含白消安注射液的预处理方案治疗急性髓细胞白血病二例并文献复习

 目的 评价白消安注射液（ivBu）作为急性髓细胞白血病（AML）造血干细胞移植（HSCT）预处理的疗效和安全性。方法 2例AML患者采用ivBu联合环磷酰胺（Cy）进行预处理,进行HLA相合的同胞外周血干细胞移植,观察其疗效和安全性。结果 2例患者均成功植入,没有严重毒副反应、肝窦状隙阻塞综合征（SOS）、严重急性移植物抗宿主病（GVHD）发生。结论 ivBuCy2方案作为AML预处理方案安全有效。     

Functional organization of the hematopoietic stem cell compartment: implications for cancer and its therapy

Recent discoveries indicate that hematopoietic stem cells have limits on their proliferative capacity and are unable to divide indefinitely. There is great heterogeneity within the compartment as to the extent of this proliferative limitation. At any given time it appears that hematopoiesis is maintained by the progeny of only a few stem cells. When these are exhausted the progeny from other stem cells take their place. The observations of proliferative limitation, heterogeneity, and clonal succession must be incorporated into any model of stem cell organization. These new discoveries and the models incorporating them have important clinical implications. They may explain the inability of normal tissues to develop drug resistance and they also offer a mechanism by which cell renewal systems decrease the development of malignancies. In the selection of chemotherapeutic agents not only the effectiveness of the drug upon the tumor must be considered, but also how specific agents affect the stem cell compartment. These data have important implications in the use of bone marrow transplantation for both malignant and nonmalignant disease.     

Residual injury to the hemopoietic microenvironment following sequential radiation and busulfan

Our earlier studies in mice showed that sequential radiation and cyclophosphamide suppressed marrow stromal cells (MSC) and prevented local hemopoietic repopulation for several months. Because others have shown that busulfan administration caused marrow aplasia, we studied its ability, combined with radiation, to produce a peristent microenvironmental defect in mice. Intraperitoneal administration of four weekly doses of 20 mg/kg busulfan, starting one week after 1500 rad leg irradiation, produced a severe microenvironmental lesion for 6 months reflected by lack of repopulation in femoral marrow to greater than 50 % of normal by MSC, hemopoietic stem cells (CFU-S), and granulocyte-macrophage precursors. Differential marrow cell counts revealed that precursors of hemopoietic cells were more profoundly affected than their progeny. Hemopoietic stem cells and MSC failed to recover in busulfan-treated mice at 6 months to the same extent as those treated with cyclophosphamide. In addition, the busulfan-treated mice had an excessive number of myeloid blast cells and a severe erythroid depletion suggesting that these animals were preleukemic. We conclude that: 1) sequential radiation and busulfan administration caused long-term microenvironmental damage reflected by incomplete repopulation of the femoral marrow and suppression of MSC, and 2) multiple courses of busulfan prevented hemopoieticrepopulation longer than a similar regimen of cyclophosphamide.     

Assessing permanent damage to primitive hematopoietic stem cells after chemotherapy using the competitive repopulation assay

The competitive repopulation assay was used to document the effects of six chemotherapeutic agents on primitive hematopoietic stem cells. The assay measures the relative abilities of donor cells to produce circulating erythrocytes and lymphocytes in lethally irradiated congeneic mice over a period of 6 months. Long-lasting marrow reconstitutive deficits in cells of donor origin occurred after exposure to 5-fluorouracil (5FU), bis-chloronitrosourea (BCNU), cyclophosphamide (CTX), vincristine (VCR), and actinomycin D (ACT) but not after exposure to cytosine arabinoside (ARA). Repopulating abilities were reduced after as little as a single dose of CTX or BCNU. A second dose of BCNU caused even more severe effects. A single dose of 5FU had no effect on repopulating abilities despite a temporary 10-fold reduction in marrow cell number, but multiple doses reduced the marrow stem-cell replicative ability to less than half of the normal control levels. These effects were not reliably predicted or detected by colony-forming assays or by reductions in marrow cell number. Thus, long-lasting proliferative defects in the primitive hematopoietic stem-cell (PHSC) population can result from the use of chemotherapeutic agents. Such findings may have clinical implications, especially in individuals receiving repeated or prolonged administration of these agents or in instances of marrow transplantation.This work was supported in part by National Institutes of Health grants DK-25 687, AG-00 594, and AG-06 232     

