Platelet Metabolism during the Interiorization of Two Different Types of Particulate Matter

It has been suggested that human platelets possess the ability to phagocytose particulate matter similar to the polymorphonuclear leukocyte. However some difference of opinion has arisen regarding this contention, particularly as differences have been demonstrated with regard to the observed metabolic changes occurring in platelets related to such a process.

The experiments reported in this paper were designed to observe the aerobic and anaerobic metabolism in human platelets during and following interiorization of two different particles, viz. polystyrene latex and thorotrast. The results of these experiments show a marked difference between both types of particles with regard to observable metabolic changes despite the rapid interiorization of both types of material. Some alteration occurs in both aerobic and anaerobic metabolism a considerable time after interiorization of latex, whereas no alteration could be demonstrated after interiorization of thorotrast. It is suggested that the interiorization of particulate matter is by some process other than phagocytosis and that observed metabolic changes related to latex may be due to a release reaction.

Prognostic markers of disease activity in Hodgkin's disease

The erythrocyte sedimentation rate (ESR), liver alkaline phosphatase (ALP), serum copper (Cu) and urinary nucleoside excretion (UNs) have been proposed as independent prognostic markers in Hodgkin's Disease (HD). However, their prognostic value has not satisfactorily been directly compared to recognised clinical prognostic factors. One hundred and sixty-eight patients with HD had the above markers performed prior to initial treatment. At a median follow-up of 10.9 yrs, the predicted 10 year relapse free survival (RFS) and overall survival (OS) for the entire cohort is 64% and 66%, respectively. In general, patients with elevated markers were significantly less likely to achieve CR, remain in CR and survive. However, multivariate analysis revealed this was due to the association of elevated markers with stage and constitutional symptoms. Following therapy, elevated markers were also correlated with evidence of clinically detectable disease. We conclude that although UNs, Cu, ALP and ESR reflect disease activity, they do not provide independent information beyond that of clinical assessment.

Long-term survival advantage of MACOP-B over CHOP in intermediate-grade non-Hodgkin's lymphoma. The Australian and New Zealand Lymphoma Group

BACKGROUND

The initial publication of the results of the Australian and New Zealand Lymphoma Group (ANZLG) randomized controlled trial comparing MACOP-B and CHOP in patients with intermediate-grade non-Hodgkin's lymphoma (NHL) showed equivalent complete response rates, time to treatment failure, and survival. Here we report the long-term follow-up of the 236 patients entered on that study to determine if there were any long-term advantages or disadvantages associated with MACOP-B.

PATIENTS AND METHODS

Two hundred thirty-six eligible patients were randomized between October 1986 and June 1991. The median duration of follow-up has been extended from 3.2 years in our previous publication to 6.5 years.

RESULTS

As previously reported, the complete response (CR) rate for MACOP-B and CHOP chemotherapy was 51% and 59%, respectively. The estimated failure-free survival rate for MACOP-B and CHOP patients was 42% and 30%, respectively, at 5 years (P = 0.045) and 37% and 25%, respectively, at 8 year (P = 0.057). The estimated overall survival rate at 5 years was 54% for MACOP-B and 41% for CHOP patients (P = 0.035) and at 8 years was 45% and 36%, respectively (P = 0.16).

CONCLUSION

With this extended follow-up, we have shown a long-term survival advantage for MACOP-B chemotherapy over standard CHOP in patients with intermediate-grade non-Hodgkin's lymphoma.

Interaction between a murine myeloma cell line and bone marrow stromal cells

Intravenous transplantation of an in vitro maintained murine myeloma cell line, 5T33, results in progressive growth in the bone marrow of C57Bl/KaLwRiJ mice. Concurrent with the growth of the tumor in vivo, the bone marrow stromal cells are inhibited, as assayed by their ability to form stromal cell foci and long-term monolayers in vitro. Inhibition of normal mouse marrow stromal cell growth also occurs when 5T33 cells are added to the marrow cells in vitro, and contact between the marrow and 5T33 cells is not necessary to achieve inhibition, indicating secretion of one or more diffusible inhibitory factors.

Randomized comparison of MACOP-B with CHOP in patients with intermediate-grade non-Hodgkin's lymphoma. The Australian and New Zealand Lymphoma Group

PURPOSE

To compare complete response rates, time to failure, survival, and toxicity for patients with intermediate-grade non-Hodgkin's lymphoma (NHL) treated with cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) versus those treated with a regimen consisting of methotrexate, doxorubicin, cyclophosphamide, vincristine, prednisolone, and bleomycin (MACOP-B), in a multicenter, randomized controlled trial performed by 22 centers of the Australian and New Zealand Lymphoma Group (ANZLG).

PATIENTS AND METHODS

Between October 1986 and June 1991, 304 patients were randomized, of whom 236 were eligible for analysis. Eligibility criteria included diffuse small cleaved-cell, diffuse mixed small- and large-cell, follicular large-cell, diffuse large-cell, and large-cell immunoblastic, stages I bulky or II to IV.

RESULTS

There was no significant difference in complete response rates (51% for MACOP-B v 59% for CHOP), failure-free survival, or overall survival in the two treatment arms. The rate of death of MACOP-B patients relative to CHOP patients was estimated to be 0.91 (P = .64) when stratified by prognostic group. There were no significant differences between the two regimens in any of the prognostic subgroups. Toxicity was significantly more severe with MACOP-B, particularly cutaneous toxicity, stomatitis, and gastrointestinal ulceration. The average relative dose-intensity (RDI) of MACOP-B was 0.91 and of CHOP was 0.90, indicating good dose delivery in this multicenter group setting.

CONCLUSION

CHOP chemotherapy produced results equivalent to those of MACOP-B in patients with intermediate-grade NHL and with significantly fewer toxic complications. Despite relatively poor results in some patient subgroups, CHOP remains the standard chemotherapy for this disease, against which all new regimens should be compared.

