Therapy with recombinant human erythropoietin in patients with myelodysplastic syndromes

We conducted a Phase I-II trial of recombinant human erythropoietin-beta (rhEPO) in patients with myelodysplastic syndrome (MDS). Patients with anemia and pathologically confirmed MDS were eligible for the study. Treatment consisted of rhEPO by subcutaneous injection thrice weekly for 6 weeks at one of three dose levels (100 U/kg (three patients), 200 U/kg (three patients) and 400 U/kg (14 patients)). Ferrous sulfate (325 mg po tid) was also administered if the transferrin saturation was below 30% (two patients). Patients were monitored with weekly CBC, white cell differential, and reticulocyte counts. Bone marrow examinations were performed at the conclusion of the treatment period and after a 2 week washout period. Patients who responded to therapy were continued on rhEPO at the same dose for 6 additional months. Response criteria included: 50% reduction in transfusion requirements compared with the 6 week pre-study period; doubling of reticulocyte count that was maintained on two determinations at least 1 week apart; or an increase in hemoglobin by at least 1.2 gm/dl without transfusions. Pre-treatment factors potentially predictive of response were analyzed by univariate analysis and in a multivariate fashion by classification and regression trees. Seven of the twenty patients sustained an untransfused rise in serum hemoglobin > or = 1.2 gm/dl. Four of the sixteen patients (including three of seven patients experiencing a rise in serum hemoglobin) who were transfusion-dependent prior to the study achieved a reduction or elimination of their transfusion requirements. Five of thirteen patients who received rhEPO during the extension phase had a continued response. A low baseline erythropoietin level (< 50 mU/ml) was the best predictor of hemoglobin response when controlling for other variables. rhEPO has a role in the treatment of certain patients with MDS, particularly in those whose endogenous serum erythropoietin levels are not markedly elevated.

The immunophenotype of acute promyelocytic leukemia (APL): an ECOG study

In 452 adult patients with de novo acute myeloid leukemia (AML), a series of 22 monoclonal antibodies was used to identify immunophenotypic characteristics of acute promyelocytic leukemia (APL) as compared to other AMLs (groups FAB M1/M2 and M4/M5). Only those patients with FAB M3 cytology were included in the analysis for which APL was confirmed by the presence of the t(15;17) cytogenetic aberration and the detection of the PML/RAR alpha gene fusion transcript by PCR amplification (35 cases). Significantly fewer APL blast cells were positive for the stem cell antigen, CD34 (p = 0.0001) as well as for HLA-DR (p < 0.0001). With respect to myeloid antigens, APLs less frequently expressed the myelomonocytic antigens, CD11b (p = 0.0001) and CD14 (p = 0.0013), whereas expression of CD33, a pan-myeloid marker, was more frequent in APL (p = 0.0001). CD15, the X-hapten carbohydrate structure (lacto-N-fucopentaose-III), typically expressed at the maturation stage of normal promyelocytes, was found to be sialylated on APL blasts as recognized by differential binding of the anti-CD15 antibodies, VIM-D5 (non-sialylated CD15) and VEP-9 (sialylated CD15). Expression of the T-cell associated CD7 antigen was rarer on APL than non-APL cells (p = 0.0001), as was that of the multidrug resistance P-glycoprotein (p = 0.0038). Marginal correlations existed between antigen profile (particularly CD2) and the type of PML/RAR alpha transcripts. In addition to its unique genotypic features, these data establish APL as a distinct immunophenotypic entity.

