bone marrow transplantation versus immunosuppressive therapy

Arch Iranian Med 2004; 7 (4): 272 – 278Original ArticleBONE MARROW TRANSPLANTATION VERSUSIMMUNOSUPPRESSIVE THERAPY IN SEVERE APLASTICANEMIA, 1990 – 2001Ardeshir Ghavamzadeh MD, Masood Iravani MD, Farahnaz Vafaiezadeh MD • ,Mohammad Jahani MD, Asadollah Mousavi MDBackground – Bone marrow transplantation (BMT) and immunosuppressive therapy are twochoices of therapy for aplastic anemia. In BMT, abnormal cells are replaced by normal donor’shematopoetic stem cells in those patients who have an HLA-identical match donor and are aged 45 years old.Methods – In this study we compared these two modalities of treatment in acquired severeaplastic anemia. We had 70 patients in two groups. Twenty-nine patients had completed BMT and41 patients had completed non-BMT treatment. The conditioning regimen in BMT group wascyclophosphamide plus ALG. Patients with severe aplastic anemia who had been referred to theHematology Clinic of Shariati Hospital from 1990 through 2001, were selected according to age(< 45 or > 45 years) and presence of HLA match donor. Ethical considerations were strictlyfollowed. Data were analyzed by SPSS version 10. Survival probabilities were estimated usingKaplan-Meier method.Results – The 5 years overall survival in BMT group was 67% and in cyclosporin group was36.6% and we found that after the day 200 posttherapy overall survival in BMT group was higher incomparison with non-BMT treatment (p = 0.02).Conclusion – BMT has the best results and long-term survival in severe aplastic anemiapatients.Archives of Iranian Medicine, Volume 7, Number 4, 2004: 272 – 278.Keywords: Antilymphocyte globulin (ALG) • aplastic anemia • bone marrow transplantation(BMT) • cyclosporinIntroductionSevere aplastic anemia (SAA) is a raredisease and probably an immunemediated disorder. 1 – 4 It is manifestedby pancytopenia in peripheral circulation.Patient’s hematopoetic activity in bonemarrow histologically decreases, the numberof CD34 cells is low, and colony formation in1, 2, 4, 5bone marrow is not significant. In mostAuthors affiliation: Hematology, Oncology, and BMT ResearchCenter, Tehran University of Medical Sciences, Tehran, Iran.•Corresponding author and reprints: Farahnaz Vafaiezadeh,MD, BMT Research Center, Shariati Hospital, Tehran, Iran.Fax: +98-21-6004165, E-mail: f_vafaie@hotmail.com.cases the etiology of SAA is unknown. Itspathophysiology is not completely understoodand it is possible that there are variousetiologies ultimately presenting as marrowfailure.Bone marrow transplantation (BMT) is thetreatment of choice for SAA. The source ofstem cells can be from bone marrow orperipheral blood and is generally performedfor the patients who are younger and haveHLA-identical sibling donor. 1 During the1970s the survival rate among patientsreceiving transplants from HLAgenotypicallyidentical donor was commonly40 – 50% compared to 60 – 90% in recentyears. 6, 7 Successful allogeneic BMT is272Archives of Iranian Medicine, Volume 7, Number 4, October 2004

A. Ghavamzadeh, M. Iravani, F. Vafaiezadeh, et aldependent on a stem cell product of sufficientquality to guarantee stable engraftment. 8Intensive conditioning regimens are used forpreventing graft rejection of allogeneic BMTfrom HLA-identical sibling donor.6 – 8Infection and graft-versus-host disease(GVHD) are the major complications ofBMT. 