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Keywords:

  • bone marrow transplantation;
  • stem cell transplantation;
  • Fanconi's anaemia;
  • related donor

Abstract

  1. Top of page
  2. Abstract
  3. PATIENTS and METHODS
  4. Results
  5. Discussion
  6. Acknowledgments
  7. Appendix
  8. References

Twenty-seven consecutive Italian patients with Fanconi's anaemia (FA) underwent stem cell transplantation (SCT) from an HLA-matched related donor in 10 Italian centres of the Associazione Italiana Ematologia ed Oncologia Pediatrica (AIEOP), Gruppo Italiano di Trapianto di Midollo Osseo (GITMO). Twenty-two patients (81·5%) were conditioned with low-dose (median 20 mg/kg) cyclophosphamide (Cy) and thoraco-abdominal or total body irradiation (median dose 500 cGy), five patients (18·5%) with high-dose Cy (median 120 mg/kg). Graft-vs.-host disease (GVHD) prophylaxis was carried out with cyclosporin A in 26 cases; methotrexate (MTX) was added in eight cases. One patient received MTX alone. The median follow-up was 36 months. Ninety-two percent of patients (25 out of 27) engrafted, grade II and III acute GVHD occurred in 28% and 8% of patients, respectively, with chronic GVHD in 12·5%. Conditioning-related toxicity was mild: 4% of patients had grade III mucositis, 7·4% had grade II haemorrhagic cystitis, 14·8% had grade III liver toxicity and 11·1% had grade III renal toxicity. Transplant-related mortality at 12 months was 19·2%, survival at 36 months was 81·5%, with a median Karnofsky score of 100%. No late tumours occurred after a mean follow-up of the survivors of 5 years. None of the studied variables significantly affected the survival, including conditioning regimen, acute GVHD and clinical non-haematological phenotype. Among the studied variables, only conditioning regimens containing high-dose Cy and the presence of genital abnormalities were significantly (P < 0·05) associated with an increased rate of acute GVHD. Our study demonstrates that the Italian FA patients undergoing SCT from an HLA-matched related donor have a very good outcome. These patients, when compared with others of different ethnic origin who underwent allogeneic bone marrow transplantation, showed a less severe non-haematological phenotype, raising the possibility that this milder phenotype may have, at least in part, contributed to the outcome. Our data may provide a useful tool for further studies aiming to correlate genotype with phenotype.

Fanconi's Anaemia (FA) is a rare autosomal recessive disease characterized by progressive bone marrow failure, chromosomal fragility, malformations, skin hyperpigmentation and a tendency to develop malignancies, primarily acute leukaemia.

FA is a genetically heterogeneous disease. At least seven different complementation groups (A to G) (Joenje et al, 2000) and five different genes (A, C, E, F, G) have been identified to date (Strathdee et al, 1992; Lo Ten Foe et al, 1996; The Fanconi Anaemia/Breast Cancer Consortium, 1996; De Winter et al, 1998, 2000a, b; Waisfisz et al, 1999). Another gene, D (Hejna et al, 2000), has been localized on chromosome 3. About 65% of patients have been shown to belong to group A (Joenje et al, 1998) and virtually all the tested Italian patients are of group A (Savoia et al, 1996). There seems to be some relationship between genotype and clinical phenotype as a number of studies provided evidence that different genetic lesions do correspond to clinical phenotypes of different severity (Verlander et al, 1995; Yamashita et al, 1996; Gillio et al, 1997).

Among the various therapeutic options currently available, stem cell transplantation (SCT) represents the only alternative capable of providing adequate long-term haemopoiesis in FA. However, the heterogeneity of the disease seems also to be reflected in the SCT setting. Whereas the vast majority of patients achieve satisfactory results with conditioning regimens including either radiation plus low-dose (20 mg/kg) cyclophosphamide (LDCy) (Gluckman et al, 1983; Gluckman, 1989; Socièet al, 1998) or high-dose (≥ 100 mg/kg) (HD) Cy alone (Zanis-Neto et al, 1995; Flowers et al, 1996), some patients have been successfully transplanted using a conditioning regimen containing only LDCy (Dokal & Roberts, 1996). Moreover, a recent study (Guardiola et al, 2000) on a multi-ethnic, heterogeneous population has shown that patients with extensive malformations, transplanted from an unrelated donor, have a worse survival than those with limited malformations, thus implying that there is a relationship between phenotype and outcome of bone marrow transplantation (BMT) in FA patients.

