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Porrata LF. Natural Killer Cells Are Key Host Immune Effector Cells Affecting Survival in Autologous Peripheral Blood Hematopoietic Stem Cell Transplantation. Cells 2022; 11:3469. [PMID: 36359863 PMCID: PMC9657161 DOI: 10.3390/cells11213469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/18/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Abstract
The infusion of autograft immune effector cells directly impacts the clinical outcomes of patients treated with autologous peripheral blood hematopoietic stem cell transplantation, suggesting the possibility of an autologous graft-versus tumor cells. Furthermore, the early recovery of immune effector cells also affects survival post-autologous peripheral blood hematopoietic stem cell transplantation. Natural killer cells are among the immune effector cells reported to be collected, infused, and recovered early post-autologous peripheral blood hematopoietic stem cell transplantation. In this review, I attempt to give an update on the role of natural killer cells regarding improving survival outcomes on patients treated with autologous peripheral blood hematopoietic stem cell transplantation.
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Affiliation(s)
- Luis F Porrata
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55902, USA
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Strong Cellular Immune Response, but Not Humoral, against SARS-CoV-2 in Oncohematological Patients with Autologous Stem Cell Transplantation after Natural Infection. J Clin Med 2022; 11:jcm11082137. [PMID: 35456230 PMCID: PMC9032116 DOI: 10.3390/jcm11082137] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 01/27/2023] Open
Abstract
Oncohematological patients show a low immune response against SARS-CoV-2, both to natural infection and after vaccination. Most studies are focused on the analysis of the humoral response; therefore, the information available about the cellular immune response is limited. In this study, we analyzed the humoral and cellular immune responses in nine individuals who received chemotherapy for their oncohematological diseases, as well as consolidation with autologous stem cell transplantation (ASCT), after being naturally infected with SARS-CoV-2. All individuals had asymptomatic or mild COVID-19 and were not vaccinated against SARS-CoV-2. These results were compared with matched healthy individuals who also had mild COVID-19. The humoral response against SARS-CoV-2 was not detected in 6 of 9 oncohematological individuals prior to ASCT. The levels of antibodies and their neutralization capacity decreased after ASCT. Conversely, an enhanced cytotoxic activity against SARS-CoV-2-infected cells was observed after chemotherapy plus ASCT, mostly based on high levels of NK, NKT, and CD8+TCRγδ+ cell populations that were able to produce IFNγ and TNFα. These results highlight the importance of performing analyses not only to evaluate the levels of IgGs against SARS-CoV-2, but also to determine the quality of the cellular immune response developed during the immune reconstitution after ASCT.
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Infused Autograft Absolute Lymphocyte Count Predicts Superior Survival in Diffuse Large B Cell Lymphoma Patients Post-Autologous Peripheral Blood Hematopoietic Stem Cell Transplantation: A Matched Case-Control Study. Transplant Cell Ther 2021; 27:769.e1-769.e8. [PMID: 34091071 DOI: 10.1016/j.jtct.2021.05.026] [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: 01/07/2021] [Revised: 03/04/2021] [Accepted: 05/27/2021] [Indexed: 11/22/2022]
Abstract
Our group published a double phase III trial showing that patients infused with an autograft absolute lymphocyte count (A-ALC) ≥0.5 × 109 cells/kg experienced superior survival post-autologous peripheral blood hematopoietic stem cell transplantation (APBHSCT). Based on the results from our phase III study, as well as published retrospective studies, on April 1, 2017, our Bone Marrow Transplant Program changed our standard practice to collect an A-ALC ≥0.5 × 109 cells/kg in addition to stem cells for lymphoma patients undergoing APBHSCT. The primary objective of the present study was to continue to assess the prognostic ability of A-ALC by evaluating overall survival (OS) and progression-free survival (PFS) of diffuse large B cell lymphoma (DLBCL) patients who underwent APBHSCT after April 1, 2017, compared with matched control groups at a 1:1:1 ratio with DLBCL patients infused with an A-ALC <0.5 × 109 cells/kg and A-ALC ≥0.5 × 109 cells/kg before April 1, 2017. Using the GREEDY algorithm, 85 DLBCL patients (cases) infused with an A-ALC ≥0.5 × 109 cells/kg after April 1, 2017, were matched at a 1:1:1 ratio with control groups of DLBCL patients who underwent transplantation before April 1, 2017: patients infused with an A-ALC <0.5 × 109 cells/kg (control 1) and patients infused with an A-ALC ≥0.5 × 109 cells/kg (control 2) before April 1, 2017. Groups were matched in terms of sex, age, stage, lactate dehydrogenase (LDH) level, performance status, extranodal disease, International Prognostic Index (IPI), and disease status before APBHSCT (complete or partial response). Survival follow-up was truncated at 3 years from the date of transplantation. Cases, control 1, and control 2 were balanced as to age (P = .8), sex (P = .9), LDH (P = .6), performance status (P = .5), extranodal disease (P = .2), IPI (P = .6), and disease status before APBHSCT (P = .2). Cases and control 2 showed superior OS and PFS compared with control 1. Multivariate analysis including all patients continued to show A-ALC ≥0.5 × 109 cells/kg as an independent predictor for OS (hazard ratio [HR], 0.382; 95% confidence interval [CI], 0.241 to 0.605; P < .0001) and PFS (HR, 0.437; 95% CI, 0.279 to 0.629; P < .0001). Our matched case-control study supports the results of previously published retrospective studies and our phase III study showing that the infusion of A-ALC is a prognostic factor for survival in DLBCL patients undergoing APBHSCT. Our findings support the practice of collecting not only enough stem cells for hematologic engraftment, but also enough immune effector cells (ie, A-ALC) to improve clinical outcomes in DLBCL patients post-APBHSCT.
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Human NK Cells in Autologous Hematopoietic Stem Cell Transplantation for Cancer Treatment. Cancers (Basel) 2021; 13:cancers13071589. [PMID: 33808201 PMCID: PMC8037172 DOI: 10.3390/cancers13071589] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 12/18/2022] Open
Abstract
Simple Summary Natural killer (NK) cells are key elements of the innate immune system that have the ability to kill transformed (tumor and virus-infected) cells without prior sensitization. Hematopoietic stem cell transplantation (HSCT) is a medical procedure used in the treatment of a variety of cancers. The early reconstitution of NK cells after HSCT and their functions support the therapeutic potential of these cells in allogenic HSCT. However, the role of NK cells in autologous HSCT is less clear. In this review, we have summarized general aspects of NK cell biology. In addition, we have also reviewed factors that affect autologous HSCT outcome, with particular attention to the role played by NK cells. Abstract Natural killer (NK) cells are phenotypically and functionally diverse lymphocytes with the ability to recognize and kill malignant cells without prior sensitization, and therefore, they have a relevant role in tumor immunosurveillance. NK cells constitute the main lymphocyte subset in peripheral blood in the first week after hematopoietic stem cell transplantation (HSCT). Although the role that NK cells play in allogenic HSCT settings has been documented for years, their significance and beneficial effects associated with the outcome after autologous HSCT are less recognized. In this review, we have summarized fundamental aspects of NK cell biology, such as, NK cell subset diversity, their effector functions, and differentiation. Moreover, we have reviewed the factors that affect autologous HSCT outcome, with particular attention to the role played by NK cells and their receptor repertoire in this regard.