Effect of etoposide,carmustine, vincristine, 5-fluorouracil,or methotrexate on radiobiologically oxic and hypoxic cells in a C3H mouse mammary carcinoma in situ

Summary The effect of etoposide (VP16), carmustine (BCNU), vincristine (VCR), methotrexate (MTX), and 5-fluorouracil (5-FU) on the oxic and hypoxic cells in a C3H mammary carcinoma in CDF₁ mice was investigated using an in situ local-tumor-control (TCD₅₀) assay. The surviving fraction (SF) was calculated from the size of the radiation dose needed to inactivate the surviving tumor cells in drug-treated tumors relative to untreated controls. Preferential drug cytotoxicity towards oxic and hypoxic cells was evaluated from the difference in the response to irradiation under ambient and clamped conditions, respectively. Three drugs caused a significant (P<0.05) reduction in the survival of hypoxic cells, the SFs being 0.31 (VP-16), 0.13 (BCNU) and 0.16 (VCR). VCR was also toxic towards oxic cells (SF, 0.17), whereas VP16 and BCNU had no significant effect on these cells (SF, 0.5 and 0.76, respectively). Two drugs produced significant killing of cells in the oxic compartment: 5-FU (SF, 0.10) and MTX (SF, 0.22); these two drugs had no effect on hypoxic cells (SF, 0.78 and 1.11, respectively).This work was supported by the Danish Cancer Society and the Jacob and Olga Madsen Foundation     

早期进行同胞及非亲缘异基因造血干细胞移植治疗45岁以下多发性骨髓瘤

 目的　了解早期进行同胞及非亲缘异基因造血干细胞移植治疗45岁以下多发性骨髓（MM）的疗效及不良反应。方法　3例38～44岁的MM患者,在两疗程化疗达到缓解后,早期进行HLA相合异基因造血干细胞移植,其中例1、2为同胞供者,例3为非亲缘供者。例1、2预处理方案采用氟达拉滨、白消安联合环磷酰胺,预防移植物抗宿主病（GVHD）采用甲氨蝶呤联合环孢素A。例3预处理方案采用改良白消安、环磷酰胺联合抗胸腺细胞免疫球蛋白,预防GVHD采用吗替麦考酚酯、甲氨蝶呤联合环孢素A。结果　3例患者均移植成功,例1出现Ⅱ度急性GVHD及广泛型慢性GVHD,例2、3均未出现GVHD,至今随诊时间为48、27、6个月,3例均至今均生存,无疾病复发迹象。结论　对45岁以下的MM患者,化疗缓解后,早期进行HLA相合的同胞及非亲缘异基因造血干细胞移植治疗,移植相关死亡率较低,完全缓解率高,有可能长期生存。     

非T细胞去除单倍体造血干细胞移植治疗T淋巴母细胞性淋巴瘤的初步临床研究

 目的　探讨非T细胞去除单倍体造血干细胞移植（haplo-HSCT）治疗T淋巴母细胞性淋巴瘤（T-LL）的疗效。方法　3例确诊的T-LL患者获得缓解后接受了粒细胞集落刺激因子（G-CSF）动员后的非T细胞去除的单倍体亲缘供体的骨髓干细胞输注。其中2例患者预处理采用包含环磷酰胺（CTX）、全身照射（TBI）和阿糖胞苷（Ara-C）的清髓性方案,另1例患者采用包含CTX和白消安（BU）、Ara-C的清髓性方案;3例患者都采用了包含兔抗人胸腺细胞球蛋白（ATG）的加强的急性移植物抗宿主病预防方案。结果　所有患者均获得快速完全的造血重建,中性粒细胞和血小板中位恢复时间分别为12 d和13 d。3例患者中位随访24个月（9～75个月）,均无瘤生存。结论　非T细胞去除haplo-HSCT治疗T-LL的相关不良反应可以耐受,患者可能获得长期生存。     

