Extracorporeal photopheresis in the treatment of acute graft-versus-host disease: a single-center experience.

BACKGROUND: Steroid-refractory acute graft-versus-host disease (aGVHD) is a serious complication after hematopoietic stem cell transplantation. The long-term outcome of the patients is poor. Various immunosuppressive agents have been proposed as the second-line therapy but none of them has turned out more effective than the others. Extracorporeal photopheresis (ECP) is a treatment option that does not predispose the patients to severe side effects of the immunosuppressive drugs. STUDY DESIGN AND METHODS: We analyzed the treatment results of ECP in 52 patients with steroid-refractory or steroid-dependent aGVHD. Eighty-one percent of the patients suffered from a severe, Grade III or IV, aGVHD. ECP was started alone as the second-line treatment in 23 patients and in combination with an immunosuppressive drug in 18 patients. Eleven patients received ECP as the third-line or later treatment. RESULTS: A total of 62% of the patients responded, with 48% achieving complete response. In the patients with complete or partial response, the probabilities of survival at 4 years were 54 and 17%, respectively. The outcome of nonresponders was poor. The 1-year overall survivals of the patients with ECP as the second-line treatment either alone or in combination with an immunosuppressive drug or as the third-line treatment were 51, 28, and 18%, respectively. In multivariate analysis, starting ECP no later than 10 days after the start of the first-line treatment correlated with a good response and a consequent survival benefit. CONCLUSION: Extracorporeal photopheresis is an effective and well-tolerated treatment that should be considered as a second-line treatment for aGVHD.

A randomized study of cyclosporine and methotrexate with or without methylprednisolone for the prevention of graft-versus-host disease: Improved long-term survival with triple prophylaxis.

BACKGROUND: In a previously published study, the authors randomized 108 adult patients with a malignant hematologic disorder undergoing allogeneic bone marrow transplantation from a human leukocyte antigen-identical sibling to receive methylprednisolone (53 patients; MP+) or not to receive methylprednisolone (55 patients; MP-) as a part of graft-versus-host disease (GVHD) prophylaxis. All patients received cyclosporine and methotrexate. The cumulative incidence of acute GVHD was found to be significantly lower among the patients given MP. METHODS: In the current study, the authors performed a long-term follow-up to discover possible late effects of the intensified GVHD prophylaxis. RESULTS: The median follow-up for surviving patients was 24.5 years. In the MP+ group, the overall survival and recurrence-free survival were higher (P = .021 and P = .028, respectively) and the nonrecurrence mortality was lower (P = .003) than in the MP- group. There was a trend toward a lower cumulative incidence and a significantly lower prevalence (P = .031) of chronic GVHD in the MP+ group. There was no difference noted with regard to the rate of disease recurrence or in the incidence of secondary malignancies. Eleven patients in the MP- group but none in the MP+ group died >15 years after transplantation. At the end of follow-up, the overall survival rates in the MP+ and MP- groups were 55% and 20%, respectively, and the recurrence-free survival rates were 49% and 15%, respectively. CONCLUSIONS: Long-term survival was found to be higher among the patients given MP in addition to cyclosporine and methotrexate. There was marked late nonrecurrence mortality observed in the group not given MP. No adverse late effects caused by the addition of corticosteroid were observed. Cancer 2018;124:727-33. © 2017 American Cancer Society.

[Where to find a suitable red cell product, if the patient has a rare blood group?]. / Mistä sopiva punasoluvalmiste, jos potilaalla on harvinainen veriryhmä?

A rare blood group and the associated anti-red cell antibody against a very common blood group factor make it significantly more difficult to find suitable red cell products, possibly endangering the additional treatment of the patient. The need of rare blood should be anticipated early enough. The availability of red cells is secured by extensive blood group studies among blood donors, by donor registers, freezing of rare red cells and through international collaboration. The determination of rare blood groups by genotyping provides a longed-for addition to the investigational repertoire of both patients and blood donors. Systematic freezing of red cells was started in Finland in 2010.

Impact of Epoetin-beta on anemia and health-related quality of life in cancer patients: a prospective observational study using the generic 15D instrument.

