[Treatment of acute host-versus-graft reaction in patients after allogeneic hematopoietic cell transplantation with multipotent mesenchymal stromal cells from a bone marrow donor].

AIM: To evaluate the efficiency of administration of multipotent mesenchymal stromal cells obtained from a bone marrow donor for the treatment of an acute host-versus-graft reaction (HVGR) resistant to therapy with glucocorticosteroids (GCS). SUBJECTS AND METHODS: The experience in treating 6 patients with GCS-resistant acute HVGR following allogeneic hematopoietic stem cell transplantation is given. The patients were intravenously injected cultured multipotent mesenchymal stromal cells (MMSC) in a dose of 10(6) per kg body weight. RESULTS: Four weeks after MMSC administration, a complete or partial response was obtained in 3 cases; clinical improvement was noted in 2; one patient showed no response. MMSC therapy proved to be effective in 5 of the 6 cases with acute HVGR resistant to GCS therapy. CONCLUSION: MMSC therapy turned out to be effective in case of acute HVGR resistant to GCS therapy.

[Thromboelastographic characteristics of different infusion therapy regimens in healthy bone marrow donors].

Infusion solutions are able to change the hemostatic system. Thromboelastography (TEG) is an integral technique to evaluate the hemostatic system. TEG was used to evaluate the effect of three infusion solutions (6% hydroxyexyethyl starch (HES) 200/0.5 - Hemohes; HES 130/0.4 - Voluven; modified gelatin solution - Gelofusin) on the hemostatic system in 36 bone marrow donors (healthy individuals). The solutions were used in combination with crystalloid solutions during a procedure to compensate for intraoperative blood loss. Hemostatic changes were noted by the end of an operation in all groups; however, these were less pronounced when Voluven was administered. Thus, all colloid infusion solutions have varying effects on the hemostatic system, with a tendency toward both hypo- and hypercoagulation. According to TEG, HES 130/0.4 (Voluven) has a minimal effect on the hemostatic system.

[Results of the treatment of adult acute lymphoblastic leukemia according to ALL-2005 protocol as a basis for new trials].

AIM: To analyse the results of the treatment according to ALL-2005 protocol for adult patients with acute lymphoblastic leukemia (ALL); on the basis of the summarized evidence on ALL treatment to propose principles for development of a new program of ALL treatment in 15-55-year-old patients. MATERIAL AND METHODS: Five hematological centers (in Moscow, Saransk, Volgograd, Tambov, Kirov) participated in ALL-2005 protocol trial initiated in 2005. A total of 71 adult patients with ALL (age median 27 years) were treated. The results of the MB-2002 study with participation of 16 patients aged 16-23 years performed in the State Hematological Research Center (SHRC) were reviewed RESULTS: The results of the induction therapy according to ALL-2005 protocol conducted in Moscow SHRC were good: a complete remission was achieved in 90% patients, early lethality was 6%, resistance was observed in 4%. In regional centers lethality in remission was higher, 5-year overall survival was 28% (in SHRC it was 56%), recurrence-free survival in regional center was 22% versus 51%, respectively. Long-term response by ALL-2005 and MB-2002 in patients aged 19-23 was the same, but toxicity of ALL-2005 treatment was higher (no lethality and 5, 4% in induction and remission, respectively). CONCLUSION: The decision was made on design of a new protocol of treatment of Ph-negative ALL for patients aged from 15 to 55 years the main principles of which are the following: continuous treatment with modification of cytostatic drugs doses depending on myelosuppression severity; assessment of tumor cells sensitivity to prednisolone and its replacement for dexametasone throughout the treatment; prolongation of L-asparaginase treatment with elevation of its total dose; monitoring of minimal residual disease (MRD) for decision on late intensification in patients with MRD at late treatment stages (5 months).

[Transplantations of allogenic and autologous hemopoietic stem cells in acute leukemia (results of 20-year experience)].

