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Approaches to treatment for extraocular retinoblastoma: Children's Hospital Los Angeles experience.

Extraocular retinoblastoma is associated with a very poor outcome. At Children's Hospital Los Angeles, 10 of 207 patients with retinoblastoma had extraocular disease. Four patients with no histopathologic risk factors developed extraocular disease. All patients with direct extension into the central nervous system or with distant metastatic disease died. One of three patients with trilateral retinoblastoma and one patient with regional recurrence are alive after autologous bone marrow transplant. Patients with extraocular retinoblastoma who achieve remission may benefit from consolidation of their therapy with autologous bone marrow transplant.

Antineoplastic Agents↗

Hematopoietic cell proliferation and hematopoietic growth factors.

In vivo studies using hematopoietic growth factors in humans have more clearly defined the ability of these molecules to accelerate hematopoietic cell proliferation in postchemotherapy aplasia and constitutive marrow deficiency states. Studies applying combinations of two growth factors have been added. Investigation of negative regulators of hematopoietic cell proliferation has opened new approaches to protect against damage or loss of candidate stem cells in vitro or in vivo, as well as to selectively recruit malignant cell populations into cell cycle while protecting benign cells. New insights into the synergism of positive regulators of hematopoietic cell proliferation have come from a panoply of in vitro studies, underscoring the value of growth factors previously not associated with effects on hematopoietic cells that have now been found to confer significant synergism with known hematopoietic regulators.

Animals↗

Current status of hematopoietic stem cell transplantation after nonmyeloablative conditioning.

PURPOSE OF REVIEW: Allogeneic hematopoietic stem cell transplantation was originally developed as a form of rescue from high-dose chemoradiotherapy, which is given both to eradicate malignancy and provide sufficient immunosuppression for allogeneic engraftment. However, it was observed that allogeneic immunocompetent cells transplanted with the stem cells, or arising from them, mediated therapeutic antitumor effects independent of the action of the high-dose therapy. This was termed a graft-versus-tumor effect. This has prompted the recent development of nonmyeloablative conditioning regimens for allogeneic hematopoietic stem cell transplantation that have opened the way to include elderly patients and those with comorbid conditions. RECENT FINDINGS: Recent retrospective studies comparing hematopoietic stem cell transplantation after myeloablative or nonmyeloablative regimens suggested that the use of nonmyeloablative conditioning might be associated with lower transplant-related toxicity, lower nonrelapse mortality, and at least similar intermediate-term progression-free survival. SUMMARY: Hematopoietic stem cell transplantation after nonmyeloablative conditioning might become the procedure of choice also for younger patients. Phase 3 studies are needed to determine outcomes for different diseases and age groups.

Animals↗

The use of immunocompromised animals as models for human septic shock.

Although it is generally understood that no single animal model truly reflects human sepsis, the study of sepsis in immunocompromised animals is highly relevant to human sepsis research. The majority of patients with severe sepsis have significant underlying diseases that may alter innate immune defenses, disrupt microbial clearance mechanisms, and complicate the pathophysiology of human sepsis. Septic shock itself has significant effects upon the innate and adaptive host immune responses that may contribute to a state of sepsis-induced immune dysregulation. A number of animal models of sepsis displaying an array of immunocompromised states are now available. Most of these systems are small animal models with genetically defined defects of immune defenses or acquired defects from receipt of immunosuppressive or myeloablative agents. Greater emphasis should be placed on preclinical models of immunocompromised animals in the future to assess the potential clinical utility of novel drugs for human septic shock.

Aged↗

Targeted bone marrow radioablation with 153Samarium-lexidronam promotes allogeneic hematopoietic chimerism and donor-specific immunologic hyporesponsiveness.

