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. 1989 May;81(5):518–523.

Bone marrow transplantation: a review.

R E Hardy, E V Ikpeazu
PMCID: PMC2626005  PMID: 2664196

Abstract

Bone marrow transplantation represents the technical application of basic immunologic principles to the treatment of a variety of neoplastic and allied disorders that originate in the bone marrow. The results have improved during the past 15 years, being most striking for the treatment of the acute and chronic leukemias. The promise of autologous bone marrow transplantation for the treatment of leukemias and solid tumors is awaiting the perfection of techniques for the effective removal of residual neoplastic cells as well as more effective therapy. The use of this technique at its present stage of development for the treatment of benign hematologic disorders, which cause severe morbidity (ie, thalassemia or sickle cell anemia), is controversial, raises serious ethical issues, and cannot be recommended routinely at this time. Complications of bone marrow transplantation such as graft rejection, graft-versus-host disease, and opportunistic infections are discussed.

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Selected References

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  1. Appelbaum F. R., Clift R. A., Buckner C. D., Stewart P., Storb R., Sullivan K. M., Thomas E. D. Allogeneic marrow transplantation for acute nonlymphoblastic leukemia after first relapse. Blood. 1983 May;61(5):949–953. [PubMed] [Google Scholar]
  2. Appelbaum F. R., Dahlberg S., Thomas E. D., Buckner C. D., Cheever M. A., Clift R. A., Crowley J., Deeg H. J., Fefer A., Greenberg P. D. Bone marrow transplantation or chemotherapy after remission induction for adults with acute nonlymphoblastic leukemia. A prospective comparison. Ann Intern Med. 1984 Nov;101(5):581–588. doi: 10.7326/0003-4819-101-5-581. [DOI] [PubMed] [Google Scholar]
  3. Atkinson K., Storb R., Prentice R. L., Weiden P. L., Witherspoon R. P., Sullivan K., Noel D., Thomas E. D. Analysis of late infections in 89 long-term survivors of bone marrow transplantation. Blood. 1979 Apr;53(4):720–731. [PubMed] [Google Scholar]
  4. Bach F. H., Albertini R. J., Joo P., Anderson J. L., Bortin M. M. Bone-marrow transplantation in a patient with the Wiskott-Aldrich syndrome. Lancet. 1968 Dec 28;2(7583):1364–1366. doi: 10.1016/s0140-6736(68)92672-x. [DOI] [PubMed] [Google Scholar]
  5. Bach F. H., Rood J. J. The major histocompatibility complex--genetics and biology (second of three parts). N Engl J Med. 1976 Oct 14;295(16):872–878. doi: 10.1056/NEJM197610142951606. [DOI] [PubMed] [Google Scholar]
  6. Bach F. H., van Rood J. J. The major histocompatibility complex - genetics and biology (third of three parts). N Engl J Med. 1976 Oct 21;295(17):927–936. doi: 10.1056/NEJM197610212951705. [DOI] [PubMed] [Google Scholar]
  7. Bach F. H., van Rood J. J. The major histocompatibility complex--genetics and biology. (First of three parts). N Engl J Med. 1976 Oct 7;295(15):806–813. doi: 10.1056/NEJM197610072951504. [DOI] [PubMed] [Google Scholar]
  8. Baum E., Nachman J., Ramsay N., Weetman B., Neerhout R., Littman P., Griffin T., Norris D., Sather H. Prolonged second remissions in childhood acute lymphocytic leukemia: a report from the Childrens Cancer Study Group. Med Pediatr Oncol. 1983;11(1):1–7. doi: 10.1002/mpo.2950110102. [DOI] [PubMed] [Google Scholar]