AIM: To analyse results of transplantation of allogenic and autologous hemopoietic stem cells (allo-THSC and auto-THSC) with myeloablation preconditioning in patients with acute leukemia (AL) performed in 1987-2006. MATERIAL AND METHODS: A total of 71 allogenic and 45 autologous THSC were performed in 116 patients with different AL variants. Conditioning in all allo-THSC included busulfan (16 mg/kg) and cyclophosphamide (120 mg/kg). This regimen was used in 29 recipients of auto-HSC. Cyclophosphamide in a dose 120 mg/kg and total radiation of the body in a dose 12 Gy were given to 16 recipients. Overall, relapse-free and event-free survival of patients after THSC were analysed as well as early (first 100 days) and overall lethality. Auto-THSC in 15 patients was for the first time followed by immunomodulating therapy aimed at prevention of AL relapses: in acute myeloid leukemia ATRA in combination with alpha-interferon, in acute lymphoblastic leukemia (ALL)--ronkoleukin, interleukin-2 preparation. RESULTS: Overall survival of AL patients after allo-THSC for the observation period increased from 31 to 58%, early lethality fell from 44 to 4%. Results of allo-THSC conducted in the first complete remission were much better than in patients with other AL stages at the time of THSC. After auto-THSC 5-year survival rose from 22 to 60% while early lethality reduced from 33 to 4%. Administration of immunomodulating therapy after auto-THSC increases 5-year survival from 35 to 80%. CONCLUSION: Outcomes of THSC in AL has improved for the last 20 years. Outcomes of allo-THSC performed in the first complete remission are much higher. Immunomodulating therapy after auto-THSC promoted better results.

[Acute lymphoblastic leukemias with aberrations of BCR-ABL genes].

AIM: To develop an original therapeutic strategy in Ph-positive acute lymphoblastic leukemia (ALL). MATERIAL AND METHODS: In November 2001 Hematological Research Center (HRC) initiated the study of chimeric BCR-ABL gene. During the first stage of the study (November 2001-July 2004), 18 primary ALL patients were recruited in HRC, from July 2004 to January 2005--16 patients in HRC, N.N. Burdenko Central Military Hospital, regional Samara hospital. The diagnosis of Ph-positive ALL was established in detection of translocation t(9;22) by standard cytogenetic test or fluorescent hibridization in situ with double signal (D-FISH), or by polymerase chain reaction with reverse transcription (RT-PCR). In detection of aberration of BCR-ABL gene the patients received stem hemopoietic cells, from June 2004 imatinib was added to chemotherapy in the period of induction and consolidation. RESULTS: Incidence rate of BCR-ABL-positive ALL by standard cytogenetic test and D-FISH makes up 20%, by RT-PCR--25%. Differences in chimeric transcripts detectability by different methods may be explained by different sensitivity of the methods. Complete hematological remissions were achieved in the majority of the patients (6 of 8) irrespective of imatinib administration. Achievement of molecular remission in BCR-ABL-positive ALL occurs also in standard chemotherapy but molecular remissions begin 2-4 months later than clinicohematological ones. CONCLUSION: In using imatinib combination with chemotherapy, molecular remission can be achieved simultaneously with hematological one. Long-term results will be analysed later.

[Infectious complications after transplantation of autologous hemopoietic blood cells in patients with hematological malignancies].

AIM: To characterize infectious complications arising within 30 days after transplantation of autologous hemopoietic blood cells in 42 patients with hematological malignancy (HM); to compare the course of early posttransplantation period with reference to a kind of high-dose conditioning and dose of transplanted CD34+ cells. MATERIAL AND METHODS: Autotransplantation (AT) was conducted as consolidation of a complete or partial remission in 20 patients with multiple myeloma, 14 patients with lymphogranulomatosis and lymphosarcoma, 7 patients with acute leukemia and 1 patient with rabdomyosarcoma. The program of pretransplantation conditioning corresponded to the disease form and included: melphalan, BEAM, busulphane-cyclophosphamide. The number of transplanted CD34+ cells was 1.7-20.1 (median 5.3) x l0(6) cell/kg. The transplantation was followed by selective intestinal decontamination and mycosis prophylaxis. Fever was managed with antibiotics. RESULTS: An early period after AT ran without febrile episodes in 7 (17%) patients. This allowed physicians to avoid systemic antibiotic therapy. The infectious focus was not definitely localized in 35 patients with febrile fever in 77% cases. Clinically and bacteriologically verified infections were detected in 8 (19%) patients: 7 cases of pneumonia and 1 of bacteriemia. None of the patients died of infection early after AT. Not a single case of invasive aspergillesis was registered. CONCLUSION: Incidence and features of infections did not vary with the above diseases and did not depend on the dose of transplanted CD34+ cells. The kind of high-dose conditioning had a significant influence on the time of granulocyte recovery, duration of agranulocytosis, duration of one febrile episode and of antibiotic therapy. The dose of transplanted CD34+ cells also influenced the time of granulocyte recovery and duration of antibiotic therapy.

