Kettering Award Lecture. The role of marrow transplantation in the eradication of malignant disease

Age at Exposure to Radiation Determines Severity of Renal and Cardiac Disease in Rats

Radiotherapy with sparsely ionizing photons is a cornerstone of successful cancer treatment. Age at time of exposure to radiation is known to influence biological outcomes for many end points. The effect of dose and age at exposure upon the occurrence of radiogenic cardiovascular disease is poorly understood. The goal of this work was to determine the response of maleWAG/RijCmcr rats at 6 months of age to gamma rays, and at 6 months or 6 weeks of age to X rays, using clinically relevant biomarkers of cardiovascular disease and kidney injury. Overall, there were significant radiation-induced effects on the levels of bicarbonate (P=0.0016), creatinine (P=0.0002), calcium (P = 0.0009), triglycerides (P = 0.0269) and blood urea nitrogen, albumin, protein, AST, alkaline phosphatase, total cholesterol and HDL (all P < 0.0001). Of those variables with a significant radiation-dose effect, there were significant modifications by age at time of exposure for bicarbonate (P = 0.0033), creatinine (P = 0.0015), AST (P = 0.0040), total cholesterol (P = 0.0006) and blood urea nitrogen, calcium, albumin, protein, alkaline phosphatase and HDL (all P < 0.0001). Cardiac perivascular collagen content was significantly increased in rats that were 8.0 Gy X-ray irradiated at 6 weeks of age (P < 0.047) but not at 6 months of age. While systemic blood pressure was elevated in both cohorts after 8.0 Gy X-ray irradiation (compared to agematched sham-irradiated controls), the magnitude of the increase above baseline was greater in the younger rats (P < 0.05). These findings indicate that dose and age at time of irradiation determine the timeline and severity of cardiac and renal injury.

Simvastatin mitigates increases in risk factors for and the occurrence of cardiac disease following 10 Gy total body irradiation

The ability of simvastatin to mitigate the increases in risk factors for and the occurrence of cardiac disease after 10 Gy total body irradiation (TBI) was determined. This radiation dose is relevant to conditioning for stem cell transplantation and threats from radiological terrorism. Male rats received single dose TBI of 10 Gy. Age-matched, sham-irradiated rats served as controls. Lipid profile, heart and liver morphology and cardiac mechanical function were determined for up to 120 days after irradiation. TBI resulted in a sustained increase in total- and LDL-cholesterol (low-density lipoprotein-cholesterol), and triglycerides. Simvastatin (10 mg/kg body weight/day) administered continuously from 9 days after irradiation mitigated TBI-induced increases in total- and LDL-cholesterol and triglycerides, as well as liver injury. TBI resulted in cellular peri-arterial fibrosis, whereas control hearts had less collagen and fibrosis. Simvastatin mitigated these morphological injuries. TBI resulted in cardiac mechanical dysfunction. Simvastatin mitigated cardiac mechanical dysfunction 20–120 days following TBI. To determine whether simvastatin affects the ability of the heart to withstand stress after TBI, injury from myocardial ischemia/reperfusion was determined in vitro. TBI increased the severity of an induced myocardial infarction at 20 and 80 days after irradiation. Simvastatin mitigated the severity of this myocardial infarction at 20 and 80 days following TBI. It is concluded simvastatin mitigated the increases in risk factors for cardiac disease and the extent of cardiac disease following TBI. This statin may be developed as a medical countermeasure for the mitigation of radiation-induced cardiac disease.

Graft-versus-Host Disease, the Graft-versus-Leukemia Effect, and Mixed Chimerism following Nonmyeloablative Stem Cell Transplantation

Allogeneic bone marrow or blood stem cell transplantation represents an important therapeutic tool for the treatment of otherwise incurable cancer and a large spectrum of nonmalignant diseases. Until recently, bone marrow transplantation was used primarily to eliminate malignant, genetically abnormal, or otherwise deficient stem cells; hence, highly toxic myeloablative regimens were considered mandatory for the eradication of undesirable cells of host origin. Recent data suggest that high-dose chemoradiotherapy may be successively replaced by nonmyeloablative stem cell transplantation (NST), which represents a safer biologic tool that involves the induction of host-versus-graft transplantation tolerance. NST thus provides allogeneic donor lymphocytes with the capacity to induce immune-mediated graft-versus-malignancy effects, either against mismatched minor or major histocompatibility alloantigens or against tumor-specific or tumor-associated antigens expressed by tumor or other hematologic cells of host origin. The future goals of the wider and safer clinical application of NST for the treatment of a larger number of indications and larger numbers of patients in need depend, on the one hand, on the development of more effective and safer modalities for maximizing the antitumor potential of donor lymphocytes (T-cells as well as natural killer and natural killer T-cells). On the other hand, these goals depend on using more selective approaches for targeting anticancer effector cells to their target cells. Such changes will thus set the stage for smarter rather than stronger modalities for the treatment of malignant and life-threatening nonmalignant diseases.

Immunotherapy of hematologic malignancies and metastatic solid tumors in experimental animals and man

New approaches are needed for maximizing specific responses against tumor cells resistant to chemotherapy. While cytokine therapy may amplify natural resistance against minimal residual disease, more robust anti-leukemia reactivity can be provided by allogeneic bone marrow transplantation (BMT) in conjunction with myeloablative, hence hazardous, conditioning, at the cost of graft-versus-host disease (GVHD). Documentation of the capacity of donor lymphocyte infusion (DLI) given late post BMT, when patients were off immunosuppression, in early 1987, with successful reversal of relapse and cure of patients fully resistant to maximally tolerated doses of chemoradiotherapy, with many patients alive and well >10-15 years later, indicated two important facts. First, resistant tumors are unlikely to be cured with higher doses of chemoradiotherapy that may harm the patient but not eliminate all his clonogenic tumor cells. Second, that under condition of tolerance to donor alloantigens, DLI may provide a cure to otherwise resistant patients. These observations paved the road for clinical application of non-myeloablative stem cell transplantation (NST), in the early 90s, based on a two-step procedure, first involving induction of transplantation tolerance to donor alloantigens by engraftment of donor stem cells, following safe lymphoablative rather than myeloablative conditioning. Second, use of donor lymphocytes for elimination of residual tumor or otherwise abnormal hematopoietic cells by immune-mediated graft-versus-host effects inducible by mobilized blood stem cell allografts containing larger inocula of donor T cells, or supported by post-grafting DLI when patients were off immunosuppressive modalities.

