Investigation on adaptations of broiler chickens to high dietary free amino acid levels in nitrogen utilisation and plasma amino acid concentrations

1. A reduction in crude protein (CP) in feed for broiler chickens necessitates elevated free amino acid (AA) levels to meet the requirement of each AA. This study investigated adaptations following a change to diets with increasing free AA concentrations and possible reasons for the limitation caused by the inclusion of more free AA.2. Male Ross 308 broiler hatchlings received a starter diet (164 g CP/kg containing 80 g/kg soy protein isolate (SPI)) until d 7. From d 7-22, birds received a diet almost identical to the starter diet or two other diets, where 50% or 100% of digestible AA in SPI were substituted with a free AA mixture. Birds were allocated to metabolism units located in the same barn to determine performance (n = 7 units) and blood traits (n = 14 birds). Total excreta collection was performed on d 7-8, 8-9, 9-10, 11-12, 14-15 and 21-22. Blood samples were collected on d 7, 8, 9, 11, 14 and 21.3. Average daily weight gain (ADG) and average daily feed intake (ADFI) was unaffected at 50% AA substitution but decreased at 100% AA substitution on d 7-22 (p ≤ 0.001). The 100% substitution led to a decline in ADG and ADFI consistently on all days (p ≤ 0.037) except on d 11-12. A 50% AA substitution resulted in lower ADFI on d 7-8 and 14-15 (p ≤ 0.032). Nitrogen utilisation efficiency (NUE) was on a level of ~ 0.74 and was only affected by treatment up to d 11-12 (p ≤ 0.008). Concentrations of 10, 9, 8, 10 and 4 plasma free AA were affected on d 8, 9, 11, 14 and 21, respectively (p ≤ 0.037).4. Following a change to diets containing high levels of free AA, NUE and free AA concentrations in the circulation became more balanced within 3 to 7 d. The results suggested that peptide-bound and free AA did not cause different NUE, particularly 3 and 7 d after the diet change.

Amino acid digestibility and metabolizable energy of soybean meal of different origins in cecectomized laying hens

This study investigated the variation in amino acid (AA) digestibility and MEn of 18 samples of solvent-extracted soybean meal (SBM; 6 European, 7 Brazilian, 2 Argentinian, 2 North American, 1 Indian) in cecectomized laying hens. The experimental diets contained either 300 g/kg of cornstarch or one of the SBM samples. Pelleted diets were fed to 10 hens in two 5 × 10 row-column designs so that 5 replicates were obtained from each diet during 5 periods. A regression approach and the difference method were used to determine AA digestibility and MEn, respectively. The variation in the digestibility of SBM differed among AA with ranges in digestibility of 6 to 12%-units for most AA. Among the first-limiting AA, the digestibility was 87 to 93%, 63 to 86%, 85 to 92%, 79 to 89%, and 84 to 95% for Met, Cys, Lys, Thr, and Val, respectively. The range of MEn for the SBM samples was 7.5 to 10.5 MJ/kg DM. Indicators of SBM quality (including trypsin inhibitor activity, KOH solubility, urease activity, and in vitro N solubility) and analyzed SBM constituents were significantly correlated (P ≤ 0.05) with AA digestibility or MEn only in a few cases. No differences were observed in AA digestibility and MEn between countries of origins, except low digestibility of some AA and MEn for the 2 Argentinian SBM samples. These results suggest that the precision of feed formulation benefits from considering the variations in AA digestibility and MEn. Often used indicators for SBM quality and analyzed constituents were not suitable to explain variations in AA digestibility and MEn, suggesting that AA digestibility and MEn are determined by other factors.

Research Note: Influence of monocalcium phosphate and phytase in the diet on phytate degradation in cecectomized laying hens

This study investigated the effects of phytase and monocalcium phosphate supplementation on the dephosphorylation of phytic acid [myo-inositol 1,2,3,4,5,6-hexakis (dihydrogen phosphate); InsP₆] in cecectomized laying hens using total excreta collection. Four corn-soybean meal-rapeseed meal-based diets were mixed with or without 6 g of monocalcium phosphate/kg, with or without supplementation of 1,500 FTU phytase/kg, and had the same calcium concentration at 39 g/kg of feed. Each diet was tested in 5 replicates using a row-column design with 10 cecectomized laying hens in 2 periods. The hens received 120 g/d of feed while being housed individually in metabolism units, and total excreta were collected for a period of 4 d. The monocalcium phosphate × phytase interaction was not significant for InsP₆ degradation (P = 0.054). Phytase increased InsP₆ disappearance from 13% to 83% (P < 0.001), whereas monocalcium phosphate had no effect. Concentrations of most of the lower inositol phosphate isomers in excreta were higher when monocalcium phosphate was added to the diets. The concentration of Ins(1,2,5,6)P₄ in excreta was the highest among the studied partially dephosphorylated inositol phosphates with phytase supplementation and was higher than in diets without phytase supplementation (P < 0.001). Supplementation with phytase increased myo-inositol concentration in excreta (P = 0.002), whereas monocalcium phosphate had no effect. Phosphorus utilization ranged from 4% to 18% and was not significantly affected by the treatments. These results suggest that phytase supplementation markedly increased InsP₆ degradation in laying hens. The cecectomized laying hen assay may be suitable for studying the effects of phytase supplementation on phytate dephosphorylation under dietary conditions when performance and phosphorus excretion are unlikely to be affected.

Meta-analysis-based estimates of efficiency of calcium utilisation by ruminants

The most abundant mineral in the body of animals is Ca, which has crucial importance for the regulation of various processes. The maintenance of Ca balance has become more challenging, especially in lactating ruminants, owing to the increased milk yields and thus Ca requirement. To determine the Ca requirement, factors such as Ca secretion via milk or Ca deposition in body tissues and conception products are summed up to the net Ca requirement. Nevertheless, dietary Ca cannot be completely utilised by the animal to cover the net Ca requirement, therefore a value for the efficiency of Ca utilisation is applied, which is the maximum proportion of Ca from the feed that the animal can use for covering the net requirement. However, current estimates for the efficiency of Ca utilisation are inconsistent. Therefore, the objective of the present meta-analysis was to estimate the efficiency of Ca utilisation for ruminants, considering the Ca supply of the animal. A data set of 223 observations was compiled from 37 studies, including data on cattle and small ruminants. Standardised Ca digestibility was calculated from data on Ca intake and faecal Ca excretion, corrected for faecal endogenous losses. Furthermore, a data subset on only lactating ruminants was created. For this subset, Ca excretion via faeces and urine and standardised Ca digestibility were related to the Ca supply of the animal. An exponential function was fitted to standardised digestibility data in response to Ca concentration in the diet and Ca supply, revealing that standardised Ca digestibility decreased with increasing dietary Ca concentration and Ca supply. The median for standardised Ca digestibility was 40%, with a remarkable variation between 9% and 88%. In response to Ca supply, faecal Ca excretion increased in a strong linear manner (slope = 0.76, R² = 0.96). Excretion of Ca via urine was very low even when Ca supply was very high. To conclude, Ca digestibility is a suitable indicator for the efficiency of Ca utilisation, since excessive Ca is almost completely excreted in faeces; however, Ca digestibility has to be determined at a Ca supply level below the requirement of the animal. To date, only very limited number of data have been reported for such supply conditions. Comparative studies using various Ca sources are suggested for future studies but should be conducted using a marginal Ca supply level.

