The decision to re-induce patients with acute myeloid leukemia (AML) based on results of the day 14 bone marrow (BM) biopsy is variable and lacks evidence based data. The aim of our review was to evaluate the accuracy of a day 14 BM biopsy in determining the need for re-induction chemotherapy.
Seventy-four patients with newly diagnosed de novo AML treated with induction chemotherapy were retrospectively reviewed for the purpose of evaluating treatment decisions and outcomes based on their day 14 BM biopsy. Response to therapy in this analysis was based on morphology alone.
Of the 74 patients undergoing standard induction, 45 patients (61%) had no evidence of leukemia on their day 14 BM biopsy. Eighteen patients (24%) had definitive residual disease (RD), and 11 patient’s (15%) were classified as indeterminate response (IR). Fifteen patients with RD and one with IR underwent re-induction chemotherapy. However, thirteen patients (3 RD and 10 IR) were observed until count recovery without any re-induction therapy. Eleven of these 13 patients who were observed eventually attained a morphologic complete remission (CR), including two patients with RD.
A day 14 BM biopsy may have suboptimal sensitivity for the detection of residual leukemia. Some patients with an IR on day 14 may not require re-induction chemotherapy, but instead, may benefit from careful observation until count recovery to avoid the mortality and morbidity associated with re-induction chemotherapy.
AML; D14 BM biopsy; Re-induction
High fever and/or rash prior to neutrophil engraftment are frequently observed after umbilical cord blood (UCB) transplantation, and the condition is referred to as pre-engraftment syndrome (PES). Few studies have evaluated the risk factors for and treatment response to PES. Therefore, we retrospectively characterized PES in 57 consecutive engrafted patients (≥12 years old) who received myeloablative dual UCB transplantation. All patients received TBI (≥13.2Gy)-based myeloablative conditioning. Tacrolimus (n=35) or cyclosporine (n=22) combined with mycophenolate mofetil was used as GVHD prophylaxis. PES was defined as the presence of non-infectious fever (≥38.5°C) and/or rash prior to or on the day of neutrophil engraftment. The incidence (95% CI) of PES was 77% (66%–88%). The incidence of PES was significantly higher in patients who received cyclosporine as a GVHD prophylaxis than those who received tacrolimus (P<0.001), and this association was confirmed in the multivariate analysis. The occurrence of PES did not impact overall survival or tumor relapse, although it may have increased non-relapse mortality (P=0.071). The incidence of acute GHVD or treatment-related mortality was not influenced by the choice to use corticosteroids to treat PES. This study suggests that use of cyclosporine for GVHD prophylaxis increases the risk of PES following dual umbilical cord blood transplantation.
pre-engraftment syndrome; dual umbilical cord blood transplantation; myeloablative
Burkitt lymphoma is characterized by deregulation of MYC, but the contribution of other genetic mutations to the disease is largely unknown. Here, we describe the first completely sequenced genome from a Burkitt lymphoma tumor and germline DNA from the same affected individual. We further sequenced the exomes of 59 Burkitt lymphoma tumors and compared them to sequenced exomes from 94 diffuse large B-cell lymphoma (DLBCL) tumors. We identified 70 genes that were recurrently mutated in Burkitt lymphomas, including ID3, GNA13, RET, PIK3R1 and the SWI/SNF genes ARID1A and SMARCA4. Our data implicate a number of genes in cancer for the first time, including CCT6B, SALL3, FTCD and PC. ID3 mutations occurred in 34% of Burkitt lymphomas and not in DLBCLs. We show experimentally that ID3 mutations promote cell cycle progression and proliferation. Our work thus elucidates commonly occurring gene-coding mutations in Burkitt lymphoma and implicates ID3 as a new tumor suppressor gene.
We report the outcome of early donor lymphocyte infusions (DLI) following T-cell depleted non-myeloablative transplantation using stem cells from human leukocyte antigen (HLA) matched or mismatched donors.
Patients and Methods
Sixty-nine patients with high risk hematologic malignancies received DLI following fludarabine, cyclophosphamide, and alemtuzumab with infusion of stem cells from a matched sibling (52) or partially matched family member donor (17).
