Guiomar Bautista

Cord blood transplants supported by co-infusion of mobilized hematopoietic stem cells from a third-party donor

This open label clinical study provides updated evaluation of the strategy of single unit cord blood transplants (CBTs) with co-infusion of third-party donor (TPD) mobilized hematopoietic stem cells (MHSC). Fifty-five adults with high-risk hematological malignancies, median age 34 years (16–60 years) and weight 70 kg (43–95 kg), received CBTs (median 2.39 × 107 total nucleated cell (TNC) per kg and 0.11 × 106 CD34+ per kg) and TPD-MHSC (median 2.4 × 106 CD34+ per kg and 3.2 × 103 CD3+ per kg). Median time to ANC and to CB-ANC >0.5 × 109/l as well as to full CB-chimerism was 10, 21 and 44 days, with maximum cumulative incidences (MCI) of 0.96, 0.95 and 0.91. Median time to unsupported platelets >20 × 109/l was 32 days (MCI 0.78). MCI for grades I–IV and III–IV acute GVHD (aGVHD) were 0.62 and 0.11; 12 of 41 patients (29%) who are at risk developed chronic GVHD, becoming severely extensive in three patients. Relapses occurred in seven patients (MCI=0.17). The main causes of morbi-mortality were post-engraftment infections. CMV reactivations were the most frequent, their incidence declining after the fourth month. Five-year overall survival and disease-free survival (Kaplan–Meier) were 56 % and 47% (63% and 54% for patients ⩽40 years). In conclusion, CBT with single units of relatively low cell content and 0–3 HLA mismatches is feasible as a first choice option for adult patients who lack a readily available adequate adult donor.

Haematopoietic transplants combining a single unrelated cord blood unit and mobilized haematopoietic stem cells from an adult HLA-mismatched third party donor. Comparable results to transplants from HLA-identical related donors in adults with acute leukaemia and myelodysplastic syndromes.

We describe results of the strategy, developed by our group, of co-infusion of mobilized haematopoietic stem cells as a support for single-unit unrelated cord blood transplant (dual CB/TPD-MHSC transplants) for treatment of haematological malignancies in adults, and a comparative analysis of results obtained using this strategy and transplants performed with mobilized haematopoietic stem cells from related HLA-identical donors (RTD) for treatment of adults with acute leukaemia and myelodysplastic syndromes. Our data show that the dual CB/TPD-MHSC transplant strategy results in periods of post-transplant neutropenia, final rates of full donor chimerism and transplant-related mortality rates comparable to those of the RTD. Final survival outcomes are comparable in adults transplanted because of acute leukaemia, with different incidences of the complications that most influence these: a higher incidence of infections related to late recovery of protective immunity dependent on T cell functions, and a lower incidence of serious acute graft-versus-host disease and relapses. Recent advances in cord blood transplant techniques allow allogeneic haematopoietic stem cell transplantation (HSCT) to be a viable option for almost every patient who may benefit from this therapeutic approach. Development of innovative strategies to improve the post-transplant recovery of T cells function is currently the main challenge to further improving the possibilities of unrelated cord blood transplantation.

Pharmacological Profiles of Acute Myeloid Leukemia Treatments in Patient Samples by Automated Flow Cytometry: A Bridge to Individualized Medicine

BACKGROUND We have evaluated the ex vivo pharmacology of single drugs and drug combinations in malignant cells of bone marrow samples from 125 patients with acute myeloid leukemia using a novel automated flow cytometry-based platform (ExviTech). We have improved previous ex vivo drug testing with 4 innovations: identifying individual leukemic cells, using intact whole blood during the incubation, using an automated platform that escalates reliably data, and performing analyses pharmacodynamic population models. PATIENTS AND METHODS Samples were sent from 24 hospitals to a central laboratory and incubated for 48 hours in whole blood, after which drug activity was measured in terms of depletion of leukemic cells. RESULTS The sensitivity of single drugs is assessed for standard efficacy (EMAX) and potency (EC50) variables, ranked as percentiles within the population. The sensitivity of drug-combination treatments is assessed for the synergism achieved in each patient sample. We found a large variability among patient samples in the dose-response curves to a single drug or combination treatment. CONCLUSION We hypothesize that the use of the individual patient ex vivo pharmacological profiles may help to guide a personalized treatment selection.

Immune reconstitution after cord blood transplants supported by coinfusion of mobilized hematopoietic stem cells from a third party donor.

Low severity of GVHD, substantial graft vs tumor (GVT) and slow development of protective immunity are well-documented features of cord blood transplants (CBT). We have evaluated the immune reconstitution of adult recipients of single-unit CBT supported by the coinfusion of third party donor (TPD) mobilized hematopoietic stem cells (MHSC), a procedure—‘dual CB/TPD-MHSC transplant’—that results in early recovery of circulating granulocytes, high rates of CB engraftment and full chimerism. Cumulative recovery of natural killer and B cells at or above the median values of normal controls were 1.0 and 0.76 by the sixth and ninth months. Recovery of T cells was much slower, naive cells lagging behind those of memory and effector (committed) immunophenotypes. Serial analyses of signal joint TCR excision circles showed a general pattern of very low levels by the third month after CBT, followed by recovery to levels persistently similar or higher than those observed before transplantation and in normal controls. Our results are consistent with the clinical observations of substantial GVT effect together with low incidence of serious GVHD and slow development of protective immunity and suggest that thymic function contributes substantially to the recovery of T-cell populations in adults receiving dual CB/TPD-MHSC transplants.