In the scenario of such a rare and heterogeneous disease, we believe that a study on a relatively large, ethnically homogeneous group of patients may contribute to the understanding of some SCT-related aspects. In light of this, we present a retrospective multicentric analysis of the outcome of 27 Italian FA patients who underwent SCT from HLA-matched related donors, and identify factors, including clinical phenotype, that may be associated with the transplant outcome.

PATIENTS and METHODS

  1. Top of page
  2. Abstract
  3. PATIENTS and METHODS
  4. Results
  5. Discussion
  6. Acknowledgments
  7. Appendix
  8. References

Patients and disease characteristics Between February 1979 and March 1998, 27 Italian patients with FA underwent a first transplant from a family related donor in 10 AIEOP/GITMO centres. Over this 19-year period, 89 patients (48 men and 41 women) were diagnosed with FA and registered in the ‘Registro Italiano dell’ Anemia di Fanconi (RIAF)'. During this period, in the AIEOP/GITMO centres, 15 subjects underwent SCT from an alternative donor. In the current study, all patients were Italian and of Italian ancestry. Nineteen patients were men and eight were women. The median age at diagnosis was 6·3 years (range 2·4–13 years). Non-haematological phenotypic abnormalities are reported in Table I.

Table I.  Patient, disease and treatment characteristics for 27 patients receiving stem cell transplant for Fanconi's anaemia from an HLA-matched related donor.
 Number of patients (%)Median (range)
  1. SCT, stem cell transplant; CMV, cytomegalovirus; TAI, thoraco-abdominal irradiation; LDCy, low-dose cyclophosphamide (median 20 mg/kg, range 20–80 mg/kg); ATG, anti-thymocyte globulin; TBI, total body irradiation; HDCy, high-dose cyclophosphamide (median 120 mg/kg, range 100–200 mg/kg); CSA, cyclosporin A; MTX, methotrexate.

Physical abnormalities  
 Growth retardation18 (67) 
 Skin hypo/hyperpigmentation16 (59) 
 Microcephaly11 (41) 
 Kidney malformations 8 (30) 
 Thumb malformations 7 (26) 
 Genital malformations 6 (22) 
 Upper limb malformations 4 (15) 
 Skeleton malformations 3 (11) 
 Microphthalmia 3 (11) 
 Micrognathia 2 (7) 
 Learning disabilities 2 (7) 
 Ear malformations 1 (4) 
 Agenesia corpus callosum 1 (4) 
 No abnormalities 4 (11) 
 Malformative score  1 (0–3)
 Phenotypic score  4 (0–6)
Treatment for aplastic anaemia before transplant  
 None12 
 Corticosteroids 7 
 Androgens 5 
 Androgens + corticosteroids 2 
 Cytokines 1 
Pre-transplant transfusions  
 Number of red cell-transfused patients20 
 Number of platelet-transfused patients15 
 Number of red cell transfusions  3 (1–18)
 Number of platelet transfusions  2 (1–20)
Age at transplant (years)  9 (2·5–19·5)
Diagnosis–SCT interval (months) 12·3 (1–115)
Donor–recipient AB0-matched13 
Donor–recipient sex-match  
 Male to male13 
 Male to female 3 
 Female to male 6 
 Female to female 5 
Donor–recipient CMV-match  
 Neg.–Neg. 6 
 Other13 
 Unknown 8 
Disease status at transplant  
 Hypoplastic marrow 1 
 Aplastic marrow24 
 Dysplastic marrow 2 (1 with 7-) 
 WBC (× 109/l)  3·1 (1·7–12)
 PMNs (× 109/l)  1 (0·1–4·7)
 Hb (g/dl)  8·2 (5·5–11·2)
 Platelets (× 109/l) 25 (2–87)
Conditioning regimen  
 TAI + LDCy ± ATG12 (44) 
 TBI + LDCy ± ATG10 (37) 
 HDCy 5 (19) 
Number of nucleated cells (× 108/kg)  4·2 (0·14–9·8)
 Marrow26 
 Cord Blood 1 
GVHD prophylaxis  
 CSA18 
 CSA + MTX 8 
 MTX 1 

