Fractionation and dose rate effects in mice: a model for bone marrow transplantation in man

This study was designed to compare several fractionation and dose rate schedules to optimize the therapeutic ratio for total body irradiation (TBI). C3H/HeJ mice were given TBI and the bone marrow survival fraction was calculated using the CFUS assay. Irradiation was given at two dose rates: low dose rate (LDR) at 5 cGy/min or high dose rate (HDR) at 80 cGy/min in single fraction and fractionated regimens. The fractionated regimens were given as either 120 cGy three times daily, 200 cGy twice daily, or 200 cGy daily. The Do was 80 cGy for the single fraction, HDR group and 85 for the LDR group. For the fractionated regimens, the apparent Do's ranged from 55-65 indicating no sparing effect of fractionation for the normal bone marrow stem cells. Indeed, the Do's were smaller suggesting an increased sensitivity to irradiation with fractionation. Low dose rate (LDR) and fractionation were also studied for their influence on normal tissue toxicity following upper half body irradiation (UHBI). All the fractionated regimens had higher LD50/30 and LD50/30-180 values than those achieved by single fraction LDR alone. There was no significant dose rate effect for LD50/30 when 120 or 200 cGy fractions were used. However, dose rate was important for LD50/30-180 with 200 cGy but not with 120 cGy fractions. These results demonstrate protection of non-hematopoietic tissues with fractionation and low dose rate without protecting hematopoietic stem cells and may have implications for human bone marrow transplantation.     

In vitro radiation studies on Ewing's sarcoma cell lines and human bone marrow: application to the clinical use of total body irradiation (TBI)

Patients with Ewing's sarcoma who present with a central axis or proximal extremity primary and/or with metastatic disease have a poor prognosis despite aggressive combination chemotherapy and local irradiation. In this high risk group of patients, total body irradiation (TBI) has been proposed as a systemic adjuvant. To aid in the design of a clinical TBI protocol, we have studied the in vitro radiation response of two established cell lines of Ewing's sarcoma and human bone marrow CFUc. The Ewing's lines showed a larger Do (1.26 Gy, 2.04 Gy) and n (6.0, 3.2) compared to the bone marrow CFUc (Do = 0.86 Gy, n = 1.2). No repair of potentially lethal radiation damage (PLDR) was found after 4.5 Gy in plateau phase Ewing's sarcoma cells. A theoretical split dose survival curve for both the Ewing's sarcoma lines and human bone marrow CFUc using this TBI schedule shows a significantly lower surviving fraction (10(-4)-10(-5] for the bone marrow CFUc. Based on these in vitro results, two 4.0 Gy fractions separated by 24 hours is proposed as the TBI regimen. Because of the potentially irreversible damage to bone marrow, autologous bone marrow transplantation following the TBI is felt to be necessary. The details of this clinical protocol in high risk Ewing's sarcoma patients are outlined.     

Total body irradiation in bone marrow transplantation: fractionated vs single dose. Acute toxicity and preliminary results

The usefulness of total body irradiation (TBI) plus chemotherapy as a preparative regimen prior to bone marrow transplantation has been widely documented. However, the procedure can be highly toxic. Fractionated and low dose rate TBI has been said to enhance therapeutic ratio by increasing normal tissue tolerance and increasing leukemic cell kill. We report here the acute toxic effects and preliminary results on 2 consecutively groups of patients, treated with bone marrow transplantation (BMT) for leukemia or multiple myeloma, and conditioned by 2 TBI regimens. Group A patients received 10 Gy-Co-60 single dose of TBI plus 120 mg/kg of cyclophosphamide over a period of 2 days (8 Gy lungs). Group B received 12 Gy Co-60 of TBI in 6 fractions (2/day), (8 Gy lungs) plus 120 mg/kg of cyclophosphamide over a period of 3 days. The acute toxic effects recorded were similar in both groups. Only a 40% vs 0% (P = 0.02) incidence of parotiditis in groups A and B favors fractionation. Other results obtained to date are as follows: an incidence of interstitial pneumonitis of 39% and 31% (ns); relapses of 10% and 20% (ns), and mortality of 55% and 60% for each group respectively. An interesting finding was that IP was associated with acute grade II-IV graft vs host disease in 87% and 100% of cases of group A and B, respectively. We conclude that fractionated TBI is at least as effective as single dose TBI as a conditioning regimen; however, only randomized trials would allow definitive conclusions.     

