Autografting with bone marrow exposed to multiple courses of very high dose cyclophosphamide in vivo and to 4-hydroperoxycyclophosphamide in vitro

Intensive chemotherapy prior to harvesting autologous bone marrow may be advantageous for cancers that infiltrate the bone marrow. This approach, however, may deplete hemopoietic reserves or damage the hemopoietic microenvironment and thereby jeopardize posttransplant engraftment; in vitro treatment of bone marrow to ensure a tumor-free state may enhance the risk of nonengraftment. We addressed these concerns in a pilot study of patients with disseminated neuroblastoma. Bone marrow was harvested after initial intensive therapy that included 1) three to six courses of very high dose cyclophosphamide (CPM) (100-140 mg/kg in five patients, 140-160 mg/kg in nine patients), plus doxorubicin and vincristine, followed by 2) a median of three strongly myelosuppressive courses of cisplatin/VP16. The median interval between courses was 23 days. The marrow was treated in vitro with the CPM congener 4-hydroperoxycyclophosphamide (4-HC) and cryopreserved. It was infused after a massive cytoreduction regimen of melphalan 180 mg/m2 (n = 7) or thiotepa 900 mg/m2 (n = 7), plus cisplatin, BCNU, VP16, and local radiation. All 14 patients reconstituted hemopoiesis (median of 37 days to neutrophils greater than or equal to 500/microliter and of 63 days to platelets greater than 50,000/microliters). The number per kilogram body weight of hemopoietic progenitor cells (CFU-GM, BFU-E) in the autografts correlated significantly with the rate of hematologic recovery. Preharvest CPM dosage, however, did not. The use of thiotepa, as opposed to melphalan, was associated with a significantly slower posttransplant platelet recovery, suggesting a possible adverse effect of high-dose thiotepa on posttransplant hemopoiesis. In sum, while reinforcing evidence of a stem cell sparing effect of CPM, this pilot study more importantly delineates the degree to which high-dose alkylator therapy can be exploited to attain maximal dose intensity beginning at diagnosis. This aggressive treatment approach may have wide applicability, since CPM is among the most active agents against a spectrum of pediatric cancers.

Radiosensitivity of NK lytic activities and NK-mediated hematopoietic colony inhibition: effect of activation with IL-2 and blocking of the T-200 molecule

NK cells are capable of a variety of effector functions including the unprimed lysis of certain tumor cell targets and the nonspecific suppression of hematopoietic colony formation. In this study we have evaluated in parallel the radiosensitivity of lytic and colony inhibitory activity (CIA) by peripheral blood lymphocytes and large granular lymphocytes before and after activation by 72-96 hr of culture in medium containing interleukin 2 (IL-2). Our results show that (1) cells exhibiting CIA and lytic activities have almost identical patterns of radioresistance both before and following activation by IL-2; (2) the amount of preculture irradiation which completely blocks IL-2-stimulated cell proliferation only minimally affects CIA and lytic activities; (3) lysis of K562 and inhibition of CFU-GM are more resistant to preculture irradiation than is the killing of NK insensitive targets; (4) both the CIA and the lytic activities of PBL, but not of LGL, can be increased by 500-1000 rad of gamma-irradiation; and (5) NK lytic activity and CIA both before and following activation by IL-2 are primarily mediated by cells bearing the NKH1A antigen. Evidence that suggests NK cells mediate both the lysis of K562 and the inhibition of myeloid cells by a common mechanism came from experiments which showed that a monoclonal antibody to the T-200 molecule (13.3) could block both activities.