Patients received the first infusion a median of 50 days following transplant and doses ranged from 1×104 CD3+ cells/kg to 3.27 ×108 CD3+ cells/kg, depending on clinical status and physician’s discretion. A median cell dose of 1× 105 CD3+ cells/kg in the mismatched setting and 1×106 CD3+ cells/kg in the matched sibling setting appears safe with only 1/7 (14%) and 4/31 (13%) respectively experiencing severe aGVHD at these doses. Importantly, 38% of patients with persistent disease prior to DLI attained a remission following infusion. Nine of the 69 remain alive and disease free 32–71 months following the first DLI infusion.
Low doses of DLI can be safely provided soon after T-cell depleted non-myeloablative therapy and provide a chance of remission. However, long term survival still remains poor due primarily to relapse in these patients however.
DLI; haploidentical donors; Non-myeloablative Allogeneic Transplantation; Leukemia/Lymphoma
Impact of activating (aKIR) and inhibitory (iKIR) on overall survival (OS), relapse-related mortality (RRM), and acute graft-vs.-host disease (aGVHD) were studied in 84 adults with high risk hematologic malignancies receiving reduced intensity conditioning (RIC) T-cell depleted hematopoietic stem cell transplantation (HSCT) from haploidentical related donors. In this clinical model, freedom from RRM was more dependent on graft-vs-leukemia (GVL) effect. Patients were divided into myeloid (n=49) and lymphoid (n=35) malignancy groups. KIR-ligand and ligand-ligand models were studied in both directions and statistically correlated with outcome measures. In the myeloid group, OS was higher (p=0.009) and RRM lower (p=0.036) in patients missing HLA-C group2 ligand to donor inhibitory KIR. OS was higher if patients had >1 missing ligand (p=0.018). In lymphoid malignancy, missing ligand to donor KIR had no impact on OS or RRM. However, OS was longer with donor activating KIR 2DS2 (p=0.028). There was a trend toward shorter OS in recipient with KIR 2DS1, 2DS5 and 3DS1, although sample sizes are too small to provide inferential statistics. These results suggest that absence of appropriate HLA ligands in the recipient to donor iKIR may induce GVL without aGVHD in myeloid malignancy patients undergoing TCD-RIC transplants.
KIR; Activating KIR; Inhibitory KIR; Haploidentical; Reduced Intensity Conditioning (RIC); Hematopoietic Stem Cell Transplantation (HSCT)
Infusing Natural Killer (NK) cells following transplantation may allow less infections and relapse with little risk of acute graft versus host disease (aGVHD). We delivered 51 total NK cell enriched donor lymphocyte infusions (DLIs) to 30 patients following a 3-6/6 HLA matched T cell depleted nonmyeloablative allogeneic transplant. The primary endpoint of this study was feasibility and safety.
Eight weeks following transplantation, donor NK cell enriched DLIs were processed using a CD56+ selecting column (@Miltenyi) with up to 3 fresh infusions allowed. Toxicity, relapse and survival were monitored. T cell phenotype, NK cell functional recovery, and KIR typing were assessed for association with outcomes.
Fourteen matched and sixteen mismatched transplanted patients received a total of 51 NK cell enriched DLIs. Selection resulted in 96% (standard deviation (SD) 8%) purity and 83% (SD 21%) yield in the matched setting and 97% (SD 3%) purity and 77% (SD 24%) yield in the mismatched setting. The median number of CD3− CD56+ NK cells infused was 10.6 (SD 7.91) × 10e6 cells/kg and 9.21 (SD 5.6) × 10e6 cells/kg respectively. The median number of contaminating CD3+CD56− T cells infused was .53 (1.1) × 10e6 and .27 (.78) × 10e6 in the matched and mismatched setting respectively. Only 1 patient each in the matched (n=14) or mismatched (n=16) setting experienced severe aGVHD with little other toxicity attributable to the infusions. Long term responders with multiple NK cell enriched infusions and improved T cell phenotypic recovery had improved duration of responses (p=.0045) and overall survival (p=.0058).
A one step, high yield process is feasible and results in high doses of NK cells infused with little toxicity. NK cell enriched DLIs result in improved immune recovery and outcomes for some. Future studies must assess whether the improved outcomes are the direct result of the high doses and improved NK cell function or other aspects of immune recovery.
