Non-supralethal mitobronitol/cytarabine/cyclophosphamide conditioning without irradiation before bone marrow transplantation for accelerated chronic granulocytic leukemia: apparent absence of acute graft-versus-host disease.

Cytostatic chemotherapy instead of supralethal total body irradiation (TBI) has been increasingly used as an alternative myeloablative regimen before bone marrow transplantation (BMT). While irreversible azoospermia/amenorrhoea seems to occur less frequently with such conditioning, graft-versus-host disease (GVHD) remains unaffected. Five-year disease-free survival in accelerated chronic granulocytic leukemia (CGL), after BMT with matched sibling grafts has been 0.10-0.30. Mitobronitol, cytosine arabinoside, and cyclophosphamide were used for conditioning. Patients were transplanted with unmanipulated HLA/MLC identical sibling bone marrow. For recovery, a pathogen-low room was available without air filtering and laminar airflow. Seven of eight accelerated-CGL patients were engrafted: full allogeneic reconstitution was detected in four and mixed chimerism in three patients. Five out of the seven engrafted patients survived at least nine months (median = 42 months), two are considered cured (8-9 years survival). The four leukemia-free survivors displayed full allogeneic reconstitution and presented symptoms of chronic GVHD. One patient became a genetically verified father. Acute GVHD and veno-occlusive liver disease (VOLD) were absent in all patients, diffuse interstitial pneumonitis (IP) occurred in one case. Non-supralethal conditioning with mitobronitol/cytarabine/cyclophosphamide in accelerated-CGL allows allogeneic bone marrow reconstitution with survival and cure rates comparable to those achieved with other protocols using TBI or busulphan conditioning. Unlike the latter treatments, however, our protocol leads to fewer transplant-related complications including acute GVHD, IP, VOLD, and azoospermia/amenorrhoea.

Pregnancy in aplastic anemia treated with fetal liver and bone marrow hemopoietic cells and antithymocyte globulin.

This report describes a patient who had severe refractory anemia and thrombocytopenia during her first pregnancy. She had a remission after delivery but two years later aplastic anemia refractory to steroid and splenectomy developed. After treatment with steroids and antithymocyte globulin the patient had repeated infusions of hemopoietic cells derived from fetal liver and bone marrow, leading to a 7-year remission during which time she had a further successful pregnancy. The patient had a relapse one year later.

What kind of morphologically recognizable haemopoietic cells do we inject when doing foetal liver infusion in man?

There is no agreement, how to define the age of the embryo/foetus. From the 15th (fertilization) week onwards the whole foetal liver contains some 10(9) free haemopoietic cells. Before, and up to the 30th-34th weeks, the liver is the main site of haemopoiesis. The differential of embryonic smears (up to wk 9) differs from that of foetal ones. The first invasion of circulating primitive erythroblasts seeding in the liver (early 5th wk) is accompanied by the appearance of a lot of sinusoidal macrophages. Definitive erythropoiesis expands during the 6th-7th wks. Granulocytic representation peaks at 15-16 wks. Megakaryocytes are small and have few nuclei/nuclear lobes. Five to 8, or even more per cent of single haemopoietic cells were lymphoid-like cells in the 5th-6th wk liver smear. These cells precede the development of any lymphoid structure in the foetus. Ordinary lymphocytes amount to less than 2% between 10 and 18 wks, and reached 3% at wk 24. Percentage of dyserythropoietic nuclei in smears has been used to decide whether the injected cells could be regarded as 'physiological' cells. Ten out of 11 apparently healthy foetuses, delivered by hysterectomy/hysterotomy for maternal interest, aged 10 1/2 to 20 1/2 weeks, had mean 4.5% liver dyserythropoiesis. Extremely high dyserythropoiesis was associated with multilineage, instead of overwhelmingly erythroid haemopoiesis.

Human B cell development. II. Subpopulations in the human fetus.