  9. Blume K. G., Beutler E., Bross K. J., Chillar R. K., Ellington O. B., Fahey J. L., Farbstein M. J., Forman S. J., Schmidt G. M., Scott E. P. Bone-marrow ablation and allogeneic marrow transplantation in acute leukemia. N Engl J Med. 1980 May 8;302(19):1041–1046. doi: 10.1056/NEJM198005083021901. [DOI] [PubMed] [Google Scholar]
  10. Brandt S. J., Peters W. P., Atwater S. K., Kurtzberg J., Borowitz M. J., Jones R. B., Shpall E. J., Bast R. C., Jr, Gilbert C. J., Oette D. H. Effect of recombinant human granulocyte-macrophage colony-stimulating factor on hematopoietic reconstitution after high-dose chemotherapy and autologous bone marrow transplantation. N Engl J Med. 1988 Apr 7;318(14):869–876. doi: 10.1056/NEJM198804073181401. [DOI] [PubMed] [Google Scholar]
  11. Buckner C. D., Clift R. A., Sanders J. E., Meyers J. D., Counts G. W., Farewell V. T., Thomas E. D. Protective environment for marrow transplant recipients: a prospective study. Ann Intern Med. 1978 Dec;89(6):893–901. doi: 10.7326/0003-4819-89-6-893. [DOI] [PubMed] [Google Scholar]
  12. Camitta B. M., Quesenberry P. J., Parkman R., Boxer L. A., Stossel T. P., Cassady J. R., Rappeport J. M., Nathan D. G. Bone marrow transplantation for an infant with neutrophil dysfunction. Exp Hematol. 1977 Mar;5(2):109–116. [PubMed] [Google Scholar]
  13. Camitta B. M., Storb R., Thomas E. D. Aplastic anemia (first of two parts): pathogenesis, diagnosis, treatment, and prognosis. N Engl J Med. 1982 Mar 18;306(11):645–652. doi: 10.1056/NEJM198203183061105. [DOI] [PubMed] [Google Scholar]
  14. Camitta B. M., Storb R., Thomas E. D. Aplastic anemia (second of two parts): pathogenesis, diagnosis, treatment, and prognosis. N Engl J Med. 1982 Mar 25;306(12):712–718. doi: 10.1056/NEJM198203253061204. [DOI] [PubMed] [Google Scholar]
  15. Camitta B. M., Thomas E. D., Nathan D. G., Santos G., Gordon-Smith E. C., Gale R. P., Rappeport J. M., Storb R. Severe aplastic anemia: a prospective study of the effect of early marrow transplantation on acute mortality. Blood. 1976 Jul;48(1):63–70. [PubMed] [Google Scholar]
  16. Coccia P. F., Krivit W., Cervenka J., Clawson C., Kersey J. H., Kim T. H., Nesbit M. E., Ramsay N. K., Warkentin P. I., Teitelbaum S. L. Successful bone-marrow transplantation for infantile malignant osteopetrosis. N Engl J Med. 1980 Mar 27;302(13):701–708. doi: 10.1056/NEJM198003273021301. [DOI] [PubMed] [Google Scholar]
  17. Congdon C. C. Bone marrow transplantation. Science. 1971 Mar 19;171(3976):1116–1124. doi: 10.1126/science.171.3976.1116. [DOI] [PubMed] [Google Scholar]
  18. Deeg H. J., Storb R., Thomas E. D., Appelbaum F., Buckner C. D., Clift R. A., Doney K., Johnson L., Sanders J. E., Stewart P. Fanconi's anemia treated by allogeneic marrow transplantation. Blood. 1983 May;61(5):954–959. [PubMed] [Google Scholar]
  19. Dinsmore R., Kirkpatrick D., Flomenberg N., Gulati S., Kapoor N., Brochstein J., Shank B., Reid A., Groshen S., O'Reilly R. J. Allogeneic bone marrow transplantation for patients with acute nonlymphocytic leukemia. Blood. 1984 Mar;63(3):649–656. [PubMed] [Google Scholar]
  20. Doney K., Buckner C. D., Sale G. E., Ramberg R., Boyd C., Thomas E. D. Treatment of chronic granulocytic leukemia by chemotherapy, total body irradiation and allogeneic bone marrow transplantation. Exp Hematol. 1978 Oct;6(9):738–747. [PubMed] [Google Scholar]
  21. Epstein R. B., Storb R., Clift R. A., Thomas E. D. Autologous bone marrow grafts in dogs treated with lethal doses of cyclophosphamide. Cancer Res. 1969 May;29(5):1072–1075. [PubMed] [Google Scholar]
