RESUMO
Fanconi anaemia (FA) is a genetic disorder due to mutations in any of the 22 FANC genes (FANCA-FANCW) and has high phenotypic variation. Siblings may have similar clinical outcome because they share the same variants; however, such association has not been reported. We present the detailed phenotype and clinical course of 25 sibling sets with FA from two institutions. Haematological progression significantly correlated between siblings, which was confirmed in an additional 55 sibling pairs from the International Fanconi Anemia Registry. Constitutional abnormalities were not concordant, except for a moderate degree of concordance in kidney abnormalities and microcephaly.
Assuntos
Anemia de Fanconi , Rim , Microcefalia , Sistema de Registros , Irmãos , Anemia de Fanconi/sangue , Anemia de Fanconi/genética , Anemia de Fanconi/imunologia , Feminino , Humanos , Rim/anormalidades , Rim/imunologia , Rim/metabolismo , Masculino , Microcefalia/genética , Microcefalia/imunologia , Microcefalia/metabolismo , Estudos RetrospectivosRESUMO
FA is the most common cause of inherited BMF syndromes. The only cure for BMF in FA remains HSCT. Due to DNA instability in FA, RIC has been used to decrease immediate and late complications of HSCT. Most FA conditioning regimens in mismatched and unrelated donor transplants rely on TBI, which increases the risk of secondary malignancies. Most of the non-TBI conditioning regimens use an ex vivo T-cell depletion approach, but this is not feasible at all pediatric stem cell transplant programs. To evaluate the success of HSCT in patients with FA using non-TBI conditioning regimens with in vivo T-cell depletion approach. HSCT using non-TBI based conditioning was performed on two siblings with FA. The first sibling underwent matched unrelated donor transplant with a BM graft using fludarabine, alemtuzumab, busulfan, and cyclophosphamide conditioning and cyclosporine and mycophenolate as GVHD prophylaxis. The second sibling underwent MSD transplant with UCB and BM grafts using similar approach, but without busulfan and mycophenolate. Both siblings had engraftment without signs of acute or chronic GVHD. Acute post-transplant complications included brief viral reactivations. At last follow-up, both siblings continued to have full immune reconstitution with stable chimerism. Conditioning regimens without radiation and inclusion of alemtuzumab can lead to successful engraftment without development of GVHD and reduce risk of developing secondary neoplasms, even with unrelated donor transplants.
Assuntos
Transplante de Medula Óssea , Anemia de Fanconi/terapia , Depleção Linfocítica/métodos , Agonistas Mieloablativos/uso terapêutico , Condicionamento Pré-Transplante/métodos , Vidarabina/análogos & derivados , Criança , Quimioterapia Combinada , Anemia de Fanconi/imunologia , Humanos , Irmãos , Linfócitos T/imunologia , Vidarabina/uso terapêuticoRESUMO
Fanconi anemia (FA) is an inherited bone marrow failure syndrome characterized by chromosomal fragility, progressive marrow failure, and cancer predisposition. Hematopoietic cell transplantation (HCT) is curative for FA-related marrow failure or leukemia, but both radiation exposure during transplant and graft-versus-host disease (GVHD) may increase risk of later malignancies of the head and neck and anogenital area. In this study, we tested a radiation-free conditioning regimen with a T-cell-depleted graft to eliminate radiation exposure and minimize early and late toxicities of transplant. Forty-five patients (median age, 8.2 years; range 4.3-44) with FA underwent HCT between June 2009 and May 2014. The preparative regimen included busulfan, cyclophosphamide, fludarabine, and rabbit anti-thymocyte globulin. Busulfan levels were monitored to avoid excess toxicity. All grafts were CD34-selected/T-cell-depleted using the CliniMacs CD34 columns (Miltenyi). Thirty-four patients (75.6%) with marrow failure and 11 (24.4%) with myelodysplastic syndrome underwent HCT using matched unrelated (n = 25, 55.5%), mismatched unrelated (n = 14, 31.1%), or mismatched related donors (n = 6, 13.4%). One year probabilities of overall and disease-free survival for the entire cohort, including patients with myeloid malignancy and those receiving mismatched related/haploidentical grafts, were 80% (±6%) and 77.7% (±6.2%), respectively (median follow-up 41 months). All young children (<10 years of age) undergoing HCT for marrow failure using low-dose busulfan-containing regimen survived. No patients developed acute grade 3-4 GVHD. Sequential reduction of busulfan dose was successfully achieved per study design. Our results show excellent outcomes in patients with FA undergoing alternative donor HCT without radiation exposure. The study is registered to www.clinicaltrials.gov as #NCT01082133.
