Maija Itälä-Remes

Novel activating STAT5B mutations as putative drivers of T-cell acute lymphoblastic leukemia.

Novel activating STAT5B mutations as putative drivers of T-cell acute lymphoblastic leukemia

Depth of response assessed by quantitative ASO-PCR predicts the outcome after stem cell transplantation in multiple myeloma

Achievement of complete response (CR) is a new goal of therapy for multiple myeloma (MM). By sensitive methods, the depth of response can be measured even among the patients in CR. We used a sensitive real‐time quantitative polymerase chain reaction by allele‐specific primers (qASO‐PCR) to assess the level of minimal residual disease (MRD) in bone marrow of 37 patients with myeloma who had achieved CR/near‐to‐CR after autologous or allogeneic stem cell transplantation (SCT). Allele‐specific primers could be successfully designed for 86% of patients. Three to six months after autotransplantation, the PCR target was not detectable in 53% of patients (16/30 patients), and the respective figure after allotransplantation was 71% (5/7 patients); the median sensitivity of PCR assay was <0.002%. The proportion of patients without detectable PCR target was 22% of all autotransplanted patients. A threshold level of 0.01% in the qASO‐PCR assay 3–6 months after SCT was found to be a useful cut‐off limit to divide the patients into two prognostic groups: MRD low/negative vs. MRD high. Low/negative MRD after SCT was a significant predictive factor for the prolongation of progression free (70 vs. 19 months; P = 0.003) and suggestively also for overall survival. We conclude that not only CR but also its depth is important for the long‐term outcome in MM.

A prospective randomized trial comparing cyclosporine/methotrexate and tacrolimus/sirolimus as graft-versus-host disease prophylaxis after allogeneic hematopoietic stem cell transplantation

Improvement of graft-versus-host disease prophylaxis remains an important goal in allogeneic hematopoietic stem cell transplantation. Based on reports of possibly preferential properties of sirolimus, we compared the standard regimen of cyclosporine and methotrexate (n=106) with a combination of tacrolimus and sirolimus (n=103) as graft-versus-host disease prophylaxis after allogeneic hematopoietic stem cell transplantation in a prospective, open, randomized trial. The hypothesis was that the tacrolimus/sirolimus regimen would lead to less acute graft-versus-host disease and reduced transplant-related mortality. There was no significant difference in the cumulative incidence of acute graft-versus-host disease of grades II–IV (41% vs. 51%; P=0.19) or grades III–IV (13% vs. 7%; P=0.09) between the groups. Time to neutrophil engraftment (18 days vs. 17 days; P=0.24) was similar, but time to platelet engraftment was longer in cyclosporine/methotrexate patients (14 vs. 12 days; P<0.01). No significant differences in incidence of oropharyngeal mucositis, time to full donor chimerism, or number of cytomegalovirus infections were seen between the two treatment arms, and transplant-related toxicities were equally distributed. Triglyceride (P=0.005) and cholesterol (P=0.009) levels were higher in tacrolimus/sirolimus patients. Transplant-related mortality (18% vs. 12%; P=0.40) and 5-year overall survival (72% vs. 71%; P=0.71) were similar. Five-year relapse-free survival in patients with malignant diagnoses was 65% in the cyclosporine/methotrexate group and 63% in the tacrolimus/sirolimus group (P=0.73). We conclude that tacrolimus/sirolimus remains a valid and safe alternative to cyclosporine/methotrexate as graft-versus-host disease prophylaxis after allogeneic hematopoietic stem cell transplantation, with comparable transplant-related outcomes. The trial was registered at clinicaltrials.gov identifier: 00993343.

Thrombopoietin receptor agonists can be used temporarily with patients suffering from refractory chronic lymphocytic leukemia-associated immunologic thrombocytopenia

