Early Stem Cell Transplantation Research Articles

Early Autologous Stem Cell Transplantation (SCT) in Genetically Poor-Risk Chronic Lymphocytic Leukemia Is Feasible and Effective: Results from a Prospective Multicenter Study (GCLLSG CLL3 Protocol).

From July 1997 through June 2002, the German CLL Study Group conducted a prospective multicenter trial to assess the feasibility and efficacy of early SCT in patients with poor-risk chronic lymphocytic leukemia (CLL). The protocol comprised optional cytoreduction with CHOP, fludarabine, or FC; PBSC mobilization using the Dexa-BEAM regimen; and myeloablative therapy with TBI/CY followed by reinfusion of purged stem cells. Inclusion criteria were age <61 years, stage Binet B/C or poor-risk stage A as defined by short lymphocyte doubling time plus elevated STK, and one line of pretreatment or less. Endpoints were feasibility (as defined by the proportion of patients able to successfully undergo all study procedures); toxicity; efficacy; and quality of life (QOL) as defined by the Spitzer QOL Index.Results: As of July 2004, 128 of 179 eligible patients were evaluable. Median age was 51 (27–60) years. Binet stages were poor-risk A 15%; B 61%; C 24%. An unmutated VH rearrangement was present in 72%. Eighty-six percent of the patients were chemotherapy naive at study entry. Best documented response during the pretransplant phase was complete remission (CR) in 28% and partial remission (PR) in 64% of the patients, giving an overall response rate of 92%. Immunomagnetically purged grafts were obtained in 83% of the patients in whom mobilization was attempted, containing 4.6 (1.2–22.1) CD34+ cells per kg body weight. Altogether, 98 of 128 patients (77%) proceeded to SCT. Reasons for exclusion from SCT were disease progression, mobilization failure, toxicity during the mobilization phase, or patient's refusal. At 3 months post SCT CR was reported in 78% and PR in 21%. With a follow-up time of 36 (3–77) months, median progression-free survival of all 128 patients intended to treat was 59 months (54 months for those with unmutated VH). 4-year overall survival of all 128 patients was 84% (95%CI 74–94). Grade 3/4 non-hematological toxicity was mainly due to infections, which occurred in 21% of the patients (18% pretransplant; 7% post transplant). Six complications were fatal (4 pretransplant, 2 post transplant), translating into a 5% probability of treatment-related death. A single case of treatment-related myelodysplasia / AML has been reported to date. One year after SCT, QOL index had the maximum score of 10 points in 48 of 57 evaluable patients (84%). In comparison to prestudy levels, QOL had increased in 35%, remained similar in 50%, and decreased in 15% of the patients.Conclusions: Early sequential high-dose therapy including SCT for poor-risk CLL is feasible and has promising efficacy. Whereas the transplant-related toxicity appears to be acceptable, future studies should aim at replacing Dexa-BEAM by a similarly effective but less toxic mobilization regimen.

Salvage of Primary Refractory Acute Leukemia (AL) with High-Dose Etoposide (VP) and Cyclophosphamide (CY) Followed by Early Stem Cell Transplantation (SCT): An Effective Treatment Strategy for AML but Not for All.