With the aim of investigating whether the non-haematological phenotype had an impact on the outcome of SCT, we analysed our patients with the method adopted by Guardiola et al (2000) that only included the malformations and evaluated the extent of these by considering the number of anatomical sites involved. Guardiola et al (2000) considered six anatomical sites (head, limbs, kidneys, gastrointestinal tract, urogenital tract, cardiovascular system) and gave every patient a score of 1 whenever a single site was affected by one or more stigmata. If more than one sign was present in two different sites (i.e. microphthalmia, strabismus, deafness, abnormal thumb and hexadactylia), the patient would be given a score of 2. Moreover, the condition was defined as extensive malformative syndrome with ≥ 3 sites involved and as limited malformative syndrome with < 3 sites involved. Using this system our patients had a median score of 1 (0–3), with only four patients (13·8%) scoring 3.

However, as the above method considered only the malformations and did not encompass some clinical characteristics, such as growth retardation and skin hypo/hyperpigmentation, which recurred in the majority of our patients (65% and 55% respectively), we devised our own phenotypic scoring system in which every non-haematological sign or symptom involving different body sectors/functions was considered to count as 1. For example, microphthalmia was considered as scoring 1 and so did microcephaly. Skin involvement, despite consisting of multiple areas of hypo/hyperpigmentation, was considered as 1. Therefore, a patient who had a thumb abnormality, microcephaly and skin hyper/hypopigmentations was given a score of 3. Another patient who, in addition to the above anomalies, also had another upper limb abnormality, a renal malformation, growth retardation and learning disability was given a score of 7. When our phenotypic scoring system was adopted, our patients had a median score of 4 (0–6).

At diagnosis, 25 out of 27 patients had hypocellular marrow (cellularity < 25%), two patients had dysplastic marrow and one of these had monosomy of chromosome 7. Median white blood cell counts (WBC) were 3·2 × 109/l (range, 1·1–8·2 × 109/l), polymorphonuclear cells (PMNs) were 0·9 × 109/l (range 0–2·8 × 109/l), haemoglobin (Hb) was 9 g/dl (range 4·7–13·6 g/dl), and platelets were 40 × 109/l (range 5–117 × 109/l).

Treatment for marrow failure, transfusions received before transplantation and haematological status at transplantation are shown in Table I. No clinically important infections were present at the time of SCT.

Conditioning regimen Among the 27 patients who received their first graft, three main categories of conditioning regimens could be identified. The first category included 12 patients (44%) who received LDCy (20 mg/kg) and thoraco-abdominal irradiation (TAI) at a median dose of 500 cGy (range 500–600 cGy), with the addition of anti-thymocyte globulin (ATG) pre-BMT in one case. The second category encompassed 10 patients (37%) who received total body irradiation (TBI) at a median dose of 500 cGy (range 300–600 cGy) and LDCy (median dose 20 mg/kg, range 20–80 mg/kg), with addition of ATG in one case. The third category included five patients (19%) who were conditioned with HDCy at a median dose of 120 mg/kg (100–200 mg/kg), with the addition of ATG pre-BMT in two cases.

One patient rejected his first transplant and was re-engrafted from the same donor after reconditioning with melphalan 40 mg/m2 and ATG. Another patient who rejected her first transplant was retransplanted from another HLA-identical brother after reconditioning with Cy 80 mg/kg, total lymphoid irradiation 600 cGy and Campath in vivo. This second transplant also failed to engraft, however, a third transplant from the first HLA-identical brother following preparation with Cy 80 mg/kg, thiotepa 10 mg/kg, cytarabine (Ara-C) 6 g/m2 and ATG was successful.

Donors and source of haemopoietic stem cells Stem cells were obtained from 28 Italian family related donors (17 men, 11 women, median age 14 years, range 0–39 years). All donors were tested for chromosomal fragility before the transplant and were found to be unaffected.

All patients were engrafted from an HLA-matched related donor who was a genoidentical sibling in 25 cases and a phenoidentical parent in two cases. One patient received two transplants from the same HLA-identical sibling. Another patient had three transplants from two different HLA-identical siblings.

