Related Peripheral Blood Stem Cell Research Articles

Rippled skin, fasciitis, and joint contractures

A 41-year-old man was referred to the National Institutes of Health (NIH) for evaluation of extensive skin thickening and rippled appearance of his upper extremities, torso, and lower extremities. The patient was day +671 status post a myeloablative 6/6 HLA-matched related (sister) peripheral blood stem cell transplant for acute myelogenous leukemia. The conditioning regimen consisted of busulfan and cyclophosphamide, and graft-versus-host disease prophylaxis included tacrolimus and a short course of methotrexate.

Bloodstream Infection after Reduced-Intensity Umbilical Cord Blood Transplantation Versus Other Reduced-Intensity Allogeneic Hematopoietic Stem Cell Transplantation.

Blood stream infection (BSI) is a major cause of transplant-related mortality (TRM) following allogeneic hematopoietic stem cell transplantation, and to overcome it, reduced-intensity preparative regimens were developed in recent years. However, little information has been reported on BSI after reduced-intensity cord blood transplantation (RI-CBT). To clarify the characteristics of BSI after RI-CBT, we compared the incidence of microbiologically documented BSI before day 100 between RI-CBT and reduced-intensity non-cord blood allogeneic hematopoietic stem cell transplant (RI-non-CBT) recipients in Toranomon hospital, Japan. RI-non-CBT group includes related bone marrow (rBM), related peripheral blood stem cell (rPBSC) and unrelated bone marrow (uBM) transplantation. We retrospectively reviewed the first events of BSI in 211 consecutive adult patients between Jan 2004 and July 2006. One hundred and fifteen patients received RI-CBT and 96 patients received RI-non-CBT (4 from rBM, 34 from rPBSC and 58 from uBM). The median ages of patients in both groups were 55 years. All of the preparative regimens were fludarabine-based and prophylaxis against GVHD was tacrolimus alone in most of the RI-CBT recipients and combination of calcinurin inhibitor and short-term methotrexate in most of the RI-non-CBT recipients. The median time to achieve neutrophil engraftment was delayed in RI-CBT group (day 20 vs. day15). The cumulative incidence of engraftment at day 60 was 73.0% in RI-CBT group versus 90.6% in RI-non-CBT group. The cumulative incidence of BSI was 39.3% at day 100 and RI-CBT group tended to have more BSI compared to RI-non-CBT group (46.1% vs. 31.3%, p=0.0122), particularly at the early points after transplantation. Median day of positive culture for bacteremia was earlier (day 9 vs. day 14) in RI-CBT group. In spite of reduced-intensity preparative regimen, RI-CBT in adults is associated with higher rates of BSI at early time points after transplantation.

Treatment of T Cell Large Granular Lymphocyte Leukemia with Reduced-Intensity Allogeneic Stem Cell Transplantation.

T cell large granular lymphocyte (LGL) leukemia is a lymphoproliferative disorder of clonal CD3-positive cytotoxic T cells. Clinical manifestations include neutropenia, anemia, thrombocytopenia, recurrent infections and splenomegaly. Two patients with refractory LGL leukemia were treated with an allogeneic stem cell transplantation following a reduced-intensity conditioning regimen. The first patient was a 54 yo female with transfusion dependent anemia and splenomegaly. Prior therapy included low dose methotrexate, cyclosporin A, equine antithymocyte globulin and alemtuzumab. The second patient was a 34 yo female with lymphocytosis and recurrent infections. Prior therapy included cyclosporin A and splenectomy. The hematopoietic cell source was related donor peripheral blood stem cells (5.79 x 106 CD34+ cells/kg) for the first patient, and unrelated donor peripheral blood stem cells (8.04 x 106 CD34+ cells/kg) for the second patient. The preparative regimen was fludarabine 30mg/m2 daily on days −5, −4, −3; melphalan 140 mg/m2 on day −2; the unrelated donor recipient also received rabbit antithymocyte globulin 6mg/kg in 3 divided doses on days −3, −2, −1. GVHD prophylaxis was provided with tacrolimus and methotrexate 5mg/m2 on days +1, 3, 6, 11. Granulocyte engraftment >0.5/μL occurred on day +20 and +11; platelet engraftment >100/μL occurred on day +26 and +116 for the first and second patient respectively. The patient receiving the unrelated donor developed stage 1 skin GVHD and did not require systemic treatment. Patients achieved 100% donor chimerism by day 100. There was no chronic GVHD in either patient. Both patients achieved a complete remission and remain in CR, off immunosuppressive therapy, at 13 and 14 months post transplantation. Allogeneic transplantation using a reduced-intensity preparative regimen is an effective therapy for T cell large granular cell leukemia in patients who have failed prior therapy.

