Hematopoietic stem cell transplantation for primary lymphoid immunodeficiencies

Hematopoietic stem cell (HSC) transplantation is curative therapy for many primary immunodeficiencies. All forms of severe combined immune deficiency (SCID) can be cured, but the extent of the immunologic correction is dependent on the pathophysiology of the primary defect. Defects involving lymphocyte differentiation are more easily corrected than defects in lymphocyte function because a selective advantage exists for the progeny of the normal donor HSC when the primary defect affects lymphocyte differentiation. T-cell-depleted (TCD), haploidentical-HSC transplantation can cure many forms of SCID, but not other primary immunodeficiencies like the Wiskott-Aldrich syndrome (WAS). Unrelated bone marrow and umbilical cord blood are alternative sources of HSC for patients who do not have histocompatible donors.

Extracorporeal photochemotherapy for treatment of drug-resistant graft-vs.-host disease

Extracorporeal photochemotherapy (EP) is a therapeutic approach to the treatment of drug-resistant graft-vs.-host disease (GVHD) that uses the known immunosuppressive and immunomodulatory effects of ultraviolet light. In 1990, we initiated a pilot study to evaluate the efficacy and safety of EP in patients with refractory GVHD. Between 1991 and 1996, six patients with acute grade IV liver GVHD, 12 patients with chronic following acute GVHD, and six patients with de novo chronic GVHD were treated with EP. All patients had failed to respond to conventional GVHD immunosuppressive drug therapy of cyclosporine and prednisone. The six patients with acute liver GVHD had also received antithymocyte globulin (ATG); therapy for chronic GVHD included thalidomide in eight patients, psoralen plus ultraviolet A in five patients, and ATG in two patients. All patients with acute liver GVHD had progressive liver failure with short survival despite frequent EP. The response rate with EP treatment was 3 of 6 for patients with de novo chronic GVHD and 3 of 12 for patients with chronic following acute GVHD. Three patients with bronchiolitis obliterans had either no response or no documented disease progression while undergoing EP. Side effects of EP were minor and included gastrointestinal upset frequently, catheter-related sepsis in four patients, increased red blood cell and platelet transfusion requirements in one patient, and leukopenia in two patients. EP was discontinued in three patients because of side effects, including GI upset in one patient and bone marrow suppression in two patients. Side effects were reversible with the discontinuation of EP. We were unable to correlate response to EP with the level of methoxypsoralen, number of lymphocytes treated, or pattern of pre- and posttreatment CD4/CD8 ratio. We concluded that EP has some efficacy in the treatment of drug-resistant chronic GVHD, with minor overall toxicity.

T lymphocytes with a normal ADA gene accumulate after transplantation of transduced autologous umbilical cord blood CD34+ cells in ADA-deficient SCID neonates

Adenosine deaminase-deficient severe combined immunodeficiency was the first disease investigated for gene therapy because of a postulated production or survival advantage for gene-corrected T lymphocytes, which may overcome inefficient gene transfer. Four years after three newborns with this disease were given infusions of transduced autologous umbilical cord blood CD34+ cells, the frequency of gene-containing T lymphocytes has risen to 1-10%, whereas the frequencies of other hematopoietic and lymphoid cells containing the gene remain at 0.01-0.1%. Cessation of polyethylene glycol-conjugated adenosine deaminase enzyme replacement in one subject led to a decline in immune function, despite the persistence of gene-containing T lymphocytes. Thus, despite the long-term engraftment of transduced stem cells and selective accumulation of gene-containing T lymphocytes, improved gene transfer and expression will be needed to attain a therapeutic effect.

Improving cancer radiotherapy with 2-deoxy-D-glucose: phase I/II clinical trials on human cerebral gliomas

PURPOSE

Evaluation of tolerance, toxicity, and feasibility of combining large fraction (5 Gy) radiotherapy with 2-deoxy-D-glucose (2DG), an inhibitor of glucose transport and glycolysis, which has been shown to differentially inhibit repair of radiation damage in cancer cells.

