Related Bone Marrow Transplantation Research Articles

Poor outcome in a pediatric patient with acute myeloid leukemia associated with a variant t(8;21) and trisomy 6

RUNX1T1/RUNX1 (formerly ETO/AML1) is a molecular marker that is usually associated with a favorable outcome in both pediatric and adult patients with acute myeloid leukemia (AML). We describe a 10-year-old girl with AML associated with an RUNX1T1/RUNX1 fusion. The patient’s karyotype at the time of diagnosis was 46,X,-X,t(4;21;8)(q25;q22;q22),+6. She had an early relapse while being treated on a standard protocol and had significant difficulty in attaining a second remission. She subsequently underwent a matched related donor bone marrow transplant, but a second bone marrow relapse with extensive extramedullary disease followed on day +199. Cytogenetic analysis at second relapse showed evidence of clonal evolution in the form of a highly complex karyotype with numeric and structural abnormalities in addition to the t(4;21;8) and trisomy 6 detected in the diagnostic sample. Trisomy 6 is an uncommon cytogenetic abnormality in myeloid diseases. As a sole abnormality, it has been associated mainly with myelodysplastic syndrome and AML. The presence of this novel variant of t(8;21)(q22;q22) associated with trisomy 6 may have abrogated the usual favorable prognosis associated with RUNX1T1/RUNX1 in AML.

Post-Transplantation High Dose Cyclophosphamide (Cy) Is Effective Single Agent for Prevention of Acute and Chronic Graft Versus Host Disease after Myeloablative HLA Matched Related and Unrelated Bone Marrow Transplantation (BMT)

Based on our results in animal models and promising results in HLA-haploidentical setting (L. Luznik, Blood 2002 and BBMT 2008), we studied whether high dose Cy alone is sufficient as GVHD prophylaxis after myeloablative HLA-matched related or unrelated BMT in patients with advanced, poor risk, hematologic malignancies. One hundred and seventeen consecutive patients (median age 48, range 23–65; 36 de novo AML, 23 2° AML (arising from previous MDS/MPD or therapy-related), 13 high-risk MDS, 9 ALL, 8 CML, 3 CLL, 5 MM, 9 NHL and 11 HL), of whom the majority (57%) were not in remission, received HLA-matched related (n=78) or unrelated (n=39) BMT. Conditioning consisted of oral or IV busulfan (pharmacokinetically adjusted) on days −7 to −3 and Cy (50 mg/kg/day) on days −2 and −1. Cy (50 mg/kg/day) was also given on days +3, and +4 as a sole agent for GVHD prophylaxis. All patients received bone marrow allografts without growth factor support. Three patients failed to engraft, but two were successfully rescued with a second allograft. The cumulative incidence of non-relapse mortality (NRM) at day 100 and 1 year after transplantation was 8.5% and 16%, respectively. Of the 18 patients dying of NRM, 2 were from VOD, 3 from non infectious pneumonia, 3 were from GVHD, 3 from sepsis/bacterial infections, 4 from MOF, and 3 of CNS/organ hemorrhage. The incidences of acute grade II–IV and grade III–IV GVHD were 43% and 11%, respectively. With a median follow-up of 19 months, 66 (56.4%) patients are alive, of whom 52 (44.4%) are in complete remission. Only 7/66 related and 4/32 unrelated patients developed chronic GVHD (classic limited in 7, overlap syndrome limited in 1, and classic extensive in 3 patients). Since in a competing risk model (relapse and death as competing risks) the cumulative incidence of chronic GVHD remained low, we analyzed the impact of the preceding history of acute GVHD and systemic immunosuppressive treatment given beyond the originally prescribed prophylaxis with high dose Cy on the incidence of chronic GVHD. Only one patient without a preceding history of acute GVHD developed de novo chronic GVHD. Overall, 3 patients with grade II–IV acute GVHD were untreated, 10 patients received steroids alone, 31 received steroids + a calcineurin inhibitor (CNI), and 7 received steroids + non CNI-based agents. The use of CNI for the treatment of acute GVHD did not appear to influence the development of chronic GVHD: 6/31 (19%) patients who received CNI-based immunosuppressive treatment developed chronic GVHD compared to 3/20 (15%) patients who did not. These results suggest that highdose of post-transplantation Cy is effective as the sole prophylaxis for acute and chronic GVHD after HLA-matched related or unrelated BMT. This approach is associated with rapid immunologic recovery as indicated by the low incidence of opportunistic infections, as well as a low incidence of acute and especially chronic GVHD. Further clinical and correlative studies are needed to elucidate the mechanisms behind the unique effectiveness of post-transplantation Cy on the prevention of acute and chronic GVHD.