Prececal amino acid digestibility and phytate degradation in broiler chickens when using different oilseed meals, phytase and protease supplements in the feed

The purpose of this study was to investigate the effects of phytase and protease supplementation on prececal (pc) amino acid (AA) digestibility, phytate (InsP6) degradation, and MEn concentration in diets using 3 oilseed meals as main protein sources in broiler chicken feed. The broiler chicken diets, which lacked mineral phosphorus, contained either soybean meal (SBM), SBM and rapeseed meal (SBM/RSM), or SBM and sunflower meal (SBM/SFM) as main protein sources. Diets were not supplemented with enzymes or supplemented with 1,500 or 3,000 FTU phytase/kg, or with 1,600 mg protease/kg. For diets containing SBM as the main protein source, the effects of phytase supplementation with and without monocalcium phosphate were also investigated. Data were obtained during 2 subsequent runs from days 14 to 22 and from days 23 to 31. Each diet was tested using 8 replicates with 4 replicates per run. For pc AA digestibility, no significant interactions were observed between main protein sources, enzyme supplementation, or addition of monocalcium phosphate except for Cys. Supplementation of 1,500 FTU phytase/kg increased pc digestibility of all AA. No differences in pc AA digestibility were observed between 1,500 and 3,000 FTU phytase/kg supplementation treatments. Prececal disappearance of InsP6 and pc P digestibility were greater in the high phytase supplementation treatment. Protease supplementation increased pc digestibility of all AA except for Cys when SBM/RSM was the main protein source. Supplementation of protease and 3,000 FTU phytase/kg increased MEn concentrations. The effect of phytase on pc AA digestibility was fully expressed at a lower supplementation level than needed for a maximized pc InsP6 disappearance and MEn concentration.

Effects of protease and phytase supplements on small intestinal microbiota and amino acid digestibility in broiler chickens

The objective of this study was to determine the effects of protease origin and dosage on the prececal (pc) amino acid (AA) digestibility and the influence on composition of the microbial community in the small intestine. In addition, the effects of phytase supplementation were investigated. A total of 8 dietary treatments were included. The basal diet contained mainly corn and soybean meal. Three protease products were added to the basal diet, each at the level recommended by the supplier and at an 8-fold level. Phytase was supplemented in another dietary treatment. Each dietary treatment was allocated to 8 replicates of 15 birds each. The experimental diets were offered from day 15 to 21 for ad libitum consumption. The effect of protease supplementation on the pc AA digestibility depended on the protease product type and the amount supplemented. The pc AA digestibility was significantly increased by 1 protease product when supplemented at high level and when phytase was supplemented. In all the other treatments, protease supplementation had no significant influence or it decreased pc AA digestibility, when compared with the treatment with no enzymes added. In general, Firmicutes was the most abundant phylum among the ileal microbiota across all the treatments. Significant effects on microbiota composition were observed at the genus level for some but not all protease treatments and phytase supplementation. The genera Streptococcus, Lactobacillus, and uncultured Clostridiaceae were responsible for these differences. Furthermore, microbial networks established for each diet showed either high or low number of intergeneric interactions, but without a consistent enzyme effect. We conclude that enzyme supplementation effects were evident in the terminal small intestine microbiota composition, and to a lesser extent, in pc AA digestibility. However, the changes in microbiota composition and pc AA digestibility could not be correlated, indicating absence of a causal relationship.

The relevance of glycine and serine in poultry nutrition: a review

1. Dietary glycine equivalents (Gly_equi) for glycine and serine represent the first-limiting non-essential amino acid in poultry diets. Targeted adjustment of essential amino acids and Gly_equi in diets can considerably decrease crude protein (CP) in poultry diets below the limit of CP reduction when only essential amino acids are adjusted. 2. The level to which CP can be reduced in diets adequate in Gly_equi depends on the objective; which includes reducing dietary CP without affecting performance and increasing nitrogen utilisation efficiency. Dietary CP can be reduced to ~15-16% in diets for up to 21 d old broiler chicken without affecting growth performance compared to responses to diets with currently common CP concentrations by considering Gly_equi in the diet formulation. Dietary CP can be further reduced to maximise nitrogen utilisation efficiency; however, this leads to reduced growth performance. 3. The dietary Gly_equi requirement of poultry varies depending on other dietary constituents. In broiler chickens up to 21 days of age, the dietary Gly_equi requirement is estimated to be between 11 and 20 g/kg. This estimate is influenced by the concentrations of Cys and the endogenous Gly_equi precursors, threonine and choline. Urinary nitrogen excretion seems to be a major determinant of the response to dietary Gly_equi, because it is needed for uric acid formation. 4. The variable requirement for dietary Gly_equi means that its static recommendation in poultry diets would lead to high safety margins in Gly_equi supply or the risk of Gly_equi deficiency. Variable recommendations for dietary Gly_equi concentrations would help to supply birds based on their specific requirements and could reduce nitrogen emissions originating from poultry farming.

Variability of amino acid digestibility of lupin and pea grains in caecectomised laying hens

1. The objective of this study was to investigate the variations in amino acid (AA) digestibility of lupin and pea grains in caecectomised laying hens. The relationship between AA digestibility and chemical constituents of the grains was determined. 2. Twelve variants of lupins and peas were each added to a basal diet at a concentration of 300 g/kg, at the expense of maize starch. The lupin and pea variants were separately investigated in two subsequent trials. Each trial consisted of two 7 × 7 Latin squares, each comprising the basal diet and six diets with lupins or peas. 3. Fourteen caecectomised laying hens (LSL-classic) were individually housed in metabolism cages and 120 g/d of experimental diets were provided for eight days. During the last four days, excreta were collected quantitatively and feed intake was recorded. A regression approach was used to determine the AA digestibility of the lupin and pea variants. 4. Amino acid digestibility of the lupins and peas was high, although significant differences in AA digestibility among the lupins and peas were detected. The digestibility of lysine was in the range of 0.87-0.91 and 0.87-0.93 for lupins and peas, respectively. The digestibility of methionine in lupins and peas varied between 0.80-0.88 and 0.72-0.90. Variations in AA digestibility in peas were more pronounced than in lupins. 5. Significant correlations between chemical constituents of lupins, such as alkaloids, and AA digestibility were detected in some cases, without a consistent pattern. In peas, tannin concentration and the insoluble protein fraction were negatively correlated with digestibility of some AAs, but only when one colour flower variant was considered. Trypsin inhibitor activity in peas was negatively correlated with AA digestibility, particularly for the white flower variants.

Effect of particle size distribution of maize and soybean meal on the precaecal amino acid digestibility in broiler chickens

1. Herein, it was investigated whether different particle size distributions of feed ingredients achieved by grinding through a 2- or 3-mm grid would have an effect on precaecal (pc) amino acid (AA) digestibility. Maize and soybean meal were used as the test ingredients. 2. Maize and soybean meal was ground with grid sizes of 2 or 3 mm. Nine diets were prepared. The basal diet contained 500 g/kg of maize starch. The other experimental diets contained maize or soybean meal samples at concentrations of 250 and 500, and 150 and 300 g/kg, respectively, instead of maize starch. Each diet was tested using 6 replicate groups of 10 birds each. The regression approach was applied to calculate the pc AA digestibility of the test ingredients. 3. The reduction of the grid size from 3 to 2 mm reduced the average particle size of both maize and soybean meal, mainly by reducing the proportion of coarse particles. Reducing the grid size significantly (P < 0.050) increased the pc digestibility of all AA in the soybean meal. In maize, reducing the grid size decreased the pc digestibility of all AA numerically, but not significantly (P > 0.050). The mean numerical differences in pc AA digestibility between the grid sizes were 0.045 and 0.055 in maize and soybean meal, respectively. 4. Future studies investigating the pc AA digestibility should specify the particle size distribution and should investigate the test ingredients ground similarly for practical applications.

