Busulfan plus cyclophosphamide followed by autologous blood stem-cell transplantation for patients with acute myeloblastic leukemia in first complete remission: a report from a single institution

PURPOSE

To determine if peripheral-blood stem cells (PBSC) collected during the recovery of standard induction and consolidation chemotherapy in acute myeloblastic leukemia (AML) can be used as a safe tool for autologous transplantation, and to study aspects of the autologous blood stem-cell transplantation (ABSCT) procedure and their results in AML patients in first remission.

PATIENTS AND METHODS

Twenty-four AML patients in first remission received busulfan (BU; 16 mg/kg) and cyclophosphamide (CY; 200 mg/kg) followed by ABSCT. PBSC were collected by continuous-flow leukaphereses after induction and consolidation courses.

RESULTS

The median numbers of mononuclear cells (MNCs) and colony-forming unit granulocyte-macrophage (CFU-GM) administered were 6 x 10(8)/kg and 11 x 10(4)/kg, respectively. ABSCT induced engraftment in 22 patients and there were two graft failures. The median times to reach a polymorphonuclear (PMN) leukocyte count of 0.5 x 10(9)/L and a platelet count of 50 x 10(9)/L were 13 and 19 days, respectively. Fatal hepatic veno-occlusive disease (VOD) was observed in two cases. Other toxicities were mild and uncommon. Twelve patients relapsed between 1 and 9 months posttreatment. Actuarial disease-free survival (DFS) and actuarial risk of relapse at 30 months were 35% (95% confidence interval [CI], 25% to 45%) and 60% (95% CI, 50% to 72%), respectively.

CONCLUSION

These preliminary results show the fast hematopoietic recovery and the low infectious and hemorrhagic morbidity associated with the procedure and strongly suggest that ABSCT may be as effective as autologous bone marrow transplantation (ABMT) in AML. However, further strategies for reducing leukemic relapse must still be investigated.

Long-term acyclovir prophylaxis for prevention of varicella zoster virus infection after autologous blood stem cell transplantation in patients with acute leukemia

Twenty-one adult patients with acute leukemia who underwent autologous blood stem cell transplantation (ABSCT) and who received acyclovir during the first 6 months after transplant to prevent varicella zoster virus (VZV) infection were studied retrospectively to determine the incidence and outcome of VZV infection after ABSCT. The cumulative risk of VZV infection was 32% by 1 year after transplant. No patient developed VZV while on prophylactic acyclovir but five (24%) had localized herpes zoster within 1 month of acyclovir withdrawal. There were no deaths related to VZV infection and only one patient had disseminated disease and post-herpetic neuralgia. These preliminary results suggest that the incidence and outcome of VZV infection after ABSCT largely parallel those reported in marrow transplant patients and that long-term acyclovir prophylaxis delays but does not prevent VZV infection. Prophylaxis of VZV infection after ABSCT requires new therapeutic approaches.

Carboplatin alone or in combination in high-risk acute nonlymphoblastic leukemia

The use of newly developed antileukemic agents is one of the therapeutic options available to overcome clinical resistance in refractory or other high-risk acute leukemias. Carboplatin is a second-generation platinum compound that has demonstrated significant activity against acute leukemia, particularly when administered via continuous intravenous infusion in phase I clinical trials. Based on the preliminary reports of these trials, we designed a phase II clinical trial to evaluate the efficacy and toxicity of carboplatin via continuous infusion (300 mg/m2/d for 5 days) for remission induction in adult patients with high-risk acute leukemia. Because of the significant antileukemic activity and the scarce extrahematologic toxicity noted in this trial, in order to increase the response rate, we were encouraged to try carboplatin in combination in a similar set of patients. A phase II study of carboplatin 300 mg/m2/d for 5 days in combination with etoposide 100 mg/m2/d for 3 to 4 days was designed by our group to treat patients with high-risk acute leukemia. This combination was chosen because (1) each drug has independent activity in acute nonlymphoblastic leukemia (ANLL) and (2) carboplatin/etoposide has been extensively tested in patients with small and non-small cell lung cancer, and therefore the toxicity and maximum tolerated dose are known. The complete remission rate achieved was somewhat higher (40%) than with carboplatin alone despite the increased incidence of extrahematologic toxicities, particularly gastrointestinal bleeding. At present, carboplatin should be considered as a new effective agent for the treatment of ANLL.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hyperleukocytic acute leukemia. Clinico-biological characterization, response to treatment and prognostic factors]

