Gabriel Cividalli

T-cell-depleted allogeneic bone marrow transplantation for acute leukaemia using Campath-1 antibodies and post-transplant administration of donor's peripheral blood lymphocytes for prevention of relapse

One hundred and forty‐six patients with acute leukaemia (81 with ANLL and 65 with ALL) received allogeneic bone marrow transplantation from their fully matched siblings. 121 patients underwent T‐cell depletion (TCD) using Campath 1 monoclonal rat anti‐human lymphocyte (CDw52) antibodies; 67 with Campath 1M and 54 with Campath 1G isotypes. Patients were conditioned for transplant using either total body irradiation combined with chemotherapy (125 patients) or busulfan and cyclophosphamide (21 patients). 112 recipients of T‐cell depleted allografts received in addition total lymphoid irradiation (TLI) for prevention of rejection. Engraftment of neutrophils (>0.5 × 109/l) and platelets (>25 × 109/l) occurred on days 15 and 18, and on days 18 and 20 in recipients of Campath 1M and Campath 1G treated marrows respectively. Rejection was documented in 6.8% of T‐cell depleted transplants. Leukaemia relapse‐free survival at 2 years was 83% for patients transplanted in first CR, 76% in second CR (P2= 0.34) and 42% in advanced leukaemia (P2= 0.009). 81 marrow recipients, 38 with Campath 1M and 43 with Campath 1G treated marrow, received post‐transplant graded increments of donors peripheral blood lymphocytes (PBL) to induce graft‐versus‐leukaemia (GVL) effects. Administration of donors PBL was associated with clinically significant GVHD and with decreased relapse rate especially in patients with ALL. Our data suggest that in patients receiving marrow allografts depleted of T cells by Campath 1 monoclonal antibodies, rejection can be reduced by adequate pregrafting immunosuppression. In patients with advanced disease, post‐transplant cell‐mediated immunotherapy (CMI) using donors PBL may be beneficial; however, further studies are needed to define the optimal schedule of CMI for safe and effective prevention of relapse following TCD bone marrow transplantation in malignant haematological diseases.

Nonmyeloablative stem cell transplantation for the treatment of cancer and life-threatening nonmalignant disorders : past accomplishments and future goals

Abstract. Allogeneic bone marrow transplantation (BMT) or blood stem cell transplantation represents an important therapeutic tool for the treatment of otherwise incurable malignant and nonmalignant diseases. Until recently, autologous and allogeneic BMT or mobilized blood stem cell transplantation was used primarily to replace a malignant, genetically abnormal, or deficient immunohematopoietic compartment, and therefore highly toxic myeloablative regimens were considered mandatory for eradication of all undesirable host-derived hematopoietic elements. Our preclinical and ongoing clinical studies have indicated that more effective eradication of host immunohematopoietic system cells could be achieved by adoptive allogeneic cell therapy with donor lymphocyte infusion following BMT. Thus eradication of blood cancer cells, especially in patients with chronic myelogenous leukemia and less frequently in patients with other hematologic malignancies, can frequently be achieved despite complete resistance of such tumor cells to the maximum tolerated doses of chemoradiotherapy. Our cumulative experience suggests that graft vs leukemia (GVL) effects might be a useful tool for eradication of otherwise resistant tumor cells of host origin. Based on the cumulative clinical experience and experimental data in animal models of human diseases, it appears that induction of host vs graft tolerance as the first step may allow durable engraftment of immunocompetent donor lymphocytes, which may be used for induction of effective biologic warfare against host-type immunohematopoietic cells that need to be replaced, whether they are malignant, genetically abnormal, or self-reactive. Based on this rationale, we speculate that the therapeutic benefit of BMT may be increased by using safer conditioning as part of the transplantation procedure, with the goal of inducing host vs graft tolerance to enable subsequent induction of GVL, possibly graft vs tumor, or even graft vs autoimmunity effects, rather than attempting to eliminate host cells with hazardous myeloablative chemoradiotherapy. Our hypothesis suggests that effective BMT procedures might be accomplished without lethal conditioning of the host, using new, well-tolerated nonmyeloablative regimens, possibly minimizing immediate and late side effects related to myeloablative procedures. Recent clinical data suggest that effective BMT procedures may be accomplished with nonmyeloablative stem cell transplantation (NST) regimens, with no major toxicity. Thus new NST approaches may make BMT procedures safer for a spectrum of clinical indications in children and elderly individuals without lower or upper age limits, while minimizing procedure-related toxicity and mortality. Our cumulative data suggest that high-dose chemotherapy and radiation therapy may be successively replaced by more effective alloreactive donor lymphocytes, thus setting the stage for innovative therapeutic procedures with safer and more effective treatment of patients requiring BMT.

