Independent contribution of bronchoalveolar lavage and serum galactomannan in the diagnosis of invasive pulmonary aspergillosis

The optimal combination of galactomannan index (GMI) testing for the diagnosis of invasive pulmonary aspergillosis (IPA) remains unclear. For diagnostic approaches that are triggered by clinical signs and symptoms in high-risk patients, institutional variation remains, with some centers routinely relying on only serum GMI or bronchoalveolar lavage (BAL) GMI testing. In addition, use of mold-active agents before diagnosis of IPA is becoming increasingly common, and understanding the effect of these drugs on test yield is important when making time-critical treatment decisions. In a single-center cohort of 210 allogeneic hematopoietic cell transplant recipients, we found that serum and BAL GMI testing contributed independently to IPA diagnosis, supporting the practice of sending both tests simultaneously to ensure a timely diagnosis of IPA. BAL GMI sensitivity was not affected by receipt of mold-active therapy in our cohort.

Melanoma as a subsequent neoplasm in adult survivors of childhood cancer: a report from the childhood cancer survivor study

BACKGROUND

Childhood cancer survivors have a sixfold increased risk of developing subsequent neoplasms when compared to the general population. We sought to describe the occurrence of melanoma as a subsequent neoplasm among adult survivors of childhood cancer.

PATIENTS AND METHODS

Among 14,358 5-year survivors of childhood cancer diagnosed between 1970 and 1986, we calculated the cumulative incidence, standardized incidence ratio (SIR), and absolute excess risk (AER) of subsequent melanoma. Potential risk factors were assessed using a cause-specific hazards model.

RESULTS

Fifty-seven melanomas (46 invasive, 2 ocular, and 9 in situ) occurred in 51 survivors. The median time to the development of melanoma was 21.0 years (range: 5.6-35.4 years) and the median age at melanoma was 32.3 years (range: 10.9-49.0 years). Initial cancer diagnoses included soft tissue and bone sarcoma (n = 15), leukemia (13), lymphoma (14), central nervous system malignancy (5), Wilms tumor (3), and neuroblastoma (1). The cumulative incidence of first subsequent melanoma at 35 years from initial cancer diagnosis was 0.55% [95% confidence interval (CI): 0.37-0.73]. The SIR of subsequent invasive malignant melanoma of the skin was 2.42 (95% CI: 1.77-3.23), and the AER was 0.10 (95% CI: 0.05-0.15) per 1,000 person-years. No statistically significant associations were found between melanoma risk and family history of cancer, demographic, or treatment-related factors.

CONCLUSION

Survivors of childhood cancer have an approximate 2.5-fold increased risk of melanoma. Early screening and prevention strategies are warranted.

Dynamic changes in fetal microchimerism in maternal peripheral blood mononuclear cells, CD4+ and CD8+ cells in normal pregnancy

OBJECTIVE

Cell trafficking during pregnancy results in persistence of small populations of fetal cells in the mother, known as fetal microchimerism (FMc). Changes in cell-free fetal DNA during gestation have been well described, however, less is known about dynamic changes in fetal immune cells in maternal blood. We have investigated FMc in maternal peripheral blood mononuclear cells (PBMC) longitudinally across gestation.

STUDY DESIGN

Thirty-five women with normal pregnancies were studied. FMc was identified in PBMC, CD4+ and CD8+ subsets employing quantitative PCR assays targeting fetal-specific genetic polymorphisms. FMc quantities were reported as fetal genome equivalents (gEq) per 1,000,000 gEq mother's cells. Poisson regression modeled the rate of FMc detection.

MAIN OUTCOME MEASURE

FMc in PBMC.

RESULTS

The probability of detecting one fetal cell equivalent increased 6.2-fold each trimester [Incidence Rate Ratio (IRR) 95% CI: 1.73, 21.91; p = 0.005]. Although FMc in PBMC was not detected for the majority of time points, 7 of 35 women had detectable FMc during pregnancy at one or more time points, with the majority of positive samples being from the third trimester. There was a suggestion of greater HLA-sharing in families where women had FMc in PBMC. FMc was detected in 9% of CD4+ (2/23) and 18% of CD8+ (3/25) subsets.

