Autologous Stem Cell Grafts Research Articles

Pericardial effusion post-SCT in pediatric recipients with signs and/or symptoms of cardiac disease

The objective of this study was to assess the incidence, risk factors, outcome and impact on OS of pericardial effusion (PEF) in a cohort of 156 pediatric SCT recipients. The mean age was 8.15±6.25 years. In all, 74% of the patients had malignant disease and 35% of the patients received autologous stem cell grafts. Twenty-three subjects developed effusion at 2.75±3.54 months after SCT. The overall probability of developing a PEF after SCT was 16.9%. In the multivariate analysis of risk factors associated with time to PEF, increased age, allogeneic risk status and conditioning type, were all significant factors. In a multivariate analysis of time to death, PEF, CMV status and risk status were all independent risk factors. PEF, however, had the highest HR of 3.334. Of the 23 patients with PEF, 19 died (82.6%); however, none died as a direct result of pericardial tamponade. In summary, our results suggest that PEF is a significant risk factor for post transplant mortality. These results suggest a need for more frequent evaluation and monitoring for development of PEF. Studies are needed to determine the etiology of, and new therapeutic strategies for, PEF in the post-SCT population.

Long‐term cryopreservation of autologous stem cell grafts: a clinical and experimental study of hematopoietic and immunocompetent cells

Autologous stem cell transplantation(ASCT) is used in the treatment of several malignancies.Harvesting sufficient peripheral blood progenitor cells (PBPCs) for a potential second autotransplantation at the time of relapse several years after diagnosis is becoming an increasingly common practice. Cryopreserved PBPCs were prepared with different concentrations of dimethyl sulfoxide (DMSO; 2, 4, 5, and 10%) and stored for at least 5 years before the recovery of CD34+ cells and various T- and natural killer (NK)-cell subsets were analyzed by flow cytometry. Furthermore,clinical variables for myeloma patients having a second autotransplantation with long-term-stored autografts were evaluated. The number of viable CD34+ cells in longterm-stored grafts was higher when autografts were cryopreserved with 4 or 5% than with 2 and 10%DMSO. The number of viable CD34+ cells was reduced by 13.9% after 5 years of cryostorage in 5% DMSO.Lymphocyte viability was also higher with 4 or 5%DMSO. However, the frequencies of several T-cell subsets showed DMSO-dependent differences,whereas NK-cell subsets did not. Furthermore, after a second autotransplantation with long-term-stored PBPC grafts at the time of myeloma relapse (median storage time, 42 months) all 17 patients reached neutrophil counts exceeding 0.5 x 10⁹/L and platelet counts exceeding 20 x 10⁹/L within 15 days. There was no difference in engraftment between patients receiving autografts preserved with 5 and 10% DMSO. PBPC autografts can safely be stored for at least 5 years in 5% DMSO and used for ASCT.

Increased plasma EPO and MIP-1α are associated with recruitment of vascular progenitors but not CD34(+) cells in autologous peripheral blood stem cell grafts

Increased levels of endothelial-like vascular progenitor cells (VPCs) in peripheral blood stem cell (PBSC) products have been associated with reduced transplant-related toxicity following autologous hematopoietic stem cell transplantation. In this study, a panel of angiogenic and inflammatory plasma proteins were quantitatively analyzed in patients undergoing PBSC collection for autologous hematopoietic stem cell transplantation to identify profiles associated with greater VPC recruitment. A panel of 16 candidate plasma factors were quantified using multianalyte fluorescence and/or enzyme-linked immunosorbent assay. VPC clusters were enumerated using a standard cell culture assay. Thirty-six patients (mean age=51 years, 42% female) had plasma collected at baseline prior to PBSC mobilization and on the day of PBSC collection. Only erythropoietin (EPO) levels increased significantly on the day of PBSC collection in comparison with baseline plasma levels (2.2-fold increase; p=0.003). Interleukin-2, -10, epidermal growth factor, interferon-alpha, and angiopoietin-1 all decreased significantly between baseline and the day of PBSC collection (p<0.02). The remaining cytokine levels did not change appreciably (p=NS). The cohort was divided into "low" graft VPCs (<2.0 x 10(3)/kg) and "high" graft VPCs (>or=2.0 x 10(3)/kg) and cytokine levels were compared between the groups. At baseline, increased levels of macrophage inflammatory protein-1 alpha (MIP-1 alpha) were associated with increased graft VPCs (p=0.05) while higher EPO concentrations on the day of PBSC collection predicted higher graft VPC levels (p=0.02). These cytokines were not associated with CD34(+) cell mobilization. The association of different plasma proteins with graft VPC and CD34(+)-cell levels suggests that mobilization of vascular and hematopoietic progenitors occurs through independent mechanisms. Patients with low levels of MIP-1 alpha at baseline may be candidates for interventions aimed at increasing graft VPC levels. Strategies that increase plasma EPO concentrations may be most promising to augment the regenerative properties of PBSC products.

