Treatment of steroid-refractory acute graft-versus-host disease with anti-CD147 monoclonal antibody ABX-CBL.

ABX-CBL, an immunoglobulin M murine monoclonal antibody, recognizes CD147 and initiates cell killing through complement-mediated lysis. In a dose-finding trial, 27 patients with steroid-refractory acute graft-versus-host disease (GVHD) received ABX-CBL at 0.01 (presumed no effect dose), 0.1, 0.2, or 0.3 mg/kg per day, and an additional 32 patients were given ABX-CBL at 0.2 or 0.15 mg/kg per day. All patients had undergone allogeneic transplantation for malignant or nonmalignant disorders and received GVHD prophylaxis, generally with methotrexate- and cyclosporine-containing regimens. None responded to methylprednisolone, given for a minimum of 3 days. ABX-CBL was started 20 to 236 (median, 47) days after transplantation; it was given for 7 consecutive days and was followed by 2 infusions per week for 2 more weeks. Among 51 patients evaluable for efficacy, 26 (51%) responded, including 13 with complete responses (CR) and 13 with partial responses (PR). CR lasting 14 days or longer or PR lasting 7 days or longer occurred in 21 (41%; 8 CR, 13 PR) patients, including 19 of 43 (44%) patients who received 0.1 to 0.3 mg/kg ABX-CBL and 2 of 8 (25%) patients given 0.01 mg/kg per day. Myalgias at doses 0.2 mg/kg or greater were dose limiting and resolved without sequelae. Causes of death included organ failure, progressive GVHD, and infection. No death was attributed to ABX-CBL. At 6 months after the initiation of ABX-CBL therapy, 26 (44%) patients were surviving. These results are encouraging. Further studies on the use of ABX-CBL in the management of GVHD are warranted.

Molecular classification of multiple tumor types.

Using gene expression data to classify tumor types is a very promising tool in cancer diagnosis. Previous works show several pairs of tumor types can be successfully distinguished by their gene expression patterns (Golub et al. 1999, Ben-Dor et al. 2000, Alizadeh et al. 2000). However, the simultaneous classification across a heterogeneous set of tumor types has not been well studied yet. We obtained 190 samples from 14 tumor classes and generated a combined expression dataset containing 16063 genes for each of those samples. We performed multi-class classification by combining the outputs of binary classifiers. Three binary classifiers (k-nearest neighbors, weighted voting, and support vector machines) were applied in conjunction with three combination scenarios (one-vs-all, all-pairs, hierarchical partitioning). We achieved the best cross validation error rate of 18.75% and the best test error rate of 21.74% by using the one-vs-all support vector machine algorithm. The results demonstrate the feasibility of performing clinically useful classification from samples of multiple tumor types.

High-dose chemotherapy for high-risk primary breast cancer: an on-site review of the Bezwoda study.

BACKGROUND: The efficacy of high-dose chemotherapy with progenitor-cell rescue for women with breast cancer is a controversial issue. Although historically controlled trials have suggested a survival advantage for high-dose chemotherapy, several randomised studies have yet to confirm this advantage. Two studies, however, by Bezwoda, of patients with high-risk and metastatic disease, seemed to show a significant survival advantage for high-dose compared with conventional-dose chemotherapy for metastatic and high-risk primary breast cancer. METHODS: To corroborate the study results before starting a large international confirmatory study, a US team did an on-site review of records for patients in the high-risk study. Limited numbers of records were made available for review, all of which were for patients who received the high-dose-chemotherapy regimen. FINDINGS: There was much disparity between the reviewed records and the data presented at two international meetings. In addition, the reviewers saw no signed informed consent, and the institutional review committee had no record of approval for the investigational therapy. After the site visit, Bezwoda admitted scientific misconduct by using a different control chemotherapy regimen from that described in presented data. INTERPRETATION: The Bezwoda study should not be used as the basis for further trials to test the efficacy of the cyclophosphamide, mitoxantrone, etoposide regimen for high-dose chemotherapy in women with high-risk primary breast cancer. This review validates the essential nature of on-site audits, especially in single-institution studies.

Growth of oncology physician practice management companies.

The practice of oncology is changing dramatically, spurred on by managed care initiatives throughout the United States. As a result, physicians are faced with multiple demands from insurers, managed care organizations, and patients. In response to these demands, oncology physician practice management companies have entered the cancer market. This article describes the driving factors leading to consolidation in practice settings, the risks and benefits to oncologists of affiliating with these companies, and the organizational characteristics of four of these larger corporations. This review article is of broad interest to oncologists practicing in the United States and is meant to provide a useful reference for considering a physician practice management company as a business partner.

Delphi-panel analysis of appropriateness of high-dose therapy and bone marrow autotransplants in newly diagnosed multiple myeloma.