Donor lymphocyte infusion: the use of alloreactive and tumor-reactive lymphocytes for immunotherapy of malignant and nonmalignant diseases in conjunction with allogeneic stem cell transplantation

Donor lymphocyte infusion (DLI), pioneered in Jerusalem in January 1987, represents the first proof of principle of the absolute efficacy of immunotherapy as a means of curing cancer. Immunotherapy with alloreactive donor lymphocytes can eliminate "the last tumor cell" even in patients with hematological malignancies resistant to maximally tolerated doses of chemoradiotherapy. Alloreactive lymphocytes that can mediate anti-tumor effects following induction of host-versus-graft tolerance induced by transplantation of donor stem cells, can induce graft-versus-malignancy (GVM) effects which are usually accompanied by graft-versus-host disease (GVHD). However, occasionally GVM effects may also be accomplished independently of clinically overt GVHD. Interestingly, allogeneic donor lymphocytes may also eliminate undesirable host-derived hematopoietic cells in a large number of nonmalignant indications including genetic diseases, diseases caused by deficiency of stem cell products, and autoimmune disorders mediated by self-reactive lymphocytes. The cumulative clinical experience suggests feasibility of effective induction of graft-versus-leukemia (GVL); graft-versus-lymphoma (GVLy); graft-versus-multiple myeloma, as well as graft-versus-solid tumors (GVT), well-documented in patients with renal and breast cancer, even in patients with resistant disease that have failed myeloablative chemoradiotherapy. These observations that suggested that cell therapy by donor lymphocytes is the main therapeutic benefit of bone marrow transplantation (BMT) led to development of the nonmyeloablative approach for safer allogeneic stem cell transplantation. Nonmyeloablative stem cell transplantation (NST) makes it possible to offer an option for cure to elderly patients with no upper age limit, as well as to patients with poor performance status not considered eligible for conventional BMT. Using well-tolerated NST regimen, allogeneic stem cell transplantation can be accomplished with minimal procedure-related toxicity and mortality, possibly even on an outpatient basis. Immunotherapy mediated by adoptive allogeneic cell-mediated immunotherapy can be further improved by utilizing specifically immune donor lymphocytes, thus maximizing their efficacy against undesirable target cells of host origin on the one hand, while minimizing their ontoward efficacy against normal cells of host origin that could result in GVHD on the other. Taken together, DLI and subsequently NST, may have opened new horizons for treatment of life-threatening malignant and nonmalignant disorders correctable by allogeneic stem cell transplantation. It is anticipated that further improvement of reactivity and specificity of donor lymphocytes will lead to safer clinical application of cell therapy for a larger number of indications toward improving disease-free survival in a large number of indications while minimizing immediate and late procedure-related complications.

Nonablative stem cell transplantation for older patients with acute leukemias and myelodysplastic syndromes

High-dose chemoradiotherapy with allogeneic bone marrow or peripheral blood stem cell transplantation (SCT) is a potentially curative treatment for advanced or poor-prognosis hematological malignancies. This procedure was initially considered as a means to deliver supralethal doses of chemotherapy and radiation for the eradication of the malignancy, but it has subsequently become apparent that much of the therapeutic benefit of SCT relates to an associated immune-mediated graft-versus-leukemia (GVL) effect. Additionally, due to the increased risk of morbidity and graft-versus-host disease (GVHD) that occurs with advanced age, the use of standard myeloablative preparative regimens with allogeneic progenitor cell transplantation has been generally limited to younger patients in good medical condition. However, most patients with hematologic malignancies are older and therefore the overall impact of allografting is relatively small. Thus despite resulting in high rates of long term disease control, allografting is only performed in a small fraction of patients, either because of lack of a suitable donor or the high risk of toxicity due to age or the general medical condition. Therefore strategies aimed at improving the safety and tolerability of allografting to allow for its more frequent application in older patients are necessary.

Immune reconstitution following allogeneic stem cell transplantation in recipients conditioned by low intensity vs myeloablative regimen

We have investigated the immune status of patients with hematologic malignancies treated with a low intensity conditioning in preparation for allogeneic stem cell transplantation. Conditioning consisted of fludarabine, anti-T lymphocyte globulin and low-dose busulfan, followed by infusion of allogeneic blood stem cells. This protocol resulted in rapid engraftment and complete replacement of host with donor hematopoietic cells. Immunological parameters of these patients were compared to those patients who were conditioned by an aggressive myeloablative regimen. Distribution of cell surface markers of lymphocyte subsets from both groups of patients was similar, but different from that of normal control cells. Reduced intensity or non-myeloablative conditioning prior to allogeneic stem cell transplantation (NST), hardly lowered the normal T cell-dependent mitogenic response even during the early period following transplant, while the myeloablative treatments resulted in a suppressed mitogenic reaction and in slow immune recovery. Reactivity of non-MHC restricted cytotoxic T cells was also at a normal level in patients who were treated with NST. We conclude that stem cell engraftment following reduced conditioning may result in early reconstitution of immune responses assessed in vitro. We hypothesize that clinical application of NST may lead to faster development of effective immune responses against residual host-type malignant and abnormal non-malignant hematopoietic cells, although the role of fludarabine on post-transplant infections remains to be investigated in a larger cohort of patients.

