Cost-effectiveness of rituximab in refractory cold agglutinin disease.

Cold haemagglutinin disease (CHAD) is an uncommon condition frequently associated with B-cell lymphoproliferative disorders and is refractory to conventional treatments used in autoimmune haemolytic anaemia. Rituximab has been used in this condition with favourable and lasting responses. Cost has been a major limitation to its use in such indication. We present cost-effectiveness analysis of the use of rituximab in two patients with CHAD. Rituximab successfully controlled haemolysis in both cases of CHAD and was found to be cost-effective through reducing transfusion needs.

Acute leukaemia in Jehovah's Witnesses.

The refusal of Jehovah's Witnesses with leukaemia to accept transfusion provides a major clinical challenge because of the myelosuppressive effects of chemotherapy. Experience in treating five such patients is described. Two patients with acute lymphoblastic leukaemia (ALL) achieved remission following chemotherapy, the first without transfusion support, the second, a minor, receiving transfusion under a court order: the first patient remains in remission 5 years later, whereas the second subsequently relapsed and died. Of three patients with acute myeloid leukaemia (AML), two received chemotherapy: one died of anaemia during induction chemotherapy whereas the second eventually consented to transfusion but died of refractory leukaemia. The third patient died of anaemia despite erythropoietin. We feel Jehovah's Witnesses should not be denied antileukaemic therapy if they fully understand the risks involved. Minimizing phlebotomy, use of antifibrinolytic agents and growth factors may make chemotherapy feasible, especially in ALL where remission may be induced with less myelosuppressive agents. The outlook for those with AML treated with conventional chemotherapy appears poor; alternative approaches to treatment should be considered in these patients.

Fludarabine, cytarabine, G-CSF and idarubicin (FLAG-IDA) for the treatment of poor-risk myelodysplastic syndromes and acute myeloid leukaemia.

Nineteen patients with high-risk myelodysplastic syndrome (MDS)/acute myeloid leukaemia (AML) received fludarabine, cytarabine, granulocyte-colony stimulating factor (G-CSF), and idarubicin chemotherapy (de novo MDS/MDS-AML, nine; relapsed/refractory MDS/AML, seven; therapy-related MDS, three). Median age was 44 years and median disease duration 10 months. 16/19 (84%) patients had abnormal cytogenetics with seven (37%) harbouring abnormalities of chromosome 7. 18/19 (94.7%) patients responded to FLAG-idarubicin with 12 (63%) achieving complete remission (CR) (< 5% blasts and normal cytogenetics). 7/9 (78%) patients with de novo MDS/MDS-AML achieved CR compared to 5/10 (50%) with alternative diagnoses. Response was associated with age < 50 years, disease duration < 3 months, and cytogenetics other than abnormalities of chromosome 7. Haemopoietic regeneration was rapid in most patients and there were no toxic deaths. Nine patients received a second course of chemotherapy, three have proceeded to allogeneic bone marrow transplant and three to autologous blood stem cell/bone marrow transplantation. Follow-up is short (median 10 months). 12/19 (63%) patients remain alive and 5/12 (42%) have relapsed at a median 5 months following CR achievement. FLAG-idarubicin was well tolerated. High rates of morphological and cytogenetic remission, especially in de novo MDS, offer a window of opportunity for assessment of autologous BMT in this group of diseases where no treatment except alloBMT has led to prolongation of survival.

Post-transfusion hyperhaemolysis in a patient with sickle cell disease: use of steroids and intravenous immunoglobulin to prevent further red cell destruction.

Delayed haemolytic transfusion reactions (DHTRs) are seen more frequently in patients with sickle cell disease (SCD) than in other groups of patients, and are characterised by a positive direct antiglobulin test and the appearance of previously undetected red blood cell (RBC) alloantibodies in the patient's serum. Recently a syndrome of post-transfusion hyperhaemolysis has been described in children with SCD, characterised by destruction of both autologous and transfused RBCs with negative serological findings: continuation of RBC transfusion exacerbated haemolysis further. We describe a case of life-threatening post-transfusion hyperhaemolysis in an adult patient with SCD in whom severe anaemia necessitated further RBC transfusion, which was successfully performed in conjunction with intravenous immunoglobulin. This approach may be useful in the management of post-transfusion hyperhaemolysis in SCD as well as in the management of severe DHTRs.

Relapse of chronic myeloid leukemia after allogeneic bone marrow transplant: the case for giving donor leukocyte transfusions before the onset of hematologic relapse.

