Raffaella Stocchi

Incidence, outcome, and risk factors of late-onset noninfectious pulmonary complications after unrelated donor stem cell transplantation

Summary:We evaluated the incidence, the risk factors, and the outcome of late-onset noninfectious pulmonary complications (LONIPCs) among 50 patients who underwent allogeneic stem cell transplantation from unrelated donors. Of the 39 patients surviving at least 3 months, 10 (26%) fulfilled the diagnostic criteria of LONIPCs and were further subclassified as having bronchiolitis obliterans (four patients), bronchiolitis obliterans with organizing pneumonia (four patients), and interstitial pneumonia (two patients). Two patients had a durable partial remission after treatment with prednisone and cyclosporine; the remaining eight patients did not respond to treatment and five of them died of respiratory failure. Advanced stage of disease at transplant and chronic extensive graft-versus-host disease (GVHD) were significantly associated with the development of LONIPCs. Pulmonary function test (PFT) results before transplantation were similar in all patients, but patients with LONIPCs had a significant decrease in PFT indexes at the third month after BMT compared with controls. Moreover, the rate of cyclosporine taper during the fourth and fifth months after BMT was significantly more rapid in patients with LONIPCs than in controls, suggesting that the risk of LONIPCs may be influenced by a faster reduction of GVHD prophylaxis.

P-glycoprotein, lung resistance-related protein and multidrug resistance-associated protein in de novo adult acute lymphoblastic leukaemia

Summary.  P‐glycoprotein (P‐gp), lung resistance‐related protein (LRP) and multidrug resistance‐associated protein (MRP) expression, and blast cell intracellular daunorubicin accumulation (IDA) were evaluated in 95 previously untreated cases of adult acute lymphoblastic leukaemia (ALL) using flow cytometry. Forty‐five out of 95 (47%) patients were P‐gp positive (+), 12/66 (18%) were LRP+ and 11/66 (17%) were MRP+. Eighteen out of 66 (28%) patients showed a simultaneous multidrug resistance (MDR)‐related protein expression higher than controls for more than one protein, while 24/66 (36%) cases did not overexpress any protein. Twenty‐one out of 24 (87%) cases overexpressing at least one MDR‐related protein had a defect in accumulating daunorubicin into their blast cells, while only 4/24 (16%) cases who did not overexpress any protein had similar features. The complete remission rates were similar in MDR‐positive and ‐negative (–) patients but relapses within 6 months were more frequent in P‐gp+ cases, and therefore the disease‐free survival duration was shorter in P‐gp+ than in P‐gp– patients (P = 0·01). The number of MRP+ and/or LRP+ cases was too small to be able to draw any conclusion on their role in affecting or predicting therapy outcome. In conclusion, P‐gp overexpression associated with a defect in daunorubicin accumulation is a frequent feature in adult ALL at onset and seems to be related to poorer therapy outcome and, consequently, a shorter disease‐free survival. LRP and MRP overexpression seems to be a rare event and no conclusion can be drawn on its prognostic role.

Dendritic cell recovery after autologous stem cell transplantation

There is persistent immunosuppression not only in allogeneic but also in autologous stem cell transplantation because humoral and cellular immunity may take a year or more to return to normal, with increased risk of infectious complications. This immune defect may also involve antigen presentation, in particular dendritic cell (DC) function. We evaluated DC subset reconstitution in 58 patients who underwent bone marrow (BM) or peripheral blood (PB) autologous haematopoietic stem cell transplantation (HSCT). In all patients DC type 1 (DC1) and DC type 2 (DC2) were already significantly lower than in normal individuals before conditioning therapy (DC1/μl 3.1 ± 1.0, DC2/μl 3.0 ± 1.1). On day 0 and day +7 the mean DC1 and DC2 numbers were very low in both groups. Patients who received unmanipulated marrow or peripheral blood stem cells reached pre-conditioning levels of DC1 and DC2 cells on day +20. In patients receiving selected CD34 cells, DC increased slowly and pre-transplant counts were observed only on day +60. Nearly ‘normal’ levels of DC1 and DC2 could be observed in the first group from day +180, and were maintained thereafter; in CD34+ selected patients DC1 and DC2 counts remained lower than normal. Our data emphasise that circulating antigen presenting cells (APC) recover quickly. It remains to be determined if DC frequency in PB reflects their tissue function. The relatively low incidence of infections in patients undergoing autologous transplantation, despite defective lymphocyte reconstitution, could be related to functionally efficient DC.

The therapy of primary adult systemic CD30-positive anaplastic large cell lymphoma: results of 40 cases treated in a single center.

