Acute lymphoblastic leukemia followed by chronic myelocytic leukemia

Second hematologic malignancies occur rarely in patients previously treated for leukemia. This report describes a patient with acute lymphoblastic leukemia who remained in complete remission for 5 yr and then developed chronic myelocytic leukemia (CML). The original lymphoblasts were associated with a partial deletion of chromosome 21, while CML was associated with a classic Philadelphia marker, indicating the independent origin of the two leukemias.

Phase I-II trials of poly IC stabilized with poly-L-lysine

Poly IC, stabilized with poly-L-lysine and carboxymethyl cellulose (poly ICLC), resists hydrolysis by primate serum (unlike the parent compound), induces high levels of serum interferon, and is effective in acute viral infections of subhuman primates. In a phase I-II clinical trial, poly ICLC was given iv in 15 daily doses of 0.5-27.0 mg/m2 to 19 patients with various solid tumors and to six patients with acute leukemia (1-65 years of age). At least three complete trials were conducted at each of six dose levels. Toxic reactions included fever (in 100% of trials), nausea (44%) hypotension (28%), thrombocytopenia and leukopenia (68%), erythema (12%), and polyarthralgia plus myalgia (16%). Hypotension and arthralgia-myalgia were related to dose level and/or magnitude of interferon induction, but other toxic manifestations were not. Poly ICLC induced significant serum interferon levels in 76% of trials, and the correlation between dose and peak interferon titer was linear. The maximum tolerated dose for all patients at a given drug dose was 12 mg/m2; at this dose, the mean peak interferon titer was 1940 reference units/ml. At a dose of 18 mg/m2, the mean peak interferon titer was 4473 reference units/ml, but severe myalgia and arthralgia were intolerable in at least half of the patients, and most had significant hypotension. At a dose of 27 mg/m2, one patient had acute renal failure. At high doses, iv poly ICLC also induced interferon in the cerebrospinal fluid.

Phase I study of methanesulfonamide, N-[4-(9-acridinylamino)-3-methoxyphenyl]-(m-AMSA) using a single-dose schedule

Methanesulfonamide, N-[4-(9-acridinylamino)-30methoxyphenyl]-(NSC-249992), an acridine derivative with significant antitumor activity in animal tumor systems, was administered to 29 patients in a phase I clinical trial. The dose ranged from 10 to 160 mg/m2 with a single dose given every 28 days. The toxic effects included moderate to severe leukopenia and mild thrombocytopenia. Myelosuppression was more severe in patients with prior whole abdominal or pelvic radiotherapy. Superficial phlebitis occurred when the drug was diluted in a volume of less than 500 ml of 5% dextrose in water. Antitumor activity was detected in one patient with ovarian carcinoma. Phase II studies are indicated with this compound since it has reproducible and reversible toxicity with some evidence of antitumor activity. The starting dose of the drug for phase II trials should be 120 mg/m2 as a single iv dose repeated at 4-week intervals.

Recent developments in the supportive therapy of acute myelogenous leukemia

The prognosis for patients with AML is improving, but mortality due to bleeding and infection remains significant. HLA compatibility has been the cornerstone of matching for prophylactic platelet transfusion; while HLA matched platelets are often of benefit, we have observed that HLA matching does not reliably predict transfusion responses. The platelet migration inhibition assay is, however, consistently predictive. The matching problem may be circumvented by the use of frozen autologous platelets, which circulate and function hemostatically. In the granulocytopenic patient with de novo fever (frequently due to bacterial sepsis), the immediate empiric use of broad spectrum antibiotics is mandatory. If the marrow begins to recover from chemotherapy shortly after the onset of infection, such that the peripheral granulocyte count will approach normal within 10 days, the likelihood of survival from an episode of septicemia after antibiosis now approaches 80%. If the marrow does not recover shortly, however, the likelihood of survival with antibiosis alone is poor. In this setting, survival is improved if patients are given granulocyte transfusions in addition to antibiotics. Patients who receive chemotherapy in a laminar air-flow room (LAFR) experience fewer severe infections than do patients in a conventional ward. However, most patients who are unresponsive to initial chemotherapy remain so in spite of protection from infection. Thus, the available results do not suggest that the LAFR is likely to improve appreciably the rate or duration of remission. Using malignant lymphoma as a model, we have found that cryopreserved autologous marrow infusions can hasten hematopoietic recovery in man after high-dose chemotherapy, and earlier reconstitution may be of clinical benefit to the patient; techniques are at hand that might permit the application of this concept to AML.