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Lee L, Alrasheed N, Khandelwal G, Fitzsimons E, Richards H, Wilson W, Chavda SJ, Henry J, Conde L, De Massy MR, Chin M, Galas-Filipowicz D, Herrero J, Chain B, Quezada SA, Yong K. Increased Immune-Regulatory Receptor Expression on Effector T Cells as Early Indicators of Relapse Following Autologous Stem Cell Transplantation for Multiple Myeloma. Front Immunol 2021; 12:618610. [PMID: 33717112 PMCID: PMC7946836 DOI: 10.3389/fimmu.2021.618610] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 01/21/2021] [Indexed: 12/18/2022] Open
Abstract
The benefit of autologous stem cell transplantation (ASCT) in newly diagnosed myeloma patients, apart from supporting high dose chemotherapy, may include effects on T cell function in the bone marrow (BM). We report our exploratory findings on marrow infiltrating T cells early post-ASCT (day+100), examining phenotype and T cell receptor (TCR) repertoire, seeking correlations with timing of relapse. Compared to healthy donors (HD), we observed an increase in regulatory T cells (CD4+FoxP3+, Tregs) with reduction in CD4 T cells, leading to lower CD4:8 ratios. Compared to paired pre-treatment marrow, both CD4 and CD8 compartments showed a reduction in naïve, and increase in effector memory subsets, suggestive of a more differentiated phenotype. This was supported by increased levels of several immune-regulatory and activation proteins (ICOS, PD-1, LAG-3, CTLA-4 and GzmB) when compared with HD. Unsupervised analysis identified a patient subgroup with shorter PFS (p=0.031) whose BM contained increased Tregs, and higher immune-regulatory markers (ICOS, PD-1, LAG-3) on effector T cells. Using single feature analysis, higher frequencies of marrow PD-1+ on CD4+FoxP3- cells and Ki67+ on CD8 cells were independently associated with early relapse. Finally, studying paired pre-treatment and post-ASCT BM (n=5), we note reduced abundance of TCR sequences at day+100, with a greater proportion of expanded sequences indicating a more focused persistent TCR repertoire. Our findings indicate that, following induction chemotherapy and ASCT, marrow T cells demonstrate increased activation and differentiation, with TCR repertoire focusing. Pending confirmation in larger series, higher levels of immune-regulatory proteins on T cell effectors at day+100 may indicate early relapse.
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Affiliation(s)
- Lydia Lee
- Research Department of Hematology, Cancer Institute, University College London, London, United Kingdom
| | - Nouf Alrasheed
- Research Department of Hematology, Cancer Institute, University College London, London, United Kingdom
| | - Garima Khandelwal
- Bill Lyons Informatics Centre, Cancer Institute, University College London, London, United Kingdom
| | - Evelyn Fitzsimons
- Research Department of Hematology, Cancer Institute, University College London, London, United Kingdom
| | - Huw Richards
- Research Department of Hematology, Cancer Institute, University College London, London, United Kingdom
| | - William Wilson
- Cancer Research UK & UCL Cancer Trials Centre, London, United Kingdom
| | - Selina J. Chavda
- Research Department of Hematology, Cancer Institute, University College London, London, United Kingdom
| | - Jake Henry
- Research Department of Hematology, Cancer Institute, University College London, London, United Kingdom
- Cancer Immunology Unit, Research Department of Hematology, University College London Cancer Institute, London, United Kingdom
| | - Lucia Conde
- Bill Lyons Informatics Centre, Cancer Institute, University College London, London, United Kingdom
| | - Marc Robert De Massy
- Research Department of Hematology, Cancer Institute, University College London, London, United Kingdom
- Cancer Immunology Unit, Research Department of Hematology, University College London Cancer Institute, London, United Kingdom
- Department of Immunology, University College London, London, United Kingdom
| | - Melody Chin
- Research Department of Hematology, Cancer Institute, University College London, London, United Kingdom
| | - Daria Galas-Filipowicz
- Research Department of Hematology, Cancer Institute, University College London, London, United Kingdom
| | - Javier Herrero
- Bill Lyons Informatics Centre, Cancer Institute, University College London, London, United Kingdom
| | - Benny Chain
- Department of Immunology, University College London, London, United Kingdom
| | - Sergio A. Quezada
- Research Department of Hematology, Cancer Institute, University College London, London, United Kingdom
- Cancer Immunology Unit, Research Department of Hematology, University College London Cancer Institute, London, United Kingdom
| | - Kwee Yong
- Research Department of Hematology, Cancer Institute, University College London, London, United Kingdom
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Pinheiro PF, Justino GC, Marques MM. NKp30 - A prospective target for new cancer immunotherapy strategies. Br J Pharmacol 2020; 177:4563-4580. [PMID: 32737988 PMCID: PMC7520444 DOI: 10.1111/bph.15222] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 06/23/2020] [Accepted: 07/27/2020] [Indexed: 12/16/2022] Open
Abstract
Natural killer (NK) cells are an important arm of the innate immune system. They constitutively express the NKp30 receptor. NKp30-mediated responses are triggered by the binding of specific ligands e.g. tumour cell-derived B7-H6 and involve the secretion of cytotoxic mediators including TNF-α, IFN-γ, perforins and granzymes. The latter two constitute a target cell-directed response that is critical in the process of immunosurveillance. The structure of NKp30 is presented, focusing on the ligand-binding site, on the ligand-induced structural changes and on the experimental data available correlating structure and binding affinity. The translation of NKp30 structural changes to disease progression is also reviewed. NKp30 role in immunotherapy has been explored in chimeric antigen receptor T-cell (CAR-T) therapy. However, antibodies or small ligands targeting NKp30 have not yet been developed. The data reviewed herein unveil the key structural aspects that must be considered for drug design in order to develop novel immunotherapy approaches.
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Affiliation(s)
- Pedro F. Pinheiro
- Centro de Química Estrutural, Instituto Superior TécnicoUniversidade de LisboaLisbonPortugal
| | - Gonçalo C. Justino
- Centro de Química Estrutural, Instituto Superior TécnicoUniversidade de LisboaLisbonPortugal
| | - M. Matilde Marques
- Centro de Química Estrutural, Instituto Superior TécnicoUniversidade de LisboaLisbonPortugal
- Departamento de Engenharia Química, Instituto Superior TécnicoUniversidade de LisboaLisbonPortugal
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Sonmez M, Sonmez B, Eren N, Yilmaz M, Karti SS, Ovali E. Effects of Interferon-α-2a on Th3 Cytokine Response in Multiple Myeloma Patients. TUMORI JOURNAL 2018; 90:387-9. [PMID: 15510980 DOI: 10.1177/030089160409000404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background Multiple myeloma cells increase Th3 cytokine response by secreting TGF-β, which causes defective Th1 and Th2 cytokine responses. Therefore, a significant suppression of the immune system is seen in multiple myeloma. Interferon-α (IFN-α) is used in the treatment of multiple myeloma due to its immunomodulatory and anti-tumoral effects. We attempted to define the characteristics of immune cytokine responses and the effects of IFN-α-2a on the immune response in multiple myeloma. Methods Fifteen patients with multiple myeloma and 15 healthy controls were enrolled. IFN-α-2a, 3 million units/day x 3 times/week, was administered subcutaneously to the patients for 2 weeks. Cytokines (TGF-β, IL-1, IL-2, IL-4, IL-10, IFN-γ) were assessed by the ELISA method in sera of the patients in pretreatment and posttreatment periods and in the sera of the controls. Results IL-2 and IL-4 levels in patients, before IFN-α-2a, were lower than the controls, whereas TGF-β levels were higher than the controls. In other words, Th3 cytokine response was increased and Th1 and Th2 cytokine responses were decreased in patients. A short course of IFN-α-2a increased IL-2 levels. Conclusions These findings suggest IFN-α-2a may enhance nonTh3 cytokine responses in multiple myeloma patients.
