Peter J. Tutschka

Marrow Transplantation for Acute Nonlymphocytic Leukemia after Treatment with Busulfan and Cyclophosphamide

Fifty-one patients with acute nonlymphocytic leukemia (16 with end-stage disease, 17 in second or third remission or in early relapse, and 18 in first remission) were given infusions of HLA-identical sibling marrow after cytoreduction with high doses of busulfan and cyclophosphamide. Actuarial two-year survival rates were 0 per cent, 29 per cent, and 44 per cent, respectively. Twelve patients are still alive and in remission after 327 to 1488 days, with 10 surviving beyond two years. Acute graft-versus-host disease and viral pneumonia were the major causes of death. Leukemic cells failed to clear in one patient with end-stage disease, and a relapse with meningeal leukemia occurred in another. Only one other relapse was seen--in a patient given a transplant during a third remission. Survival was favorably affected by younger age and transplantation during first remission. We conclude that high-dose chemotherapy with busulfan and cyclophosphamide, followed by allogeneic-marrow transplantation, can produce long-term remission of acute leukemia. Chemotherapy with high-dose busulfan and cyclophosphamide before transplantation provides an effective alternative to cyclophosphamide and total-body irradiation before transplantation for the treatment of acute nonlymphocytic leukemia.

Ocular Manifestations of Graft-vs-Host Disease

In patients who have graft-vs-host disease (GVHD) after bone marrow transplantation, ocular involvement occurs in approximately 60% of cases. Among 13 such GVHD patients, the most frequent ocular manifestations included keratoconjunctivitis sicca, cicatricial lagophthalmos, and sterile conjunctivitis and uveitis. The severe ocular complications of persistent corneal epithelial defects and both noninfected and infected stromal ulceration were related to the concomitant dry-eye condition and could be managed by conventional therapy including topical lubricants and antibiotics, punctal occlusion, bandage soft contact lenses, tarsorrhaphy, tissue adhesive, conjunctival flap, and conjunctival homograft. Postmortem and surgical tissues from four patients revealed conjunctival and corneal epithelial thinning and keratinization, lacrimal inspissation without inflammatory infiltration, and diffuse choroiditis. Keratoconjunctivitis sicca in GVHD patients might be a combined result of drug toxicity effects and GVHD. The frequent and potentially severe ocular problems in these patients suggest that close ophthalmic monitoring is mandatory in bone marrow transplant recipients.

Lymphocytic bronchitis associated with graft-versus-host disease in recipients of bone-marrow transplants.

Graft-versus-host disease, a complication of allogeneic bone-marrow transplantation, involves primarily the skin, liver and intestines, but may also be associated with pneumonia. To determine the relation of graft-versus-host disease with pneumonia, we evaluated the autopsies of 59 allogeneic and two autologous recipients and 74 control patients with various pulmonary diseases, who had not received a bone-marrow transplant. Lymphocytic bronchitis, characterized by lymphocyte-associated necrosis of the bronchial mucosa and often the submucosal glands, was present in 12 of 20 patients with Grade 2 or greater graft-versus-host disease but in only three of 39 with Grade 0 to 1 disease (P less than 0.0005). Onset of respiratory disease correlated with the time of onset of graft-versus-host disease. Patients with lymphocytic bronchitis had a higher incidence of bronchopneumonia and acute bronchitis of the lower respiratory tract. Lymphocytic bronchitis did not occur in the controls and appears to be a component of graft-versus-host disease that leads to bronchopneumonia, probably through destruction of the mucociliary apparatus.

An in vitro predictive test for graft versus host disease in patients with genotypic HLA-identical bone marrow transplants

Acute graft versus host disease remains a major cause of morbidity and mortality in allogeneic bone marrow transplantation. To date, no clinically useful test has been reported that will predict the occurrence of graft versus host disease in genotypic HLA-identical donor-recipient pairs. We have developed a skin-explant model using donor lymphocytes that have been sensitized against recipient lymphocytes in vitro and cocultured with the recipients skin. Histologic changes compatible with acute graft versus host disease are found in the positive explants. To date 32 patients have been tested in a prospective manner. Among the 18 recipient-donor pairs that were positive, 16 patients were found to have histologic Grade 2 or higher graft versus host disease of the skin on biopsy. Among the 14 negative pairs, only 3 patients had histologic Grade 2 or higher graft versus host disease of the skin on biopsy. Thus, the model has a sensitivity of 84 per cent and a specificity of 85 per cent, and is a significant predictor of the histologic occurrence of graft versus host disease (P less than 0.0005 by chi-square test). The test may be useful in the selection of donors for bone marrow transplantation and in the planning of prophylaxis against graft versus host disease.

Bone marrow transplant in adrenoleukodystrophy

An allogeneic bone marrow transplant (BMT) from a normal HLA identical sibling donor was performed in a 13-year-old boy with rapidly progressive adrenoleukodystrophy (ALD). Engraftment and complete hematologic recovery occurred within 4 weeks, but neurologic deterioration continued. The patient died of an adenovirus infection 141 days after BMT. ALD is characterized by abnormally high plasma levels of very long chain fatty acids (VLCFA) as a result of impaired capacity to degrade them. Ten days after BMT, the white blood cell VLCFA levels and enzyme activity became normal; after 3 months, there was progressive reduction of plasma VLCFA to levels only slightly above normal.

