Subsequent Allogeneic Stem Cell Transplantation Research Articles

Second-generation tyrosine kinase inhibitors before allogeneic stem cell transplantation in patients with chronic myeloid leukemia resistant to imatinib

Philadelphia-positive chronic myeloid leukemia (Ph+ CML) patients who are resistant to imatinib are commonly treated with second-generation tyrosine kinase inhibitors (TKIs). Limited data exist on the possible effects of these drugs on subsequent allogeneic hematopoietic stem cell transplantation (allo-HSCT).The outcome of 12 imatinib-resistant CML patients treated with dasatinib or nilotinib or both before allo-HSCT, was retrospectively analyzed. Patients were treated with second-generation TKIs for 1–17 months (median, 8). At the time of transplant, 3 patients were in complete cytogenetic response (CCgR), 3 patients in partial cytogenetic response (PCgR) and 6 patients were in less than PCgR. Donors were HLA-matched related in 4 cases and unrelated in 8 cases. Stem cell source was peripheral blood, bone marrow or cord blood in 6, 5 and 1 cases, respectively. All patients engrafted successfully and all but one achieved a full donor chimerism. Three patients experienced acute and chronic graft-versus-host disease. No cases of transplant-related mortality were recorded. Best response to allo-HSCT was complete molecular response (CMR) in 9 patients, major molecular response (MMR) in 1 patient and CCgR in 2 patients. Median follow-up was 16.5 months. At the last evaluation, 9 patients were in continuous CMR and 1 patient was in MMR; 2 patients had died of disease progression. Second-generation TKIs given before allo-HSCT do not negatively affect transplant engraftment and response rate, nor increases transplant-related toxicity.

Secondary antifungal prophylaxis in paediatric allogeneic haematopoietic stem cell recipients

Presumed or proven invasive pulmonary aspergillosis (IPA) is an important cause of infectious morbidity in patients with acute leukaemia. Although prior IPA is not a contraindication for subsequent allogeneic haematopoietic stem cell transplantation (HSCT), its management during granulocytopenia and immunosuppression remains challenging. In the absence of an evidence-based approach, 11 adolescents (11-18 years) with acute leukaemia and a history of antecedent possible (4) or probable (7) IPA received liposomal amphotericin B (LAMB; 1 mg/kg once a day) from the start of the conditioning regimen until engraftment and ability to take oral medication, followed by oral voriconazole (200 mg twice a day) until the end of the at-risk period. Nine patients had a good partial response (>50% reduction in pulmonary infiltrates) and two had a complete response prior to HSCT. The median duration of intravenous treatment with LAMB was 30 days (range, 19-36), followed by a median of 152 days (range, 19-210) of oral voriconazole. LAMB was discontinued early in one patient and voriconazole was transiently or permanently discontinued due to adverse events/new contraindications in two and two patients, respectively. At +180 days post-transplant, eight patients were alive, six with complete, and one each with near complete and ongoing resolution of pulmonary infiltrates; all but one were in continuing haematological remission. Three patients had succumbed either to recurrent leukaemia (two) or refractory graft failure (one); whereas one of these patients had maintained a complete response, two died with secondary possible (one) or probable (one) IPA. Both patients had discontinued voriconazole early and developed IPA in lung areas involved during the primary episode. This prospective paediatric series supports the notion that secondary antifungal prophylaxis for possible or probable IPA can be safely achieved in allogeneic HSCT. In the absence of chronic graft-versus-host disease, breakthrough infection appeared to be associated with recurrent leukaemia/graft failure and shorter duration of post-engraftment prophylaxis.

First Successful Allogeneic Hematopoietic Stem Cell Transplantation in Children with Chronic Myeloid Leukemia, Preceded by Imatinib Prior Transplantation.