In man, during fetal development the B cell populations show distinct phenotypes at different tissue sites. The pre-B and B lymphocytes of the fetal liver and bone marrow express IgM and B cell markers, B1 (CD20) and BA-1 (CD24). These "early" cells are negative with a number of other reagents, anti-IgD, RFB4 (CD22), RFB6 (CD21), and RFA-2, which on the other hand recognize peripheral B cells. These peripheral B lymphocytes in the developing fetus are heterogeneous. The diffusely distributed B cells in the earliest lymph node samples, 16 to 17 wk of gestational age, and from 16 to 21 wk in the spleen, are strongly IgM+ (IgD+,RFB4+,RFB6+, and RFA-2+) but lack T cell-associated markers such as T1 (CD5, p 67,000 dalton equivalent of murine Ly-1) and Tü-33. In fetal lymph nodes, primary nodules develop around the follicular dendritic (FD) cells from 17 wk onward, and contain a virtually pure population of B cells; B1+,BA1+,RFB4+,RFB6+,RFA-2+, which simultaneously express IgM,IgD together with T1 (CD5), a T cell-associated antigen. A sizeable subpopulation of these IgM+,T1+ cells are also positive for Tü-33, another T cell-associated marker. In the spleen, the B cells of the IgM+,IgD+,T1+ type appear in smaller numbers and only relatively late around wk 22. These cells are diffusely distributed at first, and start accumulating around the small FD cell clusters as soon as these emerge about the 23rd gestational wk. At that time, the IgM+,T1+B cells can also be washed out from the peritoneal and pleural cavities. The T1+,IgM+B cells may represent the normal equivalent cells of B chronic lymphoid leukemia and centrocytic lymphoma, and appear to be the counterpart of Ly-1+,IgM+B cells in the mouse.

Bone marrow transplantation in accelerated chronic granulocytic leukaemia using dibromomannitol-preconditioning instead of total-body irradiation.

In a preliminary study on five patients with accelerated CGL, transplantation of allogeneic matched bone marrow was shown to be feasible without whole-body irradiation. Animal experiments and studies with cells cultured in vitro suggest that the cytocastic drug used to kill leukaemic clones (Myelobromol-Chinoin) does not injure haemopoietic stroma. The administration of this protocol is cheap and easy. Our preconditioning does not, in itself, eradicate the malignant CGL clone immediately: 15-20% of marrow mitoses were Ph1+ one month after transplantation. For this reason, additional cytostatic therapy was given in the course of the 3rd to 6th post-transplant months. No Ph1+ cells were observed from the fourth post-transplant month onwards. Very few severe acute complications were seen and two out of three matched transplanted patients are disease-free 27 + and 13 + months later. On the basis of the developing normal spleen architecture and the changing pattern of circulating NAP score values, particularly the months-long persistence of distinctly low scores, and then the delayed emergence of normal levels, we put forward a hypothesis, emphasizing the role of environmental factors, including the formation of a normal haemopoietic stroma in the successfully transplanted CGL patient.

Developmental age estimated by bone-length measurement in human fetuses.

The lengths of 491 long bones of the extremities derived from 193 freshly delivered human fetuses of 7 to 22 weeks fertilization age were measured. Fetuses delivered after spontaneous abortion, twin pregnancy, or known maternal disease were excluded. The correlation between fetal age (measured by crown-rump length) and bone length was linear. The term "developmental age" was used for bone length-derived age values. Developmental age can be determined from the length of even a single bone, i.e., when mechanical injury of the delivered fetus inhibits crown-rump length measurement. The results could aid researchers dealing with human embryology, clinicians performing fetal tissue transplantation, and could be applied in forensic medicine as well.

[A case of congenital cystic intrahepatic bile duct dilatation (Caroli syndrome) treated with hepato-lobectomy]. / Mit Hepato-Lobektomie operierter Fall einer congenitalen, cystischen, intrahepatischen Gallengangserweiterung (Caroli-Syndrom).

The authors report a successful hepatolobectomy of Caroli's disease (segmentally dilatated intrahepatic bile ducts). They also give a survey of congenital and acquired bile duct dilatations, with a view to differential diagnosis and medical treatment. When Caroli's disease is suspected, echography and ERCP can be a valuable diagnostic aid. The definitive cure i. e. the elimination of the anatomical basis of recidive cholangitis, can only be achieved by the resection of the liver containing the dilated intrahepatic bile ducts. Postoperative administration of antibiotics and anticholelithic drugs can help the liver to full recovery.

Macrophages are the first differentiated blood cells formed in human embryonic liver.

Up to 70% of free, intravascular hemopoietic cells belonged to the macrophage series in half-thin sections prepared from the liver of a 4.5 week old human embryo (fertilization age) and 50 to 10% were found in the liver sinusoids up to the end of the 7th week. The number of apparent macrophage precursors could reach 10% of cells of the series. Intravascular macrophage clusters were discovered; the majority of contributing cells were phagocytic. The percentage of circulating macrophages in smears was only 0.5% or less during the investigated time period. Peak values for yolk sac macrophages did not exceed 10% of intravascular cells, and apparently followed peak values found in the liver. In half-thin sections large, pale, endodermally located hemocytoblasts of the definitive series also appeared during the 5th gestational week, but the amount of these cells was less than 5%. Their relation to the intrasinusoidal macrophage has not been proved till now. So, the first differentiated definitive blood cells apparently formed in, or at least preferentially attracted to the liver are not definitive erythroblasts, but macrophages.