非清髓性異基因造血干細(xì)胞移植治療惡性血液病26例(1)

1、    非清髓性異基因造血干細(xì)胞移植治療惡性血液病26例(1)    】 為研究非清髓性異基因造血干細(xì)胞移植（non-myeloablative allogeneic stem cell transplantation，allo-NST）治療惡性血液病的療效及相關(guān)技術(shù)，選擇26例惡性血液病患者作為研究對象（急性白血病10例，慢性髓性白血病14例，多發(fā)性骨髓瘤2例），其中14例采用FAC（fludarabin ATG Cy)預(yù)處理，12例采用MAC（melfalan/maleran ATG Cy)預(yù)處理；用G-CSF

2、 600 g/d或G-CSF 300 g/d GM-CSF 300g/d進(jìn)行外周血干細(xì)胞動員，于第5天開始用Cobe Spectra血細(xì)胞分離機(jī)連續(xù)采集2-3次；用環(huán)孢菌素A聯(lián)合短程甲氨蝶呤預(yù)防GVHD；移植后第4周開始供體淋巴細(xì)胞輸注，首劑1×107/kg，之后依據(jù)臨床反應(yīng)及嵌合體形成情況，每4周1次，劑量逐級遞增；微衛(wèi)星短串聯(lián)重復(fù)序列（STR）分析、Bcr/Abl融合基因、Ph染色體、HLA位點(diǎn)分析、性染色體及ABO血型等為植活檢測指標(biāo)。結(jié)果顯示： 植入率84.62%，aGVHD發(fā)生率11.54%，cGVHD發(fā)生率23.07%；感染和出血等毒副反應(yīng)發(fā)生率低、反應(yīng)輕。結(jié)論：非清髓性

3、異基因造血干細(xì)胞移植治療惡性血液病療效確切，毒副作用小，但相關(guān)技術(shù)，如適應(yīng)癥的選擇、預(yù)處理方案、移植過程中的免疫治療等需進(jìn)一步深入研究。 【關(guān)鍵詞】 造血干細(xì)胞移植；非清髓性異基因造血干細(xì)胞移植； 惡性血液病Nonmyeloablative Allogeneic Hematopoietic Stem cell Transplantation in 26 Cases of Hematological MalignanciesAbstract The purpose of this study was to investigate the efficacy of non-myeloablative

4、 allogeneic stem cell transplantation (allo-NST) and its related technologies in hematological malignancies. 26 patients with hematological malignancies (acute leukemia 10，chronic myeloid leukemia 14，multiple myeloma 2) received allo-NST following conditioning regimens with fludarabin/cyclophosphami

5、de/ATG in 14 cases  or  busulfan  or melphalan/ cyclophosphamide/ATG in 12 cases prior to infusion of 2 or 3 collections of G-CSF(600 g/d) or G-CSF(300 g/d) plus GM-CSF(300 g/d) mobilized blood stem cell on the fifth day. A combination of cyclosporine A (CsA)

6、and methotrexate(MTX) was administered for GVHD prophylaxis. Patients were eligible for donor lymphocyte infusion (DLI) (or donor stem cell infusion (DSI) )given in graded increments according to the chimeric formation and clinical feature. Generally，the dose of the first infusion was 1×l07/kg

7、in 4th week post-transplantation. The engraftment analyses included the detection of microsatellite short tandem repeats (STRs)，bcr/abl fusion gene，Philadelphia chromosome，HLA-locus analysis，sex chromosome and ABO blood type or blood subtype. The results showed that out of 26 patients，22 (

8、84.62%) were engrafted，18/22 were full donor chimerism (FDC) up to now. Acute GVHD occurred in 3/26 (11.54%)，while chronic GVHD was diagnosed in 6 out of 26 (23.07%) patients. The incidence and degree of infection and hemorrhage were low and slight. It is concluded that NST is a safe and effective t

