Michele Pohlen

Targeting Interleukin-2 to the Bone Marrow Stroma for Therapy of Acute Myeloid Leukemia Relapsing after Allogeneic Hematopoietic Stem Cell Transplantation

Schliemann and colleagues report the use of immunocytokine F16-IL2 in combination with low-dose cytarabine in four patients with relapsed AML after allogeneic hematopoietic stem-cell transplantation; antibody-mediated delivery of IL2 to the AML stroma can activate immune effector cells in the bone marrow of patients. The antibody-based delivery of IL2 to extracellular targets expressed in the easily accessible tumor-associated vasculature has shown potent antileukemic activity in xenograft and immunocompetent murine models of acute myelogenous leukemia (AML), especially in combination with cytarabine. Here, we report our experience with 4 patients with relapsed AML after allogeneic hematopoietic stem cell transplantation (allo-HSCT), who were treated with the immunocytokine F16-IL2, in combination with low-dose cytarabine. One patient with disseminated extramedullary AML lesions achieved a complete metabolic response identified by PET/CT, which lasted 3 months. Two of 3 patients with bone marrow relapse achieved a blast reduction with transient molecular negativity. One of the 2 patients enjoyed a short complete remission before AML relapse occurred 2 months after the first infusion of F16-IL2. In line with a site-directed delivery of the cytokine, F16-IL2 led to an extensive infiltration of immune effector cells in the bone marrow. Grade 2 fevers were the only nonhematologic side effects in 2 patients. Grade 3 cytokine-release syndrome developed in the other 2 patients but was manageable in both cases with glucocorticoids. The concept of specifically targeting IL2 to the leukemia-associated stroma deserves further evaluation in clinical trials, especially in patients who relapse after allo-HSCT. Cancer Immunol Res; 3(5); 547–56. ©2015 AACR.

Efficacy and toxicity of a rituximab and methotrexate based regimen (GMALL B-ALL/NHL 2002 protocol) in Burkitt's and primary mediastinal large B-cell lymphoma.

There have been several attempts to improve treatment and outcome of patients with primary mediastinal B-cell lymphoma (PMBL) and Burkitts lymphoma (BL). In recent years, chemotherapy dose intensification and the addition of rituximab have led to a remarkable progress and have developed into integral parts of treatment for both entities of lymphoma [1–4]. Here, we report our monocenter results of a high-dose methotrexate based alternating regimen with rituximab (B-ALL/NHL 2002 protocol) in 15 patients with PMBL and 28 patients with sporadic BL. Since the early 1980s, protocols of GMALL have been continuously adapted and in the meantime they have become reference treatment for BL and B-ALL in Germany. The latest changes comprised the additional use of rituximab, standardized G-CSF support,implementation of high-dose cytarabine, intrathecal triple therapy,and age-adjusted stratification. Furthermore, we additionally amended supportive care with palifermin as it reduced severity and prevalence of mucositis [5].

Impact of High-Cut-Off Dialysis on Renal Recovery in Dialysis-Dependent Multiple Myeloma Patients: Results from a Case-Control Study.

Background High-cut-off hemodialysis (HCO-HD) can effectively reduce high concentrations of circulating serum free light chains (sFLC) in patients with dialysis-dependent acute kidney injury (AKI) due to multiple myeloma (MM). Therefore, the aim of this study was to analyze renal recovery in a retrospective single-center cohort of dialysis-dependent MM patients treated with either conventional HD (conv. HD) or HCO-HD. Methods and Results The final cohort consisted of 59 patients treated with HCO-HD (n = 42) or conv. HD (n = 17). A sustained sFLC response was detected in a significantly higher proportion of HCO-HD patients (83.3%) compared with conv. HD patients (29.4%; p = 0.007). The median duration of sFLC required to reach values <1000 mg/l was 14.5 days in the HCO-HD group and 36 days in the conv. HD group. The corresponding rates of renal recovery were 64.3% and 29.4%, respectively (chi-squared test, p = 0.014). Multivariate regression and decision tree analysis (recursive partitioning) revealed HCO-HD (adjusted odds ratio [OR] 6.1 [95% confidence interval (CI) 1.5–24.5], p = 0.011) and low initial uric acid values (adjusted OR 1.3 [95%CI 1.0–1.7], p = 0.045) as independent and paramount variables associated with a favorable renal outcome. Conclusions In summary, the results from this retrospective case-control study suggest in addition to novel agent-based chemotherapy a benefit of HCO-HD in sFLC removal and renal outcome in dialysis-dependent AKI secondary to MM. This finding was especially pertinent in patients with low initial uric acid values, resulting in a promising renal recovery rate of 71.9%. Further prospective studies are warranted.