A simplified method for stem cell autografting in multiple myeloma: a single institution experience

In a 14-year period in a single institution 31 autografts were performed in 26 patients with multiple myeloma (MM), using a simplified and affordable autografting procedure: conducting the grafts on an outpatient basis and avoiding stem cell freezing. Autografts were started on an outpatient basis in all instances, but four patients were admitted to the hospital. Median time to achieve more than 0.5 x 10(9)/l granulocytes was 27 days, whereas median time to recover above 20 x 10(9)/l plts was 37 days. CR was achieved in 19 cases and a very good partial response in 6 cases. The 100-day mortality was 9.6%. The overall median post-transplant survival has not been reached, being above 76 months, whereas the 76-month survival is 80%. The median cost of each procedure was US$ 15 000. Survival results were substantially better than those of historical control in a group of patients treated in the same institution with melphalan/prednisone. It is concluded that high-dose therapy rescued with a simplified autologous stem cell graft is a valid, useful and affordable therapeutic option for patients with MM, even with economical restraints.

Use of different DMSO concentrations for cryopreservation of autologous peripheral blood stem cell grafts does not have any major impact on levels of leukocyte-and platelet-derived soluble mediators

Infusion of stem cell autografts can be associated with adverse effects. Necrotic normal leukocytes, cytokines or intracellular mediators released from leukocytes and platelets or the cryo-protectant dimethyl sulfoxide (DMSO) may contribute to this. Cryopreservation using 5% instead of 10% DMSO improves CD34(+) cell viability and therefore we investigated whether using less DMSO had favorable outcomes on leukocyte viability and levels of various soluble mediators in the graft supernatant. Peripheral blood autografts were harvested by 20 apheresis procedures in 16 cancer patients, and autograft samples were cryopreserved with 2%, 4%, 5% and 10% DMSO and stored for 5-6 years. After thawing, the viability of neutrophils and lymphocytes was analyzed by flow cytometry and supernatant levels of soluble mediators were determined by enzyme-linked immunosorbent assay (ELISA) analyzes. The highest viability of both neutrophils and lymphocytes was detected with 4% and 5% DMSO, whereas decreased viability was observed with 2% and 10% DMSO. Low or undetectable levels of leukocyte-derived interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha and CXCL8, high levels of platelet-derived CCL5 and CXCL4, and high levels of monocyte-derived soluble CD14 were measured independent of the DMSO concentration, except for slightly increased CXCL8 and decreased CXCL4 levels with 2% DMSO. Perforin levels showed a significant inverse correlation with the DMSO concentration. The use of different DMSO concentrations affects the viability of normal leukocytes in autologous peripheral blood stem cell grafts, but has only minor effects on supernatant levels of leukocyte- and platelet-derived soluble mediators.

The Use of Clinical Grade Magnetic Beads to Deplete Immune Suppressive Elements from Autologous Peripheral Blood Hematopoietic Stem Cell Grafts Enhances T Cell Immune Responses.