9、herapy for hematological malignancies，whereas related technologies such as adaptation selected，conditioning regimen and transplantation immunotherapy should be studied further.Key words    hematopoietic stem cell transplantation; nonmyeloablative allogeneic hematopotetic stem cel

10、l transplantation; hematological malignancyAs conventional allogeneic hematopoietic stem cell transplantation (HSCT) for patients with hematological malignancies both eradicates the patients underlying diseases and suppresses their immune responses，they do not reject the subsequent allografts. The a

11、llografts serve to “rescue” patients from the marrow lethal    effects of the conditioning regimens. Consequently，the conditioning therapy intensity would be limited only by toxicities to non-marrow organs，such as gut，lung，kidney，heart，and liver. These toxicities have restric-ted

12、 HSCT to younger，medically fit patients，with treatment administered in specialized hospital wards. Almost no allogeneic HSCT have been carried out in patients>60 years old，and in only a few patients older than 50 years. Since median ages at diagnoses of patients with acute myelocytic leukemias (A

13、ML)，chronic myelocytic leukemias(CML)，chronic lymphocytic leukemias(CLL)，non-Hodgkin lymphomas (NHL)，and multiple myelomas (MM) range from 65-70 years，so that conventional allogeneic HSCT benefit only a minority of patients with candidate disease.    Nonmyeloablative allogeneic s

14、tem cell transplantation (NST) was first described and applied in 1997 by Giralt and colleages1-3. Because of their low toxicity，nonmyeloablative allogeneic stem cell transplantation shows a promise to reduce the morbidity and mortality associated with conventional high-dose chemoradiotherapy and al

15、lows allogeneic transplants in elderly or medically infirm patients who are not eligible for conventional myeloablative HSCT. So it has been increasingly explored as a safe alternative to conventional high-dose transplantation regimens.    We analyzed NST with its adapt

16、ation，conditioning regimen，engraftment，immunotherapy and complications，such as GVHD，in details in 26 patients with hematological malignancies who underwent NST from September 1998 to September 2002.            作者：蘇麗萍，許蓮蓉，姜波，葉芳，朱秋娟，鹿育晉，崔月娥，朱

17、鐳，張麗，馬香蘭【摘】為研究非清髓性異基因造血干         本篇論文是由3COME文檔頻道的網(wǎng)友為您在網(wǎng)絡(luò)上收集整理餅投稿至本站的，論文版權(quán)屬原作者，請不用于商業(yè)用途或者抄襲，僅供參考學(xué)習(xí)之用，否者后果自負(fù)，如果此文侵犯您的合法權(quán)益，請聯(lián)系我們。Materials and MethodsPatient characteristicsDuring the period from September 1998 to September 2002，26 patients were diagnosed as hema

18、tological malignancies and treated with NST in our department. Of these patients，male and female were 15 and 11，respectively. Ages ranged from 19 to 58 years (median，40). Ten patients had acute leukemia (3 of B-cell acute lymphoblastic leukemia; 7 of acute myelocytic leukemia，i.e. 3 of M2a，l of M4a，

19、3 of M5a，respectively). Fourteen patients had chronic myelocytic leukemia (11 in chronic phase，2 in accelerated phase，1 in blast phase). Two patients suffered from multiple myeloma.Patient status before transplantationThe patients with acute leukemia were all in the first complete remission but one

20、patient with B-cell acute lymphocytic leukemia and one M2a in the second complete remission. Those with chronic myelocytic leukemia were all in the first chronic phase but 1 case was in blast phase and 2 cases were in the second chronic phase. All 2 patients with multiple myeloma showed partial remi

21、ssion.Laboratory parametersSerum cytomegalovirus(CMV)-IgM antibody was determined by enzyme linked immunosorbent assay (ELISA)，serum CMV-DNA was detected by polymerase chain reaction (PCR) in some patients and the results were negative. HBsAg，HBeAg and HBcAb tests were positive in l patient，HBeAb an

