Management of adults and children receiving CAR T-cell therapy: 2021 best practice recommendations of the European Society for Blood and Marrow Transplantation (EBMT) and the Joint Accreditation Committee of ISCT and EBMT (JACIE) and the European Haematology Association (EHA).

BACKGROUND: Several commercial and academic autologous chimeric antigen receptor T-cell (CAR-T) products targeting CD19 have been approved in Europe for relapsed/refractory B-cell acute lymphoblastic leukemia, high-grade B-cell lymphoma and mantle cell lymphoma. Products for other diseases such as multiple myeloma and follicular lymphoma are likely to be approved by the European Medicines Agency in the near future. DESIGN: The European Society for Blood and Marrow Transplantation (EBMT)-Joint Accreditation Committee of ISCT and EBMT (JACIE) and the European Haematology Association collaborated to draft best practice recommendations based on the current literature to support health care professionals in delivering consistent, high-quality care in this rapidly moving field. RESULTS: Thirty-six CAR-T experts (medical, nursing, pharmacy/laboratory) assembled to draft recommendations to cover all aspects of CAR-T patient care and supply chain management, from patient selection to long-term follow-up, post-authorisation safety surveillance and regulatory issues. CONCLUSIONS: We provide practical, clinically relevant recommendations on the use of these high-cost, logistically complex therapies for haematologists/oncologists, nurses and other stakeholders including pharmacists and health sector administrators involved in the delivery of CAR-T in the clinic.

[What is established in cell therapies? : Possibilities and limits in immuno-oncology]. / Was ist gesichert bei den Zelltherapien? : Möglichkeiten und Grenzen in der Immunonkologie.

Cell and gene therapy as part of immuno-oncology has reached an important milestone in medicine. After decades of experience stem cell transplantation is well established with worldwide >1 million transplantations to date. Due to the improved success of the last years using chimeric antigen receptor (CAR) T cells for CD19 positive leukemia and lymphomas, the interest in cellular therapies is continuously increasing. The current review also gives a short overview about donor lymphocytes, antigen-specific T cells, regulatory T cells, natural killer (NK) cells, mesenchymal stromal cells and induced pluripotent stem (iPS) cells in immuno-oncology.

Dendritic cell reconstitution is associated with relapse-free survival and acute GVHD severity in children after allogeneic stem cell transplantation.

DCs are potent APCs and key regulators of innate and adaptive immunity. After allo-SCT, their reconstitution in the peripheral blood (PB) to levels similar to those in healthy individuals tends to be slow. We investigate the age- and sex-dependant immune reconstitution of myeloid (mDC) and plasmacytoid DC (pDC) in the PB of 45 children with leukaemia or myelodysplastic syndrome (aged 1-17 years, median 10) after allo-SCT with regard to relapse, acute GVHD (aGVHD) and relapse-free survival. Low pDC/µL PB up to day 60 post SCT are associated with higher incidence of moderate or severe aGVHD (P=0.035), whereas high pDC/µL PB up to day 60 are associated with higher risk of relapse (P<0.001). The time-trend of DCs/µL PB for days 0-200 is a significant predictor of relapse-free survival for both mDCs (P<0.001) and pDCs (P=0.020). Jointly modelling DC reconstitution and complications improves on these simple criteria. Compared with BM, PBSC transplants tend to show slower mDC/pDC reconstitution (P=0.001, 0.031, respectively), but have no direct effect on relapse-free survival. These results suggest an important role for both mDCs and pDCs in the reconstituting immune system. The inclusion of mDCs and pDCs may improve existing models for complication prediction following allo-SCT.

Formation of cytosine arabinoside-5'-triphosphate in different cultured lymphoblastic leukaemic cells with reference to their drug sensitivity.

The accumulation of intracellular cytosine arabinoside-5'-triphosphate (Ara-CTP) is determined in five lymphoblastic cell lines: Molt 4, H9 and three newly established cell lines from paediatric patients, KFB-1, KFB-2, KFT-1. The cell lines KFB-1 and KFB-2 are B-lymphoblastic (B-ALL), the others are T-lymphoblastic leukaemic cells (T-ALL). The Ara-CTP levels were compared with the sensitivity of the cells to Ara-C. The cells were incubated at different concentrations (100 nM-100 microM) of Ara-C for 4 h or incubated for variable times (30 min-11 h) at 0.1, 1 and 10 microM Ara-C to form Ara-CTP. The Ara-CTP-concentrations were measured by high pressure liquid chromatography (HPLC). To determine the sensitivity of the cells to Ara-C, the MTT colorimetric-assay was used. The studies indicate that different B- and T-lymphoblastic leukaemia cell lines accumulate Ara-CTP to a markedly different extent. Ara-CTP plateau levels and sensitivity of the cells to Ara-C correlated well in four of the five cells lines studied.