AIM: Cancer-related anemia has a negative impact on the health-related quality of life (HRQoL). Our aim was to evaluate prospectively the effect of treatment of anemia with an erythropoietin on the hemoglobin level and HRQoL in cancer patients with anemia. PATIENTS AND METHODS: Consecutive patients (N=114) treated for the first time with epoetin (epoetin beta 30000 IU/wk, NeoRecormon®) for anemia during cancer treatment were eligible for study inclusion. Baseline characteristics were collected from patients' records. HRQoL was measured by the generic 15D instrument and fatigue by visual analogue scale (VAS) at baseline and four months from the start of the treatment with epoetin. The majority (87%) of patients had solid tumors; 69% with a metastatic disease and 89% disease with comorbidities. RESULTS: The mean hemoglobin concentration (SD) in blood increased from 96.6 (8.9) g/L to 112.9 (21.2) g/L, by 16.5 (20.6) g/L (p<0.0001). The mean 15D score rose from 0.72 to 0.77. The change was statistically significant (p=0.0047) and clinically important. The mean fatigue VAS score decreased by 16.0 points, or from 55.4 to 38.4 (+24.4) (p<0.0001). CONCLUSION: Correction of anemia increased the health-related quality of life in anemic cancer patients, as measured with the generic 15D instrument and the fatigue VAS.

Improved survival with ursodeoxycholic acid prophylaxis in allogeneic stem cell transplantation: long-term follow-up of a randomized study.

We report the long-term results of a prospective randomized study on the use of ursodeoxycholic acid (UDCA) for prevention of hepatic complications after allogeneic stem cell transplantation. Two hundred forty-two patients, 232 with malignant disease, were randomized to receive (n = 123) or not to receive (n = 119) UDCA from the beginning of the conditioning until 90 days post-transplantation. The results were reported after 1-year follow-up. UDCA administration reduced significantly the proportion of patients developing high serum bilirubin levels as well as the incidence of severe acute graft-versus-host disease (GVHD), liver GVHD, and intestinal GVHD. In the UDCA prophylaxis group, nonrelapse mortality (NRM) was lower and overall survival better than in the control group. After a 10-year follow-up, the difference in the survival and NRM in favor of the UDCA-treated group, seen at 1 year, was maintained (survival 48% versus 38%, P = .037; NRM 28% versus 41%, P = .01). A landmark analysis in patients surviving at 1 year post-transplantation showed no significant differences between the study groups in the long-term follow-up in chronic GVHD, relapse rate, NRM, disease-free survival, or overall survival. These long-term results continue to support the useful role of UDCA in the prevention of transplant-related complications in allogeneic transplantation.

miRNA expression profiles in myelodysplastic syndromes reveal Epstein-Barr virus miR-BART13 dysregulation.

Recently, the microRNA (miRNA) signature has been used for better characterization and understanding of the pathogenesis of different malignancies, including myelodysplastic syndromes (MDS). MDS are a heterogeneous group of stem cell disorders in which the genetic and molecular defects are not well defined. In the present study, we applied array based miRNA profiling to study 19 bone marrow cell samples of de novo MDS compared with eight healthy individuals. In addition, integration of the miRNA profiling data with our previous array comparative genomic hybridization data, from the same cohort of patients, was performed. We observed up-regulation of hsa-miR-720 and hsa-miR-21, and down-regulation of hsa-miR-671-5p and one human virus miRNA (Epstein-Barr virus miR-BART13) in MDS samples compared with normal samples. In our study, the copy number alteration harboring miRNA was not affecting miRNA expression, but a distinct microRNA expression pattern was observed, not only in MDS compared with controls, but also between MDS entities.

High-resolution oligonucleotide array comparative genomic hybridization study and methylation status of the RPS14 gene in de novo myelodysplastic syndromes.

In myelodysplastic syndromes (MDS), close to one half of patients do not have any visible karyotypic change. In order to study submicroscopic genomic alterations, we applied high-resolution array comparative genomic hybridization techniques (aCGH) in 37 patients with de novo MDS. Furthermore, we studied the methylation status of the RPS14 gene in 5q deletion (5q21.3q33.1) in 24 patients. In all, 21 of the 37 patients (57%) had copy number alterations. The most frequent copy number losses with minimal common overlapping areas were 5q21.3q33.1 (21%) and 7q22.1q33 (19%); the most frequent copy number gain was gain of the whole chromosome 8 (8%). Recurrent, but less frequent copy number losses were detected in two cases each: 11q14.1q22.1, 11q22.3q24.2, 12p12.2p13.31, 17p13.2, 18q12.1q12.2, 18q12.3q21.3, 18q21.2qter, and 20q11.23q12; the gains 8p23.2pter, 8p22p23.1, 8p12p21.1, and 8p11.21q21.2 were similarly found in two cases each. No homozygous losses or amplifications were observed. The RPS14 gene was not methylated in any of the patients.

