[Treatment response of a two-dose regimen of dose-adjusted inotuzumab ozogamicin in relapsed/refractory B-cell acute lymphoblastic leukemia]

Objective: To observe the treatment response of a two-dose regimen of inotuzumab ozogamicin (inotuzumab), a monoclonal antibody targeting CD22, for patients with heavily treated relapsed/refractory B-cell acute lymphoblastic leukemia (R/R B-ALL), including those failed or relapsed after chimeric antigen receptor (CAR) -T-cell therapy. Methods: Pediatric and adult patients who received two doses of inotuzumab and who were evaluated after inotuzumab treatment were included. Antibody infusions were performed between March 2020 and September 2022. All patients expressed CD22 antigen as detected by flow cytometry (>80% leukemic cells displaying CD22) before treatment. For adults, the maximum dosage per administration was 1 mg (with a total of two administrations). For children, the maximum dosage per administration was 0.85 mg/m(2) (no more than 1 mg/dose; total of two administrations). The total dosage administered to each patient was less than the standard dosage of 1.8 mg/m(2). Results: Twenty-one patients with R/R B-ALL were included, including five children (<18 years old) and sixteen adults. Seventeen patients presented with 5.0% -99.0% leukemic blasts in the bone marrow/peripheral blood or with extramedullary disease, and four patients were minimal residual disease (MRD) -positive. Fourteen patients underwent both CD19 and CD22 CAR-T-cell therapy, four underwent CD19 CAR-T-cell therapy, and three underwent blinatumomab therapy. Eleven patients underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT). After inotuzumab treatment, 14 of 21 patients (66.7% ) achieved a complete response (CR, one was MRD-positive CR), and all four MRD-positive patients turned MRD-negative. Four of six patients who failed recent CD22 CAR-T-cell therapy achieved a CR after subsequent inotuzumab treatment. Seven patients (33.3% ) demonstrated no response. Grade 1-3 hepatotoxicity occurred in five patients (23.8% ), one child with no response experienced hepatic veno-occlusive disease (HVOD) during salvage transplantation and recovered completely. Conclusion: For patients with heavily treated R/R B-ALL, including those who had undergone allo-HSCT and CD19/CD22 CAR-T-cell therapy, the two-dose regimen of inotuzumab resulted in a CR rate of 66.7%, and the frequency of hepatotoxicity and HVOD was low.

Post-HSCT relapsed precursor B-cell ALL successfully salvaged by BiTE followed by consolidation CAR-T cell therapy: A report of two cases

Precursor B-cell acute lymphoblastic leukemia (pre-B ALL) relapse after allogeneic hematopoietic stem cell transplantation (HSCT) typically has poor outcomes. Both bispecific T-cell engager (BiTE, blinatumomab) and chimeric antigen receptor T-cell (CAR-T) are novel immuno-designed therapies for advanced acute lymphoblastic leukemia. However, the treatment and effects of their combination remain unclear. Two patients with pre-B ALL experienced overt leukemic relapse after allogeneic HSCT. Both patients received one standard cycle of blinatumomab treatment, and complete remission was achieved. Subsequently, during remission, both patients underwent treatment with CAR-T cells prepared from their own T-cells. One patient received CD22-CAR-T cell as a consolidative therapy, while the other underwent CD19-CAR-T cell therapy. No cytokine release syndrome occurred. After treatment, both patients are alive and do not have leukemia recurrence for more than one year. In conclusion, sequential combination of BiTE followed by CAR-T cell therapy may show promising results for relapsed and advanced B-cell leukemia. This novel combination is worthy of further investigation.

[Effect of NCCN (2015) risk stratification on prognosis of patients with acute myeloid leukemia after allogeneic hematopoietic stem cell transplantation]

Objective: To analyze the effect of NCCN (2015) risk stratification on prognosis of patients with acute myeloid leukemia (AML) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) . Methods: Retrospective analysis of 258 patients with AML in CR (186 cases in CR(1), 72 cases in CR(2)) who underwent allogeneic HSCT in our hospital between April 2012 and March 2015 according to NCCN (2015) risk stratification. Of them, 63 cases were classified as low risk, 112 cases intermediate risk and 83 cases high risk. Results: ①With the median follow up of 18 (5-41) months, two-year disease free surviva (DFS) in 258 patients was 78.0% (95% CI 60.4%-96.6%) . Two-year DFS in AML after transplantation was 78.6% (95% CI 61.0%-96.2%) in low risk, 76.0% (95% CI 84.0%-93.6%) in intermediate risk and 80.3% (95% CI 62.7%-97.9%) (P=0.886) in high risk groups respectively. ②Univariate analysis showed that DFS has no significant difference in patient age, the median disease course before HSCT, the WBC number at the beginning of the disease, blood routine and chromosomes examination before transplantation, extramedullary disease before transplantation, disease status before transplantation, conditioning regimen, donor type, donor and recipient sex, recipient blood type, transfused MNC number, transfused CD34(+) cell number and transfused CD3(+) cell number. DFS was significant lower in primary AML than that in secondary AML (P=0.006) and also lower in MRD positive than that in MRD negative (P=0.003) . The accumulative relapse was significant higher in CR(2) compared to that in CR(1) (P=0.046) . Accumulative non-relapse mortality (NRM) was significanlyt higher in secondary AML compared to that in primary AML (P=0.004) and also higher in MRD positive compared to that in MRD negative (P=0.010) . ③Multivariate analysis showed that MRD positive was the only significant factor in DFS and NRM. Conclusion: Allo-HSCT treatment of AML CR patients could achieve a high efficacy, which is similar between CR(1) and CR(2) patients. There is no significant correlation between NCCN (2015) risk stratification and the prognosis of AML patients with allo-HSCT treatment. Pre-conditioning MRD status monitored by multiparameter flow cytometry was the only impact factor on DFS and NRM in allo-HSCT for CR-AML patients.