Alarmin S100A8 Activates Alveolar Epithelial Cells in the Context of Acute Lung Injury in a TLR4-Dependent Manner

Alveolar epithelial cells (AECs) are an essential part of the respiratory barrier in lungs for gas exchange and protection against pathogens. Damage to AECs occurs during lung injury and PAMPs/DAMPs have been shown to activate AECs. However, their interplay as well as the mechanism of AECs’ activation especially by the alarmin S100A8/A9 is unknown. Thus, our aim was to study the mechanism of activation of AECs (type I and type II) by S100A8 and/or lipopolysaccharide (LPS) and to understand the role of endogenous S100A8/A9 in neutrophil recruitment in the lung. For our studies, we modified a previous protocol for isolation and culturing of murine AECs. Next, we stimulated the cells with S100A8 and/or LPS and analyzed cytokine/chemokine release. We also analyzed the contribution of the known S100-receptors TLR4 and RAGE in AEC activation. In a murine model of lung injury, we investigated the role of S100A8/A9 in neutrophil recruitment to lungs. S100A8 activates type I and type II cells in a dose- and time-dependent manner which could be quantified by the release of IL-6, KC, and MCP-1. We here clearly demonstrate that AEC s are activated by S100A8 via a TLR4-dependent pathway. Surprisingly, RAGE, albeit mainly expressed in lung tissue, plays no role. Additionally, we show that S100A8/A9 is an essential factor for neutrophil recruitment to lungs. We, therefore, conclude that S100A8 promotes acute lung injury via Toll-like receptor 4-dependent activation of AECs.

Combination of romiplostim and rituximab: effective therapy of severe immune thrombocytopenia

To the Editor: Immune thrombocytopenia (ITP) leads to accelerated platelet destruction accompanied by reduced platelet production. Here, we describe two patients with severe ITP that were successfully treated with a combination of romiplostim and rituximab. A 59-year-old woman was referred for relapsed ITP. Splenectomy was not possible because of a platelet count of 1000 ⁄lL and signs of bleeding. Further analysis revealed high-titer anti-platelet antibodies in the serum and increased numbers of megakaryocytes in the bone marrow. Initial treatment with prednisolone and intravenous immunoglobulins (IVIG), followed by dexamethasone and anti-rhesus-D immunoglobulin, did not lead to any significant increase in the platelet counts. As the disease was unresponsive to therapy(1), administration of romiplostim was initiated on day 1 (1 lg ⁄kg) with subsequent dose increases (1 lg ⁄kg per week) up to a dose of 6 lg ⁄kg on day 34 after the first dose of romiplostim without any change in platelet counts (Fig. 1). Platelet transfusions as well as administration of dexamethasone, factor XIII, and tranexamic acid were necessary for acute and life-threatening bleeding episodes. Rituximab (375 mg ⁄m) was given on day 40 and day 47 after the first dose of romiplostim, and the last dose of romiplostim (7 lg ⁄kg) was administered on day 41. Platelet counts increased from 3000 ⁄ lL and 6000 ⁄ lL on days 40 and 44 to 239 000 ⁄ lL on day 47. Both romiplostim and rituximab were stopped on day 47, and thromboprophylaxis was started. Platelet counts continued to rise to 1 053 000 ⁄ lL on day 53. Three weeks later, when platelets began to decrease again, the patient decided to undergo splenectomy as definite treatment for ITP. Afterward, platelet counts remained stable (between 500 000 and 600 000 ⁄lL). No further bleeding episodes occurred. Our second patient, a 25-year-old female with a history of two relapses of Hodgkin’s disease was admitted for newly onset petechiae (platelets 4000 ⁄ lL) 1 year after having completed her last chemotherapy and autologous transplant. Direct monoclonal antibody immobilization of platelet antigen (MAIPA) was positive, and bone marrow examination showed an increased megakaryocyte count. Bleeding was initially controlled by IVIG as well as steroids. In light of potential graft failure after multiple previous chemotherapies, an autologous stem cell boost (8.9 · 10 CD34 cells ⁄kg) was given. After more than 4 weeks without response (platelets 4000 ⁄ lL), administration of romiplostim was started (1 lg ⁄kg) (Fig. 1). Seven days later, the patient developed an acute headache. Magnetic resonance tomography of the brain revealed punctual cerebral hemorrhage, and platelet transfusions were administered. Rituximab (375 mg ⁄m weekly) was given on days 12, 19, 26, and 33 after romiplostim treatment initiation. On day 25, platelets increased to 41 000 ⁄ lL and continued to rise to normal levels, and romiplostim doses were not further escalated (4 lg ⁄kg). Interestingly, platelet counts decreased when romiplostim was tapered. ITP patients show a significant decrease in platelet production(2). Romiplostim, a novel thrombopoiesisstimulating protein, effectively binds and activates the human thrombopoietin receptor(3, 4). Clinical trials with romiplostim and eltrombopag(5, 6) have shown sustained elevations of platelet counts in patients with ITP either before or after splenectomy. Previously, romiplostim was combined with corticosteroids, azathioprin, danazol, or other drugs. However, to our knowledge, a combination with rituximab has not been described, although one patient receiving romiplostim 4 weeks after rituximab has been described(3). We reasoned that in cases of ITP unresponsive to both first-line therapy and romiplostim monotherapy, a combination of rituximab and romiplostim may inhibit platelet destruction and at the same time increase platelet production. Indeed, as seen in both cases, this combination can lead to a strong and even overwhelming increase in platelet counts. Frequent laboratory examinations and thromboprophylaxis are therefore necessary to prevent adverse reactions such as thrombotic events. Furthermore, our data reinforce existing recommendations of careful romiplostim dose increases to prevent uncontrolled increases in platelet counts. In the first case, the long latency of platelet increase after romiplostim initiation, the steep increase with rituximab, and the extent of the platelet response to up to 1 000 000 ⁄ lL which is uncommon for rituximab alone(7) strongly suggest that rituximab played a major role in the platelet response. This platelet response to rituximab may be explained by prestimulated thrombopoiesis as a doi:10.1111/j.1600-0609.2009.01406.x European Journal of Haematology 84 (362–364)