Failure of intensive chemotherapy in poor prognosis non-Hodgkin's lymphoma

In an attempt to improve response and survival rates in patients with non-Hodgkin's lymphoma, a relatively intense six drug regimen MATCOP was developed comprising four-weekly cycles of methotrexate (100 mg/m2, IV, day 8), Adriamycin (30 mg/m2, IV, days 1,2), teniposide (75 mg/m2, IV, day 1), cyclophosphamide (300 mg/m2, po, days one to five), Oncovin (1.4 mg/m2, IV: maximum 2 mg, days 8, 15) and prednisolone (100 mg, po, days one to five). A randomised trial was conducted comparing MATCOP with the standard CHOP regimen, comprising three-weekly cycles of cyclophosphamide (750 mg/m2, IV, day 1), Adriamycin (50 mg/m2, IV, day 1), Oncovin (1.4 mg/m2 IV: maximum 2 mg, day 1) and prednisolone (100 mg, po, days two to six). Eighty patients with large cell lymphoma, diffuse mixed small cleaved and large cell lymphoma or diffuse small cleaved cell lymphoma were randomised, 47 to MATCOP and 33 to CHOP. MATCOP patients experienced increased granulocytopenia, thrombocytopenia (p less than 0.0001), mucositis (p = 0.002) and infections (p = 0.01) compared to CHOP patients. Complete response rates were similar: 66% for MATCOP patients and 61% for CHOP patients. There were no apparent differences in the time to relapse for patients achieving CR, the time to treatment failure or the overall survival time. Thus despite an increase in toxicity, the more intense regimen MATCOP failed to confer any therapeutic benefit compared with the standard CHOP regimen. Survival was not influenced but toxicity was increased by dose intensification.

A randomised double-blind study of high-dose intravenous prochlorperazine versus high-dose metoclopramide as antiemetics for cancer chemotherapy

High-dose prochlorperazine 0.8 mg/kg administered intravenously 30 min pre and 7 h 30 min post the initial dose of emetogenic chemotherapy was compared to high-dose metoclopramide 2 mg/kg over 20 min every 2 h for five doses starting 30 min prior to chemotherapy in a randomised, double-blind, parallel subjects design study. On the prochlorperazine arm intravenous dextrose placebos every 2 h maintained blinding. Complete suppression of vomiting occurred in 42% on metoclopramide (53% with non-cisplatin regimens) and 36% on prochlorperazine (52% with non-cisplatin-containing regimens) while major responses (2 or less vomits) occurred in 58% on metoclopramide and 54% on prochlorperazine. In patients who vomited after cisplatin, prochlorperazine achieved a significantly shorter duration of vomiting, a median of 5 h compared to 15 h on metoclopramide (P = 0.03). The response rate to prochlorperazine for cisplatin-induced emesis between 12 and 24 h was significantly better than for metoclopramide (prochlorperazine = 0.02). Toxicities were equivalent except for significantly greater sedation and dry mouth on prochlorperazine. Extrapyramidal reactions were recorded equally on both arms but were only severe enough to stop treatment on metoclopramide. The metoclopramide regimen was five times as expensive as prochlorperazine. High-dose prochlorperazine is an active and cost-effective antiemetic.

Infradiaphragmatic Hodgkin's disease, long term follow-up of a rare presentation

Hodgkin's disease limited to the infradiaphragmatic region was seen in 30 of 306 (9.8%) of all Stage I and II patients referred to the Peter MacCallum Cancer Institute between 1968 and 1980. The male:female ratio was 2.3:1 with median age of 43.5 years at presentation. Of the seven patients with clinical stage (CS) IA-IIA disease who had staging laparotomy and splenectomy only one CSIIA patient had splenic involvement. The patients were staged as pathological stage (PS) IA 2, PSIIA 5, CSIA 4, CSIIA 10, CSIIB 9. Primary treatment was by radiation in 24 patients, combination chemotherapy in five and surgical excision in one. Twenty-five patients achieved complete response. Relapse free survival (RFS) at five and ten years was 59% and the five and ten-year survival was 75% and 67% respectively. On univariate analysis the significant prognostic factors for RFS and survival were stage, constitutional symptoms and presence of bulky disease. Using Cox regression analysis the only significant variable for RFS and survival was bulky disease (p = 0.01, 0.02). A treatment policy for patients with infradiaphragmatic Hodgkin's disease is recommended.

Etoposide in leukemia

Etoposide (VP16-213, NSC 141540) induces a complete response (CR) in 15% to 25% of previously treated patients with acute nonlymphocytic leukemia (ANLL) when used as a single agent. Etoposide has been used successfully in combination with cytarabine, daunorubicin, and amsacrine for salvage and consolidation therapies. Previously untreated ANLL patients 15 to 70 years of age were randomly assigned to cytarabine (100 mg/m2) on days 1 to 7 plus daunorubicin (50 mg/m2) on days 1 to 3 (7-3) or to the same drugs plus etoposide (75 mg/m2) on days 1 to 7 (7-3-7). Patients achieving a CR received two consolidation courses (5-2, attenuated 7-3 or 5-2-5). Among 264 eligible patients, there was a 56% CR rate with 7-3 therapy and a 59% CR rate with 7-3-7 therapy. Remission duration was significantly improved with 7-3-7 (median, 12 months with 7-3 and 18 months with 7-3-7; P = 0.01), but survival was not. Subset analysis in patients younger than 55 years of age revealed prolonged remission (median, 12 months with 7-3 and 27 months with 7-3-7; P = 0.01) and survival (median, 9 months with 7-3 and 17 months with 7-3-7; P = 0.04) with the 7-3-7 regimen. Hematologic toxicity was similar for both regimens during induction, but significantly more severe for 7-3-7 during consolidation therapy. Etoposide is active in ANLL and prolongs remission when used in induction therapy.

