Allogeneic peripheral blood stem cell transplantation for standard risk leukemia: experience of Ibni Sina Hospital

Fifty-three patients with standard risk leukemia who underwent allogeneic peripheral blood stem cell transplantation (alloPBSCT) from their HLA-identical siblings were analyzed for engraftment, incidence and severity of GVHD, and relapse rate. Standard risk leukemia was defined as AML in first complete remission or CML in first chronic phase within the first year after diagnosis. The median age was 34.5 years (range 13-47). Stem cells were mobilized by using 10 microg/kg G-CSF subcutaneously for 5 days. A median of 5. 7 (2.1-21.4) x 106/kg CD34+ cells was collected over a median of 2 (range 1-5) apheresis procedures. Cyclosporin A (CsA) plus short-course MTX were used for GVHD prophylaxis. Recovery to granulocytes >0.5 x 109/l and platelets >20 x 109/l occurred at a median of day +13 (range 8-32) and +13 (range 8-51), respectively. Day +100 transplant-related mortality was 13.2% (7/53). Acute GVHD occurred in 20 of 49 (41%) evaluable patients and only six (12.3%) of them had severe disease (grade III-IV). Chronic GVHD occurred in 30 of 42 (71.4%) evaluable patients. Relapse rate at 2 years was 7. 5%. The median overall and leukemia-free survivals were 22 (4-44) and 20 (3-44) months, respectively. Estimated 4 year leukemia-free and overall survival rates were 60% and 62%, respectively. In conclusion, alloPBSCT in standard risk leukemia seems to be associated with a low relapse rate and no increased risk of acute GVHD, but there is a trend for higher incidence of cGVHD. Bone Marrow Transplantation (2000) 25, 1229-1232.

Rare benign tumours of oral cavity--capillary haemangioma of palatal mucosa: a case report

Haemangiomas are benign tumours composed of blood vessels, they are probably developmental rather than neoplastic in origin. Haemangiomas are often present at birth but may become more apparent during life. The tumours appear as a flat or raised reddish-blue lesions and are generally solitary. They are occasionally seen on the palatal mucosa. Haemangiomas are classified on the basis of their histological appearance as capillary, mixed, cavernous or a sclerosing variety that tends to undergo fibrosis. Their differential clinical diagnosis is based on appearance. The tumours may be slowly progressive, involving extensive portions of the superficial and deep blood vessels. Function may be affected where development of the lesion is extra-invasive. Colour change on pressure is a common finding with return to the original colour on withdrawal of pressure. The case presented here was referred because of swelling and recurrent periodontal bleeding. The lesion was diagnosed as a capillary haemangioma through histopathology. Although different therapeutic procedures have been reported, in this case surgical excision was carried out under general anaesthesia following hospitalization. Despite their benign origins and behaviour, haemangiomas in the region of oral cavity are always of clinical importance to the dental profession and require appropriate clinical management. Dental practitioners and oral surgeons need to be aware of these lesions because they may pose serious bleeding risks.

A phase I dose escalation study of high-dose thiotepa, melphalan and carboplatin (TMCb) followed by autologous peripheral blood stem cell transplantation (PBSCT) in patients with solid tumors and hematologic malignancies

The purpose of this study was to determine the maximum tolerated dose of carboplatin administered with 500 mg/m2 thiotepa and 100 mg/m2 melphalan followed by autologous peripheral blood stem cell (PBSC) infusion in patients with refractory malignancies. Twenty-eight patients with refractory malignancies received high-dose thiotepa (500 mg/m2, melphalan (100 mg/m2) and escalating doses of carboplatin 900-1500 mg/m2) followed by infusion of cryopreserved autologous PBSCs. The maximum tolerated doses were determined to be 500 mg/m2 thiotepa, 100 mg/m2 melphalan and 1350 mg/m2 carboplatin. Two consecutive patients receiving 1500 mg/m2 carboplatin experienced grade 3 mucositis and colitis. Ten patients were enrolled at the maximum tolerated dose and none had grade 3-4 regimen-related toxicity and mortality. All patients at this level experienced grade 1-2 mucositis, 90% grade 1-2 gastrointestinal toxicity, 30% grade 1-2 cardiac and renal toxicity, and 10% experienced grade 1 hepatic toxicity. The median time to achieve a granulocyte count of 0.5x10(9)/l was 9 days (range 7-12 days) and platelet count of 20x10(9)/l was 10 days (range 7-15 days). Of eight patients with stage IV refractory breast cancer, even were evaluable for response, one patient on day 75 will be evaluated soon. Five of seven (71.5%) evaluable patients achieved a complete remission (CR) and two had no response. Of seven patients with non-Hodgkin's lymphoma (n = 4) or Hodgkin's disease (n = 3), five achieved a CR (71.5%). Thiotepa, melphalan and carboplatin can be administered in high doses with tolerable mucositis as the major side-effect. This combination has significant activity in patients with breast cancer, and phase II studies in patients with breast cancer and other chemotherapy-sensitive malignancies are warranted.

