Niels Jacobsen

Malignant Neoplasms in Long-Term Survivors of Bone Marrow Transplantation

Bone marrow transplantation offers a chance for cure to patients with leukemia, lymphoma, and severe aplastic anemia (1-3). However, long-term survival may be impaired by the development of secondary neoplasms (4). Secondary malignant diseases are known complications of the radiation and chemotherapy used to treat primary cancers (5-7). An increased risk for malignant neoplasms has also been reported in patients who receive organ transplants (8, 9) and those treated with immunosuppression for aplastic anemia (10). Patients who receive marrow transplants are at increased risk for malignant neoplasms because of several risk factors: ionizing radiation and chemotherapy used for pretransplantation conditioning and treatment of the primary malignant disease, immune deficiency due to delayed and incomplete recovery of the immune system, immune stimulation and immunosuppression by the graft-versus-host reaction, and immunosuppressive therapy for graft-versus-host disease. Most reports on malignant neoplasm after marrow transplantation have included patients early after transplantation and have had short follow-up (1, 4, 11-15). A recent multicenter study of more than 19 000 patients (16) included patients early after transplantation and evaluated solid cancers only. The aim of this study was to assess the risk for malignant neoplasm in long-term survivors of marrow transplantation and to identify risk factors for new malignant disease. Methods Marrow transplantation programs were started in Europe in the early 1970s in several university hospitals. The indication for marrow transplantation changed with time: Before 1976, the main indication was severe aplastic anemia, whereas after 1980, the main indication was leukemia. The European Cooperative Group for Blood and Marrow Transplantation (EBMT) was founded in 1977. A central registry of all cooperating centers was instituted at the University of Leiden; this registry includes basic information on disease-related and transplant-related variables, including the form of radiation, radiation dose, dose rate, fractionation, and treatment times. Patients We studied 1036 patients who underwent transplantation in 45 European centers cooperating in the EBMT. We limited our study to patients surviving more than 5 years for two reasons. First, mortality due to transplant-related complications other than malignant neoplasm and recurrence of the original disease are high in the first years after transplantation. These causes of death may interfere in a nonrandom manner with the development of malignant neoplasms. In addition, most major complications other than malignant neoplasm occur within that time, and their influence on the development of new malignant disease can be studied independently. Data Collection The EBMT registry provided basic data on patients who underwent transplantation before 1986 and on the transplantation centers, including age and sex of the patient and his or her donor; diagnosis and status of the disease at the time of transplantation; histocompatibility with the donor in the transplantation categories of monozygotic twin, HLA-identical family member, HLA-mismatched family member, and autologous; conditioning treatment, including radiation, radiation source, radiation field, radiation dose, dose rate, fractionation schedule, number of days with radiation, and the form of chemotherapy; methods of prevention of graft-versus-host disease; and the occurrence of acute graft-versus-host disease, graded on a 0 to 4 scale, and chronic graft-versus-host disease, graded on a 0 to 2 scale. Additional information on occurrence of a secondary neoplasm, date of tumor detection, International Classification of Diseases code, histology report on the tumor, recurrence and treatment of the original disease, agents used for the treatment of graft-versus-host disease, the date of last follow-up, clinical performance status at the time of last follow-up, and cause of morbidity or death was requested. The transplantation centers were asked to check the registry data and to provide the additional information. Furthermore, they were asked to report all consecutive patients undergoing transplantation who survived more than 5 years. Copies of the original histology reports were provided for 62% of all tumors. Radiation as preparative treatment was classified as single-dose or fractionated total-body radiation and partial-body radiation, including total lymphoid and thoracoabdominal radiation. The radiation source, dose, acute dose rate, number of fractions, number of days with radiation, and dose to the lungs were scored as radiation variables. Statistical Analysis Kaplan-Meier survival analysis was performed to estimate the risk for malignant neoplasm with time after transplantation (8, 17). The date of onset of a pathologically confirmed malignant neoplasm was the date on which the clinical diagnosis was first suspected. The risk for neoplasms in the observation group was compared with that in the general population; patients were matched for age and sex. Data were provided by the Danish Cancer Registry and the Cancer Registry of the Saarland/Germany (18) on the annual incidence of malignant cancer at all body sites, including the skin. These registries are representative of the European population. The expected number of cases (E) in the cohort was calculated by using age, sex, and length of follow-up, and the incidence rates were compared with the incidence in the transplant cohort (O). Significance was assessed under the null hypothesis that O is equal to E in a Poisson distribution. A standardized ratio (O/E) was also calculated. Analysis of potential risk factors was performed with the time to diagnosis of malignant neoplasm in a log-rank test for univariate analysis. Multivariate regression analysis was performed with the Cox model for proportional hazards. Analyses were performed by using the NCSS statistical package (Dr. J.L. Hintze, Kaysville, Utah). Results Survival The median duration of observation was 128 months; the longest observation was 265 months (Figure 1). 90 patients died more than 5 years after transplantation. Causes of death were recurrence of the original disease in 44 patients, chronic graft-versus-host disease with or without pulmonary complications in 22 patients, secondary malignant neoplasm in 10 patients, AIDS in 5 patients, pulmonary complications and infections in 3 patients, and accidents in 3 patients. The cause of death was not known for 3 patients. Secondary malignant neoplasms in patients who died were brain tumors in 3 patients; squamous-cell carcinoma of the oral cavity, larynx, esophagus, and anus in 5 patients; and secondary leukemia and neurofibrosarcoma in 1 patient each. The risk for death from all causes ( SE) was 7.9% 0.9% at 10 years and 12% 1.4% at 15 years after transplantation. Figure 1. Cumulative probability of developing a malignant neoplasm as a function of time after bone marrow transplantation. n Tumors New malignant disease was diagnosed in 53 patients. The most frequent tumors were carcinomas of the skin; basal-cell and squamous-cell carcinomas; tumors of the oral cavity; carcinomas of the uterus, including carcinoma in situ of the cervix; breast cancer; thyroid gland cancer; and brain tumors (Table 1). The actuarial risk for a malignant neoplasm was 3.5% 0.6% at 10 years and 11.5% 2.3% at 15 years (Figure 1). The overall incidence of malignant tumors is about fivefold greater than that in an age- and sex-matched population (Figure 2). This increase was more than 10-fold for cancer of the oral cavity, esophagus, or thyroid gland (Figure 3). Table 1. Malignant Neoplasms in Patients Who Survived 5 Years after Transplantation Figure 2. Cumulative number of malignant neoplasms after bone marrow transplantation as a function of age. Figure 3. Standardized incidence ratios of malignant neoplasms after bone marrow transplantation. circles Risk Factor Analysis The median age of donors and patients was 21 years (range, 1 to 51.9 years). Older age of the recipient at the time of transplantation was a risk factor for malignant neoplasm in female patients only (Table 2). Older age of the donor was also a risk factor for neoplasms in the recipient if the donor was female. Neoplasms were detected earlier in these recipients. The increased incidence of malignant neoplasms in recipients of allogeneic transplants compared with recipients of autologous and syngeneic transplants did not reach statistical significance. Only patients with extensive, chronic graft-versus-host disease had a significantly increased risk. Treatment of graft-versus-host disease with cyclosporine, azathioprine, and thalidomide significantly increased the risk for malignant neoplasms (Table 2). Variables with P values less than 0.2 in a log-rank test comparing time until tumor development were entered into a multivariate analysis using the Cox proportional-hazards model. Only patient age remained significant after adjustment for histocompatibility group and development of graft-versus-host disease (Table 3). Treatment of graft-versus-host disease with cyclosporine, thalidomide, or methotrexate was a significant risk factor (Table 3). Table 2. Malignant Neoplasm after Bone Marrow Transplantation: Univariate Analysis Table 3. Malignant Neoplasms after Bone Marrow Transplantation: Multivariate Analysis in Cox Proportional Hazards Model In the subgroup analysis, the effect of age on carcinogenesis was limited to female patients (Table 2), in part because of carcinomas of the breast and the uterus. However, the effect of age in female patients was still significant after malignant disease of the genital organs and breast was excluded from analysis (P=0.04). Neoplasms of the skin are frequent in patients who receive solid organ transplants (8). We also analyzed the risk factors in patients with tumors in organs other than skin. In these patients, chronic graft-versus-h