Single-operator cholangioscopy for biliary complications in liver transplant recipients

AIM To evaluate cholangioscopy in addition to endoscopic retrograde cholangiopancreatography (ERCP) for management of biliary complications after liver transplantation (LT). METHODS Twenty-six LT recipients with duct-to-duct biliary reconstruction who underwent ERCP for suspected biliary complications between April and December 2016 at the university hospital of Muenster were consecutively enrolled in this observational study. After evaluating bile ducts using fluoroscopy, cholangioscopy using a modern digital single-operator cholangioscopy system (SpyGlass DS™) was performed during the same procedure with patients under conscious sedation. All patients received peri-interventional antibiotic prophylaxis and bile was collected during the intervention for microbial analysis and for antibiotic susceptibility testing. RESULTS Thirty-three biliary complications were found in a total of 22 patients, whereas four patients showed normal bile ducts. Anastomotic strictures were evident in 14 (53.8%) patients, non-anastomotic strictures in seven (26.9%), biliary cast in three (11.5%), and stones in six (23.1%). A benefit of cholangioscopy was seen in 12 (46.2%) patients. In four of them, cholangioscopy was crucial for selective guidewire placement prior to planned intervention. In six patients, biliary cast and/or stones failed to be diagnosed by ERCP and were only detectable through cholangioscopy. In one case, a bile duct ulcer due to fungal infection was diagnosed by cholangioscopy. In another case, signs of bile duct inflammation caused by acute cholangitis were evident. One patient developed post-interventional cholangitis. No further procedure-related complications occurred. Thirty-seven isolates were found in bile. Sixteen of these were gram-positive (43.2%), 12 (32.4%) were gram-negative bacteria, and Candida species accounted for 24.3% of all isolated microorganisms. Interestingly, only 48.6% of specimens were sensitive to prophylactic antibiotics. CONCLUSION Single-operator cholangioscopy can provide important diagnostic information, helping endoscopists to plan and perform interventional procedures in LT-related biliary complications.

