The ABO blood group antigens in patients with oral lichenoid reaction

Evaluating the association of ABO blood group with different delayed hypersensitivity reactions, such as oral lichenoid reaction (OLR), can provide a new perspective for clinical practice. Therefore, this study designed to investigate ABO blood group antigens in OLR patients. In this case-control study, the ABO blood group of 112 OLR patients and 117 individuals without oral lesions were included. Gender, age, characteristics of the lesions, medications and restorative materials recorded. Chi-square test used to compare the frequency of ABO blood groups in OLR patients with controls. The O blood group was significantly higher in OLR patients and all its subtypes. Also, there were significant relation between O blood group, and severity of lesions. The frequency of dysplasia was non-statistically significant higher in OLR patients with O blood group than other blood group. Based on the results of the present study, O blood group was significantly more in patients with lichenoid reaction than control group, and AB blood group was the lowest. Also, O blood group showed a positive association with the more severe form of OLR lesions and frequency of dysplasia.

Immediate pain alleviation in oral mucositis and other oral ulcerative diseases through photobiomodulation therapy: the preemptive treatment concept

OBJECTIVE

Photobiomodulation (PBM) therapy is recommended by multiple international societies for managing oral mucositis (OM). These recommendations are based on extensive evidence. However, the search for an optimal PBM protocol continues. This mapping review focuses on a novel aspect of PBM therapy which is the immediate effect on pain levels associated with oral ulcerative conditions.

DATA SOURCES

This literature review systematically compiles and evaluates the evidence about OM, alongside other oral ulcerative conditions, as the protocols that achieved pain relief for these oral conditions may have potential applicability to OM management. The scientific database used was PubMed.

CONCLUSION

Whereas most of the randomized controlled trials about PBM therapy for OM and other ulcerative oral diseases reported delayed pain relief, certain PBM therapy protocols reported immediate pain relief. The results of this review highlight the concept of preemptive PBM therapy, in which PBM therapy is delivered early in the development of OM throughout the oncotherapy and may achieve immediate pain relief consistently in most of the patients and close to a negligible pain level. PBM therapy, as a powerful non-pharmacologic tool for immediate pain relief, has a great beneficial value in patients suffering from OM and other painful oral ulcerative diseases such as recurrent aphthous stomatitis and chronic graft-versus-host disease.

One-way donor-to-recipient human leukocyte antigen mismatch and graft-versus-host disease in liver transplantation: an observational study of a single-center experience in Korea

Background

Graft-versus-host disease (GVHD) is a rare, but potentially fatal complication of liver transplantation. One-way human leukocyte antigens (HLA) mismatch has emerged as a risk factor for GVHD. However, the risk of mortality associated with HLA-one-way mismatch (OWMM) remains uncertain. We investigated the incidence and characteristics of GVHD.

Methods

In total, 899 patients who underwent liver transplantation at a single center were retrospectively reviewed. The incidence of GVHD and 1- and 5-year survival rates were compared according to whether HLA-OWMM developed.

Results

In the HLA-OWMM group, GVHD developed in two patients (14.3%). Notably, GVHD was only observed in living donor liver transplant (LDLT) recipients in the HLA-OWMM group. The HLA-OWMM group exhibited a lower 1-year patient survival rate than the control (i.e., non-HLA-OWMM) group (78.6% vs. 90.7%, P=0.120). However, the 5-year survival rate in the HLA-OWMM group was similar to that in the control group (78.6% vs. 78.2%, P=0.821). When the HLA-OWMM group was further stratified by the number of mismatched loci, the 5-year survival rate was 83.3% in patients with HLA-OWMM at one to two loci and 75.0% in those with HLA-OWMM at three loci.

Conclusions

Despite the higher incidence of GVHD in LDLT recipients with HLA-OWMM, the 5-year patient survival rates were comparable to those in recipients without HLA-OWMM. The decision to perform LDLT in patients with HLA-OWMM depends on the patient's status and the organ supply of a specific region.

Bone Marrow Quality Index: A Predictor of Acute Graft-versus-Host Disease in Hematopoietic Stem Cell Transplantation for Thalassemia

Bone marrow (BM) continues to be the preferred source of stem cells in allogenic transplantation for nonmalignant disorders. Granulocyte colony-stimulating factor (G-CSF)-primed BM is associated with low rates of acute graft-versus-host disease (aGVHD) and allows reduced collection volumes while ensuring speedy engraftment. However, variability in BM harvest quality is a concern. This study evaluated the utility of a novel indicator, the Bone Marrow Quality Index (BMQI), to predict aGVHD. We analyzed 184 consecutive first matched related donor bone marrow transplants for thalassemia using G-CSF-primed bone marrow over 6 years from March 2017 to April 2023 across 2 centers in India. BMQI was defined as the ratio of the G-CSF-primed BM WBC count to the peripheral blood WBC count within 24 hours of harvest. European Society for Blood and Marrow Transplantation criteria were used to grade aGVHD. The log-rank test was used to assess the impact of BMQI on aGVHD. The chi-square test was used to compare categorical data, and the Wilcoxon rank-sum test was used to compare the numerical data. A Cox proportional hazards model was used to investigate the association of BMQI vis-à-vis other factors on aGVHD. Of the 184 patients studied, 19 had a BMQI <.9, 18 had a BMQI between .9 and 1, and the remaining 147 had a BMQI >1. The rate of aGVHD grade II-IV was 37% in patients with a BMQI <.9 , 22% in those with BMQI .9 to 1, and 12% in those with BMQI >1 (P = .018). Patients with BMQI <.9 had a 3.1-fold greater chance (95% confidence interval [CI], .9 to 10.6) and those with BMQI .9 to 1 had a 2-fold greater chance (95% CI, .5 to 6.6) of developing aGVHD grade II-IV. BMQI was the significant predictor associated with aGVHD hazard (P = .014). BMQI appears to be the most relevant and controllable predictor of aGVHD. It is a novel, informative, and very simple indicator that could influence aGVHD prophylaxis decision making. Our indicator is accurately measurable, inexpensive, precise, and timely; furthermore, it does not involve any sophisticated equipment and thus may be widely applicable. Prior knowledge of poor BM quality may help intensify prophylaxis and monitoring for aGVHD, as well as trigger a review of collection procedures.

