Sequential vs myeloablative vs reduced intensity conditioning for patients with myelodysplastic syndromes with an excess of blasts at time of allogeneic haematopoietic cell transplantation: a retrospective study by the chronic malignancies working party of the EBMT

The optimal conditioning for patients with higher risk MDS receiving potentially curative allogeneic haematopoietic stem cell transplant(allo-HCT) remains to be defined. This is particularly the case for patients with excess of blasts at time of allo-HCT. Sequential (Seq) conditioning, whereby chemotherapy is followed rapidly by transplant conditioning, offers an opportunity to decrease disease burden, potentially improving outcomes allo-HCT outcomes. Herein we present the only analysis comparing Seq to myeloablative (MAC) and reduced intensity conditioning (RIC) specifically focussed on MDS patients with excess of blasts at allo-HCT. 303 patients were identified in the EBMT registry, receiving RIC (n = 158), Seq (n = 105), and MAC (n = 40). Median follow-up was 67.2 months and median age at allo-HCT was 59.5 years (IQR 53.5-65.6). For the entire cohort, 3 y overall survival (OS) was 50% (95% CI 45-56%) and relapse free survival (RFS) 45% (95% CI 40-51%). No significant differences in OS (log-rank p = 0.13) and RFS (log-rank p = 0.18) were observed between conditioning protocols. On multivariable analysis, lower performance status, worse IPSS-R cytogenetics, sibling donor (compared to 8/8 MUD) and ≥20% blasts at allo-HCT were associated with worse outcomes. In conclusion, the Seq protocol did little to influence the outcome in this high-risk group of patients, with outcomes mostly determined by baseline disease risk and patient characteristics such as performance status.

Sequential therapy combining clofarabine and T-cell-replete HLA-haploidentical haematopoietic SCT is feasible and shows efficacy in the treatment of refractory or relapsed aggressive lymphoma

Prognosis is poor for patients with biologically aggressive Non-Hodgkin lymphoma (NHL), refractory to chemotherapy or relapsed after autologous transplantation, especially when no disease control before allogeneic transplantation is achieved. In 16 patients (median age 53, median prior regimes 5) with relapsed or refractory non-remission NHL, we analysed retrospectively the efficacy of a sequential therapy comprising clofarabine re-induction followed by a reduced-intensity conditioning with fludarabine, CY and melphalan, and T-cell-replete HLA-haploidentical transplantation. High-dose CY was utilized post-transplantation. All patients engrafted. Early response (day +30) was achieved in 94%. Treatment-related grade III-IV toxicity occurred in 56%, most commonly transient elevation of transaminases (36%), while there was a low incidence of infections (19% CMV reactivation, 19% invasive fungal infection) and GVHD (GVHD: acute III-IV: 6%; mild chronic: 25%). One-year non-relapse mortality was 19%. After a median follow-up of 21 months, estimated 1- and 2-year PFS was 56 and 50%, respectively, with 11 patients (69%) still alive after 2 years. In summary, sequential therapy is feasible and effective and provides an acceptable toxicity profile in high-risk non-remission NHL. Presumably, cytotoxic reinduction with clofarabine provides enough remission time for the graft-versus lymphoma effect of HLA-haploidentical transplantation to kick in, even in lymphomas that are otherwise chemo-refractory.

Proteomic analysis of the acidocalcisome, an organelle conserved from bacteria to human cells

Acidocalcisomes are acidic organelles present in a diverse range of organisms from bacteria to human cells. In this study acidocalcisomes were purified from the model organism Trypanosoma brucei, and their protein composition was determined by mass spectrometry. The results, along with those that we previously reported, show that acidocalcisomes are rich in pumps and transporters, involved in phosphate and cation homeostasis, and calcium signaling. We validated the acidocalcisome localization of seven new, putative, acidocalcisome proteins (phosphate transporter, vacuolar H+-ATPase subunits a and d, vacuolar iron transporter, zinc transporter, polyamine transporter, and acid phosphatase), confirmed the presence of six previously characterized acidocalcisome proteins, and validated the localization of five novel proteins to different subcellular compartments by expressing them fused to epitope tags in their endogenous loci or by immunofluorescence microscopy with specific antibodies. Knockdown of several newly identified acidocalcisome proteins by RNA interference (RNAi) revealed that they are essential for the survival of the parasites. These results provide a comprehensive insight into the unique composition of acidocalcisomes of T. brucei, an important eukaryotic pathogen, and direct evidence that acidocalcisomes are especially adapted for the accumulation of polyphosphate.