Molecular adsorbent recirculating system (MARS) in acute liver injury and graft dysfunction: Results from a case-control study

Background The primary therapeutic goals in the treatment of liver injury are to support liver regeneration or bridge the gap to liver transplantation (LT). Molecular adsorbent recirculating system (MARS) therapy has shown beneficial effects for specific symptoms of liver failure; however, general survival advantages have not yet been demonstrated. Aim We studied the effects of MARS therapy compared to standard medical treatment (SMT) in two patient cohorts: in patients with an acute liver injury and in those with graft dysfunction (GD). Methods We report on our experience over a 6.5-year period with 73 patients treated with SMT or with SMT and MARS (MARS group). In total, 53 patients suffered from acute liver injury in their native liver without a preexisting liver disease (SMT: n = 31, MARS: n = 22), and 20 patients showed a severe GD after LT (SMT: n = 10, MARS: n = 10). Results The entire cohort was predominantly characterized by hemodynamically and respiratorily stable patients with a low hepatic encephalopathy (HE) grade and a model of end-stage liver disease (MELD) score of 20.57 (MARS) or 22.51 (SMT, p = 0.555). Within the MARS group, the median number of extracorporeal therapy sessions was four (range = 3–5 sessions). Independent of the underlying etiology, MARS improved the patients’ bilirubin values in the short term compared to SMT alone. In patients with acute liver injury, this response was sustained even after the end of MARS therapy. By contrast, the majority of patients with GD and an initial response to MARS therapy experienced worsened hyperbilirubinemia. No differences in 28-day mortality were observed with respect to acute liver injury (MARS 5.3% (95% CI: 0–15.3); SMT 3.3% (95% CI: 0–9.8), p = 0.754) or GD (MARS 20.0% (95% CI: 0–44.7), SMT 11.1% (95% CI: 0–31.7), p = 0.478). Conclusions Although it did not improve 28-day mortality, MARS therapy improved the short-term response in patients with acute liver injury as well as in those with GD. In cases of acute hepatic injury, the use of MARS therapy resulted in the sustained stabilization of liver function and improved liver regeneration. A short-term response to MARS may predict the future course of the disease.

Patients with Acute Myeloid Leukemia Admitted to Intensive Care Units: Outcome Analysis and Risk Prediction

Background This retrospective, multicenter study aimed to reveal risk predictors for mortality in the intensive care unit (ICU) as well as survival after ICU discharge in patients with acute myeloid leukemia (AML) requiring treatment in the ICU. Methods and Results Multivariate analysis of data for 187 adults with AML treated in the ICU in one institution revealed the following as independent prognostic factors for death in the ICU: arterial oxygen partial pressure below 72 mmHg, active AML and systemic inflammatory response syndrome upon ICU admission, and need for hemodialysis and mechanical ventilation in the ICU. Based on these variables, we developed an ICU mortality score and validated the score in an independent cohort of 264 patients treated in the ICU in three additional tertiary hospitals. Compared with the Simplified Acute Physiology Score (SAPS) II, the Logistic Organ Dysfunction (LOD) score, and the Sequential Organ Failure Assessment (SOFA) score, our score yielded a better prediction of ICU mortality in the receiver operator characteristics (ROC) analysis (AUC = 0.913 vs. AUC = 0.710 [SAPS II], AUC = 0.708 [LOD], and 0.770 [SOFA] in the training cohort; AUC = 0.841 for the developed score vs. AUC = 0.730 [SAPSII], AUC = 0.773 [LOD], and 0.783 [SOFA] in the validation cohort). Factors predicting decreased survival after ICU discharge were as follows: relapse or refractory disease, previous allogeneic stem cell transplantation, time between hospital admission and ICU admission, time spent in ICU, impaired diuresis, Glasgow Coma Scale <8 and hematocrit of ≥25% at ICU admission. Based on these factors, an ICU survival score was created and used for risk stratification into three risk groups. This stratification discriminated distinct survival rates after ICU discharge. Conclusions Our data emphasize that although individual risks differ widely depending on the patient and disease status, a substantial portion of critically ill patients with AML benefit from intensive care.

