Effect of G-CSF on peripheral blood progenitor cell mobilization and collection from healthy donors.

We studied granulocyte colony-stimulating factor (G-CSF) mediated peripheral blood progenitor cells (PBPC), which were mobilized and collected from healthy donors for allogeneic transplantation. A total of 26 donors, age ranged from 21-41 years were mobilized with G-CSF at a dose of 7.5 microg/kg/day subcutaneously for 5 days and the collection was started on day 5. The CD34 cell counts reached a maximum on day 5 and subsequently declined despite continually given G-CSF. White blood cells (WBC), absolute neutrophil counts (ANC), absolute lymphocytes (AL) and their subsets, absolute mononuclear cells (AMNC), colony-forming unit-granulocyte, macrophage (CFU-GM) and CD34+ cells were increased about 6, 9, 2, 3, 34 and 40-fold, respectively, but red blood cells (RBC), hematocrit (Hct) and platelets (Pit) decreased on day 5 when compared to day 0. All parameters decreased after stem cell collection. For stem cell collection by Cobe Spectra, we used a blood volume of 19.27 +/- 4.65 liters, flow rate of 60.53 +/- 10.03 ml/minute, acid citrate dextrose solution (ACD)/blood ratio of 1:13.31, the final product volume was 314.14 +/- 72.24 ml, collection time was 325.40 +/- 73.36 minutes and one or two procedures were sufficient. The correlation between the number of CD34+ cells/kg, CFU-GM/kg and MNC/kg found in the harvested product and CD34 cells can be used for determining the necessary amount of progenitor cells for transplantation.

High dose chemotherapy and peripheral blood stem cell transplantation for high risk primary breast cancer: a single center experience in Thailand.

Twenty patients with high risk primary breast cancer underwent a high dose chemotherapy program at Ramathibodi Hospital, Bangkok. Eligible patients included 21 women who had a histological diagnosis of breast cancer with more than 10 axillary lymph nodes involved. The patients first underwent modified radical mastectomy, followed by conventional doxorubicin containing adjuvant chemotherapy, before entering the treatment program. Peripheral blood stem cells were mobilized with cyclophosphamide and G-CSF and were harvested by leukapheresis. High dose chemotherapy consisted of cyclophosphamide 5,625 mg/m2, cisplatinum 165 mg/m2 and carmustine (BCNU) 600 mg/m2 were subsequently given, followed by infusion of the harvested peripheral blood stem cells. The median duration of cytopenia after transplantation was 8 days (range 7-12). The median expense for the transplantation, in addition to the cost of mastectomy and conventional chemotherapy, was 224,396 Baht (approximately US $5,350). Three out of the first four patients developed interstitial pneumonitis within three months after transplantation. There was one fatal case which was the only regimen related mortality. BCNU was then reduced to 450 mg/m2 and lung complications were markedly reduced afterwards. The median follow up time was 37 months with a median disease free survival of 38 months and overall survival of four years at 84%.

Amifostine and hematologic effects.

Amifostine is a protective agent of normal tissue from adverse effects of radiochemotherapy. It is the prodrug that is dephosphorylated by alkaline phosphatase on plasma membrane into the active form named WR-1065. More than 90 per cent of the drug is cleared from plasma in 6 minutes and the peak tissue concentration is 10-30 minutes after intravenous administration. Amifostine has the selective property to protect normal tissue but not cancer cells by mainly scavenging free radicals induced by radiation and chemocytotoxic agents. Both preclinical and clinical studies of this drug provide the significant protection of hematopoietic progentitors from a broad range of cytotoxic agents such as cyclophosphamide, cisplatin, vinblastine, carboplatin, mitomycin-C, fotemustine, doxorubicin, daunorubicin and radiation as well. Moreover, this drug can protect other normal organs or tissues including kidney, salivary gland, liver, heart, lung and small intestine. Amifostine is quite safe, the two major side effects are vomiting and hypotension, and the minor effects are flushing, sneezing, dizziness, chills, metallic taste etc. The drug was approved by the FDA of U.S.A. for use as a cytoprotectant in cyclophosphamide and cisplatin treatment for advanced ovarian cancer and non small cell lung cancer.