Value of bilateral bone marrow biopsy specimens in non-Hodgkin's lymphoma

A study of 260 patients with non-Hodgkin's lymphoma (NHL) who underwent bilateral bone marrow biopsy at initial diagnosis showed marrow disease in 99 (38%) cases. The highest incidence of disease (83%) was seen in small lymphocytic lymphoma (SLL) and the lowest (19%) in diffuse large cell lymphoma (DLCL). Among cases with positive marrows, disease was bilateral in all 15 cases of SLL but in only 10 of 20 (50%) of the DLCL cases. In 30 of 99 (30%) positive marrows disease was unilateral. Follicular lymphomas were strongly associated with a paratrabecular pattern, with 40 of 45 positive cases showing this. Discordant histology was seen in six of 20 positive cases of DLCL and two of 37 positive cases of follicular small cleaved cell lymphomas (FSCCL). A bone marrow aspirate was positive in only 56 of the 99 (57%) cases. Peripheral blood disease was present in 15% of the bone marrow positive cases and in 6% of the cases overall. The incidence of marrow disease varies with the histological subtype of lymphoma. The paratrabecular pattern is associated with follicular lymphoma, and bilateral biopsy specimens increase the positivity rate in most subtypes of NHL.

A study of splenic irradiation in chronic lymphocytic leukemia

A retrospective study was performed to assess the effect of splenic irradiation (SI) on splenomegaly, splenic pain, anemia, and thrombocytopenia in patients with chronic lymphocytic leukemia. Twenty-two patients received 32 courses of SI. Of 31 courses of SI given for splenomegaly there were 19 responders (61%). Ten courses of SI were given for splenic pain resulting in partial relief of pain in 4 courses and complete relief in 4 courses. Only 4 of 16 courses given for anemia resulted in elevations of hemaglobin of 2 g/dL or more. Of the 14 courses of SI given for thrombocytopenia there were only 2 responses with platelet counts decreasing further in another 9 courses. The median duration of response was 14 months (range: 3-116 months). There was no dose-response relationship detected for SI in CLL. Treatment related toxicity was hematologic and secondary to leucopenia and thrombocytopenia. We recommend the use of small fraction sizes of 25 cGy to 50 cGy and close monitoring of hematological parameters. Splenic irradiation effectively palliates splenomegaly and reduces spleen size in CLL. It was of limited value in correcting anemia and thrombocytopenia in this patient population.

Nitrogen mustard, vincristine, procarbazine, and prednisolone for relapse after radiation in Hodgkin's disease. An analysis of long-term follow-up

One hundred and sixty-one patients who were treated with nitrogen mustard, vincristine, procarbazine, and prednisolone (MOPP) chemotherapy for Hodgkin's disease have been observed for a median of 10.2 years. Eighty-two percent of those patients received MOPP after relapse from previous irradiation. The complete response (CR) rate was 71%. For the 116 patients achieving CR the relapse-free survival at 5 years was 83% and at 10 years, 79%. The overall survival was 72% at 5 years and 64% at 10 years. In a stepwise logistic regression analysis the most important clinical factors influencing response were B symptoms at presentation (fever greater than 38 degrees C, night sweats, weight loss greater than 10% of body weight), histologic subtype, and lung or pleural involvement. Patients who received MOPP as first-line therapy had a significantly worse response rate than those who received MOPP upon relapse after radiotherapy. This difference is reduced when adjustments are made for the presence of the above prognostic factors. A Cox regression analysis showed that Stage IV at presentation and lymphocyte-depleted histology were the most important factors indicating reduced survival. Patients who achieved a CR to MOPP had a significantly improved survival. Of the 65 patients who had died at the time of the analysis of this series, 46 died of progressive Hodgkin's disease. All four patients who developed secondary acute nonlymphocytic leukemia had received radiation as well as MOPP.

Clinical factors influencing the efficacy of pooled platelet transfusions

To determine the relative importance of clinical factors on the efficacy of platelet transfusions, 941 pooled platelet transfusions from HLA-unmatched donors were studied prospectively in 133 patients with bone marrow failure. Multiple linear regression analyses identified the major factors influencing one-hour-corrected increments (CI) as prior splenectomy, bone marrow transplantation, disseminated intravascular coagulation, concurrent intravenous amphotericin B, splenomegaly, and HLA antibody grade. The relative impact of these factors on CI has been quantitated by using a formula developed from these data. A linear relationship was demonstrated between increasing percentage of HLA antibody grade and decreasing CI. A number of other factors were less important in the linear regression model than the aforementioned major factors. These included platelet-specific antibodies, concurrent antibacterial antibiotics, clinical bleeding grade, and temperature. Factors that did not influence CI included the number of prior platelet transfusions, prior granulocyte transfusions, prior red cell transfusions, infection, age, blood group, diagnosis, sex, pretransfusion platelet count, prior pregnancies, and concurrent antineoplastic drugs. This study identified major clinical factors that significantly influenced CI and were major causes of refractoriness to pooled platelet transfusions.

Randomized, double-blind, cross-over study comparing prochlorperazine and lorazepam with high-dose metoclopramide and lorazepam for the control of emesis in patients receiving cytotoxic chemotherapy

To further define optimal combinations of antiemetics, high-dose metoclopramide and lorazepam (M+L) were compared with prochlorperazine and lorazepam (P+L) in a randomized, double-blind, cross-over study. Both patient and observer assessments were documented in 66 patients receiving cisplatin and noncisplatin chemotherapy. M+L significantly reduced the severity of vomiting (P = 0.01), duration of vomiting (P = 0.05), and number of vomiting episodes (P = 0.003). Comparing the severity or duration of nausea, M+L and P+L were not significantly different. M+L significantly reduced severity of vomiting (P = 0.005) and number of vomiting episodes (P = 0.03) in the cisplatin subset. The number of vomiting episodes was also reduced in the noncisplatin subset (P = 0.03). When asked to nominate a preferred regimen, 41% of patients preferred P+L, 35% preferred M+L, and 24% rated them equally. M+L was associated with significantly more anxiety and less sedation than P+L. Patient assessments produced similar results to observer assessments but gave a broader understanding of our patients' tolerance to chemotherapy. M+L is a superior regimen in controlling vomiting induced by chemotherapy.

