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Jimbo K, Konuma T, Watanabe E, Kohara C, Mizukami M, Nagai E, Oiwa-Monna M, Mizusawa M, Isobe M, Kato S, Takahashi S, Tojo A. T memory stem cells after allogeneic haematopoietic cell transplantation: unique long-term kinetics and influence of chronic graft-versus-host disease. Br J Haematol 2019; 186:866-878. [PMID: 31135974 DOI: 10.1111/bjh.15995] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 04/11/2019] [Indexed: 12/21/2022]
Abstract
T memory stem cells (TSCMs) are a subset of primitive T cells capable of both self-renewal and differentiation into all subsets of memory and effector T cells. Therefore, TSCMs may play a role in immune reconstitution and graft-versus-host disease (GVHD) in patients receiving allogeneic haematopoietic cell transplantation (HCT). We conducted a cross-sectional study to evaluate the proportions, absolute counts, phenotypes and functions of TSCMs in 152 adult patients without disease recurrence at least 12 months after undergoing HCT. CD4+ TSCMs were negatively correlated with number of months after transplantation in HCT patients that received cord blood transplantation, but not in patients that received bone marrow transplantation or peripheral blood stem cell transplantation. The proportions and absolute counts of CD4+ TSCMs and expression levels of inducible co-stimulator (ICOS) in CD8+ TSCMs were significantly higher in patients with mild and moderate/severe cGVHD compared to patients without cGVHD. These data suggested that, more than 12 months after allogeneic HCT, the kinetics of CD4+ TSCMs were dependent on the type of donor source, and further that CD4+ TSCMs and ICOS levels in CD8+ TSCMs were associated with cGVHD.
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Affiliation(s)
- Koji Jimbo
- Department of Haematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Takaaki Konuma
- Department of Haematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Eri Watanabe
- Department of IMSUT Clinical Flow Cytometry Laboratory, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Chisato Kohara
- Department of Haematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Motoko Mizukami
- Department of Laboratory Medicine, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Etsuko Nagai
- Department of Laboratory Medicine, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Maki Oiwa-Monna
- Department of Haematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Mai Mizusawa
- Department of Haematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Masamichi Isobe
- Department of Haematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Seiko Kato
- Department of Haematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Satoshi Takahashi
- Department of Haematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Arinobu Tojo
- Department of Haematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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Fleischhauer K, Hsu KC, Shaw BE. Prevention of relapse after allogeneic hematopoietic cell transplantation by donor and cell source selection. Bone Marrow Transplant 2018; 53:1498-1507. [PMID: 29795435 PMCID: PMC7286200 DOI: 10.1038/s41409-018-0218-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 03/16/2018] [Accepted: 03/24/2018] [Indexed: 01/27/2023]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is the most established form of cancer immunotherapy and has been successfully applied for the treatment and cure of otherwise lethal neoplastic blood disorders. Cancer immune surveillance is mediated to a large extent by alloreactive T and natural killer (NK) cells recognizing genetic differences between patient and donor. Profound insights into the biology of these effector cells has been obtained over recent years and used for the development of innovative strategies for intelligent donor selection, aiming for improved graft-versus-leukemia effect without unmanageable graft-versus-host disease. The cellular composition of the stem cell source plays a major role in modulating these effects. This review summarizes the current state-of the-art of donor selection according to HLA, NK alloreactivity and stem cell source.
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Affiliation(s)
- Katharina Fleischhauer
- Institute for Experimental Cellular Therapy, University Hospital Essen, Essen, Germany.
- German Cancer Consortium, Heidelberg, Germany.
| | - Katharine C Hsu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Immunology Program, Sloan Kettering Institute, New York, NY, USA.
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
| | - Bronwen E Shaw
- Center for International Blood and Marrow Transplant Research (CIBMTR), Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA.