Continent urinary diversion in preparation for renal transplantation: a staged approach.

BACKGROUND: We prospectively assessed the safety of kidney transplantation into continent urinary intestinal reservoirs as a planned two-stage procedure in patients with absent or dysfunctional lower urinary tract. METHODS: Between November 1990 and June 1999, 12 patients have undergone renal transplantation into continent urinary reservoirs, and a further patient with a diversion is awaiting transplantation. This was part of a larger series of 356 patients who had undergone continent diversions during that period. A further 174 patients (33%) had diversions into ileal conduits. FINDINGS: Within a mean follow-up of 26.1 months (5-72) after transplantation renal function was stable with serum creatinine values ranging from 0.9 to 1.8 mg/dl. There were 5 reoperations in the 12 patients (40%). Two patients needed their continence mechanism replaced. One had renal vein thrombosis with loss of the transplant. The cause for this was unknown but it had been speculated that it could have been caused by graft/body size disproportion. A second kidney was successfully transplanted after 12 months. Two further revisions were required for ureteric kinking and lymphocele. The patient with orthotopic substitution voids to completion. The other patients are continent day and night with easy catheterization. INTERPRETATION: This is one of the largest single series reported to date of renal transplantation into continent urinary diversions, and we commend the approach in carefully selected patients, but the difficulties must not be underestimated and the specific problems of intestinal urinary reservoirs have to be reckoned with. These procedures should be confined to centers with considerable experience with this type of surgery and its complications. Lifelong close surveillance is critical for the success of this concept.

Clinical scale isolation of T cell-depleted CD56+ donor lymphocytes in children.

We present a clinical scale method for immunomagnetic separation of CD56+ donor natural killer cells for adoptive immunotherapy of pediatric leukemias after allogeneic transplantation. This time-saving and partially automated procedure employed CD56+ selection followed by CD3+ depletion, resulting in a median purity of 98.6% NK cells and a four-log depletion of T cells. The enriched NK cells demonstrated high cytotoxic activity against K562 target cells and fresh leukemic blasts with low HLA class I expression, which could be further enhanced by IL-2 stimulation. Lysis of NK-insensitive leukemic cells with high HLA class I expression could also be demonstrated via ADCC. Due to the high degree of T cell depletion, alloreactive proliferation in mixed lymphocyte cultures and response to T cell-specific mitogen stimulation was profoundly decreased. Our results suggest that, even in the case of mismatched donors, infusions of donor NK cells with extremely low T cell content may be a promising treatment option for leukemic minimal residual disease after allogeneic transplantation without risk of inducing severe GVHD.

Multiple (five) synchronous primary malignant neoplasms of dissimilar histogenesis including a malignant fibrous histiocytoma of the bladder.

A unique case was recently encountered involving the synchronous presentation of five primary malignancies of different histology. Malignant neoplasms of the colon, kidney, prostate and bladder were treated surgically. Bladder was affected by two separate tumours: a transitional cell carcinoma and a malignant fibrous histiocytoma. The latter constitutes an extremely rare malignant lesion of the organ. The pathologic characteristics, histogenesis, differential diagnosis and treatment considerations of this soft tissue sarcoma, and the incidence, terminology and incriminating factors of multiple primary malignant neoplasms, as well as their association with the genitourinary system are reviewed.

[Adrenalectomy within the scope of tumor nephrectomy--overtreatment?]. / Adrenalektomie im Rahmen der Tumornephrektomie--ein Overtreatment?

Metastatic spread to the ipsilateral adrenal gland occurs in 1.2-10% of patients with renal cell carcinoma (RCC). In the majority of these cases, the primary tumor is locally advanced with poor differentiation, venous invasion, and involvement of the regional lymph nodes. Adrenal metastases are usually detected preoperatively by CT scan or MRI. Adrenal metastases are indicators of systemic disease with poor prognosis quo ad vitam. Only 0.5-2.3% of patients with RCC and adrenal metastases are free of venous invasion or lymphatic disease. In this small subset of patients, cure is possible by surgical removal of the adrenal gland. In 97.7-99.5% of patients with RCC, ipsilateral adrenalectomy has no impact on their prognosis. We therefore conclude that this procedure should be performed only if there is radiological suspicion of an adrenal mass.

