[Severe respiratory syncytial virus pneumonia following bone marrow autograft. 3 cases]

Three patients developed severe respiratory syncytial virus pneumonia after bone marrow autograft for acute leukaemia. Clinically, the disease presents as interstitial or bilateral alveolo-interstitial pneumonia with hypoxaemia. Signs of ENT infection (otitis media, sinusitis) are present in 30 percent of the cases. In all 3 patients, the syncytial virus was isolated by direct immunofluorescence in bronchoalveolar lavage fluid. In 2 patients the infection began soon after the autograft, in deeply aplastic subjects, and required intubation and assisted ventilation. These 2 patients died despite inhalation of aerosolized ribavirin combined, in one of them, with ribavirin injections. In the third patient the infection began some time after the autograft and responded well to ribavirin in aerosols. In these three cases the viral infection occurred in an epidemic and nosocomial context. The respiratory syncytial virus is usually transmitted by the hands. Owing to the severity of this infection with lung involvement in immunodepressed patients, specific prophylactic measures should be taken side by side with the conventional measures.

Prophylactic heparin does not prevent liver veno-occlusive disease following autologous bone marrow transplantation

Veno-occlusive disease (VOD) is a major cause of toxic death after autologous bone marrow transplantation (ABMT). We studied the potential role of continuous administration of low-dose heparin for VOD prevention in 234 consecutive patients who underwent ABMT in our institution. The population consisted of 98 patients autografted before October 1984 who did not receive heparin, and a series of 136 patients autografted from October 1984 to March 1989 containing 98 patients included in a randomized trial comparing heparin administration (n = 52) vs no heparin (n = 46), and an additional group of 38 patients who received non-randomized heparin in view of high-risk criteria to develop VOD (n = 31) or other reasons unrelated to VOD (n = 7). Overall, 90 patients (38%) received heparin and 144 (62%) did not. The global incidence of VOD was 13/234 (5-5%). Heparin did not reduce the risk of VOD in all subgroups studied. In particular, in the randomized trial, the incidence of VOD was 2.2% in the group without heparin vs 7-7% in the group receiving heparin. We analyzed in depth the 13 patients who developed VOD and we compared them to a control group of 13 patients pair-matched for age, sex, diagnosis and preparative regimen, who did not develop VOD. We found that abnormal LFT before ABMT predisposed patients to VOD; refractoriness to platelet transfusion was observed in 85% of the patients in the VOD group vs 15% in the control group (p less than 0.05). VOD patients had an increased requirement for red cells and platelet transfusions, a lower recovery (R less than 25%) after the second and third platelet transfusion, and shorter intervals separating the first four platelet transfusions. Further, the platelet reconstitution after ABMT in the VOD group was slower in comparison to the control group (p less than 0.01). Again, in this pair-matched analysis continuous infusion of low-dose heparin did not prevent VOD.

GM-CSF instead of autologous bone-marrow transplantation after the BEAM regimen

Five patients with resistant non-Hodgkin lymphoma (NHL) were given granulocyte-macrophage colony-stimulating factor (GM-CSF, 250 micrograms/m2 daily) after the BEAM pretransplant chemotherapy regimen (carmustine 300 mg/m2, etoposide 1.2 g/m2, cytarabine 800 mg/m2, melphalan 140 mg/m2) because persistent lymphoma cell infiltration of the bone marrow precluded autologous bone-marrow transplantation (BMT). In three patients full haemopoietic reconstitution occurred, with similar kinetics to that seen after autologous BMT. The other two patients died without sustained haemopoietic recovery. GM-CSF may replace autologous BMT in highly selected cases of NHL with progressive disease and bone-marrow involvement.

[Autologous bone marrow graft in the initial treatment of follicular lymphomas in young high risk subjects. A new therapeutic approach]

Low grade malignant follicular lymphoma is characterized by its slow course over many years. However, despite a median survival of 4 to 8 years the cure rate is lower than 10 percent and even nil for some authors. The best therapeutic approach of the disease is unknown, and many teams of oncologists are in favour of a more intense chemotherapy. We present a study of 10 patients selected for their young age and for the presence of detrimental prognostic factors (index 3 of Coiffier's classification in 8/10 patients). Nine patients received BCNU, cytosine arabinoside, etoposide and melphalan, followed by reinjection of autologous bone marrow purged in vitro by mafosfamide in the adjusted dose CFUGM LD 95. Eight of these 9 patients are in complete, unmaintained remission 15 to 43 months after the bone marrow transplantation (including 3 patients in a more than 2 years' remission). The 10th patient had autologous bone marrow transplantation in 1979; after treatment with heavy TACC chemotherapy followed by reinjection of unpurged bone marrow, he remained in complete remission for 9 years, then relapsed; he is now alive with a progressive tumour. Although the follow-up was relatively short for a particularly slow disease, this study shows that, owing to autologous bone marrow transplantation as early as the first complete remission, one of the heaviest types of chemotherapy can be delivered in patients with non-Hodgkin's lymphoma, unless precluded by toxicity. At the moment, this protocol is experimental and can be used only in young subjects at high risk. Further studies on larger series of patients and with a longer follow-up are needed to evaluate the effectiveness of this new type of treatment compared with conventional chemotherapies.

