All 5 patients were engrafted with a median time to ANC>500 cells/μL for 3 consecutive days of 18 days. Acute GVHD after first HSCT was mild (grade I to II) in all patients, and was successfully managed with a short course of corticosteroids. Greater than 25% recipient chimerism was demonstrated in all patients before second SCT. Once mixed chimerism was detected, cyclosporine and methotrexate were discontinued in all patients. All patients also had evidence of persistent or recurrent disease verified by bone marrow aspiration completed between days +35 to +185.
Indications for second transplant varied among the 5 patients in addition to all demonstrating decreased donor chimerism after initial transplant. Chimerism studies obtained before and after second HSCT are detailed in Table 2. Time to second transplant for all patients ranged from 55 to 731 days. All 5 patients were prepared with Ara-C (3000 mg/m2 IV) every 12 hours on days −8 through −3, and mitoxantrone (10 mg/m2/d IV) on days −8, −7, −6 followed by 2 days of rest and second bone marrow HSCT from their original donors. No GVHD prophylaxis was given after the second transplant.
Standard G-banded analysis was performed on direct and 24-hour unstimulated bone marrow aspirates. The methods of chromosome preparation for cytogenetic analysis are described elsewhere.18,19 Peripheral blood specimens were obtained periodically posttransplant for studies of hematopoietic chimerism of either white blood cells or separated CD3(+) cells. Specimens were analyzed by polymerase chain reaction amplification for polymorphic markers (AmpFISTR Profiler PCR Amplification Kit; Applied Biosystems, Foster City, CA) composed of short-tandem repeats. Nine short-tandem repeat markers were used, including D3S1358, vWA, FGA, TH01, TPOX, CSF1PO, D5S818, D13S317, D7S820, and the sex marker Amelogenin.20
After second HSCT, median time to ANC>500 cells/μL for 3 consecutive days was 12 days (range, 9 to 28 d), last red cell transfusion was 45 days (range, 13 to 95 d), and last platelet transfusion was 63 days (range, 9 to 122 d). Two patients had mild acute GVHD (grade I to II), 3 patients developed chronic GVHD, and 1 patient had no evidence of GVHD after second HSCT. All 5 patients are alive and disease free at 88, 179, 199, 234, and 246 months after second HSCT with continued 100% donor chimerism (Table 2). The preparative regimen was well tolerated with no or minimal organ dysfunction and no significant infectious complications. All 5 patients have returned for follow-up within the last 12 months, and all are well with no evidence of cGVHD. Four of 5 patients demonstrate Karnofsky scores of 100% and 1 child (case 4) has a score of 80% secondary to persistent pulmonary hypertension that developed soon after first transplant and delayed the second transplant.
Other investigators have suggested either the withdrawal of immunosuppressive therapy or donor lymphocyte infusion (DLI) as possible treatment modalities, given the lower relapse rates in patients who develop GVHD.23 However, in an evaluation of 21 patients with mixed chimerism after initial HSCT for JMML, only 1 patient was alive and in remission for >1500 days after receiving DLI.24 Moreover, all 21 patients in the study with mixed chimerism experienced a hematological relapse, further clarifying mixed chimerism status as a risk factor.24 A recent review of 16 patients with JMML who received HSCT by Inagaki et al25 confirmed these results, given that only 1 of 5 patients who received DLI achieved a longstanding remission.
For this reason, second HSCT is the treatment of choice at our institution for patients with increasing mixed chimerism and frank evidence of relapsed or progressive JMML. Previous reports have highlighted the importance of GVL effect in the successful control of JMML.26 We reasoned that if we could reduce the malignant cell burden by using myeolablative chemotherapy, GVL would be augmented. Given the efficacy of high-dose Ara-C and mitoxantrone for reinduction of relapsed myeloid leukemias we chose these agents as our cytoreductive regimen. As this regimen causes profound and prolonged myelosuppression, we provided a second stem cell infusion using the same donor in an effort to achieve earlier recovery of counts. In an effort to promote the GVL effect, we chose not to use GVHD prophylaxis after the second transplant. We felt this was reasonable as all patients only had mild, self-limited aGVHD after first HSCT from the same donor. We theorize that the elimination of GVHD prophylaxis after second transplant promoted a more robust GVL effect, thus eradicating residual disease.21 The omission of GVHD prophylaxis did not result in increased transplant morbidity, and only 2 of 5 patients developed grade I and II aGVHD and 3 of 5 mild self-limited chronic GVHD (Table 2). Furthermore, Ara-C and mitoxantrone were well tolerated by all 5 patients with minimal nonhematopoietic toxicity.
In conclusion, our findings support the strategy of second HSCT with the same donor combined with reduced or no GVHD prophylaxis to optimize the GVL effect in patients with persistent or recurrent JMML. Our experience further suggests utilizing a relatively nontoxic regimen of high-dose Ara-C and mitoxantrone as the preparative regimen in children with JMML.
1. Gassas A, Doyle J, Dror Y, et al..Basic classification and a comprehensive examination of pediatric myeloproliferative syndromes.J Pediatr Hematol Oncol.2005;27:192–196.
