Comparison of marrow vs blood-derived stem cells for autografting in previously untreated multiple myeloma

Sixty-three new untreated patients with multiple myeloma under the age of 70 years received C-VAMP induction treatment followed by high-dose intravenous melphalan (200 mg m(-2)) and autologous stem cell transplant, either with marrow [autologous bone marrow transplants (ABMT), n = 26] or with granulocyte colony-stimulating factor (G-CSF)-mobilized stem cells from the blood [peripheral blood stem cell transplants (PBSCT), n = 37]. This was a sequential study and the two groups were not significantly different for all known prognostic variables. The complete remission (CR) rate after high-dose treatment was the same for both groups [ABMT 84% and PBSCT 70%; P = not significant (NS)]. Neutrophil recovery to 0.5 x 10(9) l(-1) occurred at a median of 22 days in the ABMT patients compared with 19 days for the PBSCT patients (P = NS). Platelet recovery to 50 x 10(9) l(-1) was significantly faster in PBSCT patients (19 days vs 33 days; P = 0.0015), and the PBSCT patients spent fewer days in hospital (median 20 vs 27 days; P = 0.00001). There was no difference in the two groups with respect to starting interferon (58 days for ABMT vs 55 days for PBSCT), and tolerance to interferon was identical. The median overall survival (OS) and progression-free survival (PFS) for the PBSCT patients has not yet been reached. The OS in the ABMT patients at 3 years was 76.9% (95% CI 60-93%) compared with 85.3% (95% CI 72-99%) in the PBSCT patients (P = NS), and the PFS at 3 years in the ABMT patients was 53.8% (95% CI 34-73%) and in the PBSCT patients was 57.6% (95% CI 34-81%) (P = NS). The probability of relapse at 3 years was 42.3% in the ABMT arm compared with 40% in the PBSCT patients (P = NS). Thus, PBSCT patients had a faster engraftment and a shorter stay in hospital than ABMT; the survival outcome and probability of relapse was the same for both groups.

Angiotensin II stimulates sperm motility

The physiological factors which induce and maintain mammalian sperm maturation and motility generally remain unclear, although several agents are known to be involved. We recently described the application of immunocytochemical and immunoblotting methods to identify the angiotensin II type 1 (AT1) receptor in the tails of ejaculated rat and human sperm, and gave evidence to show that angiotensin II may promote sperm motility. These data are extended here by the application of a computerised sperm tracking system (the Hobson Sperm Tracker) to demonstrate that AII has actions on specific motility parameters, including curvilinear velocity, straight line velocity, and amplitude of lateral head movement. Since local tissue renin-angiotensin systems are present in both male and female tracts, the data suggest that angiotensin II has a role in the maintenance of sperm function and fertility.

Melphalan alone prior to allogeneic bone marrow transplantation from HLA-identical sibling donors for hematologic malignancies: alloengraftment with potential preservation of fertility in women

Melphalan has rarely been used as a single agent for conditioning prior to allogeneic marrow transplantation. Twenty-eight patients (median age 19.5 years) undergoing allogeneic BMT for acute leukemia (n = 26) or lymphoblastic lymphoma (n = 2) in first remission (n = 10) or beyond (n = 18) from HLA-identical siblings received 240 mg/m2 melphalan. Death due to primary graft failure was seen in two patients. Sustained hematopoietic recovery was seen in all the others (n = 22) not dying early due to toxicity (n = 2) or persistent active disease (n = 2). The 3-year probabilities of transplant-related mortality and relapse were 35% and 62%, respectively. Seven patients are alive and well at 103-163 months (median 136) with Karnofsky scores of 100% (10-year disease-free survival, 25%). Of the 16 patients with donors of the opposite sex, seven underwent cytogenetic studies after BMT and showed complete chimerism with donor cells. Amongst the four women who were 15-30 years at the time of the transplant, there were seven pregnancies over 297 months of follow-up beyond 2 years from transplant. In contrast, no pregnancies were seen in 53 women with hematologic malignancies who were conditioned with other regimens over 3524 months of follow-up beyond 2 years from transplant. The pregnancy rate was significantly higher (P < 0.001) for women conditioned with melphalan alone (three of four) than for those conditioned with other regimens (0 of 53). We conclude that pre-transplant conditioning with melphalan alone permits alloengraftment of marrow from HLA-identical siblings, and may preserve fertility better than other regimens in some women.

