Successful pregnancies in women following single autotransplant for acute myeloid leukemia with a chemotherapy ablation protocol

Of 30 women surviving a minimum of 18 months following treatment for AML with a high-dose chemotherapy regimen with autologous bone marrow transplantation (ABMT), 24 were premenopausal at the time of transplantation. All were given a detailed questionnaire concerning menstruation, menopausal symptoms and pregnancy; 22 responded. Of these 22, 10 had received a single transplant procedure and 12 a double transplant procedure. In the 10 recipients of a single transplant, 4 women (age range 32-50 years) developed ovarian failure and 6 (age range 21-32 years) resumed spontaneous cyclical menstruation. Five of the 6 menstruating women became pregnant between 4 and 40 months following ABMT. Three pregnancies went to term and each resulted in the delivery of a full-term apparently normal infant. Of the 12 women who received a double ABMT (age range 32-47 years), 11 developed clinical and/or biochemical evidence of ovarian failure. The median age in the latter group was 35 years, however, compared with 28 years in the single ABMT group. These data show that it is possible to give a single very high-dose course of chemotherapy in younger patients without compromising fertility.

A British National Lymphoma Investigation randomised trial of single agent chlorambucil plus radiotherapy versus radiotherapy alone in low grade, localised non-Hodgkins lymphoma

Local radiotherapy (RT) alone was compared with radiotherapy plus continuous oral chlorambucil (RT+CHL) for the treatment of localised, low grade non-Hodgkins lymphoma (NHL) in a prospective randomised study of 148 patients. After a maximum of 18 years follow up there was no significant difference in overall survival or disease free survival between the two treatment groups. Age greater than 50 years and low serum albumin at diagnosis correlated with a poor prognosis in the series overall. Over one third of patients with localised, low grade NHL may be cured by RT alone and adjuvant chlorambucil as initial therapy confers no survival advantage.

Neopterin release by myeloid leukaemic cells can be synergistically augmented by 1,25-dihydroxyvitamin D3 in combination with gamma interferon or granulocyte-macrophage colony stimulating factor

Neopterin is a pteridine molecule released by immune activated monocytes. Monocytic maturation may be induced in acute myeloid leukaemia (AML) blasts and the U937 leukaemic cell line by 1,25-dihydroxyvitamin D3 [1,25(OH)2D3], an effect which is augmented by both gamma interferon (IFN) or granulocyte-macrophage colony stimulating factor (GM-CSF). We have demonstrated that, while 1,25(OH)2D3 and GM-CSF alone have little effect, both IFN and GM-CSF act synergistically with 1,25(OH)2D3 to increase neopterin secretion in the U937 cell line. Neopterin secretion was associated with, but not necessarily dependent on, the degree of phenotypic differentiation achieved by cells. Neopterin secretion was also synergistically enhanced in AML blasts by the action of 1,25(OH)2D3 in combination with IFN but not GM-CSF; secretion was enhanced in AML blasts without concomitant evidence of phenotypic maturation. We have shown that the monocytoid cell line U937, under appropriate conditions, may secrete neopterin in response to stimulatory agents other than IFN. In addition, the distinct difference in the pattern of response to the combination of 1,25(OH)2D3 with GM-CSF compared with that of 1,25(OH)2D3 plus IFN suggests that the augmentation of 1,25(OH)2D3 effect by IFN and GM-CSF is mediated by separate mechanisms.

Structure-dependent antitumor activities of novel anthracyclines YM1, YM3, YM4 and YM6: drug transport properties and effects on biomacromolecule synthesis in drug sensitive and resistant leukemia cells

