Tohoku
J. Exp.
Med.,
1992, 168, 345-350
Allogeneic
Bone
Marrow
Malignant
Hematologic
Transplantation Disorders
for
in Children
SHIGERU TSUCHIYA, MASAYOSHI MINEGISHI, HIROMIFUJIE, NAOKOMINEGISHI, YOSHIYUKI OHASHI,MASAYUKI ITANO, SET MORITA,YOSHIKOYAMAGUCHI, TETSUOSATO and TASUKEKONNO Department of Pediatrics, The Research Institute for Tuberculosisand Cancer, Tohoku University,Sendai 980 TSUCHIYA, S., MINEGISHI, M., FUJIE,H., MINEGISHI, N., OHASHI,Y., ITANO,M., MORITA,S., YAMAGUCHI, Y., SATO,T. and KONNO,T. Allogeneic Bone Marrow Transplantation for Malignant Hematologic Disorders in Children. Tohoku J. Exp. Med., 1992, 168 (2), 345-350 In the present study we carried out allogeneic bone marrow transplantation (BMT) in 14 leukemia children with high risk prognostic factors. Six patients with acute nonlymphocytic leukemia (ANLL), four with acute lymphocytic leukemia (ALL), two with chronic myelogenous leukemia (CML), and two with myelodysplastic syndrome (MDS). Among these patients, six with ANLL, two with ALL, one with CML and one with MDS were alive in complete remission 8 to 58 months post-BMT. Four patients died of relapse (one with ALL, and one with MDS), and chronic GVHD (one with ALL and one with CML). In six patients recombinant granulocyte colony stimulating factor (rG-CSF)was used to shorten the period of granulocytopenia. The mean time of recovery to granulocyte count of 500/mm3 was 13.2days in the rG-CSF+ group, being 15.9 days faster than that in the rG-CSF- group. In light of these results, allogeneic BMT is shown to be a choice of treatment for leukemia children with high risk prognostic factors and rG-CSF may be an effective reagent to prevent infectious episodes in BMT. allogeneic bone marrow transplantation ; leukemia ; high risk prognostic factors ; recombinant granulocyte colony stimulating factor
Even though remarkable progress has been made in the treatment of children with acute leukemia, there is still significant proportion of the patients who are not being cured of disease. To improve the survival of leukemia patients with poor prognosis the efficacy of bone marrow transplantation (BMT) has been evaluated with promising results (Thomas 1983). However, there still remains many problems to be solved to establish BMT as a safe and reliable procedure. Among those problems we frequently meet infectious complications and graftversus-host disease (GVHD). Bacterial and fungal infections mainly occur during a period of granulocytopenia after conditioning chemotherapy. Recently recombinant granulocyte colony stimulating factor (rG-CSF) was molecularly Addressfor reprints : 4-1 Seiryomachi,Aoba-ku, Sendai 980, Japan. 345
346
S. Tsuchiya
et al.
cloned and its clinical use became possible in Japan as well as United States and European countries (Nagata et al. 1986; Souza et al. 1986). rG-CSF is expected to induce a rapid recovery of granulopoiesis from severe granulocytopenia and eventually to decrease infectious complications. We joined the Phase II and Phase III studies of rG-CSF and administered rG-CSF to six patients who received marrow grafts. In the present report the results of BMT for 14 children with leukemia are described including the preliminary results concerning clinical use of rG-CSF, and its safety and efficacy. PATIENTS AND METHODS Between 1986 and 1991, BMT was carried out for six patients with acute nonlymphocytic leukemia (ANLL), four with acute lymphocytic leukemia (ALL), two with chronic myelogenous leukemia (CML) and two with myelodysplastic syndrome (MDS). The indication of BMT in Our Institute was decided according to the following criteria : the first complete remission for ANLL patients, the first complete remission for ALL patients with high prognostic risk factors, chronic phase for CML, the onset of a disease for MDS and all the relapsed leukemia patients (Appelbaum et al. 1983). All the patients were transplanted in the laminar air flow rooms. Standard preparative regimen for BMT was intravenous cyclophosphamide, 60 mg/kg, on each of two successive days. This was followed by 2 gray of total body irradiation, 6 times during 5 days (Thomas 1983). For patients with ALL or with relapsed leukemia high dose cytosine arabinoside was added at a dose of 3 g/m2 every 12 hr for 8 doses before administration of cyclophosphamide. As a postgrafting immunosuppressive treatment cyclosporine and/or methotrexate were administered to the patients (Deeg et al. 1985; Storb et al. 1989). Grades of acute GVHD was evaluated according to the description of Thomas et al. (1975). Documentation of hematopoietic engraftment was based on the recovery of normal blood counts and routine marrow aspirates with cytogenetic studies. rG-CSF was provided by Chugai Pharmaceutical Co. (Tokyo) and Sankyo Pharmaceutical Co. (Tokyo). Sterility, general safety, and purity studies met the standards of Ministry of Health and Welfare in Japan. After obtaining informed consent from the parents, rG-CSF was given to the patients 5 or 10 ,ug/kg from day 1 to 14 or 21 of BMT. Complete blood counts including white and red blood cells, reticulocytes, platelets, and differential counts were performed daily.