Multi-parametric MRI in the diagnosis and scoring of gastrointestinal acute graft-versus-host disease

OBJECTIVES

Acute gastrointestinal graft-versus-host disease (GI-aGVHD) is a severe complication of allogeneic hematopoietic stem cell transplantation (HSCT). Diagnosis relies on clinical, endoscopic, and pathological investigations. Our purpose is to assess the value of magnetic resonance imaging (MRI) in the diagnosis, staging, and prediction of GI-aGVHD-related mortality.

METHODS

Twenty-one hematological patients who underwent MRI for clinical suspicion of acute GI-GVHD were retrospectively selected. Three independent radiologists, blinded to the clinical findings, reanalyzed MRI images. The GI tract was evaluated from stomach to rectum by analyzing fifteen MRI signs suggestive of intestinal and peritoneal inflammation. All selected patients underwent colonoscopy with biopsies. Disease severity was determined on the basis of clinical criteria, identifying 4 stages of increasing severity. Disease-related mortality was also assessed.

RESULTS

The diagnosis of GI-aGVHD was histologically confirmed with biopsy in 13 patients (61.9%). Using 6 major signs (diagnostic score), MRI showed 84.6% sensitivity and 100% specificity in identifying GI-aGVHD (AUC = 0.962; 95% confidence interval 0.891-1). The proximal, middle, and distal ileum were the segments most frequently affected by the disease (84.6%). Using all 15 signs of inflammation (severity score), MRI showed 100% sensitivity and 90% specificity for 1-month related mortality. No correlation with the clinical score was found.

CONCLUSION

MRI has proved to be an effective tool for diagnosing and scoring GI-aGVHD, with a high prognostic value. If larger studies will confirm these results, MRI could partly replace endoscopy, thus becoming the primary diagnostic tool for GI-aGVHD, being more complete, less invasive, and more easily repeatable.

KEY POINTS

• We have developed a new promising MRI diagnostic score for GI-aGVHD with a sensitivity of 84.6% and specificity of 100%; results are to be confirmed by larger multicentric studies. • This MRI diagnostic score is based on the six MRI signs most frequently associated with GI-aGVHD: small-bowel inflammatory involvement, bowel wall stratification on T2-w images, wall stratification on post-contrast T1-w images, ascites, and edema of retroperitoneal fat and declivous soft tissues. • A broader MRI severity score based on 15 MRI signs showed no correlation with clinical staging but high prognostic value (100% sensitivity, 90% specificity for 1-month related mortality); these results also need to be confirmed by larger studies.

Covid-19, HLA, and race common link: A novel hypothesis

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) accountable for the coronavirus disease 2019 (Covid-19) prompted a catastrophic pandemic striking millions of people with diverse presentations, from asymptomatic to severe, potentially lethal disease requiring unprecedented levels of specialized care and extraordinary resources that have overwhelmed healthcare systems around the world. In this detailed communication we postulating a novel hypothesis, based on the viral replication and transplantation immunology. This based on reviewing published journal articles and text book chapters to account for variable mortality and degrees of morbidity among various race and origins. Homo sapiens evolution over millions of years, for that the matter the origin of any biologic form of life form initiated by microorganisms. The entire body of a human has several millions of bacterial and viral genomes incorporated over millions of years. Perhaps the answer or a clue lies how compatible a foreign genomic sequence fits into three billion copies of human genome.

Manufacturing regulatory T cells for adoptive cell therapy in immune diseases: A critical appraisal

Regulatory T cells (Tregs) are a unique subset of lymphocytes that play a vital role in regulating the immune system by suppressing unwanted immune responses and thus preventing autoimmune diseases and inappropriate inflammatory reactions. In preclinical and clinical trials, these cells have demonstrated the ability to prevent and treat graft vs. host disease, alleviate autoimmune symptoms, and promote transplant tolerance. In this review, we provide a background on Treg cells with a focus on important Treg cell markers and Treg subsets, and outline the methodology currently used for manufacturing adoptive regulatory T cell therapies (TRACT). Finally, we discuss the approaches and outcomes of several clinical trials in which Tregs have been adoptively transferred to patients.

The effect of pre-conditioning immunoglobulin and absolute lymphocyte count on the outcomes of allogeneic hematopoietic cell transplantation

INTRODUCTION

The prevention of mortality and morbidity related to the increasingly used allogeneic hematopoietic cell transplantation (allo-HCT), along with the effects of pre- and post-transplant immune status on transplant outcomes, have become the focus of the studies conducted on this subject in recent years. In parallel, this study was designed to investigate the effects of pre-conditioning immunoglobulin (pre-conditioning-Ig) and pre-conditioning absolute lymphocyte count (pre-conditioning-ALC) levels on transplant outcomes.

METHODS

This study was designed as a retrospective, observational and cross-sectional study. The objective of the study is to investigate the effects of pre-conditioning-Ig and ALC levels primarily on the rate of patients with febrile neutropenia (FEN) and the duration of FEN and length of hospital stay (LoS), and secondarily on acute graft-versus-host disease (aGVHD), cytomegalovirus (CMV) viremia, and mortality in the acute leukemia patients who underwent allo-HCT.

RESULTS

A total of 104 acute leukemia patients, of whom 55 had acute lymphoblastic leukemia (ALL) and 49 had acute myeloid leukemia (AML), were included in the study. Compared to the AML group, the median pre-conditioning-IgG, IgA, and IgM levels were found to be significantly lower in the ALL group (11.3 vs. 6.6, p < 0.001; 1.8 vs. 0.9, p < 0.001; and 0.7 vs. 0.4, p < 0.001; respectively). But, there was no significant difference between the groups in pre-conditioning-Ig and ALC levels and transplant outcomes. However, subgroup analysis revealed that high pre-conditioning-ALC levels were significantly correlated with aGVHD levels (Odds Ratio: 1.02; p = 0.034) and low pre-conditioning-IgM levels were significantly correlated with increased mortality rate (Hazard Ratio: 0.08; p = 0.042) in AML patients.