9 – 10Another treatment for aplastic anemia isimmunosuppressive therapy. This treatment isemployed in the patients who are older and in1, 5, 11, 12cases without an HLA match donor.The goal of treatment in aplastic anemia is animprovement in peripheral blood cell countsso that, these patients no longer requiretransfusions and are not at risk ofopportunistic infections.In contrast to BMT where the impairedorgan is replaced by healthy stem cells,immunosuppressive therapy is not curative.The goal here is the elimination of theautoaggressive cells responsible for aplasticbone marrow that result in pancytopenia.Today’s combination of antilymphocyteglobulin (ALG) plus cyclosporin is thetreatment of choice for aplastic anemia2, 3, 7,patients who are not candidates for BMT.13 – 17The rate of response to the combinationof ALG and cyclosporin has been 60 – 70%. 18In contrast to BMT, response toimmunosuppressive therapy is often slow andincomplete.It has been shown that androgens couldinduce remission in congenital and acquiredaplastic anemia but this does not seem toimprove survival in aplastic anemia. It istherefore used as minor treatment in somecases of moderate disease whereimmunosuppression has failed.12, 19 – 21Corticosteroids were used long before ALG totreat aplastic anemia. Today, most ALGprotocols include a median dose ofcorticosteroids for a short duration in an effortto reduce the ALG toxicity and symptoms ofserum sickness disease. 12 Splenectomy shouldbe considered for selected non-BMT patientswho despite of maximum therapy need longtermtransfusion. 22Since BMT is curative for SAA, in ourstudy we compared outcomes of BMT versusimmunosupressive therapy in patients withsevere aplastic anemia.Materials and MethodsAll patients with SAA who had beenreferred to the Hematology Clinic of ShariatiHospital from 1990 through 2001, wereselected according to age (< 45 or > 45 years)and presence of HLA match donor. All ethicalconsiderations were strictly followed.In patients who had an HLA-identicalmatch sibling donor and were younger than45 years old, BMT was performed. Theconditioning regimen for immunosuppressionwas cyclophosphamide 50 mg/kg for 4 daysand in high-risk patients ALG 10 mg/kg for 3days. 6The stem cells were infused afterconditioning the bone marrow or peripheralblood. GVHD prophylaxis regimen wasintravenous cyclosporin 3 mg/kg (days _ 3 to+5) followed by 12.5 mg/kg orallycontinuously for one year. 23, 24 Acutecomplications of BMT such as infection andGVHD were treated if these occurred.Immunosuppressive therapy was performedin patients older than 45 years and/orwithout an HLA-identical match donor. Inthis method oral cyclosporin 3 mg/kg for 6months to 2 years was used. In ALGcontaininggroup, ALG was infused 10 mg/kgfor 4 days. Blood cyclosporin level was alsomaintained between 100 – 200 ng/mL.In addition, in some cases androgens plusprednisolone were used. Danazol with an averagedose of 100 mg (50 – 200 mg) or oxymetholonewith an average dose of 150 mg (100 – 300 mg)was used and the average dose of prednisolone was15 mg/day. 19Statistical methodsUsing the SPSS Version 10 software package,survival probabilities were estimated by theKaplan-Meier method and comparisons were basedon log-rank statistics and frequencies werecalculated.ResultsIn this study, we had a total of 70 patients ofwhom 29 patients were in the BMT group and 41patients in the non-BMT group. Patient’s data havebeen summarized in Table 1. Possible etiologies inthe different groups are presented in Table 2. Themean number of transfused packed cells beforeArchives of Iranian Medicine, Volume 7, Number 4, October 2004 273