Significantly lower P-glycoprotein expression in acute promyelocytic leukemia than in other types of acute myeloid leukemia: immunological, molecular and functional analyses

Expression of P-glycoprotein (Pgp), the product of the multidrug resistance (MDR1) gene, detected by flow cytometric analysis of the binding of antibody 4E3.16, was found on significantly fewer leukemic cells in 35 adult patients with de novo acute promyelocytic leukemia (APL) (mean 14.8%, median 7%) than in 184 patients with non-APL acute myeloid leukemia (AML) at diagnosis (mean 28.3%, median 18%) (p = 0.0038). APL was diagnosed based on morphology, the detection of t(15;17) and of the chimeric fusion transcript PML/RAR alpha by PCR. To further substantiate low MDR1 expression in APL, we studied cells from 11 APL patients at the molecular and functional level in comparison to 48 non-APL cases. The diagnosis of APL was associated with the absence of Pgp function by the rhodamine efflux assay (p = 0.0001). Furthermore, MDR1-specific transcript levels, determined by quantitative PCR with two distinct sets of primers, were significantly lower in mononuclear cells from the APL than the other AML cases (p = 0.013). The frequency of leukemic cells positive for CD34, an antigen presumably associated with Pgp expression in AML, was significantly lower in APL than other AMLs (p = 0.0001). In contrast to non-APL leukemias, those few cases of CD34 strongly positive APL neither expressed Pgp nor contained significant MDR1 transcript levels. Low expression of Pgp by APL cells may provide the biologic basis for the high sensitivity of this leukemia subtype to chemotherapeutic agents in vivo.

Use of distal splenorenal shunt in children referred for liver transplant evaluation

Variceal bleeding remains a common cause of morbidity for children with both intrahepatic and extrahepatic portal hypertension. Occasionally, patients referred for liver transplant evaluation have significant variceal bleeding, despite adequate synthetic liver function. During a 7-year period, 322 children were referred for liver transplant evaluation. Six underwent distal splenorenal shunt surgery after evaluation. There were four boys and two girls. The average age was 11 +/- 4 years, and the average weight was 39 +/- 15 kg. The etiology of variceal bleeding was intrahepatic portal hypertension in five (1 biliary atresia, 2 chronic hepatitis, 2 congenital hepatic fibrosis) and extrahepatic portal vein thrombosis in one. Two patients had no previous attempts at sclerotherapy (one because of an abnormality in platelet function, the other because of extensive gastric varices), and four had multiple previous sclerotherapy treatments. No patient had preoperative encephalopathy. Three cases were Child's class A, and three were Child's class B. Preoperative evaluation of the portasystemic system was performed with magnetic resonance (MR) imaging or splenoportography. All patients underwent a distal splenorenal shunt procedure, four of whom also had splenopancreatic disconnection. One patient required 100 mL of blood replacement, and five required no blood. The average length of hospital stay was 9.8 +/- 2.2 days. Postoperative complications were minimal. All patients are alive, without recurrent gastrointestinal bleeding or encephalopathy, and they have patent shunts, which was confirmed by MR or Doppler ultrasound at a mean of 25 +/- 20 months after shunt surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[AIDS with apoplectic onset]

Four cases with an apoplectic debut of AIDS are reported. Two of the patients had not earlier been identified as being HIV-positive. In three patients, the underlying cause was probably cerebral toxoplasmosis. It is important to consider AIDS in the differential diagnosis of stroke, particularly in young adults.

Continuous infusion ABDIC therapy for relapsed or refractory Hodgkin's disease

BACKGROUND

Patients whose Hodgkin's disease is refractory to standard combination chemotherapy usually have a poor prognosis. These patients are generally considered for bone marrow transplantation if the disease is still sensitive to chemotherapy.

METHODS

Between May 1988 and January 1992, 19 patients with refractory or relapsed Hodgkin's disease were treated with a regimen of doxorubicin, bleomycin, dacarbazine, lomustine, and prednisone (ABDIC). The ABDIC regimen as modified for continuous infusion by Hagemeister consisted of doxorubicin 25 mg/m2 by continuous infusion daily for 2 days, dacarbazine 200 mg/m2 by continuous infusion daily for 5 days, bleomycin 5 U/m2 intravenously on days 1 and 5, CCNU 40 mg/m2 on day 1, and prednisone 40 mg/m2 daily on days 1-5. Treatment was repeated every 28 days.