Targeted immunotherapy with gemtuzumab ozogamicin (GO) following reduced intensity allogeneic stem cell transplantation (RI AlloSCT) to reduce minimal residual disease (MRD) in children with acute myeloid leukemia (AML): MRD monitoring by Wilms tumor gene

9532 Background: RI vs myeloablative (MA) AlloSCT in adults with AML is associated with significantly less transplant related mortality but increased rate of relapse, presumably secondary to MRD (Alyea et al; Blood, 2005). Quantification of the WT1 has been used successfully to detect MRD in children with acute myeloid leukemia (AML) (Kletzel et al; Pediatr Dev Pathol, 2002). GO has induced ORR in >30% of patients with overt relapsed CD33+ AML and may have a better effect in the setting of MRD (Sievers et al; J Clin Oncol, 2001). We have shown that RI AlloSCT followed by 2 doses of GO in average risk AML has resulted in >94% donor chimerism (Roman/Cairo, Clin Can Res, 2005). We explored changes in MRD prior to and after consolidation with 2 doses of GO targeted immunotherapy in children with average risk AML post RI AlloSCT. Methods: 11 pts, 11 years (0.5–21) with CD33+ (8 CR1, 3 CR2) received fludarabine 30 mg/m2x6d and busulfan 3.2–4 mg/kgx2d. Donors: 7 6/6 HLA related peripheral blood stem cells (RPBSC), 1 5/6 RPBSC, 1 6/6 related cord blood (CB) and 2 4/6 unrelated CB. GOx2 was administered =60d post AlloSCTx2 (8wks apart), at 4.5–7.5 mg/m2 (dose escalation). Samples were collected for WT1 analysis prior to and after each dose of GO (n=5). WT1 levels were determined by quantitative RT-PCR and compared with WT1 expression in a K562 leukemia line. Positive MRD was a ratio of K562 WT/patient's WT1>0.5. Results: The MTD for GO post RI AlloSCT has not been reached. 8/11 are NED (3 deaths: 1 relapse, 1 graft failure, 1 cGVHD) Pre GO WT1–0.079±0.07 (n=5), pre GO-dose #2–0.012±0.016 (n=3). One of these patients had detectable MRD (WT1–1.56) prior to the GO-dose #2, no MRD at 1year and is alive and in remission at 2 years post GOx2. The fifth patient entered transplant with +MRD (WT-0.866), relapsed after the first dose of GO and died of relapse prior to receiving the second dose. Conclusions: Targeted therapy with GOx2 may be useful in eradicating MRD in patients post RI AlloSCT. A larger cohort is necessary to assess the impact of GO (at the MTD) on MRD post RI AlloSCT in children with AML. No significant financial relationships to disclose.

The Graft Content of Donor T Cells Expressing γδTCR+ and CD4+foxp3+ Predicts the Risk of Acute Graft versus Host Disease after Transplantation of Allogeneic Peripheral Blood Stem Cells from Unrelated Donors

Recently, high numbers of regulatory T cells within the stem cell graft were described to be associated with less graft-versus-host disease (GVHD) after related peripheral blood stem cell transplantation (PBSCT). Studies in mice also suggest a distinct role of gamma delta TCR(+) T cells in mediating GVHD. Therefore, the aim of this study was to define the yet-unknown role of regulatory and gamma delta TCR(+) T cells in human PBSCT from unrelated donors. The frequency of both T-cell subsets within the graft was analyzed in 63 patients receiving unrelated allogeneic PBSCT. The respective amounts were quantified by flow cytometry and PCR and further correlated with clinical outcome. The grafts contained a median of 11.2 x 10(6)/kg CD4(+)foxp3(+) and 9.8 x 10(6)/kg gamma delta TCR(+) T cells, respectively. Patients receiving more CD4(+)foxp3(+) cells had a lower cumulative incidence of acute GVHD II-IV (44% versus 65%, P=0.03). Interestingly, in patients who received higher concentrations of donor gamma delta TCR(+) T cells, acute GVHD II-IV was more frequent (66% versus 40%, P=0.02). In multivariate analysis, only the graft concentration of gamma delta TCR(+) T cells (P=0.002) and a positive cytomegalovirus status of the recipient (P = 0.03) were significantly associated with the occurrence of acute GVHD II-IV. Graft composition of T-cell subsets seems to affect the outcome of patients receiving allogeneic PBSCT from unrelated donors. Therefore, selective manipulation or add-back of particular subsets might be a promising strategy to reduce the incidence of GVHD.