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Gary R, Aigner M, Moi S, Schaffer S, Gottmann A, Maas S, Zimmermann R, Zingsem J, Strobel J, Mackensen A, Mautner J, Moosmann A, Gerbitz A. Clinical-grade generation of peptide-stimulated CMV/EBV-specific T cells from G-CSF mobilized stem cell grafts. J Transl Med 2018; 16:124. [PMID: 29743075 PMCID: PMC5941463 DOI: 10.1186/s12967-018-1498-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 04/30/2018] [Indexed: 11/22/2022] Open
Abstract
Background A major complication after allogeneic hematopoietic stem cell transplantation (aSCT) is the reactivation of herpesviruses such as cytomegalovirus (CMV) and Epstein–Barr virus (EBV). Both viruses cause significant mortality and compromise quality of life after aSCT. Preventive transfer of virus-specific T cells can suppress reactivation by re-establishing functional antiviral immune responses in immunocompromised hosts. Methods We have developed a good manufacturing practice protocol to generate CMV/EBV-peptide-stimulated T cells from leukapheresis products of G-CSF mobilized and non-mobilized donors. Our procedure selectively expands virus-specific CD8+ und CD4+ T cells over 9 days using a generic pool of 34 CMV and EBV peptides that represent well-defined dominant T-cell epitopes with various HLA restrictions. For HLA class I, this set of peptides covers at least 80% of the European population. Results CMV/EBV-specific T cells were successfully expanded from leukapheresis material of both G-CSF mobilized and non-mobilized donors. The protocol allows administration shortly after stem cell transplantation (d30+), storage over liquid nitrogen for iterated applications, and protection of the stem cell donor by avoiding a second leukapheresis. Conclusion Our protocol allows for rapid and cost-efficient production of T cells for early transfusion after aSCT as a preventive approach. It is currently evaluated in a phase I/IIa clinical trial. Electronic supplementary material The online version of this article (10.1186/s12967-018-1498-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Regina Gary
- Dept. of Hematology/Oncology, University Hospital of Erlangen, Ulmenweg 18, 91054, Erlangen, Germany.
| | - Michael Aigner
- Dept. of Hematology/Oncology, University Hospital of Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Stephanie Moi
- Dept. of Hematology/Oncology, University Hospital of Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Stefanie Schaffer
- Dept. of Hematology/Oncology, University Hospital of Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Anja Gottmann
- Dept. of Hematology/Oncology, University Hospital of Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Stefanie Maas
- Center for Clinical Studies CCS, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Robert Zimmermann
- Department of Transfusion Medicine and Hemostaseology, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Jürgen Zingsem
- Department of Transfusion Medicine and Hemostaseology, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Julian Strobel
- Department of Transfusion Medicine and Hemostaseology, University Hospital of Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Andreas Mackensen
- Dept. of Hematology/Oncology, University Hospital of Erlangen, Ulmenweg 18, 91054, Erlangen, Germany
| | - Josef Mautner
- Clinical Cooperation Group Pediatric Tumor Immunology, Helmholtz Zentrum München, and Technical University of Munich, Marchioninistr. 25, 81377, Munich, Germany
| | - Andreas Moosmann
- DZIF Research Group Host Control of Viral Latency and Reactivation (HOCOVLAR), Helmholtz Zentrum München, Marchioninistr. 25, 81377, Munich, Germany
| | - Armin Gerbitz
- Department of Hematology, Oncology and Tumorimmunology, Charité Berlin, Berlin, Germany