Fourteen patients with chronic myeloid leukemia (CML) relapsing after allogeneic bone marrow transplant (BMT) were treated with leukocyte transfusions from the original marrow donor (sibling, n = 9; volunteer unrelated, n = 5). The relapse was defined at the molecular level in two cases, cytogenetically in five cases and hematologically in seven cases. Ten patients responded, seven of seven patients with cytogenetic/molecular relapse compared with three of seven with hematologic relapse (P < .03). All five recipients of cells from unrelated donors responded. Eight of the 10 responders have achieved polymerase chain reaction-negative status and this persisted in three patients for more than 2 years; no responder has shown sign of relapse. Reversible marrow aplasia occurred in two patients, both treated in hematologic relapse. Severe graft-versus-host disease occurred in four patients and was fatal in one. We confirm previous reports that donor leukocyte transfusions are effective in the management of CML in relapse after BMT. In this series, therapeutic intervention before the onset of hematologic relapse was associated with an increased likelihood of response and no marrow aplasia.

Binding of BCR/ABL junctional peptides to major histocompatibility complex (MHC) class I molecules: studies in antigen-processing defective cell lines.

Leukaemia-specific proteins may be recognized by T-lymphocytes as neoantigens if peptides corresponding to mutated sequences bind to major histocompatibility complex (MHC) molecules on leukaemic cells. We studied the ability of a series of synthetic peptides corresponding to the junctional sequences of BCR/ABL proteins to bind to class I molecules in two human cell lines, LBL 721.174 (T2) (HLA-A2, B5) and BM36.1 (HLA-A1, B35), and one murine cell line RMA-S (H-2Kb, Db). These cell lines are defective in intracellular peptide loading of class I molecules, resulting in markedly reduced cell surface class I expression: class I expression can be rescued by provision of peptides binding to the alleles expressed by the mutant cell. Eighteen peptides spanning the junctional sequences of the b2a2 and b3a2 proteins were tested for their ability to rescue expression of the class I alleles borne by these cells using flow cytometry. Allele-specific control peptides known to bind HLA-A2, HLA-B35, H-2Kb and H-2Db increased expression of these alleles 2- to 3-fold: 0/18 BCR/ABL peptides enhanced HLA-A2, HLA-B35 or H-2Kb expression, but three b2a2 peptides consistently increased H-2Db expression. These results suggest that BCR/ABL junctional peptides are unlikely to be presented to T-cells in association with HLA-A2, HLA-B35 or H-2Kb. Conversely, the finding that some b2a2 peptides bind specifically to H-2Db suggests that a murine model of graft-versus-leukaemia (GVL) could be constructed.

Allogeneic bone marrow transplantation for chronic myeloid leukemia using sibling and volunteer unrelated donors. A comparison of complications in the first 2 years.

OBJECTIVE: To compare the short- and medium-term complications (particularly infection) of bone marrow transplantation for chronic myeloid leukemia in patients with HLA-identical sibling donors or volunteer unrelated donors. DESIGN: Retrospective review of two cohorts of patients. SETTING: Tertiary referral center. PATIENTS: One hundred three patients with chronic myeloid leukemia in first chronic phase. INTERVENTION: Patients were treated with bone marrow transplantation using marrow from HLA-identical siblings (n = 57) and volunteer donors (n = 46). MAIN RESULTS: In total, 68 patients survived a median of 22 months from bone marrow transplant (range, 7 to 81 months). The actuarial probabilities of overall survival and leukemia-free survival at 2 years for the sibling donor group were 73% (95% CI, 60% to 86%) and 72% (CI, 60% to 84%), respectively, and for the volunteer donor group, 47% (CI, 31% to 63%) and 42% (CI, 26% to 58%) (P = 0.07 and 0.05, respectively). However, after adjustment for duration of disease, overall and disease-free survival in the two donor groups did not differ significantly. A major problem was an increased incidence of severe viral infection in the volunteer unrelated donor group (19 episodes in 16 of 46 patients compared with 7 episodes in 7 of 57 sibling donor patients, P = 0.01). The actuarial incidence of chronic graft-versus-host disease (GVHD) was higher in volunteer unrelated donor patients (77% [CI, 63% to 91%] compared with 49% [CI, 35% to 63%]; P = 0.02) but that of acute GVHD was not. The median performance status of the survivors in the volunteer donor group is similar to that in the sibling donor group. The incidence of hematologic relapse in both groups so far is low. CONCLUSION: Results appear to justify the continued use of volunteer donors in chronic-phase chronic myeloid leukemia, but infection and chronic GVHD are still major problems.

T cell and NK cell mediated graft-versus-leukaemia reactivity following donor buffy coat transfusion to treat relapse after marrow transplantation for chronic myeloid leukaemia.

