Complete Remission Of Acute Leukemia Research Articles

Transplantation of ovarian tissue after complete remission of acute leukemia: The case of Julie

Transplantation of ovarian tissue after complete remission of acute leukemia: The case of Julie

Prognostic value of minimal residual disease before allogeneic hematopoietic stem cell transplantation in patients with acute leukemia

Introduction. One of the main causes of treatment failure after allogeneic hematopoietic stem cells transplantation (alloHSCT) for acute leukemia (AL) is disease relapse. In recent years, multiparameter fl ow cytometry (MPC) has been widely used to detect minimal residual disease (MRD) because of its capacity to identify patients with a high risk of relapse due to availability and the ability to obtain results in a timely manner.Aim — to evaluate the prognostic value of MRD status before allo-HSCT and the effect of donor type and conditioning intensity on long-term results of allo-HSCT of MOB-positive patients.Patients and methods. The analysis included 107 patients with acute myeloid leukemia (AML) and 63 patients with acute lymphoblastic leukemia (ALL) who underwent allo-HSCT between September 2015 and June 2020. All patients were in complete morphological remission before allo-HSCT. At the time of allo-HSCT 91 patients with AML and 37 patients with ALL were in the first complete remission (CR), in their second and more than two CRs were 16 and 26 patients, respectively. The median follow-up was 18 (1.5–48) months for AML and 14 (1.8–60.1) months for ALL. Immunophenotypic study was performed before allo-HSCT. MRD was detected using a combination of the “different from normal” method and the search for cells with a leukemia-associated immunophenotype.Results. The disease status at the time of transplantation and the presence of MRD before allo-HSCT were independent factors infl uencing the probability of relapse (disease status: HR = 2.911, 95% CI: 1.328–6.379; MRD before allo-HSCT: HR = 7.667, 95% CI: 3.606–16.304) and post-transplant mortality (disease status: HR = 2.911, 95% CI: 1.328–6.379; MRD before allo-HSCT: HR = 7.667, 95% CI: 3.606–16.304). In univariate analysis, the relapse-free survival of MRD+ patients with AL in the first CR was significantly worse than in MRD– (AML: 23 % versus 57 %, p < 0.0001, ALL: 34 % versus 61.7 %, p = 0.0484), and the probability of relapse in MRD+ patients was significantly higher (AML: 75 % versus 12 %, p < 0.0001, ALL: 57 % versus 7 %, p = 0.0072). Pre-transplant MRD status was not prognostically significant for AL-patients in the second and third remission. The development of chronic GVHD reduces post-transplant mortality if it does not require systemic therapy with glucocorticosteroids (HR = 0.006, 95% CI: 0.008–0.446).Conclusion. Testing for MRD of patients with AL in the first CR before allo-HSCT is necessary for risk stratification and identification of patients who will need preventive post-transplant therapy in order to prevent disease relapse.

Adverse effects of intrathecal methotrexate in children with acute leukemia in remission.

A toxic syndrome characterized by fever, headache, and vomiting, lasting 2-5 days, occurred in 61% of 39 children with acute leukemia in complete remission, receiving central nervous system prophylaxis with intrathecal methotrexate, and in 14% of 34 children receiving the same plus cranial radiation. The syndrome was accompanied by pleocytosis with lymphocytes, monocytoid cells, and neutrophils. There was evidence of cumulative Mtx toxicity, since the toxic syndrome occurred mostly after the third and fourth dose and did not recur with longer intervals between doses. The incidence of the syndrome was significantly reduced by the use of Elliott's B solution as Mtx diluent, rather than water or normal saline. The occurrence of pleocytosis and toxic clinical syndrome was also significantly reduced in patients receiving concomitant cranial radiation, probably due to the lympholytic action of radiotherapy and the depressed cellular response of irradiated tissues. The use of Elliott's B solution as diluent for IT Mtx and an appropriate interval between Mtx doses are suggested for prevention of this toxic syndrome.

50 Years Ago in TheJournalofPediatrics: The Need for Chemotherapy after Prolonged Complete Remission in Acute Leukemia of Childhood

50 Years Ago in TheJournalofPediatrics: The Need for Chemotherapy after Prolonged Complete Remission in Acute Leukemia of Childhood

The Total Body Irradiation Schedule Affects Acute Leukemia Relapse After Matched T Cell–Depleted Hematopoietic Stem Cell Transplantation

We sought to determine whether the total body irradiation (TBI) schedule affected outcome in patients with acute leukemia in complete remission who received Tcell-depleted allogeneic hematopoietic stem cell transplantation from HLA identical siblings. The study recruited 55 patients (median age, 48years; age range, 20-66years; 30 men and 25 women; 34 with acute myeloid leukemia and 21 with acute lymphoid leukemia). Hyperfractionated TBI (HTBI) (1.2Gy thrice daily for 4days [for a total dose of 14.4Gy] from day -12 to day -9) was administered to 29 patients. Single-dose TBI (STBI) (8Gy, at a median dose rate of 10.7cGy/min on day -9) was given to 26 patients. All patients achieved primary, sustained engraftment with full donor-type chimerism. At 10years, the overall cumulative incidence of transplant-related mortality was 11% (SE, ±0.1%). It was 7% (SE, ±0.2%) after HTBI and 15% (SE, ±0.5%) after STBI (P=.3). The overall cumulative incidence of relapse was 33% (SE, ±0.5). It was 13% (SE, ±0.5%) after HTBI and 46% (SE, ±1%) after STBI (P=.02). The overall probability of disease-free survival (DFS) was 59% (SE, ±7%). It was 67% (SE, ±0.84%) after HTBI and 37% (SE, ±1.4%) after STBI (P=.01). Multivariate analyses showed the TBI schedule was the only risk factor that significantly affected relapse and DFS (P=.01 and P=.03, respectively). In patients with acute leukemia, HTBI is more efficacious than STBI in eradicating minimal residual disease after HLA-matched Tcell-depleted hematopoietic stem cell transplantation, thus affecting DFS.