Impact of Disease Risk on Efficacy of Matched Related Bone Marrow Transplantation for Pediatric Acute Myeloid Leukemia: The Children's Oncology Group

There is considerable variation in the use of HLA-matched related bone marrow transplantation (BMT) for the treatment of pediatric patients with newly diagnosed acute myeloid leukemia (AML). Some oncologists have argued that BMT should be offered to most patients in first complete remission (CR). Others have maintained that transplantation in first remission should be reserved for patients with high-risk disease. We performed this study to determine how disease risk influences the efficacy of BMT. We combined data from four cooperative group clinical trials: Pediatric Oncology Group 8821, Children's Cancer Group (CCG) 2891, CCG 2961, and Medical Research Council 10. Using cytogenetics and the percentage of marrow blasts after the first course of chemotherapy, patients were stratified into favorable, intermediate, and poor-risk disease groups. Patients who could not be risk classified were analyzed separately. Outcomes for patients assigned to BMT and for patients assigned to chemotherapy alone were compared. The data set included 1,373 pediatric patients with AML in first CR. In the intermediate-risk group, the estimated disease-free survival at 8 years for patients who did not undergo transplantation was 39% +/- 5% (2 SE), whereas it was 58% +/- 7% for BMT patients. The estimated overall survival for patients who did not undergo transplantation was 51% +/- 5%, whereas it was 62% +/- 7% for BMT patients. Both differences were significant (P < .01). There were no significant differences for survival in the other two risk groups or in the non-risk-stratified patients. Our study indicates that HLA-matched related BMT is an effective treatment for pediatric patients with intermediate-risk AML in first CR.

Glutathione S‐Transferase A1 Genetic Variants Reduce Busulfan Clearance in Children Undergoing Hematopoietic Cell Transplantation

The effect of glutathione S-transferase variants on pediatric busulfan metabolism was investigated by noncompartmental and population pharmacokinetic modeling. Twenty-nine children who underwent related or unrelated bone marrow or umbilical cord blood hematopoietic cell transplant were retrospectively studied. GSTA1, GSTP1, and GSTM1 variants were explored for their effects on busulfan exposures. Noncompartmental pharmacokinetic analyses showed that carriers of GSTA1*B had a 2.6-fold higher busulfan area under the curve and concentration at steady state compared with noncarriers (P <or= .01). Population pharmacokinetic modeling demonstrated that carriers of GSTA1*B reduced busulfan clearance by 30%. Monte Carlo simulations were then performed to assess busulfan dosing regimens based on GSTA1 genotypes. Simulations determined that dosing based on GSTA1 genotype, weight, and age resulted in fewer children exceeding the upper therapeutic limit compared with dosing using age and weight only. Larger, prospective studies are needed to confirm these findings.

Correction of Clinical Manifestations of Canine Mucopolysaccharidosis I with Neonatal Retroviral Vector Gene Therapy

Mucopolysaccharidosis I (MPS I) (Hurler syndrome) is due to deficient alpha-L-iduronidase (IDUA) activity and is the most common of the MPS disorders. Neonatal MPS I dogs were injected intravenously (IV) with a gamma retroviral vector containing a complete long-terminal repeat (LTR) and an internal human alpha(1)-antitrypsin (hAAT) promoter upstream of the canine IDUA complementary DNA (cDNA). This resulted in stable serum IDUA activity of 366 +/- 344 units (U)/ml (28-fold normal) for up to 1.8 years, which likely derived primarily from secretion of IDUA by transduced liver cells. Retroviral vector (RV)-treated dogs had >18% of normal IDUA activity in organs and had decreased severity and/or incidence of hernias, chest deformities, joint disease, facial dysmorphia, corneal clouding, valvular heart disease, and aortic dilatation as compared with untreated MPS I dogs. The marked reduction that was observed in lysosomal storage in the brain of RV-treated dogs may have been due in part to expression from the LTR of the vector in cells in the brain. This possibility will be explored in future studies, because the potential for insertional mutagenesis has raised concerns about using vectors with an intact LTR. If proven safe, this gene therapy technique may be utilized in treating children with Hurler syndrome.