An economic evaluation of peripheral blood stem cell transplantation as an alternative to autologous bone marrow transplantation in multiple myeloma

Autologous peripheral blood stem cell transplantation (PBSCT) is increasingly being utilised as an alternative to autologous bone marrow transplantation (ABMT) in the treatment of malignant diseases. We have performed a pharmacoeconomic study using cost-minimisation analysis to evaluate the two techniques in a population of multiple myeloma patients undergoing PBSCT (n = 37) or ABMT (n = 14). In the PBSCT group, the time to > 0.5 x 10(9)/l neutrophils was significantly shorter (16 vs 22 days; P = 0.0019) as was the time to > 50 x 10(9)/l platelets (19 vs 27 days; P = 0.0019). The faster haematopoietic recovery resulted in a reduced period of intravenous antibiotic therapy (12 vs 19 days; P < 0.0001), reduced requirements for platelet transfusions (12 vs 31.5 units; P = 0.0005), and ultimately, a significant reduction in duration of hospitalisation (19 vs 27.5 days; P < 0.0001). These clinical benefits translated into economic benefits such that the total cost in the PBSCT group was 27.5% less than in the ABMT group (< Pounds 7995 vs < Pounds 11026; P = 0.0001). We conclude that the use of PBSCT as an alternative to ABMT in patients with multiple myeloma is associated with demonstrable economic advantages in addition to clinical benefits.

Role of CD34+ cells in engraftment after high-dose melphalan in multiple myeloma patients given peripheral blood stem cell rescue

During the period December 1992 to June 1995, 95 patients were treated with high-dose melphalan (HDM) with peripheral blood stem cell rescue (PBSCR). Sixty-five had received previous treatment and 28 had relapsed. Among patients who had relapsed 21/28 had received HDM previously including one who received HDM twice during the course of the study. Seventy-five patients were given HDM/PBSCR for the first time. Comparisons have been made between engraftment times for platelets and neutrophils among patients who received less than or greater than 2 x 10(6) CD34+ cells at rescue. Analyses have also been done to evaluate the effect of previous HDM on recovery. Mobilization of progenitor cells was done with granulocyte colony-stimulating factor (G-CSF). Patients received only PBSCR. No growth factors were given to the PBSCR recipients during the recovery period. The percentage of patients from whom the number of CD34+ cells mobilized was > 2 x 10(6)/kg was similar in patients who received HDM for the first time (23%) compared with those who had had it previously (19%). The yield of CD34+ cells correlated with the number of granulocyte-macrophage colony forming units (CFU-GM). Although the number of CD34+ cells infused was < 2 x 10(6)/kg in 77% of patients, all engrafted for neutrophils to > 0.5 x 10(9)/l. This was delayed in patients who had had previous HDM (P < 0.02). Platelet recovery to > 25, 50 and 100 x 10(9)/l was delayed in all patients who received < 2 x 10(6) CD34+ cells/kg infused (P < 0.02). In patients who had had previous HDM both neutrophil (P < 0.05) and platelet recovery (P < 0.007) were delayed compared with recovery in patients who had not had HDM. In patients who had had previous HDM and received < 2 x 10(6) CD34+ cells/kg infused only 3/17 regained platelets to > 100 x 10(9)/l compared with 3/4 who had > 2 x 10(6) CD34+ cells/kg infused (P < 0.05 Fisher's exact test). There was no evidence that low numbers of CD34+ cells in the PBSCR were associated with early death. The data show that previous treatment with HDM had adverse effects on the subsequent engraftment of platelets among patients given HDM/PBSCR. The data suggest that additional measures are needed to achieve platelet reconstitution in these heavily pre-treated patients.