Influence of protective isolation on outcome of allogeneic bone marrow transplantation for leukemia

Various isolation strategies are used to prevent infections during bone marrow transplantation; data on their efficacy are lacking. We studied whether use of high efficiency particulate air filtration (HEPA) and/or laminar airflow (LAF) units affect transplant-related mortality (TRM) or survival in the first year after allogeneic transplantation. 5065 patients with leukemia receiving bone marrow transplants from an HLA identical sibling (nu2009=u20093982) or alternative related or unrelated donors (nu2009=u20091083) between 1988 and 1992 were reported to the International Bone Marrow Transplant Registry by 222 teams. Two types of isolation were considered: (1) conventional protective isolation with single patient room and any combination of hand-washing, gloves, mask and gown; and (2) HEPA and/or LAF. Cox proportional hazards regression models were used to determine the relative risks (RRs) of transplant-related mortality (TRM) and of deaths from any cause in patients treated in HEPA/LAF units compared to patients treated in conventional isolation. HLA-identical sibling and alternative donor transplants were analyzed separately. Risks of TRM and overall mortality in the first 100 days post-transplant were significantly lower among patients treated in HEPA/LAF units than in those treated conventionally. RRs of TRM were 0.76 (Pu2009=u20090.009) for recipients of HLA-identical sibling transplants and 0.65 (Pu2009=u20090.003) for recipients of alternative donor transplants. Correspondingly RRs of overall mortality were 0.80 (Pu2009=u20090.02) and 0.65 (Pu2009=u20090.0006). Decreased risks of TRM and of death in the first 100 days post-transplant resulted in significantly higher 1-year survival rates in patients treated in HEPA/LAF rather than in conventional isolation units. Use of HEPA and/or LAF to prevent infections decreases TRM and increases survival after allogeneic bone marrow transplants for leukemia.

Results of Transplanting Bone Marrow from Genetically Identical Twins into Patients with Aplastic Anemia

