Graft failure after allogeneic hematopoietic stem cell transplantation in pediatric patients with acute leukemia: autologous reconstitution or second transplant?

BACKGROUND

Graft failure (GF) is a rare but serious complication after allogeneic hematopoietic stem cell transplantation (HSCT). Prevention of graft failure remains the most advisable approach as there is no clear recommendation for the best strategies for reversing this complication. Administration of growth factor, additional hematopoietic progenitor boost, or a salvage HSCT are current modalities recommended for the treatment of GF. Autologous recovery without evidence of disease relapse occurs rarely in patients with GF, and in the absence of autologous recovery, further salvage transplantation following a second conditioning regimen is a potential treatment option that offers the best chances of long-term disease-free survival. The preconditioning regimens of second HSCT have a significant impact on engraftment and outcome, however, currently there is no consensus on optimal conditioning regimen for second HSCT in patients who have developed GF. Furthermore, a second transplant from a different donor or the same donor is still a matter of debate.

OBSERVATIONS

We present our experience in managing pediatric patients with acute leukemia who encountered graft failure following stem cell transplantation.

CONCLUSIONS AND RELEVANCE

Although a second transplantation is almost the only salvage method, we illustrate that some pediatric patients with acute leukemia who experience graft failure after an allogeneic stem cell transplant using Myeloablative conditioning (MAC) regimen may achieve long-term disease-free survival through autologous hematopoiesis recovery.

Corrigendum: Determining the predictive impact of donor parity on the outcomes of human leukocyte antigen matched hematopoietic stem cell transplants: a retrospective, single-center study

[This corrects the article DOI: 10.3389/fonc.2024.1339605.].

Determining the predictive impact of donor parity on the outcomes of human leukocyte antigen matched hematopoietic stem cell transplants: a retrospective, single-center study

Introduction

Donor choosing remains to play a pivotal role in allogeneic hematopoietic stem cell transplantation (allo-HSCT). Numerous criteria beyond HLA compatibility impact the selection of a suitable donor.

Methods

We evaluated the effect of donor parity on transplant outcomes in a large homogeneously treated population that received an HLA-matched allo-HSCT between 2010 and 2021 at our center. All patients were transplanted from a peripheral blood stem cell source following a myeloablative Busulfan-based conditioning and an identical protocol for graftversus-host disease (GVHD) prophylaxis regimen.

Results

A total of 1103 allo-HSCT recipients were included. 188 (17.04%) had transplants from parous female donors, whereas 621 (56.30%) and 294 (26.70%) received transplants from male and nulliparous female donors, respectively. HSCTs from parous female donors compared to male and nulliparous females were associated with a significantly higher incidence of grade III-IV acute (a) GVHD (55.27% vs. 11.34 and 10.84%) and extensive chronic (c) GVHD (64.32% vs. 15.52 and 13.65%), as well as lower relapse incidence (RI).

Discussion

This study finds that while parous female donors are associated with higher incidences of grade III-IV aGVHD and extensive cGVHD post-allo-HSCT, the advantages, such as a lower RI, outweigh the risks. The results of our study provide valuable insights for donor selection.

Hematopoietic Stem Cell Transplantation in Sickle Cell Disease: A Multidimentional Review

While exagamglogene autotemcel (Casgevy) and lovotibeglogene autotemcel (Lyfgenia) have been approved by the US Food and Drug Administration (FDA) as the first cell-based gene therapies for the treatment of patients 12 years of age and older with sickle cell disease (SCD), this treatment is not universally accessible. Allogeneic hematopoietic stem cell transplant (HSCT) has the potential to eradicate the symptoms of patients with SCD, but a significant obstacle in HSCT for SCD is the availability of suitable donors, particularly human leukocyte antigen (HLA)-matched related donors. Furthermore, individuals with SCD face an elevated risk of complications during stem cell transplantation due to SCD-related tissue damage, endothelial activation, and inflammation. Therefore, it is imperative to consider optimal conditioning regimens and investigate HSCT from alternative donors. This review encompasses information on the use of HSCT in patients with SCD, including the indications for HSCT, conditioning regimens, alternative donors, and posttransplant outcomes.

