Doney K

Methotrexate and Cyclosporine Compared with Cyclosporine Alone for Prophylaxis of Acute Graft versus Host Disease after Marrow Transplantation for Leukemia

We treated 93 patients who had acute nonlymphoblastic leukemia in the first remission or chronic myelocytic leukemia in the chronic phase (median age, 30 years) with high-dose cyclophosphamide and fractionated total-body irradiation, followed by infusion of marrow from an HLA-identical sibling. To evaluate postgrafting prophylaxis for graft versus host disease, we studied these patients in a sequential, prospective, randomized trial that compared the effect of a combination of methotrexate and cyclosporine (n = 43) with that of cyclosporine alone (n = 50). All patients had evidence of sustained engraftment. A significant reduction in the cumulative incidence of grades II to IV acute graft versus host disease was observed in the patients who received both methotrexate and cyclosporine (33 percent), as compared with those who were given cyclosporine alone (54 percent) (P = 0.014). Seven patients who received cyclosporine alone acquired grade IV acute graft versus host disease, as compared with none who received both methotrexate and cyclosporine. Thirty-five of the 43 patients given both methotrexate and cyclosporine and 31 of the 50 patients given cyclosporine are alive as of this writing, at 4 months to 2 years (median, 15 months); the actuarial survival rates in the two groups at 1.5 years were 80 percent and 55 percent, respectively (P = 0.042). We conclude that the combination of methotrexate and cyclosporine is superior to cyclosporine alone in the prevention of acute graft versus host disease after marrow transplantation for leukemia, and that this therapy may have a beneficial effect on long-term survival.

Effect of HLA Compatibility on Engraftment of Bone Marrow Transplants in Patients with Leukemia or Lymphoma

We analyzed the relevance of HLA compatibility to sustained marrow engraftment in 269 patients with hematologic neoplasms who underwent bone marrow transplantations. Each patient received marrow from a family member who shared one HLA haplotype with the patient but differed to a variable degree for the HLA-A, B, and D antigens of the haplotype not shared. These 269 patients were compared with 930 patients who received marrow from siblings with identical HLA genotypes. All patients were treated with cyclophosphamide and total-body irradiation followed by the infusion of unmodified donor marrow cells. The rate of graft failure was 12.3 percent among the recipients of marrow from a donor with only one identical haplotype, as compared with 2.0 percent among recipients of marrow from a sibling with the same HLA genotype (both haplotypes inherited from the same parents) (P less than 0.0001). The incidence of graft failure correlated with the degree of donor HLA incompatibility. Graft failure occurred in 3 of 43 transplants (7 percent) from donors who were phenotypically HLA-matched with their recipient (haplotypes similar, but not inherited from the same parents), in 11 of 121 donors (9 percent) incompatible for one HLA locus, in 18 of 86 (21 percent) incompatible for two loci, and in 1 of 19 (5 percent) incompatible for three loci (P = 0.028). In a multivariate binary logistic regression analysis, independent risk factors associated with graft failure were donor incompatibility for HLA-B and D (relative risk = 2.1; 95 percent confidence interval, 1.7 to 2.5; P = 0.0004) and a positive crossmatch for anti-donor lymphocytotoxic antibody (relative risk = 2.3; 95 percent confidence interval, 1.8 to 2.8; P = 0.0038). Residual host lymphocytes were detected in 11 of 14 patients with graft failure, suggesting that the mechanism for graft failure could be host-mediated immune rejection. We conclude that donor HLA incompatibility and prior alloimmunization are significant risk factors for graft failure, and that a more effective immunosuppressive regimen than those currently used is needed for consistent achievement of sustained engraftment of marrow transplanted from donors who are not HLA-identical siblings.

