目的 探讨CD19嵌合抗原受体T(CD19-CAR-T)细胞治疗复发/难治急性B淋巴细胞白血病(R/R B-ALL)的疗效及并发症.方法 回顾性分析2016年1月至2018年1月14例接受CD19-CAR-T细胞治疗的R/R B-ALL患者的临床资料.监测CD19-CAR-T细胞回输后细胞因子水平(IFN-γ、TNF-α、IL-6、IL-8、IL-10、IL-17A、IL-18)以及C反应蛋白和铁蛋白水平,观察近期和远期疗效及细胞因子释放综合征(CRS)的发生情况.结果 14例患者回输CD19-CAR-T细胞总量的中位数为0.6×106/kg.13例患者可进行d28疗效评价,获完全缓解7例,部分缓解2例,无效4例,有效率为92.3％.体内CD19-CAR-T细胞数在d10～d21达到高峰,在d90时能检测到较低水平的CD19-CAR-T细胞.全组中位总生存时间(OS)为10.2个月.14例患者均出现CRS,其中1级2例,2级6例,3级3例,4级2例,5级1例.CRS发生时,IL-6、IFN-γ、IL-10、C反应蛋白和铁蛋白水平明显升高.14例患者均出现发热,出现肝功能异常9例、心血管功能障碍3例、肾功能异常3例、胰腺炎1例、神经毒性7例以及呼吸衰竭2例.结论 CD19-CAR-T细胞治疗R/R B-ALL的近期疗效较好,但是CD19-CAR-T细胞体内维持时间短,早期容易复发.IL-6、IFN-γ、IL-10、C反应蛋白和铁蛋白水平升高有助于CRS的诊断.

目前,初治急性早幼粒细胞白血病(APL)诱导治疗后完全缓解率已超过90％[1-3],缓解后仍需进行巩固和维持治疗,否则容易复发.传统的巩固和维持治疗包括以蒽环类药物为主的联合化疗,但是化疗存在短期及长期的治疗毒性,如感染、心力衰竭及诱发第二肿瘤等[4-5],影响患者的生活质量,增加其经济负担.本研究纳入80例达完全分子学缓解后的初诊APL患者,将其分为三氧化二砷(As2 O3 )和全反式维A酸(ATRA)交替序贯维持治疗组(无化疗组)与As2 O3、ATRA和化疗交替序贯维持治疗组(化疗组),比较两组的长期生存率、并发症、平均每次住院经济花费等,现将结果报道如下.

目的 观察以地西他滨为基础的低强度化疗对青中年难治/复发性急性髓系白血病(RR-AML)的临床疗效.方法 分析78例接受以地西他滨为基础的低强度化疗治疗(观察组)的青中年RR-AML患者和50例接受中剂量以阿糖胞苷为基础的高强度化疗治疗(对照组)的青中年RR-AML患者的临床资料并随访.结果 (1)观察组完全缓解率为76.9％,对照组完全缓解率为52.0％,两组差异有统计学意义(P=0.003).(2)在不良反应方面,观察组较对照组中粒细胞缺乏的中位持续时间和血小板<20×109·L-1的中位持续时间更短,胃肠道反应(如恶心、呕吐、便秘等)、皮肤黏膜损伤(如皮疹、黏膜充血等)方面更轻,两组差异有统计学意义(P<0.05),其他方面的不良反应两组差异无统计学意义(P>0.05).结论 (1)对青中年RR-AML患者来说,以地西他滨为基础的低强度化疗效果要优于以中剂量阿糖胞苷为基础的高强度化疗.(2)对青中年RR-AML患者来说,接受以地西他滨为基础的低强度化疗的不良反应在某些方面要小于接受以中剂量阿糖胞苷为基础的高强度化疗.

