[Allogeneic hematopoietic stem cell transplantation for acute myeloblastic leukemia in first remission].

AIM: To evaluate the efficiency of allogeneic hematopoietic stem cell transplantation (allo-HSCT) in patients with acute myeloblastic leukemia in first remission depending on the regimens of conditioning, the source of a graft, and the characteristics of a donor and a recipient. SUBJECTS AND METHODS: In 66 treated patients, including from partially HLA-mismatched relatives (n=4), the efficiency of allo-HSCT from related donors (n=26) and unrelated donors (n=40), were compared. According to cytogenetic findings, 7 (11%), 31 (47%), and 10 (15%) patients belonged to low-, intermediate-, and high-risk groups, respectively. RESULTS: Five-year overall survival (OS) and mortality associated with transplantation were 56 and 22% for allo-HSCT from related donors, 68 and 23% for that from HLA-matched donors, and 71 and 25% for that from partially HLA-mismatched donors, respectively (p=0.8 and p=0.7). The relapse risk after allo-HSCT from unrelated donors was significantly lower than after that from related donors (13 and 35%, respectively; p=0.8). Univariate analysis showed that the OS rates depended on the cytogenetic risk group (OS was 24 and 64% in the high- and intermediate-risk groups, respectively (p=0.027). The relapse risk in chronic graft-versus-host reaction (GVHR) and in grade 3 acute GVHR (p=0.01) was shown to be less than that in grades 1-2 acute GVHR (p=0.06). CONCLUSION: OS rates after allo-HSCT from related and unrelated donors were comparable and unrelated to the source of a graft, the regimen of conditioning, and other characteristics of a donor and a recipient.

[Efficacy of donor lymphocyte infusion in patients after different types of allogeneic hematopoietic stem cell transplantation].

AIM: To evaluate the efficacy of donor lymphocyte infusion (DLI) to prevent and treat recurrences in patients after different types of allogeneic hematopoietic stem cell transplantation (allo-HSCT). SUBJECTS AND METHODS: Data from 118 patients with malignant blood diseases were analyzed. Allo-HSCTs from HLA-matched related donors (n=49), HLA-matched unrelated donors (n=50), partially HLA-matched unrelated donors (n=2), and haploidentical donors (n=24) were performed. The indications for DLI were underlying disease relapse (59 DLIs), resistant disease course (n=40), minimal residual disease (n=1 6), falling donor chimerism (n=1 5), and recurrence prevention (n=1 3). RESULTS: Therapy response was obtained after 57 (44%) DLls. There were 36 (25%) and 30 (21%) cases of acute and chronic graft-versus-host reactions (GVHR), respectively. The use of DLI from HLA-matched donors, its performance in the periods of D+100 to one year after allo-HSCT, a donor chimerism level of over 90% at the moment of DLI, the administration of the initial DLI dose of below 1.10(6) CD3+/kg, and the development of chronic GVHR after DLI were associated with the highest rate of therapy responses. The overall survival rates of patients with DLI were significantly influenced by factors, such as DLI periods, donor chimerism levels at DLI, and the development of chronic CVHR after DLI. CONCLUSION: The choice of the optimal dose of cells, the periods of DLI and its preventive administration improve prognosis in patients after allo-HSCT. The occurrence of acute GVHR is affected by the degree of HLA matching and the type of a donor. The development of chronic GVHR after DLI is associated with the highest rate of responses to DLI and higher survival rates.

[Extracorporeal photopheresis in the treatment of patients with refractory chronic graft-versus-host disease after allogeneic bone marrow transplantation].