Long term disease-free survival in acute leukemia patients recovering with increased γδ T cells after partially mismatched related donor bone marrow transplantation

Allogeneic stem cell transplantation (ASCT) has improved leukemia-free survival (LFS) in many but not all patients with acute leukemia. This is an eight-year follow-up to our previous study showing a survival advantage to patients with an increased gammadelta T cells following ASCT. gammadelta T cell levels were collected prospectively in 153 patients (acute lymphoblastic leukemia (ALL) n = 77; acute myelogenous leukemia (AML) n = 76) undergoing partially mismatched related donor ASCT. Median age was 22 years (1-59), and 62% of the patients were in relapse at transplant. Patient-donor human leukocyte antigen (HLA) disparity of three antigens was 37% in the graft-versus-host disease (GvHD) and 29% in the rejection directions. All patients received a partially T cell-depleted graft using T10B9 (n = 46) or OKT3 (n = 107). Five years LFS and overall survival (OS) of patients with increased gammadelta compared to those with normal/decreased numbers were 54.4 vs 19.1%; P < 0.0003, and 70.8 vs 19.6% P < 0.0001, respectively, with no difference in GvHD (P = 0.96). In a Cox multivariate analysis, normal/decreased gammadelta (hazard ratio (HR) 4.26, P = 0.0002) and sex mismatch (HR 1.45 P=0.049) were associated with inferior LFS. In conclusion, gammadelta T cells may facilitate a graft-versus-leukemia (GvL) effect, without causing GvHD. Further evaluations of this effect may lead to specific immunotherapy for patients with refractory leukemia.

6: Post-transplantation high-dose cyclophosphamide (Cy) is effective single agent GVHD prophylaxis that permits prompt immune reconstitution after myeloablative HLA matched related and unrelated bone marrow transplantation (BMT)

6: Post-transplantation high-dose cyclophosphamide (Cy) is effective single agent GVHD prophylaxis that permits prompt immune reconstitution after myeloablative HLA matched related and unrelated bone marrow transplantation (BMT)

173: Outcomes of matched related donor bone marrow transplantation in pediatric patients with myelodysplastic syndrome

Myelodysplastic syndromes (MDS) in children are associated with significant morbidity and risk of leukemic transformation. Allogeneic hematopoietic stem cell transplantation is the only curative therapy. The ideal allogeneic donor is an HLA-identical sibling or relative or Matched Related Donor (MRD). From 1990 to 2005, a total of 12 pediatric or young adult patients with MDS received bone marrow transplant from an HLA matched sibling at our institution. M:F ratio of the study group was 1.4; One patient belonged to ethnic minorities (8%); the median age at transplant was 13.4 years (range 1.1-20.6) and median weight was 54.7 kg (range 10.8-78).

The Effect of Natural Killer Cell Killer Ig-Like Receptor Alloreactivity on the Outcome of Bone Marrow Stem Cell Transplantation for Severe Combined Immunodeficiency (SCID)

Natural killer (NK) cell alloreactions against recipient cells in the setting of bone marrow transplantation have been associated with decreased rates of graft-versus-host disease (GVHD) and improved survival in transplant recipients with myeloid leukemia. These alloreactions are predicted by the absence of recipient HLA class I ligands for donor inhibitory killer Ig-like receptors (KIR). We hypothesized that donor NK cell alloreactions against recipient cells may affect the development of T and B-cell functions and incidence of GVHD in infants with severe combined immunodeficiency (SCID). Of the 156 patients with SCID who had received related bone marrow transplants without pretransplant chemotherapy or posttransplant GVHD prophylaxis, 137 patient-donor pairs were evaluated for the absence of recipient HLA class I ligands for donor inhibitory KIR. Analysis showed that the absence of a KIR ligand had no effect on the incidence or severity of GVHD (RR [corrected] = 0.95, p = 0.84), development of T-cell function (RR [corrected] = 1.05, p = 0.69), production of IgA (p = 0.46) or IgM (p = 0.33), or on 5-year survival (RR [corrected] = 1.21, p = 0.10). Further, in patients possessing native NK cells, the absence of KIR ligands in donors for recipient-inhibitory KIR did not alter transplantation outcomes. This study suggests that inhibitory KIR/HLA interactions do not play a significant role in bone marrow transplantation for SCID.