[Invasive pulmonary aspergillesis].

AIM: To evaluate the results of therapy of invasive pulmonary aspergillesis (IPA) in one medical center from 2000 to 2005. MATERIAL AND METHODS: Diagnosis of IPA was made according to the International criteria. Incidence of verified IPA was 2%, probable--84%, possible--14%. RESULTS: IPA was diagnosed in 50 cases in 49 patients aged 16- 78 years, median 35. Most of the patients consisted of acute leukemia cases (54%). Intensive cytostatic therapy was given in 41% cases. In 54% IPA developed in critical neutropenia, median of duration of which being 29 days (3 to 144 days). 29 patients received glucocorticoid drugs. In diagnosis of IPA Aspergillus spp was isolated in 46% cases (A. fumigatus-59%, A. flavus-29%, A. niger-4%, A-versicolor-4%, in 1 (4%) case identification was not made. Positive antigen Aspergillus was detected in 27 cases. All the patients had pulmonary involvement detected at x-ray or computed tomography. Coincidence of pulmonary lesions seen at x-rays and computer tomograms was only in 30% patients. Cure was achieved in 44%, lethality was 56%. Overall survival in IPA for 90 days was 47%. Amphotericine was effective in 29%. Voriconasol--in 3 of 5 patients, kaspofungin--in 3 of 7. Surgical treatment was given to 4 patients. CONCLUSION: Lethality in IPA for 5 years when basic therapy was amfotericin B reached 56%. Reduction of lethality can be achieved due to early diagnosis of the infection and administration of voriconasol at the initial stage of IPA. It is necessary to conduct multicenter studies to ascertain indications for combined antifungal therapy.

[Allogenic bone marrow transplantation in chronic myeloid leukemias]. / Transplantatsiia allogennogo kostnogo mozga pri khronicheskom mieloleikoze.

AIM: To assess the role of allogenic bone marrow (ABM) transplantation in chronic myeloid leukemia (CML). MATERIAL AND METHODS: 44 ABM transplantations were performed in 37 CML patients in the chronic phase and 7 patients in acceleration or blast crisis. RESULTS: A complete molecular remission was achieved in 26 (59%) patients: 67.6% after ABM transplantation in the chronic phase and only 14.3% after myelotransplantation in non-chronic phase. Follow-up was 8-150 months (median--59 months). Early lethality after ABM transplantation in the chronic phase was under 14%. A phase of the disease plays a key role in ABM transplantation. If it is made in a chronic phase, CML recurrence rate is low (in our series it was 14%), efficacy of donor's bone marrow lymphocyte transfusions is high. The second complete molecular remission was achieved in 3 of 4 cases of posttransplantation recurrences. Probability of maintenance of a complete remission after ABM transplantation in a chronic phase was 75%, recurrence-free survival--64%, uneventful survival 55% for 90 months. CONCLUSION: The experience of many years demonstrates high efficacy of ABM transplantation in the treatment of chronic myeloid leukemia. It promotes long-term molecular remission the maintenance of which did not require therapy in 65% patients.

[Is leukemic transformation of donor cells possible?]. / Vozmozhna li leikemicheskaia transformatsiia donorskikh kletok?

