A. Della Volpe

Autologous haematopoietic stem cell transplantation without CD34 + cell selection in refractory Crohn’s disease

Objectives: Autologous haematopoietic stem cell transplantation (HSCT) with CD34+ cell selection has recently been used in the treatment of refractory Crohn’s disease, showing good safety and promising efficacy. We investigated the safety and efficacy of HSCT with unselected peripheral blood stem cells (PBSCs) in moderate–severe refractory Crohn’s disease. Patients: Four patients (three male, one female; age range 26–45 years) with active moderate–severe Crohn’s disease (median Crohn’s Disease Activity Index (CDAI) 319, range 272–345), refractory or intolerant to multiple drugs including infliximab, were enrolled. Interventions: Unselected PBSCs were collected after mobilisation with cyclophosphamide (CTX) 1.5 g/m2 and granulocyte-colony stimulating factor (G-CSF) 10 μg/kg. The conditioning regimen included CTX 50 mg/kg on days −5 to −2 and rabbit anti-thymocyte globulin (ATG) 2.5 mg/kg on days −4 to −2. Main outcome measures: Primary endpoints were toxicity and clinical remission (CDAI<150) at 3 months. Secondary endpoints were clinical and endoscopic response at 3 months and toxicity, clinical and endoscopic remission at 12 months. Results: No improvement or slight deterioration was observed following mobilisation (median CDAI 339, range 258–404). At the third month, the primary endpoint of clinical remission was achieved in all patients, with a median CDAI of 91 (range 56–102), and complete endoscopic remission was achieved in 2/3 patients. After a median follow-up of 16.5 months, 3/4 patients maintained both clinical and endoscopic remission, despite withdrawal of all drugs, and complete fistula closure was observed in all affected patients. No deaths or life-threatening infection occurred. Unexpected adverse events included a perianal abscess after mobilisation in one patient, pleural and pericardial effusions in another and BK virus-related macrohaematuria in another, all rapidly resolved with conservative treatment. Conclusion: Autologous HSCT with unselected PBSC appears to be safe and can induce and maintain remission in previously refractory Crohn’s disease patients.

Short- and long-term effects of hormone replacement therapy (transdermal estradiol vs oral conjugated equine estrogens, combined with medroxyprogesterone acetate) on blood coagulation factors in posimenopausal women

We compared the effects on hemostatic variables of transdermal estradiol and oral equine conjugated estrogens (CEE), both combined with medroxyprogesterone acetate, in 40 postmenopausal women, 22 randomly allocated to transdermal estradiol and 18 to CEE. Antithrombin III (AtIII), fibrinogen, factor VII, factor VIII and tissue plasminogen activator before and after venous stasis were measured at the start of therapy and after two and four months in all patients, and after 12 months in a subgroup of 21 patients (12 from the estradiol and nine from the CEE group). In the short-term study (two and four months), analysis of variance did not reveal any significant difference between treatments for any of the hemostatic variables. A significant treatment by time interaction was found only for fibrinogen levels: at two months they were significantly higher in the estradiol group. In the long-term study (12 months), a significant decrease in AtIII and a significant increase in factor VIII were observed in both groups, without differences between treatments. The clinical relevance of the observed changes is doubtful, but nevertheless they should be considered in a more extensive evaluation of the potential cardiovascular risk and benefits of hormone use.

Treatment of advanced mycosis fungoides by allogeneic stem-cell transplantation with a nonmyeloablative regimen.

Summary:Given the poor prognosis of patients with advanced cutaneous T-cell lymphoma and the high transplant-related mortality associated with conventional allogeneic bone marrow transplantation, we performed nonmyeloablative transplantation of allogeneic stem cells (ASCT) from HLA-identical siblings in three patients with this disease. All patients achieved full donor engraftment, clearance of clonal T cells leading to durable complete remissions but experienced high incidence of infections, which proved fatal in one case. These results suggest that nonmyeloablative ASCT is a novel and potentially curative therapy for patients with advanced T-cell lymphomas who have a histocompatible sibling.

The PLAT Study: a multidisciplinary study of hemostatic function and conventional risk factors in vascular disease patients

In this paper are reported the basal results of a multidisciplinary, multicenter study designed to explore in a population with ischemic disease the relation between hemostatic variables, conventional risk factors and atherothrombotic sequelae. 953 patients less than or equal to 69 yrs with documented coronary, cerebral or peripheral atherosclerotic disease were studied and followed-up for 24 months. Examinations included hemostatic and lipid laboratory assays, arterial Doppler examination, cerebral computerized tomography and nuclear magnetic resonance, exercise electrocardiogram and coronary angiography. Fibrinogen (301.4 +/- 71.52 mg/dl) correlated positively with antithrombin III (r = 0.27) and leukocytes (r = 0.25), negatively with HDL-cholesterol (r = 0.18) and tended to increase with smoking. Heavy smokers had higher leukocyte counts than non-smokers (8.0 +/- 2.0 vs. 7.2 +/- 2.1 x 10(3)/microliters), higher triglycerides (1.87 +/- 1.12 vs. 1.53 +/- 1.35 mmol/l) and lower HDL-cholesterol (0.93 +/- 0.27 vs. 1.00 +/- 0.25 mmol/l). FVII correlated positively with triglycerides (r = 0.16) and protein C (r = 0.45). vWF:Ag (145.4 +/- 70.58%) ad FVII:C (139.7 +/- 59.10%) were positively correlated (r = 0.44). FVIII:C correlated positively with fibrinogen (r = 0.21). Myocardial infarction survivors with associated cerebral and peripheral vascular lesions had higher FVIII:C, FVII, fibronogen and vWF:Ag. These findings suggest that hemostatic factors may enhance and/or mediate the effects of conventional risk factors in atherothrombotic ischemic events.

