Antimycotic therapy with liposomal amphotericin-B for patients undergoing bone marrow or peripheral blood stem cell transplantation

Suspected deep or systemic mycosis in patients undergoing high-dose therapy and autologous or allogeneic bone marrow transplantation (BMT) requires an immediate systemic antimycotic therapy. Intravenous therapy with the standard drug conventional amphotericin-B is associated with severe adverse effects like nephrotoxicity and chills. Furthermore, BMT patients often receive other potential nephrotoxic drugs such as CsA or virustatics. In this study, we report 74 BMT-patients treated with liposomal amphotericin-B for culture-documented aspergillosis (n = 5) or candidiasis (n = 6), or for serologically (n = 35) or clinically suspected mycosis or as prophylaxis (n = 2). Therapy was initiated with a median dose of 2.8 (0.64-5.09) mg/kg body-weight and continued for 13 (1-55) days. The drug was excellently tolerated and only in one was therapy stopped due to severe chills and fever. Severe organ impairment was not observed under therapy with liposomal amphotericin-B. Creatinine decreased in five patients after an increase under preceding therapy with the conventional formulation. Influence of liposomal amphotericin-B on bilirubin and transaminases was difficult to evaluate due to therapy-related toxicity, veno-occlusive disease (VOD), and graft-versus-host disease (GvHD). 10/11 culture-positive patients died from aspergillosis (5/5) or candidiasis (5/6), but in 9/11 of these subjects the immunity was additionally compromised by GvHD, steroid therapy, and VOD. Liposomal amphotericin-B was effective in preventing relapse of systemic mycosis in 10/12 patients with a history of aspergillosis (n = 11) or candidiasis (n = 1). We conclude, that favourable toxicity of liposomal amphotericin-B should encourage dose escalation studies of liposomal amphotericin-B randomised against the conventional formulation and that the comparison of patients undergoing BMT with patients under standard chemotherapy might be difficult because of additional risk factors of the BMT-patients.

Factors influencing the haematological recovery after allogeneic bone marrow transplantation in leukaemia patients treated with methotrexate-containing GVHD prophylaxis: a single-centre experience

In the present single institution study of 66 leukaemia patients (28 AML, 23 ALL, 15 CML), the factors influencing haematological recovery after allogeneic bone marrow transplantation (alloBMT) were analysed retrospectively in order to identify the optimal conditions required for a rapid haematological recovery after alloBMT. All patients received GVHD prophylaxis with cyclosporine A plus methotrexate. The mean number of days required to achieve > or = 0.5 x 109/l neutrophil count after alloBMT was 17 (median 17, range 9 to 27 days) and 19 patients (28.8%) had rapid neutrophil recovery within 15 days after alloBMT. The haematological recovery was more rapid in the 38 patients without GVHD or with only grade I GVHD. Furthermore, 50% and 40% of patients receiving 10 (n = 18) or 5 (n = 20) micrograms/kg/day G-CSF had rapid neutrophil recovery within 15 days after alloBMT, versus only 7.1% of patients not receiving G-CSF post-transplant (n = 28), p < 0.001. The neutrophil recovery was similar in patients receiving either fresh or cryopreserved allografts and either TBI-containing or busulfan-containing conditioning regimen. A significant correlation was found between neutrophil recovery and either the MNC or CFU-GM content of the allografts, r = 0.33, p < 0.01. The mean number of days required for neutrophil recovery was only 16 days (median 16, range 9 to 24 days) in patients receiving allografts containing > 1 x 10(5) CFU-GM/kg (n = 28) versus 19 days (median 19, range 13 to 27 days) in patients receiving allografts containing < 1 x 10(5) CFU-GM/kg (n = 35). Three patients receiving allografts containing less than 0.5 x 10(5) CFU-GM/kg had primary neutrophil engraftment failure. The mean number of days required to achieve 20 x 109/l platelet count was 21 (median 20, range 11 to 50 days) and 30 patients (46.9%) had platelet recovery within 20 days after alloBMT. The platelet recovery after alloBMT was not significantly affected by the type of leukaemia, conditioning regimen, or G-CSF administration. The mean number of days required for platelet recovery after alloBMT was only 20 days (median 18 days) in patients receiving allografts containing > 1.0 x 10(5) BFU-E/kg (n = 35) versus 23 days (median 20 days) in patients receiving allografts containing < 1.0 x 10(5) BFU-E/kg (n = 24). Seven patients receiving allografts containing less than 0.5 x 10(5) BFU-E/kg had primary platelet engraftment failure. The present study has identified the high number of progenitor cells in the allografts infused and the daily administration of G-CSF post-transplant as the optimal combination for a rapid neutrophil recovery after alloBMT. More significantly, the number of BFU-E in allografts was the most significant factor to determine platelet recovery after alloBMT. The development of GVHD of grade II or more during the first weeks after alloBMT was associated with slower haematological recovery and longer period of fever during neutropenia and hospitalisation.

