Phyllis Warkentin

Successful bone-marrow transplantation for infantile malignant osteopetrosis

A five-month-old girl with autosomal-recessive osteopetrosis received a bone-marrow transplant from her five-year-old HLA-MLC-identical brother after preparation with cyclophosphamide and modified total-body irradiation. Engraftment was documented by chromosomal analysis. Anemia, thrombocytopenia, and leukoerythroblastosis corrected within 12 weeks of transplantation. Low serum calcium and elevated serum alkaline and acid phosphatase levels became normal. Serial x-ray studies revealed bony remodeling and new nonsclerotic bone formation. A pretransplantation bone biopsy revealed small marrow spaces, rare marrow elements, increased osteoclasts, and no bony resorption. After transplantation, osteoclasts were actively resorbing bone, and medullary cavities contained normal bone marrow. Fluorescent Y-body analysis after transplantation revealed donor (male) osteoclasts and recipient (female) osteoblasts. Monocyte bactericidal activity, markedly decreased before transplantation, became normal. Vision, hearing, growth, and development were progressively improving 16 months after transplantation. Allogeneic bone-marrow transplantation appears to be the treatment of choice in this fatal disorder.

Outcomes of Treatment of Children and Adolescents With Recurrent Non-Hodgkin’s Lymphoma and Hodgkin’s Disease With Dexamethasone, Etoposide, Cisplatin, Cytarabine, and l-Asparaginase, Maintenance Chemotherapy, and Transplantation: Children’s Cancer Group Study CCG-5912

PURPOSE To determine the toxicity and response rate in children treated with dexamethasone, etoposide, cisplatin, high-dose cytarabine, and L-asparaginase (DECAL) for recurrent non-Hodgkins lymphoma (NHL) and Hodgkins disease (HD). PATIENTS AND METHODS Ninety-seven children with recurrent NHL (n = 68) or HD (n = 29) were enrolled. Treatment consisted of two cycles of DECAL, then bone marrow transplantation or up to four cycles of ifosfamide, mesna, and etoposide alternating with DECAL maintenance therapy. RESULTS After two cycles of DECAL induction therapy, complete response (CR) or partial response (PR) was reported in 19 (65.5%; 10 CRs and nine PRs) of 29 patients with HD and 29 (41.6%; 23 CRs and six PRs) of 68 patients with NHL. When only 24 patients with HD and 58 patients with NHL who were assessable for response were considered, the response rates were 79.2% (19 of 24 patients) and 50.0% (29 of 58 patients), respectively. Five-year event-free survival was 26% +/- 9% and 23% +/- 5% in patients with HD and NHL, respectively. Five-year survival was 31% +/- 14% and 30% +/- 6%, respectively. Although median time to treatment failure was significantly longer in patients with HD (EFS, P =.002; survival, P =.011), this difference did not translate into a higher long-term survival. Grade 3 or 4 toxic effects were observed during induction in 70 (72%) of 97 patients and during maintenance in 45 (70%) of 64 courses of DECAL therapy. Pancytopenia and systemic infections in particular were frequently observed. Other toxic effects were uncommon. Although not a formal part of the therapy or the study design, 42 patients who responded to therapy who underwent bone marrow transplant did not show any benefit from this approach. CONCLUSION DECAL is an effective and tolerable salvage regimen for treating patients with recurrent NHL and HD.

Transplantation of major ABO-incompatible bone marrow depleted of red cells by hydroxyethyl starch

Abstract. 23 bone marrow transplant recipients whose donors where major ABO‐incompatible received marrow depleted of red cells prior to infusion utilizing gravity sedimentation in hydroxyethyl starch. The in vitro red cell‐depletion procedure effectively removed 97.8% (mean) of the red cells from the harvested marrows and preserved 86.8% of the nucleated cells and 98.2% of the CFU‐C activity in 25.4% of the original volume. All recipients had a significant quantity of isohemagglutinins of both IgM and IgG classes demonstrable in their serum at the time of the marrow infusion. Patients were premedicated and well‐hydrated prior to the infusion and tolerated the infusion well. These patients demonstrated bone marrow engraftment at the same rate as did those patients whose marrow donors were either ABO‐identical or minor ABO‐incompatible. There was no difference in the incidence of or time to development of graft versus host disease, the incidence of graft rejection, or patient survival among the groups. Recipients of red cell‐depleted major ABO‐incompatible bone marrow transplants demonstrated production of donor‐type red cells somewhat later and required slightly more red cell transfusion support that did the other groups of recipients. This red cell‐depletion technique is safe and effective in the management of major ABO‐incompatible bone marrow transplantation.

