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Neoplastic cells are frequently intermingled with normal cells in vivo in man and in laboratory animals. In addition, tumor cells frequently consist of functionally distinct cell subpopulations. We have used both centrifugal elutriation and electronic cell sorting to separate leukemic cells from nonleukemic hematopoietic cells and to separate kinetically distinct subpopulations of leukemia cells. In addition, methods have been developed to use pulse cytophotometry to detect the interaction of the anthracyclines with leukemic cells during exposure, both in vitro and in vivo.

Ten patients with active acute myelogenous leukemia (AML) received either 13 cis retinoic acid (RA) + alpha interferon (IFN) or recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) for 3 days. Cell cycle measurements were performed before and at the conclusion of administration of the bioactive agent(s). The proliferative rate of the leukemia cells in vivo decreased in four of five patients receiving RA+IFN whereas in one patient proliferation accelerated. The proliferative rate of AML cells accelerated in three of the five patients who received rhGM-CSF and slowed in two patients. These data show that while the proliferative rate of AML cells can be altered in vivo, the effect produced by bioactive agents may be the opposite of the desired effect. Furthermore, the studies described here demonstrate the usefulness of marrow biopsies for measuring the percent S-phase cells and the importance of measuring the duration of S phase so that the effects of bioactive agents on the cell cycle time of the leukemia cells can be determined.

Tumor necrosis factor alpha (TNF alpha) is a pleiotropic cytokine that is constitutively produced by leukemic cells in B Chronic Lymphocytic Leukemia (B-CLL). It has been shown to have autocrine and paracrine functions in normal B cells and in B lymphoproliferative diseases. This study was conducted to determine the effect of TNF alpha (in vitro) on CD20 expression on cells from patients with B-CLL. Currently, anti-CD20 monoclonal antibody therapy is becoming a second line treatment in the management of B cell disorders like low-grade non-Hodgkin's lymphoma (NHL) and B-CLL. Our results demonstrate amply that very low doses of TNF alpha (0. 0125 ng/ml) can be used to significantly increase CD20 expression on cells from patients of B-CLL as evidenced by increases in both percentage positivity and mean fluorescence intensity. The upregulation is evident as early as 24 hours and is maintained for up to 72 hours. We propose that the upregulation is a direct result of in vitro differentiation stimulated by TNF alpha. The results presented can be exploited in the designing of priming protocols prior to antibody therapy and this is discussed.

Myelodysplastic syndromes (MDS) have previously been reported to show competitively high rates of apoptosis and proliferation in the bone marrow (BM). Using a double-labelling technique in the present study, we demonstrated that a significantly high number of S-phase cells were simultaneously apoptotic (signal antonymy; SA) in MDS (mean +/- s.e.m. 53.5 +/- 6.7%, n = 24, P0.001). In contrast, SA was negligible in all other specimens studied, including normal control BM (n = 13) from non-Hodgkin's lymphoma (NHL) patients, BM from patients with de novo acute myelogenous leukaemia (1'AML; n = 5), or secondary AML that had transformed from MDS (2'AML; n = 10), or the solid tumours from patients with NHL (n = 9) or head and neck squamous cell carcinoma (HNSCC; n = 10). Subsequently, the expression of a transcription factor, E2F1, was studied in density-separated BM aspirate mononuclear cells from MDS patients (n = 9) and a normal control. Two separate sets of primers were used that recognized the regulatory retinoblastoma (Rb) protein-binding region and the functional DNA-binding region of E2F1. Interestingly, although the latter manifested the expected band (280 bp) in all samples, the Rb-specific primers showed the expected band (380 bp) in the normal and in 4/9 MDS specimens. Two other MDS specimens also showed a smaller band ( approximately 325 bp), whereas 3/9 MDS patients showed exclusively the smaller band. The levels of SA were significantly higher in those MDS cases that showed the smaller Rb-specific band either alone or in addition to the expected band (median 19.5%, n = 4, P = 0.037) than in those showing exclusively the expected band (median 0.4%, n = 3). Our present studies show SA as a characteristic feature of MDS and, importantly, demonstrate its link with an altered expression of E2F1 in some MDS patients.