RESULTSAND DISCUSSION The results of the BMT to 14 patients with hematologic malignancies were summarized in Table 1. Five of 6 patients with ANLL were transplanted at their first complete remission, while an ANLL patient with unique patient number (UPN) 21 was transplanted at his first relapse. They received HLA matched and MLC negative marrow grafts from their siblings. No patients suffered from acute GVHD more than grade II. Histologic findings of chronic GVHD as determined of lip and skin biopsies were very mild. All of 5 patients with ANLL are alive without relapse and the duration of their survival ranges from 6 months to 58 months. Three male patients and one female patient with ALL were transplanted from HLA and MLC compatible siblings. The patient, UPN 7, who had T cell leuke-
Allo geneic TABLE 1.
Bone
Marrow
Transplantation
in Children
Results of allogeneic bone marrow transplantation for nancies (Oct. 1991)
hematologic
347 malig-
mia, underwent BMT at his first remission. Other three ALL patients with common ALL antigen suffered from relapse of leukemia and subsequently underwent BMT either at their relapse or in remission. Two patients, UPN 7 and 15, are alive without relapse 47 months and 22 months, respectively. The patient, UPN 13, died from relapse at 7 months post-BMT. The patient, UPN 19, died of severe chronic GVHD and interstitial pneumonitis at 7 months post-BMT. Two patient, UPN 11 and 20, were diagnosed as Ph 1 positive CML, in chronic phase. Since they had no HLA identical siblings, the 17-year-old boy, UPN 20, underwent BMT from his HLA phenotypically matched mother and the 13-year-old girl, UPN 11, from her HLA D/DR incompatible mother. The UPN 20 patient had suffered from craniopharyngioma 6 years before BMT. Granulocytosis had been noticed 2 years after the disease and the diagnosis of Phi positive CML had been made (Ishii et al. 1989). He is alive 8 months post-BMT with no evidence of relapse of both craniopharyngioma and leukemia. Another patient with CML, UPN 11, who received HLA D/DR incompatible marrow graft showed severe GVHD and died 14 months after BMT. The last group of the patients who underwent BMT had MDS. The 6-year-
348
S. Tsuchiya et al.
old boy, UPN 5, was diagnosed as refractory anemia with excess blasts and transplanted the marrow from an HLA matched and MLC negative sister. He is alive 52 months post-BMT without relapse. Another patient, UPN 17, was the 2-year-old boy with refractory anemia with excess blasts in transformation. He was quite resistant to ordinary chemotherapy and underwent BMT from his HLA compatible brother at relapse, resulting in a complete remission for a short period. However, he died of relapse 9 months after BMT. GVHD was one of the major severe complications seen in our patients. The 13-year-old female patient (UPN 11) with CML underwent one-antigen mismatched BMT from her HLA D/DR incompatible mother. From day + 66 after transplantation she showed general skin exanthema, liver dysfunction with hyperbilirubinemia and thrombocytopenia. Overall evaluation of her acute GVHD was grade III. Although intensive immunosuppressive therapy was given, her acute GVHD progressed and shifted to chronic GVHD with severe hepatic dysfunction and thrombocytopenia. She died 14 months after BMT. Another patient, UPN 19, who had severe GVHD was the 14-year-old girl with ALL. She received HLA matched and MLC negative marrow graft from her brother. Her acute GVHD was grade I. However, lip biopsy performed at day + 100 showed severe involvement of minor salivary glands and oral mucosa as chronic GVHD. She also showed severe thrombocytopenia during late her life and died of interstitial pneumonitis. Since GVHD is deeply involved in BMTrelated death, rapid assessment of more precise predictable factors or more effective methods for treatment should be explored. TABLE 2.
