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Abstract
The best therapy for people with acute myelogenous leukemia (AML) in first remission is controversial. Options include postremission chemotherapy, a bone marrow transplant (HLA-identical sibling or autotransplant) or chemotherapy followed by a transplant at relapse. Four large cooperative group trials address this issue. In this review design and implementation of these trials is considered. Whether data from these trials will answer the questions of the best therapy for AML in first remission, is focused upon.
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Domenech J, Roingeard F, Binet C. The mechanisms involved in the impairment of hematopoiesis after autologous bone marrow transplantation. Leuk Lymphoma 1997; 24:239-56. [PMID: 9156654 DOI: 10.3109/10428199709039012] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Hematopoiesis after autologous bone marrow transplantation (BMT) is characterized by a prolonged and severe deficiency of marrow progenitors for several years, especially of erythroid and megakaryocyte progenitors, while the peripheral blood cells and marrow cellularity have reached relatively normal values within a few weeks. These anomalies are comparable to those reported for allogeneic BMT, despite the absence of any allo-immune reaction or post-graft immunosuppressive therapy. Post-graft hematopoietic impairment is the consequence of quantitative and qualitative changes involving both stem cell and stromal compartments which are expressed by an impaired capacity of stem cell self-renewal and commitment towards erythroid and megakaryocytic lineages. Besides the toxicity of conditioning regimens, hematopoietic reconstitution using autologous grafts is particularly dependent on a combination of factors related to the patient, such as underlying disease and pre-graft chemotherapy regimens, and to the graft processing itself, such as in vitro purging with chemotherapeutic agents.
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Affiliation(s)
- J Domenech
- Laboratory of Hematology, Bretonneau University Hospital, Tours, France
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van Besien K, Giralt S. Autologous bone marrow transplantation for leukemia and lymphoma. Cancer Treat Res 1996; 84:207-259. [PMID: 8724632 DOI: 10.1007/978-1-4613-1261-1_10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- K van Besien
- University of Texas M.D. Anderson Cancer Center, Department of Hematology, Houston 77030, USA
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Affiliation(s)
- M A Morgan
- Department of Obstetrics and Gynecology, University of Pennsylvania Medical Center, Philadelphia
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Abstract
Arabinosylguanine (araG) is a nucleoside analogue that is rapidly converted by cells of the T lymphoid lineage to its corresponding arabinosylguanine nucleotide triphosphate (araGTP), resulting in inhibition of DNA synthesis and selective in vitro toxicity to T lymphoblastoid cell lines as well as to freshly isolated leukemia cells from patients with T cell acute lymphoblastic leukemia (ALL). We have previously demonstrated that araG is an effective agent to use for chemoseparation of malignant T lymphoblasts from human bone marrow. When freshly isolated human T leukemia cells or T lymphoblastoid cells were treated with 100 microM araG for 18 hours, up to 6 logs of clonogenic T cells are eliminated without appreciable toxicity to the normal myeloid, erythroid, and megakaryocytoid clonal progenitor cells. We subsequently described studies in a murine model of T cell acute lymphoblastic leukemia (ALL) in which we tested whether bone marrow contaminated with malignant T cells and purged ex vivo with araG, could reconstitute both the lymphoid and myeloerythroid lineages in the absence of leukemic relapse. The model utilized 6C3HED tumor cells, derived from a Thy 1.2+ malignant murine T cell line, which were shown to cause lethal leukemia in C3H/HeN mice. Intravenous injection of 10(6) 6C3HED cells resulted in 100 percent mortality within 18 days, with autopsy revealing tumor infiltration of multiple organs. Evidence of araG's ability to purge bone marrow of malignant tumor cells without causing significant toxicity to normal marrow-derived hematopoietic progenitor cells was documented in experiments in which 75 percent of lethally irradiated mice receiving transplants of syngeneic bone marrow contaminated with 6C3HED tumor cells and treated ex vivo with 100 mM araG for 18 hours survived for 250 to > 400 days. Reconstitution of the lymphoid, myeloid, and erythroid lineages with donor cells in surviving mice was documented. The data presented indicate that araG may effectively purge bone marrow of malignant T cells without irreversible toxicity to hematopoietic stem cells. This purging regimen is recommended for consideration for clinical trials in patients with T cell malignancies undergoing autologous bone marrow transplantation and may also be a viable option for T cell depletion as a strategy to prevent graft versus host disease.
