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Oligoclonal B cell proliferation, as defined by the presence of more than one leukemic clone, has been detected in approximately 20% to 30% of patients with acute lymphoblastic leukemia (ALL) using PCR or Southern blotting. An accurate assessment of these populations is required to avoid false negative measurements of minimal residual disease (MRD) in follow-up bone marrow (BM) samples of ALL patients. In this study, we analysed 29 ALL patients with two or more immunoglobulin heavy (IGH) chain gene rearrangements in the presentation samples using IGH fingerprinting PCR and sequence analysis. Thirty-nine (51%) of 76 sequences (from 15 patients), shared no VNDNJ homology (ie different CDR3 regions). In the remaining 14 patients, at least two related VH sequences were identified in each patient (identical DNJ sequences). Numerical abnormalities of chromosome 14 was detected in 10 patients. Eight patients were analysed at presentation and relapse. In four of them, expansion of a minor presentation-clone was detected at relapse while the major presentation clone disappeared, confirming 'subclonal evolution'. Finally, in our cohort of patients, the presence of related or unrelated IGH clones did not influence overall survival. [ABSTRACT FROM AUTHOR]

Although IL-2 infusion enhances cell-mediated cytotoxicity in patients with neoplastic disease, administration is paradoxically associated with a modest fall in total serum IgG and an increased risk of infection. We now show that the adverse effects of IL-2 infusion on the humoral immune system are substantial. Although IL-2 induces the B cell growth and differentiating factors IL-4 and IL-6, infusion abrogates primary antibody responses entirely and reduces secondary antibody responses 50-fold following antigen challenge. There is no evidence of the generation of cells with suppressive activity on B cells but IL-2 increases the ratio of circulating virgin : memory cells. These results may help to explain the increased rate of bacterial infection in patients receiving IL-2. As IL-2 plays a central role in the generation of an immune response, the finding that it is also sufficiently immunosuppressive to inhibit primary- and secondary-type antibody responses suggests that exploration of the underlying mechanisms may provide insights into immune system homeostasis and may offer new approaches to therapeutic immunosuppression. [ABSTRACT FROM AUTHOR]

The regeneration of T cell subsets was studied with double immunofluorescence marker methods in 37 patients who received HLA matched T lymphocyte depleted bone marrow transplants (BMT) as part of the treatment for their haetnatological disease. A cocktail of anti-pan-T(CD6: MBG6)and anti-suppressor/cytotoxic-T cell (CD8: RFTS) monoclonal antibodies was used with rabbit serum as a source of cytolytic complement to achieve achieve T cell lysis. The T8+ cells reached low normal values around 60 days post-transplant and remained within the normal range throughout the study (> 150 days). This observation is in contrast to our previously published results in patients who, after receiving BMT without efficient T cell depiction, had increased numbers of circulation T8+ cells from 60 days post-transplant. In the present study Leu-7+,RFT8- cells reached normal values rapidly but the reconstitution of T4+ lymphocytes was slow; low normal levels were reached only around day 150 following BMT. The degree of graft-versus-host disease (GVHD) seemed to be related to the number of residual T cells infused: two of the three patients who received the highest numbers of T cells developed Grade II and III: otherwise GVHD was minimal. Among the clinical parameters studied cytomegalovirus (CMV) immune status moderately influenced reconstitution: at 55-90 days post-transplant T8+ cells were present at the upper normal levels in seven out of 15 patients receiving BMT from CMV seronegative donors, but in none of the 16 individuals receiving BMT from seropositive donors. CMV related complications were relatively uncommon. Thus the most significant factor in preventing'T8+ cell overshoot' and T cell imbalance during regeneration appears to be the depletion of T (including T8+) lymphocytes from marrow, The differences of T8+ cell reconstitution in this and previous studies may reflect a different regeneration pattern from T cell precursors as opposed to inoculated mature T ceils. [ABSTRACT FROM AUTHOR]

The purpose of the study was to examine the influence of age on outcome in a large cohort of children and adults with lymphoblastic leukaemia who were treated on two similar trials. Factors influencing outcome were examined in 2204 patients aged over 1 year treated between 1985 and 1992 on the parallel Medical Research Council Trials UKALL X and XA, for children and adults, respectively. There was a progressive worsening in survival with increasing age from 85% (95% CI 83-87) at 5 years for children aged 1-9 to 24% (CI 17-31) for patients over 40. Induction failures, deaths in remission and bone marrow relapses increased significantly with age. Analysis of clinical and biological features showed dominance of early B-ALL in childhood and increasing incidence of the Ph' chromosome with age. Over 80% of eligible children, but a much lower proportion of adults especially those over 40, was entered. Compliance was stricter in the paediatric trial but most deviations in adults involved giving more treatment. Analysis of results in a proportional hazards model confirmed the overwhelming independent influence of age; with all other factors equal a 10 year old had half the risk of treatment failure of a 20 year old and a 44 year old double the risk. Selective entry to therapeutic trials and increased treatment-related toxicity are features of adult ALL but age itself remains a dominant prognostic factor. While improved supportive care and refinements of conventional therapy may have some effect on prognosis, new understandings and treatment approaches to adult ALL are needed. [ABSTRACT FROM AUTHOR]

