Analysis of factors affecting hematopoietic recovery after autologous bone marrow transplantation for lymphoma

Thirty patients with relapsed lymphoma (14 Hodgkin's disease, 16 non-Hodgkin's lymphoma) who underwent autologous bone marrow transplantation (ABMT) were assessed for the effect of different parameters on the rate of hematologic recovery post-ABMT. There was no correlation between nucleated cells count or numbers of CFU-GM or BFU-E in the infused marrow on either neutrophil or platelet recovery times. Patients with lymphoma who received more salvage chemotherapy (greater than six cycles) prior to marrow harvest took significantly longer to recover neutrophils to greater than 0.5 x 10(9)/l (p = 0.0229) and platelets to greater than 20 x 10(9)/l (p = 0.0007) than patients who received less than five cycles of salvage chemotherapy prior to harvest. There was no significant correlation between underlying disease, use of total body irradiation or status of cytomegalovirus serology and recovery times post-ABMT. The results suggest that extensive salvage chemotherapy may result in considerable stem cell damage to marrow, and that potential ABMT candidates with lymphoma should undergo harvest of tumor-free bone marrow as soon as possible following first relapse.

Acute transient parotitis after high dose etoposide and autologous bone marrow transplantation

Etoposide is an important component of several intensive therapy regimens in allogeneic and autologous bone marrow transplantation for advanced hematologic malignancies. We observed the occurrence of transient acute parotid and submandibular sialoadenitis in nine of 19 patients receiving high dose etoposide and melphalan followed by autologous bone marrow rescue. Manifestations included pain, tenderness and swelling of the parotid and submandibular glands. Symptoms arose 4-16 h after completion of etoposide infusion and resolved within 72 h. Elevation of serum amylase accompanied the symptoms, and was also observed in some patients who were asymptomatic. Discomfort was controlled with analgesics and the clinical course was uncomplicated in all cases. Transient parotitis is a relatively frequent and benign complication of high dose etoposide therapy.

Chronic myeloid leukemia arising in a progenitor common to T cells and myeloid cells

Until recently, T cells were believed not to be involved in chronic myeloid leukemia. We describe an example of CML in T lymphoblastic crisis with massive generalized lymphadenopathy in which the blasts were CD2(+), CD5(+), and CD7(+), variably CD1(+) and CD3(+), and both responded to and could be induced to produce the T cell growth factor, interleukin-2. Additionally, the blasts were shown to contain the CML-related tyrosine kinase P210bcr-abl rather than the smaller kinase associated with Ph1(+) ALL. Finally, the participation of the T lymphoid lineage in the CML clone was proven by the presence of the same BCR rearrangement in blasts as in granulocytes, suggesting the existence of a bone marrow progenitor common to the T cell and myeloid lineages.

Autotransplants in chronic myelogenous leukaemia: strategies and results

Autotransplants are increasingly used in chronic myelogenous leukaemia (CML). Most are performed in advanced leukaemia; now, autotransplants in chronic phase are being evaluated. Treatment involves high-dose chemotherapy with or without radiation followed by a transplant of previously cryopreserved stem cells derived from bone marrow or blood. The transplanted bone marrow may be manipulated in vitro to remove CML cells. Results vary. Transplants in advanced CML usually re-establish chronic phase but responses are brief. After transplants in chronic phase some recipients become Philadelphia chromosome negative for a year or more; others remain Ph-chromosome positive. There are insufficient data to show whether these early transplants prolong chronic phase duration or increase survival. The incurability of CML by conventional therapy should encourage further studies of this approach.

Neutrophilic myelofibrosis presenting as Philadelphia chromosome negative BCR non-rearranged chronic myeloid leukemia

Chronic myeloid leukemia consists of Philadelphia chromosome positive disease in 90% of cases, and a further 5%, although Philadelphia chromosome negative, exhibit bcr gene rearrangements consistent with the disease. The remaining 5% of cases have a heterogeneous clinical picture with a course unlike that of classical chronic myeloid leukemia, and may belong to different pathologic entities. We report five cases belonging to the latter group, initially identified as Philadelphia chromosome negative, bcr non-rearranged chronic myeloid leukemia, that developed progressive leucocytosis, absolute monocytosis, myelodysplasia, extramedullary hematopoiesis, and had evidence of myelofibrosis. These cases may represent a distinct clinical entity characterized by neutrophilic myelofibrosis, which can be identified prospectively by clinical and pathologic criteria. Standard therapy for treating chronic myeloid leukemia or idiopathic myelofibrosis may not be appropriate for this group.