Failure of cyclosporine to induce graft-vs-host disease or graft-vs-leukemia after syngeneic bone marrow transplantation in mice

Cyclosporine administration can result in graft-vs-host disease (GVHD) after syngeneic or autologous bone marrow transplantation (BMT). However, data on its anti-tumor effects are limited. We have tried to produce cyclosporine-induced GVHD or graft-vs-leukemia (GVL) against two Ia-bearing murine leukemias. BALB/c mice undergoing syngeneic BMT after total-body irradiation received 1 mg/kg or 10 mg/kg cyclosporine or dextrose intraperitoneally for 30 days post-transplant, followed by 5 x 10(3) BCL1 murine leukemia cells 1 or 3 weeks after stopping cyclosporine. Similarly, SJL/J mice undergoing syngeneic BMT received 10 mg/kg cyclosporine or dextrose intraperitoneally for 30 days post-transplant, and were inoculated with 5 x 10(3) or 10(5) murine acute myeloid leukemia (mAML) cells 3 weeks after stopping cyclosporine. No clinical or histological evidence of GVHD was seen, and leukemia-free and overall survival was similar with cyclosporine and dextrose. We conclude that under the experimental conditions used, it is not possible to induce syngeneic GVHD with cyclosporine in BALB/c or SJL/J mice. In the absence of GVHD, this approach is also not associated with any GVL effect against murine leukemias BCL1 and mAML.

Idarubicin, high-dose cytarabine, and etoposide for induction of remission in acute leukemia

Between 1990 and 1944, 52 newly diagnosed patients with primary (n = 47) or therapy-related (n = 5) acute myeloid leukemia (AML) under the age of 55 years received an induction chemotherapy protocol (designated BF12) consisting of idarubicin ([IDA] 5 mg/m2), high-dose cytarabine ([HD-Ara-C] 2 mg/m2 per 12 hours, 3-hour infusion), and etoposide ([VP-16] 100 mg/m2, 1-hour infusion) on each of 5 consecutive days. Thirty-seven of 51 assessable patients (72.5%), including all five patients with therapy-related AML, attained remission with one cycle. The overall remission rate was 78.4%. Total therapy of AML, with BF12 followed by two courses of consolidation therapy and allogeneic or unpurged autologous bone marrow transplantation (BMT) in first remission, has resulted in actuarial 3-year survival of 49.9% of consecutive unselected patients with newly diagnosed primary AML (minimum follow-up period, 1 year). Twenty-five patients have received BF12 for relapsed acute leukemia, including 13 relapsing after BMT. Five patients died of toxicity and were not assessable for response. Of the remaining 20 patients, five were refractory, two attained partial remissions, and 13 (65%) achieved complete remission (CR). Four of the 13 patients relapsing after BMT died of toxicity, four were refractory, and five of nine assessable patients (56%) attained CR. We conclude that the combination IDA/HD-Ara-C/VP-16 is highly effective in the treatment of newly diagnosed AML and relapsed acute leukemia.

Long-term follow-up of patients undergoing allogeneic bone marrow transplantation for acute myeloid leukemia in first complete remission after cyclophosphamide-total body irradiation and cyclosporine

Eighty-five patients (median age 28 years) with acute myeloid leukemia (AML) in first remission underwent allogeneic bone marrow transplantation (BMT) from HLA-identical siblings between 1978 and 1987 after cyclophosphamide and single-fraction total body irradiation with cyclosporine for graft-versus-host disease (GVHD) prophylaxis. The actuarial probabilities of development of acute and chronic GVHD were 57% and 47%, respectively. Twenty-six patients died of transplant-related complications at a median of 3.5 months, and two of unrelated causes. Seventeen patients relapsed at a median of 6.5 months. Forty patients were alive and well at 74-197 months (median 157) after BMT; seven (18%) with limited chronic GVHD requiring therapy. The actuarial 10-year probabilities of transplant-related death, relapse, and disease-free survival were 33%, 25% and 48% respectively. In multivariate analysis, infusion of a lower cell dose, development of GVHD, and age > 35 years were associated with increased transplant-related mortality, donor-recipient ABO incompatibility with a lower relapse rate, and age > 35 years and a lower cell dose with poorer disease-free survival. We conclude that with long-term follow-up, allografting in AML after cyclophosphamide-TBI and cyclosporine has resulted in disease-free survival that is comparable to most currently reported series. Patients who are alive and well 3-4 years after BMT have excellent prospects of long-term survival.

