Autologous Bone Marrow Transplantation Research Articles

Therapeutic use of autologous hematopoietic bone marrow transplant combined with concentrated platelet in infected surgical wounds: single-center prospective study

The healing wound is the consecutive process of maintaining tissue integrity including inflammatory, proliferative, and remodeling processes. Stem cells can self-renew, and also to differentiate into all cell types, and are involved in physiological regeneration, use of mesenchymal stem cells deriving from the bone marrow with PRP has potentiated the healing process. We conducted a single-arm pilot prospective analytical study was performed on 15 patients whose mean age was 31 years (range: 29–51 years), with refractory abdominal wounds at a private hospital in Iraq from March 30, 2022, to March 2023. Ten days after the stem cell transplant the re-enforcement with PRP subcutaneous injection around wounds. Small papules of granulation tissue appeared over the wound, and tissue granulation increased from 80% (30.26–80.00%) to 100% (81–100%). At the same time, the wound size was reduced by 60% (52.10–78.23%). The follow-up period was 7–24 months, during which no recurrence of the wound was found. In conclusion, the current study is the first to characterize the safety and efficacy of bone marrow-derived stem cells in combination with PRP in the treatment of refractory abdominal wound infection. All patients achieved a 100% healing rate in a short time, and no treatment-related adverse reactions occurred during the treatment.

Pathogenetic parallels and clinical relationships of HIV infection and Hodgkin’s lymphoma

Aim: to show the importance of the features of the development of Hodgkin’s lymphoma (HL) against the background of HIV infection, possible clinical relationships and consequences of simultaneous diseases in patients, as well as complex therapy. Material and methods. The article presents an analytical review of the problem and retrospective data on 63 patients with HIV[1]associated HL (HIV-HL) who were diagnosed with HL in St. Petersburg hospitals in the period 2000–2017. For the diagnosis of HIV-HL, regulated morphological, immunohistochemical, instrumental and laboratory research methods were used, the tumor stage was determined based on the Cotswolds-modified Ann Arbor classification. The diagnosis of HIV infection was confirmed by the detection of specific antibodies to HIV (and the p24 antigen) during serological and enzyme immunoassay of blood, by immune blotting. The number of copies of HIV RNA and the number of CD4 lymphocytes in the blood of patients were determined using commercial test systems approved for use in the territory of the Russian Federation. The analysis of overall survival was performed using the Kaplan–Meyer method. Statistical processing of the research results was performed using statistical programs MS Excel 2010, GraphPad Prism 8 (GraphPad Software, Inc., USA), SPSS version 22.Results. The study group was dominated by men (73%), the median age was 32 years, in 16 (25.4%) patients HIV and HL were detected simultaneously. The number of CD4 lymphocytes > 500 cl/μl at the HL debut was noted in 33.3% of patients, patients with severe immunosuppression prevailed (50–250 cl/μl in 20 (31.7%), 250–500 cl/μl in 11 (17.5%), less than 50 cl/μl in 11 (17.5%). The amount of HIV RNA>400 kop/ml was noted in 82.5%, HIV infection at stages 4B-5 was detected in 89% of cases, at the time of detection of HL ART was performed in 16 patients. EBV coinfection (77.8%), cytomegalovirus (60%), viral hepatitis (55.6%) with a predominance of viral hepatitis C, common opportunistic infections (tuberculosis, pneumocystis pneumonia, toxoplasmosis of the brain, common candidiasis), simultaneously occurring from 1 to 3 infections were observed in 77.8%. Stage IV HL was established in 54%, III — in 22%, II — in 24% of patients, the presence of B-symptoms was confirmed in 73% of cases. The predominant histological variant of HIV-HL was nodular sclerosis (58 patients), mixed[1]cell sclerosis in 4 patients, with lymphoid predominance in 1 case. Extranodal lesions were observed in 34 (54%), complications of the tumor process in 33 (37.5%) patients. 42 (66.7%) patients received antitumor treatment for HL: line 1 according to the ABVD scheme — 85.7% (80% achieved PET-negative complete remission (CR), according to the VEASORR esc or VEASORR schemes — 33.3%; line 2 — according to the ICE or DHAP schemes (n=10). An objective response was noted in 4 patients, PET-negative response in 2 of them, partial PET-positive regression in 2 patients. Progression was observed in 2 people. Autologous bone marrow transplantation was performed in 2 patients (in partial PET-positive regression); line 3 (n=3) — chemoimmunotherapy with bendamustine, gemcitabine (2 patients underwent autologous bone marrow transplantation). The cumulative life expectancy of patients for 1 year and 2 years was 44% and 37%, respectively, 1-year overall survival was 75%, 2-year — 60%. The factors negatively affecting survival and life expectancy were tumor progression and complications, ECOG≥2 (p=0.0001), candidiasis, pneumonia (p=0.001), viral hepatitis B and C (p=0.045), lack of antitumor treatment and ART (p=0.0001), age younger than 40 years, central nervous system damage, the presence of 1 or more concomitant infections (p=0.024). Conclusion. HIV-HL is one of the most common hematological malignancies, characterized by heterogeneity in its manifestations, polymorphism of pathogenetic and clinical features and relationships. During the dispensary supervision of PLHIV, special attention should be paid to the factors of an unfavorable prognosis of the disease, the timeliness of the appointment of ART and the assessment of the risks of developing lymphoproliferative diseases within the framework of the immune system restoration syndrome (IRIS) in order to increase their survival and quality of life. Further research is needed on the pathogenesis, early diagnosis and effective treatment of lymphomas associated with the human immunodeficiency virus

