not statistically significant increase in the hazards of relapse and nonrelapse mortality in the high ΔFD subgroup, whereas no differences were observed for acute and chronic graft-versus-host disease. Seven nonconservative AA substitutions in peptide-binding positions had a significantly stronger impact on ΔFD compared with 5 others (P = .0025), demonstrating qualitative differences in the relative impact of AA polymorphism in HLA-DPB1. The novel concept of ΔFD sheds new light onto nonpermissive HLA-DPB1 mismatches in unrelated HCT.
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17
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Fleischhauer K, Beelen DW. HLA mismatching as a strategy to reduce relapse after alternative donor transplantation. Semin Hematol 2016; 53:57-64. [PMID: 27000727 DOI: 10.1053/j.seminhematol.2016.01.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Human leukocyte antigen (HLA) mismatches are targets of alloreactive T cells, mediators of graft-versus-leukemia (GvL) and graft-versus-host disease (GvHD) after alternative donor transplantation. Exploitation of HLA mismatching in order to reduce relapse is hampered by necessary interventions aimed at controlling GvHD on the one hand, and by the possibility of immune escape through selective loss of mismatched HLA in relapsing leukemia on the other. Retrospective studies reporting the impact of HLA mismatches on post-transplant relapse need to be interpreted with caution, due to many confounding factors, including disease and use of T-cell depletion, and to be constantly updated to the rapidly changing clinical protocols. Current evidence suggests similar relapse rates for 8/8, 7/8 HLA-matched unrelated, T-cell-replete haploidentical and umbilical cord blood transplantation; however, investigations of locus-specific effects are still scarce in the latter two settings. In unrelated transplantation, a specific role for mismatches at HLA-C and HLA-DPB1, and therein of permissive mismatches defined on the basis of T-cell alloreactivity and/or expression levels, in reducing relapse has been demonstrated in independent studies. This observation suggests new approaches to utilize HLA matching in unrelated donor searches, and the need for further research in the field.
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Affiliation(s)
- Katharina Fleischhauer
- Institute for Experimental Cellular Therapy, University Hospital Essen, Essen, Germany; German Cancer Consortium (DKTK), Heidelberg, Germany.
| | - Dietrich W Beelen
- Department for Bone Marrow Transplantation, West-German Cancer Center, University Hospital Essen, Essen, Germany
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