22、d HBcAb tests were positive in 2 patients. Human leukocyte antigen (HLA)-identification was carried out by serological examination for class I and PCR-SSP for class .DonorThe donors were 13 males and 13 females，age ranged from 22 to 52 years (median 38). All donors were sibling but 1 was the patient

23、s father. Out of these donors，1 was positive in HBsAg，HBeAb and HBcAb. 17 donors were HLA-identical matched，4 were single locus mismatched，4 were two loci mismatched，1 was three loci-mismatched. 11 were the same ABO blood type and 15 were different (7 major incompatible，8 minor incompatible ).Method

24、s of transplantation1 patient was treated by bone marrow transplantation，7 received peripheral blood stem cell transplantation combining with bone marrow transplantation，18 underwent peripheral blood stem cell transplantation.Mobilization，separation and collection of peripheral blood stem cell(1) G-

25、CSF 300 g，s.c. twice daily; (2) G-CSF 300 g plus GM-CSF 300 g，s.c. once a day. Collection started from the fifth day of mobilization with blood cell separator (leukapheresis) known as Cobe Spectra for 2-3 times.Number of MNC and CD34 cells infusedThe number of mononuclear cells (MNC) was (4.15-16.28

26、)×108/kg of recipent weight (median，6.87±2.93×108/kg). The number of CD34 cells determined by flow cytometry was (3.62-19.32)×106/kg (median，5.05±4.3×106/kg).Conditioning regimen(1) 14 patients received fludarabin 50 mg/d for 5 consecutive days (day 9 to 5 pre-transplan

27、tation)，anti-T lymphocyte globulin (ATG) 10 mg/(kg·d) for 4 consecutive days (day 7 to 4 pre-transplantation)，cyclophosphamide 30 mg/(kg·d) on day 4 to 3 pre-transplantation3; (2) 12 patients underwent melphalan/busulfan 2 mg/(kg·d) on day 8 to 5 pre-transplantation，ATG 10 mg/(kg·

28、;d) on days 7 to 4 pre-transplantation (24 patients received the products of Wuhan Institute of biological preparations，2 were treated with IMTIX-SANGSTAT made in France)，cyclophosphamide 30 mg/(kg·d) on day 4 to 3 pre-transplantation.Donor lymphocyte infusion (DLI)4-524 patients were eligible

29、for DLI given once every 4 weeks in graded incresments according to the chimeric formation and clinical reaction. Generally，the dose of the first infusion was 1×107/kg in 4th week post-transplantation. 2 patients underwent donor stem cell infusion (DSI，donors peripheral blood stem cell infusion

30、) also once every 4 weeks in graded incresments with first infusion of 1×107/kg. All patients need to be infused regularly for 2-3 times.Efficacy assay(1) Short tandem repeats (STRs) 6 assay was on day 10 and 28 post-transplant，followed once a month; (2) HLA-locus analysis; (3) bcr/abl fusion g

31、ene and Philadephia chromosome for CML patients bimonthly or trimonthly; (4) Sex chromosome; (5) ABO blood type.Follow-upPatients were regularly followed-up after transplantation to assess disease response and remission status. To November 2002，the follow-up time was 1 month to 30 months (

32、median，21 months). Up to now，13 patients are still in disease-free survival.ResultsSide effects of hematopoietic system and reconstitution of hematopoietic functionThe clinical data are listed in Table. The absolute neutrophil counts (ANC) of 26 patients post-transplantation decreased to 0.5，0.2 and

33、 0.1×109/L，respectively. The incidences of ANC approaching to zero were 69.23%，38.46%，57.69%，11.53% respectively. The median time was 6.39，7.20，7.27 and 7.67 days respectively. The incidence of platelet (Plt) constantly dropping to 20×109/L was 57.69% for 0-16 days. The ANC and Plt of 25 p