Immunoglobulin heavy chain gene (IgH gene) rearrangements are found in the majority of patients with B lineage acute lymphoblastic leukaemia (ALL). Two hundred and three bone marrow samples from 54 patients (33 adults and 21 children) were analysed by PCR within specific time-points after diagnosis (ie 1, 2-3, 4-6 and 7-12 months) using FR1 and JH primers (fingerprinting with a sensitivity > or =1:5 x 10[3]). CDR3-derived allele specific oligoprimers (ASO to achieve a sensitivity between 1:10[4] and 1:10[5]) were applied to 12 children and 18 adults, while size of CDR3 region, oligoclonality and background problems prevented their application to the remaining patients. All patients were followed clinically for > or =24 months. Thirty adults and 16 children presented as newly diagnosed ALL, while the remaining eight patients were analysed in first or subsequent relapse. Patients destined to relapse showed a higher proportion of positive tests (> or =50%), particularly after 1 month, than in the remission group, irrespective of age. Among patients staying in remission, a decrease in MRD-positive tests occurred during the first 12 months in both age groups. However, the proportion of positive tests dropped below 15% at a later stage in adults (4-6 months) than in children (2-3 months). Among children, only patients destined to relapse were MRD positive beyond 1 month, with the exception of only one patient, still positive at 2-3 months in the remission group. The difference in MRD positivity between relapse and remission patients was statistically significant in children (P < 0.03) at any time of testing, but only at 4-6 months in adults (P < 0.01). These data suggest that resolution of MRD in ALL occurs more rapidly in children compared to adults, particularly within the first 6 months. Children and adults, studied in first or subsequent relapse, showed a higher proportion of positive tests during reinduction compared to newly diagnosed patients. [ABSTRACT FROM AUTHOR]

The immunological basis of the inflammatory response in the lungs of patients with pneumonitis after bone marrow transplantation has been investigated by means of bronchoalveolar lavage. Ten episodes of pneumonitis associated with cytomegalovirus and nine episodes due to various other infectious and non-infectious causes were investigated in 16 patients (three patients had two episodes of pneumonitis). Total lavage cell counts and differential cell counts were determined and compared with results from normal control subjects. In most patients with pneumonitis the total cell yield was greater than normal (mean 6.8 (SD 6.0) x 10(5) cells/ml; normal 1-2 x 10(5) cells/ml). The percentage distribution of these cells was 71.9 (17) macrophage like cells, 24.1 (15.8) lymphocytes, 5.0 (5.0) polymorphonuclear cells, and 0.7 (1.0) eosinophils. None of the patients had peripheral lymphocytosis despite the increased number of lymphocytes in the lavage fluid. Further analysis of the lymphocyte population using monoclonal antibodies with immunocytochemical techniques showed that B cells were generally present in normal proportions, whereas the proportion of cells expressing T lymphocyte markers (CD2+, CD5+, CD8) were reduced in nine out of 19 cases. In 10 of the 19 episodes there were substantial numbers of cells expressing none of the B or T cell antigens studied ("null" cells). These abnormalities bore no relation to survival. The total cell yield, the proportion and number of lymphocytes, and the proportion and number of T cells in the bronchoalveolar lavage fluid were all lower in the group with cytomegalovirus infections than in those with pneumonitis from other causes. These results suggest that the pneumonitis in recipients of bone marrow transplants is associated with a local immune response despite the fact that the individuals are otherwise immunosuppressed. [ABSTRACT FROM PUBLISHER]

After the death from massive haemoptysis of two neutropenic patients who had developed apparent pulmonary mycetomas, two subsequent patients underwent successful resection of similar lesions. Histological examination of these lesions confirmed that these so called mycetomas were masses of devitalized lung tissue infiltrated with fungus. The term mycotic lung sequestrum is therefore proposed to distinguish this condition from a fungus ball arising in a previously formed cavity. A review of 34 similar cases reported previously showed that haemoptysis occurred in about half of the cases and was fatal in just over half of these. Medical treatment appears to have little impact on survival and early consideration of surgical intervention is important. [ABSTRACT FROM PUBLISHER]

