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Letter to the Editor

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This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

143 DOI: 10.5045/kjh.2011.46.2.143

The Korean Journal of Hematology Volume 46ㆍNumber 2ㆍJune 2011

Letter to the Editor

What should we consider in mixed chimerism after hemato- poietic stem cell transplanta- tion?

TO THE EDITOR: Mixed chimerism (MC) was initially thought to indicate impending relapse; however, it has be- come clear that it is an important parameter for estimating immunologic balance after hematopoietic stem cell trans- plantation (HSCT). Moreover, the emergence of more tail- ored HSCT procedures, including reduced-intensity stem cell transplantation (RIST), depletion of the donor’s T cells from bone marrow graft, and donor lymphocyte infusion (DLI), makes it even more important to estimate the exact chimeric status after HSCT.

Recently, Goh et al. reported MC results in 24 myeloa- blative HSCT patients. MC in nucleated cells (NCs) was significantly correlated with relapse, and MC in NCs, T cells, and NK cells was correlated with mortality. Further- more, MC in all cell types was uncorrelated with the in- cidence of acute and chronic graft-versus-host disease (GVHD). These data were analyzed in limited cases, but individual diseases and HSCT strategy were not considered [1].

Myeloablative HSCT without T cell depletion often results in GVHD but is associated with less frequent relapse. T cells in the graft lead to full donor complete chimerism (CC), although early CC indicates GVHD. However, T cell-depleted (TCD) myeloablative HSCT is commonly found to give rise to MC, and is therefore used to avoid GVHD. In the case of RICT, all cases typically experience MC. Therefore, MC has to be precisely evaluated. Low donor T cell and NK cell chimerism levels around the second week after HSCT are associated with high probabilities of graft rejection, whereas early establishment of donor NK

cell chimerism is associated with better progression-free survival [2]. In contrast to NK cell chimerism, early estab- lishment of donor T cell chimerism is associated with the development of acute GVHD [3]. In recent interesting re- ports on lineage-specific chimerism, monitoring of leukemia lineage-specific chimerism has been shown to be important for DLI response in the case of relapse after HSCT [4].

Further, a low donor T cell chimerism of <60% at day 30 may be associated with a poor prognosis in HSCT when using a busulfan-containing reduced-intensity conditioning regimen [5]. Although MC is an important indicator of disease relapse, graft rejection, or GVHD post HSCT, it should be taken into consideration that the recipient cells in MC could be normal hematopoietic cells or leukemic cells. Therefore, it is important to identify those patients who develop an increasing or progressive MC of recipient cells by monitoring serial chimerism levels. Additionally, with respect to accurate analysis of chimerism, it should be recognized that variation in the degree of MC is influ- enced by a number of factors, including the sensitivity of the method used, the timing of the assay, the disease in- dication for HSCT, the stage of disease at the time of HSCT, and the choice of conditioning regimen.

Jihyang Lim, M.D.

Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea, 505 Banpo-dong, Seocho-gu, Seoul 137-701, Korea Tel: +82-2-2258-1643, E-mail: ljh117@catholic.ac.kr

1. Goh RY, Kim SH, Han JY. Lineage-specific chimerism analysis in nucleated cells, T cells and natural killer cells after myeloablative allogeneic hematopoietic stem cell transplantation. Korean J Hematol 2011;46:18-23.

2. Baron F, Baker JE, Storb R, et al. Kinetics of engraftment in patients with hematologic malignancies given allogeneic hematopoietic cell transplantation after nonmyeloablative conditioning. Blood 2004;104:2254-62.

3. Mattsson J, Uzunel M, Brune M, et al. Mixed chimaerism is com-

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Korean J Hematol 2011;46:143-4.

144 Letter to the Editor

mon at the time of acute graft-versus-host disease and disease re- sponse in patients receiving non-myeloablative conditioning and allogeneic stem cell transplantation. Br J Haematol 2001;115:935- 44.

4. Sairafi D, Remberger M, Uhlin M, Ljungman P, Ringdén O, Mattsson J. Leukemia lineage-specific chimerism analysis and mo- lecular monitoring improve outcome of donor lymphocyte

infusions. Biol Blood Marrow Transplant 2010;16:1728-37.

5. Saito B, Fukuda T, Yokoyama H, et al. Impact of T cell chimerism on clinical outcome in 117 patients who underwent allogeneic stem cell transplantation with a busulfan-containing reduced-in- tensity conditioning regimen. Biol Blood Marrow Transplant 2008;14:1148-55.

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