Hematopoietic stem cell transplantation from non-replicative hepatitis B virus carriers is safe

BACKGROUND/AIMS

Hepatitis B virus can cause serious problems in individuals undergoing organ transplantation. The aim of this study was to evaluate the hepatic events among HBs-Ag positive recipients and HBs-Ag negative recipients who received products from hepatitis B virus carriers.

METHODS

A total of 151 patients received an allogeneic hematopoietic stem cell transplantation at the Department of Hematology-Oncology, University of Ankara, between June 1989 and June 1998. Among these, eight HBs-Ag positive and four HBs-Ag negative recipients received a product from a hepatitis B virus positive donor. The median follow-up period for these 12 patients was 13.2 months.

RESULTS

Three of the eight HBs-Ag positive recipients died (one from hepatic failure); of the remainder, two are HBs-Ag negative, two HBs-Ag positive with normal liver injury tests and one HBs-Ag positive with elevated ALT levels. Of the four HBs-Ag negative recipients who received stem cells from a hepatitis B positive donor, two died; none of the patients in this group became HBs-Ag positive after transplantation.

CONCLUSION

Hepatitis B virus infection is a common problem in patients being considered for allogeneic hematopoetic stem cell transplantation, especially in areas where hepatitis B virus infection is endemic. We believe that the presence of HBs-Ag positivity is not an absolute contraindication for allogeneic hematopoetic stem cell transplantation unless the hepatitis B virus is in a replication phase.

A retrospective comparison of allogeneic peripheral blood stem cell and bone marrow transplantation results from a single center: a focus on the incidence of graft-vs.-host disease and relapse

To detect the effect of the stem cell source, allogeneic peripheral blood stem cell transplantations (alloPBSCTs) performed between 1995 and 1997 from human leukocyte antigen (HLA)-identical siblings in 40 patients with acute and chronic hematological disorders were compared with a historical group of 40 patients with similar variables who had received allogeneic bone marrow transplants (alloBMTs) between 1993 and 1995. Patients in both groups were identical except that both the recipient and the donor ages were, on average, higher in the alloPBSCT group (26 vs. 36 [p = 0.005] and 27 vs. 32 [p = 0.024], respectively). Patients received similar therapy excluding posttransplant granulocyte colony-stimulating factor administration (97% in alloBMT vs. 12.5% in alloPBSCT). The median time to reach neutrophil counts >0.5 x 10(9)/L and platelet counts >20 x 10(9)/L was 13 and 14 days, respectively, in patients receiving alloPBSCTs compared with 19 and 27 days in patients receiving alloBMTs (p = 0.0014 and p = 0.0002). The alloPBSCT group required similar transfusions of red blood cells or platelets. The incidence of grade II-IV acute graft-vs.-host disease (aGVHD) was similar in both groups. However, chronic GVHD (cGVHD) of all grades developed in 78.1% of patients in the alloPBSCT group after a median follow-up period of 12.5 (range 0.5-34) months. In alloBMT recipients, cGVHD of all grades developed in 21.4% after a median follow-up period of 38 (range 0.5-62) months (p = 0.00001). Day 100 transplant-related mortality was also similar: 20% (8 of 40) in the alloBMT patients and 17.5% (7 of 40) in the alloPBSCT group. Although not statistically significant, a relatively higher relapse rate occurred in the alloBMT group (21.4 vs. 10.7%). The estimated disease-free survival in month 24 was 51.3% for alloBMT and 54.6% for alloPBSCT, and the estimated overall survival in month 24 was 56.1% for alloBMT and 64.6% for alloPBSCT. In conclusion, this retrospective comparison suggests that alloPBSCT from HLA-identical donors is associated with faster engraftment, fewer transfusions, and no greater incidence of aGVHD, but a high incidence of cGVHD.