Assuntos
Anemia de Fanconi/terapia , Transplante de Células-Tronco Hematopoéticas , Agonistas Mieloablativos/uso terapêutico , Síndromes Mielodisplásicas/terapia , Condicionamento Pré-Transplante/métodos , Adolescente , Adulto , Soro Antilinfocitário/uso terapêutico , Medula Óssea/efeitos dos fármacos , Medula Óssea/imunologia , Medula Óssea/patologia , Bussulfano/uso terapêutico , Criança , Pré-Escolar , Ciclofosfamida/uso terapêutico , Anemia de Fanconi/imunologia , Anemia de Fanconi/patologia , Feminino , Doença Enxerto-Hospedeiro/imunologia , Doença Enxerto-Hospedeiro/patologia , Humanos , Depleção Linfocítica , Masculino , Síndromes Mielodisplásicas/imunologia , Síndromes Mielodisplásicas/patologia , Estudos Prospectivos , Irmãos , Análise de Sobrevida , Linfócitos T/imunologia , Linfócitos T/patologia , Transplante Homólogo , Resultado do Tratamento , Doadores não Relacionados , Vidarabina/análogos & derivados , Vidarabina/uso terapêuticoRESUMO
Patients with inherited bone marrow failure syndromes (IBMFS), such as Fanconi anemia (FA), dyskeratosis congenita (DC), or Diamond Blackfan anemia (DBA), can have hematologic manifestations cured through hematopoietic cell transplantation (HCT). Subsequent late effects seen in these patients arise from a combination of the underlying disease, the pre-HCT therapy, and the HCT process. During the international consensus conference sponsored by the Pediatric Blood and Marrow Transplant Consortium on late effects screening and recommendations following allogeneic hematopoietic cell transplantation for immune deficiency and nonmalignant hematologic diseases held in Minneapolis, Minnesota in May 2016, a half-day session was focused specifically on the unmet needs for these patients with IBMFS. This multidisciplinary group of experts in rare diseases and transplantation late effects has already published on the state of the science in this area, along with discussion of an agenda for future research. This companion article outlines consensus disease-specific long-term follow-up screening guidelines for patients with IMBFS.
Assuntos
Anemia Aplástica/diagnóstico , Anemia de Diamond-Blackfan/diagnóstico , Doenças da Medula Óssea/diagnóstico , Disceratose Congênita/diagnóstico , Anemia de Fanconi/diagnóstico , Transplante de Células-Tronco Hematopoéticas , Hemoglobinúria Paroxística/diagnóstico , Anemia Aplástica/imunologia , Anemia Aplástica/patologia , Anemia Aplástica/terapia , Anemia de Diamond-Blackfan/imunologia , Anemia de Diamond-Blackfan/mortalidade , Anemia de Diamond-Blackfan/terapia , Doenças da Medula Óssea/imunologia , Doenças da Medula Óssea/patologia , Doenças da Medula Óssea/terapia , Transtornos da Insuficiência da Medula Óssea , Criança , Consenso , Conferências de Consenso como Assunto , Disceratose Congênita/imunologia , Disceratose Congênita/mortalidade , Disceratose Congênita/terapia , Anemia de Fanconi/imunologia , Anemia de Fanconi/mortalidade , Anemia de Fanconi/terapia , Hemoglobinúria Paroxística/imunologia , Hemoglobinúria Paroxística/patologia , Hemoglobinúria Paroxística/terapia , Humanos , Cooperação Internacional , Análise de Sobrevida , Transplante HomólogoRESUMO
Common variable immunodeficiency (CVID) is the most common adult-onset primary antibody deficiency disease due to various causative genes. Several genes, which are known to be the cause of different diseases, have recently been reported as the cause of CVID in patients by performing whole exome sequencing (WES) analysis. Here, we found FANC gene mutations as a cause of adult-onset CVID in two patients. B cells were absent and CD4+ T cells were skewed toward CD45RO+ memory T cells. T-cell receptor excision circles (TRECs) and signal joint kappa-deleting recombination excision circles (sjKRECs) were undetectable in both patients. Both patients had no anemia, neutropenia, or thrombocytopenia. Using WES, we identified compound heterozygous mutations of FANCE in one patient and homozygous mutation of FANCA in another patient. The impaired function of FANC protein complex was confirmed by a monoubiquitination assay and by chromosome fragility test. We then performed several immunological evaluations including quantitative lymphocyte analysis and TRECs/sjKRECs analysis for 32 individuals with Fanconi anemia (FA). In total, 22 FA patients (68.8%) were found to have immunological abnormalities, suggesting that such immunological findings may be common in FA patients. These data indicate that FANC mutations are involved in impaired lymphogenesis probably by the accumulation of DNA replication stress, leading to CVID. It is important to diagnose FA because it drastically changes clinical management. We propose that FANC mutations can cause isolated immunodeficiency in addition to bone marrow failure and malignancy.
Assuntos
Imunodeficiência de Variável Comum/genética , Imunodeficiência de Variável Comum/imunologia , Proteínas de Grupos de Complementação da Anemia de Fanconi/genética , Estudos de Associação Genética , Predisposição Genética para Doença , Mutação , Adolescente , Adulto , Biomarcadores , Criança , Pré-Escolar , Imunodeficiência de Variável Comum/diagnóstico , Imunodeficiência de Variável Comum/terapia , Análise Mutacional de DNA , Diagnóstico Diferencial , Anemia de Fanconi/diagnóstico , Anemia de Fanconi/genética , Anemia de Fanconi/imunologia , Proteína do Grupo de Complementação D2 da Anemia de Fanconi/genética , Proteína do Grupo de Complementação D2 da Anemia de Fanconi/metabolismo , Feminino , Citometria de Fluxo , Humanos , Lactente , Masculino , Receptores de Antígenos de Linfócitos T/genética , Linfócitos T/imunologia , Linfócitos T/metabolismo , Sequenciamento do Exoma , Adulto JovemRESUMO
BACKGROUND: Fanconi anemia (FA) is a rare genetic disorder characterized by genome instability, bone marrow failure, and cancer predisposition. Previously, small studies have reported heterogeneous immune dysfunction in FA. PROCEDURE: We performed a detailed immunologic assessment in a large FA cohort who have not undergone bone marrow transplantation or developed malignancies. Comprehensive quantitative and functional immunologic assessment of 29 FA individuals was compared to healthy age-matched controls. RESULTS: Compared to non-FA persons of similar ages, FA individuals showed lower absolute total B cells (P < 0.001), lower memory B cells (P < 0.001), and decreased IgM (P < 0.001) but normal IgG. NK cells (P < 0.001) and NK cytotoxicity (P < 0.001) were decreased. CD4+ T cells were decreased (P = 0.022), while CD8+ T cell and absolute T-cell numbers were comparable. Cytotoxic T cells (P < 0.003), and antigen proliferation response to tetanus (P = 0.019) and candida (P = 0.019), were diminished in FA. Phytohemagglutinin responses and plasma cytokines were normal. Within FA subjects, adults and older children (≥10 years) exhibited higher CD8+ T cells than younger children (P = 0.004). Documented atypical infections were infrequent, although oral human papilloma virus (HPV) prevalence was higher (31% positive) in FA. CONCLUSIONS: Overall, these results demonstrate a high rate of significant humoral and cellular immune dysfunction. Continued longitudinal study of immune function is critical to understand evolution with age, bone marrow failure, and cancer development.