METHODS AND MATERIALS

Twenty patients with supratentorial glioma (Grade 3/4), following surgery were treated with four weekly fractions of oral 2DG (200 mg/kg body weight) followed by whole brain irradiation (5 Gy). Two weeks later, supplement focal radiation to the tumor (14 Gy/7 fractions) was given. Routine clinical evaluation, x-ray computerized tomography (CT), and magnetic resonance (MR) imaging were carried out to study the acute and late radiation effects.

RESULTS

All the 20 patients completed the treatment without any interruption. The vital parameters were within normal limits during the treatment. None reported headache during the treatment. Mild to moderate nausea and vomiting were observed during the days of combined therapy (2DG + RT) in 10 patients. No significant deterioration of the neurological status was observed during the treatment period. Seven patients were alive at 63, 43, 36, 28, 27, 19, and 18 months of follow-up. In these patients, the clinical and MR imaging studies did not reveal any late radiation effects.

CONCLUSIONS

Feasibility of administering the treatment (2DG + 5 Gy) is demonstrated by the excellent tolerance observed in all 20 patients. Further, the clinical and MR studies also show the absence of any brain parenchymal damage.

HLA-B44-directed cytotoxic T cells associated with acute graft-versus-host disease following unrelated bone marrow transplantation

We describe the recipient of a marrow graft from an HLA-serologically identical unrelated donor from whom highly potent host-reactive CTL of donor origin were isolated in association with acute GVHD. Extensive sequence and biochemical analysis of the HLA complex of this donor and recipient revealed several disparities in class I and class II HLA with the potential to be recognized by T cells from the donor or the host. The donor-derived CTL exclusively recognized a class I HLA difference associated with HLA-B44. Nucleotide sequencing of donor and recipient cells revealed that the patient possessed the HLA-B*4402 allele recognized by IEF as B44.2 while the donor possessed HLA-B*4403 (IEF variant B44.1). These alleles differ at one amino acid residue located at position 156 in the alpha 2 domain. The donor-derived CTL were shown to be specific for B44.2 by blocking studies and by the lysis of five different B44.2+ unrelated cell lines, two of which were confirmed by sequencing to be homozygous for B*4402. A host-specific difference involving a HLA-DRB1 allele was not recognized by the CTL, neither did HLA differences unique to the donor HLA-B*4403 and HLA-DQ8 elicit a host response. These data show that certain HLA disparities may be tolerated at the same time that other disparities elicit a potent immunologic response. The chemical nature of the difference, its structural impact, as well as the conditions of transplant appear to influence the type of response which occurs.

Controlled trial of orally administered immunoglobulin following bone marrow transplantation

Between May 1987 and September 1989, 72 patients undergoing marrow transplantation at a single institution were randomized to receive 50 mg/kg of a commercial gammaglobulin preparation or placebo daily in four divided doses for 28 days following transplantation. Patients receiving oral gammaglobulin had significantly increased concentrations of stool IgG (p = 0.01) compared with the placebo group. There was no difference in the amount of diarrhea, frequency of GVHD, duration of hospitalization or survival in the two groups. The present study demonstrates that orally administered IgG can survive passage through the gastrointestinal tract of bone marrow transplantation recipients but there was no effect of oral administration of immunoglobulin on morbidity or mortality following bone marrow transplantation.

Allogeneic bone marrow transplantation following busulfan and 90 mg/kg of cyclophosphamide

Ten patients with AML or CML aged 40-55 years underwent allogeneic marrow transplantation from HLA-identical siblings following a preparation regimen of busulfan 16 mg/kg and cyclophosphamide (CY) 90 mg/kg. The CY dose was substantially lower than has been previously used in combination with busulfan. All 10 individuals engrafted. Cytogenetic analysis of marrow and peripheral blood cells demonstrated similar patterns of chimerism to those previously described using higher CY doses. This study demonstrates that when administered with busulfan 16 mg/kg a dose of 90 mg/kg CY is adequately immunosuppressive to permit consistent engraftment of marrow from HLA-identical sibling donors.