Feasibility of autologous bone marrow transplantation for early consolidation of follicular non-Hodgkin's lymphoma

In contrast to intermediate- and high-grade non-Hodgkin's lymphomas (NHL), patients with follicular lymphomas retain a poor prognosis in the long run. Several reports suggested that they are incurable by conventional chemotherapy. 10 patients with follicular NHL were autografted for consolidation of early remission. One of these patients treated in 1979 received the TACC regimen with unpurged marrow. The other 9 (8 in first, 1 in second remission) treated since July 1987 received the BEAM regimen followed by autologous bone marrow transplantation (ABMT) with marrow purged in vitro by mafosfamide at levels individually adjusted. There were no toxic deaths. 8 patients remain in unmaintained CR 15 to 43 months post-ABMT-2 are beyond 2 years. The patient autografted in 1979 has relapsed 9 yr later. ABMT is feasible with no indue toxicity for consolidation of follicular NHL early in first remission, as an alternative aggressive strategy. Further studies and a longer follow-up will be needed to evaluate its antitumor efficacy.

Successful autologous bone marrow transplantation in second remission of malignant histiocytosis

This report describes an 18-year-old man with disseminated malignant histiocytosis (MH). The patient initially attained complete remission (CR1) with conventional chemotherapy and then relapsed 14 months later. In second complete remission (CR2) 2 years and 8 months after initial diagnosis, an autologous bone marrow transplantation (ABMT) was undertaken following conditioning with the BEAM regimen. Bone marrow collected in CR2 was incubated with mafosfamide at a dose adjusted to the individual sensitivity of normal CFU-GM according to our current protocol. At the time of writing, 4 years post-transplant, this patient remains disease free. This is the first report of ABMT with marrow treated in vitro by mafosfamide in MH.

The role of autologous bone marrow transplantation in 46 adult patients with non-Hodgkin's lymphomas

Forty-six patients with non-Hodgkin's lymphoma (NHL) were treated with autologous bone marrow transplantation (ABMT) in two different institutions. All patients were pretreated with conventional chemotherapy. Three different conditioning regimens were used, and 20 patients underwent bone marrow purging. Twelve patients were treated in first complete remission (CR); eight are in unmaintained CR 8 to 104 months after ABMT. Five patients were grafted in first partial remission (PR) after conventional therapy; all achieved CR, and all remain in prolonged CR (first CR for four patients, second CR for one patient). Of 21 patients with chemosensitive relapses, 13 patients are in prolonged unmaintained CR 8 to 94 months after ABMT. Eight patients with resistant disease remained uncured by ABMT; all eight died, six from progressive illness and two from toxicity. The current 3-year disease-free probability is 60% for all patients, 0% for refractory disease; 82% for first PR or CR, and 60% for sensitive relapses (SRs). These results confirm the efficacy of ABMT in the treatment of chemosensitive NHL with bad prognosis.

Expansion by folinic acid of the peripheral blood progenitor pool after chemotherapy: its use in autografting in acute leukaemia

We have tested folinic acid (FA) for ability to increase peripheral blood stem cells (PBSC) after chemotherapeutic aplasia in acute leukaemia. Five adult patients (four AML, one ALL) entered the study, each patient underwent two series of three leukapheresis, the first following induction chemotherapy and the second following the first course of consolidation. The first leukapheresis of each series was done when the white blood cell count reached 10(9)/l with subsequent leukapheresis every other day. Folinic acid (Lederle Laboratories, France) was administered at a dose of 50 mg (i.v.) per day, 15 days from initiation of chemotherapy and continuing through the third leukapheresis of the series (days 25-30). PBSC were collected on a Haemonetics V50 cell separator. In these five cases we observed an increased yield of both colony-forming units, granulocyte macrophage (CFU-GM) and burst forming units-erythroid (BFU-E) expressed per ml of cytapheresis product: CFU-GM x 18, BFU-E x 3 and if expressed per 10(4)/kg of body weight: CFU-GM x 30, BFU-E x 3 (CFU-GM P less than 0.05, BFU-E less than 0.01). Long-term blood culture (LTSC) from FA stimulated leukapheresis, in an attempt to quantitate the most primitive stem cells, demonstrated that this expansion of the PBSC was sustained in time. We found by means of LTSC that FA did not stimulate CFU-L from patients with AML (two cases tested). Finally two AML patients were grafted with FA-PBSC after Cytotoxan and total body irradiation (TBI). Haematopoietic reconstitution was rapid complete and sustained in time in both patients. This indication for folinic acid should be further studied with or as an alternative to haematopoietic growth factors.

[Contribution of enzyme-linked immuno-electrotransfer blot assay for the diagnosis of human neurocysticercosis]

An enzyme-linked immunoelectrotransfer blot (EITB) is developed for immunodiagnosing human neurocysticercosis. The assay's efficacy is evaluated in 71 neurocysticercotic patients whose diagnosis of the disease and evaluation of disease activity is based on CT scan findings. We identified eight bands (molecular weigh less than 35 000) that evaluate the disease activity: active disease, calcification in progress, inactive disease. All samples patients with active disease recognized 14 000 band. This band is missing in the others parasitic diseases and in serum of the patients with inactive diseases or calcification in progress. The enzyme-linked immunoelectrotransfer blot is simple to perform and may be used in sero-epidemiology.

