Lysis of autologous tumor cells by large granular lymphocytes in patients with acute leukemia in complete remission: correlation between lytic activity and clinical outcome

In order to evaluate the effect of specific immune response on prognosis in acute leukemia, we investigated the correlation between the lysis of autologous tumor cells (ATC) by lymphocytes and prognosis. Peripheral mononuclear cells (PMC) from most patients with acute leukemia in complete remission (CR) do not exhibit cytotoxic activity against fresh-frozen ATC, although they have adequate cytotoxic activity against K562 cells. When the large granular lymphocyte (LGL) fraction was used in this study, we observed lysis of ATC in 17 (43.6%) of 39 patients with acute leukemia (12 (42.9%) of the 28 patients with acute myelogenous leukemia (AML) and 5 (45.5%) of the 11 patients with acute lymphocytic leukemia (ALL)). With regard to prognosis, the lytic activity of the LGL fraction did not reflect the duration of CR. The median CR duration in AML patients was 13 months for the lysis-positive group and 11 months for the lysis-negative group. No significant correlation was also found between lytic activity of the LGL fraction and overall survival in each patient. However, the lysis-positive group tended to have a longer survival, the median overall survival being 48 months for the lysis-positive group vs 12 months for the lysis-negative group. The prolonging of overall survival in the lysis-positive group was attributed to a high rate of induction of second remissions in this group. Long-term patient survival in the two groups did not differ.

[Increased blood cell destruction during vigorous regeneration of bone marrow after CAMBO-VIP chemotherapy for non-Hodgkin's lymphoma]

Alternating non-cross-resistant chemotherapy has been induced for the treatment of non-Hodgkin's lymphoma (NHL) with the aim of cure, even in advanced cases. We formulated a new high dose regimen, CAMBO-VIP, which was a weekly treatment. They were administered during alternate weeks for a total period of 12 weeks. We obtained high response rate and prolonged disease-free survival with this regimen. We noticed the elevation of serum LDH level in some patients at or shortly after the completion of CAMBO-VIP treatment. LDH elevation was not associated with liver function abnormality in terms of elevation of GOT or total bilirubin. All of these patients were in complete or partial response with no evidence of tumor progression. An LDH isozyme study which was done at the time of LDH elevation showed elevation of both LDH1 and LDH2. Interestingly serum haptoglobin was undetectable in all 6 patients measured at the time of LDH elevation. Reticulocytosis and leukoerythroblastosis in peripheral blood were also observed in all of these patients. These abnormalities including LDH elevation returned to normal within a rather short period, usually within 1 to 3 weeks. From these observations, it is most likely that these abnormalities were due to excessive blood cell destruction, which was observed in association with rapid recovery from myelosuppression.

Detection of AML1/ETO fusion transcript as a tool for diagnosing t(8;21) positive acute myelogenous leukemia

The nonrandom chromosomal translocation t(8;21)(q22;q22) can be found frequently in acute myelogenous leukemia with maturation (AML-M2). The breakpoint of this translocation has been cloned and characterized, and fusion transcript AML1/ETO has been identified. Reverse transcription polymerase chain reaction (RT-PCR) can be used to amplify the breakpoint site of AML1/ETO in t(8;21)-positive AML-M2 patients. The chimeric transcript can be detected in all 16 (100%) t(8;21)-positive AML-M2 patients. In all samples, the size of the amplified DNA fragments and pattern of restriction digest were identical, indicating that the t(8;21) translocation breakpoint occurs within a single intron of the AML1 and ETO genes. Interestingly, this fusion transcript was also detected in one of 13 AML-M2 patients without the t(8;21) translocation, indicating that a masked translocation involving chromosomes 8 and 21, exists in AML. Minimal residual disease was detected by semi-nested RT-PCR in all four patients tested, who had been in complete remission for 12, 15, 34, and 52 months, respectively. These results indicate that RT-PCR amplification of the AML1/ETO fusion transcript is a powerful tool for diagnosing and monitoring minimal residual disease in AML-M2 patients.

