Wharton’s jelly mesenchymal stem cells (WJ-MSCs) are a class of stem cells with high differentiative potential, an immuno-privileged status and easy access for collection, which raise no legal or ethical issues. WJ-MSCs exhibit several features of embryonic stem cells, both in the phenotypic and genetic aspects, with only a few differences, such as a shorter doubling time and a more extensive ex vivo expansion capacity. WJ-MSCs have immunomodulatory properties, involving both innate and adaptive immune responses. This review focuses on the role of WJ-MSCs in the management of graft-versus-host disease (GvHD), a life-threatening complication of the allogenic transplantation of hematopoietic stem cells. Different studies documented the beneficial effect of the infusion of WJ-MSCs, even when not fully HLA identical, in patients with severe GvHD, refractory to standard treatment. Finally, we summarized current ongoing clinical trials with WJ-MSCs and their potential in regenerative medicine.

In 1963 George Mathé announced to the world that he had cured a patient of leukaemia by means of a bone-marrow transplant. Since than much progress has been made and nowadays Hematopoietic Stem Cell Transplantation (HSCT) is considered the most effective treatment of numerous severe haematological diseases. Gynaecological complications in HSCT women represent a serious concern for these patients, but often underestimated by clinicians in the view of Overall Survival. The main gynaecological complications of HSCT are represented by: premature ovarian failure (POF), thrombocytopenia-associated menorrhagia, genital symptoms or sexual problems in course of chronic GVHD (cGVHD), osteoporosis, secondary solid tumours due to immunosuppressive drugs to treat cGVHD and severity of cGVHD, and fertility and pregnancy issues. In particular fertility-related issues are always more relevant for patients, whose life expectation is constantly growing up after HSCT.Thus, taking care of a patient undergoing HSCT should primarily include gynaecological evaluation, even before conditioning regimen or chemotherapy for the underlying malignancy, as, in our opinion, it is of great importance to ensure a complete diagnostic work-up and intervention options to guarantee maximum reproductive health and a better quality of life in HSCT women.The present review aims at describing principal features of the aforementioned gynaecological complications of HSCT, and to define, on the basis of current international literature, a specific protocol for the prevention, diagnosis, management and follow-up of gynaecological complications of both autologous and heterologous transplantation, before and after the procedure.

Intraparotid spindle cell lipoma (SCL) of the salivary gland is a rare entity. Review of the literature revealed only two previous reports describing its cytological features. We report a case of a 44-year-old man who complained for a slowly growing, asymptomatic mass in the left parotid gland that since 12 months. Fine needle aspiration biopsy (FNAB) showed a loose collections of bland-appearing spindle cells in a myxoid background admixed with capillary fragments and some mature fat cells suggesting a diagnosis of SCL. A cytological diagnosis of mesenchymal myxoid spindle cell tumor with lipomatous differentiation, possibly an intraparotideal SCL was performed. Histological examination of the mass and the positive immunostaining for CD34 and negativity for S-100, CK-cocktail, and actin confirmed the diagnosis of SCL. The diagnosis of intraparotid SCL can be made by examining cytologic material containing mature fat with bland spindle cells in a myxoid background. FNAB diagnosis on SCL also allows to rule out other primary salivary gland tumors that may be clinically and instrumentally indistinguishable and thereby permits an appropriate surgical procedure to ensue.

AbstractThe management of older patients with chronic primary immune thrombocytopenia (ITP) is still very challenging because of the fragility of older patients who frequently have severe comorbidities and/or disabilities. Corticosteroid-based first-line therapies fail in most of the cases and patients require a second-line treatment, choosing between rituximab, thrombopoietin-receptor agonists and splenectomy. The choice of the best treatment in elderly patients is a compromise between effectiveness and safety and laparoscopic splenectomy may be a good option with a complete remission rate of 67% at 60 months. But relapse and complication rates remain higher than in younger splenectomized ITP patients because elderly patients undergo splenectomy with unfavorable conditions (age >60 year-old, presence of comorbidities, or multiple previous treatments) which negatively influence the outcome, regardless the hematological response. For these reasons, a good management of concomitant diseases and the option to not use the splenectomy as the last possible treatment could improve the outcome of old splenectomized patients.