The white-cell count acquires an important prognostic value in acute leukaemia. Thus, very high leucocytosis conveys high risk of early death due to leucostasis. The clinico-biological features at diagnosis, response to therapy and prognostic factors of 69 cases of acute leukaemia with hyperleucocytosis (ALHL) are reported in this paper. All the patients had white-cell count over 100 x 10(9)/L and had been followed up at the Haematology Service of the Hospital La Fe between 1977 and 1989. There were 49 cases of acute nonlymphoblastic leukaemia (ANLL), 18 cases of acute lymphoblastic leukaemia (ALL) and 2 of unclassified acute leukaemia. The incidence of ALHL was 14%, and the mortality on the first week after diagnosis reached 20%, this being higher in ANLL. The actuarial median of complete remission duration was 9 months. The achievement of remission was associated with the morphological subtype, the patient's age and the presence of constitutional symptoms at onset, while the duration of remission was associated with the presence of fever and the need more than one chemotherapy course to attain remission. ALHL need new therapeutic strategies in order to diminish the rate of early death and to achieve longer survival.

Prognostic factors in myelodysplastic syndromes

The extreme variability in prognosis among patients with myelodysplastic syndromes (MDS) complicates decision-making regarding their therapy. Several studies carried out in recent years have recognized the prognostic value of some clinical and biological characteristics. The percentage of blast cells in bone marrow, cytopenias, age and chromosome abnormalities are the most relevant factors affecting outcome. More importantly, some of these studies have resulted in the development of prognostic regression formulas and scoring systems for accurately estimating the individual prognosis of patients. The major aim of this review is to offer the clinician useful tools for treating MDS patients on a risk-fitted strategy.

Disseminated Scedosporium inflatum infection in a patient with acute myeloblastic leukemia

A case of disseminated Scedosporium inflatum infection occurring in a neutropenic patient with acute myeloblastic leukemia is reported. Scedosporium inflatum was isolated from skin lesions, blood, urine and vitreous cultures. Amphotericin B treatment was ineffective in avoiding hematogenous spread. At autopsy, hyphae and ovoid conidia with truncate bases consistent with the morphology of Scedosporium inflatum were found in the lungs, kidneys, myocardium, liver, thyroid, spleen, lymph nodes, brain and the left eye. This is the first report of disseminated Scedosporium inflatum infection and the first time this organism has been isolated from a patient in Europe.

[Culture of cells forming granulomonocytic colonies in bone marrow (GM-CFU) in myelodysplastic syndromes and their relation to hematological findings and FAB subtype]

The results of "in vitro" culture of granulomonocytic precursor cells (CFU-GM) of the bone marrow from 44 patients were analysed in the present work. The correlation with the patient's haematological characteristics, their FAB subtypes (i.e., 6 cases of refractory anaemia (RA), 11 of acquired sideroblastic anaemia (ASA), 15 cases of refractory anaemia with excess blasts (RAEB), 5 cases of RAEB in transformation (RAEBT) and 7 cases of chronic myelomonocytic leukaemia (CMML), and the survival were examined as well. The technique used for cell culture was that of Pike and Robinson, following the classification proposed by Florensa for estimating the growth patterns. Anomalies of the myeloid clonal proliferation were found in 81% of the cases. There was direct correlation between the number of aggregates and the polymorphonuclear cell count, whereas the highest number of blast cells coincided with increased number of clusters in cultures. CNNL showed the highest aggregate counts. The B growth pattern (both colony and aggregate growth) was most frequently seen in CMML; pattern C2 (decreased colonies with increased aggregate count) appeared in RAEB, RAEBT and CMML, and pattern C3 (decrease of both colony and aggregate counts) was found only in RA and ASA. None of the culture findings appreciably associated with the survival.

A phase II clinical trial of carboplatin infusion in high-risk acute nonlymphoblastic leukemia

Carboplatin (CBDCA) is a second-generation platinum drug that has been shown to be useful when used as a continuous infusion in treatment of refractory adult leukemia. We report on the effectiveness of continuous infusion CBDCA, 300 mg/m2/d x 5 days, as evaluated in nine patients with secondary acute nonlymphocytic leukemia (ANLL) (seven previous myelodysplastic syndrome and two treatment-associated ANLL), three ANLL patients in first relapse, six refractory ANLL, and nine patients with blastic phase of chronic myelogenous leukemia (BP-CML). All patients were considered assessable. The response rate was 44% (eight complete remissions [CRs], four partial remissions [PRs]). Median duration of postchemotherapy neutropenia was 36 days (range, 18 to 45). Therapy was well tolerated, and toxicity was mainly hematologic and nondose-limiting. Despite prolonged neutropenia, severe infections were rarely seen, and most patients were managed as outpatients. Twelve patients had nausea and vomiting, two had symptomatic hypomagnesemia, and one patient showed reversible ototoxicity. Because of substantial antileukemic activity and unusual extrahematologic toxicity, CBDCA appears to be an effective second-line agent in the treatment of ANLL and should be considered for upgrading to first-line treatment regimens.