BMT versus immunosuppressive therapy in SAA between years 1990 – 2001Table 1. Data of the patients.GroupNumber of patientsMean age (yr)MaleSexFemaleDurationbetweendiagnosis totreatment (D)Follow-up (D)Response rate(%)CompletePartial5 years survival (%)Mortality (%)Splenectomy (%)BMT 29 19 19 10 377 878 65.5 10.3 67.5 31 —Cyclosporinalone24 25 18 6 110 403 20.8 20.8 36.6 58.3 41.6Androgen 15 24 9 6 71 570 20 0 16 80 20D = day; BMT = bone marrow transplantation.BMT was 11 units (0 – 100) and the meannumber of transfused platelets before BMTwas 16 units (0 – 100). In this group, themean number of mononuclear cells (MNC)for transplantation was 5.66 × 10 8 /kg (2.2 –11.25). Of 29 patients of BMT group, 17patients had received bone marrow stem cellsand 12 patients had received peripheral bloodstem cells transplantations. The patients werefollowed-up for between 24 to 2,750 daysIn the cyclosporin alone group, 24patients had been treated with cyclosporinalone and 2 patients with cyclosporin plusALG. The mean time of cyclosporinconsumption was 10 months (2 – 28). Themedian time of response was 11.9 months (3– 18). Complications of cyclosporin arepresented in Table 4. Five years overallsurvival in cyclosporin alone group was36.6%. There were 2 patients who hadTable 2. Probable etiology of severe aplastic anemia.Group Idiopathic Chemicals Hepatitis PostpartumBMT 79.3 13.7 3.4 3.4Cyclosporin alone 79.1 16.6 4.1 —Androgen 93.3 6.7 — —BMT = bone marrow transplantation.(mean 878 days). At the time of study 20patients (69%) were still alive but 9 patients(31%) had died. The cause of death in 2 cases(22.2%) was GVHD, in 6 cases (66.6%)infection, and in one case due to no response.The overall response rate in this group was75.9% (65.5% complete response, 10.3%partial response, and 24.1% no response).As a complication of BMT, acute GVHDdeveloped in 21 patients (72.4%). Data aboutacute GVHD are presented in Table 3. Themean time of GVHD development was day+10.5 (+2 to +46). Five years overall survivalin BMT group was 67% and 5-year diseasefree survival was 67%. Eight patients (27.6%)experienced recurrence.Table 3. Incidence of acute GVHD (grading andsites).Grade Percentage Site PercentageI 24.1 Skin 65.5II 27.6 GI 51.7III 20.7 Liver 17.2Total 72.4 — —GI = gastrointestinal.received cyclosporin plus ALG and at thetime of study both of them were alive andboth had partial responses with good generalconditions and no more need for transfusion.Among cases patients with moderatedisease who had received androgens(oxymetholone or danazol) plus prednisolone.Complication of androgen therapy wascholestasis due to oxymetholone seen in onecase. This led to drug interruption.The comparison between 5 years overallsurvival in BMT group (67.5%) andcyclosporin alone group (36.6%) shows thatdespite a prominent difference, this is notstatistically significant (p = 0.30).Five years overall survival in BMT groupwas 67.5% and in non-BMT group was 31%(p = 0.1). This difference is not significant butwhen this is viewed according to the followuptime after each treatment—groups divideto first 200 days and after +200 days—we cansee that survival in non-BMT group betweenthe days 0 to +200 is higher than BMT274Archives of Iranian Medicine, Volume 7, Number 4, October 2004

A. Ghavamzadeh, M. Iravani, F. Vafaiezadeh, et al1.21.0Cum Survival.8.6.4.20.0-.20100Time of follow-up (day)200Kind of treatmentBMTBMT-censoredChemoFigure 1. Survival BMT and non-BMT between days 0 to +200 (p = 0.0007).group (p = 0.0007) (Figure 1). After the day+200 survival is higher in BMT group thannon-BMT group (p = 0.02) (Figure 2).Since the number of infused mononuclearcells (MNC) in stem cell transplantation mayhave a result on response rate, BMT patientswere divided into two groups according to thenumber of infused MNC × 10 8 /kg. Thesurvival rate in the group of 2 – 5 × 10 8 /kgwas 62% and in the group of > 5 × 10 8 /kg was75%. This difference was not statisticallysignificant (p = 0.4).Considering age as a prognostic factor,patients in BMT group and non-BMT groupwere divided into three age groups: 0 – 19years, 20 – 49 years, and > 50 years. In 0 – 19years of non-BMT group (16 patients)survival was 18% and in 20 – 49 years (22patients) survival was 42% (p = 0.2). In BMTgroup in 0 – 19 years (14 patients) the overallsurvival was 62% and in 20 – 49 years (15patients) it was 71%. This difference was alsonot significant (p = 0.3). In non-BMT group 5years survival in cyclosporin alone group was36.6% and in androgen group was 16%,showing a significant difference (p = 0.03)and highlighting a preference forimmunosuppressive therapy rather thanandrogen therapy in the treatment of severeaplastic anemia (Figure 3).Thirty-five percent of patients within thenon-BMT group had undergone splenectomyand 65% had not had this procedure.Splenectomy in non-BMT group with p =0.38 had no effect on survival rate in thisgroup.Table 4. Complications in cyclosporine alone group.Complication Number PercentageRise of creatinine 1 4.2Gingival hypertrophy, skin hyperpigmentation 1 4.2Gingival hypertrophy 1 4.2Gynecomastia gingival hypertrophy 1 4.2Headache, vomiting 1 4.2Seizure 1 4.2Skin-gingival hyperpigmentation 1 4.2Skin hyperpigmentation 1 4.2Total 8 33.6Archives of Iranian Medicine, Volume 7, Number 4, October 2004 275

BMT versus immunosuppressive therapy in SAA between years 1990 – 20011.0Cum survival.9.8.7.6Kind of treatmentBMTBMT-censored.5Chemo.4010002000Time of follow-up (day)30004000Chemo-censoredFigure 2. Survival in BMT and non-BMT after the day +200 (p = 0.02).The overall survival in BMT group whopresented with GVHD was 70% and withoutGVHD was 60%. This difference was notsignificantly different (p = 0.63).DiscussionSAA is a rare disease that, when treated withsupportive care including blood transfusions andantibiotics, only 25 – 30% of patients survive for 2years. 24 More than 50% are expected to die within6 months of diagnosis without specific therapy.25Effective treatment for SAA consists of eitherBMT or immunosuppressive therapy with agents4, 17such as ALG and cyclosporin.For almost three decades, patients with SAAhave been treated successfully by HLA-identicalBMT. Outcome has improved from about 45%survival in early studies to 65 – 90% in mostrecent trials. 2, 6, 7, 24, 26 Improvement is due in part toa decreased incidence of graft rejection, resultingfrom the judicious use of transfusions before BMT,the removal of sensitizing leukocytes fromtransfusion products, 27 and a decrease in theincidence and severity of acute GVHDprophylaxis e.g. use of cyclosporine. Comparison1.21.0.8Cum Survival.6.4.20.0020406080100120Follow-up (wk)Figure 3. Survival in cyclosporin alone versus androgen therapy groups (p = 0.03)new treatmentnono-censoredcyxcyx-censored276Archives of Iranian Medicine, Volume 7, Number 4, October 2004

A. Ghavamzadeh, M. Iravani, F. Vafaiezadeh, et alof the overall survival between our BMT groupand non-BMT group in first 200 days and post 200days after each treatment. This comparison showsthat BMT has the best results and patients in BMTgroup have better long-term survival (p = 0.02).Bone marrow and more recently stem celltransplantation from a histocompatible siblingusually cure the underlying bone marrow failure.Mortality rates for first 200 days aftertransplantation have decreased probably as a resultof less graft rejection and improved control ofinfections.Cyclophosphamide and ALG have been used asa conditioning regimen for patients receivingtransplants since 1988. 6, 8, 28 Since our BMT grouppatients had also received cyclophosphamide andALG, according to our 75.9% response rate and 5years overall survival of 67%, we can concludethat our conditioning regimen was appropriate incomparison with reports from other countries.Despite the use of prophylaxis, GVHDcontinues to be a problem and has a strong adverseeffect on survival. 10, 29 Reduction of acute GVHDhas resulted in improved survival. 