Distribution of myeloma plasma cells in peripheral blood and bone marrow correlates with CD56 expression

There is a wide variation in the degree of marrow and blood involvement between patients with multiple myeloma. Both of these parameters are known to be highly significant prognostic factors, and the differences between patients may be due to variable expression of adhesion molecules. To test this we used three-colour flow cytometry to study three adhesion molecules associated with myeloma, namely CD38, CD56 and CD138. The level of expression of these molecules was compared with the distribution of myeloma plasma cells in bone marrow (n=59) and peripheral blood (n=26) in patients at presentation or relapse. The extent of marrow infiltration on the trephine biopsy correlated inversely with CD56 expression (Mann-Whitney U Test, P=0.022); there was no difference in CD38 or in CD138 expression. CD56 expression also correlated inversely with the number of circulating plasma cells (linear regression, R2=0.4268, slope=-0.58, P=0.0003). Peripheral blood plasma cell numbers correlated weakly with bone marrow plasmacytosis, and inversely with CD38 expression. The level of CD56 expression by neoplastic plasma cells was assessed in 37 patients over a median of 11 months (range 6-25). There was no significant change in expression (Wilcoxon Signed Rank, P=0.6271). We conclude that plasma cell CD56 expression is constant over the course of the disease; unlike CD138 expression, it is significantly linked to the degree of both bone marrow and peripheral blood involvement.

The efficacy of developmentally sensitive interventions and sucrose for relieving procedural pain in very low birth weight neonates

BACKGROUND

Procedural pain management for very low birth weight (VLBW) neonates has been minimal or nonexistent in most neonatal intensive care units (NICUs).

OBJECTIVES

To compare the efficacy of developmentally sensitive behavioral interventions (nonnutritive sucking via a pacifier, positioning) and sucrose for relieving procedural pain in VLBW infants and to determine the influence of contextual factors (gestational age, postnatal age, birth weight, severity of illness, frequency of painful procedures) on pain response.

METHOD

In a prospective randomized crossover trial, pain was assessed in 122 VLBW neonates using the Premature Infant Pain Profile following four randomly ordered interventions during consecutive routine heel lance procedures.

RESULTS

Significant differences in pain existed among treatment interventions (F = 16.20, p < .0001). The pacifier with sucrose (F = 24.09, p < .0001) and pacifier with sterile water (F = 9.00, p = .003) significantly reduced pain. Prone positioning did not decrease pain (F = 2.24, p = .137). Frequency of painful procedures approached significance in influencing pain response (F = 3.59, p = .01).

CONCLUSIONS

The most efficacious interventions for reducing pain from single painful events were the pacifier with sucrose and the pacifier with sterile water. Research on the efficacy and safety of implementing these interventions, alone and in combination, for repeated painful procedures is needed. In addition, research is needed on the influence of implementing these interventions on pain response and clinical outcomes (e.g., health status and neurodevelopmental status) in VLBW neonates in the NICU.

Five-year follow-up of a prospective randomised multi-centre trial of weekly chemotherapy (CAPOMEt) versus cyclical chemotherapy (CHOP-Mtx) in the treatment of aggressive non-Hodgkin's lymphoma. Central Lymphoma Group

BACKGROUND

Weekly alternating regimen known as CAPOMEt is compared to standard cyclical chemotherapy (CHOP-Mtx) in aggressive non-Hodgkin's lymphoma (NHL).

PATIENTS AND METHODS

Three hundred and eighty-one patients with aggressive NHL were randomised to receive either cyclophosphamide, doxorubicin, vincristine, prednisone and methotrexate (CHOP-Mtx) on a cyclical basis or a weekly regimen incorporating the same drugs with the addition of etoposide (CAPOMEt).

RESULTS

After pathological review, 281 patients were deemed eligible. At the census date of 31 March 1994, 158 patients were alive with a median follow up of 5.9 years (minimum 3.0 years). Analysis of all patients and eligible patients showed no significant treatment differences in the rates of complete remission (CR), failure free survival (FFS) or overall survival (OS) between the two arms. The actuarial median OS was 24 months for CAPOMEt compared with 31 months for CHOP-Mtx, with five-year actuarial survival rates of 37% and 43%, respectively. Myelosuppression was significantly more severe with CHOP-Mtx and neurotoxicity was much more common with CAPOMEt.

