G. Marit

Autologous blood stem cell transplantation for chronic granulocytic leukaemia in transformation: a report of 47 cases

Forty‐seven patients with chromosome Philadelphia‐positive (Ph1) chronic granulocytic leukaemia (CGL) in transformation underwent autologous transplantation of peripheral blood stem cells (ABSCT) collected at the original diagnosis before any treatment. They were treated with three consecutive strategies: single transplant (group I=17 patients), double transplant (group II = 13 patients), double transplant followed by recombinant alpha interferon (group III=17 patients). Forty‐three patients were restored to a second chronic phase with a cytogenetic conversion (more than 10%, Ph1‐negative marrow metaphases) occurring in 14 of the 29 evaluable patients. Most patients had a recurrent transformation occurring 2‐43 months after ABSCT and finally eight patients are still alive in second chronic phase 4‐49 months after ABSCT (median = 24 months). The actuarial median duration of second chronic phase was 3 months, 10 months and 18 months for group I. group II and group III patients (P < 0·0001). The encouraging results observed for group III patients prompt us to propose ABSCT for patients in chronic phase with initial prognostic factors, suggesting that recombinant alpha interferon will not be effective if administered as front‐line therapy.

Acute eosinophilic leukemia with a translocation (10p +; 11q−)

Eosinophilic leukemias are difficult to individualize amid the hypereosinophilic syndromes. Chromosomal abnormalities when present within the eosinophils are of critical value in the diagnosis of a malignancy. We report here the case of a 27-year-old woman who had been healthy, until recently when she suddenly developed hepatosplenomegaly and lymph node enlargement, and considerable eosinophilia in blood and bone marrow. The morphologically abnormal cells (large pseudo Pelger eosinocytes) predominated in the cytology. The establishment in these cells of a clonal chromosomal anomaly, t(10;11)(p14;q21), favored the malignancy and diagnosis of acute eosinophilic leukemia.

Collection of circulating haemopoietic cells after chemotherapy in acute non-lymphocytic leukaemia.

Recently, To et aZ (1 984) reported that in patients with acute non-lymphocytic leukaemia (ANLL), induction chemotherapy caused a very strong overshoot of circulating granulocytemacrophage progenitor cells (PB-CFU-GM), occurring 15-35 d after the end of chemotherapy. During this period, repeated cytaphereses allowed harvest of 1.8-3.0 x lo8 white blood cells (WBC) and of 15-60 x lo4 CFU-GM per kg body weight, i.e. quantities, in theory, largely sufficient for successful autografting. We currently use the same culture method as To et aZ(1984) and our normal results fall within the same range (PB-CFU-GM/ml in 2 1 normal adults: log-normal distribution, mean 98, median 82, range 10-232). Thus we can compare our results with those of To et al (1984). Two patients with ANLL, while they were in complete remission, received intensification chemotherapy consisting of one course of the ‘DAT’ regimen (daunorubicin 100 mg/m2/d for 3 d; cytosine arabinoside 100 mg/m2/d for 5 d; thioguanine 200 mg/m2/d for 5 d). For the first patient (age 30) six cytaphereses were performed and cryopreserved between days 18 and 43 after chemotherapy. The total quantities harvested (measured after thawing) were 7.7 x lo8 WBC and 128.5 x lo4 CFU-GM per kg body weight. Each cytapheresis provided a similar number of WBC but 97% of the total CFU-GM were collected during the first three cytaphereses (days 18, 22 and 26). For the second patient (age 17) seven cytaphereses were made between days 22 and 43 after chemotherapy. A total of 7.8 x 10’ WBC and 9.3 x lo4 CFU-GM per kg body weight was harvested and cryopreserved. 80% of the total CFU-GM were collected during the first three cytaphereses (days 22, 27 and 29). Compared with the study of To et al(1984), our study differs in two points. First, our two cases were studied at a different period in disease history. However, our post-intensification results fall in the same range as those obtained by To et al (1984) in their post-induction study. This suggests that the period of study is less important than the chemotherapy regimen for high PB-CFU-GM expansion. The second difference is in the cytapheresis techniques. We used a semi-continuous blood flow separator (Haemonetics 30) and each cytapheresis lasted about 3 h. In a pilot study performed in 11 normal donors, the mean harvest was 0.9 x 10’ WBC and 0.3 x lo4 CFU-GM per kg body weight. This result is again in the same range as that obtained by To et al (1984) using continuous flow cytaphereses lasting 1.5 h in normal subjects. Thus the differences between cytapheresis techniques may have littie importance. Marrow was harvested from our two patients and cryopreserved. Having this back-up marrow in reserve, on the relapse of the second patient we were able to try autografting using the cytapheresis products. The back-up marrow did not turn out to be necessary as the