The paradox of peripheral cytopenias despite cellular bone marrow (BM) observed in myelodysplastic syndromes (MDS) has been associated with excessive intramedullary apoptosis of hematopoietic cells. Since MDS is regarded as a stem cell disorder, the present studies were undertaken to examine the relative susceptibility and propensity of early progenitor CD34+ cells to undergo apoptosis as compared to more maturing/matured CD34- cells. Five serial studies were performed on 4 independent groups of 36 newly diagnosed MDS patients. First, in 2 separate groups of 16 and 8 patients each, measurement of the extent of apoptosis in CD34+ and CD34- fractions of the BM aspirate mononuclear cells was carried out using independent biparametric flow cytometry methods, CD34 labeling/terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) (n = 16), and CD34 labeling/reduced uptake of nucleic acid staining dye LDS751 (n = 8). The difference in the median degrees of apoptosis in CD34+ vs. CD34- cells was not statistically significant by either technique (P = 0.583 and P = 0.674 for TUNEL and LDS751, respectively). In the next group of 4 MDS patients, a double-labeling was performed on plastic embedded marrow biopsy sections, to detect CD34 antigen with specific monoclonal antibody and apoptosis by in situ end labeling (ISEL) of fragmented DNA. Despite high overall apoptosis (56.2% +/- 18.4%), only an occasional CD34+ cell was found to be simultaneously labeled with ISEL. Finally, in the last group of 8 MDS patients, CD34+ cells were separated from CD34- cells on affinity column and cultured in serum containing medium for 4 hours. At 0- and 4-hour time points, ISEL was carried out to label apoptotic cells. In addition, a fluorometric assay was employed to estimate the activity of a proapoptotic enzyme, Caspase 3. Both the net increase in % ISEL labeled cells (apoptotic index or AI) and Caspase-3 activity were significantly lower in CD34+ cells as compared to CD34- cells (AI, 0.87% +/- 0.5% vs. 3.97% +/- 1.4%, n = 6, P = 0.028 and Caspase-3 Units/mg protein, 46.9 +/- 25.0 vs. 71.7 +/- 23.03, n = 5, P = 0.042, respectively). We conclude that when estimated in a total population of mononuclear cells, CD34+ cells and CD34- cells show comparable degrees of apoptosis. However, once separated the CD34+ fraction demonstrates lower propensity to undergo apoptosis, thereby suggesting the CD34- fraction as being a possible source for proapoptotic signaling.

The secondary hematologic disorders consist of the progressive appearance of increasingly abnormal marrow cell populations with increasingly abnormal hemopoiesis culminating in the appearance of secondary acute myelogenous leukemia. At the biological level the secondary hematologic disorders result from the accumulation of molecular genetic lesions which confer a proliferative advantage on a stem cell and its progeny which in turn results in the successive overgrowth of increasingly abnormal monoclonal cell populations. We have identified 4 of 15 female patients cured of lymphoma by intensive cytotoxic therapy as having monoclonal hemopoiesis. Despite the presence of normal peripheral blood counts, the bone marrows of the 3 patients who were studied intensively manifested evidence of grossly abnormal hemopoiesis. We have named this state of normal blood counts in combination with monoclonal hemopoiesis in patients previously exposed to hemopoietic toxins “preMDS.” This “preMDS” state either represents an earlier stage of the secondary hematologic disorders or represents a transient preclinical manifestation of myelodysplasia. Longitudinal patient follow up is needed to distinguish between these two possibilities.

Preisler et al. first provided evidence that cytokine production by AML cells in vitro may not reflect cytokine production in vivo in patients. To address this question we placed bone marrow aspirate cells into GITC immediately after removal from the patient. Parallel marrow aspirates were placed on ice, sent to the laboratory and then placed into GITC after density cut separation or macrophage removal. Multiplex rtPCR was used to detect transcripts for IL1β, TNFα, HSCF, GMCSF, IL6, IL1ra, flt3. Among 13 patients studied, transcripts for IL1β were detected in 12, TNFα in 7, IL1ra in 3 of 9 studied. Among AML which did not produce TNFα, there were 4/4 CRs while there was 6 treatment failures among 6 patients whose cells contained TNFα mRNA with the one “CR” being characterized by persistent dysplasia with leukocytosis upon marrow recovery. Repeat studies during remission induction therapy were performed in 4 patients. HSCF appeared in one patient and was associated with leukemia cell proliferation during treatment. The appearance of IL1ra transcripts was associated with a significant fall in the proliferation rate of the AML cells. As a result of in vitro processing of cells, TNFα transcripts appeared in 4 specimens, HSCF in 4, GMCSF in 4, IL6 in 4. There were 4 CR among 5 pts whose leukemia cells did not produce GMCSF in vitro and no CRs among 4 pts whose AML cells produced GMCSF in vitro. These data demonstrate that cytokine production by AML cells differs among patients and such differences appear to have clinical significance. Further, cytokine production during treatment can change and is associated with clinical consequences. In vitro assessments of cytokine production cannot be used to characterize cytokine production by AML cells in patients but maybe predictive of response to therapy.

Histone H3 mRNA in situ hybridization was compared to a reference method, iododeoxyuridine (IdUrd) immunohistochemistry of tissues labeled in vivo, as a means for assessing the proportion of S-phase cells (labeling index, LI) in oral tumor and normal mucosa. Paraffin sections from 16 patients with oral squamous cell carcinoma were studied. Patients received an IdUrd infusion before the biopsy was taken. Tissue sections were coded before counting the percentages of S-phase cells. A high correlation was found between the results obtained by the two techniques. The average histone H3 and IdUrd LIs of the tumors were 28.5 +/- 2.4% and 29.2 +/- 2.7%, respectively (P = 0.85), with a Spearman correlation coefficient r = 0.95 (P0. 0001). The histone H3 LI of the basal layer of normal mucosa was 3.1 +/- 0.8%, whereas the IdUrd LI was 2.7 +/- 0.9% (P = 0.74), with r = 0.78 (P = 0.004). In the suprabasal layers, these parameters were 21. 3 +/- 2.3% and 23.9 +/- 3.2%, respectively (P = 0.56), with r = 0.93 (P0.0001). In sections stained for both histone H3 and IdUrd, most cells were double labeled, with very few cells containing only one of the labels. In some specimens, large areas of H3-stained cells did not contain IdUrd-labeled cells, suggesting that during the IdUrd infusion, the precursor did not reach these areas. Two specimens were histone H3 negative. They were also negative when hybridized with beta-actin probe, indicating degradation of mRNAs in these samples. The results of this study demonstrate that the histone H3 mRNA in situ hybridization performed in human formalin-fixed, paraffin-embedded tissues provides the same data as does labeling the tumors in vivo with halogenated pyrimidine.

