Allogeneic blood stem cell transplantation in chronic myeloid leukaemia-chronic phase following conditioning with busulphan and cyclophosphamide: a follow up report.

BACKGROUND: Allogeneic bone marrow transplantation (BMT) or peripheral blood stem cell transplantation remains the only modality of treatment that can eradicate a leukaemia clone in the majority of patients with chronic myeloid leukaemia (CML). However, the advent of the targeted molecule imatinib mesylate (formerly STI-571) against the bcr-abl chimeric protein in the disease has brought the issue of managing newly diagnosed CML patients, especially those with available donors, to the crossroads. Although the curative potential of this agent remains unknown, it can produce complete cytogenetic response in > 60% of newly diagnosed patients. METHODS: From May 1991 to October 2002, a total of 55 Ph+ CML-chronic phase patients received oral busulphan 16 mg/kg and cyclophosphamide 120 mg/kg i.v. as a conditioning regimen. All patients received human leucocyte antigen (HLA)-identical sibling donor haematopoletic stem cells--bone marrow in 41 patients (74.5%) and peripheral blood stem cells in 14 (25.4%). Post-transplant prophylaxis for graft-versus-host disease included a short course of methotrexate (on days +1, +3, +6 and +11) and cyclosporin till day +180 in 38 patients (69.1%), while a combination of cyclosporin and methylprednisolone was used in the remaining 17 (29%). RESULTS: At a median follow up of 48 months (10-144 months), 26 patients (47.3%) are alive. Early mortality (100-day) occurred in 17 patients (30.9%). Acute graft-versus-host disease developed in 37 patients (67.3%), and was grade IV in 6 of them. Chronic graft-versus-host disease developed in 17 patients (30.9%). Relapse occurred in only 2 patients (3.6%) till date. The leukaemia-free survival is 64.3% in the peripheral stem cell group, whereas it is 41.5% in the bone marrow recipient group. CONCLUSION: Allogeneic BMT appears to result in eradication of CML and ensure disease-free survival in about half the patients. However, efforts should be made to prevent graft-versus-host disease and minimize early mortality.

Preliminary study of HLA-ABCDR antigens in CML, ANLL, thalassemia and severe aplastic anemia in Thais.

The objective of this study was to analyse human leukocyte antigen (HLA) and disease association in common blood diseases [chronic myelogenous leukemia (CML), acute nonlymphocytic leukemia (ANLL), thalassemia and severe aplastic anemia] in Thais. The subjects were patients from the Hematological Clinic, Departments of Medicine and Pediatrics, Ramathibodi Hospital who were referred for HLA typing for bone marrow transplantation (BMT) at the Histocompatibility Laboratory from March 1988 to September 1997. A total of 129 patients had complete HLA-ABC typing. The patients included 45 CML, 40 ANLL, 26 thalassemia (Thal) and 18 severe aplastic anemia (SAA). Of these, 88 patients were typed for HLA class II. The HLA class I (ABC) and II (DR, DQ) typings were performed by microlymphocytotoxicity test. It was found that HLA class I was associated with CML, ANLL and Thal, whereas, HLA class II was associated with SAA. HLA-B8 and HLA-B18 were increased in CML with R.R. values of 12.2 and 3.9, respectively, whereas, HLA-B18 was increased in ANLL with R.R. value of 4.5. In addition, HLA-DR2 and DR3 were increased in SAA with R.R. values of 3.8 and 4.8, respectively. For Thal, HLA-A2 and B46 were increased in Thal in Central Thais with R.R. values of 3.3 and 6.1, respectively, whereas, HLA-B13 was increased in Thal in Northern Thais with R.R. value of 8.5. On the other hand, HLA-B7 was absent in CML. HLA-Cw7 was decreased in CML and SAA, whereas, HLA-DR6 was decreased in ANLL and SAA. Furthermore, HLA-Cw6 was also decreased in CML, whereas, HLA-A33 and Bw4 were decreased in SAA. Although the sample size of each disease was small, the increase of HLA-DR2 was observed in SAA in Thais which was similar to other studies in different ethnic groups. These preliminary data may be useful for further study in HLA and blood disease association.