Of the 27 patients who underwent a first transplant, 26 received unmanipulated marrow cells at a median dose of 4·7 × 108/kg (range 0·74–9·8 × 108/kg) of the recipient's body weight (Table I). One patient received unmanipulated cord blood cells at the dose of 0·14 × 108/kg. The two patients who underwent more than one graft also received unmanipulated marrow cells.

GVHD prophylaxis With the exception of one patient who received MTX alone, all the patients were given cyclosporin A (CSA) i.v. from d-1 during the first 2 weeks after BMT at a dose of 3 mg/kg/d. Afterwards, CSA was given orally and the dose was adjusted according to serum levels. The drug was tapered by 5% per week after d 180 and discontinued on d 360 after SCT in patients without signs of GVHD. In eight patients, a short course of MTX was added to CSA (Table I).

End-points The following end-points were analysed: engraftment, acute and chronic GVHD, conditioning-related toxicity, post-transplant infections, transplant-related mortality (TRM), survival, post-transplant Hb, PMN and platelet values, late tumours and Karnofsky score.

Engraftment was defined as an increase of absolute neutrophil count (ANC) greater than 0·5 × 109/l for three consecutive days. Graft failure, defined either as primary (engraftment never occurred) or secondary (loss of take after a transient engraftment defined as above), was analysed in patients surviving 21 d following transplant (Champlin et al, 1989). Chimaerism studies were performed in all the 25 patients who were evaluable for engraftment. These studies included cytogenetics for sex-mismatched patient/donor pairs in nine cases and ABO typing in 14 patients with major red blood cell group differences. In addition, the 12 patients who were transplanted from 1995 onwards, including the subjects who were not assessed using the above methods, were also evaluated using short tandem repeat (STR) polymorphism via polymerase chain reaction (PCR)-based technology on peripheral blood (Lygo et al, 1994; De Stefano et al, 1996).

Acute GVHD was assessed in patients surviving more than 21 d following engraftment using published criteria (Glucksberg et al, 1974). Chronic GVHD was defined using clinical criteria in patients surviving more than 90 d following engraftment (Atkinson et al, 1990).

Conditioning-related toxicity was dependent on the agents used in the conditioning regimens. The degree of conditioning-related complications was evaluated according to Bearman criteria (Bearman et al, 1988). Infections were considered separately from conditioning-related complications.

The values of post-transplant Hb, PMNs and platelets were those assessed at the time of the last follow-up i.e 15th May 1998.

The Karnofsky score was evaluated according to published criteria (Karnofsky & Burchenald, 1949).

The comparison between subjects transplanted before 1988 and patients engrafted between 1989 and 1998 in terms of the above end-points was not practicable because of the small number of patients transplanted in the period 1979–88.

Statistical methods Patients data were collected as previously reported (Pession et al, 1998) by orientated reporting forms completed by the physician in charge at each BMT Centre. All information was stored, controlled and analysed using venus, an integrated system of software facilities, running on an IBM mainframe at the North-East Italian Interuniversity Computing Centre (CINECA).

With the purpose of evaluating the outcome of the patients, as reported in Table II, survival (SUR), Karnofsy score, acute and chronic GVHD, acute toxicity, graft failure and deaths were expressed in terms of incidence. In addition, SUR, transplant-related mortality (TRM) and acute GVHD frequency were estimated using the Kaplan–Meier method (Kaplan & Meier, 1958) as of 15th May 1998. SUR was chosen as the better indicator of procedure effectiveness. Time on study or time to terminal event was calculated from the day of transplantation. Terminal events were death as a result of any cause for SUR, death as a result of any cause except rejection for TRM, and grade II–IV appearance for acute GVHD incidence. The log-rank test (Mantel & Haenszel et al, 1959) was adopted to assess differences in univariate analysis. The impact of the following variables (median value cut-off for continuous variables) on SUR was analysed: age at diagnosis (< 6 years vs. ≥ 6 years), age at BMT (< 9 years vs. ≥ 9 years), diagnosis–BMT interval (< 1 year vs. ≥ 1 year), PMNs (< 0·9 × 109/l vs. ≥ 0·9 × 109/l), platelets (< 40 × 109/l vs. ≥ 40 × 109/l) and Hb (< 9 g/dl vs. ≥ 9 g/dl) at diagnosis, phenotypic score (≥ 4 vs. < 4 phenotypic abnormalities), growth retardation and skin hypo/hyperpigmentation (presence vs. absence), malformative score (≤ 1 vs. > 1 malformation), type of malformations (presence of upper limb and genital malformations vs. their absence as evaluated by the EBMT system) (Guardiola et al, 2000), pre-BMT therapy (yes vs. no), PMNs at BMT (< 1 × 109/l vs. ≥ 1 × 109/l), donor age (< 15 years vs. ≥ 15 years), donor–recipient ABO incompatibility (ABO-matched vs. ABO non-matched), number of pretransplant platelets (< 2 vs. ≥ 2) and packed red cell (< 3 vs. ≥ 3) transfusions, type of preparative regimen (HDCy-containing regimens vs. LDCy + radiation-containing regimens), and number of infused cells (< 4·2 × 108/l vs. ≥ 4·2 × 108/l nucleated cells).

