Role Of Bone Marrow Transplantation Research Articles

Two National Clinical Trials Poised to Expand the Role of Bone Marrow Transplant in Newly Diagnosed Severe Aplastic Anemia

Two National Clinical Trials Poised to Expand the Role of Bone Marrow Transplant in Newly Diagnosed Severe Aplastic Anemia

Gut immunopathological signatures in Rag1 hypomorphic mice

Inflammatory bowel disease (IBD) has been reported in ~15% of patients with partial RAG deficiency. To investigate the pathophysiology of intestinal disease, we studied the interplay of T-cell immune dysregulation and microbiome abnormalities in a mouse model (Rag1w/w) homozygous fora hypomorphic Rag1 mutation (R972W) whose orthologue variant (R975W) has been reported in patients. Analysis of gut tissue in Rag1w/w mice revealed severe spontaneous colitis with lymphocytic infiltrates, which become histologically evident after weaning. To assess the relative contribution of genetic and environmental factors on the pathogenesis of gut inflammation, we performed flow cytometry and single-cell RNA-seq of lamina propria (LP) T cells and microbiome studies of fecal specimens in Rag1w/w and Rag1+/+ mice. Rag1w/w mice showed skewing towards a Th1/Th17 phenotype in CD4+ cells infiltrating the LP. Analysis of the fecal microbiota composition revealed a severe restriction of microbial diversity in Rag1w/w mice, with progressive depletion of three genera of firmicutes (Lachnospiraceae, Oscillibacter, Intestinimonas) producing butyrate. Principal component analysis of metabolomics data of fecal specimens clustered Rag1w/w separately from Rag1+/+ mice, with a severe defect in the amount of butyrate in the former. Consistent with an important role of butyrate in facilitating priming of IL-10 producing Tr1 cells, Il10 expression was markedly reduced in CD4+ LP T-cells from Rag1w/w compared to Rag1+/+ mice. Furthermore, scRNAseq of LP CD4+ T-cells revealed reduced presence of Tr1 cells in Rag1w/w mice, indicating that microbiome abnormalities contribute to the intestinal immune dysregulation. Treatment of Rag1w/w mice with vedolizumab (aiming at blocking gut homing of pathogenic T cells) had no effect on intestinal inflammation and on restriction of microbiome diversity. By contrast, both use of broad-spectrum antibiotics and bone marrow transplantation (BMT) significantly improved the inflammation and normalized the number of LP CD4+ cells. However, the LP CD4+ T cells of antibiotic-treated mice retained a strong Th1/Th17 signature, whereas only BMT rescued the phenotype, and induced normalization of microbiome diversity and restoration in the relative abundance of firmicutes. These data provide mechanistic insights into the pathophysiology of IBD associated with partial RAG deficiency, and confirm a curative role of bone marrow transplantation.

Abstract B23: The role of bone marrow transplantation in patients with Fanconi anemia and head and neck squamous cell carcinoma receiving radiotherapy: An examination of the International Fanconi Anemia (IFAR) Registry