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Fidyk W, Mitrus I, Ciomber A, Smagur A, Chwieduk A, Głowala-Kosińska M, Giebel S. Evaluation of proinflammatory and immunosuppressive cytokines in blood and bone marrow of healthy hematopoietic stem cell donors. Cytokine 2017; 102:181-186. [PMID: 28927758 DOI: 10.1016/j.cyto.2017.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 08/17/2017] [Accepted: 09/02/2017] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Cytokine composition of bone marrow microenvironment in comparison to blood is poorly explored. The goal of this study was to investigate the levels of cytokines present in peripheral blood and bone marrow of healthy hematopoietic stem cells donors. The data obtained on this subject with addition to cytometric analysis can provide new insight into the hematopoietic stem cells microenvironment. METHODOLOGY Study consisted of cytokine concentration analysis performed by ELISA tests of peripheral blood of healthy peripheral blood stem cells donors and bone marrow of healthy bone marrow donors. Additionally we have tested the expression of CD47 and CD274 proteins on the surface of hematopoietic stem cells by the flow cytometry analysis. RESULTS The results has shown different composition of analyzed cytokines (IL-1 β, IL-2, IL-4, IL-6, IL-10, IL-17A, TGF-β1, IFN-γ and TNF-α) present in bone marrow and blood of stem cells donors. The hematopoietic stem cells in peripheral blood are subjected to higher levels of proinflammatory cytokines whilst the lower level of those cytokines in bone marrow with a very high level of TGF-β1 which possibly creates a more immunosuppressive environment. The IL-10 level was significantly higher in peripheral blood of PBSC donors after the administration of mobilizing factor (G-CSF). The percentage of CD47+HSCs was significantly higher in bone marrow compared to peripheral blood of mobilized donors.
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Affiliation(s)
- Wojciech Fidyk
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute Oncology Center, Gliwice Branch, 44-101 Gliwice, Wybrzeże Armii Krajowej 15 Street, Poland.
| | - Iwona Mitrus
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute Oncology Center, Gliwice Branch, 44-101 Gliwice, Wybrzeże Armii Krajowej 15 Street, Poland
| | - Agnieszka Ciomber
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute Oncology Center, Gliwice Branch, 44-101 Gliwice, Wybrzeże Armii Krajowej 15 Street, Poland
| | - Andrzej Smagur
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute Oncology Center, Gliwice Branch, 44-101 Gliwice, Wybrzeże Armii Krajowej 15 Street, Poland
| | - Agata Chwieduk
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute Oncology Center, Gliwice Branch, 44-101 Gliwice, Wybrzeże Armii Krajowej 15 Street, Poland
| | - Magdalena Głowala-Kosińska
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute Oncology Center, Gliwice Branch, 44-101 Gliwice, Wybrzeże Armii Krajowej 15 Street, Poland
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute Oncology Center, Gliwice Branch, 44-101 Gliwice, Wybrzeże Armii Krajowej 15 Street, Poland
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Zhang XY, Zhang PY. Stem cell transplantation during cancer. Oncol Lett 2017; 12:4297-4300. [PMID: 28105145 PMCID: PMC5228504 DOI: 10.3892/ol.2016.5260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 09/27/2016] [Indexed: 11/05/2022] Open
Abstract
Hematological malignancies account for approximately 9.5% of new cancers diagnosed annually. Lymphoma is the most frequent of all known categories of hematological malignancies. Worldwide, extensive research has focused on this type of cancer. However, new treatments are investigated in various clinical as well as pre-clinical studies. Hematopoietic stem cell transplantation (HSCT) is a recent and upcoming treatment strategy for patients with hematopoietic malignancies and inborn errors of metabolism or immune deficiencies. Recent studies have revealed that successful clinical outcome of this treatment strategy depends on multiple factors including the protocol applied, disease under treatment, health of the patient, source of the grafts, severity of complications such as graft versus host disease during grafting and associated infections. The scope of this review is to achieve greater understanding of various clinical effects of the disease and related mechanisms. The electronic database Pubmed was searched for pre-clinical as well as clinical controlled trials reporting efficacy of the HSCT against hematological malignancies.