Second allogeneic stem cell transplantation using nonmyeloablative conditioning for patients who relapsed or developed secondary malignancies following autologous transplantation

OBJECTIVE

Second allogeneic stem cell transplants for hematological malignancies are associated with a high incidence of transplant-related mortality due to the cumulative incidence of toxicity of the high-dose chemoradiotherapy traditionally used as an essential component of the conditioning. We have demonstrated previously that nonmyeloablative conditioning for primary allogeneic transplants from both sibling and unrelated donors results in minimal transplant-related toxicity and excellent stem cell engraftment. This study explores the possibility of using nonmyeloablative conditioning to minimize transplant-related toxicity in patients who have undergone second allogeneic transplants.

PATIENTS AND METHODS

Twelve high-risk, heavily treated patients-five with acute myelogenous leukemia (AML); five with non-Hodgkin's lymphoma (NHL); one with Burkitt's lymphoma, and one with acute lymphoblastic leukemia (ALL)-underwent second allogeneic nonmyeloablative stem cell transplantation (NST) from human leukocyte antigen (HLA)-matched donors, 29 (median) (range 3-57) months following their first transplantation procedure. The conditioning consisted of fludarabine 30 mg/m(2) daily for 6 days, busulfan 4 mg/kg daily for 2 days, and anti-T-lymphocyte globulin 10 mg/kg daily for 4 days. Anti-graft-vs-host disease (anti-GVHD) prophylaxis consisted of cyclosporine A alone, 3 mg/kg.

RESULTS

Engraftment was observed in all recipients, with complete and stable chimerism. None of the patients developed veno-occlusive disease of the liver or multi-organ failure. Five very high-risk patients with NHL (n = 3), Burkitt's lymphoma (n = 1), and AML (n = 1) relapsed 2 to 6 months post-transplant, and four of them died. Six patients appear to be disease-free after median follow-up of 23 months. One additional patient died from grade IV hemorrhagic cystitis. Actuarial survival and disease-free survival at 34 months are 56% and 50% respectively, with 95% confidence interval (25-78%).

CONCLUSION

These results suggest that nonmyeloablative conditioning significantly reduces transplant-related toxicity, thus making a second transplant feasible.

Allogeneic hematopoietic transplantation for acute and chronic myeloid leukemia: non-myeloablative preparative regimens and induction of the graft-versus-leukemia effect

High-dose chemoradiotherapy with allogeneic blood or bone marrow transplantation is an effective and potentially curative treatment for advanced or high-risk hematologic malignancies, but it has been associated with significant morbidity and mortality resulting from toxicity of the preparative regimen, graft-versus-host disease, and the immunodeficient state that accompanies the procedure. Development of safer and less toxic treatment has been the subject of much research. This review summarizes the current understanding of the mechanisms by which allogeneic transplants cure leukemia and the rationale for non-myeloablative preparative regimens. Experience of the authors is related with 116 patients diagnosed with acute or chronic myeloid leukemia who underwent allogeneic hematopoetic transplantation with two non-ablative regimens that differed in intensity.

Graft-versus-lymphoma effect after allogeneic peripheral blood stem cell transplantation for primary central nervous system lymphoma

Allogeneic peripheral blood stem cell transplantation (allo PBSCT) is a recognized treatment modality for hematological malignancies resistant to conventional chemoradiotherapy. The post-transplant immune-mediated graft-versus-leukemia effect has major curative potential. In this case presentation, the allogeneic approach to resistant recurrent primary central nervous system (CNS) lymphoma using peripheral blood stem cells from an HLA identical sibling after immuno-suppressive non-myeloablative conditioning, was examined clinically. The patient in question had relapsing refractory primary CNS lymphoma and is the first to be treated with this modality. She developed early skin and liver-localized grade II graft-versus-host disease after allo PBSCT, which then responded to short-term treatment. Chimeric studies at the time showed 100% donor cells and repeated magnetic resonance imaging of the brain revealed gradual shrinkage of the tumor. Three months after transplant the cerebral mass was no longer evident and currently, 30 months after transplantation, the patient continues to be disease free. The absence of any signs of malignancy suggests the development of a durable graft-versus-lymphoma effect in this brain tumor and indicates that this effect may be achieved even after non-myeloablative conditioning.

Stem cells from bone marrow, umbilical cord blood and peripheral blood for clinical application: current status and future application

Bone marrow transplantation (BMT) has progressed rapidly during the past two decades to that of a treatment of choice as a therapeutically effective modality for the treatment of selected patients with malignant disease and non-malignant hematological disorders. However, its use is limited by availability of human leukocyte antigens (HLA)-matched donor cells, engraftment and graft-versus-host disease (GVHD). Prevention of GVHD, improvement in the speed and quality of marrow reconstitution, and screening of new immunomodulating agents which improve engraftment and augment hemopoiesis are intense areas of investigation. To this end there has clearly been progress in purification and characterization of human stem cells from different tissue sources. Discussed in this review are: (a) stem cell purification, characterization and ex vivo expansion; (b) bone marrow stem cell transplantation; (c) cord blood stem cell transplantation; (d) peripheral blood stem cell transplantation; (e) fetal liver stem cell transplantation; (f) in utero stem cell transplantation; and (g) evaluation of the capacity of stem cells to serve as targets for gene therapy.

Simultaneous occurrence of osteosarcoma and osteochondroma following treatment of neuroblastoma with chemotherapy, radiotherapy, and bone marrow transplantation

Radiation-induced bone changes and second malignancies, as well as benign tumors, following bone marrow transplantation are being reported with increasing frequency. An osteosarcoma of the fourth right rib and an osteochondroma of the left scapula developed in a long-term survivor of abdominal neuroblastoma treated with chemotherapy, local radiation, and bone marrow transplantation. All these treatment modalities are known to induce neoplasia.