Fibronectin increases both non-adherent cells and CFU-GM while collagen increases adherent cells in human normal long-term bone marrow cultures

Normal haematopoietic proliferation and differentiation occur within the human bone marrow microenvironment which is comprised of stromal cells including fibroblasts, adipocytes, macrophages and endothelial cells as well as the extracellular matrix made of collagen, fibronectin, laminin, vitronectin, thrombospondin and haemonectin. All haematopoietic progenitor cells including primitive LTC-IC, multilineage CFU-mix, myeloid CFU-GM and erythroid BFU-E adhere to the heparin-binding domains of the extracellular matrix component fibronectin. Human long-term bone marrow cultures (LTHBMC) represent the best available approximation for the in vivo marrow microenvironment in which the proliferation and differentiation of haematopoietic progenitor cells depend on the presence of marrow stromal cells and their attendant matrices. Since extracellular matrix components have been shown to promote myelopoiesis in long-term murine bone marrow cultures, we have examined the effect of two main components of the extracellular matrix: fibronectin and collagen type I on myelopoiesis in LTHBMC in an effort to increase the myeloid progenitor cell production. The present study revealed different modulatory effects for these two components. Collagen significantly increased the adherent fraction of LTHBMC (p < 0.05) but always resulted in a decreased myeloid progenitor cell (CFU-GM) production throughout the whole 8 weeks of culture. On the other hand, fibronectin significantly increased the number of both non-adherent cells. CFU-GMs (p < 0.01) and to a lesser extent the number of adherent cells as well as maintaining the LTHBMC up to 14 weeks. Fibronectin has been previously shown to stimulate the development of CFU-GMs in short-term semisolid cultures and to play an active role in haematopoietic progenitor cell-microenvironment interactions. Therefore, the presence of fibronectin in LTHBMC could increase both the productivity and longevity of myelopoiesis in the system. The integration of fibronectin in the ex vivo expansion systems currently undergoing development would ensure a sustained effective cumulative production of the myeloid progenitor cells (CFU-GMs), and consequently could accelerate the rate of haematological recovery in transplanted patients.

Nontransferrin-bound iron in serum of patients receiving bone marrow transplants

Nontransferrin-bound iron (NTBI) and other parameters of iron status were measured in 40 patients undergoing bone marrow transplantation (BMT) prior to conditioning therapy (between day -10 and -7), at the time of BMT (day 0), and 2 weeks later (day + 14). Serum iron and transferrin saturation values were normal before conditioning therapy. At day 0 serum iron values were high and median transferrin saturation was 98% (changes in the values of both serum iron and transferrin saturation, p < .0001). Transferrin saturation values were still elevated 2 weeks posttransplant (day +14 vs. baseline values, p = .0001). Starting at low NTBI levels pretransplant (median 0.4 micromol/l, range 0-4.2 micromol/l, controls: < or = 0.4 micromol/l), all patients revealed high levels on day 0 (median 4.0 micromol/l, range 1.9-6.9 micromol/l, p < .0001) and 2 weeks posttransplant (median 2.7 micromol/l, range 0-6.2 micromol/l, p < .0001). These observations indicate that the plasma iron pool in patients undergoing BMT increases to a level at which the normal ability to sequestrate iron becomes exhausted and considerable amounts of NTBI appear in serum. This "free" form of iron can mediate the production of reactive oxygen species and may cause organ toxicity in the early posttransplantation period.

Phenotype of lymphocyte subsets after autologous peripheral blood stem cell transplantation

The expression of CD45RA+ and CD45RO+ isoforms on T cells and the recovery of B lymphocytes and NK cells after autologous peripheral blood stem cell transplantation (PBSCT) were studied during the early period following transplantation. The same panel of monoclonal antibodies was used to analyze the lymphocyte subsets after allogeneic bone marrow transplantation (allo-BMT) and in cord blood. The CD4+ subsets regenerated differently from the CD8+ isoforms and the CD4+CD45RA+ subsets appears to be the only thymus-dependent regenerating population post-transplantation. Since the CD8+ CD45RA+ and CD8+ CD45RO+ isoforms recovered to normal levels within a month after PBSCT and within 3 months after allo-BMT, there seems to be no thymic influence on the regeneration of the immature CD8+CD45RA+ subset. The regeneration of the CD4+ cells was markedly delayed, but was faster in the PBSCT recipients, mainly because of the faster recovery of the mature CD4+ CD45RO+ subset. The pattern of surface antigens on T lymphocytes after transplantation did not resemble the antigen pattern on cord blood cells. The CD19+ CD20+ cells recovered earlier in the PBSCT group and remained compromised after allo-BMT during the time studied. The faster B lymphocyte regeneration correlates with the faster reconstitution of the mature CD4+CD45RO+ cells. The pattern of antigens CD38+, HLA-DR+, CD10+ on B lymphocytes of the recovery phase resembled the pattern on B cells of cord blood lymphocytes. The NK cells were not deficient at any time post-transplant in both groups.

