Sezary Syndrome (SS) is a rare leukemic variant of primary cutaneous T-cell lymphoma. Relapsed or refractory disease is generally considered incurable by conventional therapeutic approaches, although durable responses can be achieved with novel monoclonal antibodies. Allogeneic hematopoietic stem cell transplantation (alloHSCT) may have potential value by inducing graft vs-lymphoma (GvL) effects, but there is currently no consensus regarding the timing of alloHSCT or type of conditioning regimen. Here we present the case of a male patient who achieved a complete remission (CR) of primary refractory SS after non-myeloablative alloHSCT. Patient: Two years prior to HSCT, the patient had been refractory to CHOEP-based chemotherapy, interferon, extracorporeal photopheresis (ECP), and bexarotene. Directly prior to alloHSCT brentuximab-vedotin (BV) was applied resulting in a partial remission of the skin compartment and overall in a stable disease. Prior to HSCT, flow cytometry of the bone marrow and peripheral blood showed an infiltration with T-cells positive for CD5, CD4, low CD3, low CD2 and negative for CD7, CD38, HLA-DR and CD8. The trephine biopsy showed a 7% infiltration of SS cells. The CD4:CD8 ratio in peripheral blood (pb) was massively increased at 76.67, with 63.5% of white blood cells expressing a SS immune phenotype. The conditioning regimen included 30 mg/m2 fludarabine on days -5, -4 and -3 and total body irradiation with 2 Gy on day -1. Immunosuppression consisted of cyclosporine A from day-1 and mycophenolate mofetil from day 0. The patient received 6.55x106 CD34+ cells and 1.11x108 CD3+ cells/kg body weight. Bone marrow evaluation on day 28 still showed persistent SS cells by flow cytometry. After tapering immunosuppression until day 169, the CD4:CD8 ratio in pb normalized. CR was documented on day 169 after alloHSCT and is now ongoing for almost 3 years after alloHSCT. Conclusions: We confirm that an alloHSCT can be a curative option for refractory patients with SS. The achievement of a CR after tapering the immunosuppressive therapy indicates a significant role of the GvL effect. In present treatment algorithms for patients with SS, the timing of an alloHSCT and the intensity of conditioning should be further explored.

Background The role of allogeneic hematopoietic cell transplantation (alloHCT) in acute myeloid leukemia (AML) with mutated IDH1/2 has not been defined. Therefore, we analyzed a large cohort of 3234 AML patients in first complete remission (CR1) undergoing alloHCT or conventional chemo-consolidation and investigated outcome in respect to IDH1/2 mutational subgroups (IDH1 R132C, R132H and IDH2 R140Q, R172K). Methods Genomic DNA was extracted from bone marrow or peripheral blood samples at diagnosis and analyzed for IDH mutations with denaturing high-performance liquid chromatography, Sanger sequencing and targeted myeloid panel next-generation sequencing, respectively. Statistical as-treated analyses were performed using R and standard statistical methods (Kruskal–Wallis test for continuous variables, Chi-square test for categorical variables, Cox regression for univariate and multivariable models), incorporating alloHCT as a time-dependent covariate. Results Among 3234 patients achieving CR1, 7.8% harbored IDH1 mutations (36% R132C and 47% R132H) and 10.9% carried IDH2 mutations (77% R140Q and 19% R172K). 852 patients underwent alloHCT in CR1. Within the alloHCT group, 6.2% had an IDH1 mutation (43.4% R132C and 41.4% R132H) and 10% were characterized by an IDH2 mutation (71.8% R140Q and 24.7% R172K). Variants IDH1 R132C and IDH2 R172K showed a significant benefit from alloHCT for OS (p = .017 and p = .049) and RFS (HR = 0.42, p = .048 and p = .009) compared with chemotherapy only. AlloHCT in IDH2 R140Q mutated AML resulted in longer RFS (HR = 0.4, p = .002). Conclusion In this large as-treated analysis, we showed that alloHCT is able to overcome the negative prognostic impact of certain IDH mutational subclasses in first-line consolidation treatment and could pending prognostic validation, provide prognostic value for AML risk stratification and therapeutic decision making.