BACKGROUND: Transplantation tolerance, defined as acceptance of a graft by an otherwise fully immunocompetent host, has been an elusive goal. Although robust tolerance has been achieved by the induction of stable hematopoietic chimerism after bone marrow transplantation, lethal or sublethal radiation conditioning used to induce long-term chimerism precludes its clinical use. We studied whether targeted delivery of radiation to bone marrow could allow for bone marrow cell (BMC) engraftment, chimerism, and donor-specific tolerance in the absence of the side effects associated with external irradiation. METHODS: We administered a radioactive bone-seeking compound (Samarium-Lexidronam, Quadramet, Berlex Laboratories, Wayne, NJ) together with transient T-cell costimulatory blockade to recipient mice. Allogeneic BMCs were given 7 or 14 days after preconditioning. Costimulatory blockade was obtained by the use of an anti-CD154 antibody for 4 weeks. Chimerism was assessed by flow cytometry. Mice then received donor-specific and third-party skin grafts. Graft survival was analyzed with mechanisms of donor-specific hyporesponsiveness. RESULTS: High levels of stable chimerism across an allogeneic barrier were achieved in mice by a single administration of Samarium-Lexidronam, transient T-cell costimulatory blockade, and BMC transplantation. A large percentage of chimeric animals retained donor-derived skin grafts for more than 120 days without requiring additional immunosuppression, suggesting that harsh cytotoxic preconditioning is not necessary to achieve stable chimerism and donor specific hyporesponsiveness. Analysis of the T-cell repertoire in chimeras indicates T-cell deletional mechanisms. CONCLUSIONS: These data broaden the potential use of BMC transplantation for tolerance induction and argue for its potential in treating autoimmune diseases.

Animals↗

Transplantation of a child with sickle cell anemia with an unrelated cord blood unit after reduced intensity conditioning.

Sickle cell disease can be corrected by hematopoietic cell transplantation but success is limited by low availability of matched related/unrelated donors and comorbidities leading to the increased transplant-related morbidity/mortality. There is a need for expanded donor pools and reduced intensity regimens. We describe a case of a second unrelated cord blood transplant after a novel preparative regimen in a child with sickle cell disease related stroke and liver fibrosis. Hydroxyurea, rituximab, and alemtuzumab were followed by thiotepa and low dose total body irradiation before unrelated cord blood transplant. Rapid full donor chimerism and improved performance status was achieved and sustained over 2 years after transplant.

Anemia, Sickle Cell↗

Allogeneic haematopoietic cell transplantation for chronic myelogenous leukaemia in the era of imatinib: a retrospective multicentre study.

OBJECTIVE: To analyse the results of allogeneic haematopoietic cell transplantation (HCT) in patients with advanced stages of Philadelphia chromosome-positive chronic myelogenous leukaemia (CML) who had previously been treated with imatinib mesylate (IM). METHODS: We analysed the outcome of 61 patients with CML who had received allogeneic HCT from sibling (n = 18) or unrelated (n = 43) donors after having been treated with IM. Forty-one patients had received IM because of accelerated or blast phase CML. Conditioning therapy contained standard doses of busulfan (n = 25) or total-body irradiation (n = 20) in conjunction with cyclophosphamide in the majority of cases. Sixteen patients received dose-reduced conditioning with fludarabine-based regimens. RESULTS: The incidence of grades II-IV and III-IV graft-versus-host disease was 66% and 38% respectively. The probability of overall survival (OS), disease-free survival (DFS) and relapse at 18 months for the whole patient cohort were 37%, 33% and 24% respectively. The probability of non-relapse mortality (NRM) at 100 d and 12 months was 30% and 46% respectively. Univariate analysis showed that fludarabine-based conditioning therapy, age > or = 40 yr and >12 months interval between diagnosis and transplantation were associated with a significantly lower OS and DFS and a higher NRM. CONCLUSION: These data suggest that although pretreatment with IM is not an independent negative prognostic factor, it cannot improve the dismal prognosis of CML patients at high risk for transplant-related mortality.

Adolescent↗

Further development of a model of chronic bone marrow aplasia in the busulphan-treated mouse.

Aplastic anaemia (AA) in man is an often fatal disease characterized by pancytopenia of the peripheral blood and aplasia of the bone marrow. AA is a toxic effect of many drugs and chemicals (e.g. chloramphenicol, azathioprine, phenylbutazone, gold salts, penicillamine and benzene). However, there are no widely used or convenient animal models of drug-induced AA. Recently, we reported a new model of chronic bone marrow aplasia (CBMA = AA) in the busulphan (BU)-treated mouse: eight doses of BU (10.50 mg/kg) were administered to female BALB/c mice over a period of 23 days; CBMA was evident at day 91/112 post-dosing with significantly reduced erythrocytes, platelets, leucocytes and nucleated bone marrow cell counts. However, mortality was high (49.3%). We have now carried out a study to modify the BU-dosing regime to induce CBMA without high mortality, and investigated the patterns of cellular responses in the blood and marrow in the post-dosing period. Mice (n = 64/65) were dosed 10 times with BU at 0 (vehicle control), 8.25, 9.0 and 9.75 mg/kg over 21 days and autopsied at day 1, 23, 42, 71, 84, 106 and 127 post-dosing (n = 7-15); blood and marrow samples were examined. BU induced a predictable bone marrow depression at day 1 post-dosing; at day 23/42 post-dosing, parameters were returning towards normal during a period of recovery. At day 71, 84, 106 and 127 post-dosing, a stabilized, late-stage, nondose-related CBMA was evident in BU-treated mice, with decreased erythrocytes, platelets and marrow cell counts, and increased MCV. At day 127 post-dosing, five BU-treated mice showed evidence of lymphoma. In this study, mortality was low, ranging from 3.1% (8.25 mg/kg BU) to 12.3% (9.75 mg/kg BU). It is concluded that BU at 9.0 mg/kg (or 9.25 mg/kg) is an appropriate dose level to administer (10 times over 21 days) to induce CBMA at approximately day 50-120 post-dosing.

