AUTOLOGOUS STEM CELL TRANSPLANTATION

Advances in Blood Disorders The major new advances in cytogenetics, molecular biology and chemotherapy along with development of growth factors, have radically changed the clinical and basic approaches to therapy of blood disorders. The topics covered in this series reflect the many changes in this field of hematology over the last decade. Each will appear as a separate handbook, covering both clinical and laboratory aspects of blood disorders.

Series Editor Aaron Polliack Lymphoma-Leukemia Unit, Department of Hematology Hadassah University Hospital,Jerusalem, Israel

Volume 1: Diagnosis and Therapy of Acute Leukemia in Adults edited byJacob M. Rowe andJane L. Liesveld

Volume 2: Autologous Stem Cell Transplantation: Biological and Clinical Results in Malignancies edited by Angelo M. Carella

Volume 3: Drug Resistance in Leukemia and Lymphoma edited by R. Pieters, AJP. Veerman and GJL. Kaspers

Volumes in Preparation: Multiple Myeloma edited by Robert Kyle

T-Lymphoproliferative Disorders edited by Estella Matutes

This book is part of a series. The publisher will accept continuation orders which may be cancelled at any time and which provide for automatic billing and shipping of each title in the series upon publication. Please write for details.

AUTOLOGOUS STEM CELL TRANSPLANTATION

Biological and Clinical Results in Malignancies

Edited by

Angelo M. Carella COORDINATOR OF HEMATOLOGY AND ABMT UNIT,

Ospedale S. Martino, Genoa, Italy

I~ ~~o~~~~n~~:up LONDON AND NEW YORK

Copyright © 1998 Taylor & Francis

Published by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN 52 Vanderbilt Avenue, New York, NY 10017

Rout/edge is an imprint ofthe Taylor & Francis Group, an informa business

Transferred to Digital Printing 2007

All rights reserved.

No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying and recording, or by any information storage or retrieval system, without permission in writing from the publishers.

British Library Cataloguing in Publication Data

Autologous stem cell transplantation: biological and clinical results in malignancies. - (Advances in blood disorders series) 1. Autotransplantation 2. Hematopoietic stem cells­Transplantation 3. Blood - Tumors - Treatment I. Carella, Angelo M. 616.9'94'18'06

ISBN 3-7186-5933-6

Publisher's Note The publisher has gone to great lengths to ensure the quality of this reprint but points out that some imperfections in the original may be apparent

CONTENTS

Introduction to the Series IX

Preface Xl

Foreword xiii

1 Autotransplant Activity 1989-1994 R.P Gale, PA. Rowlings and]. 0. Armitage 1

2 Purification and Evaluation of Hematopoietic Stem Cells for Transplantation T.E. Thomas and PM. Lansdorp 5

3 Cytokine Regulation of Primitive Progenitors in Culture M.A.S. Moore 15

4 Isolation of both Normal and Leukemic Cells within the Hematopoietic Stem Cell Compartment of Chronic Myelogenous Leukemia Mobilized Peripheral Blood A.S. Tsukamoto, D. van den Berg, C. Reading,]. Tong, L. Murray, A. Carella, F. Frassoni, D. Snyder, G. Herzig, C. Gorin,]. LaPorte, R. Negrin, K. Blume, 1. Cunningham, D. Claxton, A. Deisseroth and R. Hoffman 27

5 Expansion and Clinical Use of Hematopoietic Progenitor Cells in Human Marrow and Peripheral Blood RJ Tushinski and R. Hoffman 33

6 Theoretical Basis for Autografting H.M. Prince and A. Keating 47

7 Pattern of Reconstitution and Relapse following Autologous Bone Marrow Transplantation for Chronic Myelogenous Leukemia A.B. Deisseroth, M. Talpaz, R. Berenson, S. Heimfeld, C. Reading, ]. Hester, M. Korbling,]. Liang, D. Seong, R. Champlin, H. Kantarjian, I. Khouri and S. Giralt 65

8 Harnessing Immune Control of Leukemia in Autografting R.~ n

v

vi CONTENTS

9 Pharmacology of High-Dose Therapy with Bone Marrow Transplantation R.B. jones, P. Cagnoni, S.I. Bearman and EJ Shpall 81

10 The Detection of Minimal Residual Disease in Acute Leukemia L. Foroni, L. Coyle, M.F Cole Sindair,JC. Yaxley,JS. Chim and A. V Hoffbrand 89

11 Marrow Contamination: Detection and Significance U.M. Gehling, c.H. Hogan, A. Gee, P. Cagnoni, W. Franklin, R.B. jones, S.I. Bearman, M. Ross and EJ Shpall 103

12 Marrow Contamination: Pharmacological Treatment S. Gulati, C. Romero, V Rizzoli and C. Carlo-Stella 115

13 Marrow Contamination: Immunological Treatment JG. Cribben 137

14 Hemopoietic Growth Factors and Autografting G. Molineux and I.K. McNiece 147

15 Autologous Graft-versus-Host Disease RJ jones and A.D. Hess 167

16 Approaches to Improving the Results of Total Body Irradiation in Marrow Transplantation FR. Appelbaum 177

17 Pretransplant Regimens without Total Body Irradiation (TBI) G. W. Santos 187

18 New Pre-transplant Regimens R.S. Negrin and K.G. Blume 195

19 How does Autologous Hemopoietic Cell Transplantation Cure Acute Myeloid Leukemia? F Frassoni and N. C. Gorin 201

20 Treatment of Acute Lymphoblastic Leukemia (ALL) in Adults: Problems and Pitfalls D. Hoelzer 211

21 Autologous Stem Cell Transplantation for Acute Lymphoblastic Leukemia in Children E. Plouvier and P. Herve 221

vii CONTENTS

22 Autologous Bone Marrow Transplantation for Acute Lymphoblastic Leukemia in Adults JM. Rowe, I.M. Franklin and H.M. Lazarus 229

23 Treatment of Acute Myloid Leukemia: State of the Art T. Buchner and L. W. Hiddemann 239

24 The Present Status of Autologous Bone Marrow Transplantation in Acute Myeloid Leukaemia A.K. Burnett 251

25 Minimal Residual Disease in Leukemia C. Saglio and F. Lo Coco 269

26 Autografting for Chronic Myelogenous Leukemia: Is there a Role? JM. Goldman and S.C. O'Brien 277

27 Autografting with Cultured Marrow for the Myeloid Leukemias: The Vancouver Experience MJ Barnett, H. G. Klingemann, CJ Eaves and A. C. Eaves 287

28 In Vivo Mobilization of PhI ­ Negative Peripheral Blood Progenitor Cells and Autografting in Chronic Myelogenous Leukemia: The Genoa Experience A.M. Carella, F. Chimirri, F. Benvenuto, O. Figari, E. Lerma, A. Dejana, E. Prencipe, L. Celesti and M. Podestd 299

29 How does Autografting Cure Aggressive Malignant Non-Hodgkin's Lymphoma? A.K. Fielding and A.H. Coldstone 307

30 The Role of Autografting in Low-grade Lymphoma J M. Vose, P. J Bierman and J O. Armitage 321

31 Autologous Stem Cell Transplantation in Intermediate and High Grade Lymphoma C. Cisselbrecht and B. Coiffier 329

32 Autografting for Lymphoblastic Lymphoma J W. Sweetenham 335

33 High Dose Therapy (HDT) in Burkitt's Lymphoma D. Frappaz, J Y. Blay, E. Bouffet, M. Brunat-Mentigny and T. Philip 341

34 Autografting for Hodgkin's Disease D.L. Longo 347

viii CONTENTS

35 The Role of Intensive Therapy and Autotransplantation for Hodgkin's Disease Patients in an Initial Complete or Partial Remission D.E. Reece 355

36 Autologous Transplants for Multiple Myeloma B. Barlogie, S. Jagannath, D.H. Vesole, N. Munshi, D. Siegel and G. Tricot 369

37 Autografting in Breast Cancer JA. Ledermann and A.L. Jones 377

38 High Dose Chemotherapy with Stem Cell Support for Miscellaneous Solid Tumors B.D. Cheson 385

39 High-Dose Therapy followed by Bone Marrow Rescue in Pediatric Solid Tumors O. Hartmann and D. Valteau-Couanet 397

40 Autografting with Blood Stem Cell in Hematological Neoplasias: Review of Indications Ph. Henon 409

41 Umbilical Cord Biology and Transplant E. Gluckman 425

42 Immunotherapy by Allogeneic Lymphocytes and Cytokines following Autologous and Allogeneic Bone Marrow Stem Cell Transplantation S. Slavin, E. Naparstek, A. Nagler, A. Ackerstein, G. Varadi, J Kapelushnik and R. Or 431

43 Immune Ablation Followed by Stem Cell Transplantation (Allogeneic) or Support (Autologous) for Severe Autoimmune Diseases Progress, Controversies and Suggested Guidelines A.M. Marmont 441

Index 451

INTRODUCTION TO THE SERIES

Much has changed in the field of hematology, particularly during the past decade. New advances in therapy and great achievements in cytogenetics, molecular biology and chemotherapy, coupled with development of growth factors, have all radically changed the clinical and basic approach to the therapy of many blood disorders. In particular, our understanding of the basic concepts of neoplasia has altered quite radically during this period of time.

The chapters covered in this series reflect these changes and each will appear as a separate handbook in the series. I have also requested the authors to summarize major issues in hematology and to cover both clinical and laboratory aspects of these disorders. These will include the addition of all new data made available via the great advances in research of these topics, which have added so much to our understanding of these disorders.

I do hope that the reader will benefit from the entire series which should be suited for all specialists and postgraduate physicians in training as well as for undergraduate teaching in hematology.

Professor Aaron Polliack, M.D. Hadassah-Hebrew University Medical Centres

Jerusalem, Israel

ix

http://taylorandfrancis.com

PREFACE

The present book aims to present the "historical" development of use of Autologous Stem Cell Transplantation (ASCT) in hematological and non hemato­logical malignancies in such a way as to preserve a proper balance between what may be called "clinical history" and "biological history" that have determinated the cause of that development at different periods.

The editor is convinced that the basis for an understanding of present-day research on ASCT in hematological and non hematological malignancies and for an enlightened attitude towards questions affecting this scientific matter today is a knowledge of the path which it has pursued in becoming what it is. For this reason, many investigators worldwide have been requested to report their experi­ence and achievements in this field.

It is a pleasure to acknowledge the many obligations incurred in the preparation of the book. To all scientists who have accepted to take part in this work; without their willingness and enthusiasm it wouldn't have been possible to collect all up-to­date reviews of the variety of therapeutic methods available today.

To Francesca Chimirri, Maria Angela Capurro, Paula Debbia for their assistance in typing and correction of the proofs.

I am indebted to Professor Alberto Marmont, not only for his introduction to the book but for his willingness at any time to share with me his scientific knowl­edge and judgment.

Finally, I should like to record the debt of gratitude which I owe to my wife for her cheerful assistance.

Angelo Michele Carella

xi

http://taylorandfrancis.com

FOREWORD

This is, under all aspects, an important book. It comprises 43 chapters, all of them written by well-established and in most cases truly outstanding investigators, both biologists and clinicians. The customary question arises, whether it is timely, gen­uinely instructive for the average hematologist-oncologist, and worthy of being included in the Olympus of 'recommended reading' . The answer is most emphati­cally affirmative, and Angelo Carella should be congratulated for the excellent selection of themes and authors.

It is quite impossible even to give an outline of the series of chapters composing this impressive volume. One general point I should like to make is that very rarely, outside of hematology, does one find a more intimate and rewarding relationship between basic biology and clinical interventions. To give an example, the very competent discussions of hematopoietic stem cells by Thomas/Lansdorp and by Malcolm Moore are quite fundamental to all clinical procedures that follow, whether utilizing marrow or peripheral stem cells; these last are discussed with his usual competence by Philippe Henon. Some contributions review simultaneously biological and clinical aspects, as in Eliane Gluckmann's state of the art discussion of cord stem cells. Will it be possible, in the near future, to concretely expand the few stem cells contained in a single, easy to perform myeloaspirate, up to the point of disposing of an adequate, promptly acting hematopoietic graft, as sug­gested by Tushinsky and Hoffman? Will it be possible to compensate/ control the telomeric attrition which is being gradually identified as the main factor of stem cell aging?

This is not to say, of course, that the clinical chapters are less informative and interesting. But it is good to know that basic pharmacology, as discussed by Jones, will perhaps render so-called conditioning regimens somewhat less empirical, and that radioimmunotherapy will perhaps replace the staid and rather immobile TB!. Other aspects that have fired my imagination are the careful analysis of the Ph­negative stem cells in CML, where Tsukamoto et al. show the greater relevance (to be expected) of FISH versus conventional cytogenetics in characterising these cells.

Immunologists will find specific chapters, such as the ones by Foa and by Slavin, interesting and stimulating. Oncologists will appreciate the able discussion by Ledermann/Jones of autografting in breast cancer, and of others on adult and pediatric solid tumors. Finally, it is indeed interesting to learn from Barlogie that more than 1,000 patients with multiple myeloma have undergone autologous transplants worldwide, and that so-called tandem autotransplants are being per­formed currently and with rewarding outcomes, as already reported in the frame­work of EBMT.

xiii

xiv FOREWORD

In conclusion, this is a book that one reads with intellectual relish and an unimaginable wealth of information. Our normal hematopoietic stem cells, wher­ever they may reside or circulate, are being collected, nourished, educated and uti­lized better and better.

Alberto M. Marmont Director Emeritus

Hematology and Bone Marrow Transplantation Center, Ospedale S. Martino, Genoa, Italy

1 AUTOTRANSPLANT ACTIVITY 1989-1994

R.P. GALE, PA ROWLINGS andJ.O. ARMITAGE

Autologous Blood & Marrow Transplant Registry - North America, Health Policy Institute, Medical College of Wisconsin, Milwaukee, USA; Division of Bone Marrow and

Stem Cell Transplantation, Salick Health Care, Inc., Los Angeles, USA; and the University of Nebraska Medical Center, Omaha, USA

Autotransplants are increasingly used to treat cancer. In 1989 the National Institutes of Health of the United States began support of the Autologous Blood & Marrow Transplant Registry (ABMTR) to study outcomes of autotransplants. The ABMTR is a voluntary scientific organization of more than 130 autotransplant centers in the US, Canada, South America, Russia, Cuba and Austria. Distribution of centers and registered cases is indicated in Table 1.

The ABMTR registers all consecutive autotransplants at participating centers. More detailed reporting is requested in specific diseases. Presently these are breast cancer, lymphomas and acute myelogenous and lymphoblastic leukemias (AML, ALL). Detailed reporting will begin soon for multiple myeloma.

The more than 14,000 autotransplants done between January 1989 and June 1994 at participating centers are summarized in Figure 1 and Table 2. Most auto­transplants (N = 5845) were for lymphomas (non-Hodgkin, N = 3708; Hodgkin, N = 2137), breast cancer (N = 4004), acute myelogenous leukemia (N = 1433) and multiple myeloma (N = 610). A detailed description is presented in Table 2. We estimate that these include about 50% of all autotransplants done in North America during this time period.

Table 3 describes the more than 3000 cases reported in detail to the ABMTR during this interval including breast cancer (N = 1346), lymphomas (N = 1134; non­Hodgkin, N = 739; Hodgkin, N = 395) and leukemia (N = 780; AML, N = 600; ALL, N = 180).

Table 1 Geographic distribution of registering teams and registered patients

Geographic Area Registering Teams Registered Patients

United States 117 13531 (88%) Canada 18 1312 (9%) South America 4 322 (2%) Other 3 109 (1%) TOTAL 142 15274

4

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1990

19

91

1992

19

93

1994

* T

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Acu

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yel

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leu

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ia

213

(13)

20

7 (1

0)

281

(10)

29

4 (9

) 29

0 (9

) 14

8 (9

) 14

33 (

10)

Acu

te l

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obla

stic

leu

kem

ia

79 (

5)

68 (

3)

80 (

3)

69 (

2)

62 (

2)

24 (

1)

382

(3)

No

n-H

od

gk

in l

ym

ph

om

a 35

9 (2

2)

541

(27)

71

1 (2

6)

858

(28)

84

7 (2

7)

392

(25)

37

08 (

26)

Ho

dg

kin

ly

mp

ho

ma

356

(21)

42

8 (2

1)

440

(16)

36

9 (1

2)

392

(12)

15

2 (9

) 21

37 (

15)

Bre

ast

can

cer

274

(16)

34

7 (1

7)

681

(25)

10

24 (

33)

1062

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) 61

6 (3

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4004

(28

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24

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147

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75

(4)

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7 (5

) 92

(3)

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) 61

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sto

ma

63 (

4)

88 (

4)

58 (

2)

75 (

2)

86 (

3)

45 (

3)

415

(3)

Tes

ticu

lar

can

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36 (

2)

65 (

3)

45 (

2)

53 (

2)

50 (

2)

9 (1

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var

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31 (

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49 (

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55 (

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33 (

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Bra

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34 (

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ance

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118

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01

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95

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a fo

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rst

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.

3 AUTOTRANSPLANT ACTIVITY 1989-1994

Figure 1 Autotransplants registered with ABMTR, 1989-94

Table 3 Autotransplants reported 1989-1994a

Acute myelogenous leukemia 600 Acute lymphoblastic leukemia 180 Non-Hodgkin lymphoma 739 Hodgkin disease 395 Breast cancer 1346

TOTAL 3260

aComprehensive clinical data available for all cases.

These data indicate increasing use of autotransplants in cancer. Future ABMTR studies will consider variables associated with transplant outcome, compare results of auto- and allotransplants and compare autotransplant outcome with other therapies.

Supported by Public Health Service Grant No. POl-CA-40053 from the National Cancer Institute, the National Institute of Allergy and Infectious Diseases, and the National Heart, Lung and Blood Institute of the D.S. Department of Health and Human Services; the D.S. Army Medical Research and Development Command; and by grants from Arngen Inc.; Astra Pharmaceutical Products; Baxter H ealth­care Corporation; Bristol-Myers Oncology; Caremark, Inc.; CellPro, Inc.; Center for Advanced Studies in Leukemia; COBE BCT, Inc.; Glaxo Pharmaceutical;

AML (n=1433

ALL (n=382) CML (n=147)

NHL (n=3708)

Other Malignancies (n=681) Neuroblastoma (n=415)

Testicular Cancer (n=258) Ovarian Cancer (n=250) CNS Tumor (n=210) Lung Cancer (n=60)

areast Cancer (n=4004)

Hodgkin Disease Multiple Myeloma (n=2137) (n=610)

n = 14,295

4 R.P. GALE, P.A. ROWLINGS and].O. ARMITAGE

Rewlett-Packard Company; Immunex Corporation; RobertJ. Kleberg,jr. and Relen C. Kleberg Foundation; Lederle Laboratories; Marion Merrell Dow Inc.; Milstein Family Foundation; Milwaukee Foundation/EIsa Schoeneich Research Fund; Ortho Biotech, Inc.; Pharmacia; Quadra Logic Technologies; Roerig/Pfizer Pharmaceut­icals; Sandoz Oncology; StemCell Technologies; SyStemix; and Upjohn Company.

13 PURIFICATION AND EVALUATION OF HEMATOPOIETIC

In summary, technical advances in scale up and cell labeling have produced a large scale lineage depletion technique capable ofpuritying human stem/progenitor cells with efficiencies comparable to current positive selection techniques. The inher­ent advantages of lineage depletion over positive selection are that it isolates a puri­fied cell population which has not been labeled with antibodies and gives the opportunity for more rigorous tumor cell purging.

It is quite possible that the optimum method for purifYing stem cells for thera­peutic use will be a combination of both positive and negative selection but one must keep in mind that any clinical protocol should be easily adapted to a stan­dard processing laboratory and take no more than a few hours. It is equally impor­tant not to loose sight of the basic clinical role of stem cell purification which is to eliminate tumor/T-cells and reduce the volume of the graft while preserving its potential for hematopoietic rescue.

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Brenner, M.K., Rill, D.R, Moen, RC., Krance, RA., Mirro,].Jr., Anderson, w.F. and Ihle,].N. (1993) Gene-marking to trace origin of relapse after autologous bone marrow transplantation. Lancet, 341, 85-86.

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14 T.E. THOMAS and P.M. LANSDORP

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24 M.A.S. MOORE

important in conjunction with cytokine combinations for cycle activating and ex vivo expansion of very early stem cells.