AIM: To evaluate the efficiency of extracorporeal photopheresis (ECP) in the treatment of patients with refractory chronic graft-versus-host disease (cGVHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). SUBJECTS AND METHODS: The study included 49 patients aged 2 to 55 years. Allo-HSCT was carried out in 38 (79%) patients with acute leukemias, 5 (10%) with chronic leukemias, 4 (8%) with myelodysplastic syndrome/myeloproliferative disease, and 2 (3%) with other hematologic diseases. The patients included in the study had glucocorticosteroid (GCS)-refractory disseminated cGVHD or a history of severe complications from GCS therapy. RESULTS: When evaluating the efficiency of therapy, its response was recorded in 37 (77%) cases; the best results were obtained in patients with hepatic (82%), mucosal (76%), and skin (74%) lesions. The mean severity according to the cGVHD Working Group, National Institutes of Health, and a platelet level of more than 100.10(9)/1 were defined as factors improving a therapy response. In the patients receiving ECP, the overall survival was 70%. The latter was higher in the group of patients who had responded to ECP therapy without involving the gastrointestinal tract in the cGVHD process and in those receiving a combination of ECP and other immunosuppressive drugs. CONCLUSION: ECP is an effective treatment for patients with refractory cGVHD, it may be used in those with a history of severe complications from GCS therapy. ECP allows the dose of GCS to be reduced to the point of complete discontinuation.

[Our experience with tracheotomy in the hematological patients in need of prolonged artificial lung ventilation].

The objective of the present work was to study the possibility and technical peculiarities of planned tracheotomy in the hematological patients with thrombocytopenia and coagulopathy suffering severe concomitant pathology. A total of 45 tracheotomies were performed in hematological patients during the period from 2009 till July 2012. The case histories of 32 patients were available for the retrospective analysis. At the time of surgical intervention, 81% of the patients presented with grade IV thrombocytopenia. Five of the patients (15.6%) suffered bleeding from the tracheostomic canal in the early postoperative period. In four of them, hemorhage was stopped by the placement of the hemostatic sponge. One patient had to be managed by means of cauterization . Two (6.25%) patients developed inflammation around tracheotsoma. It is concluded that thrombocytopenia and probable coagulopathy do not constitute an absolute contraindication for planned tracheostomy. However, such operation may have a favourable outcome only after preliminary transfusion, the application of cauterization, and delicate surgical intervention.

[Invasive mucormycosis in patients with hemoblastosis in St.-Petersburg].

Thirty four patients with mucormycosis in 10 hospitals of St. Petersburg were observed in 2004-2013. The most frequent underlying diseases of mucormycosis were acute leukoses (64%). In 100% of the patients mucormycosis developed as a nosocomial infection. The risk factors, etiology, basic clinical signs and strategy in the treatment of mucormycosis were analyzed.

[Invasive mycoses during hematopoietic stem cell transplantation].

AIM: To define the frequency, etiology, and risk factors of invasive mycoses (IM) in patients with allogeneic (allo) and autologous (auto) hematopoietic stem cell transplantation (HSCT) and to evaluate the impact of IM on overall survival (OS). MATERIALS AND METHODS: Data on 356 patients after allo-HSCT (n = 237) and auto-HSCT (n = 119) from 2000 to 2010 were analyzed. The diagnosis of IM was established according to the EORTC/MSG 2008 criteria. RESULTS: The incidence of myocardial infarction (MI) was 19.1%; that was 23.2 and 10.9% in allo-HSCT and auto-HSCT recipients, respectively. The incidence of MI following allo-HSCT was significantly higher than that after auto-HSCT. Aspergillus spp. (82.3%), Candida spp. (11.8%), zygomycetes (Mucor spp., Rhizopus spp.) (4.4%), and Cryptococcus neoformans (1.5%) are involved in the etiology of MI. Its risk factors are acute lymphoblastic leukemia; non-myeloablative conditioning regimen; use of fludarabine and antilymphocyte globulin; peripheral blood stem cells as a source for grafting; long-term lymphopenia, neutropenia; use of granulocyte colony-stimulating factor (G-CSF); acute graft-versus-host reaction; grade 3-4 mucositis; infections, such as cytomegalovirus, sepsis. The development of MI in HSCT recipients did not significantly reduce one-year OS after allo-HSCT and auto-HSCT--53.6 and 55% and 86.7 and 90.3% (with and without MI, respectively). In patients with invasive aspergillosis, OS (12 weeks after IM being diagnosed) was significantly longer in those with other invasive mycoses (91.3 and 50%, respectively). CONCLUSION: The incidence of MI after allo-HSCT was higher than that after auto-HSCT. MI induced by the fungal genus Aspergillus spp. was most common. Along with known risk factors, there was a poor prognostic factor, such as G-CSF. The development of MI failed to affect one-year OS, which was indicative of the adequate quality of its early diagnosis and therapy. The prognosis was poor in patients with invasive candidiasis, zygomycosis, and cryptococcosis. Investigations need to be continued to specify the reasons for high morbidity rates and the factors provoking discussion by investigators worldwide.