[Clinical analysis of 12 cases of acute myeloid leukemia with Ph chromosome and BCR-ABL positive]

This study was purposed to analyze the characteristics of morphology, immunology, cytogenetic and molecular biology of leukemia cells in 12 AML patients with Ph(+) and their correlation with survival of patients. 12 patients with Ph(+) AML were diagnosed according to diagnostic criteria of WHO and existence of t(9;22) (q34;q11) or t(9;22) abnormality, meanwhile no evidence of CML chronic phase was observed. The results showed that 8 out of 12 cases were confirmedly diagnosed to be AML by morphologic and immunophenotypic examination, 4 cases were diagnosed as myeloid and B lymphocytic mixed acute leukemia. The Ph chromosome was detected in 10 cases by chromosome analysis at the first time of diagnosis, and some of the cases had coexistence of complex chromosome and/or normal karyotype. BCR-ABL transcript was detected in all 12 cases, including 7 cases with b3a2, 1 case with b2a2, 1 case with b2a2 variants, 2 cases with e1a2 and 1 case with e18a2. The 12 cases all got complete remission after chemotherapy and/or gleevec treatment, out of them 3 cases received chemotherapy and gleevec treatment, but 2 cases died; 9 cases received allogeneic hematopoietic stem-cell transplantation (allo-HSCT), 1 case died from relapse, among them 1 case died from transplant complications. The median survival was 24 (8 - 80) months, the overall survival of 3 years was (51.4 ± 17.7)%. It is concluded that the Ph(+) AML is a acute myelogenous leukemia with poor prognosis, but long-term survival may be achieved with HSCT as quick as after complete remission from gleevec and chemotherapy treatment. Meanwhile, the detection of BCR-ABL gene and it variants may be give more opportunity for diagnose and treatment, which can be used as routine screening for newly diagnosed leukemia.

[Flow cytometric monitoring of minimal residual diseases in patients with acute leukemia after allogeneic hemapoietic stem cell transplantation]

OBJECTIVE

To study the significance of flow cytometric monitoring minimal residual diseases (MRD) in patients with acute leukemia (AL) after allogeneic hemapoietic stem cell transplantation (HSCT).

METHODS

From January 2007 and January 2008 MRD were detected by flow cytometry (FCM) in 402 bone marrow (BM) in 102 AL patients without leukemic gene and chromosomal changes at first diagnosis after HSCT (1, 2, 3, 6,12 months after HSCT; adding detection frequency in part of high risk patients), The relationship between the MRD results and clinical prognosis were observed. Patients with significantly higher MRD were treated and the effectiveness was monitored by FCM (MRD > 0.01% considered as positive).

RESULTS

(1) 71 cases were persistently negative for MRD after HSCT and all them were in hematologic complete remission (CR). Only 3 cases had extramedullary relapse. The disease free survival (DFS) and overall survival (OS) were 66.2% and 90.1%, respectively. (2) Of 27 MRD(+) cases 11 converted to MRD negativity after chemotherapy plus donor lymphocyte infusion (DLI), CIK, NK cells. The DFS and OS were 63.6% and 72.7%, respectively. Other 16 cases had hematologic relapse. The DFS and OS were 11.1% and 25.0%, respectively. The median time from MRD increasing to hematologic relapse was 48 days (7-69 day). (3) Four cases had hematologic relapse after HSCT and died in the end.

CONCLUSIONS

(1) The DFS and the OS in MRD(-) cases are significantly higher than those of MRD(+) cases. (2)MRD(+) patients after HSCT coveted to MRD(-) after intervention. Therapy, whose DFS and the OS are still significantly higher than those of MRD(+) cases. (3) Patients with hematologic relapse after HSCT have the worst prognosis and the DFS and OS are significantly low. FCM monitoring of MRD in patients after HSCT is a sensitive, specific, quick and simple method. It can indicate recurrent state in time, facilitates early intervention, reduces the hematologic relapse risk and improves DFS.

[Cytomegalovirus enteritis after allogeneic hematopoietic stem cell transplantation]

OBJECTIVE

To analyse the clinical features, diagnostic methods and risk factors of cytomegalovirus (CMV) enteritis after allogeneic hematopoietic stem cell transplantation (allo-HSCT).

METHODS

Analysis was made on 24 cases of CMV enteritis after allo-HSCT in Beijing Daopei Hospital from Aug. 2007 to Jul. 2009, including clinical data, endoscopic diagnosis, histopathological and virological results, and the association between CMV enteritis with viremia and graft-versus-host disease(GVHD).

RESULTS

87.5% of the patients were over 18 years old. The median time to diagnosis of CMV enteritis was 63 days after HSCT. The mucosal lesions in enteroscopic examination had no significant differences between CMV enteritis and gastrointestinal GVHD complicated with the enteritis. The methods used in diagnosis included histopathology (32.1%) and virology (92.9%). The copies of CMVDNA in mucosal samples greater than 10(5)/10(6) PBNC was better diagnosis. A number of risk factors were compared between the survival and death groups: type of transplant, conditioning regimen, the time span of ganciclovir prophylaxis therapy, grade II-IV GVHD before enteritis, the time of diagnosis as GVHD, using MP > or = 1 mg/kg to treat GVHD, the time between GVHD and enteritis, CMV viremia before enteritis, the time of diagnosis as enteritis, CMVDNA quantitation, and there were no any statistic differences.

CONCLUSION

Cytomegalovirus enteritis should be carefully diagnosed by histopathology and virology through endoscopic examination. It is better to undertake pan-colon endoscopy as well as terminal ileum examination for more accurate diagnosis. PCR can significantly improve the detection rate. CMVDNA detection in patients' stool may be helpful to diagnosis, especially for those patients who can not stand the endoscopy examination.

[The effect of inhibitory and activating natural killer cell immunoglobulin receptor on haplo-identical hematopoietic stem cell transplantation]

OBJECTIVE

To investigate the effect of inhibitory and activating KIRs on a cohort of Chinese leukemia patients who received haplo-identical hematopoietic stem cell transplantation (HSCT).