Abstract Introduction: Fanconi anemia (FA) patients have a high predilection for developing aggressive head and neck squamous cell carcinoma (HNSCC) at an early age. Because of their aggressive HNSCC, these patients frequently require multiple modality treatment, including radiation therapy. However, their underlying chromosomal instability makes giving radiation to these patients difficult because of increased radiation-induced complications. In order to better understand this problem, we evaluated a large population of FA patients with HNSCC who received radiation therapy for HNSCC. Hypothesis: FA patients who have undergone prior bone marrow transplant (BMT) and present with head and neck squamous cell carcinoma (HNSCC) demonstrate decreased relative risk of radiation-induced complications compared to FA patients who have not received BMT. Study Design: Retrospective Cohort Study Methods: Demographic information, genotypic data, prognostic factors, therapeutic management, and survival outcomes for FA patients enrolled in the International Fanconi Anemia Registry (IFAR) who developed HNSCC from 1981-2017 were analyzed. Results: Data were collected from the IFAR registry for n=50 patients. The mean age at time of HNSCC diagnosis was 30.5 + 9.0 years, and 36% of total patients were male. 42% of the patients received adjuvant or neoadjuvant radiotherapy for HNSCC, with the most common subsites involving the oral tongue (n=8), followed by alveolus (n=3) and supraglottis (n=2). The average dose given was 48.8 + 16.9 Gy over a 28- to 70-day period. Among patients receiving radiotherapy, 24% had received a bone marrow transplant. No patients who had a prior BMT were noted to develop pancytopenia as a radiation-related complication, while 68% of those without prior BMT developed pancytopenia from radiation. 6/16 patients who did not undergo transplant completed the full course of radiation, while 4/5 BMT patients were able to complete treatment. Both mucositis and sepsis were secondary complications more common in the non-BMT group (56% vs. 40%, and 12% vs. 0%, respectively). The relative risk of pancytopenia among patients receiving BMT and adjuvant radiation was 0.15 (95% CI 0.01-2.2); however, this was not statistically significant given the small BMT-group sample size (p=0.17). Interestingly, 80% of patients in the BMT group exhibited genetic mutations of the Fanconi complementation group C. Among patients who received a BMT and adjuvant radiotherapy, 5 patients died of XRT-related complications, while only 1 patient died from these complications in the BMT group. Conclusion: While it is well known that FA patients have a high predilection for developing aggressive HNSCC at an early age, among the patients who received preradiation bone marrow transplant the incidence of radiation-induced pancytopenia was reduced. This reduction suggests that FA patients undergoing radiotherapy for HNSCC may exhibit less adverse side effects of radiation treatment if they received a prior BMT. Citation Format: Ade Obayemi, K.R. Patel, O. Rosti, A. Smogorzewska, D. Kutler. The role of bone marrow transplantation in patients with Fanconi anemia and head and neck squamous cell carcinoma receiving radiotherapy: An examination of the International Fanconi Anemia (IFAR) Registry [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; 2019 Apr 29-30; Austin, TX. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(12_Suppl_2):Abstract nr B23.

Fludarabine, High Dose Cytarabine and Idarubicin-Based Induction Is Highly Effective in Young AML Patients with Concomitant NPM1 and FLT3-ITD Mutation Irrespectively of FLT3-ITD Allelic Burden

