Identification of megakaryocyte precursors in peripheral blood stem cell collections from normal donors.

Platelet engraftment, the time course and magnitude of platelet recovery (PR) post-transplant, is imprecisely defined but is most often reported as the time to transfusion (tx) independence and/or a platelet count > or = 20,000/microl. While correlations between engraftment time for granulocytes (PMN) and the dose of CD34-positive cells per kilogram are established, such associations have not been established for platelet engraftment. The objective of this study was to quantify subpopulations of CD34-positive cells in peripheral blood stem cell (PBSC) collections of normal, colony-stimulating factor-granulocyte) (G-CSF) primed donors that might represent megakaryocyte (MK) precursors, and to determine whether there is a statistical association between the dose transfused and the time course of the recovery. Based on previously published data of the sequential expression of CD34, HLA-DR, and CD61, among others, during MK maturation, a combination of corresponding antibodies for the detection of various antigen coexpressions by flow cytometry fluorescence-activated cell sorting [FACS] was chosen. CD34-positive cells were further subdivided into CD34++ (bright) and + (dim). Ploidy of density-gradient separated cells was examined in subsequent donor samples by FACS. For the entire group of patients, there was no strong correlation between any of the studied subpopulations and time to PR. Only in a selected groups of patients whose platelet counts showed a sustained increase during the first 6 days after engraftment, there was a weak correlation between the time to PR and the quantity of CD34+/+CD61+ (r = -0.57) and CD34++HLA-DR-CD61+ (r = -0.62) cells infused. The magnitude of platelet production in these pt., a product of the peripheral blood platelet count and the patient's blood volume, was correlated with the time to PR (r = -0.73). We conclude from this study that subpopulations within CD34+ cells are making some contribution to PR in allogeneic peripheral blood stem cell transplantation, but the correlations are not sufficiently strong because there are probably too many unpredictable and unknown variables in the allogeneic setting that influence the pattern of engraftment.

Treatment of neutropenia-related fungal infections with granulocyte colony-stimulating factor-elicited white blood cell transfusions: a pilot study.

Neutropenia-related fungal infections can be life-threatening despite antifungal therapy. We evaluated the role of recombinant granulocyte colony-stimulating factor (rG-CSF)-elicited white blood cell (WBC) transfusions in patients with neutropenia-related fungal infections. Adult patients with hematologic malignancies, absolute neutrophil counts (ANC) <500/microl and fungal infections refractory to amphotericin B, received daily transfusions of rG-CSF-elicited and irradiated WBC transfusions from related donors. Donors received 5 microg/kg/day of rG-CSF subcutaneously. Donors achieved a mean ANC of 29.4 x 10(3) per microliter. The mean yield of neutrophils per transfusion was 41 x 10(9) (range, 10-116). Fifteen patients received a median of eight transfusions (range, 3-16). Fourteen patients had received rG-CSF for a median of 12 days. The median ANC baseline was 20/microl. Eleven patients had favorable responses and eight of them remained free of infection 3 weeks after therapy. Favorable responses occurred among patients with better Zubrod performance status (median, 3 vs 4) and shorter duration of both profound neutropenia (median, 15 vs 25 days) and active infection (median, 8 vs 17 days). The mean 1- and 24-h post-transfusion ANCs were 594/microl (range, 98-1472/microl) and 396/microl (range, 50-1475/microl), respectively. Adverse reactions were observed in nine of 35 donors and in the recipients of six of 130 transfusions. rG-CSF-elicited WBC transfusions may be a safe and promising approach for treating neutropenia-related fungal infections.

Splenectomy in the accelerated or blastic phase of chronic myelogenous leukemia: a single-institution, 25-year experience.

