Optimizing conditioning regimen with low-dose irradiation or busulfan enables the outcome of transplantation from a 6-7/8 HLA-matched donor comparable to that from an 8/8 HLA-matched unrelated donor in severe aplastic anemia patients under 40 years.

With the dramatic improvements in outcomes following alternative donor hematopoietic stem cell transplantation (HSCT), interest in the use of alternative donors in severe aplastic anemia (SAA) is increasing. We conducted a multicenter prospective study to explore the efficiency and safety of upfront HSCT from a 6-8/8 HLA-matched unrelated donor (MUD) or 6-7/8 HLA-matched related donor (MRD) in acquired SAA patients under 40 years. Between August 2014 and July 2017, 115 patients were enrolled, including 48 (41.7%) patients receiving grafts from an 8/8 MUD, 25 (21.7%) from a 6-7/8 MRD, and 42 (36.5%) from a 6-7/8 MUD. The incidence of grade II-IV acute graft-versus-host disease (GVHD) was higher in the 6-7/8 MUD group than in the 8/8 MUD group (42.9% vs. 12.8%, P=0.001). The corresponding incidence in the 6-7/8 MRD group was comparable to that in the 8/8 MUD group (21.7% vs. 12.8%, P=0.332). There was no significant difference in the incidence of chronic GVHD (24.3%, 13.6%, and 17.9%, P=0.676), graft failure (2.4%, 8.0%, and 6.3%, P=0.551), overall survival (85.7%, 96.0%, and 87.5%, P=0.424), and failure-free survival (83.3%, 88.0%, and 83.3%, P=0.885) among the three groups (6-7/8 MUD, 6-7/8 MRD, and 8/8 MUD). In multivariate analysis, conditioning regimen without low-dose irradiation or busulfan was associated with an inferior failure-free survival (HR=2.973, P=0.042). In conclusion, after an intensified conditioning regimen with additional low-dose irradiation or busulfan, the outcome of HSCT from a 6-7/8 MRD or 6-7/8 MUD is comparable to that from an 8/8 MUD.

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Haploidentical hematopoietic stem cell transplantation is a recommended alternative therapy for children with severe aplastic anemia who lack a human leukocyte antigen (HLA)-identical sibling donor and do not respond well to immunosuppressive therapy; however, due to non-identical HLA, the patients may have donor-specific anti-HLA antibody, which may lead to a relatively high incidence rate of poor graft function. Compared with HLA-identical transplantation, conditioning regimen for haploidentical transplantation still needs to be explored. This article reviews the detection and treatment of donor-specific anti-HLA antibody, the selection of conditioning regimen, and the mechanism and treatment of poor graft function in haploidentical hematopoietic stem cell transplantation.

Unmanipulated haploidentical haematopoietic stem cell transplantation for children with severe aplastic anaemia.

Haploidentical haematopoietic stem cell transplantation (haplo-HSCT) used to be a third-line treatment option for childhood severe aplastic anaemia (SAA). We conducted this retrospective study of 36 children (38 transplants) who received haplo-HSCT from human leucocyte antigen (HLA)-mismatched related donors between July 2002 and November 2013 at five HSCT centres in China, including 17 cases that were 5/6 HLA matched (Group 1) and 21 that were 4/6 or 3/6 HLA matched (Group 2). Although patients in Group 2 had a higher incidence of grade II-IV acute graft-versus-host disease (57·9% vs. 5·9%, P = 0·001), they had similar rates of graft failure (5·3% vs. 5·9%, P = 0·742) and overall survival (80·8% vs. 93·8%, P = 0·234) as Group 1. Unmanipulated haplo-HSCT is an effective treatment for SAA children with satisfactory outcome of this cohort, especially in the 5/6 HLA-matched group. For patients in critical situations, such as unresponsive to immunosuppressive therapy, refractory infection and failing first HSCT, to bring forward the timing of haplo-HSCT is a feasible salvage strategy with better and faster donor accessibility.

[FIP1L1/PDGFRalpha fusion gene-negative chronic eosinophilic leukemia with t(5;12)(q31;p13): a case report and review of literatures].

OBJECTIVE: To deepen the understanding of chronic eosinophilic leukemia (CEL). METHODS: The course of diagnosis and treatment in a case of FIP1L1/PDGFRalpha fusion gene negative CEL was reported. Flow cytometry was used to analyze the immunophenotype of the cells in peripheral blood and pleural fluid. Karyotype was analyzed with G-banding. The expression of FIP1L1/PDGFRalpha fusion gene was detected by RT-PCR technique. Routine pathological examination of the tissues from bone marrow, lung and spleen were performed. RESULT: A sixteen-year-old girl had severe anemia, fever, splenomegaly, thrombocytopenia and dominant hypereosinophilia lasting for 22 months. Trephine biopsy showed a hypercellular marrow with eosinophilic proliferation and moderate reticular fibrosis. Eosinophilic infiltration was found in lung and spleen and embolism was also found in spleen. She had a clonal chromosomal abnormality t(5;12)(q31;p13). The expression of FIP1L1/PDGFRalpha was negative. An abnormal clone of T cells expressing CD(3)(-), CD(4)(-), CD(8)(+) was found in peripheral blood and pleural fluid, in which the clonal T cell accounted for 5.43% and 1.66% of the total lymphocytes respectively. The patient was refractory to treatment with hydroxyurea, prednisone and interferon alpha. She had poor response to a combination of therapy with low dose cytosine arabinoside, mitoxantrone, vincristine, cyclophosphamide, methotrexate and prednisone. She did not respond to imatinib and died of multiple organ failure. CONCLUSION: The present case fulfilled the WHO diagnostic criteria of FIP1L1/PDGFRalpha(-) CEL which did not respond to routine treatment and imatinib. Allogenic stem cell transplantation should be considered as early as possible in this case. It is noteworthy that clonal CD(3)(-), CD(4)(-), CD(8)(+)T-cell abnormality is related to the pathogenesis of CEL.