Clinical Features and Risk Factors of Relapse and Mortality in Thrombotic Thrombocytopenic Purpura Patients: A Seven-Year Experience

Background: Thrombotic thrombocytopenic purpura (TTP) is associated with microangiopathic hemolytic anemia, thrombocytopenia, and microvascular thrombosis. No comprehensive report exists on clinical characteristics and risk factors of relapse and mortality in Iranian TTP patients. In this study, we aimed to report clinical features of Iranian TTP patients, to evaluate disease relapse and mortality rate and their associated risk factors. Materials and Methods: This study was a cohort study of patients diagnosed with microangiopathic hemolytic anemia admitted to the Shariati Hospital, Tehran, a referral center for TTP patients, from 2010 to 2017. Demographic, clinical, and laboratory data were recorded and patients were followed for 3 years regarding disease relapse and mortality. Results:  114 patients (80 females, 34 males) with a mean age of 39.3 ± 14.99 years were included.  Hematologic and neurologic symptoms were the most common manifestations. Abnormal laboratory findings at the presentation included thrombocytopenia, anemia, and elevated LDH. All patients were treated with plasma exchange, and 75.5% of them had a response to treatment, while the 3-year relapse and mortality rate was 23.6 and 26.3%.  Lower platelet count was a predictor of disease relapse. Age, hematological, or neurological initial presentation were associated with TTP mortality. Conclusion: Based on the largest study of TTP patients ever in Iran, the demographic and clinical characteristics of Iranian TTP patients are similar to other existing reports. Knowledge of the risk factors for TTP relapse and mortality could be useful to alert hematologists for prompt therapeutic actions when necessary.

Comparable Outcomes of Pre- Versus Post-Tyrosine Kinase Inhibitor Era Treatment in Chronic Myeloid Leukemia: A Retrospective Cohort Study With Long-term Follow-up

Imatinib, a selective BCR-ABL tyrosine kinase inhibitor (TKI), was introduced after allogeneic hematopoietic stem cell transplantation (allo-HSCT) for patients with chronic myeloid leukemia (CML). However, the long-term effects of allo-HSCT in chronic phase CML patients are mostly unknown. We retrospectively analyzed the outcomes of 204 patients with sibling donors who received peripheral stem cells and underwent allo-HSCT of chronic phase I (CP1) in the pre- and post-TKI era at Shariati Hospital in Tehran, Iran, from 1998 to 2017 and followed up till the end of 2021. The median follow-up time for all patients was 8.7 (SD = 0.54) years. Fifteen-year overall survival (OS), disease-free survival (DFS), graft-versus-host disease-free relapse-free survival (GRFS), relapse, and non-relapse mortality (NRM) incidence were 65.70%, 57.83%, 17.56%, 13.17%, and 28.98%, respectively. Using multivariable analyses, the only risk factor increasing the hazard of death was the time between diagnosis to allo-HSCT greater than 1 year compared to this time less than 1 year by 74% [hazard ratio (HR) = 1.74, P = 0.039]. Also, age is a significant risk factor for DFS (HR = 1.03, P = 0.031). Our findings suggested that allo-HSCT is still an important treatment option for CP1 patients, especially those resistant to TKI treatment. TKI consumption can have a desirable effect on NRM after allo-HSCT for CP1 CML.

The Economic Burden of Acute Myeloid Leukemia in Iran

Background

Cancer imposes a significant economic burden on the health system and society. Acute myeloid leukemia (AML) is the third deadliest leukemia and is one of the leading health problems worldwide. The present study aimed to estimate the economic burden of AML in Iran for 2020.

Methods

In this study, we estimated a prevalence-based on the cost-of-illness of the AML in Iran. A societal perspective was considered, in which the direct costs and productivity losses with the adoption of the human capital approach in the AML cases were estimated for 2020. Moreover, in the present study, several resources including national cancer registry reports, hospital records, occupational data, and interviews with experts were cited.

Results

Approximately 98% of patients with AML received induction therapy. The AML economic burden was $33,243,107.39. Indirect costs accounted for 60% (21,593,764.4$) of this amount, and direct medical costs and direct non-medical costs make up for 19% (6,359,380.88$) and 16% (5,289,962.11$) of this estimated economic burden, respectively.

Conclusion

The economic burden of AML in Iran is very remarkable and due to the increasing prevalence of this disease, it is expected to increase gradually. Having insights into the costs associated with the disease provide an excellent opportunity for health policymakers and managers to effectively improve resource allocation.

COVID-19 and cancer: A comparative case series

BACKGROUND

Cancer patients, with an incidence of more than 18 million new cases per year, may constitute a significant portion of the COVID-19 infected population. In the pandemic situation, these patients are considered highly vulnerable to infectious complications due to their immunocompromised state.

MATERIAL & METHODS

In this retrospective case series, the documents of solid cancer patients infected by SARS-CoV-2, hospitalized in Shariati hospital between 20 February and 20 April 2020, were evaluated. The diagnosis of COVID-19 was based on laboratory-confirmed COVID-19 and/or features of chest CT scan highly suggestive for SARS-CoV-2.