[CAMBO-VIP for advanced diffuse large cell lymphoma (LSG classification)--a long-term follow-up study]

Twenty-two patients with advanced diffuse large cell lymphoma (LSG classification) were treated with the combination chemotherapy of cyclophosphamide, doxorubicin, methotrexate with leucovorin rescue, bleomycin, vincristine, etoposide, ifosfamide and prednisolone (CAMBO-VIP) from Oct. 1987 to Sept. 1989. Eighteen (90%) of 20 evaluable patients achieved complete remission and 2 patients had partial remission. With a median follow-up of 52 mos, 3 patients relapsed (17%), and 2 patients died. The actuarial overall survival and relapse-free survival at 4 years were estimated to be 90% and 83%, respectively. Myelosuppression was severe, but transient. No serious infection was seen, and no platelet transfusion was required. Oral mucositis and liver damage (Grade 3 in WHO grading) was seen in one patient each, but no treatment-related fatalities were observed. CAMBO-VIP is a well tolerated, effective treatment regimen for advanced diffuse large cell lymphoma.

Detection of the AML1/ETO fusion transcript in the t(8;21) masked translocation in acute myelogenous leukemia

The fusion transcript AML1/ETO was detected in the bone marrow of two t(8;21)-negative acute myelogenous leukemia (AML) patients by means of reverse transcription-polymerase chain reaction. This fusion transcript is identical to the one transcribed from the t(8;21) translocation base, as deduced from (a) the size and restriction pattern of the amplified DNA fragment and (b) the DNA sequence analysis of the fusion junction. We also showed that the ETO gene is highly expressed in these patients, much as it is in the t(8;21)-positive AML. Southern blot analysis showed rearrangement of the AML1 gene in one of the patients. Together, our results demonstrate that there is a masked t(8;21) translocation in AML that is not detectable by cytogenetic analysis but is able to transcribe an AML1/ETO fusion transcript similar to that transcribed in t(8;21)-positive AML-M2 patients.

[A study of toxicities and complications observed in alternating non-cross-resistant chemotherapy (CAMBO-VIP) for non-Hodgkin's lymphoma]

Thirty-nine patients with non-Hodgkin's lymphoma were treated with weekly alternating non-cross-resistant chemotherapy (CAMBO-VIP). We obtained a high response rate, and prolonged disease-free survival with side effects and complications of various severity were observed. Three patients were withdrawn from the study due to aggravation of liver cirrhosis, cerebral infarction, and poor tolerance. Thirty-six patients completed this 12-week intensive chemotherapy. The median treatment delay in all patients was 3 days (-4 to 29 days), and a delay of over 15 days was seen in 5 patients. The nadir of the neutrophil count was 0 to 2,100/microliters (median 140/microliters), and 15 patients were below 100/microliters. Two patients had pneumonia and 4 had herpes zoster infection. The platelet count nadir was 20,000 to 240,000/microliters (median 90,000/microliters). Ten patients were below 50,000/microliters, but none required platelet transfusion. Red cell transfusion was given in 6 patients. Elevation of transaminases was seen in 25 patients, but it was not serious except for a patient with liver cirrhosis. The elevation of serum LDH level and decrease of serum haptoglobin level seen shortly after completion of treatment seemed due to the increased blood cell destruction. Stomatitis was observed in 32 patients, 17 of whom showed more than grade 3 toxicity. Blister formation on palms and/or soles was noted in 6 patients. There was no treatment-related death observed.

[Rearrangements of immunoglobulin light chain and heavy chain constant region genes in B-cell malignancies]

We analyzed immunoglobulin (Ig) gene rearrangements in 69 patients with B-cell malignancies by Southern hybridization. We used 5 probes which covered JH 5'S mu and S gamma 3 loci of the Ig heavy (IgH) chain gene, and C kappa and kappa de loci of the Ig light (IgL) chain kappa gene, respectively. DNA rearrangements were observed in 68 out of the 69 patients using the JH probe. In 97% (33/34) of patients with non-Hodgkin's lymphoma (NHL), 100% (5/5) of chronic lymphocytic leukemia (CLL), 42% (10/24) of non-T cell acute lymphoblastic leukemia (non-T ALL), and in 0% (0/4) of chronic myelogenous leukemia lymphoid crisis (CML-LBC), the rearrangements were detected by C kappa and/or kappa de probes. Furthermore, the genotype of the light chain was defined by rearrangement patterns of these 2 probes. The by using the 5'S mu-probe, class switch recombinations were detected in 76% (25/33) of NHL, 20% (1/5) of CLL, 17% (4/24) of non-T ALL, and in 0% (0/4) of CML-LBC. Among them, 1 case of IgM NHL and 3 cases of double bearer NHL had rearranged on both IgH alleles by the constant region. The results of this study indicate that genotypes correspond well to phenotypes of B-cell malignancies and that the determination of genotype will be useful for making an exact diagnosis of B-cell malignancies.