The antitumor activities of four novel doxorubicin (DOX) analogues, YM1, YM3, YM4 and YM6 in relation to their structure and drug transport properties, have been investigated in U937 monocytic and CCRF-CEM lymphoid drug sensitive leukemia cell lines, as well as in CEM/VLB100, a drug resistant subline displaying high levels of P-glycoprotein. Treatment of all cell lines with YM1, 3, 4 and 6 produced a dose-dependent decrease in DNA, RNA and protein synthesis as measured by [3H]-thymidine, [3H]-uridine and [3H]-leucine uptake respectively. YM1 was more effective than YM3, YM4 or YM6 against the drug sensitive cells. The antitumor effects of all these DOX-analogues on macromolecule synthesis in U937 and CCRF-CEM cells were lower than that of DOX and epirubicin (EDR). A rapid accumulation of the novel anthracyclines was found in all cell lines compared with DOX or EDR. However, the maximal accumulation of the DOX-analogues was lower than that of EDR. There is a greater efflux from CCRF-CEM sensitive cells and less from CEM/VLB100 resistant cells of the DOX-derivatives when compared with EDR and DOX. Drug-induced cytotoxicity significantly correlated (P < 0.05) with drug retention levels in CCRF-CEM and U937 drug sensitive cells as indicated by an inverse correlation curve between anthracycline retention and drug-induced IC50 value. It was demonstrated that an increased level of drug retained within the sensitive cells would therefore produce a more cytotoxic effect of the drug. However, no such correlation was observed in CEM/VLB100 resistant cells. YM3 was shown to have an increased antitumor activity against CEM/VLB100 resistant cells compared with DOX with a lower resistance factor. These results showed that the antitumor effects of four novel DOX-analogues, like DOX or EDR, were associated with inhibition of DNA replication, transcription and translation. The finding that resistant leukemic cells are more susceptible to the cytotoxic effect of YM3 than DOX warrants further investigation to identify the intrinsic mechanism of resistance.

Induction of surface tumor necrosis factor (TNF) expression and possible facilitation of surface TNF release from human monocytic cells by granulocyte-macrophage colony-stimulating factor or gamma interferon in combination with 1,25-dihydroxyvitamin D3

1,25-dihydroxyvitamin D3 (1,25(OH)2D3), gamma interferon (IFN-gamma) and granulocyte-macrophage colony-stimulating factor (GM-CSF) can regulate monocyte maturation and activation. Using the human monocytoid cell line U937, we have shown that these agents increase surface tumor necrosis factor (TNF) expression without directly affecting TNF release. GM-CSF and IFN-gamma combined with 1,25(OH)2D3 increased cellular TNF secretion to levels not seen with these agents alone. Ability to express and secrete TNF in part depended on degree of monocytic maturation. The combination of 1,25(OH)2D3 and GM-CSF, however, facilitated lipopolysaccharide (LPS)-mediated release of surface TNF from U937 cells, an effect that was temporally independent of maximal maturation. 1,25(OH)2D3 plus IFN-gamma was less effective than 1,25(OH)2D3 plus GM-CSF at facilitating TNF secretion. We postulate that 1,25(OH)2D3 and GM-CSF are required together to prime a specific mechanism, probably a protease, which cleaves TNF from the surface of monocytic cells. This protease, once primed, can be activated by a secondary stimulus such as LPS.

von Willebrand factor as a marker of endothelial cell activation following BMT

Endothelial cell activation may play a role in thrombotic complications of BMT such as hepatic veno-occlusive disease (VOD), right atrial line thrombosis and microangiopathic haemolysis. To assess this, von Willebrand factor antigen (vWF:ag) was measured in 72 patients (25 allografts, 46 autografts and one syngeneic) during the first 6 weeks post-transplant. There was a significant rise in vWF:ag in both allografts and autografts but a greater increase was seen in the allografts. The changes in vWF:ag did not correlate with changes in C reactive protein showing that this was not merely an acute phase response. vWF multimers were normal in a subgroup of uncomplicated transplants showing that there was no large scale endothelial cell disruption. Patients with VOD did not have changes in vWF:ag that were consistently different from uncomplicated controls. Three of four patients who developed line thrombosis had higher levels of vWF:ag compared with control groups; multimeric structure of the vWF was again normal. These results show that there is endothelial cell activation post-BMT and that this is greater in allografts compared with autografts, thus suggesting a possible mechanism for the higher incidence of VOD in this group. There were no useful predictive markers of VOD or thrombosis in individual patients.

Selective automatic neuropathy as a novel complication of BMT

Neurological complications have been reported in approximately 30% of patients following bone marrow transplantation. We report a case of selective sympathetic autonomic neuropathy following allogeneic BMT, a phenomenon not previously described.

Piperacillin/tazobactam plus gentamicin as empirical therapy for febrile neutropenic patients with haematological malignancy

The efficacy of piperacillin/tazobactam (PIPC/TBT) in combination with gentamicin was assessed as empirical therapy in 44 febrile neutropenic patients with haematological malignancy. A favourable response to therapy was seen in 67% patients overall and in 57% of patients with microbiologically documented infection. PIPC/TBT demonstrated good clinical and in vitro activity against isolated pathogens, particularly Gram positive cocci such as Staphylococcus epidermidis. The MIC of both Gram positive and Gram negative pathogens to PIPC was reduced in the presence of TBT. PIPC/TBT plus gentamicin is a safe and effective combination for empirical therapy in febrile neutropenic patients, even in a unit with a predominance of Gram positive infections.

