HLA-identical sibling allogeneic peripheral blood stem cell transplantation with reduced intensity conditioning compared to autologous peripheral blood stem cell transplantation for elderly patients with de novo acute myeloid leukemia.

We conducted a retrospective registry-based analysis to compare the outcome of 361 allogeneic human leukocyte antigen (HLA)-identical peripheral blood stem cell transplants (PBSCT) with reduced intensity conditioning (RIC) to that of 1369 autologous (auto) PBSCT in patients aged 50 years or older with de novo acute myeloid leukemia (AML), performed from 1997 until 2003 and reported to the European Group for Blood and Marrow Transplantation. Median age was 58 and 57 years in the RIC and auto groups, respectively. RIC patients had more advanced disease at the time of transplant. At a median follow-up of 24 months for RIC and 16 months for auto, multivariate analysis showed a lower risk for relapse (RR 0.77, P=0.013) without increased non-relapse mortality (NRM) in RIC patients (RR 1.26, P=0.28). Moreover, leukemia-free survival (RR 1.22, P=0.02) and overall survival (OS) (RR 1.32, P=0.005) were superior in the RIC group. In patients in 1st (CR), fewer relapses were counterbalanced by significantly increased NRM. Therefore, there was no survival advantage in this subgroup. In patients in 2nd or subsequent CR, LFS and OS were superior in the RIC group. RIC transplants show encouraging results in this older patient population with de novo AML.     

Autologous bone marrow transplantation in adult patients with acute lymphoblastic leukemia

Autologous bone marrow transplantation (ABMT) was introduced as a treatment for terminal leukemic relapse more than 40 years ago. For childhood acute lymphoblastic leukemia (ALL) the role of ABMT is well defined. Some studies suggest that it is also beneficial for adult patients with high-risk factors or with relapse. However, these inferences are based on a relatively small number of patients with short follow-up. Nevertheless patients with high-risk ALL are candidates for ABMT if no histocompatible sibling is available. Similarly patients in second or later complete remission (CR) in the absence of a histocompatible donor may derive benefit from ABMT. The different conditioning regimens used by the treatment centers are associated with different toxicities but none has been proven to be superior than others. In the majority of studies the marrow has been purged of leukemic cells, but this maneuver has never been evaluated in a randomized comparative trial. Transplant related mortality rate of ABMT is low compared to allogeneic transplantation. The GvL effect, which is important to eliminate malignant cells in acute and chronic myelocytic leukemia, has not been definitively demonstrated in ALL. The tyrosine-kinase inhibitor STI 571 offers new perspectives for patients with the Phl/bcr/abl translocation. It may be especially useful for treating minimal residual disease (MRD) before and/or after ABMT.     

Modern trends in bone marrow transplantation for acute myeloid and acute lymphoblastic leukemia.

A greater understanding of the underlying mechanisms of hematopoiesis and leukemogenesis in the clinical management of acute myeloid and lymphoblastic leukemia has led to an improvement in survival from what were invariably fatal diseases. Bone marrow transplantation is increasingly becoming an accepted form of therapy for acute myeloid leukemia and acute lymphoblastic leukemia in certain situations. This review seeks to address some of the recent advances and controversies including whether bone marrow transplantation is more efficacious than modern intensive chemotherapy, the role of autologous bone marrow transplantation and matched-unrelated donor transplants, the graft-versus-leukemia effect, and the role of purging in autologous bone marrow transplantation. Furthermore, advances in supportive therapy including the introduction of hematopoietic growth factors is critically evaluated. Finally, the appropriate timing and role of bone marrow transplantation is discussed in the context of previous ongoing and future clinical trials.     