Nocardia infection in splenectomized patients: case reports and a review of the literature

Opportunistic infections are increasingly becoming a problem in cancer patients amongst whom infection with Nocardia species is particularly difficult to detect due to the capricious natural history of the disease. Three cases of Nocardia infection in patients who had undergone splenectomy for haematological malignancy are presented. These cases illustrate the diverse mode of presentation, the natural history and the difficulties in early and accurate diagnosis of Nocardia infection. Despite the difficulties in arriving at the correct diagnosis, these cases highlight the importance of early institution of appropriate antibiotic therapy. Antibiotics should be given in adequate doses to control the initial infection and be maintained for a prolonged period to prevent relapses.

Expression of leucocyte-common antigen and large sialoglycoprotein on leukemic cells in B-cell chronic lymphocytic leukemia and non-Hodgkin's lymphoma

Patterns of leucocyte-common antigen (L-CA) and large sialoglycoprotein (LSGP) expression on leukemic peripheral blood lymphocytes of 13 patients with chronic lymphocytic leukemia (CLL), 17 with non-Hodgkin's lymphoma (NHL) in leukemic phase and one with hairy cell leukemia (HCL) have been examined by means of surface labelling and electrophoresis in 5% polyacrylamide gels. The 13 CLL, 10 of the 11 diffuse NHL and the six nodular poorly differentiated lymphocytic lymphoma (PDLL) patients fell into three groups according to expression of 210, 198 and 185k forms of L-CA. Group 1 (210 less than 198 less than 185k L-CA) included eight CLL and one diffuse NHL; Group 2 (210 greater than or equal to 198 and 185k L-CA) included four CLL, three diffuse NHL and four nodular PDLL; Group 3 (mainly 210k L-CA) included one CLL, six diffuse NHL and two nodular PDLL. A patient with diffuse large cell lymphoma and the HCL patient both had patterns of multiple, diffuse, very high Mr labelled glycoproteins. LSGP on these cells varied from nil to very high and levels were not related to L-CA patterns. Lymph node cells from five patients were also studied and were found to express larger numbers of L-CA forms and less LSGP than corresponding peripheral blood lymphocytes. Possible relationships of L-CA forms and LSGP to lymphocyte function and disease patterns are discussed.

Diagnosis of granulocytic sarcoma facilitated by monoclonal antibodies

A 36 year old woman presented with a nasopharyngeal tumour which was diagnosed and treated as diffuse large cell lymphoma. Twelve mth later the patient developed acute myeloid leukemia. At this stage, the original biopsies were reviewed and considered in retrospect to be granulocytic sarcoma on the basis of staining for chloracetate esterase and lysozyme. She achieved and maintained marrow and peripheral blood remission with chemotherapy, but developed several cutaneous nodules and 2 breast lumps. One breast lump was excised and was found, by the use of monoclonal antibodies, to carry myeloid markers. Thus monoclonal antibodies provided additional confirmatory evidence for the diagnosis of granulocytic sarcoma.

Delayed DNA methylation is an integral feature of DNA replication in mammalian cells

In the majority of sites of methylation in the DNA of mammalian cells, the symmetry of methylation is restored within a few minutes of the passage of a replication fork. However, it has been shown that daughter strand methylation in immortalised cell lines is delayed in a substantial minority of sites for up to several hours after replication. We report here the results of two new approaches to the determination of the functional significance of delayed DNA methylation in mammalian cells. Firstly, we demonstrate that normal, nontransformed cells (human peripheral lymphocytes in short-term primary culture) have comparable proportions of delayed DNA methylation to many immortalised cell lines, showing that delayed DNA methylation is not just a secondary consequence of abnormally high methionine requirements commonly observed in transformed cells and that delayed DNA methylation would be unlikely not to occur in vivo. Secondly, we have used 5-aza-2'-deoxycytidine (5azadCyd) to derive subclones of cells from the Chinese hamster ovary cell line which have stably hypomethylated DNA. In three of these subclones which had lost on average one fourth of the methylation sites from their genomes, the proportion of daughter strand methylation which was delayed after replication was reduced by less than 10%. If delayed DNA methylation were site-specific, this implies that of the order of twice the number of "immediate" methylation sites than delayed methylation sites had been lost from the genomes of these hypomethylated subclones. Thus, delayed DNA methylation is an integral part of the process whereby replicating mammalian cells maintain the pattern of methylation in their genomes. These observations are discussed in relation to the significance of delayed DNA methylation for the accurate maintenance of methylation patterns in the genome and the consequent implications for the possible role of methylated deoxycytidines in mammalian gene control.

DNA ploidy patterns and cytokinetics of non-Hodgkin's lymphoma

Flow cytometry studies for cellular DNA analysis were performed in 115 cases of non-Hodgkin's lymphoma, 53 of which had not received any prior chemotherapy or radiotherapy. DNA content was measured in ethanol fixed cells stained with chromomycin A3. According to the criteria of the International Working Formulation there were 43 low grade, 58 intermediate grade, and eight high grade lymphomas; six cases were in the miscellaneous group. Seventy seven (67%) had only diploid DNA content. Thirty eight (33%) showed DNA aneuploidy; 20 of these had been previously treated with chemotherapy or radiotherapy, or both. DNA aneuploidy was seen as hyperdiploidy in all cases except one, and it varied from slightly hyperdiploid to tetraploid. The incidence of aneuploidy increased significantly with increasing histological grade (p = 0.0002) and was not related to previous treatment. The low, intermediate, and high grade lymphomas had 14% (six of 43), 47% (27 of 58), and 62.5% (five of eight) cases, respectively, that showed DNA aneuploidy. The percentage of cells in S phase increased significantly with a higher histological grade (p less than 0.0001). The median S fraction in the low, intermediate, and high grade lymphomas was 1.0 (0.5 to 10)% 4 (0.4 to 35)%, and 27 (4.6-56)%, respectively. There is a significant correlation between histological grade and S fraction and the presence or absence of aneuploidy. There is heterogeneity, however, within both histological grade and a histological subtype.