CONCLUSION

The significant difference determined between the ALL and AML groups in pre-conditioning-Ig levels was not reflected on the effects of pre-conditioning-Ig and ALC levels on transplant outcomes. However, we observed that pre-conditioning-IgM and ALC levels have an impact on transplant outcomes in AML patients.

Immunopathological insights into villitis of unknown etiology on the basis of transplant immunology

Villitis of unknown etiology (VUE) is an inflammatory disease characterized by the infiltration of maternal CD8 +T cells into the placental villi. Although the pathogenesis of VUE is still debated, dysregulation of the immune system appears to be an important factor in the development of the disease. Interaction of maternal T cells with the fetal antigens seems to be the trigger for the VUE onset. In this context, graft vs host disease (GVHD) and allographic rejection seem to share similarities in the VUE immunopathological mechanism, especially those related to immunoregulation. In this review, we compared the immunological characteristics of VUE with allograft rejection, and GVHD favoring a better knowledge of VUE pathogenesis that may contribute to VUE therapeutics strategies in the future.

Efficacy of adoptively transferred allogeneic CIK cells on colorectal cancer: Augmentative antitumoral effects of GvHD

OBJECTIVE

A preclinical study was designed to evaluate the effects of adoptively transferred cytokine-induced killer (CIK) cells on colorectal adenocarcinoma.

METHODS

Forty NOG mice bearing HT-29 xenograft tumors were developed and equally divided into 2 groups of treatment and control. The mice in the treatment group received cumulatively 40-60 × 10⁶ CIK cells in four divided doses.

RESULTS

Median tumor doubling times for HT-29 xenograft tumors in the treatment and control groups were found to be 8.98 and 4.32 days; respectively. The treatment resulted in tumor growth delay (TGD) of 52.5 %. CIK cell-induced log cell kill (LCK) was found to be 0.67, which implies reduction of 78.6 % of neoplastic colorectal cells. Median length of survival in the treated mice was significantly longer than controls (57 (41-63) vs 41 (31-57) days, P < 0.001). Mice in the treatment group experienced graft-versus-host disease (GvHD) from median of day 13th after the cell therapy. LCK and TGD significantly increased after emergence of GvHD. After necropsy, tumors of the treatment group contained high levels of human-originated CD3⁺, CD4⁺ and CD8⁺ cells and showed significantly lower mitotic counts (P < 0.001) and residual tumor scores (P = 0.005) than the controls (entirely negative for the mentioned CD markers). Ninety percent of the treated mice were found to be responding.

CONCLUSIONS

Adoptive transfer of allogeneic CIK cells may be an efficient antitumoral therapy for colorectal cancer. Allogeneic CIK cell-mediated GvHD may contribute to amplification of graft-versus-tumor effects of the cellular therapy.

Effect of ruxolitinib on the oral mucosa of patients with steroid-refractory chronic Graft-versus-Host disease and oral involvement

BACKGROUND

Chronic Graft-versus-Host Disease (cGVHD) can impact quality of life, especially in patients with oral involvement. Half of the patients with cGVHD do not respond to first-line therapy with corticosteroids and calcineurin inhibitors. Ruxolitinib is effective in steroid-refractory (SR)-cGVHD cases, but the long-term effects of ruxolitinib on the oral mucosa are unknown.

OBJECTIVE(S)

This study aims to assess the effect of ruxolitinib on the oral mucosa of SR-cGVHD patients with oral involvement.

MATERIALS AND METHODS

An observational longitudinal patient study was conducted in 53 patients with SR-cGVHD and oral involvement who were treated with ruxolitinib. The baseline condition of the oral mucosa was compared to its condition at 4 and 12 weeks after starting ruxolitinib.

RESULTS

The overall response was 81% (43/53), with a complete response in 53% (28/53) and partial response in 28% (15/53) after 12 weeks (p < 0.001). Men and patients concurrently using immunosuppressive therapy responded better than women (p = 0.005) and patients with ruxolitinib monotherapy (p = 0.02), respectively. At a longer follow-up (median 20 months), oral symptoms were comparable to the 12-week symptoms (p = 0.78), regardless of ruxolitinib use (p = 0.83).

CONCLUSION

Ruxolitinib treatment of SR-cGVHD patients with oral involvement was associated with a significant response of the oral manifestations at 12 weeks.

CLINICAL RELEVANCE

The oral mucosa of SR-cGVHD patients is likely to improve after 4 and 12 weeks of ruxolitinib treatment. Symptom severity at baseline does not affect the response of the oral mucosa.

Immune cell subsets in interface cutaneous immune-related adverse events (cirAEs) associated with anti-PD-1 therapy resemble acute graft vs host disease more than lichen planus

Background

Checkpoint immunotherapy is frequently associated with cutaneous immune‐related adverse events (cirAEs), and among those, the most common subtype shows interface reaction patterns that have been likened to lichen planus (LP); however, cutaneous acute graft versus host disease (aGVHD) may be a closer histopathologic comparator. We used quantitative pathology to compare the immunologic composition of anti‐PD‐1‐associated interface reactions to LP and aGVHD to assess for similarities and differences between these cutaneous eruptions.

Methods

Immunohistochemistry for CD4, CD8, CD68, PD‐1, and PD‐L1 was performed on formalin‐fixed paraffin‐embedded tissue from patients with anti‐PD‐1 interface cirAEs (n = 4), LP (n = 9), or aGVHD (n = 5). Densities of immune cell subsets expressing each marker were quantified using the HALO image analysis immune cell module. Plasma cell and eosinophil density were quantified on routine H&E slides.

Results

Specimens from patients with anti‐PD‐1 interface cirAEs showed equivalent total cell densities and immune cell composition to those with aGVHD. Patients with LP showed higher total immune cell infiltration, higher absolute T‐cell densities, increased CD8 proportion, and reduced histiocytic component. The cases with the highest plasma cell counts were all anti‐PD‐1 interface cirAEs and aGVHD.