Xenografts in pharmacologically immunosuppressed mice as a model to test the chemotherapeutic sensitivity of human tumors

A human tumor xenograft model using pharmacologically immunosuppressed mice was assessed for its suitability to test preclinically the sensitivity of colorectal carcinomas, bone sarcomas and melanomas against anticancer agents. Besides ionizing radiation, 14 cytotoxic drugs including 5-fluorouracil (5-FU), dimethylmyleran (DMM), cytosine arabinoside, cyclophosphamide, melphalan, BCNU, mitomycin C, adriamycin, bleomycin, etoposide, vinblastine, cisplatin, procarbazine and DTIC were assayed. Ionizing radiation, 5-FU and DMM were also applied at lethal doses followed by bone-marrow rescue heavy therapy. Four colon carcinomas responded poorly to most of the agents but one tumor displayed marked sensitivity to BCNU. Lethal doses of radiation, 5-FU and DMM could also show considerable activity. High sensitivity was shown by a Ewing sarcoma to DMM and cyclophosphamide and by an osteosarcoma to the latter drug. No strong effects were seen against melanomas. Lethal doses of DMM induced the best regression of one colon carcinoma. In general, the superiority of heavy therapy for solid human tumors compared to maximally tolerated doses was demonstrated. Individual carcinomas of the same type displayed different drug sensitivity.     

A proposed mechanism of resistance to cyclophosphamide and phosphoramide mustard in a Yoshida cell line in vitro

Summary A Yoshida sarcoma cell line (Y_R/cyclo) showing decreased sensitivity to metabolically activated cyclophosphamide in vitro has been shown to be cross-resistant to phosphoramide mustard, the ultimate alkylating agent formed from cyclophosphamide. Resistance to these alkylating agents has been shown to be associated with increased activity of the glutathione S-transferase group of enzymes, and with elevated levels of glutathione, the cosubstrate of the enzyme. The resistant cell line shows lower levels of cellular damage, as measured by alkaline elution following treatment with phosphoramide mustard, than the parental (Ys) line. The mechanism of resistance is ascribed to increased deactivation of potentially damaging metabolites of cyclophosphamide by the glutathione S-transferase enzymes, resulting in decreased cellular damage in the resistant cell line.This work was supported by a grant from the Cancer Research Campaign     

Effects of cyclophosphamide and of busulfan on spleen colony-forming units and on hematopoietic stroma.

The effects of cyclophosphamide (CY) and busulfan (BU) on the hematopoietic stromal function (HS-P) of mouse marrow were evaluated. Stromal function of femoral marrow was assessed by implanting the test femur s.c. into an isogeneic host and determining the number of CFU-S in the implant 6 weeks later. Since the CFU-S have been shown previously to be primarily of host origin, this presumably measures the abilit- of donor hematopoietic sites to harbor host CFU-S. After injection of CY, the number of CFU-S in the marrow fell but recovered to normal within 6 weeks. The HS-P function fell to half-normal after 10 mg of CY and did not regenerate detectably in 6 weeks. On the other hand, 2 mg of BU i.p. caused a lesser initial decline in the number of CFU-S, but recovery was still incomplete after 6 weeks. BU given p.o. had a more marked effect on CFU-S and caused a significant decline in the HS-P function. Doses of CY (5 mg/dose) given intermittently appear to cause cumulative damage to HS-P function. HS-P function did not, in any experiment, recover significantly in the 6 weeks following the last dose of CY. This result suggests that large doses of the alkylating agent CY causes prolonged and perhaps permanent HS-P damage. This damage to the HS-P is cumulative when the CY is given at weekly intervals. Despite lack of HS-P recovery, CFU-S regenerate rapidly after CY therapy is stopped. On the other hand, BU also causes damage to the HS-P. However, even when BU is given at a dosage that does not significantly affect the HS-P, CFU-S recovery is delayed, suggesting that BU affects the CFU-S in a manner that differs qualitatively from that of CY.     

