Acute cerebral infarct with elevated factor VIII level during the thrombocytopenic stage after hematopoietic stem cell transplant

Thromboembolism is a complication of hematopoietic stem cell transplant. However, a literature search showed no previous reports of cerebral infarction during the thrombocytopenic stage after hematopoietic stem cell transplant. A 35-year-old woman with acute lymphoblastic leukemia (precursor B-cell type) was treated with hematopoietic stem cell transplant after induction and consolidation chemotherapy. On day 2 after transplant, she was unconscious, and had urinary incontinence and left hemiplegia. A computed tomography scan of the brain showed an acute ischemic infarct in the right middle cerebral artery region and an old infarct at the left thalamus without atherosclerosis. Factor VIII level was elevated (190%; normal range, 60% to 150%). She was treated with rehabilitation and low-dose aspirin. At 6 months after transplant, the leukemia remained in remission and she had no further thromboembolic events. This case suggests that prudent treatment of patients who have hematopoietic stem cell transplant may include monitoring for thromboembolism and testing factor VIII level before transplant.

Primary cutaneous precursor B-cell lymphoblastic lymphoma with late dissemination

A 20-year-old woman presented with multiple painless nodular swellings on the skin of the extremities and face, without any systemic symptoms. Biopsy with immunohistochemistry revealed a diagnosis of precursor B-cell lymphoblastic lymphoma. There was no extracutaneous site of involvement. The patient denied chemotherapy and was subsequently lost to follow-up. She presented with symptomatic disseminated disease 18 months later and rapidly succumbed to her illness.

[26 year-old male patient with bone marrow transplantation. Report of a partial autopsy]

26 year-old male patient with diagnosis of acute lymphoblastic leukemia in 2006, who underwent chemotherapy and suffered a relapse and pulmonary aspergillosis as a complication. In 2009, he received bone marrow transplant. After it, he developed cutaneous and intestinal graft versus host disease (GVH). He was admitted for diarrhea. Then he presented grade IV dyspnea, patchy alveolar infiltrates on chest computed tomography and pancytopenia with impaired renal function as laboratory findings. He entered Intensive Care Unit, dying 7 days later. The oncologist who discussed the case defined this patient as a high risk case because of type of transplant received, relapse and complications. His diagnostic hypotheses were: CMV infection, pulmonary aspergillosis reactivation, chronic GVH, Pneumocystis jiroveci infection, mycobacteriosis and pseudomembranous colitis. Partial autopsy revealed diffuse intra-alveolar hemorrhage, diffuse alveolar damage, right pulmonary infarction with microthrombosis and bronchiolitis obliterans organizing pneumonia.

The use of higher dose clofarabine in adults with relapsed acute lymphoblastic leukemia

The standard dose of clofarabine is 52 mg/m2 for pediatrics and 40 mg/m2 in adults. Clofarabine dosed at 52 mg/m2 was used in adult patients with refractory ALL to maximize response before allo-HSCT. All patients had a significant response to therapy. Published pharmacokinetic analysis revealed no difference in peak plasma or intracellular concentrations at clofarabine dosed above 40 mg/m2, yet inhibition of replication in leukemia cells was only sustained over 24 hr at 55 mg/m2. Despite this, there have been no reports of high dose clofarabine used in this setting. Our experience implies that there may be a niche role for clofarabine in reducing disease burden before allo-HSCT for adults with relapsed ALL.

Clearance of minimal residual disease after allogeneic stem cell transplantation and the prediction of the clinical outcome of adult patients with high-risk acute lymphoblastic leukemia

BACKGROUND AND OBJECTIVES

The molecular analysis of minimal residual disease (MRD) may provide information on the risk of recurrence in patients with acute lymphoblastic leukemia (ALL). The aim of this study was to correlate the kinetics of MRD clearance after allogeneic transplantation with the clinical outcome of adults with ALL.

DESIGN AND METHODS

MRD was evaluated by real-time quantitative polymerase chain reaction (RQ-PCR) using probes derived from fusion chimeric genes (BCR/ABL and MLL/AF4) (n=22) or rearrangements of the T-cell receptor or immunoglobulin genes (n=21). Forty-three adult patients with ALL were studied to correlate the kinetics of MRD clearance before and after allogeneic hematopoietic stem cell transplantation.

RESULTS

At 36 months, the overall survival of patients who underwent transplantation in hematologic remission (n= 37) was 80% for those who were PCR-negative before transplantation (n= 12) compared to 49% for PCR-positive patients (n= 25)(p=0.17). For the same patients the cumulative incidence of relapse was 0% and 46%, respectively (p=0.027). Moreover, the relapse rate of patients who were PCR-negative at day +100 after transplantation was remarkably low (7%) compared to that among patients who were PCR-positive (80%, p=0.0006).

