Akin Uysal

Mobilization of peripheral blood stem cells with chemotherapy and recombinant human granulocyte colony-stimulating factor (rhG-CSF): a randomized evaluation of different doses of rhG-CSF.

Summary. To date, no randomized study has compared different doses of recombinant human granulocyte colony‐stimulating factor (rhG‐CSF) following submyeloablative mobilization chemotherapy. Therefore, we evaluated the effect of different doses of rhG‐CSF following mobilization chemotherapy on yields of CD34+ peripheral blood stem cells (PBSC). Fifty patients were randomized to receive 8 (n = 25) versus 16 µg/kg/d (n = 25) of rhG‐CSF following mobilization chemotherapy. The median number of CD34+ cells collected after 8 µg/kg/d of rhG‐CSF was 2·36 × 106/kg (range, 0·21–7·80), compared with 7·99 (2·76–14·89) after 16 µg/kg/d (P < 0·001). Twenty out of 25 (80%) patients in the low‐dose and 23 out of 25 (92%) in the high‐dose rhG‐CSF arm underwent high‐dose chemotherapy (HDC) and autologous stem cell transplantation (ASCT). Median days to white blood cell engraftment in patients mobilized with 8 µg/kg and 16 µg/kg of rhG‐CSF were 12 (10–20) and 9 (8–11) respectively (P < 0·001). There was no difference between the two groups regarding the other parameters of peritransplant morbidity: days to platelet engraftment (P = 0·10), number of red blood cell (P = 0·56) and platelet transfusions (P = 0·22), days of total parenteral nutrition requirement (P = 0·84), fever (P = 0·93) and antibiotics (P = 0·77), and number of different antibiotics used (P = 0·58). These data showed that higher doses of rhG‐CSF following submyeloablative mobilization chemotherapy were associated with a clear dose–response effect based on the collected cell yields. Based on the parameters of peritransplant morbidity, 8 µg/kg/d was as effective as 16 µg/kg/d except for a rapid neutrophil engraftment in the high‐dose arm. Therefore, in routine clinical practice, despite some advantage in the use of higher doses of rhG‐CSF, lower doses may be used for PBSC collections following chemotherapy‐based mobilization regimens in this cost‐conscious era.

Hepatitis B virus infection in allogeneic bone marrow transplantation

Fourty-four patients who underwent allogeneic bone marrow transplantation (alloBMT) were studied for hepatitis B virus (HBV)-related complications. The mean follow-up period was 15.3 months. Positivity for HBV surface antigen (HBsAg) was observed in 10 patients (22.7%) throughout the study. Four of the 10 patients were HBsAg carriers before alloBMT, while the remaining six became HBsAg(+) after alloBMT. During the follow-up period (from 6 months to 45 months), an elevation in serum ALT activity was observed in the four carriers when immunosuppression was reduced or withdrawn. All of the four HBsAg carriers developed hepatitis, but none of them died of liver failure due to HBV. Only one death due to GVHD and diabetic ketoacidosis was observed in this group. Two of the four carriers received marrow from anti-HBs positive donors and one of them cleared HBsAg from his serum via adoptive immunity 8 months after transplantation. The remaining six patients acquired HBV after alloBMT, but we were unable to demonstrate the source of HBV. Five of them had a moderate increase in serum ALT activity while the other patient had a normal ALT. Two patients seroconverted to anti-HBs spontaneously. Two patients died during the follow-up, one due to intracranial hemorrhage and the other due to GVHD and accompanying pulmonary infection. The rest of the study group (34 patients) remained HBsAg(−) throughout the study. Two of them had an HBsAg(+) donor, but neither developed HBV infection in their follow-up period. The acquisition rate of HBV infection was relatively low in recipients who were positive for anti-HBs compared to those who were negative for anti-HBs (8 vs 19%). Anti-HBs positivity remained for a longer period in recipients who received marrow from anti-HBs positive donors compared to those recipients who had anti-HBs negative donors (median 12 vs 3 months). We think that HBV is a frequent cause of liver dysfunction in alloBMT patients where HBV infection is endemic. Whether the disease is in the form of reactivation of HBsAg-positive recipients, or is acquired from unknown sources in recipients who never had contact with the virus, the course of the disease is not fatal. Silent serologic changes can be demonstrated if viral serologic markers are sought serially. Among them, the disappearance of serum anti-HBs may be important as it increases the risk of HBV contamination in recipients.

The impact of the CD34+ cell dose on engraftment in allogeneic peripheral blood stem cell transplantation.