Immunological assessment in patients of leukaemia.

In the present study delayed cutaneous hypersensitivity response (DNCB test) and humoral response (by uantification of immunoglobulins) ware carried out in 20 cases of leukaemias. None of the cases was found to be anergic or immunodeficient. In remission also patients showed the normal response.

Abnormal immunological response to Mycobacterium tuberculosis antigens in a patient with chronic myelocytic leukemia and active tuberculosis

The pathogenic mechanisms of immunosuppression leading to susceptibility of Mycobacterium tuberculosis (MT) infection in chronic myelocytic leukemia (CML) are not clear. To address this issue, we measured the proliferative response, variation of T cell subpopulations (CD4+, CD8+, TCR-V delta 2 and TCR-V beta 8 T cells) and the cytokine profile (IL-1 beta, IL-2, IL-4, IL-6, IL-10, TNF-alpha, IFN-gamma) after MT stimulation of peripheral blood mononuclear cells (PBMC) in a patient with concomitant CML and active pulmonary tuberculosis. The results were compared to four patients with active pulmonary tuberculosis and no other coexistent diseases. The immunologic response to phytohemagglutinin (PHA) was also evaluated. In contrast to controls, the CML PBMC failed to proliferate in response to MT antigens. Mycobacterium-reactive CD4+, V delta 2 and V beta 8 T cells did not expand after MT stimulation of the CML PBMC. In MT antigens-stimulated cultures from the CML patient, IL-2 was not produced and mild reduction of IL-1 beta and INF-gamma were observed. In contrast, IL-10 was markedly elevated in these cultures. Similarly, PHA-stimulated PBMC from the CML patient showed no expansion of CD4+ and CD8+. T cells. In these cell cultures, INF-gamma concentration in supernatants was decreased and IL-10 was significantly elevated. This study suggests that patients with CML may present a profound immunosuppression of essential cellular and molecular immune effectors, a scenario which might contribute to the development of active tuberculosis. These findings further support the need of establishing immunotherapeutic modalities with potential value for myeloproliferative disorders.

HLA y Leucemias. Estudio de 144 casos / HLA and leukaemias. A estudy of 144 cases

Se determinaron frecuencias de 33 antígenos HLA de los loci-A,B y C en 144 pacientes leucémicos: 89 con leucemia linfoblástica aguda (LLA), 28 con leucemia aguda no linfoblástica y 27 con leucemia mieloide crónica, estratificados fenotípicamente en blancos, negros y mestizos, para evaluar la posible asociación entre estos marcadores genéticos con dichas enfermedades. Los antígenos HLA-A19 (19) mostraron asociaciones negativas con la LLA con un riesgo relativo (RR) de 0,08 y de 0,84, respectivamente. Se obtuvieron frecuencias estadísticamente significativas con una pc < 0,02 para el A19 y pc < 0,002 para el A-29, al compararlos con controles normales no relacionados. Los enfermos con LLA blancos positivos al antígeno HLA-A19 mostraron asociaciones negativas (RR =0,10, p < 0,002) en relación con los controles blancos. Estos resultados sugieren protección individual y poblacional o ambas (fracción preventiva (FP) > 0), al desarrollo de LLA. El resto de los antígenos, HLA estudiados no mostraron asociación con leucemias

