Successful transplantation of CD34 þ selected peripheral blood stem cells from an unrelated donor in an adult

Patients with acute myeloid leukaemia (AML) who have failed haematopoietic stem cell transplantation (HSCT) have a poor prognosis (Webb, 1999). The monoclonal anti-CD33 antibody, gemtuzumab ozogamicin (GO) (Mylotarg, CMA-676; Wyeth Laboratories, Philadelphia, PA, USA) is an emerging therapeutic option for patients with CD33-positive disease (Sievers et al, 2001). We report two patients with recurrent AML who received GO as part of their minimal conditioning before allogeneic HSCT as a second transplantation. The first patient, a 40-year-old woman, was diagnosed with AML [French–American–British (FAB) classification M2] with a normal karyotype in October 2000. First-line chemotherapy led to complete remission (CR) in February 2001. Treatment was accompanied by serious complications and as a result no consolidation therapy was performed. The patient's first relapse was treated with high-dose busulphan (16 mg/kg) and autologous HSCT. Because of further disease progression, allografting from a human leucocyte antigen-matched, unrelated donor was planned. The second patient was a 19-year-old woman who was diagnosed with AML (FAB M4) in April 2001. After achieving CR, the patient underwent myeloablative conditioning therapy (busulphan 16 mg/kg, cyclophosphamide 120 mg/kg) with an allogeneic bone marrow transplantation (BMT) from a matched sibling donor. Unfortunately, only 3 months later, a haematological relapse was diagnosed and a second allogeneic transplant with peripheral blood stem cells (PBSC) from the same donor was scheduled. As a second high-dose conditioning appeared inappropriate for both patients, they received 6 mg/m2 and 3 mg/m2 of mylotarg 21 and 14 d before allogeneic HSCT respectively. Minimal conditioning consisted of 30 mg/m2 fludarabine (on d −3 to −1) and 2 Gy total body irradiation on (d 0) (McSweeney et al, 2001). Granulocyte colony-stimulating factor (G-CSF)-mobilized PBSC were infused on d 0. Patient 1 received PBSC from a matched unrelated donor (5·3 × 106/kg CD34+ cells, 3·1 × 108/kg CD3+ cells). Patient 2 received a PBSC infusion from the original sibling (8·2 × 106/kg CD34+ cells, 4·3 × 108/kg CD3+ cells). Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporin A (CsA) and mycophenolate mofetil (on d 0–35) in patient 1, and no prophylactic immunosuppression was administered to patient 2. The maximum non-haematological toxicity observed was grade 2 stomatitis and hyperbilirubinaemia, occurring on d 7 and d 21 after HSCT in patient 1. Both patients achieved a fast and sustained haematological engraftment. Full donor chimaerism could be detected on d +26 in patient 1 and on d +17 in patient 2. Both patients developed acute GVHD grade II involving the skin and liver, as well as limited chronic GVHD. CR was documented on d +25 for patient 1 and on d +49 for patient 2. Both patients remained in CR at the time of writing, 10 and 14 months after the second HSCT with stable donor chimaerism. Figure 1 summarizes the clinical course and the subset chimaerism of patient 2. The clinical course and subset chimaerism in patient 2, with relapsed AML after a first allogeneic bone marrow transplantation (BMT), and who was successfully treated by gemtuzumab ozogamicin and a second allogeneic peripheral blood stem cell transplant (PBSCT) from the same donor. Preparation of cellular subsets and chimaerism analysis were performed as previously described (Thiede et al, 2001). The figure shows the percentage donor chimaerism of the patient against the markers CD4, CD8 and CD34 over a period of 350 d. The time of allogeneic BMT (allo-BMT), relapse, allogeneic PBSCT (allo-PBSCT), and the onset of acute and chronic GVHD are also shown. Sievers et al (2001) reported on 15 patients who underwent allogeneic (n = 10) or autologous (n = 5) HSCT as successful consolidation therapy several weeks after remission induction with GO. In contrast to the reported serious hepatotoxicity [common toxicity criteria (CTC) grade 3–4] in up to 23% of patients, we observed only mild hepatic side-effects in our patients (CTC grade 0–2). However, the cumulative dose of GO in our study was only 9 mg/m2, compared with 18 mg/m2 reported for the pivotal trial (Sievers et al, 2001). Despite poor prognostic factors, the patients in the present study achieved a sustained CR. The use of peripheral PBSC after failure of the first allogeneic BMT in patient 2 might be another cause of the higher antileukaemic efficacy of PBSC when compared with marrow. Furthermore, apoptosis induced by the administration of the anti-CD33 antibody may have induced a potent cytotoxic T-cell response (Selenko et al, 2002). In conclusion, gemtuzumab ozogamicin seems to be a feasible adjunct to minimal conditioning before allogeneic transplantation of haematopoietic stem cells from both related and unrelated donors. This study was supported in part by the Deutsche Krebshilfe (grant no. 70–2755 to CT/MB).