Deregulation of expression of the cell cycle regulator cyclin D1 (cD1) may be responsible for rapid proliferation of squamous cell carcinoma of the head and neck (SCCHN). We have studied the expression of cD1 in 46 SCCHNs using immunohistochemistry. Before biopsy, the patients received an in vivo infusion of iododeoxyuridine (IdUrd) for cell proliferation assessment. Additionally, the level of apoptosis was estimated using in situ end labeling (ISEL). Among 33 tumors, the proportion of cD1(+) cells varied from 0.5 to 51.3% (19.9 +/- 2.2%). Thirteen tumors did not express cD1. The fraction of S-phase (IdUrd-positive) cells was 26.3 +/- 1.8% in cD1(+) versus 20.0 +/- 2.4% in cD1(-) tumors (P = 0.06). The percentages of cD1(+) cells and of S-phase cells were not correlated (P = 0.37). Apoptosis was detected by ISEL in 15 of 33 tumors studied. ISEL-positive tumors contained a significantly higher proportion of cD1(+) cells (14.9 +/- 2.6%) than cD1(-) ones (7.9 +/- 2.8%; P = 0.03). There was a positive correlation between the percentage of cD1(+) cells and the degree of ISEL (r = 0.54; P0.001). In noninvolved oral mucosa, cD1(+) cells were located primarily in the suprabasal layers (29.3 +/- 3.8% versus 1.2 +/- 0. 2% in the basal layer). Only 23 of 44 mucosal specimens contained cD1(+) cells. All cD1(-) samples were proliferatively active and contained IdUrd-labeled cells. The percentage of cD1(+) cells in the oral epithelium from nontumor controls (uvula samples) was significantly higher than in the SCCHN group in both basal (2.4 +/- 0.4%; P = 0.008) and suprabasal (42.7 +/- 3.3%; P = 0.005) layers. Additionally, whereas in uvuli, cD1(+) cells were distributed evenly along the epithelial lining, in SCCHN samples the regions showing cD1 expression alternated with areas in which cD1 expression was undetectable. These data indicate that cD1 expression in SCCHN varies among tumors and is not correlated with cell proliferation. In noninvolved oral mucosa, cD1 expression differs from that in truly normal epithelium obtained from nontumor patients. A correlation between cD1 expression and the extent of ISEL positivity suggests a possible involvement of cD1 expression in the apoptotic pathways.

Morphologically noninvolved mucosa in patients with head and neck cancer is altered by carcinogens. These alterations may include chromosome alterations, gene mutations, and other molecular abnormalities which may explain very high incidence of second tumors in this group of patients. The purpose of this study was to investigate the in vivo proliferative characteristics in epithelial tissues adjacent to the tumor in a series of patients with head and neck cancer.Twenty-one patients with head and neck tumors received IV infusions of iododeoxyuridine (IdUrd) and/or bromodeoxyuridine (BrdUrd). Surgical specimens containing normal-appearing epithelium adjacent to the tumor were selected and stained with the respective monoclonal antibody. The percentage of S-phase cells (labeling index, LI) was counted in the basal and suprabasal layers of the epithelium.In 27 samples of oral epithelium obtained from 14 previously untreated patients, labeled (S-phase) cells were predominantly located in suprabasal layers with LI 31.6 +/- 3.1% (range 13.5-73.2%). In contrast, the LI of the basal layer was very low: 1.6 +/- 0.2% (range 0.5%-8.8%). There was no statistically significant difference between normal appearing and dysplastic samples (p0.05). In 10 samples obtained from 7 patients whose biopsies were studied 2 days to 2 month after concomitant radiation and chemotherapy, the LI of the oral mucosa basal layer was significantly higher (21.0 +/- 4.1%, range 6.3-39.2%). The LI of the suprabasal layer in treated patients was 14.3 +/- 2.4% (range 5.9-31.1%). The LI of nasal pseudostratified epithelium (4 samples) was 11.2%. The average LI of "basal" cells was 8.3% (range 5.9-11.9%) and that of "suprabasal" cells was 13.8% range (3.2-29.5%). The basal layer of the skin (5 samples) contained 9.3% labeled cells (range 3.3-16.3%); the LI of suprabasal layers of skin was 21.3% (range 7.8-33.2%).Both the frequency and the spatial distribution of S-phase cells are disordered in noninvolved epithelia in patients with head and neck tumors. These observations suggest that disordered proliferation may be an early consequence of field cancerization, a consequence that occurs prior to appearance of morphologically apparent hyperplasia or dysplasia.