[Safety and effectiveness of tumor-ablative chemotherapy combined with low intensity modified conditioning regimen for 30 patients with hematologic malignancies receiving allogeneic hematopoietic stem cell transplantation].

This study was aimed to investigate the safety and effectiveness of tumor-ablative Chemotherapy combined with low intensity conditioning regiment BUCy/TBICy for patients with hematologic malignancies receiving allogeneic hematopoietic stem cell transplantation (allo-HSCT). The clinical data of 30 patients with hematologic malignancies received above-mentioned therapeutic method from January 2012 to January 2013 was analyzed retrospectively, and the engraftment, GVHD, infection, conditioning-related toxicity, relapse and survival rates were evaluated. All the patients signed the informed consent before transplantation. The median follow-up duration was 20.5 (16.3-27.3) months. The results indicated that all the patients had been engrafted successfully. One year overall survival (OS) and disease-free survival (DFS) rates were 93.3% and 83.3% respectively. No conditioning-related toxicity occurred. The incidences of II-IV grade aGVHD was 37.9%, among which incidence of III-IV grade aGVHD was 3.4%; incidence of extensive cGVHD was 13.8%. So far, 1 case relapsed, 1 case displayed graft rejection, and poor function of graft occurred in 1 case, death occurred in 2 cases(6.7%). It is concluded that tumor-ablative chemotherapy combined with low intensity-modified BUCy/TBICy is safe and effective in allogeneic hematopoietic stem cell transplantation for hematologic malignancies, and it is useful to reduce relapse of hematologic malignancies after transplantation.

[Salvaged allogeneic hematopoietic stem cell transplantation for refractory/recurrent acute myeloid leukemia].

OBJECTIVE: To evaluate the efficacy of salvaged allogeneic hematopoietic stem cell transplantation (allo-HSCT) for refractory/recurrent acute myeloid leukemia (AML). METHODS: A total of 45 patients with refractory/recurrent AML were enrolled from September 2006 to April 2010. The median blasts in bone marrow (BM) were 36% (20% to 92%) before conditioning. The donors were identical siblings (6) or unrelated ones (9) or haploidentical family members (30). Conditioning regiments were individualized according to patients' status, the regimen with high-dose cytarabine plus BuCy/CY was mostly used (20). The patients with impaired organ function received above regimen except using fludarabine instead of cyclophosphamide (16). FLAG followed by reduced-intensified BuCy was employed for the recipients with more than 40% blasts in BM (6) to reduce leukemia burden. TBI/CY or TBI/Fludarabine was used for the recipients with extramedullary infiltration of leukemia or multidrug resistant leukemia. G-CSF, MTX, NVT, Vm26, Acla or Thaltipa was added into conditioning regiments according to leukemia character. RESULTS: All but 2 patients attained durable engraftment. The incidence of grade II to IV aGVHD and cGVHD were 34%, 59.1%, respectively. With median follow-up 30 (0.5 - 57) months, the relapse rate was 29.2%. Twenty-nine of 45 (60.2%) patients remained in complete remission since salvaged HSCT. Three-years disease-free survival and overall survival were 60.2% and 62.6%, respectively. CONCLUSION: Our results indicated that the combination of salvaged HSCT with prophylactic immunotherapy might be a promising modality for treatment of refractory/recurrent AML, even with high leukemia burden.

[Clinical features of severe intestinal graft-versus-host disease in 34 cases following allogeneic hematopoietic stem cell transplantation].

This study was purposed to investigate the clinical features and related factors influencing prognosis of patients with severe intestinal graft-versus-host disease (siGVHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). 710 patients received allo-HSCT in Beijing Dao-Pei hospital from Jan 2007 to Jan 2011 were enrolled in this study. A total of 34 patients with siGVHD out of 710 patients were analyzed retrospectively, and the univariate analysis for related factors influencing prognosis were carried out by using SPSS 19.0 software. The results showed that the incidence of siGVHD was 4.79%, its medium occurrence time was 29 (18 - 210) days after allo-HSCT. 18 out of 34 patients with siGVHD received colonoscopy, among them 6 patients were complicated with viral enteritis. The deep ulcers could be found under colonoscope. Histopathologic examination revealed the viral inclusion bodies or positive viral antigen. Methylprednisolone (MP), cyclosporine A (CsA) or tacrolimus combined CD25 monoclonal antibody and oral budesonide were used for treatment of siGVHD. 29 out of 34 cases achieved complete response (CR) with CR rate of 85.29%, overall survival rate was 58.82% (20/34). 9 out of 29 cases achieving CR died of other complications. The univariate analysis of the related factor indicated the hyperacute GVHD is the adverse factor influencing overall survival of patients with siGVHD. It is concluded that early colonoscopy is an effective way for definitive diagnosis of siGVHD. The combined treatment including MP, CsA or tacrolimus, CD25 monoclonal antibody and oral budesonide shows a significant curative effects. Intensive treatment of complications in late period of GVHD can enhance the overall survival rate.