Marrow Transplantation for the Treatment of Chronic Myelogenous Leukemia

One hundred ninety-eight patients with chronic myelogenous leukemia received marrow transplants after intensive chemotherapy and total body irradiation. Multivariate analysis showed disease status at time of transplantation to be the most powerful predictor of survival. The probability of long-term survival for allogeneic graft recipients was 49% for 67 patients in the first chronic phase, 58% for 12 in the second chronic phase, 15% for 46 in the accelerated phase, and 14% for 42 in the blastic phase. The major cause of death was interstitial pneumonia for patients in the chronic phase, and relapse for those in the blastic or accelerated phases. Factors favoring survival were early transplantation, age less than 30 years, and absence of severe graft-versus-host disease. Splenectomy or spleen size did not influence survival. For recipients of syngeneic grafts survival probability was 87% for 16 patients in the chronic phase, 27% for 7 in the accelerated phase, and 12% for 8 in the blastic phase. Of the 198 patients, 71 are alive without Philadelphia chromosomes 1 to 9 years after receiving their graft. All but 4 long-term disease-free survivors have Karnofsky performance scores of 80% or better.

Graft-versus-host disease and survival in patients with aplastic anemia treated by marrow grafts from HLA-identical siblings. Beneficial effect of a protective environment

One hundred thirty patients with severe aplastic anemia were conditioned with cyclophosphamide for transplantation of marrow from HLA-identical siblings. The patients were selected for the present analysis according to the criterion of sustained marrow engraftment. Of the 130 patients, 97 are now alive between 1.4 and 11 years (median, 5) after transplantation. Twenty-nine of the thirty-three who died had either acute or chronic graft-versus-host disease (GVHD). Our analysis was directed at identifying factors predicting GVHD and survival after transplantation in patients. Our key findings were that moderately severe to severe acute GVHD had a strong adverse influence on survival; that a protective environment significantly reduced mortality, which corresponded in part to a reduction in and delayed onset of acute GVHD; that refractoriness to random-donor platelet infusions at transplantation adversely influenced survival, particularly among patients with acute GVHD; and that increasing age was associated with increased mortality.

Secondary cancers after bone marrow transplantation for leukemia or aplastic anemia

To determine the incidence of secondary cancers after bone marrow transplantation, we reviewed the records of all patients at our center who received allogeneic, syngeneic, or autologous transplants for leukemia (n = 1926) or aplastic anemia (n = 320). Thirty-five patients were given a diagnosis of secondary cancer between 1.5 months and 13.9 years (median, 1.0 year) after transplantation. Sixteen patients had non-Hodgkins lymphomas, 6 had leukemias, and 13 had solid tumors (including 3 each with glioblastoma, melanoma, and squamous-cell carcinoma). There were 1.2 secondary cancers per 100 exposure-years during the first year after transplantation (95 percent confidence interval, 0.7 to 2.0). The rate declined to 0.4 (95 percent confidence interval, 0.2 to 0.7) after one year. The age-adjusted incidence of secondary cancer was 6.69 times higher than that of primary cancer in the general population. In a multivariate model, the predictors (and relative risks) of any type of secondary cancer were acute graft-versus-host disease treated with either antithymocyte globulin (relative risk, 4.2) or an anti-CD3 monoclonal antibody (13.6) and total-body irradiation (3.9). Two additional factors were associated with secondary non-Hodgkins lymphomas: T-lymphocyte depletion of donor marrow (12.4) and HLA mismatch (3.8). We conclude that recipients of bone marrow transplantation have a low but significant risk of a secondary cancer, particularly non-Hodgkins lymphoma.

Ovarian function following marrow transplantation for aplastic anemia or leukemia.

One hundred eighty-seven women between 13 and 49 years of age had ovarian function evaluated from 1 to 15 years (median, 4) after marrow transplant for aplastic anemia or leukemia. Among 43 women transplanted for aplastic anemia following 200 mg/kg cyclophosphamide (CY), all 27 less than 26 years of age, but only five of 16 greater than 26 years of age recovered normal ovarian function. Nine of the 43 have had 12 pregnancies, resulting in eight live births, and two elective and two spontaneous abortions. All eight children are normal. Nine of 144 women transplanted for leukemia following 120 mg/kg CY and 9.20 to 15.75 Gy total body irradiation (TBI) recovered ovarian function. Two of these nine have had three pregnancies, resulting in two spontaneous and one elective abortion. The probability of having ovarian failure was 0.35 by 7 years for patients receiving CY alone and was 1.00 at 1 year for patients receiving CY plus TBI (P less than .0001). By 7 years after transplant the probabilities of having normal ovarian function were 0.92 after CY alone and 0.24 after CY plus TBI (P less than .0001). Multivariate analysis showed that TBI was the only factor significantly influencing ovarian failure and that both TBI and greater patient age at transplant were significantly associated with a decreased probability of recovering normal ovarian function. These data demonstrate that after high-dose CY, recovery of ovarian function occurs in younger women and in a minority of older women, but after CY and TBI, recovery occurs in only a few younger women and none of the older women.

