Dahlia Kirkpatrick

TRANSPLANTATION FOR ACUTE LEUKAEMIA WITH HLA-A AND B NONIDENTICAL PARENTAL MARROW CELLS FRACTIONATED WITH SOYBEAN AGGLUTININ AND SHEEP RED BLOOD CELLS

A new procedure for enrichment of marrow precursors and removal of T lymphocytes from large volumes of human bone marrow, involving initial differential agglutination of T lymphocytes and mature marrow elements with soybean agglutinin, followed by rosetting with sheep red blood cells, was used to fractionate marrow cells from an HLA-A, B, DR non-identical, MLC non-reactive, paternal donor for transplantation into an infant with acute leukaemia. This transplant became completely engrafted and resulted in full recovery of normal, donor-derived haematopoietic function without graft-versus-host disease, sustained for 11 weeks after transplantation, at which time the patients leukaemia recurred. Subsequently, the patient received chemotherapy and achieved a remission with regeneration of normal marrow cells of donor origin. The patients course demonstrated the potential of lectin-separated marrow grafts to restore durable haematopoiesis, without graft versus host disease, in a lethally irradiated allogeneic host.

Identification by HLA Typing of Intrauterine-Derived Maternal T Cells in Four Patients with Severe Combined Immunodeficiency

AFTER our initial observation in 1978 of engraftment of nonfunctional intrauterine-derived maternal T cells in a patient with severe combined immunodeficiency without graft-versus-host disease,1 , ...

Hyperfractionated total body irradiation for bone marrow transplantation: I. Early results in leukemia patients.

Abstract Bone marrow transplantation following cytoreduction with total body irradiation and cyclopbospbamide has previously been shown to be of value in treating refractory leukemias. Major problems, however, have been fatal interstitial pneumonitis and leukmmac relapse. In an attempt to minimize these problems, we initiated a new hyperfractionsted regimen for total body irradiation, with partial long sparing. From May, 1979 throughJuly, 1980, we treated 48 leukemia patients according to this regimen, varying in age from 1.5 to 42 years old (mead age: 18 y). Analysis in September, 1980, with follow-up from 2–16 mos, showed that we have a significantly reduced incidence of interstitial pneumonitis compared with single dose (1000 rad) irradiation (33 vs 70%), as well as decreased deaths attributable to interstitial pneumonitis (23 vs 50%). This is reflected in the survival curves, with loss of the early drop in survival previously observed with single dose irradiation. One year actuarial survival was 65% for acute lympbocytic leukemia (n - 16) and 72% for acute non-lymphocytic leukemia (n - 29). This compares with only 17% for acute non-lympbocytic leukemia patients (n = 12) on our previous single dose regimen. Age was: also found to be an important parameter for both survival and interstitial pneumonitis.

Hyperfractionated total body irradiation for bone marrow transplantation. results in seventy leukemia patients with allogeneic transplants

From May, 1979 to March, 1981, 76 leukemia patients were prepared for bone marrow transplantation (BMT) with a new hyperfractionated total body irradiation (TBI) regimen (1320 cGy in 11 fractions, 3x/day), followed by cyclophosphamide, 60 mg/kg, for two days. Partial lung shielding was done on each treatment, with supplemental electron beam treatments of the chest wall to compensate, and of the testes, a sanctuary site. This regimen was initiated to potentially reduce fatal interstitial pneumonitis as well as decrease leukemic relapse. These patients were analyzed in May, 1982, for a minimum follow-up of 14 months. Overall actuarial survival at 1 year for acute non-lymphocytic leukemia (ANLL) patients is 63%, while relapse-free survival at 1 year is 53%. For those ANLL patients who underwent BMT while in remission (first, second, and third combined), relapse-free survival is 61% at 1 year compared with 40% for those patients who had their BMT at the time of relapse (greater than or equal to 10% blasts in marrow). On the other hand, for acute lymphocytic leukemia (ALL) patients, there is no significant difference between relapse or remission patients with regard to overall survival or relapse-free survival, when relapse is defined as greater than 5% blasts in the marrow at the time of cytoreduction. Overall actuarial survival at 1 year for ALL is 61% and relapse-free survival is 45% at 1 year. Patients with ALL who had their BMT cytoreduction at the time of relapse have a survival equal to that of our remission patients, and greater than that of patients in relapse cytoreduced with a single dose as reported by others. However, patients with greater than or equal to 10% blasts have not fared as well, having only a 22% 1 year relapse-free survival compared with a 68% 1 year relapse-free survival for patients with less than 10% blasts. Fatal interstitial pneumonitis has dropped to 18% compared with 50% in our previous single-dose TBI regimen (1000 cGy), in which the same doses of cyclophosphamide were given prior to TBI. In conclusion, not only has fatal interstitial pneumonitis been reduced by hyperfractionation and partial lung blocking, but there may be a survival advantage in ALL patients in relapse, who have a survival equal to that of remission patients. This may indicate a greater cell kill with the higher dose (1320 cGy) attained with this regimen, in these patients with a higher leukemic cell burden.

Marrow transplantation for juvenile osteopetrosis

Two children with the juvenile form of osteopetrosis were treated with marrow transplants from their HLA identical siblings. Following transplantation each child exhibited extensive bone reabsorption with a marked augmentation of osteoclastic function attributable to donor osteoclasts, including remodeling of bone with expansion of intramedullary hematopoiesis and correction of associated abnormalities of thymic factor and natural killer cells. Osteopetrosis ultimately recurred in one patient in whom engraftment of donor hematopoietic elements was not achieved. Our studies indicate that marrow transplantation will correct osteopetrosis but that permanent reconstitution necessitates sustained engraftment of marrow precursors of cells with osteoclastic activity.

