Germline CDKN2A mutation implicated in predisposition to multiple myeloma

Germline mutations of the CDKN2A (p16(INK4A)) tumor suppressor gene predispose patients to melanoma and pancreatic carcinoma. In contrast, mutations of the murine CDKN2A gene predispose BALB/c mice to pristane-induced plasmacytoma. We describe here a family in which a germline mutation of CDKN2A is present in 4 individuals who developed melanoma as well as in a fifth family member who is suffering from multiple myeloma. To determine whether the CDKN2A mutation predisposed the myeloma patient to her disease, we carried out loss of heterozygosity studies on sorted bone marrow from this individual and observed loss of the wild type CDKN2A allele in the malignant plasma cells. We suggest that germline mutations of CDKN2A may predispose individuals to a wider variety of malignancy than has been hitherto reported, but that the expression of these cancers may depend heavily on the genetic background of the patient. (Blood. 2000;95:1869-1871)

The National Cancer Data Base Report on treatment patterns for hepatocellular carcinomas: improved survival of surgically resected patients, 1985-1996

BACKGROUND

The Commission on Cancer data from the National Cancer Data Base (NCDB) has previously reported data evaluating time trends in various cancers, including such elements as stage of disease at diagnosis, treatment, and survival for multiple tumor sites. In this report, data collected from 1985, 1986, 1990, 1991, 1995, and 1996 for primary hepatocellular carcinoma (HCC) tumors are presented.

METHODS

The data presented in this review were collected from hospital cancer registries from across the U.S. Eight calls for data have yielded a total 6.9 million cases for the years 1985-1996, including 1158 HCC cases in 1985-1986, 3319 cases in 1990-1991, and 5683 cases in 1994-1995 from hospital cancer registries across the U. S. These data represent approximately 4.3%, 11.2%, and 14.8% of the estimated cases of carcinomas of the liver and biliary tract diagnosed in the U.S. in each of the three respective time periods.

RESULTS

The outcome for patients diagnosed with HCC remains poor, with only 10% of patients with American Joint Committee on Cancer Stage I disease surviving 5 years. Approximately 50% of patients received no therapy for their HCC, even those with early stage disease. Over these three time periods, the use of chemotherapy appears to have decreased. Among patients diagnosed with Stage II and III disease a difference in survival was noted between those treated with surgery only and those treated with chemotherapy only. Women appear to have a limited survival advantage over men.

CONCLUSIONS

In spite of an overall poor prognosis, subsets of patients with HCC appear to benefit from surgical resection/ablation of their tumor. The decreasing use of chemotherapy and the early reports of newer ablative techniques (e.g., cryotherapy) suggest that other treatment modalities are emerging. These NCDB data provide a baseline for HCC treatment from which prospective studies are being developed to assess the newer treatments as well as the underlying causes.

Ectopic expression of fibroblast growth factor receptor 3 promotes myeloma cell proliferation and prevents apoptosis

The t(4;14) translocation occurs in 25% of multiple myeloma (MM) and results in both the ectopic expression of fibroblast growth factor receptor 3 (FGFR3) from der4 and immunoglobulin heavy chain-MMSET hybrid messenger RNA transcripts from der14. The subsequent selection of activating mutations of the translocated FGFR3 by MM cells indicates an important role for this signaling pathway in tumor development and progression. To investigate the mechanism by which FGFR3 overexpression promotes MM development, interleukin-6 (IL-6)-dependent murine B9 cells were transduced with retroviruses expressing functional wild-type or constitutively activated mutant FGFR3. Overexpression of mutant FGFR3 resulted in IL-6 independence, decreased apoptosis, and an enhanced proliferative response to IL-6. In the presence of ligand, wild-type FGFR3-expressing cells also exhibited enhanced proliferation and survival in comparison to controls. B9 clones expressing either wild-type FGFR3 at high levels or mutant FGFR3 displayed increased phosphorylation of STAT3 and higher levels of bcl-x(L) expression than did parental B9 cells after cytokine withdrawal. The mechanism of the enhanced cell responsiveness to IL-6 is unknown at this time, but does not appear to be mediated by the mitogen-activated protein kinases SAPK, p38, or ERK. These findings provide a rational explanation for the mechanism by which FGFR3 contributes to both the viability and propagation of the myeloma clone and provide a basis for the development of therapies targeting this pathway.

Human herpesvirus 8 (KSHV) contamination of peripheral blood and autograft products from multiple myeloma patients

Human herpesvirus 8 (HHV-8), also known as Kaposi's sarcoma-associated herpesvirus (KSHV), has recently been identified within the bone marrow dendritic cells of multiple myeloma (MM) patients. This virus contains homologues to human cytokines such as IL-6 that could potentially stimulate myeloma cell growth and contribute to disease pathogenesis. Since mobilization chemotherapy may increase circulating dendritic cell numbers, we searched for HHV-8 in peripheral blood mononuclear cells (PBMCs) before and after mobilization chemotherapy given to MM patients. Furthermore, we determined if autograft purging using the CEPRATE SC device would reduce the percentage of HHV-8 infected stem cell products. Only two of the 39 PBMC samples collected prior to mobilization chemotherapy contained PCR detectable virus, yet nine of 37 PBMCs collected on the first day of leukapheresis had detectable HHV-8 (P = 0.016). HHV-8 was more frequently identified in autograft products before vs after Ceprate SC selection (40% vs 15%, P = 0.016). Although the role HHV-8 plays in myeloma pathogenesis remains unclear, these results imply that mobilization chemotherapy increases the numbers of circulating HHV-8-infected dendritic cells within the peripheral blood. In addition, CD34 selection of autograft products in MM patients may reduce the reintroduction of virally infected cells following high-dose chemotherapy. Bone Marrow Transplantation (2000) 25, 153-160.

Intensification of the stem cell transplant induction regimen results in increased treatment-related mortality without improved outcome in multiple myeloma

Randomized trials conducted by the Intergroupe Française du Myelome (IFM) demonstrate that the use of high-dose chemotherapy (HDCT) and stem cell transplantation (SCT) improves event-free (EFS) and overall survival (OS) in younger patients with multiple myeloma (MM). Nevertheless, current HDCT regimens remain inadequate as all patients ultimately relapse following SCT. In an attempt to improve the OS of MM patients post-SCT we used an escalated HDCT regimen incorporating both intensified melphalan (160 mg/m2) and fractionated total body irradiation (12 Gy) to maximize the dose response of myeloma cells to these agents and included infusional etoposide 60 mg/kg in an attempt to eradicate clonal B cells potentially contributing to the myeloma clone. One hundred patients with MM received this intensified SCT regimen. The 100-day treatment-related mortality was 12% predominantly reflecting the development of interstitial pneumonitis (IP) in 28% of patients of whom 7/28 (25%) died. The predicted 5-year OS and EFS following the diagnosis of MM were 60% and 35%, respectively. The median OS from the time of transplant is 41 months and the median EFS is 28 months. More than two prior chemotherapy regimens, previous radiation therapy (RT) and the presence of an abnormal karyotype involving chromosomes 11 or 13 were significantly predictive of poor outcome. Interferon maintenance was not associated with improved outcome. Intensification of the HDCT regimen utilizing etoposide together with escalated melphalan and TBI increases morbidity and mortality without increasing OS beyond that reported with less toxic regimens.

The National Cancer Data Base report on patterns of care for testicular carcinoma, 1985-1996

BACKGROUND

Previous Commission on Cancer data from the National Cancer Data Base (NCDB) have examined time trends in stage of disease, treatment patterns, and survival for selected cancers. In the current study data relating to patients diagnosed with testicular carcinoma in 1985, 1986, 1990, 1991, 1995, and 1996 are described.

METHODS

The data reported in this review were collected from hospital cancer registries from across the U.S. Case information is submitted to the NCDB following guidelines established by the North American Association of Central Registries. Data items include patient demographics, tumor characteristics, initial course of therapy, and follow-up status. Eight calls for data have yielded a total of 6.9 million cases for the years 1985-1996, including 2280 testicular carcinoma cases in 1985-1986, 5677 cases in 1990-1991, and 7452 cases in 1995-1996. These data represent approximately 22.6%, 47.3%, and 51.4%, respectively, of the estimated cases of testicular carcinoma diagnosed in the U.S. in each of these 3 respective time periods. Cases diagnosed and reported to the NCDB between 1985-1991 and that had been staged according to the 4th edition of the American Joint Committee on Cancer (AJCC) manual for the staging of cancer (1567) were used in the analysis of survival outcomes.

RESULTS

Four principle findings are reported. First, young men (age < 25 years) are diagnosed with advanced stage nonseminomatous germ cell tumors more frequently than are older men (age >/= 30 years). Second, although surgery and concomitant radiation are the standard therapy for early stage seminomas, surgery alone increasingly is being used. In the treatment of patients with advanced stage seminomas the use of surgery and radiation has declined slightly whereas surgery with concomitant chemotherapy appears to be employed with greater frequency. Third, surgery alone is the treatment of choice for patients with early stage nonseminomatous germ cell tumors and has been employed with increasing frequency over the three time periods studied. The use of surgery and concomitant chemotherapy has remained relatively stable over time in the treatment of patients with advanced stage nonseminomas. And fourth, survival rates decrease with increasing AJCC stage of disease.