Feasibility of autologous peripheral blood stem cell transplantation in elderly patients with acute myeloid leukemia

Most studies showing that autologous stem cell transplantation (ASCT) is feasible in older patients with acute myeloid leukemia (AML) referred to highly selected patients considered as eligible after complete remission (CR) achievement and bone marrow or peripheral blood stem cell (PBSC) collection. This study evaluated the feasibility of ASCT from 155 consecutive AML patients aged over 60 years (median age 72 years, range 61 - 94) programmed to receive ASCT by using PBSCs after CR achievement. Overall, 90 out of 155 patients (58%) were judged as eligible for aggressive chemotherapy and 45 (50%) achieved CR. Among these, 36 (80%) received consolidation and 32 (89% of consolidated) were monitored for PBSC mobilization. A successful collection was registered in 25/32 patients (78% of monitored). Finally, 20 patients received ASCT. Reasons for not autografting five mobilizing patients included relapse pre-ASCT, toxicity, and refusal. Median survival was 4 months for the whole patient population and 19 months for patients actually autografted. Overall, 20 out of 90 patients accrued into intensive chemotherapy (22%) and 20 out of the entire patient population (13%) underwent ASCT. It is concluded that APBSCT can result in an improvement of therapeutic results in AML of the elderly, but it is feasible in a minority of selected patients.     

急性髓系白血病患者来源白血病干细胞的分选与鉴定

 目的　分选急性髓系白血病患者白血病干细胞并进行鉴定,为白血病干细胞的进一步研究奠定基础。方法　采用Ficoll密度梯度离心法从患者骨髓中分离单个核细胞。采用流式细胞术从单个核细胞中分选CD+34 CD+123白血病干细胞,通过集落形成能力和鹅卵石形成能力检测分选后白血病干细胞的自我更新与分化能力,同时检测CD+34 CD+123 细胞纯度,观察其细胞形态。结果　分选后的CD+34 CD+123 白血病干细胞比例占总分选细胞的10.7 %,具有集落形成能力和鹅卵石形成能力,CD+34 CD+123 细胞纯度为62.1 %。结论　成功分选与鉴定了白血病干细胞,可用于其后的进一步研究工作。     

Total body irradiation, thiotepa, and cyclophosphamide as a conditioning regimen for children with acute lymphoblastic leukemia in first or second remission undergoing bone marrow transplantation with HLA-identical siblings.

PURPOSE: Allogeneic hematopoietic stem-cell transplantation (HSCT) from HLA-identical siblings can be used to treat children with acute lymphoblastic leukemia (ALL). However, a significant proportion of patients with ALL who undergo HSCT relapse. For this reason, we prospectively evaluated a preparative regimen that included total body irradiation (TBI), thiotepa (TT), and cyclophosphamide (CY) in patients with high-risk ALL in first complete remission (CR) and in children with ALL in second CR. PATIENTS AND METHODS: Forty children (median age, 9 years; range, 1 to 18 years) with ALL in first or second CR who underwent allogeneic HSCT from HLA-identical siblings were conditioned with a combination of fractionated TBI, TT (10 mg/kg), and CY (120 mg/kg over 2 days). Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine administered intravenously at a dose of 1 to 3 mg/kg/d for the first 21 days and subsequently orally at a dose of 6 mg/kg/d. RESULTS: All assessable patients were engrafted, with a median time of 11 and 24 days for neutrophil and platelet recovery, respectively. The preparative regimen was well tolerated. Only one patient died as a result of regimen-related causes. Eight patients relapsed at a median time of 8 months after transplantation (range, 3 to 9 months), and this determined a cumulative probability of relapse of 23%. Twenty-six of 40 patients (65%) are alive and in complete hematologic remission, with a median observation time of 36 months (range, 14 to 57 months), which results in a disease-free survival (DFS) at 3 years of 65%. The 13 patients who underwent transplantation in first CR had a DFS of 85%, whereas the 27 patients who underwent HSCT in second CR had a DFS of 56%. CONCLUSION: These data suggest that TT is an effective cytotoxic drug that can be safely added to the classical TBI-CY regimen. Because of its cell cycle-independent action, good CNS diffusion, and limited extramedullary toxicity, TT may contribute to increasing the percentage of children with ALL who are successfully cured with allogeneic BMT.     