The impact of the CD34+ cell dose on engraftment in allogeneic peripheral blood stem cell transplantation

Forty-five patients who underwent allogeneic peripheral blood stem cell transplantation (PBSCT) were evaluated in order to investigate any relationship between CD34+ cell dose given and hematological recovery. Granulocyte counts > 1.0 x 10(9)/L and platelet > 50 x 10(9)/L were considered as hematological recovery. Three different regimens were used for mobilization, by adjusting the recombinant granulocyte colony stimulating factor (rhG-CSF, Roche) dose. The first group (n = 3), whose donors mobilized with 5 micrograms/kg/d s.c. rhG-CSF received a mean of 5.9 x 10(6)/kg (95% confidence interval for mean (CI); 2.4-9.3) CD34+ cells. The second group (n = 37), mobilized with 10 micrograms/kg/d s.c. rhG-CSF and the third group (n = 5) mobilized with 15 micrograms/kg/d s.c. rhG-CSF, received a mean of 5.7 x 10(6)/kg (95% CI; 4.6-6.75) and 6.56 x 10(6)/kg (95% CI; 4.57-8.55) CD34+ cells, respectively. CD34+ cell dose was 5.82 x 10(6)/kg (95% CI; 4.97-6.68) for all the patients. All patients received rhG-CSF from day +1 until attaining granulocyte count > 1.0 x 10(9)/L for three consecutive days. Median granulocyte and platelet engraftment days for the whole group was 15 (range; 11-44) and 14 (11-54) days respectively. There was a close correlation (r = -0.301, p < 0.05) between the CD34+ cell dose and granulocyte recovery for the whole group. When these analyses were performed separately within groups, this correlation was also found significant for the first group (r = -0.99, p < 0.05) for granulocyte recovery. On the contrary the same analysis did not reach significance for the other groups, nor for platelet recovery for the whole group (r = 0.039, p = 0.821). We calculated a minimum dose of 4 x 10(6)/kg CD34+ cells for a safe alloPBSCT. There was no difference between patients who received more than 5 x 10(6)/kg CD34+ cells, and those who received more than 2 x 10(6)/kg and less than 5 x 10(6)/kg CD34+ cells. In conclusion, we have demonstrated a correlation between the CD34+ cell dose given and faster hematological recovery for alloPBSCT patients.

Seroprevalence of enzootic bovine leukosis in Trakya district (Marmara region) in Turkey

In this study, 481 cattle belonging to 77 farms from nine localities in Trakya district in the Marmara region of Turkey were blood sampled and serologically tested for enzootic bovine leukosis (EBL). Antibodies to bovine leukosis virus (BLV) were detected in 51 cattle sera (11%) belonging to nine farms in five localities. Cattle tested were mostly female Holstein or Brown Swiss of ages ranging between 18 months and 10 years. Analysis of the relationships between age, breed or sex and seropositivity to EBL in seropositive herds indicated no significant associations (p > 0.05). The relationship between seropositivity and haematological changes was also studied, and seropositive cattle had higher lymphocyte percentage and lower neutrophil percentage than seronegative cattle (p < 0.001).