Comparison of the content and subpopulations of CD3 and CD34 positive cells in bone marrow harvests and G-CSF-mobilized peripheral blood leukapheresis products from healthy adult donors

Recombinant human granulocyte colony-stimulating factor (G-CSF)-mobilized peripheral blood stem/progenitor cells (PBPC) have replaced bone marrow (BM) harvests for autologous transplantation after myeloablative therapy in cancer patients. G-CSF-mobilized PBPC from healthy donors contain one log excess of T lymphocytes representing a potential risk for graft-versus-host disease (GVHD). However, recent pilot clinical studies of G-CSF-mobilized allogeneic PBPC transplantation have shown rapid haematological recovery and no severe acute GVHD except in a very few cases. Therefore, the risk of inducing severe acute GVHD is not as high as was expected during the pioneering period of allogeneic PBPC transplantation. The present study was performed to address the possible reasons for the rapid haematological recovery and the absence of severe acute GVHD observed after allogeneic PBPC transplantation by comparing the contents and subsets of CD3+ and CD34+ G-CSF-mobilized PBPC (n = 31) with those of BM (n = 26) allografts from healthy adult donors. The present results revealed that the phenotypic profiles of CD3+ and CD34+ cells differ between PBPC and BM allografts. The single PBPC leukapheresis product contained 10 times more mononuclear cells, 1.5 times more CD34+ cells, 5.5 times more CD3+ T lymphocytes, 3 times more CD19+ B lymphocytes and 3.8 times more CD14+ monocytes than the single BM harvest. Both CD34+CD33+ myeloid progenitor cells and CD34+HLA-DR-long-term reconstituting haemopoietic stem cells were significantly increased in the CD34+ G-CSF-mobilized PBPC compared with the CD34+ BM cells; median 73.1% and 30.4% vs 60.6% and 5.0%, respectively, P < 0.01. The percentage of CD3+ cells coexpressing CD4 (T helper/inducer) was similar in both PBPC and BM allografts, 47.2% and 45.6%, respectively, whereas the percentage of CD3+ cells coexpressing CD8 (T suppressor/cytotoxic) was significantly decreased in PBPC compared with BM; 37.0% vs 55.9%, p < 0.01. The rapid haematological recovery after allogeneic PBPC transplantation could be due to the increased content of CD34+CD33+ myeloid committed cells and the CD34+HLA-DR-long-term reconstituting haemopoietic stem cells in the PBPC allografts. Also, the absence of an increased risk of severe acute GVHD after allogeneic PBPC transplantation could be due to the increased T lymphocyte ratio of CD4+/CD8+ in the PBPC allografts. In conclusion, rapid haematological recovery without an increased risk of severe acute GVHD can be achieved using G-CSF-mobilized PBPC rather than BM for allogeneic transplantation.

Reverse transcriptase/polymerase chain reaction detection of cytokeratin-19 mRNA in bone marrow and blood of breast cancer patients

A two-step reverse-transcriptase-based polymerase chain reaction (PCR) with nested primer pairs was developed to amplify sensitive and specific cytokeratin-19 (CK-19) mRNA sequences from human breast cancer cells. No CK-19 pseudogene interference was seen. The larger DNA-derived amplification products could be clearly discriminated from mRNA-derived products. The CK-19 message was not amplified from bone marrow or blood of healthy volunteers and patients with haematological malignancies nor from myeloid and lymphoid cell lines. Breast cancer cells were diluted in buffy coat cells up to 10(-6) and CK-19 mRNA sought by PCR. The CK-19 message was detected in 14 of 26 blood samples and 14 of 24 marrow samples but in neither of two peripheral blood stem cell samples taken from 35 breast cancer patients. By sequence-analysis control of two of these samples and two cell lines, the amplified DNA fragments were confirmed to be homologous with the CK-19 sequence. The CK-19 message was further sought in matched blood/marrow samples taken from 13 untreated women in the same cohort at the time of diagnosis. In 3 of these, CK-19 RNA was detected in blood and marrow and, in 3 others, only in blood, but never in marrow alone. The results show that CK-19 assay by reverse transcriptase/PCR is a sensitive and specific technique for the detection of cancer cells in bone marrow and blood. It could be helpful in diagnosis and monitoring of metastatic breast cancer and detection of micrometastases. This should be evaluated on larger numbers of patients, with different clinical samples and epithelial malignancies.