Effect of different promoters on expression of genes introduced into hematopoietic and marrow stromal cells by electroporation

Electroporation is a simple and relatively efficient means of introducing genes into hematopoietic cells. However, achieving and maintaining high levels of gene expression in transfected hematopoietic progenitor cells remains problematic. In order to address this problem we examined the effect of different viral and cellular promoters on the transient expression of reporter genes transferred into K562, KG1a, and human marrow stromal cells. We found that although the Rous sarcoma virus long terminal repeat was most active in K562 cells in a transient expression assay, the murine cytomegalovirus immediate early promoter was strikingly more active than the other promoters in KG1a cells as well as in the marrow stromal cell population. Long-term stable gene expression was also demonstrated in stromal cells. We infer that the murine cytomegalovirus immediate early promoter may be highly active in human hematopoietic progenitor cells and that human marrow stromal cells may be an attractive vehicle for gene delivery.

Evaluation of cytoreductive therapy prior to high dose treatment with autologous bone marrow transplantation in relapsed and refractory Hodgkin's disease

Based on observations that bulky disease at autologous bone marrow transplantation (ABMT) may be correlated with poor outcome in Hodgkin's disease, we have assessed the ability of conventional-dose chemoradiotherapy to reduce tumour burden to a minimum prior to ABMT. Thirty-seven patients with relapsed or refractory Hodgkin's disease referred for intensive therapy and ABMT were treated initially with one to five cycles of DHAP chemotherapy. All patients had previously received MOPP and ABVD chemotherapy or similar regimens. Four patients achieved complete remission (CR) and 12 partial remission (PR), for a total response rate of 43%. Eight partial responders and four non-responders to DHAP achieved significant further tumour reduction with local radiotherapy (five CR, seven PR). Six of 10 non-responders to DHAP responded to alternative salvage chemotherapy (mini-BEAM, CEP or augmented CVP). Overall, 24/37 patients (65%) achieved effective cytoreduction (nine CR, 15 PR with minimal disease) and have proceeded to ABMT. Patients with bulky disease at relapse or limited stage (II, IIIA) at diagnosis were less likely to respond to DHAP, but some of these could be cytoreduced with alternative therapy. In addition, the number of prior chemotherapy regimens correlated inversely with likelihood of response to DHAP. The results indicate that approximately two-thirds of patients with Hodgkin's disease who relapse after MOPP and ABVD-like regimens can achieve effective cytoreduction with conventional-dose chemoradiotherapy and proceed to ABMT in CR or PR with minimal disease.

Human long-term bone marrow culture

Major advances in our understanding of human hematopoiesis have come from the development of semisolid in vitro culture techniques for the detection of progenitor cells capable of colony formation (see Chapter 28 , this volume). However, colony assays select for hematopoietic precursors committed to a specific lineage(s) and, therefore, are of limited value in the assessment of very early progenitor cells. Also, they do not provide a means of assessing the influence of microenvironmental cells deemed essential for maintaining hematopoiesis in vivo (1). Furthermore, for the assays to be valid, cells must be plated at a sufficiently low concentration to ensure clonality (a condition in which each colony has arisen from a single progenitor cell). Consequently, cell-cell interactions that may be important in exerting regulatory effects on hematopoiesis are likely to be minimal.

In vitro clonal culture of human hematopoietic progenitor cells

Human hematopoietic tissue represents a complex developmental system that is closely regulated to ensure the maintenance of appropriate levels of circulating blood cells. At least nine distinct lineages of cells at various stages of maturation have been described (1). Substantial progress in the study of hematopoietic stem cell ontogeny has resulted from the development of semisolid culture methods for the detection of committed progenitor cells. The assays define specific individual precursor cells indirectly by the ability of these cells to form colonies consisting of clonally expanded progeny at varying stages of differentiation. In turn, these methods have led to the identification, characterization, and synthesis by recombinant DNA techniques of some of the growth factors capable of stimulating colony formation and infer to an in vivo regulatory role for such factors in hematopoiesis.