Treatment of Relapsed Acute Myeloid Leukemia Using GM-CSF Before Intensive Chemotherapy

Ten patients with acute myeloblastic leukemia (AML) in first relapse were treated with high-dose cytosine-arabinoside (ara-C, 3 g/m2/12 hours x 4) and amsacrine (150 mg/m2/day x 5). In order to prime the cells, the patients were given rh-GM-CSF (3 micrograms/kg/d) for four days, the first infusion starting 48 hours before chemotherapy. Two patients died during the aplastic phase, seven patients achieved a second complete remission (CR2) and one patient remained leukemic. The median duration of aplasia was 17 days (14-21). These results were comparable to those obtained in our previous series of 27 patients treated for AML in first relapse with the same chemotherapy but without GM-CSF (66% CR2). After 48 hours of GM-CSF infusion, (before chemotherapy was started), seven patients had an increase in the white blood cell count with an increase in the absolute number of blast cells in five of these cases. Marrow blast cells percentages increased in 3 of the 8 patients analysed. Six of seven patients tested showed an increase in the percentage of cells in S-phase (studied by flow cytometry using the bromodeoxyuridine (BrdU/DNA) labelling technique and BrdU incorporation). GM-CSF used to prime leukemic cells may be safely administered but its clinical usefulness needs to be further evaluated.

Autologous stem cell transplantation in chronic myeloid leukemia: a single center experience

Between 1980 and 1996, we transplanted 72 patients with CML using blood stem cells collected at diagnosis before treatment and without any mobilization. The median age of patients at diagnosis was 47.5 years (range 20.5–59.5). The median numbers of nucleated cells and CFU-GM transplanted were 10 × 108/kg and 97 × 104/kg, respectively. The median duration to reach more than 0.5 × 109/l neutrophils and 50 × 109/l platelets was 12 (range 5–19) and 11 days (range 0–79), respectively. Twenty patients (group I) were transplanted in chronic phase either for resistance to IFN (14 patients) (group IA) or because the Sokal index was more than 1.2 (six patients) (group IB). All those patients had preparative regimen with busulfan (4 mg/kg/day × 4) and melphalan (140 mg/m2). They were treated with recombinant alpha-interferon (IFN) after transplant. The cumulative incidence of major cyto- genetic response (MCR) at 12 months was 25 ± 21% (95% CI), the 5-year survival was 75 ± 42% (95% CI). These results (observed in patients with bad prognosis factors) are similar to those usually observed in CML patients treated by IFN, whatever the Sokal risk. Thus autologous transplantation is able to reproduce for poor prognosis patients the results observed in standard risk patients treated with IFN. This suggests that it could prolong survival. Fifty-two other patients (group II) were transplanted for CML in transformation (accelerated phase = 32; blast crisis = 20) after a preparative regimen containing either total body irradiation (TBI) or busulfan. The median survival was short (10.4 months) and only 21 patients survived more than 1 year. The survival was longer for patients transplanted in accelerated phase (vs blast crisis), those who were due to receive a double transplant (vs single) (34 patients), those who were treated with IFN after transplant (vs hydroxyurea) and for the patients who obtained a complete hematologic response.