Tumor-specific transplantation antigen: use of the Ad2+ND1 hybrid virus to identify the protein responsible for simian virus 40 tumor rejection and its genetic origin

Cells transformed by simian virus 40 (SV40) possess a tumor-specific transplantation antigen (TSTA) that has the property of immunizing animals against syngeneic tumor challenge. We find that the early SV40 DNA segment present in the human adenovirus 2 (Ad2)-SV40 hybrid, Ad2+ND1, is sufficient to induce this SV40-specific TSTA in BALB/c mice. Moreover, studies on the intracellular distribution of TSTA activity in Ad2+ND1-infected cells, as determined by the ability of various subcellular fractions to immunize mice against syngeneic tumor challenge, have suggested a correlation between this biological activity and the presence of the SV40-specific 28,000Mr protein in coded by this hybrid virus. Both the TSTA activity and the 28,000 Mr protein are found in the plasma membrane fraction and in the perinuclear region of infected cells but are virtually undetectable in the cytoplasmic fraction. Using a hamster antitumor antiserum that can specifically immunoprecipitate the 28,000 Mr protein, we are able to demonstrate a loss of TSTA activity concomitant with the removal of this SV40-coded protein. Thus, it appears that antigenic determinants responsible for SV40-specific tumor rejection in mice are contained within the 28,000 Mr protein coded for by the early SV40 DNA segment that extends from 0.17 to 0.28 map unit.

Successful engraftment of cryopreserved autologous bone marrow in patients with malignant lymphoma

In an effort to evaluate the possible utility of cryopreserved autologous bone marrow infusions in man, 22 patients with malignant lymphoma resistant to conventional chemotherapy were treated with high-dose chemotherapy. This was followed in 12 patients by an infusion of their cryopreserved autologous bone marrow; 10 patients received chemotherapy alone and serve as controls. Following chemotherapy, severe leukopenia (less than 100 leukocytes/mm3) lasted 6-10 (median 8) days in patients receiving cryopreserved marrow, compared to 10-29 (median 16) days in controls (p less than 0.001). Recovery to 1000 leukocytes/mm3 occurred 10-18 (median 13) days after chemotherapy in autograft recipients but was delayed until 12-38 (median 23) days after chemotherapy in controls (p less than 0.001). Autografted patients also recovered granulocyte and platelet function significantly faster and had significantly fewer febrile days after chemotherapy than did controls. Cryopreserved autologous bone marrow infusions can hasten hemopoietic recovery in man after high-dose chemotherapy; this earlier reconstitution may be of clinical benefit to the patient.

Cardiac candidiasis in cancer patients

Histologically proven infection of the heart by Candida organisms occurred in 17 (10%) of 168 cancer patients with candidiasis studied at necropsy. All 17 patients were among the 85 patients with disseminated Candida infection; none of the 83 patients with localized candidiasis had involvement of the heart. Abscesses in the myocardium were present by histologic examination in all 17 patients and in 8 were evident on gross inspection as well. The mural endocardium was also affected in 5 patients from direct extension of a myocardial abscess. The valves were uninvolved. Pericardial infection was detected in 2 patients. The 17 patients with cardiac Candida infection had a higher frequency of positive premortem blood and cerebrospinal fluid cultures and of presence of Candida in the heart's blood than did the 68 patients with disseminated candidiasis but without involvement of the heart. Symptoms or signs of cardiac dysfunction resulting from the cardiac Candida infection were not readily detected in any patient. The clinical and pathologic features of cardiac candidiasis in cancer patients are distinct from those observed in Candida endocarditis.