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Affiliation(s)
- Xiao-Ying Zhang
- Nanjing University of Chinese Medicine, Information Institute, Nanjing, Jiangsu 221009, P.R. China
| | - Pei-Ying Zhang
- Department of Cardiology, Xuzhou Central Hospital, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, Jiangsu 221009, P.R. China
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Jobin C, Cloutier M, Simard C, Néron S. Heterogeneity of in vitro–cultured CD34+ cells isolated from peripheral blood. Cytotherapy 2015; 17:1472-84. [DOI: 10.1016/j.jcyt.2015.05.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 05/04/2015] [Accepted: 05/16/2015] [Indexed: 12/20/2022]
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Yeral M, Kasar M, Boga C, Kozanoglu I, Ozdogu H, Sariturk C. Clinical Relevance of Apheretic Graft Composition in Patients With Acute Myeloblastic Leukemia Who Received a Busulfan-Fludarabine-Antithymocyte Globulin Conditioning Regimen for Allogeneic Transplant. EXP CLIN TRANSPLANT 2015; 13:453-60. [PMID: 26103468 DOI: 10.6002/ect.2014.0223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Sparse data are available about the effects of apheretic graft composition on the clinical transplant outcome in allotransplanted patients who have hematologic malignant disease. Major obstacles in recent studies have included heterogeneity of patient populations and differences in the conditioning regimens used. MATERIALS AND METHODS This prospective study included 50 patients who had acute myeloblastic leukemia and received busulfan-fludarabine-antithymocyte globulin-based conditioning for peripheral allogeneic stem cell transplant. The concentration of CD34+ cells, T-cell subsets, B cells, and natural killer cells in the graft were analyzed by flow cytometry in the donors who were matched for human leukocyte antigen. RESULTS In univariate analysis, infusion with a higher dose of natural killer cells (> 1.55 × 106/kg) was associated with improved survival (P = .007 for disease-free survival; P = .024 for overall survival) in patients with acute myeloblastic leukemia. Cox regression models revealed that increased concentration of natural killer cells and CD34+ cells positively affected the clinical outcome of allotransplanted patients (P = .005 for both cell types). According to univariate analysis, these findings were dependent on minimal residual disease and acute graft-versus-host disease. Graft-versus-host disease (acute and chronic forms) was not affected by graft composition. CONCLUSIONS Our results suggest that increased concentration of natural killer cells and CD34+ cells in the apheretic product may predict better survival. In contrast, busulfan-fludarabine-antithymocyte globulin-based conditioning eliminates the disadvantages that resulted from the high content of T-cell subsets and B cells, and the course of the transplant and clinical parameters were not affected by the amount of T and B cells.
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Affiliation(s)
- Mahmut Yeral
- Baskent University Adana Adult Bone Marrow Transplantation Center, Adana, Turkey
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The number of T cell allo-epitopes associates with CD4+ and CD8+ T-cell infiltration in pediatric cutaneous GVHD. Cell Immunol 2015; 295:112-7. [DOI: 10.1016/j.cellimm.2015.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/02/2015] [Accepted: 03/09/2015] [Indexed: 12/18/2022]
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Human herpesvirus 6 reactivation before engraftment is strongly predictive of graft failure after double umbilical cord blood allogeneic stem cell transplantation in adults. Exp Hematol 2014; 42:945-54. [PMID: 25072620 DOI: 10.1016/j.exphem.2014.07.264] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 07/12/2014] [Accepted: 07/22/2014] [Indexed: 11/21/2022]
Abstract
Our main objective was to determine new factors associated with engraftment and single-unit predominance after double umbilical cord blood (UCB) allogeneic stem-cell transplantation. Engraftment occurred in 78% of cases in this retrospective study including 77 adult patients. Three-year overall survival, disease-free survival, relapse incidence, and nonrelapse mortality were 55 ± 6%, 44 ± 6%, 33 ± 5%, and 23 ± 4%, respectively. In multivariate analysis, Human herpesvirus 6 reactivation during aplasia (hazard ratio [HR] = 2.63; 95% confidence interval [CI]: 1.64-4.17; p < 0.001), younger recipient age (<53 years) (HR = 1.97; 95% CI: 1.16-3.35; p = 0.012), and lower human leukocyte antigen matching between the two units (3 of 6 or 4 of 6) (HR = 2.09; 95% confidence interval: 1.22-3.59; p = 0.013) were the three factors independently associated with graft failure. Also, factors independently predicting the losing UCB unit were younger age of the UCB unit (odds ratio [OR] = 1.01; 95% CI: 1-1.02; p = 0.035), lower CD34(+) cell dose contained in the UCB unit (≤ 0.8 × 10(5)/kg) (OR = 2.55; 95% CI: 1.05-6.16; p = 0.04), and presence of an ABO incompatibility between the UCB unit and the recipient (OR = 2.53; 95% CI: 1.15-5.53; p = 0.02). Thus, Human herpesvirus 6 reactivation during aplasia, lower unit-unit human leukocyte antigen matching, and younger UCB unit age, as new unfavorable predictive factors, may represent new parameters to take into account after double UCB allogeneic stem-cell transplantation in adults. These results need to be confirmed prospectively, as they may influence unit selections and patient outcomes.