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Affiliation(s)
- J Kurtzberg
- Pediatric Bone Marrow Transplant Program, Duke University Medical Center, Durham, North Carolina 27710
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Shpall EJ, Stemmer SM, Bearman SI, Jones RB. Role of Autotransplantation in Treatment of Other Solid Tumors. Hematol Oncol Clin North Am 1993. [DOI: 10.1016/s0889-8588(18)30237-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Morgan MJ, Dodds AJ, Wolf M, Januszewicz H, Ma D, Downs K, Cooper I. High dose chemotherapy and autologous bone marrow transplantation in advanced Hodgkin's disease. Med J Aust 1992; 157:527-30. [PMID: 1282656 DOI: 10.5694/j.1326-5377.1992.tb137348.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To present the use of high dose chemotherapy with autologous bone marrow transplantation as salvage therapy for advanced Hodgkin's disease in Australia. DESIGN A prospective open study for patients whose disease was resistant to conventional treatment. SETTING The bone marrow transplantation units of four Australian tertiary hospitals. PATIENTS Seventeen patients (median age 30 years) entered and completed the study. The stage of the disease at initial diagnosis was I or II (seven patients), III (seven patients) and IV (three patients). Histological types were lymphocyte predominant (one), nodular sclerosis (12), mixed cellularity (three) and unknown (one). Therapy before consideration for transplantation included radiotherapy (13), mustine, vincristine, procarbazine and prednisone (MOPP--17 patients) or doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD--13 patients) and other chemotherapy regimens (five). The median interval from diagnosis to transplantation was 29 months (range, 9-178 months). The patient's disease was classified as sensitive (nine) or resistant (eight) to treatment, depending on the response to the most recent course of chemotherapy. INTERVENTIONS Morphologically normal autologous bone marrow was harvested and cryopreserved. The conditioning regimen given was cyclophosphamide, carmustine and etoposide (14) or busulphan and cyclophosphamide (three). The marrow was then infused. MAIN OUTCOME MEASURES Remission (complete or partial), disease-free survival and overall survival. RESULTS Over all, 10 of 17 patients (59%) entered or remained in complete remission and four of 17 (24%) achieved partial remission. The overall actuarial survival at 30 months was 70%. Eight of the nine patients with treatment-sensitive disease (89%) remain disease-free at a median of 22 months (range, 18-29 months) after transplantation. Two of the eight patients with resistant disease (25%) are disease-free at 20 and 28 months. There was one procedure-related death from haemorrhage and four disease-related deaths at six, seven, eight and 13 months after transplantation. CONCLUSION Autologous bone marrow transplantation may provide an effective salvage therapy in advanced Hodgkin's disease, particularly for patients with treatment-sensitive disease and a low tumour burden.