Teicoplanin plus ciprofloxacin versus gentamicin plus piperacillin in the treatment of febrile neutropenic patients

Teicoplanin plus ciprofloxacin was compared with gentamicin plus piperacillin for the empirical treatment of fever in 80 neutropenic patients. A favourable response was seen in 78% of patients receiving teicoplanin plus ciprofloxacin and in 49% receiving gentamicin plus piperacillin (p less than 0.05). When microbiologically documented episodes were analysed separately, the response to teicoplanin plus ciprofloxacin was favourable in 81% of patients whereas only 35% responded favourably to gentamicin plus piperacillin (p = 0.034). Gram-positive organisms accounted for 76% of bacterial isolates, Staphylococcus epidermidis being the most common pathogen. Ten of 12 (83%) Staphylococcus epidermidis infections resolved when treated with teicoplanin plus ciprofloxacin as compared with 2 of 8 (25%) treated with gentamicin plus piperacillin. Teicoplanin is at least as effective as gentamicin plus piperacillin in the empirical treatment of febrile neutropenic patients and may be more effective in situations where gram-positive organisms are prevalent. The high incidence of gram-positive infections in our unit justifies the use of an agent with specific activity against gram-positive organisms in the first-line antibiotic regimen.

Functional significance of induction of differentiation in human myeloid leukaemic blasts by 1,25-dihydroxyvitamin D3 and GM-CSF

We studied the effect of 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) and granulocyte-macrophage colony stimulating factor (GM-CSF) on monocytic differentiation of the U937 leukaemic cell line and blasts from patients with AML. 1,25(OH)2D3 and GM-CSF synergistically increased functional and phenotypic aspects of differentiation in the U937 cell line. In addition, the effective concentration of 1,25(OH)2D3 was reduced by up to 100 times in the presence of GM-CSF. GM-CSF alone had little differentiation-inducing effect on AML blasts. 1,25(OH)2D3 induced CD14 antigen expression in 67% AML blast populations and increased functional activation in 36%. 1,25(OH)2D3 and GM-CSF in combination cooperated to further induce CD14 antigen expression in one third of blast populations, while having no further effect on function. Failure to induce functionally effective levels of FcRII antigen on AML blasts following stimulation with 1,25(OH)2D3 and GM-CSF may account for the lack of functional activation.

Aztreonam plus vancomycin versus gentamicin plus piperacillin as empirical therapy for the treatment of fever in neutropenic patients: a randomised controlled study

The efficacy of aztreonam in combination with vancomycin was compared with that of gentamicin plus piperacillin as empirical antibiotic treatment for fever in 61 neutropenic patients. Aztreonam plus vancomycin was as effective, but no more effective, than gentamicin plus piperacillin. Aztreonam showed excellent clinical and in vitro efficacy against Gram-negative pathogens. Failure to respond to aztreonam plus vancomycin was, in most cases, due to presumed or documented fungal infection; by contrast, failure to respond to gentamicin plus piperacillin was frequently to be due to resistant or superadded infection with Gram-positive bacteria.

Absorption of low and therapeutic doses of ferric maltol, a novel ferric iron compound, in iron deficient subjects using a single dose iron absorption test

Ferric maltol is a novel ferric iron compound with potential use as an oral therapy for iron deficiency anaemia. Using a single, low dose iron absorption test we compared absorption of ferric maltol with absorption of ferrous sulphate in 21 iron deficient subjects. Absorption of 10 mg of ferric maltol as either aqueous solution or a single tablet compared favourably with that of an equivalent dose of ferrous sulphate. At a higher, more therapeutic dose of 60 mg elemental iron as tablets, absorption of ferric maltol appeared to be both more rapid and total absorption greater, than that seen with ferrous sulphate. We conclude that iron from ferric maltol, both at low dose and higher, more therapeutic doses, is at least as well absorbed as from ferrous sulphate. Ferric maltol is the first ferric iron formulation to be absorbed to a degree equivalent to that of ferrous iron salts and may represent a viable form of administration for ferric iron in the treatment of iron deficiency anaemia.