Conclusion

The composition of immune cell subsets in anti‐PD‐1 interface cirAEs more closely resembles the immune response seen in aGVHD than LP within our cohort. This warrants a closer look via advanced analytics and may have implications for shared pathogenesis and potential treatment options.

Association Between Baseline Patient-Reported Outcomes and Complications of Hematopoietic Stem Cell Transplantation

Hematopoietic cell transplantation (HCT) is a potentially curative therapy for hematologic malignancies, but it often results in significant toxicities and impaired quality of life (QOL). Although the value of patient-reported outcomes (PROs) is increasingly recognized in HCT, data are limited regarding the relationship between PROs and HCT complications. We conducted a secondary data analysis of 250 patients who were hospitalized for autologous or allogeneic HCT at Massachusetts General Hospital from 2011 through 2016. We assessed QOL (Functional Assessment of Cancer Therapy-General), mood (Hospital Anxiety and Depression Scale), and fatigue (FACT-Fatigue) at baseline. We abstracted from the Electronic Health Record (1) hospitalization during the first 100 days after HCT, (2) days alive and out of the hospital in the first 100 days after HCT, and (3) cumulative incidence of acute graft-versus-host disease (GVHD) among allogeneic HCT recipients. We assessed the association of baseline PROs with HCT complications using multivariable models adjusting for patient and transplant characteristics. Overall, 44.4% (111/250) of patients underwent an autologous HCT, 25.2% (63/250) received a myeloablative allogeneic HCT, and 30.4% (76/250) underwent a reduced-intensity allogeneic HCT. In multivariable logistic regression, higher anxiety (odds ratio [OR] = 1.14, P = .004) was associated with higher likelihood of rehospitalization within 100 days after HCT. In multivariable Poisson regression, lower fatigue (β = 0.003, P = .015) was associated with increased days alive and out of the hospital in the first 100 days post-HCT. In multivariable logistic regression, lower baseline QOL (OR = 0.97, P = .034), higher fatigue (OR = 0.95, P = .004), and higher depression (OR = 1.15, P = .020) were associated with increased likelihood of acute GVHD. Baseline PROs are associated with health care utilization after HCT and risk of acute GVHD in allogeneic HCT recipients. These findings underscore the potential utility of pretransplantation PROs as important prognostic factors for HCT.

Rehabilitation Interventions in the Multidisciplinary Management of Patients With Sclerotic Graft-Versus-Host Disease of the Skin and Fascia

Graft-versus-host disease (GVHD) is a multisystemic disorder that affects 30%-80% of patients who undergo allogeneic hematopoietic stem cell transplantation 10%-15% of GVHD patients develop sclerotic features affecting the skin or deeper tissues, leading to functional limitations and poor quality of life. There is limited literature regarding the indications and efficacy of specific rehabilitative interventions in sclerotic GVHD (sclGVHD). In this article, we summarize the current evidence supporting rehabilitation intervention in sclGVHD and offer our approach to the multidisciplinary management of this disease. In addition, we review techniques that have been employed in other sclerotic skin diseases (eg, iontophoresis, extracorporeal shock waves, botulinum toxin A, adipose derived stromal vascular fraction), but that require further validation in the sclGVHD setting. Ultimately, optimal care for this complex disease requires a multidisciplinary approach that includes a rehabilitation and adaptive program tailored to each patient's needs.

Allogeneic hematopoietic stem cell transplantation in aplastic anemia: current indications and transplant strategies

Treatment options for newly diagnosed aplastic anemia (AA) patient includes upfront allogeneic hematopoietic stem cell transplant (HSCT) or immunosuppressive therapy (IST). With recent advances in supportive care, conditioning regimens and post-transplant immunosuppression the overall survival for HSCT approaches 70-90%. Transplant eligibility needs to be assessed considering age, comorbidities, donor availability and probability of response to immunosuppressive therapy (IST). Upfront HSCT should be offered to children and young adults with matched related donor (MRD). Upfront HSCT may also be offered to children and young adults with rapidly available matched unrelated donor (MUD) who require urgent HSCT. Bone marrow (BM) graft source and cyclosporine (CsA) plus methotrexate (MTX) as graft versus host disease (GVHD) prophylaxis are preferable when using anti-thymocyte globulin (ATG) based conditioning regimens. Alemtuzumab is an acceptable alternative to ATG and is used with CsA alone and with either BM or peripheral blood stem cells (PBSC). Cyclophosphamide (CY) plus ATG conditioning is preferable for patients receiving MRD transplant, while Fludarabine (Flu) based conditioning is reserved for older adults, those with risk factors of graft failure and those receiving MUD HSCT. For haploidentical transplant, use of low dose radiotherapy and post-transplant cyclophosphamide has resulted in a marked reduction in graft failure and GVHD.

Small Bowel Perforation Associated With Gastrointestinal Graft-Versus-Host Disease and Cytomegalovirus Enteritis in a Patient With Leukemia: A Case Report With Literature Review

Gastrointestinal graft-versus-host disease (GVHD) is a common complication after hematopoietic stem cell transplantation. Concomitant cytomegalovirus (CMV) enteritis worsens the prognosis of this condition. We report a case of small bowel perforation associated with gastrointestinal GVHD and CMV enteritis in a patient with leukemia who was successfully treated surgically. A 39-year-old man presented with intestinal perforation necessitating emergency surgical intervention. He was diagnosed with T-cell acute lymphoblastic leukemia and developed severe gastrointestinal GVHD and CMV enteritis after hematopoietic stem cell transplantation. His terminal ileum showed a perforation with diffuse wall thinning, and petechiae were observed over long segments of the distal ileum and the proximal colon. Small bowel segmental resection and a subtotal colectomy with a double-barreled ileocolostomy were performed. The patient recovered uneventfully after the operation. Based on reports described in the literature, surgery plays a minor role in the management of gastrointestinal GVHD; however, timely surgical intervention could be effective in selected patients.

