Importance of Parenteral Nutrition in Patients Undergoing Hemopoietic Stem Cell Transplantation Procedures in the Autologous System

OBJECTIVE

The aim of this study was to assess the frequency of parenteral nutrition and to compare the impact of parenteral and oral feeding on the nutrition and clinical status of adults undergoing autologous hemopoietic stem cell transplantation.

METHODS

The study involved 35 patients with neoplasm of the hemopoietic system who underwent hemopoietic cell autotransplantation at the Hematology Clinic (Jagiellonian University, Krakow, Poland). The patients' nutrition status was assessed using body mass index (BMI) values, body mass components, concentration of albumin, and total protein in blood serum. The clinical status evaluation included duration of hematologic reconstruction, concentration of bilirubin, enzyme activity (alanine aminotransferase and aspartate aminotransferase), severity of infections, and duration of hospitalization.

RESULTS

Parenteral nutrition was required in 19 patients. Oral feeding was used in 16 patients. Symptoms of malnutrition on the day preceding the introduction of conditioning treatment were recorded only in patients requiring parenteral nutrition (31.6%). In the posttransplantation period, a statistically significant decrease in body mass was observed in both groups, whereas the share of fatty tissue in total body mass was significantly less in patients (men and women) fed parenterally.

CONCLUSION

A supply of 25-30 kcal/kg and 1-1.5 g protein/kg/day as an element of parenteral nutrition (where 20%-30% of the energy requirement was covered by fats, 15%-20% by amino acids, and 50%-55% by glucose) helped prevent the development of malnutrition and restore the functions of the hemopoietic system at a level comparable to that for patients fed naturally.

Status of minimal residual disease determines outcome of autologous hematopoietic SCT in adult ALL

The role of autologous hematopoietic SCT (autoHSCT) in the treatment of high-risk (HR) adult ALL is controversial. In this study, we retrospectively analyzed the results of autoHSCT according to the status of minimal residual disease (MRD) at transplantation, as a joint analysis of the European Study Group for Adult ALL (EWALL). Data on 123 recipients of autoHSCT, aged 31 (16-59) years, with B-lineage (n=77) or T-lineage (n=46) ALL were included. In a cohort of Ph-negative ALL, the probability of leukemia-free survival at 5 years was higher for patients with MRD <0.1% compared with those with MRD > or = 0.1% (57 vs 17%, P=0.0002). The difference was significant for T-lineage ALL (62 vs 8%, P=0.001), and a tendency was observed for B-lineage ALL (54 vs 26%, P=0.17). In a multivariate analysis, adjusted for other potential prognostic factors, high MRD level remained the only independent factor associated with increased risk of failure (risk ratio, 2.8; P=0.0005). We conclude that MRD determines the outcome of autoHSCT in HR adult ALL. Our results suggest the need to reevaluate the role of this treatment option in prospective trials.

Efficacy and Safety of Fludarabine and Cyclophosphamide Combined Therapy in Patients with Refractory/Recurrent B-Cell Chronic Lymphocytic Leukaemia (B-CLL)—Polish Multicentre Study

The aim of this study was to investigate the efficacy of a combination of fludarabine (F) and cyclophosphamide (C) in the treatment of patients with refractory/recurrent B-cell chronic lymphocytic leukaemia (B-CLL). Between November 1999 and December 2001, 63 patients with B-CLL (median age 60 years) received a regimen that consisted of F 25 mg/m2 and C 250 mg/m2, days 1-3, intravenously, every 4 weeks, for a maximum of 6 courses, Response and toxicity were assessed according to current criteria (NCI-WG and WHO). Complete and partial remissions were achieved in 17.5% and 55.6% of patients, respectively; 19% of patients had stable disease and 7.9% of patients showed disease progression. The median follow-up was 16.5 (range 1.5-32) months. The median duration of progression-free survival (PFS) has not been reached among patients treated with FC regimen as second-line therapy. The median PFS was 13 (range 8-26) months in the 19 responding patients treated with FC regimen as third-line therapy. The most frequent side-effects were neutropenia (45%), thrombocytopenia (42%) and infections (57%). We conclude that the combination of fludarabine and cyclophosphamide demonstrated significant efficacy in pretreated, advanced B-CLL patients, with tolerable toxicity.

Survival benefit of post induction consolidation therapy in MCL (mantle cell lymphoma): A Polish Lymphoma Research Group (PLRG) retrospective multicenter analysis

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Background: In MCL, early intensification and consolidation of the first line therapy by ASCT is the treatment of choice. Elderly age and co-existing co-morbidities makes it however feasible for less than a third of patients. Methods: All MCL cases consulted in 8 PLRG centers within the last 5 years (n=140) were included in a retrospective analysis. Only 23% (n=32) were consolidated with ASCT, further 28% (n=40) by radioimmunotherapy (Ibritumomab), while in 49% (n=68) neither consolidation was performed. Rituximab was used in 36/72 patients subjected to consolidation and 25/68 treated without consolidation. There were no statistically significant differences in IPI, CS (clinical stage), frequency of extranodal manifestations and B symptoms between analyzed subgroups ( Table ) although patients subjected to ASCT were younger (median age 54 vs 62) and tend to have higher LDH (556 IU vs 473), while those who were not consolidated more frequently had a large tumor burden (defined as a mass > 7 cm, 24 vs 15%). Results: There was a clear impact of consolidation on overall and progression-free survival (OS,PFS): at 5 years OS 65 vs 20 % (p= 0.0003 in Gehan Wilcoxon test); and PFS 40 vs 0 % (p= 0.0003 in Gehan Wilcoxon test). Rituximab used in the first line therapy further increased it's efficiency in terms of PFS, prolonging median time to progression from 15 to 26 months, however the OS benefit was seen only in consolidated patients (at 5 years 75% OS in those with Rituximab including induction followed by consolidation). Conclusions: With all limitations of retrospective analysis, it strongly supports the necessity of post induction therapy in MCL patients. The role of ASCT is established in younger patients, radioimmunotherapy may prove to be a feasible approach for the elderly and unfit ones.

