Tsila Zuckerman

bcl-2 and immunoglobulin gene rearrangement in patients with hepatitis C virus infection

An association between chronic hepatitis C virus (HCV) infection and clonal proliferation of B cells, including B cell lymphoma, has recently been demonstrated. However, the mechanism of malignant transformation is still unknown. It has been shown that B cells from patients with type II mixed cryoglobulinaemia (MC), strongly express the antiapoptotic bcl‐2 oncogene product. Therefore, we investigated a possible mechanism of lymphomagenesis, the occurrence of bcl‐2 and immunoglobulin gene rearrangement (IgH) in HCV‐infected patients. Three groups of patients were studied: (1) 44 patients with HCV and MC (anti‐HCV and HCV RNA positive); (2) 59 patients with chronic HCV infection without MC; (3) 50 patients with chronic liver disease (CLD) not related to HCV infection. The t(14;18) translocation (MBR bcl‐2–JH) and IgH rearrangement (FR3/JH) were detected by polymerase chain reaction (PCR) in peripheral mononuclear cells. bcl‐2 translocation was detected in 17/44 (39%), 7/59 (12%) and in none of the patients of groups 1, 2 and 3 respectively (P < 0·01). Monoclonal IgH rearrangement was detected in 15/44 (34%), 5/59 (8·5%) and 2/50 (4%) patients of groups 1, 2 and 3 respectively (P < 0·05). HCV‐infected patients had a higher prevalence of monoclonal IgH rearrangement and bcl‐2 translocation than patients with CLD of other aetiologies. These data suggest that HCV may play a role in the multistep mechanism of lymphomagenesis by inducing clonal proliferation of B cells and inhibition of apoptosis.

Eradication of carbapenem-resistant Enterobacteriaceae gastrointestinal colonization with nonabsorbable oral antibiotic treatment: A prospective controlled trial

BACKGROUND Carbapenem-resistant Enterobacteriaceae (CRE) are emerging. In attempt to eradicate CRE colonization, we conducted a semirandomized, prospective, controlled trial using oral nonabsorbable antibiotics. METHODS Consecutive hospitalized CRE carriers were studied. Patients whose rectal isolates were gentamicin sensitive but colistin resistant were treated with gentamicin. Patients whose isolates were colistin sensitive but gentamicin resistant were treated with colistin. Patients whose isolates were sensitive to both drugs were randomized to 3 groups of oral antibiotic treatment: gentamicin, colistin, or both. Patients whose isolates were resistant to both drugs, and those who did not consent, were followed for spontaneous eradication. RESULTS One hundred fifty-two patients were included; 102 were followed for spontaneous eradication for a median duration of 140 days (controls), and 50 received 1 of the 3 drug regimens: gentamicin, 26; colistin, 16; both drugs, 8, followed for a median duration of 33 days. Eradication rates in the 3 treatment groups were 42%, 50%, and 37.5%, respectively, each significantly higher than the 7% spontaneous eradication rate in the control group (P < .001, P < .001, and P = .004, respectively) with no difference between the regimens. No significant adverse effects were observed. CONCLUSION Oral antibiotic treatment with nonabsorbable drugs to which CRE is susceptible appears to be an effective and safe for eradication of CRE colonization and, thereby, may reduce patient-to-patient transmission and incidence of clinical infection with this difficult-to-treat organism.

Cell lineage analysis of acute leukemia relapse uncovers the role of replication-rate heterogeneity and microsatellite instability

Human cancers display substantial intratumoral genetic heterogeneity, which facilitates tumor survival under changing microenvironmental conditions. Tumor substructure and its effect on disease progression and relapse are incompletely understood. In the present study, a high-throughput method that uses neutral somatic mutations accumulated in individual cells to reconstruct cell lineage trees was applied to hundreds of cells of human acute leukemia harvested from multiple patients at diagnosis and at relapse. The reconstructed cell lineage trees of patients with acute myeloid leukemia showed that leukemia cells at relapse were shallow (divide rarely) compared with cells at diagnosis and were closely related to their stem cell subpopulation, implying that in these instances relapse might have originated from rarely dividing stem cells. In contrast, among patients with acute lymphoid leukemia, no differences in cell depth were observed between diagnosis and relapse. In one case of chronic myeloid leukemia, at blast crisis, most of the cells at relapse were mismatch-repair deficient. In almost all leukemia cases, > 1 lineage was observed at relapse, indicating that diverse mechanisms can promote relapse in the same patient. In conclusion, diverse relapse mechanisms can be observed by systematic reconstruction of cell lineage trees of patients with leukemia.

