RESUMEN
Therapeutic effects of haematopoietic stem cell transplantation are not limited to maximal chemoradiotherapy and subsequent bone marrow regeneration, but include specific as well as unspecific immune reactions known as graft-versus-leukaemia (GvL) effects. Specific immune reactions are likely to be particularly relevant to the long-term treatment of diseases, such as chronic myeloid leukaemia (CML), in which residual cells may remain quiescent and unresponsive to cytotoxic and molecular therapies for long periods of time. Specific GvL effects result from the expression on leukaemic cells of specific tumour-associated antigens (TAAs) in the context of HLA proteins. As human leukocyte antigen (HLA) types vary widely, the development of broadly applicable tumour vaccines will require the identification of multiple TAAs active in different HLA backgrounds. Here, we describe the identification of NM23-H2 as a novel HLA-A32-restricted TAA of CML cells and demonstrate the presence of specifically reactive T cells in a patient 5 years after transplantation. As the NM23 proteins are aberrantly expressed in a range of different tumours, our findings suggest potential applications beyond CML and provide a new avenue of investigation into the molecular mechanisms underlying CML.
Asunto(s)
Leucemia Mielógena Crónica BCR-ABL Positiva/inmunología , Nucleósido Difosfato Quinasas NM23/inmunología , Adulto , Células Presentadoras de Antígenos/inmunología , ADN Complementario , Ensayo de Inmunoadsorción Enzimática , Humanos , Hibridación Fluorescente in Situ , Leucemia Mielógena Crónica BCR-ABL Positiva/tratamiento farmacológico , Leucemia Mielógena Crónica BCR-ABL Positiva/cirugía , Masculino , Nucleósido Difosfato Quinasas NM23/genética , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Linfocitos T/inmunologíaRESUMEN
Although thymoglobulin and alemtuzumab are frequently used in hematopoietic stem cell transplantation (HSCT), little is known of their effects on NK cells, which mediate important functions in post-transplantation immunology. In the present study, we determined NK cell death in vitro using propidium iodide and Annexin V. The NK cell activity in 34 patients at day +30 after allogeneic HSCT was assessed using the CD107a assay. Alemtuzumab and thymoglobulin were similarly very potent in inducing NK cell death in vitro. Even in low concentrations (<1 microg/ml) the antibodies induced apoptosis and necrosis in a relevant percentage of NK cells (>30%). However, the number of tumor reactive (CD107a+) NK cells was 13.16 per mul and 1.15 per microl (mean) in patients receiving T-cell depletion with 6 mg/kg thymoglobulin and in patients receiving 100 mg alemtuzumab, respectively (P=0.02). Although thymoglobulin and alemtuzumab are equally NK cell toxic in vitro, the recovery of NK cell frequency and anti-tumor reactivity is reduced in recipients of alemtuzumab. Our findings can be explained by a longer half-life of alemtuzumab as compared to active thymoglobulin under therapeutic conditions. Prolonged immunosuppression with increased risk of infections and tumor relapse are a potential threat to patients undergoing HCST and receiving alemtuzumab as T-cell depletion.
Asunto(s)
Anticuerpos Monoclonales/farmacología , Anticuerpos Antineoplásicos/farmacología , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Inmunosupresores/farmacología , Células Asesinas Naturales/efectos de los fármacos , Depleción Linfocítica/efectos adversos , Adolescente , Adulto , Anciano , Alemtuzumab , Anticuerpos Monoclonales Humanizados , Suero Antilinfocítico , Apoptosis/efectos de los fármacos , Muerte Celular/efectos de los fármacos , Línea Celular Tumoral , Humanos , Persona de Mediana Edad , Trasplante HomólogoRESUMEN
Human cytomegalovirus (CMV) is a major cause of death after transplantation. The frequency of pp65-specific T cells was examined in 38 HLA-A2+ stem cell recipients during the first year after transplantation. Patients were divided into four groups based on donor/recipient serostatus: d+/r+ (n=17), d+/r- (n=7), d-/r+ (n=9) and d-/r- (n=5). Peripheral blood mononuclear cells were stimulated with the CMVpp65 peptide NLVPMVATV, and the specific T-cell frequency was assessed by interferon gamma (IFN-gamma) ELISPOT assay. Responding T cells were characterized by flow cytometry revealing a terminal differentiated effector phenotype. Surveillance of CMV infection was carried out by real-time polymerase chain reaction (n=26) or immunofluorescence (n=12). Infection was present in 7/9 d-/r+ high-risk patients, and CMV disease occurred exclusively in this group with delayed or absent virus-specific T-cell recovery. In contrast, 16/24 intermediate-risk patients showed CMV-specific T cells. Our data suggest that CMV infection and disease rates are elevated in high-risk patients with delayed CMV-specific T-cell immune reconstitution and lower in those with early recovery of T-cell immunity. We recommend preferring CMV seropositive donors for CMV seropositive recipients, as this should lead to durable CMV-specific T-cell responses soon after transplantation with consecutive protection from CMV disease.
