Original Article
Infusions of Donor Leukocytes to Treat Epstein-Barr Virus-Associated Lymphoproliferative Disorders after Allogeneic Bone Marrow Transplantation
N Engl J Med 1994; 330:1185-1191April 28, 1994
- Abstract
Background
Lymphoma associated with Epstein-Barr virus (EBV) is a complication of bone marrow transplantation that responds poorly to standard forms of therapy. The lymphoma is usually of donor origin. We hypothesized that treatment with infusions of donor leukocytes, which contain cytotoxic T cells presensitized to EBV, might be an effective treatment.
Methods
We studied five patients in whom EBV-associated lymphoproliferative disorders developed after they received a T-cell-depleted allogeneic bone marrow transplant. Biopsy specimens were immunophenotyped, subjected to the polymerase chain reaction to determine the origin of the lymphoma (donor or host) and to detect the presence of EBV, and analyzed by Southern blotting for the presence of the clonal EBV genome and immunoglobulin-gene rearrangement. Patients were treated with infusions of unirradiated donor leukocytes at doses calculated to provide approximately 1.0 × 106 CD3+ T cells per kilogram of body weight.
Results
Histopathological examination of biopsy specimens from all five patients demonstrated monomorphic, malignant lymphomas of B-cell origin. Each of the four specimens that could be evaluated was of donor-cell origin. Evidence of clonality was found in two of the three samples adequate for study. EBV DNA was detected by the polymerase chain reaction in all five samples. In all five patients there were complete pathological or clinical responses. The responses were first documented histologically within 8 to 21 days after infusion. Clinical remissions were achieved within 14 to 30 days after the infusions and were sustained without further therapy in the three surviving patients for 10, 16, and 16 months.
Conclusions
In a small number of patients, infusions of unirradiated donor leukocytes were an effective treatment for EBV-associated lymphoproliferative disease that arose after allogeneic bone marrow transplantation.
Media in This Article
Figure 1
Photomicrographs of a Section of Cervical Lymph Node Obtained from Patient 2 before Treatment, Showing Diffuse Large-Cell Lymphoma (Panel A), and a Section of Mediastinal Lymph Node Obtained after Treatment, Showing No Residual Lymphoma (Panel B) (Hematoxylin and Eosin, x180).Figure 2
Endoscopic Photographs of the Body of the Stomach of Patient 4, Showing Multiple Large Ulcerated Tumor Masses before Treatment (Panel A) and Almost Complete Disappearance of the Masses and Substantial Healing of the Ulcers after Treatment (Panel B).Article Activity
- Article
In marrow-transplant recipients, lymphoproliferative disorders associated with Epstein-Barr virus (EBV) usually present as malignant B-cell lymphomas of donor origin, which may be either polyclonal or monoclonal1-4. The latter have a rapidly progressive, fulminant, and uniformly fatal course1,3,5. Chemotherapy and radiation therapy have been ineffective. Although there are reports of successful treatment of polyclonal or oligoclonal proliferations with agents such as interferon alfa and intravenous gamma globulin, high-dose acyclovir, and anti-B-cell monoclonal antibodies, monoclonal disease has been refractory to treatment in marrow-transplant recipients6-8.
We describe the successful eradication of EBV-associated lymphoproliferative disorders in five recipients of T-cell-depleted allogeneic grafts, including two with monoclonal proliferations, after infusions of unirradiated leukocytes from the marrow donor.
Methods
Characteristics of the Patients
The five patients (Table 1Table 1
Characteristics of the Patients and Outcome of Treatment.) received an HLA-identical bone marrow graft from a relative (n = 4) or an unrelated donor (n = 1). All transplants had been depleted of T lymphocytes by agglutination with soybean lectin and rosetting with sheep erythrocytes (SBA-E-)9. No prophylaxis against graft-versus-host disease (GVHD) was used other than T-cell depletion. The patients and their preparatory regimens are described in Table 1. Antithymocyte globulin (Atgam, Upjohn, Kalamazoo, Mich.) and methylprednisolone were administered as prophylaxis against graft rejection. Exposure of the donors and recipients to EBV was documented by the detection of IgG antibody titers to viral capsid antigen of 1:10 or greater. The protocols were approved by the Memorial Hospital Institutional Review Board, and the patients gave written informed consent.Pathological and Molecular Studies
All biopsy specimens were reviewed, and the diagnosis of a lymphoproliferative disorder was based on the International Working Formulation for lymphoma classification10. Immunoperoxidase staining was performed on fixed tissues with the L26 (CD20) and UCHL-1 (CD45RO) monoclonal antibodies, which are specific for B cells and T cells, respectively (Dakopatts, Santa Barbara, Calif.).