RESULTS

A total of 33 COVID-19-infected cancer patients were included. Mean age was 63.9 years, and 54.5% of the patients were male. LDH level was significantly higher (1487.5 ± 1392.8 vs. 932.3 ± 324.7 U/L, P-value=0.016) and also serum albumin was significantly lower in non-survivors (3.6 ± 0.5 vs. 2.9 ± 0.6 g/dL, p-value=0.03). Among 16 patients with stage IV cancer, thirteen patients died, which was significantly higher compared to stage I-III cancer patients (81.3% vs. 18.8% P-value= <0.001). In terms of developing complications, sepsis, invasive ventilation and mortality was significantly higher in patients who received cytotoxic chemotherapy within the last 14 days.

CONCLUSION

In this study, we showed that the mortality rate among cancer patients affected by COVID-19 was higher than general population and this rate has a significant correlation with factors including the stage of the disease, the type of cancer, the activity of cancer and finally receiving cytotoxic chemotherapy within 14 days before diagnosis of COVID-19.

Clinical characteristics, outcomes, and risk factors for mortality in hospitalized patients with COVID-19 and cancer history: a propensity score-matched study

BACKGROUND

COVID-19 has caused great concern for patients with underlying medical conditions. We aimed to determine the prognosis of patients with current or previous cancer with either a PCR-confirmed COVID-19 infection or a probable diagnosis according to chest CT scan.

METHODS

We conducted a case control study in a referral hospital on confirmed COVID-19 adult patients with and without a history of cancer from February25th to April21st, 2020. Patients were matched according to age, gender, and underlying diseases including ischemic heart disease (IHD), diabetes mellitus (DM), and hypertension (HTN). Demographic features, clinical data, comorbidities, symptoms, vital signs, laboratory findings, and chest computed tomography (CT) images have been extracted from patients' medical records. Multivariable logistic regression was used to estimate odd ratios and 95% confidence intervals of each factor of interest with outcomes.

RESULTS

Fifty-three confirmed COVID-19 patients with history of cancer were recruited and compared with 106 non-cancerous COVID-19 patients as controls. Male to female ratio was 1.33 and 45% were older than 65. Dyspnea and fever were the most common presenting symptoms in our population with 57.86 and 52.83% respectively. Moreover, dyspnea was significantly associated with an increased rate of mortality in the cancer subgroup (p = 0.013). Twenty-six patients (49%) survived among the cancer group while 89 patients (84%) survived in control (p = 0.000). in cancer group, patients with hematologic cancer had 63% mortality while patients with solid tumors had 37%. multivariate analysis model for survival prediction showed that history of cancer, impaired consciousness level, tachypnea, tachycardia, leukocytosis and thrombocytopenia were associated with an increased risk of death.

CONCLUSION

In our study, cancer increased the mortality rate and hospital stay of COVID-19 patients and this effect remains significant after adjustment of confounders. Compared to solid tumors, hematologic malignancies have been associated with worse consequences and higher mortality rate. Clinical and para-clinical indicators were not appropriate to predict death in these patients.

Outcome of peripheral blood allogeneic hematopoietic stem cell transplantation as a treatment option in patients with severe aplastic anemia between 40 and 50 years

The frontline treatment for patients younger than 40 years with severe aplastic anemia (AA) is allogeneic hematopoietic stem cell transplantation (HSCT) from a human leukocyte antigen-identical sibling donor. However, in patients with severe AA who are older than 40 years, allogeneic HSCT has been found to be associated with increased treatment-related mortality and toxicity, even when matched sibling donors are used. We report our institutional experience with allogeneic HSCT in patients with severe AA between 40 and 50 years. A total of 19 patients with severe AA were included in the study. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method. The mean age of patients at the time of transplant was 43.79 years, and 57.9% were male. The mortality rate was 36.8%, attributed to infection (10.5%), relapse (15.8%), and renal failure (5.3%) in all cases. Acute graft-versus-host disease (GVHD) occurred in five patients (26.3%), and chronic GVHD occurred in two patients (10.5%). The 5-year OS was 62% and the 5-year DFS was 52%. We found that the patient's age, platelet level prior to transplantation, and the number of CD3 cells infused for each transplant were independent prognostic factors for OS, and the age and sex of the patient, graft rejection, and platelet level prior to transplantation were significant prognostic factors associated with DFS. We recommend that immunosuppressive therapy be considered as a first-line treatment in patients with severe AA who are older than 40 years. Allogeneic HSCT can be considered a valid alternative option in patients whose suppression therapy fails.