Early recurrence or persistence of autoimmune diseases after unmanipulated autologous stem cell transplantation

Autologous stem cell transplantation with or without in vitro lymphocyte depletion has been suggested as a new treatment option for severe autoimmune diseases. We describe five patients with autoimmune diseases (CREST syndrome, myasthenia gravis and Hashimoto's thyroiditis, systemic lupus erythematosus, atopic dermatitis, and rheumatoid arthritis) who underwent autologous bone marrow (n = 1) or peripheral blood progenitor cell (n = 4) transplantation with unmanipulated grafts as treatment for the autoimmune disease in one case or as treatment for a malignant disorder with a concomitant autoimmune disorder in four cases. In all patients serological and clinical signs of the autoimmune disease recurred early or persisted. These observations should be regarded as a cautionary note concerning the efficacy of high-dose therapy followed by transplantation of unmanipulated autologous stem cells for treatment of severe autoimmune diseases.

Detection of cancer cells in peripheral blood stem cells of women with breast cancer by RT-PCR and cell culture

The benefit of high-dose therapy and blood stem cell reinfusion for women with high-risk breast cancer is currently under investigation. Contaminations of autologous blood stem cells with cancer cells have been described. Cancer micrometastases may be detected by immunocytochemistry, culture techniques and cytokeratin-19 mRNA reverse transcriptase PCR. Women with breast cancer received adjuvant HD-CTM with peripheral blood stem cell (PBSC) support after surgical therapy and 4 cycles conventional chemotherapy. Peripheral blood stem cells were mobilised by G-CsF and harvested after the third or fourth cycle of standard therapy. Aliquots of PBSC-collections (10(7)-2*10(7) cells) were subjected to CK19-mRNA reverse transcriptase PCR. RNA was extracted by standard methods and reverse transcription was performed with MMV-RT. Integrity of RNA was checked by coamplification of housekeeping sequences. Aliquots of the RT-mix were subjected to PCR-amplification with outer and inner primer pairs, subsequently. A second aliquot of 2*10(7) cells was cultured over 42 days in liquid culture. Cytospins were prepared weekly from cultured cells and evaluated by light microscopy with or without prior immunocytochemistry. Ten leukaphereses from 6 women were available for PCR-analysis and cell culture. Six leukaphereses were negative for CK19-mRNA and for detection of cancer cells by culture technique, two samples were positive for CK19-mRNA and culturally enriched cells and two samples were positive for CK19-mRNA and negative for cultured cancer cells. No sample was positive for cultured cells and negative for CK19-mRNA. Overall, the results corresponded in 80%. Two sensitive techniques for the detection of cancer micrometastases were applied to aliquots from 10 leukaphereses of six breast cancer patients with corresponding results in 80%. PCR-mediated detection of cancer cells was confirmed by culture technique and light microscopy, however, further comparison of CK19-PCR with standard techniques like cell culture and immunocytochemistry is still necessary.

Thrombocytopenia after high-dose chemotherapy and autologous stem cell transplantation: an unresolved problem and possible approaches to resolve it

Prolonged thrombocytopenia is a frequent clinical problem in cancer patients undergoing high-dose chemotherapy and autologous transplantation. The use of GM-CSF as an adjuvant to autologous bone marrow transplantation (ABMT) has significantly reduced the duration of neutropenia after high-dose chemotherapy but failed to accelerate platelet recovery in transplanted patients. The more rapid hematopoietic reconstitution obtained by autologous mobilized peripheral blood progenitor cell transplantation (PBPCT) after high-dose chemotherapy has resulted in its increasing use instead of ABMT. However, PBPCT does not always produce faster platelet engraftment after high-dose chemotherapy, and persistent thrombocytopenia remains a significant clinical problem in PBPC-transplanted patients. The duration of severe thrombocytopenia (requiring frequent platelet transfusions) until platelet recovery varies widely depending on the quality of the autograft and previous radiotherapy or chemotherapy. The median days to reach 20,000/microliters platelets ranged from 10 to 32 days. Pilot clinical studies in which cancer patients were transplanted with enriched CD34+ cell autografts, obtained from G-CSF-mobilized PB, showed a similar platelet recovery after high-dose chemotherapy but also wide variation among the patients. The median days to reach 20,000/microliters platelets ranged from 9 to 38 days. The dose of CFU-GM in the autograft has been identified as the best predictive factor for hematopoietic recovery (p < 0.0001) after high-dose chemotherapy and autologous PBPCT in 118 patients with hematologic malignancies. A similar assessment of the megakaryocyte progenitor cells (BFU-MK and CFU-MK) in the autograft not only could predict time to platelet recovery but also could help to optimize the number and method of mobilization of the PBPC required to shorten the problematic obligatory 2-week duration of thrombocytopenia after high-dose chemotherapy. A routine assessment of the number of BFU-MK and CFU-MK present in each autograft and correlation with platelet recovery after transplantation would enable us to define the clinical threshold cell dose required for rapid platelet recovery. Recently, several non-specific cytokines with thrombopoietic activity have been evaluated in phase I clinical trials, including interleukin-1, interleukin-3 followed by GM-CSF, interleukin-6, and interleukin-11 in cancer patients, showing an encouraging trend toward a decrease in thrombocytopenia after chemotherapy. The recently cloned specific platelet cytokine, thrombopoietin, is currently undergoing phase I clinical studies, and the results are awaited with interest.