CONCLUSION

Weekly CAPOMEt is equally effective as standard cyclical CHOP-Mtx treatment in aggressive NHL.

A phase 1 study to address the safety and efficacy of granulocyte colony-stimulating factor for the mobilization of hematopoietic progenitor cells in active rheumatoid arthritis

OBJECTIVE

To examine the safety and efficacy of granulocyte colony-stimulating factor (G-CSF) alone for the mobilization of peripheral blood progenitor cells in patients with resistant active rheumatoid arthritis (RA).

METHODS

Five patients with resistant active RA were studied. A dose of 5 microg/kg of G-CSF (Filgrastim) was given subcutaneously each day for 5 days, and the number of stem cells mobilized into the peripheral blood was assessed by daily CD34 counts. RA disease activity was assessed by standard clinical methods.

RESULTS

The absolute numbers of peripheral blood CD34+ cells peaked on day 4, with a mean value of 0.025 x 10(9)/liter (range 0.013-0.048 x 10(9)/liter). There was no significant change in disease activity during the study or in the month following therapy.

CONCLUSION

Using G-CSF alone, CD34+ progenitor peripheral blood cells were mobilized in numbers suitable for leukopheresis. G-CSF therapy was well-tolerated in patients with active RA, and was not associated with a flare during treatment or in the month following treatment.

[Hepatocellular carcinoma: a preventable cancer]

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide and a public health concern in many developing countries. The main risk factor is the chronic carriage state of the hepatitis B virus which is found in about 20% of the adult population in many African and Asian countries. Other important risk factors are HCV infection, aflatoxin exposure and alcohol consumption. The Gambia Hepatitis Intervention Study was launched in 1986 with the aim of evaluating the efficacy of the hepatitis B vaccination, given in early infancy, in preventing HBV infection, its chronic carriage status, and later, HCC. For this purpose, a randomised vaccine trial was designed and carried out. Over a period of four years a total of 124.577 children were recruited, one half received the usual EPI vaccines (BCG, DTP, OPV, measles, yellow fever) and the other half the hepatitis B vaccine in addition to the EPI ones. Hepatitis B vaccination has been successfully integrated into the "Expanded Programme of Immunization" in The Gambia, since every new born baby can receive this vaccination in addition to the EPI vaccine. The first mid point evaluation showed that in four-year-old children, hepatitis B vaccine efficacy was 84% in preventing infection and 94% in preventing chronic carriage status of HBV. Other mid point evaluations are still ongoing. A nationwide Cancer Registry was set up to detect HCC cases in the cohort under study. Follow-up through the Cancer Registry is planned for the next 30 years.

Changing trends in the incidence of non-Hodgkin's lymphoma in Europe. Biomed Study Group

Non-Hodgkin's lymphoma (NHL) is not a uniform disease entity, and in order to investigate the reported changes in incidence we have set up a study in seven population-based cancer registries in Europe. The study is designed to look at changes in the incidence of total NHL and disease subgroups using standard definitions and methodology. The registries are based in Leeds, Dijon, Kuopio, Odense, Florence, Eindhoven, and Ragussa. The classification system we have used is based on the REAL classification and has utility for epidemiological studies. We have used it to convert data sets which have utilized both local cases and the ICD-O classification. In order to improve data reproducibility, CLL/LL, myeloma/MGUS, lymphoblastic disease, and Hodgkin's disease have been excluded because of the difficulty in defining incident cases accurately. The preliminary results of this study show that there is still an upward trend in incidence rate and that in Yorkshire this is 3% per annum in total NHL. The subgroups which are increasing are extranodal and nodal peripheral T-cell lymphoma. Similar increases in incidence have been reported for the other registries. We conclude that there is a continued upward trend in incidence of NHL, the causes of which are uncertain.