AIM: To genotype tumor cells in the recurrence of leukemia after allogenic transplantation of bone marrow (TBM). MATERIAL AND METHODS: Standard cytogenetics and fluorescent hybridization in situ (FISH) with a probe to the centrometic sites of X/Y chromosomes were used in examination of 2 patients with acute promyelocytic and acute non-differentiated leukemia after allogenic TBM from donors of the opposite gender. Bone marrow was studied 1, 2, 3, 6, 9, 12, 15, 17, 18 months after the transplantation. RESULTS: One of the patient in leukemia recurrence there were 72% cells with one X chromosome with unknown origin. 28% donor cells were with genotype XX. The primary archival cytological sample of the recipient's bone marrow 68% cells did not contain Y chromosome. Thus, the clone with Y loss is the recipient's clone and leukemia after transplantation developed from the recipient's cells. The other patient had only 8% dividing cells with her karyotype XX with translocation t(10;11) while 92% metaphases were donor's ones; the interphase cells ratio was 75% of host cells and 25% donor cells. This confirms leukemia origin from the recipient's cells. CONCLUSION: High sensitive quantitative method FISH indicates a true correlation between the host and donor cells and is a method of choice for genotyping leukemic cells in recurrence after transplantation of bone marrow. While standard caryotyping depends on mytotic activity of donor and host cell populations, use of only one cytogenetic test for determination of leukemia origin after TBM may provoke diagnostic errors.

[Lung biopsy in the diagnosis of causes of lung involvement in hemoblastosis]. / Biopsiia legkogo v diagnostike prichin porazheniia legkikh u bol'nykh gemoblastozami.

AIM: To ascertain the role of lung biopsy in diagnosis of lung lesions in hemoblastosis (HB) patients. MATERIAL AND METHODS: The results of diagnostic biopsies of the lungs obtained from 22 HB patients are presented. Ten patients had no respiratory insufficiency (RI), twelve patients had RI. The biopsy was transbronchial in 1 case, thoracoscopic in 10 and open in 11 cases. RESULTS: In RI-free patients lung biopsy was informative in all the cases. The biopsy provided information which allowed therapy modification resulting in improvement of the patient condition. In RI patients biopsy was informative in 8 of 12 patients. Nonspecific changes in the lungs were identified histologically in 2 of 12 patients. In 2 RI patients lung biopsy confirmed the diagnosis made after examination of the bronchoalveolar lavage. Modification of therapy after the biopsy was conducted in 58.3% HB patients with RI. Improvement was seen in 2 of them. 10 of 12 patients with RI died within 1-2 weeks after biopsy. CONCLUSION: Lung biopsy in HB patients should be obtained only after examination with noninvasive methods and before development of RI as prognosis after lung biopsy in the presence of RI is unfavourable. The histological material should be examined for all expected pathogens.

[Cytomegaloviral infection in patients with hemoblastoses]. / Tsitomegalovirusnaia infektsiia u bol'nykh gemoblastozami.

AIM: To estimate the incidence of cytomegaloviral (CMV) infection and CMV disease in patients with acute leukemia at different stages of chemotherapy and in patients after transplantation of hemopoietic cells. MATERIAL AND METHODS: The trial was carried out in 33 patients with acute leukemia at different stages of chemotherapy, 20 patients subjected to transplantation of autologic hemopoietic cells and 21 patients who had received transplantation of allogenic hemopoietic cells. To study the dynamics of the CMV infection markers, enzyme immunoassay of the titer of the specific immunoglobulins M and G was made, detection of the viral antigen in immunofluorescence reaction and cultivation with fibroblast cell culture and determination of the cytomegalovirus DNA by polymerase chain reaction (PCR). RESULTS: Before chemotherapy, up to 90% patients with acute leukemia were infected with cytomegalovirus (similar rate of infection was observed in healthy donors of hemopoietic cells). By the time of transplantation all the patients were infected with cytomegalovirus. During chemotherapy of acute leukemia, the primary infection and reactivation of latent infection occurred in 30% patients, whereas CMV disease developed in 18% patients. In case of transplantation of autologic hemopoietic cells the rate of reactivation of CMV infection (15%) was one-half of that value in patients with acute leukemia (30%). Similar trend was observed in case of development of CMV disease (5% and 18%, respectively). In case of transplantation of allogenic hemopoietic cells the incidence of reactivation of CMV infection was three times higher than in case of transplantation of autologic hemopoietic cells (47.6% and 15%, respectively, p = 0.02). The incidence of development of CMV disease in case of transplantation of allogenic hemopoietic cells was also significantly higher than in case of transplantation of autologic hemopoietic cells (28.6% and 5%, respectively, p = 0.05). CONCLUSION: Cytomegalovirus is an infection agent responsible for severe complications of chemotherapy of acute leukemia and transplantation of hemopoietic cells in patients with hemoblastoses. Among hematological patients, the group of the highest risk of development of this complication includes recipients of transplantation of allogenic hemopoietic cells, particularly from seronegative donors.