The effect of cytotoxic therapy on the proliferation of squamous cell carcinoma of the head and neck in vivo in patients was evaluated before and 15-35 days after the start of therapy. To accomplish this, iododeoxyuridine was administered at t = 0, and bromodeoxyuridine was administered 15-35 days later during treatment with a tumor biopsy obtained for study immediately after each pyrimidine infusion. Monoclonal antibodies specific for the halogenated pyrimidines were used to identify cells that were in the S-phase at the time of the infusions. Eleven patients were studied prior to treatment. Of those, the intratreatment biopsy of eight patients contained tumor tissue. In the other three patients, tumor tissue was not present in the second biopsy. Continued precursor incorporation into DNA-synthesizing cells during treatment was detected in six of eight tumor specimens. In two tumor specimens, an increase in the percentage of S-phase cells was noted, in two specimens tumor cells synthesizing DNA were not detected, and in four specimens the percentage of S-phase tumor cells was lower than that in the pretherapy specimen. Patients in whom there were no S-phase cells detected during treatment or in whom no tumor was detected in the second biopsy had a favorable treatment outcome in comparison to those patients in whom continued tumor proliferation during treatment was detected. The number of cells in S-phase prior to the initiation of treatment was not predictive of whether or not proliferation would continue during cytotoxic therapy. Evidence for reentry of kinetically quiescent cells into the cycle during treatment was noted. Additionally, cytotoxic therapy altered the proliferation pattern of normal-appearing mucosa as well. The results of this study demonstrate that tumor cell proliferation does continue in some squamous cell carcinoma of the head and neck during intensive cytotoxic therapy.

While most recent studies have focused on the MDR1 gene and other similar types of multidrug resistance, two other phenomena (inhibition of the apoptotic pathway and regrowth resistance) have the potential for producing a much broader type of resistance to cytotoxic therapy. This speculative review discusses the potential contribution of these types of resistance and the possible interrelationships between the various types of resistance to cytotoxic therapy. The need for new approaches to assess the effects of biological agents is discussed.

Two new enzymatic reactions were described recently to detect apoptotic cell death in situ viz in situ end labeling (ISEL) and terminal deoxynucleotidyl transferase mediated UTP nick end labeling (TUNEL) of fragmented DNA. A comparative study was conducted to detect in vivo and in vitro apoptotic death using these two techniques. Experimental design; Spontaneous apoptous cell death was detected in plastic embedded tumor biopsies from patients with non-Hodgkin's lymphoma (NHL), head and neck squamous cell carcinomas (HNSCC), and breast cancer using these two in situ methods. Uninvolved normal tissues adjacent to breast tumors and a lymph node metastasis of breast tumor were also studied. Furthermore, apoptotic death induced by different doses of etoposide (VP16) was also studied in HL60 cells by in situ methods and by agarose gel electrophoresis.Interestingly, whereas NH1 and HNSCC biopsies showed comparable levels of detectability with the two techniques, the breast tissues be it neoplastic, normal or metastatic, revealed apoptosis detectable only by TUNEL and not by ISEL. Similarly in HL60 cells, the percentage of apoptotic cells or apoptotic index (AI) determined by TUNEL was significantly higher than that determined by ISEL. A double labelling of these HL60 cells for ISEL and TUNEL also revealed a higher proportion of cells labeled positively for TUNEL as compared to those labeled for ISEL. Agarose gel electrophoresis revealed characteristic DNA laddering only at 35 microM dose of VP 16. No smearing of DNA was found in any group ruling out the necrotic death. In vivo, in one HNSCC specimen apoptosis and necrosis could be differentiated by the difference in staining intensity. Both methods stained necrotic chromatin fragments very lightly. The DNA fragments generated during apoptosis could be of unique lengths (ie 180-200 bp or multiples) but have differently staggered ends. These fragments may be 3' recessed, 5' recessed or blunt ended. While TUNEL can label all three types, ISEL labels only those with 3' recessed ends.Thus our data show that the DNA fragments formed during spontaneous apoptosis in breast tissues and preferentially during VP16 induced apoptosis in HL60 cells are either 5' recessed or blunt ended, being distinctly different from 3' recessed fragments seen in NHL and HNSCC or with a lesser frequency in VP 16 treated HL60 cells. Specific fragmentation patterns could be a result of activation of different endonucleases which as indicated by our data could be tissue specific and may be differentially activated by different chemotherapeutic agents. Therefore, screening for the presence of specific endonucleases in different tissues and for agents specifically activating them would have major clinical implications.

We measured the tumor cell proliferative rate in 26 patients with head and neck cancer, 22 of which were squamous cell carcinomas (SCCs). Patients received sequential infusions of iododeoxyuridine and bromodeoxyuridine, after which the tumor was biopsied and studied. The percentage of labeled cells [labeling index (LI)] in well-differentiated SCCs was 20.4 +/- 2.7% (mean +/- SE) and 23.8 +/- 2.1% in moderately differentiated SCCs (P = 0.135). The LIs of two poorly differentiated SCCs were 39.4 and 55.9%. The LI was 2.5% in a high-grade lymphoepithelioma and 24.8% in a malignant lymphoma. In one well-differentiated and one poorly differentiated mucoepidermoid tumor, the LIs were 3.0% and 29.1%, respectively. S-phase duration time measurements ranged from 5.1-21.5 h (12.8 +/- 1.5). The calculated potential doubling times ranged from 18.8-84.5 h (47.3 +/- 6.7). The duration of G2 was between 90 and 180 min. To track the fate of labeled cells, in four patients a repeat biopsy was obtained 7-14 days after the iododeoxyuridine/bromodeoxyuridine infusion. These patients did not receive treatment between the biopsies. Due to the dilution of the label, most labeled cells in the second biopsy demonstrated a "fragmented" pattern resulting from repeated cell divisions. In two patients, however, 25% of cells in the second biopsy had undiluted label, suggesting that these cells had not divided after incorporating iododeoxyuridine/bromodeoxyuridine. On Day 7 labeled cells migrated to keratinized parts of tumors and to necrotic foci. Thus, the arrest of cell cycle transition, tumor cell differentiation, and cell death may be major routes of tumor cell loss from the proliferative compartment. This may explain the difference between very short potential doubling times and the actual rate of tumor growth.