Caries-related salivary microorganisms and salivary flow rate in bone marrow recipients

Cancer treatments often induce oral complications. In this study we investigate longitudinally the salivary gland function, the salivary caries-related microorganisms, and buffer capacity in bone marrow recipients. Stimulated saliva samples were taken midmorning. The salivary factors were studied in 42 patients from before transplant until 4 months after transplant. A dramatic reduction (66%) of salivary flow rate is noticed in all patients at 1 month after transplant, and only a partial recovery (42% reduction) is seen after 4 months. A clear shift toward a lower buffer capacity and a higher amount of cariogenic microorganisms is seen posttransplant. This shift is more pronounced when total body irradiation was included in the pretransplant conditioning therapy. These findings indicate that the studied parameters in transplant recipients can contribute to a higher caries risk and oral complications during the early posttransplant period.

Role of interleukin-2 in human hematological malignancies

Clinical studies with Interleukin-2 (IL-2) in human hematologic malignancies were initiated in the late 1980s. Based on clinical studies on various solid tumors, and laboratory research on hematopoietic cells, IL-2 was shown to be effective in 150 acute myeloid leukemia (AML) patients mainly for maintenance therapy in first complete remission, or with residual blast cells in the marrow. IL-2 has also been shown to be effective in remission induction in 10 patients with chronic myeloid leukemia (CML). The role of IL-2 in lymphoma patients remains to be established. IL-2 alone or in combination with Interferon-alpha, may intensify remission and prolong disease-free survival when given post autologous bone marrow transplantation (BMT) to patients with lymphoma and myeloid leukemia, and to a lesser degree, to patients with acute lymphatic leukemia (ALL). IL-2 in combination with HLA-matched or mismatched peripheral blood lymphocytes was also used post autologous BMT in preliminary studies. IL-2 was administered with or without peripheral blood lymphocytes, for prevention of relapse post T-cell-depleted allogeneic BMT in CML, ALL and AML, with encouraging results. The same strategy was shown to be effective in the reinduction of remission in patients with CML, who relapsed post BMT.

Assessment of proton magnetic resonance spectroscopy of blood serum as a diagnostic tool in bone marrow transplantation

The use of proton high-resolution magnetic resonance spectroscopy (MRS) allows the rapid detection and quantitation of modification in the blood serum metabolic profiles in haematooncological patients. This study examines the feasibility of using proton MRS as a diagnostic tool in predicting the outcome of bone marrow transplantation (BMT) at the earliest possible date. Proton spectra of serum samples from 18 BMT patients (11 autologous-BMT and seven allogeneic-BMT), six hematooncological patients that did not undergo BMT and six normal individuals were recorded at 400 MHz. A longitudinal MRS study was carried for these groups and the data were evaluated for statistical significance. It was determined that the MRS results, taken at different time points before and after the BMT treatment, are statistically significant. However, no significant difference was observed in the MRS parameters between the transplanted patients and the control patients. We could not obtain significant correlation between the MRS results and the immunoglobulin level, engraftment parameters or the age, sex, stage of basic disease, conditioning protocols, transplant type, post transplant complications (including death) and outcome.

Intracranial haematomas following bone marrow transplantation

Intracranial haemorrhage (ICH) is a known grave complication of leukaemia and has been described post mortem following bone marrow transplantation (BMT). Ante mortem following BMT, the incidence and significance of ICH is not well defined. The records of 471 bone marrow transplantation recipients over 11 years at the Hadassah University Hospital Bone Marrow Transplantation Department were reviewed. The relevant data of all patients with ICH were analysed. A resolute diagnostic and treatment protocol for subdural haematomas had been employed. The indication for transplantation in 273 of the patients was leukaemia. Thirteen of these patients developed subdural haematomas within 42 days of the transplant, and nine of these haematomas were bilateral. None of the 198 patients with other malignancies or nonmalignant indications for BMT (predominantly aplastic anaemia and beta thalassaemia major) had subdural haematomas. One thalassaemia patient and three leukaemia patients had intracerebral haematomas. There was no mortality or major morbidity from the subdural haematomas, which were all successfully resolved. In contrast, all of the patients with intracerebral haematomas consequently died. Subdural haematomas occur in approximately 5% of patients with leukaemia following BMT, but the clinical outcome is relatively benign. Intracerebral haematomas are a sporadic, lethal complication following BMT.(ABSTRACT TRUNCATED AT 250 WORDS)

Verification of lung attenuator positioning before total body irradiation using an electronic portal imaging device

PURPOSE

We report the first clinical experience with an electronic portal imaging device for lung attenuator positioning before delivery of total body irradiation. We demonstrate a technique for lung attenuator placement which reduces the dose to the patient during setup, reduces the patient setup time, and increases the accuracy of lung attenuator positioning.

METHODS AND MATERIALS

Patients are treated with total body irradiation using a dedicated dual source irradiation facility prior to receiving bone marrow transplantation. The dose rate to the patient's midline is limited to 0.10 Gy/min, and partial transmission lung blocks are used to minimize radiation induced pneumonitis while delivering adequate dose to the regions under the blocks. Lung blocks are placed on the patient's back and chest wall, and portal images are used to verify proper block placement before the remaining treatment dose is delivered.

RESULTS

We report the use of a liquid ionization chamber matrix electronic portal imaging device for imaging total body irradiation patient setups.

CONCLUSION

The dose to the patient using the EPID for portal imaging is a factor of 7.5 lower than that needed for film. Image quality is superior to that of film due to digital processing. Since less time and dose are needed for imaging, it is demonstrated that better and more efficient final placement of the lung blocks can be achieved.