Single dose versus hyperfractionated total body irradiation before allogeneic bone marrow transplantation: a non-randomized comparative study of 54 patients at the Institut Gustave-Roussy

At the Institut Gustave-Roussy (IGR), from January 1982 to December 1986, 54 patients received total body irradiation (TBI) as a part of the conditioning regimen before allogeneic bone marrow transplantation. The patients were non-randomly assigned to either single dose TBI (STBI) (31 patients receiving 10 Gy at a 4.5 cGy/min dose rate, 8 Gy to the lungs) or to a hyperfractionated scheme (HTBI) (23 patients receiving 13.2 Gy in 11 fractions, 3 fractions per day, 9 Gy to the lungs). Relapse rate and overall survival were not significantly different in the two STBI and HTBI groups, in spite of a larger number of 2nd and 3rd remission patients in the HTBI subset. The incidence of interstitial pneumonitis (IP) was significantly reduced in the HTBI group (13%, versus 45% after STBI, p = 0.02). Lethality by IP was also lower after HTBI (4%, versus 26% after STBI, p = 0.08). There was no case of veno-occlusive disease of the liver in the HTBI group, whereas three cases were observed after STBI. Based on these results, the IGR activated, in January 1987, a randomized trial comparing the single dose 10 Gy TBI (8 Gy to the lung) to a new hyperfractionated schedule (11 fractions of 1.35 Gy, 3 fractions per day, 9 Gy to the lungs).     

Dose response and factors related to interstitial pneumonitis after bone marrow transplant

PURPOSE: Total body irradiation (TBI) and chemotherapy are common components of conditioning regimens for bone marrow transplantation. Interstitial pneumonitis (IP) is a known regimen-related complication. Using published data of IP in a multivariate logistic regression, this study sought to identify the parameters in the bone marrow transplantation conditioning regimen that were significantly associated with IP and to establish a radiation dose-response function. METHODS AND MATERIALS: A retrospective review was conducted of articles that reported IP incidence along with lung dose, fractionation, dose rate, and chemotherapy regimen. In the final analysis, 20 articles (n = 1090 patients), consisting of 26 distinct TBI/chemotherapy regimens, were included in the analysis. Multivariate logistic regression was performed to determine dosimetric and chemotherapeutic factors that influenced the incidence of IP. RESULTS: A logistic model was generated from patients receiving daily fractions of radiation. In this model, lung dose, cyclophosphamide dose, and the addition of busulfan were significantly associated with IP. An incidence of 3%-4% with chemotherapy-only conditioning regimens is estimated from the models. The alpha/beta value of the linear-quadratic model was estimated to be 2.8 Gy. The dose eliciting a 50% incidence, D50, for IP after 120 mg/kg of cyclophosphamide was 8.8 Gy; in the absence of chemotherapy, the estimated D50 is 10.6 Gy. No dose rate effect was observed. The use of busulfan as a substitute for radiation is equivalent to treating with 14.8 Gy in 4 fractions with 50% transmission blocks shielding the lung. The logistic regression failed to find a model that adequately fit the multiple-fraction-per-day data. CONCLUSIONS: Dose responses for both lung radiation dose and cyclophosphamide dose were identified. A conditioning regimen of 12 Gy TBI in 6 daily fractions induces an IP incidence of about 11% in the absence of lung shielding. Shielding the lung to receive 50% of this dose lowers the estimated incidence to about 2.3%. Because the lungs can be adequately shielded, we recommend against using busulfan as a substitute for fractionated TBI with cyclophosphamide.     

Impact of drug therapy, radiation dose, and dose rate on renal toxicity following bone marrow transplantation

PURPOSE: To demonstrate a radiation dose response and to determine the dosimetric and chemotherapeutic factors that influence the incidence of late renal toxicity following total body irradiation (TBI). METHODS AND MATERIALS: A comprehensive retrospective review was performed of articles reporting late renal toxicity, along with renal dose, fractionation, dose rate, chemotherapy regimens, and potential nephrotoxic agents. In the final analysis, 12 articles (n = 1,108 patients), consisting of 24 distinct TBI/chemotherapy conditioning regimens were included. Regimens were divided into three subgroups: adults (age > or =18 years), children (age <18 years), and mixed population (both adults and children). Multivariate logistic regression was performed to identify dosimetric and chemotherapeutic factors significantly associated with late renal complications. RESULTS: Individual analysis was performed on each population subgroup. For the purely adult population, the only significant variable was total dose. For the mixed population, the significant variables included total dose, dose rate, and the use of fludarabine. For the pediatric population, only the use of cyclosporin or teniposide was significant; no dose response was noted. A logistic model was generated with the exclusion of the pediatric population because of its lack of dose response. This model yielded the following significant variables: total dose, dose rate, and number of fractions. CONCLUSION: A dose response for renal damage after TBI was identified. Fractionation and low dose rates are factors to consider when delivering TBI to patients undergoing bone marrow transplantation. Drug therapy also has a major impact on kidney function and can modify the dose-response function.     