[Table: see text]

No significant financial relationships to disclose.

Hospital outbreak of vancomycin-resistant enterococci caused by a single clone of Enterococcus raffinosus and several clones of Enterococcus faecium

A mixed outbreak caused by vancomycin-resistant Enterococcus raffinosus and Enterococcus faecium carrying the vanA gene was analysed. The outbreak occurred in a large hospital in Poland and affected 27 patients, most of whom were colonised, in three wards, including the haematology unit. The E. raffinosus isolates had a high-level multiresistant phenotype and were initially misidentified as Enterococcus avium; their unambiguous identification was provided by multilocus sequence analysis. The molecular investigation demonstrated the clonal character of the E. raffinosus outbreak and the polyclonal structure of the E. faecium isolates. All of the isolates carried the same Tn1546-like element containing an IS1251-like insertion sequence, located on a c. 50-kb conjugative plasmid. One of the E. faecium clones, found previously to be endemic in the hospital, was probably the source of the plasmid. The results of the study suggest that difficulties in identification may have led to an underestimate of the importance of E. raffinosus in vancomycin-resistant enterococci (VRE) control strategies.

The choice of first-line therapy in advanced Hodgkin lymphoma: Retrospective comparison of ABVD and escalated BEACOPP regimen

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Background: HD patients with high risk have a relatively poor prognosis with less than 50% 5-year overall survival (OS) if treated with ABVD regimen. Methods: Therapy results of all 105 patients with advanced HL (CS IIBX -IV) treated from diagnosis at our Department in the last decade, are presented. The choice of initial 3 cycles between ABVD and escalated BEACOPP was done at the patients preferal and physician's adivice. Further 3 chemotherapy cycles depended on initial response assessment: poorly responding ABVD treated patients were offered therapy escalation. Patients with a good response (over 80% regression) after the first 3 cycles were later treated with ABVD. EFS and OS were primary endpoints of the study. Results: We divided patients into 2 treatment groups, depending on the first 3 cycles (escalated BEACOPP n = 57 or ABVD n = 48). Poor response resulting in therapy intensification was not considered as an event defined only as a relapse or progression during therapy. There was a statistically insignificant imbalance between the risk factor distribution with less favorable prognosis in patients treated with esc BEACOPP: 38 % of pts in IV th clinical stage (as compared to 31% in ABVD group), 3,08 EORTC risk factors (as compared to 2,64 in ABVD group) and 2,19 according to German Hodgkin Study Group (1.93 respectively). Increased toxicity of esc BEACOPP regimen was due to grade 3/4 cytopaenia (present in all patients) resulting in more infection episodes (according to WHO scale stage 3 - 16 pts , stage 4 - 8 pts; in ABVD group, 2 and 1 pt respectively). There were no treatment related mortalities. In esc BEACOPP projected 5 y OS was 96% and EFS 89% , which is comparable to GHSG results. 5 y OS and EFS in ABVD group are 87% and 66% respectively. The difference in EFS is statistically significant (p< 0.05). Conclusions: In our study we checked the feasibility of esc BEACOPP regimen in high risk HD pts. The results show the importance of the intensity of the first line approach. In the poor responders after the initial 3 cycles, even early treatment intensification, didn’t improve the outcome. De-escalation of therapy after the first 3 cycles, in good responders, didn’t make OS and EFS inferior to GHSG results in which they recommend 6 cycles of esc BEACOPP therapy.

No significant financial relationships to disclose.

Addition of cladribine to induction/consolidation regimen does not impair peripheral blood stem cell mobilization and bone marrow harvest for autotransplantation in acute myeloid leukemia patients

BACKGROUND

The previous study by the Polish Adult Leukemia Group has demonstrated that addition of cladribine to standard DNR+AraC induction potentiates the antileukemic activity. The goal of this study was to compare the efficacy of bone marrow or peripheral blood hematopoietic cell collection in patients who obtained remission after daunorubicine plus cytarabine induction with cladribine (DAC-7) or without addition of cladribine (DA-7) in preparation for autotransplantation.

PATIENTS AND METHODS

Sixty-six patients aged 41 years (range, 17-58 years) were included in this study: 33 cases in the DAC-7 and 33 in the DA-7 arm. Hematopoietic cells were collected from the bone marrow (ABMT, n = 29) or from the peripheral blood (ABCT, n = 37) using cytopheresis after administration of AraC (2 x 2 g/m2) on days 1, 3, 5 and subsequent G-CSF (10 microg/kg) from day 7 as mobilization therapy.

RESULTS

The numbers of harvested CD34+ cells were similar in the DAC-7 and DA-7 pretreated patients both after harvesting from peripheral blood (2.55 x 10(6)/kg vs 2.5 x 10(6)/kg) and from bone marrow (1.62 x 10(6)/kg vs 1.55 x 10(6)/kg), respectively. The proportion of patients with sufficient material for autologous bone marrow transplantation was higher in the DAC-7 compared with the DA-7 arm. All patients engrafted; hematopoietic recovery was similar in both subgroups.