[High-dose adjuvant chemotherapy with peripheral blood stem cell transplantation for breast cancer with poor prognosis--a pilot study]

Three patients with breast cancer with poor prognosis were treated with high-dose chemotherapy (HD-CT) and peripheral blood stem cell transplantation (PBSCT) as adjuvant treatment. After radical mastectomy, the consolidation chemotherapy with Adriamycin 50 mg/m2, Cyclophosphamide 1,000 mg/m2, Vincristine 1.0 mg/m2 and Methotrexate 200 mg/m2 with Leucovorin rescue was started. Recombinant human granulocyte colony stimulating factor (rhG-CSF) was also added for early recovery from myelosuppression. This combination chemotherapy was given every 3 weeks for 3 courses, and after the 2nd and 3rd courses, peripheral blood stem cells (PBSC) were collected and cryopreserved. HD-CT with Cyclophosphamide 2,000 mg/m2/day, Thio-TEPA 200 mg/m2/day, and Etoposide 300 mg/m2/day, were administered for 3 consecutive days, and after 48 hours of last doses, frozen-thawed PBSC (6.4-8.9 x 10(4)/kg of CFU-GM) were administered. rhG-CSF was also added. HD-CT and PBSCT were well tolerated, recovery from myelosuppression of the HD-CT was very quick and no serious side effects were observed.

Intensive sequential post-induction therapy for adults with acute myelogenous leukemia in first remission: long-term follow-up and results

We designed a post-induction therapy including intensive sequential therapy with non-cross-resistant drugs in an effort to prolong disease-free survival (DFS) for adults with acute myelogenous leukemia. Forty-five patients entered this study and 33 of 35 patients entering complete remission received the post-induction therapy. With a median follow-up for survivors of 3.5 years from complete remission, the actuarial 5-year DFS was 46% +/- 19% (95% confidence interval). The five-year DFS for patients over 45 years of age was comparable to that for patients under 45 years of age (50% +/- 26% vs 47% +/- 28%). Furthermore, the actuarial 5-year DFS for patients who required two courses of induction therapy was comparable to that for patients who required only one course of induction therapy (45% +/- 29% vs 50% +/- 25%). The toxicity of post-induction therapy was tolerable and no patients died during complete remission.

[Recent progress in the chemotherapy program and its theoretical background--malignant lymphoma]

Recently developed third generation chemotherapy programs have improved long-term disease free survival of patients with non-Hodgkin's lymphoma of aggressive histology, as compared with their predecessors. These protocols have been developed based on the cancer chemotherapy principles derived mainly of experimental tumor studies by H. Skipper and his group, and the theoretical approach by Goldie and Coldman to the occurrence of and chemotherapeutic overcoming of resistant clones. They are characterized by the use of multiple non-cross-resistant drugs in maximally elevated dose intensity. Our third generation protocol, CAMBO-VIP, has produced 90% CR and 76% DFS at 3 years. Further improvement may be obtained by application of new drugs with different mechanism of action, effective means to destruct resistant cells, and further elevation of dose intensity by myelostimmulatory cytokines or transplantation of autologous/allogeneic peripheral blood or bone marrow stem cells.

[Disseminated varicella-zoster virus infection without vesicles in a patient with malignant lymphoma]

A 76-year-old man was diagnosed as having malignant lymphoma (non-Hodgkin's lymphoma, diffuse medium cell-sized, B cell type). He was treated with CHOP therapy but with no response. In the terminal stage, he had continuous high temperature despite the administration of anti-bacterial and anti-fungal agents. Paralytic ileus, liver and pancreas dysfunction, and gastrointestinal bleeding developed. No skin eruptions occurred throughout the clinical course. He died on day 36 of treatment. Postmortem examination revealed foci of hemorrhagic necrosis containing many multinuclear giant-cells some of which with intranuclear inclusion bodies (Cowdry type A), in the liver, pancreas, gastrointestinal tract, bone marrow and other organs. Electron microscopy showed viral particles in the cytoplasm but not the nuclei of infected cells which were covered with a capsule, which was characteristic of varicella-zoster virus infection. Cells of the above organs were positive for immunohistochemical staining using antivaricella-zoster antibodies. The multiorgan failure seen in the terminal stage was considered to be due to disseminated varicella-zoster infection.