Effect of rGCSF on the recovery of hematopoietic cells in patients who underwent allogeneic bone marrow transplantation for hematologwmalignancies
Allogeneic
Bone
Marrow
Transplantation
in Children
349
Table 2 shows the preliminary results concerning clinical use of rG-CSF. After infusion of marrow grafts rG-CSF was administered to six patients and was compared its safety and efficacy with other eight historical controls. The rGCSF + group included two patients with ANLL, three with ALL and one with CML. Before BMT we examined colony formation of patients' bone marrow cells in methylcellulose medium in the presence of rG-CSF and observed that leukemic colonies did not grow under the condition. The number of days to white blood cell recovery to 1,000/mm3 and to granulocyte recovery to 500/mm3 was calculated and compared between two groups treated with and without rG-CSF. In the rG-CSF + group days to white blood cell count of 1,000/mm3 ranged from 10 to 17 (mean, 13 days) and days to granulocyte count of 500/mm3 ranged from 15 to 17 (mean, 13 days). In the rG-CSF group days to white blood cell count of 1,000/mm3 ranged from 12 to 35 (mean, 20 days) and days to granulocyte count of 500/mm3 ranged from 20 to 52 (mean, 29 days). These results clearly show that the administration of rG-CSF induces a rapid recovery of granulopoiesis in patients who undergo BMT. We examined the effect of rG-CSF in a different way. When the bone marrow donor and recipient are different in sex, engraftment of marrow is clearly confirmed by the detection of karyotype of donor origin. We found 4 sets of such combination in rG-CSF + and rG-CSF - groups. The mean time of days to the first detection of the donor karytype in BMT recipients in the rG-CSF + group was 13 and that in the rG-CSF - group was 21, indicating that the rG-CSF + group was 8 days faster in engraftment of donor marrow than the rG-CSF - group. Based on the results obtained above, allogeneic BMT is considered, in accordance with studies by other investigators, to be a choice of treatment of leukemia childred with high risk prognostic factors. In addition, rG-CSF is shown to have a dramatic effect on rapid engraftment of donor marrow and to be expected to decrease BMT-associated infectious complications. However, it is still controversial whether rG-CSF induces proliferation of residual leukemic cells in vivo. Up to the present time, none of our patients as well as other Japanese patients who were treated with rG-CSF has had early relapse of leukemia after BMT (Asano et al. 1990). Much longer follow-up time and more eligible patients would be required to obtain the conclusion. Acknowledgments This work was supported Science
and
Culture,
in part
by a Research
Grant
from the Ministry
of Education,
Japan.
References 1) Appelbaum, F, R., Clift, R.A., Buckner, C.D., Stewart, P., Sullivan, K.M. & Thomas, ED. (1983) Allogeneic bone marrow transplantation for acute nonlymphoblastic leukemia after first relapse. Blood, 61, 949-953.
350
S. Tsuchiya
et al.