Background: Despite the demonstrated efficacy of high dose chemotherapy and autologous hematopoietic stem cell transplantation in Myeloma and relapsed Lymphoma, relapse continues to be a problem. Improving post transplant immune reconstitution in general and tumor specific immune response can reduce relapse rates. Pre-clinical and clinical data suggest that the abundance of CD4+/CD25+ regulatory T-cells (T-regs) and CD14+ monocytes in the autologous graft can contribute to the well described immune suppression state in the early months post transplant. We hypothesized that it is feasible to deplete both of these cellular inhibitory elements from the autologous grafts using clinical grade CD25 and CD14 magnetic beads from Miltenyi. We also hypothesized that the depletion of these populations would improve the proliferative capacity of T-cells in these grafts.Methods: Samples of peripheral blood hematopoietic stem cell grafts from 9 patients (4 lymphomas and 5 myelomas) undergoing autologous stem cell transplantation, with G-CSF mobilized grafts. We depleted T regs and monocytes, using CD25 and CD14 beads from these graft samples. Then we compared T cell reactivity between the manipulated graft versus the unmanipulated graft samples, in a mixed lymphocyte reaction.Results: We show that it is feasible to deplete both populations based on phenotype analysis that confirmed selective depletion of CD4+/CD25+/CD127-T reg population (70–80%) and CD14 population (74%.). The positively selected population was enriched for T regs CD4+CD25+CD127-(50–85%) and monocytes CD14+ (75%+). Furthermore in 9 out of 9 patients T cell proliferation measured by 3H thymidine uptake was close to two fold or higher in the double depleted grafts compared to the unmanipulated grafts (P=0.004 Wilcoxon Signed Rank Test).Conclusion: Double depletion of T regs and monocytes from autologous grafts using clinical grade magnetic beads, leads to enhanced T cell proliferation. This work will lay the ground for a subsequent clinical trial of regulatory T-cell/Monocyte depleted autologous transplantation using the same strategy, to enhance immune recovery post transplant and achieve better anti-lymphoma, or anti-myeloma immune response. [Display omitted]

Sphincter Contractility After Muscle-Derived Stem Cells Autograft into the Cryoinjured Anal Sphincters of Rats

PurposeThis study was designed to determine whether the injection of muscle-derived stem cells into the anal sphincter can improve functional properties in a fecal incontinence rat model.MethodsCryoinjured rats were utilized as a fecal incontinence model. The gastrocnemius muscles of normal three-week-old female Sprague-Dawley rats were used for the purification of the muscle-derived stem cells. The experimental group was divided into three subgroups: normal control; cryoinjured; and muscle-derived stem cells (3 × 106 cells) injection group of cryoinjured rats. All groups were subsequently employed in contractility experiments using muscle strips from the anal sphincter, one week after preparation.ResultsContractility in the cryoinjured group was significantly lower than in the control after treatment with acetylcholine and KCl. In the muscle-derived stem cells injection group, contraction amplitude was higher than in the cryoinjured group but not significantly (20.5 ± 21.3 vs. 17.3 ± 3.4 g per gram tissue, with acetylcholine (10−4 mol/l); 31 ± 14.2 vs. 18.4 ± 7.9 g per gram tissue, with KCl (10−4 mol/l)). PKH-26-labeled transplanted cells were detected in all of the grafted sphincters. Differentiated muscle masses stained positively for alpha smooth muscle actin and myosin heavy chain at the muscle-derived stem cells injection sites.ConclusionsThis is the first study reporting that autologous muscle-derived stem cell grafts may be a tool for improving anal sphincter function.

In vitro evidence for impaired neuroprotective capacities of adult mesenchymal stem cells derived from a rat model of familial amyotrophic lateral sclerosis (hSOD1 G93A)

Protection of neurons by stem cells is an attractive challenge in the development of efficient therapies of neurodegenerative diseases. When giving preference to autologous grafts, the bone marrow constitutes a valuable source of adult stem cells. Therefore, we herein studied the acquisition of neuroprotective functions by cultured mesenchymal stem cells (MSCs) exposed to growth factors known to promote the differentiation of neural stem cells into astrocytes. In these conditions, MSCs showed increased transcription and expression of the high-affinity glutamate transporter GLT-1 and functional studies revealed increased aspartate uptake activity. In addition, differentiation was shown to endow the cells with the capacity to respond to riluzole which triggers a robust up-regulation of the GDNF production. In parallel, MSCs derived from the bone marrow of a transgenic rat model of familial ALS (hSOD1 G93A) were also characterised. Unexpectedly, cells from this rat strain submitted to the differentiation protocol showed modest capacity to take up aspartate and did not respond to the riluzole treatments. These data highlight the neuroprotective potential attributable to MSCs, supporting their use as valuable tools for the treatment of neurodegenerative disorders. However, the cells from the transgenic animal model of ALS appeared deficient in their capacity to gain the neuroprotective properties, raising questions regarding the suitability of autologous stem cell grafts in future therapies against familial forms of this disease.