Prececal amino acid digestibility of soybean cake in fast- and slow-growing broiler chickens

The objective of the present study was to determine whether there are differences in prececal amino acid digestibility between commonly used slow- and fast-growing broiler strains when the regression approach is applied. ISA J-275 and Ross 308 were selected as common representatives of slow- and fast-growing broiler strains, respectively. The experimental diets with soybean cake at levels of 0, 100, and 200 g/kg were offered for ad libitum consumption between 22 and 29 d post-hatch. Titanium dioxide was used as an indigestible marker. Each treatment was tested with six pens comprising 10 birds each. Digesta samples were collected on a pen basis from the distal two-thirds of the intestine section between Meckel's diverticulum and 2 cm anterior to the ileocecal-colonic junction. The prececal amino acid digestibility of soybean cake was calculated by linear regression simultaneously for both strains. There was no significant interaction between broiler strain and inclusion level of soybean cake with respect to the prececal CP and amino acid digestibility of complete diets; there was a significant strain effect for 5 out of the 16 measured amino acids. The prececal CP and amino acid digestibility of soybean cake did not differ significantly between strains and was numerically almost identical. The results of the present study provide evidence of the transferability between broiler strains of prececal amino acid digestibility data, determined using the regression approach, thus improving the accuracy of diet formulation without drawbacks.

Results of an international phosphorus digestibility ring test with broiler chickens

The objective of this ring test was to investigate the prececal phosphorus (P) digestibility of soybean meal (SBM) in broiler chickens using the trial protocol proposed by the World's Poultry Science Association. It was hypothesized that prececal P digestibility of SBM determined in the collaborating stations is similar. Three diets with different inclusion levels of SBM were mixed in a feed mill specialized in experimental diets and transported to 17 collaborating stations. Broiler chicks were raised on commercial starter diets according to station-specific management routine. Then they were fed the experimental diets for a minimum of 5 d before content of the posterior half of the ileum was collected. A minimum of 6 experimental replicates per diet was used in each station. All diets and digesta samples were analyzed in the same laboratory. Diet, station, and their interaction significantly affected (P < 0.05) the prececal digestibility values of P and calcium of the diets. The prececal P digestibility of SBM was determined by linear regression and varied among stations from 19 to 51%, with significant differences among stations. In a subset of 4 stations, the prececal disappearance of myo-inositol 1,2,3,4,5,6-hexakis (dihydrogen phosphate)-P; InsP6-P) also was studied. The prececal InsP6-P disappearance correlated well with the prececal P digestibility. We hypothesized that factors influencing InsP6 hydrolysis were main contributors to the variation in prececal P digestibility among stations. These factors were probably related to the feeding and housing conditions (floor pens or cages) of the birds in the pre-experimental phase. Therefore, we suggest that the World's Poultry Science Association protocol for the determination of digestible P be should extended to the standardization of the pre-experimental period. We also suggest that comparisons of P digestibility measurements among studies are made only with great caution until the protocol is more refined.

Activity of thalidomide in patients with platinum-refractory germ-cell tumours

The aim of this study was assess the activity of thalidomide in patients with progressive relapsed or platinum-refractory germ-cell tumours (GCT). Between April 2002 and January 2003, 15 patients with inoperable progressive GCT were treated with escalated daily doses of 200-600 mg thalidomide. All patients had failed first-line and salvage chemotherapy with a median of 6 (range 4-12) cisplatin-based treatment cycles, 13/15 (87%) patients had received high-dose chemotherapy (HDCT) and 8/15 (53%) patients were considered platinum-refractory or absolute refractory; 8/15 (53%) patients had previously received other palliative chemotherapy regimens. No patient achieved a complete remission (CR) or partial remission (PR). However, 5/15 (33%) patients achieved serological PR and 1 additional patient had stable disease for 3 months. The median duration of remissions was 3 months (range 2-12 months) including 2 patients with a progression-free survival of 9 and 12 months. Responses occurred mainly in patients with a low tumour burden, slow disease progression and alpha-foetoprotein (AFP) elevations. Responses to thalidomide were independent from platinum-sensitivity. Toxicity was mild, with lethargy and constipation in the majority of patients. Skin rash grade II developed in 2 patients and peripheral neurotoxicity grade II/III developed in 4 patients. One responding patient died suddenly from an unknown cause. It is concluded that thalidomide shows single-agent activity in patients with heavily pre-treated GCT, AFP elevations and slowly progressive disease.

Evaluation of prognosis in relapsed germ cell tumors: Identification of patients who profit from high dose chemotherapy (HDCT)

4585

Background: To identify prognostic variables in patients (pts) with metastatic germ cell tumors (GCT) and relapse or progression after first-line chemotherapy (FLC). Methods: In our database of 257 GCT pts treated with HDCT, 176/257 (67.4%) pts with first relapse or progression were identified. All patients had received platinum-based FLC. As salvage treatment all pts had received 1–3 cycles of conventional-dose salvage chemotherapy (CDCT) followed by one cycle HDCT. First, pts were retrospectively classified according to a prognostic score developed for CDCT by Fossa et al. [Br J Cancer 1999,80:1392], based on variables present at the time of relapse. Thereafter, a multivariate analysis was performed to evaluate further risk factors. Results: After a median follow up of 9 years the event-free survival (EFS) and overall survival (OS) for all 176 patients was 34% and 38%, respectively. Patients with good (n= 100/176, 57%) and poor (n = 76/176, 43%) prognosis in accordance to Fossa et al. showed an EFS of 41% and 26% (p < 0.01) and an OS of 47% and 26% (p < 0.01). Thus, in contrast to the data of Fossa et al, long-term survival could be demonstrated even in the poor prognosis subset. In the multivariate analysis, the level of elevated tumor markers alfa-fetoprotein and human chorionic gonadotrophin (p < 0.01), the presence of extrapulmonal visceral metastases (p < 0.01) and refractoriness to cisplatin (p < 0.01) adversely influenced OS after HDCT significantly. Based on these latter factors three different groups with increasingly poor OS could be identified: none factor (n = 39/176, 22%) 4 year OS of 59%, one factor (n = 78/176, 44%) 6 year OS of 42% and more than one factor (n = 59/176, 34%) 4 year OS of 17%. Conclusion: In pts with first relapse or progression after platinum-based FLC high serum tumor markers, presence of extrapulmonal visceral metastases and cisplatin refractoriness proved to be independent prognostic significance for OS after salvage HDCT. However, even in the poor prognosis subset long-term survival could be demonstrated.

No significant financial relationships to disclose.

A randomised trial of high-dose chemotherapy in the salvage treatment of patients failing first-line platinum chemotherapy for advanced germ cell tumours

BACKGROUND

Incomplete remission or relapse from first-line chemotherapy has poor prognosis in male germ cell tumour patients. This phase III randomised trial compares conventional salvage to high-dose-intensification chemotherapy.