[Complex chromosome damages in patients with recurrent acute leukemias after allogeneic hematopoietic stem cell transplantations].

AIM: To study the pattern of complex chromosome damages (CCD) in acute leukemias (AL) and their place in the development of post-transplant recurrences (PTR) of AL. MATERIALS AND METHODS: Cytogenetic and partially molecular biological studies of bone marrow cells were conducted in 10 patients with PTR. Of them, 6 patients were diagnosed as having acute lymphoblastic leukemia (ALL), including T-ALL and Ph-positive ALL in 2 and 4 patients, respectively; and 4 patients had acute non-lymphoblastic leukemia (ANLL), including one case secondarily induced by previous polychemotherapy (PCT) and irradiation. The standard G-band staining technique complemented by multicolor fluorescence in situ hybridization in one of the cases was used. RESULTS: It was shown that CCD had the similar pattern in 4 patients before transplantation and in PTR, progressed in 4 more patients, was absent or unnoticed in the early stage of the disease. The other recurrent chromosomal abnormalities that are worthy of notice are as follows: a) the presence of two Ph chromosomes in the cells of two of the 4 patients with Ph+ ALL; b) the frequent involvement of chromosome pairs 9, 19, 5, and 7 into the numerical and structural rearrangements. CONCLUSION: The important feature of PTR of AL is cellular CCDs, a portion of which is clearly related to previous PCT and may be of pathogenetic value for the development of recurrences.

[The experience in non-relative allogenic transplantation of stem hemopoietic cells in the Clinic of Bone Marrow Transplantation at I.P. Pavlov St-Petersburg Medical Academy].

AIM: To evaluate efficacy of allogenic transplantation of hemopoietic stem cells (allo-THSC) from non-relative donor in patients with hematological diseases in the Clinic of Bone Marrow Transplantation at L.P. Pavlov St-Petersburg Medical Academy for the period 2000-2006. MATERIAL AND METHODS: A total of 84 allo-THSC from non-relative donor to patients aged from 10 months to 65 years (median 18 months, 44 years) was carried out. RESULTS: Six-year overall survival (OS) in all the patients was 51.4%, in remission of AML--66.7%, ALL--33%, depending on the presence or absence of acute reaction graft versus host reaction (GVHR)--54 and 50.9%, chronic FVHR--75.6 and 58.2%, blood group compatibility or incompatibility in donor/recipient pairs--58.4 and 47.9%, by gender--61.4 and 40.6%, in use of HSC of the bone marrow--58.3%, peripheral blood--26.7%. OS in the dose of transplanted CD 34+ cells per 1 kg body mass < 5.0 x 10(6)/kg--173%, in the dose 5.0--8.0 x 10(6)/kg--38.8%, > 8.0 x 10(6)/kg--35.5%. Acute GVHR developed in 56% patients, chronic--in 20%, hemorrhagic cystitis--in 27.7%, bacterial, cytomegalovirus and fungal infection--in 10, 70 and 30%, respectively. The causes of death were acute GVHR (20%), infection 99%), polyorganic failure (4%), transplant rejection (5.3%), recurrence (18.7%). CONCLUSION: Bone marrow transplantation clinics in the Russian Federation must develop all kinds of allo-THSC--relative, non-relative and haploidentical using bone marrow, peripheral blood, umbilical blood as the source of HSC. It is necessary to create a national register of non-relative donors.

[Use of dexamethasone in treatment of high- and low-grade non-Hodgkin's lymphoma]. / Primenenie deksametazona pri nekhodzhinskikh limfomakh vysokoi i nizkoi stepeni zlokachestvennosti.