[Cerebral infarction in pernicious malaria. Diagnostic value of computed tomography]

Case report of a severe form of neuropaludism, contracted in a territory with Plasmodium falciparum completely insensitive to chloroquine. CAT Scan views displayed a small brain infarction. Complete recovery was obtained with a treatment including quinine, tracheal intubation and ventilatory support, sedation with barbiturates. CAT Scan views demonstrated a complete regression of cerebral lesions.

[Bone marrow autograft treated with mafosfamide in the acceleration phase in chronic myeloid leukemia. Inversion of the clinical development]

A 21-year old male patient with Philadelphia chromosome-positive chronic myeloid leukaemia received an autologous bone marrow transplant in consolidation of the 2nd chronic phase. The bone marrow had been treated with mafosfamide in adequate doses. The post-transplantation course of the disease was marked by an inversion: the duration of the 2nd chronic phase was more than 4 times longer than that of the first one, suggesting some degree of effectiveness of autologous bone marrow transplantation performed in the 2nd chronic phase and/for of the in vitro treatment of the bone marrow with mafosfamide. Cytogenetic monitoring was pursued throughout the course of leukaemia: regression of the Philadelphia chromosome was only partial and transient, and 3 clones appeared, each of them involving chromosome 1, for which mafosfamide was most probably responsible.

[Immunologic diagnosis of the cerebrospinal fluid and serum in developing brain cysticercosis]

ELISA detection of specific antibodies in the serum (IgG) and cerebrospinal fluid (IgG, IgM and IgA) was evaluated in 28 patients. Diagnosis of cerebral cysticercosis and evaluation of disease activity was based on CT scan findings. Specific IgG antibodies were found in the serum in 83.3% of patients with active disease and 10% of those with inactive disease. Cerebrospinal fluid tests evidenced specific antibodies in all patients with active disease and none of the patients with inactive disease. The specific CSF antibodies were IgG (94.4%), IgM (66.6%) or IgA (66.6%). Antibody titers were significantly higher in patients with an intraventricular vesicle or cyst.

A new combination of two intercalating agents (mitoxantrone + daunomycin) in adult refractory acute leukemia: the DON protocol

A combination of two intercalating agents, mitoxantrone and daunorubicin with vincristine (the DON regimen) was studied in 16 patients with refractory acute leukemia, including three patients with myeloblastic transformation of refractory anemia with excess of myeloblasts after the failure of first-line chemotherapy and one additional patient with AML relapsing while off therapy. All patients had been heavily pretreated prior to receiving the DON regimen, and all but two had previously received high-dose anthracyclines. Of the 17 patients, nine (53%) who achieved complete remissions (CR) had myeloblastic leukemia. The three patients with acute lymphocytic leukemia did not achieve CR. Cardiac toxicity occurred in two patients and contributed to death in one. These results in very poor risk leukemia suggest a possible synergism in the action of the two intercalating agents and absence of increased cardiotoxicity.

[Diagnosis of cerebral cysticercosis on Réunion Island by an immuno-enzymological method (ELISA): comparison with x-ray computed tomography]

An immunoenzymologic (Elisa) serodiagnosis of cysticercosis is evaluated in 75 encephalic cysticercosis patients whose diagnosis of the disease and its progression in assessed by tomodensitometry. A Taenia solium antigen is used. Only IgG are investigated. The sensibility of serodiagnosis is 85% and specificity 87% when there is a progression of the disease; no difference is noticed in the patients without any progression of the disease and in control normal subjects. This serodiagnosis of cysticercosis appears of value for the evaluation of the activity of the disease.

Difference in kinetics of hematopoietic reconstitution between ALL and ANLL after autologous bone marrow transplantation with marrow treated in vitro with mafosfamide (ASTA Z 7557)

The kinetics of hematopoietic recovery after autologous bone marrow transplantation (ABMT) reflect the hematopoietic capacity of the infused marrow. In vitro treatment of marrow with high doses of mafosfamide (ASTA Z 7557) alters the hematopoietic regenerative capacity of the graft. Thirty-two patients with acute leukemia (12 acute lymphoblastic leukemia (ALL) and 20 acute non-lymphoblastic leukemia (ANLL] with 27 in complete remission and five in partial remission were consolidated with cyclophosphamide (60 mg/kg x 2) and total body irradiation (10 Gy), followed by reinfusion of autologous marrow treated in vitro with mafosfamide. The marrow of each patient had been incubated with the highest tolerable dose of mafosfamide, individually predetermined from a preincubation test. We report here that the kinetics of engraftment are strikingly different in ANLL and ALL patients. In the ANLL group recovery to 0.1% reticulocytes took a median of 20.5 days (range 14-32) versus 15 (11-28) in the ALL group; 33.5 days (18-45) versus 19 (15-30) for leukocytes to reach 1.0 x 10(9)/l; 35 (19-60) versus 20.5 (15-30) for neutrophils to reach 0.5 x 10(9)/l; 110+ (45-480+) versus 50 (23-90) for platelets to reach 50 x 10(9)/l (p less than 0.01 and p less than 0.05). Detection of granulocyte-macrophage progenitors (CFU-GM) regeneration in marrow aspirates post-ABMT was delayed in ANLL (p less than 0.05). Neither the nature of the previous induction therapy, nor the status of the blood or bone marrow at the time of collection (CFU-GM and erythroid burst-forming units/ml) nor the stem cell sensitivity to mafosfamide, nor the doses of progenitor cells infused could explain these differences. We interpreted these observations as suggesting that the engraftment potential has been more severely altered in ANLL than in ALL, which may reflect both the intensity of the in vitro treatment and the intrinsic fragility of the stem cell pool in ANLL.

