A rat model of syngeneic bone marrow transplantation during breast cancer therapy.

The purpose of this study was to develop a breast cancer model in rats, in which myeloablative chemotherapy and syngeneic bone marrow transplantation (SBMT) could be evaluated systematically for therapeutic effect. The Wistar-Furth (WF) DMBA-4 breast cancer cell line transplanted into naive WF rats produced rapidly growing tumors that were lethal within 2 months. SBMT was performed following preparation with a regimen (Bu-Cy), consisting of busulfan 16 mg/kg by gastric gavage on days -3 and -2 followed by 250 mg/kg of cyclophosphamide i.p. on day -1. Marrow was prepared from the femurs of donors and infused i.v. into the recipient on day 0. In all, 15 rats treated with Bu-Cy without marrow died, while 22 of 25 transplanted rats survived. In total, 16 rats with measurable tumors showed tumor responses following transplantation, but tumors recurred and survival was minimally prolonged. Of nine rats transplanted before clinical tumors were detected, five became long-term survivors that resisted further tumor challenge. It was concluded that the DMBA-4 breast cancer in WF rats could serve to evaluate SBMT following myeloablative doses of chemotherapy at various tumor loads. At large tumor loads therapy was not curative, but at low tumor burdens cures were possible and resistance to subsequent tumor challenge was demonstrated. The model may be useful for further studies of stem cell infusion in rodent tumor systems.

Characterization of a reproducible rat model of hepatic veno-occlusive disease.

Lack of a reproducible animal model has hampered progress in understanding hepatic veno-occlusive disease (HVOD). This article characterizes a reproducible model of HVOD. Rats gavaged with monocrotaline, 160 mg/kg, were killed between days 1 and 10. Sections were evaluated by light microscopy with a standardized scoring system, by immunoperoxidase staining with ED-1 (monocytes, macrophages) and ED-2 (Kupffer cells) antibodies, and by transmission (TEM) and scanning electron microscopy (SEM). On days 1 and 2, the earliest manifestations were progressive injury to the sinusoidal wall with loss of sinusoidal lining cells, sinusoidal hemorrhage, and mild damage to central vein (CV) endothelium. On days 3 through 5 ("early HVOD"), there was centrilobular coagulative necrosis, severe injury to sinusoids, severe sinusoidal hemorrhage, and severe CV endothelial damage; inflammation with ED-1-positive cells was most marked on these days. Days 6 and 7 ("late HVOD") were characterized by subendothelial and advential fibrosis of CVs, damage of the CV endothelium with subendothelial hemorrhage, and some restoration of the sinusoidal wall. Between days 8 and 10, sections showed interindividual variation ranging from mild, residual fibrosis to severe, late HVOD. From days 1 through 10, ED-2-positive cells were decreased in number, and the number of ED-1-positive cells was increased. Sinusoidal damage is the earliest change in HVOD. Coagulative necrosis follows sinusoidal injury and resolves with improvement in sinusoidal endothelial cell (SEC) morphology. Moderate-to-severe CV fibrosis occurs after reappearance of sinusoidal lining cells and resolution of hepatocyte necrosis. The inflammatory response within the lobule and CVs is a result of recruitment of monocytes, whereas Kupffer cells are decreased in number.

Marrow and stem cell transplantation in Oklahoma: fifteen years of experience and results.

From September 1982 to August 1997, 767 bone marrow or peripheral blood stem cell transplants have been performed at the Health Sciences Center in Oklahoma. Five hundred and two (502) autologous transplants (AutoTX) preceded by high-dose myeloablative therapy were performed for breast cancer (BC, 36%), non-Hodgkin's lymphomas (NHL, 24%), Hodgkin's disease (HD, 10%), acute myeloid leukemia (AML, 8%), testicular cancer (TC, 4%), multiple myeloma (MM, 2%) and other malignancies (16%). Two hundred and sixty-five (265) allogeneic marrow transplants (AlloTX) (related, unrelated) were carried out in chronic myeloid leukemia (CML, 30%), AML (23%), acute lymphoid leukemia (ALL, 14%), myelodysplastic syndrome (MDS, 9%), severe aplastic anemia (SAA, 8%), and other diseases (14%). Compared between 1980s to 1990s, 100-day mortality rates have decreased from 28% to 5% for AutoTX and from 40% to 25% for AlloTX. In the AutoTX setting, major changes included the routine use of growth factors post-transplant and the switch from bone marrow to growth factor-mobilized peripheral blood as a source of stem cells over the last five years. In the AlloTX setting, improvements in recognition and control of cytomegalovirus and Candida organisms, the selective use of growth factors and screened blood products, and better selection of unrelated donors using DNA-based techniques of HLA-matching have contributed to reduce early mortality from infection and primary graft failure. The five-year survival outcomes are comparable to those reported in registry data from the International Bone Marrow Transplant Registry (IBMTR) and the National Marrow Donor Program (NMDP).