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Affiliation(s)
- M J Morgan
- Haematology Department, St Vincent's Hospital, Darlinghurst, NSW
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High-Dose VP-16 (HD VP-16) and Fractionated Total Body Irradiation (F-TBI) Followed by Autologous Bone Marrow Transplantation (ABMT) in Children with Relapsed or High-Risk Acute Lymphoblastic Leukemia (ALL). ACTA ACUST UNITED AC 1992. [DOI: 10.1007/978-3-642-76591-9_97] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Burnett AK. Autologous bone marrow transplant in the treatment of acute leukaemia. BAILLIERE'S CLINICAL HAEMATOLOGY 1991; 4:751-73. [PMID: 1958890 DOI: 10.1016/s0950-3536(09)90011-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
For a minority of patients with acute leukaemia, usually in children and predominantly with acute lymphoblastic leukaemia, existing chemotherapy protocols are curative. For a minority of the remaining group myeloablative chemoradiotherapy supported by allogeneic marrow from an HLA-matched donor can cure the disease. Major efforts are being made to free the potential benefit of this approach from the limitations imposed by the associated immune-biological complications, and limited donor availability. In the last decade the resurgence of autologous transplantation in remission has been a major new source of hope for further progress. Many groups have produced encouraging results, which now that they have substantial follow-up, suggest that this approach is altering the normal pattern of relapse. Almost all the experience, however, while producing consistent results, at least in AML, is anecdotal. The possibility of selection bias, particularly by the time-censoring effect, cannot be excluded, and prospective controlled trials are needed. The data available suggest which investigations could be expected to yield clear results. Other questions, particularly whether or not to purge the marrow, are only practical to investigate in well-defined patient subgroups. The opportunity to identify predictive parameters in this new clinical setting, using the more powerful techniques now becoming available should not be missed. National and international trials now in progress will yield crucial data in the next 2 or 3 years.
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Brenner M, Mirro J, Hurwitz C, Santana V, Ihle J, Krance R, Ribeiro R, Roberts WM, Mahmoud H, Schell M, Garth K, Moen RC, French-Anderson W. Autologous bone marrow transplant for children with AML in first complete remission: use of marker genes to investigate the biology of marrow reconstitution and the mechanism of relapse. Hum Gene Ther 1991; 2:137-59. [PMID: 1911934 DOI: 10.1089/hum.1991.2.2-137] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Raul Ribeiro
- St. Jude Children's Research Hospital Memphis, Tennessee 38101
| | - W. Mark Roberts
- St. Jude Children's Research Hospital Memphis, Tennessee 38101
| | - Hazem Mahmoud
- St. Jude Children's Research Hospital Memphis, Tennessee 38101
| | - Michael Schell
- St. Jude Children's Research Hospital Memphis, Tennessee 38101
| | - Katy Garth
- St. Jude Children's Research Hospital Memphis, Tennessee 38101
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Ramsay NK, Davies S. Bone marrow transplant for acute leukaemia. BAILLIERE'S CLINICAL HAEMATOLOGY 1991; 4:483-510. [PMID: 1912667 DOI: 10.1016/s0950-3536(05)80168-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Hervé P, Cahn JY. Ex vivo and conditioning chemotherapy for autologous bone marrow transplantation. BAILLIERE'S CLINICAL HAEMATOLOGY 1991; 4:223-46. [PMID: 2039860 DOI: 10.1016/s0950-3536(05)80292-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Shpall EJ, Clarke-Pearson D, Soper JT, Berchuck A, Jones RB, Bast RC, Ross M, Lidor Y, Vanacek K, Tyler T. High-dose alkylating agent chemotherapy with autologous bone marrow support in patients with stage III/IV epithelial ovarian cancer. Gynecol Oncol 1990; 38:386-91. [PMID: 2121627 DOI: 10.1016/0090-8258(90)90079-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- E J Shpall
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710
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Koeppler H, Pflueger KH, Wolf M, Weide R, Havemann K. High-dose chemotherapy with noncryopreserved autologous bone marrow transplantation for acute myeloid leukemia in first complete remission. HAEMATOLOGY AND BLOOD TRANSFUSION 1990; 33:699-701. [PMID: 2323669 DOI: 10.1007/978-3-642-74643-7_127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Seven patients with acute myeloid leukemia (AML) in first complete remission were treated with escalating high doses of cyclophosphamide, etoposide, and cytosine arabinoside (Ara-C). In all patients autologous bone marrow preservation was performed prior to therapy. Bone marrow was stored in blood bags in a refrigerator for 48-72 h at 4 degrees C and then reinfused over a central line. All patients had a full hematological recovery. The mean time of neutropenia (neutrophils less than 500/microliters) was 14 days (range 9-24 days), and the mean time of thrombocytopenia (platelets less than 20,000/microliters) was 9 days (range 7-11 days). The nonhematological toxicity was tolerable with mild to moderate nausea/vomiting, mucositis and diarrhea, and so far not dose-limiting. Six patients remain in complete remission 17+, 9+, 5+, 5+, 4+, and 1+ months after autotransplantation. One patient relapsed 8 months after autotransplantation. High-dose chemotherapy with noncryopreserved bone marrow autotransplantation may be useful as intensified consolidation for patients with AML in first complete remission.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bone Marrow Transplantation