CONCLUSION

Addition of cladribine to a standard DA induction does not impair the harvesting of hematopoietic cells and their engraftment after autotransplantation.

Clinical efficacy, safety and pharmacokinetic properties of the factor VIII concentrate HaemoctinR SDH in previously treated patients with severe haemophilia A

Clinical efficacy, safety and pharmacokinetic properties of the high-purity double-virus inactivated plasma-derived factor VIII concentrate Haemoctin SDH (pdFVIII) were evaluated in three prospective open-label uncontrolled studies in previously treated patients (PTPs) with severe haemophilia A. The pharmacokinetic properties assessed at baseline and after 3 months of treatment are in accurate accordance with published data and remain unchanged over time (study A, n = 12). Mean terminal elimination half-life was 11.8 and 11.9 h, mean incremental recovery (IU dL(-1)/IU kg(-1)) was 2.3 and 2.0, respectively. Long-term efficacy and safety, in particular the potential immunogenicity, were investigated in a total of 53 PTPs (studies A and B) treated prophylactically and on-demand, as required. PdFVIII has shown to be effective in preventing and controlling bleeding episodes; 23.5% of patients were free of bleeding events. A total of 177 haemorrhages occurred with 74.0% resolving after a single infusion, 87.6% within two infusions. 98.3% of responses reported on haemorrhages were rated as 'excellent' or 'good'. Moreover, 'excellent' haemostatic efficacy has been demonstrated in 10 surgical procedures including general and severe orthopaedic interventions (study C). No complication occurred in any surgery. Few adverse events were reported, one patient developed a high-titre FVIII inhibitor without clinical relevance. In all three studies, over 6 million units were administered in nearly 4300 infusions, approximately 94% units or infusions were given for prophylaxis and only 6% for treatment on-demand. In conclusion, pdFVIII has shown to be effective, safe and well tolerated in long-term prophylaxis and treatment on-demand as well as after minor and major surgical procedures.

Acute lymphoblastic leukemia in elderly: the Polish Adult Leukemia Group (PALG) experience

This is a retrospective, multicenter study to evaluate biological features and outcome of elderly patients diagnosed with acute lymphoblastic leukemia (ALL) during the last 10 years in ten hematological centers in Poland. Eighty-seven patients aged 60 years or older were studied. To our knowledge, this is one of the largest group of elderly patients with ALL evaluated. We have not observed differences in immunological subtypes and Ph chromosome incidence as compared with younger adult ALL presented in the literature. Induction chemotherapy was administered in 75 patients. We observed complete remission (CR) in 34 (45%, 95% CI: 33-56%) patients. Induction death occurred in 11 (15%) patients. Thirty patients (40%) showed primary resistance to chemotherapy. Median overall survival (OS) of all patients was 150 days. Median disease-free survival (DFS) of responding patients was 180 days. We observed four long-term survivors (DFS longer than 3 years) in our group of patients. Factors influencing OS were CR achievement, female gender, and WBC below 30 x 10(9)/l. Male gender was the only prognostic factor negatively affecting probability to achieve CR. We have not observed any differences in either biology or outcome between patients aged 60-69 years and those aged more than 70 years. ALL of the elderly is a rare disease with poor prognosis. Further clinical trials evaluating the disease features, outcome, and new therapeutic approaches are warranted.

[Veno-occlusive disease--an important complication in hematopoietic cells transplantation]

Hemopoietic stem cell transplantation is frequently used in clinical practice. However, many severe complications limit its usage. One of the most important is veno-occlusive disease of the liver (VOD). The key pathophysiologic event is a damage to epithelium during chemotherapy. Gradual development of intrahepatic portal hypertension leads to clinical manifestations (jaundice, liver enlargement, ascites). Many risk factors has been identified (pre-transplant liver disturbance, chemotherapy and conditioning, drugs). The diagnosis is based on clinical criteria and exclusion of other diseases. Laboratory, haemodynamic, ultrasound studies and histopathology are very important in diagnosis. In pharmacological prophylaxis heparin is widely used. Therapy requires strict fluid and electrolyte balance. Some patients can benefit from transjugular intrahepatic portosystemic shunt (TIPS) or liver transplantation. Defibrotide gives more hope for patients but further investigations are needed.

Cladribine combined with cyclophosphamide and mitoxantrone as front-line therapy in chronic lymphocytic leukemia