Etiology and incidence of thrombotic and hemorrhagic disorders in Thai patients with extreme thrombocytosis.

A retrospective study of 126 patients with extreme thrombocytosis (defined as a platelet count > or = 1,000 x 10(9)/L) was performed during a five-year period (June 1994-June 1999). The aim of this study was to determine the etiology and to evaluate the clinical consequences of extreme thrombocytosis. Seventy patients (55.5%) had reactive thrombocytosis (RT) with an age range of 43 +/- 2.2 years, 56 (44.5%) had chronic myeloproliferative disorders (MPD) with an age range of 53 +/- 2.4 years. Underlying causes of RT were malignancy (25/70 or 35.7%), infection (16/70 or 22.9%), postsplenectomized beta-thalassemia/Hb E (11/70 or 15.7%), inflammation (12/70 or 17.1%), iron deficiency anemia (6/70 or 8.6%). Duration post splenectomy in our beta-thalassemia/Hb E patients ranged from 4 months to 21 years, with a median of 10 years. Subtypes of our MPD cases were chronic myeloid leukemia (30/56 or 53.6%), essential thrombocytosis (18/56 or 32.1%), polycythemia vera (4/56 or 7.1%), agnogenic myeloid metaplasia (3/56 or 5.4%) and unclassified MPD (1/56 or 1.8%). Bleeding and thrombotic tendency were respectively noted in 7 (12.5%) and 2 (3.6%) of MPD patients. Two patients of the MPD group (3.6%) experienced both bleeding and thrombotic episodes. One patient (1.4%) of the RT group developed vasculitis-associated thrombosis. However, none of the patients in the RT group had bleeding complications. Extreme thrombocytosis was not a rare condition in a university hospital population, and bleeding and/or thrombotic complication was more common in the MPD group.

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.

Serum erythropoietin levels in thalassemia major and intermedia.

Serum erythropoietin (EPO) levels were determined by enzyme linked immunosorbent assay (ELISA) in 61 thalassemic patients, consisting of 23 thalassemia major (TM) patients with multiple transfusion, 38 patients with thalassemia intermedia (TI). Thirty-two normal controls were also studied. The mean serum EPO levels were significantly higher in both groups with TM (165.96 +/- 17.31 mlU/ml) and TI (126.43 +/- 50.56 mlU/ml) compared with the control group (8.33 +/- 3.91 mlU/ml). The mean value of hematocrit (Hct) in the patients with TM (18.70 +/- 3.51%) was lower than those with TI (25.24 +/- 4.19 %) whereas the mean serum EPO level were significantly higher in TM than TI patients. An inverse correlation between the serum values of EPO and Hct was observed in both TI and TM patients, however this correlation was significant only in TI (r = -0.61, p<0.001). These data showed that serum EPO levels increased in all thalassemia patients despite repeated transfusion. Multiple transfusion may modulate the response of serum EPO to the degree of anemia, resulting in increased EPO levels and independent anemia in the TM patients.

Delayed administration of G-CSF in both mobilization and post transplantation in autologous peripheral blood stem cell transplantation.

Granulocyte colony stimulating factors (G-CSFs) play a very important role in the current technique of stem cell transplantation. The conventional timing of administration of G-CSF in both mobilization and post transplantation has been right after chemotherapy or right after transplantation. We have studied the effects of timing of administration of G-CSF in 21 patients who had autologous stem cell transplantation for breast cancer, lymphoma or nasopharyngeal cancer. Their stem cells were mobilized by chemotherapy followed by G-CSF, which were given on day +1 or day +5 after chemotherapy. The median peak percentage of CD34 positive cells harvested using both technique were 1.88 and 0.48% respectively. After transplantation, G-CSF were given on day +1 or day +6 after stem cell infusion until neutrophil recovery. The time until bone marrow recovery was significantly longer in the group with delayed administration of G-CSF (10 days versus 8 days). However, there was no difference in duration of neutropenic fever or hospital stay after transplantation. The transplantation outcome was also unaffected. We therefore concluded that G-CSF can be given in the delayed fashion in both mobilizing and post transplantation settings without jeopardizing the outcome and this would result in a significant cost saving.