Toxoplasmosis in cord blood transplantation recipients

Toxoplasmosis is a devastating opportunistic infection that can affect immunocompromised patients such as cord blood transplantation (CBT) recipients. The clinical characteristics of 4 toxoplasmosis CBT patients treated at our institution are reviewed, together with 5 cases collected from the literature. The rate of toxoplasmosis in our hospital was 6% in CBT recipients and 0.2% in other types of allogeneic hematopoietic stem cell transplantation (P < 0.001). Five patients (56%) presented disseminated toxoplasmosis and 4 patients (44%) had localized infection in the central nervous system. In 5 of the 9 patients considered (56%), cytomegalovirus viral replication had been detected before the clinical onset of toxoplasmosis. Seven patients (78%) had previously developed graft‐versus‐host disease. All patients who exhibited disseminated disease died due to Toxoplasma infection. Pre‐transplant serology was positive in 1 patient, negative in 3 patients, and not performed in another. Only 1 of these 5 patients with disseminated disease had received Toxoplasma prophylaxis with cotrimoxazole. It could be concluded that mortality in CBT patients with disseminated toxoplasmosis is unacceptably high. The negative results of serology in the majority of these cases, and its unspecific clinical presentation, makes diagnosis exceedingly difficult. Better diagnostic tests and prophylaxis strategy are needed in CBT recipients.

Bosutinib shows low cross intolerance, in chronic myeloid leukemia patients treated in fourth line. Results of the Spanish compassionate use program.

The role of bosutinib as rescue treatment of Philadelphia chromosome‐positive chronic myeloid leukemia (CML) patients after failing three previous tyrosine kinase inhibitors (TKIs) is currently unknown. We report here the largest series (to our knowledge) of patients treated with bosutinib in fourth‐line, after retrospectively reviewing 30 patients in chronic phase, and pretreated with imatinib, nilotinib, and dasatinib. With a median follow up of 11.1 months, the probability to either maintain or improve their CCyR response was 56.6% (17/30) and 11 patients (36.7%) achieved or maintained their baseline MMR. In patients not having baseline CCyR, the probabilities of obtaining CCyR, MMR, and MR4.5 were 13, 11, and 14%, respectively. The probabilities of obtaining MMR and deep molecular response MR4.5 in patients with baseline CCyR were 40.0% (6/15) and 20.0% (3/15). At 20 months, progression‐free survival was 73%. Grade 3–4 hematological toxicities were more frequent in resistant than intolerant patients (45.4 vs. 0.0%). Nonhematological toxicities were also more frequent in resistant patients, being diarrhea the most conspicuous one. Bosutinib seems to be an appropriate treatment option for patients resistant or intolerant to three prior TKIs.Am. J. Hematol. 90:429–433, 2015.

Visceral leishmaniasis in hematopoietic stem cell transplantation

Dear Sir, Visceral leishmaniasis (VL) is a parasitic disease caused by the Leishmania donovani complex. The most important endemic areas are Southern Asia, the Middle East, the Mediterranean, and Brazil [1]. Immunocompromised patients have a higher incidence and severity of VL than immunocompetent patients, and a marked tendency to suffer relapses [1]. During the last two decades, cases of VL in transplanted patients have been increasingly reported, most of them being observed in the Mediterranean basin [2]. So far, there have been 77 reported cases of VL in solid organ transplant recipients (57 kidney, 11 liver, 4 heart, 2 lung, 2 kidney plus pancreas, and pancreas 1) [2–5]. Fever is the most common symptom of VL in organ transplanted patients (94% of the cases). However, splenomegaly is reported less frequently than in immunocompetent patients [6]. A 60-year-old man with acute lymphoblastic leukemia refractory to chemotherapy underwent cord blood transplantation (CBT). It was supported by the co-infusion of a low number of T-cell-depleted, mobilized hematopoietic stem cells from a third party donor (‘‘dual’’ CBT). Patient pretransplant and third party donor CMV serology were positive. Blood CMV pp65 antigenemia and DNA determination by polymerase chain reaction (PCR) were performed weekly during the first 6 months. The patients had been living in an endemic region, namely the central Iberian Peninsula. On day +110 the patient presented positive serum CMV DNA that was treated with ganciclovir for 3 weeks. On day +151 the patient reported fever, profuse sweating, rhinorrhea, odynophagia, and liquid diarrhea, without blood or pus, during the preceding 7 days. At that time he was receiving prophylactic treatment with fluconazole 100 mg qd, acyclovir 400 mg tid and sulfadoxine/pyrimethamine 500/25 mg qd. The spleen was palpated 5 cm below left costal margin. A chest X-ray was normal. Laboratory tests showed 6300 leukocytes/ll and 3270 neutrophils/ll, 14.5 g/dl of hemoglobin and 34 000 platelets/ mm (the previous count was 146 000 platelets/mm) Blood cultures were negative. Stool cultures revealed normal bowel flora. Leishmania serology was positive with a titer of 1:320 (IgG indirect immunofluorescence test, anti-rk39). The diagnosis of VL was confirmed by positive bone marrow culture (Novy-Nicolle-McNeal medium) and by the identification of numerous Leishmania amastigotes in the bone marrow aspirate (hematoxylin– eosin stain). Leishmania PCR in bone marrow was negative. Interestingly, parasites were also observed in granulocytes in peripheral blood (hematoxylin–eosin stain, Fig. 1). Liposomal amphotericin B (3 mg/kg IV qd) was administered for 2 weeks. The fever disappeared after 4 days and the platelet count slowly returned to normal. Consequently, liposomal amphotericin B was administered weekly for 5 weeks, and then monthly for the following 3 years. No relapses have occurred during 6 years’ follow-up. Three cases of LV in HSCT patients have been previously reported [7–9]. Two patients received allogenic, and one patient autologous, HSCT. In one case CMV disease had been detected during the previous 3 months. The mechanism of infection was presumed to be reactivation in two patients and primary infection in one patient. The time of presentation after HSCT was 1, 3, and 23 months, respectively. The clinical presentation consisted of fever in one patient and pancytopenia in the other two (50%). In two patients, amastigotes of Leishmania were seen in peripheral blood smears. All patients were treated with