Primary yolk sac (endodermal sinus) tumor of the prostate: case report and review of the literature

A primary yolk sac (endodermal sinus) tumor of the prostate is described in a 40-year-old male. This is the second documented case of a yolk sac tumor occurring in the prostate gland. Treatment included surgical removal and subsequent combination chemotherapy. Four months following diagnosis, the patient died of complications. At autopsy, no residual tumor was detected. The role of combination chemotherapy as potentially curative therapy in the treatment of extragonadal yolk sac tumors is discussed.

Synergistic effect of ketoconazole and antineoplastic agents on hormone-independent prostatic cancer cells

Ketoconazole has been recently used in the primary treatment of patients with metastatic cancer of the prostate and is identified as a potent inhibitor of cytochrome P450-dependent adrenal and testicular androgen production. The drug has also shown activity in patients failing conventional hormonal manipulation. We subsequently showed that ketoconazole in vitro has a direct cytotoxic effect on human androgen-independent prostatic cancer cell lines. In order to better define the possible role of ketoconazole on hormone-independent prostatic cancer, we incubated the cells from human androgen-independent prostatic cancer lines in a methylcellulose tumour colony assay with different doses of the drug and increasing doses of conventional cytotoxic agents (etoposide, bleomycin, vinblastine, methotrexate, and teniposide). We demonstrated synergistic suppression of prostate cancer clonogenic cell growth by ketoconazole in the presence of vinblastine or etoposide. This observation may assign a new and important role for ketoconazole as part of combination chemotherapy in the treatment of patients with advanced prostatic cancer.

Tissue-specific activity of heterologous viral promoters in primary rat hepatocytes and Hep G2 cells

In preparation for studies using gene transfer, we have identified transcriptional control elements which are active in primary rat hepatocytes. We used plasmids which were constructed so that the promoter or enhancer of interest initiated transcription of the bacterial chloramphenicol acetyltransferase (CAT) gene. Plasmids were introduced into primary rat hepatocytes in culture, into Hep G2 cells and other human and animal cell lines and into bone marrow stromal cells, and CAT activity was assayed after 48 hr. In primary rat hepatocytes, the highest CAT activity was obtained with plasmids carrying the Rous sarcoma virus long terminal repeat (pRSVCAT), or the SV40 early region promoter and enhancer (pSV2CAT). Hepatocytes carrying the murine cytomegalovirus immediate early promoter (pUCRNmCMVX/HCAT) also had appreciable CAT activity. No CAT activity was detected in rat hepatocytes carrying pSVOCAT (a promoterless construct), pUCRNtKCAT (herpes simplex thymidine kinase gene promoter), pLPVCAT (lymphocytotrophic papovavirus promoter) and pHBV1CAT (hepatitis B virus enhancer and core gene promoter). Therefore, for future studies of gene transfer in primary rat hepatocytes, the Rous sarcoma virus long terminal repeat or the SV40 early region promoter and enhancer can be effectively used to drive gene expression. Hep G2 cells carrying pHBV1CAT had high CAT activity. Hep G2 cells carrying pHBV2CAT (similar to pHBV1CAT, but with the hepatitis B virus sequences in reverse orientation with respect to the CAT sequences) and pHBV3CAT (similar to pHBV2CAT, but hepatitis B virus sequences are separated from the CAT sequences by about 700 bases) also expressed CAT activity, but not as strongly as with pHBV1CAT.(ABSTRACT TRUNCATED AT 250 WORDS)

An evaluation of outpatient bone marrow harvesting

In order to avoid the difficulties in scheduling and cost involved in admitting patients to hospital to undergo bone marrow harvests, we assessed outpatient marrow harvesting for autologous bone marrow transplant (BMT) candidates. Over a 13-month period, 39 consecutive patients with hematologic malignancies underwent bone marrow harvests as outpatients. For comparison we also evaluated 20 consecutive patients with similar disease status who had undergone bone marrow harvests as inpatients over the preceding 6 months. The mean hemoglobin value prior to harvest the mean volume of marrow harvested, and the mean nucleated cell count in the outpatient group were not significantly different from those of the inpatient group. There were no intraoperative complications. Of these 39 patients, 36 were discharged later the same day on oral iron supplements, with no adverse sequelae. Local pain was well controlled at home with mild oral analgesics. Two patients required admission due to postoperative hypotension--both responded promptly to intravenous (IV) fluids and blood and were discharged the following day. One patient was admitted postoperatively due to fever. There was a trend for the outpatients to receive less intra- and postoperative blood transfusions, but this did not reach statistical significance. The results suggest that most candidates for autologous BMT can safely undergo bone marrow harvesting as outpatients, thereby relieving pressure for hospital beds, potentially reducing costs and improving bed utilization. The study also raises the possibility of safely performing outpatient harvests on allogeneic BMT donors.