The leukemias can be divided into acute and chronic varieties, both of which have a myelocytic and lymphocytic type. When untreated, the acute leukemias are associated with a more rapid clinical course than are the chronic leukemias. Paradoxically, to the present time, the acute leukemias have been curable with chemotherapy, whereas the chronic leukemias have not. Until recently the treatment goal for patients with chronic leukemias has been to return the patient's life to normal for as long as possible. With recent advances, it may now be possible to cure some patients with chronic leukemia. Acute leukemias are treated with intensive chemotherapy, which is associated with severe and life-threatening side effects. Although this approach to treatment will cure some patients, the use of bone marrow transplantation has had an increasingly important role in the treatment of younger patients with these diseases.

Pretherapy bone marrow (BM) aspirates of 143 patients with acute myeloid leukemia (AML) were incubated simultaneously with bromodeoxyuridine (BrdU) and tritiated cytosine arabinoside ([3H]Ara-C) to determine the labeling index (LI) and extent of [3H]Ara-C incorporation. Of 143 AML patients, 121 received high-dose Ara-C (HDAra-C) as a single agent for induction therapy (55 newly diagnosed, 66 in first relapse), whereas 22 received HDAra-C plus mAMSA. The data demonstrate that a subset of patients who will fail HDAra-C remission induction therapy because of drug-resistant disease can be prospectively identified on the basis of the low amount of Ara-C incorporated by their leukemia cells.

Since the proliferative characteristics of leukemia cells play an important role in determining response to therapy, one may assume that an alteration of these characteristics could be therapeutically beneficial. To this end appropriate methods should be used to evaluate the effects of bioactive agents on leukemia cells in vivo in patients.

This paper describes the use of the bromodeoxyuridine/propidium iodide method to assess the effects of bioactive and cytotoxic agents on the kinetic characteristics of acute myelogenous leukemia cells. By careful selection of gates, the following parameters can be measured simultaneously using only 50,000 cells: the proportion of cells in S-phase, the distribution of cells within the S-phase compartment, the relative rate of DNA synthesis, the relative distribution of S-phase times, the proportion of S0 cells, and the proportion of cells in G1 and G2/M. This method was used to demonstrate that while retinoic acid, alpha-interferon, and cytosine arabinoside may all "inhibit" DNA synthesis, the actual effects of these agents differ. Retinoic acid appears to arrest cells in G1 without affecting the rate of DNA synthesis, while alpha-interferon and cytosine arabinoside "inhibit" DNA synthesis by reducing the rate of synthesis per se.

Pluripotent hemopoietic stem cells, progenitors of all hemolymphopoietic lineages, and clonogenic cells from many patients with acute nonlymphocytic leukemia (ANLL) and chronic myeloid leukemia (CML) express the CD34 antigen on their surface. Isolation of these cell populations is of primary experimental and clinical importance.Six bone marrow (BM) and 10 peripheral blood (PB) samples were obtained from 2 normal individuals, 3 patients with CML and 9 with ANLL. The CD34+ cell fraction was isolated using MY10 antibody, sheep anti-mouse immunomagnetic beads and the enzyme chymopapain. Indirect immunofluorescence and semisolid culture were employed to evaluate the percentage of CD34+ cells and that of clonogenic cells in each cell fraction.The frequency of CD34+ cells in the original unseparated populations was (mean +/- SE) 24.3 +/- 7.3%, and reached 85.0 +/- 2.7% in the isolated CD34-positive fractions; in the negative fractions it was only 2.7 +/- 1.7%. According to these results, the great majority of clonogenic cells was separated in the CD34-positive fractions and depleted in those CD34-negative. Moreover, chymopapain was shown to be non-toxic to the clonogenic cells.Positive immunoselection using My10 Ab, immunomagnetic beads and chymopapain is a method for isolating almost pure progenitors from the BM and PB of normal individuals and patients with myeloid leukemias.

c-myc, c-erbB-2, and Ki-67 expression was examined by immunohistochemistry in 11 normal breast tissues and 42 invasive and 14 noninvasive breast carcinomas. The c-myc product was detected in all breast carcinoma specimens and in 7 of 11 normal breast tissues. Invasive tumors stained more frequently with the anti-myc monoclonal antibody than did noninvasive tumors, while the level of expression in normal breast tissue was much less than that in breast cancer. Membrane staining of the c-erbB-2 protein was demonstrated in 29% (4 of 14) of noninvasive ductal carcinomas and in 45% (19 of 42) of invasive breast carcinomas. None of the 11 normal breast tissue samples was positive. The mean value of Ki-67-positive cells was 0.91 +/- 0.31% for normal breast tissue, 4.57 +/- 1.36% for noninvasive ductal carcinoma, and 12.76 +/- 2.18% for invasive breast cancer. In 42 invasive breast carcinomas, the expression of c-myc, c-erbB-2, and Ki-67 proliferation marker were compared with lymph node status, estrogen receptor status, progesterone receptor status, and age of patients at diagnosis. c-erbB-2 overexpression and Ki-67 overexpression were identified as the only factors associated with lymph node status. We concluded that they might be additional prognostic factors for breast carcinoma.

