Autologous bone marrow transplantation with monoclonal antibody purged marrow for high risk acute lymphoblastic leukemia

Fifty-four patients with acute lymphoblastic leukemia (ALL: 1 relapse, 21 high risk first complete remission (CR 1), 29 second CR (CR 2), and 3 third CR (CR 3) were treated by autologous bone marrow transplantation at three centers. Before storage, the marrows were purged ex vivo with appropriate MAbs RFAL3 (CD10), SB4 (CD19), and RFT2 (CD7), with rabbit serum as the source of complement. All patients received total body irradiation either 750 cGy (middose 15 cGy/min) as a single fraction or 6 x 200 cGy over 3 days (midline dose 16 cGy/min) with lung shielding from 1,100 cGy. The patients who received 750 cGy also received cyclophosphamide or the same drug combined with ara-C or prednisone, teniposide, vincristine, ara-C, and dauno-rubicin. Patients receiving 200 cGy x 6 also received either cyclophosphamide, melphalan, or ara-C and cyclophosphamide. Three patients died of post transplantation complications (interstitial pneumonia, hepatitis B liver necrosis, or encephalitis). This gives a procedure related mortality of 5%. Nonfatal complications were 10 cases of septicemia, 4 interstitial pneumonia, 2 interstitial nephritis, 1 veno-occlusive disease (VOD), and 1 case of hemolytic uremic syndrome. The patient autografted in relapse died of relapse within 2 months. In CR 1 6 or 21 patients have had a relapse, and the actuarial leukemia free survival from CR is 65% (median follow-up 16 months). In CR 2-3 18 of 32 patients have relapsed, and the actuarial leukemia free survival is 31% (median follow-up 18.5 months) from CR. Twelve patients have achieved an inversion, (i.e., present CR longer than previous CR), with a further seven with the potential to achieve inversion. We conclude that ABMT in high risk ALL has a low procedure related mortality (5%), and there are few other complications. The in vitro purging with MAbs had no adverse effect on bone marrow reconstitution, but this study was not designed to demonstrate its antileukemic efficacy. The actuarial leukemia free survival time in the present study for patients with high risk CR 1 and the inversions in CF 2-3 are promising and indicate a potential beneficial effect of ABMT.

Infective endocarditis as a complication of a permanent indwelling right atrial catheter in a patient with severe aplastic anaemia

Endocarditis is a recognized complication of both temporary and permanent indwelling right atrial catheters. Endocardial damage by the catheter may result in non-bacterial thrombotic endocarditis. Sterile vegetations composed of platelets and fibrin may become infected, either by direct spread of bacteria along the catheter, or following an episode of bacteraemia. Bacteria in infected vegetations may be protected from phagocytosis by a 'roof' of fibrin. Echocardiography is a valuable non-invasive method of diagnosis and may be used to monitor the resolution of vegetations and valve function. The right atrial catheter produces reflections which must be distinguished from cardiac abnormalities. We report a case of infective endocarditis in a patient with severe aplastic anaemia and a permanent indwelling right atrial catheter which was managed conservatively.

Seronegative blood products prevent primary cytomegalovirus infection after bone marrow transplantation

Seventy one patients underwent bone marrow transplantation for aplastic anaemia or haematological malignancy, 39 as allografts and 32 as autografts. All patients who were seronegative to cytomegalovirus received blood product support exclusively from seronegative community blood donors; seropositive patients received unscreened products. In no patients was there any attempt to reduce cytomegalovirus (CMV) infection by giving prophylaxis with immunoglobulin, and granulocyte transfusions were not given. The incidence of cytomegalovirus infection in the seronegative recipients (22 allograft, 15 autograft) was 0%; in the seropositive recipients 16 (63%) in allografts and 17 (18%) in autografts. These results suggest that provision of exclusively seronegative blood products is an important contribution for seronegative transplant recipients, but make little impact in autologous transplantation where the incidence of infection is low.