Preliminary Results of the Safety of Immunotherapy with Gemtuzumab Ozogamicin following Reduced Intensity Allogeneic Stem Cell Transplant in Children with CD33+ Acute Myeloid Leukemia

Myeloablative allogeneic stem cell transplantation (SCT) has been successful in the treatment of childhood acute myeloid leukemia (AML), but may be associated with significant toxicity and recurrent disease. Reduced-intensity allogeneic SCT may offer a less toxic approach to patients with AML. Targeted immunotherapy with gemtuzumab ozogamicin has been shown to be safe, well tolerated in children, and, as a single agent, gemtuzumab ozogamicin has induced responses in 30% of patients with recurrent CD33+ AML. There are no safety data with gemtuzumab ozogamicin post allogeneic SCT in children. Therefore, we explored the feasibility and toxicity of targeted immunotherapy following reduced-intensity allogeneic SCT in children with CD33+ AML. Eight patients with CD33+ AML received a reduced-intensity allogeneic SCT following fludarabine 30 mg/m2 for 6 days and busulfan 3.2 mg/kg (<4 years, 4 mg/kg/d) for 2 days. Donor sources included six 6/6 HLA-matched related peripheral blood stem cells, one 6/6 sibling cord blood, and one 4/6 unrelated cord blood. Day 30 and day 60 donor chimerisms in seven of eight evaluable patients were 96 +/- 2% (n = 7) and 94 +/- 3% (n = 6), respectively. Five of six patients (too early for one patient) received two doses of gemtuzumab ozogamicin and one patient received only one dose. After each dose, all patients developed grade 4 neutropenia, with recovery on median days 16 and 13, respectively, after dose 1 and dose 2. Grade 4 thrombocytopenia was only observed in 2 of 11 gemtuzumab ozogamicin courses. No patients have developed dose-limiting toxicity secondary to gemtuzumab ozogamicin. The administration of gemtuzumab ozogamicin post reduced-intensity allogeneic SCT in children with average risk AML is feasible and well tolerated with minimal toxicity. The maximal tolerated dose has yet to be determined for gemtuzumab ozogamicin post reduced-intensity allogeneic SCT in children with CD33+ AML. Additional studies in a larger group of patients will be required to adequately assess the safety of this approach.

An Experimental and Clinical Study of CMV Infection after Allogeneic Hematopoietic Stem Cell Transplantation.

Objective: To establish quick and reliable diagnostic methods for detecting the cytomegavirus (CMV) infection after allogeneic hematopoietic stem cell transplantation (allo-HSCT) and to evaluate their clinical value in early diagnosis of CMV infectionMethods: (1) From March 2001 to December 2003, Seventy-four patients undergoing allo-HSCT were enrolled in this study. After allo-HSCT, all the patients were detected for CMV gB DNA in peripheral blood by haplo-nested PCR methods and 35 of 74 patients for CMV PP65 antigen in peripheral blood by the fluorescent immunohistochemistry (FIHT) assay. The positive rate and correspondence of these two methods were evaluated.Results: (1) In 35 of 74 patients who were tested for CMV infection by two assays at the same time, the CMV-viremia was first detected at a median of 36 days after transplantation by FIHT assay and 26 days by haplo-nested PCR assay during the follow-up time of 90~720 days. The median time of positive persistence was 19 days by FIHT assay and 28 days by haplo-nested PCR assay. The significant difference of them was observed (P<0.05). The corresponding of the two assays was 88.57%. The difference of the two methods was not significant statistically. The incidence of CMV-agtigenemia and CMV-DNAemia were 65.71% and 71.43% during the follow-up days, respectively. (2) The infection rate in the nonmyeloablative allogeneic peripheral stem cell transplantation (NST) group was 78.95%, in the group of related peripheral blood stem cell transplantation (R-PBSCT) and/or related bone marrow transplantation (R-BMT) 48.57%, and in the group of unrelated bone marrow transplantation (UR-BMT) 61.54%. The infection rate of CMV in the UR-BMT group was higher than that in R-PBSCT and/or R-BMT group, but without significant difference (P>0.05). The infection rate of CMV in the NST group was significantly higher than in R-PBSCT and/or R-BMT group (P<0.05), but only a litter higher than in UR-BMT group (P>0.05). Both CMV-antigen and CMV-DNA were detected in all seven patients undergoing haploidentical hematopoietic stem cell transplantation (Hi-HSCT).Conclusion: (1) Both FIHT and haplo-nested PCR assays were quick and reliable diagnostic methods for detecting the CMV infection after allo-HSCT and their correspondence was good. However CMV infection could be found earlier by haplo-nested PCR assay than by FIHT assay. (2) The infection rate of CMV is high after allo-HSCT and might be different in different types of allo-HSCT.