High relapse rates and infections remain primary causes of failure in non-myeloablative transplantation. Interleukin-2 (IL-2) may stimulate the immune system and improve outcomes. The primary objective of this pilot study was to evaluate the feasibility of administering IL-2 following a T cell-depleted nonmyeloablative hematopoietic stem cell transplant.
Patients received T cell depleted nonmyeloablative transplant from a matched or mismatched related donor. Those with allogeneic engraftment, < grade 2 acute GVHD at time of study entry, and no severe end organ damage were eligible and received IL2 starting 6 weeks after the first day of stem cell infusion. Patients received 1 mu/m2 daily for 5 days each week for 4 weeks followed by a 2 week rest period for a 6 week cycle to continue for up to 1 year.
Eight patients aged 28–69 were treated. Significant toxicities were limited to GVHD of the skin ≤ grade 2 in 3 patients and severe fatigue in 4 patients, limiting the duration of therapy. Two of the 8 patients died of relapsed disease and one from CMV. With a median overall duration of follow up of survivors of 48 months, five patients (63%) remain alive and in continuous complete remission.
Non-myeloablative Allogeneic Transplantation; Leukemia /Lymphoma; IL-2; NK cells
Twenty percent to 30% of CML patients are not being treated according to clinical practice guidelines. The authors review the most recent guidelines published by the National Comprehensive Cancer Network and the European LeukemiaNet.
Clinical practice guidelines are developed to improve the quality of care and outcomes for patients. Guidelines facilitate clinical decisions, promote efficient use of health care resources, and provide guidance to practitioners. For chronic myeloid leukemia (CML), tyrosine kinase inhibitors (TKIs) have changed the paradigm of therapy by lowering the disease burden and by providing more precise monitoring of response. These advances affect treatment guidelines for CML and inform CML clinical trial protocols.
Guidelines developed by the National Comprehensive Cancer Network (NCCN) and European LeukemiaNet (ELN) synthesize the best available evidence to support decision-making in the management of CML patients. Both guidelines recognize specific milestones for treatment response. At each time point, the ELN guidelines define overall response benchmarks, and the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) provide an algorithm that specifies the timing for evaluations of cytogenetic and molecular parameters during therapy. The NCCN Guidelines also include strategies for providing supportive care and for managing toxicities. Molecular monitoring now plays a greater role in CML management. Molecular response as a milestone is currently recommended by the ELN but has not yet been adopted by the NCCN. As evidence continues to accumulate, the NCCN and ELN Guidelines are likely to evolve to reflect new data and standards of care.
chronic myeloid leukemia; tyrosine kinase inhibitors; imatinib; nilotinib; dasatinib; clinical practice guidelines
Primary graft failure after allogeneic hematopoietic cell transplantation is a life-threatening complication. A shortened conditioning regimen may reduce the risk of infection and increase the chance of survival. Here, we report the outcome of 11 patients with hematologic diseases (median age, 44; range, 25–67 years, 7 males) who received a 1-day reduced-intensity preparative regimen given as a re-transplantation for primary graft failure. The salvage regimen consisted of fludarabine, cyclophosphamide, alemtuzumab, and total-body irradiation, all administered 1 day before re-transplantation. All patients received T-cell replete peripheral blood stem cells from the same or different haploidentical donor (n = 10) or from the same matched sibling donor (n = 1). Neutrophil counts promptly increased to >500/µL for 10 of the 11 patients at a median of 13 days. Of these, none developed Grade III/IV acute graft-versus-host disease. At present, 8 of the 11 patients are alive with a median follow-up of 11.2 months from re-transplantation and 5 of the 8 are in remission. In conclusion, this series suggests that our 1-day preparative regimen is feasible, leads to successful engraftment in a high proportion of patients, and is appropriate for patients requiring immediate re-transplantation after primary graft failure following reduced-intensity transplantation.
allogeneic hematopoietic cell transplantation; primary graft failure; re-transplantation
To describe renal shielding techniques and dosimetry in delivering total body irradiation (TBI) to patients with severe systemic sclerosis (SSc) enrolled on a hematopoietic stem cell transplant protocol.