Detection of active human cytomegalovirus in patients with multiple myeloma

Abstract BACKGROUND: Human cytomegalovirus (HCMV) infection is ubiquitous and successfully reactivated in patients with immune dysfunction as in patient with multiple myeloma (MM), causing a wide range of life-threatening diseases. Early detection of HCMV and significant advances in MM management has amended patient outcomes and prolonged survival rates. OBJECTIVES: The aim of the study was to estimate the frequency of active HCMV in MM patients. MATERIALS AND METHODS: This is a case–control study involved 50 MM patients attending Hematology Center, Baghdad Teaching Hospital; 25 of them were newly diagnosed and 25 on treatment compared to 50 of apparently healthy control. HCMV-viral load was measured using a real-time polymerase chain reaction (RT-PCR). RESULTS: Active HCMV was detected in 8 patients out of 50 (16%); 6/25 (24%) in newly diagnosed and 2/25 (8%) on treatment and had autologous bone marrow transplant with mean ± standard deviation of 910 × 1010 ± 210 × 1010, and 32,000 × 1010 ± 1500 × 1010 IU/mL, respectively. HCMV viremia is equally detected in both remission and relapsed cases. CONCLUSION: RT-PCR detected a significant number of MM patients infected by cytomegalovirus compared to healthy individuals. Further studies are needed to verify if this finding has a relation to etiology or disease progression.

Improved Outcome of Primary Plasma Cell Leukemia in the Current Era with the Use of Novel Agents and Autologous Bone Marrow Transplants—A Single Centre Experience

Improved Outcome of Primary Plasma Cell Leukemia in the Current Era with the Use of Novel Agents and Autologous Bone Marrow Transplants—A Single Centre Experience

Blood Product Support in Multiple Myeloma Patients Undergoing Autologous Bone Marrow Transplantation May Predict Improved Outcome.

Blood Product Support in Multiple Myeloma Patients Undergoing Autologous Bone Marrow Transplantation May Predict Improved Outcome.

Evaluation of 5-Year Survival Rate of Patients with Multiple Myeloma Undergoing Bone Marrow Transplantation: A Descriptive Study

Background: Multiple myeloma is a progressive and high mortality neoplasm, and the prevalence increases with aging. The main treatment for new cases aged less than 65 years is high-dose chemotherapy with autologous bone marrow transplantation. This study aims to determine the five-year survival rate of patients with multiple myeloma.
 Methods: In this descriptive-analytical study, 97 patients with multiple myeloma who underwent bone marrow transplantation between 2011 and 2016 were investigated. Then, information related to gender, age at the time of transplantation, the time interval between diagnosis and transplantation, cases of death and, date of death of the studied patients were collected, and the survival of the patients from the date of diagnosis to the end of the study period (five years) was calculated. Data were analyzed using Cox proportional and chi-square tests.
 Results: Five-year survival of patients was 59.8%. The median overall survival of patients was 54.22 months, which shows that age (p value = 0.003), gender (p value = 0.591), and the time delay between diagnosis and bone marrow transplantation (p value = 0.005) all affect patient survival. There was a significant relationship between the patient's age and the time interval between diagnosis and transplantation with the five-year survival of the patients.
 Conclusion: As a result, bone marrow transplantation provides a higher survival rate. Also, the effect of the patient‘s age and time interval between diagnosis and transplantation, early diagnosis of the disease and, earlier bone marrow transplantation can bring longer survival for patients.

Hematopoietic stem cell heterogeneity in non-human primates revealed by five-lineage output bias analysis.

Understanding hematopoietic stem cell (HSC) heterogeneity is crucial for treating malignant blood disorders. Compared with mice, we have limited knowledge of the heterogeneity of human HSCs. Fortunately, non-human primates (NHPs) have become the best animal models for studying human HSCs. Here, we employed a public dataset derived from NHP autologous bone marrow transplantation, and focused on a total of 820 HSC clones with reconstitution capacity of all available five lineages (granulocyte, monocyte, B cell, T cell, and natural killer cell) at two time points (11/12 and/or 42/43 months). Intriguingly, unsupervised clustering on these clones revealed six HSC subtypes, including a lymphoid/myeloid balanced (LM-balanced) subtype and five single-lineage-biased subtypes. We also observed that the subtypes of these HSC clones might change over time, and a given subtype could transition into any one of the other five subtypes, albeit with a certain degree of selectivity. Particularly, each of the six subtypes was more likely to turn into lymphoid-biased rather than myeloid-biased ones. Additionally, our five-lineage classification method exhibited strong correlation with traditional lymphoid/myeloid bias classification method. Specifically, our granulocyte- and monocyte-biased subtypes were predominantly attributed to α-HSCs, while LM-balanced, B cell-biased, and T cell-biased subtypes were primarily associated with β-HSCs. The γ-HSCs were composed of a small subset of B cell-biased and T cell-biased subtypes. In summary, our five-lineage classification identifies more finely tuned HSC subtypes based on lineage output bias. These findings enrich our understanding of HSC heterogeneity in NHPs and provide important insights for human research.

Nursing Care of Adolescents Undergoing HSCT

Autologous bone marrow transplant (ABMT), also known as autologous hematopoietic stem cell transplant (HSCT), is a medical procedure where a patient’s own stem cells are collected and later infused back into the patient after high-dose chemotherapy or radiation. This procedure is often used in the treatment of certain cancers, such as neuroblastoma or leukemia, as well as certain non-malignant conditions. Nursing care for a child undergoing autologous bone marrow transplant involves various aspects of physical, emotional and psychosocial support. Here are some key nursing considerations Pre-transplant care education provides age-appropriate education about the transplant process, including what to expect before, during and after the procedure. Educate the child and family about potential side effects, complications and the importance of strict infection control measures. Children undergoing HSCT face lot of challenges and pediatric nurses play a vital role in providing safe and quality care.