Asunto(s)
Linfocitos T CD8-positivos/inmunología , Infecciones por Citomegalovirus/inmunología , Citomegalovirus/inmunología , Recuperación de la Función/inmunología , Trasplante de Células Madre , Adolescente , Adulto , Anciano , Femenino , Estudios de Seguimiento , Antígeno HLA-A2/inmunología , Neoplasias Hematológicas/inmunología , Neoplasias Hematológicas/terapia , Humanos , Interferón gamma/inmunología , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico , Péptidos/inmunología , Fosfoproteínas/inmunología , Factores de Riesgo , Trasplante Homólogo , Proteínas de la Matriz Viral/inmunologíaRESUMEN
Transplantation-associated microangiopathy (TAM) or renal insufficiency (RI) after allogeneic hematopoietic stem cell transplantation is associated with a high mortality. As calcineurin inhibitors (CI) may contribute to TAM or RI, we evaluated the efficacy of replacing CI by daclizumab in patients with graft-versus-host disease (GVHD). Thirteen patients with GVHD-associated TAM and five patients with RI were treated with daclizumab 1 mg/kg intravenous (i.v.)/week, discontinuation of the CI and continuation of the remaining GVHD treatment. All patients had acute GVHD (steroid-sensitive (n=4), steroid-refractory (n=10)) or chronic GVHD (n=4) and were treated with CI before the start of daclizumab. Nine of 13 patients with TAM treated with daclizumab and discontinuation of CI achieved complete remission of TAM, two had stable disease, and one patient did not respond. Patients receiving daclizumab for RI without TAM showed stabilization (2/5) or improvement (3/5) of renal function. Four of 14 patients with acute GVHD achieved CR, two partial remission, eight patients did not respond and 11/14 died at a median of 39 days after start of the daclizumab. Our data demonstrate that replacement of CI by daclizumab can improve TAM and RI. However, mortality remains high in patients with acute GVHD.
Asunto(s)
Anticuerpos Monoclonales/administración & dosificación , Enfermedad Injerto contra Huésped/tratamiento farmacológico , Trasplante de Células Madre Hematopoyéticas , Inmunoglobulina G/administración & dosificación , Inmunosupresores/administración & dosificación , Insuficiencia Renal/tratamiento farmacológico , Enfermedades Vasculares/tratamiento farmacológico , Enfermedad Aguda , Adolescente , Adulto , Anciano , Anticuerpos Monoclonales Humanizados , Inhibidores de la Calcineurina , Daclizumab , Femenino , Enfermedad Injerto contra Huésped/etiología , Enfermedad Injerto contra Huésped/mortalidad , Neoplasias Hematológicas/complicaciones , Neoplasias Hematológicas/mortalidad , Neoplasias Hematológicas/terapia , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Trasplante de Células Madre Hematopoyéticas/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia Renal/etiología , Insuficiencia Renal/mortalidad , Trasplante Homólogo , Enfermedades Vasculares/etiología , Enfermedades Vasculares/mortalidadRESUMEN
Radioimmunotherapy (RIT) of relapsed lymphoma is gaining increasing importance. Especially the commercially available anti-CD20 antibody 90Y-ibritumomab tiuxetan is currently under investigation in various trials including dose escalation and autologous hematopoietic progenitor cell support. It is not clear, however, whether the implementation of this radiolabeled antibody into another treatment option for relapsed or poor risk lymphoma patients-allogeneic hematopoietic cell transplantation-interferes with or delays successful engraftment. This study reports encouraging results with 2 relapsed lymphoma patients (1 transformed marginal zone lymphoma and 1 mantle cell lymphoma) who underwent allogeneic hematopoietic cell transplantation from HLA-matched donors. The conditioning regimen consisted of Rituximab 250 mg m(-2) on days -21 and -14, 0.4 mCi kg(-1) body weight 90Y-ibritumomab tiuxetan on day -14 and fludarabine (30 mg m(-2)) plus cyclophosphamide (500 mg m(-2)) on days -7 to -3. The data demonstrate that engraftment is fast and reliable with leukocytes >1 x 10(9) L(-1) on day 12 and platelets >50 x 10(9) L(-1) on day 10. Thus, the incorporation of radioimmunotherapy into allogeneic transplant protocols combines established modalities with proven anti-lymphoma activity and, hence, offers an attractive new therapeutic option for relapsed lymphoma patients.