Alternating non-cross-resistant chemotherapy for non-Hodgkin's lymphoma of intermediate-grade and high-grade malignancy. A pilot study

Thirty-two patients with advanced non-Hodgkin's lymphoma (NHL) with aggressive histologic findings were treated with cyclophosphamide, doxorubicin, methotrexate with leucovorin rescue, bleomycin, vincristine, etoposide, ifosfamide, and prednisolone (CAMBO-VIP), in which presumably non-cross-resistant myelosuppressive and nonmyelosuppressive agents were administered during alternate weeks for 12 weeks. To ensure the high-dose intensity of the protocol, dose reduction and delay in treatment were minimized. Three patients were treated inadequately. Twenty-six (89.7%) of 29 evaluable patients had a complete response, and three had a good partial response. Relapse occurred in four patients, with a median follow-up of 29 months. The actuarial overall survival and disease-free survival were estimated to be 87.6% and 75.9%, respectively. The CAMBO-VIP treatment was well tolerated; myelosuppression was severe but transient and caused no serious infections. Side effects that affected dose intensity were oral ulceration, occurring in 28 patients, and blister formation under the thickened skin of palms and/or soles, followed by desquamation (5 patients). Hepatic toxicity was generally mild to moderate; it was severe in one patient. A 12-week regimen of CAMBO-VIP was effective for advanced NHL with aggressive histologic findings.

[Rearrangement of immunoglobulin light chain and heavy chain constant region genes in multiple myeloma]

We analysed immunoglobulin (Ig) gene rearrangements in 28 patients with multiple myeloma by Southern hybridization method. We used 5 probes which cover C kappa and kappa de loci of Ig light chain kappa gene, and JH, 5'S mu and S gamma 3 loci of Ig heavy chain gene. In 11 out of 12 patients with kappa-producing myeloma, DNA rearrangements were observed using C kappa probe. Among them, kappa de region was rearranged in 7 patients and kept germline configuration in 4 patients. In all of 14 patients with lambda-producing myeloma, C kappa region was deleted and kappa de region was rearranged. 5'S mu-probe was very useful for detecting class switch recombination, and furthermore by using S gamma-probe together, S mu-S gamma joining could be detected. In all of 10 patients with gamma-producing myeloma, 5'S mu and S gamma-probes detected the rearranged band of the same size on at least 1 allele, which suggested the presence of S mu-S gamma joinings. In 8 of 10 patients with Bence-Jones myeloma, 5'S mu-probe detected rearranged bands and the presence of class switch recombinations were suggested as observed in other Ig secretory myelomas. In other 2 patients with Bence-Jones myeloma, non-functional class switch recombinations were detected. The results of this study indicated that genotypes corresponded well to phenotypes in multiple myeloma, and further analysis in other types of B cell malignancies will be interesting.

Mixed lymphocyte-autologous tumor cell reaction in hematological malignancies--effect of interferon-beta and correlation with the expression of MHC class I antigen on tumor cells

The mixed lymphocyte-autologous tumor cell reaction (MLTR) was performed in 15 patients with hematological malignancies. Lymphocyte proliferative response and generation of cytotoxic cells against autologous tumor cells were evaluated and as was the effect of interferon-beta (IFN-beta) (750 IU/ml). Lymphocytes from patients during complete remission had sufficient functions in mixed lymphocyte culture with normal lymphocytes. Tumor cells stimulated allogeneic lymphocytes, although to a generally lesser extent as compared with remission lymphocytes from the same patients. Increased [3H]TdR uptake was observed in 5 patients and was suppressed by the addition of IFN-beta. Autologous tumor cell kill activity was induced by MLTR in 3 patients; IFN-beta-enhanced killing activity was present in these patients as well as in 3 other patients. Tumor cells from the 3 patients with positive autologous tumor cell kill activity had almost the same stimulating capacity as lymphocytes. The expression of MHC class I antigen and IFN-beta-enhanced expression was observed in all tumor cells studied by indirect immunofluorescence. These data suggest that some factors on tumor cells, in addition to MHC class I antigen, participate in the generation of cytotoxic cells against autologous tumor cells and its enhancement by IFN-beta.