Predictive Factors in Chronic Graft-Versus-Host Disease in Patients with Aplastic Anemia Treated by Marrow Transplantation from HLA-Identical Siblings

One hundred ten of 175 patients with aplastic anemia conditioned by cyclophosphamide had sustained engraftment of marrow from human leukocyte antigen (HLA)-identical siblings and lived for more than 6 months. Forty-nine of the 110 patients developed chronic graft-versus-host disease between 85 and 464 days. Ninety-seven patients are alive from 1.4 to 11 years after engraftment; 13 died between 208 and 726 days. Twenty of the 36 surviving patients with chronic graft-versus-host disease have Karnofsky performance scores of 100%, 7 of 90%, 5 of 80%, 1 of 70%, 2 of 60%, and 1 of 40%. Our analysis, using a binary logistic regression model, identified three factors predicting chronic graft-versus-host disease: moderate to severe acute graft-versus-host disease with an estimated relative risk of 11.65; increasing patient age; and the use of viable donor buffy coat cells in addition to the marrow to prevent graft rejection. The last two factors were significant only in patients without acute graft-versus-host disease.

Factors associated with graft rejection after HLA-identical marrow transplantation for aplastic anaemia

Summary. One hundred and seventy‐five consecutive patients with severe aplastic anaemia were given high‐dose cyclophosphamide followed by marrow grafts from healthy, HLA‐identical family members, and 168 lived long enough to show engraftment. In 38 patients the graft was rejected and 29 of these died. This analysis, using a binary logistic regression model, was aimed at identifying factors that predicted marrow graft rejection. Five factors correlated with graft rejection: (1) previous blood transfusion; (2) a positive relative response in mixed leucocyte culture indicating sensitization of patient against donor; (3) a low number of marrow cells used for transplantation; (4) marrow grafts from male donors; and (5) lack of infusion of viable donor buffy coat cells in addition to the marrow for transfused patients. The findings confirm the importance of transplanting early before transfusion and indicate that the greatest possible amount of donor marrow (supplemented by stem cells/lymphoid cells derived from the peripheral blood) should be obtained.

Primary Treatment of Acquired Aplastic Anemia: Outcomes with Bone Marrow Transplantation and Immunosuppressive Therapy