Primary refractory AL has a poor prognosis although some patients (pts) can be salvaged with allogeneic SCT. Induction of complete remission (CR1) with conventional chemotherapy prior to conditioning and SCT may improve long-term event-free survival (EFS). Between 03/91 and 10/03, 59 adults with primary refractory AL (defined as >15% marrow blast cells on day 30 of induction) were treated with VP 2.4 g/m2 by 34 hr. IV infusion beginning on day 1 followed by CY 2.0 g/m2 IV daily on days 3, 4 and 5 with hyperhydration (3 L/m2/d) as bladder prophylaxis. Six pts received VP 3.0 g/m2 and 1 patient received CY 1.8 g/m2 x 4 days. The study included 39 males and 20 females with a median age of 41 years (range 17–60). Diagnoses were AML (42 pts), ALL (13 pts) and biphenotypic AL (4 pts). Eleven pts (19%) presented with a WBC count > 50 x109/L and MRC karyotype was favourable in 4 pts, intermediate in 34 pts and adverse in 20 pts; metaphase analysis failed in 1 patient. All AML pts had already received high-dose cytosine arabinoside (HIDAC) and either daunorubicin (DNR) (n=33) or mitoxantrone and VP (n=9). ALL pts had previously received DNR, vincristine and prednisone with (n=9) or without (n=4) L-asparaginase. Biphenotypic AL pts had been induced with HIDAC, DNR, vincristine and prednisone. Induction day 30 marrow blast count was > 40% in 35 pts (59%). The most common grade I/II non-hematologic toxicities of VP/CY were oral mucosal (44% of pts), GI (20% of pts) and hepatic (15% of pts); only one patient developed grade III/IV toxicity (pulmonary). Median time to recovery of ANC > 0.5 x109/L and platelets > 20 x109/L was 26 and 22 days, respectively. Three pts (5%) died prior to day 21 of VP/CY and were not evaluable for response (2 pts sepsis, 1 patient pulmonary hemorrhage). Twenty-four pts (43%) were also refractory to VP/CY but 32 pts (57%) entered CR1. Response rates were similar in AML (54%) and ALL/ABL (67%) (p=0.52) and analysis of baseline patient characteristics did not reveal any predictors of response to VP/CY. Twenty-nine of 32 CR1 pts proceeded to SCT (24 allogeneic, 5 autologous); five pts with AL refractory to VP/CY also underwent allogeneic SCT although all subsequently relapsed. Four of the autologous SCT pts relapsed with only one patient remaining alive in CR1. Estimated 5-year EFS for the entire cohort of pts is 23%. The only positive predictor of survival was male sex (p=0.03) and cytogenetic risk group did not influence outcome (p=0.69). In the allogeneic SCT group, 5-year EFS was 45% and was signficantly better for pts with AML (52%) compared to pts with ALL (14%, p=0.04). In conclusion, VP/CY is able to induce CR1 in the majority of pts with primary refractory AL. For pts with AML in CR1 that have a suitable donor, subsequent allogeneic SCT results in a favourable long-term EFS. Although pts with primary refractory ALL have a high CR1 rate with VP/CY, overall outcome for this subgroup remains poor.

Hematopoietic Stem Cell Transplantation Cures Oc/Oc Mice from Osteopetrosis.

Background: Infantile malignant osteopeterosis is a rare autosomal recessive disorder affecting osteoclast function. Fifty % of the affected children have a mutation in the Tcirg1 gene coding for one subunit of an osteoclast specific proton pump. This pump is used by the osteoclast for acidification to enable bone resorption. Patients with this disease have normal or elevated numbers of non-functional osteoclasts, leading to increase in bone mass. The dense, sclerotic bones cause among other things pancytopenia, hepatosplenomegaly and progressive visual loss. The only curative treatment so far is hematopoietic stem cell transplantation (SCT). Without treatment, this disease results in death of 70% of the patients by the age of 6 years. The oc/oc mouse has a mutation in the gene homologous to Tcirg1 giving rise to similar symptoms as in patients. However, previous attempts to cure these mice with SCT have been unsuccessful (M.F. Seifert and S.C. Marks, Jr, Tissue & Cell 1987).Aim: To determine if early hematopoietic SCT can cure oc/oc mice from osteopetrosis.Material and Methods: One day old litters from oc/+ breeding pairs where given a radiation dose of 400 or 600 cGy. Four hours later the pups where injected ip with 1 or 5x106 lineage depleted (lin−) bone marrow (BM) cells from normal mice. Three weeks after injection, pups were genotyped and engraftment levels (based on CD45 variant expression) were checked 3 and 12 weeks after injection. X-ray examination of mutant and normal mice were performed.Results: Irradiated oc/oc mice transplanted with normal lin− BM survive past the normal lifespan of 26 days and show normalisation of the bone structure. 18 weeks after transplantation oc/oc mice are still alive. Levels of engraftment were as follows:Engraftment in transplanted mice400 cGy 1x106 cells400 cGy 5x106 cells600 cGy 5x106 cells3 w12 w3 w12 w3 w12 woc/oc15,138,830,048,321,248,3wt or oc/+13,410,828,128,519,328,5Percentage of engrafted cells in transplanted oc/oc mice and control littermatesEven though they increase in weight, the oc/oc mice remain smaller then their littermates. In contrast to untreated animals where teeth eruption is delayed or absent, teeth develop but with abnormal structure and shape making them not usable. If the transplant was delayed until day 8 the mice did not survive longer than untransplanted oc/oc mice.Discussion: Previous attempts to cure these mice with transplantation were not successful with only 2 out of 29 mice surviving past normal lifespan. However, these transplants were performed with non-purified cells and without matching for tissue type. We found 400 cGy and 5 million cells to be optimal for successful transplantation of 1 day old oc/oc mice.Engraftment levels were generally higher in oc/oc mice than in transplanted oc/+ or wt littermates indicating a smaller competing stem cell pool in these mice or a survival advantage of normal transplanted cells compared to stem cells in oc/oc mice. It appears that an engraftment level of 10–15 % in enough to make the mice survive long term and correct the disease phenotype.