Two regression models and a scoring system for predicting survival and planning treatment in myelodysplastic syndromes: a multivariate analysis of prognostic factors in 370 patients

Therapy planning in patients with myelodysplastic syndromes (MDSs) is complicated by its high prognostic heterogeneity. Forty-one patient and disease characteristics at onset of 370 patients with MDS were analyzed to identify significant prognostic factors for survival and transformation to acute myeloblastic leukemia (AML), and to develop and validate a regression model for predicting survival. Multivariate regression analysis showed that the total bone marrow percentage of blast cells, age, platelet count, WBC count, and hemoglobin level were the characteristics more significantly associated with survival in the overall series. The bone marrow percentage of type I blast cells was the most important factor predicting transformation into AML. Proportional hazards regression analysis in a randomly selected training sample of 240 patients demonstrated that the combination of total bone marrow percentage of blast cells, platelet count, and age had the strongest predictive relation to survival length. The resulting regression models, continuous and categorized, were validated in the remaining test sample of 130 patients by demonstrating its capability of segregating patients into low-, intermediate-, and high-risk groups, with distinctively different survival curves (P less than .0001). A scoring system derived from the categorized model also had a great prognostic value (P less than .0001). These regression models and the simpler scoring system may be accurately used for decision-making regarding therapy in MDS patients.

[Prediction of survival in myelodysplastic syndrome. Analysis of 2 scoring systems with prognostic value]

The wide prognostic variability of myelodysplastic syndromes (MDS) complicates decision-making regarding the choice and evaluation of alternative treatments to transfusional and antiinfectious supportive measures. Due to its simplicity the Bournemouth scoring system seems to have achieved wide acceptance for establishing the prognosis in MDS patients. The aims of this study were to examine the Bournemouth system in a series of 370 patients with MDS and to evaluate the capability of the prognostic index recently proposed by our group to better define the outcome predicted by the former. The Bournemouth scoring system identified 3 risk groups, A (0-1 points), B (2-3 points) and C (4 points), in the whole series (p less than 0.0001) and it allowed us to stratify refractory anemia (RA), RA with excess of blasts (RAEB) and RAEB in transformation (RAEB-t) patients into two distinct prognostic groups (p = 0.03 and p = 0.01, respectively). This scoring system did not show a significant value in RA with ringed sideroblasts (RARS) and chronic myelomonocytic leukemia (CMML) patients (p greater than 0.05). Our prognostic index clearly segregated patients in the whole series into low- (0-1 points), intermediate- (2-3 points) and high-risk (4-5 points) groups (p less than 0.00001) as well as stratifying ARSA (p = 0.0005), CMML (p less than 0.0001) and RAEB and RAEB-t patients (p less than 0.00001) into different prognostic subset, although it failed to demonstrate a significant predictive value in RA patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic factors in chronic myelodysplastic syndromes: a multivariate analysis in 107 cases

A retrospective multivariate analysis of 37 clinical, biochemical, and hematological data was performed in 107 cases of primary myelodysplastic syndromes (MDS) in order to recognize their prognostic significance. The most important individual variables, isolated in a previous univariate analysis, were placed in a multiple regression modeling procedure to identify major significant prognostic factors. Multivariate analysis tends to identify prognostic variables containing significant independent predictive information. Characteristics were examined on both continuous and binary bases. The FAB classification was the first parameter entered in regression equations on both models, followed by platelet count, hemoglobin level, and circulating erythroblasts in the binary model, and by hemoglobin level, systemic symptoms, platelet count, age, and dyserythropoiesis in the continuous model. Our analysis confirms FAB classification as the main prognostic factor in MDS, supports the previously noted predictive value of platelet count, hemoglobin level, and age, and recognises the importance of circulating erythroblasts, systemic symptoms, and dyserythropoiesis as prognostic characteristics in MDS.

Teniposide and cytarabine combination chemotherapy in the treatment of relapsed adolescent and adult acute lymphoblastic leukemia

Nineteen adolescents and adults with relapsed acute lymphoblastic leukemia (ALL) were treated with teniposide (VM-26) plus cytarabine (ara-C). Eight patients (42%) achieved complete remission. Infection and bleeding secondary to myelosuppression were the most serious complications seen. Responders received periodic reinductions with VM-26 and ara-C, but all relapsed within 16 weeks from remission. Our data demonstrate the effectiveness of combination chemotherapy with VM-26 plus ara-C in adolescent and adult ALL in relapse and suggest testing of this combination in first-line protocols. For remission maintenance, the association of other drug combinations is necessary.