Impact of cord blood banking technologies on clinical outcome: a Eurocord/Cord Blood Committee (CTIWP), European Society for Blood and Marrow Transplantation and NetCord retrospective analysis.

Techniques for banking cord blood units (CBUs) as source for hematopoietic stem cell transplantation have been developed over the past 20 years, aimed to improve laboratory efficiency without altering the biologic properties of the graft. A large-scale, registry-based assessment of the impact of the banking variables on the clinical outcome is currently missing. A total of 677 single cord blood transplants (CBTs) carried out for acute leukemia in complete remission in centers affiliated with the European Society for Blood and Marrow Transplantation were selected. An extensive set of data concerning CBU banking were collected and correlations with clinical outcome were assessed. Clinical endpoints were transplant-related mortality, engraftment, and graft-versus-host disease (GVHD). The median time between collection and CBT was 4.1 years (range, 0.2-16.3 years). Volume reduction (VR) of CBUs before freezing was performed in 59.2% of available reports; in half of these the frozen volume was less than 30 mL. Cumulative incidences of neutrophil engraftment on Day 60, 100-day acute GVHD (II-IV), and 4-year chronic GVHD were 87, 29, and 21 ± 2%. The cumulative incidence of nonrelapse mortality (NRM) at 100 days and 4-year NRM were, respectively, 16 ± 2 and 30 ± 2%. Neither the variables related to banking procedures nor the interval between collection and CBT influenced the clinical outcome. These findings indicate a satisfactory validation of the techniques associated with CBU VR across the banks. Cell viability assessment varied among the banks, suggesting that efforts to improve the standardization of CBU quality controls are needed.

Protein and mRNA expression of CTGF, CYR61, VEGF-C and VEGFR-2 in bone marrow of leukemia patients and its correlation with clinical features

This study was aimed to investigate the mRNA and protein expression of CTGF, CYR61, VEGF-C and VEGFR-2 in bone marrow of patients with leukemia, and to analyze the role and clinical significance of these 4 factors in genesis and development of leukemia, infiltration and metastasis of leukemic cells. A total of 100 cases of newly diagnosed leukemia, 26 cases of acute leukemia in complete remission and 30 controls were enrolled in this study. The mononuclear cells of bone marrow were collected, the mRNA and protein expression levels of CTGF, CYR61, VEGF-C, VEGFR-2 in leukemia patients and controls were detected by real time PCR and Western blot, respectively. The results showed that the mRNA and protein expression levels of above mentioned 4 factors were significantly higher than those in control (P < 0.05), only CTGF mRNA expression in AL patients after complete remission showed statistical difference as compared with control (P < 0.05), but the expression of CTGF mRNA showed statistical significance in different bone marrow hyperplasia of acute leukemia (P < 0.05). The expression level of CTGF protein showed difference in different chromosome karyotypes of leukemia (P < 0.05). The expression levels of CYR61 and VEGF-C proteins showed statistical difference in different bone marrow hyperplasia of acute leukemia (P < 0.05). The expression level of CTGF, CYR61, VEGF-C mRNA and protein in CML group were higher than that in control group. The expression levels of CTGF and CYR61 protein were higher than that in control. The mRNA and protein expression levels of above-mentioned 4 factors in sex and infiltration lf leukemic cells did not show statistical significance(P < 0.05). In correlative analysis, the mRNA expressions of above mentioned 4 factors were positively correlated with bone marrow blast count(P < 0.05), the protein expression of CTGF, CYR61 and VEGF-C were positively correlated with bone marrow blast count. It is concluded that the CTGF, CYR61, VEGF-C and VEGFR-2 mRNA and protein play a role in acute leukemia. In acute leukemia (AML/ALL), the expression of above mentioned factor was high, but except VEGFR-2. Most of them were positively correlated with bone marrow blast count. Joint block of these angiogenesis-related factors is likely to play an important role in targeting treatment of leukemia.

Expression and clinical significance of Atg3 and Atg5 genes in bone marrow mononuclear cells isolated from children with acute leukemia

Objective To detect the expression of autophagy-related gene Atg3 and Atg5 in bone marrow mononuclear cells (BMMNCs) from children with acute leukemia(AL), so as to explore the relationship between autophagy and the pathogenesis of AL in children. Methods Seventy-four bone marrow specimens were obtained from children with AL in the First Affiliated Hospital of Zhengzhou University Pediatrics Hematology Ward, including 37 cases of initially diagnosed AL without any treatment, 28 cases of AL in complete remission, 9 cases of refractory or relapse AL and 28 bone marrow specimens from children without tumor were also collected as the control group.BMMNCs were separated by Lydroxypropylmethyl Cellulose.After BMMNCs were stained by Monodansylcadaverine, the autophagy phenomenon was observed by using fluorescence microscope, and the ratio of autophagy was detected by using flow cytometry.Reverse transcription polymerase chain reaction(RT-PCR) was used to detect the expression of Atg3 mRNA and Atg5 mRNA in each group. Results It was found that autophagy phenomenon was more common in the initially diagnosed group and the refractory/relapse group, and the autophagy ratio in both groups was respectively(17.07±2.31)%, (15.37±1.59)%, respectively, which were obviously higher than that of the control group(2.71±1.57)% and that of the complete remission group.The differences were statistically significant(t=28.29, 20.96, all P 0.05). The autophagy ratio in the refractory/relapse group higher than that in the complete remission group(t=16.61, P 0.008). Conclusions The autophagy ratio and the expressions of Atg3 mRNA and Atg5 mRNA in initially diagnosed group and the refractory/relapse group were both obviously higher.It was revealed that higher autophagy activity, which was caused by upregulated expressions of Atg3 mRNA and Atg5 mRNA, had a closely connection with the mechanism of occurrence, development and resistance of AL in children. Key words: Acute leukemia; Autophagy-related gene; Atg3; Atg5; Bone marrow mononuclear cells; Child