Objectives: Although very rare in children, chronic myeloid leukemia (CML) can be cured by hematopoietic stem cell transplantation (HSCT). However, the 5-year survival probability following allogeneic HSCT is only about 50–60% in childhood CML. With imatinib successful in CML patients, the impact of imatinib treatment on subsequent allogeneic hematopoietic stem cell transplantation (HSCT) remains unclear. Imatinib therapy prior to HSCT has not been reported in children. Herein we describe imatinib induction preceding HSCT in three children newly diagnosed.Methods: Imatinib was administered as induction in three boys, aged 11, 14, 15 years, newly diagnosed in the chronic phase. Between induction and cytogenetic remission, two patients received HSCT from matched unrelated donors (MUD) and one received HSCT from matched sibling donor. Busulphan and cyclophosphamide were utilized as a conditioning regimen. Cyclosphorin A and methotrexate were both used as graft versus host disease (GVHD) prophylaxis. Anti-thymocyte globulin was added for MUD cases.Results: Successful engraftment and neither severe liver toxicity nor acute GVHD were encountered. All three cases show cytogenetic remission, with chronic GVHD well controlled in one. We monitored each patient's status for minimal residual disease by real-time quantitative polymerase chain reaction. Absence of detectable minimal residual disease was found in two patients at 28 and 63 months after HSCT. At present, all of these three patients have good quality of life.Conclusions: As first-line therapy, imatinib appears useful for providing a bridge to HSCT in children with CML. Further study is warranted to determine impact of imatinib prior transplantation on child CML.

Successful treatment of disseminated fusariosis with posaconazole during neutropenia and subsequent allogeneic hematopoietic stem cell transplantation

We report the case of a 16-year-old girl with acute myelogenous leukemia with disseminated fusariosis, who responded to salvage posaconazole therapy. She subsequently received additional cytotoxic chemotherapy and allogeneic hematopoietic stem cell transplantation with posaconazole continued as secondary prophylaxis. Despite intensive immunosuppressive therapy for graft-versus-host disease, no recrudescence of infection occurred.

Early Stem Cell Transplantation for Refractory Acute Leukemia after Salvage Therapy with High-Dose Etoposide and Cyclophosphamide

Primary refractory acute leukemia (AL) has a poor prognosis, although some patients can be salvaged with allogeneic stem cell transplantation (SCT). Induction of complete remission (CR) with conventional chemotherapy before SCT may improve outcome in this patient population. Between March 1991 and October 2003, 59 adults with primary refractory AL were treated with continuous-infusion etoposide (VP) 2.4 to 3.0 g/m 2 followed by cyclophosphamide (Cy) 6.0-7.2 g/m 2 intravenously over 3 to 4 days with the intention of proceeding to SCT in CR1. Forty-two patients had acute myelogenous leukemia (AML), 13 patients had acute lymphoblastic leukemia (ALL), and 4 patients had acute biphenotypic leukemia. The most frequent nonhematologic toxicities were oral mucosal, gastrointestinal, and hepatic toxicities (44%, 20%, and 15% of patients, respectively). Thirty-two (57%) of 56 evaluable patients entered CR1 with a median time to platelet and neutrophil recovery of 22 and 26 days, respectively. CR1 rates were similar in AML (54%) and ALL/acute biphenotypic leukemia (67%; P = .52), and analysis of baseline characteristics did not reveal any predictors of response to VP/Cy. Twenty-nine of 32 CR1 patients subsequently underwent SCT (24 allogeneic and 5 autologous). Estimated 5-year event-free survival (EFS) and overall survival for the entire cohort are 23% and 26%, respectively. In the allogeneic SCT group, 5-year EFS was 52% for AML patients and 14% for ALL patients ( P = .04), and only male sex was predictive of a favorable outcome ( P = .03). VP/Cy is able to induce CR1 in most patients with primary refractory AL with an acceptable toxicity profile. Subsequent allogeneic SCT can lead to long-term EFS in a significant proportion of patients.

