Anna Koclega

CCR5 gene polymorphism affects the risk of GvHD after haematopoietic stem cell transplantation from an unrelated donor.

The main barrier to successful haematopoietic stem cell transplantation (HSCT) is the development of post-transplant complications. Although human leucocyte antigen (HLA)-matching is critical in both HLA-matched familial and matched unrelated donor transplants to deter acute graft-versus-host disease (aGvHD) and rejection, recently functional non-HLA immune associated genes have also been considered in attempts to evaluate their potential prediction values and uncover novel factors that may optimize donor selection processes. Mutations and polymorphisms within these non-HLA encoded genes affect, for example, the amount of cytokine/chemokine produced in response to alloantigen or infection. Knowledge of both patient and donor non-HLA genotype may therefore aid the development of new preventative and therapeutic strategies by taking the degree of ‘risk-associated’ genotype into account. The results of our present work contribute to these studies and strongly suggest that the 32-nucleotide deletion within the CCR5 gene (CCR5D32 polymorphism; rs333) is of prognostic value for the outcome of HSCT from unrelated donors. The present study investigated the CCR5 polymorphism in relation to transplant outcome in 360 patients (Table I) transplanted in seven Polish institutions and their unrelated donors. The CCR5D32 polymorphism was analysed by polymerase chain reaction as described previously (BoguniaKubik et al, 2006, 2007). Written informed consent was obtained from each patient. The study was approved by the ethics committee of the Medical University in Wroclaw. In univariate analyses, recipients homozygous for the 32 bp deletion suffered more frequently from severe aGvHD than patients lacking this mutation (5/10 vs. 34/313, P = 0 001 and 2/10 vs. 15/313, P = 0 034, for grade III–IV and IV aGvHD, respectively). Also patients grafted from CCR5D32 homozygous donors were more likely to develop aGvHD (3/8 vs. 37/ 318, P = 0 028 and 3/8 vs. 15/318, P = 0 001 for grade III–IV and grade IV aGvHD, respectively). The CCR5D32 polymorphism was not found to affect the development of other complications except for observed worse overall survival of patients homozygous for this deletion (12% vs. 52%, P = 0 145). However this latter relationship did not reach statistical significance. CCR5 heterozygosity was not associated with the risk of aGvHD. The incidence of aGvHD was similar in patients with different conditioning regimens, stem cell sources, GvHD prophylaxis or various loci HLA mismatches (data not shown). Logistic regression analysis (Table II) considering recipient age, donor-recipient gender, 10/10 HLA match and the recipient and donor CCR5 polymorphism confirmed the role of

The Presence of Anti-HLA Antibodies before and after Allogeneic Hematopoietic Stem Cells Transplantation from HLA-Mismatched Unrelated Donors

Although anti-human leukocyte antigen antibodies (anti-HLA Abs) are important factors responsible for graft rejection in solid organ transplantation and play a role in post-transfusion complications, their role in allogeneic hematopoietic stem cell transplantation (allo-HSCT) has not been finally defined. Enormous polymorphism of HLA-genes, their immunogenicity and heterogeneity of antibodies, as well as the growing number of allo-HSCTs from partially HLA-mismatched donors, increase the probability that anti-HLA antibodies could be important factors responsible for the treatment outcomes. We have examined the incidence of anti-HLA antibodies in a group of 30 allo-HSCT recipients from HLA-mismatched unrelated donors. Anti-HLA Abs were identified in sera collected before and after allo-HSCT. We have used automated DynaChip assay utilizing microchips bearing purified class I and II HLA antigens for detection of anti-HLA Abs. We have detected anit-HLA antibodies against HLA-A, B, C, DR, DQ and DP, but no donor or recipient-specific anti-HLA Abs were detected in the studied group. The preliminary results indicate that anti-HLA antibodies are present before and after allo-HSCT in HLA-mismatched recipients.

Occurrence and Impact of Minor Histocompatibility Antigens' Disparities on Outcomes of Hematopoietic Stem Cell Transplantation from HLA-Matched Sibling Donors

We have examined the alleles of eleven minor histocompatibility antigens (MiHAs) and investigated the occurrence of immunogenic MiHA disparities in 62 recipients of allogeneic hematopoietic cell transplantation (allo-HCT) with myeloablative conditioning performed between 2000 and 2008 and in their HLA-matched sibling donors. Immunogenic MiHA mismatches were detected in 42 donor-recipient pairs: in 29% MiHA was mismatched in HVG direction, in another 29% in GVH direction; bidirectional MiHA disparity was detected in 10% and no MiHA mismatches in 32%. Patients with GVH-directed HY mismatches had lower both overall survival and disease-free survival at 3 years than patients with compatible HY; also higher incidence of both severe acute GvHD and extensive chronic GVHD was observed in patients with GVH-directed HY mismatch. On contrary, GVH-directed mismatches of autosomally encoded MiHAs had no negative effect on overall survival. Results of our study help to understand why posttransplant courses of allo-HCT from siblings may vary despite the complete high-resolution HLA matching of a donor and a recipient.

