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Scheinberg P, Wu CO, Nunez O, Young NS. Predicting response to immunosuppressive therapy and survival in severe aplastic anaemia. Br J Haematol 2008; 144:206-16. [PMID: 19036108 DOI: 10.1111/j.1365-2141.2008.07450.x] [Citation(s) in RCA: 152] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Horse anti-thymocyte globulin (h-ATG) and ciclosporin are the initial therapy for most patients with severe aplastic anaemia (SAA), but there is no practical and reliable method to predict response to this treatment. To determine whether pretreatment blood counts discriminate patients with SAA who have a higher likelihood of haematological response at 6 months to immunosuppressive therapy (IST), we conducted a single institution retrospective analysis on 316 SAA patients treated with h-ATG-based IST from 1989 to 2005. In multivariate analysis, younger age, higher baseline absolute reticulocyte count (ARC), and absolute lymphocyte count (ALC) were highly predictive of response at 6 months. Patients with baseline ARC > or = 25 x 10(9)/l and ALC > or = 1 x 10(9)/l had a much greater probability of response at 6 months following IST compared to those with lower ARC and ALC (83% vs. 41%, respectively; P < 0.001). This higher likelihood of response translated to greater rate of 5-year survival in patients in the high ARC/ALC group (92%) compared to those with a low ARC/ALC (53%). In the era of IST, the baseline ARC and ALC together serve as a simple predictor of response following IST, which should guide in risk stratification among patients with SAA.
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Affiliation(s)
- Phillip Scheinberg
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1202, USA.
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Barrett AJ. Allogeneic bone marrow transplantation for severe aplastic anaemia--the London experience. CLINICAL AND LABORATORY HAEMATOLOGY 2008; 1:95-107. [PMID: 43792 DOI: 10.1111/j.1365-2257.1979.tb00457.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Using the Seattle protocol with minor modifications, 23 patients with severe aplastic anaemia received allogeneic bone marrow transplants from HLA/mixed leucocyte culture matched sibs in three London centres between 1973 and 1977. Ten patients (43.5%) are alive 6 months to 5 years after transplantation, and are well with full haemopoietic reconstitution, two with autologous bone marrow recovery following the graft procedure. A failure of the marrow graft to take, or take followed by rejection occurred in 12 patients (52%). Failure of marrow recovery was associated with a high early mortality from bacterial or fungal infection. The only survivors amongst those who rejected the first graft were four patients in whom a subsequent graft from the same donor was successful, and two in whom autologous recovery occurred. Graft versus host disease (GVHD) occurred in seven patients, and was fatal in one case. The most frequent complication after successful engraftment was varicella-zoster infection which occurred in five patients and was fatal in one patient. The overall results compare favourably with those from other transplant centres, but the high rate of graft rejection and low incidence of GVHD differ from other series. The results should encourage further referral of patients with severe AA for bone marrow transplantation.
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Schrezenmeier H, Marin P, Raghavachar A, McCann S, Hows J, Gluckman E, Nissen C, van't Veer-Korthof ET, Ljungman P, Hinterberger W. Relapse of aplastic anaemia after immunosuppressive treatment: a report from the European Bone Marrow Transplantation Group SAA Working Party. Br J Haematol 1993; 85:371-7. [PMID: 8280610 DOI: 10.1111/j.1365-2141.1993.tb03181.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This study was designed to determine the incidence of relapse and factors predictive for relapse in 719 patients with severe aplastic anaemia (SAA) after immunosuppressive treatment (IS). Patients developing myelodysplasia or acute leukaemia after IS, and patients receiving a transplant, were excluded from this analysis. Response was defined as reaching complete independence from transfusions, relapse was defined as becoming again transfusion dependent. This criteria was validated by similar figures when using other 'relapse criteria' such as drop in neutrophil or platelet counts. Of 358 patients responding to IS. 74 patients relapsed after a mean time of 778 d after treatment. The actuarial incidence of relapse is 35.2% at 14 years after IS. The risk for relapse was higher in patients responding within 120 d from IS (48%) compared to patients responding between 120 and 360 d (40%) and only 20% for slow responders (> 360 d from IS) (P < 0.00001). In multivariate analysis this factor still proved significant (P < 0.0001). The mean time between diagnosis and treatment was significantly longer in patients relapsing compared to patients who did not relapse (260 v 134 d, P = 0.037). Relapse was not predicted by the severity of the disease, age, and sex. In 39 of the 74 relapsing patients a second response could be achieved. Responses after relapse were associated in univariate analysis with early response to previous IS and early occurrence of relapse. The actuarial survival of patients not relapsing is significantly better than survival of patients relapsing (79.8% v 67.1%, P = 0.0024). However, the actuarial survival of 39 relapsing patients who responded again to IS was similar to patients not relapsing (86%) and significantly better than in 35 patients not reaching a second response after relapse (49.3%, P = 0.0015). This study indicates that relapse is a relevant problem in the treatment of aplastic anaemia, and does have an impact on overall survival. Prospective studies of immunosuppressive regimens, looking at responses, should also address this problem in the future.