CONCLUSIONS

The NCDB data regarding testicular carcinoma highlight a number of important trends in the presentation and management of testicular tumors. These trends not only evaluate new protocols of treatment but also can be used to direct new strategies toward achieving earlier patient presentation.

Shiga-like toxin-1 receptor on human breast cancer, lymphoma, and myeloma and absence from CD34(+) hematopoietic stem cells: implications for ex vivo tumor purging and autologous stem cell transplantation

The ribosome-inactivating protein, Shiga-like toxin-1 (SLT-1), targets cells that express the glycolipid globotriaosylceramide (CD77) on their surface. CD77 and/or SLT-1 binding was detected by flow cytometry and immunocytochemistry on lymphoma and breast cancer cells recovered from biopsies of primary human cancers as well as on B cells or plasma cells present in blood/bone marrow samples of multiple myeloma patients. Breast cancer cell lines also expressed receptors for the toxin and were sensitive to SLT-1. Treatment of primary B lymphoma, B-cell chronic lymphocytic leukemia, and myeloma B or plasma cells with SLT-1-depleted malignant B cells by 3- to 28-fold, as measured by flow cytometry. Depletion of myeloma plasma cells was confirmed using a cellular limiting dilution assay followed by reverse transcriptase-polymerase chain reaction analysis of clonotypic IgH transcripts, which showed a greater than 3 log reduction in clonotypic myeloma cells after SLT-1 treatment. Receptors for the toxin were not detected on human CD34(+) hematopoietic progenitor cells (HPC). HPC were pretreated with a concentration of SLT-1 known to purge primary malignant B cells and cultured for 6 days. The number of HPC was comparable in toxin-treated and untreated cultures. HPC were functionally intact as well. Colony-forming units (CFU) were present at an identical frequency in untreated and SLT-1 pretreated cultures, confirming that CFU escape SLT-1 toxicity. The results suggest the ex vivo use of SLT-1 in purging SLT-1 receptor-expressing malignant cells from autologous stem cell grafts of breast cancer, lymphoma, and myeloma patients.

Genetic manipulation of primitive leukemic and normal hematopoietic cells using a novel method of adenovirus-mediated gene transfer

Gene transfer into early hematopoietic cells has been problematic due to the quiescent nature of primitive cells and the lack of gene transfer vehicles with high efficiency for hematopoietic cell types. Previously, we have shown that adenoviral vectors can be used for the transduction of normal human progenitors with gene transfer efficiencies of approximately 30%. However, this approach is limited by relatively slow uptake kinetics (24-48 h) and a strong dependence on the presence of exogenous cytokines. Thus, we have modified this approach by combining adenoviral vectors with polycations to generate a virus-polycation complex, or VPC. Vehicles of this nature, when composed of conventional adenoviral vectors and polyamidoamine dendrimers, are a highly efficient means of transducing both normal and acute myelogenous leukemia (AML) cells. Moreover, the kinetics of gene transfer are markedly increased using the VPC strategy, with approximately 70% of transduction complete within 2 h. In this study, using viruses that encode green fluorescence protein (GFP), or the T cell costimulatory molecule B7.1 (CD80), we show that VPC-mediated gene transfer is an effective means of transducing normal and AML cells, including those with a highly primitive phenotype. Our data suggest that transient genetic manipulation of primitive hematopoietic cells can readily be achieved and should therefore permit a variety of research and clinical endeavors.

Retroviral-mediated transfer and expression of the multidrug resistance protein 1 gene (MRP1) protect human hematopoietic cells from antineoplastic drugs

Multidrug resistance protein (MRP1) is a member of the ATP-binding cassette (ABC) transmembrane transporter superfamily that confers multidrug resistance. The transfer and expression of the MRP1 gene in human hematopoietic stem cells may be a useful alternative to multidrug resistance (MDR1) gene transfer for protection from the myelosuppressive effects of chemotherapy in cancer patients. We constructed a gibbon ape leukemia virus packaging cell line (PG13) using the human MRP1 cDNA in a Moloney murine leukemia virus (MoMuLV) backbone containing a modified LTR. This PG13-based cell line, designated MRP1-PG13, produces retroviral vectors bearing the MRP1 gene at a titer of 1.7x10(5) viral particles/ml. Transduction of the human leukemic cell line K562 showed that viral MRP1-PG13 supernatants routinely transfer the MRP1 gene to approximately 35% of target K562 cells, of which at least one third are capable of proliferating in the presence of otherwise toxic concentrations of etoposide. Southern blot analyses indicated that most clones had only one proviral integration. Northern blot analysis of expanded K562 clones showed the presence of a major full-length approximately 8-kb MRP1 transcript as well as a minor approximately 6-kb transcript in all clones. Flow cytometric analysis of the producer cells and clones of transduced K562 cells demonstrated significantly increased MRP1 expression in these cells (approximately 30-fold increase). Human bone marrow mononuclear cells and CD34+ cells were also transduced with MRP1-PG13 supernatants on fibronectin-coated culture flasks in the presence of SCF, IL-3, and IL-6. PCR analysis of individual hematopoietic colonies in methylcellulose cultures demonstrated proviral DNA in approximately 10% of unselected human hematopoietic progenitor cells cultured from nonsorted mononuclear cell samples and in up to approximately 75% of progenitors when CD34-enriched cell populations were targeted. To assess functional MRP1 gene expression, normal human hematopoietic progenitors and K562 cells were cultured in methylcellulose assays containing vincristine or etoposide. All transduced samples gave rise to approximately 10% drug-resistant colonies, which were shown to be provirus-positive by PCR. Our studies document the development of an amphotropic MRP1 retroviral vector producer cell line and pave the way for large animal and preclinical studies of chemoprotection by MRP1 gene transfer.

Engraftment of gene-marked hematopoietic progenitors in myeloma patients after transplant of autologous long-term marrow cultures

We conducted a phase I hematopoietic stem cell (HSC) gene-marking trial in patients undergoing autologous blood or marrow stem cell transplant for the treatment of multiple myeloma. Between 500 and 1000 ml of bone marrow was harvested from each of 14 myeloma patients and 1 syngeneic donor. A mean of 3.3x10(9) cells per patient were plated in 20 to 50 long-term marrow culture (LTMC) flasks and maintained for 3 weeks. LTMCs were exposed on days 8 and 15 to clinical-grade neo(r)-containing retrovirus supernatant (G1Na). A mean of 8.23x10(8) day-21 LTMC cells containing 5.2x10(4) gene-marked granulocyte-macrophage progenitor cells (CFU-GM) were infused along with an unmanipulated peripheral blood stem cell graft into each patient after myeloablative therapy. Proviral DNA was detected in 71% of 68 tested blood and bone marrow samples and 150 of 2936 (5.1%) CFU-GM derived from patient bone marrow samples after transplant. The proportion of proviral DNA-positive CFU-GM declined from a mean of 9.8% at 3 months to a mean of 2.3% at 24 months postinfusion. Southern blots of 26 marrow and blood samples were negative. Semiquantitative PCR analysis indicated that gene transfer was achieved in 0.01-1% of total bone marrow and blood mononuclear cells (MNCs). Proviral DNA was also observed in EBV-transformed B lymphocytes, in CD34+ -enriched bone marrow cells, and in CFUs derived from the latter progenitors. Gene-modified cells were detected by PCR in peripheral blood and bone marrow for 24 months after infusion of LTMC cells. Sensitivity and specificity of the PCR assays were independently validated in four laboratories. Our data confirm that HSCs may be successfully transduced in stromal based culture systems. The major obstacle to therapeutic application of this approach remains the overall low level of genetically modified cells among the total hematopoietic cell pool in vivo.

Identification of c-myc promoter-binding protein and X-box binding protein 1 as interleukin-6 target genes in human multiple myeloma cells

Interleukin-6 (IL-6) is implicated in the in vivo proliferation of malignant plasma cells in multiple myeloma. To define the molecular basis of the IL-6-induced mitogenic response in myeloma cells, we applied STAR (subtractive transcriptional amplification of mRNA), a new differential expression analysis technology, to isolate mRNAs preferentially expressed in IL-6-treated versus untreated cultures of the factor-responsive myeloma cell line U266. From the resulting collection of STAR clones, sequence information was obtained for a total of 72 distinct transcripts. Of these, 29 were found to correspond to known genes, 22 matched expressed sequence tags in public databases and 21 showed no sequence similarity to any existing entries. Among the known genes uncovered in the screen were those encoding proteins that function in cell division, cell signalling and gene/protein expression. Northern blot analysis documented that two transcription factor genes chosen for further study, c-myc promoter-binding protein (MBP-1) and X-box binding protein 1 (XBP-1), were up-regulated in U266 cells about 3-fold relative to the cell cycle-dependent beta-actin gene 12 h after IL-6 treatment. Both genes were also similarly up-regulated by IL-6 in factor-dependent ANBL-6 myeloma cells. These results indicate that MBP-1 and XBP-1 are IL-6 genes in myeloma cells; as such, they may play a role in IL-6-mediated growth control in multiple myeloma.