The objective of the study was to determine the effectiveness and the toxicity of a combined chemotherapy consisting of cladribine (2-CdA), mitoxantrone and cyclophosphamide (CMC regimen) in the treatment of previously untreated B cell chronic lymphocytic leukemia (B-CLL). From August 1998 to December 2000 2-CdA was administered at a dosage of 0.12 mg/kg for 3 (CMC3) or 5 (CMC5) consecutive days, mitoxantrone at 10 mg/m2 on day 1 and cyclophosphamide at 650 mg/m2 on day 1 to 62 patients with advanced or progressive B-CLL. The cycles were repeated at 4 week intervals or longer if severe myelosuppression occurred. Twenty patients received CMC5 and 42 patients CMC3. Within the analyzed group an overall response (OR) rate (CR+PR) of 64.5% (95% CI: 52.7-76.3%) was reported, including 29.0% CR. There was no difference in the CR rate between the patients treated with CMC5 (30%) and CMC3 (28.6%) (P = 0.9), nor in the OR rate (55.0% and 69.0%, respectively, P = 0.3). Residual disease was identified in seven out of 18 (38.9%) patients who were in CR, including two treated with CMC5 and five treated with CMC3 protocols. CMC-induced grade III or IV thrombocytopenia occurred in 12 (19.4%) of patients, including four (20%) CMC5-treated and eight (19%) CMC3-treated patients (P= 0.8). Neutropenia grade III or IV was observed in seven (35%) and 11 (26.2%) patients, respectively (P = 0.8). Severe infections, including pneumonia and sepsis, occurred more frequently after CMC5 (11 patients, 55.0%) than CMC3 (10 patients, 28.6%) (P = 0.03) Fourteen patients died, including six treated with CMC5 and eight treated with CMC3 (30% and 19%, respectively). Infections were the cause of death in nine patients, including four in the CMC5 group and five in the CMC3 group. In conclusion, our results indicate that the CMC programme is an active combined regimen in previously untreated B-CLL patients; its efficiency seems to be similar to that observed earlier in B-CLL patients treated with 2-CdA as a single agent. However, toxicity, especially after CMC5 administration, is significant. Therefore, we recommend the CMC3 but not the CMC5 programme for further evaluation.

[Hemorrhagic cystitis related to the high-dose conditioning therapy in a bone marrow recipient]

Hemorrhagic cystitis (HC) is the syndrome of hematuria combined with symptoms of lower urinary tract irritation in the absence of bacterial infection or generalized hemorrhagic diathesis. HC often occurs as a difficult complication after autologous as well as allogeneic hematopoietic cell transplantation (HCT). It may be secondary to pretransplant preparative regimen (chemotherapy and/or radiation therapy) or viral infection by adenovirus, JC and BK viruses. The most effective treatment for HC has not been established yet. We report a case of a 17-year-old male with common acute lymphoblastic leukemia (cALL) in second CR, who was treated with high-dose chemotherapy (BuCy conditioning regimen) followed by autologous bone marrow transplantation (ABMT), complicated by hemorrhagic cystitis on day 0 (several hours after infusion of transplant material). The immediate use of increased dose of 2-mercaptoethane sulfonate sodium (mesna), bladder irrigation and intensive hydration with forced diuresis resulted in resolution of macroscopic hematuria on day +3 after the transplant and urinary tract recovery with normalization of urine analysis parameters on day +7.

Cladribine with prednisone versus chlorambucil with prednisone as first-line therapy in chronic lymphocytic leukemia: report of a prospective, randomized, multicenter trial

The efficacy and toxicity of cladribine (2-CdA) + prednisone (P) versus chlorambucil (Chl) + P were compared in previously untreated patients with progressive or symptomatic chronic lymphocytic leukemia (CLL) in a randomized, multicenter prospective trial. Eligible patients were assigned to either 2-CdA 0.12 mg/kg per day in 2-hour infusions and P 30 mg/m(2) per day for 5 consecutive days or Chl 12 mg/m(2) per day and P 30 mg/m(2) per day for 7 consecutive days. Three courses were administered at 28-day intervals or longer if myelosuppression developed. The therapy was finished if complete response (CR) was achieved. Of 229 available patients 126 received 2-CdA+P and 103 received Chl+P as a first-line treatment. CR and overall response rates were significantly higher in the patients treated with 2-CdA+P (47% and 87%, respectively) than in the patients treated with Chl+P (12% and 57%, respectively) (P = .001). Progression-free survival was significantly longer in the 2-CdA-treated group (P = .01), but event-free survival was not statistically different. Thirteen percent of patients were refractory to 2-CdA+P and 43% to Chl+P (P = .001). Drug-induced neutropenia was more frequently observed during 2-CdA+P (23%) than Chl+P therapy (11%) (P = .02), but thrombocytopenia occurred with similar frequency in both groups (36% and 27%, respectively). Infections were seen more frequently in the 2-CdA+P-treated group (56%) than in the Chl+P-treated group (40%; P = .02). Death rates have so far been similar in patients treated with 2-CdA (20%) and with Chl (17%). The probability of overall survival calculated from Kaplan-Meier curves at 24 months was also similar for both groups (78% and 82%, respectively). (Blood. 2000;96:2723-2729)

[Nonmyeloablative allogeneic hematopoietic stem cell transplantation: minitransplantation]

Allogeneic hematopoietic stem cell transplantation (alloHCT) is considered as a treatment of choice for many malignant hematologic disorders and genetic diseases. Unfortunately toxicities of conventional alloHCT remain a major limitation to successful application of the procedure. A radically new approach for alloHCT has been developed. Nonmyeloablative preparative regimen allows to establish mixed hematopoietic chimerism after alloHCT. A state of stable mixed chimerism may represent a starting point for induction of full donor derived hematopoiesis. A published results of several clinical trials have confirmed potential benefits of this new approach such as less procedure--related toxicity, protection from severe acute GVHD (graft versus host disease), lower TRM (transplant related mortality). Intensive investigations are done to replace in the future pretransplant chemotherapy and/or radiation by nontoxic anti-T-cell agents. These include antibody to the T-cell receptor alpha beta and blockers of T-cell costimulation (e.g. CTLA4lg).