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31 ISOLATION OF BOTH NORMAL AND LEUKEMIC CELLS

cells was performed. The data in Table 2A and B shows the results obtained from CML chronic phase and accelerated and blast crisis MPB samples. Several signifi­cant findings can be concluded from this data. First, cells isolated based on a HSC phenotype, CD34+Thy-PLin-, do contain Ph+ cells. These results suggest that the lack of detection of bcr/abl transcripts in purified HSC containing populations using the PRC based assay may be due to lack of transcription of the fusion product in these quiescent cells. A comparison of the percent Ph+ cells in the Thy-l+and Thy-l- fractions shows that the Thy-l- cells contain a higher percentage of Ph+ cells than the Thy-l + HSC fraction. This difference is more significant in chronic phase samples (p = 0.034). These results suggest that one can reduce the total number of disease cells in a graft by using additional selection parameters in conjunction with CD34 selection. The data presented in Table 2B are results from MPB samples obtained from patients in accelerated phase or blast crisis. These samples show a marked increase in the percentages of Ph+ cells in both the Thy-P and Thy-l- samples. The finding that >50% of the HSC containing CD34+Thy­l-Lin- population are Ph+ would indicate that isolation of benign HSC's would be difficult from this patient population. Additional or alternate parameters would need to be employed to obtain HSC's reduced in Ph+ cells.

CONCLUSIONS

The detection and isolation of benign stem cells, devoid of the bcr-abl transloca­tion from MPB samples of CML patients supports both clinical and experimental observations of the presence of normal hematopoietic cells in in vivo and in vitro cultures. Many challenges lie ahead for the successful isolation of these normal HSC's. These include defining optimal harvest procedures for peripheralized stem cells in CML patients. The data presented here would indicate that a greater number of benign stem cells can be obtained from chronic phase patients than from patients in either acute phase or blast crisis. However, even when HSC's were purified from samples obtained from chronic phase patients, one detects some level of Ph+ cells. Is this level of Ph+ cells present in the stem cell graft sufficiently large to lead to hematological relapse? These are key questions which need to be addressed before proceeding with the isolation of CD34+Thy-l +Lin- cells as HSC grafts in these patients. Alternatively, one must search for additional selection parameters for the isolation of HSC's that are entirely free ofleukemic cells.

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40 R]. TUSHINSKI and R HOFFMAN

expand the grafts of patients who do not mobilize adequately, or to totally avoid mobilization and create an expanded hematopoietic cell graft from marrow aspi­rate specimens that could be obtained under local anesthesia. Another possibility would be to generate an expanded graft ex vivo from the mononuclear cells present in a unit of whole blood, thereby avoiding the inconvenience and cost of mobilization entirely. Although these approaches appear highly speculative, the technology to achieve many of these goals are presently available.

Transfer of genetically modified somatic cells will likely play an important role in the treatment of a growing number diseases. Gene transfer into hematopoietic stem cells has remained problematic. Bienzle et al. has recently shown that gene transfer into hematopoietic cells is facilitated by long-term ex vivo cultureYo By exposing hematopoietic cells in LTBMC to a replication-defective retrovirus, bearing the reporter gene neo, on multiple occasions during 21 days of LTBMC, this group using a canine system have shown remarkable success of gene transfer into cells which can sustain hematopoiesis for several yearsYo These studies suggest that such ex vivo expansion systems may serve as optimal targets for gene therapy involving adoptive transfer of transduced hematopoietic cells.

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45 HUMAN MARROW AND PERIPHERAL BLOOD

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70 AB. DEISSEROTH ET AL.

CONCLUSIONS

These results show that the autologous cells used for transplant are indeed con­tributing to hematopoietic recovery not only immediately after transplant but also for very extended periods after transplant.7 In addition, these studies very strongly suggest that the original conclusions of Carella,4 that collection of peripheral blood cells soon after the recovery from conventional dose chemotherapy-induced myelosuppression results in populations enriched in diploid cells, were correct. Finally, the marking studies as well as the experience with autologous transplants using these cells suggest that residualleukemic cells in the autologous transplants can contribute to recovery. These results suggest that more attention in the future needs to be devoted to the use of ex vivo fractionation methods so as to make autol­ogous bone marrow transplants less likely to result in a relapse following treatment.

ACKNOWLEDGEMENTS

The authors recognize support given to Albert Deisseroth from the NCI (PO! CA49639, The Therapy of CML, and ROl CA58655), the Bush Leukemia Fund, and the Anderson Chair for Cancer Treatment and Research. Many thanks to Rosemarie Lauzon andJoyce Palmer for editorial assistance.

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71 RECONSTITUTION FOR CHRONIC MYELOGENOUS LEUKEMIA

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78 R.FOA

following incubation in the presence of low dose IL2 plus IL12. These data open the way to considering new cytokine combinations with IL2 for the management of acute leukemia.

Although autografted patients would appear the ideal candidates for such approaches of "immunomanipulation", based on the clinical results so far obtained with exogenous IL2 in patients with evidence of disease (4,5) and on the above mentioned demonstration that an autologous lytic machinery may be gen­erated against autologous blasts, one should also take into account the possibility that a measurable proportion of leukemic cells may be necessary in order to induce the activation of effector cells with lytic potential against the host tumor. Should this be the case, the feasibility of activating cytokine gene therapy proto­cols would deserve further attention. In this respect, studies will need to investi­gate whether cytokine gene transduced leukemic cells enable better conditions of immunological harnessing compared to cultures set up with comparable levels of exogenous molecules. This has been recently documented in human melanoma where IL2 gene transduced neoplastic cells proved to be better stimulators of an autologous specific recognition compared to exogenous IL2 (16).

Based on our present knowledge it can be foreseen that an adequate exploit­ment of the immune compartment of tumor bearing patients is likely to become a true therapeutic option for the management of different neoplasms, including acute leukemia.

ACKNOWLEDGMENTS

Work supported by Associaxione Italiana per la Ricerca suI Cancro (AIRC), Milan, Special Project on "Gene Therapy" and by Consiglio Nazionale delle Ricerche (CNR), "Applicazioni Cliniche delta Ricerca Oncologica" (ACRO), Roma, Italy.

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80 R. FOA

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87 PHARMACOLOGY OF HIGH-DOSE THERAPY

marrow, and avoidance of unnecessary toxicity. Optimization of chemotherapy and irradiation may be the single most important method for improving the ther­apeutic index of these programs. In vitro, virtually every anticancer drug produces increases in killing of sensitive tumor cells with increasing dose (24). Therapeutic improvement is magnified when multiple agents are used, because multiple cellu­lar pathways for antitumor effects are exploited. However, as the number of drugs and modalities that are used to treat these patients increase, there is a geometric increase in the probability of drug-drug interactions producing toxicity or at least outcomes which are more difficult to predict.

The data cited in this chapter illustrate how PK/PD analysis can improve our understanding of the seemingly capricious variation in outcome often observed in patients undergoing transplantation. This analysis should also point the way to methods to improve outcome for these patients. Since fatal organ toxicity remains an all too common outcome for transplant patients, further efforts to exploit and expand this knowledge seem warranted.

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97 THE DETECTION OF MINIMAL RESIDUAL DISEASE IN ACUTE LEUKEMIA

SUMMARY

MRD detection at the morphological, clinical and molecular level remains a very important analysis in the assessment of the quality of complete remission of leukaemic patients. Through the past 10 years different approaches had been taken as new and progressively more sensitive techniques became available. Targeting the leukaemic clone, feasibility and sensitivity are the most important parameters for the choice of the ideal method of investigation. In Table 2 differ­ent approaches, and relative sensitivity of each method discussed in this chapter have been listed. Although cytogenetic and Southern blotting remain valid and relatively fast methods of investigation for the detection of clones at presentation, PCR remains the most sensitive technique for the investigation of MRD in remis­sion patients. Several studies have indicated that contamination is the most impor­tant technical problem, oligoclonality and change of clonality represent the most cumbersome biological problems for this type of investigation. However, longer trials with collection of samples at more regular interval, comparison of different randomised studies using bone marrow transplantation and chemotherapy, com­parison between autologous and allogeneic BMT are awaited to put the PCR approach to its finals test. The final aim of all these MRD studies is to provide prognostic information. These data that will help to improve therapy and results in improved DFS in acute leukaemia patients.

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CONCLUSION

Whether hematopoietic cell purging or purification improves the clinical outcome of patients remains to be determined. It is clear that further refinements in methods for tumor cell detection and careful, comprehensive correlation with clinical results is required before definitive answers can be obtained.

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131 PHARMACOLOGICAL TREATMENT

the absence of marked relapse, rather than an effect on survival or relapse, even small-scale clinical trials could be informative.

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142 ].G. GRlBBEN

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31. Montgomery, R.B., Kurtzberg.J., Rhinehardt-Clark, A, Haleen, A, Ramakrishan, S., Olsen, G.A, Peters, W.P., Smith, C.A., Haynes, B.F., Houston, L.L. and Bast, RC. (1990) Elimination of malig­nant clonogenic T cells from human bone marrow using chemoimmunoseparation with 2'­deoxycoformycin, deoxyadenosine and an immunotoxin. Bone Marrow Transplantation, 5, 395-402.

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33. Gribben, J.G., Saporito, L., Barber, M., Blake, KW., Edwards, RM., Griffin, J.D., Freedman, AS. and Nadler, L.M. (1992) Bone marrows of non-Hodgkin's lymphoma patients with a bcl-2 translo­cation can be purged of polymerase chain reaction-detectable lymphoma cells using monoclonal antibodies and immunomagnetic bead depletion. Blood, 80, 1083-9.

34. Berenson, RJ., Bensinger, W.1. and Hill, RS. (1991) Engraftment after infusion of CD34+ marrow cells in patients with breast cancer or neuroblastoma. Blood, 77, 1717-1722.

35. Anderson, KC., Andersen,J., Soiffer, R, Freedman, AS., Rabinowe, S.N., Robertson, M.]., Spector, N., Blake, K, Murray, C., Freeman, A.S., Coral, F., Marcus, KC., Mauch, P., Nadler, L.M. and Ritz,J. (1993) Monoclonal antibody-purged bone marrow transplantation therapy for multiple myeloma. Blood, 82, 2568-2576.

36. Simonsson, B., Burnett, A.K, Prentice, H.G., Hann, I.H., Brenner, M.K, Gibson, B., Grob, J.P., Lonnerholm, G., Morrison, A, Smedmyr, B., Todd, A., Oberg, G., Gilmore, M., Campana, D. and Totterman, T. (1989) Autologous bone marrow transplantation with monoclonal antibody purged marrow for high risk acute lymphoblastic leukemia. Leukemia, 3, 631-6.

37. Billett, AL., Kornmehl, E., Tarbell, N.]., Weistein, H.]., Gelber, RD., Ritz,J. and Sallan, S.E. (1993) Autologous bone marrow transplantation after a long first remission for children with recurrent acute lymphoblastic leukemia. Blood, 81, 1651-1657.

38. Robertson, MJ., Soiffer, RJ., Freedman, AS., Rabinowe, S.N., Anderson, KC., Ervin, T.]., Murray, C., Dear, K, Griffin,J.D., Nadler, L.M. and Ritz,J. (1992) Human bone marrrow depleted ofCD33­positive cells mediates delayed but durable reconstitution of hematopoiesis: clinical trial of My9 monoclonal antibody-purged autigrafts for the treatment of acute myeloid leukemia. Blood, 79, 2229-2236.

39. De Fabritiis, P., Ferrero, D., Sandrelli, A, Tarella, C., Meloni, G., Pulsoni, A, Pregno, P., Badoni, R, De, F.L., Gallo, E., Amadori, S., Mandelli, F. and Pileri, A (1989) Monoclonal antibody purging and autologous bone marrow transplantation in acute myelogenous leukemia in complete remis­sion. Bone Marrow Transplant, 4, 669-74.

40. Humblet, Y, Feyens, A.M., Sekhavat, M., Agaliotis, D., Canon, J.L. and Symann, M.L. (1989) Immunological and pharmacological removal of small cell lung cancer cells from bone marrow autografts. Cancer Res., 49, 5058-61.

41. Kemshead, J.T., Heath, L., Gibson, F.M., Katz, F., Richmond, F., Treleaven, J. and Ugelstad, J. (1986) Magnetic microspheres and monoclonal antibodies for the depletion of neuroblastoma cells from bone marrow: experiences, improvements and observations. Br.]. Cancer, 54, 771-8.

42. Combaret, v., Favrot, M.C., Chauvin, F., Bouffet, E., Philip, I. and Philip, T. (1989) Immuno­magnetic depletion of malignant cells from autologous bone marrow graft: from experimental models to clinical trials.]. Immunogenet, 16, 125-36.

43. Saleh, RA., Gross, S., Cassano, W. and Gee, A. (1988) Metastatic retinoblastoma successfully treated with immunomagnetic purged autologous bone marrow transplantation. Cancer, 62, 230l-3.

44. Brenner, M.K, Rill, D.R, Moen, RC., Kcance, RA, Mirro,J., Anderson, W.F. and Ihle,J.N. (1993) Gene-marking to trace origin of relapse after autologous bone-marrow transplantation. Lancet, 341, 85-86.

45. Rill, D.R, Santana, V.M., Roberta, W.M., Nilsen, T., Bowman, L.C., Kcance, RA, Heslop, H.E., Moen, RC., Ihle, J.N. and Brenner, M.K (1994) Direct demonstration that autologous bone marrow transplantation for solid tumors can return a multiplicity of tumorigenic cells. Blood, 84, 380-383.

145 IMMUNOLOGICAL TREATMENT

46. Kemshead,J.T., Treleaven,J., Heath, L. , Meara, A.O., Gee, A. and Ugelstad,J. (1987) Monoclonal antibodies and magne tic microspheres for the depletion ofleukemic cells from bone marrow har­vested for autologous transplantation. Bone Marrow Transplantation, 2, 133-139.

47. Preijers, F.W.M.B., De Witte, T., Wessels,J.M.C., De Gast, G.C., Van Leewen, E., Capel, PJA. and Haanen, C. (1989) Autologous transplantation of bone marrow purged in vitro with anti­CD7-(WT1-) ricin A immunotyoxin in T-cell lymphoblastic leukemia and lymphoma. Blood, 74, 1152-1158.

48. Uckun, F., Kersey, J.H., Vallera, D.A., Ledbetter, J.A. , Weisdorf, D. , Myers, D.E., Kaake, R. and Ramsey, N.KC. (1990) Autologous bone marrow transplantation in high risk remission T-lineage acute lymphoblastic leukemia using immunotoxins plus 4-hydroperoxycyclophosphamide for mar row purging. Blood, 76, 1723-1733.

160 G. MOLINEUX and I.K McNIECE

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Schmitz, N., Linch, D.C., Dreger, P., Boogaerts, M.A., Goldstone, AH., Ferrant, A et al. (1994) A ran­domized phase III study of filgrastim-mobilised peripheral blood progenitor cell transplantation (PBPCT) in comparison with autologous bone marrow transplantation (ABMT) in patients with Hodgkins disease (HD) and non-Hodgkins lymphoma (NHL). Blood, supplement to 84, 204a.

Schmitz, N., Dreger, P., Suttorp, M., Rohwedder, E.B., Haferlach, T., Loffler, H. et al. (1995) Primary transplantation of allogeneic peripheral blood progenitor cells mobilized by filgrastim (granulocyte colony-stimulating factor). Blood, 85,1666.

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Sheridan, WP., Beglet, C.G.,Juttner, C.A., Szer,J., To, L.B., Maher, D. et al. (1992) Effect of peripheral­blood progenitor cells mobilised by filgrastim (G-CSF) on platelet recovery after high-dose chemo­therapy. Lancet, 339, 640.

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165 HEMOPOIETIC GROWTH FACTORS AND AUTOGRAFTING

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172 RJ.JONES and A.D. HESS

contrast to most hematologic malignancies, breast cancers usually do not constitu­tively express la antigen.14,15 However, la-expression can be induced in most breast cancers with the use of gamma-interferon.15 Therefore, we initiated a pilot clinical trial with interferon-y to augment CsA-induced autologous GVHD in patients undergoing autologous BMT for metastatic breast cancer.46 36 women undergoing autologous BMT for metastatic breast cancer still responding to conventional-dose salvage therapy were treated with CsA at 2.5 mg/ kg/ day for 28 days and interferon­I' at 0.025mg/m2 SC every other day from day 7 to 28. Although the incidence of autologous GVHD (56%) was unchanged with interferon-I', the degree was signifi­cantly increased. Stage III skin rash (involvement of >50% of body) occurred in 36% of patients on interferon-y46 compared to 3% of the breast cancer patients who received just CsA.45 However, the autologous GVHD remained self-limited with no evidence of visceral GVHD and only 2 patients requiring systemic steroids. There was no delay of engraftment or other toxicity attributable to interferon. Moreover, there may be an improved antitumor effect in the patients receiving interferon-I'. At a median follow-up over 3 years, the event-free survival in the patients who received interferon-ywas 42% compared to 12% in those who received only CsA.

The combination of interferon and low-dose IL-2 is the most effective approach for enhancing the efficacy of CsA-induced autologous GVHD in animal models. In pilot clinical studies, the addition of interferon to CsA-induced autologous GVHD appears to have produced the predicted immunomodulatory effects and an improved outcome. We are just beginning clinical trials combining IL-2 and inter­feron with CsA in both refractory hematologic malignancies and metastatic breast cancer.

CONCLUSIONS

CsA-induced autologous GVHD appears to generate immunologic antitumor activ­ity that is similar in magnitude to that seen with allogeneic GVHD. However, whereas the beneficial immunologic antitumor activity associated with allogeneic BMT is offset by the toxicity of allogeneic ,GVHD, autologous GVHD appears to improve the disease-free survival because it does not increase post-transplant mor­tality. Since autologous GVHD is a mild, self-limited disease, it is possible that the antitumor effect associated with this syndrome could be amplified without sub­stantially increasing toxicity. Furthermore, it appears that the clinical antitumor activity of autologous GVHD can be enhanced by immunomodulation of either the effector cells of the syndrome, the tumor cells, or both.

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173 AUTOLOGOUS GRAFT-VERSUS-HOST DISEASE

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174 R].JONES and AD. HESS

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175 AUTOLOGOUS GRAFT-VERSUS-HOST DISEASE

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184 F.R. APPELBAUM

Table 3 The influence of various factors on the effects of TBI

Effects

Factor Marrow Immuno­ Toxicities Ablation Suppression

Early Late

Increased dose i i i i

Increased dose rate i i i i Dose fractionation No change or J.a J. No change J.

Directed TBI i or J.b or J. or

aDose rate dependent. hAs desired.

toxicities. At high dose rates, dose fractionation diminishes the myeloablat­ive effects of TB!. Directed radiotherapy can diminish early toxicities without diminishing marrow ablative or anti-tumor effects. The utility of this approach as an immunosuppressive regimen is unknown but under active investigation.

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192 G.w. SANTOS

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Grochow, L.B. (1993) Busulfan disposition: The role of therapeutic monitoring in bone marrow trans­plantation induction regimens. Seminars in Oncology, 20(suppl. 4), 18-25.

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193 PRETRANSPLANT REGIMENS WITHOUT TOTAL BODY IRRADIATION (TBI)

Linker, C.A, Damon, L.E., Ries, C.A., Rugo, H.S. and Wolf, J.L. (1993) Busulfan plus etoposide as a preparative regimen for autologous bone marrow transplantation for acute myelogenous leukemia: An update. Seminars in Oncology, 20(suppl. 4), 40-48.

Mandelli, F., Razzoli, V. and Carrella, AM. (1986) Italian Study Group Autologous BMT, Massive cytore­ductive therapy (MCT) and autologous BMT after intensive conventional chemotherapy in CR­IANLL patients. Bone Marrow Transplantation, 1 (suppl. 1), 259-260.

Michel, G., Gluckman, E., Experou-Bourdeau, H., Reiffens, J., Pico, J.L., Bordigoni, P. et al. (1994) Allogeneic bone marrow transplantation for children with acute myeloblastic leukemia in first com­plete remission: Impact of conditioning regimen without total-body irradiation - a report from the Societe Francaise de Greffe de Moelle. Journal of Clinical Oncology, 12, 1217-1222.

Phillips, G.L. and Reece, D.E. (1986) Clinical studies of autologous bone marrow transplantation in Hodgkin's disease. In Goldstone, A.H. (ed.) Clinics in Hematology - Autologous Bone Marrow Transplantation, W.B. Saunders Company, Philadelphia, pp. 151-166.

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Santos, G.W. (1983) History of bone marrow transplantation. Clinics in Haematology, 12, 611-639. Santos, G.W. (1989) Marrow transplantation in acute non-lymphocytic leukemia. Blood, 74, 901-908. Santos, G.W. (1991) Bone marrow transplantation: Current studies. In Spivak, J.L., Bell, W.R.,

Quesenberry, PJ. and Wiernik, P.H. (eds.) Yearbook of Hematology, Yearbook-Mosby, Chicago, IL, pp. 181-201.

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Thomas, E.D., Storb, R., Fefer, A, Slichter, SJ., Bryant,J.I., Buckner, C.D. et al. (1972) Aplastic anaemia treated by marrow transplantation. The Lancet, 1, 284-289.

Tutschka, PJ., Copelan, E.A. and Klein,J.P. (1987) Bone marrow transplantation for leukemia follow­ing a new busulfan and cyclophosphamide regimen. Blood, 70, 1382-1388.