2. Emanuel PD.Juvenile myelomonocytic leukemia and chronic myelomonocytic leukemia.Leukemia.2008;22:1335–1342.
3. Niemeyer CM, Kratz CP.Paediatric myelodysplastic syndromes and juvenile myelomonocytic leukaemia: molecular classification and treatment options.Br J Haematol.2008;140:610–624.
4. Niemeyer CM, Locatelli F.Chronic Myeloproliferative Disorders. Childhood Luekemias.2006:2nd ed.New York:Cambridge University Press;571–598.
5. Arico M, Biondi A, Pui CH.Juvenile myelomonocytic leukemia.Blood.1997;90:479–488.
6. Side LE, Emanuel PD, Taylor B, et al..Mutations of the NF1 gene in children with juvenile myelomonocytic leukemia without clinical evidence of neurofibromatosis, type 1.Blood.1998;92:267–272.
7. Bentires-Alj M, Paez JG, David FS, et al..Activating mutations of the Noonan syndrome-associated SHP2/PTPN11 gene in human solid tumors and adult acute myelogenous leukemia.Cancer Res.2004;64:8816–8820.
8. Sheng XM, Kawamura M, Ohnishi H, et al..Mutations of the RAS genes in childhood acute myeloid leukemia, myelodysplastic syndrome and juvenile chronic myelocytic leukemia.Leuk Res.1997;21:697–701.
9. Schubbert S, Zenker M, Rowe SL, et al..Germline KRAS mutations cause Noonan syndrome.Nat Genet.2006;38:331–336.
10. Loh ML.Recent advances in the pathogenesis and treatment of juvenile myelomonocytic leukemia.Br J Haematol.2011;152:677–687.
11. Locatelli F, Nollke P, Zecca M, et al..HSCT in children with JMML
: results of EWOG-MDS/EBMT trial.Blood.2005;105:410–419.
12. Niemeyer C, Arico M, Basso G, et al..Chronic myelomonocytic leukemia in childhood: a retrospective analysis of 110 cases.Blood.1997;89:3534.
13. Chan RJ, Cooper T, Kratz CP, et al..Juvenile myelomonocytic leukemia: a report from the 2nd International JMML
14. Yusuf U, Frangoul HA, Gooley TA, et al..Allogeneic bone marrow transplantation in children with myelodysplastic syndrome or juvenile myelomonocytic leukemia: the Seattle experience.Bone Marrow Transplant.2004;33:805–814.
15. Smith FO, King R, Nelson G, et al..Unrelated donor bone marrow transplantation for children with juvenile myelomonocytic leukaemia.Br J Haematol.2002;116:716–724.
16. Yoshimi A, Mohamed M, Beirings M, et al..Second allogeneic hematopoietic stem cell transplantation (HSCT) results in outcome similar to that of first HSCT for patients with juvenile myelomonocytic leukemia.Leukemia.2007;21:556–560.
17. Locatelli F, Lucarelli B.Treatment of disease recurrence after allogeneic hematopoietic stem cell transplantation in children with juvenile myelomonocytic leukemia: a great challenge still to be won.Pediatr Blood Cancer.2013;60:1–2.
18. Dave BJ, Nelson M, Sanger WG.Lymphoma Cytogenetics.Clin Lab Med.2011;31:725–761.
19. Horsman DE, Conners JM, Pantzar T, et al..Analysis of secondary chromosomal alterations in 165 cases of follicular lymphoma with t(14:18).Genes Chromosomes Cancer.2001;30:375–382.
20. Rubocki RJ, Parsa JR, Hershfield MS, et al..Full hematopoietic engraftment after allogeneic bone marrow transplantation without cytoreduction in a child with severe combined immunodeficiency.Blood.2001;97:809–811.
21. Manabe A, Okamura J, Yumera-Yagi K, et al..Allogeneic hematopoietic stem cell transplantation for 27 children with juvenile myelomonocytic leukemia diagnosed based on the criteria of the International JMML
22. Bergstraesser E, Hasle H, Rogge T, et al..Non-hematopoietic stem cell transplantation treatment of juvenile myelomonocytic leukemia: a retrospective analysis and definition of response criteria.Pediatr Blood Cancer.2007;49:629–633.
23. Korthof ET, Snijder PP, de Graaff AA, et al..Allogeneic bone marrow transplantation for juvenile myelomonocytic leukemia: a single center experience of 23 patients.Bone Marrow Transplant.2005;35:455–461.
24. Yoshimi A, Bader P, Matthes-Martin S, et al..Donor leukocyte infusion after hematopoietic stem cell transplantation in patients with juvenile myelomonocytic leukemia.Leukemia.2005;19:971–977.
25. Inagaki J, Fukano R, Nishiwaka T, et al..Outcomes of Immunological Interventions for mixed chimerism
following allogeneic stem cell transplantation in children with juvenile myelomonocytic leukemia.Pediatr Blood Cancer.2013;60:116–120.
26. Locatelli F, Niemeyer C, Angelucci E, et al..Allogeneic bone marrow transplantation for chronic myelomonocytic leukemia in childhood: a report from the European Working Group on Myelodysplastic Syndrome in Childhood.J Clin Oncol.1997;15:566–573.
27. Locatelli F, Crotta A, Ruggeri A, et al..Analysis of risk factors influencing outcomes after cord-blood-transplantation in children with juvenile myelomonocytic leukemia.Blood.2001;97:809–811.