CONCLUSIONS

FMc in PBMC increased as gestation progressed and was found within CD4+ and CD8+ subsets in some women in the latter half of gestation. A number of factors could influence cellular FMc levels including sub-clinical fetal-maternal interface changes and events related to parturition. Whether FMc during pregnancy predicts persistent FMc and/or correlates with fetal-maternal HLA relationships also merits further study.

Relationship of maternal plasma leptin and risk of pre-eclampsia: a prospective study

OBJECTIVE

We measured maternal plasma leptin concentrations in 55 women with pre-eclampsia and 487 normotensive women to determine whether elevated leptin concentrations were associated with the occurrence of pre-eclampsia.

METHODS

Maternal blood samples were collected at 13 weeks' gestation, on average. Plasma leptin concentrations were determined using immunoassay. Logistic regression procedures were used to calculate odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

Leptin concentrations were 78% higher in cases than control subjects (median 34.6 vs. 19.5 ng/ml; p < 0.001). Relative to women with leptin concentrations of < 27.4 ng/ml, those with elevated leptin concentrations (> or = 27.4 ng/ml) experienced a 2.3-fold increased risk of pre-eclampsia (OR 2.3; 95% CI 1.1-4.6). We observed evidence of a strong linear component of trend in risk of pre-eclampsia with increasing maternal plasma leptin concentration. Each 10-ng/ml increase in leptin concentration was associated with a 30% increase in pre-eclampsia risk (OR 1.3; 95% CI 1.1-1.5). Overweight women with elevated leptin concentrations experienced the highest risk of pre-eclampsia (OR 6.4; 95% CI 3.1-13.2) as compared with lean women with no leptin elevations.

CONCLUSION

Elevated plasma leptin concentration and maternal overweight status appear to be independently associated with an increased risk of pre-eclampsia.

Prevalence and predictors of posttraumatic stress disorder in adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study

CRA10002

Background: This study examined prevalence and demographic- and disease-related correlates of posttraumatic stress disorder (PTSD) among 6,542 adult childhood cancer survivors and 368 siblings from the Childhood Cancer Survivor Study. Methods: Subjects were dichotomized based on full PTSD criteria, using the Foa PTSD self-report measure to assess posttraumatic stress symptoms of intrusion of unwanted memories, avoidance of event reminders, and increased startle response, and the Brief Symptom Inventory-18 and the SF-36 subscale, role limitation due to emotional health, to evaluate clinical distress or impaired function. A self-report questionnaire provided demographic information and medical abstraction provided cancer reatment data. Multivariable generalized linear models were used to compare prevalence of PTSD among cancer survivors to siblings and to examine relationships between PTSD and demographic and disease-related factors. Relative risks (RR) were calculated based on a Poisson distribution with robust error variances. Results: Five hundred eighty-nine (9%) childhood cancer survivors and 8 (2%) siblings met criteria for a diagnosis of PTSD (RR = 3.83, 95% CI 1.96–7.48, p < 0.0001). Among cancer survivors, there was significantly more PTSD reported by women from minority backgrounds (p < 0.05). Other demographic factors associated with PTSD were having less than a college education (p < 0.05), being unmarried (p < 0.001), having an annual income less than $20,000 (p < 0.05) and being unemployed (p = 0.001). Risk of PTSD was significantly higher for survivors diagnosed at ages 15 to 20 years (p < 0.05). PTSD was more common among survivors treated with intensive chemotherapy (p < 0.05) or radiation therapy (p < 0.001) and who relapsed or developed a second malignant neoplasm (p < 0.001). Neuroblastoma and Wilms tumor survivors had a significantly lower risk of PTSD than did leukemia survivors (p < 0.05). Conclusions: While the majority of childhood cancer survivors did not demonstrate PTSD, a clinically significant number did meet diagnostic criteria. Prospective assessment of survivors with high risk demographic-, diagnosis-, and treatment-related characteristics should be considered as part of long-term health screening.

No significant financial relationships to disclose.