Yeager, A.M., Wagner, J.E., Graham, M.L., Jones, RJ., Santos, G.W. and Grochow, L.B. (1992) Optimization of busulfan dosage in children undergoing bone marrow transplantation: A pharma­cokinetic study of dose escalation. Blood, 80, 2425-2428.

198 RS. NEGRIN and K.G. BLUME

collected PBPCs. A variety of diseases have been treated in this fashion including breast cancer, Hodgkin's disease, non-Hodgkin's lymphoma with impressive response rates. Many of these regimens have been administered on an outpatient basis with gastrointestinal and pulmonary toxicity being the major limiting factors. Future studies are required to definitively test the validity of this approach com­pared to standard autografting or dose-intensive chemotherapy with only growth factor support.

RADIOLABELLED MONOCLONAL ANTIBODIES

The maximally tolerated dose of total body irradiation is approximately 1,500 cGy. In randomized studies of two different doses of total body irradiation (1220 vs. 1575 cGy), decreased relapse rates were observed with the higher dose which was offset by an increased incidence of regimen related extramedullary toxicity (Clift et al., 1990; Clift et al., 1991). This suggested that if the radiation could be locally delivered to tumor or medullary sites with decreased exposure to other sites that this may improve tumor control without compromising the patient due to toxicity. One approach has been to conjugate monoclonal antibodies (MAb) with high energy emitting radioisotopes which would allow targeting to the tumor and marrow with potentially decreased dose to other organs such as the liver, lungs and kidneys. A recent report documented the use of 1311 conjugated CD45 with FTBI/Cy to prepare patients with leukemia for autografting. MAb directed against CD45 was utilized because this cell surface glycoprotein is broadly expressed by hematopoietic cells but is not expressed by non-hematopoietic cells (Omary 1980). In this study, 20 patients with acute leukemia were treated with 1311 conju­gated anti-CD45 with estimated marrow doses of 4,000-30,000 cGy followed by FTBI/Cy. Estimated doses to the liver were 3,500-7,000 cGy. Toxicity was no greater than that expected with FTBI/Cy and excellent responses were noted (Matthews et al., 1995). A variety of other MAbs and radioisotopes are likely to be tested in the future. This exciting approach opens the possibility of directing the preparative regimen to sites of disease and thereby sparing normal tissues. A concern is that the high doses of radiation that are delivered to the marrow microenvironment may destroy stromal cells. In addition, delivery of radiolabelled MAbs requires sophisticated expertise, equipment and shielding of the patient to avoid risk to health care workers.

REFERENCES

Blume, K.G., Forman, SJ., O'Donnell, M.R. et al. (1987) Total body irradiation and high-dose etopo­side: A new preparatory regimen for bone marrow transplantation in patients with advanced hema­tologic malignancies. Blood, 69, 1015-1020.

Chao, N.]., Kastrissios, H., Long, G.D., Negrin, R.S., Horning, SJ., Wong, RW. et al. (1995) A new preparatory regimen for autologous bone marrow transplantation for advanced lymphoid malignan­cies: lomustine (CCNU), etoposide and cyclophosphamide. Cancer, in press.

199 NEW PRE-TRANSPLANT REGIMENS

Chao, Nj., Stein, AS., Long, G.D., Negrin, RS., Arnylon, M.D., Wong, RM. et al. (1993) Busulfan/ etoposide - initial experience with a new preparatory regimen for autologous bone marrow trans­plantation in patients with acute nonlymphoblastic leukemia. Blood, 81, 319-323.

Clift, RA, Buckner, C.D., Appelbaum, F.R., Bearman, S.I., Peterson, F.B., Fisher, L.D. et al., (1990) Allogeneic marrow transplantation in patients with acute myeloid leukemia in first remission. A ran­domized trial of two irradiation regimens. Blood, 76, 1867-1871.

Clift, RA., Buckner, C.D., Appelbaum, F.R, Bryant, E., Bearman, S.I., Peterson, F.B. et al. (1991) Allogeneic marrow transplantation in patients with chronic myeloid leukemia in the chronic phase. A randomized trial of two irradiation regimens. Blood, 77, 1660-1665.

Crown,]., Warrerheit, C., Hakes, T., Fennelly, D., Reich, L., Moore, M. et al. (1992) Rapid delivery of multiple high-dose chemotherapy courses with granulocyte colony-stimulating factor and peripheral blood-derived progenitor cells.] Natl. Cancer Institute, 84,1935-1936.

Crown,]., Kritz, A, Vahdat, L., Reich, L., Moore, M., Hamilton, N. et al. (1993) Rapid administration of multiple cycles of high-dose myelosuppressive chemotherapy in patients with metastatic breast cancer.] Clin. On col. , 11, 1144-1149.

Deeg, Hj., Flournow, N., Sullivan, K.M. et al. (1984) Cataracts after total body irradiation and marrow transplantation: a sparing effect of dose fractionation. Int.] Radiat. Oncol. BioI. Phys., 10,957-964.

Gassbard, M.H., Maraninchi, D., Stoppa, AM. et al. (1988) Intensive chemotherapy with high doses of BCNU, etoposide, cytosine arabinoside and melphalan (BEAM) followed by autologous bone marrow transplantation: toxicity and antitumor activity in 26 patients with poor risk malignancies. Cancer Chemother. Pharmacol., 22, 256--262.

Horning, Sj., Negrin, R.S., Chao, NJ., Long, G.D., Hoppe, RT. and Biume, K.G. (1994) Fractionated total body irradiation, etoposide and cyclophosphamide and autografting in Hodgkin's disease and non-Hodgkin's lymphoma.] Clin. Oncol., 12,2552-2558.

Linker, C.A, Ries, C.A, Damon, L.E. et al. (1993) Autologous bone marrow transplantation for acute myeloid leukemia using busulfan plus etoposide as a preparative regimen. Blood, 81, 311-318.

Long, G.D., Negrin, RS., Hoyle, C.F., Kusnierz-Glaz, C.R., Schriber, ].R., Biume, K.G. and Chao, N j. (1995) Multiple cycles of high dose chemotherapy supported by hematopoietic progenitor cells as treatment for patients with advanced malignancies. Cancer, 76, 860-868.

Matthews, D.C., Appelbaum, F.R, Eary, ].F., Fisher, D.R, Durack, L.D., Bush, S.A. et al. (1995) Development of a marrow transplant regimen for acute leukemia using targeted hematopoietic irra­diation delivered by 13lI-labeled anti-CD45 antibody, combined with cyclophosphamide and total body irradiation. Blood, 85, 1122-1131.

Negrin, R.S., Kusnierz-Glaz, C.R, Still, B., Schriber, ].R, Chao, NJ., Long, G.D. et al. (1995) Transplantation of density enriched and purged peripheral blood stem cells from a single apheresis product in patients with non-Hodgkin's lymphoma. Blood, 85, 3334-3341.

Omary, M.B., Trowbridge, I.S. and Battifora, H.A (1980) Human homologue of murine T-200 glyco­protein.] Exp. Med., 152, 842-852.

Peters, W.P., Ross, M., Vredenburgh,Jj. , Meisenberg, B., Marks, L.B., Winer, E. et al. (1993) High-dose chemotherapy and autologous bone marrow support as consolidation after standard-dose adjuvant therapy for high-risk primary breast cancer.] Clin. Oncol., 11, 1132-1143.

Peters, W.P., Shpall, Ej., Jones, RB. et al. (1988) High-dose combination alkylating agents with bone marrow support as initial treatment for metastatic breast cancer.] Clin. Oncol., 6, 1368-1376.

Reece, D.E., Barnett, MJ., Connors,].M. et al. (1991) Intensive chemotherapy with cyclophosphamide, carmustine and etoposide followed by autologous bone marrow transplantation for relapsed Hodgkin's disease.] Clin. Oncol., 9,1871-1879.

Reece, D.E., Connors,].M., Spinelli,Jj. et al. (1994) Intensive therapy with cyclophosphamide, carmus­tine, etoposide +/- cisplatin and autologous bone marrow transplantation for Hodgkin's disease in first relapse after combination chemotherapy. Blood, 83,1193-1199.

Shea, T.C., Mason,].R, Storniolo, A.M., Newton, B., Breslin, M., Muller, M. et al. (1992) Sequential cycles of high-dose carboplatin administered with recombinant human granulocyte-macrophage colony-stimulating factor and repeated infusions of autologous peripheral-blood progenitor cells: A novel and effective method for delivering multiple courses of dose-intensive therapy.] Clin. Oncol., 10,464-473.

200 RS. NEGRIN and K.G. BLUME

Thomas, E.D. , Clift, RA., Hersman, J. et al. (1982) Marrow transplantation for acute nonlymphocytic leukemia in first remission using fractionated or single-<iose irradiation. Int. J Radiat. Oncol. Bioi. Phys., 8, 817-82l.

Tricot, G.,Jagannath, S., Vesole, D., Nelson,]., Tindle, S., Miller, L. et at. (1995) Peripheral blood stem cell transplants for multiple myeloma: identification of favorable variables for rapid engraftment in 225 patients. Blood, 85, 588-596.

Tutschka, RJ., Copelan, E.A. and Klein, ].P. (1987) Bone marrow transplantation for leukemia follow­ing a new busulfan and cyclophosphamide regimen. Blood, 70,1382-1388.

Valteau, D., Hartrnann, 0 ., Benhamou, E. et al. (1988) Nonbacterial nonfungal interstitial pneumonitis following autologous bone marrow transplantation in children treated with high dose chemotherapy without total-body irradiation. Transplantation, 45, 737-740.

Weaver, C.H., Petersen, F.B., Appelbaum, F.R et al. (1994) High-<iose fractionated total-body irradia­tion, etoposide, and cyclophosphamide followed by autologous stem-cell support in patie nts with malignant lymphoma. J Glin. Oncol. , 12,2559-2566.

Wheeler, C., Antin, ].H., Churchill, W.H. et al. (1990) Cyclophosphamide, carmustine and etoposide with autologous bone marrow transplantation in refractory Hodgkin's disease and non-Hodgkin's lymphoma: a dose-finding study. J Glin. Oncol., 8, 648-656.

208 F. FRASSONI and N.C. GORIN

RELEVANCE OF THE NUMBER OF NORMAL HEMOPOIETIC CELLS GRAFTED

Although a major emphasis has been directed toward the identification of MRD there is a complementary aspect that deserves the same kind of attention and investment.

Normal marrow is essential for the cure of leukemia until we are able to con­vince leukemic cells to behave as normal ones by finding "magic hematopoietic factors". It is likely that the competition between normal and leukemic marrow is crucial in the final outcome of BMT, as mentioned above.

Very soon we will be able to evaluate whether the number of hemopoietic cells play a major role in preventing relapse in allogeneic transplants since with the use of donor peripheral blood cells the inoculum contains many more stem cells than previously obtained with marrow. In the autologous setting the evaluation of the normal marrow has been poorly explored. Nevertheless data have already been produced independently in two centers (14,27) indicating a lower relapse rate in patients autografted with higher numbers of clonogeneic hemopoietic cells.

In conclusion, autografting in acute myeloid leukemia seems to be the best ther­apeutic choice for patients with AML who lack an HLA identical donor. However, at present, a major concern is the feasibility of autografting: one would have pre­dicted that autografting might be offered to many more patients than allografting but the current trials indicate that this is not the case. This was a common feature in most recent trials; major efforts should be made to design trials with the aim of considerably increasing the number of patients who can profit from autografting.

It is likely that to improve the results and to reduce the relapse incidence new strategies should be introduced. At the moment, it is unclear whether boosting the autologous immune response may add substantial benefit, but this is worth pursu­ing (28).

ACKNOWLEDGMENTS

This work was supported by Associazione Italiana per la Ricerca suI Cancro -Milano 1995.

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209 TRANSPLANTATION CURE ACUTE MYELOID LEUKEMIA

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14. Laporte, ].P., Douay, L., Lopez, M. et al. (1994) One hundred twenty five adult patients with primary acute leukemia autografted with marrow purged by mafosfamide: A 10 year single institu­tion experience. Blood, 84, 3810.

15. Spooncer, E., Fairbe irn, L., Cowling, GJ. et al. (1994) Biological consequences of p160 v-abl protein tyrosine kinase activity in a primitive, multipotent haemopoitic ce ll line. Leukemia, 8, 620.

16. Frassoni, F., Sessarego, M., Bacigalupo, et al. (1988) Competition between normal and leukemic cells after bone marrow transplantation for chronic myeloid leukemia. Br. J. Haematol., 69, 471.

17. Giralt, S., Escudler, S., Kantarjian, H. et al. (1993) Preliminary results of treatment with filgastrim for relapse leukemia and myelodisplasia after allogeneic bone marrow transplantation. N. Engl. J. Med., 329, 757-761.

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28. Foa, R (1993) Does interlukin-2 have a role in the management of acute leukemia? J. Clin. Oncol. , 11,1817.

217 PROBLEMS AND PITFALLS

outcome. In B-ALL the CR and LFS rates could not only be improved but also the duration of treatment considerably reduced from the conventional regimens of 2-2' / 2 years to schedules lasting only three months. In addition, these treatment regimens have implications for new treatment approaches to high-grade lym­phoblastic lymphomas e.g. for Burkitt's lymphoma. Also in T-ALL it has to be eval­uated whether a shorter treatment period e.g. of 1 year, is sufficient. Common ALL, corresponding to the standard-risk children with ALL, is still the subgroup where apparently longer treatment (2 years) is needed. For this subtype, as well as for the others, monitoring by detection of minimal residual disease is to be recom­mended. The role of BMT in first CR, either for all patients or for selected high­risk patients, is under investigation. In particular, the role of autologous BMT most probably with purging and the value of unrelated BMT have to be determined for adult ALL. A significant change in the overall outcome seems to be possible only if the treatment results for elderly patients and for high-risk groups such as Ph/BCR­ABL positive ALL can be improved.

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20. Lluesma-Gonalons, M., Pavlovsky, S., Santarelli, M.T., Eppinger-Helft, M., Dorticos Bavea, E., Corrado, C. and Carnot, j. and members of GATLA-GLATHEM. (1991) Improved results of an intensified therapy in adult acute lymphocytic leukemia. Ann. Oncol., 2, 33-9.

21. Ludwig, W-D., Rieder, H ., Bartram, C.R , Griesinger, F., Hossfeld, D.K, Heinze, B., Gakbuget, N., Herrmann, F. , Hiddemann, W., Laffler, H., Fonatsch, C. , Thiel , E. and Hoelzer, D. (1994) . Immunophenotypic and genotypic heterogeneity of adult pre-pre-B acute lymphoblastic leukemia (ALL): experience of the German multicentre trials (03/87 and 04/89). Blood, 84(SI), 516a.

22. Miwa, H. , Kita, K, Mishii, K, Morita, N. , Takakura, N., Ohishi, K, Mahmud, N., Kageyama, S., Fukumoto, M. and Shirakawa, S. (1993) Expression of MDRI gene in acute leukemia cells: associa­tion with CD7+ acute myeloblastic leukemia/ acute lymphoblastic leukemia. Blood, 82,3445.

23. Nagura, E., Kimura, K, Yamada, K, Ota, K , Maekawa, T., Takaku, F., Uchino, H. , Masaoka, T., Amaki, I., Kawashima, K, Ohno, R., Nomura, T., Hattori,j., Kawamura, S. , Shibata, A., Shirakawa, S. and Hamajima, N. (994) Nation-wide randomized comparative study of doxorubicin, vin­cristine and prednisolone combination therapy with and without L-asparaginase for adult acute lymphoblastic leukemia. Cancer Chemother. Pharmacol., 33, 359-65.

24. Scherrer, R, Bettelheim, P., Geissler, K , Jager, U., Knobl, P., Kyrle, P.A., Laczika, K , Mitterbauer, G., Neumann, E., Schneider, B., Schwarzinger, I. and Lechner, K (1994) High efficacy of the German multicenter ALL (GMALL) protocol for treatment of adult acute lymphoblastic leukemia (ALL) - a single institution study. Ann. Hematol., 69, 181-8.

219 PROBLEMS AND PITFALLS

25. Smedmyr, B., Simonsson, B., Bjorkholm, M., Carneskog,]., Gahrton, G., Grimfors, G., Hast, R, Jirnmark, M., Killander, A., Kimby, E., Lerner, R, LoiVenberg, E., Maim, C., Nilsson, P.G., Paul, C., Rodjer, S., Stahlfeldt, AM., Sundstrom, C., Turesson, 1., Uden, AM., Wahlin, A, Willen, L., Westin, ]., Vikrot,]., Winqvist, 1., Zettervall and Ost, A the Swedish ALL-group. (1991) Treatment of adult acute lymphoblastic and undifferentiated (ALL/AUL) leukemia, according a national protocol in Sweden. Haematologica, 76(suppl. 4), 107.

26. Stryckmans, P., de Witte, T., Marie,].P., Fillet, G., Peetermans, M., Bury,]., MullS, P., Andrien,].M., Hayat, M., Jaksic, B., Labar, B., Debusscher, L., Solbu, G., Sucui, S. and Zittoun, R for the EORTC Leukemia Cooperative Study Group. (1992) Therapy of adult ALL: overview of 2 successive EORTC studies: (ALL-2 & ALL-3). Leukemia, 6(suppl. 2), 199-203.

27. Thiel , E., Kranz, B.R, Raghavachar, A, Bartram, C.R, Loffler, H., Messerer, D., Ganser, A, Ludwig, W-D., Buchner, T. and Hoelzer, D. (1989) Prethymic phenotype and genotype of pre-T (CD7+/ER-) cell leukemia and its clinical significance within adult acute lymphoblastic leukemia. Blood, 73, 1247.

28. Todeschini, G., Meneghini, v., Pizzolo, G., Cassibba, v., Ambrosetti, A, Veneri, D., Nadali, G., Zanotti, R, Tecchio, C. and Perona, G. (1994) Relationship between daunorubicin dosage deliv­ered during induction therapy and outcome in adult acute lymphoblastic leukemia. Leukemia, 8, 376-81.

29. Tomonaga, M., Omine, M., Morishima, Y, Hirano, M., Dohi, H., Imai, K, Hiroaka, A., Asoh, N., Tsubaki, K, Ohshima, T., Ueda, T., Kodera, K, Toki, H., Suzuki, H., Ohno, R. and Japan Adult Leukemia Study Group. (1991) Individualized induction therapy followed by intensive consolida­tion and maintenance including asparaginase in adult ALL: JALSG-ALL87study. Haematologica, 76(suppl. 4), 68.

226 E. PLOUVIER and P. HERVE

In the context of adoptive immunotherapy, infusion of haploidenticallympho­cytes harvested by cytapheresis from related donors transduced with suicide gene (HS-TK) and infused after autologous stem cell transplantation could induce an anti-Ieukemic effect (Tiberghien, 1994).

In conclusion, the current results of autografting are encouraging though they have to be improved in the next few years by a better post-transplant immunother­apeutic approach and more sensitive techniques for the quantitation of minimal residual disease in the graft, in order to better identify the children who are to benefit from such a therapeutic strategy.

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228 E. PLOUVIER and P. HERVE

33. Schmid, H ., Henze, G. , Schwardtfeger, R. , Baumgarten, E., Besserer, A., Scheffler, A., Serke, S. , Zingsem, J. and Siegert, W. (1993) Fractionated total body irradiation and high dose VP-16 with purged autologous bone marrow rescue for children with high risk relapsed acute lymphoblastic leukemia. Bone Marrow Transplant, 12,597-602.

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marrow transplantation in high risk remission B-lineage acute lymphoblastic leukemia using a cocktail of three monocIonal antibodies (BA-1 / CD24); BA2/ CD9 and BA3/ CDI0) plus com­plement and 4-hydroxyperoxycycIophosphamide for ex vivo bone marrow purging. Blood, 79, 1094-1104.

37. Wasserman, R., Galini, N., Ito, Y, Silber,J.M., Reichard, B.A., Shane, S. , Womer, R.B., Lange, B. and Rovera, G. (1992) Residual disease at the end of induction therapy as a predictor of relapse during therapy in childhood B-Iineage acute lymphoblastic leukemia.]. Glin. Oncol., 10, 1879-1888.

38. Yokota, S., Hansen-Hagge, T.E., Ludwig, W.D., Reiter, A., Raghavacher, A., K1eihauer, E. and Bartram, C.R. (1991) Use of polymerase chain reaction to monitor minimal residual disease in acute lymphoblastic leukemia patients. Blood, 77, 331-339.

236 J.M. ROWE ET AL.

transplantation is rigorously defined to allow for reliable comparisons. Such prospective collaborative studies are critical to the understanding of the best thera­pies for adult ALL in first remission and are likely to influence the treatment strate­gies over the next decade.

Until prospective, randomised trials of marrow (or peripheral blood stem cells) purging have been performed, it will be impossible to conclude that ex vivo bone marrow treatment is of clinical benefit for any patient with ALL. Unfortunately, at the present time there are no such randomised trials and as in AML, it is unlikely that such a trial will be conducted satisfactorily. Gene marking studies, as per­formed in AML, may assist in confirming whether re-infused leukemic cells con­tribute to relapse, but will not be able to answer the question as to whether purging will reduce relapse.