Cytomegalovirus (CMV) reactivation is one of the most frequent complication after hematopoietic stem cell transplantation (HSCT). Pre-transplant CMV-positive recipient serostatus is the most significant independent variable for viral reactivation. Oral valgancyclovir (VGCV) is a prodrug of intravenous gancyclovir (GCV) and is an effective and safety alternative for the management of CMV reactivation prophylaxis and preemptive therapy. However, VGCV at standard dose (900 mg twice a day) increases risk of myelosuppression in HSCT recipients. The efficacy of low dose (LD, 450 mg daily) oral VGCV was retrospectively evaluated in 30 allogeneic HLA-matched related patients and 2 unrelated, with a median age of 40 years (range, 18-59) and a median follow-up of 30 months (range, 3-56). Primary diseases were acute myeloid leukemia (AML, n=19), acute lymphoblastic leukemia (n=4), non-Hodgkin’s lymphoma (n=3), multiple myeloma (n=3) and myelodysplastic syndrome (n=3). Seventeen of twenty-three acute leukemia (AL) patients were transplanted in first complete remission (CR), while the remaining (n=6) were transplanted in 2nd CR. Five patients suffered from AML secondary to long-lasting MDS (n=3) or Hodgkin disease and breast cancer (n=2). Based upon CMV serostatus (D/R, donor/recipient), thirty (94%) of HSCT recipients were classified as high risk (D-/R+ = 3 and D+/R+ = 27) for CMV reactivation and only 6% as low risk (D-/R- = 2); none of the patients was in the intermediate risk group (D+/R-). Fifteen and 17 patients received a myeloablative and RIC regimens, respectively. Twenty-one patients received GvHD prophylaxis with cyclosporin A (CsA, 1 mg/kg intravenously from day -1 to +21, then 8 mg/kg orally for at least 6 months) and short-course methotrexate (MTX, 10 mg/kg on days +1, +3, +6 and +11). The others (n=11) received CsA with MTX and antithymocyte globulin (ATG, as a part of the conditioning regimen at 10 mg/kg at days -3, -2 and -1). According to the Glucksberg scoring system, thirteen patients experienced grade I-II and two grade III-IV acute GvHD, while 7 patients developed limited (n=6, 18%) and extensive (n=3, 10%) chronic GvHD. Starting from time of engraftment, LD oral VGCV was given prophylactically for at least 6 months. CMV infection was monitored weekly using polymerase chain reaction (PCR) in high risk seropositive recipients and we started preemptive therapy when the peak viral load exceeding 1000 copies/mL in two consecutive plasma samples. Six patients (4 early and 2 late) developed a positive PCR after a mean of 59 days post-HSCT successfully treated with 900 mg of VGCV twice a day for at least when PCR negative (in a median of 12 days). Only one patient developed late fatal gastrointestinal CMV disease. Indeed, asymptomatic early and late CMV-DNA PCR reactivation occurred only in 17% (n=5) of high risk seropositive HSCT recipients, in contrast to 37% and 18% of early and late CMV reactivation observed in matched gender, disease phase, graft source and CMV serostatus cohort of 32 HSCT recipients treated prophylactically with oral acyclovir (ACV, 15 mg/kg daily) and high dose intravenous immunoglobulins (IVIG, 0.4 gr/kg weekly for at least 6 months) . Seven patients presented hematological toxicity do not requiring drug discontinuation. The rate of non CMV-related infections was 25% and was similar in both groups with and without CMV reactivation. At the end of the follow-up, 18 of 32 (56%) patients were alive with a median follow-up of 31 months (range, 2-56). Relapsed-related mortality was 20%, transplant-related mortality was 9% and did not differ between group with and without CMV reactivation. Our data provide evidence that LD-VGCV is safe and effective as CMV reactivation prophylaxis in allogeneic HSCT recipients. These results require further validation in randomized studies. Disclosures: No relevant conflicts of interest to declare.