34、atients restored to 0.5 and 20×109/L from 15.5 and 20.57 days post-transplant respectively. Only a patient with CML-CP can not be restored and died of pulmonary infection.            作者：蘇麗萍，許蓮蓉，姜波，葉芳，朱秋娟，鹿育晉，崔月娥，朱鐳，張麗，馬香蘭【摘】為研究非清髓性異基因造

35、血干         本篇論文是由3COME文檔頻道的網(wǎng)友為您在網(wǎng)絡(luò)上收集整理餅投稿至本站的，論文版權(quán)屬原作者，請不用于商業(yè)用途或者抄襲，僅供參考學(xué)習(xí)之用，否者后果自負(fù)，如果此文侵犯您的合法權(quán)益，請聯(lián)系我們。    EngraftmentTwenty-two patients (84.62%) were engrafted，including CML-CP1 (n=10)，CML-CP2 (n=2)，ALL-CR1 (n=2)，M2a (n=2)，M4a-CR1 (n=l)，

36、M5a-CR1 (n=3)，MM (n=2)，who had donor-DNA from 20% to 100% detected by STRs on 1 month post-transplantation，with 18 patients being full donor chimerism (FDC) up to now. Of these patients，15 cases were HLA-matched (88.24%)，4 cases were single-locus mismatched (100%)，3 cases were two-loci-mismatched (7

37、5%). 4 patients failed to be engrafted，including ALL-CR1 (n=l) who was HLA-matched，CML-BC (n=l) who was also HLA-matched，M2a-CR2 (n=l) whose stem cells were donated by his father with three-loci mismatched，CML-CP1 (n=l) who was two-locus mismatched.GVHDAcute GVHD (aGVHD) occurred in 3 patients (1154

38、%)，including 1 patient diagnosed as CML-CP1 and performed by MAC preparative regimen，1 M2a-CR1    patient given FAC conditioning regimen and 1 MM patient received FAC conditioning regimen. The first case of aGVHD grade IV in liver occurred on day 30 after transplantation and reoc

39、curred on day 90 after a first DLI，then was controlled by high-dose methylprednisolone and developed chronic GVHD (cGVHD) grade on mucosa and skin. The second case of aGVHD grade on mucosa and skin occurred on day 60 after transplant. The last case of extensive exfoliative dermatitis (aGVHD grade IV

40、) occurred on day 55 Note:-represents pre-transplantation， represents post-transplantation.Table . Hematopoietic side-effects and reconsititution of 26 cases of hematological malignanies after-transplantation（略）after transplantation because of stopping oral CsA for 2 weeks. He responded promptly to

41、high-dose methyl-prednisolone，but died of progressive dyspnea after 24 hours. All three patients were HLA-matched，whose donors were females，in particular，the last two were 50 and 46 years old respectively. cGVHD occurred mainly on skin and mucosa in 6 patients (23.07%) composed of 2 transformed from

42、 aGVHD，CML-CP1 (n=1)，CML-CP2 (n=l)，M4a-CR1 (n=l) and B-ALL-CR1 (n=l)，out of which aGVHD of 1 patient occurred in liver and another in bulbar conjunctiva. Out of the last 4 patients，3 cases received FAC conditioning regimen and 1 MAC，3 cases were HLA-matched and 1 was single-locus mismatched，whose do

43、nors were 2 males and 2 females.Infectious complicationsStaphylococcus aureus infection occurred by catheter in 1 patient，pulmonary staphylococcus aureus infection occurred in 2，all the strains of staphylococcus aureus are sensitive to antibiotics and were controlled by them. One patient suffered fr

44、om frequent micturition，urgency of urination and urodynia，with severe hyperemia，edema，bladder contracture observed by cystoscopy and CMV negative in serum and urine. Fortunately，these symptoms were relieved by intravenous kenai and -globulin. Another patient died of asphyxia on 9 months post-transpl