Considerable data suggest that aplastic anemia is heterogeneous: Some cases are caused by a lack of or a defect in hematopoietic stem cells, whereas others result from immune abnormalities [1-7]. In rare cases, aplastic anemia is caused by an abnormal bone marrow microenvironment [8]. The outcomes of transplanting bone marrow from genetically identical twins into patients with aplastic anemia may provide insight into the causes of bone marrow failure. The infusion of genetically identical bone marrow cells without pretransplantation conditioning should permanently correct bone marrow function in persons whose bone marrow failure has resulted from a lack of or defective hematopoietic stem cells. In contrast, persons whose bone marrow failure is caused by immune abnormalities may only improve when transplantation of genetically identical bone marrow is preceded by conditioning. Finally, persons with abnormal bone marrow microenvironments might never improve [8]. We addressed these issues using data on 40 patients with aplastic anemia who received transplants from their identical twins and were reported to the International Bone Marrow Transplant Registry. Methods Patients Forty patients with severe aplastic anemia who received one or more bone marrow transplants from their genetically identical twins between 1964 and 1992 were reported to the International Bone Marrow Transplant Registry by 31 centers worldwide. Severe aplastic anemia was defined according to published criteria [9]. Nineteen patients have been described in previous reports [4, 10-14]. Genetic identity was established by measuring concordance for HLA-A, -B, -C and -DR antigens (n = 39; HLA testing was not done in 1 patient); ABO blood group (n = 39); erythrocyte antigens (n = 1); and immunoglobulin allotypes (n = 1) and by a history of a single placenta (n = 40). Outcomes Hematologic response, graft-versus-host disease, and survival were the study outcomes. Complete response was defined as normalization of at least two of three hematologic variables (hemoglobin level > 12 g/dL, granulocyte count > 1.5 109/L, and platelet count > 150 109/L) and improvement in the third (hemoglobin level > 8 g/dL, granulocyte count > 0.5 109/L, and platelet count > 20 109/L without transfusion). Partial response was defined as improvement in two or more variables. Lack of response was defined as levels less than those indicated above and continuing dependence on transfusion. Responses were considered to be sustained if they persisted through the date of last contact. Diagnosis and grading of graft-versus-host disease were based on published criteria [15]. Persons at risk included those with complete or partial responses who survived 21 days or longer. Statistical Analysis We compared patient, disease, and transplantation variables using the Mann-Whitney and Fisher exact tests. Probabilities of survival were calculated using the Kaplan-Meier product limit estimator and were expressed as probabilities with 95% CIs. The latter were computed using the arcsine-square root transformation [16]. Survival distributions were compared using the log-rank test. Results Patients We studied 25 male patients and 15 female patients. The median patient age was 19 years (range, 4 to 69 years). Physicians at the transplantation centers ascribed aplastic anemia to drugs or toxins (7 patients), hepatitis (4 patients), or other causes (3 patients). We did not ascertain which criteria were used to make these designations. In 26 cases, no cause of aplastic anemia was identified. Treatments given between diagnosis and transplantation included corticosteroid therapy (9 patients), androgen therapy (1 patient), and both (7 patients). Twenty-three patients received no therapy other than transplantation. Thirty-seven patients received transfusions before transplantation (median number of transfusions, 14 [range, 1 to 263]). Median values for hematologic variables before transplantation were the following: hemoglobin level, 7.5 g/dL (range, 4.8 to 11.3 g/dL); leukocyte count, 1.7 109/L (range, 0.5 to 5.2 109/L); granulocyte count, 0.3 109/L (range, 0 to 1.6 109/L); and platelet count, 17 109/L (range, 1.5 to 101 109/L). Survivors were followed for a median of 7 years (range, 13 months to 29 years); all but one were followed for at least 2 years after transplantation. Transplantation First Transplantation Not Preceded by Conditioning Twenty-three patients received a first transplant without pretransplantation conditioning. Fifteen patients who did not have a sustained complete response received one or more additional transplants after first receiving conditioning with the following regimens: Ten patients received cyclophosphamide alone (150 to 200 mg/kg of body weight); 2 received cyclophosphamide (200 mg/kg) and total-body radiation (3 to 4.5 Gy); 1 received cyclophosphamide (194 mg/kg) and cyclosporine; 1 received nitrogen mustard and antilymphocyte globulin; and 1 received azathioprine. A