SEARCH:   Advanced

Prepublished online as a Blood First Edition Paper on August 29, 2002; DOI 10.1182/blood-2002-02-0571. This Article Abstract Full Text (PDF) All Versions of this Article: 2002-02-0571v1 101/2/469    most recent Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Rights and Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Uzunel, M. Articles by Ringdén, O. Search for Related Content PubMed PubMed Citation Articles by Uzunel, M. Articles by Ringdén, O. Related Collections Transplantation Brief Reports Clinical Trials and Observations Social Bookmarking                   What's this?  Previous Article  |  Table of Contents  |  Next Article  Blood, 15 January 2003, Vol. 101, No. 2, pp. 469-472 CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS Brief report Kinetics of minimal residual disease and chimerism in patients with chronic myeloid leukemia after nonmyeloablative conditioning and allogeneic stem cell transplantation Mehmet Uzunel, Jonas Mattsson, Mats Brune, Jan-Erik Johansson, Johan Aschan, and Olle Ringdén From the Department of Clinical Immunology, Center for Allogeneic Stem Cell Transplantation (CAST), and Department of Hematology, Karolinska Institute at Huddinge University Hospital, Stockholm, Sweden; and Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.     Abstract Top Abstract Introduction Study design Results and discussion References The kinetics of minimal residual disease (MRD) and chimerism were studied in 15 patients with chronic myeloid leukemia (CML) receiving nonmyeloablative stem cell transplantation (NST) and in 10 patients receiving conventional stem cell transplantation (CST). All NST patients showed T-cell mixed chimerism (MC) while granulocyte and B-cell MC occurred in 80% and 60% of the NST patients, respectively. In CST patients, T-cell MC was detected in 5 patients, of whom 3 were mixed only during the first month. MRD was detected in all NST patients. During the first 3 months the median BCR-ABL/ABL ratio was 0.2% in NST patients compared with 0.01% in CST patients (P < .01). However, 12 months after transplantation, the percentage of reverse transcriptase-polymerase chain reaction (RT-PCR)-positive patients was 20% in NST patients and 50% in CST patients. In conclusion, molecular remission can be induced in most patients after NST, albeit with different kinetics from CST. (Blood. 2003;101:469-472) © 2003 by The American Society of Hematology.     Introduction Top Abstract Introduction Study design Results and discussion References Allogeneic hematopoietic stem cell transplantation (SCT) is the treatment of choice for patients with chronic myeloid leukemia (CML) who have a suitable donor.1 In older patients and among those with comorbidity, however, there is a high risk of regimen-related toxicity that makes conventional stem cell transplantation (CST) unsuitable for these patients. In recent years, nonmyeloablative stem cell transplantation (NST) has been studied as a safer approach for older patients.2-4 Such transplantations are more dependent on a graft-versus-leukemia effect, which is known to be powerful in CML patients.1,5 Molecular techniques for chimerism and minimal residual disease (MRD) analysis after SCT are routinely used in many laboratories to follow engraftment and predict a threatening relapse of leukemia. In the conventional SCT setting, such analyses have been well evaluated in CML patients.6-9 With the introduction of nonmyeloablative transplantations, the significance of chimerism and MRD results to clinical outcome after allogeneic SCT needs to be reevaluated.10,11 In the present study, we determined the incidence and kinetics of chimerism and MRD in 15 CML patients receiving NST and compared them with 10 patients receiving CST.     