Coverage of bone marrow transplant patients: a survey of American and Canadian institutions

Personnel involved in supportive care of bone marrow transplant (BMT) patients include fellows (F), medical house-staff (HS), nurse practitioners (NP), physician assistants (PA), and moonlighting physicians (MP). We have obtained surveys from 108 American and Canadian transplant centers on the composition of inpatient support teams. Eighty-seven percent of institutions responding to the survey were university-based programs. Eighty-eight percent of the centers performed both allogeneic and autologous transplants, and 60% performed unrelated donor grafts. The mean number of transplants performed annually at each center was 101 (range 4-515). For daytime coverage, the percent of programs involving F, HS, NP, PA, or MP was 57, 50, 35, 25, and 0%, respectively, and for nighttime coverage, the composition was 50, 56, 7, 6, and 13%, respectively. Medical HS were incorporated into the care of BMT patients at some level in 93% of the programs. Involvement by HS included full 24-hour coverage (44%), full nighttime coverage (8%), stat coverage (18%), and code blue only coverage (21%). HS involvement was similar in small and large transplant programs. HS were more involved in university-based programs. Programs on the East Coast had more HS involvement, with 54% of the programs reporting full 24-hour coverage by HS compared with 32% of the programs in the Pacific region. Coverage of transplant patients varies throughout the country, and nonphysician providers are often used. HS are more active in university-based programs, and their role is similar in both large and small programs.

Bone marrow transplantation for therapy-related myelodysplasia: comparison with primary myelodysplasia

Therapy-related myelodysplasia (MDS) is a fatal marrow disorder distinct from primary MDS. We examined the efficacy of bone marrow transplantation (BMT) as a treatment for patients with therapy-related MDS. Eighteen patients with therapy-related MDS and twenty-five patients with primary MDS received an allogeneic, syngeneic, or unrelated donor BMT. Graft-versus-host disease prophylaxis included methotrexate, methotrexate plus cyclosporine, FK-506, or T cell depletion. Conditioning regimens consisted of cyclophosphamide/total body irradiation, with and without cytosine arabinoside, busulfan/cyclophosphamide, and cyclophosphamide/etoposide/carmustine. For patients with therapy-related MDS, the median age was 32 years and the actuarial disease-free survival was 24% (95% confidence interval 6, 42%) with a median follow-up of 3 years. For patients with primary MDS, the median age was 36 years and the actuarial disease-free survival at 3 years was 43% (95% confidence interval 22, 64%). Four of the therapy-related patients and two of the primary patients have relapsed. Three patients experienced graft failure; all three had received T cell-depleted marrow and two had marrow fibrosis. Our results suggest that patients with therapy-related MDS can be successfully transplanted. Transplantation should be considered early in the disease, since long-term disease-free survival is achievable.

Expression and activation of protein kinase C isoforms in a human megakaryocytic cell line

Megakaryocytes undergo a unique differentiation program, becoming polyploid through repeated cycles of DNA synthesis without concomitant cell division. We have shown previously that phorbol 12-myristate 13-acetate (PMA) induces the Dami human megakaryocytic cell line to become polyploid and to express platelet-specific proteins, including von Willebrand factor (vWF) and glycoprotein Ib (GpIb). Phorbol esters are thought to regulate gene expression principally through the activation of protein kinase C (PKC), a family of structurally related kinases with potentially unique activation requirements and substrate specificities. A survey of PKC isoforms in Dami cells revealed that, by both Western and Northern analyses, PKC isoforms alpha, beta, delta, epsilon, eta, theta, and zeta were reproducibly detected. PKC-gamma was not detected. In order to define the role of individual PKC isoforms in megakaryocytic maturation, PMA and 2-deoxyphorbol 13-phenylacetate 20-acetate (dPPA), a putative selective activator of the PKC-beta 1 isotype, were compared for their effects on Dami cell maturation. Treatment with either dPPA or PMA caused Dami cells to cease proliferating, to become polyploid, and to express vWF. We also examined dPPA and PMA for their ability to activate and to downregulate expression of different PKC isoforms. Fifteen-minute treatment with PMA resulted in the translocation of PKC isoforms alpha, epsilon, and theta from the cytosolic to the membrane fraction; twenty-four hour treatment resulted in the downregulation of these isoforms. In contrast, dPPA was found to be a potent activator of PKC-epsilon alone and exhibited weaker effects on alpha and theta. These data suggest that PKC isoforms beta, delta, eta, and zeta, which appear not to be activated by either phorbol ester, are unlikely to be primarily involved in megakaryocytic maturation in response to these agents. The isoforms that are translocated by both phorbol esters-PKC isoforms alpha and theta, and particularly epsilon-are more likely to transduce the signals that stimulate Dami cell differentiation.

Recombinant human interleukin-1 receptor antagonist in the treatment of steroid-resistant graft-versus-host disease

Acute graft-versus-host disease (GVHD) that is resistant to therapy is a highly lethal complication of marrow transplantation. Inflammatory cytokines such as interleukin-1 (IL-1) may be critical mediators of this process. If so, specific inhibition of IL-1 activity with recombinant human IL-1 receptor antagonist (IL-1Ra), a naturally occurring competitive inhibitor of IL-1, may ameliorate acute GVHD. We performed an open-label, phase I/II trial to evaluate the safety and efficacy of IL-1Ra in 17 patients with steroid-resistant GVHD. The IL-1Ra was administered as a 24-hour continuous infusion over 7 days. The dose was escalated in cohorts of patients from 400 to 3,200 mg/d. Acute GVHD was evaluated in each affected organ and as an overall grade. Stage-specific improvement of acute GVHD occurred in the skin (8 of 14, 57%), gut (9 of 11, 82%), and liver (2 of 11, 18%). Overall, acute GVHD improved by at least one grade in 10 of 16 (63%) patients. Response to therapy was associated with a reduction of tumor necrosis factor-alpha (TNF-alpha) mRNA levels in blood mononuclear cells (P = .001). The only toxicity attributable to IL-1Ra was reversible transaminase elevation in two patients. Inhibition of IL-1 activity with IL-1Ra is safe and has demonstrable efficacy in acute GVHD that failed to respond to conventional treatment. These data provide further evidence that IL-1 is a mediator of GVHD.