A survey on unmanipulated haploidentical hematopoietic stem cell transplantation in adults with acute leukemia

The use of unmanipulated graft is increasingly adopted in the setting of allogeneic hematopoietic stem cell transplantation from haploidentical family donors (haplo-SCT) in acute leukemia (AL). We analyzed the outcome of 229 adult patients with de novo AL, who received an unmanipulated haploidentical transplant as their first allo-SCT between 2007 and 2011. Median follow-up was 30 months. Disease status at transplant was: first complete remission (CR1) for 77, second CR (CR2) for 56, and advanced for 96 patients. One hundred and seventy-one patients received in vivo T-cell depletion by monoclonal antibodies (75%). The 60-day cumulative incidence (CI) of engraftment was 93±2%. The 100-day CI of acute graft-versus-host disease (GvHD) was 32±3% for grade II-IV, 12±3% for grade III-IV. The 3-year CI of chronic GvHD was 34±3%. The 3-year CI of non-relapse mortality was 31±4% with in vivo T-cell depletion and 17±5% without. At 3 years, for patients transplanted in CR1, CR2 or advanced disease leukemia-free survival was 44±6, 42±7 and 12±3%, overall survival was 55±6, 51±7 and 14±4% and CI of relapse was 32±6, 24±6 and 61±5%, respectively. These data suggest that unmanipulated haplo-SCT is a valid treatment option for adult AL patients in complete remission lacking a matched donor.

[Steroid-refractory graft-versus-host disease: extracorporeal irradiation of leucocytes induces immunotolerance]

A 42 year-old woman develops steroid refractory graft-versus-host disease (GVHD) after second allogeneic stem cell transplantation for acute myelogenous leukemia with severe GVHD of her skin with blisters, severe GVHD of her gut with watery and bloody diarrhea and GVHD of her liver with cholestasis. In a further attempt to control GVHD extracorporeal photochemotherapy is administered. The treatment exposures peripheral mononuclear cells to photoactivated psoralen before they subsequently are given back to the patient. This approach apparently offers selective immune tolerance.

Hematopoietic stem cell transplantation (HSCT) in patients with primary granulocytic sarcoma (GS)

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Background: GS preceding acute myeloid leukemia (AML) is extremely rare and the prognosis is poor. Patients usually undergo systemic chemotherapy (CT) but the role of HSCT is not sufficiently defined. Methods: We report on 3 cases of non-leukemic GS, all of those treated with inductive CT followed by either autologous or allogeneic SCT. Furthermore, the literature on the role of HSCT in GS is reviewed. Results: Case 1: A 55-year-old man presented with a mediastinal mass and right pleural effusion. Fluid cytology revealed hematopoietic cells. Mediastinoscopy showed GS but peripheral blood and bone marrow were free of blasts. He underwent 2 cycles of anthracyline-cytarabine (AC) containing induction CT followed by myeloablative conditioning and autologous SCT in 1st remission. Radiotherapy to the mediastinum was applied afterwards. He remained in CR for 6 months when a leukemic relapse was diagnosed. He is currently undergoing reinduction CT and will proceed to receive an unrelated donor (URD) SCT. Case 2: A 51-year old man was diagnosed with GS of the right testicle. After orchiectomy he was followed by observation only. 8 months later a leukemic relapse [karyotype 46 XY, del (9)(q22), der(13) t(8;13)] occurred. The patient received 2 courses of AC-based induction CT followed by myeloablative conditioning and an HLA-matched URD transplant in 1st CR. However, 27 months after HSCT another leukemic relapse was diagnosed. He received a 2nd URD transplant but died of severe graft versus host disease (GvHD) and veno-occlusive disease 10 weeks later. Case 3: A 37 year-old woman was diagnosed with non-leukemic GS located at multiple bone sites. She underwent 4 courses of AC-containing CT resulting in a CR. 6 months later she presented with multiple recurrent GS confined to the skeleton. She received myeloablative conditioning followed by an allogeneic SCT from her HLA-mismatched brother. Another CR was attained. However, she suffered from severe GvHD and died of severe sepsis 3 months after HSCT. Conclusions: The outcome of patients with primary GS appears to be poor even after treatment with HSCT. However, allogeneic SCT has curative potential as indicated by some cases of successful transplants reported in the literature.