Allogeneic bone marrow transplantation for patients with high-risk acute lymphoblastic leukemia

Seventy-four consecutive patients with high-risk acute lymphoblastic leukemia (ALL) were given cyclophosphamide (CY; 50 mg/kg on each of 4 days) plus total body irradiation (TBI; 300 rad on each of 4 days) followed by a human leukocyte antigen (HLA)-identical allogeneic bone marrow transplant (BMT). Eighteen patients in first complete remission (CR1), 36 in CR2, 16 in CR3, and four in CR4 were transplanted. Patients in CR1 were transplanted 1 to 8 months (median, 3 months) after attaining CR. All 18 patients in CR1 had one or more poor risk factors: age more than 18 (N = 17), initial leukocyte count greater than or equal to 20,000 (N = 11), Ph 1 chromosome (N = 2), delay in attaining CR more than 6 weeks (N = 8), or extramedullary disease (N = 1). Of those transplanted in CR2, 72% had relapsed on therapy. The 5-year event-free survival (EFS) rates for patients transplanted in CR1, CR2, and CR3 are 42%, 43%, and 25%, respectively, at median follow-up times of 57, 54, and 72 months, respectively. Children aged less than 18 years transplanted in CR2 have a 5-year EFS rate of 54%. All CR4 patients died early after transplant. The actuarial probability of relapse is 20%, 26%, and 48% for those transplanted in CR1, CR2, and CR3, respectively. Although there was substantial transplant-associated mortality, it decreased over the decade of the study (P = .01). This study indicates that BMT offers an attractive alternative to postremission chemotherapy in patients in CR1 with poor prognostic factors and in patients in second remission.     

Rapid natural killer cell recovery determines outcome after T-cell-depleted HLA-identical stem cell transplantation in patients with myeloid leukemias but not with acute lymphoblastic leukemia.

Natural killer (NK) cells are the first lymphocytes to recover after allogeneic stem cell transplantation (SCT) and can exert powerful graft-versus-leukemia (GVL) effects determining transplant outcome. Conditions governing NK cell alloreactivity and the role of NK recovery in sibling SCT are not well defined. NK cells on day 30 post-transplant (NK30) were measured in 54 SCT recipients with leukemia and donor and recipient killer immunoglobulin-like receptor (KIR) genotype determined. In univariate analysis, donor KIR genes 2DL5A, 2DS1, 3DS1 (positive in 46%) and higher numbers of inhibitory donor KIR correlated with higher NK30 counts and were associated with improved transplant outcome. NK30 counts also correlated directly with the transplant CD34 cell dose and inversely with the CD3+ cell dose. In multivariate analysis, the NK30 emerged as the single independent determinant of transplant outcome. Patients with NK30 >150/microl had less relapse (HR 18.3, P=0.039), acute graft-versus-host disease (HR 3.2, P=0.03), non-relapse mortality (HR 10.7, P=0.028) and improved survival (HR 11.4, P=0.03). Results suggest that T cell-depleted SCT might be improved and the GVL effect enhanced by selecting donors with favorable KIR genotype, and by optimizing CD34 and CD3 doses.     

急性白血病骨髓间充质干细胞调控免疫的功能及机制

目的 探讨急性白血病患者骨髓间充质干细胞(MSC)的免疫原性及抑制异体T淋巴细胞增殖的功能和机制.方法 采用细胞贴壁法获取急性髓细胞白血病(AML)和急性淋巴细胞白血病(ALL)骨髓MSC,在低血清培养液中培养和扩增.采用流式细胞仪和免疫组化方法检测免疫表型,应用酶联免疫吸附实验检测MSC培养上清液中细胞因子的分泌水平,Transwell检测骨髓MSC抑制T淋巴细胞增殖的能力,混合淋巴细胞反应检测骨髓MSC抑制异体T淋巴细胞增殖的能力.结果 ALL骨髓MSC在倒置显微镜下为梭形,CD29、CD44和CD105的表达阳性率分别为98.81%、99.25%和90.52%,而CD31、CD34和CD45均为阴性.AML骨髓MSC表达CD29和CD44.ALL和AML骨髓MSC不表达人白细胞DR抗原(HLA-DR)和共刺激分子CD80、CD86和CD40.ALL骨髓MSC和AML骨髓MSC均具有分泌TGF-β1(567.58±52.64和357.15±33.52)、HGF(647.27±102.54和219.67±62.37)、IL-6(59.67±15.69和54.35±12.31)和IL-11(102.58±23.54和78.21±9.67)的功能,但是AML骨髓MSC的TGF-β1和HGF分泌水平明显低于ALL骨髓MSC(均P＜0.05).在MSC数量分别为0.5×104、1×104、2×104和5×104个时,加入AML骨髓MSC的CD3+T淋巴细胞3H-TdT掺入的CPM值分别为(3.58±0.54)×104、(2.87±0.33)×104、(1.78±0.51)×104和(1.15±0.15)×104,加入ALL骨髓MSC相应的CD3+T淋巴细胞3H-TdT掺入的CPM值分别为(1.96±0.31)×104、(1.57±0.28)×104、(0.91±0.41)×104和(0.22±0.11)×104,而未加入MSC的CD3+T淋巴细胞3H-TdT掺入的CPM值为(4.01±0.72)×104,AML和ALL骨髓MSC抑制T淋巴细胞的增殖存在明显差异.ALL骨髓MSC抑制T淋巴细胞增殖的能力可以被抗TGF-β1和HGF抗体逆转.结论 ALL骨髓MSC具有低免疫原性及体外调节免疫的功能,该免疫调节功能与其分泌细胞因子有关.AML骨髓MSC调控免疫的能力存在病理改变.