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Affiliation(s)
- Mehmet Sonmez
- Division of Hematology, Karadeniz Technical University, School of Medicine, Trabzon, Turkey
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Chiu J, Ernst DM, Keating A. Acquired Natural Killer Cell Dysfunction in the Tumor Microenvironment of Classic Hodgkin Lymphoma. Front Immunol 2018; 9:267. [PMID: 29491867 PMCID: PMC5817071 DOI: 10.3389/fimmu.2018.00267] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/30/2018] [Indexed: 12/21/2022] Open
Abstract
An understanding of interactions within the tumor microenvironment (TME) of classic Hodgkin lymphoma (cHL) has helped pave the way to novel immunotherapies that have enabled dormant and tumor-tolerant immune cells to be reactivated. The immunosuppressive nature of the TME in cHL specifically inhibits the proliferation and activity of natural killer (NK) cells, which contributes to tumor immune-escape mechanisms. This deficiency of NK cells begins at the tumor site and progresses systemically in patients with advanced disease or adverse prognostic factors. Several facets of cHL account for this effect on NK cells. Locally, malignant Reed-Sternberg cells and cells from the TME express ligands for inhibitory receptors on NK cells, including HLA-E, HLA-G, and programmed death-ligand 1. The secretion of chemokines and cytokines, including soluble IL-2 receptor (sCD25), Transforming Growth Factor-β, IL-10, CXCL9, and CXCL10, mediates the systemic immunosuppression. This review also discusses the potential reversibility of quantitative and functional NK cell deficiencies in cHL that are likely to lead to novel treatments.
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Affiliation(s)
- Jodi Chiu
- Cell Therapy Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Daniel M Ernst
- Cell Therapy Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Armand Keating
- Cell Therapy Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
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Singleton A, Khong D, Chin LY, Mukundan S, Li M, Parekkadan B. An engineered biomarker system to monitor and modulate immune clearance of cell therapies. Cytotherapy 2017; 19:1537-1545. [PMID: 28917628 DOI: 10.1016/j.jcyt.2017.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 08/01/2017] [Accepted: 08/03/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND AIMS Cell transplants offer a new opportunity to deliver therapies with novel and complex mechanisms of action. Understanding the pharmacology of cell transplants is important to deliver this new therapy effectively. Currently, however, there are limited techniques to easily track cells after intravenous administration due to the dispersion of the graft throughout the entire body. METHODS We herein developed an engineered cell system that secretes a luciferase enzyme to sensitively detect cell transplants independent of their locale by a simple blood test. We specifically studied a unique feature of cell transplant pharmacology-namely, immune clearance-using mesenchymal stromal cells (MSCs) as a proof-of-concept cell therapy. MSCs are a clinically relevant cell therapy that has been explored in several disease indications due to their innate properties of altering an immune response. RESULTS Using this engineered reporter, we observed specific sensitivity of cell therapy exposure to the preparation of cells, cytolysis of MSCs in an allogeneic setting and a NK cell-mediated destruction of MSCs in an autologous setting. CONCLUSIONS Our cellular tracking method has broader implications at large for assessing in vivo kinetics of various other cell therapies.
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Affiliation(s)
- Amy Singleton
- Center for Engineering in Medicine and Surgical Services, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Shriners Hospitals for Children, Boston, Massachusetts, USA
| | - Danika Khong
- Center for Engineering in Medicine and Surgical Services, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Shriners Hospitals for Children, Boston, Massachusetts, USA
| | - Ling-Yee Chin
- Center for Engineering in Medicine and Surgical Services, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Shriners Hospitals for Children, Boston, Massachusetts, USA
| | - Shilpaa Mukundan
- Center for Engineering in Medicine and Surgical Services, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Shriners Hospitals for Children, Boston, Massachusetts, USA
| | - Matthew Li
- Center for Engineering in Medicine and Surgical Services, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Shriners Hospitals for Children, Boston, Massachusetts, USA
| | - Biju Parekkadan
- Center for Engineering in Medicine and Surgical Services, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Shriners Hospitals for Children, Boston, Massachusetts, USA; Harvard Stem Cell Institute, Cambridge, Massachusetts, USA; Department of Biomedical Engineering, Rutgers University, Piscataway, New Jersey, USA.
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Fujita Y, Tsuno H, Nakayama J. Fermented Papaya Preparation Restores Age-Related Reductions in Peripheral Blood Mononuclear Cell Cytolytic Activity in Tube-Fed Patients. PLoS One 2017; 12:e0169240. [PMID: 28060858 PMCID: PMC5218495 DOI: 10.1371/journal.pone.0169240] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 12/14/2016] [Indexed: 12/16/2022] Open
Abstract
Tube-fed elderly patients are generally supplied with the same type of nutrition over long periods, resulting in an increased risk for micronutrient deficiencies. Dietary polyphenols promote immunity and have anti-inflammatory, anti-carcinogenic, and anti-oxidative properties. Carica papaya Linn. is rich in several polyphenols; however, these polyphenols are poorly absorbed from the digestive tract in their original polymerized form. Therefore, we determined the molecular components of a fermented Carica papaya Linn. preparation, as well as its effects on immunity and the composition of gut microbiota in tube-fed patients. Different doses of the fermented C. papaya L. preparation were administered to three groups of tube-fed patients for 30 days. Its effects on fecal microbiota composition and immunity were assessed by 16S rRNA gene sequencing and immune-marker analysis, respectively. The chemical composition of the fermented C. papaya L. preparation was analyzed by capillary electrophoresis- and liquid chromatography- time of flight mass spectrometry. The fermented C. papaya L. preparation restored peripheral blood mononuclear cell (PBMC) cytolytic activity; however, no other biomarkers of immunity were observed. Treatment with the preparation (9 g/day) significantly reduced the abundance of Firmicutes in the fecal microbiota. In particular, treatment reduced Clostridium scindens and Eggerthella lenta in most patients receiving 9 g/day. Chemical analysis identified low-molecular-weight phenolic acids as polyphenol metabolites; however, no polymerized, large-molecular-weight molecules were detected. Our study indicates that elderly patients who are tube-fed over the long-term have decreased PBMC cytolytic activity. In addition, low-molecular-weight polyphenol metabolites fermented from polymerized polyphenols restore PBMC cytolytic activity and modulate the composition of gut microbiota in tube-fed patients.