Asunto(s)
Anticuerpos Monoclonales/uso terapéutico , Antineoplásicos/uso terapéutico , Trasplante de Células Madre Hematopoyéticas , Linfoma de Células B Grandes Difuso/terapia , Linfoma de Células del Manto/terapia , Radioinmunoterapia , Acondicionamiento Pretrasplante/métodos , Adulto , Anticuerpos Monoclonales/administración & dosificación , Antineoplásicos/administración & dosificación , Ciclofosfamida/administración & dosificación , Ciclofosfamida/uso terapéutico , Progresión de la Enfermedad , Estudios de Seguimiento , Humanos , Linfoma de Células B Grandes Difuso/tratamiento farmacológico , Linfoma de Células del Manto/tratamiento farmacológico , Masculino , Recurrencia , Inducción de Remisión , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Vidarabina/administración & dosificación , Vidarabina/análogos & derivados , Vidarabina/uso terapéutico , Radioisótopos de Itrio/administración & dosificación , Radioisótopos de Itrio/uso terapéuticoRESUMEN
The activation of natural killer (NK) cells leads to degranulation and secretion of cytotoxic granula. During this process, the lytic granule membrane protein CD107a becomes detectable at the cell surface. Based on this phenomenon, we have analyzed by a novel flow cytometry-based assay, the number and phenotype of NK cells responding to tumor targets. Using human leukemia and lymphoma cell lines, we observed a close correlation between CD107a surface expression and target cell lysis, indicating that NK cell cytotoxicity can be assessed by this method. The number of degranulating NK cells was closely related to the ratio of effector and target cells and showed a maximum at a ratio of 1:1. Moreover, we were able to show that the population of CD56(dim)/CD16(neg) NK cells is primarily responsible for the cytotoxic activity against tumor targets whereas neither CD56(dim)/CD16(pos) nor CD56(bright) NK cells degranulated in response to the cell lines. Our results indicate that the CD107a assay represents a promising new method for the quantification and characterization of cells exhibiting natural cytotoxicity.
Asunto(s)
Antígeno CD56/metabolismo , Citotoxicidad Inmunológica , Inmunidad Innata , Células Asesinas Naturales/inmunología , Leucemia/inmunología , Antígenos CD/análisis , Antígenos CD/biosíntesis , Antígenos CD/genética , Antígeno CD56/análisis , Degranulación de la Célula/inmunología , Línea Celular Tumoral , Citometría de Flujo , Humanos , Células Asesinas Naturales/metabolismo , Proteína 1 de la Membrana Asociada a los Lisosomas , Proteínas de Membrana de los Lisosomas , FenotipoRESUMEN
With increasing donor age, the potential of transmitting diseases from donor to recipient reaches new dimensions. Potentially transmittable diseases from donors include infections, congenital disorders, and acquired illnesses like autoimmune diseases or malignancies of hematological or nonhematological origin. While established nonmalignant or malignant diseases might be easy to discover, early-stage hematological diseases like CML, light-chain multiple myelomas, aleukemic leukemias, occult myelodysplastic syndromes and other malignant and nonmalignant diseases might not be detectable by routine screening but only by invasive, new and/or expensive diagnostic tests. In the following article, we propose recommendations for donor work-up, taking into consideration the age of the donors. In contrast to blood transfusions, stem cells from donors with abnormal findings might still be acceptable for HCT, when no other options are available and life expectancy is limited. This issue is discussed in detail in relation to the available donor and stem cell source. Finally, the recommendations presented here aim at harmonized worldwide work-up for donors to insure high standard quality.