Eight Cases of Leukemia Treated with HLA Haploidentical Related Bone Marrow Transplantation and Chinese Herbal Medicine.

Objective: To explore the feasibility of Chinese herbal medicine in haploidentical related allogeneic bone marrow transplantation (Allo-BMT) without T-cell depletion for the treatment of leukemia.Methods: From 2003 to 2005, four patients with CML and four patients with AML received allo-BMT with grafts from 1 or 3 HLA antigen mismatched related donors. All patients were preconditioned with high dose Ara-c, cyclophosphamide (CY)and total body irradiation (TBI) or Busulfan (Bu). Donors were given G-CSF 250μg/d for seven days prior to marrow harvest. GVHD prevention regimen consisted of CSA, MTX, ATG, MMF and CD25-mab. Chinese herbal medicine was given orally to all patients after transplantation according to the theory (syndrome differentiation) of Traditional Chinese Medicine (TCM). One or 2 weeks after transplantation, TCM were given with the purpose to increase Qi and cultivate Yin, strengthen the function of Spleen and Stomach. At the time of bone marrow convalescence, about 1 month post transplantation, different TCM was prescribed for increasing Qi, cultivating Blood, strengthening the function of Kidney, and fasting distillation.Results: All patients were successfully engrafted. The median days of granulocyte >0.5×109/L and platelet >20×109/L were 12 (10–14) and 20(18–25) days, respectively. Seven patients developed grade I-IVGVHD, with two of them advanced to grade IV gut and liver GVHD and died of concurrent infection eventually. Two patients developed hemorrhagic cystitis. Six patients were alive in a disease-free situation after median following-up of 20 (6–36) months.Conclusion: The major histoincompatibility barriers in the haploidentical related donor/recipient allo-BMT could be successfully carried out with G-CSF stimulated donor bone marrow combined with GVHD preservation and Chinese Herbal Medicine. Our patients were treated with TCM to regulate immunity immediately after clearing out of their bong marrow; With this remedy method, we improved the curative effect of bone marrow transplant and this deserves further study with a well designed clinical trial.

Acute Graft Versus Host Disease (GVHD) Is Increased in Patients Receiving Cyclosporine/Cellcept as Frontline Prophylaxis Against GVHD in Pediatric Patients Undergoing Allogeneic Stem Cell Transplantation.

Traditionally, pediatric patients are prophylaxed against GvHD with cyclosporine (CSA) plus either methotrexate (Mtx) or methylprednisolone (Pred). Mtx worsens the severity of mucositis and renal insufficiency while pred causes muscle wasting, hypertension, hyperglycemia and increased infections. Cellcept (myophenolic acid) is a better tolerated, less toxic agent with synergistic immunosuppressive effects when combined with cyclosporine or tacrolimus. We explored its use in combination with cyclosporine in 63 pediatric patients (49% male, 74% Caucasian, 36% CMV+) undergoing allogeneic transplantation. Patients with both malignant (n=24) and non-malignant (n=39) conditions ranging in age from 2 weeks to 26 years were transplanted after myeloablative preparative regimens with either related bone marrow or cord blood (n=11) or unrelated cord blood (n=52), using cellcept and cyclosporine for GVHD prophylaxis. Cellcept and CSA were administered intravenously through the first 40–60 days post transplant using cellcept at a dose of 15mg/kg/dose IV q8H beginning on day -2 or -3 and CSA in traditional fashion targeting trough levels of 200–450 (infusion) and 150–350 with intermittent dosing. The patient then transitioned to oral therapy at the same dose and schedule until day 100–180 for cellcept and day 270 for cyclosporine and then tapered if no active GVHD was present. There were no acute toxicities attributable to cellcept observed in patients on IV or oral therapy. Despite the lack of steroids in the GVHD prophylactic regimen, all patients required treatment with antihypertensive therapy. Grossly, infection rates did not vary from those previously observed in conventionally treated patients at our center. The cumulative incidence (CINC) of neutrophil engraftment by day 42 was 79.4% (95% CI 64.7–91.2) which is comparable to previous reports. Two patients engrafted after a second unrelated cord blood transplant. Of the six patients who did not engraft, 3 died of infectious complications, two died of VOD and multi-system organ failure and one died of congenital pulmonary hypertension. Of the 59 patients evaluable for GVHD, follow-up ranged between 52 and 994 days (median 224 days). The CINC of acute GVHD grades II–IV by day 100 was 64.1% (95% CI 47.8–82.1) and the CINC of acute GVHD grades III– IV by day 100 was 6.3% (95% CI 0–17.0). Follow-up is too short to comment on the incidence of chronic GvHD, but to date, 5 of 14 patients followed for >100 days have developed mild chronic GvHD. The incidence of grade II acute GVHD was higher than that previously reported in pediatric patients receiving CSA/Pred while the incidence of grade III–IV GVHD was comparable. While this data is early, it appears that the incidence of acute Grade II GVHD is increased compared to previous series in patients treated with cellcept instead of Mtx (related bone marrow transplantation) or pred (unrelated cord blood transplantation). Engraftment in UCBT recipients was not compromised with the use of IV cellcept administered in the peritransplant period. Overall, despite the use of steroids to treat aGVHD, there was overall steroid sparing with this regimen. Additional patients will need to be tested with this regimen and longer follow-up is necessary to fully define the risks or benefits of this therapy.