Standard conditioning regimen and t-depleted donor bone marrow for transplantation in chronic myeloid leukemia

Between January 1984 to June 1985, 18 Ph¹ positive chronic myeloid leukemia (CML) patients in chronic phase (CP) underwent allogeneic bone marrow transplantation (BMT) from HLA identical and MLC negative siblings. The median age was 32.5 yr and median disease duration of CML at time of BMT was 19.3 months. The pretransplant conditioning regimen consisted of cyclophosphamide (CTX) (120 mg/kg) and 10.20 Gy total body irradiation (TBI) at 6 doses of 1.7 Gy each, administered in 3 daily fractions over 2 days at a dose rate of 15–20 cGy/min. To prevent graft-vs-host disease (GvHD) we used methotrexate (MTX) in one patient and cyclosporin-A (CYA) in the other 17 patients. In addition to CYA, given until day +365, 10 patients received donor marrow depleted of T cells with CAMPATH-1. The residual marrow lymphocytes were always <1%. The rate of engraftment was significantly correlated with the number of nucleated cells infused. Neither GvHD nor graft failure were observed among CAMPATH-1 patients. In this group one cytogenetic and one hematologic relapse occurred. The overall actuarial survival at 24 months is 78%. Of the 10 patients treated with donor marrow depleted of T cells, 9 are alive after a median follow-up of 9 months (range 5–18), with an actuarial survival of 90%.

Of the other 8 patients transplanted with untreated marrow, 5 are alive after a median followup of 19.3 months (range 3.7–24) and the actuarial survival is 63.8%. This pilot study seems to demonstrate that T-cell depletion of donor bone marrow with CAMPATH-1 is effective to prevent GvHD, while the risk of graft failure can be avoided using a “standard” conditioning regimen including a fractionated TBI with a fast dose rate and a prolonged administration of CYA at the maximum tolerable dosage. While the high frequency of relapses suggests the employ of more aggressive anti-leukemic conditioning regimens in CAMPATH-1 treated marrow recipients.     

Effect of irradiation on thermal sensitivity of bone marrow progenitors

The heat sensitivity of murine CFU-GM and CFU-E following 2.5 Gy of total body irradiation (TBI) was studied. C3H f/Sed female mice were treated with 2.5 Gy TBI and femoral bone marrow was heated in vitro at 43 degrees C. CFU-GM show heat radiosensitization when bone marrow was heated immediately following irradiation. There was a brief decline in heat and radiation interaction when cells were heated 3 hours following 2.5 Gy of TBI, but heat radiosensitization returned to its maximum from 1 to 2 days following irradiation and remained significantly different from the control on days 5 and 7 following irradiation. The heat and radiation interaction disappeared by 30 days. CFU-E shows significant heat radiosensitization only on day 2 following 2.5 Gy of TBI. Total nucleated cells per femur showed a decrease by 70 per cent in days 1 to 2 following TBI, recovered to control values by day 5, and did not correlate with the changes in heat radiosensitization. Cell cycle analysis of CFU-GM using hydroxyurea showed no significant changes in cell cycle parameters on days 1 and 2 following 2.5 Gy, when maximum heat sensitization was observed. It is concluded that bone marrow progenitors may respond in a different way from other normal tissues to heat and irradiation sequencing, and that these differences must be considered when designing clinical trials.     

Influence of dose on regeneration of murine hematopoietic stem cells after total body irradiation and 5-fluorouracil.

