Search

Objective: To identify changes in practice and outcome of bone marrow transplants for leukemia in the 1980s., Design: Comparison of key explanatory and outcome variables in five 2-year cohorts, from 1980 through 1981 to 1988 through 1989, using a large database of detailed clinical information., Patients: Recipients (7788) of bone marrow transplants for acute lymphoblastic, acute myelogenous, or chronic myelogenous leukemia reported to the International Bone Marrow Transplant Registry, Milwaukee, Wis, by 185 transplant teams worldwide., Results: Linear increases occurred during the periods 1980 through 1981 to 1988 through 1989 as follows with 95% confidence intervals: (1) transplants for chronic myelogenous leukemia from 14% +/- 2% to 35% +/- 2%; (2) transplants from unrelated donors from 1% +/- 1% to 7% +/- 1%; (3) preparative regimens without radiation from 3% +/- 1% to 30% +/- 2%; and (4) use of methotrexate plus cyclosporine to prevent graft-vs-host disease from 2% +/- 1% to 55% +/- 2%. Among recipients of human lymphocyte antigen-identical sibling bone marrow, the 2-year probability of treatment-related mortality decreased by 6% to 22%. The probability of relapse decreased from 46% +/- 6% to 38% +/- 6% in intermediate leukemia but did not change appreciably in early or advanced leukemia. Probabilities of leukemia-free survival improved from 51% +/- 4% to 57% +/- 3% in early leukemia, from 28% +/- 4% to 36% +/- 5% in intermediate leukemia, and from 12% +/- 4% to 18% +/- 5% in advanced leukemia. A separate analysis of a homogenous population of patients indicated that improvements in outcome in the 1980s were due to improvements in transplant practice rather than improved patient selection., Conclusions: Modest increases in leukemia-free survival rates occurred after human lymphocyte antigen-identical sibling bone marrow transplants in the 1980s. Improvements were due primarily to reductions in treatment-related mortality with little or no change in relapse risk. More effective antileukemia strategies and continued reductions in treatment-related toxic effects are needed.

Seventeen patients who had a relapse at a median of 9 months after marrow transplant (14 allogeneic and three syngeneic) received second transplants. Eight patients were in remission when transplanted. Of the nine patients with active disease at the time of transplant, six had complete remissions, and one converted from blastic to chronic phase of chronic myelogenous leukemia. The median survival was 9 months (95% confidence interval, 4 to 17 months). Four patients died within 100 days of transplantation, and three were disease-free. Ten patients died after 100 days, all except two of disease relapse. Five patients had remissions that were greater than 12 months and longer than the remission after their first transplant (inversions). Three patients remain alive and disease-free at 37+, 55+, and 61+ months, the former two despite remissions of less than 1 year after their first transplant. Second transplants with a different cytoreductive regimen can eradicate disease resistant to prior myeloablative treatment; some patients may benefit from second transplants, even if the first transplant only achieves a short remission.

We analyzed the effects of T-cell depletion on the outcome of HLA-identical sibling bone marrow transplants for leukemia by comparing 731 T-cell-depleted transplants with 2,480 non-T-cell-depleted transplants. T-cell depletion decreased acute graft-versus-host disease (GVHD) (relative risk [RR] 0.45; P less than .0001) and chronic (GVHD) (RR 0.56; P less than .0001). However, it increased graft failure (RR 9.29; P less than .0001). Leukemia relapse also was increased. In first remission acute leukemia or chronic phase chronic myelogenous leukemia, leukemia relapse was 2.75 times more likely after T-cell-depleted transplants (P less than .0001). T-cell depletion increased the risk of treatment failure (RR 1.35; P less than .0003) and decreased leukemia-free survival. We also studied controllable variables associated with outcome of T-cell-depleted transplants. The unique findings were that among recipients of T-cell-depleted transplants for early leukemia, radiation doses greater than or equal to 11 Gy (RR 0.54; P less than .01), dose rates greater than 14 cGy/min (RR 0.56; P less than .002), and additional posttransplant immune suppression with cyclosporine alone (RR 0.53; P less than .0006) or cyclosporine plus methotrexate (RR 0.36; P less than .01) were associated with fewer treatment failures. Use of monoclonal antibodies rather than physical techniques for T-cell depletion (RR 2.01; P less than .03) and fractionated radiation (RR 1.69; P less than .05) were associated with increased treatment failure and lower leukemia-free survival. These data may be useful in designing strategies to improve results of T-cell-depleted transplants.