The regulation of hematopoietic stem cell and progenitor mobilization by chemokine SDF-1

The chemokine, stromal derived factor-1 (SDF1) has been shown to modulate the homing of stem cells to its site by mediating chemotaxis. We demontrated overexpression of SDF-1 induced mobilization of cells with stem cell potential (CFU-S, long-term reconstituting cells). Moreover, SDF-1 activated matrix metalloproteinase-9 induced in bone marrow (BM) cells, causing the release soluble Kit-ligand and permitting the transfer of hematopoietic stem cells (HSCs) from a quiescent to a proliferative niche. The role of SDF-1 in the process of HSC migration and the mechanism underlying this HSCs migration will be reviewed. These studies lay the foundation for using SDF-1 to induce mobilization of progenitor cells in a BM transplantation setting.     

Long-term consequences of chemotherapeutic agents on hematopoiesis: development of altered radiation tolerance

The long-term effects of chemotherapeutic agents on subsequent radiation tolerance of the hematopoietic marrow were studied after a single injection of doxorubicin, 5-fluorouracil, or cyclophosphamide at a maximum tolerated dose. At designated intervals following drug treatment, drug-treated and age-matched control male B6D2F1 mice were exposed to 4.5 Gy of total-body irradiation, and the recovery kinetics of the stem cell (assayed at days 8 and 13 colony-forming spleen units) and progenitor (burst-forming erythroid units, and colony-forming erythroid and granulocyte/macrophage units) compartments were established. Response deficits were calculated for each compartment by comparison of treated and control recovery curves at 5 intervals over 32 weeks. Based on these response deficits, a number of conclusions were drawn: 1) There is selective drug specificity for the more primitive (13d) and mature (8d) CFUs subpopulations; 2) these sensitivities determine the temporal consequences of drug treatment on subsequent radiation tolerance in the marrow (e.g., acute, delayed, or long term); and 3) drugs that influence long-term radiation tolerance of the marrow are dose dependent and initially affect the more primitive stem cells. The data suggest that the initial lesion in the stem cell compartment, resulting in long-term enhancement of radiosensitivity, involves a major restriction (either in cell number or in genetic functionality) of the proliferative potential necessary for recovery from subsequent radiation insult.     

Cyclophosphamide Mobilization Does Not Improve Outcome in Patients Receiving Stem Cell Transplantation for Multiple Myeloma

PurposePatients with multiple myeloma who undergo autologous stem cell transplantation (ASCT) and exhibit a complete response (CR) have a superior overall survival and time to progression (TTP). High-dose cyclophosphamide is often used before ASCT for mobilization of hematopoietic stem cells. We hypothesized that cyclophosphamide might further improve CR rates in patients undergoing ASCT. We searched the Mayo Clinic myeloma transplantation database for patients who had stem cell mobilization with hematopoietic growth factor alone or cyclophosphamide and growth factor. The impact of cyclophosphamide on CR rates and TTP was evaluated.Patients and MethodsA cohort of 201 patients was identified: 127 mobilized with cyclophosphamide and growth factor and 74 with growth factor alone. There were no statistically significant differences between the 2 cohorts in regard to age, sex, β₂-microglobulin level, plasma cell labeling index, cytogenetics, conditioning regimen, or disease status at time of transplantation.ResultsComplete response rates were 37.4% and 41.3% (P = 0.6115) for patients mobilized with cyclophosphamide combined with growth factor and growth factor alone, respectively, and TTPs were 19.9 months and 20.9 months (P = 0.59). In a multivariate analysis for TTP, cytogenetics and CR rates were the only independent variables (P = 0.0012 and P < 0.0001, respectively).ConclusionWe conclude that high-dose cyclophosphamide does not increase overall CR rates or improve TTP for patients with myeloma undergoing ASCT.     