RESULTS

At the time of treatment, mean age was 30.5 years (range 19-70), and time to ABDIC from initial diagnosis was 5.6 years (range 1-14). The mean number of prior chemotherapy regimens was 2.7 (range 1-5), and three of the patients had had autologous bone marrow transplantation before ABDIC: All patients had earlier received either mechlorethamine, vincristine, procarbazine, and prednisone or a regimen of doxorubicin, bleomycin, vinblastine, and dacarbazine, and 16 had received both. The mean number of ABDIC cycles was 3.9 (range 2-12). Total response rate was 63%, with 10 patients having partial response and 2 having complete response of 12 and 27 months' duration. Seven patients subsequently underwent bone marrow transplantation; two of these are free of disease at 35 and 41 months. The treatment was well tolerated; major toxicities were nausea and bone marrow suppression.

CONCLUSION

ABDIC is an active and well tolerated therapy in patients with relapsed or refractory Hodgkin's disease, including those previously treated with ABVD. More importantly, perhaps, ABDIC as cytoreductive therapy followed by bone marrow transplantation offers the possibility of long term disease free survival in this heavily pretreated patient population.

Characterization of natural and recombinant nuclease isoforms by electrospray mass spectrometry

Isoforms of natural and recombinant nuclease have been characterized on the basis of their M(r) as determined by electrospray m.s.. The natural nuclease was isolated and purified from Serratia marcescens B10M1 and the recombinant nuclease from Escherichia coli MT102 carrying the plasmid p403-SD2. The primary structure of each of the isoforms isolated from the nuclease preparations was established by comparing their mass with the known amino acid sequence derived from the nucleotide sequence of the nuc gene. All the preparations were found to be contaminated with the same N-terminal split variants of native nuclease, although the natural nuclease contained much larger amounts of these isoforms than did the recombinant nuclease. The structure of some of the isoforms could be verified by N-terminal sequencing, and nearly all of them by isoelectric focusing.

Expression of connexin-43 in human myometrium and leiomyoma

OBJECTIVES

The expression of connexin-43 was examined in human leiomyomas and in autologous myometrium.

STUDY DESIGN

Indirect immunofluorescence was used to detect connexin-43 gap junctions in myometrial and leiomyoma tissues and in primary cultures. Immunoblot and Northern analyses were used to examine the levels of connexin-43 protein and cx43 messenger ribonucleic acid in primary cultures.

RESULTS

Connexin-43 gap junctions were detected in leiomyoma tissue from nonpregnant premenopausal women but not in autologous myometrial tissue. Connexin-43 gap junctions form spontaneously in primary cultures of myometrium and leiomyoma in the presence of 17 beta-estradiol. Fluorescent dye injection confirmed that the gap junctions were coupled in the primary cells. Connexin-43 protein and messenger ribonucleic acid levels generally were higher in leiomyoma cells compared with those of autologous myometrial cells. Steady-state levels of cx43 messenger ribonucleic acid decreased with addition of medroxyprogesterone acetate to the cultures.

CONCLUSIONS

Differences in the levels of cx43 expression in leiomyoma and myometrial cells may reflect differences in responses to steroid hormones.

Monoclonal antibody-purged bone marrow transplantation therapy for multiple myeloma