PATIENTS AND METHODS

Between February 1994 and September 2001, 280 patients from 43 institutions in 11 countries, were randomly assigned to receive either four cycles of cisplatin, ifosfamide and etoposide (or vinblastine) (arm A), or three such cycles followed by high-dose carboplatin, etoposide and cyclophosphamide (CarboPEC) with haematopoietic stem cell support (arm B).

RESULTS

Similar complete and partial response rates were observed in both treatment arms (56%; 95% CI 50% to 62%). There were 3% and 7% toxic deaths in arms A and B, respectively. No significant improvements with CarboPEC were observed in either 3-year event-free survival (35% versus 42%, P=0.16) or overall survival (53%; 95% CI 46% to 59%). Complete responders with CarboPEC had a significant improvement in disease-free survival (55% versus 75% at 3 years, P <0.04).

CONCLUSIONS

The single cycle of high-dose salvage chemotherapy after three cycles of standard dose chemotherapy had no effect on treatment outcomes. These results suggest that data from uncontrolled studies should not be used to justify routine use of a toxic and expensive treatment without confirmation in a randomised trial.

Second-line high-dose chemotherapy in patients with mediastinal and retroperitoneal primary non-seminomatous germ cell tumors: the EBMT experience

BACKGROUND

Results of second-line chemotherapy in patients with extragonadal non-seminomatous germ cell tumor (NSGCT) appear inferior to results in testicular NSGCT. Patients with retroperitoneal NSGCT achieve a comparable long-term survival rate of 30%, but the salvage rates of patients with mediastinal primary are less than 10%. We conducted a retrospective analysis on patients with mediastinal and retroperitoneal NSGCT treated with second-line high-dose chemotherapy (HDCT) registered with the European Group for Blood and Marrow Transplantation (EBMT).

PATIENTS AND METHODS

Between 1987 and 1999, 59 registered patients with retroperitoneal (n=37) and mediastinal (n=22) primary NSGCT, median age 28 years (range 18-60), were treated with second-line HDCT. All had received cisplatin-containing chemotherapy as first-line treatment.

RESULTS

Toxic death occurred in three cases (5%). With a median follow-up of 58 months (range 14-114), 18/59 patients (30%) continue to be disease-free. Of three patients who had a disease recurrence after HDCT, one patient achieved a disease-free status with further chemotherapy and surgery. In total, 19 patients (32%) are currently disease-free. Sixteen of 37 patients (43%) with retroperitoneal NSGCT, and three of 22 patients (14%) with mediastinal NSGCT are currently alive and disease-free.

CONCLUSIONS

Second-line HDCT might represent a possible option for patients with retroperitoneal primary NSGCT. New salvage strategies are needed for patients with mediastinal NSGCT.

Residual tumor resection after high-dose chemotherapy in patients with relapsed or refractory germ cell cancer

PURPOSE

To assess the role of residual tumor resection performed after high-dose chemotherapy (HDCT) in patients with relapsed or refractory germ cell tumors (GCT).

PATIENTS AND METHODS

Between July 1987 and October 1999, postchemotherapy resections of residual tumors were performed in 57 patients who had been treated with HDCT for relapsed or refractory GCT and who had achieved a partial remission to this treatment.

RESULTS

Complete resections of residual masses were achieved in 52 (91%) of 57 patients who were rendered disease free; in five (9%) of 57 patients, the resections were incomplete. Resection of a single site was performed in 39 (68%) of 57 patients, and the remaining 18 (32%) of 57 patients required interventions at two or more residual tumor sites. Necrosis was found in 22 (38%) of 57 patients, mature teratoma with or without necrosis was found in nine (16%) of 57 patients, and viable cancer with or without additional necrosis or mature teratoma was found in 26 (46%) of 57 patients. Viable cancer consisted either of residual germ cell or undifferentiated cancer in 22 (85%) of 26 patients, with additional non-GCT histologies in the remaining four patients. Patients with viable cancer had a significantly inferior outcome after surgery compared with patients with necrosis and/or mature teratoma even if all cancer was completely resected. Pulmonary lesions with a diameter of more than 2 cm were the only predictive variable for viable cancer in univariate analysis.

CONCLUSION

Resections of all residual tumors should be attempted in patients with relapsed or refractory GCT and partial remissions after HDCT.

European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG)

Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception.

The role of high-dose chemotherapy in relapsed germ cell tumors

Overall, patients with relapsed or progressive germ cell tumors after cisplatin-based chemotherapy have a low chance of cure. Using conventional-dose chemotherapy (CDCT) as salvage treatment, only 15-30% of the patients will become long-term survivors. It is well known that the majority of these patients will ultimately die of their disease. Therefore, improvement of the standard treatment is clearly desirable. In the last years, high-dose chemotherapy (HDCT) has been established as an effective salvage modality. A matched-pair analysis showed an advantage for HDCT compared with CDCT with an improvement in event-free and overall survival. Furthermore, due to increasing clinical experience in the management of side-effects, the use of peripheral blood progenitor cells and the availability of hematopoietic growth factors, HDCT has become relatively safe. Therefore, HDCT should be administered in patients with first relapse and unfavorable prognostic factors, and as second or subsequent salvage treatment followed by complete resections of tumor residuals. Patients with relapse or progressive disease after HDCT who do not qualify for desperation surgery could be salvaged with palliative chemotherapy combinations using gemcitabine, oxaliplatin and paclitaxel. This report reviews the current treatment strategies and recent developments with respect to HDCT given as salvage treatment and discusses the role of prognostic factors in the management of such situations.

Reduced-intensity conditioning with busulfan and fludarabine with or without antithymocyte globulin in HLA-identical sibling transplantation – a retrospective analysis

It is unknown whether the addition of antithymocyte globulin (ATG) to reduced-intensity conditioning with busulfan (BU) and fludarabine (FLU) is beneficial in HLA-identical sibling transplantation. Therefore, we analyzed retrospectively data on 83 patients, who received peripheral blood stem cells from HLA-identical siblings after conditioning with either 8 mg/kg BU and 150 mg/m2 FLU (n=45) or 8 mg/kg BU, 180 mg/m2 FLU and 40 mg/kg ATG (n=38). Graft-versus-host disease (GVHD) prophylaxis consisted of CSA alone (n=32) or a combination with either MTX or MMF (n=51). The median age was 52 years. Graft failure occurred in two patients after BU/FLU and in three after BU/FLU/ATG (P=0.66). After conditioning with BU/FLU, platelet recovery was significantly faster (P=0.017), and less platelet (P<0.001) and red blood cell (P=0.002) support was needed. Incidences of acute GVHD grades II and IV were 46 and 49%, respectively. Limited chronic GVHD occurred more often after BU/FLU compared to BU/FLU/ATG (54 vs 23%, P=0.02). The overall survival, non-relapse and relapse mortality did not differ significantly. We conclude that in peripheral blood stem cell transplantation from HLA-identical siblings after reduced-intensity conditioning with BU and FLU, ATG has no major impact on the rate of graft rejection and acute GVHD, but it reduces the incidence of limited chronic GVHD.

[Quantitative determination of CMV-DNA in saliva of patients with bone marrow and stem cell transplantation using TaqMan-PCR]

BACKGROUND

Human cytomegalovirus (HCMV) infection is associated with severe and life-threatening diseases in immunocompromised patients, especially after bone marrow (BM) and stem cell (SC) transplantation. Prior to transplantation the potential risk of HCMV disease is therefore determined by HCMV-antibody blood testing of transplant donor (D) and recipient (R). Virus carriers are positive for anti-CMV-IgG. Virus patterns are distinguished as follows: group 1 (D+/R+), group 2 (D-/R+), group 3 (D+/R-), and group 4 (D-/R-).