Sirolimus and Tacrolimus as Graft-vs.-Host Disease Prophylaxis in Allogeneic Stem Cell Transplantation: The Dana-Farber Cancer Institute Experience.

Sirolimus is a novel immunosuppressant similar to tacrolimus, however, sirolimus inhibits T cell function uniquely via FKBP12/mTOR and can impair dendritic cell function. Sirolimus acts synergistically with tacrolimus and has a non-overlapping toxicity profile, making their use in combination attractive. We began employing sirolimus as GVHD prophylaxis in 2000, and herein describe our experience with this compound in the myeloablative transplant setting.Methods: Two clinical trials were performed using sirolimus (target serum level 3–12 ng/ml) and tacrolimus (target serum level 5–10 ng/ml) as primary GVHD prophylaxis. Cytoxan (1800 mg/m2/d x 2) and TBI (14 Gy, 7 fractions) was the conditioning regimen used in all patients. Trial 1 enrolled 76 patients who received HLA-matched, unrelated or 1-Ag mismatched related or unrelated bone marrow or peripheral blood stem cells. Abbreviated methotrexate (20 mg/m2 total) was routinely given post-transplant. Trial 2 enrolled 53 patients who received HLA-matched, related peripheral blood stem cells. No methotrexate was given post-transplant.Results: The median times to neutrophil engraftment (>500/ml) after transplantation were 17 (range 11–32) and 14 (range 9–17) days for trials 1 and 2 respectively. The median times to platelet engraftment (>20,000/ml) after transplantation were 29 (range 11–98) and 12 (range 10–47) days for trials 1 and 2. Grade II–IV acute GVHD occurred in 35% and 19% of patients in the two trials. Grade III–IV acute GVHD occurred in 21% and 4% of patients in the two trials. The median time to first hospital discharge was 33 and 19 days from transplantation for trials 1 and 2. Seven patients in trial 1 (9%) and 3 patients in trial 2 (6%) did not survive to first hospital discharge. The non-actuarial incidence of chronic GVHD in the two trials was 49 and 44%, respectively. Treatment-related mortality at 100 days was 13% and 6% in the trials. At two years, the relapse-free and overall survival estimates for trial 1 are 46 and 48% (Median follow-up of survivors: 27 months). One year relapse-free and overall survival estimates for trial 2 are 71% and 75% (Median follow-up of survivors: 15 months). Overall survival at 2 years is 72%. Toxicity related to the addition of sirolimus was modest. Among all patients (n=129), VOD occurred in 16 patients (12%), idiopathic pneumonia syndrome occurred in 9 patients (7%) and thrombotic microangiopathy occurred in 13 patients (10%).Conclusions: Sirolimus, when added to tacrolimus after allogeneic stem cell transplantation is effective for GVHD prophylaxis. Engraftment is prompt, the incidence and severity of acute GVHD are reduced and transplant-related morbidity and mortality is reduced, regardless of stem cell source and methotrexate use. Early survival estimates are excellent due to reduced GVHD and transplant-related toxicity. Sirolimus is worthy of broader study in allogeneic transplantation.