Assuntos
Subpopulações de Linfócitos B/imunologia , Anemia de Fanconi/complicações , Síndromes de Imunodeficiência/etiologia , Células Matadoras Naturais/imunologia , Subpopulações de Linfócitos T/imunologia , Imunidade Adaptativa , Adolescente , Adulto , Criança , Pré-Escolar , Citocinas/metabolismo , Anemia de Fanconi/imunologia , Feminino , Seguimentos , Humanos , Síndromes de Imunodeficiência/patologia , Masculino , Prognóstico , Adulto JovemRESUMO
Fanconi anemia (FA) is a genetic disorder associated with bone marrow (BM) failure and leukemia. Recent studies demonstrate variable immune defects in FA. However, the cause for FA immunodeficiency is unknown. Here we report that deletion of Fanca or Fancd2 dysregulates the suppressive activity of regulatory T cells (Tregs), shown functionally as exacerbation of graft-vs-host disease (GVHD) in mice. Recipient mice of Fanca(-/-) or Fancd2(-/-) BM chimeras exhibited severe acute GVHD after allogeneic BM transplantation (BMT). T cells from Fanca(-/-) or Fancd2(-/-) mice induced higher GVHD lethality than those from wild-type (WT) littermates. FA Tregs possessed lower proliferative suppression potential compared with WT Tregs, as demonstrated by in vitro proliferation assay and BMT. Analysis of CD25(+)Foxp3(+) Tregs indicated that loss of Fanca or Fancd2 dysregulated Foxp3 target gene expression. Additionally, CD25(+)Foxp3(+) Tregs of Fanca(-/-) or Fancd2(-/-) mice were less efficient in suppressing the production of GVHD-associated inflammatory cytokines. Consistently, aberrant NF-κB activity was observed in infiltrated T cells from FA GVHD mice. Conditional deletion of p65 in FA Tregs decreased GVHD mortality. Our study uncovers an essential role for FA proteins in maintaining Treg homeostasis, possibly explaining, at least in part, the immune deficiency reported in some FA patients.
Assuntos
Proteína do Grupo de Complementação A da Anemia de Fanconi/deficiência , Proteína do Grupo de Complementação A da Anemia de Fanconi/imunologia , Proteína do Grupo de Complementação D2 da Anemia de Fanconi/deficiência , Proteína do Grupo de Complementação D2 da Anemia de Fanconi/imunologia , Linfócitos T Reguladores/imunologia , Animais , Transplante de Medula Óssea , Citocinas/biossíntese , Anemia de Fanconi/genética , Anemia de Fanconi/imunologia , Anemia de Fanconi/metabolismo , Proteína do Grupo de Complementação A da Anemia de Fanconi/genética , Proteína do Grupo de Complementação D2 da Anemia de Fanconi/genética , Fatores de Transcrição Forkhead/metabolismo , Expressão Gênica , Doença Enxerto-Hospedeiro/imunologia , Doença Enxerto-Hospedeiro/patologia , Humanos , Tolerância Imunológica , Camundongos , Camundongos Endogâmicos BALB C , Camundongos Endogâmicos C57BL , Camundongos Knockout , Linfócitos T Reguladores/metabolismo , Quimeras de TransplanteRESUMO
Fanconi anemia (FA) is a genetic disorder characterized by bone marrow failure and cancer predisposition. Several studies show alterations of the immunological status of FA patients including defects in peripheral blood lymphocyte subsets, serum immunoglobulin levels, and inflammatory cytokines. However scanty information is available on the response of FA cells to specific infectious antigens. In this work we examined the response of FA cells to different immunological stimuli and found a defective response of IL-1ß, TNF-α and IL-17 to Candida albicans stimulation thus pointing to a potentially impaired response to fungal infections of FA patients.