2) Asano, S., Masaoka, T., Takaku, F. & The rhG-CSF Clinical Study Group in Japan (1990) Multi-center phase II-III clinical studies of recombinant human granulocyte colony-stimulating factor in bone marrow transplantation. Exp. Hematol., 18, 705. 3) Deeg, H.J., Storb, R., Thomas, E.D., Flournoy, N., Kennedy, M.S., Banaji, M., Appelbaum, F.R., Bensinger, WI., Buckner, C.D., Clift, R.A., Doney, K., Fefer, A., McGuffin, R., Sanders, J.E., Singer, J., Stewart, P., Sullivan, K.M. & Witherspoon, R.P. (1985) Cyclosporine as prophylaxis for graft-versus-host disease. Blood, 65, 1325-1334. 4) Ishii, A., Kakuta, K., Tsuchiya, S. & Konno, T. (1989) Chronic myelocytic leukemia probably promoted by growth hormone. Tohoku J. Exp. Med., 158, 263-264. 5) Nagata, S., Tsuchiya, M., Asano, S., Kaziro, Y., Yamazaki, T., Yamamoto, 0., Hirata, Y., Kubota, N., Oheda, M., Nomura, H. & Ono, M. (1986) Molecular cloning and expression of cDNA for human granulocyte colony-stimulating factor. Nature, 319, 415-418. 6) Souza, L.M., Boone, T.C., Gabrilove, J., Lai, P.H., Zsebo, K.M., Murdock, D.C., Chazin, YR., Bruszewski, J., Lu, H., Chen, K.K., Barendt, J., Platzer, E., Moore, M.A.S., Mertelsmann, R. & Welts, K. (1986) Recombinant human granulocyte colonystimulating factor : Effect on normal and leukemic myeloid cells. Science,232, 61-65. 7) Storb, R., Deeg, H.J., Pepe, M., Appelbaum, F., Anasetti, C., Beaty, P., Bensinger, W., Berenson, R., Buckner, D., Longhran, T., Martin, J.P., Singer, J., Sanders, J., Stewart, P., Sullivan, K., Witherspoon, R. & Thomas, E.D. (1989) Methotrexate and cyclosporine versus cyclosporine alone for prophylaxis graft-versus-host disease in patients given HLA-identical marrow grafts for leukemia : Long-term follow-up of a controlled trial. Blood, 73, 1729-1734. 8) Thomas, E.D. (1983) Marrow transplantation for malignant disease. I. Clin. Oncol., 1, 517-531. 9) Thomas, E.D., Storb, R., Clift, R.A., Fefer, A., Johnson, L., Neiman, P.E., Lerner, K. G., Glucksberg, H. & Buckner, C.D. (1975) Bone marrow transplantation. N. Engl. J. Med., 292, 832-843, 895-902.
J. Exp.
Med.,
1992, 168, 345-350
Allogeneic
Bone
Marrow
Malignant
Hematologic
Transplantation Disorders
for
in Children
SHIGERU TSUCHIYA, MASAYOSHI MINEGISHI, HIROMIFUJIE, NAOKOMINEGISHI, YOSHIYUKI OHASHI,MASAYUKI ITANO, SET MORITA,YOSHIKOYAMAGUCHI, TETSUOSATO and TASUKEKONNO Department of Pediatrics, The Research Institute for Tuberculosisand Cancer, Tohoku University,Sendai 980 TSUCHIYA, S., MINEGISHI, M., FUJIE,H., MINEGISHI, N., OHASHI,Y., ITANO,M., MORITA,S., YAMAGUCHI, Y., SATO,T. and KONNO,T. Allogeneic Bone Marrow Transplantation for Malignant Hematologic Disorders in Children. Tohoku J. Exp. Med., 1992, 168 (2), 345-350 In the present study we carried out allogeneic bone marrow transplantation (BMT) in 14 leukemia children with high risk prognostic factors. Six patients with acute nonlymphocytic leukemia (ANLL), four with acute lymphocytic leukemia (ALL), two with chronic myelogenous leukemia (CML), and two with myelodysplastic syndrome (MDS). Among these patients, six with ANLL, two with ALL, one with CML and one with MDS were alive in complete remission 8 to 58 months post-BMT. Four patients died of relapse (one with ALL, and one with MDS), and chronic GVHD (one with ALL and one with CML). In six patients recombinant granulocyte colony stimulating factor (rG-CSF)was used to shorten the period of granulocytopenia. The mean time of recovery to granulocyte count of 500/mm3 was 13.2days in the rG-CSF+ group, being 15.9 days faster than that in the rG-CSF- group. In light of these results, allogeneic BMT is shown to be a choice of treatment for leukemia children with high risk prognostic factors and rG-CSF may be an effective reagent to prevent infectious episodes in BMT. allogeneic bone marrow transplantation ; leukemia ; high risk prognostic factors ; recombinant granulocyte colony stimulating factor
Even though remarkable progress has been made in the treatment of children with acute leukemia, there is still significant proportion of the patients who are not being cured of disease. To improve the survival of leukemia patients with poor prognosis the efficacy of bone marrow transplantation (BMT) has been evaluated with promising results (Thomas 1983). However, there still remains many problems to be solved to establish BMT as a safe and reliable procedure. Among those problems we frequently meet infectious complications and graftversus-host disease (GVHD). Bacterial and fungal infections mainly occur during a period of granulocytopenia after conditioning chemotherapy. Recently recombinant granulocyte colony stimulating factor (rG-CSF) was molecularly Addressfor reprints : 4-1 Seiryomachi,Aoba-ku, Sendai 980, Japan. 345
346
S. Tsuchiya
et al.