A randomized study of teicoplanin plus ciprofloxacin versus gentamicin plus piperacillin for the empirical treatment of fever in neutropenic patients

We compared the combination of teicoplanin plus ciprofloxacin with gentamicin plus piperacillin for the empirical treatment of fever in 80 neutropenic patients. A favourable clinical response rate was achieved in 28/38 (74%) patients receiving teicoplanin plus ciprofloxacin and in 17/35 (49%) of those receiving gentamicin plus piperacillin (P = 0.05). Microbiologically documented infections accounted for 55% of febrile events. When these episodes were analysed separately, response to teicoplanin plus ciprofloxacin remained unchanged at 74% whereas only 35% patients responded to gentamicin and pieracilin (P = 0.034). Gram-positive organisms accounted for 78% bacterial isolates with Staphylococcus epidermidis the most common pathogen. Ten out of 12 (83%) Staph. epidermidis infections resolved when treated with teicoplanin and ciprofloxacin as compared with a response rate of only two out of eight (25%) with gentamicin and piperacillin (P = 0.032). The combination of teicoplanin and ciprofloxacin was associated with no severe drug-related adverse events; by contrast, two patients receiving gentamicin plus piperacilin were withdrawn owing to adverse drug reactions, one with acute renal failure and one following a severe allergic reaction to piperacillin. We conclude that teicoplanin with ciprofloxacin is more effective than gentamicin plus piperacillin for the empirical treatment of febrile neutropenic patients. The high incidence of Gram-positive infection in our unit probably justifies the use of a specific anti-Gram-positive agent in the first-line antibiotic regimen.

Assessment of the interaction between ciprofloxacin and teicoplanin in vitro and in neutropenic patients

The interactions of ciprofloxacin and teicoplanin were investigated against methicillin-sensitive and methicillin-resistant Staphylococcus aureus and Staph. epidermidis isolated during a clinical trial of the efficacy of this combination. In-vitro studies of the combination of ciprofloxacin and teicoplanin found no evidence of any antagonism between these two drugs in terms of inhibition of bacterial multiplication, as determined by Fractional Inhibitory Concentration Indices, and lethality. Clinical use of teicoplanin plus ciprofloxacin as empirical therapy in 29 febrile neutropenic patients revealed an overall response rate of 75%. Response rate for staphylococcal infections, which accounted for 53% of isolated pathogens, was 80%. No serious adverse drug reactions were seen. Our results show that both in vitro, and in the treatment of febrile neutropenic patients, teicoplanin plus ciprofloxacin is an effective anti-staphylococcal combination.

IgG subclass levels and immune reconstitution after T cell-depleted allogeneic bone marrow transplantation

Defects of humoral immunity are well documented after bone marrow transplantation (BMT). Immunoglobulin recovery can be impaired and selective deficiencies of IgG subclasses have been reported. The nature of these deficiencies may reflect patterns of infection in the post-BMT period. We studied immunoglobulin and IgG subclass recovery in 20 long term (greater than 100 days) survivors of T depleted allogeneic BMT. Although there was no fall in mean levels of IgG, IgM or IgA for the patient group, 14 patients (70%) developed a deficiency of one or more immunoglobulin isotype at some stage post-BMT. Eight patients (40%) had deficiency of IgG, IgA and IgM and six had selective deficiencies. When IgG subclasses were measured it was seen that mean levels of IgG2 and IgG4 fell post-BMT with trough levels occurring at around 120 days post-transplant. Sixty per cent of patients developed IgG2 subclass deficiency and of these patients 78% had an associated IgG4 deficiency. Deficiencies of IgG1 and IgG3 were less common and less prolonged than those of IgG2 and IgG4; in addition, mean levels of IgG1 and IgG3 showed a rise early post-BMT. In conclusion, a majority of our patients developed immunoparesis following BMT, usually at around 120 days after transplantation. IgG2 subclass deficiency, often in association with IgG4 deficiency, is common and may occur despite normal total IgG levels. Deficiencies of immunoglobulin and IgG subclasses may persist for longer than 1 year post-BMT. Differing profiles of immunoglobulin and IgG subclass recovery may help dictate patterns of infection in long-term survivors of BMT.