Objective To study the changes of programmed death factor-1/programmed death factor-1 ligand（ PD-1/PD-L1）in patients with myelodysplastic syndrome（ MDS） before and after using decitabine（ DAC）. Methods From Jan 2016 to Jan 2017,18 cases newly diagnosed as MDS with WHO 2008 type WPSS prognostic stratification in middle-risk group and high-risk group were enrolled. Patients were applied with DAC（ 20 mg/m;d;-d;,21-28 days as a cycle） for 2 cycles. Five patients with non-malignant hematologic diseases were treated as control. Peripheral blood and bone marrow cells were collected before and after DAC application for 2 cycles. FCM was used to determine PD-1 of CD3+CD4+T and CD3+CD8+T cells in peripheral blood lymphocytes and PD-L1 in bone marrow progenitor cells before and after treatment with DAC. The relative expression of PD-1 mRNA and PD-L1 mRNA in peripheral blood and bone marrow mononuclear cells before and after DAC treatment was detected by QPCR. PD-1/PD-L1 level was compared between remission group（ n = 5） and non-remission group（ n = 13）. Results FCM analysis showed that the proportion of PD-1 of CD3+CD4+T and CD3+CD8+T lymphocytes,and PD-L1 of bone marrow monounclear cells in middle-risk group after DAC treatment was（ 11. 43±1. 88） %,（ 11. 46±1. 60） % and（ 16. 59±0. 72） %,and the data in high-risk group after treatment were（ 16. 36±3. 71） %,（ 16. 59±3. 81） % and（ 18. 69±1. 60） %,all higher than those before treatment and those of control group（ P<0. 05）. The proportion of PD-1 of CD3+CD4 + T and CD3 + CD8 + T lymphocytes,and PD-L1 of bone marrow mononuclear cells in non-remission group was（ 18. 51±2. 62） %,（ 19. 03±2. 18） % and（ 19. 22±1. 40） %,higher than those in remission group（ P<0. 05）. QPCR analysis showed that after DAC treatment the relative expression of PD-1 mRNA in peripheral blood and PD-L1 mRNA in bone marrow mononuclear cells of middle-risk group was 6. 32±3. 37 and 2. 88±1. 72,and they were 12. 55±6. 27 and 7. 47±4. 90 in high risk group,higher than those before treatment（ P<0. 05）. The relative expression of PD-1 mRNA of peripheral blood mononuclear cells and PD-L1 mRNA of bone marrow mononuclear cells in non-remission group was 16. 28±4. 64 and 9. 16± 5. 40,significantly higher than those in remission group（ P<0. 05）. Conclusion After treatment with DAC,the expression of PD-1/PD-L1 in peripheral blood and bone marrow of MDS middle-risk,high-risk patients increased significantly,especially in non-remission group. High expression of PD-1/PD-L1 may be one of the reasons leading to drug resistance of DAC.

Objective To compare the efficacies of different doses of decitabine sequential low-dose chemotherapies in the treatment of acute myeloid leukemia（AML）.Methods A retrospective analysis of 65 patients with AML treated with different doses of decitabine sequential low-dose chemotherapies was performed.All patients were divided into Group A（20 mg/m;× 5 d） and Group B（20 mg/m;× 3 d）.The remission rate of the two groups was compared.Results In the Group A,32 of 37 patients had complete remission,the complete remission rate was 86.5%.In the Group B,18 of 28 patients had complete remission,and the complete remission rate was 64.3%.The difference between the two groups was statistically significant（P = 0.035）.Compared group A with group B,the median durations of platelet< 20 × 109·L;and leukocytes < 0.5 × 109·L; were no significant difference（P > 0.05）.Other treatment-related adverse events in patients of groups A and B were predominantly infections（pulmonary infections and bloodstream infections）.Other adverse reactions were more frequent with fatigue,constipation,loss of appetite.Infections of these patients were controlled by anti-infective therapy.There were no deaths in both groups,and there was no significant difference in adverse reactions between the two groups（P > 0.05）.Conclusion In the treatment of AML,decitabine 20 mg/m2× 5 days sequential low-dose chemotherapy may be better.

>患者,男性,54岁。主因"齿龈、皮肤出血、发热7 d"于2012年1月2日入院。查体:贫血貌,全身皮肤黏膜可见散在出血点及瘀斑,齿龈出血,心肺听诊未见异常,腹软,肝脾肋缘下未及。入院查血常规:WBC 8×10～9/L,HGB 90 g/L,PLT 10×10～9/L,RBC 2.5×10 12 /L;外周血涂片示早幼粒细胞占0.73;骨髓象:有核细胞增生活跃,异常早幼粒细胞占0.901,

Objective:To study the influence of chloroquine combined with decitabine in the apoptosis of leukemia K562 cells and KG-1a1Aor1a cells,to explore the effect of autophagy on the leukemia cell apoptosis induced by decitabine,and to clarify its mechanism.Methods:The leukemia K562 and KG-1a1Aor1a cells were cultivated in vitro and divided into blank control group,decitabine group (10 μmol · L 1) and chloroquine (50 μmol · L 1) combined with decitabine group (combined group).The leukemia cells in combined group were pre-treated with chloroquine for 6 h before experiment.After treatment with drugs for 24 and 48 h,the number of cells was detected and by CCK-8 method the inhibitory rates of proliferation cells were calculated;the apoptotic rates and mitochondrial membrane potential were detected by flow cytometry.Q-PCR method was carried out to determine the gene expression levels of Atg7 and Atg12,and Western blotting was used to test the protein expression of LC3.Results:After treatment for 24 and 48 h,the number of K562 and KG-1a1Aor1a cells in decitabine group and combined group were decreased compared with blank control group (P＜0.05 or P＜0.01);the apoptotic rates and mitochondrial membrane potential were remarkably increased (P＜0.05 or P＜0.01).Compared with decitabine group,the number of K562 and KG-1a1Aor1a in combined group was significantly decreased,and the apoptotic rates were remarkably increased (P＜0.05).After treatment for 24 h,the expression levels of Atg7,Atg12 and LC3-Ⅱ/LC3-Ⅰ in the leukemia K562 and KG-1a1Aor1a cells in decitabine group were significantly increased compared with blank control group (P＜0.05 or P＜0.01);the expression levels of Atg7,Atg12 and LC3-Ⅱ/LC3-Ⅰ in the leukemia K562 and KG-1a1Aor1a cells in combined group were significantly decreased compared with decitabine group (P＜0.05 or P＜0.01).Conclusion:Decitabine could promote the apoptosis of leukemia cells,and the inhibition of autophagy by chloroquine can promote the apoptosis induced by decitabine.