cloned and its clinical use became possible in Japan as well as United States and European countries (Nagata et al. 1986; Souza et al. 1986). rG-CSF is expected to induce a rapid recovery of granulopoiesis from severe granulocytopenia and eventually to decrease infectious complications. We joined the Phase II and Phase III studies of rG-CSF and administered rG-CSF to six patients who received marrow grafts. In the present report the results of BMT for 14 children with leukemia are described including the preliminary results concerning clinical use of rG-CSF, and its safety and efficacy. PATIENTS AND METHODS Between 1986 and 1991, BMT was carried out for six patients with acute nonlymphocytic leukemia (ANLL), four with acute lymphocytic leukemia (ALL), two with chronic myelogenous leukemia (CML) and two with myelodysplastic syndrome (MDS). The indication of BMT in Our Institute was decided according to the following criteria : the first complete remission for ANLL patients, the first complete remission for ALL patients with high prognostic risk factors, chronic phase for CML, the onset of a disease for MDS and all the relapsed leukemia patients (Appelbaum et al. 1983). All the patients were transplanted in the laminar air flow rooms. Standard preparative regimen for BMT was intravenous cyclophosphamide, 60 mg/kg, on each of two successive days. This was followed by 2 gray of total body irradiation, 6 times during 5 days (Thomas 1983). For patients with ALL or with relapsed leukemia high dose cytosine arabinoside was added at a dose of 3 g/m2 every 12 hr for 8 doses before administration of cyclophosphamide. As a postgrafting immunosuppressive treatment cyclosporine and/or methotrexate were administered to the patients (Deeg et al. 1985; Storb et al. 1989). Grades of acute GVHD was evaluated according to the description of Thomas et al. (1975). Documentation of hematopoietic engraftment was based on the recovery of normal blood counts and routine marrow aspirates with cytogenetic studies. rG-CSF was provided by Chugai Pharmaceutical Co. (Tokyo) and Sankyo Pharmaceutical Co. (Tokyo). Sterility, general safety, and purity studies met the standards of Ministry of Health and Welfare in Japan. After obtaining informed consent from the parents, rG-CSF was given to the patients 5 or 10 ,ug/kg from day 1 to 14 or 21 of BMT. Complete blood counts including white and red blood cells, reticulocytes, platelets, and differential counts were performed daily.
RESULTSAND DISCUSSION The results of the BMT to 14 patients with hematologic malignancies were summarized in Table 1. Five of 6 patients with ANLL were transplanted at their first complete remission, while an ANLL patient with unique patient number (UPN) 21 was transplanted at his first relapse. They received HLA matched and MLC negative marrow grafts from their siblings. No patients suffered from acute GVHD more than grade II. Histologic findings of chronic GVHD as determined of lip and skin biopsies were very mild. All of 5 patients with ANLL are alive without relapse and the duration of their survival ranges from 6 months to 58 months. Three male patients and one female patient with ALL were transplanted from HLA and MLC compatible siblings. The patient, UPN 7, who had T cell leuke-
Allo geneic TABLE 1.