Severe Delayed Hemolytic Transfusion Reaction Complicating an ABO‐Incompatible Bone Marrow Transplantation

Abstract. A 26‐year‐old, blood group O bone marrow transplant recipient experienced a severe, delayed hemolytic transfusion reaction 6 days following transplantation of marrow from his HLA‐mixed lymphocyte culture ‐ identical, blood group AB sister. The patients pretransplant serum contained both anti‐A (IgG titer = 1:128; IgM = 1:32) and anti‐B (IgG = 1:16; IgM = 1:64) which was reduced by a two‐plasma volume plasma exchange followed by transfusion of four units of incompatible, donor type red cells. The patient experienced no immediate adverse reaction. On the 6th posttransplant day, he became acutely dyspneic. His hematocrit dropped to 18%; the direct antiglobulin test was positive for IgG and complement; anti‐A and anti‐B were eluted from his red cells. His peripheral blood smear demonstrated extensive agglutination resembling a mixed field reaction. This case demonstrates that significant morbidity may be associated with major ABO‐incompatible bone marrow transplantation, that the transfusion of incompatible red cells should be undertaken with extreme caution, and that efforts should be continued to develop methods of pretransplant in vitro red cell removal from the infused bone marrow.

Successful engraftment of NA1 positive bone marrow in a patient with the neutrophil antibody, anti-NA1

An 11-yr, 9-mo-old girl with a 5-hr history of severe aplastic anemia unresponsive to androgen or steroid therapy was treated a bone marrow transplant from her 7-yr-old, HLA-MLC identical, APO incompatible, male sibling. Donor neutrophils were positive for the NA1 antigen. The patients pretransplant serum contained a neutrophil specific antibody, anti-NA1, reactive against donor neutrophils, which was demonstrable by both granulocyte agglutination and granulocyte cytotoxicity assays. The transplant preparative regimen consisted of cyclophosphamide, 50 mg/kg/day for 4 days, and total lymphoid irradiation (750 rads, 26 rads/min by 4 meV linear accelerator). A two plasma volume exchange (4,800 ml) by continuous flow centrifugation with an Aminco cell separator was performed one day prior to transplant because of ABO incompatibility. Following plasma exchange, anti-NA1 cytotoxic titer, 1:8 preexchange, was no longer detectable; anti-NA1 agglutinating titer had only decreased from 1:64 to 1:32. She experienced no adverse reaction to transplantation of 4:8 X 10(8) nucleated cells/kg. Marrow engraftment was demonstrable by Day 14 by steadily increasing leukocyte and platelet counts, red cells of donor ABO group, and bone marrow chromosomes showing a normal male, 46 XY karyotype. This case of successful bone marrow engraftment without delayed neutrophil recovery in the presence of a neutrophil specific antibody NA1 suggest that neutrophil specific antigens are not functionally present on the pluripotent stem cell. Histoincompatibility for neutrophil specific determinants need not eliminate the possibility of bone marrow transplantation for aplastic anemia between siblings identical for the major histocompatibility loci.

Combined Immunosuppression Using Cyclophosphamide Plus Total Lymphoid Irradiation in Preparation for Allogeneic Marrow Transplantation in Humans

Cellular engineering using allogeneic bone marrow offers an attractive form of therapy for a variety of human immunologic and hematologic disorders. The full potential of allogeneic marrow transplantation is yet to be realized, in large part due to problems associated with graft rejection and graft versus host disease [1–5]. Graft rejection (GR) continues to provide formidable obstacles to allogeneic marrow grafting when cyclophosphamide (CY) alone or CY in combination with other agents is used for pretransplant immunosuppression [1–5]. Graft versus host disease (GVHD) has been reported to occur following all immunosuppression combinations including CY and total body irradiation, reported to date [1–5]. In the present studies, we have attempted to reduce the incidence of GR and GVHD in man using new combinations of CY irradiation, or more recently, CY combined with total lymphoid irradiation. Results to date are the subject of this report.

672 SUCCESSFUL BONE MARROW TRANSPLANTATION (BMT) FOR APLASTIC ANEMIA WITH AN HLA-MLC NON-IDENTICAL PARENT DONOR

Successful BMT was performed in a 9 yr. old black female with severe idiopathic aplastic anemia from her HLA-MLC non-identical father. Initial Hgb.=3.8 gm.%, retic. count=0.1%, WBC=700 cmm., platelets=10,000 cmm.; bone marrow biopsy was markedly hypocellular with 85% non-hematopoietic elements. Tissue typing showed the patient to be HLA A-1 B-8, A-26 B-7; the father was HLA A-1 B-8, A-3 B-7. In mixed leukocyte culture (MLC), there was low but significant bidirectional (10%; 16%) stimulation. Cell mediated lympholysis demonstrated no significant killing. Pre-transplant preparation included Procarbazine 15 mg/kg/day × 3 days, anti-thymocyte globulin (ATG) 15 mg/kg/day x 3 days, and 750 rads of total body irradiation by linear accelerator. Cells from the donor (6.9 × 108/kg) were infused intravenously. Graft versus host (GVH) prophylaxis following BMT consisted of IV Methotrexate weekly × 100 days and ATG and corticosteroids on days 7-21. By day 28 post BMT, cells of donor HLA type were present and marrow chromosomes were 100% XY. On days 29-31 mild GVH developed with fever, rash and slight liver enzyme elevations. Skin biopsy was consistent with GVH. Skin GVH resolved with Prednisone treatment. At 7 months post BMT peripheral counts are normal, however liver enzyme elevations persist. Marrow engraftment with minimal GVH in this patient should encourage further trials of BMT in patients without HLA-MLC identical siblings.