Acute lymphoblastic leukemia with the (8;14)(q24;q32) translocation and FAB L3 morphology associated with a B-precursor immunophenotype: the Pediatric Oncology Group experience.

Five pediatric patients are described with acute lymphoblastic leukemia (ALL) who at presentation had clinical findings suggestive of B cell ALL and lymphoblasts with FAB L3 morphology and the characteristic t(8;14)(q24;q32). However, the leukemia cells of all five patients failed to express surface immunoglobulin (sIg) and kappa or lambda light chains. Based on initial immunophenotyping results consistent with B-precursor ALL, four of these cases were initially treated with conventional ALL chemotherapy. These four patients were switched to B cell ALL treatment protocols once cytogenetic results became available revealing the 8;14 translocation. The fifth case was treated with B cell ALL therapy from the outset. Four of the five patients are in complete remission at 64, 36, 29 and 13 months from diagnosis. One patient relapsed and died 6 months after initial presentation. These five unusual cases with clinical B cell ALL, the t(8;14), and FAB L3 morphology, but negative sIg, demonstrate the importance of careful and multidisciplinary evaluation of leukemic cells with morphology, cytochemistry, immunophenotyping and cytogenetic analysis. Future identification of patients with this profile will allow us to expand our knowledge regarding prognostic significance and optimal treatment for this rare subgroup of patients.

Decreased hematopoietic accessory cell function following bone marrow transplantation.

Hematologic engraftment following bone marrow transplantation requires not only pluripotent stem cells but also functioning accessory cells whose trophic factors support the proliferation and differentiation of stem cells and progenitors to mature blood cells. To better understand the regulation of hematopoiesis following transplantation, we studied hemopoietic accessory cell function in bone marrow transplant recipients 3 weeks to 10 months following transplantation. In general, hematopoietic accessory cell function was decreased following bone marrow transplantation. Sequential fractionation of accessory cells demonstrated that adherent cells often produced near-normal functional burst-promoting activity (BPA) and granulocyte-macrophage colony-stimulating activity (GM-CSA), but Fc receptor-positive (Fc+) cells and T cells uniformly produced greatly reduced BPA and GM-CSA, as compared to transplant donor cells. This cellular deficiency was corrected by soluble burst-promoting activity and granulocyte-macrophage colony-stimulating activity and so appeared to be due to the failure of accessory cells to produce trophic hormones. Limiting-dilution analysis (LDA) for proliferating T-cell precursors demonstrated a greatly reduced frequency in phytohemagglutinin-responsive cells, supporting the role of deficient hematopoietic growth factor production by activated T cells in transplant recipients. This hemopoietic accessory cell defect may thus reflect more generalized lymphocyte dysfunction in these patients. Hematopoiesis following bone marrow transplantation appears to rely upon growth factors released by accessory cells in the adherent layer.

Functional assessment of T cell depletion from bone marrow prior to therapeutic transplantation using limiting dilution culture methods.

We evaluate the usefulness of limiting dilution culture methods in assessing the extent of T lymphocyte depletion from bone marrow inocula, prior to transplant, using either ex vivo antibody/complement-mediated depletion or immunotoxin treatment. Complement-mediated depletion using anti-Leu-1 antibody was shown to result in a consistent decline of 99%-99.9% in the frequencies of T cells able to proliferate in mitogen-stimulated, interleukin-2 (IL-2)-supplemented cultures. Equivalent declines were demonstrated in frequencies of "helper" T cells able to respond to mitogen by making IL-2, and in "killer" T cells able to give rise to clones of cytotoxic effectors. In most experiments, a second cycle of anti-Leu-1 + complement treatment did not further diminish the fraction of proliferating cells, although T cells able to secrete IL-2 were additionally depleted following a second cycle of antibody and complement. The limiting dilution methods were found to be at least as sensitive as flow cytometric (FACS) methods for detecting residual T cell contamination after protocols involving complement-mediated lysis, and superior to FACS analysis for protocols involving T cell depletion by a ricin A chain-anti-T101 immunotoxin, in which treated T cells suffer functional impairment and eventual death after exposure to immunotoxin, but remain phenotypically detectable during FACS analysis. Although limiting dilution methods do not provide data as rapidly as FACS analyses, they do not require a cytofluorimeter, provide equal or greater sensitivity, and can assess functional impairment, for both helper and killer T cell sets, even in situations in which the depletion procedure does not lead to immediate cytolysis.