AbstractAutoimmune hemolytic anemia (AIHA) is a rare hematologic disease, primarily affecting adults or children with immunodeficiency disease. First-line therapy consists of long course of steroids administration, with an early complete response rate (CRr) of 75-80%, but up to 20-30% of patients requires a second-line therapy. Rituximab is the first choice in refractory old AIHA patients, because of its safety and efficacy (early CRr at 80-90% and at 68% at 2-3 years). For this reason, splenectomy is even less chosen as second-line therapy in elderly, even though laparoscopic technique decreased complication and mortality rates. However, splenectomy can be still considered a good therapeutic option with a CRr of 81% at 35.6 months in patients older than 60 year-old, when rituximab administration cannot be performed.

Bendamustine (BENDA) alone or in combination with other drugs is being increasingly used in the treatment of chronic lymphocytic leukaemia (CLL), non-Hodgkin lymphomas (NHL), and multiple myeloma (MM) due to its safety and efficacy. Variable infection rates both in BENDA monotherapy and in BENDA-containing regimens have been documented, while it is reported that CD4+ lymphocytes are severely reduced during BENDA therapy, that their recovery is impaired and that CD4+ lymphopenia persists for a long time after the end of BENDA administrations.Since January 2017 we started monitoring levels of CD4+ lymphocytes of patients undergoing to a treatment with schedules BENDA based. At today 51 consecutive patients, 15 female and 36 male with median age of 70 old years (range 40-88 years), had at least one CD4+ lymphocytes detection. All the patients had a B-NHL diagnosis. 34 patients were treated with BENDA plus Rituximab (R-BENDA), while 17 with BENDA plus Rituximab plus Dexamethasone (RD-BENDA). In 41 new patients, our measurements started before the beginning of BENDA courses, with a median of basal CD4+ lymphocytes of 617 cells/mm3 (range 154-1278 cells/mm3). After 2/3 BENDA courses, it dropped to 42 cells/mm3 (range 0-118 cells/mm3). (P value <0.004) 30 patients are evaluable on their last planned BENDA course (4 to 6 courses). Their median of CD4+ lymphocytes was 53 cells/mm3 (range 15-160 cells/mm3). 25 patients are evaluable after 3 months from the end of the therapy.Their median of CD4+ lymphocytes was 94 cells/mm3 (range 41-288 cells/mm3).After 6 months, CD4+ lymphopenia is still present in 15 evaluable patients. Their median of CD4+ lymphocytes was 186 cells/mm3 (range 114-399 cells/mm3). In 15 (30%) patients we have documentedthe reactivation of CMV virus; 7 in the group RD-Benda and 8 in the group R-Benda (41% and 23% of treated patients).This single-center study provides further evidence that BENDA regimens for lymphoproliferative diseases are associated with a deep reduction of CD4+ lymphocytes which persists even after 6 months off-therapy and requires an adequate monitoring and prophylaxis to avoid infections.Background: Off-label use (OLU) of drugs in haematology/oncology is increasing, however, little is known on the frequency of OLU in lymphoma therapy and whether it is more common than for solid tumors. It is also unclear how often requested OLU is actually reimbursed by health insurers.Methods: We conducted a cross-sectional study using information from routinely collected health data. We included all patients treated for a malignant disease between manually screened their electronic patient records. For all patients, for which at least one request for OLU reimbursement was issued, we extracted information on patient demographics, disease characteristics, treatment history and correspondence with the health insurer.We defined OLU as intentional drug use outside of the Swissmedic label. Main outcomes were the drug type and approval/rejection of an OLU request. We used descriptive statistics to investig...