Survival of patients with chronic myelogenous leukaemia relapsing after bone marrow transplantation: comparison with patients receiving conventional chemotherapy

Treatment with busulphan and/or hydroxyurea rarely produces remission in patients with chronic myelogenous leukaemia (CML) in chronic phase. HLA-identical sibling transplants almost always produce remission, and only about 20% of patients relapse post-transplant. The increased anti-leukaemic efficacy of transplants results from intensive pretransplant treatment and immune-mediated anti-leukaemia effects. We studied 433 patients surviving > or = 2 years after diagnosis of CML to determine if patients who have relapsed after a transplant in chronic phase have longer survival from diagnosis than comparable subjects receiving chemotherapy. The chemotherapy cohort included 344 adults < 50 years of age treated on consecutive trials of the Italian Cooperative Study Group on CML between 1973 and 1986. The transplant cohort included 89 patients reported to the International Bone Marrow Transplant Registry who relapsed after an HLA-identical sibling bone marrow transplant carried out between 1978 and 1992. Survivals in the two groups were compared using Cox proportional hazards regression to adjust for prognostic variables. Median survival was 65 months in the chemotherapy cohort and 86 months in the transplant cohort. The 7-year probability (95% confidence interval) of survival was 34% (28-39%) in the chemotherapy cohort and 57% (43-70%) in the transplant cohort (P=0003). There was no difference in survival of patients relapsing after T-cell depleted and non-T-cell-depleted transplants. We conclude that patients who relapse after an HLA-identical sibling bone marrow transplant for CML in chronic phase have longer survival from diagnosis than comparable patients receiving chemotherapy. This effect is most likely to be the result of intensive chemotherapy and/or radiation given for pretransplant conditioning.

Loss of tolerance associated with disappearance of B cells in a patient sequentially transplanted with paternal and maternal bone marrow for the treatment of severe combined immunodeficiency disease

We have studied the tolerance of engrafted T cells from a severe combined immunodeficiency disease patient sequentially transplanted with T-cell-depleted bone marrow from both HLA haploidentical parents. The T cells from this patient were shown by HLA typing and cytogenetic analysis to be of material origin (donor of the second graft) while HLA typing of peripheral E--populations and of an Epstein-Barr virus-transformed B-cell line established 2 1/2 years after transplantation revealed the presence of host, maternal, and paternal (donor of the first graft) HLA antigens. When tested at 30 and 60 months after the last transplant, engrafted T cells from this patient had only weak mixed lymphocyte culture reactivity to paternal cells which could be inhibited by monoclonal antibodies to HLA-DQ and DR but not by anti-DP. T cells obtained 60 months after transplant were stimulated with paternal cells in both bulk and limiting dilution cultures and failed to generate typical allocytotoxic cells to paternal T- or B-cell targets. Mixed lymphocyte cultures performed at 71 months revealed an increased proliferative response by patient cells to paternal antigens; however, the engrafted T cells remained tolerant to maternal and host antigens. Limiting dilution analysis performed at this time revealed the presence of cytolytic cells directed to paternal antigens. There were no detectable B cells (only identified source of paternal antigen) as measured by immunofluorescent analysis of peripheral blood, nor any evidence of B-cell function as assessed by in vitro assays (proliferation to staphylococcus aureus Cowen strain A and mitogen-stimulated immunoglobulin production) or in vivo production of serum immunoglobulin at 60 and 71 months. The appearance of alloreactivity associated with the loss of B cells in this patient further supports the conclusion that the maintenance of tolerance to major histocompatibility complex disparate cells requires the continued in vivo presence of cells bearing the tolerizing antigens.

Bone marrow transplantation in two multiply transfused patients with thalassaemia major

Bone marrow transplantation has generally been unsuccessful when applied to patients with thalassaemia major over the age of 6 years. We report here two successful transplants for this disorder in a 7 1/2-year-old boy and an 11-year-old girl following a pre-transplant cytoreductive/immunosuppressive regimen of total body irradiation and cyclophosphamide. Complete durable engraftment of donor haematopoietic and lymphoid populations was documented through several approaches, including cytogenetic analysis, haemoglobin electrophoresis, globin chain synthetic ratios, red cell typing and DNA restriction enzyme analysis. Both patients are surviving in good health, 28 and 9 months from transplantation. The successful outcome in these patients demonstrates the feasibility of marrow transplantation for the treatment of thalassaemia in multiply transfused and, presumably, highly sensitized patients.