Prevalence and predictors of posttraumatic stress disorder in adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study

CRA10002

The full, final text of this abstract will be available in Part II of the 2009 ASCO Annual Meeting Proceedings, distributed onsite at the Meeting on May 30, 2009, and as a supplement to the June 20, 2009, issue of the Journal of Clinical Oncology.

No significant financial relationships to disclose.

Adolescent psychopathology and adult health behaviors in long-term survivors of childhood cancer: Findings from the Childhood Cancer Survivors Study

10027

Background: Psychological problems have been identified as important risk factors for poor health behavior in a variety of noncancer populations. We report the association between adolescent psychopathology and future health behaviors in adult survivors of childhood cancer. Methods: Study participants included 1,656 survivors of childhood cancer (50.8% female); 12 - 17 years old and ≥ 5 years post diagnosis at baseline assessment and 18 - 27 years of age at study follow-up. Parents provided medication information and ratings of psychopathology for adolescents at baseline, including symptoms of depression/anxiety, social withdrawal, inattention, and oppositional and antisocial behavior. Survivor self-report of health behavior was collected 6 - 10 years post baseline. Odds ratios (OR) were calculated comparing those with psychopathology to those without on outcomes of obesity, physical activity, smoking, and sunscreen use. Estimates were adjusted for cancer diagnosis, cancer therapy, sex, age, and history of special education. Results: Adult obesity was associated with adolescent social withdrawal (OR 1.5, 95% CI 1.1–2.1) and adolescent use of stimulant medications (OR 1.9, 95% CI 1.1–3.2). Physical inactivity among adults was also associated with adolescent social withdrawal (OR 1.7, 95% CI 1.1–2.5) and to antidepressant use during adolescence (OR 3.2, 95% CI 1.2–8.2). These impacts on obesity and inactivity were above and beyond the risk associated with high body mass index at baseline. Stimulant medication use was associated with decreased likelihood of poor sunscreen use as an adult (OR 0.4, 95% CI 0.2–0.8). Adult smoking was associated with adolescent antisocial behavior (OR 2.6, 95% CI 1.6–4.2). Conclusions: These results suggest that psychological problems in adolescence predict future health behavior in adult survivors of childhood cancer. Furthermore, psychopharmacologic therapy for such problems may increase risk for certain conditions, and decrease risk for others. Increased psychological screening and medication monitoring is warranted to reduce overall risk of poor outcomes.

No significant financial relationships to disclose.

Prolonged anorexia and elevated plasma cytokine levels following myeloablative allogeneic hematopoietic cell transplant

Myeloablative conditioning regimens commonly lead to prolonged anorexia and poor oral intake. In a prospective study of 147 patients receiving CY, total body irradiation and allogeneic hematopoietic cells, we determined the extent of decline in oral intake and assessed plasma cytokine levels and development of acute GVHD as explanations for protracted anorexia. For each patient, daily oral caloric intake was expressed as a percent of estimated basal requirements, calculated as basal energy expenditure, through day 20. Oral caloric intake was significantly reduced in 92% of patients and remained low. The nadir in oral intake occurred at days 10-12, when median oral caloric intake was 3% of basal energy requirements. Plasma cytokines known to affect appetite (IL2, IL6, tumor necrosis factor-alpha) were significantly elevated above normal following conditioning therapy (P<0.001 for each cytokine). Acute GVHD did not appear to affect oral intake to transplant day 20 in this cohort of patients; however, plasma levels of IL6 rose steeply before the clinical onset of GVHD. Persistent fever occurred with the greatest frequency in patients with most profound reduction in oral intake. We conclude that prolonged alterations in oral intake following this myeloablative regimen may be related to circulating cytokines known to alter eating behavior.