Long-term human blood cultures: application to circulating progenitor cell autografting

Peripheral blood cells collected by cytapheresis from patients with acute leukemia following induction therapy or with multiple myeloma off-therapy, were maintained in a one-stage long-term liquid culture system. The data indicate that: (1) blood-derived granulopoietic proliferation can be sustained for up to 8 weeks with generation of CFU-GM in a way similar to bone marrow cells; and (2) this normal hematopoiesis can be sustained in spite of the absence of any development of a substantial stromal adherent layer, which suggests that, unlike hematopoiesis from bone marrow, the blood-derived non-adherent cell population is a self-sustaining compartment. While autologous transplantation with peripheral progenitor cells is gaining importance as an alternative to autologous bone marrow transplantation, this study suggests that circulating progenitor cells may have a different behavior from marrow cells. This observation may be relevant to the understanding of cases of defective hematopoietic reconstitution.

[Addition of HPA 23 to cyclosporin in the treatment of thrombopenic purpura in HIV-positive subjects]

We associated HPA 23 (inhibitor of the reverse transcriptase) to cyclosporin A (CSA) for two homosexual patients with positive HIV serology, who had a peripheral thrombocytopenia resistant after alone CSA treatment. HPA 23 was given for 15 days at a dose of 4 mg/kg/day in a 24 hours continuous perfusion. The circulating tungsten blood concentration was about 4.4 micrograms/ml (between 3 and 8.4 micrograms/ml). Even if HPA 23 has frequently been responsible of thrombocytopenia at a dose superior than 2 mg/kg/day and in spite of any CSA activity in single treatment, this association shows a significant platelets increase. But thrombocytopenia reappeared a week after the stay of HPA 23 treatment. So, it is possible that HPA 23 might have, at this circulating blood concentration, an antiviral activity in vitro. In this hypothesis there might be a relation between antiviral replication and autoimmune disorders and, at least, CSA might oppose against the thrombocytopenia induced by HPA 23.

[Autograft of bone marrow treated by in vitro chemotherapy (Asta Z 7557) for consolidation of acute leukemia in adults in the first complete remission]

Fourteen adult patients in first complete remission of acute leukemia (A.L.) [6 with acute lymphoblastic leukemia (ALL), 8 with acute non lymphoblastic leukemia (ANLL)] were consolidated with high dose cyclophosphamide and total body irradiation followed by autologous bone marrow transplantation (ABMT) with marrow cleansed in vitro by Asta Z 7557. According to our previously described protocol showing evidence for a wide range of sensitivity from patient to patient, the marrow of each individual patient was incubated with the highest tolerable dose of Asta Z 7557. This dose, individually determined, was defined as the dose sparing between 0 and 10% of CFU-GM (CFU-GM DL95). ABMT was not followed by maintenance therapy. Hematological reconstitution was significantly faster in ALL patients when compared to ANLL patients. Out of these 14 patients: 2 relapsed on months 5 and 15 respectively after ABMT, and 2 died in complete remission on months 3 and 16 respectively, of veno-occlusive disease and encephalitis. Ten patients (70%) remain in complete remission up to a median of 15 months +, with 4 patients over 24 months +.

Erythrocyte mean corpuscular volume during cytotoxic therapy is a predictive parameter of secondary leukemia in Hodgkin's disease

Mean corpuscular volume (MCV) evolution during cytotoxic therapy was studied in 32 patients with Hodgkin's disease (HD) who developed therapy-related acute nonlymphocytic leukemia (t-ANLL) and in 64 HD controls matched for age, therapy duration, and MOPP (mechlorethamine, vincristine, procarbazine, and prednisone) administration. Maximum MCV during therapy reached 108.3 +/- 8.2 fl in t-ANLL patients and 103.4 +/- 9.1 fl in the controls (P = 0.001). Maximum MCV increase was 26.7 +/- 8.3 fl in t-ANLL patients and 16.6 +/- 8.3 fl in the controls (P = 10(-9). The greatest 3-month increase observed during therapy was 14.8 +/- 6 fl in the t-ANLL patients and 10.1 +/- 4.8 fl in the controls (P = 0.0001). During initial MOPP therapy, the greatest 3-month increase reached 14.1 +/- 5.3 fl in t-ANLL patients and 9.8 +/- 4.5 fl in the controls (P = 0.01). The relative risk of developing t-ANLL was 9 for a MCV maximum increase over 24 fl during therapy, which was observed in 71% of the patients with t-ANLL and in only 22% of the controls. For the greatest 3-month MCV increase over 15 fl observed in 57% of the t-ANLL patients and in 17% of the controls, the relative risk reached 15. This suggests that there is at least one factor, independent from therapy, which predisposes to t-ANLL. MCV evolution during therapy appears useful in determining which HD patients have a high risk of developing t-ANLL.