Objective:To observe the effects of allogeneic compact bone derived-mesenchymal stem cells(CB-MSCs)on proliferation and differentiation of T cells,and investigate the molecular mechanisms of the immunosuppressive ability.Methods:With an established co-culture system of CB-MSCs and mouse spleen lymphocytes(SP)in vitro,we observed the effects of CB-MSCs on proliferation,apoptosis and cell cycle of SP by MTS/PES assay and flow cytometry.Also,we measured the effects of CB-MSCs on regulatory T cells(Treg)ratio and expressions of CCR5,CCR7 and CXCR3 in SP.Results:CB-MSCs could obviously inhibit the PHA-stimulated SP proliferation with a dose-dependent manner;MSCs could significantly inhibit the spontaneous apoptosis of SP and induce SP cell cycle G0/G1 phase arrest.After co-culture with SP,CB-MSCs could obviously increase the proportion of Treg in SP,down-regulate the expression of CXCR3 and CCR5,as well as up-regulate the expression of CCR7.Conclusion:Allogeneic CB-MSCs can significantly inhibit cell proliferation of SP,the mechanisms mainly involved the G0/G1 cell cycle arrest rather than apoptosis induction.In addition,CB-MSCs can exert immunomodulatory effects by increasing the Treg ratio,regulating the expressions of chemokine receptors.

The research advances of myeloid neoplasms in 2015 will be introduced,such as new molecularly targeted therapies for acute myeloid leukemia(AML),reclassifying myelodysplastic syndromes(MDS),precise diagnosis and risk assessment of MDS,novel therapeutic approaches of MDS,refining risk stratification and treatment strategy in primary myelofibrosis.

BACKGROUND The aim of this study was to evaluate the efficiency, adverse effects, and pharmacoeconomic impact of empirical and preemptive antifungal therapy for febrile neutropenic hematological malignancy patients in China. MATERIAL AND METHODS Patients with febrile neutropenia during hematological malignancy were randomly divided into an empirical group and a preemptive group. The preemptive antifungal treatment was initiated if patient status was confirmed by clinical manifestation, imaging diagnosis, 1-3-β-D glucan(G) testing, and galactomannan (GM) test. The treatment was ended 2 weeks later if the patient was recovered from neutropenia. Voriconazole was used as the first-line medicine. All patients received intravenous administration of voriconazole every 12 h, with an initiating dose of 400 mg, then the dose was reduced to 200 mg. RESULTS The overall survival rate was 97.1% and 94.6% in the empirical group and preemptive group, respectively, with no significant difference observed (χ²=1.051, P=0.305). However, the occurrence rate of invasive fungal disease (IFD) in the preemptive group was 9.2% vs. 2.2% in the empirical group. Moreover, the mortality rate due to IFD was 0.7% and 2.3% for the empirical group and preemptive group, respectively. The average duration and cost of preemptive antifungal therapy were 13.8±4.7 days and 8379.00±2253.00 RMB, respectively, which were lower than for empirical therapy. However, no significant differences were observed for incidence of adverse effects and hospital stay between the 2 groups. CONCLUSIONS Preemptive antifungal therapy for patients with febrile neutropenic hematological malignancy demonstrated a similar survival rate as with empirical therapy but is economically favorable in a Chinese population.

Objective: To evaluate the therapeutic efficacy and safty of decitabine alone or in combination with pre-excitation regimen in the treatment for patients with myelodysplastic syndrome (MDS)/acute myeloid leukemia (AML).Methods: The therapeutic efficacy and safty of decitabine alone or in combination with pre-excitation regimen in the treatment for 18 patients with MDS/AML were retrospectively analyzed.Results: Of the 18 patients, 12 patients achieved complete remission, 2 patients achieved marrow complete remission, and the overall response rate was 77.8% (14/18). The infection emerged in 15 patients (83.3%, 15/18); only one patient died of chemotherapy-related infection (5.6%, 1/18).Conclusion: The remission rate of patients with MDS/AML receiving decitabine alone or in combination with pre-excitation regimen was high, and the adverse effects can be accepted. DOI: 10.3781/j.issn.1000-7431.2015.33.858

The introduction focuses at the diagnostic criteria and treatment principle of relapsed/refractory acute myeloid leukemia(AML).Here discuss the usual combined chemotherapy regimens.The clinical characteristics and therapy strategies of FLT3-ITD positive AML and AML of older patients are summarized simultaneously.