Differential immunosuppressive action of carbimazole and propylthiouracil

Carbimazole and Propylthiouracil (PTU) are widely used in the treatment of Graves' disease, although controversy still exists as to whether or not they have any direct effect on the immune system. While many previous studies have investigated the possible effects of one or other of these drugs on the immune system only a few have directly compared the effects of equivalent doses of each drug. This study aimed to examine the effects of both drugs, during the initial 8 weeks of treatment, on various biochemical and immunological parameters. The results obtained showed that while thyroid hormone levels fell at similar rates in both treatment groups, TRAb levels and T cell subset abnormalities returned towards normal more rapidly in patients receiving Carbimazole compared to PTU. These results indicate that the effects of Carbimazole on TRAb levels and T cell subset abnormalities are not due solely to its action in controlling the biochemical features of Graves' disease and provide indirect evidence of an action on the immune system in vivo.

Role of specific cytochrome P-450 isoenzymes in the regio-selective metabolism of 7,12-dimethylbenz[a]anthracene in microsomes from rats treated with phenobarbital or Sudan III

The rates of formation of diols of dimethylbenz[a]anthracene (DMBA-3,4-diol, DMBA-5,6-diol and DMBA-8,9-diol) have been determined in hepatic microsomes prepared from untreated rats or from animals treated with phenobarbital (PB) or Sudan III. PB treatment enhanced the formation of the proximate carcinogen, DMBA-3,4-diol, and of the 5,6-diol while treatment with Sudan III suppressed the formation of DMBA-3,4-diol but greatly increased the rates of formation of the other two diols. Metyrapone, a reagent which is specific for members of the major PB-induced cytochrome P-450 subfamily (P-450-PB3), did not alter the rate of formation of the diols other than in microsomes prepared from PB-treated animals in which formation of the 5,6-diol was inhibited. Incubation of DMBA with microsomes resulted in the formation of covalent, DMBA-microsome adducts. Treatment of the animals with PB and Sudan III increased the rate of formation of DMBA-microsome adducts to a similar extent (approximately 5-fold). The formation of adducts could be inhibited by metyrapone in microsomes from untreated and PB-treated animals but the reagent had no effect on adduct formation in microsomes from Sudan III-treated animals. These observations may indicate that adduct formation in microsomes from Sudan-treated animals involves primary epoxide metabolites while in microsomes from PB-treated animals secondary metabolites are involved and these may be formed by a P-450-PB3 isoenzyme. Specific P-450 isoenzymes involved in the regioselective formation of DMBA-diols have been identified by the use of antibodies directed against specific isoenzymes. An antibody to P-450-MC1b inhibited the formation of DMBA-5,6-diol and 8,9-diol in microsomes from Sudan III-treated animals. Western blot analysis demonstrated that P-450-MC1b was induced in microsomes of animals treated with Sudan III but was not present in the other two microsomal preparations. In accord with the observations with metyrapone, anti-P-450-PB3 inhibited formation of DMBA-5,6-diol in microsomes from PB-treated animals but was without effect on the formation of other diols. Anti-P450-PB1 inhibited the formation of DMBA-3,4-diol in microsomes from PB-treated animals. Western blot analysis of microsomes from animals treated with several xenobiotics indicated a qualitative correlation between the content of P-450-PB1 and the rate at which DMBA-3,4-diol was formed.

Absence of gradient of thyrotropin receptor antibody and T cell subset distribution between thyroid and peripheral venous blood in patients with Graves' disease prepared for surgery with carbimazole and potassium iodide

The aim of the study was to examine tri-iodothyronine, thyroxine, thyroid antibody and thyrotropin receptor antibody levels in thyroid and peripheral venous blood at the time of surgery in patients with Graves' disease. T cell subset patterns in peripheral and thyroidal venous blood were compared to the distribution of T cell subset patterns within the thyroid gland itself. The results showed that at the time of surgery there were no significant differences in any of the parameters measured between thyroidal and peripheral venous samples. T cell subset patterns within the thyroid gland were subjectively similar to those in the venous samples.