Anemia, Aplastic↗

Unrelated cord blood transplantation after myeloablative conditioning in patients over the age of 45 years.

We report the results of unrelated cord blood transplantation (CBT) after myeloablative conditioning in 21 patients over the age of 45 years. Among the patients the median age was 48 years (range, 45-53 years), the median weight was 58.6 kg (range, 43.6-76.2 kg) and the median number of cryopreserved nucleated cells was 2.45 x 10(7)/kg (range, 1.63-3.71 x 10(7)/kg). Nineteen patients had myeloid reconstitution and the median time to more than 0.5 x 10(9)/l absolute neutrophil count was 22 d. A self-sustained platelet count more than 50 x 10(9)/l was achieved in 17 patients at a median time of 49 d. Acute graft-versus-host disease (GVHD) above grade II occurred in 7 of 19 evaluable patients and chronic GVHD occurred in 14 of 16 evaluable patients. Among 14 chronic GVHD patients, in seven patients the disease was extensive. Fifteen patients were alive and free of disease at between 217 and 1798 d after transplantation. With a median follow-up of 847 d, the probability of disease-free survival at 2 years was 71.4%. These results suggest that patients over 45 years of age without suitable related or unrelated bone marrow donors should be considered as candidates for CBT.

Chronic Disease↗

Influence of the intensity of the conditioning regimen on the characteristics of acute and chronic graft-versus-host disease after allogeneic transplantation.

The graft-versus-host disease (GVHD) characteristics of 150 consecutive patients undergoing reduced intensity conditioning allogeneic (allo-RIC) transplants and 88 patients undergoing myeloablative conditioning regimen were analysed. All patients received the same GVHD prophylaxis and peripheral blood stem cells from a human leucocyte antigen identical sibling. The cumulative incidence of acute GVHD (aGVHD) was 67% and 44% in the myeloablative and allo-RIC regimen groups, respectively (P < 0.001), and was 39% vs. 29%, respectively (P = 0.043), for grades 2-4 aGVHD. Only conditioning type (myeloablative versus allo-RIC) significantly influenced the incidence of aGVHD in multivariate analysis: Hazard ratio (HR) = 2.16 [95% confidence interval (CI): 1.52-3.07], P < 0.0001. The cumulative incidence of chronic GVHD (cGVHD) was 63% and 71% among myeloablative and allo-RIC patients respectively (P = 0.084). This trend was because of the higher incidence of limited cGVHD, but not extensive cGVHD among allo-RIC recipients [HR = 3.3 (95% CI: 1.42-8.08), P = 0.0017]. Moreover, among patients who developed cGVHD, the cumulative incidence of limited cGVHD was significantly lower in the myeloablative group than in the allo-RIC group (7% vs. 25%, P = 0.007). Duration of immunosuppression was shorter among allo-RIC patients (35.5% vs. 68.8% required systemic immunosuppression 36 months after transplant, P = 0.028). Although prospective controlled trials are required to further evaluate the effect of the conditioning regimen on GVHD, our results suggest that RIC modifies the incidence and characteristics of both acute and cGVHD after allogeneic transplantation, and decreases the immunosuppression requirements in long-term follow up when compared with myeloablative conditioning.

Acute Disease↗

Current management of follicular lymphomas.