INTERPRETATION AND CONCLUSIONS

The kinetics of MRD clearance may help to identify patients at high risk of leukemia relapse after allogeneic stem cell transplantation. Patients not achieving an early molecular remission after transplantation require prompt and appropriate pre-emptive treatments such as infusions of donor lymphocytes or new experimental drugs.

Two consecutive immunophenotypic switches in a child with MLL-rearranged acute lymphoblastic leukemia

An 18-month-old girl was diagnosed with pre-pre-B ALL/t(4;11) leukemia, which during the treatment and after matched bone marrow transplantation (BMT), underwent two consecutive switches from lymphoid to myeloid lineage and vice versa. The high expression of HOXA9 and FLT3 genes remaining genotypically stable in a leukemia throughout phenotypic switches, suggests that this leukemia may have originated as a common B/myeloid progenitors.

Three cases of renal relapse after allogeneic hematopoietic stem cell transplantation for childhood acute lymphoblastic leukemia

Isolated renal relapse after allogeneic hematopoietic stem cell transplantation (alloHSCT) in children with acute lymphoblastic leukemia (ALL) is a rare condition. Generally, in ALL, the sites most frequently affected by extramedullary relapse are the central nervous system (CNS) and the testicles. Here we report on three young boys with relapsed B-precursor ALL, who underwent alloHSCT from HLA-identical siblings and suffered a histopathologically proven isolated unilateral renal relapse (two patients) or a combined renal and testicular relapse (one patient) 6, 10 and 12 months post alloHSCT. In all patients at the time of relapse bone marrow showed complete remission with complete donor hematopoiesis. They all received total body irradiation with partial shielding of the kidneys as part of their conditioning therapy, such that renal shielding could be an explanation for the observed accumulation of renal relapses. Moreover, during the past few years so called immune privilege has been postulated for frequent relapse sites such as the CNS, the testicles and the anterior chamber of the eye. Impaired accessability of these organs by cytotoxic T-cells (CTLs) with a reduced graft-versus-leukemia (GvL) effect after alloHSCT is based on a number of different molecular and cellular mechanisms. Similar mechanisms have been shown to be effective in the tubulointerstitial space of the kidney, rendering the kidney a potentially immune privileged site. Due to these observations we advocate sufficient treatment of the kidneys during conditioning therapy.

Amsacrine combined with etoposide and high-dose methylprednisolone as salvage therapy in acute lymphoblastic leukemia in children

In a retrospective analysis of 24 children with refractory or multiply relapsed acute lymphoblastic leukemia (ALL), a salvage regimen comprising amsacrine, etoposide, and high-dose methylprednisolone AEP achieved a significant treatment response in 11 of 19 evaluable patients (8 complete and 3 partial remissions). Five of 9 AEP-responsive patients who underwent subsequent stem cell transplantation are alive (median follow-up: 43 months; range 10 to 91). The load of minimal residual disease prior to transplantation appears to be predictive for outcome in this very poor-prognosis subgroup of ALL.

Membranous glomerulopathy in children given allogeneic hematopoietic stem cell transplantation

Graft-versus-host disease (GVHD) is a common complication of allogeneic hematopoietic stem cell transplantation (HSCT), but membranous glomerulopathy (MG) has rarely been described as a manifestation of chronic GVHD. We report two cases of MG in children who underwent allogeneic HSCT. The clinical findings were characterized by edema of the lower extremities and nephrotic proteinuria in one case and hypertension, hematuria and edema with non-nephrotic proteinuria in the other one. Renal biopsy was consistent with MG and appropriate immunosuppressive therapy was prescribed. Both patients achieved complete remission and are alive without renal disease 4 and 2 years after the diagnosis of MG. The normal levels of albumin and non-nephrotic proteinuria in one of the two cases raise the question of whether the real incidence of MG after HSCT is underestimated. Therefore, we strongly suggest regular urine analysis during the follow-up of children undergoing HSCT in order to diagnose MG early.