Table II.  Outcome of 27 patients who underwent SCT from an HLA-matched related donor.
 Median (range) % (number)
  1. MOF, multiple organ failure; ARDS, acute respiratory distress syndrome.

Follow-up (months)36 (1·9–196)
Alive81·5% (22/27)
 Hb g/dl13·8 (10·3–16·6)
 PMNs ( × 109/l)3·1 (2·1–8)
 Platelets ( × 109/l)225 (145–441)
 Karnofsky100% (80–100%)
Acute GVHD
 ≥ grade II36% (9/25)
 grade II28% (7/25)
 grade III8% (2/25)
Chronic GVHD
 total12·5% (3/24)
 limited4% (1/24)
 extensive8·5% (2/24)
Acute toxicity > grade II18·5%(5/27)
Graft failure8% (2/25)
Deaths18·5% (5/27)
Causes of death
 GVHD1/5
 MOF3/5
 ARDS1/5

Analysis of grade II-IV AcGVHD frequency was only conducted for 25 evaluable patients (see above) to explore the association with the following variables (median value cut-off for continuous variables): age (< 15 years vs. ≥ 15 years) and sex of the donor, type of prophylaxis (CSA vs. CSA + MTX), phenotypic score (< 4 vs. ≥ 4 phenotypic abnormalities), growth retardation and skin abnormalities (presence vs. absence), malformative score (≤ 1 vs. > 1 malformation), type of malformation (presence of upper limb, genital malformations vs. their absence as evaluated by the EBMT system) (Guardiola et al, 2000), and type of conditioning regimen (HDCy-containing vs. LDCy + radiation-containing regimen).

Results

  1. Top of page
  2. Abstract
  3. PATIENTS and METHODS
  4. Results
  5. Discussion
  6. Acknowledgments
  7. Appendix
  8. References

Table II shows the data of the outcome of SCT.

Engraftment

Two out of 27 patients died before d +21 and were not evaluable for engraftment. Twenty-three out of 25 evaluable patients (92%) reached a sustained PMN engraftment at a median of 12 d (range 8–23 d) after transplantation. The two patients who did not achieve a sustained PMN engraftment had secondary graft failure that occurred on d +26 and d +50 respectively. Platelet engraftments were reached at a median of 21 d (range 15–43 d) after transplant. Chimaerism studies revealed that haemopoiesis was entirely that of the recipient in all 25 studied patients except the two who had secondary graft failure, in whom chimaerism was partial in the patient who had graft failure on d +26 and autologous in the other patient.

Acute GVHD

Nine out of 25 evaluable patients (36%) developed grade II (seven patients) or grade III (two patients) AcGVHD. No patients had grade IV AcGVHD (Table II).

Overall grade II–IV acute GVHD frequency at 36 months as estimated by the Kaplan–Meier method (Kaplan & Meier, 1958) was 40% (SE 9·8%).

Table III shows that the only variables significantly associated with grade II–IV acute GVHD were the type of conditioning and the presence of genital malformations. Patients who received regimens including Cy at dose ≥ 100 mg/kg had a 100% rate of acute GVHD II–IV compared with an incidence of 25% in those who were conditioned with regimens containing Cy < 100 mg/kg + TBI/TAI (P = 0·0001) (Fig 1). Patients who had genital malformations had a significantly greater occurrence of grade II–IV acute GVHD (83·3%) than those who had no genital malformations (26·3%) (P = 0·016) (Fig 2). It should be noted that the number of patients with genital malformations was the same when either the EBMT or the phenotypic system was adopted.