Rhodotorula species fungaemia causes low mortality in haematopoietic stem-cell transplantation. A case report and review.

Rafael Forés, Antonio Ramos, Beatriz Orden, Almudena de Laiglesia, Guiomar Bautista, Martı́n Cabero, Elena Muñez, Isabel Sánchez-Romero, Belén Navarro, Julio Bravo and Rafael Cabrera Department of Hematology, Hospital Universitario Puerta de Hierro, 28220 Majadahonda, Madrid, Spain, Department of Internal Medicine (Infectious Disease Unit), Hospital Universitario Puerta de Hierro, 28220 Majadahonda, Madrid, Spain and Department of Microbiology, Hospital Universitario Puerta de Hierro, 28220 Majadahonda, Madrid, Spain

Haplo-Cord transplantation compared to haploidentical transplantation with post-transplant cyclophosphamide in patients with AML

For patients with AML, the best alternative donor remains to be defined. We analyze outcomes of patients who underwent myeloablative umbilical cord blood or haploidentical hemopoietic stem cell transplantation (HSCT) in Spain. Fifty-one patients underwent single umbilical cord blood transplantation supported by a third party donor (Haplo-Cord) between 1999 and 2012, and 36 patients received an haploidentical HSCT with post-transplant cyclophosphamide (PTCY–haplo) between 2012 and 2014 in GETH centers. The Haplo-Cord cohort included a higher proportion of patients with high disease risk index and use of TBI in the conditioning regimen, and hematopoietic cell transplantation–age Comorbidity Age Index was higher in PTCY–haplo patients. Cumulative incidence of neutrophil engraftment was 97% in the Haplo-Cord and 100% in the PTCY–haplo group, achieved in a median of 12 and 17 days, respectively (P=0.01). Grade II–IV acute GvHD rate was significantly higher in the PTCY–haplo group (9.8% vs 29%, P=0.02) as well as chronic GvHD rates (20% vs 38%, P=0.03). With a median follow-up of 61 months for the Haplo-Cord group and 26 months for the PTCY–haplo cohort, overall survival at 2 years was 55% and 59% (P=0.66), event-free survival was 45% vs 56% (P=0.46), relapse rate was 27% vs 21% (P=0.79), and non-relapse mortality was 17% vs 23% (P=0.54), respectively. In this multicenter experience, Haplo-Cord and PTCY–haplo HSCT offer valid alternatives for patients with AML. Neutrophil engraftment was faster in the Haplo-Cord cohort, with similar survival rates, with higher GvHD rates after haploidentical HSCT.

Severe infections after single umbilical cord blood transplantation in adults with or without the co‐infusion of CD34+ cells from a third‐party donor: results of a multicenter study from the Grupo Español de Trasplante Hematopoyético (GETH)

Umbilical cord blood transplantation (CBT) is an established alternative source of stem cells in the setting of unrelated transplantation. When compared with other sources, single‐unit CBT (sCBT) is associated with a delayed hematologic recovery, which may lead to a higher infection‐related mortality (IRM). Co‐infusion with the sCBT of CD34+ peripheral blood stem cells from a third‐party donor (TPD) (sCBT + TPDCD34+) has been shown to markedly accelerate leukocyte recovery, potentially reducing the IRM. However, to our knowledge, no comparative studies have focused on severe infections and IRM with these 2 sCBT strategies.