Bone
Marrow
Transplantation
in Children
Results of allogeneic bone marrow transplantation for nancies (Oct. 1991)
hematologic
347 malig-
mia, underwent BMT at his first remission. Other three ALL patients with common ALL antigen suffered from relapse of leukemia and subsequently underwent BMT either at their relapse or in remission. Two patients, UPN 7 and 15, are alive without relapse 47 months and 22 months, respectively. The patient, UPN 13, died from relapse at 7 months post-BMT. The patient, UPN 19, died of severe chronic GVHD and interstitial pneumonitis at 7 months post-BMT. Two patient, UPN 11 and 20, were diagnosed as Ph 1 positive CML, in chronic phase. Since they had no HLA identical siblings, the 17-year-old boy, UPN 20, underwent BMT from his HLA phenotypically matched mother and the 13-year-old girl, UPN 11, from her HLA D/DR incompatible mother. The UPN 20 patient had suffered from craniopharyngioma 6 years before BMT. Granulocytosis had been noticed 2 years after the disease and the diagnosis of Phi positive CML had been made (Ishii et al. 1989). He is alive 8 months post-BMT with no evidence of relapse of both craniopharyngioma and leukemia. Another patient with CML, UPN 11, who received HLA D/DR incompatible marrow graft showed severe GVHD and died 14 months after BMT. The last group of the patients who underwent BMT had MDS. The 6-year-
348
S. Tsuchiya et al.
old boy, UPN 5, was diagnosed as refractory anemia with excess blasts and transplanted the marrow from an HLA matched and MLC negative sister. He is alive 52 months post-BMT without relapse. Another patient, UPN 17, was the 2-year-old boy with refractory anemia with excess blasts in transformation. He was quite resistant to ordinary chemotherapy and underwent BMT from his HLA compatible brother at relapse, resulting in a complete remission for a short period. However, he died of relapse 9 months after BMT. GVHD was one of the major severe complications seen in our patients. The 13-year-old female patient (UPN 11) with CML underwent one-antigen mismatched BMT from her HLA D/DR incompatible mother. From day + 66 after transplantation she showed general skin exanthema, liver dysfunction with hyperbilirubinemia and thrombocytopenia. Overall evaluation of her acute GVHD was grade III. Although intensive immunosuppressive therapy was given, her acute GVHD progressed and shifted to chronic GVHD with severe hepatic dysfunction and thrombocytopenia. She died 14 months after BMT. Another patient, UPN 19, who had severe GVHD was the 14-year-old girl with ALL. She received HLA matched and MLC negative marrow graft from her brother. Her acute GVHD was grade I. However, lip biopsy performed at day + 100 showed severe involvement of minor salivary glands and oral mucosa as chronic GVHD. She also showed severe thrombocytopenia during late her life and died of interstitial pneumonitis. Since GVHD is deeply involved in BMTrelated death, rapid assessment of more precise predictable factors or more effective methods for treatment should be explored. TABLE 2.
Effect of rGCSF on the recovery of hematopoietic cells in patients who underwent allogeneic bone marrow transplantation for hematologwmalignancies
Allogeneic
Bone
Marrow
Transplantation
in Children
349
Table 2 shows the preliminary results concerning clinical use of rG-CSF. After infusion of marrow grafts rG-CSF was administered to six patients and was compared its safety and efficacy with other eight historical controls. The rGCSF + group included two patients with ANLL, three with ALL and one with CML. Before BMT we examined colony formation of patients' bone marrow cells in methylcellulose medium in the presence of rG-CSF and observed that leukemic colonies did not grow under the condition. The number of days to white blood cell recovery to 1,000/mm3 and to granulocyte recovery to 500/mm3 was calculated and compared between two groups treated with and without rG-CSF. In the rG-CSF + group days to white blood cell count of 1,000/mm3 ranged from 10 to 17 (mean, 13 days) and days to granulocyte count of 500/mm3 ranged from 15 to 17 (mean, 13 days). In the rG-CSF group days to white blood cell count of 1,000/mm3 ranged from 12 to 35 (mean, 20 days) and days to granulocyte count of 500/mm3 ranged from 20 to 52 (mean, 29 days). These results clearly show that the administration of rG-CSF induces a rapid recovery of granulopoiesis in patients who undergo BMT. We examined the effect of rG-CSF in a different way. When the bone marrow donor and recipient are different in sex, engraftment of marrow is clearly confirmed by the detection of karyotype of donor origin. We found 4 sets of such combination in rG-CSF + and rG-CSF - groups. The mean time of days to the first detection of the donor karytype in BMT recipients in the rG-CSF + group was 13 and that in the rG-CSF - group was 21, indicating that the rG-CSF + group was 8 days faster in engraftment of donor marrow than the rG-CSF - group. Based on the results obtained above, allogeneic BMT is considered, in accordance with studies by other investigators, to be a choice of treatment of leukemia childred with high risk prognostic factors. In addition, rG-CSF is shown to have a dramatic effect on rapid engraftment of donor marrow and to be expected to decrease BMT-associated infectious complications. However, it is still controversial whether rG-CSF induces proliferation of residual leukemic cells in vivo. Up to the present time, none of our patients as well as other Japanese patients who were treated with rG-CSF has had early relapse of leukemia after BMT (Asano et al. 1990). Much longer follow-up time and more eligible patients would be required to obtain the conclusion. Acknowledgments This work was supported Science
and
Culture,
in part
by a Research
Grant
from the Ministry
of Education,
Japan.
