A 16-year-old girl with refractory acute lymphoblastic leukemia underwent reduced-intensity hematopoietic stem cell transplantation from her ...
Bone Marrow Transplantation (2003) 31, 1061–1063 & 2003 Nature Publishing Group All rights reserved 0268-3369/03 $25.00
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Case report Successful T-cell-replete peripheral blood stem cell transplantation from HLA-haploidentical microchimeric mother to daughter with refractory acute lymphoblastic leukemia using reduced-intensity conditioning K Umeda1, S Adachi1, H Ishihara1, Y Higashi1, M Shiota1, K-I Watanabe1, M Hishizawa2, T Ichinohe2, T Kitoh3, E Maruya4, H Saji4, T Uchiyama2 and T Nakahata1 1 Department of Pediatrics, Graduate School of Medicine, Kyoto University, Japan; 2Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Japan; 3Department of Pediatrics, Shiga Medical Center for Children, Shiga, Japan; and 4HLA Laboratory, Kyoto, Japan
Summary: A 16-year-old girl with refractory acute lymphoblastic leukemia underwent reduced-intensity hematopoietic stem cell transplantation from her two-locus-mismatched haploidentical mother, who was microchimeric for the patient’s hematopoietic cells. The conditioning regimen comprised melphalan, fludarabine, and low-dose total body irradiation. Non-T-cell-depleted peripheral blood stem cells were infused with graft-versus-host disease (GVHD) prophylaxis consisting of tacrolimus, prednisolone, and short-course methotrexate. Complete donortype engraftment without evidence of residual leukemia was confirmed on day 22. Severe GVHD was not observed despite rapid cessation of immunosuppression. The patient remains well in continuous remission 15 months after transplant. This successful experience suggests that maternal hematopoietic stem cell transplants for children, in the presence of microchimerism, may be associated with hyporesponsiveness to the inherited paternal HLA antigens (IPA); preventing severe GVHD. Bone Marrow Transplantation (2003) 31, 1061–1063. doi:10.1038/sj.bmt.1704057 Keywords: acute lymphoblastic leukemia; long-term fetomaternal microchimerism; graft-versus-host disease; graftversus-leukemia effect
Recent studies have demonstrated the presence of minute amounts of fetal hematopoietic cells in the mother, and vice versa; ‘long-term feto-maternal microchimerism’.1 The persistence of bidirectional cell traffic has been confirmed through the detection of inherited paternal antigens (IPA) in peripheral blood of the mother and noninherited maternal antigens (NIMA) in the blood of the offspring.1 Solid organ transplantation studies have suggested that
Correspondence: Dr K Umeda, Department of Pediatrics, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan Received 15 September 2002; accepted 20 January 2003
allograft acceptance is favorably affected by immunotolerance to NIMA persisting even after birth.2,3 Recent reports, however, have questioned the feasibility of hematopoietic stem cell transplantation (HSCT) without T-cell depletion (TCD) from an HLA-mismatched mother or sibling in the presence of long-term feto-maternal microchimerism.4–6 We performed a successful blood stem cell allograft from a two-locus mismatched haploidentical mother based on long-term feto-maternal microchimerism in a patient with refractory acute lymphoblastic leukemia (ALL).
Case report The patient was a 16-year-old girl with ALL in third relapse that was chemorefractory. There was no HLA-identical sibling, and an unrelated umbilical cord blood unit with a sufficient number of nucleated cells could not be found. Owing to rapid disease progression, an unrelated donor could not be found. The patient and her mother were mismatched at two HLA loci (patient: HLA-A 31/33, -B 35/07, -C 1402/1403, -DR 0901/1302, and mother: HLA-A 31/33, -B 35/51, -C 1402/1403, -DR 0901/0101). Polymerase chain reaction with sequence-specific primer typing (PCR-SSP) demonstrated IPA in maternal peripheral whole blood. NIMA was not detected in the patient’s peripheral blood (Figure 1). The patient and her parents gave their written informed consent, approved by the ethical Committee of Kyoto University, for an unmanipulated blood cell allograft. White blood cell (WBC) was 32.0 109/l containing 100% blasts just before starting the conditioning regimen. The clinical course of allo-peripheral blood stem cell transplantation (PBSCT) is shown in Figure 2. As mild elevation of amylase (214 IU/l) and lipase (277 IU/l) levels occurred soon after starting the planned conditioning regimen, the patient received a modified, fractioned regimen to reduce regimen-related toxicity. The regimen consisted of 25 mg/m2 melphalan (L-PAM) on day 15 and 40 mg/m2 on days 10, 6 and 2. Fludarabine (Flu)
Allo-PBSCT from HLA haploidentical mother K Umeda et al
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band 9: Mother, Nested PCR, 10^-8 dil of 1st PCR product
7: Mother, usual SSP of HLA-B*07 (pos contr.)
8: Mother, Nested PCR, 10^-6 dil of 1st PCR product
6: Offspring, PB, Nested PCR, 10^-3 dil of 1st PCR product
5: Offspring, PB, Nested PCR, 10^-2 dil of 1st PCR product
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2: Mother, PB genome, SSP of HLA- B*51-(neg/contr.)