  22. FORD C. E., HAMERTON J. L., BARNES D. W., LOUTIT J. F. Cytological identification of radiation-chimaeras. Nature. 1956 Mar 10;177(4506):452–454. doi: 10.1038/177452a0. [DOI] [PubMed] [Google Scholar]
  23. Falk P. M., Herzog P., Lubens R., Wimmer R. S., Sparkes R., Naiman J. L., Gale R. P., Koch P., August C., Feig S. A. Bone marrow transplantation between a histocompatible parent and child for acute leukemia. Transplantation. 1978 Feb;25(2):88–90. doi: 10.1097/00007890-197802000-00011. [DOI] [PubMed] [Google Scholar]
  24. Fefer A., Cheever M. A., Thomas E. D., Appelbaum F. R., Buckner C. D., Clift R. A., Glucksberg H., Greenberg P. D., Johnson F. L., Kaplan H. G. Bone marrow transplantation for refractory acute leukemia in 34 patients with identical twins. Blood. 1981 Mar;57(3):421–430. [PubMed] [Google Scholar]
  25. Gale R. P. Immediate medical consequences of nuclear accidents. Lessons from Chernobyl. JAMA. 1987 Aug 7;258(5):625–628. [PubMed] [Google Scholar]
  26. Gale R. P., Kay H. E., Rimm A. A., Bortin M. M. Bone-marrow transplantation for acute leukaemia in first remission. Lancet. 1982 Nov 6;2(8306):1006–1009. doi: 10.1016/s0140-6736(82)90048-4. [DOI] [PubMed] [Google Scholar]
  27. Haghbin M. Chemotherapy of acute lymphoblastic leukemia in children. Am J Hematol. 1976;1(2):201–209. doi: 10.1002/ajh.2830010204. [DOI] [PubMed] [Google Scholar]
  28. Johnson F. L., Look A. T., Gockerman J., Ruggiero M. R., Dalla-Pozza L., Billings F. T., 3rd Bone-marrow transplantation in a patient with sickle-cell anemia. N Engl J Med. 1984 Sep 20;311(12):780–783. doi: 10.1056/NEJM198409203111207. [DOI] [PubMed] [Google Scholar]
  29. Johnson F. L., Thomas E. D., Clark B. S., Chard R. L., Hartmann J. R., Storb R. A comparison of marrow transplantation with chemotherapy for children with acute lymphoblastic leukemia in second or subsequent remission. N Engl J Med. 1981 Oct 8;305(15):846–851. doi: 10.1056/NEJM198110083051502. [DOI] [PubMed] [Google Scholar]
  30. Jones J. M., Wilson R., Bealmear P. M. Mortality and gross pathology of secondary disease in germfree mouse radiation chimeras. Radiat Res. 1971 Mar;45(3):577–588. [PubMed] [Google Scholar]
  31. Keng P. C., Rubin P., Constine L. S., Frantz C., Nakissa N., Gregory P. Characterization of the biophysical properties of human tumor and bone marrow cells as a preliminary step to the use of centrifugal elutriation in autologous bone marrow transplantation. Int J Radiat Oncol Biol Phys. 1984 Oct;10(10):1913–1922. doi: 10.1016/0360-3016(84)90272-4. [DOI] [PubMed] [Google Scholar]
  32. Kersey J. H., Ramsay N. K., Kim T., McGlave P., Krivit W., Levitt S., Filipovich A., Woods W., O'Leary M., Coccia P. Allogeneic bone marrow transplantation in acute nonlymphocytic leukemia: a pilot study. Blood. 1982 Aug;60(2):400–403. [PubMed] [Google Scholar]
  33. Krolick K. A., Uhr J. W., Vitetta E. S. Selective killing of leukaemia cells by antibody-toxin conjugates: implications for autologous bone marrow transplantation. Nature. 1982 Feb 18;295(5850):604–605. doi: 10.1038/295604a0. [DOI] [PubMed] [Google Scholar]
  34. Lazarus H. M., Herzig R. H., Graham-Pole J., Wolff S. N., Phillips G. L., Strandjord S., Hurd D., Forman W., Gordon E. M., Coccia P. Intensive melphalan chemotherapy and cryopreserved autologous bone marrow transplantation for the treatment of refractory cancer. J Clin Oncol. 1983 Jun;1(6):359–367. doi: 10.1200/JCO.1983.1.6.359. [DOI] [PubMed] [Google Scholar]