METHODS

Donor's inhibitory and activating KIRs and recipient's HLA-C from 47 cases who received haplo-identical HSCT were tested by PCR-SSP. 2 year overall survival (OS), incidence of severe (grade III to IV) acute GVHD (aGVHD) and relapse rate (RR) were analyzed.

RESULTS

(1) According to Matched (M) vs Mis-Matched (MM) between donor's inhibitory KIR and recipient's HLA-C1/C2 subgroup, 2 year OS rate in M group [(87.5 +/- 8.3)%] was significantly higher than that in MM group (54.5 +/- 9.0)%, (P = 0.03). Lower incidence of relapse rate was seen in M group than in M/MM groups [0 vs (25.4 +/- 9.5)%, P = 0.05]. In 30 cases of myeloid leukemia patients, there was lower RR in M group than in MM groups [0 vs (35.0 +/- 14.4)%, P = 0.04]. (2) According to the 3 activating KIR genes: KIR2DS1/ KIR2DS2/ KIR2DS3, lower incidence of grade III-IV aGVHD was seen in KIR2DS1 (+) group than in KIR2DS1 (-) group (13% vs 28%, respectively, P > 0.05); and so was done in KIR2DS3 (+) group (11% vs 26%, respectively, P > 0.05). The RR was lower in KIR2DS2 (+) group [0% vs (17.3 +/- 7.1)%, respectively, P > 0.05].

CONCLUSIONS

In our haplo-identical HSCT setting, match between donor's inhibitory KIR and recipient's HLA-C can significantly reduce the incidence of relapse rate and improve OS. Although lower incidences of severe aGVHD are noted in the donors with KIR2DS1 (+) or KIR2DS3 (+), and lower relapse rate is noted in the donors with KIR2DS2 (+) but without statistic difference, no remarkable effects of activating KIRs on OS have been found in our relatively small clinical series.

[The clinical and laboratory features of 9 cases with gammadeltaT cell lymphoma or leukemia]

OBJECTIVE

To analyze the clinical and laboratory features of 9 cases of gammadeltaT cell lymphoma or leukemia.

METHODS

From 2007 to 2011, 9 patients with gammadeltaT-cell lymphoma/leukemia were diagnosed in our hospital. The immunophenotype of the abnormal cells were detected by flow cytometry, clonal gene rearrangement of IgH, TCRgamma, TCRdelta by PCR, chromosome karyotype analysis by G banding, acute leukemia gene and the DNA of type 1 - 8 human herpes virus by multiple nested PCR, The gammadeltaT cells were determined by T cell with TCR gammadelta chain, the malignant gammadelta T cells by the abnormal expression of T cell antigens and the precursor malignant gammadelta T cells by the expression of CD34, TDT, CD99, CD1 a or acute leukemia genes.

RESULTS

In the 9 patients with gammadeltaT cell lymphoma leukemia, significant malignant gammadeltaT cells infiltration of bone marrow were found in 8 with blast morphology. 5 were diagnosed as T-ALL/LBL (gammadeltaT type) and 4 HSgammadelta TCL. The clonal gene rearrangement of TCRgamma and/or TCRB were detected in 6/6 patients. Patients either did not achieve complete remission(CR) after induction therapy or relapsed quickly after CR. Only 4/5 patients remained continuous CR(CCR) at 2, 2, 3,12 months respectively, after allogeneic hematopoietic stem cell transplantation (allo-HSCT), the fifth T-ALL (gammadeltaT) relapsed 1 month after allo-HSCT.

CONCLUSIONS

The incidence of gammadelta T cell lymphoma or leukemia may be higher than reported, part of them were T-ALL/LBL with poor prognoses. FCM and clonal gene rearrangement of TCRgamma and/or TCRdelta are helpful to diagnosis. Allo-HSCT may be the only curative approach.

[The study of gene mutations in unknown refractory viral infection and primary hemophagocytic lymphohistiocytosis]

OBJECTIVE

To study the type and corresponding clinical characteristics of primary hemophagocytic lymphohistiocytosis (HLH) associated immune gene mutations in the refractory virus infection or HLH of unknown causes.

METHODS

From December 2009 to July 2010, the patients with refractory virus infection or HLH of unknown causes were screened for the primary HLH associated immune genes mutations by DNA sequence analysis, including PRF1, UNC13D, STX11, STXBP2, SH2D1A and XIAP. The clinical characteristics and outcomes were followed up.

RESULTS

Totally 25 patients with refractory virus infection or HLH of unknown causes were investigated for the 6 genes and 13 cases were found carrying gene mutations, composing of 6 of PRF1 mutation, 3 of UNC13D, and each one of STX11, XIAP, SH2D1A and STXBP2, respectively. Among the 13 cases with gene mutations, 5 suffered from Epstein-Barr virus associated HLH (EBV-HLH), 1 human herpes virus 7 associated HLH (HHV7-HLH), 1 HLH without causes, 4 chronic activated EB virus infection (CAEBV) with 1 progressing to Hodgkin's lymphoma carrying abnormal chromosome of t(15;17) (q22;q25) and hyperdiploid, 2 EBV associated lymphoma. Among the other 12 patients without gene mutation, 4 suffered from EBV-HLH with 1 progressing to peripheral T lymphoma, 8 suffered from CAEBV.

CONCLUSIONS

Primary HLH associated immune gene mutations are critical causes of refractory virus infection of unknown causes, most patients manifest as HLH, some cases appear in CAEBV and EBV associated lymphoma. DNA sequence analysis is helpful to early diagnosis and correct decision-making for treatment.