Fluorescent polymerase chain reaction of a panel of CA repeats on chromosome 6 in the indolent phase of follicular centre cell lymphoma

Twenty-four cases of histologically defined follicle centre cell (FCC) lymphoma have been examined for allele imbalance at 19 microsatellite loci spanning the length of chromosome 6, including six markers within the major histocompatibility complex (MHC), using fluorescent polymerase chain reaction (PCR) to amplify microsatellites. Nineteen cases were observed in which imbalance of one or more markers on chromosome 6 had occurred (79%). The frequency of allele imbalance was significantly higher on 6p than 6q, and two regions of deletions, 6p24-25 and 6p21.3-23, were identified in which the loci showed a significantly high allele imbalance frequency.

Assessment of IgH PCR strategies in multiple myeloma

AIMS

To compare the ability of four commonly used PCR techniques to demonstrate clonal IgH rearrangements in multiple myeloma.

METHODS

Bone marrow samples (containing a minimum of 10% plasma cells) were obtained from 127 patients with confirmed multiple myeloma. Framework 3 (Fr3) PCR was performed in all cases and the Framework 1 (Fr1f) PCR, which utilises six VH family specific primers, in 98 cases. In addition, 44 cases were assessed by Fr3, Fr1f, Framework 2 (Fr2) and Framework 1 consensus (Fr1 con) PCR techniques. JH primer selection was also assessed such that each PCR strategy was performed twice in each of the 44 cases, using the JH consensus primer (JH con) alone and then repeated with an equimolar mixture of JH con, JH3 and JH6 (JH mix).

RESULTS

Clonal rearrangements were demonstrated in 71 (56%) of 127 cases with the Fr3 PCR and in 52 (53%) of 98 with the Fr1f PCR. However, by using both techniques it was possible to demonstrate clonal IgH rearrangements in 92 (75%) of 122 cases. Forty four cases were assessed by all four PCR techniques; in these cases the Fr3 and Fr1f PCRs demonstrated clonal rearrangements in 26 (59%) cases with a combined yield of 34 (77%). The Fr2 and Fr1 con PCR techniques had inferior pick up rates, demonstrating clonal rearrangements in 21 (48%) of 44 cases and a combined yield of 28 (63%). The Fr2 PCR did, however, demonstrate a clonal rearrangement in one case negative by both Fr3 and Fr1f. Two additional rearrangements were demonstrated by using JH mix; one became positive by Fr3, Fr1f and Fr2 and the other positive by Fr1f, Fr1 con and Fr2.

CONCLUSIONS

By utilising both the Fr3 and Fr1f PCR techniques it is possible to demonstrate definitive clonal rearrangements in the majority of patients with multiple myeloma. The Fr1 con and Fr2 PCR techniques have inferior pick up rates but may detect some additional rearrangements.

Peripheral blood stem cell transplantation in myeloma using CD34 selected cells

We have performed nine CD34 selection procedures on peripheral blood stem cells harvested from eight patients with myeloma using the Cellpro avidin-biotin immunoaffinity column (Ceprate). They all received CVAMP chemotherapy to maximum response prior to mobilisation. Six of the patients have been transplanted using these cells, one receiving successive autografts. Median absolute cell numbers processed and retrieved were: 31.1 x 10(9) pre-column, 2.07 x 10(8) in the final product and 30.4 x 10(9) in the column waste. Mean CD34 positivity in the product was 49% (range 18.4-98) with a median CD34+ yield of 31.4% (range 21-37.8). IgH PCR was performed and seven of the eight patients were amplifiable. Of these, two were positive in the pre-column product and both of these were successfully purged with a negative result in the final, post-column product. Patients were transplanted with a median of 2.0 x 10(6) CD34+ cells/kg (range 1.5-9.4) following conditioning with melphalan 200 mg/m2. The mean time to recovery of neutrophils to > 0.5 x 10(9)/l and platelets to > 20 x 10(9)/l was 16 and 17 days, respectively. At a mean follow-up of 9 months, four of the six patients transplanted are alive, three of them in complete remission and one in a clinically stable relapse. One has died of disease relapse and one of progressive neurological problems the aetiology of which was uncertain but there was no sign of progression of their myeloma. We conclude that PBSCT using CD34 selected cells is safe and practical in myeloma following remission induction with CVAMP chemotherapy.