Controlling unwanted sources of threshold change in disability glare studies: a prototype apparatus and procedure

One of the main purposes of cataract surgery is to reduce the debilitating effects of light scatter by the lens. An important effect of this intraocular forward scatter is to produce a veiling retinal illuminance from a glare source. The retinal contrast of the stimulus is thus reduced, and a quantifiable "disability glare" effect may be measured. A complication is introduced by the fact that intraocular scatter arises from other sources in addition to the lens. All present tests of glare disability fail to eliminate or control for these factors, nor do they control for the light adaptation effect of the glare source. The effects of lens removal may not be predicted accurately by such tests, and patients may report little improvement in visual function after surgery. The goal of this research is to provide the background for developing a method of measuring disability glare due only to light scatter in the lens. Thirty-seven patients with mild to moderate cortical cataracts served as subjects. A disability glare effect (DG) was measured with a Maxwellian-view system that eliminates or controls scatter from the iris, sclera, and retina, and which controls for light-adaptation effects from the glare source. DG with this method showed a significant correlation with objective measures of lens light back scatter. Suggestions were made for improvements in the apparatus and procedures for future clinical studies.

Megakaryocyte colony stimulating activity in allogenic bone marrow recipients prepared with busulfan and cyclophosphamide

Increased megakaryocyte colony stimulating activity (MK-CSA) has been reported after total body irradiation (TBI) for bone marrow transplant (BMT). We studied the effect of a busulfan (Bu) and cyclophosphamide (Cy) marrow transplant conditioning regimen, without radiation, on MK-CSA production. Initial screening of MK-CSA was done on previously collected and banked sera from 14 BMT patients. MK-CSA was expressed as the ability to stimulate growth of megakaryocyte progenitors (CFU-MK) in standard plasma clot cultures. In the initial samples, MK-CSA peaked at day 7. This preliminary data led to a prospective study of MK-CSA and clinical parameters in seven allogeneic recipients. MK-CSA activity increased from day -7 pre-transplant (2.9 +/- 1.7 CFU-MK/10(5) NATD, mean +/- SD) to day 0 (10.3 +/- 4.7 CFU-MK) and peaked by day 9 post-transplant (20.6 +/- 6.4 CFU-MK). MK-CSA activity decreased in all seven patients by day 21 at which time five of seven patients studied had recovery of platelet counts to greater than 100 x 10(9)/l. MK-CSA activity rose rapidly in both groups of sera after the initiation of this non-irradiation, BMT preparative regimen. High MK-CSA levels, early after transplant, may contribute to the rapid platelet recovery in some patients.

Survey of oral hygiene regimens among bone marrow transplant centers

Oral complications may occur as an adverse effect of the preparative regimens used in bone marrow transplantation (BMT). A variety of oral-care regimens are used to manage the prevention and treatment of oral complications. The purpose of this descriptive survey was to identify similarities and differences in oral-care regimens among various BMT centers. A 35-item questionnaire was sent to 92 BMT centers, with an 80% response rate. The responses were analyzed using descriptive statistics. Following a variety of guidelines, routine oral assessments were performed by physicians (41%), nurses (33%), and dentists (25%). Thirty-eight percent of the BMT centers used WBC counts as a basis for changing the oral hygiene regimen; 90% used platelet counts. When toothbrushing was discontinued, 50% of the centers used toothettes. In 54% of the centers, flossing was not used in oral hygiene regimens. The two primary mouth-rinses used were chlorhexidine and normal saline. In summary, few similarities existed in the assessment and management of oral care.

Effect of GVHD on the recovery of NK cell activity and LAK precursors following BMT

The mechanism by which GVHD augments the graft-versus-leukemia (GVL) effect of marrow transplants has not been ascertained. One possibility involves the secondary activation of natural killer (NK) cells by cytokines released during the GVHD process. To evaluate this possibility we have compared NK activity and lymphokine-activated killer cell precursor (LAKp) frequencies in serially sampled PBMC from recipients of unmanipulated autologous or allogeneic marrow with and without active GVHD. NK activity recovered rapidly after BMT and was elevated during episodes of acute GVHD. However, NK activity did not differ between recipients of autologous or allogeneic marrow without GVHD nor was NK activity increased in association with chronic GVHD. Endogenously-activated NK cells were detected only in recipients of allogeneic marrow but this did not correlate with GVHD status. In contrast to NK activity, LAKp frequencies fell below the control range during the first 8 weeks after BMT. By 9-14 weeks the median LAKp frequency was normal and did not differ between the three groups then or later after transplant. We conclude that acute GVHD may serve to increase the lytic activity of NK cells but does not result in increased LAKp. LAKp frequencies are below normal during the first two months after BMT, a finding not previously recognized from bulk culture LAK studies. The role of LAK effectors in GVL may involve more the degree of cellular activation rather than the number of cells activated.