Abstract：

Objective To study the immunomodulatory effects and mechanisms of mesenchymal stem cells(MSC) derived from the bone marrow in acute leukemia patients in vitro. Methods Bone marrow mononuclear cells from acute myeloid leukemia(AML) and acute lymphoblastic leukemia(ALL)were obtained and cultured in low serum medium.The immunophenotypes were assessed by FACS and immunol histochemistry.The levels of cytokines were evaluated by enzyme linked immunosorbant assay (ELISA).T-cell suppression ability was evaluated by Transwell chamber assay.Moreover,the immunoregulatory ability of AML-and ALL-derived MSC was detected by mixed lymphocyte culture assay. Results ALL-derived MSC showed a typical fibroblast-like morphology.They were positive for CD29,CD44 and CD105,the positive rate were 98.81%,99.25% and 90.52%,respectively,while negative for CD31,CD45 and CD34.Moreover,ALL-and AML-derived MSC didn't express HLA-DR and costirnulatory molecules(CD40,CD80 and CD86ALL and AML derived MSC could secret several cytokines,such as TGF-β1(567.58 ±52.64 and 357.15 ±33.52),HGF(647.27 ± 102.54 and 219.67 ±62.37),IL-6(59.67 ± 15.69 and 54.35 ±12.31) and IL-11(102.58 ±23.54 and 78.21 ±9.67),the level of secretion of TGF-β1 and HGF were higher in ALL bone marrow derived MSC than that of in AML bone marrow derived MSC.ALL and AML derived MSC significantly suppressed T lymphocyte proliferation in a dose-dependent manner,the counts per minute(CPM) were(3.58 ± 0.54) × 104,(2.87 ± 0.33) ×104,(1.78 ±0.51) × 104 and(1.15 ± 0.15) × 104 for AML derived MSC,and CPM were(1.96 ± 0.31)×104,(1.57 ±0.28) ×104,(0.91 ±0.41) ×104 and(0.22 ±0.11) ×104 for ALL derived MSC when MSCwere0.5×104,1×104,2×104 and5×104.In addition,the CPM was(4.01 ±0.72) ×104 in control group.The immunosuppressive ability was different between MSCs derived from AML and ALL.The immunosuppressive effect of ALL derived MSC could be reversed by anti-TGF-βl and anti-HGF antibody.Conclusion ALL-derived MSC show immunoregulatory effect in vitro and this effect is achieved through cytokines.But MSCs derived from AML display abnormal changes in T-cell suppression ability.     

Age has no influence on mobilization of peripheral blood stem cells in acute myeloid leukemia

The upper age limit for autologous stem cell transplantation (ASCT) in acute myeloid leukemia (AML) is increasing and peripheral blood (PB) represents the standard source of stem cell (SC). However, no data are available on the impact of age on SC mobilization in AML. We analyzed a cohort of 150 consecutive AML patients in first complete remission in order to make a comparison between patients up to 60 years and above 60 years, by evaluating CD34+ cells mobilization into PB and the number of leukapheresis needed to collect at least one single SC graft. The successful mobilization rate (>2 x 10(6) CD34+ cells/kg) was comparable between the two groups (87% vs. 80%, p = 0.29). In addition, no statistically significant difference was found in terms of either median number of CD34+ cells collected (p = 0.54) or CD34+ cells peak in PB (p = 0.70). Both groups of patients needed a median of two apheresis and no difference was found in the median number of CD34+ cells collected per single apheresis (p = 0.67). Finally, no correlation was found between age and total number of CD34+ cells collected (r = 0.003, p = 0.58). We conclude that age has no impact on mobilization of PBSCs in AML.     