Background: The presence of FLT3 "internal tandem duplication" (FLT3-ITD) mutation is associated with poor prognosis in acute myeloid leukemia (AML). However, the concomitant presence of NPM1 mutation (NPM1-mut) partially overcomes the negative prognostic impact of FLT3-ITD, which is also modulated by FLT3-ITD/wild-type allelic ratio. NPM1 and FLT3 mutational status assessment is strongly recommended for risk stratificationat diagnosis by the last European Leukemia Net (ELN) guidelines. Aims: To investigate the efficacy of an intensive fludarabine-containing induction regimen (FLAI) for fit, de novo AML patients according to NPM1 and FLT3-ITD mutational status. Methods: One-hundred and sixteen consecutive AML patients, treated in 3 Hematology Italian centers from January 2008 to January 2018, were included in this analysis. Twenty five patients showed isolated FLT3-ITD, 39 concomitant FLT3-ITD and NPM1-mutation and 52 isolated NPM-1-mutation.Median age was 52 yrs (range: 18-65 years). All patients received fludarabine, high dose cytarabine-based induction (fludarabine 30 mg/sqm and ARA-C 2g/sqm ondays 1 to 5 plus idarubicin 10 mg/sqm on days 1-3-5). For patients achieving CR fludarabine was omitted on II induction course and idarubicin dose was increased to 12 mg/sqm. Before2017 patients with isolated FLT3-ITD mutation were scheduled to receive allogeneic bone marrow transplantation (BMT) in first complete remission regardless of allelic burden whereas after 2017 only patients with high allelic burden received BMT in 1st CR. Minimal residual disease was evaluated on marrow samples using multicolor flow-cytometry (MFC)or NPM1 expression levels. Negative MFC-MRD wasdefined by the presence of less than 25 clustered leukemic cells/105 total events (threshold of 0.025% residual leukemic cells, Minetto et. al, BJH 2019). NPM1mutation (NPM1-A, B and D) was measured using Muta Quant Kit Ipsogen from Qiagen. FLT3-ITD allelic burden was available in31/64 of FLT3-ITD patients. Results: Overall 60-days mortality was 4%. After two induction cycles, 101 patients achieved CR (87%). Thirty-three/101 (33%) CR patients underwent BMT in first CR. After a median follow up of 61 months, 3-year overall survival (OS) was 56.8% (median not reached). In univariate analysis OS duration was favorably affected by age <55 yrs (p<0.05), MRD-negative status after induction (both MFC and NPM1 based MRD) (p<0.001) and wild-type FLT3(p<0.05). However, in multivariate analysis only MRD status significantly affected OS (p<0.003). The probability of achieving a molecular MRD negative CR after first cycle among NPM1-mut patients was similar between patients with or without concomitant FLT3-ITD mutation (61% and 66%, respectively, p=n.s.). Interestingly, in younger patients (< 55yrs) OS was comparable in case of isolated NPM1 mutation or concomitant NPM1/FLT3-ITD mutation (3-year OS 68.4% and 62.3%, respectively, p= n.s, Figure 1), regardless of FLT3-ITD allelic burden.Patients with isolated FLT3-ITD mutation had a significantly worse prognosis (3-year OS 34.4%, p<0.05). Again, multivariate analysis showed that persistence of MRD (by any method, p <0.05) was the strongest predictor of outcome. Moreover, performing BMT infirst CR did not impact OS neither in univariate or multivariate analysis. Conclusion: Despite the potential bias due to the retrospective nature of the analysis, our data indicate that intensive fludarabine-high dose cytarabine-based induction exerts a strong anti-leukemic efficacy in younger AML patients carrying NPM1 mutation irrespectively of FLT3 mutational status.Thus, the synergism of fludarabine and cytarabine seems to affect the intrinsic chemosensitivity of NPM1-mut leukemic cells, overcoming the negative impact of FLT3-ITD. Moreover, our data suggest the strong prognostic impact on survival of MRD clearance and question the role of BMT in I CR in this setting of patients. Figure 1 Disclosures Candoni: Gilead: Honoraria, Speakers Bureau; Celgene: Honoraria; Pfizer: Honoraria; Janssen: Honoraria; Merck SD: Honoraria, Speakers Bureau. Bocchia:Incyte: Honoraria; Novartis: Honoraria; BMS: Honoraria.

Hyperimmunoglobulin E syndrome.

Hashemi et al recently published an article with title: Hyperimmunoglobulin E syndrome: Genetics, immunopathogenesis, clinical findings, and treatment modalities in your journal that it is a good paper. Despite without limitation for searching, there are not a few of related papers in their working. Incidence of Hyperimmunoglobulin E syndrome (HIGE) is 1/100000 to 1/200000. This syndrome divided in two groups including; autosomal dominant with mutation in signal transducer and activator of transcription-3 (STAT 3) (chromosome 17, MIM=147060) type one and autosomal recessive with mutation in Dedicator of Cytokinesis 8 (Dock-8) (chromosome 9, MIM=243700) (type2) (1). Mutations of autosomal recessive HIES-like disorders following; 1. Tyrosine kinase 2 gene ( TYK2 ), encoded on chromosome 19p13.2 (MIM #611521). 2. Phosphoglucomutase 3 gene ( PGM3 ), which encodes an enzyme in the biosynthesis of N-glucans (MIM #615816) (2). About skin manifestations of HIGE syndrome, we reported a boy (16-year-old) of HIGE presented with skin psoriasis disease from one year ago. His history was recurrent infections including otitis media, pneumonia, diarrhea and skin infection. Histologic finding was hyperkeratosis; parakeratosis of acanthotic epidermis with regular elongation of rete ridges. This is the first report of association or relation between hyperactive IgE immunoglobulinemia and psoriasis disorder. We reported another case of HIGE whit recurrent infections and pneumatocle in the left and right of lung. Because there were multiple large pneumaocles, there was no possible surgery. The role of Bone Marrow Transplant (BMT) has different results. Hematopoietic stem cell transplantation (HSCT) was done for different kinds of HIES, but information and experience about the long term results of this therapy is little (1). Recently studies suggest that HSCT can improve immunologic parameters and reduce frequency and severity of infections although Nonhematologic organ failers are not corrected (5).