In the past 25 years, the role of bone marrow transplantation for the treatment of aplastic anemia has been established. In patients with severe aplasia who have genotypically or phenotypically HLA-identical, related donors, bone marrow transplantation is usually considered the treatment of choice. Because morbidity and mortality from bone marrow transplantation increase with patient age, many centers do not transplant bone marrow into patients older than 50 years of age. Thus, for older patients and for patients who do not have matched, related donors, immunosuppressive therapy is usually recommended as primary treatment. Since 1978, the Fred Hutchinson Cancer Research Center, Seattle, Washington, has offered either immunosuppressive therapy or bone marrow transplantation to patients with aplastic anemia on the basis of the availability of a bone marrow donor. In this analysis, we summarize the outcomes of each treatment and examine prognostic factors associated with survival after treatment. Methods Patient Selection All patients who had a diagnosis of acquired aplastic anemia and were treated between January 1978 and December 1991 were included in our analysis. The records of 395 consecutive patients were reviewed. Before therapy, diagnoses were confirmed by aspirates and biopsies of bone marrow and by cytogenetic studies of unstimulated bone marrow cells. Severe aplastic anemia was defined according to the criteria of the International Aplastic Anemia Study Group [1]. These criteria include the presence of at least two of the following three peripheral blood findings: 1) a neutrophil count of less than 0.50 109/L, 2) a corrected reticulocyte count of less than 1%, and 3) a platelet count of less than 20 109/L. These criteria also stipulate that the bone marrow must be hypocellular, with lymphoid cells usually being predominant. For our study, patients with clonal cytogenetic abnormalities were considered to have a myelodysplastic syndrome and were excluded. Except for short-term androgen therapy or treatment with low-dose corticosteroids, bone marrow transplantation or immunosuppressive therapy was the primary treatment received. For the 168 patients having transplantation, bone marrow donors were either genotypically (n = 162) or phenotypically (n = 6) HLA-identical family members. Patients who received syngeneic transplants were excluded. Before therapy, informed consent was obtained using forms that had been approved by the Institutional Review Board of the Fred Hutchinson Cancer Research Center. Patient characteristics by treatment group are shown in Table 1. The groups did not differ in median age or in the duration and cause of aplasia. Most patients had recently received a diagnosis of idiopathic disease. The groups were also similar with regard to history of previous treatment with steroids, refractoriness to transfusion of platelets from randomly selected donors, not having transfusion before treatment, and absolute neutrophil count at hospital admission. All patients receiving transplants had severe aplastic anemia. Thirty-four (15%) of the patients who received immunosuppressive therapy did not fulfill all of the criteria for severe aplasia and were therefore classified as having moderate disease. Table 1. Patient Characteristics by Treatment Group* Treatment Regimens All 168 patients who received a bone marrow transplant were conditioned with 200 mg of cyclophosphamide per kg of body weight, given over 4 days (Table 2). No patient received irradiation therapy. Seventy-eight patients also received unirradiated donor buffy-coat cells after the bone marrow infusion. Starting in 1988, 21 patients received horse antihuman thymocyte globulin (ATGAM, Upjohn Co., Kalamazoo, Michigan), 90 mg/kg, in addition to cyclophosphamide without buffy-coat cells [2, 3]. The primary prophylactic regimen for graft-versus-host disease was either a long course of methotrexate therapy or a short course of methotrexate plus cyclosporine therapy [4, 5]. The severity of acute and chronic graft-versus-host disease was assessed according to previously described criteria [6, 7]. Treatment of acute graft-versus-host disease varied with time depending on the active protocols; primary therapy included single-agent or combination therapy with corticosteroids, antithymocyte globulin, and cyclosporine [8-11]. Therapy for chronic graft-versus-host disease also varied with time and included corticosteroids, azathioprine, and cyclosporine, alone or in combination [12, 13]. Table 2. Conditioning Regimens and Engraftment Data of Bone Marrow Transplant Recipients (n = 168)* Table 3 shows the treatment regimens for the 227 patients who received immunosuppressive therapy. These regimens were defined by a sequential series of protocols that were used during the period of this analysis. Two hundred twenty-three patients received antithymocyte globulin, 15 mg/kg intravenously each day for 10 days, as the primary immunosuppressive agent [14-18]. Two patients received horse antihuman thoracic duct lymphocyte globulin (Swiss Serum Institute, Basel, Switzerland), and single patients who had positive reactions on skin tests to antithymocyte globulin received either cyclosporine or high-dose corticosteroid therapy [19]. All patients received corticosteroids during antithymocyte globulin therapy to reduce the side effects of antithymocyte