sixteenth patient who did not have a sustained complete response after the first transplantation received the second transplant without first receiving conditioning. The median dose of nucleated bone marrow cells for the first transplant was 3.6 108/kg (range, 0.4 to 9.8 108/kg). Four of 15 female donors had had transfusion or at least one pregnancy before donating bone marrow. No patients received immunosuppressive therapy after transplantation. First Transplantation Preceded by Conditioning Seventeen patients received conditioning before the first transplantation. Thirteen received cyclophosphamide alone (100 to 200 mg/kg), 1 received cyclophosphamide (152 mg/kg) and cyclosporine, 2 received cyclophosphamide (156 and 219 mg/kg, respectively) and busulfan (12 and 16 mg/kg, respectively), and 1 received cyclophosphamide (200 mg/kg) with total-body radiation (3.0 Gy). The median dose of nucleated bone marrow cells was 3.6 108/kg (range, 1.6 to 4.9 108/kg). After transplantation, 6 patients received immunosuppressive therapy: One received methotrexate, 1 received corticosteroids, 2 received cyclosporine, and 2 received cyclosporine and corticosteroids. We did not ascertain the reasons why immunosuppressive therapy was given after transplantation. The likelihood that the first transplantation would be preceded by conditioning increased during the study years: Only 3 of the initial 20 (15%) patients receiving their first transplant received conditioning compared with 14 (70%) of the subsequent 20 patients receiving their first transplant (P = 0.05). Patients who had conditioning before receiving their first transplants had lower leukocyte, granulocyte, and platelet counts and had had more pretransplantation transfusions than the patients who did not have pretransplantation conditioning (Table 1). Table 1. Variables Correlated with Use of Conditioning before First Transplantation* Outcomes The results of transplantation are summarized in Figure 1. Figure 1. Outcome of transplanting bone marrow from genetically identical twins into 40 patients with aplastic anemia. Hematologic Response: First Transplantation Not Preceded by Pretransplantation Conditioning Seven of the 23 patients (30%) who received a first transplant without first receiving conditioning had a sustained complete response; 16 did not. Five of the 16 had a complete response but had relapse a median of 35 weeks after transplantation (range, 11 to 103 weeks). Seven other patients had a partial response; relapse occurred a median of 10 weeks after transplantation (range, 8 to 16 weeks). Four patients had no response. Granulocyte counts before transplantation were higher in the 12 complete responders than in the 11 patients who did not have a complete response (0.9 109/L [range, 0 to 1.6 109/L] compared with 0.3 109/L [range, 0 to 1.2 109/L]; P = 0.048). Granulocyte and platelet counts and number of transfusions before transplantation did not differ between the 7 patients who had sustained complete response and the 5 patients who had complete response and later had relapse. No correlation was seen between the likelihood of a sustained complete response and age, sex, cause of aplastic anemia, interval from diagnosis to transplantation, previous therapy, infections developing within 1 week before transplantation, previous transfusions, donor pregnancies, or number of cells transplanted. The 16 patients who did not have a sustained complete response after receiving the first transplant without first receiving conditioning had one to four additional transplantations. One patient who did not have conditioning before receiving a second transplant had a sustained complete response. Eleven of 15 patients (73%) who received conditioning before the second transplantation had a sustained complete response. One of the 15 patients died of treatment-related toxicity 1 month after transplantation. Three of the 15 did not have a sustained complete response after receiving a second transplant: Of these, one patient with a partial response and one patient with no response received a third transplant after conditioning. Both had sustained complete responses after the third transplantation. After each of five transplantations, one patient had transient hematologic responses that lasted 11 to 38 months. He died after receiving the fifth transplant. Hematologic Response: First Transplantation Preceded by Conditioning Seventeen patients received their first transplant after first receiving conditioning. Thirteen (76%) had a complete response, and 11 (64%) had a sustained complete response. One patient had relapse 20 months after transplantation; a second transplantation preceded by conditioning resulted in a sustained complete response. Patients who received conditioning before receiving the first transplant had a higher incidence of sustained complete responses than did patients who did not receive conditioning before receiving the first transplant (P = 0.033; Fisher exact tes