Role of Bone Marrow Transplantation in Reducing the Dangerous Effect of Multi-Walled Carbon Nanotubes or / and Gamma Rays on Male Rats

Aim of the work: this study evaluated the efficacy of bone marrow (BM) transplantation to protect male rats from dangerous effect of multi-walled carbon nanotubes (MWCNTs) or/and γ-irradiation on the hematopoietic and lung tissues. Materials and methods: experimental animals were divided into 8 groups each consist of 6 male albino rats. Control group, BM-injected group, MWCNTs-injected group, 5Gy γ-irradiated group, 5Gy γ-irradiated+ MWCNTs-injected group, MWCNTs-injected+ BM-injected group, 5Gy γ-irradiated+ BM-injected group and 5Gy of γ-irradiated+ MWCNTs-injected + BM-injected group. All the treated animal groups were sacrificed after 28 days of the treatments. Blood components, MDA and GSH levels in the lung tissue were analyzed. The histopathological study in the lung tissue was also recorded. Results: exposure to MWCNTs or/and γ-radiation induced a significant decrease in certain blood components (WBCs, RBCs, Hb content, HCT value and PLT count). Furthermore, a significant elevation in MDA level and a significant decrease in GSH content were detected in the lung tissue. The histopathological changes after exposure of rats to MWCNTs recorded perivasculitis, atelectasis and interstitial pneumonia. Also, γ-radiation represented more collapsed and thickened walls in the alveoli, thickened bronchiolar walls with partial epithelial lining and foci of pulmonary hemorrhage in the lung tissue. The effect of BM transplantation after MWCNTs or/and γ-radiation ameliorated the values of blood components, MDA and GSH levels in the lung tissue. The improvement occurred by BM transplantation in rats treated with MWCNTs or/and exposed to γ-radiation were also recorded. The lung tissue showed numerous alveoli with thin interalveolar septa, alveolar sacs and terminal bronchioles with highly folded mucosa. Conclusion: treatment with BM transplantation improved the most deleterious parameters obtained in the blood and lung tissue of MWCNTs exposed or/and γ-irradiated rats.

The Current Role of Bone Marrow Transplantation in the Treatment of Hemophilia A

Bone marrow transplantation (BMT) is nowadays used in various hematological disorders including leukemias. Hemophilia A is sex linked bleeding disorder in which there are various genetic abnormalities in factor VIII gene. Among various hematological disorders, bleeding disorders mainly hemophilia in now widely treated using plasma derived and recombinant factor VIII concentrates. Day to day transfusion of coagulation factor VIII in current lifelong disorder is a burden for the patients and decreases their quality of life. Although infection of coagulation products with blood-borne viruses that was major concern in treatment of hemophilia has been eliminated nearly complete at the present time, but appearance of factor VIII inhibitor is huge burden in treatment of hemophilia for both clinicians and patients. In this day and age BMT has gathered new insight and acceptable treatment for many hematological and non-hematological disorders. If BMT will be successful in treatment of hemophilia, it will improve quality of life (by nearly permanent treatment without necessary of daily treatment) and decrease mortality rate (by providing continuous coagulation factor level in blood system).

The Possible Protective Role of Bone Marrow Transplantation against Alternations Induced by Gamma Radiations on Heart of Pregnant Albino Rats and Their Fetuses

Aim of the work: It is well recognized that radiation can be carcinogenic. Bone marrow cells (BM) suppress immune cell responses and have beneficial effects in various inflammatory-related immune disorders. The present study is designed to evaluate the possible role of bone marrow to restore certain histopathological and histochemical changes in the cardiac tissues of pregnant rats which exposed to gamma rays. Material and Methods: The experimental animals were divided into five groups: 1- Group of control pregnant rats. 2- Group I&II of pregnant rats irradiated with γ-rays on days 7 or 14 of gestation. 4- Group III& IV of pregnant rats irradiated with γ-rays on day 7 or 14 of gestation and treated with BM one hour post-exposure. All the previous groups were sacrificed on day 20 of gestation (1 day prior delivery). Results: Exposure of pregnant rats to γ-rays on day 7 or day 14 of gestation showed many pathological and histochemical changes in the cardiac tissues. These changes were more pronounced on day 14 of gestation. Bone marrow transplantation post-irradiation improved cardiac muscle architecture. On the other hand, fetal cardiac tissue was more sensitive to γ-rays than those of their mothers especially on day 14 of gestation. Bone marrow transplantation post-irradiation improved the tissue architecture which restored its normal histological and histochemical pictures. Conclusion: It can be concluded that bone marrow transplantation post-irradiation showed somewhat a considerable ability to overcome radiation injuries or damages from the histological and histochemical point of view on day 7 or 14 of gestation.