After decades of stagnation, the prognosis of patients with follicular lymphomas (FL) has changed substantially within the last few years due to new and effective therapeutic modalities. These include myeloablative therapy followed by autologous stem cell transplantation (ASCT) in younger patients in first remission, which showed a significant prolongation of remission duration in three prospective randomised trials while the impact on overall survival still needs to be determined. Adding the anti-CD 20 antibody Rituximab to conventional chemotherapy resulted in a significant increase in remission rate, remission duration and, in two of four currently available prospective randomised studies, even in a longer overall survival. A prolongation of remission duration was also seen when Rituximab was given as maintenance after cytoreductive therapy including Rituximab. Radio-immunotherapy (RIT) with radioisotopes coupled to monoclonal antibodies produced encouraging data in several phase II studies. New therapeutic perspectives have also emerged from increasing insights into the biology of the disease that unravel molecular targets for novel agents, some of which have entered clinical evaluation already.

Adoptive Transfer↗

Myeloablative allogeneic stem cell transplantation for advanced stage multiple myeloma: very long-term follow up of a single center experience.

We aimed to review the long-term outcome of myeloablative allogeneic stem cell transplantation (SCT) performed for multiple myeloma (MM) at our institution. Records of all patients who received standard myeloablative allogeneic SCT for MM were retrospectively reviewed. Overall survival (OS), progression-free survival (PFS), and event-free survival (EFS) were calculated using the Kaplan-Meier method. In total 37 transplants had been performed. Median follow up post-SCT was 108 months (range: 33-148). The majority of patients suffered advanced stage disease and/or had received multiple prior therapies prior to SCT. Transplant-related mortality (TRM) at 100 days was 32%. Grades 2-4 acute graft-vs.-host disease (GVHD) occurred in 18 patients (49%), and extensive stage chronic GVHD in seven (28%) of 25 patients surviving greater than day 100. Median OS, PFS, and EFS were 28 months, 66 months and 13 months, respectively, with 5 year OS, PFS, and EFS 40%, 54% and 24%. Our results suggest that allogeneic SCT, even when performed in advanced stage, heavily pretreated MM, still results in long-term EFS in a significant minority of patients. Efforts should continue on alternative allogeneic SCT approaches to reduce the high early TRM rate associated with myeloablative conditioning.

Adult↗

Longitudinal scintigraphic study of parotid and submandibular gland function after total body irradiation in children and adolescents.

OBJECTIVE: Total body irradiation (TBI) and cyclophosphamide (CY) during allogeneic stem cell transplantation (ASCT) cause salivary gland dysfunction in children. The aim of this investigation was to study the scintigraphic functional changes over time of the parotid and submandibular glands in children and young adults one year after treatment with CY and TBI at ASCT. METHODS: Salivary gland scintigraphy (SGS) was performed before ASCT, and 3-6 months and 12 months after ASCT. The three male patients who fulfilled the scintigraphic study had a mean age (+/- SD) of 17.3 +/- 9.8 years at ASCT. RESULTS: The parotid secretion capacity (SPar) was 83.5 +/- 3.2% before ASCT and 48.5 +/- 25.8% during the next 3-6 months (P < 0.05). The SPar did not increase (48.1 +/- 12.4%) during the rest of the first year after ASCT. The submandibular emptying capacity (SSub) was 91.3 +/- 12.9% before ASCT and 35.4 +/- 2.3% after 3-6 months (P < 0.05). The SSub was 87.9 +/- 17.9% one year after ASCT. CONCLUSIONS: The parotid glands were more sensitive to irradiation since they did not recover lost capacity to secrete saliva, while the submandibular glands recovered the secretion capacity at the one-year follow-up.

Adolescent↗

Treatment of X-linked childhood cerebral adrenoleukodystrophy by the use of an allogeneic stem cell transplantation with reduced intensity conditioning regimen.

Childhood cerebral form of X-linked adrenoleukodystrophy (X-ALD) is a rapidly progressive demyelinating condition affecting the cerebral white matter, which rapidly leads to total disability and death. The only known curative treatment for this condition is allogeneic hematopoietic stem cell transplantation (HSCT). Procedure-related toxicity is assumed to be the cause of death of patients with X-ALD. Three cases of ALD successfully transplanted with the use of non-myeloablative fludarabine based conditioning are described. Patients showed smooth peri-bone marrow transplantation course with fast and stable engraftment. In the 3- to 5 yr follow-up period, patients showed no deterioration in their clinical and neurological condition. Levels of very long chain fatty acids were very variable and had a tendency to decrease in at least one of the three patients. In another patient, an improvement of magnetic resonance imaging changes was found. Non-myeloablative HSCT should be considered as an early treatment for X-ALD.

Adrenoleukodystrophy↗

Unrelated donor cord blood transplantation for childhood severe aplastic anemia after a modified conditioning.