Refractory T cell acute lymphoblastic leukemia with unusual karyotype and interesting immunophenotype.

Karyotype, immunophenotype, and molecular studies are important in the evaluation of Acute Lymphocytic Leukemia as these data provide diagnostic as well as prognostic information. We present a case of acute lymphoblastic leukemia with unusual cytogenetics, 45,XY,i(7q),der(9)t(3;9)(q12;p22),del(12)(p12), :der(18)t(3;18)(p14;q22),-3. This karyotype is hypodiploid, showing loss of chromosome 3, a very rare occurrence. Hypodiploidy and translocations are suggestive of a poor clinical outcome. Cytogenetics also showed a chromosome 12p deletion which has been implicated in the oncogenesis of some acute leukemias. Immunophenotype by flow cytometry was positive for CD7 and CD10, T, and precursor B cell markers respectively. Given the specificity of CD7 for T cell processes, it was felt that the flow cytometry was more suggestive of a T cell process. Gene rearrangement studies showing a T cell receptor rearrangement helped confirm the T cell lineage of this malignancy. Hypodiploidy and T cell phenotype are indicators of poor prognosis. Interestingly this patient was refractory to two conventional chemotherapeutic protocols and finally responded to an unconventional protocol of high dose Ara C, etopside, and L asparaginase.

Long-lasting deficit of functional T cell precursors in human bone marrow transplant recipients revealed by limiting dilution methods.

We have applied limiting dilution methods suitable for the estimation of mitogen-reactive helper (pHTL) and cytotoxic (pCTL) T cell frequencies to the analysis of immune function in patients 1 mo to 6 yr after allogeneic bone marrow transplantation (BMT). Although the majority of these patients have regained normal levels of Leu-3+ (helper) and Leu-2+ (killer/suppressor) cells by 6 to 12 mo after BMT as assessed by cytofluorimetry, the fraction of these cells that can function in limiting dilution cultures is substantially below normal levels in nearly all patients. Although some BMT patients eventually recover normal frequencies of pCTL and pHTL, values typically remain greatly depressed even in patients transplanted as many as 4 to 6 yr previously. In contrast, recovery of precursors able to proliferate (without expressing either helper or cytotoxic function) in response to phytohemagglutinin (PHA) and interleukin 2 occurs in many patients by 1 yr after transplant. In spite of the decreased frequency of functional precursor cells found after BMT, each precursor is capable of giving rise to the same amount of function at limiting dilutions as that produced by cells from normal controls. In many BMT patients, proliferation in conventional PHA-stimulated cultures returns to near-normal levels even though precursor frequencies remain low. The limiting dilution method is sensitive to residual immune dysfunction in BMT recipients not easily quantitated by other, more conventional techniques.

Stages of T cell activation: continued antigen dependence of IL 2-producing cells after IL 2 receptor expression.

Alloantigen stimulation leads, within 48 to 72 hr, to the expression of IL 2 receptors (IL 2R) on the surface of most of the helper T cells with specificity for the stimulating antigens. The IL 2R-bearing cells, separated by flow cytometry from 3-day human or mouse mixed lymphocyte cultures, were found by limiting dilution methods to be enriched 10- to 20-fold (compared to IL 2R- cells) for antigen-specific helper T cells detected by IL 2 production. Although these cells have been activated to an IL 2R+ stage, most of them are unable to produce detectable IL 2 unless they are cultured together with the original, activating antigen. Even when IL 2 is supplied, and lymphokine production measured by assay of a second factor, IL 3, the large majority of individual activated helper T cells remain dependent on further antigenic exposure for their continued maturation into lymphokine-secreting effectors. Helper T cells at this early stage of activation can therefore proliferate when given IL 2 alone, but lymphokine secretion involves a second antigen-dependent step.