Assuntos
Candida albicans/imunologia , Anemia de Fanconi/imunologia , Anemia de Fanconi/microbiologia , Imunidade , Adolescente , Linfócitos T CD8-Positivos/imunologia , Proliferação de Células , Células Cultivadas , Criança , Pré-Escolar , Citocinas/biossíntese , Anemia de Fanconi/patologia , Humanos , Lactente , Adulto JovemRESUMO
Immune function abnormalities have been reported in patients with Fanconi anemia (FA), dyskeratosis congenita (DC) and, rarely, in Shwachman-Diamond syndrome (SDS), and Diamond-Blackfan anemia (DBA), but large systematic studies are lacking. We assessed immunological parameters in 118 patients with these syndromes and 202 unaffected relatives. We compared the results in patients with reference values, and with values in relatives after adjusting for age, sex, corticosteroid treatment, and severe bone marrow failure (BMF). Adult patients (≥18 years) with FA had significantly lower immunoglobulins (IgG, IgA and IgM), total lymphocytes, and CD4 T cells than reference values or adult relatives (P < 0.001); children with FA had normal values. Both children and adults with FA had lower B- and NK cells (P < 0.01) than relatives or reference values. Patients with DC had essentially normal immunoglobulins but lower total lymphocytes than reference values or relatives, and lower T-, B-, and NK-cells; these changes were more marked in children than adults (P < 0.01). Most patients with DBA and SDS had normal immunoglobulins and lymphocytes. Lymphoproliferative responses, serum cytokine levels, including tumor necrosis factor-α and interferon-γ, and cytokine levels in supernatants from phytohemagglutinin-stimulated cultures were similar across patient groups and relatives. Only patients with severe BMF, particularly those with FA and DC, had higher serum G-CSF and Flt3-ligand and lower RANTES levels compared with all other groups or relatives (P < 0.05). Overall, immune function abnormalities were seen mainly in adult patients with FA, which likely reflects their disease-related progression, and in children with DC, which may be a feature of early-onset severe disease phenotype.
Assuntos
Anemia de Diamond-Blackfan/diagnóstico , Doenças da Medula Óssea/diagnóstico , Disceratose Congênita/diagnóstico , Insuficiência Pancreática Exócrina/diagnóstico , Anemia de Fanconi/diagnóstico , Hemoglobinúria Paroxística/diagnóstico , Lipomatose/diagnóstico , Adolescente , Corticosteroides/uso terapêutico , Adulto , Idoso , Anemia Aplástica , Anemia de Diamond-Blackfan/tratamento farmacológico , Anemia de Diamond-Blackfan/imunologia , Anemia de Diamond-Blackfan/patologia , Linfócitos B/efeitos dos fármacos , Linfócitos B/imunologia , Linfócitos B/patologia , Doenças da Medula Óssea/congênito , Doenças da Medula Óssea/tratamento farmacológico , Doenças da Medula Óssea/imunologia , Transtornos da Insuficiência da Medula Óssea , Estudos de Casos e Controles , Criança , Pré-Escolar , Citocinas/biossíntese , Citocinas/imunologia , Disceratose Congênita/tratamento farmacológico , Disceratose Congênita/imunologia , Disceratose Congênita/patologia , Insuficiência Pancreática Exócrina/congênito , Insuficiência Pancreática Exócrina/tratamento farmacológico , Insuficiência Pancreática Exócrina/imunologia , Família , Anemia de Fanconi/tratamento farmacológico , Anemia de Fanconi/imunologia , Anemia de Fanconi/patologia , Feminino , Fator Estimulador de Colônias de Granulócitos/biossíntese , Fator Estimulador de Colônias de Granulócitos/imunologia , Hemoglobinúria Paroxística/congênito , Hemoglobinúria Paroxística/tratamento farmacológico , Hemoglobinúria Paroxística/imunologia , Humanos , Imunoglobulinas/biossíntese , Lactente , Interferon gama/biossíntese , Interferon gama/imunologia , Células Matadoras Naturais/efeitos dos fármacos , Células Matadoras Naturais/imunologia , Células Matadoras Naturais/patologia , Lipomatose/congênito , Lipomatose/tratamento farmacológico , Lipomatose/imunologia , Masculino , Proteínas de Membrana/biossíntese , Proteínas de Membrana/imunologiaRESUMO
AIM: To determine the role of natural killer (NK) cytotoxic activity in patients with suspected hemophagocytic lymphohistiocytosis syndrome (HLH). DESIGN: A prospective study was conducted from September 2008 to February 2014. SCOPE: The study was carried out in the Hematological Oncology Laboratory of Hospital Infantil Universitario Niño Jesús, Madrid (Spain). PATIENTS: We analyzed 30 peripheral blood samples from intensive care patients with suspected HLH. There were 18 males and 12 females, with a mean age of 4.7 years (range 0.2-22). NK cell cytotoxicity was compared with healthy controls according to age and sex. INTERVENTION: In vitro NK cell cytotoxicity against the K562 cell line was determined by time-resolved fluorescence (Europium-TDA) under resting conditions, after interleukin 15 stimulation, and following block with Fas ligand antibody. VARIABLE OF INTEREST: NK cell cytotoxicity. RESULTS: A total of 20 patients showed a significant decrease of NK cell activity compared with controls (P=.001). Nine of these patients were diagnosed with primary HLH. A total of 10 patients were diagnosed with secondary HLH. Cytotoxic activity was normal in 10 subjects. None of them were diagnosed with HLH. Interleukin 15 stimulation increased NK cell cytotoxicity in secondary HLH, and blocking Fas ligand on NK cells decreased cytotoxic activity in primary HLH patients (P=.001). CONCLUSIONS: In our experience, NK cell cytotoxic activity measured by time-resolved fluorescence is a simple and useful clinical diagnostic test for HLH. Interleukin 15 stimulation and Fas ligand blocking on NK cells could help differentiate between primary and secondary HLH.