Two patients with chronic myeloid leukaemia in cytogenetic relapse following T lymphocyte-depleted BMT were treated with transfusions of donor buffy coat leucocytes. In both patients the marrow reverted to a completely normal karyotype and was negative for the BCR-ABL fusion gene transcript by polymerase chain reaction analysis. Before buffy coat transfusion the cytotoxic T lymphocyte precursor frequency against pre-BMT patient leukaemia cells (Lk-CTLP) was lower than that against pre-BMT patient PHA-transformed lymphocytes (Ly-CTLP) in both cases. At 2 weeks (case 1) and 8 weeks (case 2) after transfusion this ratio inverted so that Lk-CTLP predominated. Natural killer (NK) function fell initially and then recovered to exceed pre-transfusion values prior to normalization of the bone marrow karyotype. These changes in cytotoxic T lymphocytes and NK cells following donor buffy coat transfusions for patients with relapsed chronic myeloid leukaemia after marrow transplantation support the concept of a graft-versus-leukaemia effect mediated by both MHC restricted and non-restricted pathways.

Matched unrelated donor bone marrow transplantation for chronic myeloid leukaemia in chronic phase: comparison of ex vivo and in vivo T-cell depletion.

Between January 1985 and March 1992, 48 patients with chronic phase CML underwent BMT from volunteer unrelated donors (MUD) serologically identical at HLA-A, B and DR loci. 19 patients received donor marrow ex vivo T-cell depleted (EX-TCD) with Campath monoclonal antibodies. 29 patients received unmanipulated donor marrow with CsA/MTX GVHD prophylaxis; 28 received additional intravenous antilymphocyte therapy from day +1 to +5 (IN-TCD). Overall 26 patients survive at median follow up of 362 days; actuarial survival at 3 years is 50%. 3 patients have sustained haematological relapse; actuarial leukaemia-free survival is 38%. There is no difference in overall survival between the EX-TCD and IN-TCD groups, but primary graft failure (n = 4) occurred only in the EX-TCD group, while GVHD (grade II or greater) occurred more frequently in the IN-TCD group (61% vs. 29%, p = 0.084). The optimum method for GVHD prophylaxis in MUD BMT remains uncertain.

Unresolved pulmonary embolism: the role of fibrinolysis.

A minority of patients with acute pulmonary embolism (PE) show failure of resolution when assessed by serial ventilation/perfusion (V/Q) radionuclide lung imaging. The fibrinolytic systems were studied in six such patients (group I), and in 11 patients in whom PE had resolved (group II), together with 17 healthy control subjects. Assays of the fibrinolytic system included euglobulin clot lysis times (ECLT), tissue plasminogen activator (tPA), and plasminogen activator inhibitor-1 (PAI-1). Euglobulin clot lysis times were not prolonged in the unresolved PE group, but were significantly longer in patients in group II when compared to control subjects (P < 0.03). This could not be explained either on the basis of tPA levels, which were higher in group II when compared to group I (P < 0.05) and control subjects (P < 0.02), or on the basis of PAI-1 levels which did not differ significantly between the three groups. Our inability to demonstrate derangements of fibrinolysis in the patients with unresolved PE makes defective fibrinolysis an unlikely aetiological factor in the persistence of thrombosis in these patients.

Relapse into blast crisis following bone marrow transplantation for chronic phase chronic myeloid leukaemia: a report of five cases.

A proportion of patients receiving allogeneic bone marrow transplants (BMT) for chronic myeloid leukaemia (CML) in first chronic phase relapse; most of these relapses show features of chronic phase disease. We report here a series of five patients seen at a single institution over a 10 year period who developed blast crisis as the first sign of relapse after BMT for CML in chronic phase. The blast cells were myeloid in three cases and lymphoid in two. In one case the relapse may have occurred in cells of donor origin. The possible explanations for this unusual sequence of events include incipient transformation that was not detected before BMT, undetected relapse into chronic phase proceeding into transformation post-BMT, and transformation occurring de novo post-BMT in small numbers of residual leukaemic stem cells.

HLA-identical sibling donor bone marrow transplantation for chronic myeloid leukaemia in first chronic phase: influence of GVHD prophylaxis on outcome.