Study design Top Abstract Introduction Study design Results and discussion References Patients Patient characteristics for the 25 CML patients included in this study are shown in Table 1. Fifteen patients received a nonmyeloablative conditioning regimen and allogeneic SCT (NST) between April 1999 and April 2001. Of these 15 patients, 8 were either too old or considered unfit for conventional SCT (CST). Seven patients requested NST after shared decision making. Thirteen patients received CST between January 1999 and March 2001. Three patients were excluded because samples were not available. Of these, 1 patient relapsed 2 years after SCT and 2 patients are alive in clinical remission 18 and 19 months after SCT, respectively. The ethics committee at Karolinska Institute, Huddinge University Hospital, approved this study. Informed consent was provided according to the Declaration of Helsinki.                                View this table: [in this window] [in a new window]   Table 1. Patient characteristics Conditioning The NST patients received fludarabine (Flu) 30 mg/m2/d for 6 days, busulfan (Bu) 4 mg/kg/d for 2 consecutive days, and antithymocyte globulin (ATG) 2 to 10 mg/kg for 4 days.4 The CST group was conditioned with cyclophosphamide (Cy) 120 mg/kg with 10 to 12 Gy total body irradiation (TBI) (n = 5) or busulfan 16 mg/kg (n = 5).12 Details regarding supportive care have been described elsewhere.13 Samples Samples for chimerism and MRD analyses were 5 to 10 mL of peripheral blood. A median of 8 (range, 3-35) chimerism analyses and 10 (range, 3-30) MRD analyses was performed for each patient. Lineage-specific chimerism analysis Polymerase chain reaction (PCR) amplification of variable number of tandem repeats (VNTRs) was used to evaluate various degrees of donor and recipient chimerism in CD3+, CD19+, and CD45+ cells as previously described.14 Reverse transcriptase (RT)-PCR analysis for BCR-ABL Quantification was done by competitive PCR using plasmid constructs containing a modified BCR-ABL fusion gene.15 Dr N. C. P. Cross, Hammersmith Hospital, London, kindly provided pNC210/G (p210) and pNC190/G (p190) competitor plasmids. BCR-ABL and ABL transcript numbers were estimated by comparing the competitor and sample band intensity to find the equivalence point. Results were expressed as the ratio between BCR-ABL and ABL transcript numbers (BCR-ABL/ABL).     Results and discussion Top Abstract Introduction Study design Results and discussion References Sensitivity of BCR-ABL detection RNA from K562 cells was serially diluted in RNA from HL-60 cells in a total amount of 20 µg RNA. After cDNA synthesis and 40 cycles of PCR amplification, a sensitivity of 106 was obtained. Patients In the NST group, 13 patients are alive with a median follow-up of 20 months (range, 6-29 months). Two patients died of graft-versus- host disease (GVHD) and progressive disease 5 and 17 months after SCT, respectively (Table 1). One patient (N1) relapsed 7 months after SCT. In the CST group, 9 patients are alive with a median follow-up of 25 months (range, 9-34 months). One patient died of GVHD 7 months after SCT. Two patients relapsed 9 and 16 months after SCT, respectively. Chimerism results NST. T-cell mixed chimerism (MC) was detected in all 15 patients, and all but 2 (N7 and N15) converted to donor chimerism (DC) at the end of this study (Figure 1). The median time for T-cell DC to occur was 87 days (range, 28-145 days) and was significantly delayed (21 days [range, 14-60 days]) compared with the CST group (P < .01). Granulocyte and B-cell MC were found in 12 (80%) and 9 (60%) of the patients, respectively. Median times to granulocyte and B-cell DC were 29 days (range, 14-128 days) and 30 days (range, 14-190 days), respectively. View larger version (21K): [in this window] [in a new window]   Figure 1. The incidence and level of MRD and T-cell chimerism after SCT. MRD levels (A) and T-cell chimerism engraftment (B) are shown for both patient groups at different time points after SCT.  represents NST (nonmyeloablative) patients; , CST (conventional stem cell transplantation patients). Differences in levels between the 2 patient groups are calculated at each time point using the Mann-Whitney U test. NS indicates not significant. CST. Five patients showed T-cell MC after SCT. Three patients had MC only