[Telomeres and telomerase in leukemias]

There is increasing evidence that telomere shortening both in vitro and in vivo is the clock that counts cell divisions and determines the onset of cellular senescence. Cells overcome the normal senescence mechanism by stabilising telomere length; probably due to the activity of telomerase activity that specifically elongates telomeres. Most human primary tumors contain telomerase, while the cells of most normal tissues lack this activity. Normal haematopoietic cells express telomerase activity. This review is a discussion of utility of telomere length and telomerase activity measurements in the diagnostics and prognosis of leukaemia as well as the potential value of antitelomerase therapy. Results of telomere lengths measurements in young recipients of allogenic transplants are also reported.

Cladribine with or without prednisone in the treatment of previously treated and untreated B-cell chronic lymphocytic leukaemia - updated results of the multicentre study of 378 patients

Between January 1992 and January 1999, we treated 378 B-chronic lymphocytic leukaemia (CLL) patients with cladribine (2-CdA), and 255 of the patients were also treated with prednisone. A total of 194 patients were previously untreated, and 184 had relapsed or refractory disease after previous other therapy. Complete response (CR) was obtained in 111 (29.4%) and partial response (PR) in 138 (36.5%) patients, giving an overall response (OR) rate of 65.9%. CR and OR were achieved more frequently in patients in whom 2-CdA was a first-line treatment (45.4% and 82.5% respectively) than in the pretreated group (12.5% and 48.4% respectively) (P < 0.0001). The median duration of OR for previously untreated patients was 14.7 months and for pretreated patients 13.5 months (P = 0.09). The median survival evaluated from the beginning of 2-CdA treatment was shorter in the pretreated group (16.3 months) than in the untreated group (19.4 months) (P < 0.0001). A total of 117 (63.9%) patients died in the pretreated group and 63 (32.6%) in the untreated group. In pretreated patients, 2-CdA + prednisone (P) and 2-CdA alone resulted in similar OR (51.0% and 45.0% respectively; P = 0.4). In contrast, in untreated patients, 2-CdA + P produced a higher OR (85.4%) than 2-CdA alone (72.1%) (P = 0.04). Infections and fever of unknown origin, observed in 91 (49.4%) pretreated and 74 (38.1%) untreated patients (P = 0.03), were the most frequent toxic effects. Our results indicate that 2-CdA is an effective, relatively well-tolerated drug, especially in previously untreated CLL.

[History of Kraków hematology]

The development of the studies of the blood diseases at the IIIrd Department of Internal Medicine and later at the Department of Hematology of the Medical Academy and subsequently the Collegium Medicum at the Jagiellonian University in the years 1950 to 2000 are presented here. The Cracow Hematological Center, headed by professor Julian Aleksandrowicz from 1950 to 1979, by professor Julian Blicharski from 1979 to 1989, by ass. professor Jerzy Lisiewicz from 1990 to 1993, and presently by Aleksander B. Skotnicki--has drawn many brilliant hematologists who have initiated, developed and verified new concepts of pathogenesis as well as new methods of diagnosis and therapy of haematological diseases. The Polish Haematological Society was founded in 1949 in Cracow where the first Conference took place in May 1950. The first specialistic haematological journal--Haematologica Cracoviensia later retitled as Haematologica Polonica was first published in Cracow in 1957. Finally here, in Cracow, one of the first syngeneic bone marrow transplantation was performed in 1958. Presently the Chair and Department of Haematology of the Collegium Medicum at the Jagiellonian University is a modern and well facilitated center of research and didactics (both pre and post graduate studies); the modern cytological, immunophenotype, cytogenetic and molecular diagnostic methods are used in haematological patients from the Macroregion of South-Eastern Poland (inhabited by approximately 8 million people). The offered treatment includes chemo- and radiotherapy, immunotherapy and autologous and allogeneic bone marrow transplantation.

[Aplastic anemia--contemporary procedures and therapeutic perspectives]

Severe aplastic anaemia (SAA) state of art is summarised. Currently there are two therapeutic possibilities: allogeneic bone marrow transplantation (BMT) and immunosuppressive therapy. Decision should be based on disease severity, patient performance status, age and the availability of the HLA identical donor. Allogeneic BMT is the treatment of choice for the young (less than 25 years) SAA patients. It's side effects including graft versus host disease markedly increase with age. Immunosuppressive therapy is an option for patients older than 45, or younger ones with no HLA compatible donor. Optimisation of the treatment protocols is the subject of various ongoing randomised multicentre studies.

[Rationale and methods for high dose chemotherapy in oncology]

Waiting for a new, highly effective cytotoxic drugs it is necessary to improve antineoplastic treatment using presently existing drugs and methods. Chemosensitive tumors should be treated with intensive, short-lasting courses of the induction as well as of the adjuvant chemotherapy. Chemotherapy delay, dose reduction, unproper therapy regimen increases risk of the development of drug-resistance and treatment failure. Autologous hemopoietic cell transplantation allows cytostatics dose escalation (high-dose chemotherapy, HDCT) with an acceptable non-hematological toxicity. HDCT with autologous peripheral blood stem cell transplantation (auto-PBSCT) is increasingly used. Auto-PBSCT has the same efficacy as autologous bone marrow transplantation (ABMT), but it is a safer procedure, allows more rapid hemopoietic recovery and shorter hospitalization.