Allogeneic bone marrow transplantation for adult acute lymphoblastic leukemia: a single-centre experience.

Between 1990 and 1997, we performed 29 allogeneic BMTs for acute lymphoblastic leukemia (ALL) patients with HLA-identical sibs. Their median age was 31 years (range 15 to 43); there were 15 males and 14 females. The conditioning protocol was Cy-TBI (n = 15), VP16-Cy-TBI(n = 12), CBV (n = 1) and Bu-Cy (n = 1). Cyclosporin and methotrexate were used for GVHD prophylaxis. The median disease-free survival (DFS) was 12 months (range 1 to 92) with an actuarial 4-years DFS of 42.3 per cent. Three patients died of transplant-related complications before 100 days. Relapse occurred in 11 cases at a median time of 5 months (range 3 to 14). All nine patients relapsing within one year died form resistant leukemia. Three patients died of late treatment-related complications. There were 13 survivors (median follow-up 38 months, range 12-98), with 12 in remission. Only four had limited cGVHD, and all had 100 per cent performance scores. One patient also cleared her chronic hepatitis B carrier status due to acquired immunity. The DFS rates amongst CR1 cases and R1/CR2 cases were comparable (p = 0.39). No long-term DFS is obtained from patients with resistant disease (n = 4). The survival results for BMT at CR1 were superior to those using intensive chemotherapy consolidation (p = 0.29), mainly due to poor late results in the chemotherapy arm. For young ALL patients with HLA-matched siblings, the option of BMT should be considered in light of local consolidation survival results.     

Differing patterns of human protooncogene expression in peripheral blood and bone marrow acute leukemia cells

The levels of protooncogene RNA in matched bone marrow and peripheral blood cells obtained from patients with newly diagnosed acute myelogenous leukemia were compared. While the absolute amounts of c-myc RNA in the matched specimens are similar, the levels are not correlated. In contrast, while the levels of c-fos RNA in the matched bone marrow and peripheral blood cells are correlated, the absolute levels of c-fos RNA differ substantially. The level of histone H3 RNA is higher in bone marrow cells than in peripheral blood cells. These substantial differences in protooncogene RNA levels between leukemic cells found in the bone marrow and in the peripheral blood make it impossible to accurately "characterize" gene expression in leukemic cells if studies are restricted to the cells in either compartment. Additionally, there appears to be a significant relationship between the levels of c-fos RNA and triose phosphate isomerase RNA and the height of the white blood cell count and between the level of c-fos RNA in marrow cells and the proportion of monocytic cells present.     

Persistence of peripheral blood and bone marrow blasts during remission induction in adult acute lymphoblastic leukemia confers a poor prognosis depending on treatment intensity.

Our objectives were to evaluate the prognostic implications of persistence of peripheral blood blasts on day 7 (D7PBb) and of bone marrow blasts >5% on day 14 (D14Mb) after initiation of induction chemotherapy in adults with acute lymphoblastic leukemia (ALL) treated with two different chemotherapy regimens. Records of 365 consecutive newly diagnosed adult ALL patients treated with: (a) vincristine-, doxorubicin-, and dexamethasone-based chemotherapy (VAD, n = 219; 1984-1992); or (b) fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone, alternating with methotrexate/high-dose cytarabine (HCVAD, n = 146; 1993-1996), were analyzed. The complete remission (CR) rates were 73% with VAD and 91% with HCVAD (P<0.0001). Three-year event-free survival (EFS) rates were 23 and 40%, respectively (P = 0.00003). The impact of D7PBb and D14BMb on outcome varied with the induction regimen. Patients treated with VAD who had D7PBb had similar EFS rates compared with patients without D7PBb (P = 0.12), but EFS was inferior if they had persistent D14BMb compared with those patients without D14BMb (P = 0.00006). In HCVAD-treated patients, EFS was significantly worse in patients with persistent D7PBb (P = 0.003) but not in patients with D14BMb (P = 0.19). By multivariate analysis, D14BMb was an independent adverse feature for patients treated with VAD, whereas D7PBb was an independent adverse feature for EFS in HCVAD-treated patients. Early clearance of leukemia cells from blood and bone marrow is associated with improved outcome in adult ALL, but the prognostic significance of D7PBb and D14BMb clearance varies with treatment efficacy.     