  35. Lazarus H. M., Herzig R. H., Wolff S. N., Phillips G. L., Spitzer T. R., Fay J. W., Herzig G. P. Treatment of metastatic malignant melanoma with intensive melphalan and autologous bone marrow transplantation. Cancer Treat Rep. 1985 May;69(5):473–477. [PubMed] [Google Scholar]
  36. Lucarelli G., Galimberti M., Polchi P., Giardini C., Politi P., Baronciani D., Angelucci E., Manenti F., Delfini C., Aureli G. Marrow transplantation in patients with advanced thalassemia. N Engl J Med. 1987 Apr 23;316(17):1050–1055. doi: 10.1056/NEJM198704233161703. [DOI] [PubMed] [Google Scholar]
  37. MATHE G., JAMMET H., PENDIC B., SCHWARZENBERG L., DUPLAN J. F., MAUPIN B., LATARJET R., LARRIEU M. J., KALIC D., DJUKIC Z. Transfusions et greffes de moelle osseuse homologue chez des humains irradiés à haute dose accidentellement. Rev Fr Etud Clin Biol. 1959 Mar;4(3):226–238. [PubMed] [Google Scholar]
  38. Meyers J. D., Flournoy N., Thomas E. D. Nonbacterial pneumonia after allogeneic marrow transplantation: a review of ten years' experience. Rev Infect Dis. 1982 Nov-Dec;4(6):1119–1132. doi: 10.1093/clinids/4.6.1119. [DOI] [PubMed] [Google Scholar]
  39. Meyers J. D., Flournoy N., Thomas E. D. Risk factors for cytomegalovirus infection after human marrow transplantation. J Infect Dis. 1986 Mar;153(3):478–488. doi: 10.1093/infdis/153.3.478. [DOI] [PubMed] [Google Scholar]
  40. Mickelson E. M., Fefer A., Storb R., Thomas E. D. Correlation of the relative response index with marrow graft rejection in patients with aplastic anemia. Transplantation. 1976 Sep;22(3):294–302. doi: 10.1097/00007890-197609000-00011. [DOI] [PubMed] [Google Scholar]
  41. Nadler L. M., Takvorian T., Botnick L., Bast R. C., Finberg R., Hellman S., Canellos G. P., Schlossman S. F. Anti-B1 monoclonal antibody and complement treatment in autologous bone-marrow transplantation for relapsed B-cell non-Hodgkin's lymphoma. Lancet. 1984 Aug 25;2(8400):427–431. doi: 10.1016/s0140-6736(84)92907-6. [DOI] [PubMed] [Google Scholar]
  42. O'Reilly R. J., Dupont B., Pahwa S., Grimes E., Smithwick E. M., Pahwa R., Schwartz S., Hansen J. A., Siegal F. P., Sorell M. Reconstitution in severe combined immunodeficiency by transplantation of marrow from an unrelated donor. N Engl J Med. 1977 Dec 15;297(24):1311–1318. doi: 10.1056/NEJM197712152972403. [DOI] [PubMed] [Google Scholar]
  43. Opelz G., Gale R. P., Feig S. A., Walker J., Terasaki P. I., Saxon A. Significance of HLA and non-HLA antigens in bone marrow transplantation. Transplant Proc. 1978 Mar;10(1):43–46. [PubMed] [Google Scholar]
  44. Parkman R., Rappeport J., Geha R., Belli J., Cassady R., Levey R., Nathan D. G., Rosen F. S. Complete correction of the Wiskott-Aldrich syndrome by allogeneic bone-marrow transplantation. N Engl J Med. 1978 Apr 27;298(17):921–927. doi: 10.1056/NEJM197804272981701. [DOI] [PubMed] [Google Scholar]
  45. Pinkerton R., Philip T., Bouffet E., Lashford L., Kemshead J. Autologous bone marrow transplantation in paediatric solid tumours. Clin Haematol. 1986 Feb;15(1):187–203. doi: 10.1016/s0308-2261(86)80011-x. [DOI] [PubMed] [Google Scholar]
  46. Powles R. L., Morgenstern G., Clink H. M., Hedley D., Bandini G., Lumley H., Watson J. G., Lawson D., Spence D., Barrett A. The place of bone-marrow transplantation in acute myelogenous leukaemia. Lancet. 1980 May 17;1(8177):1047–1050. doi: 10.1016/s0140-6736(80)91497-x. [DOI] [PubMed] [Google Scholar]