Comparable 2-Year-Overall and Progression Free Survival Among Unrelated Cord Blood Transplantation, Unrelated Bone Marrow Transplantation, and Related Peripheral Blood Stem Cell Transplantation In Adult Patients With Standard-Risk Hematological Diseases; A Single Center Retrospective Analysis

Comparable 2-year overall and progression free survival among unrelated cord blood, unrelated bone marrow, and related peripheral blood stem cell transplantation in adult patients with standard-risk hematological diseases; A single center retrospective analysis BackgroundCord blood has become one of the major alternative donor sources for those who lack identical related donors in recent years. In Japan, an annual number of unrelated cord blood transplantation (uCBT) has been increasing and it reached 1179 cases in 2012, which is comparable to those of unrelated bone marrow transplantation (uBMT) and related peripheral blood stem cell transplantation (rPBSCT). So far, there is still limited data available on the comparative outcomes of adult standard risk patients receiving uCBT, uBMT and rPBSCT. Objectiv and methodTo compare the outcome of uCBT with those of uBMT and rPBSCT for adult patients with standard-risk hematological diseases, we retrospectively reviewed medical records of 142 patients with standard risk hematological diseases who underwent first allogeneic hematopoietic stem cell transplantation (allo-HSCT) at Toranomon Hospital from Jan 2005 to December 2011. The definition of standard risk disease is severe aplastic anemia (SAA), myelodysplastic syndrome (MDS) in refractory anemia (RA), refractory anemia with ringed sideroblasts (RARS), and refractory cytopenia with multilineage dysplasia (RCMD), acute leukemia in complete remission (CR) 1 or 2, chronic myeloid leukemia in chronic phase, non-Hodgkin lymphoma (NHL) in CR, and adult T-cell leukemia/lymphoma (ATL) in CR. Patients with active infection were excluded. ResultThe median follow-up day of survivors was 654 (19-2745). The characteristics of patients are summarized in Table 1. Forty-six patients performed uCBT, 66 did uBMT, and 30 did rPBSCT. The median age of the patients was 50 years (range, 16-70). There were more elderly patients in uCBT group than uBMT and rPBSCT groups (p=0.009). Cumulative incidence of neutrophil recovery at 50 days after transplantation was lowest in uCBT group and highest in rPBSCT group (uCBT= 87.1%, uBMT= 94.7%, rPBSCT=100%; P<0.001). Among 9 patients who did not engraft after uCBT, 6 achieved engraftment following 2nd uCBT. The cumulative incidence of grade II-IV acute graft-versus-host disease was comparable in three groups (uCBT= 43.7%, uBMT= 52.7%, rPBSCT=46.7%, P=0.57). Overall survival (OS) (uCBT=66.4%, uBMT=69.7%, rPBSCT=69.8%, P=0.73)(Figure 1), disease free survival (DFS) (uCBT=63.0%, uBMT=63.7%, rPBSCT=63.2%, P=0.82), relapse rate (uCBT=14.8%, uBMT=14.7%, rPBSCT=20.2%, P=0.67), and treatment related mortality (TRM) (uCBT=19.6%, uBMT=21.6%, rPBSCT=16.7%, P=0.52) at 2 years were all comparable among 3 groups. [Display omitted] [Display omitted] ConclusionClinical outcomes of uCBT, uBMT and rPBSCT groups for adult standard-risk hematological diseases were comparable. Early death is prominent in uCBT, but the increase of late relapse and GVHD-related complications in rPBSCT offset it. Although immune cells in CB are primarily immature, comparable incidence of relapse with other donor sources indicate sufficient anti-tumor effect of uCB for longterm. uCB can now be considered as a promising donor source almost equivalent to uBM or rPB for adult standard-risk hematological diseases. Disclosures:No relevant conflicts of interest to declare.

Effects of KIR ligand incompatibility on clinical outcomes of umbilical cord blood transplantation without ATG for acute leukemia in complete remission

To clarify the effect of killer cell immunoglobulin-like receptor (KIR) ligand incompatibility on outcomes of acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) patients in complete remission after single cord blood transplantation (CBT), we assessed the outcomes of CBT registered in the Japan Society for Hematopoietic Cell Transplantation (JSHCT) database. A total of 643 acute leukemia (357 AML and 286 ALL) patient and donor pairs were categorized according to their KIR ligand incompatibility by determining whether or not they expressed HLA-C, Bw4 or A3/A11 by DNA typing. A total of 128 patient–donor pairs were KIR ligand-incompatible in the graft-versus-host (GVH) direction and 139 patient–donor pairs were incompatible in the host-versus-graft (HVG) direction. Univariate and multivariate analyses showed no significant differences between the KIR ligand-incompatible and compatible groups in the GVH direction for both AML and ALL patients of overall survival, disease-free survival, relapse incidence, non-relapse mortality and acute GVH disease. However, KIR incompatibility in the HVG direction ameliorated engraftment in ALL patients (hazard ratio 0.66, 95% confidence interval 0.47–0.91, P=0.013). Therefore, there were no effects of KIR ligand incompatibility in the GVH direction on single CBT outcomes for acute leukemia patients without anti-thymocyte globulin use. However, it is necessary to pay attention to KIR incompatibility in the HVG direction for engraftment.