A European multicenter study of chronic graft-versus-host disease : the role of cytomegalovirus serology in recipients and donors-acute graft-versus-host disease, and splenectomy

A group of 466 leukemic bone marrow transplanted patients were reported from 17 European bone marrow transplantation teams. Of these, 285 survived more than 3 months and could be evaluated for chronic GVHD. The cumulative incidence of chronic GVHD was 32% two years after BMT. The following factors were statistically significantly associated with chronic GVHD in bivariate analysis: high donor and recipient age, splenecacute GVHD, pretransplant seropositivity to CMV among the recipients and the donors, and donor seropositivity to 3 or 4 different herpesviruses, compared with 0-2, prior to BMT. In multivariate analysis pretransplant recipient CMV seropositivity in combination with donor CMV seropositivity prior to BMT (P = 0.0006), a previous grade II-IV acute GVHD (P = 0.001), and splenectomy (P = 0.01) were significantly associated with chronic GVHD. Thus, in addition to acute GVHD, CMV immune donor cells may be triggered by latent CMV in the recipient, which may play a role in the triggering of chronic GVHD. The possible role of splenectomy in GVHD is also discussed.

CD25 Blockade Delays Regulatory T Cell Reconstitution and Does Not Prevent Graft-versus-Host Disease After Allogeneic Hematopoietic Cell Transplantation

Daclizumab, a humanized monoclonal antibody, binds CD25 and blocks formation of the IL-2 receptor on T cells. A study of daclizumab as acute graft-versus-host disease (GVHD) prophylaxis after unrelated bone marrow transplantation was conducted before the importance of CD25+FOXP3+ regulatory T cells (Tregs) was recognized. Tregs can abrogate the onset of GVHD. The relation between Tregs and a graft-versus-malignancy effect is not fully understood. An international, multicenter, double-blind clinical trial randomized 210 adult or pediatric patients to receive 5 weekly doses of daclizumab at 0.3u2009mg/kg (nu2009=u200969) or 1.2u2009mg/kg (nu2009=u200976) or placebo (nu2009=u200965) after unrelated marrow transplantation for treatment of hematologic malignancies or severe aplastic anemia. The risk of acute GVHD did not differ among the groups (Pu2009=u2009.68). Long-term follow-up of clinical outcomes and correlative analysis of peripheral blood T cell phenotype suggested that the patients treated with daclizumab had an increased risk of chronic GVHD (hazard ratio [HR],u20091.49; 95% confidence interval [CI], 1.0 to 2.3; Pu2009=u2009.08) and a decreased risk of relapse (HR, 0.57; 95% CI, 0.3 to 1.0; Pu2009=u2009.05), but similar survival (HR,u20090.89; 95% CI, 0.6 to 1.3; Pu2009=u2009.53). T cells from a subset of patients (nu2009=u2009107) were analyzed by flow cytometry. Compared with placebo, treatment with daclizumab decreased the proportion of Tregs among CD4 T cells at days 11-35 and increased the proportion of central memory cells among CD4 T cells at 1 year. Prophylactic administration of daclizumab does not prevent acute GVHD, but may increase the risk of chronic GVHD and decrease the risk of relapse. By delaying Treg reconstitution and promoting immunologic memory, anti-CD25 therapy may augment alloreactivity and antitumor immunity.