The Possible Protective Role of Bone Marrow Transplantation against Alternations Induced by Gamma Radiations on Fetal Gastrointestinal Tract of Pregnant Albino Rats

Aim of the work:It is well recognized that radiation can be carcinogenic for a wide variety of tumors, especially, in breast, thyroid, and bone marrow which appear to be radiosensitive. Bone marrow cells (BM) suppress immune cell responses and have beneficial effects in various inflammatory-related immune disorders. The present study is designed to evaluate the possible role of bone marrow to restore certain histopathological and histochemical changes in the fetal gastrointestinal tract of pregnant rats which exposed to gamma rays. Material and Methods: The experimental animals were divided into five groups: 1-Control pregnant rats. 2- Group of pregnant rats irradiated with γ-rays on day 7 of gestation. 3- Group of pregnant rats irradiated with γ-rays on day 14 of gestation. 4- Group of pregnant rats irradiated with γ-rays on day 7 of gestation and treated with BM one hour post- exposure . 5-group of pregnant rats irradiated with γ-rays on day 14 of gestation and treated with BM one hour post-exposure. All the previous groups were sacrificed on day 20 of gestation (1 day prior delivery). Results: Exposure of pregnant rats to γ-rays on day 7 or day 14 of gestation showed many pathological and histochemical changes in the fetal gastrointestinal tract. These changes were more pronounced on day 14 of gestation. The changes include increased proliferation in the mucosal layer, increased signs of lymphocytic infiltration and pyknotic nuclei in addition to highly distorted circular muscle fibers. Also, altered collagen, total protein, polysaccharides contents were noted post-irradiation. Bone marrow transplantation post-irradiation improved the tissue architecture which restored it's normal histological and histochemical pictures. Conclusion: It can be concluded that bone marrow transplantation post-irradiation showed somewhat a considerable ability to overcome radiation injuries or damages from the histological and histochemical point of view on day 7 or 14 of gestation in the studied previous fetal tissues although the healing was incomplete on day 7 or 14 of gestation when compared with the control groups.

The Possible Protective Role of Bone Marrow Transplantation against Alternations Induced by Gamma Radiations on Fetal Gastrointestinal Tract of Pregnant Albino Rats

The Possible Protective Role of Bone Marrow Transplantation against Alternations Induced by Gamma Radiations on Fetal Gastrointestinal Tract of Pregnant Albino Rats

Role of bone marrow transplantation for correcting hemophilia A in mice

AbstractTo better understand cellular basis of hemophilia, cell types capable of producing FVIII need to be identified. We determined whether bone marrow (BM)–derived cells would produce cells capable of synthesizing and releasing FVIII by transplanting healthy mouse BM into hemophilia A mice. To track donor-derived cells, we used genetic reporters. Use of multiple coagulation assays demonstrated whether FVIII produced by discrete cell populations would correct hemophilia A. We found that animals receiving healthy BM cells survived bleeding challenge with correction of hemophilia, although donor BM-derived hepatocytes or endothelial cells were extremely rare, and these cells did not account for therapeutic benefits. By contrast, donor BM-derived mononuclear and mesenchymal stromal cells were more abundant and expressed FVIII mRNA as well as FVIII protein. Moreover, injection of healthy mouse Kupffer cells (liver macrophage/mononuclear cells), which predominantly originate from BM, or of healthy BM-derived mesenchymal stromal cells, protected hemophilia A mice from bleeding challenge with appearance of FVIII in blood. Therefore, BM transplantation corrected hemophilia A through donor-derived mononuclear cells and mesenchymal stromal cells. These insights into FVIII synthesis and production in alternative cell types will advance studies of pathophysiological mechanisms and therapeutic development in hemophilia A.