Purpose: Our study was to detect the effect of Decitabine (DAC) combined with arsenic trioxide (AS2O3) on DAPK gene and HL-60 cell proliferation and apoptosis. Methods: DAC and AS2O3 monotherapy, combination treatment and DAC pretreatment were used in this study after incubating with HL-60 cell for 24 h, 48 h, 72 h. CCK8 was used to detect the cell proliferation of HL-60 cell. Flow cytometry was used to detect the cell apoptosis. Then, we used RT-PCR to obtain the gene expression level of DAPK. Results: HL-60 cells were treated with different concentrations of DAC (20 μmol/L, 40 μmol/L, 80 μmol/L), AS2O3 (1 μmol/L, 2.5 μmol/L, 5 μmol/L) monotherapy for 24 h, 48 h, 72 h; along with the extension of the drug concentration and time, proliferation inhibition rate had gradually increased. Monotherapy of DAC, AS2O3 could inhibit the proliferation and induce apoptosis of HL-60 cells, and was time- and dose-dependent. DAC (80 μmol/L) was firstly used for pretreatment, and then, different concentrations of AS2O3 (1 μmol/L, 2.5 μmol/L, 5 μmol/L) were used for 24 h, 48 h, 72 h. It was found that cell proliferation inhibition rate and apoptosis rate had increased significantly. When the two drugs were used together, the increasing proliferation inhibition rate, apoptosis rate and DAPK had become more obvious. Conclusion: DAC and AS2O3 had a synergetic effect for the HL-60 cell proliferation inhibition, apoptosis and expression of DAPK.

免疫性血小板减少性紫癜(immune thrombocytopenic purpura, ITP)是临床上最常见的出血性疾病之一,现就循证医学指南和国际共识会的信息综述如下. 1 规范成人ITP命名、定义和疗效标准 欧洲血液学会血小板减少性紫癜学术工作组(EHASNGT)于2007年10月在意大利的Vicenza召开专家组对成人和儿童ITP的命名、定义、疗效标准的研讨会,简称Vicenza共识会[1,2].并以国际工作组的名誉撰文发表.

Objective To construct a DC-CIK(cytokine-induced killer cell) co-culture system using peripheral blood mononuclear cells(PBMCs) derived-DC from hematopoietic stem cell transplantation(HSCT) patients with post-transplant lympholiferative disorder(PTLD) after pulsed with EBV-special peptides,so as to lay a foundation for new adoptive immunotherapy of patients with PLTD after HSCT.Methods: PBMCs were obtained from patients with PTLD after HSCT;DC was induced from adherent cells;and CIK was induced from suspension cells.DC was further pulsed with EBV-special peptides and co-cultured with CIK to establish the DC-CIK co-culture system;the immunophenotype of cells in DC-CIK system before and after co-culture were determined by FACS,IFN-γ secretion was assayed by ELISA,and TCRβ genealogy was examined by genetic analyzer.Results: The ratio of HLA-DR+CD86+DC increased from 12.5% to 91.17% after cytokine stimulation.After co-culture with DC for 14 d,the numbers of CIK in two patients with PTLD increased to 5.3 and 6.8 times,respectively.The ratios of CD3+,CD8+,CD3+CD8+,and CD3+CD56+ cells were significantly increased after DC-CIK co-culture.IFN-γ level in peptide-pulsed DC-CIK group was significantly higher than that in peptide-unpulsed DC-CIK group([1 332.6±92.38] pg/ml vs [693.42±62.41] pg/ml,P0.05]);TCRβ genealogy assay found the clone expansion peak of 5.2 TCRβ subfamily in DC-CIK co-culture system.Conclusion: EBV peptide-pulsed DC can induce CD3+CD8+ and CD3+CD56+ cell expansion in DC-CIK co-culture system with high level of IFN-γ.DC-CIK can be used as a new adoptive immunotherapy to HSCT patients with EBV infection and PTLD.

<正>骨髓增殖性疾病(MPD)主要包括真性红细胞增多症(PV)、原发性血小板增多症(ET)、原发性骨髓纤维化(IMF)等疾病,以一系或多系血细胞的过度增多为临床表现[1]。近来国内外的病例报道显示,在这些患者中会出现假性高血钾的情况。本文报道4例出现假