Reduction of pulmonary toxicity by prednisolone prophylaxis during all-trans retinoic acid treatment of acute promyelocytic leukemia. Australian Leukaemia Study Group.

All-trans retinoic acid (ATRA) induces complete remission (CR) in most cases of acute promyelocytic leukemia (APL) but its use is associated with potentially fatal pulmonary toxicity in approximately 25% of APL patients in the setting of a rapidly rising peripheral blood white cell count (WBC). The efficacy of oral corticosteroid for prophylaxis against pulmonary toxicity has been investigated in a prospective multi-center study. ATRA was administered at 45 mg/m2/day as single agent therapy throughout induction treatment in 19 patients with an initial WBC < 10 x 10(9)/l, and prednisolone 75 mg/day was added in those 12 patients in whom the WBC rose above 10 x 10(9)/l. Combination chemotherapy plus prednisolone was added to ATRA in six other patients on the basis of criteria specified in the protocol. All 19 patients who received ATRA without chemotherapy achieved CR without signs of pulmonary toxicity despite a rise in WBC to peak values as high as 112 x 10(9)/l. Pulmonary toxicity developed in two patients commenced on ATRA in association with an unusually rapid increment in WBC of 7.5 x 10(9)/l and 32.5 x 10(9)/l in the first 2 days; both were subsequently treated with chemotherapy. The low incidence of pulmonary toxicity in this study compared with that in previous trials suggests that prednisolone prophylaxis increases safety of ATRA therapy in APL irrespective of the peak WBC.

Clonally rearranged antigen receptor gene DNA studies in evaluation of susceptibility of neoplastic lymphocytic and plasmacytic disorders to selective loss in long-term marrow culture.

Survival of neoplastic cells of disorders involving the lymphocytic lineage in relation to normal hemopoietic cells has been investigated in long-term culture of bone marrow (LTMC) infiltrated by conditions in which a clonally rearranged B- or T-cell antigen receptor gene provided an objective marker of the neoplastic cell population. Relative amounts of clonally rearranged and germline antigen receptor gene DNA were assessed by Southern analysis of bone marrow cell DNA, before and after LTMC in studies on ten cases of non-Hodgkin's lymphoma (NHL), four of myeloma (MM), and two of chronic lymphocytic leukemia (CLL). Clonally rearranged DNA became undetectable during LTMC in 12 studies (seven NHL, four MM, one CLL), and in seven of these studies the extent of the decrease determined by densitometric analysis of rearranged and germline bands on the autoradiograms was sufficient to demonstrate that preferential loss of neoplastic relative to other cell series had taken place. At the same time, there was a net increase in normal myeloid series, to indicate that a selective adverse effect similar to that reported to operate on leukemic cells in LTMC also applied to certain malignancies involving the lymphocytic lineage. In four of the 16 studies (three NHL, one CLL), the neoplastic cells possessing clonally rearranged DNA were maintained in LTMC, demonstrating that susceptibility to this selective adverse effect was not a uniform characteristic of neoplastic lymphocytic disorders.

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.

Differential action of diffusible molecules in long-term marrow culture on proliferation of leukaemic and normal haemopoietic cells.

The capacity of diffusible molecules in the fluid phase of long-term human bone marrow culture (LTMC) to exert preferential adverse effects on leukaemic relative to normal haemopoietic cells has been investigated. Responses of isolated cell populations were assessed in diffusion chamber inserts which permitted contact with fluid phase molecules but not with the adherent stromal cell layer of the LTMC system. Growth of AML cells in diffusion chambers was inhibited during co-culture with LTMC of autologous leukaemic bone marrow, and the same effect was produced during co-culture with normal LTMC. No inhibitory action was exerted on growth of normal haemopoietic precursors under the same conditions. Comparable responses were observed with human leukaemic cell lines and patient leukaemic cells, and studies on cell lines demonstrated inhibition of growth was induced by molecules generated in LTMC which caused accumulation in G1 phase of leukaemic cells of both myeloid and lymphoid lineage. The inhibitory effect was not reproduced by TGF beta, IFN gamma, IFN alpha, TNF alpha, LIF, SCF or Il-6, and was not impaired by inhibitors of nitric oxide or PGE production in the LTMC. These observations suggest the action of diffusible molecules of undefined constitution contributes to the preferential loss of leukaemic cells in LTMC.

