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Fu W, Gao S, Luo Y, Chen L, Chen J, Gao L, Wang L, Xu L, Wang Y, Wang Z, Yue W, Cheng H, Tang G, Wang J, Yang J, Ni X. Comparison of Stem Cell Transplantation Using Unrelated, Haploidentical, and Sibling Donors for Patients with Acquired Severe Aplastic Anemia: A Single-Center Retrospective Cohort Study. Transplant Cell Ther 2024; 30:245.e1-245.e8. [PMID: 37977336 DOI: 10.1016/j.jtct.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/08/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023]
Abstract
The preferred donor (haploidentical donor [HID] versus matched unrelated donor [URD]) choice in patients with acquired severe aplastic anemia (SAA) who lack an HLA-matched sibling donor (MSD) and fail upfront immunosuppressive treatment (IST) therapy is unknown. We retrospectively investigated SAA patients (n = 58) who underwent allogeneic stem cell transplantation (allo-SCT) between January 2012 and October 2022. The 5-year overall survival (OS) and 5-year failure-free survival (FFS) were comparable among the URD (n = 8), HID (n = 25), and MSD (n = 25) cohorts (OS: mean, 87.5 ± 11.7% versus 98.0 ± 6.5% versus 83.3 ± 7.6% [P = .926]; FFS: mean, 60.0 ± 18.2% versus 87.0 ± 7.0% versus 78.3 ± 8.6% [P = .222]). Multivariate analysis revealed that primary engraftment failure independently predicted OS and secondary graft failure predicted FFS among SAA patients who underwent allo-SCT, but donor type and age were not predictive of these outcomes. An urgent second SCT for patients with engraftment failure may be an effective salvage treatment. Our findings show that an alternative donor SCT is indicated for eligible SAA patients without an MSD even if age ≥40 years.
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Affiliation(s)
- Weijia Fu
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai 200433, China
| | - Su Gao
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai 200433, China
| | - Yanrong Luo
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai 200433, China
| | - Li Chen
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai 200433, China
| | - Jie Chen
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai 200433, China
| | - Lei Gao
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai 200433, China
| | - Libing Wang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai 200433, China
| | - Lili Xu
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai 200433, China
| | - Yang Wang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai 200433, China
| | - Ziwei Wang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai 200433, China
| | - Wenqin Yue
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai 200433, China
| | - Hui Cheng
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai 200433, China
| | - Gusheng Tang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai 200433, China
| | - Jianmin Wang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai 200433, China.
| | - Jianmin Yang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai 200433, China.
| | - Xiong Ni
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai 200433, China.
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Zhang C, Hou Y, Yang Y, Zhang J, Zheng X, Yan J. Second haploidentical bone marrow transplantation with antithymocyte antibody-containing conditioning regimen for graft failure in eight patients with severe aplastic anemia. Sci Rep 2024; 14:2293. [PMID: 38280947 PMCID: PMC10821899 DOI: 10.1038/s41598-024-52917-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 01/25/2024] [Indexed: 01/29/2024] Open
Abstract
The effects of a second haploidentical bone marrow transplantation with an antithymocyte antibody-containing conditioning regimen after graft failure in patients with severe aplastic anemia remain unclear. Eight severe aplastic anemia patients with graft failure with a median age of 12.5 (range, 3-22) years were retrospectively reviewed. At the second transplantation, they received a median mononuclear cell number of 15.7 (range, 11.2-20.9) × 108/kg or a median CD34+ cell number of 6.2 (range, 2.5-17.5) × 106/kg. They were all successfully engrafted, with a median time of 12.5 (range, 11-16) days for neutrophils and 24 (range, 14-50) days for platelets. Three patients developed skin acute graft-versus-host disease Grades I-II, and another 3 developed limited chronic graft-versus-host disease. All patients successfully recovered after treatment with methylprednisolone (0.5-1 mg/kg/day) and tacrolimus. One patient each died of respiratory failure caused by multidrug-resistant Klebsiella pneumoniae at 8 months and invasive fungal disease at 23 months after transplantation. Six patients survived with a 5-year estimated overall survival of 75% and a median follow-up time of 61 (range, 8-129) months. A second haploidentical bone marrow transplantation with an antithymocyte antibody-containing conditioning regimen was feasible for saving severe aplastic anemia patients with graft failure.