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Kochupillai V, Sharma S, Sundaram KR, Ahuja RK. Hemopoietic improvement following fetal liver infusion in aplastic anemia. Eur J Haematol 1991; 47:319-25. [PMID: 1761117 DOI: 10.1111/j.1600-0609.1991.tb01854.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
41 (38 males, 3 females) patients with aplastic anemia received fetal liver infusion (FLI) from 74 abortuses with gestation periods of 8-32 (Median(M)-16) weeks and cell dose of 0.004-11.1 x 10(8) (M-2.3 x 10(8)) from September, 1976 until November, 1987. 35 persons received single FLI; those with recurrence or no response received two or more FLI. 8 received two; 7, three; 2, four; and 1, six FLI. There was a slow and incomplete autologous hematopoietic improvement in 40% and expected survival of 52% at 1 year, 45% at 2 yr, and 37% at 5 yr (Kaplan Meier estimate). There was rise in fetal hemoglobin (Hb), 0-15.7%, (M-3.5) among responders in 3-20 (M-6) months. Patients who survived for more than 12 months had, on average, a longer duration of disease (4 months or more), and higher granulocyte and platelet counts. Statistically, however, these differences were not significant. Reticulocyte count was significantly lower in those who survived beyond 12 months. 1 patient developed acute undifferentiated leukemia 3 yr post-FLI. The study indicates that fetal liver infusion is likely to benefit about 40% of individuals suffering from severe aplastic anemia. Longer surviving patients, however, may be at risk of developing clonal diseases.
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Affiliation(s)
- V Kochupillai
- Department of Medical Oncology, Institute Rotary Cancer Hospital, New Delhi, India
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de Planque MM, Bacigalupo A, Würsch A, Hows JM, Devergie A, Frickhofen N, Brand A, Nissen C. Long-term follow-up of severe aplastic anaemia patients treated with antithymocyte globulin. Severe Aplastic Anaemia Working Party of the European Cooperative Group for Bone Marrow Transplantation (EBMT). Br J Haematol 1989; 73:121-6. [PMID: 2803967 DOI: 10.1111/j.1365-2141.1989.tb00230.x] [Citation(s) in RCA: 141] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
468 severe aplastic anaemia (SAA) patients registered in the EBMT-SAA registry who did not undergo bone marrow transplantation and were treated with immunosuppressive therapy (IS; 96% of patients received ATG) were evaluated. Their median age was 23 years (range 1-73) at initial IS therapy, 59% were males; in 69% the aetiology of SAA was idiopathic. Of these 468 patients, 245 had a follow-up of less than 2 years after IS 166/245 died, 71/245 are still alive, 8/245 are lost to follow-up. Of 223 patients who survived greater than or equal to 2 years (LTS long-term survivors), 191 are alive, 21 died greater than 2 years and 11 are lost. Median follow-up of 223 LTS was 4.1 years (range 2.0-10.9). Comparison of 166 patients who died less than 2 years and 223 LTS revealed no difference at time of initial IS therapy as regards sex, duration of AA, or its aetiology, but the age distribution and, in particular, severity of SAA differed significantly: more LTS were between 21 and 40 years old (44% v. 32%, P less than 0.02), less LTS had reticulocytes less than 20 x 10(9)/l (63% v. 80%, P less than 0.001), polymorphonuclear granulocytes (PMN) less than 0.2 x 10(9)/l (30% v. 57%, P less than 0.001), haemorrhages (58% v. 79%, P less than 0.002) and infection (30% v. 49%, P less than 0.005) at time of IS. A gradual improvement of blood counts was seen in patients alive greater than or equal to 2 years after IS. At 2 years after IS 80% had a normal haemoglobin and PMN greater than 0.5 x 10(9)/l, but only after 5 years 80% of cases had platelets greater than 50 x 10(9)/l. Development of clonal disease was reported of 31 LTS: 19 developed paroxysmal nocturnal haemoglobinuria (PNH), one acute leukaemia, 11 myelodysplastic syndromes and of these 11 five subsequently acute leukaemia. The majority of these patients (23/31) are still alive. Actuarial mortality of LTS is 22% at 8 years, but so far no plateau was achieved. It is concluded that SAA patients who become LTS following IS, show an improvement in haematological status but are probably not cured and are prone to develop clonal (malignant) disease.