Splenectomy in homozygous beta thalassaemia: a retrospective study of 30 patients.

In order to clarify the indications for splenectomy in patients with homozygous β thalassaemia we studied, retrospectively, the basal pre‐transfusion haemoglobin levels and blood transfusion requirements before and after splenectomy, in a series of patients with this disorder.

Engraftment of marrow allografts treated with Campath-1 monoclonal antibodies

We have analyzed the factors associated with engraftment in 216 recipients of T-cell depleted allogeneic HLA identical sibling marrow transplants using Campath 1 monoclonal antihuman lymphocyte (CD52) antibodies. The patient population consisted of 168 patients with hematologic malignancies, 26 with severe aplastic anemia (SAA), and 22 with hemoglobinopathies, half of whom received marrow treated in vitro with Campath-1M (IgM) and half received marrow with Campath-1G (IgG2b isotype). Patients with durable engraftment had fast hematopoietic recovery: SAA patients reached ANC > 0.5 x 10(6)/L on Day 14; those with leukemia attained ANC > 0.5 x 10(6)/L on Days 18, 17, and 15 for ANLL, ALL and CML respectively, while patients with thalasemia reached ANC > 0.5 x 10(6)/L on Day 21. Overall, 24 patients (17 with leukemia, 4 with SAA, and 3 with thalassemia) suffered graft failure: 10 patients (all grafted with Campath-1M) rejected their grafts, while 14 others (9 grafted with Campath-1M, and 5 with 1G isotype) never engrafted (p = 0.009). Multivariate analysis revealed that neither pretransplant protocol, nor stage of disease or type of antibody used, donor sex and ABO match had any impact on engraftment. The variables favorably associated with engraftment were older age (p = 0.030, RR = 1.016) and CFU-GM number (p = 0.013, RR = 1.001). Patients with ANLL or SAA had a better chance to engraft (p = 0.027, RR = 1.400; and p = 0.003, RR = 2.677, respectively) compared to patients with thalassemia (p = 0.001, RR = 0.551). A higher concentration of Campath-1 antibody in vitro and in vivo adversely affected engraftment. Our data show that satisfactory engraftment can be achieved in patients transplanted with Campath-1 treated marrow allografts. However, despite the measures undertaken to prevent rejection, graft failure still poses a problem. Further pretransplant immunosuppression and perhaps more selective T-cell depletion may reduce the increased graft failure in these patients.

Familial hemophagocytic lymphohistiocytosis (FHLH) in Israel. I. Description of 11 patients of Iranian—Iraqi origin and review of the literature

Eleven patients with familial hemophagocytic lymphohistiocytøsis (FHLH) are described. They all belonged to four Jewish families of Iranian and Iraqi origin. Parental consanguinity was found in three families. The age of onset of disease ranged from 6 weeks to 36 months. All patients had fever, wasting, and enlargement of the liver and spleen. In addition, lymph‐node enlargement and neurologic complications were common. The most consistent laboratory findings were pancytopenia, atypical lymphomonocytoid cells in the peripheral blood, abnormal liver function test results, and increased cerebrospinal fluid protein. The course was fatal in all patients. Nine of the 11 patients died within 2 weeks to 3 months of presentation, and 2 patients achieved temporary remissions but died of disease within 8 and 24 months, respectively. Response to antibiotic therapy or to the administration of corticosteroids and cytotoxic drugs was unimpressive. Pancytopenia complicated by sepsis or bleeding, hepatic failure, or encephalopathy were the terminal events. This report draws attention to the existence of FHLH in Jews of Iranian‐Iraqi origin in whom parental consanguinity is very common.