Asunto(s)
Envejecimiento , Selección de Donante , Trasplante de Células Madre/efectos adversos , Trasplante de Células Madre/métodos , Donantes de Tejidos , Factores de Edad , Enfermedades Autoinmunes/etiología , Transfusión Sanguínea , Células de la Médula Ósea/microbiología , Células de la Médula Ósea/parasitología , Células de la Médula Ósea/virología , Transmisión de Enfermedad Infecciosa/prevención & control , Enfermedades Hematológicas/etiología , Enfermedades Hematológicas/terapia , Prueba de Histocompatibilidad , Humanos , Leucemia/etiología , Leucemia/terapia , Tamizaje MasivoRESUMEN
Kinetics of BCR-ABL transcript elimination and its prognostic implications on relapse were analyzed in patients with chronic myeloid leukemia (CML) after reduced intensity hematopoietic cell transplantation (HCT). In all, 19 CML patients were conditioned with 2 Gy total-body irradiation in combination with (n=14) or without (n=3) fludarabine 3 x 30 mg/m(2) (Flu) or 4.5 Gy total lymphoid irradiation (TLI) with Flu and OKT3 3 x 5 mg (n=2) and were treated with cyclosporine (CSP) and mycophenolate mofetil after allogeneic HCT. BCR-ABL transcripts were analyzed by nested RT-PCR and Taqman((R)) RT-PCR on days +28, +56 and +84 after HCT and were evaluated for their association with relapse. Of the 19 patients, 14 achieved sustained remissions of which six had a negative RT-PCR 28 days after HCT. Five patients relapsed +41, +54, +57, +136 and +234 days after HCT. Predictors for relapse were advanced disease stage (P=0.02) and slow reduction of BCR-ABL transcripts at day 28 (P=0.006) and day 56 (P=0.047) post-transplant. We conclude that a complete clearance of BCR-ABL transcripts is achievable within 4 weeks from HCT even after minimal conditioning and that early kinetics of BCR-ABL transcripts significantly correlate with the probability of hematological relapse.
Asunto(s)
Proteínas de Fusión bcr-abl/genética , Trasplante de Células Madre Hematopoyéticas , Leucemia Mielógena Crónica BCR-ABL Positiva/diagnóstico , Ácido Micofenólico/análogos & derivados , Recurrencia Local de Neoplasia/diagnóstico , ARN Mensajero/análisis , Acondicionamiento Pretrasplante , Vidarabina/análogos & derivados , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Terapia Combinada , Ciclosporina/administración & dosificación , Femenino , Sistema Hematopoyético/efectos de los fármacos , Sistema Hematopoyético/efectos de la radiación , Humanos , Leucemia Mielógena Crónica BCR-ABL Positiva/genética , Leucemia Mielógena Crónica BCR-ABL Positiva/terapia , Masculino , Persona de Mediana Edad , Ácido Micofenólico/administración & dosificación , Recurrencia Local de Neoplasia/genética , Recurrencia Local de Neoplasia/terapia , Pronóstico , ARN Neoplásico/genética , ARN Neoplásico/metabolismo , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Sensibilidad y Especificidad , Trasplante Homólogo , Vidarabina/administración & dosificación , Irradiación Corporal TotalRESUMEN
The haemodynamic and electrophysiological benefits of dual chamber pacing are well recognized at the cost of a more complex and expensive implant. In selected groups of patients VDD-mode dual chamber pacing offers the advantages of dual chamber pacing with the use of a single catheter and is nowadays gaining increasing popularity. The following report describes an uncommon and potentially harmful pacemaker malfunction secondary to the dislodgement of the catheter.
Asunto(s)
Falla de Equipo , Bloqueo Cardíaco/diagnóstico , Hipertensión/diagnóstico , Marcapaso Artificial , Anciano , Anciano de 80 o más Años , Cateterismo Cardíaco/instrumentación , Estimulación Cardíaca Artificial , Electrocardiografía , Electrocardiografía Ambulatoria , Femenino , Estudios de Seguimiento , Bloqueo Cardíaco/terapia , Humanos , Hipertensión/terapia , Radiografía TorácicaRESUMEN
The paper describes the diagnosis, clinical, anatomopathological and etiopathogenetic aspects of a case of congenital multiple arthrogryposis. The importance of the dialogue between the obstetrician and the parents is underlined in terms of the latters' psychological preparation. The obstetrician must also prepare for an atraumatic delivery, in addition to planning the treatment protocol for the neonate.