Lower uric acid and adequate hydration are associated with lower risk of febrile neutropenia following autologous bone marrow transplantation in patients with lymphoma

Background. Despite the promising results of autologous bone marrow transplantation (BMT) in patients with lymphoma, infectious complications limit its positive outcomes. This study evaluated the incidence and associated factors of febrile neutropenia (FN) following BMT in patients with lymphoma. Materials and methods. The study consecutively included 147 patients with lymphoma who were candidates for BMT. Clinical and laboratory results were recorded, and after BMT, the occurrence of FN was investigated through the daily evaluation of neutrophil count and body temperature. Results. On average, FN occurred in 91 patients (61.9%) after 12.77 ± 2.45 days after BMT. Lower fluid balance was associated with a higher risk of FN (lowest adjusted odds ratio [OR] at day -2 = 0.602, 95% confidence interval [CI] = 0.299 – 0.870, p-value = 0.007). The higher uric acid level was associated with a higher risk of FN (highest adjusted OR at day -10 = 1.617, 95% CI = 1.328 – 1.963, p-value = 0.035). LDH was also positively correlated with FN (highest adjusted OR at day 0 = 1.501, 95% CI = 1.198 – 2.104, p-value = 0.004). Conclusions. Adequate hydration of the patients is of paramount importance for preventing FN in patients who receive BMT. Furthermore, uric acid and LDH could be considered in future studies for the risk stratification of FN.

Sclerosing mesenteritis.

A patient with light chain multiple myeloma and no evidence of disease following autologous bone marrow transplantation, developed asymptomatic mass in the right lower quadrant mesentery, which increased in size and showed FDG uptake on PET CT. The only other change of note on imaging was chronic appendicitis, confirmed on surgery and pathology. Suspecting a neoplastic mass in the mesentery, surgical resection was undertaken but the pathology revealed sclerosing mesenteritis. This rare, non-neoplastic fibro-inflammatory disease, its protean manifestations, disease associations, and treatment are briefly discussed, including the perplexing coexistence with adjacent appendicitis.

Evaluation of the frequency of hepatitis b virus reactivation and the importance of hepatitis b prophylaxis in hematology patients receiving immunosuppressive therapy: a single-center study

Aims: The aim of this study was to evaluate the rate of hepatitis B virus reactivation (HBVr) in hematology patients receiving immunosuppressive therapy in our center and the clinical characteristics of patients with HBVr. We will also investigate the importance of effective prevention of this potentially life-threatening event and management of hepatitis B virus (HBV) prophylaxis. Methods: In this study, hepatitis B prophylaxis and its effects on patients over 18 years of age receiving immunosuppressive therapy in the hematology clinic were analyzed. 122 patients were included in the study. The HBV markers of the patients were determined by the chemiluminescence method. In the study, HbsAg(+) and isolated antiHbc IgG-positive patients received prophylactic antiviral treatment. The differential diagnosis of HBV reactivation and the criteria determined to define HBV reactivation were performed. Clinical characteristics and descriptive information of patients receiving HBV prophylaxis were analyzed using SPSS 25.0. Results: The median age of 122 patients (59.8% male) was 58 years. It was determined that five HbsAg-positive patients had no prior follow-up and did not receive antiviral treatment. 117 patients had isolated anti-HBc IgG positivity. The median duration of prophylaxis was 15 (9- 21.25) months, and the total follow-up period was 19.5 (11.75- 30.25) months. 81.1% of the patients received regular HBV prophylaxis treatment; 59% of them received entecavir, and the rest received tenofovir disoproxil. Bone marrow transplantation was performed in 25 patients. HBV reactivation was detected in only 4 patients (3.3%); one of these patients had received allogeneic and one autologous bone marrow transplantation; and three patients had received chemoimmunotherapy including Rituximab. The diagnoses of the patients with HBVr were acute myeloid leukemia, lymphoma, and chronic lymphocytic leukemia. During the follow-up period, 29 patients (23.8%) died due to their primary disease, but there were no deaths due to HBV reactivation. Conclusion: The data obtained in this study show that effective hepatitis B prophylaxis treatment is successful in preventing HBV reactivation in hematology patients. HBVr was observed in four patients who did not take HBV prophylaxis medication regularly.

Oncology Care at Home: A Patient-Centered Approach to Managing Care for Bone Marrow Transplant and CAR-T Cell Therapy Patients