Non-Hodgkin's lymphoma presenting as an endobronchial tumor: Report of eight cases and literature review

Non‐Hodgkins lymphoma (NHL) involving the endobronchial tree is uncommon, and the initial presentation of NHL as an endobronchial tumor is extremely rare. In a series of 441 patients with newly diagnosed non‐Hodgkins lymphoma over a 7‐year period, we reviewed the clinical features of eight patients who presented with an endobronchial tumor. All patients had local pulmonary disease without extrathoracic involvement. The major presenting symptoms were dyspnea, chest pain, cough, and hoarseness. None of the patients had systemic symptoms. Radiographs revealed lobar collapse in all cases. Five patients had mediastinal masses and three had isolated endobronchial lesions. Although MALT lymphoma is the most common primary pulmonary lymphoma, it was present in only one of our patients, while seven patients had aggressive lymphoma. All patients received chemotherapy. Six of the eight patients responded favorably to treatment with complete remission. The prognosis of patients with isolated endobronchial lymphoma is not worse than other local presentations of lymphoma. Bronchoscopic examination with biopsy is essential to differentiate these lesions from primary bronchongenic carcinoma. Am. J. Hematol., 2008.

Gonadotropin-releasing hormone agonist may minimize premature ovarian failure in young women undergoing autologous stem cell transplantation

OBJECTIVE To compare the rate of premature ovarian failure (POF) after stem cell transplantation (SCT) in young women receiving GnRH-agonist (GnRH-a) in conjunction with gonadotoxic chemotherapy. DESIGN Prospective, nonrandomized study. SETTING Tertiary university hospital. PATIENT(S) Ninety-five women received conditioning chemotherapy, with or without GnRH-a before SCT. Complete information was available for only 83 patients. INTERVENTION(S) Conditioning chemotherapy, with or without GnRH-a before SCT. MAIN OUTCOME MEASURE(S) Cyclic ovarian function (COF) or POF after SCT. RESULT(S) There were no significant differences in age, chemotherapy treatment, or diagnoses between the study and control groups. In the GnRH-a group, 38.3% (18/47) patients resumed COF, compared with 11.1% (4/36) for patients who did not receive GnRH-a. Patients who resumed COF were on average 3.7 years (median, 3 years) younger at the time of transplantation than those who experienced POF. GnRH-a had a significant effect on long-term COF in patients with lymphomas (66.7% [14/21] for GnRH-a group vs. 18.2% [2/11] for control) but not for leukemia patients. CONCLUSION(S) GnRH-a cotreatment in conjunction with conditioning chemotherapy before SCT may significantly decrease the gonadotoxicity and POF from 82% to 33% in lymphoma but not in leukemia patients.

How I treat hematologic emergencies in adults with acute leukemia.

Acute myeloid leukemia and acute lymphoblastic leukemia remain devastating diseases. Only approximately 40% of younger and 10% of older adults are long-term survivors. Although curing the leukemia is always the most formidable challenge, complications from the disease itself and its treatment are associated with significant morbidity and mortality. Such complications, discussed herein, include tumor lysis, hyperleukocytosis, cytarabine-induced cellebellar toxicity, acute promyelocytic leukemia differentiation syndrome, thrombohemorrhagic syndrome in acute promyelocytic leukemia, L-asparaginase-associated thrombosis, leukemic meningitis, neutropenic fever, neutropenic enterocolitis, and transfussion-associated GVHD. Whereas clinical trials form the backbone for the management of acute leukemia, emergent clinical situations, predictable or not, are common and do not readily lend themselves to clinical trial evaluation. Furthermore, practice guidelines are often lacking. Not only are prospective trials impractical because of the emergent nature of the issue at hand, but clinicians are often reluctant to randomize such patients. Extensive practical experience is crucial and, even if there is no consensus, management of such emergencies should be guided by an understanding of the underlying pathophysiologic mechanisms.