Most transplant preparative regimens in ALL have included TB!, in varying dose schedules, and in combination with chemotherapeutic agents. To date, no single optimal regimen has been demonstrated, but some form of TB! is likely to con­tinue to be used because of the treatment it provides to sanctuary sites at the time of the transplant.

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21. Allieri, M.A., Lopez, M., Douay, L. et al. (1991) Clonogenic leukemia progenitor cells in acute mye­locytic leukemia are highly sensitive to cryopreservation: Possible purging effect for autologous bone marrow transplantation. Bone Marrow Transplant, 7,101.

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23. Simonsson, B., Burnett, A.K. and Prentice, H.G. (1989) Autologous bone marrow transplantation with monoclonal antibody purged marrow for high risk acute lymphoblastic leukemia. Leukemia, 3, 631.

24. Ramsay, N., LeBien, T., Weisdorf, D. et al. (1989) Autologous BMT for patients with acute lymphoblas­tic leukemia. In Bone Marrow Transplantation: Current Controversies ed. R. Gale and R. Champlin, p. 57, New York: Alan R. Uss.

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28. Uckun, F.M., LeBien, T.W., Gajl-Peczalska, K.j. et al. (1987) Ex vivo marrow purging in autologous bone marrow transplantation for acute lymphoblastic leukemia: Use of novel colony assays to test the anti-leukemic efficacy of various strategies. In: Progress in Bone Marrow Transplantation: AUCLA Symposium on Molecular and Cellular Biology ed. R. Gale and R. Champlin. New Series, Vo\. 53, p. 759, New York: Alan R. Liss.

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238 ].M. ROWE ET AL.

35. Tura, S. (1989) Long-term survivors in adult acute lymphoblastic leukemia. Bone Marrow Transplant, 4(suppl. 1), 104.

36. Advisory Committee of the International Bone Marrow Transplant Registry. (1989) Report from the International Bone Marrow Transplant Registry. Bone Marrow Transplant, 4, 221.

37. Butturini, A., Bortin, M.M. and Gale, RP. (1987) Graft-versus-leukemia following bone marrow transplantation. Bone Marrow Transplant, 2, 233.

38. Sullivan, K.M., Storb, R, Buckner, C.D. et al. (1989) Graft-versus-host disease as adoptive immuno­therapy in patients with advanced hematologic neoplasms. N. Engl. J. Med., 320, 828.

39. Horowitz, M.M., Gale, R.P., Sondel, P.M. et al. (1990) Graft-versus-leukemia reactions after bone marrow transplantation. Blood, 75, 555.

40. Weisdorf, DJ., Nesbit, M.E., Ramsay, N.K.C. et al. (1987) Allogeneic bone marrow transplantation for acute lymphoblastic leukemia in remission: Prolonged survival associated with acute graft­versus-host disease. J. Clin. Oncol., 5, 1348.

41. Yeager, A.M., Vogelsang, G.B., Hess, A.B. et al. (1989) Induction of graft-versus-host disease after autologous bone marrow transplantation. Lancet, 1, 754.

42. Talbot, D.C., Powles, R.L., Sloane,].T. et al. (1990) Cyclosporine-induced graft-versus-host disease following autologous bone marrow transplantation in acute myeloid leukemia. Bone Marrow Transplant, 6, 17.

43. Yeager, A.M., Vogelsang, G.B., jones, RJ. et al. (1992) Induction of cutaneous graft-versus-host disease by administration of cyclosporine to patients undergoing autologous bone marrow trans­plantation for acute myeloid leukemia. Blood, 79, 3031.

44. Rowe, ].M., Nilsson, B.I. and Simonsson, B. (1993) Treatment of minimal residual disease in myeloid leukemia. The immunotherapeutic options with emphasis on Linomide. Leukemia and Lymphoma, 11,321.

45. van Dongen,jJ., Breit, T.M., Adriaansen, HJ. et al. (1992) Detection of minimal residual disease in acute leukemia by immunological marker analysis and polymerase chain reaction. Leukemia, 6(suppl. I), 147.

46. Gehly, G.B., Bryant, E.M., Lee, A.M. et al. (1991) Chimeric bcr-abl messenger RNA as a marker for minimal residual disease in patients transplanted for Philadelphia chromosome positive acute lym­phoblastic leukemia. Blood, 78, 458.

47. Biondi, A., Yokota, S., Hansen-Hagge, T.E. et al. (1992) Minimal residual disease in childhood acute lymphoblastic leukemia: Analysis of patients in continuous complete remission or with con­secutive relapse. Leukemia, 6, 282.

48. Uckun, F.M., Kersey,].H., Haake, R et al. (1993) Pre-transplantation burden ofleukemic progeni­tor cells as a predictor of relapse after bone marrow transplantation for acute lymphoblastic leukemia. N. Engl.J. Med., 329,1296.

49. Brenner, M.K., Rill, D.R, Moen, R.C. et al. (1993) Gene-marking to trace origin of relapse after autologous bone marrow transplantation. Lancet, 341, 85.

50. Biaise, D., Gaspard, M.H., Stoppa, A.M. et al. (1990) Allogeneic or autologous bone marrow trans­plantation for acute lymphoblastic leukemia in first complete remission. Bone Marrow Transplant, 5, 7.

51. Blume, K.G., Kopecky, K.]., Henslee-Downey,].P. et al. (1993) A prospective randomized compari­son of total body irradiation-etoposide versus busulfan-cyclophosphamide as preparatory regimens for bone marrow transplantation in patients with leukemia who were not in first remission: A Southwest Oncology Group study. Blood, 81, 2187.

52. Bostrom, B., Weisdorf, DJ., Kim, T. et al. (1990) Bone marrow transplantation for advanced acute leukemia: A pilot study of high-energy total body irradiation, cyclophosphamide and continuous infusion etoposide. Bone marrow transplant, 5, 83.

246 T. BUCHNER and L.w. HIDDEMANN

Apart from genotypes some features like serum LDH (59,60), autonomous colony growth of blasts (61) and detection of minimal residual disease using abnormal coexpression of immunmarkers (62-64) reflect functional patterns related to prognosis. Although some prognostic factors seem to have more impact on patients outcome than treatment variables including bone marrow transplanta­tion have further analysis of cellular features on the basis of standardised treat­ment is required before a risk adapted system of individual chemotherapy and transplantation can be established.

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247 STATE OF THE ART

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249 STATE OF THE ART

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265 TRANSPLANTATION IN ACUTE MYELOID LEUKAEMIA

risk. With longer follow-up this may convert into a survival advantage. In MRC 10, the analysis was done with a median follow-up of 2.7 years. However, the major inhi­bition on the autograft was the 13% procedural related deaths. The potential sur­vival difference in the arms of the EORTC/GIEMEMA Trial may be masked at present because patients who relapsed from chemotherapy remain alive. For many this may not be a long-term proposition, but it does raise the question of whether a planned policy of salvaging patients after relapse can improve the overall cure rate.

This approach is probably now justified for patients with good risk disease as defined by karyotype (e.g. t8,21, inv 16; tl5, 17), but it is unclear whether it is prac­tical for the majority of patients, who often will have a lower chance of successfully re-entering remission. This approach seems to have been contributing in the EORTC/GIEMEMA study but has been relatively ineffective in the MRC Trial, where the 3 year projected survival of those who relapsed from the chemotherapy arm is 10%. It is an open question whether salvage is likely to be more effective with an autograft as the primary treatment of relapse as suggested by the Pedersen study or indeed whether it provides added value to chemotherapy in second remis­sion. This latter point is probably impossible to clarity, since the selection biases operating in this phase of treatment are very substantial and short term outcome evaluation may be misleading.

CONCLUSION

It is now 15 years since the first autografts were performed for AML in remission. We have just emerged from a period of major evaluation of the procedure in the context of prospective trials, based on a recognition that the early results were achieved on selected patients and therefore the true benefit was unclear. Interest­ingly allogeneic BMT has not yet been subjected to such rigorous scrutiny. It is clear that during this period, chemotherapy for preventing relapse has improved. It seems legitimate to conclude, at the moment, that in whatever setting in first remission autograft does provide an improved anti-Ieukaemic effect. This, so far, has not always converted into a survival advantage because the benefit has been outweighed by procedural mortality or it has been possible to salvage chemother­apy patients. In both cases it remains perfectly possible for major differences to emerge with longer follow-up.

Optimisation of this modality will depend on improving safety - which could depend on improved engraftment, appropriate timing of the procedure and recognition of patients who mayor may not benefit from this approach.

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19. Butturini, A and Gale, RP. (1989) Chemotherapy versus transplantation in acute leukaemia. British Journal of Haematology, 72, 1-8.

20. Sharkis, SJ., Santos, G.W. and Colvin, M. (1990) Elimination of acute myelogenous leukemic cells from marrow and tumour suspensions in the rat with 4-hydroperoxycycfophosphamide. Blood, 55, 521-523.

21. Kaizer, H., Stuart, RK, Brookmeyer, R. et al. (1985) Autologous bone marrow transplantation in acute leukemia: A phase 1 study of in vitro treatment of marrow with 4-Hydroperoxycyclophosphamide to purge tumor cells. Blood, 65,1504-10.

22. Herve, P., Tamayo, E. and Peters, A. (1983) Autologous stem cell grafting in Acute Myeloid Leukaemia: Technical approach of marrow incubation in vitro with pharmocological agents (pre­requisite for clincial applications). British Joumal of Haematology, 53, 683-684.

23. Singer, C.RJ. and Linch, D.C. (1987) Comparison of the sensitivity of normal and leukaemia myeloid progenitors to in vitro incubation with cytotoxic drugs: a study of pharmacological purging. Leukaemia Research, 11,953-959.

267 TRANSPLANTATION IN ACUTE MYELOID LEUKAEMIA

24. Yeager, A.M., Kaizer, H., Santos, G.W. et al. (1986) Autologous bone marrow transplanta­tion in patients with acute non-lymphocytic leukemia, using ex vivo marrow treatment with 4­hydroperoxycyclophosphamide. New England Journal of Medicine, 315, 141-147.

25. Chopra, R, Goldstone, A.H., McMillan, A.K. et al. (1991) Successful treatment of acute myeloid leukemia beyond first remission with autologous bone marrow transplantation using busulfan/ cyclophosphamide and unpurged marrow: The British Autograft Group Experience. Journal of Clinical Oncology, 9, 1840-1847.

26. Gorin, N.C., Labopin, G., Meloni, M. et al. (1991) Autologous bone marrow transplantation for acute myelocytic leukemia in Europe: further evidence of the role of marrow purging by mafos­famide. Leukemia, 5, 896--904.

27. Siena, S., Castro-Malaspina, H., Gulati, S.C. et al. (1985) Effects of in vitro purging with 4­Hydroperoxycyclophosphamide on the hematopoietic and microenvironmental elements of human bone marrow. Blood, 65, 655-662.

28. Gorin, N.C., Aegerter, P., Auvert, B. et al. (1991) Autologous bone marrow transplantation for acute myelocytic leukemia in first remission: A European survey of the role of marrow purging. Journal of Clinical Oncology, 9,1840-1847.

29. Ball, E.D., Mills, L.E., Cornwell, G.G.1. et at. (1990) Autologous bone marrow transplantation for acute myeloid leukemia using monoclonal antibody purged bone marrow. Blood, 75, 1199-206.

30. Ball, E.D., Mills, L.E., Coughlin, C.T., Beck, j.R and Cornwell, G.G.1. (1995) Autologous bone marrow transplantation in acute myeloid leukemia: In vitro treatment with myeloid cell-specific monoclonal antibodies. Blood, 68, 1311-1315.

31. Chang, j., Morgenstern, G. and Deaking, D. (1986) Successful treatment of acute myeloid leukaemia using busulphan/cyclophosphamide as conditioning: The British Autograft Group experience. Lancet, 294-295.

32. Chang,j., Morgenstern, G.R, Coutinho, L.H. et at. (1989) The use of bone marrow cells grown in long-term culture for autologous bone marrow transplantation in acute myeloid leukaemia: an update. Bone Marrow Transplantation, 4,5-9.

33. Burnett, A.K., Alcorn, M., Graham, S. and Singer, j.W. (1988) Correlation of growth of marrow in long-term culture with outcome of autologous bone marrow transplantation. Bone Marrow Transplantation, 3, 335.

34. Brenner, M.K., Rill, D.R, Moen, RC. et at. (1993) Gene marking to trace origin of relapse after autologous bone marrow transplantation. Lancet, 341, 85-86.

35. Reittie, J.E., Gottlieb, D., Hesiop, H.E. et at. (1989) Endogenously generated activated killer cells circulate after autologous and allogeneic marrow transplantation but not chemotherapy. Blood, 73, 1351-1358.

36. Burnett, A.K., Tansey, Pj., Hills, C. et al. (1983) Haematological reconstitution following high dose and supralethal chemo - radiotherapy using stored non-cryopreserved autologous bone marrow. BritishJoumal of Haematology, 54, 309-316.

37. Pendry, K., Alcorn, Mj. and Burnett, A.K. (1993) Factors influencing haematological recovery in 53 patients with acute myeloid leukemia in first remission after autologous bone marrow trans­plantation. BritishJournal of Haematology, 83, 45-52.

38. Korbling, M., Fliedner, T.M., Holle, R, Magrin, S.M., Holdermann, E. and Eberhardt, K. (1991) Autologous blood stem cell (ABSCT) versus purged marrow transplantation (pABMT) in standard risk AML: influence of source and cell composition of the autograft on hemopoietic reconstitution and disease-free survival. Bone Marrow Transplantation, 7, 343-349.

39. Szer, j., Juttner, C.A. and To, L.B. (1992) Post-remission therapy for acute myeloid leukemia with blood-derived stem cell transplantation. Results of collaborative phase II trial. IntemationalJournal of Cell Cloning, 10, 114-116.

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41. Demirer, T., Buckner, C.D., Appelbaum, F.R. et al. (1994) Rapid engraftment after autologous transplantation utilising marrow and recombinant granulocyte-colony stimulating factor mobilised peripheral blood stem cells in patients with acute myelogenous leukemia. Blood, 84, 92a.

268 AK. BURNETT

42. Reiffers, J. , Gaspard, M.H. , Maraninchi , D. et at. (1989) Comparison of allogeneic or autologous bone marrow transplantation and chemotherapy in patients with acute myeloid leukaemia in first remission: a prospective controlled trial. BritishJoumal of Haematology, 72, 57-63.

43. Harousseau, J.L., Pignon, B., Dufour, P. et al. (1966) Autologous bone marrow transplantation vs intensive chemotherapy in first complete remission: interim results of GOELAM study in AML. Leukemia, 6,120-123.

44. Zittoun, R.A, Mandelli, F. , Willemze, R. et al. (1995) Autologous or allogene ic bone marrow trans­plantation compared with intensive chemotherapy in acute myeloid leukaemia. New England Joumal

of Medicine, 332, 217-223. 45. Rowe,J. (1995) Personal Communication. 46. Burnett, AK., Goldstone, A.H., Stevens, R.F. et al. (1994) The role ofBMT in addition to intensive

chemotherapy in AML in first CR: Results of the MRC AML 10 trial. Blood, 84(10), 252(a). 47. Lowenberg, B., Verdonck, LJ., Dekker, A.W. et at. (1990) Autologous bone marrow transplantation

in acute myeloid leukemia in first remission: results of a Dutch prospective study. Journal of Clinical

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49. Keating, MJ., Smith, T.L., Kantarjian, H. et al. (1988) Cytogenetic pattern in acute myelogenous leukaemia: a major reproducible determinant of outcome . Leukemia, 2, 403-412.

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274 C. SACLIO and F. LO COCO

which patients will/will not benefit from marrow-ablative chemo-radiotherapy and BMT), leukemia contamination as well as the efficacy of purging procedures in autologous marrow or blood stem cell grafts could be established in a more precise way and the onset of drug- resistant leukemic clones could be detected earlier.

Moreover, what is progressively becoming clearer, is that the PCR-based studies on the MRD are providing not only important clinical and prognostic parameters, but also information on the biology and on the kinetics of growth of different types of leukemia. In particular they are helping to answer to a very crucial ques­tion for the clinicians: whether in particular types of leukemias there is a critical threshold as regards to the number of residualleukemic cells that can be tolerated or whether allleukemia cells have to be eradicated to cure a patient.

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275 MINIMAL RESIDUAL DISEASE IN LEUKEMIA

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283 IS THERE A ROLE?

phosphamide and total body irradiation or busulfan and cyclophosphamide, may not be optimal in the autograft setting where immunosuppression is not required and where supra lethal myeloablation may be inappropriate. Possible alternative schedules include busulfan and melphalan or busulfan alone69; the MRC/ECOG study has opted for use ofbusulfan only (at a dose of 16 mg/kg divided over 4 con­secutive days). It is likely that this dose will provide major suppression or even eradi­cation in some cases of Ph-hematopoiesis without the major toxicity sometimes associated with cyclo/TBI.

5. How should patients be treated after the autograft procedure? There is some sugges­tion that patients who failed to respond to interferon-a at diagnosis may be ren­dered more responsive to interferon-a after autografting. Whether or not this is true, it seems logical to treat autografted patients with interferon-a partly because patients in the control arm will also be receiving this drug. It is likely however that the maximal dose of interferon-a attainable after autografting will be relatively low in some patients.

CONCLUSIONS

In some senses CML is the ideal disease in which to test the various possible strate­gies by which autografting for malignant hematological disorders may offer the prospect of prolongation of life and possibly cure. This is because: (1) Residual normal hematopoiesis is present at diagnosis at least in some patients, (2) The leukemia cells (in chronic phase) can be destroyed with relatively ease by both chemotherapy and radiotherapy, (3) Various markers exist whereby leukemia cells can readily be recognized and quantitated, and (4) The basic genetic lesion thought to underlie the chronic phase has been characterized and may thus be exploited for therapeutic purposes. Thus it is likely that attention will continue to focus on the role of autografting in the management of CML and that the princi­ples established in treating this disease will over the next 10-20 years be extended to other forms of leukemia and to lymphoma.

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67. Charak, B.S., Agah, R, Gray, D. et al. (1991) Interaction of various cytokines with interleukin 2 in the generation of killer cells from human bone marrow: application in purging of leukemia. Leuk. Res., 15,801-810.

68. Anafi, M., Gazit, A., Zehavi, A et al. (1993) Tyrphostin-induced inhibition of p2lObcr-abl tyrosine kinase activity induces K562 to differentiate. Blood, 82, 3524-3529.

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296 MJ. BARNETT ET AL.

A start has been made in the application of cell culture techniques for the preparation of autografts. Much remains to be done. However, the mystique of such an approach has been dispelled and the groundwork laid for its more con­trolled use to address specific questions of clinical importance to the treatment of leukemia.

ACKNOWLEDGMENTS

The studies described were supported in part by grants from the British Columbia Health Research Foundation, the National Cancer Institute of Canada with funds from the Canadian Cancer Society, and Schering Canada.

Interleukin-2 was supplied by Biotest Pharma (Dreieich, Germany).

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297 THE VANCOlNER EXPERIENCE

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303 CHRONIC MYELOGENOUS LEUKEMIA

12 PhI-positive collections were any LTC-IC found and only at low levels (Podestit et aI., unpublished data).

In conclusion, in patients not pretreated with IFN-a and mobilized during the first weeks from diagnosis, the collection of peripheral blood progenitor cells during hemopoietic recovery after chemotherapy produces a yield of precursor cells (committed and LTC-IC) which is largely sufficient for performing autografts and is associated with rapid hemopoietic recovery. This allows the restoration of PhI-negative hemopoiesis in many patients. Further studies need to be performed to determine whether and how long PhI-negative status can be maintained.

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317 MALIGNANT NON-HODGKIN'S LYMPHOMA

disease, The contribution to the cure of factors specific to the autograft such as purging of marrow and the use of peripheral blood stem cells as opposed to marrow is uncertain but is not likely to be great, It is clear that dose intensification using currently available drugs cures only those patients whose disease is at least partially sensitive to lower doses of chemotherapy drugs and therefore that "the autograft" is successsful because the dose: response for NHL is exploited success­fully, The poor outcome for patients with chemoresistant disease suggests that this curve is not steep and that alternative strategies are needed for these patients, With the advent of PBSCT, it has become relatively easier to collect sufficient stem cells for rescue from several rounds of high dose therapy. Most currently used reg­imens would be poorly tolerated twice but the question of whether even futher intensification of therapy would lead to improved outcome for patients with resis­tant disease should be addressed. The Lyon consensus (37) has suggested that HDC should not be considered standard care for NHL because "no definitive study exists establishing that HDC is either superior to or significantly worse than conventional chemotherapy in any stage of NHL". With the publication of the results of the PARMA study, HDC with ABMT may become part of the routine management of chemosensitive relapsed NHL. For other stages of the disease, patients must be entered into randomised studies in order to confirm or refute the curative role of high dose chemotherapy with autograft.