There is controversy whether high-dose therapy and a bone marrow autotransplant or conventional chemotherapy is a better treatment for newly diagnosed multiple myeloma. Data from 1 comparative study and 1 randomized trial provide insufficient subject-level data to advise specific people whether to have an autotransplant. We analyzed appropriate use of high-dose therapy and bone marrow autotransplants in people with newly diagnosed, multiple myeloma using a modified Delphi-panel group judgment process. The panel consisted of 9 myeloma experts from diverse geographic sites and practice settings who reviewed Boolean MEDLINE searches of multiple myeloma and chemotherapy or autotransplants. The panel rated a metric of 64 clinical setting developed by permuting age, performance score, disease-stage and disease-related prognostic variables and response to initial therapy. Each panelist rated appropriateness of high-dose therapy and an autotransplant versus conventional-dose chemotherapy on a 9-point ordinal scale (1, most inappropriate, 9, most appropriate). An appropriateness index was developed based on median rating and amount of disagreement. Relationship of appropriateness indices to the permuted clinical variables was considered by analysis of variance and recursive partitioning. Autotransplants were rated appropriate in persons <55 years old with stage 3 disease and a complete or partial response or stable disease after initial chemotherapy, inappropriate in persons with stage 1 or 2 disease, a performance score <70% and a complete or partial response or stable disease after initial chemotherapy and uncertain in all other settings.

Hodgkin's disease following solid organ transplantation.

BACKGROUND: The incidence of second malignancies is markedly increased following transplantation of solid organs. However, the development of Hodgkin's disease has been described relatively infrequently in this setting, and there is little clinical information on these patients and few details on management. PATIENTS AND METHODS: We have reviewed the pathologic specimens and clinical history of four patients who developed Hodgkin's disease following transplantation of solid organs. RESULTS: Hodgkin's disease appeared 26-68 months following transplantation of the kidney (2 cases), liver, and heart. Three cases demonstrated evidence of Epstein-Barr virus (EBV) in Reed-Sternberg cells. One case appears to have arisen after a previous EBV-driven polymorphous lymphoproliferation. Hodgkin's disease was localized in three cases and disseminated in one. All patients achieved remission with standard therapy and continue in remission between 9 and 61 months after therapy. Graft function was preserved in all patients. CONCLUSION: Hodgkin's disease occurring in the post-transplantation period should probably be treated like Hodgkin's disease in non-immunosuppressed patients. Prolonged disease-free survival is possible and function of the transplanted organ can be preserved.

An unexpected complication following immunoadsorption with a staphylococcal protein A column.

Extracorporeal immune adsorption with staphylococcal protein A (SPA) columns can remove immune complexes and immunoglobulins in the treatment of a variety of diseases. We present the case of an elderly man with neuropathy associated with monoclonal gammopathy, treated by 3 on-line SPA procedures. At the completion of these treatments his neuropathy relapsed, progressing to near-total paralysis. Return to a baseline clinical status required several months. The reason for this severe relapse is not clear. Possible explanations include SPA activation of T-lymphocytes, with release of gamma interferon and increased antigen recognition, or removal of an antiidiotype control mechanism. We advise caution in the application of immunoadsorption to conditions in which it has not yet been evaluated.

A phase I study of therapy with recombinant granulocyte-macrophage colony-stimulating factor administered by IV bolus or continuous infusion.

Sixteen patients with primary or secondary bone marrow failure were treated with recombinant human granulocyte-macrophage colony-stimulating factor (rGM-CSF) given as either an intravenous bolus or by continuous infusion. The dose range studied was from 15 micrograms/m2/d to 960 micrograms/m2/d. Administration of rGM-CSF on a bolus schedule failed to elicit a hematologic response, but resulted in side effects of epigastric distress and eructation in over 30% of administered courses. Administration of rGM-CSF by continuous infusion resulted in a dose-dependent increase in the total leukocyte, granulocyte, and eosinophil counts. The mean maximal rise in granulocyte count was 8.5-fold. After cessation of therapy, blood counts returned to near baseline in most patients by 7 days. A 36 percent decrease from baseline in mean serum cholesterol level was observed in the continuous infusion group, but not in patients receiving rGM-CSF as an IV bolus. Fever, fatigue, and bone pain were dose-limiting in the continuous infusion group at a dose of 240 micrograms/m2/d. The maximally tolerated dose was 480 micrograms/m2/d. No life-threatening toxicities were observed in either group. Our data demonstrate that continuous infusion rGM-CSF is biologically active and non-toxic at a dose of 120 micrograms/m2/d in patients with bone marrow failure.

Malignant melanoma--profile of an epidemic.

Cutaneous malignant melanoma is occurring in epidemic proportions in the United States. To provide a profile of persons at risk and the epidemiologic features of malignant melanoma, we reviewed the records of 325 patients with cutaneous malignant melanoma seen at the University of Colorado Health Sciences Center between 1973 and 1983. Most patients had fair skin, brown or blonde hair, blue or green eyes, and had difficulty in suntanning. The majority of melanomas (72%) developed in preexisting nevi. In women, melanomas were most common on the extremities, and in men they occurred most frequently on the trunk, head or neck. The most frequently noted depth of invasion was Clark's level IV. At diagnosis, most of the patients (77%) were at stage I. We conclude that malignant melanoma constitutes a major disease problem in the western United States that is largely preventable with appropriate physician and patient education.