The Permanent Improvement of Proteinuria and Renal Failure With Colchicine and Enalapril in a Leukemic Patient With Renal Amyloidosis Secondary to Ankylosing Spondylitis

Acute leukemia has been reported as secondary to radiation therapy in patients with ankylosing spondylitis (AS). AA amyloidosis secondary to AS causes progressive organ failure. Although new therapeutic choices can be used, response to therapy in secondary amyloidosis is not good enough. In AA amyloidosis, clinical symptoms partially regress with colchicine. Here, we report a patient with acute leukemia and AS. After complete remission of acute leukemia, pulmonary tuberculosis, acute renal failure and nephrotic syndrome developed. After treatment of leukemia and tuberculosis, Colchicine and enalapril therapy resulted in an improvement of clinical symptoms. He was followed up for >15 years and is doing very well and has minimal symptoms related to AS.

Hematopoietic Cell Transplantation from an HLA-Mismatched Familial Donor After Reduced-Intensity Conditioning Containing Busulfan, Fludarabine, and Antithymocyte Globulin for Patients with Acute Leukemia and Myelodysplastic Syndrome

AbstractAbstract 3538For patients who suffer hematologic malignancies and lack suitable HLA-matched sibling or unrelated donors, there is a need to develop a safe and effective method of hematopoietic cell transplantation (HCT) from an HLA-mismatched family donor. In a previous report including 29 patients with acute leukemia and myelodysplastic syndrome (MDS), we showed that HCT from an HLA-mismatched familial donor is feasible without ex vivo-T cell depletion when reduced-intensity conditioning (RIC) with busulfan (BU), fludarabine (FLU), and antithymocyte globulin (ATG) is performed (Biol Blood Marrow Transplant 15: 61–72, 2009). Since the publication, we have extended our experience of HLA-mismatched HCT using same approach in 54 additional patients. Thus, the entire cohort of 83 patients, transplanted between April 2004 and December 2009, consisted of 47 male and 36 female with median age of 40 years (range, 16–70). Fifty-two patients had acute myelogenous leukemia (AML), 16 had acute lymphoblastic leukemia (ALL), and 15 had MDS. Of 68 patients with acute leukemia, 15 were in their 1st complete remission (CR) status, 19 in 2nd/3rd CR, and 34 in a refractory state. Twelve patients had undergone allogeneic HCT previously. RIC included iv BU 3.2 mg/kg/day ×2, FLU 30 mg/m2/day ×6, and ATG [Thymoglobulin 3 mg/kg/day ×4 (n=69) or ×3 (n=12); or Lymphoglobulin 15 mg/kg/day ×4 (n=2)]. Cell donors (age, 3–68 years) were either mother (n=24), HLA-haploidentical sibling (n=21), or offspring (n=38) of the patients with a mean HLA-antigen disparities of 2.24/6 in both graft-versus-host and rejection directions. Eleven of 71 evaluated donor-patient pairs (15%) showed natural killer (NK) cell-alloreactivity. The donors received granulocyte-colony stimulating factor (10 μg/kg/day) for 4 to 7 days and underwent daily 2 to 5 leukapheresis. Collected cells were infused into patients without further manipulation [medians (range) of; 8.1 (1.8-17.0)x108/kg mononuclear cells, 7.5 (0.2-73.5)x106/kg CD34+ cells, and 4.8 (0.5-10.0)x108/kg CD3+ cells]. Graft-versus-host disease (GVHD) prophylaxis included cyclosporine and methotrexate. As a part of separate phase 1/2 studies, 20 patients received donor-derived NK cells (up to 1×108/kg) after HCT. Other than 7 patients who had progressive leukemia or died early, all remaining 76 patients achieved absolute neutrophil count >500/μL median 13.5 days (range, 9–53; cumulative incidence, 92%). Seventy-two patients achieved platelet count >20,000/μL median 17 days (range, 11–119; cumulative incidence, 87%). Cumulative incidences for grade II-IV acute and chronic GVHD were 20% (95% CI, 13–30%) and 35% (95% CI, 26–47%), respectively. After median follow-up of 16.3 months (range, 6.3–72.9), 4 patients experienced secondary graft failure (cumulative incidence, 5%; 95% CI, 2–13%). Sixteen patients died without leukemia/MDS progression (4 due to acute GVHD, 3 secondary graft failure, 2 pulmonary complications, 1 EBV-PTLD, 1 EBV hepatitis, 1 CMV colitis, and 4 other infections), giving 1-year transplantation-related mortality (TRM) of 18% (95%, 11–28%). Thirty-five patients experienced leukemia/MDS progression. Cumulative incidences for disease progression were 21% for patients with acute leukemia in the 1st CR, 35% for acute leukemia in 2nd/3rd CR, 71% for refractory acute leukemia, and 20% for MDS. Kaplan-Meier event-free and overall survivals were 62% and 61% for patients with acute leukemia in 1st CR, 55% and 35% for acute leukemia in 2nd/3rd CR, 8% and 6% for refractory acute leukemia, and 53% and 50% for MDS, respectively. Disease status [standard risk (acute leukemia in CR and low-risk MDS) vs. high risk (refractory acute leukemia and high-risk MDS)] was an independent predictors for disease progression (P<0.001), graft failure (P=0.007), 1-year TRM (P=0.005), event-free (P<0.001), and overall survivals (P<0.001). Previous allogeneic HCT was an independent predictor for disease progression (P=0.004). The degree of HLA mismatch and NK cell-alloreactivity between the donor and patient did not predict above outcomes. In patients with acute leukemia and MDS, HCT from an HLA-mismatched family donor is feasible with low frequencies of GVHD and TRM. Prospective studies have been initiated to compare the HCT outcomes among various cell donors (HLA-matched siblings vs. HLA-matched unrelated donors vs. HLA-mismatched family) in patients with acute leukemia in remission. Disclosures:Lee:Genzyme: Honoraria; Otsuka Phamaceuticals: Consultancy.