Fatal disseminated Scedosporium inflatum infection in a neutropenic immunocompromised patient.

Disseminated infection with the fungus Scedosporium inflatum in a neutropenic patient with non-Hodgkins lymphoma presented with the triad of muscle tenderness, papular skin lesions and fever, and progressed rapidly to a fatal outcome. This represents the first reported instance of fatal widely disseminated infection with this organism, and demonstrates that the triad of presenting clinical features, formerly reported to be pathognomic of systemic candidiasis, can no longer be regarded as specific for infection with a particular species of yeast or fungus.

An assessment of the ability of human bone marrow cultures to generate osteoclasts.

Several groups have successfully generated osteoclasts in cultures of murine haemopoietic cells. This approach would clearly be useful in the analysis of mechanisms of regulation of human osteoclast formation if analogous results could be obtained in cultures of human bone marrow. This communication describes independent attempts by three groups to generate unequivocally defined osteoclasts from bone marrow obtained from human iliac crest, femoral neck, rib, and from foetuses. The haemopoietic tissue was incubated using techniques described by others for production of osteoclast-like cells, and with variants of this technique using strategies based on our experiences with murine osteoclastogenesis. Haemopoietic cells were incubated with calcium regulating hormones, cytokines, osteoblastic supernatants, and osteoblastic or bone marrow stromal cell layers. Formation of cells capable of excavation of bone slices was rarely seen. Despite the paucity of bone resorbing cells, multinucleate cells (MNCs) developed with similar characteristics to the MNCs that have been interpreted as osteoclast-like in human bone marrow cultures. The MNCs were, however, calcitonin-receptor (CTR) negative, and did not show the typical pattern of reactivity with osteoclast-specific antibodies. They possessed instead an antigenic profile characteristic of macrophage polykaryons. We conclude that the MNCs which consistently generate in human bone marrow cultures do not possess phenotypic characteristics specific for osteoclasts and appear to be macrophage polykaryons. The conditions required for osteoclast generation in cultures of human haemopoietic cells remain to be defined.

A method for identifying megakaryocytic and erythroid cells by a combined immunocytochemical and cytochemical stain.

The effectiveness of immunoperoxidase staining for platelet glycoprotein IIb/IIIa coupled with cytochemical staining for hemoglobin has been evaluated as a dual staining technique for identifying lineage-specific characteristics of the megakaryocytic and erythroid series in cells of the same hemopoietic tissue preparation. A sequence of staining was established which produced a circumferential brown stain around cells of the megakaryocytic series, and a diffuse yellow to orange stain in the cytoplasm of cells of the erythroid series. Each staining reaction possessed a high degree of specificity and sensitivity which enabled the combined stain to provide a convenient means for establishing the megakaryocytic and erythroid nature of individual cells in hematological specimens where classification cannot be achieved with certainty on morphological grounds.

Contrasting patterns of neoplastic cell behaviour in long-term culture of bone marrow from patients with acute leukaemia and myelodysplastic disorders. A survey of responses in 31 cases with cytogenetic determination of neoplastic status of cultured cells in 17 studies.