Intensive postgrafting immune suppression combined with nonmyeloablative conditioning for transplantation of HLA-identical hematopoietic cell grafts: results of a pilot study for treatment of primary immunodeficiency disorders

This study was designed to determine the safety of a nonmyeloablative regimen in patients with primary immunodeficiency disorders (PID) who had infections, organ dysfunction or other risk factors that precluded conventional hematopoietic cell (HC) transplant. Fourteen patients received HLA-matched related (n=6) or unrelated (n=8) HC grafts from marrow (n=8), peripheral blood mononuclear cells (n=5) or umbilical cord blood (n=1), either without conditioning (n=1), or after 200 cGy total body irradiation alone (n=3) or with 90 mg/m2 fludarabine (n=10). All patients were given postgrafting immunosuppression with mycophenolate mofetil and cyclosporine. Mixed (n=5) or full (n=8) donor chimerism was established in 13 patients, and one patient rejected the graft. Eight patients developed acute grade III (n=1) and/or extensive chronic GVHD (n=8). With a median follow-up of 4.9 (range, 0.7-8.1) years, the 3-year overall survival, event-free survival and transplant-related mortality were 62, 62 and 23%, respectively. Correction of immune dysfunction was documented in 8 of 10 patients with stable donor engraftment. These preliminary results indicated that this approach was associated with stable donor engraftment and a low incidence of early mortality and, thus, can be considered for certain high-risk patients with PID. However, there was a risk of GVHD, which is an undesirable outcome for this group of patients.

Fecundity of males after treatment for childhood cancer. A report from the Childhood Cancer Survivor Study (CCSS)

9516

Background: Determine the proportion of male (M) survivors with impaired fecundity (IF). Methods: 6,555 CCSS M participants and 1,606 M siblings (S) were classified as surgically sterile (SS) for contraceptive purpose, SS for non-contraceptive purpose, IF (ongoing attempts to become pregnant for a period of one year without success or use of medication to help achieve a pregnancy), or fecund (F). Odds ratios (OR) were estimated using logistic regression, controlling for education level, marital status, age at baseline questionnaire, race/ethnicity and smoking status. Results: M were 6–29 years from cancer diagnosis (mean-16.3 years) and 15–44 years of age at the time of study (mean-25.4 years). 331 (5.0%) M or their partners were SS, 487 (7.4%) had IF and 5,737 (87.5%) were F. The OR (95% confidence interval (CI)) for being F was 0.66 (95% CI, 0.54–0.80) (p<0.0001) compared to F MS. Among M, the OR for IF was 2.60 (95% CI, 1.97–3.42) (p<0.0001) compared to F MS. The OR for IF was increased among those with a testicular (T) radiation dose (RD) of 0.1–499 cGy (OR=1.42; 95% CI 1.07–1.89; p=0.015), 500–599 cGy (OR=3.16; 95% CI 1.48–6.72; p=0.0028), 600–1,499 cGy (OR=2.53; 95% CI 1.26–5.09; p=0.009) and ≥ 2,400 cGy (OR=3.04; 95% CI 1.39–6.64; p=0.0054), pituitary (P) RD of 0.1–499 cGy (OR=1.89; 95% CI 1.41–2.55; p<0.0001), CCNU (OR=2.14; 95% CI 1.25–3.66; p=0.0054), cyclophosphamide (OR=1.56;95% CI 1.23–1.97; p=0.0002), nitrogen mustard (OR=2.88;95% CI 2.08- 4.00; p<0.0001), procarbazine (OR=2.97; 95% CI 2.24–3.93; p<0.0001), vinblastine (OR=2.07;95% CI 1.41–3.04; p=0.00022), vincristine (OR=1.90; 95% CI 1.45–2.49; p<0.0001) and melphalan (OR=2.43; 95% CI 1.09–5.43; p=0.03). The OR for IF increased with increasing alkylating agent score (AAS) (1st tertile OR=1.70; 95% CI 1.19–2.43; p=0.0035; 2nd tertile OR=2.63; 95% CI 1.82–3.81; p<0.0001; 3rd tertile OR=3.42; 95% CI 2.41–4.86; p<0.0001). Multivariate analysis demonstrated that the combination of P ≥ 500 cGy and T ≥ 500 cGy (OR= 2.65; 95% CI 1.44–4.86; p=0.0017) and increasing AAS (1st tertile OR=1.56; 95% CI 1.04–2.34; p=0.031; 2nd tertile OR= 2.22; 95% CI 1.43–3.44; p=0.00036; 3rd tertile OR=2.72;95% CI 1.74–4.25; p<0.0001) were associated with IF. Conclusions: M have IF due in part to TRD and PRD and increasing AAS.