Ketoconazole: a possible direct cytotoxic effect on prostate carcinoma cells

Ketoconazole has been recently used in the treatment of advanced prostatic cancer and is believed to exert its effect by inhibition of androgen production. In order to determine whether ketoconazole exerts an additional direct cytotoxic effect on prostate cancer cells, we studied its effect on human hormone-independent prostate cancer cell lines (PC-3 and DU-145) in an in vitro clonogenic tumor assay. We showed that clinically achievable doses of ketoconazole caused greater than 90% suppression of tumor colony growth.

Acute leukemia: diagnosis, management, and potential for cure

Acute leukemia is an uncommon malignant disorder resulting from the clonal proliferation of hematopoietic precursors of the myeloid or lymphoid lineages. Of the two major subgroups, acute lymphoblastic leukemia is more common in children, while acute myelogenous leukemia predominates in adults. With modern chemotherapy 60%-70% of all children with acute lymphoblastic leukemia can be long-term survivors and are potentially cured. Although the prognosis in acute myelogenous leukemia is less favourable, recent therapy, including bone-marrow transplantation, offers possible cure in selected patient groups.

Hierarchical organization of hematopoietic microenvironments: role of proteoglycans

The orderly process of hematopoietic cell differentiation depends on the organization of specific microenvironments which function by assembling progenitor cells and appropriate concentrations of necessary growth factors. We propose that this organization involves a spectrum of microenvironmental complexity concomitant with changing cellular requirements, that it is achieved by the extracellular matrix produced by marrow stromal cells, and that its specificity is conferred by the heterogeneity intrinsic in the conformation of proteoglycans and their constituent glycosaminoglycans.

Electric field-mediated gene transfer: characterization of DNA transfer and patterns of integration in lymphoid cells

Southern analysis of individual transfectants generated by electroporation demonstrated a strong preference for the integration of DNA in low copy number even when electroporation was performed in the presence of increasing DNA concentrations. Although transfer of multiple DNA copies was detected at higher DNA concentrations (16 pmoles/ml or greater), the average gene copy number even at 36 pmoles DNA per ml, was only 13. Multiple gene copies were integrated at either a few chromosomal sites, or at a single site within individual transfectants. Restriction endonuclease cleavage data were consistent with a random orientation of molecules within a concatemer, suggesting that the concatemer may have risen via end-to-end ligation of linear molecules, rather than by homologous recombination. Integration of exogenous DNA into the host chromosome occurred preferentially at the ends of the linear molecule. Although the linearization site was lost upon integration, endonuclease sites as close as 18 bp from the linearization site were retained. These data, as well as direct restriction mapping of the transferred genes, indicate that DNA transfer and integration occur without DNA rearrangement. Taken together, these results suggest that electroporation may offer some unique advantages for the transfer of eukaryotic genes.

Anticonvulsant-induced marrow suppression and immune thrombocytopenia

Phenytoin and carbamazepine are rarely associated with serious hematologic side effects but can include impairment of either humoral or cell-mediated immunity. We describe a patient who developed severe granulocytopenia while taking phenytoin. The phenytoin was replaced by carbamazepine and the patient subsequently developed erythroid hypoplasia, neutropenia and persistent thrombocytopenia. In vitro studies demonstrated a phenytoin-dependent antigranulocyte antibody directly implicating phenytoin in the leukopenia. An extremely high titre of platelet-associated IgG was found which was independent of the presence of carbamazepine. Autoantibodies directed against the patient's red cells, granulocytes and lymphocytes were also demonstrated. In vitro marrow culture studies failed to detect cellular or humoral inhibitors and were suggestive of a stem cell defect. These studies indicate that anticonvulsant therapy can result in sustained humoral abnormalities as well as in nonimmune mediated marrow suppression.