Allogeneic peripheral blood stem cell transplantation in acute non-lymphoblastic leukemia

Unmodified allogeneic peripheral blood stem cell transplantation (alloPBSCT) was performed in 20 consecutive acute non-lymphoblastic leukemia (ANLL) patients from their HLA-identical siblings. There were 11 males and 9 females. Median age was 34 years (range 17-43). Donors were primed with 2.5-15 micrograms/kg/day s.c. granulocyte-colony stimulating factor (G-CSF, Neupogen, Roche). Conditioning regimen was Bu (16 mg/kg) + Cy (120 mg/kg) in 19 patients and high dose Ara-C (3 gr/m2 twice daily for 3 days) for one patient who relapsed after bone marrow transplantation. Eighteen patients were in CR1. CsA + short-term MTX (n = 19) or CsA alone (n = 1) were used for graft versus host disease (GVHD) prophylaxis. The median number of apheresis procedures for each patient was 2 (2-4). A median of 6.5 (3.2-38.2) x 10(8)/kg MNC or 9.4 (2.2-12.4) x 10(6)/kg CD34+ cells were given. Median days to reach granulocyte of > 0.5 x 10(9)/l and platelet of > 50 x 10(9)/l were 12 (10-14) and 15 (11-35) respectively. Day 100 transplant-related mortality was 20 per cent (4/20). Grade 2 to 4 AGVHD was seen in 8 out of 17 (47%) evaluable patients. Severe AGVHD occurred in 3 out of 17 (18%). Clinical CGVHD of all grades developed in 12 out of 17 (70%) evaluable patients. The mean disease-free survival and overall survival were 17 (range: 8-33 months) and 18 months (range: 10-34 months), respectively. In conclusion, alloPBSCT in ANLL is associated with a faster engraftment, no greater incidence of AGVHD, but increased risk of CGVHD.

Serum erythropoietin levels in patients with leukemia on cytostatic treatment

Anemia is the major stimulus for erythropoietin (Epo) secretion. Various studies have reported increase of Epo following chemotherapy. The mechanism of this phenomenon is not yet clarified. In this study, the serum Epo levels have been evaluated before, during (7 and 14 days), and after (day 25) chemotherapy in patients with acute myeloblastic leukemia (n = 13) and lymphoblastic leukemia (n = 4). As a control group, 12 healthy age-matched subjects were evaluated. Epo levels were high in untreated leukemia patients compared to controls and continued to increase following chemotherapy. There was no significant difference in post-treatment values of Epo as compared with pre-treatment levels. In patients with pre-treatment values of Hb < or = 9 g/dl, Epo levels were inversely correlated with Hb (r = 0.552; p < 0.05). This correlation disappeared during and following treatment. There was no correlation between Epo levels and hematological or biochemical parameters. Therefore, elevated levels of Epo regardless of anemia may be due to a response to tissue hypoxia or increased synthesis of Epo in liver or bone marrow.

Randomised unicenter trial for comparison of three regimens in de novo adult acute nonlymphoblastic leukaemia

Various regimens have been explored in the treatment of acute nonlymphoblastic leukaemia (AML), but so far none has been shown to be superior. Here we report on a comparison of three widely used protocols defined by Berman (Group 1), MRC AML 10 (Group 2), and Arlin (Group 3). Group 1 includes cytosine arabinoside (Ara-C) (100 mg/m2/d, days 1-7) and idarubicin (Ida) (12 mg/m2/d, days 1-3) for induction, and Ara-C (200 mg/m2/d, days 1-6) and Ida (15 mg/m2/d, day 1) twice for consolidation. Group 2 includes Ara-C (200 mg/m2/d, days 1-10), daunorubicin (Dnc) (50 mg/m2/d, days 1, 3, 5) and etoposide (VP16) (100 mg/m2/d, days 1-5) for induction. The first consolidation therapy consisted of the same schedule except for Ara-C given on days 1-8. The second consolidation regimen consisted of Ara-C (200 mg/m2/d, days 1-8), VP16 (100 mg/m2/d, days 1-5) and amsacrine (100 mg/m2/d, days 1-5). Mitoxantrone (Mitox) (10 mg/m2/d, days 1-5) and Ara-C (200 mg/m2/d, days 1-3) were given as the third consolidation therapy. Group 3 was identical to Group 1 except for Ida being replaced with Mitox. During the study period 99 patients were enrolled and 34 were allocated randomly to Group 1, 36 to Group 2, and 29 to Group 3. Except for age distribution all patients' characteristics were similar between the groups. As there were more elderly patients in Group 1, time to complete remission (CR) was longer in this group as they needed more second induction. Induction deaths were 9.7%, 12.9% and 14.8% in Groups 1, 2 and 3, respectively. Patients in Group 2 received a higher amount of Ara-C compared with the other groups (P < 0.001). After a median follow-up period of 45 months (1-67 for survivors) an advantage in Group 1 was observed. Relapse-free survival (RFS) was better in Group 1 (P = 0.014) at 3 years. Fourteen of the patients were transplanted (11 allografts, 3 autografts). When patients with transplants were excluded, overall survival was longer in Group 1 both at 3 years and 5 years (P = 0.05). In conclusion, despite patient advanced age and lower dose of Ara-C, the idarubicin-containing treatment was superior to the other regimens.