AIM

The aim of this study was qualitative and quantitative determination of the HCMV DNA load in saliva of BM and SC transplantation patients.

PATIENTS AND METHOD

Unstimulated saliva was collected from 20 patients prior to BM and SC transplantation, during the time of conditioning, and after transplantation. DNA was isolated and analyzed for evidence of HCMV DNA with TaqMan PCR.

RESULTS

HCMV DNA was isolated in seven cases. In all group 1 patients (D+/R+) HCMV DNA could be demonstrated. Only three of seven group 2 patients (D-/R+) were positive for HCMV DNA. The only group 3 patient (D+/R-) and all eight group 4 patients (D-/R-) were negative.

CONCLUSION

TaqMan PCR is a reliable method for HCMV DNA quantification. In three patients (anti-HCMV-IgG positive) who received an anti-CMV-IgG negative transplant HCMV DNA was isolated. In contrast, no HCMV-DNA was evident in HCMV-negative patients who received an HCMV-negative transplant. Accordingly, the risk of HCMV reactivation is more probable than the risk of reinfection.

Cytomegalovirus infections in allogeneic stem cell recipients after reduced-intensity or myeloablative conditioning assessed by quantitative PCR and pp65-antigenemia

Since the incidence of cytomegalovirus (CMV) infections after hematopoietic stem cell transplantation (HSCT) may depend on the intensity of the pretreatment, we studied the incidence of CMV infections after reduced-intensity compared to myeloablative conditioning. A total of 82 patients with matched related or unrelated donors were prospectively monitored for CMV infections after HSCT by CMV-PCR techniques, CMV-antigenemia and clinical observation. A total of 45 patients received reduced-intensity conditioning consisting of fludarabine, busulfan and ATG and 37 patients received myeloablative conditioning. Leukocyte engraftment occurred after a median of 15 vs 18 days (P=0.012) and platelet engraftment after 12 days vs 20 days (P=0.001), respectively. Acute graft-versus-host disease (GVHD) grade II-IV was observed in 58 vs 54% patients (P=0.737), respectively. The onset and peak values of CMV-antigenemia and DNAemia and the incidence of CMV infections did not differ statistically significantly between the two treatment groups. Multivariate analysis confirmed CMV seropositivity of the recipient (P=0.035), acute GVHD II-IV (P=0.001) but not the type of conditioning as significant risk factors for CMV-antigenemia. In conclusion, the kinetics of CMV-antigenemia and DNAemia and the incidence of CMV infections were not statistically different in patients who received HSCT after reduced-intensity conditioning with fludarabine, busulfan and ATG compared to myeloablative conditioning.

Response to imatinib in patients who relapse after allogeneic stem cell transplantation for chronic myeloid leukemia

We studied 128 patients with chronic myeloid leukemia (CML) relapsing after allogeneic stem cell transplantation (SCT). Disease at the time of treatment with Imatinib was in chronic phase (CP) in 51 patients, accelerated phase (AP) in 31 and blastic crisis (BC) in 46. Of the 51 patients in CP, 14 were in cytogenetic and two in molecular relapses. The median interval between relapse and Imatinib therapy was 5 months (0-65). A total of 50 patients had failed treatment with donor lymphocyte infusions prior to Imatinib. The overall hemato-logical response rate was 84% (98% for patients relapsing in CP). The complete cytogenetic response (CCR) was 58% for patients in CP, 48% for AP and 22% for patients in BC. Complete molecular responses were obtained in 25 patients (26%), of whom 21 were in CP or AP. With a median follow-up of 9 months, the estimated 2-year survival for CP, AP and BC patients was 100, 86 and 12%, respectively. Out of 79 evaluable patients, 45 (57%) achieved full donor and 11 (14%) mixed chimerism after Imatinib. We conclude that Imatinib has significant activity against CML in relapse after allogeneic SCT. Durable cytogenetic and molecular remissions are obtainable in patients in CP.

Individualised dosing strategy for high-dose carboplatin in patients with germ cell cancer

In contrast to conventional chemotherapy, carboplatin is still dosed per unit of body surface area (BSA) in high-dose chemotherapy protocols in clinical practice. To individualise dosing, a population pharmacokinetic model for poor-risk germ cell tumour patients receiving 1500 mg m(-2) carboplatin was developed. The typical central volume of distribution (19.9 l) and typical clearance (110 ml min(-1)) corresponded approximately to the extracellular fluid space or glomerular filtration rate, respectively. The covariate analysis identified several patient-specific factors. Carboplatin clearance was significantly related to creatinine clearance and body height, explaining 73% of the interindividual variability. Thus, an equation to predict individual clearance prior to treatment was developed (CL=0.41 x creatinine clearance+1.05 x body height-124.4). The relative frequency of developing toxicity increased significantly with higher AUC values for different types of toxicity. In addition, overall nonhaematological toxicity correlated significantly with exposure of carboplatin, leading to the assessment of a target AUC. Based on the prediction of individual clearance and the definition of a target AUC associated with moderate toxicity, an individualised dosing equation is proposed. Retrospectively, the individualised dosing strategy would have led to a higher dose on average and a broader range to be administered, compared to empirical dosing per unit BSA in the high-dose setting.

Evidence of a graft-versus-leukemia effect in chronic lymphocytic leukemia after reduced-intensity conditioning and allogeneic stem-cell transplantation: the Cooperative German Transplant Study Group

PURPOSE

To study whether hematopoietic stem-cell transplantation (HSCT) after reduced-intensity conditioning is effective and tolerable in patients with advanced chronic lymphocytic leukemia (CLL).

PATIENTS AND METHODS

Thirty patients with advanced B-cell CLL were included into the study. After reduced-intensity conditioning with fludarabine, busulfan, and antithymocyte globulin, patients received a transplant from related (n = 15) or unrelated donors (n = 15). Minimal residual disease (MRD) was monitored with a clone-specific polymerase chain reaction.

RESULTS

After a median follow-up of 2 years, 23 patients are alive (to date). Neutrophil and platelet engraftment occurred after a median of 17.5 and 15 days, respectively. Acute graft-versus-host disease (GVHD) grade 2 to 4 was observed in 17 patients (56%), and chronic GVHD was observed in 21 patients (75%). Twelve patients (40%) achieved a complete remission (CR), and 16 patients (53%) achieved a partial remission. Late CR occurred up to 2 years after transplantation. MRD was monitored in eight patients with CR. All patients achieved a molecular CR. At last follow-up, six patients were in ongoing molecular CR. Causes of death were treatment-related complications in four patients and progressive disease in three patients. The probability of overall survival, progression-free survival, and nonrelapse mortality at 2 years was 72% (95% confidence interval [CI], 54% to 90%), 67% (95% CI, 49% to 85%), and 15% (95% CI, 1% to 29%), respectively.

CONCLUSION

Treatment-related mortality after reduced-intensity conditioning followed by allogeneic HSCT was low. The procedure induced molecular remissions in patients with advanced CLL. The observation of late remissions provided evidence of a graft-versus-leukemia effect.