Retarded recovery of functional T cell frequencies in T cell-depleted bone marrow transplant recipients.

We have studied the effect of removing donor T cells by treatment with the monoclonal antibody Leu-1 and complement before marrow transplantation on the regeneration of functionally competent T lymphocytes in the blood at selected times after transplant. Using sensitive limiting-dilution methods that allow us to enumerate helper, cytotoxic, and proliferating T lymphocyte precursors, we report that regeneration of a functional T cell compartment is more severely impaired for the first 180 days after transplantation in those patients given T cell-depleted bone marrow than in recipients of untreated marrow. After this first 6 months, however, patients given T cell-depleted bone marrow had blood T cell frequencies comparable to those observed in patients given untreated marrow. Diminished frequencies of reactive T cells in recipients of depleted marrow could leave them more susceptible to infection or to the recurrence of neoplastic cells.

Hurler syndrome: II. Outcome of HLA-genotypically identical sibling and HLA-haploidentical related donor bone marrow transplantation in fifty-four children. The Storage Disease Collaborative Study Group.

Untreated patients with Hurler syndrome (MPSIH) experience progressive neurologic deterioration and early death. Allogeneic bone marrow transplantation (BMT) ameliorates or halts this course. The Storage Disease Collaborative Study Group was formed to evaluate the effectiveness and toxicity of BMT. Effectiveness was defined as engrafted survival with continuing cognitive development. Fifty-four patients deficient in leukocyte alpha-L-iduronidase enzyme activity (median age, 1.8 years; range, 0.4 to 7.9) received high-dose chemotherapy with or without irradiation and BMT from HLA-genotypically identical sibling (GIS) or HLA-haploidentical related (HIR) donors between September 16, 1983 and July 14, 1995; all children were included in this report. Thirty-nine of 54 patients (72%) engrafted following the first BMT. The probability of grade II to IV acute graft-versus-host disease (GVHD) at 100 days was 32% for GIS and 55% for HIR patients. The probability of extensive chronic GVHD was 0% for GIS and 24% for HIR patients. The actuarial probability of survival at 5 years was 64% for all patients, 75% for GIS patients, 53% for HIR patients, and 53% for patients with donor marrow engraftment. The baseline Mental Developmental Index (MDI) was examined both for children less than and greater than 24 months of age at BMT. Children transplanted before 24 months had a mean baseline MDI of 78, while those transplanted after 24 months had a mean baseline MDI of 63 (P = . 0002). Both baseline and post-BMT neuropsychologic data were available for 26 of 30 engrafted survivors. Of 14 patients transplanted before 24 months of age, nine demonstrated developmental trajectories that were normal or somewhat slower than normal. In contrast, of 12 patients transplanted after 24 months of age, only three showed developmental trajectories that were normal or somewhat slower than normal (P = .01). For children with a baseline MDI greater than 70, there was a significant correlation between the MDI at follow-up study and leukocyte alpha-L-iduronidase enzyme activity (P = .02). Children were more likely to maintain normal cognitive development if they were fully engrafted following BMT from a donor with homozygous normal leukocyte alpha-L-iduronidase enzyme activity. Children who developed acute GVHD of grade II or worse had significantly poorer cognitive outcomes (P < .009). No difference in the post-BMT MDI was observed between patients whose preparative therapies did (n = 10; radiation dose, 300 to 1,400 cGy) or did not (n = 16) include radiation. We conclude that MPSIH patients, particularly those less than 24 months of age with a baseline MDI greater than 70, can achieve a favorable long-term outcome with continuing cognitive development and prolonged survival after successful BMT from a related donor with homozygous normal enzyme activity.