Regional versus general anesthesia for bone marrow harvesting

STUDY OBJECTIVE

To compare regional versus general anesthesia for bone marrow harvesting.

DESIGN

Retrospective study.

SETTING

Inpatients at a bone marrow transplantation unit of a university medical center.

PATIENTS

One hundred sixty-two donors: 63 healthy patients donating heterologous marrow, 99 patients donating autologous marrow.

INTERVENTIONS

Anesthesia and patient charts from 1986 to 1990 were reviewed.

MEASUREMENTS AND MAIN RESULTS

Regionally anesthesized patients required less transfused blood in the perioperative period, even though more bone marrow was aspirated. This group also required less postoperative analgesia. We found no difference between the groups with regard to length of hospitalization or amount of colloid required in the perioperative period.

CONCLUSIONS

Our data suggest that both modes of anesthesia can be safely administered. Further investigations should be carried out to determine whether the two types of anesthesia, regional and general, are equivalent.

Antitumor alkylating agents: in vitro cross-resistance and collateral sensitivity studies

Cell lines resistant to five antitumor alkylating agents (CDDP, PAM, 4-HC, HN2, and BCNU) were developed from five parental human tumor lines representative of solid tumors with a range of sensitivities to antitumor alkylating agents. The parental cell lines were SCC-25 squamous carcinoma of the head and neck, MCF-7 breast carcinoma, SW2 small-cell lung cancer, SL6 non-small-cell lung carcinoma, and G3361 melanoma. Survival curves using colony formation as the endpoint were generated for each of the 25 cell lines to each of the five alkylating agents. Comparison of the drug concentrations that reduced the survival of the alkylating agent-resistant cell lines by 90% (IC90 values) with the IC90 values obtained for the corresponding parental cell lines was used as a measure of the resistance/sensitivity of the alkylating agent-resistant lines to each drug tested. Although cross-resistance among the alkylating agents was generally uncommon, several patterns of response emerged. Cross-resistance occurred in 27 of the 105 determinations and occurred most frequently in the cell lines in which resistance was developed to PAM (57%) or BCNU (38%). Cross-resistance to HN2 occurred most frequently. Collateral sensitivity was equally as common, occurring in 25 of the 105 determinations. Collateral sensitivity occurred most frequently in the cell lines made resistant to 4-HC. The 4-HC-resistant cell lines were most frequently collaterally sensitive to PAM and to BCNU. Cross-resistance developed most frequently in the MCF-7 breast carcinoma and SCC-25 squamous-cell carcinoma cell lines, whereas collateral sensitivity developed most frequently in the SW2 small-cell lung cancer line and the G3361 melanoma cell line and least frequently in the MCF-7 breast carcinoma cell line and the SL6 non-small-cell lung cancer cell line. The implication of these findings for the development of strategies for clinical treatment are discussed.

The use of G-CSF or GM-CSF mobilized peripheral blood progenitor cells (PBPC) alone or to augment marrow as hematologic support of single or multiple cycle high-dose chemotherapy

High dose chemotherapy with autologous bone marrow support (ABMT) can achieve prolonged relapse-free survival in relapsed lymphomas, leukemias, and certain solid tumors. The principal morbidity and mortality relate to the infectious complications that occur during the 3-4 week aplasia until the marrow autograft recovers. Progenitor cells can be mobilized into the peripheral blood compartment by hematopoietic growth factors, used alone or after chemotherapy. We describe four trials using cytokine-mobilized peripheral blood progenitor cells (PBPC). In the first trial, PBPC collected after GM-CSF administration were used to augment marrow. Reconstitution of trilineage marrow function occurred promptly, resulting in short hospital stays and fewer platelet transfusions. In a second study, GM-CSF/chemotherapy-mobilized PBPC were used as the sole hematopoietic support during high dose chemotherapy. Granulocyte and platelet reconstitution was rapid. Time to hematopoietic recovery, transfusion requirements, and duration of hospital stay were all significantly improved for the patients receiving PBPC compared with similar patients receiving marrow alone. While most patients experienced prompt hematopoietic recovery they showed sluggish platelet engraftment. The next two trials built on the observation that a few PBPC alone could support both granulocyte and platelet recovery and were designed to test the feasibility of sequential high-dose therapies. In one trial, PBPC given with and without marrow made it possible to deliver two sequential cycles of high-dose therapy. The second trial utilized PBPC plus cytokines to deliver four cycles of dose-intensive chemotherapy at doses that could not be given with cytokine support alone.(ABSTRACT TRUNCATED AT 250 WORDS)

Three-dimensional dose distribution of total body irradiation by a dual source total body irradiator

This study describes the three-dimensional dosimetric characteristics of total body irradiation by our dedicated irradiation unit, which consists of two modified 4-MV linear accelerators mounted opposite each other, providing a field size of 220 cm x 80 cm at the midplane. Our dose calculation algorithm considers the three-dimensional contour of the patient to evaluate the primary and scatter doses. The data base for the calculation includes tissue-to-maximum ratios measured for the large fields. The lung dose correction was calculated using the methods of Batho or ratio of TMR. The accuracy of the calculated dose distributions was verified by measurements with ionization chambers in a humanoid phantom. We also describe and verified a technique to achieve desirable midline lung doses using lead shields. The flexibility and the accuracy of the planning system offers the potential in optimizing the therapeutic ratio for total body treatments.