Cloning and expression analysis of a novel WD repeat gene, WDR3, mapping to 1p12-p13

WD repeat proteins are components of multiprotein complexes that are involved in a wide spectrum of cellular activities, such as cell cycle progression, signal transduction, apoptosis, and gene regulation. These proteins are characterized by repeat units bracketed by Gly-His and Trp-Asp (GH-WD). We report here the isolation of a new member of the WD repeat gene family, WDR3, which encodes a putative 943-amino-acid nuclear protein consisting of 10 WD repeat modules. WDR3 is widely expressed in hematopoietic cell lines and in nonhematopoietic tissues. Fluorescence in situ hybridization mapped WDR3 to human chromosome 1p12-p13, a region that is affected by chromosomal rearrangements in a number of hematologic malignancies and solid tumors.

Combined results of two phase II studies of Taxol (paclitaxel) in patients with relapsed or refractory lymphomas

This study was performed to determine the clinical activity and safety of paclitaxel in the treatment of patients with refractory or relapsing aggressive Non-Hodgkin's lymphoma (NHL). Between May 3, 1994 and February 16, 1996, 39 patients with refractory or relapsing NHL consented to be enrolled in two, multicenter, open-labelled studies to evaluate the efficacy, safety, time to progression and overall survival of paclitaxel given at a dose of 175 mg/m2 by a 3-hour IV infusion every three weeks without G-CSF use. Data from the two studies is combined. One patient, although registered, did not receive treatment. Of the remaining 38 patients, 17 men and 21 women aged 26-82 years (median 60) were given 104 courses of paclitaxel [median 2 (range 1-6)]. Seventeen patients had stage IV, 7 stage III, 8 stage II, 5 stage 1 and 1 unknown stage of disease. Histologic grades included 1 low, 33 intermediate, and 4 high. Three patients had bone marrow involvement. Median time from diagnosis to study entry was 19 months (1-160). The median number of previous chemotherapy regimens was 2 (range 1-6). Three of the 35 (8.6%) patients evaluable for response had partial remission (PR) of their disease for 1-7 months (median 2) and 11/35 (31.4%) stable disease (SD) for 1 to 19 months (median 3). All three responders and 3 of the 11 SD patients had received paclitaxel after relapsing from a CR. At analysis, nine of the 38 patients were alive. Median duration of follow up at analysis was 6 months (3 days-29 months). The estimated survival rates for all patients at 1 and 2 years are 34% and 27%, respectively (Kaplan-Meier) from the start of paclitaxel treatment. The median survival time was 5.4 months (3 days to 28+ months). Febrile neutropenia occurred in two patients. Seven (18%) patients developed a neutrophil nadir of < 0.5 x 10(9)/L and 2 (5%) patients developed a platelet nadir of < 50 x 10(9)/L. Six patients received blood transfusions. Non-hematologic toxicity was generally mild to moderate with all patients experiencing some toxicity. Twenty-seven patients experienced grade III toxicity including: alopecia (n = 19), pain (n = 9), fatigue (n = 5), nausea/vomiting (n = 3), diarrhoea (n = 2), pulmonary/shortness of breath (n = 2), anorexia (n = 1) and fluctuating levels of consciousness and somnolence (n = 1). Two patients experienced grade IV toxicity (infection, peripheral neuropathy, pain). No patient discontinued paclitaxel for a severe hypersensitivity reaction. In summary, administered as a 3-hour infusion, paclitaxel 175 mg/m2 results in mild myelotoxicity but minimal antitumor activity in patients with refractory NHL.

A novel role for carbonic anhydrase: cytoplasmic pH gradient dissipation in mouse small intestinal enterocytes

1. The spatial and temporal distribution of intracellular H+ ions in response to activation of a proton-coupled dipeptide transporter localized at the apical pole of mouse small intestinal isolated enterocytes was investigated using intracellular carboxy-SNARF-1 fluorescence in combination with whole-cell microspectrofluorimetry or confocal microscopy. 2. In Hepes-buffered Tyrode solution, application of the dipeptide Phe-Ala (10 mM) to a single enterocyte reduced pHi locally in the apical submembranous space. After a short delay (8 s), a fall of pHi occurred more slowly at the basal pole. 3. In the presence of CO2/HCO3--buffered Tyrode solution, the apical and basal rates of acidification were not significantly different and the time delay was reduced to 1 s or less. 4. Following application of the carbonic anhydrase inhibitor acetazolamide (100 microM) in the presence of CO2/HCO3- buffer, addition of Phe-Ala once again produced a localized apical acidification that took 5 s to reach the basal pole. Basal acidification was slower than at the apical pole. 5. We conclude that acid influx due to proton-coupled dipeptide transport can lead to intracellular pH gradients and that intracellular carbonic anhydrase activity, by facilitating cytoplasmic H+ mobility, limits their magnitude and duration.

Multicenter phase III trial to evaluate CD34(+) selected versus unselected autologous peripheral blood progenitor cell transplantation in multiple myeloma

High-dose chemotherapy followed by autologous transplantation has been shown to improve response rates and survival in multiple myeloma and other malignancies. However, autografts frequently contain detectable tumor cells. Enrichment for stem cells using anti-CD34 antibodies has been shown to reduce autograft tumor contamination in phase I/II studies. To more definitively assess the safety and efficacy of CD34 selection, a phase III study was completed in 131 multiple myeloma patients randomized to receive an autologous transplant with either CD34-selected or unselected peripheral blood progenitor cells after myeloablative therapy. Tumor contamination in the autografts was assessed by a quantitative polymerase chain reaction detection assay using patient-specific, complementarity-determining region (CDR) Ig gene primers before and after CD34 selection. A median 3.1 log reduction in contaminating tumor cells was achieved in the CD34 selected product using the CEPRATE SC System (CellPro, Inc, Bothell, WA). Successful neutrophil engraftment was achieved in all patients by day 15 and no significant between-arm difference for time to platelet engraftment occurred in patients who received an infused dose of at least 2.0 x 10(6) CD34(+) cells/kg. In conclusion, this phase III trial demonstrates that CD34-selection of peripheral blood progenitor cells significantly reduces tumor cell contamination yet provides safe and rapid hematologic recovery for patients receiving myeloablative therapy.

Adenovector-mediated gene delivery of interleukin-2 in metastatic breast cancer and melanoma: results of a phase 1 clinical trial

We conducted a phase 1 trial of direct injection of an E1, E3-deleted adenovirus encoding interleukin-2 (AdCAIL-2) into subcutaneous deposits of melanoma or breast cancer. Twenty-three patients were injected at seven dose levels (10(7)-10(10) p.f.u). Local inflammation was observed at the site of injection in 60% of patients, but side-effects were otherwise minor. Incomplete local tumor regression occurred at the site of injection in 24% of patients, but no conventional clinical responses were seen. Circulating CD4 and CD8 counts fell significantly 24 h after injection. Post-injection biopsies demonstrated tumor necrosis and lymphocytic infiltration with the predominant tumor-infiltrating cells both CD3- and CD8-positive. Vector-derived sequences were detected in 14 of 18 biopsies examined 7 days after injection and vector-derived hIL-2 mRNA was detected in 80% of 7-day biopsies processed after injection of 10(8) p.f.u. of AdCAIL-2 or higher. While IL-2 was detectable by ELISA in tumor biopsies at 48 h, no protein was detectable in injected tumors after 7 days and no circulating IL-2 was detectable at any time-point. No Ad5E1 sequences were detected either before or after injection indicating absence of replication-competent virus or endogenous E1-like sequence; furthermore, only rare vector shedding was detected. Anti-adenovirus and neutralizing antibody titers were elevated 1 month after injection in all patients. This trial therefore confirms the safety of use of adenoviral vectors for gene delivery in humans and demonstrates successful transgene expression even in the face of pre-existing immunity to adenovirus.

Adoptive transfer of genetically modified human hematopoietic stem cells into preimmune canine fetuses

To develop a surrogate model system for assaying gene transfer into human hematopoietic stem cells (HSCs) with in vivo repopulating potential, we injected human marrow cells transduced with a reporter retroviral vector in long-term marrow cultures (LTMCs), into the yolk sacs of preimmune canine fetuses. Of eight mid-gestation fetuses injected through the exteriorized uterine wall and under ultrasound guidance, seven were born alive. One puppy died in the neonatal period accidentally. The remaining six puppies are all healthy at 31 months of age. There was no evidence for graft-versus-host disease or any untoward effects of in utero adoptive transfer of transduced human LTMC cells. All puppies were chimeras. Human cells, detected by fluorescence in situ hybridization, were present in blood, declining from 38% to 0.05% between 10 and 44 weeks after birth. Corresponding numbers for marrow were from 20% to 0.05%. Human cells were also detected in assays of hematopoietic cell progenitors and in stimulated blood cultures. All six puppies were positive for the presence of proviral DNA at various time-points after birth. In three dogs, provirus was detected up to 41 weeks after birth in blood or marrow, and in one dog up to 49 weeks in blood. These data support the further development of this large-animal model system for studies of human hematopoiesis.