Assuntos
Estado Terminal , Células Matadoras Naturais/imunologia , Linfo-Histiocitose Hemofagocítica/imunologia , Adolescente , Varicela/complicações , Criança , Pré-Escolar , Doenças Transmissíveis/diagnóstico , Doenças Transmissíveis/imunologia , Citotoxicidade Imunológica , Diagnóstico Diferencial , Anemia de Fanconi/diagnóstico , Anemia de Fanconi/imunologia , Proteína Ligante Fas/antagonistas & inibidores , Proteína Ligante Fas/imunologia , Feminino , Transplante de Células-Tronco Hematopoéticas , Humanos , Síndromes de Imunodeficiência/complicações , Síndromes de Imunodeficiência/terapia , Lactente , Interleucina-15/farmacologia , Células K562 , Células Matadoras Naturais/efeitos dos fármacos , Linfo-Histiocitose Hemofagocítica/diagnóstico , Linfo-Histiocitose Hemofagocítica/etiologia , Linfo-Histiocitose Hemofagocítica/genética , Masculino , Proteínas de Membrana/genética , Proteínas Munc18/genética , Adulto JovemRESUMO
We report the outcome of 12 consecutive pediatric patients with Fanconi anemia (FA) who had neither an HLA-identical sibling nor an HLA-matched unrelated donor and who were given T cell-depleted, CD34(+) positively selected cells from a haploidentical related donor after a reduced-intensity, fludarabine-based conditioning regimen. Engraftment was achieved in 9 of 12 patients (75%), and the cumulative incidence of graft rejection was 17% (95% confidence interval [CI], 5% to 59%). Cumulative incidences of grades II to IV acute and chronic graft-versus-host disease were 17% (95% CI, 5% to 59%) and 35% (95% CI, 14% to 89%), respectively. The conditioning regimen was well tolerated, with no fatal regimen-related toxicity and 3 cases of grade III regimen-related toxicity. The cumulative incidence of transplant-related mortality was 17% (95% CI, 5% to 59%). The 5-year overall survival, event-free survival, and disease-free survival were 83% (95% CI, 62% to 100%), 67% (95% CI, 40% to 93%), and 83% (95% CI, 62% to 100%), respectively. These data demonstrate that a fludarabine-based conditioning regimen, followed by infusion of high doses of T cell-depleted stem cells, is able to ensure engraftment with good overall survival and disease-free survival, confirming the feasibility of haploidentical hematopoietic stem cell transplantation in FA. To the best of our knowledge, this is the largest series of hematopoietic stem cell transplantation from a haploidentical related donor in FA patients reported to date.
Assuntos
Anemia de Fanconi/terapia , Sobrevivência de Enxerto , Transplante de Células-Tronco Hematopoéticas , Agonistas Mieloablativos/uso terapêutico , Condicionamento Pré-Transplante , Vidarabina/análogos & derivados , Adolescente , Antígenos CD34/imunologia , Criança , Anemia de Fanconi/imunologia , Anemia de Fanconi/mortalidade , Anemia de Fanconi/patologia , Feminino , Doença Enxerto-Hospedeiro/imunologia , Doença Enxerto-Hospedeiro/mortalidade , Doença Enxerto-Hospedeiro/patologia , Antígenos HLA/imunologia , Teste de Histocompatibilidade , Humanos , Depleção Linfocítica , Masculino , Estudos Prospectivos , Análise de Sobrevida , Linfócitos T/citologia , Linfócitos T/imunologia , Transplante Homólogo , Resultado do Tratamento , Doadores não Relacionados , Vidarabina/uso terapêuticoRESUMO
Hematopoietic cell transplantation (HCT) can cure bone marrow failure in patients with Fanconi Anemia (FA), and it is generally accepted that these patients should receive low-intensity conditioning because of the underlying DNA repair defect in their cells. Outcomes for recipients of matched related HCT have generally been favorable, but only a few studies have scrutinized the factors that may affect the eventual outcome of these patients. This retrospective analysis of 94 pediatric patients with FA who underwent related HCT at King Faisal Specialist Hospital & Research Center was carried out to attempt to identify factors that may affect outcome. Results showed overall survival (OS) probabilities of 92.5%, 89%, and 86% at 1, 5, and 10 years, respectively. In univariate analysis, use of higher dose cyclophosphamide (CY) (60 mg/kg) conditioning was associated with a better 10-year OS than lower dose CY (20 mg/kg) conditioning (91% versus 82%, respectively; P = .035), and use of radiation-containing regimens was associated with a significantly lower 10-year OS than nonradiation regimens (76% versus 91%, respectively; P = .005). Of the 4 regimens used in this study, the fludarabine-based regimen was associated with the highest survival (95.2%; P = .034). The use of the higher dose CY (60 mg/kg) was associated with a significantly increased incidence of hemorrhagic cystitis (HC) (20% versus 5.6% respectively; P = .049). Three patients (3%) developed squamous cell carcinoma (2 oropharyngeal and 1 genitourinary), at 9.4, 5.4, and 13.3 years after HCT; 2 of them had radiation-containing conditioning. In conclusion, our data suggest that although using a higher dose CY (60 mg/kg) conditioning regimen may be associated with better survival, it is also associated with a significantly increased risk of HC. The addition of fludarabine to the low-dose CY (20 mg/kg) is associated with the best survival. On the other hand, radiation-containing regimens are associated with significantly lower survival.