CD34, which was first detected in hemopoietic and lymphopoietic progenitors, is a heavily glycosylated Type I transmembrane protein that does not share any significant similarity with other transmembrane proteins. Its functions are still unknown. Several monoclonal antibodies were raised against CD34, and at least 4 different epitopes could be recognized. CD34 expression is confined to a few cell lines, to 1-4% of adult bone marrow mononuclear cells (including marrow-repopulating cells, all multipotent and committed myeloid progenitors, B and T lymphoid precursors, osteoclast precursors, and most likely the precursors for stromal cells), and to less than 1% of peripheral blood mononuclear cells. In non-lymphohemopoietic tissues its expression is confined to endothelial cells and to some cells of the skin. In malignancies, CD34 expression is not fully elucidated. Immature hemolymphopoietic malignancies (namely acute leukemias) and the blast cells of chronic myeloid leukemia are frequently positive. Chronic lymphoproliferative disorders and lymphomas are negative. Among other tumors, only vascular derived tumors are positive. Clinical applications of CD34+ cells include autologous transplantation of putative CD34+ stem cells isolated by positive selection from the bone marrow, and transplantation of autologous peripheral blood stem cells, using the proportion and number of CD34+ cells as a guideline for the harvesting procedure.

The revolution in cell and molecular biology presents an unprecedented opportunity to develop an understanding of neoplastic diseases. The emerging technologies resulting from this revolution also present an opportunity to make the diagnosis and staging of neoplastic diseases more accurate. Unfortunately, the integration of these technologies into current clinical practice is not a simple task. The problems associated with the clinical applications of these technologies include standardization and simplification of the technologies so that they can be established in nonresearch institutions, selection of those technologies which provide clinically meaningful information, and finally, the implementation of large-scale clinical trials which will permit multivariate statistical analyses to determine if performance of the new studies actually add to a physician's ability to diagnose and stage cancer patients. In the future, the staging of patients with neoplastic diseases will include anatomic studies together with morphologic and biologic studies of the tumor cells. Data derived from these studies will be used to assess each patient's risk status regarding the likelihood of local and distant metastases being present. These highly accurate estimates of risk status will lead to an improvement in our ability to make individualized recommendations for therapy.

Prior to the initiation of remission induction therapy patients with AML a combination of 13-cis retinoic acid and a interferon was administered for 3 days with measurement of the % leukemia cells in S phase prior to and after the administration of these two agents. Patients then received remission induction therapy consisting of idarubicin on days 1, 2, 3 and cytarabine on days 1–7. Patients whose leukemia entered CR [66%] received 3 courses of remission consolidation therapy with courses #s 1 and 3 being identical to remission induction therapy and course #2 consisting of cytarabine 2 gm/m 2 q 12 h on days 1–4. Patients received a combination of retinoic acid and a interferon between each course of remission consolidation therapy. 44% of patients remain in remission at 5 years. 69% of leukemias with intermediate cytogenetic characteristics and with a LI less than the median value prior to the 3 day administration of RA/IFN are in remission at 5 years while the same is the case for 26% of leukemias whose LI was greater than the median value. Considering the post RA/IFN LI, 88% of intermediate cytogenetic leukemias with a LI less than the median value are in remission at 5 years. 76% of leukemias with favorable cytogenetic characteristics are in remission at 5 years. Leukemias with these cytogenetic characteristics have low % cells in S phase. Leukemias with favorable cytogenetic characteristics or with intermediate cytogenetic characteristics and a low % S phase cells constitute 48% of newly diagnosed standard prognosis AML. When treated with the remission consolidation regimen described here these patients have a 76% to 88% likelihood of being in remission beyond 5 years. Studies are underway to determine if a reduction of the LI of cytogenetic intermediate AML whose LI exceeds the median value will result in a prolongation of the remission durations of these patients.

The expression of the c-myc proto-oncogene product was examined by immunohistochemistry in 11 normal breast tissues, 31 invasive and 14 non-invasive breast carcinomas. The c-myc product was detected in all breast carcinoma specimens and in seven of 11 normal breast tissues. Invasive tumors stained more frequently with the anti-myc monoclonal antibody (MAb) than non-invasive tumors, while the level of expression in normal breast tissue was much less than that in a breast cancer. Marked heterogeneity in the c-myc expression was seen among different tumors and within individual tumors. None of the eight invasive tumors with a high protein level of the c-myc showed evidence of gene amplification by Southern blot analysis.

