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Prepublished online as a Blood First Edition Paper on August 1, 2002; DOI 10.1182/blood-2002-01-0339.
CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS
From the Dipartimento di Ematologia Ospedale San
Martino, Genova, Italy.
We have studied the impact of cell dose on short- and long-term
graft function and outcome in 905 patients undergoing an unmanipulated allogeneic bone marrow transplantation (BMT) from an
HLA-identical sibling (n = 735), a one-antigen mismatched related
donor (n = 35), or a matched unrelated donor (n = 135). Median
number of nucleated cells infused was 3.4 × 108/kg (25th
percentile 2.4 × 108/kg, 75th percentile 5 × 108/kg). Patients were stratified according to cells
infused in 3 groups: Cell dose is recognized as an important positive
predictor of outcome in allogeneic bone marrow transplantation (BMT),
both in the animal model1,2 and in human
beings.3 It is unclear whether the beneficial effect is
due to a larger dose of hemopoietic progenitors or other cell
subpopulations4: One hypothesis would be that a larger
number of grafted hemopoietic progenitors would lead to faster
hematologic recovery.5 In this context, mobilized peripheral blood (PB) progenitor cell transplants have called the
attention of several investigators to the kinetics of
hematologic reconstitution after engraftment. Comparison of PB with
bone marrow (BM) transplant recipients has revealed shorter neutropenia
and thrombocytopenia in the former group: In a randomized study
conducted by the European group for Blood and Marrow Transplantation
(EBMT), the median day to reach a granulocyte count of
0.5 × 109/L was 12 versus 15 (P < .0001)
for PB versus BM grafts, respectively.6 Similarly, the
median day to reach a platelet count of 20 × 109/L was
15 versus 20 (P < .0001).6 Therefore,
hemopoietic recovery is significantly faster in PB graft recipients. In
the same study, however, transplant-related mortality (TRM) and
survival were identical in the 2 groups.6 Most
retrospective and prospective studies comparing PB versus BM
transplants show that, despite faster hematologic recovery,
transplant-related complications and mortality are quite
similar.6-16 Therefore, a larger number of progenitor
cells in PB grafts leads to faster hematologic recovery, with little
influence on transplant mortality.
In the present study we asked whether increasing the cell dose in BM
grafts would influence long-term hematologic recovery and possibly TRM.
We therefore studied 905 consecutive patients undergoing an allogeneic
BMT and analyzed graft function, as indicated by leukocyte and
platelet counts and hemoglobin levels, at different time points as well
as TRM, survival, and relapse.
Patient characteristics
Conditioning regimen and graft-versus-host disease
prophylaxis
Stem cell harvest and infusion Bone marrow (BM) was collected using small-volume (2 mL) aspirations, 20 to 25 mL/kg of recipient body weight,18 under general anesthesia; it was processed through small-gauge needles (20 G) to avoid losing cells in the infusion filters. In cases of major ABO incompatibility, the BM was not depleted of red cells, but patients' isohemagglutinins were reduced to a titer of 1:16 or less in saline, with 1 or 2 plasma exchanges. BM was administered intravenously after completion of the conditioning regimen.Graft function Platelet and white blood cell (WBC) counts were used to evaluate graft function, as were hemoglobin levels.Statistical analysis Transplant-related mortality (TRM) is defined as death due to causes unrelated to the underlying disease: Patients relapsing are censored as surviving at the time of relapse. Disease-free survival is defined as the probability of being alive free of disease; events are death in remission, relapse, and death due to the underlying disease, whichever occurs first. The Student t and Mann-Whitney tests were used for continuous variables and the 2 test for
2 × 2 tables. Actuarial probabilities of transplant-related mortality and overall survival were calculated with the Kaplan-Meier method,19 and the log-rank test was used to evaluate the
differences between curves. The following factors were studied in
multivariate Cox analysis for potential effect on transplant-related
mortality rates: donor type, donor/recipient age, type and disease
phase, cell dose, and conditioning regimen. The number-cruncher
software (NCSS, version 5.0; JL Hintze, Kaysville, UT) was used to
perform the analysis.
Clinical data of patients receiving a low, intermediate, or a high cell dose The median nucleated cells infused was 3.4 × 108/kg (25th percentile 2.4 × 108/kg, 75th percentile 5 × 108/kg). Patients were stratified into 3 groups according to low, intermediate, or high cell dose: 2.4 × 108/kg (n = 247);
> 2.4 × 108/kg and
5 × 108/kg (n = 452), and
> 5 × 108/kg nucleated cells (n = 206).
Table 2 outlines the clinical
characteristics of patients in the 3 groups. Patients in the high cell
dose group were significantly older (P = .0005), had
significantly older donors (P = .001), and comprised
significantly more alternative donor transplants (P = .05)
and fewer patients receiving TBI (P = .000 01). Notably, all of these factors have a negative influence on TRM in univariate
Hematopoietic recovery Platelet recovery is outlined in Figure 1 in patients stratified according to the cell dose received (low, intermediate, or high): Patients in the latter group had higher platelet counts at all time points up to 1 year after transplantation, and the difference was significant at the P < .01 level. Similar results were obtained when looking at WBC counts (Figure 2) on days +20, +50, and +180 after BMT (P < .01). Hemoglobin levels were comparable at different time points after transplantation.