Storage of platelet concentrates--an in vitro study of four types of plastic packs

Four types of plastic blood collection packs were studied for their ability to preserve platelet function during a 5 d storage period. The platelet concentrates were stored in polyvinyl chloride (Tuta Laboratories), PL 1240 and PL 732 (Fenwal Laboratories) and CLX (Cutter Laboratories) packs, on a Fenwal elliptical rotator at 20 degrees-24 degrees C. Plasma pH, lactate concentration, hypotonic shock response (HSR), platelet aggregation in response to ADP, collagen and ristocetin and levels of the plasticisers, di-2-ethylhexyl phthalate (DEHP) and tri-ethylhexyl trimellitate (TEHTM), were measured. Morphological changes were assessed by electron microscopy. No significant fall in pH occurred in any type of pack but in vitro function and platelet morphology was generally better preserved in Tuta and CLX packs than in PL 732 and PL 1240. Very little TEHTM leached out of the PL 1240 and CLX packs whereas the mean concentration of DEHP in the platelet concentrates stored in Tuta packs was 27.4 mg/100 ml plasma after 5 d of storage. The results indicate that it is possible to prepare and store platelet concentrates in polyvinyl chloride plastic packs for a period of 5 d and maintain their function and viability.

Vincristine neurotoxicity enhanced in combination chemotherapy including both teniposide and vincristine

A high incidence of severe peripheral neuropathy occurred during the pilot study of a new regimen for the treatment of non-Hodgkin's lymphoma. The clinically observed incidence and severity of vincristine-induced peripheral neuropathy was considerably enhanced by the sequential use of vincristine and teniposide in this combination chemotherapy.

Pathological rupture of the spleen in transforming non-Hodgkin's lymphoma

Two patients with an initial diagnosis of a poorly differentiated lymphocytic lymphoma suffered a pathological rupture of the spleen in association with the histological transformation of the disease to a large cell lymphoma and the development of a leukaemic phase. The value of computerized tomographic scanning of the upper abdomen in confirming the diagnosis of splenic rupture is demonstrated.

The phenotype of mantle zone lymphoma studied by monoclonal antibodies

The clinical, pathological and immunological features of a case of mantle zone lymphoma are described. The patient presented at the age of 16 with a history of painless enlargement of the inguinal lymph nodes, biopsy of which revealed a nodular small cell lymphoma. During the course of 11 yr he was treated with total nodal irradiation, splenectomy and combination chemotherapy at different times. A recent lymph node biopsy reviewed along with the previous node biopsies was diagnosed as mantle zone lymphoma. At this stage, the immunological studies showed that the neoplastic lymphoid cells had characteristic markers of mantle zone lymphocytes. He is asymptomatic with mild generalized lymphadenopathy 11 yr after the initial diagnosis. This case illustrates the diagnostic and therapeutic problems which may be encountered. Detailed immunological marker studies with an extended panel of monoclonal antibodies are described.

Levels and stability of DNA methylation in random surviving cell clones derived from a Chinese hamster cell line after prolonged treatment with 5-aza-2'-deoxycytidine

SCC30 cells (derived from a single cell from the Chinese hamster ovary CHO-K1 cell line, selected on the basis of a stable chromosome complement) were used to select cell variants with hypomethylated DNA. Cells were treated with 5-aza-2'-deoxycytidine (5azadCyd) at 0.1, 1, or 5 microM for two weeks with the medium and drug renewed twice weekly. From the few surviving cells, 25 random single cell-derived clones were grown for freezing cell stocks, and for DNA isolation for 5-methyldeoxycytidine (5medCyd) estimations. After a minimum of one month's recovery from the drug, these cells showed a continuum of 5medCyd levels ranging from ones with the same as the parental clone (2.93%) to ones having lost almost 50% of their DNA methylation. The modal value corresponded to a loss of one third to one quarter of methylated sites. Five subclones with hypomethylated DNA were grown from the frozen stocks. These cells were shown not to be 5azaCyd-resistant cell variants. By the time sufficient cells had been grown to determine DNA methylation levels, the average percentage of 5medCyd had increased to 76% of the SCC30 value compared to 67% at the time of freezing cell stocks. However, this level of DNA hypomethylation remained constant over two months of continuous culture. Cells of one of these hypomethylated subclones were subjected to a second cycle of 5azaCyd treatment. Six random clones from the survivors showed a further decrease averaging 11% in the level of DNA methylation but, by two months in continuous culture, 5medCyd levels had returned to that present before the second cycle of selection. Hence, cell variants can be readily obtained which have lost some 8-10 million methylated sites (pairs of methylated deoxycytidines), and this loss does not compromise cell viability in in vitro culture. This is consistent with mammalian genomes containing a high level of background methylation in non-essential sites. The usefulness of such single cell-derived clones with stably hypomethylated genomes is discussed in relation to understanding the functions of deoxycytidine methylation in mammalian DNA.

Vincristine neurotoxicity in Charcot-Marie-Tooth syndrome

The case of a patient with Charcot-Marie-Tooth syndrome and diffuse large-cell lymphoma, in whom a severe generalized weakness developed after the intravenous administration of vincristine (2 mg) during combination chemotherapy, is reported. Spontaneous resolution of the severe weakness occurred when teniposide was substituted for vincristine in the chemotherapy regimen.