Human leucocyte antigen-Cw-specific cytotoxic T lymphocytes generated from naive cord blood used for cord blood stem cell transplantation

Human leucocyte antigen (HLA)-Cw-reactive cytotoxic T lymphocytes (CTL) were generated from cord blood (CB) lymphocytes of two cases used for cord blood stem cell transplantation (CBSCT). In both cases, the CTL were cytotoxic against the patient's leukaemic cells, as well as the patient's Epstein-Barr virus (EBV)-lymphoblastoid cell line (EBV-LCL) and phytohaemagglutinin blasts, and the cytotoxicity was blocked by anti-HLA-class I monoclonal antibodies. In the first case, the CTL recognized Cw 3 (Cw 9 and Cw 10)-positive EBV-LCL, while in the second case, the CTL recognized Cw1 and/or Cw7. These cases suggest that CB T cells may be competent enough for generating CTL to induce a graft-versus-leukaemia effect and/or graft-versus-host disease in patients with CBSCT and that the mismatching of Cw antigens between patient and CB may be related to the outcome of CBSCT.

Autologous BMT in high risk patients with CALLA-positive ALL: possible efficacy of ex vivo marrow leukemia cell purging with monoclonal antibodies and complement

Autologous BMT (auto-BMT) has been conducted for 17 high-risk common ALL antigen (CALLA)-positive non-T cell type ALL patients. Ex vivo purging of leukemia cells from infused BM cells was performed using complement and three kinds of mouse monoclonal antibodies reactive to CALLA-positive leukemia cells: NL-1 (IgG2a), NL-22 (IgM), and HL-47 (IgM). Minimal residual leukemia cells in BM were examined by PCR method in Philadelphia chromosome (Ph1)-positive ALL cases. BCR/ABL chimeric transcript, which was positive in BM samples before purging, was shown to be absent after ex vivo purging in all three cases tested. Among four Ph1-positive cases transplanted in first CR, three cases survived in CR remission 77, 29 and 26 months after BMT, and one case died without relapse 4 months after BMT. The other four Ph1-negative cases transplanted in the first CR also remained in CR except one who relapsed. The results of minimal residual leukemia cell studies and clinical data indicate the effectiveness of our ex vivo leukemia cell purging method and auto-BMT in the early stage of CR for patients with high risk ALL.

Polymerase chain reaction: a method for monitoring tumor cell purge by long-term culture in BCR/ABL positive acute lymphoblastic leukemia

We report the successful purging of leukemia cells bearing the Philadelphia chromosome and BCR/ABL transcripts by long-term marrow culture (LTC), and subsequent grafting of the purged marrow in a case of refractory acute lymphoblastic leukemia. The efficiency of the purge was evaluated by polymerase chain reaction (PCR) for BCR/ABL transcripts. In two LTCs initiated in the blastic stage, we demonstrated the selective effect of three culture media (serum dependent, serum-free (SF) supplemented or not with IL3 and GM-CSF) on the proliferative potential of normal hematopoietic (CFU-GM/BFU-E) and leukemic progenitors (CFU-ALL). BCR/ABL positive cells disappeared after 3 to 4 weeks of culture. The addition of IL3 and GM-CSF to the SF medium enhanced the growth of CFU-GM/BFU-E and shortened the purging period. We therefore carried out a LTC in the presence of IL3 and GM-CSF with marrow harvested in morphological remission. BCR/ABL positivity was detected at the outset, although no leukemia cells could be identified. The BCR/ABL was no longer found by PCR in the 7 and 14 day LTCs. The patient, consolidated by high dose polychemotherapy and total body irradiation, was infused with the 14 day LTC. This study indicates that PCR is a useful and sensitive technique for monitoring tumor cell reduction after LTC prior to autografting.

Effect of mafosfamide (ASTA-Z-7654) on the clonogenic cells in precursor-B acute lymphoblastic leukaemia: significance for ex vivo purging of bone marrow for autologous transplantation

Lymphoblasts from 11 patients with acute lymphoblastic leukaemia (ALL) of precursor-B type were exposed to the cyclophosphamide derivative mafosfamide (ASTA-Z-7654), and examined for growth inhibition using an in vitro colony assay. Leukaemic clonogenic cells were significantly more resistant to this cytotoxic drug (mean IC50 29.2 micrograms/ml, IC90 64.8 micrograms/ml) compared with myeloid progenitors from seven normal bone marrow samples (mean IC50 9.0, IC90 19.9) (p less than 0.0001). This effect was most pronounced in the four previously treated cases examined (mean IC90 84.4 micrograms/ml). The implications of these findings for bone marrow purging with ASTA-Z in patients with ALL for autologous marrow transplantation are discussed.