We and other investigators have previously reported our findings on oncogene expression in human leukemia in an attempt to study the possible involvement of these genes in the leukemic state. An important shortcoming of these studies has been the lack of information on the expression of these genes in normal hematopoietic cells. To address this question we analyzed both the transcript size and level of expression of six oncogenes in fresh hematopoietic cells obtained from hematologically normal individuals and compared the results to those found in fresh samples obtained from patients with various forms of leukemia (acute myelogenous leukemia, acute lymphocytic leukemia, and chronic myelogenous leukemia). We found low level expression of c-myc, c-myb, c-fes, and c-raf in normal bone marrow in sharp contrast to the high levels of expression found in some forms of leukemia. C-fos was highly expressed in both normal bone marrow and certain leukemias. We were unable to detect c-sis expression in our normal samples. With the exception of c-fes, there was no variation in transcript size when comparing normal and leukemic samples. Having defined the transcript sizes and levels of expression for these proto-oncogenes in normal hematopoietic cells, we know that aberrant transcript size for the genes we have studied is not a common event in leukemias. The levels of expression, however, vary widely between normal hematopoietic cells and leukemia as well as between different types of leukemia.

A colloidal suspension of Co2B with avidin irreversibly adsorbed to the surface has been used with biotinylated antibodies and lectins to eliminate specific cell populations from mixtures with peripheral blood or bone marrows. Using the monoclonal antibodies CF-1 and PM-81 with this magnetic affinity colloid (MAC), we can eliminate five logs of K562 cells from mixtures with peripheral blood or marrow cells as determined by a linear limiting dilution clonogenic assay. We have also used this separation to eliminate clonogenic leukemia cells from fresh samples of peripheral blood and bone marrow from relapsed acute leukemia patients. Using CF-1 alone or in combination with PM-81, we eliminated two logs of colonies and clusters of leukemia cells from the fresh samples. The same antibodies used with MAC separation of hematologically normal marrows allow recovery of greater than 30% of the hematopoietic progenitors.

Previous classification in vitro of adult acute leukemia incorporating morphology has been complex and difficult to understand. We have devised a simplified classification based solely on leuekemic proliferation in vitro. Seventy-six patients with adult acute leukemia previously untreated were included in this study and received identical chemotherapy. Three groups were recognized. The complete remission rate was 76% in the 21 patients with no leukemic growth in vitro (Group 1), 75% in 36 patients with leukemic cell growth but aggregates of 20 cells or less (Group 2), and only 21% in the 15 patients with aggregates of greater than 20 (Group 3). There was a highly significant difference in complete remission rates between Group 3 and the other two groups (p less than 0.001). Linear logistic regression analysis demonstrated the independence of the growth in vitro from other prognostic variables. A predictive model utilizing the in vitro result more accurately predicted for remission, both retrospectively and prospectively, than a model constructed with presently known prognostic parameters. The cause of death in failures suggested that this system detects resistance to the chemotherapy.

One hundred and twenty-seven patients with acute leukemia were treated with high-dose cytoreductive programs in conjunction with autologous marrow. Transplantation in relapse resulted in a complete remission rate ranging from 33% to 72%, depending on the time of transplantation, the conditioning regimen used and the performance status of the patient. Remission duration was short, ranging from three to nine months. Transplantation in second or subsequent remission did not change the natural history of the disease. In 14% of the cases, transplantation remissions were obtained exceeding the duration of the preceding remission, results equivalent to those obtained by normal dose chemotherapy. Transplantation in first remission (CR1) resulted in a projected two-year disease-free survival of 72% (13% SE) in acute myelogenous leukemia and of 45% (17% SE) in acute lymphocytic leukemia. We conclude from these data that the results look promising in CR1 and that in second and subsequent remissions a realistic study design is possible by which the influence on the natural history of disease by changing the bone marrow transplantation program, such as purging in vitro, can be studied.