Blood and spleen haematopoiesis in patients with myelofibrosis

Blood nucleated cells collected by leukapheresis and spleen cell suspension from patients with myelofibrosis with myeloid metaplasia (MMM) were studied for their haematopoietic capacity. Using committed progenitor cell assays (CFU-GM, BFU-e) and a one-stage long-term liquid stem cell system, we have shown: (1) a preferential expansion of the circulating committed progenitor cell pool above the more primitive stem cell compartment; (2) the absence of any development of a stromal adherent layer in long-term cultures of peripheral blood nucleated cells suggesting the self-sustaining capacity of the circulating primitive stem cells; (3) that the spleen is only a production site of committed progenitor cells but does not generate primitive stem cells; (4) the presence, in the spleen, of stromal progenitor cells. We conclude that the peripheral blood primitive stem cells in patients with MMM are not of splenic origin.

A prospective study of the value of bone marrow erythroid progenitor cultures in polycythemia

The diagnostic value in polycythemia of the presence of endogenous erythroid colonies derived from bone marrow cells (EECs) was assessed in a prospective study on 108 patients referred for polycythemia (Hb greater than g/dL in men, greater than 16 g/dL in women) with normal plasma volume by comparison with the standard criteria, the bone marrow grade, and the serum erythropoietin (Epo) level. Total red cell volume (TRCV) was high (greater than 36 mL/kg in men, 32 mL/kg in women) in 87 cases (group A) and slightly increased in 21 cases (group B). Standard criteria were applicable in 63 of 108 cases (57%); 46 were PV and 17 were secondary polycythemia (SP). Standard criteria were nonapplicable in 45 cases. EECs were present in 65 cases (60%) with a ratio of EEC/Epo-stimulated colonies of 39.5% +/- 18% (extremes 10% to 80%). EECs were noted in 43 of 46 polycythemia vera (PV) and 0 of 17 SP. Among the 45 unclassified cases, EECs were noted in 22: 18 of 29 cases from group A (10 with 2 major and 1 minor criteria; 8 with 2 major criteria) and 4 of 16 cases from group B (with variable standard criteria, 2 belonging to a PV family). In group A, there was a positive significant correlation between EECs and the presence of two major and 1 minor criteria (P less than .0001). In group B, there was a positive significant correlation between EECs and the presence of at least 1 major criterion and 2 minor criteria or a family background (P less than .0001). The unclassified polycythemias with EECs in the bone marrow are characterized by a bone marrow grade and a mean serum Epo level not different from that of patients with PV and an active course of the disease. The unclassified polycythemias without EECs in the bone marrow are a heterogeneous group corresponding in some cases to SPs of unknown origin (slightly increased bone marrow grade and/or high serum Epo level), and in others cases to spurious polycythemias (normal bone marrow grade and/or normal Epo level). In conclusion, EECs were of great value in differentiating PV from SP (P less than .001), and in allowing the diagnosis of PV in the absence of all the standard criteria even when TRCV was slightly increased. In our study, EEC improved the classification of polycythemia by 22%. The recommended diagnostic steps for the evaluation of polycythemia must be reconsidered.

Preleukemic changes in cases of nonlymphocytic leukemia secondary to cytotoxic therapy. Analysis of 105 cases

Peripheral blood changes preceding therapy-related leukemia were studied in 105 patients who had received cytotoxic therapy, 53 for Hodgkin's disease and 52 for other cancers. Preleukemic anomalies were observed in 74.3% of the cases, appearing after a mean interval of 68.7 months after diagnosis of the initial cancer. This interval was only 57.5 months in patients aged 50 years or older and only 42.3 months in patients with Hodgkin's disease having received cytotoxic therapy for 6 months or less. The first changes most frequently observed were pancytopenia (24.8%) and isolated erythrocyte abnormalities such as anemia or macrocytosis (18.1%). Involvement of two cell lines, isolated thrombocytopenia or leukopenia, circulating immature cells, monocytosis, leukocytosis, or thrombocytosis were also observed. Therapy-related myelodysplastic syndrome was recognized in 19 patients and myelofibrosis in 3. Median duration of the preleukemic phase was 6 months; 9 months in cases of isolated erythrocyte involvement and 5 months in the other cases. Myelomonocytic or monoblastic leukemia appeared less frequently when the first sign involved erythrocytes only. Hematological surveillance thus appears necessary in all patients having received cytotoxic therapy. Bone marrow study with cytogenetic examination should be performed in cases of persistent peripheral blood abnormalities.