Forty episodes of pneumonitis in 30 recipients of allogeneic bone marrow transplants were investigated by fibreoptic bronchoscopy and bronchoalveolar lavage. A positive diagnosis was made in 32 episodes of pneumonitis (24 patients), giving a diagnostic yield of 80%. In 31 of these the diagnosis was made within 24 hours of bronchoscopy and this enabled the appropriate treatment to be instituted early. Eighteen patients recovered from their primary infection, although two died subsequently of respiratory failure due to postpneumonic lung destruction. Ten patients later developed a second episode of pneumonitis and a diagnosis was made in nine of these. Only three survived a second episode. Bronchoalveolar lavage was well tolerated by all patients and there was no morbidity or mortality that could be directly attributed to the procedure. Bronchoalveolar lavage is a safe and valuable early diagnostic procedure for the investigation of pulmonary complications in patients who have received bone marrow transplants. [ABSTRACT FROM PUBLISHER]

A retrospective analysis of 48 patients with documented or probable invasive aspergillosis (IA) prior to bone marrow transplantation (BMT) was conducted in 16 centers. Treatment of primary IA was medical in all 48 patients and surgical in 20; clinicoradiological resolution of IA occurred in 30 of 48 patients. Pretransplantation risk factors for relapse IA, total mortality, and IA-related mortality were analyzed by multivariate logistic regression with the following dichotomous risk factors: surgery as part of the initial treatment, resolution of IA by the time of BMT, donor type, conditioning regiment, total-body irradiation, T cell depletion, immunosuppressive therapy, type of antifungal prophylaxis, and growth factor prophylaxis. Conditioning with busulfan/cyclophosphamide was associated with a beneficial outcome for total survival and reduced IA-related mortality. Posttransplantation risk factors such as the development of graft-vs.-host disease (GVHD), therapy for GVHD, and the duration of neutropenia did not have a significant effect on relapse IA, IArelated mortality, or total mortality. The overall incidence of relapse IA was lower than expected (33% [16 of 48 patients]), but the mortality rate among relapsed patients was 88% (14 of 16). Patients receiving prophylaxis with absorbable or intravenous antifungals had less relapses of IA than did those not receiving prophylaxis (12 of 41 vs. four of seven, respectively). This finding reflects the need for better prophylaxis and new antifungal treatments for patients undergoing BMT who have a history of IA. [ABSTRACT FROM PUBLISHER]

Six hundred and seventy four yeast isolates obtained from routine microbiological screening of 153 patients with haematological disease were identified and Candida albicans isolates biotyped over nine months to determine longitudinal and cross sectional patterns of yeast colonisation. A yeast microflora persisted in many patients despite the routine prophylactic use of oral antifungal agents. Analysis of the yeast species isolated on a cross sectional basis showed that C albicans accounted for 65% of yeasts isolated from the oral cavity but only 45% of the faecal yeast flora. Longitudinal changes in yeast flora occurred significantly more often in faecal samples than in oral samples and significantly less often in sites colonised with C albicans than in sites colonised with other species. No associations were found between the yeasts isolated and the nature of antifungal prophylaxis used, or the extent of a patient's stay in hospital. [ABSTRACT FROM PUBLISHER]

Bone marrow transplantation is now an accepted component in the overall therapy of acute and chronic (myeloid) leukaemia for some selected patients. Some of the obstacles to success have been partially overcome. Many advances in supportive care have been made. Pneumocystis carinii and herpes simplex infections are preventable. Effective decontamination of the gastrointestinal tract for bacteria and fungi is now readily achievable and may have reduced the risk of serious systemic infections. New antibiotics which, in combination, are effective in life-threatening infections are under study. Recent developments in the prevention or amelioration of graft versus host disease (GvHD) have included T lymphocyte depletion in the donor marrow and the use of the fungal polypeptide cyclosporin A. Less than 10% of patients would now be expected to succumb to this complication. Outstanding problems remaining to be resolved are the improvement in the antileukaemic conditioning prior to transplantation and the prevention or treatment of cytomegalovirus infection in the seropositive recipient. This infection can cause pneumonitis and is currently the single most frequent transplant related cause of mortality. [ABSTRACT FROM PUBLISHER]

