Long-term outcome of patients surviving for more than ten years following treatment for acute leukaemia

Between 1972 and 1988, 832 consecutive patients were treated for acute leukaemia at St. Bartholomew's Hospital; a retrospective analysis has been conducted to determine the clinical course and outcome for 101 who have survived > or = 10 years following treatment. At a median follow-up of 16 years (range 10-28 years), 86 patients (86 out of 834 total, 11%) were still alive. Long-term follow-up of patients who have survived > or = 10 years following treatment for acute leukaemia revealed that most patients were in normal health, although a significant number of complications had occurred.

Older patients with high-risk fungal infections can be successfully allografted using non-myeloablative conditioning in combination with intensified supportive care regimens

Leukaemic patients with advanced disease and severe fungal infections as well as older patients with substantial co-morbidity are usually excluded from conventional allotransplantation because of increased morbidity and mortality. We approached allogeneic transplantation in four patients with a median age of 62 years (one chronic myeloid leukaemia in blast crisis, one high-risk acute myeloid leukaemia (AML) in first complete remission (CR1), one AML in 2nd relapse, one AML in CR2 with pre-existing fungal lung infections (two aspergillus, two mucor) and additional co-morbidity (diabetes n = 2, aortic aneurysm n = 1, arterial sclerosis n = 2) by combining non-myeloablative conditioning with an intensified supportive care regimen, including amphotericin B and 4-12 (median 9) prophylactic granulocyte transfusions from granulocyte colony-stimulating factor (G-CSF)-stimulated volunteer donors. G-CSF was also given to patients until neutrophil recovery. All four patients recovered to a neutrophil count of 0.5 x 109/l after a median of 11.5 d (range 11-13 d). Prophylactic granulocyte transfusions also reduced the need for platelet transfusions and minimized mucositis. All patients were discharged at a median of 25 d (range 18-59 d) and are alive and well after a median follow-up of > 390 d (range 336-417 d) without evidence of leukaemia. Regression of the fungal lesions was documented in three patients, with a slight progression detected by computerized tomography scan of the chest in one patient. We conclude that pulmonary fungal infections are not a contraindication for allogeneic stem cell transplantation, if non-myeloablative conditioning regimens are used in combination with granulocyte transfusions, intravenous amphotericin B and G-CSF.

Changes in the pattern of TCR V beta repertoire expression after bone marrow transplant is linked to the HLA haplotype in humans

Neutrophil, monocyte, natural killer- and B-cell number and function are rapidly restored after bone marrow transplant (BMT), whereas T-cell reconstitution is often quite delayed. Our hypothesis was that V beta T-cell receptor (TCR) repertoire diversity among recipients of allogeneic BMT is influenced by the expression of major and minor HLA antigens in the host. The study population comprised unmanipulated and CD34(+)-selected allogeneic bone marrow grafts, autologous peripheral blood stem cell transplants and recipients of volunteer unrelated donor (VUD) bone marrow transplants. Using flow cytometry, the relative frequencies of 18 V beta TCR families were determined and ranked for each time point studied. Comparisons and correlations were made between paired blood samples obtained within a single patient over time, and between donors and their recipients. The pattern of the V beta TCR repertoire from allogeneic recipients and their HLA-matched donors was very similar, with a correlation coefficient (CC) of 0.59. This similarity was not as marked in VUD pairs (CC = 0.32). By 3 months after transplant, the pattern of the V beta TCR repertoire in recipients of HLA-matched sibling transplants was more similar to the pattern seen in pretransplant recipients than to the donor pattern (CC = 0.40 vs. 0.31). Our data suggest that both major and minor HLA antigens influence V beta TCR repertoire diversity and reconstitution after BMT.

[Place of hematopoietic stem cell transplantation in the treatment of myelodysplastic syndromes]

CONVENTIONAL TREATMENT: Myelodysplastic syndromes are hematopoietic stem cell disorders characterized by peripheral cytopenia, hypercellular bone marrow with dysplastic cell morphology and a tendency to evolve into acute myeloid leukemia. Supportive treatment with transfusions, antimicrobial agents, hematopoietic growth factors and conventional chemotherapy has only palliative character.