A novel HLA class II-independent TCR-mediated T cell activation mechanism is distinguished by the V beta specificity of the proliferating oligoclones and their capacity to generate interleukin-2

Superantigens can induce proliferative T cell responses after complex formation with major histocompatibility complex (MHC) class II antigens. In this study, highly purified variant T cells from a histocompatibility leukocyte antigen (HLA) (human major histocompatibility complex) class II-deficient patient were stimulated with toxic shock syndrome toxin 1 (TSST-1) in the presence of either HLA class II-negative or normal antigen-presenting cells (APC). The proliferative responses were similar to those of normal T cells even when HLA class II structures were absent on both responding T cells and costimulatory APC. However, the V beta specificity of responding T cells differed depending on the presence or absence of HLA class II antigens on the APC. In the presence of HLA class II-negative costimulatory APC, TSST-1 induced primarily proliferation of V beta 2-expressing T cells, whereas in the presence of normal APC virtually all responding T cells expressed V beta elements different from V beta 2. In addition, in the presence of normal APC, T cells responding to TSST-1 produced much higher amounts of interleukin-2 than T cells proliferating in the presence of HLA class II-negative APC. These findings suggest that T cells bearing selected V beta elements can directly interact with and respond to superantigen without involvement of HLA class II structures. Thus, our findings introduce a novel and distinct T cell receptor-mediated activation mechanism by which specific subpopulations of T cells respond to superantigen in the absence of HLA class II structures on APC.

Toxicological and immunological evaluation of the MHC-non-restricted cytotoxic T cell line TALL-104

The human MHC-non-restricted cytotoxic T cell line TALL-104 has been shown to display potent antitumor effects in several animal models with spontaneous and induced malignancies. In view of its potential future use in cancer therapy, we investigated the tolerability and target-organ toxicity of these cells in various animal species. The acute toxicity of TALL-104 cell administrations was evaluated in: (a) healthy immunocompetent mice and immunodeficient (SCID) mice bearing human tumors using multiple (up to 15) intraperitoneal (i.p.) injections, and (b) healthy dogs, tumor-bearing dogs, and healthy monkeys using multiple (up to 17) intravenous (i.v.) injections. TALL-104 cells were gamma-irradiated (40 Gy) prior to administration to mice and dogs, but administered without irradiation in monkeys. Cell doses ranged from 5 x 10(7)/kg to 10(10)/kg for each injection. All regimens were well tolerated, the main clinical signs observed being transient gastrointestinal effects. Moderate and transient increases in liver transaminase levels were observed in all animal species. Discrete and transient leukocytosis with neutrophilia was also noted in dogs and monkeys after i.v. injections of TALL-104 cells. Histological analysis revealed foci of hepatic necrosis with lympho-/mono-/granulocytic infiltration in immunocompetent mice injected i.p. with 5 x 10(9)-10(10) cells/kg. In the same mice, the colon showed an increased number of muciparous cells and alterations in the villi structure: these alterations were completely reversed by 72 h after the last injection, while liver alterations reversed more slowly (1 week). No delayed or chronic toxicity was observed in any of the animals even when non-irradiated TALL-104 cells were administered: both immunocompetent mice and healthy dogs were found to be grossly and histopathologically normal when sacrificed (1 year and 1 month after the last TALL-104 injection respectively). TALL-104 cells did not persist in these hosts. In addition, monkeys showed no molecular signs of TALL-104-cell-induced leukemia in their blood 1 year after the last cell injection. Despite immunosuppression, most of the tumor-bearing dogs as well as the healthy dogs and monkeys developed both humoral and cellular immune responses against TALL-104 cells. The data derived from these preclinical studies suggest that administration of high doses of irradiated TALL-104 cells is well tolerated and would be unlikely to induce severe toxicity if applied in clinical trials to the treatment of patients with refractory cancer.

Coronary angiographic nomenclature. Current status and a plea for standardization

Currently, there is no universal agreement on coronary angiographic anatomic nomenclature. A standardized version is proposed with regional anatomy as the unifying concept. The suggested nomenclature adds no new names to the long list currently in use but rather utilizes those arterial branch names which denote regional perfusion. The goals are to simplify the learning process and to provide more meaningful clinical communication.