Alterations in neoplastic cell behaviour responsible for increased production of terminally-differentiated granulocytes during long-term culture of bone marrow in different categories of acute leukaemia and myelodysplasia have been investigated. An increase in neutrophils associated with transition to a morphological picture identical to normal control cultures occurred in 15 of 25 studies on acute leukaemia in contrast to one of six studies on myelodysplastic disorders. An abnormal neoplastic karyotype was employed as a marker for monitoring the course of the neoplastic cell population in 11 studies in which there was progression towards a normal pattern of differentiation. An increase in differentiation was shown by this means to represent increased maturation of cells of the neoplastic process in one study on a myelodysplastic disorder, demonstrating domination of proliferative activity in culture by all of the myelodysplastic disorders examined. Transition towards normal differentiation in nine studies on acute leukaemia, however, correlated with partial or complete replacement of the acute leukaemic cells by normal haemopoietic series in de novo acute leukaemia, and by Ph positive cells in blast crisis of CML. Conversion to morphologically and cytogenetically normal cell populations in five studies on de novo acute leukaemia occurred in four cases which failed to respond to remission-induction therapy, suggesting the selective toxic effect capable of purging acute leukaemic cells from bone marrow operated by a mechanism which lacked cross-resistance to currently-employed cytotoxic agents.

Cytotoxic immunosuppressive drug treatment strategy in pure red cell aplasia.

Remissions occurred in 2 of 5 consecutive cases of acquired pure red cell aplasia (PRCA) during an initial course of treatment with either azathioprine and prednisolone, or cyclophosphamide and prednisolone. Crossover to therapy with the alternative cytotoxic immunosuppressive agent in conjunction with continued administration of prednisolone in 3 unresponsive cases resulted in remission induction. Crossover to azathioprine was effective in 2 cases initially unresponsive to cyclophosphamide, and crossover to cyclophosphamide in 1 initially unresponsive to azathioprine. This emphasises that lack of cross-resistance to these drugs can occur in PRCA, and that crossover to treatment with the alternative agent in refractory cases is a useful strategy which has been underutilised in reported approaches to management. Administration of the effective regimen was continued for a mean of 15 months, and this more extended period of treatment was associated with a longer mean duration of remission than reported in previous studies.

Differentiation in acute myeloid leukemia and myelodysplastic disorders. Is differentiation-induction therapy possible?

In this review we have discussed the data which indicates that differentiation can indeed occur to a limited degree in the neoplastic cells in acute leukemia and myelodysplastic syndromes. Attempts to increase the degree of differentiation as an approach to the treatment of these disorders have utilised a variety of chemical agents which have been reported to exert such an effect in vitro. Analysis of the results, however, indicates that beneficial effects of these agents in patients is due to cytotoxic action which selectively reduces the neoplastic cell population. Leukemic cells can also undergo incomplete differentiation in vitro when exposed to appropriate growth factors, which raises the question of whether leukemia and myelodysplasia can be treated by the induction of differentiation in the malignant cells following the administration of these agents. This question, and questions about the nature of complete remission, will be answered in the coming years by clinical trials of growth factors, and further studies of the DNA in mature cells to analyse whether these cells are derived from leukemic progenitors.

Treatment of hairy cell leukemia with increasing doses of recombinant alpha A interferon.

Since July 1984, eight patients with advanced hairy cell leukemia have received treatment with recombinant alpha A interferon. At commencement of interferon, seven patients had progressive cytopenia, and one was in leukemic phase (greater than 20 x 10(9)/L circulating hairy cells). All patients had had previous splenectomy. Interferon was administered subcutaneously. The initial dose was 3 x 10(6) U/day, continued until peripheral counts stabilised. Subsequently, patients received 6 x 10(6) U/day, 9 x 10(6) U/day, and finally 12 x 10(6) U/day. The dose increases proceeded every 8-12 weeks, as tolerated. Seven patients had an objective response. There were four complete remissions, two partial remissions, and one minor response. Complete remission was documented only in patients on at least 6 x 10(6) U/day for 12 weeks. The median time to complete remission was 40 weeks (range 35-53). Normalisation of peripheral blood counts preceded histologic marrow improvement. The median times for response (platelets greater than or equal to 100 x 10(9)/L, hemaglobin greater than or equal to 12 gm/dL, neutrophils greater than or equal to 1.5 x 10(9)/L), were six to eight and 17 weeks, respectively. Toxicity included myelosuppression during the first four weeks of therapy. With increasing doses of interferon, myelosuppression did not recur. A transient, mild, flu-like syndrome affected all patients. Two patients developed asymptomatic transaminitis at doses greater than 6 X 10(6) U/day. This resolved with dose reduction. In one case impotence was reported during the first four weeks of each interferon level.(ABSTRACT TRUNCATED AT 250 WORDS)

Cytosine arabinoside in the treatment of T-cell acute lymphoblastic leukemia.