ALLOGENEIC TRANSPLANTATION

Allogeneic hematopoietic stem cell transplantation from HLA-matched family or unrelated donors is currently the only potentially curative therapy. Outcome is determined by disease-, patient- and treatment-related features, which will be discussed in this review.

AUTOLOGOUS TRANSPLANTATION

Autologous transplantation is an alternative approach for patients which lack a suitable allogeneic stem cell donor. Autografts should be harvested in complete remission after intensive chemotherapy. Reduced treatment-related mortality is accompanied by increased risk of relapse.

FUTURE DIRECTIONS

Clinical trials are currently evaluating dose-modified preparative regimens with decreased toxicity, which offer transplantation options also to older patients or patients with comorbidities.

Purging of acute myeloid leukaemia cells from stem cell grafts by hyperthermia: enhancement of the therapeutic index by the tetrapeptide AcSDKP and the alkyl-lysophospholipid ET-18-OCH(3)

Hyperthermia has been shown to be a potential purging modality in autologous stem cell transplantation settings owing to its selective toxicity towards leukaemic cells. We describe two approaches to further increase the therapeutic index of the hyperthermic purging modality by using normal murine bone marrow cells and a murine model for acute myeloid leukaemia. First, the tetrapeptide AcSDKP was used to protect the normal haematopoietic progenitor cells against hyperthermic damage. Pretreatment for 8 h at 37 degrees C with 1 x 10(-9) mol/l AcSDKP resulted in a decrease in hyperthermic sensitivity of only normal haematopoietic progenitor cells. This combined treatment protocol revealed a therapeutic index (ratio of surviving fractions of normal vs. leukaemic cells) of > 500, which was considered to be sufficient for purging. This was confirmed in vivo by the survival of lethally irradiated recipients transplanted with purged simulated remission bone marrow (1 x 10(6) normal bone marrow cells and 5 x 10(4) leukaemic cells). A further increase of the therapeutic index cells was achieved by the alkyl-lysophospholipid ET-18-OCH(3). An incubation for 4 h at 37 degrees C with 25 microg/ml in the presence of 5% fetal calf serum preferentially enhanced the cytotoxic effect towards the leukaemic stem cell. The combination of AcSDKP and ET-18-OCH(3) with hyperthermia resulted in a therapeutic index of > 5000. This enabled a reduction of the hyperthermic treatment and will further minimize the toxicity to normal haematopoietic stem cell subsets, while a therapeutic index far above the required value is achieved. This tripartite purging treatment therefore offers a safe and fast purging protocol for the elimination of residual leukaemic cells in autografts.

Clinical course and predictive factors for cyclosporin-induced autologous graft-versus-host disease after autologous haematopoietic stem cell transplantation

The administration of cyclosporin A (CyA) after autologous haematopoietic stem cell transplantation (HSCT) induces a systemic autoimmune syndrome mimicking graft-vs.-host disease (GVHD). This syndrome, termed autologous GVHD has notable anti-tumour activity in animal studies. We intended to induce autologous GVHD with CyA in patients undergoing an autologous HSCT. We prospectively studied 118 patients with miscellaneous malignancies undergoing an autologous HSCT with low-dose CyA to characterize the clinical syndrome, its frequency and clinical course, and to determine the factors affecting its incidence. Patients received CyA from d -1 through to d 28, first starting at 2 mg/kg intravenously and then orally as soon as feasible. The dose was adjusted to achieve pre-dose blood levels around 100 ng/ml. A skin biopsy was performed when a skin rash was observed. Thirty-three percent of the patients developed clinical GVHD: clinical stage 1 in 21 patients, stage 2 in seven patients, and stage 3 in three patients. Although total body irradiation (TBI) or high-dose cyclophosphamide were previously thought to be needed, autologous GVHD occurred in five out of 12 patients (42%) after a preparative regimen with high-dose melphalan alone. Autologous GVHD was significantly more frequent in patients older than 33 years, in patients who had received high doses of granulocyte-macrophage colony forming units (CFU-GM) and in those with a diagnosis of myeloid malignancy, compared with those with lymphoid malignancies or solid tumours. A significant negative association was also found with HLA-DR6. In lymphoma patients, GVHD occurred more frequently in advanced disease than in first or second complete remission (CR1-2) patients. All other factors studied were not predictive for GVHD. In conclusion, CyA-induced GVHD is reproducibly and safely induced with doses of CyA adapted to achieve blood levels around 100 ng/ml. In retrospective analysis, there was no survival advantage for patients with GVHD. Phase III trials with this approach are needed to evaluate its anti-tumoral effect.