BACKGROUND: Patients in the accelerated or blastic phases of chronic myelogenous leukemia (CML) often have painful splenomegaly and secondary thrombocytopenia. We tested the hypothesis that splenectomy can be performed with minimal complications in advanced CML, thereby alleviating pain, reversing thrombocytopenia, and minimizing transfusion requirements. METHODS: We reviewed the records of 53 patients in the accelerated or blastic phases of CML who underwent splenectomy between 1970 and 1995 at the U. T. M. D. Anderson Cancer Center. RESULTS: Twenty-eight patients were in accelerated phase and 25 in blastic phase at the time of splenectomy. The most common indications for splenectomy were symptomatic splenomegaly (median splenic weight, 1000 gm; range, 120 to 6700 gm) or thrombocytopenia (platelet count less than 100,000/microliter) or both. There was 1 death within 30 days of splenectomy. The preoperative platelet count increased 3.72-fold +/- 0.53-fold (mean +/- SEM) by postoperative day 7 (p < 0.001; paired t test). Patients with transfusion-dependent thrombocytopenia had significantly fewer platelet and red blood cell transfusions in the 6 months after splenectomy than in the 6 months before splenectomy (p = 0.016; sign test). CONCLUSIONS: Splenectomy can be performed with minimal morbidity and mortality in advanced CML, thereby relieving symptomatic splenomegaly, reversing thrombocytopenia, and minimizing transfusion requirements.

Effects of in vitro and in vivo cytokine treatment, leucapheresis and irradiation on the function of human neutrophils: implications for white blood cell transfusion therapy.

Treatment of human polymorphonuclear leucocytes (PMNL) separated by density sedimentation (DS) from normal donors (PMNL-NL-DS) with interferon-gamma (IFN-gamma) + granulocyte colony-stimulating factor (G-CSF) lessens the damage caused by isolation and irradiation. We have studied granulocyte-macrophage colony-stimulating factor (GM-CSF) in this system, as well as the behaviour of PMNL collected by continuous flow leucapheresis (CFL) from donors treated with G-CSF (PMNL-GCSF-CFL). After isolation, PMNLs were treated with IFN-gamma + G-CSF, GM-CSF or IFN-gamma + G-CSF + GM-CSF, irradiated with 0 or 30 Gy and studied after 0 and 20 h in cell culture. All regimens reduced apoptosis of PMNL-NL-DS. Killing of Candida albicans by 20-h-old PMNL-NL-DS was best preserved by IFN-gamma + G-CSF treatment. A similar pattern of results was obtained for assays of PMNL-NL-DS chemotaxis and superoxide production. There was a consistent trend toward reduced function after irradiation in all assays. PMNL-GCSF-CFL less often demonstrated the morphological features of apoptosis, and this was further reduced by cytokine regimens containing IFN-gamma + G-CSF. In assays of C. albicans killing and chemotaxis, 20-h-old untreated PMNL-GCSF-CFL performed as well as freshly isolated PMNL-GCSF-CFL. PMNL-GCSF-CFL showed decay in CD11b (CR3), CD16 (Fc gamma III) and CD64 (Fc gamma R1) expression after 20 h in cell culture, but treatment with IFN-gamma + G-CSF preserved expression. There was a trend toward reduced function after radiation. Comparison of PMNL-GCSF separated by CFL and DS demonstrated that CFL itself is a strong inducer of the morphological features of apoptosis. This study shows that while separation by CFL, and irradiation are damaging to PMNLs, damage may be reduced by use of cytokines.

Invasive Aspergillus sinusitis during bone marrow transplantation.

Aspergillus sinusitis is usually a lethal condition in bone marrow transplanted patients. We report the case of a patient known to have a sinus infection with Aspergillus flavus before treatment with allogenic bone marrow transplantation for a refractory acute myelogenous leukemia. Exacerbation of the sinusitis during the neutropenic period required a multidisciplinary approach. Cure was achieved after treatment with a combination of surgery (Caldwell-Luc procedure), long term ABCD (amphotericin B colloidal dispersion) therapy (7 months) and granulocyte transfusions during the period preceding engraftment. The use of granulocyte transfusion in this salvage setting is discussed. Aggressive multimodality management of aspergillus sinusitis in immunosuppressed patients may lead to a cure and might not preclude allogenic transplantation.

Photopheresis therapy for cutaneous T-cell lymphoma.