The regeneration of murine bone marrow stem cells after treatment with 5-fluorouracil (5-FU) and total body irradiation (TBI) was investigated by means of the spleen colony assay. 5-FU was given intraperitoneally in doses ranging from 75 to 225 mg/kg body weight. TBI was administrated as a single fraction in the dose range 0.75-3.50 Gy. The frequency of stem cells declined rapidly and reached a minimum (nadir) on day 1-2 after either of the 2 treatments. Their number returned to near-pretreatment values by day 7-10. Increasing the dose of either 5-FU or TBI resulted in a lower nadir in stem cell survival and a higher regeneration rate of the stem cells. The maximal regeneration rate corresponded to a doubling time of 19 h. The time to complete regeneration was constant and neither influenced by the treatment modality nor by the dose. Both this work and previous studies on cyclophosphamide and combined 5-FU and TBI may indicate that the regeneration rate of bone marrow stem cells after a cytotoxic assault is influenced primarily by the stem cell surviving the treatment rather than the treatment modality.     

Effect of irradiation on thermal sensitivity of bone marrow progenitors

The heat sensitivity of murine CFU-GM and CFU-E following 2.5 Gy of total body irradiation (TBI) was studied. C3H f/Sed female mice were treated with 2.5 Gy TBI and femoral bone marrow was heated in vitro at 43°C. CFU-GM show heat radio-sensitization when bone marrow was heated immediately following irradiation. There was a brief decline in heat and radiation interaction when cells were heated 3 hours following 2.5 Gy of TBI, but heat radiosensitization returned to its maximum from 1 to 2 days following irradiation and remained significantly different from the control on days 5 and 7 following irradiation. The heat and radiation interaction disappeared by 30 days. CFU-E shows significant heat radiosensitization only on day 2 following 2.5 Gy of TBI. Total nucleated cells per femur showed a decrease by 70 per cent in days 1 to 2 following TBI, recovered to control values by day 5, and did not correlate with the changes in heat radiosensitization. Cell cycle analysis of CFU-GM using hydroxyurea showed no significant changes in cell cycle parameters on days 1 and 2 following 2.5 Gy, when maximum heat sensitization was observed. It is concluded that bone marrow progenitors may respond in a different way from other normal tissues to heat and irradiation sequencing, and that these differences must be considered when designing clinical trials.     

Hyperfractionated total body irradiation for T-depleted HLA identical bone marrow transplants

Twenty patients suffering from malignant hemopathies (mean age 31.7 years) were given hyperfractionated total body irradiation (TBI) (120 cGy/3 fractions per day: total dose = 1440 cGy/4 days) as conditioning for T-depleted HLA identical allogeneic bone marrow transplantation. At an average of 12 months (range of 4.5-22 months) follow-up there were two cases of early death and two cases (11%) of rejection. There were no cases of acute or chronic graft versus host disease (GVHD) nor cases of interstitial pneumonitis. The average time for durable engraftment was 22 days. Disease-free survival at 12 months was 65%. To improve the results and further reduce the percent of rejection, the authors propose intensifying the immunosuppressive conditioning by increasing the cyclophosphamide dose and that of TBI so that a total dose of 1560 cGy is reached.     

Radiobiological considerations in magna-field irradiation

Radiobiological considerations are described for total body irradiation (TBI) as given to patients undergoing bone marrow transplantation (BMT). Although much progress has been made in the use of BMT for refractory leukemias, many patients still die from interstitial pneumonia and relapse. Fractionated TBI has been introduced in order to improve leukemic cell kill, while increasing the degree of normal tissue tolerance. Traditionally, bone marrow stem cells, leukemic cells and immunocytes have been considered as having a limited ability to repair radiation damage while cells of lung tissue and intestinal epithelial cells have a greater capacity. During fractionated radiation therapy or continuous low-dose rate exposure, repair of sublethal damage between fractions allows greater recovery in the cells of lung tissue compared to those in the bone marrow. Clinically, the potential benefit of six fractions over one fraction or low dose-rate TBI has yet to be proved, although there is suggestive evidence for a reduced incidence of interstitial pneumonitis. However, other extraneous factors such as doses to the lung, differences in conditioning regimens, effect of increased delay in BMT for patients receiving fractionated TBI, and the immeasurable differences between institutions make definite conclusions impossible. Despite this, a consensus for dose fractionation has developed and most centers are moving away from the use of large single dose TBI.     