- Combined Modality Therapy
- Cyclophosphamide/administration & dosage
- Cytarabine/administration & dosage
- Drug Evaluation
- Etoposide/administration & dosage
- Humans
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/surgery
- Leukemia, Myeloid, Acute/therapy
- Leukemia, Myelomonocytic, Acute/drug therapy
- Leukemia, Myelomonocytic, Acute/surgery
- Leukemia, Myelomonocytic, Acute/therapy
- Transplantation, Autologous
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Affiliation(s)
- H Koeppler
- Department of Internal Medicine, Philipps-University, Marburg, FRG
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Meloni G, De Fabritis P, Pulsoni A, Sandrelli A, Simone F, Mandelli F. Acute myelogenous leukemia in first relapse treated with two consecutive autologous bone marrow transplantations: a pilot study. Eur J Haematol 1989; 42:441-4. [PMID: 2659381 DOI: 10.1111/j.1600-0609.1989.tb01468.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The feasibility and the antileukemic activity of a double sequential autograft has been evaluated in 3 patients affected by AML in first hematological relapse. Bone marrow collection and cryopreservation was performed twice: during first complete remission (CR) and during second CR. At the time of relapse patients underwent first ABMT with BAVC preparative regimen achieving a second CR without any remarkable complications. After 4, 5 and 4 months respectively a second ABMT was performed with a different preparative regimen, consisting of cyclophosphamide and fractionated total body irradiation (Cy + F-TBI). A delay in platelet recovery was observed after the second procedure as compared to the first, while neutrophils recovery was comparable. 1 patient died in CR (on day +91 after second ABMT) of interstitial pneumonitis. 2 patients are alive and well without evidence of disease after 46 and 53 months of unmaintained second CR. This experience shows the high antileukemic potential of treatment with a double sequential autograft; 2 relapsed patients in fact are long-term survivors with a second CR longer than the first.
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MESH Headings
- Adult
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bone Marrow Transplantation
- Child
- Follow-Up Studies
- Humans
- Leukemia, Myeloid, Acute/blood
- Leukemia, Myeloid, Acute/therapy
- Leukemia, Myelomonocytic, Acute/blood
- Leukemia, Myelomonocytic, Acute/therapy
- Leukocyte Count
- Neoplasm Recurrence, Local
- Neutrophils
- Pilot Projects
- Platelet Count
- Remission Induction
- Time Factors
- Transplantation, Autologous
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Affiliation(s)
- G Meloni
- Institute of Hematology, University La Sapienza, Rome, Italy
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Reiffers J, Gaspard MH, Maraninchi D, Michallet M, Marit G, Stoppa AM, Corront B, David B, Gastaut JA, Scotto JJ. Comparison of allogeneic or autologous bone marrow transplantation and chemotherapy in patients with acute myeloid leukaemia in first remission: a prospective controlled trial. Br J Haematol 1989; 72:57-63. [PMID: 2660902 DOI: 10.1111/j.1365-2141.1989.tb07652.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Eighty-five adult patients under the age of 50 years with acute myeloid leukaemia (AML) were entered into a prospective controlled study conducted to compare the effectiveness of allogeneic or autologous bone marrow transplantation and intensive chemotherapy for patients in first complete remission. Sixty-one patients (72%) achieved complete remission then received a consolidation treatment. After consolidation, 58 patients who were still in remission were assigned to three different therapeutic modalities. Fifty-two patients were evaluable: 20 patients who had an HLA-identical sibling donor underwent allogeneic bone marrow transplantation within 3 months after achievement of complete remission; the other 32 patients were randomized to receive autologous bone marrow transplantation or intensive sequential chemotherapy. The actuarial risk of relapse at 3 years was 18% for the allogeneic patients, 50% for the autologous patients and 83% in the chemotherapy group. The difference was highly significant (P less than 0.0002). The disease-free survival was respectively 66% (95% confidence interval 41-85%), 41% (95% confidence interval 16-66%) and 16% (95% confidence interval 0-31%) (P less than 0.004). We conclude that allogeneic bone marrow transplantation is presently the best therapeutic approach for patients with AML in first complete remission.