Impact of Serum Ferritin Levels on the Incidence of Chronic Graft-Versus-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation.

AbstractAbstract 1248 Background:Iron overload is an important adverse prognostic factor in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-SCT). Many studies have shown that elevated pre-transplant serum ferritin levels are associated with an increased risk of morbidity and mortality after allo-SCT. Conversely, a couple of other studies have suggested that elevated pre-transplant ferritin levels are associated with a low incidence of the chronic graft-versus-host disease (GVHD). To verify these apparently paradoxical findings, we analyzed the association between pre-transplant serum ferritin levels and clinical outcomes of allo-SCT. Patients and methods:We retrospectively studied 161 consecutive patients (age, 16–65 years; median age, 46 years) who underwent their first allo-SCT for hematologic diseases at the Kyoto University Hospital between September 2004 and April 2010. The primary diseases were myeloid (n = 87) and lymphoid malignancies (n = 68), and non-malignant diseases (n = 6). Patients with acute leukemia in complete remission, untreated MDS, CML in the chronic phase, or non-malignant diseases were considered to have standard-risk diseases (n = 96), whereas those with any other hematologic disease status were considered to have high-risk diseases (n = 65). Stem cells were obtained from the bone marrow (BM) or peripheral blood (PB) of HLA-matched related donors (n = 56) and partially matched related donors (n = 18), BM of unrelated donors (n = 65), and cord blood of unrelated donors (n = 22). Conventional myeloablative regimens were used in 99 patients while reduced-intensity regimens were used in 62. The primary endpoint was the cumulative incidence of chronic GVHD, which is defined according to the Seattle criteria, while the secondary endpoints were overall survival, acute GVHD, treatment-related mortality (TRM), and relapse rate. For statistic analyses, cumulative incidence curves were used in a competing-risks setting to determine the incidence of GVHD, TRM, and relapse rate, whereas the Kaplan–Meier method was used to determine survival rate. The Fine and Gray proportional-hazards model for the sub-distribution of a competing risk and the Cox proportional-hazards regression model were used as appropriate. Factors evaluated in the analysis included the recipient's age, sex, diagnosis, disease status at the time of transplant, source of stem cells, conditioning regimen, GVHD prophylaxis, serum ferritin levels (<900 vs. ≥900 ng/mL), and serum CRP levels (<0.2 vs. ≥0.2 mg/dL). Only ferritin levels, CRP levels (which is associated with ferritin levels), and those factors with P-values of <0.10 in the univariate analysis were included in the multivariate analysis. Result:There was no significant difference in patient characteristics between the low-ferritin group (n = 105) and the high-ferritin group (n = 56). The median follow-up period among survivors was 38 months (range, 2–113 months). The cumulative incidence of chronic GVHD was lower in the high-ferritin group (32%) than in the low-ferritin group (49%) (P = 0.080) (Figure 1). In the multivariate analysis, serum ferritin level was significantly associated with the incidence of chronic GVHD (hazard ratio, 0.59; P = 0.045). Even when the serum ferritin level was treated as a continuous variable, this association remained significant. A trend toward a higher incidence of grade 3–4 acute GVHD was observed in the high-ferritin group; however, this association was not statistically significant. TRM was significantly higher in the high-ferritin group, but the relapse rate was not different between the 2 groups. High serum ferritin levels, the male sex, and high-risk diseases were significantly associated with a lower overall survival in the multivariate analysis. Conclusion:In our cohort, elevated pre-transplant ferritin levels were significantly associated with a lower incidence of chronic GVHD. Conversely, patients in the high-ferritin group tended to have a high incidence of severe acute GVHD. These patients had lower overall survival probably due to a higher incidence of TRM. Further clinical and biological studies on the immunomodulatory effects of iron or iron-related molecules, such as ferritin, may provide clues on the prophylaxis and management of acute and chronic GVHD. For this purpose, studies on post-transplant iron status in association with acute and chronic GVHD should also be conducted. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Outcomes of Unrelated Cord Blood Transplantation for Non-Malignant Diseases in Children Are Not Associated with KIR-Ligand Matching Between Donor and Recipient: a Study On Behalf of Eurocord.