Since it exerts a stronger antitumor action than predinisolone, dexamethasone was used for therapy of patients with non-Hodgkin's lymphoma refractory to CHOP. All patients (66), resistant to CHOP, suffered bone marrow involvement. Dexamethasone pulsed therapy was given to 45 patients, with 21 COP-BLAM or ASHAP, MAD, Dexa-BEAM treated in control. Median response duration in high- and low-grade non-Hodgkin's lymphoma groups was 2 and 12 months, respectively.

[Effectiveness of dose-intensive polychemotherapy with autologous hemopoietic cell transplantation for high-grade non-Hodgkin lymphoma]. / Effektivnost' intensifikatsii polikhimioterapii, vkliuchaia autologichnuiu transplantatsiiu gemopoéticheskikh kletok, u bol'nykh nekhodzhkinskimi limfomami vysokoi stepeni zlokachestvennosti.

The study included 29 patients with high-grade non-Hodgkin's lymphoma. Nine patients (group 1) received 6-8 cycles of CHOP, another 20-6 cycles of CHOP and Dexa-BEAM followed by autologous hemopoietic cell transplantation with CBV or BEAM conditioning regimen (bone marrow or peripheral stem cells) (group 2). The groups were comparable as far as gender and age are concerned. Overall 5-year survival was in 24.1 and 71.4%, respectively. Double CHOP-Dexa-BEAM plus autologous hemopoietic cell transplantation proved superior to standard CHOP-therapy.

[Effectiveness of high-dose polychemotherapy and autologous hemopoietic cell transplantation in patients with low-grade non-Hodgkin lymphoma]. / Effektivnost' intensifikatsii polikhimioterapii i autologicheskoi transplantatsii gemopoéticheskikh kletok u bol'nykh nekhodzhkinskimi limfomami nizkoi stepeni zlokachestvennosti.

The study included 70 patients with high-grade malignant non-Hodgkin's lymphoma (Kiel) who received the following treatment: group 1(24)--6-8 cycles of CHOP; group 2 (relapse or tumor progression after standard chemotherapy--13)--6 cycles of CHOP and Dexa-BEAM, and group 3 (relapse or tumor progression after standard chemotherapy--8)--6 cycles of CHOP plus Dexa-BEAM plus autologous hemopoietic cell transplantation with CBV or BEAM conditioning regimen (bone marrow or peripheral stem cells). The groups were comparable as far as gender and age are concerned. Overall 5-year survival rates were 81, 20 and 48%, respectively. CHOP-Dexa-BEAM plus autologous hemopoietic cell transplantation proved superior to CHOP-Dexa-BEAM alone.

[Administration of liposomal preparation of DaunoXome for breast cancer in patients with poor prognosis]. / Opyt primeneniia liposomnogo preparata Daunokhome u bol'nykh prognosticheski neblagopriiatnymi formami raka molochnoi zhelezy.

A liposomal drug DaunoXome was used as a single agent for stage III-IV breast cancer in 9 patients. Response was recorded in 6; partial regression of tumor--3, and stabilization of disease--in 3 cases. Nausea and vomiting were among the most frequent side-effects; stage I leukopenia was observed in 4; stage II--3, stage III--2 patients. No cardiotoxicity was reported.

[A trial of using allogeneic bone marrow transplantation in children with different hematologic neoplastic diseases]. / Opyt primeneniia allogennoi transplantatsii kostnogo mozga u detei s razlichnymi onkogematologicheskimi zabolevaniiami.

AIM: To define optimal time for transplantation of bone marrow (TBM) in children with hematological malignancies. MATERIALS AND METHODS: 20 allogenic TBMs were performed in children with acute myeloblastic leukemia (6 patients, 2 of them in recurrence), acute lymphoblastic leukemia (7 patients, 4 of them in recurrence), chronic myeloid leukemia (CML) in a chronic stage (3 patients), severe aplastic anemia (3 patients), generalized neuroblastoma (1 patient). Pretransplantation preparation included cyclophosphamide and busulphane or cyclophosphamide, busulphane and vepezide. The graft-versus-host reaction (GVHR) was prevented with cyclosporin A plus methotrexate or cyclosporin A plus urbazone. Engrafting was recognized by change of karyotype and blood group. RESULTS: From 13 children with acute leukemia subjected to TBM in a complete remission 4(33%) are alive, 5 died within 100 days after TBM (TBM was made in recurrence in 4 children), 3 patients died of recurrence 12 months after TBM. One patient with CML and one with severe aplastic anemia remain in remission. The main complications and causes of death in early posttransplantation period were hemorrhagic syndrome, infectious complications, GVHR. According to a one-year follow-up, the recurrent disease caused death most frequently. CONCLUSION: Positive result of TBM is related to the disease stage at transplantation.