Is immunological recovery clinically relevant at 100 days after allogeneic transplantation?

BACKGROUND/AIMS

Immune reconstitution following allogeneic hematopoietic stem cell transplantation (HSCT) is affected by multiple variables during the transplantation.

METHODS

We assessed the clinical factors contributing to immune function reconstitution at 100 days post-allogeneic HSCT in 114 patients receiving fludarabine-based conditioning. Immunophenotypic analysis using flow cytometry was performed to evaluate the percentage and the absolute numbers of T-cell subsets, natural killer cells, and B-cells as clinical outcomes.

RESULTS

Tacrolimus-based graft-versus-host disease (GVHD) prophylaxis, T-cell depletion, and acute GVHD were significantly associated with delayed immune reconstitution of T-cell subsets. The incidence of chronic GVHD was significantly increased in the normal recovery group compared to the abnormal group (p = 0.01). Epstein-Barr virus reactivation was more frequently observed in the abnormal group of T-cell subsets (p = 0.045). All viral reactivation events including cytomegalovirus reactivation appeared to be more frequent in the abnormal group of T-cell subsets.

CONCLUSION

The immune recovery status post-allogeneic HSCT was affected by GVHD prophylactic regimens, especially in cases receiving tacrolimus-based GVHD prophylaxis, T-cell depletion, and possibly those manifesting acute GVHD. Delayed immune reconstitution might increase the morbidity due to viral reactivation. Treatment strategies are needed to prevent infectious complications and enhance immune reconstitution based on the immune recovery status following allogeneic HSCT with fludarabine-based conditioning.

Clinical impact of anti-thymocyte globulin on survival and graft-versus-host disease in patients undergoing human leukocyte antigen mismatched allogeneic stem cell transplantation

BACKGROUND/AIMS

Rabbit anti-thymocyte globulin (ATG) is usually incorporated in hematopoietic stem cell transplantation (HSCT) to reduce the incidence of graft-versus-host disease (GVHD). This study aimed to find optimal ATG doses in patients undergoing human leukocyte antigen (HLA)-mismatched allogeneic HSCT.

METHODS

We retrospectively collected medical records from 352 consecutive patients with acute myeloid leukemia (n = 214), acute lymphoblastic leukemia (n = 62), or myelodysplastic syndrome (n = 76) in eight centers of Korea between 2005 and 2015. All patients received busulfan-based conditioning without total body irradiation (TBI) and received stem cells from HLA-mismatched donors.

RESULTS

In the current study, 5-year overall survival rates of patients receiving low to medium doses of ATG (2.5 to 7.5 mg/kg) were higher than those receiving other doses of ATG (hazard ratio [HR], 0.528; 95% confidence interval [CI], 0.311 to 0.897; p = 0.018). The incidence rates of extensive chronic GVHD (ecGVHD) after administration of low to medium doses of ATG were lower than those after other doses of ATG (HR, 0.447; 95% CI, 0.224 ton 0.889; p = 0.022).

CONCLUSION

The low to medium doses of ATG may be associated with improving survival outcomes and reducing incidence of ecGVHD without enhancing the chances of relapse in patients with acute leukemia or myelodysplastic syndrome undergoing non-TBI-based HLA-mismatched allogeneic HSCT.

Rehabilitation in Children With Sclerodermoid Chronic Graft-Versus-Host Disease: Case Series

Joint contracture in chronic graft-versus-host disease (cGVHD) is refractory to treatment, and tends to deteriorate gradually over time. There is scant clinical research focusing on timing and intensity of rehabilitation on joint contractures in children with sclerodermoid cGVHD after hematopoietic stem cell transplantation. We retrospectively reviewed rehabilitative therapeutic effects in 6 children with sclerodermoid cGVHD, whose clinical records documented their condition, before and after rehabilitation therapies. Three children who started treatment within a mean of 2 months after the onset of joint symptoms, and who underwent home-based exercise twice daily for 30 minutes showed more prominent improvement in range of motion compared with the other 3 children, who started rehabilitation therapy later than 6 months after onset of joint symptoms, without regular home-based exercise.

Is It Time to Revisit the Role of Allogeneic Transplantation in Lymphoma?

PURPOSE OF REVIEW

A multitude of new drug and cell therapy approvals for lymphoma has prompted questions about the role of allogeneic blood or marrow transplantation (allo-BMT). We sought to review the latest evidence examining the role of allo-BMT for lymphoma in this evolving landscape.

RECENT FINDINGS

Despite several new drug classes, there remains a large unmet need, particularly in hard to treat subtypes of lymphoma and for patients with relapsed/refractory disease. Allo-BMT can provide an opportunity for cure due to a potent graft vs lymphoma effect in high-risk relapse/refractory follicular lymphoma, mantle cell lymphoma, and aggressive T cell lymphomas. Chimeric antigen receptor T cell therapy and checkpoint blockers have improved outcomes for patients with relapsed /aggressive B cell lymphomas and Hodgkin lymphoma respectively; the role of allo-BMT consolidation in the treatment algorithm for responders to these therapies is an evolving topic. Expanded donor availability including haploidentical relatives has improved access to allo-BMT. Non-myeloablative conditioning regimens and post-transplant cyclophosphamide prophylaxis have improved early transplant-related morbidity and rates of graft versus host disease and translated into long-term survival for patients with lymphoid malignancies. Patient selection remains key, but allo-BMT remains the only modality able to deliver durable long-term remissions across different types of lymphoma.