Study of hematopoietic progenitor cells, hematological values and lymphocyte subsets in cord blood: application for cord blood transplantation.

Hematological values, lymphocyte subsets and hematopoietic progenitor cells from normal term cord blood samples were studied, compared with normal adult blood, and analysed to determine whether a single collection of cord blood is sufficient for transplantation in adults. The parameters were assayed by automatic cells counter, flow cytometry and semisolid cell culture. All of the hematological values except RBC and MCHC were higher than in normal adult blood. Sex had an influence on RBC, Hb, Hct, Plt and reticulocyte counts. For lymphocyte subsets, all of the absolute CD3+, CD4+, CD8+ counts and T helper: suppressor ratio were higher than those of adult blood. All of the hematopoietic progenitor cells in cord blood were also higher than in adult blood. The mean volume of cord blood for each collection was 80.75 +/- 4.81 ml and the mean numbers of nucleated cells, CFU-GM and CD34+ were 13.51 +/- 0.38 x 10(8) cells, 4.33 +/- 0.66 x 10(5) colonies and 42.65 +/- 7.00 x 10(5) cells respectively. This 80 ml of cord blood would contain sufficient marrow repopulating cells for a recipient weighing about 20 kg. Recently developed technology, including ex vivo expansion may even permit transplants in adults.

Levels of serum tumor necrosis factor alpha in relation to clinical involvement and treatment among Thai adults with Plasmodium falciparum malaria.

Concentrations of tumor necrosis factor alpha (TNF-alpha) in serum were measured in 17 Thai men infected with Plasmodium falciparum malarial infections to determine whether they were affected by severity of infections or exchange transfusions. Twelve patients were considered having complicated malarial infections, eight of whom had cerebral malaria. Five patients had uncomplicated malarial infections. The results showed that malarial infection markedly raised TNF-alpha level above normal values (mean +/- SEM 406 +/- 38 vs 15 +/- 5, p = 0.004). In complicated malaria, cerebral involvement appeared to significantly increase concentration of TNF-alpha when compared to values in uncomplicated malaria (mean +/- SEM 496 +/- 64 vs 339 +/- 12, p = 0.01). Degree of parasitemia, intravenous quinine (day 0 value vs day 7 value) and exchange transfusion did not significantly affect TNF-alpha levels. Conclusion: Serum level of TNF-alpha is increased in Plasmodium falciparum malarial infections and may be a useful index to predict severity of malarial infection, cerebral malaria in particular.

Multivariate analysis of prognostic factors in Philadelphia chromosome positive chronic myeloid leukemia: an update of the first series in Thailand.

The prognostic importance of pretreatment clinical and laboratory features was investigated in a group of 243 patients with Philadelphia chromosome positive chronic phase chronic myeloid leukemia from 1977-1995. Chemotherapy consisted of busulfan before 1993 or hydroxyurea after 1993. The overall median survival from diagnosis was 28 months. The mean age of the patients was 38 years, about 10 years below that of Western populations. Univariate analysis identified 4 poor prognostic features: thrombocytopenia, more than 5% peripheral blasts, more than 5% erythroid precursors and less than 7 g/dl of hemoglobin. The median survival times of patients with these 4 risk factors were 5, 11, 11 and 12 months respectively. Multivariate analysis only identified 2 significant prognostic features: thrombocytopenia and more than 5% peripheral blasts. Splenomegaly of more than 10 cm, basophilia and leukocytosis were associated with a shorter median survival but was not statistically significant. A risk scoring system was developed and used to classify patients into low, intermediate and high risk groups at 30.9%, 30.2% and 38.8% respectively. The median survival time according to the low, intermediate and high risk group was observed at 60, 27 and 14 months respectively. Prognostic factors for Thai patients with chronic myeloid leukemia have both similarities and differences with previously observed factors but the median patient survival time is shorter.

Detection of BCR/ABL fusion gene in CML: a preliminary report.