Comparison of Therapeutic Effect between Related Donor and Unrelated Donor Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT) in the Treatment of Leukemia.

Objective : To compare the effect for leukemia between related donor hematopoietic stem cell transplantation (RD-HSCT) and unrelated donor hematopoietic stem cell transplantation (URD-HSCT).Methods: 115 patients received allo-HSCT, of whom 68 received RD-HSCT and 47 received URD-HSCT. All patients are HLA serologically matched. Total body irradiation (TBI) plus cyclophosphamide (CTX) was adopted in 56 cases and modified BuCY conditioning regimen (busulfan, Ara-C, Cyclophosphamide) in 59 cases. T and B cell reconstitution at different time points was assayed by flow cytometer in one year after transplantation. GVHD and nonage infection are observed after transplantation. The diference of haematopoietic and immunological reconstitution between the two groups are estimated with Independent-Samples T test. Kaplan-Meier survival analysis model is used to estimate the overall survival and the disease-free survival (DFS) in two groups.Results: The time in WBC>1.0×109/L are +13.09±2.39 and +16.28±3.01d(P=0.003), the time in BPC>20×109/L are +14.91±6.62 and +20.21±7.29d(P=0.042), respectively, in related donor bone marrow transplantation (RD-BMT) and unrelated donor bone marrow transplantation (URD-BMT). The time in WBC>1.0×109/L are +12.47±2.96 and +13.13±4.09d(P=0.488), the time in BPC>20×109/L are +12.16±4.24 and +15.67±7.12d(P=0.020), respectively, in related donor peripheral blood stem cell transplantation (RD-PBSCT) and unrelated donor peripheral blood stem cell transplantation (URD-PBSCT). The reconstitution of CD4+CD3+ at 1, 3, 6, 9, 12months and CD45RA+CD4+ at 1 month, and CD8+CD3+ at 3 months were different significantly between RD-HSCT and URD-HSCT(P value was 0.001, 0.017, 0.029, 0.041, 0.015, 0.015, 0.043, respectively). The incidence of II~IV°acute GVHD(aGVHD), chronic GVHD(cGVHD) and the lethality of GVHD are 45.45% and 52.27%(P=0.560), 45.31% and 63.16%(P=0.102), 6.06% and 15.91%(P=0.112), respectively, in RD-HSCT and URD-HSCT groups. The relapse rate are 18.18% and 11.36%(P=0.424), respectively, in RD-HSCT and URD-HSCT groups. The incidence of nonage infection are 42.42% and 47.73% (P=0.696), respectively, in RD-HSCT and URD-HSCT groups.The overall survival and the disease-free survival rate at three-year were 67.80±6.90% and 61.60±7.70%(P=0.133), 62.30±6.90% and 56.80±7.90%(P=0.177), respectively, in RD-HSCT and URD-HSCT groups.Conclusion The therapeutic effect for leukemia is not different between RD-HSCT and URD-HSCT.

Post-Transplantation High-Dose Cyclophosphamide (Cy) Is Effective Single Agent GVHD Prophylaxis That Permits Prompt Immune Reconstitution after Myeloablative HLA Matched Related and Unrelated Bone Marrow Transplantation (BMT).