Biology of cell killing by 1-beta-D-arabinofuranosylcytosine and its relevance to molecular mechanisms of cytotoxicity

Cells of the Chinese hamster ovary cell line were used to study the process of cell death induced by pulse treatment with 1-beta-D-arabinofuranosylcytosine (ara-C). Cells were synchronized by mitotic selection and pulse treated in early S phase with a concentration of ara-C (1 mM) which was sufficient to reduce plating efficiency to a few percentages of the control. The process of when and how the lethally damaged cells die was studied using a series of techniques in parallel. These included time-lapse microcinematography, flow microfluorimetry, and chromosome morphology in both anaphases/telophases and Colcemid-arrested metaphases. Most of the lethally damaged Chinese hamster ovary cells progressed through one, and many through two, cell cycles before death occurred. The cell death and abnormal divisions can be accounted for by the chromosome aberrations observed in Colcemid metaphases and anaphases/telophases. Death without any attempted division occurred between 3 and 9 normal cell cycle times after ara-C treatment. Chinese hamster ovary cells were also treated continuously with 1 mM ara-C. Under these conditions, cell death was still primarily division related. We argue that these data are not consistent with the actual incorporation of ara-C moieties into DNA being the primary cause of cell death. The data are discussed in relation to the postulated molecular mechanisms of toxicity of this drug.

Non-Hodgkin's lymphoma involving the central nervous system

In 44 out of 758 patients (5.8%) with non-Hodgkin's lymphoma presenting between 1971 and 1982, the central nervous system (CNS) was involved. Patients with a diffuse histology had a 7.6% (34/449) incidence of CNS involvement compared to 3.9% (10/257) for patients with nodular lymphoma. In 63% of patients there was evidence of progressive systemic lymphoma at the time of diagnosis of CNS disease and in 23% CNS relapse occurred in clinical remission. Bone marrow was involved in 34% of patients at diagnosis and in 52% at some time prior to the onset of CNS complications. Cerebrospinal fluid cytology was positive in 63% and an elevated protein level was found in 95% of patients. The median length of survival of the 44 patients was only 3.2 months, but patients who responded to treatment of CNS lymphoma survived significantly longer than those who showed no response or progressed on therapy. Complete response to CNS treatment was achieved in five patients, of whom none relapsed in the CNS and two are long-term disease-free survivors. CNS prophylaxis appears justified for patients with lymphoblastic lymphoma, Burkitt's tumour, and diffuse undifferentiated lymphoma, who are at high risk of developing CNS complications. Patients with diffuse histiocytic, and diffuse poorly differentiated lymphocytic, lymphoma who have bone marrow involvement may also benefit from CNS prophylaxis.

Secondary polycythaemia associated with large cell lymphoma

We describe the case of a 53-year-old woman in whom early stage large cell lymphoma appears to be associated with secondary erythrocytosis. A haemogram obtained six months earlier had been normal, but at the time lymphoma was diagnosed, investigations showed haemoglobin 20.5 gm/dl, total red cell count 6 X 10(12)/liter, haematocrit 0.60 liters/liter, whole blood volume 81.1 ml/kg, red cell volume 43.2 ml/kg, and plasma volume 37.8 ml/kg. Other investigations revealed no evidence of any other myeloproliferative disorder, and common causes of tissue hypoxia and other well-known causes of secondary polycythaemia were excluded. Combination chemotherapy employed to treat lymphoma reverted the abnormal blood counts to normal. We believe this to be the first described case of an association of lymphoma and secondary polycythaemia.

Sequence specificity of cytosine methylation in the DNA of the Chinese hamster ovary (CHO-K1) cell line

We have determined the DNA renaturation kinetics for those DNA sequences of the Chinese hamster ovary (CHO-K1) cells in which enzymatic cytosine methylation occurred immediately after strand synthesis and for those in which methylation was delayed after strand synthesis. DNA sequences showing immediate or delayed methylation were found to be distributed throughout all repetition classes of the DNA of these cells, with a slight concentration of immediate methylation in moderately repetitive sequences and with delayed methylation being slightly over-represented in the highly repetitive fraction. However, DNA sequences showing both classes of methylation were represented equally in unique DNA sequences. We interpret these data to mean that the methylase acting near the replication forks (the 'immediate' methylase) is a relatively inefficient enzyme, missing some 20% of hemimethylated sites produced by DNA replication in these cells. We suggest that the methylase performing maintenance methylation at sites remote from the replication forks (the 'delayed' methylase) is simply a back-up enzyme for the first and that it has no true sequence specificity. The implications of this for the function(s) of DNA methylation in mammalian cells are discussed.

Inhibition of normal human macrophage progenitors by retinoic acid

The effects of retinoic acid on the clonal growth in nutrient agar of neutrophil and macrophage progenitors from normal bone marrow and fetal liver were studied. The technique of whole plate fixation and staining with luxol fast blue and haematoxylin was employed to distinguish colonies and clusters into morphological groups. Retinoic acid at a concentration of 3 X 10(-7) M resulted in 97% inhibition of macrophage clonal growth and a mean increase in neutrophil clonal growth from bone marrow of 150 +/- 14%. These effects of retinoic acid were most obvious on bone marrow cluster forming cells. The inhibition of macrophage cluster growth was independent of exogenous colony stimulating factor. This dual action of retinoic acid is likely to be a direct effect on the progenitor cells since it is (1) independent of cell concentration, (2) not mediated by phagocytic cells or other bone marrow cells, and (3) was maximal in the first 2 d of incubation before the appearance of clusters.

Lorazepam: a randomized, double-blind, crossover study of a new antiemetic in patients receiving cytotoxic chemotherapy and prochlorperazine

Lorazepam was compared to placebo to assess its control of nausea and vomiting in patients receiving cytotoxic chemotherapy and prochlorperazine. The study design was a randomized, double-blind crossover in which three consecutive chemotherapy courses were compared so that each patient acted as his or her own control. Of 107 patients entered, 80 were evaluable for analysis. Lorazepam significantly reduced the severity and duration of nausea, the severity of vomiting, and the number of vomiting episodes when compared to placebo. Anxiety was reduced during lorazepam courses but not significantly when compared to placebo. There was significantly more sedation with lorazepam courses. Overall, patients preferred lorazepam courses although this preference was significant only in the patient subset receiving doxorubicin and cyclophosphamide. Lorazepam is a useful adjunct to prochlorperazine in patients receiving cytotoxic chemotherapy.