BACKGROUND: Cutaneous T-cell lymphoma is a chronic peripheral lymphoma in which aggressive combined therapy elicits high response rates but does not improve survival. Photopheresis therapy has reportedly induced remissions and prolonged survival in patients with advanced disease. OBJECTIVE: We studied all patients who began photopheresis treatment between February 1988 and July 1994 to determine whether we could confirm the remission rates of previous studies, to evaluate variables that might predict a response, and to discover whether an accelerated delivery system would improve the remission rate or response time. METHODS: After an oral dose of methoxsalen was administered, a leukocyte-enhanced quantity of blood was exposed to UVA radiation for 1.5 hours and returned to the patient. With our accelerated system, 6 x 10(9) cells were irradiated in nine cycles. Treatments were given on 2 consecutive days once a month. RESULTS: Among 34 patients whose results could be evaluated, the overall response rate (complete and partial remissions) was 50%; most patients had mild side effects. All responders except one had erythroderma. Responders had a decrease of 75% in mean skin scores, whereas nonresponders had an increase of 21%. CONCLUSION: Photopheresis appears to be effective for selected patients with erythrodermic cutaneous T-cell lymphoma, although we did not achieve as high a remission rate as previously reported by others.

Results with high-dose chemotherapy and unpurged autologous stem cell transplantation in 73 patients with chronic myelogenous leukemia: the MD Anderson experience.

The purpose of this study was to evaluate the effectiveness of unpurged autologous stem cell transplantation (ASCT) for chronic myelogenous leukemia (CML) and its impact on the survival of patients in first and late chronic phase (CML-CP) including those resistant to or unable to tolerate interferon alfa (IFN-alpha) therapy. Between 1982 and 1993, 73 patients with CML who underwent ASCT were evaluated. Twenty-eight patients had signs of transformation, 20 were in second or subsequent CP, 22 had CML-CP and had shown resistance to or were unable to tolerate IFN-alpha therapy, and there had Philadelphia (Ph) chromosome-negative CML. Survival of patients in CML-CP who underwent ASCT was compared to controls who were in first CP receiving INF-a therapy. Patients and controls were matched for age, decade of therapy, response to IFN-alpha therapy (resistance vs toxicity) and the time to ASCT (study group) vs time to resistance (control group). Nine 12% patients failed to achieve hematologic recovery, and five (7%) had early death secondary to toxicity. Twenty-seven (58%) patients who received transplants in advanced-stage CML and 18 (82%) transplanted in CML-CP achieved complete hematologic remission (CHR). The incidence of complete cytogenetic response was 10 and 14%, respectively. The median survival of these two groups of patients was 5 and 34 months, respectively (P < 0.001). However, the survival of patients in CML-CP was not significantly different from controls (34 vs 49 months; P = 0.17). We conclude that unpurged ASCT does not prolong the survival of patients in CML-CP who are resistant to IFN-alpha therapy. Progress in autotransplantation in CML might require innovative approaches to eradicate the leukemic cells from the autologous stem cells prior to transplants.

Principles of bone marrow processing and progenitor cell/mononuclear cell concentrate collection in a continuous flow blood cell separation system.

The application of continuous flow apheresis technology to processing bone marrow for collection of the mononuclear progenitor cell population appears to follow the same principles as collection of mononuclear cells from peripheral blood. Unlike peripheral blood, however, where mobilization of cells from extravascular sites during the procedures contributes significantly to the final cell yield, the entire quantity of progenitor cells available for recovery from marrow is present in the original marrow when it is pooled. The process then becomes one of attempting optimal recovery of the cells of interest while excluding contaminating erythrocytes and cells of the myeloid series. This study reports the development of a protocol for recovery of MNC, CD33+, CD34+, and CD34+/DR- cells from harvested marrow for autologous and allogeneic transplants using a continuous flow blood cell separator, the variables influencing the recovery of the cells of interest and the clinical response to infusion of the processed cells.

Protection of human polymorphonuclear leukocyte function from the deleterious effects of isolation, irradiation, and storage by interferon-gamma and granulocyte-colony-stimulating factor.

