粒细胞集落刺激因子动员的异基因外周血单个核细胞输注治疗一例纤维化期高危原发性骨髓纤维化患者的临床分析

Clinical analysis on granulocyte colony stimulating factor mobilized allogenetic peripheral blood mononuclear cell transfusion for one patient with primary myelofibrosis in fibrosis stage

目的探讨粒细胞集落刺激因子动员的异基因外周血单个核细胞(G-PBMNC)输注,治疗不适宜接受异基因造血干细胞移植(allo-HSCT)的纤维化期高危原发性骨髓纤维化(PMF)患者的安全性及疗效。 方法选择2016年3月攀枝花学院附属医院血液科收治的1例年龄为70岁的男性纤维化期高危PMF患者为研究对象。对该例患者进行相关实验室及影像学检查,结合病史及外院相关检查结果进行诊断,并确定疾病分期及危险度。入院后对患者进行口服达那唑、沙利度胺及泼尼松,深部肌肉注射去铁胺、皮下注射红细胞生成素(EPO)治疗;同时,输注悬浮红细胞。2016年4月,患者接受G-PBMNC输注治疗,G-PBMNC供者为其女儿。治疗后观察患者的一般情况及治疗安全性,并且监测血常规检测结果、悬浮红细胞输注量及脾大小。回顾性分析本例患者的相关检查结果、诊断、治疗及疗效,并且对相关文献进行复习。本研究经攀枝花学院附属医院的伦理委员会审查(批准文号:2015伦审第11号),并与受试对象签署临床研究知情同意书。结果①入院后患者血常规检查结果示,白细胞计数为2.0×10^9/L,红细胞计数为1.5×10^12/L,血红蛋白(Hb)值为39.0 g/L,血小板计数为23.0×10^9/L,外周血中原始细胞比例为2%;血清EPO值>774 mIU/mL,铁蛋白值>2 250 μg/L;骨髓穿刺干抽。骨X射线摄片结果示骨硬化;上腹部彩色多普勒超声示脾大,肝轻度增大。本例患者诊断符合PMF,并且处于纤维化期,危险分层为高危。②共分离供者G-PBMNC悬液140 mL,将分离、计数后的G-PBMNC用于患者输注治疗。G-PBMNC悬液中单个核细胞(MNC)输注量为3.0×10^8/kg,CD34^+细胞输注量为1.6×10^6/kg。患者接受G-PBMNC输注治疗后,未出现急性移植物抗宿主病(aGVHD)相关临床表现。③患者主要血常规检查指标于G-PBMNC输注治疗后,均呈上升趋势。患者接受G-PBMNC输注后1与11个月时,中位白细胞计数分别为4.0×10^9/L(3.1×10^9/L^4.6×10^9/L)与3.6×10^9/L(2.7×10^9/L^4.0×10^9/L),均高于输注前的1.8×10^9/L(1.3×10^9/L^2.3×10^9/L);输注后8与13个月时,中位Hb值分别为69.7 g/L (59.2~82.5 g/L)与70.5 g/L(61.3 ~84.1 g/L),均高于输注前的46.8 g/L(33.5~60.3 g/L);输注后6、11与12个月时,中位血小板计数分别为36.5×10^9/L(22.6×10^9/L^43.6×10^9/L)、41.0×10^9/L(29.9×10^9/L^56.7×10^9/L)与39.0×10^9/L(25.7×10^9/L^50.3×10^9/L),亦均高于输注前的14.0×10^9/L(7.2×10^9/L^18.5×10^9/L)。④患者接受G-PBMNC输注治疗前1个月内,共计输注悬浮红细胞12 U;患者接受G-PBMNC输注治疗后1个月时,悬浮红细胞输注量下降为6.5 U;治疗后3~4个月时,悬浮红细胞输注量进一步降低至1.5 U。患者于接受G-PBMNC输注治疗后11个月时,悬浮红细胞输血量仅为3.5 U,并且患者接受悬浮红细胞输注治疗的最长时间间隔达1个月。⑤患者在接受G-PBMNC输注治疗后,脾无进行性增大。结论G-PBMNC输注治疗可以安全地改善纤维化期高危PMF患者的外周血血常规检测指标,减低患者对输血治疗的依赖性。对于不适宜接受allo-HSCT的纤维化期高危PMF患者,G-PBMNC可能是安全、有效的治疗选择。但是该结论仅限于对单一病例的临床分析,尚需大样本、多中心、随机对照试验,进一步研究、验证。