Two patients with high-risk acute myeloid leukemia (AML) whose bone marrow aspirates showed more than 25% blasts between 2 and 4 weeks after the first induction chemotherapy immediately received modified conditioning therapy with intravenous busulfan at 50% of the usual dose and fludarabine, before hematologic recovery occurred. Unmanipulated G-CSF mobilized peripheral blood stem cells from an HLA-identical sibling donor were transfused and haematopoietic recovery was achieved in both recipients. Both of them are in continuing hematological remission with full donor chimerism 12 and 22 months after transplantation. Early treatment intensification with allogeneic cell therapy during marrow aplasia might cure high-risk AML patients who are unlikely to achieve remission with conventional chemotherapy protocols.

We performed a prospective trial investigating the feasibility of a double lumen port access in 26 patients with hematological malignancies or solid tumors receiving either standard conditioning (n = 9, median age 49 years (range 19-65)) or dose-reduced conditioning (n = 17, median age 56 years (range 35-66)) followed by allogeneic blood stem cell transplantation. The port system was implanted within 3 months (n = 20, range 7-91 days) before transplantation or as indicated at different time points after transplantation (n = 6, range 28-680 days). Most infusions, including the graft itself and all blood drawings, were performed via the port. Over a cumulative duration of 5622 days (1310 days after standard conditioning (range 56-349) and 4431 days after dose-reduced conditioning (range 49-489)) two port systems of patients receiving standard conditioning were removed due to early postimplantation pocket infection on day 6 and 8 after insertion, respectively. In the dose-reduced conditioning group only one late removal (day 287) of a port was required. Most of the patients in both groups reported less pain and a higher degree of comfort compared to peripheral or central venipuncture. The use of double lumen port access during conditioning and in an outpatient setting after allogeneic hemopoietic stem cell transplantation is feasible and advantageous for both patient and medical staff. Implantation several weeks before the start of conditioning might help in avoiding early infectious complications after conventional myeloablative conditioning.

Objective: To evaluate late effects concerning growth and endocrine function in children and adolescents after stem cell transplantation (SCT). Patients and Methods: 318 patients treated with SCT from 1996 to 1999 were investigated for late effects. The underlying diseases were ALL 21%, AML 13%, CML 7%, MDS 8%, lymphoma 4%, SAA 8%, NB 11%, solid tumours 15% and others 13%. They were followed-up according to a standardised protocol: determination of weight, height (HT), sitting height, leg length, arm-span, head circumference and pubertal status. Analysis of TSH, T4 and fT4, LH, FSH, estradiol and testosterone, in addition, TRH and GnRH testing was performed. Evaluation of the GH axis included measurement of IGF-I and IGFBP-3 and an arginine test. Patients were examined before SCT and 3, 6, 12, 24, 36 months after SCT. Results: HT-SDS before SCT was significantly, p , 0.005, reduced compared to target HT (n = 145) at -0.52 SDS (median) (range -4.02 to 2.71) versus 0.11 SDS (2.43 to 2.18). HT-SDS significantly decreased further to -0.67 SDS (-5.03 to 2.94), p , 0.05, and -1.03 SDS (-4.17 to 0.16), p , 0.05, after 24 and 36 months. IGF-I and IGFBP-3 had no predictive value for changes in HT-SDS. Individual changes in HT-SDS ranged from -2.02 to 1.93 after 12 to 36 months. Before SCT, primary hypothyroidism was seen in 13.4% (23/172) and after SCT in 18.7% (44/235). Central hypothyroidism was suspected in 64.4% (96/149) with low values for fT4 and/or T4 and a ’normal’ TSH. This was confirmed by low TSH peaks in 21% (25/119) of the TRH tests. After SCT, 64.9% (124/191) had low fT4 and/or T4 levels and a ’normal’ TSH. Hypergonadotropic hypogonadism was detected in 21.9% (14/64) female (f) and 14.2% (15/106) male (m) patients before SCT. GnRH tests, however, revealed a much higher rate of gonadal dysfunction: 50.0% (32/64) and 21.6% (23/147), respectively. Longitudinal data in 28 f and 45 m patients showed normal LH/FSH levels before and elevated levels after SCT in 28.6% f and 18.0% m patients. Conclusions: Growth failure and endocrine deficiencies are very frequent after SCT. The right diagnostic tools have to be applied for detection of developing dysfunction. The time and order of their occurrence cannot be predicted. To ensure normal growth and development each patient has to be followed individually. Investigations must be performed according to a standardised protocol with co-operation of the paediatric haematologist and the paediatric endocrinologist.