Autologous peripheral blood progenitor cells cryopreserved with 5 and 10 percent dimethyl sulfoxide alone give comparable hematopoietic reconstitution after transplantation

Previous in vitro studies have demonstrated decreased apoptosis and necrosis in peripheral blood progenitor cells (PBPCs) cryopreserved with 5 percent instead of 10 percent dimethyl sulfoxide (DMSO). This study was carried out to investigate whether these in vitro findings were supported by clinical data concerning hematopoietic engraftment after autologous stem cell transplantations with PBPCs cryopreserved with 5 and 10 percent DMSO. During a 6-year period, 103 consecutive patients with newly diagnosed multiple myeloma (MM; n = 58) and lymphoma (n = 45) were transplanted with autologous PBPCs. Throughout the first part of the period cells were cryopreserved with 10 percent DMSO and later with 5 percent. A retrospective comparison was carried out of the clinical results for these two groups. No significant difference in median time to neutrophil and platelet (PLT) engraftment was demonstrated for MM and lymphoma patients transplanted with PBPCs cryopreserved with 5 or 10 percent DMSO. Time until neutrophil counts of more than 0.5 x 10(9) per L was 10 days both for the 5 and 10 percent MM groups and 12 days for both the 5 and the 10 percent lymphoma patients. Median time until stable PLT counts of more than 20 x 10(9) per L was 11 days in all four groups. In addition, transfusion requirements and duration of days admitted to hospital did not differ between the groups. The routines for cryopreservation of autografts vary considerably between transplantation centers, and this makes it difficult to compare different clinical studies. Our results suggest that cryopreservation with 5 percent DMSO alone followed by storage in nitrogen is a simple, highly standardized, and safe procedure for cryopreservation of autologous stem cell graft.

Lentiviral RNAi-induced downregulation of adenosine kinase in human mesenchymal stem cell grafts: A novel perspective for seizure control

Cell therapies based on focal delivery of the inhibitory neuromodulator adenosine were previously shown to provide potent seizure suppression in animal models of epilepsy. However, hitherto used therapeutic cells were derived from rodents and thus not suitable for clinical applications. Autologous patient-derived adenosine-releasing cell implants would constitute a major therapeutic advance to avoid both xenotransplantation and immunosuppression. Here we describe a novel approach based on lentiviral RNAi mediated downregulation of adenosine kinase (ADK), the major adenosine-removing enzyme, in human mesenchymal stem cells (hMSCs), which would be compatible with autologous cell grafting in patients. Following lentiviral transduction of hMSCs with anti-ADK miRNA expression cassettes we demonstrate up to 80% downregulation of ADK and a concentration of 8.5 ng adenosine per ml of medium after incubating 10 5 cells for 8 h. hMSCs with a knockdown of ADK or cells expressing a scrambled control sequence were transplanted into hippocampi of mice 1 week prior to the intraamygdaloid injection of kainic acid (KA). While mice with control implants expressing a scrambled miRNA sequence or sham treated control animals were characterized by KA-induced status epilepticus and subsequent CA3 neuronal cell loss, animals with therapeutic ADK knockdown implants displayed a 35% reduction in seizure duration and 65% reduction in CA3 neuronal cell loss, when analyzed 24 h after KA-injection. We conclude that lentiviral expression of anti-ADK miRNA constitutes a versatile tool to generate therapeutically effective adenosine releasing hMSCs, thus representing a model system to generate patient identical autologous adult stem cell grafts.

Postirradiation Hyperthermia Selectively Potentiates the Merocyanine 540-Sensitized Photoinactivation of Small Cell Lung Cancer Cells¶

Abstract Lung cancer has long been considered a disease that might benefit from the dose escalation of radio/chemotherapy afforded by a stem cell transplant. However, the clinical experience with high-dose chemotherapy and autologous bone marrow transplantation in lung cancer has been disappointing, with most trials showing little or no improvement in long-term survival. Unfortunately, lung cancer has a tendency to metastasize to the bone marrow, and lung cancer cells are known to circulate in the peripheral blood. Therefore, there is concern that autologous stem cell grafts from lung cancer patients may reinoculate recipients with live tumor cells. Photochemical purging of stem cell grafts with Merocyanine 540 (MC540) is highly effective against a wide range of leukemia and lymphoma cells and is well tolerated by normal hematopoietic stem and progenitor cells. Most solid tumor cells (including lung cancer cells), however, are only moderately sensitive or refractory to MC540-mediated photodynamic therapy ...