Long-term results of autologous marrow transplantation for relapsed or refractory male or female germ cell tumors.

Twenty-one patients with relapsed or refractory germ cell tumors were treated with high-dose chemotherapy and marrow transplantation (HDC/BMT) from 1982-1993. Primary sites of disease were testis (17), ovary (three), and pineal gland (one). Pathology included dysgerminoma (one), choriocarcinoma with adenocarcinoma (one), seminoma (four), and nonseminoma or mixed germ cell tumor (15). Nineteen had at least two prior chemotherapy regimens and eight had cisplatin-refractory disease defined as progression within 4 weeks of a cycle of cisplatin-based chemotherapy. HDC regimens were mostly combinations of cyclophosphamide with etoposide and cisplatin or carboplatin. There were only two treatment-related deaths (aspergillosis and interstitial pneumonitis). Times to engraftment of granulocytes (21+/-8.3 days) and platelets (32+/-20.2 days) were reasonable with only the last nine patients receiving growth factors. At a minimum of 4 years follow-up, eight patients have died of disease, six of whom were cisplatin-refractory prior to transplant. Eleven patients (52% overall) are alive and continuously free of disease after 4-10 years including one of three with refractory ovarian germ cell tumor. HDC/BMT provides significant long-term disease-free survival as salvage therapy for both male and female relapsed germ cell tumor patients who are not refractory to cisplatin.

High-dose carboplatin, etoposide and cyclophosphamide with autologous bone marrow transplantation for the treatment of advanced malignancies: a phase I study.

Carboplatin is a platinum-derivative widely used in conditioning regimens with ABMT, particularly in combination with cyclophosphamide and etoposide, drugs which co-express synergism in vitro. The objective of this study was to determine the maximum tolerated dose (MTD) of this combination. Thirty-four patients with refractory lymphoid or solid tumors were treated in a dose-escalation study with continuous infusion carboplatin (1.2-2 g/m2) on days -7 to -4, etoposide (1.2-2.4 g/m2) on days -7 to -5 and cyclophosphamide (120 mg/kg) given in two dose schedules: (1) day -3, -2; (2) day -9, -8. Autologous bone marrow or peripheral blood stem cells were infused on day 0. Mucositis/enterocolitis was dose limiting. In addition, severe cardiac dysfunction occurred in schedule 1 but not in schedule 2. Renal dysfunction occurred in the setting of fungemia, respiratory failure and congestive heart failure, and did not correlate with carboplatin dose. Hepatic and pulmonary dysfunction were minimal. The MTD was etoposide 2.1 g/m2 and carboplatin 2.0 g/m2, in combination with cyclophosphamide (120 mg/kg) on schedule 2. Responses were seen in 16 of 19 patients with measurable disease. Seven patients are disease-free survivors 50-60+ months post-ABMT. This study defines the MTD of carboplatin when combined with etoposide and cyclophosphamide in patients with adequate renal function and suggests significant anti-tumor activity.

Long-term survival after autologous bone marrow transplantation for metastatic breast carcinoma.