Cell cycle characteristics including labeling indices (LI), duration of S-phase (Ts), and total cell cycle time (Tc) were determined in 54 standard-risk, newly diagnosed patients with acute myeloid leukemia following an infusion of bromodeoxyuridine. Remission induction therapy consisting of cytosine arabinoside and daunomycin was then administered to all patients, followed by three courses of consolidation to those who achieved complete remissions (CR). Older patients appeared to have more rapidly cycling cells (P = .003). No unique cell cycle characteristics were identified for patients who achieved remission versus those who had resistant disease. However, the pretherapy cell cycle characteristics were a strong prognosticator for remission duration. CR patients were divided into those whose leukemic cell Tc were above median (A) and below median (B). Among 14 B patients, median duration of response was 211 days, and all relapsed by day 600. Among 18 A patients, the median has not as yet been reached, with nine patients in continuous complete remission (log rank P = .007, Wilcoxon P = .04). We conclude that cell cycle characteristics of leukemic cells play a role in determining remission duration, perhaps because the leukemic cells of the former patients regrow slowly between courses of chemotherapy.

To determine the cytogenetic origin of maturing granulocytes in the bone marrow of patients with acute myelogenous leukemia, bone marrow cells were studied using a modified cytogenetic technique, which does not disrupt the cell membrane, in conjunction with periodic acid-Schiff (PAS) staining. In four cases successfully studied, myeloblasts were PAS-negative and granulocytes were PAS-positive. In three cases successfully studied following 0-2 days of culture, metaphase spreads with abnormal karyotypes characteristic of the patients' leukemic clones were seen in five of five, six of nine, and four of four PAS-positive cells successfully studied. These patients' bone marrows were AN, AA, and AA, respectively, by standard cytogenetic study. Therefore, the cytogenetic status of PAS-positive cells did not necessarily correlate with presence or absence of normal metaphases determined by standard cytogenetic study. Bone marrow cells which underwent full and partial granulocytic maturation in suspension culture were studied following 2 weeks of culture. Abnormal karyotypes were seen in five of five and two of two metaphases in PAS-positive cells successfully studied in two patients. Therefore, we have demonstrated that when acute myelogenous leukemia cells undergo myeloid maturation in culture, the mature cells may be definitely proven to derive from leukemic progenitors rather than from normal stem cells.

In almost all studies using paraffin embedded tissue, c-myc protein has been found in the cytoplasm of cells. Since the protein is normally localized in the nucleus it is difficult to determine which histochemical observations are real and which are artefactual. The study designed here evaluated several different methods of fixation prior to paraffin embedding in an attempt to identify which would prevent the diffuse of the protein out of the nucleus. Using various fixation procedures (formalin, paraformaldehyde, B-5, Zamboni and AMeX) we found that fixation in cold acetone (-20 degrees C) overnight followed by 2x15 min fixation in acetone at +4 degrees c and at room temperature, cleared in methyl benzoate and xylene (AMeX procedure) gives reproducible nuclear staining when a variety of normal and tumor tissues are treated with an anti c-myc protein antibody. This method was then compared to frozen sections. While there was no cytoplasmic staining in same tissue specimens in both AMeX processed and frozen sections, the tissue architecture was much better preserved in AMeX processed samples. Our data strongly suggest that AMeX fixation, originally developed for T and B lymphocyte antigens, should be used for immunolocalization of c-myc oncoprotein in paraffin embedded tissues.

Expression of the granulocyte-macrophage colony-stimulating factor (GM- CSF) gene in acute myelocytic leukemia (AML) was assayed by Northern blot analysis. GM-CSF messenger RNA (mRNA) was detected in the freshly obtained mononuclear cells of only one of 48 cases of AML, in contrast with recent reports that GM-CSF mRNA might be detected in half of the cases of AML when RNA is prepared from T-cell- and monocyte-depleted leukemic cells. We did find, however, that expression of the GM-CSF gene was detectable in five of ten cases after in vitro T-cell and monocyte depletion steps. Additional studies suggest that expression of GM-CSF in the bone marrow of the one positive case, rather than being autonomous, was under exogenous control, possibly by a paracrine factor secreted by marrow stromal cells. These studies emphasize the potential for altering in vivo patterns of gene expression by in vitro cell manipulation.

Given the time and effort expended by investigators and given the large numbers of patients studied, there are disappointingly few "predictors" of response. From the clinical perspective, aside from performance status, age, prior history of toxic exposure, and grossly abnormal organ function, there are essentially no reliable indicators of the likelihood of a patient surviving remission induction therapy. The absence of such indicators might reflect the fact that without grossly abnormal organ function, all patients generally begin with an equal possibility of survival and that events which occur during therapy determine survival. One thing is certain, death directly attributable to leukemic cell overgrowth despite chemotherapy is an extremely rare event. Hence, therapeutic inadequacy in this sense, at the time of initial diagnosis, is not a common cause of treatment failure. Studies aimed at the prediction of leukemic cell responsiveness to therapy have been plagued by two general problems. The first is that the drug sensitivity assays have been quite primitive. For example, the ability of a cell to take up a drug is not synonymous with sensitivity to that drug. Additionally, tests which are dependent upon assays capable of making measurements in only a small subpopulation of cells, such as in vitro clonogenic assays, are likely to have only limited applicability. On the other hand, assays which measure the properties of the leukemic cell population as a whole are incapable of recognizing arabinoside therapy have provided data which suggest that in addition to patient survival three conditions must be satisfied if a complete remission is to occur: the pretherapy leukemic cell mass must be moderate or low, an adequate number of cells must be synthesizing DNA, and cytosine arabinoside must produce significant inhibition of DNA synthesis in vitro. Each factor is consistent with what is known about cytosine arabinoside: it is an S-phase-specific agent which must be incorporated into DNA in order to kill leukemic cells. When the relationship between these same factors and response to combination chemotherapy were studied, not unexpectedly, no relationship was discerned. Finally, in this setting pharmacokinetic studies have demonstrated that the amount of araCTP formed in leukemic cells in vivo when doses of 2 g and 3 g/m2 are administered are indistinguishable, thereby explaining the clinical equivalence of these two dosage levels.(ABSTRACT TRUNCATED AT 400 WORDS)