We have analysed the results of treating 140 consecutive patients with chronic myeloid leukaemia (CML) in chronic phase by bone marrow transplantation (BMT) using marrow from HLA-identical siblings performed between February 1981 and July 1991. Three different regimens were used sequentially to prevent graft-versus-host disease (GVHD): cyclosporin A (CsA) alone (n = 39), T-cell depletion of donor marrow (n = 51) and CsA with methotrexate (MTX) (n = 50). Eighty-four patients (61%) survive at a median of 49 months from BMT (range 3-120). The actuarial overall and leukaemia-free survivals at 5 years were 52% and 41% respectively. The actuarial probabilities of leukaemia-free survival and haematological relapse at 2 years for the CsA only group were 65% and 4%, for the T-cell depletion group 40% and 41% and for the CsA/MTX group 68% and 6% respectively. For the T-cell depletion group the probability of leukaemia-free survival was significantly lower (P less than 0.001) and the probability of relapse significantly higher (P less than 0.001) than for other methods of GVHD prophylaxis; differences between the other two groups were not significant. Previous reports that T-cell depletion with Campath-1M results in a high rate of relapse are confirmed. Patients in the CsA/MTX group have been monitored with cytogenetic and polymerase chain reaction studies for residual BCR/ABL transcripts. We conclude that the combination of CsA/MTX is currently the best available approach to prevention of GVHD after BMT for CML and in our hands it is not associated with a major risk of relapse.

Second transplants for patients with chronic myeloid leukaemia in relapse after original transplant with T-depleted donor marrow: feasibility of using busulphan alone for re-conditioning.

Between July 1986 and March 1991, 16 patients who had relapsed after T-lymphocyte depleted bone marrow transplantation (BMT) for chronic myeloid leukaemia (CML) received a second transplant using unmanipulated marrow cells from the same HLA-identical sibling donor. The median numbers of days from first BMT to haematological relapse and to second BMT were 557 (range 273-1543) and 1211 (range 476-2310) respectively. 11 patients were in uncomplicated chronic phase at time of second BMT, and five had more advanced disease. As conditioning for second BMT, eight patients received various combinations of cytotoxic drugs, and eight received high-dose busulphan alone. Eight (50%) patients survive at a median of 424 d post-second BMT (range 158-1789) and all are free of leukaemia by conventional criteria: five had been conditioned with high-dose busulphan alone. Causes of death in the eight patients who died included relapse (n = 2), graft-versus-host disease (n = 2), interstitial pneumonitis (n = 2), and infection (n = 2). We conclude that patients relapsing into chronic phase after BMT with T-lymphocyte depleted donor marrow may be offered the option of second BMT with unmanipulated marrow from the original donor. Conditioning with high-dose busulphan alone may be safer than use of more intensive schedules.

Graft vs. leukaemia reactions in chronic myeloid leukaemia.

A 39-year-old female relapsed 36 months after allogeneic bone marrow transplantation for chronic myeloid leukaemia. Infusion of peripheral blood leucocytes from her bone marrow donor resulted in complete remission, and she remains leukaemia-free 18 months later. This case provides direct evidence for a 'graft vs. leukaemia' (GVL) effect contributing to the eradication of leukaemia after marrow transplantation. Existing evidence for GVL and its possible mechanisms are reviewed.

Graft-versus-leukaemia following allogeneic bone marrow transplantation: emergence of cytotoxic T lymphocytes reacting to host leukaemia cells.

Cytotoxic T lymphocyte precursor (CTLp) frequency assays were examined in patients with chronic myeloid leukaemia (CML) following bone marrow transplantation (BMT) using recipient lymphocytes or CML cells as targets in a 51Cr release cytotoxicity assay. Eighteen patients were studied; 11 received marrow from a fully HLA A, B and DR matched sibling donor, and six from matched unrelated donors or a partially matched sibling (one patient). Two of the unrelated donor transplant recipients received marrow depleted of T lymphocytes, and the remainder received unmanipulated marrow and cyclosporin with or without methotrexate as prophylaxis against graft-versus-host disease (GVHD). Donor cells tested before BMT did not generate CTL against the patients' leukaemia, but up to 9 months after BMT a low frequency of CTLp directed against the patients' CML cells (Lk-CTLp) was detected in all patients. The Lk-CTLp frequency was significantly lower than the frequency of CTLp directed against the recipients' PHA transformed pretransplant lymphocytes (Ly-CTLp) (p less than 0.05). Lk-CTLp showed MHC restricted cytotoxicity and did not demonstrate cytotoxicity in an NK assay. The Lk-CTLp frequency correlated with both GVHD severity and relapse: severe GVHD was only seen with Lk-CTLp frequencies greater than 1:400,000, while leukaemic relapse was only observed in two patients with Lk-CTLp frequencies less than 1:400,000. These results show that a low frequency of alloreactive cells of presumed donor origin with cytotoxic potential against residual leukaemia normally circulate after BMT. Their relationship with the graft-versus-leukaemia phenomenon and their cross-reaction with GVHD reacting cells remain to be determined.