ACKNOWLEDGMENTS

A.K Fielding is supported by the Leukaemia Research Fund of Great Britain.

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4. Fisher, R.I., Gaynor, E.R. , Dahlberg, S. and Oken, M.O. (1987) Comparison of a standard regimen (CHOP) with three intensive chemotherapy regimens for advanced non-Hodgkin's lymphoma. NEJM 1993,328, lO02-1006.

5. Velasquez, W.S., Cabinillas, F., Salvador, P., McLaughlin, P., Fridrick, M., Tucker, S. et al. (1988) Effective salvage therapy for lymphoma with cisplatin in combimation with high dose AraC and dexamethasone (DHAP). Blood, 71, 117.

6. Cabinillas, F., Hagemeister, F.B., Bodey, G.P. and Freireich, EJ. (1982) IMVPI6: an effective regimen for patients with lymphoma who have relapsed after initial combination chemotherapy. Blood, 60, 693.

7. DeLord, C., Newland, A.C., Linch, D.C., Vaughan Hudson, B. and Vaughan Hudson, G. (1992) Failure of IMVP16 as second line treatment for relapsed or refractory high grade non-Hodgkin's lymphoma. HaematologicalOncology, 10,81-86.

318 AK FIELDING and AH. GOLDSTONE

8. Philip, T., Armitage,].O., Spitzer, G., Chauvin, F.,jagganath, S., Cahn,].Y. et al. (1987) High dose therapy and autologous bone marrow transplantation after failure of conventional chemotherapy in adults with intermediate or high grade non-Hodgkin's lymphoma. NEJM, 316,1493-1498.

9. Takvorian, T., Canellos, G., Ritz,]., Freedman, A.S., Anderson, KC., Mauch, P. et al. (1987) Prolonged disease free survival after autologous bone marrow transplantation in patients with non­Hodgkin's lymphoma with a poor prognosis. NFJM,316,1499-1505.

10. Gribben, ].G., Goldstone, A.H., Linch, D.C., Taghipour, G., McMillan, A.K, Souhami, R.L. et al. (1989) Effectiveness of high dose combination chemotherapy and autologous bone marrow trans­plantation for patients with non-Hodgkin's lymphoma who are still sensitive to conventional-dose therapy.] Clin. Oncol., 7,1621.

11. Colombat, P., Gorin, N.C., Lemonnier, M.P., Binet, C., Laporte,].P., Douay, L. et al. (1990) The role of autologous bone marrow transplantation in 46 adult patients with non-Hodgkin's lymphomas. ] Clin. Oncol., 8, 630-637.

12. Petersen, F.B., Appelbaum, F.R., Hill, R., Fisher, L.D., Bigelow, C.L., Sanders, ].E. et al. (1990) Autologous marrow transplantation for malignant lymphomas: a report of 101 cases from Seattle. ] Clin. Oncol., 8, 638-647.

13. Freedman, AS., Takvorian, T., Anderson, KC., Mauch, P., Rabinowe, S.N. et al. (1990) Autologous bone marrow transplantation in B cell non-Hodgkin's lymphoma: Very low treatment related mor­tality in 100 patients in sensitive relpase.] Clin. Oncol., 8, 784-791.

l4. Gulati, S., Yahalom,]., Acaba, L., Reich, L., Matzer, R., Crown,]. et al. (1992) Treatment of patients with relasped and resistant non-Hodgkin's lymphoma using total body irradiation, etoposide and cyclophosphamide and autologous bone marrow transplantation.] Clin. Oncol., 10,936-941.

15. Rapoport, AP. , Rowe, ].M., Kouides, P.A., Duerst, R.A., Abboud, C.N., Liesveld,].L. et al. (1993) One Hundred Autotransplants for Relapsed or Refractory Hodgkin's Disease and Lymphoma: Value ofPretransplant Disease Status for Predicting Outcome.] Clin. Oncol., 11,2352-2361.

16. Wheeler, C., Strawderman, M., Ayash, L., Churchill, W.H., Bierer, B.E., Elias, A. et al. (1993) Prognostic Factors for Treatment Outcome in Autotransplantation of Intermediate and High Grade non-Hodgkin's Lymphoma With Cyclophosphamide, Carmustine and Etoposide.] Clin. Oncol., 11, 1081-1091.

17. Fielding et al. (1995) EBMT data. 18. Philip, T., Chauvin, F., Armitage, j., Bron, D., Hagenbeek, A, Biron, P. et al. (1991) PARMA

International protocol: Pilot study of DHAP followed by involved field radiotherapy and BEAC with autologous bone marrow transplantation. Blood, 77, 1587.

19. Philip, T., Gugliemi, C., Chauvin, F. et al. (1995) The PARMA international randomised prospective study in relapsed NHL: First results of the final analysis. Bone Marrow Transplantation, 15(suppl. 2), S155.

20. Attal, M., Canal, P., Schlaifer, D., Chatelut, E., Dezeuze, A., Huguet, F. et al. (1994) Escalating doses of mitoxantrone with high dose cylophosphamide, Carmustine and etoposide in patients with refractory lymphoma undergoing autologous bone marrow transplantation.] Clin. Oncol., 12, 141-148.

21. Klumpp, T.R., Mangan, KF., Glenn, D.R., Malaspina, D.R., Cropper, T., Mullaney, M. et al. (1993) Phase 1/11 study of high dose cyclophosphamide, etoposide, and cisplatin followed by autologous bone marrow or peripheral blood stem cell transplantation in patients with poor prognosis Hodgkin's disease or non-Hodgkin's lymphoma. Bone Marrow Transplantation, 12,337-345.

22. Weaver, C.H., Petersen, F.B., Applebaum, F.R., Bensinger, W.!., Press, O.P., Martin, P. et al. (1994) High dose fractionated total body irradiation, etoposide, and cyclophosphamide followed by auto­logous stem cell support in patients with malignant lymphoma.] Clin. Oncol., 12, 2559-2566.

23. Homing, S.J., Negrin, R.S., Chao, N.J., Long, G.D., Hoppe, R.T. and Blume, KG. (1994) Fractionated total body irradiation, etoposide, and cyclophosphamide plus autografting in Hodgkin's disease and non-Hodgkin's lymphoma.] Clin. Oncol., 12, 2552-2558.

24. Ross, AA., Cooper, B.W., Lazarus, H.M., Mackay, W., Moss, T.J., Ciobanu N. et al. (1993) Detection and Viability of Tumour Cells in Peripheral Blood Stem Cell Collections From Breast Cancer Patients Using Immuncytochemical Clonogenic Assay Techniques. Blood, 82, 2605-2610.

319 MALIGNANT NON-HODGKIN'S LYMPHOMA

25, Brugger, W., Bross, KJ., Glatt, M., Weber, F., Mertlesmann, R. and Kanz, L. (1994) Mobilization of Tumour Cells and Haematopoetic Progenitors Into Peripheral Blood of Patients With Solid Tumours. Blood, 83, 636-640.

26. Vose,J.M., Anderson,J.R, Kesinger, A, Bierman, PJ., Coccia, P., Reed, E.C. et al. (1993) High dose chemotherapy and autologous hematopoietic stem cell transplantation for aggressive non­Hodgkin's lymphoma.] Glin. Oncol., 11, 1846-1851.

27. Brenner, M.K., Rill, D.R, Moen, RC., Krance, RA, Mirro, J., Anderson, W.F. et al. (1993) Gene Marking to Trace the Origin of Relapse Mter Autologous Bone Marrow Transplantation. The Lancet, 341, 85-86.

28. Coiffier, B., Gisselbrecht, C. and Vose,J.M. (1991) Prognostic factors in aggressive malignant non­Hodgkin's lymphomas: Description of a prognostic index that could identity patients requiring a more intensive therapy.] Glin. Oncol., 4, 211.

29. Freedman, AS., Takvorian, T., Neuberg, D., Mauch, P., Rabinowe, S.N., Anderson, K.C. et al. (1993) Autologous Bone Marrow Transplantation in Poor Prognosis Intermediate-Grade and High-Grade B cell non-Hodgkin's Lymphoma in First Remission: A Pilot Study.] Glin. Oncol., 11, 931-936.

30. Shipp et al. (1993) A predictive model for agressive non-Hodgkin's lymphoma. NEJM, 329, 987-994.

31. Haioun, C., Lepage, E., Gisselbrecht, C., Coiffier, B., Bosly, A, Tilly, H. et al. (1994) Comparison of autologous bone marrow transplantation with sequential chemotherapy of intermediate and high grade non-Hodgkin's lymphoma in first complete remission: a study of 464 patients.] Glin. Oncol., 12,2543-2551.

32. Coiffier, B., Gisselbrecht, C., Herbrech, R et al. (1987) LHN84 regimen: A multicentre study of intensive chemotherapy in 737 patients with aggressive malignant non-Hodgkin's lymphoma. ] Clin. Oncol. , 7, 1081-26.

33. Haq, R, Sawka, C.A., Franssen, E. and Berinstein, N.L. (1994) Significance of a partial or slow response to front line chemotherapy in the management of intermediate grade or high grade non­Hodgkin's lymphoma: a literature review.] Clin. Oncol., 12, 1074-1084.

34. Verdonk, L.F., van Putten, W.LJ., Hagenbeek, A. et al. (1995) Comparison of CHOP chemotherapy with autologous bone marrow transplantation for slowly responding patients with aggressive non­Hodgkin's lymphoma.] Glin. Oncol., 332, 1045-1051.

35. Verdonk, L.F. and Dekker, AW. (1992) Autologous bone marrow transplantation for adult poor­risk lymphoblastic lymphoma in first complete remission.] Glin. Oncol., 10,644-646.

36. Sweetenham,J.W., Liberti, G., Pearce, R, Taghipour, G., Santini, G. and Goldstone, A.H. (1994) High dose therapy and autologous bone marrow transplantation for adult patients with lym­phoblastic lymphoma: results of the European group for bone marrow transplantation.] Clin. Oncol., 12, 1358-1365.

37. Coiffer, B., Philip, T., Burnett, AK. and Symann, M.L. (1994) Consensus Conference on Intensive Chemotherapy Plus Haematopoetic Stem Cell Transplantation in Malignancies, Lyon June 4-6 1993. Annals of Oncology, 5,19-23.

326 J.M. VOSE, PJ. BIERMAN andJ.O. ARMITAGE

centers have recently performed pilot trials evaluating the role of transplantation in first complete response or very good partial response. Horning et al. (34) reported 25/29 patients transplanted in first remission to be alive and disease-free at a median of 13 months (range 3-48) post-transplant. In another study at Dana Farber Cancer Institute, patients with extensive follicular lymphoma received CHOP chemotherapy for 6-8 cycles until complete remission, then received cyclophosphamide/TBI and purged autologous bone marrow transplant in first complete remission. Freedman et al. (35) reported with a median follow-up of 22 months, 48/73 patients to be alive and disease-free. The overall survival at the time of evaluation was 95%. Prolonged follow-up of these patients will be neces­sary in order to compare these results to conventional treatment.

FUTURE DIRECTIONS

In order to provide the most optimum treatment for patients with low-grade NHL, identification of high-risk patients at the time of diagnosis to allow alternative strategies to be tested such as earlier transplantation would be beneficial. Using the International Prognostic Factor Index which was originally developed for patients with aggressive NHL (36), some investigators have found this index to have prognostic significance in patients with low-grade NHL as well (37).

Other new areas of investigation in addition to early transplantation include the use of radiolabelled antibody therapy in conjunction with high-dose chemother­apy and transplantation (38) or the use of agents such as anti-B4-blocked ricin (39) or Interleukin-2 (40) post-transplant to decrease the minimal residual disease possible present which could contribute to disease relapse. Only through well designed clinical trials can progress be made to allow improvements for future patients with low-grade NHL.

REFERENCES

l. The Non-Hodgkin's Lymphoma Pathologic Classification Project. (1982) National Cancer Institute sponsored study of classifications of non-Hodgkin's lymphomas: Summary and description of a Working Formulation for clinical usage. Cancer, 49, 2112-2135.

2. Weisenburger, D.D., Kim, H. and Rappaport, H. (1982) Mantle zone lymphoma: A follicular variant of intermediate lymphocytic lymphoma. Cancer, 49, 1429-1438.

3. Sheibani, K., Burke,J.S. and Swartz, W.G. (1988) Monocytoid B-celllymphoma: Clinicopathologic study of21 cases ofa unique type oflow-grade lymphoma. Cancer, 62,1531-1538.

4. Isaacson, P.G. and Spencer, J. (1987) Malignant lymphoma of mucosa-associated lymphoid tissue. Histopathology, 11, 445-462.

5. Fisher, R.I., Dahlberg, S., Nathwani, B.N. et al. (1995) A clinical analysis of two indolent lymphoma entities: Mantle cell lymphoma and marginal zone lymphoma (including the mucosa-associated lymphoid tissue and monocytoid B-cell subcategories): A Southwest Oncology Group Study. Blood, 85, 1075-1082.

6. Morrison, Y.A. and Peterson, B.A. (1993) Combination chemotherapy in the treatment of follicu­lar low-grade lymphoma. Leukemia and lymphoma, 10,29-33.

327 THE ROLE OF AUTOGRAFTING IN LOW-GRADE LYMPHOMA

7. Gallagher, CJ., Gregory, W.M.,Jones, AE. et al. (1986) Follicular lymphoma: Prognostic factors for response and survival.] Glin. Oncol., 4,1470-1480.

8. Portlock, C.S. (1990) Management of the low-grade non-Hodgkin's lymphomas. Sem. Onc., 17, 51-59.

9. Spinolo,J.A, Cabanillas, F., Dixon, D.O. et al. (1992) Therapy of relapsed or refractory low-grade follicular lymphomas: Factors associated with complete remission, survival and time to treatment failure. Ann. Oncol., 3, 227-232.

10. Young, RC., Longo, D.L., Glatstein, E. et al. (1988) The treatment of indolent lymphomas: Watchful waiting vs. aggressive combined modality treatment. Sem. Hem., 25, 11-16.

11. Dana, B.W., Dahlberg, S., Nathwani, B.N. et al. (1993) Long-term follow-up of patients with low­grade malignant lymphomas treated with doxorubicin-based chemotherapy or chemoimmuno­therapy.] Clin. Oncol., 11,644-651.

12. Zinzani, P.L., Lauria, F., Rondelli, D. et al. (1993) Fludarabine: An active agent in the treatment of previously-treated and untreated low-grade non-Hodgkin's lymphomas. Ann. Oncol., 4, 575-578.

13. Day, AC., Saven, A., Carrera, CJ. et al. (1992) 2-chlorodeoxyadenosine treatment oflow-grade lym­phomas.] Glin. Oncol., 10,371-377.

14. Solal-Celigny, P., Lepage, E., Brousse, N. et al. (1993) Recombinant interferon alfa-2b combined with a regimen containing doxorubicin in patients with advanced follicular lymphoma. N. Engl.] Med., 329,1608-1614.

15. Smalley, RV., Andersen, J.W., Hawkins, MJ. et al. (1992) Interferon alfa combined with cytotoxic chemotherapy for patients with non-Hodgkin's lymphoma. N. Engl.] Med., 327,1336-1341.

16. Hagenbeek, A, Carde, P., Somers, R et al. (1992) Maintenance of remission with human recombi­nant alpha-2 interferon (Roferon-A) in patients with stages III and IV low-grade malignant non­Hodgkin's lymphoma: results from a prospective, randomized Phase III clinical trial in 331 patients. Blood, 80(suppl. 1), 288a.

17. Bosly, A., Coiffier, B., Gisselbrecht, C. et al. (1992) Bone marrow transplantation prolongs survival after relapse in aggressive-lymphoma patients treated with the LNH-84 regimen.] Clin. Oncol., 10, 1615-1623.

18. Vose, J.M., Anderson, J.R, Kessinger, A. et al. (1993) High-dose chemotherapy and autologous hematopoietic stem-cell transplantation for aggressive non-Hodgkin's lymphoma.] Glin. Oncol., 11, 1846-1851.

19. Homing, SJ., Negrin, R.S., Chao, NJ. et al. (1994) Fractionated total-body irradiation, etoposide, and cyclophosphamide plus autografting in Hodgkin's disease and non-Hodgkin's lymphoma. ] Glin. Oncol., 12, 2552-2558.

20. Freedman, AS., Ritz,J., Neuberg, D. et al. (1991) Autologous bone marrow transplantation in 69 patients with a history oflow-grade B-cell non-Hodgkin's lymphoma. Blood, 77, 2524-2529.

21. Rohatiner, AZ.S., Johnson, P.W.M., Price, C.G.A. et al. (1994) Myeloablative therapy with autolo­gous bone marrow transplantation as consolidation therapy for recurrent follicular lymphoma. ] Glin. Oncol., 12, 1177-1184.

22. Schouten, H.C., Colombat, Ph., Verdonck, L.F. et al. (1994) Autologous bone marrow transplanta­tion for low-grade non-Hodgkin's lymphoma: The European Bone Marrow Transplant Group experience. Ann. Oncol., 5, SI47-S149.

23. Gribben, J.G., Freedman, A.S., Neuberg, D. et al. (1991) Immunological purging of marrow assessed by PCR before autologous bone marrow transplantation for B-cell lymphoma. N. Engl.] Med., 325, 1525-1533.

24. Johnson, P.W.M., Price, C.G.A., Smith, T., Cotter, F.E., Meerabux,J., Rohatiner, AZ.S. et al. (1994) Detection of cells bearing the t(14,18) translocation following myeloablative treatment and autolo­gous bone marrow transplantation for follicular lymphoma.] Clin. Oncol., 12, 198-805.

25. Negrin, RS. and Pesando, J. (1994) Detection of tumor cells in purged bone marrow and peripheral-blood mononuclear cells by polymerase chain reaction amplification ofbcl-2 transloca­tions.] Glin. Oncol., 12, 1021-1027.

26. Kessinger, A., Anderson, J., Bierman, P. et al. (1994) Mobilized vs. non-mobilized peripheral stem cell transplantation after high-dose therapy for low grade non-Hodgkin's lymphoma: Effect on progression-free survival. Blood, 84, 1568a.

328 ].M. VOSE, PJ. BIERMAN and].O. ARMITAGE

27. Berinstein, N.L., Reis, M.D., Ngan, B.Y et al. (1993) Detection of occult lymphoma in the periph­eral blood and bone marrow of patients with untreated early-stage and advanced-stage follicular lymphoma. I Glin. Oncol., 11, 1344-1352.

28. Bishop, M.R, Anderson,].R,jackson,].D. et al. (1994) High-dose therapy and peripheral blood progenitor cell transplantation: effects of recombinant human granulocyte-macrophage colony­stimulating factor on the autograft. Blood, 83, 610-616.

29. Nademanee, A., Sniecinski, I., Schmidt, G.M. et al. (1994) High-dose therapy followed by autolo­gous peripheral-blood stem-cell transplantation for patients with Hodgkin's disease and non­Hodgkin's lymphoma using unprimed and granulocyte colony-stimulating factor-mobilized peripheral-blood stem cells. I Glin. Oncol., 12,2176-2186.

30. Kotasek, K., Shepherd, K.M., Sage, RE. et al. (1992) Factors affecting blood stem cell collections following high-dose cyclophosphamide mobilization in lymphoma, myeloma dn solid tumors. Bone Marrow Transplant, 9,11-17.

31. Neben, S., Hemman, S., Montgomery, M. et al. (1993) Hematopoietic stem cell deficit of trans­planted bone marrow previously exposed to cytotoxic agents. Exp. Hem., 21, 156-162.

32. Bishop, M.R, Vose, ].M., Bierman, PJ. et al. (1985) A comparison of peripheral blood versus bone marrow autografting following high-dose therapy in patients with malignant lymphomas. Proc. ASGO.

33. Talpaz, M. and Spitzer, G. (1984) Low natural killer cell activity in the bone marrow of healthy donors with normal natural killer cell activity in the peripheral blood. Exp. Hematol., 12, 629-632.

34. Horning, SJ. (1993) Low-grade lymphoma 1993: State of the art. Proc. fifth International conf on lymphoma 24a.

35. Freedman, A., Gribben,]., Rabinowe, S. et al. (1993) Autolgous bone marrow transplantation in advanced low grade B-cell non-Hodgkin's lymphoma in first remission. Blood, 82, 1313a.

36. The Non-Hodgkin's Lymphoma Prognostic Factors Project. (1993) Development of a predictive model for aggressive lymphoma: The International NHL Prognostic Factors Project. N. Engl. I Med., 329, 987-994.

37. Lopez-Guillermo, A., Montserrat, E., Bosch, F. et al. (1994) Applicability of the International index for aggressive lymphomas to patients with low-grade lymphoma. I Glin. Oncol., 12, 1343-1348.

38. Appelbaum, F.R, Brown, P., Sandmaier, B. et al. (1989) Antibody-radionuclide conjugates as part of a myeloablative preparative regimen for marrow transplantation. Blood, 73, 2202-2208.