Forty-five patients who underwent allogeneic peripheral blood stem cell transplantation (PBSCT) were evaluated in order to investigate any relationship between CD34+ cell dose given and hematological recovery. Granulocyte counts > 1.0 x 10(9)/L and platelet > 50 x 10(9)/L were considered as hematological recovery. Three different regimens were used for mobilization, by adjusting the recombinant granulocyte colony stimulating factor (rhG-CSF, Roche) dose. The first group (n = 3), whose donors mobilized with 5 micrograms/kg/d s.c. rhG-CSF received a mean of 5.9 x 10(6)/kg (95% confidence interval for mean (CI); 2.4-9.3) CD34+ cells. The second group (n = 37), mobilized with 10 micrograms/kg/d s.c. rhG-CSF and the third group (n = 5) mobilized with 15 micrograms/kg/d s.c. rhG-CSF, received a mean of 5.7 x 10(6)/kg (95% CI; 4.6-6.75) and 6.56 x 10(6)/kg (95% CI; 4.57-8.55) CD34+ cells, respectively. CD34+ cell dose was 5.82 x 10(6)/kg (95% CI; 4.97-6.68) for all the patients. All patients received rhG-CSF from day +1 until attaining granulocyte count > 1.0 x 10(9)/L for three consecutive days. Median granulocyte and platelet engraftment days for the whole group was 15 (range; 11-44) and 14 (11-54) days respectively. There was a close correlation (r = -0.301, p < 0.05) between the CD34+ cell dose and granulocyte recovery for the whole group. When these analyses were performed separately within groups, this correlation was also found significant for the first group (r = -0.99, p < 0.05) for granulocyte recovery. On the contrary the same analysis did not reach significance for the other groups, nor for platelet recovery for the whole group (r = 0.039, p = 0.821). We calculated a minimum dose of 4 x 10(6)/kg CD34+ cells for a safe alloPBSCT. There was no difference between patients who received more than 5 x 10(6)/kg CD34+ cells, and those who received more than 2 x 10(6)/kg and less than 5 x 10(6)/kg CD34+ cells. In conclusion, we have demonstrated a correlation between the CD34+ cell dose given and faster hematological recovery for alloPBSCT patients.

Molecular alterations in the TP53 gene of peripheral blood cells of patients with chronic myeloid leukemia

The TP53 gene has been extensively studied in patients with chronic myeloid leukemia (CML), both in chronic phase and in blast crisis. Mutations in the gene were found in up to 30% of the patients, especially among those in blast crisis. We report the results of an analysis of 29 blood samples from CML patients: 8 samples from chronic phase patients, 8 from patients in the accelerated phase, and 13 from patients in blast crisis. By using genomic DNA, we sequenced PCR products of the coding exons and most introns of the TP53 gene, finding genetic changes in 30% of the blast crisis samples and 12% in chronic phase. All mutations were found in introns and were previously unreported. Immunocytochemical studies revealed accumulation of TP53 in blood cells of samples both from chronic phase and blast crisis patients. Since these samples had no TP53 mutations, we believe that wild type TP53 accumulates in blood cells of CML patients. Our results, therefore, indicate that molecular changes in coding regions of the TP53 gene are rare. The significance of the abundance of intronic changes should be investigated further. Accumulation of wild type TP53 in CML cells may indicate an additional mechanism involving this gene in the pathogenesis of this disease. Genes Chromosomes Cancer 21:2–7, 1998.

Recombinant human granulocyte colony-stimulating factor (rh-G-CSF) may accelerate hematopoietic recovery after HLA-identical sibling allogeneic peripheral blood stem cell transplantation.

We studied the effects of recombinant human granulocyte colony-stimulating factor (G-CSF) on hematopoietic recovery and clinical outcome in patients undergoing allogeneic peripheral blood stem cell (PBSC) transplantation. Fifty-six patients with hematological malignancies who underwent allogeneic PBSC transplantation between 1995 and 1998 were entered into this study. Twenty-eight patients who received daily G-CSF from day +1 after allogeneic PBSC transplantation until the absolute neutrophil count (ANC) reached >0.5 × 109/l for 3 consecutive days were compared with 28 patients (control group) who did not receive G-CSF in a non-randomized manner. The study group and the control group were comparable with respect to baseline patient and transplantation characteristics. Median times to ANC of >0.5 × 109/l and 1 × 109/l with or without G-CSF were 12 days (range 8–21), 13 days (10–32) (P = 0.04) and 13 days (9–21), 15 days (11–44) (P = 0.02), respectively. Median times to reach a platelet count of >20 × 109/l with and without G-CSF were 11 days (0–20) and 13 days (9–26), respectively (P = 0.03). The incidence of febrile episodes was significantly lower with G-CSF, 75% vs 100% (P = 0.008). Patients receiving G-CSF had less grade III–IV mucositis than those who did not receive G-CSF (P = 0.01). There was also no increase in the incidence and severity of acute GVHD in patients using G-CSF (P = 0.22). Although the number of relapsing patients was greater in the G-CSF group (seven vs three patients), this was not statistically significant (P = 0.24). Disease-free and overall survival rates did not differ between the two groups (P = 0.58 and 0.53, respectively). The administration of G-CSF after allogeneic PBSC transplantation provided faster neutrophil and platelet engraftment associated with less severe mucositis and less febrile episodes. Bone Marrow Transplantation (2001) 27, 499–505.