[Clinical analysis of six cases with the de novo glomerulitis after allogeneic hematopoietic stem cell transplantation]

目的

探讨异基因造血干细胞移植（allo-HSCT）后肾小球肾炎的发病、诊断及治疗情况。

方法

回顾性分析2008年1月至2016年12月河南省肿瘤医院allo-HSCT后肾小球肾炎患者的临床资料。

结果

478例allo-HSCT患者中6例（1.26%）发生肾小球肾炎，男3例，女3例，中位年龄22（12~36）岁；重型再生障碍性贫血（SAA）2例，急性髓系白血病（AML）4例，移植前均无明确的肾脏病病史，中位发生时间为移植后447（272~1 495）d。4例患者肾功能异常，5例尿潜血阳性，3例高血压，2例高血脂。5例患者曾发生急性GVHD，4例发病时伴有慢性GVHD。肾脏病理：微小病变型肾病1例，膜性肾病4例，系膜增生性肾小球肾炎伴缺血性损伤1例。肾脏免疫组化：IgG阳性4例，IgM阳性1例，C3阳性3例，C1q阳性1例。2例血清抗核抗体阳性，IgG和IgM升高各1例。仅1例患者糖皮质激素治疗有效。5例患者采用低剂量环磷酰胺联合霉酚酸酯治疗，2例完全有效，3例部分有效。4例患者生存良好，2例患者死于肺感染。

结论

allo-HSCT后肾小球肾炎的病理类型以膜性肾病为主，低剂量环磷酰胺联合霉酚酸酯可获得较好疗效。

[Treatment of four cases of Fanconi anemia by allogeneic hematopoietic stem cell transplantation with low intensity conditional regimen]

目的

评估减低剂量预处理异基因造血干细胞移植（allo-HSCT）对范可尼贫血（FA）患儿的治疗效果。

方法

回顾性分析4例接受allo-HSCT FA患儿的临床资料。

结果

4例FA患儿中男1例、女3例，移植时中位年龄为7（5~10）岁，非亲缘10/10 HLA全相合外周血干细胞移植2例，同胞10/10 HLA全相合骨髓联合外周血干细胞移植、非亲缘10/10 HLA全相合脐血干细胞移植各1例。采用白消安联合低剂量环磷酰胺（20 mg/kg）为基础的预处理方案。4例FA患儿均获得造血重建，中性粒细胞植活中位时间为11（9~15）d，血小板植活中位时间为12（8~28）d。1例患儿发生Ⅰ度急性移植物抗宿主病，1例患儿发生出血性膀胱炎，4例患儿均未发生肝静脉闭塞病。

结论

减低剂量预处理allo-HSCT治疗FA患儿是安全、有效的。

[Impact of mycophenolate mofetil prophylaxis duration on acute graft-versus-host disease after haploidentical stem cell transplantation]

Objective: To investigate the impact of mycophenolate mofetil (MMF) prophylaxis duration on acute graft-versus-host disease (aGVHD) after haploidentical stem cell transplantation (haplo-HSCT) using 'Beijing Protocol'. Methods: Adult patients (≥14 years) received haplo-HSCT in Peking University Institute of Hematology from Sep, 2016 to Mar, 2017 were retrospectively reviewed if they fulfilled the criterias: ①diagnosed with hematological maligancies; ②standard-risk status at haplo-HSCT. A total of 237 patients [including 102 patients with long MMF duration (defined as started on day -9 with 100 mg/d, adjusted to 500 mg/d from day +30 and discontinued on day +45 to +60 or occurrence of CMV/EBV reactivation or late-onset hemorrhagic cytitis), and 135 patients with short MMF duration (defined as started on day -9 with 500 mg/d and discontinued on the day achieved neutrophil engraftment)] were reviewed. The incidence of aGVHD, virus infection and overall survival (OS) were compared between the two groups. Results: The median durations of MMF prophylaxis of long and short duration groups were 27(7-71) and 15(9-24) days, respectively after haplo-HSCT. There were no differences of baseline characteristics (including sex, patient age, disease, mismatched HLA loci, donor-recipient relation, donor-recipient sex and donor age) between the two groups. The incidences of the grade Ⅱ-Ⅳ and Ⅲ/Ⅳ aGVHD in long and short duration groups were 31.1% versus 17.6% (P=0.018) and 7.4% verus 7.8% (P=0.900), respectively. The duration of MMF prophylaxis was not found to be associated with gradeⅡ-Ⅳ aGVHD by the multivariate analysis. There were no significant differences in terms of CMV viremia, EBV viremia, hemorrhagic cytitis and OS between the two groups. Conclusion: Prophylaxis with short duration MMF in the setting of 'Beijing protocol' haplo-SCT was not associated with increased acute GVHD with no impact on OS, which indicated that short duration MMF might be a feasible GVHD prophylaxis regimen.

[Application of low-dose ATG for GVHD prophylaxis in patients undergoing PBSCT aged over forty years old]

目的

探讨在供、受者年龄均≥40岁同胞相合外周血干细胞移植（MSD-PBSCT）移植物抗宿主病（GVHD）预防方案中增加低剂量抗胸腺细胞球蛋白（ATG）的效果。

方法

回顾性分析2013年3月至2017年4月行MSD-PBSCT且供、受者年龄均≥40岁恶性血液病患者的临床资料。43例患者在常规急性GVHD预防方案（环孢素A或他克莫司联合短疗程甲氨蝶呤）中加入ATG 1.5 mg·kg⁻¹·d⁻¹×3 d（ATG组），55例患者应用常规GVHD预防方案（对照组）。

结果

①ATG组中性粒细胞植入中位时间短于对照组[13（11~17）d对14（12~24）d，P=0.001]，血小板植入中位时间差异无统计学意义[14（11~43）d对15（11~42）d，P=0.071）]。②ATG组+100 d内急性GVHD累积发生率低于对照组[25.6%（95%CI 13.7%~39.3%）对49.1%（95%CI 35.2%~61.6%），P=0.018]，Ⅱ~Ⅳ度急性GVHD、慢性GVHD发生率差异无统计学意义[18.6%（95%CI 8.6%~31.5%）对23.6%（95%CI 13.4%~35.6%），P=0.509；49.6%（95%CI 31.6%~65.3%）对56.4%（95%CI 41.4%~69.0%），P=0.221]。③ATG组与对照组移植后1年巨细胞病毒血症累积发生率差异无统计学意义[21.1%（95%CI 10.3%~34.5%）对31.1%（95%CI 18.8%~44.2%），P=0.429]。④ATG组及对照组移植后2年累积复发率[24.0%（95%CI 11.5%~38.9%）对24.0%（95%CI 12.1%~38.2%），P=0.608]、非复发死亡率[10.2%（95%CI 3.1%~22.1%）对21.6%（95%CI 9.4%~37.0%），P=0.411]及无病生存率[65.8%（95%CI 50.3%~81.3%）对54.4%（95%CI 37.7%~71.1%），P=0.955]差异均无统计学意义，但ATG组移植后2年总生存率优于对照组[83.8%（95%CI 71.8%~90.0%）对58.0%（95%CI 42.2%~73.9%），P=0.019]。