Defibrotide for the treatment of hepatic veno-occlusive disease: results of the European compassionate-use study

Severe hepatic veno-occlusive disease (VOD) is a recognized complication of autologous and allogeneic stem cell transplantation (SCT) that is often fatal. Defibrotide (DF) is a polydeoxyribonucleotide that has been found to have anti-thrombotic, anti-ischaemic and thrombolytic properties without causing significant anticoagulation. Preliminary studies have demonstrated activity for DF in the treatment of VOD, with minimal associated toxicity. In the present study, 40 patients who fulfilled established criteria for VOD were treated with DF on compassionate grounds in 19 European centres; 28 patients met risk criteria predicting progression of VOD and fatality or had evidence of multiorgan failure (MOF), and were defined as 'poor-risk'. DF was commenced intravenously at a median of 14 d (range, -2 d to 53 d) post SCT at doses ranging from 10 to 40 mg/kg. The median duration of therapy was 18 d (range, 2--71 d). Twenty-two patients showed a complete response (CR) (bilirubin < 34.2 micromol/l and resolution of signs/symptoms of VOD and end-organ dysfunction) [CR = 55%, confidence interval (CI) 40--70%] and 17 patients (43%) are alive beyond d +100. Ten poor-risk patients showed a complete response (CR = 36%, CI 21--51%). These results demonstrate that DF is an active treatment for VOD following SCT and a randomized trial is now underway in order to further evaluate its role.

Encouraging preliminary results in 12 patients with high-risk haematological malignancies by omitting graft-versus-host disease prophylaxis after allogeneic transplantation

Immunosuppressive therapy, routinely given after allogeneic transplantation to modulate graft-versus-host disease (GVHD) may have an adverse effect on the graft-versus-tumour (GVT) effect. Twelve patients with high-risk haematological malignancies were given cyclophosphamide, total body irradiation and antithymocyte globulin followed by peripheral blood stem cell grafts from HLA-identical siblings without prophylactic immunosuppression. At the earliest clinical evidence of GVHD, patients were treated with high-dose solumedrol and tacrolimus. Prompt haematological recovery [absolute neutrophil count (ANC) > 1.0 x 109/l] was observed (median time 9 d). All patients developed grade III-IV GVHD (median onset 9 d), involving the skin (11), intestine (five) and liver (three). Of nine evaluable patients, seven developed chronic GVHD [extensive (six), limited (one)]. Six patients died 1-6.5 months after transplantation. Three patients died from treatment-related complications, two from acute GVHD and one from relapsing disease. The remaining six patients are alive 5-26 months after transplantation, five in complete remission and one myeloma patient in very good partial remission. In conclusion, omission of post-transplantation GVHD prophylaxis is feasible, does not lead to graft failure or a high incidence of uncontrollable GVHD and appears to be associated with encouraging clinical responses in a group of patients with high-risk disease features.

Parvovirus B19 transmitted by bone marrow

We describe a case of symptomatic parvovirus B19 infection transmitted by bone marrow (BM). The infection caused prolonged anaemia, thrombocytopenia, arthralgia and erythema infectiosum in a 16-year-old girl with acute myeloid leukaemia receiving a BM transplant (BMT). The BM donor was a 19-year-old asymptomatic brother who had parvovirus B19 viraemia at the time of BM harvest. Sequencing of the VP2 gene from the patient and the donor showed a perfect match of DNA sequences, confirming the mode of transmission. Parvovirus B19 represents a potential complicating factor in patients undergoing BMT, but screening by polymerase chain reaction (PCR) of donor BM may reduce the risk of infection.