Forty patients with plasma cell dyscrasias underwent high-dose chemoradiotherapy and either anti-B-cell monoclonal antibody (MoAb)-treated autologous, anti-T-cell MoAb-treated HLA-matched sibling allogeneic or syngeneic bone marrow transplantation (BMT). The majority of patients had advanced Durie-Salmon stage myeloma at diagnosis, all were pretreated with chemotherapy, and 17 had received prior radiotherapy. At the time of BMT, all patients demonstrated good performance status with Karnofsky score of 80% or greater and had less than 10% marrow tumor cells; 34 patients had residual monoclonal marrow plasma cells and 38 patients had paraprotein. Following high-dose chemoradiotherapy, there were 18 complete responses (CR), 18 partial responses, one non-responder, and three toxic deaths. Granulocytes greater than 500/microL and untransfused platelets greater than 20,000/microL were noted at a median of 23 (range, 12 to 46) and 25 (range, 10 to 175) days posttransplant (PT), respectively, in 24 of the 26 patients who underwent autografting. In the 14 patients who received allogeneic or syngeneic grafts, granulocytes greater than 500/microL and untransfused platelets greater than 20,000/microL were noted at a median of 19 (range, 12 to 24) and 16 (range, 5 to 32) days PT, respectively. With 24 months median follow-up for survival after autologous BMT, 16 of 26 patients are alive free from progression at 2+ to 55+ months PT; of these, 5 patients remain in CR at 6+ to 55+ months PT. With 24 months median follow-up for survival after allogeneic and syngeneic BMT, 8 of 14 patients are alive free from progression at 8+ to 34+ months PT; of these, 5 patients remain in CR at 8+ to 34+ months PT. This therapy has achieved high response rates and prolonged progression-free survival in some patients and proven to have acceptable toxicity. However, relapses post-BMT, coupled with slow engraftment post-BMT in heavily pretreated patients, suggest that such treatment strategies should be used earlier in the disease course. To define the role of BMT in the treatment of myeloma, its efficacy should be compared with that of conventional chemotherapy in a randomized trial.

Corneal topography: photokeratoscopy including the central region

The central corneal zone is depicted on keratoscope photographs using a small target aperture and a large object distance. Information on the peripheral area is included by employing a hemispherical target with a dense circular and radial pattern. On a 16 mm (R = 8 mm) reference steel sphere the diameter of the innermost reflected mire is 0.20 mm and the distance between mires 0.13 mm. The standard deviation on focusing precision, determined to 0.20 mm employing a fixed object, corresponds to an error of 0.06% in linear measurements on keratographs. The variation in object distance due to the curved image plane is at most 0.55 mm within 60 deg from the optical axis of the system for the reference sphere. Nevertheless, all reflected mires are distinctly reproduced on the keratoscope photograph. For a test object the slopes of light intensity curves on the passage between black and white areas are reduced by only 1.0% with a variation in object distance of 0.55 mm around focus.

Corneal topography: image processing and numerical analysis of keratoscopy

Keratoscope photograph negatives of one normal cornea and calibration steel spheres were digitized by a CCD video camera connected to a frame grabber. The centroid of the innermost reflected mire was determined and used for conversion of the image to polar coordinates. The distance to each reflected ring was computed. Calculations of the radius of curvature describing the reflecting surface locally were performed by an iterative procedure based on differential equations. The calculated mean radius for steel spheres in the range of 5.5 to 11 mm in diameter conformed with the known values. The average difference between observed and expected values was 0.2% and the average coefficient of variation was 0.1%. The standard deviations on observed ring means decreased inversely with ring number with an average coefficient of variation of 0.2%. Likewise, on a corneal surface SD also decreased inversely with ring number from 0.080 to 0.032 mm. In terms of refractive power this meant, that outwards from the third ring 95% of observations were within +/- 0.4 diopters from the average value.

[Measurement of the wound cavity area by means of PC based planimetry. The method and observer variations]

A method for wound area measurement is presented. A wound cavity was cut in a chine of pork. A thin PVC plastic film was applied closely to the entire wound cavity surface and a line was drawn close to the cutaneous border with a marker pen. The film was then placed on a system of coordinates and coordinates were determined and entered into a PC-programme which calculated the area. No significant intra-or inter-observer variation appeared on analyses of variance between five observers each of whom performed three consecutive measurements (p > 0.2). Thus, employment of the method for clinical purposes seems feasible.