Microsatellite instability in follicle centre cell lymphoma

Fluorescent polymerase chain reaction (PCR) was used to assay 12 microsatellite markers (APC x 2, DCC, P53 x 2, RB1, NM23, WT1, D6S260, D6S262, D6S281 and TNFa) to look for evidence of microsatellite instability in 40 cases of follicle centre cell lymphoma (FCC). Evidence of novel alleles seen in the tumour tissue but not the normal uninvolved tissue was seen in seven cases (17%). In only two of these cases (5%) was more than one locus involved but in these cases multiple affected loci were seen (4/12 and 7/12 respectively). The detection of microsatellite instability indicates a DNA repair defect such as that which would be predicted to occur in cells with mutated mismatch repair genes, a novel finding in FCC lymphoma.

32P-incorporation PCR for the detection of rearrangements at the TCR-gamma locus

We have adapted and developed a PCR (polymerase chain reaction)-based technique for the T-cell receptor (TCR)-gamma chain gene, which has subsequently been used for routine diagnosis. Variable-region oligonucleotide primers were chosen from subgroups I and II, and the joining region primer was from the J2 segment. The primers were used to perform a 32P-incorporation PCR, and the products were then separated on an 8% denaturing polyacrylamide gel. In our hands, this technique is more reliable than cold methods, when separation is performed on either agarose or nondenaturing polyacrylamide. The radioactive technique was used to look at 102 T-cell proliferations, of which eight of eight T-acute lymphoblastic leukemia (ALL), 24 of 34 T-non-Hodgkin's leukemia (NHL), and 35 of 60 large granular lymphocyte (LGL) expansions were clonal. Of 122 B-cell proliferations investigated, including 72 cases of B-cell lineage ALL, 36 demonstrated a T-cell rearrangement (33 ALLs and three myelomas). Samples from nonlymphoid tumors were tested and produced a normal distribution ladder of PCR products after autoradiography, a pattern also observed with antenatal and preoperative patients. The radiolabel-incorporation method detected an abnormal pattern of a ladder with prominent dark bands in 29 of 122 B-cell and 27 of 102 T-cell cases and in 0 of 49 of the nonlymphoid and normal samples. The abnormal banding patterns obtained in a proportion of the B- and T-cell cases was not readily discernible by nondenaturing-acrylamide or agarose-separation methods.

MALToma-like lesions in the murine gastric mucosa after long-term infection with Helicobacter felis. A mouse model of Helicobacter pylori-induced gastric lymphoma

The long-term consequences of helicobacter infection were observed in an established murine model of human helicobacter infection. Stomachs of specific pathogen-free BALB/c mice infected with Helicobacter felis were examined for inflammation with particular reference to lymphoid cell proliferation and lymphoepithelial lesions. There was little evidence of an inflammatory response in animals sacrificed up to 19 months after infection. In contrast, from 22 months, 38% of infected animals had lymphoid follicles, whereas no lymphoid follicles were found in noninfected control animals. Lymphoepithelial lesions were observed in 25% of infected mice compared with none in controls. Immunostaining confirmed the B-cell nature of the lymphoid infiltrate. The morphology of these lesions closely resemble those seen in human gastric MALToma. This animal model would provide an opportunity to study the pathogenesis of lymphoproliferative disease.

Further development of the locus control region/murine erythroleukemia expression system: high level expression and characterization of recombinant human calcitonin receptor

In order to demonstrate the potential of the LCR/MEL expression system for the expression of seven-transmembrane helix receptors the human calcitonin receptor (hCTR) has been cloned and expressed at high levels in this system. Using the newly developed single-step expression vectors pEV and pNV, stable recombinant MEL cells which express the hCTR at approximately 6 pmol of receptor/mg of total cell protein (60 pmol/mg of membrane protein), or 1.9 x 10(6) receptors per cell, have been generated. Ligand binding studies have shown that the cloned receptor expressed in MEL cells has properties which are indistinguishable from those of the native receptor in T47D cells. It is suggested that MEL cells expressing seven-transmembrane helix receptors provide an efficient and readily attainable source of material for ligand binding experiments using these receptors.