GM-CSF potentiated peripheral blood progenitor cell (PBPC) collection with or without bone marrow as hematologic support of high-dose chemotherapy: two protocols

High-dose chemotherapy with autologous bone marrow support (ABMS) achieves prolonged relapse-free survival in relapsed lymphomas and leukemias and has provided durable complete responses in certain solid tumors. The principal morbidity and mortality result from the infectious and bleeding complications during the 3-4 week aplasia until the bone marrow autograft can recover. Hematopoietic growth factors, alone or used after chemotherapy, increase the number of circulating progenitor cells in the peripheral blood compartment. In one trial, 12 patients with solid tumors were treated with high-dose chemotherapy and supported with both bone marrow and peripheral blood progenitor cells (PBPC) collected after GM-CSF administration. Reconstitution of bone marrow function occurred quickly (ANC greater than 500/microliters by day 17; platelet-transfusion independence by day 16), resulting in short hospital stays (median, 28 days). In a second study, 12 patients with metastatic breast cancer responding to induction chemotherapy (doxorubicin, 5-fluorouracil, and methotrexate) were given GM-CSF during induction to collect PBPCs during leukocyte recovery. These PBPCs were used as the sole hematopoietic support during high-dose chemotherapy with cyclophosphamide, thiotepa, and carboplatin. Granulocyte and platelet reconstitution were extremely rapid (median, 14 and 12 days, respectively). When compared with 29 patients undergoing the same intensification therapy using ABMT as sole support, time to hematopoietic recovery, transfusion requirements, and duration of hospital stay were all significantly improved for the patients receiving PBPC. PBPC with or without marrow may enhance the safety, tolerance, and cost of high-dose therapy. Moreover, PBPC may render multiple course combination, high-dose therapy feasible.

Oral gram-negative bacilli in bone marrow transplant patients given chlorhexidine rinses

Fifteen bone marrow transplant (BMT) patients who received three 0.12% chlorhexidine digluconate (CHX) mouthrinses daily for eight weeks were monitored weekly for the occurrence of oral opportunistic Gram-negative bacilli (GNB). Tongue and buccal mucosa were sampled with use of Culturette swabs that were streaked on plates containing selective MacConkey agar. After incubation, colony-forming units were scored and putative GNB classified with use of the API 20E rapid identification system and supplemental biochemical tests. After identification, the susceptibilities of all GNB to CHX were determined by means of a disk diffusion sensitivity assay. Sixty-seven percent (10) of the BMT subjects had at least one GNB-positive tongue culture, and 53% (8) had GNB in samples taken from the buccal mucosa. Of 218 samples taken, 26% and 24% from the tongue and buccal mucosa, respectively, were GNB-positive. The predominant clinical GNB isolates were Enterobacter cloacae (46%) and Klebsiella pneumoniac (30%). Their respective CHX minimum inhibitory concentrations (MICs) were similar to those of ATCC reference strains. Although the CHX MIC values of the clinical GNB isolates were high (less than or equal to 37.5 to less than or equal to 300 micrograms/mL), they were not dependent upon length of exposure to the agent. Therefore, changes in sensitivity or resistance to CHX did not appear to occur. The results suggest that the mouths of BMT patients--and perhaps of other immunosuppressed individuals--should be routinely monitored for GNB, as are other clinically important sites, such as the throat and the urinary and gastro-intestinal tracts.

Current problems and future goals in clinical bone marrow transplantation

Allogeneic bone marrow transplantation (BMT) is associated with the cumulative toxicity of high dose chemotherapy and/or radiation therapy regimens currently in use, with acute and chronic graft vs host disease (GVHD), as well as with the consequences of delayed immunological reconstitution due to slow maturation of the immune system and drugs currently used for prevention of GVHD. Although GVHD may be overcome by T-cell depletion it leads to an increased incidence of graft rejection and relapse of the original malignancy. These too represent major problems. Autologous BMT results in high relapse rates due to lack of immune-mediated allogeneic interactions of grafted cells against tumor cells of the host. In view of the fact that experiments in animal models of human disease suggest that antileukemic effects of allogeneic marrow grafts may be partially independent of GVHD, new approaches for amplification of antitumor effects of autologous and allogeneic cells by cytokines and by lymphokine-activated cells are discussed. Evidence for antileukemia effects of IL-2 therapy in animals is presented. Beneficial effects of several cytokines in autologous and allogeneic BMT are suggested by significant facilitation of immunological and hematopoietic reconstitution following transplantation of bone marrow cells treated in vitro with cytokines (including ASTA-Z-purged marrow) and following in vivo administration of cytokines in conjunction with BMT. Overall, in view of several innovative biological interventions, it seems that significant progress in autologous and allogeneic BMT may be underway; the concept yet to be established is that successful and less risky BMT may be accomplished by replacing aggressive chemoradiotherapy regimens with sophisticated immunomanipulations and biological response modifying agents.

Late effects of cyclophosphamide and total body irradiation as a conditioning regimen for bone marrow transplantation in rats (a preliminary report)

The longterm survival and occurrence of neoplastic and nonneoplastic lesions following total body irradiation (TBI), 8.5 Gy, with or without additional cyclophosphamide (Cy; 100 mg kg-1 i.p.) treatment as a conditioning regimen for bone marrow transplantation (BMT) were studied in male BN/BiRij rats. The two groups of rats that were treated with Cy (Cy and Cy + TBI) that survived beyond 100 days after treatment, had a severely decreased median (post treatment) survival time (Cy + TBI: 14.5 months and Cy: 14.1 months). Survival time in the TBI group was moderately decreased (18.5 months) as compared with the untreated controls (27.2 months). All treatment modalities were carcinogenic according to the raw data. After Cy-treatment a high incidence of, frequently multiple, malignant nerve-sheath tumours (Cy: 66 per cent, Cy + TBI: 31 per cent, controls: 2 per cent) was observed. TBI induced an increased occurrence of a great variety of tumours, especially mesenchymal tumours. This effect was more pronounced in animals receiving TBI alone as compared to animals receiving the combined treatment of Cy + TBI; an effect that most likely resulted from the longer median survival after TBI. The multi-target effect of TBI was also reflected in the occurrence of nonneoplastic effects in a variety of tissues, including high incidences of biliary cysts in the liver and severe testicular atrophy. The most important Cy-induced nonneoplastic lesion was incisor dysplasia, which resulted in feeding problems that could only be partly overcome by administering powdered food. Early mortality in the Cy-treated groups was associated with emaciation and generalized organ atrophy. A more definitive estimate of the late effects of supralethal chemoradiotherapy as part of a treatment of malignant disease has to await the results of various conditioning regimens for BMT in rats employing the acute BN myelocytic leukaemia (BNML) as a rat model for human acute myelocytic leukaemia (AML).