The outcome of a series of adult patients, affected by primary systemic CD30-positive anaplastic large cell lymphoma (ALCL), treated with a sequential intensive therapeutic program, has been analyzed and all data available in the literature have been reviewed. Forty consecutive, unselected patients with ALCL were treated with the F-MACHOP regimen, followed by radiotherapy (RT) for residual mediastinal disease (15 cases) and by autologous stem cell transplantation (ASCT) conditioned with BAVC (29 cases). Eighty-nine percent (32/36) of the patients younger than 60 years were eligible for completing the sequential treatment. Since then, 3 patients in CR refused ASCT, 1 was excluded for cardiac toxicity and 3 progressed and died of disease. Thus, 29 have been so far submitted to the transplant procedure. CR and PR rates were 40% and 45% respectively after CHT; 52.5% and 35% after RT; 80% and 5% after ASCT, with 78% of patients transplanted in PR convertin to a CR. Actuarial overall survival is 85% at 48.5 months (93% at 66 months for the 29 transplanted patients) and disease free survival is 100% at 54 and 64 months respectively, with no relapses observed among patients who reached a CR. Considering our data and those of the literature, it can be concluded that although the role of ASCT in the therapy of ALCL must not be considered as definitive, its efficacy in converting PR into CR and in preventing relapses, suggests that a randomized trial comparing CHT alone vs CHT+ASCT should be undertaken.

Antibody Binding Capacity for Evaluation of MDR-Related Proteins in Acute Promyelocytic Leukemia: Onset Versus Relapse Expression

Multidrug resistance (MDR) remains a major obstacle for successful treatment in cancer, in particular in acute leukemia. In acute promyelocytic leukemia (APL), the high sensitivity to anthracyclines appears to be attributable to the low frequency of MDR proteins overexpression at onset even if 30% of patients still relapse and become resistant to therapy. In attempt to explain different blast cell sensitivity, we studied the expression of PGP, MRP1, MRP2, and LRP in 45 cases of APL, comparing onset of disease with relapse.

Autologous stem cell transplantation for aggressive non-Hodgkin’s lymphomas in first complete or partial remission: a retrospective analysis of the outcome of 52 patients according to the age-adjusted International Prognostic Index

The aim of the study was to retrospectively evaluate the outcome of patients with aggressive non-Hodgkin’s lymphoma (NHL), undergoing autologous stem cell transplantation (ASCT) in first complete (CR) or partial (PR) remission, according to the age-adjusted International Prognostic Index (IPI). Fifty-two consecutive patients, aged less than 60 years, with intermediate- or high-grade NHL, and at least one of the following adverse risk factors: bulky disease, B symptoms or Ann Arbor stage III–IV, and at least a PR after CHT (and radiotherapy (RT) on residual mediastinal mass when required), underwent ASCT conditioned with BAVC. Sixty-five percent (33/52) of the patients achieved CR after CHT; 69% (36/52) after CHT + RT; 90% (47/52) after CHT ± RT + ASCT. One death during conditioning and three major toxic events after ASCT were recorded. Overall survival (OS) is 98% at 37 months (16–88); disease-free survival (DFS) is 100% at 27 months (7–82). Comparing the observed results with those expected if patients were treated only with CHT, the sequential treatment including ASCT conferred an advantage in terms of CR rate of 14, 23 and 54%, respectively, in the low-intermediate (LI), high-intermediate (HI) and high (H)-risk groups, respectively. The 2-year OS advantage is 10, 21, 31 and 63%, respectively, and the 2-year DFS advantage is 12, 26, 38 and 39%, respectively. Even more striking is the 5-year projected advantage in the number of patients alive without disease, even when considering only the low (L) (P < 0.0001) and the li (P < 0.0001) risk groups. for patients in the higher (hi + h) risk groups, asct should be included in the initial plan of treatment as consolidation of first cr or pr, but the differences seen in this study suggest a formal comparison in a randomized study also for patients in the li risk group.

Effect of amifostine on the cytotoxicity of daunorubicin and daunoxome in tumor and normal cells

Anthracyclines are powerful cytotoxic agents, used as first-line treatment of leukemias and many other tumors, but host-tissue toxicity is their main dose-limiting factor. However, their therapeutic effects depend not only on the toxicity, hence on the dose, but also on drug resistance. Among the mechanisms that can account for cell sensitivity to anthracyclines, there is an overexpression of drug transport proteins, like the transmembrane P-glycoprotein (PGP), the multidrug- resistance-related protein (MRP) and the lung-resistance-related protein (LRP). Attempts to reduce the toxicity of chemotherapeutic agents without affecting their efficacy have been made using liposomal anthracyclines or cytoprotective agents, as Amifostine. The aim of this study was to evaluate and compare the toxic effects of Daunorubicin, in normal or liposomal formulation, used in combination with WR1065, the active metabolite of Amifostine, against normal and tumor cells. In conclusion these data show that the preincubation with WR-1065 does not inhibit the drug toxic effect on blast cells and on tumor cell lines, independently by their multidrug resistance phenotype, but has a cytoprotective effect on stem cells causing a drug cytotoxicity reduction of 10–20%. This advantage is even higher using the liposomal formulation of DNR. Therefore, Amifostine can offer a chance of protecting normal cells from the toxicity of anthracyclines, in normal or liposomal formulation. The combination of liposomal anthracyclines with Amifostine can confer further advantages in management of leukemic patients, especially the elderly where treatment toxicity is a main problem. These patients may be candidates for alternative therapeutic strategies and the combination of DNX and Amifostine is an attractive treatment for these cases where a low nonhematological toxicity is required.

