Morgani Rodrigues

Brazilian experience with two conditioning regimens in patients with multiple sclerosis: BEAM/horse ATG and CY/rabbit ATG

Studies have shown that autologous hematopoietic SCT (HSCT) can be used as an intensive immunosuppressive therapy to treat refractory patients and to prevent the progression of multiple sclerosis (MS). This is a prospective multicentric Brazilian MS trial comparing two conditioning regimens: BEAM/horse ATG and CY/rabbit ATG. Most (80.4%) of the 41 subjects in the study had the secondary progressive MS subtype and the mean age was 42 years. The baseline EDSS score in 58.5% of the subjects was 6.5 and 78% had a score of 6.0 or higher, respectively. The complication rate during the intra-transplantation period was 56% for all patients: 71.4% of the patients in the BEAM/hATG group and 40% in the CY/rATG group (P=0.04). Three subjects (7.5%) died of cardiac toxicity, sepsis and alveolar hemorrhage, all of them in the BEAM/ATG group. EFS was 58.54% for all patients: 47% in the BEAM/hATG group and 70% in the CY/rATG group (P=0.288). In conclusion, the CY/rATG regimen seems to be associated with similar outcome results, but presented less toxicity when compared with the BEAM/hATG regimen. Long-term follow-up would be required to fully assess the differences in therapeutic effectiveness between the two regimens.

Mycobacterium tuberculosis infection: a rare late complication after cord blood hematopoietic SCT

Mycobacterium tuberculosis infection: a rare late complication after cord blood hematopoietic SCT

Peripheral blood stem cell yield calculated using preapheresis absolute CD34+ cell count, peripheral blood volume processed, and donor body weight accurately predicts actual yield at multiple centers.

Accurate prediction of stem cell yield is important for planning leukapheresis procedures. A formula has been published (Pierelli et al., Vox Sang 2006;91:126‐34) to estimate the CD34+ dose collected on the first day of leukapheresis that was based on the preapheresis peripheral blood (PB) CD34+ counts, the blood volume processed, and the donors weight. The aim of this study was to assess the predictive value of this formula.

Unrelated Donor Transplantation for Acute Myelogenous Leukemia in First Remission

We retrospectively analyzed the outcomes of all acute myelogenous leukemia (AML) patients in first remission (n = 44; median age = 48 years; high-risk cytogenetics = 59%) who received unrelated donor hematopoietic cell transplantation (HCT) with myeloablative conditioning regimen of i.v. busulfan, fludarabine, and antithymocyte globulin (ATG) between January 2002 and November 2009 at our institution. Donor-recipient pairs were matched by high-resolution HLA-A, -B, -C, -DRB1, and -DQB1 typing (10/10 matches, n = 41; 9/10 matches, n = 3). With a median follow-up of 34 months, actuarial 3-year event-free survival (EFS) and overall survival (OS) is 70% and 78%, respectively. The 3-year EFS and OS in patients with and without poor risk cytogenetics is similar (63% versus 82%, P = 0.43 and 78% versus 82%, P = .89, respectively). The 3-year EFS and OS is also similar in patients above age 55 year versus patients age 55 year or younger (80% versus 67%, P = .47 and 80% versus 78%, P = .81, respectively). The 100-day and 3-year cumulative incidence of transplant-related mortality is 5% and 15%, respectively. Six patients have relapsed, and 3 of them are alive and in remission after salvage therapy, with a median follow-up of 23 months. These results indicate that the majority of AML patients eligible for this treatment can achieve long-term disease control.