Phase II study of CHOP-GR therapy for advanced-stage follicular lymphoma

Recently, the cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) regimen plus rituximab (R-CHOP) have been used widely to treat patients with follicular lymphoma. We investigated a fixed scheme of combination chemotherapy protocol including CHOP, granulocyte colony stimulating factor (G-CSF) and rituximab (CHOP-GR) for patients with advanced-stage grade 1 or grade 2 follicular lymphoma in a phase II clinical trial, assessing enhancement of antibody-dependent cellular cytotoxicity of rituximab by G-CSF. Twenty-one untreated patients received two courses of CHOP chemotherapy followed by four courses of CHOP-GR, including G-CSF (s.c.) on days 11 – 14 and rituximab on day 15. Overall response rate was 76% (16 of 21 patients). Two patients, one with no response and subsequent allogeneic hematopoietic stem cell transplantation and one with progressive disease, died of lymphoma. One patient refused to continue therapy, whereas two were rediagnosed and no longer met histologic criteria; these three patients were classified as nonresponders. After a median observation time of 23 months, the 19 histologically assessable patients showed a 2-year progression-free survival rate of 82%, whereas 2-year overall survival was 95%. Fifteen patients (79%) continued in remission during this median follow-up period. Of seven patients with initial bulky mass, five responded to therapy. The most frequent adverse events were leukocytopenia (100%) and neutropenia (100%), followed in turn by alopetia (94%) and nausea/vomiting (79%). Of 11 patients examined for bcl-2 translocation in peripheral blood or marrow by polymerase chain reaction (PCR), four were positive, whereas three of the four had complete remissions and converted to PCR negativity after therapy. According to short-term observation, CHOP-GR is a safe and effective therapy for patients with advanced-stage follicular lymphoma.

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

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

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

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

Rapid isolation of chromosomal breakpoints from patients with t(4;11) acute lymphoblastic leukemia: implications for basic and clinical research

Abstract Chromosomal translocations t(4;11)(q21;q23) are associated with agroup of acute lymphoblastic leukemias with very poor prognosis. Fromthe complete sequences of the breakpoint cluster regions of the humanMLL and AF-4translocation partner genes, a novel set of 66 oligonucleo-tides that facilitates the rapid identification of translocation breakpointsby PCR analysis of genomic DNA was designed. For each breakpoint, apair of optimally suited primers can be assigned, which improves themonitoring of the disease during treatment. Comparison of the break-points with the corresponding parental sequences also contributes to ourbetter understanding of the illegitimate recombination events leading tothese translocations. IntroductionCertain chromosomal translocations are known to be the initialsteps of the malignant transformation of hematopoietic cells leading tothe development of myeloid and lymphoblastic leukemias and lym-phomas (1). Translocations to the MLL 3 gene (2, 3) are associatedwith an AML or ALL disease phenotype. More than 30 differentchromosomal translocations to the 11q23 region have so far beenidentified, all of which are associated with hematological malignan-cies, and many translocation partner loci have been analyzed at themolecular level (for review see Refs. 4–6). Among these transloca-tions, the chromosomal translocation t(4;11) is regularly associatedwith high-risk infant acute pro-B lymphoblastic leukemias and hasbeen proposed to initiate the development of this malignancy (4–8).Leukemic blasts with chromosomal translocation t(4;11) are highlyresistant against current treatment protocols. Although an initial re-mission can be achieved in about 80–90% of all cases, the relapse rateis exceedingly high. Thus, there is need for a better control of appliedtherapy. Monitoring of MRD allows the control of the efficacy ofinduction chemotherapy or subsequent allogeneic stem cell transplan-tation. Molecular methods for MRD-monitoring of t(4;11)-patients, sofar, were based mostly on RT-PCR analysis of breakpoint mRNAs(9). However, RT-PCR experiments using one t(4;11) break-regiontranscript as the sole molecular marker may generate ambiguousresults, as it has been demonstrated recently (10). Derivative (der) 11breakregion transcripts were identified in normal biopsy materialwithout any accompanying cytogenetic evidence for a chromosomalrearrangement t(4;11). In addition, the RNA may be degraded andsteady-state RNA concentration or transcriptional activity may changeduring therapy, which may negatively affect a precise analysis.The use of genomic DNA as template for PCR experiments is veryattractive because chromosomal fusion sites are characteristic andusually stable features of t(4;11) cells (11). However, this type ofanalysis, so far, was hampered by the fact that the DNA sequence ofthe breakpoint cluster region of the human AF-4gene was not avail-able, and systematic analyses of t(4;11) breakpoints on the genomicDNA level could not be performed. In this study, the completebreakpoint cluster region of the AF-4gene was subcloned and se-quenced. The sequence was used to design sets of specific oligonu-cleotides, allowing investigators to retrieve chromosomal breakpointinformation from t(4;11) patient DNA. This resulted in the assignmentof optimally suited DNA primer pairs for each individual patient. Thisnew tool can be applied in any clinical setting and may close adiagnostic gap for this group of high-risk acute leukemias.Materials and Methods