Abstract 2301Poster Board II-278NK-cell alloreactivity in the setting of allogeneic transplantation is largely determined by the specificity of the killer immunoglobulin receptors (KIR) on donor NK cells for recipient HLA class I. We have recently shown that KIR ligand mismatch in the graft-versus-host (GvH) direction between donor and recipient is associated with improved outcomes after unrelated cord blood transplantation (UCBT) for patients with acute leukemia in complete remission. However, this finding was not confirmed in a series of reduced intensity conditioning and UCBT using 2 unrelated cord blood units. Therefore, those controversial results can raise some questions on the donor choice based on KIR ligand matching status. It is not known whether KIR ligand matching is associated with outcomes after UCBT for non-malignant disorders.To address this question we have analyzed patients with non-malignant disorders who had received a UCBT using a single cord blood unit and were reported to the Eurocord registry with sufficient HLA-A, -B, -C typing to assign KIR ligand groups. In agreement with previous studies in malignant diseases, KIR ligand mismatch (KIR+) in the GvH direction occurred when the donor expressed one or several of the following KIR ligands which were lacking in the recipient: HLA-Bw4, and HLA-C group 1 or 2. In addition patients and cord blood units were grouped according to HLA A-3/A-11 alleles, which are putative KIR ligands. One-hundred-thirty-seven eligible patients were selected, mostly children (n=124). UCBT was performed from January 2000 to December 2008 in 47 EBMT-centers. The frequency of KIR ligand mismatched (KIR+) pairs reported was 23% (n=31). Forty-three percent of patients had bone marrow failure syndromes (BMFS) (n=60), other diagnosis included metabolic disorders (n=41), SCID (n=32), hemoglobinopathies (n=2), autoimmune diseases (n=2). Median follow up was 24 months (4-101). Median recipient age was 3 years. UCB units were HLA matched at 6 of 6 (n=38), 5 of 6 (n=62), 4 of 6 (n=34) and 3 of 6 (n=3). Median cell dose infused was 5.6 ×10E7 TNC/Kg and 2.4 ×10E5 CD34 cells/Kg. Conditioning regimen was myeloablative in 48% of cases and reduced intensity in 52% and included ATG in 90% and fludarabine in 42%. Graft-versus-host disease (GvHD) prophylaxis consisted of cyclosporine (CsA) and corticosteroids, CsA alone and CsA and MMF in 47%, 23% and 14% of patients, respectively.Cumulative incidence (CI) of the day-60-neutrophil recovery was 76±3% (median time: 22 days) and it was not associated with KIR mismatch [(74±4% for KIR- and 80±6% for KIR+ group (p=0.9)]. CI of aGvHD was 21±3%, only 3 patients out of 31 with KIR+ presented aGvHD (II-IV). The estimated probability of 2-year overall survival (OS) was 63±4%; it was 64±5% in the group of KIR- and 63±3% in the KIR+ (p=0.5). The main cause of death was graft failure associated with infections (n=16, 32%). There was no statistical difference in frequency of causes of death between the 2 KIR ligand groups.We have also looked the association of KIR ligand mismatch in the host versus graft (HvG) direction. The frequency of KIR mismatched pairs in the HvG direction was 22% and it was not associated with neutrophil recovery (76±4% for KIR ligand matched in HvG direction versus 73±6% for KIR ligand mismatched in HvG direction, p=0.9) or OS (64±5% for KIR ligand matched in HvG direction versus 58±7% for KIR ligand mismatched in HvG direction, p=0.6)In conclusion KIR ligand mismatching in the GvH or HvG direction is not associated with outcomes after UCBT for children with non malignant disease. Therefore it is not useful in the algorithm of donor choice in this setting. Disclosures:No relevant conflicts of interest to declare.

Low Relapse without Excessive Transplant-Related Mortality following Myeloablative Cord Blood Transplantation for Acute Leukemia in Complete Remission: A Matched Cohort Analysis

Growing evidence supports the efficacy of cord blood transplantation (CBT), and the number of CBTs is increasing. Numerous studies confirm the presence of a graft-versus-leukemia (GVL) effect following CBT, and preliminary data suggests that double-unit CBT may be associated with a decreased risk of relapse. We have observed a low relapse rate following CBT among patients with acute leukemias in morphologic complete remission (CR) at the time of myeloablative (MA) transplant. To further assess this observation, we conducted a matched cohort analysis comparing relapse rates and outcomes for patients receiving CBTs versus patients receiving matched unrelated donor (MURD) and mismatched unrelated donor (MMURD) transplants at our center. Thirty-one consecutive CBT patients (aged 0.6-42 years, median 22 years), transplanted between April 2006 and June 2008, were compared to matched subjects selected on the basis of disease type and remission number, cytogenetic risk status, minimal residual disease status (MRD), time from diagnosis to first relapse (for patients beyond CR1), use of imatinib for chronic myelogenous leukemia (CML) and Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL) patients, age, and date of transplant. With a median follow-up among surviving CBT patients of 21.1 months (range: 6.6-32.6 months), there has been 1 relapse among cord patients versus 8 relapses among MURD patients (P=.018) and 7 relapses among MMURD patients (P=.019). Treatment-related mortality (TRM) between cohorts is comparable. Although we have observed a high incidence of acute graft-versus-host disease (aGVHD) following CBT, the incidence of National Institutes of Health (NIH) consensus criteria chronic GVHD (cGVHD) has been low. These data support increased investigation of the use of CBT.

KIR-ligand incompatibility in the graft-versus-host direction improves outcomes after umbilical cord blood transplantation for acute leukemia