References 1) Appelbaum, F, R., Clift, R.A., Buckner, C.D., Stewart, P., Sullivan, K.M. & Thomas, ED. (1983) Allogeneic bone marrow transplantation for acute nonlymphoblastic leukemia after first relapse. Blood, 61, 949-953.
350
S. Tsuchiya
et al.
2) Asano, S., Masaoka, T., Takaku, F. & The rhG-CSF Clinical Study Group in Japan (1990) Multi-center phase II-III clinical studies of recombinant human granulocyte colony-stimulating factor in bone marrow transplantation. Exp. Hematol., 18, 705. 3) Deeg, H.J., Storb, R., Thomas, E.D., Flournoy, N., Kennedy, M.S., Banaji, M., Appelbaum, F.R., Bensinger, WI., Buckner, C.D., Clift, R.A., Doney, K., Fefer, A., McGuffin, R., Sanders, J.E., Singer, J., Stewart, P., Sullivan, K.M. & Witherspoon, R.P. (1985) Cyclosporine as prophylaxis for graft-versus-host disease. Blood, 65, 1325-1334. 4) Ishii, A., Kakuta, K., Tsuchiya, S. & Konno, T. (1989) Chronic myelocytic leukemia probably promoted by growth hormone. Tohoku J. Exp. Med., 158, 263-264. 5) Nagata, S., Tsuchiya, M., Asano, S., Kaziro, Y., Yamazaki, T., Yamamoto, 0., Hirata, Y., Kubota, N., Oheda, M., Nomura, H. & Ono, M. (1986) Molecular cloning and expression of cDNA for human granulocyte colony-stimulating factor. Nature, 319, 415-418. 6) Souza, L.M., Boone, T.C., Gabrilove, J., Lai, P.H., Zsebo, K.M., Murdock, D.C., Chazin, YR., Bruszewski, J., Lu, H., Chen, K.K., Barendt, J., Platzer, E., Moore, M.A.S., Mertelsmann, R. & Welts, K. (1986) Recombinant human granulocyte colonystimulating factor : Effect on normal and leukemic myeloid cells. Science,232, 61-65. 7) Storb, R., Deeg, H.J., Pepe, M., Appelbaum, F., Anasetti, C., Beaty, P., Bensinger, W., Berenson, R., Buckner, D., Longhran, T., Martin, J.P., Singer, J., Sanders, J., Stewart, P., Sullivan, K., Witherspoon, R. & Thomas, E.D. (1989) Methotrexate and cyclosporine versus cyclosporine alone for prophylaxis graft-versus-host disease in patients given HLA-identical marrow grafts for leukemia : Long-term follow-up of a controlled trial. Blood, 73, 1729-1734. 8) Thomas, E.D. (1983) Marrow transplantation for malignant disease. I. Clin. Oncol., 1, 517-531. 9) Thomas, E.D., Storb, R., Clift, R.A., Fefer, A., Johnson, L., Neiman, P.E., Lerner, K. G., Glucksberg, H. & Buckner, C.D. (1975) Bone marrow transplantation. N. Engl. J. Med., 292, 832-843, 895-902.