[Molecular basis of chronic myelogenous leukemia and significance of diagnostic methods based on BCR-ABL gene amplification]

Chronic myelogenous leukemia is characterized by an abnormal 22nd chromosome known as a Philadelphia chromosome, which can be detected in 95% of patients with CML. Molecular equivalent of this aberration is a BCR-ABL translocation resulting in chimeric gene formation. A BCR-ABL chimeric gene plays a key role in the hematopoietic cells proliferation regulation. RT-PCR can be used in diagnosis of CML, to detect chimeric BCR-ABL gene, and to reveal the type of translocation what could have prognostic importance, and in monitoring of minimal residual disease, confirming the eradication of pathological cells clone after treatment and identifying the group of patients with best prognosis and best overall survival. RT-PCR in monitoring of minimal residual disease after allo- or autologous hemopoietic cells transplantation can early reveal relapse of the disease. Detection of molecular relapse is an important prognostic factor and may implicate induction of treatment which should prevent haematological relapse of the disease.

[Evaluation of transplantation material based on immunophenotype and in vitro clonogenic assays of hematopoietic stem and progenitor cells]

The qualitative and quantitative methods of transplant material (hematopoietic stem and progenitor cells) evaluation in the Hematology Department of Jagiellonian University in Cracow are performed. Our experience in the first 26 patients suffered from hematological malignancies and solid tumors subjected to high-dose chemotherapy supported with autologous hematopoietic cells transplantation are presented.

[The role of autologous hematopoietic cell transplantation in adult acute myelogenous leukemia]

High dose chemotherapy with autologous hemopoietic cell transplantation (AHCT) is a common method of treatment of acute myelogenous leukemia (AML). AHCT is a treatment of choice for patients who have no matched family donor. AHCT is particularly recommended for older patients, excluded from allogeneic transplantation procedures. Prospective randomised trials have shown better efficacy of AHCT comparing with conventional chemotherapy in postremission treatment of AML. Both in vitro and in vivo bone marrow purging allow to achieve better transplantation results. Since two years peripheral blood instead of bone marrow is increasingly used as a source of transplant material. It allows more rapid hemopoiesis regrowth. Various methods of immunotherapy such as interleukin-2, Linomid and mixed hemopoietic cell transplantation (delayed donor lymphocytes transfusion) are used to evoke an autologous graft versus leukemia (GvL) phenomenon and to reduce AML relapse rate. Analysis of prognostic factors allows to identify a group of AML patients for whom AHCT is strongly recommended.

[Autologous transplantation in acute lymphoblastic leukemia in adults]

Over the past ten years considerable experience has been gained in autologous bone marrow transplantation (ABMT) for acute myelogenous leukemia and it is becoming possible to identify patients who may benefit from this approach. In acute lymphoblastic leukemia (ALL)the precise role of autologous transplantation particularly in first remission is much less clear than in AML. Formerly, most adult ALL patients who underwent ABMT did so in relapse or in second or subsequent remission. The fact that some of these patients could become long term survivors has encouraged the use of ABMT in first remission. In most studies 40-50% of first remission patients attained long term disease free survival (DFS). Relapse rates are considerably higher in patients receiving ABMT when compared to those receiving an allogeneic transplant, but the latter group of patients experience significant morbidity and mortality (15-30%) due to graft-versus-host disease and opportunistic infections. ABMT clearly has the potential to effect cures in ALL patients and its role and timing are now the subject of major clinical studies. As the mortality of ABMT for ALL rapidly decreases to approximately 5%, more widespread use of such a procedure may replace the protracted maintenance chemotherapy usually given in this disease.

[Multiple myeloma--new therapeutic perspectives]

This article contains the data related to diagnosis and treatment of multiple myeloma from several bone marrow transplantation centers. High-dose chemotherapy with stem cell transplantation is currently the best way of treatment in patients with multiple myeloma. The risk factors are chromosomal aberrations, high level of beta-2-microglobulin, CRP and LDH serum levels. The optimal source of stem cells is the blood because of financial and hematological reasons.

[Methods of mobilizing hematopoietic cells, their collection using cell separation, purging--processing of pathologic cells and enrichment with CD 34+ cells--negative and positive selection]

Autological transplantation of bone marrow as well as hematopoietic and precursor cells obtained from peripheral blood with the use of cell apheresis is a therapy applied in the treatment of hematological diseases and solid tumours. The mobilization of hematopoietic cells is performed by applying cytostatic drugs and/or recombinant growth factors (G-CSF, GM-CSF). The collection of CD 34+ cells is performed by using cell separators. An important role in the transplantation procedure is played by purging techniques of transplantation material from residual neoplastic cells (negative selection) or isolation of hematopoietic cells (positive selection). The considerable progress in this field is connected with the implementation of Immunoadsorbtive or magnetic methods as well as those of molecular biology. The improvement of the procedure of hematopoietic cells transplantation and its efficacy is caused by the stimulation of the hematopoiesis by using the combination of cytokines (G-CSF, GM-CSF, IL-3, SCF) and purging of the hematopoietic cells obtained from the cellular apheresis.

[Harvesting bone marrow from the posterior superior iliac crest for transplantation]

The purpose of bone marrow cells harvesting is to isolate haemopoietic stem cell for the transplantation, by means of multiple punctures from the posterior iliac crest under general anaesthesia. This method is the alternative procedure for collecting circulating peripheral blood progenitor cells performed with continuous-flow cell separators. The aim of the both procedures is the collection of progenitor cells for transplantation in the number enabling reconstitution of marrow function after myeloablative therapy. The bone marrow cell harvesting is a safe measure: the infrequent complication related to general anaesthesia may occur and the simultaneous or subsequent blood transfusion is usually required.