A phase II study of doxorubicin (Adriamycin)-based induction chemotherapy followed by cyclophosphamide/BCNU (CyBCNU) intensification and autologous bone marrow transplantation (ABMT) was conducted in 20 consecutive women with hormone-resistant metastatic breast cancer referred to our center. Of these 20 women, aged 24 to 56 (median age, 41), 9 had complete remission and 11 had partial remission after induction chemotherapy. Predominant sites of metastases included liver (5), lung (4), bone/bone marrow (5), and soft tissue (6). The dose of cyclophosphamide was 160 mg/kg and the dose of BCNU, 600 mg/m2, followed by infusion of a mean 2.30 x 10(8) nucleated marrow cells per kilogram of body weight. All patients achieved durable engraftment. Three patients remain disease-free at 62+, 67+, and 73+ months; two of these were in complete remission before ABMT. Actual relapse-free survival at 5 years is 15% and median survival from ABMT is 17 months. Induction chemotherapy followed by CyBCNU intensification in metastatic breast cancer can achieve prolonged relapse-free survival in 15% of patients, some of whom may be cured.

Autologous bone marrow transplantation for metastatic breast cancer.

UNLABELLED: Metastatic breast cancer accounts for 18% of cancer deaths among women in the U.S. Conventional combination chemotherapy produces responses in 50% to 80% of women with metastatic breast cancer, but is never curative. A major medical center administered high-dose chemotherapy and autologous bone marrow transplantation to 68 women with metastatic breast cancer between 1983 and 1993. Forty-nine of these women had estrogen receptor-negative tumors, a poor prognostic sign. Eighteen women with estrogen receptor-positive tumors had failed prior hormonal manipulation or had metastatic breast cancer at initial diagnosis. Prior to transplantation, 37 women were in first complete or partial remission, 8 were in their second complete or partial remission, 4 had stable disease, 14 had progressive disease, and 5 were in untreated relapse. Bone marrow transplantation preparatory regimens included high doses of single agents or combination chemotherapy. Among women not in remission before transplantation, 71% entered a partial or complete remission following transplantation. Overall, 29 women (43%) were in complete remission after marrow transplantation. Twelve women (18% overall) remain free of disease between 2 and 73+ months post-ABMT. Those in first complete or partial remission prior to transplant (37 patients) had a higher response rate (86%) and higher complete responses (62%), and 10 (27%) are free of disease. There were nine treatment-related deaths (13%). Forty-seven patients (69%) have died from breast cancer following autologous transplantation. Relapses occurred primarily at sites of previous disease. All relapses have occurred within 22 months of ABMT. CONCLUSION: Autologous bone marrow transplantation for metastatic breast cancer in first complete or partial remission has produced a 27% disease-free survival. This therapy should be considered for selected patients with metastatic breast cancer.

Autologous bone marrow transplantation for non-Hodgkin lymphoma.

UNLABELLED: Non-Hodgkin lymphomas (NHLs) are a group of malignant disorders that can be cured with chemotherapy and/or radiotherapy in 30% to 50% of cases. For those who fail initial therapy, cure is rarely achieved with standard dose chemotherapy; therefore higher doses of chemotherapy have been used with autologous bone marrow support. This major medical center has performed 74 autologous bone marrow transplants (ABMT) for patients with non-Hodgkin lymphoma who had failed initial therapy between 1984 and 1993. Preparatory regimens included high doses of chemotherapy with or without radiotherapy. There were 14 patients with low grade, 41 with intermediate grade, and 18 with high grade histologies. Among patients with low grade histologies, 90% responded and 50% are relapse-free between 1 and 33 months post-ABMT. Among patients with intermediate and high grade histologies, 25% are relapse-free between 2 and 80 months post-ABMT. CONCLUSION: Autologous bone marrow transplantation is effective in patients with relapsed non-Hodgkin lymphoma and should be considered an important therapeutic option.

Allogeneic bone marrow transplantation: experience with 92 patients.

Allogeneic bone marrow transplantation (BMT) is potentially curative therapy for leukemia, lymphoma, and marrow failure. Ninety-two patients have received allogeneic BMT at Oklahoma Memorial Hospital in the past 10 years. Patients with acute myelogenous leukemia (AML; N = 30), chronic myelogenous leukemia (CML; N = 27), acute lymphoblastic leukemia (ALL; N = 12), myelodysplastic syndromes (MDS; N = 8), lymphomas (N = 8), and aplastic anemia (N = 7) were treated with a variety of myeloablative preparative regimens. The major causes of mortality were bacterial, viral, and fungal infections, or disease relapse. Standard and high risk (refractory or multiply-relapsed disease) AML, CML, and ALL patients had median survivals of 14.5 months vs. 3 months, > 18 months vs. 9 months, and 10 months vs. 4.5 months (p = 0.01), respectively. At 7.5 years median follow-up, 71% of the aplastic anemia patients are disease-free. Guidelines for the optimal time for BMT have been developed that encourage transplantation earlier in the course of the disease, thus facilitating better outcomes with these otherwise fatal disorders.