No significant financial relationships to disclose.

Dental health of long-term survivors of childhood cancer: The childhood cancer survivor study (CCSS)

9017

Background: This study describes the frequencies of and risk factors for altered oral health and dental development in pediatric patients who have survived childhood cancer. Methods: We identified 8,522 participants and 2,831 siblings in the CCSS with information on dental health. Dental outcomes of treatment and socioeconomic-demographic (SED) data, were analyzed using univariate and multivariate logistic regression models to estimate odds ratios (OR). Results: Survivors included 4,249 females (49.9%), 7,367 white non-Hispanic (86.5%). Median age at cancer diagnosis, 6.8y (range, 0–20 y); time from diagnosis to interview, 31.4 y (range, 17–54 y). Overall, 30% of survivors self-reported ≥ 1 oral-dental abnormality: microdontia (10%), hypodontia (8%), > 5 caries (55%), root stunting (6%), enamel hypoplasia (13%), gingivitis (7%). Compared to siblings, survivors were at increased risk of ≥ 1 oral-dental abnormalities when adjusted for SED (OR = 2.0, p<0.001). Increased risk of abnormalities was associated with being female (p<0.001) or white non-Hispanic (p=0.001), having an income < $20K (p=0.001) or lower education (p=0.004), and lack of health insurance (p=0.02). Patients with central nervous system tumors, neuroblastoma and soft tissue sarcoma had highest risk of abnormality (all P-values < 0.001). In multivariate models adjusted for SED, radiation dose to jaw, and exposure to increasing doses of alkylating agents increased risk of oral-dental abnormalities (radiation dose = 20 Gy OR = 5.6, p < 0.001; alkylating agent score OR=1.6, p<0.0001). Conclusions: Childhood cancer therapy results in adverse long- term oral-dental sequelae and is associated with specific treatment factors.

No significant financial relationships to disclose.

Late recurrence in survivors of childhood and adolescent cancer: A report from the Childhood Cancer Survivor Study (CCSS)

9534

Background: An increasing percentage of childhood cancer patients are surviving their disease, but limited research suggests that late recurrences may impact overall survival. The goal of this study is to estimate late recurrence rates for the most common pediatric cancers and to determine additional risk factors for late recurrence. Methods: CCSS is a retrospective cohort study of five-year survivors of childhood cancer diagnosed before 21 years of age, between 1970 and 1986 at one of 26 consortium centers. Late recurrence was defined as first recurrence occurring > five years post-diagnosis. Recurrences were determined by self-report questionnaire or by confirmation through medical record, death certificate or pathologic review. Probability of late recurrence was calculated using cumulative incidence. Adjusted hazard ratios (HR) were obtained using Cox proportional hazards regression. Results: In 12,948 survivors with no recurrence = five years from diagnosis, 670 (5.2%) subjects had a first recurrence > five years after their primary diagnosis. Late recurrences ranged from 5 to 28.9 years from diagnosis (median 7.9 years). Cumulative incidence varied by diagnosis ( table ). In multivariate analysis, significant risk factors for increased late recurrence included a primary diagnosis of Ewing's sarcoma or CNS tumors (HR of 2.3 and 2.7 respectively vs. leukemia survivors), age = 10 years at diagnosis (HR 1.4 vs. age < 10 years), chemotherapy exposure (HR 1.5 vs. none), and radiation exposure (HR 1.4 vs. none) (p < 0.001 for all). At the time of last follow-up, 51.6% of subjects with a late recurrence had died versus 6.4% of those with no history of recurrence. Conclusions: Late recurrences occur in survivors of childhood cancers with a significant risk of mortality. This emphasizes the importance of long-term survivor follow-up into adulthood, particularly for adolescents and patients with Ewing's sarcoma and CNS tumors.

[Table: see text]

No significant financial relationships to disclose.