[Role of HLA protein three-dimensional conformation difference in unrelated hematopoietic stem cell transplantation]

This study was purposed to investigate the value of Histocheck and HLA-Matchmaker softwares in evaluating influence of HLA protein three dimensional conformation among individuals on outcome of unrelated donor hematopoietic stem cell transplantation (URHSCT). Data of the HLA-A/B/C/DRB1/DQB1 genotypes from 62 cases of URHSCT (HLA-allele 10/10 match 30 cases, 9/10 match 32 cases) were input into Histocheck and HLA-Matchmaker softwares respectively. The relationship between the software dissimilar scores and the 1 year overall survival (OS), incidence of aGVHD of III-IV grade and relapse rate was analyzed. The results showed that (1) with increase of the Histocheck scores, incidence of aGVHD of III-IV increased from 0% to 20% (p = 0.25), while no or mild aGVHD occurred in 70% cases with the high scores. For the relapsed cases, there was no significant difference between the cases with low scores and with highest scores (relapse rate 20%) except that 9 cases had no relapse in the group with higher score (11 - 20). (2) the analysis using HLA matchmaker software showed that incidence of aGVHD of III-IV grade increased with the increase of numbers of mismatch Eplets, arranging from 0% to 30%, the incidence of moderate aGVHD reduced (p = 0.019), whereas 60% cases in highest scores group had moderate aGVHD. No relapse occurred in the group with higher scores (≥ 3) (n = 10), whereas high relapse rate appeared in the lower score group (20%, p = 0.54). It is concluded that the value of Histocheck and HLA-Mtchmaker software for analysing the outcome of URHSCT may be similar despite of different calculating methods; for the certain pair of recipient and donor, correlation of the two score systems with incidence of aGVHD and relapse rate is similar, but with less accuracy; The HLA Matchmaker software appears better than Histocheck software in terms of correlation.

[An analysis of etiological and genetic factors of a patient with familial hemophagocytic lymphohistiocytosis]

OBJECTIVE

To analyze the etiological factor and genetic feature of a familial hemophagocytic lymphohistiocytosis patient with PRF1 mutation (FHL2) with human herpesvirus 7 (HHV7) infection and its family constellation.

METHODS

Clinical characteristics, laboratory examinations of a FHL2 case with HHV7 infection were reported. HHV1-HHV8 virus DNA was screened by PCR; NK cell function was analyzed by flow cytometry; PRF1 gene mutations were analyzed by PCR and direct sequencing, structure of mutant PRF1 proteins were analyzed using ExPasy and I-TASSER server and genetics pedigree were analyzed.

RESULTS

The patient's HHV7 viral was detected positive with DNA copy number of 350/10(6) peripheral nucleated cells. Flow cytometry analysis showed decrease both in proportion of perforin positive NK cells and perforin protein expression. Genetic testing showed PRF1 biallelic heterozygote mutations (c.503G > A/p.S168N and c.1177T > C/p.C393R) and pedigree analysis showed they were inherited. The patient was then treated with antivirus therapy, dexamethasone and VP16 therapy, but only achieved partial response. The patient was then followed by human leukocyte antigen 10/10 allele identical non-consanguinity allogeneic hematopoietic stem cell transplantations (allo-HSCT) and soon the successful implantation of donor hematopoietic cells and persistent recovery was achieved. The patient was now surviving without recurrence for 9 months after allo-HSCT.

CONCLUSIONS

FHL is prone to be misdiagnosed as lymphoma. Genetic analysis of related gene mutation and herpes simplex virus detection will help in early and accurate diagnosis. Allo-HSCT is a fundamental treatment of FHL.

[Influence of HLA-A/B/C/DRB1/DQB1 on unrelated donor hematopoietic stem cell transplantation]

This study was purposed to explore the influence of number and locus of HLA allele mismatch on unrelated donor hematopoietic stem cell transplantation (URHSCT) in Chinese Han population. Total 10 alleles within the HLA-A/B/C/DRB1/DQB1 loci were analyzed by PCR-SSP for 101 pairs of donor and recipients who received URHSCT. 101 cases of URHSCT were divided into four groups: HLA-allele 10/10 match (n = 30), 9/10 (n = 32), 8/10 (n = 31) and 7/10 match (n = 8). The correlation of the HLA with overall survival (OS ≥ 1 year), incidence of acute GVHD (aGVHD) of grade II to IV and relapse rate of primary diseases were evaluated. The results showed that (1) The OS rates in HLA-10/10 and 9/10 groups were higher than that in HLA-8/10 match group (78% and 82% vs 50%, p = 0.39); incidence of aGVHD in the HLA-10/10 were lower than that in HLA-9/10 and HLA-8/10 group (0% vs 10% and 10%; p = 0.28); relapse rates among the 3 groups were close (16%, 18% and 20%, respectively). Although there were only 8 cases in HLA-7/10 match URHSCT, the data indicated that they were safe and effective; (2) Compared to the HLA-10/10 match URHSCT (n = 30), the HLA-C mismatch URHSCT (n = 12) harbored higher incidence of severe aGVHD (0% vs 25%, p = 0.006), longer OS (77% vs 85%, p = 0.30), and tendency to low relapse rate (8% vs17%, p = 0.47); (3) According to HLA-C1/C2, the ligands of inhibitory KIR, the 42 cases of HLA-10/10 match URHSCT and HLA-C mismatch URHSCT were grouped into donor/recipient HLA-C1/C2 match and mis-match subgroups. There was no difference between the two subgroups for OS, incidence of aGVHD and relapse rate (78% vs 80%, 14% vs 20%, and 5% vs 20%). It is concluded that for 0 to 2 locus of HLA allele mismatch in URHSCT, the fewer mismatch numbers, the longer OS, but with similar aGVHD incidence and the relapse rate; triple HLA allele mismatch (HLA-7/10 match) is safe in URHSCT. The HLA-C mismatch may be related to higher incidence of aGVHD and lower relapse rate and prolonged OS, remaining to be further studied.