Prolonged pharmacologic immunosuppression is a major obstacle to early immunologic recovery after allogeneic BMT. Based on our results in animal models, we studied whether properly timed high-dose Cy post-HLA matched related and unrelated BMT is an effective strategy for limiting GVHD; we hypothesized that avoiding prolonged immunosuppression would speed immune recovery and reconstitution of regulatory T cells (T regs) thereby decreasing post-transplant complications. We are reporting results on 46 consecutive patients (median age 41, range 1–64) with high-risk hematologic malignancies (20 AML, 12 ALL, 6 NHL, 3 HD, 2 MM, 2 CML, 1 CMMoL); 28 received related and 18 unrelated unmanipulated HLA-matched BM (median of 2.2 x 108 MNC per kg) after conditioning with busulfan on days -7 to -3 and Cy (50 mg/kg/day) on days -2 and -1, and followed by Cy (50 mg/kg/day) on days +3 and +4 as the sole GVHD prophylaxis. All the patients had advanced disease (20 in advanced remission with the rest having refractory disease), and the median follow-up is 13 (range 6–24) months. All but two patients had sustained engraftment. The cumulative incidence of acute grades II–IV and grades III–IV GVHD were 41% and 9%, respectively. All patients with GVHD responded fully to standard therapy (steroids ± tacrolimus) or therapy per BMT CTN0302, and all except 2 patients were rapidly weaned from all immunosuppressive agents. Of the thirty-six patients alive after day 100, only 1 of the 23 patients that received HLA-matched related, and 3 of 13 patients that received unrelated allografts, developed chronic GVHD. Twenty-six (56%) patients are alive, of whom 21 (45%) are in complete remission. There were no deaths secondary to infection or GVHD. CMV reactivation was detected in 11 of 36 (31%) patients, of whom 9 had GVHD. There was no CMV infection. Median (± SEM) CD4+ T cell counts were 99 ± 16/mL and 209 ± 49/mL on days 60 (n = 23) and 180 (n= 8), respectively. Corresponding values for CD8+ T cells were 248 ± 132/mL and 228 ± 161/mL on days 60 and 180, respectively. Patients with grade II–IV GVHD had significantly fewer peripheral blood (PB) CD4+Foxp3+ T cells compared to patients with grade 0–I GVHD (p<0.05). Development of grade II–IV GVHD negatively correlated with the expression of the Foxp3 (p<0.05) and was associated with relatively higher expression of interferon-γ mRNA (p=0.08) in PB, suggesting higher effector function in the absence of Tregs in patients with grade II–IV GVHD. No differences in IL-10 mRNA expression between patients with or without GVHD were found, while significantly higher expression of interleukin-2 mRNA was detected in patients with grade II–IV GVHD (p<0.025). These results indicate that high-dose post-transplantation Cy is effective as a single agent strategy for limiting acute and chronic GVHD after myeloablative HLA-matched related and unrelated allografting; this approach also limits the need for prolonged immunosuppression, resulting in favorable immunoreconstitution with few opportunistic infections in this unfavorable group of patients. Longer follow-up and larger numbers of patients are needed to assess the impact of this strategy on survival.

Il-10 Polymorphism and TGF-β Haplotypes Are Associated with Rejection of Graft in Children with Beta Thalassemia Major Undergoing Matched Related Bone Marrow Transplantation (BMT).