Eighteen recipients of allogeneic T cell-depleted bone marrow who developed 22 episodes of interstitial pneumonitis were investigated by bronchoalveolar lavage for the cause of pneumonitis. The cells obtained were examined using a panel of monoclonal antibodies with immunocytochemical techniques to identify lymphocyte subsets and the presence of surface molecules indicative of lymphocyte activation. The majority of patients had an excess of lymphocytes in lavage and most of these cells were positively stained with the McAb recognizing the CD8 antigen (suppressor/cytotoxic type T cells). Although the proportions of CD4+ (helper type) T cells were below normal, the absolute numbers were within normal limits, thus the CD4:CD8 ratio was consistently 1:1 or less. A large proportion of the CD8+ cells displayed HLA-DR molecules (RFDRI+), interleukin-2 (LL-2) receptors (CD25+) and high concentration of CD7 antigen (RFT2+). Further analysis revealed that most CD8+ cells were CD5+ (RFT1+) yet a large proportion (20-40%) were CD5-. A majority of CD8+ cells was also CD38+ (RFT10+) and Leu7+. No clear correlation between the emergence of a raised proportion of activated CD8+ cells and diagnosed cytomegalovirus infection was found. These results demonstrate, however, that cells with the phenotype of the resident T cells of the bronchial epithelium (CD8+CD5-) emerge to the air spaces and express activation markers. This raises the intriguing paradox of an aggressive local immune response occurring in an otherwise immunosuppressed group of patients. [ABSTRACT FROM AUTHOR]

We investigated 20 bone marrow transplant recipients with pneumonitis using bronchoalveolar lavage (BAL) to assess the humoral immune response in the lung. We measured the levels of total IgG, IgM and IgA in bronchoalveolar lavage fluid and serum, and albumin measurements were used to correct for simple diffusion of immunoglobulins from serum into the lung. We found evidence for the local production of immunoglobulins G, M and A in 15 patients. This was independent of the cause of the pneumonitis. We also found that, although seven patients who recovered from their pulmonary problem had evidence of considerable local production of immunoglobulin, eight patients who died were also producing immunoglobulins in the lung. Death due to pneumonitis in BMT recipients cannot, therefore, be ascribed to a failure of the local humoral immune response. [ABSTRACT FROM AUTHOR]

CD5 is an antigen normally found on T cells and on a minority subpopulation of B cells in fetal spleen and tonsil and on the majority of cells in B-chronic lymphocytic leukaemia. Recent reports described the occurrence of large numbers of CD5-positive B cells in the peripheral blood after bone marrow transplantation (BMT). We examined the peripheral blood for CD5-positive B cells in 21 patients who underwent allogeneic BMT for leukaemia with marrow first depleted of T cells using anti-T monoclonal antibodies and complement mediated lysis, Twenty-six samples were obtained from patients 24-644 days after BMT and examined for the existence of blood-borne CD5-positive B cells by immunofluorescence analysis microscopically and by flow cytometry. The number of CD5-positive B cells was consistently lower than 2%. The absence of CD5-positive B cells in this series may be due to the method of T cell depletion of the marrow or to methodological differences in the analysis of the cells. [ABSTRACT FROM AUTHOR]

Various T cell subsets were characterized by double immunofluorescent staining using monoclonal antibodies (MoAb) in blood, bone marrow (BM) and tissues of 29 patients after allogeneic BM transplantation (BMT). In an attempt to prevent graft versus host disease (GvHD), 15 patients received cyclosporin A (Cy A). In the remaining 14 patients the BM was pre-incubated with a MoAb. OKT3, The regeneration of T4+ subset was delayed and the level of T8+ cells was abnormally high even 1 year after engraftment. This did not have any predictive value for the appearance of complications such as GvHD or severe viral infections. The number of T8+ ceils was lower in the group of patients who received Cy A than in the OKT3 group (0.7 ±0.2 vs 1.5 ±0.3 × 109/1 at day 90). In contrast to normal individuals, the T4/T8 ratio in both blood and regenerating BM of BMT patients was < 1, A sizeable subset of circulating T cells expressed the phenotype T8+,T10+,HNK-1+,DR+. Circulating cells of this phenotype were transiently very high (up to 50%) in patients with active GvHD or suffering from severe viral infection. This subpopulation of lymphocytes was not found in the epidermal infiltrate that accompanied GvHD where the predominant phenotype was T8+,T1-T10-,HNK-l-,DR-. We conclude therefore that after BMT the number and phenotype of circulating T cells reflects the T cell distribution seen in the regenerating BM. [ABSTRACT FROM AUTHOR]

Immunohistochemical analysis was performed on skin biopsies from patients suffering from graft versus host disease (GVHD) following bone marrow transplantation for aplastic anaemia and leukaemia. Lymphoid cells infiltrating the skin were exclusively T cells with the 0KT8+ phenotype and these are probably cytotoxic T cells. Langerhans cells were reduced in number in all specimens and a variable number of HLA-DR positive macrophages were seen in the dermis. In several cases HLA-DR antigens were expressed on keratinocytes. These results show consistent features which may help discriminate rashes in the skin in the post-transplant period. [ABSTRACT FROM AUTHOR]