The second-generation thrombopoietin receptor (TPO-R) agonists (romiplostim and eltrombopag) were introduced in the treatment of chronic immunologic thrombocytopenia (ITP) approximately 2 years ago. Their use in ITP was recently reviewed by, for example, Stasi and colleagues [1] and Newland [2]. Chronic lymphocytic leukemia (CLL) is sometimes associated with ITP, which proves highly refractory under several conventional therapies. These agents are not as yet indicated in CLL, but there is one case report on the treatment of CLLassociated ITP with eltrombopag [3]. We have used TPO-R agonists temporarily before surgical procedures to increase the platelet count in patients with CLL-associated ITP. Here, we report on two patients who responded very quickly to the TPO-R agonist romiplostim. Surgical procedures could be safely undertaken thereafter. Patient 1 is a 64-year-old man diagnosed with Binet A stage CLL in 2004. His bone marrow showed 50% lymphocyte infiltration without any high-risk features in fluorescence in situ hybridization (FISH) analysis, and he had no splenomegaly or lymphadenopathy. Since diagnosis his major problem and the only indication for treatment has been thrombocytopenia. He has had petechiae and occasional nose-bleeding, with a platelet count below 206 10/L, but no major hemorrhage. Over the years he has received prednisolone, chlorambucil, several intravenous immunoglobulin infusions (ivig), and a weekly standard dose of rituximab for 4 weeks. None of these treatments led to a sustained response. Eventually splenectomy was planned, and to increase his platelet count to a safe level prior to surgery, he received romiplostim injections. Weekly romiplostim was started in June 2009, when his platelet count was 116 10/L, and within 3 weeks the count rose to 1036 10/L. Prior to splenectomy his platelet count was 2386 10/L; romiplostim was discontinued and laparoscopic splenectomy was performed in August 2009. His prednisolone dose was tapered from 40 mg to 10 mg daily. Unfortunately, 4 weeks after the splenectomy his platelet count dropped to 56 10/L, he had bleeding, and romiplostim treatment was resumed. Patient 2 is a 62-year-old man with a 3-year history of CLL. At diagnosis he had hematuria, mild splenomegaly, and lymphadenopathy. He had marked thrombocytopenia, his platelet count being only 86 10/L, but there was no other indication for CLL treatment. The disease was Binet A stage with thrombocytopenia, and there was 60% lymphocyte infiltration in the bone marrow. FISH analysis was not performed. He responded poorly to prednisolone and the responses to ivig and standard-dose rituximab treatments were transient. Splenectomy was not undertaken. He had markedly cariotic teeth, and to remove all potential infectious focuses possibly sustaining the thrombocytopenia, tooth extraction was planned. To increase his platelet count to a safe level, romiplostim was initiated, and 1 week after the first injection he reached a platelet count of 1106 10/L. All cariotic teeth were removed, and he has not received romiplostim since.

Indoleamine 2,3-Dioxygenase Activity and Expression in Patients With Chronic Lymphocytic Leukemia

UNLABELLED Indoleamine 2,3-dioxygenase (IDO) activity and expression is increased in many hematological malignancies, but has not been previously studied in chronic lymphocytic leukemia (CLL). We determined IDO activity and expression in 49 patients with CLL. We found that IDO activity is increased in CLL. This may have some influence on CLL progression. BACKGROUND Indoleamine 2,3-dioxygenase (IDO) is an enzyme involved in the catabolism of tryptophan, suppressing T-cell activity. IDO activity and expression are increased in many malignant diseases, including hematological malignancies. IDO expression can mediate immunotolerance to tumors. IDO activity and expression have not previously been studied in chronic lymphocytic leukemia (CLL). METHODS We measured IDO activity by calculating the kynurenine-tryptophan (kyn-trp) ratio. IDO and IDO2 gene expression was determined by using real-time polymerase chain reaction (PCR). RESULTS In patients with CLL, the serum kyn-trp ratio--reflecting increased IDO activity--was significantly higher compared with controls, but in peripheral blood mononuclear cells (PBMCs)--mainly representing malignant B cells--the expression of genes encoding IDO and IDO2 enzymes was reduced. CONCLUSIONS Increased IDO activity in patients with CLL may affect disease progression, although it originates from cells other than malignant B cells.

Prognostic impact of pretransplant iron overload measured with magnetic resonance imaging on severe infections in allogeneic stem cell transplantation.

Infections and graft‐versus‐host disease (GVHD) are the main causes of transplant‐related mortality (TRM) of patients undergoing allo‐SCT. The role of iron overload (IO) has been debated in this context. Studies, performed with non‐specific surrogate markers of iron, suggest that IO predicts poor outcome after allo‐SCT.

Graft Immune Cell Composition Associates with Clinical Outcome of Allogeneic Hematopoietic Stem Cell Transplantation in Patients with AML

Complications of allogeneic hematopoietic stem cell transplantation (HSCT) have been attributed to immune cells transferred into the patient with the graft. However, a detailed immune cell composition of the graft is usually not evaluated. In the present study, we determined the level of variation in the composition of immune cells between clinical HSCT grafts and whether this variation is associated with clinical outcome. Sizes of major immune cell populations in 50 clinical grafts from a single HSCT Centre were analyzed using flow cytometry. A statistical comparison between cell levels and clinical outcomes of HSCT was performed. Overall survival, acute graft-versus-host disease (aGVHD), chronic graft-versus-host disease (cGVHD), and relapse were used as the primary endpoints. Individual HSCT grafts showed considerable variation in their numbers of immune cell populations, including CD123+ dendritic cells and CD34+ cells, which may play a role in GVHD. Acute myeloid leukemia (AML) patients who developed aGVHD were transplanted with higher levels of effector CD3+ T, CD19+ B, and CD123+ dendritic cells than AML patients without aGVHD, whereas grafts with a high CD34+ content protected against aGVHD. AML patients with cGVHD had received grafts with a lower level of monocytes and a higher level of CD34+ cells than those without cGVHD. There is considerable variation in the levels of immune cell populations between HSCT grafts, and this variation is associated with outcomes of HSCT in AML patients. A detailed analysis of the immune cell content of the graft can be used in risk assessment of HSCT.

Good responses but high TRM in adult patients after MSC therapy for GvHD.