The BCR/ABL fusion gene in 31 patients with chronic myeloid leukemia (CML) was detected by RT/PCR. In 18 cases of Ph' positive patients, 13 had BCR 3/ABL II rearrangement, 1 had BCR 2/ABL II rearrangement and 4 had both rearrangements. One case with complex translocation: 46,XY,t(9;9;22), had BCR 3/ABL II rearrangement. In 8 cases of Ph' negative patients, 4 had BCR 3/ABL II rearrangement, 3 had both rearrangements while 1 had no BCR/ABL rearrangement. Interestingly, in 4 patients who had no cytogenetic result, we could observe BCR 3/ABL II rearrangement in 3 cases and both rearrangements in 1 case. The results suggest that this procedure is sensitive and independent of the presence or absence of an identifiable Ph' chromosome.

The value of HLA-ABC common typing tray in relation to bone marrow transplantation.

Bone marrow transplantation (BMT) is one of the most effective procedures to cure the previously uncured hematologic diseases. However, it is costly and HLA typing to select the compatible donors contributed to its cost. A total of 53 prospective patients for BMT and their 114 siblings were analyzed to evaluate the use of locally prepared HLA-ABC common typing tray (ABCCT) during Mar 1988-Mar 1992. The 16, 9, 7, 5, 5 and 12 patients were diagnosed as aplastic anemia, CML, thalassemia, ALL, ANLL and other blood diseases, respectively. It was found that 18 patients were HLA-identical (HLA-ID) with one of their siblings except one patient had 2 HLA-ID sibs. All of those who appeared to be HLA-ID were further tested for the HLA-ABCDR typings. It was observed that 16 (88.89%) of 18 patients and 17 (89.47%) of 19 sibs were confirmed as HLA-ID. After careful clinical screening, only 13 HLA-ID pairs were able to proceed to the mixed lymphocyte culture and confirmed their status of HLA-ID by this test. Finally, only 6 (46.15%) of 13 patients received BMT with a high rate of success, ie all patients have survived with bone marrow engraftment. Thus, ABCCT is very useful for related BMT. It was highly efficient to exclude HLA-non-ID and haplo-ID yet the cost and workload were greatly reduced.

Experience with factor VIII: C inhibitors and acquired von Willebrand's disease in an adult at Ramathibodi Hospital.

Eleven cases of acquired inhibitors against factor VIII: C and von Willebrand's factor (vWF) seen at the Department of Medicine, Ramathibodi Hospital from 1979 to 1991 were reviewed. Factor VIII: C inhibitor was found in 6 of 36 patients (17%) with hemophilia A (median age 18 years). Three patients each were weak (titer < 10 Bethesda units/ml), and strong antibody producers. Two cases of weak antibody producers had spontaneous disappearance of inhibitor, while all 3 strong antibody producers required specific treatment (corticosteroids, immunosuppressive drugs, and plasmapheresis). The inhibitor level temporarily declined in 2 patients, and disappeared in one. Spontaneous acquired inhibitor to factor VIII: C was seen in 3 patients. One each respectively had pemphigus vulgaris and bullous pemphigoid, autoimmune disease, and NIDDM. They were characterized by older age (median age 54 years), frequent skin and soft-tissue hematoma, but less hemarthroses. Inhibitor titer ranged from 15-280 Bethesda units/ml. Disappearance of the inhibitor after treatment with corticosteroids and immunosuppressive drugs were observed in all patients. Acquired von Willebrand's disease developed in 2 previously healthy patients. One patient was in the postpartum period, while the other had simultaneous acute viral hepatitis A infection. Both presented with the recent onset of spontaneous severe gingival bleeding, and demonstrated a prolonged bleeding time, reduced vWF:Ag (F VIIIR:Ag), and ristocetin cofactor (F VIIIR:vWF). Treatment with cryoprecipitate and corticosteroid resulted in remission of bleeding symptoms. Despite the rarity of these disorders, the recognition and proper management are of importance.

Bone marrow transplantation in Ramathibodi Hospital: progress report.