Introduction. More than half of patients with cancer who receive cytotoxic chemotherapy and/or immunotherapies experience deleterious side effects such as febrile neutropenia, infection, neurotoxicity, and cytokine release syndrome. Early intervention and treatment for these side effects can help avoid complications and improve outcomes, but delays in treatment administration are common as most outpatient management approaches depend on patient self-assessment and patient-initiated pursuit of follow-up care. Remote patient monitoring through digital health technologies offers the opportunity to bridge this gap without imposing undue burden on either patients or healthcare providers. This feasibility study assessed the results of a technology-assisted in-home oncology care program to remotely monitor bone marrow transplant and CAR T-cell therapy patients and provide early intervention for symptomatic episodes needing clinical management. The program also offered support for patients to obtain routine lab draws, hydration, antiemetics, intravenous antibiotics, and a provider assessment at home. Technical and operational feasibility were evaluated together with perceived user experience among patients, caregivers, and providers. Methods. Ten patients between 18-89 years old participated in the study for up to 90 days following allogeneic bone marrow transplant and up to 30 days following CAR T-cell therapy or autologous bone marrow transplant. Patients used continuous-wear biometric sensors for passive vital sign monitoring around the clock seven days per week and engaged with a chatbot by SMS text for health status checks and symptom reporting. Scheduled home care was administered by licensed home health providers. Virtual care center personnel evaluated patient status based on wearable data and patient messaging and followed up directly with patients or engaged patients' treating clinicians for notification and management of urgent issues as needed. Patients and caregivers were asked to complete surveys about their experience with and perceptions of the program at midpoint and study completion, while providers were asked to complete end-of-study surveys to capture their perspectives across all patients. Patients were also asked to participate in brief interviews at study midpoint and at the end of the study. Interim Results. Eighty percent of patients participated in the program as intended through wearing devices and responding to engagement prompts. Wearable sensors detected a total of 184 outpatient alerts from patients between April and July 2023, of which 57 led to follow up with patients, 12 required further follow up with the clinical care team, and 5 required follow up care in a clinical setting due to elevated temperature or respiratory rate. Sixty percent of patients responded more than 50% of the time to requested health assessment surveys. Patient engagement with the chatbot and symptom reporting system led to 48 events needing virtual care team follow up, of which 20 were to answer patient questions and 28 were in response to reports of concerning symptoms. A total of 11 events were further referred by the virtual care team to the clinical care team, of which 5 required follow up care in a clinical setting. Study data collection will complete in August 2023. Initial Conclusions. Technology-assisted remote patient monitoring is feasible for use with bone marrow transplant and CAR T-cell therapy patients at home. Successful integration with clinical practice settings requires tailoring to existing workflows. Further assessment of patient acceptance for short-term versus long-term monitoring is recommended.

Incidence, Clinical Characteristics and Risk Factors for Poor Mobilization of Hematopoietic Stem Cells in a Colombian Bone Marrow Transplantation Unit: A Retrospective Cohort Study

Background: mobilized peripheral hematopoietic stem cells (PHSC) are the main cell source for autologous bone marrow transplantation. Failure to mobilize an appropriate number of PHSC can jeopardize autologous bone marrow transplantation procedure. Objective: our aim was to describe the clinical and demographics characteristics, the incidence of mobilization failure and the prevalence of risks factors for poor mobilization in patients in whom PHSC mobilization were attempted for autologous bone marrow transplantation between January 1st 2017 and 31 December 2022. A univariate and multivariate analysis (binary logistic regression) were done to determinate the association between risk factors and mobilization failure. Results: 129 patients were included , the patients median age was 54 years. Indications for autologous bone marrow transplantation were multiple myeloma in 50,4 %, lymphoma in 46,5 % and systemic sclerosis in 2,3 % of patients respectively. Mobilization was attempted with Filgrastim in 71,1 %, Filgrastim plus Plerixafor in 26,6 % and chemotherapy (Cyclophosphamide) plus Filgrastim in 2,3 % of patients respectively. Mobilization failure occurred in 9,3 % of patients (12 patients) occurring in 11 % of patients who received Filgrastim, in 5,6 % who received Filgrastim plus Plerixafor and in none of patients who received chemotherapy plus Filgrastim. No difference in mobilization failure was found between patients who received Filgrastim monotherapy versus those who received Filgrastim plus Plerixafor ( χ 2 p=0,388, relative risk: 1,8, confidence interval 95% 0,43 - 8,1). Patients who received Filgrastim plus Plerixafor had been treated more frequently (four of more cycles of Lenalidomide) compared with patients who received Filgrastim alone (63,3 % versus 18,7 %, χ 2 p < 0,001, RR=4,01, CI 95 %; 2,32-6,87).The median age of patients was superior in patients who received Filgrastim plus Plerixafor compared with those who received Filgrastim (58 vs 51 years, U Mann Whitney p = 0,02). The median number of treatment lines tended to be superior in patients receiving Filgrastim plus Plerixafor compared to those receiving Filgrastim (2 lines versus 1 line of therapy, U Mann Withney p= 0,054). Patients who had been treated with intensive chemotherapy regimens like DHAP, ESHAP or Hyper CVAD (p=0,004, RR: 4,3, CI 1,5-12,3)) and patients older than 60 years (p=0,018, RR: 3,4 (1,2-9,85)) were significant more prone to mobilization failure in bivariate and multivariate analysis. Conclusion: mobilization failure occurred in 9,3 % of patients , Filgrastim monotherapy was more frequently used, no difference in mobilization failure was found between those who received Filgrastim versus Filgrastim plus Plerixafor, history of treatment with more than 4 cycles of lenalidomide and older age were more frequently in patients who received Filgrastim plus Plerixafor. History of a treatment intensive chemotherapy regimen and being older than 60 years were consistently associated with mobilization failure in univariate and multivariate analysis.

Using Human Genetics to Develop Strategies to Increase Erythropoietic Output from Genome-Edited Hematopoietic Stem and Progenitor Cells