Non-transferrin-bound iron in haematological patients during chemotherapy and conditioning for autologous stem cell transplantation.

Free iron induced hydroxyl radical formation is one possible mechanism for tissue injury during cytotoxic therapy. We studied the appearance of free, non-transferrin-bound iron (NTBI) at baseline and during the 20-d period after the onset of cytotoxic chemotherapy in patients with haematological malignancy undergoing intensive chemotherapy or conditioning for autologous stem cell transplantation (aSCT). NTBI was detected on average for 15.6 d in patients treated with chemotherapy only, and for 6.1 d in patients undergoing aSCT. The recovery of the bone marrow function coincided with the disappearance of NTBI. The type of the conditioning regimen was also associated with the appearance of NTBI. The timing of the presence of NTBI accords with the presence of the most important non-infectious complication of intensive chemotherapy and autologous transplantation, mucosal injury, and free iron is likely to contribute to this and probably other complications of the intensive treatments.

JAK2V617F mutation and spontaneous megakaryocytic or erythroid colony formation in patients with essential thrombocythaemia (ET) or polycythaemia vera (PV).

The in vitro cultures of erythroid (BFU-E) and megakaryocytic (CFU-Meg) progenitors have been useful diagnostic tools in myeloproliferative disorders (MPD). However, after the discovery of the JAK2V617F mutation, their diagnostic role has been uncertain. In this single-centre retrospective study we analyzed JAK2V617F mutation in 58 ET and 42 PV patients diagnosed according to WHO criteria and compared the results with those of colony forming assays with special emphasis on CFU-Meg growth. 91% of PV and 57% of ET patients had JAK2V617F mutation and they all showed spontaneous BFU-E growth. However, endogenous BFU-E formation was also seen in nine JAK2V617F mutation negative patients displaying also a normal JAK2 exon 12 allele. Endogeneous CFU-Meg colony formation was found in 59% of PV and 53% of the ET patients. A subgroup of ET patients (n=7) displayed sole spontaneous CFU-Meg growth without spontaneous BFU-E growth. They all were JAK2 mutation negative, but one of them had MPL mutation. In conclusion, in vitro cultures of haematopoietic progenitors are sensitive diagnostic tools in the present group of 100 MPD patients revealing also JAK2 mutation negative ET and PV patients displaying sole spontaneous CFU-Meg or BFU-E growth.

Effect of fluconazole prophylaxis on the incidence of invasive candida infections and bacteraemias in patients with acute leukaemia.

OBJECTIVES: The efficacy of fluconazole prophylaxis to prevent invasive candida infections in patients with acute leukaemia receiving chemotherapy is not clear. Fluconazole prophylaxis might increase the number of bacteraemias and cause outbreaks of non-albicans yeast infections. A retrospective single-centre study was conducted to investigate the effect of fluconazole prophylaxis on the incidence and the species of invasive candida infections and on the number of bacteraemias. METHODS: All 1089 adult acute leukaemia patients treated with chemotherapy in 1978-2004 at Helsinki University Central Hospital were included. Data of positive blood cultures, histological samples, and fungal cultures was collected from the patient charts and the microbiology laboratory database. Fluconazole prophylaxis was used in all patients from 2000 on. RESULTS: Invasive candida infection was diagnosed in 74 out of 847 patients (8.7%) treated without fluconazole prophylaxis and in four out of 242 patients (1.6%) receiving the prophylaxis (P < 0.001). The incidence of non-albicans infections did not increase in the fluconazole prophylaxis group. A larger proportion of patients developed bacteraemias in the prophylaxis group (65%) compared to the non-prophylaxis group (52%) (P < 0.001). A trend towards more gram-positive bacteraemias was seen in the prophylaxis group. Invasive candida infections were more common in patients with acute lymphoblastic leukaemia than those with acute myeloid leukaemia, 10.5% vs. 5.9% (P = 0.008). CONCLUSIONS: Fluconazole prophylaxis was effective in preventing invasive candida infections in patients with acute leukaemia without increasing non-albicans infections. The risk of bacteraemias, however, increased.

Valproic acid combined with 13-cis retinoic acid and 1,25-dihydroxyvitamin D3 in the treatment of patients with myelodysplastic syndromes.

Valproic acid (VPA), an inhibitor of histone deacetylases, inhibits the growth of leukemia cells and induces their differentiation in vitro. In the present study, VPA in combination with two differentiating agents, 13-cis retinoic acid and 1,25-dihydroxyvitamin D3, was given to 19 previously untreated patients with MDS or CMML. Eight patients had to discontinue treatment before week 16 due to toxicity. According to international working group criteria, three patients (16%) responded to treatment. No correlation between VPA serum level, histone acetylation or clinical response was observed.