结论

对于年龄较大的MSD-PBSCT患者，在常规GVHD预防方案基础上加入低剂量ATG可以显著降低移植后急性GVHD发生率、改善OS率，病毒感染发生率和复发率无明显增加。

Resolution of Hematocolpos in Adolescents Affected with Graft vs Host Disease

BACKGROUND

Bone marrow transplantation is a lifesaving procedure for a range of serious benign or malignant hematological conditions. A proportion of patients, however, will develop graft vs host disease (GVHD), acute or chronic, with serious long-term sequalae.

CASES

We present 2 cases of hematocolpos that developed in adolescence because of vaginal synechiae due to GVHD. The condition was initially asymptomatic, resolved spontaneously at first and recurred. In 1 girl blunt lysis of the adhesions was performed with the patient under general anesthesia, followed thereafter by local hydrocortisone and estriol treatment.

SUMMARY AND CONCLUSION

Genital symptoms might not be readily reported by adolescents after bone marrow transplantation. Physicians should be aware of possible late effects of GVHD on genitalia, inquire about symptoms, and be acquainted with addressing complications, such as vaginal obstruction.

[Research progress of topical treatment of oral chronic graft versus host disease: a review]

Oral cavity is one of the main organs involved in chronic graft versus host disease (cGVHD). Oral cGVHD seriously affects the patient's quality of life. Topical use of glucocorticoid and other agents is the primary topical treatment of oral cGVHD, oral photochemical therapy and various new methods have also been applied in patients recently. These important adjuvant therapies are based on the systemic use of drugs such as immunosuppressive agents, and sometimes, may be the only effective treatment for oral cGVHD. This review will focus on the application of topical agent treatment and oral photochemotherapy in oral cGVHD patients.

Myasthenia Gravis Associated With Thymoma And Aplastic Anemia: Case Report

Myasthenia gravis is associated in 10 to 15 percent of patients with thymic tumors, rarely with aplastic anemia. We report a 45-year-old male diagnosed with myasthenia gravis associated with thymoma. We started treatment with pyridostigmine. After thymectomy, the patient received 30 irradiation sessions. In the postoperative course, he had mild worsening of myasthenia gravis, which improved with prednisone. Five months later, he developed severe aplastic anemia. He was dependent on blood supplement. After allogeneic transplantation of bone marrow, he improved but later he -developed graft versus host disease. Myasthenia gravis was under good control with 480 mg of pyridostigmine per day.

Does anti-thymocyte globulin have a place in busulfan/fludarabine conditioning for matched related donor hematopoietic stem cell transplantation?

BACKGROUND/AIMS

There is controversy about the prophylactic effect of anti-thymocyte globulin (ATG) on graft versus host disease (GVHD) in the setting of matched related-donor hematopoietic stem cell transplantation (HSCT). This study assessed the inf luences of ATG on the incidences of acute and chronic GVHD and other clinical outcomes in matched related-donor HSCT.

METHODS

Sixty-one patients received allogeneic HSCT from human leukocyte antigen-matched, related donors. Patients received busulfan/fludarabine conditioning regimens and standard GVHD prophylaxis with or without additional ATG.

RESULTS

There was no significant difference in the cumulative incidences of overall acute GVHD, grade II to IV acute GVHD at day 100, and chronic GVHD during the follow-up period between the ATG and non-ATG groups. Three-year overall survival rates were very similar, but three year disease-free survival of the non-ATG group was higher than that of the ATG group (56.2% for ATG vs. 63.1% for non-ATG, p = 0.597). Relapse rate at 3 years in the ATG group was slightly higher than that of the non-ATG group (37.5% vs. 20%, p = 0.29). Non-relapse mortality rate at 3 years was lower in the ATG group (6.25% vs. 15.6%, p = 0.668).

CONCLUSIONS

Although the addition of ATG doesn't guarantee a reduction in the incidences of acute and chronic GVHD, pre-transplantation ATG may result in lower non-relapse mortality in the context of matched related-donor HSCT with a busulfan/fludarabine conditioning regimen. However, caution is needed when using ATG because of a possibility to increase relapse rate.

Immune therapy of metastatic melanoma developing after allogeneic bone marrow transplant

Metastatic melanoma is frequently treated with immune activating therapy, which poses a theoretical risk of inducing graft versus host disease (GVHD) in those who have received allogeneic stem cell transplantation. The literature reporting the safety of immunotherapy in post transplant patients is limited. We report two patients with metastatic melanoma who received treatment with immunotherapy after allogeneic stem cell transplantation that did not result in GVHD.

Harnessing the power of alloreactivity without triggering graft-versus-host disease: how non-engrafting alloreactive cellular therapy might change the landscape of acute myeloid leukemia treatment

Human leukocyte antigen-mismatched leukocyte infusions outside of the context of transplantation are a promising strategy for acute myeloid leukemia. Recent studies using such non-engrafting alloreactive cellular therapy (NEACT) revealed that survival of elderly patients increased from 10% to 39% when NEACT was given following chemotherapy, and that durable complete remissions were achieved in about a third of patients with relapsed or chemorefractory disease. We review the clinical reports of different NEACT approaches to date and describe how although T-cell and NK alloreactivity could generate immediate anti-leukemic effects, long-term disease control may be achieved by stimulating recipient-derived T-cell responses against tumor-associated antigens. Other variables likely impacting NEACT such as the release of pro-inflammatory cytokines from donor-host bidirectional alloreactivity and the choice of chemotherapeutics as well as future avenues for improving NEACT, such as optimizing the cell dose and potential synergies with adjuvant pharmacologic immune checkpoint blockade, are discussed.

