Case report

A 4-year-old boy was diagnosed with stage 4 NBL (INSS: international neuroblastoma staging system) involving his right adrenal gland, multiple para-aortic lymph nodes, bone marrow and multiple bones in April 1997. Tumor markers were abnormally elevated at the diagnosis. Urinary vanillymandelic acid (VMA) and homovanillic acid (HVA) were 313.6 (upper limit 16.0) and 251.0 (upper limit 35.0) g/mg creatinine, respectively. Serum neuron-specific enolase (NSE) was beyond the range of measurement (>1000 ng/ml, upper limit 10.0). The response for induction chemotherapy (modified A1:⁴ vincristine, cyclophosphamide, pirarubicin and cisplatin, CPT-11) was partial and double megatherapy was performed (Figure 1) according to our strategy. The first megatherapy, consisting of ifosfamide (12.5 g/m²) and LPAM (210 mg/m²) followed by autologous CD34-positive BM cell rescue, was given in November 1997. CD34-positive cells were collected by the Isolex system (NEXELL, Deerfield, IL, USA) and cryopreserved during repeated first-line chemotherapy aimed at purging of tumor cells. Extirpation of the primary tumor with ipsilateral nephrectomy and biopsy of the para-aortic lymph nodes and a bone marrow were carried out after the first megatherapy in December 1997. Viable NBL cells were found histologically in the resected tumor, sampled lymph nodes and a bone specimen. Prognostic evaluations of the resected tumors were as follows. The characteristics were unfavorable histology according to Shimada's system, diploid and a single copy of N-myc. However, these evaluations were not carried out at the diagnosis, and the findings may have been be modified with chemotherapy. Urinary VMA was still elevated as 44.6 g/mg creatinine 3 weeks after the surgery, and imaging techniques revealed remaining metastatic para-aortic lymph nodes and multiple bone lesions. Owing to its mild myelosuppression and effectiveness, we administered CPT-11 postoperatively.

Figure 1.

Clinical Course of the patient. VMA=vanillymandelic acid; HVA=homovanillic acid; NSE=neuron specific enolase; ABM=autologous bone marrow; LN=lymph node.

Full figure and legend (48K)

As we could not harvest autologous hematopoietic stem cells for the second graft, we decided to perform an allogeneic HSCT. An HLA-matched donor was not available, so his HLA haplo-identical father was chosen as the donor. The conditioning regimen consisted of TBI (12 Gy), thioTEPA (800 mg/m²) and etoposide (30 mg/kg). The transplanted bone marrow was CD34 selected and contained 6.9 10⁵ CD34-positive cells/kg and 1.34 10⁴ CD3-positive cells/kg. Tacrolimus was used for GVHD prophylaxis. Ganciclovir was administered from day -8 to day-1 because the patient was CMV-seropositive. Engraftment was prompt with neutrophils rising to 0.5 10⁹/l on day 16. Platelet count rose to 20 10⁹/l on day 47 and reticulocytes reached 1% on day 33. Complete chimerism was confirmed by HLA typing of peripheral blood on day 42. The patient developed grade I acute GVHD (skin: stage 1). Skin biopsy was performed and histological findings were compatible with GVHD. Acute GVHD was well controlled by a short course of methylprednisolone and tacrolimus was discontinued at day 140, without any recurrence of GVHD thereafter. No other complication was observed.

Following transplant the patient still had persistent disease with elevated urinary VMA (24.6 g/mg creatinine 80 days after the second transplant). The patient received additional conventional dose chemotherapy (CPT-11 and cyclophosphamide+pirarubicin) after the second transplant. However, conventional chemotherapy did not influence the urinary level of VMA, and the residual disease was still detected by imaging evaluation. Therefore, we decided to change our plan from curative therapy to supportive care to maintain quality of life (QOL). Contrary to our expectations, urinary VMA normalized and para-aortic lymph nodes were not detected by imaging techniques 18 months after the second transplant. Abnormal MIBG uptake imaging of multiple bones had disappeared at three years after allogeneic SCT (Figure 2). The patient has been well for more than 4 years after the second transplant and there has been no sign of relapse.

Figure 2.

MIBG (123 1-meta-iodobenzylguanidine) scintigram of the patient. Uptake of MIBG in multiple bones indicating bone metastases was seen on day 84. Abnormal uptake of MIBG had reduced gradually and there was no abnormal uptake of MIBG at 35 months after allogeneic BMT.