The Glasgow Coma Scale: a mathematical critique

The Glasgow Coma Scale permits 120 possible mathematical combinations of eye, verbal and motor scores. Out of these only about 15 are clinically valid and useful in the assessment of altered consciousness. A mathematical analysis of this pruned scale shows a predominant skew towards the motor response. Without clinically altering the scale. The numerical values can be modified to produce a more equitable dominance by each of the factors and greater precision. This is also necessary as the value of a unit is the same in the sum score, whether contributed by the eye, verbal or motor elements.

Allogeneic bone marrow transplantation for acute myelogenous leukemia, acute lymphocytic leukemia, and multiple myeloma following preparation with busulfan and cyclophosphamide (BuCy2)

The combination of busulfan (Bu) and cyclophosphamide (Cy) has been found to be effective preparative therapy for patients treated with allogeneic bone marrow transplantation (BMT). We developed the BuCy2 regimen, which contains a lower dose of cyclophosphamide than the original BuCy regimen, in the hope of reducing regimen-related toxicities. We have studied the use of BuCy2 as preparation for allogeneic BMT in patients with acute myelogenous leukemia, acute lymphocytic leukemia, and multiple myeloma. In patients with acute myelogenous leukemia, the leukemia-free survival and regimen-related toxicity rates obtained in our study appear similar to those achieved with other preparative regimens, including those containing Cy and total body irradiation (TBI). BuCy2 is also an effective BMT preparative regimen in patients with acute lymphocytic leukemia and multiple myeloma. Treatment with BuCy2 results in a lower incidence of severe stomatitis and probably of interstitial pneumonia than does treatment with Cy/TBI, but hepatic veno-occlusive disease occurs more frequently in BuCy-treated patients. The incidence of veno-occlusive disease appears to be affected by agents used as prophylaxis for graft-versus-host disease. Compared with Cy/TBI regimens, BuCy treatment is likely to result in fewer delayed effects of treatment, such as impairment of fertility and second malignancies. Current clinical efforts are focusing on ways to improve the antileukemic activity of the BuCy preparative regimen and to reduce regimen-related toxicities.

Preparation for marrow transplantation in Hodgkin's and non-Hodgkin's lymphoma using Bu/CY

The results of autologous and allogeneic BMT in 44 patients with Hodgkin's or non-Hodgkin's lymphomas who received preparative therapy consisting of busulfan 16 mg/kg and cyclophosphamide 120 mg/kg are presented. Sixteen patients are surviving free of disease between 8 months and 6 years after transplantation. Thirteen patients either did not attain complete remission or experienced a recurrence of their disease. Fifteen patients died from treatment-related complications. Karnofsky score < or = 70, lactate dehydrogenase greater than twice normal and the development of hepatic veno-occlusive disease were associated with failure to achieve lymphoma-free survival.

Verruciform xanthoma in a bone marrow transplant recipient

The verruciform xanthoma is an uncommon benign condition of uncertain cause that affects either mucosa or, less commonly, skin. Most lesions are solitary, and most have been reported to involve the oral mucosa. In some instances, chronic damage to the lesional site has been identified. This report describes a verruciform xanthoma that developed on the lower vermillion zone of the lip of a young person who had undergone allogeneic bone marrow transplantation for acute lymphoblastic leukemia. To our knowledge, this is the first reported case of this lesion occurring in a bone marrow transplantation patient. We speculate that immunologically mediated damage to the patient's epithelium in this area may be related to the pathogenesis of the lesion.

Temporal characteristics of proximally-induced accommodation

This study sought to determine whether proximally-induced accommodation (PIA) is capable of sustaining an accommodative response over time. Accordingly, the steady-state PIA response was measured during the course of a continuous 5 min stimulus period for targets located at distances of 0.2 or 6 m. The vergence and accommodation loops were opened by subjects (n = 8) monocularly viewing the targets through a 0.5 mm pinhole, while accommodation was assessed using an objective, open-field, infrared optometer. The mean PIA response did not change significantly during the fixation period. This finding suggests that PIA is indeed capable of maintaining a sustained response. This observation is consistent with the constancy of apparent target distance perception during extended fixation of a stationary object of regard under these conditions.