Bone marrow dysplasia in patients with newly diagnosed acute myelogenous leukemia does not correlate with history of myelodysplasia or with remission rate and survival

BACKGROUND

The records and initial bone marrow studies of 106 patients with newly diagnosed acute myelogenous leukemia (AML) were analyzed retrospectively to determine whether bone marrow dysplasia was predictive of a previous myelodysplastic disorder or correlated with remission rate and survival.

METHODS

Bone marrow aspirates and biopsy specimens were reviewed in a blinded fashion; dysplasia was assessed in as objective a manner as possible by numerically scoring nine specific findings: erythrocyte multinuclearity, nuclear fragmentation, megaloblastic characteristics, leukocyte granulation abnormalities and nuclear malformations, Pelger-Huet cells, and megakaryocytic dysplasia (mononuclear megakaryocytes, micromegakaryocytes, and megakaryocytes with multiple distinct nuclei).

RESULTS

Dysplasia of the megakaryocytic line was seen in 34% of patients; 70% of the patients had erythrocyte dysplasia; and 68% had leukocyte dysplasia. Pelger-Huet cells were seen in bone marrow of 35% of the patients. Overall dysplasia score and specific dysplastic findings such as Pelger-Huet cells did not correlate with a known history of myelodysplasia (P = 0.47), cytogenetic abnormalities (P = 0.35), prior chemotherapy treatment with or without alkylating agents (P = 1.00), previous malignant disorders such as polycythemia vera (P = 1.00), remission rate (P = 0.93), or survival (P = 0.42). Multivariate analysis confirmed known independent risk factors for remission in this patient population, including age (P = 0.04), history of prior chemotherapy (P = 0.04), abnormalities in chromosomes 5, 7, or 8 (P = 0.02), and type of antileukemia therapy (P < 0.001).

CONCLUSIONS

Bone marrow dysplasia is common in patients with AML and does not correlate with a history of myelodysplasia or predict outcome when patients are treated with standard intensive AML therapy.

Treatment of therapy-related acute myelogenous leukemia and myelodysplastic syndromes

The number of cases of therapy-related acute myelogenous leukemia and myelodysplastic syndromes has risen with the advances of successful combination chemotherapy. Unfortunately, the therapy-related diseases are difficult to treat. Aggressive induction chemotherapy can induce a complete remission, but the remission duration is short. Differentiating agents, hormonal agents, and growth factors have all been disappointing. Allogeneic bone marrow transplantation remains the only curative approach.

Monoclonal antibody AG-1 initiates platelet activation by a pathway dependent on glycoprotein IIb-IIIa and extracellular calcium

The biochemical responses of intact human platelets to the monoclonal antibody (mAb) AG-1 were investigated. AG-1 is a murine IgG mAb that recognizes a series of platelet membrane glycoproteins (Gp) from M(r) 21,000 to 29,000, one of which is the M(r) 24,000 (p24) receptor for anti-CD9 mAbs. AG-1 causes platelet aggregation and secretion. Platelets binding AG-1 demonstrate a dose- and time-dependent breakdown of phosphatidylinositol 4,5-bisphosphate (PIP2), production of diacylglycerol, and generation of phosphatidic acid (PA). These events are associated with the activation of protein kinase C (PKC), an increase in intracellular calcium, and fibrinogen binding. Platelet PA generation and PKC activation in response to AG-1 are inhibited by mAbs to platelet GpIIb-IIIa or by extracellular EGTA, but not by a mAb to platelet GpIb or by inhibiting platelet Na+/H+ exchange with 5-(N-ethyl-N-isopropyl)amiloride. Platelet cytoplasmic free calcium ([Ca2+]i) is elevated in response to AG-1, and this elevation is inhibited by mAbs to GpIIb-IIIa, an RGDS peptide or by chelating extracellular calcium. These results suggest that AG-1 binding to a unique platelet-surface glycoprotein initiates platelet responses through the activation of PIP2-specific phospholipase C, and that this occurs through a signal pathway that is dependent on GpIIb-IIIa and extracellular calcium.

Neuroendocrine carcinoma in a patient with hairy cell leukemia: a case report

Second malignancies are common in hairy cell leukemia. We report a case of a neuroendocrine carcinoma arising in a patient who had been diagnosed with hairy cell leukemia 6 years earlier. This case is the first report of these two tumors' occurring together. The pathogenetic basis for the presence of these two uncommon tumors in our patient is discussed.

Fatal acute respiratory failure following vinblastine and mitomycin administration for breast cancer

We report a case of acute fatal respiratory failure following mitomycin and vinblastine administration in a patient with metastatic breast cancer. This case, the first reported fatal case in a breast cancer patient and also the first fatal case in a nonsmoker, suggests an acute hypersensitivity reaction as the cause of the respiratory distress.