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Affiliation(s)
- Chengtao Zhang
- Department of Hematology, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, No. 467, Zhongshan Road, ShaHeKou District, Dalian, 116027, China
- Liaoning Key Laboratory of Hematopoietic Stem Cell Transplantation and Translational Medicine, Blood Stem Cell Transplantation Institute, Dalian Key Laboratory of Hematology, Diamond Bay Institute of Hematology, The Second Hospital of Dalian Medical University, Dalian, 116027, China
| | - Yutong Hou
- Department of Hematology, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, No. 467, Zhongshan Road, ShaHeKou District, Dalian, 116027, China
- Liaoning Key Laboratory of Hematopoietic Stem Cell Transplantation and Translational Medicine, Blood Stem Cell Transplantation Institute, Dalian Key Laboratory of Hematology, Diamond Bay Institute of Hematology, The Second Hospital of Dalian Medical University, Dalian, 116027, China
| | - Yan Yang
- Department of Hematology, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, No. 467, Zhongshan Road, ShaHeKou District, Dalian, 116027, China
| | - Jingjing Zhang
- Department of Hematology, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, No. 467, Zhongshan Road, ShaHeKou District, Dalian, 116027, China.
- Department of Pediatric, Pediatric Oncology and Hematology Center, The Second Hospital of Dalian Medical University, Dalian, 116027, China.
| | - Xiaoli Zheng
- Department of Hematology, Air Force Medical Center, PLA, No. 3 Fuchen Road, Haidian District, Beijing, 100142, China.
| | - Jinsong Yan
- Department of Hematology, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, No. 467, Zhongshan Road, ShaHeKou District, Dalian, 116027, China.
- Liaoning Key Laboratory of Hematopoietic Stem Cell Transplantation and Translational Medicine, Blood Stem Cell Transplantation Institute, Dalian Key Laboratory of Hematology, Diamond Bay Institute of Hematology, The Second Hospital of Dalian Medical University, Dalian, 116027, China.
- Department of Pediatric, Pediatric Oncology and Hematology Center, The Second Hospital of Dalian Medical University, Dalian, 116027, China.
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3
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Gong S, Chen C, Chen K, Yang R, Wang L, Yang K, Hu J, Nie L, Su T, Xu Y, He X, Yang L, Xiao H, Fu B. Alternative Transplantation With Post-Transplantation Cyclophosphamide in Aplastic Anemia: A Retrospective Report From the BMF-WG of Hunan Province, China. Transplant Cell Ther 2023; 29:48.e1-48.e7. [PMID: 36272527 DOI: 10.1016/j.jtct.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 10/06/2022] [Accepted: 10/11/2022] [Indexed: 11/15/2022]
Abstract
Although the possibility of first-line hematopoietic cell transplantation (HCT) from alternative donors in severe aplastic anemia (SAA) patients has been suggested recently, transplantation strategies are still being investigated. We established a novel post-transplantation cyclophosphamide-based HCT protocol for patients with SAA in prior studies. We explores the effectiveness and safety of this HCT approach either as first-line or as salvage treatment in SAA patients. Outcomes of 71 consecutive young patients, who received HCT from unrelated or haploidentical donors, were retrospectively analyzed. According to their treatment before transplantation, the patients were classified into treatment-naive (TN) and relapsed or refractory (R/R) patients. The R/R patients were designated as such when a patient did not respond to previous immunosuppressive therapy or relapsed. We administered an antithymocyte globulin (ATG)-free, total body irradiation (TBI)-free conditioning regimen comprising cyclophosphamide, busulfan, and fludarabine, all in an intravenous formula. We used a thorough post-transplantation prophylaxis regimen for GVHD, including post-transplantation cyclophosphamide (PTCy) and short-term methotrexate and long-term cyclosporine A. The median age of the cohort was 16 (95% confidence interval, 12-20) years at transplantation. Most patients (61 of 71) received HCT from haploidentical donors, and the others received HCT from unrelated donors. TN patients (n = 38) were younger and had a shorter time-to-transplant and lower HCT-specific comorbidity index than patients with R/R diseases (n = 33). The frequencies of graft failure, grade II-IV acute graft-versus-host disease (GVHD), and moderate-severe chronic GVHD were similar, at 5.3% versus 6.5% (P = .057), 8.3% versus 0% (P = .109), and 5.7% versus 0% (P = .199) between R/R and TN patients. With a median 42-month follow-up, the frequencies of overall survival (OS) and event-free survival (EFS) were higher in the TN group than in the R/R group (100% versus 84.8% [P = .013] and 86.8% versus 75.8% [P = .255], respectively). All patients who achieved successful engraftment showed full donor chimerism. Four patients, all in the R/R group, suffered from donor-type aplasia; of these, 2 died, 1 was salvaged with another transplantation, and the final one was still receiving transfusion at the last follow-up. Currently, 93.9% (62 of 66) of the patients are alive more than 12 months after transplantation; of these 93.5% (58 of 62) no longer receive immunosuppression, including 91.7% (33 of 34) of the TN group and 89.3% (25 of 28) in the R/R group. This novel TBI-free and ATG-free HCT protocol using a reduced-intensity conditioning regimen followed by modified PTCy achieved promising engraftment, minimal GVHD risk, and encouraging OS and EFS. Our study suggests that unrelated or haploidentical HCT with PTCy can be used as a first-line treatment for young patients with SAA. Nevertheless, further efforts are needed to explore possibilities for older patients and patients with a poor performance status.