[ES] Los receptores tipo Toll, TLR, son receptores clave en la defensa contra los patógenos capaces de iniciar la respuesta inmunitaria innata para proteger al huésped. Su papel no solo se relega a responder a estímulos foráneos, sino que también pueden detectar daños en los tejidos o células lesionadas induciendo su respuesta a lo que se conoce como "inflamación estéril". Las células del sistema inmunitario no son las únicas que presentan TLR; también se encuentran en células de la glía, neuronas y precursores neurales (NPC). Concretamente, TLR2 y TLR4 en NPC en cerebro contribuyen a la determinación del destino celular y plasticidad neuronal durante el desarrollo. Sin embargo, sus funciones en la fisiología y patología de la médula espinal no están bien definidas, así como en procesos críticos como la neurogénesis, autorrenovación o proliferación. Esta tesis doctoral, distribuida entre tres capítulos, se ha centrado 1) en el estudio del papel de TLR2 y TLR4 en precursores derivados de medula espinal neonatal (Capítulo 1); 2) en evaluar el papel de ambos, TLR2 y TLR4 en el proceso de regeneración espontánea o tras trasplante ectópico de NPC, en un modelo de lesión medular inducida (Capítulo 2); 3) en el estudio del papel de TLR4 en la modulación del fenotipo inflamatorio en respuesta al proteoglicano condroitín sulfato (CSPG) secretado tras la lesión medular con actividad inhibitoria del recrecimiento axonal tras lesión medular (Capítulo 3). / [CA] Els receptors tipus Toll, TLR, són receptors clau en la defensa contra els patògens capaços d'iniciar la resposta immunitària innata per a protegir l'hoste. El seu paper no sols es relega a respondre a estímuls forans, sinó que també poden detectar danys en els teixits o cèl·lules lesionades induint la seua resposta al que es coneix com a "inflamació estèril". Les cèl·lules del sistema immunitari no són les úniques que presenten TLR; també es troben en cèl·lules de la glia, neurones i precursors neurals (NPC). TLR2 i TLR4 en NPC en cervell contribueixen a la determinació del destí cel·lular i plasticitat neuronal. No obstant això, les seues funcions en la fisiopatologia de la medul·la espinal no estan ben definides, així com en processos crítics com la neurogènesi, autorenovació o proliferació. Aquesta tesi doctoral, distribuïda entre tres capítols, s'ha centrat: 1) En l'estudi del paper de TLR2 i TLR4 en precursors derivats de medul·la espinal neonatal (Capítol 1); 2) A avaluar el paper de tots dos, TLR2 i TLR4, en el procés de regeneració espontània o després de trasplantament ectòpic de NPC, en un model de lesió medul·lar induïda (Capítol 2); 3) En l'estudi del paper de TLR4 en la modulació del fenotip inflamatori en resposta al proteoglicà condroití sulfat (CSPG) secretat després de la lesió medul·lar amb activitat inhibitòria del recreixement axonal després de lesió medul·lar (Capítol 3). / [EN] Toll-like receptors, TLRs, are key receptors in the defence against pathogens capable of initiating the innate immune response to protect the host. Their role is not only limited to responding to foreign stimuli, but they can also detect damage to injured tissues or cells, inducing their response to what is known as 'sterile inflammation'. Immune system cells are not the only cells that display TLRs; they are also found in glial cells, neurons and neural precursors cells (NPCs). TLR2 and TLR4 NPCs from brain contribute to cell fate determination and neuronal plasticity. However, their roles in spinal cord pathophysiology and in critical processes such as neurogenesis, self-renewal or proliferation are not well defined. This doctoral thesis, distributed among three chapters, has focused: 1) on the study of the role of TLR2 and TLR4 in neonatal spinal cord-derived precursors (Chapter 1); 2) on evaluating the role of both TLR2 and TLR4 in the process of spontaneous regeneration or after ectopic transplantation of NPC, in a model of induced spinal cord injury (Chapter 2); 3) to study the role of TLR4 in modulating the inflammatory phenotype in response to chondroitin sulphate proteoglycan (CSPG) secreted after spinal cord injury with inhibitory activity on axonal regrowth after spinal cord injury (Chapter 3). / The student has been granted with a PhD fellowship from a predoctoral program at the CIPF and with International Research and Training Exchange Programme at the CIPF. This work has been supported by the Spanish Ministry of Economy and Competitiveness (projects RTI2018-095872-B-C21; MAT2015-66666-C3-R; SAF2015-69187R) and Spanish Ministry of Heath, PNSD2018 I003. / Sánchez Petidier, M. (2022). Toll-like receptors in spinal cord derived neural precursor cells: implications on spinal cord injury and cell transplantation [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/180753