Polymorphisms in candidate genes in patients with congestive heart failure (CHF) after childhood cancer: A Report from the Childhood Cancer Survivor Study (CCSS)

9004

Background: In cancer survivors, CHF associated with the use of anthracyclines is an important clinical complication. Risk factors for anthracycline associated cardiac toxicity, including cumulative dose, gender, and age, have been described. However, these risk factors do not fully explain the observed clinical variability. Notably, the potential role of genetic risk factors has not been studied. A recent “unifying hypothesis” postulates that the early cardiac damage is mediated mostly by oxidative stress while the more chronic type of toxicity is induced by anthracycline alcohol metabolites synthesized by carbonyl reductases (CBRs). Therefore we hypothesized that genetic polymorphisms in genes encoding for enzymes involved in oxidative stress pathways, and the metabolism of anthracyclines may impact on the risk of anthracycline-related cardiotoxicity. Methods: We conducted a nested case-control study within a cohort of 5,739 patients enrolled in the CCSS. Forty-seven cases with CHF and 195 matched controls (matched for demographics, follow-up and treatment) were genotyped for 10 genetic polymorphisms in 7 genes: catalase (CAT), GSTP, GSTT, GSTM, superoxide dismutase (SOD 1), NQO1, and CBR3. Results: In the subjects who received anthracyclines, multivariable analyses of CHF risk, adjusted for gender, smoking history, recurrence, and family history of heart disease, showed the GSTP +313A>G polymorphism was a significant risk factor, HR = 5.0, p = 0.01 for the A/G genotype vs. A/A; HR = 3.3, p = 0.19 for the G/G genotype vs. A/A. In addition, a suggested association between CBR3 V244M polymorphism and the risk of CHF after treatment with anthracyclines, HR=10.2, p=0.06 for G/G vs. A/A; HR = 4.0, p=0.18 for G/A vs. A/A was seen in an identical multivariable analysis. Conclusions: These data suggest that specific polymorphic genetic variants on a panel of candidate genes relevant to the anthracycline pharmacodynamics may modify the risk of CHF in childhood cancer survivors. Future studies to further refine the role of these novel genetic risk factors affecting a large population are warranted.

No significant financial relationships to disclose.

Low-dose cyclophosphamide conditioning for haematopoietic cell transplantation from HLA-matched related donors in patients with Fanconi anaemia

Allogeneic haematopoietic cell transplantation (HCT) is effective therapy for Fanconi anaemia (FA). FA patients do not tolerate conditioning with 200 mg/kg of cyclophosphamide (Cy), typically used in aplastic anaemia. We previously published results of studies in which Cy doses were gradually reduced from 200 to 100 mg/kg. Here we update results of the initial studies and report data on 30 new patients conditioned with Cy either at 80 mg/kg (n = 7) or at 60 mg/kg (n = 23), given over 4 days before HCT from human leucocyte antigen-matched related donors. Methotrexate and cyclosporine were given for graft-versus-host disease (GVHD) prophylaxis. All seven patients given Cy at 80 mg/kg and 21 of 23 given Cy at 60 mg/kg had sustained engraftment, while two patients, both with clonal cytogenetics abnormalities, experienced graft failure. Grades 2-3 acute GVHD rates were 57% and 14% for patients given the higher and lower Cy doses, respectively (P = 0.001). Four patients given Cy at 80 mg/kg and 22 given Cy at 60 mg/kg were alive at a median of 47 (44-58) months and 16 (3-52) months, respectively. Cy at 60 mg/kg has acceptable toxicities, low rates of GVHD, and is sufficient for engraftment of related grafts in most FA patients.

Expression of FLIP(Long) and FLIP(Short) in bone marrow mononuclear and CD34+ cells in patients with myelodysplastic syndrome: correlation with apoptosis

