Autologous bone marrow and peripheral blood stem cell transplantation in haematological malignancies: current status

Autologous bone marrow and peripheral blood stem cell transplants permit the use of higher doses of chemoradiotherapy than would have been possible without "rescuing' bone marrow function. This may well allow cure of malignant disorders in cases where this was previously not feasible. This short review attempts to summarize the current status of such a treatment approach for the various haematological malignancies.

Allogeneic bone marrow transplantation for primary myelofibrosis

The published experience of allogeneic bone marrow transplantation for primary myelofibrosis (PMF) is limited. Three patients (24-49 years) with PMF received allogeneic marrow grafts from HLA-identical sibling donors after conditioning with 110 mg/m2 melphalan and 1050 cGy total-body irradiation (TBI). Donor marrow was not depleted of T cells, and graft-versus-host disease (GVHD) prophylaxis comprised cyclosporine and methotrexate. None of the patients was splenectomized prior to the transplant. Two patients received G-CSF post-transplant to hasten neutrophil recovery. One patient died of multi-organ failure 23 days post-transplant. Hematopoietic recovery was relatively slow in the other two who had gradual resolution of the marrow fibrosis over several months. One of the two died of overwhelming pneumococcal sepsis within 2 weeks of stopping prophylactic penicillin 31 months post-transplant. The other patient is alive and well 20 months post-transplant with a Karnofsky score of 100% and no fibrosis of the marrow. We conclude that PMF is correctable by allogeneic BMT. Hematologic recovery post-transplant is slow, but counts may normalize with time without the need for splenectomy.

Comparison of Cobe Spectra and Haemonetics MCS-3P cell separators for peripheral blood stem cell harvesting

A prospective study was undertaken to compare the total nucleated cell (TNC), mononuclear cell (MNC), CD34+ cell, and CFU-GM yields of two different cell separators. A Haemonetics MCS-3P and a Cobe Spectra machine were used to leukapherese 10 patients with malignant diseases on 4 consecutive days after mobilization with G-CSF. All patients were harvested twice on each machine for a fixed period of time. The blood volume processed (10.47 vs 3.79 l, P < 0.001), MNC yield (2.66 vs 0.90 x 10(8)/kg; P < 0.001), MNC yield rate (1.66 vs 0.55 x 10(6)/kg/min; P < 0.001), MNC purity (81 vs 42%; P < 0.001), CFU-GM yield (18.1 vs 5.5 x 10(4)/kg; P = 0.001), and CFU-GM yield rate (11.27 vs 3.42 x 10(2)/kg/min; P = 0.001) were significantly higher with the Spectra. The CD34+ cell yields and yield rates were comparable. Although CFU-GM and MNC yields per unit blood volume processed were comparable for both machines, there was a trend for higher CD34+ yields per unit volume processed with MCS-3P. We conclude that Spectra is faster than MCS-3P with more blood processed per unit time resulting in higher cell yields, but yields per unit volume processed are comparable for both machines. The choice of machine for a given patient depends upon convenience, venous access and the time available.

Listeriosis in bone marrow transplant recipients: incidence, clinical features, and treatment

Cultures of blood and/or cerebrospinal fluid from four of 1,013 bone marrow transplant recipients treated at our center between January 1972 and April 1994 were positive for Listeria monocytogenes. The overall occurrence of listeriosis was 0.39 case per 100 transplantations. Allograft recipients had received prior treatment with parenteral methylprednisolone, thus supporting an association between listeriosis and corticosteroids. Treatment with parenteral ampicillin (200 mg/[kg.d]) and gentamicin is recommended for a minimum of 3 weeks before oral therapy. Two patients with penicillin allergies in this study failed to respond to chloramphenicol-based therapeutic regimens. Recurrent meningitis occurred in two patients, and the therapeutic use of intrathecal gentamicin/vancomycin did not confer a survival advantage (i.e., the patients did not survive).