39. Grossbard, M.L., Press, O.W., Appelbaum, F.R et al. (1992) Monoclonal antibody-based therapies of leukemia and lymphoma. Blood, 80, 863-878.

40. Ackerstein, A., Kedar, E. and Slavin, S. (1991) Use of recombinant human interleukin-2 in con­junction with syngeneic bone marrow transplantation in mice as a model for control of minimal residual disease in malignant hematologic disorders. Blood, 78, 1212-1215.

333 INTERMEDIATE AND HIGH GRADE LYMPHOMA

randomized study may be needed but will be difficult to achieve because of the dramatic difference of toxicity of PBPC. Finally, the eventual impact of stem cell bone marrow manipulation in vitro deserves further attention. Pharmacological agents and immunological methods with monoclonal antibodies [MoAb] have been used separately or in combination. Because patients with aggressive lym­phoma who receive ABMT often relapse after treatment in their prior sites of disease, it has been claimed that bone marrow purging has no major influence on the outcome Philip et al. (1987). However, recent data suggest that efficient immunological purging may significantly decrease the relapse rate after BMT in bcl-2 positive lymphoid malignancies. Gribben et al. (1991) report that frequency of relapse after BMT is correlated with the presence in the bone marrow of lym­phoma cells which will grow in appropriate in vitro assays Sharp et al. (1992). Although these results must be confirmed in prospective studies, they suggest that the use of purged bone marrow (and perhaps PBPC uncontaminated by tumor cells) may be beneficial.

In the coming years, new tools will appear enabling us to approach our goal to improve overall survival. It will become easier to test different modalities of high dose therapy in lymphoma.

REFERENCES

Armitage,j.O., Weisenburger, D.D., Hutchins, M., Moravec, D.F., Dowling, M., Sorensen, S. et al. (1986) Chemotherapy for diffuse large-cell lymphoma-Rapidly responding patients have more durable remission. Journal of Clinical Oncology, 4, 160-164.

Baro,j., Richard, C., Calavia,j., Gonzales San Miguel,j.D., Bello Fernandez, C, Alsar, MJ. et at. (1991) Autologous bone marrow transplantation as consolidation therapy for non-Hodgkin's lymphoma patients with poor prognostic features. Bone marrow Transplantation, 8, 283-289.

Bosly, A, Coiffier, B., Gisselbrecht, C., Tilly, H., Auzanneau, G., Andrien, F. et al. (1992) For the Groupe d'Etude des Lymphomes Agressifs. Bone marrow transplantation significantly prolongs survival after relapse in aggressive lymphoma patients treated with the LNH84 regimen. Journal of Clinical Oncology, 10,1615-1623.

Brice, P., Marolleau, j.P., Pautier, P., Makke, j., Dombret, H., D'Agay, M.F. et at. (1996) Hematologic recovery and survical of lymphomas patients after autologous stem cell transplantation (ASCT): Comparision of bone marrow with peripheral blood progenitors cell (PBSC). Leukemia and lymphoma, 22(5-6),449-456.

Cabanillas, F., Hagemeister, F.B., McLaughlin, P., Velasquez, W.S., Riggs, S., Fuller, L. and Smith, T (1987) Results of MIME salvage regimen for recurrent or refractory lymphoma. Journal of Clinical Oncology, 3, 407-412.

Fisher, R.t, Gayuor, E., Dahlberg, S., Oken, M.M., Grozan, TM., Mize, E.M. et al. (1993) Comparison of a standard regimen (CHOP) with three intensive chemotherapy regiments for advanced non­Hodgkin's lymphoma. The New EnglandJournal of Medecine, 328, 1002-1006.

Gianni, AM. (1994) 5-Year update of the milan cancer institute randomized trial of high-dose sequen­tial (HDS) vs. MACOP-B therapy for diffuse large-cell lymphomas. In Proceedings of the American Society of Clinical Oncology (1994), voL 13, pp. 373.

Gordon, L.t, Harrington, D.P., Andersen,J., Golgan,j., Glick,j., Neiman, R. et at. (1992) Comparison of a second generation combination chemotherapeutic regimen (m-BACOD) with a standard regimen (CHOP) for advanced diffuse non-Hodgkin's lymphoma. The New England Journal of Medecine, 327, 1342-1349.

334 C. GISSELBRECHT and B. COIFFIER

Gribben ,j.G. , Goldstone, A.H., Linch, D.C., Taghipour, G., McMillan, A.K. , Souhami, R.L. et al. (1989) Effectiveness of high-dose combination chemotherapy and autologous bone marrow transplantation for patients with non-Hodgkin's lymphoma who are still responsive to conventional-dose therapy. Journal of Clinical Oncology, 7,1621-1629.

Gribben, j.G., Freedman , A.S., Neuberg, D., Roy, D.C., Blake, K.W., Woo, S.D. et al. (1991) Immunologic purging of marrow assessed by PCR before autologous bone marrow transplantation for B-celllymphoma. The New England Journal of Medecine, 325, 1525-1533.

Gulati, S.C., Shank, B., Black, P., Yopp, j., Koziner, B. , Straus, D. et at. (1988) Autologous bone marrow transplantation for patients with poor prognosis lymphoma. Journal of Clinical Oncology, 6, 1303-1313.

Haioun, C., Lepage, E., Gisselbrecht, C., Coiffier, B., Bosly, A., Tilly H. et al. (1994) for the GELA. Comparison of autologous bone marrow transplantation with sequential for intermediate and high grade non hodgkin's lymphoma in first complete remission . A study of 464 patients. Journal of Clinical Oncology, 12, 2543-2551.

Haioun, C., Lepage, E. , Gisselbrecht, C., Coiffier, B., Bosly, A. , Plan tier, I. et al. (1995) . Autologous trans­plantation versus conventional salvage therapy in aggressive Non Hodgkin's lymphoma (NHL) par­tially responding to first line chemotherapy. Study of 96 patients enrolled in the LNH87-2 protocol. Blood, 86 n'10, abstract n ' 1816.

Martelli, M. , Vignetti, M., Zinzani, P.L., Gherlinzoni, F., Meloni, G., Fiacchini, M. et at. (1996) Hogh-dose chemotherapy followed by autologous bone marrow transplantation versus desxamethasone, cisplatin, and cytarabine in aggressive non-Hodgkin's lymphoma with partial reponse to front-line chemother­apy: A prospective randomized italian multicenter study. Journal of Clinical Oncology, 14,534-542.

Nademanee, A., Schmidt, G., O'Donnell, M.R., Snyder, D.S., Parker, P.A., Stein, A. et al. (1992) High dose chemoradiotherapy followed by autologous bone marrow transplantation as consolidation therapy during firs complete remission in adult patients with poor-risk aggressive lymphoma: A pilot study. Blood, 80, 1130-1134.

Philip, T., Armitage,j.O. , Spitzer, G., Chauvin, F., SundarJagannath, Cahn,j.Y et at. (1987) High dose therapy and autologous bone marrow transplantation after failure of conventional chemotherapy in adults with intermediate-grade or high grade non Hodgkin lymphoma. The New England Journal of Medicine, 316,1493-1498.

Philip, T., Guglielmi, C., Hagenbeek, A. Sommers, R., Vand der Lelie, H., Bron, D. et al. (1995) A prospective randomized study comparing autologous bone marrow transplantation (ABMT) and salvage chemotherapy (DHAP) in sensitive relapse of non-Hodgkin 's lymphoma (NHL): Final analysis of the PARMA study. N.]. Engl.]. Med., 333, 1540-1545.

Salles, G., Shipp, M.A. and Coiffier, B. (1994) Chemotherapy of non-Hodgkin's aggressive lymphomas. Seminars in Hematology, 31, 46-69.

Shipp, M.A. and Harrington, D.P. (1993) Development of a predictive model for aggressive lymphoma: The International Non-Hodgkins Lymphoma Prognostic Factors Project. The New England Journal of Medecine, 329, 987-994.

Sharp, j.G., Joshi, S.S., Armitage, j.0., Bierman, P. , Coccia, P.F., Harrington, D.S. et al. (1992) Sigificance of detection of occult non-Hodgkin's lymphoma in histologically univolved bone marrow by a culture technique. Blood, 79, 1074-1080.

Velasquez, W.S., Cabanillas, F., Salvadore, P., McLaughlin, P., Fridrik, M., Tucker, S. et al. (1988) Effective salvage therapy for lymphoma with cisplatin in combination with high dose Ara C and dex­amethasone (DHAP) . Blood, 71 , 117.

Verdonck, L.D., Van Putten, W.Lj. , Hagenbeek, A., Schouten, H.C. , Sonneveld, P., Van Imhoff, G.W. et at. (1995) Comparison of CHOP chemotherapy with autologous bone marrow transplantation for slowly responding patients with aggressive non-Hodgkin's lymphoma. The New England Journal of Medecine, 332, 1045-1092.

Vose, Mj. , Anderson,j.R., Kessinger, A., Bierman, PJ., Coccia, P., Reed, E.C. et at. (1993) High dose chemotherapy and autologous hematopoietic stem cell transplantation for aggressive non-Hodgkin's lymphoma. Journal of Clinical Oncology, 11, 1846-1851.

339 AUTOGRAFTING FOR LYMPHOBLASTIC LYMPHOMA

reviewed above are superior to those reported for conventional dose salvage therapy when used as the sole form of treatment, although no comparative data are available to confirm these observations. Patients who fail initial induction therapy should receive further conventional dose therapy in an attempt to induce a second remission prior to autografting. However, high dose therapy should still be considered for patients who prove refractory to conventional dose treatment. The role of autografting in first remission is still unclear, and the results from the EBMT study are awaited.

There is no evidence to support the use of allogeneic marrow transplantation instead of autografting for these patients. Peripheral blood progenitor cells are being used with increasing frequency in patients with LBL. No data are currently available to suggest that malignant cells are mobilised into the peripheral blood in patients with LBL. In the EBMT series, a small number of patients have received PBPC transplants with no difference in outcome compared with those receiving autologous bone marrow. It is likely that PBPCs will become the preferred source of haemopoietic rescue for these patients.

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340 j.w. SWEETENHAM

11. Gribben, j.G. , Goldstone, A.H., Linch, D., Taghipour, G. , McMillan, A.K. , Souhami, R.L. et al. (1989) Effectiveness of high dose combination chemotherapy and autologous bone marrow trans­plantation for patients with non-Hodgkin's lymphoma who are still responsive to conventional dose therapy. Journal of Clinical Oncology, 7,1621-1629.

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344 D. FRAPPAZ ET AL.

may renew interest in allogenic transplants (Appelbaum et al., 1990). Reports have shown the efficiency of immunomagnetic depletion to remove detectable tumors cells from bone marrow (Philip et al., 1986). Positive selection of progenitors (CD 34 positive) may be a further advance. The use of peripheral blood stem cells, and/or of hematopoietic growth factors shortens the duration of neutropenia (Spitzer et al., 1994).

One challenge for the 1990s will be to find early symptoms that would indicate a poor prognosis and argue for early intensification. An other challenge is to increase salvage rates in previously heavily treated patients. Trials are under study to evaluate new combination of alkylating agents and also the possible value of adjuvant immunotherapy after HDT.

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345 HIGH DOSE THERAPY (HDT) IN BURKITT'S LYMPHOMA (BL)

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352 D.L. LONGO

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365 THE ROLE OF INTENSIVE THERAPY AND AUTOTRANSPLANTATION

ence, which has not included transplantation as part of primary therapy, use of this modality at the time of first relapse has yielded the best outcome. The use of transplant therapy even earlier, when patients are responding to first-line chemo­therapy, is attractive for patients anticipated to have a high recurrence rate with chemotherapy alone. Both the non-relapse mortality and relapse rates should be very low after transplantation, as demonstrated in initial pilot studies. However, the difficulty in identifying universally-accepted prognostic features, present at diagnosis or early in therapy, that define a "poor-risk" population of Hodgkin's disease patients has hindered the development of an early transplant approach. International efforts to develop a prognostic system from a large patient data base may assist in this regard. In addition, the two randomized trials in progress com­paring conventional chemotherapy and autotransplantation as part of first-line therapy should provide important information about the usefulness of the current prognostic systems, as well as the desirability of using transplantation as part of the initial therapy plan, rather than reserving its use for a "salvage" maneuver.

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366 DONNA E. REECE

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Kuentz, M., Reyes, F., Brun, B., Leborgeois, j.P., Bierling, P. and Farcet, j.P. (1983) Early response to chemotherapy as a prognostic factor in Hodgkin's disease. Cancer, 52, 780-785.

Levis, A., Vitolo, U., Ciocca, V, Cametti, G., Urgesi, A, Bertini, M. et at. (1987) Predictive value of the early response to chemotherapy in high-risk stages 11 and III Hodgkin's disease. Cancer, 60, 1713-1719.

Longo, D.L., Duffey, P.L., Young, RC., Hubbard, S.M., Ihde, D.C., Glatstein, E. et al. (1992) Conventional-dose salvage combination chemotherapy in patients relapsing with Hodgkin's disease after combination chemotherapy: The low probability for cure. Journal of Clinical Oncology, 10,210-218.

Mauch, P., Tarbell, N. and Skarin, A (1987) Wide-field radiation therapy alone or with chemotherapy for Hodgkin's disease in relapse from combination chemotherapy. Journal of Clinical Oncology, 5, 544-549.

Miller,j.S., Arthur, D.C., Litz, C.E., Neglia,j.P., Miller, WJ. and Weisdorf, DJ. (1994) Myelodysplastic syndrome after autologous bone marrow transplantation: An additional late complication of curative cancer therapy. Blood, 83, 3780-3786.

Moreau, P., Milpied, N., Mechinaud-Lacroix, F., Mahe, B., Rapp, M.T, El Tartaric, S. et al. (1993) Early intensive therapy with autotransplantation for high-risk Hodgkin's disease. Leukemia and Lymphoma, 12,51-58.

Nademanee, A, O'Donnell, M.R., Snyder, D.S., Schmidt, G.M., Parker, P.M., Stein, AS. et al. (1995) High-dose chemotherapy with or without total body irradiation followed by autologous bone marrow and/or peripheral blood stem cell transplantation for patients with relapsed or refractory Hodgkin's disease: Results in 85 patients with analysis of prognostic factors. Blood, 85,1381-1390.

Oza, AM., Ganesan, TS., Dorreen, M.,Johnson, P.W.M., Waxman,j., Gregory, W. et al. (1992) Patterns of survival in patients with advanced Hodgkin's disease (HD) treated in a single centre over 20 years. British Journal of Cancer, 65, 429-437.

Phillips, G.L., Wolff, S.N., Herzig, RH., Lazarus, H.M., Fay,j.W., Lin, H-S. et at. (1989) Treatment of progressive Hodgkin's disease with intensive chemoradiotherapy and autologous bone marrow trans­plantation. Blood, 73, 2086--2092.

Proctor, SJ., Taylor, P., Donnan, P., Boys, R., Lennard, A. and Prescott, RJ. (1991) A numerical prog­nostic index for clinical use on identification of poor-risk patients with Hodgkin's disease at diagno­sis. EuropeanJournal of Cancer, 27, 624-629.

367 THE ROLE OF INTENSIVE THERAPYAND AUTOTRANSPLANTATION

Radford,J.A., Cowan, R.A., Flanagan, M., Dunn, G., Crowther, D.,Johnson, RJ. et al. (1988) The signi­ficance of residual mediastinal adenopathy on the chest radiography following treatment for Hodgkin's disease. Journal of Clinical Oncology, 6, 940-94l.

Reece, D.E. (1995a) Early autologous transplantation (ABMT) in the treatment of Hodgkin's disease. Leukemia and Lymphoma, 15(suppl. 1),55-58.

Reece, D.E. (1995b) Should high-risk Hodgkin's disease patients be singled out for heavier therapeutic regimens while low-risk patients are spared such therapy? Leukemia and Lymphoma, 15(suppl. 1), 19-21.

Reece, D.E., Barnett, MJ., Shepherd, J.D., Hogge, D.E., Klasa, RJ., Nantel, S.H. et al. (1995) High­dose cyclophosphamide, carmustine (BCNU) and etoposide (VP-16) with or without cisplatin (CBV ± P) and autologous transplantation for patients with Hodgkin's disease who fail to enter a complete remission after combination chemotherapy. Blood, 86, 451-456.

Reece, D.E., Connors, J.M., Spinelli, JJ., Barnett, MJ., Fairey, R.N., Klingemann, H-G. et al. (1994) Intensive therapy with cyclophosphamide, carmustine, etoposide ± cisplatin, and autologous bone marrow transplantation for Hodgkin's disease in first relapse after combination chemotherapy. Blood, 83, 1193-1199.

Reece, D.E. and Phillips, G.L. (1994) Intensive therapy and autotransplantation in Hodgkin's disease. Stem Cells, 12,477-493.

Reece, D.E. and Phillips, G.L. (1995) Intensive therapy and autologous stem cell transplantation for Hodgkin's disease in first relapse after combination chemotherapy. Leukemia and Lymphoma, 18, 179-184.

Roach, III M., Kapp, D.S., Rosenberg, S.A. and Hoppe R.T. (1987) Radiotherapy with curative intent: An option in selected patients relapsing after chemotherapy for advanced Hodgkin's disease. Journal of Clinical Oncology, 5, 550-555.

Seong, D., Andersson, B., Korbling, M., Lauppe, J., Hagemeister, F., van Beisen, K. et al. (1995) Predicting parameters of successful peripheral blood stem cell (PBSC) collection after chemo/ cytokine primed mobilization in relapsed Hodgkin's disease. Proceedings of the American Society of Clinical Oncology, 14, 321a.

Stone, R.M., Neuberg, I., Soiffer, R., Takvorian, T., Whealan, M., Rabinowe, S. et al. (1994) Myelodysplastic syndrome as a late complication following autologous bone marrow transplantation for non-Hodgkin's lymphoma. Journal of Clinical Oncology, 12, 2535-2542.

Straus, DJ., Gaynor, J.J., Myers, J., Merke, D.P., Caravelli, J., Chapman, D. et al. (1990) Prognostic factors among 185 adults with newly diagnosed advanced Hodgkin's disease treated with alternating potentially non-cross-resistant chemotherapy and intermediate-dose radiation therapy. Journal of Clinical Oncology, 8, 1173-1186.

Taylor, P.R.A., Jackson, G.H., Lennard, A.L., Lucraft, H. and Proctor, SJ. on behalf of the Newcastle and Northern Regional Lymphoma Group (1993) Autologous transplantation in poor risk Hodgkin's disease using high-dose melphalan/etoposide conditioning with non-cryopreserved marrow rescue. BritishJournal of Cancer, 67, 383-387.

Traweek, ST, Slovack, M.L., Nademanee, A.P., Brynes, R.K., Niland, J.C., and Forman, SJ. (1993) Myelodysplasia occurring after autologous bone marrow transplantation (ABMT) for Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL). Blood, 82(suppl. 1), 455a.

van Leeuwen, F.E., Chorus, A.MJ., van den Belt-Dusebout, A.W., Hagenbeek, A., Noyon, R., van Kerkoff, E.M.H. et al. (1994a) Leukemia risk following Hodgkin's disease: Relation to cumulative dose of alkylating agents, treatment with teniposide combinations, number of episodes of chemotherapy and bone marrow damage. Journal of Clinical Oncology, 12, 1063-1073.

van Leeuwen, F.E., Klokman, WJ., Hagenbeek, A., Noyon, R., van den Belt-Dusebout, A.W. et al. (1994b) Second cancer risk following Hodgkin's disease: A 20-year follow-up study. Journal of Clinical Oncology, 12, 312-325.

Viviani, S., Santoro, A., Negretti, E., Bonfante, V., Valagussa, P. and Bonadonna, G. (1990) Salvage chemotherapy in Hodgkin's disease: Results in patients relapsing more than twelve months after first complete remission. Annals of Oncology, 1, 123-127.

Weaver, C.H., Appelbaum, F.R., Petersen, F., Clift, R., Singer, J., Press, O. et al. (1993) High-dose cyclophosphamide, carmustine, and etoposide followed by autologous bone marrow transplantation in patients with lymphoid malignancies who have received dose-limiting radiation therapy. Journal of Clinical Oncology, 11, 1329-1335.

374 B. BARLOGIE ET AL.

stem cell collection.14.I5 In view of the usual presence of circulating clonal B cells in the peripheral blood that have a pre-plasmacytic phenotype and a higher prolif­erative activity and express MDR, selection of normal hemopoietic progenitor cells may become more important now that the preparatory regimens have been opti­mized. A few studies have been performed to evaluate tumor cell removal by chemotherapy or monoclonal antibody purging. Trials with immunotoxin (e.g. anti-CD19 ricin-A chain) are in progress. An intriguing tumor-specific immuno­logic approach has recently been reported by Kwak and coworkers utilizing idio­type vaccination.16 A trial has been initiated at our institution with both autologous and allogeneic transplantation including idiotype vaccination.