Several apoptosis-inducing systems, including Fas/Fas ligand and TNF-related apoptosis-inducing ligand (TRAIL) and its receptors, are upregulated in myelodysplastic syndrome (MDS). FLIP (FLICE (FAS-associated death-domain-like IL-1beta-converting enzyme)-inhibitory protein)) was identified as an inhibitor of FAS and TRAIL signals. Here, we characterized FLIP(Long) (FLIP(L)) and FLIP(Short) (FLIP(S)) expression in bone marrow mononuclear cells (BMMNCs) and in CD34+ cells of 29 MDS patients, and in 17 normal volunteers. The expression was correlated with apoptotic indices. In CD34+ cells, FLIP(L) levels were higher among normal individuals than in MDS patients (P=0.04). Among total BMMNC, FLIP(L) levels also tended to be higher in normal subjects than in MDS patients, although this difference was not significant (P=0.71). FLIP(L) levels in CD34+ cells were negatively correlated with apoptosis in both normal and MDS marrows (P=0.03). FLIP(Short) RNA expression was higher in MDS patients than in normal controls in both BMMNC (P=0.03) and CD34+ cells (P=0.08). In contrast to FLIP(L), FLIP(St) levels were positively correlated with apoptosis. At the protein level FLIP was most readily detectable in patients with high blast counts. The data suggest that FLIP(L) and FLIP(S) are differentially regulated, and that the relative levels of both isoforms play a role in the regulation of apoptosis in MDS.

Stable mixed hematopoietic chimerism after bone marrow transplantation for sickle cell anemia

A multicenter investigation of allogeneic bone marrow transplantation for children with sickle cell disease was conducted that included 27 European and North American transplant centers. Fifty-nine patients who ranged in age from 3.3 to 15.9 years (median, 10.1 years) received HLA-identical sibling marrow allografts between September 1991 and April 2000. Fifty-five patients survive, and 50 survive free from sickle cell disease, with a median follow-up of 42.2 months (range, 11.8 to 115 months) after transplantation. Of the 50 patients with successful allografts, 13 developed stable mixed donor-host hematopoietic chimerism. The level of donor chimerism, measured > or =6 months after transplantation in peripheral blood, varied between 90% and 99% in 8 patients. Five additional patients had a lower proportion of donor cells (range, 11% to 74%). Among these 5 patients, hemoglobin levels varied between 11.2 and 14.2 g/dL (median, 11.3 g/dL; mean, 12.0 g/dL). In patients who had donors with a normal hemoglobin genotype (Hb), the Hb S fractions were 0%, 0%, and 7%, corresponding to donor chimerism levels of 67%, 74%, and 11%, respectively. Among patients who had donors with sickle trait, the Hb S fractions were 36% and 37%, corresponding to donor chimerism levels of 25% and 60%, respectively. Thus, allograft recipients with stable mixed chimerism had Rb S levels similar to donor levels, and only 1 patient required a red blood cell transfusion beyond 90 days posttransplantation. None of the patients have experienced painful events or other clinical complications related to sickle cell disease after transplantation. These observations strongly suggest that patients with sickle cell disease who develop persistent mixed hematopoietic chimerism after transplantation experience a significant ameliorative effect.

Comparison of multidimensional flow cytometry with standard morphology for evaluation of early marrow response in pediatric acute lymphoblastic leukemia

PURPOSE

We compared multidimensional flow cytometry (MDF) with morphology in evaluating early marrow response to induction chemotherapy in pediatric ALL.

METHODS

Chemotherapy response was determined by standard morphology or by MDF assessed by residual leukemic cell percentage remaining in the marrow on days 7, 14, and 28 of induction. Bone marrow response was classified as M3 (>25% leukemic blasts) or M1/M2 (< or = 25% leukemic blasts). Multidimensional flow cytometry evaluation was compared with that of standard morphology. Available day-7 and day-14 marrow slides were also reevaluated by a single pathologist without patients' clinical information.

RESULTS

Of 46 day-7 specimens, eight (17%) had discordant MDF and morphologic results (P < 0.001), including six classified as M3 by morphology but were M1/M2 by MDF, and two were classified as M3 by MDF but were M1/M2 by morphology. Of 24 day-14 bone marrow specimens, five (20.5%) were discordant (P < 0.001), including two classified as M3 by morphology but were M1/M2 by MDF, and three were classified as M3 by MDF but were M1/M2 by morphology. Reevaluation of the blinded day-7 and day-14 marrow slides yielded discordance between repeated pathology readings of 11% (P < 0.001) and 6% (P = 0.04), respectively.