Th2 cytokines, IL-10 and TGF-β have immunoregulatory functions that can affect allograft acceptance. We have evaluated the correlation between IL-10 (-1082, -819, -592) and TGF-β codon 10C>T and 25G>C polymorphisms {(haplotype: TT/GG, TC/GG, high production); (haplotype: TC/GC, CC/GG, TT/GC, intermediate production); (haplotype: CC/GC, CC/CC, TT/CC, TC/CC, low production)}and graft rejection in 129 patients with β thalassaemia major who underwent matched related alloBMT. Patients who expired before day 15 (n=9) and for whom DNA samples was unavailable (n=18) were excluded from this study. None of these patients had graft rejection. Of the 102 patients who were evaluated, 73 (72%) patients received conditioning with Bu (16 mg/kg) / Cy (200 mg/kg) with ALG while 29 (28%) patients received Bu (600 mg/m2) / Cy (200 mg/kg) without ALG. All patients received unmanipulated bone marrow and standard cyclosporine / short course methotrexate regimen as prophylaxis against GVHD. Patients who died before day 21 after transplant (n=2) without achieving ANC >500/mm3 were not evaluated for engraftment. 9 out of 102 patients rejected their graft. Apart from the immunogenetic markers, the effect of other risk factors for rejection like recipient and donor age, sex mismatch, conditioning regimen, cell dose and Lucarelli class were also analyzed. Of these, only increasing donor age was found to mildly increase the risk of rejection (RR=1.06; p=0.019; 95% CI-1.01–1.1). Donor TGF-β haplotypes associated with intermediate or low production and IL-10 polymorphism accounting for low production were found to very significantly increase the risk of graft rejection (Table). TGF-β and IL-10 are essential for both development and the effector function of CD4 regulatory T cells which are important for tolerance induction. Therefore, it is possible that genotypes associated with lower production of these cytokines might contribute to increased graft rejection. We have previously reported that rejection in children with β thalassemia major is influenced by pharmacokinetics of busulfan and cyclophosphamide and genes implicated in their metabolism (BMT 2005 36, 839–845). We conclude that rejection of graft in this condition appears to be a multifactorial event affected not only by pharmacogenetics of the drugs used for conditioning but also by various immunogenetic factors.Risk factorsRelative riskP-value95% CITGFβ haplotypesLow + intermediate6.970.0151.4 – 33.6HighReferenceIL-10 -819 TT5.340.0181.3 – 21.4-819 TC + CCReferenceIL-10 -592 AA5.340.0181.3 – 21.4-592 AC + CCReference

Infant leukaemia: Clinical, biological and therapeutic advances

AbstractInfant acute lymphoid leukaemia (IALL) represents a distinct subset with an extremely poor response to therapy, despite major progress in the treatment of childhood leukaemia. However, several studies have shown that, even in this generally considered homogeneous group, a distinction could be made with regard to prognosis. The outcome of IALL patients with ALL‐1/MLL rearrangements at the 11q23 cytogenetic band, early pre‐B immunophenotype, high WBC count and age below 6 mo is significantly worse than in patients without these characteristics, and current therapies appear inadequate in a significant number of cases. Therefore, an international protocol (Interfant 99) was recently started, using a more aggressive approach, which included lymphoid‐ and myeloid‐specific drugs, and indications for stem‐cell transplantation. We reviewed the clinical characteristics of the disease, the results of several recent international clinical trials, and our experience with 16 infants with acute lymphoid leukaemia diagnosed and treated at our institution. Conclusion: It is extremely important to stratify patients for prognosis, taking into account clinical and biological variables with independent prognostic value. The aim is to select more adequate, risk‐adapted, therapeutic strategies which also consider related or unrelated bone marrow transplant consolidation for patients with very poor prognosis.

Infant leukaemia: Clinical, biological and therapeutic advances

Infant acute lymphoid leukaemia (IALL) represents a distinct subset with an extremely poor response to therapy, despite major progress in the treatment of childhood leukaemia. However, several studies have shown that, even in this generally considered homogeneous group, a distinction could be made with regard to prognosis. The outcome of IALL patients with ALL-1/MLL rearrangements at the 11q23 cytogenetic band, early pre-B immunophenotype, high WBC count and age below 6 mo is significantly worse than in patients without these characteristics, and current therapies appear inadequate in a significant number of cases. Therefore, an international protocol (Interfant 99) was recently started, using a more aggressive approach, which included lymphoid- and myeloid-specific drugs, and indications for stem-cell transplantation. We reviewed the clinical characteristics of the disease, the results of several recent international clinical trials, and our experience with 16 infants with acute lymphoid leukaemia diagnosed and treated at our institution. It is extremely important to stratify patients for prognosis, taking into account clinical and biological variables with independent prognostic value. The aim is to select more adequate, risk-adapted, therapeutic strategies which also consider related or unrelated bone marrow transplant consolidation for patients with very poor prognosis.