Southern blotting of genomic DNA extracted from snap-frozen tissues and digested with EcoRI, HindIII, or BamHI was performed with a semiautomated blotting system (Probe Tech II, Oncor, Gaithersburg, Md.). Placental DNA was used as a normal control for germ-line DNA. The probes used included a 5.6-kb HindIII-BamHI fragment spanning the entire J region of the immunoglobulin heavy-chain gene; a 2.5-kb EcoRI fragment containing the constant region (C-kappa) or a 1.8-kb fragment containing the J region (J-kappa) of the immunoglobulin kappa light-chain gene; a 0.6-kb EcoRI fragment of the constant region or a combination of JβI and JβII (Oncor) of the T-cell receptor β gene; and a 1.9-kb XhoI fragment containing the fused termini of EBV for the detection of EBV DNA clonality11. Rearrangements were studied in DNA digested with EcoRI and HindIII, except C-kappa and EBV, which were studied in DNA digested with BamHI.
EBV DNA was detected by the polymerase chain reaction (PCR) with techniques previously described for the amplification of cytomegalovirus DNA from clinical specimens12. The primers used amplify a segment of the internal repeat 1 sequence of EBV consisting of 128 base pairs13,14. The genetic origin of the lymphoproliferations was identified by analysis of allelic polymorphisms of minisatellites unique to the donor or host, as described by Mackinnon et al.15.
Procurement and Phenotyping of Donor Leukocytes
Peripheral-blood mononuclear cells (PBMC) from the donors were separated from heparin-treated blood on Ficoll-Hypaque density gradients (Lymphoprep, Nyegaard, Oslo, Norway). The doses of T lymphocytes were calculated on the basis of the fraction of lymphocytes binding a fluorescein-conjugated CD3-specific monoclonal antibody (Leu 4, Becton Dickinson, Mountain View, Calif.) with a FACScan cell sorter (Becton Dickinson). The cell doses and dates of administration after transplantation are shown in Table 1.
Case Reports
Patient 1
Patient 1 received an HLA-matched, SBA-E- marrow transplant from an unrelated donor for Philadelphia chromosome-positive acute lymphoblastic leukemia in third remission. Engraftment and hematopoietic reconstitution occurred uneventfully. On day 90 after transplantation, fever (temperature to 40 °C) developed. The physical examination was unremarkable. Computed tomographic (CT) scans revealed a right axillary lymph node measuring 1.5 cm, a pleural-based nodule in the left upper lobe, several small parenchymal nodules scattered in the lungs, and multiple nodules measuring up to 6 mm in liver and spleen. At exploratory laparotomy on day 99, biopsies of liver and peripancreatic lymph nodes revealed a diffuse large-cell lymphoma, positive for EBV by PCR. High-dose intravenous acyclovir (500 mg per square meter of body-surface area every eight hours) was started. On day 105, endoscopy of the upper gastrointestinal tract revealed a normal-appearing gastric mucosa, but biopsies of randomly obtained gastric tissue again revealed diffuse large-cell lymphoma.
On day 105, the patient received unirradiated donor PBMC. Twelve days later, she remained febrile, with intermittent hematemesis, progressive bilateral enlargement of axillary lymph nodes, left-sided pleural effusion, bilateral nodular infiltrates in the lung, persistent hepatic nodules, further growth of splenic nodules, ascites, and new retrocaval nodes measuring up to 2 cm in diameter. Thickening of the gastric wall was also documented. A CT scan of the neck revealed widespread bilateral adenopathy. Magnetic resonance imaging of the head and sinuses revealed a nasopharyngeal mass.