Acute myeloblastic leukemia associated with hyperleukocytosis and diabetes insipidus

Two cases with acute myeloblastic leukemia (AML M4-FAB) associated with diabetes insipidus (DI) are presented here. Both patients presented with hyperleucocytosis. One had a white blood cell count (WBC) of 150 x 10(9)/L and the second patient had 200 x 10(9)/L. One of these patients was a 40 year-old male and MRI of the hypophysis showed an infindibuler mass. This patient did not respond to remission induction chemotherapy and reinduction chemotherapy was given. The other patient was a 16-year-old male with a normal CT scan of the head. Both patients had DI with typical clinical and laboratory findings. The first patient died early on during reinduction chemotherapy and the second patient died of intracranial bleeding before induction chemotherapy was given. These findings are consistent with the data in the literature suggesting that the prognosis of AML associated with DI is poor and that these cases generally present with hyperleucocytosis.

Incidence of tuberculosis after bone marrow transplantation in a single center from Turkey

Tuberculosis (TB) is generally seen in immunodeficient states and its incidence would be expected to increase after hematopoietic stem cell transplantation (SCT), particularly in the allogeneic setting. However, recent reports from developed countries did not support this hypothesis. Turkey is one of the countries where the disease is endemic. Over a period of 10 years two cases of TB among 120 allogeneic and 65 autologous bone marrow or peripheral blood SCT were encountered. The first patient was a 42-year-old male with acute nonlymphoblastic leukemia (ANLL) who underwent allogenic SCT from his HLA-identical sister in first remission. His early post transplant period was unremarkable and showed no clinical acute or chronic graft versus host disease (GVHD). His chest X-ray and CT scan revealed alveolar infiltrate of the left apical lobe one year after the procedure and sputum showed acid-fast bacilli, later identified as Mycobacterium tuberculosis. He was put on combination chemotherapy. He is now well and disease-free 30 months after transplant with no complaints of pulmonary TB. The second patient with chronic phase CML underwent allogeneic peripheral SCT from his HLA-identical sister. He suffered from grade II acute and extensive chronic GVHD partially treated with immunosuppressive therapy. He showed pulmonary TB 15 months after transplantation. He is still on combination chemotherapy. Although our numbers are small, the annual incidence of TB after SCT is 1.1% (2/185) which is nearly 30 to 40 times higher than the incidence of TB in the general Turkish population. In other words, an immunosuppressive state after allogenic SCT seems to increase the risk of TB in Turkey. In conclusion, TB should be considered in the differential diagnosis of unexplained infections after SCT, especially in countries, where the disease is endemic.

Molecular alterations in the TP53 gene of peripheral blood cells of patients with chronic myeloid leukemia

The TP53 gene has been extensively studied in patients with chronic myeloid leukemia (CML), both in chronic phase and in blast crisis. Mutations in the gene were found in up to 30% of the patients, especially among those in blast crisis. We report the results of an analysis of 29 blood samples from CML patients: 8 samples from chronic phase patients, 8 from patients in the accelerated phase, and 13 from patients in blast crisis. By using genomic DNA, we sequenced PCR products of the coding exons and most introns of the TP53 gene, finding genetic changes in 30% of the blast crisis samples and 12% in chronic phase. All mutations were found in introns and were previously unreported. Immunocytochemical studies revealed accumulation of TP53 in blood cells of samples both from chronic phase and blast crisis patients. Since these samples had no TP53 mutations, we believe that wild type TP53 accumulates in blood cells of CML patients. Our results, therefore, indicate that molecular changes in coding regions of the TP53 gene are rare. The significance of the abundance of intronic changes should be investigated further. Accumulation of wild type TP53 in CML cells may indicate an additional mechanism involving this gene in the pathogenesis of this disease.