Early Myeloablative Allogeneic Stem Cell Transplantation during High-Dose Cytarabin Induced Cytopenia in Patients with Refractory or Relapsed Myeloid Leukemias.

Allogeneic stem cell transplantation is the most effective therapy for myeloid leukemias. Still, especially patients with refractory disease, unfavourable cytogenetics or blast transformation of a myeloproliferative disorder (mpd) have a poor prognosis as a result of a high rate of treatment related mortality and relapse with conventional conditioning regimens. Recently, Kolb et al. have introduced a sequential protocol utilizing early TBI-based non-myeloablative transplantation following conventional induction therapy in high-risk patients.In this study, in dependence to Kolb, we have treated 21 patients (median age 51 years, range 17–63, 4 female, 17 male) with advanced leukemias according to an intensified sequential high-dose protocol. Diagnoses were AML (primary refractory 2, relapsed 5), MDS (refractory 7, untreated 1) and blast transformation of a MPD (refractory 6, untreated 0). The median blast count at induction was 22% (range 1–90) and 9 patients (43 %) had unfavourable cytogenetics. Induction therapy consisted of fludarabine, high-dose cytarabine with or without idarubicine, amsacrine or topotecan. ATG, high-dose melphalan with or without high-dose thiotepa was used for conditioning while patients were still cytopenic from the preceeding induction therapy. Following transplantation of a median of 6.1x10E6 CD34+ cells/kg (range 0.85–12.0) from related (6) or unrelated (15) donors, the median time to a wbc>1000/μl and plt>20000/μl was 15 days (range 10–24) and 17 days (range 8–30), respectively. No toxic death was observed during the first 30 days and 95% of patients achieved CR by day 28, 100% by day 50. Twelve patients (57%) developed aGvHD (12I-II°, 0III-IV°) and 7 patients (33%) at risk have developed chronic GvHD (5 limited, 2 extensive) so far. After a median time of 181 days (range 3 – 596 days) fifteen patients (72%) are alive and all are in complete remission. Six patients died, one of infection (5%), two of a combination of a chronic GvHD and infections (9%), two of disease progression (9%) and one patient from a second malignancy (SCLC).We conclude that early sequential transplantation during induction therapy induced cytopenia using high-dose melphalan and thiotepa based conditioning is feasible and highly effective in patients with advanced myeloid leukemias and poor prognosis. Although these early results are promising, a longer follow up and comparison with standard regimens are required.

Combined stratification of refractory anemia according to both WHO and IPSS criteria has a prognostic impact and improves identification of patients who may benefit from stem cell transplantation

A retrospective analysis of the relationship between the initial classification according to either FAB or WHO criteria, the presence of risk factors and the type of therapy including stem cell transplantation (SCT) on the survival was performed in a group of 106 patients with primary myelodysplastic syndrome (MDS) of FAB RA subtype. Allogeneic SCT early in the course of the disease did not significantly affect median survival in RA patients evaluated either according to FAB criteria (63.2 months in 17 SCT patients versus 64.4 months in 89 non-transplanted (non-SCT) patients) or in subgroups classified separately according to WHO (64.0 months in SCT versus 91.0 months in non-SCT RA patients and 66.2 months in SCT versus 43.0 months in non-SCT refractory cytopenia with multilineage dysplasia (RCMD) patients) or International Prognostic Scoring System (IPSS) criteria despite decreased incidence of leukemic transformation (5% in SCT versus 32% in non-SCT patients). Neither univariate or multivariate analysis of different clinical and laboratory parameters revealed a significant effect of SCT on 3 or 5 years survival in RA patients. The most probable explanation was a relatively high rate of transplantation related mortality (41%) on one hand together with a slow disease progression towards leukemia (24% at 5 years in non-SCT) on the other hand. A more refined stratification of patients based on the combined WHO morphology classification and IPSS cytogenetic criteria revealed subgroup of 11 non-SCT patients with RCMD and poor karyotype with median survival significantly different from that in five SCT patients (9.2 months in non-SCT versus 89.3 months in SCT, P=0.05). Thus, combined WHO morphology/IPSS cytogenetics criteria may be helpful for identification of the high risk patients with the RA group who may benefit from early SCT despite the relatively high incidence of SCT-related complications.

Juvenile myelomonocytic leukemia.