Feasibility of peripheral blood stem cell rescue as intensification in elderly patients with acute myelocytic leukaemia: a pilot study from the Gimema Group. Gruppo Italiano Malattie Ematologiche Maligne Dell'Adulto

Elderly patients with untreated acute myeloid leukaemia (AML, n = 47) tested the feasibility of out-patient consolidation therapy and post-consolidation treatment (for patients aged < 71 years) with autologous peripheral blood stem cell transplantation (APBSCT). Overall, 13 patients out of 24 (51%) who achieved complete remission (CR) were eligible for further treatment after consolidation. Five patients were primed with granulocyte colony stimulating factor (G-CSF); a suitable number of CD34+ cells were harvested in three patients and were actually autotransplanted. The toxicity of APBSCT was negligible. Psychosocial problems impaired treatment of some patients on an out-patient basis. Resistant disease, toxicity and logistic problems reduced the number of patients to whom this procedure could actually be applied.

Experience with the first 200 allogeneic blood cell transplants (BCT) in Calgary

Allogenic peripheral blood stem cells transplantation (BCT, allo-PBSCT) have an established place in currently active protocols at the University of Calgary, we now use BCT as the third approach for acute myeloid leukemia (AML) in first complete remission (CR). For chronic myelogenous leukemia (CML) beyond first chronic phase (CP) and other hematological malignancies BCT gives outcomes at least equivalent to bone marrow transplantation (BMT). BCT recipients benefit from faster engraftment. However a tendency to develop more graft-versus-host disease (GVHD) is observed. Bone marrow is still the preferred source of stem cells for CML in first CP and for patients with non-malignant disorders. The ability to obtain high number of blood cells allows us to be able to perform haptoidentical transplants using T-cell depletion and to obtain engraftment in most cases. Refining tha latter technique however remains a challenge particularly with respect to immune reconstitution.

Reduced intensity thiotepa-cyclophosphamide conditioning for allogeneic haemopoietic stem cell transplants (HSCT) in patients up to 60 years of age

Transplant-related mortality (TRM) remains a major problem in older patients undergoing allogeneic haemopoietic stem cell transplants (HSCTs). We have therefore explored a less intensive conditioning in 33 patients with a median age of 52 years (range 43-60) transplanted from human leucocyte antigen (HLA)-identical siblings. The underlying disease was chronic myeloid leukaemia (n = 15), acute myeloid leukaemia (n = 6), myelodysplasia (n = 7) or a chronic lymphoproliferative disorder (n = 5); 15 patients (45%) had advanced disease. The regimen consisted of thiotepa (THIO; 10 mg/kg) on day -5 and cyclophosphamide (CY; 50 mg/kg) on days -3 and -2 (total dose 100 mg/kg). The source was bone marrow (BM) (n = 17) or granulocyte colony-stimulating factor (G-CSF)-mobilized peripheral blood (PB) (n = 16), which were infused without manipulation. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporin A (CyA) and a short course of methotrexate. Mean time to achieve a neutrophil count of 0.5 x 109/l was 17 d (range 11-23) and full donor chimaerism was detected in 79% of patients by day 100. Acute GVHD grade III or IV occurred in 3% of patients. Chronic GVHD was seen in 45% of patients, with a significant difference for PB (69%) compared with BM transplants (23%) (P = 0.009). For BM grafts, the actuarial 2-year TRM was 6%, the relapse 56% and survival 87%; for PB grafts, these figures were, respectively, 27%, 33% and 68%. Twenty-five patients are alive at a median follow-up of 762 d (range 216-1615) and 20 patients (60%) remain free of disease. Thirteen patients (39%) received donor lymphocyte infusion (DLI) either for persisting or relapsing disease and six patients had complete remission.

IN CONCLUSION

(i) patients up to the age of 60 years can be allografted with reduced intensity conditioning; (ii) the procedure was associated with a low transplant-related mortality, particularly for bone marrow grafts, because of a lower risk of chronic GVHD; and (iii) DLI were required after transplant in half the patients for persisting disease or relapse.