Reduced intensity conditioning for allogeneic hematopoietic stem cell transplantation in patients with acute myeloid leukemia: disease status by marrow blasts is the strongest prognostic factor

We analyzed predictive factors for the outcome of 113 acute myeloid leukemia patients receiving reduced-intensity conditioning prior to allogeneic hematopoietic stem cell transplantation (HSCT). Patients were ineligible for conventional-intensity HSCT. Conditioning consisted of fludarabine and 50% of the conventional dose of busulfan (n=93) or total body irradiation (n=20). The source of stem cells was blood in 102 patients, marrow in 10, and both in one. In total, 50 (44.2%) donors were HLA-matched siblings, 50 (44.2%) unrelated fully matched and 13 (11.5%) partially mismatched family (n=1) or unrelated (n=12) donors. In all, 107 (94.6%) patients showed neutrophil and platelet engraftment after a median time of 13.5 and 13 days. The probabilities of event-free survival (EFS) (median follow-up: 12 months) were 49% for patients with less than 5% blasts in the marrow, 24% for patients with 5-20% blasts (P=0.002) and 14% with >20% blasts (P<or=0.001). Death occurred because of relapse in 29 patients (25.6%), infection in 12 patients (10.6%), acute graft-versus-host disease in eight patients (7.0%) and organ toxicity in nine patients (7.9%). In multivariate analysis, higher number of blasts in the marrow, alternative donors and low Karnofsky performance score were independent adverse prognostic factors for EFS.

Reduced non-relapse mortality after reduced intensity conditioning in advanced chronic lymphocytic leukemia

We studied in 30 patients with progressive or relapsing chronic lymphocytic leukemia (CLL) if hematopoietic stem cell transplantation (HSCT) after conditioning with fludarabine, busulfan and ATG is effective and if treatment related mortality can be reduced compared to myeloablative conditioning regimens. Patients had 15 matched related and 15 matched unrelated donors. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine alone or a combination with "short course" methotrexate or mycophenolate mofetil. The median follow-up is 24 months. At last follow up 11 patients were in complete and 13 in partial remission. Six patients had stable or progressive disease. Late complete remissions occurred up to one year after transplantation and the number of patients with CR is still increasing. Four patients died due to treatment related complications resulting in a probability of treatment-related mortality of 15% (CI 95%, 1% to 29%) at 2 years. The probability of overall survival and progression free survival at two years was 79% and 61%, respectively. In conclusion, HSCT after reduced conditioning may lower the treatment-related toxicity and has the capacity to induce complete remissions.

Influence of amifostine on reconstitution of lymphocyte subpopulations after conventional- and high-dose chemotherapy in patients with germ cell tumor

We assessed the influence of amifostine on immune reconstitution after conventional-dose paclitaxel, ifosfamide, cisplatin and high-dose carboplatin, etoposide and thiotepa followed by autologous peripheral blood progenitor cell (PBPC) rescue in patients with germ cell tumor (GCT). A total of 40 patients were treated with one cycle of paclitaxel and ifosfamide (TI) followed by granulocyte-colony stimulating factor (G-CSF) to mobilize PBPC, three cycles of paclitaxel, ifosfamide and cisplatin (TIP) and one course of high-dose carboplatin, etoposide and thiotepa (CET) plus PBPC rescue. Patients were randomized to receive an absolute dose of 500 mg amifostine (group A, n=20) on each day of chemotherapy or no amifostine (group B, n=20). Prior to each cycle of chemotherapy, after hematologic engraftment from CET, 6 weeks and 3 months after transplantation the subpopulations of lymphocytes were phenotyped. Between the two study groups no statistically significant differences were observed concerning reconstitution of lymphocyte subpopulations. Throughout treatment with TIP or CET lymphocyte counts and their subpopulations remained low without severe clinical complications. Delayed reconstitution of the CD4(+) cell compartment after PBPC rescue was observed in both study groups, but did not result in any severe or atypical infections. Treatment with amifostine administered at this dose did not significantly influence the reconstitution of lymphocyte subpopulations. Low numbers of lymphocytes during chemotherapy and delayed reconstitution of CD4(+) cells and other lymphocyte subpopulations after PBPC rescue had no clinical relevance for patients with GCT.

High-dose chemotherapy as salvage treatment for seminoma

Between October 1989 and February 1997, 13 patients with refractory or relapsed seminomas were treated with high-dose chemotherapy (HDCT) as part of consecutive phase I/II studies. Six patients had failed prior cisplatin-based first-line treatments and seven patients had also failed cisplatin-based salvage treatments. After HDCT 4/12 (33%) patients became disease-free, 4/12 (33%) patients achieved partial remissions and 4/12 (33%) patients suffered progressive disease despite HDCT. One patient developed multiorgan failure and died. With a median follow-up of 4.5 years (range 3.4 to 8 years) five patients (38%) are alive and eight patients (62%) have died. Patients with non-pulmonary visceral metastases, with short relapse-free intervals and with cisplatin-refractory tumors were more likely to fail. HDCT can be curative in seminoma patients even if offered as second salvage treatment.

High-dose versus conventional-dose chemotherapy as first-salvage treatment in patients with non-seminomatous germ-cell tumors: a matched-pair analysis

BACKGROUND

The purpose of this study was to compare high-dose chemotherapy (HDCT) with conventional-dose chemotherapy (CDCT) as first-salvage treatment in patients with relapsed or refractory non-seminomatous germ-cell tumors (NSGCT).

PATIENTS AND METHODS

One hundred and ninety-three patients with relapsed or refractory NSGCT, between 1981 and 1995, were identified from two large databases. In 74 of these, intensification of first-salvage treatment by HDCT was planned. Patients were matched based on primary tumor location, response to first-line treatment, duration of this response and serum levels of the tumor markers, human chorionic gonadotrophin (HCG) and alpha-fetoprotein (AFP). Multivariate analyses were performed using event-free survival and overall survival as primary endpoints.

RESULTS

Full matches on all five factors were found for 38 pairs of patients; for a further 17 pairs, matches on at least four factors could be identified. Hazard ratios in favor of HDCT were obtained between 0.72 and 0.84 [confidence interval (CI) 0.59-1.01] for event-free survival and between 0.77 and 0.83 (CI 0.60-0.99) for overall survival, depending on the type of analysis.

CONCLUSIONS

The current analysis suggests a benefit from HDCT, with an estimated absolute improvement in event-free survival of between 6 and 12% and in overall survival of between 9 and 11% at 2 years. This benefit is lower than expected from previous phase I/II studies.

Second German consensus on immunogenetic donor search for allotransplantation of hematopoietic stem cells

The present paper summarizes the results of the second German consensus meeting on immunogenetic donor search for allotransplantation of hematopoietic stem cells held in Essen in November 1999 under the auspices of the German Society for Immunogenetics (DGI) and the German Working Party for Blood and Marrow Transplantation (DAG-KBT). Immunogeneticists and transplant physicians from all over the country agreed to update the national standards for: (1) search strategy including the role of unrelated and extended family donor search after unsuccessful core family donor search, (2) histocompatibility loci to be typed, (3) histocompatibility typing techniques to be used (HLA serology vs DNA-based HLA typing, cellular tests, serum cross-match), and (4) acceptable HLA mismatches in the context of a defined underlying disease, donor type, and conditioning regimen.