Juvenile myelomonocytic leukemia is an aggressive neoplasia of early childhood. Only allogeneic stem cell transplantation (SCT) offers long-term cure. In the absence of an HLA-matched family donor, early SCT from an unrelated donor is the treatment of choice for most children. With clear evidence of a graft-versus-leukemia effect and a high post-transplant relapse rate, the outcome of SCT depends, in part, on the management of immunosuppression during the procedure. The impact of pretransplant cytoreductive treatment, such as intensive chemotherapy, splenectomy, or 13-cis retinoic acid, is unclear. Hypersensitivity for granulocyte-macrophage colony-stimulating factor and pathologic activation of the Ras/MAPK pathway play an important role in the pathophysiology of juvenile myelomonocytic leukemia and provide the opportunity for several novel therapeutic approaches.

THE AMOUNT OF SCURFIN PROTEIN DETERMINES PERIPHERAL T CELL NUMBER AND RESPONSIVENESS

Khattri R, Kasprowicz D, Cox T, et al. J Immunol. 2002;167:6312–6320The disorder IPEX (immunodysregulation, polyendocrinopathy, enteropathy, X-linked syndrome) is characterized by enlargement of secondary lymphoid structures, diabetes mellitus beginning in early infancy, and chronic enteropathy. The gene defect was identified in 2001 as FOXP3 on the X chromosome. The FOXP3 gene is a member of the forkhead family of transcription factors, however, the basis for IPEX has remained poorly characterized. Previous groups have shown that the immune system is in a state of chronic activation in these patients with overproduction of cytokines and immunoglobulins, but the relationship of these problems to the FOXP3 mutations has been unclear. This article describes work defining the role of the FOXP3 protein product, scurfin, to the manifestation of T cell expansion.The authors use mouse models including the scurfy mouse, which has an inactive FOXP3 gene and mice transgenic for overexpression of FOXP3. Flow cytometry and histology are used to characterize changes in peripheral T cells and the T cell compartments in secondary lymphoid structures.The scurfin protein is expressed in the thymus but had no demonstrable affect on the phenotype of the scurfy mouse. Overexpression of scurfin in the thymus in a normal mouse had modest affects on various thymic subsets but did not induce any changes in the periphery. Overexpression of scurfin globally in normal mice caused decreased T cell proliferation and interleukin (IL)-2 production. Similarly, overexpression of scurfin inhibited cytolytic T cell activity.The function of scurfin appears to regulate the function and size of the peripheral T cell compartment.IPEX is an uncommon but nearly always fatal immunodeficiency. Affected boys are often total parenteral nutrition-dependent because of their enteropathy and require very stringent immunosuppression for even short-term survival. Stem cell transplantation may be effective. The importance of this article is in its description of a global overactivity of the T cell compartment. This contributes to our understanding of the pathogenesis of this disorder and reinforces the growing belief that the best management option may be early stem cell transplantation.

Risk assessment in adult acute lymphoblastic leukaemia before early haemopoietic stem cell transplantation with a geno-identical donor: an easy clinical prognostic score to identify patients who benefit most from allogeneic haemopoietic stem cell transplantation.

In 1402 patients allografted in Europe during the period 1990-2000 with an HLA-identical sibling in first remission (CR1), the median interval from CR1 to allotransplant (96 days) was a major prognostic factor, patients transplanted earlier having a worse outcome. We studied in depth the 414 fully evaluable patients transplanted less than 96 days after achieving CR1; in these patients, only three factors predicted for the outcome by multivariate analysis: patient age, CR1 achievement with one or more induction courses and the recipient/donor sex combination. These three factors overcame the information from cytogenetics and source of stem cells. Three prognostic groups could be identified in relation to the outcome, using a prognostic score affecting 1 to each poor risk factor (total from 0 to 3): Group 1 (good prognosis) includes patients <35 years old, achieving CR1 with one induction course and to be transplanted with any other sex combination than female to male (score 0); group 2 (intermediate) with one adverse factor (score 1); and group 3 (bad prognosis) with two or three adverse criteria (scores 2 and 3). In these three groups, the 3-year leukaemia-free survival was 56+/-5%, 48+/-4% and 29+/-4% and the overall survival was 65+/-5, 53+/-4 and 29+/-5%, respectively. Therefore, adult patients with ALL and a score of 0 or 1 are good candidates for an early transplant if they have an identical sibling donor. Patient age, response to induction and the sex of the HLA-identical family donor (if existing) are the strongest easy predictors of the outcome for an early transplant in an adult patient with ALL. No additional information is mandatory.

Juvenile myelomonocytic leukemia.