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Affiliation(s)
- J Reiffers
- Département de Hématologie CHR Bordeaux, Hôpital Haut Leveque, Pessac, France
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Abstract
We reviewed the hospital course of 35 patients who underwent autologous bone marrow transplantation. Fever and profound neutropenia developed in all. Microbiologically confirmed infection developed in 22 patients, and unconfirmed but clinically evident infection developed in six. A bacterial infection developed in 21 patients (most commonly bacteremia without a detectable focus). Mucocutaneous fungal (12 patients) and viral (13 patients) infections were common, whereas invasive fungal (two patients) and viral (one patient) infections were uncommon. New pulmonary infiltrates developed in seven patients. Six deaths occurred during the initial hospitalization for transplantation, only one of which was directly attributable to infection. Stepwise logistic regression analysis retained male gender, total body irradiation, administration of trimethoprim/sulfamethoxazole, and development of mucositis or diarrhea as predictors of decreased survival, whereas higher pretreatment albumin levels and the administration of oral nonabsorbable antifungals were associated with an increased likelihood of survival. A comparison of these infectious complications with those found in allogeneic bone marrow transplant recipients shows similarities and differences with potentially important implications for patient management.
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Affiliation(s)
- J L Kirk
- Department of Medicine, University of Oklahoma College of Medicine, Oklahoma City
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Affiliation(s)
- A K Burnett
- Department of Haematology, Royal Infirmary, Glasgow, U.K
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Bone Marrow Transplantation in the Treatment of Children with Cancer: Current Status. Hematol Oncol Clin North Am 1987. [DOI: 10.1016/s0889-8588(18)30652-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Juttner CA, To LB, Ho JQ, Thorp DL, Kimber RJ. Successful peripheral blood stem-cell autograft with a near-critical dose of myeloid progenitor cells in acute non-lymphoblastic leukaemia in relapse. Med J Aust 1987; 147:292-3. [PMID: 2888008 DOI: 10.5694/j.1326-5377.1987.tb133460.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Rapid, complete and sustained haemopoietic reconstitution was achieved in a 69-year-old man with acute non-lymphoblastic leukaemia in relapse who received an autograft of peripheral blood cells that were collected during very early remission. The patient received 1.7 X 10(8) nucleated cells/kg bodyweight containing 63 X 10(4) myeloid progenitor cells (CFU-GM)/kg bodyweight. Trilineage engraftment was evident in the bone marrow seven days after the graft. Normal neutrophil and platelet counts were attained by day 17, on which day the patient was discharged from hospital. He remained in complete remission three months after the graft with normal blood counts and bone-marrow cellularity. The rapid and sustained haemopoietic activity in this patient, in conjunction with our previous experience of four other patients who received autografts with peripheral blood stem cells, supports the concept we have proposed that a minimum CFU-GM dose of 50 X 10(4)/kg bodyweight produces complete and sustained engraftment. The rapid recovery minimizes aplasia-related risks and suggests that such autografting can be carried out safely in first remission even in older patients. This technique should be considered as a new therapeutic option for patients with acute non-lymphoblastic leukaemia.
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Sheridan WP, Boyd A, Morstyn G. Autologous bone marrow transplantation: present status and future prospects. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1987; 17:275-8. [PMID: 3314831 DOI: 10.1111/j.1445-5994.1987.tb01223.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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