the first month, whereas 2 patients (C9 and C10) had increasing levels of recipient cells in all cell fractions; both relapsed. In accordance with other NST studies, we found a high incidence of MC.10,14,16 The engraftment of T cells lagged behind granulocytes and B cells, which is in agreement with some but not other studies.10,17 MRD results NST. All patients in this group had detectable BCR-ABL transcripts after SCT. The BCR-ABL/ABL ratio during the first 3 months was, with a median of 0.2%, significantly more compared with 0.01% in CST patients (P < .01) (Figure 1). This probably reflects the lower antitumor effect of nonmyeloablative conditioning. Eleven patients became MRD negative within 7 months (median, 3.5 months; range, 1-7 months). Three patients (N6, N12, N15) were BCR-ABL positive during the entire posttransplantation period. However, in 2 patients, the follow-up was less than 9 months. CST. After SCT, 7 of 10 patients showed at least 1 positive PCR assay for BCR-ABL. The percentage of MRD-positive patients was 50% at 1 year (Figure 1). Long persistent expression of BCR-ABL in the absence of clinical relapse has been observed in many studies.6,18-21 For these patients, it is important to monitor the change in transcript levels with quantitative analysis.15,22 Chimerism and MRD NST. A switch from T-cell MC to DC was usually seen before (n = 5) or at the time (n = 4) of MRD negativity. In the former group, the median interval between T-cell DC and MRD negativity was 40 days (range, 24-90 days). One patient (N3) had T-cell MC with no signs of the BCR-ABL transcript for 1 month. The short interval between T-cell DC and MRD negativity suggests that complete DC is not necessary for disease response.11 Twelve patients with MC in the granulocyte cell population were all PCR positive for BCR-ABL. Among those, a BCR-ABL/ABL ratio of at least 0.1% was found in 10. CST. MC beyond 1 month after SCT was seen in only 2 patients (C9 and C10). Both had increasing BCR-ABL levels, and MC in B cells and granulocytes appeared only at BCR-ABL/ABL ratios of more than 1%. Three patients (C2, C5, and C8) with persistent BCR-ABL transcript (ratio less than 0.1%) more than 1 year after SCT had DC in all cell fractions. GVHD and MRD The incidence of acute GVHD was 73% and 90% in the NST and CST groups, respectively (Table 1). Interestingly, 4 NST patients without acute GVHD became MRD negative. This suggests that an allogeneic graft-versus-leukemia (GVL) effect may be seen even in the absence of GVHD, which is in accordance with a report in patients with acute leukemia.23 In conclusion, despite high BCR-ABL levels during the early posttransplantation period and a high incidence of mixed chimerism, nonmyeloablative transplantation for CML patients may induce molecular remission in most patients. Close monitoring of chimerism and MRD is needed to guide the timely introduction of immune-therapeutic interventions.     Acknowledgments We thank all staff at the departments for excellent and skillful patient care.     Footnotes Submitted February 21, 2002; accepted August 19, 2002. Prepublished online as Blood First Edition Paper, August 29, 2002; DOI 10.1182/blood-2002-02-0571. Supported by grants from the Swedish Cancer Society (0070-B99-13XAC), the Children's Cancer Foundation (1997/073), the Swedish Medical Research Council (K2000-06X-05971-20A), the Cancer Society in Stockholm, the Tobias Foundation, the FRF Foundation, and the Karolinska Institute. 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: Mehmet Uzunel, Department of Clinical Immunology F79, Huddinge University Hospital, SE-141 86 Huddinge, Sweden; e-mail: mehmet.uzunel{at}impi.ki.se.     References Top Abstract Introduction Study design Results and discussion References 1. Goldman JM, Gale RP, Horowitz, et al. Bone marrow transplantation for chronic myelogenous leukemia in chronic phase: increased risk for relapse associated with T-cell depletion. Ann Intern Med. 1988;108:806-814[Medline] [Order article via Infotrieve]. 