Meta-analysis of autologous bone marrow transplantation versus chemotherapy in adult patients with acute myeloid leukemia in first remission

In the present study, we have conducted a meta-analysis comparing autologous bone marrow transplantation (ABMT) and intensive chemotherapy in adult acute myeloid leukemia (AML) patients in first remission. Combined results of the six appropriate randomised controlled studies indicate that ABMT had no advantage over chemotherapy or no further treatment concerning death rate (overall rate ratio (RR)-0.95, 95% CI, 0.81-1.11), while was superior to chemotherapy concerning event rate (overall RR--0.82, 95% CI, 0.71-0.94). In conclusion, ABMT did not improve survival but it improved event-free survival (EFS) when compared with chemotherapy or no further treatment in patients with AML in first complete remission.     

急性髓细胞白血病患者外周血及骨髓CD87表达的改变

目的探讨急性髓细胞白血病（AML）患者外周血及骨髓CD87表达的改变。方法应用流式细胞术（FCM）检测了30例AML患者（M1 2例,M2 6例,M4 8例,M5 14例）外周血及骨髓CD87表达,应用配对t检验分析外周血及骨髓CD87表达的改变。结果14例M5患者骨髓CD87表达为9.47％～80.32％,外周血CD87表达为11.49％。87.46％;8例M4患者骨髓CD87表达为14．27％～46．28％,外周血CD。表达为14.79％～47.19％;6例M2患者骨髓CDg7表达为4．67％～34．26％,外周血CD＂表达为8.96％。39.78％;2例M,患者骨髓CDg7表达为3．56％～7.69％,外周血CDg7表达为5.21％～8.96％。30例急性髓细胞性白血病外周血及骨髓CD87表达差异有统计学意义（t=3．13,P〈0．05）。结论AML患者外周血及骨髓CD87表达有变化,外周血CD。表达高于骨髓,推荐应用外周血代替骨髓检测CD87表达。     

Long-term outcome of adult acute leukemia patients who are alive and well two years after allogeneic bone marrow transplantation from an HLA-identical sibling.

We studied the long-term outcome of 136 adults with acute leukemia (age 15-48 years at transplant, median 28; 112 myeloid, 22 lymphoblastic, 2 undifferentiated) who were alive in continuous remission two years after allografting from HLA-identical sibling donors. Six relapsed 25-46 months (median 30) after BMT. Fourteen (10%) died of non-relapse causes (12 transplant-related and 2 unrelated) 24-140 months (median 73) after BMT; mainly due to complications of chronic GVHD (8 infections, 3 secondary malignancies). One hundred and seventeen (86%) patients are alive in remission 25-226 months (median 103) after BMT; 116 (85%) in continuous remission. Eight survivors have symptomatic chronic GVHD requiring therapy (Karnofsky scores 60-90%, median 80%). The majority of those without chronic GVHD have Karnofsky scores of 100%. The 10-year probabilities of survival, toxic death, and relapse (from the 2-year mark) are 81%, 13%, and 5%. Twenty-two (19%) survivors had creatinine levels of > 110 mumol/L (one more than double), and 11 (9%) had bilirubin levels of > 17 mmol/L (one more than double) at the last follow-up. The absence of chronic GVHD at the 2-year mark (RR 3.5, P = .004), and female sex (RR 2.9, P = .04) influenced overall survival favorably, and the absence of chronic GVHD at the 2-year mark (RR 8.1, P = .001) influenced toxic death favorably. We conclude that patients with acute leukemia who are alive and well without chronic GVHD two years following an allograft have a high probability of being cured, whereas patients with active chronic GVHD requiring immunosuppression continue to be at risk of non-relapse death. The incidence of long-term liver and kidney dysfunction measured by serum bilirubin and creatinine is low.