[Clinical and molecular biologic characteristics of 36 cases of leukemia with 11q23/mll]

This study was aimed to analyze the clinical and cytogenetic characteristics of acute leukemia with 11q23/mll rearrangement and explore the reasonable therapeutic principles. Characteristics in general situation, morphology, immunology, molecular biology, cytogenetics, treatment and overall survival of 36 cases of acute leukemias with mll gene rearrangement were studied and analyzed. The results showed that 36 cases with mll gene rearrangement were found positive (7.2%) in 494 patients with acute leukemia. Among the 36 cases of mll rearrangement positive, 32 cases were diagnosed as acute myeloid leukemia (AML) with myeloid antigen expression, of which 5 cases expressed lymphoblastic differentiation antigen; 4 cases were classified as B-lineage acute lymphoblastic leukemia (ALL), of which non-lineage myeloid expression pattern were found in 3 cases. In 29 out of 36 cases (80%) the clonal chromosomal aberration were detected, of which chromosome 11 aberration were observed in 22 cases. All patients received chemotherapy with a total response rate of 47.2%. Of the responded patients, 10 cases relapsed within 6 months, with a recurrence rate of 40%; 9 cases received hematopoietic stem cell transplantation (HSCT), 7 cases of which survived after transplantation. The median survival time of 36 cases was 16 months (range 2 - 46) and their 2-year overall survival rate was 41.4%. The 2-year overall survival rate of 9 patients who received HSCT was 87.5%. It is concluded that acute leukemia patients with mll gene rearrangement show poor response to chemotherapy, high recurrence rate and poor prognosis. Hematopoietic stem cell transplantation may be a reasonable treatment principle to improve these patients' survival situation.

[Successful treatment of high risk/refractory leukemia by tumor-ablative individualized conditioning allogeneic hematopoietic stem cell transplantation]

OBJECTIVE

To explore the efficacy of tumor-ablative individualized allogeneic hematopoietic stem cell transplantation for the treatment of patients with high risk/refractory leukemia.

METHODS

Fivety-seven patients with high risk/refractory leukemia were enrolled. Tumor-ablative individualized conditioning regimens included HDAra-C + Bu/Cy, Ara-C + Bu/Fludarabine, G-CSF primed HDAra-C + Bu/Cy, and FLAG followed by reduced-intensified BuCy. Overall survival (OS), disease free survival (DFS), graft versus host disease, infection and relapse post grafting were analyzed.

RESULTS

Fifty-six patients attained durable engraftment. The median follow-up duration was 17.5 (2 - 34) months. The 18 months probabilities of OS and DFS were (74.7 ± 6.1)% and (62.4 ± 6.7)%, respectively. In addition, the 18 months probabilities of OS and DFS in patients who attained complete remission (CR) before transplantation were (74.2 ± 7.1)% and (58.8 ± 8.1)%, respectively, while in those not attained CR were (77.0 ± 11.8)% and (72.7 ± 11.7)%, respectively. Twenty nine patients developed acute GVHD (aGVHD) (grade I in 18, grade II in 4, grade III in 2 and grade IV in 5). The probabilities of aGVHD was (50.9 ± 6.6)% by Kaplan-Meier curve analysis. The probabilities of grades 2-4 and grades 3-4 aGVHD were (19.3 ± 5.2)% and (12.3 ± 4.3)% respectively. Extensive chronic GVHD (cGVHD) was observed in 36 patients. The probabilities of cGVHD was (64.3 ± 6.4)% by Kaplan-Meier curve analysis. Cytomegaloviremia (CMV) was observed in 39 (68.42%) patients, hemorrhagic cystitis in 13 (22.8%) patients, fungous infection in 16 (28.07%) patients and bacterial infection in 38 (66.67%) patients. Relapse occurred in 14 patients (hematologic relapse in 11 and extramedullary relapse in 3), probabilities of relapse being (24.6 ± 5.7)%. The 17.5-month probability of relapse in patients who attained CR before transplantation was (28.1 ± 7.7)%, while in those not attained CR was (15.6 ± 10.2)%. Fifteen patients died (6 from hematological relapse, 5 from infection of bacterial and fungous, 4 from cGVHD) after 100 days.

CONCLUSION

Tumor-ablative individualized allogeneic hematopoietic stem cell transplantation is a promising and safe choice for treatment of high risk/refractory leukemia, even with high leukemia burden.

[Evaluation of polymorphic post-allotransplant lymphoproliferative disorder by flow cytometry.]

OBJECTIVE

To study the role of flow cytometry (FCM) in detection of polymorphic post-transplant lymphoproliferative disorders (PTLD).

METHODS AND RESULTS

Two patients presented with fever and multiple lymphadenopathy on day 46 and day 50 respectively after successful allogeneic hematopoietic stem cell transplantation (allo-HSCT). The symptoms couldn't be controlled by antibiotics. The polymorphic PTLD was diagnosed based on the elevation of bone marrow EB virus DNA and detection of subsets of light chain restricted B cells and/or plasma cells in peripheral blood (PB) samples. The lymphocyte immunophenotypes from PB and/or bone marrow (BM) samples were serially tested by FCM after lowering the dose of immunosupressive agents and treating with antivirus drugs, anti-CD20 antibodies, and cytotoxic T cell infusion. B cells were undetable in two patient, but monoclonal plasma cells appeared or maintained. One patient died after two weeks. Another patient was still on treatment. B cells and plasms cells couldn't be detected in her PB, but there were monoclonal plasma cells in her BM. FCM have a prominent advantage in detect polymorphic PTLD, since it can effectively recognize different cell groups in blood and identify monoclonal subsets. Besides, the immunophenotype of plasma cells in polymorphic PTLD might be different from that in typical plasma cell myeloma.

CONCLUSION

Polymorphic PTLD can be detected and followed up by FCM. BM is more suitable than PB for monitoing the disease. Besides lymph node biopsy, B cell abnormaliity could be detected in PB in allo-HSCT patients.