Methods and Materials
The SCOT protocol employs a lymphoablative preparative regime including 800cGy TBI delivered in two 200 cGy fractions twice a day before CD34+ selected autologous hematopoietic stem cell transplantation. Lung and kidney dose is limited to 200 cGy to protect organs damaged by SSc. Kidney block proximity to the spinal cord was investigated and guidelines were developed for acceptable lumbar area TBI dosing. Information on kidney size and the organ shifts from supine to standing positions were recorded using diagnostic ultrasound (US). Minimum distance between the kidney blocks (dkB) and the lumbar spine region dose were recorded and in vivo dosimetry was performed at several locations to determine doses of irradiation delivered.
Eleven patients were treated at our center with an AP/PA TBI technique. A 10–20% dose inhomogeneity in the lumbar spine region was achieved with a minimum kidney block separation of 4–5 cm. The average lumbar spine dose was 179.6 ± 18.1 cGy, with an average dkB of 5.0 ± 1.0 cm. Kidney block shield design was accomplished using a combination of US and non-contrast CT (computerized tomography) or CT imaging alone. The renal US revealed a wide range of kidney displacement from upright to supine positions. Overall, the average in vivo dose for the kidney prescription point was 193.4 ± 5.1 cGy.
The dose to the kidneys can be attenuated while maintaining a 10–20% dose inhomogeneity in the lumbar spine area. The kidneys were localized more accurately using both US and CT imaging. With this technique, renal function has been preserved and the study continues to enroll.
total body irradiation; renal shielding; hematopoietic stem cell transplant; autoimmune disease; scleroderma; systemic sclerosis
Patients with acute leukemia refractory to induction or reinduction chemotherapy have poor prognoses if they do not undergo hematopoietic stem-cell transplantation (HSCT). However, HSCT when a patient is not in complete remission (CR) is of uncertain benefit. We hypothesized that pretransplantation variables may define subgroups that have a better prognosis.
Patients and Methods
Overall, 2,255 patients who underwent transplantation for acute leukemia in relapse or with primary induction failure after myeloablative conditioning regimen between 1995 and 2004 were reported to the Center for International Blood and Marrow Transplant Research. The median follow-up of survivors was 61 months. We performed multivariate analysis of pretransplantation variables and developed a predictive scoring system for survival.
The 3-year overall survival (OS) rates were 19% for acute myeloid leukemia (AML) and 16% for acute lymphoblastic leukemia (ALL). For AML, five adverse pretransplantation variables significantly influenced survival: first CR duration less than 6 months, circulating blasts, donor other than HLA-identical sibling, Karnofsky or Lansky score less than 90, and poor-risk cytogenetics. For ALL, survival was worse with the following: first refractory or second or greater relapse, ≥ 25% marrow blasts, cytomegalovirus-seropositive donor, and age of 10 years or older. Patients with AML who had a predictive score of 0 had 42% OS at 3 years, whereas OS was 6% for a score ≥ 3. Patients with ALL who had a score of 0 or 1 had 46% 3-year OS but only 10% OS rate for a score ≥ 3.
Pretransplantation variables delineate subgroups with different outcomes. HSCT during relapse can achieve long-term survival in selected patients with acute leukemia.
Although the role of Hedgehog (Hh) signalling in embryonic pattern formation is well established1, its functions in adult tissue renewal and maintenance remain unclear, and the relationship of these functions to cancer development has not been determined. Here we show that the lossof Smoothened (Smo), an essential component of the Hh pathway2, impairs haematopoietic stem cell renewal and decreases induction of chronic myelogenous leukaemia (CML) by the BCR–ABL1 oncoprotein3. Loss of Smo causes depletion of CML stem cells—the cells that propagate the leukaemia—whereas constitutively active Smo augments CML stem cell number and accelerates disease. As a possible mechanism for Smo action, we show that the cell fate determinant Numb, which depletes CML stem cells, is increased in the absence of Smo activity. Furthermore, pharmacological inhibition of Hh signalling impairs not only the propagation of CML driven by wild-type BCR–ABL1, but also the growth of imatinib-resistant mouse and human CML. These data indicate that Hh pathway activity is required for maintenance of normal and neoplastic stem cells of the haematopoietic system and raise the possibility that the drug resistance and disease recurrence associated with imatinib treatment of CML4,5 might be avoided by targeting this essential stem cell maintenance pathway.