Gamma interferon augments functional and phenotypic characteristics of vitamin D3-induced monocytoid differentiation in the U937 human leukaemic cell line

We studied the effect of gamma interferon on 1,25-dihydroxyvitamin D3 (1,25(OH)2D3)-induced differentiation of the human leukaemic cell line U937. Both phenotypic and functional aspects of 1,25(OH)2D3-induced differentiation were significantly augmented by gamma interferon (IFN). Gamma interferon had little effect alone but increased butyrate esterase staining and expression of CD14 antigen and the 40 kD Fc receptor (FcRII) in response to 1,25(OH)2D3. Ability to phagocytose IgG-opsonized bacteria, and superoxide burst in response to both IgG-opsonized bacteria and phorbol ester, was greater after incubation with both IFN and 1,25(OH)2D3 than with either agent alone. The degree of functional activation of cells showed a positive correlation with FcRII expression. In addition, IgG-induced generation of superoxide by differentiated cells was considerably reduced by pre-incubation with the anti-Fc receptor antibody IV3. We conclude that gamma interferon augments 1,25(OH)2D3-induced differentiation and functional activation of the U937 cell line. Increased functional activation may, in part, be due to up-regulation of surface FcR11.

A comparative study of intravenous ciprofloxacin and benzylpenicillin versus netilmicin and piperacillin for the empirical treatment of fever in neutropenic patients

We examined the efficacy of ciprofloxacin as an empirical treatment for fever in 97 neutropenic patients in a randomized study of ciprofloxacin and benzylpenicillin versus netilmicin and piperacillin. Benzylpenicillin was included because of evidence of in-vitro resistance to ciprofloxacin in some streptococci. Clinical response rate was similar in the two groups (46% resolution for ciprofloxacin/benzylpenicillin and 52% for netilmicin/piperacillin). Microbiological assessment revealed more pathogens eradicated by ciprofloxacin and benzylpenicillin (66%) and fewer persisting (3%) than in patients receiving netilmicin and piperacillin (52% and 13% respectively). Staphylococcus epidermidis was the commonest pathogen, accounting for 38% of all isolates and 30% of all treatment failures. There were no treatment failures or superinfections due to streptococci. More therapy-related adverse reactions were seen in patients on netilmicin and piperacillin (28%) compared with those on ciprofloxacin and benzylpenicillin (10%). The combination of ciprofloxacin and benzylpenicillin is as effective as a standard regimen of netilmicin and piperacillin, with fewer adverse effects, and is highly attractive as empirical therapy for the febrile, neutropenic host. The inclusion of benzylpenicillin prevents streptococcal-associated treatment failure.

Intravenous ciprofloxacin as empirical treatment of febrile neutropenic patients

A randomized study of treatment with ciprofloxacin combined with benzylpenicillin (CB) versus a standard regimen of netilmicin combined with piperacillin (NP) as first-line empiric therapy was conducted in febrile neutropenic patients. Ninety-six patients were evaluable for determination of efficacy: 50 patients received CB and 46 patients received NP. There was no significant difference between the two groups in terms of age or primary diagnosis. Overall clinical response rate at the end of therapy was 66 percent for CB and 65 percent for NP. Microbiologic assessment revealed more pathogens eradicated by CB (64 percent) and fewer persisting (4 percent) than in the NP group (52 percent eradicated, 13 percent persisting). Only 10 percent of patients in the CB group had treatment-related adverse reactions as opposed to 28 percent of the NP-treated patients; these were predominantly renal impairment and were likely to have been due to the aminoglycoside. Staphylococcus epidermidis was the most commonly isolated pathogen, accounting for 38 percent of all isolates and 30 percent of all patients in whom treatment failed. Although streptococci accounted for 18 percent of the isolated pathogens, no treatment failures or superinfections were due to these organisms. This indicates an advantage of combining ciprofloxacin with benzylpenicillin. We conclude that the CB regimen is as effective as the NP treatment and is associated with fewer side effects.

Cytomegalovirus seroconversion in patients receiving intensive induction therapy prior to allogeneic bone marrow transplantation

Cytomegalovirus (CMV) seropositivity in recipients of an allogeneic bone marrow transplant (BMT) is a major risk factor for development of post-transplant CMV infection. CMV serology was assessed in 98 patients during intensive chemotherapy for haematological malignancy prior to allogeneic BMT. Thirty-seven patients eventually received a BMT; the remaining 61 patients were treated with chemotherapy alone. The proportion of seropositive patients in the BMT group increased from 36% to 48% between presentation and transplantation. This represents an increase in recipient seropositivity of 33% as a direct result of pre-transplant therapy. Mean time to seroconversion was 186 days. Seropositivity in patients receiving chemotherapy only increased from 43% to 56% during treatment and follow-up. The most likely source of the CMV acquired by these patients is CMV-infected blood products. We suggest that, wherever possible, CMV-negative blood products should be used exclusively from presentation to support all patients receiving chemotherapy in whom BMT is a therapeutic option.