Novel T-cell receptor delta gene rearrangement involving a recombining element located 2.6 kb 3' from the Vdelta2 gene segment

In this study, we describe a novel T-cell receptor delta (TCRdelta) gene rearrangement observed in acute myeloid leukemia with coexpression of T-lymphoid antigens (Ly+AML) and in peripheral blood leukocytes (PBL) from one out of ten healthy donors. The rearrangement was identified by Southern blot analysis using a joining region (Jdelta1) specific probe and amplified by polymerase chain reaction (PCR) with a variable region (Vdelta2) and Jdelta1 specific primers. The nucleotide sequence analysis of an atypical 3000 bp PCR product allowed localization of the breakpoint within the TCRdelta gene locus, 2.6 kb 3' from the Vdelta2 gene segment. A regular Ddelta2-Ddelta3-Jdelta1 joining was found at the 3' end of the breakpoint, indicating that the rearrangement was mediated by the VDJ recombinase, but no TCRdelta gene segment was detected at the 5' end. Analysis of the germline sequence 3' from the breakpoint revealed an isolated recombination signal sequence (RSS) capable of initiating a rearrangement. The RSS motif described by us is the second TCRdelta recombining element (deltaRec2). The deltaRec2(Ddelta)Jdelta1 recombination is a rather rare event and can be found in acute leukemia and in PBL from healthy individuals. Most likely, the nonfunctional deltaRec2(Ddelta)Jdelta1 rearrangement is a transient step during the VDJ recombination. It may potentially lead to deletion of the deltaRec2(Ddelta)Jdelta1 complex and either to direct joining of a Vdelta region to one of the downstream Jdelta regions or to a rearrangement of the TCRalpha gene.

A fludarabine-based dose-reduced conditioning regimen followed by allogeneic stem cell transplantation from related or unrelated donors in patients with myelodysplastic syndrome

We investigated the feasibility and efficacy of a fludarabine-based dose-reduced conditioning regimen followed by stem cell transplantation from related (n = 5) or unrelated HLA-matched donors (n = 7) in 12 patients with high risk MDS, who were not eligible for a standard myeloablative conditioning regimen. The conditioning regimen consisted of fludarabine 30 mg/m(2) daily for 6 days, busulfan 4 mg/kg daily for 2 days and anti-thymocyte globulin (ATG, rabbit) 10 mg/kg daily for 4 days in 11 patients, while one patient received fludarabine, ATG, cyclophosphamide and thiotepa. Graft-versus-host disease prophylaxis consisted of cyclosporine and a short course of methotrexate. The median age of the patients was 53 years (range 37-59). The median percentage of blasts in bone marrow aspirate at transplantation was 15% (range <5% to 35%). Diagnosis at transplant was RA (n = 1), RAEB (n = 5), RAEB-T (n = 5) and sAML (n = 1). A complex karyotype including monosomy 7 was noted in five patients. The reasons for using a dose-reduced conditioning regimen were prior autologous/syngeneic BMT (n = 4), active fungal infection (n = 2) or age/reduced performance status (n = 6). Engraftment was observed in all patients with complete donor chimerism. The incidence of acute GVHD (grade II-IV) was 33%. Eight patients died during follow-up due to relapse (n = 4), liver toxicity (n = 2), aspergillus (n = 1) or aGVHD grade IV (n = 1). After a median follow-up of 19 months, the 2-year estimated disease-free survival is 12% (95% CI: 2-23%) and the overall survival is 26% (95% CI: 4-52%). Fludarabine dose-reduced conditioning prior to allogeneic stem cell transplantation in high risk MDS patients, who were not eligible for standard transplantation, resulted in stable engraftment with complete chimerism, but the toxicity and relapse rate were considerable.

Chemotherapy in patients with metastatic or relapsed germ-cell tumours

The optimal treatment in patients with poor prognosis germ-cell tumours (GCT), according to the International Germ Cell Cancer Collaborative Group (IGCCCG) classification, and in patients with refractory or relapsed disease after cisplatin-based chemotherapy is controversial. As the majority of patients will suffer systemic relapses, chemotherapy is the mainstay of treatment. However, the question of whether or not to use conventional-dose or high-dose chemotherapy (HDCT) in these patients arises. Prognostic factors have recently been recognised to aid in this decision. However, reliable data on chemotherapy as primary treatment in poor prognosis patients and as the first-salvage attempt in patients with relapsed or refractory GCT are lacking. This report reviews the recent developments in first-line and salvage HDCT strategies and discusses the role of predictive factors for treatment outcome.

Dose-reduced conditioning for allografting in 44 patients with chronic myeloid leukaemia: a retrospective analysis

This retrospective study describes the outcome of patients with chronic myeloid leukaemia after allografting using dose-reduced conditioning with fludarabine and busulphan. Forty-four Philadelphia chromosome (Ph)-positive patients were transplanted in nine German centres; 26 patients were in chronic phase, 11 in accelerated phase and seven in blast crisis. Thirty-four patients achieved complete remission, with 18 alive and disease-free at a median follow-up of 562 d (range 244-922 d). Grade II-IV acute graft-versus-host disease (GVHD) incidence was 43%. Twenty patients died, 15 of causes unrelated to relapse. Risk factors predisposing to graft failure by univariate analysis were an unrelated donor (8/23 compared with a related donor 2/21, P = 0.07) and interferon therapy within 90 d of transplant (4/6 versus 3/17, P = 0.025). At the last follow-up, of 31 patients for whom molecular or cytogenetic data were available, 16 (52%) were polymerase chain reaction-negative, and seven (23%) were Ph-negative by fluorescent in situ hybridization. These findings demonstrate that dose-reduced conditioning with fludarabine and busulphan provides durable engraftment and a low rate of relapse. However, in this population, many of whom were not eligible for high-dose conditioning due to age, reduced performance status, previous complications or extensive pre-treatment, these data highlight the need for effective anti-infectious and GVHD prophylaxis. In addition, this study supports the discontinuation of interferon therapy at least 90 d before transplant

Bioequivalence investigation of high-dose etoposide and etoposide phosphate in lymphoma patients

PURPOSE

To compare etoposide pharmacokinetics following administration of high-dose etoposide and etoposide phosphate, a water-soluble prodrug of etoposide. Bioequivalence was assessed using a two-treatment randomized crossover design.

METHODS

Ten patients with high-risk or relapsed lymphoma were treated with a sequential high-dose chemotherapy. They were randomized to receive either 3 x 400 mg/m2 etoposide or an equimolar amount of etoposide phosphate (as 1-h infusions on three consecutive days) in the first course and the alternative drug in the second course. Serial plasma and ultrafiltered plasma samples were collected and analysed for etoposide by a reversed-phase HPLC method with UV and electrochemical detection. Pharmacokinetic parameters were estimated using a two-compartment model. Bioequivalence was assessed calculating the 90% confidence intervals (CI) for the ratios of the geometric means of AUC(0-infinity) and additionally of Cmax of etoposide derived from etoposide phosphate relative to etoposide in plasma and ultrafiltered plasma as point estimates (level of significance alpha < 0.05).

RESULTS

Pharmacokinetic parameters of etoposide were comparable in both treatment arms except that terminal half-life was significantly shorter and apparent Vss in ultrafiltered plasma was significantly larger following administration of the prodrug. The point estimates for AUC(0-infinity) of etoposide derived from etoposide phosphate relative to etoposide were 102.9% and 88.4% for plasma and ultrafiltered plasma, respectively. The 90% CIs were in the range from 80% to 125% where bioequivalence can be assumed. The point estimates of Cmax on day 3 of chemotherapy were 96.5% and 81.7% in plasma and ultrafiltrate with the 90% CI in ultrafiltered plasma being out of the range from 80% to 125%.