BACKGROUND:Mycophenolate mofetil (MMF) has shown synergistic effects in combination with cyclosporin A (CsA) in prevention of acute graft versus host disease (GvHD) after allogeneic blood stem cell transplantation (BSCT) in preclinical animal models. After having measured low plasma levels of the active metabolite mycophenolic acid (MPA) in recipients of allogeneic blood stem cell transplants after oral administration of MMF, we initiated a phase I/II study evaluating different dose levels of the intravenous (i.v.) formulation together with standard dose CsA. METHODS:A total of 15 patients received i.v. MMF in two split doses for 21 d after allogeneic BSCT from related (n=9) and unrelated (n=6) donors. Total daily doses of 25, 28, 31 and 34 mg/kg were investigated in 3-5 patients at each dose level. Plasma concentrations of MPA and its metabolite mycophenolic acid glucuronide (MPAG) were measured by high-performance liquid chromatography (HPLC). RESULTS:Mean trough blood levels of MPA ranged between 68.8 and 340 ng/mL with a median of 146.7 ng/mL. The mean MPA AUC0-12 h after first dose ranged between 19349+/-5087 ng * h/mL and 25705+/-3042 ng * h/mL and correlated with the dose level of MMF. The incidence of acute GvHD>grade I was 40%. No dose limiting toxicities were observed. CONCLUSIONS:The application of i.v. MMF is safe at a weight-adjusted dose between 25 and 34 mg/kg after allogeneic BSCT. The measured trough blood levels of MPA in patients after BSCT were ten times lower than in healthy volunteers. The toxicity induced by the conditioning therapy seems to negatively influence the pharmacokinetic behavior of MMF, MPA and MPAG.

BACKGROUND:Cidofovir (CDV) is a nucleotide analogue with proven in vitro effects against cytomegalovirus (CMV) and adenovirus and has been successfully used in the treatment of CMV retinitis in AIDS patients. METHODS:We performed a prospective study to evaluate the efficacy of CDV in 17 patients with hematological malignancies after allogeneic blood stem cell transplantation from related (n=3) and unrelated (n=14) donors. Dose-reduced conditioning (DRC) regimen consisted of busulfan (Bu)/fludarabine (Flu) (n=9) and idarubicin/cytosine arabinoside/Flu (n=1). Myeloablative conditioning (MC) was performed with Bu/cyclophosphamide (Cy)/etoposide (Eto) (n=4), Bu/Cy (n=2), and total body irradiation (TBI)/Cy/Eto (n=1). Antithymocyte globulin (ATG) was used in seven patients with DRC and in six patients with MC. In all patients, either the donor, host, or both were CMV IgG positive pretransplant. Indication for therapy was preemptive treatment of primary CMV antigenemia defined as two consecutive positive tests of pp65 antigenemia assay after transplant. In case of response with a decreasing number of pp65-positive leukocytes, CDV was scheduled in a dosage of 5 mg/kg body weight once a week for 2 weeks followed by maintenance therapy every 2 weeks in an outpatient setting. All patients received probenecid and prehydration as recommended. Patients were monitored using an immunostaining assay for pp65 antigen and a qualitative and quantitative CMV polymerase chain reaction (PCR). Success of treatment was defined as negativity for the pp65 antigen. RESULTS:After DRC, nine of ten patients (90%) showed a response with seven of nine revealing a complete clearance of the virus (pp65 negative, qualitative PCR negative). In the remaining two responders, treatment was changed to ganciclovir because of either renal impairment or slow clearance of antigenemia. Only one of seven patients in the MC group experienced a temporary clearance of pp65 antigen. After MC, two patients experienced CMV disease. Treatment-related toxicity rate was moderate with four patients developing reversible renal impairment (creatinine 133-180 micromol/L); one patient with proteinuria and three patients with complaints of nausea and vomiting. CONCLUSION:Our data suggest the feasibility of CDV administration in patients after allogeneic transplantation. In the recommended dose, it might be used successfully for low-risk patients, e.g., after DRC or organ transplantation, in an outpatient setting.