The influence of dental care associated with laser therapy on oral mucositis during allogeneic hematopoietic cell transplant: retrospective study

OBJECTIVE To verify decrease in frequency and severity of oral mucositis in patients submitted to dental care and laser therapy during allogeneic hematopoietic cell transplant. METHODS Medical records of patients submitted or not to dental care associated with laser therapy during allogeneic transplant were reviewed. The following data were collected: sex, age, underlying disease, myeloablative conditioning regimens, prophylaxis for graft versus host disease, extension and severity of oral mucositis, pain in the oral cavity and when swallowing, diarrhea, need of peripheral parenteral nutrition and presence of acute graft versus host disease. RESULTS Significant reduction in extension and severity of oral mucositis, as well as in frequency of oral cavity pain, was observed in patients with dental care/laser therapy (p < 0.01). There were no statistically significant differences regarding frequency of diarrhea, pain when swallowing, and need of parenteral nutrition among the groups. Significant association was found between acute graft versus host disease and pain when swallowing (p < 0.01). Acute graft versus host disease was not associated with oral mucositis severity, oral cavity pain, and diarrhea. CONCLUSION Dental care associated with laser therapy reduces the extension and severity of oral mucositis in patients with allogeneic hematopoietic transplant. Further studies are necessary to clarify the isolate efficacy of laser therapy in these conditions, mainly regarding the influence of reduced oral mucositis on the graft versus host disease.

Guidelines of the Brazilian Society of Bone Marrow Transplantation on hematopoietic stem cell transplantation as a treatment for the autoimmune diseases systemic sclerosis and multiple sclerosis

. The procedure has improved and the incidence of complications and mortality decreased over time. There are still many points of discussion, some of which should be clarified by ongoing randomized studies. This consensus paper aims to gather data available in the international literature and to compare it to the Brazilian experience in order to establish evidence-based recommendations for the application of hematopoietic stem cell transplantation (HSCT) in the treatments of systemic and multiple sclerosis in Brazil. Systemic sclerosis Systemic sclerosis is an autoimmune disease in which the skin and, in most cases, internal organs are involved. The clinical evolution usually begins from vascular hyperreactivity and endothelial changes associated with inflammatory phenomena that result in progressive tissue damage, leading to fibrosis. The etiology is still unknown, but it certainly comes from the interaction between genetic predisposition and environmental stimuli that cause an immune imbalance and tissue lesions. Cardiopulmonary involvement is common and affects up to 80% of patients (1) . The

Haploidentical bone marrow transplantation with post transplant cyclophosphamide for patients with X-linked adrenoleukodystrophy: a suitable choice in an urgent situation

Allogeneic hematopoietic stem cell transplantation (HSCT) is the only treatment that enhances survival and stabilizes neurologic symptoms in X-linked adrenoleukodystrophy (X-ALD) with cerebral involvement, a severe demyelinating disease of childhood. Patients with X-ALD who lack a well-matched HLA donor need a rapid alternative. Haploidentical HSCT using post transplant cyclophosphamide (PT/Cy) has been performed in patients with malignant and nonmalignant diseases showing similar outcomes compared to other alternative sources. We describe the outcomes of transplants performed for nine X-ALD patients using haploidentical donors and PT/Cy. Patients received conditioning regimen with fludarabine 150 mg/m2, cyclophosphamide 29 mg/kg and 2 Gy total body irradiation (TBI) with or without antithymocyte globulin. Graft-vs.-host disease prophylaxis consisted of cyclophosphamide 50 mg/kg/day on days +3 and +4, tacrolimus or cyclosporine A and mycophenolate mofetil. One patient had a primary graft failure and was not eligible for a second transplant. Three patients had secondary graft failure and were successfully rescued with second haploidentical transplants. Trying to improve engraftment, conditioning regimen was changed, substituting 2 Gy TBI for 4 Gy total lymphoid irradiation. Eight patients are alive and engrafted (17–37 months after transplant). Haploidentical HSCT with PT/Cy is a feasible alternative for X-ALD patients lacking a suitable matched donor. Graft failure has to be addressed in further studies.

Consenso brasileiro para transplante de células-tronco hematopoéticas para tratamento de doenças autoimunes

Neste trabalho, foram revisadas a literatura internacional e a experiencia nacional com transplante de celulas-tronco hematopoeticas (TCTH) para doencas autoimunes. A evidencia acumulada indica que o TCTH autologo pode beneficiar pacientes com esclerose multipla em fase inflamatoria, refrataria aos tratamentos medicamentosos disponiveis, e pacientes com esclerose sistemica cutânea difusa de carater progressivo, com ou sem comprometimento sistemico. Esse tratamento deveria ser disponibilizado na rede publica de saude, numa fase inicial, em centros de referencia com experiencia em TCTH e no manejo clinico de doencas autoimunes sistemicas graves.