Cell dose and transplant-related mortality The actuarial 5-year transplant-related mortality (TRM) was 41% versus 36% versus 28%, respectively, (P = .01) in patients receiving low, intermediate, or high cell dose (Figure 3). Crude TRM within day +100 was 24% for patients receiving a low cell dose, 19% for intermediate, and 16% for a high cell dose (P = .008). Crude TRM for patients surviving 100 days was 23%, 17%, and 11%, respectively, in the 3 groups (P = .01). The cell dose effect on TRM was more pronounced in patients with advanced-phase disease (47% vs 33% vs 26%, P < .008) as compared with patients with early-phase disease (32% vs 31% vs 21%, P = .1). The same was true for older patients (age > 30 years; 56% vs 35% vs 27%, P < .0001) as compared with younger patients (age 30 years; 31% vs 32% vs 20%, P = .1). The cell dose
effect on TRM was seen in patients grafted from an alternative donor
(62% vs 44% vs 33%, P = .004) as well as in patients
grafted from an HLA-identical sibling (37% vs 31% vs 22%,
P = .006). When patients were stratified according to
diagnosis, the cell dose effect on TRM was most significant in patients
with CML (52%, 39%, 18%, respectively, for low, intermediate, high
cell dose; P = .001), MDS (39%, 35%, 25%;
P = .006), and chronic lymphoproliferative disorders
(70%, 22%, 20%; P = .01) as compared with patients with
acute leukemia (29%, 26%, 21%; P = .3) and marrow
failure (52%, 42%, 32%; P = .2). Acute GVHD was scored
as grade 0, I, II, III, and IV, respectively, in 92 (10%), 332 (37%),
342 (38%), 104 (11%), and 35 (4%) patients. Acute GVHD grade III to
IV was 17% and 16% in patients receiving low or intermediate
cell dose, and this is higher when compared with patients grafted with
the high cell dose (11%; P < .05). Chronic GVHD was
scored as absent, limited, or extensive, respectively, in 672 (74%),
186 (21%), and 47 (5%) patients and was not different in the 3 groups
(P = .2).
Survival and causes of death The actuarial 5-year overall survival was significantly different in patients receiving low, intermediate, or a high cell dose: 45% versus 51% versus 56% (P = .0008; Figure 4). Deaths due to GVHD and infections were 28% versus 23% versus 16%, respectively, in the 3 groups, P = .009. There was also a difference in the risk of being infected on day +30 after transplantation: Bacterial infections were seen in 16%, 14%, and 10% in the 3 groups (P = .1); fungal infections in 32%, 11%, and 9% (P = .001); and viral infections in 13%, 5%, and 4% (P = .01), respectively, in the low, intermediate, and high group. Causes of TRM other than GVHD and infections were comparable (P = .5). The number of deaths due to leukemia was similar in the 3 groups (17%, 14%, 14%; P = .8), and this was confirmed in the Kaplan-Meier analysis.
Disease-free survival The actuarial 5-year disease-free survival was significantly different in patients receiving low, intermediate, or high cell dose: 41% versus 42% versus 48% (P = .02).Leukemia relapse The actuarial risk of relapse at 5 years in patients who received low, intermediate, and high cell dose was, respectively, 30% versus 33% versus 35% (P = .3); for patients in first remission the actuarial risk is 19%, 23%, and 26% (P = .4).Multivariate analysis The cell dose was analyzed in multivariate Cox analysis for potential effect on TRM together with 6 other clinical factors: donor type, donor age, recipient age, type and disease phase, conditioning regimen, and year of transplantation. In multivariate Cox analysis on TRM, cell dose was a significant predictor (P = .002; relative risk 0.6) together with donor type (P = .0001), year of transplantation (P = .0001), conditioning regimen (P = .02), and recipient age (P = .02; Table 3).