Use of cyclosporin A in allogeneic bone marrow transplantation in the rat

ALLOGENEIC bone marrow transplantation (BMT) has become the therapy of choice for the treatment of severe aplastic anaemia and severe combined immunodeficiency diseases and is considered beneficial for the treatment and possible cure of malignant diseases, especially lymphohaematopoietic malignancies1. Several serious complications, however, prevent the full realisation of the therapeutic potential of this procedure. To accept an allogeneic marrow graft, patients (even those treated for aplastic anaemia) have to be conditioned with cytoreductive agents like cyclophosphamide (Cy) or total body irradiation (TBI), agents that have relatively low therapeutic indices for immunosuppression and marked toxicities. Furthermore, patients, even if matched with their respective donors at the major histocompatibility complex (MHC), have after engrafting successfully, a high incidence of potentially fatal graft-versus-host disease (GvHD). Third, patients, who successfully engraft have a severe immunodeficiency for several months after transplantation that apparently contributes to potentially fatal opportunistic infections in the post-grafting period2. Attempts to overcome these complications have had only limited success. Cyclosporin A (Cs A), an undecapeptide of fungal origin3, has been reported to have very profound antilymphocytic activities with very low degrees of myelotoxicity4. It has been shown to suppress a variety of humoral and cellular immune phenomena5, including the rejection of renal allografts in rabbits.6 It seemed reasonable, therefore, to study its effects in an animal model of bone marrow transplantation. Cs A permits the full establishment of a rat marrow graft across the major histocompatibility barrier. Given post grafting it prevents GvHD in an AgB mismatched donor–recipient combination and allows recovery of T-dependent immune functions as early as 28 d after transplantation. Thus, Cs A seems to be a promising agent for use in clinical marrow transplantation.

Suppressor cells in transplantation tolerance. I. Suppressor cells in the mechanism of tolerance in radiation chimeras.

Histoincompatible-complete radiation chimeras, after resolving acute graft-versus-host disease (GVHD), establish specific tolerance to host and donor alloantigens. This tolerance can be perturbed with immunosuppressive agents and infusions of small numbers of donor-type cells, with infusions of massive numbers of donor-type cells, or with infusions of a small number of donor-type cells, that were sensitized against host antigens prior to transfer. These chimeras possess T lymphocytes in the spleen that specifically suppress donor to host mixed lymphocyte reactions and adoptively transfer suppression of GVHD to secondary hosts. Nylon-wool fractionation of chimeric spleen cells restores the response of chimeric lymphocytes to host alloantigens, suggesting that transplantation tolerance is not attributable to clonal deletion but the activity of nylon-wool-adherent T suppressor spleen cells.

4-Hydroperoxyclophosphamide: a model for eliminating residual human tumour cells and T-lymphocytes from the bone marrow graft

Summary. Autologous bone marrow transplantation in acute leukaemia carries the risk of relapse from reinfusion of tumour cells present in marrow collected in remission and cryopreserved. An effective method for clearing marrow of tumour cells in required for a successful outcome. In the animal model 4‐hydroperoxycyclophosphamide (4‐HC) has proved to be effective in eliminating tumour cells from an autologous marrow graft. In the present studies, the in vitro effect of short‐and long‐term marrow cell incubation with 4‐HC on haemopoietic stem cells was investigated to determine the maximum concentration of 4‐HC that can be used for in vitro incubation without destroying the capacity of the marrow to effect complete haematological recovery as judged by residual CFUc content. However, loss of CFUc may not necessarily parallel survival of pluripotential stem cells. 4‐HC was also shown to be effective against peripheral T‐lymphocytes. Its possible therapeutic use in preventing or ameliorating graft‐versus‐host disease in allogeneic marrow grafts by preincubation with 4‐HC prior to transplantation is discussed.

Chronic graft-versus-host disease in the rat radiation chimera, I : clinical features, hematology, histology and immunopathology in long-term chimeras

The clinical features, pathology, and immunopathology of chronic graft-versus-host disease (GVHD) developing in the long-term rat radiation chimera are described. At 6 to 12 months post-transplant, the previously stable ACI/LEW chimeras developed patchy to diffuse severe hair loss and thickened skin folds, and had microscopic features resembling scleroderma, Sjögrens syndrome, and chronic hepatitis. Skin histology showed dermal inflammation and acanthosis with atrophy of the appendages, with progression to dermal sclerosis. The liver revealed chronic hepatitis with bile duct injury and proliferation and periportal piecemeal necrosis. The tongue had considerable submucosal inflammation, muscular necrosis, and atrophy and arteritis. The serous salivary glands, lacrimal glands, and bronchi had lymphocytic inflammation and injury to duct, acinar, and mucosal columnar epithelium. The thymus had lymphocyte depletion of the medulla with prominent epithelium. The spleen and lymph nodes had poorly developed germinal centers but increased numbers of plasma cells. IgM was observed along the basement membrane and around the basal cells of the skin and tongue and along the basement membrane of the bile ducts. IgM was present also in the arteries of the tongue. Immunoglobulins eluted from the skin cross-reacted with the bile duct epithelium and usually with both ACI and Lewis skin. Increased titers of speckled antinuclear antibodies were present in the serum of rats with chronic GVHD. Chronic GVHD in the long-term rat radiation chimera is very similar to human chronic GVHD and is a potentially excellent model for autoimmune disorders including scleroderma, Sjögrens syndrome, and chronic hepatitis.

Cutaneous busulfan effect in patients receiving bone‐marrow transplantation

Epidermal keratinocytes with abnormally large nuclei were found in 12 of 13 patients who received high‐dose busulfan and cyclophosphamide prior to receiving bone‐marrow transplantation for treatment of hematological malignancies. These cells were similar to those previously described in the lungs, cervix and bladder of patients on long‐term busulfan therapy. Marked keratinoeyte nuclear abnormalities were not observed in bone‐marrow transplant recipients who received a preparatory regimen of cyclophosphumide and total‐body irradiation. This histologic cutaneous busulfan effect was transient and was unrelated to the development of graft ‐versus‐host reaction.