globulin. Oxymetholone, 3 mg/kg per day orally, was administered for 3 months unless toxicity required discontinuation of therapy. Patients who had started therapy more recently also received granulocyte-macrophage colony-stimulating factor concurrently with immunosuppressive therapy. Table 3. Treatment Regimens and Responses to Therapy in Patients Receiving Immunosuppressive Therapy (n = 227) Supportive Care All patients who received immunosuppressive therapy and 58 patients who had transplantation were treated in private, nonsterile rooms. One hundred ten transplant recipients were treated in rooms with laminar air flow isolation. Patients who had an absolute neutrophil count less than 0.5 109/L and whose body temperature exceeded 38.5 C were empirically treated with broad-spectrum antibiotics. Patients received transfusions with irradiated red blood cells when the hematocrit was 0.25 or less, and they received transfusions with irradiated platelets when the platelet count was 20 109/L or less. Patients who had transplantation received care at the transplantation center for 3 months after bone marrow grafting; when clinically stable, patients receiving immunosuppressive therapy were discharged to the care of their referring physicians. Criteria for Response to Immunosuppressive Therapy Response to immunosuppressive therapy was initially evaluated 75 days after the start of treatment. We defined nonresponders as patients in whom peripheral blood counts did not improve and patients who died before day 75. For responders, degree of response was assessed when the maximum improvement in peripheral blood counts occurred. We used the following functional definitions of response: 1) Complete responders attained a normal hematocrit, an absolute neutrophil count of 1.0 109/L or greater, and a platelet count of 100 109/L or greater without transfusion; 2) partial responders had improvement in all three cell lines, with an absolute neutrophil count of 0.5 109/L or greater, no infections, and no transfusion requirement; and 3) minimal responders had an increase in the absolute neutrophil count of 0.5 109/L or more but remained dependent on transfusion. Statistical Analysis Survival probabilities were estimated using the Kaplan-Meier method, and comparisons between curves were based on the log-rank statistic [20]. All P values are two sided. Survival data were censored as of the date of last contact. Cumulative incidence curves are presented as estimates of the probability of certain events (such as relapse) when a competing event (such as death) occurred that would eliminate the possibility of observing the event of interest. These methods and their advantage over the Kaplan-Meier method in this setting have been described elsewhere [21]. Results Bone Marrow Transplantation Results in the transplant recipients are shown in Table 2. These patients reached an absolute neutrophil count of 0.20 109/L a median of 17 days after transplantation and reached a count of 1.00 109/L 26 days after transplantation. The median time to independence from platelet transfusion was 22 days. In 18 patients (11%), bone marrow grafts were rejected; median time to rejection was 141 days after bone marrow infusion. Sixteen of these 18 patients had a second transplantation; 12 of the 16 received transplanted cells from the same donor; and 4 received transplants from other family donors. Ten of the 16 had sustained engraftment; 6 had poor or no engraftment. Eight patients survive, and 8 died. The primary cause of death was chronic, extensive graft-versus-host disease. One patient refused a second transplantation, received immunosuppressive therapy, did not respond, and died. One patient had three transplantations with cells from the same donor before achieving sustained engraftment. This patient is a long-term survivor. Forty-six of the 150 patients (31%) who had sustained engraftment after the first transplantation developed grade II to IV acute graft-versus-host disease. Twenty-six of these patients developed chronic extensive graft-versus-host disease that required therapy. Currently, 23 of the 46 patients are alive, with a median Karnofsky score of 90% (range, 80% to 100%). An additional 42 patients with no or grade I acute graft-versus-host disease developed chronic extensive graft-versus-host disease that required therapy. Of these 42 patients, 31 are alive. The surviving patients have a median Karnofsky score of 100% (range, 80% to 100%). A secondary malignant condition developed in three patients: Squamous-cell carcinoma developed in two of t

TREATMENT OF CHRONIC GRANULOCYTIC LEUKAEMIA IN CHRONIC PHASE BY ALLOGENEIC MARROW TRANSPLANTATION

Ten patients with chronic granulocytic leukaemia in the chronic phase have been treated with chemoradiotherapy followed by transplantation of bone marrow from HLA-identical siblings. Engraftment was achieved in all patients, and Philadelphia chromosome disappeared from the nine patients who had it before transplantation. Four patients have died, three with interstitial pneumonitis and one with severe graft-versus-host disease (GvHD). Six patients are alive and well in complete clinical, cytogenetic, and haematological remission, 1-3 years after transplantation, despite complications in three patients (one had interstitial pneumonitis, one had mild veno-occlusive disease of the liver, and one had severe GvHD).