Frequent monoallelic loss of D13S319 in multiple myeloma patients shown by interphase fluorescence in situ hybridization

Deletions or monosomy of chromosome 13 are frequent in multiple myeloma (MM). A candidate tumor suppressor gene might reside telomeric of the retinoblastoma gene (RBl) at band 13q14 and to play a role in B cell neoplasm. The D13S319 locus, between RB1 and D13S25 loci at 13q14 is the most commonly deleted marker in chronic lymphocytic leukemia (CLL) and non-Hodgkin's lymphoma (NHL). We evaluated the D13S319 locus in 24 MM cases by fluorescence in situ hybridization (FISH). We observed monosomy for D13S319 in 6/20 (30%) MM patients with an apparently normal karyotype. As expected, in four karyotypically abnormal MM cases with partial or complete monosomy for chromosome 13, all of them had monoallelic loss of D13S319. Our results indicated that the loss of D13S319 is commonly found in MM, even at diagnosis, and is more frequent than predicted based on conventional cytogenetic analysis of metaphase spreads. This finding implicates a candidate tumor suppressor gene at 13q14 in the pathogenesis of MM.

Presentation of tumor antigens

Dendritic cells, with their extraordinary capacity for initiating primary and secondary T-lymphocyte responses, may be pivotal in the development of immunotherapeutic strategies for multiple myeloma. Although host lymphocytes are able to recognize tumor-associated antigens (TAAs), many tumors are able to avoid dendritic cell-mediated immune surveillance. One reason may be that the tumor environment inhibits the maturation and activation of dendritic cells. A recently developed strategy to use dendritic cells in immunotherapy involves removing them from the tumor, pulsing them in vitro with antigen, and reinfusing them into the patient to generate responding T cells in vivo. Methods for reliably obtaining dendritic cells for therapeutic use are currently being investigated. Among other efforts to induce T-cell-mediated immunity against cancer, the presentation of tumor antigens by the tumor cells themselves is being investigated. Issues to be resolved include defects of antigen presentation by tumor cells and whether all cells present the same set of peptides. Moreover, as long as all the tumor antigens have not been identified, the tumor cell itself remains the primary source of unknown antigens and, therefore, is a worthwhile subject for study. Phase I trials of immunotherapy using adenovirus-infected autologous plasma cells have recently been undertaken. The adenoviral vectors carry genes with therapeutic potential, including interleukin-2 (IL-2), interleukin-12, and B7-1. Initial results showed that the vector can be readily detected in tumor cells at 13 days postinjection, and IL-2 expression was evident at 7 days. The chief side effect reported was inflammation.

The National Cancer Data Base report on carcinoma of the gallbladder, 1989-1995

BACKGROUND

Reports utilizing data from the Commission on Cancer's National Cancer Data Base (NCDB) have previously contained evaluations of time trends for stage of disease at diagnosis, treatment, and survival for multiple tumor sites. Data collected from 1989, 1990, 1994, and 1995 for carcinoma of the gallbladder are presented herein.

METHODS

The data presented in this review were collected from hospital cancer registries from across the U.S. Seven calls for data yielded a total of 5,850,000 cases for the years 1985-1995, including 2574 gallbladder carcinoma cases from 1989-1990 and 2914 cases from 1994-1995 from hospital cancer registries across the U.S. These data represent approximately 8.8% and 8.4% of the estimated cases of liver and biliary track cancers diagnosed in the U.S. during the two respective time periods.

RESULTS

There were no changes in patient demographics between 1989-1990 and 1994-1995. Most gallbladder carcinoma patients were white women. The documentation of tumor stage improved noticeably between the two study periods. There was no increased frequency in the occurrence of early stage tumors between the two reporting times, an era that saw the development and widespread application of laparoscopic cholecystectomy. Treatment differed according to stage of disease. Surgery alone, particularly nonradical surgery, was performed more frequently in the initial treatment of gallbladder carcinoma. A large percentage of gallbladder carcinoma patients received no definitive therapeutic intervention because of the advanced stage of disease at presentation and the lack of effective treatments for these cancers. Multimodality treatment was utilized more often for young patients. Survival was closely related to tumor stage, with 60% 5-year survival for Stage 0 patients, 39% for Stage I patients, and 15% for Stage II patients, but only 5% for Stage III patients and 1% for Stage IV patients. Patient outcome was not demonstrably affected by more aggressive therapy, nor was an adverse effect in results seen in early stage cancers between 1989-1990 and 1994-1995.

CONCLUSIONS

The NCDB data are valuable in the evaluation of trends in malignant diseases, treatments, and patient survival. No substantial differences were apparent in the diagnosis, treatment, and survival of patients during this 7-year study period. The data do not support any adverse effect on outcome results with the introduction of laparoscopic cholecystectomy in the U.S.

The National Cancer Data Base report on patterns of care for adenocarcinoma of the rectum, 1985-95

BACKGROUND

The Commission on Cancer data from the National Cancer Data Base (NCDB) examining current time trends (1985-1995) in stage of disease, treatment patterns, and survival relating to patients with rectal adenocarcinoma are described in this report.

METHODS

Seven calls for data to hospital cancer registries across the U.S. have yielded a total of 5,850,000 cancer cases for the years 1985-1995 and include 20,461 rectal and rectosigmoid junction adenocarcinoma cases in 1985-1986, 36,007 cases in 1989-1990, and 42,069 cases in 1994-1995. These data represent 24.4%, 44.5%, and 52.5%, respectively, of the estimated cases of rectal and rectosigmoid adenocarcinoma cases diagnosed in the U.S. in each of the 3 respective time periods. Analysis of the data is limited to cases with American Joint Committee on Cancer (AJCC) Stage I-IV disease.

RESULTS

Four trends were observed. 1) Stage I disease was diagnosed with decreasing frequency, decreasing from 37.1% of cases with known AJCC stage of disease in 1985-1986 to 33.8% in 1994-1995. 2) There was an increase in the frequency with which local excision was utilized as all or part of the primary treatment for Stage I disease. 3) Stage for stage, there was an increase in the frequency with which anterior/posterior resections were utilized and a corresponding decline in the use of abdominoperineal resections. 4) Multimodal treatment regimens are being used with greater frequency, particularly in patients with Stage II and III disease.

CONCLUSIONS

The NCDB data have important implications for analyzing cancer treatment and outcome in the U.S. These data suggest that rectal adenocarcinoma is being diagnosed at a later stage, especially among the young and African Americans. The guidelines for colorectal carcinoma screening issued by the American Cancer Society and the American Gastroenterological Association should be promoted more vigorously to increase the proportion of patients presenting with early stage disease and improve overall survival. The increased use of multimodal therapy for the treatment of Stage II and III disease continues.

Patterns of care for metastatic carcinoma of the prostate gland: results of the American College of Surgeons' patient care evaluation study

The annual incidence of prostate cancer more than doubled between 1984 and 1990, increasing from an estimated 76 000-200 000 cases respectively. Part of this increase may have been the result of increased detection. This study utilizes data from an American College of Surgeons Patient Care Evaluation (PCE) study to report on changes in the management of metastatic disease. Approximately 2000 hospitals were invited to submit data on a standard collection form designed by a multidisciplinary committee of specialists. Data were received from 730 hospitals on 14 716 patients with newly diagnosed cancer of the prostate in 1984, and from 1035 hospitals for 23 214 patients in 1990. Between 1984 and 1990 there was a decrease in the percentage of reported patients diagnosed with Stage IV disease, falling from 25.3-21.2%. The number of patients receiving a prostate specific antigen (PSA) test increased from 6.3-74.8% and the proportion of abnormal PSA results increased from 82-92.7%. The proportion of patients diagnosed by transurethral resection of the prostate (TURP) and perineal biopsy decreased, while an increase was noted in the proportion of men diagnosed by transrectal biopsy and transrectal ultrasound (TRUS). Treatment by orchiectomy alone increased from 31.8-40.7% of patients, while the administration of exogenous hormone therapy alone declined from 22.3-14.9% of patients. Two and five-year survival rates for the most common forms of therapy were 56.7% and 22.5% respectively for orchiectomy, 57% and 24.6% respectively for exogenous hormone therapy, and 50.3% and 23.5% respectively for no cancer directed therapy. Following a second course of therapy, the two-year survival rate for patients receiving a subsequent orchiectomy was 36.7 vs 17.8% for those receiving secondary exogenous hormone therapy. The percentage of patients diagnosed with Stage IV disease has decreased while prostate cancer diagnoses are being made more frequently utilizing the PSA test and TRUS biopsies. Hormone treatment remains the most common form of therapy with either orchiectomy or exogenous hormone therapy having higher survival rates than other common treatment modalities.