Massive therapy and autologous bone marrow transplantation in pediatric and young adults Burkitt's lymphoma (30 courses on 28 patients: a 5-year experience)

A 5-yr experience of massive therapy and autologous bone marrow transplantation (ABMT) for Burkitt's lymphoma is reviewed. Thirty courses were given to 28 patients. Three patients were in resistant relapse and all three died before day 54 post ABMT. Thirteen patients were in non-resistant relapse and seven are alive with non-evidence of disease (NED). All three patients grafted in partial remission (PR) are alive NED including two with initial central nervous system (CNS) disease. Nine patients were grafted in 1st complete remission (CR) either because of long delay to achieve CR or as consolidation in those with initial CNS involvement or leukaemia. Three of these nine are alive including 2/3 with a long delay to CR and 1/5 initial CNS. The overall survival NED for the 28 patients is 46%. The median observation time post ABMT, 22 months. Clear indications for ABMT in BL are in our opinion restricted to about 20% of the patients: non-resistant relapses and PR after initial induction therapy. Massive therapy as consolidation of 1st CR after initial CNS involvement and in resistant relapses should still be considered as experimental. In 14 patients whose marrow was purged there is laboratory evidence suggesting that the purging procedures used in this study may have been incomplete. Purging techniques still require perfection at a laboratory level and their rationale should not be judged on the basis of incomplete procedures.

Autologous marrow transplantation for patients with chronic myeloid leukemia in accelerated or blastic phase: report of 14 cases

Between June 1979 and October 1983, 14 autografts were performed in 13 patients with CML (ten blast crisis, four accelerated phase). Results were disappointing: four patients died during aplasia; seven returned to chronic phase, but three died of hemorrhage, four relapsed, and three did not reverse. The main problem was the very low rate of successful engraftment. Both the collection of bone marrow after treatment with busulfan and a particular sensitivity of CFU-GM to cryoinjury were responsible for the infusion of very low doses of CFU-GM. However, we observed some promising results: In one patient in acute blast crisis, the Ph 1 chromosome disappeared, as well as the cytogenetic marker of transformation; in another patient with acute pure cytogenetic acceleration, the abnormal clone disappeared for 27 months; a third patient was maintained in a second chronic phase for 20 months. Thus we suggest that the results of autografting in chronic myeloid leukemia would be improved by infusing the largest possible dose of stem cells collected before or long after treatment by busulfan, and freezing them following a careful program.

Failure of bone marrow cryopreservation in chronic granulocytic leukemia: relation to excessive granulo-macrophagic progenitor pool

Autologous bone marrow transplantation (ABMT) in chronic granulocytic leukemia (CGL) aims at reversing the acute or acceleration phases by injection of stem cells collected during the chronic phase. This study was designed to explain an unusual rate of delayed engraftment (50%) in our experience of ABMT in CGL patients. We investigated all the factors possibly responsible for abnormal perpetuation of aplasia following infusion of cryopreserved marrow stem cells. The study of CFU-gm recovery in 41 bags of frozen marrow from 25 patients revealed an overall deficiency with a mean CFU-gm recovery of 55 +/- 38% in CGL patients versus 73 +/- 15% in the control group (p less than 0.001). Our data also showed an inverse linear relation (r = -0.40, p less than 0.05) between CFU-gm concentration and recovery after freezing. A good CFU-gm recovery (greater than or equal to = 50%) was observed in 70% of cases when the concentration was less than 3700 CFU-gm/ml as compared to 30% of cases when the concentration was over 3700 CFU-gm/ml (p less than 0.001). The lack of improvement by diluting rich CFU-gm marrows to reduce CFU-gm concentration/ml, as well as the absence of relationship between CFU-gm recovery after freezing and nucleated cells concentration, suggest a particular fragility of CGL stem cells to freezing, probably related to their excessive amplification. At the present time, we strongly recommend that the highest possible dose of progenitor cells be cryopreserved, preferably at a low concentration, in patients with CGL, and particular attention devoted to the freezing procedure in each individual patient, with numerous appropriate efficiency tests.

Evaluation of lymphocyte subsets after autologous bone marrow transplantation with marrow treated by ASTA Z 7557 in acute leukemia: incidence of the in vitro treatment

The lymphocyte subset reconstitution after high-dose chemotherapy and total body irradiation followed by autologous bone marrow transplantation (ABMT) has been studied in ten patients with acute leukemia (AL) (6 ALL and 4 ANLL) in complete remission (CR). Bone marrow was treated in vitro with high-dose ASTA Z 7557, individually determined according to CFU-GM sensitivity. The different peripheral blood lymphocyte subsets were characterized by means of monoclonal antibodies (indirect immunofluorescence assay) belonging to the following classes of differentiation: OKT11-T11 (CD2), OKT3-T3 (CD3), OKT4-T4 (CD4), OKT8-T8 (CD8), OKIal-I2 (HLA-DR), Leu7 (natural killer/killer) and by means of polyspecific antiimmunoglobulin sera (direct immunofluorescence assay). Data in these ten patients were compared with those of a control group of 21 normal donors and with a control group of 14 patients in CR without ABMT. Our results showed a marked depression of the T4:T8 ratio in patients with AL before ABMT, compared with normal donors who had respective values of 1.02 and 1.33 (p less than 0.01). This depression was increased and prolonged up to day 515 after ABMT, with a value of 0.32 (p less than 0.01 compared with the pregraft situation; p less than 0.001 compared with normal donors). This T4:T8 ratio imbalance was related to the depletion of the T4+ population and to the increase of the T8+ subset. This imbalance was emphasized after ABMT. The Leu 7+ population was also increased in grafted patients compared with normal donors (p less than 0.01). The B-cell population remained unchanged throughout the study. We conclude that patients autografted with marrow treated in vitro by high-dose ASTA Z 7557 may experience a long-term T-cell subset imbalance.