Recent observations of a graft-versus-myeloma effect in the context of donor buffY coat administration to patients failing to respond to chemoradiotherapy with T-cell depleted matched unrelated allografts have stimulated trials to evaluate this approach with both sibling and unrelated donor transplants using thymidine kinase gene transduction of donor T-cells, so that, in the case of severe graft­versus-host disease, donor T-cell suicide can be initiated again by ganciclovir administration.17 Autoregulatory circuits have been described in MM including immunoglobulin binding factors that are isotype-specific and capable of down­regulating the myc oncogene (frequently abnormal in MM cells) and inducing programmed cell death. IS The SCID mouse model offers great opportunity to study whether CD16 gene transduction into T-cells or CD34 hemopoietic stem cells will provide sustained tumor control in IgG myeloma. 19

In summary, MM patients are no longer excluded from novel therapeutic inves­tigations including autologous and allogeneic transplants, which bring about tumor control of several years' duration, especially when applied early in the disease with an increase in CR rates from 5% with standard therapy to the 50% range with myeloablative therapy. The high level of safety with autotransplants seems to be an important first step toward the long range goal of achieving durable remissions and eventually cure which, however, may require additional maneuvers such as tumor cell depletion of the graft and immune modulation post­transplantation, since cures appear unlikely with autotransplant approaches cur­rently in use.

REFERENCES

1. Barlogie, B., Alexanian, R. and Jagannath, S. (1992) Plasma cell dyscrasias.J. Am. Med. Assoc., 268(20), 2946--2951.

2. Barlogie, B., Smith, L. and Alexanian, R. (1984) Effective treatment of advanced multiple myeloma refractory to alkylating agents. New Engl.J. Med., 310, 1353-1356.

3. McElwain, TJ. and Powles, RJ. (1983) High-dose intravenous melphalan for plasma-cellleukemia and myeloma. Lancet, 2, 822-824.

4. Barlogie, B., Alexanian, R., Dicke, K. et al. (1987) High-dose chemoradiotherapy and autologous bone marrow transplantation for resistant multiple myeloma. Blood, 70, 869-872.

5. Barlogie, B., Anderson, K., Berenson, J., Crowley, J., Cunningham, D., Gertz, M., Henon, P., Horowitz, M.,Jagannath, S., Powles, R., Reece, D., Reiffers,J., Salmon, S., Tricot, G. and Vesole, D. (1994) Transplants for multiple myeloma. Journal of Cellular Biochemistry, (suppl. 18B), page 56.

375 AUTOLOGOUS TRANSPLANTS FOR MULTIPLE MYELOMA

6. Gianni, AM., Siena, S., Bregni, M., Tarella, C., Stem, AC., PiIeri, A and Bonadonna, G. (1989) Granulocyte-macrophage colony-stimulating factor to harvest circulating haemopoietic stem cells for autotransplants. Lancet, 2, 580.

7. Barlogie, B. (1995) Plasma cell myeloma. In: Kipps T (ed): Hematology, William's Hematology, Fifth Edition, McGraw-Hill, Inc., Baltimore, MD pp. 1l09-1126.

8. Barlogie, B.,Jagannath, S., Vesole, D. and Tricot, G. (1995) Autologous and allogeneic transplants for multiple myeloma. Sem. in Hematol., 32(1), 31-44.

9. Vesole, D.H.,Jagannath, S., Tricot, G. et al. (1994) 400 autotransplants (AT) for multiple myeloma (MM). Blood, 84, 535a.

10. Tricot, G.,Jagannath, S., VesoIe, D. et al. (1995) Peripheral blood stem cell transplants for multiple myeloma: Identification of favorable variables for rapid engraftment in 225 patients. Blood, 85(2), 588-596.

11. Gahrton, G., Tura, S., Ljungman, P. et al. (1991) Allogeneic bone marrow transplantation in multi­ple myeloma. N. Engl.j. Med., 325, 1267-1273.

12. Barlogie, B., Jagannath, S., Vesole, D., Miller, L., Cheson, B., Bracy, D. and Tricot, G. (1994) Total therapy (TT) for 202 newly diagnosed patients (PTS) with multiple myeloma (MM). Blood, 84, 386a.

13. Attal, M., Harousseau,J.L., Stoppa, A.M. et al. (1996) A prospective randomized trial of autologous bone marrow transplantation and chemotherapy in multiple myeloma. NEfM, 335, 91-97.

14. Schiller, G., Rosen, L., Vescio, R et al. (1994) Threshold dose of autologous CD34- positive periph­eral blood progenitor cells (PBPC) required for engraftment after myeloablative treatment for multiple myeloma. Blood, 84, 207a.

15. Gazitt, Y., Reading, C.C., Hoffman, R et al. (1995) Purified CD34+Linlhy+ stem cells do not contain clonal myeloma cells. Blood, 86, 381-389.

16. Kwak, L.W., Taub, D.D., Duffey, P.L., Bensinger, W.!. et al. (1995) Transfer of myeloma idiotype­specific immunity from an actively immunised marrow donor. Lancet, 345, 1016-1020.

17. Tricot, G., Vesole, D.H., Jagannath, S. et al. (1996) Graft-versus-myeloma effect: Proof of principle. Blood, 87, 1196-119S.

IS. Hoover, RG., Lary, C., Page, R, Travis, P. et al. (1995) Autoregulatory circuits in myeloma: Tumor cell cytotoxicity mediated by soluble CDI6.j. Clin. Invest., 95, 241-247.

19. Munshi, N.C., Ding, L.M., Kornbluth, J., Naugler, S., Srivastava, A., Iyer, R, Saylors, Rand Barlogie, B. (1994) Gene therapy strategies for multiple myeloma. Blood, 84, 672a.

382 J.A. LEDERMANN andA.L.JONES

CONCLUSIONS AND FUTURE DIRECTIONS

In there last five years there have been enormous technical advances in the admin­istration of high dose chemotherapy. Experience with the use of haematopoeitic growth factors has led to the widespread introduction of PBSC transplantation in many units in place of ABMT. PBSC transplantation leads to faster regeneration of the bone marrow, shorter hospital admission and it is therefore likely to be safer and cheaper than ABMT. The mortality of high dose chemotherapy with PBSC support has fallen as units become more experienced with the drugs and care of patients.

Many oncologists hold a conviction that this treatment will increase the propor­tion of women surviving breast cancer and this has led to further investigations of the technique of high dose chemotherapy to try and build on the results already achieved. There is some concern that despite induction chemotherapy bone marrow or peripheral blood stem cell collections may contain small numbers of malignant cells. Purging of bone marrow with 4-hydroxy-cyclophosphamide and enrichment of CD34+ cell populations are two strategies that have been investi­gated in breast cancer (25-27) . The benefit of these more costly strategies is unclear as most patients with metastatic breast cancer relapse in previous sites of disease (13). It has been argued that single high dose chemotherapy many not be sufficient and double or multiple transplants should be used. The concept is not new but it now easier to perform. Ayash et al. (28) have used a tandem approach of melphalan followed by the CTCb regimen. Mucositis was the main problem but there were no treatment-related deaths in twenty patients. Others have given two courses of cyclophosphamide, etoposide and thiotepa (29), tandem carboplatin, etoposide and cyclophosphamide with ABMT (30) or sequential high dose cyclophosphamide, melphalan and two doses of thiotepa fourteen days apart and supported by PBSC and GC SF (31) .

A very large number of patients have already been treated with high dose chemotherapy (more than 2500 are registered with the North American Bone Marrow Transplant Registry) and very few of these have been entered into ran­domised trials. The health care costs are considerable and they will be even greater if multiple sequential high dose chemotherapy is adopted. It is important that we establish whether adjuvant high dose chemotherapy cures more women and whether this approach really benefits patients with metastatic breast cancer. This information will only come from the results of randomised trials. Only then can one gain an idea of the magnitude of the benefit and justify the increased health care costs of the procedure.

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383 AUTOGRAFfING IN BREAST CANCER

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384 ].A. LEDERMANN and A.L. lONES

25. Kennedy, MJ., Beveridge, R.A., Rowley, S.D., Gordon, G.B., Abeloff, M.D. and Davidson, N.E. (1991) High-dose chemotherapy with reinfusion of purged autologous bone marrow following dose-intense induction as initial therapy for metastatic breast cancer.] Nat!. Cancer Inst., 83, 920-6.

26. Shpall, EJ., lones, R.B., Bearman, S.l. et al. (1994) Transplantation of enriched CD34-positive autologous marrow into breast cancer patients following high-dose chemotherapy: influence of CD34-positive peripheral-blood progenitors and growth factors on engraftment.] Clin. Oncol., 12, 28-36.

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393 HIGH DOSE CHEMOTHERAPY WITH STEM CELL SUPPORT

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394 B.D. CHESON

18. Herzig, R.H., Phillips, G.L., Lazarus, H.M. et al. (1985) Intensive chemotherapy and autologous bone marrow transplantation for the treatment of refractory malignancies. In: Dicke, KA., Spitzer, G., Zander, A.R., ed. Autologous Bone Marrow Transplantation: First International Symposium. Houston, TX: M.D. Anderson Hospital and Tumor institute, 197-202.

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29. Harada, M., Yoshida, T. , Funada, H. and Hattori, K-1. (1984) Team KUBMT. Clinical trial of inten­sive therapy and autologous bone marrow transplantation in the treatment of malignant diseases. jpn.]. Clin. Oncol., 14(suppl. 1),543-552.

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395 HIGH DOSE CHEMOTHERAPY WITH STEM CELL SUPPORT

34. Shpall, E., jones, R., Egorin, M. et al. (1987) A phase I trial of high-dose combination cyclophos­phamide (C), cisplatinum (P) and thiotepa (T) with autologous bone marrow support (ABMS) in the treatment of resistant solid tumors. Proc. Amer. Soc. Clin. Oncol., 6, 139(abstr.).

35. Slease, R.B., Benear,].B., Selby, G.B. et al. (1988) High-dose combination alkylating agent therapy with autologous bone marrow rescue for refractory solid tumors.J. Clin. Oncol., 6,1314-1320.

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39. Suzuki, T., Ochiai, T., Nagata, M., Koide, Y, Gunji, Y, Nakajima, K, Yokoyama, T., Kashiwabara, H. and Isono, K (1993) High-dose chemotherapy with autologous bone marrow transplantation in the treatment of advanced gastric cancer. Cancer, 72, 2537-2542.

40. Stewart, F.M., Lazarus, H.M., Levine, P.A., Stewart, KA., Tabbara, LA. and Spaulding, C.A. (1989) High-dose chemotherapy with autologous marrow transplantation for esthesioneuroblastoma and sinonasal undifferentiated carcinoma. Am. J. Clin. Oncol., 12, 217-221.

41. Kemeny, N. (1987) Role of chemotherapy in the treatment of colorectal carcinoma. Sem. Surg. Oncol., 3,190-214.

42. Moertel, C.G. (1994) Chemotherapy for colorectal cancer. New Engl.J. Med., 330,1136-1142. 43. Knight, W.A., Goodman, P., Taylor, S.A. et al. (1990) Phase 11 trial of intravenous melphalan for

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tumor and normal tissues in the mouse to alkylating agents. Br.J. Cancer, 45, 700-708. 46. McCullen, M., Vyas, S.K, Winwood, P.j., Loehry, C.A., Parham, D.M. and Hamblin, T. (1994)

Long-term survival associated with metastatic small cell carcinoma of the esophagus treated by chemotherapy, autologous bone, marrow transplantation, and adjuvant radiation therapy. Cancer, 73, 1-4.

47. Eden, B.V., Debo, R.F., Lamer, ].M., Kelly, M.D., Levine, P.A., Stewart, F.M., Cantrell, R.W. and Constable, W.C. (1994) Esthesioneuroblastoma. Long term outcome and patterns offailure - the University of Virginia experience. Cancer, 73, 2556-2562.

48. Kessinger, A., Mclntosh, D. and Smith, M. (1992) High dose chemotherapy and autologous hematopoietic stem cell transplantation for patients with refractory or metastatic carcinoma of the uterine cervix. Proc. Amer. Soc. Clin. Oncol., 11, 237(abstr. 763).

49. Warkentin, P.L, Brochstein, ].A., Strandjord, S.E., Gordon, B.G., Abromowitch, M., Bayever, E., Harper,].L. and Coccia, P.F. (1993) High dose therapy followed by autologous stem cell rescue for recurrent Wilms' tumor (WT). Proc. Amer. Soc. Clin. Oncol., 12, 414(abstr. 1418).

50. Fennelly, D., Vahdat, L., Schneider,].L.R., Hamilton, N., Hakes, T., Raptis, G., Wasserheit, C., Kritz, A., Gulati, S., Markman, M., Hoskins, W., Norton, L. and Crown,]. (1994) High-intensity chemotherapy with peripheral blood progenitor cell support. Sem. Oncol., 21 (suppl. 2), 21-25.

405 RESCUE IN PEDIATRIC SOLID TUMORS

Second Cancers

The probability that second cancers will occur in children receiving conventional treatment is of the order of 15% at 30 years post diagnosis. The additional risk due to high-dose chemotherapy is therefore difficult to appreciate. However, second cancers have been described after allogeneic or autologous bone marrow transplan­tation. The role of alkylating agents and etoposide in the occurrence of secondary leukemia must be taken into account, even if the incidence of these late complica­tions remains seemingly very low (Hartmann et al., 1984; Witherspoon et al., 1989).

CONCLUSIONS

High-dose chemotherapy with hematopoietic stem cell rescue has a foremost role to play in pediatric oncology because of the usual chemosensitivity of malignant tumors of childhood. In the EBMT registry, 52% of grafted patients are children. In 1995, what is the exact role of this therapeutic strategy in pediatric oncology? Some indications, although rare, are currently considered gold standards, for example those described for lymphomas and Hodgkin's disease. With respect to the treatment of neuroblastomas and Ewing's sarcoma, this strategy has a predomi­nant role to play, as mentioned earlier: ongoing randomized studies (neuroblas­tomas) or in the process of being designed, should validate these indications. For the other tumors, studies are still too preliminary for such indications to be consid­ered established as yet. A case in point, the results of a small series of medulloblas­tomas, are however very encouraging. Homogeneous, co-operative studies must be developed to better define the role of such an approach in these rare diseases.

The current increasing use of hematopoietic growth factors and peripheral stem cell grafts will lead, in a not too distant future, to major upheavals in indications and the wide use of high-dose chemotherapy in pediatric oncology. All the studies conducted to date, have served to prove that the dose effect is indeed a reality and that it exerts an impact on survival. A new impetus, linked to these, hitherto unavailable forms of hematopoietic support, is emerging. Sequential high-dose chemotherapy followed by repeated stem cell grafts is an area of research under­going active development in oncology.

The authors are grateful to Lorna Saint-Ange for revising the manuscript.

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419 REVIEW OF INDICATIONS

residual myeloma cells might reduce the relapse rate, or would at least indirectly demonstrate that relapse actually results from some sanctuary sites in the patient.

Therefore, the efficacy of myeloablative therapy by additional therapeutic options would have to be further enhanced, as for example, by chemosensivitizers, biological response modifiers, systemic radiation therapy or others... Broad program! Unless less toxic ways to achieve a definite cure appear soon to be worthwhile ...

GENERAL CONCLUSIONS

While incredibly developing within the past years, ABCT is presently at a cross­roads. It certainly presents several important advantages over autologous or allo­geneic BMT, mainly: rapidity of posttransplant hematopoietic recovery, lower procedure-related mortality rate, better cost effectiveness and better posttrans­plant quality of life. Also, the risk of contamination by residual tumor cells result­ing from graft products is probably lower than for ABMT, at least if BC are collected in steady state or after mobilization with chemotherapy alone. Whether ABCT is more efficient in terms of DFS and OS than other transplant procedures, and even than conventional chemotherapies, still remains vague. There are too few randomized trials which, although needed, are now difficult to offer consider­ing the vital short term advantages of the ABCT procedure.

Further trainings are currently developed, as enhancement of BC mobilization either by cytokines, or by in vitro stem cell expansion for instance. However, any procedures have their drawbacks. These are expensive, and will therefore consid­erably increase the total cost of ABCT. Furthermore, cytokines are not only able to enhance mobilization of BC, but also that of tumor cells, at least in several malig­nant diseases. Consequently, it becomes absolutely necessary to purge graft prod­ucts in vitro from mobilized tumor cells, using either CD34 positive selection or negative selection, and like in a vicious circle, it increases the expenses even more. This cost explosion could be, likely, partially balanced by a reduction of hospital­ization duration. BC mobilization and sometimes reinfusion might also be safely managed in the out-patient setting, at least for some indications, which would reduce the costs even more.

However, one of, if not the most important anticipated progress from mobiliza­tion and reinfusion of autologous hematopoietic BC, is their further use for gene therapy, still in infancy stage, but offering great therapeutic expectations for the future.

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420 PH.HENON

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9. Brenner, M.K., Rill, D.R., Moen, R.C. et al. (1993) Gene marking to trace origin of relapse after autologous bone marrow transplantation. Lancet, 341 , 85-86.

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11. Korbling, M., Fliedner, T.M., Holle, R., Magrin, S. et al. (1991) Autologous blood stem cell (ABSCT) versus purged bone marrow transplantation (pABMT) in standard risk AML: influence of source and cell composition of the autograft on hematopoietic reconstitution and disease-free survival. Bone Marrow Transplant, 7, 343-349.

12. Reiffers,j., Korbling, M., Labopin, M., Henon, Ph. and Gorin, N.C. (1992) Autologous blood stem cell transplantation versus autologous bone marrow transplantation for acute myeloid leukemia in first complete remission. Int.]. Cell Cloning, 10(suppl. 1), 111-113.

13. Szer, j., Juttner, C.A., To, L.B., Bradstock, K.F., Sage, R.E., Enno, A and Toogood, I.R.G. (1992) Post-remission therapy for acute myeloid leukemia with blood-derived stem cell transplantation. Results ofa collaborative phase 11 trial. Int.]. Cell Cloning, 10(suppl.l), 114-116.

14. Reiffers,j., Stoppa, AM., Attal, M. and Michallet, M. (1994) Is there a place for blood stem cell transplantation for the younger adult patient with acute myelogenous leukemia? ]. Clin. Oncol. , 12, 1100 (letter).

15. Sanz, M.A, De La Rubia, j., Sanz, G.F. et al. (1993) Busulfan plus cyclophosphamide followed by autologous blood stem cell transplantation for patients with acute myeloblastic leukemia in first complete remission: a report from a single institution.]. Clin. Oncol., 11, 1661-1667.

16. Brenner, M.K. (1995) Lessons from gene marking. Personal communication. 1st Annual Meeting of the American Society for Blood and Marrow Transplantation, Keystone, USA, January 26-28.

17. Takamatsu, Y, Teshima, T., Akashi, K., Inaba, S., Harada, M. and Niho, Y (1994) Successful second autologous blood stem cell transplantation after G-CSF-combined conditioning for the treattnent of high-risk acute myelogenous leukemia. Bone Marrow Transplant, 13,325-327.

18. Gorin, N.C. (1994) High dose therapy and transplantation of autologous stem cells for acute leukemia. Exp. Hematol., 22, 678 (abstract).

19. Grande, M., Barbu, v., Van den Akker,j. et aL (1994) Autologous bone marrow transplantation in ALL: relapse linked to infusion of tumor cells with the back-up marrow. Bone Marrow Transplant, 14,477-480.

20. Langlands, K., Anderson, j.S., Parker, A.C. and Anthony, R.S. (1992) Polymerase chain reaction analysis of tumor contamination in peripheral blood stem cell harvests. Int.]. Cell Cloning, lO(suppl. 1),95-97.

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421 REVIEW OF INDICATIONS

23. Kessinger, A. and Armitage,].O. (1992) Peripheral stem cell transplantation for patients with non­Hodgkin's lymphoma. Int.] Cell Cloning, 10(suppl. 1), 127-128.

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25. Siena, S., Bregni, M., Brando, B., Ravagnani, F., Bonadonna, G. and Gianni, A.M. (1989) Circulation of CD34+ hematopoietic stem cells in the peripheral blood of high-dose cyclophos­phamide-treated patients: enhancement by intravenous recombinant human granulocyte­macrophage colony-stimulating factor. Blood, 74,1905-1914.

26. Pettengel, R., Morgenstern, G.R., Woll, PJ. et al. (1993) Peripheral blood progenitor cell trans­plantation in lymphoma and leukemia using a single apheresis. Blood, 82, 3770-3777.

27. Jones, H.M., Jones, S.A., Watts, MJ. et al. (1994) Development of a simplified single-apheresis approach for peripheral-blood progenitor-cell transplantation in previously treated patients with lymphoma.] Clin. Oncol., 12, 1693-1702.

28. Sharp,].G.,Joshi, S.S., Armitage,].O. et al. (1992) Significance of detection of occult non-Hodgkin's lymphoma in histologically uninvolved bone marrow by a culture technique, Blood, 79, 1074-1080.

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30. Clark, H.M., Jones, D.B. and Wright, D.H. (1992) Cytogenetic and molecular studies of t(14,18) and t(14,19) in nodal and extra-nodal B-celllymphoma.] Pathol., 166, 129-134.