Effects of hematopoietic growth factors following myeloablation in a primate model

The complex effects of hematopoietic growth factors (granulocyte and granulocyte-macrophage colony-stimulating factors and interleukin 3 and interleukin 1 beta) following myeloablation in juvenile male cynomolgus monkeys was studied. Since the effects of a given cytokine in vivo do not necessarily reflect the in vitro situation, and since cytokines are frequently species specific, extrapolation from rodent models to man may be fraught with inaccuracies. A primate model, therefore, was developed which has provided useful preclinical information on hematopoietic responses, dose response relationships and toxicities associated with administration of recombinant hematopoietic growth factors. This information has direct application to human trials.

Successful treatment of Diamond-Blackfan anemia with interleukin 3

This report describes the response of 18 Diamond-Blackfan anemia (DBA) patients to recombinant human interleukin 3 (rhIL-3). rhIL-3 was administered s.c. once daily on an escalating dose schedule (0.5-10 micrograms/kg/day). The rhIL-3 dose was escalated every 21 days until erythroid response was attained, grade III or IV nonhematologic toxicity was observed, or the maximal rhIL-3 dose was reached. Four patients experienced clinically significant erythroid responses. Two of the responders were steroid-dependent and transfusion-independent, while two were steroid-independent and transfusion-dependent. Baseline clinical or laboratory parameters, in particular in vitro bone marrow erythroid progenitor assays, were not useful in predicting rhIL-3 response. Two of the responding patients remain on maintenance rhIL-3 without diminution of effect at 490 and 855+ days. rhIL-3 was discontinued in the other two responders because of the development of deep venous thrombi.

Surgical implications of hepatic venocclusive disease following bone marrow transplantation

Hepatic venocclusive disease occurs with a spectrum of severity in an estimated 21% of bone marrow transplant patients. Clinical features include severe right upper quadrant pain, ascites, weight gain and initially minimal derangement of liver function. In contrast to hepatic graft versus host disease, venocclusive disease usually occurs within the first three weeks of engraftment and in autologous grafts. Urgent surgical consultation is requested when these features are prominent enough to mimic common acute processes requiring laparotomy. This condition must be included in the differential diagnosis in order to avoid an unnecessary laparotomy in this select group of patients who are usually severely thrombocytopenic and leukopenic. Clinical diagnosis alone is very reliable.

Dyshematopoiesis in combined immune deficiency with congenital neutropenia

This report describes a patient with combined immune deficiency associated with congenital neutropenia (CID/CN) and reports a partial characterization of his hematopoietic abnormalities. The CID/CN syndrome described is characterized by neutropenia and by deficiencies in B-lymphoid and T-lymphoid cell number and function. Red cell and platelet counts were normal. In vitro assays indicate that the myeloid lineage was developmentally arrested at the level of the committed monocyte/granulocyte progenitor (CFU-GM), while precursors to the CFU-GM progenitor were normal. In vitro studies showed that the defect in myeloid development was not corrected with G-CSF or GM-CSF. However, combinations of cytokines present in conditioned media from the T-cell lines MO or C5MJ, or defined multiple cytokine combinations containing IL-1, IL-3, GM-CSF, kit ligand, IL-6, and IL-9, restored myelopoiesis in-vitro. In contrast, C5MJ-conditioned media did not correct deficiencies in immune function in the patient's lymphocytes and accessory cells. No abnormalities in the production of G-CSF, GM-CSF, M-CSF, or IL-1 from the patient could be identified to account for the defects in myelopoiesis orimmune function.