PURPOSE:A fludarabine-based "nonmyeloablative" preparative regimen was investigated in 42 patients with hematological malignancies receiving hematopoietic stem cell grafts from unrelated volunteer donors. EXPERIMENTAL DESIGN:Recipient conditioning consisted of fludarabine 30 mg/m(2) on days -6 to -2 and i.v. busulfan 3.3 mg/kg on days -6 to -5. Antithymocyte globuline was added at 2.5 mg/kg i.v. on days -5 to -2. The patients were grafted with bone marrow (n = 13) or peripheral blood stem cells either unmanipulated (n = 20) or CD34+ selected (n = 9). Graft-versus-host disease prophylaxis was performed with cyclosporine A (CsA, n = 12), CsA/methotrexate (n = 12), or CsA/mycophenolate mofetil (n = 18). RESULTS:With a median follow-up of 13 months (range, 5-26 months), the actuarial disease-free survival is 64% and 38% for patients with lymphoid malignancies and standard-risk leukemia compared with only 14% for patients with high-risk disease. The main cause of treatment failure was relapse of disease in high-risk patients (n = 14). An increased incidence of primary (n = 1) or secondary graft-failure (n = 8) was observed (21%). Chimerism analysis of CD56+/CD3--sorted natural killer (NK) cells, available in 10 patients, showed an impaired increase of donor NK cell chimerism between day 10 and 30 after transplantation in three of four patients with graft failure, whereas the percentage of donor NK cells surpassed 75% in all of the six patients with stable engraftment. CONCLUSIONS:Unrelated transplants after dose-reduced conditioning are associated with a higher risk of graft-failure. Pretransplant host immunosuppression has to be optimized to overcome resistance to grafts from unrelated donors after nonmyeloablative conditioning therapy.

A 37-year-old male patient with a diffuse pleomorphic B-cell-lymphoma, which has been diagnosed two month earlier with the primary site at the pterygopalatine fossa on both sides with infiltration of the clivus and cavernous sinus was referred to our hospital for continuation of the third course of CHOP chemotherapy. At admission he reported about a recent history of painful swallowing and intermittent substernal chest pain. Alleviation of the pain on swallowing and the chest pain was apparently only possible by drinking 10 to 15 l of cold coca cola throughout the day and night, a regimen that resulted in polyuria. Physical examination revealed extensive thrush stomatitis and soor esophagitis. Despite successful treatment with fluconazole, polydipsia continued unabated. The classic osmotic test of dehydration and exogenous vasopressin revealed hypothalamic diabetes insipidus (DI). Basal hormones and stimulated endocrine function tests of the adenohypophysis were found to be normal. MRI-scan revealed lymphoma infiltration of the neurohypophysis. After the third course of CHOP chemotherapy the patient surprisingly recovered completely from his excessive thirst. The present report shows that clinical disorders such as thrush stomatitis can mask diabetes insipidus caused by an early relapsing lymphoma.

Between February 1998 and October 1999, 24 patients with advanced leukemia, lymphoma or solid tumors received G-CSF mobilized peripheral blood stem cells (PBSC) from HLA-matched sibling donors after dose-reduced conditioning therapy. Only patients with reduced performance status or major infectious complications, not eligible for standard transplant procedures, were included. The 5-day conditioning therapy consisted of 3.3 mg/kg intravenous busulphan x 2 days and 30 mg/m2 fludarabine x 5 days. GVHD prophylaxis was performed with either CsA alone (n = 5), CsA combined with short course methotrexate (n = 5) or mycophenolate mofetil (n = 14). The day 100 survival was 95.2% for the whole group. All patients engrafted after a median of 15 days (range, 11-19) and 12.5 days (range, 10-19) for neutrophils and platelets, respectively. The median time to a neutrophil count of <0.5 x 109/l was 7 days (range, 2 to 12). Acute GVHD >I was observed in six patients, whereas eight patients have signs of chronic GVHD. The prospective 12 month overall survival with a median follow-up of 7 months is 63%. Relapse of disease and toxicity associated with chronic GVHD were the main causes of death. The treatment-related mortality was 12.5%. Dose-reduced conditioning using intravenous busulphan and fludarabine allows stable engraftment without ATG in related transplants and leads to a reduction of transplant-related mortality.