Biosynthesis, immunological specificity, and intracellular distribution of the simian virus 40-specific protein induced by the nondefective hybrid Ad2+ND1

Ad2(+)ND(1), a nondefective hybrid virus containing a segment of the early region of simian virus 40 (SV40) DNA covalently inserted into the human adenovirus 2 genome, enhances the growth of human adenoviruses in simian cells and induces the SV40 U antigen. This hybrid previously has been shown to code for a 28,000 (28K) molecular weight protein not present in wild-type adenovirus 2-infected cells. By radioimmunoprecipitation using sera from hamsters bearing SV40-specific tumors, we have established that the Ad2(+)ND(1)-induced 28K protein is SV40-specific. This Ad2(+)ND(1)-induced protein is synthesized as a 30K molecular weight precursor, which is detectable only when infected cells are pulse-labeled in the presence of the protease inhibitor tosylamino phenylethyl chloromethyl ketone. Upon fractionation of labeled cell extracts, about 80% of the 28K protein is found in the plasma membrane fraction, whereas the remaining 20% is associated with the outer nuclear membrane. This protein is not detectable either in the nucleus or in the cytoplasm. Blockage of proteolytic cleavage by tosylamino phenylethyl chloromethyl ketone did not alter the topographic distribution of this SV40-specific protein, although the amount of the precursor protein in the outer nuclear membrane increased fourfold while that in the plasma membrane was proportionately decreased. This result suggests that the 28K protein is transferred from the outer nuclear membrane to the plasma membrane after posttranslational cleavage of the 30K precursor polypeptide. These data offer further support to the proposal that the 28K protein contains the determinants for SV40 U antigen and is responsible for SV40 enhancement of adenovirus growth in simian cells.

Identification of a transformation-specific protein induced by a Rous sarcoma virus

Using antisera obtained from rats bearing Schmidt-Ruppin strain Rous sarcoma virus-induced tumors, we have idnetified a protein with an apparent molecular weight of 56,000 daltons and an isoelectric point of 6.3 in extracts of chick embryo fibroblasts transformed by a wild-type nondefective Rous sarcoma virus (Schmidt-Ruppin strain). This protein was not found in cells infected by trnasformation-defective mutants with either a partial or complete deletion of the src gene, nor in cells infected by a nontransforming avian leukosis virus. The 56,000 dalton molecular weight protein was found to be synthesized at both the permissive and nonpermissive temperatures in cells infected by either of two conditionallethal mutants that are temperature-sensitive in cell transformation. The amount of this protein, however, accumulated in cells infected by these temperature-sensitive mutants, relative to the structural polypeptides, differed significnatly from that seen with the nondefective virus. Pulsechase experiments indicate that the protein is extremely unstable, with a half-life of about 20 min, and does not serve as a precursor to any of the detectable virion polypeptides. Furthermore, incubation of the rat antiserum with purified, disrupted virus did not affect its immunoreactivity to this particular protein. We conclude that this 56,000 dalton molecular weight protein is a nonstructural protein specific to cells transformed by Rous sarcoma virus.

Prolonged complete remission following high dose chemotherapy of Burkitt's lymphoma in relapse

Fourteen patients with American Burkitt's lymphoma resistant to conventional chemotherapy were treated with high-dose combination chemotherapy and intensive supportive care. Four patients died shortly after chemotherapy, 3 of an acute carditis. All ten remaining patients demonstrated tumor regression and 3 remain in prolonged complete unmaintained remission 29+, 19+, and 9+ months after treatment. These findings demonstrate that high-dose chemotherapy will benefit some patients with Burkitt's lymphoma unresponsive to conventional chemotherapy, but the medullary and extramedullary toxicity of this treatment strategy remains a formidable obstacle.

Sequential combination chemotherapy (containing high-dose cyclophosphamide) for metastic osteogenic sarcoma

Eleven patients with metastatic osteogenic sarcoma were treated with cyclophosphamide, adriamycin, and, in some cases, high-dose methotrexate. In the event of metastatic progression, the dose of cyclophosphamide was escalated by increasing the number of consecutive daily infusions (dose, 45 mg/kg/day). The results indicate that metastatic osteogenic sarcoma is marginally responsive to adriamycin and cyclophosphamide but rarely responsive to high-dose methotrexate as administered in this trial. The response of metastatic lesions was not improved by escalating the dose of cyclophosphamide.

Increasing incidence of Gram-positive sepsis in cancer patients

A review of the agents causing septicemia in cancer patients during a nine-year period (1968--76) revealed that Gram-positive organisms (especially S aureus) have become the most frequent isolates during the last two years. This unanticipated increase (P less than 0.001) in the number of Gram-positive isolates could not be related to horizontal transmission nor to changes in patient characteristics or therapy.