Genetic abnormalities during transition from Helicobacter-pylori-associated gastritis to low-grade MALToma

The helicobacter-associated transition from chronic gastritis to MALToma (lymphoma of mucosa-associated lymphoid tissue) may require genetic change in the host. We have studied gastrectomy specimens from twelve cases of primary B-cell gastric lymphoma showing evidence of chronic gastritis and low-grade or high-grade MALToma to look for allele imbalance at microsatellites for six tumour-suppressor genes. We detected allelic imbalance at two of these loci (DCC in three, APC in two). In two DCC cases allele imbalance was seen in the transition from chronic gastritis to low-grade MALToma and in the third between low-grade and high-grade. Allele imbalance between chronic gastritis and low-grade MALToma is not necessarily causal in the transition. Rather, genetic change has occurred in the process of transformation.

Management of the moribund carbon monoxide victim

Carbon monoxide (CO) poisoning is the commonest single cause of fatal poisoning in the U.K. (Broome & Pearson, 1988). The clinical features are numerous and include headache, fatigue, dizziness, confusion, memory loss, paraesthesia, chest pain, abdominal pain, nausea, and diarrhoea as well as coma, convulsions and death. Without adequate treatment many patients develop neuropsychiatric sequelae including headaches, irritability, memory loss, confusion and personality changes. The diagnosis of CO poisoning is often suggested only by circumstances surrounding the victim, and remains a challenge to the A&E department. Hyperbaric oxygen therapy (HBO) is internationally accepted as the most powerful form of treatment in severe cases (Drug & Therapeutics Bulletin, 1988; Lowe-Ponsford & Henry, 1989). However, in the U.K. treatment with HBO is often not considered due to lack of hyperbaric facilities (Meredith & Vale, 1988; Anand et al., 1988), and due to inadequate awareness on the part of hospital staff. We report a case of a patient deeply unconscious as a result of CO poisoning, in which serial treatments with HBO over a period of 14 days, produced dramatic results.

Transformation of mouse skin endothelial cells in vivo by direct application of plasmid DNA encoding the human T24 H-ras oncogene

Plasmid DNA containing the human T24 H-ras oncogene, with or without viral transcriptional enhancer sequences, was applied to scarified mouse skin, followed by multiple treatments with the tumour promoter 12-O-tetradecanoyl-phorbol-13-acetate. This resulted in the formation of vasoformative tumours histologically characterized as lymphangiosarcomas. All of the animals treated developed cystic fluid-filled swellings. Polymerase chain reaction analysis revealed the presence of human H-ras sequences within the cystic fluid from 3 out of 4 swellings. An endothelial cell line established from the cystic fluid removed from one of these swellings was found to contain human H-ras sequences and to express the mutant human p21ras. Injection of the cell line into nude mice, or adult syngeneic mice, resulted in the formation of aggressive angiosarcomas. Further experiments showed that 12-O-tetradecanol-phorbol-13-acetate promotion is not required for tumour formation and would appear to reduce the yield of tumours. These results indicate that a single application of the human H-ras oncogene is sufficient to induce endothelial cell transformation in vivo, even in the absence of any further promotional stimulus.

Scales modified for dose determination in population-based chemotherapy

Integration of schistosomiasis control into primary health care services in The Gambia required semiliterate health workers to administer praziquantel and metrifonate to the community in doses based on weight. Special scales to weigh people with a direct readout in the form of numbers of tablets obviated the need to read figures or make calculations at the scene. The scales were used with a simple record system. Coverage of up to 97% was achieved with single dose praziquantel; for three doses of metrifonate spread over 2 months, coverage reached 82.4%. The tablet scale was easy to devise and fit to commercial scales.