Treatment of severe aplastic anemia (SAA) patients who lack human leukocyte antigen (HLA)-matched donors and failed immunosuppressive therapy (IST) is challenging. Recently, umbilical cord blood transplantation (CBT) after non-myeloablative therapy has been reported in adult but not in childhood SAA. However, most cases resulted in mixed donor chimerism and incomplete hematological recovery. We reported an 11-yr-old girl with recurred SAA 5 yr after IST who underwent unrelated donor CBT after a modified regimen. This patient had renal and cardiac dysfunction, and lacked suitable bone marrow donors. The 3.9 x 10(7)/kg CB cells from an HLA one-locus mismatched unrelated donor were infused after conditioning with total body irradiation (5 Gy), melphalan (120 mg/m(2)), and fludarabin (120 mg/m(2)). Hematological recovery was favorable in complete chimerism. A major complication was only skin graft-versus-host disease (grade I). CB could be an alternate stem cell source for childhood SAA after modified preparative regimen.

Anemia, Aplastic↗

Rapid progression of metastatic osteosarcoma after initiation of a reduced-intensity conditioning regimen with immunosuppressive fludarabine.

Indications for RIST have not been established in patients with solid tumors. In this study, we performed RIST as immunotherapy in a 13-yr-old girl with intractable but not progressive osteosarcoma, which originated from the inter-costal region. Carcinomatous pleurisy suddenly developed after the start of a conditioning regimen that included Flu and BUS. She died of respiratory failure on day +19 without signs of engraftment. This case suggests that unexpected acceleration of tumor growth may occur following RIST with immunosuppressive drugs before the development of a beneficial GVT effect.

Antineoplastic Agents↗

Myeloablative chemotherapy and stem cell transplantation in myeloma or primary amyloidosis with renal involvement.

BACKGROUND: High-dose chemotherapy and stem cell transplantation are being applied increasingly to the treatment of selected patients with multiple myeloma or primary systemic amyloidosis. Stem cell transplantation presents unique challenges to the nephrologist because of the high prevalence of renal involvement in myeloma and the issues that are associated with high-dose chemotherapy in patients with the nephrotic syndrome due to renal amyloid. METHODS: We review the published literature on stem cell transplantation in patients with reduced renal function. RESULTS AND CONCLUSIONS: The specifics of transplantation pertaining to patients with renal amyloid nephrotic syndrome are discussed in detail.

Amyloidosis↗

Comparison of peripheral blood progenitor cell yield from standard chemotherapy used in the treatment of lymphoid malignancies and high-dose cyclophosphamide: a retrospective review of 141 patients.

BACKGROUND: Peripheral blood progenitor cells (PBPCs) are often collected after mobilization with high-dose cyclophosphamide (HDC) combined with growth factors. HDC may not be needed for PBPC mobilization, and patients with lymphoid malignancies can be harvested with treatment regimens of chemotherapy. STUDY DESIGN AND METHODS: A retrospective analysis was performed on 141 patients with lymphoma or multiple myeloma whose PBPCs were harvested after chemotherapy. The PBPC yield and time to mobilization was compared between patients who received HDC (n = 51) and other chemotherapy regimens (n = 90) including high-dose cyclophosphamide and etoposide (HDC plus VP-16; n = 41), CHOP, ESHAP, ABVD, VAD, and others (n = 49). A multiple linear regression model and proportional hazards model determined factors influencing yield and time to mobilization, respectively. RESULTS: The difference in mean yield between HDC and all non-HDC regimens was significant, with HDC plus VP-16 resulting in the highest yields. The proportion of patients achieving a CD34 count in excess of 5 x 10(6) per kg did not differ significantly between the regimens. In a multiple linear regression model, HDC plus VP-16 resulted in a higher PBPC yield than HDC but all other regimens did not. In addition, patients exposed to more than one prior chemotherapy regimen had lower yield regardless of the mobilization regimen. The mean number of days to mobilization with HDC was 10.2 days, 17.1 days for HDC plus VP-16, and 14.2 days for all other regimens. The timing of mobilization was influenced by the chemotherapy used and the number of prior regimens in a proportional hazards model. CONCLUSION: These results demonstrate a higher mean yield of PBPCs with HDC plus VP-16 but no difference in yield between non-HDC plus VP-16 regimens used for first-line or relapse therapy and HDC, suggesting that HDC may be an unnecessary additional therapy.

Adult↗