On days 118 and 121, the patient received additional doses of PBMC. The patient's fever disappeared 14 days after the initial infusion (day 119). Subsequent CT scans (days 124, 127, and 134) revealed progressive reductions in the size of the pulmonary nodules and the left-sided pleural effusion, decreased gastric-wall thickening, and measurable reductions in the size of the axillary nodes, cervical nodes, and nasopharyngeal mass. The patient remained afebrile despite the discontinuation of antibiotics. Gastric bleeding ceased. On day 138, biopsy-proved grade II acute GVHD of the skin developed, which resolved with topical steroids16. No hepatic or intestinal evidence of GVHD was observed. A biopsy of a cervical lymph node on day 139, 34 days after the first infusion of donor cells, revealed necrosis without evidence of lymphoma. Gastric-biopsy specimens were also negative for lymphoma. By day 165, CT scans demonstrated resolution of the pulmonary nodules and pleural effusion, continued reductions in the size and number of splenic lesions, further resolution of abdominal adenopathy, and complete resolution of the hepatic lesions. The patient was well without evidence of lymphoma 300 days after transplantation. Limited chronic GVHD of the skin and oral mucosa subsequently developed, which resolved with topical immunosuppressive therapy.
Patient 2
Patient 2 received an HLA-matched bone marrow transplant from a related donor. Engraftment occurred, and the patient did well until day 74 after transplantation, when fever, exudative pharyngitis, and bilateral cervical adenopathy developed. Cultures were negative for pathogens. The adenopathy progressed despite treatment with antibiotics. Biopsy of a cervical lymph node on day 81 revealed a diffuse large-cell lymphoma (Figure 1AFigure 1
Photomicrographs of a Section of Cervical Lymph Node Obtained from Patient 2 before Treatment, Showing Diffuse Large-Cell Lymphoma (Panel A), and a Section of Mediastinal Lymph Node Obtained after Treatment, Showing No Residual Lymphoma (Panel B) (Hematoxylin and Eosin, x180).), which was found to be monoclonal (see the Results section). CT scans obtained on day 80 also demonstrated bilateral basilar pulmonary nodules and diffuse abdominal and retroperitoneal adenopathy. High-dose intravenous acyclovir was initiated. On day 85, dyspnea and tachypnea developed, and progressive bilateral pulmonary infiltrates were apparent on a chest film. On day 87, the patient received a dose of donor leukocytes without incident.Over the next three days, pulmonary disease progressed. An examination of bronchoalveolar-lavage fluid obtained on day 89 failed to demonstrate an infectious cause or lymphoma. On day 90, shock and further respiratory decompensation requiring ventilatory support developed. On day 93, the patient received a second infusion of donor leukocytes. The infusion was well tolerated without additional respiratory or hemodynamic compromise. However, the patient died of respiratory failure and hypotension on day 94. At autopsy, eight days after the initial leukocyte infusion, extensive lymphadenopathy was still present, but a pathological analysis revealed no residual lymphoma (Figure 1B). The lungs had diffuse alveolar damage without lymphoma or inflammatory infiltrates. The cause of the pulmonary deterioration was uncertain. Immunoperoxidase staining of lung tissue for viruses (cytomegalovirus, herpes, varicella-zoster, and adenovirus) was negative.
Patient 3
Patient 3 received an HLA-matched bone marrow graft from a related donor. Her post-transplantation course was complicated by cytomegalovirus esophagitis and pneumonia beginning on day 31, which responded to 45 days of treatment with ganciclovir and intravenous gamma globulin. On day 107, fever, bilateral exudative tonsillitis, and cervical adenopathy developed. A CT scan of the chest showed bilateral enlargement of axillary and mediastinal nodes as well as nodular infiltrates in the right apex and right lower lobe. Viral and microbiologic cultures were negative. Treatment with antibiotics and high-dose intravenous acyclovir was begun. The tonsils were excised on day 110 and revealed diffuse large-cell lymphoma. Monoclonality could not be established by molecular techniques (see the Results section). On day 111, the patient began to have signs of respiratory insufficiency. The results of culturing and cytologic analysis of bronchoalveolar-lavage fluid were negative, but on day 112 foscarnet and intravenous gamma globulin were administered as empirical treatment for possible cytomegalovirus pneumonia. One dose of interferon alfa-2a was administered. On day 113, blood from the donor, providing 1 × 106 CD3+ cells per kilogram of body weight, was infused.
Over the next week, progressive dyspnea developed, necessitating ventilatory support on day 120. A chest film showed diffuse bilateral interstitial infiltrates. On day 125, fever abated. By this time, the lymph nodes in the neck and groin were smaller. On day 129, the patient received a second infusion of donor cells. From day 120 onward, however, pulmonary function continued to deteriorate and the patient died on day 130. At autopsy, peripheral adenopathy was absent. The lymph nodes showed no residual lymphoma. There was marked interstitial pneumonitis with diffuse alveolar damage but no evidence of lymphoma. Immunoperoxidase staining of lung tissue for viruses was negative.