[Autologous bone marrow transplantation for acute leukemia]

Autologous bone marrow transplantation (ABMT) was performed in 20 common ALL antigen (CALLA) positive acute lymphoblastic leukemia (ALL) cases. Bone marrow cells harvested in complete remission (CR) were in vitro treated with monoclonal antibodies NL-1 (IgG2a: anti-CD10), NL-22 (IgM), HL-47 (IgM) and baby rabbit complement and cryo-preserved. Three children with high risk factor such as Ph1 chromosome were transplanted in 1st CR, 5 in 2-3 CR, 8 adults in 1st CR, 2 in 2nd CR and 2 in relapse. As conditioning of ABMT, 12 cases mostly in 1st CR were treated with 4 doses of 2 g/m2 cytarabine (CA), 2 doses of 60 mg/kg cyclophosphamide (CY) and 4 doses of 3 Gy total body irradiation (TBI). 6 cases refractory to CA/CY were treated with 3 doses of 60 mg/m2 melphalan and 4 doses of 3 Gy TBI. Disease free survival (DFS) of 11 cases in 1st CR was 81.8% at 2 years from ABMT, and 9 cases are alive in CR. DFS of 5 cases in 2nd CR was 40.0%. In one Ph1 chromosome positive case, minimal residual bcr-abl mRNA was detected by polymerase chain reaction in the 1st CR bone marrow, but disappeared after purging procedures and after 3 months from ABMT. Our results indicate that ABMT with purged bone marrow is an effective mode of therapy for high risk CALLA positive ALL.

Immunomagnetic purging procedure for autologous bone marrow transplantation in lymphoid malignancies

In this report we describe the use of the immunomagnetic depletion of tumor cells from harvested bone marrow in two patients with acute lymphoblastic leukemia. The immunomagnetic procedure of purging involved one incubation of the marrow cells with a mixture of 4 monoclonal antibodies which bind to antigens of CD10 (ALB2), CD19 (HD37), CD20 (B1) and CD22 (HD39). Two incubations with magnetic beads (Dynabeads M-450) covered with antimouse antibodies followed by magnetic separation were performed. The bead/target B cell ratio was 50:1. After purging the recovery of mononuclear cells was 56% and 40%, while the recovery of CFU-GM was 45% and 38% respectively. Both patients engrafted rapidly without serious complications. One patient relapsed 4 months after transplant, the other remains in complete remission after 5 months. Our results confirm that the use of immunomagnetic beads is a simple, safe and reproducible technique to remove tumor cells before ABMT in patients with B malignancies using a broad mixture of MoAbs. However only a randomized trial using autologous marrow purged or not will clarify the effective clinical value of the procedure.

Virus-associated hemophagocytic syndrome following bone marrow transplantation

Multiple-organ infiltration by mature, benign erythrophagocytic histiocytes is the pathologic hallmark of the virus-associated hemophagocytic syndrome (VAHS). Although VAHS has been described in a number of clinical settings, it has been reported following bone marrow transplantation (BMT) only once previously. Our report identifies the clinical and laboratory features associated with VAHS and compares the immune defects described in VAHS with those known to occur following BMT.

Use of the polymerase chain reaction to monitor engraftment following allogeneic bone marrow transplantation

Engraftment following allogeneic bone marrow transplantation (BMT) was assessed in three cases, two of which were sex-mismatched and one sex-matched. The polymerase chain reaction (PCR) was used to amplify the hypervariable region lying 3' to the apolipoprotein B gene on chromosome 2. Amplification of this region provided informative marker bands capable of distinguishing host/donor populations in each case. The method allowed rapid analysis of minimal numbers of cells from peripheral blood and bone marrow in the early stages following BMT and was predictive of either successful engraftment or graft failure.

Successful treatment of CMV retinitis with ganciclovir after allogeneic marrow transplantation

Cytomegalovirus (CMV) infection of the retina is a well recognized complication in patients with the acquired immune deficiency syndrome but is rarely seen after bone marrow transplantation (BMT). Among a variety of drugs ganciclovir so far appears to be the most effective therapy for CMV retinitis, but in previous studies relapses occurred in all patients in whom ganciclovir was interrupted. We report the clinical findings in a 22-year-old BMT recipient who developed bilateral exudative CMV retinitis 64 days after BMT despite prophylactic treatment with high-titer CMV-immunoglobulins and transfusions of CMV-negative blood products and donor bone marrow. During a 12 day course of treatment with 7.5 mg/kg/day of ganciclovir the CMV retinitis improved and viruria ceased on day 4 of therapy. In contrast to the previous reports, CMV retinitis in this patient continued to improve even after ganciclovir was stopped and eventually complete healing of all intraretinal lesions as well as total reconstitution of the visual acuity was achieved. He is now free of disease and without relapse of CMV retinitis more than 1 year after transplantation.