Donor killer cell immunoglobulin-like receptor (KIR)-ligand incompatibility is associated with decreased relapse incidence (RI) and improved leukemia-free survival (LFS) after haploidentical and HLA-mismatched unrelated hematopoietic stem cell transplantation. We assessed outcomes of 218 patients with acute myeloid leukemia (AML n=94) or acute lymphoblastic leukemia (n=124) in complete remission (CR) who had received a single-unit unrelated cord blood transplant (UCBT) from a KIR-ligand-compatible or -incompatible donor. Grafts were HLA-A, -B or -DRB1 matched (n=21) or mismatched (n=197). Patients and donors were categorized according to their degree of KIR-ligand compatibility in the graft-versus-host direction by determining whether or not they expressed HLA-C group 1 or 2, HLA-Bw4 or HLA-A3/-A11. Both HLA-C/-B KIR-ligand- and HLA-A-A3/-A11 KIR-ligand-incompatible UCBT showed a trend to improved LFS (P=0.09 and P=0.13, respectively). Sixty-nine donor–patient pairs were HLA-A, -B or -C KIR-ligand incompatible and 149 compatible. KIR-ligand-incompatible UCBT showed improved LFS (hazards ratio=2.05, P=0.0016) and overall survival (OS) (hazards ratio=2.0, P=0.004) and decreased RI (hazards ratio=0.53, P=0.05). These results were more evident for AML transplant recipients (2-year LFS and RI with or without KIR-ligand incompatibility 73 versus 38% (P=0.012), and 5 versus 36% (P=0.005), respectively). UCBT for acute leukemia in CR from KIR-ligand-incompatible donors is associated with decreased RI and improved LFS and OS.Supplementary informationThe online version of this article (doi:10.1038/leu.2008.365) contains supplementary material, which is available to authorized users.

KIR-Ligand Incompatibility in the Graft-Versus-Host Direction Is Associated with Better Outcomes after Unrelated Cord Blood Stem Cell Transplantation for Acute Leukemia in Complete Remission

HLA class I, killer-cell immunoglobulin-like receptor (KIR) ligands which are missing in the recipient may trigger cytotoxicity of donor NK cells leading to graft-versus- host disease (GvHD) and/or graft-versus-leukemia reactions. Donor KIR(-ligand) incompatibility in the graft-versus-host (GvH) direction is associated with decreased relapse incidence (RI) and improved disease-free survival (DFS) in haplo-identical and HLA-mismatched unrelated hematopoietic stem cell transplantation (HSCT). Since it is unknown whether KIR-ligand mismatching impacts outcomes in unrelated cord blood stem cell transplantation (UCBT), we studied patients reported to Eurocord Registry with acute leukemia in complete remission (CR) with available high resolution typing of HLA-A, -B and -C in recipient/donor pairs who received a single UCBT. Patients and donors were categorized to their KIR-ligand groups by determining whether or not they expressed: HLA-C group 1 or 2, HLA-Bw4 and HLA-A3 or -A11. A total of 218 patient-donor pairs met the eligibility criteria. The patients had ALL (n=124) or AML (n=94) and were transplanted in 1st CR (n=105), 2nd CR (n=91) or >2nd CR (n=22). Median age was 13.4 yrs, weight 49 kg, and nucleated cell dose infused was 3.0×10E7/kg. The cord blood was HLA identical (6/6) in 21, 5/6 in 91, 4/6 in 91 and <4/6 in 15. Conditioning was myeloablative (84%) or reduced intensity (16%), and included ATG in 80%. Forty-one donors were HLA-C, 12 HLA-Bw4 and 22 HLA-A3/-A11 KIR-ligand mismatched in the GvH direction with the patient whereas fifty-one patients were HLA–C group 1 or 2, 19 HLABw4 and 18 HLA-A3/-A11 KIR-ligand mismatched in the HvG direction with the donor. When studying only donor-patient pairs in the GvH direction a total of sixty-nine patients had a KIR-ligand mismatched (KIR+) donor and 149 had not (KIR−). There were no statistical differences for patient-, disease- and transplantion-related factors between the KIR+ and KIR− group, except for more cytogenetically bad risk AML patients in the KIR+ group. HLA-C group 1 and 2, and HLA-A3/-A11, KIR-ligand incompatible UCBT showed independently a trend to improved DFS (p=0.09 and p=0.13, respectively). Analysis of the combined HLA-A, -B and -C KIR-ligand (mis)matches showed no statistical association with neutrophil recovery (81±4% KIR+, 79±3% KIR− group, p=0.21), non-relapse mortality (25±6% KIR+, 32±4% KIR−, p=0.34), acute GvHD (27±5% KIR+, 29±3% KIR−, p=0.82) and chronic GvHD (18±4% KIR+, 14±3% KIR−, p=0.38). However, differences were shown in RI (20±6% KIR+, 37±4% KIR−, p=0.03), DFS (55±7% KIR+, 31±4% KIR−, p=0.005) and overall survival (57±7% KIR+, 40±4% KIR−, p=0.02). In multivariate analysis, donor KIR-ligand incompatibility was associated with decreased RI (HR=0.53, p=0.05), increased DFS (HR=2.05, p=0.016) and overall survival (HR=2, p=0.004). In subgroup analysis for AML: RI for KIR+ vs KIR− was 5±4% vs 36±7% (p=0.005) and DFS 73±10% vs 38±7% (p=0.012); and for ALL: RI was 29±8% vs 37±6% (p=0.71) and DFS 44±9% vs 27±6% (p=0.10), respectively. The use of KIR-ligand incompatible donors in UCBT resulted in a lower RI and increased DFS and overall survival, especially in AML. If these results are confirmed in a larger series of patients KIR-ligand incompatibility in the GvH direction might be considered as a criterion of cord blood donor choice.