2. Giralt S, Estey E, Albitar M, et al. Engraftment of allogeneic hematopoietic progenitor cells with purine analog-containing chemotherapy: harnessing graft-versus-leukemia without myeloablative therapy. Blood. 1997;89:4531-4536[Abstract/Free Full Text]. 3. Khouri IF, Keating M, Korbling M, et al. Transplant-lite: induction of graft-versus-malignancy using fludarabine-based nonablative chemotherapy and allogeneic blood progenitor-cell transplantation as treatment for lymphoid malignancies. J Clin Oncol. 1998;16:2817-2824[Abstract]. 4. Slavin S, Nagler A, Naparstek E, et al. Nonmyeloablative stem cell transplantation and cell therapy as an alternative to conventional bone marrow transplantation with lethal cytoreduction for the treatment of malignant and nonmalignant hematologic diseases. Blood. 1998;91:756-763[Abstract/Free Full Text]. 5. Horowitz MM, Gale RP, Sondel PM, et al. Graft-versus-leukemia reactions after bone marrow transplantation. Blood. 1990;75:555-562[Abstract]. 6. Cross NC, Hughes TP, Feng L, et al. Minimal residual disease after allogeneic bone marrow transplantation for chronic myeloid leukaemia in first chronic phase: correlations with acute graft-versus-host disease and relapse. Br J Haematol. 1993;84:67-74[Medline] [Order article via Infotrieve]. 7. Roman J, Serrano J, Jimenez A, et al. Myeloid mixed chimerism is associated with relapse in bcr-abl positive patients after unmanipulated allogeneic bone marrow transplantation for chronic myelogenous leukemia. Haematologica. 2000;85:173-180[Medline] [Order article via Infotrieve]. 8. Serrano J, Roman J, Sanchez J, et al. Molecular analysis of lineage-specific chimerism and minimal residual disease by RT-PCR of p210(BCR-ABL) and p190(BCR-ABL) after allogeneic bone marrow transplantation for chronic myeloid leukemia: increasing mixed myeloid chimerism and p190(BCR-ABL) detection precede cytogenetic relapse. Blood. 2000;95:2659-2665[Abstract/Free Full Text]. 9. Olavarria E, Kanfer E, Szydlo R, et al. Early detection of BCR-ABL transcripts by quantitative reverse transcriptase-polymerase chain reaction predicts outcome after allogeneic stem cell transplantation for chronic myeloid leukemia. Blood. 2001;97:1560-1565[Abstract/Free Full Text]. 10. Childs R, Clave E, Contentin N, et al. Engraftment kinetics after nonmyeloablative allogeneic peripheral blood stem cell transplantation: full donor T-cell chimerism precedes alloimmune responses. Blood. 1999;94:3234-3241[Abstract/Free Full Text]. 11. Mattsson J, Uzunel M, Brune M, et al. Mixed chimaerism is common at the time of acute graft-versus-host disease and disease response in patients receiving non-myeloablative conditioning and allogeneic stem cell transplantation. Br J Haematol. 2001;115:935-944[CrossRef][Medline] [Order article via Infotrieve]. 12. Ringden O, Ruutu T, Remberger M, et al. A randomized trial comparing busulfan with total body irradiation as conditioning in allogeneic marrow transplant recipients with leukemia: a report from the Nordic Bone Marrow Transplantation Group. Blood. 1994;83:2723-2730[Abstract/Free Full Text]. 13. Remberger M, Svahn BM, Hentschke P, Lofgren C, Ringden O. Effect on cytokine release and graft-versus-host disease of different anti-T cell antibodies during conditioning for unrelated haematopoietic stem cell transplantation. Bone Marrow Transplant. 1999;24:823-830[CrossRef][Medline] [Order article via Infotrieve]. 14. Mattsson J, Uzunel M, Tammik L, Aschan J, Ringden O. Leukemia lineage-specific chimerism analysis is a sensitive predictor of relapse in patients with acute myeloid leukemia and myelodysplastic syndrome after allogeneic stem cell transplantation. Leukemia. 2001;15:1976-1985[Medline] [Order article via Infotrieve]. 15. Cross NC, Feng L, Chase A, Bungey J, Hughes TP, Goldman JM. Competitive polymerase chain reaction to estimate the number of BCR-ABL transcripts in chronic myeloid leukemia patients after bone marrow transplantation. Blood. 1993;82:1929-1936[Abstract]. 