Thrombocytopoiesis in normal and sublethally irradiated dogs: response to human interleukin-6.

The response of megakaryocytes and platelets to the administration of recombinant human interleukin-6 (IL-6) was investigated in normal and sublethally irradiated dogs. IL-6 was administered for 2 weeks at doses of 10 to 160 micrograms/kg/d to normal animals to assess dose-response and toxicity. Subsequently, 40, 80, or 160 micrograms/kg/d for 2 weeks was administered to animals treated with 200 cG total body irradiation. Analysis of normal dogs showed a significant increment in the platelet count detectable approximately 11 days after initiation of IL-6 at all administered doses. Large platelets greater than 6.3 microns in diameter were observed 1 day after beginning IL-6, progressively increasing to as many as 19.1% of the total circulating platelets by day 10. The ploidy distribution of the marrow megakaryocytes did not differ from the normal at doses of less than or equal to 80 micrograms/kg/d, but at 160 micrograms/kg/d, a shift toward higher ploidy cells was noted. No change in total white count was noted; however, a decrease in hematocrit was seen at all doses. In the irradiated animals, the platelet count recovered earlier in the IL-6-treated dogs than in the controls, but no consistent change in the ploidy distribution was observed irrespective of dose. Large platelets were also noted in the treated animals, comprising up to 6.9% of the total platelet count. Fibrinogen levels were elevated to greater than 4 times normal. A significant decrease in hematocrit was seen in all animals, while no consistent change was noted in the white count. Elevations in serum cholesterol, triglycerides, and alkaline phosphatase, together with a decline in serum albumin were observed in all the treated animals (both normal and irradiated), but clinical symptoms were observed only in the dogs receiving greater than or equal to 80 micrograms/kg/d. The data show that IL-6 alone is capable of enhancing platelet recovery in dogs with bone marrow suppression.

A canine model for hepatic venoocclusive disease.

Hepatic venoocclusive disease is a frequent lethal complication of bone marrow transplantation. It has also been associated with hepatic irradiation and administration of chemotherapeutic agents without BMT. The pathogenesis and therapy of VOD are unclear. The present studies were directed at developing a canine model for VOD. Three groups of dogs were studied. Group one consisted of 8 dogs in which monocrotaline (MC) was administered at 125 mg/kg orally on an intermittent schedule. In 7 of the 8 dogs 6 to 9 doses of drug were administered between 42 and 110 days. Group 2 consisted of 6 dogs receiving busulfan 2 mg/kg/day for 17-25 days, when platelet counts decreased to less than 5 x 10(4)/mm3 or clinical bleeding occurred. Group 3 consisted of 2 dogs receiving 24 Gy and 4 dogs receiving 36 Gy of whole-liver irradiation. Seven of 8 dogs in group 1 developed significant liver function abnormalities and evidence of portal hypertension. Histologic findings of VOD were present at autopsy. Group 2 dogs failed to develop clinical or laboratory liver abnormalities, but 3 of 6 animals had minimal histologic evidence of VOD. Three of 6 dogs in group 3 receiving 36 Gy developed hepatic dysfunction and had findings of fibrosis at autopsy. It was concluded that MC administration produced consistent clinical and histologic features of VOD in dogs. Changes occurring after busulfan or total-liver irradiation administration were less reproducible. Dogs are a suitable large-animal model for studies of VOD.

Synergistic effects of vinblastine and recombinant interferon-beta on renal tumor cell lines.