Cytogenetic and immunologic study in chronic leukemia

Cytogenetic study of peripheral blood and bone marrow aspirate as well as HLA typing were done in 17 patients with chronic myeloid leukemia [CML] and 14 patients with chronic lymphocytic leukemia [CLL]. Chromosomal studies of phytohemagglutinin stimulated lymphocytes usually reveal normal karyotype. Clonal chromosomal aberrations are revealed in about half of the patients if lymphocyte cultures are stimulated by B-cell mitogen such as pokeweed mitogen and other polyclonal mitogens. In CML, the most common abnormality was the presence of Philadelphia chromosome [Ph1] which was found in 88% of the cases: Additional chromosomal abnormalities were found in 47% of the patients, including deletions, breaks, duplication of X- chromosome and monosomy 6. These aberrations were found in patients in the accelerated phase or in the blastic phase of the disease. Ph1 negative patients were found to have more aggressive course of the disease, while the presence of a single Ph1 carries a better prognosis. In patients with CLL, only one patient had monosomy 7 and another one had monosomy 8 and 10 patients showed normal karyotype, while the cytogenetic study failed in two patients. As regards HLA typing, CML patients have significantly high frequency of the specificities HLA- A9, CW3, and CW4, whereas the frequency of HLA-AW19 was decreased significantly as compared to the typing of 100 normal random individuals from the same population. In patients with CLL, there was a significantly high relative risk of the phenotypes HLA-B8, B14, and A9 as compared to those in controls. The present study revealed the importance of cytogenetic studies in the diagnosis, classification, course and prognosis of leukemic patients. The appearance of aneuploid metaphases in a previously diploid marrow may herald imminent relapse of the disease and may be used for diagnostic purposes in cases in which other parameters are confusing. The cytogenetic data when combined with clinical data can preferably predict an impending transformation in chronic leukemia patients. The appearance of additional chromosomal aberrations together with Ph1 denotes disease metamorphosis whether to accelerated phase or actual blastic crisis. The presence of chromosome aberrations in patients with CLL denotes advanced disease stage or resistance to therapy, while normal karyotype carries a better prognosis

Serum immunoglobulins in leukaemia and malignant lymphoma.

The serum immunoglobulin levels were studied in 25 healthy control subjects and 23 cases of leukaemia (6 cases of acute lymphatic leukaemia, 5 cases of acute myeloid leukaemia, 2 cases of chronic lymphatic leukaemia and 10 cases of chronic myeloid leukaemia) and 17 cases of malignant lymphoma (13 cases of Hodgkin's lymphoma and 4 cases of non-Hodgkin lymphoma). The mean levels of IgG, IgA and IgM in 25 control subjects were 1573.56 +/- 91.45 mg/dl, 209.64 +/- 12.55 mg/dl and 109.81 +/- 10.03 mg/dl respectively, those in 23 cases of leukaemia were 1338.23 +/- 109.74 mg/dl, 195.53 +/- 20.72 mg/dl and 127.47 +/- 13.29 mg/dl respectively and those in 17 cases of malignant lymphoma were 996.99 +/- 99.50 mg/dl, 147.47 +/- 19.61 mg/dl and 129.35 +/- 19.95 mg/dl respectively. The mean levels of IgG and IgA were found to be decreased in cases of leukaemia with elevated levels of IgM, however, it was found to be insignificant (p less than 0.4). The mean IgG, IgA and IgM levels were found to be almost identical in different leukaemia irrespective of cytological types except in 2 cases of chronic lymphatic leukaemia which showed low levels of IgG and IgA. The mean levels of IgG and IgA were found to be significantly decreased in malignant lymphoma (p less than 0.02). IgM levels were found to be increased in 3 cases of non-Hodgkin lymphoma.

Evaluación longitudinal del sistema complemento e inmunocomplejos circulantes en la leucemia mieloide crónica / Longitudinal evaluation of complement and circulating immunocomplexes system in chronic myeloid leukemia

Se evaluó longitudinalmente la actividad hemolítica del sistema complemento por la vía clásica, vía alternativa, actividad funcional del factor B, C3 y C4, así como la detección de inmunocomplejos circulantes (ICC) mediante la prueba de desviación del C1q y el método de precipitación con polietilenglicol 6 000 al 3,75 % en un grupo de pacientes con leucemia mieloide crónica (LMC) en diferentes fases clínicas. Se observó un aumento en la actividad de la via alternativa, factor B y C3 en las fases activas de la enfermedad; la vía clásica y el C4 estaban incrementados solamente en los enfermos con crisis blástica. Se demostraron niveles elevados de ICC en las fases más activas de la enfermedad