[Molecular cytogenetic monitoring of chimerism and minimal residual disease in patient with chronic myeloid leukemia after allogenic and syngenic bone marrow transplantation]. / Molekuliarno-tsitogeneticheskii monitoring khimerizma i minimal'noi ostatochnoi bolezni u bol'nykh khronicheskim mieloleikozom posle allogennoi i singennoi transplantatsii kostnogo mozga.

AIM: To study trends in restoration of normal and tumor hemopoiesis after transplantation of allogenic and syngenic hemopoietic cells. MATERIAL AND METHODS: The examination of bone marrow before transplantation and 1, 2, 3, 6, 9 months, 1, 2 and 3 years after bone marrow transplantation (BMT) was made in 25 patients with chronic myeloid leukemia (CML) after allogenic transplantation of the bone marrow (TBM) and 4 patients after syngenic TBM. The method of G-differential staining of chromosomes and fluorescent hybridization in situ (FISH) with DNA probe to centromeric sites X/Y of chromosomes and genes BCR/ABL was used. RESULTS: 56% of CML patients after allogenic BMT were in cytogenetic and clinicohematological remission, 16% developed early cytogenetic recurrence. Single metaphase with t(9;22) were identified in 28%; 14.3% developed late cytogenetic and hematological recurrence. In patients in posttransplantation remission there were from 0.1 to 5.8% cells of the host. The number of cells of the host and the number of BCR/ABL-positive cells correlated significantly. CONCLUSION: The results of 8-year monitoring of chimerism and minimal residual disease validate application of molecular-cytogenetic methods for assessing transplant condition.

[Study of the time course of mixed chimerism by fluorescent in situ hybridization in patients with chronic myeloid leukemia after allogenic transplantation of bone marrow]. / Izuchenie dinamiki smeshannogo khimerizma metodom fliuorestsentnoi gibridizatsii in situ u bol'nykh khronicheskim mieloleikozom posle allogennoi transplantatsii kostnogo mozga.

AIM: To determine the type of chimerism in patients with chronic myeloid leukemia (CML) in various periods after allogenic transplantation of bone marrow (TBM) and its association with subsequent relapse. MATERIALS AND METHODS: Ten patients were examined after allogenic TBM, which was performed during the chronic phase of CML in 9 patients and during acceleration phase in 1. Two patients received therapy with donor lymphocytes during relapse after transplantation. Time course of chimerism and minimum residual illness was studied by standard cytogenetic methods, fluorescent in situ hybridization (FISH) with DNA probes to centromer sites of X and Y chromosomes and BCR and ABL genes. The studies were carried out 30, 60, 90, 180 days, 9 months, 1 year, and then every 6 months after transplantation. RESULTS: Mixed chimerism was observed in all patients during 9 months after TBM. The count of host cells was 0.1-5.8% in 8 patients; later the count of autologous cells was less than 1% in 5 patients, and in 3 patients complete donor chimerism was observed. Clinical hematological remission was stable in these patients. Relapses of leukemia with 40 and 83.1% host cells occurred in 2 patients 13 and 23 months after transplantation, respectively. Donor lymphocytes were transfused in order to induce the graft versus host effect, and in patient No. 2 restoration of donor hemopoiesis was attained. CONCLUSION: Highly sensitive FISH method with DNA probe to centromer sites of X and Y chromosomes detects early relapse of the disease and demonstrates the time course of donor hemopoiesis recovery after transfusion of donor lymphocytes. The data indicate that 9 months after transplantation molecular cytogenetic studies should be carried out more often (once a month), particularly in patients with poor prognosis, for earlier detection of the relapse and beginning of immunotherapy.