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Affiliation(s)
- Yuhzo Fujita
- Yuno Onsen Hospital, Yuno, Syunan-shi, Yamaguchi, Japan
| | - Haruo Tsuno
- Yuno Onsen Hospital, Yuno, Syunan-shi, Yamaguchi, Japan
| | - Jiro Nakayama
- Laboratory of Microbial Technology, Division of Systems Bioengineering, Department of Bioscience and Biotechnology, Faculty of Agriculture, Graduate School, Kyushu University, Hakozaki, Higashi-ku, Fukuoka, Japan
- * E-mail:
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Kim Y, Kim SJ, Cheong JW, Cho H, Chung H, Lee JY, Jang JE, Min YH, Kim JS. Clinical impact of early recovery of peripheral blood absolute lymphocyte count after frontline autologous stem cell transplantation for diffuse large B-cell lymphoma. Hematol Oncol 2016; 35:465-471. [DOI: 10.1002/hon.2332] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 06/10/2016] [Accepted: 06/24/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Yundeok Kim
- Division of Hematology, Department of Internal Medicine; Yonsei University College of Medicine, Severance Hospital; Seoul Korea
| | - Soo-Jeong Kim
- Division of Hematology, Department of Internal Medicine; Yonsei University College of Medicine, Severance Hospital; Seoul Korea
| | - June-Won Cheong
- Division of Hematology, Department of Internal Medicine; Yonsei University College of Medicine, Severance Hospital; Seoul Korea
| | - Hyunsoo Cho
- Division of Hematology, Department of Internal Medicine; Yonsei University College of Medicine, Severance Hospital; Seoul Korea
| | - Haerim Chung
- Division of Hematology, Department of Internal Medicine; Yonsei University College of Medicine, Severance Hospital; Seoul Korea
| | - Jung Yeon Lee
- Division of Hematology, Department of Internal Medicine; Yonsei University College of Medicine, Severance Hospital; Seoul Korea
| | - Ji Eun Jang
- Division of Hematology, Department of Internal Medicine; Yonsei University College of Medicine, Severance Hospital; Seoul Korea
| | - Yoo Hong Min
- Division of Hematology, Department of Internal Medicine; Yonsei University College of Medicine, Severance Hospital; Seoul Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine; Yonsei University College of Medicine, Severance Hospital; Seoul Korea
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Kasemwattanaroj P, Moongkarndi P, Pattanapanyasat K, Mangmool S, Rodpai E, Samer J, Konlata J, Sukapirom K. Immunomodulatory Activities of α-Mangostin on Peripheral Blood Mononuclear Cells. Nat Prod Commun 2013. [DOI: 10.1177/1934578x1300800919] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Mangosteen ( Garcinia mangostana L.) a tropical fruit, has been used in traditional medicine. A frequently used part of mangosteen is the pericarp, containing a high content of xanthones. α-Mangostin, one of the major xanthone derivatives, exhibits a variety of actions, including antimicrobial, antioxidant, cytotoxic and antitumor; however, its function on the immune system is still equivocal. This study aimed to examine the immunomodulatory activities of α-mangostin on lymphocyte lineage and cytokine production in human peripheral blood mononuclear cells (PBMCs). The cytotoxic activity of α-mangostin was measured by MTT assay. The concentration of α-mangostin at 5.55 μg/mL resulted in a 50% survival of PBMCs, which was as potent a cytotoxic activity as that of paclitaxel. After 24 h of PBMCs culture, the percentages of T cells (CD3+), B cells (CD19+) and NK cells (CD3-CD16+CD56+) were not significantly changed by treatment with 1, 2 and 4 μg/mL of α-mangostin compared with untreated-PBMCs; in addition, the percentages of these lymphocytes treated with the combination of α-mangostin (1, 2 and 4 μg/mL) and the mitogen concanavalin A (ConA) was not significantly different from that of ConA-treated PBMCs. For cytokine secretion, α-mangostin (1, 2 and 4 μg/mL) did not significantly induce either proinflammatory cytokines (i.e., TNF-α and IL-1β) or cytokine of adaptive immunity (i.e., IL-2). The combination of α-mangostin (1, 2 and 4 μg/mL) and ConA did not significantly alter the relative difference of TNF-α and IL-1β compared with ConA-treated PBMCs; however, these combinations could significantly decrease the relative difference of IL-2 compared with ConA-treated PBMCs. These data indicated that α-mangostin was able to inhibit IL-2 release without interfering with human immune cells; therefore, further studies are necessary to investigate its effect on IL-2 production.
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Affiliation(s)
| | - Primchanien Moongkarndi
- Department of Microbiology, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand
| | - Kovit Pattanapanyasat
- Office of Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Supachoke Mangmool
- Department of Pharmacology, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand
| | - Ekkarat Rodpai
- Department of Microbiology, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand
| | - Jutima Samer
- Department of Microbiology, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand
| | - Julaporn Konlata
- Department of Microbiology, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand
| | - Kasama Sukapirom
- Office of Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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Yeap SK, Omar AR, Ho WY, Beh BK, Ali AM, Alitheen NB. Rhaphidophora korthalsii modulates peripheral blood natural killer cell proliferation, cytokine secretion and cytotoxicity. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 13:145. [PMID: 23800124 PMCID: PMC3701493 DOI: 10.1186/1472-6882-13-145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 06/10/2013] [Indexed: 11/10/2022]
Abstract
Background Rhaphidophora korthalsii (Araceae) is a root-climber plant which has been widely used in Chinese traditional medicine for cancer and skin disease treatment. Previous reports have recorded its immunomodulatory effects on mice splenocyte and human peripheral blood. This study investigated the potential immunostimulatory effect of Rhaphidophora korthalsii on human PBMC enriched NK cell. Methods PBMC was exposed to various concentrations of R. korthalsii extract and the T and NK cell population in the control and extract treated PBMC were identified by immunophenotyping. Intracellular perforin and granzyme B expressions were detected by flow cytometry and extra-cellular Granzyme B, IFN-γ and TNF-α production in the isolated NK cells were determined by ELISA. The cytotoxicity of effector NK cell towards target K562 cell was assessed by CytoTox 96 assay. Results Rhaphidophora korthalsii methanol extract significantly increased PBMC NK cell population and intracellular perforin and granzyme B expressions. Moreover, the extract also enhanced the secretion of IFN-γ and TNF-α which subsequently enhanced the cytotoxicity of NK cell against the NK sensitive target K562 cell line. NK cell enriched with extract treated PBMC showed better activation than NK cell directly treated with the extract. Conclusion Our findings indicated a potential IL-2 free immunotherapy through direct and indirect R. korthalsii stimulation on NK cell activation.
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14
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Godfrey J, Benson DM. The role of natural killer cells in immunity against multiple myeloma. Leuk Lymphoma 2012; 53:1666-76. [PMID: 22423650 DOI: 10.3109/10428194.2012.676175] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Multiple myeloma (MM) is an essentially incurable malignancy associated with profound immune dysregulation. Despite the advent of novel therapies and improvements in survival over the last 10 years, death from progressive disease and infection remains a common outcome. Natural killer (NK) cells are CD56(+)CD3(-) large granular lymphocytes that constitute a key cellular subset of the innate immune system. For over 30 years, the relationship between NK cells and MM has been described in the clinical setting and characterized in the laboratory. Data suggest that NK cells may play a role in the immune response to MM; however, this effect is lost due to immunoevasive strategies utilized by MM. Nevertheless, progress in the understanding of the mechanisms perpetuating this effect have led to new opportunities to recover or augment NK cell function therapeutically in MM. In fact, the novel agents thalidomide, lenalidomide and bortezomib all confer anti-MM effects, in part, through enhancement of NK cell function. Currently, the development of therapies designed specifically to increase NK cell cytotoxicity against MM is under way. The present review summarizes the current understanding of the NK cell versus MM effect and characterizes therapeutic interventions that exert anti-MM efficacy via NK cell function against the disease.
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Affiliation(s)
- James Godfrey
- The Ohio State University College of Medicine, Columbus, OH, USA
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15
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Interleukin-15 affects patient survival through natural killer cell recovery after autologous hematopoietic stem cell transplantation for non-Hodgkin lymphomas. Clin Dev Immunol 2010; 2010:914945. [PMID: 20414345 PMCID: PMC2855983 DOI: 10.1155/2010/914945] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Revised: 01/18/2010] [Accepted: 02/11/2010] [Indexed: 12/02/2022]
Abstract
Natural killer cells at day 15 (NK-15), after autologous peripheral blood hematopoietic stem cell transplantation (APHSCT), is a prognostic factor for overall survival (OS) and progression-free survival (PFS) in non-Hodgkin lymphoma (NHL). The potential role of the immunologic (homeostatic) environment affecting NK-15 recovery and survival post-APHSCT has not been fully studied. Therefore, we evaluate prospectively the cytokine profile in 50 NHL patients treated with APHSCT. Patients with an interleukin-15 (IL-15) ≥ 76.5 pg/mL at day 15 post-APHSCT experienced superior OS and PFS compared with those who did not; median OS; not reached versus 19.2 months, P < .002; and median PFS; not reached versus 6.8 months, P < .002, respectively. IL-15 was found to correlate with (rs = 0.7, P < .0001) NK-15. Multivariate analysis showed only NK-15 as a prognostic factor for survival, suggesting that the survival benefit observed by IL-15 is most likely mediated by enhanced NK cell recovery post-APHSCT.