Blastic transformation of chronic lymphocytic leukemia

A case is described of a patient with chronic lymphocytic leukemia whose disease underwent blastic transformation. The transformed cells had the same immunoglobulin types (mu and kappa) as the original chronic lymphocytic leukemia cells. Immunoperoxidase staining technique demonstrated that, in the transformed cells of the bone marrow, much of the immunoglobulin was intracellular. In the peripheral blood the transformed cells had dense surface immunoglobulin and features of primitive T-cells. These findings suggest that transformation to an immunoblastic type of leukemia had occurred.

Requirements for growth of human erythroid progenitors in nutrient agar

Human erythroid bursts and neutrophil colonies from fetal liver, term cord blood, and adult bone marrow were grown in nutrient agar, and the colonies were scored using a fixed whole plate method. Human placental conditioned medium was shown to contain burst promoting activity, and low oxygen tension markedly enhanced growth of erythroid bursts. Morphological analysis of colonies showed that eosinophil colonies were more numerous in bone marrow than fetal liver and conversely macrophage and neutrophil-macrophage colonies were more numerous in fetal liver. Erythroid bursts were more numerous and larger in fetal liver. Human fetal liver cells do not produce endogenous colony-stimulating factor.

DNA sequences showing a delay in cytosine methylation after replication. Time course of methylation in synchronized mammalian cell populations and relationship to DNAase I sensitive domains

We have shown that in several mammalian cell lines a minor fraction of cytosine methylation is delayed for up to several hours after strand synthesis and that different methylases performed the immediate and the delayed classes of DNA methylation. To investigate the time course of this delayed methylation we have used three different cell lines, two of human and one of hamster origin. These were synchronized by two different methods: mitotic detachment and double hydroxyurea blocks. A uniform picture was obtained with all three cell lines. Delayed methylation of early replicating sequences occurred while cells were still in mid-S-phase, with the maximum rate of delayed methylation occurring in cells in the second half of S and in G2. Delayed methylation seems to be complete before cells entered the next G1-phase. Limited DNAase I hydrolysis of cell nuclei was used to test whether the delay in methylation in some DNA sequences was due to high levels of transcriptional activity. However, DNA sequences exhibiting delayed methylation showed no preferential concentration in or exclusion from DNAase I hypersensitive regions.

Adriamycin combinations as salvage therapy in advanced MOPP-resistant Hodgkin's disease

Thirty one patients with advanced MOPP-resistant Hodgkin's disease were treated with adriamycin, bleomycin, vinca alkaloid and prednisolone (ABVP). Sixteen patients received vinblastine, seven received vincristine and in eight VM26 was substituted for the vinca. Of 28 patients evaluable for response 17 (61%) achieved an objective response with five (18%) complete responders. Response was significantly inferior in patients receiving VM26. Patients with a prolonged interval since previous chemotherapy had a greater chance of complete response (p less than 0.02) as did those with previous complete response to MOPP therapy (p less than 0.05). Response to treatment did not affect overall survival (p = 0.8) although relapse free survival was significantly longer for those achieving complete response (p less than 0.01). The regimen produced minimal gastrointestinal toxicity, but significant myelosuppression. ABVP is a well tolerated salvage therapy in advanced MOPP-resistant Hodgkin's disease.

Aberrant replication of chromosomal DNA segments in CHO cells as a manifestation of a DNA repair system

We have previously demonstrated that transient blocking of DNA synthesis with drugs such as 1-beta-D-arabinofuranosylcytosine results in some segments of the chromosomal DNA being replicated more than once in a single cell cycle. One explanation for this phenomenon might be that it is due to a perturbation of the cellular mechanism which normally controls the process of initiating replication of the chromosomal DNA and which ensures that each DNA segment is normally replicated once only in each cell cycle. To examine an alternative explanation, we have used the Chinese hamster ovary CHO-K1 cell line to test whether UV irradiation induces aberrant double replication of chromosomal DNA segments. We present data which show that UV irradiation induces a linear increase (regression coefficient, 0.996) in aberrant reinitiation of DNA replication in DNA segments replicated earlier in the same cell cycle. This was shown by DNA strands labelled with bromodeoxyuridine (BrdU) being synthesized off 3H-labelled template strands which were themselves synthesized during a [3H]thymidine pulse shortly before the UV irradiation. We suggest that blocked replication forks trigger an emergency response to unreplicated DNA segments in which abnormal origins of replication are used to circumvent this damage. This results in abnormal patterns of DNA replication, and it occurs whether DNA replication forks are blocked metabolically (such as with an inhibitor of DNA polymerase) or physically (as in the case of pyrimidine dimers).

Mantel irradiation for stage I and stage II Hodgkin's disease--results of a 10 year experience

One hundred and thirty patients with Stage I and II supradiaphragmatic Hodgkin's disease treated with mantle irradiation alone at the Peter MacCallum Hospital, Melbourne between 1968-1977 were analysed retrospectively. The median followup was 7.4 years with a minimum of three years. There were 64 clinically staged (CS) and 66 pathologically staged (PS) patients. The major difference between the two groups was the transdiaphragmatic relapse which occurred in 33% of CS patients, and 7.5% in PS patients. The actuarial five year relapse free survival (RFS) was 48% for CS patients and 67% for PS patients, but the five year overall survival was 90% for both groups, reflecting the impact of salvage treatment. Avid attention must be given to radiotherapy techniques to minimise local treatment failures. High grade nodular sclerosis Hodgkin's disease is associated with poor RFS even after adjustment has been made for stage and constitutional symptoms (p less than 0.003). Further studies will be made on this group of patients who may benefit from combined modality treatment. For PS I and II patients mantle irradiation gives a five year RFS of 67%, thus offering potential for cure in these patients.