[Detection of chromosome translocation t(9;22) using RT-PCR]. / Vyiavlenie khromosomnoi translokatsii t(9;22) metodom RT-PTSR.

The investigation deals with a simplified modification or molecular-genetic detection of translocation t(9;22) using a combination of reverse transcription and polymerase chain reactions (RT-PCR). Unlike the available protocols, analysis is carried out using one enzyme--TET-Z polymerase--(instead of two) which has both revertase and DNA-polymerase activities. The present modification is highly sensitive, less time-consuming and cheaper. The method has proved useful for both diagnosing t(9;22) translocation and diagnosing and monitoring minimal residual disease remaining after marrow transplantation.

[PCR-detection of cytomegalovirus infection in oncologic and non-oncologic patients with organ and tissue transplantation]. / PTSR-diagnostika tsitomegalovirusnoi infektsii u onkologicheskikh i neonkologicheskikh bol'nykh, perenesshikh transplantatsiiu organov i tkanei.

Cytomegalovirus (CMV) infection often causes death after organ transplantation. Therefore, adequate prevention, diagnosis and treatment of this complication are of critical importance. The experience of establishing routine PCR-detection of CMV is presented. A widely accepted PCR protocol was used for clinical purposes. The strategy included 3 steps: 1) PCR amplification of CMV-sequences from leukocytes of patients; 2) visualization of PCR-product in polyacrylamide gel; 3) verification of the identity of PCR product by its hybridization to a membrane-bound specific probe. This approach allowed to detect CMV infection in 10 out of 28 bone marrow and in 4 out of 32 kidney recipients. The administration of specific antiviral treatment led to the elimination of CMV sequences from the blood.

[Effects of embryonal bone tissue on hemopoiesis]. / Vliianie émbrional'noi kostnoi tkani na hemopoéz.

The influence of human fetal bone (FB) on the hemopoietic and stromal cells were studied in the morphometric assay of the bone marrow trephine biopsy samples after a preliminary cultivation using the Marbrook system for 1-5 weeks. The rat FB effect on the hemopoiesis and survival were also studied in experiment with FB transplantation to rats with prior administration of lethal and sublethal doses of cyclophosphamide. In long-term cultivation of the bone marrow trephine biopsy samples, enhanced proliferation of the fibrous tissue and elimination of hemopoietic elements were seen. Combined cultivation of the trephine biopsy samples of the bone marrow and FB inhibited the fibrous tissue proliferation and enhanced the viability of the hemopoietic and lipid cells. Transplantation of the FB in experiment shortened the leukocytopenia period in rats after sublethal (300 mg/kg) and lethal (500 mg/kg) doses of cyclophosphamide and increased their survival.

[Structure of the bone marrow stroma and hematopoiesis following chemotherapy in patients with acute myeloblastic leukemia]. / Struktura stromy kostnogo mozga i gemopoéz posle khimioterapii bol'nykh ostrym mieloblastnym leikozom.

Histometric methods were used to examine interrelations between hemopoiesis and bone marrow stroma in the trepanned iliac bones from 17 healthy subjects, 30 patients with acute myeloblastic leukemia and 6 patients at different times after chemotherapy. In health, young granulocytes were located endosteally, less frequently along the periphery of the vessels and around reticular cells. Erythro-normoblasts were mostly demonstrable perivascularly or near reticular cells and macrophages. During acute myeloblastic leukemia the interrelations under consideration were deranged. The significance of the endosteum in the regeneration of the stroma and hemopoiesis after cytostatic aplasia is demonstrated.