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16
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Venstrom JM, Zheng J, Noor N, Danis KE, Yeh AW, Cheung IY, Dupont B, O'Reilly RJ, Cheung NKV, Hsu KC. KIR and HLA genotypes are associated with disease progression and survival following autologous hematopoietic stem cell transplantation for high-risk neuroblastoma. Clin Cancer Res 2009; 15:7330-4. [PMID: 19934297 DOI: 10.1158/1078-0432.ccr-09-1720] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE NK cells exhibit cytotoxicity against neuroblastoma. Gene polymorphisms governing NK cell function, therefore, may influence prognosis. Two highly polymorphic genetic loci instrumental in determining NK cell responses encode the NK cell killer immunoglobulin-like receptors (KIR) and their class I human leukocyte antigen (HLA) ligands. We hypothesized that patients with a "missing ligand" KIR-HLA compound genotype may uniquely benefit from autologous hematopoietic stem cell transplantation (HSCT). EXPERIMENTAL DESIGN One hundred sixty-nine patients treated with autologous HSCT for stage IV neuroblastoma underwent KIR and HLA genotyping. Patients were segregated according to the presence or absence of HLA ligands for autologous inhibitory KIR. Univariate and multivariate analyses were done for overall and progression-free survival. RESULTS Sixty-four percent of patients lacked one or more HLA ligands for inhibitory KIR. Patients lacking a HLA ligand had a 46% lower risk of death [hazard ratio, 0.54; 95% confidence interval (95% CI), 0.35-0.85; P = 0.007] and a 34% lower risk of progression (hazard ratio, 0.66; 95% CI, 0.44-1.0; P = 0.047) at 3 years compared with patients who possessed all ligands for his/her inhibitory KIR. Among all KIR-HLA combinations, 16 patients lacking the HLA-C1 ligand for KIR2DL2/KIR2DL3 experienced the highest 3-year survival rate of 81% (95% CI, 64-100). Survival was more strongly associated with "missing ligand" than with tumor MYCN gene amplification. CONCLUSION KIR-HLA immunogenetics represents a novel prognostic marker for patients undergoing autologous HSCT for high-risk neuroblastoma.
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Affiliation(s)
- Jeffrey M Venstrom
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA
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17
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Yoong Y, Porrata LF, Inwards DJ, Ansell SM, Micallef INM, Litzow MR, Gertz MA, Lacy MQ, Dispenzieri A, Gastineau DA, Tefferi A, Elliott M, Snow DS, Hogan WJ, Markovic SN. The effect of absolute lymphocyte count recovery kinetics on survival after autologous stem cell transplantation for non-Hodgkin's lymphoma. Leuk Lymphoma 2009; 46:1287-94. [PMID: 16109605 DOI: 10.1080/10428190500126380] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Absolute lymphocyte count (ALC) >or=500 cells/microl at day 15 after autologous stem cell transplantation (ASCT) is a powerful independent, prognostic indicator for survival in multiple hematological malignancies. A limitation in these studies was the selection of a single time point (day 15 post-ASCT) as the only discriminator of clinical outcome in relation to ALC recovery. We hypothesized there is a continuous and not discrete relationship between ALC recovery and clinical outcome post-ASCT in NHL. Therefore, we analyzed 274 consecutive patients who underwent ASCT for NHL between 1987 and 2001. The primary end point was to assess the impact of the kinetics of post-ASCT lymphocyte recovery>or=500 cells/microl (K-ALC) on overall survival (OS) and progression-free survival (PFS). K-ALC was a predictor of OS and PFS when the Cox proportional hazards model was used with K-ALC entered as a continuous variable (p<0.0001). Multivariate analysis demonstrated K-ALC recovery post-ASCT to be an independent prognostic indicator for OS and PFS. These data support our hypothesis that the K-ALC post-ASCT is associated with clinical outcome in NHL.
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Affiliation(s)
- Yinlee Yoong
- Division of Hematology, Department of Internal Medecine, Mayo Clinic, Rochester, MN 55909, USA
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18
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Porrata LF, Inwards DJ, Ansell SM, Micallef IN, Johnston PB, Gastineau DA, Litzow MR, Winters JL, Markovic SN. Early lymphocyte recovery predicts superior survival after autologous stem cell transplantation in non-Hodgkin lymphoma: a prospective study. Biol Blood Marrow Transplant 2008; 14:807-16. [PMID: 18541201 PMCID: PMC4494659 DOI: 10.1016/j.bbmt.2008.04.013] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2008] [Accepted: 04/24/2008] [Indexed: 02/06/2023]
Abstract
Day 15 absolute lymphocyte count (ALC-15) after autologous peripheral blood hematopoietic stem cell transplantation (APHSCT) has been reported to be a significant predictor for survival in multiple hematologic malignancies. Limitations of previous reports included their retrospective nature and the lack of ALC-15 lymphocyte subset analyses. To address these limitations, from February 2002 until February 2007, 50 non-Hodgkin lymphoma (NHL) patients were enrolled in a prospective study. The primary endpoint of the study was to confirm prospectively the ALC-15 survival role after APHSCT in NHL. The secondary endpoint was to identify the ALC-15 lymphocyte subset affecting survival after APHSCT. With a median follow-up of 22.2 months (range: 6-63.7 months), patients with an ALC-15 > or =500 cells/microL (n = 35) experienced superior overall survival (OS) and progression-free survival (PFS) compared with those who did not; median OS: not reached versus 5.4 months, 3-year OS rates of 80% (95% confidence interval [CI]: 55%-95%) versus 37% (95% CI: 15%-65%), P < .0001; and median PFS: not reached versus 3.3 months, 3-year PFS rates of 63% (95% CI: 40%-85%) versus 13% (95% CI: 4%-40%), P < .0001, respectively. Univariately, CD16+/56+/CD3- natural killer (NK) cells were the only ALC-15 lymphocyte subset identified as a predictor for survival. Patients with an NK cell count > or =80 cells/microL (n = 38) experienced superior OS and PFS compared with those who did not (median OS: not reached versus 5 months, 3-year OS rates of 76% [95% CI: 57%-92%] versus 36% [95% CI: 11%-62%], P < .0001; and median PFS: not reached versus 3 months, 3-year PFS rates of 57% [95% CI: 38%-85%] versus 9% [95% CI: 1%-41%], P < .0001, respectively). Multivariate analysis showed that NK cells are an independent predictor for survival. This is the first study confirming the ALC-15 survival role prospectively and identifying NK cells as the key ALC-15 lymphocyte subset affecting survival after APHSCT.
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Affiliation(s)
- Luis F Porrata
- Division of Hematology, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
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19
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Early lymphocyte recovery post-allogeneic hematopoietic stem cell transplantation is associated with significant graft-versus-leukemia effect without increase in graft-versus-host disease in pediatric acute lymphoblastic leukemia. Bone Marrow Transplant 2007; 41:245-52. [PMID: 17952129 DOI: 10.1038/sj.bmt.1705891] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
To study the effect of early lymphocyte recovery post-allogeneic hematopoietic stem cell transplantation (HSCT) on outcome in pediatric ALL, we reviewed 136 consecutive pediatric patients with ALL who received allogeneic HSCT between 1994 and 2005 at the Hospital for Sick Children, Toronto, Canada. Patients with an absolute lymphocyte count (ALC) <0.3 x 10(9) per liter at day 21 (n=104) had more than five times risk of relapse compared to those with ALC >0.3 x 10(9) per liter (n=32) (hazard ratio (HR) 5.3; P=0.002) and had inferior 3-year event-free survival, (EFS), 0.42 (95% confidence interval (CI) 0.32, 0.51) compared to 0.66 (95% CI 0.48, 0.82; P=0.02). Similarly, patients with an ALC <0.3 x 10(9) per liter (n=48) at day 30 were more than twice as likely to relapse compared to those with an ALC >0.3 x 10(9) per liter (n=88) (HR 2.2; P=0.01) and had an inferior 3-year EFS, 0.30 (95% CI 0.18, 0.45) compared to 0.57 (95% CI 0.46, 0.68; P=0.0001). Interestingly, increasing ALC at days 21 and 30 was not associated with increased incidence of acute or chronic GVHD or transplant-related mortality (TRM). Early lymphocyte recovery post-HSCT is associated with a significant GVL without increase in GVHD.