Reduced intensity conditioning and allogeneic stem cell transplantation (RI AlloSCT) in children and adolescents with malignancies following unrelated cord blood and matched family donor AlloSCT results in ≥90% achieving ≥98% donor chimerism

8506 Background: Although RI AlloSCT induces complete donor chimerism in adults with hematological malignancies (Slavin et al, Blood 91:756–763, 1998), there is little data in children and adolescents. We determined the degree of engraftment following RI AlloSCT in 14 children with malignant diseases following matched-family donor (MFD) and umbilical cord blood transplants (UCBT). Methods: Donors included: 8 unrelated UCB, 1 related UCB, and 5 related peripheral blood stem cells (PBSC). RI conditioning consisted of: fludarabine and busulfan +/- rabbit anti-thymocyte globulin (r-ATG) or alemtuzumab (N=12); and fludarabine, melphalan +/- horse ATG (N=2). Graft-vs.-host disease (GVHD) prophylaxis consisted of tacrolimus and mycophenolate mofetil. Demographics were as follows: median age 14.5 (0.5–21) yrs; 6 pts. with Hodgkin's disease (3 in 2nd CR, 1 in PR, 2 pts with PD), 1 pt with non-Hodgkin's lymphoma in PR, 2 pts with neuroblastoma - 1 in CR and one with PD, 2 pts with Wilms' tumor and PD, 1 pt with chronic myelogenous leukemia in chronic phase, and 2 pts with acute myelogenous leukemia in 1st CR. The UCB median cell dose was 3.43 × 107 NC/kg (0.9–10.8). The PBSC dose was 5.7 × 108 NC/kg (4.3–9.9). Results: Maximal donor chimerism (MDC) following UCBT was 100% for 7 pts, 98% for 1 pt, and 55% for 1 pt (died of PD on day +79), and 100% for all 5 pts after PBSC transplant. Graft failure was not observed. There was one non-infectious grade 4 toxicity (hepatic) secondary to busulfan, which resolved. The probability of developing acute GVHD grade II-IV in UCB vs. PBSC transplants was 11.11% (CI, 0–31.64) vs. 60.0% (CI, 38.1–81.9). The overall probability of chronic GVHD was 32.5% (CI, 0–73.2). The probability of 1-yr OS is 67.7 % (CI, 48.69–99.45). 1-yr OS for good-risk patients vs. poor-risk patients was 100% vs. 33.3% (CI, 20.47–93.81). Conclusions: RI AlloSCT is feasible and tolerable in children and adolescents with malignancies. Evaluation of graft-vs.-malignancy effect is ongoing, but 4 patients with active disease responded. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Roche Pharmaceuticals

Reduced intensity conditioning and allogeneic stem cell transplantation (RI AlloSCT) in children and adolescents with malignancies following unrelated cord blood and matched family donor AlloSCT results in ≥90% achieving ≥98% donor chimerism

8506 Background: Although RI AlloSCT induces complete donor chimerism in adults with hematological malignancies (Slavin et al, Blood 91:756–763, 1998), there is little data in children and adolescents. We determined the degree of engraftment following RI AlloSCT in 14 children with malignant diseases following matched-family donor (MFD) and umbilical cord blood transplants (UCBT). Methods: Donors included: 8 unrelated UCB, 1 related UCB, and 5 related peripheral blood stem cells (PBSC). RI conditioning consisted of: fludarabine and busulfan +/- rabbit anti-thymocyte globulin (r-ATG) or alemtuzumab (N=12); and fludarabine, melphalan +/- horse ATG (N=2). Graft-vs.-host disease (GVHD) prophylaxis consisted of tacrolimus and mycophenolate mofetil. Demographics were as follows: median age 14.5 (0.5–21) yrs; 6 pts. with Hodgkin's disease (3 in 2nd CR, 1 in PR, 2 pts with PD), 1 pt with non-Hodgkin's lymphoma in PR, 2 pts with neuroblastoma - 1 in CR and one with PD, 2 pts with Wilms' tumor and PD, 1 pt with chronic myelogenous leukemia in chronic phase, and 2 pts with acute myelogenous leukemia in 1st CR. The UCB median cell dose was 3.43 × 107 NC/kg (0.9–10.8). The PBSC dose was 5.7 × 108 NC/kg (4.3–9.9). Results: Maximal donor chimerism (MDC) following UCBT was 100% for 7 pts, 98% for 1 pt, and 55% for 1 pt (died of PD on day +79), and 100% for all 5 pts after PBSC transplant. Graft failure was not observed. There was one non-infectious grade 4 toxicity (hepatic) secondary to busulfan, which resolved. The probability of developing acute GVHD grade II-IV in UCB vs. PBSC transplants was 11.11% (CI, 0–31.64) vs. 60.0% (CI, 38.1–81.9). The overall probability of chronic GVHD was 32.5% (CI, 0–73.2). The probability of 1-yr OS is 67.7 % (CI, 48.69–99.45). 1-yr OS for good-risk patients vs. poor-risk patients was 100% vs. 33.3% (CI, 20.47–93.81). Conclusions: RI AlloSCT is feasible and tolerable in children and adolescents with malignancies. Evaluation of graft-vs.-malignancy effect is ongoing, but 4 patients with active disease responded. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Roche Pharmaceuticals