Juvenile myelomonocytic leukemia is an aggressive neoplasia of early childhood. Only allogeneic stem cell transplantation (SCT) offers a long-term cure. In the absence of an HLA-matched family donor, early SCT from an unrelated donor will be the treatment of choice for most children. With clear evidence of a graft-versus-leukemia effect and a high post-transplant relapse rate, outcome of SCT will depend, in part, on the management of immunosuppression during the procedure. The impact of pretransplant cytoreductive treatment, such as intensive chemotherapy, splenectomy, or 13-cis retinoic acid, is unclear. Hypersensitivity for granulocyte-macrophage colony-stimulating factor and pathologic activation of the Ras/MAPK pathway play an important role in the pathophysiology of juvenile myelomonocytic leukemia and will provide the opportunity for several novel therapy approaches.

Clinical Implications of Abnormalities of Chromosomes 1 and 13 in Multiple Myeloma

Stratification of patients with multiple myeloma according to clinical severity was attempted by chromosomal analysis of 180 bone marrow specimens from 79 patients. The 79 patients were hospitalized and treated between 1994 and 1999. Abnormalities of chromosome 1 were detected at the initial medical examination in 8 (10%) of the 79 patients and were found during follow-up in additional 3 patients. Abnormalities of chromosome 1 were often detected in IgA (4/17) and IgD (2/4) multiple myeloma, while detection in IgG myeloma was relatively rare (4/42). The relevant break points were 1q12 in 5 patients and 1q42 and 1q21 in 3 patients, while 3 patients had trisomy 1. Deficiency of the long arm of chromosome 13 was detected in 6 patients, and this was believed to imply a prognosis. The long arm was completely deleted in 2 patients and part of the arm (13q10–14) was deleted in 4 patients. It is interesting that all 6 patients had concomitant abnormalities of chromosome 1. Although the initial response to treatment of patients having abnormal chromosomes 1 and 13 was comparable to that of patients having other chromosomal abnormalities or patients who were karyotypically normal, the median survival time was only 18 months (p < 0.02). Consequently, aggressive treatment such as early stem cell transplantation and so on is needed to improve their survival.

The role of high-dose cytarabine in induction therapy for adult ALL

In adult acute lymphoblastic leukemia (ALL) remission (CR) rates of 75–80% and a long-term disease-free survival (DFS) of 30–35% can be achieved with contemporary chemotherapy regimens [1]. The majority of these regimens is based on “conventional” induction therapy as derived from pediatric protocols including vincristine, prednisone and an anthracycline—mostly daunorubicine. Asparaginase, cyclophosphamide, cytarabine and other cytostatic drugs in conventional doses are added in some protocols. Postremission therapy generally includes rotational consolidation therapy followed by maintenance treatment for up to 2.5–3 years. Stem cell transplantation (SCT) is included to a different extent in recent studies. Several groups scheduled allogeneic SCT from sibling donor for high risk patients only whereas others included allogeneic SCT for all patients with sibling donor and compared autologous SCT and chemotherapy in the remaining patients [2,3]. Although considerable progress has been made in treatment of subgroups of ALL such as mature B-ALL and T-ALL no substantial improvement of overall DFS was achieved with modifications of induction regimens— particularly if only results from larger patient cohorts are considered [1]. Therefore, various approaches are made to define innovative strategies for induction therapy in adult ALL with the aim not only to improve CR rate but remission quality and thereby DFS [1]. The early application of high-dose cytarabine (HDAC) as described by Sotomajor et al. in this issue is one of these approaches. This study also evaluated intensification of postremission treatment with early SCT—allogeneic or autologous—in all patients. It seems relevant to discuss these two new approaches for induction and postremission therapy in adult ALL.

Reviewing Omenn syndrome.

Omenn syndrome is a form of severe combined immunodeficiency associated with high mortality. Early recognition is required in order to initiate life-saving therapy. This review provides information on the clinical symptoms, laboratory parameters and pathology of the disease, supporting early diagnosis in suspected patients. A literature search was performed using Medline, encompassing the period 1965-1999. Sixty-seven cases were identified and with the addition of a recently diagnosed patient at our hospital, 68 children were included. Median age at onset of symptoms was 4 weeks. Key symptoms were erythematous rash (98%), hepatosplenomegaly (88%), lymphadenopathy (80%), often accompanied by recurrent infections (72%) and alopecia (57%). An elevated WBC (55%) was frequently observed, due to eosinophilia and/or lymphocytosis. B-cell counts were significantly decreased whereas T-cell counts were elevated. A high serum IgE was another frequent finding (91%). Therapeutic options include bone marrow transplantation or cord blood stem cell transplantation; however, the mortality still was 46%. Omenn syndrome is a fatal disease if untreated. The mortality may be reduced when diagnosis is established early and treatment is initiated rapidly by using early compatible bone marrow transplantation or cord blood stem cell transplantation.

The hepatologist in the haematologists' camp.

The hepatologist in the haematologists' camp.