Potential synergistic interactions between vinblastine (VBL) and recombinant interferon-beta (rIFN-beta) were assessed using median effect analysis. Calculation of the combination index demonstrated values less than 1 (indicating synergy) over a wide range of drug-induced growth inhibition for each of four different renal carcinoma cell lines (RCC). The degree of synergy observed could not be predicted from the morphology, doubling time, or relative sensitivity of the RCC lines to VBL and rIFN-beta. The optimal ratio of VBL to rIFN-beta in the combination appeared to be close to the ratio of the concentrations of each agent which yielded a 50% inhibition of growth. Although simultaneous presence of VBL and rIFN-beta in the culture medium was not required to demonstrate a synergistic effect, the minimum exposure time for rIFN-beta was determined to be 7 days. The uptake but not the egress of tritiated VBL into RCC cells was enhanced after growth for 4 days in 2.25 ng/ml of rIFN-beta. Median effect analysis can be shown to be independent of the mechanism of action of VBL and rIFN-beta and gives an indication of potential synergistic interactions over a wide range of drug effects. This method may prove useful in the selection of combinations of IFNs and antitumor drugs for clinical study.

Comparison of etoposide and cisplatin with bis-chloro-ethylnitrosourea, thiotepa, vincristine, and cyclophosphamide for salvage treatment in small cell lung cancer. A Southwest Oncology Group Study.

Small cell lung cancer patients who failed primary systemic therapy or who failed after response were randomly assigned to salvage treatment with etoposide (VP-16) and cisplatin (CDDP) or bis-chloro-ethylnitrosourea, thiotepa, vincristine, and cyclophosphamide (BTOC). Good risk patients were those who had tolerated prior chemotherapy well, those who had not had prior radiation therapy, and those who were 65 years of age or younger. Patients with a history of poor tolerance, prior radiation therapy, or those who were older than 65 years of age were classified as poor risk. Forty-five patients were randomized to the BTOC regimen and 58 to the VP-16/CDDP regimen. The overall remission rate was 13% (13 of 103 patients). Good risk patients treated with the BTOC regimen had a remission rate of 27% (three of 11 patients), which was the same rate as patients treated with the VP-16/CDDP regimen (three of 11 patients). Poor risk patients had remission rates of 9% (three of 34 patients) with the BTOC regimen and 9% (four of 47 patients) with the VP-16/CDDP regimen. The median survival time from the start of therapy was 16 weeks for all patients. BTOC good risk patients had a median survival time of 10 weeks, as compared with 14 weeks for poor risk patients. VP-16/CDDP good risk patients had a median survival time of 35 weeks, as compared with 12 weeks for poor risk patients. Although based on small numbers, the advantage in survival time for good risk patients treated with VP-16/CDDP over those treated with BTOC is statistically significant. Prior exposure to VP-16 did not influence the outcome of patients treated with VP-16/CDDP. Both regimens produced moderate toxicity, but were generally well tolerated. It was concluded that VP-16/CDDP may be a useful salvage treatment for good risk patients, despite its limited remission rate. Also, it was found that BTOC has no value for patients in this setting and that neither regimen helps patients who are poor risk.

Analysis of early infectious complications after autologous bone marrow transplantation.

We reviewed the hospital course of 35 patients who underwent autologous bone marrow transplantation. Fever and profound neutropenia developed in all. Microbiologically confirmed infection developed in 22 patients, and unconfirmed but clinically evident infection developed in six. A bacterial infection developed in 21 patients (most commonly bacteremia without a detectable focus). Mucocutaneous fungal (12 patients) and viral (13 patients) infections were common, whereas invasive fungal (two patients) and viral (one patient) infections were uncommon. New pulmonary infiltrates developed in seven patients. Six deaths occurred during the initial hospitalization for transplantation, only one of which was directly attributable to infection. Stepwise logistic regression analysis retained male gender, total body irradiation, administration of trimethoprim/sulfamethoxazole, and development of mucositis or diarrhea as predictors of decreased survival, whereas higher pretreatment albumin levels and the administration of oral nonabsorbable antifungals were associated with an increased likelihood of survival. A comparison of these infectious complications with those found in allogeneic bone marrow transplant recipients shows similarities and differences with potentially important implications for patient management.

High-dose combination alkylating agent therapy with autologous bone marrow rescue for refractory solid tumors.