Table III.  Impact of clinical parameters on grade II–IV acute GVHD frequency.
 CasesEventsFrequency of acute GVHD II–IV (%)SEP
  1. HDCy, high-dose cyclophosphamide (median 120 mg/kg, range 100–200 mg/kg); LDCy, low-dose cyclophosphamide (median 20 mg/kg, range 20–80 mg/kg); TAI/TBI, thoraco-abdominal irradiation/total body irradiation; CSA, cyclosporin A; MTX, methotrexate.

Genital malformations
 Presence 65 83·315·20·016
 Absence195 26·310·1 
Growth retardation
 Presence179 52·912·1NS
 Absence 81 12·511·7 
Skin hypo/hyperpigmentation
 Presence157 46·712·9NS
 Absence103 3014·5 
Upper limb malformations
 Presence 72 28·617·1NS
 Absence188 44·411·7 
Phenotypic score
 < 4123 2512·5NS
 ≥ 4137 53·813·8 
Malformative score
 ≤ 1145 35·712·8NS
 > 1115 45·415·0 
Donor age
 < 15 years154 28·612·1NS
 ≥ 15 years106 6015·5 
Donor gender
 Male168 5012·5NS
 Female 92 22·213·9 
Conditioning regimen containing
 HDCy 55100 00·0001
 LDCy + TAI/TBI205 25 9·7 
Prophylaxis
 CSA187 5013·4NS
 CSA + MTX 71 14·313·2 
image

Figure 1. Frequency of grade II–IV acute GVHD [95% Confidence interval (CI)] according to conditioning regimen. LDCY Cy, < 100 mg/kg (median 20 mg/kg, range 20–80 mg/kg). TBI/TAI, total body/thoraco-abdominal irradiation. HDCY CY, (100 mg/kg, median 120 mg/kg, range 100–200 mg/kg).

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image

Figure 2. Frequency of grade II–IV acute GVHD (95% CI) by presence of genital malformations.

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Chronic GVHD

Chronic GVHD developed in 3 out of 24 evaluable patients (12·5%). One of them (4%) had extensive disease, while two of them (8·5%) had limited disease.

Conditioning-related toxicity

Sixteen out of 27 (59%) patients had one or more toxic complications that were of grade > II in five cases (18·5%) (Table II). Mucositis recurred in 11 (41%) patients; in four cases it was grade I, in six patients it was grade II and in one case it was grade III. Grade III liver and renal toxicity occurred in four (14·8%) and three patients (11·1%), respectively, and grade II haemorrhagic cystitis occurred in two patients (7·4%). Overall conditioning-related toxicity was lethal in three patients who died of multiple organ failure (MOF).

Among the five patients who were conditioned with HDCy, four (80%) had one or more toxic complications, which were grade I mucositis in three cases, grade II haemorrhagic cystitis in two cases and grade III liver toxicity in one case. Toxicity recurred in 11 out of 22 (50%) individuals who received LDCy + TAI/TBI. Mucositis recurred in eight patients (36%) and was grade I in two patients, grade II in five cases and grade III in one subject. Grade III renal and liver toxicity were each present in three patients (13·6%).

Infections

One or more post-SCT infectious episodes occurred in 9 out of 27 patients (33%). They consisted of bacterial sepsis in seven cases (26%), CMV infections in four patients (15%), pneumonia in three cases (11%) and herpes simplex virus (HSV) infection in one patient (4%) respectively. All infections were non-lethal.

Transplant-related mortality

Overall, 5 out of 27 subjects (18·5%) died from MOF (three patients), acute respiratory distress syndrome (ARDS; one patient) and chronic GVHD (one patient) (Table III). TRM at d +100 as estimated by the Kaplan–Meier method (Kaplan & Meier, 1958) was 11·1% (SE 6%), whereas at 12 months it was 19·2% (SE 7·7%). All the deaths were attributable to TRM.

Survival

Twenty-two out of 27 patients (81·5%) survive with a median Hb of 13·8 g/dl (range 10·3–16·6), PMN level of 3·1 × 109/l (range 2·1–8 × 109/l), platelet level of 225 × 109/l (range 145–441 × 109/l) and a Karnofsky score of 100% (range 80–100%), after a median follow-up of 36 months (range 1·9–196) (Table III).