Assuntos
Carcinoma de Células Escamosas/patologia , Cistite/patologia , Anemia de Fanconi/terapia , Transplante de Células-Tronco Hematopoéticas , Hemorragia/patologia , Neoplasias Orofaríngeas/patologia , Condicionamento Pré-Transplante/métodos , Adolescente , Carcinoma de Células Escamosas/induzido quimicamente , Carcinoma de Células Escamosas/imunologia , Carcinoma de Células Escamosas/mortalidade , Criança , Pré-Escolar , Ciclofosfamida/efeitos adversos , Cistite/induzido quimicamente , Cistite/imunologia , Cistite/mortalidade , Anemia de Fanconi/imunologia , Anemia de Fanconi/mortalidade , Anemia de Fanconi/patologia , Feminino , Raios gama/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/imunologia , Hemorragia/mortalidade , Teste de Histocompatibilidade , Humanos , Lactente , Masculino , Agonistas Mieloablativos/efeitos adversos , Neoplasias Orofaríngeas/induzido quimicamente , Neoplasias Orofaríngeas/imunologia , Neoplasias Orofaríngeas/mortalidade , Estudos Retrospectivos , Irmãos , Análise de Sobrevida , Transplante Homólogo , Doadores não Relacionados , Vidarabina/efeitos adversos , Vidarabina/análogos & derivadosRESUMO
Tumor necrosis factor-alpha (TNF-α) is a major pro-inflammatory cytokine involved in systemic inflammation and the acute phase reaction. Dysregulation of TNF production has been implicated in a variety of human diseases including Fanconi anemia (FA). FA is a genomic instability syndrome characterized by progressive bone marrow failure and cancer susceptibility. The patients with FA are often found overproducing TNF-α, which may directly affect hematopoietic stem cell (HSC) function by impairing HSC survival, homing and proliferation, or indirectly change the bone marrow microenvironment critical for HSC homeostasis and function, therefore contributing to disease progression in FA. In this brief review, we discuss the link between TNF-α signaling and FA pathway with emphasis on the implication of inflammation in the pathophysiology and abnormal hematopoiesis in FA.
Assuntos
Medula Óssea/patologia , Proteínas de Grupos de Complementação da Anemia de Fanconi/genética , Anemia de Fanconi/genética , Células-Tronco Hematopoéticas/patologia , Transdução de Sinais/genética , Fator de Necrose Tumoral alfa/genética , Apoptose , Medula Óssea/imunologia , Proliferação de Células , Sobrevivência Celular , Transformação Celular Neoplásica/imunologia , Transformação Celular Neoplásica/patologia , Anemia de Fanconi/imunologia , Anemia de Fanconi/patologia , Proteínas de Grupos de Complementação da Anemia de Fanconi/imunologia , Regulação da Expressão Gênica , Instabilidade Genômica , Células-Tronco Hematopoéticas/imunologia , Humanos , Inflamação/genética , Inflamação/imunologia , Inflamação/patologia , Transdução de Sinais/imunologia , Fator de Necrose Tumoral alfa/imunologiaRESUMO
BACKGROUND AIMS: Fanconi anemia is an autosomal recessive or X-linked genetic disorder characterized by bone marrow (BM) failure/aplasia. Failure of hematopoiesis results in depletion of the BM stem cell reservoir, which leads to severe anemia, neutropenia and thrombocytopenia, frequently requiring therapeutic interventions, including hematopoietic stem cell transplantation (HSCT). Successful BM transplantation (BMT) requires reconstitution of normal immunity. METHODS: In the present study, we performed a detailed analysis of the distribution of peripheral blood subsets of T, B and natural killer (NK) lymphocytes in 23 patients with Fanconi anemia before and after BMT on days +30, +60, +100, +180, +270 and +360. In parallel, we evaluated the effect of related versus unrelated donor marrow as well as the presence of graft-versus-host disease (GVHD). RESULTS: After transplantation, we found different kinetics of recovery for the distinct major subsets of lymphocytes. NK cells were the first to recover, followed by cytotoxic CD8(+) T cells and B cells, and finally CD4(+) helper T cells. Early lymphocyte recovery was at the expense of memory cells, potentially derived from the graft, whereas recent thymic emigrant (CD31(+) CD45RA(+)) and naive CD4(+) or CD8(+) T cells rose only at 6 months after HSCT, in the presence of immunosuppressive GVHD prophylactic agents. Only slight differences were observed in the early recovery of cytotoxic CD8(+) T cells among those cases receiving a graft from a related donor versus an unrelated donor. Patients with GVHD displayed a markedly delayed recovery of NK cells and B cells as well as of regulatory T cells and both early thymic emigrant and total CD4(+) T cells. CONCLUSIONS: Our results support the utility of post-transplant monitoring of a peripheral blood lymphocyte subset for improved follow-up of patients with Fanconi anemia undergoing BMT.
Assuntos
Transplante de Medula Óssea/métodos , Anemia de Fanconi/imunologia , Transplante Homólogo/métodos , Adolescente , Adulto , Linfócitos T CD8-Positivos/imunologia , Criança , Pré-Escolar , Anemia de Fanconi/genética , Anemia de Fanconi/patologia , Anemia de Fanconi/terapia , Feminino , Doença Enxerto-Hospedeiro/genética , Doença Enxerto-Hospedeiro/imunologia , Humanos , Células Matadoras Naturais/transplante , MasculinoRESUMO
Fanconi anemia (FA), a rare genetic disease in which patients' life is compromised mainly by hematological abnormalities and cancer prone, seems to be affected by subtle immune cell irregularities. Knowing that FA presents developmental abnormalities and, based on recent reports, suggesting that natural killer (NK) CD56(dim) and NK CD56(bright) correspond to sequential differentiation pathways, we investigated if there were changes on the total number of NK cells and subsets as well as on T CD4 and T CD8 lymphocytes and their ratio. A large sample of FA patients (n = 42) was used in this work, and the results were correlated to clinical hematological status of these patients. Among FA patients, a decreased proportion of T CD8(+) and NK CD56(dim)CD16(+) cells were observed when compared to healthy controls as well as an imbalance of the subsets NK lymphocytes. Data suggest that FA patients might have a defective cytotoxic response due to the lower number of cytotoxic cells as well as impairment in the differentiation process of the NK cells subsets which may be directly related to impairment of the immune surveillance observed in these patients.
