Autologous hematopoietic stem cell transplantation as an intensive consolidation therapy for adult patients in remission from acute myelogenous leukemia

Autologous peripheral blood stem/progenitor cell transplantation (APBSCT) has been investigated as a potential therapeutic option to improve outcome in patients with acute myelogenous leukemia (AML). However, its optimal role in treatment for adults in remission has not been clearly established. We performed a retrospective analysis on 45 patients aged 21 to 73 years (median 51 years) with de novo AML who underwent APBSCT stratified by age, complete remission status, and cytogenetic risk. The 5-year disease-free survival (DFS) for all patients was 33.9% (95% confidence interval [CI], 20.1%-53.7%) and overall survival (OS) was 43.6% (CI, 29.2%-62.8%). For patients under the age of 60 years, the 5-year DFS for intermediate and high cytogenetic risk was 53.3% (CI, 23.5%-85.6%) and 50.0% (CI, 16.1%-100.0%); the 5-year OS for patients under the age of 60 years with low, intermediate, and high cytogenetic risk was 80.0% (CI, 40.0%-100.0%), 60.0% (CI, 31.2%-90.7%), and 75.0% (CI, 39.0%-100.0%), respectively. For patients over the age of 60 years, the 5-year DFS and OS for intermediate cytogenetic risk was 21.4% (CI, 7.9%-58.4%) and 21.4% (CI, 7.9%-58.4%). The DFS and OS of these patients are comparable to the historic survival of those who underwent allogeneic stem cell transplantation when adjusted by age. In addition, there was no treatment-related mortality (TRM). We conclude that APBSCT is a reasonable and safe intensive consolidation for patients with AML who do not have a suitable HLA-matched donor.

Peripheral blood progenitor cell mobilization with intermediate-dose cyclophosphamide, sequential granulocyte-macrophage-colony-stimulating factor and granulocyte-colony-stimulating factor, and scheduled commencement of leukapheresis in 225 patients undergoing autologous transplantation

BACKGROUND

Interpatient variability in the kinetics of peripheral blood progenitor cell (PBPC) mobilization is commonly seen with conventional chemotherapy-based mobilization regimens. This necessitates the availability of leukapheresis (LP) facilities 7 days a week.

STUDY DESIGN AND METHODS

The efficacy of an approach where LP was invariably commenced on Day 11 after intermediate-dose cyclophosphamide followed by sequential administration of granulocyte-macrophage-colony-stimulating factor (CSF) and granulocyte-CSF (Cy/GM/G) was retrospectively analyzed in 225 consecutive, unselected patients undergoing autologous hematopoietic stem cell transplantation for all diagnoses other than acute leukemia at our center. Cy/GM/G was scheduled to avoid weekend LP.

RESULTS

After Cy/GM/G, a CD34+ cell yield of at least 2.0x10(6) per kg was achieved in 90.7 percent of patients. Optimal yield (OY; >or=5x10(6) or 10x10(6) CD34+ cells/kg depending on diagnosis) was achieved in 67.6 percent of patients. Only three patients (1.3%) required LP on Saturday or Sunday. Febrile neutropenia (FN) was encountered in 5.3 percent. PBPC yield was highest on Day 1 of LP (p<0.001). In multivariate analyses, platelet (PLT) count on Day 1 of LP (PLT-D1LP) was positively associated with achievement of OY (p<0.001). PLT-D1LP and diagnosis of myeloma were associated with a shorter time to achieve a CD34+ cell yield of at least 5x10(6) per kg (p<0.001 and p=0.002, respectively).

CONCLUSION

Cy/GM/G with scheduled LP commencement on Day 11 enables optimal CD34+ cell yields in most patients undergoing autologous transplantation, despite a low risk of FN and avoidance of weekend LP.

Phase II trial of idiotype vaccination in previously treated patients with indolent non-Hodgkin's lymphoma resulting in durable clinical responses

PURPOSE

To evaluate idiotype (Id) vaccination as a single agent in previously treated patients with indolent non-Hodgkin's lymphoma.

PATIENTS AND METHODS

Patients underwent biopsy for determination of their lymphoma-specific Id sequence. Recombinant Id protein was manufactured and covalently linked with keyhole limpet hemocyanin (KLH) to generate Id/KLH. Patients received Id/KLH 1 mg on day 1 subcutaneously, with granulocyte-macrophage colony-stimulating factor 250 mug on days 1 to 4, monthly for 6 months. Booster injections were administered until progression. Both clinical and immune responses were evaluated.