Cardiac complications after bone marrow transplantation. A report on a series of 63 consecutive transplantations

Cardiac complications related to bone marrow grafting were investigated in a group of 63 patients undergoing bone marrow transplantation (57 autologous, 6 allogeneic) in the transplant unit of Hôpital Saint-Antoine (Paris, France) between February 1977 and October 1983. The pregraft regimen was cyclophosphamide, 6-thioguanine, cytosine arabinoside, and CCNU (TACC) in 39 cases, cyclophosphamide (CY) associated with whole-body irradiation in 16 cases, and multiple chemotherapeutic agents in 8 cases. The study was retrospective in 49 patients, and prospective in 14. The morbidity was 43% and the mortality 9%. There were 6 fatal cases of cardiomyopathies and/or pericarditis, 14 nonfatal cases of heart failure, 7 nonfatal cases of pure pericarditis, and 32 arythmias including 14 bradycardias, diversely associated on a total of 27 patients. Cyclophosphamide and/or TACC/cyclophosphamide, 6-thioguanine, cytosine arabinoside, and BCNU (BACT) were the factors basically responsible for the cardiac toxicity. The best-defined entity was an acute fatal cardiomyopathy with associated pericarditis of which we report three additional cases. The best predictors of CY toxicity were the daily weight (a gain of more than 2 kg for more than 48 hours) and the electrocardiogram (a decrease of more than 14% in the sum of the QRS complexes in the standard leads on the fourth day of chemotherapy). Routine echocardiography confirmed the high incidence of subclinical cardiac abnormalities and their reversibility. It would seem that radiotherapy and anthracyclines play a secondary role. Currently, we consider that cardiac toxicity is one of the most important limiting factors for bone marrow transplantation. We suggest, therefore, that the transplantation should be done as early as possible and preference should be given whenever possible to whole-body irradiation over high-dose chemotherapy combinations such as TACC.

Autologous bone marrow transplantation using marrow incubated with Asta Z 7557 in adult acute leukemia

The sensitivity of human myeloblastic leukemic (CFU-L) and normal hemopoietic stem cells (CFU-GM and BFU-e) to Asta Z 7557 (INN Mafosfamide) was studied with regard to autologous bone marrow transplantation (ABMT) with cleansed marrow for consolidation therapy in adult patients with acute leukemia (AL) in remission. Establishment of the dose-response curves for CFU-GM (n = 37), BFUe (n = 11), and myeloblastic CFU-L (n = 9) demonstrated a wide range of sensitivity from patient to patient for all three progenitors. Whereas CFU-L, CFU-GM, and BFU-e grown in semisolid cultures disclosed similar sensitivities to Asta Z 7557, long-term culture (LTC) studies (n = 41) indicated a higher resistance of early progenitors. In an effort to achieve a maximum tumor cell kill and yet spare a sufficient amount of normal stem cells to ensure consistent engraftment, we defined the optimal dose for marrow cleansing as the dose sparing 5% CFU-GM (LD95). This dose was established from a preincubation test (PIT) realized on a 10-mL marrow aspirate taken 15 days before marrow collection in each individual patient. Twenty-four adult patients while in remission of AL (20 in complete remission, four in partial remission) were consolidated by cyclophosphamide 60 mg/kg X 2 and total body irradiation at 10 Gy followed by ABMT with marrow cleansed by Asta Z 7557 according to the specification described above. Patients were divided in two groups: group 1, unfavorable prognosis (11 patients); group 2, standard prognosis [13 patients in first complete remission (CR)]. All patients engrafted on leukocytes (median day for recovery to 10(9)/L: day 30), patients with ALL recovered faster than patients with ANL (median day 19 v 34). Similarly, recovery of platelets to 50.10(9)/L occurred sooner in patients with ALL (median day 67, range day 23 through 90) whereas three patients with acute nonlymphoblastic leukemia (ANLL) in group 2 had to be supported with platelet transfusions for more than one year. In group 1, six patients had recurrent tumor within six months; three patients died from toxicity with no evidence of tumor. Two patients are still disease-free with a short follow-up (nine and ten months). In group 2, two patients died from toxicity with no evidence of leukemia three and 16 months post-ABMT. One patient with a M5 ANLL and one patient with ALL relapsed at six and 15 months, respectively. Nine patients have remained in CR or are disease-free with a median follow-up of 22 months.(ABSTRACT TRUNCATED AT 400 WORDS)

Standardization and characterization of the procedure for in vitro treatment of human bone marrow with cyclophosphamide derivatives

Thirty human bone marrow (BM) suspensions from patients with acute leukaemia patients in remission were processed with the Haemonetics 30 flow cell separator in order to separate buffy-coats and to treat them in vitro with a derivative of cyclophosphamide (ASTA Z 7557). After processing, the volumes of BM suspensions were reduced to 25%. Recoveries of leucocytes, CFUc and BFUe were respectively 62, 85 and 84%. In vitro treatment with doses of ASTA Z ranging from 50 to 140 micrograms/2 X 10(7) leucocytes (according to the CFUc sensitivity of each patient) destroyed 95 +/- 5% of initial CFUc. After freezing and thawing, recovery of CFUc from treated BM was poor (24%) in comparison to that obtained with untreated BM (79%).