Assuntos
Linfócitos T CD4-Positivos/patologia , Antígeno CD56/imunologia , Linfócitos T CD8-Positivos/patologia , Anemia de Fanconi/patologia , Células Matadoras Naturais/patologia , Receptores de IgG/imunologia , Adolescente , Adulto , Linfócitos T CD4-Positivos/imunologia , Antígeno CD56/genética , Linfócitos T CD8-Positivos/imunologia , Estudos de Casos e Controles , Diferenciação Celular , Linhagem da Célula/imunologia , Criança , Pré-Escolar , Citotoxicidade Imunológica , Anemia de Fanconi/imunologia , Anemia de Fanconi/metabolismo , Feminino , Proteínas Ligadas por GPI/genética , Proteínas Ligadas por GPI/imunologia , Expressão Gênica , Humanos , Vigilância Imunológica , Imunofenotipagem , Células Matadoras Naturais/imunologia , Células Matadoras Naturais/metabolismo , Contagem de Linfócitos , Masculino , Receptores de IgG/genéticaRESUMO
Patients with Fanconi anemia (FA) have a high risk of developing acute myeloid leukemia (AML). In this study, we attempted to identify cell-surface markers for leukemia-initiating cells in FA-AML patients. We found that the IL-3 receptor-α (IL-3Rα) is a promising candidate as an leukemia-initiating cell-specific antigen for FA-AML. Whereas IL-3Rα expression is undetectable on normal CD34(+)CD38(-) HSCs, it is overexpressed on CD34(+)CD38(-) cells from FA patients with AML. We examined the leukemia-initiating cell activity of IL-3Rα-positive FA-AML cells in a "humanized" FA xenotransplant model in which we separated AML cells into IL-3Rα-positive and IL-3Rα-negative CD34 fractions and transplanted them into irradiated recipient mice. In all 3 FA-AML samples, only IL-3Rα-positive cells showed significant levels of engraftment and developed leukemia in the recipient mice. The FA CD34(+)IL-3Rα(+) blasts isolated from leukemic mice exhibited hypersensitivity to IL-3 deprivation and JAK2-STAT5 overactivation after IL-3 treatment. Finally, treatment of FA CD34(+)IL-3Rα(+) blasts with an IL-3Rα-neutralizing antibody inhibited IL-3-mediated proliferation and STAT5 activation. These results demonstrate that IL-3Rα is a cell-surface marker present on FA-AML leukemia-initiating cells and may be a valuable therapeutic target.
Assuntos
ADP-Ribosil Ciclase 1/imunologia , Antígenos CD34/imunologia , Anemia de Fanconi/complicações , Subunidade alfa de Receptor de Interleucina-3/genética , Leucemia Mieloide Aguda/imunologia , Células-Tronco/imunologia , Regulação para Cima , Animais , Anemia de Fanconi/imunologia , Humanos , Subunidade alfa de Receptor de Interleucina-3/antagonistas & inibidores , Subunidade alfa de Receptor de Interleucina-3/imunologia , Janus Quinase 2/imunologia , Leucemia Mieloide Aguda/etiologia , Camundongos , Camundongos Endogâmicos NOD , Fator de Transcrição STAT5/imunologia , Transplante HeterólogoRESUMO
In this study, the immunological status of 61 patients with Fanconi anemia (FA) with advanced marrow failure before hematopoietic stem cell transplantation was analyzed by assessing the phenotype of peripheral blood lymphocytes, serum immunoglobulin (Ig) levels, and inflammatory cytokines. In patients with FA, total absolute lymphocytes (P < 0.0001), B cells (P < 0.0001), and NK cells (P = 0.003) were reduced when compared with normal controls. T cells (CD3), that is, cytotoxic T cells, naïve T cells, and regulatory T cells, showed a relative increase when compared with controls. Serum levels of IgG (P < 0.0001) and IgM (P = 0.004) were significantly lower, whereas IgA level was higher (P < 0.0001) than in normal controls. TGF-ß (P = 0.007) and interleukin (IL)-6 (P = 0.0007) levels were increased in the serum of patients when compared with controls, whereas sCD40L level decreases (P < 0.0001). No differences were noted in the serum levels of IL-1ß, IL-2, IL-4, IL-10, IL-13, IL-17, and IL-23 between FA subjects and controls. This comprehensive immunological study shows that patients with FA with advanced marrow failure have an altered immune status. This is in accordance with some characteristics of FA such as the proinflammatory and proapoptotic status. In addition, B lymphocyte failure may make tight and early immunological monitoring advisable.