Potentiation of the Antitumor Effect of Merocyanine 540‐mediated Photodynamic Therapy by Amifostine and Amphotericin B

Leukemia and lymphoma cells are much more sensitive to Merocyanine 540 (MC540)-mediated photodynamic therapy (PDT) than normal pluripotent hematopoietic stem cells and normal colony forming unit-granulocyte/macrophage progenitors (CFU-GM). By contrast, most solid tumor cells are only moderately sensitive to MC540-PDT. The limited activity against solid tumor cells has detracted from MC540's appeal as a broad-spectrum purging agent. We report here that noncytotoxic concentrations of amifostine (Ethyol, Ethiofos, WR-2721) and amphotericin B used either alone or in combination potentiate the MC540-sensitized photoinactivation of leukemia cells, wild-type small cell lung cancer cells and cisplatin-resistant small cell lung cancer cells. Amphotericin B also enhances the MC540-sensitized photoinactivation of normal CFU-GM, whereas amifostine protects CFU-GM against the cytotoxic action of MC540-PDT. The yield of CD34-positive normal hematopoietic stem and progenitor cells is only minimally diminished by pretreatment with amifostine, amphotericin B or combinations of amifostine plus amphotericin B. Purging protocols that combine MC540-PDT with amifostine or with amifostine plus amphotericin B could offer a simple and effective approach to the purging of autologous stem cell grafts that are contaminated with solid tumor cells or the purging of stem cell grafts from heavily pretreated leukemia patients that contain reduced numbers of normal stem and progenitor cells and, therefore, can ill afford additional losses caused by purging.

Placental mesenchymal stem cells as potential autologous graft for pre- and perinatal neuroregeneration

Mesenchymal stem cells (MSCs) have a broad differentiation potential. We aimed to determine if MSCs are present in fetal membranes and placental tissue and to assess their potential to differentiate into neurogenic and mesodermal lineages. MSCs isolated from first and third trimester chorion and amnion and first trimester chorionic villi and characterized morphologically and by flourescence-activated cell sorting analysis. Their ability to mature under different culture conditions into various cells of mesodermal and neuroectodermal cell lines was assessed by immuno- and cytochemical staining. Independent of gestational age, cells isolated from fetal membranes and placenta showed typical MSC phenotype (positive for CD166, CD105, CD90, CD73, CD49e, CD44, CD29, CD13, MHC I; negative for CD14, CD34, CD45, MHC II) and were able to differentiate into mesodermal cells expressing cell markers/cytologic staining consistent with mature chondroblasts, osteoblasts, adipocytes, or myocytes and into neuronal cells presenting markers of various stages of maturation. The differentiation pattern was mainly dependent on cell type. Mesenchymal cells from chorion, amnion, and villous stroma can be differentiated into neurogenic, chondrogenic, osteogenic, adipogenic, and myogenic lineage. Placental tissue obtained during prenatal chorionic villous sampling or at delivery might be an ideal source for autologous stem cell graft for peripartum neuroregeneration and other clinical issues.

Placental mesenchymal stem cells as potential autologous graft for pre- and perinatal neuroregeneration

Placental mesenchymal stem cells as potential autologous graft for pre- and perinatal neuroregeneration

Mobilization of Endothelial Progenitor Cells in Autologous and Allogeneic Peripheral Blood Stem Cell Grafts.