Studies on the self-renewal ability of CFU-S which have been serially transferred in long-term culture or in vivo

The progressive decline in the repopulating ability of bone marrow serially-transferred through a succession of recipients is well documented. A similar series of transfers onto successive long-term culture adherent layers has been carried out using as 'donor' cells both adherent layer cells and cells from the culture supernatant. For as long as the in vitro serial transfer regime can be maintained the decline in self-renewal ability ('quality') of the CFU-S parallels the similar decline observed in vivo and occurs irrespective of the quality of CFU-S transferred. In both the in vivo and in vitro transfer regimes there is little or no loss of quality of CFU-S as a result of one 'transfer' although there may be a reduction in the total numbers of CFU-S in the mouse. However, a second and third transfer in vivo or in vitro leads to a rapid decline in the quality (self-renewal ability) of the CFU-S. Furthermore, despite the fact that the cells are transferred in vitro to a new adherent layer there is no recovery of the quality lost in the second transfer of the CFU-S. This fact implies that self-renewal potential of the CFU-S is a property intrinsic to the cell. The data presented here appear to exclude mitotic history and proliferative stress as factors determining the loss of self-renewal in CFU-S. They also fail to implicate stromal involvement in the decline. It may be that the dilution of an accessory cell or simply the disaggregation of the marrow may be major factors. The work presented indicates that the loss of self-renewal and repopulating ability of haemopoietic stem cells as a result of marrow transplantation may be studied using the long-term marrow culture and yield results relevant to in vivo marrow transplantation.     

BEAM or BuCyE high-dose chemotherapy followed by autologous stem cell transplantation in non-Hodgkin's lymphoma patients: A single center comparative analysis of efficacy and toxicity

We compared the efficacy and toxicity of BEAM (BCNU, etoposide, cytarabine and melphalan) and BuCyE (busulfan, cyclophosphamide and etoposide), given prior to autologous stem cell transplantation (ASCT), in 65 patients with non-Hodgkin's lymphoma. Of these 65 patients, 43 received BEAM and 22 received BuCyE. Their age, gender distribution, International Prognostic Index, status of disease at ASCT and median number of infused CD34⁺ cells/kg were similar. Neutrophil and platelet engraftment were significantly faster in the BuCyE group. Rates of mucositis, nausea/vomiting, diarrhea, bleeding and infections were similar in the two groups. Median overall survival and event-free survival did not differ significantly between the two groups. These findings indicate that BuCyE is an effective conditioning regimen, showing similar survival outcomes and toxicity profiles as BEAM. Furthermore, hematologic recovery is significantly faster in patients given the BuCyE conditioning regimen.     

Chemotherapy-induced pulmonary toxicity in mice bearing L1210 leukemia

Fatal pulmonary toxicity can be consistently produced in L1210 leukemia-bearing mice by single therapeutic doses of cyclophosphamide, BCNU, and mitomycin C but not by adriamycin. Lung toxicity is principally determined by an existing tumor burden at the time of drug administration. Thus when any of the four chemotherapeutic agents was given 5 days after L1210 transplantation there was no mortality. Pulmonary pathology in these mice was equivalent to that noted in normal mice receiving identical drug treatment or to that noted in untreated L1210-bearing mice sacrificed 7, 8, or 10 days after tumor transplantation. When chemotherapy was delayed to day 7 after L1210 transplantation for mitomycin C or to day 8 after transplantation for BCNU and cyclophosphamide, more severe pulmonary toxicity was found. Mortality within the first 5 days of treatment was 38, 50, and 80%, respectively. Pulmonary pathology included moderate to severe vascular congestion and interstitial pneumonitis, diffuse pulmonary hemorrhage often involving the entire pulmonary parenchyma, pulmonary edema, and alveolar cell metaplasia. A unique finding, associated with cyclophosphamide treatment, was the occurrence of perivascular-intramural edema of the walls of medium-size pulmonary vessels. It is hypothesized that stasis within the pulmonary capillary circulation, resulting from advanced tumor growth and from drug treatment, may contribute to the development of chemotherapy-related toxicity.     