[ES] La lesión medular traumática (LM) se refiere a una condición neurológica en la que un insulto mecánico interrumpe la adecuada comunicación de impulsos nerviosos a través del sistema nervioso central (SNC), resultando en la pérdida de función locomotora por debajo del área lesionada. Lamentablemente, en la actualidad aún no existe cura efectiva para restaurar la funcionalidad después de una LM. La búsqueda de un tratamiento eficiente sigue siendo un gran desafío debido a nuestra aún incompleta comprensión de la multitud de procesos biológicos desencadenados por la lesión. La terapia celular destaca como la aproximación más recurrente para el tratamiento de la LM. En las últimas décadas, se han explorado varias estrategias celulares, siendo una de las más prometedoras el trasplante de células progenitoras neurales (CPN). Muchos estudios preclínicos demostrado el potencial del trasplante de CPN para proporcionar una recuperación motora en modelos animales, sin embargo, las mejoras funcionales en ensayos clinicos humanos son limitadas. Por lo tanto, aún se deben realizar esfuerzos para descubrir la cascada precisa de procesos moleculares a lo largo de la fisiopatología de LM, así como el mecanismo subyacente de los CPN. En ese contexto, el Capítulo 1 del presente trabajo tuvo como objetivo proporcionar una caracterización de los cambios en el perfil transcripcional medular a lo largo de las diferentes etapas temporales de una lesión severa contusiva. Además, hemos descrito el impacto transcripcional del trasplante de CPN en ratas lesionadas. Hemos demostrado que mientras la LM conllevó una fuerte desregulación de varios componentes de señalización de AMPc (entre ellos EPAC2), el trasplante de CPN pudo restaurar estas alteraciones transcripcionales. Para explorar el papel de EPAC2 en el mecanismo terapéutico mediado por CPN, realizamos un experimento de inhibición sostenida de EPAC2 mediante la administración de ESI-05. En comparación con los animales solo trasplantados, los animales CPN +ESI-05 mostraron un aumento en el área de cicatriz, una exacerbación de la polarización de la microglía hacia un perfil inflamatorio y una ampliación de la brecha de neuronas preservadas a lo largo de la lesión, sugiriendo que el trnasplante de CPN en el contexto de LM implican un mecanismo dependiente de EPAC2, reduciendo la neuroinflamación y proporcionando un entorno neuro-permisivo. El Capítulo 2 explora el potencial del AMPc para la regeneración de la LM. Hemos diseñado una estrategia innovadora para inducir AMPc en las neuronas corticoespinales a través de la activación optogenética de un adenilato ciclasa foto-inducible (bPAC). La estimulación optogenética en ratas con una hemisección dorsal torácica promovió una recuperación locomotora en comparación con el grupo control. Además, la estimulación de bPAC aumentó el número de neuronas marcadas retrógradamente desde el segmento lumbar tanto en la corteza motora como en la formación rafe-reticular, pero no en el núcleo rojo.La inmunotinción del tracto rafespinal mostró que la estimulación de bPAC aumenta el ratio de axones serotonérgicos caudales a la lesión correlacionando con una mejora funcional. Por último, la depleción del sistema serotoninérgico mediante la administración de 5,7-Dihydroxytryptamina suprimió la abolió la mejora mediada por bPAC, confirmando la implicación de la vía serotoninérgica en la recuperación de los animales estimulados. En resumen, se han proporcionado nuevos conocimientos sobre los cambios transcripcionales que ocurren a lo largo de la progresión de la LM y tras el trasplante de CPN, con énfasis en la señalización de AMPc. La manipulación optogenética de AMPc en las neuronas corticoespinales después de la LM ha demostrado ser efectiva para la recuperación funcional y permitido descubrir una ruta cortical alternativa a través del tracto descendente serotoninérgico / [CA] Lesió medul·lar traumàtica (LM) es una condició neurològica en la qual un traumatisme interromp la comunicació adequada dels impulsos a través del sistema nerviós central (SNC), amb el resultat de la pèrdua de la funció locomotora per baix de la zona lesionada. Lamentablement, en l'actualitat encara no hi ha una cura efectiva per a restaurar completament la funcionalitat de la medul·la espinal després de la lesió. La recerca d'un tractament eficient per a la LM roman un repte complex a causa de la nostra comprensió encara incompleta de la gran quantitat de processos biològics desencadenats per la lesió primària. La teràpia cel·lular destaca com l'aproximació més recurrent per al tractament de la LM. En les dècades passades, s'ha explorat diverses estratègies basades en cèl·lules i una de les més prometedores és el trasplantament de cèl·lules progenitores neurals (CPN). Molts estudis preclínics han demostrat el potencial del trasplantament de CPN per proporcionar una recuperació motora en models animals, no obstant això, les millores funcionals en pacients humans tractats són limitades. Per tant, encara s'han de fer esforços per a descobrir la cascada precisa de processos moleculars al llarg de la fisiopatologia de la LM, així com el mecanisme subjacent dels CPN. El Capítol 1 del present treball va tindre com a objectiu proporcionar una caracterització dels canvis en el perfil transcripcional espinal al la llarga de les diferents etapes temporals de una lesió contusiva. A més, s'ha descrit l'impacte transcripcional del trasplantament d'CPN en animals lesionats. S'ha demostrat que mentre la LM va causar una forta desregulació de diversos components de senyalització de AMPc (sent EPAC2 el gen més regulat a la baixa), el transplantament de CPN van ser capaç de restaurar les alteracions derivades de la LM. Per a explorar el paper d'EPAC2 en el mecanisme terapèutic mediat per CPN, es va realitzar un experiment de inhibició sostinguda d'EPAC2 degut a l'administració d'ESI en animals lesionats. En