Comparison between bone marrow and G-CSF-mobilized peripheral blood allografts undergoing clinical scale CD34+ cell selection

Allogeneic transplantation of selected CD34+ cells, rather than conventional transplantation of bone marrow (BM) harvest or peripheral blood (PB) leukapheresis products, has the advantage of reducing volume, facilitating storage and decreasing the amount of dimethylsulfoxide (DMSO) and cell lysis products, as well as reducing the number of T-lymphocytes responsible for graft-versus-host disease (GVHD). Using biotinavidin immunoaffinity columns (Ceprate SC system, CellPro; Bothell, WA), CD34+ cells were selected from each of 20 allografts (12 G-CSF-mobilized PB and 8 BM) collected from 14 HLA-identical normal healthy donors for transplantation. After the clinical-scale selection, the median concentration of CD34+ cells was 44.6% (range, 13% to 91%) in BM and 50.4% (range, 15% to 77%) in PB. Whereas 75% of the PB allografts had a CD34+ cell yield of more than 65%, only 37.5% of the BM allografts achieved such a yield, p < 0.01. The number of T-lymphocytes in the selected CD34+ cell allografts was reduced by two to three logs from a median of 4.2 x 10(9) to 7.8 x 10(5) CD3+ cells. The enrichment in CD34+ cells was 240-fold (range, 24- to 382-fold) in PB versus only 34-fold (range, 14- to 108-fold) in BM. Also, the enrichment in clonogenic cells was significantly more in PB (median value of 38.6-fold) than in BM (median value of 19.2-fold) and more in allografts from younger (< 50 years old) rather than older (> or = 50 years old) adult donors. A correlation was found between the percentage of CD34 or CD3+ cells before and after selection (r = 0.58 or r = 0.60, respectively, p < 0.05). Selective enrichment of the colony forming units-granulocyte-macrophage (CFU-GM) was found in all 20 allografts. The progenitor cell recovery after freezing and thawing was similar in BM and PB allografts, with a mean of about 60% for the CFU-GM and BFU-E. In the same six donors, the CD34+ cell yield was significantly more in the PB after mobilization (median 78.5%, range 50% to 90%) than in the BM before mobilization (median 41.5%, range 25% to 87%), p < 0.01. Ten patients with hematologic malignancies have been allotransplanted with 14 of the 20 selected CD34+ cells either combined BM + PB (n = 4) or single (n = 6) grafts. Seven patients did not develop acute GVHD, and only two patients developed > or = grade II GVHD, one of whom developed only grade II GVHD that resolved after brief treatment with corticosteriods. Only one patient showed chronic GVHD (skin and liver). The low incidence and severity of GVHD seen in the present study (only 30%) could be due to the two- to three-log reduction of T-lymphocytes in the selected CD34+ cell allotransplants. All 10 patients had stable hematological recovery, and seven had full donor hematopoiesis. In conclusion, G-CSF-mobilized PB leukapheresis products undergoing selection of CD34+ cells have a greater yield and enrichment of progenitor cells than BM harvests collected from HLA-identical normal healthy donors for allogeneic transplantation. The low incidence and severity of both acute and chronic GVHD (30%) seen in the present study are very encouraging.

Increase of mobilized CD34-positive peripheral blood progenitor cells in patients with Hodgkin's disease, non-Hodgkin's lymphoma, and cancer of the testis

G-CSF (filgrastim) can effectively mobilize peripheral blood progenitor cells (PBPC) when administered during steady-state hematopoiesis. In this single center study, we compared the effectiveness of two different doses of G-CSF on the mobilization of peripheral blood stem cells in patients with Hodgkin's disease, non-Hodgkin's lymphoma, and cancer of the testis. A first group including 33 patients received 10 micrograms G-CSF/kg BW per day (group A), whereas a second group comprising 34 patients was treated with 24 (2 x 12) micrograms G-CSF/kg body weight (BW) per day (group B) prior to the leukapheresis. A significant difference (P = 0.015) in the total number of CD34+ cells between group A: 11.32 x 10(7) (range 0.34-110.2) and group B: 48.25 x 10(7) (range 1.33-447.4) has been observed in the first leukapheresis product. Moreover, the total number of CFU-GM increased significantly from 34.79 x 10(4) (range 1.07-300.9) to 147.69 x 10(4) (range 1.03- 1204.0) (P < 0.005), and the number of MNC increased from 1.35 x 10(10) (range 0.41-3.09) group A) to 2.93 x 10(10) (range 0.66-9.7) (group B) (P < 0.001). Comparable results were obtained in the second leukapheresis. Our data indicate, that the application of higher doses of G-CSF can significantly improve the effectiveness of mobilizing PBPC during steady-state conditions, and thereby considerably contribute to a safe and fast engraftment as well as a reduced number of leukapheresis procedures to achieve sufficient number of PBPC.