[Focal necrotising vasculitis of the testis. Testicular manifestations of immunologic diseases in differential diagnosis of testicular cancer]. / Fokale nekrotisierende Vaskulitis des Hodens. Testikuläre Manifestationen immunologischer Erkrankungen in der Differentialdiagnostik des Hodentumors.

We report on the case of a 31-year-old male patient with focal testicular vasculitis as the only clinical manifestation of endangiitis obliterans (Winiwarter-Buerger disease), who presented with acute scrotal pain and swelling suggestive of a testicular tumor. Doppler sonography revealed significantly increased vascularization at the borders of the lesion, which rather indicated a vascular process; however, the presence of solid areas meant that the possibility of testicular cancer could not be excluded. Left inguinal orchiectomy was performed. The surgical specimen revealed histological patterns compatible with endangiitis obliterans; Raynaud phenomenon was the only sign of systemic disease, and no other organs were found to be affected. Despite the high sensitivity and specificity of ultrasound/Doppler sonography, in the differential diagnosis of an unexplained testicular mass surgical exploration is still mandatory. The different types of focal vasculitis are described and discussed with reference to the literature.

Serological survey and risk factors for Toxoplasma gondii in domestic ducks and geese in Lower Saxony, Germany.

To obtain estimates for the prevalence of Toxoplasma gondii infection in ducks and geese in Germany, enzyme-linked immunosorbent assays (ELISA) were established based on affinity-purified T. gondii tachyzoite surface antigen 1 (TgSAG1) and used to examine duck and goose sera for T. gondii-specific antibodies. The results of 186 sera from 60 non-infected ducks (Anas platyrhynchos) and 101 sera from 36 non-infected geese (Anser anser) as well as 72 sera from 11 ducks and 89 sera from 12 geese inoculated experimentally with T. gondii tachyzoites (intravenously) or oocysts (orally) and positive in a T. gondii immunofluorescent antibody test (IFAT) were used to select a cut-off value for the TgSAG1-ELISA. Sera obtained by serial bleeding of experimentally inoculated ducks and geese were tested to analyze the time course of anti-TgSAG1 antibodies after inoculation and to assess the sensitivity of the assays in comparison with IFAT. In ducks, IFAT titres and ELISA indices peaked 2 and 5 weeks p.i with tachyzoites, respectively. Only three of six geese inoculated with tachyzoites at the same time as the ducks elicited a low and non-permanent antibody response as detected by the IFAT. In the TgSAG1-ELISA, only a slight increase of the ELISA indices was observed in four of six tachyzoite-inoculated geese. By contrast, inoculation of ducks and geese with oocysts led to an increase in anti-TgSAG1 antibodies within 1 or 2 weeks, which were still detectable at the end of the observation period, i.e. 11 weeks p.i. Inoculation of three ducks and three geese with oocysts of Hammondia hammondi, a protozoon closely related to T. gondii, resulted in a transient seroconversion in ducks and geese as measured by IFAT or TgSAG1-ELISA. Using the newly established TgSAG1-ELISA, sera from naturally exposed ducks and geese sampled in the course of a monitoring program for avian influenza were examined for antibodies to T. gondii; 145/2534 (5.7%) of the ducks and 94/373 (25.2%) of the geese had antibodies against TgSAG1. Seropositive animals were detected on 20 of 61 duck and in 11 of 13 goose farms; the seroprevalences within positive submissions of single farms ranged from 2.2% to 78.6%. Farms keeping ducks or geese exclusively indoors had a significantly lower risk (odds ratio 0.05, 95% confidence interval 0.01-0.3) of harboring serologically positive animals as compared with farms where the animals had access to an enclosure outside the barn.

[Identical psychosis of a monocygous twin set--a case report (author's transl)]. / Identische Psychose bei einem eineiigen Zwillingspaar

This is a report about a pair of identical twins with identical symptoms of a similar to schizophrenic psychosis. The course of the disease with special reference to the influence by each other and a similar and a dissimilar treatment is described. This disease is subgrouped to the symbiontic psychoses. Nosology, aetiology and psychodynamic aspects are discussed.