High-dose hydroxyurea and G-CSF to collect Philadelphia-negative cells in chronic myeloid leukemia: preliminary results

Five patients with Ph+ chronic myeloid leukemia and no detectable diploid cells in the marrow received 6 g hydroxyurea twice daily for 7 days followed by G-CSF to harvest Ph-cells 1-84 months after diagnosis. Three were in first chronic phase, and two in accelerated phase. One stopped hydroxyurea after 4 doses due to intractable vomiting and was not apheresed, while two stopped hydroxyurea after 9 and 11 doses because of mucositis and skin rash. Two tolerated all doses; one with no significant side effects, and one with mucositis and painful plantar rash. The nadir leukocyte, neutrophil, and platelet counts were 0.4-0.8, 0-0.1, and 2-19 x 10(9)/L respectively. Apheresis was commenced when the leukocytes were 1.2-3.8 x 10(9)/L 9-10 days after starting G-CSF, and 6 aphereses were performed. Four collections were 100% Ph+, and two 22% and 90% Ph-. The total nucleated cell, CD34+/CD34-subset, CD34+/CD33+ subset, and CFU-GM yields per kg per collection were 0.48-2.38 (median 1.18) x 10(8), 0-0.48 (median 0.012) x 10(6), 0.028-10.19 (median 0.92) x 10(6), and 0.29-41.81 (median 21.78) x 10(4) respectively. We conclude that hydroxyurea in the dose we used is poorly tolerated, and is associated with significant adverse effects including severe myelosuppression. It is possible to harvest diploid cells during recovery, but achievement of Ph-negativity appears to be erratic and cell yields are poor.

Factors affecting engraftment and hematopoietic recovery after unpurged autografting in acute leukemia

Factors affecting hematologic recovery to 0.5 x 10(9)/l neutrophils and 50 x 10(9)/l platelets after unpurged autografting (210 marrow, 30 blood) were analyzed in 240 patients with acute myeloid (AML, n = 128) or lymphoblastic (ALL, n = 112) leukemia. Cytokines were not administered routinely after transplant. Age, sex and cryopreservation did not influence hematologic recovery in multivariate analysis. Blood cell grafts (P < 0.0001), ALL (P = 0.003), and a nucleated cell dose of > or = 2 x 10(8)/kg (P = 0.035) were associated with faster neutrophil recovery. First remission (P = 0.001), a higher cell dose (P = 0.011), ALL (P = 0.023), and a short remission-transplant interval (P = 0.023) were associated with faster platelet recovery. There was a strong correlation between blood cell grafts and higher cell doses, and marrow and lower cell doses. Amongst marrow recipients, neutrophil recovery was faster in ALL (P = 0.001) and with higher cell doses (P = 0.032). Platelet recovery was faster in first remission patients (P = 0.005) and ALL (P = 0.043), and with higher cell doses (P = 0.031). We conclude that hematologic recovery after autografting is faster in ALL and first remission patients, probably due to the nature and the amount of prior chemotherapy. Using blood stem cells hastens engraftment, but even if marrow is used due to concern over relapse with blood, higher cell doses are associated with faster recovery.

Transfusion requirements after bone marrow transplantation from HLA-identical siblings: effects of donor-recipient ABO incompatibility

Transfusion requirements of 477 patients with hematologic malignancies undergoing BMT from HLA-identical siblings were studied. The median (range) number of red cells transfused in the first, second and third months were 4 (0-32), 1 (0-39), and 0 (0-22) respectively, and the number of random donor platelet concentrates 32.5 (0-196), 0 (0-220) and 0 (0-135). On multivariate analysis, diagnosis other than acute leukemia, conditioning regimen other than cyclophosphamide-TBI, cyclosporine-methotrexate GVHD prophylaxis, and occurrence of acute GVHD increased platelet requirements significantly in the first month. Diagnosis other than acute leukemia, donor-recipient ABO incompatibility, conditioning regimen other than cyclophosphamide-TBI, and age over 18 years increased red cell requirements significantly in the first month. Platelet requirements in the second month and red cell requirements in the second and third months were increased significantly by the occurrence of acute GVHD, a diagnosis other than acute leukemia, and a conditioning regimen other than cyclophosphamide-TBI. Platelet requirements in the third month were influenced only by acute GVHD. We conclude that ABO incompatibility does not influence platelet requirements after allogeneic BMT. It affects red cell requirements in the first month along with the diagnosis, conditioning regimen, and age. However, other factors outweigh the influence of ABO-incompatibility on red cell requirements beyond the first month.