Myelosarcoma of the cavernous sinus in a nonleukemic patient--case report

Myelosarcomas are rare, solid extramedullary tumors composed of granulocyte precursors in most cases associated with leukemia. A 38-year-old nonleukemic female presented with a myelosarcoma of the cavernous sinus. After surgical removal of the cavernous sinus tumor she was treated by chemotherapy and whole brain radiation therapy. Despite this aggressive therapy, she died 4 months after surgical intervention.

Immunotherapy of AML: future directions

Immunotherapy in the form of allogeneic GvL has been curing AML patients for nearly 30 years but our understanding of the mechanisms has been poor. Our rapidly evolving understanding of the human immune system and the concomitant technical developments in ex vivo cell manipulation, the vision of funding bodies, the dedication of clinical and research staff, and above all the commitment of our patients, promise substantial progress in the treatment of this disease in the year 2000 and beyond.

Isolated recurrence of granulocytic sarcoma of the brain: successful treatment with surgical resection, intrathecal injection, irradiation and prophylactic systemic chemotherapy

We describe a 40-year-old male who developed an isolated recurrence of granulocytic sarcoma (GS) of the brain 2 years following successful treatment of acute myeloblastic leukemia (AML; M2). Computed tomography (CT) scans and magnetic resonance (MR) images demonstrated a homogeneously enhanced tumor mass in the left temporal lobe and massive peritumoral edema. There was no evidence of relapse in the bone marrow. The patient underwent an emergency surgical resection of the tumor. Five courses of injection with cytarabine and prednisolone through an Ommaya reservoir and whole brain irradiation (total 40 Gy) were performed. Furthermore, prophylactic systemic chemotherapy with cytarabine and etoposide was added. He has been in complete remission for 21 months. Our results, together with other reported cases, indicate that a favorable outcome could be obtained by intensive and combined treatment for an isolated recurrence of GS of the brain if the bone marrow remained in complete remission.

Marrow and stem cell transplantation in Oklahoma: fifteen years of experience and results

From September 1982 to August 1997, 767 bone marrow or peripheral blood stem cell transplants have been performed at the Health Sciences Center in Oklahoma. Five hundred and two (502) autologous transplants (AutoTX) preceded by high-dose myeloablative therapy were performed for breast cancer (BC, 36%), non-Hodgkin's lymphomas (NHL, 24%), Hodgkin's disease (HD, 10%), acute myeloid leukemia (AML, 8%), testicular cancer (TC, 4%), multiple myeloma (MM, 2%) and other malignancies (16%). Two hundred and sixty-five (265) allogeneic marrow transplants (AlloTX) (related, unrelated) were carried out in chronic myeloid leukemia (CML, 30%), AML (23%), acute lymphoid leukemia (ALL, 14%), myelodysplastic syndrome (MDS, 9%), severe aplastic anemia (SAA, 8%), and other diseases (14%). Compared between 1980s to 1990s, 100-day mortality rates have decreased from 28% to 5% for AutoTX and from 40% to 25% for AlloTX. In the AutoTX setting, major changes included the routine use of growth factors post-transplant and the switch from bone marrow to growth factor-mobilized peripheral blood as a source of stem cells over the last five years. In the AlloTX setting, improvements in recognition and control of cytomegalovirus and Candida organisms, the selective use of growth factors and screened blood products, and better selection of unrelated donors using DNA-based techniques of HLA-matching have contributed to reduce early mortality from infection and primary graft failure. The five-year survival outcomes are comparable to those reported in registry data from the International Bone Marrow Transplant Registry (IBMTR) and the National Marrow Donor Program (NMDP).

Human herpesvirus-6 meningoencephalitis in a recipient of an unrelated allogeneic bone marrow transplantation

BACKGROUND

Human herpesvirus-6 (HHV-6) has been implicated in bone marrow suppression, interstitial pneumonitis, and fatal meningoencephalitis in bone marrow transplant (BMT) recipients.

METHODS

We describe the case of a woman with acute myeloid leukemia in second remission who developed febrile meningoencephalitis 8 months after a second unrelated BMT.