[Alternating non-cross resistant multi-drug chemotherapy against malignant lymphoma (CAMBO-VIP)--consideration of the dose intensity]

Dose intensity defined as the amount of drug used per unit time, expressed as mg/m2/week, was reported to be a significant determinant of antitumor activity of single or combined drugs in cancer chemotherapy. We formulated a 12 week high dose intensity chemotherapy (CAMBO-VIP) for the treatment of advanced non Hodgkin's lymphoma with aggressive histology. The treatment consists of weekly alternate administration of myelosuppressive and non-myelosuppressive agents. Doxorubicin was administered every other week in combination with either cyclophosphamide, etoposide or ifosfamide. On the weeks in between, non-myelosuppressive vincristine was given with either methotrexate with leucovorin rescue or bleomycin. Prednisolone was given for the first and the last 4 weeks. Dose reduction and treatment delay were kept minimal for the purpose not lowering dose intensity. As of February 1990, 32 patients (pts), median age 52, entered the study, 29 of whom completed the treatment. There were 3 incomplete cases, in which 2 were due to interruption of the treatment at 5 and 6 weeks, respectively and 1 due to a half dose given because of the old age. CR was obtained in 29 pts (90.6%). Relapse occurred in 3 (10.4%) with the median follow-up of 12 months. Two year disease-free survival (DFS) was estimated to be 76.0% for all the patients and 83.9% for CR patients. Toxicity of CAMBO-VIP was moderate with no chemotherapeutic death. Myelosuppression was severe but of short duration, requiring virtually no dose reduction. Treatment delay was 3 days, median, and maximally 28 days. The average actual dose intensity calculated from given amount of drugs and treatment duration was as high as 90% of the protocol dose intensity. Dose intensity of CAMBO-VIP protocol is highest, equaling to that of MACOP-B, among representative series of reported lymphoma protocols. A highly significant correlation was observed between 9 drug relative dose intensity and DFS of the patients treated with each protocol. Significance of dose intensity as an independent prognostic factor, however, should be determined, by a prospective carefully designed stratified randomized studies.

T-cell malignancy following B-cell lymphoma in remission

A T-cell malignancy developed in a 64-year-old man with recurrent B-cell lymphoma after one and a half years of remission. Immunophenotypic and DNA analyses confirmed clonality and cell lineage of both lymphoid malignancies. Sequential development of B- and T-cell malignancies in this patient may be an example of biclonal lymphoma or treatment-related secondary lymphoma. However, another possibility would be the existence of a transformed lymphoid stem cell that underwent intraclonal conversion from B- to T-cell lines.

[Clinicopathologic analyses of eleven patients with Hodgkin's disease]

Clinicopathologic analyses were performed on 11 patients with histopathologic diagnosis of Hodgkin's disease which was confirmed immunohistochemically with the use of anti-Leu M 1 which is known to be specific to Reed-Sternberg cells. Patients with clinical stage II developed infradiaphragmatic involvement after Mantle field irradiation and should have been treated with extended field irradiation or combined modality therapy because of the possibility of PSIII1. Maintenance VENP therapy seemed to sustain remission but may have caused opportunistic infections. There were no rearrangements in either immunoglobulin or T cell receptor genes studied in two patients.

[Lymphocyte cytotoxicity against autologous tumor cells and the effect of interferon-beta on their activities. (1) Evaluation by modification of target tumor cells]

IFN is known to enhance NK activity against cultured cell lines such as K562, but not against frozen autologous tumor cells. In order to obtain increased NK cytotoxicity using IFN-beta, various modifications were performed on autologous tumor cells. IFN-beta induced more enhanced NK cytotoxicity of normal lymphocytes when frozen tumor target cells were cultured for 4-5 days in the medium, or when these cells were treated with Vibrio cholerae neuraminidase (VCN). However, in an autologous setting, IFN-beta did not enhance NK cytotoxicity against either cultured autologous tumor cells or VCN-treated tumor cells. Also, IFN-beta did not enhance cytotoxic T cell activity against autologous tumor cells induced by mixed lymphocyte-tumor cell culture, although IFN-beta was able to induce enhancement of allospecific cytotoxic T cells mediated by mixed lymphocyte culture.

[Lymphocyte cytotoxicity against autologous tumor cells and the effect of interferon-beta on their activities. (2) Evaluation of large granular lymphocytes (LGL)]

Large granular lymphocytes (LGL) were obtained by Percoll density gradient centrifugation of peripheral mononuclear cells from 15 patients with hematological malignancies (10 acute leukemias and 5 non-Hodgkin's lymphomas). Five-hour 51Cr-release cytotoxic assay by LGL was performed against frozen autologous tumor cells in these patients. Mean percentage cytotoxicity by LGL was 5.6%, and this was enhanced to 15.0% by the addition of IFN-beta to the culture medium. A decrease of cytotoxicity was observed when LGL was treated with anti-Leu 11b antibody plus complement, or when LGL was pretreated with the unlabelled K562 as a competitive inhibition assay. The addition of monocytes also induced a decrease of cytotoxicity, suggesting that monocytes may act as a suppressive agent in autologous tumor cell killing by LGL.