Molecular and serological examination of the relationship of human herpesvirus 8 to multiple myeloma: orf 26 sequences in bone marrow stroma are not restricted to myeloma patients and other regions of the genome are not detected

Human herpesvirus 8 (HHV-8) genomic sequences were recently detected by polymerase chain reaction (PCR) and in situ hybridization in bone marrow stromal cells grown from multiple myeloma (MM) patients, but not in cells from control subjects (Rettig et al, Science 276:1851, 1997). We sought to confirm these observations in our own group of MM patients (n = 30). DNA was extracted from adherent stromal cells grown under varying conditions and assayed for HHV-8 sequence using PCR to amplify the orf 26 (KS330) sequence (Chang et al, Science 266:1865, 1997), as initially reported. Samples from human control subjects (n = 25) were concurrently extracted and analyzed. After 30 cycles of amplification, we did not detect any positive samples. In a more sensitive nested PCR, samples from 18 of 30 (60%) MM patients were positive, at about the limit of detection, but orf 26 sequence was also amplified from 11 of 25 (44%) human control samples. However, PCR amplification from other regions of the viral genome (orf 72 and orf 75) was uniformly negative for all MM and control samples, despite equivalent sensitivity. Additionally, all sera from MM patients were negative for HHV-8 IgG by immunofluorescence. Our data do not support a role of HHV-8 in the etiology of MM but may suggest the presence of a related (KS330-containing) virus in MM patients and in some control subjects. This is a US government work. There are no restrictions on its use.

Safety of therapeutic anticoagulation in patients with multiple myeloma receiving autologous stem cell transplantation

The use of autologous stem cell transplantation (ASCT) for the treatment of multiple myeloma is increasing. Anticoagulation may be required during ASCT for conditions such as Hickman line thrombosis. The safety of anticoagulation in patients receiving ASCT is unknown. We report a retrospective case-control study of the safety of therapeutic anticoagulation in patients with multiple myeloma receiving ASCT. We identified 10 patients who received therapeutic anticoagulation during ASCT. For each of the 10 cases identified, two matched controls were selected. As a primary endpoint, bleeding complications were assessed. Secondary endpoints included survival, length of hospital stay, transfusion requirements, grade 4 toxicity, and days to platelet engraftment. Bleeding complications were not significantly different between patients receiving anticoagulation and controls (P = 0.3). Three of 10 anticoagulated patients and two of 20 controls had a bleeding complication. Mortality during admission was similar (P = 1.0); one anticoagulated patient and one control died of sepsis. A trend towards increased median number of platelet transfusions in the heparinized patients was seen (27 vs 12 units, P = 0.055), reflecting the higher transfusion threshold chosen for the anticoagulated patients. The other secondary endpoints did not differ between patients and controls. In this case control study, bleeding was not significantly increased in the group receiving anticoagulation during ASCT. This group electively received more units of platelets than controls. Thus, therapeutic anticoagulation can be managed with minimal increased toxicity during ASCT.

Ovarian function after autologous bone marrow transplantation

PURPOSE

To determine the frequency of return of ovarian function after autologous bone marrow transplantation (ABMT), and the major factors that predict recovery.

PATIENTS AND METHODS

Records of 200 consecutive women who underwent ABMT at the University of Toronto Autologous Blood and Marrow Program (Toronto, Canada) were reviewed. Seventeen patients met the inclusion criteria, which were (1) alive at the time of evaluation, (2) disease-free at least 18 months after transplantation, (3) age younger than 50 years at transplantation, and (4) premenopausal before transplantation. Recovery of ovarian function was determined by pregnancy or regular menses, with no menopausal symptoms and an estradiol level greater than 20 pmol/L off hormonal therapy.

RESULTS

All 17 patients became menopausal immediately after ABMT. Five patients (29%) recovered ovarian function a median of 24 months post-ABMT (range, 6 to 48 months). The median age at transplantation of women with restored ovarian function was 19 years (range, 19 to 28 years) versus 30 years (range, 22 to 48 years) for those who did not regain function. Younger age at transplantation predicted ovarian recovery (P = .03) by means of a log-rank test. Only one of five women who regained ovarian function received total-body irradiation (TBI) compared with five of 12 women who did not. Univariate analysis suggested a trend for TBI to predict a sustained loss of ovarian function (P = .067). The number of regimens of induction or salvage chemotherapy that contained an alkylating agent ranged from none to five and was not predictive (P = .45).

CONCLUSION

All women became menopausal after ABMT but 29% recovered ovarian function. Younger age at transplantation predicted return of ovarian function, whereas TBI may have had a negative effect.

Superior survival of young women with malignant melanoma

BACKGROUND

The Commission on Cancer data from the National Cancer Data Base (NCDB) relating to patients with malignant melanoma are used to examine patterns of long-term survival by patient gender and age, stage of disease, disease morphology, and anatomic subsite.

METHODS

Five calls for data have yielded more than 3,700,000 cases of cancer for the years 1985 through 1993, including 23,341 cases of malignant melanoma between 1985 and 1989, from hospital cancer registries across the US, representing slightly less than a quarter of all melanoma cases diagnosed in the US between 1985 and 1989.

RESULTS

Three statements can be made from this data: (1) There is little difference in the frequency of malignant melanoma between men and women with respect to stage of disease or morphology. However, differences between the genders do appear with respect to the anatomic subsite of melanotic tumors. (2) Overall, young women (45 years of age and under) enjoy superior survival rates when compared with older women (55 years of age and older) and men of any age. (3) The survival advantage held by young women is particularly pronounced among patients diagnosed with advanced stage disease.

CONCLUSIONS

These data suggest that factors present in younger women may be critical in the superior survival rates seen among premenopausal women and might be hormonal in nature.

A novel method for the direct quantification of gene transfer into cells using PCR in situ

There are several limitations to current methods for the detection of target genes following gene transfer. We report a novel PCR in situ procedure which overcomes many of these and permits the direct quantification of gene transfer in individual cells. PCR amplification of a proviral specific nucleotide sequence in target cells was followed by in situ hybridization using fluorescent probes complementary to different regions of the amplicon. Many of the problems previously encountered using in situ PCR, particularly the generation of false positive results and extracellular leakage of PCR products, were overcome by modifications of existing protocols. Positive cells were readily identified by fluorescence microscopy and a high sensitivity, specificity and correlation coefficient were demonstrated in mixing experiments using varying proportions of known provirus positive and negative cells. The method was applied successfully to identify low numbers of gene-modified hematopoietic cells in clinical specimens in a trial of retrovirus-mediated gene transfer into blood forming stem cells. This approach is simple and reliable, has the potential for use in a variety of gene therapy applications and may become the method of choice for the assessment of gene transfer efficacy.

Identification of sequence-tagged transcripts differentially expressed within the human hematopoietic hierarchy

Hematopoiesis is regulated by a complex gene expression program. To gain further insight into the molecular mechanisms underlying this process in humans, we sampled the transcriptional activity of the CD34+ hematopoietic progenitor line KG1a by single-pass sequencing the 5' ends of 1018 clones from a unidirectional cDNA library. Searches of public databases with the resulting expressed sequence tags (ESTs) identified 101 clones that showed no sequence similarity to any of the existing entries and that were therefore considered to derive from previously undescribed genes. Of the remaining 917 ESTs, 553 (a total of 485 distinct transcripts) corresponded to known genes. A further 279 KG1a ESTs matched or exhibited sequence similarity to ESTs or genomic sequences from humans and other species. Among the latter were putative human orthologs of developmental and cell cycle control genes from Caenorhabditis elegans, Drosophila, and yeast, as well as genes whose predicted amino acid sequences showed similarity to mammalian transcription factors. Hybridization of selected novel KG1a ESTs to globally amplified cDNAs prepared from single primary human hematopoietic precursors and homogeneous populations of terminally maturing hematopoietic cells revealed transcripts that are expressed preferentially at a specific stage or in a particular lineage within the hematopoietic hierarchy. Thus, included in the KG1a EST dataset are candidates for new human genes that may play roles in hematopoietic differentiative progression and lineage commitment.

Retrovirus-mediated gene transfer into human hematopoietic stem cells

Human hematopoietic stem cells genetically modified by retroviral-mediated gene transfer may offer new treatment options for patients with genetic disease. The potential of gene-modified hematopoietic stem cells as vehicles for gene delivery was first illustrated by the demonstration that hematopoietic systems of lethally irradiated mice can be reconstituted with retroviral vector transduced syngeneic bone marrow, and that these cells can in turn provide genetically marked progeny which persist in blood and marrow over extended time periods. In contrast, hematopoietic stem cells from large animals prove difficult to transduce with retroviral vectors and are consequently less likely to function as vehicles for long-term gene therapy. Indeed, clinically relevant levels of gene transfer into large animal and human hematopoietic stem cells has not been widely achieved. The need for improved retroviral vector systems and for understanding the biology of hematopoietic stem cell gene transfer continue to fuel intense research activity. Preliminary results from human stem cell gene marking and gene therapy trials currently underway are encouraging. This contribution reviews the underlying concepts relevant to retroviral-mediated gene transfer into hematopoietic stem cells. We survey the evolution of approaches for gene transfer into hematopoietic stem cells, from murine and large animal models to the first human clinical trials. Finally, we discuss new strategies which are currently being pursued.