Overall survival at 36 months, as estimated by the Kaplan–Meier method (Kaplan & Meier, 1958), was 80·8% (SE 7·7%).

None of the studied variables was found to be significantly associated with survival, including non-haematological phenotype of the patients as assessed by both our phenotypic system (which included the number and type of all abnormalities) and the EBMT score (which considered only the number and the type of the malformations) (Guardiola et al, 2000). The comparison between subjects with extensive malformative syndrome (score ≥ 3) and patients with limited malformative syndrome (score < 3) in terms of survival was not practicable because of the small sample of patients scoring ≥ 3.

Late tumours

No late tumours occurred after a mean follow-up of the survivors of 5 years (2 months-12·1 years).

Discussion

  1. Top of page
  2. Abstract
  3. PATIENTS and METHODS
  4. Results
  5. Discussion
  6. Acknowledgments
  7. Appendix
  8. References

This retrospective multicentric review evaluated the outcome of SCT from family HLA-matched donors in a relatively large group of patients with FA all sharing the same ethnic origin. We aimed to identify factors associated with the outcome and compared the data obtained in our patients with those from other studies.

None of the studied variables, including different conditioning regimens, acute GVHD and non-haematological phenotype, significantly affected survival. The latter finding is in contrast to the EBMT study (Guardiola et al, 2000), which showed that patients transplanted from HLA-matched unrelated donors who have extensive malformations had a significantly worse 3-year overall survival than those with limited malformations (14% vs. 44%, P 0·001). The two different BMT settings (HLA-identical unrelated donor vs. HLA-identical sibling donor) may in part explain this difference. Another possible explanation is that our patients were uniformly less extensively malformed than those of the EBMT study, as shown by the much lower occurrence of extensive malformations (14%) in our group when compared with the EBMT patients (34%) (Guardiola et al, 2000).

Whether the different and milder phenotype of the Italian patients was the result of a different and possibly less severe genetic background has not been proved, as only two subjects of our group underwent either complementation or mutation analysis. The absence of suitable material precludes a genetic analysis of our patients. However, given that virtually all of the tested Italian FA individuals, including two subjects of our group, have been shown to be group A (FANCA) (Savoia et al, 1996; Savino et al, 1997), it is probable that the vast majority of our patients are also of group A. Nonetheless, in the absence of genotypic studies of the Italian transplanted FA patients, the hypothesis that group A subjects have a favourable BMT outcome, while interesting, still remains speculative.

The engraftment rate was high (92%). It is known that transfusions increase the risk of rejection (Champlin et al, 1989), possibly by sensitizing the recipient to donor minor histocompatibility antigens. The low number of transfusions received by our patients as a group may have contributed to the low rejection rate.

Acute GVHD rate in our group was lower than that reported in other studies (Socièet al, 1998). Factors that statistically influenced the occurrence of acute GVHD were the conditioning regimen and the presence of genital malformations. Patients who received Cy at dose ≥ 100 mg/kg but not irradiation had a significantly higher incidence of grade II–IV acute GVHD (100%) than those who were conditioned with regimens containing Cy < 100 mg/kg and irradiation (25%). This finding might be explained by the stronger immunosuppression caused in the recipient by HDCy, which could have made donor lymphocytes more aggressive towards the host tissues. As for genital abnormalities, their influence on acute GVHD has already been described by others (Guardiola et al, 2000), who showed that the presence of urogenital tract and/or kidney malformations were associated with a significantly higher incidence of grade III–IV acute GVHD. These authors hypothesized that some impairment in maintaining adequate blood levels of CSA might have been involved. As in our series 50% of genital abnormalities were represented by cryptorchidism, it seems improbable that some mechanism of excretion of the drugs used in GVHD prophylaxis is involved. Therefore, the reason for this association in our patients remains unclear and the fact that it could have occurred by chance cannot be excluded.

In our patients, chronic GVHD was remarkably decreased compared with previous studies (Gluckmann et al, 1995; Zanis-Neto et al, 1995; Socièet al, 1998) and was in keeping with that recently reported by other groups (Medeiros et al, 1999). GVHD has been shown to be one of the significant risk factors associated with development of malignancies (Deeg et al, 1996; Socièet al, 1998). It is possible that the very low chronic GVHD rate has contributed to the lack of late tumours to date.