Natural killer/T cell lymphoma initiating with pleural effusion: the significance of MICM combined techniques for the diagnosis

Natural killer (NK)/T-cell lymphomas represent a rare type of lymphoma derived from either activated NK cells or cytotoxic T cells. They are most commonly extranodal and tend to present as destructive lesions within the midline facial structures. Other than the nasal cavity and Para nasal sinuses, several other extra nodal sites of involvement have been reported, including the pharynx, gastrointestinal tract, and testis. Occasionally, pleural effusion has also been observed. Here, a case of lymphoma of NK/T-cell type presented as pleural effusion was reported. The patient was previously misdiagnosed as B cell non-Hodgkin's lymphoma by pathological and immunohistochemistry (IH) analysis for pleural membrane biopsy specimen. After the analysis of the pleural fluid cells by a combination of morphologic, immunophenotypic, cytogenetic and molecular (MICM) methods in Beijing Dao-Pei hospital, some lymphoblasts were found morphologically, which expressed cytoplasmic CD3 (cCD3) and CD56 by flow cytometry analysis and had a clonal T-cell receptor gamma (TCR-gamma) gene rearrangement by molecular analysis, so that the diagnosis was finally corrected as NK/T-cell lymphoma and an allogeneic stem cell transplantation was successfully performed. In conclusion, this unusual case highlights the significance of MICM combined techniques for the diagnosis of lymphoma, as well as an unusual presentation of a rare disease and the successful treatment.

[Diagnostic value of plasma (1, 3)-beta-D glucan assay for invasive fungal infections in patients with hematological disorders]

The invasive fungal infections (IFI) in immunocompromised patients are associated with a high mortality rate and diagnostic difficulty. Serological methods such as aspergillus galactomannan assay (GM test) and (1, 3)-beta-D glucan (BG) assay (G test) can be used as an adjunctive method for IFI diagnosis based on their characteristics of easy-operating, rapidness and high sensitivity. Compared with GM test, G test can be more widely used except for the diagnosis of aspergillosis. The purpose of this study was to investigate the value of G test in the diagnosis of IFI in patients with hematological disorders. The plasma was collected from 162 suspected IFI patients with hematological disorders in Beijing Daopei Hospital, including 85 patients after chemotherapy and 77 patients after stem cell transplantation from May 2007 to May 2008, BG level was measured with MB-80 Microbiology Kinetic Rapid Reader and the measured results together with the clinical characteristics were retrospectively analyzed. According to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria, there were 2 patients diagnosed as proven IFI, 18 as probable IFI, 75 as possible IFI and 67 as no IFI. The results showed that at a cutoff of 20 pg/ml, the sensitivity and specificity of G test were 75% and 91% respectively, with a positive predictive value (PPV) of 71.4% and a negative predictive value (NPV) of 92.4%. 51 out of the 75 possible IFI patients with elevated BG level were responsive to antifungal treatment but non responsive to broad-spectrum antibiotics, retrospectively were diagnosed as IFI, suggesting that G test improved the IFI diagnostic rate by 31.4%. In conclusion, G test is a rapid and simple method for early diagnosis of IFI in patients with hematological disorders.

[Correlation of JAK2V617F mutation burden with clinical features in patients with polycythemia vera and essential thrombocythemia]

This study was aimed to analyze the correlation of JAK2V617F mutation burden with clinical features in patients with polycythemia vera (PV) and essential thrombocythemia (ET), The JAK2V617F mutation ratios in 47 PV samples and 43 ET samples were detected by real-time PCR. The correlation of mutation allele ratio in PV and ET samples with clinical features (hemoglobin, hematocrit, white blood cell count and platelet count) was analyzed. The results showed that the JAK2V617F mutation burden was higher in PV (0.441 +/- 0.270) than that in ET (0.209 +/- 0.192). The JAK2V617F mutation burden was positively correlated with levels of hemoglobin (PV: R = 0.518, p < 0.001; ET: R = 0.528, p = 0.005), hematocrit (PV: R = 0.510, p < 0.001; ET: R = 0.524, p = 0.005) and leukocyte (PV: R = 0.584, p = < 0.001; ET: R = 0.471, p = 0.013) in PV and ET samples. The higher JAK2V617F mutation burden was negatively correlated with levels of platelet count in PV samples (R = -0.354, p = 0.020), but there was no correlation between the JAK2V617F mutation burden and platelet count in ET samples (R = 0.233, p = 0.242). It is concluded that the higher JAK2V617F mutation burden is related with higher hemoglobin, hematocrit and leukocyte count in both PV and ET samples. The higher JAK2V617F mutation burden is correlated with lower platelet count in PV samples, but there is no correlation between JAK2V617F mutation burden and platelet count in ET samples.

[Changes of T-cell clonality after induction-cultivation of peripheral T lymphocytes in adoptive immunotherapy for leukemias]

This study was purposed to analyze the changes of T-cell clonality after induction of peripheral T lymphocytes by autogenous DC and cytokines in the preparation of adoptive immunotherapy for leukemias. The bone marrow and peripheral blood from 21 leukemia patients at remission stage after treatment and subjected to adoptive immunotherapy were collected. Their DCs and T-cells were stimulated with cytokines and then were mixed to activate T-cells. T-cell receptor beta variable region (TCRBV) families were amplified by RT-PCR, and genescan method and sequencing of the PCR products were used to observe the clonality changes of T-cells before and after the induction and cultivation of T-cells. The flow cytometry was used to identify CD3(+), CD4(+), CD8(+), CD3(+)CD56(+) and CD4(+)CD25str(+)FOXP3(+) cells to disclose the ratio change of cytotoxic T lymphocytes (CTL), helper T-cells, regulatory T-cells and NK T-cells before and after induction and cultivation of T-cells. The results showed that in the 21 patients, most of the 24 TCRBV families presented as oligoclonal distribution on genescan, several families were not expressed, and only a few families remained polyclonal. TCRBV24 was found to be oligoclonal in all of the 21 patients. DNA sequence analysis of TCRBV24 revealed a common motif of VAG in CDR3 in 3 cases and a common motif of GGG in CDR3 in 2 cases. In patient 5, both TCRBV 24 and TCRBV8 contained the same motif of GGG in CDR3. The identical motif in these patients may suggest that these T-cells recognize the same antigen. The peripheral lymphocytes demonstrated recovery of clonal profile on genescan from oligoclonal profile and absence of several families before the induction and cultivation to typical polyclonal profile in all TCRBV families after the induction by DC and cytokines for 13 days. After the induction and cultivation, the number of lymphocytes increased to 3.38 +/- 1.20 times. CD3(+), CD4(+), CD8(+), CD3(+)CD56(+) and CD4(+)CD25str(+)FOX P3(+) cells were 71.1 +/- 11.8%, 26.7 +/- 11.4%, 35.7 +/- 12.9%, 3.1 +/- 1.6% and 0.12 +/- 0.1% respectively before the induction and cultivation, and changed to 95.4 +/- 3.2% (p < 0.01), 27.0 +/- 13.1% (p > 0.01), 55.5 +/- 13.8% (p < 0.01), 9.8 +/- 6.1% (p < 0.01) and 0.22 +/- 0.18% (p < 0.01) respectively after the induction and cultivation. It is concluded that the major action of this induction and cultivation method on T-lymphocytes in vitro is the promotion of CTL and NK T-cell proliferation. In leukemic patients at the remission stage, the TCRBV profile is characterized by the oligoclonal proliferation of T-lymphocytes. Several proliferated clones may have the same motif in CDR3, suggesting the recognition of the same antigen by these lymphocyte clones. Cytokine induction and co-culture with autogenous DCs can stimulate the T-lymphocytes to recover their immunocompetence as manifested by the polyclonal profile and the proliferation of CTL and NK-T cells.