comparació amb els animals només trasplantats, els animals CPN+ESI-05 van mostrar un augment de l'àrea de cicatriu, una exacerbació de la polarització de les micròglies cap a un perfil inflamatori i una ampliació de la bretxa de neurones preservades a través de la lesió.Aquests resultats suggereixen que el trasplantament de CPN en el context de la LM involucren un mecanisme depenent d'EPAC2, reduint la neuroinflamació i proporcionant un entorn més neuropermissiu. El Capítol 2 va tindre com objectiu explotar el potencial de regeneració de AMPc dissenyant una nova estratègia per a les induccions artificials de AMPc en les neurones corticoespinals mitjançant l'activació optogenètica d'una adenilat ciclasa fotoinduïble (bPAC). L'estimulació diària de AMPc en rates que pateixen una hemisècció dorsal toràcica va promoure una recuperació en comparació amb els control. L'estimulació de bPAC va augmentar el nombre de neurones marcades retrògradament des del segment lumbar, tant a l'escorça motora com a la formació rafe-reticular, però no al nucli roig. A més, la immunotinció del tracte rafespinal va mostrar que l'estimulació de bPAC va augmentar la ràtio d'axons serotoninèrgic cabals a la lesió, cosa que es va correlacionar significativament amb una millora dels paràmetres funcionals. Finalment, la depleció del sistema serotoninèrgic mitjançant l'administració de 5,7-Dihydroxytryptamina va abolir la millora mediada per bPAC, confirmant la implicació de la via serotoninèrgica en la recuperació. En resum, la investigació ha proporcionat coneixements sobre els canvis transcripcionals que tenen lloc a la llarga de la progressió de la LM i després del trasplantament de CPN, amb un èmfasi especial en la senyalització d'AMPc. La manipulació optogenètica d'AMPc a les neurones corticoespinals després de la LM ha demostrat ser efectiva per a la recuperació funcional i ha permès descobrir una ruta cortical alternativa a través del tracte descendent serotoninèrg / [EN] Traumatic spinal cord injury (SCI) refers to a neurological condition in which a mechanic insult disrupts the proper communication of the impulses through the central nervous system (CNS), resulting on the loss of locomotor function below the injured area. Unfortunately, nowadays there is still no effective cure to completely restore the functionality of the spinal cord after the injury. Cell therapy is the most recurring approach for SCI treatment. In the past decades several cell-based strategies have been explored, being one of the most promising the transplantation of neural progenitor cells (NPCs). Many pre-clinical studies evidenced the potential of the NPCs transplantation to provide a substantial motor recovery in animal models, yet functional improvements in clinical trials have been limited. Therefore, efforts still need to be made in disclosing the precise cascade of molecular processes along SCI pathophysiology as well as the NPCs underlying mechanism. In that context, Chapter 1 of the present work aimed to provide a comprehensive characterization of the spinal transcriptional changes along the different temporal stages of rats suffering a severe contusive injury. Additionally, we have described the transcriptional impact of acute and subacute NPCs transplantation in injured animals. Interestingly we have shown that while SCI caused a strong dysregulation of several cAMP-signaling components (being EPAC2 the most downregulated gene), NPCs was able to restore SCI-derived alterations over this pathway with EPAC2 significant upregulation. In order to further explore EPAC2 role in NPCs-mediated therapeutical mechanism we performed a loss-of-function experiment by sustained EPAC2 inhibition via ESI-05 administration along with NPCs transplantation after SCI. Compared with only transplanted animals, NPCs+ESI-05 animals showed increased scar area, exacerbated microglia polarization into an inflammatory profile and widened gaps of preserved neurons across the lesion. Overall, these results suggest that NPC therapeutic mechanisms in the context of SCI involve an EPAC2-dependent mechanism, reducing neuroinflammation and providing a neuro-permissive environment. Chapter 2 aimed to further explore cAMP potential for SCI regeneration. We designed a novel strategy for artificial cAMP inductions in corticospinal neurons via optogenetic activation of a photoinducible adenylyl cyclase (bPAC). Daily optogenetic cAMP stimulation in rats suffering a thoracic dorsal hemisection, which completely disrupt the dorsal aspect of the corticospinal tract (CST), promoted and early and sustained locomotor recovery compared to non-treated control animals. We have shown that bPAC stimulation increased the number of retrograde traced neurons from the lumbar segment both in the motor cortex and the raphe-reticular formation, but not in the red nuclei. Moreover, immunolabelling of the raphespinal tract by 5-HT showed that bPAC stimulation increased the ratio of descending serotoninergic axons caudal to the injury which significantly correlated with improved functional parameters. Our results from corticobulbar projection study, WGA trans-synaptic tracing, and P-CREB analysis suggest that bPAC modulation of cortico-serotonergic pathway might occurs at the brainstem level. Lastly, the serotonergic system depletion by 5,7-Dihydroxytryptamine