The efficacy of once daily intravenous busulfan with fludarabine as a preparative regimen for partially matched umbilical cord blood transplantation has not been formally studied. We randomized 10 adult patients with myeloid malignancies to receive either concurrent or sequential administration of intravenous busulfan 130mg/m2 once daily × 4 days and fludarabine 40mg/m2 daily × 4 days followed by dual umbilical cord blood transplantation. The median combined cryopreserved total nucleated cell dose was 3.6 × 107/kg recipient body weight (range 2.8 to 4.5 × 107/kg). Graft versus Host disease prophylaxis was provided by tacrolimus and mycophenolate mofetil. Donor-derived neutrophil recovery was observed in only 2 of 10 patients resulting in premature closure of the study as per graft failure stopping rules. We conclude that the myeloablative conditioning regimen of once daily intravenous busulfan with fludarabine provides insufficient immunosuppression to allow for engraftment of partially matched, dual umbilical cord blood grafts.
End-organ damage is common in patients with sickle cell disease (SCD) thereby limiting the use of allogeneic stem cell transplantation (SCT). We report the outcome of two adult SCD patients, one with end stage renal disease (ESRD), who underwent fludarabine-based non-myeloablative SCT from HLA-identical matched siblings. To prevent fludarabine toxicity, the patient with ESRD underwent aggressive dialysis following adjusted fludarabine dosing. Pharmacokinetics of the fludarabine metabolite F-Ara-A was studied on the patient with ESRD and two additional patients with normal renal function. Both patients with SCD achieved full donor erythroid chimerism, have normal blood counts and are on no immunosuppressive medications. With a 20% dose reduction followed by daily dialysis, we achieved fludarabine drug exposure that is nearly identical to that achieved in patients with normal renal function. We conclude that fludarabine-based non-myeloablative allogeneic SCT for adult patients with SCD is feasible, even in the setting of ESRD.
This study evaluated combination drug partners for CP-4055, the C18:1Δ9,trans unsaturated fatty acid ester of cytarabine in HL-60 and U937 cells. Growth inhibition was assessed by ATP assay and drug interaction by the combination index and three dimensional methods. Synergy was observed in HL-60 cells for simultaneous combinations of CP-4055 with gemcitabine, irinotecan and topotecan, while combinations with cloretazine (VNP40101M) and idarubicin were additive. In U937 cells, synergy was observed with gemcitabine and additivity for the other drugs. In HL-60, the IC50 concentration of CP-4055 could be reduced 10-fold and that of gemcitabine 3-fold in combination versus the agents alone, an interaction that was independent of drug sequence, ratio and exposure time. In contrast, interactions of CP-4055 with the topoisomerase inhibitors became antagonistic when the drugs were administered 24 h prior to CP-4055 and at certain drug ratios, particularly in U937 cells. In summary, CP-4055 produced additive to synergistic anti proliferative activity when combined simultaneously with drugs from four mechanistic classes in cell culture models of human leukemia and lymphoma. The impact of drug sequence and ratio on the interactions argues for incorporation of these parameters into the design of combination chemotherapy regimens.
DNA antimetabolite; combination chemotherapy; drug synergy; median effect analysis; leukemia; lymphoma
In this study, we investigated whether elimination of CD4+/CD25+ Tregs using the recombinant IL-2 diphtheria toxin conjugate DAB389IL-2 (also known as denileukin diftitox and ONTAK) is capable of enhancing the immunostimulatory efficacy of tumor RNA-transfected DC vaccines. We show that DAB389IL-2 is capable of selectively eliminating CD25-expressing Tregs from the PBMCs of cancer patients without inducing toxicity on other cellular subsets with intermediate or low expression of CD25. DAB389IL-2–mediated Treg depletion resulted in enhanced stimulation of proliferative and cytotoxic T cell responses in vitro but only when DAB389IL-2 was omitted during T cell priming. DAB389IL-2 significantly reduced the number of Tregs present in the peripheral blood of metastatic renal cell carcinoma (RCC) patients and abrogated Treg-mediated immunosuppressive activity in vivo. Moreover, DAB389IL-2–mediated elimination of Tregs followed by vaccination with RNA-transfected DCs significantly improved the stimulation of tumor-specific T cell responses in RCC patients when compared with vaccination alone. Our findings may have implications in the design of immune-based strategies that may incorporate the Treg depletion strategy to achieve potent antitumor immunity with therapeutic impact.