Previous studies have suggested that the technique of premature chromosome condensation (PCC) is useful in the study of human leukemia, both as a predictive tool for course of disease and as a probe to better understand the biology of the disease process. The purpose of this study was to determine how the various subcomponents of bone marrow populations contribute to the overall PCC pattern. Thirty bone marrow aspirations from persons at various stages of disease (2 normal, 11 untreated, 12 in remission, and 5 n relapse) were fractionated according to density in albumin gradients, and the various fractions were characterized by determining the proliferative potential index (PPI, or the fraction of G1 cells in late G1) using the PCC technique. In general, normal bone marrow and marrow from patients In remission showed lower PPI values throughout the gradients, with the most dense and most mature cells yielding the lowest PPI values in the gradient. In contrast, bone marrow from newly presenting patients and from patients in relapse showed higher PPI values, with the highest PPI values found In the most dense fractions containing the most mature cells. Thus, residual mature cells from patients with active disease exhibit the malignant characteristic of accumulating in late G1 phase. It is postulated that these morphologically mature cells from patients with active disease either represent matured cells of malignant origin or represent residual normal cells pushed beyond the restriction point in early G1 phase by a putative tumor growth factor synthesized by the leukemic cell population.

Previous in vitro classification of adult acute leukemia incorporating morphology has been complex and difficult to understand. We have devised a simplified classification based solely on leukemic proliferation in vitro. Forty-four patients with adult acute leukemia previously untreated were included in this study and received identical chemotherapy. Three in vitro groups were recognized. The complete remission rate (CR) was 77% in the 13 patients with no leukemic growth in vitro (Group 1), 81% in 16 patients with leukemic cell growth but aggregated of 20 cells or less (Group 2) and only 27% in the 15 patients with aggregates of greater than 20 (Group 3). There was a highly significant difference in complete remission rates between Group 3 and the other 2 groups (p less than 0.01). Linear logistic regression analysis demonstrated the independence of the in vitro growth from other prognostic variables. The cause of death in failures suggested that this system detects resistance to the chemotherapy. Similar multifactorial analysis including in vitro agar culture may help to predict for chemotherapy response in preleukemia and leukemia with a low blast cell infiltrate when cytotoxic therapy is clinically indicated.

An in vitro culture technique for colony formation of marrow cells and peripheral blood cells from untreated acute leukemia patients and from patients in relapse is described. The colonies from bone marrow cells of an untreated acute myelogenous leukemia (AML) patient were demonstrated to be of leukemic origin by cytogenetic analysis. Cells obtained from colonies of leukemic origin contained the human malignancy-associated nucleolar antigen (HMNA) as detected by indirect immunofluorescence. This nucleolar antigen was not present in marrow or peripheral blood cells or cells from colonies of marrow from hematologically normal individuals. Colonies could be grown from over 70% of the marrow and peripheral blood samples from untreated acute leukemia patients. The median number of colonies obtained was 75 per 10(5) marrow cells from patients with AML. In 1/3 of the cases an increased number of colonies could be grown from marrow cell suspensions kept in liquid culture for 5 days. This is indicative of the proliferative capacity of the colony forming cell population. This assay may be useful for detection of residual clonogenic leukemic cells in marrow and peripheral blood cell suspensions.

On radiobiological grounds, a therapeutic advantage should result when total body irradiation (TBI) in preparation for bone-marrow engraftment is given as a fractionated course, rather than as a single exposure at logistically reasonable dose rates. This is because cells of hemopoietic origin in general show less capacity for repair of sublethal radiation injury than do cells of other organs. Dose-limiting lung tolerance, in the context of fractionated TBI, is estimated to be at least 12 Gy (without correction) in increments of 2 Gy regardless of dose rate. A practical method for delivering TBI using a high-energy linear accelerator is described.

From March, 1976 to February, 1979, 28 cases of adult acute leukemia of which 24 were evaluable were treated in irreversible relapse with high dose chemotherapy (piperazinedione) and supra-lethal total body irradiation (TBI) in conjunction with autologous bone marrow transplantation (ABMT). The marrow cells grafted were collected and stored in liquid nitrogen at the time of remission. In 12 patients the marrow cells were fractionated using discontinuous albumin gradients in an attempt to separate normal cells from residual leukemic cells. Twelve patients achieved complete remission (CR); in 9 additional patients signs of engraftment were evident but death occurred before achievement of CR. Seven of 12 AML patients, which were treated with bone marrow transplantation as first treatment of their relapse, achieved CR. Four of 5 patients with ALL, whose bone marrows were collected during first remission, reached CR. The median CR duration was 4+ months and the median survival of the patients reaching CR was 6+ months. Autologous bone marrow transplantation offers a good chance of CR (66%) when marrow is collected during first remission and used as first treatment for AML in third relapse and ALL in second relapse.