Simian virus 40-transformed adherent cells from human long-term marrow cultures: cloned cell lines produce cells with stromal and hematopoietic characteristics

Adherent cells from long-term marrow cultures from 23 individuals were transformed with wild-type simian virus 40 (SV40). After transformation, cloned cell lines were developed that even after rigorous subcloning invariably produced both stromal cells and round cells. The stromal cells expressed cytoskeletal filaments similar to those of long-term marrow culture adherent cells and produced interstitial and basal lamina collagen types. The round cells had the electron microscopic appearance of primitive hematopoietic cells and when examined with cytochemical stains and monoclonal antibodies to hematopoietic differentiation antigens had reaction patterns suggestive of cells from several lineages. Most round cells expressed the pan-hematopoietic T-200 determinant, and lesser percentages expressed the early T cell antigens CD-1 and CD-3, HLA-DR determinants, the monocytic antigen recognized by Leu M3, and the myeloid antigens detected by monoclonal antibodies 1G10 and 12.8. In addition, when plated in semisolid medium in the presence of a source of colony-stimulating activity, up to 11% of the cells formed colonies consisting of blastlike cells that also expressed hematopoietic cell surface determinants. The data suggest that adherent cells in long-term marrow cultures contain a cell that after transformation by SV40 obligately produces cells with hematopoietic as well as stromalike features.

Acute leukemia occurring 19 years after treatment of acute lymphoblastic leukemia

A 22-year-old woman presented with acute lymphoblastic leukemia (ALL) during pregnancy. She had been successfully treated for ALL at the age of 3 years and had received maintenance treatment for 11 years. Complete remission of 3 years or more is an important factor for long-term survival and potential cure. Relapses may occur in the first 5 years after maintenance is discontinued. Later relapses are distinctly unusual. We have found six more cases of ALL occurring long after the initial remission in the English literature. It is unclear whether late relapse represents true relapse or a second leukemia. Life-long follow-up of children with ALL may be necessary.

Treatment of acute myeloid leukemia cells in vitro with a monoclonal antibody recognizing a myeloid differentiation antigen allows normal progenitor cells to be expressed

Monoclonal antibody L4F3 reacts with most acute myeloid leukemia (AML) cells and virtually all normal granulocyte/monocyte colony-forming cells (CFU-GM). Our objective was to determine whether lysis of AML cells with L4F3 and complement allowed expression of normal myeloid progenitors. The five glucose-6-phosphate dehydrogenase (G6PD) heterozygous patients with AML studied manifested only a single G6PD type in blast cells and in most or all granulocyte colony-forming cells, indicating that the leukemias developed clonally. The cells remaining after L4F3 treatment from two of the patients gave rise to granulocytic colonies that expressed the G6PD type not seen in the leukemic clone, indicating that they were derived from normal progenitors (CFU-GM). L4F3-treated cells from these two patients cultured over an irradiated adherent cell layer from normal long-term marrow cultures also gave rise to CFU-GM, which were shown by G6PD analysis to be predominantly nonleukemic. In the other three patients, the progenitor cells remaining after L4F3 treatment were derived mainly from the leukemic clone. The data suggest that in vitro cytolytic treatment with L4F3 of cells from certain patients with AML can enable normal, presumably highly immature progenitors to be expressed.

Correlation between cytogenetic and molecular findings in human chronic myelogenous leukemia lines EM-2 and EM-3

Few established cell lines derived from patients with chronic myelogenous leukemia have been reported. Cytogenetic examinations of two independently derived Philadelphia chromosome (Ph)-positive cell lines from a patient with chronic myelogenous leukemia were performed serially from their initiation in 1982 to the present. Subcultures of each of these lines maintained separately in two laboratories for over 2 years were compared for degree of divergence. The modal chromosome number declined substantially within the first few months and slowly thereafter. Despite hyperploidy, these lines have remained remarkably stable cytogenetically. For each line, the modal chromosome number is hypotetraploid, multiple copies of Ph are present and no normal chromosome #9 remains. Only a few marker chromosomes have arisen. Despite the multiple copies of Ph, a single bcr restriction pattern was seen, suggesting duplication of a single Ph, rather than independent translocation events. These lines should be very useful for in vitro studies of chronic myelogenous leukemia.