MICA, MICB, and MHC Beta Block Matching in Bone Marrow Transplantation: Relevance to Transplantation Outcome

Genetic testing of the MHC is required for selection of donors for bone marrow transplantation. The outcome of related bone marrow transplantation is usually superior to that of unrelated bone marrow transplantation. This may be the result of inaccurate or incomplete genetic testing employed for selection of donor for transplantation. Based on MHC haplotype matching, MHC block matching has been developed for selection of potential unrelated donor. Block matching has been shown previously to improve outcome when added to the conventional method of human leukocyte antigen (HLA) typing for selection of donors. In this study, we have retrospectively analyzed 44 donor recipient pairs from the Australian Bone Marrow Donor Registry Repository with respect to matching of HLA-B and HLA-Cw by sequence-based typing and MICA and MICB by polymerase chain reaction–sequence specific primer and MHC beta block matching and correlated these results with survival. Beta block matching was correlated with MIC matching ( p < 0.005) and with HLA-B and HLA-Cw matching. Patients who were HLA-B and - Cw matched had significantly improved survival when they were additionally matched for MHC beta block ( p c = 0.04) or MIC ( p c = 0.05).

Randomized use of cyclosporin A (CsA) to modulate P-glycoprotein in children with AML in remission: Pediatric Oncology Group Study 9421

Relapse is a major obstacle in the cure of acute myeloid leukemia (AML). The Pediatric Oncology Group AML Study 9421 tested 2 different strategies to improve event-free survival (EFS) and overall survival (OS). Patients were randomized to receive standard-dose DAT (daunorubicin, cytarabine, and thioguanine) or high-dose DAT during induction. To interfere with P-glycoprotein (P-gp)-dependent drug efflux, the second randomization tested the benefit of cyclosporine (CsA) added to consolidation chemotherapy. Of the 282 children randomly assigned to receive standard DAT induction, 248 (87.9%) achieved remission compared to 253 (91%) of the 278 receiving high-dose DAT (P = ns). Children with HLA-identical sibling donors who achieved a complete remission received an allogeneic bone marrow transplant as consolidation. For the 83 patients receiving a matched related donor bone marrow transplantation (BMT), the 3-year disease-free survival (DFS) is 67%. Of the 418 children who achieved remission and went on to consolidation with and without CsA, the DFS was 40.6% and 33.9%, respectively (P = .24). Overexpression of P-gp was infrequent (14%) in this pediatric population. In this study, intensifying induction with high-dose DAT and the addition of CsA to consolidation chemotherapy did not prolong the durations of remission or improve overall survival for children with AML.

Post-transplantation Cyclophosphamide (Cy) as a single agent for GVHD prophylaxis after HLA matched related and unrelated bone marrow transplantation

In animal models of BMT, a properly timed high dose of Cy post-BMT selectively eliminates host-versus-graft and graft-versus-host reactive T cells, thereby preventing graft rejection and reducing GVHD. We hypothesized that high dose posttransplant Cy (50 mg/kg IV) administered on days +3 and +4 after BuCy conditioning may be effective in preventing GVHD and can limit, or entirely eliminate the need for, standard postgrafting immunosuppression. This should lessen immunosuppression and allow early institution of additional posttransplant immunotherapy such as DLI.

Current Status of Hematopoietic Cell Transplantation for Adult Patients with Hematologic Diseases and Solid Tumors in Japan

A nationwide survey of hematopoietic cell transplantation (HCT) was started in Japan in 1991, and the analyzed survey data have been presented as the annual report of the Japan Society for Hematopoietic Cell Transplantation. The 10-year overall survival (OS) rates after HCT for each disease are as follows: acute myelogenous leukemia, 44.2%; acute lymphocytic leukemia, 33.7%; adult T-cell leukemia, 24.6%; chronic myelogenous leukemia, 53.3%; myelodysplastic syndrome, 37.3%; non-Hodgkin's lymphoma, 41.5%; Hodgkin's lymphoma, 50.8%; aplastic anemia, 72.5%; breast cancer, 37.1%; germ cell tumor, 52.6%; and ovarian cancer, 44.2%. The 5-year OS rates for multiple myeloma and lung cancer were 40.6% and 23.6%, respectively. Except in cord blood transplantation, engraftment was accomplished in more than 90% of patients. The respective frequencies of acute graft-versus-host disease (GVHD) and chronic GVHD were 41.1% and 34.9% for related bone marrow transplantation (BMT), 66.8% and 34.5% for unrelated BMT, 52.9% and 36.0% for allogeneic peripheral blood stem cell transplantation, and 53.3% and 32.1% for allogeneic cord blood transplantation. OS for each disease was analyzed by patient age, stem cell source, donor type, disease status, and disease type. These data provide objective and valuable information for hematologists as well as for patients who need HCT.