Anna Ghiso

Unmanipulated Haploidentical Bone Marrow Transplantation and Posttransplantation Cyclophosphamide for Hematologic Malignancies after Myeloablative Conditioning

Fifty patients with high-risk hematologic malignancies, underwent an unmanipulated haploidentical bone marrow transplantation (BMT), followed by posttransplantation high-dose cyclophosphamide (PT-CY): the myeloablative (MA) conditioning consisted of thiotepa, busulfan, fludarabine (n = 35), or total body irradiation (TBI), fludarabine (n = 15). The median age was 42 years (range, 18-66 years); 23 patients were in remission, 27 had active disease, and 10 patients were receiving a second allograft. Graft-versus-host disease (GVHD) prophylaxis consisted in PT-CY on day +3 and +5, cyclosporine (from day 0), and mycophenolate (from day +1). Three patients died before engraftment, and 2 patients had autologous recovery: 45 patients (90%) had full-donor chimerism on day +30. The median day for neutrophil engraftment was day +18 (range, 13-30 days). The cumulative incidence of grade II-III acute GVHD (aGVHD) was 12%, and of moderate chronic GVHD (cGVHD) 10%. With a median follow-up for surviving patients of 333 days (range, 149-623 days), the cumulative incidence of transplantation-related mortality (TRM) was 18%, and the rate of relapse was 26%. The actuarial 22-month disease-free survival (DFS) rate was 68% for patients in remission and 37% for patients with active disease (P < .001). Causes of death were pneumonia (n = 3), hemorrhage (n = 3), sepsis (n = 3), and relapse (n = 7). In conclusion, an MA conditioning regimen followed by haploidentical BMT with PT-CY results in a low risk of aGVHD and cGVHD and encouraging rates of TRM and DFS.

Hepatitis B reactivation in HBsAg-negative/HBcAb-positive allogeneic haematopoietic stem cell transplant recipients: risk factors and outcome

HBsAg-negative/HBcAb-positive haematopoietic stem cell transplant (HSCT) recipients are at high risk of hepatitis B virus (HBV) reactivation. Allogeneic HSCT recipients from years 2000 to 2010 were evaluated in order to study the impact of being HBsAg-negative/HBcAb-positive in this population. Overall, 137 of 764 patients (18%) were HBsAg-negative/HBcAb-positive before HSCT. Overall survival, non-relapse mortality (NRM), acute and chronic graft-vs.-host disease were similar in HBcAb-positive and HBcAb-negative patients. Reactivation occurred in 14 patients (10%) within a median of 19 months after HSCT (range 9-77). Cause-specific hazard for reactivation was decreased in the case of an HBV-immune/exposed donor (HRadjusted = 0.12; 95% CI, 0.02-0.96; p 0.045) and increased in patients who received rituximab treatment (HRadjusted = 2.91; 95%CI, 0.77-10.97; p 0.11). Competing risk analyses documented a protective role of an HBV-immune/exposed donor (p 0.041) and an increased probability associated with the length of treatment with cyclosporine (p <0.001) and treatment with rituximab (but not with low-dose rituximab prophylaxis, p <0.001 at each landmark point). No differences in overall survival and NRM were found between patients with and without HBV reactivation. The donors immunity was independently and consistently associated with a decreased risk of HBV reactivation, while rituximab and cyclosporine treatments increased the probability.

WT1 overexpression at diagnosis may predict favorable outcome in patients with de novo non-M3 acute myeloid leukemia