Simian virus 40-specific ribosome-binding proteins induced by a nondefective adenovirus 2-simian virus 40 hybrid

We have studied the intracellular distribution of the two simian virus 40-specific proteins, with apparent molecular weights of 56,000 and 42,000, detectable in human KB cells infected by a nondefective adenovirus 2-simian virus 40 hybrid, Ad2+ND2. After a 20-min pulse of [35S]methionine, about two-thirds of the newly synthesized 56K protein and one-third of the 42K protein were found localized on the plasma membrane. The remainder of each protein was found in the cytoplasm, whereas the nuclear fraction was virtually free of either component. A significant portion of both proteins present in the cytoplasmic fraction was complexed to the 40S ribosomal subunits and was not removed by treatment with 0.5 M KCl. Moreover, the portion that was found free in the cytoplasm could bind preferentially and quantitatively to purified 40S ribosomes in vitro, leading us to propose that these simian virus 40 proteins may act as translational control elements in cells.

Cutaneous infarction. Manifestation of disseminated mucormycosis

We describe the second reported case of cutaneous infarction as a manifestation of disseminated mucormycosis. The lesion, which closely resembled ecthyma gangrenosum, occurred in a leukemic patient who was on a regimen of broad-spectrum antibiotics. In this case as in the only other reported case, Mucor pusillus was the cause.

The relationship of fever, granulocytopenia and antimicrobial therapy to bacteremia in cancer patients

The relationship of fever, granulocytopenia, and antimicrobial therapy to bacteremia was studied retrospectively in 53 cancer patients. Severe granulocytopenia was present at the time blood cultures were positive in 27 to 31 episodes of bacteremia. Twenty-five episodes of bacteremia documented before the initiation of antimicrobial therapy in patients who were granulocytopenic and febrile. No bacteremia occurred in the absence of fever. Only two bacteremias occured while patients were receiving parenteral antimicrobials. Antimicrobial therapy was terminated 30 times in the presence of granulocytopenia and fever, and subsequent bacteremia occurred in 14 patients within 4 days. Patients who died with fungal disease did not receive more antibiotics than patients who died without fungal disease. These data suggest a rationale for long-term use of antimicrobial therapy in patients with persistent granulocytopenia and fever.

A re-examination of the biphasic theory of skeletal muscle growth

Because of the importance of fibre diameter measurements it was decided to re-evaluate the biphasic theory of skeletal muscle growth and development. This theory proposes an initial memophasic distribution of muscle fibres which changes to a biphasic distribution during development. The theory is based on observations made on certain muscles in mice, where two distinct populations of fibre diameters (20 and 40 micronm) contribute to the biphasic distribution. In the present investigation corss sections of frozen biceps brachii of mice in rigor mortis were examined. The rigor state was used to avoid complications produced by thaw-rigor contraction. The diameters of the outermost and innermost fibres were found to be significantly different. However, if the outer and inner fibres were combined to form one group, no significant difference between this group and other random groups was found. The distributions of all groups were monophasic. The diameters of isolated fibres from mice and rats also displayed a monophasic distribution. This evidence leads to the conclusion that the biphasic theory of muscle growth is untenable. Some of the variables which may occur in fibre size and shape are discussed.

Synthesis and processing of the precursor to the major core protein of adenovirus type 2

An isopycnic Metrizamide-detergent gradient system was developed in which the newly synthesized precursor (polypeptide P-VII) to the major core protein of adenovirus type 2 (polypeptide VII) was confined to a spectrum of complexes with densities equal to or higher than that of adenovirions. The majority of the newly synthesized P-VII was, at the beginning of the logarithmic period of virus production, present as an entity of protein density. This pool of P-VII was efficiently depleted. P-VII was also associated with high-molecular-weight structures of intermediate density, sharing some properties with empty capsids or incomplete particles. The transfer of P-VII from the intermediate-density region was not quantitative, and only particles of true virion density subsequently contained polypeptide VII. No structures equivalent to the core structure of disrupted virions or identical to incomplete particles were detected in this system. A temperature-dependent transition of radioactivity from polypeptide P-VII into polypeptide VII was also detectable after in vitro incubation of P-VII-containing complexes. Addition of Ad2-infected cell extracts was required for processing of complexes derived from regions of protein density, whereas P-VII was processed spontaneously upon incubation in complexes of virion density.