Cytotoxic and proliferative T-cell clones with antidonor reactivity from a patient transplanted for severe combined immunodeficiency disease

Patients who have become split lymphoid chimeras (T cells of donor origin, B cells and monocytes of host origin) following transplantation of HLA-haploidentical marrow for the treatment of severe combined immunodeficiency disease provide a unique model for the study of tolerance. One such patient, UPN 345, was transplanted with maternal marrow and was found to have antidonor proliferative reactivity without detectable donor-directed cytotoxicity when tested at 18, 23, and 66 mos following bone marrow transplantation. In bulk culture, the proliferation to donor cells could be blocked by monoclonal antibodies to HLA-DR and -DQ. Nine clones with antidonor reactivity were established by limiting dilution techniques from a mixed lymphocyte culture between engrafted T cells and irradiated donor E rosette-negative cells. All of the clones were of maternal donor origin, and all were CD3+CD4+CD8-. The clones were tested for proliferative and cytotoxic activity toward donor, host, and paternal B-lymphoblastoid cell lines (B-LCL). Six clones proliferated strongly to maternal B-LCL but not to host B-LCL. Six clones were found to exclusively lyse maternal B-LCL. Four of the clones had both antidonor cytotoxic and antidonor proliferative reactivity. Monoclonal antibody blocking studies were performed on five of the six clones with cytotoxic activity. The antidonor cytotoxicity was not inhibited by monoclonal antibodies to class I determinants; however, three clones were inhibited in the presence of monoclonal antibody to DR, one clone was inhibited by anti-DQ monoclonal antibody, and one clone was inhibited by anti-DP monoclonal antibody. The cytotoxicity of all five clones was inhibited by monoclonal antibody to CD4. These data indicate that antidonor reactivity may also include a cytotoxic component which is not apparent in bulk cultures and which, based on our limiting dilution studies, is probably controlled by regulatory cells. Both the antidonor cytotoxicity and the antidonor proliferation appear to be directed primarily toward donor HLA class II antigens that are not shared with the patient.

Detection of posttransplant minimal disease chronic myelogenous leukemia by bcr rearrangement analysis

Until recently, cytogenetic detection of the Philadelphia chromosome (Ph) was the only reliable test to diagnose chronic myelogenous leukemia (CML) and detect minimal disease or early relapse following treatment. However, the recently developed ability to detect the Ph chromosome as a rearrangement in the bcr gene of chromosome 22 permits identification of the leukemic clone comprising as little as 5% of the cell population. We present results of simultaneous cytogenetic and DNA rearrangement studies in 28 CML patients considered for or treated with bone marrow transplantation. Our results show that the molecular method is significantly more sensitive than the cytogenetic method in the detection of minimal disease Ph-positive clones.

Purification and partial characterization of a human hematopoietic precursor population

This study reports the development of an assay, the Pre-colony-forming unit (CFU) assay, which detects human hematopoietic precursors. The Pre-CFU assay is based on the observation that precursors to CFU-granulocyte-macrophage (CFU-GM) that are undetectable in clonogenic assays differentiate into CFU-GM preferentially following treatment in suspension culture with recombinant human interleukin-1 alpha (rhIL-1 alpha) combined with rhIL-3. Using the Pre-CFU assay, hematopoietic precursors were detected in human bone marrow depleted of CFU-GM progenitors and differentiated hematopoietic elements via 4-hydroperoxycyclophosphamide treatment coupled with selection for CD34+ cells (4-HCresistant/CD34+ marrow). Additionally, the Pre-CFU assay detected recovery of hematopoiesis substantially earlier than the CFU-GM assay in primates following myeloablation with 5-fluorouracil. The Pre-CFU assay was used to asses purification of a phenotypically defined hematopoietic precursor population, the lin-CD34+ population. The lin-CD34+ population lacks detectable surface markers for T-cell, B-cell, natural killer cell, and myeloid lineage, possesses the CD34 antigen, is devoid of CFU-GM progenitors, and yields Pre-CFU assay values comparable with 4-HCresistant/CD34+ marrow. Using a combination of phenotypic analysis and Pre-CFU assay analysis, the action of rhIL-1 alpha plus rhIL-3 treatment on lin-CD34+ cells was further characterized. The data indicate that rhIL-1 alpha plus rhIL-3 treatment induces proliferation and differentiation of early hematopoietic precursors into progenitors and terminally differentiated cells, without inducing a significant expansion of the precursor population itself.