RESULTS

Computed tomography and magnetic resonance images of the brain were nonspecific. Analysis of cerebrospinal fluid (CSF) revealed lymphocytosis and an increased protein level. Using polymerase chain reaction methods, HHV-6 was the only pathogen detected in CSF, peripheral blood mononuclear cells, and bone marrow. The patient was treated with ganciclovir and foscarnet for 3 months. All clinical manifestations resolved and HHV-6 polymerase chain reaction analysis of CSF became negative 40 days after the beginning of antiviral treatment.

CONCLUSIONS

This observation strongly suggests that HHV-6 should be sought in BMT patients with neurological complications and that HHV-6 meningoencephalitis may respond to ganciclovir and foscarnet therapy.

Peripheral blood progenitor cell transplantation as an alternative to autologous marrow transplantation in the treatment of acute myeloid leukemia

Herein we report on the feasibility of mobilizing peripheral blood progenitor cells (PBPC) in a prospective study of the HOVON-SAKK Groups in 96 cases with newly diagnosed acute myeloid leukemia (AML). Among 96 patients, 76 patients (79%) entered complete remission. Mobilization was undertaken with variable dosages of G-CSF in 63 patients, and 54 patients (87%) were leukapheresed. The comparative yields of pheresis following the G-CSF schedules and hematopoietic recovery data are presented and discussed. PBPC transplantation results in faster hematopoietic regeneration compared to autologous marrow grafting in the prior AML HOVON study.

[Unrelated peripheral blood stem cell transplantation for a patient with acute myeloid leukemia]

OBJECTIVE

To carry out unrelated donor peripheral blood stem cell transplantation for treatment of hematological malignancies, and to observe the persistent hematopoietic reconstitution and transplantation related complications.

METHODS

A 11-year-old boy with acute myeloid leukemia, who was in second CR, received peripheral blood stem cell transplantation from a unrelated healthy adult donor. The conditioning regimen consisted of FTBI (8Gy), cyclophosphamide (120 mg/kg) and Vp16 (30 mg/kg). The patient received 8. 3 x 10(8) mononuclear cells/kg, 1.079 x 10(8) CD34+ cells/kg and 1. 09 x 10(6) CFU-GM/kg. CsA and MTX were given for prophylaxis of aGVHD.

RESULTS

Engraftment with allogeneic peripheral blood stem cells was rapid, ANC reached 1. 30 x 10(9)/L on day 10 post-transplantation, DNA D1S80 showed engraftment on day 23, and the blood type(AB) changed into the donor's (A) on day 120. The patient developed mild aGVHD (I degrees) on day 11 and mild cGVHD on day 143, which were controlled by methylprednisolone and prednisone, respectively. Ten months after transplantation, the patient's blood counts were normal.

CONCLUSION

Unrelated donor peripheral blood stem cell can maintain persistent hematopoiesis.

Granulocytic sarcoma of the spine in nonleukemic patients: report of three cases

OBJECTIVE AND IMPORTANCE

Granulocytic sarcomas involving the spine in patients without myelogenous leukemia are rare. We report three cases and review the literature.

CLINICAL PRESENTATION

Three patients presented with spinal epidural tumors, which caused spinal cord compression in one and cauda equina compression in two.

INTERVENTION

All patients underwent surgery, and biopsies revealed histological features of granulocytic sarcomas. Bone marrow aspirates and biopsies showed no evidence of acute leukemia at initial presentation, for all three patients.

CONCLUSION

Granulocytic sarcomas in nonleukemic patients are rare, and when they affect the spine they are frequently misdiagnosed. Appropriate therapy for these tumors requires early identification.

Factors influencing the outcome of donor marrow transplantation in adults from less than ideal donors: experience from two Australian centres

BACKGROUND

This paper reports the results of 78 marrow transplants in two Australian hospitals between 1991 and 1996, using unrelated (n = 54) or mismatched related (n = 24) donors. Twenty-six patients received granulocyte-macrophage colony stimulating factor (GM-CSF) post-transplant as part of a phase II study. Fifty-four patients (74%) had advanced disease.

AIMS

To identify factors associated with a superior outcome post-transplant, to evaluate the effect of GM-CSF on engraftment and other transplant parameters, and to compare the overall results with those of published series.

METHODS

Review of patient records, a Medline search of the relevant literature and appropriate statistical analysis.