Alteration in hematopoietic stem cell seeding and proliferation by both high and low dose rate irradiation of bone marrow stromal cells in vitro

The mechanism of physiologic alteration by high (HDR) or low dose rate (LDR) (5 or 120 cGy/min) irradiation of plateau-phase bone marrow stromal cell cultures was investigated using a technique of in vitro bone marrow transplantation. Purified stromal cell cultures from C57BL/6J, C3H/HeJ, or (C57BL/6J X DBA2/J)F1 (B6D2F1) mouse marrow were irradiated to doses of 2.5 to 10 Gy at LDR or 10-100 Gy at HDR and were then engrafted in vitro with nonadherent hematopoietic cells from murine continuous bone marrow cultures. Parameters of engraftment quantitated included: (1) numbers of adherent proliferating hematopoietic cell colonies, "cobblestone islands" (2) cumulative production of nonadherent hematopoietic cells over 8 weeks after engraftment, (3) M-CSF, GM-CSF and multi-CSF (IL-3) dependent hematopoietic progenitor cells forming greater than or equal to 50 cell colonies in semisolid medium, (4) cumulative production of CFUs, and (5) number of adherent stromal cells positive for detectable extracellular laminin or collagen type IV (markers of endothelial cells, reticular adventitial cells, or sinus lining cells). There was a decrease in cobblestone island formation between 5 and 10 Gy and this parameter possibly increased at doses of 50 and 100 Gy. There was no difference between HDR and LDR irradiation to 10 Gy. Irradiation to doses above 10 Gy decreased support of engrafted cells forming CFU-GM and CFU-GEMM. Measures of CFUs after 10 Gy were variable but indicated a possible increase with HDR and no effect of LDR at 1 week and a decrease in both HDR and LDR groups at 3 weeks after engraftment. Thus, LDR and HDR irradiation in vitro alter several specific parameters of marrow stromal cell support for engrafted hematopoietic stem cells.     

Fractionated total body irradiation and allogeneic bone marrow transplantation for standard risk leukemia

From March 1982 to December 1986, 32 patients with standard risk leukaemia were conditioned for allogeneic bone marrow transplantation (BMT) with low dose fractionated total body irradiation (TBI) after infusion of alkylating agents. This series includes six children and 26 adults. Minimal follow-up was 24 months. The total dose of 11 Gy, given in 5 daily fractions of 2.20 Gy, was given in the lateral position, following chemotherapy with either melphalan or cyclophosphamide. Lungs were shielded for 2 out of the 5 fractions. All patients had in vivo dosimetry. The death rate is 25% without relapse or rejection. Disease-free survival is 73% at 5 years. Toxic deaths are detailed: 2 from sepsis and veino-occlusive disease of the liver, 3 from severe graft versus host disease (GVHD), 2 from GVHD associated with virus pneumonitis and one from HIV infection. Fractionated low dose rate TBI is discussed regarding its decreased toxicity and its efficiency for disease control.     

Enhancement of murine bone marrow ablation by combining whole body hyperthermia with total body irradiation and cyclophosphamide

Bone marrow ablation using combined whole body hyperthermia (WBH), total body irradiation (TBI), and cyclophosphamide (Cy) was investigated in C3H f/Sed mice to demonstrate cytotoxic synergism between the three modalities. TBI was given on day 0. WBH treatment was for 1 hr at 41.8 degrees C, given in daily sessions for 1, 2 or 3 modalities. TBI was given on day 0. WBH treatment was for 1 hr at 41.8 degrees C, given in daily sessions for 1, 2 or 3 consecutive days following TBI. Total cyclophosphamide doses were 160 and 240 mg/kg given in 2 daily injections on days 1 and 2 following TBI. Polymorphonuclear leukocyte and lymphocyte numbers were determined by differential cell counts. The total peripheral blood cell counts were also determined. WBH alone, given in daily sessions for 3 days, did not reduce the total peripheral blood cell counts. However, when WBH was added to TBI (6.3 Gy) peripheral blood cellularity was reduced on day 2, but no significant heat/radiosensitization was evident after day 2. WBH (3 daily sessions) significantly reduced the peripheral blood cellularity and resulted in bone marrow ablation when it was combined with TBI and Cy. CY (160-240 mg/kg) combined with TBI (5.4 Gy) resulted in bone marrow ablation and subsequent death in 14-22% of mice treated; 60-100% of mice died from bone marrow ablation when WBH was added to TBI (5.4 Gy) and Cy (160-240 mg/kg). Femoral and vertebral tissue sections showed total loss of progenitor cells when WBH, TBI (5.4 Gy), and Cy (240 mg/kg) were combined whereas lessor treatment was associated with histologically verified reconstitution of progenitor cells inside the marrow cavities. These studies indicate that bone marrow ablation can be achieved when using WBH in combination with lower doses of TBI and Cy.     