Patient 4
Patient 4 received an HLA-matched bone marrow transplant from a related donor. Engraftment occurred, and the patient did well until day 107 after transplantation, when fever and midepigastric pain developed. On day 113, endoscopy demonstrated multiple large ulcerated masses with deep craters involving the fundus, body, and antrum of the stomach (Figure 2AFigure 2
Endoscopic Photographs of the Body of the Stomach of Patient 4, Showing Multiple Large Ulcerated Tumor Masses before Treatment (Panel A) and Almost Complete Disappearance of the Masses and Substantial Healing of the Ulcers after Treatment (Panel B).). A biopsy revealed a diffuse large-cell lymphoma, which was positive for EBV on PCR. An abdominal CT scan revealed a lesion in the inferior right lobe of the liver and diffuse thickening of the gastric fundus. On day 121, the patient received an infusion of donor leukocytes. He was also treated with intravenous acyclovir. On day 132, a nonpruritic maculopapular rash developed over more than 50 percent of his body. A skin biopsy on day 134 did not confirm the diagnosis of acute GVHD. The rash cleared after treatment with topical steroids. Two weeks after the leukocyte infusion, the patient's fever disappeared. A second endoscopy on day 142 showed marked improvement of the gastric mucosa, with nearly total resolution of the masses (Figure 2B). A second gastric biopsy revealed no evidence of lymphoma. A CT scan also revealed marked diminution in the size of the hepatic nodule. On day 270, oral changes consistent with chronic GVHD developed, which resolved after treatment with prednisone. Steroids were subsequently discontinued without a recurrence of the oral symptoms. The patient was well and disease-free 16 months after transplantation.Patient 5
Patient 5 received an HLA-matched bone marrow transplant from a related donor. Her post-transplantation course was initially complicated by pneumonia attributed to aspergillus and cytomegalovirus. She was successfully treated with ganciclovir, intravenous gamma globulin, and amphotericin B and discharged on day 70. On day 127, a right-sided exudative tonsillitis and cervical adenopathy developed. CT scans also revealed a mass measuring 1.5 by 1.5 cm in the right retropharyngeal space without additional adenopathy. Biopsy of a cervical lymph node on day 132 revealed diffuse large-cell lymphoma, which was monoclonal and positive for EBV according to molecular studies (see the Results section). Treatment with high-dose intravenous acyclovir was begun, and the patient received donor PBMC on day 140. The right tonsillar lesion and cervical adenopathy subsequently resolved completely. Sixteen months after transplantation, the patient remained in complete remission, but had oral mucocutaneous manifestations of chronic GVHD.
Results
The histologic and molecular characteristics of the EBV-associated lymphoproliferative disorders in the five patients are listed in Table 2Table 2
Characteristics of EBV-Associated Lymphoproliferative Disorders in the Five Patients.. In all five patients biopsies revealed morphologically malignant, monomorphic, diffuse large-cell lymphomas of B-cell origin. All four lymphomas that could be analyzed were of donor origin. Only one of three lymphomas examined had a clonal rearrangement of the immunoglobulin gene (from Patient 2) (Figure 3Figure 3
Results of Southern Blotting., lane 1). Clonality was also established in Patient 2 (Figure 3, lane 2) and Patient 5 (Figure 3, lane 4) by the detection of clonal EBV DNA in the lymphoma DNA. In all five patients, EBV was detected by PCR in all biopsy specimens with documented malignant lymphoma. In contrast, PCR analysis of lymph-node-biopsy specimens from 22 seropositive patients undergoing a workup for metastatic cancer failed to reveal EBV (data not shown).The characteristics of the donor-leukocyte infusions as well as the clinical outcomes are summarized in Table 1. These small doses of mononuclear cells (equivalent to the number of mononuclear cells provided by 50 to 150 ml of blood) were well tolerated and were not associated with alterations in vital signs or constitutional symptoms. The deaths of Patients 2 and 3 could not be directly attributed to the infusion of donor leukocytes, since in both patients, respiratory distress began before the infusion of donor cells and progressed despite treatment.