Assuntos
Anemia de Fanconi/imunologia , Adolescente , Adulto , Criança , Pré-Escolar , Citocinas/sangue , Citocinas/imunologia , Anemia de Fanconi/sangue , Feminino , Humanos , Imunoglobulinas/sangue , Imunoglobulinas/imunologia , Imunofenotipagem , Subpopulações de Linfócitos/imunologia , Masculino , Estudos Retrospectivos , Adulto JovemRESUMO
Low-dose cyclophosphamide (CY) is now considered the backbone of many of the conditioning regimens used in patients with Fanconi anemia undergoing allogeneic stem cell transplantation (SCT). To reduce the risk of rejection and improve results, CY is usually used in combination with other agents/modalities, such as antithymocyte globulin (ATG), busulfan, radiation, and, more recently, fludarabine (Flu). In this study, we used a uniform Flu-based conditioning regimen (ie, CY, Flu, ATG) in 26 pediatric patients with Fanconi anemia undergoing SCT. The median patient age at the time of SCT was 7.8 years, and the stem cell source was an HLA-matched related donor in 19 patients and partially HLA-matched unrelated cord blood in 7 patients. The CY, Flu, ATG regimen was well tolerated overall, with a remarkably low incidence of graft-versus-host disease and hemorrhagic cystitis. All 19 patients in the matched related donor group engrafted and were alive and transfusion-independent at a median follow-up time of 19 months, compared with only 2 of 7 patients in the unrelated cord blood group. We conclude that the combination of CY, Flu, and ATG in the doses used in this study is well tolerated, and that the proclaimed positive effect of adding Flu to the conditioning regimens of patients with Fanconi anemia undergoing SCT is most pronounced in recipients of HLA-matched related transplants. Its value in unrelated cord blood transplantation probably depends on other factors, such as the degree of HLA matching and the cell dose.
Assuntos
Anemia de Fanconi/terapia , Doença Enxerto-Hospedeiro/prevenção & controle , Transplante de Células-Tronco Hematopoéticas , Imunossupressores/uso terapêutico , Condicionamento Pré-Transplante , Adolescente , Soro Antilinfocitário/administração & dosagem , Soro Antilinfocitário/uso terapêutico , Criança , Pré-Escolar , Transplante de Células-Tronco de Sangue do Cordão Umbilical , Ciclofosfamida/administração & dosagem , Ciclofosfamida/uso terapêutico , Cistite/imunologia , Cistite/prevenção & controle , Intervalo Livre de Doença , Anemia de Fanconi/imunologia , Anemia de Fanconi/mortalidade , Feminino , Doença Enxerto-Hospedeiro/imunologia , Teste de Histocompatibilidade , Humanos , Imunossupressores/administração & dosagem , Lactente , Masculino , Estudos Prospectivos , Arábia Saudita , Transplante Homólogo , Doadores não Relacionados , Vidarabina/administração & dosagem , Vidarabina/análogos & derivados , Vidarabina/uso terapêuticoRESUMO
Allogeneic hematopoietic cell transplantation (HCT) is the only known cure for patients with Fanconi anemia (FA) who develop aplasia or leukemia. However, transplant regimens typically contain high-dose alkylators, which are poorly tolerated in FA patients. Furthermore, as many patients lack human leukocyte antigen (HLA)-matched family donors, alternative donors are used, which can increase the risk of both graft rejection and graft-versus-host disease (GVHD). To improve on these three concerns, we developed a multi-institutional clinical trial using a fludarabine (FLU)-based conditioning regimen with limited alkylators/low-dose radiation, HLA-haploidentical marrow, followed by reduced-dose cyclophosphamide (CY) to treat three FA patients with aplasia. All three patients engrafted with 100% donor CD3 chimerism at 1 month. One patient died early from disseminated toxoplasmosis infection. Of the two survivors, one had significant pretransplant co-morbidities and inadequate immunosuppression, and developed severe acute GVHD. The other patient had only mild acute and no chronic GVHD. With a follow-up of 2 and 3 years, respectively, both patients are doing well, are transfusion-independent, and maintain full donor chimerism. The patient with severe GVHD has resolving oral GVHD and good quality of life. We conclude that using low-intensity conditioning, HLA-haploidentical marrow, and reduced-dose CY for in vivo T-cell depletion can correct life-threatening aplasia in FA patients.
Assuntos
Anemia de Fanconi/terapia , Rejeição de Enxerto/prevenção & controle , Doença Enxerto-Hospedeiro/prevenção & controle , Antígenos HLA/imunologia , Transplante de Células-Tronco Hematopoéticas , Depleção Linfocítica , Linfócitos T/imunologia , Vidarabina/análogos & derivados , Adolescente , Antineoplásicos/uso terapêutico , Criança , Terapia Combinada , Anemia de Fanconi/imunologia , Feminino , Seguimentos , Humanos , Quimeras de Transplante/imunologia , Condicionamento Pré-Transplante , Transplante Homólogo , Vidarabina/uso terapêuticoRESUMO
Head-and-neck squamous cell carcinomas (HNSCCs) are relatively common in patients with Fanconi anemia (FA), a hereditary chromosomal instability disorder. Standard chemo-radiation therapy is not tolerated in FA due to an overall somatic hypersensitivity to such treatment. The question is how to find a suitable alternative treatment. We used whole-exome and whole genome mRNA sequencing to identify major genomic and transcriptomic events associated with FA-HNSCC. CRISPR-engineered FA-knockout models were used to validate a number of top hits that were likely to be druggable. We identified deletion of 18q21.2 and amplification of 11q22.2 as prevailing copy-number alterations in FA HNSCCs, the latter of which was associated with strong overexpression of the cancer-related genes YAP1, BIRC2, BIRC3 (at 11q22.1-2). We then found the drug AZD5582, a known small molecule inhibitor of BIRC2-3, to selectively kill FA tumor cells that overexpressed BIRC2-3. This occurred at drug concentrations that did not affect the viability of untransformed FA cells. Our data indicate that 11q22.2 amplifications are relatively common oncogenic events in FA-HNSCCs, as holds for non FA-HNSCC. Therefore, chemotherapeutic inhibition of overexpressed BIRC2-3 may provide the basis for an approach to develop a clinically realistic treatment of FA-HNSCCs that carry 11q22.2 amplifications.