Trends in the use of radiation and chemotherapy in the initial management of patients with carcinoma of the uterine cervix

PURPOSE

The Commission on Cancer of the American College of Surgeons conducts Patient Care Evaluation studies to describe practice patterns and trends in disease management. This report surveys changing strategies in the initial treatment of patients with invasive cancer of the uterine cervix.

METHODS AND MATERIALS

Using a standard data collection form designed by a multidisciplinary committee of specialists, cancer registrars at 703 hospitals submitted anonymous data on 11,721 total cervical cancer patients diagnosed in 1984 and 1990.

RESULTS

Between the two study years, the use of radiation as all, or a component, of the initial course of therapy declined from 70 to 60.3%, coincident with a 32.3% increase in the use of hysterectomy alone and a 33.7% reduction in the use of radiation alone. The percentage of all patients receiving combined hysterectomy and radiation (preoperative or postoperative) remained virtually unchanged--10.2% in 1984, and 9.3% in 1990. However, women who were treated by hysterectomy in 1990 were less likely to receive radiation as part of their treatment than patients treated by hysterectomy in 1984. Among patients treated by radiation without hysterectomy, the use of intracavitary brachytherapy techniques substantially exceeded interstitial brachytherapy techniques in both study years. Among patients treated by local radiation without hysterectomy, the frequency of adjunctive chemotherapy use increased from 6.9% in 1984 to 24.8% in 1990, with chemotherapy and radiation increasingly administered concurrently rather than sequentially. Although differences based on age, histology, race/ethnicity, and insurance status were observed, these general management trends were seen in all groups.

CONCLUSIONS

Changes in the utilization of radiation and surgery may reflect the increasing surgical involvement of gynecologic oncologists in the management of early stage cervical cancer, rather than significant alterations in the demographics of the disease. Although brachytherapy is recognized as an important component of radiation treatment, some patients may not receive the potential benefit of this modality. Despite controversy concerning its efficacy, the use of adjuvant systemic chemotherapy to supplement local treatment modalities appears to be increasing rapidly.

Peptide mimics as substrates for the intestinal peptide transporter

4-Aminophenylacetic acid (4-APAA), a peptide mimic lacking a peptide bond, has been shown to interact with a proton-coupled oligopeptide transporter using a number of different experimental approaches. In addition to inhibiting transport of labeled peptides, these studies show that 4-APAA is itself translocated. 4-APAA transport across the rat intact intestine was stimulated 18-fold by luminal acidification (to pH 6.8) as determined by high performance liquid chromatography (HPLC); in enterocytes isolated from mouse small intestine the intracellular pH was reduced on application of 4-APAA, as shown fluorimetrically with the pH indicator carboxy-SNARF; 4-APAA trans-stimulated radiolabeled peptide transport in brush-border membrane vesicles isolated from rat renal cortex; and in Xenopus oocytes expressing PepT1, 4-APAA produced trans-stimulation of radiolabeled peptide efflux, and as determined by HPLC, was a substrate for translocation by this transporter. These results with 4-APAA show for the first time that the presence of a peptide bond is not a requirement for rapid translocation through the proton-linked oligopeptide transporter (PepT1). Further investigation will be needed to determine the minimal structural requirements for a molecule to be a substrate for this transporter.

Testicular plasmacytoma following chemical orchiectomy: potential role of hypogonadism in myeloma proliferation

We present a case of a 55 year old man with multiple myeloma who underwent autologous stem cell transplantation and subsequently developed testicular myeloma. Testicular enlargement was observed only after treatment of an incidental prostatic adenocarcinoma with chemical orchidectomy at a time when myeloma was controlled systemically. A subsequent bilateral surgical orchiectomy revealed plasmacytoma in both testis. Enhanced production of B-lymphocytes after castration has been reported and implicates testosterone as a possible negative regulator of B-cell production. We propose that the androgen deficient state may have contributed to the development of plasmacytoma of the testes in our patient. The regulatory role of sex steroids in B-cell development is discussed.

Efficient adenovirus-mediated gene expression in malignant human plasma cells: relative lymphoid cell resistance

Although adenoviruses offer several potential advantages as gene transfer vectors, some hematopoietic cells, particularly lymphoid cells, are considered relatively resistant to adenovirus-mediated gene transfer. To examine the role of adenovirus-mediated gene transfer in the lymphoid malignancy multiple myeloma (MM), we used E1- and E3-deleted adenoviral vectors to infect myeloma and lymphoma cell lines and subsequently primary bone marrow plasma cells and lymphocytes from patients with MM. Adenoviral vectors expressing LacZ or luciferase (AdCA18) reporter genes were used initially. Subsequently, we studied adenoviral vectors expressing genes of potential value in therapeutic immunomodulation, i.e., CD80 (AdB7-1) and interleukin-2 (AdIL-2). A human plasma cell line (OCI-My5) infected with LacZ or AdB7-1 vectors expressed the corresponding gene product in 95% and 85% of exposed cells, respectively. Time course experiments indicated that maximum expression of adenoviral transgenes in plasma cells was reached 3 days after infection. IL-2 was detected in the supernatant of AdIL-2-infected plasma cells, was functional, and could be detected for at least 30 days after infection. In contrast, three lymphoma cell lines (OCI-Ly2, OCI-Ly13.2, and OCI-Ly17) were significantly less sensitive to adenovirus infection, with relatively low efficiencies of gene transfer even using high adenoviral titers: Surface CD80 expression (13-25% of infected cells) and positive LacZ staining (0-5% of infected cells). Indeed, expression of luciferase was 96-168 times higher in AdCA18-infected OCI-My5 cells than in the OCI-Ly2 lymphoma cell line. Similar patterns were observed in primary plasma cells and lymphocytes from 19 MM patient bone marrow samples. After infection with AdB7-1, increased levels of CD80 expression on CD38 bright bone marrow plasma cells were observed in 84% of patients, with a 33% average increase in the number of plasma cells expressing CD80. In contrast, although increased CD80 expression was also detected on AdB7-1-infected CD19+ B lymphocytes from 63% of the MM patients, an average of only 14% of the infected lymphocytes demonstrated increased expression of CD80. Circulating T lymphocytes could not be transduced with AdB7-1. The relative resistance of B and T lymphocytes to adenovirus-mediated gene transfer warrants further investigation. Adenoviral vectors can efficiently infect malignant plasma cells and may be useful vehicles for therapeutic gene transfer.

The National Cancer Data Base: report on kidney cancers. The American College of Surgeons Commission on Cancer and the American Cancer Society

BACKGROUND

The National Cancer Data Base (NCDB) examining current time trends (1993) in stage of disease, treatment patterns, and survival of patients with kidney cancer are reported.

METHODS

Five calls for data have yielded a total of 3,700,000 cancer cases for the years 1985 through 1993, including 8140 kidney cancer cases in 1988 and 10,617 in 1993 from hospital cancer registries across the U.S. These data represent 36% and 39% of all cases of kidney cancers diagnosed in the U.S. in 1988 and 1993, respectively.

RESULTS

Three trends were observed. 1) Stage II disease is being diagnosed with increasing frequency. 2) There has been an overall increase in the frequency with which surgery alone is utilized as the primary treatment for patients with Stage I, II, and III disease; however, surgical treatment of patients with Stage IV kidney cancer has declined. 3) Partial nephrectomy rather than total nephrectomy is performed with increasing frequency as surgical treatment of patients with Stage I renal carcinoma.

CONCLUSIONS

The NCDB data have important implications for analyzing cancer treatments and outcomes in the U.S. These data suggest that kidney cancers are being diagnosed at an earlier stage and with greater precision. As a result, changes in surgical practice are apparent in the treatment of patients with lower stage disease (Stage I and II). Stage for stage, surgery remains the most effective form of treatment for patients with kidney cancer.

Castleman's disease in a 44-year-old male with neurofibromatosis and pheochromocytoma

A case of Castleman's disease in a patient with type I neurofibromatosis and pheochromocytoma is reported. The association of pheochromocytoma and neurofibromatosis is well documented, but uncommon. Castleman's disease has not been previously documented in a patient with neurofibromatosis or pheochromocytoma and may represent a previously unrecognized association of this disease. Castleman's disease is an interleukin-6 (IL-6) mediated B-cell proliferation. We postulate a relationship between pheochromocytoma IL-6 secretion and Castleman's disease. The relevant literature relating to this unusual case is reviewed.

Role of splenectomy in gastric cancer surgery: adverse effect of elective splenectomy on longterm survival

BACKGROUND

Splenectomy, and in some cases pancreatico splenectomy, has been advocated by surgeons in an effort to improve clearance of metastatic nodes to splenic hilum (node 10) and splenic artery (node 11). Although splenectomy has known effects on increasing morbidity and even mortality after a variety of surgical maneuvers including gastrectomy, the longterm effect on survival is controversial. The purpose of this study is to review and analyze the effect of splenectomy on survival in patients having curative gastrectomy for stomach cancer.