Acute myeloblastic leukemia associated with hyperleukocytosis and diabetes insipidus

Two cases with acute myeloblastic leukemia (AML M4-FAB) associated with diabetes insipidus (DI) are presented here. Both patients presented with hyperleucocytosis. One had a white blood cell count (WBC) of 150 x 10(9)/L and the second patient had 200 x 10(9)/L. One of these patients was a 40 year-old male and MRI of the hypophysis showed an infindibuler mass. This patient did not respond to remission induction chemotherapy and reinduction chemotherapy was given. The other patient was a 16-year-old male with a normal CT scan of the head. Both patients had DI with typical clinical and laboratory findings. The first patient died early on during reinduction chemotherapy and the second patient died of intracranial bleeding before induction chemotherapy was given. These findings are consistent with the data in the literature suggesting that the prognosis of AML associated with DI is poor and that these cases generally present with hyperleucocytosis.

An Unusual Presentation of Plasma Cell Dyscrasias: Cardiac Tamponade due to Myelomatous Infiltration

Pericardial involvement, a rare complication of multiple myeloma (MM), is caused by amyloidosis, infections, bleeding abnormalities or plasma cell infiltration, usually at a late or terminal stage of the disease. Three cases of MM with pericardial involvement are reported here and discussed in the light of current literature. In a retrospective review of all patients with MM at two institutions, three cases of pericardial involvement were identified. In one case, we were able to obtain cytospin preparations of the pericardiocentesis fluid. In the remaining two patients, the pericardial biopsy specimen was obtained via a pericardial window. All patients had progressive dyspnea and signs of pericardial tamponade. The pericardiocentesis fluid showed infiltration with plasma cells in one of the three patients, who had a progressive and fatal course. In the second patient pericardial invasion was proven by biopsy and the third was diagnosed with a plasma cell leukemia but developed a pericardial effusion demonstrated by pericardial biopsy. All these three patients died of progressive disease without any response to chemotherapy and supportive measures. In conclusion, optimal treatment for malignant involvement of the pericardium by myeloma cells has not yet been established and is often fatal.

A phase I dose escalation study of high-dose thiotepa, melphalan and carboplatin (TMCb) followed by autologous peripheral blood stem cell transplantation (PBSCT) in patients with solid tumors and hematologic malignancies.

The purpose of this study was to determine the maximum tolerated dose of carboplatin administered with 500 mg/m2 thiotepa and 100 mg/m2melphalan followed by autologous peripheral blood stem cell (PBSC) infusion in patients with refractory malignancies. Twenty-eight patients with refractory malignancies received high-dose thiotepa (500 mg/m2, melphalan (100 mg/m2) and escalating doses of carboplatin 900–1500 mg/m2) followed by infusion of cryopreserved autologous PBSCs. The maximum tolerated doses were determined to be 500 mg/m2 thiotepa, 100 mg/m2 melphalan and 1350 mg/m2 carboplatin. Two consecutive patients receiving 1500 mg/m2 carboplatin experienced grade 3 mucositis and colitis. Ten patients were enrolled at the maximum tolerated dose and none had grade 3–4 regimen-related toxicity and mortality. All patients at this level experienced grade 1–2 mucositis, 90% grade 1–2 gastrointestinal toxicity, 30% grade 1–2 cardiac and renal toxicity, and 10% experienced grade 1 hepatic toxicity. The median time to achieve a granulocyte count of 0.5 × 109/l was 9 days (range 7–12 days) and platelet count of 20 × 109/l was 10 days (range 7–15 days). Of eight patients with stage IV refractory breast cancer, even were evaluable for response, one patient on day 75 will be evaluated soon. Five of seven (71.5%) evaluable patients achieved a complete remission (CR) and two had no response. Of seven patients with non-Hodgkins lymphoma (n = 4) or Hodgkins disease (n = 3), five achieved a CR (71.5%). Thiotepa, melphalan and carboplatin can be administered in high doses with tolerable mucositis as the major side-effect. This combination has significant activity in patients with breast cancer, and phase II studies in patients with breast cancer and other chemotherapy-sensitive malignancies are warranted. Bone Marrow Transplantation (2000) 25 , 697–703.