Multiple autoimmune events after autologous bone marrow transplantation

A 36-year-old woman with RAEB-t and severe bone marrow fibrosis undergoing autologous BMT, developed a histologically documented GVHD-like skin rash. Thereafter, autoimmune thyroiditis, autoimmune thrombocytopenic purpura and autoimmune hemolytic anemia and a lupus anti-coagulant (LAC) were diagnosed. The patient is still alive, symptom-free and in first complete remission (CR); however, all of the autoantibodies are still detectable, with the exception being the anti-erythrocyte antibody. The most outstanding feature of the present case is the polymorphism of the autoimmune events, in the absence of a coexisting systemic autoimmune disease. This patient has achieved long-term disease-free survival (DFS) in first CR despite high-risk MDS and the repeated immunosuppressant therapy required because of the complications described above; a GVL reaction somewhat similar to the autoimmune events may have contributed towards maintaining disease control.

Haematopoietic abnormalities after autologous stem cell transplantation in lymphoma patients.

Haematopoietic reconstitution after autologous stem cell transplantation (ASCT) was evaluated at different times in 26 lymphoma patients. All of the patients showed a significant decrease in the number of both committed (CFU-C) and more primitive progenitor cells (LTC-IC). The expansion of bone marrow progenitor cells in a ‘stroma-free’ long-term liquid culture system supplemented with SCF, IL-3, IL-6 and GM-CSF from 19 transplanted patients was significantly reduced compared to normal controls. The stromal cell compartment, evaluated by means of a CFU-F assay, was also greatly reduced. The number of haematopoietic and stromal cell progenitors was, nevertheless, very similar to their pre-transplant values. Bone marrow histology, which was evaluated at different times after transplant, showed an increase in reticulin fibres, the dilatation of parenchymal sinusoids and some morphological evidence of trilineage dysplasia in 11 patients; however, the same abnormalities were seen in the majority of pre-transplant samples. No cytogenetic abnormalities were observed in 15 patients before transplant, but four subsequently developed persistent clonal karyotypic alterations and five showed non-clonal abnormalities that generally disappeared over time. Our data suggest that both the stromal and the haematopoietic compartments are somehow damaged after ASCT for lymphoma; however, these defects generally pre-exist the transplant conditioning regimen and seem to become less pronounced over time.

Caspofungin treatment of Pneumocystis pneumonia during conditioning for bone marrow transplantation

Pneumocystis pneumonia (PCP) is a well-known compli-cation in AIDS patients, but it is also frequently diagnosedin hemato-oncological patients [1]. High-dose cotrimoxa-zole is the first-line treatment for PCP, but some patientsshow contraindications and drug resistance may appear[2]. Since Pneumocystis jirovecii cannot be cultivated invitro, mutations in the genes involved in folate metabo-lism have been investigated as a possible expression ofcotrimoxazole resistance [3], but the search for a clinicalcorrelate has so far led to equivocal results [4]. There issome doubt as to what may be the best alternative tocotrimoxazole in the treatment of PCP [5]. The presentreport refers to the use of caspofungin to treat a patientwith PCP undergoing bone marrow transplantation (BMT)in whom cotrimoxazole had to be discontinued because ofits myelotoxicity.A 45-year-old male patient with T-lymphoblastic leu-kemia in second complete remission was scheduled to re-ceive an allogeneic BMT from an unrelated HLA-matcheddonor in October 2004. In September, he was admitted tohospital because of acute respiratory failure. Subsequentexamination of bronchoalveolar lavage (BAL) led to thediagnosis of PCP, and a computed tomography (CT) scanshowed diffuse, bilateral, interstitial disease with “groundglass”parenchymaandthickeningoftheinterlobularsepta.Molecular, cultural and cytological investigations of theBAL failed to identify any other pathogen. Transbronchialbiopsy was not performed. High-dose cotrimoxazole wasstarted in combination with methylprednisolone. A bonemarrow aspirate revealed signs of an initial leukemic re-lapse that was treated with weekly vincristine and dailyoral 6-mercaptopurine, which led to a stable bone marrowblast count and the maintenance of normal peripheralhematometry.During cotrimoxazole treatment, the CT findings im-proved significantly but did not normalize, and the drugwas discontinued after 2 weeks because of patient refusal.On 7 October, the patient was discharged for personalreasons, and he continued taking oral cotrimoxazole at adaily dose of 3,840 mg. Two weeks later, a further CTscanshowed persistence of significant lung infiltrates.On 11 November, when the patient was admitted toundergoBMT,apositronemission tomography(PET)scanrevealed the presence of diffuse, active, alveolar disease(Fig. 1) and high-dose intravenous cotrimoxazole wasresumed. On 22 November, standard-dose caspofungin(70mgonthefirstday,followedby50mg/day)wasadded,and a conditioning regimen was started including thio-tepa (15 mg/kg divided into three equal doses on days −8and−7),andcyclophosphamide(50mg/kg/dayondays−4,−3 and −2). A bone marrow aspirate showed a raised butstable blast count. On 29 November, the CT findings wereunchanged, and cotrimoxazole was discontinued. On 30November, BMT was performed, with standard-dose cy-closporine-Aandmethotrexatebeingadministeredasgraft-versus-host disease prophylaxis. During pancytopenia,mixed Enterobacter/coagulase-negative Staphylococcusbacteremia was observed. Polymorphonuclear recoverywasachievedonpost-BMTday25,andplateletrecoveryonday 34, after being delayed by mild microangiopathichemolytic anemia responsive to defibrotide therapy. On22 December, a CT scan showed complete resolution ofthe lung infiltrates. On 5 January, caspofungin was dis-continued and a bone marrow aspirate showed completeremission and full donor chimerism. On 12 January thepatient was discharged. One month later, the leukemiarelapsed; a CTscan did not show any lung infiltrates.A diagnosis of PCP is frequently established in BMTrecipients,inwhomimmunodepressionmayplayaprimaryrole, and also in hematological patients receiving che-motherapy alone [1]. In such cases, cotrimoxazole mayinterfere with the possibility of delivering the subsequent