Prevention of graft-versus-host disease by ex vivo T cell depletion: reduction in graft failure with augmented total body irradiation

Graft-versus-host disease prevention was attempted in 35 consecutive patients with hematological malignancy who received bone marrow from an HLA match sibling donor who was depleted of T cells ex vivo. Five of the first 8 patients who received cyclophosphamide 60 mg/kg on 2 consecutive days followed by fractionated total body irradiation (TBI) (6 x 2 Gy) had graft failure. The subsequent 27 patients had received an extra fraction of TBI (7 x 2 Gy), and only one failed to have stable engraftment. There were no differences in nucleated cell dose, granulocyte-macrophage colony-forming units, or T cell numbers given to the two groups. Neutrophil but not platelet regeneration of those patients who successfully grafted was slower than in a group of historical controls receiving unmanipulated marrow. Significant graft-versus-host disease was prevented with no increase in relapse rate. We suggest that engraftment can be reliably achieved by augmenting the TBI conditioning in recipients of T cell-depleted matched allogeneic bone marrow.

The distribution of DMBA and its dihydrodiols in tissues of control and Sudan-III-treated Long-Evans rats after the injection (i.v.) in vivo of a leukaemogenic dose of the hydrocarbon

7,12-Dimethylbenz[a]anthracene (DMBA) is a potent leukaemogenic agent in Long-Evans rats when it is administered i.v. in vivo. The prior oral administration of Sudan III [1(p-phenylazo-phenylazo)-2-naphthol] protects animals from the leukaemogenic effects of this compound. Sudan-III-treatment resulted in an increased rate of removal of DMBA from the livers and blood of treated animals and resulted in a reduced level of accumulation of the hydrocarbon in its presumed target tissue, the bone marrow. The regio-selective hepatic metabolism of DMBA was altered in Sudan-III-treated animals, thus only trans-3,4-dihydro-3,4-dihydroxy-DMBA was recovered from the livers of control animals whereas only trans-8,9-dihydro-8,9-dihydroxy-DMBA was recovered from the livers of Sudan-III-treated animals. The distribution of DMBA dihydrodiols in the blood and in the bone marrow was found to reflect the findings in the liver. DMBA, when incubated with rat bone marrow cells in vitro, was metabolized to probable phenolic compounds but no evidence whatsoever was found for dihydrodiol formation in these cells. Taken together these results are consistent with a model in which Sudan-III-induced alterations in the regio-selective hepatic metabolism of DMBA are responsible for the protection against leukaemogenesis afforded by the administration of that compound. The probable mechanism of protection is the induction in liver of a cytochrome P450, probably P450c.

Distribution of leukemia, lymphoma, and allied disease in parts of Great Britain: analysis by administrative districts and simulations of adjacencies. Leukaemia Research Fund 1984 Data Collection Group

An analysis is presented of the distribution of cases of leukemia and allied disorders occurring in 151 administrative districts from England, Wales, and Scotland during 1984. The age-adjusted rates for certain conditions present an unusual pattern highlighting excessively high and low rates in parts of the country, some of which share contiguous boundaries. In particular, high rates for non-Hodgkin's lymphoma are found in rural Yorkshire districts, whereas leukemias and primary polycythemias are much more common in the Midland districts.

Alterations in the metabolism of 7,12-dimethylbenz[a]anthracene and various xenobiotics by rat hepatic microsomes following Sudan III treatment in vivo

Sudan III treatment of Long-Evans rats results in increased hepatic monooxygenase activity using ethoxycoumarin and aniline as substrates. Monooxygenase activity towards amino-pyrine and nitrosodimethylamine is not affected. Sudan III treatment results in increased microsomal cytochrome P448 and increased amounts of a protein band which comigrates with purified cytochrome P448 during SDS polyacrylamide gel electrophoresis. The proportions of the different dihydrodiols formed during the incubation of 7,12-dimethylbenz[a]anthracene with microsomes vary between untreated and treated animals. Thus, extracts of microsomes from untreated rats were found to contain materials with chromatographic properties identical to those of the 3,4-dihydrodiol and the 5,6-dihydrodiol when examined on two different h.p.l.c. systems. Extracts of microsomes from Sudan III treated animals were found to contain materials with chromatographic properties identical to those of the 5,6-dihydrodiol and the 8,9-dihydrodiol when similarly examined. These findings suggest that the protective effect of Sudan III against DMBA induced leukaemia is mediated by an alteration in monooxygenase activity.