Etanercept for steroid-refractory acute graft versus host disease following allogeneic hematopoietic stem cell transplantation

BACKGROUND/AIMS

The treatment for steroid-refractory acute graft versus host disease (GVHD) after allogeneic stem cell transplantation (allo-SCT) needs to be standardized. We report our clinical experience with etanercept for steroid-refractory acute GVHD.

METHODS

Eighteen patients who underwent allo-SCT and presented with steroid-refractory acute GVHD at Ajou University Hospital were studied retrospectively. They were given 25 mg of etanercept subcutaneously twice weekly for 4 weeks. The clinical responses were evaluated with regard to the severity of acute GVHD.

RESULTS

The median patient age was 43.5 years. Using nonparametric tests, etanercept had a down-grading effect on acute GVHD (p = 0.005), although no patient experienced complete remission. Partial responses were seen in 80%, 17%, and 57% of grade II to IV patients, respectively. Skin and gut GVHD were well controlled with etanercept, whereas hepatic GVHD was not. Four patients died of fatal infections. No factors affecting the clinical outcome of etanercept were identified.

CONCLUSIONS

Etanercept has a modest effect on steroid-refractory acute GVHD after allo-SCT, with tolerable side effects.

Gynecologic complication of chronic graft-versus-host disease: Vaginal obstruction

Allogenic peripheral blood stem cell transplantation (Allo-PBSCT) is being used to treat hematological malignancies with increasing frequency. Graft-versus-host disease (GvHD) is a complex complication of PBSCT. A 43-year-old woman came to the gynecology clinic for amenorrhea. She had been diagnosed with acute myeloid leukemia 2 years earlier and treated with induction and consolidation chemotherapy. After developing complete remission, she underwent Allo-PBSCT. When she started chemotherapy, her menstrual cycle completely disappeared. Fourteen months after menopausal hormone replacement therapy, it was discovered that her upper vaginal canal was completely obstructed. The lower vagina had an atrophic appearance. We report a rare case of partial vaginal obstruction as a complication of chronic GvHD and review the literature. We expect that this case report provides an opportunity to remind clinician of the gynecologic complications of GvHD.

Importance of killer immunoglobulin-like receptors in allogeneic hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation is the treatment of choice for many hematologic diseases, such as multiple myeloma, bone marrow aplasia and leukemia. Human leukocyte antigen (HLA) compatibility is an important tool to prevent post-transplant complications such as graft rejection and graft-versus-host disease, but the high rates of relapse limit the survival of transplant patients. Natural Killer cells, a type of lymphocyte that is a key element in the defense against tumor cells, cells infected with viruses and intracellular microbes, have different receptors on their surfaces that regulate their cytotoxicity. Killer immunoglobulin-like receptors are the most important, interacting consistently with human leukocyte antigen class I molecules present in other cells and thus controlling the activation of natural killer cells. Several studies have shown that certain combinations of killer immunoglobulin-like receptors and human leukocyte antigens (in both donors and recipients) can affect the chances of survival of transplant patients, particularly in relation to the graft-versusleukemia effect, which may be associated to decreased relapse rates in certain groups. This review aims to shed light on the mechanisms and effects of killer immunoglobulin-like receptors - human leukocyte antigen associations and their implications following hematopoietic stem cell transplantation, and to critically analyze the results obtained by the studies presented herein.

Clinical applications of mesenchymal stem cells

Mesenchymal stem cells (MSCs) are self-renewing, multipotent progenitor cells with multilineage potential to differentiate into cell types of mesodermal origin, such as adipocytes, osteocytes, and chondrocytes. In addition, MSCs can migrate to sites of inflammation and exert potent immunosuppressive and anti-inflammatory effects through interactions between lymphocytes associated with both the innate and adaptive immune system. Along with these unique therapeutic properties, their ease of accessibility and expansion suggest that use of MSCs may be a useful therapeutic approach for various disorders. In the clinical setting, MSCs are being explored in trials of various conditions, including orthopedic injuries, graft versus host disease following bone marrow transplantation, cardiovascular diseases, autoimmune diseases, and liver diseases. Furthermore, genetic modification of MSCs to overexpress antitumor genes has provided prospects for clinical use as anticancer therapy. Here, we highlight the currently reported uses of MSCs in clinical trials and discuss their efficacy as well as their limitations.

Therapeutic effect of 0.03% tacrolimus ointment for ocular graft versus host disease and vernal keratoconjunctivitis

Purpose

To determine whether topical tacrolimus might prove effective in the treatment of refractory anterior segment inflammatory diseases, and to evaluate its efficacy in eyes with ocular graft versus host disease (GVHD), and vernal keratoconjunctivitis (VKC).

Methods

Twenty-eight eyes of 14 patients with anterior segment inflammation refractory to steroid treatment were treated with 0.03% tacrolimus ointment at the Samsung Medical Center, Seoul, Korea from March 2008 through August 2009. Seven patients had ocular GVHD and seven had VKC. We evaluated the conjunctival and corneal inflammatory change at one, two, four, and eight weeks after treatment with a scoring system. Time to initial response of treatment and therapeutic effect between GVHD and VKC was also analyzed. After the eight-week treatment period, patients were divided into two groups (maintenance group and discontinuance group). Eight patients maintained the treatment for an additional four months, and six patients discontinued the treatments. Therapeutic effect was also compared between the groups at eight weeks and six months after treatment.

Results

The mean conjunctival and corneal inflammation score was reduced significantly at eight weeks after treatment (p < 0.0001). The therapeutic effect in conjunctival inflammation was first noted at week two after the initial treatment (p = 0.002); reduction in corneal inflammation was first noted at one week (p = 0.0009). When compared according to diagnosis, no therapeutic difference was detected between the groups (p > 0.05). Six months after treatment, we noted no therapeutic differences between the maintenance group and discontinuance group (p > 0.05).

Conclusions

0.03% tacrolimus ointment was safe and effective for use in anterior segment inflammatory disease refractory to steroid.