CONCLUSION

Our data show significant discordance between the morphologic and MDF evaluation of early marrow response. Early response to therapy is a significant prognostic indicator in pediatric acute lymphoblastic leukemia and is used to alter subsequent treatment; thus, precise assessment of response is important. A larger comparison of MDF with morphology for the evaluation of early response, including correlation with clinical outcome, is warranted.

Absence of major histocompatibility class II expression does not impair hematopoiesis in mice

OBJECTIVE

Major histocompatibility class II (MHC II) molecules are among the earliest antigens to be expressed in hematopoietic progenitor cells; however, the functional role of these molecules in hematopoiesis remains controversial. We examined the role of MHC II antigens during hematopoiesis using a mouse model of MHC II deficiency related to the absence of the critical transcriptional activator, CIITA.

METHODS

Sca-1(-), Sca-1(+)lin(+), and Sca-1(+)lin(-) populations of marrow cells from CIITA(-)(/-) and wild-type mice were analyzed by immunofluorescence for MHC II expression. Hematopoietic capacity was assessed in CIITA(-/-) and wild-type mice by CFU-S, CFU-GM, and radiation sensitivity assays.

RESULTS

Flow cytometric characteristics of hematopoietic progenitors from CIITA(-/-) and wild-type mice were identical except for the absence of MHC II expression in CIITA null mice. There were no significant differences in capacity for hematopoietic reconstitution and clonogenicity as measured by radiation sensitivity, CFU-S, and CFU-GM assays among CIITA(-/-) and wild-type mice.

CONCLUSIONS

These experiments show that downregulation of MHC II gene transcription does not effectively alter normal hematopoiesis, and provide strong evidence that MHC II expression on hematopoietic progenitors is not required for normal hematopoietic development.

Cyclophosphamide and antithymocyte globulin to condition patients with aplastic anemia for allogeneic marrow transplantations: the experience in four centers

This report summarizes the experience with a conditioning regimen of cyclophosphamide and antithymocyte globulin in patients with severe aplastic anemia given HLA-matched related marrow grafts at 4 transplantation centers. Enrolled were 94 consecutive patients, of whom 87 had received multiple transfusions and 38 had failed immunosuppressive therapy. Their ages ranged from 2 to 59 years. After transplantation, 89 patients received a methotrexate/cyclosporine regimen for graft-versus-host disease (GVHD) prevention. Cyclosporine with or without prednisone was given in 4 patients, and no immunosuppression was given in 1 patient. Ninety-six percent of patients had sustained grafts, whereas 4% rejected grafts between 2 and 7 months after transplantation. Of the 4 rejecting patients, 3 are alive with successful second engraftments. Acute grade II GVHD was seen in 21% of patients, grade III in 7%, and grade IV in 1% of patients. Chronic GVHD was seen in 32% of patients, most of whom responded completely to immunosuppressive therapy. With a median follow-up of 6.0 years (range, 0.5-11.6 years), the survival rate was 88%. No unusual long-term side effects have been seen with the regimen. We conclude that the cyclophosphamide/antithymocyte globulin regimen combined with methotrexate/cyclosporine after transplantation is well tolerated and effective in heavily pretreated patients with aplastic anemia.

A proposed objective way to assess results of randomized prospective clinical trials with acute graft-versus-host disease as an outcome of interest

The assessment of graft-versus-host disease (GVHD) as an end-point in clinical trials requires subjective judgement to distinguish morbidity caused by GVHD from morbidity caused by other complications. We developed a method based on ordinal regression for longitudinal assessment of morbidity involving the skin, liver and gut, regardless of cause as an objective end-point in randomized prospective phase III treatment or prevention trials for which GVHD is an outcome of interest. This method was validated for treatment studies by showing that morbidity was more severe among patients with grade II-IV GVHD than among those who did not have GVHD. We found no differences in morbidity involving the skin, liver and gut after the diagnosis of GVHD in a group of 30 patients who received peripheral blood stem cells and a group of 37 who received marrow in a randomized phase III clinical trial. These preliminary results suggest that objective end-points could be used in randomized clinical trials for treatment of GVHD. Further studies will be needed to determine if similar methods could be used in randomized clinical trials for prevention of GVHD.