Hodgkin and Reed-Sternberg (HRS) cells in classical Hodgkin Lymphoma (HL) are surrounded by a rich inflammatory infiltrate which aids in their survival and escape from cytotoxic CD8+ T cells (CTLs) and Natural Killer cells (NKs). Within HL environment, T regulatory cells (Tregs) directly suppress the activity of CTLs and NKs, enhancing the tolerance against HRS cells. B regulatory cells (Bregs) have been shown to support the differentiation of Tregs through IL-10 production; thus, we hypothesized that they could have a role in the pathophysiology of HL. We evaluated 30 classic HL patients (M/F: 18/12; median age, 31 years, range 15-62) and 5 healthy controls (HC) for circulating peripheral blood (PB) Bregs, Tregs, CTLs, NKs, and NKTs. Twenty-four of them were new-diagnosed patients (NwHL) and 6 received a previous diagnosis of HL but were in complete remission (CR) for more than 12 months (PvHL). NwHL patients were divided according to the International Prognostic Score (IPS) and the Ann-Arbor Staging System. All subjects were treated following the ABVD protocol (doxorubicin 25 mg/m2, bleomycin 10 U/m2, vinblastine 6 mg/m2, and dacarbazine 375 mg/m2). Flow cytometry was performed on heparinized PB samples with a 5-color Beckman Coulter Cytomics FC500 flow cytometer. Breg (CD19+CD24+), Treg (CD3+CD4+CD25+), CTL (CD3+CD8+), NK (CD3-CD56+), and NKT (CD3+CD56+) levels were measured simultaneously with the PET/CT evaluations, ie at diagnosis, at the end of the second ABVD administration, at the end of treatment, and at 6 and/or 12 months off-therapy. Moreover, Breg levels were compared to IPS and Ann-Arbor staging groups, and also were correlated to the erythrocyte sedimentation rate (ESR) and to the absolute lymphocyte count (ALC). We found decreased circulating Bregs in NwHL and PvHL patients compared to controls (0.39% vs 0.875% vs 1.813%, respectively, p<0.0001). In addition, we found decreased CTLs in NwHL compared to PvHL and HC (2.815% vs 4.057% vs 5.780%, respectively, p=0.0228). Thus, all HL patients showed lower numbers of Bregs, but there were no differences between patients of different IPS or stage. Besides, lower Breg levels were correlated with higher ESR values (r2=0.3193, p=0.0117), while no correlation was found for ALC (r2=0.0414, p=0.3898). The levels of Tregs, NKs, and NKTs were not significantly different between patients and controls at diagnosis. As a result, the greater reduction of Bregs compared to Tregs in PB caused a larger Bregs/Tregs ratio in NwHL and PvHL patients compared to controls (1.014 and 1.003 vs. 5.975, p=0.0094). Further reduction of circulating Bregs was observed in 58% of NwHL patients at the end of the second ABVD administration for patients experiencing both CR and partial remission (PR) (based on PET/CT scans) and in 80% at the end of treatment (71% CR, 29% PR). Interestingly, post-treatment Breg levels of NwHL were initially lower than that of PvHL patients and controls (NwHL post-treatment 0.4062% vs PvHL 0.8750% vs HC1.813%, p=0.0030) but normalized after 6 months off-therapy (1.444%, p=0.6189). Similar trends were observed for CTLs (NwHL post-treatment 4.615% vs NwHL 6 months off therapy 5.603% vs PvHL4.057% vs HC 5.780%, p=0.7558) and Bregs/Tregs ratio (0.9613 vs 5.975, p=0.0678). These data suggest that the B cell depletion phase during chemotherapy may interrupt the positive feedback between B and T cell compartments and the normalization of Bregs and CTLs after treatment may be linked to the restoration of a normal immune response, supporting by the achievement of CR in all patients. Our preliminary data suggest involvement of Bregs in the escape and survival of HRS cells during active disease. Peripheral blood may mirror disease activity in lymphoid tissues. Thus, the decrease of circulating Bregs may be related to the recruitment of these cells to the tumor site; amplification of the Bregs/Tregs ratio may result in a greater Breg-dependent Treg activation with subsequent inhibition of CTL and NK function. Additionally, the normalization of Bregs and the Bregs/Tregs ratio after chemotherapy could be used to predict disease remission. While larger prospective studies are required to validate these results, we present intriguing evidence of the involvement of Bregs in the pathophysiology of HL. Disclosures No relevant conflicts of interest to declare.