[Sucralfate versus placebo in the treatment of abdominal wound abscesses]

Twenty-seven patients were divided at random into two groups following abscess formation and complete reopening of the abdominal wound in a prospective double blind investigation to study the effect of topical sucralfate on the wound healing rate in secondary abdominal wounds. Fifteen patients were treated with sucralfate powder and 11 patients with placebo while one patient was excluded. The two groups were comparable as regards age, sex and factors predisposing to abscess formation. In the sucralfate group the median healing rate was 2.8 cm2/24 hours as compared with 2.4 cm2/24 hours in the placebo group (p = 0.92, Mann-Whitney test). From this investigation, it is concluded that topical application of sucralfate powder does not appear to increase the rate of healing in secondary abdominal wounds after incision of a wound abscess.

Maternal administration of granulocyte colony-stimulating factor improves neonatal rat survival after a lethal group B streptococcal infection

Maternally administered recombinant human granulocyte colony-stimulating factor (rhG-CSF) has been shown to cross the placenta and induce a peripheral neutrophilia and increases in the marrow and spleen neutrophil storage pools in fetal and newborn rats. In the present study, we have used this model system to investigate the efficacy of prenatally administered rhG-CSF on neonatal defense to a lethal challenge with Group B-beta hemolytic Streptococcus (GBS). Pregnant rats were injected with rhG-CSF twice daily beginning 6 days before parturition. At birth, all pups were infected with a dose of GBS that is lethal for 90% of infected pups (LD90). Survival was monitored daily for 5 days. Survival of infected pups from saline-treated mothers beyond 60 hours after infection was 10%. No difference in survival was observed among pups from mothers treated 2 and 4 days before parturition. In contrast, we determined that survival was 82.5% among infected pups from mothers treated for 6 days before parturition with rhG-CSF. Our results demonstrate that maternal administration of rhG-CSF augments neonatal defenses against a lethal bacterial challenge.

Hepatic cytosolic oestrogen receptors in patients with liver disease

Patients with liver disease present many of the features of 'feminized' hepatic metabolism. Oestrogens exert their effects through interaction with specific cellular high-affinity receptors (ER). We measured hepatic ER in 102 needle biopsies from patients with chronic alcoholic and non-alcoholic liver disease using an enzyme immunoassay. Fifteen patients with no or minimal changes in liver histology served as controls. The hepatic ER concentrations were significantly (P = 0.05) lower in the 44 men (median 13 fmol mg-1 protein, interquartile range 7-17 fmol mg-1 protein) compared to the 58 women (median 15 fmol mg-1 protein, interquartile range 10-21 fmol mg-1 protein). Patients with alcoholic liver disease (n = 63) had significantly (P < 0.05) lower ER concentrations than controls (n = 15) (median 13 fmol mg-1 protein, interquartile range 7-17 fmol mg-1 protein vs. median 16 fmol mg-1 protein, interquartile range 10-26 fmol mg-1 protein), and compared with patients with non-alcoholic liver disease (n = 24) (P < 0.05, median 20 fmol mg-1 protein, interquartile range 11-24 fmol mg-1 protein). ER concentrations were significantly lower (P < 0.05) in patients with alcoholic liver disease and alcoholic hepatitis (n = 21) compared to those without alcoholic hepatitis (n = 42) (medians 10 vs. 14 fmol mg-1 protein, interquartile ranges 6-15 fmol mg-1 protein vs. 9-18 fmol mg-1 protein), while ER concentrations did not differ significantly (P > 0.05) between actively drinking (median 13 fmol mg-1 protein, interquartile range 7-17 fmol mg-1 protein) and abstaining alcoholic patients (median 13 fmol mg-1 protein. interquartile range 7-18 fmol mg-1 protein). In summary, the small but significant variation in hepatic ER concentrations reflects variation in liver function rather than an effect of ethanol.