Myeloid Neoplasm with PDGFRB Translocation, t(1;5)(q21;q33): A Congenital Presentation of An Imatinib Responsive Congenital JMML with Eosinophilia

AbstractAbstract 4092Eosinophilia is seen in several myeloproliferative disorders (MPD), including the newly WHO recognized category of MPDs associated with translocations involving alpha and beta chains of PDGFR (platelet derived growth factor receptor). A subset of these MPDs, which consistently involve the PDGFRB (platelet derived growth factor receptor beta) gene rearrangement at 5q31–33, demonstrate a t(1;5) (q23;q33). Only a few cases of MPD with this translocation have been described, with the youngest patient being 5 months old at presentation. Imatinib mesylate was recently shown to be efficacious in MPDs with PDGFR rearrangements.Here we describe the first case of a congenital presentation of a myeloproliferative neoplasm with t(1;5) (q21;q33) resulting in PDGFRB rearrangement. The patient, born at 34 weeks gestation, was noted at birth to have hepatomegaly and multiple nodular purpuric cutaneous lesions over his entire body. An extensive work up for congenital infections was negative. A biopsy of the skin lesion shortly after birth demonstrated myeloid proliferation with prominent eosinophilic infiltrate. He continued to demonstrate hepatosplenomegaly and nodular skin lesions at 3 months of age, at which time his white blood cell count (WBC) was 91K/uL with 20% eosinophils, hemoglobin 7g/dl, platelets 35K/uL. Chromosome analysis of peripheral blood revealed a t(1;5) (q21;q33) in 64% of the cells and FISH analysis showed evidence of 5q33 rearrangement involving the PDGFRB locus.The patient was initially treated with a 10 day course of hydroxyurea which resulted in a decrease in the total WBC count, but showed no improvement of the rash or hepatosplenomegaly. After the diagnosis was confirmed, he was started on Imatinib at a dose of 100 mg QD (370 mg/m2). His WBC decreased from 69K/uL to 21K/uL within 4 days and normalized within a month of initiating Imatinib. The dose of Imatinib was decreased to 50 mg QD (185mg/m2) after the first week of therapy. His counts remained normal and a repeat chromosomal analysis of peripheral blood after 10 months of therapy showed no evidence of the prior t(1;5) (q21;q33) abnormality. His dose, therefore, remains at 50 mg QD, which, taking into account his interval growth corresponds to 113 mg/m2. The child is currently 16 months old with normal peripheral blood counts. He is clinically well, growing and developing normally and is tolerating Imatinib without any significant side effects.Summary: Here we describe the first case of a congenital presentation of a myeloid neoplasm with a t(1;5) (q21;q33) translocation and eosinophilia. The child presented at birth with an extensive “blueberry muffin” pattern of cutaneous lesions, hepatomegaly, leukocytosis with eosinophilia, thrombocytopenia and anemia and demonstrated a complete and rapid response to Imatinib monotherapy. There are currently no guidelines on dosing Imatinib in newborns. Three remaining clinical challenges regarding this patient include choosing the best method for monitoring the leukemic clone, choosing the proper dose of Imatinib for this growing child and determining the potential role of bone marrow transplant in an otherwise well infant. Disclosures:No relevant conflicts of interest to declare.

Porphyrie cutanée tardive chez un enfant greffé de moelle

Porphyria cutanea tarda (PCT) is rare in childhood and association with bone marrow transplant has occasionally been reported. A 13-year-old boy was referred to our department for bullous lesions on sun-exposed areas. His past medical history revealed acute biphenotypic leukaemia with complete remission after allogeneic hematopoietic stem cell transplantation (unrelated donor). Complications of bone marrow transplant comprised anaemia (treated by blood transfusions), primary cytomegalovirus (CMV) infection, pulmonary aspergillosis and acute digestive graft-versus-host disease. The diagnosis of type I sporadic PCT was based on high levels of porphyria and normal erythrocytic uroporphyrinogen decarboxylase activity. The bullous lesions disappeared on bleeding, but the patient subsequently developed sclerodermiform lesions. An association between PCT and bone marrow transplant has been reported previously in two independent cases, of which one involved a child. The causative role of bone marrow transplantation in the development of PCT could be related to several triggering factors: primary CMV infection, hepatotoxic drugs, blood transfusion and possible chronic hepatic graft-versus-host disease. We report the second case in a child of type I PCT associated with bone marrow transplantation. This new case reinforces the hypothesis of a non-random relationship between the two conditions.