Effect of several inhibitors of enzymatic DNA methylation on the in vivo methylation of different classes of DNA sequences in a cultured human cell line

We have previously demonstrated that, while most enzymatic formation of 5-methylcytosine in the DNA of mammalian cells occurs very shortly after strand synthesis, there is also a minor fraction of methylation which occurs in some DNA sequences up to at least several hours after strand synthesis. Using a human cell line, we have examined the effects on these two classes of enzymatic DNA methylation of several compounds which have been reported to be inhibitors of methylation reactions. We have found that cycloleucine, ethionine, and 5'-deoxy-5'-methylthioadenosine (MTA) are all effective as inhibitors of enzymatic DNA methylation, but that there is no differential effect between the delayed and non-delayed methylation reactions. Tubericidin (7-deaza-adenosine) plus homocysteine inhibited delayed DNA methylation much more than non-delayed methylation (by up to 4 times). By contrast, 5-azacytidine produced a higher level of inhibition of DNA methylation at sites in the DNA in which the methylation occurred very shortly after strand synthesis. Also 5-azacytidine was by far the most potent inhibitor of DNA methylation of the compounds tested. S-Adenosyl-homocysteine and caffeine were found to have no effect on DNA methylation. These results are discussed in relation to the number and specificity of DNA methylases in these cells and to the cellular functions of those DNA sequences in which methylation is delayed for some hours after strand synthesis.

Relationship between aberrant DNA replication and loss of cell viability in Chinese hamster ovary CHO-K1 cells

We have previously presented evidence that a transient block to DNA replication induces an aberrant form of DNA synthesis. The most feasible explanation for this data is that the block to DNA replication results in some segments of the chromosomal DNA being replicated more than once in a single cell cycle. This form of aberrant DNA synthesis was demonstrated to occur following direct inhibition of DNA replication by 1-beta-D-arabinofuranosylcytosine or 9-beta-D-arabinofuranosyladenine or after indirect inhibition with cycloheximide. We have proposed mechanisms whereby this phenomenon could induce chromosome damage and cell death. In this paper, we present data on the relationship between this aberrant form of DNA replication and the loss of cell viability. Using Chinese hamster ovary CHO-K1 cells growing as monolayer cultures, we have simultaneously monitored the loss of cell viability as measured by colony formation and the relative extent of this aberrant DNA replication induced by 2-hr pulses of a series of concentrations of inhibitors of DNA replication. We have found that, with either direct inhibition of DNA replication with 1 beta-D-arabinofuranosylcytosine or with indirect inhibition, with cycloheximide, pulses of inhibitor administered to Chinese hamster ovary cells at increasing of this aberrant DNA replication which paralleled the increase in cell killing.

Pattern of isoaccepting transfer RNAs common to 26 patients with Hodgkin's disease

The elution profiles of aminoacyl transfer RNAs from Hodgkin's tumors have been compared with the corresponding patterns from normal splenic tissue. Aminohexyl-Sepharose and reversed-phase 5 chromatography have been used in the fractionation studies. Three peaks of acceptor activity have been observed in phenylalanyl, histidyl, aspartyl, and asparaginyl transfer RNAs. A second peak was shown in the case of tyrosyl and methionyl transfer RNAs. Seryl transfer RNA showed no change in elution profile; namely, a single species was observed in both normal and tumor transfer RNAs. These observations are confirmation that Hodgkin's disease is a malignant disease. The uniformity of the extra species of tRNA suggests that there is a commonly occurring aberration in the cell of origin of the Hodgkin's tumor.

Characteristics of enzymatic DNA methylation in cultured cells of human and hamster origin, and the effect of DNA replication inhibition

In mammalian cells, inhibitors of DNA replication have been shown to induce chromosomal aberrations, cell death and changes in gene control. Inhibition of DNA synthesis has been reported to induce hypermethylation of mammalian DNA (enzymatic postsynthetic formation of 5-methylcytosine). These 5-methylcytosines in mammalian DNA have variously been suggested to be important in gene control, DNA repair, and control of DNA replication. In establishing the normal characteristics of enzymatic DNA methylation, we have demonstrated that, in asynchronously growing cells of both human and hamster origin, some cytosine methylation is delayed for several hours after strand synthesis and that this delayed methylation is completed before the DNA strand acts as a template for DNA replication in the next S-phase. Further, in testing whether the deleterious effects on mammalian cells of DNA synthesis inhibitors might be mediated via changes in enzymatic DNA methylation, we have found, contrary to some previous findings, no evidence for any change in the level of DNA methylation in DNA strands synthesized during 6 h of treatment of cells of human origin with high concentrations of four different inhibitors of DNA replication or during the 4 h following the 6 h treatment. Almost totally blocking DNA replication had no effect on the small amount of delayed methylation of DNA strands not involved in semi-conservative replication during the time of the experiment. This lack of effect on DNA methylation was obtained when the labelling medium contained normal, undialysed serum. In contrast, if dialysed serum was used in the labelling medium in order to maximize L-[Me-3H]methionine utilization, highly variable, totally irreproducible patterns of apparent DNA hypermethylation were obtained.

Bone marrow necrosis diagnosed during life: clinical and laboratory features of extensive involvement

Bone marrow necrosis occurred in two patients with non-Hodgkin's lymphoma. One had a four-year history of lymphoma for which he received combination chemotherapy. Severe bone pain, abdominal pain and fever occurred during the terminal part of his illness. The other patient presented initially with symptoms of bone pain and lymphadenopathy. At bone marrow examinations, both had anatomically extensive bone marrow necrosis with associated evidence of involvement by lymphoma. The previously recognized clinical features of bone marrow necrosis and its complications occurred in one or both of these illustrative cases, with the exception that bone tenderness was absent in both. Attempts were made to correlate the technetium-99m sulphur colloid scans with sites of disease as determined by the bone marrow examinations.