Genome editing is a powerful tool that enables precise changes in the genetic code of a cell. Genome-edited hematopoietic stem and progenitor cells (HSPCs) yield genome-corrected cells of all lineages, yet the only cell type of clinical relevance in red blood cell (RBC) disorders is the RBC. Most applications of genome editing have sought to correct disease-causing mutations of monogenic diseases. However, human genetic variation reveals variants that confer positive health benefits as well. In this study we took advantage of a naturally occurring human variant to increase erythropoietic output from genome-edited HSPCs. The variant leads to a condition termed congenital erythrocytosis (CE), a rare phenotype in which people have higher than normal levels of RBCs and consequently elevated hemoglobin. It is caused by truncations in the erythropoietin receptor (tEPOR) in which the intracellular inhibitory domain to erythropoietin (EPO) signaling is eliminated. The genetic cause of this phenotype was identified in a family of a Finnish Olympic gold medal-winning cross-country skier who was found to have levels of hemoglobin >50% higher than normal. One of the challenges in gene therapy is to achieve sufficient engraftment of genetically engineered cells to have a clinical effect. Here we sought to give edited cells a selective advantage such that low levels of engraftment might still result in a clinical benefit through use of genome editing to recreate the CE phenotype by engineering tEPOR into HSPCs in different ways. We hypothesized we could recapitulate the CE variant using CRISPR/Cas9 genome editing of HSPCs to create insertions/deletions (indels) at the EPOR locus near the site of the mutation ( EPOR c.1316G>A) and then transfer the cells into culture media that promotes erythroid differentiation (Fig. 1). We demonstrated increased erythropoietic output from cells containing truncating mutations in EPOR, measured by an increase in indel formation throughout erythroid differentiation (1.3-3.8-fold increase). Because not all indels created cause truncations in EPOR, we explored if we could amplify this effect by integrating an AAV6 repair template that introduces a stop codon into EPOR followed by a BGH-polyA tail and GFP marker driven by a constitutive UbC promoter. This strategy enriched for GFP + cells with the truncation even more dramatically as they developed during erythroid differentiation (2.5-4.6-fold increase). We also found a substantial increase in the total number of cells produced from the tEPOR edited condition at the end of differentiation (3.3 times greater fold increase compared to mock edited cells). Importantly, we observed no enrichment in cells kept in HSPC media or cultured in RBC media without EPO, indicating this effect is EPO-dependent (Fig. 2). Next, we investigated whether a tEPOR cDNA could be targeted to the CCR5 safe harbor locus under ubiquitous expression or to the HBA1 RBC-specific safe harbor site imparting high levels of erythroid specific expression. Integration of the tEPOR cDNA at both loci yielded strong enrichment of edited alleles in an EPO-dependent manner when put through erythroid differentiation (6.2-8.6-fold increase at CCR5 and 2.9-5.2 at HBA1). Lastly, we sought to pair the tEPOR cDNA with a clinical edit for β-thalassemia to boost production of disease-corrected RBCs. We showed that through use of bi-cistronic cassettes we were able to drive a >2-fold enrichment of edited alleles over the course of differentiation. Additionally, we were able to pair the tEPOR cDNA and clinical edit for β-thalassemia through multiplexed gene editing at EPOR and HBA1, respectively, and again demonstrated enrichment of edited alleles. Ultimately, we believe this work has the potential to amplify the efficacy of gene and cell therapies for blood disorders currently in the clinic. Expression of tEPOR could be integrated into any treatment for blood disorders that involve transplantation of HSPCs, including both allogeneic and autologous bone marrow transplants. Further, as low chimerism in the bone marrow could produce high levels of peripheral RBCs using our strategy, it has the potential to reduce the morbidity of myeloablation regimens currently required for cure of blood disorders. This work, in effect, has the potential to improve the safety and accessibility to currently available treatments for the millions of patients affected by RBC disorders worldwide.

Intermittent Sargramostim Administration Expands Proliferating Naïve T Cells, Tregs, HLA-DR+ PD-L1+ Monocytes and Myeloid-Derived Suppressor Cells: Results from a Randomized Placebo-Controlled Clinical Trial of GM-CSF in Patients with Peripheral Artery Disease

Introduction: Sargramostim (rhuGM-CSF; Leukine ®) is an FDA-approved drug known for mobilizing hematopoietic progenitor cells and expediting hematopoietic reconstitution in patients with acute myeloid leukemia (AML) as well as after autologous and allogeneic bone marrow transplantation. While GM-CSF has been explored as an adjuvant for cancer vaccines due to its ability to promote dendritic cell differentiation and maturation, continuous daily administration of sargramostim has been associated with leukocytosis and adverse side effects. To validate and expand upon our previously published findings that thrice-weekly sargramostim administration in patients with severe peripheral artery disease (PAD) is both well-tolerated and beneficial for claudication symptoms, we conducted a placebo-controlled randomized clinical trial to assess the efficacy of an extended dosing regimen of sargramostim in PAD patients. Data regarding progenitor mobilization kinetics and claudication symptoms will be presented elsewhere. In this analysis, we investigated the impact of intermittent sargramostim dosing on immune cell subsets in the bloodstream, aiming to support the use of this dosing schedule for enhancing adaptive immunity. Methods: Symptomatic atherosclerotic PAD patients were enrolled and randomly assigned to receive either 500 μg/day of sargramostim or placebo via self-administered subcutaneous injections thrice weekly for 3 weeks, for two separate courses 3 months apart. The study was IRB-approved with adverse events and safety signals monitored by an independent Data Safety Monitoring Board. A total of 61 patients (40 receiving sargramostim and 21 receiving placebo) participated in the immune-monitoring sub-study. Blood mononuclear cells were collected at various time points and cryopreserved. Thawed peripheral blood mononuclear cells (PBMCs) were stained using immune cell-specific antibody cocktails, and analyzed by flow cytometry. Statistical significance was determined using the Student's t-test. Results: No dose-limiting leukocytosis or drug-related side effects were observed. As expected, the numbers of white blood cells (WBCs) increased by an average of 68% in the blood of sargramostim-treated patients compared to placebo-treated patients, with peak values reached after 3 weeks of intermittent study drug administration, followed by return to baseline before the next treatment course. Absolute counts of CD3+, CD4+, and CD8+ T cells, B cells, and CD14+ monocytes significantly increased one and two weeks after starting intermittent sargramostim treatment compared to the control group. Notably, sargramostim-treated patients exhibited higher levels of proliferating naïve, Ki-67+ CD4+ T cells (106.83/uL ± 70.28) compared to placebo-treated patients (44.94/uL ± 33.84, p=0.001), as well as increased numbers of naïve Ki-67+ CD8+ T cells (33.05/uL ± 25.43 after sargramostim versus 15.77/uL ± 15.73 for placebo, p=0.01) (Fig. 1, A). However, sargramostim treatment did not influence the quantities of central memory CD4+ and CD8+ T cells. Besides the heightened proliferation of naïve T cells, sargramostim treatment also resulted in a significant increase in the numbers of CD3+CD4+CD25+FoxP3+ Tregs (Fig. 1, A), as well as PD-1-expressing CD4+ and CD8+ T cells, compared to the control group. Moreover, sargramostim treatment led to elevated levels of CD14+HLA-DR+ and CD14+PDL-1+ monocytes, as well as myeloid-derived suppressor cells, 2 and 3 weeks after initiation of treatment, when compared to the control group (Fig. 1, B). Conversely, sargramostim treatment had no impact on the levels of gamma-delta T cells, natural killer (NK) cells, plasmacytoid dendritic cells, or classical dendritic cells. Conclusions: Our findings demonstrate that intermittent dosing with sargramostim is well-tolerated and induces significant but transient increases in the numbers and activation status of T cells in the bloodstream. Sargramostim treatment also increased numbers of proliferating naïve T cells, Tregs, and certain subsets of myelo-monocytic cells with immunosuppressive phenotypes. These results support the use of intermittent sargramostim dosing to avoid excessive leukocytosis and associated adverse effects. Further investigation is warranted to elucidate the clinical implications of these findings in the context of immune modulation.