CONCLUSION

With respect to total drug exposure, represented by AUC(0-infinity), high-dose etoposide phosphate is bioequivalent to high-dose etoposide.

Assessment of amifostine as protection from chemotherapy-induced toxicities after conventional-dose and high-dose chemotherapy in patients with germ cell tumor

BACKGROUND

We assessed the efficacy of amifostine for protection from chemotherapy-induced toxicities in patients treated with conventional-dose paclitaxel, ifosfamide, cisplatin (TIP) and high-dose carboplatin, etoposide and thiotepa (CET) followed by peripheral blood progenitor cell (PBPC) rescue.

PATIENTS AND METHODS

In a prospective single-center study 40 patients with relapsed or refractory germ-cell tumors (GCT) were treated with 3 cycles of conventional-dose TIP followed by one cycle of high-dose CET. Patients were randomized either to receive one fixed dose of 500 mg amifostine per day of conventional-dose TIP and two fixed doses of 500 mg per day amifostine during high-dose CET (group A, n = 20) or no amifostine (group B, n = 20). Prior to the first cycle of TIP, one course of 175 mg/m2 paclitaxel and 5 g/m2 ifosfamide (TI) followed by granulocyte-colony stimulating factor (G-CSF) at 10 microg/kg/day were given for PBPC mobilization.

RESULTS

Toxicities and response to conventional-dose TIP and high-dose CET could be evaluated in 40 patients (100%) and 32 of 40 patients (80%), respectively. Peripheral neurotoxicity (i.e. paresthesia or sensorymotor impairment), hearing impairment, hematologic toxicity, nephrotoxicity, nausea, myalgia, skin- and liver-toxicity did not differ siginificantly between the two patient groups. Likewise, the response rates to TIP and high-dose CET were comparable in patients with or without amifostine. After a median follow-up of 18 months, 8 of 20 (40%) patients of group A and 6 of 20 (30%) patients of group B are without relapse.

CONCLUSION

Repeated low doses of 500 mg amifostine additional to conventional-dose TIP or high-dose CET showed no unequivocal advantage in protection from treatment-related toxicities. Furthermore, no significant differences in response rates or survival could be observed in this small number of patients.

A pilot study on the role of cytomegalovirus & human herpesvirus-6 infections in Indian bone marrow transplant recipients

BACKGROUND & OBJECTIVES

Studies from Western transplant centers have shown the importance of cytomegalovirus (CMV) in infections among immunosuppressed post-transplant patients (both solid and bone marrow transplant recipients). Human herpesvirus-6 (HHV-6) infection is also important. Since such data are lacking from India, we carried out a pilot study to investigate the role of these two viruses in infections among Indian allogeneic bone marrow transplant (BMT) recipients.

METHODS

A total of 21 BMT patients who developed acute graft versus host disease (GVHD), two patients who developed chronic GVHD, and eight recipients who did not develop GVHD but had skin rash/elevated liver enzymes, persistent cytopaenia or interstitial pneumonitis with a high clinical suspicion of possible CMV association were studied for markers of CMV and HHV-6 infections.

RESULTS

CMV DNAemia was documented in 9 (42.8%) and CMV IgM in 4(19%) of the 21 patients with acute GVHD. HHV-6 DNAemia was not seen in any patient with acute GVHD but 2 (9.5%) had HHV-6 IgM. Of the 2 patients with chronic GVHD, 1 was positive for CMV DNA and IgM, and both were negative for HHV-6 markers. The lower incidence of CMV DNAemia in our recipients may be attributable to the presence of neutralizing antibody (anti gB/AD-1) among the 17 CMV and HHV-6 DNAemia negative recipients, 4(23.5%) had neutralizing antibodies (S/N ratio > or = 5). Of the 13 CMV DNAemia positive recipients, only one (7.7%) was positive for neutralizing antibodies. Among the 5 neutralizing antibody (S/N ratio > or = 5) positive recipients, 4 (80%) were negative for CMV DNAemia. The one nPCR positive was revealed only at high DNA (> 0.1 microgram) input indicating low CMV signal strength.

INTERPRETATION & CONCLUSION

The present study shows the use of DNAemia in detecting CMV infections among BMT recipients. All recipients had high avidity CMV IgG (AI > 50%) confirming CMV reactivation or reinfection in these patients. There was evidence from this study suggesting that neutralizing antibodies may play a role in controlling CMV reactivation. We found no significant HHV-6 association with GVHD in Indian allogeneic BMT recipients.

Quantification of human cells in NOD/SCID mice by duplex real-time polymerase-chain reaction

BACKGROUND AND OBJECTIVES

The aim of this study was the development of a fast and reliable polymerase chain reaction (PCR) assay which quantifies the proportion of human cells in immunodeficient chimeric mice, for example transplanted with human hematopoietic stem cells.

DESIGN AND METHODS

We developed a TaqMan chemistry-based, real-time duplex PCR assay to quantify human and murine DNA in a single-tube reaction in parallel (HUmu PCR). Two independent sets of primers and exonuclease probes, located in the tumor necrosis factor-a gene of both species, were selected to amplify specifically human and murine genomic DNA. Serial dilutions of defined numbers of human cells in mouse cells served to construct calibration curves. The test was applied to NOD/SCID mice transplanted with CD34(+) cells isolated from human cord blood and compared to FACS analysis.

RESULTS

Analysis of DNA from human cells diluted stepwise into a fixed number of murine cells - and vice versa - led to calibration curves with good correlation for human and murine cells (r(2)>0.99) with a detection limit of 2% human cells. Results obtained with the HUmu PCR paralleled those of FACS analysis. However, in contrast to FACS analysis, which requires fresh single cell suspensions, the HUmu PCR can be carried out on already stored samples, even from solid organs and, moreover, the quantity of material required for analysis is very low.

INTERPRETATION AND CONCLUSIONS

The HUmu PCR presented here is the first real-time PCR assay for simultaneous quantification of human and murine cells. It is extremely fast, accurate and is an interesting alternative method for quantifying the proportion of human DNA in organs of chimeric mice.

ICE--an efficient drug combination for stem cell mobilization and high-dose treatment of malignant lymphoma

Between 1989 and 1999 we studied the ICE regimen in sequential trials in 290 patients with malignant lymphoma and germ-cell tumours. For patients with relapsed or refractory lymphoma we could demonstrate a comparable efficacy of ICE to other high-dose chemotherapy (HDCT) regimens but with a toxicity profile in favour of ICE. From a retrospective comparative analysis of ICE as HDCT regimen in patients with malignant lymphoma and germ-cell tumours we conclude that the characteristic toxicity profile of ICE varies depending on prior drug exposure of individual patients. Further dose intensification of ICE may be achieved with acceptable toxicity by adding further drugs (e.g. anthracyclines) or by treatment with sequential cycles of ICE (Tandem-HDCT). More convenient drug formulations (e.g. etoposide phosphate) might further improve the therapeutic index of ICE.

Skin involvement as the first manifestation of systemic aspergillosis in patients after allogeneic hematopoietic cell transplantation

Skin involvement due to a systemic infection with Aspergillus species in the course of allogeneic hematopoietic cell transplantation is extremely rare. We report the clinical course of two patients with hematologic malignancies who underwent allogeneic hematopoietic cell transplantation (HCT) and developed disseminated skin involvement as the first clinical symptom of a proven systemic Aspergillus infection.