administration suppressed bPAC-mediated recovery, confirming the implication of the serotonergic tract in the recovery of stimulated animals. In summary, our research has provided new insights into the transcriptional changes that occur along SCI progression and after NPCs transplantation with a special emphasis on cAMP signaling. Optogenetic cAMP manipulation in corticospinal neurons after SCI has proven to be effective for functional recovery and allowed to unveil a cortical rerouting pathway through the serotonergic descending tract. / This research was funded by FEDER/Ministerio de Ciencia e Innovación – Agencia Estatal de Investigación [RTI2018-095872-BC21/ERDF]. Part of the equipment employed in this work was funded by Generalitat Valenciana and cofinanced with ERDF funds (OP ERDF of Comunitat Valenciana 2014– 2020) and the UE; Fondo Europeo de Desarrollo Regional (FEDER) incluido en el Programa Operativo FEDER de la Comunidad Valenciana 2014-2020. B. MartinezRojas was supported by a grant from the Conselleria de Educación, Investigación, Cultura y Deporte de la Generalitat Valenciana and the European Social Fundation ACIF/2019/120. / Martínez Rojas, B. (2024). Transcriptional Insights for Spinal Cord Injury and Neural Precursor Cell Therapy: Toward a Novel Optogenetics-Based Treatment for cAMP Neuronal Induction [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/202972

Ein neuartiger Ansatz für die Immunphänotypisierung wird vorgestellt. Die Durchflusszytometrie (FACS) ist die übliche Methode für die Charaketrisierung des Immunsystems. Jedoch ist die Verfügbarkeit von frischem Vollblut, sowie ein schnelle Probenlogistik Vorraussetzung für die Analyse. Als potentialle Alternative werden epigentische qPCR Assays vorgestellt. Für die Quantifizierung von B- und NK-Zellen wurden epigenetische qPCR Systeme etabliert. Anhand eines erweiterten epigenetischen Markerpanels wurde die klinische Anwendung in drei Kohorten getestet: a) 41 Patienten mit primären Immundefizienzen (PID); b) 19 Neugeborene mit und ohne PID und c) 28 Patienten nach einer Stammzelltransplantation (SZT). In Kohorte a) und c) konnte die Äquivalenz der Ergebnisse mit FACS bestätigt werden. Diskrepanzen bei der regulatorischen T-Zell Quantifizierung in einzelnen PID Patienten wurde festgestellt, welche durch Mutationen verursacht wurden, die die Integrität der analysierten Proteine beeinflussen. Zudem konnte die Anwendung der epigentischen Quantifizierung in Trockenblutkarten von Neugeborenen gezeigt werden. Dies würde die Anwendung auch im Neugeborenen-Screening für die Erkennung von PIDs ermöglichen. Für die Anwendung in der SZT konnte gezeigt werden, dass das epigenetische System eine frühe Analyse der Immunrekonstitution ermöglicht, welche eine prädiktive Aussage über das Überleben der Patienten erlaubt. Patienten, welche eine Immunantwort der Lymphozyten gegen eine Virusinfektion bereits am Tag 26 nach Transplantation aufwiesen, hatten eine signifikant höhere Überlebenschance als Patienten ohne Immunantwort. Zusammengefassend zeigen die Daten, dass die epigenetische Systeme für klinische Anwendungen eine zuverlässige Methode darstellt. Die Aussagekraft der Daten ist aufgrund der Studiengröße noch limitiert, und komplizierte klinische Szenarien erschweren die Evaluierung. Deshalb sind weitere Studien erforderlich, um das gezeigte Potenzial zu validieren. / A novel approach for immunophenotyping for clinical applications is presented here. Flow cytometry is currently a common method to characterize the immune system but requiring fresh whole blood and good sample logistics which is not always available. To overcome this limitations, epigenetic qPCR assays are introduced as potential alternative. New epigenetic qPCR systems to quantiy B and NK cells have been established. Using an extended epigenetic marker panel, clinical applications were tested in three patient cohorts: a) 41 patients with different primary immunodeficiencies (PID); b) 19 newborns with and without PID and c) 28 patients after stem cell transplantation (SCT). In cohort a) and c) the equivalence of the epigenetic quantification with flow cytometry was confirmed. However, discrepancies between both methods for regulatory T-cell quantification were found in individual PID patients caused by disease-associated mutations affecting the integrity of the respective protein. Furthermore, the epigenetic quantification using dried blood spots from newborns was demonstrated. This would allow the implementation of epigenetic immunophenotyping in neonatal screening for the detection of congenital immunodeficiencies. For the application in SCT, it was shown that the epigenetic system allows an early analysis of immune reconstitution, which may allow a prediction of the patients' overall survival. Patients who showed an immune response of lymphocytes against viral infections at day 26 after transplantation had a significantly higher survival rate. In summary, the available data show that epigenetic immunophenotyping is a reliable analytical method for various clinical applications. The significance of the data is still limited due to the size of the study and complicated clinical scenarios make the evaluation of individual measurements difficult. Therefore, further extensive investigations are needed to clinically validate the demonstrated potential.