Melphalan-Induced Multiple Myeloma Cells Exhibit a Senescent-like Dormant Phenotype

Multiple myeloma (MM) is an incurable plasma cell malignancy. Despite therapeutic advances that have vastly improved survival, all patients are expected to relapse. One mechanism that may contribute to MM relapse is tumor dormancy. Dormant MM cells may persist in the bone marrow, where they exhibit reduced proliferative capacity and resistance to treatment. These cells may then exit dormancy following treatment to drive disease relapse. Dormancy shares many features with cellular senescence, a state of stable growth arrest induced by cell stress. Chemotherapies that produce genotoxic stress have been associated with therapy-induced senescence (TIS). One such genotoxic agent, melphalan (Mel), is routinely administered to MM patients for myeloablation prior to autologous bone marrow transplant. We hypothesized that High Dose Mel (HDM) induces a senescent-like dormant phenotype in surviving MM cells. To test our hypothesis, we developed an in vitro model for HDM. We identified 10µM Mel as a concentration to induce >90% cell toxicity (HDM) in 5TGM1 mouse MM cells over 10 days. 5TGM1-GFP MM cells were cultured with HDM or vehicle (Veh) for 6 hours; cells were then cultured in normal growth medium in the presence of primary mouse (C57BL/6) bone marrow stromal cells (BMSCs). Co-cultures were imaged by fluorescent microscopy every other day to quantify cumulative population doublings (CPD) and cell morphology over the following 10 days. The effect of HDM on CPDs was also evaluated in the human RPMI-8226 MM cell line. 5TGM1-GFP cells were isolated by FACS on day 10 for evaluation of senescence histological characteristics and gene expression. All studies represent n=3 independent experiments unless otherwise indicated. HDM-5TGM1 cells exhibited a significant reduction in mean CPDs over 10 days compared to Veh (HDM 0.32±0.31, Veh 6.72±0.69, p<0.0001), indicating stable growth arrest in HDM treated cells consistent with senescence. HDM-5TGM1 cells were also significantly larger versus Veh (median size in pixels units: HDM 413.2±99.98, Veh 207±8.88, p<0.05), consistent with classical enlarged morphology in senescent cells. Preliminary assessment (n=1) of HDM-RPMI-8226 cells showed similar growth arrest (mean cumulative doublings: HDM 0.058±0.101, Veh 4.185±0.358) and enlargement (mean size in pixel units: HDM 804.1±6.048, Veh 526.9±2.115), suggesting a translatable mechanism in humans. FACS-sorted 5TGM1-GFP cells were stained for telomere associated foci (TAF), a marker of persistent DNA damage characteristic of senescent cells. HDM-5TGM1 cells showed a higher percentage of TAF+ cells (Percent TAF+ cells: HDM 39.7%±9.1%, Veh 10.6%±0.8%, n=2). Sorted HDM-5TGM1 cells also exhibited significant increases over Veh (p<0.001) in senescence markers ( Cdkn1a, Cdkn1c, Glb1), senescence cell anti-apoptosis pathway genes (SCAPs, Bcl2l1), and senescence associated secretory phenotype (SASP) genes ( Ccl5, Icam1, Mmp13). In addition, HDM-5TGM1 cells showed significant increases in myeloid markers that have previously been shown to be increased in dormant 5TGM1 ( Axl, Fcer1g, Mpeg1). Single cell RNA-sequencing was used to further evaluate senescence gene expression changes in growth arrested HDM-5TGM1 cells. Gene set enrichment analysis (GSEA) of genes differentially expressed in HDM-5TGM1 versus Veh cells was performed for custom senescence phenotyping gene sets (Senescence Up, SenUp; Senescence Growth Arrest, SenGA; Inflammatory SASP, iSASP; SCAPs; and Plasma Cell Senescence; PCSen) as well as mouse ortholog versions of a published senescence and biological aging gene set (SenMayo) and KEGG curated gene sets. GSEA of HDM-5TGM1 versus Veh cells confirmed significant (FDR<0.25) upregulation of iSASP, MayoSen, PCSen, SenUp, SCAPs, and SenGA gene sets. Concurrently, GSEA revealed significant downregulation of KEGG DNA replication, cell cycle, and nucleotide excision repair gene sets, supporting our observations of proliferative arrest and persistent DNA damage TAF. Our findings demonstrate that HDM-MM cells exhibit multiple features of senescence, suggesting a potential mechanistic role for TIS in MM dormancy and highlight a novel therapeutic target that may be present in patients post-HDM. Thus, targeting senescence may be a novel approach to eliminate dormant MM cells and prevent relapse.