Endothelial-like progenitor cells circulate in the peripheral blood and can be enumerated using cell culture progenitor assays. These circulating vascular progenitor cells (VPCs) are implicated in new vessel formation and regenerative potential in several animal and human models of tissue injury. A small proportion likely arise from rare marrow-derived hemangioblasts, a greater number from vessel-wall endothelial precursors, and the majority derive from circulating monocytic progenitors under angiogenic stimulation. Given the emerging role of VPCs in regenerative processes, we sought to characterize the mobilization of VPCs in peripheral blood stem cell grafts used in autologous and allogeneic hematopoietic transplantation. Mononuclear cells were separated from peripheral blood (PB) or peripheral blood stem cell (PBSC) samples using Ficoll density centrifugation and plated on fibronectin-coated plastic dishes in RPMI supplemented with 20% fetal calf serum, 50 μg/ml endothelial cell growth factor, and 10 IU/ml heparin. After 48 h, the more immature non-adherent cells were collected, washed and re-plated in fibronectin-coated dishes under similar angiogenic conditions. Media and growth factors were replaced every 2 – 3 days and putative VPC clusters were enumerated 7 days after replating. Immunohistochemistry revealed that VPC clusters from PB and PBSCs were CD45+ and acquired endothelial features (CD31 and VE-cadherin) in vitro under angiogenic stimulation and gradually lost monocytic surface markers (CD14) suggesting the important contribution of monocyte-derived VPCs. VPCs were then enumerated in transplant candidates with hematologic malignancies (multiple myeloma = 4 pts, and lymphoma = 3 pts, having received a median of 2 previous chemotherapy regimens (range: 1–4) and 7 previous treatment cycles (range: 4–14)), and compared to healthy controls (n=21). Before mobilization, VPCs were markedly reduced in patients with hematologic malignancies as compared to normal donors with 16±10 vs 99±21 VPCs per ml (mean±SD), respectively (p=0.006). In 5 patients undergoing mobilization with cyclophosphamide and G-CSF, VPCs in the PB increased from 7±2 on day 0 to 51±9 by day 7 of mobilization (p=0.05), representing a median fold-increase of 8.9 (range, 3.0 – 29.8). Levels of VPCs in PB on day 7 of mobilization correlated with the peripheral blood CD34 counts measured on the same day (r=0.94). In an effort to compare the regenerative capacity and blood-forming potential of autologously mobilized PBSCs (n=5) and PBSCs from normal donors (n=14), graft VPCs were compared with levels of CD34+ cells, total CFU and CFU-GM. None of these hematopoietic progenitors correlated with VPC numbers in a significant manner (r < 0.5 in all tests of linearity). Using standard mobilization strategies, we have observed that VPCs were higher in allogeneic (7.5±1.6 x103/kg) than autologous (2.7±1.7 x103/kg) mobilized peripheral blood grafts (p=0.05). Our analysis of PBSC grafts indicates that VPC content in patients undergoing autologous SCT is low both before and after standard mobilisation strategies. In addition, VPC mobilization may occur independently of hematopoietic mobilization. In view of the potential role of VPCs in recovery from transplant related tissue injury, it may be useful to devise angiogenic mobilization strategies that complement hematopoietic mobilization.

Successful treatment of disseminated aspergillosis with the combination of voriconazole, caspofungin, granulocyte transfusions, and surgery followed by allogeneic blood stem cell transplantation in a patient with primary failure of an autologous stem cell graft

The treatment of disseminated aspergillus infections in neutropenic patients remains a major challenge in spite of several new antifungal drugs. We report the case of a patient with multiple myeloma in prolonged neutropenia after primary failure of an autologous stem cell graft who developed invasive aspergillosis despite voriconazole monotherapy. He responded to a combination of voriconazole and caspofungin, supported by granulocyte transfusions and surgery. A subsequent allogeneic peripheral blood stem cell transplantation did not lead to recurring aspergillus infection. The patient is well and free of clinical disease with respect to the fungal infection and myeloma more than 18 months after the allogeneic transplantation.

Immunological autologous stem cell graft engineering using combination G-CSF and aldesleukin (IL-2) in patients with non-Hodgkin’s lymphoma

Immunological autologous stem cell graft engineering using combination G-CSF and aldesleukin (IL-2) in patients with non-Hodgkin’s lymphoma

Antifungal Prophylaxis with Itraconazole in Patients with Acute Leukemia and after Stem Cell Transplantation (SZT): High Plasma Concentrations with a Loading Dose Strategy.