METHODS

We reviewed the role of splenectomy in patients having curative gastrectomy in a data base of stomach cancer patients that had been collected in 1987 as part of an American College of Surgeons Patterns of Care Study. This analysis had involved 18,344 patients, of whom 11,252 were first diagnosed in 1982 as part of a longterm study, and 7,092 were first diagnosed in 1987 as part of a shortterm study. From the two data collection periods information was available on 12,439 patients who received cancer directed abdominal surgery; 21.2% of these patients received a splenectomy. Among the 3,477 patients reported as having a curative gastrectomy (pathologically clear margins), 26.2% received a splenectomy.

RESULTS

The operative mortality was 9.8% with splenectomy and 8.6% without splenectomy. In patients having a curative gastrectomy, the 5-year observed survival rate was 20.9% in patients having splenectomy versus 31% in patients who did not receive splenectomy (p < 0.0001). Examination of differences in survival by stage of diagnosis showed significantly reduced survival outcomes among patients with stage II and III, but not for those diagnosed with stage I or IV disease. The pattern of recurrence was moderately different with a larger proportion of patients having distant metastases among the group of patients who had undergone splenectomy compared with the patients who had not, 29% and 15.5%, respectively. Whether these differences are inherent in the splenectomy or in the associated cofactors was not determined in this study.

CONCLUSIONS

The data suggest elective splenectomy should generally be avoided in patients with stage II and III gastric cancer. In patients with resectable proximal advanced (stage IV) cancer or who have extension to spleen and pancreas or macroscopic nodal metastases to splenic hilum, splenectomy might be necessary to facilitate complete removal of the tumor in an effort to achieve longterm tumor control. The importance of surgical judgment is emphasized as the major deciding factor in determining the need for splenectomy in the individual cancer patient.

Salvage chemotherapy with mini-BEAM for relapsed or refractory non-Hodgkin's lymphoma prior to autologous bone marrow transplantation

BACKGROUND

The role of intensive chemotherapy with autologous blood and marrow transplantation (ABMT) for patients with relapsed or refractory intermediate grade non-Hodgkin's lymphoma has recently been established. However, conventional dose salvage chemotherapy is frequently used to determine chemotherapy sensitivity and reduce tumor bulk prior to intensive therapy. Different salvage regimens have been proposed but none appears significantly superior. The purpose of this study was to determine the efficacy of mini-BEAM salvage chemotherapy in patients referred for AMBT and to define prognostic factors of response.

PATIENTS AND METHODS

One hundred four patients referred for consideration of AMBT after failure of primary anthracycline-based chemotherapy received BCNU 60 mg/m2 day 1, etoposide 75 mg/m2 day 2-5, ara-C 100 mg/m2 q12 h day 2-5, melphalan 30 mg/m2 day 6 (mini-BEAM) until maximum tumor reduction. Median age was 52 (range 18-65), 57% had failed to achieve a complete response (CR) to doxorubicin-based chemotherapy at diagnosis and only 13% had a previous CR lasting > 12 months. Seventy-six received mini-BEAM as first salvage chemotherapy.

RESULTS

The overall response rate (RR) was 37% (95% confidence interval (CI) 28-46%) with 12 patients achieving CR and 25 achieving PR. The response rate among patients treated as first salvage was 43% compared to 20% for patients who had failed to respond to a previous salvage regimen. Only 15% of patients who failed to respond to mini-BEAM responded to another conventional dose salvage regimen. Thirty-eight of 104 patients ultimately demonstrated sufficient response to proceed to ABMT. Actuarial survival at four years is 22% for all 104 patients, and 36% for those who went on to AMBT. For those who were not transplanted, four-year survival was 18%. B symptoms and tumor burden at relapse were significant predictors of response to mini-BEAM in multivariate analysis, and identified a poor prognosis group of patients unlikely to be cured by the approach.

CONCLUSIONS

Mini-BEAM does not appear to be a superior salvage regimen in this high-risk group of relapsed or refractory NHL patients for whom ABMT was the ultimate treatment intention. Only one-third of patients referred for ABMT ultimately proceed to transplant; alternative treatment strategies should be developed for those with a low likelihood of cure by this approach.

A phase I study of interleukin-6 after autologous bone marrow transplantation for patients with poor prognosis Hodgkin's disease

We performed a pilot study of human recombinant IL-6 (SDZ ILs 969) in 6 patients with poor prognosis Hodgkin's disease following autologous bone marrow transplantation (ABMT) to determine its safety and tolerability. IL-6 was administered the day following bone marrow infusion by subcutaneous injection once daily at a dose of 1 micro/kg/day to 3 patients and 2.5 microg/kg/day to 3 patients and was continued for 6 weeks or until platelet engraftment (>50 x 10(9)/L independent of transfusion). No severe or life threatening toxicities were seen at either dose level. A reversible elevation in alkaline phosphatase occurred in 4 patients and all patients complained of headache, myalgias, and fever. Gastrointestinal toxicity was low, grade 3-4 mucositis occured less frequently than in similarly-treated historical controls receiving GM-CSF. Serum concentrations of other cytokines such as IL-3 and G-CSF after ABMT differed from results obtained in transplant recipients given GM-CSF. The median time to an ANC >0.5 x 10(9)/L was 25.5 days and to a platelet count of >20 x 10(9)/L independat of transfusion was 35.5 days. Engraftment was no different from controls. Five patients relapsed at a median of 5 months post-ABMT and four remain alive at a median of 12 months post-ABMT. We conclude that IL-6 administration is safe and well tolerated in patients following ABMT. Further efforts to evaluate its effect on hematopietic recovery as well as relapse following transplantation in a larger patient series are warranted.

In vitro maintenance and retroviral transduction of human myeloma cells in long-term marrow cultures

One objective of clinical gene marking trials in multiple myeloma (MM) is to determine the extent to which relapse after stem cell transplant is attributable to contamination of the autograft with myeloma cells. A requirement in these studies is ex vivo genetic marking of malignant cells present in autografts which are derived from patients exposed to significant prior chemotherapy. We evaluated gene marking of cloonogenic myeloma cells in marrow aspirates from 14 patients with MM. To effect gene transfer we utilized a long-term marrow culture (LTMC) system previously shown to facilitate gene transfer into a spectrum of hematopoietic progenitor and stem cells. Transduction of cells in LTMC was performed by multiple supernatant exposure. At LTMC initiation and after 21 days of culture malignant cells were assessed by morphology, flow cytometry, and polymerase chain reaction (PCR). The mean number of day 21 LTMC adherent layer-derived granulocyte/macrophage progenitors as a percentage of the original inoculum was within the normal range for this technique. The efficiency of transduction of normal hematopoietic progenitors as determined by the number of colonies positive for proviral DNA by PCR, G418 resistance, and X-gal staining was also within the expected range; 65%, 44% and 23%, respectively. Thus, there was no evidence that prior chemotherapy exposure or malignant cell contamination compromised cell survival or gene transfer efficiency in LTMC. All patients retained plasma cells in LTMCs for the duration of the 21-day culture period. Molecular analysis confirmed the persistence of clonal IgVH gene rearrangements in day 21 LTMC-derived DNA from 6 of 12 informative patients (50%). PCR using allele-specific primers when available confirmed the specificity of IgVH rearrangements for the myeloma clone. In 2 of the 14 patients, expansion of clonogenic cells was demonstrated in LTMC. In both cases there was strong evidence for transfer of reporter genes (neo and LacZ) into the myeloma clone: morphologically abnormal G418-resistant colonies demonstrated intense staining for beta-galactosidase, and cytospin preparations showed 100% plasma cells with monoclonal heavy and light chain restriction. In one patient, individual colonies positive for beta-galactosidase bore a cytogenetic abnormality characteristic of the patient's myeloma clone. PCR of DNA from pooled plasma cell colonies using tumor-specific CDR3 primers was positive. Our results demonstrate the maintenance of myeloma cells in vitro for up to 21 days in LTMC. They further illustrate that these cells can be genetically marked using transduction protocols currently being tested in clinical trials of hematopoietic cell gene transfer.

Autologous and allogeneic transplantation for multiple myeloma at a single centre

We report the results of a consecutive series of patients who underwent autologous (auto) (40), allogeneic (allo) (22) or syngeneic transplantation (2) for multiple myeloma (MM) at our centre. Median age at diagnosis was 45.5 (auto) and 43 (allo) years. Most patients had stage 2 (27% auto; 27% allo) or stage 3 (62% auto; 50% allo) disease and 73% demonstrated chemosensitivity prior to transplant. Median time from diagnosis to transplant was 18.6 months (auto) and 16.4 months (allo). Standard conditioning regimens were used. Median time to neutrophil engraftment was 11 days (7-18) (auto) and 18 days (13-24) (allo) and median time to platelet engraftment was 11 days (6-60) and 18 days (13-105), respectively. Ninety-day mortality was 5% (auto) and 27% (allo). Median follow-up was 15 months (6-48) (auto) and 42 months (24-52) (allo). Three-year progression-free survival (PFS) was 17 +/- 10% (auto) and 22 +/- 9% (allo) and 3-year overall survival (OS) was 74 +/- 11% (auto) and 32 +/- 10% (allo). Autologous transplantation for MM is a safe procedure with good OS although disease progression following transplant is frequent. Allogeneic transplantation has a high procedure-related mortality and PFS comparable to autologous transplantation but OS is poor. The early mortality and high OS of autologous transplantation in MM compares favourably with both the results of allogeneic transplantation and published results of standard therapy in this retrospective analysis.