No significant financial relationships to disclose.

Incidence and severity of ifosfamide-induced encephalopathy

This retrospective trial was performed to determine risk factors, incidence and severity of ifosfamide-induced encephalopathy in correlation with patient and treatment characteristics. Patients receiving ifosfamide were included consecutively with no restrictions concerning disease, prior chemotherapy or disease stage. Incidence and severity of encephalopathy were graduated according to common toxicity criteria. Between July 2001 and July 2002, 60 patients (32 male, 28 female, median age 47.5 years) were included; 26.6% of the patients (n = 16) developed neurological symptoms [grade 1: 6.7% (n = 4); grade 2: 3.3% (n = 2); grade 3: 11.7% (n = 7); grade 4: 5% (n = 3)]. Encephalopathy occurred for the first time in 87.5% (n = 14) in chemotherapy courses 1 and 2. In 56.25% (n = 9) of these 16 patients only one episode was observed. There was no significant difference concerning age (38 versus 50 years, p = 0.08) and dosage (median 2.9 versus 2.8 g, p = 0.74) between patients with and without encephalopathy. No risk factors could be identified by this study, suggesting an individual predisposition in each patient. On the other hand, ifosfamide can be administered in older patients without increased risk of neurotoxicity.

Dose-dependent effects of in vivo antithymocyte globulin during conditioning for allogeneic bone marrow transplantation from unrelated donors in patients with chronic phase CML

We conducted a dose-escalation study with antithymocyte globulin (ATG) in patients undergoing unrelated donor bone marrow transplantation (URD-BMT). This study analyzes the results for 97 patients with chronic myelogenous leukemia (CML) in first chronic phase. Median age was 36 years (16-51). In all, 40 patients were transplanted within 2 years after diagnosis and 57 later during disease. ATG-S (Fresenius) 20-120 mg/kg body weight (b.w.) was given prior to transplantation. A total of 31 patients received less than 60 mg/kg b.w. and 66 patients received 60 mg/kg b.w. or more. All patients except one were grafted with bone marrow, and graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporin A and methotrexate. Graft failure did occur in one patient. Grade II-IV acute GVHD developed in 56.7% and extensive chronic GVHD in 11.3% of the patients. The relapse rate was 13.4%. With a median follow-up of 5.8 years (1.5-12.1), 5-year disease-free and overall survival for all patients were 56 and 66%, and for patients transplanted within 2 years of diagnosis it was 72 and 82%. A lower dose of ATG was a significant risk factor for poor outcome. In summary, URD-BMT remains an excellent treatment option for patients with early phase CML, if a sufficient amount of ATG is included in the preparative regimen.

Persistence of heterologous nucleic acids after uptake by mammalian cells

Plasmids containing the complete genome of poliovirus-1 are transcribed at random in transfected cells and give rise to infectious RNA molecules. These generate viruses which can be detected easily in a plaque assay. Using this system, we analyzed the persistence of the biologically active portion of transfected poliovirus cDNA by determining its infectious activity in mammalian cells. Transfection and the cultivation of the cells for up to 16 days were performed under the influence of guanidine or other drugs which inhibit plaque formation. Removal of the drug then allowed viral development to start at defined time points. We thus ensured that the reduction of plaques correlated with the decay of the transfected polio cDNA or the viral RNA synthesized exclusively from that DNA. We showed that the intracellular cDNA kept its full capacity to generate viruses for as long as 8 to 10 days post-transfection. After this time, this capacity declined, and no viruses were detected after 14 to 16 days. The plaque-producing activity depended primarily on the stability of the cDNA and its ability to be transcribed and not on the stability of the RNA transcripts, which decayed within hours.