Die Hochdosischemotherapie (HDCT) wurde als Therapiestrategie zur Verbesserung des Therapieansprechens bei Patienten mit rezidivierten und/oder refraktären Keimzelltumoren entwickelt. Im Zeitraum von August 1989 bis September 1995 wurden insgesamt 150 Patienten mit rezidivierten und/oder refraktären Keimzelltumoren in konsekutive Therapieprotokolle mit einer konventionell-dosierten Chemotherapie gefolgt von einem Zyklus HDCT mit Carboplatin in der Dosierung 1500-2000 mg/m², Etoposide in der Dosierung 1200-2400 mg/m² und Ifosfamid in der Dosierung 0-10 g/m² eingeschlossen und retrospektiv ausgewertet. Nach einem medianen Follow-up von 55 Monaten (Spanne 21-88 Monate) lebten 51/150 (34%) Patienten und waren tumorfrei. Das berechnete ereignisfreie Überleben lag bei 29%, das Gesamtüberleben bei 39%. Die Bedeutung von Prognosefaktoren für das Therapieansprechen auf HDCT wurden prospektiv bestätigt. Persistierende Toxizitäten traten bei gut einem Drittel der Langzeitüberlebenden auf. Die intensivierte Behandlung mit HDCT resultierte in einem signifikanten Anteil an Langzeitüberlebenden bei Patienten mit rezidivierten und/oder refraktären Keimzelltumoren. Klinische Studien zur prospektiven Evaluierung der HDCT als frühe Therapieintervention scheinen gerechtfertigt. / High-dose chemotherapy (HDCT) has evolved as a strategy to improve treatment outcome in patients with relapsed and/or refractory germ cell tumors. Between August 1989 and September 1995, 150 consecutive patients with relapsed and/or refractory germ cell tumors were treated with conventional-dose salvage chemotherapy followed by one cycle of HDCT with carboplation 1500-2000 mg/m², etoposide 1200-2400 mg/m² and ifosfamide 0-10 g/m² and were retrospetively analysed. With a median follow-up time of 55 month (range 21-88 month) 51/150 (34%) patients were alive and disease free. The projected event-free and overall survival are 29% and 39% respectively. The relevance of prognostic variables for long-term survival after HDCT were prospectively confirmed. Persisting toxicities occured in approximately one third of long-term survivors. Treatment intensification with HDCT resulted in a significant proportion of long-term survivors in patients with relapsed and/or refractory germ cell tumors. Trials to prospetively evaluate HDCT as an early intervention in these patients semm justified.

Células mesenquimais indiferenciadas humanas foram obtidas por digestão enzimática e centrifugação do produto de lipoaspiração, expandidas in vitro, e implantadas no tecido subcutâneo de camundongos atímicos. No grupo I, cada animal recebeu o implante de uma membrana de 0,25cm2 de ácido glicólico e carbonato de trimetileno semeada com 1 x 106 destas células .No grupo II, cada um recebeu a injeção de 0,2ml de gel de ácido hialurônico reticulado contendo o mesmo número destas células. Com três semanas de implante, células humanas e vasos foram identificados nos dois carreadores. Entretanto, com oito semanas, somente no gel de ácido hialurônico as células humanas e os vasos estavam presentes / Human undifferentiated mesenchymal cells were obtained by enzymatic digestion and centrifugation of the product of liposuction. These cells were expanded, in vitro, and implanted subcutaneously in athymic mice. In group I, each animal received the implant of a 0,25cm2 membrane of glycolic acid and trimethylene carbonate, seeded with 1 x 106 of these cells. In group II, each one received 0,2 ml of cross-linked hyaluronic acid gel containing the same amount of these cells. With three weeks of implantation, human cells and vessels were identified in both carriers. However, with eight weeks of implantation, only in hyaluronic acid gel human cells and vessels were present

Células mesenquimais indiferenciadas humanas foram obtidas por digestão enzimática e centrifugação do produto de lipoaspiração, expandidas in vitro, e implantadas no tecido subcutâneo de camundongos atímicos. No grupo I, cada animal recebeu o implante de uma membrana de 0,25cm2 de ácido glicólico e carbonato de trimetileno semeada com 1 x 106 destas células .No grupo II, cada um recebeu a injeção de 0,2ml de gel de ácido hialurônico reticulado contendo o mesmo número destas células. Com três semanas de implante, células humanas e vasos foram identificados nos dois carreadores. Entretanto, com oito semanas, somente no gel de ácido hialurônico as células humanas e os vasos estavam presentes / Human undifferentiated mesenchymal cells were obtained by enzymatic digestion and centrifugation of the product of liposuction. These cells were expanded, in vitro, and implanted subcutaneously in athymic mice. In group I, each animal received the implant of a 0,25cm2 membrane of glycolic acid and trimethylene carbonate, seeded with 1 x 106 of these cells. In group II, each one received 0,2 ml of cross-linked hyaluronic acid gel containing the same amount of these cells. With three weeks of implantation, human cells and vessels were identified in both carriers. However, with eight weeks of implantation, only in hyaluronic acid gel human cells and vessels were present