  47. Rai K. R., Holland J. F., Glidewell O. J., Weinberg V., Brunner K., Obrecht J. P., Preisler H. D., Nawabi I. W., Prager D., Carey R. W. Treatment of acute myelocytic leukemia: a study by cancer and leukemia group B. Blood. 1981 Dec;58(6):1203–1212. [PubMed] [Google Scholar]
  48. Ramsay N. K., Kersey J. H., Robison L. L., McGlave P. B., Woods W. G., Krivit W., Kim T. H., Goldman A. I., Nesbit M. E., Jr A randomized study of the prevention of acute graft-versus-host disease. N Engl J Med. 1982 Feb 18;306(7):392–397. doi: 10.1056/NEJM198202183060703. [DOI] [PubMed] [Google Scholar]
  49. Reisner Y., Kapoor N., Kirkpatrick D., Pollack M. S., Cunningham-Rundles S., Dupont B., Hodes M. Z., Good R. A., O'Reilly R. J. Transplantation for severe combined immunodeficiency with HLA-A,B,D,DR incompatible parental marrow cells fractionated by soybean agglutinin and sheep red blood cells. Blood. 1983 Feb;61(2):341–348. [PubMed] [Google Scholar]
  50. Snydman D. R., Werner B. G., Heinze-Lacey B., Berardi V. P., Tilney N. L., Kirkman R. L., Milford E. L., Cho S. I., Bush H. L., Jr, Levey A. S. Use of cytomegalovirus immune globulin to prevent cytomegalovirus disease in renal-transplant recipients. N Engl J Med. 1987 Oct 22;317(17):1049–1054. doi: 10.1056/NEJM198710223171703. [DOI] [PubMed] [Google Scholar]
  51. Storb R., Deeg H. J., Whitehead J., Farewell V., Appelbaum F. R., Beatty P., Bensinger W., Buckner C. D., Clift R. A., Doney K. Marrow transplantation for leukemia and aplastic anemia: two controlled trials of a combination of methotrexate and cyclosporine v cyclosporine alone or methotrexate alone for prophylaxis of acute graft-v-host disease. Transplant Proc. 1987 Feb;19(1 Pt 3):2608–2613. [PubMed] [Google Scholar]
  52. Storb R., Prentice R. L., Buckner C. D., Clift R. A., Appelbaum F., Deeg J., Doney K., Hansen J. A., Mason M., Sanders J. E. Graft-versus-host disease and survival in patients with aplastic anemia treated by marrow grafts from HLA-identical siblings. Beneficial effect of a protective environment. N Engl J Med. 1983 Feb 10;308(6):302–307. doi: 10.1056/NEJM198302103080602. [DOI] [PubMed] [Google Scholar]
  53. Storb R., Prentice R. L., Thomas E. D. Marrow transplantation for treatment of aplastic anemia. An analysis of factors associated with graft rejection. N Engl J Med. 1977 Jan 13;296(2):61–66. doi: 10.1056/NEJM197701132960201. [DOI] [PubMed] [Google Scholar]
  54. Storb R., Prentice R. L., Thomas E. D. Treatment of aplastic anemia by marrow transplantation from HLA identical siblings. Prognostic factors associated with graft versus host disease and survival. J Clin Invest. 1977 Apr;59(4):625–632. doi: 10.1172/JCI108680. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Storb R., Thomas E. D., Buckner C. D., Clift R. A., Deeg H. J., Fefer A., Goodell B. W., Sale G. E., Sanders J. E., Singer J. Marrow transplantation in thirty "untransfused" patients with severe aplastic anemia. Ann Intern Med. 1980 Jan;92(1):30–36. doi: 10.7326/0003-4819-92-1-30. [DOI] [PubMed] [Google Scholar]
  56. Storb R., Thomas E. D., Weiden P. L., Buckner C. D., Clift R. A., Fefer A., Goodell B. W., Johnson F. L., Neiman P. E., Sanders J. E. One-hundred-ten patients with aplastic anemia (AA) treated by marrow transplantation in Seattle. Transplant Proc. 1978 Mar;10(1):135–140. [PubMed] [Google Scholar]