[General characteristics, basis and procedures for high dose chemotherapy procedures supported by hemopoietic stem cell transplantation]

Indications for autologous and allogeneic bone marrow transplantation in hematological malignancies and solid tumours are summarised. AML treatment protocol including induction and consolidation chemotherapy followed by conventional maintenance chemotherapy or high dose chemotherapy with subsequent autologous or allogeneic stem cell transplant are presented. We compared elements and targets of autologous and allogeneic procedures pointing out the major differences regarding transplant related mortality, disease free survival and relapse rates.

[Hodgkin's disease--diagnostic basis and therapy in light of randomized clinical trials]

Hodgkin Disease has a relatively good prognosis and high curability due to the effectiveness of risk adapted treatment. Protocol currently used at the Department of Haematology in Cracow is based on randomised multicentre clinical trials, summarised in this paper. Proper choice of the first line treatment is most important for overall survival--no salvage therapy for resistant or recurrent disease is equally effective. High dose chemotherapy with autologous stem cell support should be considered in certain clinical situations, as partial response or relapse after conventional treatment.

[Autotransplantation for solid tumors]

Over the last three decades, there have been a number of advances made in the treatment of haematological malignancies including an increasingly defined role in curative therapy programmes for high dose chemotherapy (HDC) with stem cell support. This has provided an impetus for similar approaches to be tested in solid tumours. Drug resistance is one of the most important reasons for treatment failure in these diseases, and therefore attempting to overcome it with HDC is an obvious strategy to investigate. This rationale is supported by laboratory data demonstrating that dose correlates with number of cells killed, and that increasing drug doses by 5-10 fold can overcome resistance. Clear evidence of a dose-response effect in patients is provided by numerous clinical trials of chemotherapy in solid tumours. A large number of studies have investigated HDC in solid tumours, particularly in those malignancies which demonstrate initial chemo-sensitivity, but later relapse. Except for breast cancer, for other solid tumours there are no randomised trials defining the role of HDC. Many of the trials are small pilot studies in heavily pretreated patients with large volume disease and therefore any conclusions must be guarded.

[Methods for freezing, thawing and viability estimation of hemopoietic stem cells]

Freezing and thawing of hemopoietic stem cells (CD34+) are indispensable stages between their collection from peripheral blood or bone marrow and transfusion to the patient who has previously undergone myeloablative chemotherapy. At present there are two methods of the cells freezing: non-controlled--placing CD34+ cells directly in the final temperature and rate-controlled--gradual cooling them at programmed speed. Non-controlled freezing leads to the considerable loss of cells viability (up to 50%), but it doesn't require the expensive equipment used for rate-controlled freezing (viability loss up to 10%). In order to reduce the loss resulting from intra-cellular crystallization of water the haemopoietic cells are mixed with one of the cryopreservative substances: dimethylsulphoxide-DMSO, hydro-xyethylstarch-HES, polyvinylpyrrolidone-PVP or glycerol. The most important moment of freezing procedure is the phase transition of water. The adequate shape of the cooling curve leads to a considerable reduction of the loss of the cells viability. Further cooling is the most effective when it takes place at max. speed of 5 degrees C/min. The storage of the frozen cells is the best in very low temperatures (-170-180 degrees C-vapour phase of liquid nitrogen), but mechanical freezers (-80 degrees C) are used, too. The thawing procedure should be very fast (up to 90 degrees C/min.) and the defrosted cells must be immediately transfused to the patient because of very high toxicity of cryopreservative agents to non-frozen cells. The cells viability estimation is carried out with trypan blue or cytofluorometrically after incubation with propidine iodide.

[Supportive therapy in patients with autologous hemopoietic stem cell transplantation]

Infectious complications remain one of the most serious diagnostic and therapeutic problems in modern hematology and are the major cause of morbidity and mortality following stem cell transplantation. Myeloablative therapy supported by haemopoietic stem cell transplantation remains standard policy in the treatment of certain haematological malignancies and solid tumors. Proper preventive strategies for patients in deep immunosuppression including prompt diagnosis and treatment of infections correlate with favourable prognosis and survival. Prophylaxis and therapy of bacterial, fungal and viral infections in neutropenic patients following myeloablative chemotherapy have been submitted in this article. Our guidelines are based on European Group for Bone and Marrow Transplantation recommendations and some European transplantological centres protocols. These standards were adapted to Polish conditions and now are used at Bone Marrow Transplantation Ward at Haematology Department at the Jagiellonian University.

[Autologous hemopoietic stem cell transplantation in treatment of chronic myelogenous leukemia]

Chronic myelogenous leukemia in more than 90% of patients is associated with the abnormal Philadelphia chromosome, which results in aberrant BCR-ABL chimeric gene expression. The mean overall survival on standard chemotherapy (which is not curative) ranges between 54-72 months. Selected patients with CML can be cured by allogeneic hemopoietic stem cell transplantation. Only 30% of patients has an optimal HLA-identical sibling donor. It is possible to find well-matched unrelated donor for another 20-30% of patients, however matched-unrelated donor transplantation is still associated with relative high risk of complications and cannot be used in elderly patients. Interferon alpha treatment in monotherapy or in combination with ARA-C can induce a cytogenetical and molecular remission in selected group of patients, which benefits with significantly prolonged survival. Nevertheless the cost of this treatment is high and long period of therapy is required to assess its efficacy. In patients lacking matched related or unrelated donors for allogeneic transplantation, autologous stem cell transplantation could be the alternative method of treatment. Discussed in the paper method of mobilization and transplantation of Philadelphia-negative peripheral-blood progenitor cells collected during early phase of bone marrow regeneration after "mobilizing" chemotherapy (mini-ICE) enables to achieve a complete or major cytogenetical response in about 77% of patients. There is only minimal morbidity and no transplant-related mortality. This procedure and the post-transplant immunotherapy (IFN alpha, interleukin-2) can considerably suppress the pathological clone and significantly prolong the overall survival in CML patients not eligible for allogeneic transplantation.