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Affiliation(s)
- Susu Gong
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Cong Chen
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Keke Chen
- Department of Pediatric Hematology, Hunan Provincial People's Hospital, Changsha, Hunan Province, China
| | - Rui Yang
- Department of Pediatric Hematology, First People's Hospital of Chenzhou, Chenzhou, Hunan Province, China
| | - Leyuan Wang
- Department of Pediatric Hematology, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Kaitai Yang
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Jian Hu
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Lin Nie
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Tao Su
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Yajing Xu
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, Hunan Province, China; National Clinical Research Center for Geriatric Diseases, Changsha, Hunan Province, China; National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Hangzhou, Jiangsu Province, China
| | - Xianglin He
- Department of Pediatric Hematology, Hunan Provincial People's Hospital, Changsha, Hunan Province, China
| | - Liangchun Yang
- Department of Pediatric Hematology, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Hong Xiao
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Bin Fu
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, Hunan Province, China; National Clinical Research Center for Geriatric Diseases, Changsha, Hunan Province, China; National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Hangzhou, Jiangsu Province, China.
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Zhang D, Yu J, Liu L, Wang F, Wang S, Xie X, Li Y, Jiang Z. Acute arrest of hemopoiesis presenting as severe aplastic anemia: a retrospective analysis. Hematology 2021; 26:1057-1063. [PMID: 34902294 DOI: 10.1080/16078454.2021.2010329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE The clinical manifestations of acute arrest of hemopoiesis (AAH) are very similar with severe aplastic anemia (SAA). Currently there are no clear diagnostic criteria to distinguish AAH from SAA. Differentiation of AAH from SAA is challenging in the routine clinical practice. This study aimed to analyze the clinical and laboratory features between AAH and SAA patients. PATIENTS AND METHODS We performed a retrospective study with cohort of 425 suspected patients who were hospitalized to the First Affiliated Hospital of Zhengzhou University from 1 January 2019 to 31 December 2020. We identified 11 AAH patients and 49 SAA patients to investigate the differentiation diagnostic features. RESULTS Clinical and laboratory examinations of 11 patients with AAH met the diagnostic criteria of SAA, and hematopoietic recovery occurred within a median time of 12 (4-21) days. The median time for neutrophils to recover above 1 × 109/L and platelet to recover above 50 × 109/L in all patients with AAH was 5 (3-8) days and 8 (1-13) days, respectively. Compared with the control group SAA, the 11 AAH patients were older, with a median age of 53 (21-69) years old, and their first symptom is usually fever. CONCLUSIONS The spontaneous remission of AAH was rapid in most patients, and relapses were rarely observed. With supportive treatment, the AAH patients would show significant improvement on blood routine about a week, otherwise the patients should be treated as early as possible with the SAA regimen.
