Blood, 15 April 2003, Vol. 101, No. 8, pp. 3334-3336
TRANSPLANTATION
Brief report
Non-T-cell-depleted HLA haploidentical stem cell
transplantation in advanced hematologic malignancies based on the
feto-maternal michrochimerism
Chihiro Shimazaki,
Naoya Ochiai,
Ryo Uchida,
Akira Okano,
Shin-ichi Fuchida,
Eishi Ashihara,
Tohru Inaba,
Naohisa Fujita,
Etsuko Maruya, and
Masao Nakagawa
From the Second Department of Medicine, Kyoto
Prefectural University of Medicine, Japan, and the HLA
Laboratory, Kyoto, Japan.
 |
Abstract |
Feto-maternal microchimerism suggests that immunologic tolerance
exists between mother and fetus. Based on this hypothesis, we performed
haploidentical stem cell transplantation (SCT) without T-cell depletion
(TCD) in 5 patients with advanced hematologic malignancies. HLA
incompatibilities for graft-versus-host disease (GVHD) direction
included 3-loci mismatches in 4 patients, and 2-loci mismatches in one
patient. Recipient chimeric cells were detected in all patients. The
prophylaxis against GVHD was tacrolimus with minidose methotrexate.
Engraftment was obtained in all patients. An acute GVHD of less than or
equal to grade 2 developed in all patients except one who developed
tacrolimus encephalopathy. Two patients died, 1 from fungal
pneumonia and 1 from disease progression. The other 3 patients
survived, with one patient in complete remission. These observations
suggest that haploidentical SCT based on the feto-maternal
microchimerism without TCD is possible.
(Blood. 2003;101:3334-3336)
© 2003 by The American Society of Hematology.
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Introduction |
The presence of fetal hematopoietic cells in the
maternal blood and vice versa, which is called feto-maternal
microchimerism, suggests that immunologic tolerance exists between
mother and offspring.1 The role of feto-maternal
immunologic tolerance in allogeneic stem cell transplantation (SCT) was
recently demonstrated.2-4 Maternal stem cell donation was
found to be better for SCT than paternal donation, based on the results
of a nationwide SCT survey conducted in Japan.2 Van Rood
et al3 also showed that the recipients of
non-T-cell-depleted (TCD) maternal transplants had a significantly
lower incidence of chronic graft-versus-host disease (GVHD) than the
recipients of paternal transplants in haploidentical 1- or
2-antigen-mismatched transplantations. They also demonstrated a lower
rate of acute GVHD in sibling transplantations mismatched for
noninherited maternal antigens (NIMAs) compared with those mismatched
for noninherited paternal antigens (NIPAs). NIMA-mismatched sibling
donor and recipient share the inherited paternal antigens (IPAs) and
are mismatched at the maternal antigens, but there are microchimeric
cells expressing the NIMAs. These observations support the
hypothesis that offspring may be tolerant to haploidentical relatives
expressing NIMAs (mother or NIMA-mismatched siblings), and the
microchimeric mother may be hyporesponsive to IPAs of the
offspring.5 Recently, we successfully treated a patient with blast crisis of chronic myelogenous leukemia (CML) by
transplanting a haploidentical 3-loci mismatched maternal graft without
TCD.4 This prompted us to conduct a clinical trial of
non-TCD haploidentical 2- or 3-loci-mismatched SCT from mothers to
their offspring and vice versa, and from NIMA-mismatched siblings of
patients with advanced hematologic malignancies who lack HLA-matched donors.
| |
Study design |
This study included 5 patients with hematologic
malignancies; patient characteristics are shown in Table
1. All patients had no available
HLA-matched donors in family members, unrelated bone marrow, and cord
blood banks. Donors were selected from healthy haploidentical family
members who mutually linked with feto-maternal microchimerism,
including mothers in 3 patients, 2 offspring in one patient, and 2 NIMA-mismatched siblings in one patient. HLA incompatibilities for GVHD
direction included 3-loci mismatches in 4 patients, and 2-loci
mismatches in one patient. The conditioning regimen consisted of 1 g/m2 to 2 g/m2 of cytarabine (CA) twice on
day 
6 and once a day on day 5 and day 4, 50 mg/kg to 60 mg/kg of
cyclophosphamide (CY) on day 4 and day 3, and total body
irradiation of 2.0 Gy to 2.5 Gy twice on day 2 and day 1 in 4 patients, or 4 mg/kg of busulfan (BU) on day 6 to day 3 and 60 mg/kg of CY on day 2 and day 1 in one patient (Table
2). The GVHD prophylaxis consisted of
0.02 mg/kg per day of tacrolimus administered intravenously, and
minidose methotrexate (5 mg/m2 administered intravenously
on days 1, 3, and 6).6 After obtaining consent from the
ethical committee of Kyoto Prefectural University of Medicine and
written informed consent from the patients and donors, the donors were
given filgrastim at a dose of 300 µg/m2 subcutaneously
for 5 days. Peripheral blood stem cells (PBSCs) were collected from day
4 to day 6 using a continuous blood cell separator (CS3000; Fenwal,
Deerfield, IL).