Ciprofloxacin versus colistin prophylaxis during neutropenia in acute myeloid leukemia: two parallel patient cohorts treated in a single center

Patients undergoing intensive chemotherapy for acute myeloid leukemia are at high risk for bacterial infections during therapy-related neutropenia. However, the use of specific antibiotic regimens for prophylaxis in afebrile neutropenic acute myeloid leukemia patients is controversial. We report a retrospective evaluation of 172 acute myeloid leukemia patients who received 322 courses of myelosuppressive chemotherapy and had an expected duration of neutropenia of more than seven days. The patients were allocated to antibiotic prophylaxis groups and treated with colistin or ciprofloxacin through 2 different hematologic services at our hospital, as available. The infection rate was reduced from 88.6% to 74.2% through antibiotic prophylaxis (vs. without prophylaxis; P=0.04). A comparison of both antibiotic drugs revealed a trend towards fewer infections associated with ciprofloxacin prophylaxis (69.2% vs. 79.5% in the colistin group; P=0.07), as determined by univariate analysis. This result was confirmed through multivariate analysis (OR: 0.475, 95%CI: 0.236–0.958; P=0.041). The prophylactic agents did not differ with regard to the microbiological findings (P=0.6, not significant). Of note, the use of ciprofloxacin was significantly associated with an increased rate of infections with pathogens that are resistant to the antibiotic used for prophylaxis (79.5% vs. 9.5% in the colistin group; P<0.0001). The risk factors for higher infection rates were the presence of a central venous catheter (P<0.0001), mucositis grade III/IV (P=0.0039), and induction/relapse courses (vs. consolidation; P<0.0001). In conclusion, ciprofloxacin prophylaxis appears to be of particular benefit during induction and relapse chemotherapy for acute myeloid leukemia. To prevent and control drug resistance, it may be safely replaced by colistin during consolidation cycles of acute myeloid leukemia therapy.

Visceral leishmaniasis clinically mimicking lymphoma

Dear Editor, A 57-year-old male engineer from Germany was admitted to our hospital with the following symptoms and findings: highgrade intermittent fever and night sweats observed for the last 8 weeks, increasing pancytopenia (on admission: hemoglobin 9.9 g/dL, white blood count 1,710/μL with normal differential count, platelets 68/nL), lactatedehydrogenase elevation (415U/L), and non-measurable low haptoglobin. Past medical history revealed type 1 diabetes mellitus, arterial hypertension, and a recently diagnosed allergic rhinitis. In addition, 5 years ago, he was treated in a hospital due to Lyme disease. In recent years, he frequently traveled to Mallorca, Spain. Family history was without significant pathological findings; he never smoked and consumed only little alcohol. On physical examination, hepatosplenomegaly was prominent (liver 190×90 mm, spleen 209×67 mm), and no additional abnormalities were noted. Bone marrow aspiration showed normal hematopoiesis without evidence of malignancy or other infiltrative processes; leishmaniasis also retrospectively could not be detected. A whole body fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography scan (PET–CT) was performed for further evaluation with the prominent finding of a metabolically active (SUV 6.8) and enlarged spleen, and no further evidence of disease (see Fig. 1a, b). Splenic marginal zone lymphoma (SMZL) associated with autoimmune hemolytic anemia was the putative clinical diagnosis, and upon appropriate immunization, splenectomy was performed. Notably, the histopathological evaluation of the spleen revealed no evidence of malignancy. Nevertheless, fever declined and blood parameters began to normalize subsequently. The patient was discharged from our hospital without B symptoms and with normal complete blood count. Two months later, the patient presented again with a 4week history of progressive malaise, lethargy, relapsed pancytopenia, recurrent fever with sudden onset, and a total weight loss of 4 kg. Empirical antibiotic treatment with ceftriaxone was started, but symptoms persisted. A second bone marrow aspiration was performed, this time showing numerous macrophages and monocytes filled with inclusion bodies of Leishmania infantum (see Fig. 1c). Furthermore, polymerase chain reaction (PCR), and serological tests based on indirect fluorescence antibody (IFA) and enzyme-linked immunosorbent assay (ELISA) were carried out, confirming the diagnosis of visceral leishmaniasis (VL). With the knowledge of VL, silver staining of former spleen specimens was performed, and pathologic re-examination showed sporadic L. infantum inclusion bodies within macrophages of the red pulp (see Fig. 1d). The patient was administered liposomal amphotericin B intravenously in a dose of 3 mg/kg/day for 1 week. The therapy was well tolerated, and the symptoms improved gradually. After 7 days of treatment, blood parameters normalized continuously. Three as well as 6 months after Georg Evers and Michele Pohlen contributed equally.