The place of cytosine arabinoside (araC) in the treatment of T-cell acute lymphoblastic leukemia was studied by measuring nucleoside transport sites and the conversion of araC to its triphosphate (araCTP) in lymphoblasts from the peripheral blood of two patients, who were then treated with araC. Equilibrium binding of 3H-nitrobenzylmercaptopurine riboside (3H-NBMPR), a specific ligand of the nucleoside transporter, gave 16,510 to 29,400 sites/cell for T-lymphoblasts on presentation or early in relapse compared with 2730 +/- 1570 sites/cell for non-T-lymphoblasts. Accumulation of araCTP from 1 microM araC was four times greater in T-cell than non-T-cell lymphoblasts. One patient was treated with araC (100 mg/m2 daily x 7 days, continuous intravenously) at the time of her first leukemic relapse and complete remission was achieved with this single agent. When this patient relapsed and developed advanced disease the T lymphoblasts showed a 75% reduction in their ability to accumulate araCTP which paralleled a reduction in 3H-NBMPR binding. The second patient achieved complete remission with araC given in low dose (15 mg twice daily by subcutaneous injection) for 21 days at the time of a localised relapse in the mediastinum and pleura. These studies suggest that araC may have a place in the therapy of early stage T-lymphoblastic disease.

Antithymocyte globulin therapy for pure white cell aplasia.

Severe neutropenia due to selective loss from the bone marrow of cells of the entire neutrophil maturation sequence developed in a patient with Goodpasture's Syndrome and was associated with serious infections complicating continuous ambulatory peritoneal dialysis. Involvement of T-lymphocytes in the process affecting the neutrophil series was implicated by the relation between recovery from neutropenia and treatment with antithymocyte globulin (ATG). Azathioprine and corticosteroid administration failed to sustain recovery from neutropenia induced by ATG. It is concluded that ATG can provide a nonmyelotoxic form of therapy for pure white cell aplasia whose effectiveness is independent of responsiveness to other immunosuppressive agents.

New concepts in management of neutropenia.

Neutropenia is a life-threatening sequel of hematological disorders and a dominant factor limiting the dosage of cytotoxic chemotherapy. The role of the neutrophil is of such importance in defence against microbial invasion that measures that modify the behaviour of residual hemopoietic tissue to promote a modest increase in neutrophils, can confer considerable benefit by reducing the frequency and severity of infection. Such a change can be mediated in bone marrow depression by diversion of more progeny of immature precursors into the neutrophil series, or by enhancement of the stimulatory drive operating on neutrophil production. The former effect can be achieved by hypertransfusion of red cells to reduce the demand on the limited precursor population for cells of the erythroid series. The latter effect can be achieved by administration of lithium carbonate. Neutropenia caused by autoimmune injury to the neutrophil series can also be successfully modified by measures which suppress the underlying immune dyscrasia or the function of the reticulo-endothelial system. Corticosteroid administration and splenectomy can be helpful in certain specific types of neutropenia. Administration of cyclophosphamide and azathioprine has both mutagenic and marrow suppressive potential, but can induce remissions in severe chronic isolated neutropenia and in systemic lupus erythematosis.

Stimulation of leukocyte phagocytic activity by the platelet release reaction.