3: Mother, Nail, Nested PCR, 10^-2 dil of 1st PCR product (negative contr.)
1: Water (neg contr.)
Figure 1
Nested polymerase chain reaction sequence-specific primer typing (PCR-SSCP) demonstrated a long-term feto-maternal microchimerism in the patient and her mother. (a) An HLA-B51 (inherited paternal allele)-specific band was detected in the peripheral blood of the mother at a dilution of 102– 103 (lanes 5 and 6). (b) An HLA-B07 (noninherited maternal allele)-specific band was not detected in the peripheral blood of the patient (lanes 5 and 6). PCR ¼ polymerase chain reaction; SSP ¼ sequence-specific primer; PB ¼ peripheral blood.
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The clinical course of allo-PBSCT. l-PAM ¼ melphalan; Flu ¼ fludarabine; TBI ¼ total body irradiation; MTX ¼ methotrexate; FK506 ¼ tacrolims; PSL ¼ prednisolone; FFP ¼ fresh frozen plasma; RBC ¼ red blood cells; WBC ¼ white blood cells (circle); LDH ¼ lactic dehydrogenase (triangle).
Figure 2
was administered at 25 mg/m2/day from day 6 to day 2, while 4 Gy of total body irradiation (TBI) was given in two fractions on day 1. To prevent GVHD, the patient also received tacrolimus (FK506) at 0.03 mg/kg/day as a Bone Marrow Transplantation
continuous infusion from day 0, methotrexate 10 mg/m2 i.v. on day 1, and 5 mg/m2 on days 3 and 6, and 1 mg/kg/ day prednisolone (PSL) starting on day 11. In October 2001, the received 4.3 108 cryopreserved maternal PBSC,
Allo-PBSCT from HLA haploidentical mother K Umeda et al
containing 8.6 106 CD34+ cells and 3.8 108 CD3+ cells per kilogram body weight. The patient did not receive GCSF after allo-PBSCT. Hematological engraftment was prompt; the time for absolute neutrophil counts to reach more than 0.5 109/l was day 12, reticulocytes more than 10% was day 16, Plt more than 50 109/l was day 18. Complete chimerism in the bone marrow (BM) was confirmed by the short tandem repeat method on days 22 and 54. On day 28, the patient’s platelets levels were 12 103/l, becoming thrombocytopenia unresponsive to platelet transfusions thereafter. Although physical examinations did not show any related symptoms, a clinical diagnosis of thrombotic microangiopathy (TMA) was determined based on the elevated level of serum lactic dehydrogenase (LDH) and the presence of red blood cell fragmentation. Thus, dosages of FK506 and PSL were gradually reduced; fresh frozen plasma was given daily for a week starting on day 31, resulting in the overall improvement of the TMA. Although acute GVHD of the skin (stage 2) developed on day 33, it did not worsen after discontinuing treatment with FK506 and PSL on day 64. Chronic GVHD of the skin began at day 70 and progressed extensively thereafter. After restoring treatment with PSL at 1 mg/kg/day (day 80), the symptoms improved. RT-PCR analysis of BM demonstrated that clonal rearrangement of the IgH gene was not detected on days 22, 54, 90, 150, 240, and 360. Currently, the patient remains alive in the fourth complete remission (CR). Limited chronic GVHD of the skin alone has been observed in the absence of immuno-suppressive agents, 15 months after PBSCT.
Discussion We performed allo-PBSCT without TCD from an HLA two-loci mismatched mother based on long-term fetomaternal microchimerism on a patient with refractory ALL. Although the patient could not receive the planned intensive conditioning regimen, hematopoietic engraftment was prompt. A strong antileukemic effect was observed after the transplant. It is likely that the administered regimen was immunoablative enough to achieve donor cell engraftment despite the presence of HLA two-loci mismatches. This possibility is supported by reports detailing the combination of L-PAM and Flu as sufficiently immunosuppressive to allow allograft engraftment in nonmyeloablative HSCT.7 Alternatively, the patient’s acquired hyporesponsiveness to NIMA may have reduced alloreactivity against maternal antigens, facilitating the engraftment of maternal stem cells. Furthermore, despite HLA two-loci mismatches, no severe GVHD was observed even after the rapid cessation of immunosuppressive agents. These data support the concept that some postpartum mothers develop a persistent tolerance to offspring’s
antigens, which may be associated with long-term offspring-related microchimerism in the mother. The patient obtained CR on a genetic level as early as day 22, despite the reduced myelotoxicity of the conditioning regimen from levels normally necessary to eradicate multi-drug-resistant progressive disease. The rapid regression of chemoresistant disease was also reported in a case of CML in blast crisis after HSCT from an HLA-haploidentical mother with long-term fetomaternal microchimerism.6 This case strengthens the hypothesis that the persistence of immunotolerance to IPA has a beneficial inhibitory effect on GVHD following blood stem cell transplants from microchimeric mothers. A prospective study will be needed to elucidate the role of long-term fetal cell microchimerism in selecting an HLA-haploidentical mother as an alternative donor for hematopoietic stem cell transplantation.
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Acknowledgements We thank Dr Yuichi Akiyama (Department of Pediatrics, Kyoto National Hospital) for valuable suggestions regarding our patient.
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