Soluble adhesion molecules (sICAM-1, sL-Selectin, sE-Selectin, sCD44) in healthy allogenic peripheral stem-cell donors primed with recombinant G-CSF

BACKGROUND We analysed the effects of rhG-CSF (Amgen-Roche, USA) on serum changes of four soluble adhesion molecules (SAM) (sICAM-1, sL-Selectin, sE-Selectin and sCD44) in healthy peripheral allogeneic stem-cell transplantation donors and their correlation with acute GvHD and effect on engraftment kinetics. METHODS Serum SAM of 15 consecutive healthy HLA identical-sibling donors (median age 30 years, male:female ratio, 7:8) were monitored using a commercial ELISA Kit (Bender Med, Austria) prior to, on the day of first apheresis and 24 h after the cessation of rhG-CSF (10 microg/kg/day s.c. on 5 days) administration. Leukapheresis was started on the fifth day of rhG-CSF administration, using a continuous-flow blood separator (Cobe Spectra, COBE BCT, Inc, Lakewood, CO). Apheresis cycles were continued daily until a target of 4.0 x 10(6) CD34(+) cells/kg was reached. RESULTS The results indicate a steady rise of sL-Selectin, sE-Selectin, and sCD44, but not of sICAM-1. Median number of mononuclear cells (MNC) and CD34(+) cells transfused were 7.7x 10(8)/kg and 6.0 x 10(6)/kg, respectively. There was a near-significant correlation between the sL-Selectin levels and CD34(+) cell yield (r = 0.49, 0.06). Median granulocyte and platelet engraftment days were 11 (10-18) and 12 (9-33), respectively. There was a significant inverse correlation between the CD34(+) cell dose and granulocyte levels (r = -0.68, p = 0.022), but not for platelet engraftment. The only correlation between SAM levels and engraftment was for sICAM-1 levels. Increasing sICAM-1 levels were a sign of prolonged neutropenia (r = 0.72, p = 0.011). No correlation between the apheresis day serum levels of adhesion molecules and acute GvHD was documented. DISCUSSION Analysis of sICAM-1, sL-Selectin, sE-Selectin and sCD44 levels during allogeneic PBSC apheresis did not reveal any significant effect on engraftment and GvHD, except the correlation of sL-Selectin levels and collected CD34(+) cells. More research and data about the role of not only SAM levels, but also antigenic expression of SAM are required to enlighten leukocyte-endothelial cell interactions and egress of stem cells during G-CSF administration.

Allogeneic peripheral blood stem cell transplantation in acute non-lymphoblastic leukemia.

Unmodified allogeneic peripheral blood stem cell transplantation (alloPBSCT) was performed in 20 consecutive acute non‐lymphoblastic leukemia (ANLL) patients from their HLA‐identical siblings. There were 11 males and 9 females. Median age was 34 years (range 17–43). Donors were primed with 2·5–15 μg/kg/day s.c. granulocyte‐colony stimulating factor (G‐CSF, Neupogen, Roche). Conditioning regimen was Bu (16 mg/kg)+Cy (120 mg/kg) in 19 patients and high dose Ara‐C (3 gr/m2 twice daily for 3 days) for one patient who relapsed after bone marrow transplantation. Eighteen patients were in CR1. CsA+short‐term MTX (n=19) or CsA alone (n=1) were used for graft versus host disease (GVHD) prophylaxis. The median number of apheresis procedures for each patient was 2 (2–4). A median of 6·5 (3·2–38·2)×108/kg MNC or 9·4 (2·2–12·4)×106/kg CD34+cells were given. Median days to reach granulocyte of >0·5×109/l and platelet of >50×109/l were 12 (10–14) and 15 (11–35) respectively. Day 100 transplant‐related mortality was 20 per cent (4/20). Grade 2 to 4 AGVHD was seen in 8 out of 17 (47%) evaluable patients. Severe AGVHD occurred in 3 out of 17 (18%). Clinical CGVHD of all grades developed in 12 out of 17 (70%) evaluable patients. The mean disease‐free survival and overall survival were 17 (range: 8–33 months) and 18 months (range: 10–34 months), respectively. In conclusion, alloPBSCT in ANLL is associated with a faster engraftment, no greater incidence of AGVHD, but increased risk of CGVHD. Copyright