Amifostine Does Not Inhibit the Toxic Effects of Anthracycline Derivates or Mitoxantrone on MDR Tumor Cell Lines

In this work three hum cell lines with multidrug resistance (MDR) caused by a P-glycoprotein (PGP) overexpression, CEM VLB, HL60 DNR, LOVO DX and two cell lines with MDR associated with a multidrug related protein (MRP) or a lung resistance-related protein (LRP) overexpression named GLC4 ADR and SW1573/2R120 were tested for Amifostine protection against Daunorubicin, Doxorubicin, Idarubicin and Mitoxantrone toxicity. This class of anticancer agents was chosen because they are commonly used in the first line treatments of acute leukemias where a PGP, an LRP or an MRP overexpression often occurs even at onset. A 7-day incubation with escalating doses of anticancer agents with or without a 15 minute preincubation in Amifostine or its active metabolite WR-1065 were used. In conclusion, in none of the MDR positive and negative cell lines did Amifostine modify the toxicity of the anticancer drugs. The observation that even the WR-1065 metabolite gave no protection against Anthracyclines toxicity strengthened the data and provided confirmation for the further in vivo testing of the safety and efficacy of Amifostine in leukemias.

Impact of CD34 cell dose on acute graft versus host disease after allogeneic bone marrow stem cell transplantation

Allogeneic bone marrow transplantation is being performed more frequently for various haematological, oncologic, immune deficiency and metabolic diseases. Despite improvements in techniques to ensure histocompatibility, GVHD remains one of the more frequent complications of this procedure, resulting in significant morbidity and mortality. Although histocompatibility remains the strongest risk factor for acute GVHD, within the subset of patients receiving non-T-cell-depleted marrow transplants from HLA-matched related donors several other variables have been associated with an increased incidence of acute GVHD. These include diagnosis, recipient–donor sex mismatch, recipient age, female donor–male recipient pair, alloimmunised and/or parous donor, increased dose of total body irradiation (TBI), lower intensity of GVHD prophylaxis and cytomegalovirus seropositivity of recipient or donor [1,2]. Herein we have investigated whether demographic characteristics (of the patients and donors) and bone marrow composition (in terms of nucleated cells, MNC, CD34þ , CD3þ , CD4þ , CD8þ and CD56þ cells dose) are important risk factors for the development and the severity of acute GVHD after allogeneic bone marrow transplantation. From April 1995 to April 1999, 42 consecutive patients aged less than 60 years old were submitted to a myeloablative preparative regimen and an unmanipulated bone marrow stem cell graft from an HLA-matched related donor at the Division of Haematology, Udine. General patient characteristics and clinical features at presentation are listed in Table I. The conditioning regimen used for all the patients consisted of Busulfan 1 mg/kg b.w. forth daily from day 27 to 24 and cyclophosphamide 60 mg/kg b.w. once daily from day 23 to 22. GVHD prophylaxis consisted of cyclosporine (CSA) and methotrexate (MTX). CSA was administered at 3 mg/kg b.w./day i.v. continuous infusion from day 21: doses were adjusted to maintain whole blood steady state or trough levels at 250–350 ng/ml by radioimmunossay (RIA) for parent drug. After engraftment, CSA was converted to oral, continued through day 210, and tapered off thereafter. MTX was administered at 10 mg/m i.v. on days þ1, þ3, þ6 and þ11. Patients were observed prospectively for the development of acute GVHD. The diagnosis of GVHD was based on clinical evidence (in occasional cases by histologic confirmation) and GVHD was graded according to Glucksberg and to IBMTR criteria. Characteristics of the bone marrow stem cell grafts and of donors are shown in Table II. Bone marrow cell collections were assessed for CD34, CD3, CD4, CD8, CD16, CD56 and CD19 by flow cytometry on the day of collection, which was the same of infusion in all the patients. In case of ABO incompatibility, only MNC were infused. All analysis was performed with the last evaluation date setting as December 2000. The prognostic factors analysed in univariate and in multivariable analysis either for the development and for the severity of acute GVHD were: patient age, donor age, donor sex, donor parity, pair CMV seronegative, CD34þ , CD3þ , CD4þ , CD8þ , CD56þ , MNC and nucleated cell dose, haematological engraftment (days to PMN . 1000/mmc and PLT . 50,000/mmc). The median time for neutrophil count higher than 1000/mmc was 21 days (12–40), while the median time for reaching a self-sustained platelet count higher than 50,000/mmc was 27 days (13–70).