Interaction of inhibitor and stimulator in the regulation of CFU-S proliferation

An inhibitor and stimulator of CFU-S proliferation can be obtained from haemopoietic tissue containing, respectively, relatively quiescent CFU-S (e.g. normal bone marrow) and proliferating CFU-S (e.g. regenerating bone marrow). In this paper we explore the capacity for inhibitor and stimulator production in relation to changes in the proliferative status of the CFU-S and their mode of interaction. The increase in proliferative activity of CFU-S following a concentrated regime of phenylhydrazine injections is paralleled by an increase in the capacity for stimulator production and a decrease in the capacity for inhibitor production. These processes are reversed as the normal low proliferative activity returns. Using density fractionated marrow populations, dose-response measurements show that while inhibitor- and stimulator-producing cells persist throughout the changes in CFU-S proliferation, their magnitude of factor production moderates in relation to those changes. The inhibitor and stimulator are not mutually destructive: the two factors retain their activities after co-incubation and re-separation. On the other hand, the presence of either factor blocks the synthesis of the other by the appropriate producer cells. A model for the regulation of CFU-S proliferation by the inhibitor and stimulator is thus suggested in which the relative spatial distributions of CFU-S in a microenvironment containing inhibitor- and stimulator-producing cells are an important feature. It also implies the existence of a signal from the CFU-S compartment which determines the appropriate inhibitor or stimulator production.     

Haematopoietic late effects of prolonged bleomycin treatment in mice

Summary In two studies, haematopoietic late effects of prolonged bleomycin treatment were evaluated in mice given serial injections of 21 mg bleomycin/m² weekly for 31 and 44 weeks, respectively. Femoral bone marrow cellularity measured at 43, 45, and 49 weeks after discontinuation of the drug in the first and after 20 weeks in the second study was found to be significantly (P<0.05) lower in the treated mice than in the controls. CFU-S, BFU-E, and CFU-C contents were also reduced in the treated bone marrow, but with the exception of CFU-S in the second study, differences from control values were not significant. Additional long-term bone marrow cultures performed in the second study revealed no marked changes in the marrow proliferative activity and the self-renewal of stem cells to explain the reduced marrow cellularity and stem cell content. These last findings might, therefore, be due to a decrease in femoral size with less marrow content in the treated mice, since measurements of the tibial weights in both groups showed that the bones in the treated animals were significantly (P<0.05) lighter than those in the controls.     

Allogeneic hematopoietic stem cell transplantation for paroxysmal nocturnal hemoglobinuria: a retrospective single‐center study

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare clonal disease of hematopoietic stem cell characterized by complement mediated intravascular hemolysis. There are different treatment modalities available for PNH, such as supportive care, eculizumab, and hematopoietic stem cell transplantation (HSCT); only the last one has a potential curative role. This study reported the outcome of HSCT transplanted PNH patients. Thirteen PNH patients between 2002 and 2014 participated in this study. All had full‐matched sibling donors, and the conditioning regimen was Bu/Cy (busulfan plus cyclophosphamide), and the source of stem cells was peripheral blood of the donors. Mean age at transplant was 27.46 years, and mean time to transplant was 41.30 months. Three were female and 10 were male. Three patients died at the end of follow‐up time, and the cause of death was graft versus host disease (GVHD) for all 3 cases. Survival analysis showed a 5‐year and a 13‐year survival rate of 74.07% and a significant relationship between a positive history of thrombosis and a higher mortality rate. HSCT has curative role in management of PNH with an acceptable survival rate and therefore can be considered as an acceptable choice for selected cases.