An HLA-nested polymerase chain reaction with sequence-specific primer
typing (PCR-SSP) was used to detect chimeric cells.4,7,8 Briefly, genomic DNA was obtained from peripheral blood and fingernail clippings from patients and donors. Nail DNA was used as a nonblood DNA
control. The first PCR was performed with 500 ng DNA using the
appropriate locus-specific primer for the target HLA antigen. For the
second PCR, the target allele-specific primers were utilized. Estimates of the original cell concentration were based on a
comparison between the bands of the 1 × 102-fold
dilution of the first PCR product with the band produced by the
positive control at 1 × 106- and 108-fold
dilutions.7,8
| |
Results and discussion |
An HLA-nested PCR-SSP demonstrated the presence of the IPAs of the
patient in the peripheral blood of the mother (cases 1, 3, and 5), and
detected NIMA in the peripheral blood of the donor (cases 2 and 4),
suggesting that immunologic tolerance to the recipient cells exists
(Table 1). One of 2 offspring (a daughter) and one of 2 NIMA-mismatched
siblings (a brother) were accepted to become a donor in cases 2 and 4, respectively. The median number of CD34+ cells infused was
2.36 × 106/kg (1.26 × 106/kg to
3.57 × 106/kg). The hematopoietic recovery was rapid
with an absolute neutrophil count of more than
0.5 × 109/L and a platelet count more than
20 × 109/L obtained on days 14 (range, 10-18 days) and
15 (range, 13-21 days), respectively. All patients were full donor
chimera on day 30, examined by analyzing microsatellite polymorphism in
the donor and recipient. Acute GVHD of grade 3 developed in one patient (case 3) who developed tacrolimus encephalopathy, but it was controlled by prednisolone and cyclosporine administration. In the other 4 patients, acute GVHD of less than or equal to grade 2 developed, but
subsided promptly following prednisolone administration. Chronic GVHD
developed in 2 of 4 evaluable patients. Bronchiolitis obliterans organizing pneumonia (BOOP) was effectively treated with prednisolone in 2 patients. Cytomegalovirus antigenemia without symptoms developed in 4 patients. Complete or partial remission was obtained in 4 patients, but 2 patients relapsed at extramedullary sites such as the testis and pericardium on day 153 and day 88, respectively. One
patient died with fungal pneumonia on day 67, and another patient died
with disease progression on day 117. There were 3 patients who
survived, with one patient being in complete remission (Table
2).
These observations suggest that haploidentical SCT from mother to
offspring and vice versa, or from NIMA-mismatched siblings without TCD
or CD34+ cell selection is possible. Sustained engraftment
and the lack of severe GVHD in all patients except one suggests that
immunologic tolerance to NIMA (cases 2 and 4) or IPA (cases 1, 3, and
5) exists, because the risk of graft failure and severe GVHD is more
than 10% and 80%, respectively, if TCD is not performed in
haploidentical SCT.9,10 The only method of determining
immunologic tolerance is by the detection of microchimeric cells. To do
this, we used PCR-SSP that detected these cells with an accuracy of one
in 105 cells.4,7,8 Using this method, Maruya
et al demonstrated persistent chimeric mother cells in 66% of the 76 individuals and offspring cells in 82% of the 56 mothers.8 It is uncertain whether microchimerism is an
indicator of immune tolerance for successful transplantation.
Megadose of highly purified CD34+ SCT after high-dose
conditioning is another approach to overcome the HLA barrier in
haploidentical SCT; it diminished the risk of graft failure and
severe GVHD.11,12 However, high infection-related
mortality rates due to delayed immune reconstitution is still a
problem, especially in advanced-stage disease. Unfortunately, we did
not examine the immune recovery in detail; the risk of viral infection
in this study is lower than that reported in TCD or CD34+
cell-selected SCT.11-13 It is a concern because tolerance
to specific antigens might make relapse more likely.
In spite of the expansion of bone marrow and cord blood banking
systems, a significant number of patients lack matched donors. Non-TCD
haploidentical SCT based on feto-maternal microchimerism provides
patients with hematologic malignancies who lack an HLA-identical donor
another chance of receiving SCT. A prospective study is required to
establish this technique.
| |
Acknowledgments |
We thank Dr Hiroh Saji (HLA Laboratory, Kyoto, Japan) for pursing
HLA PCR-SSP to detect feto-maternal microchimerism, and for providing
useful discussion.
| |
Footnotes |
Submitted September 24, 2002; accepted December 2, 2002.
Prepublished
online as Blood First Edition Paper, December 12, 2002; DOI
10.1182/ blood-2002-09-2883.
The publication costs of this
article were defrayed in part by
page charge payment. Therefore,
and solely to indicate this fact,
this article is hereby marked
"advertisement"
in accordance with 18 U.S.C.
section 1734.
Reprints: Chihiro Shimazaki, Second Department of
Medicine, Kyoto Prefectural University of Medicine, 465 Kajii-cho,
Kawaramachi-Hirokoji, Kamigyoku, Kyoto, 602-8566, Japan; e-mail:
simazaki{at}koto.kpu-m.ac.jp.
| |
References |
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Abstract
Introduction