2-Chlorodeoxyadenosine (Cladribine) in the treatment of patients with chronic lymphocytic leukemia 55 years old and younger

The aim of the study was to determine the effectiveness of 2-chlorodeoxyadenosine (2-CdA) administered in 2-h i.v. infusions in the treatment of B cell chronic lymphocytic leukemia (B-CLL) in patients 55 years old and younger. One hundred and thirteen patients received three to 10 courses of 2-CdA administered at a dose of 0.12 mg/kg daily for 5 consecutive days. Sixty-seven patients were previously treated with chlorambucil and prednisone, COP and some of them also with CHOP, and 46 were untreated. Complete remission (CR) was achieved in 21 (18.6%) (19 in untreated and two in previously treated) patients and partial response (PR) in 38 (33.6%) (23 and 15, respectively) giving an overall response rate in 52.2%. The differences in CR and overall response rate between previously treated and untreated patients were statistically significant (P = 0.001). Surface immunophenotyping by flow cytometry using dual-color staining on the peripheral blood and/or bone marrow was performed in 38 patients who responded to 2-CdA therapy. Residual disease had been demonstrated in five out of 17 (29.4%) patients who were in CR and in all 21 investigated PR patients. 2-CdA-induced thrombocytopenia occurred in 24 (35.8%) of previously treated and in 13 (28.3%) previously untreated patients (P = NS). Neutropenia was observed in eight (11.9%) and in five (10.9%) patients, respectively (P = NS). Severe infections, including pneumonia and sepsis, occurred more often in previously treated (44.8%) than untreated patients (26.1%) (P < 0.05). Twenty-seven (23.9%) patients died, 11 because of infections, five because of drug-related thrombocytopenia and hemorrhage, one because of second malignancy and eight because of disease progression. In conclusion, our results indicate that 2-CdA is an effective agent in younger patients with B-CLL, especially used as a first line therapy.

[The causes of treatment ineffectiveness in acute myelogenous leukemia--the role of blast resistance to cytotoxic drugs]

Acute myelogenous leukemia (AML) represents 80% of adult acute leukemias. A standard-dose chemotherapy allows to obtain 52% to 72% of complete remission (CR). A major limitation for success in chemotherapy of AML is dominance of drug-resistant subpopulations of cells. Cytosine-arabinoside (Ara-C) is a basic drug in AML treatment. Myeloblasts resistance to Ara-C could be kinetic or pharmacological. The classical multidrug resistance (MDR) depends on presence in resistant myeloblasts ATP-dependent drug-efflux pump with ability to remove cytotoxic drugs from the cells. It is a product of MDR1 gene called P-glycoprotein (Pgp). Pgp is responsible for cell resistance to cytotoxic compounds of natural origin, such as anthracyclines, vinca alkaloids, epipodophyllotoxins, taxanes, colchicine and amsacrine. There were also identified not Pgp-dependent multidrug resistance mechanisms (non-Pgp MDR) in AML. All mentioned above drugs are involved but not taxol. Non-Pgp MDR depends on topoisomerase II alfa activity alterations, multidrug resistance-associated protein (MRP) expression and lung resistance-related protein (LRP) expression. Pgp positive AML patients have poorer complete remission (CR) rate, decreased remission duration and overall survival. Pgp expression is detected among 70% AML patients older than 55. The most promising drugs in circumventing classical MDR seems cyclosporin A (CsA) and cyclosporin D (SDZ PCS 833). They are successfully used in refractory and relapsed AML.

[Hairy cell leukemia--a potentially curable malignancy. Selected aspects of purine analog therapy]

Hairy-cell leukemia (HCL) is a lymphoproliferative B-cell malignancy--it represents about 2% of all adult leukemias. HCL is associated with pancytopenia and splenomegaly. In the late 1980s, introduction of new purine analogs such as 2-deoxycoformycin (pentostatin, DCF) and 2-chlorodeoxy-adenosine (2-CdA) significantly improved the prognosis of HCL patients. 33-89% patients can achieve a complete remission (CR) following DCF treatment and 85% CR after 2-CdA therapy. There is no cross-resistance between pentostatin and 2-CdA. Residual hairy cells are present in bone marrow of almost all patients after purine analogs therapy, detected by immunohistochemical methods. It is called minimal residual disease (MRD). The spleen may be the source of MRD after purine analogs therapy. Thus splenectomy could be a profitable approach after chemotherapy. Hairy-cell leukemia relapse appears in 47.8% of cases in 30 months after pentostatin treatment and in 23% of cases in 3 years after 2-CdA therapy. There is no perfect treatment of HCL relapse. Thanks to new purine analogs hairy-cell leukemia may be considered a potentially curable disease.