Safety and efficacy of hematopoietic stem cells mobilization in patients with multiple sclerosis

INTRODUCTION Multiple sclerosis (MS) is a T-cell-mediated chronic inflammatory disorder of the central nervous system. Several agents have been approved for the treatment of MS; however, their efficacy is limited and short term. Autologous hematopoietic stem cell (HSC) transplantation may remain an encouraging option for some MS patients who failed prior conventional treatment. Objective To assess the safety and effectiveness of HSCs mobilization in patients with MS. MATERIAL AND METHODS Thirty-nine patients (20 females and 19 males) with relapsing-remitting MS at median age of 40 years (range: 25-63) were included in this study. As a stem cell mobilization, they received either granulocyte colony-stimulating factor (G-CSF) alone (10 µg/kg s.c. daily; n = 1) or cyclophosphamide (CY; 2.0 g/m(2) i.v. on days 1-2) followed by G-CSF (n = 38). RESULTS The median number of mobilized HSCs per kg was 6.32 × 10(6) (range: 2.64-26.3 × 10(6)). One apheresis was sufficient for collection of HSCs in 30 out of 39 MS patients (77%). Two aphereses were required for seven patients, three for one and four for one (17, 3, and 3%; respectively). Side effects of HSCs mobilization have been reported for eight patients (30%) and they were following: Staphylococcus epidermidis bacteremia (n = 1), fever of unknown origin (n = 3), diarrhea (n = 3), and headache (n = 1). CONCLUSIONS Mobilization using CY and/or G-CSF resulted in effective mobilization in all MS patients. This procedure was found to be safe. No fatal outcome has been reported.Introduction: Multiple sclerosis (MS) is a T-cell-mediated chronic inflammatory disorder of the central nervous system. Several agents have been approved for the treatment of MS; however, their efficacy is limited and short term. Autologous hematopoietic stem cell (HSC) transplantation may remain an encouraging option for some MS patients who failed prior conventional treatment. Objective: To assess the safety and effectiveness of HSCs mobilization in patients with MS. Material and methods: Thirty-nine patients (20 females and 19 males) with relapsing-remitting MS at median age of 40 years (range: 25–63) were included in this study. As a stem cell mobilization, they received either granulocyte colony-stimulating factor (G-CSF) alone (10 µg/kg s.c. daily; n = 1) or cyclophosphamide (CY; 2.0 g/m2 i.v. on days 1–2) followed by G-CSF (n = 38). Results: The median number of mobilized HSCs per kg was 6.32 × 106 (range: 2.64–26.3 × 106). One apheresis was sufficient for collection of HSCs in 30 out of 39 MS patients (77%). Two aphereses were required for seven patients, three for one and four for one (17, 3, and 3%; respectively). Side effects of HSCs mobilization have been reported for eight patients (30%) and they were following: Staphylococcus epidermidis bacteremia (n = 1), fever of unknown origin (n = 3), diarrhea (n = 3), and headache (n = 1). Conclusions: Mobilization using CY and/or G-CSF resulted in effective mobilization in all MS patients. This procedure was found to be safe. No fatal outcome has been reported.

Safety and outcome of allogeneic stem cell transplantation in myelofibrosis

We evaluated the safety and outcome of allo‐HSCTs in myelofibrosis (MF).

Progress in Hematopoietic Stem Cell Transplantation

Transplantation of autologous or allogeneic hematopoietic stem cells is a method currently used to treat many malignant and nonmalignant hematological diseases. The indications, methods, goals of therapy have evolved since the introduction of transplantation to the clini‐ cal practice. Progress that has been achieved allowed for the improvement of results. Thanks to the availability of various conditioning regimens, various hematopoietic cells sources as well as variable possibilities of anti-GvHD prophylaxis the individualization of the trans‐ plantation procedure has been more and more widely used in the recent years. This chapter summarizes current clinical practices and presents major clinical problems that have to be optimally managed in order to improve the outcomes of transplantation.

HLA-inferred extended haplotype disparity level is more relevant than the level of HLA mismatch alone for the patients survival and GvHD in T cell-replate hematopoietic stem cell transplantation from unrelated donor

Serious risks in unrelated hematopoietic stem cell transplantation (HSCT) including graft versus host disease (GvHD) and mortality are associated with HLA disparity between donor and recipient. The increased risks might be dependent on disparity in not-routinely-tested multiple polymorphisms in genetically dense MHC region, being organized in combinations of two extended MHC haplotypes (Ehp). We assessed the clinical role of donor-recipient Ehp disparity levels in N = 889 patients by the population-based detection of HLA allele phase mismatch. We found increased GvHD incidences and mortality rates with increasing Ehp mismatch level even with the same HLA mismatch level. In multivariate analysis HLA mismatch levels were excluded from models and Ehp disparity level remained independent prognostic factor for high grade acute GvHD (p = 0.000037, HR = 10.68, 95%CI 5.50-32.5) and extended chronic GvHD (p < 0.000001, HR = 15.51, CI95% 5.36-44.8). In group with single HLA mismatch, patients with double Ehp disparity had worse 5-year overall survival (45% vs. 56%, p = 0.00065, HR = 4.05, CI95% 1.69-9.71) and non-relapse mortality (40% vs. 31%, p = 0.00037, HR = 5.63, CI95% 2.04-15.5) than patients with single Ehp disparity. We conclude that Ehp-linked factors contribute to the high morbidity and mortality in recipients given HLA-mismatched unrelated transplant and Ehp matching should be considered in clinical HSCT.