BACKGROUND: Fungal infections represent a difficult challenge to clinicians caring for neutropenic patients with hematologic malignancies, as antifungal therapy often has limited success in that setting. One promising yet problematic alternative approach is leukocyte transfusion. The isolation of polymorphonuclear leukocytes (PMNs) induces apoptosis and functional deterioration, and irradiation to prevent transfusion-associated graft-versus-host disease causes further functional deterioration. STUDY DESIGN AND METHODS: The ability of interferon-gamma and granulocyte-colony-stimulating factor (G-CSF), used both alone and in combination, to protect PMNs after 0 or 20 hours' storage in cell culture (as a model for function after transfusion) and irradiation with 0, 5, or 30 Gy was studied. RESULTS: Without cytokine treatment, 20-hour-old PMNs showed marked apoptosis, no appreciable chemotaxis, and no ability to kill Candida albicans. In contrast, cytokine treatment significantly reduced apoptosis and protected chemotaxis, C. albicans killing, and surface-receptor expression from both storage and irradiation. Although the majority of the benefit appeared to be due to G-CSF, consistent trends suggested better function of PMNs after combined treatment with interferon-gamma and G-CSF. CONCLUSION: Judicious use of cytokines may preserve PMN function. These findings have important implications for the transfusion of PMNs to cytopenic patients.

Collection and transfusion of granulocyte concentrates from donors primed with granulocyte stimulating factor and response of myelosuppressed patients with established infection.

Fifteen patients with prolonged neutropenia (a median of 23 days with granulocyte [PMN] < or = 500/microliters) and established fungal infections that had not responded to adequate antifungal therapy were transfused with PMN concentrates collected from 35 cytokine-primed granulocyte colony-stimulating factor (GCSF) donors. Patients received a median of six transfusions. Leukocytosis and granulocytosis were observed within 24 hours of the first GCSF injection, which yielded concentrates averaging 55 x 10(9) white blood cells and 41 x 10(9) PMN. Data analysis suggested that response might be related to the duration of neutropenia and known infection, as patients given PMN tx earlier in the infectious course tended to have a better response. No significant toxicity was observed in donors.

Abnormalities of von Willebrand factor multimers in drug-associated thrombotic microangiopathies.

Six patients with thrombotic microangiopathy associated with drug therapy had serial analyses of von Willebrand factor (vWF) multimeric patterns in their EDTA-plasma samples by sodium dodecyl sulfate-1% agarose gel electrophoresis and autoradiography. In the plasma of five patients (one with chronic myelogenous leukemia, two with prostatic cancer, and two with lymphoma), vWF abnormalities were observed during evolution of the thrombotic microangiopathy. These abnormalities were either the presence of unusually large (UL)vWF multimers of the type similar to those found within, and released or secreted by, endothelial cells (three patients) or a relative decrease in the largest plasma vWF multimers of the type that can be induced to attach to platelets (one patient) or both vWF abnormalities in different serial samples (one patient). In the one cardiac transplant patient who did not develop vWF multimeric abnormalities associated with thrombotic microangiopathy, vWF antigen levels were elevated more than threefold. This later individual received therapy with cyclosporin A alone. The other five thrombotic microangiopathy patients received cyclosporin A in combination with other chemotherapeutic agents (two patients); mitomycin-C, along with other chemotherapy (two patients); or multiple chemotherapeutic drugs, but not cyclosporin A or mitomycin C (one patient). The finding of vWF multimeric abnormalities during serial analysis of plasma samples from five of six patients with drug-associated thrombotic microangiopathy suggests the possibility that ULvWF forms derived from damaged or stimulated endothelial cells, along with the largest plasma vWF multimers, may be involved in the intravascular platelet clumping that is an essential part of the pathophysiology of this disorder.

Depletion of patients' plasma tryptophan using tryptophan side-chain oxidase columns.

The use of the enzyme tryptophan side-chain oxidase, isolated from Pseudomonas XA, was explored in 3 patients with refractory acute lymphocytic leukemia. Patients were given either a low-tryptophan diet or tryptophan-free hyperalimentation, prior to and during therapy. Their plasma, separated by pheresis, was continuously passed through a tryptophan depletion column containing the immobilized tryptophan side-chain oxidase. Up to 4 plasma volumes were passed through the column daily, 5 days per week for 2-3 weeks, and plasma tryptophan levels, both free and total, were measured by high-performance liquid chromatography. Pre- and postcolumn plasma samples were collected throughout the pheresis procedure. All postcolumn plasma samples had unmeasurable tryptophan levels throughout the treatment period, whereas precolumn samples were always measurable. Generally, tryptophan levels of plasma isolated from peripheral blood decreased after therapy, but rebounded by the next day. The enzyme depletion column reduces circulating plasma tryptophan levels, and its use is well tolerated by patients. However, further development of this method will require study of the effects of diet and of the duration, interval, and frequency of use of this column on therapeutic efficacy. Problems include difficulties with extended diet compliance and apparently intensive mobilization of tryptophan from body stores, which may preclude the clinical application of this enzyme depletion column.