Treatment of chronic myeloid leukemia with allogeneic bone marrow transplantation after preparation with BuCy2

One hundred fifteen patients with chronic myelocytic leukemia (CML) were administered busulphan 4 mg/kg for 4 days and cyclophosphamide 60 mg/kg on each of 2 days (BuCy2) followed by allogeneic bone marrow transplantation from histocompatible sibling donors. For 62 patients in chronic phase, 26 in accelerated phase, and 27 in blast transformation, the actuarial survival at 3 years was 58%, 41%, and 25%, respectively. Actuarial probability of relapse was 3%, 12%, and 27%, respectively. Only two patients in chronic phase showed a transient cytogenetic relapse and one of these died from subsequent transplant-related complications, whereas the other remains cytogenetically normal 697 days posttransplant. Patients who were transplanted within 1 year of diagnosis in chronic phase had a survival of 70% compared with 40% when transplanted beyond 1 year from diagnosis. This significant difference in survival was due to transplant-related complications and was correlated with previous exposure to high doses of busulphan. This study indicates that BuCy2 is a useful conditioning regimen for marrow transplantation in patients with CML and results in similar survival statistics and transplant-related mortality as would be expected with conditioning regimens containing total body irradiation. It is possible that relapse after BuCy2 may be lower than expected with regimens containing total body irradiation, but larger analyses are required.

Radiation-free preparation for allogeneic bone marrow transplantation in adults with acute lymphoblastic leukemia

PURPOSE

The study was undertaken to investigate the effectiveness of allogeneic bone marrow transplantation from HLA-identical siblings after preparation with busulfan and cyclophosphamide in adults with acute lymphoblastic leukemia (ALL).

PATIENTS AND METHODS

Thirty-nine patients aged 15 to 42 years underwent transplantation at three different centers from November 1984 through November 1990. All patients received 16 mg/kg busulfan and 120 mg/kg cyclophosphamide as preparative therapy. Cyclosporine plus methotrexate or cyclosporine plus corticosteroids with or without methotrexate were given for prevention of graft-versus-host disease (GVHD).

RESULTS

Twelve patients died of treatment-related complications, 12 patients relapsed, and 15 patients are leukemia-free survivors. For 27 patients in group 1 (first remission, second remission, first relapse), the estimated leukemia-free survival (LFS) rate is 42.3% (95% confidence interval [CI], 22.9% to 71.7%) at 3 years. For 12 patients with more advanced disease (group 2), the 1-year LFS rate is 13.5% (95% CI, 0% to 37.1%). Chronic GVHD occurred at an estimated incidence of 63.3% and developed significantly more frequently among patients who received corticosteroids for prevention of acute GVHD. Chronic GVHD was associated with a significantly lower incidence of relapse and with improved LFS rates.

CONCLUSION

LFS rate in this study is comparable to that obtained with radiation-containing regimens; however, the effectiveness of this preparative regimen in ALL requires further study.

Prolonged remission of accelerated phase Philadelphia chromosome negative chronic myeloid leukemia following autologous recovery of normal hematopoietic elements after busulfan/cyclophosphamide and allogeneic marrow transplantation

We describe here a patient with accelerated phase Philadelphia chromosome (Ph1) negative chronic myelogenous leukemia without BCR gene rearrangement, who received an allogeneic bone marrow transplant following a conditioning regimen consisting of busulfan (BU) and cyclophosphamide (CY). Hematopoiesis was restored following splenectomy performed 1 month post-transplant. There were no distinguishing cytogenetic differences between donor and host. Five years post-transplant the patient relapsed with the original disease. Restriction fragment length polymorphism (RFLP) studies performed at that time exhibited host specific DNA markers suggesting recurrent leukemia of host origin. RFLP analysis of the cells cryopreserved immediately post-transplant also revealed all cells to be of host origin. This patient experienced 5 years of remission with autologous hematopoietic recovery from an aggressive myeloproliferative disorder after high dose BU and CY without engraftment of donor hematopoietic cells.