Sirolimus and tacrolimus without methotrexate as graft-vs.-host disease prophylaxis after matched, related peripheral blood stem cell transplantation: low transplant related morbidity and excellent GVHD control

Sirolimus (Rapamycin, Rap) is a novel immunosuppressant similar to tacrolimus (Tac), however, Rap inhibits T cell function via FKBP12/mTOR and may also inhibit dendritic cell function. Rap is synergistic with Tac and has no overlapping toxicity, allowing their use in combination. We have shown that Rap, Tac and low-dose methotrexate (Mtx) is effective GVHD prophylaxis after URD transplantation. Since Mtx is associated with transplant toxicity and since MRD GVHD rates are lower than URD rates, we hypothesized that Rap and Tac, without Mtx, would provide effective GVHD prophylaxis after MRD PBSCT while minimizing transplant-related morbidity and mortality (TRM). Methods: 30 subjects underwent PBSCT from 6/6 HLA-matched siblings(29) or parents(1) after Cy/TBI conditioning. GVHD prophylaxis consisted of Rap (serum level 3–12 ng/ml) and Tac (serum level 5–10 ng/ml). Filgrastim (5 μg/kg) was administered from d+12 until engraftment if needed. Results: The median age of subjects was 42 years (range 19–54). Diagnoses were AML(8), MDS(7), CML(7), NHL(6), ALL(1) and ATLL(1). The median times to neutrophil engraftment (>500/μl) and platelet engraftment (>20,000/μl and >100,000/μl) were 14 (range 11–17), 13 (range 10–47), and 19 (range 11–189) days respectively. All patients survived to discharge, at a median of 18 days from day 0 (range 15–54). Gr. II GVHD occurred in 3 patients (10%), involved the skin (3) and gut (1), and resolved with corticosteroids. No patient developed Gr. III-IV GVHD or idiopathic pneumonia syndrome. 4 patients developed thrombotic microangiopathy, but recovered normal renal function when Tac was held. VOD occurred in 3 patients. 1 patient had CMV reactivation and none had invasive fungal infections. Oral mucositis was mild and as a result, 47% of patients required no TPN. The median number of days of TPN use was 6. 9/28 evaluable patients developed chronic GVHD (3 extensive, 6 limited). 6 patients with advanced malignancies relapsed. 22/30 patients remain alive in complete remission. Causes of death include relapse(6), VOD(1) and late pulmonary toxicity(1). The median follow-up is 253 days (range 34–466). Relapse-free and overall survival at day 100 are 93 and 97%, and at 1 year are 70 and 66%. Conclusions: Rap and Tac without Mtx is effective for GVHD prophylaxis after MRD PBSCT. Due to Mtx omission, mucositis was reduced, engraftment was prompt and TRM was reduced. This combination is worthy of broader study in allogeneic transplantation.

A pilot study of reduced intensity conditioning and allogeneic stem cell transplantation from unrelated cord blood and matched family donors in children and adolescent recipients.

Reduced intensity (RI) allogeneic stem cell transplantation (AlloSCT) was initially demonstrated in adults following HLA-matched family and unrelated adult donor AlloSCT. There is little information about RI AlloSCT in children. We report results of a pilot study of RI AlloSCT in 21 recipients (< or =21 years). Age: median 13 (0.5-21) years, 8F:13M, 14 unrelated cord blood units (UCB) (10 4/6, 4 5/6), two related BM (6/6, 5/6), four related PBSC (2 6/6, 2 5/6), and one related BM+PBSC (6/6). RI: fludarabine, busulfan (n=14); fludarabine, cyclophosphamide (n=4); fludarabine, melphalan (n=1); total body irradiation, fludarabine, cyclophosphamide (n=1); or fludarabine, cyclophosphamide, and etoposide (n=1). Graft-versus-host disease prophylaxis: FK506 0.03 mg/kg/day and mycophenolate mofetil 15 mg/kg/q 12 h. UCB median nuc/kg and CD34/kg was 4.3 x 10(7)/kg (0.9-10.8) and 1.9 x 10(5)/kg (0.3-6.9), and related BM/PBSC median nuc/kg and CD34/kg was 8.3 x 10(8) (4.7-18.9) and 5.0 x 10(6)/kg (4.6-6.4). Maximal chimerism following unrelated cord blood transplantation, 100% x 7, 98% x 1, 95% x 2, 55% x 1, and 0% x 3; related PBSC/BM, 100% x 5, 65% x 1, and 55% x 1. Graft failure occurred in 5/21 (24%). In summary, RI AlloSCT in children is feasible and tolerable (< or =25% GF) and results in > or =85% of recipients initially achieving > or =50% donor chimerism.