31. Lambrechts, A.C., Hupkes, P.E., Dorssers, L.CJ. and Van't Veer, M.B. (1993) Translocation t(14,18)-positive cells are present in the circulation of the majority of patients with localized (stage I and 11) follicular non-Hodgkin's lymphoma. Blood, 82, 2510-2516.

32. Lambrechts, A.C., Hupkes, P.E., Dorssers, L.CJ. and Van't Veer, M.B. (1994) Clinical significance of t(14,18)-positive cells in the circulation of patients with stage III or IV follicular non-Hodgkin's lymphoma during first remission.] Clin. Oncol., 12, 1541-1546.

33. Johnson, P.W.M., Price, C.G.A., Smith, T. et al. (1994) Detection of cells bearing the t(14,18) translocation following myeloablative treatment and autologous bone marrow transplantation for follicular lymphoma.] Clin. Oncol., 12,798-805.

34. Gribben,].G., Freedman, A.S., Neuberg, D. et al. (1991) Immunologic purging of marrow assessed by PCR before autologous bone marrow transplantation for B-celllymphoma. N. Engl.] Med., 325, 1525-1533.

35. Craig,].I.O., Langlands, K., Parker, A.C. and Anthony, R.C. (1994) Molecular detection of tumor contamination in peripheral blood stem cell harvests. Exp. Hematol., 22, 898-902.

36. Haas, R., Moos, M., Karcher, A. et al. (1994) Sequential high-dose therapy with peripheral-blood progenitor-cell support in low-grade non-Hodgkin's lymphoma.] Clin. Oncol., 12, 1685-1692.

37. Gribben,].G., Neuberg, D., Freedman, A.S. et al. (1993) Detection by polymerase chain reaction of residual cells with the bcl-2 translocation is associated with increased risk of relapse after autologous bone marrow transplantation for B-celllymphoma. Blood, 81, 3449-3457.

38. Price, C.G.A., Meerabux,]., Murtagh, S. et al. (1991) The significance of circulating cells carrying t(14,18) in long remission from follicular lymphoma.] Clin. Oncol., 9, 1527-1532.

39. Freedman, A., Neuberg, D., Gribben,]. et al. (1992) Prognostic factors for improved disease-free survival following high-dose therapy and autologous bone marrow transplantation in patients with B-cell non-Hodgkin's lymphoma in sensitive relapse. Blood, 80(suppl. 1), 259a, (abstract).

40. Vose, ].M., Anderson, ].R., Kessinger, A. et al. (1993) High-dose chemotherapy and autologous hematopoietic stem-cell transplantation for aggressive non-Hodgkin's lymphoma.] Clin. Oncol. , 11, 1846--1851.

41. Nademanee, A., Sniecinski, I., Gerhard, M. et al. (1994) High-dose therapy followed by autologous peripheral blood stem cell transplantation for patients with Hodgkin's disease and non-Hodgkin's lymphoma using unprimed and granulocyte colony-stimulating factor-mobilized peripheral blood stem cells.] Clin. Oncol., 12, 2176--2186.

42. Schenkein, D.P., Dixen, P., Desporges, ].F. et al. (1994) Phase 1/11 study of cyclophospha­mide, carboplatin, and etoposide and autologous hematopoietic stem cell transplantation with

422 PH. HENON

posttransplant interferon alfa-2b for patients with lymphoma and Hodgkin's disease.] Clin. Oncol., 12, 2423-2431.

43. Rapoport, A.P., Rowe,].M., Kovides, P.A et al. (1993) One hundred autotransplants for relapsed or refractory Hodgkin's disease and lymphoma: value of pretransplant disease status for predicting outcome.] Clin. Oncol., 11,2351-2361.

44. Chopra, R, McMillan, A.K., Linch, D.C. et al. (1993) The place of high dose BEAM therapy and autologous transplantation in poor-risk Hodgkin's disease. A single center eight-year study of 155 patients. Blood, 81,1137-1145.

45. Linch, D.C., Winfield, D., Goldstone, AH. et al. (1993) Dose intensification with autologous bone marrow transplantation in relapsed and resistant Hodgkin's disease: results of a BNLI randomised trial. Lancet, 341 , 1051-1054.

46. Kessinger, A, Armitage,]., Landmark,]., Smith, D. and Weisenburger, D. (1988) Autologous peripheral hematopoietic stem cell transplantation restores hematopoietic function following marrow ablative therapy. Blood, 71, 723-727.

47. Korbling, M., Holle , R, Haas, R. et al. (1990) Autologous blood stem cell transplantation in patients with advanced Hodgkin's disease and prior radiation to the pelvic site.] Clin. On col. , 8, 378-385.

48. Haas, R., Hohaus, S., Egerer, G., Ehrhardt, R, Witt, B. and Hunstein, W. (1992) Recombinant human granulocyte-macrophage colony-stimulating factor (rh GM-CSF) subsequent to chemother­apy improves collection of blood stem cells for autografting in patients not eligible for bone marrow harvest. Bone Marrow Transplant, 9, 459-465.

49. Haas, R, Ho, AD., Bredthauer, U. et al. (1990) Successful autologous transplantation of blood cells mobilized with recombinant human granulocyte-macrophage colony-stimulating factor. Exp. Hematol., 18,94-98.

50. Siena, S., Bregni, M., Brando, B. et al. (1991) Flow cytometry for clinical estimation of circulating hematopoietic progenitors for autologous transplantation in cancer patients. Blood, 77, 400-409.

51. Haas, R Hohaus, S., Ehrhardt, R, Goldschmidt, H. and Hunstein, w., (1993) Autologous blood progenitor cell transplantation in relapsed Hodgkin's disease. The role of hematopoietic growth factors. Bone Marrow Transplant, l1(suppl. 2), 30-35.

52. Janssen, W. and Elfenbein, G], (1995) Mobilization of peripheral blood stem cells: are all regimens created equal? In: Hematopoietic Stem Cells: Biology and Therapeutic Applications, edited by D. Levitt and R Mertelsmann, pp. 403-419. Marcel Dekker, New York.

53. Lasky, L.C., Hurd, D.D., Smith,].A and Haake, R (1989) Peripheral blood stem cell collection and use in Hodgkin 's disease. Comparison with marrow in autologous transplantation. Transfusion, 29, 323-327.

54. Kessinger, A., Vose,]., Bierman, P], and Armitage, ].0. (1992) High dose cyclophosphamide, etoposide and carmustine and peripheral stem cell transplantation for patients with relapsed Hodgkin's disease and bone marrow abnormalities. Int.] Cell Cloning, IO(suppl. 1), 135-137.

55. Haas, R, Hohaus, S., Egerer, G., Ogniben, E., Witt, B. and Hunstein, W. (1992) Autologous blood stem cell transplantation in relapsed Hodgkin's disease. Int.] Cell Cloning, IO(suppl. 1), 138-140.

56. Kessinger, A and Armitage, ].0. (1994) Blood stem cell transplants in lymphoma. In: Blood Stem Cell Transplants; edited by RP. Gale, C.A. Juttner and Ph. Henon, pp. 128-133. Cambridge University Press, Cambridge, U.K.

57. Nademanee, A, O'Donnel, M.R., Snyder, D.S. et al. (1995) High-dose chemotherapy with or without total body irradiation followed by autologous bone marrow and/or peripheral blood stem cell transplantation for patients with relapsed and refractory Hodgkin's disease: results in 85 patients with analysis of prognostic factors. Blood, 85,1381-1390.

58. Bierman, P]" Vose, ].M. and Armitage, ].0. (1994) Autologous transplantation for Hodgkin's disease: coming of age? Blood, 83,1161-1164.

59. Henon, Ph., Beck, G., Debecker, A, Eisenmann,].C., Lepers, M. and Kandel, G. (1988) Autograft using peripheral blood stem cells collected after high dose melphalan in high risk multiple myeloma. Br.] Haematol., 70, 254-255.

60. Greip, P. (1992) Advances in the diagnosis and the management of myeloma. Semin. Hematol., 29, 24-25.

423 REVIEW OF INDICATIONS

61. Gahrton, G., Tura, S., Ljungman, P. et al. (1995) Prognostic factors in allogeneic bone marrow transplantation for multiple myeloma.] Clin. Oncol., (in press).

62. Barlogie, B., Hall, R, Zander, A. et al. (1986) High-dose melphalan with autologous bone marrow transplantation for multiple myeloma. Blood, 67,1298-1301.

63. Barlogie, B., Fermand, J.P., Henon, Ph., Reiffers and J., Jagannath, S. (1994) Peripheral blood stem cell transplants in multiple myeloma. In: Blood Stem Cell Transplants, edited by RP. Gale, C.A. Juttner and Ph. Hi'non, pp. 150-163, Cambridge University Press, Cambridge, U.K.

64. Attal, M., Harousseau, J.L., Stoppa, A.M. et a!. (1993) High-dose therapy in multiple myeloma: a prospective study of the "Intergroupe Frant;ais du Myelome". Blood, 82(suppl. 1), 198a, (abstract).

65. Eisenmann,J.C., Henon, Ph., Wunder, E. et al. (1990) Unequal results of collection of peripheral blood stem cells in view of autografting in high risk multiple myeloma. Bone Marrow Transplant, 5(suppl. 1),56-57.

66. Tricot, G.,Jagannath, S., Vesole, D. et al. (1995) Peripheral blood stem cell transplants for multiple myeloma: identification of favorable variables for rapid engraftment in 225 patients. Blood, 85, 588-596.

67. Boiron,J.M., Marit, G., Faberes, C. et a!. (1993) Collection of peripheral blood stem cells in multi­ple myeloma following single high-dose cyclophosphamide with and without recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF). Bone Marrow Transplant, 12, 49-55.

68. Wunder, E., Sovalat, H., Baerenzung, M. and Henon, Ph. (1995) Impeded normal hematopoiesis in bone marrow of patients with multiple myeloma. Stem Cells, 13(suppl. 2), 51-55.

69. Reiffers,J., Marit, G. and Boiron,J.M. (1989) Peripheral blood stem cell transplantation in inten­sive treatment of multiple myeloma. Lancet, 11,1336.

70. Henon, Ph., Eisenmann,J., Beck-Wirth, G. and Liang, H. (1992) A two phase intensive therapeutic approach in high risk myeloma. Follow up. Int.] of Cell Cloning, 10(suppl. 1), 142-144.

71. Fermand, J., Levy, Y, Gerota, J. et al. (1989) Treatment of aggressive multiple myeloma by high dose chemotherapy and total body irradiation followed by blood stem cell autologous autografts. Blood, 73, 20-23.

72. Tarella, C., Boccadoro, M., Omedi', P. et al. (1993) Role of chemotherapy and GM-CSF on hemo­poietic progenitor cell mobilization in multiple myeloma. Bone Marrow Transplantation, 11, 271-277.

73. Bensinger, W., Singer, J., Appelbaum, F. et a!. (1993) Autologous transplantation with peripheral blood mononuclear cells collected after administration of recombinant granulocyte stimulating­factor. Blood, 81, 3158-3163.

74. Henon, Ph., Becker, M., Sovalat, H., Eisenmann, J.C., Donatini, B. and Sklenar, I. (1995) Mobilization of peripheral blood stem cells with chemotherapy and cytokines in multiple myeloma. Stem Cells, 13(suppl. 2),148-155.

75. Marit, G., Faberes, C., Boiron,J.M. et al. (1995) Autologous blood progenitor cell transplantation in high-risk multiple myeloma. Stem Cells, 13(suppl. 2), 160-163.

76. Dimopoulos, M.A., Hester, J., Hum, Y, Champlin, R. and Alexanian, R, (1994) Intensive chemotherapy with blood progenitor transplantation for primary resistant multiple myeloma. Br:] Haematol., 87, 730-734.

77. Alexanian, R, Dimopoulos, M.A., Delasalle, K.B., Hester,J. and Champlin, R (1995) Myeloablative therapy for primary resistant multiple myeloma. Stem Cells, 13(suppl. 2), IIS-121.

7S. Barlogie, B., Jagannath, S., Vesole, D. et a!. (1993) Total therapy (TT) for newly diagnosed multiple myeloma. Blood, 82(suppl. 1), 19Sa, (abstract).

79. Bjorkstrand, B., Ljungman, P., Bird,J.M. et al. (1995) Autologous stem cell transplantation in mul­tiple myeloma: results of the European Group for Bone Marrow Transplantation. Stem Cells, 13(suppl. 2), 140-146.

SO. Powles, R, Raje, N., Cunningham, D. et a!. (1995) Maintenance therapy for remission in myeloma with Intron-A following high-dose melphalan and either an autologous bone marrow transplanta­tion or peripheral stem cell rescue. Stem Cells, 13(suppl. 2), 114-117.

81. Fermand,J.P., Ravaud, P., Chevret, S. et al. (1995) High-dose therapy and autologous blood stem cell transplantation (ABSCT) in multiple myeloma: preliminary results of a randomized trial involving 167 patients. Stem Cells, 13(suppl. 2), 156-159.

424 PH. HENON

82. Henon, Ph., Donatini, B., Eisenmann,J.C., Becker, M. and Beck-Wirth, G., (1995) Comparative sur­vival, quality of life and cost-effectiveness of intensive therapy with autologous blood cell transplan­tation or conventional chemotherapy in multiple myeloma. Bone Marrow Transplant, 16, 19-25.

83. Bakkus, M.H.C., Van Riet, I., Van Camp, B. and Thielemans, K. (1994) Evidence that the clono­genic cell in multiple myeloma originates from a pre-switched but somatically mutated B-cell. Br. J Haematol., 87, 68-74.

84. Bergsagel, P.I., Smith, AM. Szczepek, A, Mant, MJ., Belch, A.R. and Pilarski, L.M. (1995) In mul­tiple myeloma, clonotypic B Iymphocytes are detectable among CDI9+ peripheral blood cells expressing CD38, CD56, and monotypic Ig light chain. Blood, 85, 436-447.

85. Corradini, P., Voena, C., Astolfi, M. et al. (1995) High-dose sequential chemoradiotherapy in multi­ple myeloma: residual cells are detectable in bone marrow and peripheral blood cell harvests and after autografting. Blood, 85, 1596-1602.

86. Vescio, R.A, Hong, C.H., Cao, J. et al. (1994) The hematopoietic stem cell antigen CD34 is not expressed on the malignant cells in multiple myeloma. Blood, 84, 3283-3290.

87. Vescio, R., Cao, J., Hong, C. et al. (1994) CD34-positive Ceprate selection leads to a 4.5 log­reduction in tumor burden in myeloma PBC autografts based on PCR and Poisson distribution analysis. Blood, 84(suppl. 1), 399a, (abstract).

88. Reading, C., Sasaki, D., Leemhuis, T. et al. (1994) Clinical scale purification of CD34+Thy-PLin­stem cells from mobilized peripheral blood by high speed fluorescence-activated cell sorting for use as an autograft for multiple myeloma patients. Blood, 84(suppl. 1), 399a, (abstract).

429 UMBILICAL CORD BIOLOGYAND TRANSPLANT

killer (CD3-) or cytotoxic T lymphocyte phenotype, it was shown that cord blood, in contrary to adult peripheral blood, contains exclusively cytotoxic natural killer cells and no cytotoxic T lymphocyte activity (26).

GENE TRANSFER IN CORD BLOOD

Retrovirus and adeno-associated virus 2 vectors have been transferred to purified and non purified cord blood hematopoietic stem cells. Both studies show that the efficiency of gene transfer in cord blood is higher than in bone marrow cells, even in the absence of added hematopoietic growth factors (27). This property is very important for future studies of gene therapy in genetic or acquired disorders. A first attempt has been performed by D. Kohn et al. who introduced the ADA gene in cord blood cells of 3 children with ADA deficiency whose cord blood was col­lected at birth, transfected during a short culture and reinfused to the infants. The children have been treated with enzyme replacement and are doing well; at 23 months of age, it has been shown that the gene is expressed in about 1% of the bone marrow population, and that the expression increases with age suggesting that transfected cells might have a selective growth advantage.

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438 S., SLAVIN ET AL.

ACKNOWLEDGEMENTS

This work was supported in part by a research grant from Baxter Healthcare Corp. and a grant from the German Israel Foundation (GIF) and a grant from Mrs. Ryna and Mr. Melvin Cohen (to S. Slavin). The work was done at the Max Moss Leukemia Research Laboratory supported by Mrs. Adi Moss.

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Ackerstein, A. , Kedar, E. and Slavin, S. (1991) Use of recombinant human inte rleukin-2 in conjunction with syngeneic bone marrow transplantation as a model for control of minimal residual disease in malignant hematological disorders. Blood, 78, 1212-1215.

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Foa, R, Caretto, P., Fierro, M.T., Bonferroni, M., Cardona, S., Guarini, A., Lista, P., Pegoraro, L., Mandelli, F., Forni, G. and Gavosto, F. (1990) Interleukin-2 does not promote the in vitro proliferation and growth of human acute leukaemia cells of myeloid and lymphoid origin. Br. I Haematol, 75, 34.

Horowitz, M., Gale, R.P., Sondel, P.M., Goldman Dersey, J.M., Kolb, HJ., Rimm, A.A., Ringden, 0. , Rozman, C. , Sperk, B., Tonitt, RI., Zwaan, EG. and Bortin, M.M. (1990) Graft vs leukemia reactions after bone marrow transplantation. Blood, 75, 555-562.

Johnson, B.D., Drobyski , W.R and Truitt, R.L. (1993) Delayed infusion of normal donor cells after MHC-matched bone marrow transplantation provides an anti-leukemia reaction without graft-vs-host disease. Bone Marrow Transpl., 11,329-36.

Meloni, G., Foa, R, Vignetti, M., Guarini, A., Fenu, S., Tosti, S., Gillotos, A. and Mandelli, F. (1994) Interle ukin-2 may induce prolonged remission in advanced acute myelogenous leukemia. Blood, 84(7), 2158.

Morecki, S., Nabet, C., Ackerstein, A., Schlesinger, M. and Slavin, S. (1991) The effect of in vitro T­Iymphocyte depletion on generation of IL-2 activated cytotoxic cells. Bone Marrow Transplant, 7, 269-273.

Or, R, Nagler, A., Ackerstein, A., Naparstek, E. et al. (1993) Allogeneic cell-mediated cytokine-activated immunotherapy in non-Hodgkin lymphoma for eradication of minimal residual disease in conjunc­tion with autologous bone marrow transplatation (ABMT) Blood, 82(suppl. 1), 10, 171a(669).

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Rosenberg, S.A. and Lotze, M.T. (1986) Cancer immunotherapy using interleukin-2 and interleukin-2 activated lymphocytes. Annu. Rev. Immunol., 4,681-709.

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446 ALBERTO MARMONT

The mechanism of action of allogeneic transplantation in the favourable cases has been postulated to reside in the eradication of an autoreactive immune system followed by the administration of naive HSCs. An alternative or integrating hypothesis derives from the studies of T lymphocyte mixed chimerism after allo­geneic transplants, and more particularly of its modalities after donor lymphocyte infusions to cure post-transplant leukemia (CML) relapses (74). It has been shown that such infusions are capable not only of eliminating leukemia cells, but also the recipient's surviving T lymphocytes, and therefore mixed T lymphocyte chimerism (76). The suppression of autoreactive T lymphocytes by the donor's T lympho­cytes could be interpreted as a GVA effect. However there clearly is the need for a greater clinical experience, which can be only retrospective at this time, before designing clinical phase 1-11 studies.

There is no doubt that autologous procedures are safer, and this is the reason for which they have been considered recently (77, 78). However it is doubtful that unmanipulated, non effectively T-cell depleted autologous transplants, whether marrow or peripheral, are capable of ensuring long-term remission, especially in view of the early relapses reported formerly (71). In the case reported from New Zealand (70) a prolonged and aggressive chemotherapy (Magath's modified protocol) before an equally aggressive conditioning regimen (CVB) preceded the autologous SC infusion. A similar case (CML + SLE) is being reported from

Rome (79). In evaluating these results one must keep in mind that cyclic chemo­therapy (CY) synchronised with plasma exchange has been shown to be capable of producing long-term, steroid-independent clinical and immunologic remission (80).

Finally the "new frontier" of cordonal SC should not be neglected. It is well known that placental T cells mount less of a GVH response than bone marrow from unrelated donor in HLA-mismatched recipients (81, 82). In addition also adult patients have had complete hematopoietic reconstitution following placental blood transplants (82, 83). Ex vivo expansion of cord SC, which is recently receiv­ing much attention (84), could further foster this type of approach.

Many questions, however, still remain unanswered (43). It is now proposed to proceed to a TCD of at least 3 logs, to reduce the risk of relapse or possibly more. However the possible persistence of minimal residual autoimmune disease cannot be ruled out, and the reported relapses must be considered with great attention. It is possible that this type of procedure may be utilized in the future perhaps more for the solution of a severe clinical problem in the course of an AID. The selection of patients and diseases has been discussed (39,86) .

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