We have shown in the present study that graft function is improved both in the short and long term after transplantation of a high dose of allogeneic bone marrow cells: This results in significantly higher white blood cell counts up to 6 months after engraftment and higher platelet counts at all time intervals up to 1 year after transplantation. Although this would sound expected, we could not find this information in studies comparing different cell doses or different sources of stem cells.6-16 Many reports concentrate on duration of neutropenia or thrombocytopenia and disregard peripheral blood counts beyond day +20. In the present study, instead, we could show that graft function was particularly improved beyond day +20 and even beyond day +100, suggesting a long-lasting effect of a high marrow cell dose: One-year postengraftment median platelet counts for patients receiving low, intermediate, or high marrow cell dose were 130 × 109/L, 167 × 109/L, and 191 × 109/L, respectively. The second finding is the strong correlation between cell dose and transplant mortality, in keeping with other studies20-25: In multivariate analysis patients receiving a high cell dose (> 5 × 108/kg) had a relative risk of dying of transplant-related complications of 0.6 when compared with patients receiving a low cell dose (< = 2.4 × 108/kg). This was almost entirely due to a reduction of lethal infections and GVHD: The risk of death caused by infection/GVHD (often related) was 28%, 23%, and 16%, respectively, in patients receiving a low, intermediate, or high cell dose (P = .009). Other studies have shown a positive effect of cell dose on graft-versus-host disease,20,21,26 and the fact that we find reduced GVHD with improved graft function in patients receiving a high cell dose is in keeping with the recent demonstration of a strong correlation between severity of acute GVHD and platelet counts.27 In the present study the actuarial 5-year TRM in patients receiving low, intermediate, or high cell dose was, respectively, 41%, 36%, and 28% (P = .01). This could not be explained by a selection of patients with good prognosis, because the high cell dose group contained more patients with risk factors such as older age and alternative donor transplants, and this is confirmed in the multivariate Cox analysis. The reduction of transplant-related mortality was so strong that it produced improved overall survival. We did not find a significant difference in the leukemia relapse between the 3 groups of patients, notwithstanding a recent report on a possible favorable effect of a high cell dose.25 However, if GVHD and TRM are reduced, it is unlikely that leukemia relapse would also be reduced. In keeping with these observations, we find that the disease-free survival was significantly reduced in patients grafted with low cell dose in comparison with intermediate and high dose (41% vs 42% vs 48%; P = .02). The cell dose effect on TRM was more evident in patients at high risk for dying of transplant complications, such as patients older than 30 years of age, with advanced disease, or with CML/MDS. In patients with CML, the transplant mortality was 52%, 39%, 18%, respectively, for low, intermediate, or high cell dose, in keeping with a recent report.28 One question that comes up concerns the cell component important in reducing transplant-related mortality. Is it stem cells, hemopoietic progenitors, lymphocytes, or other cells such as stromal or mesenchymal cells?29 Stem cell numbers would seem important, as shown by experimental data on radioprotection30 and clinical data in human beings on progenitor cell content and quality of hematologic reconstitution.5,31 The question is how other cells influence stem cell function. The high lymphocyte content of peripheral blood grafts, producing significant acute and chronic GVHD, may counterbalance the positive effect of cell dose and produce an overall negative effect, mostly when the total cell count exceeds 9 × 108/kg.32 This was also seen in a recent study on CD34+ selected allografts, with a cutoff for increased TRM of 3 × 106/kg CD34+ peripheral blood cells33: Thus, CD34+ cells per se or their progeny, including antigen-presenting cells,34 could have a promoting role on graft-versus-host disease and thus impair graft function. Other accessory cells, such as mesenchymal stem cells (MSCs), instead, could play a positive role on graft function, by virtue either of a suppressive effect on GVHD35 or of a direct promoting effect on stem cells36: These MSCs are found in bone marrow but not in peripheral blood harvest.4 In conclusion, this study indicates a very strong cell dose effect on graft function when using bone marrow as a stem cell source, resulting in lower transplant mortality. Data from the literature and our own institution (A.B., unpublished data, 2000) would suggest that this is not the case for peripheral blood grafts. Therefore, graft function and low transplant toxicity is not solely the result of a large CD34+ cell dose and is probably influenced by other cell subpopulations. Some of these, such as mesenchymal stem cells, are being studied as candidates for the cell dose effect. At present we would recommend using a high marrow cell dose for best graft function and low transplant mortality: How to manipulate peripheral blood grafts to mimic this effect remains to be determined.
The great work of our nursing staff is gratefully acknowledged.
Submitted February 5, 2002; accepted July 10, 2002.
Prepublished online as Blood First Edition Paper, August 1, 2002; DOI 10.1182/blood-2002-01-0339.
Supported by Associazione Italiana Ricerca contro il Cancro (A.I.R.C.) Milano grant (A.B.) and Associazione Ricerca Trapianto Midollo Osseo (A.RI.T.M.O.) Genova.
The publication costs of this article were defrayed in part by page charge payment. Therefore, and solely to indicate this fact, this article is hereby marked "advertisement" in accordance with 18 U.S.C. section 1734.
Reprints: Alida Dominietto, Dipartimento di Ematologia PAD 6/T, Ospedale San Martino, 16132 Genova, Italy; e-mail: adominietto{at}smartino.ge.it.
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© 2002 by The American Society of Hematology.
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  B. N. Savani, K. Rezvani, S. Mielke, A. Montero, R. Kurlander, C. S. Carter, S. Leitman, E. J. Read, R. Childs, and A. J. Barrett Factors associated with early molecular remission after T cell-depleted allogeneic stem cell transplantation for chronic myelogenous leukemia Blood, February 15, 2006; 107(4): 1688 - 1695. [Abstract] [Full Text] [PDF]
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J. A. Perez-Simon, M. Diez-Campelo, R. Martino, A. Sureda, D. Caballero, C. Canizo, S. Brunet, A. Altes, L. Vazquez, J. Sierra, et al. Impact of CD34+ cell dose on the outcome of patients undergoing reduced-intensity-conditioning allogeneic peripheral blood stem cell transplantation Blood, August 1, 2003; 102(3): 1108 - 1113. [Abstract] [Full Text] [PDF]
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Top
Abstract
Introduction
2-integrin LFA-1.
Blood.
1999;93:107-112