Transplantation of unpurged autologous bone-marrow in acute myeloid leukaemia in first remission

Twelve consecutive patients aged 18-53 were given autologous remission bonemarrow and cyclophosphamide and total-body irradiation to maintain first remission of acute myeloid leukaemia. Follow-up lasted at least 6 months. Seven patients remain in complete unmaintained remission 26-140 weeks post-autograft with overall remissions of 42-202 weeks. The prediction of leukaemia-free survival based on these results is 58% at 3 years. The procedure was well tolerated and resulted in little morbidity and no mortality.

Haematological reconstitution following high dose and supralethal chemo-radiotherapy using stored, non-cryopreserved autologous bone marrow

Eighteen patients with small cell carcinoma of the lung received high dose cyclophosphamide (180-200 mg/kg) intensification following five pulses of 'CHOP' chemotherapy (cyclophosphamide 750 mg/m2 i.v., adriamycin 50 mg/m2 i.v., vincristine 1.4 mg/m2 i.v., prednisolone 40 mg orally for 5 d). They received infusions of autologous bone marrow which had been stored at 4 degrees C for 34 h. Pancytopenia was predictable in onset and its duration acceptable. Recovery of neutrophils to greater than 1.0 x 10(9)/l was achieved in 17.5 +/-0.9 d (mean +/- SEM) and platelets to greater than 100 x 10(9)/l in 17.5 +/- 0.8 d. Four patients with acute myeloid leukaemia in complete remission received intensification with the supralethal combination of cyclophosphamide and total body irradiation followed by infusion of autologous marrow which had been stored at 4 degrees C for 54 h. Haematological reconstitution in these patients was acceptable but slower (greater than 1.0 x 10(9)/l neutrophils between days 26 and 40; greater than 20 x 10(9)/l platelets between days 23 and 77). Except in one case, normal peripheral counts were attained in all patients. It is concluded that bone marrow stored at 4 degrees C for up to 54 h is a simple and practical source of viable stem cells which have the capacity for acceptable haematological reconstitution.

T lymphocyte reconstitution following autologous bone marrow transplantation

Peripheral blood T lymphocyte subpopulations were analysed using OKT3, OKT4 and OKT8 monoclonal antibodies in eleven patients undergoing autologous bone marrow transplantation following high dose chemotherapy +/- total body irradiation for bronchial carcinoma or as intensification therapy for acute myeloblastic leukaemia. Marked inversion of the OKT4:OKT8 ratio was noted in all patients following the procedure. This is due to both a fall in the number of OKT4 positive cells and a rise in the number of OKT8 positive cells in all but one patient. Sequential analysis of six patients shows a return to the normal ratio in two with time and a trend towards normalization in the others. We suggest that the subpopulation inversion noted following bone marrow transplantation is an effect of marrow regeneration and is not causally related to graft versus host disease.

A new approach to the classification of human leukaemias: measurement of the relative abundance of a specific RNA sequence by means of molecular hybridisation

A recombinant plasmid library representing polyadenylated RNAs in the leucocytes of a Ph1-positive chronic granulocytic leukaemia (CGL) has been constructed. One recombinant (designated pCG14) isolated from this library contains a DNA sequence complementary to a small polyadenylated RNA that is abundant in RNA from CGL leucocytes. The relative concentrations of pCG14 RNA in the RNAs from a variety of normal and leukaemic leucocytes and human haemopoietic cell lines have been measured with a molecular hybridisation assay. This has shown that pCG14 RNA is 10 to 50 times more abundant in RNA from CGL leucocytes than in the RNAs from these other cells. The data indicate that the occurrence of pCG14 RNA in high abundance is sufficiently characteristic of a CGL leucocyte population to distinguish it from other populations of leucocytes. They suggest that the measurement of the concentrations of specific RNA species in leucocyte RNA by means of molecular hybridisation with cloned complementary DNAs may provide additional markers for the objective classification of human leukaemias which could be particularly useful since the method exploits a criterion different from any currently in use.

Acute myelomonocytic leukaemia presenting as xanthomatous skin eruption

A case of acute myelomonocytic leukaemia (AMMOL) is reported in which skin infiltration with xanthomatous nodules was the presenting feature. The histological, including ultrastructural, appearances are described.