[Autograft of bone marrow treated by immunotoxin T 101 for the treatment of T-cell leukemia and lymphoma. Initial clinical cases]

In order to consolidate a complete or partial remission, 4 patients with T-cell malignancy received cyclophosphamide 120 mg/kg plus total body irradiation, followed by reinfusion of cryopreserved autologous bone marrow purged in vitro by the immunotoxin T 101 (SR 41322) composed of the murine monoclonal T 101 antibody coupled with the A chain of ricin. The immunotoxin was applied in doses of 10(-9) and 10(-8) M for periods of 4 and 20 hours at 37 degrees C. The recovery of CFUc and BFUe progenitors was total following incubation with IT 101, but reduced after cryopreservation (1-15 to 80% for CFUc,-33 to 47% for BFUe), haematopoietic recovery occurred within normal delays, demonstrating that autologous bone marrow pretreated with the immunotoxin can be successfully transplanted. However, the slow increase in lymphocytes and the occurrence of lethal infection in 2 cases indicate that an in-depth study of immunological reconstitution after in vitro treatment of bone marrow with ITT 101 is necessary.

Autologous bone marrow transplantation with marrow decontaminated by immunotoxin T 101 in the treatment of leukemia and lymphoma: first clinical observations

Four patients with T-cell malignancies of poor prognosis (three with non-Hodgkin's lymphoma and one with acute lymphoblastic leukemia) received the following consolidation therapy for complete or partial remission: cyclophosphamide (120 mg/kg) plus total-body irradiation, followed by reinfusion of cryopreserved autologous marrow previously purged in vitro by immunotoxin T 101 (SR 41322). This immunotoxin is made of the murine monoclonal T 101 antibody coupled to chain A of ricin. The doses of immunotoxin used were 10(-9) and 10(-8) M, and the durations of incubation were 4 and 20 hours at 37 degrees C. Recovery of progenitors CFUc and BFUe was total following incubation with immunotoxin T 101, but diminished after cryopreservation (15%-80% for CFUc, 33%-47% for BFUe), suggesting an increased fragility of the incubated progenitors to freezing. In every case, hematopoietic recovery occurred within normal time periods, with a wbc count greater than 10(9)/L and a platelet count greater than 50 X 10(9)/L on Day 22 (range, 15-31) and Day 21 (range, 22-47), respectively, demonstrating the feasibility of autologous bone marrow transplantation with marrow pretreated by immunotoxin. However, the slow recovery of lymphocytes and the development of severe infections in two patients may indicate that an in-depth study of immunological reconstitution after in vitro treatment of the marrow with immunotoxin T 101 is necessary.

Vindesine-prednisone in the treatment of blast crisis of chronic myeloid leukemia

Eight patients with chronic myeloid leukemia in blast crisis were treated with a combination of vindesine and prednisone. Complete remission was achieved in three patients; partial remission was achieved in three. All six responders received maintenance treatment with hydroxyurea and 6-mercaptopurine. The median duration of survival was 9 months. Two patients had long-term survival: one survived 32 months and the other is alive after 30 months. These data suggest that vindesine-prednisone polychemotherapy might improve the prognosis of blast crisis in chronic myeloid leukemia.

Evidence for absence of toxicity of T101 immunotoxin on human hematopoietic progenitor cells prior to bone marrow transplantation

T101-ricin A-chain immunotoxin is a hybrid molecule made up of the T101 monoclonal antibody bound to the A-chain of ricin. It specifically destroys cells expressing the cell surface T65 antigen. We have designed a preclinical study to evaluate its possible use for the in vitro treatment of T-cell hematological cancers prior to autologous bone marrow transplantation. The data presented here show that conditions previously defined to produce high tumor cell killing, i.e., a 20-hr incubation at 37 degrees in the presence of T101-ricin A-chain immunotoxin up to 10(-7) M in a 10 mM ammonium chloride solution, do not affect the in vitro proliferative capacity of human hematopoietic stem cells studied by means of semisolid medium cultures (granulocyte-macrophage progenitors, burst-forming units-erythrocyte) and continuous liquid cultures (pre-granulocyte-macrophage progenitors). Therefore, autologous bone marrow transplantation with T101-ricin A-chain immunotoxin-treated graft should be feasible.

ASTA Z 7557 (INN mafosfamide) for the in vitro treatment of human leukemic bone marrows

The in vitro treatment of leukemic bone marrows, collected during complete remission, aims at eliminating residual blast cells prior to freezing and preservation, while sparing normal hematopoietic stem cells. We report our experience on the activity of ASTA Z 7557 on human leukemic (CFU-L) and normal hematopoietic stem cells. The sensitivity of human leukemic and normal progenitor cells (CFU-c), detected in semi-solid media cultures, is similar. However, pre-CFUc progenitors detected in long term marrow cultures are much less sensitive to ASTA Z 7557. Therefore autologous bone marrow transplantation can successfully be done with pretreated marrows containing 5 +/- 5% residual CFUc. The wide range of stem cells sensitivity to ASTA Z 7557 justify the predetermination of the optimal dose of drug for incubation prior to marrow collection for each individual patient. Our preliminary clinical experience is exposed.