Gastric carcinoma: does lymph node dissection alter survival?

BACKGROUND

Extragastric lymphadenectomy (D2 node dissection) is strongly supported by Japanese data to have survival benefit. Randomized trial data are either inconclusive or nonsupportive of this view. We have reviewed a prospectively gathered database of 18,346 cases of gastric carcinoma from a gastric cancer patient care evaluation study conducted by the American College of Surgeons to assess whether the performance of extragastric node dissection was associated with improved survival in patients who had resection with curative intent (all margins microscopically clear).

STUDY DESIGN

We reviewed a subgroup of patients with curatively resected gastric carcinoma and compared the outcome in patients having extragastric lymph node dissection with the outcome in patients who did not have dissection of N2 nodes.

RESULTS

Among the 3,804 patients having curative resection in the long-term study with more than a five-year follow-up, 695 had dissection of the nodes along the celiac axis, hepatic artery, or splenic artery (N2 nodes); 1,529 patients had removal of the adjacent nodes (N1 nodes) along the gastric tube or the gastric or perigastric nodes (N1 nodes); and 903 patients who had no nodes identified in the resection specimen (essentially N0 nodes removed). For patients having a dissection of N2 nodes, the median survival time was 19.7 months with a five-year survival rate of 26.3 percent; for patients having a dissection of N1 nodes, the median survival time was 24.8 months with a five-year survival rate of 30 percent; among patients having no nodes removed, the median survival time was 29.5 months with a five-year survival rate of 35.6 percent.

CONCLUSIONS

Lymph node dissection (D2) of N2 nodes did not augment survival compared with gastrectomy without node dissection or that included perigastric nodes in the resection. Subgroup analysis of patients with gastric carcinoma having a curative resection did not show benefit of the extragastric node dissection (D2). Continued study is warranted and the data from ongoing clinical trials may yield more conclusive information.

Intensive therapy and autotransplant for patients with an incomplete response to front-line therapy for lymphoma

BACKGROUND

Patients with Hodgkin's disease (HD) and intermediate or high-grade non-Hodgkin's lymphoma (NHL) who fail to achieve a complete remission (CR) with standard induction therapy have a poor prognosis with conventional-dose salvage therapy alone. We examined the role of subsequent intensive therapy and autologous bone marrow transplantation (ABMT) in patients who demonstrated a response to conventional-dose therapy.

PATIENTS AND METHODS

Sixty-six patients with either HD (n = 30) or NHL (n = 36) underwent intensive therapy with etoposide (60 mg/kg), intravenous melphalan (160-180 mg/m2) followed by infusion of unpurged autologous bone marrow and/or blood cells. All patients had advanced stage or bulky disease at diagnosis and failed to achieve a CR after an anthracycline-containing front-line chemotherapy regimen (NHL) or ABVD or equivalent regimen (HD). Patients who achieved a CR after involved-field radiotherapy were excluded. All patients demonstrated sensitivity to conventional-dose salvage treatment before advancing to intensive therapy and ABMT.

RESULTS

The CR, partial response (PR) and overall response rate (RR) following ABMT for HD patients was 48%, 17% and 65%, respectively. At a median follow-up of 35 months, the predicted three-year overall survival (OS) is 51% (95% CI: 44%-60%) and event-free survival (EFS) is 34% (95% CI: 26%-54%). For patients with NHL, the CR, PR and RR were 68%, 9% and 77%, respectively. At a median follow-up of 28 months, the predicted three-year OS is 51% (95% CI: 35%-66%) and EFS is 39% (95% CI: 21%-57%).

CONCLUSIONS

Intensive therapy with etoposide and melphalan followed by ABMT results in prolonged survival in selected patients with lymphoma who fail to achieve a complete remission to front-line chemotherapy. Based on our previous studies of outcome to conventional-dose salvage chemotherapy, we estimate that of all patients failing induction therapy, 28% with HD and 15% with NHL will be event-free at three years after ABMT.

Preclinical assessment of human hematopoietic progenitor cell transduction in long-term marrow cultures

Long-term marrow cultures (LTMCs) were established from 27 human marrows. Hematopoietic cells were subjected to multiple rounds of exposure to retroviral vectors during 3 weeks of culture. Seven different retroviral vectors were evaluated. LTMCs were assessed for viability, replication-competent retrovirus, progenitors capable of proliferating in immune-deficient mice, and gene transfer. The average number of adherent cells and committed granulocyte-macrophage progenitors (CFU-GM) recovered from LTMCs was 28% and 11% of the input totals, respectively. There was no evidence by marker rescue assay or polymerase chain reaction (PCR) of replication-competent virus production during LTMC. No toxicity to cellular proliferation due to the transduction procedure was observed. The adherent layers of LTMCs exposed to retroviral vectors were positive for proviral DNA by PCR and by Southern blot analysis. Fifty-three percent of 1,427 individual CFU-GM from transduced LTMC adherent layers were positive for vector-derived DNA. For neocontaining vectors, the average G418 resistance was 28% of 1,393 LTMC-derived CFU-GM. Forty percent of 187 tissues from 30 immune-deficient mice injected with human LTMC cells were positive for human DNA 4-5 weeks after adoptive transfer. These studies indicate that multiple exposures of human LTMCs to retroviral vectors result in consistent and reproducible LTMC viability and gene transfer into committed progenitors. Our results further support the use of transduced LTMC cells in clinical trials of hematopoietic stem cell gene transfer.

The National Cancer Data Base report on bladder carcinoma. The American College of Surgeons Commission on Cancer and the American Cancer Society

BACKGROUND

Previous Commission on Cancer Data from the National Cancer Data Base (NCDB) have examined time trends in stage of disease, treatment patterns, and survival for selected cancers. The most current (1993) data relating to patients with bladder carcinoma are described here.

METHODS

Five calls for data have yielded a total of 3,700,000 cases for the years 1985 through 1993, including 447,679 cases for 1988 and 608,593 cases for 1993, from hospital cancer registries across the U.S. Data were received on 18,053 bladder carcinoma cases in 1988 and 22,606 cases in 1993.

RESULTS

Interesting trends are 1) younger patients (49 years of age and younger) present with earlier stages of disease than do older patients; 2) women are slightly more likely to be diagnosed with later stages (II, III, and IV) of bladder carcinoma than men; 3) African Americans are less likely to be diagnosed with Stage 0 or Stage I disease than either Hispanic or non-Hispanic whites; and 4) National Cancer Institute designated centers treat more patients with advanced disease than do other types of hospitals.

CONCLUSIONS

The NCDB data are important for analyzing what cancer treatments and outcomes are used and occurring in the country. The data suggest that African Americans are diagnosed at later stages of disease progression. The relative survival rates among African Americans are lower than among Hispanics or non-Hispanic whites. Also, the decreasing utility of adjuvant chemotherapy is being recognized.

Identification of CD34+ subsets after glycoprotease selection: engraftment of CD34+Thy-1+Lin- stem cells in fetal sheep

Epitopes on the CD34 molecule detected by some CD34 antibodies can be cleaved by a unique glycoprotease from Pasteurella haemolytica, which cleaves only glycoproteins rich in O-linked glycans. A method to isolate CD34+ cells from adult bone marrow was developed subsequently, in which CD34+ cells were isolated in high purity and yield following immunomagnetic bead selection and detachment with the glycoprotease. Using a variety of other cell-surface markers shown here to be insensitive to glycoprotease, committed progenitors of T lymphoid, B lymphoid, monomyeloid, megakaryoblastic, or erythroid lineages could be identified. Significantly, candidate hematopoietic stem cells (HSC) that are contained within a CD34+Lin- (CD2-, CD14-, CD15-, CD16-, CD19-) (or CD34+CD38-) subset expressing the Thy-1 antigen (CDw90), c-kit receptor (CD117), and CDw109 but lacking expression of CD71 and HLA-DR antigens also were detected. Functionally distinct subsets of glycoprotease-selected CD34+ cells were identified and subfractionated using flow cytometry and fluorescence-activated cell sorting (FACS). These subsets included candidate HSCs expressing the CD34+Thy-1+Lin- phenotype, which were sorted from a CD34+ fraction of a mobilized peripheral blood (MPB) sample. In a fetal sheep model, when CD34+Thy-1+Lin- cells were injected intraperitoneally, they were capable of homing to the marrow, where they generated long-term multilineage hematopoiesis and maintained human CD34+ cells, indicating that candidate HSC subsets of CD34+ cells selected with this highly specific enzyme were capable of engraftment in vivo. The ability to identify and purify virtually any phenotypically defined subset of glycoprotease-selected CD34+ stem/progenitor cells should facilitate the study of hematopoiesis in vitro and in animal models in vivo as well as the development of novel genetic techniques for the correction of specific blood cell disorders in humans.