[Long-term survival analysis in 89 adult patients with acute myeloid leukemia of fusion gene aml1/eto positive]

This study was aimed to investigate various factors influencing long-term survival in adult AML patients with fusion gene aml1/eto positive. A single institutional retrospective study with long-term follow-up was performed to better define the prognostic factors for AML patients with aml1/eto positive. Newly diagnosed 89 adult AML patients with aml1/eto positive were followed up for 1 to 42 months (median 24 months) from January 2004 to July 2008. Univariate and multivariate analysis of potential factors influencing survival and prognosis were carried out by using Log-Rank and Cox regression method, including sex, age, initial WBC counts, extramedullary leukemic disease, central nervous system leukemia (CNSL), chromosome aberrations, immunophenotype, first induction regimen, chemotherapy course to complete remission (CR), time from induction therapy to CR, negative or positive rate of aml1/eto and allogeneic hematopoietic stem cell transplantation and so on. The results showed that the estimated 5-year overall survival (OS) and relapse-free survival (RFS) were (50.0 +/- 2.3)% and (47.0 +/- 1.9)% respectively in follow-up of 89 patients for 1 - 42 months (mean 24 months). Univariate analysis revealed that initial WBC counts, CNSL, chemotherapy course to CR, time from induction therapy to CR, persistent negative in remission and allogeneic hematopoietic stem cell transplantation were important prognostic factors for long-term surviva1. Multivariate study demonstrated that initial WBC counts, CNSL, CD56 positive, negative or positive rate of aml1/eto, time from induction therapy to CR, persistent negative result of RT-PCR assay in remission and allogeneic hematopoietic stem cell transplantation were all critical factors in relation to OS and RFS. It is concluded that Chinese adult AML patients with fusion gene aml1/eto positive have some different characteristics as compared with patients from other countries, a relatively poor outcome is observed in patients, HSCT should be recommended to adult AML patients.

[Analysis of variant translocation der ins (17; 15) in patient with APL by G-banding technique and interphase fluorescence in situ hybridization]

To investigate the biological characteristics of the variant translocation der ins (17;15) in a patient with acute promyelocytic leukemia (APL), the conventional G-banding technique, interphase fluorescence in situ hybridization (int-FISH), RT-PCR, gene scanning, gene sequence and flow cytometry were performed. The results indicated that the variant translocation der ins (17, 15) observed by G banding technique was a rare type, the int-FISH assay by using dual-color pml/raralpha fusion probes confirmed the cytogenetic findings. The detection results of other molecular methods demonstrated the existence of the whole pml/raralpha fusion gene, while this case had insertion variant translocation. This patient got complete remission by using combined chemotherapy, and survives with continuous complete remission during following up for 1 year. In conclusion, the variant translocation der ins (17; 15) is rare type in APL, its incidence is lower, several signal types in detection of int-FISH were observed and the combination chemotherapy for this patient showed more obvious efficacy.

[The correlation between the polyomavirus DNA load and the dose of immunosuppressant]

OBJECTIVE

To explore the correlation between the polyomavirus DNA load and the dose of immunosuppressant in patients with allogene bone marrow transplantation (allo-BMT) for preventing the development of post-transplantational hemorrhagic cystitis.

METHODS

Serial blood and urine samples from 122 cases of allo-BMT recipients were obtained and DNA was extracted from urine samples. Polyomavirus DNA-specific probe was synthesized and Fluorescence quantitative polymerase chain reaction was used for detecting the polyomavirus DNA loads and Fluorescence polarization immunoassay (FPIA) was performed for determining the dose of immunosuppressant Cyclosporin A (CsA) in blood.

RESULTS

The altered polyomavirus DNA load in urine was followed by concentration of CsA in blood. When the concentration of CsA in blood was higher than 86-105 ng/ml, the positive rate of polyomavirus DNA load was significantly increased and both presented the linable correlation.

CONCLUSION

In immunosuppression condition, polyomavirus DNA load correlated to the dose of immunosuppressant, which increased the risk of post-transplantational hemorrhagic cystitis.