[Successful treatment of high risk/refractory leukemia by tumor-ablative individualized conditioning allogeneic hematopoietic stem cell transplantation].

OBJECTIVE: To explore the efficacy of tumor-ablative individualized allogeneic hematopoietic stem cell transplantation for the treatment of patients with high risk/refractory leukemia. METHODS: Fivety-seven patients with high risk/refractory leukemia were enrolled. Tumor-ablative individualized conditioning regimens included HDAra-C + Bu/Cy, Ara-C + Bu/Fludarabine, G-CSF primed HDAra-C + Bu/Cy, and FLAG followed by reduced-intensified BuCy. Overall survival (OS), disease free survival (DFS), graft versus host disease, infection and relapse post grafting were analyzed. RESULTS: Fifty-six patients attained durable engraftment. The median follow-up duration was 17.5 (2 - 34) months. The 18 months probabilities of OS and DFS were (74.7 ± 6.1)% and (62.4 ± 6.7)%, respectively. In addition, the 18 months probabilities of OS and DFS in patients who attained complete remission (CR) before transplantation were (74.2 ± 7.1)% and (58.8 ± 8.1)%, respectively, while in those not attained CR were (77.0 ± 11.8)% and (72.7 ± 11.7)%, respectively. Twenty nine patients developed acute GVHD (aGVHD) (grade I in 18, grade II in 4, grade III in 2 and grade IV in 5). The probabilities of aGVHD was (50.9 ± 6.6)% by Kaplan-Meier curve analysis. The probabilities of grades 2-4 and grades 3-4 aGVHD were (19.3 ± 5.2)% and (12.3 ± 4.3)% respectively. Extensive chronic GVHD (cGVHD) was observed in 36 patients. The probabilities of cGVHD was (64.3 ± 6.4)% by Kaplan-Meier curve analysis. Cytomegaloviremia (CMV) was observed in 39 (68.42%) patients, hemorrhagic cystitis in 13 (22.8%) patients, fungous infection in 16 (28.07%) patients and bacterial infection in 38 (66.67%) patients. Relapse occurred in 14 patients (hematologic relapse in 11 and extramedullary relapse in 3), probabilities of relapse being (24.6 ± 5.7)%. The 17.5-month probability of relapse in patients who attained CR before transplantation was (28.1 ± 7.7)%, while in those not attained CR was (15.6 ± 10.2)%. Fifteen patients died (6 from hematological relapse, 5 from infection of bacterial and fungous, 4 from cGVHD) after 100 days. CONCLUSION: Tumor-ablative individualized allogeneic hematopoietic stem cell transplantation is a promising and safe choice for treatment of high risk/refractory leukemia, even with high leukemia burden.

[Diagnostic value of plasma (1, 3)-beta-D glucan assay for invasive fungal infections in patients with hematological disorders].

The invasive fungal infections (IFI) in immunocompromised patients are associated with a high mortality rate and diagnostic difficulty. Serological methods such as aspergillus galactomannan assay (GM test) and (1, 3)-beta-D glucan (BG) assay (G test) can be used as an adjunctive method for IFI diagnosis based on their characteristics of easy-operating, rapidness and high sensitivity. Compared with GM test, G test can be more widely used except for the diagnosis of aspergillosis. The purpose of this study was to investigate the value of G test in the diagnosis of IFI in patients with hematological disorders. The plasma was collected from 162 suspected IFI patients with hematological disorders in Beijing Daopei Hospital, including 85 patients after chemotherapy and 77 patients after stem cell transplantation from May 2007 to May 2008, BG level was measured with MB-80 Microbiology Kinetic Rapid Reader and the measured results together with the clinical characteristics were retrospectively analyzed. According to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria, there were 2 patients diagnosed as proven IFI, 18 as probable IFI, 75 as possible IFI and 67 as no IFI. The results showed that at a cutoff of 20 pg/ml, the sensitivity and specificity of G test were 75% and 91% respectively, with a positive predictive value (PPV) of 71.4% and a negative predictive value (NPV) of 92.4%. 51 out of the 75 possible IFI patients with elevated BG level were responsive to antifungal treatment but non responsive to broad-spectrum antibiotics, retrospectively were diagnosed as IFI, suggesting that G test improved the IFI diagnostic rate by 31.4%. In conclusion, G test is a rapid and simple method for early diagnosis of IFI in patients with hematological disorders.