RESULTS

Thirty-two previously treated patients received at least one injection of Id/KLH, and 31 were assessed for efficacy. Responses were observed in four patients (one complete response and three partial responses). Median time to onset of response was 5.9 months (range, 2.3 to 14.1 months). Median duration of response has not been reached but should be at least 19.4 months (range, 10.4 to 27.2+ months). Median time to progression is 13.5 months. The most common adverse events were mild to moderate injection site reactions. Six (67%) of nine patients tested demonstrated a cellular immune response, and four (20%) of 20 patients demonstrated an antibody response against their Id.

CONCLUSION

This trial demonstrates that Id/KLH alone can induce tumor regression and durable objective responses. Further study of Id/KLH is recommended in other settings where efficacy may be further enhanced as in first-line therapy or after cytoreductive therapy.

Successful perioperative management of factor X deficiency associated with primary amyloidosis

Acquired bleeding abnormalities are common in patients with primary amyloid light-chain amyloidosis. Factor X deficiency is the most common coagulopathy associated with life-threatening hemorrhagic complications when surgery is indicated. Fresh-frozen plasma (FFP) or prothrombin complex concentrates (PCCs) are the most frequently used blood products in this disease; however, FFP is often ineffective in controlling bleeding and PCCs have a significant risk of thrombosis when used intraoperatively. This report describes a patient with primary amyloidosis and factor X deficiency who underwent hemicolectomy with preoperative and intraoperative administration of recombinant human factor VIIa and postoperative administration of Bebulin (a PCC that contains the highest concentration of factor X). The management was successful with no signs of bleeding postoperatively. To our knowledge, few reports of successful perioperative management of factor X deficiency have been published to date. This is the first case report using recombinant human factor VIIa and Bebulin in the perioperative management of factor X deficiency associated with primary amyloidosis. Recombinant human factor VIIa and Bebulin may allow for successful perioperative management of bleeding disorders in patients with primary amyloidosis.

Autologous blood donation in total hip replacement

The effectiveness of autologous blood donation in reducing the need for homologous transfusion was evaluated in a review of 529 consecutive total hip replacements (THR) from 1988 to 1992. The review was retrospective from 1988 to 1990 and prospective from 1991 to 1992. Since 1988 there have been 188 primary THR performed using autologous blood donation. In 1988-89, this represented 18% of all primary THR, in 1990 37% and in 1991-92 73%. This increase reflects a growing enthusiasm for the programme and a loosening of age restrictions. In 1991-92, 4% of autologous donors undergoing primary THR required homologous transfusions compared to 84% of non-autologous donors. Over the same period after revision THR, 36% of autologous donors required homologous transfusions compared to 100% of non-autologous donors. The participation rate of patients undergoing revision THR was 33%. The prospective part of the study in 1991-92 compared autologous and matched non-autologous patients. Blood loss, transfusion volumes and operating time were identical. The pre- and postoperative haemoglobin concentrations in the autologous group were lower by 15 and 10 g/L, respectively, after primary THR and by 10 g/L in both instances after revision THR. This was not reflected in a longer admission.

Porous coated anatomic non-cemented total hip arthroplasty

Between November 1984 and December 1989, 318 non-cemented Porous Coated Anatomic (PCA; How-medica, Rutherford, New Jersey) total hip replacements were performed by the authors. A follow-up of 1 to 6 years was allowed. The average age was 53.1 years (from 17 to 71 years). The distribution of right-to-left was approximately equal. There were 192 hip replacements for primary and post-traumatic osteo-arthritis, 42 for rheumatoid arthritis, 40 for avascular necrosis, 29 for congenital dislocation or hip dysplasia with secondary osteo-arthritis, 6 for Perthes disease, 5 for previous sepsis, 2 of whom had had a Girdlestone procedure, 2 for revision of a painful cup arthroplasty, and 1 for conversion of a previously fused hip. All patients were evaluated on a one hundred point Harrington Arthritis Research Centre Scale. Points were awarded for pain (0-35), function (0-35), motion (0-10), deformity (0-10) and gait (0-10). Pre-operative total scores averaged 45.5 (9-71) and postoperative scores averaged 83.9 (55-98). The overall results were excellent 20.5% (90-100), good 59.8% (80-90), fair 16.4% (70-80), and poor 3.3%. Postoperative radiographs were evaluated using zonal analysis. There was no deterioration on the radiographs after two years.