A Phase II Multicenter Clinical Trial Assessing the Safety and Efficacy of Ixazomib, Pomalidomide and Dexamethasone Combination As Second or Third-Line Treatment for Triple-Class Exposed Patients with Relapsed and Refractory Multiple Myeloma (iPod-790 Trial)

Introduction: Despite significant improvement in the outcomes of early treatment lines in myeloma, most patients (Pts) invariably relapse. As triple and quadruple regimens are being introduced at the upfront setting, many Pts are either triple-class exposed or triple-class refractory (TCE/TCR) early in their disease course. Although novel immunotherapies are emerging with impressive efficacy among TCE/TCR myeloma Pts, their use is currently limited due to potential toxicities, costs and logistic constraints. We report the outcomes of the IPoD-790 clinical trial (NCT04790474), an all-oral regimen: ixazomib (IXA), pomalidomide (POM) and dexamethasone (DEX) (IPd) combination, in Pts with relapsed refractory multiple myeloma (RRMM) who progressed after bortezomib (BTZ), lenalidomide (LEN) and daratumumab (DARA) therapies. Methods: A phase 2, investigator initiated, open-label, single-arm, prospective, multicenter study evaluating the safety, tolerability and efficacy of IPd as a second or third-line combination treatment for TCE RRMM Pts. Pts receive IXA: 3 mg days (d) 1,4,8,11 of 21-d Cycles (Cy) 1-3; 4mg d 1,8,15 of 28-d Cy 4-24. POM 4mg: d 1-14 Cy 1-3; d 1-21 Cy 4-24. DEX 20mg: d 1,2,8,9,15,16 Cy 1-3; d 1,2,8,9,15,16,22,23 Cy 4-24. Treatment continues for 24 cycles, or until disease progression (PD) or unacceptable toxicity (the earliest of the three). After completion of 24 treatment cycles, Pts continue POM DEX as standard of care. The primary endpoint is progression free survival (PFS) according to IMWG criteria. Results: Fifty-five (out of the 60 Pts planned) were enrolled; we report data on 46 Pts who had their first dose between March 2021 and April 2023, further data will be presented at the meeting. The median age was 72 (range: 53-88); 18 (39%) were ≥75 years old; 59% were male, ISS was I/II/II for 48% / 25% and 28% respectively; 59% had high risk FISH cytogenetics (t(4:14), t(14:16), +1q21, del17p) with 14% double-hit. Nine percent had extramedullary disease at study enrollment. Exposure rates to BTZ, LEN and DARA were 100%, 98% and 96%, respectively. Forty-one percent had undergone autologous bone marrow transplantation. Refractoriness rates to BTZ, LEN and DARA were 57%, 91% and 65%, respectively. Thirty-seven percent were TCR. At data cutoff date of 15-Jun-2023, the median follow-up time was 10.4 [95% CI 7.6-13.2] months. Ninety-three percent of the Pts had at least one treatment emergent adverse event (TEAE) and 65% had a TEAE grade 3 or 4. Common (≥ 10%) TEAEs include neutropenia 35% (28% Gr 3 or 4), pneumonia 24% (17% Gr 3 or 4), thrombocytopenia 22% (15% Gr 3 or 4), back pain 22% (2% Gr 3 or 4), asthenia 20% (0% Gr 3 or 4), diarrhea 20% (0% Gr 3 or 4), peripheral edema 20% (2% Gr 3 or 4), COVID19 infection 15% (2% Gr 3 or 4 ), anemia 13% (2% Gr 3 or 4), acute kidney injury (AKI) 13% (7% Gr 3 or 4), rash 13% (0% Gr 3 or 4). At data cut-off date, 31 Pts (67%) discontinued the study treatment; 20 (43%) due to PD, 7 (15%) due to adverse events (including 3 patients with pneumonia, and 1 patient each with COVID19 infection, campylobacter gastroenteritis, upper gastrointestinal bleeding and AKI) and 4 (9%) died (2 cases of pneumonia, 1 COVID 19 infection and 1 cerebro-vascular accident). Overall response rate was 59% (27/46); 8 Pts (17%) achieved complete or very good partial response (CR/VGPR), 19 Pts (41%) achieved partial response (PR) and 12 Pts (30%) had stable disease (SD). The median PFS was 6.6 [95% CI 2.9 - 10.3] months (Figure 1a). Median duration of response (DOR) was 10.8 months. Median OS was not reached; 1-year overall survival was 81.6±6.7% (Figure 1a). One-year OS was significantly better for responders (89.3±7.3%) than non-responders (72.2±10.7%), p=0.015 ( figure 1b). Conclusions: IPd combination with a twice-weekly ixazomib induction provided an all-oral safe and efficacious therapy in triple-exposed RRMM Pts, most of whom were refractory to both DARA and LEN. Response rates and PFS are encouraging, compared to parenteral PI and IMiD combination regimens in TCE/TCR MM, with a favorable safety profile and convenience, especially among an elderly and frail population with relapsed myeloma.