Melphalan-total body irradiation and autologous bone marrow transplantation for adult acute leukemia beyond first remission

Forty-four adults with AML (n = 18) or ALL (n = 26) beyond first remission underwent unpurged (n = 39) or purged (n = 5) autografting after 110-140 mg/m2 melphalan and 1050 cGy TBI. ALL patients were eligible to receive maintenance chemotherapy with 6-mercaptopurine and methotrexate for 2 years after hematologic recovery. The duration of first remission was 1-167 months (median 11). The median time to 50 x 10(9)/I platelets was 76 days, and that to 0.5 x 10(9)/I neutrophils 31 days. Eight patients died of transplant-related toxicity; seven within 1 year. Twenty-two patients relapsed at 1-20 months (median 2.5 months). The 3-year probabilities (95% CI) of relapse and disease-free survival are 58% (43-75%) and 31% (17-45%), respectively. The duration of the first remission (< 1 year vs > or = 1 year) and the stage of transplant (second remission vs other) had no effect on relapse or disease-free survival. There was a trend towards higher relapse rates (76 vs 34%) and poorer disease-free survival (19 vs 49%) among ALL patients compared with AML which did not reach significant levels due to small patient numbers. We conclude that melphalan-TBI is a suitable conditioning regimen for autografting in advanced leukemia. The outcome of AML patients is comparable to standard regimens, but the outcome of ALL patients is poor and measures to enhance the anti-leukemic efficacy are necessary.

T cell-depleted allogeneic bone marrow transplantation from a partially HLA-mismatched unrelated donor for progressive chronic lymphocytic leukemia and fludarabine-induced bone marrow failure

A 49-year-old man with a 3-year history of chronic lymphocytic leukemia (CLL, stage B at diagnosis) responded well to four course of fludarabine, but developed marrow failure and prolonged pancytopenia lasting 9 months following the fifth course. Fludarabine therapy could not be continued due to pancytopenia, eventually resulting in disease progression. Bone marrow transplantation from an unrelated donor mismatched at one DRB1 locus and both DQB1 loci was performed as salvage therapy. The marrow was depleted of T cells with Campath-1G. Pre-transplant immunosuppression was enhanced with 600 cGy total lymphoid irradiation and Campath-1G infusions in addition to 120 mg/kg cyclophosphamide and 1200 cGy fractionated total body irradiation. Cyclosporine alone was used as post-transplant immunosuppression. Neutrophils reached 0.5x10(9)/1 on day 14 and platelets 50 x 10(9)/1 on day 40. No acute graft-versus-host disease was seen. Bulk disease detected on CT scanning prior to BMT was found to have disappeared 10 weeks after BMT. The marrow showed residual disease (5% CD5+/CD19+ cells) 9 weeks after transplantation, which had decreased markedly at 13 (0.5%) and 26 (0.4%) weeks. The patient is currently alive and well 10 months after BMT with no clinically detectable disease. We conclude that BMT from an unrelated donor is a feasible treatment option in advanced CLL.

Comparison of interferon tolerance after autologous bone marrow or peripheral blood stem cell transplants for myeloma patients who have responded to induction therapy

Interferon (INF) has been incorporated as part of maintenance therapy after high dose treatment in order to make remissions more durable. In this study we have compared peripheral blood stem cell transplant (PBSCT) versus autologous bone marrow transplant (ABMT) with respect to INF tolerance. Thirty nine PBSCT patients have been compared to 37 ABMT patients for INF tolerance. This is followed by a comparison of 15 PBSCT patients versus 21 ABMT patients for engraftment details, response and survival. INF was started at a median of 61 days in the PBSCT and 58 days in the ABMT patients (P = NS). It was well tolerated in both groups without a significant difference in toxicity in the two arms. Engraftment was more rapid in the PBSCT patients with platelet recovery being significantly faster. Response and survival showed a favourable trend for ABMT patients though statistical significance was not reached and the cost of PBSCT was 12% cheaper. We were thus able to conclude that PBSCT grafts were as durable and could tolerate INF just as well as ABMT. Engraftment was more rapid and the procedure of PBSCT was also cheaper. Further studies with a larger group of patients will be required before comments on the efficacy of treatment can be made.