The chronology of observed responses was quite similar in each patient. Defervescence was usually the first sign of improvement, occurring 12, 14, and 16 days after the initial infusion of leukocytes in the three patients who could be evaluated. Thereafter, tonsillar or palpable cervical and axillary adenopathies resolved, usually over the subsequent 7 to 14 days. Histologic evidence of a response was documented at autopsy as early as 8 days after the infusion in Patient 2, and at biopsy or autopsy on days 17, 21, and 35 in Patients 3, 4, and 1, respectively (Table 1). This response is illustrated by the immunohistologic analysis of lymph nodes obtained from Patient 2 before and eight days after the infusion of donor leukocytes (Figure 1).
Of the three patients who survived and in whom the EBV-associated lymphoproliferative disorder resolved, two had acute GVHD of the skin (grade II). Late after resolution of the EBV-associated lymphoproliferative disorder, mild chronic GVHD of the skin or oral mucosa developed in all three patients and responded to either topical (Patients 1 and 5) or oral (Patient 4) corticosteroids.
Discussion
The EBV-associated B-cell lymphoproliferative disorders in these five patients had similar clinical and pathological features and are representative of this complication of allogeneic marrow grafting1,3. The patients presented with fever and progressive adenopathy. Biopsies revealed the histologic features of monomorphic, diffuse large-cell lymphomas of B-cell lineage and donor origin. Of the three pretreatment specimens available for analysis, one was found to be clonal on the basis of the immunoglobulin-gene rearrangement and analysis of the fused termini of the EBV genome; a second had clonality only of the EBV genome within the lymphoma. The demonstration of clonality by analysis of EBV DNA but not by a finding of an immunoglobulin-gene rearrangement in the setting of post-transplantation lymphoproliferative disorders has been described previously17,18 and may be due to the presence of multiple copies of the EBV genome in each cell, resulting in a more intense hybridization signal on Southern blotting. In one patient (Patient 3), clonality was not demonstrated by either method, although EBV DNA was detected by PCR. These results suggest either a polyclonal lymphoproliferation or inadequate sampling of the lymphoma in the material studied by Southern blot analysis.
The association between EBV and post-transplantation lymphoproliferative disorders is well known19-22. In each of the five lymphomas from these patients, EBV DNA was detected by PCR. In view of the sensitivity of the PCR, the importance of the detection of EBV by PCR in the lymph nodes and tissues of these patients is uncertain. However, PCR analysis failed to detect EBV DNA in any of 22 lymph-node specimens from EBV-seropositive patients without lymphoma.
In all five patients, EBV-associated lymphoproliferative disorders developed within five months of allogeneic bone marrow transplantation. Likewise, in other series, EBV-associated lymphoproliferative disorders of donor-cell origin have been observed only within the first six months after marrow allografting,1,3,6 a period marked by a profound deficiency of T-cell function induced by immunoablative cytoreduction, which is not reversed until functional donor T cells emerge. Although recipients of unmodified marrow grafts have had major-histocompatibility-complex-restricted cytotoxic T-cell responses to EBV within six months after transplantation,23,24 the generation of virus-specific responses may be further delayed in recipients of grafts depleted of T cells.
The depletion of T cells has been implicated as a risk factor for EBV-associated lymphoproliferative disorder in series employing certain T-cell-specific monoclonal antibodies for depletion; actuarial risks of 6 to 12 percent have been reported,3,25 but not in series in which reagents that also remove B cells from the marrow allograft were used26,27. At our institution, recipients of HLA-matched, SBA-E- marrow grafts from related donors, in the absence of post-transplantation immunosuppression, had an actuarial risk of a post-transplantation EBV-associated lymphoproliferative disorder of 1.5 percent27. When treatment with antithymocyte globulin was added in the early post-transplantation period to prevent graft rejection, however, the cause-specific probability of developing an EBV-associated lymphoproliferative disorder increased to 8 percent in recipients of either HLA-matched or HLA-mismatched grafts from related donors. For this reason, alternative approaches to ensure engraftment without increasing the risk of these disorders are currently being explored.
Our use of donor-leukocyte infusions to treat these malignant EBV-associated lymphoproliferations was based on the hypothesis that these cell populations, derived from their EBV-seropositive donors, would contain cytotoxic T-cell precursors presensitized to EBV in the donor's microenvironment, which might effectively control or eradicate EBV-transformed donor cells growing in the host. Both polyclonally activated and HLA-restricted EBV-specific cytotoxic T cells can be regularly isolated from the blood of normal EBV-seropositive blood donors28. Indeed, Bourgault et al.29 suggest that the frequencies of EBV-specific cytotoxic T-cell precursors are high, ranging from 1 in 400 to 1 in 3000 T cells.