Administration of MINE protocol in untreated patients with intermediate and high grade non-Hodgkin's lymphoma

In recent years, more effective and less toxic treatment protocols have been developed to increase the cure rates in intermediate and high grade non-Hodgkin's lymphoma (NHL). This study was undertaken to investigate the efficacy and toxicity of MINE (ifosfamide, mesna, mitoxantrone and etoposide) combination chemotherapy in patients with intermediate and high grade NHL. Twenty-one patients (16 male, 5 female; age between 26 and 70 years) with NHL were included in the study. An overall response rate of 73% and complete response rate of 56% were achieved and survival rate for responding patients was 80% at the 48th month. Side effects including mild myelosuppression, nausea/vomiting and alopecia were observed. MINE combination seems to be effective and well tolerated without significant toxicity as a first-line therapy in patients with intermediate or high grade NHL.

Factors affecting postoperative morbidity and mortality in destroyed lung

BACKGROUND

The presence of specific risk factors can increase the postoperative complication rate of pneumonectomy for destroyed lung.

METHODS

Our experience in 118 consecutive patients who underwent pneumonectomy for destroyed lung over a 10-year period was retrospectively analyzed to evaluate the effect of specific risk factors on postoperative complications. The significance of tuberculosis, right pneumonectomy, preoperative empyema, and duration of illness longer than 36 months was examined by univariate analyses.

RESULTS

The most common underlying diseases were nonspecific bronchiectasis (n = 52) and tuberculosis (n = 43). Sixty-day or in-hospital morbidity and mortality rates were 11.9% and 5.9%, respectively. The combined morbidity and mortality rate was significantly higher in patients with preoperative empyema (p < 0.003), tuberculosis (p < 0.03), and right pneumonectomy (p < 0.03). The prevalence of bronchopleural fistula was higher in patients with preoperative empyema (p < 0.02) and patients with tuberculosis (p < 0.03).

CONCLUSIONS

The postoperative complication rate of pneumonectomy for destroyed lung is acceptably low. However, it is increased by preoperative empyema, tuberculosis, and right-sided resection.

Use of high-dose chemotherapy plus granulocyte colony-stimulating factor for the salvage of refractory or resistant-relapse lymphoma patients without stem cell support

The combination of cyclophosphamide (CY) and etoposide is synergistic, spares bone marrow stem cells and can be given repeatedly in high doses without stem cell support. Thirteen patients with non-Hodgkin's lymphoma (n = 8) or Hodgkin's disease (n = 5), received high-dose chemotherapy (HDC). Median age was 32 years (24-52). Male to female ratio was 10:3. All the patients were in advanced-stage. Karnofsky score prior to HDC was 60% (range 40-90). Six patients showed primary refractoriness and 7 had resistant relapse. HDC consisted of CY 1,500 mg/m2/day and etoposide 300 mg/m2/day, both for 4 days. rhG-CSF was started 24 h after the last dose of chemotherapy as a continuous intravenous infusion at a dose of 0.01 mg/kg/day and stopped when the leukocyte count reached 1 x 10(9)/1 on 3 consecutive days. Overall, 69% (9/13) of patients responded to HDC. Four achieved CR and 5 achieved PR. Two of the patients showed disease progression. The other 2 died during the early period of HDC. Neutrophil and platelet recovery after HDC were 8 (6-16) and 10 (4-14) days, respectively. The major nonhematological toxicities were nausea-vomiting (100%) and diarrhea (61%). The median follow-up was 204 (7-600) days. Two patients relapsed 48 and 185 days after HDC. Eight patients are still alive, 7 progression free. The progression-free survival is 220 (40-285) days. In conclusion, HDC + granulocyte colony-stimulating factor (G-CSF), without stem cell support seems to be promising in refractory or resistant relapse lymphoma patients bringing the need for randomized studies to show the cost effectiveness of HDC + G-CSF compared to HDC + autologous stem cell support.