Central nervous system relapse after bone marrow transplantation for acute leukemia in first remission

Four hundred and eighty-seven patients undergoing allogeneic or autologous BMT for acute leukemia in first remission received no prophylactic intrathecal chemotherapy after BMT. The conditioning regimen included total body irradiation in 433 (89%). Patients with acute lymphoblastic leukemia received cranial irradiation if they had no central nervous system (CNS) disease and all patients with CNS disease received craniospinal irradiation. Eleven of 311 patients examined had CNS disease at presentation, but none had active CNS disease at the time of BMT. Lumbar punctures were performed in 93 patients 1-2229 days (median 98) after BMT because of suspected CNS infection, hemorrhage or relapse (n = 65), or after systemic relapse (n = 28). CNS disease was seen in seven patients at 217-1209 days (median 340), none of whom had CNS disease pre-transplant. Systemic relapse had preceded CNS relapse by 4-207 (median 128) days in all seven and no isolated CNS relapse was seen. The actuarial risk of CNS and systemic relapse at 5 years was 2.9 and 35.9%, respectively. We conclude that CNS relapse is uncommon after BMT for acute leukemia in first remission, and that isolated CNS relapse is likely to be extremely uncommon. Therefore, routine prophylactic intrathecal chemotherapy is not warranted after BMT for acute leukemia in first remission.

Bone marrow transplantation for Philadelphia chromosome-positive acute lymphoblastic leukemia

Between 1986 and 1995, 19 patients with Philadelphia chromosome-positive (Ph + ) acute lymphoblastic leukemia underwent 20 autologous (n = 9) or allogeneic (n = 11) blood or marrow transplant procedures in first (n = 12) or second (n = 3) remission, or in relapse (n = 5). Four patients died due to transplant-related causes, 11 relapsed at 3-39 months, one survives with disease which did not remit after transplant, and three are alive in continuous remission at 1, 26 and 65 months. Two of the relapsing patients are alive; one autografted patient after an allograft in second remission and one allografted patient after a donor leukocyte infusion. The projected overall survival is 37.5% at 3 years and 12.5% at 5 years. The 3-year probabilities of relapse and disease-free survival for autografted patients are 65.9% and 25.6% respectively, and for allografted patients, 63.4% and 21.8% respectively. The stage of the disease at the time of transplant or the type of transplant did not affect the outcome significantly, and late relapses beyond 3 years were seen after allogeneic as well as autologous transplantation. In our experience, the outcome of patients with Ph + acute lymphoblastic leukemia continues to be poor despite high-dose therapy due to high relapse rates, and the development of additional measures to enhance the antileukemic efficacy of bone marrow transplantation is necessary.

Clinical and hematologic response of chronic lymphocytic and prolymphocytic leukemia persisting after allogeneic bone marrow transplantation with the onset of acute graft-versus-host disease: possible role of graft-versus-leukemia

One patient with refractory B cell chronic lymphocytic leukemia (CLL) and another with refractory B cell prolymphocytic leukemia (PLL) underwent bone marrow transplantation (BMT) from HLA-identical siblings. Circulating malignant cells persisted at high levels in the patient with PLL and there was clinical evidence of disease progression soon after transplant in the patient with CLL. Starting 4-5 weeks post-BMT, cyclosporine was tapered rapidly to stimulate immunologic graft-versus-leukemia (GVL) reactions. There was a fall in the number of malignant cells and reversal of organomegaly with the onset of acute graft-versus-host disease (GVHD). Both patients received conventional doses of corticosteroids for GVHD which also may have contributed to disease response to some extent. Total clearance of the leukemic cells from the peripheral blood was seen in both patients, and clearance of the marrow was seen in the patient with CLL. However, both patients died of complications of severe GVHD. We conclude that GVHD may be associated with a GVL effect after allogeneic BMT for refractory chronic B cell lymphoproliferative diseases. Whether GVL reaction occur in the absence of clinically obvious GVHD after allogeneic BMT for CLL remains to be seen.