[T cells recognizing EBV-epitopes arose in co-culture of peripheral blood mononuclear cells from EB-infected patients and dendritic cells loaded with LMP2-mixed peptides]

The latent membrane protein 2 (LMP2) is a kind of protein expressed by EBV-infected cells. This study was aimed to investigate whether the stimulation of peripheral blood mononuclear cells with peptides induces EBV-specific cytotoxic T lymphocytes (CTL). The peptides were mixture of LMP2 protein and available for people with different HLA types. Peripheral blood sample was collected from a patient with EBV-associated hemophagocytic syndrome. The mononuclear cells were isolated and cultured to obtain dendritic cells (DCs). Immature DCs were pulsed with MIX-LMP2 and added with different maturation-promoting factors. The auto-T lymphocytes were stimulated weekly with the harvested mature DCs loaded with MIX-LMP2, and totally for two times. Part of isolated lymphocytes was cultured without any stimulation as control. T-cell receptor (TCR) beta spectratyping was used to analyze the distribution of different T cell subgroups before and after culture. The phenotype of T lymphocytes was determined by flow cytometry. The IFN-gamma assay was used to estimate specific cytoxic activity of the cultured T cells. The results showed that the distribution of TCRbeta was changed according to analysis of TCR spectratypes. From the distribution of gene families of TCRbeta, the T lymphocytes were oligoclonal before culture, but shifted to a polyclonal after culture in vitro like the normalization of TCR diversity, suggesting the subgroups of lymphocyte could return to normal. The percentage of CD3+, CD3+CD8+ CD3+ CD45RA- CD45 RO+ on T lymphocytes from freshly isolated mononuclear cells were 70.73%, 42.99%, 27.56% respectively. After being stimulated twice with DC loaded with MIX-LMP2, they further increased to 95.17%, 52.54% and 81.41%. The percentages of CD3-CD56+ NK cells and CD4+CD35+ FOXP3+ regulation T cells seldom changed, from 2.12%, 0.03% to 2.35%, 0.02% respectively. The increase of CD3+CD45RA-CD45RO+ cells obviously indicated that most naive T cells could be activated. ELISA for IFN-gamma showed that when DCs loaded with LMP2 peptide were used as target cells, IFN-gamma level secreted by the T cells stimulated with LMP2 peptide-pulsed DCs was 805+/-16 pg/ml and 1729+/-49 pg/ml, the IFN-gamma level secreted by T cells stimulated twice with LMP2 peptide-pulsed DCs was 956+/-23 pg/ml and 2325+/-58 pg/ml respectively at effector-target ratios of 10:1 and 10:2. They were both significantly higher than that secreted by T cells without any stimulation (441+/-27 pg/m and 557+/-19 pg/ml) (p<0.05). But DCs unpulsed with LMP2 peptide were used as target cells, there were no significant differences between the T cells stimulated with LMP2 peptide-pulsed DCs and the T cells without stimulation (p>0.05). It is concluded that the antigen specific T cells recognizing EBV epitopes can be obtained by using DCs pulsed with MIX-LMP2 peptide in vitro, meanwhile the distribution of T cell subgroups can be changed and normalized.

[Correlation between load of polyomavirus and hemorrhagic cystitis]

OBJECTIVE

To study the correlation between polyoma virus load and hemorrhagic cystitis after allogeneic stem cells transplantation for prevention of hemorrhagic cystitis.

METHODS

Blood and urine specimens were collected from 40 healthy persons, 40 patient with stem cells transplantation and 20 cases complicated with hemorrhagic cystitis for determination of VP1 gene of polyomaviruses BK virus (BKV)/Jamestown Canyon virus (JCV) and simian virus 40 (SV40) by polymerase chain reaction (PCR) and EvaGreen stain fluorescence quantitative assay.

RESULTS

In the peripheral blood, all genes of BKV/JCV and SV40 were negative, while BKV gene in urine and blood from healthy persons and patient with stem cells transplantation was 15% (6/40) and 100% (40/40), respectively. The gene of JCV was positive in 10% (4/40) and 12% (5/40), the gene of SV40 was negative.

CONCLUSION

Genes of BKV and JCV was detectable in urine specimens of healthy persons and there was a correlation between the load of polyomavirus and incidence of hemorrhagic cystitis.

[Induction of T cell responses against autologous ovarian cancer by anti-idiotype minibody-pulsed dendritic cells]

BACKGROUND & OBJECTIVE

Immunotherapy of sensitizing dendritic cells (DCs) with antigen,protein,and frozen cancer cell has been widely used in treating various cancers. The 6B11 anti-idiotype-antibody,a fusion protein prepared by our research center,can mimic ovarian cancer-associated antigen OC166-9. This study was to induce T cell cytotoxicity against autologous tumor cells of patients with ovarian cancer by 6B11 anti-idiotype-antibody.

METHODS

Peripheral blood samples were collected from 10 patients with epithelial ovarian cancer,Monocytes were isolated and cultured to obtain DCs. Immature DCs were stimulated with 6B11 anti-idiotype-antibody (MINI-DC group); unpulsed DCs (unpulsed-DC group),mouse F(ab) '2 fragments pulsed DCs [F(ab)'2-DC group],and T cells alone (T group) were served as controls. Mature DCs were harvested. (3)H-thymidine ((3)H-TdR) incorporation approach was used to measure effect of DCs on stimulating auto-T cell proliferation. Cytotoxicity of DC-activated T cells against auto-tumor cells was measured with (51)Cr 6-h release test,tumor cell lines,SKOV3,HLE,and K562, were used as controls.

RESULTS

In 4 cases,cpm value of (3)H-TdR incorporation,as symbol of auto-T cell proliferation, in MINI-DC group was significantly higher than those in control groups. In 5 cases,specific cytotoxicity effect of T cells on auto-tumor cells was observed in MINI-DC group at effect-target ratio of 20:1,the toxicity effect of T cells in MINI-DC group was 25%-100%,significantly higher than those in F(ab)'2-DC group (18%-40%), unpulsed-DC group (13%-43%),and T group (9%-58%). In 4 cases,the toxicity effect of T cells in MINI-DC group, at effect-target ratio of 20:1,on auto-tumor cells was 25%-100%, higher than those on SKOV3 cells (5%-51%),HLE cells (2%-38%),and K562 cells (2%-25%). Moreover,the toxicity effect of T cells in MINI-DC group on auto-tumor cells can be partially blocked by anti-MHC-I antibody,which indicated that the toxicity was antigen-specific.

CONCLUSION

DCs loaded with 6B11 anti-idiotype antibody that mimic ovarian cancer antigen can induce antigen specific T cell cytotoxicity against auto-ovarian tumor cells in vitro.