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Affiliation(s)
- Danfeng Zhang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Jifeng Yu
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Lingling Liu
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Fang Wang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Shujuan Wang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Xinsheng Xie
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Yingmei Li
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Zhongxing Jiang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
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Yang K, Gong S, Jiang T, Liang X, Hu J, Zhu P, Nie L, Xu Y, Fu B. Haploidentical Peripheral Stem Cell Transplantation for Young Patients with Severe Aplastic Anemia Using Post-Transplantation Cyclophosphamide and Methotrexate. Transplant Cell Ther 2021; 27:429.e1-429.e7. [PMID: 33965186 DOI: 10.1016/j.jtct.2021.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/03/2021] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Abstract
Severe aplastic anemia (SAA) is a serious bone marrow failure disorder that is often cured with hematopoietic stem cell transplantation (HSCT). The absence of a matched related donor is common, however, and thus novel approaches are needed to safely expand the donor pool to include alternative donors, especially haploidentical related donors, for patients with SAA. This study aimed to explore a novel approach to HSCT for patients with SAA without an available HLA-identical sibling or a matched unrelated donor, termed haploidentical peripheral blood stem cell transplantation (haplo-PBSCT), using a conditioning regimen comprising cyclophosphamide, busulfan, and fludarabine (CBF) and a graft-versus-host disease (GVHD) prophylaxis regimen with post-transplantation cyclophosphamide (PTCy), low-dose methotrexate (LD-MTX), and calcineurin inhibitors. This prospectively designed nonrandomized study included 29 patients with SAA who underwent haplo-PBSCT between November 2017 and May 2020. The median patient age was 17 years (range, 14 to 30 years), and the median time to neutrophil recovery was 13 days (range, 13 to 15 days). There was 1 primary graft failure (GF) in the group receiving PTCy at a dose of 50 mg/kg and no GFs in the group receiving PTCy at a dose of 100 mg/kg. The median duration of follow-up was 736 days (95% confidence interval, 512 to 879 days). The estimated 1-year overall survival and disease-free survival were 91.7 ± 5.7% and 89.7 ± 5.7%, respectively. Only 1 of the 27 patients developed grade II acute GVHD. Four patients developed limited and mild chronic GVHD, involving only the skin or/and oral mucosa. Haplo-PBSCT following CBF and followed by PTCy and LD-MTX represents a novel approach for safely expanding the donor pool to include alternative donors for young patients with SAA.
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Affiliation(s)
- Kaitai Yang
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Susu Gong
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Tiebin Jiang
- Department of Hematology, Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Xinquan Liang
- Department of Hematology, First People's Hospital of Chenzhou, Chenzhou, Hunan, China
| | - Jian Hu
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Ping Zhu
- Department of Hematology, First People's Hospital of Chenzhou, Chenzhou, Hunan, China
| | - Lin Nie
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yajing Xu
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Bin Fu
- Department of Hematology, Xiangya Hospital of Central South University, Changsha, Hunan, China.
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Onishi Y, Mori T, Yamazaki H, Takenaka K, Yamaguchi H, Shingai N, Ozawa Y, Iida H, Ota S, Uchida N, Miyamoto T, Katayama Y, Kato J, Yoshioka S, Onizuka M, Ichinohe T, Atsuta Y. Cyclosporine/methotrexate versus tacrolimus/methotrexate with or without anti-thymocyte globulin as GVHD prophylaxis in adult patients with aplastic anemia. Ann Hematol 2020; 100:217-228. [PMID: 33033911 DOI: 10.1007/s00277-020-04290-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/28/2020] [Indexed: 11/29/2022]
Abstract
The impact of calcineurin inhibitor types and anti-thymocyte globulin (ATG) in conditioning on overall survival (OS) and GVHD-free, relapse-free survival (GRFS) has not yet been analyzed in detail for aplastic anemia. We herein examined 517 adult patients with aplastic anemia who underwent BMT from HLA-matched sibling donors (MSD, n = 255) and unrelated donors (UD, n = 262) and were treated with cyclosporine A (CSA) + methotrexate (MTX) (n = 258) and tacrolimus (TAC) + MTX (n = 259). In total, 330 patients received ATG in conditioning. CSA + MTX versus TAC + MTX did not have a significant impact on acute and chronic GVHD, OS, or GRFS in each donor type. The use of ATG in conditioning reduced the risk of grade II-IV acute GVHD in the MSD and UD cohorts (HR 0.42, P = 0.014, and HR 0.3, P < 0.001, respectively); however, a differential impact on GRFS was identified, namely, better GRFS in MSD recipients (HR 0.56, P = 0.016), but not in UD recipients (HR 1.1, P = 0.657). In conclusion, CSA + MTX and TAC + MTX were similar as GVHD prophylaxis regardless of the donor type, and ATG in conditioning increased GRFS in MSD transplants, but not in UD transplants.
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Affiliation(s)
- Yasushi Onishi
- Department of Hematology and Rheumatology, Tohoku University Hospital, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
| | - Takehiko Mori
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hirohito Yamazaki
- Division of Transfusion Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Katsuto Takenaka
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Matsuyama, Japan
| | | | - Naoki Shingai
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yukiyasu Ozawa
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Hiroatsu Iida
- Division of Cell Therapy, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Shuichi Ota
- Department of Hematology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Naoyuki Uchida
- Department of Hematology, Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital, Tokyo, Japan
| | - Toshihiro Miyamoto
- Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuta Katayama
- Department of Hematology, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Jun Kato
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Yoshioka
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Makoto Onizuka
- Department of Hematology/Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan
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