[Risk of chronic carbon monoxide poisoning in automobile garages. Results of a study in the Lausanne region]. / Risques d'oxycarbonisme chronique dans les garages. Résultats d'une enquête dans la région lausannoise

Clinical and physiologic data on chronic carbon monoxide poisoning are reviewed and the results of an investigation involving 7 garages in the Lausanne (Switzerland) area are reported. The aim was a practical approach to the relationships between carbon monoxide level in the air, COHb and clinical picture. The study covered working conditions (especially ventilation) but did not take into account of other factors (stresses) which may effect the parameters investigated. CO was measured by continuous recording with an MSA Carbon Monoxide Alarm and the hourly and daily averages were determined. The garage personnel replied to a questionnaire and underwent a brief clinical examination including taking of digital blood samples for measurement of hematocrit and carboxyhemoglobin level by the method of COMMINS and LAWTHER as modified by BUCHWALD. One of the garages did not meet present health requirements. Statistical analysis revealed a significant correlation between carbon monoxide and carboxyhemoglobin. The incidence of complaints was highest in poorly ventilated garages. On the basis of COHb level in the total group of employees, together with data from individual histories, it is possible to evaluate the risk of carbon monoxide poisoning in a given garage.

[Simple closure or stomach resection in perforated gastroduodenal ulcers (author's transl)]. / Zur Frage der Ubernähung oder primären Resektion bei perforierten Magen- und Zwölffingerdarmgeschwüren.

301 cases with perforated gastroduodenal ulcers are reported. The rate of primary stomach resection was 64%. The total letality amounted to 13.6%, after primary stomach resection 4.1%, after simple closure 31%. Both procedures are corresponding methods. Primary stomach resection is able to treat gastroduodenal ulcer definitively. Reserve with primary stomach resection is indicated in patients older than 60 years of age and times of perforation more than 12 hours.

Infections and vesicoureteral reflux.

Vesicoureteral reflux (VUR) is a common condition in children. It may cause and maintain urinary tract infections, eventually leading to progressive renal damage and end-stage renal disease. Ideally, VUR should be detected and treated before renal scarring occurs. Although fetal hydronephrosis on antenatal ultrasound may be the first indicator, the role of further diagnostic investigations in these newborns is still controversial. Because VUR is an inherited condition, offspring of women with a family history of VUR and urinary tract infection should be screened closely for early detection of VUR. Once diagnosed, however, the optimal management of VUR (i.e. medical or surgical treatment) remains controversial. Evidence-based treatment recommendations, like the American Urological Association guidelines, may aid physicians in their therapeutic decision making, but cannot replace personal experience or surgical skill.

Management of clinical data in urology. Experience with integrated personal computers and a relational database.

The use of microcomputers in medicine is rapidly increasing. To handle clinical data and to facilitate clinical research, a system based on several personal computers that can be linked together was developed. Commercially available software was used, consisting of a powerful relational database complemented by programs for statistics, graphics and desk top publishing. The low cost, modular and flexible system was handled by untrained personnel; computer specialists were not needed. Data on more than 1100 patients have been entered so far and data retrieval can be done by the physician "on the spot" using standard prefabricated reports. Data can then be analysed statistically and processed to graphics and publications.

Structural basis for altered soybean agglutinin lectin binding between a murine metastatic lymphoma and an adhesive low malignant variant.

By selection for plastic adhesiveness we have previously established a variant tumor line (ESb-MP) from the metastatic murine lymphoma ESb. In contrast to the parental line, the adhesion variant is significantly decreased in malignancy and is altered in the capacity to bind soybean agglutinin (SBA) lectin. Here we show biochemically that the major SBA-binding cell-surface component of ESb-MP cells is the T200 glycoprotein. In ESb cells, T200 antigens bind SBA only after sialidase treatment. Enzymatic studies suggested that glycans detected by the lectin with or without sialidase treatment are different. Inhibition of N-glycosylation by tunicamycin and biosynthetic labeling revealed two T200 chains for ESb-MP cells that were larger in size than the single chain detected in ESb cells. Studies on the biosynthesis revealed that ESb-MP cells expressed two precursor chains for T200 whereas ESb cells displayed only one. There was no size difference detectable in the mature T200 molecules of ESb and ESb-MP cells. Our data suggest that the molecules differ in expression of O-linked glycans that can be recognized by SBA. Additional O-linked sugars on ESb-MP T200 molecules seem to be expressed in particular after trimming of the second T200 precursor chain.

Antibody 12-15 cross-reacts with mouse Fc gamma receptors and CD2: study of thymus expression, genetic polymorphism and biosynthesis of the CD2 protein.