ABH INCOMPATIBLE BONE MARROW TRANSPLANTATION: REMOVAL OF ERYTHROCYTES BY STARCH SEDIMENTATION

Summary. Nineteen patients with acute leukaemia underwent bone marrow transplantation despite major ABH incompatibility between donor and recipient. The marrow inoculum was prepared prior to infusion by admixture with hydroxy‐ethyl starch to sediment the incompatible erythrocytes, which were then discarded. The infusion was well tolerated with two patients developing transient haemoglobinuria, seven patients developing low grade fever and 10 experiencing no reaction. Durable haematopoietic engraftment was achieved in the 18 evaluable patients and was not influenced by pre‐transplant isohaemagglutinin titres. No difference in time to engraftment, incidence of GVHD or in overall survival was found, compared to ABH compatible transplants. Therefore, the presence of incompatibility did not appear to influence transplant outcome adversely. The technique described is a rapid and safe method for overcoming the ABH barrier in marrow transplantation.

ASSOCIATION BETWEEN PRE-TRANSPLANT NATURAL KILL AND GRAFT-VERSUS-HOST DISEASE AFTER STEM-CELL TRANSPLANTATION

Natural killer activity against herpes simplex virus type 1 infected fibroblasts NK(HSV-1) was studied prospectively in patients undergoing allogenic bone-marrow or fetal-tissue stem-cell transplantation. Thirteen patients showed evidence of engraftment and survived long enough to develop graft-versus-host disease (GvHD). Of this group, all of the seven having normal NK(HSV-1) activity before transplantation acquired GvHD and the six having low NK(HSV-1) had no evidence of GvHD. These results were independent of mode of preparation of patients for transplantation, source of stem cells used, or cytomegalovirus infections, and they suggest that this assay reflects a host-determined function capable of stimulating GvHD.

Evaluation of HLA‐Haplotype Disparate Parental Marrow Grafts Depleted of T Lymphocytes by Differential Agglutination with a Soybean Lectin and E‐Rosette Depletion for the Treatment of Severe Combined Immunodeficiency

Abstract. The factors that impact upon successful bone marrow transplantation leading to immunologic reconstitution in severe combined immune deficiency (SCID), Wiskott‐Aldrich syndrome, and in other lethal congenital immunodeficiencies are reviewed. Evidence is presented that graft‐versus‐host disease (GVHD) can be abrogated by the depletion of T cells, even from histoincompatible marrow grafts. However, graft resistance or restricted immune reconstitution has been observed with significant frequency. The bases for T cell reconstitution and limitations in B cell humoral immune recovery in the postgrafting period are reviewed, together with emerging evidence that pretransplant cytoreduction might obviate some of these problems.

Effect of procarbazine and cyclophosphamide on chromosome breakage in Fanconi anemia cells: Relevance to bone marrow transplantation

Fanconi anemia (FA) patients develop stem cell defect-based pancytopenia for which bone marrow transplantation offers the potential for correction. Recently, it has become apparent that the outcome of marrow transplantation in FA patients is poor because of the hypersensitivity of these patients to the pretransplantation conditioning regimen which includes immunosuppression with high doses of the difunctional alkylating agent cyclophosphamide. In an effort to devise a less toxic immunosuppressive regimen, we compared the clastogenic effect of cyclophosphamide with that of procarbazine in cells from FA patients and normal controls. Activation of the drugs was achieved by two alternative methods, either by injection into rats (the in vivo activation method) or by incubation with a rat-liver microsome system (the in vitro activation method). Increased sister chromatid exchange following treatment of cells with cyclophosphamide or procarbazine was used as an indicator for the presence of activated drug metabolites in the system. Although FA cells were hypersensitive to the clastogenic effect of cyclophosphamide, they were not more sensitive than normal cell to procarbazine-induced chromosome breakage. Procarbazine may thus be a safer drug than cyclophosphamide for conditioning FA patients for bone marrow transplantation.

Natural killer cell function and interferon generation in patients with primary immunodeficiencies

Patients with primary immunodeficiency disorders were evaluated for three aspects of natural defense: natural killer (NK) cells which lyse HSV-infected fibroblasts [NK(HSV-FS)], NK cells which lyse K562 tumor targets [NK(K562)], and interferon-alpha generation. In addition, capacity to make interferon upon challenge with other commonly used inducers was also evaluated. Most patients with severe combined immunodeficiency disease (SCID) and deficits of both T- and B-cell function demonstrated normal NK function with one or both targets. Six of eight SCID patients generated interferon-alpha at or below the lower limit of normal while only two made clearly normal levels. Six of 10 patients with Wiskott-Aldrich syndrome (WAS) had normal NK(K562) and five of 10 generated normal levels of interferon-alpha but all had severely deficient NK(HSV-FS). Patients with Brutons agammaglobulinemia demonstrated normal NK and interferon generation, as did patients with common variable immunodeficiency, even when subdivided into patients with T-cell proliferative deficiencies and those with only hypogammaglobulinemia. Natural defense parameters may help categorize patients with SCID and WAS and help define these heterogeneous diseases.