9, 10, 23 Accordingto our study, despite the difference betweensurvival in GVHD-developed (70%) and nondevelopedpatients (60%), it was not significant (p= 0.63).GVHD, the frequency and severity of whichcorrelate with patient’s age, continues to limit thesuccess of transplantation. In most analysis,GVHD also contributed to earlier death. 2The dose of mononuclear cells (MNC) infusedis very important in SAA. In contrast to our resultsabout survival according to number of MNCinfused at the time of BMT, efforts should still bedirected at maximizing the number of marrow cellsinfused by harvesting ≥ 3.5 × 10 8 30, 31cell/kg.There is an increased risk of graft failure seen inpatients who receive low doses of marrow cells.The comparison between cyclosporine therapyand androgen therapy in treatment of SAA showedpreference of immunosuppression as a bettertreatment for SAA (p = 0.03) that increases thesurvival of these patients. Regarding age as afactor that may interfere in overall survival ofpatients, we did not find that age could have animpact on survival (p = 0.3). This finding may bedue to our limited number of patients.Despite the vast studies 4, 13 – 17 conducted onimmunosuppressive therapy with ALG andcyclosporine, it is difficult to conclude firm resultsdue to the small number of our patients whoreceived this treatment (2 patients). Prior bloodtransfusion is the major risk factor for survivalfollowing BMT for SAA. Evidence indicates thatdendritic cells in blood products are responsible forsensitization of patient and graft failure. 32, 30 Untransfusedpatients have a lower risk of graftfailure than transfused recipients and the riskincreases with larger numbers of transfusions. Itseems that, regarding the mean number of bloodproducts transfused to our patients, nearly all ofour patients were high risk for transplantation,therefore our results were satisfactory incomparison with other places of the world.Finally, bone marrow transplantation is curativefor SAA patients who have histocompatible donorand are aged younger, and for those SAA patientswho do not have a match donor,immunosuppressive therapy is preferred.AcknowledgmentThe authors thank N. Rezaei and V. Moayed fortheir technical assistance.References1 Young NS, Barrett AJ. The treatment of severe acquiredaplastic anemia. Blood. 1995; 85: 3367 – 3377.2 Young NS. Acquired aplastic anemia.Ann Intern Med. 2002; 136: 534 – 546.3 de-Medeiros CR, Ribeiro RC, Bittencourt MA, Zanis-NetoJ, Pasquini R. Long-term outcome of 25 children andadolescents with severe aplastic anemia treated withantithymocyte globulin. Braz J Med Biol Res. 2000; 33:553 – 558.4 Mollee P, Woodward N, Durrant S, et al. Single institutionoutcomes of treatment of severe aplastic anemia. InternMed J. 2001; 31: 337 – 342.5 Maciejewski JP, Anderson S, Katevas P, Young NS.Phenotypic and functional analysis of bone marrowprogenitor cell compartment in bone marrow failure. Br JHaematol. 1994; 87: 227 – 234.6 Storb R, Etzioni R, Anasetti C, et al. Cyclophosphamidecombined with antithymocyte globulin in preparation forallogeneic marrow transplants in patients with aplasticanemia. Blood. 1994; 84: 941 – 949.7 Killick SB, Marsh JC. Aplastic anaemia: management.Blood Rev. 2000; 14: 157 – 171.8 Flinn IW, Kopecky KJ, Foucar MK, et al. Long-termfollow-up of remission duration, mortality, and secondmalignancies in hairy cell leukemia patients treated withpentostatin. Blood. 2000; 96: 2981 – 2986.9 Frickhofen N, Rosenfeld SJ. Immunosuppressivetreatment of aplastic anemia with antithymocyte globulinand cyclosporin. Semin Hematol. 2000; 37: 56 – 68.10 Min CK, Kim DW, Lee JW, Han CW, Min WS, Kim CC.Supplemental peripheral blood stem cells to decreaseArchives of Iranian Medicine, Volume 7, Number 4, October 2004 277

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