16. McSweeney PA, Niederwieser D, Shizuru JA, et al. Hematopoietic cell transplantation in older patients with hematologic malignancies: replacing high-dose cytotoxic therapy with graft-versus-tumor effects. Blood. 2001;97:3390-3400[Abstract/Free Full Text]. 17. Niiya H, Kanda Y, Saito T, et al. Early full donor myeloid chimerism after reduced-intensity stem cell transplantation using a combination of fludarabine and busulfan. Haematologica. 2001;86:1071-1074[CrossRef][Medline] [Order article via Infotrieve]. 18. Snyder DS, Rossi JJ, Wang JL, et al. Persistence of bcr-able gene expression following bone marrow transplantation for chronic myelogenous leukemia in chronic phase. Transplantation. 1991;51:1033-1040[Medline] [Order article via Infotrieve]. 19. Pignon JM, Henni T, Amselem S, et al. Frequent detection of minimal residual disease by use of the polymerase chain reaction in long-term survivors after bone marrow transplantation for chronic myeloid leukemia. Leukemia. 1990;4:83-86[Medline] [Order article via Infotrieve]. 20. Miyamura K, Tahara T, Tanimoto M, et al. Long persistent bcr-abl positive transcript detected by polymerase chain reaction after marrow transplant for chronic myelogenous leukemia without clinical relapse: a study of 64 patients. Blood. 1993;81:1089-1093[Abstract]. 21. Costello RT, Kirk J, Gabert J. Value of PCR analysis for long term survivors after allogeneic bone marrow transplant for chronic myelogenous leukemia: a comparative study. Leuk Lymphoma. 1996;20:239-243[Medline] [Order article via Infotrieve]. 22. Radich JP, Gooley T, Bryant E, et al. The significance of bcr-abl molecular detection in chronic myeloid leukemia patients "late," 18 months or more after transplantation. Blood. 2001;98:1701-1707[Abstract/Free Full Text]. 23. Ringden O, Labopin M, Gorin NC, et al. Is there a graft-versus-leukaemia effect in the absence of graft-versus-host disease in patients undergoing bone marrow transplantation for acute leukaemia? Br J Haematol. 2000;111:1130-1137[CrossRef][Medline] [Order article via Infotrieve]. © 2003 by The American Society of Hematology.   CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this? This article has been cited by other articles: J. M. Goldman How I treat chronic myeloid leukemia in the imatinib era Blood, October 15, 2007; 110(8): 2828 - 2837. [Abstract] [Full Text] [PDF] M. J. Mauro and R. T. Maziarz Stem Cell Transplantation in Patients With Chronic Myelogenous Leukemia: When Should It Be Used? Mayo Clin. Proc., March 1, 2006; 81(3): 404 - 416. [Abstract] [Full Text] [PDF] J. F. Apperley Managing the Patient with Chronic Myeloid Leukemia Through and After Allogeneic Stem Cell Transplantation Hematology, January 1, 2006; 2006(1): 226 - 232. [Abstract] [Full Text] [PDF] C. Crawley, R. Szydlo, M. Lalancette, A. Bacigalupo, A. Lange, M. Brune, G. Juliusson, A. Nagler, A. Gratwohl, J. Passweg, et al. Outcomes of reduced-intensity transplantation for chronic myeloid leukemia: an analysis of prognostic factors from the Chronic Leukemia Working Party of the EBMT Blood, November 1, 2005; 106(9): 2969 - 2976. [Abstract] [Full Text] [PDF] A. Tefferi, G. W. Dewald, M. L. Litzow, J. Cortes, M. J. Mauro, M. Talpaz, and H. M. Kantarjian Chronic Myeloid Leukemia: Current Application of Cytogenetics and Molecular Testing for Diagnosis and Treatment Mayo Clin. Proc., March 1, 2005; 80(3): 390 - 402. [Abstract] [PDF] J. M. Goldman and J. V. Melo Chronic Myeloid Leukemia -- Advances in Biology and New Approaches to Treatment N. Engl. J. Med., October 9, 2003; 349(15): 1451 - 1464. [Full Text] [PDF] This Article Abstract Full Text (PDF) All Versions of this Article: 2002-02-0571v1 101/2/469    most recent Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Rights and Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Uzunel, M. Articles by Ringdén, O. Search for Related Content PubMed PubMed Citation Articles by Uzunel, M. Articles by Ringdén, O. Related Collections Transplantation Brief Reports Clinical Trials and Observations Social Bookmarking                   What's this?

	Copyright © 2003 by American Society of Hematology         Online ISSN: 1528-0020