Physicochemical analysis of Permian coprolites from Brazil

In this paper we performed the study of two coprolites (fossilized feces) collected from the exposed levels of the Pedra de Fogo Formation, Parnaiba Sedimentary Basin, and Rio do Rasto Formation, Paraná Sedimentary Basin, both of the Palaeozoic era (Permian age). They were characterized using X-ray diffractometry, infrared, Raman and energy dispersive spectroscopy techniques in order to aid our understanding of the processes of fossilization and to discuss issues related to the feeding habits of the animals which generated those coprolites, probably cartilaginous fishes. The results obtained using a multitechnique approach showed that although these coprolites are from different geological formations, 3000km away from each other, they show the same major crystalline phases and elemental composition. The main phases found were hydroxyapatite, silica, calcite and hematite, which lead to infer that those coprolites were formed under similar conditions and produced by a similar group of carnivore or omnivore fishes.

The role of magnetic resonance imaging-T2* in the evaluation of iron overload early in hereditary hemochromatosis. A cross-sectional study with 159 patients

cancers, where a higher degree of tumor-infiltrating lymphocytes (TIL) predicts improved survival independent of TNM (tumor, node, metastases) staging [1]. TIL have also shown prognostic value in various lymphoid hematological malignancies. In AML, evidence of immune modulation is seen in the “graft-versus-leukemia” effects post-allogeneic SCT together with promising preclinical activity of novel immune therapies. Furthermore, higher peripheral blood lymphocyte recovery after induction chemotherapy [2] and allogeneic SCT for AML [3] have predicted improved overall survival (OS). The prognostic significance of immune status at diagnosis has not been defined in AML. We therefore investigated whether degree of T lymphocyte infiltration within CN-AML diagnostic bone marrow trephines, which we have labeled the “leukemia-infiltrating lymphocyte” (LIL) index, had prognostic value. Patients diagnosed with CN-AML at an adult tertiary center between 2006 and 2013, treated with intensive chemotherapy and who had suitable stored, diagnostic bone marrow trephines were analyzed with institutional ethics approval. Trephines were formalinfixed, decalcified in EDTA, and processed through to paraffin. Immunostaining for pan-T cell marker, CD3, and cytotoxic markers, CD8 and Granzyme B (GB), was performed at the time of analysis using routine methods. CD4 immunostaining was attempted, however high levels of non-specific staining precluded quantitative analysis. Positive cells were quantified using FijiVC image analysis software (v1.48o) from photographs taken at 3200 magnification of three representative areas of each trephine, expressed as a percentage of total cells and averaged over the three images. The cohort included 53 patients (51% male, median age 51 years (range 19–78)) followed-up over a median of 25.9 months (range 0.17–102.6 months). Most patients (96%) had de novo AML, 47 patients (89%) achieved CR (29 (62%) of whom relapsed), 21 (40%) underwent allogeneic SCT (10 in second CR) and 20 (38%) died. From a mean of 13,768 cells per trephine analyzed, median CD3% was 4.64% (range 0.56–37.24%) (Fig. 1A,B), CD8% was 5.08% (range 0.43–43.5%) and GB% was 0.34% (range 0–10.11%). In univariate Cox regression analyses, significant risk factors for death were higher aspirate blast% (P5 0.006), primary refractory disease (P5 0.03), and relapse (P5 0.04). Increasing age (P5 0.093), FLT3-ITD (P5 0.099), and CD3% (P5 0.079) approached significance. Gender, preceding myelodysplastic syndrome, allograft, NPM1 mutation (NPM1), CD8%, and GB% were not significant. In Cox regression multivariate analyses, combining T cell numbers with the relevant univariate factors (i.e., P< 0.1), higher CD3 and CD8 were independent predictors of OS (CD3: hazard ratio (HR) 0.929 for death, 95% CI 0.870–0.992, P5 0.029; CD8: HR 0.920, 95% CI 0.869–0.973, P5 0.004). Patients were divided into quartiles to determine whether incremental