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Illiaquer M, Malard F, Guillaume T, Imbert-Marcille BM, Delaunay J, Le Bourgeois A, Rimbert M, Bressollette-Bodin C, Precupanu C, Ayari S, Peterlin P, Moreau P, Mohty M, Chevallier P. Long-lasting HHV-6 reactivation in long-term adult survivors after double umbilical cord blood allogeneic stem cell transplantation. J Infect Dis 2014; 210:567-70. [PMID: 24596281 DOI: 10.1093/infdis/jiu129] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Higher incidence of human herpesvirus 6 (HHV-6) infection has been documented after umbilical cord blood allo-transplant in adults. Here we demonstrate that HHV-6 reactivation persists for a very long time in half of the patients after this type of graft. Long-term immune reconstitution does not explain this event, which remains to be explained.
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Affiliation(s)
- Marina Illiaquer
- Centre Hospitalier et Universitaire (CHU) de Nantes, Département de Virologie, Nantes France and EA4271 «Immunovirology and Genetic Polymorphism», University of Nantes
| | - Florent Malard
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique, Centre d'Investigation Clinique en Cancérologie (CI2C), Nantes
| | - Thierry Guillaume
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique, Centre d'Investigation Clinique en Cancérologie (CI2C), Nantes
| | - Berthe-Marie Imbert-Marcille
- Centre Hospitalier et Universitaire (CHU) de Nantes, Département de Virologie, Nantes France and EA4271 «Immunovirology and Genetic Polymorphism», University of Nantes
| | - Jacques Delaunay
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique, Centre d'Investigation Clinique en Cancérologie (CI2C), Nantes
| | - Amandine Le Bourgeois
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique, Centre d'Investigation Clinique en Cancérologie (CI2C), Nantes
| | - Marie Rimbert
- Centre Hospitalier et Universitaire (CHU) de Nantes, Département d'Immunologie, Nantes
| | - Celine Bressollette-Bodin
- Centre Hospitalier et Universitaire (CHU) de Nantes, Département de Virologie, Nantes France and EA4271 «Immunovirology and Genetic Polymorphism», University of Nantes
| | - Cristina Precupanu
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique, Centre d'Investigation Clinique en Cancérologie (CI2C), Nantes
| | - Sameh Ayari
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique, Centre d'Investigation Clinique en Cancérologie (CI2C), Nantes
| | - Pierre Peterlin
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique, Centre d'Investigation Clinique en Cancérologie (CI2C), Nantes
| | - Philippe Moreau
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique, Centre d'Investigation Clinique en Cancérologie (CI2C), Nantes
| | - Mohamad Mohty
- Hôpital Saint Antoine, Hématologie Clinique, Paris, France
| | - Patrice Chevallier
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique, Centre d'Investigation Clinique en Cancérologie (CI2C), Nantes
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