The influence of material released by activated human platelets on the phagocytic activity of human neutrophils and monocytes has been investigated under conditions where there was a low background level of exposure of the leukocytes to platelet release products (PRPr). Incubation with PRPr prepared from 400 X 10(9)/l platelets resulted in an approximate 3-fold increase in the proportion of leukocytes which ingested particles. Stimulation was produced by dilutions of PRPr down to 1:4 to indicate that phagocytic activity was affected by material released by concentrations of platelets within the physiological range. This response appeared to reflect stimulation of the overall phagocytic capability of the leukocytes as equivalent ingestion was observed with particles which possessed or lacked the capacity to bind complement to their surface. Enhancement of phagocytic activity was evidently secondary to induction of a change in leukocyte behaviour which was sustained in the absence of continued exposure to preparations of PRPr. These observations extend the range of human biological processes known to be responsive to PRPr, and have implications for the assessment of leukocyte phagocytic activity in vitro as this particular property could be modified by contact with PRPr during the isolation of leukocytes from peripheral blood.

Determination of immunoglobulin class by pattern of absorption to protein A-sepharose coupled with immunoglobulin class specific antibodies.

The pattern of absorption of the different major immunoglobulin classes by protein A and protein A coupled with antibody to human IgA or IgM has been evaluated as a simple means of identifying the class of a particular immunoglobulin in small volumes of human serum. Rabbit anti-IgA or anti-IgM coupled with protein A-Sepharose gel effectively removed IgA or IgM respectively from human serum in addition to the subclasses of IgG removed by protein A alone. The manner in which an immunoglobulin-related property is removed from human serum by protein A and its conjugates with specific antibodies can thus serve as an index of the class of that particular immunoglobulin.

Clinicopathological characteristics of acute lymphoblastic leukemia with the 4;11 chromosome translocation.

Analysis of the bone marrow karyotype in 109 consecutive untreated patients with acute lymphoblastic leukemia (ALL) by the G-banding technique revealed the presence of a translocation between specific sites on the long arms of chromosomes 4 and 11, [t(4;11) (q21;q23)] in 3 adults and 2 children. Splenomegaly was present in all patients, marked leukocytosis in 4, and retinal hemorrhages in the absence of significant mucocutaneous bleeding in 3. Complete remission defined by conventional morphological criteria was achieved with combination chemotherapy in all instances, but the duration of remission was brief in 3. Three patients were studied in relapse, and clonal evolution was found to have occurred in 2. Analysis of our data in conjunction with other published reports suggests this specific karyotypic abnormality characterizes a small subgroup of ALL in which there is a strong association with recognized clinical and laboratory indices of poor prognosis, in particular its frequent occurrence in children under the age of 2.5 yr. There is a propensity to undergo clonal evolution, and the possibility exists that such a development is associated with poor prognosis.

Influence of human serum components on measurement of erythropoietin biological activity in vitro. Studies with a rabbit bone marrow bioassay procedure.

The influence of human serum components during in vitro determination of erythropoietin biological activity has been examined in a modified in vitro bioassay procedure utilising rabbit bone marrow as the erythropoietin-responsive tissue. The number of erythroblasts present after 5 d in suspension culture provided a measure of erythropoietin biological activity with a degree of sensitivity equivalent to that provided by estimation of 59Fe incorporation into haem, but possessed the advantage of lacking the susceptibility of the latter method to the level of human serum transferrin saturation. Erythropoietic stimulation was blocked by 10% human serum unless all sera incorporated into the bioassay was previously heated at 56 degrees C. Human serum under the latter conditions was shown to contain material which stimulated erythropoiesis, but which differed in its mode of action from erythropoietin in that it operated by amplifying the response to erythropoietin. Correction for these effects substantially altered interpretation of erythropoietic stimulatory activity of human serum to yield values in keeping with those reported for in vivo bioassay. These findings illustrate the need to clarify the role of human serum components which modify the action of erythropoietin under culture conditions, in view of their potential contribution to discrepancies between values obtained by different bioassay procedures.