[Colony-stimulating activity of bone marrow preparations in patients with different pathology of the blood]. / Koloniestimuliruiushchaia aktivnost' trepanatov kostnogo mozga bol'nykh s razlichnoi patologiei sistemy krovi.

The authors offer a method for cultivating trepanobiopsies in the agar drop-liquid medium system to measure the intramedullary colony-stimulating activity (CSA) in patients with different pathological conditions of the blood system. In patients with chronic idiopathic neutropenia and aplastic anemia, the CSA of the whole bone marrow tissue ranges within normal. In patients with recurrent acute myelo- and leukoblastic leukemias, the CSA of trepanobiopsies is lowered. During a remission, in these patients and in those with hemopoietic dysplasia the CSA of the whole bone marrow tissue ranges within normal. There is a positive correlation between the CSA of trepanobiopsies and the number of mature granulocytes in the peripheral blood of patients with acute myeloleukemia and lymphoblastic leukemias and a negative correlation between the CSA and the number of blast cells in the blood and bone marrow of patients with acute lymphoblastic leukemia. It has been thus shown that intramedullary level of the CSA plays a great part in regulation of granulomonocytopoiesis in health and different pathological conditions. It is assumed that stromal elements of the bone marrow may release a factor that is triggered by the colony-stimulating factor or by this factor-synthesizing cells.

[Role of the stroma of the hematopoietic organs in the development of hematologic diseases. Intramedullary regulation of granulomonocytopoiesis]. / Rol' stromy krovetvornykh organov v razvitii nekotorykh gematologicheskikh zabolevanii. Intramedulliarnaia reguliatsiia granulomonotsitopoeza.

Bone marrow trepanobiopsies were cultivated in the agar drop-liquid medium system. A total of 155 subjects with different diseases of the blood system and 31 controls were examined. It was shown that prolonged cultivation of trepanobiopsies makes it possible to functionally evaluate the stromal elements of the bone marrow. The whole medullary tissue is characterized by marked heterogeneity as regards its ability to synthesize humoral stimulants of granulomonocytopoiesis. The colony-stimulating ability (CSA) of this tissue combines the CSA of the hemopoietic and stromal cells. In bone marrow deficiency of varying degree, the function of the bone marrow stroma is highly activated. The trepanobiopsy areas short of the hemopoietic tissue possess a higher ability to form a monolayer on the dish surface. During AML and ALL relapses, the ability of the bone marrow stroma to synthesize the humoral stimulants is lowered, whereas the ability to form monolayers is less demonstrable. In diseases associated with the development of secondary fibrosis (CMF, CML, IP), the bone marrow stroma was discovered to be less capable of synthesizing the humoral stimulants, which provides evidence against the involvement of fibrous tissue in the formation of the total CSA of the bone marrow. It is assumed that fibroblasts and fatty cells are related histogenetically and that their proliferation is controlled by humoral factors.

[Nature of stromal elements of the human bone marrow capable of releasing humoral stimulators of precursor cells of granulomonocytopoiesis]. / Priroda stremal'nykh élementov kostnogo mozga cheloveka, obladaiushchikh sposobnost'iu vydeliat' gumoral'nye stimuliatory kletok-predshestvennits granulomonotsitopoéza.

Whole bone marrow fragments of trepanobiopsies of the upper flaring portion of the ilium were cultivated over 1 to 8 weeks in a liquid phase of the agar drop-liquid medium system. Fifty-two hematological patients and controls were examined in order to study the character of regeneration of different stromal cells and their role in the production of stimulants of precursor cells of granulomonocytopoiesis. It was shown that during cultivation of bone marrow fragments precursors of the stromal cells form a monolayer at the dish bottom, forming a capsule around the fragments and proliferating inside the medullary lacunae. Endosteum is the main source of the regeneration of the stromal elements. The studies did not reveal any relationship between the colony-stimulating activity of the trepanobiopsies and the area occupied in them by sinuses, fibrous and osseous tissue. A positive correlation was established between the CSA and the number of fatty cells. The magnitude of the area of the stromal cell monolayer did not influence colony formation. Based on the data obtained the authors suggest that fatty acids are the main producers of the CSA within the system under consideration.