Early (Day −7) versus Conventional (Day −1) Inception of Cyclosporine-A for Graft-versus-Host Disease Prophylaxis after Unrelated Donor Hematopoietic Stem Cell Transplantation in Children. Long-Term Results of an AIEOP Prospective, Randomized Study

We carried out a randomized, multicenter study comparing the inception of cyclosporine- A (CsA) on day -7 to conventional CsA (on day -1) to evaluate the influence of this modification on graft-versus-host disease (GVHD), treatment-related mortality (TRM), relapse rate (RR), and event-free survival (EFS) in children with hematologic malignancies given unrelated donor (UD) hematopoietic stem cell transplantation (HSCT). Between 1997 and 2002, 152 children transplanted for acute leukemia (102), myelodysplastic syndromes (23), chronic myelogenous leukemia (20), and non-Hodgkin lymphoma (7) were enrolled in the study and randomized to receive either early CsA (group 1, N = 72) or conventional CsA (group 2, N = 80), after stratification according to HLA compatibility and disease phase. The cumulative incidence of both grade II-IV and grade II-IV acute GVHD (aGVHD), as well as of chronic GVHD (cGVHD), did not differ between the 2 groups. No significant differences were observed also with regard to TRM and RR. The 8-year Kaplan-Meier estimates of EFS were 56% in group 1, and 46% in group 2 (P = NS). In the Cox model, advanced disease phase, male recipient, older donor, and occurrence of grade III-IV aGVHD predicted inferior overall EFS. These data indicate that early inception of CsA does not improve posttransplantation outcome of children with hematologic malignancies given UD-HSCT.

The Treatment of Adults with Acute Lymphoblastic Leukemia

Despite the relatively low incidence of acute lymphoblastic leukemia (ALL) in adults, large national and international collaborations have recently improved our understanding of how to treat ALL in adults. This article documents and examines the current evidence base for a "state of the art" therapy in both Philadelphia chromosome-negative and -positive adult ALL. The article comments upon areas of therapeutic debate, such as the role of bone marrow transplantation. In particular, the controversial subject of whether the superior outcome seen in younger patients is predicated on disease biology or therapeutic strategy is examined closely. Promising approaches under development are also discussed.

Role of Bone Marrow Transplantation in the Disease Pathway of Myeloma

In multiple myeloma, autologous stem cell transplantation (ASCT) has been considered a standard of care in younger patients. The introduction of novel agents (i.e., thalidomide, lenalidomide, and bortezomib) may change this scenario. These agents can be administered before or after ASCT with the goal of increasing the complete remission (CR) rate and prolonging remission. For instance, thalidomide given as maintenance therapy after double ASCT increases CR rate, event-free survival (EFS), and overall survival. Moreover, combinations of conventional chemotherapy with novel agents such as thalidomide or bortezomib yield CR rates and EFS comparable to those achieved with standard single ASCT. Prospective randomized studies are needed to evaluate the impact of novel agents versus or in combination with ASCT. Myeloablative conditioning regimens before allogeneic stem cell transplantation are being replaced with concurrent autologous-transplantation and reduced-intensity conditioning allogeneic stem cell transplantation. Transplant-related mortality associated with this procedure is lower, but more follow-up is needed before definite conclusions can be drawn.

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.

Curative bone marrow transplantation in erythropoietic protoporphyria after reversal of severe cholestasis

We report the case of a middle-age patient presenting with severe progressive protoporphyric cholestasis. To halt further progression of liver disease, medical treatment was given aimed at different mechanisms possibly causing cholestasis in erythropoietic protoporphyria. Within eighty days, liver biochemistry completely normalized and liver histology markedly improved. Bone marrow transplantation was performed to prevent relapse of cholestatic liver disease by correcting the main site of protoporphyrin overproduction. Thirty-three months after cholestatic presentation and ten months after bone marrow transplantation, liver and porphyrin biochemistry remains normal. The patient is in excellent condition and photosensitivity is absent. The theoretical role of each treatment used to successfully reverse cholestasis and the role of bone marrow transplantation in erythropoietic protoporphyria are discussed. Medical treatment can resolve hepatic abnormalities in protoporphyric cholestasis. Bone marrow transplantation achieves phenotypic reversal and may offer protection from future protoporphyric liver disease.