Abstract We reviewed the frequency and prognostic significance of FLT3 (fms-like tyrosine kinase receptor-3) and NPM (nucleophosmin) gene mutations and WT1 (Wilms’ tumor) and BAALC (brain and acute leukemia, cytoplasmic) gene expression in 100 consecutive patients with intermediate and poor cytogenetic risk de novo acute myeloid leukemia (AML) receiving conventional anthracycline–AraC based therapy. We observed a strict relationship between unfavorable karyotype and BAALC >1000 (p = 0.0001). Multivariate analysis of 81 patients with intermediate karyotype revealed that younger age (p = 0.00009), NPM gene mutation (p = 0.002), and WT1 >75th percentile (>2365) (p = 0.003) were independent, positive factors for complete remission (CR). WT1 expression above 2365 was correlated also to longer event-free survival (EFS) and overall survival (OS) in the same subset of patients (p = 0.003 and p = 0.02, respectively); the same finding occurred in younger patients with AML with intermediate karyotype (p = 0.008 and p = 0.01, respectively). In patients with intermediate karyotype, FLT3 internal tandem duplication (ITD) negatively affected EFS (EFS at 30 months: 30% vs. 6% in FLT3-ITD negative and FLT3 positive patients, respectively; p = 0.01) and OS (OS at 30 months: 38% vs. 20%, p = 0.03). The positive prognostic value of high WT1 expression does not have a clear explanation; it may be implicated either with WT1 anti-oncogenic function, or with the stimulating effect of WT1 oncogene on the leukemic cellular cycle, possibly associated with an enhanced response to chemotherapy.

Bloodstream Infections Are an Improbable Cause of Positive Serum (1,3)-β-d-Glucan in Hematology Patients

ABSTRACT Ninety-one serum samples from 51 hematology patients with bacteremia infections were tested for (1,3)-β-d-glucan (BG). Eleven samples (15%) from 7 patients (14%) were positive for BG. Of these 7 patients with positive BG results, 4 (8%) had invasive aspergillosis and 3 (6%) had no invasive fungal disease. Bacteremia was an unlikely cause of the false-positive BG results.

Enterococcal Bloodstream Infection After Hematopoietic Stem Cell Transplant: Experience of a Center With a Low Prevalence of Vancomycin-Resistant Enterococci

TO THE EDITOR—We read with interest the article by Vydra and colleagues about enterococcal bloodstream infections (EBSIs) in hematopoietic stem cell transplant (HSCT) recipients [1]. In their experience, the incidence of EBSI was 12%, and in 61 adult patients 66% of enterococci were resistant to vancomycin (VRE) [1]. The mortality 30 days after EBSI was 38% for both VRE and vancomycin-susceptible enterococci (VSE), and EBSI, particularly due to VRE, was associated with lower 1year survival [1]. Using the same statistical approach, we reviewed our experience, based on new data and a reanalysis of a previous study [2]. From 2004 to 2011, 67 cases of EBSI were diagnosed among 582 adult allogeneic HSCT recipients, with a cumulative incidence of 11.5% (95% confidence interval [CI], 9.1%–14.2%). However, only 13% of infections (9/67) were caused by VRE. Pharyngeal colonization with enterococci (irrespective of their susceptibility to vancomycin), severe mucositis, treatment with cephalosporins, and poorer general conditions (expressed by lower Karnofsky score) were significant risk factors for early (within 30 days from HSCT) EBSI, whereas previous empirical therapy with vancomycin decreased the risk [2]. The mortality 30 days after BSI was 26% for VSE and 11% forVRE. The 1-year posttransplant overall survival was 23% (95% CI, 12%–36%) for all EBSIs, 24% (95% CI, 12%–37%) for VSE, 24% (95% CI, 4%–54%) for VRE, and 65% (95% CI, 61%–69%) for patients without EBSI, compared with 48% for VSE, 23% for VRE, and 63% for no EBSI reported by Vydra and colleagues. The 1-year nonrelapse mortality was 63% (95% CI, 47%–80%) for all EBSIs, 64% (95% CI, 47%–81%) for VSE, 44% (95% CI, 13%–90%) for VRE, and 23% (95% CI, 19%–27%) for patients without EBSI, compared with 33% for VSE, 53% for VRE, and 22% for no EBSI reported by Vydra and colleagues. However, when evaluating the hazard ratio for all-cause mortality in patients with EBSI, we found that the impact of EBSI was most prominent during the first 3 months after HSCT, although it persisted at 12 months as well (Table 1). In summary, 2 main differences emerged between the 2 studies. First, the overall mortality associated with EBSIs, irrespective of vancomycin susceptibility, was as high as the one reported for VRE by Vydra and colleagues, even though most of the infections were due to VSE and vancomycin was included in initial empirical therapy. Thus, in our experience, and contrary to what has been reported by others [2, 3], we did not find any difference in mortality depending on vancomycin susceptibility. Second, EBSI, due to both VSE and VRE, had a significant impact not only on the longterm but especially on the short-term risk of all-cause mortality as compared to patients without EBSI, data that were not shown by Vydra and colleagues. We confirm that EBSI is a marker of poor shortand long-term outcome. More clinical and microbiological data are necessary to explain why in our center VSE were associated with lower survival compared to Vydra and colleagues, despite no difference between the 2 studies in overall survival and nonrelapse mortality among patients without EBSI and lower mortality 30 days after EBSI.