Full figure and legend (252K)

Discussion

The prognosis of advanced NBL is extremely poor. Although intensive therapy with autologous BMT has improved the outcome of advanced NBL, disease-free survival of the patients with metastatic disease remains around 50%.⁵ We have performed double megatherapy for these high-risk patients,⁶ and recently we have started allo-graft for patients for whom sufficient autologous stem cells are not available. In this case where no matched donor was available, we elected to use CD34-positive progenitor cell transplantation from an HLA haplo-identical parent. CD34-positive progenitor cell transplantations from an HLA haplo-identical parent have been performed safely and the rate of GVHD or other complications is comparable to unrelated cord blood stem cell transplantation.^7,8

In our experience, patients who had residual disease after the first autologous BMT tend to relapse after the second autograft. This case is therefore of interest as he has maintained CR up to 4 years post-transplant although he did not respond immediately after the allogeneic transplant. Allogeneic transplant as immunotherapy has received attention especially since the introduction of reduced-intensity preparative regimens and nonmyeloablative transplant in recent years. Childs et al² reported that metastatic renal cell carcinoma regressed in 10 patients out of 19 after nonmyeloablative allogeneic PBSCT. Regression of metastases was delayed, occurring at a median of 129 days after transplantation and often followed the withdrawal of immunosuppressive agent. They concluded that these results are consistent with a GVT effect. This experience is consistent with our patient's clinical course.

There have been no previous reports of a GVT response in NBL. Negrier et al⁹ reported immunotherapy using autologous LAK cells and interleukin 2 for advanced NBL without significant clinical response.⁹ Matthay et al¹⁰ reported a CCG pilot study of allogeneic vs autologous purged BMT for NBL. They found no advantage of allogeneic transplant in their report. Although a GVT effect in NBL so far has not been reported, we demonstrate here the interesting clinical course of a patient who shows a strong possibility of a graft-versus-NBL effect. We therefore propose that allogeneic transplant for advanced NBL should be considered in the setting of a well-designed clinical study to clarify the immunological effect on NBL.

References

1. Drobyski W, Keever C, Roth M et al. Salvage immunotherapy using donor leukocyte infusions as treatment for relapsed chronic myelogenous leukemia after allogeneic bone marrow transplantation: efficacy and toxicity of a defined T-cell dose. Blood 1993; 82: 2310–2318.  | PubMed | ISI | ChemPort |
2. Childs R, Chernoff A, Contentin N et al. Regression of metastatic renal-cell carcinoma after nonmyeloablative allogeneic peripheral-blood stem-cell transplantation. N Engl J Med 2000; 343: 750–758.  | Article | PubMed | ISI | ChemPort |
3. Pedrazzoli P, Da Prada GA, Giorgiani G et al. Allogeneic blood stem cell transplantation after a reduced-intensity, preparative regimen: a pilot study in patients with refractory malignancies. Cancer 2002; 94: 2409–2415. | Article | PubMed | ISI |
4. Kaneko M, Tsuchida Y, Uchino J et al. Treatment results of advanced neuroblastoma with the first Japanese study group protocol. J Pediatr Hematol Oncol 1999; 21: 190–197.  | Article | PubMed | ISI | ChemPort |
5. Matthay KK, Villablanca JG, Seeger RC et al. Treatment of high-risk neuroblastoma with intensive chemotherapy, radiotherapy, autologous bone marrow transplantation, and 13-cis-retinoic acid, Children's Cancer Group. N Engl J Med 1999; 341: 1165–1173.  | Article | PubMed | ISI | ChemPort |
6. Kawa-Ha K, Yumura-Yagi K, Inoue M et al. Results of single and double autografts for high-risk neuroblastoma patients. Bone Marrow Transplant 1996; 17: 957–962. | PubMed | ChemPort |
7. Yasui M, Park YD, Okamura T et al. CD34+ progenitor cell transplantation from two HLA-mismatched healthy fathers to two infants with severe aplastic anemia. Int J Hematol 1998; 67: 15–22.  | PubMed | ISI | ChemPort |
8. Kato S, Yabe H, Yasui M et al. Allogeneic hematopoietic transplantation of CD34+ selected cells from an HLA haplo-identical related donor. A long-term follow-up of 135 patients and a comparison of stem cell source between the bone marrow and the peripheral blood. Bone Marrow Transplant 2000; 26: 1281–1290.  | Article | PubMed | ISI | ChemPort |
9. Negrier S, Michon J, Floret D et al. Interleukin-2 and lymphokine-activated killer cells in 15 children with advanced metastatic neuroblastoma. J Clin Oncol 1991; 9: 1363–1370.  | PubMed | ISI | ChemPort |
10. Matthay KK, Seeger RC, Reynolds CP et al. Allogeneic versus autologous purged bone marrow transplantation for neuroblastoma: a report from the Children's Cancer Group. J Clin Oncol 1994; 12: 2382–2389. | PubMed | ISI | ChemPort |