A Myasthenic Syndrome in Childhood Leukemia

A case of the myasthenic syndrome of Eaton‐Lambert is reported in a 10‐year‐old boy with leukemia. Neurological symptoms preceded the appearance of leukemia by more than a month: the child became easily fatigued and there was generalised weakness and wasting (mainly of proximal muscle groups), ophthalmoplegia and ptosis. There was no response to anticholinesterase agents.

Cyclosporin A in the treatment of refractory immune thrombocytopenia purpura in children

Abstract: Patients with refractory autoimmune thrombocytopenia do not respond to standard therapy with high‐dose corticosteroids, intravenous immunoglobulin, and splenectomy. We describe the cases of two patients with refractory autoimmune thrombocytopenia treated with oral cyclosporin A (CsA) to evaluate the efficacy of this alternative therapy. Blood pressure and hepatic and renal function were in the normal range before initiation of treatment. Induction therapy with pulses of high‐dose methylprednisolone was used for 3 consecutive days to improve the initial immune suppression. Gradual dose reduction of CsA, according the platelet count, minimized the long‐term adverse effects of CsA. Oral CsA with pulses of high‐dose methylprednisolone induced remission of the thrombocytopenia. Gradual weaning of CsA over months, according the platelet count, produced no observable adverse effects of the CsA. Rapid dose reduction caused thrombocytopenia, which resolved with higher dosages of CsA. Our cases show the efficacy of CsA for refractory immune thrombocytopenia. This therapeutic option with oral CsA as an additional salvage option may avoid splenectomy and the adverse effects of long‐term corticosteroids. Larger clinical investigations are necessary to establish the indications and therapeutic regimen for CsA in immune thrombocytopenia.

Homozygous βd` - and β+ - Thalassemia in Kurdish Jews and Arabs

Chromatographic separation of labeled globin chains was performed on peripheral blood of 38 patients with homorygous β-thalassemia. In 11 patients globin synthesis was also studied in bone-marrow cells. The results showed β/α synthetic ratios in the common range of β+-thalassemia (from 0.11 to 0.39) in 16 out of 27 Kurdish Jews (59%) and in ten out of 11 Arabs (91%). In nine Kurdish Jews (33%) and in one Arab βd`-thalassemia was found. In a few patients from the latter group a very small peak was detected in the β region, which co-chromatographed with β-chains from non-thalassemic individuals, but apparently represents synthesis of a non-globin protein. In two affected siblings, synthesis of small amounts of β-chains was demonstrated in peripheral blood (β/α 0.018–0.025) and in one sample of bone-marrow cells (β/α 0.046). These ratios are lower than any previously reported in β+-thalassemia. Identification of the presumed β-peak in these patients was based on an approximate tenfold increase in β/α, γ/α an...

Fluorescence in situ hybridization analysis of the cryptic t(12;21) (p13;q22) in childhood B-lineage acute lymphoblastic leukemia

We evaluated retrospectively the cryptic t(12;21)(p13;q22) in 15 children with early B-lineage acute lymphocytic leukemia who had a normal karyotype by using the locus specific probes of TEL and AML1 genes in a dual color fluorescence in situ hybridization (FISH). The FISH analysis revealed six patients with the fusion gene TEL/AML1 on chromosome 21, three of whom possessed a double fusion gene. In addition, the AML1 probe revealed hyperdiploid clones that were not detected in the conventional cytogenetic analysis. A discrepancy between the proportion of cells with the fusion gene in interphase nuclei and metaphases was noted.

Juvenile myeloid leukemia with fetal erythropoiesis

A case of juvenile myeloid leukemia in a 21/2‐year‐old girl is described. Apart from the typical clinical features encountered, this case was characterized by a fetal pattern of erythropoiesis, with exceptionally high levels of fetal hemoglobin, up to 85%, associated with decreased levels of hemoglobin A2 and carbonic anhydrase. There was also a slight elevation of the sodium content and sodium outflux in the patients red blood cells similar to that recorded in six newborn babies. Significance of these findings is discussed in relation to current concepts of type of erythropoiesis found in this form of leukemia.