Marrow specimens obtained from 23 patients with acute myelocytic leukemia were exposed to cytosine arabinoside and/or daunorubicin in vitro, and the effects of these agents on colony formation in vitro was determined. Thymidine suicide indices were determined as well, which permitted a distinction to be made between kinetic and metabolic resistance to cytosine arabinoside. The sensitivity of the colony- forming cells to the two chemotherapeutic agents did not correlate with each other, indicating that sensitivity to each was independently determined. The relationship between in vitro sensitivity to daunorubicin and cytosine arabinoside and response to 25 courses of in vivo therapy with these two agents administered to 21 patients was determined. These studies indicated a clear-cut relationship between in vitro drug sensitivity and in vivo response with patients whose leukemic cells were sensitive to both agents entering complete remission, whereas patients whose leukemic cells were insensitive to one or both drugs in vitro failed to enter remission.

Myeloblast and promyelocyte enriched preparations and the original unseparated specimens were compared in regard to the phosphorylation of cytosine arabinoside (ara C) and the retention of ara CTP as well as the effects of ara C on the clonogenic cells. The immature cell-enriched preparations have a significantly higher rate of ara C phosphorylation, while retention of ara CTP is not significantly different from that of the unseparated cells. No correlation was found between the measured parameters of ara C metabolism and the drug's effects on the clonogenic cells in either cell population.

The levels of protooncogene RNA in matched bone marrow and peripheral blood cells obtained from patients with newly diagnosed acute myelogenous leukemia were compared. While the absolute amounts of c-myc RNA in the matched specimens are similar, the levels are not correlated. In contrast, while the levels of c-fos RNA in the matched bone marrow and peripheral blood cells are correlated, the absolute levels of c-fos RNA differ substantially. The level of histone H3 RNA is higher in bone marrow cells than in peripheral blood cells. These substantial differences in protooncogene RNA levels between leukemic cells found in the bone marrow and in the peripheral blood make it impossible to accurately "characterize" gene expression in leukemic cells if studies are restricted to the cells in either compartment. Additionally, there appears to be a significant relationship between the levels of c-fos RNA and triose phosphate isomerase RNA and the height of the white blood cell count and between the level of c-fos RNA in marrow cells and the proportion of monocytic cells present.

Different methods for fixation and exposure of antigenic determinants were tested for detection of a granulocytic differentiation antigen by the monoclonal antibody L12-2, using an indirect immunoperoxidase method on semi-thin sections of undecalcified, glycolmethacrylate-embedded human bone marrow biopsies. Fixation in Bouin's solution for 3 hr gave a more intense and more homogeneous immunological staining than fixation in absolute methanol, 4% formalin, B5, or Michel's medium, and the morphological detail was excellent. Digestion by pronase or trypsin was required. Coating the glass slides with Alcian blue prevented loss of sections from the slides during the staining procedure. Bouin fixation also made possible detection of two other differentiation antigens expressed in the granulocytic series, using the monoclonal antibodies 1G10 and R1B19. Furthermore, the same technique also permitted detection of factor VIII-RAg in the megakaryocytes, as well as recognition of cells of the erythroid series by use of polyclonal rabbit antisera.

Partially thiolated polycytidylic acid (MPC), an antileukemic agent, when administered to leukemic RF/UN mice inhibited the clonogenicity of bone marrow progenitor cells in a time- and dose-dependent manner. The effect of a single dose of MPC disappeared within 40 hr due to the rapid degradation of this compound in mice. When MPC was encapsulated in liposomes before injection, its activity at 19 hr after inoculation was similar to that of free MPC. The inhibitory effect of this liposome-MPC complex, however, persisted for at least 40 hr, indicating that the MPC was protected from hydrolysis by the nucleases present in blood. Drug-free liposomes increased the number of clonogenic progenitor cells, whereas a mixture of plain liposomes and MPC decreased the number of clonogenic cells to a greater extent than did MPC alone or MPC within liposomes. A possible explantation for these observations is that the liposomes per se altered the clearance function of the reticuloendothelial system and completed with MPC for uptake by the reticuloendothelial system cells, thereby resulting in increased plasma levels of MPC which in turn resulted in greater killing of the target cells.

Emphasis on the reasons for successful therapy in the treatment of acute myelocytic leukemia (AML) has generally obscured the problem of treatment failures. This paper discusses failures in remission induction and relapse of leukemia. The contribution of patient-related factors as well as the heterogeneous characteristics of the leukemic cells are considered.