[Differentiation of pain-related and morphine related impairment of cognitive performance and mood in bone marrow transplantation patients]

AIMS

Severe pain of mucositis induced by cytostatic conditioning therapy in bone marrow transplantation (BMT) patients generally requires continuous parenteral opioid treatment. Cognitive and psychological disturbances are frequent complications subsequent to BMT and may result from cerebral opioid side effects. The aim of the study was to evaluate the efficiency of continuous morphine in mucositis pain and the side-effects in BMT patients. Particular emphasis was placed on the question of whether reaction times, which are usually measured to estimate opioid effects upon vigilance, are influenced by pain-induced cognitive impairments in pain patients.

METHODS

While in hospital, 10 BMT patients were examined daily with the aid of a mucositis scale, subjective visual analog scales (VAS) for pain and mood parameters, a German version of the McGill pain questionnaire (MPQ), and a mental performance task battery, and the morphine given was documented. Mental performance tests were simple auditory reaction time and choice reaction time. Seven patients also performed a Sternberg memory search test in which they had to use 'yes' and 'no' response keys to match visually presented test letters to a previously memorized set of letters. Practice and baseline data were collected within the first week before BMT.

RESULTS

The intensity and duration of mucositis differed from patient to patient, resulting in different pain intensities and MPQ scores. Prolongation of the choice reaction time averaged over the period of mucositis treatment correlated significantly with residual pain intensity (Spearman r(s) = 0.88, p < 0.01) but not with morphine dose (r(s) = 0.35, p = 0.33). For the Sternberg memory search test greater correlation coefficients resulted between reaction time and morphine dose (r(s) = 0.86, p = 0.014) than between reaction time and residual pain intensity (r(s) = 0.61, p = 0.15). In turn, pain intensity, unlike morphine dose, was significantly correlated with high scores in the mood parameters for depression, passivity, and tiredness.

CONCLUSIONS

It is concluded that both pain and morphine can impair cognitive performance, but that these mental stressors seem to differ according to qualitative criteria. Whereas pain might slow reaction time by distracting a patient's attention, particularly in low mental demand tasks, morphine could interfere with more specific cognitive processes, such as short-term memory operations, that are required in more complex tasks.

Maintenance and expansion of erythropoiesis in human long-term bone marrow cultures in presence of erythropoietin plus stem cell factor and interleukin-3 or interleukin-11

Recently there has been great interest in the ex vivo expansion and/or purging of human bone marrow cells prior to transplantation in order to obtain a long-lasting restoration of normal hematopoiesis and freedom from relapse. Long-term human bone marrow cultures (LTHBMC) represent the best available approximation of in vivo hematopoiesis. In the traditional LTHBMC, erythropoiesis is short lived (about 2 weeks). The longevity and productivity of erythropoiesis in LTHBMC may be limited by the insufficient production of certain cytokines such as Erythropoietin (Epo), SCF, IL-3 and/or IL-11 by the stromal and hematopoietic cells ex vivo and/or suboptimal addition of these cytokines. Therefore, we have investigated the optimal presence of erythropoietin plus SCF, IL-3, and/or IL-11 as requirements for the maintenance and expansion of erythropoiesis in LTHBMC in an effort to overcome the defective erythropoiesis of the traditional LTHBMC. In LTHBMC containing Epo alone and its combinations with SCF, IL-3, and/or IL-11, the nonadherent cells consisted mainly of erythroblast and normoblast cells which became the majority in the third and fourth weeks whereas granulocytes and macrophages declined steadily from the second week. A significant increase in the number of erythroblast and normoblast cells was produced throughout the whole period of LTHBMC containing Epo + IL-11 or Epo + SCF + IL-11 or Epo + SCF + IL-3 + IL-11. In the presence of Epo alone, BFU-E decreased steadily throughout LTHBMC. However, the erythroid clonogenic cells were successfully maintained in cultures containing Epo + SCF IL-3 or Epo + SCF + IL-11 or Epo + SCF + IL-3 + IL-11 for the 4 weeks and even significantly expanded by 4.5-5.7, 8.1-10 and 5-7-fold more than in the presence of Epo alone in the second, third and fourth weeks, respectively, p < 0.01. Our optimum cultures, including Epo + SCF + IL-3 or Epo + SCF + IL-11, maintained the production of nonadherent erythroid clonogenic cells for 4 weeks in culture, representing a significant improvement over the traditional LTHBMC that exhibits a progressive decline in erythropoiesis during the first 2 weeks. We conclude that Epo alone could not maintain erythroid clonogenic cell production and the supplementation with either of the two combinations: Epo + SCF + IL-3 or Epo + SCF + IL-11 is sufficient for maintaining erythropoiesis in LTHBMC. The present LTHBMC system should have applications to the analysis and manipulation of human erythropoiesis.