Protection of mouse bone marrow by WR-2721 after fractionated irradiation

The ability of WR-2721 to protect mouse bone marrow after single or fractionated doses of radiation was assessed using both a clonogenic assay (survival of colony-forming units spleen (CFU) and a functional assay (lethality at 30 days) of stem cell survival. Cell survival curves and dose-response curves for radiation alone and drug with radiation were constructed over the dose range of .5 to 8 Gy and 1.5 to 15 Gy, respectively. The fractionated regimen consisted of four fractions ranging from 0.5 to 1.75 Gy given at 6-hr intervals for a total treatment time of 19.5 hr. WR-2721 was given 30 min before each fraction at a dose of 200 mg/kg. The protection factor was smaller after fractionated doses than after single doses for both assays, 1.3 (95% c.l., 1.0-1.6) vs. 2.3 (95% c.l., 2.0-2.6) for CFU survival and 1.34 vs. 1.8 for lethality at 30 days. No drug cytotoxicity could be demonstrated in the fractionated schedule. These data suggest that protection by WR-2721 is dependent on size of dose and will be less after clinically relevant, small dose fractions. However, some protection does remain even in the low dose range, where proportionally more damage is due to single-hit irreparable events.     

Dose Rate-Dependent Sparing of the Gastrointestinal Tract by Fractionated Total Body Irradiation in Dogs Given Marrow Autografts

Purpose: We compared gastrointestinal toxicity of single vs. fractionated total body irradiation (TBI) administered at dose rates ranging from 0.021 to 0.75 Gy/min in a canine model of marrow transplantation.Methods and Materials: Dogs were given otherwise marrow-lethal single or fractionated TBI from dual ⁶⁰Co sources at total doses ranging from 8–18 Gy and delivered at dose rates of 0.021, 0.05, 0.10, 0.20, 0.40, and 0.75 Gy/min, respectively. They were protected from marrow death by infusion of previously stored autologous marrow cells and they were given intensive supportive care posttransplant. The study endpoint was 10-day mortality from gastrointestinal toxicity. Logistic regression analyses were used to jointly evaluate the effects of dose rate, total dose, and delivery regimen on toxicity.Results and Conclusion: With increasing dose rates, mortality increased for either mode of delivery of TBI. With dose rates through 0.10 Gy/min, mortality among dogs given single vs. fractionated TBI appeared comparable. Beginning at 0.20 Gy/min, fractionation appeared protective for the gastrointestinal tract. Results in dogs given TBI at 0.40 and 0.75 Gy/min, respectively, were comparable, and dose fractionation permitted the administration of considerably higher total doses of TBI than were possible after single doses, an increment that was on the order of 4.00 Gy. The data indicate that the impact of fractionating the total dose at high dose rates differs from the effect of fractionation at low dose rates.     

Immunosuppressive effects of (131)I-anti-CD45 antibody in unsensitized and donor antigen-presensitized H2-matched, minor antigen-mismatched murine transplant models.

Iodine-131-labeled anti-CD45 antibody has been added to conventional hematopoietic stem cell transplant preparative regimens to deliver targeted radiation to hematopoietic tissues, with the goal of decreasing relapse rates without increasing toxicity. However, higher radiation doses could be delivered to leukemia cells by antibody if the systemic therapy were decreased or eliminated. To examine the ability of (131)I-anti-CD45 antibody to provide sufficient immunosuppression for transplantation across allogeneic barriers, T-cell-depleted BALB.B marrow was transplanted into H2-compatible B6-Ly5(a) mice after (131)I-30F11 (rat antimurine CD45) antibody with or without varying dose levels of total body irradiation (TBI). Groups of five or six recipient mice per (131)I or TBI dose level per experiment were given tail vein injections of 100 microg of (131)I-labeled 30F11 antibody 4 days before marrow infusion, with or without TBI on day 0. Engraftment, defined as > or =50% donor B cells at 3 months posttransplant, was determined by two-color flow cytometric analysis of peripheral blood granulocytes, T cells, and B cells using antibodies specific for donor and host CD45 allotypes and for CD3. Donor engraftment of > or =80% recipient mice was achieved with either 8 Gy of TBI or 0.75 mCi of (131)I-30F11 antibody, which delivers an estimated 26 Gy to bone marrow. Subsequent experiments determined the dose of TBI alone or TBI plus 0.75 mCi of (131)I-30F11 antibody necessary for engraftment in recipient mice that had been presensitized to donor antigens before transplant, a setting requiring more stringent immunosuppression. Engraftment was seen in > or =80% of presensitized recipients surviving after 14-16 Gy of TBI or 12-14 Gy of TBI and 0.75 mCi of (131)I-30F11 antibody. However, only 28 of 69 (41%) presensitized mice receiving 10-16 Gy of TBI alone survived, presumably because of rejection of donor marrow and ablation of host hematopoiesis. In contrast, 29 of 35 (83%) presensitized mice receiving (131)I-30F11 antibody and 10-14 Gy of TBI survived, presumably because the additional immunosuppression provided by estimated radiation doses of 53 Gy to lymph nodes and 81 Gy to spleen from 0.75 mCi of (131)I-30F11 antibody permitted engraftment of donor marrow. These results suggest that targeted radiation delivered by (131)I-anti-CD45 antibody provides sufficient immunosuppression to replace an appreciable portion of the TBI dose used in matched sibling hematopoietic stem cell transplant.     