Kinetics of paraprotein clearance after autografting for multiple myeloma

The kinetics of paraprotein clearance after autografting for multiple myeloma have not been described. We studied 33 myeloma patients in plateau phase with detectable paraprotein (3-34 milligrams, median 10 milligrams) at the time of ABMT who received melphalan (200 mg/m2) and methylprednisolone (1.5 g x 5) for conditioning. Fifteen patients received interferon-alpha post-transplant as part of a randomized study. Twenty-four of 33 (72.7%) patients eventually cleared the paraprotein at a median of 47 days (range 5-783) post-transplant. The probability of clearance was lower (46.7 vs 94.4%, P = 0.004) and the time taken to clear paraprotein longer (142 vs 29 days, P = 0.003) in patients with a higher level (> 10 milligrams) at the time of the transplant. However, clearance occurred within 6 months in 23 of 24 (95.8%) patients who ultimately cleared the paraprotein. Interferon-alpha did not influence the clearance of paraprotein. We conclude that after autografting for myeloma, the time taken to clear paraprotein is longer and the probability of clearance lower with higher levels at the time of ABMT, and most patients who eventually clear the paraprotein do so within 6 months. Because the probability of clearing paraprotein (and thus attaining remission) in patients with detectable paraprotein 6 months post-transplant is low, a decision about further treatment may be made at this point.

Autologous bone marrow transplantation for acute myeloid leukemia in first remission: identification of modifiable prognostic factors

Seventy-four consecutive patients (median age 31 years) with acute myeloid leukemia (AML) undergoing unpurged autologous bone marrow transplantation (ABMT) in first remission after melphalan and total-body irradiation were studied to assess the impact of 14 modifiable and non-modifiable prognostic factors on relapse and disease-free survival. Thirty patients were alive in continuous CR at a median of 37.5 months (range 3-94), 14 died of transplant-related toxicity at a median of 5.5 months (range 0.5-18), and 30 relapsed at a median of 7.5 months (range 2-23). The actuarial 5-year probabilities of relapse and disease-free survival were 53.4 and 34.2%, respectively. On multivariate analysis, administration of two or more courses of consolidation chemotherapy prior to the harvest and transplant was found to be the most significant factor associated with decreased relapse (relative risk 2.62, P = 0.0012) and improved disease-free survival (relative risk 3.03, P = 0.0009). A nucleated cell dose of > 2 x 10(8)/kg improved disease-free survival (relative risk 2.17, P = 0.045) by decreasing transplant-related mortality (P = 0.047). We conclude that adequate consolidation of remission before ABMT is the most important factor associated with continuing remission after ABMT. Short-term therapy of AML with two courses of consolidation therapy followed by ABMT requires comparison with repeated courses of intensive chemotherapy for efficacy and cost-effectiveness.

Costs of antifungal prophylaxis after bone marrow transplantation. A model comparing oral fluconazole, liposomal amphotericin and oral polyenes as prophylaxis against oropharyngeal infections

We used a costs model to compare alternative modes of prophylaxis against oropharyngeal fungal infections in patients with leukaemia or myeloma who had undergone bone marrow transplantation (BMT). We compared 2 innovative pharmaceutical options (oral fluconazole and intravenous liposomal amphotericin) with existing standard practice (oral polyenes). Costs were measured over a 12-week treatment period, and were compared with the 2 effectiveness measures: (i) the avoidance of colonisation or infection; and (ii) the patients' ability to continue with prophylaxis in an uninfected state. The costs and effectiveness of BMT itself were not considered in this evaluation. The costs per successfully treated patient over a 12-week period were 28,956 pounds (1 pound = $US1.60, June 1995) for oral fluconazole, 53,225 pounds for liposomal amphotericin and 32,768 pounds for oral polyenes. Sensitivity analysis showed that the costs of liposomal amphotericin always exceeded those of the oral comparators, reflecting its high acquisition, preparation and administration costs.

Autologous bone marrow or peripheral blood stem cell transplantation followed by maintenance chemotherapy for adult acute lymphoblastic leukemia in first remission: 50 cases from a single center

The aim of this study was to evaluate the use of maintenance chemotherapy after autotransplantation in adult acute lymphoblastic leukemia (ALL), and to compare the relative durability of marrow and peripheral blood stem cell grafts to chemotherapy. Fifty consecutive ALL patients received 200 mg/m2 melphalan alone or 110 mg/m2 melphalan with total-body irradiation in first remission, followed by autologous marrow (ABMT, n = 38) or peripheral blood stem cells (PBSCT, n = 12). After hematologic recovery, 6-mercaptopurine and methotrexate were administered for 2 years. 6-mercaptopurine could be given to 78.9% of ABMT recipients at a median daily dose of 33.5 mg/m2, and to 91.7% of PBSCT recipients at a median daily dose of 44.1 mg/m2. ABMT recipients started 6-mercaptopurine at a median of 58.5 days post-transplant, and PBSCT recipients at 32 days (P = 0.002). 52.6% of ABMT recipients and 75% of PBSCT recipients received weekly methotrexate. No graft failure was seen as a result of chemotherapy. The actuarial 5-year probabilities of overall survival, survival in first remission and relapse were 56.2, 53.2, and 30.6%, respectively. We conclude that administration of maintenance chemotherapy after autografting in adult ALL may reduce relapse. A randomized study is required to evaluate the relative efficacy of PBSCT vs ABMT, and the role of post-transplant maintenance chemotherapy.