differences in survival were present with increasing T cell number. Kaplan–Meier survival analyses demonstrated that CD3 and CD8 numbers were able to stratify patient survival, with significantly superior OS in patients with higher CD3% (Quartile 4 (>12.39%) vs. Quartile 1 (<1.63%), P5 0.042) (Fig. 1C, first panel) and a trend toward better OS with higher CD8% (Quartile 4 (>10.66%) vs. Quartile 1 (<2.2%), P5 0.057) (Fig. 1C, second panel). GB was not able to risk-stratify patients (Fig. 1C, third panel). Higher CD3% and CD8% measured by flow cytometry showed similar prognostic capability, however there was weak correlation between CD3 and CD8 numbers obtained by immunohistochemistry and flow cytometry (data not shown; correlation coefficient, r5 0.534 for CD3 and r5 0.613 for CD8). This may reflect inherent differences in the type of samples analyzed, particularly with sampling artifact and varying degrees of hemodilution in aspirates. Further survival analyses incorporated known prognostic significance of FLT3-ITD and NPM1. Forty-four patients (83%) who were tested for both mutations formed three subgroups: FLT3-ITD (n5 18; 3 year OS 37%), NPM1 without FLT3-ITD (NPM1/ FLT3-ITD; n5 9; 3 year OS 70%), and “double-negative” (NPM1/FLT3-ITD; n5 17; 3 year OS 62%). As small numbers within each subgroup precluded analysis with quartiles, groups split by the median were compared. Although there were no statistically significant differences in OS for CD3, CD8, and GB within the FLT3-ITD (Fig. 1D) and NPM1/ FLT3-ITD (data not shown) subgroups, there was a trend for better survival in the FLT3-ITD subgroup with higher T cells. This was in spite of older age in high (median age 63 years) compared with low T cell (median age 53 years) subgroups. In contrast, CD3>median (16.06%) and CD8>median (13.8%) in the NPM1/FLT3-ITD subgroup were associated with significantly superior OS (CD3: P< 0.001; CD8: P5 0.010) (Fig. 1E, first and second panels) with comparable patient characteristics between above and below median groups. GB>median (1.38%) was not related to survival (P5 0.247) (Fig. 1E, third panel). As the NPM1/FLT3-ITD group often lacks defining prognostic factors, T cell numbers may be most relevant for further risk-stratification of this group. The association of low T cell numbers with poor prognosis in our analyses may reflect the proliferative advantage of blasts gained by immune evasion mechanisms described in AML, including suppression of production and function of T lymphocytes [4]. The corollary is that retained specific T cell immune responses against leukemia-associated antigens, including NPM1, may contribute to improved prognosis [5]. In addition to prognostic implications, the baseline immune status may modify response to immune therapies. Patients with lower T cells generally had a dismal prognosis with cytotoxic therapy and may benefit from immune augmentation by immune-based therapies. Conversely, low T cells may limit response to immune therapies. In in vitro studies of chimeric antigen receptor T cells [6] and bispecific T cell engaging antibodies [7] in AML, less cytolysis was seen with lower T cells to blasts (i.e., effector to target (E:T)) ratios in a dose-dependent relationship. Whether this consideration applies in vivo requires further investigation. To the best of our knowledge, this study is the first to correlate higher baseline T cell infiltration in bone marrow trephines in CN-AML with improved survival. A noted strength of the study was the objective quantitation of large numbers of cells using image analysis software. Although our patient cohort was small, patient outcomes are consistent with larger cohort analyses. Notwithstanding the other limitations of a retrospective design and variability in post-remission therapies, our study introduces the LIL index as a novel prognostic marker in CN-AML, with greatest potential utility in the indeterminate-risk NPM1/FLT3-ITD group. This work provides rationale for further studies to explore the function of the infiltrating T cells, identify T cell subsets that portend the survival benefit, and assess the LIL index in other AML genetic subgroups.