Modifications in Breast Cancer Guidelines in COVID19 Pandemic; An Iranian Consensus

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Microvesicles of osteoblasts modulate bone marrow mesenchymal stem cell-induced apoptosis to curcumin in myeloid leukemia cells

Microvesicles (MVs) derived from bone marrow niche components have an important role in genetic reprogramming and subsequent drugs induce apoptosis in leukemic cells. Here, we have found that undertreatment of curcumin or daunorubicin, the cross-talk through MVs of KG-1-bone marrow mesenchymal stem cells (BMSCs), significantly downregulates the expression of the survival gene osteopontin (OPN), CXCL-12, IL-6 (interleukin-6), STAT-3, and VCAM-1 (vascular cell adhesion molecule 1) in treated-KG-1 cells as well as exclusively upregulates CXCL-12 in BMSCs. Drug treated-cell populations' MVs of both single cultured osteoblasts (OBs) and cocultured KG-1 + BMSCs + OBs similarly upregulate survival mediators' OPN, CXCL-12, IL-6, STAT-3, and VCAM-1 in treated-KG-1 cells. Likewise, isolated MVs from KG-1 cells or communication between KG-1, BMSCs, and OBs treated by drugs increase the expression of genes OPN, CXCL-12, IL-6, STAT3, and VCAM-1 by OBs. MVs derived from KG-1 + BMSCs + OBs reduce drug-induced apoptosis in KG-1 cells. This suggests MVs-mediated information transfer is a procedure whereby OBs could overcome BMSCs-induced apoptosis in drug-treated-KG-1 cells.

Attitudes and practices of healthcare providers regarding gestational diabetes: results of a survey conducted at the 2010 meeting of the International Association of Diabetes in Pregnancy Study Group (IADPSG)

OBJECTIVE

To investigate the attitudes and practices of healthcare providers regarding gestational diabetes mellitus and to identify differences between provider types and geographical locations.

RESEARCH DESIGN AND METHODS

A survey was distributed to participants at the 2010 GDM Pasadena II: International Conference regarding management of gestational diabetes.

RESULTS

Of 250 distributed surveys, there was a 60.8% (n = 152) response rate. Most responders believed it was cost beneficial to treat and screen for gestational diabetes. Approximately 2/3 accepted that the diagnosis of Type 2 diabetes could be made in pregnancy. For the diagnosis of gestational diabetes, c. 60% opted for a one-step screen while 30% opted for a two-step screen. Most responders were comfortable treating a non-pregnant woman with Type 2 diabetes. Ninety per cent of responders initiated antenatal testing at 32-34 weeks for medication-treated gestational diabetes, with a wider variation for diet-treated gestational diabetes. Obstetricians were less comfortable than other providers in treating a non-pregnant woman with Type 2 diabetes, but were more likely to prescribe glyburide. Providers in the USA, compared with those from other countries, were more likely to perform a Caesarean section based on fetal weight, use glibenclamide (glyburide), initiate exercise post-delivery and less likely to check 2-h postprandial glucose levels. At least 80% of responders routinely screened for Type 2 diabetes at 6-12 weeks post-delivery.

CONCLUSION

There are differences internationally and by provider types in attitudes and management regarding gestational diabetes. These findings may be useful in developing strategies for implementing the recent guidelines by the International Association of the Diabetes and Pregnancy Study Groups.

Comparison of ultrasonography with submentovertex films and computed tomography scan in the diagnosis of zygomatic arch fractures

OBJECTIVES

The aim of this study was to compare ultrasonography with CT scan and submentovertex films in the visualization of zygomatic arch fractures.

METHODS

17 patients, 10 men and 7 women, with suspected fracture of the zygomatic arch were studied. The data from CT and plain films were compared with the ultrasonographic findings (Aloka 3500 (Tokyo, Japan) ultrasound equipment with a 7.5 MHz transducer). The probe was situated over the fractured arch transversely to evaluate its whole length. All of the sonograms were taken and interpreted by the same sonologist, who was not aware of the results of the CT and the plain films.

RESULTS

Ultrasound was accurate in assessing the fractured arches with sensitivity of 88.2% (15 of the 17 patients, with two false negatives) and specificity of 100% (no false positives).

CONCLUSION

Ultrasound is accurate in the visualization of zygomatic arch fractures and can be used as an adjunct to plain films to reduce the overall radiation exposure.

Impact of cellular properties on red cell-red cell affinity in plasma-like suspensions

The reversible aggregation of human red blood cells (RBC) by proteins or polymers continues to be of biological and biophysical interest, yet the mechanistic details governing this process are still being explored. In this report an approach is described to compute the interaction energy between RBC by considering cellular properties as well as polymer properties. Cell-cell affinities were calculated as functions of glycocalyx thickness and glycocalyx volume concentration as well as bulk polymer concentration. Our theoretical predictions show that cell-cell affinities do not monotonically increase with polymer size and concentration, but rather demonstrate an optimum dextran molecular mass and concentration which depends on cellular properties of RBC. These results show qualitative agreement with recent experimental observations. In conclusion, our model not only confirms the concept of a depletion mechanism for RBC aggregation but also provides new insights which should help understanding how cellular properties control in vivo RBC interactions.