RESULTS

The probability of overall survival and event-free survival (EFS) at three years was 35 +/- 6% and 22 +/- 6% respectively. Pre-transplant factors significantly associated with an inferior EFS were advanced disease, poorer performance status and age > 30 years. The EFS in patients with standard risk disease was 51 +/- 13% versus 10 +/- 5% in patients with advanced disease, p < 0.0001. Severe acute graft-versus-host disease was also associated with a poorer outcome. Neutrophil engraftment was faster in patients who received GM-CSF but there was no difference in any other transplant parameters.

CONCLUSIONS

These results are consistent with reported series elsewhere and suggest that an extended family or unrelated donor transplant should generally be limited to patients with a good performance status and early phase but otherwise incurable haematological disease.

Allogeneic bone marrow transplantation for acute leukemia in patients over the age of 40 years. Acute Leukemia Working Party of the European Group for Bone Marrow Transplantation (EBMT)

Extension of allogeneic transplants to older patients has been limited by a high risk of transplant-related death and graft-versus-host disease. To evaluate the feasibility in older patients, a retrospective analysis of the procedure was performed for first remission acute leukemia in 192 patients aged over 40 years and compared with a group of 1119 recipients aged from 16 to 40 years reported to the EBMT from 1986 to 1992. Patient-, disease-, and treatment-related variables were compared between the two age groups using the chi2 statistical method for categorical variables. Variables differing significantly or recognized as potential prognostic factors were included in a multivariate analysis. Leukemia-free survival and relapse were comparable among the age groups in the two types of leukemias. Incidence of graft-versus-host disease was higher in the older group of ALL patients. Older patients with AML in first remission had a higher treatment-related mortality incidence, with no influence on survival. A pair-matched analysis of AML patients did not show any statistical difference in the probability of LFS, RI, TRM, and survival for the two age cohorts of patients. These results suggest that BMT should be considered for patients over 40 years of age.

Granulocytic sarcoma of the scapula: an unusual presentation of acute myeloblastic leukemia

The unusual presentation of acute myeloblastic leukemia as a scapular granulocytic sarcoma in an infant without systemic manifestations is reported for the first time. Granulocytic sarcoma as a presentation of leukemia should be considered in the differential diagnosis of scapular masses during childhood. Surgery is limited to obtain sufficient tissue for histopathologic diagnosis.

Allogeneic vs autologous stem cell transplantation vs chemotherapy in patients with acute myeloid leukemia in first remission: the BGMT 87 study

In 204 adult patients with de novo acute myeloid leukemia (AML), we prospectively compared allogeneic bone marrow transplantation (alloBMT), autologous stem cell transplantation (ASCT) and chemotherapy (Chemo). 162 patients (79.4%) achieved a complete remission (CR). Of the 135 patients who were still in CR after consolidation, 96 patients were less than 46 years of age: 36 patients had an HLA-identical sibling donor and were allocated for alloBMT (group I); they were compared to the 60 other patients who did not have an HLA-identical sibling donor and were treated with either ASCT or chemotherapy (group II). The 3-year disease-free survival was higher for group I patients (66.5 +/- 16%) than for the 60 group II patients (42.4 +/- 13%) (P < 0.05). The actuarial risk of relapse at 3 years was significantly lower for group I patients (24 +/- 15%) than for the other 60 group II patients (56 +/- 13%; P < 0.009). By multivariate analysis, the disease-free survival and risk of relapse were influenced by the initial WBC count (P < 0.02 and P < 0.006), the number of chemotherapy courses for CR (P < 0.001 and P < 0.01) and the type of post-induction treatment (alloBMT vs no alloBMT; P < 0.1 and P < 0.02). The 99 patients who did not fulfill the inclusion criteria for alloBMT were given intensive chemotherapy including high-dose aracytine. When they were still in CR (n = 77), these patients were then randomized for either ASCT (n = 39) or Chemo (n = 38). We were unable to detect any statistical difference between ASCT and Chemo for either disease-free survival, risk of relapse or survival. These results indicate that alloBMT seems to produce results which are at least superior to those of other therapeutic modalities. The results of either ASCT or Chemo look similar.