With regard to late tumours, it should be noted that the mean follow-up of our survivors is shorter than that of a French study (Socièet al, 1998) and, therefore, late cancers may occur in the future. Nonetheless, in the above study late tumours started to appear 5 years after the transplant, therefore we might have already seen such a complication in the 10 Italian patients whose follow-up is longer than 5 years. Interestingly, all French patients and over 80% of ours received a radiation-containing conditioning regimen. These findings and the occurrence of late tumours in non-irradiated Seattle and Curitiba patients (Flowers et al, 1996), confirms the fact that factors other than irradiation, such as chronic GVHD and disease-related genetic variables may affect the origin of malignancies.

Overall conditioning-related toxicity was relatively low. This also applied to those patients who were conditioned with HDCy and who had much less toxicity than that reported in other patients (Zanis-Neto et al, 1995, Flowers et al, 1996) who were conditioned in a similar way. This indicates that the conditioning regimen may not be the only factor affecting conditioning-related toxicity. Other variables, possibly disease-related, may have influenced the low incidence of toxic complications.

In our patients, who were mostly conditioned with LDCy and irradiation, we achieved very high survival, low toxicity, relatively mild acute GVHD, very low chronic GVHD rate and no secondary tumours to date. Moreover, preparative regimens with Cy ≥ 100 mg/kg turned out to be inferior to LDCy plus irradiation as, while not affecting the survival, this regimen significantly worsened acute GVHD. Therefore, it seems that in our group of patients, preparative regimens with LDCy plus radiation were effective and safe. Nonetheless, an optimal conditioning regimen for FA, enabling durable engraftment, low GVHD and toxicity should also aim to avoid cancer risk factors such as irradiation. Conditioning regimens including Cy 20 mg/kg alone (Dokal & Roberts, 1996) have already proved successful. Recent patients transplanted with preparative regimens including fludarabine, Cy 20 mg/kg and ATG showed sustained engraftment and very mild GVHD and toxicity (Aker et al, 1999). These ‘no-irradiation’ strategies look promising and hopefully will be validated in the future on larger numbers of patients.

In conclusion, this study demonstrates that the Italian FA patients undergoing SCT from an HLA-matched related donor have a very good outcome. These patients, when compared with others who underwent allo-BMT show different, less severe, phenotypic characteristics. This milder phenotype may have, at least in part, contributed to this very good outcome. In this respect, our data provide a useful tool for further studies aiming to correlate genotype with phenotype.

Acknowledgments

  1. Top of page
  2. Abstract
  3. PATIENTS and METHODS
  4. Results
  5. Discussion
  6. Acknowledgments
  7. Appendix
  8. References

The authors wish to thank Dr Anna Savoia for her help in providing data of genotyping of FA patients. Dr David Baker is warmly acknowledged for his constructive and helpful support in the review of the manuscript. Dr Adriana Zatterale of the RIAF (Registro Italiano Anemia di Fanconi) is also acknowledged for kindly and rapidly providing data of the patients diagnosed over the period of the study. Ms Brunella Sciaccaluga, Mrs Roberta Cancedda, Ms Francesca Losito and Ms Barbara Negroni are acknowledged for their secretarial assistance.

Appendix

  1. Top of page
  2. Abstract
  3. PATIENTS and METHODS
  4. Results
  5. Discussion
  6. Acknowledgments
  7. Appendix
  8. References

Institutions, main investigators and cases reported (EBMT code, Institution, investigators and number of grafted patients) were as follows. 274: Department of Genova, Edoardo Lanino, Sandro Dallorso, five patients; 248: Pescara, Paolo Di Bartolomeo, seven patients; 557: Pavia, Franco Locatelli, Marco Zecca, five patients; 285: Padova, Chiara Messina, three patients; 217: Genova, Andrea Bacigalupo, Maria Teresa Van Lint, two patients; 741: Brescia, Fulvio Porta, Evelina Mazzolari, one patient; 305: Torino, Enrico Madon, one patient; 529: Pesaro, Guido Lucarelli, one patient; 232: Roma, William Arcese, one patient; 279: Monza, Cornelio Uderzo, one patient.

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  5. Discussion
  6. Acknowledgments
  7. Appendix
  8. References
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