Peripheral blood stem cell transplantation for breast cancer patients with bone marrow metastases using GM-CSF priming.

Twenty-seven patients with metastastic breast cancer to the bone marrow underwent successful collection of peripheral blood progenitor cells (PBPC) following GM-CSF cytokine priming and were engrafted following courses of high-dose chemotherapy. Myeloid engraftment was observed in a median of 12 days, with a range of 8-29 days. The cell dose infused correlated, although weakly, with days to engraftment, although assays of CFU-GM and CD34+ cells did not, suggesting refinement in such assays is needed. The failure to observe complete remission of the tumor suggests alternative chemotherapy regimens should be investigated.

Tumor necrosis factor and c-fos expression in human peripheral-blood monocytes: expression is dependent on stage of in vitro differentiation.

The differentiation of monocytes and macrophages both in vitro and in vivo can be characterized by the modulation of specific functional and molecular phenotypes. We have determined in human peripheral-blood monocytes (HPBM) the role of in vitro differentiation on the expression of nonspecific tumoricidal activity, induction of soluble tumor necrosis factor (TNF) activity and TNF-specific mRNA transcription. HPBM were activatable by bacterial lipopolysaccharide (LPS; 1 microgram/ml) for nonspecific cytotoxicity to A375M (human malignant melanoma cell line) only during the first 24 h of in vitro differentiation. Activated supernatants of HPBM were found to be partially neutralizable (75 +/- 7%) by rabbit polyclonal anti-TNF antibody and, in freshly isolated HPBM, the release of soluble TNF activity determined by the L929 assay was found to occur only after activation with LPS. Maximal TNF release occurred at 8 h of LPS stimulation, and required both protein and RNA synthesis as evidenced by the ability of both actinomycin D and cycloheximide to inhibit its release. Neither control untreated HPBM nor recombinant interferon-gamma (rIFN-gamma; 1 U/ml)-treated HPBM alone released soluble TNF activity. Further in vitro culture determined that HPBM were activatable for TNF release out to 72 h of culture after which HPBM became resistant to LPS-mediated TNF release. The expression of TNF and c-fos mRNA was also determined during in vitro differentiation. Both TNF and c-fos mRNA were expressed in freshly isolated HPBM, and returned to baseline by 24 h of in vitro culture. Treatment of HPBM with LPS induced TNF transcription as late as 5 days of in vitro culture with maximal induction occurring during the first 48 h. rIFN-gamma significantly induced TNF transcription at 24 h in the absence of soluble TNF activity, but did not increase transcription at later times. The expression of nonspecific cytolytic activity, the release of soluble bioactive TNF and the induction of TNF and c-fos mRNA are regulated in HPBM by differentiation-determined processes.

Effect of retinoids on the release and gene expression of tumor necrosis factor-alpha in human peripheral blood monocytes.

The effect of retinoic acid (RA) and retinol (ROH) on the release of tumor necrosis factor (TNF) by human peripheral blood monocytes (HPBM) was determined. HPBM were cultured for various periods of time in either 5% complete (cAB) or delipidized (DLS) AB serum. TNF release (L929 cytolytic assay) in the presence of cAB occurred during the first 3 days of in vitro culture. Delipidization of AB serum completely inhibited the lipopolysaccharide (LPS)-induced release of TNF by HPBM. Addition of RA (0.5 microM) to DLS restored LPS-induced TNF release by HPBM, and supplementation with ROH (1.0 microM) resulted in release of TNF-like activity, but only after 3 days of in vitro culture. The maintenance of TNF release by the addition of exogenous RA after 3 days of in vitro culture suggested that depletion of endogenous RA was partially responsible for loss of TNF-like activity. The levels of endogenous TNF protein and mRNA were not influenced by delipidization of serum and were found to be similar to those of HPBM cultured in the presence of AB serum. TNF protein and mRNA were undetectable in HPBM ROH-treated cell lysates, although cytolytic activity was observed in culture supernatants. These results suggest that retinoids are required for the release of cytolytic factors from HPBM and that non-TNF cytolytic factors may be released by these cells at different stages of maturation.