Stem cell apheresis in patients with acute nonlymphocytic leukemia

Abstract In patients with acute nonlymphocytic leukemia (ANLL) it has previously been reported that the number of blood-derived hemopoietic stem cells (HSC) is very low during the remission phase. 1,2 However, we and others have recently demonstrated that the concentration of granulocyte-macrophage precursors (CFU-GM cells) in the peripheral blood could be increased to 10- to 40-fold above the mean value in normal subjects during the period of marrow reconstitution following aplasia (or hypoplasia) induced by previous chemotherapy. 1,3 To collect high numbers of circulating HSC, leukocyta-phereses could be performed during this short period of “recirculation” of blood-derived progenitors. However, patients with ANLL may be subjected to different chemotherapy regimens that vary according to the age of the patients, the status of the leukemia, and the therapeutic strategy. The amplitude of the recirculation of CFU-GM cells during remission is influenced mostly by the type of chemotherapy administered to the patient. 1 In order to evaluate this phenomenon, we serially assayed peripheral blood CFU-CM cells in 26 ANLL patients. The mean value of the highest recorded peak (HRP) level was 4370 CFU-GM/mL (1133 to 9066) in 13 patients who achieved complete remission after a single course of induction treatment including cytosine arabinoside (Ara-c) (100 mg/m2 × 10 days) and daunorubicin (DNR) (60 mg/m2 × 3 days). As mentioned in a previous report, HPR levels of CFU-GM cells observed in two patients given a late, intensification treatment (with DNR: 300 mg/m2) were similar to those observed in these latter 13 patients. 1 The recirculation of CFU-GM cells was less marked in seven patients who received two consecutive courses of induction chemotherapy or in four other patients receiving less intensive treatment as consolidation. 1,2 These results confirm the results of our previous report and the data reported by To et al., who studied 13 ANLL patients during the very early remission phase following induction chemotherapy. 3 They found that the mean value of the HRP level of CFU-GM cells was 2796/mL (370 to 14520) and concluded that the early remission period after one single course of chemotherapy could be the best time for collection of circulating HSC in ANLL patients.

Autologous Blood Stem Cell Transplantation Followed by Recombinant Alpha Interferon as Treatment for Patients with High-Risk Chronic Myelogenous Leukemia. A Report of 32 Cases

Autologous blood stem cell transplantation (ASCT) was performed in 32 patients with high risk chronic myelogenous leukemia (CML). Prior to ASCT, the patients were given Busulfan and high-dose Melphalan. Peripheral blood stem cells collected at diagnosis were used to rescue hematopoiesis. Recombinant Interferon was administered after ASCT. In 24 patients transplanted in transformation, 23 achieved a complete hematological response and nine are still alive 9 to 73 months after ASCT. Eight other patients were transplanted in chronic phase for either the presence of bad prognostic factors (Sokals classification) or no response to IFN. Seven are alive without transformation 16 to 48 months after ASCT. Although few patients presented a cytogenetical response (10/28), the survival observed in this series of patients compares favorably with that of patients treated conventionally. Thus, the place of ASCT in CML could now be tested prospectively.

Incomplete Stroma Formation by Bone Marrow from Chronic Myeloid Leukemia Patients Treated with Interferon

Chronic myeloid leukemia (CML) results from the neoplastic transformation of a pluripotent stem cell. The disease is characterized by a significantly increased number of granulo-monocytic progenitors in both the bone marrow and the blood, resulting in an increased peripheral blood white cell and platelet count. A feature of CML is the presence, in more than 95% of diagnosed cases, of the Philadelphia chromosome (Ph1) [1]. Conventional treatment, aimed at reducing the elevated peripheral blood counts, is generally based on the cytotoxic action of drugs such as busulfan and hydroxyurea. Whilst these agents are effective in controlling the peripheral counts, there is little or no effect on the Ph1 chromosome [1]. Recent reports using recombinant interferon-α (IFN-α) in the treatment of CML have demonstrated not only a hematological response but also the reappearance of Ph1-negative metaphases [2]. The efficacity of IFN-α in controlling the aberrant proliferation of granulocyte-macrophage progenitor (CFU-GM) cells in the bone marrow and blood of CML patients, often results in an important neutropenia. Several workers have demonstrated that, in spite of the selective antiproliferative effect of IFN-α on CML precursors, IFN-α is also capable of suppressing normal multipotential progenitors (CFU-GEMM), CFU-GM, and erythroid progenitors [3–7]. The addition of high concentrations of IFN-γ to long-term marrow cultures have been demonstrated to suppress hematopoiesis and the development of an adherent stromal layer [8] but it is not clear whether IFN-α has an effect on the hematopoietic microenvironment.