Phase I/II study exploring ImMucin, a pan-major histocompatibility complex, anti-MUC1 signal peptide vaccine, in multiple myeloma patients

ImMucin, a 21‐mer cancer vaccine encoding the signal peptide domain of the MUC1 tumour‐associated antigen, possesses a high density of T‐ and B‐cell epitopes but preserves MUC1 specificity. This phase I/II study assessed the safety, immunity and clinical response to 6 or 12 bi‐weekly intradermal ImMucin vaccines, co‐administered with human granulocyte‐macrophage colony‐stimulating factor to 15 MUC1‐positive multiple myeloma (MM) patients, with residual or biochemically progressive disease following autologous stem cell transplantation. Vaccination was well tolerated; all adverse events were temporal grade 1 2 and spontaneously resolved. ImMucin vaccination induced a robust increase in γ‐interferon (IFN‐γ‐producing CD4+ and CD8+ T‐cells (≤80‐fold), a pronounced population of ImMucin multimer CD8+ T‐cells (>2%), a 9·4‐fold increase in peripheral blood mononuclear cells proliferation and 6·8‐fold increase in anti‐ImMucin antibodies, accompanied with T‐cell and antibody‐dependent cell‐mediated cytotoxicity. A significant decrease in soluble MUC1 levels was observed in 9/10 patients. Stable disease or improvement, persisting for 17·5‐41·3 months (ongoing) was achieved in 11/15 patients and appeared to be associated with low‐intermediate PDL1 (CD274) bone marrow levels pre‐ and post‐vaccination. In summary, ImMucin, a highly tolerable cancerous vaccine, induces robust, diversified T‐ and B‐cell ImMucin‐specific immunity in MM patients, across major histocompatibility complex‐barrier, resulting in at least disease stabilization in most patients.

Single Infusion of Donor Mononuclear Early Apoptotic Cells as Prophylaxis for Graft-versus-Host Disease in Myeloablative HLA-Matched Allogeneic Bone Marrow Transplantation: A Phase I/IIa Clinical Trial

Because of its potent immunomodulatory effect, an infusion of donor mononuclear early apoptotic cells (ApoCell) was tested in addition to cyclosporine and methotrexate as prophylaxis for acute graft-versus-host disease (GVHD) after HLA-matched myeloablative allogeneic hematopoietic stem cell transplantation (HSCT) from a related donor. In a phase I/IIa clinical trial, we treated 13 patients (median age, 37 years; range, 20 to 59 years) with hematologic malignancies: 7 patients with acute lymphoblastic leukemia, 5 patients with acute myeloid leukemia, and 1 patient with chronic myeloid leukemia, who received conventional myeloablative conditioning, with 35, 70, 140, or 210 × 10(6) cell/kg of donor ApoCell, on day -1 of transplantation. Engraftment was successful in all patients with median time to neutrophil recovery of 13 days (range, 11 to 19), and platelet recovery of 15 days (range, 11 to 59). Serious adverse effects were reported on 10 occasions in the trial, all of which were considered unrelated (n = 7) or unlikely to be related (n = 3) to ApoCell infusion. The nonrelapse mortality at day 100 and 180 after transplantation was 7.7% and the overall survival at 100 and 180 days after transplantation was 92% and 85%, respectively. All ApoCell preparations showed an in vitro significant tolerogenic effect upon interaction with dendritic cells. The overall incidence of acute grades II to IV GVHD was 23%, whereas among those receiving the 2 higher doses (n = 6), the rate was 0%. These results suggest that a single infusion of donor ApoCell in HLA-matched allogeneic HSCT is a safe and potentially effective prophylaxis for acute GVHD occurring after myeloablative conditioning. No dose limiting toxicity was observed. (Clinicaltrials.gov no. NCT00524784).

Hematopoietic stem cell transplantation-50 years of evolution and future perspectives.

Hematopoietic stem cell transplantation is a highly specialized and unique medical procedure. Autologous transplantation allows the administration of high-dose chemotherapy without prolonged bone marrow aplasia. In allogeneic transplantation, donor-derived stem cells provide alloimmunity that enables a graft-versus-tumor effect to eradicate residual disease and prevent relapse. The first allogeneic transplantation was performed by E. Donnall Thomas in 1957. Since then the field has evolved and expanded worldwide. New indications beside acute leukemia and aplastic anemia have been constantly explored and now include congenital disorders of the hematopoietic system, metabolic disorders, and autoimmune disease. The use of matched unrelated donors, umbilical cord blood units, and partially matched related donors has dramatically extended the availability of allogeneic transplantation. Transplant-related mortality has decreased due to improved supportive care, including better strategies to prevent severe infections and with the incorporation of reduced-intensity conditioning protocols that lowered the toxicity and allowed for transplantation in older patients. However, disease relapse and graft-versus-host disease remain the two major causes of mortality with unsatisfactory progress. Intense research aiming to improve adoptive immunotherapy and increase graft-versus-leukemia response while decreasing graft-versus-host response might bring the next breakthrough in allogeneic transplantation. Strategies of graft manipulation, tumor-associated antigen vaccinations, monoclonal antibodies, and adoptive cellular immunotherapy have already proved clinically efficient. In the following years, allogeneic transplantation is likely to become more complex, more individualized, and more efficient.