Allogeneic peripheral blood stem cell transplantation: is there an increased risk of graft vs host disease in leukemia patients?

Fifteen patients with hematological malignancies [9 acute nonlymphoblastic leukemia (ANLL), four chronic myelogenous leukemia (CML), two acute lymphoblastic leukemia (ALL)] received allogeneic peripheral blood stem cell transplantation (alloPBSCT) from HLA-identical sibling donors. Donors received 2.5-15 micrograms/kg/day of recombinant human granulocyte colony stimulating factor (rhG-CSF) for 5-10 days. Administration of rhG-CSF was well tolerated except for mild to moderate bone pain occurring in all the donors which was relieved by oral paracetamol. A total of 40 leukaphereses were performed for the 15 donors using the bilateral antecubital veins. None of the donors needed central venous line insertion. The median number of apheresis procedures for each patient was 3 (2-3). A median of 7.7 (4-38.2) x 10(8)/kg mononuclear cells, 35 (2.4-90.0) x 10(6)/kg CD34+ cells, 1.85 (0.45-4.8) x 10(8)/kg CD3 and 0.3 (0.16-1.01) x 10(8)/kg natural killer cells were given without any manipulation. Cyclosporin A (CsA) plus short-course methotrexate (MTX) (12 patients) and CsA alone (3 patients) were used for graft versus host disease (GVHD) prophylaxis. Median granulocyte and platelet engraftments were done on days 11 (10-31) and 16 (11-54) respectively. Grades II-IV GVHD occurred in 62% of the patients and grades III-IV in 15%. Twelve patients are still alive with full engraftment and disease-free. In conclusion, alloPBSCT is an alternative to allogeneic bone marrow transplantation, because of the ease of collection and rapid hematological recovery. However, there is a trend for increased acute GVHD in our leukemia patients compared to allogeneic bone marrow.

HLA DR2: a predictive marker in response to cyclosporine therapy in aplastic anemia

The effect of immunosuppressive agents on HLA DR2-aplastic anemia (AA) has recently been investigated by different groups. In the present report, we analyzed 40 Turkish AA patients, who received immunosuppressive therapy (IST) and 12 AA's who were transplanted from HLA matched siblings. HLA DR2 frequency was 0.442 and significantly higher in AA's when compared to an unrelated healthy control group (RR: 2.93, 95% confidence interval 1.48-5.77, P = 0.001. Patients received antithymocyte or antilymphocytic globulin (AT/LG) or AT/LG plus cyclosporine-A (CsA) or CsA alone. In DR2+ and DR2- patients overall response rates were 73.3 and 30%, respectively (P = 0.03). When patients were analyzed separately, CsA administration either alone or in combination with AT/LG gave favorable results in the DR2+ group (P = 0.02). In contrast AT/LG presence alone was shown to be inadequate.

Hepatitis B virus infection in allogeneic bone marrow transplantation

Fourty-four patients who underwent allogeneic bone marrow transplantation (alloBMT) were studied for hepatitis B virus (HBV)-related complications. The mean follow-up period was 15.3 months. Positivity for HBV surface antigen (HBsAg) was observed in 10 patients (22.7%) throughout the study. Four of the 10 patients were HBsAg carriers before alloBMT, while the remaining six became HBsAg(+) after alloBMT. During the follow-up period (from 6 months to 45 months), an elevation in serum ALT activity was observed in the four carriers when immunosuppression was reduced or withdrawn. All of the four HBsAg carriers developed hepatitis, but none of them died of liver failure due to HBV. Only one death due to GVHD and diabetic ketoacidosis was observed in this group. Two of the four carriers received marrow from anti-HBs positive donors and one of them cleared HBsAg from his serum via adoptive immunity 8 months after transplantation. The remaining six patients acquired HBV after alloBMT, but we were unable to demonstrate the source of HBV. Five of them had a moderate increase in serum ALT activity while the other patient had a normal ALT. Two patients seroconverted to anti-HBs spontaneously. Two patients died during the follow-up, one due to intracranial hemorrhage and the other due to GVHD and accompanying pulmonary infection. The rest of the study group (34 patients) remained HBsAg(-) throughout the study. Two of them had an HBsAg(+) donor, but neither developed HBV infection in their follow-up period. The acquisition rate of HBV infection was relatively low in recipients who were positive for anti-HBs compared to those who were negative for anti-HBs (8 vs 19%). Anti-HBs positivity remained for a longer period in recipients who received marrow from anti-HBs positive donors compared to those recipients who had anti-HBs negative donors (median 12 vs 3 months). We think that HBV is a frequent cause of liver dysfunction in alloBMT patients where HBV infection is endemic. Whether the disease is in the form of reactivation of HBsAg-positive recipients, or is acquired from unknown sources in recipients who never had contact with the virus, the course of the disease is not fatal. Silent serologic changes can be demonstrated if viral serologic markers are sought serially. Among them, the disappearance of serum anti-HBs may be important as it increases the risk of HBV contamination in recipients.