  57. Sullivan K. M., Shulman H. M., Storb R., Weiden P. L., Witherspoon R. P., McDonald G. B., Schubert M. M., Atkinson K., Thomas E. D. Chronic graft-versus-host disease in 52 patients: adverse natural course and successful treatment with combination immunosuppression. Blood. 1981 Feb;57(2):267–276. [PubMed] [Google Scholar]
  58. THOMAS E. D., LOCHTE H. L., Jr, LU W. C., FERREBEE J. W. Intravenous infusion of bone marrow in patients receiving radiation and chemotherapy. N Engl J Med. 1957 Sep 12;257(11):491–496. doi: 10.1056/NEJM195709122571102. [DOI] [PubMed] [Google Scholar]
  59. Takvorian T., Parker L. M., Hochberg F. H., Canellos G. P. Autologous bone-marrow transplantation: host effects of high-dose BCNU. J Clin Oncol. 1983 Oct;1(10):610–620. doi: 10.1200/JCO.1983.1.10.610. [DOI] [PubMed] [Google Scholar]
  60. Thomas E. D., Fefer A., Buckner C. D., Storb R. Current status of bone marrow transplantation for aplastic anemia and acute leukemia. Blood. 1977 May;49(5):671–681. [PubMed] [Google Scholar]
  61. Thomas E. D. Karnofsky Memorial Lecture. Marrow transplantation for malignant diseases. J Clin Oncol. 1983 Sep;1(9):517–531. doi: 10.1200/JCO.1983.1.9.517. [DOI] [PubMed] [Google Scholar]
  62. Thomas E. D., Sanders J. E., Flournoy N., Johnson F. L., Buckner C. D., Clift R. A., Fefer A., Goodell B. W., Storb R., Weiden P. L. Marrow transplantation for patients with acute lymphoblastic leukemia in remission. Blood. 1979 Aug;54(2):468–476. [PubMed] [Google Scholar]
  63. Thomas E., Storb R., Clift R. A., Fefer A., Johnson F. L., Neiman P. E., Lerner K. G., Glucksberg H., Buckner C. D. Bone-marrow transplantation (first of two parts). N Engl J Med. 1975 Apr 17;292(16):832–843. doi: 10.1056/NEJM197504172921605. [DOI] [PubMed] [Google Scholar]
  64. Vallera D. A., Soderling C. C., Carlson G. J., Kersey J. H. Bone marrow transplantation across major histocompatibility barriers in mice. Effect of elimination of T cells from donor grafts by treatment with monoclonal Thy-1.2 plus complement or antibody alone. Transplantation. 1981 Mar;31(3):218–222. doi: 10.1097/00007890-198103000-00015. [DOI] [PubMed] [Google Scholar]
  65. Weiden P. L., Hackman R. C., Deeg H. J., Graham T. C., Thomas E. D., Storb R. Long-term survival and reversal of iron overload after marrow transplantation in dogs with congenital hemolytic anemia. Blood. 1981 Jan;57(1):66–70. [PubMed] [Google Scholar]
  66. Weiden P. L., Storb R., Graham T. C., Schroeder M. L. Severe hereditary haemolytic anaemica in dogs treated by marrow trasplantation. Br J Haematol. 1976 Jul;33(3):357–362. doi: 10.1111/j.1365-2141.1976.tb03551.x. [DOI] [PubMed] [Google Scholar]
  67. Weiden P. L., Sullivan K. M., Flournoy N., Storb R., Thomas E. D. Antileukemic effect of chronic graft-versus-host disease: contribution to improved survival after allogeneic marrow transplantation. N Engl J Med. 1981 Jun 18;304(25):1529–1533. doi: 10.1056/NEJM198106183042507. [DOI] [PubMed] [Google Scholar]
  68. el-Sadr W., Sidhu G. Persistence of trophozoites after successful treatment of Pneumocystis carinii pneumonia. Ann Intern Med. 1986 Dec;105(6):889–890. doi: 10.7326/0003-4819-105-6-889. [DOI] [PubMed] [Google Scholar]
  69. van Rood J. J., van Leeuwen A., Goulmy E., Termijtelen A., Bradley B. A., Brand A., Eernisse J. G. The importance of non-HLA systems and the feasibility of the use of unrelated donors in bone marrow transplantation. Transplant Proc. 1978 Mar;10(1):47–51. [PubMed] [Google Scholar]

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