Outcome of autologous rescue after failed engraftment of allogeneic marrow

Ten patients experiencing primary graft failure after allogeneic bone marrow transplantation received autologous marrow or blood cells as hematopoietic rescue 21-40 (median 22.5) days after the original transplant after which immunosuppression with cyclosporine was tapered off rapidly. The leukocyte count at the time of rescue was 0.1-0.3 x 10(9)/l with < 0.1 x 10(9)/l neutrophils. The clinical course was uneventful after rescue with hematologic recovery to 0.5 x 10(9)/l neutrophils occurring 9-61 days (median 20) later in nine patients, and to 50 x 10(9)/l platelets 17-595 days (median 40) later in eight patients. No patient had a life-threatening infection at the time of or after rescue. No patient experienced acute graft-versus-host disease. Four patients with acute leukemia had recurrent disease 46-117 days after autologous rescue, and died of relapse. Five patients with acute leukemia are alive in continuous remission at 270-3382 days, and one patient with chronic myeloid leukemia is alive in hematologic remission at 228 days. We conclude that infusion of back-up autologous cells can prevent the immediate infectious consequences of primary allogeneic graft failure through consistent myeloid recovery, and may result in long-term survival of patients with good-risk disease.

Myelosuppressive chemotherapy to mobilize normal stem cells in chronic myeloid leukemia

Ten patients with Ph+ chronic myeloid leukemia (CML) were treated with idarubicin, cytarabine and etoposide followed by G-CSF to harvest Ph-negative progenitor cells. Six were in first chronic phase (CP1), and four beyond CP1. Between two and six aphereses (median 3, total 36) were performed starting 9-26 days (median 14.5) after chemotherapy when the leukocyte count was 0.6-4.7 x 10(9)/l (median 1.2). 1.3-3.6 x 10(8) mononuclear cells/kg (median 2.8), 0-128.4 x 10(4) CFU-GM/kg (median 1.2; seven patients) and 0.3-25.1 x 10(6) CD34+ cells/kg (median 9.8; seven patients) were collected. Seven of 27 harvests showing metaphases were 100% Ph-negative, 11 partially Ph-negative, and nine were 100% Ph+. All three patients with 100% Ph-negative collections were in CP1 and within 4-26 months of diagnosis. Four of six CP1 patients showed significant cytogenetic response compared with none of four beyond CP1 (P = 0.036). The absolute neutrophil count remained < 0.5 x 10(9)/l for 9-44 days (median 15.5) following chemotherapy. Four patients (three Ph-negative) were autografted after 16 mg/kg busulfan (n = 2) or 200 mg/m2 melphalan (n = 2). One of the three patients receiving Ph-negative cells died of graft failure, and two are alive with 15% and 50% Ph-negative cells at 15 and 11 months on interferon-alpha. We conclude that it is possible to harvest Ph-negative cells after myelosuppressive chemotherapy in some CML patients treated early in the course of CP1. However, in view of lack of consistent response, investigation of alternative approaches is necessary.

Renal dysfunction following autologous bone marrow transplantation in adult patients with acute leukemia

The serum creatinine level was used to determine the incidence of renal dysfunction in 70 adults with acute leukemia who were alive and well one year following autologous bone marrow transplantation (ABMT). Creatinine measurements at the time of ABMT, one year post-ABMT and at the last follow-up (12-128 months, median 35) were recorded, and a level of >120 micromol/l arbitrarily defined as clinically significant renal impairment. The incidence of renal impairment was 2.9% (n = 2) at 1 year, and 4.3% (n = 3) at the last follow-up in continuous remission. Significant renal impairment occurred after relapse in 8 of 12 patients, but was seen in only 3 of 58 patients who remained in remission (p < 0.001, Fisher's exact test), suggesting subclinical renal damage which became obvious with further nephrotoxic therapy. We conclude that clinically significant renal dysfunction is an uncommon long-term complication of ABMT, and should not be a concern in recommending this therapy to eligible patients.

Autologous bone marrow and peripheral blood stem cell transplantation in haematological malignancies: current status

Autologous bone marrow and peripheral blood stem cell transplants permit the use of higher doses of chemoradiotherapy than would have been possible without "rescuing' bone marrow function. This may well allow cure of malignant disorders in cases where this was previously not feasible. This short review attempts to summarize the current status of such a treatment approach for the various haematological malignancies.