Incidence of graft vs host disease in allogeneic bone marrow transplantation in a single center study from Turkey

Graft versus host disease (GVHD) is one of the obstacles encountered in allogeneic bone marrow transplantation (alloBMT) and has a direct impact on the transplant outcome and survival. In this report, we summarized the incidence of acute and chronic GVHD among 71 HLA matched and 9 HLA mismatched sibling alloBMTs performed for various hematological malignancies, mainly leukemias seen at Ibn-i Sina Hospital. Fifty-five were male and 25 were female Turkish patients. Median age was 29 (12-48). Cyclophosphamide(CY)+total body irradiation (TBI)(12), CY+total lymphatic irradiation (TLI)(6), busulfan (BU)+CY(58) and ALG/ATG+CY(4) were the regimens used for conditioning. Cyclosporin A (CsA)+short term methotrexate were given for GVHD prophylaxis except for two syngeneic transplants who both received only CsA. In 22 of the patients ABO and in 30 patients sex mismatched bone marrow was given. Thirty-one (38.8%) patients showed acute GVHD (grade I-II: 22, grade III-IV: 9) and 8 (11.6%) showed chronic GVHD. In HLA matched and mismatched patients acute GVHD incidence were 33.7% and 44.4% respectively. All of the HLA mismatched patients that showed acute GVHD were in advanced stage. Of the patients with acute GVHD, 28 (96.5%) disclosed skin, 22 (75.9%) hepatic and 14 (48.3%) gut involvement. In the chronic form three patients had mild limited, two limited, two moderate and one advanced GVHD. Seven of the patients were lost due to GVHD. To determine the graft versus leukemia effect of alloBMT, we compared the disease free survival (DFS) of the 68 leukemia patients. Although the patients who had grade I-II acute GVHD showed a better DFS than the patients who did not have acute GVHD, it did not reach to a significance (15.9 vs 13.6 months: p = 0.43).

Giant hydatid cysts of the lung

BACKGROUND

Hydatid disease is a parasitic infection caused by Echinococcus granulosus, characterized by cystic lesions in the liver, lungs, and, rarely, in other parts of the body. The large cysts in the lung are a special clinical entity called giant hydatid cysts. Characteristics on presentation, operative techniques, and postoperative morbidity and mortality rates in 47 patients with 50 giant pulmonary hydatid cysts 10 cm in diameter or larger were reported in this study.

METHODS

Cystotomy plus the obliteration of the residual cavity by imbricating sutures from within (capitonnage) was the most frequently used operative technique (n = 31), followed by pericystectomy plus capitonnage (n = 6), closure of bronchial openings plus pericystectomy (n = 6), and lobectomy (n = 3).

RESULTS

The mean age of patients with giant hydatid cyst of the lung was lower than the age of those with usual-sized cysts (p = 0.04). Five patients had prolonged air leaks (more than 10 days), three had empyema, and one had pneumonia in the opposite lung after the operation. One patient died of cardiorespiratory collapse during the operation. There was one recurrence during follow-up.

CONCLUSIONS

The increase in the diameter of the cyst in younger ages was correlated with higher lung tissue elasticity and the delay in diagnosis because of delayed symptoms in these patients. Although postoperative complications occurred in 19.1% of patients, all were managed by conservative measures, and there were no indications that the affected lung should have been treated with resection instead of a parenchyma-saving operation.