Previously we described a monoclonal antibody (mAb 12-15) that reacted with murine Fc receptor proteins (beta 1, beta 2 and alpha) and an undefined molecule of 37 kDa (beta 3) on certain types of cells. Here we present serological and biochemical evidence that the beta 3 chain is expressed on mouse thymocytes and that it is identical to the CD2 antigen. By immunofluorescence staining and cytofluorographic analysis greater than 95% of thymocytes were positive. Brightly staining cells coincided with cortisone-resistant thymocytes suggesting that mature thymocytes expressed higher levels of the antigen. Biosynthetic labeling of DBA/2 thymocytes with [35S]methionine showed that the size of the CD2 precursor molecule was 43 kDa which was processed to approximately 55-65 kDa in the mature molecule. mAb 12-15 was also reactive with the tunicamycin-treated form of the CD2 antigen suggesting that the cross-reactive epitope was of protein nature. Comparison of different mouse strains indicated that two molecular forms of CD2 exist. On BALB/c thymocytes, the relative mass of the native molecule was approximately 60-70 kDa (CD2.1) and slightly larger than in DBA/2 (CD2.2). Following endoglycosidase F treatment both proteins still showed a slight difference in electrophoretic mobility. Several inbred mouse strains were analyzed for expression of CD2 forms. When mAb 12-15 was used in cytotoxic T lymphocyte inhibition experiments using specific CTL and tumor target cells it was found that the antibody could specifically inhibit CTL-mediated lysis presumably by interfering with CD2 function.

Murine Fc gamma receptor proteins: identification of a previously unrecognized molecule with a monoclonal antibody (12-15).

Previously we studied differential expression of cell surface molecules between the metastatic murine lymphoma ESb and an adhesion variant ESb-MP. Here we describe the specificity of a monoclonal antibody (12-15) that showed strong binding to the adhesion variant and weak reactivity against ESb cells. The antibody also reacted to lymphoid but not to macrophage-derived cell lines and immunoprecipitated a molecule of approx. 60-69 kDa from ESb-MP cells. N-terminal sequencing of the antigen revealed identity to the beta protein of mouse Fc gamma receptors. Using monoclonal antibodies against Fc gamma receptors (2.4G2 and K9.361) in immunofluorescence assays and cDNA probes specific for alpha, beta 1 and beta 2 Fc receptor transcripts in Northern blot experiments the differential expression of Fc receptors in ESb and ESb-MP cells was confirmed. Biochemical analysis of endoglycosidase F-treated precipitates revealed that antibody 12-15 reacted to products of all three transcripts with molecular masses for the protein core of 38.5 kDa (beta 1), 34 kDa (beta 2) and 31 kDa alpha). In addition, an unknown protein of 37 kDa (termed beta 3) was identified by antibody 12-15 which could also be detected in ESb cells and EL4 cells. Antibodies 2.4G2 and K9.361 did not react to the beta 3 chain but reacted to varying extents to the other Fc proteins in macrophage and lymphoid cells. Comparison by peptide mapping of the novel beta 3 chain to beta 1, beta 2 and alpha proteins revealed similar, but also distinct peptides. The tissue-specific reactivity of monoclonal antibody 12-15 is likely to be due to a carbohydrate epitope associated with all Fc gamma receptors in lymphoid but not macrophage cell lines.

Complications related to different continence mechanisms in ileocecal reservoirs.

PURPOSE: We compared the incidence, treatment and outcome of complications related to different continence mechanisms in a single institutional series of continent urinary diversions using an ileocecal reservoir. MATERIALS AND METHODS: From November 1990 through October 1996 in 193 consecutive cases an ileocecal pouch (Mainz I) was used as a low pressure, high capacity reservoir. A submucosally embedded in situ appendix was used in 96 patients (mean age 57.2 years, mean followup 35.6 months) and an ileal intussusception valve was used in 106 (mean age 58.4, mean followup 33.1 months). Without exception the stoma was placed in the umbilicus. RESULTS: In 172 patients (85.2%) no stoma related complication was observed. In 17 patients (17.7%) with appendix stoma 23 reinterventions were performed, for appendico-umbilical stenosis in all but 2 cases (15.6%), occurring after a mean of 20.4 months. Two complete appendix necroses required replacement by ileal nipple. Stomal stenoses could be corrected as minor outpatient procedures. In 13 of 106 patients (12.3%) with intussuscepted ileal nipple a second operation became necessary after a mean interval of 9.6 months (partial/complete necrosis of nipple in 4 cases, dislocation of nipple from ileocecal valve in 3, detachment from fascia in 4 and stomal stenosis in 2). Whereas no calculi were observed in the appendix group, stones had to be removed from 3 patients (2.8%) with ileal nipple. CONCLUSIONS: In situ appendix and intussuscepted ileal valve techniques are satisfactory in providing ileocecal reservoir continence. Besides the known advantages of the appendix as the primary reconstructive approach, the treatment of subsequent complications is simple. Therefore, whenever an appropriate appendix is encountered it should be the intestinal segment of choice in forming a continence mechanism.