45、antation because of slight interstitial pneumonia evidenced of thoracic CT with CMV negative in serum，urine，sputum but no sensitivity to kenai，ganciclovir and dasansu.TransfusionPlatelets less than 20×109/L did not occur in 11 patients who need no platelet transfusion.Complications of DLIOne pa

46、tient was rescued from acute dyshematopoiesis by cytokines after first DLI，and the other had aGVHD in liver after first DLI.DiscussionNonmyeloablative allogeneic hematopoietic stem cell transplantation (NST) is a novel method in an effort to cure hematological malignancies by reduced-intensity chemo

47、radiations，which have been designed to immunosuppress recipients immune responses and to permit allogineic hematopoietic stem cells engraftment but li-mited systemic toxicity，and by using immunosuppressants the post-transplants that form chimerism attain double immune tolerance between hosts and gra

48、fts and to induce graft versus tumor (GVT) effects to eradicate tumor cells in the hosts or genetically abnormal hematopoietic cells. Most scholars hold that GVT is the main mechanism of radically curing hematological malignancies following the evaluation on the effects of hematopoietic st

49、em cell transplantation for several decades. Therefore，NST is a brave and more rational reform than myeloablative transplantation on conditioning regimens that decrease hematopoisis toxicity but increase immunosuppressive effect. Furthermore，NST enhances immunotherapy during the whole transplant to

50、induce immune tolerance between donors and recipients and enhance the GVT effects.    Giralt et al1 firstly started the clinical study of NST in 1997 that consisted of various diseases，such as ALL，AML，CML，CLL，MM，lymphoma and MDS，and the subjects were elder，infirm and not eligible

51、 for conventional myeloablative HSCT. The results showed the higher engraftment and lighter side effects than that in myeloablative HSCT. In our study，12 patients with CML (86.70%)，2 patients with MM (100%) and 8 patients of AL (80%) were engrafted，suggesting that NST is also suitable for AL in stab

52、le phase as well as CML and AML in slow progression. Furthermore，NST is a safe and effective therapy for hematological malignancies especially for those in stable phase and advanced in years  or in poor performance status.           &#

53、160;作者：蘇麗萍，許蓮蓉，姜波，葉芳，朱秋娟，鹿育晉，崔月娥，朱鐳，張麗，馬香蘭【摘】為研究非清髓性異基因造血干         本篇論文是由3COME文檔頻道的網(wǎng)友為您在網(wǎng)絡(luò)上收集整理餅投稿至本站的，論文版權(quán)屬原作者，請不用于商業(yè)用途或者抄襲，僅供參考學(xué)習(xí)之用，否者后果自負(fù)，如果此文侵犯您的合法權(quán)益，請聯(lián)系我們。    Our study showed that (1) the engraftment of those in unstable status was lo

54、wer. 20 patients in stable phase，2 with CML-CP2 were all significantly engrafted (P=0.014); (2) the engraftment of those two-loci mismatched was as low as 75%. However，single locus mismatched had few effects on the engraftment that was 100% of engraftment as compared with HLA-matched patients (P=l.0

55、00，0.489，respectively); (3) the ages of donors and recipients had no apparent effect on the engraftment (P=1.000); (4) there was no significant difference in engraftment between the FAC groups and the MAC groups (P=0.306).    There was no remarkable variation in the incidence of

56、GVHD between two conditioning groups (P=0.391)，demonstrating that NST may reduce the difference on the occurrence of GVHD between different groups because of relative low toxicity of conditioning regimen. Three patients with aGVHD were HLA-matched whose donors were all females，which may correlate wi

57、th aGVHD (P=0.063). In addition，all these 3 patients were full donor chimerism for STRs on days 28 after transplantation，which may be one of the main reasons for the occurrence of aGVHD. The main influenced factors for GVHD in our study were not definite but the results at least showed that there was no significant association between GVHD and the ages of donors and recipients，sexes，performance status，the degree of HLA-matching.    The mixed transpla