Combined modality treatment of American Burkitt's lymphoma

Fifteen American patients with Burkitt's lymphoma were treated in a clinical trial employing chemotherapy, radiotherapy, and immunotherapy. Two patients died during induction, and 13 achieved complete responses. Eight patients relapsed at a median of 11 weeks from initial treatment, and seven of these have died. The remaining patient has enjoyed a prolonged third remission following intensive chemotherapy and bone marrow autograft. Five patients remain in their first remission in excess of 1 year. The major therapeutic goal in the management of Burkitt's lymphoma is the prevention of relapse; the identification of risk factors and various strategies to achieve this goal are discussed.

Content and expression of integrated viral DNA in hamster cells transformed by nondefective adenovirus type 2- simian virus 40 hybrid viruses

Hamster cells transformed by adenovirus 2 (Ad2) and five nondefective Ad2-simian virus 40 (SV40) hybrid viruses are all of the Ad2-transformed phenotype. All lines accumulate Ad2 RNA and Ad2 T antigen; two hybrid-transformed lines accumulate SV40 RNA, but only one contains detectable amounts of SV40 antigens. We examines selected lines from this group of transformed hamster cells for Ad2 DNA content and viral RNA expression by using hydroxyapatite chromatography and separated strands of labeled viral DNA as probes. All lines studies contain 1 to 2 Ad2 genome equivalents per haploid equivalent of cell DNA. The expression of Ad2 RNA exhibits two distinct patterns. In one pattern, transcription of the heavy strand of Ad2 DNA is less than that of the light strand, whereas in the second pattern of Ad2 RNA expression the extent of heavy-strand transcription is greatly increased. In the two lines containing SV40 RNA, the entire SV40 (-) strand is transcribed; the (+) strand is not expressed in these cells. These patterns of viral RNA expression suggest the possibility that host promoters may play a role in regulating transcription of integrated viral DNA.

Quantitative studies of integration of murine leukemia virus after exogenous infection

Using a [3H]DNA probe prepared from AKR murine leukemia virus, we determined the number of copies of the AKR virus genome integrated into the cellular DNA after exogenous infection of NIH mouse, AKR mouse, and rat cells in tissue culture. NIH mouse cells, which lack a portion of the viral genome (referred to as Gross-AKR specific sequences), incorporated three to four copies of these sequences per haploid genome. AKR cells, in which the Gross-AKR specific sequences are already present as three to four copies per haploid genome, did not shwo any distinct change in copy number after infection. Rat cells, which lack DNA sequences homologous to murine leukemia virus, incorporated one copy of the viral genome per haploid genome. It is inferred that the presence of viral sequences may affect the efficiency of integration of exogenous provirus, and that there may be a limit to the number of copies that can be inserted.

Sepsis with a new species of Corynebacterium

Sepsis with a previously undescribed species of Corynebacterium was documented in four patients. All patients had predisposing illness at the time of infection, three patients having leukemia in relapse and one having a porencephalic cyst and a ventriculoatrial shunt. The isolates from blood cultures had a characteristic metallic sheen when grown on blood agar. They were resistant to most antibiotics tested, including the penicillins, but were uniformly sensitive to vancomycin. Common biochemical characteristics, the metallic sheen, and the unusual antibiotic sensitivity pattern suggest that these isolates comprise a new species or group of closely related species of Corynebacterium that is capable of infection in man.

A phase I-II trial of multiple-dose polyriboinosic-polyribocytidylic acid in patieonts with leukemia or solid tumors

Polyriboinosinic-polyribocytidylic acid (poly I - poly C), an interferon inducer, was administered in multiple doses of 0.3-75 mg/m2 to 26 patients with a variety of solid tumors, 9 with acute leukemia, and 2 with chronic myelogenous leukemia in blast crisis. Forty-four separate drug trials were comprised of various schedules and routes of administration. Toxic reactions included fever (in 66% of the trials), transient elevation of serum glutamic-oxaloacetic transaminase and serum glutamic-pyruvic transaminase (25%), minimal laboratory evidence of coagulation abnormalities (59%), and hypersensitivity (5%). These toxic manifestations did not relate to dose level or magnitude of interferon induction. Poly I - poly C administered iv induced low serum concentrations of interferon in 24/38 trials (63%), but the correlation between drug dose and peak interferon titer was not linear. Poly I - poly C administered iv or im was not effective as an inducer of interferon in the cerebrospinal fluid. Similarly, poly I - poly C administered im or by inhalation did not produce detectable serum levels of interferon. No patients experienced an objective tumor response to the administration of poly I - poly C, and most (76%) had progression of their disease while receiving the drug.