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Affiliation(s)
- M M de Planque
- Department of Immunohaematology and Blood Bank, University Hospital, Leiden, The Netherlands
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de Planque MM, Kluin-Nelemans HC, van Krieken HJ, Kluin PM, Brand A, Beverstock GC, Willemze R, van Rood JJ. Evolution of acquired severe aplastic anaemia to myelodysplasia and subsequent leukaemia in adults. Br J Haematol 1988; 70:55-62. [PMID: 3179229 DOI: 10.1111/j.1365-2141.1988.tb02434.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Myelodysplasia (MDS) and leukaemia following acquired aplastic anaemia has been reported as a rare event occurring in about 5% of patients. Improved results in survival of patients with severe aplastic anaemia (SAA) and subsequent prolonged follow-up created the possibility of evaluating the occurrence of MDS and leukaemia in 38 adult patients with acquired SAA surviving two or more years without bone marrow transplantation. Five patients, age 22, 35, 47, 56, 72 years, two females, three males, all with idiopathic SAA and normal cytogenetic analysis developed a refractory anaemia (RA) 7, 30, 48, 56, 142 months after diagnosis of SAA. In 3/5 RA evolved into an acute myeloid leukaemia (AML) either via a chronic myelomonocytic leukaemia (CMML) (2/3) or via RA with excess of blasts (RAEB) (1/3). Three patients revealed a monosomy 7 during MDS and/or leukaemic phase. One patient died during RA phase without cytogenetic abnormalities. A pattern of evolution could be identified in these patients revealing well-documented SAA - improvement of bone marrow haematopoiesis - dyshaematopoietic features of one or more cell lines with predominance of dyserythropoiesis - RA - RAEB or CMML - AML. These five patients represent more than 10% of all patients surviving at least 2 years. This implies that the risk of developing MDS and leukaemia in SAA patients surviving with autologous marrow, might increase with longer follow-up.
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Affiliation(s)
- M M de Planque
- Department of Haematology, University Medical Centre, Leiden, The Netherlands
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Miller WJ, Branda RF, Flynn PJ, Howe RB, Ramsay NK, Condie RM, Jacob HS. Antithymocyte globulin treatment of severe aplastic anaemia. Br J Haematol 1983; 55:17-25. [PMID: 6603864 DOI: 10.1111/j.1365-2141.1983.tb01220.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Nineteen patients with severe aplastic anaemia were treated with antithymocyte globulin. Ten patients obtained remissions (transfusion independent, at least 45000 platelets and 2000 PMN/mm3) within 2-3 months and continue in remission 5-35 months after antithymocyte globulin. Ages of responders ranged from 17 to 71. Complications of antithymocyte globulin included arthralgias, rash, serum sickness, angioedema and fever. Two patients died during, two shortly after, and one 10 months after therapy. One patient with a previous remission following antithymocyte globulin relapsed and achieved a second remission with retreatment. Previous androgen therapy did not affect outcome since two of four patients with and eight of 15 patients without previous androgen therapy achieved remission with ATG. Treatment with antithymocyte globulin is a promising alternative to bone marrow transplantation in the treatment of severe aplastic anaemia.
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Jansen J, Zwaan FE, Haak HL, te Velde J, Guiot HF, Sabbe LJ, Eernisse JG, Tricot GJ, van Rood JJ. Anti-thymocyte globulin treatment for aplastic anemia. SCANDINAVIAN JOURNAL OF HAEMATOLOGY 1982; 28:341-51. [PMID: 7051265 DOI: 10.1111/j.1600-0609.1982.tb00536.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
20 patients with severe aplastic anemia were treated with anti-thymocyte globulin (ATG), 6 of them in combination with haplo-identical bone marrow. 7 patients (35%) showed a good clinical response within 6 months; they were off transfusions and had greater than or equal to 0.8 x 10(9)/l neutrophils. ATG had the greatest effect on red-cell production and the least on platelet production. The hematological recovery with ATG could not be predicted from the bone-marrow histology, CFU-c growth, or clinical data. However, patients with strong HLA antibodies seemed to respond more often. The actuarial survival was 55% at 5 years. Under intensive supportive care, even 7 out of 12 non-responders were alive after 1 year. ATG appears to be a useful form of therapy for patients with severe aplastic anemia who are not candidates for bone-marrow transplantation.