Maintenance therapy for remission in myeloma with Intron A following high-dose melphalan and either an autologous bone marrow transplantation or peripheral stem cell rescue

Eighty-four patients with myeloma were randomized to receive maintenance Intron A (Schering-Plough, Suffolk, UK), 3 mega units/m2 s.c. three times weekly or no treatment following induction therapy with cyclophosphomide, vincristine, doxorubicin, methyl prednisolone (C-VAMP), consolidated with high-dose melphalan (HDM) 200 mg/m2 + autologous bone marrow transplantation (ABMT). The patients have been followed up for a median of 52 months. Overall, median progression-free survival (PFS) from HDM was 27 months in the control group and 46 months in the Intron A group (< 0.025). For the 65 patients who achieved complete remission (CR) with HDM, there was a significant prolongation of remission (p = 0.02) for those who received Intron A and 49% of these patients remained in remission four years after high-dose treatment. However, for partial responders (PR) and nonresponders to HDM there was no significant prolongation of PFS. Overall, survival was also significantly better for the Intron A group, with 5 deaths versus 14 deaths in the control group (p = 0.006). Subsequently, 54 consecutive patients received the same HDM followed by rescue with peripheral blood stem cells after induction chemotherapy which included C-VAMP. Intron A was started in 45 of these patients at a median of 62 days which was comparable to the ABMT arm. The overall response rate in these patients was 79.62% (43/54-CR+PR) and the probability of survival at 18 months was 74.2% by the Kaplan Meier method.(ABSTRACT TRUNCATED AT 250 WORDS)

Cytokine-mediated immunotherapy with or without donor leukocytes for poor-risk acute myeloid leukemia relapsing after allogeneic bone marrow transplantation

Six patients with high-risk acute myeloid leukemia (AML) relapsing after allogeneic bone marrow transplantation (BMT) were treated with interferon-alpha 2b to stimulate graft-versus-leukemia reactions. Additionally, donor mononuclear cells were infused with or without interleukin-2 as first-line treatment or upon failure of interferon-alpha 2b in 5 patients. Two patients developed clinical acute graft-versus-host disease (GVHD) after a combination of donor leukocytes and interferon-alpha, and one developed de novo chronic GVHD after interleukin-2 and interferon-alpha. Complete remission was attained in 4 patients whereas 2 patients showed no response. Two of the responding patients relapsed rapidly. Four patients died of a combination of complications of immunotherapy and progressive disease. Two patients are alive in remission with chronic GVHD (Karnofsky performance scores of 80%) 8 and 18 months after immunotherapy. We conclude that cytokine-mediated immunotherapy with or without donor cell infusions may be effective in some cases of AML relapsing after allogeneic BMT, and may result in long-term survival. With limited data, it appears that development of chronic GVHD after immunotherapy is essential for continued remission.

Relationship between donor-recipient blood group incompatibility and serum bilirubin after allogeneic bone marrow transplantation from HLA-identical siblings

Data on 477 patients with hematologic malignancies undergoing allogeneic bone marrow transplantation from HLA-identical siblings were analyzed for correlation between donor-recipient ABO blood group incompatibility and the development of elevated bilirubin levels (over 17 mmol/l) after transplantation. The median bilirubin on day 15 after transplant and the maximum bilirubin in the first 100 days were significantly higher in 155 patients with ABO-mismatched donors compared with 322 patients with ABO-matched donors. In univariate analysis, age > 16 years (P = 0.000006), ABO incompatibility (P = 0.0004), a conditioning regimen other than cyclophosphamide-total body irradiation (P = 0.0005) and a diagnosis other than acute leukemia (P = 0.01) were associated with a higher probability of developing elevated bilirubin. Incidence of clinically diagnosed graft-versus-host disease (GVHD), and transplant-related mortality, relapse rates and overall survival were not influenced by ABO incompatibility. The hyperbilirubinemia was therefore unlikely to be the result of an increased incidence of hepatic complications such as GVHD or veno-occlusive disease. We suggest that studies on serious transplant-related complications such as GVHD and veno-occlusive disease which rely on bilirubin values for diagnosis should take donor-recipient ABO incompatibility into account.