Thrombopoietin promotes hematopoietic recovery and survival after high-dose whole body irradiation

PURPOSE: The therapeutic potential of thrombopoietin (TPO), the major regulator of platelet production, was evaluated for hematopoietic recovery and survival in mice following lethal and supralethal total body irradiation (TBI). METHODS AND MATERIALS: Hematopoietic recovery was studied in C57BL6/J mice after 8 Gy TBI (gamma-rays). Survival experiments were performed with C57BL6/J and BCBA F1 mice. Two protocols of TPO administration were evaluated: treatment for 7 consecutive days (7 x 0.3 microg/mice) beginning 2 h after exposure, or a single dose (0.3 microg/mice) administered 2 h after irradiation. RESULTS: TPO improved the platelet nadir and accelerated the platelet reconstitution of irradiated mice in comparison to placebo-treated mice. Recovery of neutrophils and erythrocytes was stimulated as well. TPO induced an accelerated recovery of hematopoietic progenitors and immature multilineage progenitors in bone marrow and spleen. In addition, TPO administration induced approximately 90% survival of 8 Gy irradiated C57BL6/J mice, a TBI dose which resulted in 100% mortality within 30 days for placebo-treated mice. Single TPO administration was as effective as repeated injections for hematopoietic recovery and prevention of mortality. Dose-effect survival experiments were performed in BCBA F1 mice and demonstrated that TPO shifted the LD50/30 from approximately 9.5 Gy to 10.5 Gy TBI given as a single dose, and from 14 Gy to as high as 17 Gy when TBI was given in three equal doses, each separated by 24 h. CONCLUSION: These results demonstrate that the multilineage hematopoietic effects of TPO may be advantageously used to protect against lethal bone marrow failure following high dose TBI.     

Phase I trial of myeloablative conditioning with 3-day total marrow and lymphoid irradiation for leukemia

This prospective phase I trial aimed to determine the recommended dose of 3-day total marrow and lymphoid irradiation (TMLI) for a myeloablative conditioning regimen by increasing the dose per fraction. The primary end-point of this single-institution dose escalation study was the recommended TMLI dose based on the frequency of dose-limiting toxicity (DLT) ≤100 days posthematopoietic stem cell transplantation (HSCT); a 3 + 3 design was used to evaluate the safety of TMLI. Three dose levels of TMLI (14/16/18 Gy in six fractions over 3 days) were set. The treatment protocol began at 14 Gy. Dose-limiting toxicities were defined as grade 3 or 4 nonhematological toxicities. Nine patients, with a median age of 42 years (range, 35–48), eight with acute lymphoblastic leukemia and one with chronic myeloblastic leukemia, received TMLI followed by unrelated bone marrow transplant. The median follow-up period after HSCT was 575 days (range, 253–1037). Three patients were enrolled for each dose level. No patient showed DLT within 100 days of HSCT. The recommended dose of 3-day TMLI was 18 Gy in six fractions. All patients achieved neutrophil engraftment at a median of 19 days (range, 14–25). One-year overall and disease-free survival rates were 83.3% and 57.1%, respectively. Three patients experienced relapse, and no nonrelapse mortality was documented during the observation period. One patient died due to disease relapse 306 days post-HSCT. The recommended dose of 3-day TMLI was 18 Gy in six fractions. The efficacy evaluation of this regimen is currently being planned in a phase II study.