Distribution of Antigenic Aberration in the Bone Marrow of Acute Leukemia in Complete Remission

The aberrant, leukemia-associated antigen expression patterns allow us to discriminate leukemic blasts from normal precursor cells. Our major goal was to determine a guideline for the detection of minimal residual disease using CD20+/CD34+ and myeloid Ag+/CD19+ combination in the bone marrow of acute leukemia in complete remission (CR) after chemotherapy. Bone marrow samples from 117 patients with acute leukemia in complete remission after chemotherapy and from 22 healthy controls were immunophenotyped by triple staining and measured by flow cytometry. The CD20+/CD34+ cells in the large lymphocyte gate (R1) ranged from 0% to 3.% (0.8plusmn;0.82%, P=0.000) in CD20+/CD34+ B-lineage ALL CR (N=31), from 0.03% to 4.2% (0.7plusmn;0.83%, P=0.000) in CD20-/CD34- B-lineage ALL CR (N=66), from 0.1% to 0.96% (0.45plusmn;0.32%, P=0.016) in T-ALL CR (N=10), and from 0.02% to 0.48% (0.18plusmn;0.15%, P=0.776) in AML CR (N=10). The CD13,33+/CD19+ cells in R1 gate ranged from 0% to 2.69% (0.37plusmn;0.48%, P<0.001) in CD13,33+/CD19+ B-lineage ALL CR (N=31), from 0% to 1.8% (0.31plusmn;0.28%, P<0.001) in CD13,33-/CD19+B-lineage ALL CR (N=65), from 0.02% to 0.64% (0.29plusmn;0.22%, P=0.071) in T-ALL CR (N=9), and from 0% to 0.17% (0.07plusmn;0.09%, P=0.341) in AML CR (N=3). Using an immunophenotypic method for the detection of early relapse or minimal residual disease of B-lineage ALL bone marrow in CR after chemotherapy, different cutoff values should be applied according to antigen combination and gating. When the proportion of aberrant antigen combination was less than 5% in large lymphocyte gate, the results should be interpreted with caution.

Proportions of Cells Expressing CD38-/CD34+, CD38+/CD34+, CD19+/CD34+, or CD13,33+/CD34+ in the Regenerating Bone Marrows During Complete Remission of Acute Leukemia or After Bone Marrow Transplantation

The hemopoietic stem cells increase in number during the regeneration after chemotherapy or bone marrow transplantation (BMT). Although the proportion of hemopoietic stem cells and their differentiation have been studied by immunophenotyping using the flow cytometry, no substantial research efforts have been directed toward the regenerating marrow. We attempted to discover the proportions of undifferentiated stem cells, committed stem cells, B cell precursors, and myeloid precursors in the regenerating bone marrows during complete remission (CR) and after engraftment of BMT. Bone marrow samples from 82 patients with acute leukemia in CR and from 25 patients after BMT engraftment, along with 22 control samples, were used to find the numbers of CD38-/CD34+, CD38+/CD34+, CD19+/CD34+, and CD13,33+/CD34+ cells in the large lymphocyte gate by flow cytometry. We cross-analyzed our results in terms of groups: CR, BMT, and initial diagnosis groups. We performed significance tests on age, relapse, chromosomal abnormalities, clinical outcomes, and initial immunophenotypes of the leukemic cells. The proportions of CD38-/CD34+, CD38+/CD34+, CD19+/CD34+, and CD13,33+/CD34+ cells are more highly distributed in acute B-lymphoblastic leukemia than the normal group and also in the CR than the BMT group. CD19+/CD34+ cells were increased in the relapse group and CD38+/ CD34+, CD19+/CD34+, and CD13,33+/CD34+ cells were increased in the group with chromosomal abnormality. The results were irrelevant to the initial immunophenotype of the leukemic blasts. The increases of the markers spanned too widely to apply one specific cutoff value to analyze them. They seemed to be the results of normal regeneration, irrelevant to relapse or initial immunophenotype of leukemic blasts.

Generation of CD4+ or CD8+ regulatory T cells upon mesenchymal stem cell-lymphocyte interaction

Mesenchymal stem cells (MSC) have been proposed as a way to treat graft-versus-host disease based of their immunosuppressive effect. We analyzed whether regulatory T cells can be generated in co-cultures of peripheral blood mononuclear cells (PBMC) and MSC. MSC were obtained from the bone marrow of four healthy donors and nine patients with acute leukemia in complete remission following chemotherapy. Short-term (4 days) co-cultures of MSC and autologous or allogeneic PBMC were set up, the lymphocytes harvested and their regulatory activity assessed. Lymphocytes harvested from MSC-PBMC co-cultures strongly inhibit (up to 95%) mixed lymphocyte reaction (MLR), recall to alloantigen, and CD3- or PHA-induced lymphocyte proliferation. These lymphocytes, termed regulatory cells (Regc), were all CD45+CD2+ with variable proportions of CD25+ cells (range 40-75% n=10) and a minor fraction expressed CTLA4 (2-4%, n=10) or glucocorticoid-induced tumor necrosis factcor receptor-related gene (0.5-4% n=10). Both CD4+ and CD8+ Regc purified from MSC-PBMC co-cultures strongly inhibited lymphocyte proliferation at a 1:100 Regc:responder cell ratio. CD4+ Regc expressed high levels of forkhead box P3 (Foxp3) mRNA while CD8+ Regc did not. The effectiveness of Regc, whether CD4+ or CD8+, was 100-fold higher than that of CD4+CD25+high regulatory T cells. Regc were also generated from highly purified CD25- PBMC or CD4+ or CD8+ T cell subsets. Soluble factors, such as interleukin-10, transforming growth factor-b and prostaglandin E2 did not appear to be involved in the generation of Regc or in the Regc-mediated immunosuppressive effect. Furthermore, cyclosporin A did not affect Regc generation or the immunosuppression induced by Regc. These findings indicate that powerful regulatory CD4+ or CD8+ lymphocytes are generated in co-cultures of PBMC with MSC. This strongly suggests that these regulatory cells may amplify the reported MSC-mediated immunosuppressive effect.