Treatment strategy and long-term results in paediatric patients treated in consecutive UK AML trials

Between 1988 and 2002, 758 children with acute myeloid leukaemia (AML) were treated on Medical Research Council (MRC) AML 10 and AML 12. MRC AML 10 tested the role of bone marrow transplantation following four blocks of intensive chemotherapy and found that while both allogeneic bone marrow transplant (allo-BMT) and autologous bone marrow transplant (A-BMT) significantly reduced the relapse risk (RR), this did not translate into a significant improvement in overall survival (OS). A risk group stratification based on cytogenetics and response to the first course of chemotherapy derived from MRC AML 10 was used to deliver risk-directed therapy in MRC AML 12. Allo-BMT was limited to standard and poor risk patients and A-BMT was not employed. Instead, the benefit of an additional block of treatment was tested by randomising children to receive either four or five blocks of treatment in total. While the results of MRC AML 12 remain immature, there appears to be no survival advantage for a fifth course of treatment. The 5 year OS, disease-free survival (DFS), event-free survival (EFS) and RR in MRC AML 12 are 66, 61, 56 and 35%, respectively; at present superior to MRC AML 10, which had a 5-year OS, DFS, EFS and RR of 58, 53, 49 and 42%, respectively. MRC AML trials employ a short course of triple intrathecal chemotherapy alone for CNS-directed treatment and CNS relapse is uncommon. Improvements in supportive care have contributed to improved outcomes and the number of deaths in remission fell between trials. Anthracycline-related cardiotoxicity remains a concern and the current MRC AML 15 trial tests the feasibility of reducing anthracycline dosage without compromising outcome by comparing standard MRC anthracycline-based consolidation with high-dose ara-C. MRC studies suggest that the role of allo-BMT is limited in 1st CR and that there may be a ceiling of benefit from current or conventional chemotherapy.

Isolation and Characterization of Umbilical Cord Blood-Derived Multipotent Stem Cells Arising from Adherent CD45+/CD34+ Cell Subset.

Introduction: Using a cell separation medium (PrepaCyte-MLPC, BioE, Inc.) and plastic adherence, umbilical cord blood (UCB)-derived multipotent stem cells were isolated, expanded, and characterized. These stem cells, termed multi-lineage progenitor cells (MLPCs), are the only such cell type from any source demonstrated to be CD45+/CD34+ upon initial isolation.Methods: PrepaCyte-MLPC, an antibody-based cell separation medium, is added to an UCB unit (American Red Cross Cord Blood Program). Following homo- and heterophilic aggregation of undesired cell populations and subsequent sedimentation to gravity, the supernatant containing stem cells is expressed. After overnight incubation in a T-flask in MSCGM (Cambrex, Inc.), non-adherent cells are washed, leaving adherent cells to expand in culture. As MLPC colonies are observed, cells are further enriched by detachment (PBS/0.1% EGTA) and transfer to a new T-flask.Results: MLPCs were isolated and expanded from 3 of 10 UCB units. Cells were initially positive for CD45, CD34, CD133, SSEA-3, SSEA-4, and several MSC markers. Several days into culture, expression of HSC/ESC markers was lost. MSC marker expression was maintained; cells remain positive for CD9, CD13, CD29, CD44, CD73, CD90, and CD105. These MLPC lines have been cultured through at least 16 passages with no apparent impact on expansion or differentiation potential. Cell lines have been successfully differentiated into cell types representative of each embryonic layer (i.e., adipocytes, osteocytes, myocytes, hepatocytes, and endothelial and neural cells). Additional experiments and limited-dilution cloning are underway, and further studies (cytogentic/molecular and animal teratoma studies) are planned.Conclusions: UCB-derived MLPCs were isolated as a rare population of adherent, initially CD45+/CD34+ cells with lymphoid morphology. Following successful expansion in culture, multi-potency was demonstrated. MLPCs may serve a role in bone marrow transplantation (for malignant and non-malignant disease) and regenerative medicine; clinical studies are in an early phase of development.