Bone marrow transplantation has become the accepted treatment for several hematologic disorders. We have done 3 autologous and 6 allogeneic bone marrow transplantations at Ramathibodi Hospital since July 1989 in patients with acute lymphoblastic leukemia, acute non-lymphocytic leukemia, chronic myeloid leukemia, non-Hodgkin's lymphoma and severe aplastic anemia. Only one patient with aplastic anemia had late graft rejection, but the rest of them engrafted and did well during the median follow up period of 317 days (range: 39 to 962 days) post transplantation. None of the allogeneic BMT had graft-versus-host disease. We use cyclosporin and short course methotrexate for post transplantation immunosuppression.

Agranulocytosis and aplastic anemia among Ramathibodi Hospital patients.

A one-year prospective prevalence study on aplastic anemia and agranulocytosis was performed in Ramathibodi Medical School. A total of 91,581 complete blood counts were screened for potential cases of aplastic anemia and agranulocytosis according to defined criteria. Nineteen cases of aplastic anemia and five cases of agranulocytosis were found. The prevalence of the two conditions was discussed.

Effect of running exercise on hematological changes, hematopoietic progenitor cells (CFU-GM) and fibrinolytic system in humans.

In order to study the effect of running exercise on hematological changes, hematopoietic progenitor cells (CFU-GM) and the fibrinolytic system in humans, a running exercise protocol was developed. The volunteers ran as fast as possible for a distance of 3.8 kilometers. Immediately after exercise, there were significant increases in hematocrit, absolute numbers of total white blood cell count, platelet count and CFU-GM, total protein and plasma fibrinogen, but all values returned to baseline within 15 minutes except hematocrit, platelet and total protein which returned to baseline value in 30, 30 and 60 minutes after exercise, respectively. The fibrinolytic reactivity increased immediately after exercise and returned to baseline level 15 minutes later. The changes in all parameters were transient and the increase in hematopoietic progenitor cells were not useful for stem cell harvesting by hemapheresis.

Multivariate analysis of prognostic factors in chronic myelogenous leukemia.

The prognostic importance of patient pretreatment clinical and laboratory features were investigated in a group of 50 patients with Philadelphia chromosome-positive benign phase chronic myelogenous leukemia. The overall median survival time was 30 months. The patient characteristic associated with shortened survival was the male sex. Anemia, thrombocytosis or thrombocytopenia tened to have adverse effect on survival. A multivariate regression analysis demonstrated only sex difference to be of prognostic importance. Evaluation of the effect of therapy showed that intensive chemotherapy was not superior to single agent chemotherapy.

Interferon alpha-2a to control thrombocytosis in chronic myelogenous leukemia and essential thrombocythemia.

Four patients with chronic myelogenous leukemia and thrombocytosis and one patient with essential thrombocythemia were treated with purified recombinant human interferon alpha-2a (IFN-alpha 2a). Significant decline in platelet counts, from a mean ( +/- SE) of 1.396 +/- 0.265 x 10(6)/mm3 to a mean of 0.396 +/- 0.04 x 10(6)/mm3 (p less than 0.05), was observed in all patients. The platelet count remained normal for 15, 21 and 30 days after discontinuation of IFN-alpha 2a in 3 patients. In 2 patients the platelet count began to rise slowly two weeks after discontinuation of IFN-alpha 2a. Our preliminary observations suggest that purified recombinant human IFN-alpha 2a may effectively control progressive thrombocytosis in advanced chronic myelogenous leukemia and essential thrombocythemia.

Hematocrit in thrombotic stroke at Ramathibodi Hospital.

A hospital-based study of the relationship between the hematocrit and thrombotic stroke was carried out among 117 patients admitted to Ramathibodi hospital. There was no significant difference in the age of patients with and without CT scan. Six patients, three males and one female with CT scan and one male and one female who did not have CT scan were found to have polycythemia vera. Ten patients had relative polycythemia (five had CT scan and five without CT scan). The mean age of patients with PV and relative polycythemia was not significantly different from those without polycythemia. The mean Hct in those with PV and relative polycythemia was generally higher than those without polycythemia. We recommended that Hct should be determined in every thrombotic stroke and a high Hct should be further studied for evidence of polycythemia vera or relative polycythemia.