Transdermal fentanyl in HSCT patients: an open trial using transdermal fentanyl for the treatment of oral mucositis pain

Summary:Fentanyl is a synthetic opioid that can be delivered through a transdermal therapeutic system (TTS). The aim of this study was to assess the efficacy of fentanyl TTS in treating oral mucositis pain in 75 adult hematopoietic stem cell transplant (HSCT) patients. The analysis was based on 62 patients who developed mucositis. Pain control was assessed by the patients using a visual analogue scale (VAS) from day 0 to day +33 after HSCT. Fentanyl TTS was administered at the patients request. In all, 20 patients did not require fentanyl (group A). The first 22 patients asking for the patch received fentanyl 25 μg/h (group B) and the subsequent 20 patients received 50 μg/h (group C). There were no significant differences in pain relief between groups B and C. The expected effect of a decrease in mean pain score (mean of the VAS scores of all of the patients in the same group each day) following the application of fentanyl TTS was not noted. We can conclude that fentanyl TTS at the doses used in this study may not adequately relieve oral mucositis pain.

Fibrinogen milano. VI, A heterozygous dysfibrinogenemia (Aα 16 Arg → His) with bleeding tendency

Abstract: Congenital heterozygous dysfibrinogenemia was diagnosed in a young woman with bleeding tendency. 3 other asymptomatic members of her family (mother and the 2 sisters) had abnormal fibrinogen. The propositas plasma exhibited prolonged thrombin and reptilase times. Plasma fibrinogen concentration determined by functional assay was 0.3 g/l, whereas immunologic assay revealed normal fibrinogen levels. Turbidity curves, representing the rate of thrombin‐induced fibrin formation, were markedly delayed both in the presence and absence of Ca2+. Isoelectric focusing and SDS electrophoresis of reduced fibrinogen showed normal charge and size of the subunit chains. Release of fibrinopeptide B by thrombin was normal, whereas HPLC elution diagrams of fibrinopeptide A showed an abnormal peak A* with a slightly shorter retention time than the normal fibrinopeptide A. The amino acid analysis showed that the arginine in peak A* is replaced by histidine (Aα 16 Arg → His).

Histological alterations in bone marrow in patients with late engraftment after autologous bone marrow transplantation

Bone marrow histology after bone marrow transplantation has rarely been studied. Here, we reviewed the pre- and post-transplant bone marrow biopsies (BMB) of 40 acute myelogenous leukemia (AML) patients autografted in our center, 28 with normal and 12 with delayed peripheral recovery. The two groups were comparable in terms of previous therapy, disease phase and the number of infused cells, and received the same conditioning regimen. In the former group, reduced bone marrow cellularity and mild reticulin abnormalities were usual histological findings; in the latter, five patients had the same pattern, but the other seven had an almost undetectable hematopoietic parenchyma and severe reticulin derangement. One of these seven patients died of reactivated hepatitis B virus infection; the others eventually achieved peripheral recovery, with none of them experiencing a relapse. Autografted AML patients are excellent subjects for histological investigations. They account for the majority of delayed engraftments, the contribution of extramedullary components to the timing of engraftment is minimal, and leukemia relapse cannot be ruled out. These results suggest that BMB is a useful investigation in the work-up of late engraftment. A high degree of reticulin derangement with an almost undetectable hematopoietic parenchyma appear to be the morphological hallmarks of late engraftment. Bone Marrow Transplantation (2000) 25, 837–841.