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Najean Y. Long-term follow-up in patients with aplastic anemia. A study of 137 androgen-treated patients surviving more than two years. Joint Group for the Study of Aplastic and Refractory Anemias. Am J Med 1981; 71:543-51. [PMID: 7282742 DOI: 10.1016/0002-9343(81)90204-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Kolb HJ, Wündisch GF, Spitzer I, Ochsler H, Stengel-Rutkowski L, Bender-Götze C, Albert ED, Sauer H, Ledderose G, Brehm G, Jehn U, Eckstein R, Mempel W, Wilmanns W, Haas RJ, Helmig M, Netzel B, Belohradsky B, Janka G, Rodt H, Grosse-Wilde H, Thiel E, von Lieven H, Roloff R, Krimmel BL, Bunde E, Wank R, Schendel D. [Bone marrow transplantation for aplastic anaemia (author's transl)]. KLINISCHE WOCHENSCHRIFT 1981; 59:325-42. [PMID: 7017255 DOI: 10.1007/bf01525001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
From March 1975 until May 1980 twelve patients with severe aplastic anemia were grafted with bone marrow from HLA-identical siblings by the Munich Cooperative Group for Bone Marrow Transplantation. Six patients are alive between 10 months and more than 5 years after grafting with normal blood values and marrow. One patient is treated as an out patient for chronic localized graft-versus-host disease (GvHD), five patients are well and without treatment. Six patients have died, one patient with a cerebral hemorrhage the day before transplantation, three patients following rejection of grafts 32, 40 and 55 days after grafting, one patient with severe GvHD 85 days after grafting and one patient, probably with interstitial pneumonia, following cerebral hemorrhage. Three of 6 patients who were conditioned with Cyclophosphamide (CY) only died following rejection of the graft. Two adults who were conditioned with CY and "total lymphoid irradiation" and three children, who wer given unirradiated leukocyte concentrates from the marrow donor after grafting, did not reject their grafts. The results of the Munich-Cooperative Group for Bone Marrow Transplantation are comparable to those of large, specialized centers for bone marrow transplantation, they indicate possibilities of cure of severe aplastic anemia by marrow grafts from HLA-identical siblings. They confirm that better results are obtained with earlier transplantation in the course of the disease.
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Sleijfer DT, Mulder NH, Nieweg HO. The value of prognostic indices in aplastic anaemia. BLUT 1981; 42:69-78. [PMID: 7470640 DOI: 10.1007/bf01030028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In 43 patients with aplastic anaemia we assessed the accuracy of different prognostic systems. Patients dying within 6 months after diagnosis were correctly predicted in 60% of cases with the Lynch-index with a sensitivity of 82%. With the Najean-index 40% of these patients are correctly predicted, this index has a sensitivity of 100%. More accurate are the prognostic criteria proposed by Camitta et al [5]. With these criteria, this rapidly fatal group is correctly predicted in 85% of the patients, indicating that 15% of the patients are incorrectly predicted to have a limited survival. The sensitivity, however, is 100%. The Lohrmann-index, based on reticulocyte count predicts 64% of this group with severe aplasia. None of these prognostic systems do accurately predict long survival. We suggest that the best differentiation between patients with a long-term prognosis (more than 5 years) and patients who die from aplastic anaemia within 5 years, is made by re-evaluating the leucocyte and platelet count 3 months after the initial diagnosis. Decrease in blood counts (over 10%) predicts death from aplastic anaemia within 5 years correctly in all patients; stable or increased blood counts predict long survival in 75% of the patients.
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Pauwels EK, te Velde J, Hermans J, Haak HL, Jürgens PJ. 111Indium-chloride bone marrow scintigraphy in aplastic anaemia. SCANDINAVIAN JOURNAL OF HAEMATOLOGY 1981; 26:81-90. [PMID: 7256214 DOI: 10.1111/j.1600-0609.1981.tb01629.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Bone marrow scintigraphy, using 111Indium-chloride, was performed in 24 patients with acquired aplastic anaemia to investigate: (1) a possible relationship between bone marrow scintigraphy and peripheral blood cell values, (2) a possible relationship between scintigraphy and histology of the bone marrow and (3) the ability to distinguish various aplastic anaemia subtypes with bone marrow scintigraphy. For this purpose a semi-quantitative scoring of scintigraphic results was used. Only a weak correlation was found between the radionuclide studies and blood counts. It appeared that an abnormal 111In-scintigraphic activity in the pelvis was related to an abnormal quality and quantity of haematopoietic tissue. To study a correlation with histological subtype grading, the patients were grouped in 4 categories based on clinical-histological results. Thus it could be demonstrated that the presence of 111In-activity in long bones ('scintigraphic extension') is an important parameter in distinguishing patients who are believed to suffer from a primary stem-cell defect, from patients who may suffer from an auto-aggressive disorder.
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Abstract
Three patients with drug-induced hypoplastic anemia terminating 2 to 6 years after presentation with erythroleukemia are described. All were treated for prolonged periods with androgen and corticosteroid and two of the patients showed apparent dependence on this therapy for optimal hematologic status. The leukemic phase was heralded by loss of this dependence and development of sideroblastic dyserythropoiesis with progression to bizarre erythroid hyperplasia and fatal cytopenia. The exact relationship between androgen and corticosteroid therapy and the erythroleukemia remains speculative.
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te Velde J, Haak HL. Histology of bone marrow failure, a follow-up study in aplastic anaemia. HAEMATOLOGY AND BLOOD TRANSFUSION 1979; 24:15-25. [PMID: 540794 DOI: 10.1007/978-3-642-67483-9_3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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