La greffe de sang de cordon est de plus en plus utilisée et a permis de traiter avec succès chez l’enfant des déficits immunitaires ainsi que des hémopathies malignes comme les leucémies. Malgré d’importants avantages tels que l’absence de risque pour le donneur ou la plus faible incidence de maladie du greffon contre l’hôte (GvHD), utiliser le sang de cordon comporte certains inconvénients. En effet, une reconstitution immunitaire retardée, des infections opportunistes en plus grand nombre et un risque de rechute sont des complications qui peuvent survenir et engendrer un risque pour le pronostic vital du patient. Par conséquent, de nouvelles stratégies d’immunothérapies doivent être envisagées. Dans le cadre de ce travail, nous nous sommes particulièrement intéressés aux cellules dendritiques plasmacytoides (pDC) dont les fonctions sont importantes pour l’initiation des réponses immunitaires innée et adaptative et particulièrement pour leur capacité à activer les cellules NK. Afin d’élucider le rôle et l’impact de ces cellules dans les greffes de sang de cordon, le nombre et la fonction des pDC et des NK a été suivi longitudinalement chez des patients ayant subi une greffe de sang de cordon comparativement à des patients transplantés avec de la moelle osseuse. Nous avons ainsi démontré que les pDC et les NK apparaissent précocement suite à une greffe de sang de cordon et que ces cellules sont fonctionnelles. Ces résultats mettent donc en lumière que ces cellules pourraient être de bons outils pour l’établissement d’une immunothérapie après greffe de sang de cordon. De plus, la caractérisation fonctionnelle des pDC du greffon de sang de cordon a permis de révéler une plus faible production d’IFN-α par les pDC, comparativement aux pDC de sang d’adulte. Cette différence pourrait jouer un rôle dans la plus faible incidence de GvHD après les greffes de sang de cordon. Dans le but de préciser les mécanismes moléculaires de régulation négative de la production d’IFN-α par les pDC de sang de cordon, nous avons étudié les protéines de la voie de signalisation TLR9-IRF7. L’expression similaire de l’ARN du TLR9, MyD88, IRAK1 et IRF7 contraste avec la plus faible expression des protéines correspondantes. De plus, l’expression des MicroARNs miR-146a et miR-155 est plus élevé dans les pDC de sang de cordon comparativement aux pDC de sang d’adultes. Ensemble, ces données pointent une régulation négative post-transcriptionnelle de la voie TLR9-IRF7 qui pourrait expliquer la plus faible production d’IFN-α des pDC du sang de cordon. L’ensemble des ces travaux suggère que les pDC pourraient représenter une cible de choix dans le développement de nouvelles approches thérapeutiques dans les greffes de sang de cordon. / Umbilical cord blood transplantation has increasingly been used as a source of hematopoietic stem cells to successfully treat immunodeficiencies and malignant diseases such as leukemia in pediatric patients. Despite important advantages, namely lack of risk for the donor and low incidence of GvHD, use of cord blood is associated with several drawbacks. Specifically, delayed immune reconstitution, more opportunistic infections and a relative risk of relapse are complications that may occur and lead to a poor prognosis. Consequently, new immunotherapeutic strategies should be considered. In this study, we were interested in plasmacytoid dendritic cells (pDC), whose functions are important for initiation of innate and adaptive immune responses and, in particular, for their ability to activate natural killer cells (NK). In order to elucidate the role and the impact of these cells in cord blood transplantation, pDC and NK numbers and function have been longitudinally followed in cord blood and bone marrow recipients. We showed that pDC and NK cells appeared early after umbilical cord blood transplantation and that these cells retained functional activity. Thus, these cells may constitute a good tool for immunotherapy in umbilical cord blood transplantation. Moreover, the functional characterization of pDC in cord blood revealed a lower production of IFN-α by cord blood pDC, which may play a role in the lower incidence of GvHD after umbilical cord blood transplantations. In order to determine the molecular mechanism for the negative regulation of IFN-α production by cord blood pDC, we studied the expression of TLR9-IRF7 pathway. The stable expression of TLR9, MyD88, IRAK1 and IRF7 mRNA contrasts with the lower expression of corresponding proteins. Interestingly, expression of microRNA miR-146a and miR-155 is higher in cord blood pDC. Together, these results point to a post-transcriptionnal negative regulation of TLR9-IRF7 pathway which may explain the lower IFN-α production by cord blood pDC. This work reinforces the idea that pDCs constitute a target of choice for developing new therapeutic approaches in cord blood transplantations.