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20
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Gassas A, Ishaqi MK, Afzal S, Dupuis A, Doyle J. Outcome of haematopoietic stem cell transplantation for paediatric acute lymphoblastic leukaemia in third complete remission: a vital role for graft-versus-host-disease/ graft-versus-leukaemia effect in survival. Br J Haematol 2007; 140:86-9. [PMID: 17894841 DOI: 10.1111/j.1365-2141.2007.06840.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Children with acute lymphoblastic leukaemia (ALL) receiving haematopoietic stem cell transplantation (HSCT) in third complete remission (CR3) are at high risk for transplant-related mortality (TRM) and relapse. Twenty-two consecutive children with ALL in CR3 received HSCT between January 1994 and August 2005. Ten patients died of TRM, seven patients relapsed, six did not have graft-versus-host disease (GVHD). Five patients were long-term survivors, (median follow-up, 5.8 years; range 2.9-11.7). Three-year event-free survival was 0.32 (95% confidence interval 0.19 and 0.59). Survivors had moderate to severe GVHD. Allowing some GVHD or exploring means of inducing GVHD should be considered in CR3 patients.
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Affiliation(s)
- Adam Gassas
- Division of Haematology/Oncology/BMT, Hospital for Sick Children, University of Toronto, Ontario, Canada.
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21
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Auletta JJ, Lazarus HM. Immune restoration following hematopoietic stem cell transplantation: an evolving target. Bone Marrow Transplant 2005; 35:835-57. [PMID: 15778723 DOI: 10.1038/sj.bmt.1704966] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) is the definitive cure for many malignant and nonmalignant diseases. However, delays in immune reconstitution (IR) following HSCT significantly limit the success of transplantation and increase the risk for infection and disease relapse in the transplant recipient. Therefore, ways to measure and to manipulate immune recovery following HSCT are emerging and their success depends directly upon an enhanced understanding for the underlying mechanisms responsible for reconstituted immunity and hematopoiesis. Recent discoveries in the activation, function, and regulation of dendritic cell (DC), natural killer (NK) cell, and T-lymphocyte subtypes have been critical in developing immunotherapies used to prevent graft-versus-host disease and to enhance graft-versus-leukemia. For example, regulatory T cells that induce tolerance and NK receptor-tumor ligand disparities that result in tumor lysis are being used to minimize GVHD and tumor burden, respectively. Furthermore, expansion and modulation of immune effector cells are being used to augment hematopoietic and immune recovery and to decrease transplant-related toxicity in the transplant recipient. Specifically, DC expansion and incorporation into antitumor and anti-microbial vaccines is fast approaching application into clinical trials. This paper will review our current understanding for IR following HSCT and the novel ways in which to restore immune function and decrease transplant-related toxicity in the transplant recipient.
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Affiliation(s)
- J J Auletta
- Comprehensive Cancer Center, Case Western Reserve University/University Hospitals of Cleveland, Cleveland, OH, USA.
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22
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Porrata LF, Gertz MA, Litzow MR, Lacy MQ, Dispenzieri A, Inwards DJ, Ansell SM, Micallef IN, Gastineau DA, Elliott M, Hogan WJ, Hayman SR, Tefferi A, Markovic SN. Early Lymphocyte Recovery Predicts Superior Survival after Autologous Hematopoietic Stem Cell Transplantation for Patients with Primary Systemic Amyloidosis. Clin Cancer Res 2005. [DOI: 10.1158/1078-0432.1210.11.3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Purpose: Absolute lymphocyte count recovery at day 15 (ALC-15) post-autologous stem cell transplantation (ASCT) is a powerful prognostic indicator for survival for multiple hematologic malignancies and metastatic breast cancer. The relationship of ALC-15 with clinical outcomes in primary systemic amyloidosis is unknown.
Experimental Design: We evaluated 145 consecutive patients with primary systemic amyloidosis who underwent ASCT at the Mayo Clinic from 1996 to 2003. The ALC-15 threshold was set at 500 cells/μL based on our previous observations.
Results: The median patient follow-up was 22 months (range, 3-87 months). Higher hematologic complete response was observed in patients with an ALC-15 ≥ 500 cells/μL compared with patients with an ALC-15 < 500 cells/μL (41% versus 21%, P < 0.0008, respectively). The median overall survival and progression-free survival times were significantly better for the 59 patients that achieved an ALC-15 ≥ 500 cells/μL compared with 86 patients with ALC-15 < 500 cells/μL (not reached versus 53 months, P < 0.0003 and not reached versus 27 months, P < 0.0001, respectively). Multivariate analysis showed ALC-15 to be an independent prognostic factor for overall survival and progression-free survival.
Conclusions: ALC-15 ≥ 500 cells/μL is associated with significantly improved clinical outcomes following ASCT in patients with primary systemic amyloidosis.
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Affiliation(s)
- Luis F. Porrata
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Morie A. Gertz
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mark R. Litzow
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Martha Q. Lacy
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Angela Dispenzieri
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - David J. Inwards
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Stephen M. Ansell
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ivanna N.M. Micallef
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Dennis A. Gastineau
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michele Elliott
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - William J. Hogan
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Suzanne R. Hayman
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Svetomir N. Markovic
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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23
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Porrata LF, Litzow MR, Inwards DJ, Gastineau DA, Moore SB, Pineda AA, Bundy KL, Padley DJ, Persky D, Ansell SM, Micallef INM, Markovic SN. Infused peripheral blood autograft absolute lymphocyte count correlates with day 15 absolute lymphocyte count and clinical outcome after autologous peripheral hematopoietic stem cell transplantation in non-Hodgkin's lymphoma. Bone Marrow Transplant 2004; 33:291-8. [PMID: 14676784 DOI: 10.1038/sj.bmt.1704355] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Absolute lymphocyte count at day 15 (ALC-15) after autologous peripheral blood hematopoietic stem cell transplantation (APHSCT) is an independent prognostic factor for survival in non-Hodgkin's lymphoma (NHL). Factors affecting ALC-15 remain unknown. We hypothesized that dose of infused autograft lymphocytes (A-ALC) directly impacts upon ALC-15. A total of 190 consecutive NHL patients received A-ALC between 1993 and 2001. The primary end point was correlation between A-ALC and ALC-15. A strong correlation was identified (r=0.71). A higher A-ALC was infused into patients achieving an ALC-15 > or =500/microl vs ALC-15 <500/microl (median of 0.68 x 10(9)/kg (0.04-2.21 x 10(9)/kg), vs 0.34 x 10(9)/kg (0.04-1.42 x 10(9)/kg), P<0.0001). The median follow-up for all patients was 36 months (maximum of 109 months). The A-ALC threshold was determined at 0.5 x 10(9)/kg. The median overall survival (OS) and progression-free survival (PFS) times were longer in patients who received an A-ALC >/=0.5 x 10(9)/kg vs A-ALC <0.5 x 10(9)/kg (76 vs 17 months, P<0.0001; 49 vs 10 months, P<0.0001, respectively). Multivariate analysis demonstrated A-ALC to be an independent prognostic indicator for OS and PFS. These data support our hypothesis that ALC-15 and survival are dependent upon the dose of infused A-ALC in NHL.
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Affiliation(s)
- L F Porrata
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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24
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Peng BG, Liang LJ, He Q, Huang JF, Lu MD. Expansion and activation of natural killer cells from PBMC for immunotherapy of hepatocellular carcinoma. World J Gastroenterol 2004; 10:2119-23. [PMID: 15237448 PMCID: PMC4572347 DOI: 10.3748/wjg.v10.i14.2119] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM: To induce efficient expansion of natural killer (NK) cells from peripheral blood mononuclear cells (PBMCs) using a culture of anchorage-dependent Wilms tumor cell lines, and to provide a reliable supply for adoptive immunotherapy of hepatocellular carcinoma.
METHODS: Culture expansion of NK cells was achieved using PBMCs cultured with Wilms tumor cells. Cytotoxicity was measured using a standard 51Cr release assay and crystal violet staining technique. The proportions of CD3+, CD4+, CD8+, CD16+, and CD56+ cells were determined by flow cytometry.