Therapeutic use of chlorhexidine in bone marrow transplant patients: case studies

Patients undergoing cytotoxic chemotherapy and radiation therapy often experience severe oral complications during and after treatment despite supervised oral hygiene and conventional antimicrobial regimens. The antimicrobial compound chlorhexidine is an effective topical prophylactic agent against oral mucositis and candidiasis. Oral mucositis developed in four patients who underwent bone marrow transplantation; the condition was severe enough to prompt use of chlorhexidine. In each case, there was clinical resolution of mucositis and a concomitant decrease in the oral microbial burden 1 week after chlorhexidine use began. This strongly suggests that, in addition to its value in protecting these severely immunocompromised patients from oral infection, chlorhexidine also offers a therapeutic benefit in the resolution of existing oral infections and of mucositis.

Chlorhexidine for prophylaxis against oral infections and associated complications in patients receiving bone marrow transplants

Intensive chemoradiotherapy damages the mucosal barrier of the mouth and throat and is often associated with severe oral inflammation and infection. This study examined the use of a 0.12% chlorhexidine gluconate mouthrinse for prophylaxis against oral complications in patients receiving bone marrow transplants. Use of chlorhexidine mouthrinse produced reductions in oral soft tissue disease and oral microbial burden, including a significant decrease in oral mucositis and Candida infections. The advantage for patients undergoing intensive antineoplastic therapy, and potentially for other immunocompromised patients susceptible to oral infections, was studied.

Hemopoietic marrow function in chronic neutropenia of blacks: cure of aplastic anemia by allogeneic marrow transplantation from a neutropenic sibling donor

A black patient with severe aplastic anemia is described who underwent successful bone marrow transplantation from a sibling with chronic neutropenia. During an evaluation to identify a suitable donor, it was found that the majority of family members tested had neutropenia, with no familial history of significant infections or related hospitalizations. In vitro hemopoietic culture studies of marrow from the patient's HLA-MLC-matched siblings showed normal numbers of pluripotential and committed hemopoietic progenitors; in vitro hemopoietic colony formation from the patient was markedly subnormal, consistent with the clinical picture of severe aplastic anemia. Following appropriate conditioning therapy, marrow transplanted from one of these neutropenic sibs produced full hematopoietic reconstitution. Posttransplant marrow culture studies of the patient showed restoration of a normal pattern of in vitro hemopoiesis. The in vitro culture studies and clinical experience in this patient support the concept that chronic neutropenia of blacks is not primarily a marrow progenitor cell disorder but, more likely, a manifestation of a genetically determined alteration in granulocyte kinetics.

Use of radiation and/or hyperthermia for treatment of mast cell tumors and lymphosarcoma in dogs

Radiation alone can be used to treat mast cell tumors that are not likely to metastasize (that is, differentiated or localized lymphorecticular tumors). In patients with mast cell tumors that are likely to metastasize (that is, undifferentiated, metastatic mast cell disease or generalized lymphoreticular neoplasms), radiation should not be used as the only treatment agent. In these patients, treatment combinations of hyperthermia/chemotherapy and radiation/hyperthermia/chemotherapy have been shown to have promise, but these treatment combinations need to be evaluated in prospective trials.

Mycobacterial pulmonary infections after allogeneic bone marrow transplantation

Allogeneic bone marrow transplant recipients are prone to pulmonary infections caused by a wide spectrum of organisms. Nonetheless, the recognition of lung disease caused by Mycobacterium tuberculosis in two patients and Mycobacterium avium-intracellulare in a third patient at the University of Texas M. D. Anderson Hospital represents the first report of these agents occurring in allogeneic marrow recipients. Diagnosis can be difficult due to atypical presentations, initial negative culture results, and the presence of more than one pathogen in these compromised hosts. In the case involving Mycobacterium avium-intracellulare infection, culture of material obtained by bronchoscopy established the diagnosis when repeated sputum samples showed no growth. A vigorous search for mycobacteria is suggested in allogeneic bone marrow transplant recipients with pulmonary infections.

Secondary tumors after high-dose cyclophosphamide and total-body irradiation followed by bone marrow transplantation in a rat model for human acute myelocytic leukemia (BNML)

Brown Norway (BN) rats carrying a transplantable acute myelocytic leukemia (BNML) were given a supralethal combination of cyclophosphamide (80-100 mg/kg i.p.) and total-body irradiation (9.0 Gy gamma rays or 8.5 Gy X-rays) followed by isologous bone marrow transplantation. Of 110 long-term survivors (greater than 95 days), 40 (45%) died of a secondary malignancy at a median posttreatment age of 450 days. At a comparable age, non-treated control BN rats show a spontaneous tumor incidence of 5% only, which increased to 83% during the aging process. Thus the latency period for the appearance of tumors was impressively shortened. Tumors of neurogenic origin and acute leukemias were the most prominent types, in contrast with non-treated control rats.

The anaesthetic management of bone marrow harvest for transplantation

The anaesthetic management of 217 donors undergoing 236 operative procedures to donate bone marrow for allogeneic transplantation or for autologous grafting is described. The procedures were those performed between November 1979 and the end of October 1982.