Despite many advances in the field of allogeneic hematopoietic stem cell transplantation (alloHSCT) only limited progress has been made in the treatment of steroid-refractory GvHD. Around 40–80% of transplant recipients experience grade II–IV acute GvHD (aGvHD), and a sustained response to first line corticosteroid treatment is achieved only in half of them. Grade IV steroidrefractory aGvHD is associated with particularly poor prognosis with a long-term survival of less than 10%. We report the outcome of 30 consecutive adult and pediatric patients who were treated for steroid-refractory GvHD with third party bone marrow-derived, platelet-lysate (PL)-expanded mesenchymal stem cells (MSCs) in a prospective single-arm study. Adult patients had undergone allogeneic SCT for a malignant or non-malignant disease at Turku University Hospital or Helsinki University Hospital and pediatric patients at Helsinki Children’s Hospital. aGvHD was graded according to the Glucksberg criteria and indications for MSC treatment were steroid resistance defined as progression or lack of response after five days of treatment with methylprednisolone 2 mg/kg, or recurrent aGvHD, while tapering steroid. Chronic GvHD (cGvHD) was graded according to the consensus criteria by the National Institute of Health. Indications for MSC treatment in cGvHD were steroid resistance defined as a lack of response after 30 days on treatment, or steroid dependency defined as a progression when steroid was tapered. All patients or their legal guardians provided written informed consent for MSC treatment. Allogeneic bone-marrow derived MSCs (LY-MSCs) were produced in the GMP facility of the Advanced Cell Therapy Centre, Finnish Red Cross Blood Service (FRCBS), Helsinki, Finland. The process development and main features of the clinical-grade LY-MSC production method based on platelet lysate has been described previously and detailed protocol is presented in Supplementary Information. The aim was to provide a total of 6 doses of MSCs to each patient, administered according to a bi-weekly (aGvHD and cGvHD) or once-weekly (cGvHD) schedule. The target dose for each infusion was 2 × 10 cells/kg recipient body weight. In aGvHD, responses to MSC therapy were evaluated on day 28 after the first MSC dose. At this time point, organ specific stage and overall grade were recorded, and the responses were categorized as complete response (CR, complete resolution of symptoms), very good partial response (VGPR, decrease in overall grade ⩾ 2 grades), partial response (PR, improvement less than VGPR) and no response (NR). Patients were considered responders if they demonstrated at least PR. In cGvHD, organ specific and global severity scores were assessed at three months post treatment, and responses were classified as CR (resolution of all symptoms relating to cGvHD), PR (decrease in overall severity score or decrease of ⩾ 2 points in the sum of organ specific scores) and NR. Most patients received mold-active antifungal prophylaxis in addition to viral and pneumocystis pneumonia prophylaxis. Statistical analyses were performed using the SPSS software package (IBM SPSS Statistics 21). Survival was calculated from the onset of GvHD to death. Survival curves were estimated with the Kaplan–Meier method and the log-rank test was applied to

The HOVON68 CLL trial revisited: performance status and comorbidity affect survival in elderly patients with chronic lymphocytic leukemia.

Abstract In the HOVON68 CLL trial, patients 65 to 75 years of age had no survival benefit from the addition of low-dose alemtuzumab to fludarabine and cyclophosphamide (FC) in contrast to younger patients. The reasons are explored in this 5-year trial update using both survival analysis and competing risk analysis on non-CLL-related mortality. Elderly FCA patients died more frequently from causes not related to CLL, and more often related to comorbidity (mostly cardiovascular) than to infection. In a Cox multivariate analysis, del(17p), performance status >0, and comorbidity were associated with a higher non-CLL-related mortality in the elderly independent of the treatment modality. Thus, while the ‘fit’ elderly with no comorbidity or performance status of 0 might potentially benefit from chemo-immunotherapy with FC, caution is warranted, when considering alemtuzumab treatment in elderly patients with cardiovascular comorbidity.

Soluble CD52 is an indicator of disease activity in chronic lymphocytic leukemia

Abstract CD52 is a glycoprotein expressed on normal as well as leukemic immune cells and shed as soluble CD52 (sCD52). We studied sCD52 levels in three CLL cohorts: the ‘early’, the ‘high-risk’, and the ‘ibrutinib-treated’. The ‘high-risk’ patients had significantly higher sCD52 levels than the ‘early’ patients. For the ‘early’ patients, high sCD52 levels were associated with a significantly shorter time to first treatment. Regarding prognostic factors, no clear correlations with stage, IGHV, or beta-2-microglobulin were found; in a cox multivariate analysis of the ‘early’ patients, sCD52 and IGHV both had independent prognostic value. Following chemo-immunotherapy, sCD52 decreased in parallel with leukocytes while during ibrutinib treatment and ibrutinib-induced ymphocytosis, sCD52 decreased along with lymph node reductions. In vitro IgM stimulation of CLL cells led to increased sCD52 levels in the medium. Our findings indicate that sCD52 reflects disease activity and potentially treatment efficacy in CLL.