Invasive aspergillosis in allogeneic stem cell transplant recipients: changes in epidemiology and risk factors

The incidence of postengraftment invasive aspergillosis (IA) in hematopoietic stem cell transplant (HSCT) recipients increased during the 1990s. We determined risks for IA and outcomes among 1682 patients who received HSCTs between January 1993 and December 1998. Risk factors included host variables (age, underlying disease), transplant variables (stem cell source), and late complications (acute and chronic graft-versus-host disease [GVHD], receipt of corticosteroids, secondary neutropenia, cytomegalovirus [CMV] disease, and respiratory virus infection). We identified risk factors associated with IA early after transplantation (<or= 40 days) and after engraftment (41-180 days). Older patient age was associated with an increased risk during both periods. Chronic myelogenous leukemia (CML) in chronic phase was associated with low risk for early IA compared with other hematologic malignancies, aplastic anemia, and myelodysplastic syndrome. Multiple myeloma was associated with an increased risk for postengraftment IA. Use of human leukocyte antigen (HLA)-matched related (MR) peripheral blood stem cells conferred protection against early IA compared with use of MR bone marrow, but use of cord blood increased the risk of IA early after transplantation. Factors that increased risks for IA after engraftment included receipt of T cell-depleted or CD34-selected stem cell products, receipt of corticosteroids, neutropenia, lymphopenia, GVHD, CMV disease, and respiratory virus infections. Very late IA (> 6 months after transplantation) was associated with chronic GVHD and CMV disease. These results emphasize the postengraftment timing of IA; risk factor analyses verify previously recognized risk factors (GVHD, receipt of corticosteroids, and neutropenia) and uncover the roles of lymphopenia and viral infections in increasing the incidence of postengraftment IA in the 1990s.

Stem cell transplantation for the treatment of Fanconi anaemia using a fludarabine-based cytoreductive regimen and T-cell-depleted related HLA-mismatched peripheral blood stem cell grafts

We have employed a new cytoreductive regimen to transplant two patients with Fanconi anaemia (FA), using T cell-depleted two HLA-allele disparate related peripheral blood stem cell transplants (PBSCTs). Patient 1, a 5-year-old male with FA and aplastic anaemia, initially received an HLA two-antigen mismatched unrelated cord blood transplant and failed to engraft. He received fludarabine (Flu) and cyclophosphamide (Cy), followed by a CD34+ E-rosette− (CD34+E−), T cell-depleted, granulocyte colony-stimulating factor (G-CSF)-mobilized PBSCT from his HLA B-DRB1 mismatched father. He received anti-thymocyte globulin (ATG), steroids, FK506 and G-CSF after transplant for rejection and graft-versus-host disease (GVHD) prophylaxis. The patient is now 23 months after SCT with no evidence of GVHD and with full haematopoietic and immune reconstitution. Patient 2, a 10-year-old boy with FA and myelodysplastic syndrome, received single-dose total body irradiation (SDTBI), Flu and Cy followed by a CD34+E−, T-cell-depleted, G-CSF-mobilized PBSCT from his HLA B-DRB1 mismatched sister. He also received ATG, steroids, FK506 and G-CSF after transplant. The patient is now 12 months after SCT in complete remission with no evidence of GVHD. Absolute neutrophil counts (ANC) of > 1 × 109/l were achieved on day 11 and day 10 post transplant respectively. Both patients are fully engrafted. In summary, we report two successful T-cell-depleted stem cell transplants from mismatched related donors for the treatment of Fanconi anaemia, using a fludarabine-based cytoreduction. Both patients experienced minimal toxicity, rapid engraftment and no GVHD.