Inhibition of erythroid and granulocyte-macrophage colony formation by non-transferrin-bound iron in vitro: protective effect of apotransferrin.

OBJECTIVES: The aim of the study was to investigate in vitro the effect of free iron on erythroid and granulocyte-macrophage colony formation and the effect of binding free iron with apotransferrin. METHODS: Normal haematopoietic progenitors were cultured in vitro with different concentrations of free iron in the form of ferric nitrilotriacetic acid (FeNTA). Parallel cultures were performed after the preincubation of FeNTA with apotransferrin. RESULTS: Free iron inhibited colony formation by erythroid and granulocyte-macrophage progenitors and reduced the size of the colonies in a dose-dependent manner. Preincubation of FeNTA with apotransferrin diminished the inhibitory effect of FeNTA on colony formation increasing both the number and the size of colonies. CONCLUSIONS: Free iron was toxic to haematopoietic progenitors in in vitro cultures; the toxic effect could be reduced with apotransferrin.

Retrospective evaluation of serum Epstein Barr virus DNA levels in 406 allogeneic stem cell transplant patients.

BACKGROUND AND OBJECTIVES: An HLA-mismatched donor and a T-cell-depleted graft are known risk factors for Epstein-Barr virus (EBV) reactivation after stem cell transplantation. We studied the frequency and outcome of serum EBV DNA levels in patients transplanted with an unmanipulated graft from an HLA-identical donor. DESIGN AND METHODS: Overall, 5479 serial serum samples from 406 consecutive allogeneic stem cell transplant recipients were analyzed retrospectively for EBV DNA with quantitative polymerase chain reaction (PCR). RESULTS: EBV DNA was found in the serum of 56 of the 406 patients (14%). EBV positivity was seen in 9 % of the recipients of a graft from a sibling donor and in 29 % of those with an unrelated donor. EBV-PCR positivity resolved without specific treatment in a third of the cases, in another third the copy number increased progressively or was high in the last serum sample, and in the remaining third the copy numbers were low in all positive sera including the last sample. In multivariate analysis antithymocyte globulin given for any reason and grade III-IV acute graft-versus-host disease were the only statistically significant risk factors for EBV reactivation. Only 8/56 patients with EBV-DNA positivity were alive at the time of the present analysis. The outcome of EBV-PCR positivity could not be predicted by the copy number or the timing of the first positive sample. INTERPRETATION AND CONCLUSIONS: EBV reactivation was a common phenomenon in allogenic stem cell transplant recipients. In many patients the viremia resolved without EBV-directed treatment. Severe acute graft-versus-host disease and antithymocyte globulin given for any reason were risk factors for EBV viremia.

Antithymocyte globulin and cyclosporine A as combination therapy for low-risk non-sideroblastic myelodysplastic syndromes.

The present study evaluated the combination of antithymocyte globulin (ATG) and cyclosporine A (CsA) in patients with low-risk myelodysplastic syndromes. Twenty patients (17 with refractory anemia and 3 with refractory anemia with excess blasts) received treatment with rabbit-ATG plus CsA. The overall response rate was 30% (6/20); three of the six responders had a complete response. The responses lasted 2-58 months, with two patients still being in complete remission at 42 and 58 months. Short-lasting cytogenetic remissions were achieved in two patients. ATG was poorly tolerated in patients over 70 years of age. Four out of 20 patients progressed to acute myeloid leukemia within a year. We conclude that immunosuppressive treatment may be a therapeutic option for selected patients with myelodysplastic syndrome.

Pregnancy in essential thrombocythaemia: experience with 40 pregnancies.

In this study, the course of 40 pregnancies in 16 women with essential thrombocythaemia (ET) was analysed retrospectively. Of the pregnancies, 45% were complicated, 55% uncomplicated, and 62% resulted in live birth. The most common complication was spontaneous abortion during the first trimester seen in 33% of all pregnancies and comprising 72% of all complications. Two intrauterine foetal deaths occurred at weeks 22 and 28. Three pregnancies were complicated by eclampsia or pre-eclampsia. Nine of 16 women with 29 pregnancies had at least one complicated pregnancy. In seven of 16 women, all 11 pregnancies were uneventful. The non-pregnancy-related symptoms of ET or the platelet count before conception or during pregnancy did not correlate with the risk of pregnancy complications. Treatment with low-dose acetylsalicylic acid (ASA) alone during pregnancy or platelet-lowering drugs before or during pregnancy reduced the risk of complications.