Bing-Neel Syndrome with Detectable MYD88 L265P Gene Mutation as a Late Relapse Following Autologous Hematopoietic Stem Cell Transplantation for Waldenström’s Macroglobulinemia

Waldenström’s macroglobulinemia (WM) affects a proportion of patients diagnosed with lymphoplasmacytic lymphoma with bone marrow involvement and Immunoglobulin M (IgM) monoclonal gammopathy of any concentration [1]. The direct central nervous system (CNS) infiltration by malignant lymphoid cells is a rare complication of WM known as BingNeel syndrome (BNS) [2]. The MYD88 L265P point mutation is detected in about 90% of WM patients and may serve as a marker in distinguishing WM from other lymphomas [3]. It is noteworthy that this mutation has recently been detected in the cerebrospinal fluid (CSF) of patients with BNS [4].

Ear involvement in acute promyelocytic leukemia

448 A 44 ‐year ‐old woman with acute promyelo‐ cytic leukemia (APL) presented to our depart‐ ment in an overall bad condition with hearing loss, severe headache, and severe weakness. Two years earlier, she had been diagnosed with APL with 46,XX, t(15;17)(q24;q21), del (16)(q11;q22), add(7)(p21), add (X)(p22), and detectable PML/RARα and FLT3 ‐ITD mutations, and had been successfully treated with the PETHEMA pro‐ tocol including all ‐trans retinoic acid (ATRA) with anthracyclines and cytarabine. She had remained in complete remission for 15 months. We performed laboratory tests, which revealed moderate anemia (hemoglobin, 10.6 g/dl) and leu‐ kopenia (3.4 × 109/l) with normal white blood cell differential. Platelet count and coagulation test re‐ sults were normal. A neurological examination re‐ vealed right ‐sided paresis and nystagmus. An oto‐ scopic examination was remarkable for the mass‐ es in the external auditory canals (FIGURE 1A). A bi‐ opsy revealed dense infiltration of immature my‐ eloid progenitors. A head computed tomography scan showed tumor infiltrates in the mastoid air cells, middle ear, and external auditory canals (FIGURE 1B). Brain parenchyma was leukemia‐free. A bone marrow aspirate demonstrated blast cells and atypical promyelocytes with detectable PML/ RARα fusion on reverse ‐transcriptase polymerase chain reaction. Cerebrospinal fluid contained leu‐ kemic cells (FIGURE 1C). The patient received arse‐ nic trioxide and ATRA with intrathecal chemo‐ therapy but died a few weeks later. APL is a subtype of acute myeloid leukemia characterized by unique chromosomal abnor‐ mality, response to ATRA, and disseminated in‐ travascular coagulation.1 Extramedullary relapse of APL occurs rarely and involves the skin, lymph nodes, and central nervous system.2 Ear involve‐ ment at relapse of APL is extremely rare, and only single cases have been reported to date. It is noteworthy that some patients with ear involve‐ ment at relapse of APL may have simultaneous involvement of other sites (eg, bone marrow or CLINICAL IMAGE

Early assessment of donor CD34 + positive cells chimerism after allogeneic stem cell transplantation in acute myeloid leukemia/myelodysplastic syndrome patients – pilot study

Introduction. In high-risk acute myeloid leukaemia/myelodysplastic syndrome patients, relapse remains the major cause of treatment failure after allogeneic stem cell transplantation (alloSCT). The investigation of lineage-specific chimerism has become an important tool in the management of patients during the post-transplant period. Aim. Early assessment of lineage specific chimerism in patients who underwent allogeneic hematopoietic stem cell transplantation. Material and methods. 55 patients with acute myeloid leukemia and myelodysplastic syndrome who underwent alloSCT were included in the study. Flow cytometric analysis and cell sorting was performed in bone marrow collected at day 30 after alloSCT. For the purpose of this study we analyzed sorted immature progenitor cells (CD34+CD19-) using STR method. Results. All patients who relapsed presented with lower donor chimerism in CD34+ positive cells in comparison to the group of patients in remission of the underlying disease. Median value of chimerism in CD34+ positive cells in the group of patients who relapsed was 14.5% (range 0-51%), whereas in patients who remained in remission of the underlying disease, chimerism in CD34+ never fell below 97% (median 100%, range 97-100%). All relapses occurred during the first year after alloSCT. Median time to relapse was 107 days (range 28-323). Conclusions. Early assessment of chimerism in CD34+ cells sorted out of bone marrow is a sensitive technique to detect residual or reoccurring disease after allogeneic SCT. The assessment of donor chimerism in CD34+ cells in day +30 after alloSCT seems to be relevant in post-transplant care of high risk patients.