[The efficacy of high-dose chemotherapy and the transplantation of autologous hemopoietic cells in lymphogranulomatosis]. / Effektivnost' vysokodoznoi khimioterapii i transplantatsii autologichnykh gemopoéticheskikh kletok pri limfogranulematoze.

AIM: To determine clinical effectiveness of high-dose polychemotherapy (PCT) and transplantation of autologous hemopoietic cells (TAHC) in patients with lymphogranulomatosis (LGM). MATERIAL AND METHODS: 27 LGM patients aged 16-42 years who have undergone TAHC after high-dose PCT (BEAM--17 patients or CBV--10 patients). 4 patients given high-dose PCT were in the first-second complete remission (CR), 7 patients--in the first partial remission (PR). Prior to TAHC, 8 patients had one, two and more relapses of LGM, and 8 patients had no remission at all. Bone marrow, hemopoietic blood cells and both were transplanted to 17, 2 and 8 patients, respectively. Mobilization of hemopoietic blood cells and stimulation of hemopoiesis after TAHC were achieved using colony-stimulating factors. RESULTS: The treatment resulted in CR or PR (from 6 to 95 months) in 70.4% of patients. The remission duration varied depending on the disease phase at transplantation. Four patients who underwent TAHC in PR maintained it for 13-95 months (median 47.5 months). Lasting remissions (29-59 months) were achieved in 42.9 and 37.5% of patients who underwent TAHC in the first PR or in recurrent LGM. None of the patients was in remission longer than 2 years after TAHC if high-dose PCT was conducted in advanced tumor process due to resistant LGM or inadequate previous treatment. Infectious complications lethality early after the transplantation reached 7.4%(2 patients). CONCLUSION: High-dose PCT followed by TAHC is effective in LGM if the tumor is chemosensitive.

[The effect of polychemotherapy on the oral mucosa in patients with acute myeloblastic leukemia]. / Vliianie polikhimioterapii na slizistuiu obolochku polosti rta bol'nykh ostrymi mieloblastnymi leikozami.

Oral mucosa was examined in 23 patients with acute myeloblastic leukemia before and after cytostatic polychemotherapy. Lesions of the oral mucosa were observed in all patients after polychemotherapy: its color was changed, atrophic processes developed in it, and salivary secretion was impaired. Destructive ulcerative changes were revealed in 35% cases; terms of their appearance, regression, and epithelialization were established and a clear-cut correlation between their development and severity of leukocytopenia was detected. Ranging of stomatitis severity is proposed, according to which medium-severe stomatitis predominates in this patient population. The study will help develop more effective approaches to prevention and treatment of oral complications and improve the results of therapy of this most grave category of hematological patients.

[Significance and features of MLC reaction in histocompatibility determination of donor and recipient in allogenic bone marrow transplantation to patients with hematological malignancies]. / Znachenie i osobennosti reaktsii smeshannoi kul'tury limfotsitov v opredelenii gistosovmestimosti donora i retsipienta pri transplantatsii allogennogo kostnogo mozga u bol'nykh gemoblastozami.

AIM: To characterize mixed lymphocyte culture (MLC) reaction used for determination of donor-recipient compatibility before bone marrow transplantation to patients with hematological malignancies and to assess the reaction significance. MATERIAL AND METHODS: The analysis was made of compatibility testing in MLC standard reaction performed in 134 patients with hematological malignancies with HLA-A, -B identical donors-sibs and in 5 patients with haploid identical donors. RESULTS: Out of 134 patients, 22(91%) appeared compatible to donor sibs in MLC reaction, 12(9%) patients were incompatible. Mean RR for MLC-compatible couples made up: in RvD direction 77 +/- 0.17%, DvR 2.61 +/- 0.32%. 93% of RR values ranged from +15 to -15%, the rest--from +25% to -25%. Bone marrow transplantation was made in 83 patients. Graft retention was observed in 77(93%) patients. Acute and chronic graft versus host reaction developed in 15 and 17 patients, respectively. CONCLUSION: An optimal protocol is proposed for examination of compatibility donor-recipient in MLC reaction in patients with hematological malignancies. It is intended for allogenic bone marrow transplantation in hematological departments.