Invasive fungal infection (IFI) is a major complication in the treatment of leukemia. Itraconazole (ITR) is an azole antifungal that has activity against both Candida species and molds. Its prophylactic use in patients at high risk for IFI has been shown to reduce invasive mold infections, but the antifungal efficacy depends on a sufficient plasma concentration early in the course of prophylaxis. We tested a loading dose strategy to reach plasma levels above 500 μg/l by 48 hours.ITR plasma concentrations from 30 patients (pts) in 51 treatment courses were sampled on day 3, 7 and 11 of prophylaxis which started one day after conclusion of chemotherapy. It consisted of 400 mg oral solution and 400 mg intravenous ITR on day 1+2 and continued with 400 mg oral solution daily until an ANC count > 500/μl, limiting toxicity or the use of empirical antifungal treatment. Plasma concentrations were measured by LC-MS/MS. Two pts received an allogeneic, 4 pts an autologous stem cell graft. Underlying diseases were 43 AML, 4 CML blast crisis, 3 Hodgkin's disease and 1 Ph+ ALL. In 45 courses chemotherapy was based on Cytarabine plus an anthracycline.Data from 51 courses were analyzed. Median time of neutropenia (ANC < 500/μl) was 11 days (4–25 days), median time of ITR was 14 days (4–28 days). Median ITR plasma concentrations were 902 μg/l (176–5149) on day 3, 604 μg/l (145–1945) on day 7 and 942 μg/l (191–2987) on day 11. The desirable plasma level of > 500 μg/l after 48 hours of ITR was achieved in 86% of courses and remained above that level in 64% on d 7 and 75% on d 11. No proven or probable IFI could be observed. In 15% of courses empiric antifungal treatment with Amphotericin B and Voriconazole was initiated because of persisting neutropenic fever. Colonization with Candida species was found in 32% of courses. Nausea and vomiting grade 1/2 CTC was observed 39%, diarrhea in 14% of courses.Sufficient plasma concentrations 48 hours after starting antifungal prophylaxis with ITR can be reached with a loading dose combining oral solution and intravenous formulation. Toxicity is mild with only 10% of patients refusing oral solution. Our strategy suggests a high prophylactic efficacy in terms of preventing IFI in this high-risk group of patients.

Reduced Intensity Conditioning Regimen for Allografting Following Cytoreductive Autografting in Metastatic Breast Cancer.

We postulated that it is possible to safely extend the benefits of allografting to metastatic breast cancer by combining cytoreduction achieved with high-dose therapy and autologous stem cell transplant (HDT/ASCT) and graft versus tumor effect mediated through transplanted donor immune cells with nonmyeloablative allografting (RICT). Seventeen patients, 41 years of age (range, 31–57), with heavily pretreated disease were given HDT/ASCT. No patient died after HDT/ASCT. Thirty-one to 92 days (median, 51 days) after HDT/ASCT the patients received fludarabine 30 mg/m2/day x 3 days and cyclophosphamide 300 mg/m2/day x 3 days and donor PBPC from HLA-identical siblings. Postgrafting immunosuppression consisted of cyclosporine and methotrexate. Donor lymphocyte infusions were given to 11 patients with stable mixed chimerism and/or progressive disease, who did not show signs of GVHD. Thirteen patients (76%) achieved sustained donor engraftment. Three patients achieved partial remission (PR) after HDT/ASCT and complete remission (CR) after RICT; another no-responsive patient achieved PR for an overall response rate of 4/17 (22%). The first signs of responsiveness in CR patients began at day +80, +90 and +110 and the maximal response was achieved on day +240, +300 and +390. The 3 remitters patients achieved full chimerism and developed GVHD before regression of the disease. Grade ≥II aGVHD occurred in 5 patients (29%) and extensive cGVHD in 5 patients (29%). No transplant-related deaths (TRD) were observed during the first 100 days. Three patients died of extensive cGVHD in the first year. At April 2004, 5/17 patients (29%) are alive 90–2160 days (median, 1320) from RICT. In conclusion, this 2-step approach is a feasible procedure in metastatic breast cancer patients; the exploitation of graft versus tumor effect is a promising finding.

Impaired bone marrow hematopoietic progenitor cell function in rheumatoid arthritis patients candidated to autologous hematopoietic stem cell transplantation.

We have evaluated bone marrow morphology, percentage of bone marrow CD34(+) cells, proliferative activity of bone marrow precursors, clonogenic assay (BFU-E and CFU-GM) in short-term bone marrow cultures, and bone marrow cell apoptosis, together with serum TNF-alpha and IL-6, in 16 chronic, refractory RA patients, as well as in five healthy controls. Of 16 RA patients (68.7%), 11 showed a reduced bone marrow cellularity, while it was normal in all the controls. In RA patients, the median percentage of CD34(+) bone marrow cells, the median percentage of proliferating bone marrow myeloid precursors, and the median number of both BFU-E and CFU-GM colonies were significantly lower than observed in the controls. As far as TNF-alpha and IL-6 titers is concerned, the latter did not significantly differ from controls' values, while TNF-alpha titers were significantly lower in healthy controls. Finally, the median apoptotic index of early bone marrow myeloid cells of RA patients was significantly higher compared with controls. These observations may identify the biological risk factors for impaired mobilization and/or engraftment when RA patients are candidates for autologous hematopoietic stem cell grafting.