Twenty-six adults, ages 27 to 60, with refractory metastatic solid tumors were treated with high-dose cyclophosphamide (Cy) + carmustine (BCNU) at one of three escalating dose schedules followed by autologous bone marrow transplantation (ABMT). Toxicity was severe and dose-related, with the maximum tolerated dose for the combination determined to be Cy 160 mg/kg and BCNU 900 mg/m2. Median time to WBC recovery (greater than or equal to 1,000/microL) was 13 days post-ABMT (range, nine to 22 days) and to a platelet count of greater than or equal to 50,000/microL, 22 days (range, 13 to 83 days). Sixteen of 20 evaluable patients (80%) responded to therapy with at least 50% reduction in measurable tumor, and three patients achieved complete remission (CR). Responders included eight of nine evaluable patients with breast carcinoma, two of five with melanoma, two of two with sarcoma, and four of four with colon carcinoma. Response durations were short (median, 4 months), even for complete responders, and relapses generally occurred at sites of previous metastases. In order for this approach to have a more significant impact on overall survival, it may need to be applied earlier in the natural history of the malignancy.

A phase II trial of vinblastine in patients with advanced or recurrent endometrial carcinoma. A Southwest Oncology Group Study.

Forty-one patients with advanced or recurrent endometrial carcinoma no longer amenable to control with surgery and/or radiotherapy were entered into study. Five of these were ineligible for study. One eligible patient never received any treatment, another had no baseline information recorded; these were thus inevaluable. The remaining 34 patients received continuous infusion vinblastine (1.5 mg/m2) as a 24-h infusion daily for 5 days every 3 weeks. One complete and 3 partial responses were observed among these 34 patients, for an overall objective response rate of 12%. Two of these 4 responders are deceased, and 2 remain alive with disease at 18 and 22 months, respectively. The most common toxicity noted was leukopenia in 22 patients (65%); 12 (35%) of these had severe or life-threatening leukopenia (less than 2,000 WBC/microliter). Fourteen of the 34 (41%) experienced nausea and vomiting. Other adverse effects were less common. Overall, 15 of the 34 patients (44%) experienced severe or life-threatening toxicity. In this trial, continuous infusion vinblastine was toxic and had minimal to moderate efficacy at best. These facts suggest that the drug at the dose and schedule tested has no role in the management of advanced or recurrent endometrial carcinoma.

Phase II evaluation of bisantrene hydrochloride in refractory malignant melanoma. A Southwest Oncology Group Study.

Patients with a pathologically proven diagnosis of malignant melanoma were entered into a phase II trial of bisantrene. Eligibility criteria included: measurable, metastatic disease; performance status 0-2 SWOG; and adriamycin total cumulative dose of less than 400 mg/m2. The initial bisantrene dosing schedule was 260 mg/m2 every three weeks for good risk patients. Due to the absence of an objective response and the lack of severe toxicity in the first 25 bisantrene treated patients, the starting dose was increased to 300 mg/m2 for good risk patients. Fifty-one patients received a median of two bisantrene courses (range 1-11 courses). Leukopenia was the major toxicity. Fifteen (68%) of the 22 good risk, intermediate dose patients (260 mg/m2), and 8 (80%) of the 10 good risk, high dose patients (300 mg/m2) evaluable for toxicity experienced mild-severe leukopenia. None of the 51 patients experienced a complete or partial response to bisantrene. Median survival was 3.3 months. We conclude that bisantrene is ineffective in the treatment of metastatic melanoma.

Radiation-induced hemopoietic death in mice as a function of photon energy and dose rate.

Radiation-induced hemopoietic death was measured in mice exposed to photons of four different energies: 250-kVp X rays, 60Co gamma rays (1.25 MeV), and 6- and 25-MV photons from a linear accelerator. For each radiation source, the lethal dose which killed 50% of the population in 30 days (LD50/30) associated with the hemopoietic syndrome was determined in groups of mice exposed to graded doses from 600 to 1150 cGy at dose rates of 20, 40, and 80 cGy/min. The calculated LD50/30 values for 25 and 6 MV were significantly different from each other at all exposure rates while no difference was observed between 6 MV and 60Co. Using 60Co gamma rays as the standard, the relative biologic effectiveness was as follows: 250 kVp greater than 25 MV greater than 6 MV = 60Co. The data suggest that there may be a greater damage to tissue within the marrow cavities following exposure to very high megavoltage radiation, a factor which must be considered with the increasing utilization of linear accelerators in the clinic and laboratory.