Repeated spontaneous pregnancies and successful deliveries after repeated autologous stem cell transplantation and GnRH-agonist treatment.

Two years ago we published an exceptional case [1] of a young patient who successfully delivered a healthy neonate after spontaneous conception despite two (repeated) stem cell transplantations and aggressive conditioning chemotherapy in parallel with monthly gonadotropin-releasing hormone agonist (GnRH-a) cotreatment (Decapeptyl CR, 3.75 mg; Ferring, Saint-Prex, Switzerland) and irradiation for lymphoma [1]. Against all the odds, this patient conceived again and again delivered a second normal neonate, most probably attributable to the GnRH-a cotreatment during chemotherapy. In brief, this young woman received chemotherapy and, in parallel, monthly depot GnRH-a injections in 1995 when she was 15 years old for stage IV anaplastic lymphoma [1]. Less than 1 year afterward she underwent autologous stem cell transplantation (SCT) with carmustine, etoposide, cytarabine, and cyclophosphamide (the BEAC protocol) for persistent disease [1], again with GnRH-a pre- and cotreatment during chemotherapy [1–3]. Her first spontaneous pregnancy occurred at the age of 24 years, but that pregnancy ended in miscarriage. One month later, she conceived again, and that pregnancy developed normally until 25 weeks of gestation, when recurrence of the lymphoma was diagnosed with subsequent intrauterine growth retardation and demise, after dexamethasone, etoposide, ifosfamide, and cisplatin (DVIP) chemotherapy during pregnancy [1]. After pregnancy termination, she again received a GnRH-a in parallel with DVIP and BEAC conditioning, followed by a second autologous SCT. An attempt at in vitro fertilization was discontinued because of a poor response, but 3 months later she spontaneously conceived, and after a normal gestation she delivered, in August 2006, a normal, term, 3,450 gram, female neonate [1]. About 1 year later she spontaneously conceived, for the fourth time, and on August 9, 2008 she again successfully delivered a normal, 3,450 gram, female neonate, with an Apgar score of 10 at 5 minutes. SCT almost invariably induces ovarian failure, irrespective of patient age or treatment protocol [1, 4–6]. Only 0.6% of patients conceive after one autologous or allogeneic SCT, according to a large survey on fertility after SCT, involving 37,362 women [5]. The estimated odds for spontaneous conception after two SCTs are negligible (0.006 × 0.006 = 0.000036) [1, 3–5]. Carter et al. [6] conducted a retrospective study on reproductive function and pregnancy outcomes in 619 women and partners of men treated with autologous or allogeneic hematopoietic SCT. They found that only 3% of their female survivors succeeded in conceiving after one SCT [6]. Thus, theoretically, according to their findings, the estimated odds for spontaneous conception after two SCTs are 0.03 × 0.03 = 0.0009, which is <1:1,000. Although several reports on spontaneous conceptions and deliveries after SCT have been published [7], we are not aware of any publication of repeated successful deliveries after repeated SCT in the same patient. To the best of our knowledge, this is the first case. The administration of a GnRH-a before and in parallel with chemotherapy simulates a prepubertal hormonal milieu, and through this mechanism, and/or possibly others [1–3], might have minimized the gonadotoxic effect of chemotherapy and increased the chance of spontaneous ovulations and successful conceptions and deliveries [1–3]. Indeed, similarly, Remerand et al. [8] recently reported on four successful pregnancies in a patient who had been treated with allogeneic bone marrow transplantation when she was 4 years old. GnRH-a treatment simulates the prepubertal hormonal milieu, in keeping with our patients recent repeated spontaneous gestation, despite SCT [8]. Because most of the methods involving ovarian or egg cryopreservation are not yet clinically established and unequivocally successful, physicians should inform these young women of the possible beneficial effect of a GnRH-a in minimizing gonadal damage and preservation of ovarian function and fertility, in addition to the options of cryopreservation of embryos and ova [1–3].