Objective To investigate the safety and efficacy of granulocyte colony stimulating factor mobilized allogenetic peripheral blood mononuclear cell (G-PBMNC) in treatment of patient with primary myelofibrosis (PMF) in fibrosis stage with high risk and unsuitable for allogeneic hematopoietic stem cell transplantation (allo-HSCT).Methods In March 2016, a case of male PMF patient (age: 70 years old)in fibrosis stage with high risk admitted to Department of Hematology, Affiliated Hospital of Panzhihua University was selected as a research subject. Laboratory and imaging examinations were performed to determine the stage and risk of the disease, combined with his medical history and outpatient examination results. After admission, the patient was treated with danazol, thalidomide and prednisone orally, deep intramuscular injection of deferoxamine, subcutaneous injection of erythropoietin (EPO), and suspended red blood cell infusion. In April 2016, the patient received G-PBMNC from his daughter. General condition and treatment safety of patient were observed, and the blood routine test results, transfusion volume of suspended red blood cell and spleen size were monitored. Relevant examination results, diagnosis, treatment and curative effect of this patient were analyzed retrospectively, and related literature was reviewed. This study protocol was approved by the Ethics Committee of Affiliated Hospital of Panzhihua College (No. 11 of the Ethics Examination in 2015), and informed consent was obtained from participant.Results ① After admitted, results of blood routine examination showed that white blood cell count was 2.0×10^9/L, red blood cell count was 1.5×10^12/L, hemoglobin (Hb) value was 39.0 g/L, platelet count was 23.0×10^9/L, ratio of primitive cells in peripheral blood was 2%. Serum EPO value was more than 774 mIU/mL, and ferritin value was more than 2 250 μg/L. No specimens were taken from the bone marrow puncture. Result of bone X ray radiography showed bone sclerosis. Result of upper abdomen color Doppler ultrasound showed splenomegaly and slight hepatomegaly. The patient was diagnosed as PMF in fibrosis stage with high risk. ② A total of 140 mL of G-PBMNC suspension was isolated from the donor, and transfused to the patient after separation and counting. Number of mononuclear cell (MNC) and CD34^+ cell were 3.0×10^8/kg and 1.6×10^6/kg, respectively, and acute graft versus host disease (aGVHD) did not develop 1 months after G-PBMNC infusion. ③ Most of the blood routine examination indexes of the patient showed an upward trend after G-PBMNC infusion. 1 and 11 months after G-PBMNC infusion, median white blood cell counts of the patient were 4.0×10^9/L (3.1×10^9/L-4.6×10^9/L) and 3.6×10^9/L (2.7×10^9/L-4.0×10^9/L), and were higher than that of 1.8×10^9/L (1.3×10^9/L-2.3×10^9/L) before G-PBMNC infusion. 8 and 13 months after infusion, median values of Hb were 69.7 g/L (59.2-82.5 g/L) and 70.5 g/L (61.3-84.1 g/L), and were higher than that of 46.8 g/L (33.5-60.3 g/L) before infusion. 6, 11 and 12 months after infusion, median platelet count were 36.5×10^9/L (22.6×10^9/L-43.6×10^9/L), 41.0 ×10^9/L (29.9 ×10^9/L-56.7 ×10^9/L) and 39.0×109/L (25.7×10^9/L-50.3×10^9/L), and were also higher than that of 14.0×10^9/L (7.2×10^9/L-18.5×10^9/L) before infusion . ④ Within one month before G-PBMNC infusion, a total of 12 U of suspended red blood cells were transfused; while one month after G-PBMNC infusion, amount of suspended red blood cell infusion decreased to 6.5 U. 3-4 months after infusion, transfusion volume of suspended red blood cell decreased to 1.5 U. 11 months after G-PBMNC infusion, transfusion volume of suspended red blood cell was only 3.5 U, and the patient did not receive blood transfusion for one month. ⑤ There was no progressive enlargement of spleen after infusion of G-PBMNC.Conclusions G-PBMNC could safely improve the routine blood test indexes of PMF patients in fibrosis stage with high risk and reduce the dependence of blood transfusion, so G-PBMNC could be a safe and effective treatment option for fibrotic PMF patients in no condition to allo-HSCT. But this conclusion is limited to the clinical analysis of a single case, and it requires large sample, multi-center, randomized controlled trials for further study and verification.