Characteristics and Outcomes of Adolescent, Young Adults, and Adults 40-50 Years Old with Multiple Myeloma: A Single Center Experience

Background Multiple myeloma (MM) is a malignant tumor with abnormal proliferation of plasma cells. Adolescent and Young Adult (AYA) patients are defined as patients between 15-39 years of age. Multiple myeloma is uncommon in non-elderly populations. Its prevalence is only 2% in AYA age group and only 10% in patients 40-50 years old. The feature of MM is not well known or understood in those two age groups. In this retrospective study we describe the clinical characteristics, cytogenetics, prognostic markers, treatments given and outcomes of MM in AYA and 40-50 years old patients. Methods We retrospectively analyzed data from the clinical database of our single tertiary hematology center, The National Center for Cancer Care and Research, Doha, Qatar. This center serves a country's population of about 2,8 million people. All patients diagnosed with MM between the age 50 or less during the period of January 2007 to December 2022 were included. Results Seventy-four patients were diagnosed at our centre with MM before the age of 50 years, total of all MM cases 222 (33%) Males was predominant 55/74 (74.3 %) with a median age of 41 years (range, 15-49). Most of the patients were from Asian 55%. At diagnosis patients had a median hemoglobin of 10.2 g/dl, creatinine 294 umol/L, total protein 90 gm/L, albumin 34.75 gm/L, calcium 2.7 mmol/L, LDH 255 U/L, IgG 2289.75 mg/dl, IgA 424.15 mg/dl, IgM 34.2 mg/dl, FLC-Kappa 1993 mg/L and FLC-Lambda 1177 mg/L. Median of bone marrow filtration by plasma cell was 51 %. Most of the patients presented at advance stages with 44 patient (59%) presented as IIIA Durie Salmon or stage III and IV by ISS 70 %. IgG Kappa most frequent type of MM 18 patients (24%), followed by Free light chain kappa (23%), IgG Lambda (18%) and others including two cases of plasmacytoma (Most recurrent cytogenetics were diploid cytogenetics in 42 patients (57%), while 7 patients (9%) had complex cytogenetics. Twenty-eight patients had spinal cord compression at single or multiple levels ( thoracic were most common site 20%) while 3 patients had pathological fractures. Bortezomib based regimen is most one used to treat our patients. Daratumumab- Velcade, Revlimid, and dexamethasone (D-VRD) was used for 35 patients (74%) and Velcade,Cyclophosphamide and Dexamethasone VCD in 20 patients (27%). The first response to treatment showed completed remission (CR) in 35 patients, very good partial remission in 10 patients, partial response in 9 patients, four patients either refractory or primary refractory disease and one patient with stable disease. Thirty -five patients (48%) underwent their first autologous bone marrow transplant ASCT. A total of 8 patients underwent second ASCT and one patient underwent third ASCT. After a median duration of follow up of 6.25 years and 72 % of the patients were still alive. We compared the characteristics and outcome for the AYA group (18-39) with patient age group 40 to 49 years. Although there was no statistical significance difference between the two groups regarding overall survival (p=0.21) , the older group had more cases of spinal cord compressions and more cases of refractory disease. Patient characteristics are described in Table 1. Conclusion One third of MM patients in our center are younger than 50 years. These patients tend to present with advanced stage and serious manifestation such as spinal cord compression. IgG kappa and free light chain are the most common myeloma type in this cohort. D-VRD is the most used protocol with a good response rate. Patient characteristics and treatment outcomes are the same for AYA patients compared with patients 40-49 years old (p=0.21). Patients who received first transplant had better OS compare the those who didn't (p0.01)

Acute interstitial nephritis secondary to sarcoid-like reaction after autologous bone marrow transplantation: Case report

Sarcoid-Like Reaction is a systemic inflammatory granulomatous condition that does not meet the criteria for systemic Sarcoidosis—it is triggered by a known underlying factor, such as immunosuppression. Here we report a case of acute interstitial nephritis without granuloma in the context of a Sarcoid-Like systemic disease in the three-year period after an autologous stem cell transplant. The patient presented with a suspected relapse, associated with hemolytic anemia and an increase of serum creatinine. The investigation showed non-caseating epithelioid cell granuloma in a chest lymph node and in bone marrow, associated with combined hypogammaglobulinemia. Evaluation of the kidney tissue demonstrated acute interstitial nephritis.

CTNI-83. MATRIX REGIMEN FOR NEWLY DIAGNOSED PRIMARY CNS DIFFUSE B-CELL LYMPHOMA

Abstract We report our experience treating 25 patients with newly diagnosed primary CNS diffuse B-cell lymphoma with the MATRix regimen as reported by Ferreri, et al in 2016. The median age was 66 y (range 30-85); 12 patients were men and 13 were women. Twenty-three had cerebral mass lesions, 1 had a paraspinal mass, and 1 leptomeningeal disease. Treatment consisted of 4 cycles of rituximab 375 mg/sq m (Days 1, 6); methotrexate 3.5 g/sq m (Day 2); cytarabine 2 g/sq m every 12 h (Days 3, 4); and thiotepa 30 mg/sq m (Day 5). Patients without disease progression received carmustine 400 mg/sq m and thiotepa 5 mg/kg followed by autologous bone marrow transplantation. Four patients were switched to MATRix after 6 cycles of methotrexate and rituximab and received only 2 initial cycles including cytarabine and thiotepa. Overall, 18 patients completed initial chemotherapy. Sixteen of these 18 went on to transplantation; one patient had had early disease progression, and in one no stem cells could be collected. Five patients (median 73 y; range 64-85 y) died early after 1-2 cycles. The causes of early death were neutropenic fever, septic thrombophlebitis, and cardiac arrest. One of the 16 patients who completed the entire regimen including transplantation died of fungal pneumonia and the other 15 experienced no serious acute toxicity. One patient had late disease progression and 2 developed symptomatic leukoencephalopathy. Seventeen of the 25 patients remain alive. Median TTP for the cohort is 605 days, and OS 738 days. These preliminary data suggest that the MATRix regimen in safe and highly effective in the newly diagnosed setting. However, the high incidence of early death in patients over 65 y shows that the regimen is too toxic for older individuals.