We have developed an indirect immunofluorescence technique to stain individual colonies in situ in agar to detect the presence of a human malignancy-associated nucleolar antigen. Bone marrow and peripheral blood cells from leukemia patients who were untreated or suffering relapse were used as a source for colony formation. The agar layer containing the colonies was stabilized by overlaying it with an additional agar layer. Cells in the colonies were fixed with methanol, rehydrated, and incubated for prolonged periods in both the primary and the secondary antibodies. The agar was then transferred onto a glass slide, air dried, and examined using a fluorescence microscope. The method is widely applicable for staining colonies in situ in agar with both polyclonal and monoclonal antibodies.

The combination of high-dose cyclophosphamide, BCNU, and VP-16-213 followed by autologous marrow rescue was evaluated in the treatment of relapsed leukemia refractory to normal-dose chemotherapy. Cyclophosphamide was given at a total dose of 4.5 g/m2, BCNU at a dose of 300 mg/m2, and VP-16-213 at a dose of 600 mg/m2. Seven high-dose treatments followed by marrow rescue were administered to six patients. Two patients achieved complete remissions, three had partial remissions, and one achieved a minimal response. The toxicity of this regimen was moderate.

High-dose cyclophosphamide, 1,3-bis-(2 chloroethyl)-1-nitrosourea (BCNU), and VP-16-213 followed by autologous bone marrow rescue was administered to 29 adult patients with acute leukemia in relapse who had failed to respond to prior salvage treatment, with the following results: 14 patients (48%) achieved complete remission (CR), two patients died early of infection and hemorrhage during hypoplasia, and 13 patients had relapsed with leukemia after an initial hypo-plastic phase. Median remission duration was 3 1/2 months (range, 1-8 months). Maintenance treatment with cyclophosphamide and VP-16, which was given to six patients, did not prolong remission duration. Subsequent salvage treatment was well tolerated by both responders and patients who failed to reach CR. This regimen, which is active in both acute lymphocytic leukemia and acute myelogenous leukemia, had a mild toxicity.

Nine patients with adult acute leukemia were treated in relapse with piperazinedione plus supralethal total body irradiation in conjunction with autologous marrow infusion. Bone marrow cells were collected and stored in first remission. Storage time varied from 3 to 23 months. Before storage, marrow cells were separated using density albumin gradients in order to reduce the number of leukemic cells in the graft. Three patients died before day 14 after transplantation because of complications already present at the time of transplantation. In six patients, hemopoietic recovery started to occur within 14 days after transplantation. In four patients leukemia-free periods were obtained, lasting 60+ days. The three patients with the longest leukemia-free period after transplantation (range 75 to 220+ days) are reported in more detail. One patient is still alive without evidence of leukemia, with full hematological recovery 220+ days after transplantation.

This article compares the outcome of 14 patients with primary refractory acute leukemia who underwent bone marrow transplantation from human leukocyte antigen (HLA)-identical donors with that of 18 age-matched control patients who received chemotherapy. Complete clearing of leukemia was seen in all 14 transplanted patients. Five of the transplanted patients are alive 98 to 1790 days posttransplant, and four are free of leukemia. Nine patients have died, eight with severe graft-versus-host disease associated with interstitial pneumonia or systemic infections and one with relapse from chemotherapy-associated infections. Engraftment was seen in all patients. Severe graft-versus-host disease (grades III and IV) was seen in ten patients and resolved in three patients following high-dose corticosteroid treatment. Three of the 18 control patients are alive, none of them in complete remission. It appears that the combination of piperazinedione and total-body irradiation followed by allogeneic transplant is effective induction treatment for primary refractory acute leukemia and will be considered in the future as first salvage treatment for patients failing induction treatment.