Effects of in vivo and in vitro alcohol administration on insulin binding and glycogenesis in isolated rat hepatocytes.

Chronic alcohol ingestion was accompanied by a mild decrease in insulin binding (from 11.7 to 8.9% per 1 X 10(6) cells) that was accounted for by changes in the dissociation constant of insulin's binding sites. The basal rate of 14C-glucose incorporation into glycogen was reduced both in alcoholic and pair-fed animals. Insulin stimulated 14C-glucose incorporation into glycogen in control (72% above basal rate) and pair-fed (76% above basal rate) animals. In contrast, only a minimal stimulation of glucose incorporation into glycogen (30%) induced by insulin was observed in alcoholic animals. Hepatocyte responsiveness to insulin was restored when the animals were switched back to normal dry food diet. When the hepatocytes were incubated with 50 mM alcohol for 1 h at 37 degrees C (in vitro experiments) insulin binding remained unchanged. There was a mild but significant decrease in insulin's ability to enhance glucose incorporation into glycogen. The anti-catabolic effect of insulin was unaffected by alcohol. In summary, chronic alcohol ingestion causes significant but reversible changes in post-receptor events of insulin's action.

The relationship between somatostatin binding and cyclic AMP-stimulated protein kinase inhibition.

Somatostatin binding and the ability to inhibit cyclic AMP stimulated protein kinase were investigated utilizing isolated pancreatic islets, anterior pituitary plasma membranes, adipocytes, erythrocyte ghosts, hepatic plasma membranes, and anterior pituitary secretion vesicles. Three types of response were observed. With type I response, somatostatin bound specifically to pancreatic islets and anterior pituitary secretion vesicles and inhibited cyclic AMP stimulated protein kinase. In type II response, adipocytes and anterior pituitary plasma membranes exhibited somatostatin binding but no effect of the ligand on the kinase. In erythrocyte membrane ghosts and hepatic plasma membranes, there was neither specific somatostatin binding nor protein kinase inhibition (type III response). The absence of somatostatin binding in erythrocytes or hepatic plasma membranes cannot be explained by degradation of the ligand per se. Secretory vesicles isolated from the anterior pituitary gland bind somatostatin with an average affinity which exceeds that observed in plasma membrane (for pituitary secretory vesicles Kd1 = 8.5 X 10(-8)M, Kd2 = 5.2 X 10(-7)M; for pituitary membranes Kd1 = 1.9 X 10(-8)M, Kd2 = 8.1 X 10(-7)M). The molar concentration of high affinity binding sites (Ro) for plasma membranes was 6.9 X 10(-10)M; for secretory vesicles 3.6 X 10(-9)M. Calculated in terms of somatostatin binding per U 5'nucleotidase activity, the binding for plasma membranes becomes 8.4 X 10(-14) mole/U 5'nucleotidase; secretory vesicles 4.4 X 10(-13) mole/U 5'nucleotidase. Thus, secretory vesicles are fivefold richer in high affinity receptor sites than plasma membranes. It is suggested that in order for somatostatin to act, both a receptor and an effector unit must be present. In the case of tissues secreting polypeptide hormones by granule extrusion, the secretory vesicle may possess both the receptor and the effector units. It is postulated that during the process of fusion of the plasma and secretory vesicle membranes, a high affinity binding site for somatostatin is incorporated into the plasma membrane, thereby allowing somatostatin to act at a specific locus in the cell in inhibiting hormone release.

Somatostatin: selective inhibition of cyclic AMP stimulated protein kinase.

Utilizing histones as a substrate and measuring the production of labelled phosphoserine from [gamma 32P-ATP], cAMP stimulated protein kinase activity was found in islet and anterior pituitary secretory vesicles. Cyclic AMP (5 X 10(-7)m)stimulated islet secretory vesicle protein kinase activity as evidenced by a net increase of 32P incorporation into phosphoserine 7.35 +/- 1.68 pmoles/micrograms, (P LESS THAN 9001). Somatostatin (0.1 ng/microgram) decreased 32P phosphoserine production from 10.64 +/- 1.72 to 5.61 +/- 1.26 pmoles/microgram (Pless than .01) by suppressing cAMP stimulated protein kinase activity. In pituitary secretory vesicles, cAMP (5 X 10(-6M) increased 32P incorporation into TCA precipitable protein from 127.3 +/- 8.6 to 202.6 +/- 12.5 pmoles/microgram, P less than .001. With somatostatin (0.2 ng/microgram) there was 55.25+/- 1.95% inhibition of cAMP stimulated protein kinase activity, (P LESS THAN .001). Somatostatin did not inhibit cAMP stimulated protein kinase activity in erythrocyte membrane ghosts nor did somatostatin inhibit the partially purified cAMP dependent protein kinase from cardiac muscle. These data suggest that either (1) a specific somatostatin sensitive dependent protein kinase is present in islet and anterior pituitary secretory vesicles or (2) that a somatostatin receptor is present in these tissues which allows somatostatin to act selectively at these sites. Somatostatin may act by inhibiting the cAMP dependent protein kinase enzme in certain key tissues or subcellular organelles.