For the treatment of our five patients, we selected a dose of donor leukocytes that we estimated to be capable of generating an immune response against EBV-transformed donor cells without inducing severe GVHD. The threshold dose of T cells administered at the time of marrow transplantation that induces GVHD in recipients of HLA-matched grafts from siblings is approximately 1 × 105 clonable T cells per kilogram30. In mice, however, a T-cell dose that is 10 to 50 times greater than that required to induce GVHD after marrow grafting can be tolerated without subsequent GVHD if it is administered three or more weeks after transplantation30-32. Accordingly, we selected a dose of 1 × 106 CD3+ cells per kilogram, an amount that is 10 times higher than that administered for an SBA-E- marrow graft, yet 10 times lower than that usually provided by an unmodified transplant. Although no drug prophylaxis against GVHD was administered, only grade II cutaneous, acute GVHD was observed. Three patients had mild chronic GVHD, limited to the skin and oral mucosa.
Two patients in this series died of a shock-like syndrome associated with progressive pulmonary failure. Both patients were suspected of having pulmonary EBV-associated lymphoproliferative disorders before their leukocyte infusions, because of the simultaneous development of progressive pulmonary disease with biopsy-proved EBV-associated lymphoproliferation at other sites. At autopsy, an infectious or malignant cause could not be demonstrated in either patient. Although we cannot rule out the possibility that leukocyte infusions contributed to their pulmonary failure and subsequent death, in both cases the patients had pulmonary deterioration before they received the infusions.
Donor leukocytes contain several other effector populations that might contribute to the eradication of EBV-transformed populations of B cells, including natural killer cells, alloreactive T cells, and activated macrophages. Since donor populations of natural killer cells recover as early as 21 days after either an SBA-E- graft or an unmodified graft33 and can then be activated with interleukin-2 to kill EBV-transformed targets,34 it seems unlikely that an infusion of a small number of such cells would, of itself, alter the growth of an EBV-associated lymphoproliferative disorder. Furthermore, although eradication of host leukemic cells induced by donor-leukocyte infusions in patients who relapse after transplantation has been ascribed to the activity of host-specific alloreactive T cells,35-37 it is difficult to implicate such cells as the effectors of the regressions observed, since the malignant B cells were of donor rather than host origin in the four patients who could be evaluated. In view of these circumstances and the known high frequency of EBV-specific cytotoxic T-lymphocyte precursors in the blood of seropositive normal donors,29 it is reasonable to suggest that donor-derived EBV-reactive T cells had a critical role in the responses observed.
In the future, techniques for the rapid expansion of donor-type EBV-specific cytotoxic T cells depleted of host-reactive allocytotoxic T cells may permit the general application of adoptive immunotherapy for the treatment or prevention of these disorders. Riddell et al.38 have already demonstrated that donor-derived cytomegalovirus-specific cytotoxic T cells, selectively increased in vitro and infused after transplantation, can provide marrow-graft recipients with detectable levels of cytomegalovirus-specific cell-mediated immunoreactivity that persists for weeks after infusion. Although the protective potential of such infusions is not yet established, our results indicate the feasibility of this approach.
Supported by a grant from the National Cancer Institute (CA23766), the Andrew Gaffney Foundation, the Lisa Bilotti Foundation, the Toys “R” Us Foundation, the Wallace Children Pavilion Fund, the Vincent Astor Chair in Clinical Research Fund, and a grant from the National Institutes of Health (U01CA58260).
We are indebted to Dr. Daniel Filippa and Dr. Philip Lieberman for their assistance in the histopathological review of the specimens, to Dr. Robert Kurtz for his technical assistance in the endoscopic evaluation of these patients, to Dr. Nancy Rosenfield for her contribution to the radiographic review and follow-up of these patients, and to the nursing staff, fellows, and house staff of Memorial Hospital for their diligent care of the patients.
Source Information
From the Bone Marrow Transplantation Service of the Departments of Medicine (E.B.P., S.M., M.H.C., H.C.-M., B.H.C., J.W.Y.) and Pediatrics (D.E., F.B., A.P.G., T.N.S., N.A.K., R.J.O.) and the Department of Pathology (M.L.), Memorial Sloan-Kettering Cancer Center, New York.
Address reprint requests to Dr. Papadopoulos at Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021.
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