Increasing the yield of harvested bone marrow cells by raising room temperature during marrow collection

The time it takes to harvest bone marrow before transplantation could be reduced significantly by increasing the temperature of the operating room by 8-10 degrees C, to about 28-30 degrees C. In healthy donors, the collected volume of marrow was increased from 22.45 to 36.31 mL/min; in patients who received chemotherapy previously, from 21.67 to 29.98 mL/min. The time to collect a volume of 1200 mL marrow could be reduced significantly, from 57.78 to 38.25 minutes in healthy donors and from 71.07 to 43.36 minutes in patients who received chemotherapy previously, without any loss of quality of the sampled marrow. Operation time and thereby time of anesthesia could be reduced significantly by heating the operating room to a temperature of 28-30 degrees C. Harvesting at higher room temperature did not result in any adverse side effects for the patients. The procedure to increase the body temperature could be simplified by using electric blankets and aluminum foils for wrapping to avoid heat emission.

Comparative studies of induction and repair of DNA double-strand breaks in X-irradiated alveolar macrophages and resting peripheral blood lymphocytes using constant-field gel electrophoresis

Induction and repair of X-ray-induced DNA double-strand breaks (dsbs) was compared for normal broncho-alveolar macrophages and human peripheral blood lymphocytes, using CHO cells as a reference cell model. The cells, upon their separation, were processed in a similar manner. After X-irradiation, cell lysis and proteinase K treatment, the DNA samples were subjected to constant-field gel electrophoresis (CFGE) followed by fluorimetric densitometry for quantification of released DNA. Induction of dsbs after X-ray doses of 5-100 Gy was found to show no gross differences for all cell systems used. Repair of dsbs was studied after X-ray dose of 60 Gy for up to 24 h after irradiation. The repair curves obtained proved to be similar for bronchoalveolar macrophages and CHO cells (97% of all dsbs rejoined after 24 h). However, in blood lymphocytes from normal subjects and from bone marrow recipients, dsb repair proceeded rapidly only for 0.5-1 h post-irradiation, being followed by the gradual degradation of DNA at longer intervals. The kinetics of DNA degradation correlated with cytological features of pyknosis and necrosis.

Separation and characterization of mobilized and unmobilized peripheral blood progenitor cells by counterflow centrifugal elutriation

Peripheral blood stem cell (PBSC) harvests are highly contaminated with lymphocytes. In allogeneic transplantations with PBSC, this might lead to an increased risk of graft-vs.-host disease (GVHD). Marrow graft T cells depletion (TCD) by counterflow centrifugal elutriation (CCE) has been performed to decrease the incidence of GVHD, but in some cases, it has also led to a reduction in the PBSC content of the graft due to the distinct elutriation properties of these cells. We studied the ability of CCE to deplete lymphocytes from recombinant human granulocyte colony-stimulating factor (rhG-CSF)-mobilized PB mononuclear cells (PBMNC) and from unmobilized PBMNC from healthy volunteers. We characterized the elutriation properties of circulating mobilized and unmobilized hematopoietic progenitors. With an experimental three-flow rate CCE procedure, originally described for separation of bone marrow, fractions 24, 28, and Rotor Off (RO) were obtained without impairing yield or viability. This CCE procedure can also be used for the separation of PBMNC harvests by reducing the T cell contamination to or below the range seen in bone marrow grafts; CD3+ cell contamination in the RO fractions of mobilized and unmobilized PBMNC was reduced to < 10% of the input. This could bring allogeneic PBSCT within the range of feasibility. In unmobilized PBMNC, 25% of the recovered CD34+ cells were found in fraction 24, where no colonies were detected, and 50% of the recovered CD34+ cells were found in fraction RO, where most of the colonies were detected. In mobilized PBMNC, 80% of the recovered CD34+ cells were found in fraction RO, together with 90% of the colonies, but almost no colonies or CD34+ cells were detected in fraction 24. CD34+ cells in fraction 24 expressed less CD13, and antigen found on more mature myeloid cells. Mobilization with rhG-CSF causes a shift of CD34+ cells from smaller cells (fraction 24) to larger cells (fractions 28 and RO).