As doenças falciformes (DF) constituem um grupo de doenças hereditárias monogênicas. São doenças extremamente relevantes no contexto de saúde pública no Brasil, portanto diferentes estratégias terapêuticas devem ser avaliadas. As oclusões vasculares afetam praticamente todos os órgãos, inclusive o baço e a medula óssea, porém não existem dados na literatura se estas comprometem também o tecido tímico. Os pacientes apresentam maior suscetibilidade às infecções cujas causas não são ainda totalmente esclarecidas Embora as infecções observadas nos pacientes sejam atribuídas à disfunção esplênica, o quadro inflamatório crônico e possíveis alterações no timo e na medula óssea, também poderiam causar uma disfunção imunológica. O objetivo deste trabalho foi avaliar a neogênese de células T e B e a diversidade do repertório de células T periféricas em pacientes com anemia falciforme (AF) sem tratamento (N = 15), tratados com hidroxiuréia (N = 20) ou transfusão crônica (N = 21) e em pacientes com DF tratados com transplante de células-tronco hematopoéticas (TCTH) alogênico (N = 29). Pacientes sem tratamento apresentaram menores níveis de sjTREC e ?-TREC, e menor taxa de divisão celular intratímica, demonstrando alterações importantes na neogênese das células T. A produção tímica de novas células T naïve foi reestabelecida em um ano pós-transplante, com normalização dos níveis de sjTREC e ?-TREC. O desenvolvimento de doença do enxerto contra o hospedeiro (DECHa) e reativação de citomegalovírus comprometeu a timopoiese nos primeiros seis meses pós-transplante, com diminuição significativa dos níveis de sjTRECs e ?-TRECs. Análises do repertório da cadeia V? dos receptores de células T (TCRs), pelo método TCRBV CDR3 spectratyping, indicaram que os pacientes com AF apresentaram um repertório menos diverso, composto predominantemente de famílias V? com padrão skewed e picos de CDR3 monoclonais, sendo a família V?3 mais frequente. A composição do repertório de células T foi alterada após o transplante, adquirindo um perfil mais policlonal dos picos de CDR3 ao longo do tempo. A família V?22 foi a mais expressa no período pré-transplante e em todos os seguimentos pós-transplante. Os pacientes com DF apresentaram aumento de linfócitos B naive, demonstrado pelos altos níveis de sjKRECs e pela taxa de proliferação homeostática. As análises multivariadas demonstraram que as alterações esplênicas influenciam diretamente os níveis de sjKREC, indicando que a baixa função esplênica leva ao aumento da produção de células B naive pela medula óssea, sugerindo um mecanismo compensatório. Os resultados desse trabalho demonstraram a existência de um desequilíbrio na neogênese de células T e B e consequentemente nesses compartimentos celulares periféricos, que pode conferir aos pacientes com DF uma maior susceptibilidade a infecções. Entre as diferentes modalidades terapêuticas, o TCTH alogênico sobressaiu-se em relação aos tratamentos convencionais, melhorando a neogênese de células T e B a longo prazo. / Sickle Cell Disease (SCD) are a group of monogenic hereditary diseases. These are extremely relevant diseases in the context of public health in Brazil, thus, different therapeutic strategies must be studied. Vascular occlusions affect practically all organs, including the spleen and bone marrow. However, there are no literature data about the impact of vaso-occlusions on the thymic tissue. Patients are more susceptible to infections whose causes are not fully elucidated. Although the infections observed in these patients are assigned to splenic dysfunction, the chronic inflammatory state and possible alterations of the thymus and bone marrow could also lead to immune dysfunction. The goal of this work was to evaluate the neogenesis of T and B cells and the diversity of peripheral T cell repertoire in patients with sickle cell anemia (SCA) without treatment (N = 15), treated with hydroxyurea (N = 20) or chronic transfusions (N = 21) and in patients with SCD treated with hematopoietic stem cell transplantation (N = 29) allogeneic. Patients without treatment had lower levels of sjTREC and ?-TREC, and lower rate of intrathymic cell division, demonstrating important alterations in the neogenesis of T cells. The thymic production of new naïve T cells was reestablished at one-year post transplantation, with normalization of sjTREC and ?-TREC levels. The development of graft-versus-host disease (aGVHD) and cytomegalovirus activation compromised thymopoiesis in the first six months post transplantation, with a significant decrease of sjTRECs and ?-TRECs levels. Analysis of the TCR V? chain repertoire by TCRBV CDR3 spectratyping indicate that patients with SCA showed a less diverse repertoire, mainly composed by V? families with a skewed pattern and monoclonal CDR3 peaks, being the V?3 family the most frequent one. The composition of the T-cell repertoire was altered after transplantation, changing over time to more polyclonal profile of the CDR3 peaks. The V?22 family was the more expressed at pre-transplantation and at all follow-up periods. Patients with SCD presented increased numbers of naive B cells, demonstrated by higher levels of sjKRECs and homeostatic proliferation. Multivariate analysis demonstrated that splenic function directly influenced sjKREC levels, indicating that compromised splenic function leads to increase of naive B cell output by the bone marrow, suggesting a compensatory mechanism. The results of this study showed the existence of an imbalanced T and B cell neogenesis and, consequently on these peripheral cell compartments, which may confer to patients with SCD an increased susceptibility to infections. Among different therapeutic modalities, allogeneic HSCT stood out in relation to the conventional treatments, improving long-term T and B cell neogenesis.