RESULTS: After PBMCs from healthy donors and hepatocellular carcinoma (HCC) were cultured with irradiated HFWT cells for 10-21 d, CD56+CD16+ cells shared more than 50% of the cell population, and more than 80% of fresh HFWT cells were killed at an effector/target ratio of 2 over 24 h. NK-enriched lymphocyte population from HCC patients killed HCC-1 and 2 cells with sensitivities comparable to fresh TKB-17RGB cells. HCC cells proliferated 196-fold with the irradiated HFWT cells at 18 d. Stimulation by HFWT cells required intimate cell-cell interaction with PBMC. However, neither the soluble factors released from HFWT cells nor the fixed HFWT cells were effective for NK expansion. The lymphocytes expanded with IL-2 killed fresh HFWT target cells more effectively than the lymphocytes expanded with the 4-cytokine cocktail (IL-l β, IL-2, IL-4 and IL-6). IL-2 was the sole cytokine required for NK expansion.
CONCLUSION: Wilms tumor is sensitive to human NK cells and is highly efficient for selective expansion of NK cells from PBMCs.
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Affiliation(s)
- Bao-Gang Peng
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou 510080, Guangdong Province, China.
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25
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Porrata LF, Gertz MA, Geyer SM, Litzow MR, Gastineau DA, Moore SB, Pineda AA, Bundy KL, Padley DJ, Persky D, Lacy MQ, Dispenzieri A, Snow DS, Markovic SN. The dose of infused lymphocytes in the autograft directly correlates with clinical outcome after autologous peripheral blood hematopoietic stem cell transplantation in multiple myeloma. Leukemia 2004; 18:1085-92. [PMID: 15042106 DOI: 10.1038/sj.leu.2403341] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Absolute lymphocyte count at day 15 (ALC-15) after autologous peripheral blood hematopoietic stem cell transplantation (APHSCT) is an independent prognostic factor for survival in multiple myeloma (MM); however, factors affecting ALC-15 in MM remain unknown. We hypothesized that the dose of infused peripheral blood autograft lymphocytes (autograft absolute lymphocyte count: A-ALC) impacts ALC-15 recovery. Between 1989 and 2001, 267 consecutive MM patients underwent APHSCT. We set out to determine the correlation between A-ALC and ALC-15 and the utility of A-ALC as a marker for ALC-15 recovery. A-ALC was found to be both a strong predictor for area under curve (AUC=0.93; P=0.0001) and strongly correlated with (r(s)=0.83; P=0.0001) ALC-15 recovery. Higher infused A-ALC was significantly correlated with an ALC-15>/=500/microl. In addition, median post-transplant overall survival (OS) and time to progression (TTP) were longer in patients who received an A-ALC>/=0.5 x 10(9) lymphocytes/kg versus A-ALC <0.5 x 10(9) lymphocytes/kg (58 vs 30 months, P=0.00022; 22 vs 15 months, P<0.00012, respectively). Multivariate analysis demonstrated A-ALC as an independent prognostic indicator for OS and TTP. These results indicate that an infused dose of autograft lymphocytes significantly impacts clinical outcome post-APHSCT in MM.
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Affiliation(s)
- L F Porrata
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
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26
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Van Besien K, Mehra R, Wadehra N, Stock W, Khouri I, Giralt S, Devine S, Wickrema A, Peace D, Sosman J, Gajewski J, Champlin R. Phase II study of autologous transplantation with interleukin-2-incubated peripheral blood stem cells and posttransplantation interleukin-2 in relapsed or refractory non-Hodgkin lymphoma. Biol Blood Marrow Transplant 2004; 10:386-94. [PMID: 15148492 DOI: 10.1016/j.bbmt.2004.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Previous work suggested that interleukin (IL)-2 can be used for eradicating residual disease in autologous grafts and for preventing recurrence. We report a phase II study of autologous peripheral blood stem cell transplantation with in vitro IL-2 incubation of peripheral blood stem cells and posttransplantation IL-2 in patients with recurrent or refractory non-Hodgkin lymphoma. Salvage chemotherapy consisted of ifosfamide and etoposide. Responding patients underwent autologous peripheral blood stem cell transplantation. IL-2-incubated stem cells were infused on day 0. IL-2 1 mIU/m2 was given from day 1 until day 28. Four monthly maintenance cycles of IL-2 4 mIU/m2 subcutaneously twice daily days 1 to 5 and days 8 to 11 were administered thereafter. Eighty-four evaluable patients were enrolled, and 60 proceeded to transplantation, of which 56 received IL-2-incubated stem cells. The average received dose of posttransplantation IL-2 was 30% to 50% of planned. Only 42 patients received maintenance IL-2. The average received maintenance dose of IL-2 was also approximately 30% of planned. Most dose reductions were due to toxicity or patient refusal. Three-year survival and progression-free survival for all registered patients were 43% (95% confidence interval [CI], 33%-53%) and 31% (95% CI, 21%-41%), respectively. For the 60 patients undergoing transplantation, they were 59% (95% CI, 46%-72%) and 44% (95% CI, 31%-57%), respectively. There was no relation between the dose of IL-2 received and outcome. Survival and disease-free survival of the study group were similar to those of a previous study cohort that received unmanipulated stem cells and no systemic IL-2. Administration of IL-2-incubated peripheral blood stem cells and intensive posttransplantation IL-2 was associated with considerable but rapidly reversible toxicity. No effect on long-term outcome was observed.
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Affiliation(s)
- Koen Van Besien
- Section of Hematology/Oncology, University of Illinois Chicago, 60637, USA.
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27
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Sun HC, Tang ZY. Angiogenesis in hepatocellular carcinoma: the retrospectives and perspectives. J Cancer Res Clin Oncol 2004; 130:307-19. [PMID: 15034787 DOI: 10.1007/s00432-003-0530-y] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2003] [Accepted: 11/06/2003] [Indexed: 12/11/2022]
Abstract
Hepatocellular carcinoma (HCC) is a typical hypervascular tumor. Many angiogenic factors have been studied in HCC, and several anti-angiogenic therapies have been tested in animal models and patients. This paper summarizes the latest findings, especially regarding the clinical significance of endothelial cell markers and angiogenic factors in HCC, and experimental and clinical anti-angiogenesis therapies. Further developments in this area, such as endothelial cell-oriented research and better experimental and clinical designs in the evaluation of anti-angiogenic therapies are discussed.
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Affiliation(s)
- Hui-Chuan Sun
- Liver Cancer Institute and Zhong Shan Hospital, Fudan University, #136 Yi Xue Yuan Road, 200032 Shanghai, P.R. China.
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28
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Deschler B, Reincke M, Bley TA, Brink I, Engelhardt M. Striking complete remission after interferon-? for secondary recurrent non-Hodgkin?s lymphoma but rare interferon-induced side effects. Ann Hematol 2004; 84:263-6. [PMID: 15004725 DOI: 10.1007/s00277-004-0861-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2003] [Accepted: 02/09/2004] [Indexed: 10/26/2022]
Abstract
Interferon (IFN) treatment is a therapeutic option in the treatment of non-Hodgkin's lymphoma (NHL). Although randomized trials have failed to show significant differences in progression-free and overall survival (OS) with IFN compared to placebo after peripheral blood stem cell transplantation (PBSCT) as well as standard therapy for NHL, anecdotal case reports have documented impressive results in selected patients. With this case report, we demonstrate an astounding success of IFN therapy given in the treatment of a young man with second relapse after two consecutive autologous PBSCTs and abdominal irradiation. With occurrence of multiple lymph node enlargements despite this intensive treatment, he received IFN and obtained a well-documented complete remission (CR). Yet, treatment with IFN always has to be considered in the context of its significant side effect profile, which can have considerable impact on the patient's quality of life as illustrated in this case report.