Infusion of tumor-contaminated bone marrow for autologous rescue after high-dose therapy leading to long-term remission in a patient with relapsed Philadelphia chromosome-positive acute lymphoblastic leukemia

We report a female patient with relapsed Philadelphia chromosome-positive acute lymphoblastic leukemia remaining in long-term second remission after high-dose radiochemotherapy followed by autologous stem cell rescue with bone marrow showing evidence of residual disease. The Philadelphia chromosome and a positive signal for the BCR/ABL p185 translocation by the polymerase chain reaction were detected in the harvested marrow. After mafosfamide-purged marrow failed to engraft, her unpurged 'back-up' bone marrow was also infused. Control marrow examinations after recovery were repeatedly positive for the BCR/ABL translocation on PCR analysis turning negative 30 months after high-dose therapy. She remains in unsustained complete clinical remission for 48+ months showing no evidence of leukemia by cytological and cytogenetic analyses.

Results of a randomised, controlled, multicentre study of recombinant human granulocyte colony-stimulating factor (filgrastim) in patients with Hodgkin's disease and non-Hodgkin's lymphoma undergoing autologous bone marrow transplantation

In 54 patients with malignant lymphoma, haematopoietic recovery after high-dose chemotherapy and autologous bone marrow transplantation (BMT) was compared between patients randomised to receive 10 or 30 micrograms/kg/day of r-metHuG-CSF (filgrastim) or no growth factor. After standard high-dose chemotherapy with cyclophosphamide, etoposide and BCNU (CVB regimen for patients with Hodgkin's disease) or BCNU, etoposide, cytosine arabinoside and melphalan (BEAM regimen for patients suffering from non-Hodgkin's lymphoma) followed by autologous BMT, r-metHuG-CSF was administered by continuous intravenous infusion from the first day after autologous BMT until neutrophil recovery. When the r-metHuG-CSF groups were compared with the control group the major findings were: the median time to reach an absolute neutrophil count (ANC) > or = 0.5 x 10(9)/L was 20 days in the control group and 12 and 14 days, respectively, in the r-metHuG-CSF groups (P = 0.0004). The duration of neutropenia (ANC < 0.5 x 10(9)/L) was reduced from 27 days in the control group to 11 and 13 days in the r-metHuG-CSF groups (P = 0.0001). In addition, fewer days of febrile neutropenia were observed in the r-metHuG-CSF groups (5 and 6 days) than in the control group (10 days; P = 0.036). No significant effects of r-metHuG-CSF administration on the number of days with fever, the use of intravenous antibiotics and hospitalisation were detected. R-metHuG-CSF was well tolerated without any serious side-effects.(ABSTRACT TRUNCATED AT 250 WORDS)

Inhibition of CFU-C growth by VP-16 containing plasma samples obtained from patients after conditioning therapy for bone marrow transplantation

The introduction of VP-16 into high-dose therapy regimens used for conditioning before BMT or PBSCT has resulted in higher remission rates and prolonged disease-free survival, even in high risk patients. VP-16 levels have been measured in plasma at the time of transplantation. The question is, is there a biological activity that corresponds with the risk of delayed engraftment or graft failure? We investigated the inhibitory effects of plasma samples obtained from patients under high-dose VP-16 therapy on the growth of human bone marrow progenitor cells. Bone marrow cells from healthy donors were exposed to the plasma samples and seeded into methylcellulose-culture (CFU-C-assay). We found a dose dependent CFU-C inhibition related to VP-16 plasma levels at the time of transplantation (k = 0.769, P < 0.01). There were signs of a correlation between CFU-C growth inhibition at the time of BMT and haematological recovery (k = 0.656, P < 0.05) between CFU-C inhibition and the time until leucocytes reached 0.2 x 10(9)/l. Patients with CFU-C growth inhibition at the time of BMT may show delayed engraftment of leucocytes and that there might be a correlation with VP-16 levels, but further investigation is necessary to determine the significance of the latter thesis and if VP-16 plasma levels could lead to failure of engraftment. We recommend a minimum time interval between VP-16 infusion and graft transplantation of 72 h.

Allogeneic bone marrow transplantation for leukemia following piperazinedione and fractionated total body irradiation

Between 1980 and 1988, 126 patients with leukemia were treated with piperazinedione and fractionated total body irradiation (TBI) followed by allogeneic bone marrow transplantation from HLA matched siblings. Sixty-one patients had acute myelogenous leukemia, 46 acute lymphoblastic leukemia, and 19 chronic myelogenous leukemia. Patients with acute leukemia in first complete remission were transplanted only if perceived to have a low probability of remaining in remission with conventional therapy. The toxicity from the preparative regimen was similar to that of cyclophosphamide and TBI except that none of the patients in the study had hemorrhagic cystitis or veno-occlusive disease. After a median follow up of 114 months, 29 patients (23%) are still alive without relapse. The survival of patients with acute myelogenous or lymphoblastic leukemia transplanted in their first remission were 35% and 43%, respectively. The survival of patients transplanted in their first chronic phase of chronic myelogenous leukemia was 60%. The results of this preparative regimen are comparable to those of cyclophosphamide and TBI.