Impact of HLA Disparity in Haploidentical Bone Marrow Transplantation Followed by High-Dose Cyclophosphamide

We studied the impact of HLA mismatching on the outcome of 318 consecutive patients who received an unmanipulated haploidentical bone marrow transplant, followed by post-transplant cyclophosphamide (PTCy). The number of HLA-mismatched antigens was tested for its impact on overall survival (OS) and nonrelapse mortality (NRM), whereas HLA mismatches in the graft-versus-host (GVH) direction were tested for prediction of graft-versus-host disease (GVHD and relapse. Finally, we studied whether graft rejection correlated with the number of HLA mismatched antigens in host-versus-graft (HVG) direction. Two hundred thirty-one donor-recipient pairs (72%) had 4/8 mismatches at the -A, -B, -C, -DRB1 HLA loci. HLA mismatches did not predict the 2-year OS (hazard ratio, .83; P = .58) and NRM (subhazard ratio, 1.08; P = .93). The cumulative incidence of acute GVHD (P = .13), 1-year chronic GVHD (P = .84), and relapse rate (P = .26) did not correlate with univectorial GVH mismatches. Similarly, no correlation was observed between the amount of HLA mismatch in the HVG direction and graft rejection. In multivariate analysis advanced disease at transplant was the strongest predictor of survival, NRM, relapse, and graft rejection. In conclusion, the degree of HLA mismatching should not be used as a criterion to select family haploidentical donors when using bone marrow as stem cell source and PTCy for GVHD prophylaxis.

Haploidentical bone marrow transplantation in patients with advanced myelodysplastic syndrome

In 1992, my coworkers and I published a paper in the American Journal of Hematology entitled “On the laboratory problems of diagnosing mild von Willebrand’s disease” and elsewhere another report “On the intraindividual and gender variability of hemostatic components.” Data in both papers were based on fifteen young healthy women, sampled 10-16 times during one month (one menstrual cycle) and on six young men sampled six times during one month. Considerable variations were found in the values of FVIII activity (FVIIIc), VWF:Ag, and VWF ristocetin cofactor (VWF:Rcof) activity, in both genders. In 3 of the 15 female volunteers, the VWF Ag values on some samples were so low that they could be suspected to have a mild form of von Willebrand’s disease (VWD) although they had no history of bleeding; this was associated with high individual variability in VWF:Ag. In one of these females, VWF:Ag varied from a low of 0.25 IU/mL to a high of 1.4 IU/mL (see Fig 1 in reference # 1). In 2001 € Onundarsson et al. investigated VWF activity ((Rcof), VWFAg, and FVIIIc during one menstrual cycle (early, middle, and late phase), in 95 young healthy women but found no comparable variation of these three parameters. Subsequently, we learned that the subjects with the highest VWF variability had run before the blood sampling took place. In our 1992 study, we failed to inform the volunteers that physical and mental stress could influence the results. In 2002 Miller et al. studied 175 women sampled during one cycle and found lowest levels of all three parameters VWF:Ag, VWF:Rcof, and FVIIIc during days 1-4 and highest during days 5-11. In 2007 we and others on behalf of ISTH/SSC summarized key preanalytical requirements such as abstain from physical exercise for at least 24 h; abstain from fatty food and smoking before sampling; take samples in morning hours after sitting in a relaxed position and environment for 20-30 min for equilibration of the hydrostatic pressure. In addition, for the diagnosis of VWD in fertile women, samples should be obtained on cycle days 1-4. Thus, I feel that the limitations of our 1992 study provide an explanation for its discrepant values, and I welcome the opportunity to correct the records.