Granulocyte collection by continuous-flow centrifugation using arteriovenous shunts

Two thousand nine hundred twenty-seven granulocyte collections were made using continuous-flow centrifugation with the Aminco Celltrifuge I, the Fenwal Celltrifuge II, and the IBM 2997. There were 231 recipients and 246 donors. In 32 patients attempts to provide daily granulocyte transfusions from a single donor were unsuccessful owing to clotting of the silastic-Teflon arteriovenous shunt. Repeated granulocyte donations produced severe anemia requiring red cell transfusions in all the females and most of the males who had previously donated marrow for transplantation. Granulocyte collections were similar when collected with the Celltrifuge I or the IBM 2997, but collections with the Celltrifuge II were smaller. Infusion of hydroxyethyl starch directly into whole blood as it entered the centrifuge increased granulocyte collections. Granulocyte collections decreased with increasing number of daily collections.

Monoclonal antibodies in the treatment of cancer

Potential uses of monoclonal antibodies in anti-cancer treatment include passive serotherapy, radioisotope conjugates, toxin-linked conjugates, and chemotherapy-monoclonal antibody conjugates. The bases for these applications have been founded in research with heterologous antisera, and in some cases with monoclonal antibodies in animal tumor models. Human trials with passive serotherapy have already begun in both hematopoietic and solid tumor malignancies. Promising results have been reported in cutaneous T cell lymphoma with anti-T cell monoclonal antibody, and in nodular lymphoma with anti-idiotype monoclonal antibody. Radioisotope conjugate work appears promising for imaging in both animals and humans, and this work will lay the foundation for possible therapeutic application of radio-immunotherapy. Toxin-linked conjugates are promising in vitro and may have application in autologous bone marrow transplantation. Research with chemotherapy conjugates is also underway. Preliminary results suggest that murine monoclonal antibodies will be well tolerated clinically except in the setting of circulating cells which bear the target antigen, where rapid infusions may be associated with intolerable side effects. In certain diseases, production of endogenous anti-mouse antibodies may also limit application. Advances in the technology for human-human hybridoma production may help solve some of these problems.

Acute and delayed toxicities of total body irradiation. Seattle Marrow Transplant Team

Total body irradiation is being used with increasing frequency for the treatment of lymphopoietic malignancies and in preparation for marrow transplantation. Acute toxicities include reversible gastroenteritis, mucositis, myelosuppression and alopecia. As the success of treatment improves and more patients become long-term survivors, manifestations of delayed and chronic toxicity become evident. These include impairment of growth and development, gonadal failure and sterility, cataract formation and possibly secondary malignancies. The contribution of total body irradition to the development of pneumonitis and pulmonary fibrosis is still poorly understood. Some of these changes are reversible or correctable, whereas others are permanent. Nevertheless, until equally effective but less toxic regimens become available, total body irradiation appears to be the treatment of choice to prepare patients with leukemia for marrow transplantation.

Intraarterial chemotherapy for head and neck cancer, Part 1: Theoretical considerations and drug delivery systems

The principal objective of regional chemotherapy is tumor cell kill. The rationale for regional delivery is based on the steep dose/response curve exhibited by most antineoplastic agents. Intraarterial (IA) chemotherapy has the potential advantage of increased drug concentration at the tumor site, decreased systemic drug levels, and continuous tumor cell exposure to an antineoplastic agent. Despite these advantages, the use of IA chemotherapy has not been universally accepted. This is in part due to the difficulties associated with establishing and maintaining arterial access. Considerable improvement in the techniques and efficacy of regional therapy for head and neck cancer will be necessary before there is widespread clinical acceptance. These improvements must be based on anatomic and pharmacologic factors that ensure success of regional therapy. In addition, the development of safe, reliable delivery systems will be necessary. Part 1 of this two-part article will review these factors and discuss delivery systems.

Fractionation of whole body irradiation before bone marrow transplantation for patients with leukaemia

Thirty patients in various stages of acute leukaemia or chronic granulocytic leukaemia (CGL) were treated with cytotoxic drugs followed by whole body irradiation (TBI) administered in 200 cGy fractions twice daily to a total of 1000 or 1200 cGy. The immediate toxicity of fractionated TBI administered in this way was negligible and patients required only minor premedication and little treatment subsequently for complications attributable to TBI. Fourteen (47%) patients have died, ten of the 12 transplanted with active disease, and four of the 18 subjected to transplantation in remission of acute leukaemia or in chronic phase of CGL. Though the duration of follow-up is still short, no patient in the latter group (follow-up of survivors ranging from six to 146 weeks) has yet relapsed with any evidence of recurrent leukaemia. We conclude that this method of fractionating TBI reduced toxicity for the patient without necessarily reducing its antileukaemic effect.

[Bone marrow transplantation in adults in acute leukemia, aplastic anemia and paroxysmal nocturnal hemoglobinuria. Results of the Medical Clinic IIi of LMU (Ludwig-Maximilians University) Munich]

Eleven adults have been transplanted for various reasons between July 1979 and July 1982: 2 with aplastic anemia (AA), 1 with paroxysmal nocturnal hemoglobinuria (PNH), 8 with acute leukemia (AL). Four patients suffered from acute lymphocytic leukemia (ALL) and four from acute non-lymphocytic leukemia (ANLL). Two of them were transplanted in relapse, 1 in a partial remission, and 5 in complete remission. All patients were in their late stage of disease. The PNH-patient had an identical twin, 8 patients had an HLA- and MLC compatible sib, 1 an unrelated donor, and 1 was transplanted from his father. Four patients are alive, 2 more than 3 years: 1 with AA and 1 with ALL who was transplanted in relapse. Six patients died of infectious complications (4 of interstitial pneumonia, 1 of a candida sepsis, 1 of acute toxoplasmosis). Patients living more than 3 weeks had a take. Acute graft-versus-host (GvH) disease did not present a major problem. All patients received methotrexate for GvH-prophylaxis, in three instances the marrow was additionally pre-incubated with anti-T-cell globulin.