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Affiliation(s)
- Barbara Deschler
- Department of Hematology/Oncology, University of Freiburg, Hugstetterstrasse 55, 79106 Freiburg, Germany
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29
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Morrison BE, Park SJ, Mooney JM, Mehrad B. Chemokine-mediated recruitment of NK cells is a critical host defense mechanism in invasive aspergillosis. J Clin Invest 2004; 112:1862-70. [PMID: 14679181 PMCID: PMC296992 DOI: 10.1172/jci18125] [Citation(s) in RCA: 153] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Invasive aspergillosis is a severe pneumonia that is usually fatal despite currently available therapy. The disease disproportionately afflicts immunocompromised patients, indicating the critical importance of the immune status of the host in this infection, but the defense mechanisms against this pathogen remain incompletely understood. In the current study, we hypothesized that the chemokine ligand monocyte chemotactic protein-1, also designated CC chemokine ligand-2 (MCP-1/CCL2) is necessary for effective host defense against invasive aspergillosis in immunocompromised hosts. We found a rapid and marked induction of MCP-1/CCL2 in the lungs of neutropenic mice with invasive aspergillosis. Neutralizing MCP-1/CCL2 resulted in twofold greater mortality and greater than threefold increase in pathogen burden in the lungs. Neutralization of MCP-1/CCL2 also resulted in reduced recruitment of NK cells to the lungs at early time points, but did not affect the number of other leukocyte effector cells in the lungs. Ab-mediated depletion of NK cells similarly resulted in impaired defenses against the infection, resulting in a greater than twofold increase in mortality and impaired clearance of the pathogen from the lungs. These data establish MCP-1/CCL2-mediated recruitment of NK cells to the lungs as a critical early host defense mechanism in invasive aspergillosis and demonstrate NK cells to be an important and previously unrecognized effector cell in this infection.
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Affiliation(s)
- Brad E Morrison
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9034, USA
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30
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Kumar S, Chen MG, Gastineau DA, Gertz MA, Inwards DJ, Lacy MQ, Tefferi A, Litzow MR. Lymphocyte recovery after allogeneic bone marrow transplantation predicts risk of relapse in acute lymphoblastic leukemia. Leukemia 2003; 17:1865-70. [PMID: 12970788 DOI: 10.1038/sj.leu.2403055] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Allogeneic blood and marrow transplantation (BMT) is curative for many patients with high-risk and relapsed acute lymphoblastic leukemia (ALL). However, relapse is an important cause of post-transplantation failure, and there are no reliable markers to predict relapse. A retrospective review of patients with ALL who underwent matched related allogeneic BMT was carried out to examine whether the rate of lymphocyte recovery after transplantation had any prognostic value in ALL. The absolute lymphocyte count (ALC) at days 21 and 30 after transplantation was obtained for 43 patients who received transplants during an 18-year period. Patients with an ALC of 175 x 10(6)/l or less on day 21 were more likely to relapse than those with ALC greater than 175 x 10(6)/l (relative risk, 4; 95% confidence interval, 1.5-11.2). Patients with slower lymphocyte recovery had significantly lower relapse-free survival than those with faster recovery (P=0.0028). There was also a trend toward poorer overall survival among those with a slow lymphocyte recovery (log-rank test; P=0.028). The rate of lymphocyte recovery is prognostic in patients with ALL undergoing allogeneic BMT, and this should be integrated with other predictors to identify patients at high risk of relapse. Such patients could be considered for interventions aimed at prevention of relapse, including rapid withdrawal of immunosuppressive medication or donor lymphocyte infusion.
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Affiliation(s)
- S Kumar
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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31
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Porrata LF, Gastineau DA, Padley D, Bundy K, Markovic SN. Re-infused autologous graft natural killer cells correlates with absolute lymphocyte count recovery after autologous stem cell transplantation. Leuk Lymphoma 2003; 44:997-1000. [PMID: 12854901 DOI: 10.1080/1042819031000077089] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Early absolute lymphocyte count (ALC) has been reported to be a powerful prognostic indicator of survival after autologous stem cell transplantation (ASCT). One possible source affecting ALC recovery includes the re-infused autologous graft lymphocytes (AGL). To assess if the re-infused AGL correlate with ALC recovery post-ASCT, we conducted a pilot study to identify which of the re-infused AGL subsets is most associated with day 15 ALC recovery in three patients with multiple myeloma and four patients with non-Hodgkin's lymphoma. Using the Spearman rank correlation coefficient analysis (r), we compared absolute numbers of CD3, CD4, CD8, CD19, and CD16+/CD56+ cells/kg of body weight from the apheresis product with ALC (cells/microl) at day 15 post-ASCT. The main lymphocyte subsets identified in the apheresis product were T cells and NK cells. There was no strong correlation between T or B cells from the apheresis product compared with the ALC at day 15 post-ASCT (CD3, r = 0.21; CD4, r = 0.32; CD8, r = 0.39; and CD19, r = 0.14). However, there was good correlation between NK cells from the apheresis product compared with ALC at day 15 post-ASCT (CD16+/CD56+/CD3-, r = 0.77). These data provide preliminary evidence that the number of re-infused autologous graft NK cells in the apheresis product significantly affect ALC recovery early post-ASCT. However, given the small sample size, our results are primarily hypothesis generating and subject of further research.
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Affiliation(s)
- Luis F Porrata
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA
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32
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Porrata LF, Litzow MR, Tefferi A, Letendre L, Kumar S, Geyer SM, Markovic SN. Early lymphocyte recovery is a predictive factor for prolonged survival after autologous hematopoietic stem cell transplantation for acute myelogenous leukemia. Leukemia 2002; 16:1311-8. [PMID: 12094255 DOI: 10.1038/sj.leu.2402503] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2001] [Accepted: 12/04/2001] [Indexed: 11/09/2022]
Abstract
Absolute lymphocyte count (ALC) recovery correlates with survival after autologous hematopoietic stem cell transplantation (AHSCT) for patients with multiple myeloma, non-Hodgkin's lymphoma, and metastatic breast cancer. The role of ALC recovery in relationship to clinical outcome after AHSCT in patients with acute myelogenous leukemia is unknown. We analyzed 45 patients who underwent AHSCT at Mayo Clinic, Rochester, Minnesota between 1990 and 2000. The ALC threshold was selected at 500 cells/microl on day 15 post-AHSCT based on our previous studies. Thirty-two females and 13 males were included in the study with a median age of 45 years (range 12-75). The median follow-up was 14 months with a maximum of 129 months. The median overall and leukemia-free survival were significantly better for the 23 patients with ALC at day 15 > or =500 cells/microl compared with 22 patients with ALC <500 cells/microl (not yet reached vs 10 months, P < 0.0009; 105 vs 9 months, P < 0.0008, respectively). In conclusion, ALC > or =500 cells/microl on day 15 post-AHSCT is associated with better survival in acute myelogenous leukemia and requires further studies.
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Affiliation(s)
- L F Porrata
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Porrata LF, Inwards DJ, Micallef IN, Ansell SM, Geyer SM, Markovic SN. Early lymphocyte recovery post-autologous haematopoietic stem cell transplantation is associated with better survival in Hodgkin's disease. Br J Haematol 2002; 117:629-33. [PMID: 12028034 DOI: 10.1046/j.1365-2141.2002.03478.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A retrospective study of 82 patients was conducted to determine the relationship of absolute lymphocyte count (ALC) recovery with clinical outcome after autologous stem cell transplantation (ASCT) in Hodgkin's disease (HD). The median overall (OS) and progression-free survival (PFS) times from the day of transplantation were significantly better for the 41 patients with ALC > or = 0.5 x 10(9) cells/l compared with the 41 patients with ALC < 0.5 x 10(9) cells/l ("not yet reached" versus 42 months, P < 0.0001; 57 versus 15 months, P < 0.002 respectively). Thus, ALC recovery on day 15 post ASCT in HD is associated with better survival and requires further study.
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Affiliation(s)
- Luis F Porrata
- Division of Hematology and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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