Agreement in psychiatric assessment

In 103 schizophrenic patients we investigated the extent of practice needed in the use of the Brief Psychiatric Rating Scale (BPRS) to enable its reliability to be assessed. The agreement level of the 7 raters was analysed. Generally, the lowest mean agreement found was for the negative symptoms of the BPRS schizophrenia subscale. A high degree of agreement was attained both for the positive symptoms of the BPRS schizophrenia subscale and for the symptoms of the depression--and of the mania subscale. The degree of disagreement observed was due to both individual differences in assessment ability and the rating procedure. These results indicate that it is necessary to state the degree of agreement achieved in studies in which several raters are taking part.

Autologous bone marrow transplant in acute myeloid leukemia in first remission

PURPOSE

The Eastern Cooperative Oncology Group conducted a prospective study of postremission high-dose chemotherapy and autologous bone marrow transplantation (autoBMT) in a group of uniformly treated adults with de novo acute myeloid leukemia (AML) to evaluate whether intensive, myeloablative therapy in first complete remission (CR) could improve the disease-free survival.

PATIENTS AND METHODS

After initial CR was induced by the combination of daunorubicin, cytarabine, and thioguanine, patients not eligible for allogeneic bone marrow transplantation (alloBMT) were offered autoBMT. Within a median of 2 months after CR, and without intervening postremission therapy, bone marrow was obtained, purged by exposure to 4-hydroperoxycyclophosphamide (4-HC), and cryopreserved. High-dose therapy consisted of oral busulfan over 4 days (16 mg/kg total) followed by intravenous (IV) cyclophosphamide 50 mg/kg daily for 4 days. The cryopreserved marrow was then reinfused.

RESULTS

Of the 39 patients scheduled for autoBMT, four relapsed before transplantation. Two of the 35 (6%) transplant patients died of transplant-related complications, and 11 (33%) relapsed a median of 8 months after marrow reinfusion. No relapse has occurred after 24 months posttransplant. With a median follow-up of 31 months, the median disease-free survival period for all 39 patients has not been reached; however, 54% +/- 16% of patients are projected to be alive and disease-free at 3 years.

CONCLUSION

Long-term, disease-free survival after autoBMT in AML seems to be better than the outcome after conventional-dose postremission therapy and rivals the results of alloBMT.

A VM 26-based regimen for patients with previously untreated non-Hodgkin lymphoma. Prolonged disease-free survival in patients younger than 60 years of age: a phase II trial of the eastern Cooperative Oncology Group

BACKGROUND

The epidophyllotoxin VM 26 has been shown to have single-agent activity in patients with diffuse aggressive lymphoma. In an attempt to determine its activity in combination with other agents known to be effective in lymphoma, a Phase II trial of a novel chemotherapy regimen was conducted.

METHODS

Forty-two patients with Stages II, III, and IV diffuse aggressive lymphoma were treated with teniposide, doxorubicin, prednisone, cyclophosphamide, vincristine, and bleomycin (PA Ten-CPOB) as part of a Phase II trial of the Eastern Cooperative Oncology Group. Fifty-five percent of patients had Stage IV disease, 21% Stage III, and 24% Stage II.

RESULTS

The overall complete response rate was 64%. Of the 27 patients who had complete response, 19 (70% [45% of the entire group]) are still alive without disease (median follow-up, 5.7 years). No patient had a follow-up time of less than 5 years. On examination of factors that were predictive of survival and relapse, it was found that age younger than 60 years was predictive of long-term survival, as 76% of patients younger than 60 years of age were alive without disease. Forty patients were evaluable for toxicity. There were four (10%) early deaths, and six patients (15%) had Grade 4 hematologic toxicity.

CONCLUSIONS

This alternating combination chemotherapy regimen (PA Ten-CPOB) results in a complete response rate comparable to what has been reported previously in the literature, but 45% of patients in this series demonstrated long-term disease-free survival. When patients younger than 60 years of age with follow-up times of at least 5 years were considered, disease-free survival was 76%.