Human herpesvirus 6 antigenaemia in allogeneic stem cell transplant recipients: impact on clinical course and association with other beta-herpesviruses.

Human herpesvirus 6 (HHV-6) antigenaemia was prospectively studied in 58 adult allogeneic stem cell transplant (SCT) recipients. Altogether 42 of 58 recipients (72%) demonstrated HHV-6 specific antigens in peripheral blood mononuclear cells after SCT, 22 of 36 (61%) when the donor was a sibling and 20 of 22 (91%) when the donor was unrelated. The cumulative incidence of HHV-6A, HHV-6B, HHV-7, and cytomegalovirus antigenaemia during the first 6 months after SCT was 33%, 62%, 44% and 63% respectively. The median day of the onset of each antigenaemia was +24, +4, +59, and +46 after SCT respectively. There were no clinical findings related to HHV-6A and HHV-7 antigenaemias. A rash was diagnosed in 10 of 38 (26%) HHV-6B antigenaemia positive patients during the first month after SCT compared with one of 20 (5%) HHV-6B negative patients. Of the HHV-6B antigenaemia cases, six of 10 rashes were treated as acute graft-versus-host disease (GVHD) and four of 10 were considered to be of a viral origin. Fifteen patients had acute GVHD diagnosed. Acute GVHD manifested statistically significantly (P = 0.034) earlier in the nine patients with HHV-6B antigenaemia compared with the six patients who were HHV-6B negative.

The predictive value of megakaryocytic and erythroid colony formation and platelet function tests on the risk of thromboembolic and bleeding complications in essential thrombocythaemia.

The predictive value of spontaneous in vitro colony formation of megakaryocytic and erythroid progenitors (154 patients), and defective platelet aggregation responses (55 patients) on the risk of thrombohaemorrhagic complications in patients with essential thrombocythaemia (ET) was evaluated retrospectively. In the in vitro cultures of haematopoietic progenitors, 114/154 patients (74%) showed either spontaneous megakaryocytic or erythroid colony formation or both. Forty-three per cent of patients with any spontaneous colony growth and only 20% of those without this phenomenon had an arterial thrombosis at diagnosis or during the follow-up (P = 0.02). In the whole patient group neither spontaneous megakaryocytic nor spontaneous erythroid colony formation alone predicted the risk of arterial thrombosis. In patients younger than 45 yr of age, the prognostic value of spontaneous megakaryocytic growth was statistically significant: 44% of the patients with spontaneous megakaryocytic colony formation, but only 14% of those without it, experienced arterial thrombosis (P = 0.04). The presence of spontaneous colony formation had no effect on the risk of bleeding complications. Forty-one of the 55 patients (75%) showed abnormalities in the platelet aggregation responses. There was no statistically significant correlation between the platelet function response and the risk of bleeding or thrombotic complications. No correlation was found between the platelet aggregation responses and the presence of spontaneous colony growth. In conclusion, spontaneous colony formation indicated an increased risk of thrombohaemorragic events but the platelet function test had no predictive value for these complications.

Podocalyxin in human haematopoietic cells.

Podocalyxin-like protein (PCLP) is a sialomucin-type membrane protein structurally related to CD34 and endoglycan. It was first described in glomerular podocytes and endothelial cells. In mice, PCLP is present in haemangioblasts, and in both chicken and mice it is a marker of early haematopoietic stem cells and lineage-restricted haematopoietic progenitors. Its expression decreases during differentiation of haematopoietic cells. Of mature blood cells, only chicken and rat thrombocytes express PCLP protein. PCLP expression in human haematopoietic cells has not been studied. Here we demonstrate PCLP mRNA in human CD34+ cells, in lineage committed erythroid, megakaryocyte and myeloid progenitors, in K562 leukaemia cells, and in peripheral blood leucocytes. The mRNA expression level was higher in developing cells than in mature leucocytes. By Northern blotting and cDNA sequencing, the haematopoietic and renal PCLP mRNAs were identical. Of the mobilized CD34+ cells, 28% (mean; range 14-61%) expressed PCLP protein and the majority of PCLP+ cells were CD117+. Almost all of the K562 cells expressed PCLP protein. Surprisingly, PCLP protein was not detected in any mature blood cells. These results suggest that human PCLP may be a valuable marker for a subset of haematopoietic stem cells.